Care Plan Audit Template - Monthly

Care Plan Audit Template for UK care homes, a checklist developed by CQC compliance experts for monthly audits (updated in 2026). Covers file integrity, clinical monitoring, daily care, consent and more. Customise as needed.

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Care Plan Audit Template - Monthly

File Integrity And Organisation

NHS Number Evident And Correct

DNAR Documentation

Hospital Passport

Admission Sheet

Pre-Admission Assessment

ADL’s (Activities Of Daily Living)

Reason For Admission

Contact Details

Transfer Form

Initial Physical Health Assessment

One Page Profile – About Me - MAP

Support Plans, Risk Assessments & Supporting MCA Documentation

Maintaining A Safe Environment

Communication

Nutrition

Weight Record

MUST Tool (Malnutrition Universal Screening Tool)

Choking Risk Assessment

Dependency Assessment

Administration Of Medication

Pain Management

Personal Care

Continence

Prevention Of Pressure Areas

Body Maps

Waterlow Score

Mobility

Manual Handling Assessment

Behaviour / Mental Ill Health

Behaviour Monitoring Charts

Other Supplementary Care / Support Plan

Activities

Sleeping

End Of Life Care & Wishes

Expressing Sexuality, Spiritual And Religious Needs:

GP/ANP/DN Recorded Visits

Other Professionals Recorded Visits

Family And Visitors Recorded Visits

MCA DoLS & Consent Additional Information & Forms

Signed Care Plan Involvement

Written Daily Notes / Records Reflect Adherence To Care Plans And Risk Assessments

Daily Notes / Records Are Written Legibly, Dated, And Signed

PEEPs Plan (Personal Emergency Evacuation Plans)

Resident Of The Day Completed On Time And Evident

Covid-19 Observations And Management

Use Of Special Medical/Nursing Equipment (e.g., CPAP Machine/Oxygen)

Other (Please State)

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Checklist by GoAudits.com – Please note that this checklist is intended as an example. We do not guarantee compliance with the laws applicable to your territory or industry. You should seek professional advice to determine how this checklist should be adapted to your workplace or jurisdiction.

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Care Plan Audit Template - Monthly

Care Plan Audit Template for UK care homes, a checklist developed by CQC compliance experts for monthly audits (updated in 2026). Covers file integrity, clinical monitoring, daily care, consent and more. Customise as needed.

1. File Intact and Presentable: Ensure the file is well-organised and in good condition.

2. Index Page: Verify the index page is present and accurately lists all included documents.

1. Confirm the NHS number is present and accurate.

1. Check for the presence of Do Not Attempt Resuscitation (DNAR) documentation, if applicable.

1. Ensure a Hospital Passport is included, providing key information for care.

1. Confirm the admission sheet is present and filled out.

1. Check for a pre-admission assessment, including any necessary evaluations.

1. Verify the document detailing the resident’s activities of daily living is included.

1. Ensure there is a clear record of the reason for admission.

1. Confirm that contact details for the patient and emergency contacts are present.

1. Check for a completed transfer form, if applicable.

1. Ensure there is an initial physical health assessment completed.

1. Verify the inclusion of a one-page profile summarising key information about the patient, including their MAP (My Action Plan).

1. Confirm that support plans, risk assessments, and any supporting documentation related to the Mental Capacity Act (MCA) are complete and up to date.

1. Ensure that all safety measures are documented, including risk assessments related to the physical environment. Photographs are needed if safety hazards are identified.

1. Check for records detailing communication needs and methods used to support effective communication.

1. Verify that there is a documented plan for nutritional needs, including any special dietary requirements

1. Ensure that weight records are maintained and regularly updated

1. Confirm that the MUST tool is used for assessing nutritional risk and is documented.

1. Check for a choking risk assessment if applicable, detailing any measures in place to mitigate choking risks.

1. Verify that a dependency assessment is in place to determine the level of support required.

1. Ensure that records of medication administration are complete, including any prescribed medication and any changes.

1. Check for a pain management plan that addresses the individual's pain and comfort needs.

1. Verify that personal care needs are documented, including any specific requirements.

1. Ensure that continence needs, and any related care plans are properly documented

1. Confirm that there are documented strategies and care plans to prevent pressure sores. Photographs are needed if pressure ulcers are present. (Photograph Mandatory if pressure areas present)

1. Check for body maps used to document the location and status of any pressure ulcers or skin conditions. Photographs are needed to visually document the condition of pressure ulcers. (Photograph Mandatory if pressure areas present)

1. Ensure that Waterlow scores are recorded and updated regularly to assess the risk of pressure ulcers.

1. Check that mobility assessments are complete and updated to reflect current needs

1. Confirm that manual handling assessments are documented and regularly reviewed.

1. Ensure that assessments and plans related to behaviour and mental health are documented.

1. Check that behaviour monitoring charts are in place and updated as necessary.

1. Confirm the presence of any additional care or support plans specific to individual needs.

1. Verify that records of activities provided to residents are documented and reflect engagement.

1. Check that sleeping patterns and any related issues are recorded.

1. Ensure that end-of-life care plans and any specific wishes are documented.

1. Confirm that documentation includes support for expressing sexuality, spiritual, and religious needs.

1. Ensure that visits from General Practitioners (GP), Advanced Nurse Practitioners (ANP), and District Nurses (DN) are recorded.

1. Confirm that visits from other professionals are documented.

1. Check that visits from family and visitors are recorded.

1. Ensure that documentation related to the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS) is complete.

1. Verify that care plans are signed and that residents (or their representatives) have been involved in the planning.

1. Confirm that daily notes and records reflect adherence to care plans and risk assessments.

1. Ensure that daily notes are clear, dated, and signed.

1. Verify that PEEPs plans are in place and updated as necessary.

1. Check that the "Resident of the Day" documentation is completed as required.

1. Ensure that Covid-19 observations, symptoms management, and any known vulnerabilities are documented.

1. Check that records are kept for the use of special medical or nursing equipment and photograph any issues if applicable. (Yes (if equipment is malfunctioning or issues are identified))

1. Document any other relevant information or requirements specific to the care needs.