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Mortality Review Policy

Learning from Deaths

Version: V6

Ratified by: Mortality Review Group

Date ratified: 26/05/2026

Job Title of author: Head of Quality and Safety Head of Safeguarding

Reviewed by Committee or Expert Group Mortality Review Group

Equality Impact Assessed by: Head of Quality and Safety

1. Introduction

Death is an inevitable outcome of people’s lives, and some deaths will occur whilst individuals are receiving care from Provide Community services. Health and social care staff work tirelessly to deliver safe, high-quality care; however, a small number of patients may experience poor quality care, sometimes due to multiple contributory factors at individual, service or system level.

It is therefore essential that Provide Community has robust systems in place to:

• Review the quality and safety of care provided in the period leading up to, and at the time of, death.

• Identify whether deaths were expected or unexpected and whether there were opportunities to improve care.

• Identify learning at individual, service, organisational and system level.

• Ensure learning leads to improvement actions and is shared to reduce the risk of recurrence.

• This overarching policy applies to all deaths occurring whilst a person is under the care of Provide Community, including:

• Adults aged 18 years and over

• Children and young people under 18 years

• People with a learning disability and/or autistic people.

This policy applies across all NHS-commissioned, privately commissioned and mixed-funded services delivered by Provide Community.

2. Purpose

The purpose of this policy is to describe the framework and procedures for:

• Identifying, screening and reviewing deaths.

• Responding proportionately to patient safety incidents involving death.

• Supporting bereaved families and carers.

• Learning from deaths and embedding improvement into practice.

This policy should be read in conjunction with:

• Provide Community Patient Safety Incident Response Plan (PSIRP)

• QSPOL01 Provide Community Incident Reporting and Management Policy

• QSPOL03 Being Open and Duty of Candour Policy

• CSPOL01 Complaints and Compliments Policy

• SGSOP16 Child Death Review Notifications

• SGPOL07 Safeguarding Adults at Risk of Abuse

• SGPOL08 Domestic Abuse and Multi-Agency Risk Assessment Conference

• SGPOL02 Safeguarding Children and Young People Policy

This policy applies to all colleagues, including:

• Permanent staff

• Bank, locum and agency staff

• Staff holding honorary contracts

• Independent contractors providing services on behalf of Provide Community Group

3. Definitions

Patient

Used generically to include service users, clients, residents or customers depending on the care setting.

Death in Scope

Any death occurring while a person is receiving care from Provide Community Group, including community, inpatient, residential and domiciliary services.

Mortality Review

A structured review of the quality and safety of care provided prior to death, including consideration of whether there were opportunities for improvement.

Patient Safety Incident

Any unintended or unexpected incident related to care that could have, or did, result in harm, including death.

Notifiable Safety Incident (Duty of Candour)

As defined in Regulation 20 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, where a death is related to the provision of care and was unexpected or avoidable.

Patient Safety Incident Response Framework (PSIRF)

The national framework for responding to patient safety incidents, focusing on proportionate, system-based learning rather than fixed thresholds.

Significant Event

An internal organisational classification for incidents that do not meet statutory escalation criteria but warrant deeper review for learning purposes within our social care settings.

Medical Examiner (ME)

An independent senior doctor responsible for scrutinising deaths not referred to the coroner, providing an additional safeguard for patients and families.

4. Duties

Chief Executive Officer and Board

The Board has overall accountability for ensuring:

• Robust systems exist to identify, review and learn from deaths.

• Compliance with legal, statutory and commissioning requirements.

• Assurance that learning from deaths results in service improvement.

Quality and Safety Committee

Responsible for:

• Oversight of mortality surveillance, review outcomes and learning.

• Ensuring adequate resourcing for mortality review processes.

• Receiving assurance reports and escalating risks to the Board.

Chief Officers and Non-Executive Directors

Must have the capability and capacity to:

• Understand mortality themes and risks.

• Provide effective challenge and oversight.

Mortality Review Group

A sub-committee of the Quality and Safety Committee which:

• Oversees screening and selection of deaths for review.

• Ensures reviews are completed using approved methodologies.

• Monitors quality, themes, actions and learning.

