Secure Services Division
Equality And Human Rights
2017-2018
1
Table of contents
Title
Page
Draft Secure Services Division Equality and Human Rights Action Plan 2017/2019 ………………………………………
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Secure Division’s Equality And Human Rights Governance Structure …………………………………………………………….
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Objective 1 …..………………………………………………………………..………………………………………………………………………………………….
Objective 2 ………………………………………………………………………………………………………………………………………………………………..
Objective 3 ………………………………………………………………………………………………………………………………………………………………..
Objective 4 ………………………………………………………………………………………………………………………………………………………………..
Objective 5 ………………………………………………………………………………………………………………………………………………………………..
Objective 6 ………………………………………………………………………………………………………………………………………………………………..
Objective 7 ………………………………………………………………………………………………………………………………………………………………..
Objective 8 ………………………………………………………………………………………………………………………………………………………………..
Objective 9 ………………………………………………………………………………………………………………………………………………………………..
Objective 10 ………………………………………………………………………………………………………………………………………………………………..
Objective 11 ………………………………………………………………………………………………………………………………………………………………..
Objective 12 ………………………………………………………………………………………………………………………………………………………………..
Objective 13 ………………………………………………………………………………………………………………………………………………………………..
Objective 14 ………………………………………………………………………………………………………………………………………………………………..
Objective 15 ………………………………………………………………………………………………………………………………………………………………..
Objective 16 ………………………………………………………………………………………………………………………………………………………………..
Secure Services – Protected Characteristics of Service Users
………………………………………………………………………
Gender
………………………………………………………………………………………………………………………………………………………………
Age ………………………………………………………………………………………………………………………………………………………………………….
Marital Status
……………………………………………………………………………………………………………………………………………………
Sexual Orientation ……………………………………………………………………………………………………………………………………………………
Religion
……………………………………………………………………………………………………………………………………………………………..
Ethnicity
………………………………………………………………………………………………………………………………………………………………
Disability
………………………………………………………………………………………………………………………………………………………………
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Draft Secure Services Division Equality and Human Rights Action Plan 2017/2019
Links into the Trust Equality Objectives/NHS Equality Delivery System (2)
Local Clinical Commissioning Groups Quality Contract
Care Quality Commission 5 Key Human Rights Standards
Robert Mclean Head of Forensic Social Care
George Sullivan Secure Services Equality and Human Rights Advisor
3
SECURE DIVISION’S EQUALITY AND HUMAN RIGHTS GOVERNANCE STRUCTURE
Oversees Division is
properly governed &
well managed
Chair –Head Of Forensic Social Care
Secure Equality and Human Rights Task Group
Decision making
Meetings
Security
Committee
Operations &
Performance
Committee
Chair- Director
of Security
Chair – Director
of Operations
Transformation
Steering Group
Chair – Director of
Operations
Service User &
Carer Strategy
Group
Clinical
Governance
Committee
Chair – Head of
Nursing & Patient
Experience
Chair – Associate
Medical Director
Senior Leadership Team Chair –
Deputy Director of Operations
Subject-specific groups
•
•
•
•
Clinical
Areas
Low
Medium
Secure
•
•
•
•
•
•
•
•
Surveillance Group (SD)
Workforce
Development Grp (SD)
Health & Safety Group
(SD)
Admission Panel (HSS)
Bed Management
Group (service-specific
and meet as & when
required)
Health Records &
PACIS User Grp (HSS)
Collaborative Working
Groups (Division &
service-specific)
Risk Management Task
Group (SD - ad hoc mtg,
as and when required)
Professional Forums
•
•
Secure
Project Board
(MSS)
Workforce
Development
Project Group
(Secure
Pathway/MSS)
•
•
•
•
Recovery
Champions Grp
(SD)
Service User &
Carer Task Group
(HSS)
Nutrition & Health
Promotion Group
(HSS)
Patients Forum
(HSS)
•
•
•
•
•
•
NICE & Clinical
Audit Group (SD)
Medicines
Management (2x
grps, HSS &
MSS/LSU/OH/CFS)
Physical Health
Care Group (SD)
Seclusion
Monitoring Grp (3x
grps, HSS, MSU,
LSU)
Safeguarding
Children & Adults
Group (SD)
Mental Health Law
Grp (SD)
•
•
•
Research &
Innovation
Committee
Ashworth
Research
Committee
(HSS)
Mersey
Forensic
Research
Group (MSS,
LSU, OH,
CFS)
4
Trust
Action
Plan ref :
Objective 1.
EDS Goal
4
To have an updated
Secure Division Equality
and Human Rights action
plan.
1. Complete Draft action plan.
2. Include Equality and Human Rights
governance structure.
3. George to complete paper for CGM.
George Sullivan
Trust
Action
Plan ref:
EDS Goal
3
Objective 2.
