policy for the performance management of serious incidents and … · 2017-11-09 · incident...

Corporate Policy

Policy for the Performance Management of

Serious Incidents and Never Events within

commissioned providers.

Incident Reporting and Management Policy (incl. Serious Incidents) of 21

Document Control Sheet

Title of document:

Policy for the performance management of serious

incidents and never events within commissioned

providers

Supersedes: New policy-was previously incorporated within the Incident Reporting and Management Policy( including Serious Incidents) V 1.1

Placement in Organisation:

Manchester CCGs

Consultation / Stakeholders

CCG Leads

Quality Teams

City Wide Commissioning

Corporate Services Team

Author(s) name: Kate Provan, Quality Lead Corinne Power, Quality, Nursing and Reporting Lead.

Department / Team: City Wide Quality Team

Approved by: Joint Corporate Governance Committee

Approval date: 18th February 2016 Review date:

18th February 2019

Implementation Date: 18th February 2016

Implementation Method: CCG Website

Manchester Matters

This document is to be read in conjunction with the following documents: Serious Incident Framework, NHS England (2015)

Revised Never Events Policy and Framework , NHS England (2015)

Version Control

Version Date Brief description of change

1.0 Oct 2015

New document, separating out the management of serious incidents from commissioned providers from the previous policy entitled: Incident Reporting and Management Policy( including Serious Incidents) V 1.1

PLEASE NOTE: the formally approved copy of this document is held on North,

Central and South CCG’s website. Printed copies or electronic saved copies must be

checked to ensure they match the current online version.


Contents

- Title Page ........................................................................................................ 1

- Document Control Sheet ................................................................................. 2

- Contents Page ................................................................................................. 3

1.0 Policy Statement ............................................................................................. 4

2.0 Introduction ...................................................................................................... 4

3.0 Purpose ........................................................................................................... 4

4.0 Responsibilities ............................................................................................... 4

5.0 Definitions of Terms Used ............................................................................... 5

6.0 Process for Managing External (Acute Provider) Serious Incidents ................ 8

7.0 Process for Managing External (Mental Health,City Wide) Serious Incidents 10

8.0 Process for Approval & Ratification ............................................................... 11

9.0 Dissemination, Training & Advice .................................................................. 11

10.0 Review, Monitoring and Compliance ............................................................. 11

11.0 References .................................................................................................... 12

Appendices

Appendix A –The Never Events List ........................................................................ 13

Appendix B –Assigining Accountability- RASCI Model ............................................ 13

Appendix C –Overview of the Investigation Process ............................................... 15

Appendix D – Equality Analysis ............................................................................... 17


1.0 Policy Statement

1.1 This policy sets out the systems, processes and accountability within the CCG for the performance management of Serious Incidents (including Never Events) within all commissioned providers By adopting this policy, the CCG aims to improve the organisation’s ability to:

commission high quality, safe and accountable health services,

minimise risk to patients and members of the public

2.0 Introduction

2.1 As a commissioner, the CCG procures a range of services some of which are large and complex. The CCG is committed to complying with legislation and NHS standards that require the CCG to have robust systems and processes in place for the management of all Serious incidents.

2.2 All providers including non-NHS providers are expected to report all serious incidents (including Never Events, and serious health-care associated infections) directly to their commissioners including any organisation or person that is accountable to the CCG through contracting and commissioning arrangements.

2.3 The CCG and all providers commissioned by the CCG will work in line with national requirements set out in the NHS England Serious Incident Framework 2015. http://www.england.nhs.uk/ourwork/patientsafety/serious-incident/

3.0 Purpose

3.1 The purpose of this policy is to ensure that all members, staff and/or employees working for or on behalf of the CCG are aware of their duties when reporting, investigating or managing incidents in relation to commissioned providers. It applies to all incidents whether they involve commissioned services, patients, carers, visitors, staff or members of the public and include property, premises, assets, information or any other aspect of the organisations business. It gives direction and organisational regulation so that managers are aware of their duties in the approval, management and investigation of incidents and key personnel are aware of their duties of reporting incidents to external bodies as appropriate. This policy aims to:

1. Ensure that all SIs are investigated in a timely, efficient and effective way.

2. Ensure compliance with national reporting requirements. 3. Ensure the CCG has an open and honest approach to provider

http://www.england.nhs.uk/ourwork/patientsafety/serious-incident/



incidents affecting patients/relatives/carers, and a commitment to sharing lessons learned.

