Equality & Diversity- EDS2 Action Plan 2016/2017

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1 Internal Grade External Grade Evidence for Rating Equality & Diversity- EDS2 Action 2016/2017 Continuous Incorporated Into Monitoring Group Better Health Outcomes 1.1 Services are commissioned, procured, designed and delivered to meet the health needs of local communities Developing Developing Significant investment into Children and Young People (CHYP) Child and The Trust will continue to work with service users and commissioners to ensure that service specifications meet Adolescent Mental Health the needs of patients and carers. Services (CAMHS) and perinatal services integration of social care workforce to aid seamless services. To continue to ensure that all care pathways are developed based on patient /carer need the Trust will work in partnership with commissioners to strengthen its engagement processes Integration of Older ensuring the views of service users and Peoples Mental Health other key stakeholders are taken into (OPMH) into community account. services Evidence of good specialist support for patients undergoing gender reassessment and sexual orientation Care Commission (CQC) Action Adult Mental Health Transformation programme Project s and Patient Safety () Operational Management Group () 1

2 1.2 Individual people s health needs are assessed and met in appropriate and effective ways Achieving Achieving Assessment tools are well developed in relation to individual groups and take into account individual needs within specified care pathways CQC report indicated that the care provided by staff for patients is good and that the equalities act requirements are met Continue to monitor care delivery through audits, patient surveys, patient complaints, Patient Advice and Liaison Service (PALs) and incidents taking actions as required to ensure care delivery ensures people s health needs are assessed and met in appropriate and effective ways. CQC Action Adult Mental Health Transformation programme Project s 1.3 Transitions from one service to another, for people on care pathways, are made smoothly with everyone well-informed Developing Developing Policy framework includes the development or refresh of policies: CAMHS to Adult transition Adult to older people transition OPA guidance Adult Mental Health Children s services Work continues across the s to support the seamless transition of patients from age determined services. Patient/carer feedback methodologies to be utilised (e.g. patient stories) to inform service improvement. CQC Action 2

3 1.4 When people use NHS services their safety is prioritised and they are free from mistakes, mistreatment and abuse Developing Developing Safeguarding policies and procedure service Work continues to promote the raising of concerns by staff. CQC Action specifications CQC Report Annual Safeguarding To continue to improve staff training compliance(mandatory) Improve appraisal compliance to ensure Quarterly & safety Report Report training and development needs to the Quarterly Duty of Candour workforce are identified with plans for safeguarding compliance delivery in place. reports Freedom to Speak up Further development of the Mental Monthly policy and campaign Health Act (MHA) governance reportable Safeguarding supervision framework to support compliance with structures MHA code of practice Integrated Audit and Governance Committee (IAGC) 1.5 Screening, vaccination and other health promotion services reach and benefit all local communities Developing Developing Further development of Learning Disability service provision Annual flu campaign Traveller community development Vaccination service across Hull & East Riding including hard to reach groups (eg traveller community, Syrian refugees) To continue to work with our commissioners, NHS and 3 rd sector providers to raise awareness of mental illness and access to services for hard to reach communities through the established frameworks. To review the Trust website to maximise health promotion information To improve our use of social media to reach all groups Early planning to increase staff uptake of the flu vaccination in 2017/18 s IAGC 3

4 Improved patient access and Experience 2.1 People, carers and communities can readily access hospital, community health or primary care services and should not be denied access on unreasonable grounds Developing Developing The Trust meets its statutory duties under the To ensure that our future Estates Strategy includes the needs of all Estates Strategy Capital programme equalities act for disabled groups Individual Board groups however Estates Service s survey under review to further develop equality needs and requirements Most properties have access and egress and alternative arrangements can be made on an individual basis if particular needs cannot be met 2.2 People are informed and supported to be as involved as they wish to be in decisions about their care Developing Developing Examples of good practice seen as part of audit Feedback from CQC identifies some areas for improvement Continuous monitoring via complaints/incidents/patient surveys with actions taken to ensure that our patients and their carers have the opportunity to be involved as they wish to be in care planning and delivery decisions. CQC Action IAGC 4

