Safeguarding of Adults at Risk of Abuse and Neglect
Policy and Procedure
Name of Author:
Ratified By:
Ratification date:
Responsible Committee:
Reference Number:
Version
Issue Date
Next Review Date
Target Audience
Revision History
Version Revision Date
2 July 18
3 July 18
4 Aug 18
5 Nov 18
6 Sept 2020
7 March 2021
Domain: Care Management
Document Type: Policy (CM 004)
Maggie McDow Director of Clinical Governance
Board of Directors
July 18, September 2020
Board of Directors
CM 004
7
Nov 2018, Sept 2020
March 2021
Sept 2023
All Staff
Allocated new reference number
Additional Appendix
Change to terminology
Additional Appendix
Review of SG Guidance amalgamated into Policy.
Updated relevant legislation.
Removal of Group SG Lead reference
Clarification of the role of HR. Reporting to the
CQC. Staff understanding of ‘Raising a
Concern/Whistleblowing’ procedure
Page 1 of 13 Version: 7
CONTENTS

1. PURPOSE .............................................................................................................................. 3

2. AIM ......................................................................................................................................... 3

3. DEFINITIONS ......................................................................................................................... 3

4. POLICY - THE APPLICATION OF SAFEGUARDING DUTIES…………………………………..3

5. RESPONSIBILITIES ............................................................................................................... 5

6. PROCEDURE ......................................................................................................................... 7

7. RELEVANT LEGISLATION .................................................................................................. 11

8. REFERENCES ……………………………………………………………………………………….11

EQUALITY IMPACT ASSESSMENT TOOL

APPENDIX ASSOCIATED WITH THIS POLICY

APPENDIX 1 SAFEGUARDING REPORTING SUSPECTED ABUSE OR NEGLECT FLOWCHART
APPENDIX 2 SAFEGUARDING CONCERN REPORT
APPENDIX 3 SAFEGUARDING ENQUIRY TEMPLATE
APPENDIX 4 SAFGUARDING LOG

Domain: Care Management

Document Type: Policy (CM 004) Page 2 of 13 Version: 7
1. PURPOSE
This policy defines the principles and our responsibilities within Healthcare Homes Group Ltd to
ensure the safeguarding of adults at risk of abuse and neglect. This policy is designed to conform
to the requirements of the Care Act 2014 and the requirement of Regulation 13 of the Health and
Social Care Act 2008 (Regulated Activities) Regulations 2014. Regulation 13 is one of the
fundamental standards of care and treatment and relate to residents and service users being
protected from abuse and improper treatment. This is intended to protected people from the risk of
abuse and neglect.

2. AIM
The aim of this policy is to ensure we are doing our utmost to promote our residents and service
user’s health and well-being, which includes preventing and stopping the risks and experience of
abuse and neglect. In the event of abuse and neglect occurring, we will demonstrate that we have
dealt with the abuse and neglect, in line with the safeguarding principles set out in the Care Act and
the specific requirements of the Local Authority.

We aim to
• ensure that all staff working for, or on behalf of Healthcare Homes Group Ltd, understand
their responsibilities in relation to safeguarding adults at risk and know who to escalate
concerns to.
• To manage the safety and wellbeing of adults in line with the six principles of safeguarding.
• To identify lessons to be learned from cases where adults have experienced abuse or
neglect.
• To support and empower each adult to make choices, to have control over how they want
to live their own lives and to prevent abuse and neglect occurring in the future which is a key
underpinning principle of Making Safeguarding Personal (MSP).
• Take this approach with all safeguarding concerns.

3. DEFINITIONS
Safeguarding means protecting an adult’s right to live in safety, free from abuse and neglect. It
means working together to prevent and stop abuse, while at the same time making sure the adult’s
well-being is promoted, including, where appropriate having regard to their views, wishes, feelings
and beliefs in deciding on any action.

Professional and other staff should not be advocating “safety” measures that do not take account
of individual well-being. (As defined in the Care Act Section 1)

Abuse is a violation of an individual’s human and civil rights by any other person or persons.

Neglect is the failure to provide necessary care, assistance and attention.

4. POLICY - THE APPLICATION OF SAFEGUARDING DUTIES

We aim to provide services that will be appropriate to the adult at risk and not discriminate because of
disability, age, gender, sexual orientation, race, religion, culture, or lifestyle. We will make every effort
to enable Residents/Service Users to express their wishes and make their own decisions to the best
of their ability, recognising that such self-determination may well involve risk.

