Equality & Inclusion

Annual Report 2015-16

Appendixes:

Ensuring inclusion for all -

Annual report into equality and inclusion for the public, patients and service users across all services and geographical areas

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Contents

Appendix 1 - Terms of Reference for EISG 30

Appendix 2 – Poster for SEPT Spirituality & Recovery Event July 2015 35

Appendix 3 – Star Chart used rate SEPT by Forensic Patients for EDS2 36

Appendix 4 - SEPT’S EDS2 Framework and Work Plan 2015-16 37

Appendix 5 -Specific objectives set by localities and specialist teams for 2016/17 48

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APPENDIX 1

SEPT

Equality and Inclusion Steering Group (EISG) TERMS OF REFERENCE

Overall Purpose of EISG

The Equality and Inclusion Steering Group is a sub-committee of the Executive Operational Committee and has delegated responsibilities to: - Ensure that the Trust remains complaint with Public Sector Equality duties - Provide assurance and support in respect of compliance and delivery of the Equality Delivery System (EDS2 Framework and work plan - To provide assurance and evidence that the Trust is meeting the equality & diversity elements of Care Quality Commission Fundamental Standards

Name of Committee: Equality and Inclusion Steering Group (EISG) Formally Equality and Diversity Steering Group (EDSG)

Chair and Co-Chairs: Executive Director of Community Services and Partnerships

Non-Executive Director (Equality Lead)

Reporting to: Executive Operational Committee

Authority: The EISG is constituted as a standing committee of the Executive Operational Committee. Its constitution and terms of reference are set out below, and are subject to annual review.

The EISG is authorised by the Board of Directors to act within its terms of reference.

The EISG will act in accordance with Monitors code of conduct and current best practice.

Terms of Reference

To promote Equality, human rights and inclusion throughout the Trust in line with latest legislation.

To oversee the implementation of the Trust’s Equality Management Framework (DH Equality Delivery System (EDS2)) and supporting action plans. To monitor and evaluate progress on an on-going basis.

To provide an Annual report on Equality and Diversity to the Executive Operational Committee, Board of Governors and

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Board of Directors.

To provide quarterly assurance reports on Equality and Diversity to the Executive Operational Committee, and Board of Directors.

To provide the Annual report (as above) to the local Clinical Commissioning Groups (CCGs), as per contractual requirements.

To report annually to NHS England on the progress on the EDS2 within the Trust.

To oversee the implementation and compliance with the Workforce Race Equality Standards (WRES).

To produce and implement a work plan which supports the delivery of the Trusts Equality Framework (EDS2) and assurance that the Trust is meeting its legal requirements in relation to Equality.

To identify work streams and support the development of action plans to be taken forward by the Equality and Diversity task and finish groups and its forums.

Service User / Patient Experience / Employees:

To ensure the Trust takes a proactive approach to equality and inclusion for all.

To receive feedback through appropriate forums and methods, providing assurance to the EISG that the views and experiences of all those who are involved in and have contact with Trust services are regularly and consistently collected and used to shape service delivery in relation to equality and diversity.

Patient Safety and Risk Management:

Ensure there is a user friendly impact assessment process in place across the Trust.

To receive reports on impact assessment and specific risk issues related to equality and diversity by any directorate within SEPT.

CQC Registration:

To ensure that work of EISG supports the Fundamental Standards of the Care Quality Commission and duty of candour that are appropriate to equality and diversity.

Equality Legislation:

To notify the Trust of any changes in equality legislation that should be incorporated in Trust policies, procedures and

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practices (including retrospectively) and recommend actions that will enable the Trust to deliver these changes.

To ensure that the Equality agenda supports the aims of Quality Governance and is embedded into Trust performance reporting requirements.

To report on diversity monitoring and ensure sufficient workforce and service delivery data is being generated and analysed to enable meaningful reports.

Compliance:

To ensure the Trust has processes to meet all its legal requirements in relation to Equality and Diversity.

The establishment of the EISG does not take away the day to day responsibilities of staff and managers to properly deal with matters relating to addressing inequality according to relevant legislation and Trust policies and procedures. The EISG will deal with those issues which have wider strategic implications service users/patients/carers and potential service users - and provide support and constructive challenge on these issues.

Assurance:

Updated the Executive Team and Trust Board (via reports) on the appropriate Equality issues, together with recommendations as appropriate.

To oversee the systems in place within the Trust that provide the Board of Directors with assurance that action is being taken to identify risks; manage identified risks and escalate risk to the appropriate level if necessary in respect to Equality and diversity.

