Care Plan and Risk Assessment Audit

• Site conducted

  Select

• Conducted on

  Date

• Prepared by

• Location
  Address

• Is DOB present on the customer profile form?

  Yes

  No

  N/A

• Preferred name present on customer profile form?

  Yes

  No

  N/A

• Full address present on customer profile form?

  Yes

  No

  N/A

• NHS number present on customer profile form?

  Yes

  No

  N/A

• Telephone number present on customer profile form?

  Yes

  No

  N/A

• Key safe number present on customer profile form?

  Yes

  No

  N/A

• Access details present on customer profile form?

  Yes

  No

  N/A

• Preferred language present on customer profile form?

  Yes

  No

  N/A

• Information if resident needs translator present on customer profile form??

  Yes

  No

  N/A

• Ethnic origin present on customer profile form?

  Yes

  No

  N/A

• Religion and beliefs present on customer profile form?

  Yes

  No

  N/A

• Allergies documented on customer profile form?

  Yes

  No

  N/A

• Residents commencement recorded date documented on the customer profile form?

  Yes

  No

  N/A

• Is it documented if the resident as pets at their home on the customer profile form?

  Yes

  No

  N/A

• Is it documented if the residents smokes or not documented on the customer profile form?

  Yes

  No

  N/A

• Is outline of support required documented on customer profile form?

  Yes

  No

  N/A

• Is outline of medical background documented on customer profile form?

  Yes

  No

  N/A

• Frequency of supported required documented on customer profile form?

  Yes

  No

  N/A

• Details of visits required documented on customer profile form?

  Yes

  No

  N/A

• Is it documented on the customer profile form, who funded the residents package of care?

  Yes

  No

  N/A

• Referred by who, documented on the customer profile form?

  Yes

  No

  N/A

Documents

• Is there a support plan uploaded on ACP from social services?

  Yes

  No

  N/A

• Is there a moving and handling risk assessment from social services uploaded on ACP?

  Yes

  No

  N/A

• Is there salts support plan from SALTs team uploaded on ACP?

  Yes

  No

  N/A

• Is there a covert medication from the medical team and best interest meeting notes uploaded on ACP?

  Yes

  No

  N/A

• Is there CHC support plan uploaded on ACP?

  Yes

  No

  N/A

Customer Care Plan

• Date care plan was drawn up documented on customer care plan form?

  Yes

  No

  N/A

• Is it documented on the customer care plan who attended the care plan assessment?

  Yes

  No

  N/A

• Is a picture of the resident uploaded on ACP?

  Yes

  No

  N/A

• Is past medical history documented on customer care plan form

  Yes

  No

  N/A

• Is current medical history documented on customer care plan form?

  Yes

  No

  N/A

• Is any known allergies documented on the customer care plan form?

  Yes

  No

  N/A

• if the resident as any known allergies, does it state what actions are needed in case of reaction?

  Yes

  No

  N/A

• Is it documented on customer care plan from , what daily routine support the resident needs?

  Yes

  No

  N/A

• Is the summary of daily routine tasks documented in a person centred way?

  Yes

  No

  N/A

• Is there a action plan documented on how to prevent any risks when delivering personal care

  Yes

  No

  N/A

• Is there a personal care outcome plan documented to support the residents personal care aspiration and goals?

  Yes

  No

  N/A

• Is it documented in the care plan what activities the residents likes to do?

  Yes

  No

  N/A

• Does the care plan show the residents likes, dislikes, hobbies and aspirations

  Yes

  No

  N/A

• Does the care plan show how we can encourage and meet the residents goals and aspirations?

  Yes

  No

  N/A

• If there is any risks involved in supporting the resident with any social activities, does the care plan state how we can help in minimising the risks but at the same time ensuring the residents is fulfilling their goals and aspirations?

  Yes

  No

  N/A

Capacity

• Does the care plan state if the resident can make their own decisions?

  Yes

  No

  N/A

• If the resident needs support in making any form of decisions, does the care plan show how care can be delivered in the best interest of the resident?

  Yes

  No

  N/A

• Does the care plan state if there is a decision maker or not?

  Yes

  No

  N/A

• Is it documented if the resident agreed to having someone making decisions in their best interest , before resident deemed to have no capacity?

  Yes

  No

  N/A

• If there is decision maker , is it clearly documented who this person is and is the LPOA form uploaded on ACP?

  Yes

  No

  N/A

• Does the care plan state why the resident needs support in decision making i.e. learning disability?

  Yes

  No

  N/A

• Does the capacity form document any risks if someone was not acting in the best interest of the resident?

  Yes

  No

  N/A

• Does the care plan have a clear outcome plan when it comes to making any decisions for the resident who lacks capacity?

  Yes

  No

  N/A

Mobility

• Does the care plan state what equipment is being used to help with any mobility issues?

