EQUALITY, DIVERSITY & INCLUSION STRATEGY

Transcription

1 EQUALITY, DIVERSITY & INCLUSION STRATEGY (Incorporating the Trust s Equality Information to demonstrate compliance with the Public Sector Equality Duty) Page 1 of 33

2 1. FOREWORD Welcome to the Southport and Ormskirk NHS Trust Equality Strategy for 2017/2019. This document includes information about our patients, our workforce our local population and outlines the Trust s commitment to promoting equality in all its functions and to valuing the diversity of staff and service users. The provision of high quality patient care is our key driver and the principles of equality, diversity and human rights are intrinsic to the Trust s core business. We are committed to delivering high quality services that are accessible, responsive and appropriate to meet the needs of all our patients. In this respect, patient pathways have been designed to reduce variations in care and improve outcomes, whilst recognising the needs of individual patients. We aim to be an employer of choice and ensure that all our staff have equality of access to jobs, to promotion and to training opportunities. The Trust is committed to creating an environment where everyone is treated with dignity, fairness and respect and to developing a culture of support and inclusion for all our employees and for those patients who access our services. Karen Jackson Chief Executive Richard Fraser Chair Page 2 of 33

3 Contents: Section Title Page 1 Foreword 2 2 About Us 1. Our Hospitals 2. Our Population 4 Our Vision and Values 3 Our Population 4 4 The Legal Context 5 1. Equality Act Public Sector Equality Duty 3. Workforce Race Equality Scheme 5 Equality Governance 6 6 Equality Delivery System (EDS2) 8 7 Caring for Our Patients 9 8 Our Workforce 10 Appendices Appendix 1 Equality Diversity and Inclusion Action Plan Appendix 2 Workforce Equality Objectives (EDS 2) Appendix 3 WRES Action Plan Page 3 of 33

4 2. ABOUT US 2.1 Our Hospitals Acute care is provided at Southport and Formby District General Hospital and Ormskirk and District General Hospital. This includes adults and children s accident and emergency services, intensive care and a range of medical and surgical specialities. Women s and children s services, including maternity, are provided at Ormskirk hospital. The North West Spinal Injuries Centre at Southport hospital provides specialist care for spinal patients from across the North West, North Wales and the Isle of Man. 2.2 Our vision and values The Trust aims to establish and embed exemplary healthcare. Our values are expressed through Scope, developed from what staff told us was important to them about the Trust. They are: Supportive Caring Open and honest Professional Efficient 2.3 Objectives of the Trust strategy The Trust s corporate strategy contains five objectives or strategic domains : Work with our partner organisations to provide lifelong, integrated care across the local health economy Ensure excellence in treatment and care Deliver performance, within resources, comparable with the best the NHS can offer Empower and develop staff to achieve their objectives Maintain organisational sustainability 3. OUR POPULATION Southport and Ormskirk Hospital NHS Trust provides healthcare to a population of 258,000 people across Southport, Formby and West Lancashire. Page 4 of 33

5 4. THE LEGAL CONTEXT 4.1 The Equality Act 2010 The Equality Act 2010 ( the Act ) provides the legislative framework to protect the rights of individuals and advance equality of opportunity for all. The Act harmonises and simplifies previous equality legislation with the aim of delivering an accessible framework of discrimination law which protects individuals from unfair treatment and promotes a fair and more equal society. The Act consolidated 116 separate pieces of equality legislation, principally: Sex Discrimination Act 1975 Race Relations Act 1976 Disability Discrimination Act 1995 The Act introduced the new terminology of protected characteristics to which it then applies, in a consistent way, the traditional elements of direct and indirect discrimination, victimisation and harassment. The protected characteristics are as follows: age disability gender reassignment marriage and civil partnership pregnancy and maternity race (includes ethnic or national origins, colour or nationality) religion or belief (Including lack of belief) sex sexual orientation 4.2 The Equality Duty The Act also introduced a new Equality Duty on all public bodies, such as Southport and Ormskirk NHS Trust, which came in to force on 5 th April The new duty replaces the three previous public sector equality duties for race, disability and gender. The aim of the Equality Duty is to embed equality considerations into the day to day work of public bodies so that they tackle discrimination and inequality and contribute to making society fairer. The duty supports good decision making by ensuring that the Trust considers how different people will be affected by its activities, it helps us to deliver policies and services which are efficient and effective; accessible to all; and which meet different people s needs. The Equality Duty has three main aims. It requires the Trust, in the exercise of all its functions, to have due regard to the need to: eliminate discrimination, harassment, victimisation and other conduct prohibited by the Act advance equality of opportunity between people who share a relevant protected characteristic and people who do not share it Page 5 of 33

