Audit template
Service User Experience
Surveys and feedback from people and families, with the resulting actions recorded. This template runs quarterly in MyCareCompliance and carries 8 mapped checks across 7 CQC quality statements.
Last reviewed: September 2026. This guidance reflects CQC information available at the date above — always refer to cqc.org.uk for current regulatory requirements.
What the audit covers
Every question in the Service User Experience is mapped to a CQC quality statement and the underlying regulation, so a failed check tells you exactly which part of the single assessment framework is at risk. This is an optional template you can switch on when it applies to your service.
- Runs quarterly — optional template
- Part of the Safety & governance audit category
- Maps to 7 regulations: Regulation 20 — Duty of candour, Regulation 18 — Staffing, Regulation 13 — Safeguarding service users from abuse and improper treatment, Regulation 11 — Need for consent, Regulation 16 — Receiving and acting on complaints, Regulation 9 — Person-centred care, Regulation 17 — Good governance
- Failed checks become tracked improvement actions with an owner, due date and evidence
The 8 checks
Learning culture
Safe — 1 check- Regulation 20 — Duty of candourService User Experience
Is the Duty of Candour consistently applied, ensuring service users are informed, supported, and apologised to following safety incidents?
What we look for: Check incident logs for notifiable safety incidents to ensure the Duty of Candour was triggered. Good practice shows a prompt verbal apology followed by a written letter explaining what happened and lessons learned. A fail is the absence of an apology or failure to inform the service user/family of a significant incident.
Evidence: Accident/Incident logs, Duty of Candour letters, Care notes, Manager's communication log
Safe and effective staffing
Safe — 1 check- Regulation 18 — StaffingService User Experience
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
Safeguarding
Safe — 1 check- Regulation 13 — Safeguarding service users from abuse and improper treatmentService User Experience
Do service users confirm they feel safe with the care staff and know how to report any safeguarding or safety concerns?
What we look for: Sample service user feedback via calls or visits to check if they feel safe and know who to contact if they don't. Good looks like clients confidently naming the manager or local authority as a point of contact. A fail is if clients do not feel safe or have no accessible information on reporting abuse.
Evidence: Service user interview notes, Safeguarding policy accessible formats, Welcome pack contents, Spot check records
Consent to care and treatment
Effective — 1 check- Regulation 11 — Need for consentService User Experience
Are service users actively involved in giving informed consent for their risk management plans, especially regarding environmental or equipment risks?
What we look for: Review risk assessments for mobility, falls, and environment to ensure the service user's views and consent are documented. Good looks like client signatures or documented discussions about balancing risk with independence. A fail is risk mitigation strategies (e.g., removing rugs, hiding keys) implemented without the client's documented consent or a best interests decision.
Evidence: Risk assessments, Signed consent forms, Mental Capacity Act assessments, Care plan review records
Listening to and involving people
Responsive — 1 check- Regulation 16 — Receiving and acting on complaintsService User Experience
Are complaints regarding safety or care quality handled transparently, with outcomes and actions clearly communicated back to the service user?
What we look for: Review 3-5 recent complaints to see if the service user was kept informed throughout the process. Good looks like clear timelines met, a formal response letter, and evidence of a follow-up call. A fail is a complaint marked 'resolved' with no evidence the complainant is satisfied or informed.
Evidence: Complaints log, Complaint response letters, Service user feedback forms, Action plans
Person-centred care
Responsive — 1 check- Regulation 9 — Person-centred careService User Experience
Are service users engaged in regular reviews of their care and risk assessments to ensure documentation matches their current lived experience?
What we look for: Check a sample of 5 care files to ensure reviews happen at least annually or as needs change, with the client actively participating. Good looks like the client's voice being prominent in the review documentation, detailing what is working well. A fail is copy-pasted reviews completed in the office without client consultation.
Evidence: Care plan review minutes, Reassessment forms, Daily notes, Quality assurance phone call records
Governance, management and sustainability
Well-led — 2 checks- Regulation 17 — Good governanceService User Experience
Does the provider actively seek and analyze service user feedback on safety and governance, driving continuous improvement?
What we look for: Examine the latest quality assurance surveys specifically looking at questions around safety, reliability, and management responsiveness. Good looks like high return rates and a published action plan based on results. A fail is collecting surveys but never analyzing the data or acting on negative feedback.
Evidence: Annual/Quarterly quality surveys, Survey analysis reports, "You said, we did" newsletters, Continuous Improvement Plan
- Regulation 17 — Good governanceService User Experience
Is there robust senior management oversight of service user experience metrics, ensuring governance structures actively monitor safety indicators?
What we look for: Look at the monthly management or clinical governance meetings to see if service user experience (complaints, incidents, late calls) is a standing agenda item. Good looks like leaders triangulating this data to identify systemic issues. A fail is a disconnect where the registered manager collects data but it is never reviewed for strategic oversight.
Evidence: Board/Management meeting minutes, Monthly KPI dashboards, Audit schedules, Provider Information Return (PIR) drafts
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