Coronavirus regulatory response: equality impact assessment

Specific equality issues by protected characteristics

Age

Impact

1. Older people in England are more likely to develop serious ill health and are more likely to have complex co-morbidities which place them at greater risk of complications if they contract COVID-19 sour ability to respond well to COVID19 will have a large impact on older people
2. A high number of older people use health and social care services so if COVID-19 has an adverse impact on our ability to regulate the quality of services, older people will be disproportionately affected
3. Providers need to consider mitigating the impact of 'social distancing' approaches tCOVID-19 on the human rights of older people, whilst still maintaining infection control in order to protect lives.
4. People over 70 are the most likely age group to be subject to a Deprivation of Liberty safeguard authorisation.
5. Older people living at home may experience the impact in relation to isolation, safety and wellbeing if home care agencies cannot deliver care due to staff shortages. Older people may also withdraw from home care because of fears of COVID-19
6. Older people living in care homes are at risk of not being able to access NHS inpatient services because some GPs and other doctors (including in hospitals) are carrying out blanket advance care plans and completing Do not attempt resuscitation forms which state that they should not transfer to acute care if they get COVID-19 (this may also be a risk for young people with long term conditions and other disabled people)
7. Older people in hospital may be at risk of not getting access to intensive care if they need it because of discriminatory decisions based on age alone, unrelated to the ability to respond to treatment
8. Older people with dementia in care homes may be subject to the use of chemical restraint to stop them walking around, as a social distancing measure when this is not the least restrictive approach available
9. Discharge of COVID-19 positive people and COVID negative older people from acute hospital into care homes may put the lives of other older residents at risk, if infection control cannot be managed
10. Potential for excess deaths due to stopping routine care for older people with long term conditions (also a specific risk for some people from Black and minority ethnic groups and disabled people)
11. A fall in the numbers of children and young people accessing front line health services, including GPs and acute or emergency care, has meant that these services are not seeing children who are at risk or who are already subject of safeguarding arrangements. This will lead to children at risk not being identified and remaining in unsafe situations without intervention.
12. Reduced visibility of children at risk or subject to safeguarding (including by health services) due to lockdown and increased risk of abuse for children not at school
13. Decreased referrals to children’s healthcare and Children and Adolescent Mental Health Services may cause surge in referrals after lockdown and also create difficulties in transition planning for young people
14. There may be risks to the wellbeing and care of children if their parents become unwell due COVID-19

Mitigation

See general comments below

Carers/people with caring responsibilities

Impact

1. Changes to the quality or availability of health and social care services during the COVID-19 outbreak are likely to have an impact on informal carers, sour response tthe preparedness of services to deal with increased numbers of people will have an impact on carers

Mitigation

See general comments below

Disability

Impact

1. Potential for excess deaths due to stopping routine care for disabled people with long term conditions.
2. Disabled people living in care homes and in the community are at risk of not being able to access NHS inpatient services because of some GPs and other doctors (including hospital doctors) carrying out blanket advance directives and do not attempt cardio-pulmonary resuscitation orders (DNACPR) which state that they should not transfer to acute care if they get COVID-19. This includes disabled people with a learning disability and autism, and others with long term conditions
3. Disabled people in hospital may be at risk of not getting access to ritical care if they need it and experience disability discrimination. National Institute for Health and Care Excellence (NICE) guidelines have been reviewed and improved but there are a number of other guidelines on access to critical care which may be confusing and hamper good clinical decisions and risk discrimination.
4. The higher numbers of deaths from COVID-19 of people living in deprived areas of England will have a disproportionate impact on disabled people who are more likely to live in these areas
5. There has been an increase in the numbers of death notifications of people detained under the Mental Health Act, who have died of confirmed or suspected COVID-19.
6. Discharge of COVID-19 positive people and COVID –19 negative disabled people from acute hospitals into care homes may put other disabled residents at risk where it is not possible for the care homes to manage the necessary infection control.
7. People with some long-term conditions (which would be classed as a disability under the Equality Act 2010) are more likely to develop serious ill health if they contract COVID-19, sour ability to respond well to COVID-19 will have a large impact on disabled people
8. A high number of disabled people use health and social care services so if COVID-19 has an adverse impact on our ability to regulate quality of services, disabled people will be disproportionately affected
9. Changes to the Care Act through coronavirus legislation, if implemented, may have a disproportionate impact on equality for disabled people, due to limiting entitlement to care and support
10. People with long term conditions may have their access to regular and specialist services and support reduced when resources (staff, facilities, specialist equipment and centres) are used to respond to COVID-19). There may also be impacts on medication supply chains.
11. COVID-19 may have an impact on hospital bed availability which may have an impact on hospital accommodation issues for people with long term conditions (eg. availability of suitable bed space)
12. Some disabled people, such as people with mental health conditions or a learning disability or autistic people are more likely to be in secure environments where

• If they contract COVID-19, they will not be able to access mainstream treatment services
• If many staff are away from work due to COVID-19, this could have a particular impact on people’s human rights if they are reliant on staff for basic needs, for example being cared for in segregation, so he human rights risk might increase at a time when we are less able to monitor this
• If CQC’s ability to undertake inspection visits is reduced, because they may be more at risk of (See general comments below) serious harm or human rights breaches unrelated to COVID -19
• These two points above are also relevant tour specific obligations relating to Mental Health Act monitoring and National Preventive Mechanism work including monitoring of Deprivation of Liberty safeguards in hospitals and care homes.
• People with a learning disability and autistic people are more at risk of being admitted and unable to be discharged from inpatient units due to the lack of social care support in the community, likely to get worse during COVID -19 pandemic.

