Nursing Home Minimum Standards - Regulation and Quality ...

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5.6 Contemporaneous nursing records, in accordance with NMC guidelines, are kept of all nursing interventions, activities and procedures that are carried out in relation to each patient. These records include outcomes for patients. 5.7 The outcome of care delivered is monitored and recorded on a day-to-day basis and, in addition, is subject to documented review at agreed time intervals and evaluation, using benchmarks where appropriate, with the involvement of patients and their representatives. 5.8 Patients are encouraged and facilitated to participate in all aspects of reviewing outcomes of care and to attend, or contribute to, formal multi-disciplinary review meetings arranged by local HSC Trusts as appropriate. 5.9 The results of all reviews and the minutes of review meetings are recorded and, where required, changes are made to the nursing care plan with the agreement of patients and representatives. Patients, and their representatives, are kept informed of progress toward agreed goals. 20
Completion of case records Standard 6: Patients’ case records are accurate and up to date. Criteria 6.1 The policy and procedure for maintaining case records in relation to treatment and care provided for patients complies with guidelines from professional and regulatory bodies. 6.2 All entries in case records are contemporaneous; dated, timed, and signed, with the signature accompanied by the name and designation of the signatory. 6.3 Any alterations or additions are dated, timed and signed, and made in such a way that the original entry can still be read. 6.4 All treatment given and recommendations made are recorded in case records. 21
Page 1 and 2: Nursing Homes Minimum Standards Jan
Page 3 and 4: 31. Volunteers 58 32. Premises and
Page 5 and 6: Regulation and Quality Improvement
Page 7 and 8: Privacy Patients have the right to
Page 9 and 10: Quality care Patients will experien
Page 11 and 12: a multi-professional team that is f
Page 13 and 14: Authority and of the arrangements f
Page 15 and 16: Admission to the home Standard 3: A
Page 17 and 18: Individual agreement Standard 4: Ea
Page 19: Nursing care Standard 5: Patients r
Page 23 and 24: Nutrition Standard 8: Nutritional n
Page 25 and 26: Responding to patients’ behaviour
Page 27 and 28: Meals and mealtimes Standard 12: Pa
Page 29 and 30: Programme of activities and events
Page 31 and 32: Death and dying Standard 14: The dy
Page 33 and 34: allowances kept by the home on the
Page 35 and 36: Protection of vulnerable adults Sta
Page 37 and 38: 17.9 Complaints are investigated an
Page 39 and 40: When the home runs a scheme where t
Page 41 and 42: Resuscitation Standard 20: Resuscit
Page 43 and 44: Palliative care Standard 22: Patien
Page 45 and 46: Management of the home Quality care
Page 47 and 48: • A copy of the relevant statemen
Page 49 and 50: 25.8 Any change to: - • The state
Page 51 and 52: 25.24 There are arrangements in pla
Page 53 and 54: Management of records Standard 27:
Page 55 and 56: Staff supervision and appraisal Sta
Page 57 and 58: • The date of all meetings • Th
Page 59 and 60: Premises and grounds Standard 32: T
Page 61 and 62: Medical devices and equipment Stand
Page 63 and 64: 34.8 Hand hygiene must be a priorit
Page 65 and 66: 35.4 There is a designated member o
Page 67 and 68: Management of medicines Standard 37
Page 69 and 70: Medicines storage Standard 39 Medic
Page 71 and 72:
process and outcomes are documented
Page 73 and 74:
Registration This section sets out
Page 75 and 76:
A fire safety management plan that
Page 77 and 78:
Fitness of the registered manager T
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Fitness of the premises - new homes
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N14. Furniture and fittings in comm
Page 83 and 84:
N26. Furniture and fittings are saf
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Clinical or treatment room N37. The
Page 87 and 88:
N55. There are separate recessed ar
Page 89 and 90:
E8. Patient/staff call points, acce
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single room when one becomes availa
Page 93 and 94:
and Schedule 3 controlled drugs sub
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E45. Secure facilities are provided
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APPENDIX 2 Policies and procedures
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Staff handover Staff induction Staf
Page 101 and 102:
Appendix 4 Glossary of terms - Nurs
Page 103:
Self-referred patient A patient who
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