Screening Outcome Report
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Screening Outcome Report 1 April 2020 – 30 June 2020
Transcript of Screening Outcome Report
Screening Outcome Report
1 April 2020 – 30 June 2020
Screening Outcome Report – 1 April – 30 June 2020
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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.
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Figure 1 provides a flowchart of how screening is conducted in Belfast Trust.
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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 1 April – 30 June 2020.
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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.
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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.
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Description of Policy or Proposal Screening Outcome
3/4/20 The intimate care, examination & chaperoning policy This policy sets out guidance for the use of chaperones and procedures that should be in place for consultations, examinations, investigations and clinical interventions that are considered to be intimate.
To produce a co-ordinated approach to the use of chaperones during consultations, examinations and procedures carried out within the Trust.
To ensure that patients’ safety, privacy and dignity is protected during intimate examinations or procedures and delivery of intimate clinical care interventions.
To ensure the HCP’s interests whilst carrying out intimate clinical examinations and clinical care interventions.
To recognise that the BHSCT policy for obtaining consent for examination, treatment or care in adults and children must be adhered to at all times
Screened out with mitigation – ongoing
6/4/20 Controlled Drugs – Use of Automated Dispensing Cabinets in Clinical Areas Purpose: The purpose of this policy is to ensure the safe and effective use and management of controlled drugs when using automated dispensing cabinets within BHSCT. Objectives: Controlled drugs – automated dispensing cabinets (CD-ADC) are used, and managed safely and securely whilst ensuring patients have timely access to the controlled drugs prescribed for them. All staff involved in the use and operation of the CD ADC are aware of their roles and responsibilities in relation to the management of controlled drugs.
Screened out without mitigation as is clinical / technical in nature.
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7/4/20 Guidance for Continuous Subcutaneous Infusion (CSCI) without a McKinley syringe pump in the COVID-19 crisis (for adults in hospital) This guidance provides governance for an alternative method of administering subcutaneous medicines where McKinley T34 syringe drivers are not available.
Screened out without mitigation as is clinical / technical in nature.
9/4/20 Cataract Services Modernisation Proposal This Transformation Implementation Project hopes to achieve a more streamlined service to ensure patients’ needs are met within the required guidance and in conjunction with Regional objectives for the delivery of timely low risk cataract surgery. Benefits:
Delivering services on fewer hospital sites will increase the capacity of the health system and allow delivery of more procedures.
Some patients may have to travel a bit further for their day surgery but there will be significant reduction in the time spent waiting for that surgery
A more streamlined service will be achieved to ensure patients’ needs are met within the required guidance and in conjunction with Regional objectives for the delivery of timely low risk cataract surgery.
The vacated Mater Hospital Day Procedure Unit lists will enable Ophthalmology services to retain a stable surgical service for ophthalmology patients therefore reducing the risk of the cancellation of elective ophthalmology surgical lists on the RVH site.
Evidence shows that dedicated resources at elective care centres will provide a better experience for both patients and staff.
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The elective care centres will operate on separate sites from urgent and emergency hospital care – meaning they will not be competing for operating rooms and other resources, leading to fewer cancellations of operations.
Screened out with mitigation – ongoing.
16/4/20 Information Sharing Agreement between The Protective Disclosure Unit (PDU) and Central Referral Unit (CRU) of the Police Service of Northern Ireland and the Health & Social Care Board (on behalf of the 5 Health & Social Care Trusts, Children’s Services Directorate) The Policy was created to facilitate the sharing of information between the two named agencies, PSNI and HSCB, in relation to children, young people and their families in order to safeguard children. In order to safeguard children there are occasions when Health Trusts need to request and receive information from the PDU/CRU and this exchange also facilitates the prevention and detection of crime with the aim of reducing the contributing factors of risk to offending behaviour. This information exchange is between the PDU/CRU and the Health & Social Care Trusts, the information is not for on-ward disclosure. Police information is information that is required for a policing purpose. Policing purposes are defined as:
(a) Protecting life and property; (b) Preserving order; (c) Preventing the commission of offences; (d) Bringing offenders to justice; (e) Any duty or responsibility arising from common or statute law.
Screened out with mitigation – ongoing.
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22/4/20 Critical Care priority Medicines list during Covid19 pandemic In order to manage additional demand for medicines in critical care and anaesthesia during the on-going COVID-19 pandemic, the Royal College of Anaesthetists, Association of Anaesthetists, Faculty of Intensive Care Medicine, Intensive Care Society and UK Clinical Pharmacy Association have worked closely with the Chief Pharmaceutical Officer at NHS England to publish the following clinical guidance.
Screened out without mitigation as is clinical / technical in nature.
