Regulatory priorities January to March 2021: equality impact assessment

Impact:

• Potential discrimination against older people in relation to Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) decisions and wider discrimination in access to acute care and critical care may be likely to increase due to capacity pressures. We will need to continue to address this in our regulation.
• Human rights of older people living in care homes in relation to visitors: we will need to address this in our regulation.
• Older people are more likely to need non-COVID health care services during the pandemic and will be disproportionately affected by any delays to these services.

Mitigation:

• Complete thematic review of DNACPR and incorporate lessons learned into regulatory methodology. Review current DNACPR guidance for inspectors if necessary.
• Continue to check for wider issues about discrimination in clinical decision making in Transitional Monitoring Approach and escalate appropriately including taking regulatory action where required.
• Consider issues about discrimination in clinical decision making as appropriate in Provider Collaboration reviews
• Continued policy work with DHSC and others to determine shared position about care home visits - on ensuring least interference with Article 8 rights to a private life whilst protecting Article 2 Rights to life.
• Incorporate any required amendments into our Transitional Monitoring Approach and inspection frameworks.
• See also general comments across all equality strands below regarding restart of non-COVID services.

Impact:

• Human rights of carers to see their relatives living in care homes.
• Increased demand on time spent on caring responsibilities for CQC staff.

Mitigation: actions as identified for age above.

Impact:

• Potential discrimination against disabled people in relation to DNACPR decisions and wider discrimination in access to acute care and critical care may be likely to increase due to capacity pressures. We will need to continue to address this in our regulation.
• Overall death rate due to COVID still high for people with a learning disability – 80% of deaths of people with a learning disability in week commencing 22nd Jan were COVID related compared to 45% in general population (Mencap figures)
• Deaf people, especially British Sign Language users, continue to experience particular barriers resulting from non-accessible communication; availability of interpreters e.g. for consent and decision-making, use of PPE masks preventing lip-reading, service changes and widespread move to remote (telephone) services (Healthwatch report, opens in new tab). This will impact on access to COVID vaccination programme non-COVID services.
• Human rights of disabled people living in care homes in relation to visitors: we will need to address this in our regulation.
• COVID 19 vaccination centres regulated by CQC need to meet regulatory requirements around accessibility for disabled people, including accessible information about treatment in line with the NHS Accessible Information Standard.
• People working in health and social care are at risk of developing longer term mental health conditions, due to the impacts of providing care during the pandemic
• Disabled children in residential education may be at higher risk of poor care during the pandemic, due to a range of factors.

Mitigation:

• Actions as identified for age above.
• Consider further particular action that we could take on death rates for people with a learning disability, beyond those in the other points in this section.
• Consider further particular action we could take to help address inequalities for d/Deaf people arising from the pandemic, especially British Sign Language users, beyond those in the other points in this section.
• Incorporate accessibility of vaccination information into relevant assessment frameworks. Work with NHSE/I on expectations for accessibility of vaccination centres.
• Consider CQC contribution to ensuring that health and social care employers take action to support the mental health of their staff during the pandemic, to help prevent longer term mental health impacts. Consider mental health impacts on staff with specific equality characteristics e.g. Black and minority ethnic staff.
• Continue to work jointly with Ofsted to monitor and review Special Educational Needs and Disability services and jointly-registered children’s homes.

Impact:

• Ensure regulation continues to address protection of Black and minority ethnic staff working in health and social care (and other staff at high risk of COVID 19).
• Checking that COVID 19 vaccination centres regulated by CQC meet regulatory requirements around consideration of ethnicity as a protected characteristic, including providing interpreters and translated information when required.
• Consider CQC contribution to tackling COVID 19 vaccine hesitancy in Black and minority ethnic communities, including for staff working in health and social care settings.
• Ensure that providers carrying out COVID 19 vaccinations are aware of the rights of migrants to receive free vaccinations without immigration checks, in line with amendments to the NHS overseas charging regulations.
• Reduction in visits to care homes can have a particular impact on Black and minority ethnic people living in care homes, if they are more likely to rely on their visitors to have their cultural or language needs met.

