2005 No. 161
HEALTH AND PERSONAL SOCIAL SERVICES
The Residential Care Homes Regulations (Northern Ireland) 2005
Made 23rd March 2005
Coming into operation 1st April 2005

The Department of Health, Social Services and Public Safety in exercise of the powers conferred on it by Articles 23(1), (2)(a) to (d) and (f) to (j), (3), (5), (7)(a) to (h), (j) and (1), 25(1), 30, 31(1), 32 and 48(2) of the Health and Personal Social Services (Quality, Improvement and Regulation) (Northern Ireland) Order 2003 and of all other powers enabling it in that behalf, having consulted such persons as appropriate as required by Article 23(8) of that Order, hereby makes the following Regulations:
S.I.2003/431 (N.I. 9)

PART 1 GENERAL

1 Citation, commencement and extent
These Regulations may be cited as the Residential Care Homes Regulations (Northern Ireland) 2005 and shall come into operation on 1st April 2005.

2 Interpretation
1 In these Regulations –
“clinical trial” has the same meaning as in the Medicines for Human Use (Clinical Trials) Regulations 2004;
“ethics committee” has the same meaning as in the Medicines for Human Use (Clinical Trials) Regulations 2004;
“Fire Authority” means the Fire Authority for Northern Ireland within the meaning of the Fire Services (Northern Ireland) Order 1984;
“general medical practitioner” means a medical practitioner providing primary medical services;
“health care professional” means a person who is registered as a member of any profession which is regulated by a body mentioned in section 25(3) of the National Health Service Reform and Health Care Professions Act 2002 or who is a clinical psychologist or child psychotherapist;
“inspection report” means a report prepared in relation to the home under Article 42(7) of the Order;
“the Northern Ireland Social Care Council” means the body established under section 1 of the Health and Personal Social Services Act (Northern Ireland) 2001;
“nurse” means a person registered in the register maintained under Article 5 of the Nursing and Midwifery Order 2001 by virtue of qualification in nursing or midwifery as the case may be;
“Nursing and Midwifery Council” means the body established under Article 3 of the Nursing and Midwifery Order 2001;
“the Order” means the Health and Personal Social Services (Quality, Improvement and Regulations) (Northern Ireland) Order 2003;
“organisation” means a body corporate or any unincorporated association other than a partnership;
“registered manager” in relation to a residential care home, means a person who is registered under Part III of the Order as the manager of the residential care home;
“registered person” in relation to a residential care home, means any person who is the registered provider or registered manager in respect of the residential care home;
“registered provider” in relation to a residential care home, means a person who is registered under under Part III of the Order as a person carrying on the residential care home;
“relative” in relation to any person, means –
(a) the person’s spouse;
(b) any parent, grandparent, child, grandchild, brother, sister, uncle, aunt, nephew or niece of his;
(c) the spouse of any relative within sub-paragraph (b) of this definition,
and for the purpose of determining any such relationship a person’s step-child shall be treated as his child, and references to “spouse” in relation to any person include a former spouse and a person who is living with the person as husband or wife;
“representative” means in relation to a resident, a person other than the registered person or a person employed at the home, who with the resident’s express or implied consent takes an interest in the resident’s health and welfare;
“resident” means a person for whom accommodation with board and personal care is provided in, or for the purposes of the residential care home;
“resident’s care plan” means the written plan prepared in accordance with regulation 16(1);
“resident’s guide” means the guide compiled in accordance with regulation 4(1);
“responsible individual” shall be construed in accordance with regulation 7(2)(c)(i);
“social care worker” including “social worker” has the meaning as defined in section 2 of the Health and Personal Social Services Act (Northern Ireland) 2001;
“staff” means persons employed by the registered person to work at the home but does not include a volunteer or a person employed under a contract for services;
“statement of purpose” means the written statement compiled in accordance with regulation 3(1).
S.I.2004/1031
S.I.1984/1821 (N.I. 11)
2002 c. 17
2001 c. 3 (N.I.)
S.I.2002/253
2 In these Regulations, references to employing a person include employing a person whether or not for payment and whether under a contract of service or a contract for services and allowing a person to work as a volunteer.

3 Statement of purpose
1 The registered person shall compile in relation to the residential care home a written statement which shall consist of –
(a) a statement of the aims and objectives of the home;
(b) a statement as to the facilities and services which are to be provided by the registered person for residents; and
(c) 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 Regulation and Improvement Authority and shall make a copy of it available for inspection by every resident and any representative of a resident.
3 Nothing in regulation 18(1) or 27(1) 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.

4 Resident’s guide
1 The registered person shall produce a written guide to the residential care home which shall include –
(a) a summary of the statement of purpose including the philosophy of care;
(b) the terms and conditions in respect of accommodation to be provided for resident's, including as to the amount and method of payment of fees;
(c) a standard form of contract for the provision of services and facilities by the registered provider to residents;
(d) a summary of the complaints procedure established under regulation 24;
(e) the address and telephone number of the Regulation and Improvement Authority.
2 The registered person shall also provide, on request, access to a copy of the most recent inspection report and information on how to access earlier inspection reports;
3 The registered person shall supply a copy of the resident’s guide to the Regulation and Improvement Authority and each resident or their representative.
4 Where a HSS Trust has made arrangements for the provision of accommodation with board and personal care to the resident at the home, the registered person shall supply to the resident a copy of the agreement specifying the arrangements made.

