Corporate Governance, Assurance & Risk Manager. Governance and Assurance Committee. Three yearly, unless guidance or circumstances change.

Transcription

1 Document reference code: Title: Developed by: Document type: Policy library: Sub Section: Document status: Date of ratification: Ratified By: Date to be reviewed: Incident Management policy Corporate Governance, Assurance & Risk Manager Policy Governance Safety Revision of previous policy 20 th October 2015 Governance and Assurance Committee Three yearly, unless guidance or circumstances change. HISTORY Revisions: (Enter details of revisions below) Date: Author: Description: 2/11/10 JJ Revisions to reflect degree of Commissioner/Provider split and to reflect change in SUI definitions and process. 09/05/2013 JJ Revisions to reflect change of organisation from CIOSPCT to KCCG and separation of incident policy from Serious Incident policy 13/10/15 JJ Document rewritten. Inclusion of new cyber incident guidance and SIRI guidance. Inc Mngt on a page. Changes in roles/titles. Consultation process completed: Distribution Methods: YES NO 19 October 2015 Document Library Awareness through Staff Bulletin. All or part of this document may be released under Freedom of Information Act 2000 unless otherwise indicated.

2 1 Purpose To set out the roles and responsibilities of all staff in Kernow Clinical Commissioning Group, in relation to incidents and the arrangements for reporting, and management of all incidents, including near misses. 2 Responsibility Corporate Governance, Assurance & Risk Manager. All Staff Please see section 4 of the policy for further detail 3 Definitions See Section 3 of the policy. 4 Training Implications None 5 This Policy/Guidance/Strategy/Protocol is cross referenced to: Policy & Procedure for Reporting and Learning from Serious Incidents Requiring Investigation Health & Safety Policy Violence & Aggression policy Disciplinary Policy and Procedure 6 Equality and Diversity Impact Assessment taken place: Yes This document Can Cannot YES Be released under the Freedom of Information Act 2000 (For more information - Please contact the FOI Co-ordinator on ). 2

3 CONTENTS Section Subject Page 1 Introduction, purpose and scope 3 2 NHS Kernow s Commitment to a Fair and Open Culture 3 3 Definitions 4 4 Key Responsibilities 6 5 NHS Kernow Committees and Subcommittees 7 6 Reporting incidents 8 7 Additional Reporting Requirements 9 8 Reporting to External Agencies 9 9 Levels of Investigations Sharing of Lessons Learnt 10 Appendix 1 Information Governance and Cyber Incidents 11 Appendix 2 Incident reporting and management flowchart 13 1 Introduction, Purpose & Scope The purpose of this policy is to outline the arrangement for identifying, reporting, managing and investigating incidents within NHS Kernow. This policy applies to all staff in NHS Kernow in relation to incidents and is designed to ensure all staff have a clear understanding of their responsibilities and the arrangements for reporting and management of incidents, including near misses and serious incidents. Incidents and near misses provide an opportunity for learning and improvement to prevent future incidents and potential harm. In order for this learning to take place it is essential that all incidents and near misses are reported and investigated, promptly, accurately and appropriately. Incident reporting also helps with ensuring a culture of openness, communication with patients, staff and other stakeholders and compliance with legal duties as an employer. 2 NHS Kernow s Commitment to a Fair and Open Culture NHS Kernow is committed to staff and patient safety. We will take a proactive and fair-blame approach to managing incidents to promote risk reduction in an open and fair culture. Fair blame is about focussing on systems not people. Incidents are more often than not the result of a system failure rather than one individual s actions. They can be caused by a variety of factors including the physical environment, a lack of training or skills, process problems, human error and communication. Reviewing the way things are done, rather than the individuals involved, assists us in establishing what corrective action can be taken in order to modify the systems and processes as opposed to apportioning blame. Blaming individuals and punishing errors can prevent the open and honest reporting of incidents and consequently impact the learning from those incidents to allow put actions in place to prevent future harm. 3

