EDS Goal Outcome Key Action Person responsible RAG rating

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Robert Gray
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1 Ref. 1.1 Collate and regularly review collected data to get a clear picture of the specific needs and requirements of the service users, area specific NNE Emma Pearson ; NW Rachael Millband; Data is regularly collected following engagement events. The reporting of this needs to become more systematic. Better Health Outcomes For All Services are commissioned, procured, designed and delivered to meet the health needs of local communities The data map that is created will help inform the commissioning cycle and effectively drive commissioning priorities NNE Emma Pearson NW Rachael Millband Reliant on the above action being implemented robustly. Continue to ensure that all procurement and contracting processes and activities are carried out in line with Service Condition 13 of the NHS Standard Contract South Notts Contract Team / CCG contract leads. Needs ongoing updating Ref 1.2 Better Health Outcomes For All Individual people's health needs are assessed and met in appropriate and effective ways Expand and monitor engagement activities to reach all disadvantaged and seldom heard groups and other stakeholders, with all 3 CCGs using an overarching Engagement Plan NNE Emma Pearson; NW Rachael Millband Engagement plan used. Annual review to identify gaps and plan future events required 1

2 Conduct trend analysis on data collected, specifically with regards A&E attendance, DNAs, Patient Experience and Complaints to identify emerging themes NUH Giles (A&E); NNE Emma Pearson, Helen NW Rachael Millband Rushcliffe Helen Limb; Helen DNAs no data. A&E data collected and reported against. Patient Experience and Complaints monitored and reported against. Use any identified emergent themes to inform the commissioning cycle Hazel Buchanan, Lynne Sharp, Craig Sharples Action reliant on meaningful outcomes from the action above. Sign up to the 'Positive about Disabled People' (Two Ticks) Scheme NNE Emma Pearson; NW Sue Clarke; Rushcliffe Caroline Stevens Sign up and commit to the British Deaf Association British Sign Language Charter to improve services for deaf/deafened and hard of hearing service users Hazel Buchanan, Lynne Sharp, Craig Sharples. Signed on 29 October Action plan now in place and monitored Continue to provide effective translation and interpretation services through existing contract South Notts Contract Team / CCG Contract leads and Caroline Stevens Delivered through Pearl Translation Services Better Health Outcomes For All Ref 1.3 Transitions from one service to another, for people on care pathways, are made smoothly with everyone well informed Continue to monitor the Transfers of Care CQUIN Rebecca Stone, Quality Team Monitored through QSP Monitor and feedback on Patient Experience and Engagement on patient transitions. Act on feedback Helen for this quarter 2

3 Prospective providers required to complete EIA of tender to identify how they will manage contract specific issues relating to the protected characteristics Procurement Team Work is being undertaken to ensure this is taking place Continue to ensure relevant E&D training is provided for all affected employees Lynne Sharp, Craig Sharples, Hazel Buchanan Training is provided and is mandatory Contractors must continue to comply with Service Condition 13 of the NHS Standard Contract and report the findings of its' annual audit at the agreed review meetings, demonstrating the extent to which service improvements have been made and showing how it has met its obligations under Section 149 of the Equality Act 2010 and section 6 of the Human Rights Act 1998 Quality team this quarter. Requires ongoing monitoring and reviewing Ref 1.4 Better Health Outcomes For All Screening, vaccination and other health promotion services reach and benefit all local communities Continue to work with NHS England to gain this information Responsibility of Public Health, updates provided to Commissioning Congress as and when necessary Monitored on a quarterly basis 3

4 Ref 2.1 Improved Patient Access and Experience People, carers and communities can readily access hospital, community health or primary care services and should not be denied access on unreasonable grounds Target Involvement and Engagement events at seldom heard from groups ensuring the overarching Engagement Plan is completed on a monthly basis Collect patient experience data at these events and ensure it is fed into the commissioning process to affect change and increase accessibility NNE Helen ; and Helen NNE Helen ; this quarter. Needs monitoring and reviewing Data is collected feedback needs to be more systematic Ref 2.1 Ensure all relevant information is accessible to all, in written and electronic formats NNE Toni Smith, Comms; Websites now fully accessible. Relevant documents also have required strapline Improved Patient Access and Experience People, carers and communities can readily access hospital, community health or primary care services and should not be denied access on unreasonable grounds Contractors must continue to comply with Service Condition 13 of the NHS Standard Contract and report the findings of its' annual audit at the agreed review meetings, demonstrating the extent to which accessibility requirements have been made and showing how it has met its obligations under Section 149 of the Equality Act 2010 and section 6 of the Human Rights Act 1998 South Notts Contract Team this quarter. Requires ongoing monitoring and reviewing 4