5 Information about fees
1 The registered person shall provide to each resident, by not later than the day on which he becomes a resident, a statement specifying –
(a) the fees payable by or in respect of the resident for the provision to the resident of any of the following services –
(i) residential accommodation with board; and
(ii) personal care;
and, except where a single fee is payable for those services, the services to which each fee relates;
(b) the method of payment of the fees and the person by whom the fees are payable.
2 The registered person shall notify the resident at least 28 days in advance of –
(a) any increase in the fees referred to in paragraph (1)(a) and payable by or in respect of the resident;
(b) any variation in the matters referred to in paragraph (1)(b).
3 Where a HSS Trust has made arrangements for the provision of residential accommodation with board and personal care at the residential care home and the charge made exceeds the fee paid, the registered person shall in the individual written agreement –
(a) record the reason for the additional charge;
(b) by whom it will be paid; and
(c) list the services, if any, provided for it.
4 Where a nursing contribution is paid in respect of nursing care provided to the resident, the registered person shall provide to the resident a statement specifying –
(a) the date payment commenced and the amount of the nursing care contribution; and
(b) the date on which the registered person is to deduct the amount of the nursing contribution from the fees referred to in paragraph (1)(a) or pay that amount to the resident.
5 In this regulation “nursing care contribution” means a payment by a HSS Trust to the registered person in respect of nursing care to be provided to a resident, but does not include a payment where –
(a) the HSS Trust has made arrangements for the provision of accommodation to the resident; and
(b) the payment relates to any period for which under those arrangements accommodation is provided to the resident.

6 Review of statement of purpose and resident’s guide
The registered person shall –
(a) keep under review and, where appropriate, revise the statement of purpose and the resident’s guide; and
(b) notify the Regulation and Improvement Authority and residents of any such revision within 28 days.

PART II REGISTERED PERSONS

7 Fitness of registered provider
1 A person shall not carry on a residential care home unless he is fit to do so.
2 A person is not fit to carry on a home unless the person –
(a) is an individual who carries on the home –
(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 Regulation and Improvement Authority 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 home; 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; and
(b) he is physically and mentally fit to carry on the home; and
(c) full and satisfactory information is available in relation to him in respect of the matters specified in paragraphs 1 to 7 of Schedule 2.
4 A person shall not carry on a home 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
(b) he has made a composition or arrangement with his creditors and has not been discharged in respect of it.

8 Appointment of manager
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.
2 Where the registered provider appoints a person to manage the residential care home he shall forthwith give notice to the Regulation and Improvement Authority of –
(a) the name of the person so appointed; and
(b) the date on which the appointment is to take effect

9 Fitness of registered manager
1 A person shall not manage a residential care home unless he is fit to do so.
2 A person is not fit to manage a home unless –
(a) he is of integrity and good character;
(b) having regard to the size of the home, the statement of purpose, and the number and needs of the residents –
(i) he has the qualifications, skills and experience necessary, for managing the home; and
(ii) he is physically and mentally fit to manage the home; and
(c) full and satisfactory information is available in relation to him in respect of the matters specified in paragraphs 1 to 7 of Schedule 2.

10 Registered person: general requirements
1 The registered provider and the registered manager shall, having regard to the size of the residential care home, the statement of purpose, and the number and needs of the residents, carry on or manage the home (as the case may be) 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;
(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 home.
3 The registered manager shall undertake from time to time such training as is appropriate to ensure that he has the experience and skills necessary for managing the home.

11 Registered Person: notification of offences
Where the registered person or the responsible individual is convicted of any criminal offence, in Northern Ireland or elsewhere, he shall forthwith give notice in writing to the Regulation and Improvement Authority of –
(a) the date and place of the conviction;
(b) the offence of which he was convicted; and
(c) the penalty imposed on him in respect of the offence.

PART III CONDUCT OF THE RESIDENTIAL CARE HOME

12 Requirements to ensure quality of care and other service provision
1 The registered person shall provide care and any other services to residents in accordance with the statements of purpose, and shall ensure that the care, treatment, if necessary, and other services provided to each resident –
(a) meet his individual need;
(b) reflect current best practice; and
(c) are (where necessary) provided by means of appropriate aids or equipment.
2 The registered person shall ensure that all aids and equipment used in or for the purpose of the residential care home is –
(a) suitable for the purposes for which it is to be used; and
(b) properly maintained and in good working order.
3 Where reusable medical devices are used in a home, the registered person shall ensure that appropriate procedures are implemented and adhered to in relation to cleaning, disinfection, inspection, packaging, sterilisation, transportation and storage of such devices.
4 The procedures implemented in accordance with paragraph (3) shall be such as to ensure that reusable medical devices are handled safely and decontaminated effectively in accordance with the manufacturer’s guidance prior to re-use.
5 The registered person shall ensure that food and drink –
(a) are provided in adequate quantities and at appropriate intervals;
(b) are properly prepared, wholesome and nutritious and meets their nutritional requirements;
(c) are suitable for the needs of residents;
(d) provide choice for the residents;
(e) that the menu is varied at suitable intervals.

13 Health and welfare of residents
1 The registered person shall ensure that the residential care home is conducted so as –
(a) to promote and make proper provision for the health and welfare of residents;
(b) to make proper provision for the care and where appropriate, treatment and supervision of residents.
2 The registered person shall so far as practicable enable residents to make decisions with respect to the care they are to receive and their health and welfare.
3 The registered person shall, for the purpose of providing care to residents, and making proper provision for their health and welfare, so far as practicable, ascertain and take into account their wishes and feelings.
4 Subject to paragraph (5) the registered person shall make suitable arrangements for the ordering, storage, recording, handling, safe keeping, safe administration and disposal of medicines used in or for the purposes of the home to ensure that –
(a) any medicine which is kept in a home is stored in a secure place; and
(b) medicine which is prescribed is administered as prescribed to the resident for whom it is prescribed, and to no other resident; and
(c) a written record is kept of the administration of any medicine to a resident.
5 Paragraph (4) does not apply to medicine which –
(a) is stored by the individual for whom it is provided in such a way that others are prevented from using it; and
(b) may be safely self-administered by that individual.
6 In this regulation, “prescribed” means –
(a) ordered for a resident for provision to him under Part VI of the Health and Personal Social Services (Northern Ireland) Order 1972; or
S.I.1972/1265 (N.I. 14)
(b) prescribed for a resident under section 58 of the Medicines Act 1968.
1968 c. 67; as amended by paragraph 7 of Part II of Schedule 2 to the Medicines (Specified Articles and Substances) Order 1976 (S.I.1976/968)
7 The registered person shall make suitable arrangements to minimise the risk of infection and toxic conditions and the spread of infection between residents and staff.
8 The registered person shall make suitable arrangements to ensure that the home is conducted –
(a) in a manner which respects the privacy and dignity of residents;
(b) with due regard to the sex, religious persuasion, ethnic origin, and cultural and linguistic background and any disability of residents.
9 The registered provider and registered manager (if any) shall, in relation to the conduct of the home –
(a) maintain good personal and professional relationships with each other and with residents and staff; and
(b) encourage and assist staff to maintain good personal and professional relationships with residents.

