Safe and effective staffing

Do staff receive appropriate training and support to effectively communicate with people using the service?

What we look for: Check the training matrix for communication-specific training (e.g., dementia communication, autism, Makaton, deaf awareness). A fail is placing staff with complex communication clients without providing them the necessary tools or training.

Evidence: Training matrix, staff supervisions, BSL certificates, Makaton training records, induction workbooks

Do appraisals accurately reflect the staff member's performance throughout the entire year, drawing on supervisions, spot checks, and feedback?

What we look for: Cross-reference appraisal content with the year's supervision notes and spot checks. Good looks like a holistic review of the year, addressing both positive feedback and prior performance issues. Fail if the appraisal ignores known performance concerns.

Evidence: Completed appraisal records, supervision notes, field observation records, compliment/complaint logs

Are specific, actionable training and professional development needs identified and recorded during the appraisal process?

What we look for: Review the development section of the appraisal. Good looks like tailored training requests (e.g., Level 3 Diploma, specialized dementia care) based on career aspirations and client needs. Fail if this section is consistently left blank.

Evidence: Appraisal documents, personal development plans (PDPs), training matrix

Are all staff, including on-call personnel, trained and competent in executing their roles within the Business Continuity Plan?

What we look for: Interview 2-3 staff members and an on-call supervisor. Ask them what they would do if the office burned down or a major winter storm hit. Good looks like staff knowing where to find the BCP and their specific role in an emergency.

Evidence: Training matrix, Staff induction records, On-call guidance, Minutes from staff meetings/briefings

Are staff rotas scheduled to deliver the full commissioned time, including adequate travel time between visits?

What we look for: Review rotas for 5 staff members across a week. Look for overlapping calls or back-to-back scheduling with zero travel time. A fail is where scheduled travel time is insufficient, forcing staff to cut visits short.

Evidence: Staff rotas, Scheduled call times, Travel time allocations on scheduling system

Are all new care workers assessed for practical competency before providing care unsupervised, particularly for medication and moving & handling?

What we look for: Sample files of 3 recently inducted staff members. Good looks like clear, signed evidence that practical competency was observed and signed off by a qualified assessor before the staff member worked solo. A fail would be staff providing unsupervised care with only e-learning completed.

Evidence: Care Certificate workbooks, induction sign-off sheets, initial spot check records, shadowing rotas

Do moving and handling competency assessments include observation of staff using specific equipment safely in the community?

What we look for: Look for evidence that staff are assessed using the actual equipment (e.g., specific hoists, slide sheets) they use with clients. Good looks like documented observations of safe technique and equipment checks. A fail would be generic assessments that do not verify competence with specific equipment.

Evidence: Moving and handling observation records, spot check forms, hoists/stand-aid specific sign-offs

Do staff rotas include sufficient, realistic travel time between care visits to ensure calls are not rushed or delayed?

What we look for: Examine 5 care workers' schedules for a week. Travel time must be explicitly scheduled and realistic based on local traffic/geography. A fail would be back-to-back scheduling forcing staff to leave early or arrive late.

Evidence: Staff rotas, travel time matrices, ECM log-in/log-out data, staff feedback forms

Are Enhanced DBS checks, including the Adult Barred List, obtained and verified for all care staff prior to them commencing regulated activity?

What we look for: Sample 5 recently recruited staff files to ensure the DBS certificate was received before their first unshadowed shift. Good looks like zero gaps in safe recruitment. A fail is any staff member providing personal care before the full DBS or appropriate risk-assessed Adult First check is confirmed.

Evidence: Staff recruitment files, central training/HR matrix, DBS certificates (or reference numbers)

If staff commence work using an Adult First check pending a full DBS, is a robust risk assessment in place ensuring they are strictly shadowed and supervised?

What we look for: Check rotas and staff files for anyone who started with an Adult First check. Ensure they were never rostered to work alone and that shadowing is clearly documented. A fail is an unsupported staff member delivering care without the full Enhanced DBS in place.

Evidence: Risk assessments, shadow rotas, supervision logs, Adult First confirmation emails

Where a DBS certificate contains positive disclosure information (e.g., convictions/cautions), is a comprehensive, manager-signed risk assessment on file?

