Patient Transfer Policy

Patient Transfer Policy

Policy Title: Executive Summary: Patient Transfer Policy All patients within East Cheshire NHS Trust that require transfer from one area to another either internally or externally must have the appropriate documentation and risk assessment completed to ensure that patient care is not compromised as a result of the transfer. This policy and its supportive guidelines aims to ensure safe and appropriate transfer of the patient with minimal risk Supersedes: Transfer Policy 2012 Description of Rewrite Amendment(s): This policy will impact on: Clinical practice, patient safety Referenced to Critical Care Transfer policy author Heather Cooper Nov 2007 Financial Implications: Nil identified Policy Area: Clinical practice, risk management Document Reference: Version Number: 1 Effective Date: November 2014 Issued By: Chris Gillespie Review Date: November 2017 Author: Urgent Care Service APPROVAL RECORD Impact Assessment Date: 3/12/14 Consultation: Approved by Director: Committees / Group Operational Management Team Meeting Kath Senior Director of Nursing, Performance & Quality Date November 2014 November 2014 2

CONTENTS: Page 1.0. Policy Statement 4 2.0 Aim of the policy 4 3.0 Scope of the policy 4 4.0 Definitions 4 5.0 Principles 5 6.0 Roles and responsibilities 5 6.1 Chief Executive 6.2 Director of Nursing, Performance and Quality 6.3 Deputy Director Of Operations 6.4 Service Urgent Care 6.4 Consultant and Medical Teams 6 6.5 Bed management team 6.6 Senior Sisters /named nurses 7 6.8 Ward Clerks 7.0 Transfer process 8 7.1 Complaints 7.2 Datix completion 7.3 Internal hospital transfers 7.4 External hospital transfers 8.0 Monitoring and Compliance 8 Appendices Appendix 1 - SBAR Verbal handover sheet for internal transfers Appendix 2 Extra Med (CRIS) Transfer letter Appendix 3 - Guidelines for Non- clinical Transfers Appendix 4 - Internal hospital transfer algorithm Appendix 5 External hospital transfer algorithm Appendix 6 Compliance Monitoring Tool Appendix 7 Impact Assessment Tool 1.0 POLICY STATEMENT 3

All patients within East Cheshire NHS Trust that require transfer from one area to another either internally or externally must have the appropriate documentation and risk assessment (internal only) completed to ensure that patient care is not compromised as a result of the transfer. The principle responsibility of all staff is to maintain patient wellbeing, provide optimal care during the period away from the principle care area/ward, report and document outcomes and action taken. This policy and its supportive guidelines aim to ensure safe and appropriate transfer of the patient with minimal risk. This policy should be read in conjunction with the bed management and escalation policy. 2.0 AIM OF THE POLICY This policy aims to inform staff of the principles underpinning the safe transfer of patients within the hospital or from the hospital to another acute care setting 24/7, and to clarify the roles and responsibilities of all those involved in the process. 3.0 SCOPE OF THE POLICY This policy applies to all staff who are involved in the transfer of patients within the hospital or from the hospital, including from Emergency Department to another acute care setting. This policy excludes the transfer of critically ill people refer to the Critical Care inter/intra transfer policy. It also excludes people from the Paediatric, Intensive care, Maternity and special care baby units and patients with deprivation of liberty (DOLS). Refer to the Guidelines for inter-hospital transfer of paediatric patients, maternity transfer, neonatal transfer and Critical Care transfer policies. It does not cover the planning/discharge of patients from the hospital at the end of an acute pathway (see Discharge Policy). This policy covers patient transfers regardless of time of day. 4.0 DEFINITIONS Clinical transfer: Critically ill patient: Named Nurse: Non-clinical transfer: Patient: Transfer of a patient within the hospital or from the hospital to obtain care/expertise which can best meet their needs. Patient who is showing signs of deterioration and who requires transfer to an area providing higher levels of care for any form of organ support. A nurse designated to take charge of, and be responsible for the patient s care during his/her stay in hospital. Other nurses may deputise on each shift when the named nurse is off duty. The named nurse is accountable to the Senior Sister who is in overall charge of the ward./ department Transfer of a patient within the hospital from one specialty ward to another due to insufficient bed capacity/ staffing. People aged over 16 years receiving acute treatment in hospital. 5.0 PRINCIPLES 4

