equality and diversity - nhs forth valley...completed equality impact assessments printed on...

Equality and Diversity Completed Equality Impact Assessments for the period 1 January 2010 to 31 December 2010

Full Date Review EQIA Owning Department Title Type Author Completed Common Themes Date Required A & E Service Emergency Department Handbook Guidance Elspeth Pitt 28/01/2010 279 No discrimination noted Neutral 01/02/2012 No

CADs CADS/FVCJDTS Process for a Death Policy Claire McIntosh14/04/2010 295 No discrimination noted Neutral 14/04/2013 No in Service 295 Age Positive 295 Disability:1:1 need met Positive 295 Accessible Information Positive 295 Community Language needs in Positive place 295 Criminal justice sytem - process in Neutral place Cancer Services PICC Line Insertion Service Policy Fiona Galbraith 24/02/2010 293 no discrimination - age Neutral 01/02/2012 Yes 293 Disability:1:1 need met Neutral 293 no discrimination - gender Neutral 293 no discrimination - religion/belief Neutral

293 no discrimination - s/orientation Neutral

293 staff Positive Guidance for the Care of Skin Guidance Fiona Galbraith 24/02/2010 294 No discrimination noted Neutral 01/02/2012 Yes Tunnelled Catheters and PICC’s 294 Disability:1:1 need met Neutral 294 Race-1:1 support given Neutral 294 religious requests/observence met Neutral

294 Mental Health Problems Neutral Chemotherapy Resource Pack Protocols Fiona Galbraith 30/03/2010 312 No discrimination noted Neutral 30/03/2012 No 312 Disability:1:1 need met Neutral 312 Accessible Information Positive 312 staff Positive

Completed Equality Impact Assessments Printed on 9-Feb-2011 10:13 of 43


Full Date Review EQIA Owning Department Title Type Author Completed Common Themes Date Required CHP South Evidence on Cough, Colds, Earache Guidance Leslie Cruickshank 28/01/2010 28/01/2012 No ans Sore Throats Using Bedrails Safely and Effectively Policy Chris Beech10/02/2010 290 no discrimination - age Neutral 10/02/2012 No Policy 290 Accessible Information Positive 290 no discrimination - gender Neutral 290 Race-1:1 support given Positive 290 no discrimination - religion/belief Neutral


290 Mental Health Problems Positive CHP Stirling/Clacks Clacks/Stirling Youth Smoking Pilot for Service Anne Currie25/11/2010 440 Age 24 and below Positive 25/11/2011 No Toolkit Development 440 Disability Neutral 440 race and ethnicity Neutral 440 religion and belief Neutral 440 sexual orientation Neutral Communications Website – NHS Forth Valley Royal Function Catherine Lawson 15/07/2010 343 See full report Positive 15/07/2012 No Hospital Community Nursing The Early Detection and Management Guidance Julie Whitecombe10/12/2010 276 No discrimination noted Neutral 10/12/2011 No of Perinatal Mental Health : information Pack



Full Date Review EQIA Owning Department Title Type Author Completed Common Themes Date Required Day Surgery DAY SURGERY UNIT, FVRH Service MARGARET REID 14/06/2010 326 Age Neutral 01/08/2011 No 326 Disability Neutral 326 Accessible Information Positive 326 Disability:1:1 need met Positive 326 Equipment for disabled people Positive available 326 gender Neutral 326 Transgender Etiquette in place Positive 326 Community Language needs in Positive place 326 Chaperone process in place Positive 326 Race-1:1 support given Positive 326 Diet and nutrition Positive 326 sexual orientation Positive 326 Staff training Positive 326 Criminal justice- support 1:1 basis Positive

Diabetes and Endocrinology Diabetic Ketoacidosis-Integrated Care Policy Dr Linda Buchanan01/08/2010 419 Age - service 16 years + Neutral 01/08/2012 No Pathway 419 No discrimination noted Neutral



Full Date Review EQIA Owning Department Title Type Author Completed Common Themes Date Required Diabetic Services Hypoglycaemia Guidance Dr Linda Buchanan 01/08/2010 353 No discrimination noted Neutral 01/08/2012 No Thyroid Storm Policy Dr Linda Buchanan 01/08/2010 354 No discrimination noted Neutral 01/08/2012 No Hyperosmolar Non–Ketotic Diabetic Guidance Dr Linda Buchanan01/08/2010 352 No discrimination noted Neutral 01/08/2012 No Coma (HONK) 352 staff Positive Diabetic Ketoacidosis Guidance Dr Linda Buchanan 01/08/2010 351 Age - service 16 years + Neutral 01/08/2012 No 351 No discrimination noted Neutral 351 staff Positive Adult Adrenal Insufficiency Guidance Dr Linda Buchanan 01/08/2010 350 No discrimination noted Neutral 01/08/2012 No Management Guidelines Guidelines for the management of Guidance Dr Linda Buchanan 28/09/2010 416 No discrimination noted Neutral 28/09/2012 No hypocalcaemia post thyroidectomy 416 staff Positive In-patient insulin use and supply Policy Alison Mackenzie 26/11/2010 441 No discrimination noted Neutral 26/06/2012 No 441 Disability:1:1 need met Positive



Full Date Review EQIA Owning Department Title Type Author Completed Common Themes Date Required Endoscopy Endoscopy Department Forth Valley Service Sandra Fleming14/06/2010 323 Age Neutral 01/08/2011 No Royal Hospital 323 Disability Positive 323 Disability:1:1 need met Positive 323 Environmental Access Positive 323 Accessible Information Positive 323 Literacy needs considered Positive 323 Equipment for disabled people Positive available 323 Sign Language Support Positive 323 signage Negative/Adverse 323 gender Neutral 323 Single rooms available Positive 323 Criminal Justice system Neutral 323 Transgender Etiquette in place Positive 323 race and ethnicity Positive 323 religious requests/observence met Positive

323 sexual orientation Positive 323 Staff training Positive 323 Gypsy travellers Neutral 323 Homeless people Neutral 323 Criminal justice- support 1:1 basis Positive



