Equality Delivery System for the NHS

Action or activity

A policy has now been created, and the Trust is piloting the Reasonable Adjustments Digital Flag across 3 areas in January 2026.

Related equality objectives

Improving the experience for and supporting those with protected characteristics under the Equality Act 2010.

Action or activity

As of 1 April 2025, a local survey on the SDMQ9 questions (a 9-item measure of the decision process in medical encounters from patients’ perspectives) has been rolled out across the Trust.

Integration of the Patient Profile and development of personalised care plan datasets into e-Care is being worked on.

Related equality objectives

Under the Public Sector Equality Duty (PSED), NHS organisations must advance equality of opportunity between people with protected characteristics and those without. This includes removing or minimising disadvantage and meeting different needs

Personalised care focuses on what matters to the individual, considering their circumstances, identity, family situation, culture, and barriers to health.

Action or activity

We have been identifying gaps in those who currently provide feedback and are working with local partners to engage with those groups.

Related equality objectives

Improving the experience for and supporting those with protected characteristics under the Equality Act 2010.

Action or activity

Promote the current interventions that are available to all our colleagues, ensuring that barriers are removed, that may limit their access, when required.

Related equality objectives

This supports the Public Sector Equality Duty (PSED) by ensuring all colleagues can access wellbeing interventions without discrimination and by proactively removing barriers that may disadvantage particular groups.

Action or activity

Ensure that workplace reasonable adjustments guidance and request process is fully embedded into the organisation's practices

Related equality objectives

This aligns with the Workforce Disability Equality Standard (WDES) and the Equality Act, ensuring that reasonable adjustments are applied consistently so disabled colleagues are supported equitably across the organisation.

Action or activity

Understand and overcome the barriers to ensuring all available wellbeing interventions are accessible across all staff groups by completing EIA's and monitoring assessment programmes.

Related equality objectives

This contributes to the PSED by identifying and addressing inequalities through EIAs and continuous monitoring, ensuring wellbeing programmes meet the needs of all staff groups.

Action or activity

Promote the benefit and purpose of occupational health service, in actively supporting the workforce’s overall health and wellbeing by creating a referral help guide.

Related equality objectives

This supports Health and Wellbeing for All, ensuring all colleagues—particularly those with specific health needs—can make informed use of occupational health services in an equitable and accessible way.

Action or activity

Upskill those with supervisory responsibilities in having supportive conversations around adjustments that can be made for individuals experiencing underline health issues and or disabilities.

Related equality objectives

This strengthens inclusive practice under the PSED by ensuring supervisors can hold supportive, fair, and informed conversations with colleagues who have health conditions or disabilities, reducing inequitable experiences.

Action or activity

Embed our newly created pathway to support the trust’s response to traumatic events affecting employees, such as the death of a colleague, verbal or physical assault or a pandemic.

Related equality objectives

This aligns with our commitments on sexual safety and antiracism, ensuring that all colleagues affected by traumatic events receive timely, consistent, and equitable support regardless of role, background, or protected characteristic.

Action or activity

• To maintain our NHS Staff survey results, around the specific question of recommended this as a place to work and to receive treatment
• To identify, act and review on the feedback gathered from our colleagues, using the NHS England Health and Wellbeing framework tool, on areas of improvement, within the working environment of our colleagues- to ensure they feel valued.
• To further develop the upskilling of our managers and leaders, to enable teams to feel safe and valued within their role, whilst being aligned to a sense of purpose.
• To use exit interview data, to make improvements to the experience of the workplace

Related equality objectives

To champion inclusivity within the Trust and to also support addressing the inequity highlighted through the following statutory reports, data sources and organisational commitments:

WRES, WDES, Sexual Safety, Pay gap, anti-racism charter.

Action or activity

Launch phase 2 of the new EIA process in Spring 2025. This will introduce a streamlined process where the development and implementation of an EIA PowerApp will digitalise the EIA process

Related equality objectives

Public Sector Equality Duty- ensuring due regard is given to equality considerations when exercising function such as decision making.

Action or activity

Trust Board members to be invited to attend every VOICE meeting to update on Board activity and to strengthen relationship between Board and our patient representatives.

