SECTION B PART 8.1- QUALITY REQUIREMENTS KPI s 1. All providers shall produce equality objectives and action plans in line with the requirements of the Equality Act 2010 and the NHS Equality Delivery System, by the April 2012. Measured by- Provider published annual report. 2. All providers shall - Achieve in all 4 Goals and 18 Outcomes of Equality Delivery System, "Developing Grade" as a minimum by 31st March 2013. Measured by- Provider published annual report. SECTION B PART 12 - SERVICE USER, CARER AND STAFF SURVEYS Equality Monitoring - Patient Experience 1. The Provider shall include an equality monitoring form in surveys requesting data on the protected characteristics and shall disaggregate results by the legal protected characteristics (age, disability, gender re-assignment -when appropriate - maternity and pregnancy, race, sex and sexual orientation) of large scale patient/ carer experience surveys, and staff surveys, as part of the analysis of feedback. Please note that providers should seek advice before implementing any gender re-assignment monitoring. 2. The Provider shall take action to improve disclosure of equality monitoring data in large and small scale patient/carer experience surveys and staff surveys. The Provider should establish a baseline of equality monitoring data within completed surveys and identify gaps for all protected characteristics, where applicable. 3. The provider will take steps to engage with staff, patients and carers from all protected groups, including those identified as not responding to surveys. 4. The Provider will monitor complaints by all protected characteristics where applicable, analyse this data for trends and report findings to the commissioner as part of the complaints reporting arrangement. Equality Monitoring - Service Usage 5. The Provider shall collect data from patients in relation to their protected characteristics and shall disaggregate this data as part of the analysis of service usage. 6. By 31st March 2012 the Provider shall ensure it has mechanisms in place to collect and analyse data on the first language of patients accessing services.
Equality and Workforce 7. The provider shall monitor its workforce representation, recruitment process (applicants, shortlisted and appointed), access to training, sick leave, staff turnover, and grievance procedures by the protected characteristics of age, disability, gender identity, maternity & pregnancy, race, religion or belief, sex and sexual orientation as outlined in the Equality Act 2010 and the Equality Delivery System. The Provider shall report on this data and how the data has been used in line with the reporting requirements outlined in clause 14.3.2. The report shall also include the publication of the organisation s gender pay gap. 8. The Provider shall ensure where possible that major staff surveys include an Equality Monitoring form requesting data on all protected characteristics, and shall disaggregate this equality data as part of the analysis of feedback. The Provider will take steps to develop equality monitoring in its staff surveys by all 9 protected characteristics. 9. The Provider shall ensure it has adequate equality diversity and human rights training available commensurate to the needs of staff at all levels. 10. The Provider shall ensure that by 31st March 2013 85% of staff have undertaken Equality, Diversity & Human Rights training in the last 3 years and shall ensure that staff refresh training at least 3 yearly. The Provider shall report on take up of training annually. 11. All non NHS providers will in addition provide the information required below. Less than 5 employees Organisations with fewer than 5 directly employed persons must provide a written assurance that they are committed to equality, diversity and human rights and will adhere to the principles of the Equality Act 2010. Following any recruitment which increases the size of the firm to 5 or more employees they will provide the information required at the appropriate level. Level 1 (5 to 49 employees) All organisations with between 5 and 49 employees must achieve criteria 1-4 listed below. 1. All organisations must provide an equal opportunities policy in respect of the legal protected characteristics (age, disability, gender re-assignment, marriage and civil partnership, maternity and pregnancy, race, religion or belief, sex and sexual orientation) covered under the Equality Act 2010 and will include at least: - a) Recruitment, selection, training, promotion, discipline and dismissal.
b) Discrimination, harassment, and victimisation, making it clear that these are disciplinary offences within the organisations. c) Identification of the senior position with responsibility for the policy and its effective implementation. d) How they will communicate the policy to your staff. 2. Evidence of effective implementation of the policy in the organisation s recruitment practices, to include open recruitment methods such as the use of NHS Jobs, job centres, careers service or press advertisements 3. Regular reviews of the policy 4. Regular monitoring of the numbers of job applicants from the different protected characteristics. Level 2 (50 or more employees) All organisations with 50 or more employees must achieve criteria 1-4 in level 1 and the additional criteria 5 10 listed below. 5. Provide written instructions to managers and supervisors on equality in recruitment, selection, training, promotion, discipline and dismissal of staff 6. Provide equality training for managers and any staff responsible for recruitment and selection 7. Carry out monitoring on the number of employees from different protected characteristics by grade when: a) in post b) applying for posts c) taking up training and development opportunities d) promoted e) transferred f) disciplined and dismissed g) leaving employment 8. If monitoring reveals under-representation of the groups listed in 7 above to take steps - including positive action to address any imbalances 9. Regular reporting and consultation on equality issues within the workforce 10. Mention in the organisation s recruitment advertisements and publicity literature that equal opportunities practices are in place.