Actions
Lead
To set up a system that
enables Secure Services
to address the proactive
support needed for
disabled staff.
To reduce the
inappropriate use of the
attendance policy to
identify and address
issues that impact on
disabled staff’s work and
wellbeing.
Actions
1. HR to undertake a review/audit of
staff within the Secure Division who
have made use of the supporting
disabled staff policy and the working
place support plan.
2. Communication to staff .HR to raise
awareness/inform Secure Services
managers about the new policy and
also about the attendance policy.
3. To support the staff ’lived in
experience‘ network.
Lead
Vicki Wilson
Helen Brook
Outcome/update
Target Date
Action plan developed
Feb 2017
Outcome/update
Target Date
1. Trust Equality Lead has
reviewed the supporting
staff with disabilities.
2. HR 27 changed policy to
supporting staff with
mental health and physical
health Needs.
3. Process supported by
Equality and Human Rights
analysis of the policy.
June
2017
4.HR to raise
awareness/inform Secure
Services managers about
the new policy and also
about the attendance
policy.
6. Communicate to staff
about the change in policy.
George/HR to support
managers in the use of the
policy.
5
Trust
Action
Plan ref:
Objective 3.
Equality and Human
Rights Analysis of any
service change/
development within the
Secure Division
specifically:
 the proposed new
build of Scott clinic
 the model of care
 Outline Business
case/plan
 CSIP
Actions
1. There is in place a process to ensure
that Equality and Human Rights
analyses are undertaken for all
policies and procedures and service
developments.
2. The plan for the new build, the
model of care and the outline
business case have all been subject
to Equality Analysis.
3. All policies within High Secure
Services have been subject to the
Equality assessment process.
4. Evidence collected re. public
consultation with communities.
5. Regular quarterly audits undertaken
to ensure compliance.
Lead
George Sullivan
Elaine Wilkinson
Need to develop a system/process of
checks where all other service related
business changes/OBC/CSIPS are subject to
Equality and Human Rights analysis.
Trust
Action
Plan ref:
Objective 4.
Assurance of usage of
translation and
interpretation services.
Actions
1. All managers across the Secure
Division have been made aware of
the process of the on line booking
system with CAPITA.
2.
Outcome/update
Target Date
Audit to be undertaken of
current Equality and
Human Rights analysis of
policies across the Secure
Division.
2017/18
On-going
George to complete a paper
for Clinical Governance and
compliance with Equality
objectives and Equality Act.
Lead
George Sullivan
Outcome/update
Target Date
1. All three secure sites
May 2017
have been given their own
codes and passwords for
use with the on line booking
system.
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Ensure all staff across
the Secure Division are
making use service when
needed.
CCG
EDS 3.4
EDS 1.2
3. Further information relayed to staff
via Sharepoint and communications.
2. Undertake audit of usage
of /and what languages
have been requested across
the Secure Division
Once a year.
Objective 5.
There is in place a target
of 100% in obtaining
staff monitoring data
across the Secure
Division.
Actions
To support the Secure Division to meet the
completion of collecting staff data.
Objective 6.
To reduce the use of
restrictive practices
across the Secure
Division have specific
targets and action .
Actions
To have targets and action plan and Process
underway to enable the analysis of secure
restrictive practices.
November
2017
Lead
Meryl Cuzak
Director of
Workforce
Outcome/update
List of those staff who have
not filled in their form
obtained.
Target Date
End 2017
Lead
Dr J Kilcoyle
Outcome/update
Target Date
Secure Division working and September
monitoring Groups has
2017
been set up to look at ‘no
force first and restrictive
practices : Use of Seclusion,
Segregation, Control and
Restraint.
Agree process with HR and managers.
Analysis recognises work needed to review/
monitor female ward in Scott Clinic
BME patients within
Low secure
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BME patients within
Medium
EDS 2.3
EDS 2.3
Objective 7.
To reduce the use of
blanket bans within all of
the secure site taking
into account an Equality
and Human Rights based
approach to decision
making.
Objective 8.
To set up a patient BME
support meeting within
High/Low /Medium
secure services.
BME patients within
High secure
Actions
Lead
Secure Division working and monitoring
Dr J Kilcoyle
Groups has been set up to look at the use of
blanket bans.
Danny Angus
Actions
Group set up a number of years ago in High
Secure – group was not successful and
patients did not see the need.
Fact finding needs of such groups for the
three secure sites.
George Sullivan has had initial discussions
with managers.
Outcome/update
Group has met up and
regular meetings planned.
Target Date
2017
Audit has been undertaken
with patients and staff
within Ashworth to see
views of blanket ban issues.
This will be extended to
both low and medium
secure services.
