Contents
1 EDS rating and scorecard
Please refer to the rating and scorecard supporting guidance document before you start to score. The rating and scorecard supporting guidance document has a full explanation of the new rating procedure, and can assist you and those you are engaging with to ensure rating is done correctly.
Score each outcome. Add the scores of all outcomes together. This will provide you with your overall score, or your EDS organisation rating. Ratings in accordance to scores are below.
| Rating | Scoring |
|---|---|
| Undeveloped activity, organisations score out of 0 for each outcome | Those who score under 8, adding all outcome scores in all domains, are rated undeveloped |
| Developing activity, organisations score out of 1 for each outcome | Those who score between 8 and 21, adding all outcome scores in all domains, are rated developing |
| Achieving activity, organisations score out of 2 for each outcome | Those who score between 22 and 32, adding all outcome scores in all domains, are rated achieving |
| Excelling activity, organisations score out of 3 for each outcome | Those who score 33, adding all outcome scores in all domains, are rated excelling |
2 Domain 1, commissioned or provided services, community learning disabilities
| Outcome | Evidence | Rating | Owner (department or lead) |
|---|---|---|---|
| 1A, patients (service users) have required levels of access to the service | Referrals into service can be made by anyone with an interest in the service users’ well-being, health professional, family member, care giver or social care staff, etc. The single access referral form (SARF) can be completed online or hard copy and can be requested via a generic inbox or generic phone number monitored via the admin team.
Referrals are triaged on duty to ascertain urgency and allocated if urgent or discussed in weekly referral allocations meeting. Red, Amber Green (RAG) rating is used to identify urgency. Dynamic support register is in operation this also uses the RAG rating system and MDT discussions. Medication reviews are identified on System 1 annually. Annual health checks are picked up via GP surgery or LD team. Postural reviews are identified on System 1 for 6 monthly postural reviews of any changes in presenting postural support needs or equipment changes. Transition work is undertaken by community nurses learning disabilities (CNLD) for young people moving into adult services from children’s services |
2.5 | Community learning disability services.
Rebecca Sanderson, Service Manager |
| 1B, individual patients (service users) health needs are met | Care plans are completed to identify the service users’ treatment targets and intervention goals and these are agreed with the service user and, or family member or carer at the outset. When the objectives have been fulfilled they are marked as completed when the health needs have been met.
There is a dementia pathway to ensure service users are screened early for this condition and strategies in place to manage this throughout progression of the disease. When service users are admitted to hospital the acute and primary liaison nurse is alerted to ensure reasonable adjustments are made for the patient and the health passport is adhered to. At discharge the hospital discharge form is completed along with a 72-hour follow-up assessment. The Health Action team provide a supportive role in advice, support and information in relation to health-related activities and health promotion such as; clinic appointments, vaccinations, blood tests, sexual health, desensitisation, breast and testicular checks, cancer screening, healthy eating, managing diabetes, etc. |
2 | Community learning disability services.
Rebecca Sanderson, Service Manager |
| 1C, when patients (service users) use the service, they are free from harm | Empowering the person to decide the level of risk they are prepared to take with their health and safety. This includes working with the tension between promoting safety and positive risk taking, including assessing and dealing with possible risk factors for service users, carers, family members, staff providing treatment and care and the wider public.
Mental capacity assessments are carried out and documented by the most appropriate person, to establish capacity (following the 5 principles of the Mental Capacity Act). Decisions are made in the service users best interest and the least restrictive option is fully explored and documented where capacity is deemed to be lacking. Functional Analysis of Care Environments (FACE) risk assessments are completed at the outset during initial assessment. There is a robust safeguarding policy for reporting concerns and keeping people safe. Care plans are given to service users, families, or care givers to ensure the strategies in place are followed as part of the service users ongoing care procedures. Positive behaviour support (PBS) plans are in place for people who have behaviours which challenge and this is regularly reviewed. PBS training for staff is to be implemented in 2023 to raise awareness and develop skills across this area of practice |
2 TRFT, would have been 3 with some outcomes data | Community learning disability services.
Rebecca Sanderson, Service Manager |
| 1D, patients (service users) report positive experiences of the service | Within the trust we have various routes and questionnaires for service users to feedback; your opinion counts friends and family test ask, listen do patient advisory liaison service easy read complaints and compliments form within LD team. | 1 | Community learning disability services.
Rebecca Sanderson, Service Manager |
3 Domain 1, commissioned or provided services, long COVID services
| Outcome | Evidence | Rating |
|---|---|---|
| 1A, patients (service users) have required levels of access to the service | GP referral stats showing GP’s aware of referral process (data available if required) Direct referral pathway created between long COVID team and respiratory consultant, respiratory nurses, or lead respiratory physio at DRI.
Long COVID clinical lead offers GP training sessions and responds to GP emails. Community engagement officer promotes by attending various support groups etc within the area and has built up a network within these |
2 |
| 1B, individual patients (service users) health needs are met | Multi-disciplinary team, holistic approach physical and mental health.