Mitigation:

• Continue to check for protection of Black and minority ethnic staff in Transitional Monitoring Approach and escalate appropriately including taking regulatory action where required.
• Consider issues about protection of Black and minority ethnic staff as appropriate in Provider Collaboration reviews.
• Continue our joint work with GMC, NMC and other regulators on requests from providers/ people using services that might be discriminatory regarding protected characteristics of staff.
• Incorporate accessibility of vaccination information into relevant assessment frameworks. Work with NHSE/I on expectations for information in translation and access to interpreters at vaccination centres.
• Contribute to work to monitor the ethnicity of people taking up the COVID 19 vaccine, so that there is good information about where take up is low, to enable targeted action to increase take up. Share good information about vaccination in different languages and formats with providers and stakeholders.
• Give information to providers about migrants’ rights to vaccination. Work with NHSE/I to see how this can be ensured in vaccination centres.
• Publish web information for adult social care providers on culturally appropriate care during COVID 19.

Impact:

• See general comments across all equality strands – though it should be noted that women are likely to experience some of the other impacts more acutely, for example the impacts on carers and also on older people, due to women being over-represented in these groups.

Mitigation:

• See general comments across all equality strands and impact section.

Impact:

• Reduction in visits to care homes can have a particular impact on trans people living in care homes, if they are more likely to rely on their visitors for their social and community contact.
• Continued delays to non-COVID treatments may have an impact on trans people going through the trans care pathway – either specialised services or the generic elements of the trans care pathway, or mental health support services.

Mitigation:

• Include issues for trans people in web information for adult social care providers on culturally appropriate care during COVID 19.
• Continue to look at the management of waiting times in our regulation of specialised parts of the pathway, where these are in the provider’s control, to help minimise any unnecessary delays
• Publish new guidance for inspectors and providers on our expectations connected with the non-specialised elements of trans care pathway to help ensure that people have a smoother experience.

Impact: none

Mitigation: none

Impact:

• Maternity services have a high level of safety risks, for all women but especially for some women such as Black and minority ethnic women and women experiencing mental health issues. We need to be able to respond to safety risks in maternity services during COVID-19.

Mitigation:

• Continued development of maternity equity for Black and minority women as a strand within our maternity focused inspections. These will have a focus on how services are engaging with women from Black and minority ethnic backgrounds, women living in deprived areas and women with mental health needs.

Impact:

• Consider CQC contribution to tackling COVID 19 vaccine hesitancy by people in particular religious groups.
• Reduction in visits to care homes can have a particular impact on people in religious minority groups within the care home living in care homes, if they are more likely to rely on their visitors to have their spiritual needs met.

Mitigation:

• Consider CQC contribution to tackling COVID 19 vaccine hesitancy related to religion and belief
• Include issues around supporting people’s religious and spiritual needs in web information for adult social care providers on culturally appropriate care during COVID-19.

Impact:Reduction in visits to care homes can have a particular impact on lesbian, gay and bisexual people living in care homes, if they are more likely to rely on their visitors for their social and community contact

Mitigation: Include issues for lesbian, gay and bisexual people in web information for adult social care providers on culturally appropriate care during COVID-19.

Impact:

• We have incorporated the equality and health inequalities requirements of the NHS Phase 3 letter into our regulatory frameworks but these may be affected by the current wave of the pandemic.
• The current wave of the pandemic may increase the delay in meeting demands for non-COVID services – and there may be inequalities in this.
• The “designated adult social care settings” for discharge of people from hospital are inevitably limited in each area and therefore may not be able to provide safe care for some people with particular equality characteristics, for example people with specific impairments.
• There are various equality dimensions to infection prevention and control in adult social care settings for both the provider’s workforce and people who use services - including PPE adaptations / reasonable adjustments, shielding, risk assessments.
• We are redeploying some staff to undertake infection prevention and control assessments in adult social care, we need to be alert to CQC colleagues who may be in higher risk groups for contracting COVID-19 during this process and staff who have clinically vulnerable family members and / or primary carer role.
• Registration has been running a COVID-19 priority registration process for some time and this will continue.
• We will continue with Mental Health Act monitoring activities to ensure the rights of people are protected and need to ensure that we continue to develop checking these rights for people with different equality characteristics.
• We are committed to continuing to respond to information from the public and whistle-blowers reporting significant risk of harm in all sectors and will need to consider equality dimensions of harm in order to assess risk.
• We continue to be concerned about the impact of reduced care home visits and blanket bans on rights of people living in care homes and the risk to people’s human rights from closed cultures.
• During this period, we will continue to undertake focused inspection activity of hospital emergency departments where our monitoring of data and local intelligence indicates that increased pressure is directly impacting on the quality and safety of care and our Infection Prevention and Control inspections where we have concerns about infection control and Trust oversight of infection risk. We will need to consider equality dimensions of harm in order to assess risk. There are challenges because some safety information that we use does not include equality monitoring information such as ethnicity and disability.
• During the current emergency it is important that we work with the system to focus on action to address the risks our regulatory work highlights. We sometimes pick up equality issues that are beyond the remit of individual providers to resolve. We share information with others in the system to highlight where we are picking up such issues and also share information about emerging risks we are seeing through our regulation. This has enabled NHSE to deliver regional or national help.
• Through our independent voice, we have opportunities to use our unique data and regulatory information to inform national and local policy and practice around ensuring equality, reducing inequalities and protecting human rights as we learn about different stages of the pandemic response in health and social care.
• The pandemic continues to change and the system changes in response. We need to continue to develop our response to equality and human rights risks and issues in an iterative way.

