Screening Outcome Report

11 July 2019 – 30 September 2019

Screening Outcome Report – 11 July – 30 September 2019

Introduction

Section 75 of the Northern Ireland Act 1998 requires the Trust, when carrying out its functions in relation to Northern Ireland, to have due regard to the need to promote equality of opportunity between nine categories of persons, namely:

 between persons of different religious belief, political opinion, racial group, age, marital status or sexual orientation;  between men and women generally;  between persons with a disability and persons without; and  between persons with dependants and persons without.

Without prejudice to its obligations above, the Trust must also have regard to the desirability of promoting good relations between persons of different religious belief, political opinion or racial group.

Belfast Trust’s Revised Equality Scheme was formally approved by the Equality Commission in September 2011. The revised Scheme outlines how we propose to fulfil our statutory duties under Section 75. Within the Scheme, the Trust gave a commitment to apply the screening methodology below to all new and revised policies and where necessary and appropriate to subject new policies to further equality impact assessment.

 What is the likely impact of equality of opportunity for those affected by this policy/proposal, for each of the Section 75 equality categories?  Are there opportunities to better promote equality of opportunity for people within Section 75 equality categories?  To what extent is the policy/proposal likely to impact on good relations between people of different religious belief, political opinion or racial group?  Are there opportunities to better promote good relations between people of different religious belief, political opinion or racial group?

In keeping with the Trust’s commitments in its Equality Scheme the Trust has applied the above screening criteria to new policies and proposals. Screening identifies policies that are likely to have an impact on equality of opportunity and or good relations.

Screening identifies the impact of the policy/proposal as major, minor or none. . If major – an Equality Impact Assessment may be carried out. . If minor – consider mitigation or alternative policy and screen out. . If none – screen out and give reasons. . Ongoing screening – for strategies/policies that are to be put in place through a series of stages – screen at various stages during implementation.

Screening Outcome Report – 11 July – 30 September 2019

Figure 1 provides a flowchart of how screening is conducted in Belfast Trust.

Screening Outcome Report – 11 July – 30 September 2019

Belfast Trust also committed within its Revised Equality Scheme to prepare and publish for information regular reports on its screening exercises. Belfast HSC Trust has provided detail on all screenings undertaken since 1 September 2011 when the Trust received Equality Commission approval for their revised Equality Scheme. To further promote openness and transparency, there is a link to each completed screening template on the Belfast Trust’s website. www.belfasttrust.hscni.net.

The quarterly screening report shall detail all policies screened over a three month period and includes decisions reached.

This screening report outlines the screening outcomes from 11 July – 30 September 2019.

Screening Outcome Report – 11 July – 30 September 2019

Communication and Engagement

Belfast Trust recognises the importance of stakeholder involvement – one of the 5 key strategic objectives that Belfast Trust devised at the outset was that of Partnership – we are committed to improving health and well-being through existing and new partnerships with a range of individuals, representative groups and voluntary and community organisations. The Trust is committed to providing people led services, drawing on the years of experience and listening to the needs and feedback that meaningful consultation can yield. There is a need to continue to effectively engage and work collaboratively with a wide range of stakeholders including Trust staff, Trade Unions, service users, carers, commissioners, primary care, public representatives and independent providers.

The Trust is committed to promoting personal and public involvement in all its activities. The development of new policies and proposals will be supported by effective engagement processes to ensure that staff, service users and all interested parties are fully involved. Planning for, and delivering safe, clinically effective and cost effective services requires close collaboration at many levels.

If you have any queries about this document, and its availability in alternative formats (including Braille, disk and audio cassette, and in minority languages to meet the needs of those who are not fluent in English) then please contact:

Orla Barron Equality Lead Belfast Health and Social Care Trust First Floor, Administration Building Knockbracken Healthcare Park Saintfield Road Belfast BT8 8BH

Telephone: 028 95046567 Textphone: 028 90637406 [email protected]

This report details each proposal and the screening outcome – for ease of reference, readers can access the full completed screening template via a link to the Trust website. Should you have concerns which are based on supporting evidence regarding the screening decision, please contact the Health and Social Inequalities Manager as above and outline your concern along with the supporting evidence. Belfast Trust will duly consider rescreening the proposal.

