Equality Delivery System Goal 1 Grading Template for Bedford Hospital NHS Trust.

Equality Delivery System Goal 1

Grading Template for Bedford Hospital NHS Trust

EDS Outcome 1.1 (EDS Objective 1 – Better health outcomes for all)“Services are commissioned, designed and procured to meet the health needs of local

communities, promote well-being, and reduce health inequalities”

Bedford Hospital Trust is a 403 bed acute district general hospital providing healthcare services to more than 270,000 people living predominantly in North and Mid Bedfordshire. These services are delivered mainly from one site (South Wing) in the centre of Bedford and include a 24hour accident and emergency department. The headcount at the end of December 2011 was 2,461 permanently employed staff.

At Bedford Hospital Trust, the Executive Directors and Clinical Business Units (CBU) are responsible for the day-to-day

management of hospitals services. Last year the Trust launched a transformation programme with the aim of demonstrating that patients are fully at the heart of the design and delivery of its services. The programme will ensure safe quality care is given to patients whilst also ensuring the trust is sustainable – clinically, financially and operationally. There are projects within the transformation plan that will help tackle and reduce local health inequalities.

The Trust published the Public Sector Equality Duty report in January 2012 in compliance with the Equality Act 2010. The

objectives are: to show that the Trust is committed to eliminating any unlawful discrimination, harassment and victimisation and any other conduct prohibited by the Act: to advance equality of opportunity between people who share a protected characteristic and those who do not: To foster good relations between people who share a protected characteristic and those who do not.

Outcome 16 of the CQC report ‘assessing and monitoring the quality of service provision’ found the Trust compliant.The Trust has set up systems through which patients can communicate to the Board using a variety of means including patient

surveys and public board meetings to inform Board members of the services they think should be provided. The patient survey collects data about seven of the protected characteristics. The Trust aims to meet health needs and reduce health inequalities for all protected groups through its annual Quality Accounts reporting.

EDS grade: Developing Reasons for rating:• Outcome – The Trust has plans in place to begin using good data and evidence from public involvement platforms to direct

future service design and organisational development, however, these plans are not yet fully developed.• Engagement. The Trust engages with patients via the in and out patient surveys and patient involvement groups. Service

provision is monitored by CQC and the Trust via the quality Account and Public Sector Equality Duty. However, the Trust is not yet reaching all protected groups.

• Mainstream processes. The Trust will use the Quality Accounts reporting to meet the needs of protected groups. A review of all contracts with commissioners will need to take place to ensure that services are run to meet the needs of all groups.

• Progression plans: To work jointly with Commissioners to ensure that all contracts meet the health needs of protected groups and help reduce health inequalities. To review and update plans regularly with all partner organisations. The Trust Equality Objectives to be published by 6th April 2012

• Disadvantaged groups: The Quality Account has prioritised for improvement patients with diabetes, dementia and the deteriorating patient.

Outcome 1 continued

EDS Outcome 1.2 (EDS Objective 1 – Better health outcomes for all)“Patients’ health needs are assessed, and resulting services provided, in appropriate and

effective ways” Bedford Hospital Trust works closely with its commissioners to ensure that services provided are informed by effective and

inclusive health assessments of its patients. Most commissioning contracts require that health needs are assessed on the grounds of age, gender and where possible ethnicity. The Trust is hoping to introduce a patient profiling system and therefore be able to analyse health assessment by other protected groups in the future. Engagement with patients could be better particularly with LBG patients. However, the Trust has made significant progress in engagement with patients with learning difficulties.

There is evidence from the CQC report that patients’ health needs are assessed and recorded through the use of care plans and

that generally services are provided in appropriate and effective ways. Data by age, gender, ethnicity, disability and other protected characteristics is routinely collected and that there are needs

assessments and resulting service provision have taken into account reasonable adjustments where appropriate and proportionate to do so. Currently, the evidence available does not offer many clear examples of how health needs assessments take into account, where appropriate to do so, particular needs in relation to aspects of diversity. Inpatient and outpatient surveys are routinely collected and show high overall levels of satisfaction.

Outcome 1 continued

There is clear evidence to show that people who use hospital services as inpatients are given a choice of food that takes account of ethical and religious beliefs. Evidence also shows that the menu is available in an easy read format and in a range of different languages. This is supported by compliance with CQC Outcome 16. MDT meetings are held to discuss care plans with patients and carers. Patients are given joint care plans when discharged. SEPT paperwork is used for discharges to enable seamless care. Maternity has hand held notes for discharge. The Trust carries out Disability Access audits that evaluate accessibility of services. We monitor effectiveness via PALS and analyse compliments and complaints by ethnicity and category of complaint.

