Safeguarding Vulnerable Adults Policy - the Royal Cornwall ...

Title:
Document author:
Document type:
Document library section:
Sub Section:
Document status:
Approved by:
Can this document be published
to the internet (publicly
available)
Brief summary of document
This document replaces (exact
title of previous document or
NA)
Approved Equality Impact
Assessment attached
Cross referenced to:
Document reference code:
NHS Cornwall and Isles of Scilly Safeguarding Vulnerable
Adults Policy
Chris Parish
Policy
Cornwall and Isles of Scilly PCT
Governance
Ratified
Safeguarding Children and Adults Executive Group
Yes
This policy has been written to provide staff working for NHS
CIOS with a guide to their responsibilities in the management
of vulnerable adults. It should be read in conjunction with the
Cornwall and Isles of Scilly Multiagency Safeguarding Adults
Policy
New Policy
Yes
Cornwall and Isles of Scilly Multi-agency Safeguarding Adults
Policy
Ratified by:
Safeguarding Children and Adults Executive Group
Date of ratification October 2011
Name of Executive signing Carol Williams
policy
Review date October 2014
Suggested key words (to be
completed by Governance
Administrator)
Expired documents should be
retained for 10 years from the
date of expiry
Version control table
Yes
Date Version number Summary of changes Changes made by
This document should not be photocopied or otherwise reproduced.
If you have any questions about this policy, please contact the Governance Administrator, Telephone
01726 627811, or via email to Policies.PCT@Cornwall.nhs.uk
This document is available in other formats such as large print, Braille &/or cassette/CD
or in any other
1

Page 2
Consultation
List the individuals (use titles only)/groups consulted. This
must include the Counter Fraud Local Security Management
Specialist
Multiagency Safeguarding Adults Unit
Cluster Director of Nursing
Safeguarding Children and Adults Executive Group
Indicate which of the
consultees in the left hand
column have responded
Yes
Yes
Yes
Consultation comments received
None
Comments
Accepted
Comments
rejected
Reason for rejection
Disseminate to: Please use titles or groups of staff
GP’s, Continuing Healthcare, Commissioning and Prescribing
Dissemination methods: Please details how dissemination will be undertaken and by whom
Electronically Via Tracey Coles
Aim:
To ensure that NHS Cornwall and Isles of Scilly Staff comply with national and local
guidance on safeguarding vulnerable adults
Purpose:
To provide NHS Cornwall and Isles of Scilly staff with guidance on safeguarding vulnerable
adults
Objectives: List the objectives to be achieved. They must be Specific, Measurable, Realistic
and Timebound (SMART)
Staff to be able to identify abuse or neglect
Staff to know where to access advice and support
Staff to know how to raise a safeguarding adults alert
Responsibilities: Detail the responsibilities of all in this section
All NHS Cornwall and Isles of Scilly Staff to work to the guidance in this policy
Definitions/Glossary:
None
2

Introduction:
This policy has been written to provide staff working for NHS CIOS with a guide to their
responsibilities in the management of vulnerable adults. It should be read in conjunction with the
Cornwall and Isles of Scilly Multiagency Safeguarding Adults Policy
Text of document (remember to refer to organisational format requirements)
Training: Has a training need been identified? If so what is it and how will it be addressed
No
Key Performance Indicators: List how you, as the policy author, will measure the success
of achievement against the objectives
Monitoring quality and number of safeguarding alerts made by NHS Cornwall and Isles of
Scilly staff
Monitoring: To which Board/sub-committee/committee will the results of the outcome of the
assessment against the key performance indicators be reported
Safeguarding Children and Adults Executive Group
Equality Impact Assessment: Attach a completed EIA prior to submitting for
approval/ratification
3

NHS Cornwall and Isles of Scilly
Safeguarding Vulnerable Adults Policy
11 th July 2011
Chris Parish, Designated Nurse for Safeguarding Adults
4

Contents Page
Page 3
Page 5
Page 5
Page 6
Page 7
Page 7
Page 8
Page 8
Page 9
Page 11
Page 12
Introduction and Scope
What should you do if you suspect someone is being abused?
Reporting suspected abuse
Reporting suspected abuse that involves a member of NHS CIOS
staff
Mental Capacity
Self-Neglect or Consent to Intervention
Commissioning Responsibilities
Staff development
Safeguarding Adults Strategy Process
Appendix One Flow Chart –How to make a safeguarding adults alert
Where to find an Safeguarding Adults Alert Form (SA22)
5

