ࡱ> y /bjbj 7{{#'PP8|r /""(."."."v#v#v#///////$1M4H&/v#v#v#v#v#&/."."H;/>%>%>%v#."."/>%v#/>%>%VH,@ -."z#, .Q/0/,x4$4 -4 -v#v#>%v#v#v#v#v#&/&/>%v#v#v#/v#v#v#v#4v#v#v#v#v#v#v#v#v#P p: Goal 1 ( Objective 1): Improving the collection and the analysis of evidence in equality & human rights across the Trust. The equality aim is to reduce discrimination, harassment and victimisation against the 9 protected characteristics.  SELF ASSESSMENT RAG RATING ActionsMeasured byTimescaleResponsibility Audit the existing systems for capturing the 9 protected characteristicsCompletion of audit Audit report with Gap analysis completedLead Nurse for Patient Experience and Quality(LNPEQ) /Head of Information(HoI)Complaints capture the 9 PCs. Patient records and patient survey cover the majority of PCs and others can be analysed through forums/qualitative data.Revising current systems for capturing the 9 protected characteristicsReport/action plan identifying timeline for implementation completedLNPEQ/HoI/Head of Human Resources (Workforce Transformation) (HHR(WT)Patient Reports for Equality and Diversity Committee redesigned to enable analysis against the 9 protected characteristics. Staff Reports for Equality and Diversity Committee redesigned into dashboard style with greater analysis into reasons linked to training and performance management cases, promotions etc.Develop staff awareness/briefing sessionsCommunication plan Staff guidance document completedLNPEQ/ HHR(WT)Equality Training programme agreed with Head of Training and Development and published on Training Directory. Staff Equality and Diversity Guidance booklet /Toolkit developed and published on the intranetImprovement in data collectionPerformance data and reports reflecting the 9 protected characteristicscompletedLNPEQ/HoI/HHR(WT)Equality Dashboard developed. Agreed that Dashboards will be reviewed by the Equality and Diversity Committee on a quarterly basis  Goal 2 (Objective 2): Establish a clear and robust engagement mechanism for engaging with patients, carers and local communities to improve their access and experience. The equality aim is to advance equality of opportunity between people who share a protected characteristics or those who do not  SELF ASSESSMENT RAG RATING ActionsMeasured byTimescaleResponsibility To provide a joint stakeholder governance group (Equality & Diversity Scrutiny group) across the health economy. Group established representing the 9 protected characteristics and agreed terms of reference31st March 2014 (revised timescale due to cessation of Equality and Diversity Scrutiny Group)LNPEQ/HHR(WT)) in collaboration with WHCT E&D LeadGroup was initially established and regular meetings chaired by Rani Virk Membership reviewed and now have wider membership from LD, Gypsies and Travellers etc.Following the dissolution of the PCT the membership decided that this would not be continued as a joint health economy action plan. The Trust has therefore revised its plan which is now reviewed by our internal Equality and Diversity Committee with membership from interest groups. Equality and Inclusion is now a standing agenda item on the Patient Experience Committee.Equality and Diversity Committee to agree the work programme which meets the equality and diversity needs of patients and the community.Trust work programme agreed for each year. Effective training programme for group membersComplete but on-goingLNPEQ/HHR(WT)) in collaboration with WHCT E&D LeadTraining of local communities was completed in 2012/13. We are now developing a programme to attend local community groups which reflect the 9 protected characteristics as we found that they could not commit to attending our meetings. Outreach is the preferred method for the these groups. Provide evidence of compliance against the Equality and Diversity group work programmeReports including action plans Reduction in complaints (Annual complaints report)Complete and on-goingLNPEQ/HHR(WT)) in collaboration with WHCT E&D LeadEDS Scrutiny Group agreed that the Trusts should have a formal process for self-assessment against the EDS goals and outcomes. The community network did not feel equipped to RAG rate the Trust despite training provided. They prefer a self-assessment model that they can then review.Equality and Diversity Committee will review and monitor performance through the Annual Report and quarterly staff and patient experience dashboards/reports. A copy of this final review will be shared with the Worcestershire Equality Group chaired by the Local Authority, and also to community engagement teams.Communication of EDS outcomes publishedPublish reports/engagement Make available in different communication formatsComplete and on-going quarterly reports and annual reportsLNPEQ/HHR(WT)) Annual reports completed for 2011/12 , 2012/13, 2013/14 and work commenced on 2014/15. Quarterly and Annual Reports are published on website and intranet. Website requires regular monitoring and updating. Goal 2 (Objective 