Section B Part 14: 14.2 National Requirements clause 4 4. Equality monitoring report Topic Reporting Elements Frequency 1. Workforce Breakdown by protected characteristics* Annual Staff by banding Staff by role (admininsttive; senior management; medical/dental; nursing qualified; nursing support; prof/tech qualified; prof/tech support; domestic/estates; other) Recruitment - applications, short-listing and appointments Training Sick leave Grievances Disciplinaries Bullying and Harassment Employment Tribunals (discrimination related) Leavers headcount summary of relevant issues from exit interviews Staff survey outcomes Annual Staff network update Annual 2.Service Use / Data sets and Completion Rate Board composition by protected characteristics (Age, Disability, race, religion or belief, sex and sexual orientation Completed initial audit of access to services by protected characteristics of patients. Audit of DNA rates by protected groups Progress on equality monitoring data improvement targets by protected characteristics for patients Annual Annual 3. Accessibility Report disability access audit Physical access by department Signage and accessibility Availability of Prayer facilities (where appropriate) 4. Patient Experience & Availability of Halal / Kosher meals for patients and staff (where applicable) Use of Interpretation & Translation (including related PALS and Significant events reports) Patient experience: Breakdown of satisfaction levels in patient experience surveys by protected characteristics of patients
Complaints Complaints: Statistics on number of complaints by equality issues, location, brief outline and details of resolution. Complainant: Statistics on number of complaints broken down by Equality group of complainant and a correlation of these. Summary of actions/lessons learnt in addressing EDHR related complaints 5.Communicat ions & Engagement Consultations with equality groups Targeted communications Equality events 6. Management Numbers attending EIA training EIAs completed and published E&D training by % of workforce achieving Trusts specific KSF levels of competency Access to training by protected characteristics of staff 7.Subcontracting Breakdown of staff undertaking PDR by protected characteristics Where other organisations are used to carry out work, outline of the equality clauses or criteria for selection included in contracts / tender specifications Annually 8.Equality Delivery System (EDS) Equality Act 2010 Objectives National Performance Framework EDS action plan and equality objectives. Issues to Report Any problems to be reported to the PCT which affect communities access to appropriate and responsive services e.g. GP lack of details on GP referral forms such as communication requirements causing operations to be delayed as not notified that consent forms needed to be translated into Braille * protected characteristics = Age, Disability, Gender re-assignment, Marriage and civil partnership, Pregnancy and maternity, Race (including national identity and ethnicity), Religion or belief, Sex (gender), Sexual orientation Please note that providers should seek advice before implementing any gender reassignment monitoring.
14.3 Local Requirements Reported Locally 1. The provider shall identify a senior manager with overall responsibility for Equality, Diversity & Human Rights and this person should meet as a minimum on a bi-annual basis with the commissioner to report progress and issues arising. 2. The provider shall provide a plan to demonstrate compliance with contract clause 19 in relation to Equality Act 2010 - both the General and Specific Duties of the Act. The provider shall provide an annual outcome report against the plan and bi-annual progress updates. 3. By April 2012, the provider shall produce evidence-based equality objectives and update these, as a minimum, every four years as outlined by the Specific Duties contained within the Equality Act 2010. 4. The provider shall provide evidence that it has published equality information it has collected and analysed to determine the equality objectives, and to make clear the impact and affect on protected groups of the decisions made and the services it designs and delivers. 5. The provider shall undertake an Equality Analysis of its activity in the form of Equality Impact Assessments in line with the Equality Act 2010. The Equality Impact Assessments are to be published to ensure access to the information for the public and the commissioner. 6. The Provider shall commit to delivering the national NHS Equality Delivery System (EDS) and the NHS Competency Framework for Equality & Diversity Leadership. 7. All providers shall report details of any court or industrial tribunal finding in the last 3 years that your organisation has discriminated against someone because of their age, disability, gender re-assignment, marriage / civil partnership, maternity and pregnancy, race, religion or belief, sex, sexual orientation or their level of pay
8. The provider should commit to partnership working across the local health economy to ensure equality of health outcomes for the 9 protected characteristics and any other agreed characteristics. 9. The provider shall ensure that it has adequate language support mechanisms for patients and, where appropriate, their guardians or carers, who do not speak adequate English to communicate effectively. This includes people whose first language is not English, people with audio and visual impairments and people with insufficient literacy capabilities. The provider shall ensure that such arrangements are in place to support patients accessing services and accessing associated support and information. 14.4 Data Quality Improvements 1. The provider shall undertake an Equality Information Audit to identify gaps in both quantitative and qualitative data and provide a plan for data improvement to be reported as part of the reporting arrangements outlined in section 14.3.2.