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Equality diversity and human rights strategic framework

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  • 1. DOCUMENT CONTROL PAGE Title: Equality, Diversity and Human Rights Overarching Strategic Framework Title Version: 1 (20.04.10) Reference Number: SET001 -2010 Supersedes: Action for Equality Supersedes Significant Changes: To meet the legislative requirements of the Trust’s and revised process for embedding, monitoring and surpassing compliance of Equality, Diversity and Human Rights Originated By: Berenice Postlethwaite Originator or modifier Designation: Modified by: Mark Nesbitt Designation: Equalities Consultant Ratification Referred for approval by: Operational Management Group Date of Referral: Application All Staff Circulation Issue Date: March 2010. Circulated by: Service Equality Team Dissemination and Implementation: Review Date: March 2013. Review Responsibility of: Head of Equality and Diversity (SET) Date placed on the Intranet: Please enter your EqIA Registration Number here: Trust Strategic Framework 2010-16 Page 0 of 16 See the Intranet for the latest version. Version Number: 1 (20.04.10)
  • 2. Equality, Diversity and Human Rights Overarching Strategic Framework 2010-2016 Trust Strategic Framework 2010-16 Page 1 of 16 See the Intranet for the latest version. Version Number: 1 (20.04.10)
  • 3. Section Contents Page 1 Introduction 3 2 Purpose 4 3 Roles and Responsibilities 5 4 What is the Framework? 5 5 Equality, Diversity and Human Rights Strategic Aims 7 6 The 2016 Position Statements 7 7 Key Strategic Objectives 8 8 Equality Impact Assessment 8 9 Consultation, Approval and Ratification Process 8 10 Implementation 8 11 Monitoring 9 12 References 9 13 Associated Documents 10 Appendix A – Measures of Success 11 Trust Strategic Framework 2010-16 Page 2 of 16 See the Intranet for the latest version. Version Number: 1 (20.04.10)
  • 4. 1. Introduction 1.1 Central Manchester University Hospitals NHS Foundation Trust (The Trust) is the leading Trust for research and teaching in the North West, the largest provider of specialist services in the North West, and is one of three NHS providers of secondary services within Manchester. The Trust was established in 2001 to incorporate Manchester Royal Infirmary, St Mary’s Hospital for Women and Children, Manchester Royal Eye Hospital, the University Dental Hospital, and Royal Manchester and Booth Hall Children’s Hospitals. 1.2 The Trust is a centre of excellence for healthcare research with a long standing and extremely successful academic partnership with the University of Manchester. The success of this partnership now sees the Trust as one of a small number of organisations in England which has attained Biomedical Research Centre (BRC) status. 1.3 The Trust has delivered its financial duties during 2007/08 and our business plan sets out strong financial plans through to 2012/13 and beyond. Recent changes to the Payments by Results (PbR) regime, and in particular the evolution of tariffs for specialist services, now means that the real costs of delivering these major element of our services are better recognised. This represents a significant financial benefit to the Trust and is factored into our financial modelling. 1.4 Our recent performance for total time in A&E has fallen short of national targets and our own ambitions. Despite the successful implementation of a range of initiatives within the Trust and in conjunction with our commissioners, the planned bed reduction within the Full Business Case for our New Hospitals Development has only been partly mitigated within the local health economy. The Trust has now initiated plans to get back on track to deliver the A&E target early in 2008/09. Data for April and May 2008 shows that we have made significant improvements in our performance and are on track to deliver the target by the end of quarter 1. 1.5 We are currently five years into a six year Private Finance Initiative (PFI) development that will facilitate the centralisation of adults and children’s services on the main Oxford Road site. This development, known as the New Hospitals’ Development (NHD), is a unique opportunity for the Trust to make a step change in the quality and effectiveness of patient care delivery for both secondary services for the local population and also specialist services for the population of the North West. The scheme concludes in 2009/10 and is on schedule, and on budget. The Trust’s Corporate Values 1.6 These are still under development but should reflect the following statements People First… 1.7 Central and core of the Trust’s whole existence is that it provides services to over 1m people every year and employs over 8,500 staff. People first, puts people in the spotlight whether they are staff, patients, visitors, stakeholders or partners. Trust Strategic Framework 2010-16 Page 3 of 16 See the Intranet for the latest version. Version Number: 1 (20.04.10)