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We will work with Residents/Service Users and others involved in their care, to ensure they receive
the support and protection they may require; that they are listened to and treated with respect
(including their property, possessions and personal information) and that they are treated with
compassion and dignity

We will follow the six principles as set out in guidance to the Care Act 2014 and this will inform
practice with all Residents/Service users:
• Empowerment – People being supported and encouraged to make their own decisions and
informed consent
• Prevention – It is better to act before harm occurs
• Proportionality – The least intrusive response appropriate to the risk presented
• Protection – Support and representation for those in greatest need
• Partnership – Local solutions through services working with their communities. Communities
have a part to play in preventing, detecting and reporting neglect and abuse
• Accountability – Accountability and transparency in delivering safeguarding

The safeguarding duties apply to ANY adult who:

• Has care and support needs
• Is experiencing, or is at risk of abuse and neglect
• Is unable to protect themselves from either the risk or experience of abuse, because of their
care and support needs

An adult with care and support needs may be:

• An older person
• A person with physical disability, a learning difficulty or a sensory impairment
• A person with a long-term health condition
• Someone who misuses substances or alcohol to the extent that it affects their ability to
manage day to day living

Adult safeguarding duties apply in whatever setting people live, except for prison and bail hostels.
They apply regardless of whether someone can make decisions for themselves at a specific time.

People with care and support needs are not inherently vulnerable, but they may come to be at risk
or neglect at any point due to:
• Physical or mental ill health
• Becoming disabled
• Getting older
• Not having support networks
• Inappropriate accommodation
• Financial circumstances
• Being socially isolated

Healthcare Homes Group Ltd understands the importance of working collaboratively to ensure that:
• The needs and interests of adults at risk are always respected and upheld
• The human rights of adults at risk are respected and upheld
• A proportionate, timely, professional and ethical response is made to any adult at risk who
may be experiencing abuse
• All decisions and actions are taken in line with the Mental Capacity Act 2005
• Each adult at risk maintains:
o Choice and control
o Safety
o Health
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 o Quality of life
o Dignity and respect

Local Authorities also have safeguarding responsibilities for carers and a general duty to promote the
wellbeing of the wider population in the communities they serve.
(Care Act Guidance Department of Health 2014)

Our robust governance processes will make sure that staff working for and on behalf of Healthcare
Homes Group recognise and respond to the main forms of abuse which are set out in the Care Act
2014 Statutory Guidance Chapter 14, which is not an exhaustive list but an illustration as to the sort of
behaviour that could give rise to a safeguarding concern:

The following list is a guide as to the sorts of behaviour that could give rise to a safeguarding concern.
• Physical abuse – including assault, hitting, slapping, pushing, misuse of medication, restraint
or inappropriate physical sanctions
• Domestic violence – including psychological, physical, sexual, financial, emotional abuse;
so called “honour” based violence.
• Sexual abuse – including rape, indecent exposure, sexual harassment, inappropriate
touching or looking, sexual teasing or innuendo, sexual photography, subjection to
pornography or witnessing sexual acts, indecent acts and sexual assault or sexual acts to
which the adult has not consented or was pressured into consenting
• Psychological abuse – including emotional abuse, threats of harm or abandonment,
deprivation of contact, humiliation, blaming, controlling, intimidation, coercion, harassment,
verbal abuse, cyber bullying, isolation or unreasonable and unjustified withdrawal or
services or supportive networks.
• Financial or material abuse – including theft, fraud, internet scamming, coercion in relation
to an adult’s financial affairs or arrangements, including about wills, property, inheritance or
financial transactions, or the misuse or misappropriation of property, possessions or benefits
• Modern slavery – encompasses slavery, human trafficking, forced labour and domestic
servitude. Traffickers and slave masters use whatever means they have at their disposal to
coerce, deceive and force individuals into a life of abuse, servitude and inhumane treatment
• Discriminatory abuse – including forms of harassment, slurs or similar treatment; because
of race, gender and gender identity, age, disability, sexual orientation or religion.
• Organisational Abuse – including neglect and poor care practice within an institution or
specific care setting such as a hospital or care home, for example, or in relation to care
provided in one’s own home. This may range from one-off incidents to on-going ill treatment.
Whether it be through neglect or poor professional practice as a result of the structure,
policies, processes and practices within an organisation.
• Neglect and acts of omission – including ignoring medical, emotional or physical care needs,
failure to provide access to appropriate health, care and support or educational services, the
withholding of the necessities of life such as medication, adequate nutrition and heating
• Self-Neglect – this covers a wide range of behaviour neglecting to care for one’s personal
hygiene, health or surrounding and includes behaviour such as hoarding. Events may be
one-off or multiple and affect one person or more.

