January 2011 - Regulation and Quality Improvement Authority
January 2011 - Regulation and Quality Improvement Authority
January 2011 - Regulation and Quality Improvement Authority
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Agenda Item <br />
Paper <br />
AGENDA<br />
RQIA Board Meeting<br />
Board Room, 9th Floor, Riverside Tower<br />
13 <strong>January</strong> <strong>2011</strong>, 2:00pm<br />
PUBLIC SESSION<br />
Item<br />
Paper Ref<br />
1 Welcome <strong>and</strong> Chairman's remarks 2:00pm<br />
2 Minutes of the meeting of the Board held on<br />
Thursday 11 November<br />
min/Nov10/<br />
public<br />
2:05pm<br />
APPROVE<br />
3 Matters arising from minutes 2:10pm<br />
4 Declaration of Interests 2:15pm<br />
5 Chairman's report - Chairman A/01/11 2:20pm<br />
NOTE<br />
6 Chief Executive's Report - Chief Executive B/01/11 2:25pm<br />
NOTE<br />
7 Finance Report - Director of Corporate<br />
Services<br />
8 <strong>Regulation</strong> of Private Dentistry - Director of<br />
Operations<br />
C/01/11<br />
D/01/11<br />
2:40pm<br />
NOTE<br />
2:55pm<br />
NOTE<br />
9 Update on IRMER - Director of Operations E/01/11 3:15pm<br />
NOTE<br />
10 Presentation on Key Issues Raised by NIAO<br />
Report, "Arrangements for Ensuring the <strong>Quality</strong><br />
of Care in Homes for Older People" - Chief<br />
Executive<br />
11 Update on Information Governance - Director of<br />
Corporate Services<br />
12 Mental Health <strong>and</strong> Learning Disability - Director<br />
of Operations<br />
F/01/11<br />
G/01/11<br />
3:30pm<br />
NOTE<br />
3:50pm<br />
NOTE<br />
4:00pm<br />
NOTE<br />
13 Any Other Business 4:10pm<br />
Page 1 of 2
Agenda Item <br />
Paper <br />
Date of next meeting:<br />
23 March <strong>2011</strong>, Venue TBC<br />
Page 2 of 2
RQIA Board Meeting<br />
Date of Meeting 13 <strong>January</strong> <strong>2011</strong><br />
Title of Paper<br />
Public Session Minutes<br />
Agenda Item 2<br />
Reference<br />
Author<br />
Presented by<br />
Purpose<br />
Executive Summary<br />
FOI Exemptions<br />
Applied<br />
Equality Impact<br />
Assessment<br />
Recommendation/<br />
Resolution<br />
Next steps<br />
min / Nov10 / public<br />
Robert Graham<br />
Dr Ian Carson<br />
To share with Board members a record of the last<br />
meeting of the RQIA Board.<br />
The minutes contain an overview of the key<br />
discussion points <strong>and</strong> decisions from the last<br />
Board meeting on 11 November 2010.<br />
None<br />
Not applicable<br />
The Board is asked to APPROVE the minutes of<br />
the Board meeting of 11 November 2010.<br />
The minutes will be formally signed off by the<br />
Chairman <strong>and</strong> will be uploaded onto the RQIA<br />
website.<br />
Page 1 of 12
PUBLIC SESSION MINUTES<br />
RQIA Board Meeting<br />
Board Room, Holywell Hospital, Steeple Road, Antrim<br />
11 November 2010, 2:00pm<br />
Present<br />
Ian Carson (Chairman)<br />
Richard Adams<br />
Geraldine Donaghy<br />
Lilian Jennett<br />
Ruth Laird<br />
Allen McCartney<br />
Patricia McCoy<br />
Una O’Kane<br />
Colin Reid<br />
Austin Smith<br />
Apologies<br />
None<br />
Officers of the Board present<br />
Glenn Houston (Chief Executive)<br />
Maurice Atkinson (Director of Corporate Services)<br />
Robert Graham (Committee Services Manager)<br />
Theresa Nixon (Director of <strong>Quality</strong> Assurance)<br />
Phelim Quinn (Director of Operations)<br />
David Stewart (Director of Service <strong>Improvement</strong>)<br />
Apologies<br />
None<br />
10.127 Welcome <strong>and</strong> Chairman's Remarks<br />
10.127.1 The Chairman welcomed Board members <strong>and</strong> Officers of the Board<br />
to the meeting.<br />
10.128 Minutes of the meeting of the Board held on Thursday 2<br />
September [Paper min/Sept/10]<br />
10.128.1 The Board APPROVED the minutes of the Board meeting held on 2<br />
September.<br />
Resolved Actions<br />
• Minutes to be formally signed off by the Chairman<br />
10.129 Matters arising from minutes<br />
10.117.5 Prisons Strategy<br />
10.129.1<br />
A Board member asked for an update on the development of an<br />
RQIA Prisons Strategy. The Director of Operations confirmed that<br />
an initial paper had been prepared but that there had been a delay in<br />
taking forward this work.<br />
10.130 Declaration of Interests<br />
10.130.1 The Chairman asked Board members if, following consideration of<br />
the agenda items, any interests were required to be declared in line<br />
Page 2 of 12
with St<strong>and</strong>ing Orders. No declarations of interests were made.<br />
10.131 Chairman's report - Chairman [Paper E/06/10]<br />
10.131.1<br />
10.131.2<br />
10.131.3<br />
The Chairman presented his report to the Board <strong>and</strong> began by<br />
advising that he had attended the CIPFA conference on the strategic<br />
implications of the Comprehensive Spending Review.<br />
The Chairman noted that the meeting with the Minister regarding the<br />
McDermott Review needed to be added to the Report.<br />
The Board NOTED the Chairman's Report.<br />
10.132 Chief Executive's Report - Chief Executive [Paper F/06/10]<br />
10.132.1<br />
10.132.2<br />
10.132.3<br />
10.132.4<br />
The Chief Executive began by thanking the review team involved in<br />
the McDermott Review for their work in completing the report. He<br />
advised Board members that he had met with survivors to share the<br />
report <strong>and</strong> to address any concerns they had with the findings. He<br />
added that the Director for Service <strong>Improvement</strong> had also held a<br />
separate meeting with another survivor, who was satisfied with the<br />
review RQIA had undertaken but felt that the terms of reference<br />
could have been extended. The Chief Executive also thanked Lorna<br />
Conn for her contribution during the review.<br />
The Chief Executive presented his report <strong>and</strong> outlined some of the<br />
key meetings he had attended since the previous Board meeting. He<br />
made reference to a useful meeting with the Permanent Secretary<br />
<strong>and</strong> the Chief Executive of the Patient Client Council. He added that<br />
he had also met with the Permanent Secretary to discuss the<br />
forthcoming Public Accounts Committee hearing following the<br />
publication of the NIAO report on the care of elderly people in<br />
residential <strong>and</strong> nursing homes.<br />
The Chief Executive advised Board members that the mid-year<br />
accountability review meeting with DHSSPS had taken place at the<br />
end of October <strong>and</strong> that the meeting had been positive. He said that,<br />
along with the Chairman, he had shared concerns with the Chief<br />
Medical Officer about vacancies in key positions. He undertook to<br />
share a minute of the meeting with Board members once it became<br />
available.<br />
The Chief Executive moved on to update on progress in respect of<br />
reviews. He advised that the Child <strong>and</strong> Adolescent Mental Health<br />
(CAMHS) Review had been submitted to DHSSPS on 8 November<br />
following incorporation of comments made by Board members. He<br />
told the Board that RQIA had completed its first inspections under<br />
the Ionising Radiation (Medical Exposure) <strong>Regulation</strong>s (IRMER) <strong>and</strong><br />
that a summary report on the key findings of these inspections would<br />
be brought to the Board in early <strong>2011</strong>.<br />
Page 3 of 12
10.132.5<br />
10.132.6<br />
10.132.7<br />
10.132.8<br />
10.132.9<br />
10.132.10<br />
10.132.11<br />
The Chief Executive informed the Board that the Director of<br />
Operations had attended the most recent EPSO (European<br />
Partnership of Supervisory Organisations) conference at which<br />
almost 20 European nations were represented. He told Board<br />
members that RQIA had volunteered to host the conference<br />
scheduled for October/November <strong>2011</strong>.<br />
The Chief Executive advised that the Finance Manager, Paul Gick,<br />
was leaving RQIA on 11 November <strong>and</strong> that an Interim Finance<br />
Manager, Jonathan King, had been appointed.<br />
The Chief Executive updated the Board on communications matters.<br />
He told the Board that RQIA inspection reports are now accessible<br />
online. He also advised the Board that a series of meetings were<br />
being organised with the Health Committee spokespersons of the<br />
main political parties.<br />
The Chief Executive concluded his report by giving an update on<br />
quality assurance issues. He thanked Board Members for their<br />
contributions to the draft EFQM action plan.<br />
A Board member asked if RQIA would be able to measure the<br />
number of hits on its website, in particular, the sections where<br />
inspection reports are held. The Chief Executive said that the<br />
Communications Manager would make the necessary arrangements.<br />
He added that RQIA was intending to write out to all registered<br />
providers to advise them that inspection reports are now online.<br />
A Board member asked if the complaints training could be extended<br />
to Board members. The Director of <strong>Quality</strong> Assurance undertook to<br />
facilitate a session for Board members at a future workshop.<br />
The Board NOTED the Chief Executive's Report.<br />
10.133 Finance Report - Director of Corporate Services [Paper G/06/10]<br />
10.133.1<br />
10.133.2<br />
The Director of Corporate Services presented the Finance Report to<br />
the Board <strong>and</strong> explained that an additional non-recurring allocation<br />
had been added to the RRL in respect of funding for ICT equipment.<br />
He added that RQIA is actively pursuing the outst<strong>and</strong>ing debts in<br />
relation to registration fees.<br />
The Director of Corporate Services advised the Board that RQIA's<br />
projected end of year position is a deficit of £34k but he was hopeful<br />
that with current financial controls, RQIA should be able to achieve<br />
break even. He added that at a recent meeting with DHSSPS there<br />
was discussion on the definition of "break even" <strong>and</strong> he was awaiting<br />
clarification on this matter.<br />
Page 4 of 12
10.133.3<br />
10.133.4<br />
The Director of Corporate Services advised the Board that he was<br />
preparing a paper for submission to the Executive Management<br />
Team on a programme management approach to the efficiency<br />
measures outlined by RQIA in its savings proposals submitted to<br />
DHSSPS. The Chief Executive added that one of the proposals<br />
which concerned fee income, had been discussed at a recent<br />
meeting of the DHSSPS Board <strong>and</strong> that there was support for this<br />
proposal. He explained that a working group was to be established<br />
with terms of reference to be agreed between RQIA <strong>and</strong> DHSSPS.<br />
The Board NOTED the Finance Report.<br />
10.134 Corporate Performance Report - Director of Corporate Services<br />
