Considerations for Developing Schedule 5 Policies and Procedures

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A nursing home is a place where elderly residents deserve the utmost care, compassion, and respect. The foundation of a well-functioning nursing home lies in its policies and procedures. These guidelines serve as a roadmap for staff, ensuring that residents receive the best possible care, their safety is prioritised, and their overall well-being is maintained.

As part of the Health Act 2007 (Care and Welfare of Residents in Designated Centres for Older People) Regulations 2013 (S.I.No. 415 of 2013), Registered Providers are required to prepare in writing, adopt and implement policies and procedures on the matters set out in Schedule 5 of the legislation.

In HCI’s recent Summary of HIQA Inspection Findings in Designated Centres for Older People, it was identified that 20% of services were not compliant with Regulation 4: Written Policies and Procedures. Findings included written policies and procedures were not available to staff working in the residential centre on the day of inspection, a number of policies required by Schedule 5 of the regulations were not in place in line with regulatory requirements and several policies reviewed were out of date.

In this blog post, we review the Schedule 5 Policies and Procedures and provide guidance to developing effective policies and procedures.

What are the Schedule 5 Policies and Procedures:

Schedule 5 policies and procedures are set out in S.I.No.415 of 2013. Designated Centres for Older People are required by law to have these Policies and Procedures in place within their service, to make them available to staff and to review the Policies and Procedures as often as the Chief Inspector may require but in any event at intervals not exceeding 3 years and, where necessary, review and update them in accordance with best practice.

Services must also review the National Standards for Residential Care Settings for Older People in Ireland (2016) to identify important information to be incorporated into the Schedule 5 Policies and Procedures. It is also important to review and incorporate requirements from other relevant other key documents such as National Standards for infection prevention and control (IPC) in community services (HIQA, 2018) and the National Standards for Adult Safeguarding (HIQA & MHC, 2019), amongst others.

Services are also obligated to ensure that staff are trained and competent to implement the relevant Policies and Procedures and that they are easily accessible to the relevant parties.

The Schedule 5 Policies and Procedures includes:

  1. The prevention, detection and response to abuse
  2. Admissions
  3. Management of behaviour that is challenging
  4. The use of restraint
  5. Residents’ personal property, personal finances and possessions
  6. Communication
  7. End of life care
  8. Staff training and development
  9. Recruitment, selection and vetting of staff
  10. Monitoring and documentation of nutritional intake
  11. Provision of information to residents
  12. The creation of, access to, retention of and destruction of records
  13. Temporary absence and discharge of residents
  14. Health and safety of residents, staff and visitors (including infection control and food safety)
  15. Risk management
  16. Responding to emergencies
  17. Fire safety management;
  18. The ordering, receipt, prescribing, storing and administration of medicines to residents
  19. The handling and disposal of unused or out of date medicines
  20. The handling, investigation and review of complaints about any aspects of service, care and treatment provided in, or on behalf of a designated centre.

Guidance for Policy and Procedure Development

Outlined below are 7 key stages to the development of a Policy and Procedure.

Stage 1: Initiation: During the initiation stage you must consider the legislative and regulatory requirements for the policy and procedure. Clarify the process to ensure standardised implementation and identify areas of potential risks, known incidents or non-conformances. Define the scope of the policy, agree who the author, reviewers and approvers are and understand the target users who will be impacted by the process. It is also important to recognise the needs and priorities of the stakeholders, including staff and residents.

Stage 2: Development: When developing the content of a Policy and Procedure, it is important to consider the below elements:

  1. Policy Statement: Include a written operational statement of intended outcomes to guide staff actions in particular circumstances (HIQA, 2016). This differs from the procedure, which is a set of instructions that describe the approved steps to be taken to fulfil a policy (HIQA, 2016).
  2. Definitions: Define all ambiguous terms, definitions should be clear and concise and if possible, reference all definitions utilising relevant sources.
  3. Responsibilities: All responsibilities should be defined upfront and throughout the procedure. Responsibilities should be allocated as per job title, and must be reflective of staff seniority, capabilities, and regulatory requirements.
  4. Procedure: The procedure describes specific step by step instructions of what will be done, by whom, and the sequence in which to perform those steps. When planning the content of the procedure, it is important to consider what it is you want to achieve, review how things are done currently and identify if there is a better way. Review the costs associated with the process, the resources required and determine what are the high-risk elements of the process. Consider the training requirements, the supervision requirements, is clear what to do if things go wrong, and how will the process be evaluated. Develop a process flow chart that illustrates a picture of the sequences of steps or actions in the process. It should flow from top to bottom, or left to right. Include numbering in the flow chart to improve clarity of the process flow.
  5. Education & Training: Identify who requires education and training, should it be included as part of induction process and how often is retraining required. Identify who will provide the training, how is it documented and how will you know if it has been effective. It is also important to consider if residents require education or communication on the policy and procedure.
  6. Audit & Evaluation: Services must audit policies and procedures to determine if they are being implemented. Identify key points from the flow chart to be audited. Communicate the audit findings to Senior Management and all staff to help ensure learnings are taken from findings. Where an audit identifies a non-conformance, complete a root cause analysis, and take corrective & preventive action as required.
  7. Records: All records referred to in the policy and procedure should be summarised. This provides clarity for related policies and procedures, particularly during review and update.
  8. References: All references used in the policy and procedure should be listed, utilising a standardised referencing format.

Stage 3: Governance and Approval: Implement a Policy on Procedure on the Development, Review, Approval and Communication of Policies and Procedures to provide clarity on roles and responsibilities in relation to the policy and procedure development team.  Identify who the author is, the owner of the document, the reviewer, the approver and who the document is to be communicated to. A draft document ready to be reviewed should be sent to the appropriate individuals/team for review. This can be done electronically or in paper format. Timeframes for feedback should be agreed. Consider the approval levels required, the method of approval and the timeframes for approval. Once approved a document can be activated.

Stage 4: Communication and Dissemination: Establish who the documents are to be communicated to and how can staff access them. Identify the process for staff to acknowledge the documents and consider how you will retain records of acknowledgement of document versions as well as original documents.

Stage 5: Implementation: Training must be provided to staff on the Policy and Procedure(s). Up to date versions much also be easily access to staff, whether that is hard copy or electronically.  

Stage 6: Monitoring, Audit, Evaluation: Annual audits should be undertaken to determine compliance with the policy and procedure. This usually includes planning, identifying risk areas, assessing internal controls, sampling of data, testing of processes, validating information and formally communicating recommendations and corrective action measures to both management and the board/or appropriate governance structures.

Stage 7: Revision / Update: Policies and Procedures should be reviewed where there is a change in practice, change in legislation and/or a request by Inspector. The Document Owner is responsible for managing the review.


Developing comprehensive policies and procedures for a nursing home is a critical step in ensuring the well-being and safety of its residents. Implementing best practice, evidence-based policies and procedures will not only create a positive environment for residents but also empower staff to deliver the best possible care.

If you are looking to develop an up-to-date suite of Schedule 5 Policies and Procedures, then HCI can support you. HCI have extensive experience in supporting nursing homes and other healthcare providers in process mapping and developing evidence-based Policies and Procedures that are in line with regulatory requirements and tailored to your specific organisation.

HCI has also developed a suite of best practice policies and procedures and records and forms for nursing homes which will help improve your quality of care and support your HIQA compliance. When you purchase this bundle package you get access to all new updates and new document releases for 12 months. Keeping policies and procedures up to date with current standards and best practice guidance can be time consuming. This is why our package is very beneficial for nursing homes. Our dedicated Best Practice Team do the hard work for you as they will continuously research all National Standards, regulations and best practice guidance relating to long-term care and include the requirements in our documents. When we release an updated document, all changes are highlighted in blue making it easier for you to educate and train staff on the updates.  All documents are available in an electronic format (Microsoft word), allowing you to tailor them to suit your specific requirements.

If you would like any further information on HCI’s support offering, please contact HCI on 01 629 2559 or

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