Equality Objectives 2014 - 2016

Equality Objectives

Introduction

Mersey Care NHS Trust is committed to meeting the Equality Act 2012 duties and the development of a Human Rights Based Approach across the services it provides and to the support it provides to the staff it employs.

The Trust has also been committed to completing the NHS Equality Delivery System (EDS)to assist in identifying Equality Objectives and support developments across the Trust to meet those Objectives. The Trust is now completing the “Refreshed Equality Delivery System for the NHS (EDS2) to identify its Equality Objectives for 2014 – 2016.

For the last two years the Trust had an Equality Objective to have comprehensive service user equality data. The Trust met its objective to have equality data of 95%+ for the protected characteristics; it did not meet its identified objective to record directly re equality data for Trans. The rationale behind this was following a discussion with community Trans groups who did not feel that to keep data on Trans would respect confidentiality. This will be recorded anonymously in a clinical record with appropriate access only on a need to know basis. There is a Trust Gender Reassignment Policy in the process of ratification. Evidence of up to date information will be provided when it is available.

For the last two years the Trust had an Equality Objective to have comprehensive staff equality data. The Trust met its objective to have equality data of 95%+ for the protected characteristics and this is now reflected in the electronic staff record; it did not meet its identified objective to record directly re equality data for Trans. The rationale behind this was following a discussion with community Trans groups who did not feel that to keep data on Trans would respect confidentiality. There is not any facility to record this on the Electronic Staff Record. There is a Trust Gender Reassignment Policy in the process of ratification.Evidence of up to date information will be provided when it is available.

The Trust has met its Equality Objectives to introduce Equality and Human Rights Analysis to replace Equality and Human Rights Impact Assessment. This is now in place and is monitored by the Corporate Review Committee. This process must take place before ratification of policies and procedures are ratified. (Appendix 1)

Setting the objectives.

The objectives are set by using the EDS 2 Goals:

  • Better health outcomes
  • Improved patient access and experience
  • A representative and supported workforce
  • Inclusive Leadership

Consideration has been given to the previous year’s objectives and outcomes and this is then used in the Equality and Human Rights Action plan along with other quality contracts such as the Quality Account. Feedback from Staff Networks is also used in determining the Equality Objectives.

The aim of the Equality Objectives

By using the Equality data collected from the previous Equality Objectives the Trust aims to identify how by use of further Equality Objectives and Equality and Human Rights Action Plan experiences by service users and staff are improved in relation to protected characteristics.

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Improving service user experience, improving Board analysis of equality information, inclusion of Equality and human rights into Trust strategy, service developments and equality analysis has been agreed to ensure that equality and human rights are at the heart of the Trust internal processes to ensure they continue to be fundamental to its work. They have been set within a time frame to enable clear goals which can be both evaluated and developed alongside the EDS2 process.

Equality Objectives for Mersey Care NHS Trust

  1. Analysis of service user experience by protected characteristics

Measures of Service User experience currently reported to the Trust Board are Membership Targets and Waiting Time It is proposed that:

  • All measures of service user experience should have a quarterly analysis by protected characteristics in place by 31.3.2013 and will continue to be collected and this will be evidenced when it is available
  • It is the intention of the Trust to increase activity based analysis of protected characteristics to identify discrimination and take action to address this.
  1. Data reported to the Trust Board and all Committees of the Board to be regularly analysed by protected characteristics

The Trust now has a reporting system that requires all Accountable Directors to submit annually a report to the Trust Board and its committees. This will include Equality Analysis of protected characteristic date to eliminate any identified discrimination affecting service users and staff (Appendix 2)

  1. Service change being developed to meet the Trust’s Strategic Objectives will explicitly take account of the needs of those with protected characteristics and using a Human Rights Based Approach eg IMROC, Community Model of Care.

Service change is being developed to meet the Trusts Strategic Objectives and will explicitly take account of the needs of any protected characteristics.

The completion of and Equality and Human Rights Analysis for Community Model of Care and Recovery College to be met by March 2015. (Appendix 2)

  1. Investigate the processes that Mersey Care has in place around use of seclusion: use of control and restraint: length of stay for BME communities, and then develop regular systematic monitoring of these areas in all services.

