Worcestershire Health and Care NHS Trust - EDS Grading
EDS Outcome 1.1 (EDS Goal 1 – Better health outcomes for all)
Services are commissioned, designed and procured to meet the health needs of local communities, promote well-being, and reduce health
inequalities
1.1 EDS Grade: Developing
Outcome: Public Health accesses a range of different data sets to assist Commissioners with commissioning, designing and procuring services. The Trust
works closely with the Commissioners to ensure that services are designed and procured to meet the health needs of patients. The Trust has undertaken
some specific work, to ensure monitoring of services around ethnicity is undertaken to meet their specific needs and to assist with any service changes. All
services new and existing undergo an equality analysis ensure no unfair practices are designed with any new services and access is equitable across
patients. Ethnicity posters and leaflets have been used to encourage staff to collect ethnicity monitoring data at every interaction with patients. Other
service specific initiatives have been, identified across some of the protected groups. However, the Trust also recognises the need to have better
data/evidence to support its service design across all protected groups. The Trust also uses feedback from patient surveys/questionnaires and complaints
to ensure that services are commissioned, designed and procured to meet the health needs of local people. The trust uses a range of engagement
opportunities to ensure that communities are informed of initiatives and programmes.
Engagement: The Trust has engaged with some of the protected groups to ensure that services are designed to meet specific needs of the protected
groups; our data shows more engagement with people from different races, age, gender and disability. The Trust has developed good links with the BME
communities and have Community Development Officer(s) whose specific role is to work with communities to promote health and well-being However,
we recognise that engagement has been limited in relation to the other protected groups and that more sustainable and meaningful engagement needs to
be developed for existing groups, as this has not been consistent across the protected groups.
Mainstream processes: The Trust aims to meet the EDS outcome for all protected groups; by using its Quality Accounts reporting and ensuring that services
which reflect the communities’ health needs are designed and procured through joint working with Commissioner’s. All new services are required to
undergo an equality analysis to ensure that it identifies and addresses any impacts on protected groups. The Trust meets with the Commissioners on a
regular basis to ensure compliance with the contract and Equality Act 2010.
Progression plans: No plans are currently in place to improve this outcome to the next level.
Disadvantaged groups: No other disadvantage groups have been identified
Summary: The Trust has undertaken some work in the past with some protected groups to assist with service design, this includes , action plans, initiatives
etc., however, no information data/evidence is available to demonstrate how these initiatives have improve or reduced health inequalities. These initiatives
HACT EDS Grading (v3)
March 2012
Page 1
also have not been sustainable across the protected groups. The Contract’s state very little in relation to equality and diversity, protected groups and
monitoring currently contracts only require some basic data on ethnicity. Therefore with limited or no evidence and data it is difficult for the Trust to
demonstrate that services are commissioned, designed and procured to meet the health needs of local communities, promote well-being and reduce health
inequalities, therefore, the only grade that can be awarded to this outcome is
Evidence: Service specifications, Contracts, Equality Impact Assessments and Equality Analysis, E&D working group, ethnic monitoring information, briefing
papers, publicity and promotional materials on monitoring ethnicity, evidence of work undertaken to look at local uptake of diabetes services, offender
Health Action plan. Community Development Officers work, Quality Accounts and feedback from patients and carers and complaints.
Action: Develop more robust monitoring mechanism to capture data across protected groups, analysis data to assist with service design .Improve
engagement opportunities to reflect all the protected groups.
HACT EDS Grading (v3)
March 2012
Page 2
EDS Outcome 1.2 (EDS Goal 1 – Better health outcomes for all)
Individual patients’ health needs are assessed, and resulting services provided, in appropriate and effective ways
1.2 EDS Grade: Developing
Outcome: The Trust undertakes a range of patient surveys/questionnaires to ascertain how individual patient’s needs are assessed, patient satisfaction,
discharge and inpatient processes, information relating to this outcome will also be accessed via the complaints procedures. The Trust encourages staff to
ensure that patients have access to relevant and appropriate communication support and all documentation includes a statement on language and
equality. However, this data is not monitored against the protected groups, so the Trust is unable to demonstrate whether or not individual patient health
needs are assessed equitably and fairly.
Engagement: The Trust has a range of ways that patients and communities are engaged with, the Patient Experience Team, has a database of local
community groups/organisations, patient groups and key stakeholders however these do not address all the protected groups.
Mainstream processes: Reports presented to Quality and Safety Committee, regular Complaints Reports and through monitoring of the contract
Progression plans: No progressions are in place to move this outcome to the next level.
Disadvantaged groups: No other disadvantage group are identified
Summary: Overall the Trust has some limited evidence about individual patient health needs, but as this is not broken down by the protected groups, it is
difficult o ascertain whether or not the health needs are equitable and fair for protected groups. Limited requirements are also contained within the
contract to meet this specific outcome
Evidence: Patient surveys/questionnaires, Quality & Safety Committee reports, complaints reports, contact monitoring, translation and interpretation
information, stakeholder database and engagement opportunities.