What we look for: Review files of any staff known to have positive disclosures. The risk assessment must detail the nature of the offence, time elapsed, relevance to care work, and mitigating factors. A fail is a positive disclosure ignored or assessed without senior management sign-off.

Evidence: Positive disclosure risk assessments, interview notes, Registered Manager sign-off

Is there a systematic process for checking the DBS Update Service (e.g., annually) for staff who have subscribed, including documented consent?

What we look for: Sample records for staff on the Update Service to ensure the provider is actively running status checks at least annually. Good practice involves a tracker alerting HR when a check is due. A fail is having staff on the Update Service but never actually verifying their status.

Evidence: Update Service consent forms, logged check dates, screenshots of status checks

For staff not subscribed to the Update Service, are DBS certificates renewed in line with the provider's stated policy (e.g., every 3 years)?

What we look for: Check the central compliance matrix against the provider's own DBS renewal policy. Identify any staff whose certificates have expired under this policy. A fail is a significant number of overdue renewals with no evidence of new applications being processed.

Evidence: HR policy, staff compliance matrix, renewal application tracking

Does the provider accurately verify that all applied DBS checks are specifically at the 'Enhanced' level and include the 'Adult Barred List' check?

What we look for: Ensure standard or basic checks are not mistakenly used for frontline care staff. Every care worker must have an Enhanced check checking the adult barred list. A fail is finding standard DBS checks on file for staff performing regulated activities.

Evidence: Central HR matrix, DBS application portal records, spot check of DBS reference numbers

Are staff driving licenses systematically checked directly with the DVLA to ensure validity and monitor for endorsements/penalty points?

What we look for: Sample 5-10 staff files of those who drive for work. Check that a DVLA check was completed at recruitment and is repeated annually. Relying solely on a physical photocopy of the license is a fail, as it does not show current points or bans.

Evidence: DVLA check printouts/digital codes, Staff personnel files, Driving license matrix/tracker

Are travel times between visits calculated realistically in rostering systems to prevent staff from rushing, speeding, or driving while fatigued?

What we look for: Review rotas for a sample week. Calculate the actual travel time allowed between calls against realistic map estimates and traffic conditions. A fail is zero travel time scheduled, forcing staff to speed or cut calls short to catch up.

Evidence: Staff rotas, Call logging/monitoring data (ECM), Travel time calculations, Staff feedback/supervision notes

Does the office team monitor live ECM alerts for late or missed calls and take immediate, documented action to ensure people's safety?

What we look for: Check the ECM alert dashboard and duty notes. Good looks like immediate follow-up on 'no-show' or 'late' alerts by coordinators calling the staff member or client. A fail would be a backlog of unacknowledged alerts or no documented evidence of action taken when a call breached the tolerance window.

Evidence: Live ECM dashboard, duty log/alert resolution notes, daily handover records, on-call logs

Does the ECM schedule and actual log data demonstrate that staff have sufficient, realistic travel time allocated between visits?

What we look for: Check the ECM schedules of 5 care workers. Good looks like clear, distinct travel blocks between calls, calculated realistically for the geography. If staff are routinely logging into a call 1 minute after logging out of a call 3 miles away, this indicates 'overlapping' and poor scheduling, which is a fail.

Evidence: Carer route schedules, travel time vs actual travel time logs, ECM overlap reports

Is there a robust and clearly communicated on-call rota ensuring trained personnel are available at all times outside office hours?

What we look for: Review the on-call rota for the last 3 months to ensure there are no gaps in cover. Good practice shows clear contingency plans if the primary on-call person falls ill. A fail would be gaps in the rota or assigning on-call duties to inexperienced staff without backup.

Evidence: On-call rota, staff communication records, on-call policy

Are care workers trained and assessed as competent in falls prevention, post-fall protocols, and safe moving and handling?

What we look for: Sample 5 staff files. Check for up-to-date practical training in moving and handling and falls response. Fail if training is expired, only e-learning without practical assessment (where required), or post-fall protocol knowledge is lacking during spot checks.

Evidence: Training matrix, moving and handling practical certificates, spot check records

Are robust lone working procedures implemented, monitored, and understood by all field-based care staff?

