HEALTH AND PERSONAL SOCIAL SERVICES PART I GENERAL Citation and commencement 1 These Regulations may be cited as the Nursing Agencies Regulations (Northern Ireland) 2005 and shall come into operation on 1st April 2005. Interpretation 2 1 In these Regulations – “the Order” means the Health and Personal Social Services (Quality, Improvement and Regulation) (Northern Ireland) Order 2003; “agency” means a nursing agency; “ bankruptcy restrictions order ” means an order made under Schedule 2A to the Insolvency (Northern Ireland) Order 1989 or Schedule 4A to the Insolvency Act 1986; “debt relief order” means an order made by the Official Receiver under Part 7A of the Insolvency (Northern Ireland) Order 1989, or Part 7A of the Insolvency Act 1986; “debt relief restrictions order” means an order made under Schedule 2ZB to the Insolvency (Northern Ireland) Order 1989, or Schedule 4ZB to the Insolvency Act 1986; “general practitioner” means a medical practitioner who provides primary services; “health care professional” means a member of a profession which is regulated by a body mentioned (at the time the agreement is made) in section 25(3) of the National Health Service Reform and Health Care Professions Act 2002 ; “holistic care” means the care provided by a multi-professional team working together to meet physical, psychological, social, religious and cultural needs of patients; “inspector” means a person authorised by the RQIA to enter and inspect premises which are used, or which he has reasonable cause to believe to be used, as an establishment or for the purposes of an agency; “local supervising authority” means a HSS Board in relation to which area the nursing agency operates; “nurse” means a person registered in the register maintained under Article 5 of the Nursing and Midwifery Order 2001 by virtue of qualifications in nursing or midwifery, as the case may be; “organisation” means a body corporate or any unincorporated association other than a partnership; “patient” means a person to whom nursing is provided by a nurse supplied by an agency; “registered manager”, in relation to an agency, means a person who is registered under Part III of the Order as the manager of that agency; “registered person”, in relation to an agency, means any person who is the registered provider or the registered manager of that agency; “registered provider”, in relation to an agency, means a person who is registered under Part III of the Order as the person carrying on that agency; “responsible individual” shall be construed in accordance with regulation 7; “service user” means a person to whom an agency – supplies a nurse who is employed by the agency; or provides services for the purpose of supplying the service user with a nurse for employment by that service user; “service user’s guide” means the written guide produced in accordance with regulation 5; “social care worker” has the same meaning as in section 2(2) of the Health and Personal Social Services Act (Northern Ireland) 2001 ; “statement of purpose” means the written statement compiled in accordance with regulation 4. 2 In these Regulations, references to the supply of a nurse mean – a the supply of a nurse who is employed for the purposes of an agency to act for and under the control of another person; and b the introduction of a nurse by an agency to a service user for employment by that service user. 3 In the definition of “service user” in paragraphs (1) and (2), the terms “employed” and “employment” include employment under a contract for services. Excepted agencies 3 For the purposes of the Order, an HSS trust which supplies nurses to work solely for other HSS trusts shall be excepted from being a nursing agency. Statement of purpose 4 1 The registered person shall compile in relation to the agency a written statement which shall consist of a statement as to the matters listed in Schedule 1. 2 The registered person shall supply a copy of the statement of purpose to the RQIA and shall make a copy of it available on request for inspection by every service user and any person acting on behalf of a service user. 3 Nothing in regulation 21 shall require or authorise the registered person to contravene, or not to comply with – a any other provision of these Regulations; or b the conditions for the time being in force in relation to the registration of the registered person under Part III of the Order. Service user’s guide 5 1 The registered person shall prepare a service user’s guide which shall include – a a summary of the statement of purpose; b the terms and conditions in respect of the services to be provided to service users, including as to the amount and method of payment of fees; c a summary of the complaints procedure established in accordance with regulation 19; and d details of how patients can engage with inspectors, including the address and telephone number of the RQIA . 