Appendix 1 Details Manager or Sponsoring

Appendix 1 Details Manager or Sponsoring Directors Name: Department/Directorate: Service/Team: Assessment Lead: Hilary Houghton Nursing & Governance Clinical Safety & Effectiveness Hilary Houghton Telephone: 01254 584385 E-mail: Who else will be involved in undertaking the equality analysis and impact assessment: Who are you involving and consulting with? How are you consulting with people from different Protected Characteristics? Who does the policy or decision being made impact upon? Hilary.houghton@lancashirecare.nhs.uk The dress code working group members This consultation process has included HR Managers, Lead Nurse for Infection Prevention & Control, Moving & Handling Lead Nurse, Staff Side Representatives, Professional Lead for Nursing, Head of Clinical Policy Development & Clinical Standards. HR virtual management group 1 Service Users 5 Carers or family 9 General Public 13 Staff 17 Partner organisation s 2 6 10 es es es 14 es 18 es 3 7 11 15 19 No No No No No 4 8 12 16 Indirectl y Indirectl y Indirectl y Indirectly 20 Indirectly Signature: H Houghton Date: 30 th August 2012 Page 1 of 15

What is being analysed and assessed? Name of activity : Dress Code & Uniform Policy Implementation Date: To be advised How was the need for the activity identified? Following TCS & the need to have a single policy for all staff. Some former organisations had this type of policy & some services in LCFT have service specific protocols. How is the activity meeting that need? Fulfilling the need for a corporate dress code and uniform policy for all staff across LCFT. What is the activity looking to achieve? To provide managers and employees with clear standards of dress and appearance. Uniform and dress code of staff will be compliant with the requirements of infection prevention & control, security and health and safety legislation. It will also benefit patients and staff by ensuring a professional image and inspiring public confidence. It will ensure the Trust is compliant with legislation and National DH guidance. What are the aims and objectives? To protect the safety of patients and staff by ensuring that he uniform and dress code of staff complies with infection control requirements, security and Health and Safety legislation and to ensure that all staff present a clean, smart and professional image, which inspires public confidence. Services currently provided: This policy will be applicable across all services provided. Recommendations following change in service: (Please outline recommendations that have been identified for implementation following a review of the activity). It is recommended that this policy will apply to everyone in the Trust and that local protocols will be agreed for specific staff groups/services to clarify the sensible application of this policy. These must be approved by the respective Network Director and the Director of Nursing after consultation with Head of Risk/Infection Prevention and Control and staff side. What Evidence have you considered as part of the Equality Analysis and Impact Assessment? (insert here) 1. All research evidence base references including nice guidance and publication please give full reference DH guidance on Religion and Belief (2009:page 15) Gender Recognition Act (2004) section 22 http://www.justice.gov.uk/guidance/docs/hr-handbook-public- authorities.pdf DH( 2010), Uniforms & workwear: Guidance on uniform and workwear policies for NHS employees and the accompanying DH Equality Impact Assessment Moving and Handling Operations Regulations 1992 (as amended 2002) Guidance on regulations L23, Health and Safety Executive (2004), HSE, ISBN 0-7176-2823 X. Welsh Assembly Government (2010) All Wales NHS Dress Code www.cymru.gov.uk Royal College of Nursing (2009) Guidance on uniforms and workwear Page 2 of 15

Does the activity have the potential to: Have a positive impact (benefit) on any of the groups? Explain how Have a negative impact / exclude / discriminate against any person or group? Explain how this was identified? Evidence/ Consultation? Equality Analysis and Impact Assessment Group Age Disability Marriage & Civil Positive (/N) Negative (/N) Don t know Reasons for positive / negative impact (Please include all evidence you have considered as part of your analysis e.g. population statistics, service user data broken down by equality group (e.g. those undergoing liposuction in the last 12 months including ethnicity, gender, age, disability/long term conditions). This is a generic policy that is applicable to individuals irrespective of their age and will provide equal benefit to all groups. This policy does not discriminate between age groups. It is possible that younger members of staff will dress differently than older members of staff but there is no need to revise the policy as the scope is for clean, neat, tidy & presentable attire rather than particular style. This policy describes smart attire including cultural dress Where this would cause a health and safety risk, restrictions may apply on a case by case basis. LCFT has 6754 employees of these 277 declared an undefined disability & a further 85 staff did not declare their status. Line managers have responsibility for needs of individual staff and will take a sensitive, supportive approach when this affects dress and uniform requirements. Advice will be obtained from occupational health service.. This is a generic policy that is applicable to individuals irrespective of their marriage / civil Guidance Please refer to the guidance notes NB: Requires (existing or new) consultation with relevant people who are from these groups or who have knowledge insight into these groups. N.B. Marriage & CP is only protected in terms of work-related activities NOT service provision (please refer to guidance notes) Page 3 of 15

Partnership partnership, religion or culture and will provide equal benefit to all groups. The policy does allow for the wearing of a plain wedding band jewellery for uniformed & clinical staff who have direct physical contact with patients. Page 4 of 15

