Document name: Policy on the use of Global Restrictive

Practices (Blanket Restrictions) in In-

patient Units
Document type: Policy

What does this policy Update of V1 - previous policy

replace?

Staff group to whom it All staff within the Trust

applies:

Distribution: The whole of the Trust

How to access: Intranet and website

Issue date: February 2022

Next review: February 2025

Approved by: Executive Management Team

Developed by: Deputy Director of Nursing, Quality

and Professions

Director leads: Director of Nursing, Quality and

professions

Contact for advice: Associate Director of Nursing, Quality

and Professions

1
Contents

1.0. Introduction........................................................................................................3
2.0. Purpose.............................................................................................................3
3.0. Definitions......................................................................................................... 3
4.0. Duties................................................................................................................ 4
4.1. Trust Board.......................................................................................................4
4.2. Executive Management Team (EMT)...............................................................4
4.3. Medical Director................................................................................................5
4.4. The MHA Code of Practice Restrictive Practices Group...................................5
4.5. Mental Health Act and Legal Team..................................................................5
4.6. Practice Governance Coaches/Quality Governance Leads/Clinical Leads......5
4.7. Team Leaders/ Ward Manager.........................................................................5
4.8. Staff.................................................................................................................. 6
4.9. Complaints........................................................................................................6
4.10. Patient Safety Team.......................................................................................6
5.0. Guidance............................................................................................................6
5.1. The need for blanket restrictions......................................................................6
5.2. Trust-wide blanket restrictions..........................................................................7
6.0. Authorisation & monitoring of implementing blanket restrictions on a specific
ward area.................................................................................................................... 9
What should not form part of a blanket restriction (exceptions may apply to
secure units – see Appendix A):..........................................................................9
6.1. Process for implementing a blanket restriction on a specified ward area......9
6.2. Secure and forensic services including PICU.................................................10
6.3. Principles of Individualised approaches to risk-based care planning..............10
7.0. Consultation.................................................................................................... 10
8.0. References and further reading.......................................................................11
9.0. Dissemination and implementation arrangements (including training)............12
Appendices............................................................................................................... 12
Appendix A - Normative expectations regarding blanket restrictions at different
levels of security....................................................................................................13
Appendix B - Prohibited and restricted items in mental health wards.......................14
Restricted & controlled items.................................................................................14
Appendix C - Equality Impact Assessment Tool.......................................................15
Appendix D - Checklist for the Review and Approval of Procedural Document.....29
Appendix E - Version Control Sheet..........................................................................32

2
Policy on the use of Global Restrictive Practices (Blanket
Restrictions) in in-patient Units

1.0. Introduction

This policy describes the arrangements for authorising, monitoring and reviewing
restrictive practices, including global blanket restrictions, in use on wards within
South West Yorkshire Partnership Foundation Trust subject to the Mental Health Act
Code of Practice (2015).

This policy and related procedures aim to ensure that the least restrictive practice is
observed at all times in line with CQC requirements, Department of Health guidance:
Positive and Proactive Care: reducing the need for physical interventions (2014) and
the Mental Health Act Code of Practice (2015).

This policy should be read in conjunction with the Trust Covid Standard Operating
procedure (SOP). The Covid SOP provides guidance to staff on temporary
restrictions such as visiting, managing outbreaks and leave.

Each ward will operate procedures that match the needs of the patient group, to
ensure therapeutic progress whilst managing risks. The following principles will guide
the approach:

 Wherever possible, the least restrictive option principle shall be observed in

order to maximise patient independence and experience.
 Where an individual needs a greater degree of restriction usually observed
and accepted in a particular ward, this is risk assessed, discussed with the
patient, clearly documented and reviewed.
 Each service user will only have restrictions placed upon them that are
planned, proportionate, identified by the ward environmental risk assessment
and/or following individual risk assessment.

2.0. Purpose

The purpose of this document is to ensure the trust has a process for understanding
and managing restrictive practices.

3.0. Definitions

Term Definition

Restrictive ‘deliberate acts on the part of other person(s) that restrict an

Intervention individual’s movement, liberty and/or freedom to act independently
s in order to:
 take immediate control of a dangerous situation where
there is a real possibility of harm to the person or others if
no action is undertaken; and

3
  end or reduce significantly the danger to the person or
others; and
 contain or limit the person’s freedom for no longer than is
necessary’.
(DoH, 2014)
These include:
 Physical & mechanical restraint (e.g. RRPI)
 Chemical restraint (e.g. rapid tranquillisation)
 Seclusion & long term segregation
Restrictive Those practices that limit an individual’s movement, liberty and/or
Practices freedom to act independently in order to maintain the safety and
security of the site, service users and staff. This policy provides
guidance regarding restrictive practices.
Examples of restrictive practice include:
 Room searches and rub down searches
 Limiting access to courtyards, kitchens and other
rooms/areas
 Monitoring of communications and visits
Blanket The Mental Health Act Code of Practice defines blanket
Restrictions restrictions as “rules or policies that restrict a patient’s liberty and
other rights, which are routinely applied to all patients, or to
classes of patients, or within a service, without individual risk
assessments to justify their application.” The Code’s default
position is that “blanket restrictions should be avoided unless they
can be justified as necessary and proportionate responses to
risks identified for particular individuals”. The Code allows that
secure services will impose some blanket restrictions on their
patients.
Where blanket restrictions are identified as necessary and
proportionate there should be a system in place, which ensures
these are reviewed within a regular time frame, with an overall aim
at the reduction of restrictive practices.