Screening Outcome Report – 11 July – 30 September 2019

Outcome of Screening

The screening outcomes are outlined below. Four possible outcomes are recorded:

1. The policy has been ‘screened in’ for equality impact assessment;

2. The policy has been „screened out’ with mitigation or an alternative policy proposed to be adopted;

3. The policy has been ‘screened out’ without mitigation or an alternative policy proposed to be adopted.

4. The policy will be subjected to ongoing screening. For more detailed strategies or policies that are to be put in place through a series of stages, screening should be considered at various times during implementation.

Screening Outcome Report – 11 July – 30 September 2019

Screening Reason for Reaching Description of Policy or Proposal Outcome Screening Outcome Belfast Health & Social Care Trust Policy on Lone Working Screened out as per Equality This policy is designed to provide Managers Commission’s guidance on and Staff with clear guidelines on their screening with no adverse responsibilities to recognise where staff may impact with regard to equality be lone workers and to ensure that staff are of opportunity and/or good aware of the risks associated with lone relations for people within the working and to manage the risk associated Screened equality and good relations with lone working activities. out categories.

Alert Notice Policy – (Review) Screened out as per Equality To have in place an Alert Notice system by Commission’s guidance on which a NHS Employer can make other NHS screening with no adverse Bodies aware and be made aware of a impact with regard to equality Healthcare Professional whose performance of opportunity and/or good and/or conduct could place Patients, Clients relations for people within the or Staff at risk. Screened equality and good relations out categories.

Guidelines for the Management of Chronic Kidney Disease (CKD) in Adults

The guidelines provide brief guidance on Screened out as per Equality investigation, monitoring and management of Commission’s guidance on chronic kidney disease (CKD) in adults. screening with no adverse impact with regard to equality The guidelines include: of opportunity and/or good relations for people within the Practical Points for Use of Estimated GFR Screened equality and good relations and Albuminuria (ACR) in Assessing CKD. out categories.

Guidance for the management of systemic anti-cancer treatment SACT hypersensitivity reactions

The policy provides guidance for those Screened out as per Equality treating patients with SACT. It outlines the Commission’s guidance on recognition and acute management of HR screening with no adverse associated with SACT. It also provides impact with regard to equality guidance for staff if patients take a of opportunity and/or good hypersensitivity reaction, and outlines what relations for people within the prophylactic measures may be taken to Screened equality and good relations reduce risk of further HR. out categories.

Screening Outcome Report – 11 July – 30 September 2019

Transfer of medically unwell patients from Withers Unit, Musgrave Park Hospital

This policy is required to clarify the process involved when transferring sick patients from MPH to another site. It refers to patients in the Orthopaedic Unit, Musgrave Park Hospital. It does not apply to other units on the MPH site such as inpatients in Meadowlands. This policy has 2 key objectives:

i) To ensure patient safety Screened out as per Equality ii) To ensure all transfers occur in Commission’s guidance on a timely manner screening with no adverse impact with regard to equality The policy will be communicated at induction of opportunity and/or good and during relevant transfers. The policy is to relations for people within the be disseminated to all the acute inpatient Screened equality and good relations services within Belfast Trust. out categories.

Management of accidental dural puncture during epidural insertion

This is policy has been updated in line with protocol.

This guideline’s purpose is to help anaesthetic, obstetric and midwifery staff who Screened out as per Equality manage a patient in labour following a dural Commission’s guidance on puncture. screening with no adverse impact with regard to equality The scope of this guideline will include of opportunity and/or good management points for clinical staff in relations for people within the delivery suite and the post-natal ward. Screened equality and good relations out categories.

Screening Outcome Report – 11 July – 30 September 2019

Dexmedetomidine premedication in children aged 1-18years, undergoing General Anaesthesia in the Belfast Health and Social Care Trust.

Purpose of policy:

• To provide an alternative anxiolytic for patients with a history of poor response or paradoxical reaction to midazolam.

• To provide guidance to staff in the BHSCT on safe prescribing and administration of dexmedetomidine as premedication.

This policy will apply to all anaesthetic and nursing staff in BHSCT using dexmedetomidine as a premedication for Screened out as per Equality anxious children aged 1- 18 years prior to Commission’s guidance on anaesthesia. screening with no adverse impact with regard to equality Initial use will be limited to Royal Belfast of opportunity and/or good Hospital for Sick Children (RBHSC), with relations for people within the outcomes audited within one year. Screened equality and good relations out categories.

