Long-Term Care Standards

Before or at admission, the resident or their legal representative receives a genuine, plain-language explanation of the admission agreement's actual terms — services included, room configuration, facility-specific rules — with understanding verified, not just a signature obtained on a document handed over at a stressful, disorienting moment.

Full guidance for 1.1 →

1. Does the resident or legal representative receive a genuine, plain-language explanation of the agreement, not just the document itself? — A real explanation, not a document handed over for signature alone.

2. Is understanding actively verified — for example, through teach-back — before the agreement is signed? — Genuine verification, not assumed from a signature.

3. Does the explanation specifically cover facility-specific characteristics and service limitations, not only generic terms? — Specific to this facility, not a generic admission script.

Every resident receives a genuine, understandable explanation of their rights — dignity, self-determination, communication and access to persons and services inside and outside the facility, including the explicit right to refuse treatment or care — not a rights document filed away unread after admission.

Full guidance for 1.2 →

1. Does every resident receive a genuine, understandable explanation of their rights, not just a document? — A real explanation, not paperwork filed without discussion.

2. Can the resident, or their representative, describe at least one specific right in their own words? — Tests genuine understanding, not just that disclosure technically occurred.

3. Are rights actively protected in daily practice, not only disclosed once at admission? — Genuine, ongoing protection, not a one-time formality.

4. Is the resident's right to refuse treatment or care explicitly disclosed, with staff able to describe what happens in practice when a resident exercises it? — A genuine, honoured right, not a line in a document with no defined practice behind it.

Every charge, included and excluded service, and payment term is disclosed in writing before admission is finalized, with no requirement for a third-party payment guarantee as a condition of admission — not costs that emerge or change only after the resident has already moved in.

Full guidance for 1.3 →

1. Is every charge and included or excluded service disclosed in writing before admission is finalized? — Complete, written disclosure before the decision is finalized, not after.

2. Is a third-party payment guarantee never required as a condition of admission? — A firm, specific exclusion, not a judgement call made case by case.

3. Are residents and families notified promptly of any change to covered services or charges during the stay? — Genuine, timely notification, not costs that change silently.

A resident is not transferred or discharged except for specific, defined, legally permitted reasons, with genuine advance notice and a real, participatory discharge plan — not moved out with inadequate warning or without a plan for where they will actually go.

Full guidance for 1.4 →

1. Does every transfer or discharge occur only for a specific, defined, legally permitted reason? — A specific, documented reason, not a general judgement call.

2. Is genuine advance written notice given to the resident and their representative before transfer or discharge? — Real, timely written notice, not informal or last-minute communication.

3. Is the discharge plan genuinely developed with the resident and family, not handed to them as a completed decision? — Genuine participation, not a plan presented as already finalized.

Residents and families can voice a grievance through a genuine, accessible process, free from any retaliation, with real evidence that grievances lead to a documented response and, where warranted, an actual change — not a suggestion box that generates no real action.

Full guidance for 1.5 →

1. Is there a genuine, accessible process for residents and families to voice a grievance? — A real, known process, not a theoretical right with no practical channel.

2. Is there real, documented evidence that grievances lead to a response and, where warranted, an actual change? — Genuine follow-through, not a process that receives complaints without acting on them.

3. Are residents and families confident that raising a grievance carries no risk of retaliation? — Genuine confidence, not just a stated non-retaliation policy.

Every resident receives a comprehensive initial assessment, performed by a qualified individual and drawing in other relevant disciplines where the resident’s needs call for it, resulting in one individualized care plan — not a set of disconnected, topic-specific plans with no single document bringing them together. The plan states explicit goals, genuinely involves the resident and family in setting them, and is documented as organisational policy requires.

1. Is there a single, comprehensive initial assessment for each resident, not only the separate topic-specific assessments required elsewhere in this standard? — One real, comprehensive evaluation, not an assumption that adding up the falls, nutrition, and dementia assessments equals a comprehensive one.

2. Is the assessment performed by a genuinely qualified individual, with other relevant disciplines drawn in where the resident’s needs call for it? — A named, qualified assessor, with real multidisciplinary input when complexity warrants it.

3. Does the resulting care plan state explicit goals, and was the resident, and family where appropriate, genuinely involved in setting them? — A real, stated goal and genuine involvement, not a plan decided for the resident and only announced to them.

4. Is there one document — not scattered, disconnected plans — that a staff member can find and understand as this resident’s actual current care plan? — A single, genuinely unified plan, not separate falls, nutrition, and dementia plans with no document tying them together.

Every resident undergoes a specific falls risk assessment at admission and after any significant change, with an individualized care plan addressing that resident's actual identified risk factors — not a generic facility-wide falls policy applied identically regardless of individual risk.

Full guidance for 2.1 →

1. Does every resident undergo a specific falls risk assessment at admission and after any significant change? — A specific, individual assessment, not a general facility-wide falls policy alone.

2. Does the resulting care plan address this specific resident's actual identified risk factors? — Individualized interventions matched to this resident's real risk factors, not generic falls precautions.

3. Is the falls risk assessment genuinely updated after a significant change in condition, not only at admission? — A living assessment, not a one-time evaluation that goes stale as the resident's condition changes.

Physical or chemical restraints are never used for staff convenience or resident discipline, only when genuinely required to treat a documented medical symptom, with the least restrictive alternative tried and documented first — not applied as a default response to a resident who is difficult to manage.

Full guidance for 2.2 →

1. Are physical or chemical restraints ever used for staff convenience or resident discipline? — A firm, specific exclusion — this should never happen, not a judgement call made case by case.

2. When restraint use is genuinely medically indicated, is it tied to a documented medical symptom, not general behavior management? — A specific, documented medical justification, not a vague behavioral rationale.

3. Is the least restrictive alternative genuinely tried and documented before restraint use, not skipped as a formality? — Real, documented attempts at less restrictive options first, not a box checked after the fact.

Every resident can summon staff assistance through a call system that reaches a staff member or centralized work area immediately, from their bed, bathroom, and any common area — verified as actually working, not assumed functional because it exists.

Full guidance for 2.3 →

1. Can every resident summon staff assistance from their bed, bathroom, and common areas? — Coverage in every location a resident might genuinely need to call for help, not just the bedroom.

2. Is the call system verified as actually functioning, not assumed working because it's installed? — Genuine, tested verification, not an assumption based on installation alone.

3. Does a call genuinely reach a staff member promptly, not go unanswered or significantly delayed? — Real, prompt response, not a system that technically rings without reliable staff response.

The facility's fire safety systems and practices — construction, egress, fire-rated doors, staff drills — follow a recognized life safety code appropriate to a residential care setting, verified through regular, genuine drills, not assumed compliant because the building passed an initial inspection.

Full guidance for 2.4 →

1. Does the facility's construction and fire safety equipment follow an applicable, recognized life safety standard? — Specific, verified compliance with the applicable standard, not general fire safety awareness.

2. Are fire drills genuinely conducted on a regular schedule, accounting for residents' actual mobility and cognitive needs? — Real, practiced drills reflecting the actual resident population, not a generic evacuation drill.

3. Are corridor doors and doors to rooms with flammable materials equipped with proper fire-rated latching hardware? — Specific, verified hardware compliance, not assumed from the building's age or general condition.

Resident rooms and bathroom facilities are configured to genuinely support privacy, dignity, and the greatest possible independence — private or accessible bathroom facilities, adequate space, personal storage — not merely meeting a minimum institutional standard.