6 foster good relations between people who share a relevant characteristic and those who do not share it (in respect of the protected characteristic of marriage and civil partnership, only the duty to eliminate discrimination applies) Having due regard means that the Trust must always consciously think about the three aims of the Equality Duty as part of process of day to day decision-making. This means that consideration of equality issues influences the Trust s decision-making process in how we act as employers; how we develop, evaluate and review policy; how we design, deliver and evaluate services and how we commission and procure from others. Further information about the Equality Act 2010 can be found at the Equality and Human Rights Commission Workforce Race Equality Scheme The NHS Equality and Diversity Council in 2014 agreed action to ensure employees from black and ethnic minority (BME) backgrounds have equal access to career opportunities and receive fair treatment in the workplace. The Council pledged its commitment to implement two measures to improve equality across the NHS, which would start in April The first, is a Workforce Race Equality Standard (WRES) that would, for the first time, require organisations employing almost all of the 1.4 million NHS workforce to demonstrate progress against a number of indicators of workforce equality, including a specific indicator to address the low levels of BME Board representation. This report provides the Southport and Ormskirk proposed Action Plan against the nine indicators within the Workforce Race Equality Standard which provides the platform and direction that encourages NHS organisations: To reduce the differences between the treatment and experience of White and BME staff on each of indicators 1-8. To compare not only their progress in reducing the gaps in treatment and Experience but to make comparisons with similar organisations about the overall level of such progress over time. To take necessary remedial action following further analysis on the causes of ethnic disparities in the indicator outcomes. The WRES Standard and the EDS2 are included in the Standard NHS Contract. The regulators, the Care Quality Commission (CQC), National Trust Development Agency (NDTA) and Monitor, use both standards to help assess whether NHS organisations are well-led Workforce Indicators (WRES) Workforce indicators 1. Percentage of BME staff in Bands 8-9, VSM (including executive Board members and senior medical staff) compared with the percentage of BME staff in the overall workforce. 2. Relative likelihood of BME staff being appointed from shortlisting compared to that of White staff being appointed from shortlisting across all posts. Page 6 of 33

7 3. Relative likelihood of BME staff entering the formal disciplinary process, compared to that of White staff entering the formal disciplinary process, as measured by entry into a formal disciplinary investigation 4. Relative likelihood of BME staff accessing non mandatory training and CPD as compared to White staff. National NHS Staff Survey findings: For each of these four staff survey indicators, the Standard compares the metrics for the responses for White and BME staff for each survey question 5. KF 18. Percentage of staff experiencing harassment, bullying or abuse from patients,relatives or the public in last 12 months 6. KF 19. Percentage of staff experiencing harassment, bullying or abuse from staff in last 12 months 7. KF 27. Percentage believing that trust provides equal opportunities for career progression or promotion 8. Q23. In the last 12 months have you personally experienced discrimination at work from any of the following? b) Manager/team leader or other colleagues Boards; Does the Board meet the requirement on Board membership in 9 9. Boards are expected to be broadly representative of the population they serve. All Trusts are required to publish the WRES data and action plan on their website. 5. EQUALITY GOVERNANCE The Equality Act 2010 and the Human Rights Act 1998 provide the legal framework within which the Trust operates its equality governance. Additionally, the Health & Social Care Act 2008, NHS England, the Operating Framework and the NHS Constitution all highlight the need to reduce discrimination in services, improve accessibility and reduce health inequalities for all. The refreshed Equality Delivery System (EDS2) is the framework by which the Trust can demonstrate how it is performing on issues of equality and health inequality to its patients, staff, communities and commissioners. At Board level the lead accountability sits with the Associate Director of HR.A Non- Executive Director also acts as an Equality Champion. The Trust s Equality Assurance Steering Group, reporting through Workforce Committee ensures that the Trust complies with externally set standards and establishes, monitors and reviews content and methods of assurance to the Workforce Committee and Patient Experience Groups in relation to all areas of Equality and Diversity. The Steering reviews relevant policies and procedures for approval and ratification at the Quality Committee. Page 7 of 33