To receive reports detailing the outcome of any independent reviews in regard to equality and diversity and for ensuring that any recommended action required is taken as a result.

Sub Group (s) : Stake holder and time limited groups, as per identified issue.

Membership: Chair of meeting

Non-Executive Director

Executive Director of Community Services and Partnerships

Associate Director of Social Care & Partnerships Consultant Social Work Practitioner

Employee Experience Manager

Patient & Public Experience Manager

Associate Directors for Community Mental Health Services (South East/ South West Essex)

Associate Director of Mental Health In-patient Services (Essex)

Lead for Specialist MH Services (secure services, Essex/ Bedfordshire)

Service manager of IAPT Associate Director for Learning Disabilities

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Associate Directors of Integrated Services (south East Essex and West Essex)

Associate Director - Bedfordshire Community Health Services

Associate Director – Children Services

Clinical Director – Medical Directorate

In Attendance: It is expected that members or a nominated appropriate representative will attend a minimum of 50% of Steering Group meetings a year.

The EDSG will invite representatives from other areas as appropriate.

Support to Committee: PA to the Associate Director for Social Care and Partnerships

Quorum: The quorum necessary for the transaction of business is:

6 members;

To include one Executive and one Non-Executive Director (the chairs to nominate and Executive Director and NED as deputies if unable to attend)

Reporting Arrangements to Executive Team and Trust Board:

The EDSG will report in writing to Executive Operational Team through:

quarterly assurance reports

presentation of the minutes

an Annual Report

The EDSG will report to the Trust Board through:

quarterly assurance reports

an Annual Report

The EDSG will report to NHS commissioners through:

an Annual report

The EDSG reports to NHS England through:

an annual reporting process and templates

Frequency of Meetings: The Steering Group will meet a minimum of bi-monthly (6 times per year) then as required to fulfil its responsibilities, as determined by the Chair.

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Minutes of Meetings: Minutes of the meetings, resolutions and any action agreed will be recorded and circulated to EDSG members for approval.

Monitoring Effectiveness: The Group will annually review all points in these terms of reference to ensure they are operating effectively and in line with the terms of reference. Amendments will be made accordingly.

Date Originally Approved:

Review Dates:

September 2005

7 September 2006; March 2007; 15 May 2008; 26 November 2009;5 September 2011; 9 January 2012;23 March 2012; September 2012; June 2013, December 2013, 15th July 2015

Frequency of Review: Annually

Next Review Date: March 2017

Sub Group : Equality and Diversity Working Group

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Field Code Changed

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Appendix 3 – Star Chart a ligned to EDS2 ratings.

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Appendix 4

SEPT’S EDS2 Framework and Work Plan 2015-16

The EDS Goal is described in column one. The outcome descriptors are in column two. The two objectives SEPT has

published are referenced in column two as a primary means of addressing the goals. These are:

Objective 1

The services we provide for patients and carers will be accessible and people will not report that they are unable to access

them because of their protected characteristic/s.

Objective 2

SEPT will be a safe and inclusive place to work for staff with equal opportunities in respect of recruitment, staff

development and progression

The remaining columns evidence our progress in addressing the goals.

Trust Self-Assessment rating undertaken July 2015.

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Stakeholder events took place in November 2105. Stakeholder ratings are aggregated. Stakeholder ratings are shown in

EDS2.

DH EDS GOAL(with narrative)

DH EDS description of outcomes & linked SEPT Published Equality Objective

Detailed Actions Timescale Lead Officers

Progress at April 2016

Proposed Grading Stakeholder grading shown

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1 BETTER HEALTH OUTCOMES: The NHS should achieve improvements in patient health, public health and patient safety for all, based on comprehensive evidence of needs and results.

1.1 Services are commissioned, procured, designed and delivered to meet the health needs of local communities SEPT Published Objective 1

(a) E&D data collection: Review the data collection across all 9 protected characteristics.

Bi-annual November 2015 March 2016

AD of

Business

Analysis &

Reporting

9 protected and data captured Nov15 (1).docx

Ethnicity inpatient and community 31.3.16..xls

(b)Access to services: We will obtain baseline data on the demographics of current service access; and compare this with population data, to analyse whether there is a disproportionate use of services by certain local communities/people with protective characteristics.