5. RESPONSIBILITIES
COMPANY RESPONSIBILITIES

Healthcare Homes Group Ltd upholds an adult’s right to live in safety, free from abuse and
neglect. We have a zero- tolerance approach to abuse, neglect, unlawful discrimination and
restraint. This includes:
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 • Neglect
• Subjecting people to degrading treatment
• Unnecessary or disproportionate restraint
• Deprivation of liberty

It is the responsibility of Healthcare Homes Group Ltd to ensure that:

• Multi-agency procedures are developed and implemented to protect adults from abuse and
neglect.
• Principles are upheld so that agencies involved, work together and actively promote the
empowerment and well-being of residents and service users.
• Staff are aware that adults are at risk of abuse and neglect.
• Staff receive training on how to deal with suspected abuse and neglect
• Ensure that there is adequate support for any individual involved in an investigation of
allegations of abuse.
• There are robust recruitment procedures in place
• There is Director level oversight of all safeguarding matters ensuring compliance with the
requirements of the Care Act and Regulation 13 of the Health and Social Care Act 2008
(Regulated Activities) Regulations 2014.

REGISTERED MANAGERS RESPONSIBILITIES

It is the responsibility of the Registered Manager to ensure that they:
• Understand their roles and responsibilities in relation to our policy and procedure to prevent
abuse and neglect
• Are aware of their individual responsibilities to prevent, identify and report abuse when
providing care and support within the requirement of Regulation 13
• Work within the requirements of the Mental Capacity Act 2005 whenever they work with
people who may lack the mental capacity to make some decisions
• Embrace, and be compliant with, the requirements of the local Safeguarding Adults Board
policies and procedures
• Are Compliant with Healthcare Homes Group Ltd recruitment procedures
• Healthcare Homes Group Ltd policies and best practice guidelines are readily available to
staff and our residents and service users, and that staff understand these and comply with
guidance.
• Staff understand the different forms of abuse and neglect, recognise the signs and
symptoms, who the abusers might be, and how to act if they suspect or are told of allegations
of abuse and neglect.
• Prompt communication is undertaken in the event of suspected abuse and neglect, informing
the Regional Director/Manager. A concern then must be raised with the Multi Agency
Safeguarding Hub Team.
• A Notification is completed and sent to the Care Quality Commission when any actual abuse
occurs, or allegation of abuse is received.
• The Safeguarding concern is logged on Sentinel Safeguarding Module and updated
accordingly.
• A root cause analysis, lessons learned, and further auditing will be conducted to determine
themes to improve care practice
• If requested to do so by the Local Authority, an enquiry in respect of suspected abuse and
neglect is carried out sensitively, at the required level and within a specified time frame.
• Where there are allegations of abuse and neglect are against a member of staff, he /she will
be treated with sensitivity and given appropriate support.

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STAFF RESPONSIBILITIES
It is the responsibility of staff to:
• Report any allegation or suspicion of abuse immediately to the Registered Manager.
• Be familiar with the requirements of Healthcare Homes Group Ltd Safeguarding of Adults at
Risk of Abuse and Neglect Policy and Safeguarding of Adults at Risk of Abuse and Neglect
Guidance
• Know and be able to give examples of the different forms of abuse and neglect.
• Recognise the signs and symptoms of abuse and neglect.
• Understand who the abusers might be.
• Listen to and understand those who say they have been abused or neglected.
• Be prepared to accept the possibility of abuse and neglect where least expected.
• Be familiar with and follow the procedure for reporting to the Registered Manager any
incident of suspected abuse and neglect.
• Be familiar and understand Healthcare Homes Group Ltd Raising a Concern/Whistleblowing
policy for circumstances where any allegation is not taken seriously at any official level
• During induction training, all employees will complete the “Safeguarding Adults’ workbook
produced by Skills for Care for the Care Certificate

6. PROCEDURE
Please also refer to (Appendix 1) Reporting Suspected Abuse and Neglect Flowchart

We must have a robust procedure and process to prevent people from being abused by staff or other
people who may have contact with them when using the service, including visitor.