Pregnancy and maternity Race In-line with Health and Safety. Risk assessments will be undertaken and alternative uniforms provided where necessary. This is a generic policy that is applicable to individuals irrespective of their race or ethnicity. This policy will be carried out with full consideration of the needs of members of these groups. This allows this policy to be sensitive to the obligations of Muslims and other faith groups whilst maintaining equivalent standards of hygiene In accordance with the DH guidance on Religion and Belief (2009:page 15) The consultation has involved Preston Racial Equality Council and Project BME Lancashire. The only amendment requested was for inclusion of a statement relating to face coverings i.e. the veil. It was advised that the face should not be covered for security & communication reasons The BME staff forum were consulted but no comments were received. Count of LCFT Employee by Ethnicity Religion or belief Data about religion or belief is not currently collected by LCFT. This is a generic policy Page 5 of 15

Sex Sexual orientation that is applicable to individuals irrespective of their race, ethnicity and will provide equal benefit to all groups In accordance with the DH guidance on Religion and Belief (2009:page 15) Wearing of the Kara by clinical staff is permitted & the requirement for sleeves to be able to be rolled up or bracelets pulled back and kept securely in place during hand washing or direct patient care is in line with the DH Equality Impact assessment for Uniforms and Workwear: Guidance This is a generic policy that is applicable to individuals irrespective of their gender, religion or culture and will provide equal benefit to all groups. This policy does not discriminate between genders. This policy will be carried out with full consideration of the needs of members of the transgender community in line with the Gender Recognition Act (2004) section 22.. The policy will have a neutral impact in terms of gender as the requirement is for is for clean, neat, tidy & presentable attire rather than particular style. This dress code policy which describes attire of smart,clean, neat, tidy & presentable including cultural dress is applicable to individuals irrespective of their sexual orientation and will provide equal benefit to all groups. Details of Page 6 of 15

staff profile re sexual orientation have been examined Count of Employee Sexual orientation.do Gender reassignment Vulnerable Groups This policy will be carried out with full consideration of the needs of members of the transgender community in line with the Gender Recognition Act (2004) section 22. The Trust has a clear policy MHA 025 Gender Reassignment Support in the Work Place which supports staff who are transitioning. Once a member of staff decides they wish to undergo gender reassignment a support network will be set up & a member of Human Resources will be assigned to act as contact for the individual concerned. Discussions about how to handle the transition whilst at work will incorporate issues relating to dress code & uniform in their new gender. Local dress codes may be agreed with the Network Director for staff working with vulnerable groups / services. Such local agreements must be wholly consistent with the principles contained within this code and the law relating to personal protective Local dress code protocols will be agreed for Page 7 of 15

Deprived Communities specific staff groups/services to clarify the sensible application of this policy. equipment. This policy applies to all staff thus includes those who work in deprived communities. Local dress code protocols will be agreed for specific staff groups/services to clarify the sensible application of this policy. If no negative impacts have been identified please explain why This dress code policy has been written to enhance public confidence in the cleanliness & hygiene of the healthcare environment. Carers Evidence gathered by the DH has shown that the way that staff dress influences people s perception on the standard of care. Uniforms & name badges can help carers to know who is providing care. Other (please state) Negative impacts have been avoided by using current legislation and DH guidance and undertaking wide consultation. This has also been informed by consultation with HR and staff side representatives, local groups and fora. However it is recognised that the pre TCS LCFT Mental Health Foundation Trust did not have a corporate dress code policy although some services had clear protocols. The introduction of a new corporate dress code may provoke negative feedback. The value of & need for such a policy may be a catalyst for debate & elicit strong personal views. The TCS providers which joined LCFT in June 2011 had approved dress code policies and managers report difficulties in maintaining standards of dress without a policy to inform this issue. A lack of negative impacts must be justified with evidence and clear reasons. Highlight how the policy negates any possible negative impacts. Page 8 of 15

Thus for some parts of the organisation the introduction of this policy will be welcomed but in others the reception may be less enthusiastic and challenging to implement. Does the activity raise any issues in relation to Human Rights as set out in the Human Rights Act 1998 This policy recognises human rights through robust contract procedures that are in place to ensure human rights are not violated. Dress code will be applied fairly and objectively to all staff. [http://www.justice.gov.uk/guidance/docs/hr-handbook-public- authorities.pdf] In developing this policy the author has followed the Human rights Flow Chart and there is no evidence of this policy restricting any human rights. See the Guidance Notes It is important to note that if the decision removes or engages a person s absolute right the policy/decision will need to be changed. Have you carried out the Privacy Impact Assessment N/A What were the findings of the privacy impact assessment when carried out: The privacy impact assessment is not relevant to this type of policy as it does not require the management of : Personal information Body searching Biometric testing Surveillance Recording & microphones Where it is a Limited or Qualified Right the decision needs to be proportional and legal. Representatives from IM&T will make this decision as part of the scrutiny process What is the overall cost Cost & Source(s) of funding Input cost e.g. Financial investment, Page 9 of 15