13. Some disabled people, such as people with advanced dementia might face difficulties using health care for people with COVID -19. This group might be more likely to be cared for in other regulated settings (e.g. nursing homes) with less access to specialist equipment or staff
14. Some disabled people receiving domiciliary care may be impacted by staff shortages due to COVID -19 and experience risks to their human rights.
15. Some disabled people with information and communication needs may receive poorer quality information about COVID - 19 when staff are working under pressure and where information is being produced quickly.
16. Providers need to consider whether 'social distancing' approaches to COVID -19 might have an impact on human rights of disabled people and people with long term conditions, eg. blanket bans on care home or hospital visitors beyond government guidance. Decision making about social distancing and self-isolation might have particular implications for disabled people restricted or deprived of their liberty through the Mental Capacity Act and Deprivation of Liberty Safeguards (engaging article 5 rights to Liberty under the European Convention of Human Rights )
17. Social distancing policies of providers might have a higher impact for disabled people people from Black and minority ethnic groups who have experienced discrimination and this may reinforce a sense of stigma
18. Changes to the Care Act through coronavirus legislation, if implemented, may have a disproportionate impact on equality for disabled people, due to limiting entitlement to care and support
19. People with a learning disability may be subject to the use of chemical restraint (as needed medications are also known as 'pro re nata' or PRN medications) to address increased distress due to social distancing measures, when this is not the least restrictive practice
20. Asymptomatic people being admitted to Mental Health Inpatient wards may be a low priority for COVID -19 testing but there are high transmission risks for other patients and staff
21. Lack of clarity over the duty to make reasonable adjustments for disabled people may lead to some health services to fail to provide British Sign Language (BSL) interpretation services for deaf people when needed
22. Providing General Practice (GP) appointments online may have accessibility issues for disabled people with information and communication needs and people who are digitally excluded may not be able to access an online GP appointment
23. Social distancing may lead to an increase in mental health issues and, for example, an increase in young people going tA&E with mental health concerns and an increase in suicides.
24. Some of our methods to gather the experience of care from people during this time when we are not carrying out inspections may not be accessible for some disabled people. There is a particular difficulty where we would normally observe care to assess people’s experience, where people are non-verbal, for example, people with advanced dementia or some people with a learning disability.
25. People with severe mental health conditions may not receive support that meets their needs as mental health service move to more digital and telephone consultations
26. Insufficient social distancing because of shared bathrooms in mental health inpatient units may put people at increased risk of infection from COVID-19

Mitigation

See general comments below

Race/Ethnicity

Impact

1. Disproportionate numbers of people from Black and minority ethnic groups are dying from COVID-19 and also there are also disproportionate numbers of people from Black and minority ethnic groups in intensive care with severe effects of COVID-19. Reasons for this are currently unknown. People from Black and minority ethnic groups may be more likely to have health conditions associated with a worse outcome from COVID-19 (such as diabetes) or be in occupations where social distancing is harder to maintain. There may also be factors connected with access to healthcare.
2. There have also been a disproportionate number of deaths of staff from Black and minority ethnic groups who have been delivering health and social care. Some of these staff have said that, because of discrimination, they are fearful of asking for adequate personal protective equipment (PPE).
3. The higher numbers of deaths from COVID-19 of people living in deprived areas of England will have a disproportionate impact on people from Black and minority ethnic groups who are more likely to live in these areas
4. Potential for excess deaths due to stopping preventative or routine care for long term conditions during the pandemic, some of these conditions are more prevalent in Black and minority ethnic communities.
5. People who speak English as a second language may have less access to information about COVID-19 and therefore may be at a higher risk
6. ‘Social distancing’ policies of providers might have a greater impact for older or disabled people from Black and minority ethnic groups who rely on family for advocacy/ social contact in care settings
7. Social distancing policies of providers might have a higher impact for older or disabled people from Black and minority ethnic groups who have experienced discrimination and this may reinforce a sense of stigma
8. People in immigration detention centres are in secure environments where a. If they contract COVID-19, they will not be able to access mainstream treatment services b. If more severe restrictions are applied in order to maintain social distancing, this may have an impact on their mental health. If CQC’s ability to undertake inspection visits is reduced, they may be more at risk of serious harm or human rights breaches
9. People who experience barriers to accessing health services e.g. homeless people, asylum seekers, refused asylum seekers and undocumented migrants may need special consideration for information about COVID-19 and access to care. Regulations came into force on 29 January to add coronavirus (COVID-19) to Schedule 1 of the NHS (Charges to Overseas Visitors) Regulations. It is very important, for public health protection, that overseas visitors and other migrants are not deterred from seeking treatment for COVID-19.
10. The emergency nature of the pandemic in the NHS, exacerbated by many staff moving roles could have an impact on work to ensure race equality in the NHS (this would also apply to work on other equality issues for the workforce)
11. The prior complete ban on hospital visiting, especially for people at the end of their life, has had different impacts on different faith groups. This may have had an impact on the decisions of families to contact the NHS about health concerns for their loved ones, particularly for older relatives and particularly where their relative did not speak English.
12. Concerns about racism and distrust of health services among people from Black and minority ethnic communities may lead to people avoiding going to hospital, for fear that their needs wouldn’t be considered a priority
13. There may be limited access to healthcare during COVID19 for victims of modern slavery and human trafficking. Modern slavery may increase, due to the economic impacts of COVID-19.

Mitigation

See general comments below

Gender

Impact

1. Women make up the majority of the frontline health and social care workforce, so may be disproportionately likely to contract COVID19
2. Women are more likely to be informal carers for older or disabled people, who are more likely to have serious illness as a result of COVID-19
3. Significant increases in domestic violence during lockdown disproportionately impacts women and will increase their need to access health services, domestic and sexual assault referral centres. This may result in increased safeguarding referrals.
4. Access to reproductive health services and medications such as hormone replacement therapy (HRT) for women may be limited during the lockdown
5. In some places, there is a particular shortage of PPE which is suitable for women health and social care staff (such as smaller face masks), putting them at a higher risk of contracting COVID-19
6. Men are more likely to experience severe COVID-19 symptoms and are disproportionately represented in deaths from COVID-19