14 Further requirements as to health and welfare
1 The registered person shall make arrangements for residents –
(a) to be registered with a general practitioner of their choice; and
(b) to receive where necessary, treatment, advice and other services from any health care professional and/or social worker.
2 The registered person shall ensure as far as reasonably practicable that –
(a) all parts of the reidential care home to which residents have access are free from hazards to their safety;
(b) any activities in which residents participate are free from avoidable risks; and
(c) unnecessary risks to the health, welfare or safety of residents are identified and so far as possible eliminated; and
(d) shall make suitable arrangements for the training of persons employed in first aid.
3 The registered person shall make suitable arrangements to provide a safe system for moving and handling residents.
4 The registered person shall make arrangements, by training persons employed or by other measures, to prevent residents being harmed or suffering abuse or being placed at risk of harm or abuse.
5 The registered person shall ensure that no resident is subject to restraint unless restraint of the kind employed is the only practicable means of securing the welfare of that or any other resident and there are exceptional circumstances.
6 On any occasion on which a resident is subject to restraint, the registered person shall record on the resident’s care plan the circumstances and nature of the restraint. These details should also be reported to the Regulation and Improvement Authority as soon as is practicable.

15 Assessment of residents
1 The registered person shall not provide accommodation to a resident at the residential care home unless –
(a) the needs of the resident have been assessed by a suitably qualified or suitably trained person;
(b) the registered person has obtained a copy of the assessment; and
(c) there has been appropriate consultation regarding the assessment with the resident or a representative of the resident as appropriate;
(d) the registered person has confirmed in writing to the resident that having regard to the assessment the home is suitable for the purpose of meeting the resident’s needs in respect of his care health and welfare;
(e) the home has been registered for the category of care appropriate to the resident’s needs.
2 The registered person shall ensure that the assessment of the resident’s needs is –
(a) kept under review; and
(b) revised at any time when it is necessary to do so having regard to any change of circumstances and in any case not less than annually.

16 Resident’s care plan
1 The registered person shall ensure that a written care plan is prepared in consultation with the resident or resident’s representative as to how the resident’s needs in respect of his care, health and welfare are to be met.
2 The registered person shall ensure that –
(a) the resident’s care plan is available to the resident;
(b) the resident’s care plan is kept under review;
(c) where appropriate and, unless it is impracticable to carry out such consultation, after consultation with the resident or a representative of his, revise the resident’s care plan; and
(d) notify the resident of any such revision.

17 Review of quality of care and other service provision
1 The registered person shall introduce and ensure systems are maintained for reviewing at appropriate intervals the quality of care and other service provision in or for the purposes of the residential care home and that any such review is undertaken no less than annually.
2 The registered person shall supply to the Regulation and Improvement Authority a report in respect of any review conducted by him for the purpose of paragraph (1) and make a copy of the report available to residents.
3 The system referred to in paragraph (1) shall provide for consultation with residents and their representatives.

18 Facilities and services
1 Subject to regulation 3(3), the registered person shall provide facilities and services to residents in accordance with the statement of purpose required by regulation 3(1)(b) in respect of the residential care home.
2 The registered person shall having regard to the size of the home and the number and needs of residents –
(a) provide, so far as is necessary for the purpose of managing the home, appropriate telephone and other communication facilities;
(b) provide telephone facilities which are suitable for the needs of residents, and make arrangements to enable residents to use such facilities in private;
(c) provide in rooms occupied by residents adequate furniture, bedding and other furnishings, including curtains and floor coverings, and equipment suitable to the needs of residents and screens where necessary;
(d) permit residents, so far as it is practicable to do so, and subject to fire and safety requirements, to bring their own furniture and furnishings into the rooms they occupy;
(e) arrange for the regular laundering of linen and clothing;
(f) so far as it is reasonable and practicable to do so, provide adequate facilities for residents to wash, dry and iron their own clothes if they so wish and, for that purpose, to make arrangements for their clothes to be sorted and kept separately;
(g) so far as it is reasonable and practicable to do so, provide adequate facilities for residents to prepare their own food and ensure that such facilities are safe for use by residents;
(h) so far as it is reasonable and practical to do so, provide sufficient and suitable kitchen equipment, crockery, cutlery and utensils and adequate facilities for the preparation and storage of food;
(i) after consultation with the environmental health department of the district council for the district in which the home is situated, make suitable arrangements for maintaining satisfactory standards of hygiene in the home;
(j) keep the home free from offensive odours;
(k) make suitable arrangements for the safe disposal of general and clinical waste;
(l) provide a place where the money and valuables of residents may be deposited for safe keeping, and make arrangements for residents to acknowledge in writing the deposit and return to them of any money or valuables;
(m) consult residents about their social interests, and make arrangements to enable them to engage in local, social and community activities and to visit, or maintain contact or communicate with, their families and friends;
(n) where activities are provided by or on behalf of the home including training, occupation and recreation, there are arrangements to ensure that –
(i) activities are planned and provided with regard to the needs of the residents; and
(ii) residents are consulted about the planned programme of activities.
3 The registered person shall ensure that so far as practicable residents have the opportunity to attend religious services of their choice