[Paper H/06/10]<br />
10.134.1<br />
10.134.2<br />
10.134.3<br />
10.134.4<br />
10.134.5<br />
The Director of Corporate Services presented the Corporate<br />
Performance Report to the Board <strong>and</strong> explained that this report was<br />
a cumulative report for the first two quarters of 2010/11. He gave an<br />
overview of the RAG rating <strong>and</strong> said that at 30 September, 78% of<br />
actions were green <strong>and</strong> 22% amber <strong>and</strong> added that the main<br />
headline achievements were laid out in Section 3. He invited<br />
questions from Board members about the content of the report.<br />
The Chairman asked how RQIA staff have responded to the new<br />
format <strong>and</strong> if it had placed additional dem<strong>and</strong>s on their workload.<br />
The Director of Corporate Services said that the report was much<br />
easier to complete as managers simply updated the report from the<br />
previous quarter <strong>and</strong> that it enabled managers to remain focused on<br />
the achievement of KPIs. The Director of Operations added that<br />
managers were beginning to consider outcomes for <strong>2011</strong>/12.<br />
A Board member asked how the information contained in the report<br />
could be verified. The Director of Corporate Services explained that<br />
the traffic lights classification of actions was supported by KPIs <strong>and</strong><br />
information in the "headlines" section of the report. Furthermore, he<br />
explained that Internal Audit were due to carry out a Performance<br />
Management audit <strong>and</strong>, as part of this audit, they would look at the<br />
report <strong>and</strong> how the information contained in it is compiled.<br />
A Board member asked about action CA1.2.6 <strong>and</strong> how RQIA was<br />
seeking to obtain the views of service users. The Director of<br />
Operations said that RQIA is implementing an initiative to reduce the<br />
number of pre-inspection questionnaires that are sent out. He added<br />
that RQIA was considering employing two staff members who would<br />
liaise with service users in advance of inspections. In the meantime,<br />
he noted that RQIA was developing links with VOYPIC, AgeNI <strong>and</strong><br />
the Community Information Branch at DHSSPS.<br />
The Chief Executive explained that the recruitment for the two<br />
additional posts was on hold due to the current vacancy controls but<br />
Page 5 of 12
that RQIA was very keen to fill these posts. In response to concerns<br />
from Board members about the implications of not filling these posts,<br />
the Director of Operations explained that RQIA was trying to<br />
reconfigure the financial resources required from within existing<br />
resources <strong>and</strong> he hoped that there would be progress by the end of<br />
the next quarter.<br />
10.134.6<br />
The Board NOTED the Corporate Performance Report.<br />
10.135 Corporate Risk Assurance Framework Report - Director of<br />
Corporate Services [Paper I/06/10]<br />
10.135.1<br />
10.135.2<br />
10.135.3<br />
The Director of Corporate Services advised the Board that the<br />
Corporate Risk Assurance Framework Report had been considered<br />
by the Audit Committee at its meeting on 21 October <strong>and</strong> that<br />
following comments from Committee members, the format of the<br />
change log had been amended.<br />
The Director of Corporate Services explained that two risks had been<br />
removed from the register, one had been de-escalated to the<br />
Corporate Services directorate register <strong>and</strong> another had been<br />
removed entirely. He explained that the ratings of some of the other<br />
risks had been amended.<br />
The Board NOTED the Corporate Risk Assurance Framework<br />
Report.<br />
10.136 Audit Committee update - Committee Chairman [Paper J/06/10]<br />
10.136.1<br />
10.136.2<br />
10.136.3<br />
10.136.4<br />
The Committee Chairman informed Board members that the Audit<br />
Committee met on 21 October <strong>and</strong> asked members to note the<br />
minutes of the meeting of 1 July.<br />
The Committee Chairman advised that John Allen from DHSSPS<br />
had attended the meeting on 21 October. She gave an overview of<br />
the main areas covered at the meeting.<br />
The Committee Chairman said that the Committee had requested<br />
that Board members receive updated risk management training. The<br />
Committee have also requested a presentation at a future Board<br />
workshop about the new incident reporting procedures. She added<br />
that the Committee had approved the Mid Year Assurance Statement<br />
for submission to DHSSPS <strong>and</strong> had considered the outcomes of the<br />
recent financial audit. She told the Board that the Committee had<br />
received correspondence from NIAO regarding the preparation of<br />
end of year accounts but noted that RQIA had met with NIAO to<br />
discuss some of the issues highlighted.<br />
The Committee Chairman expressed the concerns of the Committee<br />
around the wording of the risk on the Corporate Risk Assurance<br />
Page 6 of 12
Framework Report about RQIA's reputation <strong>and</strong> suggested the<br />
Executive Team should revise this. She went on to say that the<br />
Committee had received an update on some of the VFM initiatives<br />
being considered but that there was still some work to do.<br />
10.136.5<br />
10.136.6<br />
10.136.7<br />
The Committee Chairman advised that an analysis of aged debt had<br />
been prepared <strong>and</strong> that actions were ongoing to recover the debt.<br />
She further advised that the Committee had considered a paper on<br />
the actions taken following an investigation into unredeemed<br />
cheques that had been found. She assured the Board that all<br />
necessary steps had been taken <strong>and</strong> that there would not be a<br />
recurrence.<br />
The Committee Chairman expressed her thanks, on behalf of the<br />
Committee, to Paul Gick who was leaving as Finance Manager. She<br />
thanked him for his work in supporting the Committee.<br />
The Board NOTED the Audit Committee update.<br />
10.137 Discussion Paper on Measuring Inspection Outcomes within the<br />
Regulated Sector - Director of Operations [Paper L/06/10]<br />
10.137.1<br />
10.137.2<br />
10.137.3<br />
The Director of Operations told the Board that the forthcoming NIAO<br />
Report on "Arrangements for Ensuring the <strong>Quality</strong> of Care in Homes<br />
for Older People" had pointed to a perceived inability of RQIA to<br />
monitor inspection outcomes. He explained that in comparison to the<br />
rest of the UK, RQIA was well advanced in this area <strong>and</strong> he pointed<br />
to further work being done to develop a new approach to RQIA's<br />
inspection planning process which would be covered in the next item.<br />
The Board expressed the view that the paper should be shared with<br />
the DHSSPS. The Chairman advised that the Chief Executive had<br />
shared the draft paper with the Permanent Secretary with regard to<br />
the impact of the proposals for the forthcoming PAC hearing.<br />
The Board NOTED the discussion paper on measuring inspection<br />
outcomes.<br />
10.138 Inspection Planning Approach Project - Director of Operations<br />
[Paper M/06/10]<br />
10.138.1<br />
10.138.2<br />
Dermot Parsons <strong>and</strong> Jacqui Murphy joined the meeting <strong>and</strong><br />
delivered two presentations which outlined to the Board the rationale<br />
for the inspection planning project <strong>and</strong> how the new inspection tool<br />
would work in practice.<br />
The Chairman expressed his view that this was an innovative <strong>and</strong><br />
exciting development for RQIA <strong>and</strong> would contribute towards the<br />
overall assessment of health <strong>and</strong> social care. He asked for further<br />
clarity on whether it was necessary to conduct a public consultation<br />
Page 7 of 12
<strong>and</strong> he asked what work would take place in December as part of the<br />
planning process.<br />
10.138.3<br />
10.138.4<br />
10.138.5<br />
10.138.6<br />
10.138.7<br />
The Director of Operations explained that in 2006, RQIA had publicly<br />
consulted on its inspection methodology which had been based on<br />
the principles of the Better <strong>Regulation</strong> Taskforce. Since then, RQIA<br />
had sought to develop a more risk-based <strong>and</strong> proportionate<br />
approach, but keeping in line with RQIA's statutory obligations. He<br />
noted that there were concerns about the new approach but<br />
explained that the new rationale for inspection was more scientific.<br />
From an equality point of view, he said that this methodology had<br />
scored relatively low <strong>and</strong> thus did not require a full equality impact<br />
assessment.<br />
The Director of Operations advised that in December, RQIA would<br />
be selecting the st<strong>and</strong>ards for inspection in <strong>2011</strong>/12. Following this,<br />
training would commence for staff on the use of the new tool <strong>and</strong><br />
then the schedule of inspections for the year would be developed.<br />
He acknowledged that there was a risk with the new approach but<br />
felt that in the absence of any current rationale for inspections, the<br />
risk was minimal. Jacqui Murphy added that RQIA had undertaken a<br />
pilot of the use of the tool <strong>and</strong> it had been shown to work well.<br />
A Board member commented that the new approach appeared to<br />
make good use of staff resources, but asked if it would place more<br />
reliance on self-evaluation. The Director of Operations advised that<br />
each registered establishment would continue to have its minimum<br />
two inspections <strong>and</strong> therefore, there would be validation of the selfassessment.<br />
A Board member said that the approach was an exciting<br />
development with a clear rationale but felt it was a change in public<br />
policy <strong>and</strong> asked about consultation. Dermot Parsons said that<br />
RQIA carries out an annual series of roadshows with registered<br />
providers <strong>and</strong> that last year, almost 1,000 people attended. He<br />
added that these workshops provided a good opportunity to discuss<br />
new ideas <strong>and</strong> that in the main, managers expressed a view that<br />
they did not wish to see a reduction in inspection activity. He said<br />
that it is RQIA's intention to meet with registered providers early in<br />
<strong>2011</strong> to share the new approach with them.<br />
A Board member asked about complaints <strong>and</strong> cautioned about<br />
organisations which may become complacent if their initial<br />
assessment showed them to be of low risk. The Director of<br />
Operations explained that any new information regarding e.g.<br />
complaints, would be inputted into the system to keep it current.<br />