4 NHS Kernow will take a non-punitive approach to incidents, unless it becomes clear an individual has deliberately violated systems or processes resulting in an adverse incident. In such cases appropriate disciplinary procedures will be followed as appropriate. Staff should refer to the NHS Kernow Whistleblowing policy for guidance on what to do if they have concerns regarding a colleague s behaviour. 3 Definitions Incident/Accident. Any event that has caused, or had the potential to cause, injury/harm to a patient, member of staff, visitor or contractor or causes/may cause damage to or loss of NHS Kernow property. This includes: Personal accident. Accidental incidents which affect/involve a person or persons and resulted or could have resulted in injury. Violence, abuse, harassment, discrimination. Including physical assaults, deliberate self-harm, aggressive incidents, verbal abuse, sexual harassment, intimidation or threatening behaviour and discrimination against people on the grounds of religion/belief, gender, race, age, disability or sexual orientation Ill health, work or environmental related incidents. Illness or harm related to work or the working environment, such as contact dermatitis, unsafe environments/flooding/loss of power etc leading to loss of services. Fire incident. Smoke, fire, suspected smoke/fire, or fire alarm. Security incident. Fraud, theft, deception, bribery, criminal damage etc. Clinical incident. Incident which arises in the context of the duty of care owed to patients by healthcare professionals or consequences of decisions or judgements made by those professionals in their professional capacity or relevant work. Information governance incident. Breaches of confidentiality and information security. Inappropriate, including unintentional, sharing of confidential or sensitive information. Cyber incident. Events such as a virus attack or hacking of an information system. Also includes cyber bullying and inappropriate release of information by staff through social media. Near Miss: An event which could have resulted in injury, harm or damage but for the intervention of a third party or luck. Reporting a near miss is just as important as reporting an incident which actually happened or caused harm. Serious Incidents: Events in health care where the potential for learning is so great, or the consequences to patients, families and carers, staff or organisations are so significant, that they warrant using additional resources to mount a comprehensive 4

5 response. Serious incidents can extend beyond incidents which affect patients directly and include incidents which may indirectly impact patient safety or an organisation s ability to deliver ongoing healthcare. Serious Incidents in the NHS include: Acts and/or omissions occurring as part of NHS-funded healthcare (including in the community) that result in: Unexpected or avoidable death8 of one or more people. This includes - suicide/self-inflicted death; and - homicide by a person in receipt of mental health care within the recent past; Unexpected or avoidable injury to one or more people that has resulted in serious harm; Unexpected or avoidable injury to one or more people that requires further treatment by a healthcare professional in order to prevent:- - the death of the service user; or - serious harm; Actual or alleged abuse; sexual abuse, physical or psychological ill-treatment, or acts of omission which constitute neglect, exploitation, financial or material abuse, discriminative and organisational abuse, self-neglect, domestic abuse, human trafficking and modern day slavery where: - healthcare did not take appropriate action/intervention to safeguard against such abuse occurring; or - where abuse occurred during the provision of NHS-funded care. This includes abuse that resulted in (or was identified through) a Serious Case Review (SCR), Safeguarding Adult Review (SAR), Safeguarding Adult Enquiry or other externally-led investigation, where delivery of NHS funded care caused/contributed towards the incident A Never Event - all Never Events are defined as serious incidents although not all Never Events necessarily result in serious harm or death. See Never Events Policy and Framework for the national definition and further information; An incident (or series of incidents) that prevents, or threatens to prevent, an organisation s ability to continue to deliver an acceptable quality of healthcare services, including (but not limited to) the following: Failures in the security, integrity, accuracy or availability of information often described as data loss and/or information governance related issues ; Property damage; Security breach/concern; Incidents in population-wide healthcare activities like screening and immunisation programmes where the potential for harm may extend to a large population; Inappropriate enforcement/care under the Mental Health Act (1983) and the Mental Capacity Act (2005) including Mental Capacity Act, Deprivation of Liberty Safeguards (MCA DOLS); Systematic failure to provide an acceptable standard of safe care (this may include incidents, or series of incidents, which necessitate ward/ unit closure or suspension of services); or 5