• Reports outcomes through the Quality Professional Leadership Team (QPLT) to the Quality and Safety Committee and Board.

• Receives regular reports on the status, progress, and outcomes of ongoing and concluded inquests

Incident Review Panel (IRP)

Incident Review Panel is a panel made up of a group of multidisciplinary professionals who undertake a review of an incident following investigation by the service. This allows a full 360-degree view of the incident to be captured with an open and honest approach. The aim of IRPs is to understand where and why errors occurred and how the systems led to suboptimal care. The aim is to draw any potential learning from an incident using a Just culture approach and capture quality improvement that mitigate the risk of the incident re-occurring. This is balanced by highlighting good practice and care that will be shared across teams and services.

Directors/Divisional Leads/Managers

Responsible for:

• Ensuring all deaths within their services are appropriately screened.

• Delegating reviews to suitably trained peer reviewers.

• Ensuring actions arising from reviews are implemented and monitored.

Head of Quality and Safety

Responsible for:

• Coordinating mortality reviews and learning responses.

• Ensuring alignment with PSIRF and Duty of Candour requirements.

• Providing expert advice on escalation and investigation pathways.

Business Intelligence Team

Responsible for:

• Accurate collection, analysis and reporting of mortality data.

• Supporting mortality surveillance and trend analysis.

5. Scope and Rationale for Mortality Reviews

Provide Community delivers a wide range of community, inpatient, residential and social care services. Mortality review processes must therefore be proportionate, appropriate and risk based

Deaths involving:

• Suspicious circumstances,

• Allegations of abuse or neglect,

• Domestic abuse,

• Safeguarding concerns will be managed through statutory processes including the Coroner, Police, Safeguarding Adult Reviews, Domestic Homicide Reviews or Child Death Review processes as appropriate.

All deaths in scope will undergo an initial screening to determine:

• Whether the death was expected or unexpected,

• Whether there were patient safety concerns,

• Whether a learning response or structured review is required.

Appendix 2 provides guidance to Patients in Scope for Review or Investigation.

6. Child Death Reviews (See SGSOP16)

Child death review processes will be undertaken in line with Working Together to Safeguard Children (2026) and statutory Child Death Review guidance.

Statutory requirements

When a child dies, in any circumstances, it is important for parents and families to understand what has happened and whether there are any lessons to be learnt. The responsibility for ensuring child death reviews are carried out is held by ‘child death review partners’, who, in relation to a local authority area in England, are defined as the local authority for that area and any ICBs operating in the local authority area.

Child death review partners must make arrangements to review all deaths of children normally resident in the local area and, as indicated, of any non-resident children who have died in their area. This should be done via a Child Death Overview Panel (CDOP).

Child death review partners for two or more local authority areas may combine and agree that their areas be treated as a single area for the purpose of undertaking child death reviews. Child death review partners must make arrangements for the analysis of information from all deaths reviewed by the National Child Mortality Database (NCMD).

The purpose of a review and/or analysis is to identify any matters relating to the death, or deaths, that are relevant to the welfare of children in the area, or to public health and safety, and to consider whether action should be taken in relation to any matters identified. If child death review partners find action should be taken by a person or organisation, they must inform them. In addition, child death review partners:

• must, at such times as they consider appropriate, prepare, and publish reports on:

o what they have done because of the child death review arrangements in their area

o how effective the arrangements have been in practice

When a child dies, a child death notification is received by the Provide Safeguarding team. If a practitioner is present during the death of a child, once the death is confirmed by a medical practitioner (i.e. GP) then a form A is required to be completed via the ECDOP website

Unexpected child deaths will be managed through local Child Death Review partnerships. Provide Community Group staff will cooperate fully with:

• Rapid response processes,

• Information sharing,

• Review meetings.