Dermot Parsons added that no organisation would be treated as "low<br />
intensity" for two successive years. The Chief Executive added that<br />
RQIA would have indicators across all types of inspections - care,<br />
pharmacy, estates, finance to ensure as broad a picture could be<br />
Page 8 of 12
obtained on each registered facility.<br />
10.138.8<br />
10.138.9<br />
10.138.10<br />
10.138.11<br />
The Director of Operations told the Board that the overall<br />
responsibility lay with the Head of Programme <strong>and</strong> that over the<br />
coming months RQIA would begin to build up its intelligence base.<br />
The Chief Executive explained to Board members that this new<br />
methodology approach shows that RQIA can respond to any<br />
challenges raised by the NIAO report which had indicated that<br />
Northern Irel<strong>and</strong> lagged behind other areas of the UK in this regard.<br />
A Board member asked whether RQIA <strong>and</strong> the sector were ready for<br />
this change of approach. Another Board member felt that RQIA<br />
needed to raise awareness with service users <strong>and</strong> their families in<br />
areas such as complaints <strong>and</strong> whistleblowing.<br />
The Board APPROVED the inspection planning approach.<br />
10.139 Performance Management Framework - Director of Corporate<br />
Services [Paper K/06/10]<br />
10.139.1<br />
10.139.2<br />
10.139.3<br />
10.139.4<br />
The Director of Corporate Services presented the draft Performance<br />
Management Framework to the Board. He explained that this had<br />
been developed in line with the new Corporate Strategy <strong>and</strong> KPIs<br />
<strong>and</strong> that the framework sought to make the connection between<br />
performance measurement <strong>and</strong> performance management.<br />
The Director of Corporate Services explained that the model used<br />
within the framework was a "plan-do-review-revise" cycle <strong>and</strong> there<br />
were 4 identified within the model, i.e. where we want to be, how we<br />
will do it, how we are doing <strong>and</strong> how we need to act differently.<br />
The Chairman said that the framework was good <strong>and</strong> asked about<br />
the role of the Board <strong>and</strong> how this work linked with the December<br />
Board workshop with Bernard Marr. The Director of Corporate<br />
Services explained that the December workshop would focus more<br />
on the savings delivery plan. He added that in terms of performance<br />
management, the Board had a role to play in each stage of the cycle,<br />
<strong>and</strong> in particular, the "review" stage, where the purpose of the annual<br />
Board workshop would be to review the framework.<br />
The Board APPROVED the performance management framework.<br />
10.140 Audit of Inequalities Consultation Document - Director of<br />
Corporate Services [Paper N/06/10]<br />
10.140.1 The Director of Corporate Services told Board members that RQIA<br />
was required to have a new Equality Scheme in place by 1 May<br />
<strong>2011</strong>. He added that the Business Services Organisation (BSO) had<br />
helped to develop a template for an action plan (an "audit of<br />
Page 9 of 12
inequalities") which was broken down into the main work areas within<br />
RQIA.<br />
10.140.2<br />
10.140.3<br />
A Board member asked for further information on the proposed<br />
review of lay representation on review teams. The Director of<br />
Operation advised that RQIA would be working with AgeNI <strong>and</strong> the<br />
NI Chest, Heart <strong>and</strong> Stroke Association on future reviews. The Chief<br />
Executive added that organisations are approaching RQIA to inquire<br />
about opportunities for joint work.<br />
The Board APPROVED the audit of inequalities consultation<br />
document.<br />
10.141 Mental Health <strong>and</strong> Learning Disability / Update on a Rights<br />
Based Approach - Director of Operations [Paper O/06/10]<br />
10.141.1<br />
10.141.2<br />
10.141.3<br />
10.141.4<br />
10.141.5<br />
10.141.6<br />
10.141.7<br />
The Director of Operations presented the updated mental health <strong>and</strong><br />
learning disability report to the Board. He gave an overview of the<br />
serious adverse incidents (SAIs) recorded <strong>and</strong> noted that there were<br />
still some issues to be resolved following the introduction of new<br />
arrangements whereby incidents are reported to both RQIA <strong>and</strong> the<br />
HSC Board.<br />
The Director of Operations advised that progress continues to be<br />
made on reducing the errors in prescribed forms <strong>and</strong> guardianship<br />
applications. He added that a workstream will be developed to<br />
ensure that, in future, these forms could be received electronically.<br />
Board members were advised that the programme of inspections had<br />
commenced <strong>and</strong> that the programme for the final quarter would be<br />
reviewed shortly. It was further noted that the Guardianship <strong>and</strong><br />
Medical Panels were continuing to meet.<br />
The Director of Operations told the Board that RQIA had secured<br />
funding from GAIN to develop guidelines on the implementation of<br />
the Mental Health Order. As part of this, a web-based training<br />
package will be developed.<br />
The Director of Operations said that the Expert Advisory Panel had<br />
met <strong>and</strong> that a report on the work of the Panel would be brought to<br />
the Board in <strong>2011</strong>.<br />
A Board member asked if the reports from the mental health<br />
inspections would be made available online. The Director of<br />
Operations explained this would present difficulties in terms of<br />
patient identifiable information but that the team is considering how<br />
the key findings could be reported.<br />
The Board NOTED the update on mental health <strong>and</strong> learning<br />
disability.<br />
Page 10 of 12
10.142 Final Approval of Review Reports - Chief Executive<br />
10.142.1<br />
10.142.2<br />
10.142.3<br />
The Chief Executive advised Board members that RQIA was<br />
awaiting confirmation of publication of the review of the Northern<br />
Irel<strong>and</strong> Ambulance Service from DHSSPS. He asked if the Board<br />
would approve the publication of the report following any<br />
amendments required to be made. The Board APPROVED this<br />
approach.<br />
The Chief Executive advised that RQIA had received confirmation of<br />
publication for the Safeguarding Review Stages IV <strong>and</strong> V <strong>and</strong> the<br />
Review of Readiness for Revalidation <strong>and</strong> that these reports would<br />
be published shortly.<br />
The Board NOTED the update on review reports.<br />
10.143 Regional Healthcare Hygiene <strong>and</strong> Cleanliness St<strong>and</strong>ards <strong>and</strong><br />
Audit Tool <strong>and</strong> Inspection Process <strong>and</strong> Methodology - Director<br />
of Operations [Paper C/06/10]<br />
10.143.1<br />
10.143.2<br />
10.143.3<br />
10.143.4<br />
The Director of Operations advised Board members that RQIA had<br />
developed an audit tool for the hygiene inspection programme by<br />
working with other agencies such as DHSSPS <strong>and</strong> the Public Health<br />
Agency. He explained that RQIA would seek to undertake a full<br />
programme of announced <strong>and</strong> unannounced inspections by means<br />
of a three year rolling programme. He went on to explain the<br />
methodology for the inspection <strong>and</strong> the process for reporting on the<br />
outcomes of the inspections.<br />
A Board member felt that the document required some amendments,<br />
particularly in relation to the some of the section headings as they<br />
were unclear. The Director of Operations undertook to review these.<br />
A Board member suggested that the Royal Belfast Hospital for Sick<br />
Children should be inspected more regularly. The Director of<br />
Operations agreed to review this. A Board member asked about<br />
psychiatric wards. The Director of Operations explained that issues<br />
in these wards would be picked up by the Mental Health <strong>and</strong><br />
Learning Disability team.<br />
Subject to minor amendment, the Board APPROVED the new audit<br />
tool for hygiene inspections.<br />
10.144 Any Other Business<br />
10.144.1 There was no other business <strong>and</strong> the Chairman drew the public<br />
session to a close at 5:05pm.<br />
Page 11 of 12
Date of next meeting:<br />
Thursday 13 <strong>January</strong> <strong>2011</strong>, Board Room, Riverside Tower<br />
Signed<br />
Dr Ian Carson<br />
Chairman<br />
Date<br />
Page 12 of 12
RQIA Board Meeting<br />
Date of Meeting 13 <strong>January</strong> <strong>2011</strong><br />
Title of Paper<br />
Chairman's Report<br />
Agenda Item 5<br />
Reference A / 01 / 11<br />
Author<br />
Presented by<br />
Purpose<br />
Executive Summary<br />
FOI Exemptions<br />
Applied<br />
Equality Impact<br />
Assessment<br />
Recommendation/<br />
Resolution<br />
Next steps<br />
Dr Ian Carson<br />
Dr Ian Carson<br />
To inform the RQIA Board of the Chairman's<br />
external engagements <strong>and</strong> key meeting since the<br />
last Board meeting of the <strong>Authority</strong>.<br />
Between 11November 2010 <strong>and</strong> 13 <strong>January</strong><br />
<strong>2011</strong>, I attended 3 meetings on behalf of RQIA.<br />
None<br />
Not applicable<br />
The Board is asked to NOTE this report.<br />
Not applicable<br />
Page 1 of 2
CHAIRMAN'S REPORT<br />
Meetings attended<br />
• Effective Governance in tough times - 23 November 2010.<br />
• Chairs Forum meeting with the Justice Minister - 24 November 2010.<br />
• Public Accounts Committee Hearing, Stormont - 16 December 2010.<br />
DR IAN CARSON<br />
Chairman<br />
13 <strong>January</strong> <strong>2011</strong><br />
Page 2 of 2
RQIA Board Meeting<br />
Date of Meeting 13 <strong>January</strong> <strong>2011</strong><br />
Title of Paper<br />
Chief Executive's Report<br />
Agenda Item 6<br />
Reference B / 01 / 11<br />
Authors<br />
Presented by<br />
Purpose<br />
Executive Summary<br />
FOI Exemptions<br />
Applied<br />
Equality Impact<br />
Assessment<br />
Recommendation/<br />
Resolution<br />
Next steps<br />
Executive Team<br />
Glenn Houston<br />
The purpose of this report is to advise Board<br />
members of the key strategic issues <strong>and</strong><br />
developments arising over the past two months<br />
that have not been covered elsewhere in an<br />
individual report.<br />
This report provides an overview of key activities<br />
across each of the directorates of RQIA.<br />
None<br />
Not applicable<br />
The Board is asked to NOTE this update.<br />
Not applicable<br />
Page 1 of 5
CHIEF EXECUTIVE'S REPORT<br />
1.0 Chief Executive's Business<br />
Key Appointments (11 November 2010 - 13 <strong>January</strong> <strong>2011</strong>)<br />