5 2.3 People report positive experience of the NHS Achieving Achieving Family & Friends tests CQC report Patient compliments Although rated as achieving the Trust recognises the need to constantly improve the experience of patients and their carers, therefore this has been embedded into the quality improvement plans to ensure that we have a greater catalogue of ways people can report their experience. 2.4 People s complaints about services are handled respectfully and efficiently Excelling Excelling CQC report identifies the Trust complaints process as robust and compassionate The CQC and the Ombudsman have reported positively about the Trust complaints handling this was also a high scoring area in the national patient surveys. However the Trust seeks to continuously improve how people s concerns are dealt with and the new policy is directing staff to resolve at the point the issue is raised informally wherever policy. Training for all staff is being rolled out commencing with the Adult care Group in February CQC s s IAGC A representative and supported workforce 3.1 Fair NHS recruitment and selection processes lead to a more representative workforce at all levels Achieving Achieving The Trust adheres to the NHS standards for recruitment. The trust is a mindful employer and has a renowned positive assets service which supports people with mental health back into employment. Developing Values Based Recruitment which will consistently include service users on the interview panels. Review charter marks in line with our strategy. Workforce and Organisational Development (OD) Strategy and Implementation s Strategy Group 5

6 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 obligations Developing Developing There is a robust job evaluation process in place and the trust has not had any equal pay claims to date. Action will be undertaken in line with the proposed Gender Pay Gap legislation which is required to be published during 2017/18. A gender pay gap audit will be required as part of this work. HR Directorate work plans Grievances Executive Management team (EMT) 3.3 training and development opportunities are taken up and positively evaluated by all staff Developing Developing Staff attitude survey reports Additional training sessions provided as positively in relation to staff need arises based on performance accessing training and compliance. Additional training to be development. undertaken for new supervisors in line Performance Appraisal with PADR. Development Reviews (PADRs) are expected to Patient group/diagnosis specific training be undertaken on an programmes are procured and annual basis as well as developed as part of workforce training regular supervision across needs analysis. the trust and PADR and mandatory training are Review and develop a robust process regularly reported on within for training approval in line with budgets the trust performance and need. framework. Survey identified that high proportion of staff are satisfied with the training department and delivery of training. Lack of formal grievances. Staff Survey results Grievances Strategy Group 6

7 3.4 When at work, staff are free from abuse, harassment, bullying and violence from any source Developing Developing Staff Attitude survey shows The Trust will continue to support and improvement is needed in develop a culture that is supportive of relation to bullying and staff and free from B&H. harassment (B&H). Staff have been trained in B&H as part of the Management Development Programme. Any individual issues or concerns are supported through the Trust policy and procedure. Staff Survey results B&H claims Grievances Performance Reports Strategy Strategy Group 3.5 flexible working options are available to all staff consistent with the needs of the service and the way people lead their lives Achieving Achieving Staff attitude survey reports positively on staff experience in this area. Staff are aware of how to request flexible working requests and wherever possible these are supported and managed through a supportive policy. Staff are supported with retire and return requests. Reasonable adjustments are made in accordance with occupational health advice in relation to working hours and patterns. New recruits are able to request flexible working arrangements to their domestic commitments and carer responsibilities. The Trust will continue to consider flexible working options to maximise on the recruitment and retention of staff. Staff Survey Results Grievances Applications OCH letters 3.6 Staff report positive experience of their membership of the workforce 7

8 Developing Developing Staff attitude survey/staff family and friends test show there are areas for improvement. Evidence is also gathered and addressed on a team basis during health and safety stress audits. Inclusive leadership The Trust will continue to develop and support a positive culture where staff will be attracted into and retained in the organisation. Strategy Staff Survey Stress Audits 4.1 Boards and senior leaders routinely demonstrate their commitment to promoting equality within and beyond their organisations Developing Developing Staff attitude survey and CQC Need to ensure that we explicitly identify report identifies areas for and address Equality & Diversity (ED) Strategy improvement. when designing services with Staff Survey Equality included within the commissioners. CQC reports Sustainable Transformation Strategies (STP). Deliver E&D training to Board. Policies Positive about disabled Board Papers people (disability two ticks Develop a Leadership Framework. symbol) displayed on our documents. Implement the Workforce Disability Included within tender Equality Scheme (WDES) in April specifications. Included within strategies, policies and other documents. Built into recruitment processes. No claims around senior leaders not displaying positive commitment to promoting equality. Mindful Employer. Director of HR executive lead for E&D in partnership with the Director of Nursing, and Patient Experience. Strategy Group Board/Committees EMT 8

9 4.2 Papers that come before the Board and other major Committees identify equality-related impacts including risks, and say how these risks are managed Developing Developing Equality Impact Assessments are undertaken for strategies, policies, however, risks and how they will be managed are not explicitly included. Review of the EIA to be undertaken to include the explicit identification of risks and how they will be managed. Strategies Policies EMT Board/Committees 4.3 Middle managers and other line managers support their staff to work in culturally competent ways within a work environment free from discrimination Developing Developing Equality and Diversity training is now mandatory. Policies in place to manage E&D issues. Behaviour Framework and staff charter to be introduced. Staff Survey Strategies Policies Review current demographic data by organisation and by locality and agree actions. EMT Board/Committees 9