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Outcome BVH EDS Outcome Report-Mar14.doc

EDS 1.1 Services are commissioned, procured and designed to meet the health needs of local communities.

The Commissioners (Blackpool CCG and Fylde & Wyre CCG) have the primary responsibility for this goal. The Trust liaises with Commissioners to provide services that are designed and procured to meet the health needs of the local community and aim to reduce health inequalities. The Trust also liaises with the three local councils building a multi agency approach. The Trust demographic information from the councils when designing and delivering services to the local population and adapt to changes. The Trust also uses data from the Census and the Office of National Statistics. There are strong links with local organisations and agencies such as Health Watch in developing robust audit and data collection exercises to monitor services. The Trust actively seeks to encourage effectively with equality target groups through Trust membership, committee structures and Governors of the Trust. Evidence considered for services provided by the hospital: Joint Strategic Needs Assessment Quality Accounts Report Public Health Strategy Blackpool Strategic Partnership Acute Contract Review Equality Analysis Equality & Diversity Strategy Report on Sex Workers Working with Gypsy/Travellers Equality and Diversity Audit including Clinical and Ward areas Equality Objectives Equality Diversity & Human Rights Steering Group Partnership Working with third Sector Organisations e.g. Richmond Fellowship, BFW Deaf Society Corporate Equality Group (Fylde Coast) Dementia Project Learning Disabilities Health Needs Assessment Outcomes

EDS 1.2 Individual people’s health needs are assessed

The Trust works with the local Commissioner to target Health Improvement Initiatives and plays an active role in the implementation of the local Public Health Strategy. The Trust liaises with Blackpool Clinical Commissioning Group

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and met in appropriate and effective ways.

(BCCG) and Fylde and Wyre Clinical Commissioning Group (FWCCG) to provide services designed and procured to meet the health needs of the local community and reducing health inequalities. There are strong links with partner agencies and the development of robust audit and data collection system to monitor services. The Trust’s tertiary Lancashire Cardiac Centre draws patients from a wide and more diverse area including a high ethnic minority population. In response to the change in the makeup of the patients accessing services in the Cardiac Centre a multi faith prayer room was commissioned and facilities introduced on ward areas for patients. In addition there are interpreters/translators available for patients whose first language in not English. There are a number of avenues for patients to access further information or support through the Patient and Carers Experience Committee and networking groups such as elected Governors and the Trust’s PALS service. Evidence considered for services provided by the hospital: Report on Sex Workers Caring for People with Learning Disabilities Learning Disabilities Health Needs Assessment Outcomes Care Quality Commission Assessment Tool Ambulatory Gynaecological Service Dementia Project Quality Accounts Report Equality Analysis Equality & Diversity Strategy Outpatients Survey Continuous Improvement Report Inpatients Survey Ambulatory Gynaecological Service Corporate Equality Group (Fylde Coast) Equality and Diversity Audit Equality Objectives Equality Diversity & Human Rights Steering Group Patient and Carers Experience Improvement Group Single Equality Scheme Visually Impaired Working Group Work with Chinese Community

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Work with Polish Community Work with Gypsy/Travellers Community Governor’s Patient Experience Group Trust Membership Group – open to all local residents Motor Neurone Award (for work by the Trust) National Charter re Learning Disabilities Learning Disabilities Action Plan Lesbian Gay Foundation Charter (for work by the Trust) NAVAJO Charter Mark (for work by the Trust) Public Health Strategy Health Improvement Initiatives

EDS 1.3 Transitions from one service to another, for people on care pathways, are made smoothly with everyone well-informed.

The local Commissioners BCCG and FWCCG work closely with the Trust to target Health Improvement Initiatives. The Trust has an active role in the implementation of the local Public Health Strategy. A team from the Women’s and Children’s Unit organised a Vulnerable Women’s and Families Group to provide extra care and support to women who have a high level of social need. The Trust has strong links with partnership agencies and developing robust audit and data collection systems to monitor the service. The Governors of the Trust regularly meet with patients/service users and report back to the Board where there have been problems in relation to the provision and access of services. Changes to services will have an Equality Analysis (EA) completed and where a negative impact is identified members of the Trust will ensure that there is consultation and engagement with the group who may be disadvantaged. The EA will also be completed if the Trust commences reviews or stops the provision of a service to ensure no group is disadvantaged. Acute Contract Commissioning meetings are held quarterly and the Trust is a member of this group which actively seeks to engage effectively with reducing health inequalities for equality target groups. The Trusts Lancashire Cardiac Centre has an experienced patient representative who attends governance meetings and policy forums at the Trust. In addition the Trust’s Women’s and Children’s Division have set up a Midwifery Innovation and Additional Support Team (MIA). This encourages multidisciplinary working to ensure the possible care for vulnerable adults. Evidence considered for services provided by the hospital: Equality Analysis Equality & Diversity Strategy Quality Accounts Report Outpatients Survey

