Surrey & Sussex Healthcare NHS Trust

Transcription

1 Surrey & Sussex Healthcare NHS Trust An Organisation-wide Health and Safety Policy Version 3 Status Ratified Date Ratified 15/06/2011 Name of Owner Name of Sponsor Group Name of Ratifying Group Type of Procedural document Health & Safety Manager Health & Safety Committee Management Board for Quality & Risk Policy Policy Reference 0185 Date issued Jun 2011 Review date Jun 2014 Target audience Human Rights Statement EIA Status All staff The Trust incorporates and supports the human rights of the individual, as set out by the European Convention on Human Rights and the Human Rights Act 1988 Completed This policy is available on request in different formats and languages from the Policy Coordinator / PALS. The latest approved version of this document supercedes all other versions. Upon receipt of the latest approved versions all other version should be destroyed, unless specifically stated that the previous version(s) are to remain extant. If in any doubt please contact the document owner or Policy Coordinator. Page 1 of 24

2 Contents Page Number 1. Introduction 4 2. Purpose 4 3. Definitions 5 4. Duties 6 5. Section Headings/Content Consultation and Communication with Stakeholders Approval and Ratification Review and Revision Arrangements Dissemination and Implementation Archiving Arrangements Monitoring Compliance References Associated Documents 20 Appendices 1. Equality Impact Assessment Change history Version Date Author/Procedure Lead Details of change 1 23/07/07 Colin Pink Change format and update committee structure 2 11/01/2010 Diane Mahoney Grammatical/error amendments/title changes/format changes. 3 04/04/2011 Diane Mahoney Additions required resulting from the HSE 2010 inspection. Page 2 of 24

3 Statement of Intent Surrey and Sussex Healthcare NHS Trust is committed to ensure as far as is reasonably practicable the health, safety and welfare of every person including volunteers, who are involved in the activities of the organisation. The intention to minimise risks to all staff, while at work and to others whilst on Trust property is an integral element of the Trust s Risk Management Strategy. The successful application of this policy will be achieved through a strategy to provide ongoing planning, organisation, control, monitoring and review of the health and safety risks. In this way the Trust demonstrates its commitment to abiding by health and safety legislation. The provision of a safe working environment is an essential requirement for the delivery of an effective and efficient healthcare service. The purpose of this strategy is: i) To protect people from injury and ill health at work. ii) iii) To maintain and improve performance as an employer. To maintain and improve the communication of health and safety values and beliefs throughout the organisation. The Trust Board acknowledges that effective health and safety management is a key organisational objective and is of equal importance with the financial, operational and healthcare delivery objectives of the Trust. The allocation of responsibilities for putting this into place is outlined in the document Health and Safety Policy. The Policy will be implemented through the provision of safe systems of work covering the known risks in the Trust. These will apply Trust wide supplemented as necessary by local safe systems of work. This strategy and policy will be reviewed regularly to reflect organisational change. Signed: Dated: Michael Wilson, Chief Executive Page 3 of 24

4 1. Introduction The Trust Board aims to fully discharge its statutory and management responsibilities for health and safety. The Health and Safety at Work etc. Act 1974 places a legal duty on employers to provide for the health and safety of their employees. The purpose of this policy is to ensure that the Trust complies with all Health and Safety Legislation required by ensuring that: All risks to the health and safety of staff patients and all members of the public are risk assessed Where reasonably practicable all risks are controlled Effective planning is concerned with the prevention of risks through elimination or control Arrangements are made for implementing a comprehensive system of safety management, including providing adequate information and training. 2. Purpose Health and safety management needs to do more than just prevent work-related harm. It must also promote best practice in the provision of better working environments. Through this policy the Trust aims to achieve best practice in health and safety management through the following goals: To promote a safe and secure environment that protects patients, staff, visitors and their property, and the physical assets of the organisation. To achieve effective management of health and safety risks through the application of suitable and sufficient risk assessment process and ongoing control, monitoring and review of the health and safety risks identified through risk assessment. To achieve compliance with statutory and mandatory requirements and with professional regulation. Page 4 of 24