Following the unexpected death of a child known to Provide Services, Practitioners who have been working with the family will be identified by the Safeguarding team and may be contacted by the electronic Child Death Review (eCDR) Administrator for information sharing prior to the review. Please see process map in Appendix 3

Learning relevant to Provide Community Group will be fed back via Safeguarding reporting routes to the Quality and Safety

7. Learning from Lives and Deaths – People with a Learning Disability and Autistic People (LeDeR)

LeDeR focuses on learning from the lives and deaths of people with a learning disability and autistic people. It is about local service improvement which enables local systems to better understand why people are dying early and what we can do to change services locally and nationally to improve the health of people with a learning disability and autistic people and reduce health inequalities. By finding out more about why people have died we can understand what needs to be changed to make a difference to people’s lives.

All deaths of people with a learning disability and/or autistic people will be notified to the LeDeR programme via the national portal.

Provide Community Group will:

• Cooperate with local system-led LeDeR reviews.

• Contribute information and learning.

• Implement improvement actions identified.

See https://www.england.nhs.uk/publication/learning-from-lives-and-deaths-peoplewith-a-learning-disability-and-autistic-people-leder-policy-2021/

To report any deaths of people with a Learning Disability or Autism access the online portal at: https://leder.nhs.uk/ and click on:

8. Learning

Learning is central to improving patient safety. Provide Community Group will:

• Share learning internally across services.

• Share relevant learning with commissioners and system partners.

• Monitor actions to completion and effectiveness.

Themes and trends will be reviewed regularly by the Mortality Review Group and Quality and Safety Committee.

9. Supporting Bereaved Families and Carers

Bereaved families and carers will be treated with compassion, openness and respect.

Provide Community Group will ensure:

• Timely and honest communication.

• Compliance with Duty of Candour where applicable.

• Opportunities for families to raise questions and contribute to reviews.

• Signposting to bereavement and advocacy support.

• Feedback on learning and actions taken, where appropriate.

Appendix 4 offers further guidance on the support bereaved families and carers should receive.

10.Process

Please refer to Provide’s Learning from Deaths Flowchart (Appendix 1).

Identification and Screening

• All deaths to be reported via the local management response system DCIQ.

• All deaths to be reviewed by the Quality & Safety team and placed onto the agenda for discussion/review at an Incident Review Panel (IRP).

• Datix records to be checked for related incidents, complaints or risks by the Quality & Safety team.

• Local/handler review to be completed by the reporting service.

• Medical Examiner feedback to be reviewed where applicable.

2. Decision on Response following review at IRP

• A proportionate response is selected in line with PSIRF:

o No further review with noting at Mortality Review Group,

o Referral to LeDeR or Child Death Review,

o Escalation to a Patient Safety Incident Response Group,

o Systems-based investigation.

o Consideration made for onward reporting e.g. CQC, Local Authority, Commissioner, National Patient Safety team at NHSE.

3. Oversight and Learning

• Mortality Review Group monitors quality and completion.

• Learning and actions are tracked and reported at Quality Reference Group with noting at MRG.

4. Family Engagement

• Families are informed, supported and involved as appropriate. NHS England » Engaging and involving patients, families and staff following a patient safety incident

11.Training and Competencies

Provide Community Group will ensure staff involved in mortality reviews have access to:

• PSIRF and investigation training,

• Bereavement and communication skills training, (Advanced Communication Skills training – St. Luke’s and Farleigh Hospice; CommunicationatEnd-of-LifeCourse – eLfH)

• Clinical supervision and Quality & Safety

12.References / Associated National Guidance

Care Quality Commission (CQC). (2014). Regulation 20: Duty of Candour. Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. https://www.cqc.org.uk/guidance-providers/regulations-enforcement/regulation-20duty-candour

Care Quality Commission (CQC). (2023). Learning from deaths. https://www.cqc.org.uk/guidance-providers/nhs-trusts/learning-deaths

Department of Health and Social Care. (2015). Statutory duty of candour guidance. https://www.gov.uk/government/publications/statutory-duty-of-candour-guidance

Department of Health and Social Care. (2023). Working Together to Safeguard Children: A guide to inter-agency working to safeguard and promote the welfare of children. https://www.gov.uk/government/publications/working-together-to-safeguard-children 2

Healthcare Safety Investigation Branch (HSIB). (2021). Principles for systems-based investigations https://www.hssib.org.uk/

