These minimum standards govern the operation of Residential Care Homes in Northern Ireland, setting out requirements for quality of care, resident involvement, care planning, needs assessment, health and social care, staffing, premises, medicines management, and registration. Operators must ensure residents are treated with dignity and respect, have individualised care plans and written agreements, and that the home meets detailed standards across all aspects of daily life and management. Compliance is mandatory and is assessed by the Regulation and Quality Improvement Authority through inspection, observation, and review of records and policies.
View official sourceResidential Care Homes Minimum Standards Version 1.0: August 2011 Version 1.1: August 2021 Version 1.2: December 2022 Version 1.3: May 2026 2 Date Version Summary of Changes August 2011 Version 1 Original July 2021 Version 1.1 (i) Requirements for qualifications – pages 82 to 85 (ii) The Code of Practice for Employers was replaced in 2015 (updated 2019) by Standards of Conduct and Practice for Employers - Page 50, para 20.3 & Page 81 December 2022 Version 1.2 Standard 3.7 revised – Page 18 May 2026 Version 1.3 Standard 15 – (i) Addition of 15.14 and15.15 – Page 40 (ii) Addition of the Level 5 Diploma in Leadership and Management in Health and Social Care Services (Northern Ireland) to the minimum standards for Registered Managers – Page 83 3 Contents Introduction 5 Values underpinning the standards 8 SECTION 1 - MINIMUM STANDARDS Quality care 1. Residents’ involvement 14 2. Contact with family, friends and the community 16 3. Admission to the home 17 4. Individual agreement 19 5. Needs assessment 21 6. Care plan 23 7. Consent to examination, treatment and care 25 8. Resident records and reporting arrangements 26 9. Health and social care 28 10. Responding to residents’ behaviour 29 Care review 31 12. Meals and mealtimes 33 13. Programme of activities and events 35 14. Dying and death 37 15. Residents’ money and valuables 38 16. Protection of vulnerable adults 41 17. Complaints 4 18. Transport 45 Management of the home 19. Recruitment of staff 48 20. Management and control of operations 50 21. Policies and procedures 54 22. Management of records 55 23. Staff training and development 56 24. Staff supervision and appraisal 58 25. Staffing 59 26. Volunteers 61 27. Premises and grounds 62 28. Safe and healthy working practices 65 29. Fire safety 67 4 30. Management of medicines 68 31. Medicine records 70 32. Medicines storage 71 33. Administration of medicines 72 34. Medical devices and equipment 74 35. Infection prevention and control 75 SECTION 2 – REQUIREMENTS FOR REGISTRATION Registration 78 Statement of purpose 79 Fitness of the registered person 81 Fitness of the registered manager 82 Fitness of the premises - New homes and extensions 86 - Existing homes 96 APPENDICES Appendix 1 - Register of residents 105 Appendix 2 - Policies and procedures 106 Appendix 3 - Glossary of terms 109 5 Introduction This document sets out minimum standards for Residential Care Homes. The standards specify the arrangements, facilities and procedures that need to be in place and implemented to ensure the delivery of a quality service. Background In 2001, the Department of Health, Social Services and Public Safety (DHSSPS) issued a consultation paper entitled “Best Practice – Best Care”, setting out proposals for improving the quality of health and social care in Northern Ireland. The results of this consultation showed widespread support for a new system of regulation covering a wider range of care services. This in turn led to the development of The Health and Personal Social Services (Quality, Improvement and Regulation) (Northern Ireland) Order 2003 (‘the Order’). The Order allows for the establishment of the Northern Ireland Health and Personal Social Services Regulation and Quality Improvement Authority (now known as the Regulation and Quality Improvement Authority), an independent body with responsibility for, and powers to, regulate establishments and agencies in the Health and Social Care (HSC) and the independent sector. Responsibility for all services previously regulated by the Registration and Inspection Units of the Health and Social Services Boards is transferred to the Regulation and Quality Improvement Authority. Development of standards Article 38 of the Order confers powers on DHSSPS to prepare, publish and review statements of minimum standards applicable to all services including regulated services. The Department has developed minimum standards for a range of regulated services including residential care homes. These standards were developed with the help of residents, their representatives, providers, staff, professionals, inspectors and commissioners. The standards were also subject to a full public consultation process between September and December 2004. 6 The standard statements and associated criteria cover key areas of service provision, are applicable across various settings, and designed to be measurable through self-assessment and inspection. The Regulation and Quality Improvement Authority will look for evidence that the standards are being met through: - • Discussions with residents, managers, staff and others • Observation of activities in the home • Inspection of written policies, procedures and records. How the standards and regulations work together Article 38 of the Order gives powers to the DHSSPS to publish minimum standards that the Regulation and Quality Improvement Authority must take into account in the regulation of establishments and agencies. The regulations for residential care homes apply to independent homes for which registration was previously required under the Registered Homes (Northern Ireland) Order 1992 (NI 20), and to statutory homes. The regulations were published by the DHSSPS in accordance with Article 23 of the Order, which sets out the range of areas for which regulations may make provision. These include the management and conduct of homes and agencies, staff qualifications, premises and financial matters. Compliance with the regulations is mandatory and non-compliance with some specific regulations is considered an offence. The minimum standards amplify on the regulations and provide specific details which help in determining whether there is compliance with the regulations. The Regulation and Quality Improvement Authority must take into account the extent to which the minimum standards have been met in determining whether a service provider maintains registration, or whether to take action for breach of regulations. The minimum standards have been prepared in response to extensive consultation. They are the minimum provisions below which no provider is expected to operate. 7 Small homes The HPSS (Quality, Improvement and Regulation) (NI) Order 2003 and the associated regulations make no distinction between small homes (i.e. those providing three or less residential care places) and larger homes. These standards therefore apply to small homes. However, the Regulation and Quality Improvement Authority is expected to take a proportionate approach when applying the standards to small homes. 8 Values underpinning the standards The philosophy and practice within a home should lead to a friendly, caring and stimulating atmosphere where the residents are listened to and feel valued, their rights are upheld, their cultural and religious beliefs are respected, and living in the home is a positive and beneficial experience. In order to achieve this, managers and staff must at all times have the following values firmly embedded in their practice. Dignity and respect The uniqueness and intrinsic value of individual residents is acknowledged and each person is treated with respect. Independence Residents have as much control as possible over their lives whilst being protected against unreasonable risks. Rights Residents’ individual and human rights are safeguarded and actively promoted within the context of services delivered by the home. Equality and diversity Residents are treated equally and their background and culture are valued and respected. The services provided by the home fit within a framework of equal opportunities and anti-discriminatory practice. Choice Residents are offered, wherever possible, the opportunity to select independently from a range of options based on clear and accurate information. Consent Residents have a legal right to determine what happens to them, and their informed, genuine and valid consent to the care and support they receive is essential. 9 Fulfilment Residents are enabled and supported to lead full and purposeful lives and realise their ability and potential. Safety Residents feel as safe as is possible in all aspects of their care and life, and are free from exploitation, neglect and abuse. Privacy Residents have the right to be left alone, undisturbed and free from unnecessary intrusion into their affairs and there is a balance between the consideration of the individual’s own and others’ safety. Confidentiality Residents know that information about them is managed appropriately and everyone involved in the home respects confidential matters. When these values are integrated into all aspects of planning, delivery and review of services and the minimum standards are being met, the home will be a resource that delivers the best possible outcomes for residents living there. 10 SECTION 1 MINIMUM STANDARDS 11 Quality care Residents will experience quality care and support when they are fully informed and involved in all decisions affecting their life and care, and they can contribute to the planning and evaluation of services. A key principle within these standards is that people in receipt of services must be central in all aspects of planning, delivery and review of their care. Having a caring, open and responsive approach in a home is key to the delivery of quality services. These minimum standards promote the empowerment of residents and strongly encourage proactive engagement and a listening partnership with residents to ensure they feel involved in, and can influence, the operation of the home. The use of both informal feedback mechanisms and more formal arrangements, and where necessary, enlisting local advocacy services to gain residents’ and relatives’ views about the services provided, will provide managers and staff with essential information about improvements that can be made. Listening to and responding to compliments, comments and complaints is a vital part of this process. Maintaining or making links with the local community is very important and helps residents build and retain their positive sense of worth. Knowledge of, and a respect for, residents’ interests and preferred way of life, and listening and responding to their suggestions, will determine the content of a creative and interesting programme of events and activities. Spontaneity and flexibility are also essential for any good programme. Mealtimes are an opportunity for residents to meet others and catch up with events taking place in the home. The presentation of food and the decoration in dining areas should therefore reflect the importance of the social aspect of mealtimes. Before being admitted to a home, prospective residents and their relatives need information about the home. They can gain this through visiting the home and talking to other residents living there, and consulting with staff and management. They can also obtain information by reading the home’s “Residents’ Guide” and reports made about the home by the Regulation and Quality Improvement Authority. To enable residents to make informed choices and retain as much control as possible over their own 12 affairs, homes are expected to have open and transparent arrangements for all their services and to provide all relevant information in suitable formats. Where references are made in individual standards to information being provided to residents or their representatives, it is assumed that each home will make all reasonable efforts, including any adjustments as required, to provide the information directly to the resident in a format that the resident will understand. The information should only be provided to the resident’s representative when this is not successful or possible. Individual agreements will clarify what is expected for each resident. Homes are part of the overall provision of services within a community. They will provide the most effective care and support for residents if there is a collaborative multi-disciplinary partnership between all those involved with the residents, including relatives. In order to achieve maximum benefit and positive outcomes for residents, the interdependency between all involved needs to be recognised. Those providing care for the resident need to understand the resident’s perspective and the various interested parties’ roles and responsibilities. They therefore need to share information and respond appropriately when contacted. No particular model of care planning or format for a care plan is advocated, but the standards emphasise the resident’s right to full involvement in the care planning process. Their right to make decisions about their care and support is stressed and there must be evidence of the service user’s active involvement in the process of drawing up their care plan. This is the key mechanism for empowering service users and ensuring a partnership between the resident and staff. It is also acknowledged that the manager of a home does not normally have control of the full care planning and review processes for residents, but plays a vital role in these processes. The home must therefore have joint working arrangements with the community care teams that are responsible for the residents’ overall care, and who refer the resident to the home. These teams are responsible for providing essential information to the home prior to the resident’s admission. They also normally hold responsibility for the review systems. 13 Against this background, staff in homes need to have knowledge of the general health and social care needs of the residents, and basic care practices and interventions that promote the health and welfare of residents. Staff must treat residents as individuals and provide care that meets their individual needs. The need for ongoing assessment and identification of risks by staff is also necessary to ensure a proper fit between the care a home can provide and the changing needs of those living there. However, for residents to maintain as much autonomy and independence as possible, there needs to be a balance in managing the reasonable risks of normal living and ensuring their well-being and that of others. It should also be noted that all potential residents are entitled to avail of care management and assessment services provided by Health and Social Care (HSC) Trusts, even where residents are in a position to cover the full costs of their residential care. Non- participation in the care management system should only be as a result of an explicit opt out by the prospective resident. Guidance issued about quality initiatives and the provision of quality care will assist managers and staff to keep up-to-date with current best practice, which they can incorporate into the practices in the home. Homes committed to meeting the minimum standards and to continual improvement will provide best care and life opportunities to the residents living there. 