Abuse and improper treatment include care and treatment that is degrading for people and care or
treatment that significantly disregards their needs or that involves inappropriate recourse to restraint.
For these purposes’ “restraint” includes the use or threat of force, and physical, chemical or
mechanical methods of restricting liberty to overcome a person’s resistance to the treatment in
question.

Where any form of abuse is suspected, occurs or is discovered, or reported to a third party we must
take appropriate action without delay. The action we must take includes raising a concern to the Multi
Agency Safeguarding Hub.

Staff must understand how they might share information relating to people who use our service. Care
staff need to be particularly alert to the risk of abuse occurring, and if it does arise dealing with the
alleged abuse. If something goes wrong and a resident or service user is subjected to abuse and
safeguarding procedures where not initiated this could be seen to be non-compliant to the current
regulations referred to above.

Making it personal
Our approach to safeguarding must be personal, in that it should be person centred and outcome
focused. It engages the person in a conversation about how best to respond to their safeguarding
situation in a way that enhances involvement, choice and control as well as improving quality of life,
well-being and safety.

Staff will follow the six key principles set out above in this policy that apply to all sectors and settings
including care and support services and should inform the ways in which professionals and other staff
work with adults.
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Mitigating the risk of Abuse and Harm
Healthcare Homes Group Ltd are committed to ensuring that we employ staff who will uphold the
rights of people using our service to live safely, free from abuse and neglect. Healthcare Homes
Group Ltd will ensure the following actions are strictly adhered to.

All staff:
will under-go thorough vetting through our recruitment process including written references
in accordance with HHG recruitment policy
• will have an enhanced DBS check
• are provided thorough induction and follow up training, information relating to safeguarding
adults, our policy, and our expectation of their responsibilities in respect of ensuring the
policy is adhered to
• are issued with clear guidance as to actions to be taken where abuse and neglect is
suspected, occurs or is discovered
• receive a copy of HHG Diversity and Equality Policy, read and sign to confirm they
understand
• receive our policy on the receipt of gifts, making of wills, handling customers’ monies and
ensuring safe keeping, read and sign to confirm they understand
sign a declaration regarding confidentiality within their employment contract agreement
• regularly undergo supervision and spot checks in accordance with HHG Supervision Policy
• will comply with the principles of the Mental Capacity Act 2005
• will comply with the policy of ‘key holding’ for people using our service (MCC Home Care)
• will complete daily communication log sheets and use an Electronic Monitoring system
(MCC Home Care)
• will be given a copy and understand our complaints and compliments policy
• will receive a copy of HHG ‘How to Raise a Concern Policy’, read and sign to confirm they
understand the process raising a concern for circumstances where any allegation is not
taken seriously at any official level

Information for people using our service

All people using our service will have explained and given to them:
• ‘How to Raise a Concern’ procedure including our partners key telephone numbers should
they be concerned about possible abuse and neglect
• a copy of our complaints and compliment policy
• Key Healthcare Homes Group Ltd contact telephone numbers should they have any
concerns

Identifying signs of abuse

Staff need to be vigilant about adult safeguarding concerns. It is important that staff:
• Receive training about different types of abuse and neglect and their signs
• Support adults to keep safe
• Know who to tell about suspected abuse or neglect
• exercising choice and control

Reporting – See Appendix 1

Any suspected, occurring or discovered abuse and or neglect must be reported immediately to the
Registered Manager. The Manager should inform their immediate Line Manager who will be available
to offer support and advice.

The concern should be logged without delay on the Sentinel (Risk Management web-based system)
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Document Type: Policy (CM 004) Page 8 of 13 Version: 7
Safeguarding module. A trigger alert will then be automatically generated to Senior Management.

The chronological section of the module should be commenced as soon as possible, and full written
reports completed and uploaded to the system where appropriate. This evidences the actions you
have taken.

If the concern is being raised against another provider/family member/friend, it is logged on Appendix
2 Safeguarding Concern Report and retained as a hard copy in the file at the Registered Location as
evidence of our Duty of Care.

The primary focus must be how to safeguard the adult concerned.

The Manager will then decide what action is to be taken including raising a concern to the MASH
team. The Manager must ensure that any initial advice/action from the MASH team is adhered to
whilst also ensuring compliance in line with Healthcare Homes Group Ltd policy and reported back to
staff.