Full guidance for 2.5 →

1. Does every resident have private or genuinely accessible bathroom facilities meeting the applicable standard? — Genuine accessibility and privacy, not a distant or shared facility that functions poorly in practice.

2. Does room configuration provide adequate space and personal storage for the resident's own belongings? — Real, adequate space, not a minimal institutional footprint.

3. Do residents have genuine privacy in their own room, not routinely compromised by staff or facility practice? — Real, respected privacy, not privacy that exists on paper but is routinely overridden in practice.

A resident's ability to perform activities of daily living — hygiene, mobility, eating, toileting — is actively supported to prevent avoidable decline, with any diminution genuinely tied to an unavoidable clinical cause, documented specifically, not assumed as a normal part of aging or long-term residence.

Full guidance for 3.1 →

1. Is ADL support genuinely aimed at maintaining the resident's own ability, not simply completing the task for them? — Support that maintains capability, not task completion that bypasses it.

2. When ADL decline occurs, is it specifically tied to a documented, unavoidable clinical cause? — A specific, documented clinical reason, not an assumption that decline is simply expected.

3. Are care plans reviewed and adjusted as a resident's ADL ability changes, in either direction? — Genuine, ongoing adjustment, not a static plan set once and left unchanged.

Every resident receives a nourishing diet meeting their individual nutritional and special dietary needs, with hydration and eating assistance actively provided as needed — not a standardized menu applied uniformly regardless of individual requirements.

Full guidance for 3.2 →

1. Does every resident's diet reflect their individual nutritional and special dietary needs, not a uniform standard menu? — Genuine individualization, not a single menu applied regardless of individual requirements.

2. Is assistance with eating and drinking actively provided to residents who need it, not left for the resident to manage alone? — Real, active assistance, not passive availability of food and drink alone.

3. Is a qualified dietitian or nutrition professional genuinely involved in developing individual nutrition plans? — Genuine professional involvement, not a generic plan without individual clinical input.

Resident weight is monitored on a defined schedule, with a specific, recognised threshold for significant weight loss triggering immediate clinical review — not weight changes noticed informally or only after they become visually apparent.

Full guidance for 3.3 →

1. Is resident weight monitored on a defined, regular schedule, not informally or irregularly? — A specific, scheduled monitoring interval, not ad hoc weighing.

2. Does the specific 5% in 30 days or 10% in 180 days threshold trigger immediate clinical review? — A specific, recognised threshold, not a vague sense that weight loss seems concerning.

3. Once significant weight loss is identified, does monitoring frequency genuinely increase? — Real, increased monitoring, not the same schedule continued regardless.

Food and activities genuinely reflect each resident's cultural, religious, and personal preferences — with documented, active effort to learn these preferences even from a resident with dementia or communication barriers, not a standardized program applied uniformly regardless of individual background.

Full guidance for 3.4 →

1. Do food and activities genuinely reflect individual residents' cultural, religious, and personal preferences? — Genuine, individual reflection, not a standardized program applied uniformly.

2. For residents with dementia or communication barriers, is there documented, active effort to learn their preferences? — Specific, documented effort, not an assumption that preferences can't be learned.

3. Are learned preferences actually reflected in what's provided, not just recorded without follow-through? — Genuine follow-through, not preferences noted but not actually acted on.

The facility provides an ongoing activities program led by a genuinely qualified activities professional, offering real, varied social and recreational engagement — not passive entertainment like a television left on, or a program that exists on paper without genuine resident participation.

Full guidance for 3.5 →

1. Is the activities program led by a genuinely qualified activities professional meeting defined qualification criteria? — Specific, verified qualification, not simply a staff member assigned the role informally.

2. Does the program offer real, varied engagement matched to individual resident interests, not passive entertainment alone? — Genuine variety and individual relevance, not a single default activity like television.

3. Is genuine resident participation observed, not just a program that exists on paper? — Real, observed participation, not activities offered without residents actually engaging.

A licensed pharmacist reviews every resident's complete drug regimen at least monthly, with any irregularity — excessive dose, excessive duration, inadequate monitoring, inadequate indication — specifically reported to the attending physician and acted upon, not a review that occurs on schedule but produces no real consequence.

Full guidance for 4.1 →

1. Does a licensed pharmacist review every resident's complete drug regimen at least monthly? — A genuine, complete review, not a partial check or one that lapses under pressure.

2. Are identified irregularities specifically reported to the attending physician, medical director, and director of nursing? — Specific, documented reporting to the right people, not an informal or incomplete escalation.

3. Is there real evidence that reported irregularities are actually acted upon, not just noted and filed? — Genuine action resulting from the report, not a report that produces no real consequence.

A resident is never started on a psychotropic medication without a specific, diagnosed, clinically documented condition justifying its use — never as a general response to behavior, agitation, or the convenience of managing a resident who is difficult to care for.

Full guidance for 4.2 →

1. Is every psychotropic medication tied to a specific, diagnosed condition documented in the clinical record? — A specific, documented diagnosis, not a general behavioral rationale.

2. Are non-pharmacological, behavioral approaches genuinely tried first, before psychotropic medication is started? — Real, attempted alternatives, not psychotropic medication as the default first response.

3. Can staff describe the specific diagnosed condition behind a particular resident's psychotropic medication? — Specific, genuine knowledge, not a general sense that the medication helps with behavior.

Residents on psychotropic medication receive genuine, documented gradual dose reduction attempts combined with behavioral interventions, unless a specific clinical reason makes this genuinely contraindicated — not medication continued indefinitely without any real attempt to reduce or discontinue it.

Full guidance for 4.3 →

1. Does every resident on psychotropic medication have a genuine, documented gradual dose reduction attempt? — A real, documented attempt, not medication continued indefinitely by default.

2. Where gradual dose reduction is considered clinically contraindicated, is the specific clinical reason documented? — A specific, documented clinical justification, not contraindication assumed without real basis.

3. Are behavioral interventions combined with dose reduction attempts, not medication reduction alone? — Genuine combined approach, not dose reduction attempted in isolation.

As-needed psychotropic medication orders are limited to 14 days, with antipsychotic PRN orders specifically requiring a physician re-evaluation before any renewal — not extended or renewed automatically as a matter of routine.

Full guidance for 4.4 →

1. Are all PRN psychotropic orders genuinely limited to 14 days, not extended automatically? — A genuine, enforced 14-day limit, not a routine extension.

2. Does any PRN antipsychotic renewal require a genuine physician re-evaluation, not automatic continuation? — A real, documented re-evaluation specifically for antipsychotics, not a rubber-stamp renewal.

3. Where a PRN order is extended beyond 14 days for a non-antipsychotic, is the physician's rationale specifically documented? — A specific, documented clinical rationale, not an extension without real justification.

The facility maintains an infection prevention and control program specific to its own resident population and physical environment, with a designated, trained infection preventionist — not a generic infection control policy adopted without genuine adaptation to this facility's actual circumstances.

Full guidance for 4.5 →

1. Does the infection control program genuinely reflect this facility's own resident population and physical environment? — Facility-specific adaptation, not a generic policy adopted without genuine customization.

2. Is there a designated, trained infection preventionist with genuine responsibility for the program? — A specific, trained, designated individual, not an informal or shared responsibility.

3. Is the program genuinely reviewed and updated based on the facility's own actual assessment, not left static? — Real, ongoing adaptation, not a program written once and never revisited.

Staff are trained to understand behavioral expressions — agitation, resistance to care, repetitive movement — as genuine communication of an unmet need or distress, with a specific process to identify and address the underlying cause, not a default response aimed only at stopping the behavior itself.