EDS grade: Developing Reasons for rating:• Outcome: Evidence indicates that health needs assessments and resulting services are delivered by providers in appropriate

ways for only some protected groups..• Engagement: Only with some protected groups, however the Trust has started to carry out good work with disability groups.• Mainstream processes: improvements need to be tracked through contracts• Progression plans: To use good patient profiling so that health assessments can be matched against more of the protected

groups.• Disadvantaged groups: key disadvantaged groups are not yet taken into account.

Outcome 1.2 continued

EDS Outcome 1.3 (EDS Objective 1 – Better health outcomes for all)“Changes across services are informed by engagement of patients and local communities, and

transitions made smoothly” Bedford Hospital Trust is undertaking a significant transformation plan that involves several projects around key service areas. As

a consequence there is likely to be significant and positive changes for patients and service users. However there is currently limited evidence to show that service changes and transitions for patients from protected groups have been taken into account as service pathways are being redesigned. The PALS team are in place to manage and investigate complaints and do investigate each complaint thoroughly and they collect data on some of the protected characteristic but not all.

Throughout the Hospital there are information boards/posters which encourage people to provide feedback on their views and suggestions about how services could be improved these are the ‘Your Experience Matters’ posters. There are also boards throughout the hospital with health promotion and health awareness literature on which also include details of available support services. We consult with stakeholder representatives and NHS Bedfordshire, and Link which reports to Bedfordshire Borough Council. We contribute to PCT and Ambulance Trust newsletters. We commissioned a bereavement suite for maternity services in response to patient concerns. Hospital website details services including information on Equality and Diversity explaining the EDS monitoring and outlining the protected characteristics.

EDS grade: Developing Reasons for rating:• Outcome: the Trust is not currently able to demonstrate that service changes are discussed with all the protected groups

but through analysis of their PALS data can demonstrate that there is no evidence to suggest that any group is more or less satisfied with service changes as a whole.

• Engagement: The Trust has a well-established Learning Disability Forum, Cardiac and Cancer Support Groups and has recently started a focus group with local faith leaders, and has a Maternity Liaison Committee.

• Progression plans: - The move to Foundation Trust status will lead to more engagement with patients and the local community. Complaints to be audited to see if subject of the complaint had protected characteristics other than ethnicity. . Patient Experience Group to use a systematic approach to analysing data and looking at patterns

• Disadvantaged groups: – we already work with some service users with protected characteristics, religion, disability, learning disability.


EDS Outcome 1.4 (EDS Objective 1 – Better health outcomes for all)“The safety of patients is prioritised and assured. In particular, patients are free from abuse,

harassment, bullying, violence from other patients and staff, with redress being open and fair to all”

There is evidence that policies, procedures, and training are provided to ensure patient safety is prioritised and assured.

Grievance and complaints procedures are in place and every effort is taken to ensure that patients are free from abuse, harassment, bullying, violence from other patients and staff. Monitoring procedures are in place. Throughout the hospital, staff are able to demonstrate their awareness of various forms of abuse and are clear about procedures to follow if an allegation of abuse is made or if possible abuse is suspected. There is a local safeguarding children group and safeguarding adults group. A referrals database for children exists. All incidents are recorded on DATIX. Serious incidents and SOVA cases are part of the quarterly safeguarding reports to the Board. The Trust has a Security Strategy and a named Local Security Management Specialist. The Trust has a range of Dignity champions including care support workers, nurses and consultants.

EDS grade: Developing

Reasons for rating:• Outcome: Compliant - the CQC confirmed the Trusts compliance with outcome 7 – ‘Safeguarding people who use the

service from abuse’. Patients using the service could expect to be protected from abuse because there are systems in place and staff have had appropriate training and guidance in regards to safeguarding people. Data is collected overall but not analysed in respect of all protected characteristics.

• Mainstream processes: Staff have received safeguarding training in the last 12 months and processes are in place for renewing this every 3 years in line with CQC requirements

EDS Outcome 2.1 (EDS Objective 2 – Improved patient access and experience)“Patients, carers and communities can readily access services, and should not be denied access

on unreasonable grounds” The Trust was deemed compliant against CQC outcome 4 – ‘Care and Welfare of People who use the service’, they concluded that

staff were positive about providing a high standard of care within their roles and were sensitive to the various health issues affecting their patients and that their knowledge demonstrated that best practice and government guidelines were considered.