4.0. Duties
4.1. Trust Board

 The Board will be responsible for ensuring that there are effective
arrangements in place for the implementation of the policy

4.2. Executive Management Team (EMT)

 The Executive Management Team will approve the policy and receive
updates on implementation as required

4
4.3. Medical Director

 The Medical Director, in collaboration with the Director of Nursing, Quality and
professions has the responsibility to oversee the appropriate and effective
implementation of restrictive practice
 Report directly to the Chief Executive and the Board and MHA Committee
 Challenge inappropriate practice
 Ensure that this policy and its associated procedures are fully adhered to
within the trust

4.4. The MHA Code of Practice Restrictive Practices Group

 Will support the implementation of this policy and will be considered and
consulted upon by this group
 Will promote best practice around restrictive interventions
 Will escalate concerns to BDU’s where staff fail to comply with this policy
 Provide information and advice around the implementation and use of
restrictive practices
 Participate in, or commission audits to monitor practice in line with current
guidance
 Be responsible for the production of the policy and management procedures

4.5. Mental Health Act and Legal Team

 Monitor use of blanket restrictions and report to the Trust MHA committee
 Member of MHA/Legal team to be a member of the MHA Code of practice
group
 Advise Code of practice group on changes to legislation and guidance
relating to restrictive practice
 Provide general advice to clinical staff through clinical governance sub group
 Escalate areas of concern to general managers, if unresolved at local level

4.6. Matrons /Practice Governance Coaches/Quality Governance Leads/Clinical

Leads

 Ensure that the principles around the implementation and monitoring of

restrictive practice are adhered to
 Liaise and be members of the Code of Practice Group to ensure best practice
is followed
 Provide advice and support to staff as required
 Escalate any situation where safety is compromised

4.7. Team Leaders/ Ward Manager

 Liaise and work closely with the Code of Practice Group

5
  Ensure that their area of responsibility provides both a safe and least
restrictive environment
 Ensure that staff are fully informed and adhere to current policies and
procedures in relation to Restrictive Practice
 Participate in audits to monitor practice
 Liaise with patients and relatives, providing information as required
 Ensure representation from their service area on the Code of Practice Group

4.8. Staff

 Will adhere to the policies, procedures and guidelines on restrictive practice

 Attend appropriate training as required
 Inform the Code of Practice representative from their area of any blanket
restrictions being considered
 Report failure in protocol on the incident reporting system
 Will maintain accurate records and reasons for implementing restrictive
practice

4.9. Complaints

 To record and report on any instances where complaints have been made
concerning the application of blanket restrictions in in-patient units.

4.10. Patient Safety Team

 Monitor, track, trend and produce reports on the implementation of blanket

restrictions to the Code of Practice Restrictive Practices Group

5.0. Guidance

5.1. The need for blanket restrictions

 The 2015 Mental Health Act Code of Practice allows for the use of blanket
restrictions only in certain very specific circumstances.

 Blanket restrictions should be avoided unless they can be justified as

necessary and proportionate responses to health and safety risks and risks
identified for particular individuals. The impact of a blanket restriction on each
patient should be considered and documented in the patient’s records.

 A blanket restriction should never be introduced or applied in order to punish

or humiliate, but only ever as a proportionate and measured response to an
identified risk; they should be applied for no longer than can be shown to be
necessary.

 Within secure services, blanket restrictions can form part of the broader
package of physical, procedural and relational security measures associated
with an individual’s identified need for enhanced security in order to manage

6
 high levels of risk to other patients, staff and members of the public
(paragraph 8.8 Mental Health Act Code of Practice)

 The Trust MHA Code of Practice Restrictive Practices Group will develop, in
conjunction with all inpatient areas, an annual health and safety inpatient ward
risk assessment that considers where blanket restrictions are required to
ensure safety.

No form of blanket restriction should be implemented unless expressly authorised

on the basis of this policy and subject to local accountability and governance
arrangements (see paragraph 8.9 Mental Health Act Code of Practice).
The impact of a blanket restriction will be regularly reviewed through the Trust’s
internal governance processes.

5.2. Trust-wide blanket restrictions

In order to maintain safety and enhance the effectiveness of the services the Trust
provides, it is acknowledged that there will need to be some accepted blanket
restrictions across ward areas based on health and safety risks, including the
following:

Blanket Restriction Rationale

No smoking on The policy supports the Public Health Guidance PH48
Trust premises which prohibits smoking on Trust premises and grounds.
This blanket restriction is Trust approved. Full details can
be found in the Trust Smoke Free Policy. The Trust allows
the use of E-burn E-cigarettes within its Hospital grounds,
ward courtyards and individual patient bedrooms.
No alcohol on Trust Alcohol is not allowed as:
premises  It can undermine the person’s treatment programme
 It can be a significant destabiliser for a person’s mental
health, negatively impacting on recovery
 It can be a disinhibitor for aggressive and violent
behaviour and/or self-harm, placing the service user and
others at potential harm
 It can interact negatively and potentially dangerously
with prescribed medication and other drugs
 It can be used to trade with or to coerce other people
 Once on a unit its onward distribution cannot be
controlled
No illicit drugs on Illicit substances are not allowed as:
Trust premises  Possession and distribution can constitute a criminal
offence
 It can undermine the person’s treatment programme

7
  It can be a significant destabiliser for a person’s mental
health, negatively impacting on recovery
 It can be a disinhibitor for aggressive and violent
behaviour and/or self-harm placing the service user and
others at potential harm
 It can interact negatively and potentially dangerously
with prescribed medication
 It can be used to trade with or to coerce other people
 Once on a unit its onward distribution cannot be
controlled
No New NPSs are not allowed as:
Psychoactive  They have unpredictable effects on physical and mental
Substances (NPS or health
“legal highs”) on  They can be a significant destabiliser for a person’s
Trust premises mental health, negatively impacting on recovery
 They can be a disinhibitor for aggressive and violent
behaviour and/or self-harm placing the service user and
others at potential harm
 They can interact negatively and potentially dangerously
with prescribed medication
 They can be used to trade with or coerce other people
 Once on a unit its onward distribution cannot be
controlled
Prohibited Items The Trust has a duty to ensure the safety of staff and
List users of its services. A prohibited items list is approved by
the Trust, full details of these prohibited items are found
within the Trust’s Search Policy and examples in Appendix
B. All patients, staff and visitors are required to comply
with this requirement.

