GUIDANCE FOR PROVIDERS ON THE APPOINTMENT OF A REGISTERED MANAGER

Transcription

1 GUIDANCE FOR PROVIDERS ON THE APPOINTMENT OF A REGISTERED MANAGER Guidance for Providers on the Appointment of a Registered Manager 1

2 1. Introduction 2 Is there a requirement to register What is a registered provider? 2. Pre-Application Stage 4 When is a manager required to be appointed? What tools are available to help with the registration process? 3. Application Stage 5 Can I appoint a manager to job share a post with another person? Do both managers need to register? Can a manager manage more than one regulated service? Arrangements in the absence of the registered manager Registered provider s confirmation of fitness and statement of support 4. Outcome Stage 7 What happens to applications? How long does RQIA take to make a decision? Is there an interview? What is the purpose of the meeting? What are the potential outcomes to an application for registration? 5. Representations and Appeals 9 Can I challenge a decision not to register a manager? Complaints Data Protection Act 1998 Fair Processing Notice 6. Appendix 10 Application Flowchart Registration of manager assessment criteria Examples of regulated services Guidance for Providers on the Appointment of a Registered Manager 2

3 Introduction This guidance sets out the responsibility placed on a provider to ensure that a manager is appointed in accordance with the Health and Personal Social Services (Quality, Improvement and Regulation) (Northern Ireland) Order 2003 (the 2003 Order). The guidance explains: Requirement to register Responsibility of a registered provider Services that require a manager How to make an application Process for accessing application RQIA work to safeguard the rights of people who avail of regulated services by ensuring there is a robust, consistent registration process for managers. Our registration process is fair and equitable, regardless of the individual circumstances under consideration. We will act on behalf of our stakeholders to ensure services are well led and that care is being provided safely, effectively and compassionately. Requirement to Register Is there a requirement to register a manager with RQIA? Yes, any persons proposing to manage a regulated service must apply for registration with RQIA in accordance with Article 12 of the 2003 Order. The registered provider of these services must appoint a manager for each regulated service they are to manage. What is a registered provider? A registered provider means a person who is registered under Part III of the 2003 Order as the person carrying on the establishment or agency. The registered provider is the owner or the person with overall responsibility for the service. In the case of an organisation, voluntary or statutory body, a responsible individual can be nominated to assume this responsibility. This individual must be sufficiently senior to make decisions and implement areas for improvements against the regulations and/or standards arising from an inspection of the regulated establishment or agency. The registered provider is responsible for ensuring the establishment or agency is operated in accordance with legislation. Guidance for Providers on the Appointment of a Registered Manager 3

4 Pre Application Stage When is a manager required to be appointed In accordance with the 2003 Order a registered provider of an establishment or agency is required to appoint a manager when: You are an organisation or a partnership You do not have the relevant qualifications You do not intend to manage the service yourself Regulations set out requirements on the fitness of a registered provider; appointment of a manager and fitness of a registered manager. Minimum standards underpin the relevant regulations and cover the legal requirements of what the registered provider has to do to carry on and manage an establishment or agency. Only an individual can be appointed as manager. Where an appointment is made, the registered provider is required to give RQIA notice of the name of the person appointed and the date on which the appointment is to take effect. We will only register the manager of an establishment or agency when the individual has demonstrated to our satisfaction that they are fit to be registered in accordance with the 2003 Order, associated regulations and where relevant, DHSSPS minimum standards. What tools are available to help with the registration process? The appointment of a registered manager is crucial to the delivery of safe and effective care and RQIA has developed a self-assessment tool as part of the registration process to assist and guide managers coming forward for registration. This tool allows the manager to examine the everyday activities, systems and processes within their establishment or agency and assess them against the appropriate DHSSPS minimum standards. As the registered provider you may want to discuss the outcomes of the assessment with your manager to assist them prepare for registration. Guidance for Providers on the Appointment of a Registered Manager 4

5 Application Stage Can I appoint a manager to job share a post with another person? Do both managers need to register? Yes - where the manager post is undertaken by employees in a job share arrangement, both managers need to register with RQIA. Both managers are equally accountable for managing the establishment or agency. Both individuals will need to complete an application form and provide all the necessary documentation. Can a manager manage more than one regulated service? Yes we recognises that the legislation allows for a manager to have responsibility for more than one establishment or agency. Article 13 (4) of The Health and Personal Social Services (Quality, Improvement and Regulation) (Northern Ireland) Order 2003, states: 13 (4) A person who carries on or manages, or wishes to carry on or manage, more than one establishment or agency shall make a separate application in respect of each of them. It is RQIA s preferred position that no manager will manage more than one establishment or agency. When a manager is coming forward to manage more than one regulated service the registered provider must submit evidence to RQIA that they are able to carry on the day to day management of each service and do so effectively and safely. Registered providers should note that in some regulated services the manager is expected to be in full-time day-to-day charge of the establishment or agency. These services include nursing and residential care homes, any residential services for children, adult placement agencies and any other service type which is specified in the relevant regulations. The reason for this is to ensure that those services providing overnight accommodation for service users, receive the management focus necessary to ensure they provide safe, effective and compassionate care in a well led service to those who live there either permanently or temporarily. A person who proposes to manage more than one establishment or agency has to make a separate application in respect of each service. The arrangements in place for the registered manager to manage each of the establishments or agencies must be detailed in the application forms. We will assess the arrangements to determine if they are suitable and facilitate the delivery of safe and effective care. The assessment will take into consideration the following criteria: The number and type of services the manager is currently registered to manage The size (in terms of service users) of the respective services The nature and complexity of the needs of the people who use the service in terms of either the registered category of care or the service user group in each registered service The geographical proximity of the services Guidance for Providers on the Appointment of a Registered Manager 5