  • 5. Doing The Right Thing… 1.7 We want all our staff across the whole organisation to value the concept that they should always do the right thing. This means that they should not routinely and systematically follow the same course of action but change to the make the difference in the way they relate to their fellow colleagues and deliver services to patients, visitors or stakeholders. Being The Best… 1.8 The Trust will always strive to be best across a variety of external measures, Best Value, National NHS Surveys (Patient/Staff), CQC, National Legislation, National Indicators, NHS initiatives, Local Surveys, External Staff Surveys (IiP/Stonewall index/etc). Be Good Neighbours… 1.9 This is how and why we choose to work together, locally, regionally, and nationally. We pride ourselves, as one of the largest employers and procurer of services and goods in Manchester. By using this strength and by working with the local communities we can be a key partner in local regeneration and community investment. We acknowledge that the Trust can help tackle social as well as health inequalities. Being a good neighbour is where the Trust, in partnership with others, can make Manchester and in particular, our local communities a better place to live and work. 2. The Purpose of the Framework 2.1 The purpose of this Framework is to provide guidance to Trust staff, Board and Governors about one of the Trust’s key priorities and cross cutting themes, i.e. promoting equal opportunities, human rights and challenging discrimination. It will achieve this through a number of strategic aims and key strategic objectives which are detailed within this Framework. 2.2 It brings together the Trust policies, strategies and procedures relating to equal opportunities, achieving change for disadvantaged communities and working to eliminate health inequalities. 2.3 The principles of this Framework will be applied to everyone working (paid or voluntary) directly for or with the Trust. 2.4 The Trust will deliver this Framework by: • Mainstreaming equality and diversity in all aspects of the Trust’s work • Cascading corporate equality actions and targets into all divisional plans, departmental plans, programmes and projects • Building effective partnerships with key national, regional and local organisations • Challenging partners and providers to improve equality performance through service delivery • Influencing key decision makers to provide leadership in all equality issues Trust Strategic Framework 2010-16 Page 4 of 16 See the Intranet for the latest version. Version Number: 1 (20.04.10)
  • 6. 3. Roles and Responsibilities It is the responsibility of... 3.1 The Chair of the Trust Board, the Chief Executive and Executive Directors, to lead and model commitment to it through their behaviour, attitude and effective use of their influence and authority. They are accountable for ensuring that the Trust provides adequate resources to further develop and implement this Framework. 3.2 Executive Directors, Directors and Senior Managers of service areas, to ensure the implementation and progress of the Framework. 3.3 The Executive Director of Nursing as the executive lead of equality and diversity to provide the strategic link and coordinate the delivery of this Framework. 3.4 The Assistant Director – Patient Services as the operational lead, for ensuring the effective implementation of this Framework across the Trust 3.5 The Service Equality Team (SET) has an overall function to ensure all areas and aspects of the Trust are working towards and meeting the Trust’s key strategic equality, diversity and human rights strategic aims. 3.6 All staff to participate fully in implementing the Framework. 3.7 Partners and Stakeholders to work with us to achieve our aims 4. What is the Framework? 4.1 The Equality, Diversity and Human Rights Framework is made up of a series of documents that combined, provides guidance on the Trust’s approach to embed equal opportunities, access and outcomes for all. 4.2 The chart below indicates how some key teams across the Trust support the delivery of the Framework to achieve the Trust aims. It also shows how key strategic documents fit into the structure of this framework. Trust Strategic Framework 2010-16 Page 5 of 16 See the Intranet for the latest version. Version Number: 1 (20.04.10)
  • 7. Equality, Diversity and Human Rights Strategic Framework Patients Organisational Workforce Key Stakeholders All Staff SET/ITS HR / OD&T PPI Patient Experience Equality, Diversity & Working Practices Board/Council of /Quality Campaign Human Rights Scheme Policies Governors Equality Impact Care Quality Assessment E&D in Employment PFI Partners Commission Framework E&D Learning and Induction and NHSLA Development Mandatory Volunteers Framework Training ITS Patient Profiling/ IWL / IiP/ Third Wayfinding Best Practice Stonewall/etc. Sector/Communities Guide ITS Interpretation and Translation Service SET Service Equality Team HR/OD&T Human Resources / Organisational Development and Training PPI Patient and Public Involvement Team Trust Strategic Framework 2010-16 Page 6 of 16 See the Intranet for the latest version. Version Number: 1 (20.04.10)
