Equality analysis training to be considered for representatives within each division to be able to conduct Equality Analysis. (Q3)

Transcription

1 Equality Delivery System 2- Assessment and Action Plan Goal 1: Better Health Outcomes Outcome Lead Grade Actions for SF Acheiving Review Equality analysis guidance and form to ensure still fit for purpose and user friendly. (Q2) 1.1 Services are commissioned, designed and procured to meet the health needs of local communities. CQC KLOE Responsive 1/2 and Well led 5 Rasie profile of conducting Equality Analysis. (Q2) The Trust does not commission services, however in the design Equality Analysis s are carried out to ensure the service meets the health needs of the local community. Equality and Diversity performance and metrics are subject to commissioner scrutiny on a quarterly basis including EDS2 performance, WRES and PSED compliance. 1.2 Individual people s health needs are assessed and met in appropriate and effective ways LPFT Priority for 2017/18 CQC KLOE Effective 1/5 Equality analysis training to be considered for representatives within each division to be able to conduct Equality Analysis. SF Acheiving All equality conferences to include element of how to meet equality area health needs. E.g. LGBT conference reducing self-harm and suicide. (by end of Q4) Focussed communications on link between collecting equality monitoring data, knowing equality groups and risk factors and meeting those needs appropriately. Tracker process in place regaring completion and monitoring of Equality Analysis. Data Hub has been established on Trust Intranet site as point of reference for consideration during Equality Analysis process. Supporting indicators Clincal Priority 1 (Clincal Strategy)- Working with our stakeholders. People Strategy- Caring and capable. The Trust s patient records are on a number of clinical systems (mainly Silverlink and IAPTUS- which both collect all 9 protected characteristics). Accessible Information Standard has been implemented. Multi agency Equality conferences hosted - LGBT February BME October Lived Experience October CAMHS received trans awareness specific training during 2016/17. April

2 Apply to NMET to fund Trans awareness training for inpatient division. Resource directories/ signposting available to be put together for different equality areas to support higher risk patients during waiting times (like LGBT Directory). (Q4) Clinical Care policy. Staff information leaflet published to ensure staff know how to meet the needs of LGBT patients and service users. Feedback from listening events- concern over waiting times and points of contact for help. 1.3 Transitions from one service to another, for people on care pathways, are made smoothly with everyone wellinformed. CQC KLOE Effective 4/5 Implementation of Sexual Orientation Monitoring standard (link to new patient data system review). (by end of Q4) SF Developing Continuation of awareness around Accessible Information Standard to ensure people s communication requirements are shared appropriately. (by end of Q4) Review age demographic and experiences of transitioning between services. Delivered E&D masterclasses to clinical staff to include awareness of why the protected characteristics are important from a clinical perspective and could be part of or a contributing factor to the symptoms of their condition or a barrier to becoming well in 2015/16. Managed Care Network is assisting service users who do not meet referral criteria for mainstream services, as well as supporting those in recovery with their mental health. STP (Sustainability and Transformation Plan) work being undertaken on new models of care which will be subject to public consultation, as part of our involvement we will ensure that impact on the protected characteristic groups are considered as part of this. Implementation of the Accessible Information Standard. Clinical Priority 2- Lead on System integration. Clinical Priority 4- Improving pathways of care. Feedback from Listening events in September themes of continuity of care, range of pathways not always clear, want to see services working together in a more joined up approach and a worry about people falling through the net between services. April

