Policies and procedures
9.—(1) The registered person must prepare and implement written statements of the policies to be applied and the procedures to be followed in or for the purposes of an establishment in relation to each of the matters specified below and for the purposes of an agency each of the matters specified in sub-paragraphs (b), (d), (f), (g), (h), (i), (m) and (n)—
(a)the arrangements for admission or acceptance of patients, their transfer to a hospital, including to a health service hospital, where required and, in the case of an establishment which has approved places, their discharge;
(b)the arrangements for assessment, diagnosis and treatment of patients;
(c)ensuring that the establishment premises are at all times fit for the purpose for which they are used;
(d)monitoring the quality and suitability of facilities and equipment, including maintenance of such equipment;
(e)identifying, assessing and managing risks associated with the operation of the establishment to employees, patients, visitors and those working in or for the purposes of the establishment;
(f)the creation, management, handling and storage of records and other information;
(g)the provision of information to patients and others;
(h)the recruitment, induction and retention of employees and their employment conditions;
(i)ensuring safe recruitment of staff including undertaking checks appropriate to the work that staff are to undertake;
(j)ensuring that, where research is carried out in an establishment, it is carried out with the consent of any patient or patients involved, is appropriate for the establishment concerned and is conducted in accordance with up-to-date and authoritative published guidance on the conduct of research projects;
(k)the arrangements for ensuring the health and safety of staff and patients;
(l)the safe keeping of patient property and possessions in an establishment in cases where such property or possessions have been removed from the patient as they may put the patient at risk of harm;
(m)the ordering, recording, administration and supply of medicines to patients;
(n)the arrangements relating to infection control including hand hygiene, safe handling and disposal of clinical waste, housekeeping and cleaning regimes and relevant training and advice;
(o)the arrangements for clinical audit; and
(p)the granting, and withdrawal, of practising privileges to medical practitioners in establishments where such privileges are or may be granted.
(2) The registered person must prepare and implement a written policy setting out—
(a)how disturbed behaviour exhibited by a patient is to be managed;
(b)permitted measures of restraint and the circumstances in which they may be used;
(c)requirements for employees to report serious incidents of violence or self harm, including guidance as to how those incidents should be classified; and
(d)the procedure for review of such incidents and determination of the action which is to be taken subsequently.
(3) The written statements and policies referred to in paragraphs (1) and (2) must be prepared having regard to the size of the establishment or agency, the statement of purpose and the number and needs of the patients.
(4) The registered person must prepare and implement written statements of policies to be applied and procedures to be followed in or for the purposes of an establishment or agency which ensure that—
(a)the capacity of each patient to consent to treatment is assessed;
(b)in the case of a patient who has capacity, properly informed, and where appropriate, written consent to treatment is obtained before any proposed treatment is administered;
(c)in the case of a patient who lacks capacity the requirements of the 2005 Act are complied with before any treatment proposed for him is administered;
(d)national and best practice guidance is taken into account; and
(e)information about a patient’s health and treatment is disclosed only to those persons who need to be aware of that information in order to treat the patient effectively or minimise any risk of the patient harming himself or herself or another person, or for the purpose of the proper administration of the establishment.
(5) The registered person must review the operation of policies and procedures implemented under—
(a)this regulation;
(b)regulation 24; and
(c)in so far as they apply to the registered person, regulations 38, 44 (7) and 48;
at intervals of not more than three years and, where appropriate, revise and implement those policies and procedures.
(6) The registered person must retain copies of all policies and procedures referred in this regulation, including previous versions of policies and procedures that have been revised in accordance with paragraph (5), for a period of not less than three years from the date of creation or revision of the policy or procedure.
(7) The registered person must make a copy of all written statements prepared in accordance with this regulation available for inspection by the registration authority.