Equality Diversity and Human Rights
This module is for WMI Psychiatry administration staff who communicate with patients, families, representatives, colleagues and external organisations.
Version: 1.0
Document owner: Registered Manager
Approved by: Nominated Individual
Approval date: 01 September 2026
Review date: 01 January 2027
Training frequency: On induction and annually, or sooner following a material change
Assessment pass mark: 12 out of 15
This module supports staff training. It does not replace WMI Psychiatry policies, clinical judgement, management advice or legal advice.
1 Purpose and scope
Equality, diversity and human rights affect every contact with a patient.
Administration staff influence whether people can access the service, communicate safely, participate in decisions and feel respected. An apparently neutral booking rule, form, telephone process or communication method can create a serious barrier for some people.
This module explains:
what equality, diversity, inclusion and human rights mean in healthcare
the protected characteristics under the Equality Act 2010
how discrimination, harassment and victimisation may arise
the duty to make reasonable adjustments for disabled people
how to identify and meet communication needs
how dignity, privacy, autonomy and family life relate to administrative work
how bias, assumptions and stigma can affect access to mental health services
how to respond to discriminatory behaviour or an adjustment request
how to record, escalate and learn from concerns
how equality and human rights interact with complaints, safeguarding, capacity and data protection
The Equality Act 2010 prohibits specified forms of discrimination, harassment and victimisation in areas including services and employment.
The Human Rights Act 1998 makes it unlawful for public authorities, and organisations when exercising functions of a public nature, to act incompatibly with Convention rights.
CQC Regulation 9 requires person-centred care. CQC Regulation 10 requires people to be treated with dignity and respect.
This module does not authorise administration staff to:
decide whether unlawful discrimination has occurred
decide whether a human rights breach has occurred
decide whether a person is disabled for legal purposes
refuse an adjustment solely because it is inconvenient
make clinical decisions about capacity, risk, diagnosis or treatment
routinely demand medical evidence before recording an adjustment request
disclose information about a protected characteristic without a lawful and necessary reason
investigate allegations independently
confront the person complained about
promise a particular complaint, disciplinary or legal outcome
Administration staff must listen, reduce immediate barriers where authorised, record the person’s needs accurately and escalate concerns to the appropriate lead.
2 Learning outcomes
By the end of this module, staff should be able to:
Explain equality, diversity, inclusion and human rights in clear language.
Name the nine protected characteristics in the Equality Act 2010.
Recognise that the Act applies differently to service provision and employment.
Recognise possible direct and indirect discrimination.
Recognise discrimination arising from disability and failure to make reasonable adjustments.
Recognise possible harassment, sexual harassment and victimisation.
Explain why treating everyone identically does not always produce equality.
Recognise an adjustment request even when the person does not use legal language.
Respond appropriately to communication and accessibility needs.
Avoid assumptions based on diagnosis, identity, appearance, accent, age or family circumstances.
Protect dignity, privacy, confidentiality, choice and autonomy.
Identify human rights that are especially relevant to health and mental health services.
Respond safely when discriminatory, degrading or abusive behaviour is reported.
Record facts and preferences without judgemental or unnecessary language.
Escalate unresolved barriers and equality or human rights concerns promptly.
3 WMI Psychiatry contacts and procedures
These details must be confirmed before the module is issued.
Internal contacts
Registered Manager: Caroline Lawrence
Nominated Individual: Dr James Glass
Equality Diversity and Human Rights Lead: Registered Manager
Responsible clinician: Registered Manager
Safeguarding Lead: Registered Manager
Complaints Lead: Registered Manager
Data Protection Lead: Nominated Individual
Human resources contact: Nominated Individual
Out-of-hours escalation: Registered Manager or Nominated Individual
Systems and records
Adjustment recording location: [INSERT APPROVED RECORD AND LOCATION]
Incident reporting system: WMI Psychiatry Incident Reporting System
Location of current policies: WMI Google Drive
Staff must know
Before completing this module, staff must know:
how to record a communication need or adjustment
how to make that information visible to authorised staff
who can approve changes affecting clinical delivery, cost, staffing or security
how to obtain an interpreter
how to arrange accessible information
how to report discrimination, harassment, bullying or victimisation
how to escalate an immediate safeguarding or safety concern
where the Equality, Diversity and Human Rights Policy is stored
what to do if an adjustment cannot be provided immediately
4 Equality diversity inclusion and human rights
Equality
Equality means removing unlawful discrimination and avoidable disadvantage so people can access and use services fairly.
Equality does not always mean identical treatment. A disabled person may need a different communication method, more time or another reasonable adjustment to obtain comparable access.
Diversity
Diversity describes differences between people, including identity, background, experience, communication, health, culture and perspective.
Good administration does not require staff to know everything about every group. It requires respectful curiosity, accurate information and a willingness to ask what the individual needs.
Inclusion
Inclusion means designing and delivering processes so people can participate, understand and be heard.
Inclusion is demonstrated through practical access, not merely through a statement of welcome.