Action: Need to develop robust monitoring systems for capturing protected groups data across individual health needs, communication support and patient
surveys/questions. Improve engagement opportunities across the protected groups. Include appropriate requirements into contract and then establish
monitoring systems to ensure compliance.
HACT EDS Grading (v3)
March 2012
Page 3
EDS Outcome 1.3 (EDS Goal 1 – Better health outcomes for all)
Changes across services for individual patients are discussed with them, and transitions are made smoothly
1.3 EDS Grade: Undeveloped
Outcome: The Trust has in place a Community and Patient Relations team who are responsible for engaging service users/patients, carers and community
in the planning, development and monitoring of trust services. The Trust has recently produced and published its Community Engagement Framework. The
Trust has a range of engagement forums that can be used to ascertain how this outcome is met. To support this outcome the Trust also undertakes a
number of surveys/questionnaires. Some data is collected but information is not broken down across all the protected groups. Also little evidence to
demonstrate how specific individual patient needs are discussed.
Engagement: The Trust engages widely with the local communities, but currently this does not cover all of the protected groups. The Trust has strong
engagement links with disabled, and bme communities’ and. people with mental health.
Mainstream processes: The organisation does not meet the aim to meet the outcome using mainstream processes.
Progression plans: No plans are in place to progress to the next grade.
Disadvantaged groups: No other disadvantage groups are taken into account in the above process.
Summary: Overall, the Trust has embarked on some engagement across some of the protected groups and has now an engagement framework. However
little evidence is provided to suggest how the Trust ensures that any changes identified are used to inform future service change. Also the Trust cannot
demonstrate what monitoring takes place across the protected groups.
Evidence: Community Engagement Framework, stakeholders and bme community list, Patients Relations Team Report, Community Development Workers
reports, stakeholder briefings, website, Mental Health community Service Users Survey. Annual report from the Community and Patient Relations team,
database of group.
Actions: Need to develop robust monitoring systems for capturing protected groups data across individual health needs, communication support and
patient surveys/questions. Improve engagement opportunities across the protected groups. Include appropriate requirements into contract and then
establish monitoring systems to ensure compliance.
HACT EDS Grading (v3)
March 2012
Page 4
EDS Outcome 1.4 (EDS Goal 1 – Better health outcomes for all)
The safety of patients is prioritised and assured. In particular, patients are free from abuse, harassment, bullying, violence from other patients
and staff, with redress being open and fair to all
1.4 EDS Grade: Developing
Outcome: The Trust has a range of policies and procedures to support safeguarding children and vulnerable adults, which includes adults over 18, those
with mental health, disability and older people. NHSW is a key partner on the Safeguarding Board. Robust training is provided for employees on the process
of reporting safeguarding issues. The organisation also provides support to people experiencing domestic abuse and is a partner on a multi-agency group.
Robust procedures are in place to ensure safeguarding and domestic abuse issues are escalated and managed appropriately. However, in relation to
monitoring protected groups, information is not collated to that level and most data relates to total numbers. Other policies that support this area are the
Management of Allegations Policy and Whistleblowing policies and Provider services. Safeguarding policies for employee also in place and can be picked up
through the complaints procedure. The Commissioners’ in its contract with Providers monitors patient safety against the appropriate CQC Essential
Standards and CQUINs. Safeguarding board has systems in place for children vulnerable adults, support for unborn babies, children with disabilities. From
the evidence collected NHSW recognises that much more can be undertaken to ensure that safeguarding for all patients is addressed and that appropriate
monitoring is put in place to ensure that we capture all safeguarding issues across the protected characteristics. The Safeguarding agenda is linked to the
CQC compliance and registration Outcome 7. A number of employee related policies are in place to support this outcome.
Engagement: The Trust has a range of ways of engaging with patients to capture information and feedback about the above outcome.
Mainstream processes: The Trust reports on this issue via the Quality Accounts and the Safeguarding Board. Commissioners monitor the Providers via the
contract in relation to Safeguarding and patient safety monitoring takes place against the appropriate CQC Essential Standards.
Progression plans: The Safeguarding board has a range of plans in place which will support moving this outcome to the next level.
Disadvantaged groups: No other disadvantaged group has been identified in relation to this outcome.
Summary: The Trust has very good Safeguarding policies and procedures in place; this is also supported by the multi-agency boards for children and
vulnerable adults. Mandatory training is required for all health professionals a database is kept for all those trained across the NHS providers. This is
monitored and reviewed through the Clinical Service Reviews, Quality Schedules and Worcestershire Safeguarding Adult and Children Boards. The evidence
HACT EDS Grading (v3)
March 2012
Page 5
demonstrates the high quality of work undertaken to meet this outcome. Greater emphasis now needs to be placed on collecting data on the various
protected groups that are not currently captured in this outcome.
