Equality and diversity policy template

1. What the regulation says

The primary law for this policy is the Equality Act 2010. Its duties are also engaged for CQC-regulated providers through Regulation 10 (dignity and respect) and Regulation 9 (person-centred care) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, but the verbatim duties below are from the Equality Act 2010 itself.

age; disability; gender reassignment; marriage and civil partnership; pregnancy and maternity; race; religion or belief; sex; sexual orientation.

The duty comprises the following three requirements.

The first requirement is a requirement, where a provision, criterion or practice of A's puts a disabled person at a substantial disadvantage in relation to a relevant matter in comparison with persons who are not disabled, to take such steps as it is reasonable to have to take to avoid the disadvantage.

The second requirement is a requirement, where a physical feature puts a disabled person at a substantial disadvantage in relation to a relevant matter in comparison with persons who are not disabled, to take such steps as it is reasonable to have to take to avoid the disadvantage.

The third requirement is a requirement, where a disabled person would, but for the provision of an auxiliary aid, be put at a substantial disadvantage in relation to a relevant matter in comparison with persons who are not disabled, to take such steps as it is reasonable to have to take to provide the auxiliary aid.

Where the first or third requirement relates to the provision of information, the steps which it is reasonable for A to have to take include steps for ensuring that in the circumstances concerned the information is provided in an accessible format.

A person (A) who is subject to a duty to make reasonable adjustments is not (subject to express provision to the contrary) entitled to require a disabled person to pay to any extent A's costs of complying with the duty.

A person (a "service-provider") concerned with the provision of a service to the public or a section of the public (for payment or not) must not discriminate against a person requiring the service by not providing the person with the service.

A person must not, in the exercise of a public function that is not the provision of a service to the public or a section of the public, do anything that constitutes discrimination, harassment or victimisation.

The full text of the Act is at https://www.legislation.gov.uk/ukpga/2010/15/contents. Where this policy and the Act diverge, the Act wins.

2. Plain-English summary

Service users must be treated with dignity and respect. In particular, you have to protect their privacy, support their autonomy, independence and involvement in the community, and have due regard to any relevant protected characteristics under the Equality Act 2010. Care and treatment must also be appropriate, meet the service user's needs, and reflect their preferences. The Equality Act 2010 itself names nine protected characteristics, including: age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex, and sexual orientation. Healthcare providers are service providers under the Act and must not discriminate, and for disabled people they must make reasonable adjustments. Together, these duties mean the service must deliver care that is non-discriminatory, accessible and built around each person.

3. Scope

This policy applies to , when , at .

(Tenant completes the angle-bracket placeholders to fit their organisation.)

4. Roles and responsibilities

• Registered Manager: accountable for the Equality Act framework operating across every site. Reviews any equality-related complaint or grievance. Signs off the annual equality review.
• Nominated Individual: holds provider-side accountability.
• Equality and Accessibility Lead (named; in small services often the Registered Manager): the day-to-day Equality Act decision authority. Receives reasonable-adjustment requests, runs the annual accessibility audit, advises clinicians on accessibility considerations.
• HR Lead: accountable for the employment-side Equality Act compliance (recruitment, terms and conditions, promotion, dismissal, harassment in employment).
• Clinical Lead: accountable for the service-provider-side Equality Act compliance (anticipatory reasonable adjustments, accessible information, non-discriminatory care delivery).
• All staff: know the protected characteristics, recognise reasonable-adjustment needs (auxiliary aids, accessible information formats, physical-feature adjustments), do not discriminate, harass, or victimise, raise any incident the same shift.

(Tenant updates the named role-holders.)

5. Procedure

The Equality Act procedure operationalises the Act's service-provision and reasonable-adjustments duties across the service-delivery and employment surfaces.

1. Anticipatory reasonable adjustments. The Equality and Accessibility Lead maintains an anticipatory-adjustment plan: physical-feature adjustments (ramps, lifts, accessible toilets, hearing loops, accessible parking), provision/criteria/practice adjustments (longer appointment slots for some disabilities, quiet rooms for sensory-sensitive patients, easy-read information leaflets, BSL interpreter access, large-print materials), auxiliary aids (writing materials, communication aids, accessible technology), and adjustments to digital and telephone systems so that disabled people can use the Service's online and phone services. The plan is reviewed annually.
2. Accessible Information Standard. The Service follows the Accessible Information Standard for anyone with a disability, impairment or sensory loss, applying its six steps: identify each person's information and communication needs; record them clearly; flag them so anyone delivering care can see them; share them, with consent, when referring to another provider; meet them at every interaction; and review them when the person's needs change.
3. Per-encounter adjustment. At each service-user encounter, the clinician checks the accessibility flag on the record and applies the recorded adjustments. Where a new need surfaces, it is captured and added to the record.
4. Reasonable-adjustment requests. A service user, employee, or family member may request a reasonable adjustment. The request is logged, assessed for reasonableness (the Equality Act requires reasonable, not unlimited), and responded to in writing with the decision. Where granted, the adjustment is recorded and operated.
5. Cost of adjustment. The provider does not pass the cost of the reasonable adjustment to the disabled person.
6. Recruitment and employment. Job adverts, application forms, interview processes, terms and conditions, and promotion processes are designed not to discriminate on any protected characteristic. Reasonable adjustments at interview and in the workplace are made for disabled candidates and employees.
7. Complaint and grievance route. Equality-related complaints from service users run through the standard complaints policy with the Equality and Accessibility Lead notified. Employment-related grievances run through the HR grievance procedure. Both are recorded on the platform.
8. Public Sector Equality Duty (where applicable). Providers delivering services under NHS contract that constitute public functions must have due regard to the Section 149 duty. The Equality and Accessibility Lead documents how the provider considers the three Section 149(1) aims (eliminate discrimination, advance equality, foster good relations) at the design and review of services.
9. Annual equality review. The Equality and Accessibility Lead produces an annual equality review covering: the protected-characteristic profile of service users (where data is available and lawful to hold), the adjustments made in the year, the complaints received and outcomes, the workforce protected-characteristic data, and the action plan for the coming year.
10. Incident-pattern check. Equality-related incidents (complaints, harassment, discrimination allegations) are reviewed quarterly for patterns that may suggest systemic discrimination requiring action.