Mitigation

See general comments below

Gender reassignment

Impact

1. ‘Social distancing’ policies of providers might have a higher impact for trans older people who rely on their external contacts for advocacy/ social contact in care settings
2. COVID-19 may have an impact on hospital bed availability which may have an impact on hospital accommodation issues for trans people (eg availability of suitable bed space)
3. Social distancing policies of providers might have a higher impact for trans older people who have experienced discrimination and this may reinforce a sense of stigma
4. Social distancing, pressure on and cancellations of medical services, and logistics affecting the availability of medicines may limit trans people’s access to regular appointments, surgery and medicines they need as part of their transition. This includes closure or reduced services offered by Gender Identity Clinics, which already have long waiting lists
5. Trans people are disproportionately more likely to have poor mental health and social distancing may have disproportionate impacts on them
6. Where trans people need to “socially distance” with families who may be unsupportive of their trans identity, this could have an impact on their mental health and put them at risk of transphobic abuse and violence

Mitigation

See general comments below

Marriage and civil partnership

Impact

No differential impact

Mitigation

See general comments below

Pregnancy and maternity

Impact

1. Pregnant women are included in the list of ‘high risk’ groups.
2. Extreme pressure on health services or staff shortages may have an impact on the continuum of maternity and post-natal services
3. Social distancing for pregnant women might have an impact on their ability to manage their own healthcare, including mental health

Mitigation

See general comments below

Religion and belief

Impact

1. 'Social distancing' policies might have different impacts e.g. in terms of end of life care for people in different religious groups, for example, where it is more important in some religions that the person sees either their family or a religious or spiritual leader or official when they are nearing death.
2. Eventual vaccines for COVID-19 might not comply with requirements of some religions
3. The complete ban on hospital visiting, especially for people at the end of their life, has had different impacts on different faith groups. This may have had an impact on the decisions of families to contact the NHS about health concerns for their loved ones, particularly for older relatives and particularly where their relative did not speak English.

Mitigation

See general comments below

Sexual orientation

Impact

1. 'Social distancing’ policies of providers might have a greater impact for lesbian, gay or bisexual older people who rely on their external social networks for advocacy/ social contact in care settings
2. Social distancing policies of providers might have a higher impact for lesbian, gay or bisexual older people who have experienced discrimination and this may reinforce a sense of stigma
3. Lesbian, gay or bisexual people are disproportionately more likely to have poor mental health and social distancing may have disproportionate impacts on them
4. Because of social distancing, some lesbian, gay or bisexual people, especially young people, may be confined in family situations where they are at risk of homophobia, homophobic abuse and violence which could have an impact on their mental health
5. Some gay men’s organisations are concerned that diversion of anti-retroviral drugs to treat people with COVID-19 or disruption to the supply chain for these drugs might impact on people with human immunodeficiency virus (HIV)
6. Some lesbian, gay or bisexual people may be at risk of discrimination if hospitals do not recognise their relationships, especially when their partner is severely ill

Mitigation

See general comments below

General comments across all equality strands

Equality impacts for people who use services can be summarised as follows, with mitigations:

Impact 1: Older people and disabled people may have their access to care and treatment for COVID-19 blocked or limited:

• if unlawful blanket DNACPR orders are applied to them
• or they are unable to access NHS acute inpatient or intensive care admission because of decisions about access based on their age or disability that are irrelevant to their ability to benefit from treatment

Mitigation

Mitigation of potentially negative impact

• Make sure our methodology enables inspectors to identify if this is happening and take action to stop it; including enforcement action if necessary
• Raise awareness among providers that this is unlawful
• Work with other national organisations to amplify this message
• Where we have concerns that there is a high level of unlawful decision making in an area, use regional escalation protocols taddress this

Impact 2: The higher numbers of deaths from COVID-19 of people living in deprived areas of England will have a disproportionate impact on disabled people and people from Black and minority ethnic groups, who are more likely tlive in these areas.

Mitigation

Mitigation of potentially negative impact –

• Raise awareness through our public work
• Make sure our methodology enables our inspectors covering deprived areas to escalate issues of concern where they see them and alert providers
• Use Intelligence where possible to create better understanding about this issue and help inform our public work
• Carry out survey of people from Black or minority ethnic groups to gather their experiences of care, to help us inform our work and work with national partners

Impact 3: Disproportionate numbers of people from Black and minority ethnic groups dying of COVID-19 and also disproportionate numbers of Black and minority ethnic people in intensive care with severe effects of COVID-19.

Mitigation

Mitigation of potentially negative impact:

• Support and influence national work to identify causes and address this issue, including through using our intelligence where possible, and meeting regularly with key national partners
• Share good practice by providers in addressing the causes
• Carry out survey of people from Black or minority ethnic groups tgather their experiences of care, to help us inform our work and work with national partners
• Use our methodology, raise inspectors’ awareness of issues (at a provider level) and use regional escalation where needed

Impact 4: Disproportionate number of deaths of staff from Black or minority ethnic groups who have been delivering health and social care.

Mitigation

As above, Impact 3

Impact 5: There has been an increase in the numbers of death notifications of people detained under the Mental Health Act, who have died of confirmed or suspected COVID-19.

Mitigation

• Contact mental health providers to highlight concerns about COVID-19 related deaths of patients’ subject to the Mental Health Act
• Clarify expectations of providers on their management of coronavirus and asking some providers to urgently confirm the action they are taking to manage coronavirus outbreaks
• Continue to review data on these deaths to understand what factors might be driving this and if any additional action is required to safeguard people

Impact 6: There may be excess deaths and poorer health outcomes for people with long term conditions (especially older and people from Black or minority ethnic groups and disabled people) because routine services are stopped, reduced or impacted during the COVID-19 pandemic. This may also affect victims of modern slavery or human trafficking.

Mitigation

• Raise awareness through our public work of where services are still operating and available pandemic.
• Using our data and intelligence, work with other partners on considering health inequalities in the “restoration phase” of NHS services
• Carry out survey of people from Black or minority ethnic groups to gather their experiences of care, to help us inform our work and work with national partners

Impact 7: Reduced or no access to other services may also disproportionately impact women (eg. reproductive and maternal health, domestic violence services), trans people and children and young people (eg. safeguarding and mental health services)

Mitigation

As above, Impact 6

Impact 8: Older people and disabled people living in care homes may die from COVID-19 if people with COVID-19 (diagnosed or not) are discharged to care home which are unable to isolate residents.