5 To provide ongoing delivery of high quality education and training in health and safety and risk management skills. 3. Definitions Competent To be competent a person must have the required knowledge, ability, training and experience to carry out the required task. Hazard Anything with the potential to cause harm or adverse effects. Reasonably practicable (so far as is reasonably practicable) Ensuring a risk has been reduced so far as is reasonably practicable, is an assessment which involves weighing the risk against the sacrifice needed to further reduce it. The process is one of adopting measures to reduce risk except where they are ruled out because they involve grossly disproportionate sacrifices (time or money). The decision is weighted in favour of health and safety because the presumption is that the duty-holder should implement the risk reduction measure. For example; to spend 1m to prevent five staff suffering bruised knees is not reasonably practicable; but to spend 1m to prevent a major fire capable of killing 100 s of people is reasonably practicable. The overall process of risk analysis and risk evaluation - which involves measurement of risk to determine priorities and to enable identification of appropriate level of risk treatment or control measures. Risk management Risk management is the process of assessing the risks that an organisation is exposed to, putting in place measures to control these risks and ensuring they work in practice. Safe systems of work A formal process for an activity that ensures that all hazards which are not eliminated, are controlled to the lowest level practicable by using an agreed working methodology identified by risk assessment. Page 5 of 24

6 Statutory Required or prescribed by statute law or regulation. 4. Duties All staff, volunteers and contractors Risk Management To take reasonable care for themselves and others by assessing the risks arising from work activities. To participate in the risk assessment process. To read and understand the written risk assessments for their area, and clarify points of uncertainty with their manager (translation services available if required) Safe Systems of Work To work in a safe manner at all times. To follow safe practice laid down in their work area. To be aware of the risks identified in risk assessments and ensure that best practice and guidelines are followed Equipment / Resources To use equipment appropriate for the task. To use equipment in accordance with training received. Not to use faulty equipment. Not to recklessly or wilfully interfere or misuse anything provided for health and safety Training To attend induction and other health and safety training sessions and keep up to date with current statutory and personal professional training. To put the knowledge gained through training into practice Reporting / Communication To report any hazards, dangers or unsafe situations and shortcomings in the arrangements provided for safety to the person-in-charge and/or safety representative. Page 6 of 24

7 To report all accidents and incidents on the Trust All Purpose Report Form and inform the person in charge. To report any faulty equipment to the person in charge and take it out of use immediately. To report any health issues affecting their ability to work safely. To keep up to date with information / changes in procedures. 4.2 Responsibilities of Ward/Departmental Managers Risk Management To carry out risk assessments to identify hazards and the measures that are needed to reduce these risks to the lowest level reasonably practicable in their area of responsibility using the appropriate risk assessment process. Risk assessments must be recorded and used to develop safe systems of work and for dealing with foreseeable emergency situations. To identify appropriate personnel to undertake Risk Assessment training For trained and competent risk assessors to be responsible for entering their risks onto the Risk Register. To review local risks on the Register. To seek advice from Trust Specialist Advisors, especially to verify levels of risk and to identify need for personal health surveillance. To implement the measures needed to control the risks as far as their authority will allow following the guidance provided in the Risk Assessment Policy and the Risk Management Strategy. Any control measures that cannot be implemented must be brought to the attention of the appropriate Divisional Chief Nurse in accordance with Trust guidance. To agree a time frame and action to be taken with the Divisional Chief Nurse To take any unresolved issues to the Directorate Safety Group. To ensure all staff and others, including contractors and visitors, are informed of the risks relevant to them and the measures put in place to reduce the risks. Guidance on this can be found in the Risk Assessment Policy. To monitor / audit the outstanding risks to ensure progress is made to reduce them Safe Systems of Work To ensure that there are safe procedures for staff to follow. To train and instruct staff on the guidelines in place for their safety. Page 7 of 24