Team kept updated with emerging evidence in long COVID clinical lead has set up and chairs the regional network long COVID group where we share good practice, challenges, guidance, knowledge and skills. Run virtual group, 1-to-1 clinic and phone appointments and home visits between the hours of 8am and 6pm knowledge and skills through training and experience to assess for and deal with all symptoms of long COVID. Regular clinical supervision for staff |
2 |
| 1C, when patients (service users) use the service, they are free from harm | Appropriate risk assessments are undertaken as clinicians use red flags where needed during appointments.
Clinical lead open door policy. Staff are aware of safeguarding and incident reporting procedures. Medical support from monthly GP clinic and respiratory consultant virtual MDT. Clinicians peer support group to discuss complex patient management. Recent pathway developed for dysautonomia and 24 hr heart monitor tapes for patients with cardiac problems. Bespoke patient resources booklets for written back up after clinic visits. Proactive feedback, health questionnaires, your opinion counts, patient experience etc |
2 |
| 1D, patients (service users) report positive experiences of the service | Thank you cards and letters, group evaluation forms | 2 |
4 Domain 2, workforce health and well-being
| Outcome | Evidence | Rating | Owner (department or lead) |
|---|---|---|---|
| 2A, when at work, staff are provided with support to manage obesity, diabetes, asthma, COPD and mental health conditions | Obesity management As part of the trusts health and wellbeing offer, Slimming World vouchers (staff access only) (opens in new window) are available to staff with a BMI of 28 and over to support their weight management journey.
RDaSH offers free physical wellbeing activities (staff access only) (opens in new window) across the trust. There is also the national offer to all NHS Employees, the NHS Digital Weight Management which is part of a wider commitment in the NHS Long Term Plan, to help people living with obesity who want to improve their health. Doing Our Bit, free fitness platform available to all staff with an NHS email address, developed by the NHS for the NHS. Diabetes, Asthma and COPD:
Mental health conditions:
|
2 | Amanda Ambler |
| 2B, when at work, staff are free from abuse, harassment, bullying and physical violence from any source | As an organisation RDaSH have policies in place for “no excuse for abuse” and measures are in place to address any form of bullying, discrimination, victimisation that may be inflicted by or to any of our colleagues.
2021/2022 staff survey results indicate that:
|
2 | Amanda Ambler |
| 2C, staff have access to independent support and advice when suffering from stress, abuse, bullying harassment and physical violence from any source | Employees have access to confidential and impartial support via our employee assistance programme via Vivup, this includes support and advice when suffering from stress, bullying, harassment and physical violence from any source.
Staff can also access support through:
|
2 | Amanda Ambler |
| 2D, staff recommend the organisation as a place to work and receive treatment |
2021/2022 staff survey results indicate that:
|
2 | Amanda Ambler |
5 Domain 3, inclusive leadership
| Outcome | Evidence | Rating | Owner (department or lead) |
|---|---|---|---|
| 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 | All board members have participated in 2 cohorts of reverse mentoring for our REaCH network and DAWN network and are committed to cohort 3 for our LGBTQ+ colleagues.
All colleague network groups have an executive sponsor who feeds back to the board on a monthly basis. Board participating in RB phase II audit |
2 | Amanda Ambler |
| 3B, board or committee papers (including minutes) identify equality and health inequalities related impacts and risks and how they will be mitigated and managed | All committee paper’s have a cover sheet with an EDI risk rating which is mandatory to complete | 2 | Amanda Ambler |
| 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 | WRES and WDES annual reports are submitted on an annual basis.
WRES and WDES action plans are approved by board of directors and updated and monitored on a quarterly basis. Annual colleague inclusion network report submitted on activity. Quarterly EDI activity report submitted |
2 | Amanda Ambler |
6 Overall rating
EDS organisation rating (overall rating) 29.5.
Organisation name(s): Rotherham Doncaster and South Humber NHS Trust.
Those who score under 8, adding all outcome scores in all domains, are rated undeveloped.
Those who score between 8 and 21, adding all outcome scores in all domains, are rated developing.
Those who score between 22 and 32, adding all outcome scores in all domains, are rated achieving.
Those who score 33, adding all outcome scores in all domains, are rated excelling.
Document control
- Name of organisation Rotherham Doncaster and South Humber NHS Trust.
- Organisation board sponsor or lead: Nicola McIntosh, Executive Director of People and Organisational Development.
- Name of integrated care system: South Yorkshire ICB.
- EDS lead: Amanda Ambler, Interim Head of EDI.
- EDS engagement date(s): Peer review, 21 February 2023.
- Organisations:
- partnership (two or more organisations): The Rotherham NHS FT Doncaster and Bassetlaw Barnsley FT
- integrated care system-wide: South Yorkshire ICB
- Date completed: 21 February 2023.
- Month and year published: March 2023.
Page last reviewed: November 18, 2024
Next review due: November 18, 2025
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