Standards › Standard 28 › Standard operating procedures (SOPs)
Procedure · LTC-SOP-005 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 28.24
At a glance
- Aggression from a resident with dementia has its own assessment and response, separate from other incidents.
- Staff are trained in de-escalation for dementia-related behaviour (WRK-FRM-003).
- Triggers and the response are recorded in the resident’s care plan.
- Each incident is reviewed, and staff are supported afterwards.
- Stop and get help straight away if: a staff member is assaulted by a resident with dementia and no incident is recorded.
1. Purpose
To protect staff and residents from dementia-related aggression with a specific response (28.24).
2. Scope
| Applies to | Clinical and support staff in the hospital |
| Locations | All wards, clinics and departments of the facility |
| When | Whenever the activity described is carried out |
| Does not apply to | Activities covered by another document listed in section 15 |
3. Definitions
| Term | Meaning |
|---|---|
| Clinical lead | The doctor or nurse in charge of the area at the time |
4. Background
Staff who are attacked need specific protections, not general statements. Tracking incidents shows whether the protections work.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Clinical lead for long-term care | Owns the response and the training | Clinician or manager |
| Care staff | Respond and record each incident | Staff |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| Records and forms named in this document | Current version | Checked before use |
7. Safety
- Stop and call for help if a patient is at immediate risk. Do not delay urgent care to complete paperwork.
8. Before you start
- Confirm the forms and equipment named in this document are available and current.
9. Procedure
Step 1. Assess triggers.
- Identify the triggers and the response in the resident’s care plan.
Key point: Identified.
Step 2. Respond.
- De-escalate using the agreed approach and call for support if needed.
Key point: Responded.
Step 3. Record and review.
- Record each incident on WRK-FRM-003 and review the care plan.
Key point: Reviewed.
10. Decision points
- No decision points in this procedure.
11. Special situations
| Situation | Action |
|---|---|
| Out of hours | Follow the same steps. Use the on-call contact on the wall of the area. |
12. Escalation
- Any serious problem goes to the duty clinical lead at once and to the clinical director the same day.
13. Monitoring
| Measure | Target | Frequency | Owner | If not met |
|---|---|---|---|---|
| Dementia-related aggression incidents recorded and reviewed | 100% | Monthly | Clinical lead for long-term care | Escalate to medical director |
14. Records
| Record | Kept in | Retention |
|---|---|---|
| Record named in this document | Patient record or the area file | the period set by the facility’s records policy years |
15. Training
- Staff are trained in this document at induction and refreshed each year, with a recorded competency check.
16. Related documents
| ID | Title | Use |
|---|---|---|
| WRK-FRM-003 | Violence and aggression incident record (existing, reused) | Record |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on the WHO Global strategy and action plan on ageing and health 2016-2030, WHO Integrated care for older people (ICOPE) guidelines (2017), and WHO guidance on digital and AI governance. |
| E-006 | ASF Policy Framework v1.2. Adapted. |
| E-009 | ASF Expert Committee consensus. |
18. Change history
| Version | Date | What changed | Approval |
|---|---|---|---|
| 1.0 | the date of approval | First version | set Expert Committee approval |
E-learning for this document
References
- Accréditation Sans Frontières (2026). ASF Policy Framework v1.2. (E-006)
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)