The Equality Delivery System (EDS2) Final Grading and Summarised Evidence report May 2014

Transcription

1 The Equality Delivery System (EDS2) edsedsedsedsedsedsedsedsedsedsedsedsedsedsedsedsdsedsedsedsedsedsedsedsedsedseedseds sedsedsedsedsedsedsedsedsedsedsedsedsedsedsedsedsedsedsedsedsedsedsedsedsedsedsedsedsedsedsedsedsedsedsedsedsedsedsedsedsedsedsedsedsedsedsedsedsedsedsedsedsedsedsedsedsedsedsedsedsedsedsedsedsedsedsedsedsedsedsedsedsedsedsedsedsedsedsedsedsedsedsedsedsedsedsedsedsedsedsedsedsedsedsedsedseds Final Grading and Summarised Evidence report May

2 1. Introduction In November 2013 NHS England issued the updated Equality Delivery System (EDS2) designed to be slimmer and more flexible. The system has been simplified and two of the outcomes changes from the original EDS. EDS2 is a generic tool designed for both NHS commissioners and NHS providers. The main purpose of the Equality Delivery System (EDS) is to help local NHS organisations, in discussion with local partners including local people, review and improve their performance for people with characteristics protected by the Equality Act 2010 Using the NHS Equality Delivery System 2 provides a way for the Trust to deliver on the Public Sector Equality Duty (PSED) and ensure compliance with the Equality Act The four EDS goals are: 1. Better health outcomes 2. Improved patient access and experience 3. A representative and supported workforce 4. Inclusive leadership 1.1 EDS2 Grading For each EDS outcome, there are four grades, and a RAG plus rating, to choose from: Excelling Purple Achieving - Green Developing Amber Undeveloped - Red 2

3 Essentially, there is just one factor for NHS organisations to focus on with the grading process. For most outcomes the key question is: how well do people from protected groups fare compared to people overall? Grading Each grade is dependent on evidence of the protected characteristics including; gender, race and ethnicity, age, disability, religion or belief, sexual orientation,, pregnancy/maternity/adoption and paternity, transgender and marital status. Undeveloped People from all protected groups fare poorly compared with people overall OR evidence is not available Developing People from only some protected groups fare as well as people overall Achieving People from most protected groups fare as well as people overall Excelling People from all protected groups fare as well as people overall 3

4 Our evidence and grading is set out in section 4: 2. Getting local interests/staff involved and engaged within the Trust s EDS implementation plan: The Equality Delivery System puts local interest groups at the forefront of assessing and grading NHS performance against a series of service user and staff focussed outcomes. The Trust has facilitated engagement workshops with service users, carers, stakeholders, staff and the local community to: Inform service users and local communities of the EDS2 and how their input can help shape and deliver the best solutions to meet the needs of local communities across Dudley and Walsall Involve service users, carers, stakeholders, staff and local communities in the development of the EDS objectives and key priorities Help the Trust to assess where it as an organisation by analysing and grading performance against each EDS Goal and 18 outcomes. 4

5 3. Dudley & Walsall Mental Health Partnership NHS Trust, Grading and Engagement activity March 2014 May 2014 Activity/ Meeting DATE / LOCALITY / VENUE KEY THEME(S) Meeting with Dudley Health watch CEO Human Resources Team meeting Equality & Diversity Steering Group meeting SUMITT House Support CDW Team Meeting 11 th March 2014 DCVS Brierley Hill Dudley 25 th March 2014 Trafalgar House Dudley 8 th April Trafalgar House Dudley 28 th March 2014 SUMIT House, Dudley 4 th April 2014 Trafalgar House Dudley Mental Health Forum 28 th April 2014 Insight Carers Café Brierly Hill Dudley Communication to 3 rd Sector, voluntary and organisations via CDW database 29 th April 2014 Walsall & Dudley EDS2 Implementation Plan Role of Health watch in analysing EDS2 grades and working in partnership to further engage with local interests EDS2 Implementation progression plan Empowered, engaged and included staff Inclusive leadership at all levels EDS 2 Self-Assessment Grading (all 4 Goals and 18 Outcomes) EDS 2 Implementation Progression plan and Priority setting LGBT communities and the EDS EDS Overview and implementation Grading and priority setting Grading & Evaluating EDS 2 Goals 1,2 and 3 BME Communities and the EDS Gypsy & Traveller communities and the EDS Learning Disability and the EDS Overview of the EDS2 EDS2 Implementation Plan Grading and evaluating EDS Goals 1&2 Overview of the EDS2 EDS2 Implementation Plan EDS2 Self Assessment evaluation and grading review Staff & Service User 12 th May 2014 EDS2 Grading for Goals 1, 2 and 3 5