Mitigation

• Raise this concern through policy work
• Inspectors provide support to individual care homes where they have concerns about their ability to manage infection control
• Escalate any concerns through regional escalation processes
• Our work on providing information about deaths in care homes will support national intelligence on this

Impact 9: Older people and disabled people are more likely to have a serious illness if they contract COVID-19 so any work we do on emergency preparedness for COVID-19 should have a positive impact

Mitigation

Our work on COVID-19 preparedness will have a greater positive impact on older and disabled people than others in the population, as older and disabled people are more likely tneed treatment for COVID-19.

Impact 10: Older people and disabled people are more likely to rely on health and social care services that we regulate. This means that carers are also reliant on these services.

Mitigation

Mitigation of potentially negative impact: any change to our methods should consider how we can help the health and social care system ensure essential care quality for older people and disabled people. This includes care quality impacts caused by COVID-19 such as staff shortages which might impact on specific types of services used by older or disabled people – such as domiciliary care agencies and supported living services. Our proposals to monitor adult social care services during COVID-19 will therefore have a positive impact.

Impact 11: Providers need to consider 'social distancing' approaches to COVID-19 which might have an impact on human rights of older people and disabled people, e.g. blanket bans on care home and hospital visitors ahead of government guidance.

Mitigation

Produce quick turnaround guidance for inspectors on maintaining human rights whilst following social distancing guidelines – updated as national situation changes.

Impact 12: Self-isolation policies and the following of government advice might have a higher and more complex impact for people whose article 5 rights relate to the application of the Deprivation of Liberty Safeguards scheme in hospitals and care homes, and in more general approaches to best interest decision-making and capacity in adhering to the Mental Capacity Act.

Local authorities and Deprivation of Liberty Safeguards teams may experience stretch in required resources or redeployment reducing Deprivation of Liberty Safeguards management.

Mitigation

For self-isolation to manage infection spread, consider and agree the impact of Mental Capacity Act and Deprivation of Liberty Safeguards on any CQC guidance and liaise with stakeholders as appropriate.

Impact 13: In addition, particular groups, such as lesbian, gay, bisexual and transgender people, people from Black or minority ethnic groups, disabled and older people, people with mental health conditions and people in secure environments may be disproportionately affected by social isolation.

Article 8 (Human Rights Act) is a qualified right and any interference needs to be proportionate: is it lawful, for a legitimate reason, is it proportionate, with the least restrictive option put in place and alternatives made available so people can keep in touch with families and friends.

Mitigation

Mitigation of potentially negative impact - include issues for equality groups in guidance and communications for inspectors and providers– based on providers assessing how treduce social isolation for each person through care planning.

Impact 14: Changes to the Care Act through coronavirus legislation, if implemented, may have a disproportionate impact on equality for disabled people, due to limiting entitlement to care and support

Mitigation

CQC will engage with Department for Health & Social Care (DHSC), Local Authorities and local government stakeholders (eg. Local Government Association (LGA), Association of Directors of Adult Social Services (ADASS)) to understand and help mitigate changes under The Care Act.

We will gather and share information on Care Act Easements with providers, including information on impacts from organisations that represent people who use health and social care services.

Impact 15: For people receiving care in secure environments – including in mental health hospitals, prisons and immigration detention centres might:

• Have less access to specialist health services if they contract COVID-19.
• Be more likely to have their human rights breached if many staff contract COVID-19.
• Be at greater risk of human rights breaches unrelated to COVID-19 if CQC are not able to carry out inspection visits

More people might be moved into secure environments during the COVID-19 outbreak, for example children and young people on 52-week placements in residential special schools which are closing. Their human rights might be particularly at risk due to the urgent nature of their move and the disruption to their lives which might cause them distress which results in restrictive practice such as restraint

Mitigation

Mitigation of negative impact on equality and human rights if we cannot carry out inspection visits in secure environments.

• Consider how we use our Mental Health Act, Mental Capacity Act and Deprivation of Liberty Safeguards duties to upport providers to ensure people’s human rights are upheld during this period – focus on monitoring information/notifications/relationship management
• Consider equality and human rights in our interim methodology, with a focus on secure environments and other services with a high inherent risk of a closed cultures, as defined in our supporting information on closed cultures

Impact 16: In some circumstances, it may be preferable to care for people with COVID-19 outside hospital because of their particular equality characteristics, such as people with advanced dementia in nursing homes.

There might be issues about equitable access thigh quality clinical care for COVID-19 in these circumstances.

Mitigation

Could be positive or negative impact – work with National Health Service England (NHSE) to identify where guidance suggests that people will not be cared for on a “standard COVID-19 care pathway” to build monitoring of this into our intermediate methodology.

Address any discrimination in access to acute care, such as blanket decisions for people living in care homes.

Impact 17: A fast track registration approach is being developed to assist with extra capacity that might be required to respond to COVID-19. There may be a need to consider equality and human rights implications of this process and how these can be mitigated.

Mitigation

This will have a positive impact on older and disabled people, who are more likely to need care services during the COVID-19 outbreak but there could be individual negative impacts if the fast track registration does not identify equality or human rights concerns with services registered this way – assess fast track registration methodology for equality and human rights impacts

Impact 18: People who use health and social care services who have information and communication needs because of a disability or sensory impairment, or because English is their second language, may need targeted communications.

This includes people who experience barriers to accessing health services eg. homeless people, asylum seekers, refused asylum seekers and undocumented migrants, who may need specific consideration

Mitigation

Mitigation of potentially negative impact: Consider how we can support the health and social care system to give people accessible information about COVID-19 through research into and promotion of work in this area carried out by others.

Impact 19: As the NHS moves into the 'restoration phase' there is a need to address health inequalities that might have arisen as a result of closure of some preventative services and an opportunity to address more longstanding health inequalities, for example by looking at immunisation, screening services and community mental health services.