Screening Outcome Report – 11 July – 30 September 2019

Operational Policy and Procedural Arrangements relating to Direct Payments

This policy aims to provide clear guidance to staff on the implementation of Direct Payments, for those Users and Carers assessed as being eligible for services.

The key objectives of the policy are:

o To enhance service user choice with regard to their care needs, allowing individuals more choice and control in determining how their assessed need is met and outcomes achieved o To promote the uptake of Direct Payments as an alternative to direct Screened out as per Equality service Commission’s guidance on provision for service users screening with no adverse o To ensure consistency in the use and impact with regard to equality application of Direct Payments. of opportunity and/or good o To provide clear guidance for all staff. relations for people within the To ensure correct documentation is Screened equality and good relations completed and protocols are followed. out categories.

Transfusion of Blood Components prescribed by a medical officer and administered by a qualified midwife/nurse to a baby in Regional Neonatal Unit RNU, Royal Jubilee Maternity Service RJMS.

Purpose: To identify and define safe practices for each step of the process in the administration of blood components to neonates according to national guidelines.

Screening Outcome Report – 11 July – 30 September 2019

Objectives: • To maintain optimum safety throughout the process. • To minimise the risks to babies/neonates and Screened out as per Equality practitioners involved in the transfusion Commission’s guidance on process. screening with no adverse impact with regard to equality Policy is required for all nurses and midwives of opportunity and/or good who check and administer blood components relations for people within the in babies/neonates in the neonatal intensive Screened equality and good relations care unit. out categories.

Exchange Transfusion Procedure for babies in the Regional Neonatal Unit. (RNU) Royal Jubilee Maternity Hospital (RJMS)

This policy has been revised in line with protocol.

Purpose: To provide clear guidance to medical, nursing and midwifery staff when performing an exchange transfusion to babies.

Objectives: Screened out as per Equality To reverse or counteract the symptoms of Commission’s guidance on jaundice, blood disorders or toxins. screening with no adverse Maintain optimum safety throughout the impact with regard to equality procedure. of opportunity and/or good To minimise the risks and the potential relations for people within the complications to the baby. Screened equality and good relations out categories.

Management of Medical Scales

This policy aims to standardise best practice Screened out as per Equality and is applicable to any staff member who Commission’s guidance on uses medical scales. screening with no adverse impact with regard to equality This policy applies to all medical scales used of opportunity and/or good in conjunction with patients under the care of relations for people within the the Trust including community and patient Screened equality and good relations home environments. out categories.

Screening Outcome Report – 11 July – 30 September 2019

Caring for and safeguarding children and young people who attend adult services for admission, care or treatment

Specific aims and outcomes of the policy include:  To provide a framework which guides staff in the decision making process regarding the safe care of a child or young person whilst they receive services in an adult setting.  To ensure the child or young person’s needs are paramount and central to decisions about admission and management.  To enable staff to recognise and respond appropriately to the child’s and young person’s needs.  To inform and reassure families of the process by which decisions are considered, made and reviewed.  To ensure staff are aware of how to appropriately raise concerns of risk Screened of harm toward children and young out with people. mitigation Screened out with mitigation

20 week anomaly scan protocols

Objectives To ensure that all staff are working under one set of protocols, thus ensuring all 20 week anomaly scans are carried out at the optimum level and that the growth and structural wellbeing of the fetus is carefully Screened out as per Equality examined. The policy states which fetal Commission’s guidance on structures that must be identified as part of a screening with no adverse 20 week scan. The action to be taken in the impact with regard to equality event of a suspicious or definite abnormality of opportunity and/or good is also described. The policy relating to fetal relations for people within the measurements for dates and baseline growth Screened equality and good relations are also covered. out categories.

Screening Outcome Report – 11 July – 30 September 2019

Medicines Procurement and Purchasing Screened out as per Equality for Safety Policy Commission’s guidance on screening with no adverse Safe and cost effective procurement in line impact with regard to equality with legislation, policy and best practice. of opportunity and/or good relations for people within the Screened equality and good relations out categories.

Effective communication and handover using SBAR within maternity services

Policy Objectives: - To embed the SBAR tool in practice as a systematic and effective model of communication and handover of care within the maternity service.

- To provide a guide to the multidisciplinary team of professionals caring for women within the maternity service on effective communication and handover

- Increase focus on patient safety when communicating information and handing Screened over care by improving situational out with awareness and conveyance of vital policy Screened out with policy information amendment amendment.