Full Date Review EQIA Owning Department Title Type Author Completed Common Themes Date Required Finance NHS Forth Valley Fundraising Strategy Strategy Craig Holden06/07/2010 421 Age Neutral 30/04/2011 No 421 Disability:1:1 need met Positive 421 gender Neutral 421 Race-1:1 support given Positive 421 religion and belief Neutral 421 Community involvement Positive 421 sexual orientation Neutral 421 staff Positive 421 Criminal Justice system Neutral 421 Mental Health Problems Positive



Full Date Review EQIA Owning Department Title Type Author Completed Common Themes Date Required General Surgical Services Ward 21, Surigal Rehabilitation Ward Service Barbara-Anne Niven13/06/2010 392 Age 14 years + Neutral 13/06/2011 No 392 Disability:1:1 need met Positive 392 Loop system in place Positive 392 Assistance Dogs process in place Positive

392 Accessible Information Positive 392 no discrimination - gender Positive 392 Single rooms avaiable Positive 392 Chaperone process in place Positive 392 baby changing facilities Positive 392 Race-1:1 support given Positive 392 signage Negative/Adverse 392 access to spititual care team 24/7 Positive

392 Religion & Belief met 1:1 basis Positive 392 Criminal justice- support 1:1 basis Positive

392 Menuesavailable in picture format Positive

392 Low income needs considered Positive 392 Cognitive impairement needs met Positive

392 Rural areas Neutral Haematology Suspected Neutropenic Sepsis Guidance Dr Marie Hughes 01/07/2010 329 No discrimination noted Neutral 01/07/2010 No



Full Date Review EQIA Owning Department Title Type Author Completed Common Themes Date Required ICR A31 post acute rehab ward for the older Service Carla Tait30/06/2010 355 Advocacy Service in place Positive 01/09/2011 No person 355 Over 65 service Neutral 355 Environmental Access Positive 355 Accessible Information Positive 355 Assistance Dogs process in place Positive

355 Information in community languages Neutral

355 Interprters available BSL Positive 355 signage Negative/Adverse 355 Moving & handling Equip available Positive

355 no discrimination - gender Neutral 355 no discrimination - race/ethnicity Neutral

355 Single rooms available Positive 355 Transgender Etiquette in place Positive 355 Race-1:1 support given Positive 355 Community Language needs in Positive place 355 no discrimination - religion/belief Neutral

355 access to spititual care team 24/7 Positive

355 Diet and nutrition Positive 355 Last offices needs met Positive 355 no discrimination - s/orientation Neutral

355 Staff training Neutral 355 Homeless people - link with local Positive projects 355 Criminal Justice system needs met Neutral

355 Literacy needs considered Positive Completed Equality Impact Assessments Printed on 9-Feb-2011 10:13 of 43


Full Date Review EQIA Owning Department Title Type Author Completed Common Themes Date Required 355 Cognitive impairement needs met Positive

355 Menuesavailable in picture format Positive

355 Psychiatric Liaison service available Positive

Infection Control Infection Control for Domestic Policy Sybil Solomon 21/01/2010 283 No discrimination noted Neutral 21/01/2013 No Services Policy SCABIES IDENTIFICATION AND Policy Sybil Solomon 21/01/2010 286 No discrimination noted Neutral 21/01/2013 No TREATMENT POLICY Policy for the Prevention of Legionella Policy Sybil Solomon21/01/2010 285 No discrimination noted Neutral 21/01/2013 No in Clinical Areas Standard Infection Control Precautions Policy Sybil Solomon21/02/2010 284 No discrimination noted Neutral 21/02/2013 No Policy Isolation of Patients :Policy Policy Sybil Solomon 27/05/2010 319 No discrimination noted Neutral 27/05/2013 No Integrated C diff Pathway (ICP) Guidance Sybil Solomon 01/06/2010 320 No discrimination noted Neutral 01/06/2010 No Integrated Enteric Pathway (ICP) Guidance Sybil Solomon 01/06/2010 321 No discrimination noted Neutral 01/06/2010 No Infection Control in the Built Policy Sybil Solomon 19/08/2010 368 No discrimination noted Neutral 19/08/2013 No Environment Policy Policy for Managing Infection Risks Policy Sybil Solomon 19/08/2010 367 No discrimination noted Neutral 19/08/2013 No Associated with Last Offices 367 religion and belief Positive 367 staff Positive Head Lice Policy Policy Sybil Solomon 19/08/2010 363 No discrimination noted Neutral 19/08/2013 No Medical Physics Department Medical Equipment Management and Guidance Jack Watson08/04/2010 303 No discrimination noted Neutral 08/04/2010 No Maintenance Services



Full Date Review EQIA Owning Department Title Type Author Completed Common Themes Date Required Mental Health Services PSYCHIATRIC OBSERVATIONS – Policy Chris Beech10/02/2010 315 no discrimination - age Neutral 10/02/2013 No Mental Health Services 315 Accessible Information Positive 315 Information in community languages Positive

315 Disability:1:1 need met Positive 315 no discrimination - gender Neutral 315 no discrimination - religion/belief Neutral


315 staff Positive 315 Criminal justice- support 1:1 basis Neutral

315 Mental Health Problems Positive



Full Date Review EQIA Owning Department Title Type Author Completed Common Themes Date Required MS Services NHS Forth Valley Multiple Sclerosis Service Hazel Gaylor02/07/2010 347 Age - service 16 years + Positive 02/07/2011 No Service- offers a specialist 347 Disability:1:1 need met Positive neurological and rehabilitation service to people living within the Forth Valley 347 Accessible Information Positive Area 347 Interprters available BSL Positive 347 Accessible Venues arranged Positive 347 Home visits can be arranged Positive 347 Telephone support also aviable Positive

347 no discrimination - gender Neutral 347 no discrimination - race/ethnicity Neutral

347 Race-1:1 support given Positive 347 Community Language needs in Positive place 347 no discrimination - religion/belief Neutral


347 Staff training Positive 347 Low income needs considered Positive



Full Date Review EQIA Owning Department Title Type Author Completed Common Themes Date Required Neurology Services (Acute) Forth Valley Multiple Sclerosis Service Protocols Hazel Gaylor21/06/2010 322 Age Neutral 04/05/2011 No - Management of MS Relapses 322 Accessible Information Positive Protocol 322 Community Language needs in Positive place 322 Community Language needs in Positive place 322 Criminal justice- support 1:1 basis Positive