Mitigation/opportunity:

• Discuss with NHSE the status of actions relating to inequalities in the Phase 3 letter
• Consider how we can use our independent voice to ensure that start-up of non-COVID services reduces, rather than increases, inequalities.
  • Consider how we can look whether the start-up of non-COVID services is reducing inequalities in our future Provider Collaboration reviews and provider level assessments.
  • Consider other specific action we could take on particular inequalities arising from the pandemic e.g. for d/Deaf people, especially BSL users which are not already covered in points above.
• Check designated settings assessment frameworks to see that they cover skill mix / environment to meet needs of different people based on equality characteristics and their approach to admissions if they cannot meet a specific need. Also, to continue to support managers in these settings if they do not accept an admission because they are not able to meet that person’s needs.
• Check Infection Prevention and Control assessment frameworks for coverage of equality dimensions of risk assessments for the workforce and people using the service, PPE adaptations/ reasonable adjustments and shielding.
• Check risk assessments for redeployed CQC staff carrying out Infection Prevention and Control inspections in Adult Social Care.
• Check that there are no unintended consequences of the COVID-19 priority registration process on equality for either providers or people using services.
• Continue our work on Advanced Mental Health Equality including testing new tools to help Mental Health Act Reviewers check whether Black and minority ethnic people detained under the Mental Health Act are experiencing any inequality.
• In our response to information from the public and whistle-blowers reporting significant risk of harm in all sectors, in order to ensure we consider equality implications.
  • Continue our work to develop how risk decisions are informed by the experience of people who use services
  • Continued development work in our National Customer Contact Centre on recording equality characteristics
  • Further staff development around risk prioritisation and equality characteristics.
  • Look at how we discharge our public sector equality duty in operational decisions about responding to risk of harm
• Continue our work on issues arising from reduced visiting to support the human rights of people living in care homes closed cultures.
• We will review our Patient First assessment framework and Infection Prevention and Control assessment framework for coverage of equality dimensions of risk.
  • Continue our work on improving our use of equality data in data sets where it is currently available.
• Check process for information sharing at regional co-ordination and escalation meetings for appropriate identification of equality and human rights issues.
• Independent voice actions:
  • Review scope and messaging of equality findings from our national data now that we have completed our initial actions on reporting the data we hold on equality
  • Continue to use our Provider Collaboration Reviews to explore how local areas respond to equality and health inequalities during the pandemic, both in relation to the main topic of the review, for example people with a learning disability and for all reviews with a specific focus on the inequalities faced by Black and minority ethnic people
• Continue to use our independent voice to:
  • support providers to respond well to equality and human rights issues during the pandemic
  • inform the public and other stakeholders about equality and human rights issues related to care quality during the pandemic
  • highlight key equality, human rights and health inequalities issues to policy-makers as we continue to learn from the progress of the pandemic
• Ongoing evaluation and review
  • Ensure equality and human rights are considering in ongoing evaluation of our response to COVID-19 and that any findings of that evaluation about equality and human rights performance are acted upon
  • Carry out an assessment of equality and human rights content if there are new releases of the Transitional Monitoring tool.

Human Rights duties compliance:

• We are inspecting a small number of previously poorly performing adult social care providers to assess if they have improved enough to enable local authorities to purchase additional services and increase capacity and will need to consider any previous breaches relating to equality or human rights.
• Our Mental Health Act monitoring role is vital in delivering our responsibilities as part of the National Preventive Mechanism (NPM) which focuses attention on practices in detention that could amount to ill-treatment. As there is less outside scrutiny during COVID 19 our NPM role is vitally important during this time.
• We are committed to continuing to respond to information from the public and whistle-blowers reporting significant risk of harm in all sectors.

