February 2012 - Regulation and Quality Improvement Authority

More documents

Recommendations

Info

CA1.2.5 CA1.2.6 Actions Progress Exception Report: Reason/Action/Emerging Risk Develop and embed a range of systems and methodological improvements to enhance the delivery of the RQIA Thematic Review Programme. (March 2012) Develop and review the inspection methodology for all services subject to IR(ME)R. (March 2012) Supporting KPIs Q = KPI to be reported on quarterly basis S = KPI to reported on six monthly basis A = KPI to be reported annually % of post project evaluations completed within 3 months of the publication of each service review (Q) The introduction of Post Project Evaluations commenced in Q2 2010/2011 and of the 8 End of Project Reports which have been produced, 6 were completed within 3 months‟ of the publication of each review, ie: 75%. There were no project evaluations completed during Q3 as there were only 2 projects/reviews which were published towards the end of this quarter and would not be due to have an End of Project Report delivered until March. Report on the application of RQIA inspection principles introduced into inspection methodology (A) 19
CA1.3 - Evidenced that the results of our programme of inspections and reviews is having a demonstrable impact on service improvement CA1.3.1 CA1.3.2 CA1.3.3 CA1.3.4 Actions Progress Exception Report: Reason/Action/Emerging Risk Report on the outcomes of regulated sector inspections on a six monthly and annual basis. (March 2012) Report on the outcomes of statutory sector reviews on a quarterly and annual basis. (March 2012) Report on the outcomes of hygiene and infection control inspections in statutory health and social care facilities on a quarterly and annual basis. (March 2012) Report on the outcomes of IR(ME)R inspections on a quarterly and annual basis. (March 2012) Supporting KPIs Q = KPI to be reported on quarterly basis S = KPI to reported on six monthly basis A = KPI to be reported annually A target of 10% of services assessed as requiring high or medium intensity inspection will require a less intense inspection regime by year end (S) Of those services that were assessed as at 30 March 2011 as requiring high or medium intensity inspection by Q2 19% have improved. Report on the impact of review activity on the improvements in the quality, safety and availability of health and social care services (A) 100% of quarterly reports completed within agreed timescales (A) Completion of an annual overview report of the outcomes of the hygiene and infection inspections (A) 100% (8) outcomes of IR(ME)R inspection reports competed annually (Q) Q3 100% 20
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 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 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: CA1.2 - Improved local and national
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
Page 63 and 64: D1 - We engage effectively with our
Page 65 and 66: D2 - We maintain a robust governanc
Page 69 and 70: D4 - We manage our finances and ass
Page 71 and 72: D4.2 - Maintained and made best use
Page 75 and 76: D6.2 - Improved our performance thr
Page 77 and 78: D7.2 - Complied with best practice
Page 87: CONTENTS Page Executive summary 3 R
Page 90 and 91: • any additional actions consider
Page 92 and 93: Risk Scoring Matrix IMPACT Risk Sco
Page 94 and 95: RISK Scoring MATRIX IMPACT Risk Sco
Page 96 and 97: RISK ACTIVITY CALENDARS Action by D
Page 98 and 99: Ref No. Description of Risk What wo
Page 104 and 105:
approval from DHSSPS and DFP for th
Page 106 and 107:
Recommendation/ Resolution Next ste
Page 108 and 109:
Definitions Risk is an event or unc
Page 110 and 111:
1.0 Introduction Managing Public Mo
Page 112 and 113:
5.2 Audit Committee Responsibility
Page 114 and 115:
5.6 Responsibility of All Staff All
Page 116 and 117:
7.2 Risk Identification Risk identi
Page 118 and 119:
Level of impact (Minor) Medium (Mod
Page 120 and 121:
The relationship between the cost o
Page 122 and 123:
5. Identify any gaps in “controls
Page 124 and 125:
developed along with a summary of R
Page 126 and 127:
Checklist for Identifying Risks App
Page 128 and 129:
Corporate Risk Assurance Framework
Page 130 and 131:
BUSINESS PLAN 2012-13 To be a drivi
Page 132 and 133:
Foreword The Regulation and Quality
Page 134:
The Strategy Map provides a visual
Page 137 and 138:
to the delivery of corporate object
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
Page 145 and 146:
3 Mental Health Order Oversight Del
Page 147 and 148:
4 Engagement & Communications Engag
Page 149 and 150:
Policy and provide guidance to line
Page 151 and 152:
6 Performance Managing and monitori
Page 153 and 154:
8 Information Managing information
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 161 and 162:
Page 163 and 164:
The Regulation and Quality Improvem
Page 165 and 166:
Paper AC / min11 / Nov MINUTES RQIA
Page 167 and 168:
Paper AC / min11 / Nov 4.2 4.3 4.4
Page 169 and 170:
Paper AC / min11 / Nov 6.11 The Aud
Page 171 and 172:
Paper AC / min11 / Nov members. Res
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 186 and 187:
RQIA's Response • Where it thinks
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
Page 198 and 199:
• Objective 2.3 ‘Documented evi
Page 200 and 201:
5. Q4: Do you have any other commen
Page 202 and 203:
RQIA notes the comment in relation
Page 204 and 205:
NI Association for Mental Health NI
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 233 and 234:
Page 235 and 236:
2. Review Assuring the quality of h
Page 237 and 238:
Page 239 and 240:
Page 241 and 242:
Page 243 and 244:
Page 245 and 246:
Page 247 and 248:
Page 249 and 250:
7. Evidence Underpinning our regula
Page 251 and 252:
Page 253 and 254:
9. Governance Maintaining and promo
Page 255 and 256:
Delivering the strategy and managin
Page 257 and 258:
Glossary of Terms and Abbreviations
Page 259 and 260:
Governance Guardianship Health and
Page 261 and 262:
Mental Health Commission (MHC) Ment
Page 263 and 264:
Quality Improvement Plan Regulated
Page 265 and 266:
Contact us The Regulation and Quali
Page 267 and 268:
• People in respect of gender, ag
Page 269 and 270:
CONTENTS 1.0 Introduction 3-7 1.1 I
Page 271 and 272:
During the period under review, res
Page 273 and 274:
RQIA believes that the diverse need
Page 275 and 276:
The following standards were used a
Page 277 and 278:
1.3 Standard 10: Each child has the
Page 279 and 280:
1.4 Standard 18: The required recor
Page 281 and 282:
2.0 Boarding schools Article 176 of
Page 283 and 284:
These inspections provided sound ev
Page 285 and 286:
4. Each trust to implement robust c
Page 287 and 288:
Tasks for the group include: Agree
Page 289 and 290:
Over the course of 2011-12, RQIA’
Page 291 and 292:
Appendix 1 2. EACH CHILD HAS THE RI
Page 293 and 294:
Appendix 2 10. EACH CHILD HAS THE R
Page 295 and 296:
10.9 A homework timetable is establ
Page 297 and 298:
Appendix 3 18. THE REQUIRED RECORDS
Page 299 and 300:
18. 11 Clothing. 1 2 3 4 18.12 Acti
Page 301:
18.23 Procedure in event of fire. 1
Page 305 and 306:
Foreword RQIA wishes to thank every
Page 307 and 308:
1 The Regulation and Quality Improv
Page 309 and 310:
2 The Work Programmes of RQIA RQIA
Page 311 and 312:
• Follow-Up Review: Reducing the
Page 313 and 314:
Page 22 of 21
Page 315 and 316:
Page 317 and 318:
1.0 Introduction Through its activi
Page 319 and 320:
Private homes Voluntary/ independen
Page 321 and 322:
1.1 Inspection work residential chi
Page 323 and 324:
As illustrated above, achievement l
Page 325 and 326:
Assessment, reviews and care plans
Page 327 and 328:
Key records include: • Children's
Page 329 and 330:
with the robustness of the selectio
Page 331 and 332:
gained by the ETI, its 2011-12 educ
Page 333 and 334:
On a practical level this has led t
Page 335 and 336:
These meetings were very well atten
Page 337 and 338:
APPENDICES 23
Page 339 and 340:
2.3 Recording in the case file demo
Page 341 and 342:
10.4 Disruption in schooling is kep
Page 343 and 344:
10.14 Responsibility for a child's
Page 345 and 346:
18.5 Young people's individual care
Page 347 and 348:
18.17 Record of official visits. 1
Page 350 and 351:
Page 352 and 353:
patients’ who had difficulty swal
Page 354 and 355:
An area that has been highlighted i
Page 356 and 357:
Where issues of concern were highli
Page 358 and 359:
Page 360 and 361:
It should be noted that while figur
Page 362 and 363:
Table 4: Establishments/Agencies De
Page 364 and 365:
RQIA’s approach to regulation In
Page 366 and 367:
5 Follow-Up Evidence from Previous
Page 368 and 369:
Levels of Achievement The model use
Page 370 and 371:
Regulatory Action Normally, where a
Page 372 and 373:
Relationship between Achievement Le
Page 374 and 375:
Provider workshops and feedback In
Page 376 and 377:
Summary of the findings by register
Page 378 and 379:
Standard 5: Provision of informatio
Page 380 and 381:
and any equipment used is safe and
Page 382 and 383:
elying on a questionnaire approach
Page 384 and 385:
RQIA will issue a guidance document
Page 386 and 387:
Standard Crit. N/A 5 6 8 12 Table 1
Page 388 and 389:
achieved and 30% having substantial
Page 390 and 391:
Criterion 12.10 Staff are aware of
Page 392 and 393:
Overview Service providers were ask
Page 394 and 395:
• The use of patients'/residents
Page 396 and 397:
Residential care homes A residentia
Page 398 and 399:
Table 14 Residential (RC) - Announc
Page 400 and 401:
that the staff had not followed the
Page 402 and 403:
In a majority of homes (86%) this c
Page 404 and 405:
more importantly the outcome of com
Page 406 and 407:
had made changes or improvements to
Page 408 and 409:
Where inspectors observed poor prac
Page 410 and 411:
Day care settings A day care settin
Page 412 and 413:
Specific Commentary Standard 2 - Th
Page 414 and 415:
Criterion 8.5 - When a service user
Page 416 and 417:
awareness training regarding vulner
Page 418 and 419:
production of documents which used
Page 420 and 421:
Where issues of concern were highli
Page 422 and 423:
RQIA Annual Regulation Adult Annual
Page 424 and 425:
RQIA Board Meeting Date of Meeting
Page 426 and 427:
MENTAL HEALTH AND LEARNING DISABILI
Page 428 and 429:
Table 2 Breakdown by Trust and loca
Page 430 and 431:
Emerging Trends arising from SAIs f
Page 432 and 433:
Table 4 Analysis of Detention Forms
Page 434 and 435:
Number of Inspections undertaken fr
Page 436 and 437:
4. Review of Safeguarding of Childr
Page 438 and 439:
Regional Overview of Guardianship a
Page 440 and 441:
iv. A list of Patients for whom the
Page 442 and 443:
Other organisations have included V
Page 444 and 445:
REGISTRATION POLICY FOR THE REGULAT
Page 446 and 447:
1.0 Introduction Background 1.1 The
Page 448 and 449:
6.2 Specific regulations relating t
Page 450 and 451:
10.0 Equality • Legislative frame
Page 452 and 453:
Registration - Offences and Penalti
Page 454 and 455:
Appendix 4 Flowchart of responsibil
Page 456 and 457:
3. RQIA’s 2012-13 inspection prog
Page 458 and 459:
2. The service user’s own home (a
Page 460 and 461:
Exclusive possession includes the r
Page 462 and 463:
Following this judgement, the Care
Page 464 and 465:
The NDTi “Real Tenancy Test” ad
Page 466 and 467:
5. Restrictive practices and physic
Page 468 and 469:
RQIA’s regulatory function is ham
Page 470:
(c) Conclusion It is generally ackn
show all

February 2012 - Regulation and Quality Improvement Authority

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?