6 The hours and days of the week the service operates The day to day management arrangements when the manager is not present at each separate service Registered provider support mechanisms and arrangements for the manager The registered provider and manager s understanding of their legal obligation to comply with the relevant regulations Accountability and monitoring arrangements that will be in place to ensure the quality of the service is maintained The regulatory history of both the services and the manager involved including any current and recent enforcement action, identified areas for improvement and inspection findings Arrangements in the absence of a registered manager There are occasions where a registered manager is absent from their establishment for a period of more than 28 days for a variety of reasons. Regulations specify registered providers must inform RQIA of the absence of the registered manager and the period of the absence. In addition we also must be informed of the arrangements the registered provider has made to appoint another person to manage the day to day operation of the establishment or agency. Registered providers must also give consideration to the support available for the person and the time allocated to enable them to carry out their managerial duties. RQIA do not expect these temporary arrangements to continue indefinitely and the registered provider must continuously review the arrangements and ensure they remain suitable. Registered provider s confirmation of fitness and statement of support It is the registered provider s responsibility to ensure that the appointment of a manager has been made in accordance with the 2003 Order and that robust recruitment and selection procedures have been followed. This should ensure that the person they appoint meets the criteria with regard to the qualifications, knowledge, skills and experience detailed in the associated regulations and DHSSPS minimum standards. On appointment of a new manager, we ask the registered provider to complete the confirmation of fitness and statement of support contained in the applicant s application form. Guidance for Providers on the Appointment of a Registered Manager 6

7 Outcome Stage What happens to applications? The manager s application form is initially reviewed by the registration team for completeness and then passed to the named inspector for the service. The inspector will assess the application and the registered provider s statement of fitness along with any other information we may have in relation to the applicant. (We have detailed our assessment criteria in Appendix 2). If we require any additional information we will contact you in writing. We expect to obtain all the necessary information from the application form and/or the meeting with managers. How long does RQIA take to make a decision? RQIA aims to assess the application and inform you of an outcome within one month from the date at which all required satisfactory information has been received. Please note these are only indicative timescales, and on occasion the process may take longer than this. Is there an interview? No, however where a manager is coming forward for the first time to be registered we will organise a meeting as part of the assessment of their fitness to be registered. The meeting is not an interview and we will try and keep it as informal as possible. This meeting may occur at the offices of RQIA or at the regulated service. In the event that a registered manager is currently registered with us, we will determine if we need to undertake another meeting, we will use the intelligence available to us on the applicant, this will include: History as a manager of a regulated service Adherence to regulations Enforcement history What is the purpose of the meeting? The purpose of our meeting with a manager is to assess their fitness to be registered against the criteria of the specific service regulations. We also discuss their knowledge and understanding of the responsibility placed on them as a registered manager. We do not assess the suitability of the applicant for their post as that is the responsibility of the registered provider. The meeting is also an opportunity for the applicant to meet the inspector for their service and to encourage partnership working to ensure the best outcomes for people who use the service. Guidance for Providers on the Appointment of a Registered Manager 7

8 What are the potential outcomes to an application for registration? There are three potential outcomes to an application for registration with RQIA: Application approved Once we are satisfied the applicant meets the fitness criteria we will approve the manager s registration and issue a certificate of registration. The certificate provides details of the regulated service and the registered provider and is required to be displayed in a prominent place within the establishment or agency. Application approved (with condition) On rare occasions we may approve an application subject to conditions. A condition may be placed on registration in relation to the manager s experience/knowledge or were we feel additional support for the manager is required. Application refused Should we decide to refuse an application, we will issue a notice of proposal to the applicant who is given a period of 28 days in which to make written representation to RQIA (a form is provided). Where written representations are received by RQIA, these will be considered and we will decide whether or not to adopt the proposal to refuse registration in light of the representations. The applicant will be advised of the outcome and if the proposal is adopted a notice of decision will be served on the applicant. In these circumstances the applicant has a period of 28 days in which they may either accept the notice or appeal the decision to the Care Tribunal. A notice of decision takes effect from the original date of issue. A refusal of an application will not prevent the applicant from reapplying once they are able to evidence that all requirements for registration can be met. Guidance for Providers on the Appointment of a Registered Manager 8