6 Activation of Major Incident Plan (by provider, commissioner or relevant agency) Major loss of confidence in the service, including prolonged adverse media coverage or public concern about the quality of healthcare or an organisation. If an incident meets the above criteria staff should refer to the NHS Kernow Policy and Procedure for Reporting and Learning from Serious Incidents Requiring Investigation immediately and follow the guidance contained within that document. 4 Key Responsibilities for NHS Kernow. Staff affected by or involved in incidents will: Take appropriate immediate action to maintain the safety of patients, staff, members of the public and contractors. Report any incidents to their line manager or supervisor as soon as they become aware of events. Make a formal report of the incident within 24 hours of becoming aware of events. See section 6 and Appendix 2 for guidance. Line Managers will Take appropriate action to maintain the safety of patients, staff, members of the public and contractors Ensure any staff members affected by or involved in the incident have received appropriate care and advice, this could include referrals to occupational health. Ensure the incident has been reported. Report to external agencies if required ( see section 8) Instigate an investigation into the incident and identify the causes and any actions required to prevent recurrence. Record the findings and outcome of this investigation with the Corporate Governance, Assurance and Risk Manager. The Board Secretary will Provide guidance for staff regarding the reporting of incidents to the Health and Safety Executive (see section 8) Provide advice and support to staff who have experienced such an incident Provide advice and support in the investigation and prevention of such incidents The Head of Information Governance will Provide guidance for staff regarding the reporting and investigating of information governance incidents (see section 8 and Appendix 1) Provide advice on the actions which may be required to prevent recurrence of an information governance related incident Provide advice and support in the investigation and prevention of such incidents The Head of Clinical Governance will Report any NHS Kernow serious incidents to NHS England as per the NHS Kernow serious incident process (see Section 8) 6

7 Provide guidance on serious incident identification and reporting. Provide support with the root cause analysis of serious incidents. The Corporate Governance, Assurance and Risk Manager will Record incidents reported on a central register and ensure actions taken are recorded. Provide reports to relevant committees on incident figures and trends. Ensure risks identified through incidents are appropriately recorded, graded and that progress is made on proposed actions. Liaise with the leads for complaints and litigation for NHS Kernow on a regular basis to identify any trends in events being reported. The Head of Prescribing will Act as the Responsible Officer for Controlled Drugs for NHS Kernow. Receive reports from commissioned and contracted services (including independent contractors) on any incidents relating to controlled drugs Ensure appropriate action is taken in respect of these incidents Share lessons learnt from these events through the Controlled Drugs Local Intelligence Network. All Directors will Work together to encourage reporting and investigation of incidents and near misses and a culture of openness, honesty and learning. The Managing Director (Accountable Officer) will Lead on encouraging an organisation-wide culture of openness, honesty and learning. Emphasise the value attached to quality and safety in services provided and commissioned by NHS Kernow. The Chief Finance Officer will Act as the Governing Body Senior Information Risk Officer (SIRO), therefore taking a particular interest in information governance incidents. Act as the Governing Body lead for security, fire and counter-fraud. The Deputy Managing Director will Act as nominated director for risk management as a whole across the organisation, with a specific responsibility for organisational risk. Medical Director will Act as Caldicott Guardian Act as nominated director for issues involving Child or Adult Protection 5 NHS Kernow Committees and Sub-Committees The Governing Body will Receive reports on Serious Incidents reported by reported by NHS Kernow and by commissioned and contracted services. 7