14 Residents’ involvement Standard 1: Residents’ views and comments shape the quality of services and facilities provided by the home. Criteria 1.1 The values underpinning the standards inform the philosophy of care and staff consistently demonstrate the integration of these values within their practice. 1.2 Residents’ views are taken into account in all matters affecting them, and the home has forums or systems where residents and their representatives can express their views and be consulted about the running of the home. 1.3 Residents are involved in decisions affecting the quality of their life in the home, including the introduction or review of the home’s routines, practices and policies and procedures. 1.4 Suggestions made regarding improvements, compliments given and issues raised by residents and their representatives regarding the quality of services and facilities provided are listened and responded to. 1.5 A record is made of the matters raised by the residents and their representatives and the action taken. 1.6 The views and opinions of residents and their representatives about the running of the home are sought formally at least once a year, preferably by an organisation or person independent of the home. 15 1.7 A report is prepared that identifies the methods used to obtain the views and opinions of residents and their representatives and this incorporates the comments made, issues raised and any actions to be taken for improvement. A copy of this report is provided to residents and their representatives. 1.8 Residents and their representatives are informed about planned inspections and the arrangements for them to give their views about the home to the inspectors. 16 Contact with family, friends and the community Standard 2: Contact with family, friends and the local community is facilitated for residents. Criteria 2.1 Each resident is encouraged and facilitated to maintain, as far as possible, their existing links with family, friends and the local community. 2.2 Residents can have visitors at any reasonable time, and if there are restrictions these are made known and explained to those concerned. 2.3 There are facilities for residents to receive visitors in private if they wish and these are offered as necessary. 2.4 When agreed by the resident, their family and friends have opportunities to be involved in the resident’s daily life. 2.5 Each resident’s right to develop and maintain intimate personal relationships with people of their choice is respected unless a resident is assessed as lacking the capacity to consent to such a relationship. If such a situation occurs, information and guidance is sought on ensuring their protection. 2.6 Residents are consulted about visits by community groups and volunteers and the manager or senior member of staff on duty monitors these visits to ensure they benefit residents. 2.7 Each resident’s existing links with family, friends and the local community are identified and recorded at the time of their admission to the home. 17 Admission to the home Standard 3: Admissions are planned to facilitate a smooth introduction to the home for each resident. Criteria 3.1 Prospective residents, or their representatives, are given a “Residents’ Guide” that provides comprehensive, up-to-date information about the home and the services provided. The information is available, if required, in a format and language suitable for each prospective resident or their representative. 3.2 The residents’ guide contains information on the following: - • A summary of the statement of purpose, and services and facilities provided • The location and description of the home • The name of the registered manager and the general staffing arrangements • The current programme of activities and events • The charges for specific services and facilities, and activities and events that have costs • The arrangements for resident involvement in the running of the home • The views of residents and their representatives regarding the quality of services and facilities • The general terms and conditions of living in the home • The arrangements for inspection of the home and details on how to access inspection reports • The organisation, its structure and the name of the registered person • The referral and admission procedures. 18 3.3 Arrangements are in place for prospective residents or their representatives to visit and assess the suitability of the home prior to admission. 3.4 The manager ensures that a referral form providing all necessary information, including any risk assessment relating to the resident and the delivery of their care and services, is completed before the resident is admitted. Any documents from the referring Trust are dated and signed when received. 3.5 For self-referred clients, an appropriately experienced and qualified person within the home collates the necessary information and ensures that the home is appropriately registered to accommodate the resident. The prospective resident is involved in the process along with, where appropriate, their representative and, with the prospective resident’s agreement, any relevant professionals. 3.6 For any unplanned admission, the referral form is obtained or completed within two working days of the resident being admitted. When referral information is not received, records are kept of requests made for it. 3.7 A suitably qualified or suitably trained person, visits the resident prior to admission. When this does not happen, the reason is recorded. 3.8 A named member of staff is identified to provide support for the resident for the first few days and a key worker from the staff team is identified subsequently. 3.9 Where the home is acting in response to a self-referred resident, the manager advises the resident, or their representative, to contact the local Trust’s care management service. 19 Individual agreement Standard 4: Each resident has an individual written agreement setting out the terms of residency regarding the services and facilities to be provided. Criteria 4.1 Each resident or their representative is provided with an individual written agreement that sets out their terms of residency. The agreement is made available, if required, in a format and language suitable for the resident or their representative. 4.2 The agreement sets out, at a minimum: - • The date of admission and the duration of the stay, if known • The accommodation, services and facilities provided by the home (these are the general services and facilities agreed through contracting arrangements with a HSC Trust), the weekly fee plus an itemised list of all agreed services and/or facilities over and above the general services and facilities • The individual charges for all the agreed itemised services and facilities, arrangements for the payment of all agreed charges and the minimum period of notice for any change to the charges • The arrangements for any financial transactions undertaken on behalf of the resident by the home and the records to be kept • The general terms and conditions of residency with reference to any of the home’s relevant policies • The arrangements for the management of the resident’s valuables, if any • A copy of the home’s complaints procedure • The arrangements for regularly reviewing the signed agreement and the circumstances when 20 the agreement can be reviewed outside these arrangements • The frequency of summary reports (for persons staying for respite care) • The period of notice for terminating the agreement. 4.3 The agreement is in place before admission, or if this is not possible, it is in place within five working days of the date of admission. 4.4 The resident or their representative and the registered person sign the agreement prior to, or within five working days of, admission. Where the resident or their representative is unable to sign or chooses not to sign, this is recorded. 4.5 For residents who are admitted to the home on an unplanned basis the agreement is signed within two weeks of admission. 4.6 The resident or their representative is given written notice of all changes to the agreement and these are agreed in writing by the resident or their representative. Where the resident or their representative is unable to sign or chooses not to sign, this is recorded. 4.7 A minimum of four weeks notice is given for the introduction of new charges for services and facilities together with a statement of the reasons for such an increase. 4.8 Charges are levied in accordance with current DHSSPS guidelines on the care and assessment process. 21 Needs assessment Standard 5: Each resident has an up-to-date assessment of their needs. Criteria 5.1 Residents are encouraged and enabled to be involved in the assessment process but when a resident is unable or chooses not to be involved, this is recorded. The resident’s representative, where appropriate, and relevant professionals and disciplines are also involved. 5.2 The initial assessment details obtained at the time of referral are revised as soon as possible and at the latest within one month of the resident’s admission, to ensure there are comprehensive details of: - • The resident’s physical, social, emotional, psychological and spiritual needs • Specific needs and preferences if the resident is from a minority group • Information about the resident’s life history and current situation • Risks involved in the delivery of care and/or resulting from the resident’s behaviour • Other professionals or agencies providing a service to the resident. 5.3 Further information about the resident’s life history and previous lifestyle, values and personal preferences is obtained on an ongoing basis and recorded. 5.4 The assessment is signed by the resident or their representative, where appropriate, and the member of staff responsible for carrying it out. If the resident or their representative is unable to sign or chooses not to sign, this is recorded. 22 5.5 The assessment is kept under continual review, amended as changes occur and kept up-to-date to accurately reflect at all times the needs of the resident. 23 Care plan Standard 6: Each resident has an individual and up-to- date comprehensive care plan. Criteria 6.1 Residents are encouraged and enabled to be involved in the care planning process, but when a resident is unable or chooses not to, this is recorded. 6.2 An individual comprehensive care plan is drawn up as the assessment of the resident’s needs is carried out, and includes details of: - • Any personal outcomes sought by the resident • The daily care, support, opportunities and services provided by the home and others • How specific needs and preferences are to be met if the resident is from a specific minority group • How information about the resident’s lifestyle is used to inform practice • The resident’s agreed daily routine and weekly programme • The management of any identified risks • Strategies or programmes to manage specified behaviours • Directions for the use of any equipment used to assist the delivery of care. 6.3 The resident or their representative, where appropriate, sign the care plan along with the member of staff responsible for drawing it up and the registered manager. If the resident or their representative is unable to sign or chooses not to sign, this is recorded. 6.4 A copy of the care plan is made available to the resident in a language and format suitable for them. 24 6.5 The care plan is presented at the post-admission review meeting, modified if necessary and agreed to by those attending. 6.6 The care plan is kept up-to-date and reflects the resident’s current needs. Where changes are made to the care plan, the resident, or their representative where appropriate, the member of staff making the changes and the manager sign the revised care plan. When a resident or their representative is unable to sign or chooses not to sign, this is recorded. 6.7 When restrictions from any risk assessment are in place, or there are behaviours likely to pose a risk for the resident or others, these are highlighted for those who have authorised access to the resident’s care plan. 25 Consent to examination, treatment and care Standard 7: Residents’ consent to examination, treatment and care is obtained in accordance with policies and procedures. Criteria 7.1 The consent policy and procedures include how to obtain consent and what to do if a resident lacks capacity to give valid consent, or withdraws consent. 7.2 Procedures are explained to residents and their representatives informing them of the implications of the treatment and any options available to them. This is documented in care records. 7.3 Procedures for obtaining consent are in accordance with DHSSPS, Nursing and Midwifery Council and professional regulatory bodies’ guidance. 7.4 Completed written consent forms, where used, are maintained within individual case records. 26 Resident records and reporting arrangements Standard 8: Records are kept in accordance with professional and legislative requirements on each resident’s situation, actions taken by staff and reports made to others. Criteria 8.1 Residents or, when appropriate, their representatives, have access to their records. 8.2 Records are maintained for each resident detailing the following: - • All personal care and support provided • Changes in the resident’s needs, usual behaviour or routine and any action taken by staff • Unusual or changed circumstances that affect the resident and any action taken by staff • Contact with the resident’s representative about matters or concerns regarding the health and welfare of the resident • Contact between the staff and primary health and social care services regarding the resident • Incidents, accidents or near misses occurring and action taken. When no recordable events occur, there is an entry at least weekly for each resident to confirm that this is the case. 8.3 A summary report of any period of respite care is compiled and a copy sent to the resident’s carer in the community (if appropriate) and referring Trust in line with the resident’s written agreement. 27 8.4 There is guidance for staff on matters that need to be reported, or referrals made, to: - • The registered manager • The resident’s representative • The referring Trust • Other relevant health or social care professionals. 8.5. All records are legible, accurate, up-to-date, signed and dated by the person making the entry. 8.6 The resident’s records contain a recent photograph of the resident. 8.7 A record is kept of all property brought into the home by or on behalf of residents at the time of admission. The record is updated to note items acquired and disposed of after admission, which staff have been informed about. 8.8 There is a record of the people to be contacted and any arrangements the resident specifically requests to be put in place at the time of their death. If the resident is unable or chooses not to discuss this subject, this is recorded. 28 Health and social care Standard 9: The health and social care needs of residents are fully addressed. Criteria 9.1 The home has details of each resident’s General Practitioner (GP), optometrist and dentist. If a resident has to register with a new GP, optometrist or dentist after admission, the resident is provided with information on the choice of services in the locality and assisted in the registration process. 9.2 The general health and social care needs of the categories of residents the home accommodates are understood by staff, and they have knowledge of basic health practices and interventions that promote the health and welfare of the residents. 