Sample policy · Equality Act

Equality and diversity policy template

Statutory anchor: Equality Act 2010, engaged through Regulation 10 (dignity and respect), Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (SI 2014/2936). This policy also engages Regulation 9 (person-centred care). · primary source

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Verivius pack version v1, 2026-06-10

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

(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:

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:

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

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

10. Audit

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

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

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.

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

Version Date Author Changes
v1 2026-05-19 Verivius (sample) Initial sample template.
v1.1 2026-06-01 Verivius (sample) Filled out Sections 3 to 8 with concrete content. Section 4 names the Equality and Accessibility Lead and HR Lead roles. Section 5 expanded to a 10-step procedure covering anticipatory reasonable adjustments, Accessible Information Standard, per-encounter adjustment, request handling, no-cost-to-disabled-person, recruitment and employment, complaint and grievance route, Public Sector Equality Duty, annual equality review, incident-pattern check. Section 6 names training tiers. Section 7 names the audit cadence. Section 8 references the NHS Code of Practice and Limitation Act retention for employment records.
v1.2 2026-06-05 Verivius (sample) CQC content-checklist pass. Retitled to "Equality, Diversity and Human Rights Policy" (CQC's document name). Added Section 6 (meeting personal/cultural/religious/social needs, the Human Rights Act 1998, and no unjustified age limits), Section 7 (bullying, harassment and victimisation, with rectification through the disciplinary procedure), and Section 8 (handling protected-characteristic special-category data under the UK GDPR and Data Protection Act 2018, explicitly not the superseded 1998 Act, both being CQC red flags). Stated the AIS as its six named steps (Identify, Record, Flag, Share, Meet, Review) and applied it beyond NHS-funded work, and added digital and telephone reasonable adjustments. Sections renumbered; updated stale related slugs.
v1 (re-conformed) 2026-06-10 Verivius (sample) Re-conformed to the current Verivius policy standard, preserving the original content. Replaced the leaner disclaimer and footer with the current house wording; rebuilt the header block (statutory anchor named through engaged Regulations 10 and 9, primary source, last reviewed, pack version); added the policy owner and applies-to line; kept Section 1's verbatim Equality Act 2010 quotes (the primary law) while naming the engaged Regulations 10 and 9; retitled Section 2 to the plain-English summary; added the standard Sources and further reading and When to seek further advice blocks. Every original section and rule preserved.

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.

What good looks like here

Written from an ex-CQC inspector's chair, but the point is safe, well-led care your team can stand behind. Each row shows what strong evidence looks like, what thin evidence looks like, and where the expectation comes from.

The distinctive risk this policy guards against is the recorded-but-unmet need, and the quiet exclusions that grow out of it. A person's disability, sensory loss or communication need is captured once at registration and then never reaches the clinician in the room, so a Deaf person attends without the interpreter, someone with a learning disability is handed standard consent information they cannot follow, and a person who needs a longer appointment is rushed through a standard one. That is not merely discourteous, it can be unsafe, because consent given without accessible information is not truly informed, and a communication need that goes unmet can hide a deteriorating condition. What this policy carries beyond the accessible-information routine is the equality edge: the cost of an adjustment must never land on the disabled person, a blanket age or capability threshold needs an objective justification rather than custom, and harassment or victimisation has to be dealt with rather than absorbed. These failures rarely arrive as one dramatic event. They surface as a run of small refusals spread across different people, which is why concerns from a protected group have to be joined up before the pattern is visible to anyone. For the person, a reliable trail is the difference between a service that adapts to them and one that keeps asking them to explain their own needs. It also lets a well-led team show, rather than assert, that access is designed in and not left to the memory of whoever is on shift.

  1. The adjustment a person was promised is actually there when they arrive, with the clinician checking the accessibility flag on the record and applying the recorded adjustments, rather than a need being logged once and then never reaching the room.

    Strong evidence: The Accessible Information Standard flag on the service-user record and its per-encounter application, sampled in the quarterly accessibility audit's record checks (Procedure steps 2, 3; Audit).

    Weak evidence: An accessibility flag set on the record and a tidy anticipatory-adjustment plan filed centrally, but consultation notes across recent appointments that never mention the longer slot, the interpreter or the easy-read leaflet actually being provided, so nothing shows the recorded need reached the person in the room.

    Our recommended baseline. Not a legal or regulatory requirement, but a sensible standard we suggest where the rules leave the detail to you. Adapt it to your service.

  2. All six steps of the Accessible Information Standard run, not just the first, so a communication need is flagged for the people delivering care and reviewed when it changes, rather than sitting recorded and unused.

    Strong evidence: The identify, record, flag, share (with consent), meet and review steps evidenced on the record, checked for flag completeness in the quarterly accessibility audit (Procedure step 2; Audit).

    Weak evidence: The first two steps done and the rest blank: a communication need identified and recorded at intake, but no visible flag for the care team, no evidence it was shared with consent on referral, no sign it was met at recent contacts, and no review when the person's situation changed.

    Our recommended baseline. Not a legal or regulatory requirement, but a sensible standard we suggest where the rules leave the detail to you. Adapt it to your service.

  3. A person who asks for a reasonable adjustment has the request logged and answered in writing, and the cost of the adjustment is never passed to the disabled person, rather than the request being settled verbally with nothing on file.

    Strong evidence: The logged request with its reasonableness assessment and its written decision held on the platform, with no charge to the person for the adjustment (Procedure steps 4, 5).

    Weak evidence: Requests settled in conversation with nothing on file: no dated log of what was asked, no written reasonableness assessment showing what was weighed, no written decision to the person, and, at worst, an added charge that quietly passes the cost of an interpreter or aid to the disabled person.

    Our recommended baseline. Not a legal or regulatory requirement, but a sensible standard we suggest where the rules leave the detail to you. Adapt it to your service.

  4. Equality-related complaints and harassment allegations are read for patterns, not just closed one at a time, so repeated concerns from one protected group are joined up.

    Strong evidence: The quarterly complaint-pattern review and the annual equality review's complaints-and-outcomes section (Procedure steps 7, 10; Audit).

    Weak evidence: A complaints log where each equality or harassment concern is marked resolved and closed on its own, with no quarterly pattern review recorded, so a run of concerns from wheelchair users or from one ethnic or religious group is never joined up and no theme is named or acted on.

    Our recommended baseline. Not a legal or regulatory requirement, but a sensible standard we suggest where the rules leave the detail to you. Adapt it to your service.

  5. What the record holds about a person's disability, religion, race or sexual orientation is special-category data, handled under the current law, the UK General Data Protection Regulation and the Data Protection Act 2018 (not the superseded 1998 Act), and shared only on a lawful basis.

    Strong evidence: The Section 8 handling standard and the lawful-basis check before any onward sharing of protected-characteristic data (Section 8; Record-keeping).

    Weak evidence: A privacy notice still citing the Data Protection Act 1998, no documented lawful basis or special-category condition for holding disability, religion or sexual-orientation data, and onward sharing to another provider with nothing recorded to show the lawful basis or the benefit to the person's care.

    A legal duty. This comes from legislation that applies to your service, so meeting it is not optional. The exact provision is cited beneath the badge.

    UK GDPR Articles 9(1) and 9(2) with Article 6(1), and Data Protection Act 2018 s.10 and Schedule 1 (the 1998 Act repealed by DPA 2018 Schedule 19)

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Last verified 20 July 2026

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Last reviewed 10 June 2026