9 Representations and Appeals Can the decision not to register a manager be challenged? Yes. Decisions may be challenged by making a written representation after a notice of proposal has been issued, or by appealing to the Care Tribunal after a notice of decision has been issued. If your application is approved (with conditions) or your application is refused, you will be provided with the appropriate forms with which to make representation. Complaints RQIA operates a complaints procedure that allows any applicant to make a complaint if they are dissatisfied or consider RQIA has not followed its registration procedures. Please note that the complaints procedure cannot be used to challenge a decision made. Data Protection Act Fair Processing Notice Personal data in an application form may be accessed and used in accordance with RQIA's requirements as outlined in the 2003 Order and associated regulations in line with RQIA s registration and notification with the Information Commissioner s Office under the Data Protection Act 1998 and in compliance with the Freedom of Information Act To comply with statutory and government requirements, data may be disclosed to external agencies such as (but not exclusively): DHSSPS, Northern Ireland Audit Office, AccessNI. RQIA will not disclose any personal information to any third parties without the express consent of the applicant, except where required by law. From January 2005 personal data may, in exceptional circumstances where the public interest outweighs the individual s rights to privacy, be released under the auspices of the Freedom of Information Act Any queries concerning Data Protection and Freedom of Information should be addressed to the Head of Information within RQIA. Contact details and further information in relation to the use of personal data can be found on RQIA s web site For general information please visit Guidance for Providers on the Appointment of a Registered Manager 9

10 Appendix 1 - Overview of Registration Guidance for Providers on the Appointment of a Registered Manager 10

11 Appendix 2 - RQIA s registration of manager assessment criteria and for managers applying to manager more than one service All criteria must be considered and where they are determined to be not applicable this must be recorded on the form. Criteria Assessment Outcome An assessment of the applicant s required documentation in accordance with agencies/establishment regulations. Understanding of both the registered provider and manager of their legal obligation to comply with the relevant regulations. The service the establishment/agency is providing. The support mechanisms and arrangements the registered provider plans to have in place for the registered manager. Guidance for Providers on the Appointment of a Registered Manager 11

12 The proposed management arrangements when the registered manager is not present in either one or other of the services including: time scheduled to be spent at each service by the manager details of resources, such as senior staff, at each separate service details of deputising arrangements at each separate service Accountability and monitoring arrangements by the registered provider that will be in place to ensure the quality of the service is maintained. The regulatory history of the services and the registered manager involved including any current and recent enforcement action and inspection report findings. Guidance for Providers on the Appointment of a Registered Manager 12

13 The application of a condition to the registration of the service(s) concerned. Inspector s Signature: Senior Inspector Signature: Head of Programme Signature: Guidance for Providers on the Appointment of a Registered Manager 13

14 Appendix 3 Regulated services that require a registered manager There are a range of services that fall within the scope of the 2003 Order. We have provided some examples of the specific regulations for establishments that describe the appointment of a manager in those services. This list is not exhaustive and providers are referred to the specific regulations for their service. Nursing Homes Regulation 8 (1) Appointment of manager which states: 8. (1) The registered provider shall appoint an individual to manage the nursing home where (a) there is no registered manager in respect of the nursing home; (b) the registered provider (i) is an organisation or partnership; (ii) is not a fit person to manage a nursing home; or (iii) is not, or does not intend to be, in full-time day-to-day charge of the nursing home. Residential Care Homes Regulation 8 (1) Appointment of manager which states: 8. (1) The registered provider shall appoint an individual to manage the residential care home where (a)there is no registered manager in respect of the home; (b)the registered provider (i)is an organisation or partnership; (ii)is not a fit person to manage a home; or (iii)is not, or does not intend to be, in full-time day-to-day charge of the home. Children s Homes Regulation 7 (1) Appointment of manager which states: 7. (1) The registered provider shall appoint an individual to manage the children s home if (a) there is no registered manager in respect of the children s home; and. (b) the registered provider (i) is an organisation or a partnership; (ii) is not a fit person to manage a children s home; or (iii) is not, or does not intend to be, in full-time day to day charge of the children s home. Guidance for Providers on the Appointment of a Registered Manager 14

15 The Adult Placement Agencies Regulations (Northern Ireland) 2007 Regulation 8 Appointment of manager which states: 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. The Independent Health Care Regulations have similar requirements of registered managers, as follows: The Independent Health Care Regulations (Northern Ireland) 2005 Regulation 11 Appointment of manager which states: 11. (1) The registered provider shall appoint an individual to manage an establishment or agency if (a)there is no registered manager in respect of the establishment or agency; and (b)the registered provider (i)is an organisation or a partnership; (ii)is not a fit person to manage an establishment or agency; or (iii)is not, or does not intend to be, in full-time day-to-day charge of the establishment or agency. Guidance for Providers on the Appointment of a Registered Manager 15