Private and Voluntary Health Care (Wales) Regulations 2002

Policies and procedures

8.—(1) The registered person shall 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—

(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 admits in-patients, 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;

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

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

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

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

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

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

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

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

(b) in the case of a competent patient, properly informed written consent to treatment is obtained before any proposed treatment is administered;

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

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

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

(a) this regulation;

(b) regulation 22; and

(c) in so far as they apply to the registered person regulations 34, 40 (10), 44 and 45;

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

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