6 engagement event Public Engagement event Public Engagement event Staff and service user engagement event Staff and service user engagement event Local Interest HUB meeting (Centre for Equality & Diversity) Staff Side Forum Dorothy Patterson Hospital, Walsall 13 th May 2014 Churchill Shopping centre, Dudley 14 th May 2014 New Art Gallery, Walsall 15 th May 2014 Dove House, Bushy Fields Hospital, Dudley 16 th May 2014 Bloxwich Hospital Bloxwich, Walsall 19 th May 2014, Priory Hall, Priory Road, Dudley 2 nd June, Cross Street Surgery, Dudley Priority setting / Draft Objectives EDS2 Overview EDS2 Grading for Goals 1 and 2 Priority setting and draft objectives 2014/16 EDS2 Overview EDS2 Grading for Goals 1 and 2 Priority setting and draft objectives 2014/16 EDS2 Grading for Goals 1, 2 and 3 Priority setting / Draft objectives EDS2 Overview EDS2 Grading for Goals 1, 2 and 3 Priority setting and draft objectives 2014/16 Grading & Evaluating EDS2 Goals/Outcomes against 18 EDS outcomes Priority setting Draft Equality objectives Grading & Evaluating EDS2 Goals/Outcomes against 18 EDS outcomes Priority setting and Draft Equality Objectives

7 4. Matrices Tables for the 18 EDS2 outcomes, plus evidence of grading EDS2 Goal 1: Better health outcomes Reference Number: 1.1 Outcome: Services are commissioned, procured, designed and delivered to meet the health needs of local communities Organisations Approach: The Trust believes that patients are fully at the heart of the design and delivery of its services. It has set up systems through which patients can communicate to the Board, using a variety of means including patient surveys and public board meetings, informing Board members of the services they think should be provided. In addition to its own patient surveys, the trust also draws on CQC patient surveys. The trust can demonstrate that patients from most protected groups report high levels of satisfaction, on a par with all other groups, in the way in which services are delivered. Evidence from public engagement and patient surveys is reviewed on annually basis and plans to maintain current progress and make further improvements are updated on a regular basis. The trust aims to meet health needs and reduce health inequalities, for all protected groups, through its annual Quality Accounts reporting. The Trust works closely with commissioners to ensure that services meet the needs of the local communities. The Trust Mental Health Forum have patient/service user and carer representatives The Trust s Expert by Experience Service Users/Carers are members of internal committees to ensure that the needs of vulnerable service users are met and reduce inequalities in health outcomes. The Trust s Improving patient experience strategy, confirms the Trust is committed to developing and supporting service users in the planning, delivering and evaluating mental health services. One of the main goals for the Trust is to meet service user and carer expectations through delivery of care to the highest possible standards. In order to achieve this, the Board has a number of mainstream systems to enable patients to communicate their views: Board meetings are held in public patient surveys Equality Impact Analysis (Assessments) procedures and processes Mental Health Forum Working closely with its commissioners, the Trust shapes the contracts of its commissioners to ensure services are designed to meet the health needs of the local communities, promote well-being and reduce health inequalities. The Trust has made 7

8 improvements in designing pathways by using best evidence based care for the patients we serve. The Trust have a clinical audit programme designed to capture how pathways are used seeking views across the service areas The Trust is working towards gaining foundation status and we are collecting evidence from members to ensure we have good representation from the protected characteristics. The plan to fill the gap for Civil partnership will be added to the re-audit for sexual orientation next year and all future patient surveys will include all 9 characteristics. The Trust engages with service users via the quality account process, engaging with stakeholders to set priority areas for the year Gaps currently are around the collection of data on Gender re assignment, Civil Partnership, sexual orientation and Maternity EDS2 ACHIEVING grade: The Trust, with evidence and engagement processes covering most protected groups, is able to demonstrate that its services are designed, procured and delivered to meet the needs of most protected groups, and aim to reduce health inequalities. Plans for progression are in place. For these reasons the Reasons for Grading: suggested grade for outcome 1.1 is achieving Outcome: Using good data and evidence, the Trust can demonstrate that services are designed, procured and delivered to fully meet the needs of all protected groups, promoting well-being and reducing health inequalities. Engagement: Patients from most protected characteristics are engaged. Mainstream processes: The Trust aims to meet this EDS outcome, for all protected groups, using its Quality Accounts reporting. Contracts with its commissioners are jointly shaped. Progression plans: Plans are in place to maintain and to make further improvements. These will be reviewed/updated regularly via the Trust Equality & Diversity Steering Group and any actions or progress will be reported to the Quality & Governance Committee. Sources of Evidence: Other Disadvantaged groups: Key disadvantaged groups are taken into account in the above processes such as homeless f Patient experience reports Public Board Meeting minutes Community Engagement / membership strategy Trust membership breakdown report 8