  • 8. 5. Equality, Diversity and Human Rights Strategic Aims 5.1 Trust’s Equality, Diversity and Human Rights Framework 2010-2016 has four key overarching strategic aims: • Moving Beyond Compliance We will work to ensure that we move beyond simply complying with the current and any forthcoming legislative and regulatory framework, which we work under. By moving beyond compliance we aim to reach excellence in all areas of our work. • Creating An Inclusive Workplace We will strive to be the best employer across the NHS by ensuring we provide a supportive, inclusive and safe place to work. • Surpassing Patient Expectations We will work to ensure that all patients, family members and visitors expectations are surpassed before, during and after they have been with us. • Strength In Numbers We will work in partnership with our staff, patients, visitors and stakeholders to ensure that we deliver high quality services and invest in our local communities. 6.0 The 2016 Position Statements 6.1 The following ‘positional statements’ will be used to measure success of the strategic aims. By 2016 the Trust will strive to be: • Surpassing compliance with current equality legislative requirements and regulatory guidance • Assured that all of its policies, procedures and services are free from direct and indirect discrimination • A fully inclusive organisation, with equality and diversity embedded in everything that we do • An exemplar employer with equality of opportunity central to the recruitment and development of staff • Adaptable in service provision to meet the identified needs of patients, service users and their communities • Delivering innovative services to vulnerable people to help improve their health and well-being • Successful in our partnership work with a cross section of stakeholders and partners • A creator of innovative opportunities for all communities to participate in the decisions, which affect the delivery of services they receive Trust Strategic Framework 2010-16 Page 7 of 16 See the Intranet for the latest version. Version Number: 1 (20.04.10)
  • 9. 7.0 Key Strategic Objectives 7.1 To achieve the four Strategic aims and meet the ‘by 2016’ positional statements, the Trust will implement and deliver the following key strategic objectives: • Ensure that the Trust's internal practices and performance are surpassing compliance with equality legislative requirements, Human Rights legislation and regulatory guidance • Ensure all the policies, procedures and services are free from direct and indirect discrimination • Continue to embed equality and diversity in everything that we do • Be an exemplar employer, with equality of opportunity central to the recruitment and development of staff • Adapt service provision to meet the identified needs of our patients, service users and the wider community • Work with our main contractors and suppliers to ensure the ethos and values of the Trust re: equality and diversity are embedded within their workforce • Provide opportunities for all service users to participate in the decisions which affect the delivery of services they receive 8. Equality Impact Assessment 8.1 This policy has been subjected to a Screening Impact Assessment and will undergo a further assessment during 2010 9. Consultation, Approval and Ratification 9.1 We will consult on this framework, and all the policies and strategies that underpin it. 9.2 SET held an Equalities Summit on the 15th March 2010 where over 130 members of staff and invited guests were able to comment upon the framework and other key equality documents 9.3 The final document will be approved by the Trust Board. 10. Implementation 10.1 This Framework will be implemented via a Trust wide implementation plan. 10.2 For further information or advice on implementation of this Framework, please contact the Service Equality Team. Trust Strategic Framework 2010-16 Page 8 of 16 See the Intranet for the latest version. Version Number: 1 (20.04.10)
  • 10. 11. Monitoring our Performance 11.1 The Trust will translate what it says about Equalities, Diversity and Human Rights into an annual action plan and will monitor its progress and outcomes critically and regularly through the Equality Implementation Group. 11.2 There are a number of statutory and non-statutory requirements relating to monitoring and measuring performance. The following have the most significant impact on the way that the Trust delivers its services. Equality Act (2010). 11.3 The Trust has developed this overarching Equality, Diversity and Human Rights Framework in response to the recently introduced Equality Act (2010). Care Quality Commission (CQC) – Essential Standards for quality and safety 11.4 CQC have published guidance for all health and adult social care providers on meeting new essential standards of quality and safety that will apply across the care sector. 