4. Ensure lessons learned from incidents and trends are shared across the organisation and fully acted upon by commissioned providers.

5. Enhance learning and development through the application of good performance management principles.

4.0 Responsibilities

4.1 Accountable Officer The Accountable Officer has overarching responsibility for managing providers responses to SIs and where appropriate for commissioning and co-ordinating SI investigations.

4.2 CCG Board The CCG Board receives quality and performance reports regarding all provider SIs, trends, and lessons learned to ensure organisational learning and to prevent recurrence. It receives a summary of noteworthy investigations, including all Never Event investigations, with recommendations and actions in the confidential section of its meeting.

4.3 The CCG Committee with Responsibility for Quality The Committee with responsibility for quality receives quarterly summaries of the provider organisation’s SIs, action plans, monitoring arrangements, and lessons learned and receives assurance from the provider that the action taken to investigate the SI and to prevent future occurrences is appropriate, robust and in line with the policy.

4.4 The CCG Clinical Lead with Responsibility for Quality The Clinical Leads have corporate responsibility for the managing of the provider’s responses to SIs and for ensuring that Manchester CCGs have arrangements in place for managing the process of reporting and investigating SIs through STEIS within NHS provider services for which it is the co-ordinating commissioner. These arrangements include the grading of the incident, the quality of reporting, closure and monitoring the implementation of any action plans that arise from the SI.

4.5 The Shared Performance and Quality Team The Shared Performance and Quality Team has responsibility for managing the process that ensures that all commissioned providers are reporting, investigating, and taking action on Serious incidents in line with this policy.

4.6 Duties of commissioned organisations


All service providers have a requirement to report, investigate and monitor serious incidents as specified within contracts and put improvements in place to prevent recurrence.

5.0 Definitions of Terms Used

5.1 Serious Incidents (SIs) Serious Incident – serious incidents are events in health care where the potential for learning is so great, or the consequences to patients, families and carers, staff or organisations are so significant, that they warrant using additional resources to mount a comprehensive response. Serious incidents can extend beyond incidents which affect patients directly and include incidents which may indirectly impact patient safety or an organisation’s ability to deliver on going healthcare. There is no definitive list of events/incidents that constitute a serious incident and lists should not be created locally as this can lead to inconsistent or inappropriate management of incidents. Serious Incidents in the NHS include:

Acts and/or omissions occurring as part of NHS-funded healthcare (including in the community) that result in:

Unexpected or avoidable death1 of one or more people. This includes suicide/self-inflicted death;

homicide by a person in receipt of mental health care within the recent past2 (see Appendix 1);

Unexpected or avoidable injury to one or more people that has resulted in serious harm;

Unexpected or avoidable injury to one or more people that requires further treatment by a healthcare professional in order to prevent:— the death of the service user; or serious harm;

Actual or alleged abuse; sexual abuse, physical or psychological ill-treatment, or acts of omission which constitute neglect, exploitation, financial or material abuse, discriminative and organisational abuse, self-neglect, domestic abuse, human trafficking and modern day slavery where: healthcare did not take appropriate action/intervention to safeguard against such abuse occurring3; or where abuse occurred during the provision of NHS-funded care.

A Never Event - all Never Events are defined as serious incidents

1 Caused or contributed to by weaknesses in care/service delivery (including lapses/acts and/or omission) as opposed to a

death which occurs as a direct result of the natural course of the patient’s illness or underlying condition where this was managed in accordance with best practice. 2 This includes those in receipt of care within the last 6 months but this is a guide and each case should be considered

individually - it may be appropriate to declare a serious incident for a homicide by a person discharged from mental health care more than 6 months previously. 3 This may include failure to take a complete history, gather information from which to base care plan/treatment, assess

mental capacity and/or seek consent to treatment, or fail to share information when to do so would be in the best interest of the client in an effort to prevent further abuse by a third party and/or to follow policy on safer recruitment.


although not all Never Events necessarily result in serious harm or death. See Never Events Policy and Framework for the national definition and further information; An incident (or series of incidents) that prevents, or threatens to prevent, an organisation’s ability to continue to deliver an acceptable quality of healthcare services. ( see appendix 3 for the revised list of Never Events)

Major loss of confidence in the service, including prolonged adverse media coverage or public concern about the quality of healthcare or an organisation.

