Equality and Human Rights Screening

 This report includes published screenings from January - March 2019.

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

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Policy & Screening Document /Policy Description

Date

Screening Outcome

Reason for Outcome

Management of unlicensed Cannabis based products for medicinal use

The policy describes the standard operating procedures for the use of unlicensed cannabis-based products for medicinal use including, prescribing, and procurement responsibilities.

3/1/19 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. 

Operational Policy for Crisis Assessment & Intervention Team  (CAIT)

This policy should be read in conjunction with all other policies and procedures that guide staff within CAMHS services. Both national and local guidelines have influenced the development of this staff guidance.

The aim of this policy is to provide guidance to staff regarding the core business of the Crisis Intervention & Assessment Team (CAIT) who are managed by Belfast Trust Child & Adolescent Mental Health Service (CAMHS). The CAIT service covers both Belfast Trust and South Eastern Trust.

8/1/19

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.

Developing and Maintaining Patient Group Directions

This policy aims to address legislative and best practice requirements in the development of a Patient Group Direction PGD and ensure:

A consistent trust-wide approach in review and update of PGDs in use within the Trust

Clear lines of governance, reporting arrangements and accountability within the Trust.

9/1/19

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 Guidance on management of patients presenting with Flu or Flu-like illness during the 2018/19 Flu Season

Policy about managing Flu or Flu like illness in patients in the BHSCT. Based on national guidance which is updated yearly. Policy provides information on treatment and prophylaxis of patients in relation to Flu and provides information on the infection prevention and control precautions/management.

9/1/19

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. 

Specialist Restricted Antimicrobial BHSCT Policy

This policy will standardise the access to restricted specialist antimicrobials across the BHSCT.

This policy will document the processes required for obtaining specialist antimicrobials in the Belfast Trust. This system will reduce inappropriate use of antimicrobials and ensure parity to access across the sites.

17/1/19

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 taking of a venous blood sample, from a baby, by midwives/ neonatal nurses in the Regional Neonatal Unit (RNU) Royal Jubilee Maternity Service (RJMS)

Purpose:-

To provide clear guidance for nurses and midwives involved in the taking of venous blood samples from neonates.

17/1/19

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. 

Radiation Safety Policy

Within the BHSCT sources of ionising and non-ionizing radiation are used for patient treatments, diagnostics tests, research studies, communication and a variety of associated activities. The Trust has a duty to provide a systematic radiological protection programme that restricts so far as reasonably practicable the extent to which staff and members of the public are exposure to radiation. The Radiation Protection Policy clearly defines the responsibility, authority and accountability for each component of the radiation protection programme within the Trust. The aim of the policy is to ensure the Trust complies with all legislation approved codes and guidance pertaining to the use of ionising and non-ionising radiation.

17/1/19

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 Entitlement of non-medical staff to refer for medical ionising radiation examinations

Registered nurses and AHPs are working in extended roles and are key providers of healthcare across all settings. This policy informs practice within the Belfast Trust which gives Entitlement to non-medical healthcare staff, within the Trust, to refer for x-ray. The policy will provide advice and good practice recommendations for non-medical staff applying for entitlement and will ensure good governance practices by regulating the process and through record keeping. Emphasis will be placed on the Ionising Radiation (Medical Exposures) Regulations 2018 (IR(ME)R 2018) to ensure the protection of individuals undergoing medical exposures involving ionising radiations, including requirements regarding requests for ionising examinations. The IR(ME)R NI 2018 does not include the use of ultrasound or MRI but the same practice model can be applied across all imaging modalities.

17/1/19

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. 

Volunteer Recruitment & Selection Policy

The purpose of this policy is to provide guidance to volunteer managers, co-ordinators and other staff involved in the recruitment and selection of volunteers

This policy sets out the BHSCT values for volunteer involvement and highlights the need for procedures for managing volunteers, based on principles of equality and diversity. The recruitment and selection policy supports these principles.

22/1/19

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.

Extended list of abbreviations for haematology and bone marrow transplant within BCH.

To enable medical and nursing staff working within Haematology and Bone Marrow Transplantation to work within Trust Policy when using abbreviations. 

To provide clear and appropriate guidelines to medical and nursing staff working in Haematology and Bone Marrow Transplant.