322 gender Neutral 322 Race-1:1 support given Positive 322 Religion & Belief met 1:1 basis Neutral 322 sexual orientation Neutral 322 staff Positive Neurology Service Service Kirstine MacAskill 09/09/2010 391 Age - service 16 years + Positive 09/09/2012 No 391 Disability:1:1 need met Positive 391 Carers needs considered Positive 391 Accessible Information Positive 391 Community Language needs in Positive place 391 Religion & Belief met 1:1 basis Neutral 391 sexual orientation Neutral 391 Gypsy travellers Neutral 391 Homeless people Neutral 391 Literacy needs considered Neutral 391 Mental Health needs met 1:1 basis Neutral

391 Home visits can be arranged Positive



Full Date Review EQIA Owning Department Title Type Author Completed Common Themes Date Required Neurology Services (Acute) Neurology Service Kirstine McAskill 20/09/2010 394 Age - service 16 years + Positive 20/09/2011 No 394 Accessible Venues arranged Positive 394 No discrimination noted Neutral 394 Loop system in place Positive 394 Disability:1:1 need met Positive 394 Carers needs considered Positive 394 Disability:1:1 need met Positive 394 Disabled toilets Positive 394 Accessible Information Positive 394 Hoists available Positive 394 Community Language needs in Positive place 394 Ethnicity recorded Positive 394 staff Positive 394 Gypsy travellers Neutral 394 Homeless people Neutral 394 Criminal Justice system Neutral 394 Low income needs considered Positive 394 Mental Health needs met 1:1 basis Neutral

394 Home visits can be arranged Positive Nursing Services Flying Start Policy Policy Suzanne Lake 13/08/2010 390 No discrimination noted Neutral 06/03/2011 No 390 staff Positive 390 Disability:1:1 need met Positive Older Peoples Services Self-Administration of Medicines Policy Policy Chris Beech10/02/2010 291 Accessible Information Positive 10/02/2012 No 291 No discrimination noted Neutral 291 Information in community languages Positive

291 Literacy needs considered Positive



Full Date Review EQIA Owning Department Title Type Author Completed Common Themes Date Required Organisational Development Organisational Development / Service Anne Benton 12/04/2010 300 no discrimination - age Neutral 12/04/2012 No Learning, Education and Training Team 300 Literacy needs considered Positive 300 Loop system in place Positive 300 Environmental Access Positive 300 no discrimination - gender Neutral 300 Staff training Positive 300 Accessible Information Positive 300 religion and belief Negative/Adverse 300 no discrimination - s/orientation Neutral

300 Low income needs considered Positive Out patients services Outpatient Department Forth Valley Service Sharon Hamilton21/04/2010 313 no discrimination - age Neutral 21/04/2011 No Royal Hospital 313 Child friendly Positive 313 Breast feeding facilities Positive 313 Accessible Information Positive 313 Disability:1:1 need met Positive 313 Accessible Venues arranged Positive 313 Chaperone process in place Positive 313 no discrimination - gender Neutral 313 Race-1:1 support given Positive 313 signage Negative/Adverse 313 no discrimination - s/orientation Neutral

313 Religion & Belief met 1:1 basis Positive 313 Criminal justice- support 1:1 basis Positive

313 Low income needs considered Positive 313 Rural areas Neutral



Full Date Review EQIA Owning Department Title Type Author Completed Common Themes Date Required Pharmacy Empirical Antimicrobial Guidelines for Guidance Clare Colligan22/07/2010 349 No discrimination noted Neutral 22/06/2010 No NHS Forth Valley Acute Hospitals

Guidelines for use of high dose Guidance Pauline Morrison 04/09/2010 382 No discrimination noted Neutral 04/09/2011 No Intravenous Esomeprazole in Adults (Previously called the Hong Kong Protocol) Guidance for the Management of Guidance Jean Logan 07/09/2010 381 No discrimination noted Neutral 07/09/2013 No Depression 381 Age 18+ Positive 381 Accessible Information Positive 381 Literacy needs considered Positive 381 Low income needs considered Positive 381 Mental Health Problems Positive 381 Rural areas Positive Guidance for the Management of Guidance Jean B. Logan 16/12/2010 438 Age - service 16 years + Positive 16/12/2013 No Patients on Lithium 438 Disability Positive 438 gender Neutral 438 Accessible Information Positive 438 religion and belief Neutral 438 sexual orientation Neutral 438 Mental Health Problems Positive Planning Services Policy for NHS Funded Management Policy Graham Foster03/02/2010 287 Age Positive 23/04/2012 No of Sub-fertile couples – version 4 287 no discrimination - disability Neutral 287 Gender - ethical issues Negative/Adverse 287 race and ethnicity Positive 287 Accessible Information Positive 287 no discrimination - religion/belief Neutral

287 staff Positive 287 sexual orientation - ethical issues Negative/Adverse



Full Date Review EQIA Owning Department Title Type Author Completed Common Themes Date Required Public Health Policy for NHS Funded Management Policy Graham Foster03/02/2010 282 Age Positive 23/04/2012 No of Sub-fertile couples – version 4 282 Accessible Information Positive 282 staff Positive 282 Criminal Justice system - Positive substance misuse ReACH Service REACH Service Service Shiona Hogg 02/12/2010 435 teams tagets specific age groups Positive 02/12/2011 No

435 Disability:1:1 need met Positive 435 Accessible Information Positive 435 gender Neutral 435 race and ethnicity Neutral 435 Ethnicity recorded Negative/Adverse 435 religion and belief Neutral 435 religion belief recroded Negative/Adverse 435 sexual orientation Neutral 435 Staff training Positive 435 Homeless people - link with local Positive projects 435 Criminal justice- support 1:1 basis Positive

435 Mental Health needs met 1:1 basis Positive

435 Rural areas Positive Redesign Department ‘Self Care Toolkit’ and ‘My Support Guidance David Arundel 24/05/2010 318 Accessible Information Positive 26/04/2011 No Plan’ 318 No discrimination noted Neutral 318 sexual orientation Positive 318 Criminal Justice system Neutral 318 Disability Positive 318 Literacy needs considered Positive 318 Low income needs considered Positive 318 Rural areas Neutral 318 risk taking behaviour Positive Completed Equality Impact Assessments Printed on 9-Feb-2011 10:13 of 43


