Equality, Diversity and Human Rights Annual Report 2011

Transcription

1 Equality, Diversity and Human Rights Annual Report 2011 This document is available in alternative formats upon request. Please contact the HR department on

2 Contents Page No. 1. Introduction 3 2. Progress to Date: Corporate Governance and Scrutiny 5 3. Data Requests and Information 7 4. Progress to Date: Annual Staff Survey 8 5. Progress to Date: Workforce Equality, Diversity and Human Rights Training 8 Workforce progress by Equality Strand Age Disability Gender and Gender Identity Religion and Belief Race Development Sexual Orientation and Gender Identity Employment Policies Education and Training Progress to Date: Services The Year Ahead Conclusion Data and Contex Organisational Context Key Drivers Data Tables 18 Index Population Data 22 General Reporting Principles Staff Profiles Trust Board Profile Pay Band Information Training Employee Relations Consultant Clinical Excellence Awards Leavers Recruitment Membership Patient Services Interpreting and Translation Services Patient Incidents Patient Complaints Audits of Clinical Care Revised Data Capture Annual Report V2

3 1. Introduction 1.1 The Queen Victoria Hospital NHS Foundation Trust has been publishing an annual Equality and Diversity report since Until 2009, the reports were twice yearly. Following the implementation of the Equality Act 2010, this year s report is the most comprehensive to date, meeting the requirement to publish data across 9 protected characteristics. 1.2 At the beginning of 2011, Equality Champions were identified across the Trust to provide operational support for patient and staff equality issues. The Champions have been trained to deliver Equality Impact analysis and to assist other staff with their assessments. The Trust has also introduced Sit and See, an initiative developed to ensure that care, kindness and compassion are proactive elements of patient care. The Director of Nursing & Quality and the Head of HR undertook the first assessment. 1.3 The short notice departure of the Equality and Diversity Manager in July 2011 led to a review of the way Equality, Diversity and Human Rights support is delivered in the Trust. From November 2011 to March 2012, the Trust has a short term Service Level Agreement (SLA) with Sussex Partnership NHS Foundation Trust. A tender exercise is underway to secure a longer term SLA from April This report looks at the progress the Trust has made during It contains data and information across the protected characteristics of Age, Disability, Gender and Gender Identity, Race, Religion and Belief and Sexual Orientation for staff, service users and members of the Trust. There is still some way to go to improve our data capture and it will be a priority for 2012 onwards to secure more robust data. 1.5 During 2011, the Trust produced a Single Equality Scheme, which was consulted on with staff, members and the public. It is published on the Trust s website and includes an action plan which will be updated for The scheme is our public commitment to improve our delivery of the equality, diversity and human rights agenda. We are currently in the process of producing our Equality Objectives Scheme. 1.6 The Equality Act 2010 came into force on 1 October 2010 and superceded and simplified existing equality and anti-discrimination legislation. It replaces the Equal Pay Act 1970, Sex Discrimination Act 1975, Race Relations Act 1976 and Disability Discrimination Act 1995, as well as various regulations concerning sexual orientation, religion or belief and age. 1.7 Summary Changes resulting from the Equality Act 2010 The definition of disability is widened to make it easier to qualify for protection; A transsexual person no longer has to show that they are under medical supervision to receive protection from discrimination; Direct discrimination protection is extended to cover disability; Annual Report V2

4 Protection from discrimination by association (e.g. carers of disabled people) and discrimination by perception is extended to include gender, gender reassignment and disability; Indirect discrimination is extended to include disability and gender reassignment; Victimisation claims will be easier to bring (ie. No comparator necessary); A new type of discrimination protection is introduced specifically for disabled people; Harmonised thresholds for the duty to make reasonable adjustments for disabled patients and other disabled members of the public; Clearer protection for breast-feeding Mothers; Restricted the circumstances in which employers can ask job applicants questions about disability or health; Claims for direct gender pay discrimination will be allowed where there is no actual comparator; New powers for Employment Tribunals to make recommendations which benefit the wider workforce (not just the individual claimant s circumstances); Harmonised provisions allowing voluntary positive action; e.g. proportionate steps to help patients with protected characteristics overcome disadvantage or meet unmet needs linked with characteristic (e.g. single-sex therapy group) or steps to address the underrepresentation of particular groups in the workforce. 1.8 The Queen Victoria Hospital NHS Foundation Trust is a major employer and service provider in the East Grinstead area. The Trust recognises that the preferences and choices of our patients and staff about service provision or employment at the Trust must not be disadvantaged by race, disability, gender and gender identity, age, sexual orientation, marriage and civil partnership, pregnancy and maternity, gender reassignment or by religion or belief. 1.9 There are a number of national drivers and legal imperatives that have influenced the content of this report: Reducing inequalities Meeting the legal duties imposed on all public bodies Monitoring requirements Meeting the Care Quality Commission standards, especially on governance, patient focus, accessible and responsive care Equality and Human Rights Commission (EHRC) Codes of Practice (and codes issued by predecessor organisations) Monitor The NHS Equality Delivery System Equality Act Since 2009, the Trust has been operating in a less financially secure environment, initially from internal cost pressures and subsequently due to the Government s savings target for the NHS. As a public institution we Annual Report V2

5 will continue to screen for any negative outcome of any decisions which could unfairly affect any particular group of patient, patient relative, carer, staff or volunteer. We will ensure that we meet the requirements of the Equality Act This report summarises extensive data analysis, indicating points of progress and enabling us to indentify and respond to key challenges. It demonstrates that the Trust views Equality, Diversity and Human Rights as core to its mission and key to its future business success This report is deemed to meet the requirements of the Equality Act 2010 Public Sector Duties with regards to the publication of information and key outcomes over the past 12 months This report follows the 2010 Annual Equality and Diversity Report, published in November 2010 and covering data to September The report covers the period October 2010 to November 2011 unless otherwise stated (e.g. Recruitment data only goes back to November 2010). 2. Progress to Date: Corporate Governance and Scrutiny 2.1 Equality Scheme: The original Scheme runs from 2010 to 2013 and describes how the Trust will fulfil its legal duties and obligations to put equality at the heart of everything we do. 2.2 Priorities for action in the Scheme include: Embed leadership from the top and visible commitment to Equality, Diversity and Human Rights; Consult and involve representatives covering protected characteristics to help inform our future activities; Establish monitoring and analysis systems for our staff and service areas across protected characteristics; use clinical audit to measure patient experience by protected characteristic; Develop actions to address any areas of inequality or unmet need emanating from the data analysis or relevant research; Ensure that our buildings and working practices are accessible to all and information on accessibility is available on our website; Ensure that our website is accessible; Address gaps in our knowledge base, including pay and opportunity gaps across protected characteristics; Train staff on equality and human rights impact analysis, the general equality duties and the implications of these for their work; Develop equality awareness raising activities; Appoint Equality Champions across the Trust; Implement mentorship scheme to support staff. 23. The Trust s new Equality Objectives Scheme is currently under development and will run from 2012 to We are committed to delivering Annual Report V2

6 positive services and employment practices where people can have their different needs acknowledged, valued and respected. We recognise movement nationally toward an umbrella approach to equality diversity and human rights and the aim of the Equality Act 2010, introducing a single equality duty to increase protection for the groups of society that are not previously equally protected by legislation. We believe that a patient-centred holistic approach should be taken to reducing health inequalities considering all people as individuals and will belong to a number of the groups now termed Protected Characteristics. Our Equality Objective Scheme provides us with a unified governance structure for tackling discriminatory practice but more importantly to design in positive approaches to people in the first instance and demonstrates our commitment to the ethos of promoting equality and human rights for all. This scheme will enable us to achieve our intentions by ensuring that our policies, services and functions meet the needs of all our staff, patients and stakeholders. We are committed to ensuring quality in our service provision and to becoming a model employer. This Scheme sets out how we intend to reinforce this commitment by ensuring that Equality, Diversity and human Rights is at the heart of our work. Leadership is central to the success of the scheme, and for enabling us to realise the benefits from investing in this work. The scheme will cover the period 1 st April 2012 to 31 st March 2016 and will be closely linked to the way we develop our business and strategic plans. This revision takes into account the data and outcomes and challenges from We will align our Objectives to the NHS Equality Delivery System (EDS) Better Health Outcomes for all Improved patient access & experience Empowered, engaged & well supported staff Inclusive leadership at all levels Annual Report V2