8 The Governance & Assurance Committee will Receive an overview of Serious Incidents reported by NHS Kernow and by commissioned and contracted services. The Healthy Workplace Group will Receive regular reports on incidents relating to health and safety where a trend is identified and/or additional action is required. The Information Governance sub-committee will Receive reports on information governance incidents such as breach of confidentiality, data protection concerns and inadequate or incorrect documentation. 6 Reporting incidents The immediate priority for all staff in case of an incident is to take steps necessary to secure the safety of anyone involved. Action should then be taken to prevent or minimise reoccurrence. For example, a trip on loose paving may require first aid treatment followed by the placement of cones or barriers to warn pedestrians about the paving. Longer term action in this instance will also be required, to fix the paving. Incidents should be reported as soon as possible after they take place within 48 hours (or 24 hours if serious). Staff should inform their line manager in case they need to take any immediate action and also send an detailing what happened to the relevant address below: If the incident or near miss involves the confidentiality, integrity or availability of personal confidential information, please kccg.caldicottincidents@nhs.net. To report any other incident or near miss, such as an injury or experience of verbal abuse at work, please send an , giving the details of what happened, to KCCG.Incidents@nhs.net or make contact with the Corporate Governance, Assurance and Risk Manager by telephone, or in person. When reporting an incident it is important to remember that all details must be factual. Ensure that all relevant details are recorded to include: Incident description including any injuries/harm/loss Date of incident Location People affected / Staff involved Name of person reporting the incident Witnesses (and statements where applicable) Immediate action taken 8

9 7 Additional reporting requirements. Some types of incidents require further reporting internally or externally. Information Governance and Cyber incidents should be reported to the Head of Information Governance as soon as a member of staff becomes aware of them. There is also an reporting address kccg.caldicottincidents@nhs.net. Please see Appendix 1 for more information on information incidents. Health and Safety,. Details of these incidents will be shared with the Board Secretary, as the lead on Health & Safety, by the Corporate Governance, Assurance and Risk Manager. They may be reportable under RIDDOR, see section 8. Violence, aggression and staff security. Details of these incidents will be shared with the HR team, who can provide advice and support. These incidents may be reportable to NHS Protect, see section 8. Safeguarding. Details of any incidents raising safeguarding concerns will shared with the Safeguarding team by the Corporate Governance, Assurance and Risk Manager. 8 Reporting to External Agencies Safeguarding Children. The National Framework for Reporting and Learning from Serious Incidents Requiring Investigation states that where the incident involves a child or young person, considerations should be given to raising the alert as a serious incident under section 8 of Working Together to Safeguard Children, which relates to the Children Acts 1989 and Safeguarding Adults. If the incident involves vulnerable adults, an alert should be raised as per local safeguarding procedures and consideration should be given to raising a serious incident as per NHS Kernows Policy and Procedure for Reporting and Learning from Serious Incidents Requiring Investigation Reporting of Injuries, Diseases and Dangerous Occurrences (RIDDOR) If someone has died or has been injured because of a work-related accident this may have to be reported under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013, (RIDDOR). Reporting is undertaken by the Line Manager via an online form ( and a copy of the RIDDOR form should be forwarded to the Board Secretary (who can provide advice), this should also be copied to kccg.incidents@nhs.net RIDDOR reporting should take place: without delay for deaths, serious injuries and dangerous occurrences and; within 15 days for over seven-day incapacitation of a member of staff due to a work-related incident. This may mean absence from work OR inability to carry out the full range of their normal duties. 9

10 Should staff be uncertain as to the need for a RIDDOR report, the Board Secretary or Corporate Governance, Assurance and Risk Manager can provide guidance. NHS Litigation Authority The National Health Service Litigation Authority (NHSLA) requires notification of any staff incident that results in over 10 days sickness absence period, fatal injuries, amputation to any limb, head injury and likely HSE prosecution. Managers/Supervisors should inform the Board Secretary of any such incidents as the Board Secretary reports to the NHSLA on behalf of NHS Kernow. Information Governance (IG) and Information Technology (IT) Serious Incidents All organisations processing health and adult social care personal data are required to use the IG Toolkit Incident Reporting Tool to report certain incidents to the Department of Health, Information Commissioners Office and other regulators. Please liaise with the Head of Information Governance to establish severity of the breach and facilitate such reporting. See Appendix 1 for further detail on assessing these incidents. NHS Protect NHS Kernow will share reported instances of violence and aggression against staff by patients or members of the public with NHS Protect, via the HR team. Media Involvement If a staff member is contacted by the media regarding an incident they should refer them to the Communications team. Sometimes NHS Kernow may wish to seek the involvement of the media in incident management, for example where there may be a recall, or a public health concern. NHS Kernow may also wish to work closely with the media to ensure the incident events and the organisations actions are accurately reflected. The Communications team will co-ordinate all media relations as necessary/appropriate in line with the NHS Kernow Communications Strategy and maintain contemporaneous records of all contact and information shared with the media. 9 Levels of Investigation Some incidents may not require immediate investigation but most will require some immediate management actions to prevent any further harm or damage. It is the responsibility of the local manager to investigate the incident and record the findings as per Section 4 on Roles and responsibilities. 10 Sharing of Lessons Learnt Analysis of incidents will be undertaken and any associated risks will be reported to the relevant Director or Head of service and where appropriate added to the risk register. Learning from incidents, where trends are identified, will be shared at an organisational level through the Healthy Workplace Group. Learning can also be shared by managers through team meetings, staff briefings, newsletters and all user 10