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Continuous Improvement Report Inpatients Survey Ambulatory Gynaecological Service Midwifery Innovation & Additional Support Team (MIA’s) Corporate Equality Group (Fylde Coast) Equality and Diversity Audit Equality Objectives Equality Diversity & Human Rights Steering Group Patient Experience Improvement Group Patient Experience Representatives Single Equality Scheme Visually Impaired Working Group Work with Chinese Community Work with Polish Community Work with Gypsy/Travellers Community Equality Delivery System Consultation and Engagement Event Governor’s Patient Experience Group Trust Membership Group – open to all local residents

EDS 1.4 When people use NHS services their safety is prioritised and they are free from mistakes, mistreatment and abuse.

The Board places patient safety and quality as one of its main objectives and put in place a development programme to better understand the boards’ role in relation to the quality agenda. The focus is on ‘getting the patient in the room’, patient stories and reducing avoidable harm has also given directors a better understanding of the equality, diversity and human rights agenda. This has been supported by the work the board has done to understand the patient and staff pledges within the NHS Constitution. The Trust has a Single Equality Scheme (SES) which is a ‘living document’ continually changing to adapt to the challenges healthcare presents. The SES has been developed in conjunction with third party organisations and NHS Partners including Blackpool CCG and Fylde and Wyre CCG. In addition the Trust introduced an Equality Outcomes Analysis for Clinical and Ward areas which works in conjunction with the Equality Analysis and links to with work around patient safety. This will further assist the Trust to assess and prioritise patients’ safety and ensuring their needs are met. To encourage continuous engagement, involvement and evaluation on all equality work, including patient safety, the Trust invites all stake holders to comment via our internet, PALS, the Equality Delivery System consultation and engagement event and Governors on all equality projects, systems, policies etc and through stakeholder representation on the ED & HR Steering Group.

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Evidence considered for services provided by the hospital: Quality Governance Committee Quality Accounts Caring for People with Learning Disabilities Learning Disabilities Health Needs Assessment Outcomes Equality Analysis Equality & Diversity Strategy Outpatients Survey Continuous Improvement Report Inpatients Survey Equality and Diversity Audit Equality Objectives Equality Diversity & Human Rights Steering Group Patient Experience Improvement Group Patient Experience Committee Single Equality Scheme Visually Impaired Working Group Equality Delivery System Consultation and Engagement Event National Safety Award (recognition for work by the Trust) National Charter re Learning Disabilities National Patient Safety Learning Disabilities Action Plan Health Improvement Initiatives – links to Commissioning Groups

EDS 1.5 Screening, vaccination and other health promotion services reach and benefit all local communities.

The Trust continues to improve its work with Blackpool Clinical Commissioning Group (CCG) and Fylde and Wyre Clinical Commissioning Group in providing services that are designed and procured to meet the health needs of the local community reducing health inequalities. The Trust is strengthening its links with the three local councils which assists the Trust in assessing how best to design and deliver services to the local population and adapt to changes in trends in relation to any of the protected characteristics. The Trust also uses data from the Census and the Office of National Statistics. When the Trust commissions services from other providers evidence is requested on equality and diversity information provided to their staff along with the level of training. Acute Contract Commissioning meetings are held quarterly and the Trust is a member of this group which actively seeks to engage effectively with reducing

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health inequalities for equality target groups. The Trust’s Lancashire Cardiac Centre has an experienced patient representative who attends governance meetings and policy forums at the Trust. In addition the Trust’s Women’s and Children’s Division have set up a Midwifery Innovation and Additional Support Team (MIA). This encourages multidisciplinary working to ensure the possible care for vulnerable adults. For example a team from the Women’s and Children’s Unit have organised a Vulnerable Women’s and Families Group to provide extra care and support for this group of women requiring a high level of social need.