Any relevant service redesign or function needs to undergo an Equality and Human Rights Analysis report and also indicate that where there is an impact on people from Black and Minority Ethnic communities, what action will be taken after consideration of the impact. (Appendix 1 and 2)

  1. To set up systems that enables Mersey Care to address the proactive support needed for disabled staff.

To reduce the inappropriate use of the attendance policy in the identification and addressing of issues that impact on disabled staffs work and wellbeing. (Appendix 2)

  1. To improve the Trust’s analysis of the representation of the communities we serve.

The current data around the representation of the communities we serve within the workforce at all levels and the trust membership will be evidenced in this document when it is available for publication.

Appendix 1


Equality Analysis

Title:
Area covered:
What are the intended outcomes of this work? Include outline of objectives and function aims
Who will be affected? e.g.staff, patients, service users etc
Evidence
What evidence have you considered?
Disability inc. learning disability
Sex
Race Consider and detail (including the source of any evidence) on difference ethnic groups, nationalities, Roma gypsies, Irish travellers, language barriers.
Age Consider and detail (including the source of any evidence) across age ranges on old and younger people. This can include safeguarding, consent and child welfare.
Gender reassignment (including transgender) Consider and detail (including the source of any evidence) on transgender and transsexual people. This can include issues such as privacy of data and harassment.
Sexual orientation Consider and detail (including the source of any evidence) on heterosexual people as well as lesbian, gay and bi-sexual people.
Religion or belief Consider and detail (including the source of any evidence) on people with different religions, beliefs or no belief.
Pregnancy and maternity Consider and detail (including the source of any evidence) on working arrangements, part-time working, infant caring responsibilities.
Carers Consider and detail (including the source of any evidence) on part-time working, shift-patterns, general caring responsibilities.
Other identified groupsConsider and detail and include the source of any evidence on different socio-economic groups, area inequality, income, resident status (migrants) and other groups experiencing disadvantage and barriers to access.
Human Rights / Is there an impact?
How this right could be protected?
Right to life (Article 2)
Right of freedom from inhuman
and degrading treatment (Article 3)
Right to liberty (Article 5)
Right to a fair trial (Article 6)
Right to private and family life
(Article 8)
Right of freedom of religion or belief
(Article 9)
Right to freedom of expression
Note: this does not include insulting language such as racism (Article 10)
Right freedom from discrimination
(Article 14)
Engagement and involvement
Summary of Analysis
Eliminate discrimination, harassment and victimisation
Advance equality of opportunity
Promote good relations between groups
What is the overall impact?
Addressing the impact on equalities
Action planning for improvement
Please give an outline of your next steps based on the challenges and opportunities you have identified. Include here any or all of the following, based on your assessment
  • Plans already under way or in development to address the challenges and priorities identified.
  • Arrangements for continued engagement of stakeholders.
  • Arrangements for continued monitoring andevaluating the policy for its impact on different groups as the policy is implemented (or pilot activity progresses)
  • Arrangements for embedding findings of the assessment within the wider system,other agencies, local service providers and regulatory bodies
  • Arrangements for publishing the assessment and ensuring relevant colleaguesare informed of the results
  • Arrangements for making information accessible to staff, patients, service users and the public
  • Arrangements to make sure the assessment contributes to reviews of DH strategic equality objectives.

For the record
Name of persons who carried out this assessment (Min of 3 ):
Date assessment completed:
Name of responsible Director:
Date assessment was signed:

Action plan template

This part of the template is to help you develop your action plan. You might want to change the categories in the first column to reflect the actions needed for your policy.

Category / Actions / Target date / Person responsible and their Directorate
Involvement and consultation
Data collection and evidencing
Analysis of evidence and assessment
Monitoring, evaluating and reviewing
Transparency (including publication)