What we look for: Check if the system to track staff whereabouts (e.g., app check-ins) is actively monitored. Ask 3 staff members what they do if they feel unsafe. A fail is if the office doesn't notice a missed visit/check-in promptly, leaving staff at risk.

Evidence: Lone working policy, Staff interview notes, Spot check records, On-call logs, Staff app login/logout records

Are all staff up to date with mandatory health and safety training, including practical elements where required?

What we look for: Review the training matrix against the H&S policy requirements. Ensure moving and handling training includes a practical, face-to-face assessment. A fail is staff delivering care involving hoists without in-date practical training.

Evidence: Training matrix, Certificates (Fire safety, Manual handling, Basic H&S, First Aid), Competency sign-offs

Is there documented evidence that new staff complete a sufficient period of supervised shadowing before providing care independently?

What we look for: Review shadowing logs for new starters to ensure they do not work solo until deemed competent. Good practice involves documenting the length of shadowing and the specific tasks observed. A fail occurs if new staff are deployed solo without shadowing records.

Evidence: Shadowing logs, Timesheets, Rota records, Sign-off sheets

Are care workers' practical competencies (e.g., manual handling, medication administration) directly observed and assessed in the workplace?

What we look for: Check that competency is not just assessed via e-learning but through direct workplace observation by a competent senior. Look for signed observation forms for high-risk tasks. Lack of practical assessment before solo deployment is a fail.

Evidence: Direct observation forms, Competency assessments, Spot check records

Do all staff receive comprehensive training on data protection, confidentiality, and GDPR upon induction and annually?

What we look for: Sample the training matrix for 5-10 staff. Good looks like 100% compliance with annual IG/GDPR refreshers, plus checks during supervision. Fail: staff handling sensitive data without valid training.

Evidence: Training matrix, GDPR training certificates, induction checklists, spot check records

Do staff rotas include sufficient and realistic travel time between visits to prevent systemic late arrivals and shortened calls?

What we look for: Sample rotas for 3-5 care workers. Check that travel time is calculated realistically based on distance, traffic, and mode of transport, rather than zeroed out. A fail is back-to-back scheduling across different postcodes causing inevitable delays.

Evidence: Weekly rotas, Staff schedules, Route mapping software logs, Travel time allowances

Does the Registered Manager maintain an accurate training and supervision matrix with clear oversight of compliance and overdue interventions?

What we look for: Check the training matrix. Good looks like over 90% compliance with a clear plan for booking outstanding training or overdue supervisions. Fail if the matrix is out of date, inaccurate, or shows significant unaddressed gaps in mandatory training.

Evidence: Electronic training matrix, supervision schedule, booked training records, staff files

Have all care staff and management completed comprehensive training on the Mental Capacity Act 2005?

What we look for: Check the training matrix. Ensure MCA training is mandatory, up to date for all staff, and discussed in supervisions. Fails if staff compliance is below the provider's target (e.g., 90%) or if staff cannot explain basic MCA principles during spot checks.

Evidence: Training matrix, Training certificates, Staff supervision records

Have all staff administering medication completed up-to-date medication training and an annual practical competency assessment?

What we look for: Sample 5 staff members who administer meds. Good looks like valid training certificates and a recently completed, signed, in-person competency check by a qualified supervisor. A fail is allowing staff to administer medication prior to passing their practical competency check.

Evidence: Training matrix, staff personnel files, medication competency observation forms

Are all care workers supporting with medicines documented as having completed baseline medication training and shadowing before solitary administration?

What we look for: Sample 3-5 newly recruited staff files. Ensure they did not administer medication alone until full training and shadowing were signed off. A fail would be rota evidence of solitary medication calls before training completion.

Evidence: Training certificates, Induction checklists, Shadowing sign-off forms, Rota records

Is there a clear, up-to-date medication competency matrix demonstrating that all staff have their competencies renewed at least annually?

What we look for: Review the master tracking matrix for the service. Look for any overdue annual medication competency updates. A fail would be expired competencies without immediate risk mitigation (e.g., suspension of medication duties).

Evidence: Competency tracking matrix, Expiry date alerts, Staff training database

Is the rostering and scheduling system actively monitored to identify unallocated visits or overlapping travel times that could cause a missed visit?