Additional items are prohibited within secure forensic

services due to the level of security and risk matrix.

Regarding knives, it is recognised that some individuals

may wish to hold a knife for religious reasons. This will be
discussed with the service user and an individualised risk
assessment agreed and updated on a regular basis.
All doors into A safe and protective environment for patients, staff and
inpatient clinical visitors within in-patient areas is of the utmost importance
areas will be to the Trust. To support this, access to and exit from in-
controlled patient areas needs to be controlled. All main access
points to bed based clinical areas will have a system so
that access and exit is controlled by clinical staff and on a
request basis.
A patient’s article 8 rights should be protected by ensuring
any restriction on their contact with family and friends can
be justified as being proportionate and in the interests of
the health and safety of the patient or others.

8
 In the event of the need to lock down an individual ward or
area, please refer to the Trust Lock Down Policy
Fixed meal times All wards have fixed meal times. Lunch and Tea are
provided seven days a week at regular times to all wards
plus a supper snack each day. Each ward will also have a
snack box which provides food to anyone outside the
usual meal times. Each ward is also provided with fresh
bread, milk, cereals and preserves. Regular fixed
mealtimes are good for physical and mental health,
encouraging a balanced diet while avoiding overeating.
Mental Health Foundation (2018) https://www.mentalhealth.org.uk/a-
to-z/m/mealtimes-and-mental-health
Restrictions based Blanket restrictions may be introduced where it is
on ward health & accepted they are necessary based on the individual ward
safety risk health and safety risk assessments e.g. access to
assessment hazardous materials, locked areas in secure wards.

6.0. Authorisation & monitoring of implementing blanket

restrictions on a specific ward area

What should not form part of a blanket restriction (exceptions may apply to
secure units – see Appendix A):

 Access to (or banning) mobile phones (and chargers)

 Access to the internet
 Incoming and outgoing mail
 Visiting hours
 Access to money or the ability to make purchases
 Taking part in preferred activities
The Mental Health Act Code of Practice (2015) states that such restrictions “have no
basis in national guidance or best practice; they promote neither independence nor
recovery, and may breach a patient’s human rights”.

6.1. Process for implementing a blanket restriction on a specified ward area

There may be occasions when it is necessary for the safe running of a ward or unit
that a blanket restriction be implemented. Examples of times where there may be a
blanket restriction in place for a specific ward area or unit are provided in Appendix
A.

The expectation is that the need for such a blanket approach to manage the situation
be fully explored before implemented, and include the service user’s clinical team. If
an alternative cannot be identified and the blanket restriction still deemed necessary,
ensure the following:

 The blanket restriction is in place for the shortest possible time

 All affected service users must be made aware of why the decision was made

9
 Any impact the restriction may have on the service user should be documented
in the electronic patient record
 The decision should be reviewed regularly in the MDT
 The decision to implement a blanket restriction can be made by nurse in charge
and should be escalated to the General Manager ASAP
 All non-accepted (see above) blanket restrictions implemented outside normal
practice will be recorded on DATIX
 If the non-accepted blanket restriction needs to be in operation for over 72 hours
or for an indefinite period, this should be reported to the Legal and Mental Health
Act Team and the Director of Nursing, Quality and professions.

6.2. Secure and forensic services including PICU

It is recognised in the Code of Practice that within secure/forensic services,

restrictions may form part of the broader package of physical, procedural and
relational security measures associated with an individual’s identified need for
enhanced security. Under such circumstances, blanket restrictions are permissible in
order to manage high levels of risk to other patients, staff and members of the public.

The CQC developed a matrix to guide services on reasonable restrictions based on

level of security of the service (Normative expectations regarding blanket restrictions
at different levels of security Appendix A). However, the same principles apply
across all services.

6.3. Principles of Individualised approaches to risk-based care planning

A service user would normally have access to all the activities and opportunities
associated with that unit. However, for clinical and/or risk-based reasons, it may be
appropriate for an individual service user not to have access to one or more activities
and/or be subject to other restrictions. This decision must be:

 Based upon an individualised multi-disciplinary risk assessment

 Supported by a clear rationale why it is not appropriate at the current time
 Implemented for the shortest possible time with a date for when restrictions
will be reviewed
 Clearly documented in service user’s clinical records, usually in the
individual’s risk management care plan

The service user must be made fully aware of why the decision was made, as well
as how and when it is to be reviewed. This discussion will be documented on the
electronic clinical record, as well as the impact the restriction may have on the
service user.

7.0. Consultation

The following individuals and groups were consulted in the development of this
policy and procedure:

Stakeholder Level of involvement

10
 Executive Management Team (EMT) Approval – (may also be involved at the
outset in confirming the requirement for
a new policy or agreeing the
development process)
Directors Initiation, lead, development, receipt,
circulation
Business Delivery Units (BDUs) Development, consultation,
(including the Operational Management dissemination, implementation,
Group) monitoring
Specialist advisors Development, consultation,
dissemination, implementation
Service user and carers Development, consultation. Patient
satisfaction questionnaires will capture
service user views on restrictions
Professional groups and leaders Development, consultation,
dissemination, implementation
Trust Action Groups Development, consultation,
dissemination, implementation
Staff side Development, consultation,
dissemination
Trust learning networks Consultation
Local Authorities Development, consultation
Police Development, consultation
Other NHS Trusts Development, consultation
University Consultation

8.0. References and further reading

Documents referred to in the development of the policy and documents that should
be read in conjunction with the policy should be listed.