Appendix 2

Equality and Human Rights Action Plan 2014/15

Ref / Action / Quality Contract / Quality Account/
EDS outcome / Progress / Lead / Key Personnel / Target
Date / RAG rating
A1.06/1 / Meet Equality Objectives
2014/15
Transgender staff
Transgender Service Users. / Equality Delivery Systems 2
Compliance with Equality Act 2010 Specific duties / MET /
  • Decision not to collect data due to confidentiality /data protection issues. Agreed in consultation with Transgender networks.
  • Gender reassignment policy in place to ensure good practice across the Trust.
  • Positive engagement with Transgender networks and anonymous surveys.
/ Equality and Human Rights Lead/Workforce Lead / March 2014 / Green
A1.06/2 / Meet Equality Objectives
2013/14
Mersey Care will introduce Equality and Human Rights Analysis to replace Equality and Human Rights Impact Assessments. / Any relevant redesign of services needs to include an equality analysis report and evidence that it has been considered by decision makers
Compliance with Equality Act 2010 Specific duties / MET
EDS
1.1,
2.1
4.1,4.2,4.3
QA 6 / Process for Equality and Human Rights analysis is in place. / Equality and Human Rights Lead/Corporate policy Lead/Service Directors/
Service change leads / March 2015 / Green
A1.06/3 / Meet Equality Objectives
2014/15
Analysis of Service User experience by protected characteristics
Meet Strategic aim: We will ensure every individual is treated fairly in our organisation.
Increase in activity based analysis of protected characteristics to eliminate any identified discrimination affecting staff and service users / Equality Delivery Systems 2
Compliance with Equality Act 2010 Specific duties / EDS
1.1,1.2, 1.3,1.4,1.5,
2.1,2.2, 2.3
4.1,4.2,4.3
QA 1,2,3,4,5, / Partially met
  • System to support accessible data gathering and analysis to be available Trust wide.
  • Development of quality dashboard.
  • Patient experience data collected includes protected characteristic data analysis.
To improve :
  • Inclusion of Equality Objectives within Business planning process
  • Inclusion of Equality Objectives within Trust Annual Reporting from all contributors
  • Inclusion of Equality analysis/data re protected characteristics within CQUINs
  • Inclusion of Equality analysis/data re protected characteristics within Quality Account
  • Inclusion of Equality monitoring/analysis within key committees and governance bodies across the trust.
/ Clinical data system lead/ Equality and Human Rights Lead/
Business Plan Leads / Equality and Human Rights Coordinators/ Service leads/
corporate Lead/trust board secretary / March 2015 / Amber
A1.06/4 / Meet Equality Objectives
2013/14
Service change being developed to meet the Trust’s Strategic Objectives will explicitly take account of the needs of those with protected characteristics e.g. IMROC, Community Model of Care. / Any relevant redesign of services needs to include an equality analysis report and evidence that it has been considered by decision makers / EDS
1.1,4.1,4.2
QA 6 / Equality and Human Rights Analysis in completion for Community Model of Care.
Completion of Equality and Human Rights Analysis of the recovery College in progress / All Leads/Trust Board/ Equality and Human Rights Lead / March 2015 / Amber
A1.06/5 / Meet Strategic aim: We will ensure every individual is treated fairly in our organisation.
Annual reporting to Board and its committees to include Equality analysis of protected characteristic data to eliminate any identified discrimination affecting staff and service users. / Equality Delivery Systems 2
Compliance with Equality Act 2010 Specific duties
Any relevant redesign of services need to include an equality analysis report and evidence that it has been considered by decision maker / EDS
2.1,2.4
4.1,4.2,4.3
QA
1,2,3,4,5,6, / Minimal reporting re protected characteristics in place at present due to systems not being in place.
Developments within the quality dashboard imminent. / Head of Performance/
Quality Lead/
Equality and Human Rights Lead/Trust Board Secretary / March 2015 / Amber
A1.06/6 / Meet Strategic aim: We will ensure every individual is treated fairly in our organisation.
Work to develop Perfect Care within the strategic framework across the Trust:
Investigate the processes that Mersey Care has in place in relation to MHA; use of seclusion; use of control and restraint; and length of stay for BME communities, and then develop regular systematic monitoring of these areas in all services.
Improve clinical outcomes re. access for BME communities, Dementia and Depression register, identification of people who have been on anti-psychotics long term / Equality Delivery Systems 2
Compliance with Equality Act 2010 Specific duties
