Screening Outcome Report June 2026

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.

The Equality 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.

Screening Methodology

When screening policies/proposals the Trust will consider,

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. The screening process is used to identify which policies/proposals are likely to have an impact on equality of opportunity or good relations. Screening assesses the likely impact as major, minor or none.

If it is decided that a policy/proposal is likely to have significant/major issues relating to equality, it is then necessary to carry out a more detailed exercise called an equality impact assessment (EQIA).

This screening report outlines the screening outcomes from 1 April 2026 – 30 June 2026.

Please note: Policy Reference Numbers are not sequential; the missing reference numbers relate to internal standard operating procedures that do not require Screening.

Communication and Engagement

In order to carry out our functions 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:

Equality Unit

Route Complex, 8e Coleraine Road, Ballymoney, County Antrim, BT53 6BP

Telephone: 028 2766 1377
E-mail: equality.unit@northerntrust.hscni.net

Outcome of screening

All of the policies or proposals below had a screening outcome of ‘screened out’.

NHSCT/26/2247 Critical Care Outreach Team – Operational Policy

The purpose of this policy is to provide direction and guidance on the role of the Critical Care Outreach Team, describing the roles and responsibilities of the team within Antrim Area Hospital.

Reason for reaching Screening Outcome

This is a clinical policy/guideline which is systematically developed recommendations which assist health care professionals in making decisions about the appropriate care for patients. It is based on the best available evidence. It will help health care professionals in their work, but does not replace their knowledge and skills.

There is no evidence to suggest that the implementation of this policy will adversely impact on any group outlined in Section 75.

NHSCT/26/2248 Allied Health Professionals (AHPs) – Post Registration Education: Procedures and processes re DOH Regional AHP Education Commissioning Group Plan

This document aims to provide clear direction to staff re the post-registration education commissioning procedure.

It will provide a consistent and equitable approach to commissioning education for AHP registrants working in protected title roles, which reflects regional guidance, drives service improvements and ensures value for money.

Reason for reaching screening outcome

This document relates to the procedures in place for AHP registrants employed by the NHSCT in the following protected title roles Dietitians, Occupational Therapists, Physiotherapists, Radiographers, Paramedics, Podiatrists, Speech Language Therapists, Orthoptists.

There is no evidence to suggest that the implementation of this policy will adversely impact on any group outlined in Section 75.

NHSCT/26/2252 Sharps (Needlestick/Splash/Bite) Injuries (Prevention and Management of) Policy

This policy applies to all employees of Northern Health and Social Care Trust aged over 16years as well as Agency/ Locum staff, trainees and placement students who sustain a Sharps (Needlestick/Splash/Bite) injury whilst working within NHSCT.

Reason for screening outcome

There is no evidence to suggest that the implementation of this policy will adversely impact on any group outlined in Section 75.

NHSCT/26/2253 Regional Guidance and Procedures for the Reimbursement of Expenses for Service Users and Carers in the Department of Health and Health and Social Care Organisations

The purpose of this document is to provide guidance on the reimbursement of out-of-pocket expenses for service users and carers involved and consulted on the planning, delivery and evaluation of services. Primarily these are costs associated with travel, caring responsibilities and subsistence.

Reason for screening outcome

This is a regional policy and has been developed through extensive consultation at a regional level with service users, carers, stakeholders and HSC staff.

There is no evidence to suggest that the implementation of this policy will adversely impact on any group outlined in Section 75.

NHSCT/26/2254 Sickness Absence Management Policy & Procedure (HSC)

This Policy sets out the best practice principles for the management of sickness absence and provides employees and managers within in the Trust with guidance on the management of sickness absence.

Reason for screening outcome

This policy sets out the organisations commitment to supporting employees by providing a working environment that is conducive to positive health and wellbeing, supporting employees to be well at work, to be managed in a fair, prompt and compassionate manner when absence from work due to sickness and to return to work as soon as reasonably possible.

There is no evidence to suggest that the implementation of this policy will adversely impact on any group outlined in Section 75.

NHSCT/26/2256 Inadvertent Hypothermia Policy for Patients Attending Theatres/Day Surgery in adults 18 years and older

The purpose of this policy is to emphasize the importance of health care professionals ensuring patients remain “comfortably warm” on the wards, in the operating department, and on transfer between departments.

Reason for screening outcome

There is no evidence to suggest that the implementation of this policy will adversely impact on any group outlined in Section 75.

NHSCT/26/2257 Chemotherapy: Management of the urgent administration of intravenous/ subcutaneous chemotherapy outside of designated Systemic Anti-Cancer Therapy (SACT) locations

This policy has been developed to support safe practice and appropriate planning when an adult in the acute care setting requires intravenous/subcutaneous SACT treatment outside of the SACT treatment designated areas.