 Brief guide: the use of ‘blanket restrictions’ in mental health wards. Care Quality
Commission. (2017)
 Mental Health Act Code of Practice. Department of Health. (2015).
 Mental Capacity Act. Department for Constitutional Affairs. (2005).
 Positive & Proactive Care; reducing the need for restrictive interventions.
Department of Health. (2014)

Associated documents

 Searching of Patients and their Property

 Seclusion Policy
 Long-term Segregation Toolkit
 Rapid Tranquillisation and PRN Psychotropic Medication; Policy and Guidance
 Safeguarding Adults at Risk of Abuse or Neglect
 Safeguarding and promoting the welfare of children policy

11
9.0. Dissemination and implementation arrangements (including
training)

Once approved, the Integrated Governance Manager will be responsible for ensuring
the updated version is added to the document store on the intranet and is included in
the staff brief.

The integrated governance manager is responsible for ensuring the document being
replaced is removed from the document store and that an electronic copy, clearly
marked with version details, is retained as a corporate record.

The Policy will be presented at all BDU Governance Groups, Service Line Groups
and Operational Managers Group. The Policy will be shared at the trust-wide Clinical
Governance Group, Quality Improvement Group and Ward Mangers network
meeting.

A brief for staff will be circulated and the policy development communicated via our
Communications Team.

Appendices

All policies should include completed versions of the following:

 Equality Impact Assessment (see appendix C);

 Checklist for the Review and Approval of Procedural Document (see appendix
D);
 Version control sheet (see appendix E).

12
 Security level
General (acute) PICU Low Medium High
Banned All services will have banned and restricted items: alcohol, All services will have banned and restricted items in addition to those
items weapons, illicit drugs (see appendix B). found in general (acute) ward policies (see appendix B).
Random or Not without specific Policy on searching should consider the Random searching Routine searching Expected to be
routine cause (see appendix population within the service. likely, may be likely. Pre-discharge/ routine due to
searching B) routine at times in recovery wards may inherent risk of
response to specific have random population.
issues searching.
Access to Wards should provide personal access to the internet and mobile Some units are All access to internet All access to internet
mobile phones, particularly to communicate with friends and family. piloting access to likely to be will be supervised
phones and Restrictions on access should be individually justified and not be a mobile phones. supervised and and restricted as part
the internet. blanket measure. Wards may provide non-camera phone Dependent on the restricted as part of of ward security.
handsets and arrange for safe charging of patients’ electronic risk profile of the ward security.
items (electrical leads can be a ligature risk), e.g. with short-lead patient group.
chargers or charging in the nursing office).
Access to Restrictions on access to money should be based upon individual Restrictions on access to money will be part of security fabric of
money risk assessment, and justifiable on grounds of best interests. ward.
Buying No restrictions Restrictions on take away food may be in place to ensure that
takeaway therapeutic activity of the ward environment is not undermined.
food
Food During inpatient care staff should review the physical health of the patient as well as the mental health. Advice and encouragement
restrictions should be given to patients to have a healthy well balanced diet. Restrictions of access to certain food should not be part of this and can
be viewed as a blanket restriction.
Smoke free NHSE have issued guidance on mental health units becoming smoke-free. This should be considered to be as a blanket restriction that is
justifiable.
incoming or Staff have no legal powers to interfere with postal items but may withhold outgoing post from a detained patient Security directions
outgoing where addressee has requested that this be done (MHA s.134 (1) (a)). Staff may ask patients to open mail in allow monitoring and
mail front of them if there are concerns over contraband items or the patient’s likely reaction to mail. Staff should interference with
justify as necessary and proportionate to an identified risk. It should not amount to an interference with the postal postal items.
item itself. Staff should not read patients’ mail in such arrangements.
Telephone No legal powers to monitor patients’ telephone calls. Patients should expect privacy when using the telephone. Security directions
monitoring In exceptional cases (e.g. when a patient makes nuisance or unwarranted emergency service calls) access to the allow monitoring of
telephone might be restricted. phone calls.

Appendix A - Normative expectations regarding blanket restrictions at different levels of security

13
Appendix B - Prohibited and restricted items in mental health wards

Prohibited items

All mental health inpatient services have some prohibited or ‘contraband’

items.

The following are typically banned in all inpatient services:

 Alcohol and drugs or substances not prescribed (including illicit and legal highs)
 Items used as weapons (firearms- real or replica, knives or others sharps, bats)
 Fire hazard items (flammable liquids, matches, incense)
 Pornographic material
 Material that incites violence or racial/cultural/religious/gender hatred
 Items which could be used to cause harm to a services user or others for which
the service user or visitor can have no use whilst in hospital (screwdriver, rope)
 Clingfilm, foil, chewing gum, blue tack, plastic bags, rope, metal clothes hangers
 Laser pens
 Animals
 Equipment that can record moving or still images (camera, web cameras)
 Substances containing solvents e.g certain glues.
 Patent (over the counter) medicines e.g paracetamol
 Smoking products
 Corrosives e.g bleach
Although CQC encourages secure services to adopt the least restrictive
approach to IT items commensurate with the security requirements of the unit,
secure mental health units may also prohibit:

 Mobile phones (though may be allowed in some rehabilitation low secure

units)
 Computers, tablets, games devices with hard drives or sharing capabilities
 Items with voice recording capabilities
 Other items with enabled Wi-Fi/internet capabilities
 Items considered as an escape aid

Restricted & controlled items

Restricted items are items where the access is controlled and may be directed
according to policy and individual risk assessment. Examples of items that may fall
into this category include:
 Disposable cigarette lighters
 Toiletries- aerosols, razors, items with a cutting edge
 Identity documents, bank cards, items of stationery
 Cutlery, tinned materials, glassware
 Electrical equipment and flexes

15
Appendix C - Equality Impact Assessment Tool

Date of assessment: December 2021

Equality Evidence based answers & actions:
Impact
Assessment
Questions:

1 Name of the Policy on the use of Global Restrictive practice (blanket

document restrictions) in In patient units.
that you are
Equality
Impact
Assessing
2 Describe the The Mental Health Act Code of Practice defines blanket
overall aim of restrictions as “rules or policies that restrict a patient’s liberty and
your
document
other rights, which are routinely applied to all patients, or to
and context? classes of patients, or within a service, without individual risk
assessments to justify their application.” The Code’s default
position is that “blanket restrictions should be avoided unless
they can be justified as necessary and proportionate
responses to risks identified for particular individuals”. The Code
acknowledges that some blanket restrictions are necessary.