Evidence: Safeguarding Children policies, Adult Protection Policy, Safeguarding Adult Procedures, Management of Allegations Policy and Whistleblowing
Policies within Provider services and Worcestershire Against Domestic Abuse., Engagement activities, NHS Providers Safeguarding Training Strategy,
Training Database, monitoring data at Clinical Services Review, Quality Schedules and Worcestershire Safeguarding Adult and Children Boards.
Safeguarding incidents across all age groups monitored and reviewed by Consultant Nurse, Safeguarding and Quality Safety Team WSCB Report 2011. This
links to CQC Outcomes 7B and 7F and 7A.
Action: Establish monitoring systems to capture and analysis data to evidence equality of safety outcomes across protected groups.
HACT EDS Grading (v3)
March 2012
Page 6
EDS Outcome 1.5 (EDS Goal 1 – Better health outcomes for all)
Public health, vaccination and screening programmes reach and benefit all local communities and groups
1.5 EDS Grade: Developing
Outcome: We have a well-established county-wide contraception and sexual health (CASH) clinics. As part of our work we take cervical smears.
Some women say that our clinics are more accessible than their GP practice because we are open in the evenings and women can drop in for
their sexual health care. When women are invited for screening our clinics are mentioned as an option in the letter from the screening
programme.
Sexual health hosts the Chlamydia screening team-part of the national Chlamydia screening programme. The CASH clinics have been prolific
screeners and act as treatment centres for those who test positive. We also screen more vulnerable young people in our Time 4U and outreach
services, such as those in the looked after system, those not in education, employment, or training, younger commercial sex workers etc.
There is a new local target set by commissioners that 95% of young people in the age range for the NCSP (15-25) are offered a screen. We have
done a lot of work around this e.g. a large scale audit exploring the reasons why young people decline a screen and are running a 3 month
‘opt-out’ pilot programme at the moment.
School Health Service: immunise Year 8 girls in all schools (state and private) against the Human Papilloma virus with Cervix however from
September we change over to Gardasil within all areas of the county. Diphtheria Tetanus and polio booster offered to year 10 boys and girls
only in state schools within the South of the county. Redditch and Bromsgrove the GP's call the children to the surgery.
The main vaccination programme is for Hepatitis B vaccination. This is offered to all prisoners with a current take up rate of about 60% at
Hewell and 70% at HMP Long Lartin. The offer is an integral part of our initial prisoner screening programme to ensure that it is offered
equally to all groups. We have higher levels in the prison of BME groups and people with learning difficulties/disabilities compared to the
Worcestershire population.
Engagement: Engagement via social media aimed at gaining the views of gay men was undertaken. This highlighted that they would be more
likely to attend clinics specifically for them as they would feel more comfortable. Patients are able to access Hepatitis B vaccinations from
these and our general clinics.
HACT EDS Grading (v3)
March 2012
Page 7
Mainstream processes:
Progression plans: No plans in place to move this outcome forward
Disadvantaged groups: This outcome has identified prisoners as an additional disadvantage group.
Summary: Overall the Trust provides a range of services to ensure that the local community are made aware of public health, vaccinations and screening
programmes across, and has developed specific programmes targeted at vulnerable groups, eg the Time 4U and outreach services for NEETS and looked
after children, Out $U an. The Trust does not currently collect this information by the different protected groups and therefore cannot demonstrate that
all these programmes are reaching the protected groups.
Evidence: Contraception and Sexual Health (CASH() Clinics, National Chlamydia screening programme, Time 4U and outreach services, There is a
new local target set by commissioners that 95% of young people in the age range for the NCSP (15-25) are offered a screen. Immunise Year 8
girls in all schools (state and private) against the Human Papilloma virus with Cervix. Main vaccination programme for Hepatitis B vaccination
Action: Establish monitoring systems to capture and analysis data to evidence equality of safety outcomes across protected groups. Also look at
communication channels used to promote and raise awareness of these key programmes to ensure they are as accessible and appropriate as possible fro
the protected groups.
HACT EDS Grading (v3)
March 2012
Page 8
EDS Outcome 2.1 (EDS Goal 2 – Improved patient access and experience)
Patients, carers and communities can readily access services, and should not be denied access on unreasonable grounds
2.1 EDS Grade: Developed
Outcome: The Trust ensures that all its buildings are accessible and meets Equality Act 2010 requirements for disabled people; the Trust has contracts with
a variety of communication support organisations, e.g. telephone and face to face interpretation, deaf services etc., information is publisised and promoted
on all key leaflets and documentation. The Trust undertakes a range of engagement activities with local community groups and organisations to promote
health services; specific work is targeted at seldom heard groups, e.g. bme and disabled communities. The Trust has dedicated resources for bme
community development and officers have forged strong links with these communities and regularly use their networks to promote and raise awareness
around health issues. . However, the Trust cannot demonstrate whether or not these plans have ensured accessibility to services for protected groups as
no monitoring takes place to assess accessibility and any discriminatory practices. The Trust now has a complaints procedure which allows all patients to
raise any concerns about services or treatment, however this information is not broken down by the protected groups, so we cannot ascertain the level of
equity.