Full guidance for 5.1 →

1. Are staff trained to understand behavioral expressions as communication of an unmet need, not as problems to be stopped? — Genuine understanding of behavior as communication, not framed only as disruption to manage.

2. Is there a specific process to identify the underlying cause behind a behavioral expression? — A real, structured process, not an assumption that the cause is simply the dementia itself.

3. Does the response address the identified underlying need, not only aim to stop the visible behavior? — A response matched to the genuine cause, not suppression of the behavior alone.

Every resident with cognitive impairment is assessed for wandering and elopement risk using a validated, structured tool, at admission and after any significant change — not an informal, subjective judgement about which residents seem likely to wander.

Full guidance for 5.2 →

1. Is every resident with cognitive impairment assessed for wandering risk using a validated, structured tool? — A specific, validated assessment, not an informal staff impression.

2. Is the assessment repeated after any significant change in the resident's cognitive or physical condition? — Genuine reassessment reflecting the resident's current, actual risk, not a one-time evaluation.

3. Does the assessment result specifically inform the resident's individual care plan? — Genuine, individual application of the assessment, not a result recorded without practical use.

Elopement prevention measures are individualized and proportionate to actual assessed risk, genuinely balancing safety with the resident's autonomy and freedom of movement — not a blanket, facility-wide restriction, such as a locked unit, applied to every resident regardless of individual risk or need.

Full guidance for 5.3 →

1. Are elopement prevention measures individualized to the resident's actual assessed risk, not applied as a blanket facility-wide restriction? — Genuine individualization matched to real risk, not uniform restriction regardless of individual need.

2. Do residents with lower assessed risk retain genuine freedom of movement, not restricted by default? — Real, preserved autonomy for lower-risk residents, not restriction applied to everyone regardless of risk level.

3. Is there a specific, documented justification when a more restrictive measure is genuinely used for a specific resident? — Specific, individual justification, not a default facility-wide policy.

Staff providing direct care to residents with dementia receive specific, ongoing dementia care training — communication techniques, behavioral expression response, person-centered approach — not a single general orientation session treated as sufficient for the duration of their employment.

Full guidance for 5.4 →

1. Do staff providing direct dementia care receive specific training beyond general orientation? — Specific, dementia-focused training content, not folded into general orientation alone.

2. Is this training genuinely ongoing, not a single session treated as sufficient indefinitely? — Real, recurring training, not a one-time requirement.

3. Can staff demonstrate specific dementia care skills — communication technique, behavioral response — not just describe general awareness? — Genuine, demonstrable skill, not familiarity with the concept alone.

Each resident's individual life history — career, family, meaningful roles, personal preferences — is genuinely gathered and actively used to shape their daily care and activity engagement, not collected once as an intake formality and never referenced again.

Full guidance for 5.5 →

1. Is each resident's individual life history genuinely gathered, not skipped or treated as optional? — Real, gathered life history information, not an assumption it's unnecessary or too difficult to obtain.

2. Is this information actively used to shape daily care and activity engagement, not filed away unused? — Genuine, ongoing use, not information collected once and never referenced.

3. Can staff describe a specific way a resident's life history has genuinely shaped their care approach? — A specific, real example, not a general statement that life history is considered.

Every resident, or their legal representative, is proactively offered a genuine conversation about advance directives and life-sustaining treatment preferences at admission and periodically thereafter — not first raised during a medical crisis, when there is far less time and far more distress to make a considered decision.

Full guidance for 6.1 →

1. Is every resident or representative proactively offered a genuine advance directive conversation at admission? — A real, offered conversation, not paperwork provided without discussion.

2. Is this conversation revisited periodically, not held once and never referenced again? — Genuine, periodic revisiting, not a single admission-only conversation.

3. Are documented preferences genuinely accessible to staff at the moment they're actually needed? — Real, practical accessibility in a genuine emergency, not a document filed away and hard to locate.

Palliative care — addressing physical, emotional, social, and spiritual suffering — is genuinely available to any resident who could benefit, not restricted to residents with a terminal diagnosis or treated as identical to, and conditional upon, hospice enrollment.

Full guidance for 6.2 →

1. Is palliative care genuinely available to any resident who could benefit, not restricted to those with a terminal diagnosis? — Real availability independent of terminal prognosis, not conflated with hospice eligibility.

2. Do staff genuinely understand the distinction between palliative care and hospice, not treat them as interchangeable? — Genuine, accurate understanding of the real distinction, not confusion between the two.

3. Does palliative care genuinely address physical, emotional, social, and spiritual suffering, not medical pain management alone? — The full, genuine scope of palliative care, not a narrowed version limited to physical symptoms.

When a resident elects hospice care, the facility and the hospice agency operate under a specific, written agreement clearly defining who is responsible for each service — not an informal handoff where responsibility gaps go unnoticed until something is missed.

Full guidance for 6.3 →

1. Is there a specific, written agreement with the hospice agency defining responsibility for each service? — A real, specific written agreement, not an informal or assumed division of responsibility.

2. Can staff clearly identify who is responsible for a specific aspect of a hospice resident's care? — Specific, confident knowledge of the actual division of responsibility, not uncertainty or assumption.

3. Is there a real, documented process for identifying and closing a coordination gap if one is discovered? — An active process for catching gaps, not an assumption the written agreement alone prevents them.

A resident's pain and suffering — physical, emotional, social, spiritual — are actively anticipated and proactively addressed as part of ongoing care, not left until the resident reports significant distress, particularly for residents whose cognitive or communication impairment makes reporting pain genuinely difficult.

Full guidance for 6.4 →

1. Is pain and suffering actively, proactively assessed, not only addressed when a resident reports distress? — Genuine, proactive assessment, not reliance on the resident to initiate a report.

2. Is there a specific approach for assessing pain in residents whose cognitive or communication impairment makes self-reporting difficult? — A specific, adapted assessment approach, not the same self-report method applied regardless of communication ability.

3. Does assessment genuinely cover emotional, social, and spiritual suffering, not physical pain alone? — The full, genuine scope of suffering, not narrowed to physical symptoms.

Family members are genuinely included as participants in end-of-life care decisions and planning conversations — not merely informed of decisions after they've already been made by clinical staff.

Full guidance for 6.5 →

1. Are family members genuinely included as participants in end-of-life decisions, not just informed afterward? — Real, participatory inclusion, not notification of decisions already finalized.

2. Are family members given genuine opportunity to ask questions and express concerns before decisions are finalized? — A real opportunity before finalization, not a decision presented as already settled.

3. Do families report feeling genuinely included, not just informed, in end-of-life decision-making? — Real, reported experience of inclusion, not assumed from the process alone.

Nursing staffing levels are genuinely determined by the actual number, acuity, and diagnoses of current residents, based on a real facility assessment — not a fixed headcount applied regardless of how much the resident population's actual care needs have changed. Every clinical staff member's credentials are verified directly with the issuing body before practice and on renewal, each completes structured orientation before independent practice, and performance and competency are formally evaluated on a defined schedule.

Full guidance for 7.1 →

1. Are staffing levels genuinely determined by actual resident acuity and diagnoses, not a fixed headcount alone? — Real, acuity-based staffing determination, not a static number applied regardless of resident needs.

2. Is the facility assessment genuinely current, reflecting the actual present resident population? — A real, current assessment, not one that's grown stale relative to the facility's actual residents.

3. When resident acuity increases, does staffing genuinely adjust, not remain fixed regardless of changing need? — Real, responsive adjustment, not a static staffing level maintained regardless of actual need.