2 The registered person shall make a copy of the service user’s guide available on request by every service user and any person acting on behalf of a service user. Review of statement of purpose and service user’s guide 6 The registered person shall – a keep under review and, where appropriate, revise the statement of purpose and the service user’s guide; and b notify the RQIA of any material revision within 28 days. PART II REGISTERED PERSONS Fitness of registered provider 7 1 A person shall not carry on an agency unless he is fit to do so. 2 A person is not fit to carry on an agency unless the person – a is an individual, who carries on the agency – i otherwise than in partnership with others, and he satisfies the requirements set out in paragraph (3); ii in partnership with others, and he and each of his partners satisfies the requirements set out in paragraph (3); b is a partnership, and each of the partners satisfies the requirements set out in paragraph (3); c is an organisation and – i the organisation has given notice to the RQIA of the name, address and position in the organisation of an individual who is a director, manager, secretary or other officer of the organisation and is responsible for supervising the management of the agency; and ii that individual satisfies the requirements set out in paragraph (3). 3 The requirements are that – a he is of integrity and good character; b he is physically and mentally fit to carry on the agency; and c full and satisfactory information is available in relation to him in respect of each of the matters specified in Schedule 2. 4 A person shall not carry on an agency if – a he has been adjudged bankrupt or sequestration of his estate has been awarded and (in either case) he has not been discharged and the bankruptcy order has not been annulled or rescinded; or ab he is the subject of a bankruptcy restrictions order; or ac he is a person in relation to whom a moratorium period under a debt relief order applies or he is the subject of a debt relief restrictions order ; or b he has made a composition or arrangement with his creditors and has not been discharged in respect of it. Appointment of manager 8 1 The registered provider shall appoint an individual to manage the agency where – a there is no registered manager in respect of the agency; and b the registered provider – i is an organisation or a partnership; or ii is not a fit person to manage an agency; or iii is not, or does not intend to be, in full-time day to day charge of the agency. 2 Where the registered provider appoints a person to manage the agency, he shall forthwith give notice to the RQIA of – a the name of the person so appointed; and b the date on which the appointment is to take effect. Fitness of manager 9 1 A person shall not manage an agency unless he is fit to do so. 2 A person is not fit to manage an agency unless – a he is of integrity and good character; b having regard to the size of the agency, its statement of purpose and the number and needs of the service users – i he is a nurse; ii he has the qualifications, knowledge, skills and competencies necessary to manage the agency; and iii he is physically and mentally fit to do so; and c full and satisfactory information is available in relation to him in respect of each of the matters specified in Schedule 2. Registered person – general requirements and training 10 1 The registered provider and the registered manager shall, having regard to the size of the agency, its statement of purpose and the number and needs of the service users, carry on or (as the case may be) manage the agency with sufficient care, competence and skill. 2 If the registered provider is – a an individual, he shall undertake; b an organisation, it shall ensure that the responsible individual undertakes; or c a partnership, it shall ensure that one of the partners undertakes, from time to time such training as is appropriate to ensure that he has the experience and skills necessary for carrying on the agency. 3 The registered manager shall undertake from time to time such training as is appropriate to ensure that he has – a the experience and skills necessary for managing the agency; and b appropriate supervision and performance appraisal skills. Notification of offences 11 Where the registered person or the responsible individual is convicted of any criminal offence, whether in Northern Ireland or elsewhere, he shall forthwith give notice in writing to the RQIA of – i the date and place of the conviction; ii the offence of which he was convicted; and iii the penalty imposed on him in respect of the offence. PART III CONDUCT OF NURSING AGENCIES CHAPTER 1 QUALITY OF SERVICE PROVISION Fitness of nurses supplied by an agency 12 1 ... The registered person shall ensure that no nurse is supplied by the agency unless – a he is of integrity and good character; b he has the qualifications, knowledge, skills and competencies which are necessary for the work which he is to perform; c he is physically and mentally fit for that work; and d full and satisfactory information is available in relation to him in respect of each of the matters specified in Schedule 3. but this is subject to paragraphs (4) to (6). 2 The registered person shall ensure that the recruitment process for the supply of nurses is managed by a nurse, that selection of a nurse for supply is made by a nurse and that full and satisfactory information in respect of each of the matters listed in Schedule 2 is available in relation to the nurse carrying out the selection. 3 The registered person shall ensure that every nurse supplied by the agency acting as an employment business is instructed that when working for a service user he must at all times wear identification showing his name, signature, the name of the agency, contact number, a recent photograph and the expiry date of the card. 4 Where the conditions set out in paragraph (5) are satisfied, the agency may supply a nurse (“P”) to a service user even though the information and documents mentioned in paragraphs 2, 4 to 9 and 11 to 13 of Schedule 3 are not available. 