Human rights
Human rights protect basic interests such as:
life
freedom from degrading treatment
liberty
privacy
family life
religion and belief
expression
protection from discrimination in the enjoyment of other rights
Some human rights are absolute. Others may be restricted only when there is a lawful and proportionate reason.
Administration staff should recognise when a process may affect a person’s rights and obtain advice. They must not attempt to make complex legal decisions themselves.
5 The Equality Act 2010
The Equality Act 2010 brings together legal protection against discrimination.
WMI Psychiatry is a service provider and an employer. Different parts of the Act may therefore apply to different situations.
The nine protected characteristics
The protected characteristics are:
age
disability
gender reassignment
marriage and civil partnership
pregnancy and maternity
race, including colour, nationality and ethnic or national origins
religion or belief, including lack of religion or belief
sex
sexual orientation
All nine characteristics matter in employment.
The detailed protection applying to services differs in some respects. For example, marriage and civil partnership is not protected under Part 3 in the same way as it is in employment. Protection from age discrimination in services generally applies to adults aged 18 and over.
Staff must not use technical distinctions to dismiss a concern. Record the information and escalate it for an authorised decision.
The Equality Act 2010 Code of Practice for services, public functions and associations explains that equality may require different treatment, including reasonable adjustments and lawful positive action.
6 Forms of unlawful conduct
Direct discrimination
Direct discrimination generally means treating a person less favourably because of a protected characteristic.
Protection can sometimes include discrimination because someone:
is assumed to have a protected characteristic
is associated with another person who has a protected characteristic
Example: A member of staff refuses to book a patient because they believe people from a particular religion will be difficult.
Indirect discrimination
Indirect discrimination can arise when a provision, criterion or practice:
is applied to everyone
places people who share a protected characteristic at a particular disadvantage
places the individual concerned at that disadvantage
cannot be objectively justified
Example: Requiring every patient to communicate only by telephone may disadvantage Deaf people and people whose disability makes telephone communication difficult.
Discrimination arising from disability
This can occur when a disabled person is treated unfavourably because of something arising from their disability and the treatment cannot be justified.
The legal test includes whether the organisation knew, or could reasonably have been expected to know, about the disability.
Example: A patient’s care is cancelled because they repeatedly miss telephone calls, even though the record states that their condition makes telephone communication difficult.
Failure to make reasonable adjustments
Service providers have an anticipatory duty to consider barriers affecting disabled people generally. They must also respond appropriately to individual disadvantage.
The duty may require:
changing a rule, policy or practice
providing an auxiliary aid or service
changing or addressing a physical feature
Disabled people must not be charged for a reasonable adjustment.
Harassment and sexual harassment
Harassment includes unwanted conduct related to a protected characteristic that has the purpose or effect of:
violating a person’s dignity
creating an intimidating environment
creating a hostile environment
creating a degrading, humiliating or offensive environment
Sexual harassment is unwanted conduct of a sexual nature that has this purpose or effect.
The precise legal coverage depends on the context. All reports of harassment must be taken seriously and escalated.
Victimisation
Victimisation means subjecting someone to a detriment because they:
made an allegation of discrimination
supported another person’s allegation
provided evidence or information
took another protected action under the Equality Act
are believed likely to take such action
Staff must not give someone poorer service, delay their communication, describe them as difficult or discourage them from raising a concern because they complained about discrimination.
7 Equal treatment and equitable access
Treating everyone identically can preserve a barrier.
Staff should apply consistent standards while adapting the method where necessary.
Example 1
Identical process: Every appointment reminder is made by telephone.
Equitable response: Record and use the patient’s accessible communication method where it is available, appropriate and safe.
Example 2
Identical process: Every patient receives the same standard-length appointment.
Equitable response: Escalate a request for additional time where disability or communication needs make it necessary.
Example 3
Identical process: Every form must be completed online.
Equitable response: Offer or arrange an accessible alternative for someone who cannot use the online form.
Example 4
Identical process: Family involvement follows one standard pattern.
Equitable response: Check consent, authority, capacity, age and the patient’s wishes before sharing information.
A different process is not preferential treatment when it removes a relevant disadvantage or meets an individual need.
8 Reasonable adjustments
An adjustment request does not need to include the words “reasonable adjustment” or “Equality Act”.
A person may say:
“I cannot manage telephone calls because of my condition. Please email me.”
“I need written information after the appointment.”
“I use a screen reader and cannot open this form.”
“I need my support worker to be present.”
“I need more time to process questions.”
“I cannot wait in a crowded room.”
“Please text me before calling.”
“I need a break during longer appointments.”
When a need is identified, administration staff should:
Listen and clarify the barrier and the outcome the person needs.
Check the person’s preferred and safe communication method.
Make the adjustment if it is within their authority and safe to do so.
Escalate promptly if clinical input, cost, system change, security approval or management authority is required.
Record the need and agreed adjustment in the approved place.
Record who is responsible for arranging the adjustment.
Record any relevant review date.
Confirm the arrangement with the person in an accessible form.
Check whether the adjustment worked.
Update the record if the person’s needs change.