Processes and paperwork are in place to capture feedback and complaints about access and quality of services. Evidence is available, through inpatient and outpatient surveys to show that feedback has been broken down by some protected groups.

The service has access to interpreters for people whose first language is not English and similarly the service has access to British Sign Language interpreters and there is some evidence to assess usage of these services.

Disability access audits and action plans have been compiled. A focus group with local faith leaders has been set up recently and both Chapel and Muslim Prayer facilities are available. We have flexible times for cancer outpatients and extended times for the Therapy service. Community Midwives give 24-hour service. The Trust website has a translation facility, and high visibility format.

EDS grade: Developing-Reasons for rating:• Outcome: Bedford Hospital Trust provides some evidence that patients, carers and communities from protected groups

readily access services and report access that is as good as that reported by patients, carers and communities as a whole. The data is not yet analysed in respect of all the protected characteristics

• Engagement: Bedford Hospital Trust has in place patient involvement groups and survey information. There is a well established Learning Disability Forum

• Progression Plans: 7-day working in more areas. The Trust will move towards wider analysis of protected characteristics.• Disadvantaged Groups: It is known that patients with learning disabilities do not routinely complete surveys so an easy to

read survey is being developed

EDS Outcome 2.2 (EDS Objective 2 – Improved patient access and experience)“Patients are informed and supported to be involved in decisions about their care

and can exercise choice about type and place of treatment” The Trust is compliant with CQC Outcome 01 – ‘Respecting and Involving People who Use Services’ and their findings state that

on the whole, patients/relatives were pleased with the care and support that they received whilst in hospital and with the way in which the staff approached their care and treatment needs. They felt that staff took time to explain what was happening to them and to answer any questions about their condition or treatment plans. People felt that they received enough information to help them make informed choices about treatment options and about the focus of the care they wanted to receive. They found that people spoke highly about Cancer Care services. There has also been an improvement in Outpatient Services between 2009 and 2011. Hand held notes in Midwifery record communication and involvement. A Learning Disability assessment has been undertaken by members of the Learning Disability Forum. Action plan developed to ensure the Trust continues to meet the needs of this patient group. Patient views are sought via surveys, involvement groups and the Patient Experience Team. The Trust has a Maternity Liaison Committee, a virtual tour of facilities, diabetes and COPD integrated pathways and Cancer Services Support Group.

EDS grade: DevelopingReasons for rating:• Outcome: There is evidence that the Trust meets this outcome via the CQC assessment however in terms of EDS the data is

not analysed to cover all protected characteristics• Engagement: The Trust engages with patients via patient involvement groups and will continue to develop these and

undertake audits and analyse compliments and complaints via PALS.• Progression plans: To undertake wider analysis of patient data• Disadvantaged groups: Improvement Plan for patients with a learning disability

EDS Outcome 2.3 (EDS Objective 2 – Improved patient access and experience)“Patients and carers report positive experiences of their treatment and care outcomes and of

being listened to and respectedand of how their dignity and privacy is prioritised”

The CQC felt that Bedford Hospital Trust met the following standards – Outcome 01, ‘Respecting & Involving People Who Use the

Services’ and Outcome 02 – ‘Consent to Care and Treatment’. They felt that patients were spoken to during their time here and had consented to their treatment after fully understanding what was happening and why. In Maternity, Mothers said that their delivery options were discussed with them and that they were able to make decisions about the care they wanted. Most staff were seen to approach people in a caring and respectful manner and were heard to explain procedures and give choices. In most areas curtains were drawn and signage was used when personal care was in progress. We have single sex compliance. Local surveys show good experiences with day surgery. Teenage bays are separated by sex. Improvement Plan in place to see how we can better support patients with learning disabilities, including the development of an easy to read feedback form. Compliments are collected and monitored by PALS

EDS grade: Developing-

Reasons for rating:• Outcome:. There is evidence that the Trust meets this outcome overall however the data is not broken down in respected of

all the protected characteristics.• Engagement: The organisation uses both inpatient and outpatient patient feedback surveys to assess patient experiences of

its services. Bedford Hospital Trust has in place patient involvement groups and survey information. There is a well established Learning Disability Forum. There is a PALS service

• Disadvantaged groups: There is sometimes a problem with single sex wards when the main carer who needs to stay with a patient with dementia is of the opposite sex. Side rooms are used where available.

