Service User Reviews Audit

Are all associated risk assessments reviewed and updated to reflect any changes identified during the care review?

What we look for: Cross-reference changes in the care plan to the risk assessments. If mobility has declined, has the falls risk assessment been updated? Fails if care plans are updated but risk assessments remain static.

Evidence: Moving and handling risk assessments, Environmental risk assessments, Medication risk assessments

Where a review identifies a change in care delivery, is the care plan updated and communicated to all relevant care staff immediately?

What we look for: Verify that staff are actually working from the newly updated plan. Check handover notes or digital system alerts to ensure staff were briefed on the changes. Fails if staff are unaware of the updated needs.

Evidence: Updated care plans, Staff communication logs, Digital care planning system alerts

Is consent to the revised care plan explicitly sought, recorded, and the Mental Capacity Act (MCA) applied if capacity is in doubt?

What we look for: Check that the person has signed to consent to any changes in care. If they lack capacity, ensure there is an MCA assessment and a best interests decision involving the right people. Fails if consent is presumed.

Evidence: Consent forms, Mental capacity assessments, Best interests decision records

Does the review identify where referrals to other health or social care professionals are needed, and are these actioned?

What we look for: If the review highlights a new issue (e.g., swallowing difficulties), check that a referral to the GP or SALT was made promptly. Fails if deteriorating health needs are identified but not acted upon.

Evidence: Referral letters (e.g. SALT, OT, GP), Social worker correspondence, Review action plans

Does the review evaluate progress against the person's agreed outcomes and note any changes in their health status?

What we look for: Look for a discussion on whether the support is helping the person achieve their goals (e.g., regaining independence). Fails if the review is just a tick-box exercise with no focus on outcomes.

Evidence: Care review records, Outcome tracking sheets, Daily log audits

Does the review documentation evidence the active involvement of the service user and/or their chosen representatives?

What we look for: Check the review documentation for the person's own words and signatures from them or their family/LPA. Fails if reviews appear to be done solely by staff in the office without consulting the person.

Evidence: Review meeting minutes, Signed review documents, Feedback forms from family

Are care plan reviews conducted within agreed timeframes or promptly triggered by changes in the person's needs or incidents?

What we look for: Sample 5-10 files. Check if reviews happen at least annually or sooner if needs change (e.g. post-hospital discharge or falls). Fails if reviews are overdue without valid, documented reasons.

Evidence: Review schedule/tracker, Care plans, Incident reports, Hospital discharge summaries

Is there a robust oversight system managed by the Registered Manager to ensure no service user is overdue for their review?

What we look for: Examine the service's tracking system for reviews. The manager should have a clear view of what is due, overdue, and completed. Fails if the manager cannot easily identify when reviews are due.

Evidence: Quality assurance matrix, Review tracker spreadsheet, Management meeting minutes