Related equality objectives

Strengthen inclusive patient involvement by ensuring that patient representatives have equitable access to senior decision‑makers, enabling diverse patient voices—particularly those from underserved or marginalised groups—to influence Trust Board discussions and decisions

Evidence:

243 patients completed a survey regarding the accessibility of ED..

• 74% of respondents felt that they were easily able to access the department

Physical access

An AccessAble guide is available for the department to provide accessibility information.

Feedback from the patient survey indicates that there are issues regarding the steep hill to get to ED from the car park, as well as lack of wheelchair access or appropriate seating.

Comments also highlight no safe waiting spaces for those with poor mobility or compromised immunity, as well as high beds, lack of hoists or space for mobility aids.

Accessible information

Patient information can be provided in different formats across the Trust for patients with various communication needs, e.g. information can be provided in large print.

Whilst there are difficulties providing accessible information on demand in ED, patients can be directed to the Trust website and encouraged to access information using the accessibility toolbar, provided by ReciteMe.

There is a language line device on wheels in ED which allows for video interpreting.

Identifying barriers which service users face when accessing the department

Through engagement with service users and the local community, including those who are more likely to experience poor health outcomes, feedback about barriers to access is being shared and fed into planning/service design and improvement. The public health team work in partnership with the engagement team to identify local priorities and increase access to health.

Coordinated care

WSFT is part of the West Suffolk Alliance, which ensures coordinated health services both at the Trust and in locality hubs. We also work as part of an EDI collaborative across the SNEE ICS and are membership of a SNEE group focusing on system-wide equity and inclusion issues.

Evidence:

Of the patient survey data:

54% of respondents felt their personal requirements were assessed, with 32 of those answering that adjustments were then made

Having evaluated the survey comments…

Reasonable adjustments

Patient passports are in place for those with learning disabilities and/or autism, and the Learning Disability & Autism Liaison Nurse supports adult patients where possible.

A Reasonable Adjustments policy has recently been published which covers all patients with a disability or long-term condition.

The Reasonable Adjustments digital flag is being piloted in certain areas in January 2026 and will be rolled out to ED in March.

However, feedback from the patient survey highlights a failure to make Reasonable Adjustments; patients with learning disabilities, communication difficulties, or hearing loss report staff unwilling or unable to adapt communication methods.

Patients with Ehlers-Danlos, autoimmune, or chronic pain conditions describe disbelief or dismissal of symptoms.

Patient profiles

Patient profiles are in use across the Trust whereby patients or their loved ones can provide information about the person behind the patient: who they are, what they like/dislike and important information that may support them in their appointment by enabling person-centred, individualised care.

Evidence:

4% of incidents between 1 March 2025 and 5 December 2025 were related to ED.

Of the patent survey data mentioned below:

51% either strongly agreed or agreed with the statement that they felt their safety was prioritised by staff

Patients’ responsibility for own safety

CQC rating regarding safety

The last CQC inspection took place in September and October 2019 and rated the Trust as ‘requires improvement’ in the area of safety. The Trust has implemented significant improvement plans, including early adoption of PSIRF, and transformed the way it manages patient safety and harm.

Local incident reporting

Monthly safety meetings take place where incidents are discussed, and any learning or actions are fed back to local teams.

Evidence:

Patient satisfaction data – PALS, complaints, compliments, surveys

243 patients completed a survey regarding the accessibility of ED.

72% did not feel discriminated against by staff

53% of respondents felt that they had been involved as much as they wanted to when making decisions about their care

With regards to PALS data, between 1 March 2025 and 5 December 2025, 7% of enquiries were related to ED. 10% of formal complaints during this period were related to ED.

Any PALS enquiries or complaints that are received which are related to equality, diversity or inclusion (EDI) matters are flagged as such and investigated, including reporting to the Patient Equity Oversight Group which feeds into the Trust Board.

Ongoing patient satisfaction surveys are available, with both qualitative and quantitative data being regularly reviewed.

EDS patient survey data

Age

There appeared to be a strong pattern of age-related neglect, lack of dignity, and low prioritisation.

