EDS Outcomes
The findings in this document are from the information gathered through consultation and focus groups
held during February 2012.
The grades and information will be updated following fresh consultation and focus groups to be held
during February 2013
Any questions relating to this document should be directed to Victoria Eathorne, E&D Lead, Cornwall
Partnership Foundation Trust by emailing victoria.eathorne@cft.cornwall.nhs.uk
Score
EDS Outcome 1.1 (EDS Goal 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”
Evidence Source
Cornwall Partnership NHS Foundation Trust, through consultation with local groups, partners stakeholders and its staff has adopted its
Single Equality Scheme(SES) 2011 – 2014 and an Action Plan for implementation. The Strategy has been informed and developed with due
consideration to the Public Sector Equality Duty 2010, CQC Outcomes and has been informed by the Joint Strategic Needs Assessment
(JSNA).patient satisfaction surveys, analysis and feedback PALS, audit and research
Using the best available evidence the Trust can demonstrate a grade of “developing” for this outcome.
The Trust maintains and develops partnership work with statutory, community, third sector and other organisations working in the field of equality and
diversity and with clients from protected groups through enhanced links with diverse communities, groups and stakeholders. These groups include:
Cornwall Diversity Forum
Health and Social Care Partnership
Cornwall Migrant Workers
Equality and Human Rights Partnership
Accessible Communication Meeting
Equality Delivery System Cluster Group
Single Equality Scheme Implementation Group
Patient Environment Action Group
Regional Equality Group
RESPECT (Service Use Reference Group)
Opening Doors (Service User Reference Group)
Learning Disability and Partnership Board
Links and consultations are with, but are not limited to:
Places of worship
BME community groups and organisations
LGBT organisations and forum
Migrant workers centres.
Evidence of research on protected groups, their needs and issues is available. Research results that have been published and applied to service
improvement.
An initiative by the Department of Health, Autism Accreditation is also a CQUINN target.
Further work needs to be undertaken to establish how the health and well-being of patients and carers from protected groups compares with the
well-being of all patients and carers and establish the extent of the gap.
Copies of satisfaction surveys and the analysis of complaints and feedback are available.
The Trust is working to ensure that its clients and carers representing diverse communities across the protected groups are actively involved in
service planning, implementation and evaluation through the use of an Equality Impact Assessment Toolkit.
Evidence is available to show that involvement has contributed to culturally appropriate care and enhanced outcomes in wellbeing.
Evidence is available to demonstrate that local interest groups are involved in the evaluation of service delivery and outcomes.
Assessments, diagnosis and treatments are conducted by appropriately qualified and culturally competent staff.
Copies of satisfaction surveys, analysis of complaints and feedback are used to inform service improvements.
The Trust conducts satisfaction surveys of clients and carers from protected groups and translated where appropriate into preferred languages to:
Inform continuous improvement
Determine cultural appropriateness of various services, treatments and programmes
Determine cultural competence and attitudes of staff
Community in patient discharge questionnaires are completed and the information used to support service improvements.
Each Service Line is working towards equality and diversity engagement. This will be developed in partnership with local communities and will
reflect client equality data, under representation/ access to the service and inform strategies and outreach activities.
The Trust is working to develop appropriate working groups to share information, identify good practice and develop joint projects – to address any
barriers in relation to access or inclusion for the nine protected characteristics and other relevant groups. These groups will be formed internally and
externally.
OVERALL GRADE
EDS Outcome 1.2 (EDS Goal 1 – Better health outcomes for all)
“Individual patients’ health needs are assessed, and resulting services provided, in appropriate and effective ways”
Score
Evidence Source
Cornwall Partnership NHS Foundation Trust, through consultation with local groups, partners stakeholders and its staff has adopted its
Single Equality Scheme(SES) 2011 – 2014 and an Action Plan for implementation. The Strategy has been informed and developed with due
consideration to the Public Sector Equality Duty 2010, CQC Outcomes and has been informed by the Joint Strategic Needs Assessment
(JSNA).patient satisfaction surveys, analysis and feedback PALS, audit and research.
Using the best available evidence the Trust can demonstrate a grade of “developing” for this outcome.
The Trust maintains and develops partnership work with statutory, community, third sector and other organisations working in the field of equality and
diversity and with clients from protected groups through enhanced links with diverse communities, groups and stakeholders. These groups include:
Cornwall Diversity Forum
Health and Social Care Partnership
Cornwall Migrant Workers
Equality and Human Rights Partnership
Accessible Communication Meeting
Equality Delivery System Cluster Group
Single Equality Scheme Implementation Group
Patient Environment Action Group
Regional Equality Group
RESPECT (Service Use Reference Group)
Opening Doors (Service User Reference Group)
Learning Disability and Partnership Board
Links and consultations are with, but are not limited to:
Places of worship
BME community groups and organisations
LGBT organisations and forum
Migrant workers centres.
Evidence of research on protected groups, their needs and issues is available. Research results that have been published and applied to service
improvement.
Further work needs to be undertaken to establish how the health needs assessments and resulting services of patients from protected groups may
be provided in more appropriate ways and how they compare with patients as a whole.
Copies of satisfaction surveys and the analysis of complaints and feedback are available.
The Trust is working to ensure that its clients and carers representing diverse communities across the protected groups are actively involved in
service planning, implementation and evaluation through the use of an Equality Impact Assessment Toolkit.
Evidence is available to show that involvement has contributed to culturally appropriate care and enhanced outcomes in wellbeing.
Evidence is available to demonstrate that local interest groups are involved in the evaluation of service delivery and outcomes.
Assessments, diagnosis and treatments are conducted by appropriately qualified and culturally competent staff.
The Trust is planning to undertake a review of assessments tools and policies in relation to:
Availability
Cultural relevance and appropriateness.
Accessibility e.g. language/ formats.
Guidelines for assessment through interpreters, to develop a process for cultural validation.
An assessment and review of treatment plans is intended and will include guidance on cultural issues. This guidance will be included in training
programmes. The Trust will also undertake annual audits to assess the impact and inform service/patient improvement and experience.
Copies of satisfaction surveys, analysis of complaints and feedback are used to inform service improvements
The Trust conducts satisfaction surveys of clients and carers from protected groups and translated where appropriate into preferred languages to:
Inform continuous improvement
Determine cultural appropriateness of various services, treatments and programmes
Determine cultural competence and attitudes of staff
Community in patient discharge questionnaires are completed and the information used to support service improvements.
The Trust intends to review existing satisfaction surveys ( Meridian) to:
Identify core questions across each service line.
Benchmark performance and include in annual board reports.
Review accessibility e.g. language, format, completion
Inform service line specific outreach projects for hard to reach groups.
Each Service Line is working towards equality and diversity engagement; This will be developed in partnership with local communities and will
reflect client equality data, under representation/ access to the service and inform strategies and outreach activities
The Trust is working to develop appropriate working groups to share information, identify good practice and develop joint projects – to address any
barriers in relation to access or inclusion for the nine protected characteristics and other relevant groups. These groups will be formed internally and
externally.
OVERALL GRADE
EDS Outcome 1.3 (EDS Goal 1 – Better health outcomes for all)
“Changes across services for individual patients are discussed with them, and transitions are made smoothly”
Score
Evidence Source
Using the best available evidence the Trust can demonstrate a grade of “developing” for this outcome.
Copies of satisfaction surveys and the analysis of complaints and feedback are available.
The Trust is working to ensure that its clients and carers representing diverse communities across the protected groups are actively involved in
service planning, implementation and evaluation through the use of an Equality Impact Assessment Toolkit.
Evidence is available to show that involvement has contributed to culturally appropriate care and enhanced outcomes in wellbeing.
Evidence is available to demonstrate that local interest groups are involved in the evaluation of service delivery and outcomes.
Assessments, diagnosis and treatments are conducted by appropriately qualified and culturally competent staff.
Copies of satisfaction surveys, analysis of complaints and feedback are used to inform service improvements
The Trust conducts satisfaction surveys of clients and carers from protected groups and translated where appropriate into preferred languages to:
Inform continuous improvement
Determine cultural appropriateness of various services, treatments and programmes
Determine cultural competence and attitudes of staff
Community in patient discharge questionnaires are completed and the information used to support service improvements.
Each Service Line is working towards equality and diversity engagement. This will be developed in partnership with local communities and will
reflect client equality data, under representation/ access to the service and inform strategies and outreach activities
The Trust is working to develop appropriate working groups to share information, identify good practice and develop joint projects – to address any
barriers in relation to access or inclusion for the nine protected characteristics and other relevant groups. These groups will be formed internally and
externally.
OVERALL GRADE
EDS Outcome 1.4 (EDS Goal 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”
Score
Evidence Source
Using the best available evidence the Trust can demonstrate a grade of “developing” for this outcome.
The Trust’s objectives to meet our obligations under the Health & Safety at Work Act 1974 and
other related legislation are:
 To provide standards of Safety, Health, Welfare which comply fully with statutory
provisions
To maintain safe and healthy workplaces
To perform risk assessments on all relevant processes, procedures and equipment,
and to manage risks, so far as is reasonably practicable, to an acceptable level
To develop and maintain safe systems and methods of work
To protect employees, and others who may be affected, from foreseeable hazards on
the Trust’s premises or connected with the Trust’s work
To provide employees with adequate information, training, and supervision on safety
procedures and safe systems of work e.g. which will include lone working and dealing
with violence and aggression
To develop safety awareness amongst employees
To make employees aware of their individual responsibility to take all reasonable care
for the safety of themselves and others who may be affected by their acts or omissions,
and to co-operate with Management in matters of safety
To encourage full and effective consultation with employees on safety matters through the Health and Safety Committee
Pro-active: Risk Assessment
a) The risk assessment policy will provide a system of checklists and risk
assessment/action planning methods for all staff to use.
b) The risks and action plan identified from risk assessments should be used to develop
Risk Registers and prioritise the elimination or minimisation of risks.
Re-active: Accidents/Incidents/Near Miss.
a) All accidents/incidents and near misses must be managed, reported and investigated in
line with Trust policy.
b) Action should be undertaken to prevent reoccurrence. Organisational learning should
take place so that all Directorates can take a pro-active risk management approach.
c) Accident/incident and near miss statistical information will be presented to the Health &
Safety Committee to identify organisational trends and therefore facilitate analysis and
action planning.
The Director of Cornwall Healthcare Estates and Support Services (CHESS) is committed to achieving
high standards of Health and Safety, not only in respect of its own employees but also in relation to
Cornwall Partnership NHS Foundation Trust, Cornwall and Isles of Scilly Primary Care Trust and
Royal Cornwall Hospitals Trust employees, contractors, suppliers and others working on the Tust’s
property or providing a service and to patients and members of the public who may be affected by the
Trust’s activities.
CHESS is aware of its obligations under the Health and Safety at Work etc Act 1974 and related
legislation and is fully committed to meeting those obligations. The successful management of Health
and Safety is a key objective throughout the organisation of CHESS and this Policy details the
standards expected of employees and contractors in maintaining a responsible attitude with regard to
the well being of themselves and others.
Hazards will be identified and the risk of harm minimised, so far as is reasonably practicable, through a
process of assessment, control, instruction, information, training and supervision to ensure that
CHESS meets specific obligations to provide safe and healthy working conditions, equipment and
systems of work.
CHESS supports the concept of consultation with its staff on Health and Safety matters and has
established a Health and Safety Committee under the umbrella of the Head of Quality, Assurance and
Environmental Services, in order to provide a mechanism for such consultation.
Cornwall Partnership NHS Foundation Trust meets all statutory requirements in relation to Criminal Records Bureau checks; Cornwall Partnership
NHS Foundation Trust has a child protection policy in place that meets with the requirements of Working Together to Safeguard Children; Cornwall
Partnership NHS Foundation Trust has a process in place that meets with the standards agreed by the South West Strategic Health Authority to
ensure all children who miss an outpatient appointment about whom there are safeguarding concerns are flagged with the safeguarding team; All
eligible staff within Cornwall Partnership NHS Foundation Trust have undertaken level 1 child protection training;
Cornwall Partnership NHS Foundation Trust has undertaken an audit of safeguarding training needs and outcomes and all recommendations are
being delivered; Risk Quality and Standards a Board Level committee of Cornwall Partnership NHS Foundation Trust reviewed these systems and
processes in September 2009 and the outcome of this review was presented to the Board on 28th September 2009. All recommendations from this
review will be monitored by our Safeguarding Group and report to the Board via the Risk Quality and standards committee at least annually.
Other Trust Policies include:
Dignity at Work Policy
Health Visitor Protocols
First Aid at Work Policy
Single Equality Scheme
The Trust maintains and develops partnership work with statutory, community, third sector and other organisations working in the field of equality
and diversity and with clients from protected groups through enhanced links with diverse communities, groups and stakeholders. These groups include:
Cornwall Diversity Forum
Health and Social Care Partnership
Cornwall Migrant Workers
Equality and Human Rights Partnership
Accessible Communication Meeting
Equality Delivery System Cluster Group
Single Equality Scheme Implementation Group
Patient Environment Action Group
Regional Equality Group
RESPECT (Service Use Reference Group)
Opening Doors (Service User Reference Group)
Learning Disability and Partnership Board
Assessments, diagnosis and treatments are conducted by appropriately qualified and culturally competent staff.
Evidence of research on protected groups, their needs and issues is available. Research results that have been published and applied to service
improvement.
Further work needs to be undertaken to establish how patients, members and governors engagement into health and safety procedures can be
improved.
Copies of satisfaction surveys and the analysis of complaints and feedback are available.
The Trust is working to ensure that its clients and carers representing diverse communities across the protected groups are actively involved in
developing patient safety procedures, implementation and evaluation.
Evidence is available to show that involvement has contributed to culturally appropriate care and enhanced outcomes in wellbeing.
Evidence is available to demonstrate that local interest groups are involved in the evaluation of service delivery and outcomes.
The Trust has an Understanding Autism course on the website.
Assessments, diagnosis and treatments are conducted by appropriately qualified and culturally competent staff.
The Trust is planning to undertake a review of assessments tools and policies in relation to:
Availability
Cultural relevance and appropriateness.
Accessibility e.g. language/ formats.
Guidelines for assessment through interpreters, to develop a process for cultural validation.
An assessment and review of treatment plans is intended and will include guidance on cultural issues. This guidance will be included in training
programmes. The Trust will also undertake annual audits to assess the impact and inform service/patient improvement and experience.
Copies of satisfaction surveys, analysis of complaints and feedback are used to inform service improvements
The Trust conducts satisfaction surveys of clients and carers from protected groups and translated where appropriate into preferred languages to:
Inform continuous improvement
Determine cultural appropriateness of various services, treatments and programmes
Determine cultural competence and attitudes of staff
Community in patient discharge questionnaires are completed and the information used to support service improvements
The Trust intends to review existing satisfaction surveys ( Meridian) to:
Identify core questions across each service line.
Benchmark performance and include in annual board reports.
Review accessibility e.g. language, format, completion
Inform service line specific outreach projects for hard to reach groups.
Each Service Line is working towards equality and diversity engagement; This will be developed in partnership with local communities and will
reflect client equality data, under representation/ access to the service and inform strategies and outreach activities
The Trust is working to develop appropriate working groups to share information, identify good practice and develop joint projects – to address any
barriers in relation to access or inclusion for the nine protected characteristics and other relevant groups. These groups will be formed internally and
externally.
EDS Outcome 1.4 (EDS Goal 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”
Score
Evidence Source
Using the best available evidence the Trust can demonstrate a grade of “developing” for this outcome.
The Trust’s objectives to meet our obligations under the Health & Safety at Work Act 1974 and
other related legislation are:
 To provide standards of Safety, Health, Welfare which comply fully with statutory
provisions
 To maintain safe and healthy workplaces
 To perform risk assessments on all relevant processes, procedures and equipment,
and to manage risks, so far as is reasonably practicable, to an acceptable level
 To develop and maintain safe systems and methods of work
 To protect employees, and others who may be affected, from foreseeable hazards on
the Trust’s premises or connected with the Trust’s work
 To provide employees with adequate information, training, and supervision on safety
procedures and safe systems of work e.g. which will include lone working and dealing
with violence and aggression
 To develop safety awareness amongst employees
 To make employees aware of their individual responsibility to take all reasonable care
for the safety of themselves and others who may be affected by their acts or omissions,
and to co-operate with Management in matters of safety
 To encourage full and effective consultation with employees on safety matters through the Health and Safety Committee
Pro-active: Risk Assessment
a) The risk assessment policy will provide a system of checklists and risk
assessment/action planning methods for all staff to use.
b) The risks and action plan identified from risk assessments should be used to develop
Risk Registers and prioritise the elimination or minimisation of risks.
Re-active: Accidents/Incidents/Near Miss.
a) All accidents/incidents and near misses must be managed, reported and investigated in
line with Trust policy.
b) Action should be undertaken to prevent reoccurrence. Organisational learning should
take place so that all Directorates can take a pro-active risk management approach.
c) Accident/incident and near miss statistical information will be presented to the Health &
Safety Committee to identify organisational trends and therefore facilitate analysis and
action planning.
The Director of Cornwall Healthcare Estates and Support Services (CHESS) is committed to achieving
high standards of Health and Safety, not only in respect of its own employees but also in relation to
Cornwall Partnership NHS Foundation Trust, Cornwall and Isles of Scilly Primary Care Trust and
Royal Cornwall Hospitals Trust employees, contractors, suppliers and others working on the Trust’s
property or providing a service and to patients and members of the public who may be affected by the
Trust’s activities.
CHESS is aware of its obligations under the Health and Safety at Work etc Act 1974 and related
legislation and is fully committed to meeting those obligations. The successful management of Health
and Safety is a key objective throughout the organisation of CHESS and this Policy details the
standards expected of employees and contractors in maintaining a responsible attitude with regard to
the well being of themselves and others.
Hazards will be identified and the risk of harm minimised, so far as is reasonably practicable, through a
process of assessment, control, instruction, information, training and supervision to ensure that
CHESS meets specific obligations to provide safe and healthy working conditions, equipment and
systems of work.
CHESS supports the concept of consultation with its staff on Health and Safety matters and has
established a Health and Safety Committee under the umbrella of the Head of Quality, Assurance and
Environmental Services, in order to provide a mechanism for such consultation.
Cornwall Partnership NHS Foundation Trust meets all statutory requirements in relation to Criminal Records Bureau checks; Cornwall Partnership
NHS Foundation Trust has a child protection policy in place that meets with the requirements of Working Together to Safeguard Children; Cornwall
Partnership NHS Foundation Trust has a process in place that meets with the standards agreed by the South West Strategic Health Authority to
ensure all children who miss an outpatient appointment about whom there are safeguarding concerns are flagged with the safeguarding team; All
eligible staff within Cornwall Partnership NHS Foundation Trust have undertaken level 1 child protection training;
Cornwall Partnership NHS Foundation Trust has undertaken an audit of safeguarding training needs and outcomes and all recommendations are
being delivered; Risk Quality and Standards a Board Level committee of Cornwall Partnership NHS Foundation Trust reviewed these systems and
processes in September 2009 and the outcome of this review was presented to the Board on 28th September 2009. All recommendations from this
review will be monitored by our Safeguarding Group and report to the Board via the Risk Quality and standards committee at least annually.
Other Trust Policies include:
Dignity at Work Policy
Health Visitor Protocols
First Aid at Work Policy
Single Equality Scheme
The Trust maintains and develops partnership work with statutory, community, third sector and other organisations working in the field of equality
and diversity and with clients from protected groups through enhanced links with diverse communities, groups and stakeholders. These groups
include:


Cornwall Diversity Forum
Health and Social Care Partnership
Cornwall Migrant Workers
Equality and Human Rights Partnership
Accessible Communication Meeting
Equality Delivery System Cluster Group
Single Equality Scheme Implementation Group
Patient Environment Action Group
Regional Equality Group
RESPECT (Service Use Reference Group)
Opening Doors (Service User Reference Group)
Learning Disability and Partnership Board
Assessments, diagnosis and treatments are conducted by appropriately qualified and culturally competent staff.
Evidence of research on protected groups, their needs and issues is available. Research results that have been published and applied to service
improvement.
Further work needs to be undertaken to establish how patients, members and governors engagement into health and safety procedures can be
improved.
Copies of satisfaction surveys and the analysis of complaints and feedback are available.
The Trust is working to ensure that its clients and carers representing diverse communities across the protected groups are actively involved in
developing patient safety procedures, implementation and evaluation.
Evidence is available to show that involvement has contributed to culturally appropriate care and enhanced outcomes in wellbeing.
Evidence is available to demonstrate that local interest groups are involved in the evaluation of service delivery and outcomes.
Assessments, diagnosis and treatments are conducted by appropriately qualified and culturally competent staff.
The Trust is planning to undertake a review of assessments tools and policies in relation to:
Availability
Cultural relevance and appropriateness.
Accessibility e.g. language/ formats.
Guidelines for assessment through interpreters, to develop a process for cultural validation.
An assessment and review of treatment plans is intended and will include guidance on cultural issues. This guidance will be included in training
programmes. The Trust will also undertake annual audits to assess the impact and inform service/patient improvement and experience.
Copies of satisfaction surveys, analysis of complaints and feedback are used to inform service improvements
The Trust conducts satisfaction surveys of clients and carers from protected groups and translated where appropriate into preferred languages to:
Inform continuous improvement
Determine cultural appropriateness of various services, treatments and programmes
Determine cultural competence and attitudes of staff
Community in patient discharge questionnaires are completed and the information used to support service improvements.
The Trust intends to review existing satisfaction surveys ( Meridian) to:
Identify core questions across each service line.
Benchmark performance and include in annual board reports.
Review accessibility e.g. language, format, completion
Inform service line specific outreach projects for hard to reach groups.
Each Service Line is working towards equality and diversity engagement; This will be developed in partnership with local communities and will
reflect client equality data, under representation/ access to the service and inform strategies and outreach activities
The Trust is working to develop appropriate working groups to share information, identify good practice and develop joint projects – to address any
barriers in relation to access or inclusion for the nine protected characteristics and other relevant groups. These groups will be formed internally and
externally.
Score
EDS Outcome 1.5 (EDS Goal 1 – Better health outcomes for all)
“Public health, vaccination and screening programmes reach and benefit all local communities and groups”
Evidence Source
Using the best available evidence the Trust can demonstrate a grade of “developing” for this outcome.
The Trust works with Cornwall and the Isles of Scilly PCT to deliver immunisation programmes to make them readily accessible to all protected
groups.” Eligible groups for public health, vaccination and screening programmes are determined nationally. The PCT encourages universal access
to immunisation programmes and services are set up to invite all eligible groups to attend vaccination programmes,”
The PCT is “starting to engage with patients and communities from all protected groups and key disadvantaged groups on how health programmes
can be improved.”
The PCT and the Trust “aim to meet this outcome through its contractual agreements, especially with primary care contractors.”
The Trust maintains and develops partnership work with statutory, community, third sector and other organisations working in the field of equality and
diversity and with clients from protected groups through enhanced links with diverse communities, groups and stakeholders. These groups include:
Cornwall Diversity Forum
Health and Social Care Partnership
Cornwall Migrant Workers
Equality and Human Rights Partnership
Accessible Communication Meeting
Equality Delivery System Cluster Group
Single Equality Scheme Implementation Group
Patient Environment Action Group
Regional Equality Group
RESPECT (Service Use Reference Group)
Opening Doors (Service User Reference Group)
Learning Disability and Partnership Board
Evidence is available to demonstrate that local interest groups are involved in the evaluation of service delivery and outcomes.
Copies of satisfaction surveys, analysis of complaints and feedback are used to inform service improvements
The Trust conducts satisfaction surveys of clients and carers from protected groups and translated where appropriate into preferred languages to:
Inform continuous improvement
Determine cultural appropriateness of various services, treatments and programmes
Determine cultural competence and attitudes of staff
Each Service Line is working towards equality and diversity engagement. This will be developed in partnership with local communities and will
reflect client equality data, under representation/ access to the service and inform strategies and outreach activities
The Trust is working to develop appropriate working groups to share information, identify good practice and develop joint projects – to address any
barriers in relation to access or inclusion for the nine protected characteristics and other relevant groups. These groups will be formed internally and
externally.
OVERALL GRADE
Score
EDS Outcome 2.1 (EDS Goal 2 – Improved patient access and experience)
“Patients, carers and communities can readily access services, and should not be denied access on unreasonable grounds”
Evidence Source
Using the best available evidence the Trust can demonstrate a grade of “developing” for this outcome.
The Single Equality Scheme and supporting Action Plan identify key areas for patient and carer access to services.
Interpreting services are available for clients where a language barrier is identified.
Service Line Information is available and disseminated to existing and potential clients and carers across a range of diverse places and in a range of
languages and formats, including Braille, large print, audio tape etc to facilitate access and feedback.
The Trust website is as accessible as possible to all potential clients and carers.
CFT uses imagery and language that challenges stereotypes, prejudice and promotes equality.
Reasonable adjustments are made to improve access for service users and carers covering disability and other personal factors.
All staff are trained in equality issues relating to service accessibility.
A published accessibility survey is in place (for disabled clients) supported by an action plan for improvement.
The Trust will ensure that clients and carers have equal access to the complaints procedure (including range of languages and formats) and monitors
for trends across the nine protected characteristics and other disadvantages groups.
Establish clear links with the internal Single Equality Review Group.
An Interpreting Policy and Procedure has been written and has been ratified. Along with this the Trust has developed Interpreting guidance in
collaboration with the Community Development Worker’s which the Trust is trying to integrate into the 24 hour notification. Following liaison with
the interpreting provider the Trust now has interpreting available 24 hours a day.
Interpreting costs are recorded and reported in Quarterly reports to the Board. Any trends are highlighted with management.
The Trust website is accessible as possible to all potential clients and carers
The Trust published a new internet site on April 2012 to improve patient and public access. The site is complimented by RokTalk which offers a
range of options to enable access to information on the site.
The site meets W3C web accessibility standards.
The Trust's Board, Council of Governors and Annual Member's meetings are held in venues with disabled access. Hearing loops are routinely made
available at public meetings.
All corporately organised events consider the needs of people with disabilities and other requirements at the planning phase. A checklist of things to
consider is used by the communication's department as a memory jogger when planning corporate events
The Trusts website has information relating to Health and Well Being :
Children’s Health and Wellbeing
Customer Support
Essence of Care
Inclusion
Leaflet Library
Patient Information
Story Books
Whole Life
Documents are produced in Easy Read Format
Learning Disability Documents are available relating to “Different Kinds of Support”, ”Your pathway to support and advice”,
Understanding Autism course on Website
The Trust maintains and develops partnership work with statutory, community, third sector and other organisations working in the field of equality and
diversity and with clients from protected groups through enhanced links with diverse communities, groups and stakeholders. These groups include:
Cornwall Diversity Forum
Health and Social Care Partnership
Cornwall Migrant Workers
Equality and Human Rights Partnership
Accessible Communication Meeting
Equality Delivery System Cluster Group
Single Equality Scheme Implementation Group
Patient Environment Action Group
Regional Equality Group
RESPECT (Service Use Reference Group)
Opening Doors (Service User Reference Group)
Learning Disability and Partnership Board
Evidence is available to demonstrate that local interest groups are involved in the evaluation of service delivery and outcomes.
Copies of satisfaction surveys, analysis of complaints and feedback are used to inform service improvements.
The Trust conducts satisfaction surveys of clients and carers from protected groups and translated where appropriate into preferred languages to:



Inform continuous improvement
Determine cultural appropriateness of various services, treatments and programmes
Determine cultural competence and attitudes of staff
Each Service Line is working towards equality and diversity engagement. This will be developed in partnership with local communities and will
reflect client equality data, under representation/ access to the service and inform strategies and outreach activities
The Trust is working to develop appropriate working groups to share information, identify good practice and develop joint projects – to address any
barriers in relation to access or inclusion for the nine protected characteristics and other relevant groups. These groups will be formed internally and
externally.
OVERALL GRADE
EDS Outcome 2.2 (EDS Goal 2 – Improved patient access and experience)
“Patients are informed and supported to be as involved as they wish to be in their diagnosis and decisions about their care,
and to exercise choice about treatments and places of treatment”
Score
Evidence Source
Using the best available evidence the Trust can demonstrate a grade of “developing” for this outcome.
The Single Equality Scheme and supporting Action Plan identify key areas for patients to be informed and supported in their diagnosis
and decisions about their care.
Interpreting services are available for clients where a language barrier is identified.
Service Line Information is available and disseminated to existing and potential clients and carers across a range of diverse places and in a range of
languages and formats, including Braille, large print, audio tape etc to facilitate access and feedback.
The Trust website is as accessible as possible to all potential clients and carers.
CFT uses imagery and language that challenges stereotypes, prejudice and promotes equality.
Reasonable adjustments are made to improve access for service users and carers covering disability and other personal factors
All staff are trained in equality issues relating to service accessibility.
A published accessibility survey is in place (for disabled clients) supported by an action plan for improvement.
The Trust will ensure that clients and carers have equal access to the complaints procedure (including range of languages and formats) and monitors
for trends across the nine protected characteristics and other disadvantages groups.
Care Programme Approach (CPA) Care Pathway
The Care Programme Approach (CPA) provides a framework for effective mental health care.
It has four main elements:
Systematic arrangements for assessing the health and social needs of people accepted into specialist mental health services;
The formation of a care plan which identifies the health and social care required from a variety of providers;
The appointment of a key worker (care co-ordinator) to keep in close touch with the service user and to monitor and co-ordinate care; and
Regular review and, where necessary, agreed changes to the care plan.
The Care Programme Approach (CPA) is applicable to all adults of working age in contact with the mental health service.
An Interpreting Policy and Procedure has been written and has been ratified. Along with this the Trust has developed Interpreting guidance in
collaboration with the Community Development Worker’s which the Trust is trying to integrate into the 24 hour notification. Following liaison with
the interpreting provider the Trust now has interpreting available 24 hours a day.
The Trust website is accessible as possible to all potential clients and carers
The Trust published a new internet site on April 2012 to improve patient and public access. The site is complimented by RokTalk which offers a
range of options to enable access to information on the site.
The site meets W3C web accessibility standards.
A wider range of imagery is used by the Trust in both its publications and websites. These aim to promote inclusion and highlight diversity and
equality.
The Trusts website has information relating to Health and Well Being :
Children’s Health and Wellbeing
Customer Support
Essence of Care
Inclusion
Leaflet Library
Patient Information
Story Books
Whole Life
Documents are produced in Easy Read Format
Learning Disability Documents are available relating to “Different Kinds of Support”, ”Your pathway to support and advice”,
Understanding Autism- course available on Website
The Trust maintains and develops partnership work with statutory, community, third sector and other organisations working in the field of equality and
diversity and with clients from protected groups through enhanced links with diverse communities, groups and stakeholders. These groups include:
Cornwall Diversity Forum
Health and Social Care Partnership
Cornwall Migrant Workers
Equality and Human Rights Partnership
Accessible Communication Meeting
Equality Delivery System Cluster Group
Single Equality Scheme Implementation Group
Patient Environment Action Group
Regional Equality Group
RESPECT (Service Use Reference Group)
Opening Doors (Service User Reference Group)
Learning Disability and Partnership Board
Copies of satisfaction surveys, analysis of complaints and feedback are used to inform service improvements.
The Trust conducts satisfaction surveys of clients and carers from protected groups and translated where appropriate into preferred languages to:


Inform continuous improvement
Determine cultural appropriateness of various services, treatments and programmes and determine cultural competence and attitudes of
staff.
Each Service Line is working towards equality and diversity engagement. This will be developed in partnership with local communities and will
reflect client equality data, under representation/ access to the service and inform strategies and outreach activities.
The Trust is working to develop appropriate working groups to share information, identify good practice and develop joint projects – to address any
barriers in relation to access or inclusion for the nine protected characteristics and other relevant groups. These groups will be formed internally and
externally.
OVERALL GRADE
EDS Outcome 2.3 (EDS Goal 2 – Improved patient access and experience)
“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”
Score
Evidence Source
Cornwall Partnership NHS Foundation Trust, through consultation with local groups, partners stakeholders and its staff has adopted its
Single Equality Scheme(SES) 2011 – 2014 and an Action Plan for implementation. The Strategy has been informed and developed with due
consideration to the Public Sector Equality Duty 2010, CQC Outcomes and has been informed by the Joint Strategic Needs Assessment
(JSNA).patient satisfaction surveys, analysis and feedback PALS, audit and research
Using the best available evidence the Trust can demonstrate a grade of “developing” for this outcome.
The Trusts Customer Support Team focuses on improving services for NHS Patients. The Team aims to offer advice and support to patients, their
families and carers. They provide information on NHS Services, listen to and investigate concerns, suggestions or queries. They also feedback to
teams and management on positive feedback that they receive.
The Trust maintains and develops partnership work with statutory, community, third sector and other organisations working in the field of equality and
diversity and with clients from protected groups through enhanced links with diverse communities, groups and stakeholders. These groups include:
Cornwall Diversity Forum
Health and Social Care Partnership
Cornwall Migrant Workers
Equality and Human Rights Partnership
Accessible Communication Meeting
Equality Delivery System Cluster Group
Single Equality Scheme Implementation Group
Patient Environment Action Group
Regional Equality Group
RESPECT (Service Use Reference Group)
Opening Doors (Service User Reference Group)
Learning Disability and Partnership Board
Evidence is available to demonstrate that local interest groups are involved in the evaluation of service delivery and outcomes.
Copies of satisfaction surveys, analysis of complaints and feedback are used to inform service improvements.
The Trust conducts satisfaction surveys of clients and carers from protected groups and translated where appropriate into preferred languages to:


Inform continuous improvement
Determine cultural appropriateness of various services, treatments and programmes

Determine cultural competence and attitudes of staff
Care Programme Approach (CPA) Care Pathway
The Care Programme Approach (CPA) provides a framework for effective mental health care.
It has four main elements:
 Systematic arrangements for assessing the health and social needs of people accepted into specialist mental health services;

The formation of a care plan which identifies the health and social care required from a variety of providers;

The appointment of a key worker (care co-ordinator) to keep in close touch with the service user and to monitor and co-ordinate care; and

Regular review and, where necessary, agreed changes to the care plan.
The Care Programme Approach (CPA) is applicable to all adults of working age in contact with the mental health service.
An Interpreting Policy and Procedure has been written and has been ratified. Along with this the Trust has developed Interpreting guidance in
collaboration with the Community Development Worker’s which the Trust is trying to integrate into the 24 hour notification. Following liaison with
the interpreting provider the Trust now has interpreting available 24 hours a day.
Data is regularly analysed and feedback forms are used to review accessibility to the Customer Support Department. Areas for Action identified in
Complaints, PALS, and Patient Experience are shared with Service Line Managers to implement improvements and changes to the service as
required.
Interpreting costs are recorded and reported in Quarterly reports to the Board. Any trends are highlighted with management.
The Trust website is accessible as possible to all potential clients and carers
The Trust published a new internet site on April 2012 to improve patient and public access. The site is complimented by RokTalk which offers a
range of options to enable access to information on the site.
The site meets W3C web accessibility standards.
A wider range of imagery is used by the Trust in both its publications and websites. These aim to promote inclusion and highlight diversity and
equality.
The Trusts website has information relating to Health and Well Being :
Children’s Health and Wellbeing
Customer Support
Essence of Care
Inclusion
Leaflet Library
Patient Information
Story Books
Whole Life
Documents are produced in Easy Read Format on request.
Learning Disability Documents are available relating to “Different Kinds of Support”, ”Your pathway to support and advice”,
Further work needs to be undertaken to establish how the experience of patients and carers from protected groups compare with the experience of
patients and carers as a whole.
Each Service Line is working towards equality and diversity engagement. This will be developed in partnership with local communities and will
reflect client equality data, under representation/ access to the service and inform strategies and outreach activities
The Trust is working to develop appropriate working groups to share information, identify good practice and develop joint projects – to address any
barriers in relation to access or inclusion for the nine protected characteristics and other relevant groups. These groups will be formed internally and
externally.
OVERALL GRADE
EDS Outcome 2.4 (EDS Goal 2 – Improved patient access and experience
“Patients’ and carers’ complaints about services, and subsequent claims for redress, should be handled respectfully and efficiently”
Score
Evidence Source
Cornwall Partnership NHS Foundation Trust, through consultation with local groups, partners stakeholders and its staff has adopted its
Single Equality Scheme(SES) 2011 – 2014 and an Action Plan for implementation. The Strategy has been informed and developed with due
consideration to the Public Sector Equality Duty 2010, CQC Outcomes and has been informed by the Joint Strategic Needs Assessment
(JSNA).patient satisfaction surveys, analysis and feedback PALS, audit and research
Using the best available evidence the Trust can demonstrate a grade of “developing” for this outcome.
The Trusts Customer Support Team focuses on improving services for NHS Patients. The Team aims to offer advice and support to patients, their
families and carers. They provide information on NHS Services, listen to and investigate concerns, suggestions or queries. They also feedback to
teams and management on positive feedback that they receive.
Data is regularly analysed and feedback forms are used to review accessibility to the Customer Support Department. Areas for Action identified in
Complaints, PALS, and Patient Experience are shared with Service Line Managers to implement improvements and changes to the service as
required.
The Trust maintains and develops partnership work with statutory, community, third sector and other organisations working in the field of equality and
diversity and with clients from protected groups through enhanced links with diverse communities, groups and stakeholders. These groups include:
Cornwall Diversity Forum
Health and Social Care Partnership
Cornwall Migrant Workers
Equality and Human Rights Partnership
Accessible Communication Meeting
Equality Delivery System Cluster Group
Single Equality Scheme Implementation Group
Patient Environment Action Group
Regional Equality Group
RESPECT (Service Use Reference Group)
Opening Doors (Service User Reference Group)
Learning Disability and Partnership Board
Evidence is available to demonstrate that local interest groups are involved in the evaluation of service delivery and outcomes.
Copies of satisfaction surveys, analysis of complaints and feedback are used to inform service improvements.
The Trust conducts satisfaction surveys of clients and carers from protected groups and translated where appropriate into preferred languages to:



Inform continuous improvement
Determine cultural appropriateness of various services, treatments and programmes
Determine cultural competence and attitudes of staff
The Trusts website has information relating to Health and Well Being :
Children’s Health and Wellbeing
Customer Support
Essence of Care
Inclusion
Leaflet Library
Patient Information
Story Books
Whole Life
Documents are produced in Easy Read Format on request.
Learning Disability Documents are available relating to “Different Kinds of Support”, ”Your pathway to support and advice”,
Further work needs to be undertaken to establish how the handling of complaints made by patients and carers from protected groups compare with
the handling of complaints from patients and carers as a whole.
Each Service Line is working towards equality and diversity engagement. This will be developed in partnership with local communities and will
reflect client equality data, under representation/ access to the service and inform strategies and outreach activities.
The Trust is working to develop appropriate working groups to share information, identify good practice and develop joint projects – to address any
barriers in relation to access or inclusion for the nine protected characteristics and other relevant groups. These groups will be formed internally and
externally.
OVERALL GRADE
EDS Outcome 3.1 (EDS Goal 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”
Score
Evidence Source
Cornwall Partnership NHS Foundation Trust, through consultation with local groups, partners stakeholders and its staff has adopted its
Single Equality Scheme(SES) 2011 – 2014 and an Action Plan for implementation. The Strategy has been informed and developed with due
consideration to the Public Sector Equality Duty 2010, CQC Outcomes and has been informed by the Joint Strategic Needs Assessment
(JSNA).patient satisfaction surveys, analysis and feedback PALS, audit and research
Using the best available evidence the Trust can demonstrate a grade of “achieving” for this outcome.
The Trusts Board has agreed a Recruitment Policy the Policy states that:“The Trust seeks to recruit the best and most appropriate people to its workforce, and to
protect the wellbeing of those in its care through safe recruitment procedures and thorough
pre employment checks. It is committed to a fair, consistent and non-discriminatory
approach to its recruitment and selection, in full compliance with relevant UK legislative
requirements and NHS Employment Check Standards.”
The Trust recognises the need and desire for a diverse workforce. It is essential that the
workforce reflect the community it serves and therefore the Trust must strive to attract
applications from all sections of society.
The Trust seeks to attract and appoint the most suitable candidate for each of its vacancies,
regardless of their age, disability, gender, sexual orientation, marriage or civil partnership
status, maternity or pregnancy, race, religion or belief, or gender reassignment.
The Trust may take action to attract and appoint staff from under -represented groups in the
community. This is the case in relation to candidates who have a disability, who are
guaranteed an interview if they meet the essential criteria for a post. The Trust may also at
times target a specific group where there is a justifiable need for a particular post.
As part of the Trust’s commitment to employing a diverse workforce, the Trust supports the recruitment
of current and former service users. Experience both locally and nationally has shown that the
employment of current or former service users has a significant positive effect in terms of the
culture, values and beliefs of those within organisations. Also, the employment of individuals
who may both understand from a personal perspective some of the issues facing service users
and have an ability to engage with them in a positive and meaningful way is a valuable asset to
the Trust’s workforce.
The Trust has adopted a Recognition Agreement. The Agreement sets out a formal Recognition Agreement between Cornwall Partnership NHS
Foundation Trust and those Trade Unions in respect of negotiation, consultation and representation of staff employed by the Trust.
The main forum between the Trust and the Trade Unions is the Joint Negotiation Committee(JNC). From this a range of sub-committees are formed
either as standing committees (the Joint Consultative Committee) or short life committees by agreement, they shall have the right to make
agreements in respect of the issues delegated and shall make recommendations to the JNC or
JCC on matters affecting the Trust.
A People and Organisational Development (OD) Strategy exists to define what is required of the people who make up the workforce and how the
Trust will support its staff to deliver excellent services. It reflects and supports the Trust’s strategic organisational goals, objectives and values and
captures the essence of the sort of employer the Trust wishes to be.
The Trust’s commitments and plans for staff and for the development of the organisation as set out in the strategy are wide-ranging and
comprehensive, aiming to integrate effective people management across all activities of the Trust, ensuring that the experience of staff as employees
is a positive one. The strategy also seeks to define behaviours and processes and ensure there is clarity and cohesion between systems, strategies,
values, skills, structures and culture. The Trust recognises that the staff are key ambassadors for the organisation within the communities that they
live and work and also acknowledge the impact a positive employee experience has on the experience of service users.
Copies of satisfaction surveys, analysis of complaints and feedback are used to inform service improvements
The Trust conducts satisfaction surveys of employees to:



Inform continuous improvement
Determine cultural appropriateness of various services, treatments and programmes
Determine cultural competence and attitudes of staff
Process are in place for monitoring compliance and effectiveness of the Trust Recruitment Policy
As a minimum, they include the review/monitoring of all the minimum requirements within the
NHSLA standards.
Monitoring arrangements for compliance and effectiveness i.e. audit, review etc.
Responsibilities for conducting the monitoring/audit.
Methodology to be used for monitoring/audit.
Frequency of monitoring/audit i.e. quarterly, on a rolling basis etc.
Process for reviewing results and ensuring improvements in performance occur.
OVERALL GRADE
EDS Outcome 3.2 (EDS Goal 3 – Empowered, engaged and well-supported staff)
“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”
Score
Evidence Source
Cornwall Partnership NHS Foundation Trust, through consultation with local groups, partners stakeholders and its staff has adopted its
Single Equality Scheme(SES) 2011 – 2014 and an Action Plan for implementation. The Strategy has been informed and developed with due
consideration to the Public Sector Equality Duty 2010, CQC Outcomes and has been informed by the Joint Strategic Needs Assessment
(JSNA).patient satisfaction surveys, analysis and feedback PALS, audit and research
Using the best available evidence the Trust can demonstrate a grade of “achieving” for this outcome.
NHS Terms and Conditions Handbook.
All NHS employers are obliged to adhere to employment and tax law and other statutory provisions. The NHS Staff Council will review this Handbook
periodically, taking account of changes to relevant legislation.
The provisions set out in the handbook are based on the need to ensure a fair system of pay for NHS employees which supports modernised
working practices. The provisions recognise that modern forms of healthcare rely on flexible teams of staff providing patient care 24 hours a day, 7
days a week, 365 days a year and applying a wide range of skills.
Nationally, employer and trades union representatives have agreed to work in partnership to maintain an NHS pay system which supports NHS
service modernisation and meets the reasonable aspirations of staff. The national partners have agreed to work together to meet the reasonable
aspirations of all the parties to:

ensure that the pay system leads to more patients being treated, more quickly and being given higher quality care;

assist new ways of working which best deliver the range and quality of services required, in as efficient and effective a way as possible, and
organised to best meet the needs of patients;

assist the goal of achieving a quality workforce with the right numbers of staff, with the right skills and diversity, and organised in the right
way;

improve the recruitment, retention and morale of the NHS workforce;

improve all aspects of equal opportunity and diversity, especially in the areas of career and training opportunities and to ensure working
patterns that are flexible and responsive to family commitments;
The Trust has adopted a Recognition Agreement. The Agreement sets out a formal Recognition Agreement between Cornwall Partnership NHS
Foundation Trust and those Trade Unions in respect of negotiation, consultation and representation of staff employed by the Trust.
The main forum between the Trust and the Trade Unions is the Joint Negotiation Committee (JNC). From this a range of sub-committees are formed
either as standing committees (the Joint Consultative Committee) or short life committees by agreement, they shall have the right to make
agreements in respect of the issues delegated and shall make recommendations to the JNC or
JCC on matters affecting the Trust.
A People and Organisational Development (OD) Strategy exists to define what is required of the people who make up the workforce and how the
Trust will support its staff to deliver excellent services. It reflects and supports the Trust’s strategic organisational goals, objectives and values and
captures the essence of the sort of employer the Trust wishes to be.
The Trust’s commitments and plans for staff and for the development of the organisation as set out in the strategy are wide-ranging and
comprehensive, aiming to integrate effective people management across all activities of the Trust, ensuring that the experience of staff as employees
is a positive one. The strategy also seeks to define behaviours and processes and ensure there is clarity and cohesion between systems, strategies,
values, skills, structures and culture. The Trust recognises that the staff are key ambassadors for the organisation within the communities that they
live and work and also acknowledge the impact a positive employee experience has on the experience of service users.
Copies of satisfaction surveys, analysis of complaints and feedback are used to inform service improvements
The Trust conducts satisfaction surveys of employees to:



Inform continuous improvement
Determine cultural appropriateness of various services, treatments and programmes
Determine cultural competence and attitudes of staff
Process are in place for monitoring compliance and effectiveness of the Trust Recruitment Policy
As a minimum, they include the review/monitoring of all the minimum requirements within the
NHSLA standards.
Monitoring arrangements for compliance and effectiveness i.e. audit, review etc.
Responsibilities for conducting the monitoring/audit.
Methodology to be used for monitoring/audit.
Frequency of monitoring/audit i.e. quarterly, on a rolling basis etc.
Process for reviewing results and ensuring improvements in performance occur .
OVERALL GRADE
EDS Outcome 3.3 (EDS Goal 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”
Score
Evidence Source
Cornwall Partnership NHS Foundation Trust, through consultation with local groups, partners stakeholders and its staff has adopted its
Single Equality Scheme(SES) 2011 – 2014 and an Action Plan for implementation. The Strategy has been informed and developed with due
consideration to the Public Sector Equality Duty 2010, CQC Outcomes and has been informed by the Joint Strategic Needs Assessment
(JSNA).patient satisfaction surveys, analysis and feedback PALS, audit and research
Using the best available evidence the Trust can demonstrate a grade of “developing” for this outcome.
A People and Organisational Development (OD) Strategy exists to define what is required of the people who make up the workforce and how the
Trust will support its staff to deliver excellent services. It reflects and supports the Trust’s strategic organisational goals, objectives and values and
captures the essence of the sort of employer the Trust wishes to be.
The Trust’s commitments and plans for staff and for the development of the organisation as set out in the strategy are wide-ranging and
comprehensive, aiming to integrate effective people management across all activities of the Trust, ensuring that the experience of staff as employees
is a positive one. The strategy also seeks to define behaviours and processes and ensure there is clarity and cohesion between systems, strategies,
values, skills, structures and culture. The Trust recognises that the staff are key ambassadors for the organisation within the communities that they
live and work and also acknowledge the impact a positive employee experience has on the experience of service users.
Copies of satisfaction surveys, analysis of complaints and feedback are used to inform service improvement.
Compulsory Training Policy
Compulsory Training refers to ‘core’ training and applies to all staff (permanent, temporary & bank) across the Trust regardless of Service Area,
Profession or Directorate. In addition all staff are required to complete service specific training that has been determined through risk assessment as
essential training in relation to your role. The implementation of this policy is the responsibility of all staff across Cornwall Partnership NHS
Foundation Trust though the responsibility will vary depending upon whether the staff member is an employee, Manager, Director or Board Member,
therefore all staff will need to understand their individual obligations and demonstrate compliance through supervision and the Personal Development
Review (Appraisal) process
An Equality Impact Assessment Form was undertaken on this Policy to ensure that the organisation
designs and implement services, policies and measures that meet the diverse needs of our
service, population and workforce, ensuring that none are placed at a disadvantage over others.
The Trust conducts satisfaction surveys of employees to:



Inform continuous improvement
Determine cultural appropriateness of various services, treatments and programmes
Determine cultural competence and attitudes of staff
Process are in place for monitoring compliance and effectiveness of the Trust Recruitment Policy.
As a minimum, they include the review/monitoring of all the minimum requirements within the
NHSLA standards.
Monitoring arrangements for compliance and effectiveness i.e. audit, review etc.
Responsibilities for conducting the monitoring/audit.
Methodology to be used for monitoring/audit.
Frequency of monitoring/audit i.e. quarterly, on a rolling basis etc.
Process for reviewing results and ensuring improvements in performance occur.
OVERALL GRADE
EDS Outcome 3.4 (EDS Goal 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 and fair to all”
Score
Evidence Source
Cornwall Partnership NHS Foundation Trust, through consultation with local groups, partners stakeholders and its staff has adopted its
Single Equality Scheme(SES) 2011 – 2014 and an Action Plan for implementation. The Strategy has been informed and developed with due
consideration to the Public Sector Equality Duty 2010, CQC Outcomes and has been informed by the Joint Strategic Needs Assessment
(JSNA).patient satisfaction surveys, analysis and feedback PALS, audit and research
Using the best available evidence the Trust can demonstrate a grade of “developing” for this outcome.
DIGNITY AT WORK POLICY
Purpose
As an equal opportunities employer, the trust supports a working environment for individuals
in which dignity at work is paramount. The purpose of the policy is to support a working
environment and culture in which bullying harassment and victimisation is unacceptable.
Personnel
This policy applies to all staff working within the trust, employees, visitors, patients,
contractors and staff from other organisations working on trust premises.
Area
This policy will applies to all trust premises and all trust personnel working in other premises.
Principles
The trust recognises that all employees have the right to be treated with consideration,
dignity and respect. The trust seeks to support all staff in their professional development and
aims to provide a happy and fulfilling environment in which to work. This policy promotes
dignity at work, the respectful treatment of staff within our trust and the protection of our
employees from bullying and harassment at work. Bullying and harassment will not be
tolerated by the trust in any form.
Trade unions
The trust recognises the important role trade unions play in addressing harassment and
members are encouraged to approach these representatives regarding their concerns. The
trust will work in conjunction with the trade unions in addressing unacceptable and
inappropriate behaviours.
An equality staff network web page to support all staff including E&D leads
A range of pages on equality and diversity are available on the Trust's website - see:
http://www.cornwallfoundationtrust.nhs.uk/cft/AboutUs/EqualityAndDiversity/EqualityAndDiversity.asp
These pages include details of the Trust's Public Sector Equality Duty, workforce data and a selection of links to key documents and other useful
websites.
Each page of the site has contact details (email, telephone and a quick contact form) which ensure visitors have easy access into the Trust and can
be directed to the most appropriate person to provide further help and support.
Data relating to Workforce, Grievances, Disciplinary and Incident Reports are held by the HR Team and reported to the Board
Further comparative work is required to gage the level of abuse experienced by staff from protected groups compares with staff as a whole
OVERALL GRADE
EDS Outcome 3.5 (EDS Goal 3 – Empowered, engaged and well-supported staff)
“Flexible working options are made available to all staff, consistent with the needs of the service, and the way people lead their lives”
Score
Evidence Source
Cornwall Partnership NHS Foundation Trust, through consultation with local groups, partners stakeholders and its staff has adopted its
Single Equality Scheme(SES) 2011 – 2014 and an Action Plan for implementation. The Strategy has been informed and developed with due
consideration to the Public Sector Equality Duty 2010, CQC Outcomes and has been informed by the Joint Strategic Needs Assessment
(JSNA).patient satisfaction surveys, analysis and feedback PALS, audit and research
Using the best available evidence the Trust can demonstrate a grade of “developing” for this outcome.
Through compliance with the NHS Terms and Conditions Handbook the Trust can demonstrate
“NHS employers, in partnership with staff organisations, will develop positive flexible working arrangements which allow people to balance work
responsibilities with other aspects of their lives. In considering the provisions of this paragraph employers should also have regard to the provisions
in Section 2, Maintaining round the clock services and Annex A3: Principles for harmonised on-call arrangements.
Employers are required to consider flexible working options as part of their duty to make reasonable adjustments for disabled staff and job
applicants, under the Equality Act (2010), and staff returning from maternity leave (see Section 15). In addition, unless there are clear, demonstrable
reasons why it is not practicable, flexible working arrangements (in line with the Employment Equality (Religion or belief) Regulations 2003) should,
wherever possible, be made available to employees who undertake daily religious observance or a holy day.
New working arrangements should only be introduced by mutual agreement, whether sought by the employee or the employer.
Flexible working should be part of an integrated approach to the organisation of work and the healthy work/life balance of staff.
Policies for flexible working should be made clear to all employees.
Employers should develop policies on flexible working which, as far as is practicable, should include:
• part-time working, where a person works to a pattern and number of hours by mutual agreement;
• job sharing, where two or more people share the responsibilities of one or more full-time job(s), dividing the hours, duties and pay between them;
• flexi-time, where employees can choose their own start and finish time around fixed core hours;
• annual hours contracts, where people work a specific number of hours each year, with the hours being unevenly distributed throughout the year;
• flexible rostering, using periods of work of differing lengths within an agreed overall period;
• term-time working, where people work during the school term but not during school holidays;
Part 5: Equal opportunities Section 34: Flexible working arrangements NHS terms and conditions of service handbook The NHS Staff Council Pay
circular (AforC) 5/2010: amendment number 20
• school-time contracts;
• tele-working, where people work from home for all or part of their hours with a computer or telecommunication link to their organisation;
• voluntary reduced working time, where people work reduced hours by agreement at a reduced salary;
• fixed work patterns where, by agreement, days off can be irregular to enable, for example, separated parents to have access to their children and
flexible rostering;
• flexible retirement.
Flexible working arrangements should be available to all employees.
All jobs should be considered for flexible working; if this is not possible the employer must provide written, objectively justifiable reasons for this and
give a clear, demonstrable operational reason why this is not practicable.
There should be a clear procedure for application for flexible working, agreed by employers and local staff representatives.
All people with flexible working arrangements should have access to standard terms and conditions of employment, on an equal or pro-rata basis,
unless different treatment can be justified for operational reasons.
Monitoring and review.
Applications and outcomes should be monitored annually, in partnership with local staff representatives.
Monitoring information should be analysed and used to review and revise policies and procedures to ensure their continuing effectiveness.
Applications and outcomes, from both employer and employees, should be recorded and kept for a minimum of one year.”
Further work needs to be undertaken to obtain comparative data relating to flexible working options for staff from protected groups and the
workforce as a whole.
OVERALL GRADE
EDS Outcome 3.6 (EDS Goal 3 –Empowered, engaged and well-supported staff)
“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”
Score
Evidence Source
Cornwall Partnership NHS Foundation Trust, through consultation with local groups, partners stakeholders and its staff has adopted its
Single Equality Scheme(SES) 2011 – 2014 and an Action Plan for implementation. The Strategy has been informed and developed with due
consideration to the Public Sector Equality Duty 2010, CQC Outcomes and has been informed by the Joint Strategic Needs Assessment
(JSNA).patient satisfaction surveys, analysis and feedback PALS, audit and research
Using the best available evidence the Trust can demonstrate a grade of “achieving” for this outcome.
The Occupational Health Service covers all three Health Trusts in Cornwall.
The services they offer include:


Pre-employment health screening
Attendance management

Confidential counselling services

Immunisation and vaccination programmes

Health surveillance testing

Blood tests

Health promotion programmes

Advice on general health issues.
Staff Screening Policy
Cornwall Partnership NHS Foundation Trust has a duty of care to protect staff, patients
and visitors from the risk of cross infection and as such will take all reasonable care to
ensure the risk of infection to its staff is minimised.
Communicable diseases in staff must be identified in a timely fashion in order that
suitable and sufficient measures can be taken to reduce the risk of transmission to other
staff and patients. All staff working for the Trust have a professional responsibility to take
reasonable steps to avoid putting the health of others at risk.
Any member of staff who believes they have, or have been in recent contact with, a
communicable infection must inform the Occupational Health Department for advice and
possible management. Staff should give serious consideration to any occupational
immunisation offered when taking up employment, as part of updated national guidance
or as part of an ongoing programme.
An equality staff network web page to support all staff including E&D leads
A range of pages on equality and diversity are available on the Trust's website - see:
http://www.cornwallfoundationtrust.nhs.uk/cft/AboutUs/EqualityAndDiversity/EqualityAndDiversity.asp
These pages include details of the Trust's Public Sector Equality Duty, workforce data and a selection of links to key documents and other useful
websites.
Each page of the site has contact details (email, telephone and a quick contact form) which ensure visitors have easy access into the Trust and can
be directed to the most appropriate person to provide further help and support.
OVERALL GRADE
EDS Outcome 4.1 (EDS Goal 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
and beyond”
Score
Evidence Source
Cornwall Partnership NHS Foundation Trust, through consultation with local groups, partners stakeholders and its staff has adopted its
Single Equality Scheme(SES) 2011 – 2014 and an Action Plan for implementation. The Strategy has been informed and developed with due
consideration to the Public Sector Equality Duty 2010, CQC Outcomes and has been informed by the Joint Strategic Needs Assessment
(JSNA).patient satisfaction surveys, analysis and feedback PALS, audit and research
Using the best available evidence the Trust can demonstrate a grade of “developing” for this outcome.
The Trusts Annual Report contains information and achievements relating to Equality and Diversity.
The Board approved the SES 2011-14 and action plan which includes a robust process in place for ongoing engagement and evaluation of
performance.
The Equality & Diversity structure, leadership and accountability are clearly defined within the organisation with appropriate capacity and resources.
Identifiable structure and roles are in place. E&D corporate budget approved and identified.
Trust board and senior leaders are equipped with the appropriate level of knowledge and skills to lead on the delivery of the SES and action plan.
Equality Objectives are aligned to business planning and reflecting current and future equality priorities.
All orders that are processed from Suppliers are covered by the Standard NHS Terms and Conditions which has clauses relating to Equality and
Diversity. There is also a procurement policy that does include a section on Equality and Diversity. A questionnaire is going to be sent to 100
suppliers regarding Equality and Diversity. Tender opportunities are published in tenders in Cornwall and on a web based e tendering system
(Tactica) where they are accessible to all. All tenders are also published through the official European journal.
The Trust has and an established programme for carrying out relevant equality impact assessments when developing new policies or services, or
when revising existing ones.
EIA framework and guidance is in place.
CFT representation and participation at relevant equality community groups and partner agencies.
Relevant employer equality objectives will be identified within the annual HR Directorate objective planning process and managed as appropriate
through the Staff Engagement Group.
Clear process for setting, monitoring and reporting equality employer objectives.
Actions identified and monitored for completion and improvement e.g. implementation of the Bullying and Harassment policy ( analysis of cases
reported,
OVERALL GRADE
EDS Outcome 4.2 (EDS Goal 4 – Inclusive leadership at all levels)
“Middle managers and other line managers support and motivate their staff to work in culturally competent ways
within a work environment free from discrimination”
Score
Evidence Source
Cornwall Partnership NHS Foundation Trust, through consultation with local groups, partners stakeholders and its staff has adopted its
Single Equality Scheme(SES) 2011 – 2014 and an Action Plan for implementation. The Strategy has been informed and developed with due
consideration to the Public Sector Equality Duty 2010, CQC Outcomes and has been informed by the Joint Strategic Needs Assessment
(JSNA).patient satisfaction surveys, analysis and feedback PALS, audit and research
Using the best available evidence the Trust can demonstrate a grade of “developing” for this outcome.
Managers and service line Leads actively champion equality, diversity and inclusion issues within their own areas.
All managers and service leads are actively involved in the communication of organisation’s SES within their areas of responsibility, and their actions
demonstrate that commitment
Recording, reporting and monitoring processes are in place with findings and action plans in place and published.
The Trust’s Annual Report contains information and achievements relating to Equality and Diversity.
The Board approved the SES 2011-14 and action plan which includes a robust process in place for ongoing engagement and evaluation of
performance.
The Equality & Diversity structure, leadership and accountability are clearly defined within the organisation with appropriate capacity and resources.
Identifiable structure and roles are in place.
E&D corporate budget approved and identified
Trust board and senior leaders are equipped with the appropriate level of knowledge and skills to lead on the delivery of the SES and action plan.
Equality Objectives are aligned to business planning and reflecting current and future equality priorities.
The Trust has and an established programme for carrying out relevant equality impact assessments when developing new policies or services, or
when revising existing ones.
EIA framework and guidance is in place.
CFT representation and participation at relevant equality community groups and partner agencies.
Relevant employer equality objectives will be identified within the annual HR Directorate objective planning process and managed as appropriate
through the Staff Engagement Group.
Clear process for setting, monitoring and reporting equality employer objectives.
Actions identified and monitored for completion and improvement e.g. implementation of the Bullying and Harassment policy ( analysis of cases
reported,
OVERALL GRADE
EDS Outcome 4.3 (EDS Goal 4 – Inclusive leadership at all levels)
“The organisation uses the Competency Framework for Equality and Diversity Leadership
to recruit, develop and support strategic leaders to advance equality outcomes”
Score
Evidence Source
Cornwall Partnership NHS Foundation Trust, through consultation with local groups, partners stakeholders and its staff has adopted its
Single Equality Scheme(SES) 2011 – 2014 and an Action Plan for implementation. The Strategy has been informed and developed with due
consideration to the Public Sector Equality Duty 2010, CQC Outcomes and has been informed by the Joint Strategic Needs Assessment
(JSNA).patient satisfaction surveys, analysis and feedback PALS, audit and research
Using the best available evidence the Trust can demonstrate a grade of “undeveloped” for this outcome.
OVERALL GRADE