EDS Outcome 2.4 (EDS Objective 2 – Improved patient access and experience)“Patients’ and carers’ complaints about services, and subsequent claims for redress, should be

handled respectfully and efficiently” There are set policies and procedures in place to deal with complaints by the organisation and the Trust has a PALS service.

Audits of complaints are reported to the Board. Complaints are handled in line with DH requirements within defined timescales. There are also mechanisms for complainants to escalate concerns to the Complaints Ombudsman if they are not satisfied. Complaints are dealt with in person wherever possible and the PALS service is available for patients and carers to talk through any concerns. Meetings are held with relevant staff and complainant to try to resolve issues. PALS reports data on all complaints but they are not broken down by all protected characteristics. The trust records many protected characteristics of patients so there is the potential to undertake further analysis in line with the data we already hold as part of the patient record. The Trust has a ‘Being Open’ Policy and an information sheet for patients. The Trust is compliant with Outcome 17 of the CQC review of compliance.

EDS grade: Developing

Reasons for rating:• Outcome: Data is available and routinely collected by some protected characteristics to demonstrate that complaints by

patients and carers is handled with as much respect and efficiency as those for patients as a whole.• Engagement: Throughout the Hospital there are information boards/posters which encourage people to provide feedback

on their views and suggestions about how services could be improved these are the ‘Your Experience Matters’ posters. There are also boards throughout the hospital with health promotion and health awareness literature on which also include details of available support services.

• Progression plans: To undertake further analysis of patients who complain.

EDS Outcome 3.1 (EDS Objective 3 – Empowered, engaged and well-supported staff)“Recruitment and selection processes are fair, inclusive and transparent so that

the workforce becomes as diverse as it can be within all occupations and grades”

The Trust has a current Recruitment and Selection Policy, which was agreed with Staff Side. The policy is published on the Trust’s intranet for all staff and managers to access. The policy outlines the process all managers must adhere to when recruiting staff into the Trust. The HR department gives assurance that there is fairness and equity throughout the process.

Recruitment data on gender, disability, ethnicity, religion or belief, sexual orientation and age is captured at the point of

application (through NHS Jobs). This data is analysed on an annual basis for each of the protected characteristics listed above to give an insight into whether there is a fair proportion of applicants, those shortlisted and those appointed is fair across all protected characteristics. This information is presented to the Equality and Diversity Committee on a quarterly basis . Action plans are developed where gaps are identified.

Candidates apply through the NHS Jobs website. Managers are emailed the application forms which do not show any identifiable

information (name, address, protected characteristic information) to ensure applicants are shortlisted purely on their skills and experience. Identifiable information is only given once candidates have been shortlisted for interview.

Each successful candidate is required to forward information to the Occupational Health department regarding their fitness to be

able to undertake the role they have been offered. The Occupational Health Department will assess each candidate and advised the manager if there is any requirement to make reasonable adjustments.

The Trust as been awarded the Two Ticks Symbol to demonstrate our commitment to continuing to recruit applicants with disabilities.

The Equality and Diversity Steering Group meet on a quarterly basis. The membership includes a member of the Staff Side

organisations and a member from the Diversity network. This enables engagement with staff side and staff regarding issues relating to ensuring a fair selection process.

Complaints regarding the recruitment and selection process are fully investigated to ensure there are no unfair practices. Full

guidance is provided on our intranet site for managers who are selecting new staff, including information relating to diversity. Employment Services are responsible for ensuring fair selection processes are followed.

All new staff undertake Equality training as part of their induction. This incorporates information relating to the Equality Act and

the protected characteristics. The Trust is about to launch new Recruitment and Selection Training for all recruiting managers. Equality training is available on e-Learning and is monitored by the Training Department. Staff undergo annual appraisals and all staff apart from directors and medical staff are appraised in line with the Agenda for Change KSF outlines, which has Equality and Diversity as Core Dimension 6.

Outcomes 12 and 13 of the CQC report 2011 show there are safe and robust recruitment processes in place that show that all

staff recruited to work in the hospital were appropriately checked to ensure adequate safeguard for people using the service.