8 To regularly audit staff compliance to safe systems of work, and take action if unsafe practices are observed. To monitor and review accident statistics and take appropriate action to reduce identified trends. To write local guidelines, if required, to control identified risks specific to their area of control e.g. substances hazardous to health, violence, equipment and manual handling Equipment / Resources To ensure sufficient equipment is available to reduce identified risks, so far as is reasonably practicable. To ensure equipment is maintained in good condition with planned maintenance by the relevant department/contractor and with a replacement programme. To remove from use unsafe equipment until repaired Training To ensure staff are trained to understand and avoid risks To ensure staff are given adequate time off for training and that staff attend. To keep records of training whether it takes place in or outside their area. To ensure consideration is given to the health and safety training needs of staff at Performance and Development Reviews Reporting / Communication To ensure incidents are reported through the Trust s Incident Report Form and remedial action is taken. To report accidents which come under The Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) to the Health & Safety Manager as soon as possible after the event but within 8 working days. To receive and discuss with staff and Safety Representatives / Coordinators accident and incident report data. To inform Occupational Health of staff who have time off / leave from work as a result of an accident or ill health, or who have a condition which affects their ability to carry out their work safely. To support and consult any safety representatives / coordinators and allow them time for training and to carry out their duties. To respond in writing to any reports from safety representatives / coordinators regarding health and safety matters. Page 8 of 24

9 To ensure all members of staff see a copy of this and other relevant policies and sign to say they have read and understand their role. To ensure that staff have understood and put into practice safe systems of working that apply to the tasks they undertake as part of their work. To ensure their staff are able to understand this policy and where necessary other formats or languages are available from the Policy Coordinator Bank / Agency Staff To ensure they are informed of risks and have received adequate training and supervision relevant to the tasks they are expected to perform, or are told not to perform certain tasks. To assess their capability and competency at the beginning of their duty, using a checklist and inform staff of any relevant issues. 4.3 Responsibilities of Directors and Divisional Chief Nurses Risk Management To audit risk assessments and action plans annually. To review and update local and Divisional risks on the Risk Register. To determine the process for the implementation of action plans taking into account the requirements of the Risk Management Strategy. To agree health and safety plans for controlling risks and sustaining a positive health and safety culture To seek advice from specialist risk and safety advisors as and when required. Any areas of concern which cannot be dealt with at their Divisional Safety Group should be referred to the Trust Health and Safety Committee Safe Systems of Work To ensure Divisional/Directorate safe systems of work are regularly reviewed Equipment / Resources To ensure staff have access to equipment required to safely carry out their tasks. Page 9 of 24

10 To do all that is reasonably practicable to identify funding / resources to resolve any risks in their Directorate. To ensure pre-planned maintenance has been carried out on equipment and that a planned replacement program is in place Training To audit training records to ensure staff have received appropriate training. To ensure all staff are competent to carry out their health and safety responsibilities through appropriate training. To ensure consideration is given to the health and safety training needs of staff at Performance and Development Reviews Reporting / Communication To set up, promote and chair the Directorate Safety Group meetings to which safety representatives and managers bring problems to be resolved. A Director may appoint a deputy to chair the Safety Group. Sufficient authority must be given to act on behalf the Director on matter relating the management of health and safety. To attend Trust Health and Safety Committee meetings to bring forward issues unresolved at Directorate meetings. To receive and respond to reports from managers and safety representatives on health and safety issues. To receive and disseminate health and safety information to all departmental staff within their area of control. To monitor managers health and safety performance through the Performance and Development Review process. To ensure that health and safety responsibilities are included and clearly laid out in all job descriptions. To receive and review accident statistics for their area of control and take action to reduce identified trends / risks. 4.4 Responsibilities of Board Member with Corporate Responsibility for Health and Safety Risk Management To ensure health and safety auditing takes place on a regular basis, and that identified issues are resolved. To review outstanding risk assessments with Divisional Chief Nurses and agree action plans to reduce the risk. Page 10 of 24