1. Introduction and scope of the policy
NHS Cornwall and Isles of Scilly (NHS CIOS) works in partnership with other agencies in
Cornwall to safeguard the dignity, quality of life and safety of vulnerable adults in Cornwall.
This policy has been written to provide staff working for NHS CIOS with a guide to their
responsibilities in the management of vulnerable adults. It should be read in conjunction
with the Cornwall and Isles of Scilly Multiagency Safeguarding Adults Policy
http://www.cornwall.gov.uk/Default.aspx?page=5519
The policy applies to all staff working in NHS Cornwall and Isles of Scilly including those on
temporary or honorary contracts, bank staff, students, and independent contractors such as
GPs.
All services will be provided in a manner that respects the rights, dignity, privacy and beliefs
of all individuals concerned and does not discriminate on the basis of race, culture, religion,
language, gender, disability age, or sexual orientation
2. Definitions and Requirements
A vulnerable adult is a person ‘who is or may be in need of community care services by
reason of
mental or other disability, age or illness, and who is or may be unable to take care of him or
herself, or
unable to protect him or herself against significant harm or exploitation’
(‘No Secrets’ section 2.4)
Abuse can be defined as ‘a violation of an individual’s human and civil rights by any other
person or persons’
(‘No Secrets’ section 2.5)
Abuse can consist of a single act or repeated acts over time. It may be physical, verbal or
psychological. It may be an act of neglect or an omission to act, or it may occur when a
vulnerable person is persuaded to enter into a financial or sexual transaction to which he or
she has not consented or cannot consent.
Regulation 11 of the Health and Social Care Act 2008 (Regulated Activities)
Regulations 2009-11 state;
The registered person must make suitable arrangements to ensure that service users are
safeguarded against the risk of abuse by means of—
(a) Taking reasonable steps to identify the possibility of abuse and prevent it before it
occurs; and
(b) Responding appropriately to any allegation of abuse.
(2) Where any form of control or restraint is used in the carrying on of the regulated activity,
the registered person must have suitable arrangements in place to protect service users
against the risk of such control or restraint being—
(a) Unlawful; or
(b) Otherwise excessive.
6

(3) The registered person must have regard to any guidance issued by the Secretary of
State or an appropriate expert body, in relation to—
(a) The protection of children and vulnerable adults generally; and
(b) in particular, the appropriate use of methods of control or restraint.
(4) For the purposes of paragraph (1), “abuse”, in relation to a service user, means—
(a) sexual abuse;
(b) physical or psychological ill-treatment;
(c) theft, misuse or misappropriation of money or property; or
(d) neglect and acts of omission which cause harm or place at risk of harm.
Regulation 18 of the Health and Social Care Act 2008 (Regulated Activities)
Regulations 2009-11 state;
(1) Subject to paragraphs (3) and (4), the registered person must notify the Commission
without delay of the incidents specified in paragraph (2) which occur whilst services are
being provided in the carrying on of a regulated activity, or as a consequence of the carrying
on of a regulated activity.
(2) The incidents referred to in paragraph (1) are—
Document Reference Code:AP/003/11Page 5 of 16
(e) any abuse or allegation of abuse in relation to a service user;
(f) any incident which is reported to, or investigated by, the police;
Paragraph (2)(f) does not apply where the service provider is an English NHS body.
(4) Where the service provider is a health service body, paragraph (1) does not apply if, and
to the extent that, the registered person has reported the incident to the National Patient
Safety Agency.
(5) In this regulation—
(a) “The 2005 Act” means the Mental Capacity Act 2005;
(b) “Abuse”, in relation to a service user, means—
(i) Sexual abuse,
(ii) Physical or psychological ill-treatment,
(iii) Theft, misuse or misappropriation of money or property, or
(iv) Neglect and acts of omission which cause harm or place at risk of harm;
3. Who may be an abuser?
Anybody can be an abuser and abuse can occur in any setting. Often, people who abuse
vulnerable adults are well known to the person. For example, they may be:
• A paid carer or volunteer
• A partner, relative or friend
• A health, social care or other worker
• A visitor or other contact
• Another vulnerable adult
4. What should you do if you suspect someone is being abused?
If you are informed or suspect that an individual for whom you commission or provide care
to is being abused, you must make sure the person is not in danger and protect them from
immediate harm.
7

