Equality Analysis – Slips, Trips and Falls - Patients

Equality Analysis is a process of systematically analysing a new or existing policy or service to identify what impact or likely impact it will have on different groups within the community. The primary concern is to identify any discriminatory or negative consequences for a particular group or sector of the community. Equality Analysis can be carried out in relation to service delivery as well as employment policies and strategies.

This template has been developed to use as a framework when carrying out an Equality Analysis on a policy, service or function. It is intended that this is used as a working document throughout the process, with a final version being published on Gateshead Health NHS Foundation Trust website.

1) Policy / function details
Directorate: Trust - wide / Department/Service: / Lead: Robert Webber
Details of people involved in the policy / function development or review
Robert Webber, Falls team nurse. Karen Hunter, Clinical Specialist OT Falls and Syncope Service. Safecare Council. Director of Nursing, Midwifery and Quality. Coleen Knox, Equality & Diversity Co-ordinator / Start date:
Oct 2012
Name of policy / function / Slips, Trips and Falls Policy (Patient) RM50a
Scope of the policy / function / This is a trust wide policy and applies to:
  • all members of staff employed/working within Gateshead Health NHS Foundation Trust;
  • all in-patients and out patients attending Trust premises/services;
  • all visitors including contractors to Trust properties; and
  • all slips, trips and falls, including falls from a height

Purpose of policy / function / The National Patient Safety Agency (NPSA 2005) estimates that 250,000 slips, trips, and falls occur annually within hospital settings. Although the majority of falls result in no harm or minimal injury, the impact on the patient can still be significant, leading to loss of confidence, delayed discharges and loss of independence.
The Trust is committed to preventing or minimising the risk of slips, trips and falls to service users, staff, and other stakeholders who visit or use Trust premises. It aims to do this by:
  • Ensuring that suitable and sufficient assessments are carried out on patients who are at risk from falls, and implementing any risk reduction measures required to minimise that risk.
  • Providing a safe working environment which, so far as is reasonably practicable is free from hazards that contribute to falls.
  • Ensuring any slip and trip hazards in the workplace are identified, reported and rectified.
  • Ensuring where deficiencies are identified, appropriate risk assessments and risk reduction action plans are in place to reduce falls and ensure the best practice principles are applied.”