March 2016 AD of

Business

Analysis &

Reporting

See 1.1

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. (c) Physical Access to services: We will obtain the following performance data on physical access issues in regard to inpatient services and make year on year improvements:

Physical access to

buildings, e.g.

ramps and

adaptations

Accessible toilets

Signage in Braille

Availability of Audio

Information

Pictorial Signage

(Learning

Disabilities)

Availability of

induction loops,

including portable

loops

Availability of BSL

Signers

Availability of

Translation and

Interpretation

Services

Leaflets and

information

November 2015

Head of

Estates

Estates report for

EDS2 workplan.docx

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available in

languages other

than English Interpreting

Timetable 2015.docx

(d)Access to Psychological Services: Improve data on 9 protection characteristics of current service users accessing IAPT services with the aim to improve access to people with protected characteristics. (‘Closing the Gap report, 2014”)

Sept 15- Mar 16

Black/Ann carter. IAPT service managers

IAPT Evidence March 2016.docx

Therapy for You, routinely ask and report on 7 of the 9 characteristics as they form part of the IAPT data set. Steps are under way to ask for Pregnancy and Maternity questions to support our Peri-natal pathway. Therapy for You uses collected data to target under represente

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d target groups.

(e) Access to faith and spiritual services: Review of our Interfaith and multi-faith chaplaincy services

December 2015

Summary of faith provision prepared for Trust Executive Team. Faith, Spirituality and Recovery stakeholder event schedule to take place in quarter 1 2016-17 Chaplaincy reports prepared and taken to EDSG on 24.9.15. & 26.11.15 Chaplaincy report presented at ET January 2016.

SEPT Spirituality and Health Recovery Day 25th July 2016.pdf

Chaplaincy St Margaret total 2015-16.docx

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(f) Restraint, self-harm, seclusion and pressure ulcers practices: Commence reporting on the use of the above restraint, self-harm and in relation to the 9 protective characteristics, and monitor within the EDSG.

November 2015

Head of Risk Management

Discussion held with CK and FS. Requested incidents by 9 protective characteristics were: Restraint Self-Harm, seclusion Pressure Ulcers. Draft PU report sent for committee approval prior to restraint and self-harm. Agreement needed from committee.

Sample Report - Patient Demographic Information for Pressure Ulcer Incidents.docx

Patient Demographic seclusion Incidents V1 Jan 2016.docx

1507 CQGC Clinical Incidents Report V11.docx

1510 Patient Demographic Information for Restraint Incidents V2.docx

1510 Patient Demographic Information for Self Harm Incidents V3.docx

1601 Patient Demographic Information for Seclusion Incidents V1.docx

1510 Patient Demographic (AGE) Information for Self Harm Incidents on Fuji.docx

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1.2 Individual people’s health needs are assessed and met in appropriate and effective ways SEPT Published Objective 1

(a)We will aggregate mystery shopping feedback, patient survey and complaints where issues relating to protected characteristics are mentioned.

March 2016

Patient Experience Manager

Achieved for 2014-15 Reporting to be continuously updated

(b) Promote interpreter and translation services within service areas

January 2016

TBA

1.3 Transitions from one service to another, for people on care pathways, are made smoothly with everyone well-informed

(a)Monitor and audit carer pathways to ensure compliance with Care Act 2015 (Trust Corporate Objective) (b) Review Transitions Policy and Procedure – CAMHS to Adult Services (c)Trust to work with new provider to ensure transition of CAMHS to new provider

March 2016 November 2015 November 2015

Carers Operational Lead (SR) AD for CAMHS AD for CAMHS

Completed. New provider for south Essex CAMHS in place. Completed new provider in place from 1/11/15

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1.4 When people use NHS services their safety is prioritised and they are free from mistakes, mistreatment and abuse

(a) We will continue to promote a culture of openness and transparency and high reporting of incidents:

Review March 2016

Associate Director Clinical Governance & Quality Head of Risk Management

New Freedom To Speak Up Guardian post as been created. Post advertised November 2015 Post holder in place by endo March 2016

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(b)Safeguarding: We will continue to work to ensure that we support and protect vulnerable adults and children in line with SEPT safeguarding Policies. Safeguarding reports to include data of 9 protected characteristics to monitor how well the Trust safeguards the welfare of people with protected characteristics.

December 2015

Associate Director for Safe- guarding

1.5 1.5 Screening, vaccination and other health promotion services reach and benefit all local communities SEPT Published Objective 1

(a)IAPT is promoted to service users with the 9 protected characteristics.