You should then make a written record in their notes identifying what you have been told or
witnessed and any immediate actions you have taken. You must include the date and time,
details of any observed injuries (use of body maps to record injuries is recommended) and
the setting in which the allegation has occurred.
It is important to either raise an alert immediately (or for commissioners to ensure that alert
has been raised) and to inform the Corporate Risk Manager at the same time as making the
alert.
It is good practice to discuss your intention to make a safeguarding adults alert with the
service user involved. If they ask you to keep the information ‘a secret’ you should inform
them that you cannot do this as it is your duty to pass the information to the Access Team.
Even if the patient does not give consent, you have a duty of care to make a safeguarding
adults alert where the patient may be exposed to significant harm or where other vulnerable
adults may be at risk.
If the suspected abuse involves a colleague (or a member of staff more senior to you) and
you are anxious about raising this, you may find it helpful to refer to the Trust Whistle
Blowing Policy and/or to consult with the Designated Nurse/Associate Designated Nurse for
Safeguarding Adults.
4.2 Reporting suspected abuse
All Cornwall Safeguarding Adult alerts should be made through the Access Team on 0300
1234 131.
Telephone Contact must be followed up by faxing or emailing a completed SA22 within 48
hours to 01872 326613 /email accessteam.referral@cornwall.gov.uk
Isles of Scilly Safeguarding Adult alerts should be made to 01720 422148.
A copy of the alert form (SA22) should be faxed to the Designated Nurse/Associate
Designated Nurse for Safeguarding Adults for NHS CIOS on 01726 627829.
The Access Team will make a decision at this stage as to whether this is a safeguarding
issue and if so the information will be passed from the access team to the relevant
coordinating manager for action.
Alerters will be notified in writing whether the alert has been accepted into the safeguarding
process. If it has not staff will be informed in writing of any other action taken.
If staff are not happy with the decision taken by the access team regarding the safeguarding
adults threshold they should discuss this with their team leader / line manager and the
Designated Nurse/Associate Designated Nurse for Safeguarding Adults.
4.3 Role of the Coordinating Manager
The term ‘coordinating manager’ refers to the managers within Cornwall Partnership NHS
Foundation Trust or Department of Adult Care and Support who have the responsibility for
coordinating the response to an individual Safeguarding Adult alert.
The coordinating manager has overall responsibility for ensuring that the correct procedures
are followed according to the multi agency policy and practice guidance.
Ensure the service user remains in a place of safety until further advice is received from the
coordinating manager.
8

4.4 What Happens next
The safeguarding manager at the ACS Access Team will look at the referral and decide
whether there is a need for this to be looked at under the Safeguarding procedures. They
will liaise with the relevant Coordinating Manager and decide on the need for further action.
This may be an investigation. Depending on the outcome of interagency discussion, staff
may need to provide additional information, attend Adult Protection Strategy meetings/Case
Conferences, and participate in the investigation, needs assessment and future protection
plan. If, following the interagency discussion, it is decided that no Adult Social
Care/Cornwall Partnership Trust/Police involvement is necessary, the multi-disciplinary
team responsible for care will need to decide whether further internal
proceedings/investigation are required.
Often there will be a need for a complex care plan to support the situation, which will
sometimes need a multi agency approach.
5. Reporting suspected abuse that involves a member of NHS CIOS staff
Make an adult protection alert as detailed in section 4.2
Ensure that form SA22 is completed
Inform the HR department and take advice as to whether the Professional
Body of the alleged abuser should be informed. This decision should be taken at Executive
level of NHS CIOS.
The member of staff should be suspended from duty pending an investigation under the
trust’s disciplinary procedure. The timing of this should form part of the strategy discussion
at the earliest possible opportunity.
If you are not the staff member’s line manager, ensure their line manager is informed as
soon as possible.
A decision will be made at Executive NHS CIOS level, advised by the HR department, about
when to inform the Independent Safeguarding Authority.
9