National Quality Board (NQB). (2017). National guidance on learning from deaths: A framework for NHS trusts and NHS foundation trusts https://www.england.nhs.uk/publication/learning-from-deaths-guidance/

National Quality Board (NQB). (2018). Learning from deaths: Working with bereaved families and carers https://www.england.nhs.uk/publication/learning-from-deaths-working-with-bereavedfamilies-and-carers/

NHS England. (2021). Learning from Lives and Deaths – People with a Learning Disability and Autistic People (LeDeR) Policy https://www.england.nhs.uk/publication/learning-from-lives-and-deaths-people-witha-learning-disability-and-autistic-people-leder-policy-2021/

NHS England. (2022). Patient Safety Incident Response Framework (PSIRF) https://www.england.nhs.uk/patient-safety/patient-safety-incident-responseframework-psirf/

NHS England. (2022). Patient Safety Incident Response Plan (PSIRP) guidance https://www.england.nhs.uk/patient-safety/patient-safety-incident-responseframework-psirf/

NHS England. (2024). Medical Examiner system: Guidance for providers https://www.england.nhs.uk/medical-examiners/

Royal College of Paediatrics and Child Health (RCPCH). (2018, updated). Child Death Review: Statutory and operational guidance. https://www.rcpch.ac.uk/resources/child-death-review-statutory-operationalguidance-england

NHS England » Engaging and involving patients, families and staff following a patient safety incident

Royal College of Physicians. (2016). Using the Structured Judgement Review method: A guide for reviewers https://www.rcplondon.ac.uk/projects/outputs/structured-judgement-review

Appendix 1: Mortality Review Flowchart

Mortality Review Flowchart

All deaths reported on DCIQ

Within 24 working hours of reporting a Quality & Safety team review to be completed

Service reporting to complete local/handler review

All deaths involving a person with a learning disability or a child to be referred to LeDeR or a Child Death Review

All deaths reported to go to IRP for discussion/noting/wider review

Medical Examiner feedback to be reviewed where applicable

If gaps in care identified at IRP, to be escalated to a PSIRG

All death reviews to go to MRG for noting

If escalated for investigation, outcome to be reviewed/noted at MRG and report/action plans to go to QRG for monitoring and MRG for noting

Appendix 2: Scope of Patient Death Requiring Mortality Review or Further Investigation

Adult Inpatient Community Hospitals and Adult Community

Unless the incident of mortality meets the criteria for a more detailed investigation, all adult community hospital inpatient and adult community deaths reported will meet the criteria for a review at IRP and if deemed to have gaps in care, escalated for further investigation.

Inpatient Adult Learning Disabilities/Autism and Community Adult Learning Disabilities

All incidents of Adult Learning Disabilities/Autism inpatient or community mortality will be reported via LeDeR for investigation through this process, however, may also be reviewed via the Incident Management Policy Processes if the circumstances fall within this scope.

Children, Young People and Families

Unexpected deaths in children (018) follow a rapid response process under the Child Death Review Statutory and Operational Guidance (England) HM Government 2018.

If any of the unexpected deaths occurred as a result of any care provided by Provide Group Services, the Incident Management Policy process will be instigated.

All child deaths (0-18) (expected and unexpected) are reviewed at the Child Death Review Panel, which is a sub-group of the LSCB. See Appendix 3

Data will include these figures within the Mortality Review process (for reporting only) and within Safeguarding Reporting Processes.

Appendix 3: eCDOP CDR Review Process

Provide.safeguarding@nhs.net receive email notification of Child Death from eCDOP

SG Admin records information onto CDR TRACKER (located on the Children’s Safeguarding Spreadsheet noting Ref No and Case No

SG Admin checks SystmOne to ascertain which PROVIDE Services have delivered care to the Child within the last 3 years.

NB guidance: SG Admin to alert SG Team if the child has any current safeguarding concerns or has been known to Provide Services within the last 5 years where there were safeguarding concerns.

SG Admin sends email to CDR team administrator Tpa-tr.set-cdr-rrt@nhs.net with a list of email addresses of practitioners involved in care with a request for the Child Death Information to be sent directly to the generic email address for each of the teams involved in the child’s care.