8 Governance Structure Fig 1. Trust Board Workforce and OD Committee Quality and Safety Committee Equality Assurance Steering Group HR Governance 6. THE EQUALITY DELIVERY SYSTEM (EDS2) The Department of Health s Equality and Diversity Council (EDC) developed the original Equality Delivery System (EDS) to help the NHS improve its equality performance and embed equality considerations into mainstream business. It was designed to support NHS commissioners and providers to deliver better outcomes for patients and communities and better working environments for staff, which are personal, fair and diverse. The EDS is about making positive differences to healthy living and working lives. In November 2013 a refreshed EDS was launched, EDS2, which encouraged local adaptation with a strong focus on local issues and problems. The Trust adopted both the original EDS framework and the refreshed system (EDS2). The heart of EDS2 remains a set of 18 outcomes (17 for provider units) grouped into four goals. These outcomes focus on the issues of most concern to patients, carers, communities, NHS staff and Boards. It is against these outcomes that performance is analysed, graded and action determined. The four EDS2 goals are: 1. Better Health outcomes for all 2. Improved patient access and experience 3. A representative and supported workforce 4. Inclusive leadership The grades are as follows: 1. Excelling 2. Achieving 3. Developing 4. Undeveloped Page 8 of 33

9 During 2016/17 the Trust was self-assessed as achieving across 17 of 18 outcomes. The aim is to progress to achieving across all outcomes and to aim to excelling in two outcomes. The progress against the requirements of the EDS2 objectives assisted the Trust to achieve the NAVAJO Chartermark in March 2015 which will be re-assessed in The Navajo Merseyside & Cheshire LGBT Charter Mark is an equality mark sponsored by In-Trust Merseyside & Sefton Embrace and supported by the LGBTI Community networks across Merseyside a signifier of good practice, commitment and knowledge of the specific needs, issues and barriers facing lesbian, gay, bisexual, and transgender (LGBT) people in Merseyside 7. CARING FOR OUR PATIENTS 7.1 Learning Disability The Trust has a learning disability liaison service which supports care of a patient with a learning disability in a number of ways. The service can be contacted by patients, carers, and community teams regarding any reasonable adjustments required to support access to health services within the Trust i.e. quiet waiting areas in out-patients, specific appointment times, and facilities for carers/ family to stay with patient. (We now also have two chair-beds in the Trust which can be used to support family/carers to be comfortable when staying overnight with patients). Patients who have moderate to severe learning disability can be assessed to have their own funded carer to stay with them throughout admission. This supports familiarity in a strange environment, support with nutritional needs and compliance with treatment which contributes to a positive patient experience and outcome for the patient. The use of Medway alerts allows us to identify patients who have a learning disability and benefits the patient by allowing the communication of any necessary reasonable adjustments, the use of the LD health/hospital passport also supports the sharing of information of the needs of the patient. The service also has a strong relationship with both West Lancs and Sefton Community LD teams, which enhances care and communication for both planned and unplanned admissions of a patient with a learning disability. 7.2 Interpreter Services The Trust provides interpreter services for those patients who may speak little or no English and would prefer things to be explained in a language that they are more comfortable with. The Trust can provide a professional interpreter to accompany the patients requiring this service when they attend a hospital appointment. The Trust can offer interpretation services in any language, translations by phone and translations of our printed information leaflets in: British sign language Braille Large print Access to interpreter services can be accessed via the ward or department that the patient is attending of by contacting the ward or department of via the Trust Customer Service Team. Page 9 of 33

10 7.3 Mental Capacity Act 2005 and Deprivation of Liberty Safeguards The Mental Capacity Act (MCA) 2005, covering England and Wales, provides a statutory framework for decision-making in relation to people who lack capacity to make decisions for themselves. The MCA applies to everyone involved in the treatment, care, or support of someone who lacks capacity (including carers and family carers). The Trust staff providing care and treatment to these individuals have a legal obligation to comply with the MCA and associated Mental Capacity Act 2005 Code of Practice. The Trust has a policy which outlines the working practice to embed the requirements of the Act into usual custom, practice and commissioned contracts. The Mental Health Act 2007 has amended the MCA to introduce a system known as the Deprivation of Liberty Safeguards (DoLS). The safeguards came into force on 1 st April The Mental Health Act 2007 has amended the MCA to introduce a system known as the Deprivation of Liberty Safeguards (DoLS). The safeguards came into force on 1 st April The manager must look at all the circumstances of the individual s case and take into account all relevant information, in deciding whether there is a risk of deprivation of liberty. Trust managers are required to look at all the circumstances of the individual s case and take into account all relevant information, in deciding whether there is a risk of deprivation of liberty. The Trust has a named clinical lead for DOLS. 7.4 Patients with Mental Health Needs The Trust recognises the evidence that one third of all inpatients are likely to have some sort of mental disorder. This means that managing patients with mental health needs is a mainstream part of Trust activity. Within the Accident and Emergency department there is a designated room for mental health patients under 136 mental health section. The clinical team in the department work closely with Mersey Care NHS Trust to ensure timely assessments and plans for care are implemented. The frail elderly unit have an in reach service from a mental health practitioner to support/advise on the care of patients on the ward.the wards work closely with the mental health liaison nurses from Mersey care completing timely referrals for mental health assessments. The mental health liaison nurses are integral part of the MDT when best interest meetings are held. Patients are assessed as individual and care is tailored to their needs, additional support with close or continuous supervision is available. Side room facilities are available, with open visiting for relatives / families to support the patient as required. Page 10 of 33

