Table 2 Content of protocols regarding care delivery

Several activities aimed at quality improvement are described. First, all nursing homes work with a client satisfaction survey which is spread out periodically to all first responsible informal caregivers of the residents. Second, mechanisms for handling complaints are installed by means of a ‘complaint commission’ and a client board. Third, all incidents are registered in a national reporting system which is checked by the Health Care Inspectorate. Fourth, participating nursing homes had a nationally recognized quality label which was granted after inspection.

All nursing homes had specified in their protocols that nursing home care does not mean residents need to be supervised or watched 24 h every day. Instead, nursing homes use the term ‘attentive supervision’, which means that each resident is supervised at the level that he or she needs. A general guideline is that residents are left ‘unsupervised’ for a maximum of 10 minutes. Furthermore, all participating nursing homes could use technological aids if this is deemed necessary.

Each client has its’ own personal record consisting of a paper record and an electronic one. In the paper record a care agreement and the indication for a care package are included. The electronic record contains a care plan, daily reports, and client-related agreements. The client records need to be complete 6 weeks after admission (meaning it should also be evaluated by family members of the resident). Each half year the client records are discussed within a multidisciplinary team and if needed adjusted.

All participating nursing homes try to reduce the physical restraints to a minimum. The goal is to look for alternatives for physical restraints. However, the guidelines for these alternatives differ across settings. At green care farms, there were no defined guidelines on which alternatives to use when. At the other types of nursing homes it was clearly stated when to use a particular alternative for physical restraints. In addition, it was determined which staff was allowed to apply certain measures. At green care farms, this was left unspecified.

For medication safety, no differences were found between green care farms and other types of nursing homes. All nursing homes use individual and up to date medication lists. Medication is wrapped in individual doses which are kept in a medication cabinet. Only the responsible physicians are allowed to alter medication prescriptions.