6 Mental Capacity Act
The Mental Capacity Act 2005 is underpinned by a set of five key principles
• A presumption of capacity – every adult has the right to make his or her own decisions and
must be assumed to have capacity to do so unless it is proved otherwise
• The right for individuals to be supported to make their own decisions – people must be
given all appropriate help before anyone concludes that they cannot make their own
decisions
• That individuals must retain the right to make what might be seen as eccentric or unwise
decisions
• Best interests – anything done for or on behalf of people without capacity must be in their
best interests
• Least restrictive intervention – anything done for or on behalf of people without capacity
should be the least restrictive of their basic rights and freedoms.
• The Act introduces a new criminal offence of ill treatment or neglect of a person who lacks
capacity. A person found guilty of such an offence may be liable to imprisonment for a term
of up to five years.
Where an individual is deemed to lack capacity it is imperative that, if they do not
have family or friends to act on their behalf, an Independent Mental Capacity
Advocate is requested.
7. Self-Neglect or Consent to Intervention
It is not unusual for people to refuse a particular form of care due to lack of insight into the
need for intervention. Examples may be
• A person with dementia sends away a home care worker who is tasked to do cleaning or
prepare a meal
• A person who is incontinent but is reluctant to wear pads
• A person with schizophrenia refuses their depot injection
In these situations the assessment of the person’s capacity to make these decisions is key.
If the person lacks capacity to consent to an intervention, the law permits actions to be
taken in their best interests. In these circumstances, skilled and sensitive responses from
staff will frequently enable the task to be completed. However, a patient may have
appointed a lasting power of Attorney under the Mental Capacity Act. If so, this person is
legally empowered to make decisions on behalf of the patient and must be consulted.
The effect of the failure to provide the particular intervention will vary with the nature of the
care or treatment. Consideration must always be given to the likely effect of the failure to
provide the planned care or treatment, to the person, their environment and to those around
them. This will help determine the urgency of the decision-making needed regarding
implementation of the care plan.
It is imperative that in circumstances where an incapacitated person is refusing or resisting
care or treatment, discussions are held with senior staff to consider how to ensure the
appropriate care is delivered.
If necessary these discussions should include the wider team and family/carers and be
documented in the patient’s record.
8. Commissioning Responsibility
Where commissioners are made aware that a safeguarding alert has been made regarding
a patient that they fund they should
10

• Inform the Designated Nurse/Associate Designated Nurse for Safeguarding Adults
• Ensure commissioning is fully engaged in the safeguarding adults process includes
participation in the strategy process and attendance at meetings.
• Review the care of other patients being funded in the care setting
• Record in full the nature of the alert and any action taken on the patient’s records.
9. Staff Development
9.1 Training
There are different levels of adult protection training including:
• Induction / Introductory level Training – provided as an e learning package (All new
employees must complete on their first day at work)
• Human rights one day training (All staff having direct patient contact must complete
this course).
• Provider Manager/Team Leader Training – one half day multi-agency training
coordinated by Adult Care and Support Learning Training and Development Group.
• Specific HR training around safe recruitment and management of allegations against
staff.
9.2 Staff Recruitment
Rigorous recruitment practices will be applied for safeguarding vulnerable adults in line with
relevant requirements including 'Safer Recruitment', Care Quality Commission Standards,
National Health Litigation Authority. Accordingly the following will be completed when
recruiting staff:
Check of the relevant professional register to ensure they are currently registered, on the
correct part of the register and not subject to any action by the registering body
Confirmation of relevant educational qualifications/competencies
Acquisition of at least two references satisfactory to the Trust including one from the line
manager at their most recent or current employer. This must confirm whether or not they are
or have been subject to any fitness to practice proceedings
Confirmation of career history, accounting for any gaps in employment
Satisfactory Criminal Records Bureau check
A further level of assurance has been introduced with the Independent Safeguarding
Authority.
10 Framework for Safeguarding Adults in Cornwall
10.1 Cornwall and Isles of Scilly Safeguarding Adults Board (Formerly Adult Protection
Committee)
This is a strategic multi-agency group responsible for ensuring that all agencies work
together to minimize the risks of abuse and to protect vulnerable adults when abuse has
occurred. The NHS CIOS representative on this group is the Director of Nursing or their
representative.
11

