Care Plan Audit

• Conducted on

  Date

• Conducted by

• Room Number

FRONT SHEET

• All Risks to be aware of are completed

  Yes

  No

• Summary of care needs is in place

  Yes

  No

• A photograph of resident is in place (unless consent/best interest agreement not given)

  Yes

  No

  N/A

• a 'keyworker' is clearly stipulated

  Yes

  No

  N/A

• A DNACPR form is in place if appropriate

  Yes

  No

  N/A

• Allergy status is recorded

  Yes

  No

  N/A

ADDTIONAL INFORMATION

• Pre-admission assessment completed

  Yes

  No

  N/A

• PMH is on file (dated in the last 12 months)

  Yes

  No

  N/A

• Observations have been carried out monthly and are correctly recorded

  Yes

  No

  N/A

• A life history/'This is Me' is available and completed

  Yes

  No

  N/A

• There is a personalised plan (PEEP) for evacuation and it is fully completed

  Yes

  No

  N/A

• A permissions/best interest form has been completed

  Yes

  No

  N/A

• Personal belongings inventory has been completed

  Yes

  No

  N/A

Risk Assessments

• Dependency (Barthel index) assessment completed and up to date

  Yes

  No

  N/A

• Falls Risk assessment completed and up to date

  Yes

  No

  N/A

• Must Score completed and up to date

  Yes

  No

  N/A

• Waterlow Score Completed and up to date

  Yes

  No

  N/A

• Oral care assessment completed and up to date

  Yes

  No

  N/A

• Continence assessment completed and up to date

  Yes

  No

  N/A

• Moving and handling assessment completed and up to date

  Yes

  No

  N/A

CARE PLAN: 1 DOLS

• If the service user meets the criteria, there is a DoLS agreement in place

  Yes

  No

  Not required

• There is evidence that capacity assessments are relevant and acted upon

  Yes

  No

• A DoLS care plan is available

  Yes

  No

• The DoLS care plan is written in a person-centred format

  Yes

  No

• The care plan is detailed and appropriate

  Yes

  No

• The care plan is evaluated at least monthly

  Yes

  No

• Has a DoLs application been made?

  Yes

  No

CARE PLAN 2: MEANINGFUL ACTIVITY AND HOW I CHOOOSE TO SPEND MY DAY

• A care plan is available

  Yes

  No

  N/A

• The care plan is written in a person-centred format

  Yes

  No

• The care plan is detailed and appropriate

  Yes

  No

• 'my preferred daily routine' is comprehensively completed

  Yes

  No

• The care plan is evaluated at least monthly

  Yes

  No

CARE PLAN 3: NUTRITION AND HYDRATION

• A care plan is available

  Yes

  No

  N/A

• The care plan is written in a person-centred format

  Yes

  No

• The care plan is detailed and appropriate

  Yes

  No

• The care plan is evaluated at least monthly

  Yes

  No

• A swallowing assessment has been completed if required

  Yes

  No

  N/A

• Where weight loss is noted, there is evidence of action being taken

  Yes

  No

  N/A

CARE PLAN 4: MOBILITY, DEXTERITY & FALLS RISK

• A care plan is available

  Yes

  No

  N/A

• The care plan is written in a person-centred format

  Yes

  No

• The care plan is detailed and appropriate

  Yes

  No

• The care plan is evaluated at least monthly

  Yes

  No

CARE PLAN 5: PERSONAL CARE, ELIMINATION AND CONTINENCE

• A care plan is available

  Yes

  No

  N/A

• The care plan is written in a person-centred format

  Yes

  No

• The care plan is detailed and appropriate

  Yes

  No

• The care plan is evaluated at least monthly

  Yes

  No

• Is the service user catheterised?

  yes

  no

• Is there a Catheter Passport document

  Yes

  No

CARE PLAN 6: RESTING & SLEEPING

• A care plan is in place

  Yes

  No

  N/A

• The care plan is written in a person-centred format

  Yes

  No

• The care plan is detailed and appropriate

  Yes

  No

• The care plan is evaluated at least monthly

  Yes

  No

CARE PLAN 8: PHYSICAL HEALTH

• A care plan is available

  Yes

  No

  N/A

• The care plan is written in a person-centred format

  Yes

  No

• The care plan is detailed and appropriate and cross referenced with GP care summary/medications

  Yes

  No

• The care plan is evaluated at least monthly

  Yes

  No

CARE PLAN 9: MENTAL HEALTH WELLBEING

• A care plan is available

  Yes

  No

  N/A

• The care plan is written in a person-centred format

  Yes

  No

• The care plan is detailed and appropriate and includes details on mental state and mood

  Yes

  No

• Risk Assessments are in place if required

  Yes

  No

  N/A

CARE PLAN 10: MY FUTURE PLANNING AND END OF LIFE CARE

• There is documentation regarding ‘wishes and preferences’ for future planning and end of life care.

  Yes

  No

  N/A

• A care plan is available

  Yes

  No

• The care plan is written in a person-centred format

  Yes

  No

• The care plan is detailed and appropriate

  Yes

  No

GENERAL DOCUMENTATION

• A record is maintained of visits by other professionals (This could be in care notes)

  Yes

  No

  N/A

• All relevant letters are filed/scanned

  Yes

  No

  N/A

• There is a record of observations and specimens sent, and results received

  Yes

  No

  N/A

• There is evidence that any issues identified in care plans are acted upon in daily record

  Yes

  No

  N/A

• Risk assessments are available for other risks identified (such as self-harm, sudden deterioration) and evaluated at least monthly and more frequently if required

  Yes

  No

  Not required

• Comfort rounds have been documented

  Yes

  No

  Not required