11 To seek advice from specialist risk and safety advisors as and when required. To attend the appropriate quality and risk meetings to ensure that strategies are put in place to resolve organisational risks. To ensure that health and safety risks are appropriately recorded on the Trust Risk Register and that action plans are identified, funded, reviewed and implemented Safe Systems of Work To receive reports from Trust managers regarding accidents/incidents with organisational risk implications and make recommendations to the Trust Board Equipment / Resources To support managers and directors in doing all that is reasonably practicable to identify funding and/or resources to resolve areas of outstanding risk, discussing issues with the Trust Board as appropriate Training To ensure there are adequate arrangements for the identification of health and safety training needs to satisfy the statutory and mandatory responsibilities of the Trust Board. To ensure there is adequate provision of health and safety training for all members of staff. To ensure that all health and safety training for each staff member is recorded on a Trust training database Reporting / Communication To be Chair of the Trust Health and Safety Committee. To report relevant issues to the Chief Executive / Management Board for Quality and Risk / Trust Board as appropriate. To present the Annual Trust Health and Safety Report to Trust Board and advise on a programme of action to control risks. 4.5 Responsibilities of Chief Executive and Trust Board It is the responsibility of the Chief Executive to ensure that the necessary arrangements are in place to satisfy relevant statutory provision Page 11 of 24

12 regarding the health and safety and welfare of all affected by the conduct of the Trust s activities The Chief Executive will in co-operation with the Trust Board; Regularly review the Risk Register entries for significant health and safety risks and take the necessary action Through the risk register and each Director will report to the Trust Board, actions taken to address risk assessments, together with their proposed action plans. Make appropriate allocation of funds / resources to effectively manage health and safety risks. Ensure the development of effective health and safety policies. Ensure appropriate organisation and development of plans for the management of health and safety. Measure and monitor the performance of the organisation against agreed standards/targets. Ensure that regular audits are undertaken and regularly reviewed to be confident that lessons are learnt from all relevant experiences and applied to the improvement of health and safety performance. Ensure that the Trust complies with its legal requirements under relevant statutory health and safety provision. Encourage the development of a positive safety culture throughout the Trust. Receive the annual Health and Safety Report and act on its recommendations. 4.6 Responsibilities of Trust Specialist Advisors These are competent persons as defined in Regulation 7 of the Management of Health and Safety at Work Regulations e.g. Risk Managers, Health and Safety Manager/Officer, Fire Officers, Back Care Advisors, Infection Control Advisors, Radiation Protection Supervisors/Advisor, Security Manager and Occupational Health Advisors Risk Management To participate in risk assessment / inspection within their area of expertise when asked for their advice by a manager, link persons or safety representative or Coordinator, or if an area of risk is identified. To discuss necessary action plans with the manager(s) so they can implement the appropriate measures or report to their line manager if outside their authority. Page 12 of 24

13 Report monthly to the Board on performance targets ensuring compliance with agreed standards To carry out an ongoing programme of audits throughout the Trust to; identify hazards and trends; evaluate whether this policy and guidelines are being adhered to; and advise on how to comply with the law To participate in the development of health and safety plans to ensure compliance Safe Systems of Work To work with staff to devise safe systems of working for employees exposed to risks. To assist managers to implement the safe working practices Equipment / Resources To advise on suitable equipment and design of areas to reduce risks within the Trust, trying where possible to standardise on products. To evaluate new products as required in conjunction with the appropriate person Training To participate in the Trust Induction training programme for all new staff. To provide Risk Assessment/Risk Register training to 'link staff' in wards / departments so they can assist in risk assessment and demonstrate safe practice to others. To keep comprehensive records of training which they facilitate. To keep up to date with relevant bodies Continuous Professional Development. To provide regular suitable refresher training to all employees Reporting / Communication To report to managers / Risk Manager(s) / Health and Safety Committee areas of risk where action is required. To receive copies of accident reports relevant to their area of expertise, and action / investigate, if necessary. To be a member of the Trust Health and Safety Committee, and be coopted onto other groups as necessary. Page 13 of 24