4. Is every clinical staff member's licence or qualification verified directly with the issuing body, both at hiring and on renewal? — Direct verification, not a photocopied certificate taken on trust, rechecked when it lapses.

5. Does every new clinical staff member complete structured orientation before practising independently, beyond dementia-specific training alone? — General role orientation for every new hire, not only the specialised dementia-care training required separately.

6. Is every clinical staff member's performance and competency formally evaluated on a defined schedule, documented and shared with them? — A genuine, periodic, documented evaluation, not informal supervisor impression.

Daily nurse staffing information is posted publicly in the facility, genuinely reflecting actual hours worked by each category of staff, retained for the required period — not posted data that doesn't match what actually happened, or missing entirely.

Full guidance for 7.2 →

1. Is daily staffing information genuinely posted publicly, visible to residents, families, and visitors? — Real, visible public posting, not data technically available but not genuinely accessible.

2. Does the posted data genuinely reflect actual hours worked, not planned or idealized staffing? — Accurate, real data matching what actually happened, not a schedule that doesn't reflect reality.

3. Is staffing data retained for at least 18 months, genuinely available on request? — Real, complete retention, not gaps or missing historical data.

The facility maintains an ongoing, data-driven quality assurance and performance improvement program that genuinely identifies and acts on real indicators of care and quality of life — including at least one annual improvement project targeting a genuine high-risk or problem-prone area — not a program that exists in documentation without producing genuine improvement.

Full guidance for 7.3 →

1. Does the quality improvement program genuinely use real, current data to identify quality and safety indicators? — Real data informing the program, not documentation disconnected from reality.

2. Is there at least one annual improvement project genuinely targeting a real high-risk area? — A specific, genuine project, not a symbolic initiative.

3. Is there real evidence the program has driven measurable improvement, not just documented activity? — Actual, measurable improvement, not activity without demonstrated effect.

The facility has a named, accountable governing body with documented authority over governance, clinical governance, and financial stewardship, and a documented mission, values, and code of conduct genuinely guiding resourcing and staff behaviour. That governing body holds genuine, documented accountability for the quality improvement program continuing through leadership and staffing transitions, with adequate resourcing — staff time, technical training — not a program that quietly weakens or lapses whenever key personnel change.

Full guidance for 7.4 →

1. Does the governing body hold genuine, documented accountability for the quality improvement program? — Real, institutional accountability, not dependence on one person's commitment.

2. Has the program genuinely continued through a real leadership or staffing transition, without lapsing? — Real, demonstrated continuity, not an assumption it would hold up.

3. Is the program adequately resourced, not left to function without real support? — Genuine, adequate resourcing, not a program expected to run on goodwill alone.

4. Is there a named governing body with documented authority distinct from day-to-day management, with clinical governance and financial stewardship explicitly assigned as named responsibilities? — Real, named governance authority, with clinical and financial oversight distinct from operational management.

5. Does the facility have a documented mission, values, and code of conduct, genuinely guiding resourcing decisions and expected staff behaviour? — Specific enough to guide real decisions and conduct, not generic text that could apply to any facility anywhere.

Every staff member is screened against relevant background checks and any national or regional care-worker registry before hire, with anyone found guilty of abuse, neglect, exploitation, or resident mistreatment genuinely excluded from employment — not a screening process that exists on paper but doesn't reliably catch a real, documented finding.

Full guidance for 7.5 →

1. Is every staff member genuinely screened against relevant background checks and any national or regional care-worker registry before hire? — Real, complete screening for every hire, not an inconsistent or partial process.

2. Is anyone with a documented abuse, neglect, or mistreatment finding genuinely excluded from employment? — A firm, reliable exclusion, not a screening process that misses real findings.

3. Is screening genuinely repeated or rechecked periodically, not only performed once at initial hire? — Ongoing, periodic verification, not a one-time check that could miss a finding entered later.

An international family receives a complete, written breakdown of ongoing monthly costs, included and excluded services, and any anticipated future cost changes tied to care level increases — before placement is finalized, not costs that emerge only after the resident has already moved in.

Full guidance for 8.1 →

1. Does the family receive a complete, written breakdown of ongoing monthly costs before placement is finalized? — Written and complete, covering the ongoing commitment, not a one-time figure.

2. Are anticipated future cost changes tied to care level increases specifically disclosed in advance? — Genuine advance disclosure of likely future changes, not costs that surprise the family later.

3. Is there a specific, transparent process for communicating any actual cost change once the resident is placed? — A defined, transparent process, not an unexplained addition to the bill.

The resident's family and, where relevant, their home-country physician receive genuine, periodic updates on the resident's condition and care — not only at admission, and not only when a family member happens to ask.

Full guidance for 8.2 →

1. Does the family receive genuine, periodic updates on the resident's condition, not only when they ask? — Proactive, scheduled updates, not communication that depends entirely on the family initiating contact.

2. Is a significant change in condition specifically communicated promptly, not folded into the next routine update? — Prompt, specific communication for significant changes, not delayed until a scheduled check-in.

3. Where relevant, is the resident's home-country physician also kept genuinely informed? — Real, ongoing physician communication, not contact limited to the family alone.

A genuinely competent interpreter is available for the resident's ongoing care conversations and for family members during visits — not an ad hoc arrangement using whichever staff member happens to speak some of the family's language.

Full guidance for 8.3 →

1. Is a genuinely competent interpreter available for the resident's ongoing care conversations, not only at admission? — Real, ongoing interpreter access, not limited to a single initial conversation.

2. Is interpreter access specifically arranged for family visits, not improvised on the day? — Planned in advance for scheduled visits, matched to the family's actual language.

3. Can the resident and family genuinely communicate about care decisions, not just exchange pleasantries? — Genuine, substantive communication access, not superficial interaction alone.

The facility provides or coordinates genuine support for family members' travel and accommodation logistics when visiting from abroad — not leaving a family to navigate an unfamiliar country alone during what is often a limited, emotionally significant visit.

Full guidance for 8.4 →

1. Does the facility provide or genuinely coordinate travel and accommodation support for visiting family? — Real coordination, not information the family must act on entirely alone from abroad.

2. Is accommodation genuinely convenient to the facility, supporting maximum time with the resident? — Genuine proximity and convenience, not logistics that eat into limited visit time.

3. Is there a specific point of contact for family logistics problems during their visit? — A specific, known contact, not an assumption the family will manage independently.

The facility provides the specific documentation an international resident needs for their long-term residency or extended-stay legal status, correctly and promptly — not generic paperwork suited only to a short medical visa, applied to what is actually an ongoing, long-term placement.

Full guidance for 8.5 →

1. Does the facility provide documentation specific to long-term residency or extended-stay status, not short-term medical visa paperwork? — Documentation genuinely matched to the actual long-term nature of the placement.

2. Is documentation provided with enough lead time for realistic long-term status processing? — Genuine lead time reflecting the real processing timelines for extended-stay status.

3. Is there a specific process for renewing or maintaining legal status over the course of an ongoing placement? — A real, ongoing process, not documentation support limited to initial placement alone.

International families have access to a genuine complaint and redress process reachable from their home country, with real evidence complaints are addressed — not a process that functionally only works for a family physically present in the country.

Full guidance for 8.6 →

1. Is there a specific complaint channel genuinely reachable from the family's home country? — Genuine remote accessibility, not a channel that functionally only works locally.

2. Is the complaint channel accessible in relevant languages and adapted for time zone differences? — Genuine accessibility accounting for real language and time zone barriers.

3. Is there real, documented evidence that complaints from international families are actually addressed? — Genuine follow-through, not a channel that produces no real response.

