Last reviewed 6 June 2022
The Care Quality Commission (CQC) published guidance in 2019 to address questions about relationships and sexuality among people using adult social care services. Progress on awareness of the issue was hampered during the pandemic but now there are indications that, as inspections return, there will be a renewed focus on how registered care providers should consider people's relationship and sexuality needs. Christine Grey investigates.
Since the guidance came out the CQC has been calling on leaders across adult social care to work together to create a “culture of openness”, where service users can feel “empowered and supported to be open about sexuality and relationships”, where staff feel they can share concerns without fear of reprisal and where people and families are empowered to speak about their wants and needs in a sensitive way, while ensuring people are protected from sexual harm.
CQC’s report on open cultures
These insights came out of a report in 2020, Promoting Sexual Safety Through Empowerment, which looked at the statutory notifications of sexual incidents that were reported to the regulator between 1 March and 31 May 2018. The lessons were clear that providers and care staff need to be better supported to protect people from sexual harm while enabling people to continue or develop the intimate relationships that they want regardless of who they are, their age or mental capacity, physical ability or personal history. The report called for new, co-produced guidance on this for care managers and staff.
Meanwhile, it said inspectors will be assessing how open cultures in care settings are to discussing sex and sexuality and whether care plans give appropriate consideration to people's needs around sexuality and relationships.
What is the definition of “sexuality”?
The CQC’s Relationships and Sexuality in Adult Social Care Services guidance keeps the definition of “sexuality” broad, encompassing a person’s “gender identity, body image and sexual desires and experiences”. It also points out that it can mean different things to different groups of people. The CQC’s guidance relates to:
sex, masturbation, sensuality, physical intimacy, romance and physical attraction
gender identity; the sense of being male, female or not aligned with either
sexual orientation, including heterosexual, homosexual and bisexual
personal dress, body image, personal grooming and sexual expression.
What does CQC’s guidance focus on?
When putting together this guidance, the CQC’s focus was to help support opportunities for sexual expression and personal wellbeing and to form and maintain relationships while understanding risk within the framework of care services' regulatory responsibilities. Care providers are also expected to offer a welcoming environment to LGBT+ people, as well as look to support people with physical disabilities.
When a care provider first assesses a person’s needs, the CQC encourages questions to be asked such as whether they have a current relationship or previous ones, their sexual orientation, gender identity and whether they have an understanding of sexual health.
Only staff who are confident and competent in the area should gather information about relationships, sexual habits and intimacy. These conversations can then contribute to the development and review of care and support plans.
The CQC covers a number of considerations around “mental capacity” and consent in relation to intimate relationships of people using care services.
Sexual disinhibition is also mentioned, including aspects that staff who support people with neurological impairment need to understand and how behaviour support plans and risk assessments should be put in place.
The CQC stresses that when people in care experience unwanted sexual behaviour, including sexual contact and advances, providers must investigate and report this in a timely and appropriate way.
What training is required for members of staff?
Sexuality and relationship induction and ongoing training will help staff respond to situations in a considered and person-centred way, according to the regulator. Awareness of Equality, Diversity and Human Rights issues should help staff to reflect on their duty to maintain compassionate yet professional boundaries, as well as support a self-awareness of their own assumptions or bias about the sexuality needs of older people, or those living with disabilities, in a safe, supportive environment.
Are there any recommended training resources?
A 2021 review by Supported Loving, commissioned by Skills for Care following the CQC’s recommendations, found that staff often feel “fearful” in approaching the topic due to “a lack of appropriate support and applicable resources to address the often complex and sensitive situations they face”.
Whilst there is no mandatory requirement for staff to receive training on relationships and sexuality, 97% of respondents backed the need for a comprehensive training pack on the topic to aid their staff’s development. Focus groups were explicit in that they needed training that allowed space to discuss sensitive issues and this could be achieved in face-to-face or online training but not e-learning.
Supported Loving produced a useful assessment of the learning materials currently available to support people across all social care groups. However, it also highlighted many gaps in the topic coverage, as well as in the amount of resources available for different social care groups.
Does Skills for Care provide practical guidance?
Skills for Care’s guide, updated in light of the CQC’s recommendations, contains examples of actions that promote the values of sexual safety in an organisation. It also describes what relationships and sexuality training needs to include and how a workforce development programme can be created, with “worked examples” based on real scenarios and informal “conversation starters”.
Skills for Care says workforce development surrounding personal relationships can be supported in many ways, including by:
establishing a strong, empowering organisational culture
ensuring there is a clear policy and guidance
working proactively to give training and support to help prevent some issues before they arise
understanding that staff can be positive role models, educators and advocates
ensuring staff understand how to support people from different backgrounds and with different beliefs
valuing the role of families and friends in supporting personal relationships
ensuring learning about personal relationships is linked to care and support plans
involving a range of stakeholders to ensure available training represents participants’ lived experience.
Which laws apply to relationship and sexual situations?
Skills for Care recommends keeping training about supporting personal relationships separate from training on safeguarding, deprivation of liberty and the Mental Capacity Act; however, there is an expectation to signpost within other training.
Law that impacts specifically on relationships and sexual situations includes the Human Rights Act 1998 which says we all have the right to a private life and personal relationships. This includes being able to develop and/or maintain a relationship with a partner of our choosing, and all choices should be respected and treated equally.
The Care Act 2014 promotes the principle of “wellbeing”, which recognises the importance relationships play in people’s physical health and emotional wellbeing.
The Mental Capacity Act 2005 should be used to positively support people’s capacity to make decisions surrounding relationships wherever possible, ensuring people are not restricted unnecessarily and that staff understand how the Human Rights Act and Mental Capacity Act link with each other. Best interest decisions cannot be made in relation to a person’s ability to consent to sex.
What will the CQC ask to see in inspections?
In an inspection, registered managers, providers and registration applicants should be able to explain how their service supports people to meet their sexuality needs. Examples of possible evidence required under a range of key lines of enquiry are tabled at the end of the regulator’s guidance and possible questions include whether:
there is a relationship and sexuality policy, including easy read version
the organisation recognises people have different ways of experiencing and expressing sexuality
staff are trained to support people with personal relationship needs
service users are given information and support about relationships, sexual health and sexual health services
staff can demonstrate how people are encouraged and supported to develop relationships
staff are aware of what to do if they have concerns that someone is at risk of harm or abuse.
Promoting Sexual Safety Through Empowerment (2020), CQC
Learning Materials Review for Social Care Staff Surrounding Sexuality and Relationships (2021), Supported Loving review
Supporting Personal Relationships Guide, Skills for Care
Core Capabilities Framework for Learning Disabilities and Autism, Skills for Health
The Expression of Sexuality in Dementia, Social Care Institute for Excellence (SCIE)