11 7.5 Carers Support The Trust has signed up to John s Campaign to welcome carers whenever they are needed. The campaign recognises the rights of carers to stay with people with dementia at all times. This may be during the day or night, and the trust has purchased two chair-beds which can be used to support family/carers to be comfortable when staying with patients. There are also a number of areas in the Trust which have facilities for carers to utilise to have some quiet space away from the patient bedside. There is a relative s room on critical care, Ward 15a has developed a room for carers to rest and make refreshments, and there is the OASIS room to support family members of patients who are receiving end of life care. For patients on the Regional Spinal Unit, carers who are not local residents are supported in finding local accommodation, for individual cases the Spinal Unit Action Group may also offer an amount of financial support towards this. On the Paediatric unit there is a parent s room where they store food and make refreshments. Comfort bags are available with showering facilities for parents who have children admitted as an emergency. The Developing the Experience of Care Strategy which was launched over the summer has a pledge to develop and implement systems and processes to involve carers and families in decision making. The proposed plan includes implementation of a carer/family charter, information packs, and review of current facilities across the Trust. 8. PATIENT INFORMATION 8.1 Gender Fig 2 The Gender profile of our patients is predominantly female. As the Trust has a maternity unit this is not an unexpected profile. Page 11 of 33

12 8.2 Religion Fig 3 The religions profile of our patients is predominantly Church of England with Roman Catholic as the next biggest group. Atheist is the smallest group although the groups of unknown and none/not religious follow closely behind the Church of England and Roman Catholic Groups. 8.3 Ethnicity Fig 4 The ethnic profile of our patients is predominantly white British, which is a reflection of the local population, with Pakistani being the smallest patient group. Page 12 of 33

13 AFC Band 1 AFC Band 2 AFC Band 3 AFC Band 4 AFC Band 5 AFC Band 6 AFC Band 7 AFC Band 8 Medical Staff Trust Scale Grand Total 9. OUR WORKFORCE Each year the Trust produces information in relation to the make-up of its workforce. Whilst being a legal requirement, this information is also useful for workforce planning. This section outlines what we know about the make-up of our workforce in relation to the nine different protected characteristics. This information has been sourced from the Employee Service Record (ESR); Employees will be routinely provided with the information we hold on them and asked to update their information on a voluntary basis, some staff prefer not to disclose their personal information or have access to ESR manager self-service to update independently. 9.1 The table below shows staff in post, split by Gender and Band. The Trust has a predominantly female workforce in nursing and admin staff across all bands. However, medical staff are predominantly male. As at 31/3/2017 Trust scale staff were 66 male and 34female. The gender profile of the Trust s workforce has remained fairly consistent and shows a split of 81 female to 19 male. (see figure 1). The majority of the female workforce are employed in roles at either Band 2,3,5 and 6. Medical staff are 66 male and 34 female. As at 31/3/2017 Trust scale staff were also 66 male and 34 female. Fig 5 Staff in Post by Gender as at 31/3/17 Gender Female Male Grand Total Page 13 of 33

14 AFC Band 1 AFC Band 2 AFC Band 3 AFC Band 4 AFC Band 5 AFC Band 6 AFC Band 7 AFC Band 8 Medical Staff Trust Scale Grand Total Fig 5.1 Staff in Post by Grade and Gender 4000 Staff in Post by Grade/ Gender 31/3/ Female Male Grand Total Religion & Belief Of the staff who have chosen to disclose a religion to the Trust, the largest group remains Christianity at 60.5 of the total workforce; 17.6 of staff chose not to disclose their religious belief. There next highest groups was Atheist at 6.79, this leaves 15 of staff as declaring themselves as having a religious belief other than Christianity or Atheism. Medical Staff also have Christianity as the highest group at 28. The next highest groups for medical staff are Atheist at 14, Hindu at 12.7 and Islam at of medical staff chose not to disclose their religion or belief. Fig 6 Staff in Post by Religion Religious Belief Atheism Buddhism Christianity Hinduism I do not wish to disclose my religion/belief Islam Page 14 of 33

