Note: 1) Proposals cannot be implemented until an Equality Screening or EQIA has been completed 2) This template should be completed in conjunction with the accompanying Guidance Notes 3) Completed Screening Templates are public documents and will be posted on the Trust’s website

Section 1: INFORMATION ABOUT THE POLICY/PROPOSAL (1.1) Name of the policy/proposal Belfast HSCT Protocol for Investigating Healthcare Acquired Pressure Ulcers (HAPU)

(1.2) Status of policy/proposal (please underline) New Existing Revised

(1.3) Department/Service Group:

(please underline)

Corporate Services Group

(Please specify)

Nursing and User

Experience

Un-scheduled and Acute

Care

Surgery & Specialist Services

Specialist Hospitals & Women’s

Health

Children’s Community

Services

Adult Social & Primary

Care

(1.4) Description of the policy including intended aims/outcomes

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 patients ‘at risk’ of developing pressure damage

To guide staff in the provision of safe, standardized, evidence based pressure ulcer preventive care and management.

(1.5) How will the policy/proposal be

implemented? This policy is a review of the previous Pressure Ulcer Prevention and Management Policy in line with guidance. There are no major amendments to the key policy statements. No barriers to implementation are perceived. Practitioners can access awareness training through Trust Pressure Ulcer Prevention

Equality, Good Relations and Human Rights

SCREENING TEMPLATE

education. (1.6) Who are the internal and external

stakeholders (actual or potential) that the policy/proposal could impact upon? (E.g. service users/staff/ other public sector organisations/trade unions/ professional bodies/independent, voluntary or community sector)

Patients

Senior Nursing Assistants,

Registered Nurses,

Allied Health Practitioners,

Medical Teams,

Adult Protection Team

Department Sisters / Nurses in Charge/Managers (or designates)

Assistant Service Managers/Team Managers

Tissue Viability Nurse Team

Safety Assurance Team Directorate Representative

Divisional Nurses and Governance Leads

Section 2: CLASSIFICATION OF POLICY The purpose of this Section is to identify those policies/proposals which have no impact on equality e.g. policies of a purely clinical or technical nature. It should be noted however that the majority of policies /proposals will have some equality impact on staff and/or service users and will require the completion of the entire template.

PART A: (2A.1) Is there an impact on equality of opportunity for those affected by this policy, for each of the S75* equality categories? (2A.2) Are there better opportunities to promote equality of opportunity for people within the S75 categories? (2A.3) Does the policy impact upon good relations between people of a different religious belief, political opinion or racial group? (2A.4) Are there opportunities to better promote good relations between people of a different religious belief, political opinion or racial group? (2A.5) Are there opportunities to encourage disabled people to participate in public life and promote positive attitudes toward disabled people? (2A.6) Does the policy/proposal impact on Human Rights?

No

No

No

No

No

No

(2A.7) If you have answered Yes to any of the above questions proceed to Section 2B overleaf. If you have answered No to all of the above questions the policy may be screened out at this stage. Please give reasons supporting this decision below then sign and date below then forward to the Health & Social Inequalities Team for consideration Lesley.Jamieson@belfasttrust.hscni.net This policy is clinical in nature in terms that it is guidance for staff and does not have any adverse impact on equality or human rights for staff or service users (patients) and can be screened out at this stage. This guideline contains the current evidenced based thinking on the topic. There is no adverse impact on equality or human rights for staff or service users and so the screening outcome is ‘screened out’. This outcome is subject to review - if there are substantive changes in the guideline or additional evidence is provided.

*S75 Equality Categories: Age * Dependants * Disability * Gender * Marital - Civil Partnership Status * Political Opinion * Race * Religion * Sexual Orientation

Inherent to this screening determination is the assumption, based on person centred care, that any information provided to patients will be provided in accessible/alternative formats as required. Accessible formats can include, for example, information in easy to read formats or audio formats when the patient has a learning disability or is visually impaired. If a patient does not speak English as a first language the information will be translated or an interpreter / sign language interpreter provided as appropriate. In addition, it is recommended that staff comply with the requirement that all Belfast Trust staff complete mandatory equality, good relations and human rights training once every five years. Belfast Trust Staff can also access a suite of equality and diversity training including: disability awareness, human rights and embracing diversity in HSC training – please contact the Health and Social Inequalities team for more information.

