Equality and Human Rights Screening

This report includes published screenings from April - June 2018

If you wish to download a hard copy of the screening outcome report please click here.

Click here to go to ARCHIVE SECTION

 

Policy & Screening Document /Policy Description

Date

Screening Outcome

Reason for Outcome

Belfast Trust referral protocol for General Dental Practitioners (GDPs) and the Community Dental Service referring patients with Special Needs to the Special Care Dentistry service at the School of Dentistry.

These guidelines are intended to help General Dental Practitioners (GDPs), Community Dentists (CDS), Primary Care Specialists and General Medical Practitioners (GMPs) make an informed decision when contemplating referring HSC patients for Special Care Dentistry at the School of Dentistry/Dental Hospital.

The purpose of this policy is to ensure that general dental practitioners (GDPs), Community Dentists (CDS), general medical practitioners (GMPs) as well as Primary Care Specialist Practitioners have a clear understanding of the patients who may be referred for Secondary Care Specialist advice and treatment within the hospital setting.

This policy applies to all patients referred for Secondary Care Special Care Dentistry advice and treatment to the Dental Hospital, Belfast Trust.

 4/4/18

 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 Trust referral protocol for General Dental Practitioners (GDPs), Community Dental Service Dentists and Primary Care Orthodontic Specialty referring patients to the Orthodontic Department at the School of Dentistry.

These guidelines are intended to help General Dental Practitioners (GDPs),

Community Dentists (CDS), Primary Care Specialists and General Medical Practitioners (GMPs) make an informed decision when contemplating referring HSC patients for Orthodontics to the Dental Hospital.

The purpose of this policy is to ensure that general dental practitioners (GDPs), Community Dentists (CDS),  general medical practitioners  (GMPs)) as well as Primary Care Specialist Practitioners have a clear understanding of the patients who may be referred for Secondary Care Specialist Orthodontic advice and treatment within the hospital setting.

This policy applies to all patients referred for Secondary Care Specialist Orthodontic advice and treatment to the Dental Hospital, Belfast Trust.

 4/4/18  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 Trust referral protocol for General Dental Practitioners (GDPs), Community Dentists, Primary Care Oral Surgery Specialists and General Medical Practitioners (GMPs) referring patients for an Oral Surgery appointment at the Belfast Dental Hospital

These guidelines are intended to help General Dental Practitioners (GDPs), Community Dentists (CDS), Primary Care Oral Surgery Specialists and General Medical Practitioners (GMPs) make an informed decision when contemplating referring HSC patients for minor oral surgery to the Dental Hospital.

This policy applies to all patients referred for Secondary Care Specialist Oral Surgery advice and treatment to the Dental Hospital, Belfast Trust.

 4/4/18  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 Trust referral protocol for General Dental Practitioners (GDPs), Community Dentists, Primary Care Specialists and General Medical Practitioners (GMPs) referring patients for an Oral Medicine appointment at the Belfast Dental Hospital

These guidelines are intended to help General Dental Practitioners (GDPs),

Community Dentists (CDS), Primary Care Oral Surgery Specialists and General Medical Practitioners (GMPs) make an informed decision when contemplating referring HSC patients for oral medicine to the Dental Hospital.

The purpose of this Protocol is to ensure that general dental practitioners (GDPs), Community Dentists (CDS), general medical practitioners  (GMPs) as well as Primary Care Specialist Practitioners have a clear understanding of the patients who may be referred for Secondary Care Specialist Oral Medicine advice and treatment within the hospital setting.  

 4/4/18  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 Trust Records Management Policy

The purpose of this policy is to ensure that staff are aware of their personal responsibilities and accountabilities for safeguarding confidential information in their care.  The Policy will provide guidance and clarity when dealing with records relating to patient care and general corporate records.  Paper records include patient clinical records, social care records, personal work diaries, notebooks, documentation and all forms of electronic devices.  It is applicable to both paper and electronic records. It is the responsibility of all staff to familiarise themselves with the content of this policy.

The policy has been revised to include reference to new legislation, namely the General Data Protection Regulation (GDPR) May 2018 and Data Protection Act 2018.

 5/4/18  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.