5 The conditions are that the registered person must ensure— a whichever of the following certificates would be required to be obtained in respect of P under paragraph 13 of Schedule 3 in the absence of paragraph (4) has been applied for— i a criminal record certificate pursuant to section 113A of the Police Act 1997, or ii an enhanced criminal record certificate pursuant to section 113B of that Act; b the information and documents mentioned in paragraphs 2, 4 to 9, 11 and 12 of Schedule 3 have been requested; and c confirmation has been obtained in writing from the Department of Justice that P is included in neither the adults’ barred list nor the children’s barred list maintained under Article 6(1) of the Safeguarding Vulnerable Groups (Northern Ireland) Order 2007. 6 Where an agency supplies a nurse to a service user in the circumstances mentioned in paragraph (4), and the agency is acting as an employment business, the registered person must— a inform the service user, or the service user’s representative, of the information and documents mentioned in paragraphs 2, 4 to 9 and 11 to 13 of Schedule 3 that are not yet available; and b inform the service user, or the service user’s representative, when the information and document are available; and c terminate the supply of P to the service user where the registered person considers that the information or documents, when available, are not satisfactory. Notification of incidents 13 Where an agency acting as an employment business supplies a nurse to provide nursing care in the private residence of a service user or patient, the registered person shall notify the RQIA of any incident reported to the police not later than 24 hours after the registered person – i has reported the matter to the police; ii is informed that the matter has been reported to the police. Staffing 14 1 Where an agency is acting as an employment business, the registered person shall, having regard to the size of the agency, its statement of purpose and the number and needs of the service users, take all reasonable measures to ensure that there is at all times an appropriate number of suitably qualified, skilled and experienced persons employed for the purposes of the agency. 2 The registered person shall ensure that each employee of the agency – a receives appropriate supervision; and b is provided with a job description outlining his responsibilities. 3 The registered person shall – i collect information from service users about performance of nurses employed for the purposes of the agency; and ii take such steps as may be necessary to address any aspect of a nurse’s clinical practice. 4 The registered person shall provide to each nurse who is employed for the purposes of the agency a written statement of the terms and conditions on which he will be supplied to work for, and under the control of, a service user. 5 The statement of terms and conditions provided under paragraph (4) shall, in particular, specify the employment status of the nurse. Staff handbook 15 1 Where the agency is acting as an employment business, the registered person shall prepare a staff handbook and provide a copy to every member of staff. 2 The handbook prepared in accordance with paragraph (1) shall include a statement as to – a the conduct expected of staff, and disciplinary action which may be taken against them; b the role and responsibilities of nurses and other staff; c record keeping requirements; d recruitment procedures; and e training and development requirements and opportunities. Provision of information to service users 16 1 The registered person shall ensure that before a nurse is supplied, the service user is informed of – a the name of the nurse who is to be supplied and the means of contacting him; b the name of the member of staff of the agency who is responsible for the supply of that nurse; and c where the agency is acting as an employment business, details of how the service user may contact the registered person, or a person nominated to act on behalf of the registered person. 1A Where the agency supplies a nurse to a service user in the circumstances mentioned in regulation 12(4), and the agency is acting as an employment agency, the registered person must— a inform the service user, or the service user’s representative, of the information and documents mentioned in paragraphs 2, 4 to 9 and 11 to 13 of Schedule 3 that are not yet available; b inform the service user, or the service user’s representative, when the information and documents are available. 2 Where the service user is also the patient, the registered person must ensure that the information specified in paragraph (1) and, where applicable, paragraph (1A) is provided to the person acting on behalf of the patient. Disclosure of information 17 The registered person shall ensure that any personal information about a patient for whom a nurse is supplied by the agency is not disclosed to any member of the agency’s staff unless it is necessary to do so in order to provide an effective service to the patient. Records 18 The registered person shall ensure that the records specified in Schedule 4 are maintained, are available at all times for inspection and that they are – a kept up to date, in good order and in a secure manner; and b retained for a period of not less than eight years beginning on the date of the last entry. Complaints 19 1 The registered person shall establish a procedure (“the complaints procedure”) for considering complaints made to the registered person by a service user or a person acting on behalf of the service user. 2 The registered person shall supply a written copy of the complaints procedure to every service user and, upon request, to any person acting on behalf of a service user. 3 The written copy of the complaints procedure shall include – a the address and telephone number of the RQIA ; and b the procedure (if any) which has been notified by the RQIA to the registered person for making complaints to the RQIA relating to the agency. 