If the requested adjustment cannot be provided, do not simply refuse it. Escalate the request and consider an effective alternative with the person.
What is reasonable depends on the circumstances. Administration staff should not make the final legal decision about reasonableness unless this is explicitly part of their authorised role.
9 Accessible information and communication
The Accessible Information Standard requires health and adult social care organisations within its scope to identify, record, flag, share and meet the information and communication needs of people with a disability, impairment or sensory loss.
WMI Psychiatry must confirm how the Standard applies to each service arrangement. The same practical process should be used as good practice across the service.
Identify
Ask what the person needs to communicate and understand information.
Record
Record the need clearly and factually in the approved place.
Flag
Make the need visible to authorised staff at the point of contact.
Share
Share the need lawfully with staff or organisations involved in the person’s care.
Meet
Provide or arrange information and communication in the required form.
Review
Check that the arrangement worked and update it when the person’s needs change.
Further information is available in the NHS England Accessible Information Standard requirements.
Examples of communication support
Support may include:
British Sign Language interpretation
professional spoken-language interpretation
Easy Read information
large-print information
screen-reader-compatible documents
email or text instead of telephone contact where safe and agreed
plain language
shorter pieces of information
additional processing time
opportunities to ask questions
communication through an authorised advocate or supporter
written information following a telephone or video discussion
Do not use a child as an interpreter.
Avoid using a family member for sensitive clinical interpretation unless an authorised lead has considered confidentiality, accuracy, consent and risk.
10 Disability neurodivergence and mental health
A disability may be:
physical
sensory
cognitive
related to mental health
visible or non-visible
permanent, fluctuating or episodic
Autism, attention deficit hyperactivity disorder, learning disabilities and long-term mental health conditions may meet the legal definition of disability, depending on their effect.
Staff must not demand that someone look disabled or disclose a diagnosis before their communication need is taken seriously.
Administration staff should:
ask what helps instead of inferring needs from a label
avoid interpreting distress as rudeness
avoid interpreting reduced eye contact as dishonesty
avoid interpreting unusual speech or delayed replies as lack of capacity
avoid describing difficulty with forms as a lack of cooperation
use literal and unambiguous language when this helps
reduce unnecessary repetition and transfers between staff
allow extra time where authorised
record environmental needs or triggers when relevant and appropriate
escalate clinical or safeguarding risk without attributing every concern to a diagnosis
11 Race ethnicity nationality and language
Race includes:
colour
nationality
ethnic origins
national origins
A person’s accent, surname, address or nationality must not influence the quality, urgency or courtesy of service they receive.
A language need is not evidence of a lack of capacity, intelligence or consent.
Administration staff should:
use a professional interpreter where accurate communication is necessary
avoid asking a patient to bring a relative to interpret sensitive information as the default solution
record the person’s preferred language
record any interpretation requirement
challenge or report racial slurs and stereotyping
report differential treatment
avoid assumptions about immigration status or entitlement
avoid inferring religion or family structure from appearance, nationality or accent
12 Religion belief and cultural needs
Religion or belief includes a lack of religion or belief.
Staff should identify practical needs without treating culture or faith as a fixed explanation for a person’s choices.
Relevant needs may involve:
appointment times
fasting
prayer
diet
modesty
the sex of a practitioner
the involvement of family
religious festivals or observances
Some requests can be met administratively. Others require clinical or management review.
Confirm what matters to the individual. Explain any genuine constraints and seek an authorised alternative where possible.
A person’s beliefs do not justify abuse or discrimination against patients or staff.
If rights or needs appear to conflict, do not decide the legal balance alone. Protect immediate safety, record the facts and seek management advice.
13 Sex gender reassignment and respectful records
Sex and gender reassignment are separate protected characteristics under the Equality Act.
The law and sector guidance in this area can be fact-specific. Staff must use current WMI Psychiatry policy and obtain management advice about any contested access, privacy or single-sex issue.
In ordinary administration, staff should:
address the person respectfully
use their stated name and form of address in communication
continue to meet identity-verification and safe record-matching requirements
distinguish a preferred name from identifiers required for safe record matching
avoid disclosing a person’s trans status or previous identity without a lawful and necessary reason
correct mistakes promptly and without prolonged debate
avoid intrusive questions that are unnecessary for care or administration
escalate concerns involving clinical relevance, safeguarding, record integrity or lawful service arrangements
Privacy, dignity, accurate records and safe identification must all be considered.
Staff must not create a duplicate clinical record merely to avoid a respectful conversation about record details.
14 Sexual orientation relationships and family
Do not assume:
that a patient is heterosexual
that their partner is of a particular sex
that a legal spouse is their chosen contact
that a person described as a friend has no important role
that every family follows the same structure
Use neutral questions such as:
“Who would you like us to contact?”
“What is their relationship to you?”
“Do we have your consent to discuss this information with them?”
“What information may we share?”
A partner or family member does not automatically have authority to receive confidential information.
Follow procedures covering:
consent
capacity
parental responsibility
legal authority
confidentiality
safeguarding
Treat same-sex partners and different family structures with the same courtesy and care as others.