What we look for: Review the rostering system for the past month. Check that sufficient travel time is allocated and that no visits are left unallocated 24 hours prior. A fail is finding 'ghost' rotas or crammed schedules that make missed visits inevitable.

Evidence: Rostering system dashboard, Staff rotas, Travel time allocations, Unallocated visit reports

Are staff trained in practical moving and handling before supporting service users with mobility needs?

What we look for: Review the training matrix to verify that all staff providing manual handling have received face-to-face practical training. Good looks like annual practical updates covering hoists, slide sheets, and emergency procedures. Fail if staff are only doing e-learning for manual handling.

Evidence: Training matrix, practical moving and handling certificates, induction records.

Have staff supporting food preparation completed basic food hygiene and necessary specialist training (e.g., dysphagia)?

What we look for: Cross-reference the training matrix against staff providing meal support. Good looks like up-to-date food safety training and observed competency. Fail if staff preparing meals lack required training.

Evidence: Training matrix, staff certificates, spot check records, competency assessments

Have staff been properly matched to the new service user based on skills and preferences, and appropriately briefed before their first visit?

What we look for: Review how the first week's roster was built for the new service user. Look for evidence that staff have the right skills (e.g., hoist training if required) and were briefed on the person's needs. Sending untrained staff or staff who have not read the care plan to a new package is a fail.

Evidence: Rosters showing shadow shifts, staff briefing notes/handover logs, matching matrices, staff profiles sent to user.

Are all essential pre-employment checks, including enhanced DBS, full work history, and at least two satisfactory references, completed and recorded before the staff member's start date?

What we look for: Sample 3-5 recent new starter files. Ensure there are no unexplained gaps in employment history and references are verified. A fail would be staff commencing lone care delivery before a DBS is returned or risk-assessed properly.

Evidence: Staff files, DBS certificates/numbers, reference requests and replies, interview notes, application forms

Is there documented evidence that the provider has verified the new employee's right to work in the UK and obtained a satisfactory health declaration prior to them delivering care?

What we look for: Check that right-to-work checks were completed prior to employment and that any health conditions disclosed were risk-assessed. Good practice involves reasonable adjustments being documented; a fail is missing share codes or expired visas.

Evidence: Right to work share codes, passport copies, health questionnaires, occupational health referrals

Do new care staff complete a structured induction programme aligned with the Care Certificate, alongside all provider-mandated training, before working unsupervised?

What we look for: Review the induction timeline for recent hires. Good looks like a robust, tracked process covering all 15 standards of the Care Certificate. Missing evidence of basic safety training (e.g., manual handling, basic life support) before working alone is a fail.

Evidence: Induction workbooks, training matrix, e-learning certificates, Care Certificate portfolios

Are new staff provided with adequate, documented shadowing shifts with experienced workers, followed by formal practical competency assessments?

What we look for: Look for signed observation forms where a senior staff member has deemed the new starter competent in key practical tasks. A fail is allowing staff to administer medication or use hoists without documented practical sign-off.

Evidence: Shadowing logs, competency sign-off sheets (medication, moving & handling), senior carer feedback

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 all new staff completing a comprehensive induction, including the Care Certificate, within their probation period?

What we look for: Sample 3-5 files of recently recruited staff. Good looks like robust evidence of Care Certificate completion or progress within the first 12 weeks. A fail is staff working solo without completing basic mandatory induction elements.

Evidence: Induction checklists, Care Certificate workbooks, training matrix, certificate of completion

Do new staff complete required shadowing hours and are they signed off as competent by a senior before working solo?

What we look for: Review shadowing records to ensure they are fully signed and dated by both the new starter and the senior staff member. Good practice involves varying shadowing shifts to cover different client needs. Missing sign-offs before solo rotas is a red flag.

Evidence: Shadowing logs, sign-off sheets from senior carers, rotas showing shadowing shifts

Are field-based spot checks conducted during the probation period to monitor practice and alignment with care plans?

What we look for: Verify that at least one spot check is completed during the probationary window to assess the staff member's punctuality, uniform, interaction, and adherence to care plans. Good looks like actionable feedback given if minor issues are spotted.

Evidence: Spot check forms, quality assurance logs, client feedback notes

Are initial Right to Work (RTW) checks completed and documented for all staff prior to their first day of employment?