Reason for screening outcome

There is no evidence to suggest that the implementation of this policy will adversely impact on any group outlined in Section 75.

NHSCT/26/2259 Clinical, Professional and General Litigation Claims

This policy describes the process for the management of claims against the Trust, subsequent investigation, analysis and the identification of learning and onward reporting where required.

Reason for screening outcome

This policy, including associated procedures, details the Trust’s arrangements for the management of claims, primarily directed by DOH Circular.

There is no evidence to suggest that the implementation of this policy will adversely impact on any group outlined in Section 75.

NHSCT/26/2260 Dysphagia Management and Choking Risk Reduction Policy for Paediatric Service Users who have Dysphagia (Eating Drinking and Swallowing

The purpose of this policy is to ensure safe and appropriate management of babies, children and young people who have difficulties with eating, drinking and swallowing (EDS) (dysphagia).

Reason for screening outcome

NHSCT/26/2262 General Capital Management Process

This policy seeks to inform and assist staff who are involved in bidding for general capital funds from the Trust’s annual general capital resource limit (CRL).

Reason for screening outcome

This policy is in line with latest Department of Finance (DoF) guidance ‘User Guide to Better Business Cases NI and the Approvals Process’ i.e the Five Case Model updated in May 2024.

There is no evidence to suggest that the implementation of this policy will adversely impact on any group outlined in Section 75.

NHSCT/26/2263 Allied Health Professionals working in Multi-Disciplinary Teams: Good Practice Guidance for Professional and Operational Managers (including guidance re AHPs in generic roles)

This guidance/policy has been developed to help clarify the respective roles of operational and professional managers across all services where there are AHPs in registered title roles and generic roles and sets out requirements for the AHP.

Reason for screening outcome

There is no evidence to suggest that the implementation of this policy will adversely impact on any group outlined in Section 75.

NHSCT/26/2264 Furniture & Equipment Moves within the NHSCT

This Policy relates to the due to the movement of furniture etc between Trust sites.

Reason for screening outcome

This mandatory process has been designed to ensure that the Trust complies with corporate governance requirements.

There is no evidence to suggest that the implementation of this policy will adversely impact on any group outlined in Section 75.

NHSCT/26/2265 Risk Assessment Procedure for Staff Members who are New and Expectant Mothers

This procedure describes the Trust’s arrangements for discharge of its responsibilities for managing the risk to new and expectant mothers as defined by The Management of Health and Safety at Work Regulations (Northern Ireland) 2000.

Reason for screening outcome

The Regulations require that employers complete risk assessments of the duties being undertaken by new and expectant mothers and that appropriate measures are then put in place to preferably remove, or at least reduce, the risks to their health and safety arising from any hazards identified.

There is no evidence to suggest that the implementation of this policy will adversely impact on any group outlined in Section 75.

NHSCT/26/2267 Overseas visitors’ entitlement to Health Care

This policy is intended to provide guidance to staff on the procedures for dealing with visitors and how they will be managed within the organisation.

Reason for screening outcome

The Health and Personal Social Services Provision of Health Services to Persons Not Ordinarily Resident Regulations (Northern Ireland) 2015 (the Regulations) prescribes how health services shall be made available to visitors to Northern Ireland and sets out the categories of visitor that are exempt from charge.

There is no evidence to suggest that the implementation of this policy will adversely impact on any group outlined in Section 75.

NHSCT/26/2268 Tissue Viability Nursing Team Operational Policy

This policy provides direction to all staff making a referral to the Tissue Viability Nurse (TVN) service within the Northern Health and Social Care Trust.

Reason for screening outcome

There is no evidence to suggest that the implementation of this policy will adversely impact on any group outlined in Section 75.

NHSCT/26/2270 Systematic Examination of the Newborn and Discharge of the Newborn Infant (by Midwifery Staff)

These guidelines provide a framework for Midwives / Paediatricians / ENNPs and Advanced Neonatal Nurse Practitioners (ANNPs) undertaking the systematic newborn examination. It outlines the timing of the examination, the scope of practice that Midwives can check and how to make a referral if there is a deviation from the norm (HSC/PHA, 2017).

Reason for screening outcome

There is no evidence to suggest that the implementation of this policy will adversely impact on any group outlined in Section 75.

NHSCT/26/2271 Hysteroscopy Clinic, Outpatient

This Clinical Guideline explains the Hysteroscopy Service within the Northern Health and Social Care Trust.

This guideline aims to provide staff with information on the NHSCT Hysteroscopy Service based on the recommendations from the Royal College of Obstetricians and Gynaecologists (RCOG) Green Top Guideline No 59 Best Practice in Outpatient Hysteroscopy, 2024 and up-to-date Database.