Where blanket restrictions are identified as necessary and

proportionate there should be a system in place which ensures
these are reviewed within a regular time frame, with an overall
aim at the reduction of restrictive practices.
In order to maintain safety and enhance the effectiveness of the
services the Trust provides, it is acknowledged that there will
need to be some accepted blanket restrictions across ward areas
Who will
based on health and safety risks.
benefit from This document applies to all wards within the Trust.
this
policy/proce
dure/strategy
?

3 Who is the  Director of Nursing, Quality and Professions

overall lead
for this
assessment?

4 Who else  Equality and engagement

was involved
in
 Mental Health Act staff
conducting  Performance and Information
this
assessment?
5 Have you This document is based on the requirements of the Mental
involved and Health Act 1983, the Mental Capacity Act and the Deprivation of
consulted
service
Liberty Safeguards, and their associated codes of practice

16
 users,
carers, and As this document is for review only it has been shared with
staff in
developing
clinical staff and the Matrons/Quality Governance Leads/Practice
this Governance Coaches.
policy/proce
dure/strategy It has also been reviewed by staff from Legal services.
?

What did you

find out and
how have Minor amendments required for the policy
you used this
information?

6 What The application of this policy applies to all services users as it

equality data relates to managing the general environment to provide as far as
have you
used to
possible a safe and therapeutic environment for service users,
inform this staff and visitors. The policy has in some cases an overall impact
equality and in other cases it applies to individuals based on person
impact centred risk assessments. The data relating to patients who
assessment? were admitted to a Trust bed over the period 2020/21 has been
accessed and provided by Performance and Information on
which to base the EIA for this policy.

Data provided reflects the population statistics for our localities in

respect of race equality, disability, gender, age, religion and
belief, marriage and civil partnership from census data. We also
have access to JNA and public health profiles for our localities.

The communities we serve:

In all communities the 2011 census tells us that on average

across all areas there is a 1% difference in the population
reported as male and female, with female reporting higher.
Across all ages Calderdale has the highest 0-15 population at
19.6% and Barnsley has a higher working age population 30-44
at 26% and older population 60+ at 23.8%. Christianity and Islam
respectively are both the highest reported religion and belief.

We know that White British people make up 87% of our region’s

local authority population, more than the England average of
81%. The other main minority groups include Black or Black
British people comprised 1%, less than the England average of
3%, while Asian or Asian British people comprised 8%, the same
as the England average (2011 census). The local authorities with
the largest proportions of Asian people are Kirklees (16%) and
Calderdale (8%). This profile is likely to change significantly over
the next 20 years with BME groups accounting for almost 80% of
the UK’s population growth (Policy Exchange, 2014).

We know that those who report having a disability that impacts

17
them a lot is higher than the census 2011 national average of just
over 4% in our local areas range from 8% to over 13% in the
communities the Trust cover.

Workforce data
As per workforce annual report 2020

The Trust currently employs 4,328 staff delivering a range of

services including mental health, learning disability, forensic,
some physical health and an extensive range of community
services.

 The Trust split of 77.9% female to 22.1% male is reflected

approximately across most areas, except for Medical Staff
(36%/64%). As in previous years, female staff make up over
three quarters of Trust staff
 As in previous years, the highest number of Trust staff fall in
the age bands 40-49 and 50-59 with over 55% of the total
staff being between 40 and 59. Just over 42% of medical
staff are between 40 and 49. Support Services have the
highest percentage of staff in the 60-69 age bands with 14%
(102) being 60 or over
 The data shows that 6.1% of our staff consider themselves
to have a disability, the same figure as last year. The total
number of staff is 266, this is an increase of 11 since last
year.
 The Trusts staff profile has a larger White British
representation than the local demographic of the people that
it serves collectively. Trust wide, 90% of the total staff in post
are white British which is similar to previous years and
equates to an over-representation of 1.3% (last year 1.1%).
Mixed race staff are underrepresented by 0.2%, Chinese
staff are over-represented by 0.2%, Black staff are over-
represented by 1.6% and South Asian staff are under-
represented by 3.2%. However, the Trust’s local
demographic has large variation in BAME representation and
there is a significant under-representation of South Asian
staff in Kirklees/Calderdale (exact figures not available due
to mixed teams)
 The number of staff who have not stated their religious belief
(Unknown) has decreased slightly from 2018 (23%) to just
below 21% currently. Staff reported as 48% Christianity,
3%Islam, 12% other and 17% Atheism.
 There has been a significant increase in the number of staff
reporting their religion and sexual orientation. Currently 83%
of staff have provided data indicating their sexual orientation,
which is a slight improvement on last year’s figures.

Volunteers

18
The diversity of volunteers recruited by the Trust will be improved
following a targeted piece of work to reach communities which
highlighted several recommendations. The current position for
volunteers is reported below and the service will aim to ensure
the volunteer offer is reflective of the communities we serve.

