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Equality Impact Assessment

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					Equality Impact Assessment
Implementation of Essence of Care Benchmarking

EQUALITY IMPACT ASSESSMENT 1. Directorate: Standards and Nursing 3. Tel No: 01925 664172 5. Start date of this assessment: 20th December 2007 2. Department: Risk Management 4. Person completing this form: Ann Dyer 6. Title of policy/function/service/project etc being assessed: Implementation of Essence of Care Benchmarking across the Trust Existing & Being Reviewed [ ] or a New

7. Is the policy/function/service/project etc Development [ ]

8. Will staff or patients be affected by this policy/function/service/project etc ? Staff and patients

If staff, what is the headcount? All inpatient and community clinical/integrated teams

9. Have they been involved in the development of the policy/function/service/project etc? Yes If YES, who and how? The benchmarks are nationally recognised and have been developed, tested and endorsed by patients, professionals and user groups All teams have completed a benchmarking tool to prioritise the benchmarks that are to be implemented across the trust. All Essence of Care Leads are to attend a Workshop scheduled for January to discuss how the process will be implemented locally. 10. What are the main purpose (aims / objectives) of this policy/function/service/project etc? To improve the quality of fundamental and essential aspects of patient care. 11a. In relation to Staff do you have any data on the number of people from Equality Target Groups that will be affected by this policy/function/service/project being assessed? Such as Recruitment Monitoring, National Census
(i) People from different: racial & ethnic groups, Yes [ ] No [ ] Details: Staff recruitment and workforce data (ii) People of different gender (male, female, transgender) Yes [ ] ] No [ Details: As above except transgender

(iii) People from different religions or beliefs

Yes [

]

No [ ]

Details: Only recruitment data

(iv) Disabled people with: Physical impairments (including wheelchair users) Sensory impairment Mental illness Learning disabilities (v) People of different ages (children up to 18 and adults)

No [ ] Details: Yes [ ] Some not others [ ] Not applicable [ ] Recruitment data only

Yes [

]

No [ ]

Details: Workforce and Recruitment data

(vi) People of various sexual orientation; lesbian, gay, bisexual,

Yes [

]

No [ ]

Details: Recruitment data only

(vii) Carers (Adults & Young Carers)

Yes [

]

No [ ]

Details: Via Worklife Balance Unit

11b. In relation to patients and public do you have any data on the number of people from Equality Target Groups that will be affected by this policy/function/service/project being assessed? Such as Count Me In Census,
Service Monitoring, National Census

(i) People from different: Racial & ethnic groups, Gypsies, travellers Refugees and asylum seekers

Yes [ ] No [ ] Details: Some not others [ ] Service returns Not applicable [ ] Count me in census

(ii) People of different gender (male, female, transgender)

Yes [

]

No [ ]

Details: As above except transgender

(iii) People from different religions or beliefs

Yes [

]

No [ ]

Details: As above except transgender

(iv) Disabled people with: Physical impairments (including wheelchair users) Sensory impairment Mental illness Learning disabilities (v) People of different ages (children up to 18 and adults)

No [ ] Details: Yes [ ] Some not others [ ] Not applicable [ ] As above except transgender

Yes [ ] Yes [

]

No [

Details: As above except transgender

(vi) People of various sexual orientation; lesbian, gay, bisexual,

]

No [ ]

Details: Count me in census

(vii) Carers (Adults & Young Carers)

Yes [

]

No [ ]

Details: Service Returns

12. Are you aware of any consultation or involvement events that been held with individuals or organisations
from Equality Target Groups that could have influence on the policy/function/service/project being assessed?

(Consultation could include formal events such as face to face meetings, focus groups, questionnaires, documentation, use of website or email)
(i) People from different: Racial & ethnic groups, Gypsies, travellers Refugees and asylum seekers (ii) People of different gender (male, female, transgender) Yes [ ] No [ ] Details: Some not others [ ] Discussed at joint service user forums, locality Not applicable [ ] forums, team briefs, heads of service meetings etc Yes [ ] No [ ] Details: As above except transgender

(iii) People from different religions or beliefs

Yes [

]

No [ ]

Details: As above

(iv) Disabled people with: Physical impairments (including wheelchair users) Sensory impairment Mental illness Learning disabilities (v) People of different ages (children up to 18 and adults) (vi) People of various sexual orientation; lesbian, gay, bisexual, transsexual