The key principles for safe patient transfers are that: 5.1 People are treated as individuals and receive appropriate and timely services which meet their individual needs. Their consent will be obtained prior to any transfer taking place 5.2 All transfers should be co-ordinated by the bed management team. 5.3 Robust verbal handover regarding the patient s condition and management plan to the receiving health-care professionals is given to maintain continuity of care and should be supported by: SBAR handover sheet for internal transfer (Appendix 1) or Extramed transfer form on CRIS system for external transfer (Appendix 2) Patients passports and/or with reasonable adjustment care plans will be handed over with the patient 5.4 Where possible non-clinical transfers should be avoided. The patient should not be moved for non clinical reasons more than once. In exceptional circumstances, a patient may need to be moved more than once and on those occasions a Datix must be completed by the bed manager. The guidelines for non clinical transfer form should be completed including the incorporated risk assessment by the bed manager, named nurse for each occurrence and filed in the patients notes once completed.(appendix 3) 5.5 An out of hours transfer is a transfer that occurs after 2200 and before 0800hrs. It is not trust policy to perform non-clinical transfers out of hours unless there are exceptional circumstances and only if it is assessed as safe and reasonable and agreed with the patient. A Datix should be completed by the night sister/bed manager for every occurrence. 5.6 The engagement of individuals and their relatives/carer(s) as equal partners is central to the delivery of care. Patient and carers should be informed of any planned transfers and a full explanation given for the rationale. 5.7 If a patients first language is not English interpreting services must be accessed as per the ECT Interpreter Policy to ensure that information about the patients condition, ongoing care and transfer is accurately communicated. The needs of patients with hearing impairment will be assessed individually. Patients with learning difficulties, autism or dementia will be assessed on an individual basis for additional requirements to support their care. 6.0 ROLES AND RESPONSIBILITIES 6.1 Chief Executive 6.1.1 Has overall responsibility for the policies and procedures in place in the trust and ensuring said policies are implemented. This responsibility may be delegated. 6.2 Director of Nursing, Performance and Quality 6.2.1 Has responsibility for this policy and the effective implementation of its guidance. 6.2.2 Director of Operations 5

Will oversee the implementation of the policy on behalf of the Director of Nursing, Performance and Quality 6.3 Urgent Care Service 6.3.1 Has responsibility for the operation management of the policy and revision as required. 6.4 Consultant and Medical teams Clinical transfers 6.4.1 The consultant in charge of the patient s care is responsible for requesting clinical transfer of the patient to the appropriate area and communicating the urgency. This may be delegated to Specialist Registrars, Junior doctors or Medical Nurse Practitioner. 6.4.2 The consultant is responsible for ensuring the receiving health care personnel receive a handover, supported by relevant documentation, for all clinical transfers out of East Cheshire Trust. This may be delegated to Specialist Registrars or junior doctors 6.4.3 The consultant is responsible for authorising all transfers and ensuring the patient is clinically stable enough to transfer. This may be delegated to Specialist Registrars. Non Clinical transfers. 6.4.4 Patients clinically stable to outline to another specialty area must be identified on the daily board round by the senior clinician and the multi disciplinary team. The names of the appropriate patients suitable for outlying will be given to the bed manager by 13:30. 6.5 Bed management team Clinical Transfers 6.5.1 Has responsibility for co-ordinating patient transfers within the hospital and liaising with the bed management teams at other hospitals for transfers out of East Cheshire Trust. 6.5.2 Has responsibility for the timely repatriation of patients to East Cheshire Trust. 6.5.3 Has responsibility for informing the Heads of Service and escalate to the capacity meeting with outcomes documented; if there is likely to be a delay with undertaking a clinical transfer which may impact of the patients well being. Non clinical Transfers 6.5.4 Collect the names of suitable outliers from each area by 13.30 hrs 6.5.5 Escalate the potential lack of suitable outliers at the 13:30 capacity meeting. 6