Any placement facilitator or agent referring families to this facility is specifically verified — real business registration, a real, checkable track record — with the verification documented, not accepted based on the volume of placements they refer or how professional their marketing appears.

Full guidance for 8.7 →

1. Is each placement facilitator or agent specifically verified for legitimate business registration and a checkable track record? — Genuine, specific verification, not accepted based on referral volume or marketing professionalism alone.

2. Is verification documented and periodically reconfirmed, not done once and assumed to remain valid indefinitely? — An active, periodically reconfirmed process, not a one-time check.

3. Is there a specific process for reviewing what a facilitator actually tells families about this facility? — Active oversight of facilitator representations, not an assumption they accurately represent the facility.

For every international resident, the facility proactively discusses repatriation options and requirements with the family in advance — the documentation, timeline, and process required to return remains to the resident's home country, should death occur — not a conversation that first happens in the acute distress of an actual death.

Full guidance for 8.8 →

1. Does the facility proactively discuss repatriation options with the family in advance, not only after a death occurs? — A genuine, proactive conversation held calmly in advance, not first raised during acute grief.

2. Does the facility have genuine, current knowledge of the specific documentation and process required for this resident's home country? — Specific, current, country-relevant knowledge, not generic awareness that repatriation exists.

3. Is there a specific point of contact to support the family through the actual repatriation process, if needed? — A real, known support contact, not an assumption the family will navigate this alone.

An international resident's cultural, religious, and dietary practices from their country of origin are genuinely learned and accommodated on an ongoing basis — not assumed to be the same as, or expected to adapt to, the facility's local cultural default.

Full guidance for 8.9 →

1. Are the resident's own cultural, religious, and dietary practices from their country of origin genuinely learned? — Specific, genuine effort to learn this resident's actual practices, not an assumption of local default.

2. Are these practices genuinely accommodated on an ongoing basis, not just noted at admission? — Real, ongoing accommodation, not documentation without follow-through.

3. Does the resident have any way to maintain connection to their own cultural community, not only facility-local culture? — Genuine connection opportunity, not isolation from their own cultural background.

Communication with an international family — scheduled calls, video visits, updates — is genuinely adapted to their actual time zone and circumstances, not offered only during the facility's own local convenient hours regardless of what time it is for the family.

Full guidance for 8.10 →

1. Is scheduled family communication genuinely adapted to the family's actual time zone, not only the facility's convenient hours? — Real, practical accommodation of the family's actual circumstances, not one-sided scheduling.

2. Are video visits or calls genuinely offered at times realistically workable for the family? — Real, workable timing, not options that technically exist but are impractical for the family to use.

3. Does the family report genuine satisfaction with their ability to stay connected, not describe it as a persistent struggle? — Real, reported satisfaction, not communication that technically exists but functions poorly in practice.

Care is genuinely adapted to a resident's migration and displacement experience — including trauma-informed practice, awareness of legal-status barriers to access, and support for continuity of care — not delivered identically regardless of that history.

Full guidance for 9.1 →

1. Is care genuinely adapted to a resident's migration and displacement experience, not delivered identically regardless of history? — Genuine adaptation, not a generic cultural-awareness statement.

2. Is trauma-informed practice genuinely applied, not just referenced as a principle? — Actual practice adaptation, not an assumption of general sensitivity.

3. Are staff aware of legal-status barriers to access that may affect this specific resident? — Specific awareness, not a general sense that barriers can exist.

Residents are supported to genuinely understand both their own care and how to navigate the facility itself — with understanding actively verified through methods like teach-back, in plain language, not assumed from silence, a nod, or general goodwill information about the facility.

Full guidance for 9.2 →

1. Is understanding actively checked using a teach-back approach, for both the care plan and how the facility works, not assumed from a nod? — Asking the resident to explain both back in their own words, not just asking "do you understand?"

2. Is concrete, practical guidance provided on navigating this facility specifically — daily routines, how to raise a concern, activities available? — Real navigation guidance, not just general encouragement.

3. Is information communicated in plain language, avoiding jargon, particularly when working through an interpreter? — Complex terminology strains interpretation and comprehension together.

Trained interpreters or cultural mediators are engaged for language-discordant consultations and ongoing care conversations — never minor children, and only family members when genuinely no other option exists and the situation is not high-risk.

Full guidance for 9.3 →

1. Are trained interpreters or cultural mediators engaged for language-discordant consultations and ongoing care? — Not ad hoc bilingual staff or family members as the default, and not limited to admission alone.

2. Is a minor ever used to facilitate interpretation for a family member? — This should never happen — a specific, absolute rule, not a judgement call.

3. When a family member interprets due to genuine unavailability of a trained interpreter, is this reserved for low-risk situations only? — Not used for informed consent, complex care, or bad news — situations WHO specifically flags as requiring professional language support.

The facility actively engages with legal, community, and social support services relevant to refugee and migrant residents, and conducts effective handover of care that includes migration- and displacement-related context — not treating residential care as isolated from these interconnected factors.

Full guidance for 9.4 →

1. Does the facility actively engage with relevant legal and social support services, not treat care in isolation? — Genuine, active engagement, not a general awareness that such services exist.

2. Does handover to another provider specifically include migration- and displacement-related context? — Specific inclusion of this context, not a generic handover.

3. Are staff aware of specific local services relevant to this population, not just services generally? — Specific, current knowledge, not a vague sense that support services exist somewhere.

Staff are trained to recognise that the onset or progression of dementia can trigger the re-emergence of traumatic stress symptoms dormant for decades — particularly among refugee and displaced residents — with a resident's known life history actively used to understand and respond to these symptoms, not treated as unrelated behavioral decline.

Full guidance for 9.5 →

1. Are staff trained that dementia can trigger re-emergence of dormant trauma symptoms, particularly for refugees? — Specific training on this phenomenon, not general dementia training alone.

2. Is a resident's known trauma history actively used to understand specific symptoms or triggers? — Genuine application of known history, not care disconnected from it.

3. Are care practices — bathing, personal care, restricted movement — reviewed for retraumatising potential? — Specific, individual review, not a generic assumption.

Staff use evidence-informed guidelines specific to refugee and migrant health where they exist, recognise where the health needs of this population differ from the general elderly population, and identify where evidence gaps remain — not applying general geriatric guidelines uncritically to a population with documented, different health needs and risk factors.

Full guidance for 9.6 →

1. Are staff aware of evidence-informed guidelines specific to refugee and migrant health where they exist? — Specific, current awareness, not general geriatric knowledge assumed to be sufficient.

2. Do staff recognise where this population's health needs genuinely differ from the general elderly population? — Genuine, specific recognition — for example, elevated PTSD and chronic disease risk — not an assumption that general guidelines always apply equally.

3. Is practice adapted where population-specific evidence indicates a different approach is warranted? — Actual practice adaptation, not awareness without application.

Staff maintain active awareness of their own culture, beliefs, and potential biases through structured reflective practice, and the facility actively fosters a supportive environment with genuine access to psychological support — not assumed self-awareness or an assumption that staff will manage vicarious trauma exposure on their own.

Full guidance for 9.7 →

1. Does the facility have a structured process for staff reflective practice regarding bias and cultural awareness? — A defined process, not an assumption that staff will naturally self-reflect adequately.

2. Does the facility provide genuine, accessible psychological support for staff working with residents who have severe trauma histories? — Actual, used support, not a theoretical benefit or informal hope.

3. Can staff describe a specific instance of adapting their practice after recognising a bias, and do they recognise signs of vicarious trauma in themselves or colleagues? — Genuine, concrete examples, not general statements of good intentions or awareness.

