Title Page

  • Site conducted

  • Conducted on

  • Prepared by

  • Room Number

Care Plan Audit

    FRONT SHEET
  • All sections of the front sheet has been completed with required information

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

  • a 'named nurse'/ 'keyworker' is clearly stipulated

  • A DNACPR form is in place if appropriate

  • Allergy status is recorded

ADDTIONAL INFORMATION

  • Pre-admission assessment completed

  • GP summary care record is on file

  • A care plan index is in place and completed

  • NEWS observations have been correctly recorded

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

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

  • A permissions/best interest form has been completed

  • An Isaac Neville assessment has been completed and review is up to date

  • Personal belongings inventory has been completed

Risk Assessments

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

  • Falls Risk assessment completed and up to date

  • Must Score completed and up to date

  • Waterlow Score Completed and up to date

  • Oral care assessment completed and up to date

  • Continence assessment completed and up to date

  • Moving and handling assessment completed and up to date

  • Bed Rails risk assessment completed and up to date

  • If self-medicating, a risk assessment has been documented

CARE PLAN: 1 DOLS

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

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

  • A DoLS care plan is available

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

  • The care plan is detailed and appropriate

  • The care plan is evaluated at least monthly

  • Has a DoLs application been made?

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

  • A care plan is available

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

  • The care plan is detailed and appropriate

  • 'my preferred daily routine' is comprehensively completed

  • The care plan is evaluated at least monthly

CARE PLAN 3: NUTRITION AND HYDRATION

  • A care plan is available

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

  • The care plan is detailed and appropriate

  • The care plan is evaluated at least monthly

  • A swallowing assessment has been completed if required

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

CARE PLAN 4: MOBILITY, DEXTERITY & FALLS RISK

  • A care plan is available

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

  • The care plan is detailed and appropriate

  • The care plan is evaluated at least monthly

CARE PLAN 5: PERSONAL CARE, ELIMINATION AND CONTINENCE

  • A care plan is available

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

  • The care plan is detailed and appropriate

  • The care plan is evaluated at least monthly

  • Is the service user catheterised?

  • Is there a Catheter Passport document

CARE PLAN 6: RESTING & SLEEPING

  • A care plan is in place

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

  • The care plan is detailed and appropriate

  • The care plan is evaluated at least monthly

CARE PLAN 7: SKIN AND TISSUE VIABILITY

  • Is the service users tissue viability compromised or at risk, ie pressure damage or wounds?<br>

  • A care plan is available

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

  • The care plan is detailed and appropriate

  • There is evidence of a completed or scheduled review

CARE PLAN 8: PHYSICAL HEALTH

  • A care plan is available

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

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

  • The care plan is evaluated at least monthly

CARE PLAN 9: MENTAL HEALTH WELLBEING

  • A care plan is available

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

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

  • Risk Assessments are in place if required

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.

  • A care plan is available

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

  • The care plan is detailed and appropriate

GENERAL DOCUMENTATION

  • A transfer/discharge form is prepared

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

  • All relevant letters are filed/scanned onto person centered software

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

  • Registered nurses complete a daily entry onto Person Centered Software

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

  • The file generally is well maintained and there is evidence that documentation no longer required is archived

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

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.