HIQA expects the documents that prove each national standard is met, starting with a public statement of purpose, governance and accountability arrangements, incident, open disclosure and complaints procedures, and healthcare records management. An approved centre also needs the operating policies the 2006 Regulations require, each reviewed at least every three years.
The documents the national standards name
The National Standards for Safer Better Healthcare describe what a service meeting each standard is likely to have in place.1 Several of those features are documents an inspector will ask to see, and the judgment framework lists the information and evidence HIQA may review for each standard.2
| Standard | Document to have ready |
|---|---|
| 5.3 | A publicly available statement of purpose describing the services, and how and where they are provided |
| 5.1 and 5.2 | Accountability arrangements and formal governance structures, with terms of reference and minutes |
| 1.5 | The informed consent policy and how it is applied |
| 1.8 | The complaints procedure, and the record of complaints and outcomes |
| 3.3 and 3.5 | Incident management and open disclosure procedures |
| 8.2 and 8.3 | Information governance and healthcare records management policies |
| 6.1 to 6.3 | Workforce plans, recruitment and training records |
What an approved centre must keep
Regulation 29 requires every written operating policy of an approved centre to be reviewed at least every three years, and on the recommendation of the Inspector or the Commission. The Judgement Support Framework lists the policies inspected under it, among them visits, communication, searches, transfer of residents, provision of information to residents, medicines, staffing, maintenance of records, complaints and risk management.3 Regulation 27 also requires written policies on the creation, access, retention and destruction of records.3
- List the documents per standard. Use the judgment framework's evidence examples for each standard you expect to be assessed.
- Give each document an owner. A named role, so a review date never passes unnoticed.
- Set the review cycle. Three years at most for an approved centre's operating policies, and sooner when practice or law changes.
- Publish the statement of purpose. On your website, accurate to the services you actually run today.
- Test each policy against practice. Pick three records and check they show the policy being followed.
- Keep the version history. Who approved each version, and when it took effect.
- Document ______ Standard or regulation ______
- Owner ______ Approved by ______
- Version ______ In effect from ______
- Next review due ______
- Practice checked against three records on ______
Policies are read against practice
HIQA's inspectors assess reference material in clinical areas, including relevant policies, procedures and guidelines, and then observe practice and read healthcare records.4 A policy the records do not reflect is evidence of a gap. The guide to the inspection day covers what they read on the ward.
Questions
Does HIQA publish a list of required policies?
Not as a single list. The national standards describe what a compliant service is likely to have, and the judgment framework lists the evidence inspectors may review per standard.
How often must an approved centre review its policies?
At least every three years under Regulation 29, and when the Inspector or the Commission recommends it.
Is the statement of purpose required?
Standard 5.3 expects a publicly available statement of purpose that accurately describes the services, including how and where they are provided.
Sources
- 1Health Information and Quality Authority, 2024National Standards for Safer Better Healthcare, Version 2 (2024), in operation from 26 September 2024Read source
- 2Health Information and Quality Authority, 2024Guidance on the Assessment Judgment Framework for the monitoring of healthcare services against the National Standards for Safer Better Healthcare, version 2.0, September 2024Read source
- 3Mental Health Commission, 2026Judgement Support Framework 2026, for approved centre service providers, version 6.2, January 2026Read source
- 4Health Information and Quality Authority, 2024A guide to healthcare inspections against the National Standards for Safer Better Healthcare, version 2.0, September 2024Read source
Written by the wai team from Health Information and Quality Authority guidance, checked on 16 October 2026. This is guidance, not legal advice. Neither HIQA nor the Mental Health Commission endorses wai or any software.