Reopening of ten houses at Abbey Gardens by Belfast Trust for patients resettling from Muckamore Abbey Hospital (MAH) to Cherry Hill

Belfast Trust proposes to re-open 10 houses that it owns in Abbey Gardens (Numbers 1,2,7,8,9,10,11,12,13 and 14) to facilitate the resettlement of service users currently in MAH. Abbey Gardens is located approximately 420 yards from MAH.

Screening Outcome Report – 11 July – 30 September 2019

It is hoped that residents will have started to move into their new homes by June 2019. The process however will be phased and managed to allow the new residents to become accustomised to their new homes and new way of living. The aim of the proposal is to resettle nine service users from MAH to Abbey Gardens (Cherry Hill). Living in the community (resettlement) will be facilitated through a Supported Living model of care. The model means that a person lives independently in the local community with appropriate high quality social care support. Screened The Trust intends to use the tenth house as out with Staff Office Accommodation. mitigation Screened out with mitigation

Management of Lower Bowel Dysfunction, including Digital Rectal Examination (DRE) and Digital Rectal Removal of Faeces (DRF) in Adult Patients

 To guide and support healthcare professionals in the appropriate assessment and management of patients with bowel disorders and who require DRE/DRF.  To ensure that the patient who requires DRE/DRF receives appropriate bowel management in a safe and dignified manner. Screened out as per Equality  To ensure that the procedure is Commission’s guidance on performed by healthcare screening with no adverse professionals competent in the impact with regard to equality performance of DRE/DRF. of opportunity and/or good  To ensure safety of patients and relations for people within the staff through appropriate risk Screened equality and good relations assessment. out categories.

Screening Outcome Report – 11 July – 30 September 2019

Patients’ Finances and Private Property Policy for Adult Inpatients within Mental Health and Learning Disability Hospitals

The policy aims to:

 Establish clear guidance for staff in relation to the handling of patients’ finances and private property;  Protect patients from financial mistreatment and abuse  Protect patients financial interests  Provide direction and support to staff when managing patients finances.  Ensure there is good governance of financial management arrangements.  Ensure that the requirements relating to patients finances under the Mental Health (N.I.) Order 1986 Screened are met out with mitigation Screened out with mitigation

Levels of Supervision/Observations within Learning Disability Inpatient Services Policy

The policy aims to provide staff working within a Learning Disability inpatient facility with a structured and standardised framework for delivering care to patients across inpatient facilities within the Trust. This will ensure a consistent approach in defining appropriate levels of supervision and observation of patients. It also provides a framework of regarding the levels of supervision/observation and the decision making process to implement or adjust same. The policy is aimed at promoting and maintaining a caring and safe environmental Screened for patients admitted into any Learning out with Disability inpatient facilities in Belfast Trust. mitigation Screened out with mitigation

Screening Outcome Report – 11 July – 30 September 2019

Policy for HSC patients who wish to pay for additional treatment Oncology & Haematology services at BCH site

The intended aims of the policy are to: 1. Facilitate an effective process for the management of Oncology and Haematology patients who wish to pay for additional treatment 2. Support staff by making them fully aware of their roles/responsibilities in relation to the policy

The objectives of this policy are to:

Ensure that HSC principles are upheld, namely: - that the HSC provides a comprehensive service, available to all - that access to HSC services is based on clinical need, not ability to pay

Safeguard against: - the HSC subsidising private care with public funding - patients being charged for their publicly funded care

This policy is applicable to any HSC adult Screened oncology or haematology patient who wishes out with to pay for additional treatment. mitigation Screened out with mitigation

Management of the third stage of labour following vaginal birth. Guideline for Obstetricians and Midwives.

The purpose of this policy is to ensure the management of third stage of labour is in keeping with best practice. This policy will be widely circulated amongst; Labour Ward Forum, Midwifery and Nursing Forum, Adverse Labour Event Review Team Screened (ALERT), Supervisors of Midwives and all out with key workers within BHSCT Maternity and Policy Screened out with Policy Neonatal Service. amendment amendment.

Screening Outcome Report – 11 July – 30 September 2019

Protocol For The Recruitment And Employment Of Staff Under The Requirements Of The Safeguarding Vulnerable Groups.