EDS grade: DEVELOPING

Reasons for rating:

• Outcome: Data is collected for all applicants,, via the online application process (using NHS Jobs). Data is collected on gender, disability, ethnicity, religion or belief, sexual orientation and age. Data for other protected characteristics is currently not captured via NHS Jobs. Data available is analysed on an annual basis for the Equality and Diversity Annual report.

• Engagement: There is full engagement with staff side on the development of all policies and procedures. • Mainstream processes: there is evidence to demonstrate how hospital services reports on this outcome, for most protected

characteristics, using for example the annual Equality and Diversity report. Further work now needs to be undertaken to ensure the outcome of this analysis is imbedded.

• Disadvantaged groups: Information is currently not requested via NHS Jobs application forms on gender reassignment, and civil partnership, therefore data cannot be analysed on these protected characteristics.


EDS Outcome 3.2 (EDS Objective 3 – Empowered, engaged and well-supported staff)“3.2 Levels of pay and related terms and conditions are fairly determined for all posts, with staff

doing equal work and work rated as of equal value being entitled to equal pay”

Existing workforce data for all staff is analysed on a six monthly basis for gender, disability, ethnicity, religion or belief, sexual

orientation and age, compared to the local population and this information is presented to the Equality and Diversity Committee. Analysis is undertaken for gender and ethnicity regarding representation at board and senior management level. Action plans are developed where gaps are identified.

Currently, only data relating to gender and ethnicity is compared by pay band to ascertain if there is equality with regard to levels

of pay. Reports are produced for the Trust board. These reports incorporate what the Trust has achieved to date in line with Equality

and also provides analysis of the workforce by the protected characteristics. This Single Equality Scheme is published on the intranet for all staff and staff side to be able to review as required.

The Public Sector Equality Duty is published on the Trust’s website All new roles are evaluated using the NHS job evaluation criteria and are consistency checked by Management and Staff Side.

Trust Board positions are reviewed by the Remuneration Committee and detail published in the annual report. Medical staff are appointed on national terms and conditions as appropriate to their role.

Any local changes proposed by management to terms and conditions are presented to staff side at the monthly Joint Staff and

Management Committee as appropriate for consideration and comment prior to implementation.

EDS grade: DEVELOPINGReasons for rating:

• Outcome: The organisation engages with all staff on data relating to protected characteristics,. We currently analyse staff by pay band only for gender and ethnicity.

• Engagement: The organisation engages through the Trust’s Diversity network and though the Trust’s staff side committee. The Trust has a newly formed Staff Council which looks at all aspects of hospital life including changes to workforce configuration.

• Progression Plans: To analyse staff in relation to all the protected characteristics• Characteristics All protected characteristics can be reported through the Electronic Staff Record system . The analysis shows

that staff from minority ethnic groups are not represented widely at Board and senior manager levels compared to the workforce as a whole. A larger proportion of minority ethnic staff are employed in the lower salary bands and within the doctor category. Information is currently not collected on gender reassignment, and civil partnership, therefore data cannot be analysed on these protected characteristics.


EDS Outcome 3.3 (EDS Objective 3 – Empowered, engaged and well-supported staff)“Through support, training, personal development and performance appraisal, staff are confident and competent to do their work, so that services are commissioned or provided

appropriately” All staff, irrespective of their protected group, are required to have an annual appraisal which includes a personal development

plan. Appraisals are monitored by the Training Department and statistics are produced on a monthly basis and presented to the Executive Management Board. There is no evidence to show that staff from a particular protected group is any different from appraisal completed by staff as a whole.

All staff are given equal access to training and development as required for them to be able to be competent in their role. There is

a centralised budget for training held by the Head of OD. Training data is monitored by the Executive Management Board and the Trust Board

The Trust has Learning and Development Strategy Committee which oversees planning, commissioning and the delivery of

training . A renewed Learning and Development Policy which has been approved by staff side. The Committee would be used to establish if there has been any unfairness in the provision and uptake of training for a particular group. Any complaint of unfair treatment can be raised by staff and would be investigated in line with the Trust’s grievance procedure. There is no evidence of claims that demonstrates that this is an issue.

CQC 07 outcome showed compliance with staff having training and guidance on safeguarding issues. In the last year appraisals have increased from 60% to 75%.

EDS grade: DEVELOPING-

Reasons for rating:

• Outcome: There is no evidence of staff from any particular characteristic being specifically disadvantaged compared to the overall workforce.

