Equality and Human Rights Screening

This report includes published screenings from July - September 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

Protocol for Assessment of Needs of Children and Young People in Special Schools within the Belfast Health and Social Care Trust (BHSCT).

Purpose

It is recognised that all children with special nursing needs are individual and must have consistent care from all agencies involved. This protocol is required to ensure there is consistent standardised care provided by nurses from the Community Children’s Nursing team within BHSCT and will;

  • Standardise practice
  • Improve the standard of care to individuals
  • Improve the level of communication between all carers – both professional and non-professional
  • Improve standards of record keeping.

Objectives

  • To provide a clear framework which will support professional practice
  • To ensure that children, young people and their carers receive a service of a consistent standard.

To ensure best practice in individual care planning and communication for children and young people and all involved with their care.

 4/7/18  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 the Estates Procurement, Supplies & Contract Management Team from Musgrave park to KHCP

The policy is aimed at providing an improved working environment for staff and offers a number of advantages:

  • Individual office space for Managers
  • Provides privacy for work or for meetings with individual staff or others.
  • Separate office space for location of 2 off Procurement Leads (Band 6) which would facilitate collaborative working and sharing of ideas.
  • Separate office space for 2 off (Band 5) assistants to Procurement Leads, again facilitating collaborative work.
  • Large office, capable of accommodating a minimum of 5 staff Adequate Storage Space, Tea Point, Toilet as well as space for a small Tea Room / Meeting Room.
  • Large Conference Room available in the main Estates Department Office.
  • Adequate parking for staff and visitors.
5/7/18 Screened out with mitigation Screened out with mitigation

Policy for accessing Immunoglobulin Therapy in BHSCT

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.

31/7/18

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 the early recognition and management of a suspected head injury

Objectives

1. To ensure accurate recording of a patient’s neurological observations, including the Glasgow Coma Scale.

2. To ensure there is a clear record of what observations have been carried out, when and by whom.

3. To monitor, through regular and accurate observations, the progress of the patient’s condition by staff and ensure they understand their clinical relevance.

4. To ensure staff are aware of the immediate and subsequent steps to be taken when deterioration in the patient’s condition is noted.

5. To ensure that relevant staff are kept informed of the patient’s condition.

6. To ensure the patient’s next of kin are kept informed of the patient’s condition.

1/8/18

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 Procedural arrangement relating to the prevention and management of alcohol and drugs in the workplace

This policy and procedural arrangement is designed to provide managers and staff with clear guidelines on their responsibilities to recognise and manage the effects of alcohol, drugs and other substance misuse at work. It applies to all staff working in the delivery of the Trust’s services i.e. permanent, temporary, locum and agency staff, volunteers, students on placement and also, those staff engaged under external contract as sub-contractors. This policy also provides support to individual employees with alcohol and drug related problems to rehabilitate and continue in work

13/8/18

Screened out with mitigation

Screened out with mitigation

Guidelines for admission of a baby to the Regional Neonatal Unit (RNU), RJMS

Purpose

To provide clear guidance for nursing and midwifery staff who are involved in the              admission of a baby to the neonatal unit, RJMS

Objectives

This guideline is set out to assist with the efficient and safe admission of a baby into the neonatal unit.  
21/8/18 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. 

Guidelines for Nurse Led Assessment and aftercare of patients with colorectal cancer

This document outlines the guiding principles for nurse-led colorectal cancer follow-up.

The aim of this guideline is to set a minimum standard for nurse led assessment and follow up of patients with colorectal cancer.
21/8/18 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 & 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.
22/8/18 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. 

Addisons Guidelines

This policy is clinical in nature in terms that it is guidance for staff and does not have any adverse impact on equality or human rights for staff or service users (patients) and can be screened out at this stage.

This guideline contains the current evidenced based thinking on the topic.
22/8/18 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. 

Use of Personal Alarm Systems on the Muckamore Abbey Hospital site

To ensure a consistent approach to the use of personal alarm systems

22/8/18 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. 

Guidelines for hip fracture patients admitted taking Clopidogrel

This guideline outlines the process to be used for managing hip fracture patients taking clopidogrel in the perioperative period.

22/8/18 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. 

Protocol for telephone nurse-led follow up for patients with ovarian cancer

The purpose of this policy is to outline the aims and objectives of a telephone nurse-led follow up for patients diagnosed with ovarian cancer treated with adjuvant intent and patients treated with palliative intent who are well and deemed appropriate for shared care.

Sets outspecific protocols by which the nurse will seek guidance when reviewing patients

Provides a framework within which the Gynae Oncology Clinical Nurse Specialist may review patients on follow-up following treatment for Ovarian Cancer.
25/8/18 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. 

Visitors Policy for Royal Belfast Hospital for Sick Children (RBHSC)

Objectives

To clarify the visiting arrangements for staff which can then be communicated to parents and visitors. If parents and visitors do not speak English as a first language interpreting or written translations will be provided if required. If a person has a disability which requires assistance with communication, this will be provided.

To highlight the infection prevention and control measures which will assist in the reduction of hospital acquired infections and which must then be explained to parents and visitors.

To ensure that a quiet restful environment is maintained for children who are ill or who are recovering from surgery or investigations.

To ensure confidentiality is maintained during ward rounds.

To maintain health and safety standards by limiting the number of visitors due to limited space on the wards.
30/8/18 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 Paediatric Attendance at deliveries

This guideline sets out the indications which require paediatric presence at deliveries. This guideline also advises regarding deliveries that do not routinely require a paediatrician to be present.

4/9/18 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. 

Clinical Guideline for the management and care of children (0-16 yrs) with epidural analgesia in the post-op setting.

