Equality and Human Rights Screening

This report includes published screening from July 2017 to 8 November 2017  

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Policy & Screening Document /Policy Description

Date Screening Outcome Reason for Outcome

Infection Control during construction, renovation and maintenance

 

This policy aims to:

1. Provide consistent Trust-wide guidance on the necessary infection prevention and control (IPC) procedures that should be adhered to when construction, maintenance or renovation works are carried out in order to minimise/reduce the risk of acquisition of a nosocomial infection.

2. Ensure that all the staff and personnel involved have a clear understanding of their roles in reducing contamination of the environment as a result of construction, renovation or maintenance works.

3. Provide a method to categorise construction work so that a structured and consistent risk assessment can be performed.

4. Provide detailed advice, depending on the risk assessment, on what actions should be applied to minimise risks.

5. Reduce the incidence of healthcare associated infections and improve the safety for service users, visitors and health care workers.

6. Identify immunosuppressed patients who are at high risk of invasive aspergillosis.

3/7/17 Screened out

Screened out as per Equality Commission’s guidance on screening with no adverse impact with regard to equality of opportunity and/or good relations for people within the equality and good relations categories.

Provision of extended hours clinical pharmacy services to BCH Older People Wards

 

The service would initially be aiming for a rota frequency of 1 weekend in 6 with 1 weeknight evening in 2 weeks. The maximum rota commitment will be one weekend (Saturday and Sunday) in 4 and one weeknight evening per week.

4/7/17 Ongoing screening

The Trust has decided to subject this proposal to ongoing screening to ensure that the impact is not more adverse than originally anticipated and that the mitigation is appropriate to minimise any negative impact.

Interfacing with the Pharmaceutical Industry

 

The policy provides a framework for interaction and engagement between Trust staff and the pharmaceutical industry to ensure maximum benefit is achieved for patients, the Trust and the wider HSC.

The primary purpose of the policy is to safeguard the health and wellbeing of patients and provide Trust staff with a framework for engagement with the pharmaceutical industry. In addition, the policy will safeguard Trust medical, nursing and pharmacy staff in respect of obtaining pharmaceutical products from industry representatives. The policy will provide for awareness of pending or current contracts so decision making is informed and compliant with public sector procurement policy.

5/7/17 Screened out

Screened out as per Equality Commission’s guidance on screening with no adverse impact with regard to equality of opportunity and/or good relations for people within the equality and good relations categories.

Relocation of RV Health Records Library from L4 RVH to new purpose built location on RVH site (current use as secondary storage)

 

The records library based on Level 4 RVH has been operational since apx 1974. This area is on the risk register for reasons including the weight on the floor and storage issues.

 

The H&S executive have also visited the premises in the past due to the number of incidents occurred which fell under RIDDOR. The office space is not fit for purpose for the team or the processes, which will affect approximately 60 staff.

7/7/17 Screened out with mitigation. Screened out with mitigation.

Policy on Supporting Breast Feeding Employees

 

The purpose of this policy ensures women who work within the BHSCT are supported to continue to breastfeed on their return to work after maternity leave if they wish to do so. It also provides guidance for Trust management in supporting an employee who is breastfeeding on return to work.
Objectives:
• To provide a supportive workplace for breastfeeding employees.
• To give clarity to managers on issues around supporting employees who are breastfeeding.

17/7/17 Screened out

Screened out as per Equality Commission’s guidance on screening with no adverse impact with regard to equality of opportunity and/or good relations for people within the equality and good relations categories.

Medical Devices Policy

 

The Medical Devices Policy is intended to give clear directions to staff on the management of medical devices. This is to include procurement, training, decontamination, maintenance, reporting of incidents and safe disposal of equipment.

25/7/17 Screened out

Screened out as per Equality Commission’s guidance on screening with no adverse impact with regard to equality of opportunity and/or good relations for people within the equality and good relations categories.

Management of Medical Devices – Procedures and Guidelines

 

The Procedures and Guidelines are intended to give clear directions to staff on the management of medical devices. This is to include procurement, training, decontamination, maintenance, reporting of incidents and safe disposal of equipment.