19 Records
1 The registered person shall –
(a) maintain in respect of each resident a record which includes the information, documents and other records specified in Schedule 3 relating to the resident;
(b) ensure that the record referred to in sub-paragraph (a) is kept securely in the residential care home.
2 The registered person shall maintain in the home the records specified in Schedule 4.
3 The registered person shall ensure that the records referred to in paragraphs (1) and (2) –
(a) are kept up to date; and
(b) are at all times available for inspection in the home by any person authorised by the Regulation and Improvement Authority to enter and inspect the home; and
(c) ensure that residents are aware of arrangements to access their personal records.
4 The records referred to in paragraphs (1) and (2) shall be retained for not less than 6 years from the date of the last entry.
5 The registered person shall ensure that information about a resident’s health and treatment is handled confidentially and is only disclosed to those persons who need to be aware of that information in order to treat the resident effectively or minimise any risk of the resident harming himself or another person, or for the purpose of the proper administration of the home.

20 Staffing
1 The registered person shall, having regard to the size of the residential care home, the statement of purpose and the number and needs of residents –
(a) ensure that at all times suitably qualified, competent and experienced persons are working at the home in such numbers as are appropriate for the health and welfare of residents;
(b) ensure that the employment of any persons on a temporary basis at the home will not prevent residents from receiving such continuity of care as is reasonable to meet their needs;
(c) ensure that the persons employed by the registered person to work at the home receive –
(i) appraisal, mandatory training and other training appropriate to the work they are to perform; and
(ii) are supported to maintain their registration with the appropriate regulatory or occupational body; and
(iii) are enabled from time to time to obtain training and/or further qualifications appropriate to the work they perform; and
(iv) are provided with a job description outlining their responsibilities.
2 The registered person shall ensure that persons working at the home are appropriately supervised.
3 The registered manager shall carry out a competency and a capability assessment with any person who is given the responsibility of being in charge of the home for any period of time in his absence.

21 Fitness of workers
1 The registered person shall not employ a person to work at the residential care home unless –
(a) the person is fit to work at the home;
(b) subject to paragraph (5), he has obtained in respect of that person the information and documents specified in paragraphs 1 to 7 of Schedule 2;
(c) he is satisfied on reasonable grounds as to the authenticity of the references referred to in paragraph 3 of Schedule 2 in respect of that person.
2 Paragraph 1 applies to a person who is employed by a person (“the employer”) other than the registered person.
3 Paragraph 1 applies to a position in which a person may in the course of his duties have regular contact with residents at the home.
4 The registered person shall not allow a person to whom paragraph (2) applies to work at the home in a position to which paragraph (3) applies, unless –
(a) the person is fit to work at the home;
(b) the employer has obtained in respect of that person the information and documents specified in –
(i) paragraphs 1 to 7 of Schedule 2; and has confirmed in writing to the registered person that he has done so; and
(c) the employer is satisfied on reasonable grounds as to the authenticity of the references referred to in paragraph 3 of Schedule 2 in respect of that person, and has confirmed in writing to the registered person that he is so satisfied.
5 For the purposes of paragraphs (1) and (4), a person is not fit to work at a home unless –
(a) he is of integrity and good character;
(b) he has qualifications or training suitable to the work that he is to perform, and the skills and experience necessary for such work;
(c) he is physically and mentally fit for the purposes of the work he is to perform at the home.
(d) full and satisfactory information is available in relation to him in respect of the following matters –
(i) each of the matters specified in paragraphs 1 to 7 of Schedule 2.
6 The registered person shall ensure that all health care professionals are covered by appropriate professional indemnity.

22 Restrictions on acting for residents
1 Subject to paragraph (2), the registered person shall not pay money belonging to any resident into a bank account unless –
(a) the account is in the name of the resident to which the money belongs; and
(b) the account is not used by the registered person in connection with the carrying on or management of the residential care home.
2 Paragraph (1) does not apply to money which is paid to the registered person in respect of charges payable by a resident for accommodation or other services provided by the registered person at the home.
3 The registered person shall ensure a record is kept of persons working at the home acting as the appointee or agent of a resident.

23 Staff views as to conduct of the home
1 This regulation applies to any matter relating to the conduct of the home so far as it may affect the care, safety or welfare of residents.
2 The registered person shall make arrangements to enable staff to inform the registered person and the Regulation and Improvement Authority and the local HSS Trust in the area of which the home is situated, in confidence of their views about any matter to which this regulation applies.

24 Complaints
1 The registered person shall establish a procedure (“the complaints procedure”) for receiving, managing and responding to complaints made to the registered person by a resident or person acting on the resident’s behalf.
2 The complaints procedure shall be appropriate to the needs of residents.
3 The registered person shall ensure that any complaint made under the complaints procedure is fully investigated.
4 The registered person shall, within 28 days after 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 investigative process, outcome and action (if any) that is to be taken.
5 The registered person shall supply a written copy of the complaints procedure to every resident and to any person acting on behalf of a resident.
6 Where a written copy of the complaints procedure is to be supplied in accordance with paragraph (5) to a person who is blind or whose vision is impaired, the registered person shall so far as it is practicable to do so, supply, in addition to the written copy, a copy of the complaints procedure in a form which is suitable for that person.
7 The copy of the complaints procedure to be supplied in accordance with paragraph (5) shall include –
(a) the name, address and telephone number of the Regulation and Improvement Authority; and
(b) the procedure (if any) that has been notified by the Regulation and Improvement Authority to the registered person for the making of complaints to the Regulation and Improvement Authority relating to the residential care home.
8 The registered person shall supply to the Regulation and Improvement Authority at its request a statement containing a summary of the complaints made during the preceding twelve months and the action that was taken in response.