15 Judaism Other Sikhism Undefined Grand Total Fig 6.1 Staff in post by religion 8000 Staff in Post by Religion Grand Total Trust Scale Medical Staff AFC Band 8 AFC Band 7 AFC Band 6 AFC Band 5 AFC Band 4 AFC Band 3 AFC Band 2 AFC Band Ethnicity/Race The ethnicity profile within the Trust is outlined in Fig 7; 6 of staff have not defined their ethnicity; 84 of the workforce describe their ethnicity as White British therefore a small proportion of staff at 10 can be identified as falling into an ethnic group other than that of White British. The percentage of staff from BME groups who are employed by the Trust is generally higher than the composition of the local population. The breakdown for medical staff is 41 of medical staff describe their ethnicity as White British with 8.5 who decided not to disclose their ethnicity. Therefore 50.5 of the medical workforce could be identified as falling into an ethnic group other than that of White British. The next highest ethnic group for medical staff is Indian at 17. Page 15 of 33

16 AFC Band 1 AFC Band 2 AFC Band 3 AFC Band 4 AFC Band 5 AFC Band 6 AFC Band 7 AFC Band 8 Staff Trust Scale Grand Total Fig 7 Staff in Post by Ethnicity Ethnic Code A - White British B - White Irish C - Any Other White D - Mixed White/Black Caribbean E - Mixed White/Black African F - Mixed White/Asian G - Mixed Other H Indian J Pakistani K Bangladeshi L - Other Asian M - Black Caribbean N - Black African P - Black Other R Chinese S - Other Ethnic Group Z - Not Stated Grand Total Page 16 of 33

17 Fig 7.1 Staff in Post by Ethnicity 8000 Staff in Post by Ethnicity Grand Total Trust Scale Medical Staff AFC Band 8 AFC Band 7 AFC Band 6 AFC Band 5 AFC Band 4 AFC Band 3 AFC Band 2 AFC Band Age The age profile within the Trust (see Figure 4 below) shows that the largest age group of our workforce are those staff between the ages 51 to 60. This is for medical staff. The percentage of staff under 30 is 14 with 65 of our workforce over the age 40 and 39 over the age of 50. The percentage of staff over the age of 60 is 8, this is expected to increase within the next few years due to the changes to the state pension age. Page 17 of 33

18 AFC Band 1 AFC Band 2 AFC Band 3 AFC Band 4 AFC Band 5 AFC Band 6 AFC Band 7 AFC Band 8 Medical Staff Trust Scale Grand Total Fig 8.1 Staff in Post by Age and Band Age Band 17 to to to to to Grand Total Fig 8.2 Staff in Post by Age 8000 Staff in Post By Age Grand Total to to to to to 20 0 AFC Band 1 AFC Band 2 AFC Band 3 AFC Band 4 AFC Band 5 AFC Band 6 AFC Band 7 AFC Band 8 Medical Staff Trust Scale Grand Total The majority of staff in post are between the ages of 30 and 60. The age profile for staff who are 55 plus is a significant proportion of the workforce and also at Band 5, which is likely to contain a significant number of nursing roles in this group. Page 18 of 33

19 AFC Band 1 AFC Band 2 AFC Band 3 AFC Band 4 AFC Band 5 AFC Band 6 AFC Band 7 AFC Band 8 Medical Staff Trust Scale Grand Total 9.2 Disability There are 2.54 of staff who have declared that they have a disability with the largest group being at Band of staff have not declared and 27 of staff are undefined as to whether they have a disability or not. Fig 9 Staff in post who have declared a disability Disabled No Not Declared Undefined Yes Grand Total Fig 9.1 Staff in post who have declared a disability or long term condition Staff With Declared Disability No Not Declared Undefined Yes Grand Total 9.6 Sexual Orientation Of the staff who have disclosed their sexual orientation to us, the largest group remains Heterosexuality at 76, with 0.12 Bisexual, 0.4 Gay, 0.4 Lesbian and 13.5 of staff not disclosing their sexuality. Page 19 of 33