11 s where appropriate, to ensure the lessons are communicated not just to those directly affected by the actions, but to other groups who may be able to adapt the learning to suit their own services and needs. 11

12 Appendix 1 Information Governance and Cyber incidents The following process reflects Health & Social Care Information Centre Guidance (May 2015) and will be followed by the Head of Information Governance to categorise IG or Cyber SIRIs and decide upon reporting requirements through the IG Toolkit. Further detail is available from the Health & Social Care Information Centre and the Information Commissioners Office. Information Governance Incidents Step 1: Establish the scale of the incident. If this is not known it will be necessary to estimate the maximum potential scale point. Baseline Scale 0 Information about less than 11 individuals 1 Information about individuals 1 Information about individuals 2 Information about individuals 2 Information about individuals 2 Information about individuals 3 Information about individuals 3 Information about individuals 3 Information about individuals 3 Information about individuals Step 2: Identify which sensitivity characteristics (below) may apply and adjust the baseline scale point accordingly. Low: For each of the following factors reduce the baseline score by 1-1 for each A) No sensitive personal data (as defined by the Data Protection Act 1998) at risk nor data to which a duty of confidence is owed B) Information readily accessible or already in the public domain or would be made available under access to information legislation e.g. Freedom of Information Act C) Information unlikely to identify individual(s) High: For each of the following factors increase the baseline score by 1 D) Detailed information at risk e.g. clinical/care case notes, social care notes E) High risk confidential information F) One or more previous incidents of a similar type in the past 12 months G) Failure to implement, enforce or follow appropriate organisational or +1 technical safeguards to protect information for H) Likely to attract media interest and/or a complaint has been made directly each to the ICO by a member of the public, another organisation or an individual I) Individuals affected are likely to suffer substantial damage or distress, including significant embarrassment or detriment J) Individuals affected are likely to have been placed at risk of or incurred physical harm or a clinical untoward incident 12

13 Step 3: Where adjusted scale indicates that the incident is level 2, the incident should be reported to the ICO and DH within the reporting timescales noted in HSCIC guidance, by the Head of Information Governance. Final Level of SIRI score 1 or less Level 1 incident is not reportable to ICO and DH 2 or Level 2 incident is reportable to ICO and DH more Cyber Incidents Step 1: Establish the scale of the incident. If this is not known it will be necessary to estimate the maximum potential scale point. Cyber Baseline Scale 0 No impact: Attack(s) blocked 0 False alarm 1 Information Individual, internal group(s), team or department affected 2 Multiple departments or entire organisation affected Step 2: Identify which sensitivity characteristics (below) may apply and adjust the baseline scale point accordingly. Low: For each of the following factors reduce the baseline score by 1-1 for each 1) A tertiary system affected which is hosted on infrastructure outside health and social care networks High: For each of the following factors increase the baseline score by 1 2) Repeat Incident (previous incident within last 3 months) 3) Critical business system unavailable for over 4 hours 4) Likely to attract media interest +1 5) Confidential information release (non-personal) for 6) Require advice on additional controls to put in place to reduce each reoccurrence 7) Aware that other organisations have been affected 8) Multiple attacks detected and blocked over a period of 1 month Step 3: Where adjusted scale indicates that the incident is level 2 or more, the incident should be reported to the HSCIC and DH within the reporting timescales noted in HSCIC guidance, by the Head of Information Governance. Final Level of SIRI score 1 or less Level 0 or 1 incident is not reportable to HSCIC and Department of 2 or more Health Level 2 incident is reportable to HSCIC and Department of Health 13