11.5 Providers must show they are meeting essential standards as part of a new registration system which focuses on people rather than policies, on outcomes rather than systems. 11.6 The essential standards relate to important aspects of care such as involvement and information for people, personalised care and treatment, safety and safeguarding. Subject to legislation, the new registration system comes into force for NHS trusts on 1 April 2010. CQC will continuously monitor compliance with essential standards as part of a more dynamic, responsive, robust system of regulation accompanied by new enforcement powers. 11.7 CQC's guidance is focused on outcomes - the experiences people have as a result of the care they receive - rather than on systems and processes. It was widely consulted on earlier this year and places the views and experiences of people at the centre of the regulatory system. 12. References • Equalities Act 2010 • Commission for Equality & Human Rights - http://www.cehr.org.uk/ • Department of Health (2007) Human Rights in Healthcare – a Framework for Local Action • Department of Health – Knowledge Skills Framework (KSF) • Department of Health – Improving Working Lives (IWL) – • Department of Health (2010) – The NHS in England Operating Framework • Department of Health – Vital Connection – • Care Quality Commission (CQC) Essential Standards for quality and safety • EPIT – Equalities Monitoring (NHS North West) Trust Strategic Framework 2010-16 Page 9 of 16 See the Intranet for the latest version. Version Number: 1 (20.04.10)
  • 11. 13. Associated Documents • Corporate Integrated Business Plan 2009-10 • Equality, Diversity and Human Rights Scheme • E&D in Employment • Dignity and privacy • All HR polices • Equality Impact Assessment Framework • E&D Learning and Development Framework Trust Strategic Framework 2010-16 Page 10 of 16 See the Intranet for the latest version. Version Number: 1 (20.04.10)
  • 12. Appendix A – Measures of success Moving Beyond Compliance We will work to ensure that we move beyond simply complying with the current and any forthcoming legislative and regulatory framework, which we work under. By moving beyond compliance we aim to reach excellence in all areas of our work. Positional Statement ‘by 2016’ Key actions to achieve Measure of Success Surpassing compliance with Evidence compliance with current Evidence compliance with the requirements of current current equality legislative legislative acts (core strands of equality) legislation and the Human Rights Act requirements and regulatory Equality Act, Human Rights Act guidance Evidence compliance with the Top quartile CQC / NHSLA compliance requirements of Care Quality Progress annual updates on the Equality Scheme Commission and NHSLA Demonstrate excellence in EPIT NHS North West EPIT – Excellence level Identify and mitigate key Strategic Risks Risks identified and key mitigations updated annually regarding equality, diversity and Human Rights. Complete all actions each year 100% actions achieved for each year of Framework and Scheme Assured that all of its policies, Develop an annual programme for Equality Impact Assessment (EqIA) programme for all Divisions, procedures and services are free Equality Impact Assessments (EqIAs) to Departments and Services from direct and indirect be completed discrimination Integrate process into Service Review Full integration of EqIA process / Majority of EqIA completed Trust Strategic Framework 2010-16 Page 0 of 16 See the Intranet for the latest version. Version Number: 1 (20.04.10)
  • 13. Framework as part of the Service Review Process All Trust policies assessed Trust assured that all service are non- discriminatory Provide additional training and support Increased number of ‘accredited’ staff year on year for staff to enable the EqIA framework to be fully embedded within the Trust A fully inclusive organisation, with Further develop Equalities Equalities Implementation Group is fully established and seen equality, diversity and Human Implementation Group as a leading Strategic group across the Trust by Rights embedded in everything staff/stakeholders/partners that we do Promote and publicise through all Ensure that the Framework is embedded across the service available marketing channels the positive Promote our Framework approach to embedding equality and diversity Increase the number of Diversity Increased number of Champions/Co-ordinators year on year Champions/Coordinators and enhance their role across the Trust Creating an Inclusive Workplace We will strive to be the best employer across the NHS by ensuring we provide a supportive, inclusive and safe place to work. Positional Statement ‘by 2016’ Key actions to achieve Measure of success An exemplar employer with Monitor compliance with quality The best NHS Foundation Trust employer (Highest NHS Trust equality of opportunity central to assurance initiatives in employment upon NHS Staff Survey). Achieve high level results with the recruitment and development IiP/Stonewall and other external standards Trust Strategic Framework 2010-16 Page 1 of 16 See the Intranet for the latest version. Version Number: 1 (20.04.10)