3 1.4 When people use the NHS services their safety is prioritised and they are free from mistakes, mistreatment and abuse. CQC KLOE Safety 1/2/3/4 1.5 Screening, vaccination and other health promotion services reach and benefit all local communities. SF/ Divisions SF/ Divisions Acheiving Developing Re-tendering of interpretation and translation service as a pan-trust specification. All equality conferences to include element of how to meet equality area health needs. E.g. LGBT conference reducing self-harm and suicide. (by end of Q4) Provision of 24/7 telephone and face to face interpretation service. Complaints monitoring all 9 protected characteristic areas from April Learning Lessons- The Quality and Safety Team produce a bimonthly Learning Lessons bulletin. Reporting incidents- Reporting and Management of Risk Policy. Care planning- Clinical Care Policy which contains vital information on care plans and record keeping. CQC inspection April 2017 rated safety as Good. Falls information monitored by Age, Gender and Ethnicity. Feedback from listening events in September points of contact for help. The Trust became a completely no smoking Trust on 28 June Staff are being trained in how to support patients to give up smoking. Flu vaccinations offered to patients. Prevention/ awareness campaigns to take place to raise profile of mental health stigma within the equality areas. (link to MAPLE staff network). Goal 2: Improved patient access and experience Outcome Lead Grade Actions for People, carers and communities can readily access hospital, community health or primary care services and should not be denied access on unreasonable grounds. LPFT Priority for 2017/18 CQC KLOE Responsive 3 SF Achieving Review of PLACE Assessment results to take place to identify any equality related concerns and support to address. (Q1) Apply for funding to support Disabled Go assessments within all Trust sites. (Q3/4) Physical Healthcare Lead in post within the Trust. Feedback from Mental Health listening events held in September Prevention/ awareness. Physical Healthcare Strategy in place. Equality Lead has been involved in PLACE assessments to ensure access from protected characteristic groups perspective is considered. 24/7 interpretation and translation services (telephone, face to face and document translation) available in all areas. NHS England s Accessible Information Standard implemented. April

4 2.2 People are informed and supported to be as involved as they wish to be in decisions about their care. CQC KLOE Caring 1/2 2.3 People report positive experiences of the NHS. 2.4 People s complaints about services are handled respectfully and efficiently. CQC KLOE Safety 2/ Responsive 4 SF/ Divisions SF/ PE team SF/ PE team Developing Achieving Achieving Interpretation and Translation retender. Interpretation and translation guidance to be produced to assist staff in effectively communicating with a person who does not speak English as a first language. (Q4) Equality involvement in Peer support worker project. (by end of Q4) Review process and analyse why return rates are so low and take any appropriate action. (Q2) Data analysis of FFT and patient demographic and community. If any gaps identify actions. (Q4) Data analysis of complaints against patient demographic profile. If any gaps identify actions. (Q4) Clinical Care Policy. Clinical Priority 3- Improve access to our services. Clinical Priority 5- Enhancing our clinical enviroments. Greenlight project. Autism Reasonable Adjustments mark and Learning Disability Reasonable Adjustments mark. Equality Lead has been involved in 15 Steps/ clinical governance visits to identify/ support any areas relevant to the protected characteristic groups. Review of Clinical care policy taken place in December 2014, This specifically focusses on service users being involved in their care as much as they want to be, and consideration is given to their equality needs. Rated Good in CQC inspection December 2015 for Caring and Responsive. Accessible Information Standard successfully implemented. Clinical Care Policy. CPA work ongoing. Friends and Family Test in place and collecting all 9 protected characteristic data. Analysis of equality monitoring results from FFT, to identify any trends/ gaps in feedback received. Process is there however, the return rate is low. Quality Priorities- all priorities under Patient Experience. The Trust is collecting Equality data (8 protected characteristic areas) for all complaints that are made by patients/ service users themselves. Return rate has been very low. Quality priorities- all priorities under Patient Experience. April