What we look for: Sample 5-10 recently recruited staff files. Verify that the date on the RTW evidence is prior to or on the exact date employment commenced, not after. A fail occurs if staff have undertaken any work or induction before their RTW was formally established and recorded.

Evidence: Personnel files, onboarding checklists, signed contracts, dated RTW copies, Home Office share code PDFs

Are the retained RTW documents strictly from the Home Office's list of acceptable documents or verified via a valid Share Code?

What we look for: Review the retained evidence against the current Home Office acceptable document list (List A or List B). Ensure online checks include the PDF showing 'Right to work' with the staff member's photo. A fail is indicated if unapproved documents (e.g., a driving licence) are used as sole proof of RTW.

Evidence: Copies of passports, BRPs, birth certificates, Home Office online check PDFs

Is there documented evidence that the person checking the RTW verified the applicant's likeness, DOB, and document authenticity?

What we look for: Check that the staff member who reviewed the physical documents or online share code has signed, dated, and declared 'original seen' or 'verified via video link/in person'. Good practice includes a standard verification stamp. It is a fail if copies are simply held on file without proof of an imposter check.

Evidence: Signed and dated document copies, RTW checklist forms, HR onboarding notes

Have mandatory follow-up RTW checks been completed prior to the expiration of the previous visa or permission?

What we look for: Sample files of staff whose visas expired within the last 6 months. Verify that a follow-up check or an Employer Checking Service (ECS) check was completed before the expiry date. A fail is given if there are gaps in permission where a staff member worked without a valid check on file.

Evidence: Updated Home Office share code checks, renewed visa copies, Employer Checking Service (ECS) positive verification notices

Are travel times between consecutive domiciliary care visits scheduled realistically, accounting for distance, traffic, and preferred visit times?

What we look for: Sample a minimum of 5 staff rotas across a week. Verify that there is explicit, realistic travel time blocked out between visits. A fail would be consecutive calls booked with zero travel time or evidence of "clipping" call times to accommodate travel.

Evidence: Staff rotas, map/routing software outputs, electronic call monitoring (ECM) data, staff feedback forms

Are staff working hours monitored to ensure they do not exceed safe limits, and are adequate rest breaks provided within shifts?

What we look for: Review timesheets for 5 full-time care staff. Check for consecutive days worked without a day off, 14+ hour shifts, and lack of meal breaks. A fail is evidence of staff fatigue risk through systemic overworking without adequate rest periods.

Evidence: Timesheets, payroll reports, working time directive opt-out forms, shift patterns

Do staff training matrices demonstrate that all staff have completed safeguarding training at a level appropriate to their role, with no overdue refreshers?

What we look for: Sample the training matrix focusing on Safeguarding Adults (Levels 1-3 as appropriate). Good looks like 100% compliance with regular refreshers (usually annual). A fail is missing training records for active field staff.

Evidence: Training matrix, Training certificates, Induction records

Do service users experience safe and reliable care delivery, free from significantly late or missed calls that compromise their safety?

What we look for: Cross-reference ECM data with service user feedback to determine the real-world impact of scheduling. Good looks like proactive communication if carers are running late and zero missed calls. A fail is a pattern of late visits affecting medication times or basic safety, with no communication to the client.

Evidence: Electronic call monitoring (ECM) data, Missed call log, Service user dependency assessments, Continuity of care reports

Have care staff received adequate and up-to-date training on pressure ulcer prevention and tissue viability?

What we look for: Check the training matrix. Good looks like specific tissue viability/pressure area care training is mandated and in date for all staff supporting high-risk people. A fail is relying solely on basic manual handling training.

Evidence: Training matrix, Training certificates, Supervision records

Are robust Right to Work checks completed and retained for all sponsored workers, including verification of Biometric Residence Permits (BRPs) and visa conditions?

What we look for: Sample 5 recently recruited sponsored workers. Check that the employer has obtained and securely stored the statutory excuse (Right to Work check via Home Office portal). A fail would be missing checks, expired visas not flagged, or relying solely on physical BRPs instead of the online checking service.

Evidence: Staff files, Home Office right to work check codes, BRP copies, Passport copies, Visa condition documents

Are spot checks conducted at the frequency required by policy for all care staff, including those on probation, night staff, and bank workers?