Near Miss- A situation during any activity that fails to develop further, whether or not, as the result of intervening action, but carried with it, the potential to cause harm (i.e. “it almost happened”). A Near Miss may also constitute an SI, in that it was an event that has the potential to cause harm or was prevented from causing harm to one or more individuals, damage to property, a security breach or confidentiality breach. Being Open - Open communication of patient safety incidents that result in harm or the death of a patient while receiving healthcare. Duty of Candour – a statutory requirement has been introduced to ensure health care providers operate in a more open and transparent way. The regulation for Duty of Candour applied to health service bodies from 27 November 2014. It has been extended to all other providers from 1 April 2015. This regulation requires an NHS body to:

Make sure it acts in an open and transparent way with relevant persons in relation to care and treatment provided to people who use services in carrying on a regulated activity

Tell the relevant person in person as soon as reasonably practicable after becoming aware that a ‘notifiable safety incident4’ has occurred, and provide support to them in relation to the incident, including when giving the notification.

Provide an account of the incident which, to the best of the health service body’s knowledge, is true of all the facts the body knows about the incident as at the date of the notification.

Advise the relevant person what further enquiries the health service body believes are appropriate.

Offer an apology.

Follow this up by giving the same information in writing, and providing

4 means any unintended or unexpected incident that occurred in respect of a service user during the provision of a

regulated activity that, in the reasonable opinion of a health care professional, could result in, or appears to have resulted in— (a) the death of the service user, where the death relates directly to the incident rather than to the natural course of the service user’s illness or underlying condition, or (b) severe harm, moderate harm or prolonged psychological harm to the service user


an update on the enquiries.

Keep a written record of all communication with the relevant person Never Events - Never Events arise from failure of strong systemic protective barriers which can be defined as successful, reliable and comprehensive safeguards or remedies e.g. a uniquely designed connector to prevent administration of a medicine via the incorrect route - for which the importance, rationale and good practice use should be known to, fully understood by, and robustly sustained throughout the system from suppliers, procurers, requisitioners, training units, and front line staff alike. The Department of Health (DoH) offers guidance on what constitutes a ‘Never Event’ and CCGs are required to monitor their occurrence within the services they commission. http://www.england.nhs.uk/patientsafety/never-events/ Root Cause Analysis (RCA) - A systematic process whereby the factors that contributed to an incident are identified. As an investigation technique for patient safety incidents, it looks beyond the individuals concerned and seeks to understand the underlying causes and environmental context in which an incident happened.

6.0 Process for Managing External (Provider) Serious Incidents

6.1 Procedure for Managing Provider Serious Incidents In the event of an incident the provider should enter all relevant and known details about the incident on the NHS serious incident management system (STEIS or its successor). The provider should inform the relevant CCG incident/quality lead5.

Where an incident arises in a small provider who does not have access to STEIS, the quality team will enter the incident into STEIS on their behalf. The principal accountability of all providers is to patients and their carers/families. This means that the first consideration following an SI must be the patient’s welfare. They must be cared for, their health and welfare secured, and they must be fully involved in the response to the SI. Where a patient has died or suffered serious harm, their family must be similarly cared for and involved. The Quality team will hold the provider to account in regard to the principles

of openness and honesty as outlined in the NHS Being Open guidance. The

NHS contractual Duty of Candour6 must be applied in discussions with those

5 Where there are multiple commissioning organisations involved, this Framework encourages providers and

commissioners to establish a lead commissioning model (wherever possible) so that the provider engages with one commissioner on a frequent basis. See Part Two, section 2 of this Framework for further details. 6 The Department of Health has introduced regulations for the Duty of Candour. It requires providers to notify

anyone who has been subject (or someone lawfully acting on their behalf, such as families and carers) to a ‘notifiable incident’ i.e. incident involving moderate or severe harm or death. This notification must include an appropriate apology and information relating to the incident. Failure to do so may lead to regulatory action.

http://www.england.nhs.uk/patientsafety/never-events/


involved. This includes staff and patients, victims and perpetrators, and their

families and carers.