Engagement: The Trust uses a range of communication methods to engage with communities, however access to all protected groups is limited
Mainstream processes: The Trust does not use any mainstream process to make progress on this outcome
Progression plans: Plans are not in place to progress to next grade, with milestones.
Disadvantaged groups: Disadvantage groups have not been identified
Summary: The Trust is not making use of the data that it currently collects and does not collect data across all the protected groups. The Trust has
undertaken some good work especially in relation Community Development Workers, who engage with the local communities, there is but strong evidence
of work with bme communities, gypsy and travelers, but little evidence with other communities. Also limited evidence of the impact of this engagement
work. There are no firm processes in place that indicate an aspiration to improve performance with regard to the EDS outcome. There it is difficult to
ascertain how readily accessible the services really are.
Evidence: Community Engagement Framework, stakeholders list and bme community list, Patients Relations Team Report, Community Development
Workers reports, stakeholder briefings, website, Mental Health community Service Users Survey. Annual report from the Community and Patient Relations
HACT EDS Grading (v3)
March 2012
Page 9
team, database of group.
Actions: Need to develop robust monitoring systems for capturing protected groups data across individual health needs, communication support and
patient surveys/questions. Improve engagement opportunities across the protected groups. Include appropriate requirements into contract and then
establish monitoring systems to ensure compliance.
HACT EDS Grading (v3)
March 2012
Page 10
EDS Goal 2.2 – Improved patient access and experience
Patients are informed and supported to be as involved as they wish to be in their diagnosis and decisions about their care, and to exercise
choice and treatments and places of treatment
2.2 EDS Grade: Developing
Outcome: Patients are encouraged to ask questions, consent to treatments and choose their place of treatment. The Trust has an auditing policy which
ensures that patients are involved in any decisions made about them and are given informed information and choice. Patients can access their own records
and we have an Open Access Policy to support this. The Trust has access to translation and interpretation services to support any patients who may need
communication support. The Trust has information booklets for procedures which provide information regarding the proposed treatment, identifying the
risks and benefits to enable informed consent to treatment. Advocates to support patients are available when deciding on whether to consent to
treatment. Choose and Book system enables patients to choose the place of treatment. Feedback from Patient surveys around whether they had adequate
information, support and understood what was communicated to them is collected and reported to ensure that we are meeting patient needs.
Engagement: Patient Forums, PALS and advocates
Mainstream processes: The HACT does not use any mainstream process to make progress on this outcome
Progression plans: Plans are not in place to progress to next grade, with milestones.
Disadvantaged groups: No other disadvantaged group p identified
Summary: The Trust provides some assurance that patients are supported and informed to make informed choices about their treatment, care and places
of treatment. However this information is not monitored by the protected groups, therefore the Trust cannot confirm whether or not this is being operated
fairly across the county and protected groups.
Evidence: Consent forms. Auditing policy, Open Access Policy, Translation and Interpretation Services, Information leaflets, Patient surveys
Action: Need to develop robust monitoring systems for capturing protected groups data to ensure that patients feel they are informed, supported in
relation to care, choice treatments and places of treatment. Include appropriate requirements into contract and then establish monitoring systems to
ensure compliance.
HACT EDS Grading (v3)
March 2012
Page 11
EDS Outcome 2.3 (EDS Goal 2 – Improved patient access and experience)
Patients and carers report positive experiences of their treatment and care outcomes and of being listened to and respected and of how their
privacy and dignity is priotised.
2.3: EDS Grade: Developing
Outcome: The Trust tries to ensure that all patients have a good experience whilst using its services. The Trust has a robust complaints policy and
procedures that allows patients to raise concerns about experience. The Trust undertakes a range of engagement activities with local communities to gain
the views of patient experience; this also includes access to PALS and PPI groups and forums. Patient experience is monitored and reported to the Quality
and Safety meeting. The Trust also has a range of policies around safeguarding vulnerable adults and children. Currently the Trust does not collect
monitoring data on the protected groups for this outcome.
Engagement: The HACT engages with mainly five of the nine protected characteristics, but cannot demonstrate how this information is used to make
progress.
Mainstream process: The views of patients and carers is integrated into all key policies, procedures and practices across the Trust, patient experience is
also one of the key strategic objectives of the Trust.
Progression plans: No progression plans are currently in place to move this outcome forward
Disadvantage groups: No additional disadvantage groups are identified
Summary: Overall the Trust has some good practices in place to ensure that patients have a positive experience in relation to treatment outcomes and are
treated with respect and dignity.
Evidence: Complaints procedures, PALs and PPI groups forums, Patient surveys, safeguarding policies (children and vulnerable adults)
Action: Need to develop robust monitoring systems for capturing protected groups data on patient experience relating to this outcome. Include
appropriate requirements into contract and then establish monitoring systems to ensure compliance.