10.2 Safeguarding Adults Quality and Improvement Sub Group
This is a multi-agency sub-group of the Cornwall and Isles of Scilly Safeguarding Adults
Board. Its role is to report on and monitor progress of embedding adult protection practice
into all agencies. The group shares examples of good and poor practice and resolves
practice issues as they are identified.
The NHS CIOS representative on the Quality and Improvement Group is the Designated
Nurse for Safeguarding Adults. .
10.3 Safeguarding Adults Learning and Development Training Sub-Group
This is a multi-agency sub-group of the Cornwall and Isles of Scilly Safeguarding Adults
Board which focuses on the development and implementation of training programme for
adult protection.
The NHS CIOS representative on the Safeguarding Adults learning and development
training sub-group is Designated Nurse for Safeguarding Adults.
10.4 Safeguarding Adults Strategy Process
The adult protection strategy process requires that contact is made with the alerter and
service providers when an alert regarding suspected abuse has been made. This may be in
the form of a telephone call/conference. When contacted by telephone as part of the
strategy process you should be informed that it is part of the strategy process however staff
should always clarify the status of telephone calls requesting patient/client information. The
coordinating manager may decide that a face to face strategy meeting is necessary they will
identify who should attend this meeting. An outcome may be the decision to hold a case
conference or it may be to take no further action.
10.5 Multi-Agency Safeguarding Adults Case Conference
This is a multi-agency meeting where the ongoing protection of a vulnerable adult is
considered. It is usually an outcome from a strategy meeting.
The purpose is to consider the issues raised in the alert, agree on a course of action to
safeguarding the individual and any other who are felt to be at risk of abuse and to ensure
the agreed plan is monitored and reviewed. Consideration must be given to inviting the
vulnerable adult to this meeting.
10.6 Safeguarding Adults Review Meeting
This meeting should take place within six months of a case conference being held. It is
arranged and convened by the coordinating manager. The review looks at the outcomes for
the service user, revises the adult protection plan (if needed) and considers the need for
further action.
10.7 Safeguarding Adults Independent chair
Two independent chairs support co-ordinating managers in their role with chairing
safeguarding adults strategy meetings and case conferences. They also assist in the work
of the safeguarding adults unit, ensuring that the key principles of safeguarding vulnerable
people are embedded across all groups and organisations in Cornwall and the Isles of Scilly
12

11 Contact Telephone Numbers
Access Team - To make alerts 0300 1234 131
Safeguarding Adults Team for NHS CIOS – 01726 627971
Multiagency Safeguarding Adults Unit
Safeguarding Adults Coordinator 01872 323782
Safeguarding Adults Unit Administrator 01872 324112
Safeguarding Adults Training Coordinator 01872 323663
13

Appendix One
How to make a safeguarding adults alert
Adult protection concern established following discussion with
colleagues/line manager or accessing advice from Designated
Professional on
01726 627971
Inform vulnerable adult of the need to make a referral to
The Access Team
NB: if you feel that informing them of the referral will put either you or the
vulnerable adult at greater risk do not do so.
Ensure that the access team are aware that you have not informed the
vulnerable adult and record your reasons in your records.
A Safeguarding Adults alert should be made by telephone to the
access team on
0300 1234 131
Within 48 hours of the telephone call, an SA22 Alert form should
be completed and faxed to the access team on
01872 326613
or
emailed to
accessteam.referral@cornwall.gov.uk
A copy of the SA22 should also be faxed to the Safeguarding
Adults team for NHS Cornwall &Isles of Scilly on 01726 627829
The safeguarding Adults Manager will provide written feedback
on the status of the alert this should be stored with records for
future reference
14

Appendix Two
Where to access a Safeguarding Adults Alert Form
A safeguarding adults alert form (SA22) can be accessed by clicking on one of the following
two links.
http://www.cornwall.gov.uk/index.aspx?page=5610
http://intra.cornwall.nhs.uk/Intranet/AZServices/S/SafeguardingAdultsPCT/UsefulLinks.aspx
15

Section Officer responsible for the assessment Chris Parish, Designated Nurse for Safeguarding
Adults
Name of Policy to
be assessed
NHS Cornwall and Isles of Scilly
Safeguarding Vulnerable Adults Policy
Date of
Assessment
03/10/2011 Is this a new or existing
policy?
New
1. Briefly describe the aims, objectives and
purpose of the policy.
2. Are there any associated objectives of the
policy? Please explain.
3. Who is intended to benefit from this policy,
and in what way?
No
This procedure has been written to provide staff working for NHS CIOS with a guide
to their responsibilities in the management of vulnerable adults. It should be read in
conjunction with the Cornwall and Isles of Scilly Multiagency Safeguarding Adults
Policy http://www.cornwall.gov.uk/Default.aspx?page=5519
The policy applies to all staff working in NHS Cornwall and Isles of Scilly including those on
temporary or honorary contracts, bank staff, students, and independent contractors such as
GPs.
4. What outcomes are wanted from this policy? Employees of NHS Cornwall and Isles of Scilly to be aware of Safeguarding Adults
responsibilities, how to identify abuse and to report appropriately.
5. What factors/forces could contribute/detract
from the outcomes?
6. Who are the main NHS Cornwall and Isles of Scilly and
stakeholders in relation to Vulnerable adults.
the policy?
Multiagency Safeguarding Procedures will contribute to the outcome.
7. Who implements the policy,
and who is responsible for the
policy?
Staff. NHS CIOS
Safeguarding Children and
Adults Executive Group
8. Are there concerns that the policy could have
a differential impact on RACIAL groups?
Y
N
Please explain
16