9 Quality Accounts reporting. Community Development Worker team action plan quarterly reports Membership & Engagement events CQUIN Reports Equality Impact Analysis reports Friends and family test results EDS2 Goal 1: Better health outcomes Reference Number: 1.2 Outcome: Individual people s health needs are assessed and met in appropriate and effective ways Organisations Approach: The Trust aims to provide services that are informed by effective and inclusive health assessments of its service users. A patient profiling initiative is in the process through the Service Transformation Board. Such assessments will also be analysed by the 9 protected groups. Engagement with most patient groups is good. The Management Executive Team and Trust Board reviews the results of patient surveys and ensures that plans for providers aim to improve both its health-needs assessment methodology as well as its provision of health care services The Trust proactively assesses individual needs of patients and supports reasonable adjustments to meet their needs. The Trust s Improving patient experience strategy, confirms the Trust is committed to developing and supporting service users in the planning, delivering and evaluating mental health services. Staff and patients with learning disabilities are taken into account when accessing or designing services. This is done through the Trust EIA process and through the CDW Team. The Care Programme Approach is the framework for good practice in the delivery of mental health care. It is a system that was set up to ensure that people with mental illness have the support and treatment that they need from services. The CPA requires that adult secondary care mental health services arrange and co-ordinate the care and medical treatment that a person requires. When a person is referred to the mental health team, an assessment of their needs will take place. This can sometimes result in a 9

10 person being directed to other services, but where a person has mental health needs that need the input of the secondary mental health team, a Care Co-ordinator will be assigned. The Care Co-ordinator is the staff member who works most closely with the service user in terms of planning and co-ordinating appropriate help. The Care co-ordinator is responsible for developing the CPA Care Plan. The care plan is developed with the service user and takes into account both health and social needs. The care plan will also contain information about what to do and who to contact in a crisis. The CPA record and care plan will also contain a risk assessment. The four steps within the CPA process are: Assessment of health and social care needs including risk assessment Development of comprehensive care plan Implementation and evaluation of care plan Review and discharge planning The local authority care management functions are integrated within CPA. The eligibility criteria set under Fair Access to Care Services applies to those people who are assessed as needing a social care service. Although there is engagement with most specific groups, e.g. pregnant and maternity patients and, through the chaplaincy service, relating to the religious needs of patients, there is not yet general engagement with all groups. There is also a lack of evidence around key disadvantaged groups. The Equality & Diversity and other governance structures of the Trust helps to ensure that there is a focus on improving patient outcomes for all protected groups. EDS2 grade: ACHIEVING The Trust is able to demonstrate the processes for assessment of health-needs, and the delivery of resulting services for most protected groups. However, it has limited evidence on the outcome of this for most protected groups. Work has begun on further projects to improve these processes for protected groups where there is a perceived need, through engagement with those groups. For these reasons the suggested grade for outcome achieving 10

11 Reasons for Grading: Outcome: Using good data and evidence, the Trust can demonstrate that services are designed, procured and delivered to fully meet the needs of most protected groups, promoting well-being and reducing health inequalities. Engagement: Patients from most protected characteristics are engaged. Mainstream processes: The Trust aims to meet this EDS outcome, for all protected groups, using its Quality Accounts reporting. Contracts with its commissioners are jointly shaped. Progression plans: Plans are in place to maintain and to make further improvements. These will be reviewed/updated regularly via the Trust Equality & Diversity Steering Group and any actions or progress will be reported to the Quality & Governance Committee. Other Disadvantaged groups: Key disadvantaged groups are taken into account in the above processes. Sources of Evidence: PEARL interpreter booking form PEARL sign language interpreter booking form PEARL Interpreter feedback form staff /Service users PEARL 6 monthly management monitoring reports Community Engagement strategy Patient Experience Surveys Service User Engagement events Community Development Worker Team Action Plan quarterly reports Equality Impact Assessment process and monitoring Friends and family test resultsroups, and reducing h 11

12 EDS2 Goal 1: Better health outcomes Reference Number: 1.3 Outcome: Transitions from one service to another, for people on care pathways, are made smoothly with everyone well-informed Organisations Approach: Transition from one service to another is led by the patient s care co-ordinator or their clinical lead. A multi-disciplinary approach is taken involving the patient throughout; for example, the Care Programme Approach process is used within mental health services and shared with all involved in planning and delivering care. Transfer planning, where appropriate, is started as soon as possible on the patient s care pathway. It includes the patient s preferences and needs after discussion with them. Patients are kept informed and involved at all stages of care and are routinely involved in agreeing their care plan, which they will also receive a copy. Patients care pathways are completed and kept in their notes. These are discussed with the patient and their relatives/carers in confidence. The Trust also use consent forms for patient to sign and consent to different treatment pathways. There are processes in place to ensure that patients who do not have capacity to consent or make decisions regarding their care. Families are involved in discussions to make decisions in the best interest of patients and independent advocacy service is available. The Service Transformation Board and work streams undertake equality impact analysis to ensure a smooth transition and to alleviate and adverse impact on all protected groups. The Trust s Care Programme Policy has been revised to take into consideration the Equality Act All patient transfers take place under the umbrella of Care Programme Approach. Transfers will take place within CPA handover meetings. For patients from elsewhere the Gateway worker organises the transfer meeting with all appropriate agencies, and staff from the team taking over the care. There are some problems in the transfer of people with a diagnosis of learning disability, this is mainly because of the differing thresholds within the Specialist services and Adult Mental health services. This is usually resolved by negotiation between the service wishing to transfer the patient, GP and any other relevant agency. There may also be problems in transferring patients from Adult services to older persons services, Again this is due to differing age thresholds. Although there is engagement with specific protected groups, the Trust cannot currently evidence that service changes and transitions are considered to be equitable across all protected groups. There is evidence for some protected groups, e.g. adults and older people, that patient pathways are maintained when patients transfer across services but this evidence is not available for all groups. There is evidence on good general engagement with patients and patient representatives but there is less evidence of engagement with most protected groups. There is a lack of evidence around key disadvantaged groups. 12