Full Date Review EQIA Owning Department Title Type Author Completed Common Themes Date Required Rehabilitation WARD A22, STROKE Function ISABEL DEVOY 30/06/2010 356 Age 14 years + Neutral 01/09/2011 No REHABILITATION WARD 356 Advocacy Service in place Positive 356 Environmental Access Positive 356 access to spititual care team 24/7 Positive

356 Access to Speech and Language Positive

356 Cognitive impairement needs met Positive

356 Assistance Dogs process in place Positive

356 Accessible Information Positive 356 Single rooms available Positive 356 Chaperone process in place Positive 356 Transgender Etiquette in place Positive 356 Race-1:1 support given Positive 356 Community Language needs in Positive place 356 signage Negative/Adverse 356 Diet and nutrition Positive 356 Last offices needs met Positive 356 no discrimination - s/orientation Neutral

356 Staff training Neutral 356 Homeless people - link with local Positive projects 356 Menuesavailable in picture format Positive

356 Low income needs considered Positive 356 Psychiatric Liaison service available Positive

356 Limited access to psychology Negative/Adverse services



Full Date Review EQIA Owning Department Title Type Author Completed Common Themes Date Required Renal Unit Admission Guidelines for Renal Guidance jane rodriguez 25/05/2010 337 No discrimination noted Neutral 25/05/2011 No Haemodialysis Patients 12 hour Urokinase Infusion Guidance Jane Rodriguez 06/07/2010 333 No discrimination noted Neutral 06/07/2010 No RENAL UNIT FORTH VALLEY Service JANE RODRIGUEZ 06/07/2010 348 no discrimination - age Neutral 06/07/2010 No ROYAL HOSPITAL 348 no discrimination - disability Neutral 348 Disability:1:1 need met Positive 348 Accessible Venues arranged Positive 348 Interprters available BSL Positive 348 Assistance Dogs process in place Positive

348 Disabled toilets Positive 348 Loop system in place Positive 348 Accessible Information Positive 348 Chaperone process in place Positive 348 no discrimination - gender Positive 348 no discrimination - race/ethnicity Positive

348 Community Language needs in Positive place 348 Race-1:1 support given Positive 348 signage Negative/Adverse 348 no discrimination - religion/belief Neutral

348 Religion & Belief met 1:1 basis Positive 348 access to spititual care team 24/7 Positive

348 Mental Health needs met 1:1 basis Positive

Hyperkalaemia Guidelines Guidance Jane Rodriguez 06/07/2010 338 No discrimination noted Neutral 06/07/2011 No Management of Emergencies in the Guidance Jane Rodriguez06/07/2010 339 No discrimination noted Neutral 06/07/2011 No Renal Dialysis Unit Acute Fenal Failure Guidance Jane Rodriguez 06/07/2010 336 No discrimination noted Neutral 06/07/2011 No



Full Date Review EQIA Owning Department Title Type Author Completed Common Themes Date Required Research and Development Policy on the Management of Policy Allyson Bailey 02/02/2010 281 No discrimination noted Neutral 02/02/2012 No Intellectual Property



Full Date Review EQIA Owning Department Title Type Author Completed Common Themes Date Required Respiratory Medicine NHS Forth Valley Guideline for the Guidance William Newman 29/05/2010 314 No discrimination noted Neutral 29/05/2012 No Management of Suspected Pulmonary Embolus in Secondary Care



Full Date Review EQIA Owning Department Title Type Author Completed Common Themes Date Required Respiratory Medicine Respiratory Laboratory, Forth Valley Function Barbara Oatway12/06/2010 344 Child friendly Neutral 12/06/2012 No Royal Hospital 344 no discrimination - disability Neutral 344 Disability:1:1 need met Positive 344 Accessible Venues arranged Positive 344 Interprters available BSL Positive 344 Assistance Dogs process in place Positive

344 Disabled toilets Positive 344 Appointments can be made via Positive phone 344 no discrimination - gender Neutral 344 Chaperone process in place Positive 344 no discrimination - race/ethnicity Neutral

344 Community Language needs in Positive place 344 Accessible Information Positive 344 Race-1:1 support given Positive 344 signage Negative/Adverse 344 no discrimination - religion/belief Neutral



344 Staff training Positive 344 Gypsy travellers Neutral 344 Homeless people Neutral 344 Criminal justice- support 1:1 basis Positive

344 Literacy needs considered Positive 344 Low income needs considered Positive 344 Scottish Ambulance Service /Rural Neutral areas Completed Equality Impact Assessments Printed on 9-Feb-2011 10:13 of 43


Full Date Review EQIA Owning Department Title Type Author Completed Common Themes Date Required Respiratory Medicine Nebuliser Guideline for the in patient Guidance Olwyn Lamont15/06/2010 328 No discrimination noted Neutral 15/06/2011 No management of COPD and Asthma

Bronchoscopy guideline Guidance D Morrison 27/10/2010 422 No discrimination noted Neutral 27/10/2012 No BiPAP guideline Guidance D Morrison 27/10/2010 430 No discrimination noted Neutral 27/10/2012 No Hospital acquired pneumonia guideline Guidance D Morrison27/10/2010 428 No discrimination noted Neutral 27/10/2012 No

Risk Management NHSFV Health and Safety Policy Policy Peter Mackie 05/11/2010 426 No discrimination noted Neutral 05/11/2012 No 426 staff Positive

Completed Equality Impact Assessments Printed on 9-Feb-2011 10:13 Page

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Full Date Review EQIA Owning Department Title Type Author Completed Common Themes Date Required Salaried Dental Services Salaried Dental Services Service Cindy Wright 09/09/2010 389 no discrimination - age Neutral 09/09/2012 No 389 Child friendly Positive 389 Environmental Access Positive 389 signage Negative/Adverse 389 Loop system in place Positive 389 Disability:1:1 need met Positive 389 Interprters available BSL Positive 389 Assistance Dogs process in place Positive

389 no discrimination - gender Neutral 389 Chaperone process in place Positive 389 Religion & Belief met 1:1 basis Positive 389 baby changing facilities Positive 389 Information in community languages Positive