25 Guidance for social care workers, nurses and health care professionals
The registered person shall ensure that –
(a) the Codes of Practice for Social Care Workers and Employers of Social Care Workers and any other code prepared by the Northern Ireland Social Care Council (NISCC), a Code of Profesional Conduct, Standards for Performance, Conduct and Ethics, and any other code of ethics or professional practice prepared by the Nursing and Midwifery Council or a body which is responsible for regulation of members of a health care profession is made available, as appropriate, in the residential care home;
(b) staff are supported to meet and maintain the standards and requirements of their relevant codes of practice;
(c) appropriate action is taken when staff do not meet the expected standards of conduct in line with the relevant codes of practice.

26 Clinical trials and research
The registered person shall ensure that –
(a) before any research involving residents or information about residents is undertaken in or for the purposes of the residential care home, a research proposal is prepared and approval is obtained from the appropriate Ethics Committee;
(b) any clinical trial to be conducted in the home has been authorised in accordance with the Medicines for Human Use (Clinical Trials) Regulations 2004.
S.I.2004/1031

PART IV PREMISES

27 Fitness of premises
1 Subject to regulation 3(3), the registered person shall not use premises for the purposes of a residential care home unless the premises are suitable for the purpose of achieving the aims and objectives set out in the statement of purpose.
2 The registered person shall, having regard to the number and needs of the residents, ensure that –
(a) the physical design and layout of the premises to be used as the home meets the needs of the residents;
(b) the premises to be used as the home are of sound construction and kept in a good state of repair externally and internally;
(c) equipment provided at the home for use by residents or persons who work at the home is in good working order, properly maintained in accordance with the manufacturer’s guidance and suitable for the purpose for which it is to be used;
(d) all parts of the home are kept clean and reasonably decorated;
(e) adequate private and communal accommodation is provided for residents;
(f) the size and layout of rooms occupied or used by residents are suitable for their needs;
(g) there is adequate seating, recreational and dining space provided separately from the resident’s private accommodation;
(h) the communal space provided for residents is suitable for the provision of social, cultural and religious activities appropriate to the circumstances of residents;
(i) suitable facilities are provided for residents to receive visitors whether in communal areas or in private as the resident chooses;
(j) there are provided at appropriate places in the premises sufficient numbers of lavatories, wash-basins, baths and showers fitted with a hot and cold water supply;
(k) any necessary sluicing facilities are provided;
(l) there is suitable storage provision for the purposes of the home;
(m) suitable storage facilities are provided for the use of residents;
(n) suitable adaptations are made, and such support, equipment and facilities, including passenger lifts, as may be required are provided to meet the needs of residents;
(o) secure and safe outdoor space with seating, accessible to all residents is provided and appropriately maintained;
(p) ventilation, heating, cooling and lighting suitable for residents is provided in all parts of the home which are used by residents;
(q) the engineering services are maintained in good working order;
(r) any vehicle used by the home for transporting residents is suitable for that purpose and maintained in good working order;
(s) provision is made for the home to operate in the event of the breakdown of essential utility services; and
(t) a risk assessment to manage health and safety is carried out and updated when necessary.
3 The registered person shall having regard for the number of staff employed and the duties they undertake, provide–
(a) suitable facilities and accommodation, including –
(i) facilities for the purpose of changing; and
(ii) storage facilities.
4 The registered person shall –
(a) have in place a current written risk assessment and fire management plan that is revised and actioned when necessary or whenever the fire risk has changed;
(b) take adequate precautions against the risk of fire, including the provision of suitable fire equipment;
(c) provide adequate means of escape;
(d) make adequate arrangements –
(i) for detecting, containing and extinguishing fires;
(ii) for giving warnings of fires;
(iii) for the evacuation, in the event of fire, of all persons in the home and safe placement of residents;
(iv) for the maintenance of all fire equipment; and
(v) for reviewing fire precautions, and testing fire equipment, at suitable intervals;
(e) make arrangements for persons working at the home to receive suitable training, from a competent person, in fire prevention; and
(f) to ensure, by means of fire drills and practices at suitable intervals, that the persons working at the home and, so far as practicable, residents, are aware of the procedure to be followed in case of fire, including the procedure for saving life.
5 The registered person shall undertake appropriate consultation with the environmental health department of the district council for the district in which the home is situated.

PART V MANAGEMENT

28 Financial position
1 The registered provider shall carry on the residential care home in such a manner as is likely to ensure that the home 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 Regulation and Improvement Authority so requests, provide such information and documents to the Regulation and Improvement Authority as it may require for the purpose of considering the financial viability of the home, including –
(a) the annual accounts of the home certified by an accountant;
(b) a reference from a bank expressing an opinion as to the registered provider’s financial standing;
(c) information as to the financing and financial resources of the home;
(d) where the registered person is a company, information as to any of its associated companies;
(e) a certificate of insurance for the registered provider in respect of liability which may be incurred by him in relation to the home in respect of death, injury, public liability, damage or other loss.
3 The registered person shall –
(a) ensure that adequate accounts are maintained in respect of the home and kept up to date;
(b) ensure that the accounts give details of the running costs of the home, including rent, payments under a mortgage and expenditure on food, heating and salaries and wages of staff; and
(c) supply a copy of the accounts to the Regulation and Improvement Authority at its request.
4 In this regulation a company is an associated company of another if one of them has control of the other or both are under the control of the same person.