Approved Lead Officer: Position: Date:

Dr. Jeannie Donnelly

Lead Nurse – Tissue Viability

17/09/19

Countersigned by: Health Inequalities Manager:

Deirdre Donaghy 20/09/19

PART B (2B.1) Are there any factors that could contribute to/detract from the intended aim/outcome of the policy/ proposal? Financial, legislative or other constraints?

.

(2B.2) Other policies/strategies/information with a bearing on this policy/proposal (for example internal or regional policies) - What are they and w ho owns them?

(2B.3) Provide details of how you have or how you intend to involve stakeholders (refer 1.6 above) when screening this policy/proposal

Section 3: AVAILABLE EVIDENCE , CONSIDERATION OF IMPACTS AND MITIGATION

You will need to collect quantitative and qualitative equality data for those service users and staff affected using the templates provided in Tables 1 & 2 at the end of this document. Taking into account this data and the information gathered in Sections 1&2 you should now identify, for each of the nine Section 75 categories, the level of impact, mitigation measures and opportunities to better promote equality of opportunity. NB: Where both staff and service users are impacted, a separate table for each is required.

3A) SERVICE USERS

Equality Category Level of Impact Mitigation Measures and consideration of alternative policies or actions that might lessen the severity of the equality impact (where Major or

Minor Impact identified) Major Minor None

Age

Dependant Status

Disability

Gender

Marital Status

Race (Ethnicity)

Religion

Political Opinion

Sexual Orientation

Multiple Identity e.g. disabled minority ethnic people or young Protestant men.

3B) STAFF

Equality Category Level of Impact Mitigation Measures and consideration of alternative policies or actions that might lessen the severity of the equality impact (where

Major or Minor Impact identified) Major Minor None

Age

Dependant Status

Disability

Gender

Marital Status

Race Ethnicity

Nationality

Religion Community Background

Religious Belief

Political Opinion

Sexual Orientation

Multiple Identity e.g. female staff with caring responsibilities

Section 4: GOOD RELATIONS

To what extent is the policy/proposal likely to impact on good relations between people of different religious belief, political opinion or racial group?

Good relations category

Level of impact

Mitigation Measures and consideration of alternative policies or actions that might lessen the severity of the equality impact (where

Major or Minor Impact identified) Major Minor None

Religious belief

Political opinion

Racial group

Section 5: DISABILITY DUTIES

How does the policy/proposal or decision currently encourage disabled people to participate in public life and promote positive attitudes towards disabled people? Consider what other measures you could take. For example, have staff received disability equality training or training on the Trust’s Patient and Client

Experience Standards?

Section 6: HUMAN RIGHTS

Does the policy/proposal affect human rights in a positive or negative way? NB: If you identify potential negative impact in relation to any of the Articles seek advice from your line manager and/or a representative from the Equality Team. It may also be necessary to seek legal advice.

Article

Positive impact

Negative impact *

Neutral impact

A2: Right to life

A3: Right to freedom from torture, inhuman or degrading treatment or punishment

A4: Right to freedom from slavery, servitude & forced or compulsory labour

A5: Right to liberty & security of person

A6: Right to a fair & public trial within a reasonable time

A7: Right to freedom from retrospective criminal law & no punishment without law

A8: Right to respect for private & family life, home and correspondence.

A9: Right to freedom of thought, conscience & religion

A10: Right to freedom of expression

A11: Right to freedom of assembly & association

A12: Right to marry & found a family

A14: Prohibition of discrimination in the enjoyment of the convention rights

1st protocol Article 1 – Right to a peaceful enjoyment of possessions & protection of property

1st protocol Article 2 – Right of access to education

Please outline any actions you will take to promote awareness of human rights and evidence that human rights have been taken into consideration in decision making processes.

* A negative impact is where human rights have been interfered with or restricted

Section 7: SCREENING DECISION Major Minor None

(7.1) How would you categorise the impacts of this policy/proposal? X

(7.2) If you have identified any impact, what mitigation have you considered to address this?

NA

(7.3) Do you consider the policy/proposal needs to be subjected to on-going screening?

