Management Oversight Care Planning Documentation Audit Tool

This audit tool is designed to assess the quality, accuracy, and compliance of care planning documentation in nursing and residential care homes. The audit is aligned with the latest Care Quality Commission (CQC) frameworks, Local Authority PAMS (Performance Assessment Management Systems), and DoLS (Deprivation of Liberty Safeguards) requirements. It also incorporates standards from the Care Act 2014, Mental Capacity Act 2005, and other relevant UK health and social care legislation.

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Management Oversight Care Planning Documentation Audit Tool

Personalised Care Plans

Risk Assessments

Medication Management

Safeguarding And DoLS (Deprivation Of Liberty Safeguards)

Mental Capacity And Consent

Documentation And Record-Keeping

Review And Monitoring

Staff Competency And Training

Equality And Diversity

Family And Advocate Involvement

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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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Management Oversight Care Planning Documentation Audit Tool

1. Are care plans person-centred and tailored to meet the individual’s specific needs, preferences, and values? (Refer to Care Act 2014, Section 9)

2. Do care plans include input from the service user and/or their family and advocates? (CQC Regulation 9: Person-centred care)

3. Are care plans reviewed regularly, reflecting changes in the individual's condition and requirements? (Refer to Care Act 2014, Section 27)

4. Is there evidence of ongoing involvement and consent from the service user? (Mental Capacity Act 2005, Care Act 2014, Section 25)

1. Are comprehensive risk assessments in place, covering areas such as falls, malnutrition, and skin integrity? (CQC Regulation 12: Safe Care and Treatment)

2. Is there evidence that risks are identified, assessed, and managed effectively? (Health and Social Care Act 2008, Regulation 12)

3. Are risk assessments reviewed at least monthly or when significant changes occur? (Refer to local authority PAMS guidelines)

1. Are all prescribed medications recorded accurately in the care plan? (CQC Regulation Safe Care and Treatment, NICE Guidance on Managing Medicines in Care Homes)

2. Is there evidence of medication being administered as prescribed? (Health and Social Care Act 2008, Regulation 12)

3. Are PRN (as-needed) medications clearly documented with reasons for administration? (NICE Guidance)

4. Is the storage, handling, and disposal of medications compliant with CQC regulations and DoLS requirements? (CQC Regulation 13: Safeguarding, Mental Capacity Act 2005)

1. Are all staff aware of and trained in safeguarding procedures, including how to identify and report concerns? (CQC Regulation 13: Safeguarding, Care Act 2014, Section 42)

2. Is there evidence that safeguarding concerns are appropriately recorded and reported? (Care Act 2014, Section 42, DoLS requirements)

3. Are DoLS applications made where necessary, and is the person’s liberty protected appropriately? (Mental Capacity Act 2005, DoLS legislation)

4. Is there documentation supporting the decision-making process for those lacking mental capacity? (Mental Capacity Act 2005, Best Interest decision-making process)

1. Are mental capacity assessments conducted when necessary, and are they recorded in the care plan? (Mental Capacity Act 2005, CQC Regulation 11: Need for Consent)

2. Are decisions made in the best interests of the individual where capacity is lacking? (Mental Capacity Act 2005, Best Interest decisions)

3. Is there evidence that the individual and/or their family have given informed consent for care and treatment? (Mental Capacity Act 2005, CQC Regulation 11: Need for Consent)

1. Are all care plans, risk assessments, and records kept up to date and accurately reflect the individual's current care needs? (CQC Regulation 17: Good Governance)

2. Are all entries in care documentation signed and dated by the relevant staff members? (CQC Regulation 17)

3. Is information securely stored in line with GDPR regulations? (Data Protection Act 2018, GDPR)

1. Are care plans reviewed regularly (at least monthly) and adjusted as necessary? (Care Act 2014, Section 27, CQC Regulation 9)

2. Is there a process in place for continuous monitoring of the care provided and outcomes achieved? (CQC Regulation 17: Good Governance)

1. Are staff adequately trained to deliver person-centred care, including specific training on dementia care, safeguarding, and DoLS? (CQC Regulation 18: Staffing)

2. Is there evidence of ongoing professional development and competency assessments? (Health and Social Care Act 2008, Regulation 18)

1. Are care plans reflective of the individual's cultural, religious, and personal preferences? (Equality Act 2010, CQC Regulation 10: Dignity and Respect)

2. Is there evidence of staff promoting equality, diversity, and inclusion in care delivery? (Equality Act 2010, CQC Regulation 10)

1. Are family members and advocates involved in the care planning process where appropriate? (Care Act 2014, Section 10, CQC Regulation 9)

2. Are family and advocates kept informed about changes in care and involved in decision-making processes? (Care Act 2014, Section 10, CQC Regulation 9)