The Nursing Agencies Regulations (Northern Ireland) 2005

© Crown Copyright 2005

Statutory Rules of Northern Ireland printed from this website are printed under the superintendence and authority of the Controller of HMSO being the Government Printer for Northern Ireland.

The legislation contained on this web site is subject to Crown Copyright protection. It may be reproduced free of charge provided that it is reproduced accurately and that the source and copyright status of the material is made evident to users.

It should be noted that the right to reproduce the text of Statutory Rules of Northern Ireland does not extend to the Government Printer for Northern Ireland imprints which should be removed from any copies of the Statutory Rule which are issued or made available to the public. This includes reproduction of the Statutory Rule on the Internet and on intranet sites. The Royal Arms may be reproduced only where they are an integral part of the original document.

The text of this Internet version of the Statutory Rule which is published by the Government Printer for Northern Ireland has been prepared to reflect the text as it was Made. A print version is also available and is published by The Stationery Office Limited as the The Nursing Agencies Regulations (Northern Ireland) 2005, ISBN 0337959854. The print version may be purchased by clicking here. Braille copies of this Statutory Rule can also be purchased at the same price as the print edition by contacting TSO Customer Services on 0870 600 5522 or e-mail: customer.services@tso.co.uk.

Further information about the publication of legislation on this website can be found by referring to the Frequently Asked Questions.

To ensure fast access over slow connections, large documents have been segmented into "chunks". Where you see a "continue" button at the bottom of the page of text, this indicates that there is another chunk of text available.

"health care professional" means a member of a profession which is regulated by a body mentioned (at the time the agreement is made) in section 25(3) of the National Health Service Reform and Health Care Professions Act 2002[2];

"holistic care" means the care provided by a multi-professional team working together to meet physical, psychological, social, religious and cultural needs of patients;

"inspector" means a person authorised by the Regulation and Improvement Authority to enter and inspect premises which are used, or which he has reasonable cause to believe to be used, as an establishment or for the purposes of an agency;

"local supervising authority" means a HSS Board in relation to which area the nursing agency operates;

"nurse" means a person registered in the register maintained under Article 5 of the Nursing and Midwifery Order 2001[3] by virtue of qualifications in nursing or midwifery, as the case may be;

"organisation" means a body corporate or any unincorporated association other than a partnership;

"patient" means a person to whom nursing is provided by a nurse supplied by an agency;

"registered manager", in relation to an agency, means a person who is registered under Part III of the Order as the manager of that agency;

"registered person", in relation to an agency, means any person who is the registered provider or the registered manager of that agency;

"registered provider", in relation to an agency, means a person who is registered under Part III of the Order as the person carrying on that agency;

"responsible individual" shall be construed in accordance with regulation 7;

"service user" means a person to whom an agency -

(a) supplies a nurse who is employed by the agency; or

(b) provides services for the purpose of supplying the service user with a nurse for employment by that service user;

"service user's guide" means the written guide produced in accordance with regulation 5;

"social care worker" has the same meaning as in section 2(2) of the Health and Personal Social Services Act (Northern Ireland) 2001[4];

"statement of purpose" means the written statement compiled in accordance with regulation 4.

    (2) In these Regulations, references to the supply of a nurse mean -

(a) the supply of a nurse who is employed for the purposes of an agency to act for and under the control of another person; and

(b) the introduction of a nurse by an agency to a service user for employment by that service user.

    (3) In the definition of "service user" in paragraphs (1) and (2), the terms "employed" and "employment" include employment under a contract for services.

Excepted agencies
     3. For the purposes of the Order, an HSS trust which supplies nurses to work solely for other HSS trusts shall be excepted from being a nursing agency.

Statement of purpose
     4.  - (1) The registered person shall compile in relation to the agency a written statement which shall consist of 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 on request for inspection by every service user and any person acting on behalf of a service user.

    (3) Nothing in regulation 21 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.

Service user's guide
     5.  - (1) The registered person shall prepare a service user's guide which shall include -

(a) a summary of the statement of purpose;

(b) the terms and conditions in respect of the services to be provided to service users, including as to the amount and method of payment of fees;

(c) a summary of the complaints procedure established in accordance with regulation 19; and

(d) details of how patients can engage with inspectors, including the address and telephone number of the Regulation and Improvement Authority.

