Specialist Learning Disability DivisionEquality and Human Rights

2017-2018

1 Margaret Brown Equality & HR Officer

Equality and Human Rights Action Plan Specialist Learning Disability Division

2017 - 2019

This Action Plan Links into Trust Equality Objectives; the NHS Equality Delivery System 2 (EDS), the Care Quality Commission 5 Key Principles and the Specialist Learning Disability Division local objectives

Key to Trust Equality and Human Rights Action Plan reference:

                                      

Progress Rating

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Clinical Commissioning Group  Quality contract requirements QC

Equality Delivery System EDS

Equality Objectives EO

Workforce Race Equality Standard WRES

Accessible Information Standard AIS

Strategic Aim SA

Explanation of RAG ratingAction not yet startedAction startedAction completed on time

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Division Equality Objective 1: Effective Governance Procedure

Objective Action Lead Progress Time Frame EDS, QC, EO, WRES

1.Establishgovernance structure which gives clear, systematic arrangements to ensure equity is being met across the division

Appoint to role of Equality & HR Officer

Chief Operating Officer

Equality & HR Officer in post January 2017 QC/4EO/5EDS/4

Sanction the requirement for all sub committees of the Division to have equality requirements and analysis within their terms of reference as detailed in the Trust Equality and Human Rights Action Plan to enable the governance process to be in place.

Agree the interim Divisional E&HR Action Plan

Chief Operating Officer/Equality & HR Officer

Action sanctioned, February

Action Plan agreed

May 2017 QC/4

EDS 4

QC/2

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Agree the reporting cycle for the Equality & HR Action Plan/Governance arrangements

Equality and Human Rights to be an agenda item on Governance and other  key meetings across the division

Equality and Human Rights objectives to be included/incorporated into the action plans of:Operations & PerformancePolicy & Procedures;Surveillance;  Clinical Governance; Security, Operational Managers; Service User and Carer  Groups

Operational Management Group

Agreed and in place

Operations Performance: Objective: workforce, learning & developmentPolicy & Procedure:Objective: establish equality analysis procedureSurveillance:Objective:Clinical Governance:Objective: seclusion & segregation, blanket restrictions, restrictive interventions, MHASecurity:Objective: incidentsService Users/Carers:Patient experience

Equality and Human Rights objectives to contribute to Divisional Business Plan

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2. Equality and Human Rights training to be available and completed by staff across the division

Human Rights training including FREDA principles

Mandatory Equality and Diversity training

Equality Analysis training

All equality mandatory training to be completed and reported.

All staff to have level 1 and 2 training with the following outcome measures Red < 70% Amber 70 - 90% Green > 90%

Level 3 training for managers identified as appropriate.

E-learning to be utilized when available in April 2017.

Equality & HR Officer /Trust Equality & HR Lead

May 2017Training now on-line all staff have access

January 2017 EDS 3.3

Equality & HR training to be delivered to service users using the FREDA principles

Develop training package on FREDA principles

Equality & HR Officer/Trust Equality & HR Lead

April:Liaison with Southport LD team on delivering HR training to service usersJune:Commenced introduction of FREDA principles on LSUSouthport team will present to August Char@m meeting

June 2017

Equality & HR training to be co-produced and co-

Face-to face training ceased, this objective amended to: Equality & HR training to be

Equality & HR Officer/Trust Equality & HR

Equality & HR training included in SU Recruitment & Selection Training

June 2017

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facilitated with included in SU Recruitment & Selection Training service users

Lead

Divisional Equality Objective 2: Analysis of Service User experience by protected characteristics.

Objective Action Lead Progress Time Frame Objective

3.Review patient data across the division

Agree the most appropriate areas to focus on

AdmissionsTransfers

Protected characteristicsCurrent Patient Profile

Patients in seclusionSegregation/Seclusion patients in relation to the protected characteristics

Incidents/Complaints/Safeguarding, Patient ExperienceIn relation to the protected characteristics.

Data to be reported, analysed, discussed at

Equality &HR Officer/Senior Data Analyst

Data received, to be collated, analysed and actions agreed

February 2017 EDS2

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governance meetings and actions agreed

Ensure divisional reporting system enables recording of discriminatory behaviour relating to protected characteristics.

Collate the information related to protected characteristics. Formulate an action plan as appropriate.

Provide a regular agenda item at Surveillance Group to report incidents, review trends, agree actions

Deputy Chief Operating Officer/Senior Data Analyst/Equality & HR Officer

Systems in place to capture discriminatory behavior by service users to staff or others\users. This information now needs to be collated and analyzed via the respective Forums

Action to be discussed by governance forum

March 2017 EDS 1.4, EDS 3.4WRESEO

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5.Equality Review of service provision for female service users

Engage with staff & service users on female wards to review current service provision and to work collaboratively to develop provision in line with gender sensitive services and patient experience data.

Analysis of relevant data such as use of seclusion, incidents etc.

First engagement session taken place, task group to meet to discuss actions and time frame

March 2017

June 2017

EDS 1.4 EO/2

6Widen access to support systems to identify and address the equality issues of patients which influence /impact their health.