7 2.4 Staff, Governors, members and patient representatives were involved in helping us develop the Equality Scheme. We utilised various mechanisms including the Equality, Diversity and Human Rights steering group, the Governors steering group, the Joint Consultation and Negotiation Committee, the Patient Engagement Committee and the membership body. 2.5 Equality, Diversity and Human Rights Steering Group: the Equality, Diversity and Human Rights steering group provides strategic direction, governance and scrutiny to the development and achievement of our Equality, Diversity and Human Rights culture in the Trust. The membership of the group includes the Executive Director of Nursing and Quality, the Deputy Director of Nursing and the Head of Human Resources. 2.6 The role of the group is to ensure that the Trust complies with all relevant legal requirements and that we deliver our Equality and Diversity strategy (set out in the Equality Scheme). The group usually meets four times per year but in 2011, due to the departure of the Equality and Diversity Manager, the group met in March, June and November only. The Trust implemented a short term SLA with Sussex Partnership to ensure expert advice and support was available on equality, diversity and human rights issues. A tender for a longer term SLA is in progress and we hope to have awarded a 3 year contract by the end of February Equality Champions: During 2011, the Trust appointed15 Equality Champions across the Trust. Their role is to champion equality, diversity and human rights in clinical areas, to identify any issues and agree actions to ensure a positive approach, to undertake impact assessment and analysis and to train others to undertake impact assessment and analysis. The Equality Champions met for the first time in August 2011 and a more planned approach is intended for They are supported by the Deputy Director of Nursing. 3. Data Requests and Information 3.1 During 2011, the Trust did not receive any data requests in relation to Equality, Diversity and Human Rights. 3.2 Unlike other organisations in the South East Coast area, the Trust has not to date received any communication from the Equality and Human Rights Commission (EHRC the advisory and enforcement body for Equality and Human Rights within the UK) requesting evidence of legal compliance with equality duties. In all, 7 organisations were reviewed by the EHRC, 3 received non compliance notices and 3 had to sign a section 23 agreement (the Commission can enter into a formal agreement with any organisation it believes has committed an unlawful act). 3.3 However, there is no room for complacency. The Equality Act 2010 builds on pre-existing legislation that puts the onus on the Trust not only to have discrimination free practices, but to prove it by having robust data and Annual Report V2

8 publishing that data. The Trust acknowledges that it has some improvements to make. 3.4 The Trust website has been updated and revised on several occasions in the last few years and equality and diversity information is accessible through the about us page. We have reviewed this element recently but a bigger overhaul is planned for early We will be identifying a more regular process for updates through our equality, diversity and human rights SLA arrangement. The website provides information on our monitoring data for services and workforce, the equality scheme and action plan, policies and impact assessments. 4. Progress to Date: Annual Staff Survey 4.1 The Trust has analysed data from the 09/10 and 10/11 staff surveys by the available protected characteristics (ethnicity, disability, gender). From this, we will identify any actions that may need to be incorporated into our Equality Objective scheme for 2012 onwards. 5. Progress to Date: Workforce Despite the set-back of losing our Equality and Diversity Manager during the year, the Trust continues to ensure that progress is made in fulfilling our commitments and duties. This report looks at workforce, patient, and membership data overall but this section focuses on employment issues. 5.1 Equality, Diversity and Human Rights Training During the period of the report, the Trust has delivered the following training: Monthly Equality Diversity and Human Rights training between October 2010 and July 2011, covering new starters and refresher training; this moved to quarterly when the Equality and Diversity Manager left and has been picked up as part of our new Service Level Agreement; Impact analysis training delivered to 7 of the Equality, Diversity and Human Rights Champions in August 2011; E-learning module on equality, diversity and human rights developed and rolled out. Workforce progress by Equality Strand Where data appears to highlight a cause for concern, the Trust is committed to developing objectives to address any issues, to be included in the Equality Objectives Scheme 2012 to Age The age data held on ESR is robust in terms of recording date of birth, as this is core data required by HR and Payroll. Age equality is covered explicitly within the Equality Scheme and in other Trust policies Annual Report V2

9 5.3 Disability All new staff are asked to declare their disability status as part of the recruitment process. The formally notified status of staff that are disabled (ESR records) shows that 1 % of staff classify themselves as disabled. For nearly 80% staff, this information is not known. The number of staff who declare a long term health condition in the staff survey however is 12% (2010 data). Whilst the two definitions are not the same (the staff survey does not use the definition of disability as described in the Equality Act 2010), the Trust will need to focus on improved data collection so that we can be sure that disabled staff are getting the support they need. It should be noted however that 100% of staff who declared a long term health condition in the staff survey stated that adequate adjustments had been made to enable them to carry out their work. 5.4 Gender and Gender Identity The gender data held on ESR is robust in terms of recording male or female, as this information is core data required by Human Resources. However, we do not have robust systems at present to identify transgender staff and will need to focus on improved data collection so that we can ensure that any transgender staff are getting the support they need. 5.5 Religion and Belief 26%of staff have disclosed their religion and all new staff are asked to do so as part of the recruitment process. We will now need to improve our data collection and also continue to cultivate a climate where staff feel able and comfortable to disclose their religion and/or belief. 5.6 Race Development The percentage of staff disclosing their ethnic origin is 95.7%. Analysis of leadership bands shows that there is still under-representation of BME staff in bands 7 and above, with the exception of medical and dental staff. The Trust s mentorship scheme, funding of places at BME conferences, promotion of the Breaking Through programme and training opportunities are some of the ways that we have attempted to address this. We have also asked search agencies to ensure a diverse approach to selection when recruiting to senior positions. The Trust will develop an objective to further address this issue. The 2010 staff survey did not reveal that BME staff were dissatisfied with their opportunities there was a 12% better score for BME staff on Key Finding 10 % of staff feeling there are good opportunities to develop their potential at work, a 22% better score on having well structured appraisals and a 16% better score on having a personal development plan within the previous 12 months. The Trust is a very small organisation with comparatively few senior manager posts and there are fewer opportunities for promotion generally than in larger organisations, therefore it may take some time to alter the BME representation in more senior roles. All staff in band 6 and above and Team Leaders in band 5 have been offered a place on the Trust s Leadership Development Programme. The Executive Annual Report V2

10 Directors have all volunteered to mentor BME staff. The Trust has implemented a second round of the Step Ahead Mentorship Programme which was particularly targeted at staff in the protected characteristic groups Sexual Orientation and Gender Identity All new staff are asked to disclose their sexual orientation as part of the recruitment process. To date, 27.5% of staff have provided this information. We will now need to improve our data collection and also continue to cultivate a climate where staff feel able and comfortable to disclose their sexual orientation. The Trust applied for a free initiative with Stonewall which would have assisted us with this element of our duties but we were sadly unsuccessful. 5.8 Employment Policies The following policies have been reviewed and screened during the period of the report: Stress in the Workplace Harassment and Bullying Recruitment and Selection Capability Study Leave Guidelines on Managing Probationary periods Car Parking Uniform and Dress Code Whistle Blowing Over payments and under payments of salary Management of staff with MRSA Maintaining High Professional Standards 5.9 Education and Training All staff have access to, and take up, mandatory, statutory and discretionary internal training and development opportunities. All internal training and development requests from October 2010 to November 2011 were considered by the quarterly funding panel. In addition to Trust funding, PTDe funding and University funding, the Trust receives an annual grant of 10,000 from the League of Friends, called the Rosemary Wootton Bursary for training and development purposes The data on training is contained in the data tables at section of this report. Where applications are declined, it is for reasons such as courses offered in house or other sources of funding available. The majority of applications received full funding, 1 application received 75% funding, 1 application received 50% funding and 1 received 25% funding, all as per the study leave policy Annual Report V2

