February 2012 - Regulation and Quality Improvement Authority

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CHAIRMAN'S REPORT Meetings attended • Mid-year Accountability Review with the Permanent Secretary, Andrew McCormick, DHSSPS – 15 Nov 2011. • Conference Chairman at the Heads of Inspectorate Forum, Cultra Manor – 16 Nov 2011. • CIPFA/Chairs Forum Annual Corporate Governance Conference, Templepatrick – 18 Nov 2011. • Keynote address at the Four Seasons Healthcare Conference, Newcastle – 28 Nov 2011. • NICON Members meeting, PHA – 6 Dec 2011. • RQIA Staff Christmas event – 20 Dec 2011. • Chairs Forum, Linen Hall Library – 22 Dec 2011. • Meeting with Prof. Michael O’Flaherty, Chief Commissioner, and Virginia McVea, Director, NI Human Rights Commission – 5 Jan 2012. • New Board Members Induction Day – 12 Jan 2012. • Chairs Forum, CIPFA Office – 12 Jan 2012. DR IAN CARSON Chairman 9 February 2012 Page 2 of 2
RQIA Board Meeting Date of Meeting 9 February 2012 Title of Paper Chief Executive's Report Agenda Item 6 Reference C / 01 / 12 Authors Presented by Purpose Executive Summary FOI Exemptions Applied Equality Impact Assessment Recommendation/ Resolution Next steps Executive Team Glenn Houston This report is to advise Board members of the key strategic issues and developments arising since the previous Board meeting, held on 10 November 2011, that have not been covered elsewhere in an individual report. This report provides an overview of key activities across each of the directorates of RQIA. None Not applicable The Board is asked to NOTE this update. Not applicable Page 1 of 11
Page 1 and 2: Agenda Item Paper AGENDA RQIA Boa
Page 3 and 4: RQIA Board Meeting Date of Meeting
Page 5 and 6: they should advise the Committee Se
Page 7 and 8: 11.120.11 The Board NOTED the Chief
Page 9 and 10: 11.123.5 The Board NOTED the Corpor
Page 11: RQIA Board Meeting Date of Meeting
Page 15 and 16: 7 February; Along with Dr Stewart a
Page 17 and 18: Name of Service Date of issue FTC /
Page 19 and 20: As part of its on-going programme o
Page 21 and 22: RQIA has been commissioned by the M
Page 23 and 24: 4.2 Whistleblowing In January 2012,
Page 25 and 26: Summary Financial Position Revenue
Page 27 and 28: Revenue Financial Position Currentl
Page 29 and 30: Prompt Payment Compliance The promp
Page 31 and 32: Introduction Dental registration wa
Page 33 and 34: RQIA Board Meeting Date of Meeting
Page 35 and 36: Contents 1. INTRODUCTION 1 2. SUMMA
Page 37 and 38: 2. Summary of Traffic Light Rating
Page 39 and 40: By the end of Q3 regulation inspect
Page 41 and 42: An Information and ICT Strategy was
Page 43 and 44: Summary of Red and Amber Actions fr
Page 45 and 46: D6.1.2 Maintain and review RQIA's P
Page 47 and 48: CA1.1.4 Actions Progress Exception
Page 49 and 50: Actions Progress Exception Report:
Page 51 and 52: CA1.1.11 Actions Progress Exception
Page 53 and 54: CA1.2 - Improved local and national
Page 55 and 56: CA1.3 - Evidenced that the results
Page 57 and 58: CA2.2 - Use our information to prov
Page 59 and 60: CA3.2 - Incorporated and discharged
Page 61 and 62: CA3. 3 - Fulfilled RQIA's obligatio
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D1 - We engage effectively with our
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D2 - We maintain a robust governanc
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Actions Progress Exception Report:
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D4 - We manage our finances and ass
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D4.2 - Maintained and made best use
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D6.2 - Improved our performance thr
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D7.2 - Complied with best practice
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RQIA Board Meeting Date of Meeting
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CONTENTS Page Executive summary 3 R
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• any additional actions consider
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Risk Scoring Matrix IMPACT Risk Sco
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RISK Scoring MATRIX IMPACT Risk Sco
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RISK ACTIVITY CALENDARS Action by D
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Ref No. Description of Risk What wo
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approval from DHSSPS and DFP for th
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Recommendation/ Resolution Next ste
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Definitions Risk is an event or unc
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1.0 Introduction Managing Public Mo
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5.2 Audit Committee Responsibility
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5.6 Responsibility of All Staff All
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7.2 Risk Identification Risk identi
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Level of impact (Minor) Medium (Mod
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The relationship between the cost o
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5. Identify any gaps in “controls
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developed along with a summary of R
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Checklist for Identifying Risks App
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Corporate Risk Assurance Framework
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BUSINESS PLAN 2012-13 To be a drivi
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Foreword The Regulation and Quality
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The Strategy Map provides a visual
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to the delivery of corporate object
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1 Regulation Registering and inspec
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2 Review Assuring the quality of he
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3 Mental Health Order Oversight Del
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3 Mental Health Order Oversight Del
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4 Engagement & Communications Engag
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Policy and provide guidance to line
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6 Performance Managing and monitori
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8 Information Managing information
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8 Information Managing information
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Appendix 1 - Finance Section 1. Rev
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Strategic Objectives By 2015 we wil
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The Regulation and Quality Improvem
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Paper AC / min11 / Nov MINUTES RQIA
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Paper AC / min11 / Nov 4.2 4.3 4.4
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Paper AC / min11 / Nov 6.11 The Aud
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Paper AC / min11 / Nov members. Res
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Paper AC / min11 / Nov 14.2 The Aud
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Paper AC / min11 / Nov Action Minut
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appropriate and adequate as indicat
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CONTENTS Section Title Page 1 Backg
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1.3 Pre-Consultation Process 1.3.1.