of implementing the activity? The costs of implementation will be related to provision of uniforms. In some instances it may be that services which currently do not have a uniform will change to providing one. These decisions will be based on protocols agreed in Networks and approved by Network & Clinical Directors. Such costs will be attributable to Service Business managers and will require careful consideration during the development of protocols. Where staff are already provided with a uniform there will be an existing budget code and the impact will be neutral HR, to realise and achieve benefits of the activity Source e.g. specific funding stream, pooled budget or mainstream budget What are the benefits? What targets/indicators will be used to measure these? Benefit Improved professional image Inspire patient & public confidence Support best practice in infection prevention& control Improved consideration of H&S & security Indicator Compliments PPI feedback IPC audits Reduced moving & handling incidents relating to inappropriate footwear All staff easily identifiable by name badge For example EDS Equality Tool for NHS Care Quality Commission (CQC) Outcomes Impact Assessment Risk Score See Appendix 1 Score: 2x3=6 Moderate Potential local media & short term effect on staff + potential up to 100k cost = Minor 2 Possible reasonable chance of occurring = 3 Actions to minimise risk: HR team and Nursing & Governance directorate to have awareness campaign to launch introduction of the new policy emphasising the benefits listed in previous benefit section Network Directors & Business managers to thoroughly cost any financial impact related to any local protocols prior to their approval Staff side to inform their members about their involvement & support of this policy Page 10 of 15

Action following analysis: No major change in policy Adjust policy Continue policy Stop and reconsider policy Continue consultation of new dress code policy & make agreed amendments prior to ratification See page 7 above It is important that the correct option is chosen depending on the findings of the analysis. The action plan and risk assessment must be completed as required. Page 11 of 15

Action Plan * resources required is asking for a summary of the costs that are needed to implement the changes to mitigate the negative impacts identified What is the negative/adverse impact? Potential local media & short term effect on staff + potential up to 100k cost = Minor 2 Possible reasonable chance of occurring = 3 Risk Score current target Actions required to reduce/eliminate the negative impact 6 3 By reducing the impact of adverse publicity to contained in the organisation ( rumours) the score will drop to 1x3=3 This could be achieved by HR team & Nursing & Governance team to have awareness campaign to launch introduction of the new policy emphasising the benefits listed in previous benefit section Resources required* (see guidance note below) Who will lead on action? HR policy group Target completion date To be agreed Network Directors & Business managers to thoroughly cost any financial impact related to any local protocols prior to their approval Page 12 of 15

Staff side to inform their members about their involvement & support of this policy Staff side reps Monitoring and Review Monitoring The responsibility for establishing and maintaining the monitoring arrangements of the EIA action plan lies with the service completing the EIA. These arrangements should be built into the performance management framework. The Impact Assessment action plan will also be visible at a corporate level through the scrutiny and sign off of the EIA summary by the Equality and Diversity Lead. Monitoring arrangements for Impact Assessments and there subsequent action plans will be achieved at a strategic level, through the Strategic Equality and Diversity Group. Please describe briefly, how the action plan will be monitored? E.g. Monitored by departmental E&D group Strategic D&E Group - NHS Aspects of the action plan will be monitored in different ways Staff side & HR policy group will monitor issues & impact concerning individual employees Directors & business managers will monitor implementation process including cost associated with local protocols Head of clinical policy development & clinical standards will monitor the awareness & roll out of the new policy Review The responsibility for establishing and maintaining the review arrangements of the Impact Assessment and the action plan lies with the service completing the Impact Assessment. Page 13 of 15

Date of the next review of the Impact Assessment? It should be reviewed at least every three years to meet legislative requirements How often will the EIA action plan be reviewed? Who will carry out this review? References (websites, journals, reports etc) This will be reviewed after 12 months from date of issue This will be reviewed at 6 months after date of issue & again at 12months Head of clinical policy development DH guidance on Religion and Belief (2009:page 15) Gender Recognition Act (2004) section 22 http://www.justice.gov.uk/guidance/docs/hr-handbook-public- authorities.pdf DH( 2010), Uniforms & workwear: Guidance on uniform and workwear policies for NHS employees and the accompanying DH Equality Impact Assessment Moving and Handling Operations Regulations 1992 (as amended 2002) Guidance on regulations L23, Health and Safety Executive (2004), HSE, ISBN 0-7176-2823 X. Welsh Assembly Government (2010) All Wales NHS Dress Code www.cymru.gov.uk Royal College of Nursing (2009) Guidance on uniforms and workwear Please identify additional sources of information you have accessed to complete the EIA. Page 14 of 15

Signature of person completing the impact assessment: Hilary Houghton Head of clinical policy development Signature of Equality and Diversity Lead or Scrutiny group representative: Date Completed 3.9 12 Date received: 31.8.12 Signature of Network / Service Lead: Date Completed: Date Scrutinised: 3.9.12 Date Signed Off: 3.9.12 Page 15 of 15