  Yes

  No

  N/A

• If the resident needs support with mobility does the care plan state how this would be delivered? i.e. hoist using sling

  Yes

  No

  N/A

Incontinence

• Does the care plan show if the resident needs support with incontinence?

  Yes

  No

  N/A

• If the resident needs support with incontinence is there a clear guideline on how this will be delivered?

  Yes

  No

  N/A

• Does the care plan document any risks with incontinence? i.e bed sores etc

  Yes

  No

  N/A

• Does the care plan state if there is any outcomes in supporting with incontinence?

  Yes

  No

  N/A

Nutrition

• Does the care plan state if the resident needs support with fluid and nutrition?

  Yes

  No

  N/A

• Is there a clear plan on how this support will be delivered?

  Yes

  No

  N/A

• Does the care plan show clear guidelines on any risks around deity requirements? i.e. swallowing difficulties

  Yes

  No

  N/A

• Does the care plan show any goals in fluid and nutrition? i.e. loss weight, healthy balanced diet etc

  Yes

  No

  N/A

• Does the care plan state if any illness can effect ,fluid and nutrition in take and does it state how our carers can prevent malnutrition ? i.e. dementia saying they have already eaten carer to check for evidence and encourage intake.

  Yes

  No

  N/A

• Is the care plan around nutrition and fluid person centered?

  Yes

  No

  N/A

Skin

• Does the care plan state if the resident needs any support with skin integrity

  Yes

  No

  N/A

• If the resident needs support is there clear guidelines for the carers to follow?

  Yes

  No

  N/A

• If there is any risks, does the care plan show how this can be prevent these? i.e. body wash, clean pad and apply cream to red area of buttocks.

  Yes

  No

  N/A

• If there is any cream that needs to applied, does the care plan state what the name of the cream reasons why cream is needed?

  Yes

  No

  N/A

• If the resident as limited movement , does the care plan document what is needed to prevent pressure sores? i.e. regular re positioning, chair sling.

  Yes

  No

  N/A

Communication

• Does the care plan state if the resident needs any support with communication?

  Yes

  No

  N/A

• Does the care plan show why the person needs this support? i.e. hearing impairment

  Yes

  No

  N/A

• Does the care plan state how the resident would prefer to communicate? i.e. pictures, email,

  Yes

  No

  N/A

• Does the care plan show how to support the resident with communication in a person centred way?

  Yes

  No

  N/A

• If there is any risk, does the care plan document what the risks are and guidance on how to prevent the risk?

  Yes

  No

  N/A

Religious and cultural

• Does the care plan document if the resident as any religious and cultural beliefs

  Yes

  No

  N/A

• Does the care plan state what the residents beliefs are and how we can support in this area? i.e. halal food, take resident to church of choice.

  Yes

  No

  N/A

• If there is any risk is this clearly documented?

  Yes

  No

  N/A

Medication

• Does the care plan show what medication is taken by the resident, why they take it and when they take it?

  Yes

  No

  N/A

• Does the medication risk assessment document who will collect the medication? .i.e. pharmacy will deliver

  Yes

  No

  N/A

• Does the care plan document if the resident need any support with medication and does it show in a person centred way how this support will look like?

  Yes

  No

  N/A

• Does the care plan state where the medication is stored and why its stored there? i.e. in a locked safe in the kitchen due to risk of overdose.

  Yes

  No

  N/A

• Does the care plan document any risks? i.e. Parkinson's medication is needed and needs to be taken at certain time.

  Yes

  No

  N/A

• Does the medication risk assessment document if there is any other professionals who are administrating medication i.e. syringe drive.

  Yes

  No

  N/A

• Does the medication risk assessment match what is included in the care plan on ACP?

  Yes

  No

  N/A

• If the medication is needed to be given coverted or via peg, is there clear guidance for this.

  Yes

  No

  N/A

Mental Health

• Does the care plan state if the resident as any mental health problems?

  Yes

  No

  N/A

• Does the care plan state what mental health problem this is?

  Yes

  No

  N/A

• Does the care plan document how best our carers can support with any mental health problems in person centred way?

  Yes

  No

  N/A

Advanced care planning

• Does the care plan document if the residents needs support with end of life care?

  Yes

  No

  N/A

• Is there anyone involved in helping with these advanced decisions? i.e. hospice

  Yes

  No

  N/A

• Is the advanced care plan person centred?

  Yes

  No

  N/A

• Does the advanced care plan share any goals and aspirations of how the resident would like to be supported?

  Yes

  No

  N/A

Health

• Does the health risk assessment document if there is any health related issues? i.e COPD

  Yes

  No

  N/A

• Does the care plan document a full history of the illness, when diagnosed, how its effects them and how best to support them?

  Yes

  No

  N/A

• Does the health risk assessment document if the residents gets any difficulties from illness? i.e. pain etc

  Yes

  No

  N/A

• Does the care plan document any risks and how we can prevent these risks?

  Yes

  No

  N/A

undefined

• Yes

  No

  N/A