Key issues:

• Elderly patients left waiting 32+ hours with no communication, food, or comfort.
• Described as “not valued,” “ignored,” or “treated as a burden.”
• Families report staff unwilling to communicate or involve them in decisions for frail or confused relatives.
• Dementia care described as unsafe and distressing — patients frightened, unsupervised, or placed with unsuitable others.

Pregnancy and maternity

• Several serious concerns were raised about the treatment of women experiencing miscarriage and young pregnant patients.

Sex

While less explicitly raised, several comments reflect gendered experiences:

• Female patients reporting dismissal of symptoms as “stress-related” or “anxiety.”
• Lack of privacy during triage or discussion of personal health issues.
• Male-heavy security presence during mental health episodes causing fear and trauma for women.

The Trust provides a comprehensive framework of support to help staff effectively manage long term physical and mental health conditions while at work. This includes:

• Targeted learning and development programmes delivered through our Learning and OD teams. These focus on mental health awareness, resilience building, health coaching, and supporting colleagues through organisational change, ensuring staff are equipped with the knowledge and skills to manage their own wellbeing and support others.
• A fully resourced on-line Learning Hub, offering a wide range of self led wellbeing activities, including materials related to weight management, healthy living, stress reduction, managing long term conditions, and behaviour change.
• Clear access routes to the Staff Psychology Service, which provides confidential, therapeutic support for staff experiencing work related emotional strain, stress, or the impact of ongoing health concerns.
• The moving and handling service has been renamed to Ergonomic Health and Conflict Resolution to provide clearer recognition of the support available to staff. The new title better reflects the team’s role in promoting musculoskeletal (MSK) health, physical wellbeing, and effective conflict resolution in the workplace.
• A staff physiotherapy referral pathway remains to provide timely access to specialist support for MSK issues. This service aims to reduce the risk of MSK-related sickness absence and support early intervention to keep staff healthy and able to work.
• Occupational health service still provides Pre employment/work health assessments, management referrals, vaccinations/BBV management, health surveillance (COSHH), COVID risk support, night worker assessments, training/advice to managers
• The new ‘Green Plan’ for the Trust has been launched, which further encourages staff engagement with wellbeing initiatives and outdoor spaces. This includes activities such as regular nature walks and other environmentally focused wellbeing opportunities designed to promote physical and mental health.
• A 24/7 Employee Assistance Programme (EAP), offering independent counselling, emotional support, and specialist wellbeing tools, ensuring staff have round the clock access to evidence based help. This multi layered approach ensures staff can seek both proactive and reactive support, contributing to a healthier, safer, and more resilient workforce.

WSFT maintains a strong commitment to creating a workplace where all staff are safe from abuse, harassment, bullying, and violence, regardless of source. To uphold this commitment:

• We closely monitor concerns through the NHS Staff Survey, formal incident and security reporting, and feedback from Freedom to Speak Up (FTSU), enabling early identification of trends, risks, and required interventions.
• We actively collaborate with East of England system partners, sharing intelligence and best practice to strengthen collective efforts to reduce violence, harassment, and discrimination across the region.
• The Trust has formally signed the NHS Sexual Safety Charter, reinforcing our zero‑tolerance position on sexual harassment and ensuring staff and patients receive consistent, proactive education on safe and respectful behaviours.
• Trust‑wide awareness and behavioural campaigns have been implemented to clearly outline unacceptable behaviours, reinforce staff rights, and increase confidence in reporting concerns.
• We are preparing to launch a trust‑wide Anti‑Racism Campaign, which will directly support our equality commitments, enhance psychological safety, and further embed inclusivity across all staff groups.

These measures reflect a sustained and proactive approach to building a safe, respectful, and inclusive working environment.