November 2010<br />
12 November - Along with other members of the Executive Management<br />
Team (EMT) met with Christine Braithwaite, Director of Policy <strong>and</strong> External<br />
Relations <strong>and</strong> Rachael De Souza, External Relations Manager, Council for<br />
Health Regulatory Excellence (CHRE).<br />
22 November - Quarterly liaison meeting with Maeve Hully, Chief Executive<br />
<strong>and</strong> Sean Brown, Head of Development <strong>and</strong> Corporate Services, Patient<br />
Client Council (PCC).<br />
24 November - Along with Director of Operations <strong>and</strong> Communications<br />
Manager met with Dr. K Bell, Assembly Health Committee Clerk.<br />
30 November - Completed a pre-registration interview with Mr C Donaghy,<br />
Chief Executive, Belfast Health <strong>and</strong> Social Care Trust.<br />
December 2010<br />
1 December - Visited Bloomfields Private Nursing Home, Belfast.<br />
1 December - Attended IHCP Awards Dinner, Ramada Hotel, Belfast<br />
6 December - Along with other member s of EMT attended the quarterly<br />
liaison meeting with Eddie Rooney, Chief Executive, Public Health Agency<br />
(PHA).<br />
8 December - Visited Domnall Nursing Home, (Four Seasons Group), Belfast.<br />
9 December - RQIA Board Workshop with Bernard Marr.<br />
16 December - Along with Dr A McCormick, Perm. Sec. <strong>and</strong> Dr J.<br />
Livingstone, Director Safety <strong>Quality</strong> <strong>and</strong> St<strong>and</strong>ards, attended the Public<br />
Accounts Committee Evidence Session on NIAO Report, "Arrangements for<br />
Ensuring the <strong>Quality</strong> of Care in Homes for Older People."<br />
<strong>January</strong> <strong>2011</strong><br />
6 <strong>January</strong> - Along with Director of Operations <strong>and</strong> Head of Programme<br />
(Agencies Team) met with the Chief Executive <strong>and</strong> other representatives of<br />
IHCP.<br />
10 <strong>January</strong> - Along with other members of EMT attended the quarterly liaison<br />
meeting with DHSSPS <strong>and</strong> HSCB regarding social care issues.<br />
2.0 Operations Update<br />
2.1 Review Activity<br />
Progress in relation to governance, service <strong>and</strong> thematic reviews remains In<br />
line with the three year review programme <strong>and</strong> objectives of the review<br />
programme steering group.<br />
Page 2 of 5
Since the last Board meeting the following reviews have been published by<br />
RQIA.<br />
• Hygiene, Infection Prevention <strong>and</strong> Control Inspection Reports (1/12/10)<br />
• Child Protection Review Stages 4 <strong>and</strong> 5 (9/12/10)<br />
• Joint Review of Medical Revalidation (14/12/10)<br />
• Review of the use of IV Sedation in Dental Practices (17/12/10)<br />
The following reviews are due for publication in the next six weeks:<br />
• Governance Review of the Northern Irel<strong>and</strong> Ambulance Service<br />
(19/01/11)<br />
• Review of Child <strong>and</strong> Adolescent Mental Health Services (TBC)<br />
2.2 Inspection Activity<br />
Inspection activity has been maintained in line with statutory requirements; the<br />
minimum requirements for inspection frequency is on target for 31 March<br />
<strong>2011</strong>.<br />
Work continues with the development of the new inspection planning<br />
approach, as approved by the Board in November 2010. Inspectors are<br />
currently working with all relevant heads of programme in planning the<br />
revised, proportionate inspection schedule for the inspection year <strong>2011</strong>/12. A<br />
series of road shows are arranged for February <strong>2011</strong>, during which providers<br />
of service will be informed of inspection outcomes for 2009/10 <strong>and</strong> briefed on<br />
the new methods to be used in <strong>2011</strong>/12.<br />
In recent weeks a failure to comply notice has been issued to one Private<br />
Nursing Home. The notice relates to breaches in regulations on the ability of<br />
the home to meet the needs of its residents through its current staffing profile.<br />
3.0 Corporate Services Update<br />
3.1 Human Resources<br />
3.1.1 New appointments<br />
No new external appointments have been made since the November Board<br />
Meeting.<br />
3.1.2 Internal appointments<br />
The following internal appointments have been made since the November<br />
Board meeting - Jenny Stainsby, Agencies Team B<strong>and</strong> 4<br />
Page 3 of 5
3.1.3 Advertised vacancies<br />
The following posts have been advertised / re-advertised since the November<br />
Board meeting – second advertisement for the post of B<strong>and</strong> 7 Mental Health<br />
Officer.<br />
3.1.4 Leavers<br />
The following employees left RQIA on secondments since the November<br />
Board meeting - Catherine Gilmore to HSC Board <strong>and</strong> Louise Hunter to<br />
BHSCT.<br />
3.2 Communications<br />
A Working Group has taken forward the development of a draft<br />
Communications Strategy for approval by the Board by March <strong>2011</strong>.<br />
The Public Participation Implementation <strong>and</strong> Monitoring Group continue to<br />
meet. The implementation of the Public Participation Action Plan is ongoing<br />
<strong>and</strong> particular initiatives this year include establishing a Children's Services<br />
Advisory group, holding a series of Mental Health <strong>and</strong> Learning Disability<br />
information events across Northern Irel<strong>and</strong> <strong>and</strong> continuing to engage with a<br />
range of service users as part of planned review <strong>and</strong> inspection activity.<br />
3.3 Policies <strong>and</strong> Procedures<br />
One draft policy was approved by the Policy Group in December 2010:<br />
• Policy <strong>and</strong> Procedure for the Development, Approval <strong>and</strong> Review of<br />
Policies<br />
3.4 Information<br />
At a meeting of the CIMS Project Board in December 2010 it was agreed to<br />
keep the CIMS <strong>and</strong> EDRMS projects separate <strong>and</strong> as a consequence to (i)<br />
prioritise CIMS in the period from <strong>2011</strong> to 2013; <strong>and</strong> (ii) shift the focus away<br />
from EDRMS to the improvement of RQIA's existing manual <strong>and</strong> electronic<br />
records management processes <strong>and</strong> systems in preparation for<br />
implementation of EDRMS at a later stage i.e. circa 2013/14.<br />
RQIA has submitted its third self assessment as part of the ongoing regional<br />
data protection review. An Action Plan to implement the DHSSPSNI Data<br />
Protection Review Recommendations was approved by Board <strong>and</strong> 6 of the 13<br />
identified actions have been progressed in the period since its approval in<br />
September. Quarterly updates are provided to the Board.<br />
Within the period additional revenue funding was received from Information<br />
Technology Services (ITS), BSO for RQIA's ICT replacement programme.<br />
Page 4 of 5
A formal project has been initiated to determine the most appropriate model<br />
for the future provision of ICT services for RQIA <strong>and</strong> a business case was<br />
endorsed by the Board in November 2010 <strong>and</strong> forwarded to DHSSPS for<br />
approval. In order to further identify user needs <strong>and</strong> inform the future model,<br />
an ICT User survey is also planned in the last quarter of 2010/11.<br />
A business case for RQIA's ICT Disaster Recovery Plan was approved <strong>and</strong><br />
forwarded to DHSSPS for approval.<br />
GLENN HOUSTON<br />
Chief Executive<br />
12 <strong>January</strong> <strong>2011</strong><br />
Page 5 of 5
RQIA Board Meeting<br />
Date of Meeting 13 <strong>January</strong> <strong>2011</strong><br />
Title of Paper<br />
Finance Report<br />
Agenda Item 7<br />
Reference C / 01 / 11<br />
Author<br />
Presented by<br />
Purpose<br />
Jonathan King<br />
Jonathan King<br />
The purpose of this paper is to present RQIA's<br />
financial position as at 30 November 2010 <strong>and</strong><br />
projected to end of year.<br />
Executive Summary The latest report shows that there is a £15k<br />
projected deficit at the year end.<br />
FOI Exemptions<br />
Applied<br />
Equality Impact<br />
Assessment<br />
Recommendation/<br />
Resolution<br />
Next steps<br />
None<br />
Not applicable<br />
The Board is asked to NOTE this update.<br />
The EMT will continue to monitor the financial<br />
position <strong>and</strong> develop measures to ensure<br />
breakeven.<br />
Page 1 of 7
FINANCE REPORT<br />
Revenue Position<br />
The year to date financial position shows a deficit of £36K (-0.76%). The<br />
forecast year end deficit st<strong>and</strong>s at £15K (-0.21%).<br />
A moratorium on specified areas of expenditure has been put in place <strong>and</strong><br />
RQIA continues to proactively manage financial pressures in order to achieve<br />
breakeven at year end.<br />
Capital Position<br />
The CRL is currently set at £18K. The revised capital spend plan estimates<br />
expenditure of £26K. An increase to our CRL of £8K has been approved in<br />
principle pending the approval of a business case in relation to a Disaster<br />
Recovery Solution.<br />
Budget for 2010/11<br />
RQIA's income Budget is made up as follows:<br />
£<br />
RRL 6,393,684<br />
Fee Income 785,000<br />
Salary Recharges 144,484<br />
Total Income Budget 2010/11 7,323,168<br />
RQIA's Expenditure Budget is detailed below:<br />
£<br />
Salaries & Wages 5,964,024<br />
Goods & Services 1,359,657<br />
Total Expenditure Budget 2010/11 7,323,681<br />
Funding / Income<br />
Revenue Resource Limit (RRL)<br />
The initial RRL notified to RQIA on 30 June 2010 equalled £6,273K. This<br />
incorporated a significant level of recurring savings (£611K, 9.08%) <strong>and</strong><br />
included funding in respect of inflation, ICT <strong>and</strong> IRMER.<br />
An additional non-recurring allocation of £121K has been added to the RRL in<br />
respect of ITS funds. This relates to the PC/Laptop replacement programme.<br />
RQIA's RRL for 2010/11 st<strong>and</strong>s at £6,393,684. A detailed breakdown is<br />
included in Appendix 1.<br />
Page 2 of 7
Other Income<br />
Annual Registration Fees in 2010/11 were calculated as £736K <strong>and</strong> billed for<br />
in April. £5K (0.67%) remains outst<strong>and</strong>ing. Finance staff have followed the<br />
debt recovery procedure, including direct contact with Debtors. In December<br />
outst<strong>and</strong>ing debts were passed to the Department of Legal Services at BSO<br />
to expedite recovery. Based on debtor contact <strong>and</strong> legal advice I anticipate full<br />
recovery of this debt.<br />
Outst<strong>and</strong>ing Annual Fee Debtors from previous financial years equate to<br />
£3,744. This debt is also in the h<strong>and</strong>s of DLS for recovery. Based on legal<br />