Transportation of Records Policy

The aim of this policy is to ensure that staff safeguard all confidential information while travelling from one facility/location to another during the course of their working day or transferring confidential information through the use of third parties such as Royal Mail or other Courier Services.

The policy has been updated to ensure that it is now in line with new legislation i.e. the General Data Protection Regulations May 2018 (GDPR).

 5/4/18  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 processing requests for access to patient Client and personal records

This policy aims to provide employees of Belfast Health and Social Care Trust with guidance in respect of processing requests for access to patient/client and personal records.

The aim is to ensure that staff are processing subject access requests in a consistent and timely manner in accordance with the right of the individual and the requirements of the legislation.

 9/4/18  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 on the access to data for organisations external to the Trust.

The Purpose of this policy is to ensure that access to confidential person identifiable information and business sensitive data is governed by clear and transparent agreements that satisfy the requirement of law i.e. Data Protection Act 1998 and DHSSPS guidance.

 9/4/18  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 on the Data Protection and protection of personal information.

The aim of this policy is to empower managers to be pro-active in relation to the processing of personal information in their workplace.  It is vital that the policy and supporting procedures are implemented and adhered to by all existing and new staff including for example: students, trainees, individuals on placement and volunteers.

This also includes those contracted in temporarily, such as GPs and locums, and anyone reviewing records for the purpose of audit like the RQIA.

 9/4/18  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 on the use of faxing

The policy has been written to ensure that staff who use a fax machine for communicating person- identifiable and confidential information are aware of the terms of acceptable use. The implementation of this policy will reduce the incidence of data being mis-sent.  The Information Commissioners Office has imposed financial penalties on other organisations for the mis-faxing of personal data.

Although fax machines are rare, there are still some within the Trust that are operational. The policy has primarily been updated in line with the new GDPR legislation.

 9/4/18  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.

Intrapartum Continuous Electronic Fetal Monitoring Cardiotocograph

The policy aims to provide guidance and standardise the documentation, interpretation and management of electronic intrapartum fetal monitoring.

 12/4/18  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.

Removal of a T Tube drain in hepatobiliary surgery.

To provide guidance to medical and nursing staff in the appropriate management and removal of T-Tubes post-cholecystectomy surgery.

To ensure patients are given the relevant information and guidance when they are discharged from hospital after the T-Tube has been removed in order that they can recognise any post-drain removal complications including sepsis.

16/4/18  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 Bariatric Patient / Client Policy

The policy aims include:

To safe guard the health, safety and welfare of staff and service users.

To maintain and promote safe manual handling of service users.

To ensure all staff are aware of the arrangements and responsibilities for the management of bariatric patients/clients.

To ensure that the Belfast Trust compiles with the relevant Health and Safety legislation, approved codes of practice and associated guidelines.

To ensure that resources are available and used appropriately.

To ensure the process of risk management is used for the establishment of safe systems of work.

To establish an effective communication network regarding the bariatric patient/client.

To ensure the bariatric patient/client is treated with the same comfort, dignity, respect and privacy as other patients/clients.

 24/4/18  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.

Epidural analgesia for adult patients

This policy applies to all adult inpatients in the Belfast Trust who have an epidural in situ for pain management. It is intended to serve as a guide for safe, effective management of patients with an epidural in situ.

 27/4/18  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 Urokinase for central venous access device occlusion

The purpose of this policy is to provide nursing and medical staff with guidance on the management of CVAD occlusion.

Provide clear guidance on managing CVAD occlusion.


To standardise the management of CVAD occlusion.


Ensure staff are aware of their roles and responsibilities in the management of CVAD occlusion.

 1/5/18  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.
Immunoglobulin Request Form

The main aim of the policy is to ensure the judicious and monitored prescribing of immunoglobulins in line with Department of Health Clinical Guidelines for Immunoglobulin Use.

Also view:

Immunoglobulin HSCB Request Form

Immunoglobulin Pharmacy Dispensing Log.
 10/5/18  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.

Naloxone for Reversal of Severe Opioid Toxicity in Adult Patients on Long Term Opioid treatment for Pain Control

To provide staff with a step by step process for using naloxone to reverse life threatening opioid toxicity in adults who are taking opioid medications long term for pain control.