Number
Ethnicity of
Arab 1
Asian or Asian British
Chinese 1
Asian or Asian British
Indian 3
Asian or Asian British
Pakistani 4
Black British 1
Black or Black British
African 2
Black or Black British
Caribbean 2
Black or Black British
Other 1
Caribbean 1
Mixed White & Black
Caribbean 1
White British 210
White Irish 4
White Other 3
Not Stated 2
Cognitive Delay 4
Learning Disability 5
Long Term Condition 5
Mental Health 102
No Disability 93
Other 8
Physical Impairment 13
Blank 6
Bi-Sexual 9
Gay 8
Heterosexual 195
Lesbian 6
Transgender 0
Prefer not to say 13
Blank 5
Agnostic 2
Buddhist 3
Christian 127
Hindu 1

19
 Jewish 1
Muslim 6
No Religion 66
None stated 3
Other 16
Prefer not to say 7
Blank 4
No of Volunteers 236

7 What does The local population we serve and the staff who work in our
this data services represent a diverse population. Our public sector
say?
equality places a legal duty to ensure we do not discriminate and
ensure fair and equal access to our services making sure they
are culturally appropriate and that working conditions for staff
offer equality of opportunity in employment and development.

From the figures shown in the data there is more work to do to

ensure that our services reach and support our diverse
population and that workforce and volunteers continue to reflect
and represent the population we serve. This work will be
reflected in the annual action plan for equality and inclusion,
workforce, and volunteers.
8 Taking into No Evidence based answers & actions. Where negative
account the impact has been identified please explain what action
information
gathered
you will take to remove or mitigate this impact.
above, could
this This document is applicable to all service users who
document access in patient care and treatment from the Trust. The
affect any of MHA Code of Practice which this policy is based on
the following
equality
applies equally to all services users irrespective of their
group legal status, background and characteristics over the age
unfavourably of 16 who access Trust in patient services.. Compliance
: with the MHA code of practice are monitored by CQC.

All in-patients are given their rights both orally and in

writing which includes matters relating to access and
restrictions relating to an inpatient stay.

The Trust has a commissioned interpreting/translation

service which is available for all service users. During the
period of December 2020 – May 2021, the top 3
languages that were requested in highest requests 1st was
Polish, Urdu and Punjabi. An area that was notable is
people requiring British Sign Language services was
consistently requested within the top 5 requests.

Information leaflets should be in accessible language

including Braile

20
 The information below describes the demographic makeup
of the communities we serve, and figures are based on the
2011 census. The Trust will update these figures following
the information from the census completed in 2021, which
will be published in 2022.
8.1 Race No The Trust should consider services which meet the needs of our
diverse population. Specific targeted work to ensure the diverse
population of Kirklees are served well and the emerging growth of
an Asian population in Wakefield will be considered in all service
development and delivery. Support can be provided via the Trust
commissioned service to assist people whose first language is not
English. They can provide assistance to the assessor and the person
being assessed in respect of obtaining consent and also development
of care plans to address consent issues.

Race equality

England % 85.5
5.1% 3.4% 2.2% 1.7%
av. %
Barnsley
94.5
% average 1.9% 1.1% 1.1% 1.4%
%
Calderdale
85.3
% average 5.3% 4.1% 2.9% 2.3%
%
Kirklees
78.2 14.6
% average 2.7% 2.5% 2.0%
% %
Wakefield
92.5
% average 3.4% 1.8% 1.4% 1.0%
%
Forensic
64.3 19.0
% average 9.5% 2.4% 4.8%
% %
Taken from Census 2011 for each area

8.2 Disability Yes Across all communities the Trust will ensure that services
remain fully accessible. It is noted that in Kirklees and
Barnsley patients have identified themselves as
having a higher than national average proportion of
people whose day to day activities are limited ‘a lot’ by
their disability. We will use the service EIA to ensure we
fully understand the nature of the disability so we can
adjust and adapt our services according to need,
remaining person centred throughout.

People who have communication difficulties, whose first

21
 language is not English or who have difficulty reading or
have eyesight difficulties may be at a disadvantage in
understanding the restrictions that may be applied whilst
an inpatient.

It is also likely that patients with cognitive disabilities such

as dementia, stroke or learning disabilities may have
problems in understanding the restrictions imposed.

Disability groups

Day to day activities limited by

disability
Not at all A little A lot
England %
av. 47.2% 13.2% 4.2%
Kirklees
% average
88.9 5.1 6.0
Barnsley

% average
79.0 4.6 16.4
Calderdale

% average
82.8 15.2 2.0
Wakefield

% average
89.7 6.6 3.7
Forensic
% average 94.5 2.4 3.1

Taken from Census 2011 for each area

8.3 Gender No Gender equality is reported as part of our workforce

approach and services continue to ensure environments
and workplaces remain gender sensitive and
appropriate.

Male Female
England %
av. 49.2 50.8
Kirklees
% average 53.6 46.4
Barnsley
% average 55.1 44.9
Calderdale

22
 % average 50.5 49.5
Wakefield
% average 58.4 41.6
Forensic
% average 95.0 5.0
Taken from Census 2011 data

8.4 Age No The Trust provides services to children and young people
through to older age adults, however, does not provide in-
patient services unless in exceptional circumstances. The
table reflects the population age of patients who were
admitted to a trust ward over the reporting year of
2020/21.

Age Profile
0-15 16-29 30-49 50-69 70+
England %
av.
Barnsley
% average 17.4% 28.2% 27.3% 27.1%
Calderdale
% average 0.49% 25.0% 36.7% 28.9% 8.9%
Kirklees
% average 16.4% 28.6% 30.9% 24.1%
Wakefield
% average 24.9% 37.0% 24.9% 13.2%
Forensic
% average 26.3% 58.7% 15.1%

Taken from Census 2011 data

8.5 Sexual No The Trust will improve on the recording of sexual

orientation orientation in line with the ‘Sexual Orientation
Monitoring standard’ so the Trust can ensure that
services and workforce adequately represent the
population they serve. The 2021 census may contain
further baseline information which can be used to support
the Trust understanding further. A campaign to support
better data collection will improve our reporting.