389 Religion & Belief met 1:1 basis Positive 389 Staff speak eastern European Positive languages fluently 389 Gypsy travellers Neutral 389 Homeless people Neutral 389 Criminal justice- support 1:1 basis Positive

389 Literacy needs considered Positive 389 Home visits can be arranged Positive Scottish Simulation Centre The Scottish Clinical Simulation Centre Service Gary Buchanan25/05/2010 327 No discrimination noted Neutral 26/05/2012 No 327 staff Positive

Completed Equality Impact Assessments Printed on 9-Feb-2011 10:13 Page 23 of 43


Full Date Review EQIA Owning Department Title Type Author Completed Common Themes Date Required Sexual Health NHS Forth Valley Central Sexual Service Robby Duffy 01/12/2010 439 Age Neutral 01/12/2011 No Health Services 439 specific service available 21 and Positive below 439 NHS Ecucator working with Positive teachers in schools etc 439 Disability:1:1 need met Positive 439 Accessible Information Positive 439 web site available Positive 439 Interprters available BSL Positive 439 Learning disability support avilable Positive

439 mes health clinic available Positive 439 Gender Based Violnec work ongoing Positive

439 Transgender Etiquette in place Positive 439 service delivery re victims/survivors Positive sexual abuse 439 race and ethnicity Positive 439 Religion & Belief met 1:1 basis Positive 439 Chaperone process in place Positive 439 Men having sex with men project Neutral ongoing 439 sexual orientation Neutral 439 Homeless people Negative/Adverse 439 Criminal Justice system needs met Positive

439 Literacy needs considered Positive 439 Rural areas Positive



Full Date Review EQIA Owning Department Title Type Author Completed Common Themes Date Required Smoking Cessation Service Acute Smoking Cessation Service Service Yvonne Pringle 19/04/2010 304 Age Neutral 19/09/2010 No 304 Accessible Information Positive 304 Disability:1:1 need met Positive 304 Patient transport Negative/Adverse 304 gender Positive 304 no discrimination - gender Neutral 304 no discrimination - race/ethnicity Neutral

304 no discrimination - religion/belief Neutral


304 staff Positive 304 Gypsy Travellers Positive 304 Criminal Justice system Positive 304 Homeless people Positive 304 Literacy needs considered Positive 304 Low income needs considered Positive 304 Mental Health Problems Positive 304 Rural areas Positive Smoking Cessation Out Of Hours Guidance Yvonne Pringle 01/08/2010 362 no discrimination - age Neutral 01/09/2011 No Guidelines For Maternity In-patients 362 no discrimination - gender Neutral 362 Accessible Information Positive 362 Community Language needs in Positive place 362 Interprters available BSL Positive 362 Literacy needs considered Positive 362 staff Positive 362 no discrimination - religion/belief Neutral




Full Date Review EQIA Owning Department Title Type Author Completed Common Themes Date Required Smoking Cessation Service Acute Smoking Cessation Guidance Guidance Yvonne Pringle01/08/2010 372 Accessible Information Positive 01/09/2011 No 372 Community Language needs in Positive place 372 no discrimination - age Neutral 372 no discrimination - gender Neutral 372 no discrimination - s/orientation Neutral


372 Disability:1:1 need met Positive Smoking Cessation Out Of Hours Guidance Yvonne Pringle 01/08/2010 366 no discrimination - age Neutral 01/09/2011 No Guidelines Flow chart 366 no discrimination - gender Neutral 366 Accessible Information Positive 366 Community Language needs in Positive place 366 Interprters available BSL Positive 366 Literacy needs considered Positive 366 staff Positive



Full Date Review EQIA Owning Department Title Type Author Completed Common Themes Date Required Speech and Language Forth Valley Family File ( Hearing Guidance Frances McMenemy 19/05/2010 317 Age Positive 19/05/2013 No Impairment – Information for Parents) 317 Disability:1:1 need met Positive & Guidelines for professionals on using the Family File 317 Accessible Information Positive 317 race and ethnicity Positive 317 religion and belief Neutral 317 sexual orientation Neutral 317 Rural areas Positive 317 staff Positive Speech & Language Therapy Guidance Frances Macmenamy 09/06/2010 09/06/2013 No Guidelines for Paediatric referrals to Audiology Speech and Language Therapy Service Carol Easdon 20/09/2010 432 Age Positive 20/09/2010 No Service, Therapy Area, FVRH 432 Learning disability support avilable Positive 432 Accessible Information Positive 432 Accessible Venues arranged Positive 432 transgender needs met Positive 432 Community Language needs in Positive place 432 religion and belief Neutral 432 sexual orientation Neutral 432 Gypsy travellers Neutral 432 Homeless people - link with local Neutral projects 432 Criminal justice- support 1:1 basis Positive



Full Date Review EQIA Owning Department Title Type Author Completed Common Themes Date Required Spiritual Care Spiritual Care Policy (2010) Policy Margery Collin 04/10/2010 431 Age Neutral 04/10/2013 No 431 gender Neutral 431 Race-1:1 support given Neutral 431 religion and belief Positive 431 Religion & Belief met 1:1 basis Positive 431 Staff training Positive 431 sexual orientation Neutral 431 Mental Health needs met 1:1 basis Positive

Stirling/clacks CHP Clacks/Stirling Youth Smoking Pilot for Service Anne Currie25/11/2010 437 Age Positive 25/11/2011 No Toolkit Development 437 Health promotion Positive 437 Inequalities in health- ongoing Negative/Adverse review Strategic Projects and Property Travel Plan – Forth Valley Royal Policy Mark Craske 16/03/2010 16/03/2012 No Hospital RIA of Outline Business Case for Service Morag Farquhar 06/10/2010 420 Age 18+ Neutral 31/01/2011 Yes Falkirk Community Hospital 420 Accessible Venues arranged Positive 420 Accessible Car Parking in place Positive

420 Transport plans in place Positive 420 Single rooms available Positive 420 Staff changing facilties available Positive

420 race and ethnicity Neutral 420 religion and belief Neutral 420 sexual orientation Neutral 420 Criminal Justice system Neutral 420 Rural areas Positive RIA of Standard Business Case for the Function Morag Farquhar01/12/2010 436 No discrimination noted Neutral 01/12/2011 Yes Upgrade of the Area Sterilisation and Decontamination Unit (ASDU)