Yes No Reasons – this policy is purely technical/clinical stating roles and responsibilities in relation to simple wound care

(7.4) Do you think the policy/proposal should be subject to an Equality Impact Assessment (EQIA)? NB: A full Equality Impact Assessment (EQIA) is usually confined to those policies or proposals considered to have major implications for equality of opportunity.

Yes No Reasons

(7.5) Monitoring- Please detail how you will monitor the effect of the policy/proposal for equality of opportunity and good relations, disability duties and human rights?

We will monitor uptake of simple wound management course from hospital and community senior nursing assistants and also

from adult and paediatric specialities

Please sign and date below and forward to the Health & Social Inequalities Team Lesley.Jamieson@belfasttrust.hscni.net

Approved Lead Officer

Countersigned by:

Position

Health Inequalities Manager

Date

Employment Equality Manager

Tables 1 and 2: Qualitative and Quantitative Data required to assess level of impact, mitigation and opportunities to better promote equality of opportunity (As referred to in Section 3)

Table 1: SERVICE USERS *2011 Census Data unless otherwise stated

Equality Category

Service users Quantitative Data* Qualitative Data (Needs, Experiences, Priorities) Belfast /

Castlereagh population

Service users

affected

1. Age

0-16 16-24 25-34 35-44 45-54 55-64 65+

22% 11% 12% 14% 14% 12% 15%

2. Dependent Status

Caring for a child dependant older person/ person with a disability None Not known

12% of usually resident population provide unpaid care

3. Disability

Yes No Not known

21% 69% n/a

4. Gender Female Male

51% 49%

5. Marital Status

Married/Civil P’ship Single Other/Not known

47%

36% 17%

6. Race

Ethnicity

White Black/Minority Ethnic Not known

98%

2% n/a

7. Religion Roman Catholic

41%

Presbyterian Church of Ireland Methodist Other Christian

42%

Buddhist Hindu Jewish Muslim Sikh Other None

17%

8. Political Opinion

* 2011 Assembly election

Broadly Nationalist Broadly Unionist Other Do not wish to answer/ Unknown

45%

48% 2%

5%

9. Sexual Orientation

*2012 report by Disability Action & Rainbow Project

Opposite sex Same sex Same and Opposite sex Do not wish to answer /Not known

Estimated 6 -10% of persons identify as lesbian, gay, bisexual

*Due to small numbers of staff within certain equality categories a detailed breakdown of equality data will not be provided*.

Table 2: STAFF *@January 2017

Equality Category

Groups Quantitative Data Qualitative Data

Trust workforce*

Staff affected

1.

Age

<25 25-34 35-44 45-54 55-64

4% 24% 26% 28% 16%

65+ 2%

2.

Dependant Status

Dependants No Dependants Not known

23% 19% 58%

3.

Disability

Yes No Not known

2% 67% 31%

4.

Gender

Female Male

78% 22%

5.

Marital Status

Married/ Civil P’ship Single Other/Not known

56% 34% 10%

6. Race

a) Ethnicity

BME White Not Known

4% 76% 20%

b) Nationality

GB Irish Northern Irish Other Not known

18% 10% 2% 1% 69%

7. Religion

a) Community Background

Protestant Roman Catholic Neither

42% 50% 8%

b) Religious Belief

Christian Other No religious belief Not known

28% 1% 8% 63%

8. Political Opinion

* 2011 Assembly election

Broadly Nationalist Broadly Unionist Other Do not wish to answer/ Unknown

6%

7% 8%

79%

9. Sexual Orientation

Opposite sex Same sex or both sexes Do not wish to answer /Not known

41%

1%

58%

Section 1: Define activity subject to Section 1(1) of Rural Needs Act (NI) 2016

1A. Name of Public Authority:

1B. Short title describing activity being undertaken that is subject to Section 1(1) of the Rural Needs Act (NI) 2016:

1C. Are you developing, adopting, Implementing, Revising a policy/strategy or plan? Or delivering/designing public service? (Underline or Circle). What is official title of this?

1D. Give details of the aims and/or objectives of the Policy, Strategy, Plan or Public Service:

Section 2 - Understanding impact of Policy, Strategy, Plan or Public Service

2A. Is the Policy, Strategy, Plan or Public Service likely to impact on people in rural areas?