6.5.6 Coordinate the moves as required and ensure the documentation has been completed (appendix 3) 6.5.7 Inform the relevant Consultants via email a list of outlying patients and repatriation status on a daily basis. 6.6 Senior Sister / Named nurse Clinical transfers 6.6.1 In Conjunction with Medical Staff has responsibility for the planning and undertaking of the patient transfer process once the decision to transfer has been made, ensuring the patient and carer are kept informed. 6.6.2 The named nurse must ensure that the patient and carer are given every opportunity to have questions answered before they are transferred. 6.6.3 Patients property should be managed in accordance with the Policy for the recording of patients property and valuables. 6.6.4 Has responsibility for ensuring the receiving healthcare personnel receive a handover, supported by relevant documentation: SBAR handover sheet for internal transfer (Appendix 1) Extramed transfer form on CRIS system for external transfer (Appendix 2) 6.6.5 Ensure all notes are filed and all relevant documentation is transferred with the patient. Case-notes and associated documentation should be photocopied and sent with the patient for external transfers. In cases where photocopying is impractical, the original case-notes should be sent and this recorded on the Trust s patient management system (PAS). 6.6.6 Is Responsible for sending all relevant Medication with the patient in line with the Medicines Policy. 6.6.7 Has responsibility for ensuring a suitably qualified person escorts the patient if the patient s clinical condition requires this. 6.6.8 Has responsibility for ensuring the appropriate transport is booked. Please refer to discharge policy. Non Clinical Transfers 6.6.9 With the senior clinician identify suitable patients to outline at the daily board round. The names of the patients will be given to the bed manager by 13:30. 6.6.10 Has overall responsibility for the planning and undertaking of the patient transfer process once the decision to transfer has been made. 6.6.11 The named nurse must ensure that the patient and carer are given every opportunity to have questions answered before they are transferred. 6.6.12 Identify suitable transport and book escort if required 6.6.13 Patients property should be managed in accordance with the Policy for the recording of patients property and valuables. 7

6.6. 14 Has responsibility for ensuring the receiving healthcare personnel receive a handover, supported by relevant documentation: SBAR handover sheet for internal transfer (Appendix 1) Extramed transfer form on CRIS system for external transfer (Appendix 2) 6.6.15 Ensure all notes are filed and all relevant documentation is transferred with the patient. Case-notes and associated documentation should be photocopied and sent with the patient if applicable in cases where photocopying is impractical, the original case-notes should be sent and this recorded on the Trust s patient management system (PAS). 6.6.16 Medication should be sent with the patient in line with the Trusts Medicines Policy. 6.7 Ward Clerks Clinical Transfers 6.7.1 Have responsibility for ensuring that all documentation relevant to the patients hospital stay ( for internal transfers) is filed correctly in the patient medical notes as per the health records case notes filing instructions policy and that the notes are kept on the ward until the episode can be coded by the clinical coding staff. 6.7.2 Case-notes and associated documentation should be photocopied and sent with the patient. In cases where photocopying is impractical, the original case-notes should be sent and this recorded on the Trust s patient management system (PAS). 6.7.3 Have responsibility for arranging for the transfer of the notes, once coding is completed, to the medical records department or appropriate medical secretary and ensuring this is recorded on the Trust s patient management system (PAS) 6.7.4 Internal transfers for the receiving ward to update details on PAS/CRIS including name of Consultant and inform admissions office of any changes. 7.0 TRANSFER PROCESS 7..1 All complaints raised by patients or carers regarding the transfer process should be addressed as per the Trust complaints policy. 7.2 A datix incident form should be completed by any staff member who feels that the transfer was in anyway unsafe or inappropriate. 7.3 Internal hospital transfers Please refer to Appendix 4 7.4 External hospital transfers Please refer to Appendix 5 8.0 MONITORING AND REVIEW Refer Appendix 6 - compliance monitoring tool. 8