15 Age children and young people
Age must not be used as a shortcut for:
capacity
digital ability
reliability
understanding
communication preference
interest in participating in decisions
Older people should not be assumed to need a relative to communicate for them.
Younger people should not automatically be excluded from information about their own care.
When a child or young person is involved, administration staff should follow procedures covering:
identity
parental responsibility
consent
competence
confidentiality
safeguarding
communication appropriate to the child’s age and understanding
Obtain advice before deciding who may receive detailed information.
16 Pregnancy maternity and caring responsibilities
Pregnancy and maternity are protected under the Equality Act.
Staff must not:
provide poorer access
make negative comments
assume that someone cannot participate because they are pregnant
treat someone unfavourably because they are breastfeeding
treat someone unfavourably because they are on maternity leave
Caring responsibility is not itself a protected characteristic. However, discrimination may still arise through association with a disabled person or through another protected characteristic.
Record practical needs and apply policy consistently. Do not dismiss them as personal inconvenience.
17 Human rights in health and mental health services
The Human Rights Act applies directly to public authorities. It can also apply to other organisations when they carry out functions of a public nature.
Whether a particular WMI Psychiatry activity is a public function may require legal or commissioning advice.
CQC-regulated care must still be delivered with dignity, respect and person-centred practice.
Article 2 right to life
Urgent messages, suicide-risk information and serious safety concerns must reach the correct clinician without delay.
Article 3 freedom from torture and inhuman or degrading treatment
Reports of degrading treatment, abuse or serious neglect require immediate escalation.
Article 3 is an absolute right.
Article 5 right to liberty and security
Accurate communication and records are important where a person’s liberty may be restricted.
Administration staff do not make detention decisions.
Article 8 respect for private and family life home and correspondence
Article 8 may be relevant to:
privacy
confidentiality
identity
personal autonomy
family involvement
telephone and written correspondence
information about a person’s health and relationships
Article 9 freedom of thought conscience and religion
Belief and religious practice should be respected, subject to lawful and proportionate limitations.
Article 10 freedom of expression
People may express views, criticism or disagreement, subject to lawful restrictions that protect safety and the rights of others.
Article 14 protection from discrimination
Convention rights must be secured without discrimination on the grounds covered by Article 14.
Some rights may be limited in defined circumstances. Administration staff must not decide whether interference with a qualified right is lawful or proportionate.
Record the facts and escalate the issue.
18 Dignity privacy choice and autonomy
Dignity is demonstrated through everyday administrative behaviour.
Staff should:
use a private setting for sensitive conversations
verify identity proportionately
explain why information is required
address the patient directly
give the person adequate time to respond
respect communication preferences
avoid discussing personal information where others can overhear
Staff must not:
use mocking, infantilising or judgemental language
refer to a person only by their diagnosis
speak only to a companion when the patient can participate
share information merely because a relative is insistent
pressure someone to disclose a protected characteristic that is not needed
circulate equality information that could identify someone without authority
make assumptions about a person’s wishes from their identity or background
19 Capacity consent and supported decision making
A diagnosis, communication difficulty or unusual decision does not by itself show that someone lacks capacity.
Capacity is:
presumed unless established otherwise
specific to the decision being made
specific to the time when the decision is required
Administration staff should support communication and refer concerns to an authorised clinician or manager under the Mental Capacity Act procedure.
Do not substitute a relative’s wishes for the patient’s wishes merely because communication takes longer.
When a representative claims legal authority:
Verify that authority through the approved process.
Record the nature of the authority.
Confirm what decisions or information it covers.
Obtain advice if anything is unclear.
Do not disclose confidential information until authority has been established.
20 Bias stereotyping and microaggressions
Bias can affect:
whose call is treated as urgent
whose account is believed
who is described as difficult
which adjustments are considered
how behaviour is interpreted
whether someone is included in communication
Staff should pause when a decision relies on a generalisation instead of relevant facts.
Examples of unacceptable behaviour include:
repeated comments about an accent
jokes about identity
deliberately mispronouncing a name after being corrected
assuming distress is attention-seeking
treating someone as dangerous solely because of a mental health diagnosis
asking intrusive questions unrelated to care
dismissing an adjustment because a disability is not visible
A single comment can cause harm even if the speaker says it was intended as a joke.
Record the words used and the effect reported. Do not debate the speaker’s intention during the initial response.
21 Digital and administrative barriers
Equality risks can be built into systems and routine processes.
Examples include:
online-only registration that cannot be used with a screen reader
automated reminders that ignore a recorded communication preference
forms with limited title, name or relationship options
requiring a fixed address when another safe contact method is available
short response deadlines that do not allow for an agreed adjustment
patient portals that cannot be used with assistive technology
scanned documents that cannot be read by accessibility software
algorithms or templates that reproduce biased assumptions
Do not work around a barrier by creating inaccurate information.
Record the limitation, provide a safe authorised alternative and report recurring system problems for improvement.