CHILDREN’S SAFEGUARDING NURSE AND/OR MEMBER OF THE TEAM IS COPIED INTO EMAIL

SG Admin emails relevant practitioners with copy to Team Lead, to advise they will be contacted by eCDOP regarding the child’s death. The email requests that action is taken promptly to access the portal and complete information required. Practitioners should download a printed copy of the finalised form and email it to Provide.safeguarding@nhs.net to advise this has been completed.

CHILDREN’S SAFEGUARDING NURSE AND/OR MEMBER OF THE TEAM IS COPIED INTO EMAIL

SG Admin updates the spreadsheet with names of all Provide Clinicians involved in care and date to send ‘reminder emails’ to Practitioners if required when ‘completion emails’ are not received.

If the child is not known to Provide Services, the SG Administrator will register the child to the safeguarding unit and inform the Named Nurse for Safeguarding Children . The Named Nurse for Safeguarding Children will then email the Child Death Review Team Tpa-tr.set-cdr-rrt@nhs.net and let them know the child is unknown to any of Provide services and the SG Administrator will be copied into the response so that they are aware this has been completed and the child will be de-registered on SystmOne by the SG Administrator.

On receipt of email from practitioner confirming they have actioned the eCDOP Form B request, the email should be forwarded to the Named Nurse for Safeguarding Children The spreadsheet can then be updated. The individual practitioners will be responsible for completing the eCDOP Form B information request , downloading a copy of the form and emailing it to: provide.safeguarding@nhs.net to make them aware the request is complete . Quality Assurance will be carried out by the Named Nurse for Safeguarding Children by reviewing all completed Form Bs

Appendix 4: Support for Bereaved Families

1 It is of prime importance to work closely with bereaved families and carers to ensure a consistent level of timely, meaningful and compassionate support and engagement at every stage – from notification of death, investigation, investigation report, lessons learned and actions taken.

2 Dealing respectfully, sensitively and compassionately with families and carers of dying or deceased patients is crucially important. The principles of openness, honesty and transparency as set out in the Duty of Candour (Regulation 20 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014) must be applied in engagement and involvement with bereaved families and carers.

3 The key principles for supporting bereaved families and carers are:

• To be treated as equal partners following a bereavement.

• To always receive a clear, honest, compassionate and sensitive response in a sympathetic environment.

• To provide a high standard of bereavement care which respects confidentiality, values, culture and beliefs, including being offered or signposted to appropriate support. This includes providing, offering or directing people to specialist suicide bereavement support.

• To be informed of their right to raise concerns about the quality of care provided to their loved one.

• To offer guidance, where appropriate, on raising a concern/complaint.

• For their views to help inform decisions about whether a review or investigation is needed.

• To receive timely, responsive contact and support in all aspects of an investigation process, with a single point of contact or liaison.

• To be partners in an investigation to the extent, and at whichever stages, that they wish to be involved, as they offer a unique and equally valid source of information and evidence that can better inform investigations.

Support can include:

• Support during and following an investigation. This may include counselling or signposting to suitable organisations that can provide bereavement or post-traumatic stress counselling, with attention paid to the needs of young family members, especially siblings.

4 People who are bereaved need others to recognise and acknowledge their loss. Recognition by professionals, appropriately expressed, may be particularly valued. Communication at the time of a death and afterwards, should be clear, sensitive and honest. Bereaved families and carers should be given as much information as possible in line with the Duty of Candour for providers. Every effort should be made to hold these discussions in a private, sympathetic environment, without interruptions.

5 When reviewing or investigating possible problems with care, involvement of bereaved families and carers begins with a genuine apology. Saying sorry is not an admission of liability and is the right thing to do. The appropriate staff member should be identified for each case, including to explain what went wrong promptly, fully and compassionately. This may include clinicians involved in the case, but this may not always be appropriate and should be considered on a case-by-case basis.

6 Depending on the nature of the death, it may be necessary for several organisations to make contact with those affected. This should be discussed with the bereaved families and carers and a coordinated approach should be agreed with them and the organisations involved. If other patients and service users are involved or affected by the death, they should be offered the appropriate level of support and involvement.