HACT EDS Grading (v3)
March 2012
Page 12
HACT EDS Grading (v3)
March 2012
Page 13
EDS Outcome 2.4 (EDS Goal 2 – Improved patient access and experience)
Patient’s and carer’s complaints about services, and subsequent claims for redress, should be handled respectfully and efficiently
2.4: EDS Grade: Undeveloped
Outcome: The Trust collects data on complaints by patients and carers and has various policies and guidance about how complaints should be handled. The
Trust aims t to handle or complaints as sensitively and respectively as possible. However, complaints are not broken down by protected groups; therefore
we cannot demonstrate comparisons between different groups. Translation and interpretation services are also available to support patients in making
complaints and ensuring they understand the process and outcomes, The Trust also promotes PALS which patients can access as an advocacy service.
Engagement: The Trust engages with patients, carers and communities across some of the protected groups.
Mainstream process: The Trust fails to demonstrate improvements in handling patient and carer complaints about services, using mainstream mechanisms.
Progression plans: No plans in place
Disadvantaged groups: No other disadvantaged groups identified
Summary: The Trust has in place appropriate policies and procedures for handling complaints however lack of data collection and monitoring fails to
demonstrate how this EDS outcome is meet across the protected groups. Engagement is limited across the protected groups and no processes have been
identified to mainstream this area. Lack of awareness of the importance of collecting and monitoring data means that no plans are in place to assist the
Trust to progress this outcome.
Evidence: Complaints procedure, Annual Report and complaints leaflets and PALS leaflet.
Action: Establishing monitoring system for capturing and analysing data across protected groups.
HACT EDS Grading (v3)
March 2012
Page 14
EDS Outcome 3.1 (EDS Goal 3 – Empowered, engaged and well-supported staff)
Recruitment and selection processes are fair, inclusive and transparent so that the workforce becomes as diverse as it can be within all
occupations and grades
3.1: EDS Grade: Developed
Outcome: The Trust has a range of policies and procedures to support the recruitment and selection process. All officers who undertake recruitment and
selection are required to undergo training. The Trust also has a range of initiatives to encourage and support employment from across some of the
protected groups. However this is not directly as a result of data analysis. Data is collected through the recruitment and selection process via (NHS Job
website) and employees are required to keep information updated via the ESR system. However, there has not been any data verification to date and no
plans in place to address gaps in information across the workforce. The Trust is not represented at each grade and occupation across the protected groups.
The Trust reports annually on the recruitment and selection process and has data that covers the majority of the protected characteristics.
Engagement: The Trust engages with the staff side and establishes task and finish groups as and when the need is required. The Trust has no formal
employee focus or support groups
Mainstream process: The Trust has not looked at how it can improve R&S processes to ensure a more represented workforce.
Progression plans: Plans are not in place to progress this to the next grade.
Disadvantaged group: Key disadvantaged groups are not taken into account in the above processes.
Summary: The Trust does not have adequate processes or mechanisms in place to meet this EDS outcome. Consequently, the Trust is unable to
demonstrate that its recruitment processes are inclusive and equitable. It can only be graded as being developing
Evidence: Recruitment and selection policy and procedures, NHS jobs website, monitoring data Current positive action initiative, apprenticeship scheme,
Exemplar employer Scheme, Work experience, Local Employment Partnership, Positive about Disabled people, Short-term paid training placements .
Workforce data 2011.
Action: Monitor and analysis data across protected groups, use recruitment and selection data to identify positive action initiatives to improve workforce
diversity, establish employee support networks, across protected groups or a generic diversity group to improve engagement and communication with
these groups.
HACT EDS Grading (v3)
March 2012
Page 15
EDS Outcome 3.2 (EDS Goal 3 – Empowered, engaged and well-supported staff)
Levels of pay and related terms and conditions are fairly determined for all posts, with staff doing equal work and work rated as of equal value
being entitled to equal pay
3.2: EDS Grade: Developing
Outcome: The Trust operates the NHS job evaluation system for determining the grades of all posts. New posts are considered in accordance with the
national job profiles or are evaluated individually jointly by the HR and staff side AFC Leads. This ensures that consistency is applied in the grading process.
No data is available to demonstrate that staff from protected groups enjoys the same level of pay and related terms and conditions as other employees.
The Trust however, has in place relevant policies and procedures relating to NHS employee terms and conditions handbook, policy on job evaluation and
rebranding and starting salaries policy. These three policies set the principles of ensuring fairness in this area. However the Trust recognises that it does
not collect data or monitor this information across the protected characteristics.
Engagement: Yes the Trust does engage with staff side organisations and staff in relation to this outcome.
Mainstream process: The Trust does not yet tackle this issue as part of mainstream processes.
Progression plans: Plans are not in place to progress to the next grade.
Disadvantaged group: Key disadvantaged groups are not taken into account in the above processes.
Evidence: NHS job evaluation system, publishing information report
Action: Undertake a more robust gender job analysis.