22 Responding to a concern or discriminatory incident
A patient, family member or colleague may report:
discrimination
harassment
sexual harassment
degrading treatment
victimisation
an unmet adjustment
inaccessible communication
discriminatory or abusive language
The first response should be calm and practical.
Administration staff should:
Check for an immediate clinical, safeguarding or personal safety concern.
Listen without debating the person’s identity or experience.
Acknowledge the concern.
Explain that it will be recorded and escalated.
Record the person’s own words.
Record relevant dates and times.
Record the barrier or conduct and its reported effect.
Preserve messages, call records and documents.
Notify the appropriate manager or lead without unnecessary delay.
Follow the complaints, incident, safeguarding, data protection or human resources procedure as applicable.
Confirm what will happen next.
Confirm how the person prefers to be contacted.
Helpful wording
“I am sorry this happened. I will record what you have told me and escalate it to the appropriate manager.”
“What change would help you access the service safely?”
“I cannot determine the legal position, but I can make sure the concern is reviewed.”
“Before we continue, can I check whether anyone is at immediate risk?”
“I will record your account accurately. May I confirm the best way to contact you?”
Wording to avoid
Do not say:
“We treat everyone the same, so it cannot be discrimination.”
“You do not look disabled.”
“That is just how the system works.”
“I am sure they did not mean it.”
“People like you often find this difficult.”
“You must provide a diagnosis before we will discuss an adjustment.”
“This is definitely a human rights breach.”
“Nothing can be done.”
“You are being too sensitive.”
“If you complain, it may affect your care.”
23 Discriminatory or abusive behaviour by a patient
Staff and other patients are also entitled to dignity and safety.
A protected characteristic, disability or health condition does not excuse threatening, abusive or discriminatory behaviour.
Administration staff should:
set a calm and clear boundary
obtain assistance where required
follow the unacceptable behaviour procedure
follow the safeguarding or incident procedure where applicable
record the actual words or behaviour
record any immediate action
avoid retaliatory or discriminatory language
continue to consider the person’s clinical needs and relevant adjustments
Any restriction on access to care must be:
authorised
based on evidence
informed by clinical risk
informed by relevant adjustment needs
lawful and proportionate
Administration staff must not make an unauthorised decision to end care.
24 Complaints safeguarding incidents and data protection
Complaints
An equality or human rights concern may also be a complaint.
The person does not need to:
quote legislation
identify a protected characteristic correctly
submit a formal written complaint before an immediate barrier is addressed
Record the complaint and address any immediate access or safety issue without waiting for the complaint investigation to finish.
Safeguarding
Discriminatory abuse, coercive control, neglect, exploitation, hate crime or degrading treatment may indicate a safeguarding concern.
Follow the safeguarding procedure immediately where a child or adult may be at risk.
Incident reporting
A failed adjustment, inaccessible communication or discriminatory act may also be a patient safety incident.
Submit an incident report where the event affected or could have affected safe care.
Data protection
Information about health, race, ethnic origin, religion, sexual orientation and other identity matters may be sensitive personal data.
Staff should:
record only information that is relevant and necessary
use approved systems
restrict access appropriately
share information only where there is an appropriate basis
avoid placing sensitive details in general administrative notes unnecessarily
avoid using equality-monitoring information to make assumptions about individual care
A concern may require several procedures at the same time. One procedure does not automatically replace another.
25 Record keeping
Records should be factual, respectful and useful.
Include:
the need or concern described by the person
the person’s preferred communication method
the barrier identified
the adjustment requested
alternatives discussed
what was agreed, declined or referred for a decision
the reason for an authorised decision where applicable
who is responsible for action
when action is due
any immediate safety or safeguarding action
who was informed
the date and time of escalation
the outcome
whether the adjustment worked
Appropriate record:
“The patient stated that telephone calls trigger severe anxiety and requested appointment information by email. The preference was added to the approved communication field. The request for written post-appointment information was sent to the responsible clinician at 11:20 am.”
Inappropriate record:
“Patient is difficult and refuses normal communication.”
Do not record a protected characteristic merely because it is interesting.
Record it when it is relevant, lawful and necessary. Use the person’s own terminology where appropriate.
26 Monitoring and organisational learning
WMI Psychiatry should use complaints, incidents, adjustment requests, access information and feedback to identify recurring barriers.
Data must be interpreted carefully. A low number of complaints may reflect access or trust problems rather than the absence of discrimination.
Useful review questions include:
Are adjustment requests completed?
Are adjustments visible to the staff who need the information?
Are agreed adjustments delivered consistently?
Are patients repeatedly asked to explain the same need?
Do standard letters and forms work with assistive technology?
Are interpreter requirements met without avoidable delay?
Are equality concerns investigated?
Do investigations result in measurable action?
Do staff feel safe reporting discriminatory behaviour?
Are particular groups experiencing higher rates of missed appointments or disengagement?
What further evidence is required before drawing conclusions?
Monitoring should support improvement, not stereotyping.
Small samples, missing demographic information and differences in clinical need must be considered before conclusions are reached.