20 AFC Band 1 AFC Band 2 AFC Band 3 AFC Band 4 AFC Band 5 AFC Band 6 AFC Band 7 AFC Band 8 Medical Staff Trust Scale Grand Total Fig 10. Staff in Post by sexual orientation Sexual Orientation Bisexual Gay Heterosexual I do not wish to disclose Lesbian Undefined Grand Total Fig 10.1 Staff in post by sexual orientation 4000 Staff Sexual Orientation Bisexual Gay Heterosexual I do not wish to disclose Lesbian Undefined Grand Total 9.7 Gender Reassignment The Trust records data regarding staff who may have, or be undergoing surgery on a restricted database with the permission of the individual. The Trust is committed to supporting staff who have undergone or who are undergoing gender re-assignment and have policies to ensure that the appropriate support is in place. The Trust has a record of staff who have declared that they have undergone gender reassignment and this is only accessible to nominated staff within the HR Department. Page 20 of 33

21 9.8 Pregnancy and Maternity The Trust supports new parents through its maternity, paternity and adoption leave provision Recruitment This information demonstrates applications made to the Trust through the NHS jobs website and covers the period 1 st April st March 2017 Gender Fig 11 Nursing, AHP, Admin and Ancillary Job Applicants by Gender Equal ops Answer Applied Shortlisted Appointed Applied Shortlisted Appointed Not stated Male Gender Female I do not wish to disclose Total Of 4406 job applications for non-medical jobs 75 of applications were from females and 25 from males. There were 38 of female applicants shortlisted and of males which resulted in appointments for female applicants and of male applicants. Fig 12 Medical and Dental Job Applicants by Gender Equal ops Answer Applied Shortlisted Appointed Applied Shortlisted Appointed Not stated Male Gender Female I do not wish to disclose Total Page 21 of 33

22 Of 141 applications for Medical jobs were from male applicants and from female applicants. There were of female applicants shortlisted and 42.7 of males of which 8.33 (2) female candidates were appointed and (7) males. Disability Fig 13 Nursing, AHP, Admin and Ancillary Job Applicants by Disability Equal ops Answer Applied Shortlisted Appointed Applied Shortlisted Appointed Not stated Disability I do not wish to disclose whether or not I have a disability No Yes Total Of job applicants for non-medical jobs 5.27 declared themselves as having a disability with of those declaring a disability shortlisted and appointed. Fig 14 Non Medical Applicants Meeting Criteria for Guaranteed Interview Scheme Equal ops Answer Applied Shortlisted Appointed Applied Shortlisted Appointed Guaranteed interview scheme Not stated No Yes Total There were 6 appointments made through the guaranteed interview scheme for applicants meeting the criteria which was of applicants declaring a disability shortlisted. Page 22 of 33

23 Fig 15 Medical and Dental Job Applicants by declared disability Equal ops Answer Applied Shortlisted Appointed Applied Shortlisted Appointed Not stated Disability I do not wish to disclose whether or not I have a disability No Yes Total Of job applicants for non-medical jobs 2.13 (3) declared themselves as having a disability none of which were shortlisted or appointed. Fig 16 Nursing, AHP, Admin and Ancillary Job Applicants meeting criteria for guaranteed interview scheme Equal ops Answer Applied Shortlisted Appointed Applied Shortlisted Appointed Guaranteed interview scheme Not stated No Yes Total of applicants who stated that they met the criteria for the guaranteed interview scheme were appointed. Page 23 of 33

24 Fig 16 Medical and Dental Job Applicants meeting Criteria for Guaranteed Interview Scheme Equal ops Answer Applied Shortlisted Appointed Applied Shortlisted Appointed Guaranteed interview scheme Not stated No Yes Total The 3 applicants who believed that they met the criteria for the guaranteed interview scheme were not shortlisted or appointed. Ethnicity Fig 17 Nursing, admin and ancillary Jobs by Ethnicity Equal ops Ethnic Origin Answer Applied Shortlisted Appointed Not stated Total White Total BAME Applied Shortlisted Appointed Total of shortlisted white applicants were appointed to nursing posts compared with 14.4 of BAME applicants. Fig 18 Medical and Dental Job Applicants by Ethnicity Equal ops Ethnic Origin Answer Applied Shortlisted Appointed Not stated Total White Total BAME Applied Shortlisted Appointed Total Page 24 of 33