HACT EDS Grading (v3)
March 2012
Page 16
EDS Outcome 3.3 (EDS Goal 3 – Empowered, engaged and well-supported staff)
Through support, training, personal development and performance appraisal, staff are confident and competent to do their work, so that services are
commissioned or provided appropriately
3.3 EDS Outcome: Undeveloped
Outcome: The Trust employees are required to undergo the mandatory e-learning training, clinical staff receives regular supervision. A robust appraisal
system is place to support employees and assist with personal development. The Trust has a range of policies and procedures in place to support the above
processes and to support, and develop staff. Managers are trained to assist employees with their personal development and to manage performance
appraisal. The Trust has a dedicated team for ensuring the continued development and take up of training across the organisation. Regular training
bulletins are sent out to all employees so that they are aware of future training courses. An accredited Team Leader Development Programme has also
been developed to ensure all team leaders are equipped with the essential skills to carry out their roles. A Preceptorship scheme has been developed to
support all newly qualified Band 5, clinical staff. The Trust has designed and implemented an innovative and sustainable apprenticeship scheme which
successfully provides an excellent training scheme which and experience programme for individuals starting their career with the NHS. The Trust however,
does not collect data to demonstrate that employees from protected groups are receiving both personal development and performance appraisals that are
no different to the experiences of staff as a whole.
Engagement: The Trust currently does not have any employee forums/networks where formal engagement can take place. But a joint staff group is
available.
Mainstream processes: This outcome is integrated into the day to day role of managers within the organisation. Staff surveys will need to be used as
measure of how this process really is integrated into the organisation, as this mechanism will demonstrate how the policy is actually implemented and how
employees feel about this process.
Progression plans: No direct progression plans in place.
Disadvantaged groups: none identified.
Evidence: Education, Training and Development Policy and procedures, Equality and Diversity Training, induction training, Appraisal information.
Action: Establish employee networks/forums monitoring of training activities and integrate equality and diversity into all training functions/programmes.
Include the Competence framework into the appraisal process. Develop action plan to implement issues and concerns raised in Staff survey.
HACT EDS Grading (v3)
March 2012
Page 17
EDS Outcome 3.4 (EDS Goal 3 – Empowered, engaged and well-supported staff)
Staff are free from abuse, harassment, bullying, violence from both patients and their relatives and colleagues, with redress being open and
fair to all
3.4: EDS Grade: Undeveloped
Outcome: The Trust has a range of policies to support employees, from abuse, harassment and bullying from patients, their relatives and colleagues. The
Trust has an on-line reporting system Sentinel which employees are able to report serious untoward incidents that the Trust is able to follow up
appropriately. The Trust operates a Zero Tolerance approach to abuse from patients/relatives. The annual employee survey also includes questions around
abuse, harassment and violence. Results of the survey are scrutinised by the Trust board and action plans are developed to address areas of concern. Data
is collected from this system, but it is not collected by the protected groups, therefore the Trust cannot demonstrate that that the policies are operating in
a fair and transparent manner.
Engagement: The Trust engages with local staff side organisations and staff members on this outcome, through the employee survey.
Mainstream processes: the Trust has integrated this into mainstream processes, complaints and other employee reporting mechanisms are in place. This is
also support by robust disciplinary and grievances procedures. Employees can also raise issues through the employee surveys and Trade union
representatives.
Progression plan – No plans are in place to move this outcome on the next grade.
Disadvantaged groups: key disadvantaged groups are not taken into account in the above process.
Summary: The Trust has in place relevant and appropriate policies to support employees who may have experience, abuse, harassment, bullying or
violence, whilst at work. However the Trust does not collect, monitor or analysis that data, therefore it has no evidence to demonstrate whether or not its
policies are implemented correctly and how protected groups are treated compared to other groups within NHSW.
Evidence: Employee survey, harassment and bullying policy, appraisal policy, recruitment and selection policy and disciplinary and grievances procedures.
Action: Introduce monitoring in the above policy, need to identify where employees have raised concerns or where trends are highlighted across the
organisation. Training for managers, staff initiatives to promote, employee networks/forums to help to promote it and raise issues in a safe environment.
Ensure this is included in induction programme; ensure policies are up-to-date to reflect Equality Act changes.
HACT EDS Grading (v3)
March 2012
Page 18
EDS Outcome 3.5 (EDS Goal 3 – Empowered, engaged and well-supported staff)
Flexible working options are made available to all staff, consistent with the needs of the service, and the way people lead their lives.
3.5: EDS Grade: Developing
Outcome: All employees have access to all flexible working options. Employees attend induction training, access to policies via email, hard copies available
in certain locations. Access to the information is available to all protected groups. The currently policies relating to this outcome are: flexible working
policy, guidance on leave, sickness policy and Employment Break Scheme. These policies are open to all employees. However, no monitoring is undertaken
of these policies by protected groups. The Trust works closely with disabled members of staff to ensue reasonable adjustments are made where reasonable
possible and will seek advice from Access to Work where necessary. The Guidance on Leave Policy makes provisions for special leave and Carers leave.