27 Supporting staff and speaking up
Staff may experience discrimination, harassment or victimisation from:
colleagues
patients
family members
representatives
contractors
external professionals
Staff should know how to:
obtain immediate support
report the conduct
preserve evidence
access human resources or management advice
raise concerns without fear of retaliation
Managers should protect confidentiality as far as possible and take steps to prevent victimisation.
Bystanders should act within their role. This may include:
challenging a comment when it is safe to do so
checking on the affected person
documenting what was witnessed
reporting the behaviour
seeking immediate assistance
Do not promise complete secrecy if the information raises a serious safety or safeguarding concern. Explain who must be told and why.
28 Practical scenarios
Scenario 1 Telephone-only process
A patient says their disability makes telephone communication very difficult and asks to receive appointment information by email.
The administrator should:
Verify the safe email address.
Record the communication need.
Use email where authorised.
Escalate any part of the request that requires approval.
Confirm the arrangement with the patient.
The administrator should not insist on telephone contact merely because it is the default process.
Scenario 2 Interpreter request
A patient asks their teenage child to interpret a discussion about medication and risk.
The administrator should:
Record the person’s preferred language.
Explain that an appropriate professional interpreter should be arranged.
Seek an authorised arrangement urgently.
Inform the responsible clinician.
Avoid using the child as the default interpreter for sensitive clinical communication.
Scenario 3 Repeated missed calls
A patient has not answered three telephone calls. Their record states that unpredictable calls worsen a mental health condition and that contact should be arranged by text first.
The administrator should:
Follow the recorded adjustment.
Check whether the earlier calls complied with it.
Escalate any potential effect on care.
Correct the process for future communication.
Record the action taken.
The administrator should not label the patient as non-compliant without reviewing the barrier.
Scenario 4 Racist comment
A caller uses a racist slur about a member of staff.
The administrator should:
Set a clear boundary.
Seek support where required.
Follow the unacceptable behaviour and incident procedures.
Record the actual words used.
Inform the appropriate manager.
Any decision affecting access to care must be authorised and must consider safety, clinical need and proportionality.
Scenario 5 Family member requesting information
A patient’s same-sex partner asks for an update. The administrator assumes they are a friend and refuses to listen.
The administrator should not make assumptions about the relationship.
They should:
Check the patient’s consent.
Check the person’s authority.
Use the same verification process applied to any partner.
Receive relevant safety information even if disclosure is not authorised.
Avoid confirming confidential information without authority.
Scenario 6 Name and record mismatch
A patient uses a different name from the one shown on an identity document and explains that they are trans.
The administrator should:
Communicate respectfully.
Verify identity safely.
Record the stated name in the appropriate field.
Preserve the identifiers required for accurate record matching.
Avoid disclosing the previous identity unnecessarily.
Seek advice if clinical or record-integrity questions arise.
The administrator should not create a second clinical record.
Scenario 7 Religious observance
A patient asks whether an appointment can avoid an important religious observance.
The administrator should:
Check available alternatives.
Record the request.
Offer an available alternative where possible.
Escalate the request if approval is needed.
Explain any genuine constraint respectfully.
The request should not be dismissed without consideration.
Scenario 8 Inaccessible document
A patient who uses a screen reader says that a scanned PDF cannot be read.
The administrator should:
Arrange an accessible version.
Record the communication need.
Confirm that the replacement can be accessed.
Report the inaccessible template if it is used routinely.
Sending the same inaccessible file again does not meet the need.
Scenario 9 Possible degrading treatment
A patient says a staff member mocked their disability during an appointment. They now feel unsafe returning.
The administrator should:
Check immediate safety.
Listen to the allegation.
Record the person’s own account.
Preserve available information.
Escalate through the complaints and incident procedures.
Seek safeguarding advice where applicable.
Confirm how the patient will be contacted.
The administrator should not confront the staff member or decide whether Article 3 was breached.
Scenario 10 Capacity assumption
A patient takes longer to answer and uses an advocate. A staff member tells the advocate to make all decisions.
The administrator should:
Continue to address the patient.
Support the patient’s communication.
Check consent for the advocate’s involvement.
Seek clinical advice if capacity is genuinely in question.
Record relevant communication needs.
Communication difficulty does not establish a lack of capacity.
Scenario 11 Complaint and victimisation
After complaining about discrimination, a patient is described in an internal message as “trouble”. Their routine query is then deliberately left unanswered.
The message and delay must be preserved and escalated.
Providing poorer service because someone raised an equality concern may amount to victimisation. It is also contrary to WMI Psychiatry standards.
Scenario 12 Conflicting needs
A patient requests an arrangement based on belief. A staff member says the arrangement would affect their own dignity and safety.
The administrator should:
Avoid taking sides.
Avoid making a legal ruling.
Protect immediate safety.
Record both concerns accurately.
Refer the matter to an authorised manager.
Await a lawful, evidence-based and proportionate decision.
29 Key learning points
Equality may require a different process to remove a barrier.
The Equality Act contains nine protected characteristics.
The detailed legal protection varies according to the context.
Discrimination can be direct or indirect.