5 Ref 2.2 People are informed and supported to be as involved as they wish to be in decisions about their care Engage with seldom heard groups at engagement events Continue to ensure that carers are consulted with NNE Helen ; NW Racheal Millband; NNE Helen ;. Needs ongoing reviewing and monitoring. Needs ongoing reviewing and monitoring Improved Patient Access and Experience People are informed and supported to be as involved as they wish to be in decisions about their care Continue to work with identified isolated groups and empower them through the use of selfmanagement and self decision making in their own care needs NNE Helen ; This has been picked up as an area to focus on and initiatives are now in place Ref 2.3 Improved Patient Access and Experience People report positive experiences of the NHS Effectively collect compliments, as well as complaints and comments Where negative experiences are reported, work with those people/groups to try and improve the service experience Mariea Kennedy and Helen NNE Helen ; and Helen and Mariea Kennedy Process in place Ref 2.4 People's complaints about services are handled respectfully and efficiently Continue to ensure there is an effective complaints system in place for customers to use Mariea Kennedy and Helen Process in place 5

6 Complaints reporting system collects equality monitoring data, analyses trends and reports on them on a 6 monthly basis Mariea Kennedy and Helen Process in place Complaints and trends are sent to the relevant team/department and managers are able to put in place measures to deal with these Mariea Kennedy and Helen Process in place. Any complaints/negative responses found during engagement events is fed into this process to ensure relevant action can be taken NNE Helen ; Process in place Ref no: 3.1 Improve workforce data monitoring. Ensure that equality and diversity monitoring data is up to date for all CCG employees and Governing Body Members. NNE Hazel Buchanan Annual Staff Survey used to collect required data A Representative and Supported Workforce Fair NHS recruitment and selection process lead to a more representative workforce at all levels Use employee monitoring data to improve workforce breakdown, against the protected characteristics Annual Staff Survey used to collect required data Ensure recruitment process is inclusive of equality and diversity principles and processes Lynne, Hazel and Craig for internal recruitment There is a fair and diverse recruitment process Ref no: 3.2 The NHS is committed to equal pay for work of equal value and expects employers to use equal pay audits to help fulfil their legal Where appropriate, continue to use Agenda for Change to ensure fair and equal pay for all Lynne Sharp through GEM contract Ongoing monitoring required 6

7 obligations Carry out equality monitoring of Governing Body Annual Staff Survey used to collect required data Ref no: 3.3 Training and development opportunities are taken up and positively evaluated by all staff Ref 3.5 Continue to provide relevant, specific and targeted training to all employees Rushcliffe Helen Griffiths/Lynne Sharp Required training is provided A Representative and Supported Workforce Flexible working options are available to all staff consistent with the needs of the service and the way people lead their lives Ref 3.6 Introduce a Flexible Working Policy Ensure all employees understand how to manage an effective work/life balance NNE Hazel Buchanan NW Craig Sharples NNE Hazel Buchanan NW Craig Sharples Flexible Working Policies in place Effective workplace culture in place Staff report positive experiences of their membership of the workforce Continue to carry out an annual Staff Survey to identify any areas of good, or bad, practice, as identified by employees Monitor exit interviews to identify any negative trends NNE Hazel Buchanan/Toni Smith; NW Craig Sharples; Rushcliffe Lynne Sharp Staff Survey carried out Carried out but not enough data to be truly effective Inclusive Leadership Ref 4.1 Boards and senior leaders routinely demonstrate their commitment to promoting equality within and beyond their organisations Identify an executive lead for equality and a Governing Board champion NW Nigel Hallam/Craig Sharples; Rushcliffe Sheila Hyde/Lynne Sharp 7

8 All policy and service changes reviewed by the Needs to be embedded more Board must include an Equality Impact systematically. Assessment Ref 4.2 Relevant papers that come before the Board and other major Committees identify equality related impacts including risks, and say how these risks are to be managed Ref 4.3 Ensure Equality Impact Assessments are completed when required and published on CCG websites NNE Hazel Buchanan/Emma Pearson; Not completed systematically, many are carried out retrospectively. Also need to ensure they are consistently published on the CCGs website. Inclusive Leadership Middle managers and other line managers support their staff to work in culturally competent ways within a work environment free from discrimination Continue to ensure the Survey Monkey Staff Survey is completed and regularly reviewed NW Craig Sharples; Relevant papers that come before the Board and other major Committees identify equality related impacts including risks, and say how these risks are to be managed Continue to ensure appraisals are carried out and employees encouraged to progress and develop Rushcliffe Helen Griffiths Middle managers and other line managers support their staff to work in culturally competent ways within a Continue to ensure the Survey Monkey Staff Survey is completed and regularly reviewed 8

9 work environment free from discrimination Continue to ensure appraisals are carried out and employees encouraged to progress and develop Rushcliffe Helen Griffiths 9

Equality Delivery System for the NHS EDS2 Summary Report

Equality Delivery System for the NHS EDS2 Summary Report Implementation of the Equality Delivery System EDS2 is a requirement on both NHS commissioners and NHS providers. Organisations are encouraged to