No [ ] Details: Yes [ ] Some not others [ ] As Above Not applicable [ ] Yes [ Yes [ ] ] No [ ] No [ ] Details: As Above Details:

(vii) Carers (Adults & Young Carers)

Yes [

]

No [ ]

Details: As above plus Carers inside out including young carers Details: As above

(viii) Collective consultation, where this was open to all Yes [ stakeholders including staff, patients, carers, ] members of the general public and partners organisations

]

No [

13a. Evidence from Staff:
Do you have any evidence or reason to believe that this policy/function/service/project etc, has or could result in an adverse/negative impact on people from Equality Target Groups listed in sections 11 and 12? This includes anecdotal evidence and information from Staff involvement events, Staff Surveys, Grievances, Health & Safety, Risk, Access & Facilities Audits, Patient & Public Involvement, PEAT Reports Race Disability Gender Age Sexual Religion or orientation belief Carers Any other Groups

I have some evidence

I have no evidence

Please list the evidence and/or reasons below

13b. Evidence from Patients & Public:
Do you have any evidence or reason to believe that this policy/function/service/project etc, has or could result in an adverse/negative impact on people from Equality Target Groups listed in sections 11 and 12? This includes anecdotal evidence and information from Involvement Events, Forums, Patient Satisfaction Surveys, Complaints, Health & Safety, Risk, Access & Facilities Audits, Patient & Public Involvement Forum, PEAT Reports Race Disability Gender Age Sexual Religion or orientation belief Carers Any other Groups

I have some evidence

I have no evidence

Please list the evidence and/or reasons below:

Please Note – This section should only be completed if you are assessing a function (service). 14. Staff training and other miscellaneous issues… Not Applicable
Details: (i) Have all staff attended training on Equality & Diversity within the last 2 years? Yes [ ] ] No [

Details: (ii) Have all managers attended training on Equality & Diversity within the last 2 years? Are you confident that they apply the criteria of the ‘Two Ticks’ Positive About Disabled People accreditation in all recruitment and workforce situations? Yes [ ] ] Yes [ ] ] Yes [ ] ] No [ No [

No [

Details:

(iii) Have all staff attended training on Disability Awareness within the last 2 years?

(iv) Have all staff attended training on Deaf Awareness within the last 2 years?

Yes [ ] ]

No [

Details:

Details: (v) Do all staff know how to access language interpreter and translation services? a) Face to face? b) Telephone? c) Translation? Yes [ ] ] Yes [ ] ] Yes [ ] No [ No [ No [ ]

(vi) Are professional language interpreters always engaged during confidential consultations (including legal meetings, care planning and reviews) with patients and carers? (vii) Are professional British sign language interpreters always engaged during confidential consultations (including legal meetings, care planning and reviews) with patients and carers? (viii) Do all staff know how to access and use an induction loop facility (fixed or portable)? (viiii) Is the building where the service is located wheelchair accessible?

Yes [ ] ]

No [

Details:

Yes [ ] ]

No [

Details:

Yes [ ] ] Yes [ ] ] Yes [ ] ] Yes [ ] ] Yes [ ] ] Yes [ ] ] Yes [ ] ]

No [

Details:

No [

Details:

(x) Does the reception area have an induction loop system?

No [

Details:

(xi) Does the building have a unisex wheelchair accessible “disabled” toilet? (xii) Does the building have car parking spaces reserved for Blue Badge Holders? (xiii) Does the building have any additional facilities for disabled people such as a wheelchair, hoist, specialist bath, etc? (xiv) ) Does it have any other facilities for people from Equality Target Groups such are prayer and faith resources, etc?

No [

Details:

No [

Details:

No [

Details:

No [

Details:

(xv) Is there anything else that has been undertaken to support equality & diversity such as guidelines, policies, etc?