25 33 of shortlisted applicants from a minority ethnic background are appointed to medical and dental roles compared to 22 of white applicants of applicant did not wish to disclose their ethnic background. Age Fig 19 Nursing, AHP, Admin and Ancillary by Age Equal Applied Shortlisted Appointed ops Answer Applied Shortlisted Appointed Under Age Not stated Total There appears to be a fairly even spread of appointed applicants throughout each age profile apart from the over 60 age group where there is a higher success of appointment and the under 20 age group where there is less likelihood of success. Fig 20 Medical and Dental by Age Equal ops Age Answer Applied Shortlisted Appointed Applied Shortlisted Appointed Under Page 25 of 33

26 Not stated Total There is less likelihood of appointment for medical and dental staff in the 50 age groups who have been shortlisted. Religious Belief Fig 21 Nursing, AHP Admin and Ancillary by Religious Belief Equal ops Answer Applied Shortlisted Appointed Applied Shortlisted Appointed Not stated Atheism Buddhism Christianity Hinduism Religion Islam Jainism Judaism Sikhism Other I do not wish to disclose my religion/belief Total of applicants did not state or preferred not to disclose their ethnic origin. The majority of applicants for non-medical posts were of a Christian belief with 23 of shortlisted candidates appointed. Page 26 of 33

27 Fig 22 Medical and Dental Applicants by Religious Belief Equal ops Answer Applied Shortlisted Appointed Applied Shortlisted Appointed Not stated Atheism Buddhism Christianity Religion Hinduism Islam Jainism Judaism Sikhism Other I do not wish to disclose my religion/belief Total of applicants for medical posts did not state or did not wish to disclose their religious belief. The biggest largest group for medical staff applicants was Islam although no shortlisted candidates were appointed in comparison with of shortlisted medical candidates who had not disclosed their religious belief. Sexual Orientation Fig 23 Nursing, AHP, Admin and Ancillary Staff by Sexual Orientation Equal ops Answer Applied Shortlisted Appointed Applied Shortlisted Appointed Not stated/do not wish to state Sexual Orientation Heterosexual Bisexual Gay/Lesbian Total Page 27 of 33

28 The percentage of Gay, Lesbian and Bisexual applicants appointed is consistent with the percentage of Gay, Lesbian and Bisexual staff appointed. Fig 24 Medical and Dental Applicants by Sexual Orientation Equal ops Answer Applied Shortlisted Appointed Applied Shortlisted Appointed Sexual Orientation Not stated/do not wish to disclose Heterosexual Bisexual Gay/Lesbian Total The percentage of Gay, Lesbian and Bisexual applicants appointed is consistent with the percentage of Gay, Lesbian and Bisexual staff appointed. Transgender Fig 25 Nursing, AHP, Admin and Ancillary Staff by Transgender Equal ops Answer Applied Shortlisted Appointed Applied Shortlisted Equal ops Not stated No Transgender Yes I do not wish to answer this question Total of shortlisted candidates who identified themselves as transgender were appointed. Page 28 of 33

29 Fig 26 Medical and Dental Staff by Transgender Equal ops Answer Applied Shortlisted Appointed Applied Shortlisted Equal ops Not stated No Transgender Yes I do not wish to answer this question Total There were no applicants for medical posts who stated that they may be transgender. Action Plan and Next Steps It is acknowledged by Southport and Ormskirk NHS Trust that positive actions to support Equality, Diversity and Inclusion underpin the principles of positive staff engagement. The Trust has developed an action plan to address the areas of shortfall identified. The Action Plan is attached as Appendix1 and is monitored through the Equality Steering Group, HR Governance and Workforce Committee which is a subcommittee of the board of directors. The Trust has a separate WRES Action Plan which is monitored through the same governance structure. Page 29 of 33

30 Appendix 1 Equality Action Plan 2017/2019 This action plan will be updated as progress is made and or the objectives are reviewed/amended as appropriate including making any additional objectives to the action plan. RAG Rating Incomplete In Progress/on track Ongoing Complete Objective Action Progress Lead Target/Re view Date Equality Act 2010 (including Public Sector Equality Duty) Publication of annual workforce Produce draft report for Assistant December strategy including the workforce publication Director of 2017/ report in December each year HR 2018 Governance Review of Equality Impact Update toolkit Equality & December Assessment documents for policies Diversity 2017 and procedures Lead Equality is mainstreamed through the organisation s business through effective implementation of the Equality Delivery System (EDS) and equality analysis Equality impact assessments are used for all CIP s, Policies, Service changes and organisational change. Equality Impact Assessments are conducted for all CIP s, Policies, Service Changes and Organisational Change CBU ADO s/hr Managers, PMO Office Ongoing RAG Rating Benchmarking with other NHS Trusts and sharing of best practice Publication of WRES Indicators and progress against these Conduct benchmarking exercise Board sign off of WRES Action plan and publication on intranet alongside associated data. Report results and progress against action plan to Equality and Diversity Assurance Group and HR Governance group Action plan developed and circulated to board for sign off. Equality & Diversity Lead Assistant Director of HR Governance January 2018 March 2018 Page 30 of 33