advice It is likely that £1,500 of this will be unrecoverable.<br />
Variation to Registration Fees were budgeted at £49K for 2010/11, which is in<br />
line with 2009/10 levels. Up to the 30 th November RQIA had received £37K in<br />
variation fees. Receipt of these fees demonstrates no discernable pattern on<br />
which to base an accurate projection. However, a crude straight line<br />
projection shows that we are ahead of target <strong>and</strong> in a strong position to<br />
achieve the £12K balance over the remaining 4 months of the financial year.<br />
Salary Recharges<br />
We are currently due to under recover on salary recharges by £16K, which<br />
largely relates to the resignation of a secondee. Overall it has a neutral effect<br />
on the financial position as the resignation also led to a reduction in salary<br />
costs by a corresponding amount.<br />
Currently we have 2 staff members on secondment.<br />
Page 3 of 7
Financial Position Analysis<br />
Break-even is calculated as plus or minus 0.25% of RRL. This gives us a<br />
window of plus or minus £15,984 based on our current RRL.<br />
Year to date (April to November) shows a £37K overspend. This is forecast to<br />
be a £15K deficit at year end.<br />
This represents a deterioration from the previous forecast report which<br />
showed a £15K under spend. The £30K switch has been caused by<br />
inescapable costs to RQIA due to successful Agenda for Change appeals.<br />
These appeals relate to the previous employment of 3 RQIA staff members.<br />
Table 1<br />
RQIA Financial Position November 2010/11<br />
Summary by financial stream<br />
Year to Date<br />
Year End Projection<br />
Actual Budget Variance Forecast Budget Variance<br />
£ £ £ £ £ £<br />
Salaries &<br />
Wages 3,933,211 3,934,924 1,713 5,945,483 5,964,024 18,541<br />
Goods &<br />
Services 908,477 892,982 (15,495) 1,392,252 1,359,657 (32,595)<br />
Expenditure<br />
Total 4,841,688 4,827,906 (13,782) 7,337,735 7,323,681 (14,054)<br />
Income (5,024,000) (5,047,000) (23,000) (7,322,000) (7,323,168) (1,168)<br />
Surplus/(Deficit) (182,312) (219,094) (36,782) 15,735 513 (15,222)<br />
Salaries <strong>and</strong> Wages Expenditure<br />
The forecast pay expenditure is based on the actual staff in post at the 30th of<br />
November 2010 adjusted to account for leavers, returning secondee's <strong>and</strong><br />
other intelligence gathered during discussion with Budget Managers.<br />
Payroll expenditure shows a projected under spend of £18K. This position<br />
incorporates the unanticipated £29K AFC arrears liability.<br />
Expenditure controls around vacant posts <strong>and</strong> the judicious use of sessional,<br />
bank <strong>and</strong> agency staff have facilitated this small under spend.<br />
Page 4 of 7
Goods & Services Expenditure<br />
The forecast non-pay expenditure is based on actual costs as at the 30th of<br />
November 2010 adjusted to incorporate information gathered during<br />
discussion with Budget Managers. Part of this process involved clarifying<br />
activity to allow budgets to be refined <strong>and</strong> delegated to the most appropriate<br />
level to facilitate sound <strong>and</strong> efficient financial control. Work continues to<br />
enhance systems <strong>and</strong> information quality.<br />
Non pay expenditure shows a year to date overspend of £15K <strong>and</strong> a projected<br />
overspend of £32K.<br />
This overspend is spread over a number of categories with Staff Travel <strong>and</strong><br />
Central Computer costs contributing over half of the reported over spend.<br />
A moratorium on specified areas of expenditure has been put in place <strong>and</strong><br />
RQIA continues to proactively manage financial pressures in order to achieve<br />
overall breakeven at year end.<br />
Income Recovery<br />
Year to date Income shows an under recovery against budget of £23K. This<br />
relates to the timing of Salary Recharges <strong>and</strong> does not represent a threat to<br />
the anticipated financial position outturn.<br />
Income is projected to be largely in line with budget <strong>and</strong> therefore has no<br />
overall beneficial or detrimental impact on the projected financial position.<br />
Capital Expenditure<br />
The Capital Resource Limit was set at £18K. This was to fund Cisco Network<br />
Switches (£8K) <strong>and</strong> a Video Conferencing system (£10K). After further<br />
consideration it was agreed that the Video Conferencing scheme would be<br />
postponed as it was not a priority for RQIA in 2010/11. Work has commenced<br />
in relation to the Network Switches.<br />
A business case has been submitted to the Department regarding a Disaster<br />
Recovery Solution. This scheme along with the approved Network Switches<br />
scheme means that we have a capital requirement of £26K in 2010/11.<br />
The Capital Team at the Department have agreed in principle to increase our<br />
CRL to £26K once the disaster recovery business case has been approved.<br />
Both these schemes will be completed by the end of Match <strong>2011</strong>.<br />
Prompt Payment Compliance<br />
The prompt payment target requires the payment of 95% of invoices within 30<br />
days of receipt or agreed terms.<br />
Page 5 of 7
Payment turnaround has consistently improved from April, meeting the<br />
monthly target from July onwards <strong>and</strong> the cumulative target from September<br />
onwards.<br />
In November 100% of invoices received (60) met the prompt payment target.<br />
Cumulatively 96.4% of invoices received (759) met the prompt payment<br />
target.<br />
From April to November BSO processed 787 invoices on our behalf.<br />
JONATHAN KING<br />
Acting Finance Manager<br />
6 <strong>January</strong> <strong>2011</strong><br />
Page 6 of 7
Appendix 1<br />
RRL Baseline Reconciliation <strong>and</strong> Amendments - 2010/11<br />
Current<br />
Year<br />
Effect<br />
£'000<br />
Full<br />
Year<br />
Effect<br />
£'000<br />
RRL Brought forward to 2010/11 6,726 6,726<br />
Additional 2010 Savings (450) (450)<br />
CSR Efficiency Savings (43) (43)<br />
Recurrent Savings ex letter 8/3/10 (118) (118)<br />
Non Recurrent slippage on vacant posts (Secondments) (101) 0<br />
Inflation Increase (2.425%) 162 162<br />
Service Developments - ICT 43 43<br />
Service Developments - IRMER 54 54<br />
Total Baseline Allocation 2010/11 6,273 6,374<br />
SBA 001 - ITS Funds 68 0<br />
SBA 002 - ITS Funds 53 0<br />
RRL 6,394 6,374<br />
Page 7 of 7
RQIA Board Meeting<br />
Date of Meeting 13 <strong>January</strong> <strong>2011</strong><br />
Title of Paper<br />
<strong>Regulation</strong> of Private Dentistry<br />
Agenda Item 8<br />
Reference D / 01 / 11<br />
Author<br />
Presented by<br />
Purpose<br />
Executive Summary<br />
FOI Exemptions<br />
Applied<br />
Equality Impact<br />
Assessment<br />
Recommendation/<br />
Resolution<br />
Next steps<br />
Hall Graham<br />
Phelim Quinn<br />
To update the RQIA Board on the progress made<br />
in the regulation of private dentistry.<br />
This paper outlines the workstreams being<br />
undertaken to ensure that RQIA is prepared for<br />
the commencement of the regulation of private<br />
dentistry on 1 April <strong>2011</strong>.<br />
Non-confidential<br />
Not applicable<br />
The Board is asked to NOTE this update.<br />
The workstreams outlined in the paper will<br />
continue <strong>and</strong> the Board will be kept informed of<br />
progress.<br />
Page 1 of 4
REGULATION OF PRIVATE DENTISTRY<br />
DHSSPS has decided to proceed with changes to legislation, to enable RQIA<br />
to regulate all private dental care <strong>and</strong> treatment.<br />
Presently, establishments providing dental treatment under anaesthesia or<br />
sedation would be subject to the requirements of the Health <strong>and</strong> Personal<br />
Social Services (<strong>Quality</strong>, <strong>Improvement</strong> <strong>and</strong> <strong>Regulation</strong> (Northern Irel<strong>and</strong>)<br />
Order 2003 (the Order) as “Independent Hospitals”. This definition however<br />
excluded orthodontic practices which do not use either anaesthesia or<br />
sedation.<br />
To correct this, an amendment to the definition of “listed services” at Article<br />
2(7) (b) of the Order will substitute the present wording: “(b) dental treatment<br />
under anaesthesia or sedation” with the wording: “dental care or treatment”.<br />
An exclusion from regulation in relation to dental practices delivering<br />
exclusively HSC services will be inserted at the same time into the<br />
Independent Health Care <strong>Regulation</strong>s 2005.<br />
Fees for regulation of private dental establishments will initially be as laid<br />
down in the Fees <strong>and</strong> Frequency of Establishments <strong>and</strong> Agencies<br />
<strong>Regulation</strong>s (Northern Irel<strong>and</strong>) 2005 (as amended) for Independent hospitals.<br />
It is anticipated that legislation will be passed by 1 April <strong>2011</strong>.<br />
DHSSPS Minimum St<strong>and</strong>ards for Dental Care <strong>and</strong> Treatment - Supporting<br />
Good Governance in Dental Practice (October 2009) may be considered as a<br />
basis for inspection against minimum st<strong>and</strong>ards, in conjunction with the draft<br />
DHSSPS Independent Health Care Minimum St<strong>and</strong>ards - Hospitals <strong>and</strong><br />
Clinics (DHSSPS March 2005). It is anticipated that the delivery of dentistry<br />
in Northern Irel<strong>and</strong> will be monitored against these st<strong>and</strong>ards by RQIA.<br />
In the process for the amendment of the regulations, areas of concern were<br />
raised by representatives of the dental profession <strong>and</strong> political representatives<br />
that the revised arrangements had the potential to create an undue burden of<br />
inspection on dental practices. It was asserted that this would arise from the<br />
continued inspection of health service dentistry on a 3 yearly basis coupled<br />
with the proposed RQIA annual inspection of the private dental treatment <strong>and</strong><br />
care of the largest proportion of dental practices.<br />
In response to these concerns RQIA have been in discussion with the HSC<br />
board <strong>and</strong> have developed an options paper outlining how a collaborative<br />
approach will optimise assurances on the quality, safety <strong>and</strong> availability of<br />
private <strong>and</strong> health service dentistry, minimise the burden of inspection <strong>and</strong><br />
promote a value for money approach to inspection<br />
The proposal is for RQIA to develop a model for the regulation of private<br />
dentistry in Northern Irel<strong>and</strong> (based on the principles of RQIA's existing<br />
Inspection <strong>Improvement</strong> Project), in accordance with the relevant legislation<br />
<strong>and</strong> st<strong>and</strong>ards. This model should include the identification of the necessary<br />