2) Stage Two: scoping and analysing equality information
List the sources of evidence you have for different people from each protected group (age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex, sexual orientation?
Use qualitative or quantitative data, research or reports
Source of information
A wide range of information has been sourced in order to ensure the policy meets national standards, for example the Health and Safety at Work Act 1974; Regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010; Care Quality Commission. / See introduction for further information.
The Health and Safety at Work Act 1974 requires employers to ensure the health and safety of their employees and others who may be affected by their work activity. In addition, employees must not endanger themselves or others and must use any safety equipment provided.
Regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 requires organisations to take proper steps to ensure service users are protected against the risks of receiving care or treatment that is inappropriate or unsafe.
Guidance of this legislation from The Care Quality Commission (CQC) Essential standards of quality guidance states “People who use services have safe and appropriate care, treatment and support because their individual needs are established from when they are referred or begin to use the service. The assessment, planning and delivery of their care, treatment and support:
* Is centred on them as an individual and considers all aspects of their individual circumstances, and their immediate and longer-term needs.
* Is developed with them, and/or those acting on their behalf.
reflects their needs, preferences and diversity.
* Identifies risks, and says how these will be managed and reviewed.
* Ensures that risk assessments balance safety and effectiveness with the right of the person who uses the service to make choices, taking account of their capacity to make those choices and their right to take informed risks.
The Management of Health and Safety at Work Regulations impose a duty on employers to assess the risk of slips, trips and falls to employees and others and to take action to control these risks.
The Workplace (Health, Safety and Welfare) Regulations require floors to be suitable for the purpose for which they are used and free from obstructions and slip hazards.
The Provision and Use of Work Equipment Regulations require work equipment to be well maintained, suitable equipment to be selected and for training in its use to be provided.
The Work at Height Regulations require that work at height is properly planned, appropriately supervised and carried out in a manner which is so far as reasonably practicable safe. Any person working at height must be competent to do so. Suitable and sufficient measures should be taken to prevent any person falling a distance liable to cause personal injury.
There is legal duty on NHS organisations to involve people and their representatives in decisions about services.
Provide details of feedback from people who are affected by the policy/ function, and any consultation or engagement activities undertaken: / The Falls Team is a multidisciplinary partnership team, made up of nurses, occupational therapists and physiotherapists and is lead by a Consultant geriatrician. The team also has input from a part-time orthogeriatrician who works across both medicine and orthopaedics.
The team have used their experiences of dealing with patients to review this policy. No specific patient engagement activity was undertaken.
Does the evidence suggest the policy / function affects or is likely to affect any of the following groups differently (either positively or negatively)
There is some national evidence to suggest that the policy is likely to affect some the following groups differently. The policy therefore includes information to promote an understanding of different groups which may support the care of different patients, particularly some vulnerable or disabled patients.
Age / “The causes of falls are complex and older hospital patients are particularly likely to be vulnerable to falling through medical conditions including delirium, cardiac, neurological or muscular-skeletal conditions, side effects from medication, or problems with their balance, strength or mobility. Problems like poor eyesight or poor memory can create a greater risk of falls when someone is out of their normal environment on a hospital ward, as they are less able to spot and avoid any hazards.”(Patient Safety First, 2009)
Disability
Gender reassignment
Marriage and Civil Partnership
Pregnancy and maternity
Race
Religion or belief
Sex
Sexual orientation
If there is a greater effect on one group, is that consistent with the policy aims? / Yes, see above.
How does the policy / function meet the aim to promote equality of opportunity on the grounds of …? / Falls can be an inevitable result of a patients’ acute condition and it is not possible to exclude the risk completely. However, patients admitted to hospital following a fall or patients having been assessed as being at increased risk of falling (5 or more) can have their falls risk reduced by implementing appropriate fall prevention measures.
How does the policy /function meet the aim of eliminating discrimination on the grounds of …? / n/a
How does the policy / function meet the aim of fostering positive relations between people of different groups? / n/a
To apply core human rights values, such as equality, dignity, privacy, respect and involvement, to all organisational service planning and decision making / The policies aim to promote the human rights of patients. However risk assessment processes are used to balance the rights of the patient with the risk to themselves and others.
See section 6 for full details.
3) Stage Three: monitoring and review
No major change:The analysis demonstrates that the policy or decision is robust, the evidence shows no potential for discrimination, and that all appropriate opportunities to advance equality and foster good relations between groups have been taken
See monitoring below: / √
Adjust the policy – This involves taking steps to remove barriers or to better advance equality. It can mean introducing measures to mitigate the potential effect. It is lawful under the Equality Act to treat people differently in some circumstances, for example taking positive action or putting in place single-sex provision where there is a need for it. It is both lawful and a requirement of the general equality duty to consider if there is a need to treat disabled people differently, including more favourable treatment where necessary.
Attach the action plan to this equality analysis
Continue the policy – This means adopting the proposals, despite any adverse effect or missed opportunities to advance equality, provided the decision-maker is satisfied that it does not unlawfully discriminate. In cases where you believe discrimination is not unlawful because it is objectively justified, it is particularly important that you record what the objective justification is for continuing the policy, and how you reached this decision.
Attach details of the objective justification to this equality analysis
Stop and remove the policy – If there are adverse effects that are not justified and cannot be mitigated, the decision-maker should consider stopping the policy altogether. If a policy shows unlawful discrimination it must be removed or changed.
How will you monitor the impact of the policy / function? / There are systems in place to ensure staff training, implementation, and incidents are reported, and reviewed. There is a bi-annual sudit of inpatient records in relation to falls risk assessment completed within 24hrs of admission, and bedrail risk assessment completed within 24hrs of admission.
Policy Sponsor / Richard Webber
Approving Committee / Safecare Council
Date of approval / 25 October 2012