9.3 The general health and welfare of residents is continually monitored and recorded. Referrals are made to, or advice is sought from, primary health care services and social services when necessary and documented in the resident’s records. 9.4 Where appropriate, the resident’s representative is provided with feedback from health and social care appointments and informed about any follow up care required. 9.5 There are systems for monitoring the frequency of residents’ health screening, dental, optometry, podiatry and other health or social care service appointments, and referrals are made, if necessary, to the appropriate service. 9.6 There are systems for maintaining residents’ spectacles, dentures, personal equipment and appliances so that they provide maximum benefit for each resident. 29 Responding to residents’ behaviour Standard 10: Responses to residents are appropriate and based on an understanding of individual resident’s conduct, behaviours and means of communication. Criteria 10.1 Staff have knowledge and understanding of each individual resident’s usual conduct, behaviours and means of communication. Responses and interventions of staff promote positive outcomes for residents. 10.2 When a resident’s behaviour is uncharacteristic and causes concern, staff seek to understand the reason for this behaviour. Staff take necessary action, report the matter to the registered manager or supervisor in charge of the home at the time and monitor the situation. Where necessary, they make contact with any relevant professional or service and, where appropriate, the resident’s representative. 10.3 When a resident needs a consistent approach or response from staff, this is detailed in the resident’s care plan. Where appropriate and with the resident’s consent, the resident’s representative is informed of the approach or response to be used. 10.4 When a resident has a specific behaviour management programme, this is approved by an appropriately trained professional and forms part of the resident’s care plan. 10.5 When a behaviour management programme is in place for any resident, staff are provided with the necessary training, guidance and support. 10.6 Where any incident is managed outside the scope of a resident’s care plan, this is recorded and reported, if appropriate, to the resident’s representative and to 30 relevant professionals or services. Where necessary, this is followed by a multi-disciplinary review of the resident’s care plan. 10.7 Restraint is only used as a last resort by appropriately trained staff to protect the resident or other persons when other less restrictive strategies have been unsuccessful. Records are kept of all instances when restraint is used. 31 Care review Standard 11: The home contributes to or organises reviews of residents’ placement in the home. Criteria 11.1 The home participates in review meetings organised by the referring Trust responsible for the resident’s placement in the home. 11.2 When the resident is self-referred, the registered manager arranges a meeting at least annually to review the suitability of the placement. The resident has the right to choose to attend, to be involved in the organisation of the meeting and to be consulted about who attends. When the resident is unable or chooses not to attend, he or she can make his or her views known and these are recorded and presented at the meeting. 11.3 A written review report is prepared by staff in consultation with the resident and provided for the review meeting. 11.4 Review reports refer to: - • Progress in attaining any personal outcomes sought by the resident • The resident’s views about their care • Any changes in the resident’s situation • Details of important events including incidents or accidents occurring since the previous review • Any matters regarding the current care plan and management of risks • The need for any rehabilitation or specialist services • Any other matters regarding services and facilities provided by the home or others. 32 11.5 The home keeps records of review meetings that identify outcomes of the review, actions required and those responsible for these actions. When the meeting is organised by the home, a copy of the record of the meeting is issued to the resident and where appropriate their representative, and any others who contributed to the review, unless there are clear and recorded reasons not to do so. 11.6 Following the review the resident’s care plan is revised if necessary, and when this happens the resident is provided with a copy of the revised plan in a format and language appropriate to their needs. 33 Meals and mealtimes Standard 12: Residents receive a nutritious and varied diet in appropriate surroundings at times convenient to them. Criteria 12.1 Residents are provided with a nutritious and varied diet, which meets their individual and recorded dietary needs and preferences. Full account is taken of relevant guidance documents or guidance provided by dietitians and other professionals and disciplines. 12.2 Residents are involved in planning the menus. 12.3 The menu either offers residents a choice of meal at each mealtime or when the menu offers only one option and the resident does not want this, an alternative meal is provided. A choice is also offered to those on therapeutic or specific diets. 12.4 The daily menu is displayed in a suitable format and in an appropriate location so that residents and their representatives know what is available at each mealtime. 12.5 Meals are provided at conventional times, hot and cold drinks and snacks are available at customary intervals, and fresh drinking water is available at all times. 12.6 Residents can have a snack or drink on request or have access to a domestic style kitchen. 12.7 Menus provide for special occasions. 12.8 Residents are consulted and their views taken into account regarding the home’s policy on “take away” foods. 34 12.9 Meals are served in suitable portion sizes, and presented in a way and in a consistency that meets each resident’s needs. 12.10 Staff are aware of any matters concerning residents’ eating and drinking as detailed in each resident’s individual care plan, and there are adequate numbers of staff present when meals are served to ensure: - • Risks when residents are eating and drinking are managed • Required assistance is provided • Necessary aids and equipment are available for use. 12.11 A record is kept of the meals provided in sufficient detail to enable any person inspecting it to judge whether the diet for each resident is satisfactory. 12.12 Where a resident’s care plan requires, or when a resident chooses not to eat a meal or is unable to eat a meal, a record is kept of all food and drinks consumed. Where a resident is eating excessively, a similar record is kept. Such occurrences are discussed with the resident, and reported to the registered manager or senior staff in charge of the home. Where necessary, a referral is made to the relevant professionals and a record kept of the action taken. 12.13 Menus are rotated over a three-week cycle and revised at least six monthly, taking into account seasonal availability of foods and residents’ views. 12.14 Variations to the menu are recorded. 35 Programme of activities and events Standard 13: The home offers a structured programme of varied activities and events, related to the statement of purpose and identified needs of residents. Criteria 13.1 The programme of activities and events provides positive outcomes for residents and is based on the identified needs and interests of residents. 13.2 The programme includes activities that are enjoyable, purposeful, age and culturally appropriate and takes into account the residents’ spiritual needs. It promotes healthy living, is flexible and responsive to residents’ changing needs and facilitates social inclusion in community events. 13.3 Residents, including those residents who generally stay in their rooms, are given the opportunity to contribute suggestions and to be involved in the development of the programme of activities. 13.4 The programme of activities is displayed in a suitable format and in an appropriate location so that residents and their representatives know what is scheduled. 13.5 Residents are enabled to participate in the programme through the provision of equipment, aids and support from staff or others. 13.6 The duration of each activity and the daily timetable takes into account the needs and abilities of the residents participating. 36 13.7 Where an activity is provided by a person contracted-in to do so by the home, the registered manager either obtains evidence from the person or monitors the activity to confirm that those delivering or facilitating activities have the necessary skills to do so. 13.8 Where an activity is provided by a person contracted-in to do so by the home, staff inform them about any changed needs of residents prior to the activity commencing and there is a system in place to receive timely feedback. 13.9 A record is kept of all activities that take place, the person leading the activity and the names of the residents who participate. 13.10 The programme is reviewed regularly and at least twice yearly to ensure it meets residents’ changing needs. 37 Dying and death Standard 14: The death of a resident is respectfully handled as they would wish. Criteria 14.1 Residents can spend their final days in the home, unless there are documented health care needs to prevent this. 14.2 The home makes reasonable arrangements for relatives and friends to be with a resident who is very ill or dying. 14.3 Arrangements are in place so that spiritual care can be made available for residents who are dying, if they so wish. 14.4 Other residents and staff who wish to offer comfort to a resident who is dying are enabled to do so if the resident wishes. 14.5 The recorded wishes of the resident regarding any other specific arrangements at the time of his or her death are carried out. 14.6 The body of a deceased resident is handled with care and respect and in accordance with his or her expressed social, cultural and religious preferences. 14.7 Residents are informed in a sensitive manner about any death in the home, have opportunity to pay their respects and are provided with support if needed. 14.8 The deceased resident’s belongings are handled with care and his or her representative is consulted about the removal of these belongings. 38 Residents’ money and valuables Standard 15: Residents’ money and valuables are safeguarded. Criteria 15.1 The resident’s right to control their own money is respected. 15.2 Where the home is responsible for managing a resident’s finances, the arrangements and the records to be kept are specified in the resident’s agreement. 15.3 Where residents hand over money or valuables for safe-keeping by the home, they are aware of the arrangements for the safe storage of these and have access to their individual financial records. 15.4 Records are kept of the amounts paid by, or in respect of, each resident for all agreed itemised services and facilities as specified in the resident’s agreement. 15.5 Records are kept of the resident’s possessions handed over for safekeeping and returned to the resident. The record is signed and dated by the resident or their representative and the member of staff receiving or returning the possessions. Where the resident or their representative is unable to sign or chooses not to sign, two members of staff witness the hand-over of the possessions and sign and date the record. 15.6 A record is kept of all allowances and income received on behalf of the resident and of the distribution of this money by the staff to the resident or their representative. Each transaction is signed and dated by the resident or their representative and the member of staff. If a resident or their representative is unable to sign or chooses not to sign for receipt of the money, two members of staff witness the handover of the money and sign and date the record. 39 15.7 Records of, and receipts for, all transactions undertaken by the staff on each resident’s behalf, and of the expenditure of allowances kept by the home on the resident’s behalf are maintained and kept up-to- date. Where the resident or their representative is unable to sign or chooses not to sign, two members of staff sign the record. 15.8 If a resident has been assessed as incapable of managing their own affairs, the amount of money or valuables held by the home on behalf of the resident is reported in writing by the registered manager to the referring Trust at least annually or as specified in the resident’s agreement. 15.9 When there is evidence of a resident becoming incapable of managing their own affairs, the registered person reports the matter in writing to the local or referring Trust. 15.10 If a person associated with the home acts as an appointee, the arrangements for this are discussed and agreed with the resident or their representative and, if involved, the representative from the referring Trust. These arrangements are noted in the resident’s agreement and a record is kept of the name of the appointee, the resident on whose behalf they act and the date they were approved by the Benefits Agency. 15.11 If a member of staff acts as an agent, a record is kept of the name of the member of staff, the date they acted in this capacity and the resident on whose behalf they act as an agent. 40 15.12 Reconciliation of money/possessions held by the home on behalf of residents is carried out, and evidenced and recorded, at least quarterly. 15.13 In all cases where cash or valuables of a deceased resident have been deposited for safekeeping, they are released only: - • Where the total value of property is estimated at £5,000 or less - when forms of indemnity are given to the registered person. • Where the total value of property is estimated to be in excess of £5,000 (or such other amount as may be prescribed by any amendment to the Administration of Estates (Small Payments) Act (NI) 1967, as amended by SR 1085 No 9) - on production of Probate or Letters of Administration. 15.14 Residents’ personal monies must not be pooled (in joint bank accounts with other residents’ monies) but paid into an account in the resident’s own name (where possible, this account should be interest bearing). 15.15 Where residents’ personal monies are held securely within the home, such as in cash tins, the amount held, for each resident, does not exceed the maximum amount set out in the home’s policies and procedures. Any excess monies should be transferred into the resident’s own bank account or where appropriate, arrangements are made for the excess monies to be returned to the HSC Trust or the resident’s representative. 41 Protection of vulnerable adults Standard 16: Residents are protected from abuse. Criteria 16.1 Procedures for protecting vulnerable adults are in accordance with legislation, DHSSPS guidance, regional protocols and local procedures issued by Health and Social Care Boards and Trusts. 16.2 The procedures for protecting vulnerable adults are included in the induction programme for staff. 16.3 Staff have completed training on and can demonstrate knowledge of: - • Protection from abuse • Indicators of abuse • Responding to suspected, alleged or actual abuse • Reporting suspected alleged or actual abuse. 16.4 All suspected, alleged or actual incidents of abuse are reported to the relevant persons and agencies in accordance with procedures and legislation. 