• Engagement: JSMC, Staff Council and well established Training Department • Disadvantaged characteristics: Information is currently not collected on gender reassignment, and civil partnership,

therefore data cannot be analysed on these protected characteristic


EDS Outcome 3.4 (EDS Objective 3 – Empowered, engaged and well-supported staff)“Staff are free from abuse, harassment, bullying, violence from both patients and their relatives

and colleagues, with redress being open to all” The Trust has a ‘Dignity at Work’ policy (formerly Bullying and Harassment) and is available on the Trust’s intranet site and eHR.The policy which has been approved by staff side, clearly details what accounts for bullying, harassment, discrimination and

victimisation, gives examples of what bullying and harassment may look like and outlines what action any member of staff can take if they feel they have or believe they have received inappropriate behaviour. It also outlines what support is available. The policy encourages staff to report all incidents of bullying and harassment either to their manager or to the HR department. They are also encouraged to report incidents they witness.

The Trust works collaboratively with UNISON on this. A poster and leaflet campaign have been developed to publicise the policy. The Trust has a policy for raising concerns in the workplace and a policy on support for staff involved in potentially traumatic work

related situations.. Cases of bullying and harassment are analysed on an annual basis for each particular group. There is no evidence to show that

staff from a particular group are different compared with the level of abuse experienced by staff as a whole. Incidents of bullying and harassment are monitored via complaints, employee relations activity and through the annual staff

opinion survey.

EDS grade: DEVELOPING-

Reasons for rating:

• Outcome: The organisation, using available data and evidence, to demonstrate there is no evidence to show staff from a particular group are disadvantaged.

• Engagement: The organisation engages with both staff side and staff on issues relating to bullying and harassment.• Disadvantaged characteristics: Information is currently not collected on gender reassignment, civil partnerships, therefore

data cannot be analysed on these protected characteristics.


Outcome 3.5 (EDS Objective 3 – Empowered, engaged and well-supported staff)“Flexible working options are made available to all staff consistent with the needs of patients,

and the way people lead their lives”

The Trust is committed to providing working options that are flexible, accommodating and consistent with the needs of patients. The Trust has a policy relating to the flexible working options available to all staff. We are starting to gather for such requests made as these are normally agreed between the manager and the member of staff

and an agreed outcome is confirmed. A recent survey indicated that only one manager had been unable to support a flexible working request in the past year. The needs of the service are always considered when considering any request for flexible working. The number of staff using flexible working options is average for a Trust this size as determined by the Staff Opinion survey.

No grievances have been raised because of a refusal to grant flexible working.

EDS grade: DEVELOPING

Reasons for rating:

• Outcome: Data is currently not collected on the number of staff requesting flexible working as many of these arrangements are agreed informally between the manager and the member of staff. However data can be analysed by protected characteristics on staff who work part time compared to the workforce as a whole.

• Engagement: The organisation engages with both staff side and staff on issues relating to bullying and harassment• Disadvantaged characteristics: Information is currently not collected on gender reassignment, civil partnership, therefore

data cannot be analysed on these protected characteristic.


EDS Outcome 3.6 (EDS Objective 3 – Empowered, engaged and well-supported staff)“The workforce is supported to remain healthy, with a focus on addressing major health and

lifestyle issuesthat affect individual staff and the wider population”

The Trust has an onsite Occupational Health Department. They offer support and advice to both staff and managers relating to

health issues, especially in relation to a member of staff’s fitness to undertake their role. The Trust also employs a full-time chaplain for the pastoral care of staff and patients.

Staff are encouraged to raise concerns to either their manager or the Occupational Health department if they believe that their

physical or mental health is being adversely affected within the workplace The Trust’s sickness absence policy lays out the process that is to be followed when a member of staff is off sick either on a short

term basis or long term (over 4 weeks). Occupational Health provide advice to managers for staff who are have a disability under the Equality Act and provide advice relating to adjustments that should be made to a role or the physical premises to enable the member of staff to be able to continue working. There is evidence of adaptations being made and the use of Access to Work to enable continuity of employment. Other health related policies include Dignity at Work, support for Staff involved in Stressful situations.

Any member of staff with health issues (both long term and short term) will be assessed by the Occupational Health Department. They will assess the individual’s ability to be able to undertake the role and will advise on adjustments required or when redeployment is required. The Human Resources Department will be involved in any requirement to redeploy any member of staff.

The sickness absence policy was recently reviewed and rewritten in collaboration with staff side. Staff side represent their

members who are being formally managed under the sickness absence policy and work with management and the member of staff to find a positive outcome for all.

