Regulation 19 Assessing and monitoring the quality of service provision including annual returnsI1

England and Wales

(1)

The registered person must protect patients, and others who may be at risk, against the risks of inappropriate or unsafe care and treatment, by means of the effective operation of systems designed to enable the registered person to—

(a)

regularly assess and monitor the quality of the services provided in the carrying on of the establishment or agency against the requirements set out in these Regulations; and

(b)

identify, assess and manage risks relating to the health, welfare and safety of patients and others.

(2)

For the purposes of paragraph (1), the registered person must—

(a)

where appropriate, obtain relevant professional advice;

(b)

have regard to—

(i)

the complaints and comments made, and views (including the descriptions of their experiences of care and treatment) expressed, by patients, and those acting on their behalf, pursuant to sub-paragraph (e) and regulation 24;

(ii)

any investigation carried out by the registered person in relation to the conduct of a person employed for the purpose of carrying on the establishment or agency;

(iii)

the information contained in the records referred to in regulation 23;

(iv)

appropriate professional and expert advice (including any advice obtained pursuant to sub-paragraph (a));

(v)

reports prepared by the registration authority from time to time pursuant to section 32(5) of the Act in relation to the establishment or agency;

(c)

where necessary, make changes to the treatment or care provided in order to reflect information, of which it is reasonable to expect that a registered person should be aware, relating to—

(i)

the analysis of incidents that resulted in, or had the potential to result in, harm to a patient; and

(ii)

the conclusions of local and national service reviews, clinical audits and research projects carried out by appropriate expert bodies;

(d)

establish mechanisms for ensuring that decisions in relation to the provision of care and treatment for patients are taken at the appropriate level and by an appropriate person; and

(e)

regularly seek the views (including the descriptions of their experiences of care and treatment) of patients, persons acting on their behalf, persons who are employed for the purposes of the establishment or agency and any medical practitioner with practising privileges, to enable the registered person to come to an informed view in relation to the standard of care and treatment provided to patients.

(3)

The registered person must send to the appropriate office of the registration authority, when requested to do so, a written annual assessment (referred to as the “annual return”) setting out how, and the extent to which, in the opinion of the registered person, the requirements of paragraph (1) are being complied with in relation to the establishment or agency, together with any plans that the registered person has for improving the standard of the services provided to patients with a view to ensuring their health and welfare.

(4)

The registered person must take reasonable steps to ensure that the annual return is not misleading or inaccurate.

(5)

The registered person must supply the annual return to the appropriate office of the registration authority within 28 days of receiving a request under paragraph (3).

Annotations

Commencement

I1: Reg. 19 in force at 5.4.2011, see reg. 1(1)