25/7/17 Screened out

Screened out as per Equality Commission’s guidance on screening with no adverse impact with regard to equality of opportunity and/or good relations for people within the equality and good relations categories.

Policy for Nurse to request radiological examination for testicular cancer patients from the Testicular Cancer Clinic at Belvoir Park Suite, Cancer Centre, BCH

 

To enable nurses to request Chest x-rays for follow-up purposes on behalf of the Consultants who are responsible for the patient group. Outlines roles and responsibility of nurses highlighted in the policy as a non-medical referrer. Ultimate aim is to improve and expedite the patient experience at review clinic in Belvoir Park Suite.

4/8/17 Screened out

Screened out as per Equality Commission’s guidance on screening with no adverse impact with regard to equality of opportunity and/or good relations for people within the equality and good relations categories.

The management of patients at risk of self harm or actual self harm in acute settings (other than mental health)

 

The purpose of this policy is to ensure that all staff are aware of the standards of good practice and the appropriate steps to take in the management of patients following an incident or threat of self harm.

4/8/17 Screened out

Screened out as per Equality Commission’s guidance on screening with no adverse impact with regard to equality of opportunity and/or good relations for people within the equality and good relations categories.

Policy for implementing one to one staffing in nursing and residential care to promote management of behavioural disturbances in people with dementia/delirium

 

This policy sets out the assessment and risk management process for people with dementia/delirium within care home environments where one to one supervision has been requested. The policy will also detail good practice standards for promoting the least restrictive practice as part of the fundamental care needs of the person which is assessed to be proportionate and necessary.

 

The policy aims to set out a structured and standardised framework for the process of decision making, assessment, requesting and reviewing one to one supervision in care and nursing homes.

4/8/17 Screened out

Screened out as per Equality Commission’s guidance on screening with no adverse impact with regard to equality of opportunity and/or good relations for people within the equality and good relations categories.

       

Guidelines for the care of central venous access devices

 

• To promote consistency of practice throughout hospital and community settings.
• To ensure the following goals of best practice are achieved:
- To prevent infection
- To maintain a patent device
- To prevent damage to the device
- To maintain a closed intravenous system

8/8/17     Screened out

Screened out as per Equality Commission’s guidance on screening with no adverse impact with regard to equality of opportunity and/or good relations for people within the equality and good relations categories.

       

Weighing of infants, children and young people in RBHSC

This policy is required to ensure standardisation of practice throughout the RBHSC in relation to the weighing of infants, children and young people.
This p olicy aims to clarify best practice in relation to:
 The appropriate timing and frequency of weighing a child
 The correct method of weighing children of different ages
 The accurate use of weighing equipment
 The correct method of weight estimation
 Accurate and comprehensive documentation of a child’s weight

11/8/17  Screened out

Screened out as per Equality Commission’s guidance on screening with no adverse impact with regard to equality of opportunity and/or good relations for people within the equality and good relations categories.

       

The provision of a 7 day early supported discharge service within BHSCT.

 

This policy aims to ensure people receive more rehabilitation at home, therefore improving patient outcomes.

 15/8/17

Ongoing screening

Ongoing screening The Trust has decided to subject this proposal to ongoing screening to ensure that the impact is not more adverse than originally anticipated and that the mitigation is appropriate to minimise any negative impact.

       

NI Alcohol Use Disorders Care Pathway - management in the acute hospital setting

 

Regional document which provides guidance on alcohol screening, assessment and management of alcohol withdrawal syndrome, screening for alcohol related brain damage to support junior doctors and substance misuse liaison nurses.

19/8/17 Screened out

Screened out as per Equality Commission’s guidance on screening with no adverse impact with regard to equality of opportunity and/or good relations for people within the equality and good relations categories.

       

Policy for the management of Paediatric Haematology/Oncology patients using telephone triage service

 

The key objective of the policy is to provide guidance and support for all Paediatric Haematology/Oncology Nurses trained in Telephone Triage.

22/8/17  Screened out

Screened out as per Equality Commission’s guidance on screening with no adverse impact with regard to equality of opportunity and/or good relations for people within the equality and good relations categories.

       

Guideline for the Management of Home Birth

 

This guideline provides direction for all midwives/maternity support workers involved in the care of women who have requested a home birth.