Yes No If response is NO Go To Section 2E.

2B. How is it likely to impact on people in rural areas?

2C. If Policy, Strategy, Plan or Public Service is likely to impact on people in rural areas differently from people in urban areas, please explain how it is likely to impact on people in rural areas differently?

2D. Please indicate which of the following rural policy areas the Policy, Strategy, Plan or Public Service is likely to primarily impact on.

Jobs or Employment in Rural Areas Health or Social Care Services in Rural Areas

Education or Training in Rural Areas Broadband/Mobile Communications in Rural Areas

Poverty or Deprivation in Rural Areas

Rural Development Transport Services or Infrastructure in Rural Areas

Other (Please state) Community Safety

2E. Please explain why the Policy, Strategy, Plan or Public Service is NOT likely to impact on people in rural areas.

SECTION 3 - Identifying Social and Economic Needs of Persons in Rural Areas

3A. Has the Trust taken steps to identify the social and economic needs of people in rural areas , relevant to the Policy, Strategy, Plan or Public Service? Yes No

3B. Which of following methods or information sources were used by the Trust to identify these needs ?

Consultation/ Survey/Research/Statistics/Publications/Other methods. Please provide details:

3c. What social and economic needs of the people in rural areas have been identified?

3d Please explain why no steps were taken by the Trust to identify the social and economic needs of people in rural areas?

SECTION 4 - Considering Social and Economic Needs of Persons in Rural Areas

4a. What issues were considered in relation to the social and economic needs of people in rural areas?

SECTION 5 - Influencing the Policy, Strategy, Plan or Public Service

5A. Has the policy, strategy, plan or public service been changed by consideration of the rural needs identified?

5b. If yes, how have rural needs influenced the policy, strategy plan or public service?

5c. If no, why have the rural needs identified not influenced the policy, strategy, plan or public service?

Section 6: Documentation : 6A. Please tick below to confirm that the RNIA Template will be retained by the Trust and relevant information on the Section 1 activity compiled in accordance with paragraph 6.7 of the guidance.

I confirm that the RNIA Template will be retained and relevant information compiled.

Please sign and date below and forward to the Health & Social Inequalities Team Lesley.Jamieson@belfasttrust.hscni.net

Rural Needs Impact Assessment undertaken by:

Job Title/Division/Directorate

Date:

Approved by:

Job Title/Division/Directorate

Date

Data Protection Impact Assessment Appendix 7

Project Name:

Directorate: Department/Location:

1. PROJECT SUMMARY

Briefly describe your project, plan or proposal. Set out its purpose and any projected benefits.

2. STAKEHOLDERS

Identify the main stakeholders or bodies involved and their role in the project.

3. BRIEF DESCRIPTION OF INFORMATION INVOLVED

4. PRIVACY ASSESSMENT

Use this checklist to assess the project for privacy risks. The questions below will help you consider whether a DPIA is necessary. Answering ‘Yes’ to any of the questions is an indication that a DPIA would be a useful exercise.

Does the project involve any of the following?

Yes No If yes, explain your response

Information management

A change to an existing policy, process or system that involves personal information (eg, new legislation or policy that makes it compulsory to collect or disclose information).

☐ ☐

A change in location of a Service area (eg, plans to centralise a service or an office move).

☐ ☐

Any practice or activity that is listed on a risk register (eg, activities listed on your business area’s risk register or health and safety register).

☐ ☐

Collection

Collecting new information about an individual (eg, gathering information about individuals’ location).

☐ ☐

A new way of gathering personal information (for example, collecting information online rather than on paper forms).

☐ ☐

Storage, security and retention

A change in the way personal information is stored or secured (eg, cloud storage).

☐ ☐

A change to how sensitive personal information is managed (eg, moving health records to a new database).

☐ ☐

Transferring personal information to non-EU locations (eg, using a cloud based application to store data).

☐ ☐

A decision to retain personal information for longer than previously kept (for example, keeping information for 10 years when you previously only held it for 7).

☐ ☐

Use or disclosure

Using information classed as ‘special categories’ (eg example, information about an individual’s health).