Mitigation:

• In relation to the assessments of previously poor performing services to see if they have improved:
• Ensure development of approach gives sufficient assurance around previous human rights breaches and skill mix / environment to meet different needs relating to equality characteristics
• Provide human rights advice into development of Quality of Life Tool
• We have modified our Mental Health Act Review methodology so that we can still hear from detained patients, despite COVID restrictions, and we are continuing visits.
• In our response to information from the public and whistle-blowers reporting significant risk of harm in all sectors, in order to ensure we consider human rights implications:
• Continue our work to develop how risk decisions are informed by the experience of people who use services
• Convene work to look at consistency of decisions about risks to human rights in response to information of concern
• Develop of Human Rights triggers in the development of the Quality of Life Tool that we will be using in some settings

Human Rights duties compliance: the forthcoming change from Deprivation of Liberty authorisations to Liberty Protection Safeguards (opens in new tab) combined with the pandemic has led to a reduction in DoLs applications at a time when there may be increasing deprivations of liberty, for example to maintain social distancing. We reported on this in July 2020.

Mitigation: See Freedom from humane or degrading treatment.

(includes autonomy issues in care and treatment)

Human Rights duties compliance: Some of the issues described above, for example the rights of people in care homes to see their visitors engage Article 8.

Mitigation: Continue to check Article 8 rights through the Transitional Monitoring approach, amend if necessary, as national policy changes

Human Rights duties compliance: Many of the issues about differential access to care or differential death rates from COVID 19 could engage Article 2, depending on the outcome from differential access to care or causle of the differential death rates. For example, our work on DNACPR decision making and access to acute care for older and disabled people has highlighted Article 2 rights.

Mitigation:

• Continue to have a focus on differential death rates for equality groups in our regulation
• Continue to support providers and local systems through escalation of issues of concern and through using our independent voice to highlight what we are finding in regulation.

Review frameworks and tools for coverage of identified equality and human rights issues

Review the following frameworks/ tools for coverage of equality and human rights issues covered in this EIA and amend where possible:

1. Transitional Monitoring tool
2. Future Provider Collaboration Review frameworks
3. Hospitals vaccination centres assessment frameworks
4. Designated settings assessments
5. Infection Prevention and Control assessments (hospitals and adult social care)
6. Patient First emergency care assessments
7. COVID 19 priority registration decisions

Consider how re-inspection of previously low rated adult social care services will give assurance of compliance with equality and human rights requirements if required.

Consider how identified equality and human rights issues can be escalated from regional escalation meetings to enable meaningful analysis and action.

Action owner: Equality and human rights team.

Timescale: end Feb

Date completed:

Engage with NHSE on equality issues in vaccination programme, including how we can look at this in regulation and use our independent voice to improve vaccine take up.

1. Accessible information and communication in vaccination centres
2. Counteracting vaccine hesitancy in some communities
3. Rights of migrants to free vaccinations without immigration checks

Using CQC provider newsletters to support communication of key messages

Action owner: Deputy chief inspector for registration and regulatory assurance and Equality and human rights manager.

Timescale: end Feb

Date completed:

Engage with DHSC, consider policy work required around care home visits and human rights

Action owner: Deputy chief inspector

Timescale: end March.

Date completed:

Consider any further work required on equality for people with a learning disability during the pandemic

1. Work in closed cultures programme, including the Quality of Life Tool
2. Continuing work with LeDeR on death rates of people with a learning disability during the pandemic
3. Considering any other further work that we need to do to in response to unequal impacts of the pandemic on people with a learning disability

Action owner: Deputy chief inspector

Timescale: end March

Date completed:

Ensure that CQC regulatory staff are confident about how we are addressing equality and human right issues during this phase of the pandemic and that they have an opportunity to contribute to the development of this work

For example, via quarterly update calls with CQC directorate teams.