The Trust ensures staff have timely access to a range of independent, confidential, and specialist support services when experiencing stress, bullying, harassment, abuse, or physical violence. Key support mechanisms include:

• Our, 24/7 EAP, introduced in 2025, provides immediate, independent and in the moment support to qualified counsellors, crisis intervention, and a wide suite of clinically‑validated resources relating to stress management, trauma response, emotional wellbeing, and personal resilience
• Our Occupational Health service provides impartial assessments, advice, and recommendations relating to adjustments for staff experiencing stress or mental/physical health concerns, ensuring staff receive objective and specialist guidance.
• We are developing and strengthening relationships with expert organisations, including:
• Domestic abuse support charities, contributing to our sexual safety, safeguarding, and staff protection work.

o Suicide prevention and specialist mental health charities, offering additional pathways for crisis support, education, and signposting.

These partnerships enhance access to trauma‑informed, expert‑led support beyond the organisation’s internal provision.

Alongside our internal support, including the in‑house physiotherapy service and the staff psychology team, these services work together to ensure staff receive safe, independent, and specialist support in a way that best meets their needs.

The 2024 NHS Staff Survey reported that 48.96% of staff would recommend West Suffolk NHS Foundation Trust (WSFT) as a place to work and receive care. This represents a decline compared with 2023; updated 2025 results are expected to provide further insight.

Despite this reduction in survey scores, several indicators continue to demonstrate strong staff and patient confidence in the care we provide:

• The Friends and Family Test (FFT) consistently shows high levels of patient satisfaction, with positive feedback around personalised care and treatment experience.
• Staff who have personally used WSFT services have shared positive stories and testimonials on social media, emphasising compassionate care and strong clinical outcomes for themselves or their families.

To strengthen staff advocacy and improve future recommendation scores, we are actively delivering our People, Culture and Organisational Development Strategy, with prioritised focus on:

• Reward and Recognition:
  Launching a new recognition platform for both staff and patients to celebrate outstanding contributions, helping create a culture of gratitude and appreciation.
• Enhanced Health and Wellbeing Support:
  Improving the coordination and integration of Occupational Health, Staff Psychology, Physiotherapy and other wellbeing services to create a seamless, responsive, and proactive support system for staff.

These initiatives are designed to enhance staff experience, deepen organisational belonging, and increase the proportion of staff who feel confident recommending WSFT as both an employer and a provider of high-quality care.

Each of our four staff networks have a board level Executive Sponsor. They meet with their respective Network Chairs regularly to support the objectives of the network and utilise their privilege and knowledge of the organisation to overcome any barriers to progress.

A meeting between all Network Chairs and Executive Sponsors will shortly take place before April 2026. This will provide a space for them to reflect together on their experiences and identify ways forward to ensure that the role of the sponsor remains impactful and there is regular and consistent engagement.

All board members have at least yearly engagement with each staff network. This includes attending events organised by the networks and that are included within our organisational development calendar. The Board also invites Staff network chairs to attend meetings to elevate the collective voices of our staff networks, listen to staff stories and experiences and raise/discuss issues.

Within our Trust, we have three Staff Side EDI Leads who are Equality Reps for the Unison Branch at WSFT. They are the Black members officer, the LGBT+ officer and the Women’s officer. These colleagues are on the membership list for various meetings (such as Workforce Wellbeing and Inclusion, the People and Culture Leadership Group and the Policy Working Group) to advocate for staff and work collaboratively with other stakeholders within the Trust to ensure that progress is being made, and we are being held accountable to the EDI objectives and values we have committed to.

A key area of focus for the board is allyship and anti-racism. The board are involved in working alongside the Organisational development manager-EDI to enhance progress in these areas, and they are required to attend and participate in EDI anti-racism workshops planned for 2026. Such workshops should set clear and measurable outcomes.

Every board member has EDI objectives that are SMART and will be assessed against these as a part of their annual appraisal. More generally, from January 2024, all non-medical staff are asked to identify and set an EDI objective as a part of their annual appraisal.

In December 2025, the Trust’s CEO mentoring programme was launched for the second consecutive year. It is a positive action initiative to provide a development opportunity for colleagues who are underrepresented within our Trust, and to address the lack of diversity and underrepresentation of certain staff groups in senior roles within our organisation. Clinical and non-clinical colleagues at band 7 and above who identify as Global Majority, disabled, LGBTQ+, armed forces or are underrepresented in their professional fields due to their gender, were encouraged to apply. The opportunity includes: three 1:1 mentoring conversations, shadowing opportunities and a reflective group exercise at the end of the programme. For the first cohort there was a total of 24 applicants for this programme, 20 women and four men. Five out of the six colleagues selected to be mentored by the Chief Executive were women.