Reason for screening outcome

There is no evidence to suggest that the implementation of this policy will adversely impact on any group outlined in Section 75.

NHSCT/26/2272 Intrapartum Fetal Monitoring Guideline (Regional)

This guidance aims to encompass a pathophysiological approach to explain how a fetus defends itself against intrapartum hypoxic- ischaemic insults and highlight the signs that suggest progressive loss of compensation.

Reason for screening outcome

There is no evidence to suggest that the implementation of this policy will adversely impact on any group outlined in Section 75.

NHSCT/26/2273 Water for labour and birth guideline

This policy is directed to all Midwives and Obstetricians working within NHSCT maternity services.

Reasons for screening outcome

There is no evidence to suggest that the implementation of this policy will adversely impact on any group outlined in Section 75.

NHSCT/26/2274 Stroke Management Policy

This policy is directed to medical, nursing, pharmacy and Allied Health Professional staff working with all patients with an acute stroke.

Reason for screening outcome

There is no evidence to suggest that the implementation of this policy will adversely impact on any group outlined in Section 75.

NHSCT/26/2276 Animals – Guidelines for Staff Working in Direct Care Situations including Domiciliary Setting

The Northern Health and Social Care Trust (NHSCT) has a responsibility to provide care services in domiciliary settings.

Reason for screening outcome

These guidelines are applicable for all homes where an animal or animals are kept as a pet and / or security either inside or outside of the service users’ home, and in other situations where animals or livestock are kept as part of a livelihood.

There is no evidence to suggest that the implementation of this policy will adversely impact on any group outlined in Section 75.

NHSCT/26/2277 Pregnancy status: Guidelines for Confirming Pregnancy Status Before Commencing or Administering Systemic Anti-Cancer Therapy in Adults

The aim of these guidelines is to prevent unknowingly treating a person with potentially harmful Systemic Anti-Cancer Therapy (SACT), by clearly establishing the pregnancy status of all persons of childbearing potential before they receive SACT.

Reason for screening outcome

There is no evidence to suggest that the implementation of this policy will adversely impact on any group outlined in Section 75.

NHSCT/26/2278 Anti-Fraud & Bribery Policy (including Fraud Response Plan)

This document sets out the Northern Health and Social Care Trust’s (The Trust) policy and advice to employees in dealing with fraud and bribery or suspected fraud and bribery. The policy details the arrangements made in the organisation for such concerns to be raised by employees, third parties or members of the public.

Reason for screening outcome

The Trust is committed to reducing fraud, bribery and corruption in Health and Social Care (HSC) and will seek the appropriate disciplinary, regulatory, civil and criminal sanctions against fraudsters and, where possible, will attempt to recover losses. The aim of the policy and procedure is to protect the property and finances of the Trust and of patients in our care

There is no evidence to suggest that the implementation of this policy will adversely impact on any group outlined in Section 75.

NHSCT/26/2279 Fracture Liaison Service (FLS) – Specialist Nurse protocol for requesting DXA (Dual energy X ray Absorptiometry) scans

The purpose of the following Clinical Guidelines is to define the rationale, mechanisms and the associated governance framework, to enable requests for appropriate Radiological examinations by appropriately trained and entitled nurses, to facilitate and expedite the Fracture Liaison Service.

Reason for screening outcome

There is no evidence to suggest that the implementation of this policy will adversely impact on any group outlined in Section 75.

NHSCT/26/2280 Multidisciplinary Team Ward Round Policy – Medicine and Emergency Medicine Causeway Hospital

This policy describes the process for delivering Multi-Disciplinary Ward Rounds in Acute Hospitals.

Reason for screening outcome

There is no evidence to suggest that the implementation of this policy will adversely impact on any group outlined in Section 75.

NHSCT/26/2281 Outpatient Parenteral Antimicrobial Therapy (OPAT) policy for adult patients (from day of 16th birthday)

This policy is directed to medical, pharmacy and nursing staff working with adult patients receiving OPAT in the NHSCT.

Reason for screening outcome

There is no evidence to suggest that the implementation of this policy will adversely impact on any group outlined in Section 75.

NHSCT/26/2284 Prevention of the spread of Blood Borne virus (BBV) Infection and the management of patients with a blood borne infection within Antrim Nephrology

This policy outlines the arrangements and responsibilities of staff and patients for the prevention of the spread of BBV infection within the Department of Nephrology, including but not exclusively patients receiving haemodialysis, peritoneal dialysis, transplanted patients, inpatients and those attending low clearance clinics.

Reason for screening outcome

There is no evidence to suggest that the implementation of this policy will adversely impact on any group outlined in Section 75.