Objectives

• Aid midwives to provide evidence-based information so that women can make choices for care including home birth
• To facilitate women to give birth in their chosen environment
• To achieve a healthy outcome for mother and baby.

25/8/17 Screened out

Screened out as per Equality Commission’s guidance on screening with no adverse impact with regard to equality of opportunity and/or good relations for people within the equality and good relations categories.

       

Isolation policy for patients / clients with suspected or proven transmissible infectious microorganisms

 

To provide consistent Trust-wide guidance for risk assessment, placement and application of infection prevention and control procedures for those patients/clients with proven or suspected transmissible infections and those with high risk of contracting infection due to profound suppression of their immune system.

31/8/17 Screened out with mitigation Screened out with mitigation
       

Policy for nurses to request radiological examination for patients attending the Joint Lung @ Belvoir Park Suite, Cancer Centre, BCH

 

To enable Belvoir Park nursing staff who have undergone the appropriate training to request radiological examination (Chest X-rays) for follow-up review in patients with known lung cancer on behalf of Consultants.

1/9/17 Screened out

Screened out as per Equality Commission’s guidance on screening with no adverse impact with regard to equality of opportunity and/or good relations for people within the equality and good relations categories.

       

High Flow Nasal Oxygen HFNO use and management for in-patients.

 

The objective of this policy is to facilitate the safe and rational use of HFNO therapy within the Belfast Trust.

To promote safe and effective High Flow Nasal Oxygen (HFNO) provision by means of a standardised guideline.

This policy guides the use of HFNO and associated monitoring equipment by nursing and medical staff in patients in the Belfast Trust. It states the indications for initiating therapy, how the therapy should be utilised and prescribed and how to wean off the therapy.

4/9/17 Screened out

Screened out as per Equality Commission’s guidance on screening with no adverse impact with regard to equality of opportunity and/or good relations for people within the equality and good relations categories.

       

Local Guidance for Facilitating Visits by Children to Mental Health and Learning Disability Inpatient/Residential Facilities

 

This guidance seeks to promote and facilitate visits by children to service users, whilst safeguarding the interests of children.

These guidelines will provide staff working within Mental Health and Learning Disability inpatient or residential facilities uniform guidance on facilitating visits by children to service users.

5/9/17 Screened out

Screened out as per Equality Commission’s guidance on screening with no adverse impact with regard to equality of opportunity and/or good relations for people within the equality and good relations categories.

       

Policy for safe administration of intrathecal cytotoxic chemotherapy

 

The purpose of this policy is to ensure the safe administration of intrathecal chemotherapy within the Belfast Health and Social Care Trust in accordance with national guidance.

18/9/17 Screened out

Screened out as per Equality Commission’s guidance on screening with no adverse impact with regard to equality of opportunity and/or good relations for people within the equality and good relations categories.

       

Employers procedures for diagnostic and therapeutic uses of unsealed radioactive materials

 

The policy has been drawn up to ensure that the Trust complies with the Ionising Radiation (Medical Exposure) Regulations (NI) 2000, ensuring the safety of patients undergoing medical exposures using radioactive materials.

20/9/17 Screened out

Screened out as per Equality Commission’s guidance on screening with no adverse impact with regard to equality of opportunity and/or good relations for people within the equality and good relations categories.

       

Guidelines for cleansing the hubs/needleless device of intravascular catheters and access devices of intravenous fluid bags.

 

To provide clear guidance to nursing and midwifery staff who care for babies within the RNU, RJMS when cleaning the hubs/needleless devices of intravascular catheters and access devices of intravenous fluid bags.

To reduce the risk of infection associated with intravascular catheters in babies.

To provide safe guidelines for nursing and midwifery staff when accessing intravascular catheters inserted in babies or access devices of intravenous fluid bags.

20/9/17 Screened out

Screened out as per Equality Commission’s guidance on screening with no adverse impact with regard to equality of opportunity and/or good relations for people within the equality and good relations categories.

       

Guideline for the administration of Human Albumin to a baby in the regional neonatal unit.

 

To provide clear guidance to nursing and midwifery staff for the safe administration of intravenous human albumin to a baby in NICU.