27/4/20 Clozapine and Covid 19 To provide advice on essential monitoring and maintain safety for patients taking clozapine during the COVID-19 Pandemic. Fever is a common symptom of COVID-19 infection and is also a possible indicator of clozapine induced neutropenia. This advice is needed to provide a framework for staff to follow regarding clozapine blood monitoring during the COVID-19 pandemic. It also offers advice on management of essential blood monitoring during periods of self-isolation due to actual or suspected COVID-19 and management advice for patients who develop complications as a result of COVID-19.
Screened out without mitigation as is clinical / technical in nature.
27/4/20 Lithium and Covid 19 To provide advice on essential monitoring of Lithium during the COVID-19 Pandemic. Objectives: To align monitoring during COVID-19 pandemic with NICE Guideline CG185. Patients taking Lithium for more than one year with no risk factors may have Lithium levels checked every 6 months along with other standard monitoring.
Screened out without mitigation as is clinical / technical in nature.
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6/5/20 Trust’s strategic response to outbreak of Covid 19 Pandemic To ensure we can effectively protect the safety of our patients and staff and cater to the ever-increasing pressures this virus is placing on health and social care, the Trust has prepared a surge plan to reconfigure our services and have already made arrangements to postpone all non-urgent elective appointments in order to free staff up for additional training. In parallel the regional workforce appeal and other associated workforce measures (e.g. volunteering, deployment of final year nursing and medical students, call for retired employees to return to service etc) will increase capacity within the Trust and across the wider HSC. The Trust has and is continuing to work closely with the Department of Health, the Health and Social Care Board, the Public Health Agency and with General Practitioners in Primary Care to deliver a robust and cohesive, integrated partnership approach to tackling the pressures of Covid 19.
Screened out with mitigation – ongoing.
7/5/20 Management of missed or delayed doses of Depot or Long Acting Injection Antipsychotics during Covid-19 pandemic Purpose This Advice is needed because during the COVID-19 pandemic it might not be possible to administer Long Acting Antipsychotic medication on the due date. This may be due to staff shortages or due to the patient self-isolating. Objective To provide practical suggestions for management of missed or delayed doses of long acting antipsychotic injections.
Screened out without mitigation as is clinical / technical in nature.
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18/5/20
Reducing the Use of Restrictive Interventions for Adult & Children’s Services
This policy:
Is intended to provide guidance for managers and staff in relation to the nature, circumstances and use of restrictive practice with individuals receiving health and social care within the Trust. Its aim is to help all involved act appropriately in a safe and compassionate manner to ensure effective response in potential or actual aggression with a focus on using the least restrictive option available. It sets out a framework of good practice, ensuring legal, ethical and professional issues have been considered.
Screened out with mitigation – ongoing.
20/5/20 CAMHS Absent without leave(AWOL) Procedure for Beechcroft Aims and objectives of this Policy
To provide staff with a standardised framework of
best practice to implement when it is determined that a patient is absent without leave from Beechcroft Inpatient Unit.
To support staff to identify when a patient should be regarded as absent without leave (AWOL)
Minimise the risks to young people and/or others including the risk of disruptions to their care and treatment.
Support staff in identifying the need for Police (PSNI) involvement in a timely and appropriate manner.
Establish a formal and robust reporting and monitoring procedure for AWOLS.
Ensure lessons learnt are appropriately communicated to inform practice.
To assist in the safe return of the patient to the inpatient unit.
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To comply with all the recommendations from the following: o The Report of the Inquiry Panel (McCleery)
to the Eastern Health and Social Services Board 2006.
o The Report of the Inquiry Panel (McCartan) to the Eastern Health and Social Services Board 2007.
To be read in conjunction with: o The Mental Health (Northern Ireland) Order
1986 o Promoting Quality Care – Good Guidance on
the Assessment and Management of Risk, DHSSPSNI, May 2010
o Safeguarding Board for Northern Ireland (SBNI) Procedures Manual, May 2018
o Mental Capacity Act NI 2016 o Deprivation of Liberty Safeguards Code of
Practice : Draft April 2019 o The Human Rights Act, 1998
Screened out with mitigation – ongoing.
20/5/20 Procedure for the preparation and administration of a dinoprostone (prostaglandin E2) infusion and the care of a baby receiving this infusion in the Regional Neonatal Unit (RNU) Royal Jubilee Maternity Service (RJMS) and Royal Belfast Hospital For Sick Children (RBHSC) Purpose To provide clear and evidence based guidance for nursing and midwifery staff in the RNU, RJMS when preparing and administering a dinoprostone (prostaglandin E2) infusion and caring for a baby requiring this infusion. Objectives To ensure safe practice when preparing and administering a dinoprostone (prostaglandin E2) infusion to a baby in the RNU RJMS. To provide safe care for a baby receiving a dinoprostone (prostaglandin E2) infusion.