5 Goal 3: A representative and supported workforce Outcome Lead Grade Actions for Fair NHS recruitment and selection processes lead to a more representative workforce at all levels. CQC KLOE Well-led 3/4 3.2 The NHS is committed to equal pay for equal work of equal value and expect employers to use equal pay audits to help fulfil their legal obligation. SF/ AT Achieving A selection of questions to choose from to be implemented for the mandatory recruitment question in consultation with staff equality network members. (Q1) To achieve Level 2 of Disability Confident marker (old Two ticks Symbol). (Q2- Q4) Audit diverse panel data completion and report findings to OD committee. Map application, shortlisted and appointment data for equality areas and report findings to OD committee. (Q4) Equality Standard) metric 2 prior HR Achieving To continue Agenda for Change job evaluation and matching process (Ongoing) To complete the Gender pay gap reporting requirements (Q1) and complete action plan to try and close any gaps (by end of Q4 actions completed). Equality Standard) metric 1 prior Equality and Diversity section mandatory on all job descriptions. Values Based Recruitment toolkit includes mandatory E&D question for all interviews that take place within the Trust. Interview panels monitored for diversity. E&D section of Recruitment and Selection Training. Recruitment is completed through the national NHS Jobs 2 system or via the intranet system. NHS Jobs is a web-based system allowing applications worldwide. Recruitment and workforce equality data collated annually for review. Service user/ carer representatives at interviews are appropriately trained in E&D and represent the diverse population of Lincolnshire. Workforce Race Equality Standard (WRES). Clinical Priority 6- Developing our people. OD Strategy- High Performing. The Trust uses the Agenda for Change NHS national job evaluation scheme for all of its posts and utilizes nationally prescribed national terms and conditions. The Trust has had no equal pay claims regarding protected characteristics for pay or terms and conditions. Annual report published regarding protected characteristics and pay bands. In line with the principles of the Agenda for Change Job Evaluation the way in which new/revised roles are evaluated has been revised and reflects practices adopted by other NHS Trusts. April

6 NHS Agenda for Change Job Evaluation scheme. 3.3 Training and development opportunities are taken up and positively evaluated by staff. CQC KLOE Well-led When at work, staff are free from abuse, harassment, bullying and violence from any source. L&D Developing Analyse protected characteristic data for attendance at nonmandatory training for all equality groups collected. Work with Leadership to determine whether Equality data can be collected for evaluation of programmes. Equality Standard) metric 5 prior SF/ HR Excelling Analyse 2016 staff survey key findings by demographic information and present to OD committee for any actions required. (Q1). Anti-bullying week campaign 2017 to incorporate issues for equality groups. Equality Standard) metric 4 prior Across all staff networks agree a symbol that can be used to represent a safe and inclusive environment (e.g. rainbow flag shows LGBT Inclusive). Gender Pay Gap Report. Mandatory E&D Training online- current compliance rate = 86%. Refresher training required every 3 years. The L&D department registers attendance of staff at statutory and mandatory training and using information from the trust staff database (ESR). Non-mandatory training logged on OLM is analysed via protected characteristics collected on ESR. Clinical Priority 6- Developing our people. Equality Strategy in place to ensure that the staff and the public are clear on the expectation and standards required. The Trust has a policy on Bullying and Harassment and complaints made under this policy are monitored by protected characteristic areas. The Trust has a stress management action plan which incorporates tackling bullying and harassment. HR processes (Disciplinary/ grievance/ bullying and harassment) are analysed by Equality data annually- no adverse impact found for any protected characteristics. Whole week of activity conducted to raise awareness of Anti-Bullying week November Members of ENEI (Employers Network for Equality and Inclusion) and taken part in their e-quality benchmarking tool- results due Q2 of April

7 17-18). 3.5 Flexible working options are available to all staff consistent with the needs of the service and the way people lead their lives. 3.6 Staff report positive experiences of their membership of the workforce. CQC KLOE Well-led 4 LPFT Priority for Staff Survey results HR Achieving No actions for this year. The Trust has a process which allows all colleagues to request flexible working patterns. The request is considered against individual, organisational and patient needs. Investment in remote working technology to allow more flexible practises is within the Trusts strategic objectives. New home working procedure implemented on 19 April Achieving To continue with the Cultural Barometer and FFT. (Ongoing) SF/ HR/ Comms Analyses protected characteristic data to identify and trends/ patterns. Quarterly bulletin of activity and outcomes of staff networks following their meetings. (Q1,2,3,4) Role models and allies programme to be implemented Cultural Barometer and FFT in place. 4 staff networks are in place (Lesbian, Gay, Bisexual and Transgender (LGBT), Mental and Physical Lived Experience (MAPLE), Black, Asian and minority Ethnic (BAME) and Carers in the Workplace. All staff networks are inclusive of allies (people who don t identify as that protected group but want to support championing that agenda). Peer support session at beginning of meetings for people who identify. Hosting of Equality conferences - BME October 2016 (ULHT/ LPFT/ LCHS) - Lived Experience October 2016 (LPFT/ LCHS) - LGBT February 2017 (LPFT/ ULHT/ LCHS/ Healthwatch) Staff Survey results Work with staff wellbeing service to review offer available to staff with dyslexia. Possible HDQ training through Dyslexia Action(Q4) Clinical Priority 6- Developing our People. Infrastructure to be established to support Age equality (possibly Working Longer Toolkit) and also Younger workforce April