7 The Organisation should ensure that the deceased person’s General Practitioner is informed of the death and provided with details of the death as stated in the medical certificate at the same time as the family or carers. The GP should be informed of the outcome of any investigation.

8 Where a death is investigated under the Serious Incident Policy, early contact should be made with bereaved families and carers so that their views help to inform the decision.

9 Bereaved families and carers will expect to know what happened; why it happened; and what can be done to stop it happening again to someone else. If the Organisation proceeds with an

investigation, skilled and trained investigators need to be able to explain to bereaved families and carers the purpose of the investigation which is to understand what happened. If problems are identified, the investigation should be clear why and how these happened so that action can be taken to prevent the same problems from occurring again.

10 If a family wants to engage or contribute to an investigation, an early meeting should be held to explain the process, how they can be informed of progress, what support processes have been put in place and what they can expect from the investigation. This should set out realistic timescales and outcomes. There should be a named person as a consistent link for the families and carers throughout the investigation.

Bereaved families and carers should:

• Be made aware, in person and in writing as soon as possible, of the purpose, rationale and process of the investigation to be held.

• Be asked for their preferences as to how and when they contribute to the process of the investigation and be kept fully and regularly informed, in a way that they have agreed, of the process of the investigation.

• Have the opportunity to express any further concerns and questions and be offered a response where possible, with information about when further responses will be provided.

• Have a single point of contact to provide timely updates, including any delays, the findings of the investigation and factual interim findings. This may disclose confidential personal information for which consent has been obtained, or where patient confidentiality is overridden in the public interest. This should be considered by the organisation’s Caldicott Guardian and confirmed by legal advice in relation to each case.

• Have an opportunity to be involved in setting any terms of reference for the investigation which describe what will be included in the process and be given expectations about the timescales for the investigation including the likely completion date.

• Be provided with any terms of reference to ensure their questions can be reflected and be given a clear explanation if they feel this is not the case.

• Have an opportunity to respond on the findings and recommendations outlined in any final report; and,

• Be informed not only of the outcome of the investigation but what processes have changed and what other lessons the investigation has contributed for the future.

12 Bereaved families and carers should be informed of the role of the Medical Examiner and offered the opportunity to raise any questions or concerns with the Medical Examiner service, in line with national death certification and scrutiny arrangements.

This appendix is aligned with:

• NQB Learning from Deaths – Working with Bereaved Families and Carers (2018)

• Duty of Candour principles

• CQC expectations for compassionate engagement

EQUALITY IMPACT ASSESSMENT TEMPLATE

Stage 1: ‘Screening’

The Equality Impact Assessment needs to be completed so that any decisions made are compliant with the aims of the Public Sector Equality Duty – and that any adverse impact for any protected characteristics are identified and resolved.

Policy Title

QSPOL14 Mortality Review Policy – Learning from Deaths

Provide a brief summary (bullet points) of the aims of the Policy

To hold reviews following the death of people open to Provide Community CIC. Assess if the death was avoidable or due to problems with service delivery or wider system failure.

Disseminate any learning from the mortality reviews and change practice to ensure lessons are learnt to prevent recurrence.

EQIA Assessor Name and Job Title Date of Assessment Head of Quality and Safety April 2026

This stage establishes whether a proposed initiative will have an impact from an equality perspective on any particular group of people or community or whether it is “equality neutral” (i.e. have no effect either positive or negative)

Q1. Will this policy affect one of the following groups more or Less favourably than another?

Details If more or less, explain impact and any valid legal and/or justifiable exception. Include the source of any evidence

Age

Consider impact and detail across age ranges on old and younger people. This can include safeguarding, consent and child welfare

Disability

Consider and detail impact on attitudinal, physical, and social barriers.

Sex

Consider and detail impact on men and women (potential to link to carers)

Gender reassignment (including transgender)

Consider and detail impact on transgender and transsexual people. This can include issues such as privacy of data and harassment.

Pregnancy and maternity

Consider and detail impact on working arrangements, part-time working, infant caring responsibilities.

Race

Consider and detail impact on different ethnic groups, nationalities, Roma gypsies, Irish travellers, language and communication barriers.

