Equality, Diversity and Inclusivity Annual Action Plan 2015/16

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Equality, Diversity and Inclusivity Annual Action Plan 2015/16 This action plan has been developed to support the absolute deliverables on equality, diversity and inclusivity for 2015/16.

1 Equality, Diversity and Inclusivity Annual Action Plan 2015/16 This action plan has been developed to support the absolute deliverables on equality, diversity and inclusivity for 2015/16. It covers key work streams including delivering year one of the Equality and Diversity Strategy, Delivery of the Equality Diversity System, WRES delivery, delivering the outstanding recommendations of the internal and external reviews and cultural and organisational development. The ultimate aim of our strategy is to ensure equality of opportunity for everyone and for the Trust to be known for its best practice on equality, diversity and inclusivity. Once we have assessed ourselves against the EDS2 and WRES, consulted with staff and community groups we will more fully understand our strengths and our areas for improvement. This action plan will develop accordingly to fully incorporate and respond to our findings. It is an iterative plan and its delivery will be monitored and overseen by the Trust s Equality Diversity and Inclusivity Steering Group. Equally whilst the deliverables are significant to us in realising a positive impact on equality, diversity and inclusion, at its very heart is culture. We need to change the culture to one that embraces equality and diversity one that reaps the rewards for both our patients and staff from being an inclusive organisation. This cannot be done in isolation; we need to work with our established networks on all the protected characteristics, staff side, patient representative groups such as Healthwatch and the Overview and Scrutiny Committee, our Governors as well as local community groups. Governance, Cultural development and education 1. Governance Review the Terms of reference and membership of the Equality, Diversity and Inclusivity Steering Group (EDISG) and relaunch Review where ED&I sits in the organisation JG/GB FD/JG May 2015 May 2015 overall responsibility sits with Director of Quality, Head of Equality, Diversity and Inclusivity will be appointed in July Develop a E&D dashboard of Key Performance Indicators (KPI) metrics for reporting* Review E&D reporting structures from ward to Board EDSG / Networks GB WRES data completed need to define wider E&D KPI s Review and update E&D policies Action plan to be to be submitted to Trust Board in June. Demonstrate compliance to the Equality Act Jan 2016 Demonstrate compliance to CQC standards Equal Measures Deliver equality and diversity aspects of the contract with Commissioners July 2015 EDIActioplan.doc/version2 1 June 2015

2 Governance, Cultural development and education (Cont.) 2. Organisational and cultural development Align with Vision, Trust Strategy and values Develop and implement an awareness E&D campaign positively inclusive AA Equality and Diversity conference being held in June Undertake staff engagement on approach and direction and consult on this plan Develop a talent management programme HofED/ Networks DY Provide support for overseas staff recognising their diverse needs Utilise EDS 2 and WRES outcome measures as opportunities to create greater awareness and drive forward improvement HodE&D Nov 2015 Celebration event for overseas nurses being planned Clarify the Trust s position on zero tolerance for patients and staff Develop E&D calendar and hold supporting events (E.g. Black history month in October) Networks Review the internal and external website E&D page Adopt best practice from other Trusts shared through NHS employers, E&D partners Utilise incident reporting to drive learning from incidents involving discrimination against any characteristic Develop Root Cause Analysis (RCA) template for investigation of such incidents and a panel process for review (emulating Trust safety processes) Review staff survey and identify improvement plans for hotspot areas (e.g. disability) Undertake Voxpop to ascertain public views Retention interview BME staff at same post or level for three years to evaluate reasons why they have not progresses Appraisal paperwork to include progression Nov 2015 Jan 16 June 15 Attended first E&D partner meeting in June 3. Learning and education Develop a Trust wide training and development programme including train the trainer Ensure there are equal training opportunities for all / DY July 2015 Training package in development Survey monkey of staff to be undertaken Develop & launch a E&D newsletter and share learning Include in Board development programme JG/GB EDIActioplan.doc/version2 2 June 2015

3 Equality Diversity System (EDS2) 1. Identify leads for EDS 2 outcomes GB June 15 Leads written to and draft action plan shared 2. Identify Local Stake holders JC/ Attend Equality Reference Group (run Southampton City CCG) Links with Chrysalis, Stonewall, Wheatsheaf Trust, Polish community 3. Collate evidence against each outcome identified leads Nov 15 Need to commence collation and review at Equality & Diversity Steering group Will be published in at the end of the year 3.1 Better Health Outcomes Services are commissioned, procured, designed and delivered to meet the health needs of local communities KN Demonstrate where we influence commissioning particularly for patient pathways. Utilise joint services needs analysis Individual people s health needs are assessed and met in appropriate and effective ways DMT Divisional representatives to be asked to assess against protected characteristic Experienced based design to be used to map pathways on each protected characteristic Transitions from one service to another, for people on care pathways, are made smoothly with everyone well-informed DMT Oct 15 When people use NHS services their safety is prioritised and they are free from mistakes, mistreatment and abuse JP/CR Screening, vaccination and other health promotion services reach and benefit all local communities GC Nov 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 People are informed and supported to be as involved as they wish to be in decisions about their care JC/JW JC JC Oct 15 Jan 15 Need to develop systems to capture access to hospital People report positive experiences of the NHS People s complaints about services are handled respectfully and efficiently JW Mechanisms to capture protected characteristics data developed EDIActioplan.doc/version2 3 June 2015