November 2015

Service Manager

See 1.1 (d) for evidence

(b)Dentistry Services provide evidence of health promotion services to people with protected characteristics

March 2016 Director for Community Health Services (Essex, Bedfordshire)

Easy Read Pathway (2).doc

Oral Health Promotional Activities.doc

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2 Improved patient access and experience The NHS should Improve accessibility and information, and deliver the right services that are targeted, useful, useable and used in order to improve patient 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 SEPT Published Objective 1

See 1.2 and 1.3

2.2 People are informed and supported to be as involved as they wish to be in decisions about their care SEPT Published Objective 1

(a)We will continue to monitor our use of translation services and where patients requiring interpreters are appropriately supported.

Annually (agree date)

Associate Director for Social Care and Contracts Team

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(b) Patient engagement – We will set up/continue to run forums for service users/public to raise issues and concerns to encourage involvement across the Trust.

March 2016 Patient Experience Manager

20150914120550387.pdf

2.3 People report positive experiences of the NHS SEPT Published Objective 1

Stakeholder events to take place during year

March 2016 Patient Experience Manager

Take it To The Top meetings currently being held across the Trust. Pilot event held at Knightswick clinic on 28 July 2015, further ones being planned.

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2.4 People’s complaints about services are handled respectfully and efficiently SEPT Published Objective 1

See 1.2 (a) December 2015

Janet Aker

20150914120550387.pdf

3 A representative and supported workforce The NHS should increase the diversity and quality of the working lives of the workforce, supporting all staff to better respond to patients’ and communities’ needs.

3.1 Fair NHS recruitment and selection processes lead to a more representative workforce at all levels SEPT Published Objective 2

Please see also Employee Experience Action Plan embedded below. Monitor the actions identified within the WRES action plan (see below) and report progress. Produce full report of progress Include recruitment analysis information within the 2015 General Workforce Report

Quarterly April 2016

Employee Experience Manager

Jodie Russell

Employee Experience Action plan 2015-16(3) updates 25 august 15.docx

WRES ACTION PLAN 21 september 2015.docx

Employee Experience Action plan 2015-16 update as at end of Q3 31 December 15.docx

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3.2 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 SEPT Published Objective 2

Please see also Employee Experience Action Plan embedded Produce Gender Pay Gap information and include within the General Workforce Report.

Present to EDSG

Present to Trust Board

Publish

Identify hot spots patterns and trends to feed next year’s action plan and equality and diversity priorities.

31 January

2016

March 2016

J Debenham/

J Debenham/

C Meek

Jo Debenham

3.3 Training and development opportunities are taken up and positively evaluated by all staff SEPT Published Objective 2

Please see also Employee Experience Action Plan embedded below. (a) Analyse Training and development opportunities from an equality perspective and include within the General Workforce Report. . Report negative and positive findings and

January 2016

Head of Workforce Planning Education and Training

The training department do not hold equality information. Therefore all rejected applications are being reviewed to identify any patterns of discrimination.

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report through Equality reporting committees as appropriate. (b)Increase the proportion of PFD Champions currently in the Scheme (c)Celebrate E&D WEEK in the Trust

Jo Debenham

Additional

Champions

have been

signed up as

a result of

Induction.

Current PFD

numbers are:

1 April: 170

30 June: 178

10 August:

178

3.4 When at work, staff are free from abuse, harassment, bullying and violence from any source SEPT Published Objective 2

Complete the Review of Racism on the Wards work and report findings to the Equality and Diversity Steering Group for onwards reporting as agreed.

31 March 2016

Jo Debenham/Hari Sewell

Report progress to the EDGS September 2015 and re-group the work already undertaken

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3.5 Flexible working options are available to all staff consistent with the needs of the service and the way people lead their lives SEPT Published Objective 2

Please see also Employee Experience Action Plan embedded above. Map out Trust position in terms of access and identify areas for action

IInclude details

within the

General

Workforce

Report.

DDiscuss at

SMT / ET /

EDSG and

agree areas for

access / focus

31 Jan 2015 Jan 2015

Employee Experience Manager

Information has been requested from each HR department in order to commence the analysis Q1 14/15 action plan All data analysed and success rate for Flexible Working applications across the localities is 100%.

3.6 Staff report positive experiences of their membership of the workforce SEPT Published Objective 2

Please see also Employee Experience Action Plan embedded below. Complete Analysis of Staff Survey 2015 Results and identify areas for action. Include the results from the Staff Friends and Family Test within the

February 2016 1 October 2015 March 2016

Employee Experience Manager Human Resources Manager EDSG Executive Team Head of

Extremely positive Staff Survey results presented to Trust Board march 2014 and communications of the results to be published. Project Plan agreed Complete

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Trust KPIs . Share findings from the Staff Friends and Family Test where they relate to equality and diversity or related issues. Establish the reason for a significant increase in the proportion of staff choosing not to declare their sexual orientation as identified in the General workforce report 2014 Identify possible causes and look at solutions with a view to encouraging staff to declare their sexual orientation.

