February 2012 - Regulation and Quality Improvement Authority

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RQIA's Response • Where it thinks fit, refer to the Review Tribunal the case of any patient who is liable to be detained in hospital or subject to guardianship under the Order. Because of these specific and onerous responsibilities RQIA has established a Mental Health and Learning Disability Directorate to take this work forward and believes that this merits specific consideration within the Corporate Strategy and in the Strategy Map. We acknowledge that we need to demonstrate where appropriate and within reasonable limits the independent ethos of RQIA. To emphasise our independence we have reworded the second paragraph of the Foreword to read: • The Regulation and Quality Improvement Authority (RQIA) was established on 1 April 2005 as a non-departmental public body. RQIA provides independent assurance about the safety, quality and availability of health and social care services in Northern Ireland. RQIA is also responsible for encouraging improvements in the quality of these services. We have also removed the following bullet point from Section 3.2 ‘What we will do’ column: • agreeing Terms of reference for planned reviews with DHSSPS The Bullet point on page 2 of the document relates to the on-going risk assessment of the full range of regulated services. This risk assessment forms part of RQIA’s Inspection Planning Approach (IPA). The criteria vary in accordance with the service being regulated and the information RQIA receives on each of those services. RQIA keeps its risk assessment tools and criteria under continuous review. To detail the criteria in the corporate strategy would require a significant section or appendix. If inserted, the information may not remain accurate for the stated life of the document (i.e. up to 2015) The Bullet Point aims to convey the fact that, in line with Better Regulation Principles, RQIA uses a risk based approach, focusing the deployment of its limited regulation resources in a targeted and proportionate way. In terms of comments raised in relation to engagement with stakeholders RQIA believes that using the term ‘stakeholder’ throughout the document defines all groups or people with whom we engage. To further support this we have included the following definition of stakeholder in the ‘Glossary’ section • Any individual, group or organisation that can affect, be affected by, or perceive itself to be affected by, the activities of RQIA. The ‘Evidence’ box within the Strategy map has been reworded to read: • Underpinning our regulatory practice using research and available 6
RQIA's Response evidence The description of the “Information” key enabler is intended to make a clear distinction between the analysis and management of information on the one hand and the provision and management of technology on the other. Information Communications Technology is concerned with the storage, retrieval, manipulation, transmission or receipt of digital data. As RQIA wishes to adopt an integrated approach to information management, information governance and ICT, we believe that the current description of this key enabler should remain unchanged. The new mental health legislation is referenced in Page 4 ‘Challenges Ahead’ • RQIA will need to review the implications of the legislative changes resulting from the proposed introduction of the new Mental Capacity (Health, Welfare and Finance) Bill for the monitoring activities required of RQIA. In relation to the need to state a stronger emphasis to improve within the private sector RQIA believes the reference to improvement applies equally to both the statutory and the independent sectors. 7
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Agenda Item Paper AGENDA RQIA Boa
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RQIA Board Meeting Date of Meeting
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they should advise the Committee Se
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11.120.11 The Board NOTED the Chief
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11.123.5 The Board NOTED the Corpor
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7 February; Along with Dr Stewart a
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Name of Service Date of issue FTC /
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As part of its on-going programme o
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RQIA has been commissioned by the M
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4.2 Whistleblowing In January 2012,
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Summary Financial Position Revenue
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Revenue Financial Position Currentl
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Prompt Payment Compliance The promp
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Introduction Dental registration wa
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Contents 1. INTRODUCTION 1 2. SUMMA
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2. Summary of Traffic Light Rating
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By the end of Q3 regulation inspect
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An Information and ICT Strategy was
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Summary of Red and Amber Actions fr
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D6.1.2 Maintain and review RQIA's P
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CA1.1.4 Actions Progress Exception
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Actions Progress Exception Report:
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CA1.1.11 Actions Progress Exception
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CA1.2 - Improved local and national
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CA1.3 - Evidenced that the results
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CA2.2 - Use our information to prov
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CA3.2 - Incorporated and discharged
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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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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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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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Page 139 and 140: 1 Regulation Registering and inspec
Page 141 and 142: 2 Review Assuring the quality of he
Page 143 and 144: 3 Mental Health Order Oversight Del
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Page 147 and 148: 4 Engagement & Communications Engag
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Page 151 and 152: 6 Performance Managing and monitori
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Page 155 and 156: 8 Information Managing information
Page 157 and 158: Appendix 1 - Finance Section 1. Rev
Page 159 and 160: Strategic Objectives By 2015 we wil
Page 163 and 164: The Regulation and Quality Improvem
Page 165 and 166: Paper AC / min11 / Nov MINUTES RQIA
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Page 169 and 170: Paper AC / min11 / Nov 6.11 The Aud
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Page 173 and 174: Paper AC / min11 / Nov 14.2 The Aud
Page 175 and 176: Paper AC / min11 / Nov Action Minut
Page 177 and 178: appropriate and adequate as indicat
Page 180 and 181: CONTENTS Section Title Page 1 Backg
Page 182 and 183: 1.3 Pre-Consultation Process 1.3.1.
Page 184 and 185: Consultation Questions The followin
Page 188 and 189: 3. Q2: Have strategic objectives an
Page 190 and 191: RQIA under ‘Regulation’ of a ra
Page 192 and 193: point the ten recommendations publi
Page 194 and 195: 3.3 Mental Health Order Oversight -
Page 196 and 197: from the reviews on MHLD facilities
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Page 200 and 201: 5. Q4: Do you have any other commen
Page 202 and 203: RQIA notes the comment in relation
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Page 206 and 207: Version 4_0 26
Page 208 and 209: Strategy have been summarised below
Page 210 and 211: Section Page Details of Change 3 Me
Page 212 and 213: Section Page Details of Change 10 R
Page 214 and 215: Section Page Details of Change 16 P
Page 216 and 217: RQIA Draft Corporate Strategy 2012-
Page 218 and 219: Contents Foreword .................
Page 220 and 221: guardianship order; and preventing
Page 222 and 223: Challenges Ahead This section ident
Page 224 and 225: undertaken against a changing lands
Page 226 and 227: The Vision for 2012-15 The vision,
Page 228 and 229: The successful delivery of our outc
Page 231 and 232: Bringing it together In this sectio
Page 235 and 236: 2. Review Assuring the quality of h
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Strategic Objectives By 2015 we wil
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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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The Regulation and Quality Improvem
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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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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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