    (2) The registered person shall make a copy of the service user's guide available on request by every service user and any person acting on behalf of a service user.

Review of statement of purpose and service user's guide
     6. The registered person shall -

(a) keep under review and, where appropriate, revise the statement of purpose and the service user's guide; and

(b) notify the Regulation and Improvement Authority of any material revision within 28 days.

Appointment of manager
     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.

    (2) Where the registered provider appoints a person to manage the agency, 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.

Fitness of manager
     9.  - (1) A person shall not manage an agency unless he is fit to do so.

    (2) A person is not fit to manage an agency unless -

(a) he is of integrity and good character;

(b) having regard to the size of the agency, its statement of purpose and the number and needs of the service users -


(i) he is a nurse;

(ii) he has the qualifications, knowledge, skills and competencies necessary to manage the agency; and

(iii) he is physically and mentally fit to do so; and



(c) full and satisfactory information is available in relation to him in respect of each of the matters specified in Schedule 2.

Registered person - general requirements and training
     10.  - (1) The registered provider and the registered manager shall, having regard to the size of the agency, its statement of purpose and the number and needs of the service users, carry on or (as the case may be) manage the agency 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; or

(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 agency.

    (3) The registered manager shall undertake from time to time such training as is appropriate to ensure that he has -

(a) the experience and skills necessary for managing the agency; and

(b) appropriate supervision and performance appraisal skills.

Notification of offences
     11. Where the registered person or the responsible individual is convicted of any criminal offence, whether in Northern Ireland or elsewhere, he shall forthwith give notice in writing to the Regulation and Improvement Authority of -

(i) the date and place of the conviction;

(ii) the offence of which he was convicted; and

(iii) the penalty imposed on him in respect of the offence.

    (2) The registered person shall ensure that the recruitment process for the supply of nurses is managed by a nurse, that selection of a nurse for supply is made by a nurse and that full and satisfactory information in respect of each of the matters listed in Schedule 2 is available in relation to the nurse carrying out the selection.

    (3) The registered person shall ensure that every nurse supplied by the agency acting as an employment business is instructed that when working for a service user he must at all times wear identification showing his name, signature, the name of the agency, contact number, a recent photograph and the expiry date of the card.

Notification of incidents
     13. Where an agency acting as an employment business supplies a nurse to provide nursing care in the private residence of a service user or patient, the registered person shall notify the Regulation and Improvement Authority of any incident reported to the police not later than 24 hours after the registered person -

(i) has reported the matter to the police;

(ii) is informed that the matter has been reported to the police.

Staffing
     14.  - (1) Where an agency is acting as an employment business, the registered person shall, having regard to the size of the agency, its statement of purpose and the number and needs of the service users, take all reasonable measures to ensure that there is at all times an appropriate number of suitably qualified, skilled and experienced persons employed for the purposes of the agency.

    (2) The registered person shall ensure that each employee of the agency -

(a) receives appropriate supervision; and

(b) is provided with a job description outlining his responsibilities.

    (3) The registered person shall -

(i) collect information from service users about performance of nurses employed for the purposes of the agency; and

(ii) take such steps as may be necessary to address any aspect of a nurse's clinical practice.

    (4) The registered person shall provide to each nurse who is employed for the purposes of the agency a written statement of the terms and conditions on which he will be supplied to work for, and under the control of, a service user.

    (5) The statement of terms and conditions provided under paragraph (4) shall, in particular, specify the employment status of the nurse.

Staff handbook
     15.  - (1) Where the agency is acting as an employment business, the registered person shall prepare a staff handbook and provide a copy to every member of staff.

    (2) The handbook prepared in accordance with paragraph (1) shall include a statement as to -

(a) the conduct expected of staff, and disciplinary action which may be taken against them;

(b) the role and responsibilities of nurses and other staff;

(c) record keeping requirements;

(d) recruitment procedures; and

(e) training and development requirements and opportunities.