Protocol outlines key responsibilities of the BHSCT in relation to the implementation arrangements of the SVGO 2007 (as amended by the Protection of Freedoms Act 2012) as it relates to all permanent, temporary, locum and agency staff, volunteers, students on placement and those Screened out as per Equality staff engaged under external contract as sub- Commission’s guidance on contractors. screening with no adverse impact with regard to equality The revised Protocol will be communicated of opportunity and/or good across the Trust. There will be no changes in relations for people within the working patterns or changes to how services Screened equality and good relations will be delivered. out categories.

Broviac Central Venous Catheter (CVC): Accessing and flushing for administration of medications or IV fluids, and heparin or antibiotic locking by nurses and midwives.

Purpose To ensure best evidence based care in relation to management of a Broviac CVC.

Objectives  To prevent infection  To maintain a patent line  To minimise possible complications

To prevent damage to the device. Screened out as per Equality This policy applies to all nurses, midwives, Commission’s guidance on nursery nurses and health care assistants screening with no adverse working in the RNU, RJMS are personally impact with regard to equality responsible for being aware of infection of opportunity and/or good control policies and procedures. This relations for people within the Guideline will be widely circulated amongst Screened equality and good relations all key workers. out categories.

Screening Outcome Report – 11 July – 30 September 2019

Memorandum of understanding (MoU) between Beaumont Hospital/Dublin (BH) and Belfast Health and Social Care Trust (BHSCT) and the Health Service Executive (HSE – funding only) for the provision of living donor exchange kidney transplant service (plus data sharing agreement).

Aims and Objectives: The MoU aims to ensure that the required key elements, commitments and responsibilities of all parties are defined and in place so as to ensure the provision of an exchange kidney transplantation service in the Belfast City Hospital in accordance with best practice and the relevant EU Directives and Regulations. The data sharing agreement (approved by the BHSCT Information Governance Manager) aims to ensure the secure, correct and lawful Screened processing of the shared data agreed to by out with the parties. mitigation Screened out with mitigation

Guidance for Medicines (SAM) Scheme in Chestnut Grove

This guidance has been developed to support the NI Medicines Optimisation Quality Framework Quality Standards for Medicines which specifies … ‘people are helped to remain independent and self-manage their medicines where possible’

The main purpose of SAM is to allow clients in Chestnut Grove to:  Be as independent as possible  Participate in their own care thereby increasing their responsibility and autonomy  Make decisions about their treatment in partnership with their Carer, Medical & Community Rebab Staff (CRS) and Pharmacy Staff.

Screening Outcome Report – 11 July – 30 September 2019

 Improve their understanding of what their medicines are for and how to use Screened out as per Equality them appropriately Commission’s guidance on  Identify and resolve medicines-related screening with no adverse problems with the support of impact with regard to equality healthcare staff of opportunity and/or good  Improve trust between themselves and relations for people within the healthcare staff. Screened equality and good relations out categories.

Partial Exchange Transfusion for Polycythaemia in babies in the Regional Neonatal Unit (RNU) Royal Jubilee Maternity Hospital (RJMS)

Purpose: To provide clear guidance to medical, nursing and midwifery staff when performing a partial exchange transfusion. Objectives:

 To reduce potential complications of polycythaemia and hyperviscosity. Screened out as per Equality  To maintain optimum safety of Commission’s guidance on the infant throughout the screening with no adverse procedure. impact with regard to equality  To minimise the risks and the of opportunity and/or good potential complications to the relations for people within the baby. Screened equality and good relations out categories.

Screening Outcome Report – 11 July – 30 September 2019

Management of breast cancer patients on self directed aftercare pathway

The policy is intended to outline the guidelines used to manage patients with breast cancer who have been put on to a self-directed aftercare (SDA) pathway. The self-directed aftercare pathway offers eligible patients supported self-management with open access back to breast care services if needed. SDA is offered to patients with curative intent based on the key criteria of the patient’s ability to self-manage. This is intended to improve patients after treatment experience and provide patients with better education and information on how to self- manage and with rapid access for review if Screened needed. It is also intended to reduce out with inefficiencies in hospital follow up. mitigation Screened out with mitigation

BHSCT Adult Safeguarding Policy & Procedures 2019

This policy is guidance for staff in relation to the Trust Adult Safeguarding Policy. The Policy has been revised and extended to reflect the new Regional Policy which considers safeguarding responsibilities as a continuum from prevention through to Screened protection as opposed to simply protection. out with mitigation Screened out with mitigation

Screening Outcome Report – 11 July – 30 September 2019

Guideline for the treatment of Torus (Buckle) Fractures of the wrist with removable splints in children over 2 years old.

