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CQC briefing – ‘Sexual safety on mental health wards’

The CQC recently published ‘Sexual safety on mental health wards’, detailing their findings in relation to a review of sexual safety incidents reported through the NHS National Reporting and Learning System by 54 mental health trusts. The CQC has spoken with providers, people who use services and voluntary and charity sector stakeholders. As a result of findings, the CQC has called for national guidance to improve sexual safety of people and staff on mental health wards.

Analysis of reports

The analysis of 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. The CQC notes that more than a third of the incidents could be categorised as sexual assault or sexual harassment of patients or staff.

97% of reports were classified by reporting organisations as ‘no harm’ or ‘low harm’. The CQC comments that without national guidance recognising the potential harm caused by unwanted sexual behaviour, those who are reporting on incidents may not fully appreciate the extent of the impact that sexual incidents can have on those involved.

Feedback from providers and people who use the service:

  • Clinical leaders of mental health services do not always know the best ways to promote the sexual safety of people using services and of their staff.
  • Many staff do not have the skills to respond appropriately to incidents.
  • It is likely incidents are under-reported and reports may not reflect the true impact on the person who is affected.
  • People who use services do not always feel that they are kept safe from unwanted sexual behaviour.
  • The ward environment does not always promote the sexual safety of people using the service.
  • Joint-working with other agencies such as the police does not always work well in practice.

National guidance and recommendations

The CQC encourages providers, commissioners and improvement organisations to work together to take the following actions to improve the sexual safety of service users:

  • The health and social care system must provide co-produced guidance to enable everyone who delivers mental health services to do the right thing about sexual safety. The guidance should cover:
    • 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.
    • recognition of the potential physical and psychological harm caused by those affected.
    • the support people who experience unwanted sexual incidents can expect.
  • Staff should be given the right training to enable them to put in place new national guidance for managing sexual safety incidents.
  • Leaders must also encourage staff to have open conversations about sexual safety with people who use services.
  • Providers, stakeholders, staff, people who use services, the police and safeguarding teams should work together on the approach to sexual safety incidents to make sure that disclosures are taken seriously and given the attention and sensitivity they deserve.

Examples of effective initiatives

The CQC provided the following as examples of effective initiatives:

  • provider embedded procedures and guidelines for staff on how to carry out risk assessments which looked at historical risks. When a risk was identified, staff responded by using enhanced observations in a personalised care plan.
  • matron, clinical psychologist and nurse consultant provided sexual safety awareness sessions to staff on a monthly basis and they have developed gender and trauma-informed care plans for individual patients.
  • joint-funding, with the police, of a neighbourhood beat manager to work with the patients and staff on the trust’s wards. The beat manager has worked with staff at the trust to develop protocols, together with easy to-follow flow charts and training for both police officers and inpatient staff to support areas for joint working. This means that there are clear, shared expectations about reporting and investigating offences committed in inpatient settings.

The report recommends that the CQC itself should strengthen the process of monitoring, assurance and regulation of this issue and of the factors that influence sexual safety and wellbeing. There are of course a number of issues arising from any concern regarding a sexual safety incident in any health and social care setting, not limited to the recording and reporting of the same.

Should you have any questions or require advice in relation to the report, a particular incident or regarding the implementation of measures to reduce risk please do not hesitate to contact us.

The full report can be accessed here:


This briefing is for guidance purposes only. RadcliffesLeBrasseur LLP accepts no responsibility or liability whatsoever for any action taken or not taken in relation to this note and recommends that appropriate legal advice be taken having regard to a client's own particular circumstances.

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