Considerations Before Completing This Document

Considerations before completing this document

Undertaking a meaningful deliberation of how this policy/strategy/plan affects people (patients, staff and public) is important in the context of ensuring we work towards providing good treatment and outcomes for all, and treating people according to their individual needs. In order to do this, particular consideration needs to be given to understanding and responding to the needs of people based on their characteristics such as sex, race, disability, age, etc, Consideration should also be given to groups of people who may experience health inequalities e.g. the homeless, to try to reduce those poorer health outcomes. To do this adequately, requires careful consideration of the Equality Impact of this document before you start.  Does this affect people? If no, the EIA is not needed. Record “This is not a person-related document” on the EIA form

 If yes, how will you consult with affected people to get their views? (Think about staff groups, local community groups, networks, etc.)

 Could particular protected groups be more affected than others? If so, how will you mitigate this? (you won’t know this if you haven’t consulted)

 Why is this a good idea? Is there research to support it?

 What information is available relating to the local population, patient information (e.g. attendance, DNAs) and staff (workforce data) which will support this document?

Particular attention should be given to:

Protected characteristics Groups who experience health inequalities Age Gender (including transgender) People who may be homeless Sexual orientation People who live in poverty Religion or Belief People who are long-term unemployed Ethnicity People in stigmatised occupations (such as Disability women and men involved in prostitution) Pregnancy/maternity People who misuse drugs Marriage/Civil Partnership (workforce only) People with limited family or social networks People who are geographically isolated

Local Procedure Template Page 1 of 7 This will aid your completion of the Equality Impact Assessment which must be completed alongside the document. Training supporting the effective completion of EIAs is available via ESR or for help and advice please read the Equality Impact Assessment Policy available here or contact the Human Rights, Equality and Inclusion Lead [email protected]

LOCAL PROCEDURE FOR XXX NB: This template is only to be used for procedures, SOPs, etc that are managed locally and not published via any Trust webpage or the Documents Library. Please use the ‘help comments’ in blue to complete the template and then delete all of the ‘help comments’ including this one. 1. Introduction 1.1. This section should provide an overview of the importance and role of the subject covered by the document. If the document is created in support of a parent policy/procedure then this should be referenced.

1.2. This version supersedes any previous versions of this document. 2. Purpose of this Policy/Procedure 2.1. This should provide an explanation of the intent/purpose of the document and the rationale for its development. Where appropriate, reference should be made to statutory or legal requirements or to evidence-based good practice. An outline of the objectives and intended outcomes should be provided for the process or system being described. 3. Ownership and Responsibilities 3.1. This section should give a detailed overview of the strategic and operational roles responsible for the development, management and implementation of the policy/procedure. It should include details of the groups or committees, as well as individuals, e.g.

3.2. Role of the Managers Line managers are responsible for:

. XXX.

3.3. Role of Individual Staff All staff members are responsible for:

. XXX.

Local Procedure Template Page 2 of 7 4. Standards and Practice 4.1. This section may use more relevant wording and is used to provide details and information describing the practices, systems, and processes staff are expected to follow in order to comply with the procedural document. 5. Dissemination and Implementation 5.1. A brief summary on how the document will be disseminated should be included, together with details of any special arrangements that may be required or help in aiding retrieval. If the document replaces a previous version the summary should refer to archiving arrangements and any process in place ensuring staff are aware of the new version.

5.2. This section should also describe the arrangements for implementing the policy, e.g. provision of training and support for staff; series of roadshows; etc. If there is a training need associated with this policy the author must ensure that this is noted on the Governance Coversheet above and also ensure that the Learning and Development department are aware of this need. 6. Monitoring compliance and effectiveness This part must provide information on the processes and methodology for monitoring compliance with, and effectiveness of, the policy/procedure using the table below.

Element to be What part of the process do you intend to monitor (you may intend monitored or need to monitor all of it)

Lead Who will lead on this aspect of monitoring?

Tool What tool will be used to monitor/check/observe/asses/inspect/authenticate that everything is working according to this key element from the approved policy?

Attach the tool to the policy or no one will know what you are monitoring. Frequency How often is the need to monitor each element?

How often is the need to complete a report?

How often is the need to share the report?

Individualise the timeframe(s) Reporting Who or what committee will the completed report be sent to. arrangements How will each report be interrogated to identify the required actions and how thoroughly should this be documented in e.g. meeting minutes.

The lead or committee is expected to read and interrogate the report to identify deficiencies in the system and act upon them

Local Procedure Template Page 3 of 7 Consider stating this responsibility in committee terms of reference Acting on Which committee, department or lead will undertake subsequent recommendation recommendations and action planning for any or all deficiencies s and Lead(s) and recommendations within reasonable timeframes?

