Previous Actions / QIP Review

Have required updates to individual risk management strategies, identified in previous audits, been signed off and communicated to care staff?

What we look for: Look at the previous month's care plan audit. Check if identified gaps in risk assessments were actually rectified. Good looks like completed updates and clear messages to staff about the changes. Fails if risks remain unmanaged despite being identified in a previous audit.

Evidence: Care plan audit action plans, updated risk assessments, staff communication logs, handover notes

Is there evidence that actions arising from serious incidents or safeguarding alerts have been fully implemented in frontline practice?

What we look for: Sample 3 recent incidents. Cross-reference the resulting actions (e.g., updating a mobility risk assessment) with the actual care record. Good looks like immediate, tangible updates to records. Fails if actions are marked 'done' on the tracker but care plans remain unchanged.

Evidence: Post-incident action plans, updated risk assessments, updated care plans, spot check records

Have staff training and competency gaps, flagged as actions in recent audits, been addressed within the stipulated timeframe?

What we look for: Identify any staff-related actions (e.g., 'Care Worker A needs refresher moving and handling training'). Check their file. Good looks like prompt booking and completion of training/supervision. Fails if staff continue to deliver care without the required competencies being addressed.

Evidence: Training matrix, supervision records, spot check forms, staff files

Are actions generated from complaints or service user feedback explicitly tracked and followed up with the person who raised the concern?

What we look for: Trace 2-3 recent complaints or negative feedback surveys. Good looks like a logged action, evidence of the change being made, and a closure letter/call to the complainant explaining the outcome. Fails if actions are taken but the person is never informed.

Evidence: Complaints log, feedback survey action plan, letters to service users, contact logs

Is there a live, consolidated Quality Improvement Plan (QIP) that captures actions from all audits, inspections, and incident investigations?

What we look for: Review the central action tracker/QIP. Good looks like a single, accessible document or dashboard capturing all service improvements with clear owners and deadlines. Fails if actions are scattered across different folders or there is no master tracker.

Evidence: Central QIP document, action trackers, governance meeting minutes, digital audit system dashboards

Are overdue or delayed actions on the QIP clearly flagged, escalated to senior management, and updated with revised timelines and rationales?

What we look for: Filter the QIP for overdue actions. Good looks like active management of delays, with documented reasons and evidence of senior oversight. Fails if target dates have passed with no updates or escalation to the provider/directors.

Evidence: QIP tracker, senior management meeting minutes, escalation emails, risk register

Is there a process to evaluate the effectiveness of completed actions (closing the loop) to ensure the intervention actually solved the root cause?

What we look for: Check how actions are marked as 'closed'. Good looks like a 'check/verify' step by the manager to ensure the fix worked (e.g., a mini re-audit). Fails if actions are just ticked off when a memo is sent, without checking if practice actually improved.

Evidence: Re-audit schedules, quality assurance reports, QIP closure notes, post-action review meetings

Are the key themes, lessons learned, and progress on the QIP regularly shared with the staff team to embed a culture of continuous improvement?

What we look for: Review staff meeting minutes from the last 3 months. Good looks like a standing agenda item discussing recent audit findings, what went wrong, and how the service is improving. Fails if staff are kept in the dark about service-level performance and improvement plans.

Evidence: Staff meeting minutes, newsletters, memos, handover books, supervision notes