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Decoding the role of the DI. 21 October 2009 Kate Rolfvondenbaumen. Aims and outcomes. to help you understand the roles of the: Licence Holder (LH) Person(s) Designated Designated Individual (DI) provide you with information about the inspection process

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Decoding the role of the di

Decoding the role of the DI

21 October 2009

Kate Rolfvondenbaumen

Aims and outcomes
Aims and outcomes

  • to help you understand the roles of the:

    • Licence Holder (LH)

    • Person(s) Designated

    • Designated Individual (DI)

  • provide you with information about the inspection process

  • help you and your staff be better prepared for a site-visit inspection

Role of lh
Role of LH

  • term not defined in the Act; but the HTA must be satisfied that the applicant is suitable

    • HTA has a preference for the LH to be a corporate body, with a named contact

    • Ideally someone in a managerial capacity in the establishment

  • the LH has the right to vary a licence

    • can submit application to vary licence by changing the DI

The role of the lh in practice
The role of the LH in practice

  • In practical terms, the DI is typically the key person, with a two-way flow of communication occurring between the DI and the corporate body

Role of the pd
Role of the PD

  • no legal duty

  • ability to “direct” others in relation to the Act

    -assist DI with development and implementation procedures

    -work at a satellite offering advice and guidance

    -oversee licensable activities on behalf of the DI

Statutory duty of the di
Statutory duty of the DI

It is the duty of the DI (paragraph 18) to secure that:

  • other persons who work under the licence are suitable to participate in the licensable activities

  • suitable practices are used in undertaking those activities

  • conditions of the licence are complied with

Statutory duty of the DI cont.

The DI is the lynchpin of regulatory compliance under a licence

How does the HTA help you?

  • advice and guidance: website, codes of practice, email and telephone

  • face-to-face training and e-learning

  • conferences

  • e-newsletter

DIs and

HTA Inspections

Hta responsibility
HTA responsibility

Legal obligation to satisfy ourselves that:

  • both the DI and the LH are suitable

  • the establishment has appropriate premises, facilities and equipment

  • all procedures are carried out to required standards

  • governance and quality systems are in place

Hta inspections
HTA inspections

  • desk-based (all establishments)

  • site-visit (based on risk)

  • routine, non-routine and unannounced

Risk based approach
Risk-based approach

  • use a risk matrix to inform scheduling of site- visit inspections

  • also consider DI response time, DI training and whistleblowers


  • review the consent process

  • looking into the communication flow between you and the coroner

Governance and quality systems
Governance and quality systems

  • SOPS and RAs for licensable activities

  • records to demonstrate traceability

  • examples of forms used

  • training records

  • internal audits

  • document control

  • meetings

Premises facilities and equipment
Premises, facilities and equipment

  • Range of licensed premises – ensure that:

    • premises and facilities are fit for purpose

    • SOPs are in place for the management of equipment and materials

    • risk assessments have been undertaken

    • maintenance and cleaning records exist


  • policy in line with HTA codes of practice

  • records of disposal in place


  • DI must ensure that:

    • personnel are suitably qualified

    • there are sufficient staffing levels

    • staff receive training and CPD

    • appropriate staff facilities are in place, including protective clothing and equipment


DIs have a statutory role to fulfil

The DI has a critical role in inspections:

  • Before: providing needed information

  • During: ensuring staff are present

    ensuring all documentation is present

  • After: reviewing the report

    communicating the information in the report

    ensuring compliance with additional conditions

Number 1
Number 1

The DI must be a doctor

Fact: The HT Act does not stipulate any specific academic qualifications for the DI

Number 2
Number 2

All establishments must have at least one, but no more than three, PDs on a licence

Fact: The HTA is not prescriptive about the number of Persons Designate on a licence.

Number 3
Number 3

Not all changes to a licence need to be reported to the HTA

Fact: The DI has a responsibility to ensure that HTA is kept informed of all changes to a licence in a timely manner

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