29 Visits by registered provider
1 Where the registered provider is an individual, but not in day-to-day charge of the residential care home, he shall visit the home in accordance with this regulation.
2 Where the registered provider is an organisation or partnership, the home shall be visited in accordance with this regulation by –
(a) the responsible individual or one of the partners, as the case may be;
(b) another of the directors or other persons responsible for the management of the organisation or partnership; or
(c) an employee of the organisation or the partnership who is not directly concerned with the conduct of the home.
3 Visits under paragraph (1) or (2) shall take place at least once a month or as agreed with the Regulation and Improvement Authority and shall be unannounced.
4 The person carrying out the visit shall –
(a) interview, with their consent and in private, such of the residents and their representatives and persons working at the home as appears necessary in order to form an opinion of the standard of provided in the home;
(b) inspect the premises of the home, its record of events and records of any complaints; and
(c) prepare a written report on the conduct of the home.
5 The registered provider shall maintain a copy of the report required to be made under paragraph 4(c) in the home and make it available on request to –
(a) the Regulation and Improvement Authority;
(b) the registered manager;
(c) the resident or their representative; and
(d) an officer of the HSS Trust in the area of which the home is situated.
6 In the case of a visit under paragraph (2) –
(i) where the registered provider is an organisation, to each of the directors or other persons responsible for the management of the organisation; and
(ii) where the registered provider is a partnership, to each of the partners.

PART VI MISCELLANEOUS

30 Notification of death, illness and other events
1 The registered person shall give notice to the Regulation and Improvement Authority without delay of the occurrence of –
(a) the death of any resident, including the circumstances of his death;
(b) the outbreak in the home of any infectious disease which in the opinion of any medical practitioner attending persons in the home is sufficiently serious to be so notified;
(c) any serious injury to a resident in the home;
(d) any event in the home which adversely affects the care, health, welfare or safety of any resident;
(e) any theft or burglary in the home;
(f) any accident in the home;
(g) any allegation of misconduct by the registered person or any person who works at the home.
2 Any notification made in accordance with this regulation which is given orally shall be confirmed in writing within 3 working days of the oral report.

31 Notice of absence
1 Where –
(a) the registered provider, if he is an individual; or
(b) the registered manager;
proposes to be absent from the home for a continuous period of 28 days or more, the registered person shall give notice in writing to the Regulation and Improvement Authority of the proposed absence.
2 Except in the case of an emergency, the notice referred to in paragraph (1) above shall be given no later than 28 days before the proposed absence commences or within such shorter period as may be agreed with the Regulation and Improvement Authority 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 the running of the home during that absence;
(d) the name, address and qualifications of the person who will be responsible for the home 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 home 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 mentioned in sub-paragraphs (a) to (e) of paragraph (2).
4 Where –
(a) the registered provider, if he is an individual; or
(b) the registered manager;
has been absent from the home for a continuous period of 28 days or more, and the Regulation and Improvement Authority has not been given notice of the absence, the registered person shall without delay give notice in writing to the Regulation and Improvement Authority of the absence, specifying the matters mentioned in sub-paragraphs (a) to (e) of paragraph (2).
5 The registered person shall notify the Regulation and Improvement Authority 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.

32 Notice of changes
1 The registered person shall give notice in writing to the Regulation and Improvement Authority as soon as it is practicable to do so, if any of the following events is proposed to take place –
(a) a person other than the registered person carries on or manages the residential care home;
(b) a person ceases to carry on or manage the home;
(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;
(iii) there is to be any change of responsible individual;
(f) where the registered provider is an individual, a trustee in bankruptcy is appointed;
(g) where the registered provider is a company or partnership, a receiver, manager, liquidator or provisional liquidator is appointed; or
(h) the premises of the home are significantly altered or extended, or additional premises are acquired.

33 Notice of termination of accommodation
1 Subject to paragraph (2), the registered person shall not terminate the arrangements for the accommodation of a resident unless he has given reasonable notice of his intention to do so to –
(a) the resident;
(b) the person who appears to be the resident’s next of kin; and
(c) where a HSS Trust has made arrangements for the provision of accommodation, board and personal care to the resident at the residential care home, that Trust.
2 If it is impracticable for the registered person to comply with the requirement in paragraph (1) –
(a) he shall do so as soon as it is practicable to do so; and
(b) he shall provide to the Regulation and Improvement Authority a statement as to the circumstances which made it impracticable for him to comply with the requirement.

34 Appointment of liquidators etc.
1 Any person to whom paragraph (2) applies must –
(a) forthwith notify the Regulation and Improvement Authority of his appointment, indicating the reasons for it;
(b) appoint a manager to take full-time day-to-day charge of the residential care home in any case where there is no registered manager; and
(c) within 28 days of his appointment notify the Regulation and Improvement Authority of his intentions regarding the future operation of the home.
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 a home;
(b) a liquidator or provisional liquidator of a company which is a registered provider of a home; or
(c) the trustee in bankruptcy of a registered provider of a home.

35 Death of registered person
1 If more than one person is registered in respect of a residential care home, and a registered person dies, the surviving registered person shall without delay notify the Regulation and Improvement Authority of the death in writing.
2 If only one person is registered in respect of a home, and he dies, his personal representatives shall notify the Regulation and Improvement Authority in writing –
(a) without delay of the death; and
(b) within 28 days of their intentions regarding the future running of the home.
3 The personal representatives of the deceased registered provider may carry on the home 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 Regulation and Improvement Authority may extend the period specified in paragraph (3)(a) by such further period, not exceeding one year, as the Regulation and Improvement Authority 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 home during any period in which, in accordance with paragraph (3), they carry on the home without being registered in respect of it.

36 Offences
1 A contravention or failure to comply with any of the provisions of regulations 3, 4, 5, 11, 12, 13(1) to (4) and (7) to (9), 14, 15 to 17, 18(1), (2)(a) to (i) and (k) to (n) and (3), 19 to 24, 27 to 33, shall be an offence.
2 The Regulation and Improvement Authority shall not bring proceedings against a person in respect of any contravention or failure to comply with 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, has expired; and
(d) the person contravenes any of the provisions of the regulations mentioned in the notice.
3 Where the Regulation and Improvement Authority 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 the requirements of any of the regulations;
(b) what action, in the opinion of the Regulation and Improvement Authority, the registered person should take so as to comply with any of those regulations; and
(c) the period, not exceeding three months, within which the registered person should take action.
4 The Regulation and Improvement Authority 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 19 and for this purpose, references in paragraphs (2) and (3) to a registered person shall be taken to include such a person.