Mitigation

Mitigation of potentially negative impact

• Build consideration of health inequalities into our regulatory approach to services reinstated in the 'restoration phase'
• Engage with other system partners around the opportunities to address health inequalities in the restoration phase

Impact 20: Older people with dementia and people with a learning disability or autistic people living in care homes may be subject to the inappropriate use of chemical restraint to stop them walking around, as a social distancing measure when this is not the least restrictive approach available.

Mitigation

Mitigation of potentially negative impact:

• Make sure our methodology enables inspectors to identify if this is happening and support providers to change it
• Produce guidance and promote guidance from others regarding use of the Mental Capacity Act

Impact 21: People with a learning disability and autistic people are more at risk of being admitted and unable to be discharged from inpatient units due to the lack of social care support in the community, likely to get worse during COVID-19 pandemic

Mitigation

Mitigation of potentially negative impact

• Make sure our methodology enables inspectors and Mental Health Act reviewers to identify where this is happening.
• Escalate any specific concerns about discharge of people being cared for in segregation through the Independent Care, (Education) and Treatment Review (ICETR) process

Use our national independent voice to advocate for change if necessary

Impact 22: Disabled people with information and communication needs may not be getting the reasonable adjustments they need to access health services eg. BSL interpreters for deaf people in hospitals or at GPs or if needing access to online appointments and access to written information in formats that people need

Mitigation

• Make sure our methodology enables inspectors to identify where this is happening and to support providers to improve or take other action.
• Use our national communications to share good practice and ensure that providers are aware of their Equality Act 2010 duties to disabled people and the Accessible Information Standard

Impact 23: Concerns and distrust prevent people from Black or minority ethnic groups accessing healthcare when they need it, including for COVID-19.

Their relatives may also avoid contacting health services when needed for themselves or family, because of concerns, for example that they will not be able to visit their relative at the end of their life, especially if English is not their first language.

Mitigation

• Use our national communications to support people from Black or minority ethnic groups to access services for themselves and their relatives
• If we find that the practices of individual providers are creating access barriers for people from Black or minority ethnic groups, address this through our regulatory work, escalating as necessary
• Carry out survey of people from Black or minority ethnic groups to gather their experiences of care, to help us inform our work and work with national partners

Impact 24: Women, as the majority of the health and care workforce, and carers, are disproportionately at risk of contracting COVID-19.

This risk may be exacerbated because of poorly fitting PPE eg. masks, which are designed to fit men.

Mitigation

• Support and influence national work to address these issues, where we have the opportunity

Impact 25: Women, children and lesbian, gay, bisexual and transgender people may be at greater risk of emotional and physical abuse and violence during lockdown

• Ensure that our safeguarding alerts pick up and channel concerns when we receive them (eg. via National Customer Service Centre (NCSC), Give feedback on care)
• Identify and address through the work of the Children and Justice team

Impact 26: Closures and reductions in access to services of Gender Identity Clinics will affect the care and support for people transitioning their gender

Mitigation

• Use our influence with partners in the health and care system to address this

Impact 27: Changes tour methodology may impact on our ability to monitor how providers ensure that clinicians make ethical decisions that impact on human rights, including the right to life, when resources to address COVID-19 healthcare needs become limited

Mitigation

• Consider how we monitor how providers ensure that clinicians make ethical decisions that impact on human rights, including the right to life, when resources to address COVID-19 healthcare needs become limited
• Address COVID-19 healthcare needs become limited, as it relates to regulation 12 and 17
• Use provider engagement methods and work with system partners to flag good practice and expectations around equality issues in clinical decision-making

Impact 28: Where we change our methodology, moving to a risk-based approach and are not carrying out routine inspections, it will be harder for us to gather the views of people using services and their families and friends.

These views are a very important evidence source about whether people’s human rights and rights to equality are upheld. Additionally, there may be new equality and human rights issues arising in the way that providers respond to COVID-19, that we will only understand if we can obtain the views of these people. In addition, physical mail services into our Newcastle Customer contact centre may be interrupted, which may affect our response to people who are digitally excluded. (We have listed mitigation under public engagement mitigations)

Mitigation

CQC public engagement mitigations:

Under the Health and Social Care Act, we have a statutory duty to listen to the views of people who use services about their experiences and local groups such as Local Healthwatch, We will

• increase promotional activity of Give Feedback On Care, including piloting digital marketing in an area, encourage support by representative communities
• urge public stakeholders to promote Give Feedback On Care via their communication channels and request providers to promote Give Feedback On Care using their communication channels.
• explore new channels for promoting Give Feedback On Care and encouraging and enabling people to give their feedback
• explore ways that Experts by Experience could support interim methodology and ways of speeding up piloting of Services B in the new Expert by Experience contracts – these are services which gather feedback on care from seldom heard communities/vulnerable groups.

Organisational mitigations:

• Improve our ability to analyse large volumes of feedback from people and to provide this to inspectors to inform their decision making
• At a local/regional level, we will consider the feasibility of increasing our engagement by inspectors of representatives of communities, particularly those who are digitally excluded, in line with Engagement directorate guidance, for example increasing telephone contact or online connecting with Local Healthwatch and voluntary sector organisations representing specific groups. This will need to be done in a way which does not risk safety and welfare of CQC staff or the people that they are engaging with
• Explore new channels to better capture the views of people who are digitally excluded.

Freedom from inhumane or degrading treatment

Human rights duties compliance

Could be potential negative impact if human rights is not adequately considered in:

• development of methodology during COVID-19
• Engagement with people who use services and their families and advocates during COVID 19

Mitigation / opportunity

• Consider equality and human rights in our interim methodology, with a focus on secure environments or places of state detention and other services with a high inherent risk of a closed culture, as defined in our supporting information on closed cultures
• Consider human rights in decisions to carry out inspection activity because of risk of harm.

Right to liberty

Human rights duties compliance

As above. Article 5 rights relevant to the application of Mental Capacity Act, Deprivation of Liberty Safeguards may be more complex to monitor.