Additionally, three Executive Directors are mentoring colleagues who submitted applications to this programme but were not selected to be mentored by the Chief Executive. Out of these six mentees, two were men and four were women.

The cover sheet for every committee and board paper contains a section on equality, diversity and inclusion where staff are prompted to think about the impact that the proposed action will place upon EDI.

Additional questions and prompts were added in Spring 2024 to ensure that colleagues were completing this section fully and to support them to think further about inclusive practices and the impact that their proposed activity may have.

In Summer 2025, feedback was provided to Board to ensure that there is a section on the coversheet to specifically ask if an EIA has been undertaken, and to challenge/defer decision-making where an EIA has not been completed.

The meetings of the new Workforce Wellbeing and Inclusion group (which was previously two separate groups; Belonging in the NHS, discussing EDI matters, and Looking after our people, discussing staff wellbeing matters) will be minuted and have action logs which are reported upon at the beginning of each meeting. There is also a clear route of escalation through the Trust’s governance structure to ensure that issues and/or concerns are raised in other groups for discussion, action, and assurance.

In January 2025, phase 1 of our Equality Impact Assessment (EIA) process was launched. Further supporting resources, including a recorded manager’s essentials webinar, are planned to ensure that colleagues feel confident in completing EIAs. Phase 2 of the EIA process was launched in September 2025. This involved digitalising the process and providing a way for completed EIAs to be stored through a dedicated EIA PowerApp. Further work is underway to ensure that all committee decisions are made after EIAs are completed to ensure that the full impact of decisions are known and there are mitigating factors in place where required.

From January 2026, board members will receive an annual workforce EDI report providing a holistic overview of EDI work, achievements and progress made within the previous year. This will also include updates on the progress made on the key priorities identified from the previous year.

The report will also be forward looking and will outline key priorities over the course of the upcoming year. In addition to this annual report, a mid-year report is scheduled for the Involvement Committee in August of each year to ensure that there is a bi-annual opportunity to monitor progress.

All non-medical staff are asked to set an EDI objective as a part of their annual appraisal. This is a way for managers to have conversations about EDI with their colleagues. It is also one way for them to regularly check in with their teams, to identify the progress made towards enhancing inclusivity within their working environments in a qualitative way.

Equality impact assessments have been embedded into the Quality Impact Assessment process and the Cost improvement programme process, ensuring that decisions, and the impact of these decisions, are explored through the lens of inclusion and mitigations are implemented where necessary. There is further work to be done to ensure that EIAs are completed for all decisions entering these processes.

Trade Union Rep(s): Laura Lynas, Staff Side Lead
Reviewed in January 2026

Comment

More diversity of job roles and staff groups reflected within the Belonging in the NHS meetings

Response

To reflect the connection between wellbeing and inclusion, the ‘Belonging in the NHS group’ has been merged with the ‘Looking after our People group’ to establish the ‘Workforce Wellbeing and Inclusion group’. This process required the creation of a new membership list which is now more reflective of our diverse workforce.

Comment

Inclusive leadership training and mentoring should be provided to Chairs and Co-Chairs of staff network groups.

Response

Two Network Chairs have received coaching, and the other networks have had personnel changes resulting in new Chairs and co-Chairs. The focus over the past year has been on establishing and affirming support networks for our network chairs, which has included setting up monthly reflective practice sessions that are facilitated by the Staff Psychology Service.

Comment

Unison has three EDI Reps who attend various Trust meetings to raise the profile of protected groups. In addition to a LGBT+ Officer and Black members, there is also a Women’s Officer. There is further development to be made to strengthen the partnership between the Trust’s staff networks and Unison’s EDI reps to ensure that their protected time, their interests, and their lived experiences can benefit and progress the respective networks and the Trust’s wider equality aims.

Comment

Staff networks – their success stands or falls on the commitment of network chairs. Succession planning for network chairs would ensure consistency and security, which may encourage greater engagement.