13 Outcome: From the evidence available the Trust can demonstrate that service changes are discussed with patients from some protected groups, with the majority reporting satisfactory service changes and transitions. Engagement:. The organisation does engage with patients and patient representatives/bodies on how service changes are discussed, and transitions effected smoothly but there is not yet direct engagement with all protected groups. Mainstream processes: Management structure of the Trust allows service changes and transition arrangements to be managed through mainstream processes but there is little evidence that the needs of some specific groups are explicitly considered. Progression plans: There are plans to continue improvements with the engagement strategy, and to further develop engagement relationships with seldom heard groups. Other Disadvantaged groups: Key disadvantaged groups, such as recent migrants and people of socio-economic deprivation, are taken into consideration in the above processes. EDS2 grade: Reasons for Grading: DEVELOPING The Trust has evidence and engagement processes in place to meet this Equality Delivery System outcome. It can demonstrate that service change discussions with patients from some protected groups take place, and changes are made as smoothly as possible. Information only covers some of the protected groups and plans to improve need to be developed. For these reasons the suggested grade for outcome 1.3 is developing Outcome: Using good data and evidence, the Trust can demonstrate that services are designed, procured and delivered to fully meet the needs of all protected groups, promoting well-being and reducing health inequalities. Engagement: Patients from some protected characteristics are engaged. Mainstream processes: The Trust aims to meet this EDS outcome, for all protected groups, using its Quality Accounts reporting. Contracts with its commissioners are jointly shaped. Progression plans: Plans are in place to maintain and to make further improvements. These will be reviewed/updated regularly via the Trust Equality & Diversity Steering Group and any actions or progress will be 13

14 reported to the Quality & Governance Committee. Sources of Evidence: Disadvantaged groups: Key disadvantaged groups are taken into account in the above processes. f Care Programme Approach policy Community Engagement strategy Care Quality Commission patient survey reports Trust membership breakdown Service Experience Strategy and regular reports Equality Impact analysis processes and procedure Expert by Experience Service Users reports Community development Worker Action Progression Plans Equality & Diversity Steering Group minutes and Action Plans EDS2 Goal 1: Better health outcomes Reference Number: 1.4 Outcome: When people use NHS services their safety is prioritised and they are free from mistakes, mistreatment and abuse Organisations Approach: The safety of its patients is a priority for the Trust. All safety incidents are now reported through a more robust electronic system, embedding a detailed analysis of the causes of any incidents into the investigations. The Trust has robust policies and procedures for safeguarding adults and children and all staff receive training to ensure that they have the competencies to recognise abuse and raise an alert. Training for all staff is mandatory and all new starters receive awareness training at induction. There are processes in place to ensure that patients who do not have capacity to consent or make decisions regarding their care. Families are involved in discussions to make decisions in the best interest of patients and independent advocacy service is available across Dudley and Walsall. The Trust is proactive in deterring individuals with a history of abusing people from working within the organisation by ensuring that we have a robust recruitment process. We are clear about Trust expectation on staff as part of the job advert and job description for every vacancy and all staff are DBS checked. The Trust has zero tolerance on abuse of patients and has reported staff to professional regulatory bodies and the Independent Safeguarding Authority in the past. The Trust also operates the Dignity 14