The Serious Incident Framework (2015) states that there is no definitive list of

events/incidents that constitute a serious incident , and lists should not be

created locally as this can lead to inconsistent or inappropriate management

of incidents. However, the quality team have devised a minimum data set of

incidents that they would expect, as a minimum, to be reported by the

providers as a serious incident. This is to promote consistency across the

providers. Where a new area has been identified that the provider has not

traditionally been reporting against, there will be a phased approach taken to

allow the provider to implement.

An initial review (characteristically termed a ‘72 hour review’) should be

undertaken; this should be completed within 3 working days of the incident

being identified. The aim of the initial review is to:

Identify and provide assurance that any necessary immediate action to ensure the safety of staff, patients and the public is in place;

Assess the incident in more detail (and to confirm if the incident does still meet the criteria for a serious incident and does therefore require a full investigation); and

Propose the appropriate level of investigation.

The quality team will liaise with the provider, as a 72 hour review may not be required in all cases.

When a review is required, the 72 hour review should be put as an update into STEIS by the provider

The provider has to conduct an internal investigation and produce the

investigation report within 60 days. The quality team will review the

investigation report, and seek further assurances if required from the

provider. Once satisfied that the investigation report has captured the lessons

learned and recorded these within an action plan, the incident will be closed

on STEIS. It is the provider’s responsibility to update STEIS with the root

causes and the lessons learned. The quality team will then close the STEIS

form The quality team will seek assurance from the provider on the timeliness

of the completion of action plans.

Please refer to Appendix G for an overview of the process for managing Provider Serious Incidents.

6.2 Duties of organisations commissioned by the CCG to provide health services

Further information is available from http://www.cqc.org.uk/sites/default/files/20141120_doc_fppf_final_nhs_provider_guidance_v1-0.pdf

http://www.cqc.org.uk/sites/default/files/20141120_doc_fppf_final_nhs_provider_guidance_v1-0.pdf


All service providers commissioned by the CCG, either as a co-ordinating commissioner or associate, have a requirement to report, investigate and monitor incidents (including SIs) as specified within contracts and legislation. There are standardised NHS contracts for all service providers; the type of contract varies in relation to the size and function of the service provider. Within these contracts the requirement for the reporting, investigation and monitoring of incidents (including SIs) are outlined. As detailed within all standardised NHS contracts and explicit within legislation all service providers are required to report SIs to their lead CCG and to co-operate fully with any investigation (as directed by the CCG/NHS England). The CCG procedure for the monitoring and performance management of incidents (including SIs) within providers is attached as a schedule to all contracts the CCG holds with its service providers.

7.0 Process for Managing External Mental Health (City Wide) Serious Incidents

7.1 Procedure for Managing Provider Serious Incidents Mental Health services for Manchester patients are commissioned through a Citywide Commissioning, Quality and Safeguarding Team (Citywide Team). All incidents reported by providers of these services are reviewed and monitored by the Citywide Team. The principal accountability of mental health providers is to patients and their carers/families with wider considerations of others who may be affected. They must be cared for, their health and welfare secured, and the patient and their relative (as appropriate) must be fully involved in the review of the SI. Incidents are managed as per the guidance in the NHS England Serious Incident Framework at http://www.england.nhs.uk/ourwork/patientsafety/serious-incident/ Additionally, organisational accountabilities will underpin the response to SIs. Providers are accountable via contracts to their commissioners. The key organisational accountability for SI management is therefore from the provider in question to the commissioner. The system is regulated by the Care Quality Commission (CQC).

7.2 Duties of Organisations commissioned by the CCG to provide Mental Health Services All service providers are required to report, investigate and monitor incidents (including SIs) as specified within their contracts and legislation. There are standardised NHS contracts for all service providers; the type of



contract varies in relation to the size and function of the service provider. Within these contracts the requirements for the reporting, investigation and monitoring of incidents (including SIs) are outlined. As detailed within all standardised NHS contracts and explicit within legislation all service providers are required to report SIs to their lead CCG and to co-operate fully with any investigation (as directed by the CCG/NHS England). The CCG procedure for the monitoring and performance management of incidents (including SIs) within providers is attached as a schedule to all contracts.