4 Equality Diversity System (EDS2) Cont. 3.3 A Representative and Supported Workforce Fair NHS recruitment and selection processes lead to a more representative workforce at all levels KE Aug 15 Values based recruitment undertaken 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 obligations JJ Training and development opportunities are taken up and positively evaluated by all staff DY Jan 16 When at work, staff are free from abuse, harassment, bullying and violence from any source A T-H Flexible working options are available to all staff consistent with the needs of the service and the way people lead their lives Aug 15 Staff report positive experiences of their membership of the workforce JH 3.4 Inclusive Leadership Boards and senior leaders routinely demonstrate their commitment to promoting equality within and beyond their organisations HofCA Papers that come before the Board and other major Committees identify equalityrelated impacts including risks, and say how these risks are to be manage HofCA Oct 15 Need to review Equality Impact assessment Middle managers and other line managers support their staff to work in culturally competent ways within a work environment free from discrimination /DY 4. Agree roles with the local authority JC Establish with Healthwatch & OSC Jan Analyse Performance HofED Jan 16 Once information collated identify improvement actions and include in this plan 6. Self-assess and agree grades / Leads Feb Prepare equality objectives and prioritise plans GB June 15 through this action plan, EDSG to monitor and review progress 8. Integrate equality into mainstream business planning and this action plan Feb Publish grades, equality objectives and plans on the website March 16 Once this plan is agreed to publish on the website EDIActioplan.doc/version2 4 June 2015

5 Annual objectives from Equality and Diversity Strategy 10. Increased collection, monitoring and reporting of staff data Actively encourage staff to complete monitoring data where it is missing, ensuring staff understand the benefits of declaring their characteristics Identify underrepresented characteristics in the workforce and consider positive action to redress Monitor employee relations data to ensure all characteristics are fairly treated Monitor development and progression to ensure all characteristics have equality of opportunity Report on demographics of workforce and board as part of Public Sector Equality Duty submission 11. Increased collection, monitoring and reporting of patient data HRsystems / HRsystems / RG/HRPU HRsystems /DY March 16 Increase in monitoring data from new starters from 13/14 to 14/15 HR, T&D working with Estates to increase representation Develop mechanisms for capturing this data current database not fit for purpose ALS train the trainers course undertaken Build on reporting from 14/15 Equip and train staff to be confident in requesting monitoring data from patients in order to increase the quality of data held Identify groups of patients that are underrepresented and ensure they have equality of access to services Use evidence from EDS to identity gaps in equality for patients and make plans to redress 12. Enhanced reputation as a service provider and employer of choice (workforce and customer engagement) DY HofPE/Hof E&D HofPE/Hof E&D March 16 Engage with staff networks, local stakeholders and communities to understand the issues they face and remove barriers to equality of opportunity Link with national and regional groups to benchmark our performance and to share best practice Celebrate the diversity of patients and build links at local community events Take positive action to develop leaders from all protected characteristics group to improve diversity in more senior positions in the trust Take positive action to address underrepresented characteristics in the workforce to improve diversity Monitor and review discrimination incidents through reflective practice events to identify improvements to patient and staff experience Comms/ DY HofE& D/Staff Network Chairs Stonewall Champions, Southampton City CCG Equality Reference Group NHS E&D Partners, South Central Equality Network (SCEN) Portsmouth Pride EDIActioplan.doc/version2 5 June 2015

6 Annual objectives from Equality and Diversity Strategy Cont. 12. As Stonewall Diversity Champions, improve placing in the Stonewall Workplace Equality Index Renew two ticks award from Job Centre Plus to publicly demonstrate commitment to employ, keep and develop the abilities of disabled staff /LG BT network chairs /KE July 15 Application work in progress 13 Increase productivity Increase innovation through diversity by encouraging all staff to contribute to improvements in their working environment Improve staff morale and so quality of performance by allowing them to be themselves and share their individuality HofdE& D/Staff Network Chairs Culture change campaign Top 5 of acute Trusts Action to be taken on staff survey results Outstanding actions from internal and external reviews (* throughout action plan notes action identified in one of the reviews) 14 Increasing speed of investigations To implement new guidance for management of investigations including a process for addressing simple issues more rapidly New guidance issued in June 2014 To ensure line managers have an appropriate commitment to undertaking the investigation in a timely manner, and can make appropriate capacity to do so To continue training more investigating officers. To ensure key people managers have undertaken investigation training. March 15 Ensure that a further 50 managers have received training in investigations by 31 March Estimated 130 managers trained. Review of Capsticks being undertaken To ensure a clear escalation process is in place for investigations that exceed the timescales set out. a clear process is included as part of revised guidance 15 Resolving more grievances faster, and through informal mechanisms Roll out the new training on conflict resolution to line managers in the Trust through training sessions in March, April, June and September Train a cohort of at least 50 managers in this new training by March Reviewing disciplinary process to ensure best practice applied in all cases HR March have been trained since April 2014 Review template letters and guidance to ensure they are clear to employees. Reviewing processes for suspension and restriction of duties to ensure best practice is applied in all cases. JB JB March 15 New Policy signed off through Trust process and included in new revised policy launched on 18 June 2014 EDIActioplan.doc/version2 6 June 2015