3): Improve the health outcomes for patients, carers and communities with specific protected characteristics. The equality aim is to reduce discrimination, harassment and victimisation against the 9 protected characteristics SELF ASSESSMENT RAG RATING ActionsMeasured byTimescaleResponsibility Improving the experience of people with disabilities who use health services who access acute hospital services Visual Hearing Physical Learning disabilitiesImprovement reported against established pathways Health checkers & CQC action plans Reduction in complaintsComplete and on-going to ensure progress maintained. LNPEQ in collaboration with interest groups Health Checkers report demonstrates improvement. Health checkers are our critical partners who review services at the Trusts request. LD performance dashboard in place Monitoring of complaints against the 9 PCs commenced.To investigate the access and experiences for gypsies and travellers community Audit of the health needs of gypsies and travellers community within Worcestershire county 1 October 2014 not met - ongoingLNPEQ in collaboration with interest groups Key community linksEngagement with Gypsies and travellers lead has commenced.Accessing Gypsy & traveller training for the Trust. This has not been achieved in this plan other than publishing the Good Practice Toolkit. Work with the county council community links to get feedback regarding access of services at the 3 hospital sites has commenced This needs to be prioritised for 2015-19 action planTo investigate the access and experiences for lesbian, gay and bi-sexual populationAudit of the health needs of lesbian, gay and bi-sexual patients within Worcestershire county1 April 2015LNPEQ in collaboration with interest groupsNeed to engage with local LGB community leads. Work plan to be developed and prioritised in the 2015-19 action plan. Goal 3 (Objective 4): Establish employee support networks that represent the protected characteristics where these are requested through engagement with employees. The equality aim is to foster good relationships between people who share protected characterises and people who do not share it.  SELF ASSESSMENT RAG RATING ActionsMeasured byTimescaleResponsibility Publish the outcomes of staff surveys on the intranet site Reports available on the staff intranet siteComplete and ongoingHHR(WT)Completed on an annual basis. Management report published and staff hand outs circulated with payslips annually. Results of Staff Friends and Families Test (SFFT) will be published on intranet and daily brief.Investigate need for formal staff group addressing issues around the 9 characteristics Added question to 2012 Staff survey which did not demonstrate need at that point in time. Results of Staff SurveysCompleted. HHR(WT)Staff engagement questions added in Staff Survey. Survey results did not indicate a need for a formal group. To be considered further as part of staff engagement programme.Host annual staff engagement event Evaluation of event 1st April 2014 and then annualHHR(WT)/LNPEQThis needs to be prioritised for 2015-19 action plan.  Goal 4 (Objective 5): To provide vision, strong leadership and ensure that Equality and Diversity is embedded into the business framework of the Trust. The equality aim is to advance equality of opportunity.  SELF ASSESSMENT RAG RATING ActionsMeasured byTimescaleResponsibility To establish a robust governance structure for Equality and Diversity.Governance structure in place e.g. PCEC, E&D Committee, Workforce and OD Group, Minutes of meetings Reports/action plans Board/senior management Equality & Diversity leadsCompleteDirector of HR and OD/Director of Nursing and MidwiferyComplete and on-going. Investigate ways to embed Equality & Diversity into existing business planning processes to address the 9 PCsBusiness guidance/template Objectives and actions of business plansCompleteHHR(WT)/LNPEQ with Director of StrategyTemplate for Business Plans amended to include protected characteristics. . Develop comprehensive training programme for Managers and Staff Evidence of training programme Staff Training records On-line E&D training recordsComplete and on-goingHHR(WT)/LNPEQ with Director of StrategyCompleted with Training and Development Department in 2013. Reviewed annually as take up is monitored through OLM and through staff survey results.Equality and Diversity objectives to be included in the staff appraisal processStaff Survey, Patient Survey, Complaints, Appraisal paperwork, Staff Training recordsComplete and on-going Director of HR and OD/Director of Nursing and MidwiferyAppraisal Policy and paperwork reviewed and monitored through Staff Opinion SurveyTo review the Competency framework for Equality & Diversity Leadership course contents/programmes Evaluation of programmesRemoved by EDS2 (Nov 2013)Director of HR and OD/Head of Training and DevelopmentThe revised EDS2 removed this as an outcome.     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