The facility can name which legal status categories it actually serves — asylum seeker, recognised refugee, stateless person, and others — and demonstrates it doesn't apply a single, uniform assumption about access rights and future planning across all of them.

Full guidance for 9.8 →

1. Can staff name the specific legal status categories this facility actually serves? — Specific, named categories, not a general sense that "migrants" are served.

2. Does the facility avoid applying a single, uniform assumption about access rights and future planning across all statuses? — Genuine differentiation, not treating all categories identically.

3. Is there a specific process for verifying which category applies when it's genuinely unclear? — A real, defined process, not guesswork or assumption when status is ambiguous.

For a refugee or stateless resident who cannot return to their country of origin, even in death, end-of-life planning genuinely explores culturally and religiously appropriate alternatives — a local ceremony reflecting their tradition, connection with a diaspora community — not a default assumption that standard local practice is the only available option.

Full guidance for 9.9 →

1. Does end-of-life planning genuinely explore culturally and religiously appropriate alternatives for a resident who cannot return home? — Real, proactive exploration of meaningful alternatives, not silence or a default assumption.

2. Is there genuine effort to connect the resident with a relevant diaspora or faith community, where one exists? — Real, active effort, not an assumption none exists or that it isn't the facility's role to help find one.

3. Is this conversation held with genuine sensitivity to why return isn't possible, not treated as a routine, generic discussion? — Genuine sensitivity to the resident's specific, often painful situation, not a generic planning conversation.

Care is provided and fully documented for every resident regardless of immigration or legal status, with no differential standard of care, documentation practice, or record-keeping applied based on status — not a lesser or informal standard applied to residents without documented status.

Full guidance for 9.10 →

1. Is the same standard of care applied and documented the same way regardless of a resident's immigration or legal status? — Genuinely equal treatment, not a lesser or informal standard for undocumented residents.

2. Are staff specifically trained that immigration status is never a reason to withhold or alter care or documentation? — Specific, documented training, not assumed understanding.

3. Is resident information protected with the same confidentiality standard regardless of status, with no informal sharing of status-related information? — The same confidentiality protection extended to every resident, without exception.

Every resident receiving rehabilitation or restorative therapy has an individualized plan built from a documented functional assessment, oriented toward maintaining and slowing decline in function — not a generic protocol assuming an acute-recovery trajectory that doesn’t fit a long-term care context.

Full guidance for 10.1 →

1. Is a documented functional assessment actually performed, specifically oriented to maintenance and decline-prevention rather than assuming a return-to-baseline recovery trajectory? — A long-term care resident’s realistic goal is often maintaining current function or slowing decline, not full recovery.

2. Is the plan genuinely individualized to that assessment, not a standard template applied regardless of the resident’s actual baseline? — Verified by comparing several resident plans for genuine difference, not just name changes.

3. Is the plan reassessed on a defined schedule as the resident’s function changes over their stay? — A plan set once may not reflect gradual change over a long-term stay.

Rehabilitation and restorative therapy goals are genuinely coordinated with daily nursing and care staff, so that functional gains made in therapy sessions are reinforced and carried through in everyday care, not undone by daily practices that work against the therapy plan.

Full guidance for 10.2 →

1. Do daily care staff actually know the resident’s current therapy goals, not just the therapy team working in isolation? — A resident working on independent transfers in therapy, but lifted by staff the rest of the day, loses the functional gain.

2. Is there a genuine shared communication mechanism between therapy and daily care staff, not separate, unconnected documentation? — A shared care plan or regular communication point, not isolated discipline-specific notes.

3. Can daily care staff describe a specific resident’s current therapy goal when asked? — Evidence the coordination genuinely reaches frontline daily care, not just the therapy department.

Rehabilitation and functional maintenance goals are set collaboratively with the resident and, where appropriate, family, in understandable terms, with realistic expectations genuinely communicated — not goals set unilaterally by the clinical team.

Full guidance for 10.3 →

1. Are goals documented as genuinely collaborative, with the resident’s own input visible, not set unilaterally by staff? — A goal-setting record showing only clinical input, with no resident voice, suggests a one-way process.

2. Are realistic expectations genuinely communicated, including where the goal is maintaining function rather than improving it? — Honest, calibrated communication about what’s realistic, not false reassurance of recovery.

3. Where the resident has cognitive impairment, is family or an authorized representative genuinely involved in goal-setting? — A real, documented involvement process, not goal-setting that bypasses the resident’s actual representation.

Functional status is tracked using a validated measurement tool at defined intervals, with any meaningful decline flagged and triggering a genuine care plan review, not relying on informal impression that may miss a gradual decline over time.

Full guidance for 10.4 →

1. Is a validated, recognized functional measurement tool actually used, not an informal, ad hoc note? — A validated tool provides a consistent, comparable measure; informal notes often miss a gradual decline.

2. Is the tool applied at defined, consistent intervals appropriate to a long-term stay? — Irregular measurement makes genuine trend detection over a long stay difficult.

3. Does a flagged decline actually trigger a documented care plan review, not just get noted without follow-through? — A decline identified but not actioned provides no real protective value.

Assistive devices and equipment — mobility aids, orthotics, adaptive equipment, positioning supports — are assessed, fitted, and provided to match the resident’s actual and evolving functional need, with staff trained in correct use, not a one-time provision never revisited.

Full guidance for 10.5 →

1. Is equipment provision based on a documented individual assessment, not a default or convenience-driven choice? — Whatever’s readily available, rather than what genuinely fits the resident’s need, is a specific, checkable gap.

2. Are daily care staff trained in correct use of the resident’s specific equipment, not just the therapy team? — Equipment used incorrectly by staff unfamiliar with it can be unsafe or ineffective.

3. Is equipment reassessed as the resident’s needs evolve over their stay, not fitted once and never revisited? — A fitting assessed once at admission may no longer be appropriate months or years into a long-term stay.

Mobility and functional support is provided through the least restrictive means appropriate to the resident’s safety, with genuine effort to avoid restraint or over-restriction as a substitute for adequate staffing or supervision — not restriction used as a convenience measure.

Full guidance for 10.6 →

1. Is there a documented, genuine effort to use the least restrictive approach before any restriction is applied? — Restriction used as a first response, rather than a last resort after genuine alternatives are tried, is a specific, checkable risk.

2. Is any restriction documented with a specific, individual clinical justification, not a blanket facility policy applied regardless of the resident? — A blanket approach applied to all residents of a certain condition, rather than individual assessment, is a specific failure mode.

3. Is restriction use reviewed on a defined schedule to check whether it remains genuinely necessary? — A restriction applied once and never reviewed can persist long after it’s genuinely needed.

The facility genuinely assesses its environmental impact — energy, water, laundry, and food service consumption — reflecting the real, continuous nature of residential operation, not a partial assessment that overlooks the facility's round-the-clock resource use.

Full guidance for 11.1 →

1. Has the facility genuinely assessed its environmental impact across its full 24-hour operation, not a partial snapshot? — A real, comprehensive assessment, not one reflecting only daytime or office-hours activity.

2. Does this genuinely include laundry and food service, the facility's most resource-intensive residential functions? — Real coverage of the facility's actual largest resource users, not overlooked as outside scope.

3. Is the assessment genuinely revisited periodically? — Real, periodic review, not a static assessment assumed to remain valid.

Clinical, hazardous, and high-volume incontinence waste is genuinely segregated at the point of generation and disposed of through a responsible, verified pathway — not a waste stream mixed for convenience given the facility's continuous, high-volume generation.

Full guidance for 11.2 →

1. Is clinical and incontinence waste genuinely segregated from general waste at every point of generation? — Real, consistent segregation, not a practice that lapses under staffing pressure.

2. Is the disposal pathway genuinely verified, not simply assumed compliant? — A real, verified pathway, not an assumption resting on a vendor’s claims.

3. Are care staff genuinely trained in correct segregation, with real, observable compliance? — Real, demonstrated staff practice during actual resident care routines.

Procurement decisions genuinely factor in environmental impact alongside cost and resident need — including the facility's recurring, high-volume purchases of continence products, bedding, and food supplies — not sustainability treated as an afterthought with purchasing decided purely on price.

Full guidance for 11.3 →

1. Does procurement genuinely weigh environmental impact for the facility’s highest-volume recurring purchases? — Real, documented consideration for the purchases that actually matter most at scale.

2. Is there a real, documented instance where a procurement choice was genuinely influenced by environmental considerations? — A concrete, real example, not a policy with no actual purchasing decision behind it.

3. Are food service and catering choices genuinely reviewed for waste reduction opportunities? — A real, ongoing review, not food waste left unexamined given its recurring daily volume.

The facility genuinely monitors its energy and water consumption, pursuing real, achievable reductions — balanced against the genuine, non-negotiable need to maintain resident comfort and safety temperatures around the clock, not efficiency pursued at the expense of resident wellbeing.

Full guidance for 11.4 →

1. Is energy and water consumption genuinely tracked, not simply paid for with no real monitoring? — Real, ongoing tracking, not bills paid without genuine attention to trends.

2. Has the facility genuinely identified and pursued at least one real efficiency improvement that does not compromise resident comfort? — A real, concrete improvement balanced against genuine resident wellbeing needs.

3. Is progress genuinely reviewed periodically? — Real, periodic review, not an assumption that efficiency improves passively.

Staff genuinely understand and participate in the facility's sustainability practices, and residents and families are genuinely made aware of relevant initiatives where appropriate — not a sustainability policy known only to management with no real engagement from the people who actually live there or care for them.

Full guidance for 11.5 →

1. Can staff asked directly describe at least one genuine sustainability practice the facility follows? — Real, demonstrated staff awareness, not a policy known only to leadership.

2. Are residents and families genuinely made aware of relevant initiatives where appropriate? — Real, visible communication to the people who actually live in and visit the facility.

3. Is staff input on sustainability practice genuinely sought and considered? — Real, two-way engagement, not a top-down policy with no genuine staff voice.

The facility genuinely considers climate-related risks to the continuous safety of its residents — extreme heat, power outages affecting medical equipment and climate control, supply chain disruption — with a real, workable response, given that residents who cannot independently evacuate or self-regulate depend entirely on the facility's preparedness.

Full guidance for 11.6 →

1. Has the facility genuinely identified its specific climate-related risks to resident safety? — A real, specific risk identification, grounded in the genuine vulnerability of residents who cannot self-evacuate.

2. Is there a real, workable response plan — including backup power for climate control and medical equipment? — A genuine, usable plan, not a risk acknowledged with no actual response prepared.

3. Is this plan genuinely reviewed and tested, including with staff on duty during different shifts? — Real, periodic review and testing across the full 24-hour staffing cycle.

The facility's sustainability goals and practices are genuinely reviewed and updated as circumstances change — not a document written once and never genuinely examined for whether it still reflects the facility's actual practice.

Full guidance for 11.7 →

1. Are sustainability goals genuinely reviewed on a real, defined schedule? — A real, periodic review, not a goal document frozen at the point it was first written.

2. Is there a real, documented instance of a sustainability goal genuinely being revised based on actual experience? — A concrete, real example, not goals that have never actually changed since adoption.

3. Is responsibility for this review genuinely assigned to a specific person or role? — A real, named accountability, not a review that depends on someone remembering to do it.

Before adopting any new digital system — care management software, family communication portal, fall-detection or monitoring technology — the facility genuinely evaluates its cost, benefit, and compatibility with existing systems, not adopted on vendor assurance with no real internal evaluation.

Full guidance for 12.1 →

1. Is a genuine cost/benefit evaluation conducted before adopting a new digital system? — A real, documented evaluation, not a decision made purely on a sales presentation.

2. Is compatibility with existing resident record systems genuinely checked? — Real, verified compatibility, not an assumption.

3. Are potential unintended consequences for resident care genuinely considered before go-live? — Real, proactive consideration, not effects discovered only in hindsight.

A genuine process ensures that residents and family members who cannot use digital devices, lack internet access, or are otherwise unable to engage digitally are never disadvantaged in care communication, family updates, or resident engagement — not digital convenience purchased at the cost of real connection for the residents and families least able to adapt.

Full guidance for 12.2 →

1. Is there a genuine, equally functional alternative for families who cannot use a digital communication channel? — A real, equivalent alternative — phone calls, printed updates — not a digital-only pathway.

2. Was a new digital resident-facing service genuinely pre-tested with residents or families who might struggle with it? — Real, prior testing with the affected group.

3. Is there real evidence a resident or family using the alternative route received equivalent, undiminished engagement? — A real, demonstrated instance, not an untested theoretical alternative.

The facility has genuine access to technical support — in-house, vendor-provided, or contracted — for its digital systems, with testing before full implementation, not systems left running with no real support behind them, which carries particular risk where fall-detection or monitoring technology is involved.

Full guidance for 12.3 →

1. Does the facility have genuine, accessible technical support, including for monitoring technology that could affect resident safety? — Real, available support, with particular urgency for safety-related systems.

2. Were genuine testing and quality checks performed before full implementation? — A real pre-launch check, not a system deployed untested.

3. Is there a real, known route to support, particularly for an urgent failure of monitoring technology overnight? — A genuine, known escalation path covering night and weekend shifts.

Any artificial intelligence tool used to support fall-risk prediction, behavioural monitoring, or care planning is introduced in accordance with applicable law, or where none exists, with available best-practice guidance such as WHO's AI ethics and governance guidance — not adopted with no reference to any external standard of responsible use.

Full guidance for 12.4 →

1. Is any AI system in use genuinely introduced in line with applicable law? — Real, verified compliance, not an assumption.

2. Where no law exists, is introduction genuinely informed by recognized guidance? — A real, referenced source, not an ad hoc decision.

3. Can the facility identify, when asked, the specific basis for how an AI tool is governed, including resident consent considerations? — A real, specific answer, including how resident and family consent for monitoring was addressed.

The facility genuinely monitors any AI-assisted fall-risk or behavioural tool for false alarms, missed events, and other unintended consequences — not deploying a tool and assuming it works as intended with no real, ongoing scrutiny, given the genuine risk of alarm fatigue undermining its actual protective purpose.

Full guidance for 12.5 →

1. Is AI-assisted output genuinely audited for false alarms or missed events, not assumed reliable without checking? — Real, ongoing audit, not an assumption of reliability.

2. Is alarm fatigue among staff genuinely monitored as a real risk to the tool's actual effectiveness? — A real, specific concern for this type of tool, genuinely tracked.

3. Is there a documented instance of monitoring identifying a genuine issue, with a real response? — A real, concrete example, not a process that has never caught anything.

Direct care staff who will actually respond to an AI tool's alerts are genuinely consulted before its introduction, with real training needs identified and addressed — not a tool rolled out to care staff with no engagement beyond a brief notification.

Full guidance for 12.6 →

1. Are direct care staff genuinely consulted before a new AI system's introduction? — Real, prior consultation with the staff who will actually respond to its alerts.