‘The Avenue’ LGBT support group in place, develop plans to increase membership and ensure all service users are informed and able to access

Explore development of BME support network for service users/Women?

Head of PTS/Equality & HR Officer

Service users to devise a poster. Agenda item on speak up community meetings.Focus group to be held in June

Explore setting up separate women’s group to encourage engagement

May 2017 EDS 2.3

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7.Establish process to monitor and address any over representation of relevant protected characteristics in relation to MVA, seclusion and rapid tranquilization.

Data collection of protected characteristics undertaken in relation to restraint, seclusion and rapid tranquilization,

Data analysis to ascertain if any relevant protected characteristics are over represented in these areas.

Data showed women over represented in incidents. Work to commence with both service users and staff on analysis and actions.Further meeting in place to discuss and agree actions

Trust wide task & finish group established to examine a gendered approach to ‘No Force First’ which has been introduced in the divisionData requested

March 2017

July 2017

May 2017

EDS 1.4 EO/2

8Review translation services and move to Capita on-line booking system

Begin process of moving service to Capita; develop communication plan and training for staff on operation of new system

Equality & HR Officer/Finance

SpLD now on Capita on-line booking system. Communication re passwords and process rolled out

Audit of usage in April 2018

April 2017

9Full implementation of the Accessible Information Standard in line with NHS England Guidance

Identified all patient information systems within the Division

Identify leads re AIS for all systems/Divisions

Develop specific actions to

Equality and Human Rights advisors/IM Lead/Equality and Human Rights Lead/Communications Lead/AIS Lead

Lead identifiedJune:New form to be installedon Care Notes by end of the month to facilitate identification and flagging

Upgrade to system due to be

March 2018

July 2017

AI/S EO/6 QC/1

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enable the standard to be met

Develop internal governance process for the standard.

Develop guidance for staff to support the production of accessible information

completed end of the month

Staff guidance in developmentJune first draft completed and to be circulated

Divisional Equality Objective 3 :  To have comprehensive equality staff data

Objective Action Lead Progress Time Frame EDS level/WRES

10.To effectivelyimplement the workforce race equality standard (WRES)  and have identified outcomes from its implementation

Analysis of staff equality data

Data to be reported, analysed, discussed at governance meetings and actions agreed

Trust Equality & HR Lead/ Equality & HR Officer/Senior Data Analyst

The data for the WRES is still being put together. The ESR data has been produced; staff survey data now received will be included.Employee relations data is ready.The recruitment data is the final section to be completed.Need to pull off new data for the next submission from 1st April

June 2017Report published by 1st July 2017

WRES

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Action taken to ensure homophobic abuse can be reported onto the system

Develop anti-racism, discriminatory abuse programme in collaboration with service users

Equality & HR Officer/Service User/Carer Lead

2017 – to be downloaded to NHS employers before 1st July 2017System in place

Service users engaged will be further addressed in FREDA principle actionsHate Crime Event planned in collaboration with community groups

April 2017

June 2017

October 2017

To have lead/ actions to ensure staff survey recommendations are developed and met

Awaiting report on latest survey

June:Board received report, details and actions to be discussed at Equality Committee

July 2017

11.Merging of SpLD equality agenda with wider Trust

Merge appropriate data for equality monitoringProduce merged data for all legal /NHS requirements

Dates for SLDD to host engagement sessions for people within the service and

Chief Operating Officer/Trust Equality & HR Lead

The Trust has included the EDS arrangements for SLDD.Aligning the assessment process with the Quality Account process and priorities for the Trust. This is to be completed  June 2017

April 2017 WRES EO/5 AIS

EO/1/WRES

EO/1 EDS 3

EO/4

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12.Address support needs of disabled, LGBT, BME staff & staff who identify as carers

13.To set up systems that enable 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

community contacts to be agreed

Explore how to identify staff who are carers and feasibility of staff networks in division

Completion of Review of HR27 Support for staff with Mental and/or physical disabilities policy alongside attendance policy

Develop lived experience staff network

Develop reciprocal mentoring scheme

Equality & HR Lead & Officer

Equality & HR Team

May 2017: meeting with Employers for Carers Lead arranged

Policy review now completeHR to raise awareness & inform service & managers of the revised policy and the attendance policy.

Communicate the change in policy to staff

Scheme now underway, division fully engaged

July 2017 WRES

Equality Objective: service change being developed to meet the Trust’s strategic objectives will explicitly take

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account of the needs of those with protected characteristics and human rights based approach.

Objective Action Lead Progress Time Frame EDS Level

14.Ensure that Gender is a consideration in the outline business case for the new build.

15.Need to develop a system/process of checks where all other service related business changes OBC are subject to equality and human rights analysis

Business Development Mgr/Operational Support Mgr/ Head of OT

Plans for the new build subjected to equality analysis

Accepted lead on Calderstones acquisition equality analysis

May 2017

16.System to ensure all Divisional policies and procedures are subjected to equality analysis

Policy & procedure group to review and put EA training & system in place

Senior Operational Manager/Equality & HR Lead

Propose task group set up to conduct analysis on current policies & procedures

May 2017

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