Any relevant redesign of services need to include an equality analysis report and evidence that it has been considered by decision maker / EDS
1.2,1.4,
2.2,2.3,
4.1,4.3
QA
1,5,6
EDS
1.1,1.2,1.3
2.1,2.2,2.3,
4.1,4.3
QA
2,6 / Milestones identified.
Data requirements identified / Equality and Human Rights Lead/Perfect Care Leads/Dementia lead / March 2015 / RED
A1.06/7 / Meet Strategic aim: We will ensure every individual is treated fairly in our organisation.
Equality and Human Rights ‘training’ to be included within all training activities across the Trust. Assurance via Equality and Human Right Analysis of all Mersey Care led/directed training and that training commissioned by Mersey Care. / Equality Delivery Systems 2
Compliance with Equality Act 2010 Specific duties
Any relevant redesign of services need to include an equality analysis report and evidence that it has been considered by decision makers
To ensure people are able to access care when they need it. / EDS
1.2
2.1
3.1,3.3,3.4,3.6
4.3 / No progress at present. / Learning and Development Lead/ Executive Director of Nursing and Secure Services
/Equality and Human Rights Lead / March 2016 / Red
A1.06/8 / Meet Strategic aim: We will ensure every individual is treated fairly in our organisation.
To have individuals in key areas across the Trust to lead on local equality and human rights assurance. / Equality Delivery Systems 2
Compliance with Equality Act 2010 Specific duties / EDS
1.2
2.1,2.2,2.3
4.3 / Equality co coordinators in place across divisions with relevant action plans to provide assurance for the Trust.
Monitoring of action plans is within local governance structures.
Need to implement within new structures. / Divisional Directors/ Equality and human rights leads. / March 2015 / Amber
A1.06/9 / Meet Strategic aim: We will ensure every individual is treated fairly in our organisation. / Evidence of an analysis of usage of Translation and interpretation services
(language and disability) against the expected requirements given local demographics / patient population / EDS
1.1,1.2,
2.1,2.2,2.3
QA
1,2,3,4,5,6, / Staff SharePoint site set up to provide information, guidance and store translated information.
Production of data for the Equality Information publication and provided to commissioners quarter 4. / Finance and Performance Lead/Equality and Human Rights Lead / March 2015 / Amber
A1.06/10 / Meet Strategic aim: We will ensure every individual is treated fairly in our organisation.
Agree EDS outcomes for 2014//15 / Equality Delivery Systems 2
Compliance with Equality Act 2010 Specific duties / EDS
QA
1,2,3,4,5,6, / Goal 3 – agree outcomes to move to ‘achieving’ from developing.
To seek Board approval of EDS priorities which have been set by the inclusion of equality elements within Quality Account and CQUIN priorities. / Director of Workforce/
Equality and Human rights Lead
Head of Quality and Risk/Equality and Human Rights Lead. / December
2014 / Amber
A1.06/11 / Meet Strategic aim: We will ensure every individual is treated fairly in our organisation.
To re- constitute the Equality and Human Rights Steering Group within the New Board/Divisional structure. / Equality Delivery Systems 2
Compliance with Equality Act 2010 Specific duties
Any relevant redesign of services need to include an equality analysis report and evidence that it has been considered by decision makers / All EDS goals
QA
1,2,3,4,5,6, / Develop and agree new Terms of Reference.
Confirm Chair / Equality and Human Rights Lead/Trust Secretary/ Equality and Human Rights Steering Group Chair. / September 2014 / Amber
A1.06/12 / Meet Strategic aim: We will ensure every individual is treated fairly in our organisation.
Meet Equality Objectives
Agree new Equality Objectives for the Trust. / Equality Delivery Systems 2
Compliance with Equality Act 2010 Specific duties / EDS
3.1,3.2,3.3,3.4,3.5,3.6
EDS
1.1
4.1,4.3 / Recommend Equality objectives:-
  • To set up systems that enables Mersey Care to address the proactive support needed for disabled staff. To reduce the inappropriate use of the attendance policy to identify and address issues that impact on disabled staff’s work and wellbeing.
  • To improve the Trust’s analysis of the representation of the communities we serve within the workforce at all levels, and our involvement and participation initiatives, which include the trust membership and taking positive action when needed.
/ Director of Workforce/
Equality and Human Rights Lead
Executive Director of Communication and Corporate Governance/
Director of people participation/
Director of Workforce/
Equality and Human Rights Lead / March 2016
March 2016 / Red

Proposed Quality Account/ EDS Priorities 2014/15