Page 2 of 4
capacity/ resources to undertake this work within RQIA, which will enable the<br />
discharge of a planned programme of registration <strong>and</strong> inspection across<br />
dental surgeries in Northern Irel<strong>and</strong> where private dental treatment is being<br />
provided.<br />
Several workstreams have been identified,<br />
Work Stream One - Scoping of Process for <strong>Regulation</strong> of Private Dental<br />
Treatment<br />
• meetings with RQIA inspection staff including pharmacy, estates <strong>and</strong><br />
financial staff to inform the development of the regulation process<br />
• liaison with RQIA inspection <strong>and</strong> registration <strong>and</strong> information teams to<br />
identify additional resource requirements<br />
• meetings with dentists to review ease of information provision for the<br />
registration process<br />
• process mapping/flowcharting of the key processes<br />
Work Stream Two - Clarification of Legal Framework<br />
• to review existing RQIA processes such as enforcement, escalation,<br />
complaints in relation to the regulation of private dental treatment<br />
Work Stream Three - Registration of Private Dental Treatment<br />
• development of process maps of the key processes <strong>and</strong> partnerships<br />
• development of documentation e.g. application forms <strong>and</strong> guidance<br />
• compilation of database to monitor progress<br />
• development of a database of all dental practices linking into IAMS<br />
Work Stream Four - Workforce Planning <strong>and</strong> Resourcing<br />
• identification of workforce requirements<br />
• revision <strong>and</strong> submission of a business case<br />
• development of a training programme for inspection staff<br />
• development of an options paper with the HSC Board, examining<br />
collaborative approaches to inspection of both private <strong>and</strong> health<br />
service dentistry.<br />
Work Stream Five - Inspection of Private Dental Treatment<br />
• development of process maps of the key processes <strong>and</strong> partnerships in<br />
relation to inspection<br />
• development of documentation for the inspection of private dental<br />
treatment aligned to existing RQIA inspection activities<br />
• development of reporting process <strong>and</strong> template<br />
Work Stream Six - Communications <strong>and</strong> Public Relations<br />
• development of a dental manual for the dental profession to include<br />
guidance on completion of the required documentation<br />
• revise RQIA communications policy to reflect inclusion of the regulation<br />
of private dental treatment<br />
• Amend RQIA website to include regulation of private dental treatment<br />
• briefing sessions with dentists<br />
Page 3 of 4
HALL GRAHAM<br />
Primary Care Advisor<br />
24 December 2010<br />
Page 4 of 4
RQIA Board Meeting<br />
Date of Meeting 13 <strong>January</strong> <strong>2011</strong><br />
Title of Paper<br />
Update on IRMER<br />
Agenda Item 9<br />
Reference E / 01 / 11<br />
Author<br />
Presented by<br />
Purpose<br />
Executive Summary<br />
FOI Exemptions<br />
Applied<br />
Equality Impact<br />
Assessment<br />
Recommendation/<br />
Resolution<br />
Next steps<br />
Hall Graham<br />
Phelim Quinn<br />
To update the RQIA Board on IRMER Inspection<br />
activity <strong>and</strong> outcomes<br />
This paper outlines the schedule for inspection<br />
based on IR(ME)R, for which responsibility<br />
transferred to RQIA on 1 March 2010. The paper<br />
outlines the key findings of the first four IR(ME)R<br />
inspections that were conducted in Quarter 3.<br />
The reports of these inspections will be placed on<br />
the RQIA website.<br />
None<br />
Not applicable<br />
The Board is asked to NOTE this update.<br />
The remaining inspections outlined in the<br />
programme will be carried out in quarter 4. A<br />
further programme of inspections will be planned<br />
for the <strong>2011</strong>/12 year.<br />
Page 1 of 4
UPDATE ON IRMER<br />
The Ionising Radiation (Medical Exposure) <strong>Regulation</strong>s (Northern Irel<strong>and</strong>)<br />
2000 came into force on 1 <strong>January</strong> 2001 <strong>and</strong> lay down basic measures for<br />
the health protection of individuals against dangers of ionising radiation in<br />
relation to medical exposure. The regulations impose duties on those<br />
responsible for administering ionising radiation to protect persons undergoing<br />
medical exposure whether as part of their own medical diagnosis or treatment<br />
or as part of occupational health surveillance, health screening, voluntary<br />
participation in research or medico-legal procedures.<br />
The regulations are intended to<br />
• protect patients from unintended, excessive or incorrect exposure to<br />
radiation<br />
• ensure that, in each case, the risk from exposure is assessed against<br />
the clinical benefit<br />
• ensure that patients receive no more exposure than is necessary to<br />
achieve the desired benefit within the limits of current technology<br />
• protect volunteers in medical or biomedical, diagnostic or therapeutic<br />
research programmes <strong>and</strong> those undergoing medico-legal exposures<br />
(such as those required to fulfil employment or emigration purposes)<br />
Amendment <strong>Regulation</strong>s were issued in 2010 <strong>and</strong> responsibility for monitoring<br />
<strong>and</strong> enforcement of Ionising Radiation (Medical Exposure) <strong>Regulation</strong>s<br />
passed to The <strong>Regulation</strong> <strong>and</strong> <strong>Quality</strong> <strong>Improvement</strong> <strong>Authority</strong> (RQIA) on 15<br />
March 2010.<br />
In order to ensure that RQIA's responsibilities under IR(ME)R are met, RQIA<br />
will carry out the following activities<br />
• undertake a proportionate <strong>and</strong> risk based programme of proactive<br />
inspections to test compliance with the regulations<br />
• receive statutory notifications of exposures "much greater than<br />
intended" <strong>and</strong> investigate the circumstances of these events (may<br />
include reactive inspections)<br />
• where necessary issue advice, improvement or prohibition notices or<br />
consider prosecution<br />
• publish inspection reports<br />
Given the specialist nature of this area of work, RQIA requires expert advice<br />
<strong>and</strong> support for both the inspection <strong>and</strong> investigation elements of the process.<br />
This is provided through a contract between the RQIA <strong>and</strong> the Health<br />
Protection Agency in Engl<strong>and</strong>.<br />
INSPECTION ACTIVITY<br />
A workplan has been developed in conjunction with the HPA which is<br />
designed to cover all trusts <strong>and</strong> all modalities (diagnostic imaging, nuclear<br />
Page 2 of 4
medicine <strong>and</strong> radiotherapy). The proposed visits are outlined in the table<br />
below.<br />
Visit<br />
no<br />
Site<br />
HSC<br />
Trust<br />
Modality<br />
Days<br />
on<br />
site<br />
1 Chiropractor NI n/a 1 2<br />
2<br />
Altnagelvin Hospital<br />
(including North West<br />
independent Clinic)<br />
3 Downe hospital<br />
Western<br />
South<br />
East<br />
Diagnostic<br />
Imaging<br />
Diagnostic<br />
Imaging<br />
Total<br />
days<br />
2 4<br />
1 2<br />
Date inspection<br />
completed<br />
7th September<br />
2010<br />
27th -28th October<br />
2010<br />
16th November<br />
2010<br />
4 Daisy Hill Hospital South<br />
Diagnostic<br />
Imaging<br />
1 2<br />
14th December<br />
2010<br />
5 Antrim Area Hospital North<br />
Nuclear<br />
Medicine<br />
2 4<br />
6 Royal Group of Hospitals Belfast Cardiology 1.5 3<br />
7 Belfast City Hospital Belfast Radiotherapy 2 4<br />
To date four inspections have been carried out <strong>and</strong> the remaining three<br />
inspections will be completed by 31 March <strong>2011</strong>. A summary report of overall<br />
compliance will be prepared following completion of the inspection<br />
programme.<br />
During the inspections it was found that IR(ME)R procedures are generally<br />
quite well developed. There has been a lack of clarity regarding entitlement<br />
but this is something that has already begun to be addressed across the<br />
trusts. There were no safety issues identified. In some cases the policies <strong>and</strong><br />
procedures did not adequately reflect the operating procedures in the<br />
department.<br />
NOTIFICATIONS<br />
Under regulation 4(5) organisations are required to notify RQIA of exposures<br />
to patients that are much greater than intended.<br />
Since RQIA assumed responsibility for IR(ME)R there have been seven such<br />
notifications which is quite a small number compared with the number of<br />
procedures that take place within Northern Irel<strong>and</strong>.<br />
Of the seven notifications, six involved radiological examinations of the wrong<br />
patient <strong>and</strong> one involved an examination of the wrong site. Investigation<br />
Page 3 of 4
eports have been received from the six notifications involving the wrong<br />
patient. All doses were relatively low <strong>and</strong> the patients involved were not<br />
harmed.<br />
However, although the dose in a particular notification may be relatively<br />
minor, trusts have been encouraged to let RQIA know of any actions that<br />
have been taken to reduce the likelihood of similar errors happening in the<br />
future where the exposure may be much higher.<br />
JOINT WORKING AND COMMUNICATION<br />
We meet routinely with colleagues in the HPA <strong>and</strong> will be meeting to develop<br />
self assessment methodologies for nuclear medicine <strong>and</strong> radiotherapy. The<br />
HPA also continues to support our inspection programme <strong>and</strong> the programme<br />
for <strong>2011</strong>/2012 will be developed shortly.<br />
RQIA is a member of a group involving all UK IR(ME)R enforcement<br />
authorities, the Health Protection Agency <strong>and</strong> colleagues from the Republic of<br />
Irel<strong>and</strong> <strong>and</strong> the Department of Health. These meetings will now take place<br />
regularly <strong>and</strong> the next one is scheduled to take place in Scotl<strong>and</strong> during<br />
<strong>2011</strong>/2012.<br />
HALL GRAHAM<br />
Head of Primary Care <strong>Regulation</strong><br />
6 <strong>January</strong> <strong>2011</strong><br />
Page 4 of 4
RQIA Board Meeting<br />
Date of Meeting 13 <strong>January</strong> <strong>2011</strong><br />
Title of Paper<br />
Update on Information Governance<br />
Agenda Item 11<br />
Reference F / 01 / 11<br />
Author<br />
Presented by<br />
Purpose<br />
S<strong>and</strong>ra McElhinney<br />
S<strong>and</strong>ra McElhinney<br />
To update the Board on achievements in respect<br />
of the information governance requirements<br />