11 5.9.3 AGE, GENDER ASSIGNMENT, RELIGION & BELIEF AND DISABILITY Whilst some applications for external courses capture this data as part of the external course data collection, this is not routinely captured as part of the Practice Development application process GENDER This information is not formally collected as part of the Practice Development application process but it can be discerned from the records that 106 of the applications reviewed by the funding panel were female and 5 were male RACE/ETHNICITY This data is currently captured as part of the application process and for the period reviewed is provided in the data tables at section 9.3.5: SEXUAL ORIENTATION Whilst some applications for external courses capture this data as part of the external course data collection, this is not routinely captured as part of the Practice Development application process In view of the need to improve data capture across many of the protected characteristics, the plan for 2012 onwards is to update the application form with a separate section that includes questions on all equality strands (see annex 10 for proposals for enhanced data capture) The implementation of the Oracle Learning Management (OLM) module of the Electronic Staff Record in 2010 has enabled us to generate reports relating to training attendance from ESR records, which has improved the available data. The Trust has also rolled out a number of e-learning modules during the period of the report and data includes e-learning modules. Data tables can be found in section Progress to Date: Services 6.1 The Equality Act supports good decision-making by ensuring public bodies consider how different people will be affected by their activities, helping them to deliver policies and services which are efficient and effective; accessible to all; and which meet different people s needs. 6.2 At QVH the Patient Centre System, which is the patient administration system used by staff to register patient demographic details and referrals into teams, and to record inpatient stays and outpatient appointments, also includes some detailed Equality and Diversity data of service users. However it is not all across the protected characteristics. 6.3 The Trust is reviewing what information is currently collected by the Patient Administration System (PAS) to identify where improvements can be made to provide greater collection and breakdown detail of our service users without having to review individual medical records. The data currently collected via PAS does not currently reflect all the protected characteristics Annual Report V2

12 detailed within the Equality Act. Some of the data currently collected is listed as unknown as opposed to not disclosed or declined to answer. In order to produce more detailed reports on patient and staff demographics, from 2012 onwards the Trust will need to increase the quantity of demographic data collected and make these compulsory or mandatory fields in PAS in order to ensure that they are completed. Some demographics should have the option of information declined as this can also be audited and reported and those with unknown or not reported need to be amended so that this option is removed. Any changes will need to be supported by additional training and education of staff and patients to ensure that all parties understand the importance and relevance of the questions and how the data will be used. 6.4 The Trust has provided impact assessment training to Managers in the trust over the last few years and to the Equality Champions during The Trust will need to adopt the more detailed impact analysis process for services and policies and is in the process of organising the training for this. 6.5 Policies have been impacted analysed by the Equality, Diversity and Human Rights Strategy group. However a new impact analysis process will be adopted that reflects the protected characteristics as part of our new Equality Objective Scheme. 6.6 Action Plan for Patient Services Issue Identified Action Required Person Responsible Lack of patient demographic detail on PAS system Increase data capture to include all protected characteristics and consider making the PAS System Manager Staff/patient issues with data collection questions fields mandatory Promotional training and information for both groups to understand the reason for the questions PAS System Manager, Matrons, Directorate Manager for Clinical Specialities Some data recording on PAS identified as unknown unclear whether question has Check in Kiosks in outpatient areas would eliminate requirement for patients to give the information to a third party As part of the data capture have sections for information declined Directorate Manager for Clinical Specialities PAS System Manager Annual Report V2

13 been asked or not Some lack of data capture on incident forms and audit forms to be able to ascertain patient demographics for this report Feed back to senior managers, matrons and Health and Safety trainers to raise awareness with staff Deputy Director of Nursing 6.7 Patient data is shown in the appendices at section The Year Ahead 7.1 There is no doubt that the short notice departure of the Trust s Equality and Diversity Manager has had an impact on the progression of the Equality Scheme and Action Plan. The Trust moved quickly to secure short term support, but there was inevitably a period of time between July and October where the ability to forward plan was reduced. The Trust did however secure a short term Service Level Agreement (SLA) to provide expert Equality, Diversity and Human Rights advice, pending a tender for a longer term arrangement. 7.2 The Trust is working to secure a long term SLA and in the meantime we are working with Sussex Partnership on a short term basis until March The team there has supported the Trust with the Equality, Diversity and Human Rights Steering Group, the Trust website, an Equality Objective Scheme, delivery of training, Equality Impact Analyses and a telephone advice line service. 7.3 The Trust aims to ensure that all staff feel valued, respected and able to progress through the organisation, whilst patients and visitors feel able to access our services, receive care or support and be treated as individuals with dignity. 7.4 The Trust s new Equality Objective Scheme, still being drafted, will demonstrate the key priorities for the next four years. Though some progress has been made on data collection, a key task for the organisation will be to improve the collection of information on sexual orientation, disability, religion and belief so that we can use it in meaningful way, whilst retaining confidentiality. 7.5 Another key task will be to ensure the roll out of Impact Analyses training across the organisation and this will be undertaken as part of the SLA. 8. Conclusion This report shows that the Trust has made some progress in delivering the objectives in the existing equality scheme for patients and staff. Further development activities will be described in our Equality Objective Scheme, including further work on data gathering and equality impact analyses. The findings from this report will be used to provide information to teams and Annual Report V2

14 departments about the demography of service users - we are committed to engaging our local community and our patients to enable them to influence decisions about the Hospital and about their care. 9. Context and Data 9.1 Organisational Context Demography QVH is a leading specialist centre for reconstructive surgery and rehabilitation, helping people who have been damaged or disfigured through accidents or disease including treatment for Burns. We provide a minor injuries unit and other services for people living in and around East Grinstead, in West Sussex We have a proud heritage and are known throughout the world for pioneering new and innovative techniques and treatments. Patients rate us as one of the top hospitals in the country for quality of care, and we have been rated 'excellent' for our financial management for the past five years We employ over 900 skilled and committed staff, dedicated to helping QVH provide the very best care for our patients, and we are the largest employer in the local area As one of the country's first NHS foundation trusts (July 2004) we are accountable to local people through our 9,500 public members across Sussex, Kent and Surrey. However, due to the specialist nature of our services, patients can be referred to QVH from anywhere in the country Foundation Trust status allows local people and stakeholder organisations to have a far greater say in how the organisation is run. The Trust has greater autonomy from the Department of Health in making decisions about how services are planned and delivered. QVH is committed to eliminating discrimination, achieving equity in service delivery and meeting the diverse needs of our patients Kent, Surrey and Sussex form the former NHS South East Coast region of the Strategic Health Authority (now subsumed into NHS South of England). There are 4,283,200 people living in the South East Coast region, or 8.4% of the population of England. Overall the population will increase by 18% by 2030 and some parts of the region have a far higher proportion of older people than the national or regional average. The proportion of older people is projected to rise by 50% between 2007 and The south east deprived populations show significantly higher mortality rates for circulatory diseases, cancers and respiratory disease. These are also the commonest causes of mortality in the rest of the population, but disability and death occur earlier, on a larger scale among the most deprived groups Annual Report V2