15 and Respect Benchmarking Tool within hospital wards. The Trust s Quality improvement strategy sets out the aim of continuously improving quality and safety of patient care The Trust also has a comprehensive Privacy and Dignity policy, which provides clear guidance for staff to support and listen to any concerns from patients, and quickly find beneficial solutions. The Trust's Safeguarding Adults and Children policy outlines a robust process for supporting patient safety, the Trust's governance arrangements so that lessons can be learnt from any incident, plus staff training requirements. This policy has also been updated in February 2012 to ensure a consistent approach across all services. Both the policies and training have been reviewed to ensure they comply with the public sector equality duty under the Equality Act The Trust puts the safety of patients as the highest of priorities and has a range of mechanisms in place to ensure that this happens. The Trust's governance structures monitor patient safety against the appropriate CQC Essential Standards and safeguarding of vulnerable adult training for staff. Aids to help a person from a protected group engaged in this process are considered on an individual basis. Translation services are readily available for most of the languages spoken within Dudley and Walsall. The Trust aims to improve the safety of all patients through mainstream processes, e.g. action plans arising from incident reporting, but this is not generally focused on any issues relating to specific protected groups. There is also a lack of evidence around key disadvantaged groups. EDS2 grade: Reasons for Grading: ACHIEVING The Trust has engagement processes in place and is meeting the Equality Delivery System outcome for most protected and key disadvantaged groups. Quality Accounts reporting aims to meet this outcome, additionally, and progression plans are firmly in place. Patient safety is also monitored through the Trust s contractual agreements with its commissioning organisation. For these reasons the suggested grade for outcome 1.4 is achieving Outcome: The Trust prioritises patient safety and now has a more robust system in place to track and investigate incidents. There are comprehensive policies in place to support patients being free from abuse, harassment and bullying, with redress being clearly explained. Engagement: The Trust has a strong engagement strategy, involving people from most protected groups and continually reaching out to seldom heard groups. 15

16 Mainstream processes: There are mainstream processes in place, which report on complaints and patient safety issues regularly to the Board and in the Trust s annual Quality Accounts. Progression plans: There are plans in place to develop the clinical governance team s reporting structure to enable it to be more informative of protected groups and effective for the Trust as a whole. A 100 day plan initiative will be rolled out within the Trust during 2014/15 Other Disadvantaged groups: Key disadvantaged groups such as recent migrants and people of socio-economic deprivation are taken into consideration in the above processes. Sources of Evidence: Privacy and Dignity policy Adult Safeguarding policy Community Engagement strategy Dignity at work policy SED (Complaints) annual report Trust membership breakdown Updated safeguarding training Anti-Bullying policy Equality Impact Analysis process and procedure Equality & Diversity Policy reducing h EDS2 Goal 1: Better health outcomes Reference Number: 1.5 Outcome: Screening, vaccination and other health promotion services reach and benefit all local communities Organisations Approach: The Trust is not directly responsible for screening vaccinations. The Trust is monitored for its seasonal flu vaccination staff uptake. 16

17 Trust mental health promotion campaigns have attempted to deliver across all local communities and groups. Community Development Worker staff within the Trust have additional knowledge re local resources for support and social contact. Including those specific to protected groups. i.e. Women s refuge. People using alcohol to excess or drugs are signposted or referred to the local drug and alcohol service by the intake and treatment team. The team do have a dual diagnosis lead. For people being offered treatment/intervention within the team this will form part of their care plan. As part of people s CPA care plan and where physical health issues are identified the Rethink Physical Health Check will be carried out. People with an eating disorder are referred onto the Eating Disorder Service within the Trust. EDS2 grade: Reasons for Grading: DEVELOPING The Trust has evidence and engagement processes in place to meet this Equality Delivery System outcome. Information only covers some of the protected groups and plans to improve need to be developed. For these reasons the suggested grade for outcome 1.3 is developing Outcome: Little vaccination activity takes place within the Trust apart from the routine annual flu vaccinations for staff. Engagement: The Trust engages with patients and carers. Mainstream processes: The Trust aims to improve its services through mainstream processes. Progression plans: Plans are in place to maintain and to make further improvements. These will be reviewed/updated regularly via the Trust Equality & Diversity Steering Group and any actions or progress will be reported to the Quality & Governance Committee. Other Disadvantaged groups: Key disadvantaged groups are taken into account in the above processes. Sources of Evidence: Community Development Worker Activity reports Engagement Strategy 17

18 EDS2 Goal 2: Improved patient access and experience Reference Number: 2.1 Outcome: People, carers and communities can readily access hospital, community health or primary care services and should not be denied access on unreasonable grounds Organisations Approach: A comprehensive interpreting and translation service is in place, ensuring that people with disabilities and Black and minority ethnic groups are able to access services. The Trust s information systems are not currently set up to collect information across all protected groups, so there is a lack of evidence to compare against patients in general. Plans are in place, with clear milestones, to improve the patient information to cover all protected groups including key disadvantaged groups. Equality information on patient complaints is collected but not analysed so the experience of protected groups in relation to complaints is not reported. The Trust proactively assesses individual needs of patients and supports reasonable adjustments to meet their needs in accessing services. The Trust s Improving patient experience strategy, confirms the Trust is committed to developing and supporting service users in the planning, delivering and evaluating mental health services. Assurance is given through unannounced visits from Expert by Experience service users/carers. The Trust community development workers also review the accessibility of services by supporting the service transformation work stream/implementations groups to ensure equality of opportunity. The Community Development Worker Team also effectively engage with hard to reach communities to improve accessibility from people of protected groups under the Equality Act Evidence from surveys and other engagement suggests that patient are able to access the Trust's services as a whole however, evidence by protected characteristics is not readily available. The Trust engages with patients and with patient groups although is not routinely focused on the needs of specific protected groups Translators are arranged for assessment appointments as required and summary assessment reports are translated and sent to the person. The CDW team has recently held a multicultural forum inviting a number of local community and religious groups to discuss their needs with regards to mental health services these include working with South Asian women, New Migrants, Learning Disability groups and a number of religious groups on interfaith events. This is envisaged to become a regular event and will be valuable in providing feedback in how the Trust can improve its services to various communities in Dudley & Walsall. EDS2 ACHIEVING 18