Provision of information to service users
     16.  - (1) The registered person shall ensure that before a nurse is supplied, the service user is informed of -

(a) the name of the nurse who is to be supplied and the means of contacting him;

(b) the name of the member of staff of the agency who is responsible for the supply of that nurse; and

(c) where the agency is acting as an employment business, details of how the service user may contact the registered person, or a person nominated to act on behalf of the registered person.

    (2) Where the service user is also the patient, the registered person shall ensure that the information specified in paragraph (1) is, where appropriate, provided to the person acting on behalf of the patient.

Disclosure of information
     17. The registered person shall ensure that any personal information about a patient for whom a nurse is supplied by the agency is not disclosed to any member of the agency's staff unless it is necessary to do so in order to provide an effective service to the patient.

Records
     18. The registered person shall ensure that the records specified in Schedule 4 are maintained, are available at all times for inspection and that they are -

(a) kept up to date, in good order and in a secure manner; and

(b) retained for a period of not less than eight years beginning on the date of the last entry.

Complaints
     19.  - (1) The registered person shall establish a procedure ("the complaints procedure") for considering complaints made to the registered person by a service user or a person acting on behalf of the service user.

    (2) The registered person shall supply a written copy of the complaints procedure to every service user and, upon request, to any person acting on behalf of a service user.

    (3) The written copy of the complaints procedure shall include -

(a) the address and telephone number of the Regulation and Improvement Authority; and

(b) the procedure (if any) which has been notified by the Regulation and Improvement Authority to the registered person for making complaints to the Regulation and Improvement Authority relating to the agency.

    (4) The registered person shall ensure that every complaint made under the complaints procedure is fully investigated.

    (5) The registered person shall, within the period of 28 days beginning on and including 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 action (if any) that is to be taken in response.

    (6) The registered person shall maintain a record of each complaint, including details of the investigation made, the outcome and any action taken in consequence and the requirements of regulation 18 shall apply to that record.

    (7) The registered person shall supply to the Regulation and Improvement Authority annually a statement containing a summary of the complaints made during the preceding twelve months and the action taken in response.

    (8) The registered person shall ensure that any evidence of misconduct by a nurse is reported promptly and in writing to the Nursing and Midwifery Council[5].

Review of quality of service provision
     20.  - (1) The registered person shall introduce and maintain a system for reviewing at appropriate intervals the quality of services provided by the agency.

    (2) The registered person shall supply to the Regulation and Improvement Authority a report in respect of any review conducted by him for the purposes of paragraph (1) and shall make a copy of the report available upon request for inspection by service users and persons acting on behalf of service users.

    (3) The system referred to in paragraph (1) shall provide for consultation with service users and persons acting on behalf of service users.

    (4) The registered manager shall ensure that the agency delivers services effectively on a daily basis and reports as required to the registered person.

has been absent from the agency 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 set out in paragraph (2)(a) to (e).

    (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.

Notice of changes
     24. 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 takes place or is proposed to take place -

(a) a person other than the registered person carries on or manages the agency;

(b) a person ceases to carry on or manage the agency;

(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; or

(iii) there is any change in the identity of the 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) where the registered provider acquires additional premises for the purposes of the agency.

Appointment of liquidators etc.
     25.  - (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 agency in any case where there is no registered manager; and

(c) not more than 28 days after his appointment, notify the Regulation and Improvement Authority of his intentions regarding the future operation of the agency.

    (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 an agency;

(b) the liquidator or provisional liquidator of a company which is the registered provider in respect of an agency; or

(c) the trustee in bankruptcy of a registered provider in respect of an agency.

Death of registered person
     26.  - (1) If more than one person is registered in respect of an agency, 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 an agency, and he dies his personal representatives must 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 agency.

    (3) The personal representatives of the deceased registered provider may carry on the agency 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 agency during any period in which, in accordance with paragraph (3), they carry on the agency without being registered in respect of it.

    (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 18 and for this purpose, references in paragraphs (2) and (3) to a registered person shall be taken to include such a person.

Revocations
     29. The Nursing Agency (Northern Ireland) Regulations 1986[6] are hereby revoked.



Sealed with the Official Seal of the Department of Health, Social Services and Public Safety on


25th March 2005.