Staff Support Co-ordinators are employed to ensure employees are aware of all the available options to them including childcare and care vouchers.
Therefore we cannot demonstrate that these policies are operating fairly across the organisation.
Engagement: NHSW works with the Staff Side group to ensure any developments or improvements to flexible working options is meeting the needs of all
protected groups.
Mainstream processes: The policies are integrated into the existing human resources structure and should form part of the line management responsibility
and human resources transition framework.
Progression plans: No plans in place to progress to next grade.
Disadvantaged groups: Key disadvantaged groups are not identified in the above process.
Summary: Flexible working is taken seriously within NHSW Trust and all employees are given access to information regarding available options available. A
range of policies are in place to support employees to make an informed decision about which flexible options best suits their way of life. However the EDS
outcome is not met as the Trust does not currently collect, monitor or analysis this data across protected groups or any other group. Therefore it cannot
demonstrate whether or not the flexible working options are being fairly operated across the organisation.
Evidence: Flexible policies and procedures
Action: Collect and monitor data across protected groups, monitor take-up of flexible working. Information to be included in workforce reports.
HACT EDS Grading (v3)
March 2012
Page 19
EDS Outcome 3.6 (EDS Goal 3 – Empowered, engaged and well-supported staff)
The workforce is supported to remain healthy, with a focus on addressing major health and lifestyle issues that affect individual staff and the
wider population
3.6: EDS Grade: Developing
Outcomes: The Trust has developed a range of information sources for employees to support their health and wellbeing. A dedicated website has also
been develop, which all employees have access to. Employees are is informed about this service as part of the induction programme. A HR officer leads on
this area and emails are distributed to all employees promoting new initiatives and services, regular newsletters are also published for employees. The
Trust also provides a fast track physiotherapy service which can be accessed by employee who are or could be in the future suffering from a long term
condition. This service may also be accessed by employees that have musculo-skeletal problems as a result of being pregnant. The Trust is currently
undertaking a Health and Wellbeing project to enable employees to access initiatives to remain healthy and address lifestyle issues. Staff Support Coordinators regularly inform all employees of any courses that are available to support them in this area and also develop links with Community Groups and
leisure services to offer discounted rates of NHS staff. All employees have access to the Trust Occupational Health Services and can self-refer to Counselling
services. Employee’s area also able to access the Health Training service for support with any lifestyle or health issues. The Trust undertakes a lot of
initiates to support the health and wellbeing of employees, this information is recorded on the NCR system; therefore the Trust could capture this data by
protected characteristics, but currently do not monitor by the protected groups to demonstrate that the initiatives are accessible and promoted to ensure
take up is fair across the protected groups compared to the whole workforce
Engagement: Emails, newsletters, website, HR officers and Staff Support Co-ordinators
Mainstream Processes: This is included as part of the mainstream processes of the trust, as part of appraisals, 1-2-1 meetings return to work interviews,
and other HR practices.
Progression Plans: Plans are currently being developed with partners including health trainers, occupational health and physiotherapy to ensure the health
and wellbeing of all of our staff irrespective of their protected group. The development of a more regular health and well-being newsletter for employee is
being explored.
Disadvantaged groups: No disadvantage groups have been identified for this process. Plans are in place to move to next grade.
Summary: The Trust has a range of initiatives in place to support employees with their health and well-being and all initiatives are open to all employees
who need support. The Trust recognises the need to keep employees informed and have a dedicated employee intranet site and produces newsletter.
HACT EDS Grading (v3)
March 2012
Page 20
However, the Trust is currently developing a more regular newsletter to keep employees informed of initiatives happening. The Trust has some good work
in this area, but recognises by its failure not monitor across the protected characteristics it cannot demonstrate that the health and well-being initiatives
are fairly accessible to all and that protected groups have the same take up as other groups. Therefore this outcome will have to be graded as developed as
it currently collects no data.
Evidence: website, newsletter, emails, campaigns, policy and procedures.
Action: Establish monitoring systems to collect and monitor take up and impact on workforce.
HACT EDS Grading (v3)
March 2012
Page 21
EDS Outcome 4.1 (EDS Goal 4 – Inclusive leadership at all levels)
Boards and senior leaders conduct and plan their business so that equality is advanced, and good relations fostered, within their organisations
and beyond
4.1 EDS Grade: Undeveloped
Outcome: The Trust has dedicated resources to support this agenda and has recently appointed a Head of Equalities and Organisational Development; the
Trust also manages the equality and diversity agenda through a robust formal governance structure. Senior managers take responsibility by ensuring that
equality and diversity is integrated into the day to day business of the Trust.
Equality and Diversity sits within the remit of the Lead Nurse for Quality and Safety and this ensures that the principles of equality and diversity are
integrated into the core of business. The Trust has a Single Equality and Human Rights Scheme and Policy which has been adopted. The Trust ensures that
Equality Analysis is completed for all key decisions. All employees are required to complete the mandatory e-learning training on Equality and Diversity. As
this is a new Board it is envisaged that board members will receive appropriate training relating to this agenda. Equality and diversity is integrated into all
key strategies and plans and key objectives will be set for the next four years in line with the Equality Act 2010. The Trust excepts that there is still much
more work to do to ensure that equality and diversity is truly integrated into the day to day business of the organisation and that officers at all levels
understand their roles and responsibilities.