14 Appendix 2 Incident Reporting and Management on a Page Incident or Near Miss occurs. Take any immediate action required Tell your line manager and Head of Information Governance will Report via: kccg.caldicottincidents@nhs.net Information incident Any other incident type Report via: kccg.incidents@nhs.net Provide advice and support Inform SIRO/Caldicott Guardian Comms Team Media concerns Corporate Governance, Assurance & Risk Manager will log the incident and share as appropriate. Assess against national guidance and if necessary report to HSCIC/ICO/ DH Fraud/ bribery concerns related Local Counter Fraud Specialist Estates related NHS Property Services May be a Serious Incident Head of Clinical Governance. May report to NHS England Raises Safeguarding concerns Safeguarding team. May raise Safeguarding Alert Violence and/or aggression Human Resources May report to NHS Protect Raises litigation concerns Health & Safety Board Secretary. May report to NHSLA or H&S Executive 14

15 TO BE COMPLETED AT THE PLANNING AND SCOPING STATGES OF THE INITIATIVE Appendix Two Equality Impact Assessment Proforma Initial Screening Section Officer responsible for the assessment Jessica James, Corporate Governance, Assurance & Risk Manager Name of Policy to be assessed Incident Management Policy Date of Assessment 14 Oct 2015 Is this a new or existing policy? Revision of existing 1. Briefly describe the aims, objectives and purpose of the policy. Policy sets out the roles and responsibilities of all staff in NHS Kernow in relation to incidents and the arrangements for reporting and management of all incidents, including near misses. Aim to enable staff to report incidents to allow investigation, learning and improvements in safety and service quality. 2. Are there any associated objectives of the policy? Please explain. No 3. Who is intended to benefit from this policy, and in what way? Staff and visitors will benefit as policy drives improvements in their safety. Staff will also benefit from the fair-blame culture endorsed and outlined by the policy. Patients will benefit as the policy drives improvements in their safety. 4. What outcomes are wanted from this policy? Appropriate and timely reporting of incidents, including serious untoward incidents, leading to appropriate action being taken to ensure patient/staff safety. Improved services and safety. 15

16 5. What factors/forces could contribute/detract from the outcomes? Staff unfamiliar with reporting systems (regular reminders through daily bulletin) 6. Who are the main stakeholders in relation to the policy? NHS Kernow and all staff 7. Who implements the policy, and who is responsible for the policy? All staff, led by Directors. Corporate Governance, Assurance & Risk Manager. 8. What is the impact on people from Black and Minority Ethnic Groups (BME) (positive or negative)? Policy applies to all incidents, including those related to race issues Impact considerations include non-physical harm. Section 3 refers to discrimination against people on the grounds of religion/belief, gender, race, age, disability or sexual orientation. How will any negative impact be mitigated? No negative impact identified 9. What is the impact for male or female people (positive or negative)? Policy applies to all incidents, including those related to gender issues Impact considerations include non-physical harm. Section 3 refers to discrimination against people on the grounds of religion/belief, gender, race, age, disability or sexual orientation. How will any negative impact be mitigated? No negative impact identified 16

17 10. What is the impact on disabled people, including those with learning disabilities (positive or negative)? Positive Policy applies to all incidents, including those related to disability issues Impact considerations include non-physical harm. Section 3 refers to discrimination against people on the grounds of religion/belief, gender, race, age, disability or sexual orientation. The policy make particular reference to vulnerable adults, this includes adults with a learning disability. This is because this section of the population is felt to be particularly at risk of harm due to abuse/neglect/prejudice/communication difficulties. How will any negative impact be mitigated? No negative impact identified 11. What is the impact on sexual orientation (lesbian, gay, bisexual)? Policy applies to all incidents including those related to sexual orientation. Impact considerations include non-physical harm. Section 3 refers to discrimination against people on the grounds of religion/belief, gender, race, age, disability or sexual orientation. How will any negative impact be mitigated? No negative impact identified 17