16.5 All suspected, alleged or actual incidents of abuse are fully and promptly investigated in accordance with procedures. 16.6 All relevant persons and agencies are notified of the outcome of any investigations undertaken by the home. 16.7 Written records are kept of suspected, alleged or actual incidents of abuse. Where the home has been involved in the investigation, these records include details of the investigation, the outcome and action taken. 42 16.8 Where shortcomings in systems are highlighted as a result of an investigation, additional identified safeguards are put in place. 16.9 Refresher training on the protection of vulnerable adults is provided for staff at least every three years. 43 Complaints Standard 17: All complaints are taken seriously and dealt with promptly and effectively. Criteria 17.1 Homes should operate a complaints procedure that meets the requirements of the HSC Complaints Procedure and is in accordance with the relevant legislation and DHSSPS guidance on Complaints in Residential and Nursing Homes. 17.2 Arrangements for dealing with complaints should be publicised. 17.3 A copy of the complaints procedure is provided to every resident and to any person acting on their behalf, and this is available in a range of formats if required. 17.4 The complaints procedure includes a step-by- step guide to making a complaint, the timescales involved, an outline of the role and function of the Regulation and Quality Improvement Authority in dealing with regulated services complaints and contact details for the Authority. 17.5 Staff know how to receive and deal initially with complaints. 17.6 Advice is provided to residents/ relatives on how to make a complaint and who to contact outside the home if they remain dissatisfied or require support services, including independent advocacy. 17.7 Residents must, where appropriate, be made aware of the role of independent advocacy services and be assisted to access the support they need to articulate their concerns and successfully navigate the system. 44 17.8 Staff directly involved in the management and investigation of complaints are trained and supervised in the application of the complaints procedure. 17.9 Complaints are investigated and responded to within 28 days and when this is not possible, complainants are kept informed of any delays. 17.10 Records are kept of all complaints and these include details of all communications with complainants, the result of any investigations and the action taken. 17.11 The registered provider co-operates with any complaints investigation carried out by the HSC Trust, the Regulation and Quality Improvement Authority or the NI Commissioner for Complaints. 17.12 Where a complaint relates to a registered provider’s failure to comply with the statutory regulations, then that complaint should be referred directly to the Regulation and Quality Improvement Authority for consideration. 17.13 Where a complaint relates to abuse, exploitation or neglect, the Regional ‘Safeguarding Vulnerable Adults’ Policy and Procedural Guidance and the associated Protocol for Joint Investigation of Alleged or Suspected cases of Abuse of Vulnerable Adults should be activated. 17.14 When required, a summary of all complaints, outcomes and actions taken is made available to the Regulation and Quality Improvement Authority. 17.15 Information from complaints is used to improve the quality of services. 17.16 The complainant must be advised of their right to approach the NI Commissioner of Complaints if they remain dissatisfied with the outcome of the relevant complaints procedure. 45 Transport Standard 18: Vehicles owned or managed by a home ensure the safety of residents, comply with legislation and are well maintained. Criteria 18.1 When transport is provided by the home, procedures clarify: - • The ownership details for the vehicles • Who has use of transport • The costs involved • The method of payment • The arrangements for the maintenance and safe use of vehicles • The action to be taken in the event of a road traffic accident. 18.2 The written procedure detailing the action to be taken in the event of a road traffic accident is kept in vehicles owned or managed by the home. 18.3 Vehicles owned or managed by the home, and used for transporting residents, meet all current road traffic legislation. 18.4 Each vehicle, and equipment in the vehicle, is clean, safe, well maintained and, when necessary, complies with guidance from the Medical Device Agency on Wheelchair Tiedown and Occupant Restraint Systems (WTORS). 18.5 Individual resident’s needs while using transport are part of their overall needs assessment. Any risks involved are identified in the resident’s overall risk assessment. The management of these risks is included within the care plan and subject to periodic review as part of the review process. 46 18.6 Residents are not left unattended in a vehicle run by the home unless their risk assessment allows for this. 18.7 The registered person ensures that the appropriate hire and reward arrangements are reflected in the insurance policies. If the home runs a scheme where the residents are charged for the running costs, and no profit is included in the charges, the insurance company provides written confirmation that the insurance policy covers the shared use of the vehicle. 18.8 Where a vehicle is owned by a group of residents, records are kept of the use of the vehicle and its running costs, and the charges made to each resident. 18.9 Records are kept of the maintenance of vehicles, the reporting and repair of defects, and all required legislative documents. 18.10 Staff in the vehicle can make contact with the home by use of mobile phone or other means of communication. 47 Management of the home Homes are expected to have an open, respectful, safe and participatory culture where there is evidence that residents’ views and comments have been sought and taken into account. There should also be evidence that the management style reflects the values underpinning these standards. A range of complex and diverse issues need to be managed and there needs to be effective management systems and processes in place to facilitate the smooth running of the home. Managers are a role model for staff and need to provide leadership, direction and support for their staff team. When staff teams are properly guided and supported, and staff development is encouraged and learning is shared, effective services will be delivered to residents. The manager should be in control of all the home’s operations. However, in larger organisations, where they do not have control of specific support services - such as estates, finance and personnel - the registered person nominated on behalf of the organisation is responsible for ensuring these standards are met. 48 Recruitment of staff Standard 19: Staff are recruited and employed in accordance with relevant statutory employment legislation. Criteria 19.1 The policy and procedures for staff recruitment detail the recruitment process and comply with legislative requirements and DHSSPS guidance. 19.2 Before making an offer of employment: - • The applicant’s identity is confirmed • Two written references, linked to the requirements of the job are obtained, one of which is from the applicant’s present or most recent employer • Any gaps in an employment record are explored and explanations recorded • Criminal history disclosure information, at the enhanced level, is sought from AccessNI for the preferred candidate; (Note: Agencies that intend to employ applicants from overseas will need to have suitable complementary arrangements in place in this regard) • Professional and vocational qualifications are confirmed • Registration status with relevant regulatory bodies is confirmed • A pre-employment health assessment is obtained • Current status of work permit/employment visa is confirmed. 19.3 Records of all the documentation relating to the recruitment process are kept in compliance with the principles of the Data Protection Act 1998, and with AccessNI’s Code of Practice.1 1 AccessNI’s Code of Practice is available at http://www.accessni.gov.uk/code-of-practice.pdf 49 19.4 Staff are issued with a written statement of main terms and conditions prior to employment and no later than thirteen weeks after appointment. 19.5 Job descriptions are issued to staff on appointment. 19.6 Residents, or where appropriate their representatives, are involved in the recruitment process where possible. 50 Management and control of operations Standard 20: Management systems and arrangements are in place that support and promote the delivery of safe, quality care services. Criteria 20.1 There is a defined management structure that identifies the lines of accountability, specifies roles and details responsibilities for areas of activity. 20.2 The registered manager ensures the home delivers services effectively on a day-to-day basis in accordance with legislative requirements, DHSSPS Minimum Standards and other standards set by professional bodies and standard setting organisations. Issues arising are reported to the registered person. 20.3 Employers of social care workers adhere to the standards set out in the Northern Ireland Social Care Council (NISCC) Standards of Conduct and Practice for Employers. Employers support staff in meeting their relevant codes of practice and take appropriate action when staff do not meet expected standards of conduct. 20.4 Any absence of the registered manager of more than 28 day is notified to the Regulation and Quality Improvement Authority, and arrangements for managing the home in the absence of the registered manager are approved by the Regulation and Quality Improvement Authority. 20.5 Services are delivered in accordance with the statement of purpose as approved by the Regulation and Quality Improvement Authority at the time of registration. 20.6 The statement of purpose is kept under review. 20.7 Any change to: - 51 • Part 1 of the statement of purpose • The person registered on behalf of the organisation or any change in: - • The registered manager, or • The registered premises is made only with the approval of the Regulation and Quality Improvement Authority. 20.8 An up-to-date and accurate register of residents accommodated in the home is kept and is available for inspection at all times. (See Appendix 1) 20.9 The residents’ guide is kept under review, revised when necessary and updated versions are provided to the Regulation and Quality Improvement Authority. 20.10 Working practices are systematically audited to ensure they are consistent with the home’s documented policies and procedures and action is taken when necessary. 20.11 The registered person monitors the quality of services in accordance with the home’s written procedures and completes a monitoring report on a monthly basis. This report summarises any views of residents ascertained about the quality of the service provided, and any actions taken by the registered person or the registered manager to ensure that the organisation is being managed in accordance with minimum standards. 20.12 The quality of services provided is evaluated on at least an annual basis and follow-up action taken. Key stakeholders are involved in this process. 52 20.13 All legally required certificates and licences are kept up to date, are displayed if required and are accessible for the purpose of inspection. 20.14 There are written accounting and financial control procedures that meet professional standards of good practice and legislative requirements and provide safeguards against errors or fraud. 20.15 All accidents, incidents, communicable diseases, deaths, and events occurring in the home which adversely affect the wellbeing or safety of any resident are reported promptly to the Regulation and Quality Improvement Authority and other relevant organisations in accordance with legislation and procedures. A record is maintained of all adverse incidents. 20.16 The registered person and the registered manager undertake training to ensure they are up-to date in all areas relevant to the management and provision of services. 20.17 The registered manager provides the Regulation and Quality Improvement Authority with documentary evidence of their registration with the relevant regulatory body annually and/or on request. 20.18 There is a written policy on “Whistle Blowing” and written procedures that identify to whom staff report concerns about poor practice. 20.19 There are appropriate mechanisms to support staff in reporting concerns about poor practice. 20.20 The registered person has arrangements in place to confirm that staff supplied by an agency have been recruited and checked in accordance with the recruitment procedures used by the home. 53 20.21 The registered person has arrangements in place to register with the DHSSPS so that checks can be carried out by, and referrals made to, the Department in accordance with the Protection of Children and Vulnerable Adults legislation. 20.22 For the independent sector, insurance cover is in place against loss or damage to the assets of the business. The level of cover should reflect the full replacement value of buildings, fixture, fittings and equipment. 20.23 For the independent sector, insurance cover is held - to limits commensurate with the level and extent of activities undertaken by the home or to the minimum required by the Regulation and Quality Improvement Authority - for employer’s liability, public and third party liabilities, business interruption costs, including loss of earnings and costs to providers of meeting contract liabilities. 54 Policies and procedures Standard 21: There are policies and procedures in place that direct the quality of care and services. Criteria 21.1 The policies and procedures are in accordance with statutory requirements for all operational areas of the home. 21.2 There are arrangements to ensure that policies and procedures are developed with input from staff and residents. 21.3 Policies and procedures are centrally indexed and compiled into a policy manual. 21.4 Policies and procedures are dated when issued, reviewed or revised. 21.5 Policies and procedures are subject to a systematic three yearly review, and the registered person ratifies any revision to, or the introduction of, new policies and procedures. 55 Management of records Standard 22: Clear, documented systems are in place for the management of records in accordance with professional and legislative requirements. Criteria 22.1 Residents have access to their records in accordance with the Data Protection Act 1998 and, where relevant, the Freedom of Information Act 2000. 22.2 The policy and procedures for the management of records detail the arrangements for the creation, use, retention, storage, transfer, disposal of and access to records. 22.3 Records required under The HPSS (Quality Improvement and Regulation) (NI) Order 2003 (Regulations) are up-to-date, accurate and available for inspection in the home at all times. 22.4 The information held on record is accurate, up-to-date and necessary. 22.5 Staff are trained to create, use, manage and dispose of records in line with good practice and legislative requirements. 22.6 Records are held securely for the period of time as specified in the regulations and disposed of in accordance with legislation. 56 Staff training and development Standard 23: Staff are trained for their roles and responsibilities. Criteria 23.1 Staff who are newly appointed, agency staff and students are required to complete structured orientation and induction. 