8.0 Process for Approval & Ratification

8.1 This policy will be approved and ratified at the CCG Joint Governance Committee.

9.0 Dissemination, Training & Advice

9.1 Once ratified this policy will supersede all previous incident reporting policies and procedures. In order that this policy is disseminated and implemented correctly the following will occur after ratification:

The policy will be published on the CCG website and relevant links sent out via the communications and engagement department.

Manchester Matters will include a link to this policy.

The Datix risk management training is designed to match this policy and attendees are made aware of this policy.

Senior managers will make their staff aware of this policy when questioned about incidents.

Advice can be sought from the Corporate Services Team.

10.0 Review, Monitoring and Compliance

10.1 The policy will be reviewed every 3 years unless there is a significant change in legislation or process which requires an urgent change in procedure.

10.2 Monitoring External (Acute Provider) Serious Incidents Process The Clinical Lead with the responsibility for Quality will maintain the policy in conjunction with the Shared Performance and Quality Team The effectiveness of this policy will be monitored by routine reporting, actions taken and other aspects of the service by the CCG’s Committee responsible for Quality.

10.3 Monitoring External (Mental Health Provider) Serious Incidents Incidents reported by Mental Health Providers will be monitored by the


Citywide Commissioning, Quality and Safeguarding Team. Where possible a member of the team will attend the investigation meetings and seek assurance on actions taken and planned. Incidents logged by providers will be reported via the Citywide Patient Safety Committee for review and agreement of closure on StEIS.

11.0 References

11.1 NHS England (March 2015) Serious Incident Reporting Framework 2015 http://www.england.nhs.uk/ourwork/patientsafety/serious-incident/

National Health Service Litigation Authority (NHSLA) Risk Management Standards

The Mid Staffordshire NHS Foundation Trust Public Inquiry (Francis Report, 2013)

Department of Health (2000) “An Organisation with a Memory: Report of an Expert Group on Learning from Adverse Events in the NHS”

Organisation with Memory: Building a Safer NHS (2001)

A Promise to Learn – a Commitment to Act: Improving the Safety of Patients in England (Berwick Report, 2013)




Appendices

Appendix A- The Never Events List 2015/16

The following never events list is the list that all organisations providing NHS care

should use. It is applicable for all incidents that occur on or after 1 April 2015.

There are 14 Never Events in 2015. This has been reduced from the previous 25 for the following reasons: Firstly the purpose and definition of a Never Event has been revised in the latest version of the Framework. This is to provide greater emphasis that a Never Event arises from failure of strong systemic protective barriers. Several of the previous Never Events do not meet the updated definition and have therefore been removed from the list. This does not mean they are not considered to be patient safety priorities but that they do not meet the revised definition of a Never Event.

Please see the guidance on Never Events here


Appendix B Assigning Accountability: RASCI model 1. Providers of NHS funded care often deliver services commissioned by different

commissioning organisations. These may include, NHS England, multiple CCGS

and Local Authorities. This can lead to uncertainty and ambiguity in relation to

serious incident management.

2. Therefore, within each provider (where there are multiple commissioners), it is

recommended that a ‘lead commissioner’ (usually the commissioner with the

greatest contract value) is identified to lead oversight of serious incident

management across the organisation. This should be formally agreed for each

contract (e.g. through a collaborative agreement).

3. Accountable commissioners (i.e. contract signatory) must work collaboratively with

and through other commissioners, to ensure the reporting arrangements are

included within contracts. Whilst they may delegate responsibilities for serious

incident management to other commissioners they remain accountable for quality

assuring the robustness of the serious incident investigation, learning and action

plan implementation undertaken by their providers.

4. It is recommended that each contract should have a RASCI (Responsible;

Accountable; Supporting; Consulting; Informed) matrix (see table below) to

support the robust and effective oversight management of serious incidents. The



matrix must clearly identify the Accountable (Contracting) Commissioner (whether

NHS England or a CCG) regardless of any delegation of management

responsibilities.

5. Where serious incidents occur within services without a RASCI model, it is

recommended that a model is developed and agreed by the relevant

commissioning organisations to ensure roles and responsibilities in relation to

managing the incident are clearly set out.