15 9.1.8 Therefore equitable access to effective care at the right time is an important measure. This includes the highly specialised care offered at QVH although as a tertiary centre, we do not control the access to our services. Trust Purpose, Mission and Vision The Trust provides specialist reconstructive surgery and expert rehabilitation services for the South of England, together with some medical services for the local community. Our mission is to be an international reference centre for reconstructive surgery, therapy and rehabilitation services and to be recognised locally for the quality of our medical services Our vision is that through a fully resourced and expert team of leading clinical specialists, we will be a centre of excellence for specialist reconstructive and rehabilitation services, which we will offer through a network of facilities across the South of England, centred on East Grinstead. We will continue to provide and extend direct access to the medical and diagnostic services that we offer to our local population Through a project engaging staff across the Trust, in 2011 we established Continuous Improvement of Care, Humanity and Pride as our Trust values, underpinned by quality. Staff produced generic behaviours which demonstrate these values and each department is producing more local descriptions of how they live the values. Respect, privacy and dignity and professional and courteous behaviour are at the heart of these values. 9.2 Key Drivers There are a number of national drivers and legislative requirements that underpin the production of the Equality, Diversity and Human Rights annual report Changing Legislation The UK anti-discrimination legislation was changed by the Equality Act 2010, which came into force between October 2010 and April The act requires the Trust to meet generic and specific duties including monitoring by protected characteristics and eliminating discrimination The Care Quality Commission (CQC) As the regulator of health and adult social care in England, the CQC makes sure that the care people receive meets the essential standards of quality and safety. The CQC encourages ongoing improvements by those who provide or commission care. There are 28 outcomes, each reflecting a specific regulation. Of the 28 regulations, there are 16 that relate most directly to the core quality and safety of care standards which apply to all types of provider. The other 12 regulations may apply differently to different types of provider. The CQC has grouped the 28 outcomes into six key areas: Annual Report V2

16 Involvement and Information Outcome 1: Respecting and involving people who use services Outcome 2: Consent to care and treatment Outcome 3: Fees Personalised care, treatment and support Outcome 4: Care and welfare of people who use services Outcome 5: Consent to care and treatment Outcome 6: Co-operating with other providers Safeguarding and safety Outcome 7: Safeguarding people who use services from abuse Outcome 8: Cleanliness and infection control Outcome 9: Management of medicines Outcome 10 Safety and suitability of premises Outcome 11 Safety, availability and suitability of equipment Suitability of staffing Outcome 12: Requirements relating to workers Outcome 13: Staffing Outcome 14: Supporting workers Quality and management Outcome 15: Statement of purpose Outcome 16: Assessing and monitoring the quality of service provision Outcome 17: Complaints Outcome 18: Notification of death of a person who uses services Outcome 19: Notification of death or unauthorised absence of a person who is detained under the Mental Health Act 1983 Outcome 20: Notification of other incidents Outcome 21: Records Suitability of management Outcome 22: Requirements where service provider is an individual or partnership Outcome 23: Requirement where the service provider is a body other than a partnership Outcome 24: Requirements relating to registered managers Outcome 25: Registered person: training Outcome 26: Financial position Outcome 27: Notifications - notice of absences Outcome 28 Notifications notice of changes If you would like to know more about how the Trust responds to the CQC, then please contact Ashley Parrott, Patient Safety and Governance Manager/Head of Risk Management, Queen Victoria Hospital NHS Foundation Trust: Annual Report V2

17 9.2.3 Equality and Human Rights Commission (EHRC) The EHRC has a statutory remit to promote and monitor human rights; and to protect, enforce and promote equality across the protected characteristics age, disability, gender, race, religion and belief, sexual orientation, gender reassignment ( and to the extent that protection exists in law, civil partnerships and pregnancy). What they do: Ensure people are aware of their rights and how to use them Work with employers, service providers and organisations to help them develop best practice Work with policy makers, lawyers and the Government to make sure that social policy and the law promotes equality and Use their powers to enforce the laws that are already in place. As a single Commission it can act as one source of information and advice and tackle discrimination on multiple levels (many people face more than one type of discrimination). It brings together the work of the three previous equality commissions and has also undertaken new responsibilities Monitor Independent Regulator of NHS Foundation Trusts Monitor is the organisation that authorises and regulates NHS Foundation Trusts to make sure that they are well-managed and financially strong so that they can deliver excellent healthcare for patients. Monitor has powers to intervene in the running of a Foundation Trust in the even to failings in its healthcare standards or other aspects of its activities, which amount to a significant breach in terms of its authorisation. Equality and Diversity plays a fundamental part in ensuring excellent healthcare for all patients and Monitor will be reviewing how we ensure the standards are being met Annual Report V2

18 Queen Victoria NHS Foundation Trust Annual Equality and Diversity Report 2011 Data Appendix Annual Report V2

19 9.3 Data Tables INDEX Type of Data Table Label and Content Population Data A1 Population by Disability 22 A2 Population by Age Group 22 A3 Population by Ethnicity 22 A4 Population by Gender 22 A5 Population by Religion Staff Profile Data B1 Key to Ethnic categories 25 B2 Staff Ethnicity (headcount and % split) 26 B3 Staff Age Group (headcount and % split) 27 B4 Staff Gender (headcount and % split) 27 B5 Staff Religion & Belief (headcount and % split) 28 B6 Staff Sexual Orientation (headcount and % split) 28 B7 Staff Disability (headcount and % split) Trust Board Profile C1 Trust Board Ethnicity Pay Band Information D1 Pay band - Ethnicity (headcount) 31 D2 Pay band - Ethnicity (% split) 32 D3 Pay band - Age (headcount_ 33 D4 Pay band - Age (% split) 34 D5 Pay band - Gender (headcount) 35 D6 Pay band - Gender (% split) 35 D7 Pay band - Religion & Belief (headcount) 36 D8 Pay band - Religion & Belief (% split) 37 D9 Pay band - Sexual Orientation (headcount) 38 D10 Pay band - Sexual Orientation (% split) 39 Page no Annual Report V2

20 D11 Pay band - Disability (headcount) 40 D12 Pay band Disability (% split) Training E1 Definitions of Training 41 E2 Mandatory & Non Mandatory Training episodes - Ethnicity 43 E3 Other Training episodes - Ethnicity 44 E4 Mandatory & Non Mandatory Training episodes - Age 45 E5 Other Training episodes - Age 45 E6 Mandatory & Non MandatoryTraining episodes - Gender 46 E7 Other Training episodes - Gender 46 E8 Mandatory & Non Mandatory Training episodes - Religion 47 E9 Other Training episodes - Religion 47 E10 Mandatory & Non Mandatory Training episodes - Sexual Orientation 48 E11 Other Training episodes - Sexual Orientation 48 E12 Mandatory & Non Mandatory Training episodes - Disability 49 E13 Other Training episodes - Disability Employee Relations Cases F1 Employee relations cases - Ethnicity 50 F2 Employee Relations cases - Age 51 F3 Employee Relations cases - Gender Consultants Clinical Excellence Awards G1 Ethnicity 53 G2 Age 54 G3 Gender Leavers H - Leavers due to Redundancy H1 Redundancies - Ethnicity (headcount and % split) 55 H2 Redundancies - Age (headcount and % split) 56 H3 Redundancies - Gender (headcount and % split) 56 I - Leavers due to Other Reasons I1 Leavers - Ethnicity (headcount and % split) 57 I2 Leavers - Age (headcount and % split) 58 I3 Leavers - Gender (headcount and % split) 58 J - All Leavers J1 All Leavers - Reason for Leaving (headcount and % split) Recruitment K 1 Recruitment - Ethnicity (headcount and % split) Annual Report V2

21 K2 Recruitment - Age (headcount and % split) 61 K3 Recruitment - Gender (headcount and % split) 62 K4 Recruitment - Religion (headcount and % split) 63 K5 Recruitment - Sexual Orientation (headcount and % split) 64 K6 Recruitment - Disability (headcount and % split) Membership L1 Membership Profile - Ethnicity, Age and Gender Patient Services M1 Patient episodes - Age 68 M2 Patient episodes - Gender 69 M3 Patient episodes - Religion & Belief 70 M4 Patient episodes - Ethnicity Interpreting & Translation Services N1 Face to Face Episodes by Language 73 N2 Telephone Episodes by Language 74 N3 Episodes by Department or Area Incidents 01 Incidents by Age, Disability, Gender, Religion & Belief, Ethnicity Complaints P1 Complaints by Age, Disability, Gender, Religion & Belief, Ethnicity and Marital/Civil Partnership Status Audit of Clinical Care - pressure ulcer management, nutritional screening, VTE management and Falls Q1 Patients by Age 77 Q2 Patients by Ethnicity 78 Q3 Pressure Ulcer assessment completion/ethnicity 79 Q4 Nutrition Management assessment completion/age and Ethnicity80 Q5 VTE assessment completion/ethnicity 81 Q6 Falls assessment completion/ethnicity Proposed Data Capture Annual Report V2

