CQC calls for new national guidance to improve sexual safety on mental health wards

September 11, 2018

The Care Quality Commission (CQC) is calling for new national guidance to improve the sexual safety of people and staff on mental health wards, following analysis of how mental health trusts in England report sexual incidents. 

In its Sexual Safety on Mental Health Wards report published today (Tuesday 11 September) the CQC shares its findings and recommendations after reviewing patient safety incidents reported to the NHS National Reporting and Learning System (NRLS). The report follows engagement with trusts, national bodies, organisations representing people who use services and individuals with direct experience of sexual safety incidents. 

The review was initiated following concerns from CQC inspectors about sexual safety on mental health wards. Those admitted to a mental health ward may include people vulnerable to sexual abuse and people who may lack the mental capacity to make informed decisions about sexual relationships. This, combined with a high number of detained patients on many mental health wards – some in old and unsuitable buildings – staff shortages and few staff trained in how to promote sexual safety, can put patients and staff at risk of harm. 

The analysis of nearly 60,000 reports made between April and June 2017 found 1,120 sexual incidents involving patients, staff, visitors and others described in 919 reports – some of which included multiple incidents. More than a third of the incidents (457) could be categorised as sexual assault or sexual harassment of patients or staff.

In 95% of all reports the alleged incidents were carried out by a patient. In 5% of reports it is alleged that a member of staff was the person who carried out the incident.  About two-thirds of the people reported to have been affected by the incident were patients.  In one-third of incidents, the person affected was a staff member – despite the system being a reporting and learning system specifically for incidents that affect patients. 

In the case of a small number of particularly concerning reports, CQC followed up directly with the Trusts involved to check that they had taken the appropriate action in response, and received assurances that this was the case. 

The great majority (97%) of reports were classified by reporting organisations as ‘no harm’ or ‘low harm’. Without national guidance recognising the potential physical and psychological harm caused by unwanted sexual behaviour, staff may not fully understand the full impact that sexual incidents can have on those affected.

Although some trusts have taken the lead in developing their own initiatives to respond to the issue of sexual safety, others may find it difficult due to a lack of national guidance and training to equip staff to identify and support vulnerable patients.

CQC will be working with other regulators and stakeholders (including NHS Improvement, NHS England and the Royal College of Psychiatrists) to implement recommendations aimed at improving the sexual safety of people who use mental health services. These recommendations include:

•           National guidance on sexual safety on mental health wards that can be adapted to specific inpatient settings, co-produced by healthcare professionals working with people who have experienced inpatient care. This guidance should cover: 
• what is acceptable behaviour and what kind of behaviour would be considered sexual harassment or abuse. 
• how staff should respond to sexual incidents – including those that are triggered by disinhibition or some other feature of a person’s mental state. 
• a recognition of the potential physical and psychological harm caused by those affected by unwanted sexual behaviour. 
• what support people who experience unwanted sexual incidents can expect in terms of staff response 

•           Clinical leaders in provider services should support best practice to prevent and respond proactively to sexual safety incidents, creating a culture on mental health wards that promotes sexual wellbeing, actively encourages disclosure and supports those affected by unwanted sexual behaviour. Trusts should nominate a Board member with specific responsibility for this area of work.

•           Providers should work actively to uphold the sexual wellbeing of people who use services by promoting access to information and support for patients, their families and carers. These should take into account the culture and diversity of people who use services. 

•           Staff working on mental health wards should have access to learning and development opportunities, including trauma- informed care principles, so they can better assess patient risk (both of those carrying out and experiencing incidents), and promote strategies to support sexual safety and to respond appropriately to sexual safety incidents.

•           Providers must ensure that the physical environment of mental health wards promotes the sexual safety of patients in terms of layout and use and identify high-risk areas and locations.

•           Providers should work collaboratively with stakeholders, including patients, the police and safeguarding teams, to ensure that sexual safety incidents are taken seriously and addressed appropriately.  This should draw on the principles that underpin existing examples of successful collaboration, including police liaison models.

•           The process for reporting and learning from sexual incidents on mental health wards should be strengthened so that incident reports better reflect the impact on people who use services, and so that it enables proper reporting of incidents where staff are involved.

•           CQC should strengthen the process of monitoring, assurance and regulation of this issue and of the factors that influence sexual safety and well-being.

Dr Paul Lelliott, Deputy Chief Inspector of Hospitals (lead for mental health) at the Care Quality Commission, said: “In last year’s State of Care in mental health services report, we highlighted that on too many mental health wards, the combination of a high number of detained patients with very serious mental health conditions, old and unsuitable buildings, staff shortages and lack of basic training, make it more likely that patients and staff are at risk of suffering harm. We described mental health wards as a high-risk environment and expressed concern about the high number of incidences of violence towards both patients and staff.

“This report published today shows that sexual incidents are also common-place on mental health wards and can cause great distress to those affected, distress that may still be felt long after they leave hospital. That’s why we are working with partners to highlight this issue and make recommendations to improve sexual safety on mental health wards. Patients and staff must feel confident that any concerns will be followed up quickly and effectively and the appropriate action taken. 

“We are recommending new national guidance co-produced with people who use services, a strengthening of the reporting system so that it better reflects the impact of sexual incidents, and training to equip staff with the skills and knowledge to fully assess patient risk to help prevent incidents.
“Staff on mental health wards must work together with the police and local authority safeguarding teams to help ensure that people accessing mental health services are kept safe from sexual harm at what is a very vulnerable time in their lives.”

Dr Adrian James, Registrar of the Royal College of Psychiatrists, said: “The Royal College of Psychiatrists notes publication of the report and welcomes the recommendations made to improve sexual safety on mental health wards. 

“Sexual safety is of paramount importance for those providing and receiving treatment, and while the overwhelming majority of patients receive care in a safe environment, the report highlights that more needs to be done. The College is committed to working with the CQC and other agencies on taking the recommendations forward to ensure excellent and safe patient care.”


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