8 Infrastructure to be established to support Gender equality (Links to Gender Pay Gap report). (Q1 report, actions completed by Q4). Goal 4: Inclusive leadership at all levels Outcome Lead Grade Actions for Boards and senior leaders routinely demonstrate their commitment to promoting equality within and beyond their organisations. CQC KLOE Well-led 3/4 Board Excelling Continue membership of Stonewall Diversity Champion and participation in the workplace equality index. (Submission Q2, results Q4). Continue membership of ENEI (Employers Network for Equality and Inclusion) and submission of e-quality benchmarking tool (results Q2, submission Q4). Each Board sponsor to support their staff network group area and attend at least 1 meeting a year, and open staff conferences. (Q4) Case study of Executive Sponsor programme to be written for NHS Employers to share beyond LPFT. (Q2) Board members have sponsored a staff network and become a senior representative within the groups. All protected characteristic areas covered, regardless of whether there is a staff network in place. Executive sponsor brief in place as to what this means. Annual E&D Report is presented at Board. Stonewall membership continues to be supported- LPFT increased ranking by 14 places in 2017 results to 110 th (out of 439) -123 rd last year. LGBT History month activities sponsored by the Board- Multi-agency conference supported by LPFT as predominant sponsors along with ULHT, LGBT Patient User group and NMET. Board were awarded highly commended team of the year in May 2016 by NHS Employers for their commitment to E&D. Board signed the Diversity in the Boardroom pledge in August Papers that come before the Board and other major committees identify equality related impacts including risks, and say how these Equality Standard) metric 10 prior SF/ Board Achieving Communications and training sessions on Equality Analysis to be rolled out to ensure consistency in completion in each WRES (Workforce Race Equality Standard) WDES (Workforce Disability Equality Standard) Equality Analysis is ad-hoc at board and committee level. Tracking process now in place for all Equality Analysis completed April

9 risks are to be managed. CQC KLOE Well-led 5 LPFT Priority for area. Audit to be completed of Board papers and how many Equality Analysis completed. Review guidance associated with submission of board papers to ensure EA carried out appropriately. (Q4) through the Equality Lead. Trigger process in place on business case template that has to be completed for any changes to take place. The template for Board papers includes a section for Equality Analysis which acts as a trigger if this has not been completed before then. Data hub has been set up on intranet site for people to be able to access when completing Equality Analysis. Equality Analysis form and guidance revised during 2014/15. Managing a Diverse Team session has been included on the Introduction to Management module. 4.3 Middle managers and other line managers support their staff to work in culturally competent ways within a work environment free from discrimination. CQC KLOE Well-led 3/4 SF/ Managers Achieving Continuation and development of the staff networks. (by end of Q4) Equality Standard) metric 9 prior Communications through ILP and other methods on manager s responsibilities. Supporting staff to become Visible Leaders of protected groups aligned with the staff networks. Staff are supported to attend the Equality conferences throughout the year. (ongoing) NHS Improvement Cultural and Leadership programme- (Phase 1 Discover equality monitoring data to be collected and analysed). (Q1 and 2) and results to be incorporated into Phase 2 Implementation (Q3 and 4). Online Equality and Diversity training is mandatory and is completed at Induction and then mandatory refresher every 3 years. 4 staff networks are in place (Lesbian, Gay, Bisexual and Transgender (LGBT), Mental and Physical Lived Experience (MAPLE), Black, Asian and minority Ethnic (BAME) and Carers in the Workplace. All staff networks are inclusive of allies (people who don t identify as that protected group but want to support championing that agenda). Hosting of Equality conferences (multi-agency where possible). - BME October Lived Experience October LGBT February 2017 Sexual orientation and Gender Identity leaflet produced and copy provided for all staff. Equality Strategy has responsibilities of staff groups listed. 4 members of LGBT staff network supported to attend the Stonewall Role models/ Allies programme. April

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