The Trust has developed ways to be LGBTQI friendly

Leaflet to support inclusiveness. This identifies that
patients will be admitted to the ward setting that aligns to
their gender identity. Mandatory equality and diversity
training highlights to trust staff adjustments that may be
required for service users. This policy applies equitably to
all gender identities.

23
8.6 Religion or No Faith and spiritual care and support in an important component of
belief person-centred care provided. The Trust have a spirit in mind
service who play a central role in engaging faith and spiritual leaders
in the communities we serve and involving them in the work of the
Trust. Understanding religion and belief plays an important role in
driving our offer.

The Trust has a Pastoral care and Chaplaincy team, this service
provides digital chaplaincy services to both patients and staff.
Appointments can be made via the service. The service provides
pastoral care and is a person centred approach. It also provides
spiritual care which is a holistic approach to recovery and well-being.

The service provides:

Multi faith Sessional Chaplains
Bereavement counsellors
Befrienders
Ecumenical chaplains
Muslim chaplain
Canine Befrienders.

The information below tells us that Calderdale, Kirklees and

Forensics require a focus on the Muslim faith, with Christian faith
representing a large proportion of people who use our services
in all areas. Other faiths will be reflected in geographical areas and in
line with service EIAs and person-centred care and planning. The
table shows the self-reported religion or beliefs of those patients who
were admitted to a Trust ward during the reporting period 2020/21

Religion or Belief
Buddhis
Christia

religion
Muslim
Jewish
Hindu

Other
Sikh

No
n

England %
71.8 0.3 1.0 0.5 0.7 10.1 0.2 15.1
av.
Barnsley
% average 57.0 0.0 0.0 0.0 2.9 0.0 7.7 32.4
Calderdale
% average 47.5 0.0 0.0 0.0 14.5 0.0 8.0 30.0
Kirklees
% average 44.7 0.0 0.0 0.0 13.9 0.0 4.1 37.3
Wakefield
% average 46.0 0.0 0.6 0.0 8.4 0.2 10.7 34.2
Forensic
% average 52.9 0.0 0.0 0.7 19.3 0.7 2.1 24.3

Taken from 2011 Census data

8.7 Transgender No A trans equality policy aimed at workforce and people

24
who use services will be co-designed and the approach
endorsed by partner organisations. The policy and
agenda for transgender people will remain a key focus and
data collection will be reviewed and improved using a
campaign to support improvements to disclosure and
recording. The 2021 Census report may provide further
baseline data.

Trans people are treated with dignity and respect when

accessing hospital services. Records that we hold reflect
the correct gender identity.

The Trust has developed a policy that assists staff in

providing appropriate care and treatment to people who
are undergoing transgender procedures.
The aim of the policy is to
 Ensure that Trans people are treated with dignity and
respect.
 Ensure that Wards and Departments are supported to
ensure they are able to comply with the legal
requirements contained in the Equality Act 2010 in
respect of the Transgender protected characteristic and
Gender Recognition Act 2004 as well as duties
contained in the Data Protection Act 1998, Human
Rights Act 1998.
 Ensure that information governance and health records
protocols are in place to facilitate an individual’s choice
to change their name or gender at any time.

The Trust also has a carers passport which supports the

Trust and carers with entering into joint working, offering
the best care possible to the service user. The purpose of
the passport is to record the skills and knowledge that has
been developed by the carer and to offer the following as
a means of support:
 Carer’s champions/lead champion
 Staff and carers awareness training
 Carer information sessions
 Carer’s wellbeing workshops
 Sign posting to support services.

The Trust has been awarded the rainbow tick-Gold Award

is aware of the LGBT networks across its areas. The
Trust will use the Rainbow tick in its programme to support
LGBT and raise awareness within all aspects of
volunteering.

The Trust has developed a Ways to be LGBTQI friendly

Leaflet to support inclusiveness. This guidance includes
best practice in supporting people from the LGBT
community. This is made available to all staff and

25
 volunteers as part of their induction and on-going training
needs.

People who require admission to hospital will be admitted

to either a male or female ward that is more able to
support their stated gender identity. Mandatory equality
and diversity training highlights to trust staff adjustments
that may be required for service users.

This policy applies equitably to all gender identities.

8.8 Maternity & No There will be no differential impact of the policy

Pregnancy The Trust does not have a peri-natal unit. Inpatients who
are pregnant will not be affected differently to other
patients.
8.9 Marriage & No Marriage and civil partnerships will be recorded in line with
civil workforce recruitment and selection procedures and as
partnerships
part of person-centred care and planning. The table shows
the Marital status of patients admitted to a Trust ward over
the reporting period 2020.21

Marital Status

England % av. 46.8% 34.6% 9.0% 6.9% 2.7%

Barnsley
% average 29.1% 51.0% 8.0% 10.3% 1.5%
Calderdale
% average 18.5% 67.0% 6.3% 3.3% 4.8%
Kirklees
% average 26.4% 51.2% 9.0% 9.3% 4.1%
Wakefield
% average 23.3% 63.8% 5.8% 3.7% 3.5%
Forensic
% average 1.8% 90.0% 4.1% 2.4% 1.8%

Source SystmOne and 2011 Census data

8.10 Carers (Our No It is likely that every one of us will have caring
Trust responsibilities at some time in our lives with the
requirement)
challenges faced by carers taking many forms. Many
carers juggle their caring responsibilities with work, study
and other family commitments. Some, younger carers, are

26
 not known to be carers and this means that the sort of
roles and responsibilities that carers must provide varies
widely.
Within the local footprint of South West Yorkshire
Partnership NHS Foundation Trust, there is an estimated
160,000 unpaid carers.
The Trust will continue to record carers as part of equality
monitoring and continue to develop and deliver actions to
support carers as part of the strategy action plans.
The Trust also has a carers passport which supports the
Trust and carers with entering into joint working, offering
the best care possible to the service user. The purpose of
the passport is to record the skills and knowledge that has
been developed by the carer and to offer the following as
a means of support:
• Carer’s champions/lead champion
• Staff and carers awareness training
• Carer information sessions
• Carer’s wellbeing workshops
• Sign posting to support services.