Response

A succession planning trial is planned with one of the networks and will be supported by Organisational Development.

Comment

Consideration should be given to increasing the protected time afforded to network chairs and whether it would be beneficial to appoint assistant chairs to assist with the workload and provide a degree of succession planning.

Response

This is an ongoing discussion that has been escalated previously. Networks have been asked to record the amount of time spent on network activities to support these conversations.

Comment

Clear boundaries need to be established with network chairs/members and senior leaders as to the remit of the network and where to signpost if a member requires additional support with workplace issues.

Response

These boundaries are communicated to network Chairs regularly and will be reiterated within Trust-wide communications that will aim to provide information about the networks and raise visibility of them.

Comment

The CEO mentoring programme should not be restricted to bands 7 and above, to fully drive home the message that inclusive leadership starts at any level.

Response

Whilst the CEO programme remains open to bands 7 and above for this year, communications about this programme also include signposting to alternative, internal leadership and development programmes that are open to colleagues of any band.

Comment

EIAs – should be embedded into all organisational change processes and the Organisational Change policy amended to reflect this. Given the number of change consultations currently being undertaken, training for EIAs for managers should be stepped up as a matter of urgency. Remains a priority, as reflected by the actions within this document.

Outcome: 1A: Patients (service users) have required levels of access to the service

Objective: Improving physical access

Action: Work with the Patient Environment Group with regards to barriers identified to physical access and ensure better visibility of Access Able guides

Completion date: December 2026

Outcome: 1A: Patients (service users) have required levels of access to the service

Objective: Improving accessible information and compliance with the AIS

Action: Trust-wide priority to be discussed with the Communications Team

Completion date: December 2026

Outcome: 1B: Individual patients (service users) health needs are met

Objective: Ensure 80% of those who require Reasonable Adjustments have this recorded and implemented.

Action: Ensure learning from pilot is taken on board and implemented into Trust-wide roll out of recording impairments and adjustments needed

Completion date: March 2027

Outcome: 1B: Individual patients (service users) health needs are met

Objective: Creation of personalised care plans, integrating patient profile

Action: Support Public Health Team with this and ensure care plans are co-produced with service users

Completion date: September 2026

Outcome: 1C: When patients (service users) use the service, they are free from harm

Objective: Recruit a Patient Safety Partner

Action: To be discussed with Head of Patient Quality

Completion date: February 2026

Outcome: 1D: Patients (service users) report positive experiences of the service

Objective: Equality & compassionate care training - Emphasise communication, unconscious bias, trauma-informed practice

Action: Explore training opportunities and increase bank of patient stories.

Completion Date: Ongoing

Outcome: 1D: Patients (service users) report positive experiences of the service

Objective: Reasonable Adjustments roll-out in ED

Action: As part of Trust-wide roll out

Completion date: March 2026

Outcome: 1D: Patients (service users) report positive experiences of the service

Objective: Identify physical, procedural, and cultural barriers to accessible care

Action: Targeted patient engagement with those groups who experience these barriers when accessing care.

Completion date: Ongoing

Outcome: 1D: Patients (service users) report positive experiences of the service

Objective: Privacy, comfort, and respectful language for vulnerable groups

Action: Explore training opportunities and increase bank of patient stories.

Completion date: Ongoing

Outcome: 1D: Patients (service users) report positive experiences of the service

Objective: Targeted improvement for pregnancy loss, mental health, and dementia care

Action: Explore training opportunities with existing groups and charities in these areas and increase bank of patient stories.

Completion date: Ongoing

Outcome: 1D: Patients (service users) report positive experiences of the service

Objective: Encourage safe disclosure of protected characteristics and discrimination concerns

Action: Explore training opportunities

Completion date: Ongoing

Outcome: 1D: Patients (service users) report positive experiences of the service

Objective: Ensure Equality Impact Assessments are part of all ED service reviews

Action: Communication drive and training around the completion of EIAs.