  • 14. of staff Develop an equality, diversity and A comprehensive E&D learning and development framework is Human Rights Learning and in place and achieving high rates of participation and Development Framework satisfaction Pro-active, positive action to target Deliver HR Equality actions annually under representation across the organisation Monitor and evaluate work with partners Increase local employment (staff residing in Manchester) to maximise training and employment within the Trust related initiatives for unemployed people living in our local communities. Surpassing Patient Expectations We will work to ensure that all patients, family members and visitors expectations are surpassed before, during and after they have been with us. Positional Statement ‘by 2016’ Key actions to achieve Measure of success Adaptable in service provision to Increase and maintain the accuracy of Increased collection of patient profile information year on year meet the identified needs of our Patient Profile and accessibility High level of patient profiling intelligence which is utilised by patients, service users and their information across all core strands, staff. communities including socio economic Increase the proactive usage of resident Maximum use of guidelines for staff on communication to profile information and delivery of meet all our patients’ needs tailored services Increase the use of alternative means of High satisfaction from patients regarding accessibility (NHS communicating with Patients Patient Survey) Trust Strategic Framework 2010-16 Page 2 of 16 See the Intranet for the latest version. Version Number: 1 (20.04.10)
  • 15. Ensure that Patients Religious and Increased use of Chaplaincy Services year on year Spiritual needs are met High satisfaction from patients regarding meeting their religious needs (NHS Patient Survey) Ensure that communication and access Accessibility and Wayfinding is seen as exemplary by external barriers are removed from all accessibility auditor services/properties delivered by the Trust. Delivering innovative services to Develop projects to improve the health Worked on local projects in partnership to deliver Local vulnerable people to help improve and wellbeing of our local communities Community Co-hesion Targets – increased number of projects their health and well-being delivered year on year Strength in Numbers We will work in partnership with our patients, visitors, stakeholders and local communities to ensure that we can deliver the key success measures outlined within our Equalities, Diversity and Human Rights Strategic Framework. Positional Statement ‘by 2016’ Key actions to achieve Measure of success Successful in our partnership work Work with our main contractors and Contractor/Supplier ‘Trust Equality Standards’ being met by with a cross section of suppliers to ensure the ethos and values larger contractors (£500k plus) through contract management stakeholders and partners. of the Trust re: equality and diversity are embedded within their workforce Develop an E&D Contractor forum to share good practice and experiences Embed equality, diversity and human Embedded equalities in commissioning / procurement rights into the commissioning and Published diversity objectives and outcomes for Partnering procurement process Supply Chain Trust Strategic Framework 2010-16 Page 3 of 16 See the Intranet for the latest version. Version Number: 1 (20.04.10)
  • 16. Share best practice across partnerships, Trust is seen as a good ‘partner/neighbour’ (local survey) locally, regionally, and nationally Participation in key National, Regional and Local Partnerships ensuring the Trust benefits from best practice A creator of innovative Increase the effectiveness and diversity Effective involvement and engagement with patients and opportunities for all communities of patients and public involvement public to affect services they receive (NHS Patient Survey) to participate in the decisions, activities which affect the delivery of services they receive Ensure the Trust Board and Council of Effective partnership through strategic engagement of the Governors can obtain views and opinion Third Sector from a wide range of diverse communities Develop a strategic partnership with the SLAs with key strategic Third sector organisations across Third Sector Manchester/North West Deliver an annual stakeholder event to Successful event year on year (Participant Feedback) outline progress and joint working to tackle the Trust key themes MN - 20.04.10 Trust Strategic Framework 2010-16 Page 4 of 16 See the Intranet for the latest version. Version Number: 1 (20.04.10)