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Consultation Questions The followin
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RQIA's Response • Where it thinks
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3. Q2: Have strategic objectives an
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RQIA under ‘Regulation’ of a ra
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point the ten recommendations publi
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3.3 Mental Health Order Oversight -
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from the reviews on MHLD facilities
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• Objective 2.3 ‘Documented evi
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5. Q4: Do you have any other commen
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RQIA notes the comment in relation
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NI Association for Mental Health NI
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Version 4_0 26
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Strategy have been summarised below
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Section Page Details of Change 3 Me
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Section Page Details of Change 10 R
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Section Page Details of Change 16 P
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RQIA Draft Corporate Strategy 2012-
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Contents Foreword .................
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guardianship order; and preventing
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Challenges Ahead This section ident
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undertaken against a changing lands
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The Vision for 2012-15 The vision,
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The successful delivery of our outc
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Bringing it together In this sectio
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2. Review Assuring the quality of h
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7. Evidence Underpinning our regula
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9. Governance Maintaining and promo
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Delivering the strategy and managin
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Glossary of Terms and Abbreviations
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Governance Guardianship Health and
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Mental Health Commission (MHC) Ment
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Quality Improvement Plan Regulated
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Contact us The Regulation and Quali
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• People in respect of gender, ag
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CONTENTS 1.0 Introduction 3-7 1.1 I
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During the period under review, res
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RQIA believes that the diverse need
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The following standards were used a
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1.3 Standard 10: Each child has the
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1.4 Standard 18: The required recor
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2.0 Boarding schools Article 176 of
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These inspections provided sound ev
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4. Each trust to implement robust c
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Tasks for the group include: Agree
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Over the course of 2011-12, RQIA’
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Appendix 1 2. EACH CHILD HAS THE RI
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Appendix 2 10. EACH CHILD HAS THE R
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10.9 A homework timetable is establ
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Appendix 3 18. THE REQUIRED RECORDS
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18. 11 Clothing. 1 2 3 4 18.12 Acti
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18.23 Procedure in event of fire. 1
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Foreword RQIA wishes to thank every
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1 The Regulation and Quality Improv
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2 The Work Programmes of RQIA RQIA
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• Follow-Up Review: Reducing the
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Page 22 of 21
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1.0 Introduction Through its activi
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Private homes Voluntary/ independen
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1.1 Inspection work residential chi
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As illustrated above, achievement l
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Assessment, reviews and care plans
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Key records include: • Children's
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with the robustness of the selectio
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gained by the ETI, its 2011-12 educ
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On a practical level this has led t
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These meetings were very well atten
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APPENDICES 23
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2.3 Recording in the case file demo
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10.4 Disruption in schooling is kep
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10.14 Responsibility for a child's
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18.5 Young people's individual care
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18.17 Record of official visits. 1
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patients’ who had difficulty swal
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An area that has been highlighted i
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Where issues of concern were highli
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It should be noted that while figur
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Table 4: Establishments/Agencies De
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RQIA’s approach to regulation In
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5 Follow-Up Evidence from Previous
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Levels of Achievement The model use
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Regulatory Action Normally, where a
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Relationship between Achievement Le
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Provider workshops and feedback In
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Summary of the findings by register
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Standard 5: Provision of informatio
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and any equipment used is safe and
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elying on a questionnaire approach
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RQIA will issue a guidance document
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Standard Crit. N/A 5 6 8 12 Table 1
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achieved and 30% having substantial
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Criterion 12.10 Staff are aware of
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Overview Service providers were ask
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• The use of patients'/residents
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Residential care homes A residentia
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Table 14 Residential (RC) - Announc
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that the staff had not followed the
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In a majority of homes (86%) this c
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more importantly the outcome of com
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had made changes or improvements to
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Where inspectors observed poor prac
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Day care settings A day care settin
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Specific Commentary Standard 2 - Th
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Criterion 8.5 - When a service user
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awareness training regarding vulner
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production of documents which used
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Where issues of concern were highli
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RQIA Annual Regulation Adult Annual
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RQIA Board Meeting Date of Meeting
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MENTAL HEALTH AND LEARNING DISABILI
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Table 2 Breakdown by Trust and loca
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Emerging Trends arising from SAIs f
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Table 4 Analysis of Detention Forms
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Number of Inspections undertaken fr
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4. Review of Safeguarding of Childr
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Regional Overview of Guardianship a
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iv. A list of Patients for whom the
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Other organisations have included V
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REGISTRATION POLICY FOR THE REGULAT
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1.0 Introduction Background 1.1 The
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6.2 Specific regulations relating t
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10.0 Equality • Legislative frame
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Registration - Offences and Penalti
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Appendix 4 Flowchart of responsibil
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3. RQIA’s 2012-13 inspection prog
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2. The service user’s own home (a
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Exclusive possession includes the r
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Following this judgement, the Care
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The NDTi “Real Tenancy Test” ad
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5. Restrictive practices and physic
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RQIA’s regulatory function is ham
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(c) Conclusion It is generally ackn
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February 2012 - Regulation and Quality Improvement Authority

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