6. Involving NHS England as direct commissioners:

a. NHS England has direct commissioning responsibilities7 which are

discharged via its sub-regions. The commissioning functions within the

sub-regions vary (some have specific functions in commissioning

specialised services or healthcare within the health and justice system

for example). Wherever possible however, NHS England is working

towards a consistent approach where quality and safety concerns are

managed at a local level providing this is feasible given the level of local

resource and expertise to manage such concerns.

b. The functions of NHS England Sub-regions are described as follows:

Originating Sub-region – Sub-region where the patient comes from

Geographical Host Sub-region (or Local Sub-region) – the Sub-region in whose local boundary a service is located.

Functional Host Sub-region – Sub-regions with additional commissioning responsibilities i.e. specialised commissioning. These Sub-regions have an extended functional boundary. For specialised commissioning it has been agreed that the Functional Host will support the Geographical host to manage responsibility for quality concerns. The Functional Host will therefore populate a RASCI template (Responsible; Accountable; Supporting;Consulting; Informed) for each provider within their “functional” area in readiness to support the Geographical Host Sub-region to undertake their quality assurance functionsi

Accountable (contracting) Sub-region – the Sub-region which

negotiates and holds the contract for NHS England and is accountable

for quality assuring the robustness of the serious incident investigation,

learning and action plan implementation undertaken by their providers

accountable for the quality of the services. This Sub-region may also

be the geographical and/or functional host. 7 GP services, community pharmacy, and primary ophthalmic services (mainly NHS sight tests); all dental

services - primary, community, hospital; specialised services; high-secure psychiatric services; offender health; some aspects of healthcare for members of the armed forces and their families; and public health services (screening, immunisation, services for children aged 0-5 including health visiting) on behalf of Public Health England


7. In some circumstances the originating, geographical host, functional host and accountable (contracting) Sub-region are all located in different Sub-regions and in such circumstance a RASCI model proves fundamental for ensuring serious incident are appropriately managed.

Who? Definitions

R Responsible Doer - The team assigned to do the work

A Accountable Buck stops here - make the final decision and/or have

ultimate ownership

S Supporting Here to help - support other teams in undertaking their

quality assurance functions

C Consulted In the Loop - should be consulted before a decision or

action is taken

I Informed For Your Information – should be informed that a

decision or action has been taken

Appendix C Overview of the investigation process This schematic provides a brief overview of a systems investigation for investigating serious incidents in the NHS. It requires a ‘questioning attitude that never accepts the first response’,ii and uses recognised tools and techniques8 to identify:

o The problems (the what?) including lapses in care/acts/omissions; and o The contributory factors that led to the problems (the how?) taking into

account the environmental and human factors; and o The fundamental issues/root cause (the why?) that need to be addressed.

8 The investigation toolkit which can be accessed from https://report.nrls.nhs.uk/rcatoolkit/course/index.htm provides a

wealth of tools, techniques and resources to support each stage of the investigation.

https://report.nrls.nhs.uk/rcatoolkit/course/index.htm


Those

involved

(includin

g

patients,

staff,

victims

perpetra

tors and

their

families/

carers)

must be

informed

,

involved

and

supporte

d

appropri

ately

through

out

Opport

unities

for

sharing

safety

critical

informa

tion and

learning

must be

shared

through

out

The investigation should be underpinned by a clear terms of reference, robust management plan and

communication/media handling strategy (as required)


Appendix D – Equality Analysis

GMCSU Equality Analysis Form

The following questions will document the effect of your activity on equality, and demonstrate that you have paid due regard to the Public Sector Equality Duty. The Equality Analysis (EA) guidance should be used read before completing this form.

To be completed at the earliest stages of the activity and before any decision making and returned via email to [email protected] :

Section 1: Responsibility

1 Name & role of person completing the EA:

Natalie Davies Corporate Governance Manager

2 Service/ Corporate Area Corporate Governance

3 Head of Service or Director (as appropriate):

Nick Gomm

4 Who is the EA for? Manchester Central CCG

4.1 Name of Other organisation if appropriate

All Manchester CCGs

Section 2: Aims & Outcomes

5 What is being proposed? Please give a brief description of the activity.

Incident Reporting Policy Policy on the reporting and management of incidents within the CCG.