Required actions will be identified and completed in a specified timeframe

Consider stating this responsibility in committee terms of reference Change in How will system or practice changes be implemented the lessons practice and learned, and how will these be shared. lessons to be shared Possible wording to use for this column. Required changes to practice will be identified and actioned within … (state a specific time frame). A lead member of the team will be identified to take each change forward where appropriate. Lessons will be shared with all the relevant stakeholders 7. Updating and Review 7.1. This section covers information regarding the review process. All procedural documents should be reviewed no less than every three years. Where appropriate, the author may set a shorter review date. 8. Equality and Diversity 8.1. All new and revised documents (excluding Human Resource documents) must acknowledge adherence to the Trust agreed equality and diversity statement by inclusion of the following:

This document complies with the Royal Cornwall Hospitals NHS Trust service Equality and Diversity statement which can be found in the 'Equality, Diversity & Human Rights Policy' or the Equality and Diversity website.

8.1. All Human Resources policies must include, or refer to, the following employment statement:

Royal Cornwall Hospitals NHS Trust is committed to a Policy of Equal Opportunities in employment. The aim of this policy is to ensure that no job applicant or employee receives less favourable treatment because of their race, colour, nationality, ethnic or national origin, or on the grounds of their age, gender, gender reassignment, marital status, domestic circumstances, disability, HIV status, sexual orientation, religion, belief, political affiliation or trade union membership, social or employment status or is disadvantaged by conditions or requirements which are not justified by the job to be done. This policy concerns all aspects of employment for existing staff and potential employees.

Local Procedure Template Page 4 of 7 8.2. Equality Impact Assessment 8.3. All public bodies have a statutory obligation to undertake Equality Impact Assessments on all procedural documents. This must be undertaken by the author using the agreed Equality Impact Assessment Template. The completed assessment is to be added to the end of the policy document as an appendix prior to it being ratified.

8.4. The Initial Equality Impact Assessment Screening Form is at Appendix 1.

9. Governance Information

Date Issued/Approved: Date signed

Date Valid To: No more than 3 years from approval

Author/owner: Name of author and Job Title

Contact details: Number in full, not extension only

Manager confirming approval Head of relevant Division/Department processes Related Documents: Reference and Associated documents Version No Changes from previous version

All or part of this document can be released under the Freedom of Information Act 2000

This document is to be retained for 10 years from the date of expiry.

This document is only valid on the day of printing

Controlled Document This document has been created following the Royal Cornwall Hospitals NHS Trust Policy on Document Production. It should not be altered in any way without the express permission of the author or their Line Manager.

Local Procedure Template Page 5 of 7 Appendix 1. Initial Equality Impact Assessment Form

This assessment will need to be completed in stages to allow for adequate consultation with the relevant groups.

Are there concerns that the policy could have differential impact on: Equality Strands: Yes No Unsure Rationale for Assessment / Existing Evidence 7. The Impact PleaseName complete of Name the following of the strategy table. If / youpolicy are /proposal unsure/don’t / service know function if there to be is assesseda negative impact you need to repeat the consultation step.

Age Directorate and service area: Is this a new or existing Policy? Sex (male, female,Name trans-genderof individual / completing assessment: Telephone: gender reassignment)

Race 1. / EthnicPolicy Aim* communities /groups Who is the strategy / Disabilitypolicy / -proposal / Learningservice functiondisability, aimed physical at? impairment,2. Policy Objectives*sensory impairment, mental health3. Policy conditions – intended and some long term health conditions.Outcomes* Religion / other beliefs Marriage and Civil4. partnership *How will you measure the Pregnancyoutcome? and maternity Sexual5. Who is intended to Orientation,benefit from the Bisexual,policy Gay, ? 6aheterosexual, Who did Lesbianyou Workforce Patients Local External Other consultYou will with need to continue to a full Equality Impactgroups Assessmentorganisations if the following have been highlighted:  You have ticked “Yes” in any column above and Please record specific names of groups b). Please identify the groups No consultation who have or evidence of there being consultation- this excludes any policies which have been consultedbeen identified about as not requiring consultation. or this procedure.  Major this relates to service redesign or development What was the outcome of the consultation?8. Please indicate if a full equality analysis is recommended. Yes No

Local Procedure Template Page 6 of 7 9. If you are not recommending a Full Impact assessment please explain why.

Signature of policy developer / lead manager / director Date of completion and submission

Names and signatures of 1. members carrying out the 2. Human Rights, Equality & Inclusion Lead Screening Assessment

Keep one copy and send a copy to the Human Rights, Equality and Inclusion Lead c/o Royal Cornwall Hospitals NHS Trust, Human Resources Department, Knowledge Spa, Truro, Cornwall, TR1 3HD

This EIA will not be uploaded to the Trust website without the signature of the Human Rights, Equality & Inclusion Lead.

A summary of the results will be published on the Trust’s web site.

Signed ______

Date ______

Local Procedure Template Page 7 of 7