14 To disseminate relevant information to staff members via Trusts formal channels and Health and Safety Committee. In addition, the role of the Health & Safety Manager is to report all accidents, incidents or dangerous occurrences coming under the scope of RIDDOR to the Health and Safety Executive. 4.7 Responsibilities of Link Staff Link staff are nominated by their ward / departmental manager, who undertake extra training and assist in the management of a specific risk in their area, i.e. infection control / manual handling / risk assessment Risk Management To undertake Risk Assessment training to assist the manager to carrying out local risk assessments. To assist the manager to audit areas of risk. To identify hazards related to their higher level of knowledge and bring such hazards to the attention of their manager / Health & Safety Manager Safe Systems of Work To be able to demonstrate safe practice to colleagues. To be able to monitor and supervise colleagues to ensure that safe systems of work are followed. To assist in the implementation of guidelines to reduce the risks to the lowest level reasonably practicable Equipment / Resources To encourage the safe use of equipment. To advise their manager of any equipment that is needed to reduce risks. To evaluate new products in their area in conjunction with the Trust s specialist advisors Training To attend training sessions to maintain competency in Link Staff responsibilities. Page 14 of 24

15 To advise their manager which staff need to attend training sessions and assist in giving on the job training Reporting / Communicating To report to the person in charge any areas of concern. To liaise with Trust risk and safety advisors, to receive new information and discuss problems and disseminate this information to staff in their area. 4.8 Role of Safety Representatives / Coordinators These may be locally elected staff or appointed by a trade union to represent specific geographical and Divisional areas of the Trust. They have the right in law to carry out certain functions on behalf of those they represent, as outlined below, but there are no statutory responsibilities attached to this role Risk Management To advise their manager / colleagues of any risks or unsafe practices reported or observed in their place of work, so that remedial action can take place. To assist the manager, if trained to do so, in the process of assessing risk. To carry out safety inspections in their area of work in conjunction with their manager. To be involved in audit process for compliance with health and safety legislation Safe Systems of Work If they have reported to them unsafe practices within their area of work they should report this to their manager for action. To assist in implementing safe systems of work Equipment / Resources To encourage staff to use equipment provided in their area. To advise their manager of any equipment that is needed to reduce risks. Page 15 of 24

16 4.8.4 Training To attend appropriate health and safety training and put the knowledge gained into practice. To advise their manager of staff training needs Reporting / Communication To receive copies of all accident / incident reports which have been reported by the staff they represent, so that they may investigate the reasons for the accidents and make recommendations to their manager to prevent recurrence. To discuss any areas of concern with Trust risk and safety advisors, as appropriate. To attend the Divisional safety group meetings and Safety Representatives Forum and disseminate any information back to their staff. To attend the Trust Health and Safety Committee on behalf of their Directorate. To act as a point of reference for Trust Safety Advisors. To meet with Health and Safety Executive Inspectors / Environmental Health Officers if they visit their department, and receive any reports from them. 5. Section Headings / Content Arrangements for Health and Safety Consultation Consultation with staff is essential if the management of health and safety is to be effective. The following structure will provide opportunities for the involvement of a wide number of staff Quality and Risk Management Board To receive reports from the Health and Safety Committee for action. To ratify policies consulted on at Health and Safety Committee To make strategic recommendations regarding health and safety issues to Trust Board Trust Health and Safety Committee The Trust has established a Health and Safety Committee as the main forum for dealing with health and safety management issues. The Committee is also used to meet the statutory requirement to consult staff representatives on health and safety issues. Page 16 of 24