Mitigation / opportunity

Consider duties under National Preventive Mechanism membership and liaise/pool response with other members.

Right to respect for family and private life, home and correspondence (includes autonomy issues in care and treatment)

Human rights duties compliance

As above, plus attention to how providers consider whether 'social distancing' approaches to COVID-19 might have an avoidable impact on human rights, through taking a less restrictive approach as described above.

Article 8 is a qualified right, which means it can be ‘interfered with’ by a Public Authority in certain circumstances including public safety, protection of health or morals, or for the protection of rights and freedoms of others. Any interference must be proportionate.

Health and social care services may need to restrict access to family and friends in order to protect right to life. However, providers need to consider how they can limit visitors whilst fulfilling Article 8 rights, for example by considering alternative ways that each person can maintain contact with their family and friends if possible.

Mitigation / opportunity

1. Produce quick turnaround guidance for inspectors on maintaining human rights whilst following social distancing guidelines – updated as national situation changes
2. Use our national communications to support people from Black or minority ethnic groups to access services for themselves and their relatives
3. If we find that the practices of individual providers are creating barriers for access to people from Black or minority ethnic groups, address this through our regulatory work, escalating as necessary
4. Carry out survey of people from Black or minority ethnic groups to gather their experiences of care, to help us inform our work and work with national partners
5. make sure our methodology enables inspectors to identify where this is happening and to support providers to improve or take other action.
6. Use our national communications to share good practice and ensure that providers are aware of their Equality Act 2010 duties to disabled people and the Accessible Information Standard

Other rights, e.g. right to life, right not to be discriminated against in connection with other rights

Human rights duties compliance

As above.

Mitigation / opportunity

As above.

Action 1 – Produce quick turnaround guidance on maintaining human rights whilst following social distancing/self-isolation guidelines – updated as national situation changes

Include issues for equality groups in guidance – based on providers assessing how to reduce social isolation for each person through care planning

Include Mental Health Act and Mental Capacity Act/Deprivation of Liberty Safeguards issues.

Action Owner

Equality and Hunan Rights team/ Mental Health Policy Team

Action Timescale

Initially 27 March and ongoing

Date Completed / Progress

Internal guidance for CQC staff produced on Mental Capacity Act issues. Visiting Guidance Frequently Asked Questions (FAQ) being revised.

Action 2 – Assess fast track registration methodology for equality and human rights impacts.

Action Owner

Equality and Human Rights Team/ Registration

Action Timescale

Initially by 27 March

Date Completed / Progress

Completed.

Action 3 – Determine responsibility and work needed for regulatory activity to check COVID-19 response in secure environments, including mental health environments

Action Owner

Equality and Human Rights team/ Mental Health Policy

Action Timescale

Initially by 6 April

Date Completed / Progress

Completed.

Action 4 – Consider regulatory activity to check COVID-19 response in prison and immigration secure environments – and children’s work with Ofsted

Action Owner

Head of Children’s Health and Justice

Action Timescale

Ongoing

Date Completed / Progress

Actions underway including:

Tools for inspection

Risk sharing and escalation protocols for particular services

Risk escalation of national issues

Action 5 – Establish DHSC position on care and treatment for people that need to pay for NHSE treatment (such as people from overseas) and ensure this is communicated to providers

Action Owner

Equality and Human Rights Manager and Senior Officer

Action Timescale

Ongoing

Date Completed / Progress

COVID-19 treatment exempt, no other changes. Shared information on need to ensure providers are following correct assessment of charging with NHS trusts and at NHS Equality and Diversity Council (EDC).

Action 6 – Develop approach to Mental Health Act monitoring and National Preventive Mechanism activity including Mental Capacity Act, Deprivation of Liberty Safeguards and closed cultures

Action Owner

Mental Health Policy team

Action Timescale

Initially by 27 March 2020

Date Completed / Progress

Development completed and now in use by Mental Health Act reviewers.

Action 7 – Consider equality and human rights in our intermediate/interim methodology,

With a particular focus on:

Action Owner

Equality and Human Rights Manager and Senior Officer, Closed Cultures Policy Manager

Action Timescale

Initially by 27 March 2020

Date Completed / Progress

23rd April completed for first draft of Emergency Support Framework. Under review for future versions. Easy read version of Emergency Support framework published 14th May.

1. secure environments, those where people may be deprived of their liberty, and other services with a high inherent risk of a closed culture, as defined in our supporting information on closed cultures
2. how providers ensure that clinicians make ethical decisions that impact on human rights, including the right to life, when resources to address COVID-19 healthcare needs become limited, as it relates to regulation 12 and 17.
3. Specific safety issues for people that might be excluded from access to healthcare such as migrants and homeless people

Action 8 – Consider how CQC can monitor care quality to support providers and the care system to respond appropriately to Care Act easements in their care for older people maintain essential care quality and disabled people in our interim methodology.

This includes care quality impacts caused by COVID-19 such as staff shortages which might impact on specific types of services used by older or disabled people – such as domiciliary care agencies and supported living services.

Action Owner

Head of Adult Social Care Policy

Action Timescale

Initially by 27 March 2020

Date Completed / Progress

CQC has published a regularly updated list of councils in England which are operating easements under the Coronavirus Act to inform the public. The Care Act and the ‘easements’ to it.

CQC in regular contact with local authorities to understand impact of easements and with ADASS, LGA, and advocacy organisations to understand issues and gather their views.

Action 9 – Work to identify where people are not being cared for on a 'standard COVID-19 care pathway' to build monitoring of this into our interim methodology, for example where a decision is made not to transfer to acute care (see also action 25)

With regard to unlawful blanket Do Not Attempt Cardio-Pulmonary resuscitation (DNACPR) orders being applied:

• make sure our methodology enables inspectors to identify if this is happening and take action to stop it; including enforcement action if necessary
• raise awareness among providers that this is unlawful
• work with other national organisations to amplify this message
• where we have concerns that there is a high level of unlawful decision making in an area, use regional escalation protocols to address this.