19 grade: Reasons for Grading: The Trust is already making use of some data. It has strong engagement with patients, carers and communities in place, including with most protected groups. It also has a comprehensive interpretation and translation service. We have plans in place to improve collection and use of data about protected groups. We also plan to improve access to services, for example, talking therapies in the community for Black and minority ethnic people and disadvantaged groups. For these reasons the suggested grade for outcome 2.1 is Achieving Outcome: Some evidence is available to demonstrate that patients, carers and communities from protected groups can access services. Firm plans are in place to improve evidence and data, and progress to the next grade. Engagement: The Trust s engagement with patients, carers and communities, including people from most protected groups, is strong. The Engagement strategy outlines the way forward to strengthen these links, for example, by strengthening engagement with lesbian, gay, bisexual and transgender groups. Mainstream processes: The Board analyses patient and carer feedback through a quarterly patient experience reports, patient surveys and reports from the EbE s. Progression plans: Plans are in place to progress to the next grade, with milestones. Sources of Evidence: Other disadvantaged groups: Key disadvantaged groups are taken into account in plans to progress to the next grade. Examples include data collection and analysis, and development of self-referral regarding talking therapies in the community. Patient Experience reports (SED) Service Experience Desk annual report Community Engagement strategy PEARL management monitoring reports Care Quality Commission patient survey reports Trust membership breakdown Carer experience surveys Community Development Worker Action Plan Equality & Diversity Action Plan Triangle of Care strategy h 19

20 ESD2 Goal 2: Improved patient access and experience Reference Number: 2.2 Outcome: People are informed and supported to be as involved as they wish to be in decisions about their care Organisations Approach: The Trust has policies and procedures to support patients who do not have capacity to make decisions about their care. Families, independent advocates and community support networks such as social workers are involved in making decision in the best interest of patients. The Trust has policies in place to ensure that patient consent is respected and recorded at all times regarding treatment options. The Expert by Experience service users/carers also advocate on behalf of patients to ensure autonomy and respect with regards to decisions about patient care. The Community Development Worker Team also advocate on behalf of service users from different ethnic and religious backgrounds and those whose first language is not English, through Trust interpreters. The Trust has arrangements in place with interpreting services. This is to enable patients who require assistance communicating with staff, either due to disability or a language barrier, to be fully involved in decisions about their care. Through its monitoring of patient views (e.g. SED information, patient surveys) the Trust can demonstrate that patients have high levels of satisfaction with the Trust s services. However, information is not available to compare the specific satisfaction levels of patients for all protected groups. Also, the Trust does not have good evidence in respect of disadvantaged groups. All care is delivered under the Care Programme approach. Patients are involved in identifying their needs, and formulating their individual care plan. The involvement of families and carers is encouraged, and carers assessments are offered and completed for those meeting the criteria for these. For people from different cultures, the families are involved as appropriate. A written summary of a person s initial assessment is usually sent to them. The Intake and Treatment team involve service users, and if appropriate carers, in decisions about their care through the CPA assessment and care planning process. Service users routinely receive a copy of their care plan. Care plans written using the CPA template are signed by the service user. Care plans in letter format are not signed by the service user; copies are given to service users. Care plans are reviewed with service users on a minimum of 6-monthly 20

21 The Trust implements the Triangle of Care initiative. The Triangle of Care is a therapeutic alliance between service user, staff member and carer that promotes safety, supports recovery and sustains wellbeing. The original Triangle of Care guide was launched in July 2010 to build on existing developments and good practice to include and recognise carers as partners in care. It offered key standards and resources to support mental health service providers to ensure carers are fully included and supported when the person they care for has an acute mental health episode; the inclusion of carers benefits staff, carers and service users alike. EDS2 grade: Reasons for Grading: DEVELOPING The Trust is meeting the Equality Delivery System outcome for some protected groups, and in its processes. Plans for progressing to the next grade are in place. For these reasons the suggested grade for outcome 2.2 is developing Outcome: Using good evidence, the Trust can demonstrate that patients and carers report overall positive experiences but evidence is insufficient when looking to see if this may vary between patients from different protected groups. Engagement: The Trust engages with patients and carers but, with some exceptions, this engagement is not routinely with groups able to feedback on the experiences of patients from specific protected groups Mainstream processes: This issue is central to the patient experience work programme. It is also covered in patient surveys, analysed and reported on to the Board. Progression plans: Plans are in place to improve the monitoring of satisfaction levels by protected characteristics. Other disadvantaged groups: Key disadvantaged groups are not explicitly taken into account in the above processes Sources of Evidence: Consent policy CPA policy and procedures PEARL information and guidance Care Quality Commission patient survey reports Community Engagement strategy Trust membership breakdown Customer Care reports 21