Purpose: To provide a guideline for the management of torus / buckle fractures of the distal radius and ulna with removable splints in children aged 2 – 14 years of age in the Belfast Trust. Objectives:  To improve the management of distal radius and ulna torus / buckle fractures in line with new evidence.  To improve the functional outcome of buckle / torus fractures of the Screened out as per Equality wrist in children. Commission’s guidance on  To reduce the cost of treatment of screening with no adverse buckle / torus fractures. impact with regard to equality  To reduce unnecessary fracture of opportunity and/or good clinic appointments. relations for people within the To improve parent / patient satisfaction in Screened equality and good relations their management. out categories.

Regional Transformation Proposal 2018/19: Enhancement to Home Based Intermediate Care

This proposal is about an enhancement to a therapeutic frontline home based intermediate care team, responding rapidly and with a focus on recovery, independence and patient experience. Fundamentally the service will need to meet the aims of intermediate care as defined in the NAIC 2017 definitions (and reflected in Circular HSS (EPCC) 2/2007 – Intermediate care https://www.health- ni.gov.uk/sites/default/files/publications/dhssp s/ec-intermediate-care-circular-final.pdf )

Screened out with mitigation Screened out with mitigation

Screening Outcome Report – 11 July – 30 September 2019

Neurosciences Blood Patch Protocol

This guideline is to ensure good practice in the management of patients within Neurosciences Department who require an epidural blood patch. This includes:

1. Recognising that inadvertent dural puncture has occurred

2. Patient information and follow up

3. Treatment of dural puncture headache

This protocol is to support Medical Staff and Screened out as per Equality patients regarding the procedure. It will be Commission’s guidance on given to medical staff on commencement of screening with no adverse post and given to patients who will be impact with regard to equality receiving treatment. of opportunity and/or good relations for people within the There will be no impact on work patterns or Screened equality and good relations service delivery. out categories.

Re-organisation of BHSCT RMPS Radiation Protection and Radiological Sciences & Imaging services

This proposal relates to the re-configuration of the delivery of BHSCT Radiation Protection (RPS) and Radiological Sciences & Imaging (RSI) services, located on the Forster Green Hospital (FGH) site. These services are primality concerned with the use of ionising and non-ionising radiations within the HSC sector.

The main element of the proposal is Screened concerned with the re-organisation/merger of out with BHSCT RMPS RSI and RP Services. mitigation Screened out with mitigation

Screening Outcome Report – 11 July – 30 September 2019

Protocol for post procedural antiplatelet therapy in endovascular interventions in peripheral arterial disease (DB 1069)

The purpose of this policy is to provide clarity regarding the prescription of antiplatelet therapy post endovascular interventions in patients with peripheral arterial disease (PAD). It applies to all PAD patients treated in Belfast HSCT. The policy provides relevant prescribing advice for; Vascular Surgeons, Radiologists, Junior Doctors, Screened out as per Equality Nurses and Pharmacists. Commission’s guidance on screening with no adverse Objectives: To reduce the risk of ischaemic impact with regard to equality events post infrainguinal endovascular of opportunity and/or good interventions and to reduce the risk of relations for people within the bleeding events post infrainguinal Screened equality and good relations endovascular interventions. out categories.

Medicines Code Policy

Purpose:

The Medicines Code defines the policies and procedures to be followed within BHSCT for prescribing, administering, dispensing, monitoring, ordering, storage and transport of medicines and staff roles and responsibilities in relation to them. It also describes acceptable standards for all aspects of Screened out as per Equality medicines management for hospital sites in Commission’s guidance on BHSCT. screening with no adverse impact with regard to equality Objective: of opportunity and/or good relations for people within the To describe the requirements for the safe and Screened equality and good relations secure handling of medicines in BHSCT. out categories.

Screening Outcome Report – 11 July – 30 September 2019

Belfast Trust Kardex with New Screened out as per Equality Antithrombotic Page Commission’s guidance on screening with no adverse New medicines Kardex with added impact with regard to equality antithrombotic page. Aim is to reduce of opportunity and/or good prescribing errors with antithrombotic agents. relations for people within the Will be communicated to staff via hub and Screened equality and good relations live training sessions. out categories.