stemming from the DHSSPSNI Data Protection<br />
Review Reassessment action plan (see Appendix<br />
1) approved by the Board in September 2010.<br />
Executive Summary In the main good progress has been made with 9<br />
of the 13 (69%) actions being progressed as<br />
planned. Regional delay (e.g. e-learning<br />
package) <strong>and</strong> staff capacity (e.g. to complete<br />
information asset register) continue to delay<br />
progress on a few actions.<br />
FOI Exemptions<br />
Applied<br />
Equality Impact<br />
Assessment<br />
Recommendation/<br />
Resolution<br />
None<br />
Not applicable<br />
The Board is asked to NOTE this update.<br />
Next steps Next update due in April <strong>2011</strong>.<br />
Page 1 of 5
APPENDIX 1 ADDITIONAL INFORMATION AND RECORDS GOVERNANCE ACTION PLAN<br />
Action<br />
Required By<br />
RQIA<br />
Further<br />
Information<br />
Responsibility /<br />
Nominee<br />
Timescale<br />
Recommendation 1: Define Information Assets <strong>and</strong> Asset Owners<br />
1. The<br />
establishment<br />
<strong>and</strong> training of<br />
a Senior<br />
Information<br />
Risk Owner<br />
(SIRO).<br />
Impact on<br />
Operations<br />
Update<br />
All organisations should carry out a formal exercise to clearly define information assets held within their organisation <strong>and</strong> should appoint a Senior<br />
Information Risk Owner (SIRO) <strong>and</strong> Information Asset Owner (IAO) for the organisation.<br />
Must be at<br />
M. Atkinson August None<br />
M. Atkinson has been nominated as SIRO <strong>and</strong> will<br />
executive level <strong>and</strong> (nominee) 2010<br />
attend regional training in Jan <strong>2011</strong>.<br />
will be the focus of<br />
the management of<br />
information risk.<br />
2. The<br />
establishment<br />
<strong>and</strong> training of<br />
an Information<br />
Asset Owner<br />
(IAO).<br />
Must be senior level<br />
staff with an<br />
underst<strong>and</strong>ing of<br />
information<br />
management<br />
legislation <strong>and</strong> risks.<br />
S. McElhinney<br />
(nominee)<br />
August<br />
2010<br />
None<br />
S. McElhinney has been nominated as IAO <strong>and</strong><br />
will attend regional training in Jan <strong>2011</strong>.<br />
RAG<br />
Rating<br />
3. The<br />
establishment<br />
of Data<br />
Protection<br />
Liaison Officers<br />
(DPLOs)<br />
Similar role to local<br />
records managers in<br />
that DPLOs should<br />
be B<strong>and</strong> 4 level staff<br />
<strong>and</strong> manage data<br />
protection <strong>and</strong><br />
information security<br />
at a local level.<br />
A. McCracken Qr 2<br />
2010/11<br />
Nominations<br />
from teams<br />
<strong>and</strong> continual<br />
commitment to<br />
roll-out of<br />
information<br />
governance<br />
policies <strong>and</strong><br />
procedures.<br />
The Administrative Supervisor for each team has<br />
been nominated <strong>and</strong> will be confirmed at the first<br />
meeting of the Information Governance &<br />
Records Management Group (February <strong>2011</strong>).<br />
Page 2 of 5
Action<br />
Required By<br />
RQIA<br />
4. The<br />
establishment<br />
of an<br />
Information<br />
Assets<br />
Register.<br />
5. The<br />
establishment<br />
of regular data<br />
protection<br />
training <strong>and</strong><br />
awareness<br />
sessions.<br />
6. Employment<br />
of an e-<br />
learning data<br />
protection<br />
package.<br />
Further<br />
Information<br />
Must be a formal<br />
exercise to<br />
determine what<br />
information is held<br />
by RQIA, who has<br />
access to it, how it<br />
is updated <strong>and</strong> how<br />
it may be used for<br />
the public good.<br />
Training should be<br />
supplemented by<br />
the distribution of<br />
information bulletins<br />
<strong>and</strong> press releases.<br />
Will be made<br />
available by<br />
DHSSPSNI.<br />
Responsibility /<br />
Nominee<br />
Timescale<br />
A. McCracken Qr 3<br />
2010/11<br />
A. McCracken Annually or<br />
see action 5<br />
below.<br />
Impact on<br />
Operations<br />
Internal<br />
exercise which<br />
will become<br />
part of a<br />
regional<br />
exercise.<br />
M<strong>and</strong>atory<br />
Completion.<br />
Update<br />
This will form the main focus of the Information<br />
Governance & Records Management Group who<br />
have been identified <strong>and</strong> plan to meet in Feb<br />
<strong>2011</strong>.<br />
A plan to audit all files, including personal<br />
information will be agreed by the group in Q4<br />
2010/11. A structure for the development of an<br />
electronic information asset register will also be<br />
agreed, which will be used to track all information<br />
assets held at RQIA.<br />
Training will be carried out in Q4 2010-11 to all<br />
staff. Work will also be completed to integrate<br />
data protection <strong>and</strong> freedom of information<br />
awareness into induction for new staff.<br />
A. McCracken TBC TBC Market intelligence with indicative costs has been<br />
obtained from one provider which will be<br />
compared against any regionally arranged<br />
provision once confirmed by the regional<br />
information governance group.<br />
RAG<br />
Rating<br />
Page 3 of 5
Action<br />
Required By<br />
RQIA<br />
7.<br />
Establishment<br />
of a data<br />
protection<br />
manual.<br />
8. Encryption<br />
of personal<br />
data on<br />
portable<br />
media.<br />
9.<br />
Establishment<br />
of robust data<br />
protection<br />
agreements<br />
with<br />
contractors<br />
<strong>and</strong> other third<br />
party<br />
personnel.<br />
Further<br />
Information<br />
Must be specific to<br />
the Data Protection<br />
Act 1998 <strong>and</strong><br />
provide information<br />
on the roles of data<br />
protection officers<br />
<strong>and</strong> liaison officers,<br />
the principles of the<br />
Act <strong>and</strong> the subject<br />
access request<br />
process.<br />
Laptops <strong>and</strong><br />
safesticks to be<br />
encrypted.<br />
Formal documented<br />
assurance of data<br />
protection<br />
compliance must be<br />
maintained.<br />
Responsibility<br />
/ Nominee<br />
Timescale<br />
A. McCracken Qr 3<br />
2010/11<br />
L. MacDermott Qrs 1&2<br />
2010/11<br />
M. Atkinson As each<br />
contract is<br />
reviewed or<br />
new ones<br />
established.<br />
Impact on<br />
Operations<br />
Improved<br />
underst<strong>and</strong>ing<br />
of DPA<br />
matters, roles<br />
<strong>and</strong><br />
responsibilities.<br />
Could be<br />
included in<br />
induction<br />
manual.<br />
Lap-top reimaging<br />
exercise to be<br />
completed.<br />
None<br />
Update<br />
A data protection manual has been written based<br />
on the DHSSPSNI model. It incorporates RQIA's<br />
procedure for h<strong>and</strong>ling Subject Access Requests.<br />
This will be rolled out via the Information<br />
Governance & Records Management Group <strong>and</strong><br />
data protection training in Q4 2010-11.<br />
All lap-top <strong>and</strong> safesticks are encrypted.<br />
OGC Data Protection Terms <strong>and</strong> Conditions have<br />
been signed off with Steria. Future contracts will<br />
incorporate these as st<strong>and</strong>ard.<br />
RAG<br />
Rating<br />
Page 4 of 5
Action<br />
Required By<br />
RQIA<br />
10. Review of<br />
personal<br />
information<br />
held.<br />
11.<br />
Identification<br />
<strong>and</strong> protection<br />
of critical<br />
locations.<br />
12. Review of<br />
access<br />
privileges.<br />
13.<br />
Establishment<br />
of third party<br />
data sharing<br />
agreements.<br />
Further<br />
Information<br />
Can be carried out<br />
in line with<br />
identifying<br />
information assets<br />
in action 3 above<br />
<strong>and</strong> must ensure<br />
that there is<br />
justification for all<br />
personal information<br />
held by RQIA.<br />
Server rooms,<br />
routers,<br />
communication<br />
cabinets must be<br />
securely managed.<br />
Senior staff at IAO<br />
level must formally<br />
review <strong>and</strong> approve<br />
information access<br />
privileges at least<br />
annually.<br />
The transfer of<br />
personal<br />
information to<br />
third parties<br />
must be<br />
identified <strong>and</strong><br />
securely<br />
managed.<br />
Responsibility<br />
/ Nominee<br />
Timescale<br />
A. McCracken Qr 3<br />
2010/11<br />
Impact on<br />
Operations<br />
Continuation of<br />
exercise to<br />
determine<br />
information<br />
assets <strong>and</strong> use of<br />
PIAs<br />
See point 4, above.<br />
Update<br />
L. MacDermott Ongoing None Significant works have been completed to protect<br />
the RQIA comms room <strong>and</strong> continues to be<br />
managed by the ICT manager.<br />
S. McElhinney Ongoing 1st review to be<br />
completed by<br />
September <strong>2011</strong>.<br />
Maurice Atkinson to<br />
put in place<br />
information sharing<br />
agreements against<br />
all MOUs <strong>and</strong> with all<br />
Trusts, Agency, Board<br />
<strong>and</strong> counterpart<br />
regulators<br />
As per D6.2<br />
of 2010/11<br />
Business<br />
Plan.<br />
More definitive<br />
arrangements for<br />
sharing<br />
information <strong>and</strong><br />
enhanced<br />
underst<strong>and</strong>ing<br />
between<br />
organisations.<br />
Several information sharing agreements have<br />
been signed off since September but each<br />
existing MOU must be reviewed to determine the<br />
need for any accompanying ISA.<br />
RAG<br />
Rating<br />
Page 5 of 5
RQIA Board Meeting<br />
Date of Meeting 13 <strong>January</strong> <strong>2011</strong><br />
Title of Paper<br />
Mental Health <strong>and</strong> Learning Disability<br />
Agenda Item 12<br />
Reference G / 01 / 11<br />
Author<br />
Presented by<br />
Purpose<br />
Executive Summary<br />
FOI Exemptions<br />
Applied<br />
Equality Impact<br />
Assessment<br />
Recommendation/<br />
Resolution<br />
Next steps<br />
Patrick Convery<br />
Phelim Quinn<br />
To update the RQIA Board on the work of the<br />
mental health <strong>and</strong> learning disability team.<br />
Since the last Board meeting the mental health<br />
<strong>and</strong> learning disability team has made substantial<br />
progress on its schedule of inspections. The<br />
team has also begun a project with GAIN to<br />
develop guidelines on the Mental Health (NI)<br />
Order.<br />
None<br />
Not applicable<br />
The Board is asked to NOTE this update.<br />
Over the coming months the team will continue<br />
with its programme of inspections <strong>and</strong> an interim<br />
report will be prepared in April <strong>2011</strong>.<br />
A series of roadshows highlighting the work of the<br />
mental health <strong>and</strong> learning disability team will be<br />
taking place in March/April <strong>2011</strong>; further details<br />
will be available shortly.<br />
Page 1 of 7