Meryl Cuzak
Decision making tool to be
developed by Meryl Cuzak.
Danny Angus
Hope tool developed
Lead
George Sullivan
Outcome/update
To see BME patient groups
set up.
Target Date
June 2017
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EDS 2.3
Objective 9.
To set up a patient LGBT
support group in Scott
clinic and Rathbone to
help to support
patients/service users
with issues such as
discrimination and other
Equality issues and
provide a safe space.
Scott Clinic LGBT Group
Low secure GBT Group
EDS 3.3
Actions
Group set up a number of years ago in High
Secure.
Lead
George Sullivan
Outcome/update
Chief Executive Joe Rafferty
attended celebration of
group on 26 January.
Equality Advisor will liaise with low secure
Matron to assess the need for similar group.
Equality Advisor will liaise with Matron of
medium services to assess the need for
similar group.
Target Date
April 2017
April 2017
Objective 10.
Full implementation of
the accessible
Information Standard.
Actions
Lead
Project action plan being developed For
Andy Osbourne
secure to work with the Trust and to attend
meetings regards the Accessible
Ian Murphy
information standard.
Outcome/update
Work has started on PACIS
looking at the Accessible
standard requirement.
Target Date
June 2017
Objective 11.
Equality and Human
Rights training to be
provided for all staff
across the Secure
Division
Actions
Lead
All staff across the Secure Division
Meryl Cuzak
To undertake Equality and Human Rights
George Sullivan
training according to role/job/ management
2.Primary Face to face Half day
3.Secondary Face to face one full day
4.Tertiary Face to face
Outcome/update
For all staff to have Equality
and Human Rights training
Target Date
2017
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Objective 12.
Training for service
users/patients in
relation to human rights,
Equality Analysis
assessment and Equality.
To ensure voice is heard
and to ensure Equality
and inclusive
assessments.
Actions
Identify level of interest by service users
and carers across the Secure Division.
Lead
George Sullivan
Amanda McBride
Outcome/update
Service users and Carers to
take part in the Equality
and Human Rights
assessments.
Lead
Karen Jobson
Outcome/update
Target Date
There is a room identified
On-going
as a sacred space and it is
2017
used by the Chaplain for
services on a regular basis.
Meeting Spirituality needs
has significantly improved
since the Chaplain has
started working at the Clinic
one day a week.
Provide a venue and complete training.
Target Date
July 2017
Include training service users and carers for
the Secure Division in the Equality Analysis
process at all levels.
Training has been discussed and individuals
identified as well as venues discussed, plans
to deliver this are currently being drawn up
(within Scott).
Objective 13.
Improve provision of a
sacred space for
reflection around
religion/spirituality
within the Secure
Division. Increase service
users access to a
Chaplain to meet
spirituality needs.
Ensure that
region/spiritual
dimension/needs are
taken into account in the
outline business
case/plan for the new
build.
Actions
Improve the environment of the current
sacred space at Scott Clinic to become more
conducive to prayer and reflection.
Increase service users access to a Chaplain
for meeting spirituality needs.
Chaplain to explore needs with service
users and meet these appropriately.
As well as services, she has
offered the Labyrinth
experience and plans to use
the room for Bible study
groups and spirituality
groups in the near future.
plans to redevelop the
workshop area have taken
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into consideration the
provision of a designated
sacred space.
Objective 14.
Guidance/support
available for staff in
relation to ensuring
service user’s individual
daily needs are met e.g.
diet, language and
clothing.
Objective 15.
Actions
Liaise with catering dept.: across the Secure
Division regarding provision of culturally
suitable food options for service users.
Actions
Lead
Tracy Wilkins
Lead
Outcome/update
Catering department now
does provide culturally
suitable food for service
users.
Halal and other cultural
range improved.
Equality and Human Rights
advisor
(G Sullivan) is available for
advice.
Target Date
On-going
2017
Outcome/update
Target Date
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EDS 1.4
EDS 3.4
A system to record and
monitor discriminatory
behavior of adverse
incidents in relation to
staff or service users.
Design a system to record discriminatory
Complaints lead
behavior relating to protected
characteristics
Collate the information related to protected
characteristics. Formulate an action plan
depending on outcomes of information
collection.
To have system in place to
monitor complaints in
relation to the protected
characteristics.
August
2017
Outcome/update
The Trust have set up an
Equality network. Including
a staff BME network.
Target Date
Current systems in place to capture
discriminatory behavior by service users to
staff or others\users. This information now
needs to be collated and analyzed via the
respective Forums.
Provide a regular agenda item at Adverse
Incident, Complaints, Claims and Litigation
Sub-Group to report incidents and
outcomes of action taken.
Objective 16.
Promote Race Equality
for staff within the
Secure Division via the
NHS workforce Race
Equality standard.