Appendix 1 SBAR Verbal handover sheet for internal transfers One handover sheet per patient transfer To be completed by nurse receiving verbal handover File in patients nursing notes on arrival to ward/department SITUATION Date : Time : Patients Name : Age/ DOB : NHS Number : Hospital Number : Coming from : Going to : Next of Kin aware Yes/No How many times transferred? Property listed Yes/No Receiving Nurse : Nurse giving handover : BACKGROUND Diagnosis and treatment inc PMH and care needs. Include Reasonable adjustments /DOLS if applicable. ASSESSMENT Track and Trigger score:.. Pain score:.. Infection Risk? Yes / No If yes state why.. MRSA Screen Yes / No Invasive devices: IV Cannula Yes / No Urinary Catheter Yes / No Other please state:. VTE Yes / No Waterlow Score:.. Skin integrity (if has pressure ulcer location and grade ).. Specialist Mattress Yes / No MUST score.. Oral Status. Falls Risk? Yes / No Mobility issues?. Allergies.. RECOMMENDATIONS (plan of care including pending investigations ) Signature Print Name ID number 9

SL/ PC V8 Reviewed October 2014 Appendix 2 TRANSFER LETTER Name: Address: Next of kin: Address: Post code: Post code: DOB: Age: Telephone: G.P.: Informed of transfer? VISIT INFORMATION Ward transferring from: Admission date/time: Transfer date/time: Provisional diagnosis: Current complications: Medical history: Social history: PATIENT CARE NEEDS Mental health: Mobility: 10

PROBLEMS/NEEDS Eating/Drinking (special diet): Communication: Breathing: Elimination: Washing / dressing: Knowledge needs: Sleeping/resting: Skin integrity: Waterlow Score Additional comments: CHECKLIST Allergies: Yes/No Drugs (TTO s / Non-stock items / patient s Yes/No own drugs) Patient s notes / X-rays / Care file: Yes/No Patient s blood forms: Yes/No Property disclaimer: Yes/No Venflon removed: Yes/No Sutures: Yes/No Removal date: Safety rails night: Yes/No Safety rails day: Yes/No FUTURE HEALTHCARE Plan: Patient understanding: Relatives understanding: Name: Date: 11

Appendix 3 Guidelines for Non- clinical transfers This form should be jointly completed by the Bed /Night Co-ordinator and the Nurse in Charge of the ward and then filed in the patient s notes. Date: Patient name: Ward from: Consultant responsible for care: Reason for admission: Reason for transfer: Time: Patient Number: Ward to: Exclusion criteria (these patients should NOT be considered for transfer): Patients with dementia or demonstrating sign of confusion learning disabilities and autism Patients triggering on the Track and Trigger/Early Warning Score unless documented in the management plan that the patient is not for escalation in treatment Patients with complex social needs likely to remain in hospital longer than 48 hours Patients on the End of Life pathway Patients who are at high risk of falls Patients with clostridium difficile or any other infection that may contribute to an outbreak NB: An datix should be completed in the event that a patient transferred has had more than one non-clinically justified move. Or is moved when they have exclusion criteria? Please complete the following risk assessment and action prior to transfer Yes No Action taken if no Is there a clear treatment plan in the notes? Have the medical team agreed to the move? Has the patient been informed and consents to the move? Have the next of kin been notified of the move? If the patient has MRSA have screens been completed? Has a property list been completed? Has a datix been completed (where appropriate)? Form completed by: Bed manager/night co-ordinator Nurse in Charge Signature: Printed name: Signature: Printed name: October 2014 12