Completion date: Ongoing

Outcome: 2A: When at work, staff are provided with support to manage obesity, diabetes, asthma, COPD and mental health conditions

Objective: Enable all colleagues to access a coordinated range of wellbeing resources that empower them to build their own sense of wellbeing and take preventative action

Action:

• Strengthen alignment between all wellbeing interventions so they connect, complement one another, and provide a seamless, person‑centred and resource‑effective support offer.
• Actively identify and remove barriers that limit colleagues’ ability to access the right support at the right time (e.g., awareness, time, accessibility, referral pathways).
• Promote health education and preventative approaches focused on long‑term condition management, resilience, and early intervention.#

Completion Date: December 2026

Outcome: 2B: When at work, staff are free from abuse, harassment, bullying and physical violence from any source

Objective: Embed a culture where safe, respectful and high‑quality working relationships enable colleagues to feel valued, connected, and psychologically secure.

Action:

• Use data from the sexual safety reporting tool and other reporting mechanisms to identify patterns, hotspots and areas of organisational risk—informing targeted interventions to reduce abuse from staff, patients and visitors.
• Strengthen psychological safety across all working environments by helping leaders and teams understand, model and reinforce key safety behaviours that enable colleagues to speak up and raise concerns.
• Provide clear, consistent communication on expected behaviours and the organisational response to breaches, reinforcing a zero‑tolerance approach to abuse and harassment.

Completion date: December 2026

Outcome: 2C: Staff have access to independent support and advice when suffering from stress, abuse, bullying harassment and physical violence from any source.

Objective: Ensure colleagues can easily access confidential, independent and trusted support when they are affected by harm, stress or difficult workplace experiences.

Action:

• Further embed, promote and normalise the use of the Employee Assistance Programme (EAP) as a primary route for independent guidance and emotional support.
• Through sexual safety charter and upcoming antiracism work and wider wellbeing communications, reinforce the availability of both internal and independent support options, ensuring colleagues know how and when to access them.
• Improve visibility and accessibility of signposting so staff can quickly find the right support without navigating complex pathways and risk can be identified and escalated.

Outcome: 2D: Staff recommend the organisation as a place to work and receive treatment

Objective: Create a workplace where colleagues feel valued, recognised, and able to bring their whole selves to work—leading to improved advocacy of the organisation as both an employer and care provider.

Action:

• Use our current Wellbeing workplan framework to further gather, analyse and respond to colleague feedback, identifying priority areas for workplace improvement.
• Implement targeted actions to improve scores in the NHS Staff Survey, focusing specifically on the question relating to recommending the organisation as a place to work and receive treatment.

Strengthen recognition, inclusion and engagement initiatives that enable colleagues to feel seen, valued and supported in their roles by introducing “each person” platform to the Trust.

Outcome: 3A: Board members, system leaders (Band 9 and VSM) and those with line management responsibilities routinely demonstrate their understanding of, and commitment to, equality and health inequalities

Objective: Board members are proactive allies and play an important role in embedding inclusive practices within their own work and the culture within their wider teams and directorates.

Action:

• Increasing the completion of EIAs in their respective directorates.
• Ensuring EDI is incorporated into team away days/planning days.
• Visibly championing equity and diversity within their teams and more broadly across the trust by engaging with the ongoing areas of work in place to increase equity and address inequity within the Trust.

Completion date: August 2026

Outcome: 3B: Board/Committee papers (including minutes) identify equality and health inequalities related impacts and risks and how they will be mitigated and managed

Objective: EIAs must be completed consistently and routinely throughout the Trust.

Action:

• Continue to create further resources to inform, enable and empower colleagues to complete EIAs to the required standard.
• Identify further opportunities or organisational processes that can incorporate/embed EIAs within them.
• Ensure that all committee cover sheets require confirmation that an EIA has been completed for the proposed activity.

Completion date: May 2026

Outcome: 3C: Board members and system leaders (Band 9 and VSM) ensure levers are in place to manage performance and monitor progress with staff and patients

Objective: Staff stories are regularly scheduled at Involvement Committee meetings.

Action:

• Board members to invite each staff network lead(s) to attend Involvement Committee once a year to hear directly from the networks about the aims of each network, their achievements, and any challenges experienced by the network and/or its members that board members may be able to support or address.
• Board members invited to Experience of Care and Engagement Committee meetings