Compliance with regulations
37 Where there is more than one registered person in respect of a home, 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.
38 The Residential Care Homes Regulations (Northern Ireland) 1993 and the Residential Care Homes (Amendment) Regulations (Northern Ireland) 1998, are hereby revoked.
S.R. 1993 No. 91
S.R. 1998 No. 139
Sealed with Official Seal of the Department of Health, Social Services and Public Safety on 23rd March 2005.
N. McCann Senior Officer of the Department of Health, Social Services and Public Safety

SCHEDULE 1 INFORMATION TO BE INCLUDED IN THE STATEMENT OF PURPOSE
Regulation 3(1)(c)
1 The name and address of the registered provider and of any registered manager.
2 The relevant qualifications and experience of the registered provider and any registered manager.
3 The number, relevant qualifications and experience of the staff working at the residential care home.
4 The philosophy of care.
5 The status and constitution of the home.
6 The organisational structure of the home.
7 The number of residents to be accommodated or provided with services.
8 The range of needs, (categories of care) that the home is intended to meet and the number in each category.
9 Any criteria used for admission to the home, including the home’s policy and procedures (if any) for emergency admissions.
10 The arrangements for residents to engage in social activities, hobbies and leisure interests.
11 The arrangements made for consultation with residents about the operation of the home.
12 The fire precautions and associated emergency procedures in the home.
13 The arrangements made, so far as is practicable that residents have the opportunity to attend religious services of their choice.
14 The arrangements made for contact between residents and their relatives, friends, representatives, and the local community where practicable.
15 The arrangements for dealing with complaints.
16 The arrangements made for dealing with reviews of the resident’s care plan referred to in regulation 16(1).
17 The number and size of rooms in the home.
18 Details of any specific therapeutic techniques used in the home and arrangements made for their supervision.
19 The arrangements made for respecting the privacy and dignity of residents.

SCHEDULE 2 INFORMATION AND DOCUMENTS TO BE OBTAINED IN RESPECT OF PERSONS CARRYING ON, MANAGING OR WORKING AT A RESIDENTIAL CARE HOME
Regulation 7, 9, 21
1 Proof of the person’s identity, including a recent photograph.
2 Either –
(a) where a certificate is required for a purpose relating to registration under Part III of the Order, or the position falls within section 115(3) or (4) of that Act, an enhanced criminal record certificate issued under section 115 of the Police Act 1997;
1997 c. 50
(b) in any other case, a criminal certificate issued under section 113 of that Act, including, where applicable, the matters specified in sections 113(3EA) and 115(6EA) of that Act and the following provisions once they are in force, namely section 113(3EC)(a) and (b) and section 115(6EB) (a) and (b) of that Act.
Section 113(3EA) and 115(6EA) are inserted by S.I.2003/417 (N.I. 4) Article 17
Section 113(3EC) and 115(6EB) are inserted by S.I.2003/417 (N.I. 4) Article 47
3 Two written references relating to the person, including a reference from the person’s present or most recent employer, if any.
4 Where a person has previously worked in a position whose duties involved work with children or vulnerable adults, so far as is reasonably practicable, verification of the reason why the employment ot position ended.
5 Details and documentary evidence of any relevant qualifications or accredited training of the person and if applicable, registration with an appropriate professional regulatory body.
6 A full employment history, together with a satisfactory written explanation of any gaps in employment.
7 Evidence that the person is physically and mentally fit for the purposes of the work which he is to perform at the home or, where it is impracticable for the person to obtain such evidence, a declaration signed by the person that he is so fit.

SCHEDULE 3 RECORDS TO BE KEPT IN A RESIDENTIAL CARE HOME IN RESPECT OF EACH RESIDENT
Regulation 19(1)(a)
1 The following documents in respect of each resident –
(a) the assessment of needs and associated care plan, referred to in regulation 15(1);
(b) the resident’s care plan referred to in regulation 16(1).
2 A recent photograph of the resident.
3 A record of the following matters in respect of each resident –
(a) the name, address, date of birth and marital status of each resident;
(b) the name, address and telephone number of the resident’s next of kin or of any person authorised to act on his behalf;
(c) the name, address and telephone number of the resident’s general practitioner and of any officer of a HSS Trust whose duty it is to supervise the welfare of the resident;
(d) the date on which the resident was admitted to the residential care home;
(e) the date on which the resident was discharged from the home;
(f) if the resident is transferred to another home, nursing home or to a hospital, the name of the home or hospital and the date on which the resident is transferred;
(g) if the resident died at the home, the date and time of death;
(h) the name and address of any HSS Trust, organisation or other body, which arranged the resident’s admission to the home;
(i) a record of all medicines kept in the home for the resident, and the date on which they were administered to the resident;
(j) a record of any accident affecting the resident in the home and of any other incident in the home which is detrimental to the care, health, safety or welfare of the resident, which record shall include the nature, date and time of the accident or incident, whether medical treatment was required and the name of the individuals who were supervising the resident;
(k) a contemporaneous note of all care and services provided to the resident, including a record of his condition and any treatment or other intervention;
(l) details of any specialist communications needs of the resident and methods of communication that may be appropriate to the resident;
(m) details of any health care plan relating to the resident in respect of medication, specialist health care provision or nutrition;
(n) the wishes of the resident regarding any specific arrangements at the time of death;
(o) a record of falls and of treatment provided to the resident;
(p) a record of incidence of pressure ulcers and of treatment provided to the resident;
(q) a record of any restraint used in relation to the resident;
(r) a record of any limitations agreed with the residents to the resident’s freedom of choice, liberty of movement and power to make decisions.
4 A copy of correspondence relating to each resident.