Yes [ ] ]

No [

Details:

15. Who was involved?
List the people who were involved in this assessment. (Staff, staff side reps, service users, carers, partner agencies/organisations)

Ann Dyer, Risk Management and Joanne Mc Donnell, Modern Matron 16. What supporting evidence was used?
List the evidence which was used during this assessment (Including staff or service monitoring data, staff or service user satisfaction surveys, reports, etc) Personal and professional knowledge/ HSE Guidance Department of Health Essence of Care Guidance

17. What is the Trust doing to support Equality & Diversity in relation to the policy/function/service/project?
List the evidence such as guidelines, training, etc. The Trust has an Equality Diversity & Inclusion Unit based at Hollins Park House. The Trusts Complaints Register is checked against race, disability and gender equality. The Trust has established a Women’s Mental Health Working Group. The Trust has produced a range of Guides for Staff including Delivering Culturally Sensitive Services, Disability Related Access &Facilities, Involving Disabled People &Carers, Alternative Communications, Language Terminology & Etiquette.

Outcomes from the PPI Strategy include: - The involvement of service users and carers on the Change for the Better Programme Board and local delivery teams. The development of the Carers Inside Out Charter, which aims to support carers of Trust patients and Trust staff who have caring responsibilities outside of their paid employment. The development of a template for the design of Family Rooms on in-patient units. Ongoing involvement through the PPI Forum, Joint Service User & Carer Form, Staff Champions, local forums, staff events, newsletters and the web.

Functions Undertaken by the Equality, Diversity & Inclusion Unit: • Supporting the board, managers, & staff in legislative compliance, practical problem solving, input to new schemes & refurbishments. • Direct staff support in recruitment & retention (Access to Work, work place assessment, return to work). • Community Involvement and partnership working. • Equality Scheme incorporating Race Equality Scheme. • Positive Action Employment Scheme: - Direct support to staff with mental health problems or a learning disability - Development of services internally & externally - Raising staff awareness & prioritising needs • Implementing the Carers Inside Out Charter • Supporting the development of voluntary work and work placements within the Trust Staff Training Provided: • Disability Awareness • Equality & Diversity (Also includes Induction & Essentials for managers E & D Master class) • Impact Assessment • Recovery Model (mandatory) • Employment Needs • Dignity & Respect

18. Action Plan – List all actions (large and small) that have been identified during the assessment and include a
named person and date for completion. Action Name Lead Date to be Achieved

Representation has been sought from service users and carers and the voluntary sector in order to participate in benchmarking and development of improvement action plans

19. Following Equality Impact Assessment, what is your assessment?
Have you identified any issues that you consider could have an adverse/negative impact on people from Equality Target Groups? No If NO: You can introduce (if new) or continue to use (if existing) the policy/function/service/project etc If YES: Use the Risk Rating Matrix to assess the level of risk associated to the policy/function/service/project

Consequences

Likelihood / probability of repeat Likely Highly Certain Remote Possible 60% likely
20% chance 1 2 3 4 5 2 4 6 8 10 chance 90% chance 3 4 6 8 9 12 12 16 15 20 5 10 15 20 25

What will you do next?

Insignificant Minor Significant Serious Major

White or Yellow – New and existing. You can introduce (if new) or continue to use (if existing) the policy/function/service/project etc whilst undertaking the actions listed in Section 18. Orange – New. Only introduce the policy/function/service/project etc after undertaking the actions listed in Section 18. Existing. Contact the Equality Diversity & Inclusion Unit to discuss the priorities of further actions listed in Section 18.

Red – New policy/function/service/project etc. Do not introduce it until further investigation has been completed. Contact the Equality Diversity & Inclusion Unit to discuss the priorities of further actions listed in Section 18. Existing policy/function/service/project etc. Contact the Equality Diversity & Inclusion Unit to discuss the priorities of further actions listed in Section 18.

20. Monitoring and Review
(a) Who will be responsible for monitoring the policy/function/service/project etc Name:…………Ann Dyer……………………………………………………………………….. Job title:…………Risk Management Advisor……………………………………………………………………... Contact telephone number:………01925 664172………………………………………………….. Email:………a.dyer@5bp.nhs.uk…………………………………………………………………………… (b) Will the results of the monitoring be reported to a committee? YES If yes, what is the name of the committee? …Health and Safety Committee…………………………………….. (c) When will the policy/function/service/project etc be reviewed? Date - 2009 or if changes in legislation………………………………….

(d) Who will co-ordinate the review? Name:……Ann Dyer…………………………………………………………………………….. Job title:……Risk Management Advisor…………………………………………………………………………... Contact telephone number:…………01925 664172……………………………………………….. Email:…As above…………………………………………………………………………………
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Date assessment completed: 21st December 2007


				
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Description: Equality Impact Assessment