22 9.3.1 Population Data taken from the 2001 Census (2011 data not available at the time of writing) Annual Report V2

23 Annual Report V2 Queen Victoria Hospital NHS Foundation Trust

24 General Reporting Principles 2011, refers to the period October 2010 to 30 th November 2011, unless otherwise indicated. This is to ensure that as far as possible, not data reporting period was missed. Where possible a colour comparison has been made to baseline data- Overrepresentation is in RED Underrepresentation is in GREEN A match in data is indicated in BLUE The colour coding represents a statistical trend rather than a judgement about desirable outcomes. Workforce Data The total number of staff working for Queen Victoria NHS Foundation Trust is 920. The 920 figure includes all Permanent and Fixed Term Contract Staff and excludes Bank Workers, secondees and those employed jointly with other organisations. The workforce data has been obtained both from the Electronic Staff Record (ESR), NHS Jobs and records kept manually on spreadsheets. The staff profile is a snapshot as at 30 th November Wherever possible Staff have been broken down into Agenda for Change Bandings 1 9, Directors and Chief Executive, Non Executive Directors and Chair and M&D staff. Not all staff fit into these categories and therefore we have a small category of Other which captures all those that do not fit into the aforementioned categories. Black and Minority Network (BME) As per census ethnic classification, the term black and minority ethnic (BME) is used in this report to refer to people from the ethnic groups coded D to S, as per the table B1 on page 26. White As per census ethnic classification term White is used in this report and refers to white, white Irish and other. Whilst recognising all groups are protected under the race relations amendment act 2000, the separation of White Irish and White Other from the BME figures has highlighted issues for consideration as part of the Equality Objectives Scheme Annual Report V2

25 9.3.2 Staff profiles Table B1 Key to Ethnic codes KEY White British Irish Any other White background Mixed White & Black Caribbean White & Black African White & Asian Any other mixed background Asian or Asian British Indian Pakistani Bangladeshi Any other Asian background Black or Black British Caribbean African Any other Black background Chinese or other Ethnic group Chinese Any other Ethnic Group Not Known/Stated A B C D E F G H J K L M N P R S Z This Key shows the standard ethnic categories as per recommendation 61 of the Stephen Lawrence report (T.Cook, J. Sentamo & R.Stone, 1999), a useful tool for consistency and comparative reasons and a tool that will be used to categorize Ethnicity throughout this Annual Report Due to the limitations on the Electronic Staff Records (ESR) it is only possible to record against the 16+1 Ethnic classification breakdown when reviewing workforce data. It is however possible to improve our reporting categories to include Gypsy and Traveller and Arab when working with data on our service user case loads, Incidents, PALS and complaints Annual Report V2

26 TableB2 Ethnicity Ethnicity by Headcount/% Split Ethnic Category Code Headcount White by % split British A Irish B Any other White background C Mixed White & Black Caribbean D White & Black African E White & Asian F Any other mixed background G Asian or Asian British Indian H Pakistani J Bangladeshi K Any other Asian background L Black or Black British Caribbean M African N Any other Black background P Chinese or other Ethnic group Chinese R Any other Ethnic Group S Not Known/Stated Z BME Total Grand Total Trust staff figures are taken from ESR; as snapshot on 30 th November 2011 Table B2 shows a breakdown of the Trust workforce by Ethnicity. 12.7% of the workforce declare themselves Black Minority Ethnic (BME), this is an over representation against the population figures taken from the office of national statistics (ONS 2011). 4.3% of the workforce have not stated their ethnicity. Although this is relatively low, mitigating actions will be contained within the Trusts Equality Objective Scheme to improve the confidence in staff declaring their ethnicity and the knowledge and understanding of how the data is used to improve services Annual Report V2

27 Table B3 Age Age Group by Headcount/% Split Age Group Headcount % Split Total Trust staff figures are taken from ESR; as snapshot on 30 th November 2011 Table B3 shows the breakdown of staff by Age. The majority of staff are aged in comparison to the South East Coast population, where the majority of residents are aged Table B4 Gender Gender by Headcount/% Split Gender Headcount % Split Male Female Total Trust staff figures are taken from ESR; as snapshot on 30 th November 2011 Table B4 shows that the majority of staff are female (76.3%), a large over representation against the demographics of the South East coast, but a figure that is in line with the typical NHS trends, where 70-80% of the workforce is female Annual Report V2

28 Table B5 Religion and Belief Religious Belief by HC/% Split Religious Belief Headcount % Split Atheism Buddhism Christianity Hinduism Islamism Jainism Judaism Sikhism Other Not Disclosed Not Stated/Undefined Total Trust staff figures are taken from ESR; as snapshot on 30 th November 2011 Table B6 Sexual Orientation Sexual Orientation by HC/% Split Sexual Orientation Headcount % Split Bisexual Gay Heterosexual Lesbian Not Disclosed Not Stated/Undefined Total Trust staff figures are taken from ESR; as snapshot on 30 th November 2011 Table B5 shows the religion and belief of Queen Victoria Hospital workforce, the majority of staff have not stated or defined their religion or belief (69.5%). The highest declaration of religion is Christianity (19.1%), a large under representation against the population data (A5). Due to the poor quality of data contained within ESR, it is not possible to make any meaningful statistical analysis. Mitigating actions are contained within the EOS to monitor and improve data collection, awareness and confidence in declaration. Table B6 shows the sexual orientation of Queen Victoria Hospital workforce, the majority of staff have not stated or undefined their Sexual orientation (72.5%). 0.2% of the workforce have defined as Lesbian, Gay or Bisexual, Stonewall estimate the LGB population is 5-7%. Due to the poor quality of data contained within ESR, it is not possible to make any meaningful statistical analysis. Mitigating actions are contained within the EOS to monitor and improve data collection, awareness and confidence in declaration Annual Report V2

29 Table B7 Disability Disability by Headcount/% Split Disabled Headcount % Split No Yes Undefined Total Trust staff figures are taken from ESR; as snapshot on 30 th November 2011 Table B7 shows the disability status of QVH workforce, the majority of staff (79.1%) did not disclose their disability status. Due to the poor quality of data, it is not possible to make any meaningful statistical analysis. Mitigating actions are contained within the EOS to monitor and improve data collection, awareness and confidence in declaration Annual Report V2

30 9.3.3 Trust Board Profile by Ethnicity Table C1 Trust Board by Ethnicity Ethnic Category Code Headcount White by % split British A Irish B Any other White background C Mixed White & Black Caribbean D White & Black African E White & Asian F Any other mixed background G Asian or Asian British Indian H Pakistani J Bangladeshi K Any other Asian background L Black or Black British Caribbean M African N Any other Black background P Chinese or other Ethnic group Chinese R Any other Ethnic Group S Not Known/Stated Z BME Total Grand Total Trust staff figures are taken from ESR; as snapshot on 30 th November 2011 Table C1 shows the Ethnicity breakdown of the QVH Trust board. There are no BME colleagues at the Trust board level, which is an under representation against the workforce average. Mitigating actions are contained within the EOS, to discover if there are an potential barriers to development and leadership for BME colleagues Annual Report V2

31 9.3.4 Pay Band Information Table D1 Ethnicity by Headcount Ethnic Code by Headcount Pay scale Description A B C D E F G H J K L M N P R S Z BME Total Grand Total Band Band Band Band Band Band Band Band 8 - Range A Band 8 - Range B Band 8 - Range C Band 8 - Range D Band Directors/Chief Exec Non Exec/Chair M&D Staff Other Grand Total Trust Staff Figures are taken from ESR; a snapshot on 30th November Annual Report V2