24/1/19

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. 

Review of Mullan Mews Supported Housing Model

There is an identified urgency to take action to address the increasing void situation in Mullan Mews to secure the future of the shared household model. The preferred option would be Option 2 in the first instance.

Option 2 identifies the advantages to support the change to a stepped care model for people with dementia, which could be implemented with minimum disruption to the current tenants and staff. Option 2 could be implemented and reviewed with subsequent consideration of Option 3 should outcomes from implementation prove unsuccessful in attracting new tenancies.

25/1/19

Screened out with mitigation

Screened out with mitigation.

Testing for Chlamydia and Gonorrhoea in Community S&RH Clinics.

To standardise procedures to be carried out for patients attending community S&RH clinics run by BHSCT for Chlamydia and Gonorrhoea testing including criteria for testing and management of results to ensure patients are seen in an appropriate setting for best care and in keeping with BASHH guidelines in primary care situations.

30/1/19

Screened out with mitigation

Screened out with mitigation.

Child Protection Operational Guidelines for Nurses working in Community Child Health

These guidelines merge the Legacy Trusts operational guidelines in an effort to provide staff with a consistent trust-wide approach. The objectives of this document are to ensure that nursing staff within Community Child health promote:

-  the welfare of the child
-  high standards of practice
-  effective multi-disciplinary/multi-agency working and communication

-  the principles outlined within “Co-operating to Safeguard Children” (August 2017)

30/1/19

Screened out with mitigation

Screened out with mitigation.

Writing & Approval of Trust documents

This policy outlines the desired structure of a policy or guideline document in the Belfast Health and Social Care Trust (BHSCT).  It also outlines the approval processes to be followed and contact details for key committees.

The policy explicitly refers to the need to equality screen all policies and reminds policy authors of the need to make reasonable adjustments.  In addition, as per the approval protocol a policy will only be approved it has been equality screened.

6/2/19

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. 

Nurse-Led Follow-up of Patients with Testicular Cancer

This policy provides a framework within which the Testicular Clinical Nurse Specialist may review patients on follow-up following treatment for testicular cancer.

8/2/19

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. 

Registration Policy

The aim of this Policy is to ensure that all Health Care Professionals and those occupying all Professional Social Work / Social Care posts within the Belfast Health and Social Care Trust (BHSCT) have live and valid registration and revalidation (where relevant) with the appropriate regulatory body where this is a statutory requirement to practice in the relevant profession.

13/2/19

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. 

Injectable Medicines Guide Policy

This policy endorses the use of the NI (adult)and Belfast H&SC (paediatric) Injectable Medicines Guides within Belfast Trust.

The aim of the NI(adult) and Belfast H&SC (paediatric) Injectable   Medicines   Guides  was to ensure   that   essential   technical information on injectable medicines is available and accessible to healthcare staff in clinical areas at the point of use as recommended by the National Patient Safety Agency (NPSA).

13/2/19

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. 

Therapeutic Plasma Exchange (TPE) within the Nephrology & Transplant Service – The administration of

Objective:

To ensure that TPE is performed safely and effectively within the Nephrology and Transplant.

To ensure that the TPE performance is evidence based.

This policy applies to all registered nurses who provide TPE treatment within Nephrology and Transplant Services. They will complete the training and ensure competence is maintained and keep written documentation of training.

21/2/19

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. 

Intramuscular and Subcutaneous Diamorphine for Analgesia in Labour

This document provides guidance on the provision and administration of intramuscular or subcutaneous diamorphine by midwives in Royal Jubilee Maternity Hospital Belfast.

It outlines indications, recommended dosage, preparation and administration of the drug, along with the standards of monitoring required.

Objectives

• To support intramuscular and subcutaneous diamorphine as an analgesic for pain relief in labour

• To outline the indications and contraindications

• To recommend the dosage, preparation and administration of the drug

• To define standards of monitoring required

• To promote relevant staff training

• To outline actions to be taken in the event of diamorphine induced CNS or respiratory depression.

22/2/19

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 use of a hairdryer in Stoma Care.

To provide guidelines for nursing staff when using a hairdryer in stoma management. This specific guidance aims to reduce risks involved in the use of a hairdryer in a hospital setting.