Disability discrimination can include unfavourable treatment arising from disability.
Failure to make reasonable adjustments can be unlawful.
Harassment, sexual harassment and victimisation must be reported.
An adjustment request does not require legal language or a particular form.
Disabled people must not be charged for reasonable adjustments.
Communication needs should be identified, recorded, flagged, shared lawfully, met and reviewed.
Do not infer ability, capacity, risk or preference from a diagnosis or identity.
Dignity, privacy, family life and autonomy are central to administrative work.
Human rights questions can be legally complex.
Administration staff should recognise concerns and escalate them.
Complaints, incidents, safeguarding and data protection procedures may operate at the same time.
Records must be factual, respectful, necessary and useful.
Staff should challenge or report discriminatory behaviour.
Staff must not retaliate against someone who raises a concern.
Recurring barriers should result in system improvement.
Knowledge assessment
Learner instructions
Choose the single best answer.
You must achieve at least 12 out of 15 to pass.
Every incorrectly answered safety-critical question must be reviewed, even if the overall pass mark is achieved.
Question 1
What does equality usually require in an administration process?
A. Treating every person identically in every circumstance
B. Removing unlawful discrimination and avoidable barriers, including different arrangements where needed
C. Asking every patient to disclose all protected characteristics
D. Giving priority to anyone who asks for it
Question 2
Which list contains only protected characteristics under the Equality Act 2010?
A. Disability, race, sex and sexual orientation
B. Income, postcode, accent and education
C. Diagnosis, housing status, job title and language
D. Caring responsibilities, appearance, weight and personality
Question 3
A patient says their disability makes telephone calls difficult and asks for email contact. What should the administrator do?
A. Refuse because telephone calls are the standard process
B. Require a consultant’s letter before recording the request
C. Clarify the need, make or arrange the adjustment within their authority, record it and escalate any unresolved issue
D. Remove every telephone number from the record without checking safety
Question 4
Which statement about reasonable adjustments is correct?
A. The person must use the phrase “reasonable adjustment”
B. Disabled people may be charged an administration fee for adjustments
C. Service providers should anticipate barriers and respond to individual needs
D. Only a court can agree an adjustment
Question 5
What is indirect discrimination?
A. A rule applied to everyone that disadvantages a protected group and the individual and cannot be justified
B. Any decision a patient dislikes
C. Recording an agreed communication preference
D. Treating someone more favourably because they complained
Question 6
A patient reports that a staff member mocked their disability and they feel unsafe returning. What is the best initial response?
A. Explain that the staff member probably meant no harm
B. Check immediate safety, listen, record the allegation and escalate it promptly
C. Confront the staff member immediately
D. Decide whether a human rights breach occurred
Question 7
Which action best supports accessible communication?
A. Ask what the person needs, record it and provide or arrange the appropriate format
B. Send the standard document repeatedly
C. Ask a child to interpret sensitive information
D. Assume a diagnosis tells staff which format to use
Question 8
Which human right is especially relevant to confidentiality, correspondence and family involvement?
A. Article 5 only
B. Article 8, respect for private and family life, home and correspondence
C. Article 10 only
D. No human right is relevant
Question 9
A family member provides important safety information but is not authorised to receive confidential details. What should the administrator do?
A. Refuse to listen
B. Receive, record and escalate the information without making an unauthorised disclosure
C. Provide the complete clinical record
D. Confirm the patient’s diagnosis but nothing else
Question 10
Which record is most appropriate?
A. “Patient is difficult and refuses normal communication.”
B. “Patient claimed to need special treatment.”
C. “The patient stated that telephone calls trigger severe anxiety and requested email contact. The request was recorded and referred at 11:20 am.”
D. “Patient is probably exaggerating.”
Question 11
What is victimisation?
A. Treating someone poorly because they made or supported a discrimination allegation or may do so
B. Making any mistake in a booking
C. Asking a patient to verify their identity
D. Providing an accessible document
Question 12
A caller uses a racist slur about a staff member. What should the administrator do?
A. Ignore it because patients can say anything
B. Retaliate with an insult
C. Set a calm boundary, seek support and follow the authorised incident or unacceptable behaviour process
D. End all care permanently without authority
Question 13
A patient communicates slowly and attends with an advocate. What should staff assume?
A. The advocate automatically makes every decision
B. The patient lacks capacity
C. Nothing about capacity; staff should address the patient, support communication and check consent for the advocate’s role
D. The patient cannot use the service
Question 14
An equality concern may also require which other processes?
A. Complaints, safeguarding, incident reporting or data protection, depending on the facts
B. No other process
C. Only payroll
D. Only annual appraisal
Question 15
Which option best describes the administration team’s role?
A. Make final legal findings
B. Diagnose disability and decide capacity
C. Identify barriers, respond within authority, protect safety and dignity, record accurately and escalate concerns
D. Investigate colleagues without management involvement
Learner declaration
Learner’s name: ______________________________
Role: ______________________________
Date completed: ______________________________
Attempt number: ______________________________
I confirm that:
I have completed the full module.
