Governance and Management in Irish Designated Centres: HIQA Regulation 23 Guide

This guide covers Ireland. For the UK equivalent, see our guide: CQC Regulation 17: Good Governance Explained.

If you run a nursing home or residential centre for older people in Ireland, governance and management is the regulation that ties everything else together. It sits in Regulation 23 of the Health Act 2007 (Care and Welfare of Residents in Designated Centres for Older People) Regulations 2013 (S.I. No. 415 of 2013). That regulation was replaced in 2025, so older summaries, templates and policies may describe the previous wording. This guide sets out what the current text says, who it applies to, how HIQA looks at it, and what it leaves open. It is aimed at registered providers, persons in charge, and the HR and finance managers who support them. For the wider picture of how HIQA operates, see our overview of HIQA.

Where the governance requirement comes from

The 2013 Regulations were signed by the Minister for Health on 29 October 2013 and came into operation on 1 July 2014, according to the Irish Statute Book (irishstatutebook.ie). They have been amended several times. The amending instrument that matters most here is S.I. No. 98 of 2025, the Health Act 2007 (Care and Welfare of Residents in Designated Centres for Older People) (Amendment) Regulations 2025, which the Statute Book shows was made on 27 March 2025 and which says it came into operation on 31 March 2025.

That 2025 instrument substituted a new Regulation 23. It also replaced Regulation 14 (persons in charge), Regulation 33 (arrangements when the person in charge is absent) and several others. If your governance documents still refer to the six-paragraph version from 2013, they need updating.

What Regulation 23 now requires

Regulation 23(1) says the registered provider shall ensure the following. We summarise each paragraph; the wording is in S.I. No. 98 of 2025 on irishstatutebook.ie.

• Resources (23(1)(a)): the centre has sufficient resources to ensure the effective delivery of care in accordance with the statement of purpose.
• Management structure (23(1)(b)): there is a clearly defined management structure that identifies lines of authority and accountability, specifies roles, and details responsibilities for all areas of care provision.
• Deputising (23(1)(c)): there are deputising arrangements for key management roles. This paragraph is new in the 2025 text.
• Management systems (23(1)(d)): systems are in place to ensure the service is safe, appropriate, consistent and effectively monitored.
• Annual review (23(1)(e)): there is an annual review of the quality and safety of care delivered to residents, to ensure that care is in accordance with the relevant standards set by HIQA under section 8 of the Act and approved by the Minister under section 10.
• Consultation (23(1)(f)): the review is prepared in consultation with residents and their families.
• Access to the review (23(1)(g)): a copy is made available to residents and, if requested, to the Chief Inspector.
• Quality improvement plan (23(1)(h)): a plan is developed and implemented to address the issues highlighted by the review. This is also new in the 2025 text.

Regulation 23(2) adds a separate duty: the registered provider shall ensure effective arrangements are in place to facilitate staff to raise concerns about the quality and safety of the care and support provided to residents.

Who is responsible: provider and person in charge

Regulation 23 is framed as a duty on the registered provider. The text of Regulation 23 does not mention the person in charge. That does not make the person in charge peripheral. Regulation 14, as replaced in 2025, requires a person in charge and a person able to deputise. The Statute Book text says, among other things, that where the provider is not the person in charge, the person in charge must be a registered nurse with not less than three years' experience of nursing older persons within the previous six years, and that a person in charge needs not less than three years' experience in a nurse management role in the health and social care area. It also contains post-registration management qualification requirements with transitional dates around 31 March 2028, and it lets one person be in charge of up to two centres if the Chief Inspector is satisfied that they can govern and manage both effectively.

In practice, a provider cannot show a clear management structure without the person in charge, the deputy and any other key managers knowing what they are accountable for. Our suggestion: write the structure down as a one-page chart plus a short role description for each key post, and name who covers each role when the post-holder is away.

What the national standards add

The Regulations set the legal floor. HIQA's National Standards for Residential Care Settings for Older People in Ireland (2016, in effect from 1 July 2016) give the detail inspectors use as a reference. Theme 5, Leadership, Governance and Management, has four standards, 5.1 to 5.4. HIQA's published text includes features such as:

• Standard 5.2: clearly defined governance structures and lines of accountability; the provider, person in charge and managers being fit persons in line with regulatory requirements; a risk management framework with a regularly updated risk register; and records of complaints, concerns and adverse events so that trends are detected and learning takes place.
• Standard 5.4: feedback, compliments and complaints from residents being gathered and used; regular audits; audit findings reported, implemented and monitored; and an annual review of quality and safety carried out with residents, families and staff, with a copy given to residents.

