1. Equality Standard Guidance Document Equality Delivery System (EDS2) 2015-2018 Helen Rushworth – Director of Human Resources Molly Clark – Company Secretary Ricky Somal – Equality and Diversity Lead

2. Contents 1.Introduction to the Equality Standard 2.How does the Equality Standard work 3.Preparation and implementation 4.Assessment and Accreditation process

3. 1. Introduction We value people’s achievements and respect equality and diversity. Our commitment extends to ensure equality of opportunity and anti- discriminatory practice both in the provision of services and in our role as a major employer. Our patients, staff and services, are in many respects the driving force of the organisation and will help us meet our responsibilities to equality and diversity. We are giving our staff a toolkit to help carry the values of equality and diversity into everyday patient care and their work with the Trust.

4. 1.1 The Equality Standard will:  provide a framework for embedding equality and diversity;  help the trust meet its legal and regulatory obligations;  integrate SMART equality objectives;  encourage engagement with stakeholders, inviting challenge and involvement associated with service improvement and accessibility;  identify our performance and raise standards in equality and diversity practice across North middlesex University Hospital NHS Trust and  provide a basis for tackling all forms of unlawful discrimination.

5. 2. How does the Equality Standard work? Over three levels (Bronze, Silver and Gold) the Equality Standard will introduce a comprehensive and systematic approach to embedding equality and diversity and enable the Trust to respond positively to the requirements of the Equality Act 2010 and Equality Delivery System.

6. 2.1 Award Levels  BRONZE: documented processes are in place to achieve each standard criteria;  SILVER: practical evidence is reported against each standard criteria; and  GOLD: the Equality Impact Group (EIG) will require evidence that CSC’s have monitored their processes and demonstrate significant outcomes for equality improvement across all protected characteristics. For any Level criteria, the EIG, via the Equality and Diversity Lead may visit Clinical and Corporate Services to seek clarification on the evidence provided and visit services to verify that plans/processes are in place and working.

7. 3. Preparation and Implementation This section guides you through the steps we recommend you take when launching the Equality Standard in your Clinical or Corporate Service: Agree Governance and Reporting Structures: It is recommended the Clinical and Corporate Services identify an Equality Impact Lead (EIL) and monitor progress via mainstream business reporting Brief Staff: all staff involved should be fully briefed on the purpose of the Standard and their specific role. A summary sheet has been designed to raise awareness. Gather Evidence: A reporting Provider Compliance Assessment (PCA) has been designed to document evidence

8. 4. Assessment and Accreditation Assessment process  Clinical and Corporate services will be expected to provide evidence for each of the standard criteria listed in the Equality Standard.  All evidence will need to be recorded, collated and analysed to provide an assessment of the achievement and progress the service has made.  The Equality and Diversity Lead will be on hand throughout the process to assist, advise and make recommendations about the most appropriate evidence to support each standard criteria.  The Trust Equality Impact Group (EIG) will scrutinise evidence against the standard criteria and the Equality Delivery System Grading events will provide external challenge. The EIG, via the Workforce Committee will award the Standard Certificate.

9. Accreditation process  The EIG will act as the accreditation panel and is chaired by the Director of HR and OD and comprises of Equality Impact Leads representing the Clinical and Corporate Divisions. Once the EIG is satisfied that the standard criteria has been met and sufficient evidence submitted, the service will be awarded with a certificate as a sign of achieving the first stage (Bronze) of the equality standard.  This process will be repeated for the Silver and Gold level. Separate certificates will be awarded to Divisions that go on to achieve each of the three levels of the standard.  Once obtained, each level will be valid for 1 year, during which time the Division is expected to progress on to the next level. Failing that, the Division will be required to submit updated evidence for the level already attained.

10. Innovations to look out for in 2015/16 Everyone Counts EIG * Equality Standard * VOX POP * Diversity Scorecard * Respect and Values Improving health outcomes Improving patient experience Empowered and engaged staff Inclusive leadership at all levels

11. Equality Delivery System 2015/18 We are introducing an innovative programme of work which aims to integrate equality and diversity into our mainstream business. We will engage and draw inspiration from our patients, staff and stakeholders to ensure we develop as a Personal Fair Diverse (PFD) organisation. This is an exciting and important time in our EDS journey and we look forward to hearing about your achievements over the next year.

12. Equality Standard Integration Plan 2015/16 Corporate Equality Objectives 2015/16 1.Strategy: Redesign and launch of a brand new equality and diversity strategy ‘Equality Standard’ 2.Policy and Procedure: Undertake a full review of the current equality and diversity policy and procedure and review clinical and non-clinical policy and procedures to ensure equality and diversity implications are addressed appropriately (Equality Analysis) 3.Public Sector Equality Duty: Compile an up to date Workforce Diversity Scorecard (including WRES) and publish on website and establish equality objectives 2015/16 and publish on website 4.Learning and Development: Engage with the Learning and Development team to review current E&D training 5.Communications (Intra and Internet): As part of a communications plan of the E&D service re-design, we will review and update the information published on the Trust website to ensure we respond to our legal and regulatory requirements.

13. Equality Standard Integration Plan 2015/16 Everyone Counts EIG * Equality Standard * VOX POP * Diversity Scorecard * Diversity Moments Improving health outcomes Improving patient experience Empowered, engaged and supported staff Inclusive leadership at all levels Innovations to look out for in 2015/16

14. Equality Objectives 2015/16 Quality, safety and operational obligations Joint Strategic Needs Assessment (JSNA) Delivering person centred care - a diversity roadmap Equality Objective 1: Better health outcomes for all A great patient experience Improving diverse patient insight and engagement Involving protected groups and identifying their care experience Equality Objective 2: Improving patient access and experience Living our vision values and behaviours Diversity Moments - learning, education and development Improving employee relations performance Equality Objective 3: Empowered, engaged and supported staff Equality Objective 4: Inclusive leadership at all levels Positive Leadership and Coaching Improving workforce cultural capability Demonstrating inclusive behaviours

15. Equality Standard Award The Equality Standard is designed to mainstream equality and diversity in everything we do and offer incremental recognition of improvement with three levels of award: bronze, silver and gold. The Equality Standard toolkit includes a guidance document outlining standard criteria and a Provider Compliance Assessment (PCA) to record evidence. Bronze A bronze award recognises that the Division has a solid foundation for eliminating unlawful discrimination and developing an inclusive culture that values all staff. Silver In addition to the requirements for a bronze award, a silver award recognises a significant record of activity and achievement by the Division in promoting equality and diversity and in addressing challenges across the Division. Gold As the standard progresses we will provide detailed descriptions for what is required at gold level

16. Equality Standard We are introducing an innovative programme of work which aims to integrate equality and diversity into our mainstream business. We will engage and draw inspiration from our patients, staff and stakeholders to ensure we develop as a Personal Fair Diverse (PFD) organisation. This is an exciting and important time in our EDS journey and we look forward to hearing about your achievements over the next year. Ricky Somal Equality and Diversity Manager