What we look for: Sample 10% of staff files (min 5) to verify spot checks occur as per policy (e.g., quarterly or bi-monthly). Look for gaps for weekend/night staff. A fail would be a lack of a tracking matrix or staff missing checks for extended periods.

Evidence: Spot check matrix, staff list, individual staff files, probation records

Does the staff file contain robust evidence of verified identity, a recent photograph, and a valid Right to Work in the UK check prior to the start date?

What we look for: Sample files of the most recently hired staff. Check that ID documents were seen in their original form, copied, dated, and signed by the interviewer. A fail would be a missing RTW check or an expired visa without follow-up.

Evidence: Passport copy, biometric residence permit, share code check printout, recent photograph, signed checklist

Is there a fully completed application form with a continuous employment history, and are all gaps in employment explored and documented?

What we look for: Review the application form to ensure month and year are recorded for all previous jobs. Check interview notes to confirm any gaps (e.g., career breaks, unemployment) were discussed and a plausible explanation recorded. A fail is an unexplained gap.

Evidence: Application form, interview notes, gap analysis form, CV

Is there evidence of a satisfactory Enhanced DBS check and Barred List check in place before unsupervised work commenced?

What we look for: Verify the DBS issue date is prior to the first shadowing or solo shift. If the DBS contains convictions/cautions, ensure a detailed, signed risk assessment is on file determining fitness to practice. Fail if staff worked unsupervised prior to clearance.

Evidence: DBS certificate number record, Barred List check (Adults), DBS risk assessment if blemishes exist

Are there at least two verified written references on file, including one from the most recent employer, detailing suitability for the role?

What we look for: Check that references are from professional sources (not friends/family), ideally using company email addresses. If standard emails/letters were used, check for notes confirming telephone verification to prevent fraud. Fail if only one reference or character-only references are used for experienced carers.

Evidence: Reference request forms, returned references, phone verification notes, email trail from company addresses

Does the file contain a completed health declaration confirming the staff member's physical and mental fitness to perform the role?

What we look for: Check for a signed health declaration completed before employment started. If health issues were disclosed, review the file for a risk assessment or reasonable adjustment plan. Fail if no health check was completed.

Evidence: Health questionnaire, occupational health referral (if applicable), manager risk assessment for reasonable adjustments

Are there up-to-date, signed competency assessments for critical high-risk tasks such as medication administration and moving & handling?

What we look for: Check that theoretical training was followed by practical, observed competency sign-offs before the carer undertook these tasks alone. Competencies must be updated at least annually. Fail if a carer administers meds without an initial competency sign-off.

Evidence: Medication competency assessment, moving & handling observation form, spot check records

Are staff supervisions being conducted at the frequency specified in the provider's policy and are there clear schedules in place?

What we look for: Sample 10% of staff files to verify if supervisions occur at the required frequency (e.g., quarterly). Good practice shows a forward-planned matrix with minimal missed or cancelled sessions. A fail would be multiple staff members missing supervisions for over 6 months without documented mitigation.

Evidence: Supervision matrix, staff files, supervision policy, electronic scheduling system

Is the overall compliance rate for mandatory training above the provider's target (e.g., 90%+)?

What we look for: Review the summary percentages for core mandatory training (e.g., fire, manual handling, basic life support). Good looks like high compliance with clear action for any gaps. Fail if overall compliance drops below safe levels without mitigating action.

Evidence: Training matrix dashboard, KPI reports, Mandatory training policy

Are all new starters completing their induction and the Care Certificate within 12 weeks of starting?

What we look for: Identify staff who started in the last 3-6 months. Good looks like documented progression and sign-off of the Care Certificate within 12 weeks. Fail if staff are deployed solo without completing essential induction components.

Evidence: Training matrix, New starter list, Care Certificate workbooks, Supervision records

Are practical competency assessments (e.g., Medication, Moving and Handling) tracked alongside e-learning?

What we look for: Check that the matrix records not just knowledge (e-learning) but practical observation sign-offs. Good looks like annual practical competency sign-offs for high-risk areas. Fail if staff only do online training for manual handling or meds without practical assessment.

Evidence: Training matrix, Competency assessment forms, Spot check records