Evidence considered for services provided by the hospital: Health Improvement Initiatives – links to Commissioning Groups Public Health Strategy Blackpool Strategic Partnership Acute Contract Review Equality Analysis Equality & Diversity Strategy Quality Governance Committee Quality Accounts Report Patient Experience Improvement Group Partnership Working with third Sector Organisations Work with Chinese Community Work with Polish Community Work with Gypsy/Travellers Community Patient Experience Committee Learning Disabilities Health Needs Assessment Outcomes Liaise with Blackpool and Fylde & Wyre CCG’s

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

The Trust continues to work with the local Commissioner to target Health Improvement Initiatives and continues to play an active role in the implementation of the local Public Health Strategy. For example a team from the Women’s and Children’s Unit have organised a Vulnerable Women’s and Families Group to provide extra care and support to women who have a high level of social need. There continues to be strong links with partner agencies in developing robust audit and data collection systems to monitor the use of services. When the Trust commissions services from other providers evidence of what equality and diversity training is provided to their staff along with the level of training. In order to encourage continuous engagement, involvement and evaluation on all equality work, including patient

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safety, the Trust invites stake holders to comment via our internet, PALS, the Equality Delivery System consultation and engagement event , and Governors on all equality projects, systems, policies etc and through stakeholder representation on the ED & HR Steering Group. EA’s are quality assured by involving and consulting with the relevant equality group that had been identified as having a negative impact, which minimises or alleviates the potential for further adverse impacts. The Trust has Foundation status and a membership of over 5000 public members and 6000 staff members and actively seeks effective engagement with equality target groups through our membership and committee structure. The Trust’s Lancashire Cardiac Centre has an experienced patient representative who attends governance meetings and policy forums at the Trust. In addition the Women’s and Children’s Directorate have set up a Midwifery Innovation and Additional Support Team (MIA’s). It encourages multidisciplinary working to ensure the every possible care for vulnerable adults.

Evidence considered for services provided by the hospital: Motor Neurone Award (for work by the Trust) National Charter re Learning Disabilities Lesbian Gay Foundation Charter (for work by the Trust) NAVAJO Charter Mark (for work by the Trust) Public Health Strategy Health Improvement Initiatives – links to Commissioning Groups Blackpool Strategic Partnership Acute contract Commissioning Group Acute Contract Review Equality Analysis Equality & Diversity Strategy Single Equality Scheme Quality Governance Committee Patient Experience Improvement Group Partnership Working with third Sector Organisations Work with Chinese Community Work with Polish Community Work with Gypsy/Travellers Community Midwifery Innovation & Additional Support Team (MIA’s) Vulnerable Women’s and Families Group

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Fundamentals of Care Patient Experience Committee

2.2 People are informed and supported to be as involved as they wish to be in decisions about their care.

The Trust uses the results from the Inpatient Questionnaire, Patient Survey and complaints on equality and diversity issues to evaluate how patients are informed and supported in understanding their diagnosis, treatment and place of treatment. The Trust is part of the NHS Choose and Book system which gives patients the freedom to choose where they have their treatment. The Trust works with the local Commissioners to target Health Improvement Initiatives. The Trust has an active role in the implementation of the local Public Health Strategy. For example a team from the Women’s and Children’s Unit have organised a Vulnerable Women’s and Families Group to provide extra care and support to women who have a high level of social need. In addition the Women’s and Children’s Directorate have set up a Midwifery Innovation and Additional Support Team (MIA’s). It encourages multidisciplinary working to ensure the possible care for all especially vulnerable adults. There are strong links with partner agencies to ensure patients are informed and supported. All staff are trained in the Fundamentals of Care. Evidence considered for services provided by the hospital: Motor Neurone Award (for work by the Trust) National Charter re Learning Disabilities Lesbian Gay Foundation Charter (for work by the Trust) NAVAJO Charter Mark (for work by the Trust) Public Health Strategy Health Improvement Initiatives – links to Commissioning Groups Motor Neurone Award (for work by the Trust) National Charter re Learning Disabilities Lesbian Gay Foundation Charter (for work by the Trust) NAVAJO Charter Mark (for work by the Trust) Public Health Strategy Health Improvement Initiatives – links to Commissioning Groups Fundamentals of Care Chaplaincy Team Patient Experience Committee Governors Patient Experience Committee