The nature and timing of any concern or enquiry and who is best placed to lead will depend on the
circumstances. In exceptional circumstances, staff must remove themselves from any potential
danger.

The ‘Raising a Concern Requirements’ of Local Authorities may differ and must be adhered to by the
Registered Location.

Concerns relating to staff members

If we are aware of abuse or neglect in Healthcare Homes Group Ltd, then we are under a duty to
correct this and protect the adult from harm as soon as possible and inform the Local Authority, or
CCG (if commissioner) and the CQC.

If the Local Authority has reasonable cause to suspect that an adult may be experiencing or at risk of
abuse or neglect, then it is still under a duty to make whatever enquiries it thinks necessary to decide
what, if any, action needs to be taken and by whom.

The Local Authority may well be re-assured by our response so that no further action is required.
However, the Local Authority must satisfy itself that our response as an employer/registered provider
of care, has been enough to deal with the safeguarding issue.

We should investigate the concern unless there is compelling reason why it is inappropriate or unsafe
to do so. For example, there could be a serious conflict of interest on the part of the employer,
concerns having been raised about non-effective past enquiries or serious multiple concerns or a
matter that requires investigation by the Police.

Where a member of staff is alleged to have abused or neglected a person using our service, the
Manager must seek advice from the Regional Director/Manager, if suspension is necessary pending
an investigation. Advice should also be sought from HR. The HR advice sought should solely be on
the 'mechanics and correct procedure of suspension' and not whether or not a suspension should
occur, as that is a management decision. The key issue to be considered is whether the member of
staff poses a potential risk to other people using the service or other staff. Please note suspension
can only be authorised by a Director.

Any decision to remove staff to ensure everyone is safeguarded must be discussed with the Regional
Director/Manager and if necessary, the Operations Director and the Chief Operating Officer.

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Referrals to Disclosure and Barring Services
If a member of staff is removed by being either dismissed or re-deployed to a non- regulated activity,
from their role providing regulated activity following a safeguarding incident or a person leaves their
job (resigns or retires) to avoid a disciplinary hearing following a safeguarding incident and we feel
that we would have dismissed the staff member based on the information we held, then we have a
legal duty to refer to the Disclosure and Barring Service.

Conducting a Section 42 Enquiry

It is the Local Authority who must make enquiries under Section 42 of the Care Act or assign others to
do so if the LA reasonably suspects an adult meets the criteria as being at risk of abuse or neglect.

The Care Act requires local authorities to make proportionate enquiries where there is a concern
about possible abuse or neglect of an adult at risk, an enquiry could range from having a conversation
with the adult, prior to initiating a formal enquiry under Section 42 of the Care Act, through to a multi-
agency plan of course of action. The purpose of the enquiry is to decide whether the Local Authority,
or another organisation, or person, should do something to help and protect the adult.

If the Local Authority decides that HHG should undertake the enquiry then it will decide the timescale,
the need to know the outcomes and what action will follow if this is not done. What happens as a
result of an enquiry should reflect the adult wishes wherever possible, or by their representative or
advocate. If they lack capacity, it should be in their best interests if they are not able to make the
decision and be proportionate to the level of concern. It is important that the six safeguarding
principles are also considered in determining the next course of action.

Whatever form the enquiry takes the following must be recorded using (Appendix 3) Safeguarding
Adults Enquiry Template:
• Details of the safeguarding concern and who raised it
• The views and wishes of the adult affected, at the beginning and overtime and where
appropriate the views of their family
• Any immediate action agreed with the adult or their representative
• The reasons for all actions and decision
• Details of who else is consulted or the concern is discussed with
• Any timescales agreed for actions
• Enquiry sign off from the Regional Manager and Safeguarding lead

Further actions and safeguarding plans

The enquiry findings must be reported back to the Local Authority. It is for the Local Authority to
determine the appropriateness of the outcome of the enquiry and whether any further action or
safeguarding plans need to be discussed with the adult. This could be further focused safeguarding or
protection planning.

Safeguarding Adult Review Board

The Safeguarding Adults Review Board must arrange a review when an adult dies because of abuse
or neglect, whether known or suspected and there is concern that partner agencies could have
worked more effectively to protect the adult.

The Board must also arrange for a review to take place if any adult in its area has not died, but the
Board suspects that the adult has experienced serious abuse or neglect.