23.2 The registered manager requires newly appointed staff to provide evidence of training most recently undertaken that fulfils mandatory training requirements. 23.3 Mandatory training requirements are met. 23.4 The training needs of individual staff for their roles and responsibilities are identified and arrangements are in place to meet them. 23.5 The registered manager is aware of DHSSPS strategic targets for the training of, and attainment of vocational qualifications2 by, care assistants. 23.6 A record is kept in the home of all training, including induction and professional development activities undertaken by staff. The record includes: - • The names and signatures of those attending the training event • The date(s) of the training • The name and qualification of the trainer or the training agency • Content of the training programme. 2 Please note NVQs have now been replaced with the QCF which is the recognised vocational framework for qualification attainment in the social care workforce. Appropriate NVQs will continue to be recognised as relevant qualifications. 57 23.7 There is a written training and development plan that is kept under review and is updated at least annually. It reflects the training needs of individual staff and the aims and objectives of the organisation. 23.8 The effect of training on practice and procedures is evaluated as part of quality improvement. 58 Staff supervision and appraisal Standard 24: Staff are supervised and their performance appraised to promote the delivery of quality care and services. Criteria 24.1 Managers and supervisory staff are trained in supervision and performance appraisal. 24.2 Staff have recorded individual, formal supervision according to the home’s procedures and no less than every six months for staff who are performing satisfactorily. More frequent recorded supervision is held for new staff and staff who are not performing satisfactorily. 24.3 Supervision sessions are planned in advance and dedicated time set aside. 24.4 Supervisory staff report any serious and/or recurring issues arising in supervision to the manager. 24.5 Staff have a recorded annual appraisal with their line manager to review their performance against their job description and to agree personal development plans. 24.6 Staff who are contracted to undertake specific services receive guidance and support that corresponds to their role and responsibilities. 59 Staffing Standard 25: The number and ratio of management and care staff on duty at all times meet the care needs of residents. Criteria 25.1 At all times the staff on duty meets the assessed care, social and recreational needs of residents, taking into account the size and layout of the home, the statement of purpose and fire safety requirements. 25.2 The number and ratio of staff to residents is calculated using a method that is determined by the Regulation and Quality Improvement Authority. Students and volunteers working in the home are not taken into account in the overall staffing calculation. 25.3 There is a competent and capable person in charge of the home at all times. 25.4 Administrative and ancillary staff are employed to ensure that minimum standards relating to their respective responsibilities are fully met. 25.5 Records are kept of all staff that includes name, date of birth, previous experience, qualifications, starting and leaving dates, posts held and hours of employment. 25.6 A record is kept of staff working over a 24-hour period and the capacity in which they worked. 25.7 Time is scheduled at staff or shift changes to hand over information regarding residents and other areas of accountability. 25.8 Staff meetings take place on a regular basis and at least quarterly. Records are kept that include: - • The date of all meetings 60 • The names of those attending • Minutes of discussions • Any actions agreed. 61 Volunteers Standard 26: Volunteers contribute to the home in the best interests of the residents. Criteria 26.1 The procedure for the involvement of volunteers details the arrangements for their recruitment, training and management. 26.2 Protection of Children and Vulnerable Adults checks are carried out on volunteers and students before they participate in a volunteering role. 26.3 Residents and staff are informed about individual volunteer’s roles and responsibilities. 26.4 The scope of activity and responsibilities of each volunteer is specified in writing. 26.5 Records are kept of the recruitment, training, monitoring and support arrangements. 26.6 A record is kept of volunteers deployed, the hours of service and the range of work undertaken. 62 Premises and grounds Standard 27: The premises and grounds are safe, well maintained and remain suitable for their stated purpose. Criteria 27.1 The building is kept clean and hygienic at all times and decorated to a standard acceptable for the residents. 27.2 The temperature in areas occupied or used by residents is between 19°C - 22°C. 27.3 Furniture, fittings and any equipment or mobility aids in areas accessed by residents are positioned to take into account the mobility and overall needs of the residents, including those with sensory impairments. 27.4 The temperatures at all hot water outlets at wash hand basins, showers and baths accessible to residents are maintained in accordance with the Safe Hot Water and Surface Temperature Health Guidance Note. 27.5 The grounds are kept tidy, safe, suitable for and accessible to all residents. 27.6 Security measures are operated that restrict unauthorised access to the home to protect residents and their valuables, the premises and their contents. 27.7 Catering areas comply with Food Safety legislation at all times, and reports from the Environmental Health Department are made available to the Regulation and Quality Improvement Authority. 63 27.8 The premises, engineering services, plant and care equipment are kept safe and suitable, and maintained in line with relevant legislation and relevant manufacturers’ and installers’ guidance. 64 27.9 Records are kept of all maintenance and servicing work undertaken, and all required maintenance certificates and documents are available for inspection. 27.10 The procedures for maintaining the premises, grounds, engineering services and care equipment are in line with legislation and relevant manufacturers’ and suppliers’ guidance. 27.11 All structural changes or change of use to the registered building and/or alterations to engineering services are approved by the Regulation and Quality Improvement Authority and, where relevant, other statutory authorities. 27.12 Any changes made to furniture and fittings in communal and residents’ private accommodation meet the standards specified in the requirements for registration of the premises. 65 Safe and healthy working practices Standard 28: The home is maintained in a safe manner. Criteria 28.1 The Health and Safety procedures comply with legislation and cover: - • The maintenance of equipment • Working practices that are safe and without risk to health or welfare • The maintenance of a safe and healthy working environment • A safe and healthy place of work with safe access to it and egress from it. 28.2 There are arrangements in place to ensure the person in charge of the home at any given time receives relevant information to fulfil their health and safety responsibilities. 28.3 The registered person promotes safe and healthy working practices through the provision of information, training, supervision and monitoring of staff in the following areas: - • Fire safety • Infection control • Moving and handling • First aid • Accident Prevention • Food hygiene • Control of Substances Hazardous to Health (COSHH) • Maintenance and use of all equipment and machinery • A safe and healthy work environment and safe systems of work • A safe place of work with safe access to it and egress from it. 66 28.4 There is a designated member of staff to receive and act on health and safety information, and information from the Northern Ireland Adverse Incident Centre (NIAIC). Adverse incidents involving medical devices and equipment are reported to the NIAIC and any required action is managed appropriately. 28.5 The registered person ensures that risk assessments are carried out for every area of work in liaison with relevant others. The significant findings of the risk assessments are recorded and action taken to manage identified risks. 28.6 Publicly displayed health and safety procedures are in formats that are easily understood and take account of the special communication needs of people using the building. 28.7 Staff are provided with appropriate protective clothing and equipment suitable for the job, to prevent risk of harm, injury or infection to themselves or others. 28.8 Decontamination of re-useable medical devices is carried out in line with current best practice and standards, and related records kept. 28.9 The home has arrangements in place to provide staff with access to occupational health services when necessary. 67 Fire safety Standard 29: Fire safety precautions are in place that reduce the risk of fire and protect residents, staff and visitors in the event of fire. Criteria 29.1 There is a current Risk Assessment and Fire Management Plan that is revised and actioned when necessary or whenever the fire risk has changed. 29.2 The physical fire safety precautions are provided and maintained in accordance with relevant legislation, manufacturers and installers’ guidance, current guidance documents and British Standards, and the design and management of premises comply with the requirements of Northern Ireland Firecode. 29.3 Action recommended by the Northern Ireland Fire and Rescue Service (NIFRS) following their inspections is taken. The registered person sends any report made by NIFRS that highlights areas for action following an inspection by them to the Regulation and Quality Improvement Authority. 29.4 All staff have training in the fire precautions to be taken or observed in the home, including the action to be taken in case of fire. This training is provided by a competent person at the start of employment and is repeated at least twice every year. 29.5 There is an identified competent person who is responsible for fire safety in the home. There are arrangements in place to ensure the person in charge of the home at any given time receives relevant information to fulfil his or her fire safety responsibilities. 29.6 All staff participate in a fire evacuation drill at least once a year. Action taken on problems or defects is recorded. 68 Management of medicines Standard 30: Medicines are handled safely and securely. Criteria 30.1 The management of medicines is in accordance with legislative requirements, professional standards and DHSSPS guidance. 30.2 The policy and procedures cover each of the activities concerned with the management of medicines. 30.3 Staff who manage medicines are trained and competent. A record is kept of all medicines management training completed by staff. 30.4 The impact of medicines management training is evaluated as part of the quality improvement process, and through supervision and appraisal of staff. 30.5 When necessary, in exceptional circumstances, training in specific techniques (e.g. the administration of medicines using invasive procedures; the administration of medicines through a PEG-tube; the administration of medicines in treating a life- threatening emergency) is provided for named staff by a qualified healthcare professional in accordance with legislative and professional guidelines. 30.6 Medication errors and incidents are reported, in accordance with procedures, to the appropriate authorities. 30.7 Pharmaceutical waste is disposed of in accordance with legislative requirements and DHSSPS guidelines. 30.8 Practices for the management of medicines are systematically audited to ensure they are consistent 69 with the home’s policy and procedures, and action is taken when necessary. 70 Medicine records Standard 31: Medicine records comply with legislative requirements and current best practice. Criteria 31.1 Medicine records are constructed and completed in such a manner as to ensure that there is a clear audit trail. 31.2 The following records are maintained: - • Personal medication record • Medicines administered • Medicines requested and received • Medicines transferred out of the home • Medicines disposed of. 31.3 The receipt, administration and disposal of all Schedule 2 controlled drugs are recorded in a controlled drug register. 71 Medicines storage Standard 32: Medicines are safely and securely stored. Criteria 32.1 Medicines are stored securely under conditions that conform to statutory and manufacturers’ requirements. 32.2 The key of the controlled drug cabinet is carried by the person-in-charge. Keys to all other medicine cupboards and trolleys are securely held by either the person-in-charge or by a designated member of staff. The safe custody of spare keys is the responsibility of the registered manager. 32.3 Quantities of Schedule 2 controlled drugs and Schedule 3 controlled drugs subject to safe custody requirements are reconciled on each occasion when responsibility for safe custody is transferred. 72 Administration of medicines Standard 33: Medicines are safely administered in accordance with the prescribing practitioner’s instructions. Criteria 33.1 Residents self-administer their own medicines where the risks have been assessed and the competence of the resident to self-administer is confirmed. Any changes to the risk assessment are recorded and the arrangements for self-administering medicines are kept under review. 33.2 When a resident self-administers his or her medicines, these are kept in a locked storage space and the resident holds the key. The safe custody of the spare key is the responsibility of the registered manager. 33.3 Staff ensure that all medicine labels specify full dosage directions. Labelling enables staff to positively identify each medicine. 33.4 Prescribed medicines are only administered to the resident for whom they are prescribed. 33.5 Medicine doses are prepared immediately prior to their administration, from the container in which they were dispensed. 33.6 The administration of a Schedule 2 controlled drug is recorded and signed in the controlled drug register by the member of staff administering the drug and the witness who is present at its administration. 33.7 Any omission or refusal likely to have an effect on the resident’s health or wellbeing is reported to the prescribing practitioner. 73 33.8 The act of administering medication in disguised form is discouraged but, when necessary, is undertaken in accordance with current best practice as defined by professional bodies and national standard setting organisations. The assessment process and outcomes are documented in the resident’s records. 33.9 Non-prescribed medicines are administered in accordance with qualified medical or pharmaceutical advice, which is formalised in an agreed protocol. 74 Medical devices and equipment Standard 34: Medical devices and equipment provided for residents’ treatment and care are used safely. 34.1 There is a written policy and procedures for the use of medical devices and equipment. 34.2 Staff have up to date knowledge and skills in using medical devices and equipment for the provision of treatment and care. 34.3 Medical devices and equipment that are designated for single-use are not reused under any circumstances. 