This policy will apply to all nursing staff who may be caring for an adult patient with a stoma within the Belfast Trust; and for all patients requiring management of severely excoriated peristomal skin.

22/2/19

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 Supply of discharge medication from wards when Pharmacy is closed

This policy has been revised to provide a procedure for the supply of discharge medications when all pharmacy departments are closed to ensure a consistent approach by all Belfast Trust in-patients sites. 

The policy ensures that patients receive the correct medicines and information at discharge and incorporates a Standard Operating Procedure for revised procedure detailed above.

22/2/19

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. 

Supply of Take-Home medication from Emergency Departments

This is a review of the existing policy in line with guidelines.

This policy provides guidance to healthcare professionals on the supply of take-home medication from Emergency Departments and the wider Emergency Care Village.

22/2/19

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 Post Infection Review of MRSA bacteraemia, Clostridium difficile clusters and where MRSA or Clostridium difficile is listed on Part 1 of a patient’s death certificate

This is a revision of an existing policy which was titled ‘RCA for Healthcare Associated Infection’. The policy has been revised in line with guidelines and to include a robust ‘Post Infection Review Data Collection Tool for Clostridium Difficile Infection’.

26/2/19

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. 

Newborn Bloodspot Screening Guidelines for Health Visitors

The guidelines are intended for use by all Health Visiting staff within the Belfast Trust.

Purpose of policy is to set out the responsibilities of Health Visitors in relation to the delivery of the bloodspot screening programme in the Belfast Health and Social Care Trust (BHSCT). 

Health visitors are responsible for ensuring that screening is completed, for providing results of the bloodspot screening tests by the 6-8 week assessment and for inserting duplicate copies of laboratory results in the Personal Child Health Record (PCHR).

26/2/19

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 Unidentified Patients Reference No: SG021/08

This policy outlines the principles staff should follow to provide an Emergency Identification System for situations where it is not possible to confirm the identity of patients in order to:

Provide robust and unique identification for patients of unknown or uncertain identity

Ensure investigations, blood samples, other clinical specimens and medications and blood components meet the minimum labeling requirements

This policy outlines the correct mechanism for merging emergency alternative identifying information with the patient’s correct identification details when these are confirmed.

26/2/19

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 translation form National texture descriptors to international dysphagia diet standardised levels

One of the areas that required multidisciplinary work is the transition to new Care plans and the translation of the UK National texture descriptors on old care plans to the new IDDSI terminology.

This guideline aims to set out this process for within the multidisciplinary context.

Objectives

To give a clear process for multidisciplinary staff in the translation of the texture descriptors on current care plans to IDDSI Terminology

To support staff in the implementation of the Transition to new Care plans and the translation of the texture descriptors on old care plans to the new IDDSI terminology

To place this work within the Trust assurance framework.

26/2/19

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 Ref No: T  10 08

Aims/outcomes

To allow patients enough time to recuperate in privacy, have their meals free from interruption and to allow doctors, nurses and allied health professionals time to provide care and treatment for patients, and ensure confidentiality of ward rounds.

To clarify the visiting arrangements for staff which can then be communicated to patients and visitors.

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.

To assist in the environmental cleaning and assist in the reduction of hospital acquired infections.

6/3/19

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. 

A Zero Tolerance Approach To The Prevention And Management Of Aggression & Violence Towards Staff   In The Workplace

This Policy aims to ensure that the need to protect staff is properly balanced against the need to provide health and social care to individuals.

6/3/19

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. 

Child Contact Procedure for Shannon Clinic Regional Secure Unit

This procedure seeks to promote the development of such relationships while at the same time safeguarding the interests of children in cases or situations where there may be concerns.  It sets out the circumstances for all contact between children and patients in Shannon Clinic.

11/3/19

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.

Clozapine Policy

The purpose of this policy is to implement a system for prescribing, monitoring and communication of the physical and mental health of patients prescribed clozapine.

The main objective is to ensure a safe system for the treatment of patients with clozapine. 

21/3/19

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. 

Decontamination of endoscopes and specialist probes

Decontamination of endoscopes and TOE and specialist probes updated to reflect updated guidance HTM 01-6 and best practice.

27/3/19

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

Screenings July - September 2018.

Screenings October - December 2018 .