To ensure safe practice and consistency of care when administering intravenous human albumin to a baby in NICU.

20/9/17 Screened out

Screened out as per Equality Commission’s guidance on screening with no adverse impact with regard to equality of opportunity and/or good relations for people within the equality and good relations categories.

       

Skin care policy for adult patients receiving radiotherapy

 

This policy is an update of the existing policy - Skin Care Policy for Adult Patients Receiving Radiotherapy. The aim of the policy is to provide detailed information for health care workers within the Belfast Trust on the assessment and management of irradiated skin while the patient is having radiotherapy treatment.

The policy will also ensure that the advice and documentation is consistent across the professions within the Trust and wider community (primary care).

It is also hoped that the policy will encourage team working and seamless care.

22/9/17 Screened out

Screened out as per Equality Commission’s guidance on screening with no adverse impact with regard to equality of opportunity and/or good relations for people within the equality and good relations categories.

       

Setting a prescribed number of classes available for people affected by cancer. (Yoga, Pilates, Tai Chi and classes to be changed to 12 classes at each level).

 

Following an evaluation of the service, Friends of the Cancer Centre have now put a 12 week limit for each class, with the aim to provide value for money and to encourage
Opportunities for new clients to attend the class and ensure accessibility on an equal basis for all clients.

4/10/17 Screened out

Screened out as per Equality Commission’s guidance on screening with no adverse impact with regard to equality of opportunity and/or good relations for people within the equality and good relations categories.

       

Belfast Health & Social Care Trust Policy and Procedural Arrangements relating to the Management of Stress, Health & Wellbeing.

 

This Policy and Procedural arrangement is designed to provide managers and staff with clear information on their legislative responsibilities.

18/10/17 Screened out

Screened out as per Equality Commission’s guidance on screening with no adverse impact with regard to equality of opportunity and/or good relations for people within the equality and good relations categories.

       

Policy for transferring a patient from PICU to MRI

 

This Policy is required to ensure safe transfer of patients from PICU to MRI. The aim is that all healthcare professionals will be aware of the equipment required and the management of the patient.

18/10/17 Screened out

Screened out as per Equality Commission’s guidance on screening with no adverse impact with regard to equality of opportunity and/or good relations for people within the equality and good relations categories.

       

Belfast Health & Social Care Trust Policy and Procedural Arrangements relating to control of vibration at work regulations NI (2005)

 

This Policy and procedural arrangement is designed to provide managers and staff with clear guidelines and outline their responsibilities to manage risk associated with vibration.

18/10/17 Screened out

Screened out as per Equality Commission’s guidance on screening with no adverse impact with regard to equality of opportunity and/or good relations for people within the equality and good relations categories.

       

BHSCT Policy relating to the prevention and management of Latex sensitisation revision 3

 

This Policy & Procedural Arrangement is designed to provide managers and staff with clear information on their legislative responsibilities to provide a latex safe environment for staff, patients/clients and others.

 

This policy encourages managers to identify areas of risk within their area of responsibility, to develop procedures to prevent and manage sensitisation occurring and to raise awareness of the hazards associated with NRL and other associated chemicals, such as accelerators (added to gloves during the manufacturing process).

 

23/10/17 Screened out

Screened out as per Equality Commission’s guidance on screening with no adverse impact with regard to equality of opportunity and/or good relations for people within the equality and good relations categories.

       

Procedure for the insertion and irrigation of a Replogle tube in a baby with an oesophageal atresia and/or a transoesophageal fistula (ToF) in the Regional Neonatal Unit (RNU).

 

To provide clear guidance for nurses and midwives when inserting and irrigating a Replogle tube. To provide safe care for a baby who has a Replogle tube in situ.

26/10/17 Screened out    

Screened out as per Equality Commission’s guidance on screening with no adverse impact with regard to equality of opportunity and/or good relations for people within the equality and good relations categories.

       

Protocol for Nurse-led fluorescein and indocyanine green angiography

 

The aim of this policy is to clarify the roles and responsibilities of appropriately trained Ophthalmic nurses in relation to Ophthalmic imaging and patient care. This policy applies to adult patients who are 18 years and older.