Full Date Review EQIA Owning Department Title Type Author Completed Common Themes Date Required Subfertility Empirical Clomiphene Therapy Protocols Joyce Burrage 12/04/2010 311 Age Negative/Adverse 12/04/2010 No 311 Disability:1:1 need met Neutral 311 gender Positive 311 no discrimination - religion/belief Neutral

311 no discrimination - race/ethnicity Neutral

311 sexual orientation Negative/Adverse 311 staff Neutral 311 Gypsy Travellers Neutral 311 Homeless people Negative/Adverse 311 Criminal Justice system Negative/Adverse 311 Literacy needs considered Neutral 311 Low income needs considered Neutral 311 Mental Health Problems Negative/Adverse 311 Rural areas Neutral Eligibility Criteria for Level II Ovulation Protocols Joyce Burrage12/04/2010 310 Age Negative/Adverse 12/04/2010 No Induction 310 Disability:1:1 need met Neutral 310 gender Positive 310 Race-1:1 support given Neutral 310 no discrimination - religion/belief Neutral

310 sexual orientation Negative/Adverse 310 staff Neutral 310 Gypsy Travellers Neutral 310 Homeless people Negative/Adverse 310 Criminal Justice system Negative/Adverse 310 Literacy needs considered Neutral 310 Low income needs considered Neutral



Full Date Review EQIA Owning Department Title Type Author Completed Common Themes Date Required Subfertility Eligibility criteria for In Vetro Protocols Joyce Burrage 12/04/2010 309 Age Negative/Adverse 12/04/2010 No Fertilisation (IVF) and Intra- 309 Disability:1:1 need met Neutral Cytoplasmic Sperm Injection (ICSI) 309 gender Positive 309 no discrimination - race/ethnicity Neutral


309 sexual orientation Negative/Adverse 309 staff Neutral 309 Gypsy Travellers Neutral 309 Homeless people Negative/Adverse 309 Criminal Justice system Negative/Adverse 309 Literacy needs considered Neutral 309 Mental Health Problems Neutral New Patient Appointment Protocols Joyce Burrage 12/04/2010 307 Age Negative/Adverse 12/04/2010 No 307 Disability:1:1 need met Neutral 307 gender Positive 307 no discrimination - race/ethnicity Neutral


307 sexual orientation Negative/Adverse 307 staff Positive 307 Gypsy Travellers Neutral 307 Criminal Justice system Negative/Adverse 307 Homeless people Negative/Adverse 307 Literacy needs considered Neutral 307 Low income needs considered Neutral 307 Mental Health Problems Neutral



Full Date Review EQIA Owning Department Title Type Author Completed Common Themes Date Required Subfertility Ovarian Follicle Ultrasound Tracking Protocols Joyce Burrage12/04/2010 306 Age Negative/Adverse 12/04/2010 No Scans 306 Disability:1:1 need met Neutral 306 gender Positive 306 no discrimination - race/ethnicity Neutral


306 sexual orientation Negative/Adverse 306 staff Positive 306 Gypsy travellers Neutral 306 Homeless people Negative/Adverse 306 Criminal Justice system Negative/Adverse 306 Literacy needs considered Neutral 306 Low income needs considered Neutral 306 Mental Health Problems Neutral 306 Rural areas Neutral Criteria for Tubal Patency Testing Protocols Joyce Burrage 12/04/2010 305 Age Negative/Adverse 12/04/2010 No 305 Disability:1:1 need met Neutral 305 gender Positive 305 no discrimination - race/ethnicity Neutral


305 sexual orientation Negative/Adverse 305 staff Positive 305 Gypsy Travellers Neutral 305 Homeless people Negative/Adverse 305 Criminal Justice system Negative/Adverse 305 Literacy needs considered Neutral 305 Low income needs considered Neutral 305 Mental Health Problems Neutral 305 Rural areas Neutral



Full Date Review EQIA Owning Department Title Type Author Completed Common Themes Date Required Subfertility Weight management and infertility Protocols Joyce Burrage 12/04/2010 301 Age Negative/Adverse 12/04/2012 No treatment 301 Disability:1:1 need met Neutral 301 gender Positive 301 no discrimination - race/ethnicity Neutral


301 sexual orientation Negative/Adverse 301 staff Positive 301 Gypsy Travellers Neutral 301 Criminal Justice system Negative/Adverse 301 Homeless people Negative/Adverse 301 Accessible Information Positive 301 Literacy needs considered Neutral 301 Mental Health Problems Neutral 301 Rural areas Neutral Management of Subfertility Patients in Protocols Joyce Burrage12/04/2010 308 Age Negative/Adverse 12/04/2010 No NHS Forth Valley 308 Disability:1:1 need met Neutral 308 gender Positive 308 no discrimination - race/ethnicity Neutral

308 Accessible Information Positive 308 no discrimination - religion/belief Neutral

308 staff Positive 308 Gypsy Travellers Neutral 308 Criminal Justice system Negative/Adverse 308 Literacy needs considered Neutral 308 Low income needs considered Neutral Substance Action Team Methadone/Buprenorphine Assisted Guidance Claire McIntosh11/01/2010 280 No discrimination noted Positive 11/01/2013 No Treatment



Full Date Review EQIA Owning Department Title Type Author Completed Common Themes Date Required Transport Services NHS FORTH VALLEY WASTE Policy Gerald Ferrie 12/03/2010 289 No discrimination noted Neutral 30/03/2010 No DISPOSAL OPERATIONAL POLICY



Full Date Review EQIA Owning Department Title Type Author Completed Common Themes Date Required Women and Children’s Weighing guidelines for newborn Protocols Elaine Ronald 20/05/2010 346 no discrimination - age Neutral 20/05/2012 No Services infants 346 Disability:1:1 need met Neutral 346 Gender specific service Positive 346 Breast feeding facilities Positive 346 Community Language needs in Positive place 346 no discrimination - religion/belief Neutral