Standard 5.3 covers a publicly available statement of purpose. Under Regulation 3 as made, the provider must keep a statement of purpose and review it at intervals of not less than one year.

The annual review in practice

HIQA publishes an Annual Review Report template for older people's centres (version 2, effective from 31 March 2025). HIQA says the template is not statutory, so providers are not obliged to use it, but they must still produce an annual review and make it available as Regulation 23 requires. It is organised around the eight themes of the 2016 Standards, split into Quality and Safety (themes 1 to 4) and Capacity and Capability (themes 5 to 8). For each standard the provider records whether quality improvement is required and, where it is, an improvement plan with actions, resources and timescales.

The template's appendix suggests ways to gather the views the regulation requires, including resident forums, house meetings, surveys, comment boxes and communication with relatives and representatives. It also asks how you will tell residents and relatives the results.

Our suggestion: run the review from a calendar, not as a single push at the end of the review period. Pull audit results, complaints, incident reviews and feedback into a standing file through the year, so that the written review is a summary of evidence you already hold. Keep dated records of how residents and families were consulted: the regulation requires the review to be prepared in consultation with them, and HIQA's guidance gives lack of written evidence of consultation as a Substantially compliant example.

How inspectors look at governance

HIQA's Guidance for the assessment of designated centres for older people (version 3.1, May 2025) places Regulation 23 under capacity and capability. It describes inspectors checking whether resources are sufficient, whether annual review findings are put into practice, and whether feedback from residents, relatives and staff drives change. They speak with residents, the provider, the person in charge and staff, including about deputising arrangements and whether staff feel able to raise concerns. Documents reviewed include the statement of purpose, annual review and quality improvement plans, rosters, meeting minutes, audits and complaints.

Each regulation is rated Compliant, Substantially compliant or Non-compliant. HIQA's examples include a Substantially compliant rating where audits exist without action plans and there is no medium or high risk to residents, or where an annual review has no written evidence of consulting residents or families. A Non-compliant example is a centre that is not effectively managed, leading to risks to residents. Inspection reporting and what follows are covered in our guide to HIQA inspections and staff training.

Related regulations to keep aligned

Governance runs through other parts of the Regulations, so it helps to keep these provisions aligned with your governance documents. As made, Regulation 4 requires written policies on the matters listed in Schedule 5 to be adopted and implemented, and reviewed at intervals not exceeding three years. Regulation 21 sets record retention periods, including not less than seven years after a resident has ceased to reside for resident records. Regulation 22 requires insurance against injury to residents. Regulation 26 on risk management was also amended in 2025 to cover infectious diseases and to require processes for investigating, acting on and learning from serious incidents and adverse events.

Staff safety is a separate legal framework from resident care. The employer's duties on risk assessment and the safety statement are dealt with in our guide to safety statements and risk assessment. Our suggestion: keep that paperwork distinct from your HIQA governance documents, even if the same managers own both.

What the sources do not set

• Regulation 23 does not say how large the management team must be or what titles it should use.
• It does not set a date for the annual review, so the review period is yours to define and record. HIQA's template has From and To fields for the period.
• It does not prescribe a format. The HIQA template is optional.
• We do not state any fine or sanction for Regulation 23 here. Check the Health Act 2007 and the current regulations for enforcement provisions.

Learnsignal's offices are off Baggot Street in Dublin, and we offer in-person training from there. For current details, see our CPD pages.

Frequently asked questions

Which regulation covers governance and management in an Irish nursing home?

Regulation 23 of S.I. No. 415 of 2013, as replaced by S.I. No. 98 of 2025 with effect from 31 March 2025, per the Irish Statute Book.

Does the person in charge have duties under Regulation 23?

The text is addressed to the registered provider and does not mention the person in charge. Regulation 14 separately sets out who may act as person in charge and requires deputising arrangements.

Do we have to use HIQA's annual review template?

No. HIQA states it is not a statutory template. You must still complete an annual review, consult residents and families, make a copy available to residents, and develop and implement a quality improvement plan.

Who must see the annual review?

Regulation 23(1)(g) says a copy must be made available to residents and, if requested, to the Chief Inspector.

What changed in 2025?

Compared with the 2013 text, the new Regulation 23 adds deputising arrangements, a quality improvement plan, and an arrangement for staff to raise concerns.

Governance is easiest to demonstrate when the structure, the evidence and the improvement plan are written down and current. Check the current consolidated text on the Irish Statute Book or the Law Reform Commission site before you finalise your documents.