6. Meeting personal, cultural, religious and social needs, and human rights

Equality is more than avoiding discrimination; the Service delivers care that fits each person:

• staff actively find out and take account of each person's personal, cultural, social, religious and communication needs, and build them into the person's care, including food, daily routines, worship, language, and the people important to them
• the Service does not set age-based thresholds, or other limits affecting a protected group, without a documented and objective justification
• the Service respects people's rights under the Human Rights Act 1998, including the right to respect for private and family life, the right not to be subjected to degrading treatment, and the right to liberty, and it makes decisions that are lawful, proportionate, and respectful of those rights

7. Bullying, harassment and victimisation

The Service does not tolerate bullying, harassment or victimisation of anyone, whether a person who uses the service, a member of staff, or a visitor:

• anyone can report it; reports are taken seriously, investigated, and acted on
• a person is never treated less favourably for having raised a concern or complaint (victimisation)
• where bullying or harassment is found, the Service addresses and rectifies it, including through its disciplinary procedure for staff

8. Handling protected-characteristic information

Information about a person's protected characteristics (for example their disability, religion, race or sexual orientation) is special-category personal data. The Service records, holds and shares it only where it is lawful and necessary, securely, and in line with the UK GDPR and the Data Protection Act 2018 (not the superseded Data Protection Act 1998), and shares it with other providers only where there is a lawful basis and it benefits the person's care.

9. Training requirement

• All staff complete equality, diversity, and inclusion awareness training at induction and every three years.
• Clinical staff complete accessibility-in-practice training at induction and every three years, covering the Accessible Information Standard, reasonable-adjustment recognition, and adjustment-delivery techniques.
• The Equality and Accessibility Lead completes role-specific training at appointment and refresher every two years.
• HR staff complete Equality Act in employment training at induction and every three years.

Training records held in the tenant's training matrix register.

10. Audit

Compliance with this policy is monitored by the Equality and Accessibility Lead:

• Quarterly accessibility audit: sampled premises checks (ramps, accessible toilets, hearing loops, lighting), sampled record checks (Accessible Information Standard flag completeness), sampled patient-experience feedback for accessibility comments.
• Quarterly complaint-pattern review: equality-related complaints reviewed for patterns.
• Annual equality review: the equality review produced per Section 5 step 9.
• Annual policy review: the policy is read against the live Equality Act 2010 text and current Equality and Human Rights Commission guidance.

Audit findings recorded in the tenant's audit register; actions logged in the improvement-actions register.

11. Record-keeping

Equality Act records (reasonable-adjustment requests and decisions, Accessible Information Standard flags on service-user records, equality-related complaints, equality reviews, public-sector-equality-duty documentation) are held for a minimum of 8 years from the date of the last entry, aligned to the NHS Code of Practice on Records Management for service-user-linked records, and the standard limitation period (6 years from end of employment under the Limitation Act 1980) for employment-related Equality Act records.

Verivius preserves the per-record audit trail indefinitely while the workspace is active.

12. Related policies in this pack

• Complaints Policy
• Safeguarding Adults Policy
• Recruitment Policy

13. Sources and further reading

This template is based on CQC's guidance for providers and managers, the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, and other topic-specific legislation and guidance listed below. It is a starting point for adaptation, not a substitute for legal, clinical, HR, safeguarding or specialist professional advice.

• Equality Act 2010 (https://www.legislation.gov.uk/ukpga/2010/15/contents)
• CQC Regulation 10: Dignity and respect
• CQC Regulation 9: Person-centred care
• Equality and Human Rights Commission guidance
• CQC equality and human-rights guidance
• Accessible Information Standard (where applicable)
• Human Rights Act 1998 (https://www.legislation.gov.uk/ukpga/1998/42)
• UK GDPR and Data Protection Act 2018 (https://www.legislation.gov.uk/ukpga/2018/12/contents)
• Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (https://www.legislation.gov.uk/uksi/2014/2936/regulation/10)

14. When to seek further advice

Seek specialist advice where the issue involves serious harm, safeguarding, deprivation of liberty, restraint, children, professional misconduct, controlled drugs, radiation, termination of pregnancy, infection outbreak, water safety, employment dismissal, DBS barring referral, or regulatory enforcement.

15. Document control

This sample policy template was issued by Verivius. It is a template, not a substitute for legal advice or the tenant's own policy-development process. Where this template and live law or regulator guidance diverge, the live source wins.