(1) The registered person shall implement written statements of the policies to be applied and the procedures to be followed in or for the purposes of an establishment in relation to—

(a) the arrangements for admission or acceptance of patients, their transfer to a hospital where required and, in the case of an establishment which admits in-patients, their discharge;

(b) the arrangements for assessment, diagnosis and treatment of patients;

(c) ensuring that the premises used by or for the purpose of an establishment are at all times fit for the purpose for which they are used;

(d) monitoring the quality and suitability of facilities and equipment;

(e) identifying, assessing and managing risks to employees, patients and visitors associated with the operation of the establishment;

(f) the creation, management, handling and storage of records and other information;

(g) the provision of information to patients and others;

(h) the recruitment, induction and retention of employees and their employment conditions;

(i) the grant and withdrawal of practising privileges to medical practitioners in establishments where such privileges are granted; and

(j) ensuring that, where research is carried out in an establishment, it is carried out with the consent of any patient or patients involved, is appropriate for the establishment concerned and is conducted in accordance with up-to-date and authoritative published guidance on the conduct of research projects.

(2) The registered person shall prepare and implement a written statement of the policies to be applied and the procedures to be followed for the purposes of an agency in relation to—

(a) the arrangements for transfer to a hospital, where required; and

(b) each of the matters specified in sub-paragraphs (b), (f), (g) and (h) of paragraph (1)

(3) The registered person shall prepare and implement written statements of policies to be applied and procedures to be followed in or for the purposes of an establishment, or for the purpose of an agency, which ensure that—

(a) the competence of each patient to consent to treatment is assessed;

(b) in the case of a competent patient, properly informed consent to treatment is obtained;

(c) in the case of a patient who is not competent, he is, so far as practicable, consulted before any treatment proposed for him is administered; and

(d) information about a patient’s health and treatment is disclosed only to those persons who need to be aware of that information in order to treat the patient effectively or minimise any risk of the patient harming himself or another person, or for the purpose of the proper administration of the establishment or agency.

(4) The registered person shall review the operation of each policy and procedure implemented under—

(a) this regulation

(b) regulation 23; and

at intervals of not more than three years and shall, where appropriate, prepare and implement revised policies and procedures.

(5) The registered person shall make a copy of all written statements prepared in accordance with this regulation available for inspection by the RQIA.

”INDEPENDENT HOSPITALS THE MAIN PURPOSE OF WHICH IS TO PROVIDE MEDICAL OR PSYCHIATRIC TREATMENT FOR MENTAL DISORDER

39A

Regulations 39B to 39E apply to independent hospitals the main purpose of which, is to provide medical or psychiatric treatment for mental disorder.

Safety of patients and others

39B

(1) In addition to the statement of policies and procedures to be prepared in accordance with regulation 9A, the registered person shall prepare and implement written statements addressing policies and procedures in relation to—

(a) assessment of a patient’s propensity to violence and self harm;

(b) the provision of information to employees as to the outcome of such an assessment;

(c) assessment of the effect of the layout of the hospital premises, and its policies and procedures, on the risk of a patient harming himself or another person; and

(d) the provision of training to enable employees to minimise risk of a patient harming himself or another person.

(2) The registered person shall in particular prepare and implement a suicide protocol, which requires—

(a) a comprehensive examination of the mental condition of each patient;

(b) an evaluation of the patient’s history of mental disorder, including identification of suicidal tendencies;

(d) if necessary, appropriate action to reduce the risk of the patient committing suicide.

Management of disturbed behaviour

39C

The registered person shall prepare and implement a written statement of policy setting out—

(a) how disturbed behaviour exhibited by a patient is to be managed;

(b) permitted measures of restraint and the circumstances in which they may be used;

(c) requirements for employees to report serious incidents of violence or self harm, including guidance as to how those incidents should be classified; and

(d) the procedure for review of such incidents and determination of the action which is to be taken subsequently.

Visitors

39D

The registered person shall prepare and implement written policies and procedures in relation to patients receiving visitors.

Mental health records

39E

The registered person shall ensure that any records which are required to be made under the Mental Health (Nurses, Guardianship, Consent to Treatment and Prescribed Forms) Regulations (Northern Ireland) 1986, and which relate to the treatment of a patient in an independent hospital, are kept for a period of not less than ten years beginning on the date on which the person to whom they relate ceases to be a patient in the hospital.

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