1/11/17 Screened out

Screened out as per Equality Commission’s guidance on screening with no adverse impact with regard to equality of opportunity and/or good relations for people within the equality and good relations categories.

       

Guideline for the management of an inverted uterus

 

This guideline raises awareness of uterine inversion: to aid timely recognition and appropriate management.

All guidance within this document applies to medical/midwifery staff who care for women during the intrapartum and postpartum period.

3/11/17 Screened out

Screened out as per Equality Commission’s guidance on screening with no adverse impact with regard to equality of opportunity and/or good relations for people within the equality and good relations categories.

       

Administration of intramuscular (IM), intravenous (iv) and oral (PO) Vitamin K (Phytomenadione) to a neonate in RJMS.

 

• To provide clear guidance for nursing and midwifery staff when administering IM, IV or oral vitamin K (phytomenadione) to a neonate.
• To protect neonates from developing VKDB.

To ensure safe practice for nurses and midwives who administer IM IV or oral vitamin K (Phytomenadione) to neonates in RJMS.

3/11/17 Screened out

Screened out as per Equality Commission’s guidance on screening with no adverse impact with regard to equality of opportunity and/or good relations for people within the equality and good relations categories.

       

Preparation for the insertion of a urinary catheter in a neonate and the management of a neonate with a urinary catheter in the RNU, RJMS. 

To promote a consistent and cohesive approach to care when undertaking a urinary catheterisation in a neonate in NICU.

To provide staff with evidence based guidelines when undertaking urinary catheterisation in a neonate and the management of a neonate with a urinary catheter.

• To minimise trauma and discomfort associated with urinary catheterisation

• To reduce the incidence of infections associated with urinary catheter

• To enable accurate measurement of urinary output in a critically ill baby.

• To allow continuous emptying of the bladder in babies with a neurogenic bladder e.g. Spina Bifida.

3/11/17 Screened out

Screened out as per Equality Commission’s guidance on screening with no adverse impact with regard to equality of opportunity and/or good relations for people within the equality and good relations categories.

       

Cumulative Equality Screening on Financial Savings Proposals 17/18 - comprising efficiencies in Administration & Management Costs, Procurement & Discretionary Expenditure, Estates, Energy Efficiency & Car Parking and Slippage & Accounting Adjustments

 

The Health and Social Care (HSC) system has been working collaboratively to address the significant financial pressures facing health and social care services in 2017/18 to meet the statutory requirement of achieving a balanced financial plan across the HSC.

6/11/17 Ongoing screening

The Trust has decided to subject this proposal to ongoing screening to ensure that the impact is not more adverse than originally anticipated and that the mitigation is appropriate to minimise any negative impact.

       

Homecare Medicine Policy

 

This policy is guidance for all staff who are involved with homecare medicine service provided by third party providers.

6/11/17 Screened out

Screened out as per Equality Commission’s guidance on screening with no adverse impact with regard to equality of opportunity and/or good relations for people within the equality and good relations categories.

       

Lymphoma Nurse Led Clinic Protocols

 

This policy provides a framework within which a Lymphoma Clinical Nurse Specialist may review patients with stable haematological disease by face to face consultation.

8/11/17 Screened out

Screened out as per Equality Commission’s guidance on screening with no adverse impact with regard to equality of opportunity and/or good relations for people within the equality and good relations categories.

Archive of screening outcome reports:

Screenings Sept - Dec 2011

Screenings Jan-Mar 2012

Screenings April-June 2012

Screenings July-Sept 2012

Screenings Oct-Dec 2012

Screenings Jan-Mar 2013

Screenings April-June 2013

Screenings July-Sept 2013

Screenings Oct-Dec 2013

Screenings Jan-Mar 2014

Screenings April-June 2014

Screenings July - September 2014

Screenings Oct - Dec 2014

Screenings Jan - Mar 2015

Screnings April - June 2015

Screenings July - Sept 2015

Screenings Oct - Dec 2015

Screenings Jan - March 2016

Screenings April - June 2016

Screenings July - September 2016

Screenings Oct - December 2016

Screenings Jan - March 2017

Screenings April - June 2017