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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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