Engagement: NHSW engages with a wide range of patients, staff, staff-side organisations and communities; however this is not across all the protected
groups
Mainstream processes: NHSW has gone some way to ensure that equality and diversity is integrated into the core aspects of its business; however it
recognises that it will need to do more to demonstrate this outcome.
Progression plans: No progression plans currently in place to demonstrate moving this forward; however plans will be in place shortly.
Disadvantaged groups: No other groups identified
Summary: Overall, the Trust has started to address this outcome and with the appointment of the Head of Equality and Organisational Development, it is
intended that this area will be developed and that equality and diversity training will be provided as part of the board training programme. Equality
Analysis are undertaken on all key
HACT EDS Grading (v3)
March 2012
Page 22
Evidence: Annual report, Board papers, senior manager meetings
Action: Governance structure needs firming up, identifying champion for this agenda, greater clarity of how equality and diversity is discussed at board and
senior manager’s meetings, how it informs decision making and how it is integrated into key business/service plans.
HACT EDS Grading (v3)
March 2012
Page 23
EDS Outcome 4.2 (EDS Goal 4 – Inclusive leadership at all levels)
Middle managers and other line managers support and motivate their staff to work in culturally competent ways within a work environment
free from discrimination
4.2 EDS Grade: Undeveloped
Outcome: The Trust has a policy framework which applies to all staff to meet this outcome; this includes the following policies, Harassment and Bullying,
Equality and Diversity Scheme and policy, Recruitment and Selection, and Whistleblowing Policy. All managers receive training on equality and diversity,
through the leadership programmes. All incidents reported are investigated and appropriate action is taken. The HR teams keep a log of all incidents
reported to them. There is limited engagement with Trust employees, main engagement is through e-newsletter and team briefs. Currently there are no o
formal employee networks or support groups to improve engagement and communication.
Engagement: The Trust engages with the staff side group who works to ensure that employee needs are been meet, by ensuring that staff have safe and
healthy environments to work in and are free from harassment and bullying and that they are given equal access to employment and training opportunities.
Mainstream processes: Some issues are within mainstream practices but the Trust needs to enshrine this approach more robustly across all areas.
Progression plans: No progression plans are in place to move this outcome on to the next level.
Disadvantaged groups: No other disadvantage groups are identified
Summary: Overall the Trust has some good policies and frameworks in place to meet some aspects of this outcome; however more evidence is required to
demonstrate how managers support and motivate staff to work in culturally competent ways. The current equality and diversity training may only go some
way to addressing this issue, as it is primarily for new employees, but does not address employees who have worked in the organisation for some time. No
specific training is delivered on the harassment and bullying policy which could be used to ensure that managers understand how to create this
environment, other ways can be to ensure that equality and diversity is an integral part of any training delivered by the Trust.
Evidence: Harassment and Bullying policy, recruitment and selection policy. Guidance, Whistleblowing policy, equality and diversity training and e-learning,
team leaders training programme.
HACT EDS Grading (v3)
March 2012
Page 24
Action: Provide appropriate training for managers to equip them with skills to meet this outcome and incorporate principles of this outcome into existing
management training. Monitor and collect data on this outcome, include specific questions in employee surveys, exit questionnaires/interviews. Collate
and analysis information to gauge where areas of concern are, develop action plans to address issues. Develop employee focus groups/support groups to
ascertain the level of workplace discrimination.
HACT EDS Grading (v3)
March 2012
Page 25
EDS Outcome 4.3 (EDS Goal 4 – Inclusive leadership at all levels)
The organisation uses the Competency Framework for Equality and Diversity Leadership to recruit, develop and support strategic leaders to
advance equality outcomes
4.3 EDS Grade: Undeveloped
Outcome: The organisation does not currently use the Competency Framework for Equality and Diversity Leadership to recruit, develop and support
strategic leaders to advance equality outcomes. It is envisaged that this work will commence shortly. However, within its team leadership programme,
equality and diversity is included, managers are also trained on recruitment and selection and all employees attend induction on equality and diversity.
Progression plans: Plans will be developed shortly to address this.
Disadvantaged groups: No other disadvantage group identified
Summary: Other policies and practices are in place, the Trust uses the KSF for all job descriptions and person specifications. However, this specific
framework is not currently used by the Trust.
Evidence: Recruitment and selection policy and training, team leadership programme, equality and diversity induction training
Action: Trust to adopt the Competency Framework and develop implementation plan to incorporate into key areas of recruitment, selection, learning, and
development and appraisal system. Establish evaluation process for monitoring the effectiveness of this framework.
HACT EDS Grading (v3)
March 2012
Page 26