32 Table D2 Ethnicity by % Split Ethnic Code by % split Pay scale BME Grand Description A B C D E F G H J K L M N P R S Z Total Total Band Band Band Band Band Band Band Band 8A Band 8B Band 8C Band 8D Band Directors/CEO Non Exec/Chair M&D Staff Other Grand Total Trust Staff Figures are taken from ESR; a snapshot on 30th November 2011 Tables D1 & D2 show the breakdown of the Trust workforce by Ethnicity and Agenda for change pay banding to scrutinise if there are any barriers to progression and leadership or clusters of staff. Band 1,5,6 and M&D staff have an overrepresentation of BME staff against the Trust workforce average of 12.7%. The majority of BME staff are predominately in band 5 & 6 a trend found across the NHS, and something projects like Breaking through are looking into to establish if there is a glass ceiling for BME staff progressing to leadership positions Annual Report V2

33 Table D3 Age group by Headcount Age Group by Headcount Years of Age Pay scale Description Band Band Band Band Band Band Band Band 8 - Range A Band 8 - Range B Band 8 - Range C Band 8 - Range D Band Directors/Chief Exec Non Exec/Chair M&D Staff Other Grand Total Trust Staff Figures are taken from ESR; a snapshot on 30th November 2011 Grand Total Annual Report V2

34 Table D4 Age Group by % Split Age Group by % split Years of Age Grand Total Pay scale Description Band Band Band Band Band Band Band Band 8 - Range A Band 8 - Range B Band 8 - Range C Band 8 - Range D Band Directors/Chief Exec Non Exec/Chair M&D Staff Other Grand Total Trust Staff Figures are taken from ESR; a snapshot on 30th November 2011 Table D3 and D4 show the age breakdown of QVH staff by agenda for change bandings. The data shows an ageing workforce with a positive correlation between increasing banding and age (highlighted above in grey). There is a large over-representation of staff aged in band 8c against the workforce average, 0% of the workforce at band 8c are aged However there is such a small number of posts in these grades, it is difficult to draw robust conclusions Annual Report V2

35 Table D5 Gender by Headcount Gender by Headcount Pay scale Description Female Male Grand Total Band Band Band Band Band Band Band Band 8 - Range A Band 8 - Range B Band 8 - Range C Band 8 - Range D Band Directors/Chief Exec Non Exec/Chair M&D Staff Other Grand Total Table D6 Gender by % Split Gender by % split Pay scale Description Female Male Grand Total Band Band Band Band Band Band Band Band 8 - Range A Band 8 - Range B Band 8 - Range C Band 8 - Range D Band Directors/Chief Exec Non Exec/Chair M&D Staff Other Grand Total Trust Staff Figures are taken from ESR; a snapshot on 30th November 2011 Table D5 and D6 show the gender of staff by pay band, there is an over representation of male staff in bands 8b, Directors/chief exec, M&D staff and Non Exec/Chair. Mitigating actions are contained within the EOS to look into potential barriers for female progression into leadership positions; however this is a similar trend to the NHS nationally Annual Report V2

36 Table D7 Religion and Belief by Headcount Religious Belief by Headcount Not Disclosed Payscale Description Atheism Buddhism Christianity Hinduism Islam Jainism Judaism Sikhism Other Undefined Band Band Band Band Band Band Band Band 8 - Range A Band 8 - Range B Band 8 - Range C Band 8 - Range D Band Directors/Chief Exec Non Exec/Chair M&D Staff Other Grand Total Trust Staff Figures are taken from ESR; a snapshot on 30th November 2011 Grand Total Annual Report V2

37 Table D8 Religion and Belief by % Split Religious Belief by % split Not Disclosed Payscale Description Atheism Buddhism Christianity Hinduism Islam Jainism Judaism Sikhism Other Undefined Band Band Band Band Band Band Band Band 8 - Range A Band 8 - Range B Band 8 - Range C Band 8 - Range D Band Directors/Chief Exec Non Exec/Chair M&D Staff Other Grand Total Trust Staff Figures are taken from ESR; a snapshot on 30th November 2011 Table D7 and D8 show the religion and belief of staff by agenda for change banding. Due to the poor quality of data it is not possible to make any meaningful analysis. Mitigating actions are contained within the EOS to monitor and improve data collection, awareness and confidence in declaration. Grand Total Annual Report V2

38 Table D9 Sexual Orientation by Headcount Sexual Orientation by Headcount Payscale Description Bisexual Gay Heterosexual Lesbian Not Declared Undefined Band Band Band Band Band Band Band Band 8 - Range A Band 8 - Range B Band 8 - Range C Band 8 - Range D Band Directors/Chief Exec Non Exec/Chair M&D Staff Other Grand Total Trust Staff Figures are taken from ESR; a snapshot on 30th November 2011 Grand Total Annual Report V2

39 Table D10 Sexual Orientation by % Split Sexual Orientation by % split Grand Total Payscale Description Bisexual Gay Heterosexual Lesbian Not Declared Undefined Band Band Band Band Band Band Band Band 8 - Range A Band 8 - Range B Band 8 - Range C Band 8 - Range D Band Directors/Chief Exec Non Exec/Chair M&D Staff Other Grand Total Trust Staff Figures are taken from ESR; a snapshot on 30th November 2011 Table D9 and D10 show the sexual orientation of staff by agenda for change banding. Due to the poor quality of data it is not possible to make any meaningful analysis. Mitigating actions are contained within the EOS to monitor and improve data collection, awareness and confidence in declaration. It is clear from the information on recruitment that the information is being provided at appointment, but actions will need to be established within the EOS to understand where the information is being lost Annual Report V2

40 Table D11 Disability by Headcount Table D12 Disability by % Split Disability by Headcount Disabled Disability by % split Disabled Pay scale Description No Yes Undefined Grand Total Pay scale Description No Yes Undefined Grand Total Band Band Band Band Band Band Band Band Band Band Band Band Band Band Band 8 - Range A Band 8 - Range A Band 8 - Range B Band 8 - Range B Band 8 - Range C Band 8 - Range C Band 8 - Range D Band 8 - Range D Band Band Directors/Chief Exec Directors/Chief Exec Non Exec/Chair Non Exec/Chair M&D Staff M&D Staff Other Other Grand Total Grand Total Trust Staff Figures are taken from ESR; a snapshot on 30th November 2011 Table D11 and D12 show the disability status of staff by agenda for change banding. Due to the poor quality of data it is not possible to make any meaningful analysis. Mitigating actions are contained within the EOS to monitor and improve data collection, awareness and confidence in declaration Annual Report V2

41 9.3.5 Training Table E1 - Definitions of training Trust mandatory training, classroom courses: AED - INITIAL Doctors Clinical Mandatory Training Manual Handling Clinical INITIAL AED - UPDATE Equality, Diversity & Human Rights Manual Handling Clinical Update Basic Life Support - INITIAL ERAM Manual Handling Non Clinical - INITIAL Child Protection Level 1 Update Essential Risk Management Study Day Manual Handling Non Clinical Update Child Protection Level 2 Fire Team Training Medical Gases Clinical Mandatory Training Immediate Life Support (ILS) Non Clinical Mandatory Training Conflict Resolution INITIAL Information Governance Update Paediatric Intermediate Life Support (PILS) Conflict Resolution Update IT Log On Training Safeguarding Adults Update Defibrillation Pacing Cardioversion Junior Doctors Induction Trust Induction Non-mandatory training classroom courses: OTHER TRAINING: PTD Approximately 88 different course titles for clinical and non-clinical staff. Categories include Leadership, Personal development, Information Technology and clinical skills PTD (Personal Training Day) post registration funded continuing professional development PTD training is linked to the clinical workforce and most directly through clinical knowledge and skills development sessions. Trust staff access this training at the University of Brighton. Some PTD funds are ring-fenced for essential training and eligible staff are automatically booked to attend by virtue of their role or position Annual Report V2