MENTAL HEALTH AND LEARNING DISABILITY UPDATE<br />
This briefing note sets out the work currently being undertaken within the<br />
Mental Health <strong>and</strong> Learning Disability Team.<br />
1. Serious Adverse Incidents Review<br />
From 1 April 2010 to 30 November 2010 there have been 104 cases reported<br />
as Serious Adverse Incidents (SAI's). The cases can be summarised as<br />
follows:<br />
Trust<br />
Deaths<br />
Other<br />
Incidents<br />
Stats<br />
Suicide/Suspected<br />
Suicide<br />
Natural<br />
Causes<br />
Other<br />
Not<br />
Known<br />
Male<br />
Female<br />
Total No<br />
of SAI's<br />
BHSCT 8 3 3 11* 15 9 25<br />
NHSCT 6 3 9 5 20 3 23<br />
SEHSCT 20 5 1 17 9 26<br />
SHSCT 14 1 4 14 6 20<br />
WHSCT 8 1 8 2 10<br />
Totals 56 0 8 17 10 74 29 104<br />
At present suicides or suspected suicides are reported through to RQIA <strong>and</strong><br />
this process is to continue but letters will go to Trusts from the HSC Board<br />
following consultation <strong>and</strong> in partnership with RQIA. This is to ensure one<br />
point of information return <strong>and</strong> will stream processes <strong>and</strong> therefore avoid<br />
duplication. During the initial phase of this new arrangement RQIA are<br />
monitoring the impact of these changes on its ability to continue to discharge<br />
its functions in making inquiries into cases where it appears that there may be<br />
ill-treatment, deficiency in care or treatment. A joint workshop between<br />
PHA/HSC Board, Trusts <strong>and</strong> RQIA was held on 19th November to review the<br />
new process <strong>and</strong> address any changes which may be necessary in relation to<br />
the progress of the new system <strong>and</strong> in particular the review process. Further<br />
improvement in terms of communication was discussed at this workshop <strong>and</strong><br />
greater collaboration was identified by RQIA <strong>and</strong> refinements to the process<br />
of reviewing SAIs continue to improve.<br />
Page 2 of 7
2. Monitoring of errors in prescribed forms <strong>and</strong> guardianship<br />
applications<br />
Total number of forms received from 1 April 2010 to 31 December 2010 is<br />
7139.<br />
Trust Area<br />
Total Forms<br />
received<br />
Percentage<br />
Late >4 days<br />
Percentage<br />
Unsatisfactory<br />
BHSCT 2255 81.33% 3.46%<br />
NHSCT 1673 60.19% 1.67%<br />
SEHSCT 1229 56.96% 2.52%<br />
SHSCT 1046 64.24% 2.49%<br />
WHSCT 936 68.59% 3.10%<br />
Total 7139 68.01% 2.69%<br />
The level of improvement in relation to the satisfactory <strong>and</strong> timely completion<br />
of forms continues to be maintained through ongoing feedback <strong>and</strong><br />
communication with Trust Medical Records departments. There is currently a<br />
work stream which will address the process of electronic submission which<br />
should in the first instance address the time delay significantly.<br />
3. MHLD Inspection programme<br />
The schedule of inspections of Mental Health <strong>and</strong> Learning Disability wards<br />
<strong>and</strong> departments commenced in October 2010. Until 31 December there have<br />
been 23 announced inspections <strong>and</strong> one unannounced inspection. The<br />
following table outlines the inspections completed to date.<br />
Facility<br />
Date<br />
Brooke Lodge, Lakeview 30 September & 1 October 2010<br />
Clinic B, Gransha 5 & 6 October 2010<br />
Spruce Ward, T&F 6 & 7 October 2010<br />
Ulster Acute 19 & 20 October 2010<br />
Ward 29, Downshire 20 & 21 October 2010<br />
Elm Ward, T&F 26 & 27 October 2010<br />
Lime Ward, T&F 27 & 28 October 2010<br />
Lissan 1, Holywell 2 & 3 November 2010<br />
Clinic A, Gransha 2 & 3 November 2010<br />
Strule, Lakeview 4 & 5 November 2010<br />
Ennis, Muckamore 10 & 11 November 2010<br />
Six Mile Ass, Muckamore 16 & 17 November 2010<br />
Ward 28, Downshire 16 & 17 November 2010<br />
Greenan, Muckamore 18 & 18 November 2010<br />
Ward J, Mater 24 & 25 November 2010<br />
TNU, Holywell 24 & 25 November 2010<br />
Erne, Muckamore 30 November & 1 December 2010<br />
Ward 27, Downshire 1 & 2 December 2010<br />
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Ward L, Mater 7 & 8 December 2010<br />
Carrick 3, Holywell 14 & 15 December 2010<br />
Cranfield Female, Muckamore 15 & 16 December 2010<br />
Rathlin, Knockbracken 15 & 16 December 2010<br />
Dementia Ward, Downe 16 December 2010<br />
Additionally an unannounced inspection took place in Ward 12, Lagan Valley<br />
Hospital on 22 November 2010. This was as a result of non-return of self<br />
assessment <strong>and</strong> press article which related to over occupancy.<br />
Reports for the inspections of mental health facilities are forwarded to trusts to<br />
seek quality improvement plans. It is anticipated that the individual reports<br />
will not be subject to publication. However, a six monthly overview report of<br />
themes <strong>and</strong> issues arising from the inspection programme will be forwarded to<br />
trust chief executives <strong>and</strong> the HSC Board.<br />
4. Guardianship Panel<br />
The Guardianship Panel last met on 29 September 2010.<br />
One of the key objectives for the MHLD team has been the integration of<br />
mental Health Order Functions across other areas within RQIA's remit. As a<br />
result Guardianship has been selected as an inspection theme for the<br />
<strong>2011</strong>/12 inspection year. This will involve inspectors in regulated sector<br />
services making enquiry into the terms, care <strong>and</strong> treatment of individuals<br />
subject to guardianship. A workshop will be held in <strong>January</strong> to finalise<br />
arrangements for this inspection theme with all relevant inspectors.<br />
5. GAIN Funding for Guideline Development<br />
The MHLD team in conjunction with Dr Mary McClean Project Manager<br />
submitted an application for funding to develop a guideline on the Mental<br />
Health (NI) Order 1986 <strong>and</strong> dissemination of training to all professionals<br />
including an e-learning package. This should ensure consistency in approach<br />
<strong>and</strong> implementation of the Mental Health (NI) Order 1986 <strong>and</strong> will continue to<br />
be monitored by the MHLD team. A report will be presented at the next board<br />
meeting. The amount of money granted for the project was £28,300.<br />
An initial meeting chaired by RQIA with key stakeholders took place on 22<br />
November <strong>and</strong> involved all stakeholders namely Royal College of<br />
Psychiatrists, GPs, Directors/Asst Directors of Mental Health <strong>and</strong> Learning<br />
Disability, Nurse Directors, Legal Services, PSNI, DHSSPS, NIMDTA with<br />
user <strong>and</strong> carer representation. Apologies were received from the NI<br />
Ambulance Service (NIAS) but a follow up meeting was held to discuss the<br />
issues.<br />
A further meeting to develop an e-learning package was held at RCP on 24<br />
November 2010.<br />
Page 4 of 7
6. Child <strong>and</strong> Adolescent Mental Health Services (CAMHS)<br />
The CAMHS review has been completed. The final report was considered at<br />
the Board works shop in October 2010. The report is with the DHSSPS in line<br />
with the agreed communication protocol. Publication date is anticipated in<br />
<strong>January</strong> <strong>2011</strong>. RQIA are currently awaiting feedback comments from<br />
DHSSPS before publication.<br />
7. Meetings with Advocacy Services<br />
The MHLD team have continued to meet with User <strong>and</strong> Carer Advocates in<br />
relation to care <strong>and</strong> treatment of individuals with a mental illness. Meetings<br />
have also included Learning Disability <strong>and</strong> Dementia.<br />
The Advocacy Forum met on three occasions on 14 April, 23 September <strong>and</strong><br />
16th December 2010. The main discussions were in relation to update from<br />
Patient Experience Reviews <strong>and</strong> Inspections <strong>and</strong> discussions in relation to the<br />
provision of advocacy services.<br />
8. Patient monies<br />
On 4 October 2010 the Director of Operations arranged that the RQIA<br />
Finance Manager should conduct a review of RQIA's responsibilities in<br />
respect of financial matters under the Mental Health (NI) 1986 Order, Article<br />
116. This work has been completed <strong>and</strong> sets out the:<br />
• present position regarding Article 116 of the Order<br />
• the roles <strong>and</strong> responsibilities of trusts <strong>and</strong> RQIA, <strong>and</strong><br />
• recommendations as to the processes <strong>and</strong> procedures to enable RQIA to<br />
discharge its statutory duties on a continuing basis.<br />
Information has been received from Trusts <strong>and</strong> this will be reviewed by Head<br />
of Programme <strong>and</strong> Finance Manager to have Report on Article 116 completed<br />
by end of <strong>January</strong> <strong>2011</strong>.<br />
9. Expert Advisory Panel<br />
The Expert Advisory Panel has met on two occasions since April 2010 on 21<br />
July 2010 <strong>and</strong> 13 October 2010. An evaluation framework for use by the<br />
advisory panel was developed to assist with the assessment of how<br />
effectively RQIA are discharging its MHO functions transferred on 1 April<br />
2009. The outcome of this evaluation will form the basis of a report to the<br />
Board in April <strong>2011</strong>. Feedback to date has been very positive in relation to<br />
the work of the MHLD Team. The next Expert Advisory Panel meets on 12<br />
<strong>January</strong> <strong>2011</strong>.<br />
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10. Declaratory Order<br />
During the course of December 2010 RQIA were requested to provide a<br />
Report in relation to a Declaratory Order issued by High Court. RQIA were<br />
asked to provide an oversight into the care <strong>and</strong> treatment of an individual who<br />
lacked capacity to consent to treatment. A Report was provided for the High<br />
Court <strong>and</strong> further oversight continues to be provided by RQIA. A further<br />
Report will be provided.<br />
PATRICK CONVERY<br />
Head of Mental Health <strong>and</strong> Learning Disability<br />
6 <strong>January</strong> 2010<br />
Page 6 of 7
Month<br />
Total<br />
Forms<br />
received<br />
Average<br />
Days to<br />
receipt<br />
Percentage<br />
Late *<br />
Percentage<br />
Unsatisfactory Target<br />
Dec-09 835 7 68% 2.6% 4<br />
Jan-10 777 8 62% 2.8% 4<br />
Feb-10 799 8 75% 2.3% 4<br />
Mar-10 856 7 69% 4.4% 4<br />
Apr-10 753 6 68% 2.8% 4<br />
May-10 778 6 69% 2.7% 4<br />
Jun-10 771 6 66% 2.2% 4<br />
Jul-10 945 6 68% 3.8% 4<br />
Aug-10 965 6 71% 2.6% 4<br />
Sep-10 890 7 71% 3.0% 4<br />
Oct-10 785 6 64% 2.5% 4<br />
Nov-10 768 7 65% 1.8% 4<br />
Dec-10 477 7 69% 2.1% 4<br />
TOTAL 9724 7 66% 3.2% 4<br />
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