22 Equality Impact assessment procedure Triangle of Care Strategy EBE Work programme Equality & Diversity Policy Care h EDS2 Goal 2: Improved patient access and experience Reference Number: 2.3 Outcome: People report positive experience of the NHS Organisations Approach: The Trust s information systems are not currently set up to collect information about all protected groups so there is a lack of available evidence to compare against patients in general. Plans are in place, with clear milestones, to improve patient information obtained to cover more protected groups, including key disadvantaged groups. The Trust EBE s, CDW s and Service Experience Lead on engage with different groups on the services the Trust provides, including aspects of dignity and respect. The Trust has a programme of survey to measure patient experience and actively seek feedback through Community Development Worker Team and expert by experience service users and carers. Patient Experience surveys are regularly utilised across all Trust services with a view to provide feedback of patient experience to the Management Executive Team and Trust Board. The Trust is improving ways of capturing this feedback by introducing multiple sources of giving feedback. Information is being developed to support patients and staff with improving care. Patient stories are shred with the Trust Board to highlight positive and negative experience. The Trust s Improving patient experience strategy, confirms the Trust is committed to developing and supporting service users in the planning, delivering and evaluating mental health services. The Trust also operates the Dignity and Respect Benchmarking Tool within hospital wards. The service user/carer involvement and experience strategy was refreshed to outline how our Trust intends to involve the people who use our services, and their carers, in service developments and other areas. It also seeks to improve the experience of people, including carers, in using our services. The Trust gains informal feedback from patients about the service from patients who are in protected groups but do not systematically analyse this. Through its monitoring of patient views (e.g. SED information, patient surveys) the Trust can demonstrate that patients have high levels of satisfaction with the Trust s services. However, information is not available to compare the specific satisfaction levels of patients for all protected groups. 22

23 EDS2 grade: Reasons for Grading: DEVELOPING In General the Trust receives a good standard for patient feedback, however not for protected groups. The Trust has a plan of progression to step up to the next grade. For these reasons the suggested grade for outcome 2.3 is developing Outcome: Using good data and evidence, and innovative techniques, the Trust demonstrates that patients and carers from some protected groups report positive experiences similar to those reported by patients and carers as a whole. Engagement: The Trust has strong engagement with patients, carers and communities about their experiences of the Trust. Engagement with some protected groups is strong, with plans to develop further. Mainstream processes: Improving the experience of patients is being taken forward by the major Patient Experience Lead work Programme, which is being piloted in services for young people and people with learning disabilities. Progression plans: Firm plans are in place to progress to the next grade, with milestones. Other disadvantaged groups: Disadvantaged groups are taken into account in plans to improve data and evidence. Sources of Evidence: Consent policy CPA policy and procedures PEARL information and guidance Care Quality Commission patient survey reports Community Engagement strategy Trust membership breakdown Customer Care reports Service Experience survey reports CDW quarterly reports EBE Reports / feedback from Acute Ward rounds 23

24 EDS2 Goal 2: Improved patient access and experience Reference Number: 2.4 Outcome: People s complaints about services are handled respectfully and efficiently Organisations Approach: The Trust has a complaints process which is open to all patients. The Service Experience Desk (SED) is the central point of contact for all concerns and enquiries, whether these are informal, formal, complaints, compliments or suggestions of improvement. All complaints are acknowledged by the Trust and a timeline is agreed with the complainant to ensure that any issues are addressed in a timely manner. Interpreters and production of information in other formats can be facilitated by the Trust if patients require this service. The Trust has seen a shift in culture and reduction in complaints in terms of staff attitude due to the level of scrutiny of complaints. The SED team is the single point of access for the Trust. This allows different types of information to be compared, with a view to detecting equality-relevant themes. The Complaints, Concerns, Comments, Compliments and Enquiries policy has been updated to reflect the Equality Act 2010, and to ensure there is a consistent approach taken to complaints, concerns, comments, compliments and enquiries across all the services the Trust provides. The Trust takes complaints about services very seriously and has good processes for considering and responding to them. The Trust also has a good track record of Directors and senior clinicians giving of their time to listen to and to seek to resolve complaints. Complaints are monitored but this does not extend to monitoring by all protected groups and so it is not yet fully known whether there is a disproportionate number of complaints from some protected groups or whether there are any variances in satisfaction with the Trust s responses to complaints. There is a SED Policy outlining how these concerns should be handled. Teams promote awareness of SED and the SED team hold visibility events across the Trust. EDS2 grade: ACHIEVING Mainstream processes to tackle this outcome are cited, and firm plans are in place to improve the collection, analysis and reporting of the experience of protected groups. For these reasons the suggested grade for outcome 2.4 is Achieving 24