34.4 Any contaminated re-useable medical devices and equipment is handled, collected and prepared for transportation in a manner that avoids the risk of contamination to handlers, residents and staff. 34.5 Decontamination of re-useable medical devices is carried out in line with current best practice and standards, and related records kept. 34.6 All medical devices and equipment ‘on loan’ are maintained in good condition and are returned promptly after use. 75 Infection prevention and control Standard 35: There is a managed environment that minimises the risk of infection for staff, residents and visitors. 35.1 Responsibility for infection prevention and control is clearly defined, there are clear lines of accountability throughout the home and key members of staff have responsibility for the implementation of infection prevention and control policies and procedures. These policies and procedures must reflect DHSSPS policy in this area. 35.2 All staff, including those employed in support services, receive mandatory education and training in infection prevention and control that is commensurate with their work activities and responsibilities and is regularly updated. 35.3 There are written guidelines for staff on making referrals to infection control nurses and public health professionals, who have expertise in infection prevention and control, for advice and support. 35.4 Outbreaks of infection are managed in accordance with the home’s procedures, reported to the local Consultant in Communicable Disease Control and to the Regulation and Quality Improvement Authority and records kept. 35.5 The home provides information on infection prevention and control as requested by the Regulation and Quality Improvement Authority. 35.6 There is information available on infection prevention and control for residents, their representatives and 76 staff. This is accessible and available in a range of formats. 35.7 Hand hygiene must be a priority for the home and every effort applied to promoting high standards of hand hygiene among patients, staff and visitors. There are wash hand basins, supplies of liquid soap, alcohol hand gels, and disposable towels and sharps containers wherever care is delivered. 35.8 All staff should be offered seasonal influenza immunisation annually. 35.9 The home has a contingency plan for dealing with an influenza pandemic. 77 SECTION 2 REQUIREMENTS FOR REGISTRATION 78 Registration This section sets out the requirements that must be met by statutory, voluntary and private providers of residential care homes to obtain registration. Articles 12 to 22 of the HPSS (Quality, Improvement and Regulation) (NI) Order 2003 deal with registration and should be read in conjunction with this section. The home must have a “statement of purpose” and an “operational policy”. The statement of purpose defines what services and facilities the home will provide whilst the operational policy describes how they will be provided. An individual who intends to carry on a home must be registered and is referred to as the “registered person”. An organisation that intends to carry on a home is required to nominate one person to be registered on behalf of the organisation. The manager of the home must be registered with the Regulation and Quality Improvement Authority and is referred to as the “registered manager”. The registered person may also be the registered manager. Those applying for registration as the registered person and/or the registered manager must meet the relevant criteria for fitness of these positions. The design and construction of the home and grounds must be suitable for their stated purpose and provide a comfortable, safe and enabling environment. The environmental requirements for a home are separated into: - 1. Standards for new buildings. These apply to new buildings that require to be registered as residential care homes, to homes not previously registered with the Regulation and Quality Improvement Authority at the date of publication of these standards, and to new extensions to any existing registered home. 2. Standards for existing buildings. These apply to buildings that already operate as residential care homes. They also apply to registered homes seeking re-registration after changing ownership. 79 There must be evidence that the following requirements are met prior to homes and persons being registered. Statement of purpose The written statement of purpose for the home includes the following information: - Part 1 • Details of the person or organisation with overall responsibility for the home • The status and constitution of the home • The organisational structure of the home • The aims and objectives of the home • The philosophy of care • The services and facilities provided by the home • The number of residents and the categories of care to be accommodated or provided with services. Part 2 • The Operational Policy for the home, which includes: - ▪ The arrangements in place to ensure the fitness of persons to work at the home ▪ The arrangements in place to ensure the adequacy of numbers of persons working in the home ▪ Admission arrangements for residents, including the residents’ guide ▪ The arrangements for safeguarding and promoting the health and well-being, and spiritual needs of the resident ▪ The arrangements for the training and development of people who work in the home ▪ The care planning process ▪ The arrangements for securing health and social care services ▪ The arrangements for the management and control of the home 80 ▪ The accounting and financial control arrangements for the home ▪ The insurance arrangements (Independent sector only) ▪ The arrangements for the keeping of documents and records ▪ The arrangements for the notification of reportable events ▪ The arrangements for dealing with complaints and the steps for publicising the arrangements ▪ The arrangements for the management of medicines ▪ A fire safety management plan that demonstrates compliance with 'fire code' and The Fire Precautions (Workplace) Regulations (Northern Ireland) 2001 based on the findings from a risk assessment carried out against HTM 84 or an equivalent ▪ A written agreement or contract detailing the responsibilities of each party involved for the maintenance, safety and fire precautions for the property where the registered person does not own the building ▪ The policies and procedures listed in Appendix 2. 81 Fitness of the registered person To determine the fitness of the person applying for registration the following are required: - • Two satisfactory written references • A pre-employment health assessment • Satisfactory pre-employment checks and police checks (where applicants come from countries outside the United Kingdom, pre-employment checks are carried out with the national agency in the country of origin) • Evidence of qualifications (if any) and registration with professional regulatory bodies • Confirmation of identity • Financial/Business plan • Adequate insurance arrangements (Independent sector only). In addition, the Regulation and Quality Improvement Authority is assured through the registration process that the person: - • Has knowledge and understanding of his or her legal responsibilities • Intends to carry on the home in accordance with legislative requirements, DHSSPS Minimum Standards and other standards set by professional bodies and standard setting organisations • Intends to undertake update training to ensure they have the necessary knowledge and skills • Will adhere to the Northern Ireland Social Care Council (NISCC) Standards of Conduct and Practice for Employers. 82 RESIDENTIAL CARE HOMES Fitness of the Registered Manager To determine the fitness of the person applying for registration as the manager, the Regulation and Quality Improvement Authority (RQIA) is assured through the registration process that the person meets the following requirements. The person has the appropriate combination of qualification, registration and experience as set out below (i.e. either one of the professional qualifications under 1 combined with the experience under 2, or else the option set out at 3 combined with the experience under 4). 1. One of the professional qualifications below: (a) a professional social work qualification and registered on the appropriate part of the Northern Ireland Social Care Council (NISCC) register, without condition; or (b) a first level registered nurse on the appropriate part of the Nursing and Midwifery Council register; or (c) allied health professions3 registered with the Health Professions Council. and 2. a minimum of four years work experience in health and social care setting with one or more of the service user groups supported by the residential care home. At least two years of this experience must be in a relevant operational management capacity4 in a health and social care setting. OR 3. One of the following qualifications 3 For these purposes, ‘allied health professions’ mean: arts therapists; dietitians; occupational therapists; orthoptists; orthotists; physiotherapists; podiatrists; prosthetists; radiographers; or speech and language therapists. 4 Relevant management experience may include: a management post in health and social care team/service; staff management; service supervision; caseload management; care management; resource management; student supervision/mentoring; project management. 83 I. QCF Level 5 Diploma Leadership and Management in Health and Social Care (Adult Residential Management) Northern Ireland and Wales II. Level 5 Diploma Leadership and Management in Health and Social care (Adult Residential Management) Northern Ireland and Wales III. Level 5 Diploma in Leadership and Management in Health and Social Care Northern Ireland (Adult Residential Management) IV. Level 5 Diploma in Leadership and Management in Health and Social Care Services (Northern Ireland) and 4. a minimum of five years practice experience in any health and social care setting with one or more of the service user groups supported by the residential care home which must include at least two years relevant experience in an operational management capacity5 in a health and social care setting. The following are also required: • proof of the person’s identity, including a recent photograph; • Satisfactory criminal history disclosure information at enhanced level in respect of the preferred candidate is sought from AccessNI 6; • two satisfactory written references linked to the requirements of the job are obtained, one of which is from the applicant’s present or most recent employer; 5 For relevant management experience see Footnote 2 6 Note: AccessNI can, through PSNI, obtain conviction information from An Garda Síochána. Apart from this unique arrangement, AccessNI is unable to obtain overseas criminal records or other relevant information, which may or may not exist, as part of its disclos ure service – only details of offences committed in the UK will be provided. Registered Bodies which intend to employ applicants from overseas should contact the relevant foreign embassy in this instance. Details for embassies in the UK, and up to date information on the cost of an enquiry to a particular country's representative, can be found on the Foreign and Commonwealth website: http://www.fco.gov.uk/en/ or telephone (020) 7008 1500. Information about AccessNI and its work can be found at: http://www.accessni.gov.uk/ 84 • a full employment history, including history of management experience within health and social care, together with a satisfactory written explanation of any gaps in employment; • where a person has previously worked in a position which involved work with children or vulnerable adults, so far as it is reasonably practicable, verification of the reason why the employment or position ended; • details and documentary evidence of relevant professional or vocational qualification and any management qualification or accredited training; • confirmation of registration status with the relevant regulatory body;7 • details of any professional indemnity insurance; • a pre-employment health assessment; and • confirmation of current status of work permit/employment visa. In addition, the RQIA is assured through the registration process that the person: • has knowledge and understanding of the current legal responsibilities of the post and standards for the service, including the need for the management and delivery of person-centred services; • has knowledge of current health and social care services available in the area for the service user groups served by the residential care home; • will maintain registration with the relevant regulatory body; and • intends to manage the residential care home in accordance with relevant legislation and DHSSPS Minimum Standards. Legacy arrangements for existing managers who do not hold an appropriate qualification or registration 7 The relevant regulatory body for social workers and social care workers is the Northern Ireland Social Care Council - http://www.niscc.info/ The relevant regulatory body for first level registered nurses is the Nursing and Midwifery Council - http://www.nmc-uk.org/aDefault.aspx The relevant regulatory body for the specified allied health professionals is the Health Professions Council - http://www.hpc-uk.org 85 Managers of residential care homes who do not hold an appropriate qualification or registration but who were registered with the RQIA at the original date of publication of these standards, retain their registered status whilst they continue to work within the residential care home sector. It is strongly advised that mangers in this group undertake yearly update training and learning as part of their Continuous Professional Learning and PRTL requirements.8 Registered providers are encouraged to support these managers in pursuing the appropriate qualifications, i.e. Level 5 Diploma in Leadership and Management in Health and Social Care Northern Ireland (Adult Residential Care) All existing managers should be encouraged to seek registration with the relevant regulatory body. 8 Recommended Learning & Training to include: Update/review of DoH Policies, legislative changes/reviews, local H&SCT policy reviews and changes; updates/reviews of RQIA Guidance & Supervision and Appraisal 86 Fitness of the premises - New homes and extensions The following set of requirements (N1 – N61) applies to new buildings, and previously unregistered buildings, that require to be registered as residential care homes and to new extensions to any existing homes. The requirements for new extensions apply to that part of the home only. Premises and grounds N1. The building and grounds are designed to comply with all relevant legislation and guidance documents. Certificates and commissioning documents with regard to engineering services and plant, and approval letters and letters certifying completion of works from other agencies and authorities confirm this. N2. There are car parking spaces for residents, visitors and staff consistent with the number of residents that the home will be registered for and the number of people employed in the home. N3. There is clear access to and egress from the home for emergency and other vehicles, and there are suitably sized turning spaces for service vehicles using the site. N4. There are areas for residents to get on and off transport safely that are illuminated and offer some protection against the elements. N5. There is safe outdoor space with seating, accessible to all residents including those with physical disability or sensory impairment. The outdoor environment promotes leisure and therapeutic opportunities and stimulates sociable activity for all residents. In homes registered to accommodate people with dementia there is a secure perimeter. N6. The doorways in areas accessed by residents have a clear opening width of at least 800mm, but in homes where residents need assistance when walking or use wheelchairs wider doorways are recommended. 