Action owner: Equality and human rights team

Timescale: January to March (ongoing work)

Date completed:

Use our independent voice to highlight equality and human rights issues found in our regulation, support the health and social care sector to respond well to these issues and engage with national policy making

1. Publish final report on our review of DNACPR decision making during the pandemic: Action owner: Chief inspector primary medical services and integrated care and Head of editorial and planning end March
2. Publish web information for adult social care providers on culturally appropriate care during COVID 19, To include issues around ethnicity, religion and belief and issues for lesbian, gay, bisexual and transgender people. Action owner: Equality and human rights manager by end Feb 2021
3. Continue the development of work on maternity equity within our maternity reviews, with a focus on the agreed national priorities for the care of Black and minority ethnic women, producing national information. Action Owner: Deputy chief inspector, hospitals by Summer 2021
4. Review use of our unique data that we hold on outcomes during the pandemic for different groups of people, for example notifications data and other data that we could use in our independent voice, for example State of Care, Action owner: National reporting manager, Equality and human rights manager by end March 2021
5. Continue to use our independent voice to raise equality and human rights issues in the pandemic at a national level to policy makers. Action owner: Chief Executive by: ongoing
6. Continue to use our information to inform people who use services and their representative organisations about equality and human rights issues in the pandemic. Action owner: Head of public engagement and involvement and Equality and human rights officer by: ongoing
7. Continue to use our information to support health and social care providers to respond well to equality and human rights issues in the pandemic. Action owner: Provider engagement and Equality and human rights officer, by: ongoing

Continue our joint work with GMC, NMC and other regulators including on requests from providers/ people using services that might be discriminatory regarding protected characteristics of staff. Action owner: Equality and human rights manager by: ongoing.

Continue to look at equality and health inequalities issues in local areas through future Provider Collaboration Reviews with a focus on tackling inequalities for Black and minority ethnic people.

See also: Provider collaboration reviews: equality impact assessment

Consider CQC contribution to ensuring that health and social care employers take action to support the mental health of their staff during the pandemic, to help prevent longer term mental health impacts. Consider mental health impacts on staff with specific equality characteristics e.g. Black and minority ethnic staff.

Action owner: Head of hospital inspection

Timescale: January to March (ongoing work)

Continue development of tools and support for Mental Health Act Reviews to look at experiences of Black and minority ethnic people in inpatient services

Action owner: Mental Health Act policy manager

Timescale: January to March (ongoing work)

Date completed:

Continue to develop how we respond to information of concern shared with us by members of the public or whistleblowers, also considering their equality characteristics

Action owner: Head of public engagement, Area analytics manager and Equality and human rights manager. 

Timescale: January to March (ongoing work)

Date completed:

Continue to review data that we hold on ethnicity to enable us to see where there are differential outcomes that could inform our work.

Action owner: Deputy chief inspector - registration and regulatory assurance, Area level analytics manager.

Timescale: January to March (ongoing work)

Date completed:

Continue joint work with the Equality and Human Rights Commission (EHRC) to respond to the pandemic, including policy work and communications, when this would make the best use of the respective regulatory remits and powers of CQC and the EHRC

Action owner: Equality and human rights manager

Timescale: ongoing, to end March

Date completed:

Continue monitoring and joint work with Ofsted, to ensure disabled children and young people in residential settings get good health and social care during the pandemic

1. Continue joint work with Ofsted on interim review visits to support local areas
2. Continue joint work with Ofsted to develop the new inspection framework for future SEND inspections, to include ways for children and young people with SEND, and their families, to give their views.
3. Continue monitoring of children’s homes which are jointly registered with CQC and Ofsted and carry out inspections where there is elevated risk.

Action owner: Head of children's health and justice

Timescale: January to March (ongoing work).

Date completed:

Consider how we can help ensure a narrowing of gaps in inequality through the start up of non COVID services.

1. Through liaison with NHS England over requirements for reducing inequalities in non COVID services
2. Through embedding these in our regulatory work at a provider and an area level
3. Through our independent voice work
4. Through publishing our information about the non-specialised parts of the trans care pathway
5. Through considering other specific action we could take on particular inequalities arising from the pandemic for d/Deaf people, especially BSL users which are not already covered in actions above.

Action owner: Equality and human rights manager

Timescale: ongoing

Continue to support staff appropriately during this period to respond to the pandemic.

1. Ensure that when we redeploy staff during this period, we carry out appropriate risk assessments (including consideration where staff have clinically vulnerable family members and / or primary carer role)
2. Encourage line managers to continue supportive conversations with staff and consider capacity of staff with caring/other responsibilities for inspection / work allocation in this period.
3. Consider ways to encourage vaccination take-up, especially among staff who may be at high risk or who might be hesitant to take the vaccine (support medicines team)
4. Continue to work with staff equality networks to support this work and monitor issues arising during this period.

Action owner: Diversity and inclusion manager

Timescale: end March.

Review findings on equality and human rights from our COVID 19 evaluation and take appropriate steps.

Action owner: Equality and human rights manager and Evaluation manager

Timescale: end March.