March 2016

Workforce Planning Education. J Debenham/ C Meek J Debenham

4. Inclusive Leadership NHS organisations should ensure that throughout the organisation, equality is everyone’s

4.1 Boards and senior leaders routinely demonstrate their commitment to promoting equality within and beyond their

Achieve successful annual re- accreditation as a two ticks mindful employer

Review April 2015

EDSG Executive Team Trust Board

J Debenham

Executive Team and Trust Board have received regular updates on issues I regard to equality and diversity including in regard to specific services. They have also scrutinised equality impact

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business, and everyone is expected to take an active part, supported by the work of specialist equality leaders and champions

organisations SEPT published objectives 1 and 2

assessments to gauge the impact of change on people with protected characteristics. This oversight will be strengthened through more robust reporting arrangements from April 2014.

4.2 Papers that come before the Board and other major Committees identify equality-related impacts including risks, and say how these risks are to be managed SEPT published objectives 1 and 2

As 4.1 Achieved EDSG Executive Team Trust Board

As 4.1

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4.3 Middle managers and other line managers support their staff to work in culturally competent ways within a work environment free from discrimination SEPT published objectives 1 and 2

Increase the percentage of workforce who are signed up to the PFD champions campaign by 10% as at 31.3.15

Jan 2016 Employee Experience Manager Head of Workforce Planning Education and Training

The Workforce Race Equality Standard 2015.

a)Publish the Metrics Baseline position for the organization including observations/patterns and trends and agree priority areas of action as appropriate b)Produce progress report to the EDSG and any other relevant forums on actions identified to remedy areas of concern c) Produce end of Year

30 June 2015 November 2015 End Quarter 4

J Debenham

G Brice

A Hockley

J Russel

J Debenham

G Brice

A Hockley

J Russell

J Debenham

Report approved at EDSG, EOC and Trust Board. Published internally and externally. Shared with small BME Staff Consultative Group. Updates provided to all PFD champions and BME working group 22 6 15. Article appeared in Quality Matters 2 June 2015 edition

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Grading Mechanism

There are four descriptors which will vary in terms of the evidence required to support them, depending on the outcome.

Evaluations to be undertaken in mid 2015.

Undeveloped Developing Achieving Excelling

No evidence Some evidence Substantial evidence Exceptional evidence

Report as part of NHS contract – based on information provided from other leads.

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Appendix 5

Specific objectives set by localities and specialist teams for 2016/17

These objectives are imbedded into the Trust EDS2 2016/17 and will be monitored by the EISG

Bedfordshire CHC

Ensure there is a culture of awareness amongst staff of the 9 protected characteristics and staff are empowered to

adapt service delivery in order to meet the needs of individuals

To identify challenges within our service user and staff populations and respond innovatively and inclusively.

Essex Learning Disability Service

Our objectives will be to continue with the above and strengthen our work and to ensure inclusive services. This will be pertinent in the re-introduction of the Green Light for Mental Health Tool as an objective within the Trust. This will enable the Trust’s MH Services to bench mark themselves against a set of standards to gauge how accessible they are for people with LD and to highlight those areas where improvement is required.

Patient Experience Team

The Patient Experience Team will continue what has already been started and will work to try and reach the traditionally

harder to reach groups. At the same time it will endeavour to ensure that everyone is communicated with, listened to and

encouraged to give us their feedback, comments, suggestions and to get involved with the Trust. It will continue to work

within the framework of the Trusts EDS2 and the national principals while asserting the right of every individual to choose if

they wish to declare their ethnicity, sexuality, disability, age, faith and their gender if they so wish.

Workforce Development and training

Improve study leave monitoring by including ESR number on application form

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Work to ensure workforce development policies are assessed for equality impact during organisational changes

Introduce talent management process which will enable improved links between appraisal and study applications

and will assist equality monitoring.

Carers

Continued Staff Training for effective communication and support of carers

Monitoring and auditing of carers pathway

Establish Carers Strategy Monitoring Group. (chaired by a carer with the majority of the membership also SEPT carers

Restrictive Practice Steering Group

E&D Lead is part of Restrictive Practice Steering Group to ensure the 9 protective characteristics are embedded in this agenda.

E&D is a standardised agenda item for the Restrictive Practice Steering Group meeting.