Equality and diversity policy (Equality Act 2010)

1. What the regulation says

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 British summary

The Equality Act 2010 protects people from discrimination, harassment and victimisation across employment and the provision of services. The Act names nine protected characteristics: 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 Section 29 of the Act and must not discriminate against a person requiring the service. For disabled patients specifically, the Act imposes a duty to make reasonable adjustments under Section 20: change provisions, criteria or practices that put a disabled person at a substantial disadvantage; change physical features that put a disabled person at a substantial disadvantage; provide auxiliary aids where a disabled person would otherwise be at a substantial disadvantage; and provide information in accessible formats. The reasonable adjustments duty is anticipatory, meaning the provider must consider adjustments before a disabled person asks for them. The provider cannot require the disabled person to pay for the adjustment. Where an independent secondary care provider delivers services as part of a public function (typically under an NHS contract), the Public Sector Equality Duty in Section 149 may also apply, requiring the provider to have due regard to the need to eliminate discrimination, advance equality of opportunity, and foster good relations between people with and without protected characteristics.

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 Sections 20 and 29 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), and auxiliary aids (writing materials, communication aids, accessible technology). The plan is reviewed annually.
2. Accessible Information Standard. For NHS-funded work, the Accessible Information Standard (DCB1605) applies: identify each service user's information and communication needs; record them in the service user's record with a clear flag visible to anyone delivering care; meet the needs at every interaction; review the needs at change of circumstance; share the recorded needs with other healthcare providers when referring.
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. 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.

7. 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.

8. 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.

9. Related policies in this pack

• Person-Centred Care Policy (hscra-reg-9-person-centred-care)
• Dignity and Respect Policy (hscra-reg-10-dignity-and-respect)
• Safeguarding Adults Policy (hscra-reg-13-safeguarding-from-abuse)

10. Document control

This sample policy template was issued by Verivius as part of the Mock Inspection design partner onboarding pack. It is a template, not a substitute for legal advice or the tenant's own policy-development process. Where this template and the live regulation diverge, the live regulation wins.