SCHEDULE 4 OTHER RECORDS TO BE KEPT IN A RESIDENTIAL CARE HOME
Regulation 19(2)
1 A copy of the statement of purpose.
2 A copy of the resident’s guide.
3 A record of all accounts relating to the residential care home including a record of resident’s fees and financial arrangements that are handled by the home and a record of persons working at the home acting as the appointee or agent of a resident.
4 A copy of all inspection reports.
5 A copy of any report made under regulation 29(4)(c) or a copy of any written record or report made under regulation 30.
6 A record of all persons employed at the home, which includes in respect of each person so employed –
(a) his full name, address, date of birth, qualifications and experience and if applicable, confirmation of his registration status with an appropriate professional regulatory body;
(b) a copy of his birth certificate and passport (if any);
(c) a copy of each reference obtained in respect of him;
(d) the dates on which he commences and ceases to be so employed;
(e) the position he holds at the home, the work that he performs and the number of hours for which he is employed each week;
(f) correspondence, reports, records of disciplinary action and any other records in relation to his employment including the recruitment process under which he was appointed.
(g) the training and development activities completed by him.
7 A copy of the duty roster of persons working at the home, and a record of whether the roster was actually worked.
8 A record of the home’s charges to residents, including any separate amounts payable for additional services not covered by those charges, and the amounts paid by or in respect of each resident.
9 A record of all money or other valuables deposited by a resident for safekeeping or received on the resident’s behalf, which –
(a) shall state the date on which the money or valuables were deposited or received, the date on which any money or valuables were returned to a resident or used, at the request of the resident, on his behalf and, where applicable, the purpose for which the money or valuables were used; and
(b) shall include the written acknowledgement of the return of the money or valuables.
10 A record of furniture and personal possessions brought by a resident into the room occupied by him.
11 A record of all complaints made by residents or representatives or relatives of residents or by persons working at the home about the operation of the home, and the action taken by the registered person in respect of any such complaint.
12 A record of any of the following events that occur in the home –
(a) any accident;
(b) any incident which is detrimental to the care, health, safety or welfare of a resident, including the outbreak of infectious disease in the home;
(c) any injury or serious illness;
(d) any fire;
(e) except where a record to which paragraph 14 refers is to be made, any occasion on which the fire alarm equipment is operated;
(f) any theft or burglary.
13 Records of the food provided for residents in sufficient detail to enable any person inspecting the record to determine whether the diet is satisfactory, in relation to nutrition and otherwise, and of any special diets prepared for individual residents.
14 A record of every fire practice, drill or test of fire equipment (including fire alarm equipment) conducted in the home, including staff attending, and of any action taken to remedy defects in the fire equipment.
15 A statement of the procedure to be followed in the event of a fire, or where a fire alarm is activated.
16 A statement of the procedure to be followed in the event of accidents or in the event of a resident becoming missing.
17 A record of charges made to residents for transport and the amounts paid by or in respect of each resident.
18 Where residents collectively own the vehicles –
(a) a record is kept with the amounts paid by or in respect for each resident running the vehicle;
(b) a record is kept of journeys made and names of residents being transported.
19 A record of the programme of events and activities that includes the name of the person leading the activity and the names of those who participated.
20 A record of all staff meetings held and the names of all those attending.
21 A record of training undertaken as referred to in Regulation 20(1)(c)(i).
22 A record of all visitors to the home, including the names of all visitors.

(This note is not part of the Regulations.)
These Regulations are made under the Health and Personal Social Services (Quality, Improvement and Regulation) (Northern Ireland) Order 2003. Part II of the Order establishes the Northern Ireland Health and Personal Social Services Regulation and Improvement Authority (“the Regulation and Improvement Authority”) and Part III provides for the registration and inspection of establishments and agencies, including residential care homes, by the Regulation and Improvement Authority. It also provides powers for regulations governing the conduct of establishments and agencies.
These new arrangements replace the regulatory system provided for in relation to residential care homes by the Registered Homes (Northern Ireland) Order 1992. Under regulation 3, 4 and 5, each home must have a statement of purpose consisting of the matters set out in Schedule 1, and supply a guide of the home to each resident together with a statement giving information about fees payable.
Regulations 7 to 10 make provision about the fitness of the persons carrying on and managing the home, and require satisfactory information to be available in relation to certain specified matters. Where an organisation carries on the home, it must nominate a responsible individual in respect of whom this information must be available (regulation 7). Regulation 8 prescribes the circumstances where a manager must be appointed for the home, and regulation 10 imposes general requirements in relation to the proper conduct of the home, and the need for appropriate training. Regulation 17 requires the registered person to establish a system for reviewing and improving the quality of care and other service provision provided by the home.
Part III makes provision about the conduct of residential care homes, in particular as to the care, health, safety, welfare and protection of residents, and as to the facilities and services that are to be provided. Provision is also made about record keeping, the staffing of homes, the fitness of workers, and about complaints.
Part IV makes provision about the suitability of premises and fire precautions to be taken. Part V deals with the management of homes. Regulation 28 imposes requirements relating to the home’s financial position. Regulation 29 requires the registered person to visit the home as prescribed.
Part VI deals with miscellaneous matters including the giving of notices to the Regulation and Improvement Authority. Regulation 36 provides for offences. A breach of the regulations specified in regulation 36 may found an offence on the part of the registered person. However, no prosecution may be brought unless the Regulation and Improvement Authority has first given the registered person a notice which sets out in what respect it is alleged he is not complying with a regulation, and what action the Regulation and Improvement Authority considers it is necessary for him to take in order to comply. The notice must specify a time period for compliance, not exceeding three months.