Care Plan Audit

Are there up-to-date, specific risk assessments covering all identified hazards (e.g., mobility, environment, skin, choking)?

What we look for: Check that risks identified in the care plan have corresponding risk assessments with clear mitigation strategies. Good looks like specific guidance for staff on reducing risk. Fails if generic risks are used or mitigations are missing.

Evidence: Moving and handling risk assessment, environmental risk assessment, falls risk assessment

If the service provides medication support, is there a clear, accurate medication care plan specifying the level of support required?

What we look for: Check if the plan states exactly what staff must do (e.g., administer, prompt, assist). Good looks like clear instructions on times, routes, and specific PRN protocols. Fails if the level of support is ambiguous or contradicts the MAR chart.

Evidence: Medication care plan, PRN protocols, MAR charts, pharmacy letters

Is there a comprehensive initial assessment that captures the person's holistic needs prior to the commencement of care?

What we look for: Sample 3-5 recent care plans. Good looks like a detailed assessment covering physical, mental, and social needs completed before care starts. Fails if assessments are missing, blank, or lack detail on core needs.

Evidence: Initial assessment form, Local Authority care plan, hospital discharge summary

Is there documented evidence of the person's consent to their care plan, or a mental capacity assessment and best interests decision if applicable?

What we look for: Look for a signature from the person or their legal representative (check LPA validity if family signs). Good looks like clear, consent-specific documentation. Fails if unsigned or if family signs without legal authority and no MCA/Best Interests process is followed.

Evidence: Signed consent forms, MCA forms, Best Interests decision records, LPA documentation

Do the care staff's daily notes reflect the tasks and support requirements outlined in the care plan?

What we look for: Cross-reference the last 7 days of daily notes against the care plan tasks. Good looks like staff recording specific outcomes for scheduled tasks. Fails if staff record 'all care given' or routinely miss scheduled tasks without explanation.

Evidence: Daily log notes, care plan task lists, e-MAR or digital care records

Is there evidence that the person receiving care and/or their family were actively involved in developing and reviewing the care plan?

What we look for: Look for narrative showing the person's goals and wishes shaped the plan. Good looks like documented conversations with the person/relatives about what they want to achieve. Fails if the plan appears entirely dictated by the agency with no user input.

Evidence: Review meeting minutes, service user feedback forms, communication logs with relatives

Has the care plan been reviewed regularly (at least annually or when needs change) and updated to reflect the current situation?

What we look for: Sample care plans of people who recently had a change in health (e.g., hospital discharge). Good looks like the plan was updated immediately. Fails if reviews are out of date or if copy-pasted with no meaningful evaluation.

Evidence: Care plan review forms, updated care plan documents, correspondence with social workers

Does the care plan clearly detail the person's routines, preferences, life history, and what is important to them?

What we look for: Review the 'About Me' or equivalent section. Good looks like clear instructions on how the person likes things done (e.g., 'likes tea with two sugars, prefers female carers'). Fails if it only lists tasks with no personalization.

Evidence: 'About Me' profile, care plan preference sections, daily routine outlines