2.3 People report positive The Trust continues to work with the local Commissioner to target Health Improvement Initiatives. The Trust plays

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experiences of the NHS. an active role in the implementation of the local Public Health Strategy. For example a team from the Women’s and Children’s Unit have organised a Vulnerable Women’s and Families Group to provide extra care and support to women who have a high level of social need. There continues to be strong links with partner agencies and in developing a robust audit and data collection system to monitor the provision of services. The Trust’s Lancashire Cardiac Centre draws patients from a wide and divers area including a high ethnic minority population. In response to the change in the makeup of the patients accessing services in the Cardiac Centre there are leaflets on care and treatment in a number of languages. The Trust actively seeks effective engagement with equality target groups through our membership and committee structures in promoting the Trust’s Privacy and Dignity policy. In addition the Trust provides an opportunity for patients and service users to get involved in assessing all our services via the Equality Delivery System Consultation and Engagement held annually. Evidence considered for services provided by the hospital: Patient Experience Team Patient Experience Improvement Group Privacy and Dignity Policy PALS Complaints Procedure Equality Diversity and Human Rights Steering Group Inpatient Survey Outpatient Survey Patient Satisfaction Survey Governor Patient Experience Committee Chaplaincy Team Equality Analysis Equality & Diversity Strategy Quality Governance Committee Quality Accounts Report Partnership Working with third Sector Organisations Work with Chinese Community Work with Polish Community Work with Gypsy/Travellers Community Trust Polices on Dignity and Privacy Staff Training on Equality and Diversity

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Single Equality Scheme

EDS 2.4 People’s complaints about services are handled respectfully and efficiently.

The Trust encourages continuous engagement, involvement and evaluation of its Single Equality Scheme and invites stake holders to comment via the Trust’s internet or through PALS on the complaints procedure and how the Trust deals with complaints and any redress. The needs of the patients are listened to and all steps are taken to assure complaints are handled respectfully, effectively and efficiently. To ensure that the Complaints Procedure is fully accessible to all groups of people, an equality analysis is carried out at the point of review. To ensure issues which arise from an Equality Analysis are addressed appropriately there is an action plan at the back of each equality analysis form which has to be completed. Any action plans are monitored by the ED & HR Steering Group and any recommendations are put forward by the group to the relevant department or to the Board. Evidence considered for services provided by the hospital: Patient Experience Team Patient Experience Improvement Group Patient Experience Committee Governor Patient Experience Committee PALS Complaints Procedure Quality Governance Committee Quality Accounts Report Complaints Procedure Patient Satisfaction Survey Inpatients Survey Outpatients Survey Single Equality Scheme

EDS 3.1 Fair NHS

recruitment and selection

processes lead to a more

representative workforce at

all levels.

The Trust compares and analyses data from the three local borough councils on the makeup of the local community to ensure the number of staff reflects the community the Trust serves. By analysing the data that is available across all the protected characteristics it will highlight any sudden change in trends regarding the characteristics and allow the Trust to adopt its services or recruitment processes. The cultural competency of the Board and all staff groups is continually reviewed and developed by inviting applications from individuals from diverse backgrounds, irrespective of the equality group they may associate themselves with, to apply for any vacant post including non-executive positions. The Trust has developed a policy on ‘Employing People with a Disability’ to support members of staff with a long term health condition or disability. The policy sets out what support the member of staff can expect from the

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Trust and gives managers a resource to ensure they offer the right means of support or reasonable adjustment. The Trust developed its own Equality Objectives in accordance with the Public Sector Equality Duty (PSED). The objectives are monitored and discussed at the Equality Diversity and Human Rights Steering Group and are adjusted, renewed or amended as deemed suitable. The Equality Objectives work in conjunction with the Equality and Diversity Strategy and Single Equality Scheme which are inclusive of all protected characteristics and a best practice approach. The Trust’s Executive and Board gives full commitment to address any data gaps for equality groups and is working to improve the data collection across all protected characteristics for staff.