L.S.

Noel McCann
A senior officer of the Department of Health, Social Services and Public Safety

(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) of (4) of the Police Act 1997[7] (enhanced criminal record certificates), an enhanced criminal record certificate issued under section 115 of that Act; or

(b) in any other case, a criminal record certificate issued under section 113 of that Act (criminal record certificates),

including, where applicable, the matters specified in sections 113(3EA) and 115(6EA) of that Act[8] and section 113(3EC)(a) and (b) and section 115(6EB)(a) and (b) of that Act[9].

     3. Two written references, including a reference relating to the last period of employment of not less than three months duration.

     4. Where a person has previously worked in a position which involved work with children or vulnerable adults, verification of the reason why he ceased to work in that position, unless it is not reasonably practicable to obtain such verification.

     5. Documentary evidence of any relevant qualifications and training.

     6. A full employment history, together with a satisfactory written explanation of any gaps in employment.

     7. Details of health record.

     8. In respect of a manager to whom regulation 9(2) applies or a nurse to whom regulation 12(3) applies, confirmation of current registration with the Nursing and Midwifery Council[10], including details of the Parts of the register in which the nurse is registered.

     9. Details of any professional indemnity insurance.

(a) of which the person has been convicted, including details of any convictions which are spent within the meaning of Article 3 of the Rehabilitation of Offenders (Northern Ireland) Order 1978[11] (rehabilitated persons and spent convictions) and which may be disclosed by virtue of the Rehabilitation of Offenders (Exceptions) Order (Northern Ireland) 1979[12]; or

(b) in respect of which he has been cautioned by a constable and which, at the time the caution was given, he admitted.

     5. Two written references relating to the person, including a reference from the person's present or most recent employer, if any.

     6. Where a nurse has previously worked in a position which involved work with children or vulnerable adults, verification of the reason why he ceased to work in that position, unless it is not reasonably practicable to obtain such verification.

     7. Documentary evidence of any relevant qualifications and training.

     8. A full employment history, together with a satisfactory written explanation of any gaps in employment and details of any current employment other than for the purposes of the agency.

     9. Details of health record, including immunisation status.

     10. Confirmation of current registration with the Nursing and Midwifery Council, including details of the Part of the register in which the nurse is registered.

     11. Details of any professional indemnity insurance.

     12. In the case of a midwife, evidence that the midwife has notified the local supervising authority's responsible midwifery officer of intention to practice, and that a supervisor of midwives has been identified for the individual midwife.

     13. Either -

(a) where the position falls within section 115(3) or (4) of the Police Act 1997 (enhanced criminal records certificates), and enhanced criminal record certificate issued under section 115 of that Act;

(b) in any other case, a criminal record certificate issued under section 113 of that Act (criminal record certificates),

including, where applicable, the matters specified in sections 113(3EA) and 115(6EA) of that Act and section 113(3EC)(a) and (b) and section 115(6EB)(a) and (b) of that Act.

[2] S.I. 2002 (c. 17)back

[3] S.I. 2002/253back

[4] 2001 c. 3 (N.I.)back

[5] The Nursing and Midwifery Council was established by Article 3 of the Nursing and Midwifery Order 2001 (S.I. 2002/253)back

[6] S.R. 1986 No. 338back

[7] 1997 c. 50. A position is within section 115(3) if it involves regularly caring for, training, supervising or being in sole charge of persons aged under 18. A position is within section 115(4) if it is of a kind specified in regulations and involves regularly caring for, training, supervising or being in sole charge of persons aged 18 or overback

[8] Sections 113(3EA) and 115(6EA) are inserted by the Protection of Vulnerable Adults (Northern Ireland) Order 2003 (S.I. 2003/417 ((N.I. 4))back

[9] Sections 113(3EC) and 115(6EB) are added by the Protection of Children and Vulnerable Adults (Northern Ireland) Order 2003back

[10] The register is maintained pursuant to paragraph 10 of Schedule 2 to the Nursing and Midwifery Order 2001 (S.I. 2002/253)back

[11] 1978 No. 1908 (N.I. 27)back

[12] S.R 1979 No. 195back