Actions
Review workforce indicators looking at
processes such as promotion and
disciplinary procedures with regard to the
makeup of the workforce.
Develop positive action
plan.
Ensure Secure Services staff have access to
the reciprocal mentoring project.
Lead
The Trust via Equality and
HR dept. have set up a
reverse reciprocal
mentoring project.
CREATED BY GEORGE SULLIVAN SECURE SERVICES EQUALITY AND HUMAN RIGHTS ADVISOR 03/02/2017
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Secure Services – Protected Characteristics of Service Users
Introduction:
The remainder of this document is a digest of statistical information on the distribution of Protected Characteristics among Mersey
Care Service Users.
This particular document covers Protected Characteristics across Secure Division.
Information is presented in the form of percentages and charts prepared by the Business Intelligence Department.
Percentages for the Secure and High Secure Divisions are combined as that is the form in which they were received by the Equality
and Human Rights team.
Protected Characteristics data for Service Users are listed as follows:







Gender
Age
Marital Status
Sexual Orientation
Religion
Ethnicity
Disability
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Gender
Gender
Secure Division
Male
95.6%
Female
4.4%
4.4%
95.6%
Gender - Secure Division
Service Users
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Age
Age
14-17
Secure Division
18 - 29
30 - 49
50 - 69
25.7%
55.2%
18.5%
70 and
Over
0.6%
70 and
Over, 0.6%
50 - 69,
18.5%
18 - 29,
25.7%
30 - 49,
55.2%
Age, Service Users
Secure Division
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Marital Status
Marital Status
Divorced
Secure Division
5.1%
Married/
Cohabiting
2.1%
Not Stated,
1.7%
Widowed,
0.8%
Separated
Single
1.7%
87.6%
Not known,
1.1%
Widowed Not Stated
0.8%
Divorced,
5.1%
1.7%
Not
known
1.1%
Married/Co,
2.1%
Separated,
1.7%
Single, 87.6%
Marital Status Secure Division
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Sexual Orientation
Sexual
Heterosexual
Orientation
Secure Division
74.7%
Decline to
Answer
15.2%
Decline to
answer,
15.2%
Unable to Bisexual Gay Man
Answer
5.5%
2.7%
1.9%
Bisexual,
2.7%
Gay Man,
1.9%
Unable to
answer,
5.5%
Heterosexual,
74.7%
Sexual Orientation Secure Division
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Religion
Religion
Secure Division
Bahai
Buddhist
Christian
Hindu
Jewish
Mormon
Muslim
Pagan
Sikh
Rastafarian
Taoist
Unitarian
Not Religious
Other Belief
Not known
Patient does not wish to answer
0.0%
2.3%
48.8%
0.6%
0.8%
0.2%
6.1%
1.5%
0.0%
0.0%
0.0%
0.0%
30.1%
0.8%
5.1%
3.6%
NB Please also see following chart
18
Religion
Religion - Secure Division
60.0%
48.8%
50.0%
40.0%
30.1%
30.0%
20.0%
10.0%
6.1%
2.3%
0.6% 0.8% 0.2%
5.1%
1.5%
0.8%
3.6%
0.0%
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Ethnicity
Ethnicity
White
British
White
Other
Black
British
Black
Other
Secure Division
79.4%
2.9%
5.3%
3.6%
Other
Specified, 0.0%
Chinese, 0.0%
Asian or Asian
British, 3.4%
Black Other,
3.6%
Asian or
Asian
British
3.4%
Chinese
Mixed
Other
Specified
Other
Ethnicity
Not
Known
0.0%
3.6%
0.0%
0.6%
0.4%
Other Ethnicity,
0.6%
Patient does
not wish to
answer
0.8%
Not Known,
0.4%
Patient does
not wish to
answer, 0.8%
Black British,
5.3%
Mixed, 3.6%
White Other,
2.9%
White British,
79.4%
Ethnicity
Secure Division
20
Disability
Disability
Aspergers/Autism
Blind/Part sighted
Brain Injury
Deaf/Hard of hearing
Dyslexia
Learning Disability
Mental Health Difficulty
Multiple disability
No disability
Other Disability
Unseen disability
Wheelchair/Mobility
Patient Declined to Answer
Not Recorded
Secure Division
0.2%
0.8%
0.0%
0.4%
0.6%
1.3%
35.6%
0.8%
57.3%
0.8%
0.0%
0.8%
0.0%
1.3%
NB Please also see following chart
21
Disability
Disability -Secure Division
70.0%
57.3%
60.0%
50.0%
40.0%
35.6%
30.0%
20.0%
10.0%
0.2%
0.8%
0.4%
0.6%
1.3%
0.8%
0.8%
0.8%
1.3%
0.0%
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