To promote safe, effective and appropriate use of Naloxone for adult patients on opioid treatment for pain control in line with the Patient Safety Alerts for Naloxone.

 15/5/18  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.

Temporary re-direction of children aged under 14 from the Mater Hospital Emergency Department to the Royal Belfast Hospital for Sick Children Paediatric Emergency Department

The Trust is mindful of the ongoing constraints - primarily in terms of the expertise of the Emergency Department consultants, who are only providing services to 95 under 14s over a month-long period; this is largely for the treatment of minor injuries or minor illnesses. Equally, it is important to note that the supporting infrastructure in terms of other Children’s Specialist Services is located at the Royal Belfast Hospital for Sick Children and that there is not a paediatric environment at the Mater.

 21/5/18  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.

Guidance For The Management of Patients Who Become Ill Whilst Receiving Radiotherapy or Within Six Weeks of Radiotherapy and Who are Being Treated in The Belfast Trust

Policy is for community staff to advise them and support them in decision making when they need to prescribe for patients receiving radiotherapy in the Belfast Trust.

 23/5/18  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.

Blood Culture Policy Screening

The policy aim is to improve the quality and clinical value of blood culture investigations and reduce the incidence of contaminated blood cultures.

 24/5/18  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.

Staff Guidelines regarding managing patients with C1 inhibitor deficiency

This policy is to provide advice on managing patients with C1 inhibitor deficiency in the acute setting and pre procedure.

This policy simply advises on how to manage acute episodes of oedema in patients with known C1 inhibitor deficiency.

It also advises on medication to be given as pre procedural prophylaxis.  Practical information on obtaining supply of this medication from pharmacy is provided.

 24/5/18  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.

Guidance for the management of symptoms in patients in last days of life(EOLC Guidelines)

This guidance has been produced by the Surgery and Specialist Services Directorate. It provides recommendations to Trust staff and other healthcare professionals on managing commonly experienced symptoms at the end of life.

 19/6/18  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 and assistance by nursing and midwifery staff for the insertion of an umbilical arterial and/or umbilical venous catheter by medical staff in the Regional Neonatal Unit (RNU), Royal Jubilee Maternity Service. (RJMS.)

To provide clear guidance for nursing and midwifery staff in the preparation and assistance of medical staff with the insertion of an UAC or UVC.

To maintain safety of the baby during the insertion of an UAC or UVC.

 19/6/18  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 and procedure for taking routine swabs from a baby  in the Regional Neonatal Unit (RNU), Royal Jubilee Maternity Service(RJMS)

Purpose

To provide a policy for taking routine swabs from babies in the RNU, RJMS
To promote consistent, standardised  practice when performing the procedure for taking routine swabs from babies in the RNU, RJMS

Objectives

To identify colonisation of a baby so that investigation can commence to identify an environmental host and so prevent transmission to other babies

To ensure good practice, infection prevention and control methods are essential to providing safe and effective care to babies in the RNU, RJMS.
 19/6/18  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 weighing a baby who is nursed in an incubator or cot in the Regional Neonatal Unit (RNU) Royal Jubilee Maternity Service (RJMS).

Purpose

To monitor and record a baby’s weight.

To ensure adequate nutrition for optimal growth and development.

Objectives

To provide a procedure for weighing a baby clinically stable,  ill or clinically unstable ( if condition permits) in the RNU,RJMS
To ascertain the baby’s weight

To ensure the safety of the baby during the procedure.
 19/6/18  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 Pressure Injury Prevention and Management in the Regional Neonatal Unit (RNU), Royal Jubilee Maternity Hospital, (RJMH)

Purpose

To provide guidance on the steps that can be taken to prevent the development of pressure damage in babies in RNU RJMS and/or treat pressure damage once it has occurred.

Objectives

To facilitate the early identification of those babies at greatest risk of developing pressure damage
To provide safe standardised pressure ulcer prevention guidelines for babies at risk of pressure damage
To provide safe standardised pressure ulcer management guidelines for babies with pressure damage.

 19/6/18  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.