Religion or belief

Consider and detail impact on people with different religions, beliefs or no belief.

Sexual orientation

Consider and detail impact on heterosexual people as well as lesbian, gay and bi-sexual people

Carers

Consider and detail impact on part-time working, shift-patterns, general caring responsibilities

Other identified groups

Consider and detail on different socioeconomic groups, area inequality, income, resident status (migrants) and other groups experiencing disadvantage and barriers to access.

Assessed Impact overall  Positive X Neutral  Negative

Guidelines: Things to consider

Is the impact of the initiative – whether positive or negativesignificant enough to warrant a more detailed Stage 2 assessment?

 Yes X No

Equality impact assessments at Provide take account of relevant equality legislation and include age, (i.e. young and old,); race and ethnicity, gender, disability, religion and faith, and sexual orientation.

The initiative may have a positive, negative or neutral impact, i.e. have no particular effect on the group/community.

Where a negative (i.e. adverse) impact is identified, it may be appropriate to make a more detailed EIA (see Stage 2), or, as important, take early action to redress this – e.g. by abandoning or modifying the initiative. NB: If the initiative contravenes equality legislation, it must be abandoned or modified.

Where an initiative has a positive impact on groups/community relations, the EIA should make this explicit, to enable the outcomes to be monitored over its lifespan.

Where there is a positive impact on particular groups does this mean there could be an adverse impact on others, and if so can this be justified? - e.g. are there other existing or planned initiatives which redress this?

It may not be possible to provide detailed answers to some of these questions at the start of the initiative. The EIA may identify a lack of relevant data, and that data-gathering is a specific action required to inform the initiative as it develops, and also to form part of a continuing evaluation and review process.

It is envisaged that it will be relatively rare for full impact assessments to be carried out at Provide. Usually, where there are particular problems identified in the screening stage, it is envisaged that the approach will be amended at this stage, and/or setting up a monitoring/evaluation system to review a policy’s impact over time.

QUALITY IMPACT ASSESSMENT TEMPLATE

Stage 2

To be used where the ‘screening phase has identified a substantial problem/concern)

This stage examines the initiative in more detail in order to obtain further information where required about its potential adverse or positive impact from an equality perspective. It will help inform whether any action needs to be taken and may form part of a continuing assessment framework as the initiative develops.

Policy/ Project Title

EIA Assessor Name and Job Title Date of Assessment

EIA Review by Chief Officer name and Job Title Date Of Review

Outcome of Chief Officer Review

Q1. What data/information is there on the target beneficiary groups/communities?

Are any of these groups under- or over-represented?  Yes  No

Do they have access to the same resources?  Yes  No

What are your sources of data and are there any gaps?

Q2. Is there a potential for this initiative to have a positive impact, such as tackling discrimination, promoting equality of opportunity and good community relations?  Yes  No

If yes, how? Which are the main groups it will have an impact on?

Q3. Will the initiative have an adverse impact on any particular group or community/community relations?  Yes

If yes, in what way? Will the impact be different for different groups – e.g. men and women?

Q4. Has there been consultation/is consultation planned with stakeholders/ beneficiaries/ staff who will be affected by the initiative?  Yes

Summarise (bullet points) any important issues arising from the consultation

Q5. Given your answers to the previous questions, how will your plans be revised to reduce/eliminate negative impact or enhance positive impact?

Are there specific factors which need to be taken into account?  Yes  No

Q6. How will the initiative continue to be monitored and evaluated, including its impact on particular groups/ improving community relations? Where appropriate, identify any additional data that will be required

Guidelines: Things to consider

An initiative may have a positive impact on some sectors of the community but leave others excluded or feeling they are excluded. Consideration should be given to how this can be tackled or minimised.

It is important to ensure that relevant groups/communities are identified who should be consulted. This may require taking positive action to engage with those groups who are traditionally less likely to respond to consultations, and could form a specific part of the initiative.

The consultation process should form a meaningful part of the initiative as it develops, and help inform any future action.

If the EIA shows an adverse impact, is this because it contravenes any equality legislation? If so, the initiative must be modified or abandoned. There may be another way to meet the objective(s) of the initiative.