4 The registered person shall ensure that every complaint made under the complaints procedure is fully investigated. 5 The registered person shall, within the period of 28 days beginning on and including the date on which the complaint is made, or such shorter period as may be reasonable in the circumstances, inform the person who made the complaint of the action (if any) that is to be taken in response. 6 The registered person shall maintain a record of each complaint, including details of the investigation made, the outcome and any action taken in consequence and the requirements of regulation 18 shall apply to that record. 7 The registered person shall supply to the RQIA annually a statement containing a summary of the complaints made during the preceding twelve months and the action taken in response. 8 The registered person shall ensure that any evidence of misconduct by a nurse is reported promptly and in writing to the Nursing and Midwifery Council . Review of quality of service provision 20 1 The registered person shall introduce and maintain a system for reviewing at appropriate intervals the quality of services provided by the agency. 2 The registered person shall supply to the RQIA a report in respect of any review conducted by him for the purposes of paragraph (1) and shall make a copy of the report available upon request for inspection by service users and persons acting on behalf of service users. 3 The system referred to in paragraph (1) shall provide for consultation with service users and persons acting on behalf of service users. 4 The registered manager shall ensure that the agency delivers services effectively on a daily basis and reports as required to the registered person. CHAPTER 2 PREMISES Fitness of premises 21 1 The registered person shall not use premises for the purposes of an agency unless the premises are suitable for the purpose of achieving the aims and objectives of the agency set out in the statement of purpose. CHAPTER 3 FINANCIAL MATTERS Financial position 22 1 The registered provider shall carry on the agency in such manner as is likely to ensure that the agency will be financially viable for the purpose of achieving the aims and objectives set out in the statement of purpose. 2 The registered person shall, if the RQIA so requests, provide the RQIA with such information and documents as it may require in order to consider the financial viability of the agency, including – a the annual accounts of the agency certified by an accountant; and b a certificate of insurance for the registered provider in respect of liability which may be incurred by him in relation to the agency in respect of death, injury, public liability, damage or other loss. CHAPTER 4 NOTICES TO BE GIVEN TO THE RQIA Notice of absence 23 1 Where – a the registered provider, being an individual in full-time day to day charge of the agency; or b the registered manager, proposes to be absent from the agency for a continuous period of 28 days or more, the registered person shall give notice in writing to the RQIA of the proposed absence. 2 Except in the case of an emergency, the notice referred to in paragraph (1) shall be given no later than one month before the proposed absence commences or within such shorter period as may be agreed with the RQIA and the notice shall specify – a the length or expected length of the absence; b the reason for the absence; c the arrangements which have been made for running the agency during that absence; d the name, address and qualifications of the person who will be responsible for the agency during that absence; and e in the case of the absence of the registered manager, the arrangements that have been, or are proposed to be, made for appointing another person to manage the agency during that absence, including the proposed date by which the appointment is to be made. 3 Where the absence arises as a result of an emergency, the registered person shall give notice of the absence within one week of its occurrence specifying the matters set out in paragraph (2)(a) to (e). 4 Where – a the registered provider, being an individual in full-time day to day charge of the agency; or b the registered manager, has been absent from the agency for a continuous period of 28 days or more, and the RQIA has not been given notice of the absence, the registered person shall, without delay, give notice in writing to the RQIA of the absence, specifying the matters set out in paragraph (2)(a) to (e). 