This clinical practice guideline outlines best practice for the management of epidural analgesia in paediatric surgical patients 0-16 years of age.  The aim is to ensure safe and effective care of paediatric surgical patients who have an epidural for post-operative pain relief.  It is not concerned with epidural analgesia for obstetrics, palliative care or management of persistent non-cancer pain.

4/9/18 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 named nurses requesting radiological examination for haematology and outlying patients at specialist clinics Bridgewater Suite, BCH

This policy aims to:

  • Set out recommended practice for the Myeloma/Lymphoma CNS’srequesting chest x-rays, abdominal x-rays and x-rays of areas of suspected bony disease for lymphoma and myeloma patients for follow up and review.
  • Standardise requests for radiological examination.
  • Ensure radiological investigations are requested by the practitioner assessing the patient.
  • Improve the service users experience in the Haematology Clinic.

Radiological examination is part of the review process for patients with lymphoma and myeloma. Therefore requesting x-rays is essential for the Myeloma and Lymphoma CNS’s to expedite the patient journey through the Haematology clinic. This will improve the patient experience through the review pathway.

4/9/18 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. 

Actions to be taken after a patient’s death in hospital

This policy provides the underlying principles, guidance and information required on the actions, care and support to be provided by BHSCT staff, following the death of a patient in hospital.

4/9/18 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. 

Quality Improvement & Audit Policy

The purpose of this policy is to provide guidance to ensure that there is a standardised approach to carrying out quality improvement and audit initiatives within the Belfast Trust. It will cover issues such as:

•         Approval

•         Registration

•         Support

•         Action.
4/9/18 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. 

Guidelines for Administration of Intravenous Iron (Ferric Carboxymaltose) for Major Elective Orthopaedic Surgery

This policy clarifies the use of intravenous iron in pre-assessment clinics for major elective orthopaedic surgery. This policy applies to all trust staff involved in the pre-assessment of patients for major elective orthopaedic surgery.

This policy enables medical and nursing staff working in pre-assessment clinics to meet "Better Blood Transfusion 3- Safe and appropriate Use of Blood" and the Department of Health document – "Delivering Enhanced Recovery guidelines". Both these documents state that anaemic patients must be adequately optimised prior to elective surgery. This document also outlines how trust staff will comply with the MHRA safety update on intravenous iron prescription and administration.
5/9/18 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.  

Acute Hypocalcaemia (for use in adult patients)

Acute hypocalcaemia can be life threatening, necessitating urgent treatment .

This guideline aims to take the non-specialist through the initial phase of assessment and management.

6/9/18 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. 

Nephrology Nurse Guidelines for HIV testing in renal patients

To guide registered nurses within Nephrology in how to consent renal patient for HIV testing and to ensure patients are adequately informed prior to consenting to HIV testing.

This guideline details the indications for HIV testing, areas to be covered in pre- test discussion, how to obtain consent, what to do in exceptional circumstances, the procedure for taking blood and procedure for obtaining results.

7/9/18 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. 

Flexible Retirement Policy

The objectives of flexible retirement are to:

  • Support our ageing workforce
  • Retain skills and expertise within the Trust
  • Give staff the opportunity to retire flexibly through a managed and phased approach in advance of their chosen date to exit the Trust.
12/9/18 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. 

Medicines Reconciliation Policy

The purpose of this policy is to define the process for completing medicines reconciliation with a patient by all relevant staff:

  • on admission to hospital
  • following transfer between wards
  • on discharge from hospital

This policy is designed to assist healthcare professionals in the process of Medicines Reconciliation. 

20/9/18 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. 

Disengagement of service users within adult mental health services and CAMHS

The procedure aims to provide staff with clear guidance to follow in the event that a Service User fails to engage/disengages with services/treatment and in order to comply with the recommendations of the Inquiry Panel (McCleery) to the Eastern Health and Social Care Board.

The procedure has been put in place to reinforce good practice when dealing with Service Users who fail to engage or disengage with services/treatment and to ensure consistency in practice across the service.

20/9/18 Screened out with mitigation Screened out with Mitigation

Adjudication of new medicines & treatments

Within Belfast Trust there will be situations where decisions are required to be made regarding the introduction of new medicines and treatments

The purpose of the policy is to establish a robust and transparent process for decision making regarding the use of new medicines within the BHSCT.

This policy covers the governance arrangements for the management of new medicines and treatments within Belfast Trust. This includes prescribing at out-patients and A&E.

26/9/18 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. 

Life Port Machine Policy

This policy will provide guidance on the use of the life port machine to all nursing and medical staff employed within Nephrology and Transplant and Belfast City Hospital theatres.

26/9/18 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. 

Lithium Policy

The purpose of this Policy is to implement various National and Regional guidelines into Trust Policy to ensure safe and effective prescribing and monitoring of lithium. 

Objectives of the policy include:

To ensure the Trust’s compliance with the mandatory requirements arising from the NPSA Alert (2009) and HSC (SQSD) 84-09 Safer Lithium Therapy concerning safe lithium prescribing, dispensing and monitoring.

To comply with the recommendations of the Lithium Shared Care Guideline and the Northern Ireland Care Pathway for lithium Initiation and monitoring. 
28/9/18 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. 

Prevention and Management of Inadvertent hypothermia in Adults having Surgery.

To provide Trust staff with guidelines for the prevention and management of inadvertent hypothermia in adults undergoing surgery in the Belfast Health and Social Care Trust (BHSCT), in line with NICE guidance CG65 (2016).

•         To provide a tool for identifying patients at risk of inadvertent hypothermia and guidance for managing their care appropriately and reduce risk of associated complications.

28/9/18 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.

Screenings April - June 2018.