6 Why is it needed? Please give a brief description of the activity.

To ensure a learning culture with regard to all nature of incidents and near-miss incidents within the CCG. This may relate to incidents involving CCG staff – for example health and safety. The policy also relates to incidents within commissioned provider services. The Incident Policy is part of the CCG responsibility to ensure that patients receive safe care and that serious incidents are managed and monitored appropriately.

7 What are the intended outcomes of the activity?

Identification and appropriate management of risk across the CCG. Appropriate management of provider serious incident information. Encouragement of an open and honest culture of reporting incidents across the CCG to enhance the opportunity to learn.

8 Date of completion of analysis (and date of implementation if different). Please explain any difference

August 2015.

mailto:[email protected]


9 Who does it affect? Select from the drop down box. If more than one group is affected, use the drop down box more than once.

All CCG staff

Establishing Relevance to Equality & Human Rights

10 What is the relevance of the activity to the Public Sector Equality Duty? Select from the drop down box and provide a reason.

General Public Sector Equality Duties Relevance (Yes/No) Reason for Relevance

To eliminate unlawful discrimination, harassment and victimisation and other conduct prohibited by Equality Act 2010

Yes Reporting of any unlawful discrimination, harassment, victimisation and other conduct via the incident policy and investigation of such conduct.

To advance equality of opportunity between people who share a protected characteristic and those who do not.

Yes Reporting of discrimination and investigation of such conduct.

To foster good relations between people who share a protected characteristic and those who do not

Yes As above.

10.1 Use the drop down box and advise whether the activity has a positive or negative effect on any of the groups of people with protected equality characteristics and on Human Right

Protected Equality Characteristic Positive (Yes/No)

Negative (Yes/No)

Explanation

Age Yes No The policy encourages reporting and investigation of any incident relating to the protected equality characteristics of CCG employees and members or service users.

Disability Yes No The policy encourages reporting and investigation of any incident relating to the protected equality characteristics of CCG employees and members or service users.

Gender Yes No The policy encourages reporting and investigation of any incident relating to the protected equality characteristics of CCG employees and members or service users.


Pregnancy or maternity Yes No The policy encourages reporting and investigation of any incident relating to the protected equality characteristics of CCG employees and members or service users.

Race Yes No The policy encourages reporting and investigation of any incident relating to the protected equality characteristics of CCG employees and members or service users.

Religion and belief Yes No The policy encourages reporting and investigation of any incident relating to the protected equality characteristics of CCG employees and members or service users.

Sexual Orientation Yes No The policy encourages reporting and investigation of any incident relating to the protected equality characteristics of CCG employees and members or service users.

Other vulnerable group Yes No The policy encourages reporting and investigation of any incident relating to the protected equality characteristics of CCG employees and members or service users.

Marriage or Civil Partnership Yes No The policy encourages reporting and investigation of any incident relating to the protected equality characteristics of CCG employees and members or service users.

Gender Reassignment Yes No The policy encourages reporting and investigation of any incident relating to the protected equality


characteristics of CCG employees and members or service users.

Human Rights Yes No The policy encourages reporting and investigation of any incident relating to the protected equality characteristics of CCG employees and members or service users.

If you have answered No to all the questions above and in question 10, explain below why you feel your activity has no relevance to Equality and Human Rights.

Section 4: Equality Information and Engagement

11 What equality information or engagement with protected groups has been used or undertaken to inform the activity. Please provide details.

Details of Equality Information or Engagement with protected groups

Internet link if published & date last published

N/A

11.1 Are there any information gaps, and if so how do you plan to address them

None

Section 5: Outcomes of Equality Analysis

12 Complete the questions below to conclude the EA.

What will the likely overall effect of your activity be on equality?

None, other than the ability of all staff to report any incidents relating to E&D.

What recommendations are in place to mitigate any negative effects identified in 10.1?

None identified.

What opportunities have been identified for the activity to add value by advancing equality and/or foster good relations?

As above.

What steps are to be taken now in relation to the implementation of the activity?

Continue the policy.

Section 6: Monitoring and Review

13 If it is intended to proceed with the activity, please detail what monitoring arrangements (if appropriate) will be in place to monitor ongoing effects? Also state when the activity will be reviewed.

Monitoring of policy changes.

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