42 PTDe RW L&D PTDe (Personal Training Day elsewhere) funded continuing professional development PTDe training is commonly linked with clinical knowledge and skills development but sometimes through management and leadership development in the clinical context; all at post registration level. It enables staff to access training and development not available through the PTD contract with the University of Brighton. RW (Rosemary Wootton Fund) The League of Friends created an educational bursary intended to assist all grades of non-medical staff in the hospital who wish to attend educational courses, seminars and conferences. The fund does not apply to mandatory training activities as these are the remit of the Trust. Staff submit an application form to the Funding Panel which meets bi-monthly. L&D (Learning & Development) Mandatory and non-mandatory courses are funded from this budget as well as 'train the trainer' courses for QVH staff who deliver mandatory training. Some Funding Panel applications are also met from this budget WPL WPL (Widening Participation for Learning) for Bands 1-4 Includes NVQs, Skills for Health, Key Skills training run by FE colleges and other providers. NB: Training data records episodes of training, not headcount, as staff attend multiple training events throughout the year Annual Report V2

43 Table E2 Ethnicity Mandatory and Non Mandatory Training ETHNICITY Mandatory Training Non Mandatory Training White Attended Not attended Attended Not attended Trust % A White - British % % % % 73.7 B White - Irish % % % 7 1.5% 1.6 C White - Any other White background % % % % 7.6 Mixed D Mixed - White & Black Caribbean % 3 0.2% % 6 1.3% 0.2 E Mixed - White & Black African 4 0.1% 0 0.0% 5 0.3% 0 0.0% 0.3 F Mixed - White & Asian 5 0.1% 6 0.4% 1 0.1% 0 0.0% 0.1 G Other Mixed 3 0.1% 0 0.0% 2 0.1% 0 0.0% 0.2 Asian or Asian British H Indian % % % % 2.9 J Pakistani 6 0.2% 2 0.1% % 3 0.6% 0.5 L Other Asian % % % % 0.0 Black or Black British M Caribbean 7 0.2% 0 0.0% 3 0.2% N African % % 4 0.2% 4 0.8% 0.1 P Other Black % 2 0.1% % 3 0.6% 0.7 Other Ethnic Groups R Chinese % 8 0.5% 8 0.5% 8 1.7% 0.7 S Other % % % % 0.4 Undefined % % % 0 0.0% 4.0 Z Not Stated % % % 6 1.3% 4.3 Codes D to S (BME) % % % % 12.7 Grand Total % % % % 100.0% Annual Report V2

44 Table E3 Ethnicity Other Training OTHER TRAINING Funding Source ETHNICITY L&D PTD PTDe RW WPL Total TOTAL % Trust % A White - British % 73.7 C White - Any other White background % 7.6 H Indian % 2.9 J Pakistani % 0.5 L Other Asian % 0.0 N African % 0.1 R Chinese % 0.7 S Other % 0.4 Undefined % 4.0 BME % 12.4% Grand Total % 100.0% Table E2 shows the number of staff who attended and did not attend both mandatory and non mandatory training. The majority of staff attending mandatory and non mandatory training defined as White British. 14.8% of staff attending mandatory and 17.9% attending non mandatory defined themselves as BME, an over representation against the Trust workforce (12.6%), showing that statistically there are no barriers to training for BME staff. Table ES shows the number of staff attending Trust funded training by Ethnicity, the Majority of staff attending defined as White British. 6.4% of staff defined as BME, an under representation against the workforce average (12.4%). A large number of staff did not define their Ethnicity and actions within the EOS will monitor if there are any potential barriers for BME staff accessing funded training Annual Report V2

45 Table E4 Age Mandatory Training and Non Mandatory Training AGE Mandatory Training Non Mandatory Training Attended Not attended Attended Not attended Trust % % % % % % % % % % % % % % % % % % % % % % % % 2 0.4% % 2 0.1% 0 0.0% 0 0.0% 0.33 Undefined % % 5 0.3% % 0.00 Grand Total % % % % Table E5 Age Other Training OTHER TRAINING FUNDING SOURCE AGE L&D PTD PTDe RW WPL Total Total by % Trust % % % % % % % 6.52 Undefined % 0.33 Grand Total % Table E4 shows the number of staff attending mandatory and non mandatory training by Age, the majority of staff accessing training are aged This is a shift against the baseline data where the majority of staff are aged There is an under representation of staff aged and attending both mandatory and non mandatory training, there could statistically be a barrier to attending training for staff in bands 1-4 where the majority of staff aged are based. Mitigating actions will be contained within the EOS to investigate and monitor access to training over the next four years Annual Report V2

46 Table E6 Gender Mandatory Training and Non Mandatory Training Gender Mandatory Training Non Mandatory Training Attended Not attended Attended Not attended Trust % Female % % % % 76.3 Male % % % % 23.7 Grand Total % % % % 100.0% Table E7 Gender Other Training OTHER TRAINING FUNDING SOURCE GENDER L&D PTD PTDe RW WPL Total Total by % Trust % Female % 76.3 Male % 23.7 Grand Total % 100.0% Tables E6 and E7 show the breakdown by gender of staff accessing mandatory, non mandatory and other training, there is a large under representation of male staff attending courses against the workforce average of 23.7%. Statistically there is a barrier for male staff to access the training sessions. Mitigating actions will be contained within the EOS to monitor access over the next four years and put in place the necessary changes Annual Report V2

47 Table E8 Religion and Belief Mandatory Training and Non Mandatory Training RELIGION AND BELIEF Mandatory Training Non Mandatory Training Attended Not attended Attended Not attended Trust % Atheism % % % % 3.80 Buddhism % 5 0.3% % 3 0.6% 0.22 Christianity % % % % Hinduism 0 0.0% 2 0.1% 5 0.3% 0 0.0% 0.11 I do not wish to disclose my religion/belief % % % % 4.46 Islam 2 0.1% 6 0.4% 2 0.1% 2 0.4% 0.00 Judaism 1 0.0% 0 0.0% 1 0.1% 0 0.0% 0.00 Other % % % 8 1.7% 2.83 Undefined % % % % Grand Total % % % % 100.0% Table E9 Religion and Belief Other Training OTHER TRAINING FUNDING SOURCE RELIGION AND BELIEF L&D PTD PTDe RW WPL Grand Total Total by % Trust % Atheism % 3.80 Christianity % I do not wish to disclose my religion/belief % 4.46 Other % 2.83 Undefined % Grand Total % 100.0% Table E8 and E9 show the religion and belief of staff accessing training. Due to the poor quality of data it is not possible to make any meaningful analysis. Mitigating actions are contained within the EOS to monitor and improve data collection, awareness and confidence in declaration Annual Report V2

48 Table E10 Sexual Orientation Mandatory Training and Non Mandatory Training Sexual Orientation Mandatory Training Non Mandatory Training Attended Not attended Attended Not attended Trust % Gay 8 0.2% 1 0.1% 2 0.1% 0 0.0% 0.22 Heterosexual % % % % I do not wish to disclose my sexual orientation % % % % 3.04 Undefined % % % % Grand Total % % % % 100% Table E11 Sexual Orientation Other Training OTHER TRAINING FUNDING SOURCE Sexual Orientation L&D PTD PTDe RW WPL Grand Total Total by % Trust % Heterosexual % I do not wish to disclose my sexual orientation % 3.04 Undefined % Grand Total % 100% Table E10 and E11 show the sexual orientation of staff accessing training. The majority of staff have not defined their sexual orientation and due to the poor quality of data it is not possible to make any meaningful analysis. It should be noted that 0.2% of staff accessing mandatory training defined as Gay, this is in line with the data held on ESR, and shows no statistical barriers for Gay staff. However due the poor quality of data on ESR it is not possible to reflect if this is a true representation of confidence in staff to be open about their sexual orientation when attending training courses, or completing monitoring forms. Mitigating actions are contained within the EOS to monitor and improve data collection, awareness and confidence in declaration Annual Report V2