The Occupational Health department run a variety of campaigns during the year to tie in with national campaigns for the benefit of

staff (e.g. assistance to stop smoking, weight management). Last year 13 Health Promotion events were held by the Occupational Health Department and 13 more are planned for 2012. All staff are encouraged to have the flu vaccine (last year 987 staff were vaccinated) and all staff have access to a confidential counselling service. The Occupational Health Manager reports to the Health and Safety Committee on health related matters e.g. uptake of flu vaccine.

The Trust has a gym and yoga classes have just commenced.

EDS grade: DEVELOPING- • Reasons for rating:• Outcome: The organisation runs frequent health promoting activities. The hospital also has a Chaplain to provide pastoral

support to staff and patients of all faiths and none.• Engagement: all Health related policies are agreed with Staff Side via the JSMC• Disadvantaged characteristics: Information is currently not collected on gender reassignment, civil partnership, pregnancy

and maternity, therefore data cannot be analysed on these protected characteristic.


EDS Outcome 4.1 (EDS Objective 4 – Inclusive leadership at all levels)“Boards and senior leaders conduct and plan their business so that equality is advanced,

and good relations fostered, within their organisations”

The Trust Board receive an annual report on Equality and Diversity. Equality and Diversity training is mandatory for all staff within the Trust. This is offered as an e-learning package. Completion of this training is incorporated into the mandatory training report that is on the board agenda quarterly. A more detailed report on this training goes to the Trust Management Forum on a monthly basis.

A quarterly meeting of the Equality and Diversity Committee is chaired by a non-executive director. An action plan to take forward equality and diversity issues is monitored through this meeting. This Committee is integrated within the governance structure of the hospital, with issues being escalated to the Quality committee meeting.

All policies are assessed for their equality impact although it is not clear how consistently this impact assessment is conducted.

EDS grade: DevelopingReasons for rating:• Outcome: There is some evidence of considerations being given to equality issues, but little evidence of embedding within

contracts and business plans. This is not a high priority consideration when forming business plans. • Engagement: The Trust actively engages with community groups representing those with protected characteristics. • Progression plans: There are no plans in place currently to move to the next level within the Equality Delivery System.• Disadvantaged groups: There is limited evidence to suggest that the needs of many protected groups are taken into account

when considering this outcome.

EDS Outcome 4.2 (EDS Objective 4 – Inclusive leadership at all levels)“Middle managers and other line managers work in culturally competent ways to create a work

environment free from discrimination;and support and motivate their staff to do the same

Equality and Diversity training is mandatory for all staff and is included in the corporate induction for all new staff. This helps to set the tone for the organisation. Al staff are required to undergo ongoing training which is available via e-Learning and I monitored by the Training Department. Equality and Diversity is Core Competence 6 on the KSF outlines which form the basis of staff appraisals. The Trust has a Privacy and Dignity Policy

EDS grade: Developing- • Reasons for rating: • Outcome: There is evidence of considerations of cultural embedding within the Trust. • Engagement: There is engagement with staff side in producing policies which cover these issues.

EDS Outcome 4.3 (EDS Objective 4 – Inclusive leadership at all levels)“The organisation uses the NHS Competency Framework for Equality and Diversity Leadership

to recruit, develop and support strategic leaders to advance equality outcomes”

The Competency Framework for Equality and Diversity Leadership is a new framework that is not yet being used within the Trust to recruit, develop and support E&D leadership. The framework specifies the competencies that are needed for staff who are leading on equality and diversity. Within the framework the competencies for effective leaders of equality and diversity have been mapped to those within the NHS Knowledge and Skills Framework (KSF) and the Leadership Qualities Framework (LQF).

The framework most extensively used within the Trust is the Knowledge and skills framework (KSF), which has equality and diversity as one of the core dimensions that apply to every job at some level. Every post has a KSF outline associated with it, which is available to potential candidates as part of recruitment processes. The KSF outline is used to review the performance of the individual staff member during their annual personal development review (PDR). The numbers completing their PDRs are monitored and reported to managers monthly and to the board quarterly.

EDS grade: Undeveloped Reasons for rating:• Outcome: The competency framework for Equality and Diversity Leadership is not currently being used within the Trust but

consideration is being given to this and will be taken forward by the newly appointed Head of OD.

EDS Objectives The NHS is asked to… Outcomes EDS Rating

R A G P

1. Better health outcomes for all The NHS should achieve improvements in patient health, public health and patient safety for all, based on comprehensive evidence of needs and results

1.1 Services are commissioned, designed and procured to meet the health needs of local communities, promote well-being, and reduce health inequalities

1.2 Individual patients’ health needs are assessed, and resulting services provided, in appropriate and effective ways

1.3 Changes across services for individual patients are discussed with them, and transitions are made smoothly

1.4 The safety of patients is prioritised and assured. In particular, patients are free from abuse, harassment, bullying, violence from other patients and staff, with redress being open and fair to all

1.5 Public health, vaccination and screening programmes reach and benefit all local communities and groups

Not Applicable

2. Improved patient access and experience The NHS should improve accessibility and information, and deliver the right services that are targeted, useful, useable and used in order to improve patient experience

2.1 Patients, carers and communities can readily access services, and should not be denied access on unreasonable grounds

2.2 Patients are informed and supported to be as involved as they wish to be in their diagnoses and decisions about their care, and to exercise choice about treatments and places of treatment

2.3 Patients and carers report positive experiences of their treatment and care outcomes and of being listened to and respected and of how their privacy and dignity is prioritised

2.4 Patients’ and carers’ complaints about services, and subsequent claims for redress, should be handled respectfully and efficiently

3. Empowered, engaged and well-supported staff The NHS should Increase the diversity and quality of the working lives of the paid and non-paid workforce, supporting all staff to better respond to patients’ and communities’ needs

3.1 Recruitment and selection processes are fair, inclusive and transparent so that the workforce becomes as diverse as it can be within all occupations and grades

3.2 Levels of pay and related terms and conditions are fairly determined for all posts, with staff doing equal work and work rated as of equal value being entitled to equal pay

3.3 Through support, training, personal development and performance appraisal, staff are confident and competent to do their work, so that services are commissioned or provided appropriately

3.4 Staff are free from abuse, harassment, bullying, violence from both patients and their relatives and colleagues, with redress being open and fair to all

3.5 Flexible working options are made available to all staff, consistent with the needs of the service, and the way that people lead their lives. (Flexible working may be a reasonable adjustment for disabled members of staff or carers.)

3.6 The workforce is supported to remain healthy, with a focus on addressing major health and lifestyle issues that affect individual staff and the wider population

4. Inclusive leadership at all levels NHS organisations should ensure that equality is everyone’s business, and everyone is expected to take an active part, supported by the work of specialist equality leaders and champions

4.1 Boards and senior leaders conduct and plan their business so that equality is advanced, and good relations fostered, within their organisations and beyond

4.2 Middle managers and other line managers support and motivate their staff to work in culturally competent ways within a work environment free from discrimination

4.3 The organisation uses the “Competency Framework for Equality and Diversity Leadership” to recruit, develop and support strategic leaders to advance equality outcomes

Bedford Hospital NHS Trust Equality Delivery System

(EDS)

Grading Scores Summary 2012

Red – UndevelopedAmber – DevelopingGreen – Achieving

Purple - Outstanding

Priorities for setting objectivesUnder EDS, the Trust is required to set specific equality objectives, from April 2012, with input from local community interest groups. To date, we have identified the following priority areas for 2012/13

Goals 1 and 2To develop our Patient Experience/User Groups in a centrally coordinated manner to allow for input to services and facilities by March 2013. To review our access audit and take practical steps to further improve disabled access to ‘problem’ areas of the hospital by March 2013.

Goal 3To improve staff data collection to cover all protected characteristics and to analyse results and highlight any inequalities by 30th June 2012.To develop a programme of cultural awareness /equality & diversity training for all relevant staff by 31st May 2012 for implementation by March 2013.

Goal 4To explore the use of the competency Framework for Equality and Diversity Leadership with Head of Organisational Development by 31st May 2012 and make proposals for prioritisation within the annual training needs analysis.

Explanation of Abbreviations used

For your information, the following are an explanation of abbreviations which may be used throughout this document;

MDT – Multi Disciplinary TeamsCQC – Care Quality CommissionLGB – Lesbian, Gay and Bi-SexualPCT – Primary Care TrustSHA – Strategic Health AuthorityKSF – Knowledge Skills Framework

Equality Delivery System Goal 1 Grading Template for Bedford Hospital NHS Trust.

Documents

Transcript of Equality Delivery System Goal 1 Grading Template for Bedford Hospital NHS Trust.