87 Corridor doors have vision panels and in homes where residents need assistance when walking or use wheelchairs, there are level access thresholds at all doors. N7. The minimum corridor width in areas accessed by residents is 1.2m unobstructed between handrails, but in homes where residents need assistance when walking or use wheelchairs, a minimum width of between 1.5m and 1.8m is recommended. N8. All areas occupied or used by residents are accessible to them through the provision, where necessary, of ramps, lifts (large enough to accommodate a stretcher), other facilities and signage. N9. There are suitably positioned hand and grab rails, communication aids and other equipment, including assistive technology, which meet the general needs of the resident group and promote independence in all the areas occupied or used by residents. N10. Resident/staff call points, accessible to residents, are provided in every room used by residents and linked to a system that alerts staff a call is being made or assistance is required. N11. There is both natural and good quality artificial lighting in all areas suitable for the needs of residents and any activities planned for each room. The artificial lighting in areas used by residents is domestic in character, sufficiently bright and positioned to facilitate reading and other activities. The recommended lighting level in toilets is between 100-200 lux, and in bedrooms it is recommended that dimmable lighting is installed that provides levels between 0-400 lux. N12. All areas used by residents are naturally ventilated, have opening windows with safety glazing and guarding where necessary. The height of the windowsill affords an unobstructed view when the residents are seated. Window openings are controlled 88 to a safe point of opening of no more than 100 mm and cannot be overridden by residents. Frosted or obscured glass is fitted as required to ensure privacy. N13. The heating system can be controlled within safe limits for the residents’ comfort in areas accessed and used by them, and is able to provide a range of temperatures throughout the home. Each room accessed or used by residents has a wall-mounted thermometer. N14. Furniture and fittings in communal rooms are domestic in character, are suitably designed for the activities that take place in the room and incorporate ergonomic design principles that promote user independence and safe handling. They and any equipment or mobility aids are positioned to take into account the mobility and overall needs of the residents, including those with sensory impairments. N15. Floor coverings, wall finishes and soft furnishings are suitable for the purpose of each room and meet health and safety and infection control requirements. Finishes that produce glare, dazzle and optical illusions are avoided and where residents use wheelchairs, floor coverings have non-directional pull. According to the statement of purpose and needs of residents, for example those with a visual impairment, changes in the texture of floor coverings or other indicators should be considered to identify key areas in the home, for example doorways or the top or bottom of stairs. N16. There are arrangements in place to ensure the home can operate in the event of a utility service failure. Communal space N17. There is communal space (excluding corridors and circulation areas) amounting to at least 4.00m² for each resident. This allows for dining space of at least 89 1.5 m²/person and sitting space of approximately 2.5m²/person. N18. The communal space includes a range of rooms that can be used for a variety of activities and where the varied needs of residents can be met. This includes: - • A room where meetings can take place in private • Dining rooms to cater at any one time for all residents • A facility for residents to make or get drinks and snacks • A room where telephone calls can be made or received in private • A separate, well ventilated room for residents who smoke N19. Where residents cannot access a local hairdresser or barber, there is a hairdressing facility in the home. Residents’ bedrooms /Private accommodation N20. All accommodation is provided in single bedrooms. However, to accommodate persons wishing to share bedrooms, two adjoining bedrooms with a connecting half hour fire resistant soundproofed door or movable partition can be provided. N21. The minimum floor space (excluding ensuite facilities) is 12m², except in homes that are registered specifically for residents with physical disability, where the minimum useable floor space (excluding ensuite facilities) is 20m². N22. There is a minimum ceiling height of 2.4m, and room dimensions allow for a minimum space of 2.00 ms on one side and 0.8 ms on the other side of the bed to promote when necessary safe handling of residents and access for any equipment needed. 90 N23. The installation of ensuite facilities is in addition to the minimum useable floor space standard in any resident’s bedroom. N24. The height of the windowsill affords a view when the resident is seated or in bed. N25. Where the home provides furniture in residents’ private accommodation, these rooms contain all of the following unless the resident wishes otherwise: - • A suitable bed at a height for safe handling of residents • A mirror of suitable size at an appropriate height • Overhead and bedside or wall lighting • Suitable seating for the resident’s use with seating available for visitors • Drawers or built in shelving • An enclosed space for hanging clothes • A tabletop facility • A lockable storage space • A bedside cabinet. N26. Furniture and fittings are safely secured and positioned to take into account the mobility and overall needs of the residents. N27. The positioning of telephone and television aerial points and light switches are considered so that they are suitable for the resident. A minimum of 4 double electrical socket outlets is recommended for each bedroom. N28. Doors are fitted with appropriate master key locks, with an easy opening (thumb-turn) device fitted to the inside of the door. Toilet and washing facilities N29. A range of toilet, washing, bath and shower facilities (including assisted facilities) are provided to meet the 91 needs of residents and a toilet facility is available for use by visitors. N30. Ensuite facilities (minimum of a toilet and wash hand basin) are provided in all residents’ private accommodation. N31. There is a minimum of 2 separate toilets and 1 assisted toilet to 5 residents with a minimum of 1 facility per floor. Each toilet facility including en-suite facilities: – • Is clearly marked and conveniently located to communal rooms • Is fully and separately enclosed • Has suitable hand washing and drying facilities to meet infection prevention and control guidelines • Has an accessible call system • Has a door that opens outwards. Toilets for ambulant, semi and assisted ambulant people are a minimum of 3m². Toilets for people who use a wheelchair independently or require the assistance of one person are a minimum of 4.5m² and at least 2m long. Toilets for people who use a wheelchair and require the assistance of two people are a minimum of 5.5 m² and at least 2m long. N32. Where suitably adapted ensuite bathing or shower facilities are provided in residents’ private accommodation, there is 1 assisted bathroom or shower room per floor. Where there are no suitably adapted ensuite bathing or showering facilities, there is a ratio of 1 assisted bathroom or shower room to 8 residents. Bathrooms for ambulant people, people who require assistance and people who use a wheelchair independently are a minimum of 8.5m². 92 Bathrooms for people who require the use of a hoist are a minimum of 16 m². Shower rooms are 7 m² (non-linear layout) and 7.5 m² (linear layout) and are level access. N33. Locks and handles on toilets, bathroom and shower room doors are easy to operate and allow staff immediate access in an emergency. Medicines N34. There is an identified area where medicines can be stored in accordance with the manufacturers’ instructions. This has: - • Cupboards conforming to British Standards for the storage of medicines • Space to safely store, access and administer medicines and medicinal products • Sufficient work surfaces for the tasks required • Hand washing facilities in close proximity that meet infection prevention and control guidelines. N35. There is a controlled drug cabinet that complies with the Misuse of Drugs (Safe Custody) (Northern Ireland) Regulations 1973 for the storage of any Schedule 2 and Schedule 3 controlled drugs subject to safe custody requirements. N36. Where necessary, there is a lockable trolley or trolleys for administration of medicines. Clinical room N37. There is a clinical room in homes where nursing care is provided and homes that accommodate residents not able to attend community health services. In homes that accommodate residents who attend community health services, a clinical room is not required. 93 N38. There is space within the room to undertake minor procedures such as changing dressings, health checks or podiatry and the room has a stainless steel sink unit with drainer, separate hand washing facilities, high and low level lockable cupboards for the safe, secure storage of clinical equipment, and approved containers for the collection, storage and disposal of clinical waste including sharps. Infection prevention and control N39. There is hand-washing equipment (wash hand basins, liquid soap dispensers, paper towels and pedal operated bins) in areas where care is provided. N40. Approved containers are provided in all areas of the home that are suitable for the type of waste generated. N41. Wheeled bins for clinical waste are provided that allow for ‘single handling’ of the waste in a secure outside area. Sluice rooms N42. Where provided, sluice rooms are located away from communal areas, residents’ private accommodation and areas where food is stored, prepared, cooked or eaten. N43. Sluice rooms are ventilated, lockable and equipped with facilities for disposal of clinical waste including disposable continence products, and for cleaning and disinfecting soiled items in accordance with relevant guidelines. N44. Separate hand-washing facilities that meet infection prevention and control guidelines are provided in sluice rooms. N45. There is adequate storage in sluice rooms for bedpans, urinals and disposable continence products. 94 Laundry N46. The laundry is located away from communal areas, residents’ private accommodation and areas where food is stored, prepared, cooked or eaten. The location of the laundry ensures that dirty laundry is not transported through day or dining areas. The laundry is suitably ventilated and allows for the separation of soiled items from clean clothes and linen. N47. Laundry equipment includes a sink with drainer, washing machine with a sluicing facility and a specified programme to meet disinfection standards, and a tumble drier that is vented externally. N48. There are facilities for ironing and separately stacking individual resident’s personal laundry prior to distribution. N49. Separate hand-washing facilities that meet infection prevention and control guidelines are provided in laundries. Catering areas N50. The catering facilities and equipment are adequate for the method of food provision and for the number of residents the home will be registered to accommodate. Consideration is given to the provision of separate cooking areas to accommodate specific cultural or religious catering needs. N51. Catering areas comply with the Food Hygiene legislation. Storage N52. There is provision for the secure storage of all required records. N53. Secure facilities are provided for the safekeeping of money and valuables held on behalf of residents. 95 N54. There are separate recessed areas designated as storage space for wheelchairs on every floor and in close proximity to communal areas and residents’ private accommodation. N55. Storage space is provided for residents’ belongings that cannot be kept in their rooms. N56. There is storage space for reserve linen and bedding. N57. There is storage space for cleaning materials and equipment that is ventilated and lockable. In large facilities, there is a cleaner’s store with separate hand- washing facilities that meet infection prevention and control guidelines. (An average size for a storeroom for cleaning materials is between 5.5 m² and 7.5 m²). N58. Gas and other fuel storage facilities comply with any relevant legislative requirements and good practice guidance. N59. There is external storage space for garden furniture, equipment and other items. N60. Where necessary there is an area for charging batteries for equipment. Staff facilities N61. There are staff facilities, including at least one office, consistent with the required number of people employed in the home. 96 Fitness of the premises – Existing homes The following set of requirements (E1 – E58) applies to existing buildings that already operate as care homes and are seeking registration for the first time or re-registration after changing ownership. General premises and grounds E1. The building and grounds comply with relevant legislation and to a reasonable degree with guidance documents. Certificates and commissioning documents with regard to engineering services and plant, approval letters and, if appropriate, letters certifying completion of works from other agencies and authorities confirm this. E2. Car parking spaces are available unless the location and site prevent this. E3. Emergency vehicles and other vehicles have access to and egress from the home. E4. There are illuminated areas for residents to get on and off transport safely that, where possible, provide protection against the elements. E5. Where possible there is safe outdoor space with seating, accessible to all residents. In homes that accommodate people with dementia there is a secure perimeter. E6. The Regulation and Quality Improvement Authority approve the width of doorways and corridors so that all areas occupied or used by residents are accessible to them through the provision of (where necessary) ramps, passenger lifts, other facilities and signage. E7. There are suitably positioned hand and grab rails, communication aids and other equipment, including assistive technology, in line with the home’s stated purpose to meet the general needs of the resident 97 group and to promote independence in all the areas occupied or used by residents. E8. Resident/staff call points accessible to residents are provided in every room used by residents, and linked to a system that alerts staff a call is being made or assistance is required. E9. There is both natural and good quality artificial lighting in all areas suitable for the needs of residents and any activities planned for each room. The artificial lighting in areas used by residents is domestic in character, sufficiently bright and positioned to facilitate reading and other activities. The recommended lighting level in toilets is between 100-200 lux. E10. All areas used by residents are naturally ventilated, have opening