49 Table E12 Disability Mandatory Training and Non Mandatory Training DISABILITY Mandatory Training Non Mandatory Training Attended Not attended Attended Not attended Trust % No % % % % Undefined % % % % 79.1 Yes % % % % 0.9 Grand Total % % % % 100% Table E13 Disability Other Training OTHER TRAINING FUNDING SOURCE DISABILITY L&D PTD PTDe RW WPL Total Total by % Trust % No % Undefined % 79.1 Yes % 0.9 Grand Total % 100% Table E12 and E13 show the disability status of staff accessing training. Due to the poor quality of data held on ESR it is not possible to make any meaningful analysis, however from the data above it is evident that there is an over representation of staff attending mandatory, non mandatory and funded training who declare a disability. Statistically against the data held on ESR this would show that there are no immediate barriers to accessing training however until the data on ESR is improved no true analysis can be made. Mitigating actions are contained within the EOS to monitor and improve data collection, awareness and confidence in declaration Annual Report V2

50 9.3.6 Employee relations activity Table F1 Table F1 shows the number of staff involved in an employee relation by Ethnicity. 1 employee defined as BME, this is an under representation against the workforce average. Actions within the EOS will continue to monitor the number of BME staff involved in ER cases as nationally it is reported that they are over represented against the workforce Annual Report V2

51 Table F2 Table F2 shows the distribution of staff involved in employee relations by age. The majority of staff are aged (27.2%), which shows no significant difference against the workforce average of 27.3%. A high percentage of staff did not define their age (27.2%) and they have not been included in the supporting table Annual Report V2

52 Table F3 Table F3 shows the distribution of employee relations by gender, the majority of cases involved female colleagues (78.8%), this figure is in line with the workforce average and shows no significant imbalance for the Trust to monitor. Data on Employee relations by Sexual Orientation, Religion and Belief and Disability is not sufficient to analyse. Due to the high number of undefined data contained within ESR it is not possible to determine if staff who are LGB&T, Disabled or have a particular religion are more or less likely to be involved within employee relations. Mitigating actions are contained within the EOS to monitor and improve data collection, awareness and confidence in declaration and patterns will continue to be monitored over the next 4 years Annual Report V2

53 9.3.7 Consultant Clinical Excellence Awards There are 57 Consultants, who could apply for Clinical Excellence awards subject to eligibility. In the 2011 exercise, 7 people were awarded a local clinical excellence award. 33 people have a locally agreed award in payment and 7 people have a national award in payment, making 39 in total. The tables below show the breakdown of awards by ethnicity, age, gender, religion and belief, sexual orientation and disability. Further data gathering on religion and belief, sexual orientation and disability will be required to improve the analysis. Where the data exists, there is no evidence to suggest that any group is under-represented in receipt of awards. Ethnicity Table G1 Comparison of Consultants in post Vs CEA awards Annual Report V2 Table GI shows the percentage of consultants in post and the corresponding percentage that achieved a CEA by Ethnicity. This is the first year this data has been analysed so it is not possible to make any comparison to previous year s data. The majority of CEA winners are defined as White British or White Any Other Background (66.6%) and 10.3% are not stated. 18.1% of winners are defined as BME, this is an under representation against the number of BME consultants in post and mitigating actions within the EOS action plan will continue to monitor any imbalance over the next 4 years.

54 Age G2 - Comparison of Consultants in post Vs CEA awards Gender G3 - Comparison of Consultants in post Vs CEA awards Table G2 shows the percentage of consultants in post and the corresponding percentage that achieved a CEA by age. The majority of award winners were with no significant under or over representation against the baseline data. Table G3 shows the percentage of consultants in post and the corresponding percentage that achieved a CEA by gender. The majority of award winners were male with no significant under or over representation against the baseline data Data on Consultants and CEA winners by Sexual Orientation, Religion and Belief and Disability is not sufficient to analyse. Due to the high number of undefined data contained within ESR it is not possible to determine if consultants who are LGB&T, Disabled or have a particular religion are more or less likely to win an award. Mitigating actions are contained within the EOS Leavers to monitor and improve data collection, awareness and confidence in declaration and patterns will continue to be monitored over the next 4 years Annual Report V2

55 Section H Leavers by Reason of Redundancy Table H1 Redundancies by Ethnicity Leavers for period Leavers by % Split Trust % Ethnicity White British Irish Any other White background Mixed White & Black Caribbean White & Black African White & Asian Any other mixed background Asian or Asian British Indian Pakistani Bangladeshi Any other Asian background Black or Black British Caribbean African Any other Black background Chinese or other Ethnic group Chinese Any other Ethnic Group Not Known/Stated BME Total White % Table H1 shows the number of staff that took redundancy between January and November 2011 by ethnicity. The majority of staff taking redundancy defined as White British (89.5%), an over representation against the workforce average. No BME staff took redundancy during The Trust has completed it s restructuring programme and is not expecting any further redundancies to arise. Data on Leavers has been populated from the Electronic Staff Records (ESR) system Annual Report V2

56 Table H2 Redundancies by Age Table Age Group Leavers for period Leavers by % Split Trust % Total H3 Redundancies by Gender Gender Leavers for period Leavers by % Split Trust % Male Female Total % Data on Leavers has been populated from the Electronic Staff Records (ESR) system. Table H2 shows the number of staff taking redundancy by Age. The majority of staff were (36.8%) an over representation against the workforce demographics of 29.5% Table H3 shows the number of staff taking redundancy by gender. The Majority of redundancies were by female staff (63.2%), however there is an over representation of male redundancies, 26.8% against the workforce demographics. Data on redundancies by Sexual Orientation, Religion and Belief and Disability is not sufficient to analyse. Due to the high number of undefined data contained within ESR it is not possible to determine if staff who are LGB&T, Disabled or have a particular religion are more or less likely to take voluntary or involuntary redundancy. Mitigating actions are contained within the EOS to monitor and improve data collection, awareness and confidence in declaration and patterns will continue to be monitored over the next 4 years Annual Report V2

57 Section I Other Reasons for Leaving Table I1 Leavers by Ethnicity Ethnicity Leavers for period Leavers by % Split Trust % White British Irish Any other White background Mixed White & Black Caribbean White & Black African White & Asian Any other mixed background Asian or Asian British Indian Pakistani Bangladeshi Any other Asian background Black or Black British Caribbean African Any other Black background Chinese or other Ethnic group Chinese Any other Ethnic Group Not Known/Stated BME Total Grand Total % Table I1 shows the number of leavers during January and November 2011 by Ethnicity. 21.1% of all leavers defined as BME, an over representation against the workforce average. Mitigating actions will be contained within the EOS to monitor the retention of staff by ethnicity and ensure no protected characteristic is being disproportionately affected Annual Report V2

58 Table I2 Leavers by Age Age Group Leavers for period Leavers by % Split Trust % Total Data on Leavers has been populated from the Electronic Staff Records (ESR) system. Table I2 shows the number of staff leaving the organisation by Age. The majority of staff were age when they left (34%) an over representation against the workforce demographics of 23.7%. Actions contained with the EOS will monitor staff retention, to ensure the organisation creates an environment and culture where staff feel able to progress through the bandings. Table I3 Leavers by Gender Gender Leavers for period Leavers by % Split Trust % Male Female Total % Data on Leavers has been populated from the Electronic Staff Records (ESR) system. Table I3 shows the number of staff leaving the organisation by gender. The Majority of leavers were by female staff (60.8%), however there is an over representation of male leavers, 39.2% against the workforce demographics. Actions contained with the EOS will monitor staff retention, to ensure the organisation has an environment and culture where male staff want to stay at the organisation Annual Report V2

59 Data on leavers by Sexual Orientation, Religion and Belief and Disability is not sufficient to analyse. Due to the high number of undefined data contained within ESR it is not possible to determine if staff who are LGB&T, Disabled or have a particular religion are more or less likely to leave the organisation. Mitigating actions are contained within the EOS to monitor and improve data collection, awareness and confidence in declaration and patterns will continue to be monitored over the next 4 years. Table J1 Reason for Leaving (All Leavers) Reason Leavers for period Leavers by % Split Death in Service Retirement Resignation Redundancy End of Fixed Term Contract Total Data on Leavers has been populated from the Electronic Staff Records (ESR) system Annual Report V2