I understand the difference between equal treatment and equitable access.
I can identify the nine protected characteristics.
I understand that legal protection varies by context.
I know that legal questions must be escalated.
I can recognise a request for a reasonable adjustment.
I know how and where to record communication needs and adjustments.
I know who to contact when an adjustment cannot be provided immediately.
I understand that capacity must not be assumed from diagnosis or communication style.
I know how to report discrimination, harassment and victimisation.
I understand that immediate safety and safeguarding concerns must be escalated.
I understand that confidentiality continues to apply.
I know where the Equality, Diversity and Human Rights Policy is stored.
Signature: ______________________________
Score: ______ out of 15
Result: Pass / Further learning required
Safety-critical errors reviewed: Yes / No / Not applicable
Manager or assessor: ______________________________
Renewal date: ______________________________
Managers marking guide
Question 1
Correct answer: B
Equality requires the removal of unlawful discrimination and avoidable barriers. A different arrangement may be necessary to provide fair access.
Question 2
Correct answer: A
Age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex and sexual orientation are protected characteristics.
Question 3
Correct answer: C
The request should be recognised even without legal wording. Staff should act within their authority, record the need and escalate any unresolved part.
Question 4
Correct answer: C
The reasonable-adjustment duty for service providers is anticipatory. It also requires an appropriate response to individual disadvantage. Disabled people must not be charged for reasonable adjustments.
Question 5
Correct answer: A
Indirect discrimination concerns a generally applied provision, criterion or practice that creates particular disadvantage and cannot be justified.
Question 6
Correct answer: B
Immediate safety comes first. The allegation should be heard, recorded and escalated without making a premature legal finding or debating the speaker’s intention.
Question 7
Correct answer: A
Accessible communication begins by identifying the person’s need and then recording, flagging, sharing lawfully and meeting it.
Question 8
Correct answer: B
Article 8 protects private and family life, home and correspondence, subject to lawful limitations.
Question 9
Correct answer: B
Staff may receive relevant information without disclosing confidential information to the person providing it.
Question 10
Correct answer: C
The entry records the person’s account, the requested action and a precise escalation time without judgemental language.
Question 11
Correct answer: A
Victimisation protects someone from detriment because they have done, or are believed likely to do, a protected act.
Question 12
Correct answer: C
Staff should set boundaries and obtain support. Restrictions on access to care require an authorised, evidence-based and proportionate decision.
Question 13
Correct answer: C
Communication style and use of an advocate do not determine capacity. Staff should support the patient’s participation and verify consent.
Question 14
Correct answer: A
The same facts may engage several procedures. These should be coordinated without delaying immediate action.
Question 15
Correct answer: C
Administration staff identify and reduce barriers within their authority, keep accurate records and escalate matters requiring specialist decisions.
Safety-critical questions
Questions 3, 4, 6, 7, 9, 10, 12, 13, 14 and 15 are safety-critical.
For every incorrectly answered safety-critical question, the manager should:
Discuss the correct response with the learner.
Record that the answer was reviewed.
Ask the learner to explain the correct local process.
Confirm that the learner knows how to record and escalate an adjustment or equality concern.
Require reassessment if understanding remains uncertain.
A learner must not be recorded as competent if they remain uncertain about:
immediate safety
reasonable adjustments
accessible communication
confidentiality
safeguarding
respectful record keeping
victimisation
reporting discriminatory behaviour
escalation procedures
CQC and governance implementation requirements
Before issuing this module, WMI Psychiatry should:
approve a current Equality, Diversity and Human Rights Policy
confirm which activities are NHS commissioned or otherwise functions of a public nature
confirm how the Public Sector Equality Duty applies
confirm how the Accessible Information Standard applies to each service arrangement
identify the Equality, Diversity and Human Rights Lead
complete all contact details in this module
define who may approve reasonable adjustments
define how urgent adjustment requests are handled
provide a reliable place to record and flag communication needs
ensure staff can arrange professional interpreters
ensure staff can provide or arrange accessible formats
audit forms, websites, portals and standard letters for accessibility
audit appointment and communication processes
establish procedures for stated names, identity matching and privacy
coordinate complaints, safeguarding, incident, data protection and human resources procedures
define how discriminatory or abusive behaviour by patients will be managed
ensure any restrictions on care are authorised and proportionate
ensure staff understand consent, capacity, parental responsibility and representative authority
monitor whether agreed adjustments are delivered consistently
review complaints and incidents for recurring barriers
review access information for possible unequal outcomes
protect staff and patients from retaliation after raising a concern
retain each learner’s answers, score, declaration and attempt number
record completion in the staff training matrix
document review of safety-critical errors
provide induction and annual refresher training
review this module after material legal, regulatory or organisational change
This module supports compliance but does not replace:
the Equality, Diversity and Human Rights Policy
the reasonable-adjustment or accessible-information procedure
clinical judgement
the Mental Capacity Act procedure
the complaints procedure
safeguarding procedures
incident-reporting procedures
data-protection procedures
employment policies
human resources advice
commissioner requirements
legal advice where required