Screened out without mitigation as is clinical / technical in nature.
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21/5/20 Guidelines for discharge of a baby from the Regional Neonatal Unit (RNU) in Royal Jubilee Maternity Service (RJMS) Purpose To provide clear guidance for nursing and midwifery staff involved in the discharge of a baby from the RNU to the home environment.
Objectives To facilitate the safe discharge of a baby.
Screened out without mitigation as is clinical / technical in nature.
22/5/20 Establishment of a dedicated Clinical Service for People who have red cell disorders. Aims and Objectives The configuration of red cell disorder clinical services in England can be classified as a “Hub and Spoke” arrangement with some NHS Trusts acting as a “Specialist Haemoglobinopathy Centre (SHC)” providing specialist care to a large geographical area or a locality with a high-prevalence of individuals with red cell disorders. Trusts that serve a “low-prevalence” red cell disorder catchment area act as the “Spoke” providing routine assessment and review of individuals in their locality.
Screened out with mitigation – ongoing.
27/5/20 The Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) The key objectives of the policy are:
1. To raise awareness of the Trust’s statutory requirement to report incidents that fall within the reporting criteria for the RIDDOR Regulations.
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2. To inform staff of the processes for reporting such incidents to the enforcing authorities through the Health & Safety Department which forms part of the Risk & Governance Department, Occupational Health Service (OHS) and Estates.
3. To provide information and guidance to Managers to enable staff to identify RIDDOR reportable incidents.
Screened out without mitigation as is clinical / technical in nature.
28/5/20 Supporting Staff for Attendance at Coroner’s Court Objectives
This policy ensures that:
Staff will feel supported by the Trust when assisting in Coronial proceedings
Staff understand what is expected of them and can contribute effectively in relation to Coronial proceedings
Staff can prepare confidently for Court appearance
The Trust learns any relevant lessons from the proceedings
Staff feel supported by the Trust`s Coroners Services and the Directorate of Legal Services, Business Services Organisation (BSO) when assisting in any Trust related Coroner’s Court matter.
Staff feel supported by their Line Manager and Directorate Management when assisting in any Trust related Coroner’s Court matter.
Screened out with mitigation – ongoing.
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28/5/20 Supporting Staff for Attendance at Court Objectives
This policy ensures that staff:
will feel supported by the Trust when assisting in Court/Legal proceedings
understand what is expected of them and can contribute effectively in relation to Court/Legal proceedings
Staff can properly prepare for their Court appearance if required
Staff feel supported by the Trust`s Legal Services team, the Directorate of Legal Services and the Business Services Organisation (BSO) when assisting in any Trust related Civil Legal Court matter.
Staff feel supported by their Line Manager and Directorate Management when assisting in any Trust related Civil Legal Court matter.
Screened out with mitigation – ongoing.
1/6/20 Supporting Staff Involved in Incidents, Complaint, Claims and Coroner’s Inquests The aim of this policy is to set out the framework for the provision of support and advice to staff prior to, during and after their involvement in Incidents, Complaints, Claims and Inquests as required by:
Clarifying the availability of support for staff, in the event of them being involved in a traumatic or stressful incident, complaint, claim or investigation;
Identifying responsibilities for staff and managers in these circumstances;
Providing guidance for managers supporting staff in these situations;
Providing staff with details of how to access the support available regardless of the extent of their involvement.
Screened out without mitigation as is clinical / technical in nature.
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1/6/20 Adverse Incident Reporting and Management Policy This policy provides the framework for reporting and managing all adverse incidents which affect service users, staff and visitors to its premises or have an impact on the Belfast Health and Social Care Trust (BHSCT), its reputation or its legal duty of care. The policy has been revised to follow a regionally agreed template.
Screened out without mitigation as is clinical / technical in nature.
10/6/20 Massive Transfusion Policy Purpose: To provide all healthcare staff with guidance to ensure the provision of timely blood components and blood products to the patient and includes appropriate transfusion of blood components.
Screened out without mitigation as is clinical / technical in nature.
12/6/20 Waste & Recycling Policy Screening The purpose of this policy is to ensure that all staff are aware of the standards of good practice and the appropriate steps to take in the management of waste. It provides direction for the safe and cost effective management of all waste throughout the Trust. It gives clear information to all staff on their legal, ethical and organisational responsibilities.
Screened out without mitigation as is clinical / technical in nature.
12/6/20 Security Policy The purpose of this policy is to support the provision of high quality health and social care by providing a safe and secure environment that protects service users, staff and visitors and their property, and the physical assets of the Trust.