What existing evidence (either presumed or
otherwise) do you have for this?
9. Are there concerns that the policy could have
a differential impact due to GENDER (including
TRANSGENDER)?
What existing evidence (either presumed or
otherwise) do you have for this?
10. Are there concerns that the policy could
have a differential impact due to DISABILITY?
Y
Y
N
N
All services will be provided in a manner that respects the rights, dignity, privacy and
beliefs of all individuals concerned and does not discriminate on the basis of race,
culture, religion, language, gender, disability age, or sexual orientation
All services will be provided in a manner that respects the rights, dignity, privacy and
beliefs of all individuals concerned and does not discriminate on the basis of race,
culture, religion, language, gender, disability age, or sexual orientation
What existing evidence (either presumed or
otherwise) do you have for this?
11. Are there concerns that the policy could
have a differential impact due to SEXUAL
ORIENTATION?
What existing evidence (either presumed or
otherwise) do you have for this?
12. Are there concerns that the policy could
have a differential impact due to their AGE?
Y
N
N
All services will be provided in a manner that respects the rights, dignity, privacy and
beliefs of all individuals concerned and does not discriminate on the basis of race,
culture, religion, language, gender, disability age, or sexual orientation
All services will be provided in a manner that respects the rights, dignity, privacy and
beliefs of all individuals concerned and does not discriminate on the basis of race,
culture, religion, language, gender, disability age, or sexual orientation
17

What existing evidence (either presumed or
otherwise) do you have for this?
13. Are there concerns that the policy could
have a differential impact due to their
RELIGIOUS BELIEF?
What existing evidence (either presumed or
otherwise) do you have for this?
Y
Y
N
All services will be provided in a manner that respects the rights, dignity, privacy and
beliefs of all individuals concerned and does not discriminate on the basis of race,
culture, religion, language, gender, disability age, or sexual orientation
All services will be provided in a manner that respects the rights, dignity, privacy and
beliefs of all individuals concerned and does not discriminate on the basis of race,
culture, religion, language, gender, disability age, or sexual orientation
14. How have the Core Human Rights Values
of:
All values fully considered by working party and during the consultation period
Fairness;
Respect;
Equality;
Dignity;
Autonomy
Been considered in the formulation of this
policy/strategy
If they haven’t please reconsider the document
and amend to incorporate these values.
18

15. Which of the Human Rights Articles does
this document impact?
What existing evidence (either presumed or
otherwise) do you have for this?
The right:
• To life;
• Not to be tortured or treated in an inhuman or degrading way;
• To be free from slavery or forced labour;
• To liberty and security;
• To a fair trial;
• To no punishment without law;
• To respect for home and family life, home and correspondence;
• To freedom of thought, conscience and religion;
• To freedom of expression;
• To freedom of assembly and association;
• To marry and found a family;
• Not to be discriminated against in relation to the enjoyment of any of
the rights contained in the European Convention;
• To peaceful enjoyment of possessions and education;
• To free elections
Consultation with Stakeholders
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
16. Could the differential impact
identified in 8 – 13 amount to
there being the potential for
adverse impact in this policy? Y N
Please explain
These Guidelines have been designed to aid staff in identifying and challenging
discrimination and therefore will only have a positive impact on staff and patients within the
Cornwall and Isles of Scilly.
19

17. Can this adverse impact be
justified on the grounds of
promoting equality of
opportunity for one group? Or
any other reason?
Y
N
Please explain for each equality heading (questions 8 –13) on a separate piece of paper.
18. Should the policy proceed
to a full equality impact
assessment? Y N
17. If Yes, describe why, then proceed to a full EIA.
18. If No, are there any minor further amendments that should take place?
No
19. If a need for minor amendments is identified, what date were these completed and what
actions were undertaken.
Signed (completing officer) ……… …………………………………….. Date
Signed (Head of Section) ……………………………………………………….. Date
Please ensure that a signed copy of this form is sent to both the Policies Officer and the Equality and Diversity lead to be placed on
the Primary Care Trust website
20