17 To receive reports from members of the Directorate Health and Safety groups, advisors and health and safety groups for action, and pass on any unresolved risks to the Quality and Risk Management Board. To monitor the health and safety performance of the Trust. To review accident / incident statistics and take appropriate action if specific accident trends are identified. To agree the Annual Report for Trust Board reporting on the year s progress and giving recommendations, on high risk areas, for the coming year. To review policies prior to Quality and Risk Management Board / Trust Board approval. The Health and Safety Committee, with the agreement of the Quality and Risk Management Board, will produce Terms of Reference reflecting its role and the needs of the organisation. The Health and Safety Committee will meet every 2 months Divisional and Service Safety Groups To meet as necessary to receive reports from Safety Representatives / Coordinators and managers so that issues can be resolved. Any unresolved issues should be referred to the Trust Health and Safety Committee. To monitor accident statistics to identify any trends, hazardous practices or faulty equipment so that appropriate action can be taken to eliminate or minimise risks. The Group will produce its own Terms of Reference reflecting its role and the needs of the organisation Departmental Health and Safety Groups These may be convened where there are highly specialised areas needing detailed work to be carried out, which are outside the remit of the Divisional or Service Group. The remit may be to consider specific hazards, to write and implement risk assessments or to deal with specific projects at a local level where staff can get involved in the changes. 5.2 Cooperation and Coordination with other employers The Management of Health and Safety at Work Regulations 1999 places a duty on employers that share premises to cooperate and coordinate in matters that relate to the health, safety and welfare of employees. In order to fulfill this duty the Trust will ensure: Cooperation in identify risks that affect each others staff. Page 17 of 24

18 To bring to the attention of others the arrangements the control measures to reduce the risk. To work together to ensure safe systems of work are consistently applied. To coordinate the allocation of resources to manage health and safety where each employers staff may be affected. To cooperate and coordinate the provision of health and safety training where each employers staff are affected. To report untoward events affecting each other staff, patients and property when the untoward event takes place in the other employers area of control. To share untoward event details to ensure adequate information is available to each employer. To ensure adequate liaison between each employer s Health and Safety and other risk managers and advisors. 6. Consultation and Communication with Stakeholders The key internal stakeholders for the purposes of this policy are all staff and managers. It is the responsibility of the Health and Safety Manager to ensure proper consultation and communication processes are in place between key internal stakeholders. The key external stakeholders for the purposes of this policy are the Health and Safety executive and the NHS Litigation Authority (NHSLA). It is the responsibility of the Health and Safety Manager to ensure proper consultation and communication processes are in place with key external stakeholders. 7. Approval and Ratification The Trust Health and Safety Committee will provide the route for consultation for all health and safety policies as members are representatives of management, staff, unions and specialist advisors. The Quality and Risk Management Board will ratify this policy. 8. Review and Revision This policy will be reviewed in line with the Trust Policy on Management and Development of Procedural Documents; the standard length of time for review is three years. However, changes within the organisation affecting this process, together with any changes in legislation or the requirements of external regulators /accreditation organisations may prompt the need for revision before the 3 year natural expiry date. Page 18 of 24

19 9. Dissemination and Implementation One essential ingredient of an effective policy is how it is communicated to staff. Below are some of the channels, through which the policy will be communicated and implemented. The electronic news bulletin will be used to promote and disseminate the strategy. All associated policies are available on the Trust Intranet and are referenced in this document. Formal training and education sessions will be set up and directed through the Trusts Health and Safety trainers through a planned programme in liaison with the Trust's Training and Education Department Clinical Directors, Executive and Non-Executive Directors should have a sound working knowledge of the policy through the Trust Board approval of this document. Divisional Chief Nurses, Ward Managers, Heads of Service, Senior Nurses will be expected to hold a hard copy of the policy since they have a key responsibilities in health and safety management. Awareness of the policy is included in Corporate Induction The Trust Welcome Day. 10. Archiving The policy will be held in the Trust database, known as the library and archived in line with the arrangements in the Organisation wide Policy for the Management and Development of Procedural Documents. Working copies will be available on request from the Policy Coordinator by contacting the dedicated mailbox trustpolicies@sash.nhs.uk 11. Monitoring compliance The policy will be monitored by the Environmental Safety Department for its effectiveness by: undertaking an annual audit producing incident rate reports for Divisional/Directorate Management meetings comparing incident statistics within the different work areas and Trustwide Page 19 of 24