NHSCT/26/2285 Haemodialysis Via an Arterio-Venous Fistula (AVF) or Arteriovenous Graft (AVG) Commencing & Discontinuing

The aim of this policy is to ensure that there are standardised principles and practices in place, enabling the safe commencement and discontinuation of haemodialysis via an Arterio Venous Fistula (AVF).

Reason for screening outcome

There is no evidence to suggest that the implementation of this policy will adversely impact on any group outlined in Section 75.

NHSCT/26/2286 Transfer of a Deceased Baby or Child Guidance – Antrim Area and Causeway Hospitals: Acute Sites Only

The purpose of this guidance is to ensure that the NHSCT staff involved in coordinating the transfer of a baby or child from the ward to the mortuary do so in a way that is dignified, sensitive and respectful to the needs and preferences of the bereaved parents/guardians to avoid any further distress.

Reason for screening outcome

There is no evidence to suggest that the implementation of this policy will adversely impact on any group outlined in Section 75.

NHSCT/26/2287 Home Oxygen Service Assessment and Review (HOSAR) in Adults from 16th Birthday

This guidance reflects current good practice in the assessment, review and delivery of home oxygen services and sets out the core components of a high-quality assessment and review service for home oxygen for the community respiratory team.

Reason for screening outcome

There is no evidence to suggest that the implementation of this policy will adversely impact on any group outlined in Section 75.

NHSCT/26/2288 Renal Specialist Nurse (RNS) Operational Policy

The Aim of this policy is to provide a standardised referral protocol for the RNS in caring for patients with renal disease within the Northern Trust area and ensure the best possible management and care is provided to patients with renal disease at each stage of its progression.

Reason for screening outcome

There is no evidence to suggest that the implementation of this policy will adversely impact on any group outlined in Section 75.

NHSCT/26/2289 Charitable Trust Funds Policy (CTFs)

This Policy sets out the policy of the Northern Health and Social Care Trust and the standards of organisational procedures expected to be applied in the operation and control of charitable trust funds (CTFs).

Reason for screening outcome

The term ‘Charitable Trust Funds’ is used to describe gifts and donations received by Northern Health and Social Care Trust (the Trust) from members of the public, acting individually or as a group, or other agencies.

There is no evidence to suggest that the implementation of this policy will adversely impact on any group outlined in Section 75.

NHSCT/26/2290 Community Nursing ‘Authorisation to Administer Medication’ Documentation Policy for NMPs who prescribe using a HS21 Prescription

This policy has been developed for Non-Medical Prescribers (NMPs) within the Community Nursing services who hold an NMC recordable V100, V150 and / or V300 NMP qualification and are listed as active on the NHSCT NMP and BSO registers.

Reason for screening outcome

There is no evidence to suggest that the implementation of this policy will adversely impact on any group outlined in Section 75.

NHSCT/26/2291 Outpatient Prescribing and Recommendation to Prescribe Medicines including arrangements for assurance and oversight

This Policy defines the standard of practice to be followed in the Northern Health and Social Care Trust for the prescribing and recommendations to prescribe in the outpatient setting for both adults and children.

Reason for screening outcome

There is no evidence to suggest that the implementation of this policy will adversely impact on any group outlined in Section 75.

NHSCT/26/2292 Risk Register Production and Management Guidance

The Trust will maintain a database of Principal, Corporate, Divisional, Departmental and Service Risks. Principal and Corporate risks can be new or amalgamated risks as approved by the Risk and Assurance Group.

Reason for screening outcome

The Principal Risk Document will be utilised by the Executive Team and Trust Board as a planned and systematic approach to the identification, assessment and mitigation of risks that could compromise achievement of the Trust’s Principal Corporate Objectives.

There is no evidence to suggest that the implementation of this policy will adversely impact on any group outlined in Section 75.

NHSCT/26/2293 Taxis – Authorisation and Payment of within the Community Care Division

This policy applies to staff within the Community Care Division and sets out the requirements for procuring taxis in compliance with Standing Financial Instructions and contractual arrangements.

Reason for screening outcome

In the main, taxis are used infrequently by Community Care Division. However, where taxis are used a standardised approach is required, which incorporates authorisation and payment for such services.

There is no evidence to suggest that the implementation of this policy will adversely impact on any group outlined in Section 75.

NHSCT/26/2295 Allied Health Professions’ (AHP) Bank Policy

This policy is directed to all AHP staff and their operational line managers to provide staff with clear guidance on the operating principles when utilising AHP registrants and AHP support staff from AHP bank lists.

Reason for screening outcome

This policy advises on the use of the individual AHP Bank Lists and operational processes involved.

There is no evidence to suggest that the implementation of this policy will adversely impact on any group outlined in Section 75.

Screening Templates for any of the above are available from the Equality Unit.

Alternative format

Screening Outcome Report June 2026 (Word document, 231KB)