Evidence considered for empowered, engaged and well-supported staff: Team Brief Blackpool Way Continuous Improvement Report NHS Jobs Two Ticks Symbol Mindful Employer NAVAJO Charter Mark Employing People with a Disability Single Equality Scheme Transgender: Support in the Workplace Guaranteed Interview Initiative

EDS 3.2 The NHS is

committed to equal pay for

work of equal value and

expects employers to use

equal pay audits to help

fulfil their legal obligations.

The Trust adheres to the national Agenda for Change framework for pay and conditions across all staff groups. There is no EDS evidence for this section other than the NHS Employers website where copies of Agenda for Change can be viewed.

Evidence considered for empowered, engaged and well-supported staff: Team Brief Blackpool Way Continuous Improvement Report Agenda for Change

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EDS 3. 3 Training and

development opportunities

are taken up and positively

evaluated by all staff.

Through partnership working with external organisations and advocacies the ED & HR Steering Group minutes, complaints report and patient survey the Board members are made aware of the needs and experiences of the local community so the relevant action can b taken. To further develop the knowledge of the Board members E&D training became a mandatory element of the training programme. Further opportunities arise for Board members to attend subject specific seminars, workshops and conferences locally, regionally and nationally. The Trust has held three Equality and Diversity Conferences with a fourth planned for October 2013, all of which have been fully supported by the Board. To deliver transformational equality and diversity the Board has proactively sought organisation to be members of the ED & HR Steering Group to assist the Trust in developing actions to ensure equal provision in services for patients and in its employment practices for staff. Equality and Diversity remains and important part of the Learning and Development Strategy. The Trust was recently awarded the Gold Award for Investor in People (IIP) for the second consecutive year for the training given to all our staff, which includes equality and diversity training. The Trust also uses the results of the Patient Experience Survey and complaints around equality and diversity issues to evaluate the training. Evidence considered for empowered, engaged and well-supported staff: Team Brief Blackpool Way Continuous Improvement Report Learning and Development Strategy Staff Survey Electronic Staff Appraisal system Leadership and Development Programme Equality and Diversity Training E&D Subject Specific Training e.g. Deaf and Disability Awareness/Older and Out (LGBT) Talent Management Programme

EDS 3.4 When at work,

staff are free from abuse,

harassment, bullying and

violence from any source.

The Trust signed up to a national NHS Anti Bullying and Harassment Campaign in addition to the Zero Tolerance Campaign. The Executive Directors introduced the Blackpool Way in 2007 which sets out specific behaviour and personality characteristics all staff are to portray and have been incorporated into staff appraisals. The Blackpool Way which outlines what a manager and employee should be and setting out expectations on behaviour. This works very well alongside the equality and diversity training which includes raising awareness on how to deal with harassment and bullying. The Trust continues to use the Blackpool Way to set expectations of behaviour staff are to portray

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towards colleagues and patients. Posters placed around the Trust maintain awareness of how to behave and take action against discriminatory practices. The Trust also has a team of Staff Advocates to advise staff on dealing with anti discriminatory behaviour or practice. The Trust continues to monitor via HR the reasons and number of grievances and disciplinary cases in relation of E&D issues to evaluate the impact of training the training on the workforce. The Trust promotes the NHS Zero Tolerance Campaign with posters throughout the Trust. Evidence considered for empowered, engaged and well-supported staff: Team Brief Blackpool Way Continuous Improvement Report NHS Zero Tolerance Campaign NHS Anti Bullying and Harassment Campaign Improving Working Lives Initiative Staff Survey Harassment and Bullying Training Staff Advocates Equality and Diversity Strategy Equality and Diversity Policy Single Equality Scheme

EDS 3.5 Flexible working

options are available to all

staff consistent with the

needs of the service and

the way people lead their

lives.

The Trust has a Flexible working Policy which lays out the requirements and the process by which to apply for a flexible working pattern. The granting of any such request is subject to the needs of the service, but managers have to give sound business reasons as to why the request cannot be granted. There is an appeals process the employee can use if they are dissatisfied with the outcome of their request. However, the Trust does accept that the more flexible and diverse the workforce can be the better the Trust is to be address the needs of its service users. Evidence considered for empowered, engaged and well-supported staff: Team Brief Blackpool Way Continuous Improvement Report Improving Working Lives Flexible Working Policy Work Life Balance Project

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Outpatient Survey Inpatient Survey Patient Satisfaction Survey Patient Experience Committee Governors Patient Committee

EDS 3.6 Staff report

positive experiences of

their membership of the

workforce.

The Trust has an Occupational Health (OH) Department who work hard to provide support for its diverse staff members. OH have won awards for their Stress Management Project and arrange a variety of alternative therapies to be available for all staff to access at reduced rates. Membership at local fitness centres are reduced thanks to OH negotiating lower charges for staff. There is a Counselling Service available for all staff who can self refer if they so wish. The Trust has a Smoking Cessation Nurse who is on hand to assist staff to stop smoking. Classes in Zumba and Yoga are available for staff and take place on Trust premises on a weekly basis throughout the year, with the exception of the school Summer holidays Evidence considered for empowered, engaged and well-supported staff: Team Brief Blackpool Way Continuous Improvement Report Patient Safety Stress Project Stress Management Project Counselling Hypnotherapy Zumba Yoga Reduced membership to Weight Watchers/Slimming World Reduced membership to local Fitness clubs Smoking Cessation Team Alternative Therapies e.g. Reflexology

EDS 4.1 Boards and The cultural competency of the board is continually reviewed and developed by inviting applications from individuals from diverse backgrounds, irrespective of the equality group they may associate themselves with, to apply for

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senior leaders routinely

demonstrate their

commitment to promoting

equality within and beyond

their organisation.

executive and non-executive positions when vacant. Through the ED & HR Steering Group minutes, complaints report and patient surveys the Board members are made aware of the needs and experiences of the local community and the steps taken to address any issues. To further develop the knowledge of the board members, E&D training became a mandatory element of their training programme. The Board has set patient safety and quality as its number one objective and has gone through a broad development programme to better understand the boards’ role in relations to the agenda. The focus on “getting the patient in the room”, patient stories and reducing avoidable harm has given all directors a better understanding of the equality, diversity and human rights agenda. This work is supported by the work the board has done to understand the patient and staff pledges within the NHS Constitution. Evidence considered for inclusive leadership at all levels: Acute Contract Review Group Minutes Membership figures Membership Magazine Stress Project Procurement purchase of goods Team Brief NHS Competency Framework for Equality and Diversity Leadership Blackpool Way Equality Diversity and Human Rights Steering Group Equality and Diversity Conference Equality and Diversity Strategy Equality and Diversity Policy

EDS 4.2 Papers that come

before the Board and other

major Committees identify

equality-related impacts

including risks, and say

how these risks are to be

managed.

Each division within the hospital had an equality and diversity champion but due to changes around restructuring and staff turnover in the last year or so it has been necessary to re-launch and promote the role of the equality and diversity champion. Along with Executive Board commitment to E&D the role of the E&D Champions have historically been fulfilled by a senior Sister or Matron, to ensure there is an ability to influence leadership and colleagues. The role of E&D Champions is open to those in a position to challenge inappropriate behaviour and practices for both staff and patients. The post of Equality and Diversity Lead for the Trust was created in 2009. This person has responsibility for supporting and advising staff on issues relating to equality and diversity issues for both staff and patients. The E&D Lead delivers the training to staff at all levels across the Trust and holds an ILM Level 4 qualification in ‘Managing Diversity in Organisations’. The Trust continues to monitor via HR the reasons and

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number of grievances and disciplinary cases in relation of E&D issues to evaluate the impact of training the training on the workforce. The Trust also uses the results of the Patient Experience Survey and complaints around equality and diversity issues to evaluate the training. Evidence considered for inclusive leadership at all levels: Team Brief Outpatient Survey Management Report Blackpool Way Continuous Improvement Report CQC Assessment Tool Public Health Strategy and minutes National Patient Safety NHS Competency Framework for Equality and Diversity Leadership Equality and Diversity Champions Equality and Diversity Lead Gold Award Investors in People Equality and Diversity Strategy Equality and Diversity Policy

EDS 4.3 Middle managers

and other line managers

support their staff to work

in culturally competent

ways within a work

environment free from

discrimination.

The Trust works with the NHS Equality and Diversity Competency Framework to recruit develop and support strategic leaders to advance equality outcomes. The basis of the NHS Equality and Diversity Competency Framework was used to write the job description for the Equality and Diversity Lead. As a Foundation Trust we opted to develop our own framework around knowledge and skills. The job description for the E&D Lead and others which have equality and diversity elements requires evidence to be provided of personal and work related development in the area of E&D. At appraisals evidence is sought to prove progression on a personal level. Evidence considered for inclusive leadership at all levels: Team Brief Blackpool Way Continuous Improvement Report NHS Competency Framework for Equality and Diversity Leadership

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Equality and Diversity Lead job role Equality and Diversity Champions Equality and Diversity Conference Annually Equality and Diversity Training E&D Subject Specific Training e.g. Deaf and Disability Awareness/Older and Out (LGBT) Equality and Diversity Strategy Equality and Diversity Policy

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EDS Grading Outcomes Report Public-Mar2714.doc EDS Grading – ACUTE March 2014

Outcome Score Assessment Response Compared

UNDEVELOPED DEVELOPING ACHIEVING EXCELLING To 2013 Blackpool only

1.1 Services are commissioned, procured and designed to meet the health needs of local communities.

B+ L

Same outcome

for developing

with slight move

to achieving

1.2 Individual people’s health needs are assessed and met in appropriate and effective ways.

L B A move to

achieving at Blackpool

1.3 Transitions from one service to another, for people on care pathways, are made smoothly with everyone well-informed.

B L

Same outcome

as 2013 - developing

1.4 When people use NHS services their safety is prioritised and they are free from mistakes, mistreatment and abuse.

B+ L-

Same outcome as 2013 – bordering achieving

1.5 Screening, vaccination and other health promotion services reach and benefit all local communities.

B L- Same outcome

as 2013 - developing

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

L B A move to

achieving at Blackpool

2.2 Patients are informed and supported to be as involved as they wish to be in decisions about their care.

L B A move to

achieving at Blackpool

2.3 People report positive experiences of B Same outcome

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the NHS. L as 2013 - achieving

2.4 People’s complaints about services are handled respectfully and efficiently.

B L-

Same outcome

as 2013 - developing

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EDS Grading Outcomes Report Staff -Mar2714.doc EDS Grading – ACUTE March 2014

Outcome Score Assessment Response

Compared

UNDEVELOPED DEVELOPING ACHIEVING EXCELLING To 2013 Blackpool only

3.1 Fair NHS recruitment and selection

processes lead to a more representative

workforce at all levels.

21

74

74

15

Same as 2013

equal split

3.2 The NHS is committed to equal pay

for work of equal value and expects

employers to use equal pay audits to help

fulfil their legal obligations.

50

62

63

9

More equal between

developing and achieving

3. 3Training and development

opportunities are taken up and positively

evaluated by all staff.

51

80

46

7

Move from achieving to developing

3.4 When at work, staff are free from

abuse, harassment, bullying and violence

from any source.

64

77

32

11

Move from achieving to developing

3.5 Flexible working options are available

to all staff consistent with the needs of the

service and the way people lead their

lives.

51

71

48

14

Same as 2013 -developing

21

3.6 Staff report positive experiences of

their membership of the workforce.

49

85

45

5

Same as 2013 -

developing

4.1 Boards and senior leaders routinely

demonstrate their commitment to

promoting equality within and beyond

their organisation.

52

82

37

11

Same as 2013 -

developing

4.2 Papers that come before the Board

and other major Committees identify

equality-related impacts including risks,

and say how these risks are managed.

44

89

45

6

A move from achieving to developing

4.3 Middle managers and other line

managers support their staff to work in

culturally competent ways within a work

environment free from discrimination.

46

63

56

19

Same as 2013 - developing

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Equality Delivery System Grading Report At the Equality Delivery System Consultation and Engagement Events on 25 March 2014 in Lancaster and 27 March 2014, at Blackpool Victoria Hospital invitations had been sent to a diverse number of members and organisations requesting their attendance at the event. The invitation encouraged them to attend as this was their opportunity to have their say about the services, care and functioning of Blackpool Teaching Hospitals for both in and out patients attending Victoria Hospital and its peripheral sites. Many of the delegates did not take the opportunity to write additional comments on the Grading sheets. However, below are the comments made in respect of Goals 1 and 2. Goals 3 and 4 are staff focused and were not dealt with at this consultation and engagement event. Goal 1 1.1 Services are commissioned, procured and designed to meet the health needs of local communities. Comments here included reference to having better evaluation at grass roots level and having evidence to cover all the protected characteristics. Although it was agreed that where there is a lack of evidence for any protected characteristic, service provision and delivery of healthcare would be provided in a non-discriminatory manner and without prejudice. A comment was made that it would be nice to have representation from a senior level at the event when evidence/data in order to question or seek clarification.