Carers need to be made aware that some items are

classed as banned items so that they do not inadvertently
bring things to the unit for an inpatient. Carers also need
to be made aware that the person they are visiting may be
subject to certain access and restrictions which may need
explaining the reasons and rationale around this.
9 What This document is monitored locally by the clinical services
monitoring through its day to day implementation. The data is presented to
arrangement
s are you
the MHA Code of practice group for Trustwide oversight.
implementin
g or already CQC aims to visit each ward as a minimum every 18 month to 2
have in place years. In each MHA CQC visit consideration is given to the
to ensure Trusts compliance with the requirements of the MHA and MCA
that this
policy/proce
and their associated codes of practice. The restrictions on
dure/strategy service users and access to their property is included in their visit
:- summary report with any identified issues being raised as an
action for the Trust.

Monitoring relating to changes to legislation is managed and

disseminated via legal services department and clinical
specialists.

This policy can be influenced by changes in “case law” following

legal proceedings relating to the use of the Mental Health Act

27
 and Mental Capacity Act.

9a Promotes The Trust ensure that all training is recorded and monitored,
equality of study leave forms are completed and training outcomes are
opportunity
for people
identified through formal learning needs analyses. From the
who share workforce data in 2020 the Trust sees no adverse barriers to
the above training access for any of its staff regardless of their ethnicity,
protected disability, age, gender or sexuality
characteristi
cs
This Policy applies equally to all service users,
breaches are monitored. Any identified breaches would be
investigated and reported to MHA committee.
9b Eliminates Harassment & Bullying – The Trust has introduced a new
discriminatio model for
n,
harassment
preventing Harassment and Bullying and has a 12 month
and bullying communications plan.
for people A senior leadership forum with a focus on Making SWYT A Great
who share Place to Work is being rolled out and will include local action
the above plans on creating a team culture to prevent harassment and
protected
characteristi
bullying.
cs The RACE Forward network has been established to review the
approach to harassment and bullying from service users, carers,
and visitors.
This Policy applies equally to all service users, visitors, and staff
9c Promotes The Trust values promote good relations and these form part of
good recruitment, training, and appraisal functions. Other areas are:
relations
between  Mandatory training
different  Staff Networks
equality
groups  WRES and WDES monitoring information
 Race forward
 Accessible information standard
 Translation and interpreter services
The accessible information standard promotes equality of access
for service users by providing information in a manner that allows
sometimes complex information to be shared.

9d Public Sector The Equality Delivery System (EDS2) captures our progress
Equality Duty against several standards. These standards are reported on
– “Due
Regard”
each year and a report is shared at the Equality and Inclusion
Committee who identify a grading for the Trust.

EIAs are routinely completed at a service level and updated

every 3 years. These documents are used in the planning and
development of services.

The voice of people who use our services is captured using

28
 feedback and involvement. All activity is equality monitored and
the findings are reported for each protected group to ensure the
reach and audience are reflective of the target audience and that
any differential impact is recorded and considered.
10 Have you No action plan is indicated
developed an
Action Plan
arising from
this
assessment?

11 Assessment/
Action Plan
approved by
(Director Sign:
Lead)
12 Once approved, you must forward a copy of this Assessment/Action
Plan to the Equality and Engagement Development Managers:
Aboobaker.bhana@swyt.nhs.uk
Zahida.mallard@swyt.nhs.uk

Please note that the EIA is a public document and will be published on
the web. Failing to complete an EIA could expose the Trust to future
legal challenge.

29
Appendix D - Checklist for the Review and Approval of Procedural
Document
To be completed and attached to any policy document when submitted to EMT for consideration and
approval.
Yes/No/
Title of document being reviewed: Comments
Unsure

1. Title

Is the title clear and unambiguous? Y

Is it clear whether the document is a guideline, Y

policy, protocol or standard?

Is it clear in the introduction whether this Y

document replaces or supersedes a previous
document?

2. Rationale

Are reasons for development of the document Y

stated?

3. Development Process

Is the method described in brief? Y

Are people involved in the development Y

identified?

Do you feel a reasonable attempt has been Y

made to ensure relevant expertise has been
used?

Is there evidence of consultation with Y

stakeholders and users?

4. Content

Is the objective of the document clear? Y

Is the target population clear and Y

unambiguous?

Are the intended outcomes described? Y

Are the statements clear and unambiguous? Y

5. Evidence Base

Is the type of evidence to support the Y

document identified explicitly?

Are key references cited? Y

Are the references cited in full? Y

Are supporting documents referenced?

6. Approval

Does the document identify which Y

committee/group will approve it?

30
 If appropriate have the joint Human N/A
Resources/staff side committee (or equivalent)
approved the document?

7. Dissemination and Implementation

Is there an outline/plan to identify how this will Y

be done?

Does the plan include the necessary Y

training/support to ensure compliance?

8. Document Control

Does the document identify where it will be Y

held?

Have archiving arrangements for superseded Y

documents been addressed?

9. Process to Monitor Compliance and

Effectiveness

Are there measurable standards or KPIs to Y

support the monitoring of compliance with and
effectiveness of the document?

Is there a plan to review or audit compliance Y

with the document?

10. Review Date

Is the review date identified? Y

Is the frequency of review identified? If so is it Y

acceptable?

11. Overall Responsibility for the Document

Is it clear who will be responsible Y

implementation and review of the document?

31
Appendix E - Version Control Sheet

This sheet should provide a history of previous versions of the policy and changes made
Version Date Author Status Comment / changes
1 Decemb Director of Nursing, Final
er 2018 Quality and
professions
2 Decemb Assistant Draft Review of policy/ minor changes to
er 2021 Director legal terminology.
services

32