Title Page
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Site conducted
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Conducted on
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Prepared by
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Room Number
Care Plan Audit
- FRONT SHEET
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All sections of the front sheet has been completed with required information
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A photograph of resident is in place (unless consent/best interest agreement not given)
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a 'named nurse'/ 'keyworker' is clearly stipulated
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A DNACPR form is in place if appropriate
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Allergy status is recorded
ADDTIONAL INFORMATION
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Pre-admission assessment completed
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GP summary care record is on file
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A care plan index is in place and completed
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NEWS observations have been correctly recorded
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A life history/'This is Me' is available and completed
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There is a personalised plan (PEEP) for evacuation and it is fully completed
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A permissions/best interest form has been completed
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An Isaac Neville assessment has been completed and review is up to date
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Personal belongings inventory has been completed
Risk Assessments
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Dependency (Barthel index on PCS) assessment completed and up to date
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Falls Risk assessment completed and up to date
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Must Score completed and up to date
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Waterlow Score Completed and up to date
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Oral care assessment completed and up to date
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Continence assessment completed and up to date
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Moving and handling assessment completed and up to date
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Bed Rails risk assessment completed and up to date
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If self-medicating, a risk assessment has been documented
CARE PLAN: 1 DOLS
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If the service user meets the criteria, there is a DoLS agreement in place
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There is evidence that capacity assessments are relevant and acted upon
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A DoLS care plan is available
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The DoLS care plan is written in a person-centred format
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The care plan is detailed and appropriate
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The care plan is evaluated at least monthly
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Has a DoLs application been made?
CARE PLAN 2: MEANINGFUL ACTIVITY AND HOW I CHOOOSE TO SPEND MY DAY
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A care plan is available
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The care plan is written in a person-centred format
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The care plan is detailed and appropriate
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'my preferred daily routine' is comprehensively completed
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The care plan is evaluated at least monthly
CARE PLAN 3: NUTRITION AND HYDRATION
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A care plan is available
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The care plan is written in a person-centred format
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The care plan is detailed and appropriate
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The care plan is evaluated at least monthly
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A swallowing assessment has been completed if required
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Where weight loss is noted, there is evidence of action being taken
CARE PLAN 4: MOBILITY, DEXTERITY & FALLS RISK
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A care plan is available
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The care plan is written in a person-centred format
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The care plan is detailed and appropriate
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The care plan is evaluated at least monthly
CARE PLAN 5: PERSONAL CARE, ELIMINATION AND CONTINENCE
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A care plan is available
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The care plan is written in a person-centred format
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The care plan is detailed and appropriate
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The care plan is evaluated at least monthly
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Is the service user catheterised?
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Is there a Catheter Passport document
CARE PLAN 6: RESTING & SLEEPING
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A care plan is in place
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The care plan is written in a person-centred format
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The care plan is detailed and appropriate
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The care plan is evaluated at least monthly
CARE PLAN 7: SKIN AND TISSUE VIABILITY
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Is the service users tissue viability compromised or at risk, ie pressure damage or wounds?<br>
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A care plan is available
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The care plan is written in a person-centred format
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The care plan is detailed and appropriate
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There is evidence of a completed or scheduled review
CARE PLAN 8: PHYSICAL HEALTH
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A care plan is available
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The care plan is written in a person-centred format
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The care plan is detailed and appropriate and cross referenced with GP care summary/medications
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The care plan is evaluated at least monthly
CARE PLAN 9: MENTAL HEALTH WELLBEING
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A care plan is available
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The care plan is written in a person-centred format
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The care plan is detailed and appropriate and includes details on mental state and mood
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Risk Assessments are in place if required
CARE PLAN 10: MY FUTURE PLANNING AND END OF LIFE CARE
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There is documentation regarding ‘wishes and preferences’ for future planning and end of life care.
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A care plan is available
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The care plan is written in a person-centred format
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The care plan is detailed and appropriate
GENERAL DOCUMENTATION
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A transfer/discharge form is prepared
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A record is maintained of visits by other professionals (This could be on PCS in care notes)
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All relevant letters are filed/scanned onto person centered software
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There is a record of observations and specimens sent, and results received
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Registered nurses complete a daily entry onto Person Centered Software
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There is evidence that any issues identified in care plans are acted upon in daily record
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The file generally is well maintained and there is evidence that documentation no longer required is archived
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Risk assessments are available for other risks identified (such as self-harm, sudden deterioration) and evaluated at least monthly and more frequently if required