18 12. What is the impact on people of different ages (positive or negative)? Please explain. Positive Policy applies to all incidents including those related to age. Impact considerations include non-physical harm. Section 3 refers to discrimination against people on the grounds of religion/belief, gender, race, age, disability or sexual orientation. The policy make particular reference to vulnerable adults, this includes some elderly people. This is because this section of the population is felt to be particularly at risk of harm due to abuse/neglect/prejudice/communication difficulties. The policy make particular reference to children. This is because this section of the population is felt to be particularly at risk of harm due to their vulnerability and dependence upon others. How will any negative impact be mitigated No negative impact identified 13. What impact will there be due religion or belief (positive or negative)? Policy applies to all incidents including those related to religion or belief. Impact considerations include non-physical harm. Section 3 refers to discrimination against people on the grounds of religion/belief, gender, race, age, disability or sexual orientation. How will any negative impact be mitigated? No negative impact identified 18

19 14. What is the impact on marriage or civil partnership, this is particularly relevant for employment policies (positive or negative? Policy applies to all incidents including those related to gender and sexual orientation. Impact considerations include non-physical harm. Section 3 refers to discrimination against people on the grounds of religion/belief, gender, race, age, disability or sexual orientation. How will any negative be mitigated? No negative impact identified 15. What is the impact on people who have gone through or are going through gender reassignment, or who identify as transgender? Policy applies to all incidents including those related to gender Impact considerations include non-physical harm. Section 3 refers to discrimination against people on the grounds of religion/belief, gender, race, age, disability or sexual orientation. How will any negative impact be mitigated? No negative impact identified. 16. What is the impact on people who are pregnant or breast feeding mothers? No specific impact. Policy applies to all incidents. How will any negative impact be mitigated? No negative impact identified 19

20 17. How have the Core Human Rights Values of: Fairness; Policy makes statements regarding fair blame. Policy refers to discrimination as an incident evidencing consideration of these core values. Safeguarding issues are also highlighted potential Serious Untoward Incidents. Section 2 relates to Openness and fairness, systems not people. Respect; Equality; Dignity; Autonomy Been considered in the formulation of this policy/strategy If they haven t please reconsider the document and amend to incorporate these values. 20

21 18. Which of the Human Rights Articles does this document impact? The right: Yes No What evidence do you have for making these statements? To life; Yes Not to be tortured or treated in an inhuman or degrading way; To be free from slavery or forced labour; To liberty and security; To a fair trial; To no punishment without law; To respect for home and family life, home and correspondence; To freedom of thought, conscience and religion; To freedom of expression; To freedom of assembly and association; To marry and found a family; Not to be discriminated against in relation to the enjoyment of any of the rights contained in the European Convention; To peaceful enjoyment of possessions and education; To free elections Policy concerns the safety of individuals. Policy includes safeguarding issues. 19. How will you ensure that those responsible for implementing the Policy are aware of the Human Rights implications and equipped to deal with them? Policy will be on document library and highlighted through bulletin. Staff with specific responsibilities, eg Safeguarding, have undergone specific training. 21

22 20. If the negative impacts identified have been unable to be mitigated through amendment to the policy, explain how you will conduct a full EIA 21. If the differential impacts identified are positive, explain how this policy is legitimate positive action and will improve outcomes, services or the working environment for that group of people. NA NA 22. If you do not need to proceed to a full EIA explain what amendments have been made to the policy as a result of this screening, and when they were made. No amendments were made as the result of this screening. Signed (completing officer) JESSICA JAMES Date 14/10/15 Signed (Head of Section).. Date Please ensure that a signed copy of this form is sent to both the Policies Officer and the Equality and Diversity lead to be placed on the organisation s website. 22