Action Owner

Deputy Chief Inspector, Adult Social Care

Action Timescale

Initially by 27 March 2020 and ongoing.

Date Completed / Progress

23rd April completed for first draft of Emergency Support Framework. Under review for future versions.

Communications with providers to ensure non-discrimination in treatment decisions including:

• Chief Inspector letter to Primary Care providers on ensuring individual decisions in advance care planning.
• Joint statement on advance care planning used in Emergency Support Framework to guide inspectors
• Access to hospital care and treatment for older and disabled people during the pandemic

Action 10 – Promote accessible information and communication on COVID-19 to providers, via engagement channels

Action Owner

Equality and human rights team

Action Timescale

Ongoing

Date Completed / Progress

In provider newsletter on weekly basis. Easy read version of Emergency Support framework published 14th May.

Action 11 – Increase promotional activity of Give Feedback On Care, including piloting digital marketing in an area, encourage support by representative communities

Action Owner

Head of Public Engagement

Action Timescale

Start in Q1 2020

Date Completed / Progress

Give Feedback on your Care plan approved by Regulatory Oversight Group. Workstreams have been established.

Action 12 – Urge public stakeholders to promote Give Feedback On your Care via their communication channels

Action Owner

Head of Public Engagement

Action Timescale

Start in Q1 2020

Date Completed / Progress

Give Feedback on your Care plan approved by Regulatory Oversight Group. Workstreams have been established.

Action 13 – Engage with providers to explore how providers could use their channels (email lists, text lists) to promote Give Feedback On Care

Action Owner

Provider engagement

Action Timescale

Q1 2020

Date Completed / Progress

Give Feedback on Care plan approved by Regulatory Oversight Group.

Action 14 – Explore ways that Experts by Experience could support new inspection methodology and ways of speeding up piloting of Services B in the new Expert by Experience contracts – these are services which gather feedback on care from seldom heard communities/vulnerable groups.

Action Owner

Jill Morell

Action Timescale

Ongoing

Date Completed / Progress

Relevant learning on equality and human rights is being factored in.

Action 15 – CQC ensures that our NCSC contact centre is able identify, refer on and escalate safeguarding risks, risks of inappropriate restraint and closed cultures, accessibility and access to services. Intelligence teams improve our ability to analyse large volumes of feedback from people.

Action Owner

Deputy Chief Inspector responsible for Closed Cultures programme, Director of Intelligence

Action Timescale

Ongoing. Give Feedback on Care plan approved by Regulatory Oversight Group. Workstreams have been established.

Date Completed / Progress

Care plan approved by Regulatory Oversight Group. Workstreams have been established.

Action 16 – At a local/regional level, CQC will consider how we might, within resources available increase our engagement by inspectors of representative of communities, particularly those who are digitally excluded, in line with Engagement directorate guidance, for example increasing telephone contact or connecting with voluntary sector organisations representing specific groups whilst maintaining health and welfare of CQC staff and others.

Action Owner

Deputy Chief Inspector (Hospitals) lead on equality and human rights

Action Timescale

Ongoing

Date Completed / Progress

Give Feedback on Care plan approved by Regulatory Oversight Group. Workstreams have been established.

Action 17 – CQC will explore new channels to better capture the views of people who are digitally excluded. We will redeploy resources to prioritise this, because people affected by COVID-19 are more likely to be older people and disabled people, who are more likely to be digitally excluded.

Action Owner

Head of Public Engagement

Action Timescale

Q1 2020

Date Completed / Progress

Give Feedback on Your Care plan approved by Regulatory Oversight Group. Workstreams have been established.

Action 18 – Consider equality and human rights implications in CQC strategic work on our response to COVID-19.

Action Owner

Head of Strategy

Action Timescale

To be confirmed 2020 (TBC) – linked to all workstreams

Date Completed / Progress

Linked tall workstreams

Action 19 – CQC will engage with government at a national policy level to assist with any mitigations to potential changes to Care Act responsibilities, such as the Ethical Framework that has been developed to support Local Authorities and Providers make difficult decisions about how to prioritise with a significantly reduced workforce.

Where we gather information on the impact on individuals through our regulatory work, we will use this to inform our engagement.

Action Owner

Chief Inspector of Adult Social Care

Action Timescale

Ongoing

Date Completed / Progress

Progressing via engagement internal and external workstream.

Action 20 – CQC to use our national influence and system partnerships to influence policy

On:

• ensuring that all people who need it are able to access care and treatment for COVID-19 and to protect people’s right to life and protect them from discrimination
• ensuring that all people who need it are able to access care and treatment for long term conditions and other health, care and support needs during the COVID-19 pandemic
• emerging equality and human rights issues and risks and action to address them
• identifying and addressing the causes of the disproportionate impact of the COVID-19 pandemic on people from Black and minority ethnic groups, especially the disproportionate numbers of deaths of patients and workforce and work to prevent this and address discrimination
• addressing the causes of the higher numbers of deaths from COVID-19 of people living in deprived areas of England which disproportionately impact on disabled people and people from Black and minority ethnic groups

Action Owner

Chief Executive

Action Timescale

Immediate and ongoing

Date Completed / Progress

New action. CQC meet regularly with national partners (eg. NHS organisations and Equality and Human Rights Commission) to discuss emerging issues and plan action.

Action 21 – CQC to engage with providers so they are aware of and act (including of expectations and good practice)

To:

• ensure that all people who need it are able to access care and treatment for COVID-19 and to protect people’s right to life and protect them from discrimination
• ensure that all people who need it are able to access care and treatment for long term conditions and other health, care and support needs during the COVID-19 pandemic
• address emerging equality and human rights issues
• recognise and address the disproportionate impact of the COVID-19 pandemic on people from Black and minority ethnic groups, especially thein relation to disproportionate numbers of deaths of patients and in the workforce, work to prevent this and address possible discrimination in their services
• recognise and address the increase in numbers of deaths from confirmed or suspected COVID-19 of people detained under the Mental Health Act
• mitigate the higher numbers of deaths from COVID-19 of people living in deprived areas of England which disproportionately impact on disabled people and people from Black and minority ethnic groups, particularly where providers are based in these areas.