346 staff Positive Weighing guidelines for newborn Service Elaine Ronald 20/05/2010 316 No discrimination noted Neutral 20/05/2012 No infants 316 gender Positive Procedure for administration of MMR Guidance R Duffy30/06/2010 444 Age Neutral 30/06/2013 No vaccine 444 Accessible Information Positive 444 Disability:1:1 need met Positive 444 Gender specific service Positive 444 Community Language needs in Positive place 444 religion and belief Neutral 444 sexual orientation Neutral 444 staff Positive 444 Criminal justice- support 1:1 basis Neutral

Intra and Post Partum Bladder Care Protocols Debbie Forbes 10/08/2010 378 No discrimination noted Neutral 06/07/2012 No 378 Disability:1:1 need met Neutral 378 Gender specific service Neutral 378 Race-1:1 support given Neutral 378 staff Positive 378 Literacy needs considered Positive 378 Gypsy travellers Neutral 378 Criminal Justice system Neutral



Full Date Review EQIA Owning Department Title Type Author Completed Common Themes Date Required Women and Children’s Minor Ante-Partum Haemorrhage Service Debbie Forbes 10/08/2010 417 No discrimination noted Neutral 04/04/2012 No Services 417 Disability:1:1 need met Neutral 417 Accessible Information Neutral 417 Gender specific service Neutral 417 Race-1:1 support given Neutral 417 Religion & Belief met 1:1 basis Neutral 417 staff Positive 417 Gypsy Travellers Neutral 417 Homeless people Neutral 417 Criminal justice- support 1:1 basis Neutral

Protocol for women who wish to Service Debbie Forbes 10/08/2010 418 No discrimination noted Neutral 04/04/2012 No dispose of their own placenta 418 Accessible Information Neutral 418 Disability:1:1 need met Neutral 418 Gender specific service Neutral 418 Race-1:1 support given Neutral 418 Religion & Belief met 1:1 basis Neutral 418 staff Positive 418 Gypsy travellers Neutral 418 Homeless people Neutral 418 Criminal justice- support 1:1 basis Neutral

Epidural in labour - procedure Service Anne Paterson 10/08/2010 358 No discrimination noted Neutral 01/08/2012 No 358 Disability:1:1 need met Neutral 358 Race-1:1 support given Neutral 358 Gender specific service Neutral 358 staff Positive Steroid Therapy Service Debbie Forbes 10/08/2010 423 No discrimination noted Neutral 05/10/2011 No 423 staff Positive



Full Date Review EQIA Owning Department Title Type Author Completed Common Themes Date Required Women and Children’s Home Birth Service Anne Paterson 10/08/2010 357 no discrimination - age Neutral 01/01/2012 No Services 357 no discrimination - disability Neutral 357 Disability:1:1 need met Neutral 357 Gender specific service Neutral 357 no discrimination - race/ethnicity Neutral



357 staff Positive 357 Gypsy travellers- risk assesment Neutral completed 357 Criminal Justice system needs met Neutral

Syntocinon Infusion Service Debbie Forbes 10/08/2010 424 No discrimination noted Neutral 20/01/2012 No 424 staff Positive Documentation for Vaginal Examination Service Debbie Forbes10/08/2010 425 No discrimination noted Neutral 20/01/2012 No 425 staff Positive Fetal Blood Sampling (FBS) Service Debbie Forbes 10/08/2010 393 No discrimination noted Neutral 04/08/2012 No Undiagnosed Vaginal Breech Delivery Service Debbie Forbes10/08/2010 383 No discrimination noted Neutral 20/01/2012 No

Calling General Theatre Team - Protocols Anne Paterson 10/08/2010 377 no discrimination - age Neutral 01/08/2011 No Procedure 377 Disability:1:1 need met Neutral 377 no discrimination - disability Neutral 377 Gender specific service Neutral 377 Race-1:1 support given Neutral 377 no discrimination - religion/belief Neutral




Full Date Review EQIA Owning Department Title Type Author Completed Common Themes Date Required Women and Children’s Transferring patient to theatre in Protocols Anne Paterson 10/08/2010 376 Age Negative/Adverse 01/04/2012 No Services Queen Elizabeth Wing (QEW) – 376 no discrimination - disability Neutral Procedure 376 Disability:1:1 need met Neutral 376 Gender specific service Neutral 376 no discrimination - race/ethnicity Neutral

376 Race-1:1 support given Neutral 376 no discrimination - religion/belief Neutral


376 staff Positive Protocol for Chlamydia Testing In Protocols Anne Paterson 10/08/2010 375 no discrimination - age Neutral 01/04/2012 No Pregnant Women 375 no discrimination - disability Neutral 375 Disability:1:1 need met Neutral 375 Gender specific service Neutral 375 Race-1:1 support given Neutral 375 no discrimination - religion/belief Neutral


375 staff Positive Management of women with suspected Protocols Anne Paterson10/08/2010 374 no discrimination - age Neutral 01/04/2012 No anaphylaxis in hospital - Protocol 374 no discrimination - disability Neutral 374 Disability:1:1 need met Neutral 374 Gender specific service Neutral 374 Race-1:1 support given Neutral 374 no discrimination - race/ethnicity Neutral



374 staff Positive Completed Equality Impact Assessments Printed on 9-Feb-2011 10:13 Page 37 of 43


Full Date Review EQIA Owning Department Title Type Author Completed Common Themes Date Required Women and Children’s Sepsis in Maternity Patients - Protocol Protocols Anne Paterson10/08/2010 373 No discrimination noted Neutral 01/04/2012 No Services 373 Disability:1:1 need met Neutral 373 Race-1:1 support given Neutral 373 staff Positive 373 Gender specific service Neutral Examination 0f Placenta - Procedure Service Anne Paterson10/08/2010 370 No discrimination noted Neutral 01/06/2012 No 370 Disability:1:1 need met Neutral 370 Race-1:1 support given Neutral 370 Gender specific service Neutral 370 staff Positive Pressure area care for women who Service Anne Paterson 10/08/2010 369 No discrimination noted Neutral 01/06/2012 No have restricted mobility - Protocol 369 Disability:1:1 need met Neutral Pressure area care for women in labour - Protocol 369 Gender specific service Neutral 369 staff Positive Home Birth Service Anne Paterson 10/08/2010 01/01/2012 No Pressure area care for women who Service Anne Paterson 10/08/2010 01/06/2012 No have restricted mobility - Protocol Pressure area care for women in labour - Protocol