APPENDIX 4 INTERNAL HOSPITAL TRANSFER This pathway assumes patient and carer involvement and consent to transfer. Clinical transfer to specialist ward requested by medical team. Patient and carer informed with rationale. Non-clinical transfer requested by Bed Management Team. Named nurse informed Bed Named Nurse and bed manager to complete guidelines for non-clinical forms and file in patient s case notes (appendix 3) Bed manager liaises with receiving ward to confirm bed availability. If there is no bed available it may be necessary for the bed manager to liaise with the medical team to consider the options Named Nurse gives a verbal handover to a staff nurse on the receiving ward who will complete the SBAR documentation. (Appendix 1) Prior to transfer the named nurse must: Ensure the patient is wearing the accurate identity bracelet Pack up patient s medication Ensure all nursing documentation is updated Provide all of the patient s own property and update property checklist Arrange for an appropriately qualified escort to accompany the patient if required At transfer the named nurse must send the following with the patient: Medication All relevant documentation, ie nursing and case-notes Property 13

APPENDIX 5 EXTERNAL HOSPITAL TRANSFER This pathway assumes patient and carer involvement and consent to transfer. Patient and carer informed with rationale Bed manager keeps named nurse informed Consultant /SPR decision that clinical transfer is required to another acute care setting Medical team liaises with on call/specialist team at the other organisation.this may be done by telephone and/or support by fax. Medical team informs bed manager that the patient has been accepted by the other organisation. Bed manager liaises with bed manager at other organisation re:estimated date and time of transfer Document in patients notes Document in bed managers log book Bed manager contacts bed manager at other organisation re: progress Confirmation of date and time of transfer Prior to transfer the named nurse must: Ensure the patient is wearing the accurate identity bracelet Pack up the patients medication Ensure all nursing documentation is updated and notes photocopied Provide all of the patient s own property and update property checklist Arrange for an appropriately qualified escort to accompany the patient if required Book transport if required Complete patient transfer form (Appendix 2) Discussed at daily capacity meeting at escalated to other organisation site manager if delay is >48 hours For external transfers patient passports/reasonable adjustment care plans should go with them At transfer the named nurse must send the following with the patient: Medication Photocopies pf all relevant documentation, ie patient transfer letter, nursing documentation and case-notes relevant to the admission/case notes as appropriate Property 14

Appendix 6 - Compliance Monitoring Tool Policy Patient Transfer Policy Author Urgent Care Service Date of Approval November 2014 (updates) Date for review November 2017 NHSLA Criterion Number (as applicable) Approving Committee/Group Requirement to be monitored Process to be used for monitoring e.g. audit Responsible individual/ committee for carrying out monitoring How the patient handovers are recorded Audit Urgent Care Service Compliance of completion of Audit Urgent Care Service patient transfer documentation, eg SBAR & patient transfer letter Out of hours transfer process Audit Urgent Care Service Frequency of monitoring Annually Annually Annually Responsible individual/committee for reviewing the results Urgent Care Service Urgent Care Service Urgent Care Service Responsible individual for developing an action plan Urgent Care Service Urgent Care Service Urgent Care Service Responsible Committee/group monitoring the action plan OMT OMT OMT

Equality Analysis (Impact assessment) Please START this assessment BEFORE writing your policy, procedure, proposal, strategy or service so that you can identify any adverse impacts and include action to mitigate these in your finished policy, procedure, proposal, strategy or service. Use it to help you develop fair and equal services. Eg. If there is an impact on Deaf people, then include in the policy how Deaf people will have equal access. 1. What is being assessed? Patient transfer Policy Details of person responsible for completing the assessment: Name: Christine Gillespie Position: Urgent Care Service Team/service: Urgent Care State main purpose or aim of the policy, procedure, proposal, strategy or service: (usually the first paragraph of what you are writing. Also include details of legislation, guidance, regulations etc which have shaped or informed the document) This policy aims to inform staff of the principles underpinning the safe transfer of patients within the hospital or from the hospital to another acute care setting 24/7, and to clarify the roles and responsibilities of all those involved in the process. 2. Consideration of Data and Research To carry out the equality analysis you will need to consider information about the people who use the service and the staff that provide it. Think about the information below how does this apply to your policy, procedure, proposal, strategy or service 2.1 Give details of RELEVANT information available that gives you an understanding of who will be affected by this document This policy applies to all staff who are involved in the transfer of patients within the hospital or from the hospital to another acute care setting. This includes repatriation of patients to East Cheshire Trust. This policy excludes the transfer of critically ill people refer to the Critical Care inter/intra transfer policy. It also excludes people from the Paediatric, Intensive care, Maternity and special care baby units. Refer to the paediatric, maternity transfer, neonatal transfer and Critical Care transfer policies. Cheshire East (CE) covers Eastern Cheshire CCG and South Cheshire CCG. Cheshire West & Chester (CWAC) covers Vale Royal CCG and Cheshire West CCG. In 2011, 370,100 people resided in CE and 329,608 people resided in CWAC. Age: East Cheshire and South Cheshire CCG s serve a predominantly older population than the national average, with 19.3% aged over 65 (71,400 people) and 2.6% aged over 85 (9,700 people). Vale Royal CCGs registered population in general has a younger age profile compared to the CWAC average, with 14% aged over 65 (14,561 people) and 2% aged over 85 (2,111 people). 16

Since the 2001 census the number of over 65s has increased by 26% compared with 20% nationally. The number of over 85s has increased by 35% compared with 24% nationally. Race: In 2011, 93.6% of CE residents, and 94.7% of CWAC residents were White British 5.1% of CE residents, and 4.9% of CWAC residents were born outside the UK Poland and India being the most common 3% of CE households have members for whom English is not the main language (11,103 people) and 1.2% of CWAC households have no people for whom English is their main language. Gypsies & travellers estimated 18,600 in England in 2011. Gender: In 2011, c. 49% of the population in both CE and CWAC were male and 51% female. For CE, the assumption from national figures is that 20 per 100,000 are likely to be transgender and for CWAC 1,500 transgender people will be living in the CWAC area. Disability: In 2011, 7.9% of the population in CE and 8.7% in CWAC had a long term health problem or disability In CE, there are c.4500 people aged 65+ with dementia, and c.1430 aged 65+ with dementia in CWAC. 1 in 20 people over 65 has a form of dementia Over 10 million (c. 1 in 6) people in the UK have a degree of hearing impairment or deafness. C. 2 million people in the UK have visual impairment, of these around 365,000 are registered as blind or partially sighted. In CE, it is estimated that around 7000 people have learning disabilities and 6500 people in CWAC. Mental health 1 in 4 will have mental health problems at some time in their lives. Sexual Orientation: CE - In 2011, the lesbian, gay, bisexual and transgender (LGBT) population in CE was estimated at18,700, based on assumptions that 5-7% of the population are likely to be lesbian, gay or bisexual and 20 per 100,000 are likely to be transgender (The Lesbian & Gay Foundation). CWAC - In 2011, the LGBT population in CWAC is unknown, but in 2010 there were c. 20,000 LGB people in the area and as many as 1,500 transgender people residing in CWAC. Religion/Belief: The proportion of CE people classing themselves as Christian has fallen from 80.3% in 2001 to 68.9% In 2011 and in CWAC a similar picture from 80.7% to 70.1%, the proportion saying they had no religion doubled in both areas from around 11%-22%. Christian: 68.9% of Cheshire East and 70.1% of Cheshire West & Chester Sikh: 0.07% of Cheshire East and 0.1% of Cheshire West & Chester Buddhist: 0.24% of Cheshire East and 0.2% of Cheshire West & Chester Hindu: Jewish: Muslim: Other: None: 0.36% of Cheshire East and 0.2% of Cheshire West & Chester 0.16% of Cheshire East and 0.1% of Cheshire West & Chester 0.66% of Cheshire East and 0.5% of Cheshire West & Chester 0.29% of Cheshire East and 0.3% of Cheshire West & Chester 22.69%of Cheshire East and 22.0% of Cheshire West & Chester Not stated: 6.66% of Cheshire East and 6.5% of Cheshire West & Chester Carers: In 2011, nearly 11% (40,000) of the population in CE are unpaid carers and just over 11% (37,000) of the population in CWAC. 2.2 Evidence of complaints on grounds of discrimination: (Are there any complaints or concerns raised either from patients or staff (grievance) relating to the policy, procedure, proposal, strategy or service or its effects on different groups?) 17

No No 2.3 Does the information gathered from 2.1 2.3 indicate any negative impact as a result of this document? 3. Assessment of Impact Now that you have looked at the purpose, etc. of the policy, procedure, proposal, strategy or service (part 1) and looked at the data and research you have (part 2), this section asks you to assess the impact of the policy, procedure, proposal, strategy or service on each of the strands listed below. RACE: From the evidence available does the policy, procedure, proposal, strategy or service affect, or have the potential to affect, racial groups differently? Yes No x Explain your response: It is written into the policy that all patients whose first language is not English will have an explanation prior to their move and staff will follow the trust interpretation policy to achieve this. GENDER (INCLUDING TRANSGENDER): From the evidence available does the policy, procedure, proposal, strategy or service affect, or have the potential to affect, different gender groups differently? Yes No x Explain your response: If a patient needs to move, then staff will adhere to the DOH single sex accommodation guidance and place patients in single sex accommodation. For translgender patients, they will be placed in their chosen gender accommodation. Any move will be discussed with the patient. DISABILITY From the evidence available does the policy, procedure, proposal, strategy or service affect, or have the potential to affect, disabled people differently? Yes No x Explain your response: For disabled patients who require extra support with communication, staff will follow the trust interpretation policy. Patients who lack capacity will not be transferred for non clinical reasons and a Datix incident should be recorded if this occurs. AGE: From the evidence available does the policy, procedure, proposal, strategy or service, affect, or have the potential to affect, age groups differently? Yes No x Explain your response: This policy does not discriminate against age as it is a generic policy for the transfer of all patients within the hospital or from the hospital within the intended scope of the policy. LESBIAN, GAY, BISEXUAL: From the evidence available does the policy, procedure, proposal, strategy or service affect, or have 18

the potential to affect, lesbian, gay or bisexual groups differently? Yes No x Explain your response: LGB people are known to have poorer health outcomes and often have additional health issues such as mental health, and alcohol and drug dependency. There is also a higher risk of suicide. for any LGB patients where additional needs have been identified, these will be passed on to the receiving area so that the patient is not disadvantaged. - RELIGION/BELIEF: From the evidence available does the policy, procedure, proposal, strategy or service affect, or have the potential to affect, religious belief groups differently? Yes No x Explain your response: Where patients are being visited by leaders from their own church/religion, care will be taken to ensure the move is communicated to visitors so that the patient s spiritual needs can be met. For patients who are observing Holy periods in the calendar such as Ramadan, their particular requirements will be highlighted to the receiving area. CARERS: From the evidence available does the policy, procedure, proposal, strategy or service affect, or have the potential to affect, carers differently? Yes No x Explain your response: Carers will be involved and informed as appropriate, including same sex partners. OTHER: EG Pregnant women, people in civil partnerships, human rights issues. From the evidence available does the policy, procedure, proposal, strategy or service affect, or have the potential to affect any other groups differently? Yes No x Explain your response: No other impacts identified. 4. Safeguarding Assessment - CHILDREN a. Is there a direct or indirect impact upon children? Yes No x b. If yes please describe the nature and level of the impact (consideration to be given to all children; children in a specific group or area, or individual children. As well as consideration of impact now or in the future; competing / conflicting impact between different groups of children and young people: c. If no please describe why there is considered to be no impact / significant impact on children This policy refers to the Safeguarding children s policy. 5. Relevant consultation Having identified key groups, how have you consulted with them to find out their views and that the made sure that the policy, procedure, proposal, strategy or service will affect them in the way that you intend? Have you spoken to staff groups, charities, national organisations etc? Draft amendments circulated widely to key operational staff for comments and amendments. 6. Date completed: 3/12/14 Review Date:3/12/17 19

7. Any actions identified: Have you identified any work which you will need to do in the future to ensure that the document has no adverse impact? Action Lead Date to be Achieved 8. Approval At this point, you should forward the template to the Trust Equality and Diversity Lead lynbailey@nhs.net Approved by Trust Equality and Diversity Lead: Date:3/12/14 20