Guideline for bathing a baby in the Regional Neonatal Unit (RNU), Royal Jubilee Maternity Service (RJMS)

Purpose To provide a policy and clear guidelines to nurses, midwives, nursery nurses and auxiliary staff on bathing a baby in the RNU, RJMS Screened out as per Equality Commission’s guidance on Objectives screening with no adverse To ensure clear guidelines are in place impact with regard to equality should a baby require to be bathed in the of opportunity and/or good RNU. This procedure has been revised in line relations for people within the with new guidance. Screened equality and good relations out categories.

Policy for the choice, care and cleaning of toys in the Royal Belfast Hospital for Sick Children.

This policy highlights the key issues which must be considered in the choice and care of toys and clarifies the regimen which must be adhered to in relation to effective cleaning.

The key purposes of the policy are as follows:

 To ensure children are kept safe from Screened out as per Equality harm. Commission’s guidance on  To ensure that all staff working in areas screening with no adverse where toys are kept for public use or who impact with regard to equality use toys in their day to day work are of opportunity and/or good aware of the correct procedures for their relations for people within the selection, handling and cleaning to Screened equality and good relations minimise risk. out categories.

Screening Outcome Report – 11 July – 30 September 2019

Verification of Death in Community Adults

This policy has been reviewed in line with new Department of Health departmental guidance surrounding death (17 January 2019). Screened out as per Equality The main benefit of having a policy for Commission’s guidance on verifying of death is that when a patient dies screening with no adverse this is managed in a timely, sensitive and impact with regard to equality caring manner respecting the dignity of the of opportunity and/or good patient, relatives and carers. The timely relations for people within the removal of the remains is respectful to the Screened equality and good relations deceased and sensitive to others in the area. out categories.

Homechoice Claria TM peritoneal dialysis procedures

The purpose is to give clear guidelines on how to use Homechoice Claria TM dialysis machine and use the Claria machine to perform peritoneal dialysis.

The objectives are to ensure patient safety by ensuring all steps are taken as recommended by Baxter who produces the Claria TM Screened out as per Equality machine. Commission’s guidance on screening with no adverse This revised policy has been updated in line impact with regard to equality with new guidance and the changes are of opportunity and/or good highlighted and include the updated setup of relations for people within the the Homechoice Claria machine and Screened equality and good relations inclusion of the Physioneal APD bag usage. out categories.

Screening Outcome Report – 11 July – 30 September 2019

Fasting for Adults and Children Undergoing Elective or Emergency Procedures

Purpose: To provide evidence based guidelines for the management of pre- operative fasting before general anaesthesia or intravenous sedation. Objectives: - To promote implementation of standardised fasting guidance for adults and children who are to undergo surgical or other procedures under general or regional anaesthesia or intravenous sedation, in keeping with an international evidence base.

- To avoid unnecessary prolonged fasting and nutritional deprivation of patients prior to and following surgical or other procedures.

- To provide standardised fasting recommendations for patients scheduled for elective procedures, whether they are of low or high risk of aspiration of gastric contents.

- To facilitate identification of patients Screened out as per Equality with an increased risk of aspiration of Commission’s guidance on gastric contents. screening with no adverse impact with regard to equality - To recommend alternative measures of opportunity and/or good to minimise the risk of perioperative relations for people within the aspiration pneumonitis in patients Screened equality and good relations undergoing emergency procedures. out categories.

Screening Outcome Report – 11 July – 30 September 2019

Belfast HSCT Protocol for Investigating Healthcare Acquired Pressure Ulcers (HAPU)

This policy outlines the responsibilities of staff regarding the prevention and management of pressure damage. It applies to all patient groups including infants, children, young people and adults.

Objectives  To ensure early identification of Screened out as per Equality patients ‘at risk’ of developing pressure Commission’s guidance on damage screening with no adverse  To guide staff in the provision of safe, impact with regard to equality standardised, evidence based of opportunity and/or good pressure ulcer preventive care and relations for people within the management. Screened equality and good relations out categories.

Out of hours care for patients with congenital bleeding disorders under the care of the Royal Belfast Hospital for Sick Children

This policy is to ensure a consistent approach for the safe management of patient’s 0- 16years in Northern Ireland with haemophilia The Trust has decided to and related conditions and gives guidance for subject this proposal to their safe and timely assessment and ongoing screening to ensure treatment. that the impact is not more adverse than originally The objectives of this guideline are to anticipated and that the improve and maintain standards of clinical mitigation is appropriate to practice and quality of care service users Ongoing minimise any negative receive. screening impact.