7 Outstanding actions from internal and external reviews (Cont.) (* throughout action plan notes action identified in one of the reviews) A workshop to be held with Matrons in Division B to ensure key themes and learning is provided and discussed from panel review Feedback wider learning to Divisions during January 17 Management of employees involved in drug administration errors To issue guidance to the HR team, to set the expectation that performance management / learning approach should be used for drug errors in the first instance, unless there are serious issues of negligence, harm or wilful action. To issue new guidance to line managers on approaches to management of drug errors, using the expertise of the Clinical Drug Management group. To ensure this approach is signed off through the Clinical Quality Committee GB & GB SL March 15 To be undertaken as wider E&D training Policies in place drug errors have decreased 18 Holding performance to account Ensure performance of line managers is reviewed where clear breeches of policy have occurred. Ensure appropriate learning and or action is taken forward as a result Develop guidance to managers on Equality and Diversity GB circulated a memo to all managers on guidance 19 Raising Incident forms Ensuring that Adverse Event Records (AER) have been raised through electronic system where serious issues of misconduct have been noted JP June 15, panel process to be developed as noted earlier Review how disciplinary process and SIRI and whistleblowing process dovetail together and make any recommendations for changes in process JP 20 Reviewing complaints against staff from patients and visitors Explore a review of the patient complaint process and how this dovetails with the disciplinary investigation process to ensure this is fair, robust and effective / JW Oct 15 Clinical Resolution Multi-disciplinary Team meeting established for complex clinical cases 21 Embedding on-going learning AJ//GB Oct 15 in Oct 2014 but ongoing Ensure an on-going learning approach in partnership to issues that arise, and to share a summary of key lessons learnt and improvements at each EIN AGM EDIActioplan.doc/version2 7 June 2015

8 WRES Data 22 Collect baseline data for comparison with April 2016 for HR quarterly report MJ/SN 5 May 2015 WRES data and reported to TEC, to identify areas for improvement 23 Publication of 1st April 2015 data including identification of any essential shortcomings MJ/SN 1 July Address data shortcomings and shortfalls identified by the WRES data MJ/SN 31 March Baseline data for comparison with April 2015 should be completed including steps MJ/SN April 2016 underway to address key shortcomings in data, or significant gaps between the treatment and experience of white and BME staff 26 Baseline data to 31 March 2016 should be published to Commissioner, on Trust website and shared with Board and staff 27 Workforce Race Equality Data Indicators May 2016 Indicator 1: Percentage of BME staff in Bands 8-9, VSM (including executive Board members and senior medical staff) compared with the percentage of BME staff in the overall workforce Indicator 2: Relative likelihood of BME staff being appointed from shortlisting compared to that of White staff being appointed from shortlisting across all posts. Indicator 3: Relative likelihood of BME staff entering the formal disciplinary process, compared to that of White staff entering the formal disciplinary process, as measured by entry into a formal disciplinary investigation HofED / A T-H March 2016 Indicator 4: Relative likelihood of BME staff accessing non-mandatory training and CPD as compared to White staff Indicators 5 to 8 Staff Survey Key Findings: o KF 18. Percentage of staff experiencing harassment, bullying or abuse from patients, relatives or the public in last 12 months o KF19. Percentage of staff experiencing harassment, bullying or abuse from staff in last 12 months o KF27. Percentage believing that trust provides equal opportunities for career progression or promotion o Q23. In the last 12 months have you personally experienced discrimination at work from any of the following? o b) Manager/team leader or other colleagues Indicator 9: Boards are expected to be broadly representative of the population they serve EDIActioplan.doc/version2 8 June 2015

9 Initials Key (as they appear in the plan) JG Judy Gillow GB Gail Byrne FD Fiona Dalton EDSG Equality & Diversity Steering Group Head of Equality, Diversity and Inclusivity AA Aly Ayers DY David Young JC Juliet Cox KN Kerrie Neil DMT Divisional Management Teams JP Juliet Pearce CR Claire Rogers GC Greg Chapple JW Jenny Williams KE Kate Eyers JJ Jenny Jay A T-H Alison Thorne-Henderson Steve Harris JH Jo Hughes HofCA Head of Corporate Affairs AJ Amarjit Jassi MJ Melinda Jacobs SN Sunitha Narayan EDIActioplan.doc/version2 9 June 2015

Equality, Diversity and Inclusion Workforce focused action plan

Equality, Diversity and Inclusion Workforce focused action plan ACTION for Workforce focused Objectives 1 We will improve the capture of data in respect of our workforce. Areas of immediate development