31 All papers to Executive and Board include equality impact declaration by author Governance systems in place to clearly demonstrate compliance with Public Sector Equality Duty. Revise Equality & Diversity Assurance Group Terms of Reference Establish Navajo Task & Finish Group for re-assessment in 2018 Establish responsibility for E&D Lead for service Update Transgender Staff Support Policy Circulate schedule of HealthWatch meetings 2017/18 for specific focus on EDS2 progress Company secretary to monitor papers and ensure equality impact assessed Equality & Diversity Lead to attend HR Governance and Workforce Committee to ensure compliance and involvement across Trust activity ToR to be revised and circulated at and agreed with attendees and sent to Workforce Committee for sign off Ensure stakeholder involvement from all staff groups and schedule of dates publicised on internet E&D Lead post to be put in in place with responsibility for Equality Duties associated with service delivery and Equality Impact Assessments. Policy revisions to be agreed with sign off from E&D Assurance Group, JNC and QA Meetings to be circulated to E&D Assurance group members and attendees identified. Assistant Director of HR Governance and E&D Lead Exec lead Not yet started for Equality/Assi stant Director of HR Governance Not yet progressed Director of Nursing Not yet progressed in absence of E&D Lead Company Secretary December 2017 E&D Lead Ongoing Post not yet appoint ed to Assistant Director of HR Governance E&D (?) Lead December 2017 December 2017 November 2017 December 2017 Ongoing Post not yet appoint ed to Page 31 of 33

32 Review Equality Policy to include Equality and Inclusion EDS2 Self assessment and submission and sign off by HealthWatch against Outcomes Submission completed and published on intranet E&D Lead not yet appointed to E&D Lead E&D Lead December 2017 December 2017 EDS Goal 1: Better Health Outcomes Ensure all services are accessible consider both physical access and access to information Accessible Information Standard (from April 2016) WRES publish data and continue with actions in line with action plan Employee Network Groups are well supported and actions are delivered as appropriate Recruitment & Retention Strategy reflective of Equality and Diversity Initiatives EDS Goal 2. Improved patient access and experience All services accessible to required regulations and standards EDS Goal 3: A Representative and Supported Workforce Data published and action plan monitored through E&D Assurance and HR Governance Currently the Trust has an established disability staff network. Currently promotes LGBT and BME staff network formation via the internet. The take up is very low. Associate Director of HR and Assistant Director of HR Governance to take forward focus groups also in line with WRES action plan Review R&S policies and strategy to ensure compliance E&D Lead not yet appointed to Director of Nursing Action plan developed for board sign off. Actions progressing in accordance with timescales. Start December 2017 Assistant Director of HR Governance Associate Director of HR/Head of HR Recruitment Manager Ongoing April March 2018 December 2017 March 2018 December 2017 Page 32 of 33

33 EDS Goal 4: Inclusive Leadership Senior Leaders are engaged and Board to identify E&D Exec Lead drive equality through attendance at and Equality Champion NED. E&D group.. WRES report presented at July board. E&D champion to be identified at future board. CEO and Company Secretary Sept 2017 Training and development opportunities are available to all staff irrespective of background Leaders are equipped with the skills to manage a diverse workforce Workforce Race Equality Standard increase diversity at all levels of organisation Workforce Race Equality Standard increase diversity at all levels of the organisation Training and development opportunities to be advertised on the training and development website Training data to be added to workforce diversity report Development of a module to be delivered within Leadership and Management programmes facilitated by Education & Training Proposed internal talent management programmes to support the development of junior staff into senior positions Review recruitment practices to gain assurance of the removal of unconscious and conscious bias. Training and development opportunities are advertised on the training and development website Head of Education and Training Head of Human Resources Assistant Director of Organisation al Developmen t CBU HR Managers/A DO s June 2017 March 2018 Ongoing March 2018 Not yet started Page 33 of 33