☐ ☐

Using an individual’s personal data already held, for a new purpose.

☐ ☐

Disclosing information to a third party (eg, following a request from a law enforcement agency to provide information for a particular purpose).

☐ ☐

Sharing or matching personal information held by different organisations or in different datasets (eg, combining data with other information held on systems or sharing information to enable organisations to provide services jointly).

☐ ☐

Individuals’ access to their information

A change in policy that results in people having less access to information that you hold about them (eg, archiving documents after 6 months into a facility from which they cannot be easily retrieved).

☐ ☐

Identifying individuals

Establishing a new way of identifying individuals (eg, a unique identifier, a biometric, or online identity system).

☐ ☐

New intrusions on individuals’ property, person or activities

Introducing a new system for searching individuals’ property, persons or premises (eg, adopting a new policy of searching data on mobile phones that have been returned for upgrading).

☐ ☐

Surveillance, tracking or monitoring of movements, behaviour or communications (eg, installing a new CCTV system or monitoring a member of staff’s email

☐ ☐

account).

Changes to premises impacting on private spaces where clients/staff may discuss personal data (eg, changing the location of a reception desk where people may disclose personal details or relocating a branch where sensitive personal data is processed).

☐ ☐

New regulatory requirements that could lead to compliance action against individuals on the basis of information about them (eg, adding a new medical condition to the requirements of a licence.

☐ ☐

Other privacy intrusions such as body searches, or intrusion into physical space.

☐ ☐

Additional Comments/Notes

Signed by Service Project lead

Date signed

5. INITIAL RISK ASSESSMENT

If you answered ’Yes’ to any of the questions in section 4, use the table below to give a rating - either Low (L), Medium (M), or High (H) – to each of the aspects of the project set out in the first column. If you answered ‘No’ to all the questions in section 4, move on to section 6.

Aspect of the Project

Rating (L, M or H)

Level of personal data handling

L – Minimal personal information will be handled ☐

M – A moderate amount of personal information (or information that could become personal information) will be handled

☐

H – A significant amount of personal information (or information that could become personal information) will

☐

be handled

Sensitivity of information

L – The information is not sensitive ☐

M – The information may be considered to be, or may become, sensitive

☐

H – The information is highly sensitive ☐

Significance of the changes

L – Only minor change to existing functions/activities ☐

M – Substantial change to existing functions/activities; or a new initiative

☐

H – Major overhaul of existing functions/activities; or a new initiative that’s significantly different

☐

Interaction with third parties

L – No interaction with other agencies ☐

M – Interaction with one or two other agencies ☐

H – Extensive cross-agency (government) interaction or cross-sectional (non-government and government) interaction

☐

Public impact

L – Minimal impact on the organisation and individuals ☐

M – Some impact on individuals is likely due to changes to the handling of personal information; or the changes may raise public concern

☐

H – High impact on individuals and the wider public; concerns over aspects of project or negative media interest is likely

☐

6. SUMMARY OF PRIVACY IMPACT

The privacy impact for this project has been assessed as:

Low – There is little or no personal information involved; or the use of personal information is uncontroversial; or the risk of harm eventuating is negligible; or the change is minor and something that the individuals concerned would expect; or risks are fully mitigated.

☐

Medium* – Some personal information is involved, and (several low to medium) risks have been identified

☐

High* – Sensitive personal information is involved, and (several medium to high) risks have been identified

☐

Reduced risk – The project will lessen existing privacy risks ☐

Inadequate information – More information and analysis is needed to fully assess the privacy impact of the project.

☐

Briefly summarise reasons for the rating given

* If you have assessed the privacy impact as high or medium, a DPIA must be carried out. This can be found in the Data Protection Impact Assessment Guidance (DPIA) via this link. Once completed this should be sent to the Information Governance Team gillian.acheson@belfasttrust.hscni.net

7. RECOMMENDATION

A full data protection impact assessment is required

☐

A full data protection impact assessment is not required

☐

Reasons

Please sign and date below. This screening document should be retained by the policy author and a copy sent to Standards and Guidelines

8. SIGN OFF

Policy Author

Name: Date:

Signed:

Director

Name: Date:

Signed: