Standard 23: Long-Term Care (Version 11)

Why it matters. A resident in long-term care who loses function slowly can be left to decline unless someone plans to keep them moving. An individual maintenance plan, built from the assessment, is what keeps the resident as active as possible.

Sample. Review 10 residents receiving rehabilitation or restorative therapy, and their functional plans.

1. Each resident receiving therapy has an individual plan from a documented functional assessment.

Method. Check each sampled resident for the assessment and the plan.

Evidence to show. Functional maintenance plan record (LTC-FRM-003).

Pass when. Every sampled resident has a plan from assessment.

2. The plan aims at maintenance and slowing decline.

Method. Check each plan for maintenance goals.

Evidence to show. Functional maintenance and rehabilitation in long-term care (LTC-POL-001).

Pass when. Every plan states maintenance goals.

3. A decline triggers a plan review.

Method. Check each recorded decline for the review.

Evidence to show. Functional status measurement register (LTC-REG-002).

Pass when. Every decline has a review recorded.

Immediate fail (any one means the criterion is not met). A resident who stopped walking after a hospital stay, with no plan to restore it.

Why it matters. In long-term care the therapist and the daily nursing team see the resident at different times. If their goals differ, the resident gets mixed messages every day.

Sample. Review the therapy and care plans for 10 residents with therapy goals.

1. Therapy goals are shared with the nursing and care team.

Method. Check each sampled plan for the shared goals.

Evidence to show. Individual care plan (CLN-FRM-003).

Pass when. Every sampled plan shows the shared goals.

2. Daily practice follows the therapy plan.

Method. Observe a sample of transfers and walks against the plan.

Evidence to show. Coordinating therapy with daily nursing and care (LTC-SOP-003).

Pass when. Observed practice follows the therapy plan.

3. Conflicts are resolved and recorded.

Method. Check each recorded conflict for the resolution.

Evidence to show. Coordinating therapy with daily nursing and care (LTC-SOP-003).

Pass when. Every conflict has a resolution recorded.

Immediate fail (any one means the criterion is not met). Therapy asks for independent walking and nursing transfers the resident by hoist every time.

Why it matters. A resident who has never been asked what they want from their own rehabilitation is unlikely to work at it. Goals set with the resident, and with family where the resident wants it, give the plan a purpose.

Sample. Review the goal-setting records for 10 residents.

1. Goals are set with the resident in their own words.

Method. Check each sampled record for the resident goals.

Evidence to show. Resident and family goal-setting record (LTC-FRM-004).

Pass when. Every sampled record has the resident goals.

2. Family is involved where the resident wants it.

Method. Check each record for the family involvement.

Evidence to show. Resident and family goal-setting record (LTC-FRM-004).

Pass when. Every record shows the family involvement the resident chose.

3. Realistic expectations are explained.

Method. Check each record for the expectations explained.

Evidence to show. Resident and family goal-setting record (LTC-FRM-004).

Pass when. Every record shows the expectations explained.

Immediate fail (any one means the criterion is not met). A resident’s goal to walk to the garden never recorded.

Why it matters. A resident whose function declines slowly may not be noticed until a fall. A validated tool, used at set intervals, shows the decline early enough to act on it.

Sample. Review the functional measurement register for 10 residents over the last 6 months.

1. Function is measured with a validated tool at set intervals.

Method. Check each resident for measurements at each interval.

Evidence to show. Functional status measurement register (LTC-REG-002).

Pass when. At least 95% of intervals have a measurement.

2. Each decline is flagged.

Method. Check each decline against the last score.

Evidence to show. Functional status measurement register (LTC-REG-002).

Pass when. Every decline is flagged.

3. A flagged decline triggers a care plan review.

Method. Check each flagged decline for the review.

Evidence to show. Functional status measurement register (LTC-REG-002).

Pass when. Every flagged decline has a review recorded.

Immediate fail (any one means the criterion is not met). A resident who lost the ability to transfer over three months, with no score.

Why it matters. A resident given a walking frame or a hoist that does not fit, or that has broken, can fall or be injured. Equipment should match the need and be checked for fit and condition.

Sample. Review the equipment records for 10 residents using mobility aids, and walk through the unit.

1. Devices are assessed and fitted to the resident’s need.

Method. Check each sampled resident for the assessment and fitting record.

Evidence to show. Beds and mobility equipment check (ACS-SOP-002).

Pass when. Every sampled device has an assessment and fitting record.

2. Equipment is checked for condition and safe life.

Method. Check each device for the condition check and its service date.

Evidence to show. Mobility equipment register (ACS-REG-001).

Pass when. Every device is checked within its service interval.

3. Staff are trained in correct use.

Method. Check the training record for the staff using the equipment.

Evidence to show. Equipment Inventory and Service Log (EQP-REG-001).

Pass when. Staff using each device are trained.

Immediate fail (any one means the criterion is not met). A hoist sling used past its safe life.

Why it matters. Restraints on a resident, such as bed rails or chairs that lock, can cause falls, injury and loss of independence. Mobility support should use the least restrictive means possible.

Sample. Review the restraint records and mobility support plans for 10 residents.

1. The least restrictive means is used for mobility support.

Method. Check each sampled plan for the least restrictive option considered.

Evidence to show. Restraint and seclusion (CLN-POL-002).

Pass when. Every plan shows the least restrictive option considered.

2. Restraint is recorded and reviewed.

Method. Check each restraint for the record and review.

Evidence to show. Restraint and seclusion record (CLN-FRM-004).

Pass when. Every restraint is recorded and reviewed.

3. Restriction is not used as a substitute for staffing.

Method. Check each restraint for the reason and the staffing level.

Evidence to show. Restraint and seclusion record (CLN-FRM-004).

Pass when. No restraint is recorded for staffing reasons.

Immediate fail (any one means the criterion is not met). A resident tied to a chair for a whole day.

Why it matters. Sustainability decisions made one purchase at a time never add up to a strategy. A strategic review, held by leadership, looks at the facility’s whole environmental impact and decides what to change.

Sample. Review the leadership environmental review and its minutes for the last 12 months.

1. Leadership undertakes a strategic environmental review.

Method. Check the review for its date and scope.

Evidence to show. Leadership Environmental Review Record (ENV-FRM-006).

Pass when. A review is recorded in the last 12 months.

2. The review covers the 24-hour operation.

Method. Check the review scope for the night and weekend operation.

Evidence to show. Environmental Impact Review (leadership) (ENV-SOP-004).

Pass when. The review covers the 24-hour operation.

3. The review leads to decisions.

Method. Check the review for decisions recorded.

Evidence to show. Leadership Environmental Review Record (ENV-FRM-006).

Pass when. Each review has a decision recorded.

Immediate fail (any one means the criterion is not met). No review by leadership ever done.

Why it matters. Sharps injuries and waste exposure are common and avoidable. Containers at the point of use and correct segregation at the bin prevent most of them. A container that is overfilled is a hazard.

Sample. Walk through the unit and review the waste contract and disposal records for the last 3 months.

1. Clinical and incontinence waste is segregated at the point of generation.

Method. Observe containers at points of use and at the bin.

Evidence to show. Sharps and Clinical Waste Management (WST-SOP-001).

Pass when. Waste is segregated at the point of use.

2. Containers are present and not overfilled.

Method. Observe containers for presence and fill level.

Evidence to show. Sharps and Clinical Waste Management (WST-SOP-001).

Pass when. Every point of use has a container, none overfilled.

3. Disposal is through a verified pathway.

Method. Check the disposal records against the contract.

Evidence to show. Waste Contract and Disposal Record (WST-FRM-001).

Pass when. Every disposal is recorded with its pathway.

Immediate fail (any one means the criterion is not met). Containers absent at points of use, overfilled, or waste mixed.

Why it matters. Purchases carry environmental and social costs: wasteful packaging, disposable products, and suppliers who exploit workers. Procurement that considers these reduces both.

Sample. Review the supplier evaluation records for 5 high-volume purchases, including continence products.

1. Procurement considers environmental and social responsibility.

Method. Check each sampled purchase for the environmental criterion.

Evidence to show. Supplier Review Record (PRC-FRM-001).

Pass when. Every sampled purchase applies the criterion.

2. High-volume purchases are included.

Method. Check the purchase list for continence products and other high-volume items.

Evidence to show. Responsible Procurement Policy (PRC-POL-001).

Pass when. High-volume purchases are covered by the policy.

3. Single-use decisions are reviewed against safety.

Method. Check each single-use decision for the safety review.

Evidence to show. Procurement Stewardship Review (PRC-SOP-001).

Pass when. Every single-use decision is reviewed.

Immediate fail (any one means the criterion is not met). All purchasing on lowest price regardless of waste.

Why it matters. A facility that does not measure its energy use cannot reduce it. Monitoring electricity, gas and fuel, and taking steps away from the most polluting sources, is the first practical step.

Sample. Review the monthly energy and water records for the last 12 months.

1. Electricity, gas and fuel use are monitored.

Method. Check the monthly record for each source.

Evidence to show. Monthly Energy Use Record (ENV-FRM-008).

Pass when. Every source is recorded each month.

2. Steps are taken to reduce reliance on fossil fuels where practical.

Method. Check the reduction plan for each step.

Evidence to show. Energy Reduction and Renewable Options Plan (ENV-PLN-003).

Pass when. The plan lists the steps taken.

3. Resident comfort is protected during reductions.

Method. Check the reduction records for a comfort check.

Evidence to show. Energy Use Monitoring and Reduction (ENV-SOP-006).

Pass when. Each reduction has a comfort check recorded.

Immediate fail (any one means the criterion is not met). Energy bills paid without anyone looking at the use.

Why it matters. Staff and patients can help a sustainability goal only if they know what it is. Communicating the goals in plain words makes the approach something people do, not something on paper.

Sample. Review the sustainability communication record and the resident and family notices.

1. Staff are informed of the approach and the goals.

Method. Check the communication record for staff notice.

Evidence to show. Sustainability Communication Record (ENV-REG-001).

Pass when. The goals are communicated to staff.

2. Residents and families are informed.

Method. Check the notice for resident and family information.

Evidence to show. Staff and Patient Sustainability Notice (ENV-FRM-007).

Pass when. The notice reaches residents and families.

3. Residents and families are included in engagement.

Method. Check the engagement record for residents and families.

Evidence to show. Sustainability Communication Record (ENV-REG-001).

Pass when. Residents and families are engaged.

Immediate fail (any one means the criterion is not met). Goals never shared.

Why it matters. Floods, heatwaves, power cuts and disease outbreaks can stop a facility from working. Thinking ahead about how the service would keep running is part of keeping patients safe.

Sample. Review the climate and health emergency continuity plan and the last test.

1. Climate-related risks to service delivery are considered.

Method. Check the plan for heatwave, flood, storm and outbreak risks.

Evidence to show. Climate and Health Emergency Continuity Plan (FAC-PLN-002).

Pass when. The plan covers each risk named.

2. A range of actions is planned.

Method. Check the plan for the actions and owners.

Evidence to show. Climate and Health Emergency Risk Assessment (FAC-SOP-003).

Pass when. Actions and owners are set for each risk.

3. Resident safety during climate events is planned.

Method. Check the plan for resident safety measures.

Evidence to show. Climate and Health Emergency Continuity Plan (FAC-PLN-002).

Pass when. The plan includes resident safety measures.

Immediate fail (any one means the criterion is not met). No thought given to a heatwave that shuts the power for days.

Why it matters. Goals that are never reported to the people who govern the facility are easily dropped. A set reporting schedule to governance keeps progress visible and acted on.

Sample. Review the governance reports on sustainability for the last 12 months.

1. Progress is reported to governance on a defined schedule.

Method. Check each report against the schedule.

Evidence to show. Governance Reporting of Sustainability Progress (ENV-SOP-005).

Pass when. Every scheduled report is made.

2. Goals are reviewed on the same schedule for long-term care.

Method. Check the review for the long-term care goals.

Evidence to show. Governance Reporting of Sustainability Progress (ENV-SOP-005).

Pass when. The long-term care goals are reviewed on schedule.

3. Governance acts on the report.

Method. Check the governing minutes for the decisions taken.

Evidence to show. Governing Body Minutes Template (GOV-FRM-003).

Pass when. Each report has a decision recorded.

Immediate fail (any one means the criterion is not met). No report to governance on sustainability ever given.

Why it matters. A digital tool introduced into care without a check can slow care down, expose data, or fail when most needed. Assessing a tool before it is used, and managing it afterwards, protects the patient and the service.

Sample. Review the assessments for 5 digital care systems introduced in the last 12 months.

1. Each system is assessed before adoption.

Method. Check each system for the assessment before introduction.

Evidence to show. Digital Tool Assessment Template (DIG-FRM-002).

Pass when. Every system has an assessment before adoption.

2. Costs, benefits and compatibility are weighed.

Method. Check each assessment for the cost, benefit and compatibility entries.

Evidence to show. Digital Care System Assessment and Management (DIG-SOP-002).

Pass when. Every assessment includes all three.

3. The system is managed after adoption.

Method. Check each system for the post-adoption review.

Evidence to show. Digital Care System Assessment and Management (DIG-SOP-002).

Pass when. Every system has a review after adoption.

Immediate fail (any one means the criterion is not met). A patient-facing app introduced by a clinician with no assessment.

Why it matters. Some patients cannot use a phone app, do not have internet, or find video calls hard. A service that moves everything online without an alternative leaves those patients without care.

Sample. Review 10 residents or families who do not use digital channels, and the access record.

1. Residents and families who cannot use digital channels have an alternative.

Method. Check each sampled case for the alternative offered.

Evidence to show. Digital Alternative Record (DIG-FRM-003).

Pass when. Every sampled case has an alternative recorded.

2. No resident is disadvantaged by digital care.

Method. Check each sampled case for the outcome of the alternative.

Evidence to show. Digital Care Access and Alternatives (DIG-SOP-003).

Pass when. No case shows a disadvantage.

3. The alternative is offered at the point of booking.

Method. Check each booking record for the alternative offered.

Evidence to show. Digital Alternative Record (DIG-FRM-003).

Pass when. At least 95% of bookings offer an alternative where needed.

Immediate fail (any one means the criterion is not met). An older resident refused an appointment because they have no smartphone.

Why it matters. A digital system that no one can support when it fails leaves staff stuck and patients unseen. Access to technical expertise, in-house or from a vendor, keeps the system working when it matters.

Sample. Review the technical support arrangement, the test records and the overnight cover.

1. Technical expertise is available for each digital system.

Method. Check the support arrangement for each system.

Evidence to show. Technical Support and Testing Arrangement (DIG-PLN-001).

Pass when. Every system has a support arrangement.

2. Systems are tested before full implementation.

Method. Check each system for the test record.

Evidence to show. Digital System Test and Support Record (DIG-FRM-004).

Pass when. Every system has a test recorded before full use.

3. Support is available overnight.

Method. Check the overnight rota or contract.

Evidence to show. Technical Support and Testing Arrangement (DIG-PLN-001).

Pass when. Overnight support is confirmed in the arrangement.

Immediate fail (any one means the criterion is not met). A system down for two days with no one to call.

Why it matters. Artificial intelligence can help with diagnosis and triage, but it can also make errors that look confident. WHO’s guidance on AI in health asks for safety, transparency and human oversight, and a facility that introduces AI must follow it.

Sample. Review the AI systems in use for diagnosis, triage or care decisions, and their introduction records.

1. Each AI system is introduced in line with WHO AI governance guidance.

Method. Check each system for the assessment against WHO guidance.

Evidence to show. AI System Assessment (AI-FRM-001).

Pass when. Every AI system has an assessment recorded.

2. The governance basis, including consent, is stated.

Method. Check each assessment for the governance basis and consent.

Evidence to show. Responsible Use of AI in Care Policy (AI-POL-001).

Pass when. Every assessment states the basis and consent.

3. The responsible use policy is in force.

Method. Check the policy for the WHO principles.

Evidence to show. Responsible Use of AI in Care Policy (AI-POL-001).

Pass when. The policy is in force and covers the principles.

Immediate fail (any one means the criterion is not met). An AI triage tool used with no assessment.

Why it matters. An AI system can work well at first and then drift, missing diagnoses or over-diagnosing as the patients change. Auditing its results regularly is the only way to notice.

Sample. Review the AI monitoring register and audit records for each AI system in use.

1. AI results are audited for over- and missed diagnosis.

Method. Check each audit for the review.

Evidence to show. AI Monitoring Register (AI-REG-001).

Pass when. Every AI system has an audit in the period.

2. Patient complaints about AI-assisted care are tracked.

Method. Check the complaints log for AI-related complaints.

Evidence to show. AI Monitoring Register (AI-REG-001).

Pass when. Every AI-related complaint is tracked.

3. Fall-risk and behaviour alerts are monitored.

Method. Check the audit for fall-risk and behaviour alert review.

Evidence to show. AI Performance and Safety Monitoring (AI-SOP-001).

Pass when. The audit covers fall-risk and behaviour alerts.

Immediate fail (any one means the criterion is not met). An AI tool never checked after it went live.

Why it matters. Staff who will use an AI system every day know the practical problems that a manager may not. Consulting them before it is introduced finds those problems early.

Sample. Review the staff consultation records for each AI system introduced in the last 12 months.

1. Staff are consulted before introduction.

Method. Check each introduction for the consultation before go-live.

Evidence to show. Staff Consultation Record (AI-FRM-002).

Pass when. Every introduction has a consultation before go-live.

2. Training needs are identified.

Method. Check each consultation for the training needs recorded.

Evidence to show. Staff Consultation Record (AI-FRM-002).

Pass when. Every consultation records the training needs.

3. Night-shift staff are consulted.

Method. Check the consultation attendance for night-shift staff.

Evidence to show. Staff Consultation Before AI Introduction (AI-SOP-002).

Pass when. Night-shift staff attend each consultation.

Immediate fail (any one means the criterion is not met). An AI system introduced with no staff input.

Why it matters. When an AI system contributes to a wrong decision, it is not clear who is responsible: the clinician, the vendor or the facility. A documented accountability arrangement answers that question before there is an incident.

Sample. Review the accountability arrangements for each AI system, and any AI-assisted decision reviewed.

1. Accountability for AI-assisted care is documented.

Method. Check each AI system for the accountability arrangement.

Evidence to show. Accountability for AI-Assisted Care (AI-POL-002).

Pass when. Every AI system has accountability documented.

2. A named party is responsible for each AI-assisted decision.

Method. Check each reviewed decision for the responsible party named.

Evidence to show. Accountability for AI-Assisted Care (AI-POL-002).

Pass when. Every reviewed decision names the responsible party.

3. Monitoring does not replace direct observation.

Method. Check the policy for the statement and the practice in the sample.

Evidence to show. Accountability for AI-Assisted Care (AI-POL-002).

Pass when. The policy states it and the practice matches.

Immediate fail (any one means the criterion is not met). An AI-assisted decision with no one named as responsible.

Why it matters. A patient who is treated with the help of AI has a right to know. Telling them, rather than leaving them to assume, is part of informed consent and trust.

Sample. Review 10 resident and family records where AI was involved in care.

1. Each resident is informed when AI is involved in care.

Method. Check each sampled record for the information given.

Evidence to show. Patient Information on AI-Supported Care (template) (AI-FRM-003).

Pass when. Every sampled record shows the information given.

2. Families are told when AI is involved.

Method. Check each record where a family is involved for the information given.

Evidence to show. Informing Patients About AI-Supported Care (AI-SOP-003).

Pass when. Every family is told where AI is involved.

3. Disclosure is a standard part of care.

Method. Check the procedure for disclosure as a standard step.

Evidence to show. Informing Patients About AI-Supported Care (AI-SOP-003).

Pass when. Disclosure is a standard step in the procedure.

Immediate fail (any one means the criterion is not met). A patient never told that an AI tool helped decide their care.

Why it matters. A licence copy in a file is not verification. The issuing body must confirm it, and the check must be repeated on renewal. Agency staff and volunteers who give care are included.

Sample. Review the verification records for 10 clinical staff, including agency staff and volunteers.

1. Each clinical staff member’s qualification is verified with the issuing body.

Method. Check each sampled file for direct verification.

Evidence to show. Staff Verification Register (STF-FRM-001).

Pass when. Every sampled file shows direct verification.

2. Verification is repeated on renewal.

Method. Check each sampled renewal for the recheck.

Evidence to show. Staff Credential Verification and Recheck (STF-SOP-001).

Pass when. Every renewal shows the recheck.

3. Agency staff and volunteers are checked against their scope.

Method. Check each agency or volunteer file for the scope check.

Evidence to show. Staff Credential Verification and Recheck (STF-SOP-001).

Pass when. Every agency or volunteer file shows the scope check.

Immediate fail (any one means the criterion is not met). No direct verification in any sampled file, or a lapsed licence still in use.

Why it matters. Health workers can catch infections and be hurt at work, and they can also carry infections to patients. Protecting their health, with required vaccinations and safe working conditions, protects everyone in the building.

Sample. Review workforce health and safety records and the manual handling records for the last 12 months.

1. Required vaccinations are in place for staff.

Method. Check each sampled staff file for the vaccination record.

Evidence to show. Staff vaccination and immunisation (WRK-SOP-003).

Pass when. Every sampled file shows the vaccinations required.

2. Manual handling injuries from transfers are prevented.

Method. Check each transfer for the handling method and equipment.

Evidence to show. Manual handling and transfer risk record (LTC-FRM-005).

Pass when. Every transfer has a method and equipment recorded.

3. Needlestick injuries are responded to.

Method. Check each needlestick report for the response.

Evidence to show. Occupational exposure and needlestick response (WRK-SOP-002).

Pass when. Every report has a response recorded.

Immediate fail (any one means the criterion is not met). A staff member working without a required vaccination and no check.

Why it matters. Staff who are attacked need specific protections, not general statements. Tracking incidents shows whether the protections work.

Sample. Review the violence and aggression incident records and the response for the last 12 months.

1. Concrete measures protect staff from aggression.

Method. Check the measures against the policy.

Evidence to show. Violence and aggression prevention and response (WRK-SOP-006).

Pass when. Measures are in place for each risk.

2. Incidents are tracked.

Method. Check the incident record for each reported incident.

Evidence to show. Violence and aggression incident record (WRK-FRM-003).

Pass when. Every incident is tracked.

3. Dementia-related aggression has its own response.

Method. Check the response for dementia-related incidents.

Evidence to show. Dementia-related aggression: response (LTC-SOP-005).

Pass when. Dementia-related incidents follow the response.

Immediate fail (any one means the criterion is not met). No measures; incidents not tracked.

Why it matters. Residents in long-term care reach the end of life after years of living there, and their wishes must guide that time. Recording those wishes, and reviewing them with the resident, makes the care match what they want.

Sample. Review the end-of-life wishes and dying care plans for 10 residents who died in the last year.

1. Each resident’s wishes for end-of-life care are recorded.

Method. Check each sampled record for the wishes recorded.

Evidence to show. Goals, values and wishes record (HSP-FRM-002).

Pass when. Every sampled record has the wishes recorded.

2. The wishes are reviewed with the resident and family.

Method. Check each record for the review and the family involved.

Evidence to show. Dying care plan record (HSP-FRM-005).

Pass when. Every record shows the review.

3. Palliative care is provided when needed.

Method. Check each sampled record for the palliative care given.

Evidence to show. Care of the dying patient (HSP-SOP-003).

Pass when. Every sampled resident has palliative care given when needed.

Immediate fail (any one means the criterion is not met). A dying resident moved to hospital against their written wishes.

Why it matters. Decisions about resuscitation and hospital transfer need to be made in advance, with the resident or their representative, not in a crisis at night. Offering the conversation and recording the result protects the resident’s choice.

Sample. Review the advance care planning records for 10 residents.

1. Residents are offered advance care planning.

Method. Check each sampled record for the offer.

Evidence to show. Treatment limits record (HSP-FRM-006).

Pass when. Every sampled record shows the offer.

2. Resuscitation and treatment limits are recorded.

Method. Check each record for the decision recorded.

Evidence to show. Treatment limits record (HSP-FRM-006).

Pass when. Every record shows the decision recorded.

3. The decision is available to staff who need it.

Method. Check the record location and access for care staff.

Evidence to show. Goals, values and wishes record (HSP-FRM-002).

Pass when. The decision is available to staff on each shift.

Immediate fail (any one means the criterion is not met). A resident resuscitated against their wishes because the choice was never recorded.

Why it matters. When a resident dies, the staff, the family and the other residents are all affected. A documented process that treats the death with dignity, and reviews what could have been better, supports everyone.

Sample. Review the records of residents who died in the last 12 months and the family contact records.

1. A documented process is followed when a resident dies.

Method. Check each death for the documented steps.

Evidence to show. Bereavement follow-up (HSP-SOP-005).

Pass when. Every death follows the documented steps.

2. The family is supported and contacted.

Method. Check each death for family support and contact.

Evidence to show. Family support and bereavement follow-up record (HSP-FRM-003).

Pass when. Every family is contacted and supported.

3. Deaths requiring review are reviewed.

Method. Check each review-required death for the review.

Evidence to show. Root cause analysis of serious incidents (INC-SOP-001).

Pass when. Every review-required death has a review.

Immediate fail (any one means the criterion is not met). A family left to find out about a death by phone with no contact from staff.