20 12. References 12.1 Legal framework Health and Safety at Work, etc. Act 1974 Management of Health and Safety at Work Regulations Associated Documents Risk Assessment Policy The Risk Management Strategy An Organisation wide Policy and Procedures for Incident Reporting and Investigation An Organisation wide Policy for Health and Safety Consultation in the Workplace Management of Risk a Strategic Overview. (The Orange Book), HM Treasury, January Revised Risk Assessment Standards (Draft). National Health Service Litigation Authority, December Standards for Better Health. Healthcare Commission, Managing Risk in Healthcare. Dr Vanessa Mayatt (2nd ed.), Directors responsibilities for health and safety. Health & Safety Commission, A Safer Place to Work. National Audit Office, Management of Health & Safety in the Health Services. Health Service Advisory Committee, Revitalising Health & Safety Strategy Statement. Health & Safety Executive. June Page 20 of 24

21 Appendix 1: Equality Impact Assessment Stage One: Screening for Relevance to Equality Strands and Prioritising Names of assessors carrying out the screening procedure (min of 2- author / manager and staff member / patient representative) 1. Name of the strategy / policy / proposal / service function Diane Mahoney Meriel Flux Health & Safety Policy Name of lead author /manager & contact number Diane Mahoney 6210 Date last reviewed or created & version number Who is the strategy / policy / proposal / service function aimed at? 3. What are the main aims and objectives? Everyone involved in the activities of the organisation To ensure that the Trust complies with its statutory obligations in relation to Health & Safety at Work etc. Act Consider & list what data / information you have regarding the use of the strategy / policy / proposal / service function by diverse groups? All information is from legislation and Approved Codes of Practice and applies throughout the UK. 5. Is the strategy / policy / proposal / service function relevant to any of the equality strands below? Page 21 of 24

22 If YES please indicate if the relevance is LOW, MEDIUM or HIGH Equality Strands Patient, their carer or family Staff Age N/A N/A Gender (male, female, transgender) N/A N/A Race / Ethnic communities / groups N/A YES, LOW Availability of policy in different languages and support via translators Disability N/A YES, LOW availability of different formats a Physical N/A N/A b Learning disability N/A N/A c Sensory impairment, N/A N/A Hearing, sight d Speech or communication difficulty N/A N/A e Mental ill health N/A N/A f People with HIV / AIDS N/A N/A g Head injury, cognitive loss N/A N/A Page 22 of 24

23 h Other N/A N/A Religious / other beliefs N/A N/A Sexual Orientation, Bisexual, Gay, heterosexual, Lesbian N/A N/A Human Rights N/A N/A 6. What aspects of the strategy / policy / proposal / service function are of particular relevance to the equality strands? None 7. Does the strategy / policy / proposal / service function relate to an area where there are known inequalities? If so which and how? No 8. Please identify what evidence you have used / referred to in carrying out this assessment. Policy in line with UK legislation. 9. If you identify LOW relevance only can you introduce any minor changes to the strategy / policy / proposal / service function which will reduce potential adverse impacts at this stage? If so please identify here. Page 23 of 24

24 Availability of policy to be available in different languages and formats and translation support for staff when required. 10. Please indicate if a Full Equality Impact Assessment is recommended. NO (required for all where there is MEDIUM & HIGH relevance) 11. If you are not recommending a Full Equality Impact assessment please explain why. There are no identified issues. 12. Signature of author / manager Date of completion and submission 05/04/2011 Page 24 of 24