Implementation of a Close Circuit Television (CCTV) system within Muckamore Abbey Hospital (MAH) to assist with investigations related to adult safeguarding Issues

To ensure a more effective, timely and accurate response to alleged allegations of adult safeguarding and to assist the PSNI PPU with investigations senior management secured funding to install a CCTV system within MAH.  It is hoped that the installation of the system will enhance the protection of service users, staff and visitors.

 20/6/18  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.

Guidelines for nursing and midwifery staff providing end of life care for babies and caring for parents following the death of their baby in the Regional Neonatal Unit (RNU) and the procedures to be followed thereafter.

Purpose

To promote good practice for dignified end of life care of a baby in RNU and provide support for parents.

To provide clear guidance to all nursing and midwifery staff involved in end of life care and following the death of a baby in the RNU.

Objectives

To ensure dignified end of life care for babies in the RNU.

To support parents in the grieving process.

To recognise the needs of different cultures and religions and consult with parents and family regarding culture and religion.
 20/6/18  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 care of babies personal hygiene in the Regional Neonatal Unit (RNU)

Purpose

To provide guidelines to midwives, nurses and nursing auxiliaries who are attending to babies personal hygiene needs in the RNU.

Objectives

Maintain Babies personal hygiene.
 20/6/18  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 Knockbracken dispensary and distribution services to Belfast City Hospital Pharmacy Department and centralisation of Clozapine Dispensing to Belfast City Hospital Pharmacy

This proposal is to relocate the current Knockbracken pharmacy dispensary and distribution services to Belfast City Hospital Pharmacy Department at 31st March 2018.   The aim of the proposal is to enable the new distribution models to be established and embedded in advance of the completion of the Acute Mental Health inpatient Unit at Belfast City Hospital.  This will allow capacity within pharmacy to assist with decommissioning of Knockbracken wards and the opening of the new Acute Mental Health facility in early 2019.  Relocating the services at 31st March 2018 enables an end of year stock take at Knockbracken pharmacy and a close down of the stock holding location on the pharmacy computer system (JAC) The proposal also enables current and future staff to work in a larger dispensary / distribution team with experience of a broader range of specialties and pharmacy services.

The second part of the proposal is to centralise Clozapine dispensing to Belfast City Hospital.

 25/6/18  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.

Levels of Supervision/observations within Learning Disability Inpatient Services

This policy aims to provide staff working within a Learning Disability inpatient facility with a structured and standardised framework for delivering care to patients across the spectrum of inpatient facilities within the Trust.

 27/6/18  Screened out with mitigation Screened out with mitigation

To temporarily relocate child development services from Romanian Roma Community Association NI (RRCANI) to City Church.

This proposal involves the temporary relocation of services from RRCANI to City Church. This is based on concerns regarding RRCANI advice giving practices and organisational governance. This relocation will allow us the opportunity to clarify the situation with RRCANI and ensure the wellbeing of Trust staff in the interim.

Proposed relocation would also seek to improve equality of access to services for facilitate service users from the Roma Community (Women and Children) equality of access to quality child development programmes.

This proposal also seeks to ensure the health and safety of BHSCT staff currently based in RRCANI.

 29/6/18  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.

Electronic Prescribing on Aria Medical Oncology (MO) System

The policy describes the use of the Aria Medical Oncology(MO) system as an electronic prescribing system in oncology & haematology, the scope of its use and the roles and responsibilities of system users.

 29/6/18  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.

Guidance for the management of Haematology patients receiving Systemic Anti Cancer Therapy (SACT) in the Cancer Centre

The aim of this policy is to ensure that haematology patients receiving SACT in the Cancer Centre do so in a safe and effective manner.

The intended outcomes are to improve patient safety by providing guidance and protocols for cancer centre staff caring for Haematology patients receiving SACT.

 29/6/18  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 and procedures for Paediatric Macmillan Nurses in relation to the safe administration of intravenous Cytarabine in the community setting.

The purpose of this policy is to ensure the safe administration of a bolus dose of Cytarabine (as prescribed by medical staff) via a CVAD in the community setting by the Paediatric Macmillan Nurses.

 29/6/18  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

Screenings July - 8 Nov 2017.

Screenings 9 Nov 2017 - Dec 2017

Screenings  Jan - March 2018.