1.2 Individuals’ health needs are assessed, and met in appropriate and effective ways. To improve end-user real evidence it was suggested that a questionnaire/online survey with a followed-up telephone call a fews days after appointment might be a way to improve the evidence. 1.3 Transitions from one service to another, for people on care pathways, are made smoothly with everyone well-informed. Comments were made about improving the amount of evidence for this outcome but no suggestions as to an approach 1.4 When people use NHS services their safety is prioritised and they are free from mistakes, mistreatment and abuse. Main comments were about the lack of evidence. It was suggested that to use evidence from UIR and Risk Management-lessons learned/anecdotal evidence only, may be of benefit. 1.5 Screening, vaccination and other health promotion services reach and benefit all local communities.

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No hard evidence only anecdotal evidence for screening and vaccination- reduction in health promotion. It was suggested that perhaps to consider including North Lancashire CCG, Preston CCG, Community, UHMB and RPH at the next event for both hard and anecdotal evidence. Goal 2 2.1 Patients, carers and communities can readily access services, and should not be denied access on unreasonable grounds. Comments were made about having anecdotal evidence for some areas of non-provision 2.2 Patients are informed and supported to be as involved as they wish to be in decisions about their care. Comments were made about the lack of evidence presented on the patient experience questionnaire. Concern was raised about the figures from the in-patient survey showing 20-30% worse than average score re: ‘care and treatments’. The group would like to see more service user involvement in policy development (EIA’s will assist where necessary). Also more evidence required across the protected characteristics as there was only evidence for 3 presented. Although it was agreed that where there is a lack of evidence for any protected characteristic, service provision and delivery of healthcare would be provided in a non-discriminatory manner and without prejudice. 2.3 People report positive experiences of the NHS. Unfortunately at the Lancaster event the IT system was not working in the Lecture Theatre and it was not possible to show videos of patients’ experience. This prompted comments to be made about the lack of evidence of positive experiences being had by patients. 2.4 People’s complaints about services are handled respectfully and efficiently. Comments here were about the lack of evidence to show that complaints are handled efficiently and with respect.

Compliments The group made the following positive comments about the work the Trust is doing around equality and diversity:

There is good disability-physical accessibility

Facebook is used to communicate with young people

Children’s’ wards are well protected

Good screening for the elderly

Good screening for breast cancer

Good screening for bowel cancer

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Excellent community engagement

Some good work with BME groups

A great deal of evidence is available for services, however, it is not being used fully particularly in community. Goal 3 3.2 Since the completion of the EDS event discussions regionally have brought to light that some Trusts are not relying on AfC as evidence and have carried out equal pay audits. This may be something the Trust would want to consider for next years submission. 3.4 Some staff feel more could be done to address harassment and bullying within the workplace. Although there has been some work to improve more needs to be done. 3.5 Some staff feel that flexible working is not being used as much in some areas due to low staffing levels. Goal 4 No feedback around this goal. Conclusion Having completed the comparison with last year’s EDS report the Trust has made an improvement in three of the nine outcomes relating to patients and services. In the following outcomes 1.2, 2.1 and 2.2 our grading has moved from developing to achieving which reflects the hard work by staff to achieve better health outcomes for all and improve patient access and experience. In addition, there are two outcomes 1.1 and 1.4 where the Trust has made some improvement which is reflected in being graded as developing+. The four remaining outcomes have remained the same and graded as developing. With regard to the goals concerning staff there were two outcomes in Goal 3 Empowered engaged and well supported staff that 3.1 and 3.2 were virtually equal. There were four outcomes that remained as developing but what was disappointing to see were three outcomes had moved from achieving to developing. Further steps will be required to ascertain why a downward move occurred by getting feedback from staff, then appropriate actions can be taken to improve on these outcomes. The Trust is committed to improving its work within the Equality and Diversity arena and values the support from staff and partner organisations in its endeavours to improve.