25 Reasons for Grading: Outcome: The Trust engages with patients and carers about how their complaints and subsequent redress are handled. However, this engagement does not give specific consideration to the individuals from all protected groups. The Trust collects information on most protected groups for complaints but does not currently analyse them. It cannot demonstrate that complaints from patients and carers from protected groups are handled with just as much respect and efficiency as those for patients generally. However there are plans in place to improve the analysis and reporting to the Board of complaints, including the experience of protected groups. Engagement: The Trust seeks to achieve improvements in handling patient and carer complaints about its services using mainstream processes through its Patient Experience work. Mainstream processes: Complaints are reported to the Board with an Executive Board lead overseeing all complaints. Plans are in place to improve reporting to the Board about complaints, including the experience of protected groups and delivery of the complaints pledge in the NHS Constitution. Progression plans: Plans are in place to implement equality monitoring into the complaints procedure Sources of Evidence: Other disadvantaged groups: Key disadvantaged groups are taken into account in the above processes Consent policy SED policy CPA policy and procedures PEARL information and guidance Care Quality Commission patient survey reports Community Development Worker Team Action Plan Equality & Diversity Policy 25

26 EDS2 Goal 3: A representative and supported workforce Reference Number: 3.1 Outcome: Fair NHS recruitment and selection processes lead to a more representative workforce at all levels Organisations Approach: The Trust uses the recruitment and selection processes on the NHS Jobs2 website. An applicant s personal information is separated from the application and an anonymous application is short-listed. Data from this process is analysed for most protected groups. NHS Jobs2 captures most of the protected groups data for applicants. This process is only used at application and short-listing stages of recruitment. There is an increase in the number of staff showing undefined for some protected groups when comparing data at short listing stage with data collected at appointment through Electronic Staff Records, as individual staff are responsible for keeping their information up-to-date on the system. This makes it difficult to compare shortlisted and appointed data for disability, race, religion, belief and sexual orientation. Comparisons between application, short listing and appointment data for age and sex shows that a lower percentage of men are shortlisted but then a higher percentage of those shortlisted are appointed. A similar pattern is seen for applicants under 40. However, they are appointed in line with the application rate. The Trust has a Recruitment and Selection Policy which takes into consideration all 9 protected characteristics. Managers do not have access to details about the candidate except their employment history, education and supporting information. This process ensures that the recruitment process is fair. All data on recruitment is kept for up to 12 months and scrutinised to monitor trends in recruitment. All recruitment officers are trained in Equality and Diversity and support managers to implement the recruitment and selection policy. The Trust acknowledges that it is important to have people with the right values and culture to ensure that policies are being implemented and people are not actively discriminate. All managers are trained fully in recruitment and receive mandatory Equality and Diversity training. In terms of recruitment processes, any changes made to the process or policies that need approving have to be agreed by Staff Side. The Trust has worked closely with the Staff Side trade unions on the development and application of its Recruitment and Selection Policy but further engagement needs to be focused on the specific needs/issues of individual protected groups. In terms of developing a representative workforce, the Equality and Diversity Annual report illustrated that overall the Trust is representative of the communities it serves. EDS2 DEVELOPING grade: In General the Trust s recruitment and retention policies and processes advance equality of opportunity amongst some protected groups, however not for all protected groups. The Trust has a plan of 26

27 Reasons for Grading: progression to step up to the next grade. For these reasons the suggested grade for outcome 2.3 is developing Outcome: The Trust makes some use of data and evidence to monitor the fairness of its recruitment and selection processes and work is being carried out to have this as part of mainstream processes. Engagement: The Trust engages with staff-side organisations and staff about ensuring that recruitment and selection processes are fair, inclusive and transparent. This has tended to have been on overall policy development and on the addressing of any issues arising through the application of the process, an increase in focus regarding the needs/issues of specific protected groups needs to be included. Mainstream processes: The Human Resources Department ensures that the Trust adheres to its agreed Recruitment and Selection process. Greater focus on auditing its application in respect of individual protected groups through mainstream processes is required. Progression plans: Plans are in place to cleanse equality data and also incorporate equality data into mainstream workforce development reporting. Disadvantaged groups: BME women and men, Disabled staff, sexual orientation Sources of Evidence: Recruitment & Selection policy (revised) NHS Jobs data reports Equality objectives and enablers Equality and diversity training ESR data EDS2 Goal 3: A representative and supported workforce Reference Number: 3.2 Outcome: The NHS is committed to equal pay for work of equal value and expects employers to use equal pay audits to help fulfil legal obligations Organisations Approach: The Trust works in line with Agenda for Change guidelines. National implementation of Agenda for Change began in December Agenda for Change ensures that pay is not based on job title, but on work done with the majority of NHS posts evaluated against national job profiles. Partnership with Staff Side is done on a basis for any decisions on Agenda for Change Pay and terms and conditions, e.g. both Management and Staff Side have an equal say. The system ensures that staff members doing the same work receive the same basic pay and conditions for staff from protected groups are fairly determined for all posts 27