windows with safety glazing and guarding where necessary. Areas not naturally ventilated have mechanical ventilation. Window openings are controlled to a safe point of opening of not more than 100mm and cannot be overridden by residents. Frosted or obscured glass is fitted as required to ensure privacy. E11. The heating system can be controlled within safe limits for the residents’ comfort in areas accessed and used by them and is able to provide a range of temperatures throughout the home. Each room accessed or used by residents has a wall-mounted thermometer. E12. Furniture and fittings in communal rooms are domestic in character, are suitably designed for the activities that take place in the room and incorporate ergonomic design principles that promote user independence and safe handling. They and any equipment or mobility aids are positioned to take into account the mobility and overall needs of the residents, including those with sensory impairments. E13. Floor coverings, wall finishes and soft furnishings are suitable for the purpose of each room and meet health 98 and safety and infection control requirements. Finishes that produce glare, dazzle and optical illusions are avoided and, where reasonably possible, where residents use wheelchairs floor coverings have non-directional pull. According to the statement of purpose and the needs of residents, for example those with a visual impairment, changes in the texture of floor coverings or other indicators should be considered to identify key areas in the home, for example doorways or the top or bottom of stairs. E14. There are arrangements in place to ensure the home can operate in the event of a utility service failure. Communal space E15. The Regulation and Quality Improvement Authority approve the amount of communal space, which, where reasonably possible, amounts to at least 3.7m² for each resident (excluding corridors and circulation areas). This allows for dining space of approximately 1.4m²/person and sitting space of approximately 2.3m²/person. E16. The communal space includes rooms that can be used for a variety of activities and where the varied needs of residents can be met. This includes: - • Separate, well ventilated provision for residents who smoke • A room where meetings can take place in private • Dining room/rooms • A place where telephone calls can be made or received in private. E17. Where reasonably possible, a facility for residents to make drinks or snacks is provided. Residents’ bedrooms /Private accommodation E18. At least 80% of residents are accommodated in single bedrooms. Where a home did not provide this 99 proportion of its places in single bedroom accommodation (at the date of its registration with the Regulation and Quality Improvement Authority), it must, at the least, continue to provide the same percentage of places in single bedrooms as it provided at the date of its registration. These homes should work towards achieving the 80% standard for places in single bedrooms. E19. Shared rooms are occupied by residents who have made a positive choice to share with each other. E20. Residents sharing double/twin bedrooms are given the opportunity to move to a single room when one becomes available. E21. Rooms accommodating more than two persons are not acceptable. E22. The minimum useable floor space in residents’ private accommodation is at least 16m² in a double bedroom. Where provided, ensuite facilities are additional to the minimum useable floor space standard in any resident’s room. E23. Where 11.5m² or more of useable floorspace was provided in resident’s private single bedroom accommodation (at the date of the home’s registration with the Regulation and Quality Improvement Authority), that amount of space will continue to be provided. Where less than 11.5m² was provided at the date of registration, the home, at the least, continues to provide the same useable floorspace in these rooms as it provided at the date of registration with the Regulation and Quality Improvement Authority. E24. In bedrooms accommodating wheelchair users, the minimum useable floorspace is 12m². E25. Information on room size is set out in the “Residents’ Guide”. 100 E26. Where the home provides furniture in residents’ private accommodation, these rooms contain all of the following unless the resident wishes otherwise: - • A bed, mattress and accessories suitable for the assessed needs of the resident • A mirror of suitable size at an appropriate height • Overhead and bedside lighting • Suitable and comfortable seating for the resident’s use, with seating available for visitors • Drawers or built in shelving • An enclosed space for hanging clothes • A tabletop facility • A lockable storage space • A bedside cabinet • A wash hand basin if no ensuite is provided. E27. Furniture and fittings are safely secured and positioned to take into account the mobility and overall needs of the residents. E28. The layout of the furniture in the room ensures that, when necessary, there is room on each side of the bed to promote safe handling of residents and access for any equipment needed. E29. The Regulation and Quality Improvement Authority approves the arrangements for existing and replacement locks on doors. Toilet and washing facilities E30. A range of toilet, washing, bath and shower facilities (including assisted facilities) are provided to meet the needs of residents so that, where reasonably possible, there is a ratio of 1 assisted bathroom or shower room to 8 residents and 1 assisted toilet to 5 residents, with a minimum of 1 of each of these facilities per floor. Where suitably adapted ensuite bathing or shower facilities are provided in residents’ private accommodation, these facilities will be taken into 101 consideration in the calculation of the overall requirements. A toilet facility is identified for use by visitors. E31. Each toilet facility is clearly marked, has provision for suitable hand washing and drying facilities to meet infection control guidelines, an accessible call system and, where reasonably possible, is self-contained. E32. Locks and handles on toilets, bathroom and shower room doors are easy to operate and allow staff immediate access in an emergency. Medicines E33. There is an identified area where medicines can be stored in accordance with the manufacturers’ instructions. This has: - • Lockable cupboards for the storage of medicines • Space to safely store, access and administer medicines and medicinal products • Sufficient work surfaces for the tasks required • Hand washing facilities, in close proximity, that meet infection prevention and control guidelines. E34. Where necessary, there is a controlled drug cabinet that complies with the Misuse of Drugs (Safe Custody) (Northern Ireland) Regulations 1973 for the storage of any Schedule 2 and Schedule 3 controlled drugs subject to safe custody requirements. E35. Where necessary, there is a lockable trolley or trolleys for administration of medicines. Clinical or treatment room E36. There is a clinical room in homes where nursing care is provided. 102 E37. Where provided, the clinical or treatment room has hand-washing facilities that comply with infection control guidelines. Infection prevention and control E38. There is hand-washing equipment (wash hand basins, liquid soap dispensers, paper towels and pedal operated bins) in areas where care is provided. E39. Approved containers are provided in all areas of the home that are suitable for the type of waste generated. E40. Wheeled bins for clinical waste are provided that allow for ‘single handling’ of the waste in a secure outside area. Sluice rooms E41. Where sluice rooms are provided they are ventilated and lockable, and equipped with facilities for disposal of clinical waste including disposable continence products, and for cleaning and disinfecting soiled items in accordance with relevant guidelines. E42. Separate hand-washing facilities that meet infection prevention and control guidelines are provided in close proximity to sluice rooms. Laundry E43. The laundry is located away from areas where food is stored, prepared, cooked or eaten. It is suitably ventilated and the space allows for separation of soiled articles from clean clothes and linen. E44. Laundry equipment includes a sink with drainer, washing machine with a sluicing facility and a specified programme to meet disinfection standards, and a tumble drier that is vented externally. 103 E45. There are facilities for ironing and separately stacking individual resident’s personal laundry prior to distribution. E46. Separate hand-washing facilities that meet infection prevention and control guidelines are provided in close proximity to the laundry. Catering areas E47. The catering facilities and equipment are adequate for the method of food provision and for the number of residents the home accommodates. Consideration is given to the provision of separate cooking areas to accommodate specific cultural or religious catering needs. E48. Catering areas comply with the Food Hygiene legislation. Storage E49. There is provision for the secure storage of all required records. E50. Secure facilities are provided for the safekeeping of money and valuables held on behalf of residents. E51. Where possible, storage space for wheelchairs is in close proximity to communal areas and residents’ private accommodation. E52. Where possible, there is secure storage space for residents’ belongings that cannot be kept in their rooms. E53. There is storage space for reserve linen and bedding. E54. There is storage space for cleaning materials and equipment that is ventilated and lockable. Where possible, it has a bucket sink. 104 E55. Gas and other fuel storage facilities comply with any relevant legislative requirements and good practice guidance. E56. Where possible and if necessary, there is external storage space for garden furniture and equipment. E57. Where possible and if necessary, there is an area for charging batteries for equipment. Staff facilities E58. There are staff facilities, including at least one office, consistent with the required number of people employed in the home. 105 APPENDIX 1 Register of residents The register of residents will include the following information in respect of each person accommodated in the home: - 1. The name, address, date of birth and marital status of the resident and whether he or she is the subject of a court order or any other process. 2. The name, address and telephone number of the resident’s next of kin or of any person authorised to act on his or her behalf. 3. The name, address and telephone number of the resident’s medical practitioner and of any officer of a Trust whose duty it is to supervise the welfare of the resident. 4. The date on which the resident entered the home. 5. The date on which the resident left the home. 6. If the resident is transferred to a hospital or nursing home, the date of, and the reasons for, the transfer and the name of the hospital or nursing home to which the resident is transferred. 7. If the resident died in the home, the date, time and cause of death and the name of the medical practitioner who certified the cause of death. 8. If the resident has been received into guardianship under Articles 18 or 44 of the Mental Health (NI) Order 1986(a), the name, address and telephone number of the guardian; the name, address and telephone number of any officer of a Trust required to supervise the welfare of the resident and, if the guardian is a Trust, the officer of a Trust nominated to carry out its duties as guardian. 9. The name and address of any Trust, organisation or individual who arranged the resident’s admission to the home. 106 APPENDIX 2 Policies and procedures The following policies and procedures are associated with the minimum standards and are required to be in place in residential care homes: Absence of the manager Access to records Accidents - reporting, recording, notification Accounting and financial control arrangements Admission of residents Alcohol in the home Assessment of risks in the home Assessment, care planning and review Communications with carers and representatives Complaints Confidentiality Consent Continence promotion Dealing with dying and death Decontamination of re-useable medical devices Discharge arrangements for residents Disposal of clinical waste Equality issues Fire precautions First aid General communication arrangements Gifts to staff and donations to the home Infection prevention and control Inspections of the home Insurance arrangements Involvement of residents in the running of the home Keys for residents’ accommodation/bedrooms Listening and responding to residents’ views Maintenance of equipment, plant, premises and grounds Management of keys Management of medicines Management of records Management of risks associated with care of individual residents Management, control and monitoring of the home Managing aggression Menu planning 107 Missing items Missing residents Moving and handling Occupational health arrangements Operational policy Planning and recording the programme of activities and events Promotion of residents’ health and welfare Protection of vulnerable adults Quality improvement Recording and reporting care practices Records for food and drinks consumed Referral arrangements Referral to health and social care professionals Reporting adverse incidents Resident agreement Residents’ guide Residents’ clothing Residents bringing their own furniture into the home Residents’ meetings and forums Residents’ healthcare arrangements Residents’ involvement in activities and events Residents’ laundry Residents’ personal relationships Responding to residents’ behaviour Restraint Safe and healthy working practices Safe handling of food Safeguarding and protecting residents’ money and valuables Security of the home Skin care Smoking Spiritual care for residents Staff acting as a keyworker Staff clothing Staff discipline Staff grievance Staff handovers Staff induction Staff meetings Staff records Staff recruitment 108 Staff supervision and appraisal Staff training and development Staffing arrangements Take away foods Transport - use and provision Untoward incidents Use of agency staff Visitors Volunteers Whistle blowing. 109 APPENDIX 3 Glossary of terms - Residential Care Homes Agency staff Staff contracted from a regulated agency for work in the home. Behaviour management programme A planned programme to manage specific behaviour agreed by appropriate professionals, where staff employ pre-arranged strategies and methods, based on a risk assessment and recorded in the resident’s care plan. Controlled drugs Schedule 2 and 3 controlled drugs are as defined in the Misuse of Drugs Regulations (Northern Ireland) 2002. Keyworker The member of staff in the home responsible for co-ordinating the resident’s plan, for monitoring its progress and for staying in regular contact with the resident and everyone involved. Local trust The Trust area in which the home is located. Mandatory training Training required by legislation. (See Criteria 23.3) Minority group A specific minority ethnic, community, social, cultural or religious group. Representative A person acting on behalf of a resident, who may be a relative or friend or formally recognised advocate. Self-referred resident Those who purchase a service directly from a residential care home and who have not been referred through care management or other statutory arrangements. Referring trust The Trust responsible for referring the resident to the home.