Action Owner

Head of Provider Engagement, Deputy Chief Inspection of Hospitals (Mental Health) – bullet point 5

Action Timescale

Ongoing

Date Completed / Progress

Guidance for providers on Inappropriate use of sedative medicines to enforce social distancing

Chief Inspector letter to Primary Care providers on ensuring individual decisions in advance care planning

Joint statement on advance care planning

Weekly provider newsletters include links to guidance and accessible information for people using health and social care services

Letter to providers of mental health, learning disability and autism services to highlight concerns about coronavirus related deaths

Action 22 – CQC to engage with people who use services and their representatives, through the actions above to discover issues or to pick up intelligence about problems

Including:

• Using our national communications to support people from Black and minority ethnic groups people to access services for themselves and their relatives
• ensuring that all people who need it are able to access care and treatment for COVID-19 and to protect people’s right to life and protect them from discrimination
• ensuring that all people who need it are able to access care and treatment for long term conditions and other health, care and support needs during the COVID-19 pandemic
• on emerging equality and human rights issues and risks
• the disproportionate impact of the COVID-19 pandemic on people from Black and minority ethnic groups, especially in relation to the disproportionate numbers of deaths of patients and in the workforce, and possible risks and discrimination in services
• the higher numbers of deaths from COVID-19 of people living in deprived areas of England will have a disproportionate impact on disabled people (and people from Black and minority ethnic groups), who are more likely to live in these areas

Action Owner

Head of public engagement

Action Timescale

Q1 2020

Date Completed / Progress

Engagement to identify equality and human rights issues through surveys and engagement work with advocacy groups. Regular engagement insight information shared internally covers emerging equality and human rights issues. Surveys of people from Black and minority ethnic groups and of people with a learning disability and their families completed.

Action 23 – CQC to use methodology and raise inspectors’ awareness of issues (at a provider level) and use regional escalation:

• to ensure that all people who need it are able to access care and treatment for COVID-19 and to protect people’s right to life and protect them from discrimination
• to ensure that all people who need it are able to access care and treatment for long term conditions and other health, care and support needs during the COVID-19 pandemic
• to identify and act on safeguarding risks, risks of inappropriate restraint and closed cultures, accessibility and access to services
• on emerging equality and human rights issues and risks
• to recognise and address the disproportionate impact of the COVID-19 pandemic on people from Black and minority ethnic groups, especially in terms of the disproportionate numbers of deaths of patients and in the workforce, and on possible risks and discrimination in the services they regulate

Where we have evidence that the actions of specific providers are creating barriers for people from Black and minority ethnic groups in accessing services, enable our inspectors tact on this

Make sure our methodology enables inspectors and Mental Health Act reviewers to identify where people with a learning disability or autistic people cannot be discharged from inpatient units in a timely way

Escalate any specific concerns about discharge of people being cared for in segregation through the Independent Care, education and Treatment Review (ICETR) process.

Action Owner

Director of Policy and Strategy

Action Timescale

31 May 2020

Date Completed / Progress

See action 8 above

Qualitative briefings being prepared for inspectors to use to assess regulatory response to services at medium/high risk where a closed culture is likely

Discussions under way with NHSE on supporting the Action Plan for protecting NHS staff from Black or minority ethnic groups through our regulatory work

ICETR meetings held fortnightly with NHSE where we can address specific concerns about people cared for in long term segregation in mental health hospitals

Awareness raising with CQC contact centre.

Action 24 – The CQC Academy will develop learning so that inspection staff have access the learning and development they need to understand, identify and address equality and human rights issues during the COVID 19 pandemic

Action Owner

Head of Academy

Action Timescale

Q1 and Q2 2020

Date Completed / Progress

New mandatory introductory learning on equality and human rights for all staff launched 4th May. Mandatory learning on closed cultures and human rights during COVID 19 for inspection teams launching week commencing 8th June.

Action 25 – CQC Intelligence will, where possible, gather intelligence on equality and human rights issues in this Equality Impact Assessment

For example in relation to:

The higher numbers of deaths from COVID-19 of people living in deprived areas of England and the disproportionate impacts on disabled and people from Black and minority ethnic groups.

Disproportionate number of deaths of staff from Black and minority ethnic groups who have been delivering health and social care.

Excess deaths and poorer health outcomes for people with long term conditions (especially older people and people from Black and minority ethnic groups and disabled people) because routine services are stopped, reduced or impacted during the COVID-19 pandemic.

Disproportionate deaths from COVID-19 of older people and disabled people living in care homes to help identify the causes

The increase in numbers of deaths from confirmed or suspected COVID-19 of people detained under the Mental Health Act.

Where people with a learning disability and autistic people are admitted or are unable to be discharged from inpatient units due to the lack of social care support in the community because of COVID-19

This activity can be used to support and influence national work to identify causes and address issues relating to, for example, disproportionate numbers of people from Black and minority ethnic groups dying of COVID-19.

Action Owner

Director of Intelligence

Action Timescale

30 June 2020

Date Completed / Progress

Information on deaths in care homes being produced on weekly basis in conjunction with Office of National Statistics (ONS) and Insight reports published which gives this by ethnicity.

Information published on deaths of people with a learning disability and autistic people

Further work underway on producing more information about deaths.

Action 26 – Share good practice by providers in equality, including addressing the causes of disproportionate numbers of people from Black and minorty ethnic groups dying of COVID-19 through engagement with Equality, diversity and inclusion leads in NHS Trusts

Action Owner

Equality and Human Rights Manager and Diversity and Inclusion Manager

Action Timescale

30 June 2020

Date Completed / Progress

Meetings now being held quarterly

Action 27 –Look at how we can promote the consideration of health inequalities in the “restoration phase” of NHS services.

Action Owner

Director of Policy and Strategy and Equality, Diversity and Human Rights Manager

Action Timescale

October 2020

Date Completed / Progress / progress

Embedded into new CQC strategy as a core aim.