The review must be focussed to determine what the relevant agencies and individuals involved in the
case might have done differently that could have prevented harm or death.

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 7. RELEVANT LEGISLATION
• Domestic Violence, Crime and Victims Act 2004
• The Counter Terrorism and Security Act 2015
• The Modern Slavery Act 2015
• Anti-social Behaviour, Crime and Policing Act 2014
• The Criminal Justice and Courts Act 2015 Section 20-25
• Public Interest Disclosure Act 1998
• Protection of Freedoms Act 2012 (Disclosure and Barring Service Transfer of Functions)
Order 2012
• The Care Act 2014
• Care Quality Commission (Registration) Regulations 2009
• Equality Act 2010
• Human Rights Act 1998
• Mental Capacity Act 2005
• Safeguarding Vulnerable Groups Act 2006
• The Health and Social Care Act 2008 (Regulated Activities) (Amendment) Regulations 2012
• Serious Crime Act 2015 Section 76

8. REFERENCES
• Department of Health, (2020), Care and support statutory guidance.
https://www.gov.uk/government/publications/care-act-statutoryguidance/
• care-and-support-statutory-guidance
• Social Care Institute for Excellence, (2019), Safeguarding adults: sharing
• information. https://www.scie.org.uk/care-act-2014/safeguarding-adults/sharing-
information/
• The Ministry of Justice, (2015), Criminal Justice and Courts Act 2015: Explanatory Notes.
http://www.legislation.gov.uk/ukpga/2015/2/notes/contents
• London ADASS, (2019), London Multi-Agency Adult Safeguarding Policy and
• Procedures. http://londonadass.org.uk/wpcontent/uploads/2019/05/2019.04.23-Review-of-
the-Multi-Agency-Adult-Safeguardingpolicy-and-procedures-2019-final-1-1.pdf
• NHS England, (2018), Accessible Information Standard.
https://www.england.nhs.uk/ourwork/accessibleinfo
• Department of Health and Social Care, (2018), Safeguarding Adults Protocol Pressure
Ulcers and the interface with a Safeguarding Enquiry.
https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_
data/file/675192/
• The Royal College of Nursing on behalf of the contributing organisations,
• (2018), Adult Safeguarding: Roles and Competencies for Health Care Staff.
https://www.rcn.org.uk/professional-development/publications/pub-007069
• NHS England, (2017), Prevent Training and Competencies Framework.
https://www.england.nhs.uk/wp-content/uploads/2017/10/preventtraining-
• competencies-framework-v3.pdf
• Home Office, (2018), Criminal Exploitation of children and vulnerable adults:
• County Lines guidance.
https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_
data/file/741194/
• Local Government Association, (2017), Making Safeguarding
Personal.https://www.local.gov.uk/our-support/our-improvementoffer/care-and-health-
improvement/making-safeguarding-personal
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 • CQC, (2018), Statement on CQC’s roles and responsibilities for safeguarding children and
adults.
https://www.cqc.org.uk/sites/default/files/20190621_SC121706_CQC_statement_February
_2018_v3
• CARE QUALITY COMMISSION, (2020), Promoting sexual safety through
• Empowermenthttps://www.cqc.org.uk/sites/default/files/20200225_sexual_safety_sexuality.pdf

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 EQUALITY IMPACT ASSESSMENT TOOL

Equality Impact Assessment Tool Yes/No Comments

1. Does the policy affect one group less or more

favourably than another on the basis of:
Race No
Ethnic origins (including gypsies and travellers) No
Nationality No
Gender No
Culture No
Religion or belief No
Sexual orientation including lesbian, gay and No
bisexual people
Age No
Disability - learning disabilities, physical disability, No
sensory impairment and mental health problems
2. Is there any evidence that some groups are affected No
differently?
3. If you have identified potential discrimination, are No
any exceptions valid, legal and/or justifiable?
4. Is the impact of the policy/guidance likely to be No
negative?
5. If so can the impact be avoided? N/A
6. What alternatives are there to achieving the No
policy/guidance without the impact?
7. Can we reduce the impact by taking different No
action?

If you have identified a potential discriminatory impact of this procedural document, please refer it
to Healthcare Homes Group Human Resources, together with any suggestions as to the action
required to avoid/reduce this impact.

For advice in respect of answering the above questions, please contact Healthcare Homes Group
Human Resources