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The key objectives are: 1. To ensure the personal safety of patients,
service users, staff, visitors & others accessing Trust premises.
2. To protect Trust and personal property against theft or damage.
3. To create a safe atmosphere to support the uninterrupted delivery of health and social care.
4. To deter criminal activities by putting in place security control systems and other measures.
5. To detect and report those committing crimes on Trust property.
6. To raise awareness of security at all levels to reduce the risk of crime and to improve crime detection.
7. To ensure systems and protocols are in place to effectively respond to security issues and problems.
8. To undertake timely review of security measures to evaluate their effectiveness.
9. To liaise with the PSNI and the relevant agencies to achieve partnership working towards a safe and secure environment.
10. To ensure that security incidents are reported in compliance with the Trust’s incident reporting arrangements, to include the learning identified and actions taken to reduce the level of risks associated with the incident, to its lowest possible level.
Screened out without mitigation as is clinical / technical in nature.
2/6/20 BHSCT Covid-19 response: Rebuilding Plan: Stage 1 – 1st-30th June 2020 Whilst acknowledging that Covid-19 is still infecting people in our community, there is a clear downwards trend in the rolling average number of cases and deaths that are being reported which suggests that Northern Ireland has currently passed the first peak of the Covid-19 outbreak. Accordingly, the Department of Health has asked Trusts to publish plans on 1st June 2020 to implement the first stage of the recovery for non-Covid-19 HSC Services (for the period 1st – 30th June 2020).
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Plan Objectives Planning to deliver services over this short time period is in recognition that Covid-19 is likely to be with us for some time and that a second wave of the virus is also widely expected in the months ahead. Our plans therefore have adopted an incremental staged approach to ensure flexibility should we need to respond to a further surge in Covd-19 and to ensure learning given that the plans incorporate new ways of working and of delivering services. Stage 1 of our rebuilding plans for the month of June have been developed mindful of the objectives stated by the Department of Health (DoH) and mindful of the checklist provided by the DoH to support service planning and preparation – with the first referring to communication with the public.
Screened out with mitigation - ongoing
19/6/20 Thromboembolism and Anticoagulant Therapy during the Covid-19 pandemic: Interim clinical guidance This guidance document addresses key issues pertaining to prevention or treatment of thrombotic events in hospitalised patients with COVID-19 with the overarching purpose of striking a balance between risks and benefits of anticoagulation therapies.
Screened out without mitigation as is clinical / technical in nature.
23/6/20 Community Controlled Drugs Policy Screening Objectives: To set out the principles by which Controlled Drugs are stored, prescribed, supplied, recorded, administered, transported and destroyed in accordance with the Misuse of Drugs regulations. To clearly identify the responsibilities of BHSCT and BHSCT staff To ensure the patient receives the correct appropriate prescribed medication and that legal requirements surrounding controlled drugs are adhered to.
Screened out without mitigation as is clinical / technical in nature.
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25/6/20 Nursing & Midwifery Roster Management Policy This Roster Management Policy has been developed for use by all nursing and midwifery staff in ward, department and in community settings to ensure safe/appropriate staffing for all departments using fair and consistent rosters. This is an existing policy, which is being updated with minor changes; the updated policy will be shared with all service managers to be disseminated to all staff bound by the policy. This update will not change working patterns. Rosters should be fully approved by assistant service managers for publication to staff 4 weeks in advance of commencement. This will allow staff to have more time to arrange work life balance, childcare etc. All Rosters must be finalised for payment by the ward sister/charge nurse and in the case of the ward sister/charge nurse by the Assistant Service manager This change is to ensure financial compliance is adhered to therefore reducing risk of fraudulent activity, This action is no different that if a ward manager was completing paper timesheets and has no affect on staff.
Screened out without mitigation as is clinical / technical in nature.
29/6/20 Improving Traffic Management in Belfast Trust A reasonable and effective enforcement system is required to assist in keeping parking and traffic flow on site working properly. The Trust has looked to other Trusts throughout Northern Ireland to assess the success and impact of their enforcement systems. Three Trusts currently use a registered accredited operator to manage a Parking Charge Notice (PCN) system. Where an infringement has been seen to have taken place, a PCN is issued to the offending vehicle.
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A charge (generally around £40) would be applied and if the charge is not paid, the enforcement administrators obtain the vehicle’s registered keeper details and pursue them for payment which could result in court action. Where these systems operate they are supported by a rigorous appeals procedure which gives everyone issued with a ticket a right of appeal. The Belfast Trust is proposing to adopt a similar enforcement system initially at the Royal Group of Hospitals where there is the highest level of abuse and then rolled out to other Trust sites as necessary. This will be a pilot in the first instance to assess effectiveness and suitability.
Screened out with mitigation - ongoing.