2. Does consultation genuinely identify training needs, actually addressed before go-live? — Real needs matched by real, delivered training across all shifts.

3. Can staff asked directly describe having been genuinely consulted? — Tests whether consultation actually reached night and weekend staff too.

The facility has genuinely considered and documented accountability for care decisions made with AI support — who is responsible when a fall-risk prediction or behavioural alert is wrong or missed — not leaving this as an unexamined question until an actual resident is harmed.

Full guidance for 12.7 →

1. Is clinical accountability for an AI-supported decision explicitly documented? — A real, clear answer, not an assumption.

2. Do care staff genuinely understand their own accountability for resident safety despite AI-assisted monitoring? — Real, demonstrated understanding that monitoring technology does not replace direct observation.

3. Is there a defined process for reviewing accountability when an AI-assisted alert fails to prevent a resident fall or incident? — A real, usable process, not a question left open until an actual incident forces it.

A resident (or their family, where the resident cannot meaningfully participate) whose care involves an aspect delivered with AI system support is genuinely informed of this — not left to assume every decision was made by a human staff member alone, with disclosure treated as optional rather than a genuine, standard part of informed care.

Full guidance for 12.8 →

1. Are residents and families genuinely informed when an aspect of care involves AI system support? — Real, standard disclosure, not an assumption that the family will simply figure it out or doesn’t need to know.

2. Is this disclosure genuinely understandable, not buried in technical language or admission paperwork a family never actually reads? — A real, plain-language explanation a family could genuinely act on.

3. Can a family member asked directly confirm they were genuinely told AI was involved in an aspect of care? — A real, concrete confirmation, not disclosure that exists in policy but never genuinely reaches the family.

Every member of the facility's workforce — employed carers, nurses, contracted agency staff covering shifts, and volunteers alike — has genuine assurance of the qualifications and scope of practice their role requires — not credentialing confined to directly-employed staff while agency shift-cover goes unchecked.

Full guidance for 13.1 →

1. Does genuine credential assurance extend to agency and bank staff covering shifts, not employed staff alone? — Real, consistent coverage, not a gap for agency-covered shifts, which are common in this sector.

2. Is each person's actual scope of practice genuinely verified against real qualifications? — A specific, documented match, not an informal assumption.

3. Is there a real, defined process if someone is found practising outside their verified scope? — A genuine corrective process, not a gap identified with no actual response.

The continued competency of every workforce member — including specific competency in dementia care, safe manual handling, and medication administration appropriate to a residential setting — is genuinely, regularly evaluated, not assumed to remain current indefinitely once initial credentialing is complete.

Full guidance for 13.2 →

1. Is ongoing competency genuinely evaluated on a real, defined schedule, including manual handling and dementia-care competency? — A real, periodic evaluation covering the genuinely specific competencies this setting requires.

2. Does evaluation genuinely cover the person's actual current duties? — A specific, role-relevant evaluation, not a generic form.

3. When a genuine performance gap is identified, is there a real, defined response? — A genuine corrective process, not a gap noted with no actual follow-through.

Every workforce member has genuine access to ongoing education — including dementia care, palliative care, and safe manual handling refreshers — not education treated as a one-time induction event with nothing meaningful offered afterward.

Full guidance for 13.3 →

1. Does every workforce member have genuine, ongoing access to education beyond induction? — Real, continuing access, not training treated as a one-time event.

2. Are genuine development opportunities offered in dementia and palliative care, not only minimum compliance training? — Real development opportunities relevant to this setting’s genuine clinical complexity.

3. Can staff asked directly describe a genuine education opportunity taken in the past year? — A real, specific example, not a theoretical entitlement nobody uses.

The facility genuinely protects the health and safety of its workforce — required vaccinations, personal protective equipment, and specifically real, effective prevention of manual handling injuries from resident transfers, which represent a genuinely elevated occupational risk in this setting — not staff safety treated as secondary to resident care.

Full guidance for 13.4 →

1. Are genuine, specific manual handling measures — hoists, transfer aids, trained technique — in place and actually used? — Real, observed use of real equipment, not equipment present but not actually used under time pressure.

2. Is personal protective equipment genuinely available and actually used by staff? — Real, observed use, not equipment present but not actually worn.

3. Are required staff vaccinations genuinely tracked and current? — Real, verified tracking, particularly important given resident vulnerability to infection.

A genuine process exists for investigating and resolving workplace issues raised by staff — including whistleblowing concerns about resident care quality — with real protection from adverse treatment, not a grievance process that exists on paper with no real follow-through.

Full guidance for 13.5 →

1. Is there a genuine, accessible process for staff to raise workplace issues, including concerns about resident care quality? — A real, known process, not a theoretical right.

2. Is there real, documented evidence that raised issues lead to genuine resolution? — Genuine follow-through, not a process that receives concerns without acting.

3. Are staff who raise concerns genuinely protected from adverse treatment? — Real, demonstrated protection, not a stated policy with no actual confidence behind it.

The facility takes genuine, concrete steps to protect staff from aggression — including behavioural aggression linked to dementia or cognitive impairment, which requires a genuinely different, trauma-informed response than aggression from a cognitively intact individual — not workplace aggression treated as an unavoidable feature of residential care.

Full guidance for 13.6 →

1. Are genuine, specific measures in place, including training for dementia-related behavioural aggression specifically? — Real, specific measures appropriate to this setting’s genuine, distinct risk profile.

2. Are incidents of aggression toward staff genuinely tracked and reviewed? — Real, systematic tracking, not incidents that go unrecorded.

3. Can staff describe a real, specific instance where a protective measure genuinely worked? — A real, concrete example, not measures untested in practice.

The facility has a genuine, systematic approach to gathering staff feedback across all shifts — including night staff, whose voice is often overlooked — with real analysis and a genuine, implemented response, not feedback collected occasionally with no real pattern of actual improvement.

Full guidance for 13.7 →

1. Is workforce feedback genuinely gathered across all shifts, including night staff? — Real, ongoing collection reaching staff genuinely at risk of being overlooked.

2. Is collected feedback genuinely analysed for trends? — A real, documented analysis process, not feedback left unexamined.

3. Is there a documented instance where feedback genuinely led to an implemented change? — A real, concrete example, not a process that has never produced a visible change.

The facility genuinely monitors staff sick leave and the real reasons people leave — a sector with genuinely elevated attrition risk from physical and emotional demand — using this to inform genuine changes supporting workforce wellbeing and retention, not attrition treated as an unexamined, unavoidable cost of doing business.

Full guidance for 13.8 →

1. Is staff sick leave data genuinely monitored and analysed? — Real, ongoing analysis, not data collected and left unexamined.

2. Are the genuine reasons staff leave actually captured, particularly burnout and physical strain? — Real, specific exit data covering this sector’s genuinely common attrition drivers.

3. Is there a documented instance where this data genuinely informed a real, implemented change? — A real, concrete example, not data with no demonstrated influence on practice.

The organisation genuinely monitors and responds to real patterns of equity across recruitment, work allocation, scheduling, and promotion — not an assumption that fair treatment exists simply because no formal complaint has been raised.

Full guidance for 13.9 →

1. Is workforce data on recruitment, work allocation, scheduling, and promotion genuinely monitored for patterns of inequity? — A real, documented monitoring process, not an assumption that fairness exists by default.

2. Where a genuine pattern is identified, is there a real, defined response? — A genuine corrective process, not data collected with no real follow-through.

3. Is there a real, documented instance of this monitoring genuinely informing a change in practice? — A concrete, real example.