External Cephalic Version Service Debbie Forbes 10/08/2010 384 No discrimination noted Neutral 05/10/2011 No 384 Disability:1:1 need met Neutral 384 Race-1:1 support given Neutral 384 staff Positive 384 Criminal Justice system Neutral 384 Homeless people Neutral 384 Gypsy travellers Neutral 384 Literacy needs considered Positive



Full Date Review EQIA Owning Department Title Type Author Completed Common Themes Date Required Women and Children’s Supporting Women to Disclose Guidance Valerie Arbuckle 01/09/2010 434 Age Neutral 01/09/2012 No Services Domestic Abuse During Pregnancy 434 Disability:1:1 need met Neutral 434 Gender Based Violnec work ongoing Positive

434 Accessible Information Positive 434 Community Language needs in Positive place 434 Religion & Belief met 1:1 basis Neutral 434 sexual orientation Neutral 434 staff Positive Thyroid Pathway Guidance Debbie Forbes 14/09/2010 399 Accessible Information Positive 14/09/2012 No 399 Criminal justice- support 1:1 basis Positive

399 Disability:1:1 need met Positive 399 Interprters available BSL Positive 399 Community Language needs in Positive place 399 access to spititual care team 24/7 Positive

399 No discrimination noted Positive 399 staff Positive Antenatal Care of women with pre- Protocols Debbie paterson 14/09/2010 415 access to spititual care team 24/7 Positive 14/09/2012 No existing diabetes (Type 1 &2) admitted to ward 415 Accessible Information Positive 415 Community Language needs in Positive place 415 Disability:1:1 need met Positive 415 Interprters available BSL Positive 415 No discrimination noted Neutral 415 staff Neutral



Full Date Review EQIA Owning Department Title Type Author Completed Common Themes Date Required Women and Children’s Diabetic Ketoacidosis in pregancy Protocols debbioe forbes 14/09/2010 414 access to spititual care team 24/7 Positive 14/09/2012 No Services 414 Accessible Information Positive 414 Community Language needs in Positive place 414 No discrimination noted Neutral 414 Interprters available BSL Positive 414 Gender specific service Neutral 414 staff Positive Management of women with Protocols debbie Forbes 14/09/2010 413 access to spititual care team 24/7 Positive 14/09/2012 No gestantional diabetes on Insulin 413 Accessible Information Positive 413 Community Language needs in Positive place 413 Interprters available BSL Positive 413 No discrimination noted Neutral 413 staff Positive 413 Gender specific service Neutral Management of hypogycemia in Protocols debbie forbes 14/09/2010 412 access to spititual care team 24/7 Positive 14/09/2012 No Pregnancy 412 Accessible Information Positive 412 Community Language needs in Positive place 412 Interprters available BSL Positive 412 Disability:1:1 need met Positive 412 Gender specific service Positive 412 staff Positive



Full Date Review EQIA Owning Department Title Type Author Completed Common Themes Date Required Women and Children’s Management in labour of women with Guidance debbie Forbes14/09/2010 411 No discrimination noted Neutral 14/09/2012 No Services preexisting Diabetes (Type 1&2) 411 Accessible Information Positive 411 Community Language needs in Positive place 411 Interprters available BSL Positive 411 Gender specific service Neutral 411 staff Positive Steriod Therapy Guidance Debbie Forbes 14/09/2010 400 No discrimination noted Neutral 14/09/2012 No 400 Accessible Information Positive 400 Community Language needs in Positive place 400 Interprters available BSL Positive 400 Criminal justice- support 1:1 basis Positive


400 staff Positive Guideline for using Metformin in GDM Guidance Debbie Forbes14/09/2010 398 No discrimination noted Neutral 14/09/2012 No between 28 and 34* weeks gestation 398 Criminal justice- support 1:1 basis Neutral 398 Gender specific service Neutral 398 Accessible Information Positive 398 Community Language needs in Positive place 398 Interprters available BSL Positive 398 access to spititual care team 24/7 Positive

398 staff Positive



Full Date Review EQIA Owning Department Title Type Author Completed Common Themes Date Required Women and Children’s Diabetes Pregnancy Care Checklist Guidance Debbie Forbes 14/09/2010 396 access to spititual care team 24/7 Positive 14/09/2012 No Services 396 Accessible Information Positive 396 Disability:1:1 need met Positive 396 Community Language needs in Positive place 396 No discrimination noted Neutral 396 staff Positive 396 Gender specific service Positive Antenatal Clinic Guidelines for Guidance Debbie Forbes 14/09/2010 395 access to spititual care team 24/7 Positive 14/09/2012 No Diabetes Multi disciplinary Team for Patients with Pre-Existing Diabetes 395 Community Language needs in Positive (Type 1 and type 2) not for GDM place 395 No discrimination noted Neutral 395 Accessible Information Positive 395 staff Positive Antenatal Care outline women with Guidance Debbei Forbes 14/09/2010 401 Community Language needs in Positive 14/09/2012 No preexisting diabetes type 1&2 and place gestational diabetes 401 No discrimination noted Neutral 401 Criminal justice- support 1:1 basis Neutral

401 Interprters available BSL Positive 401 Gender specific service Neutral 401 access to spititual care team 24/7 Positive

401 staff Positive Protocol – Safety of Staff Working in Protocols Debbie Forbes25/10/2010 427 staff Positive 22/10/2012 No Community 427 No discrimination noted Neutral NHS FORTH VALLEY SCAN Protocols Debbie Forbes 25/10/2010 429 No discrimination noted Neutral 25/10/2012 No PROTOCOLS 429 staff Positive



Full Date Review EQIA Owning Department Title Type Author Completed Common Themes Date Required Women and Children’s NHS FORTH VALLEY Protocols Debbie Forbes 03/11/2010 433 Accessible Information Neutral 03/11/2012 No Services BEREAVEMENT PROTOCOLS 433 Community Language needs in Neutral place 433 No discrimination noted Neutral 433 Criminal justice- support 1:1 basis Neutral

NHS FORTH VALLEY Protocols Debbie Forbes 03/11/2010 03/11/2012 No BEREAVEMENT PROTOCOLS


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