5 The registered person shall notify the RQIA of the return to duty of the registered provider or (as the case may be) the registered manager not later than 7 days after the date of his return. Notice of changes 24 The registered person shall give notice in writing to the RQIA as soon as it is practicable to do so if any of the following events takes place or is proposed to take place – a a person other than the registered person carries on or manages the agency; b a person ceases to carry on or manage the agency; c where the registered person is an individual, he changes his name; d where the registered provider is a partnership, there is any change in the membership of the partnership; e where the registered provider is an organisation – i the name or address of the organisation is changed; ii there is any change of director, manager, secretary or other similar officer of the organisation; or iii there is any change in the identity of the responsible individual; f where the registered provider is an individual, a trustee in bankruptcy is appointed; fa where the registered provider is an individual, a debt relief order is made in respect of him; g where the registered provider is a company or partnership, a receiver, manager, liquidator or provisional liquidator is appointed; or h where the registered provider acquires additional premises for the purposes of the agency. Appointment of liquidators etc. 25 1 Any person to whom paragraph (2) applies must – a forthwith notify the RQIA of his appointment indicating the reasons for it; b appoint a manager to take full-time day to day charge of the agency in any case where there is no registered manager; and c not more than 28 days after his appointment, notify the RQIA of his intentions regarding the future operation of the agency. 2 This paragraph applies to any person appointed as – a the receiver or manager of the property of a company or partnership which is a registered provider in respect of an agency; b the liquidator or provisional liquidator of a company which is the registered provider in respect of an agency; or c the trustee in bankruptcy of a registered provider in respect of an agency. Death of registered person 26 1 If more than one person is registered in respect of an agency, and a registered person dies, the surviving registered person shall without delay notify the RQIA of the death in writing. 2 If only one person is registered in respect of an agency, and he dies his personal representatives must notify the RQIA in writing – a without delay of the death; and b within 28 days of their intentions regarding the future running of the agency. 3 The personal representatives of the deceased registered provider may carry on the agency without being registered in respect of it – a for a period not exceeding 28 days; and b for any further period as may be determined in accordance with paragraph (4). 4 The RQIA may extend the period specified in paragraph (3)(a) by such further period, not exceeding one year, as the RQIA shall determine, and shall notify any such determination to the personal representatives in writing. 5 The personal representatives shall appoint a person to take full-time day to day charge of the agency during any period in which, in accordance with paragraph (3), they carry on the agency without being registered in respect of it. PART IV MISCELLANEOUS Compliance with Regulations 27 Where there is more than one registered person in respect of an agency, anything which is required under these Regulations to be done by the registered person shall, if done by one of the registered persons, not be required to be done by any of the other registered persons. Offences 28 1 A contravention of any of the provisions of regulations 4 to 6 and 11 to 24 shall be an offence. 2 The RQIA shall not bring proceedings against a person in respect of any contravention of those regulations unless – a subject to paragraph (4), he is a registered person; b notice has been given to him in accordance with paragraph (3); c the period specified in the notice, within which the registered person may make representations to the RQIA , has expired; and d in a case where, in accordance with paragraph (3)(b), the notice specifies any action that is to be taken within a specified period, the period has expired and the action has not been taken within that period. 3 Where the RQIA considers that the registered person has contravened any of the provisions of the regulations mentioned in paragraph (1), it may serve a notice on the registered person specifying – a in what respect in its opinion the registered person has contravened any of the regulations; b where it is practicable for the registered person to take action for the purpose of complying with any of those regulations, the action which, in the opinion of the RQIA , the registered person should take for that purpose; c the period, not exceeding three months, within which the registered person should take any action specified in accordance with sub-paragraph (b); d the period, not exceeding one month, within which the registered person may make representations to the RQIA about the notice. 4 The RQIA may bring proceedings against a person who was once, but no longer is, a registered person, in respect of a failure to comply with regulation 18 and for this purpose, references in paragraphs (2) and (3) to a registered person shall be taken to include such a person. Revocations 29 The Nursing Agency (Northern Ireland) Regulations 1986 are hereby revoked. Sealed with the Official Seal of the Department of Health, Social Services and Public Safety on 25th March 2005. Noel McCann A senior officer of the Department of Health, Social Services and Public Safety