Care Plan Audit

• Conducted on

  Date

• Prepared by

• Unit

  Ash

  Beech

• Room Number

Hospital PCS Pack

• Is there a printed Hospital Pack in the folder?

  Yes

  No

• Does this show an up to date photo of the resident? (unless permissions not given)

  Yes

  No

• Is the allergy status shown?

  Yes

  No

• Does this show an up to date medical summary?

  Yes

  No

Additional information

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

  Yes

  No

  N/A

• A DNACPR/Respect Form is in place if appropriate

  Yes

  No

  N/A

• DoLs forms are in the folder (if appropriate)

  Yes

  No

  N/A

Pre-Admission Documents

• Pre-admission assessment completed

  Yes

  No

  N/A

• GP summary care record is on file

  Yes

  No

  N/A

• Personal belongings inventory has been completed

  Yes

  No

  N/A

• A permissions/best interest form has been completed

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• NEWS observations have been correctly recorded

  Yes

  No

  N/A

• A body map has been complete for any wounds on admission

  Yes

  No

  N/A

Risk Assessments

• Dependency (Barthel index on PCS) 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

• Bed Rails risk assessment completed and up to date

  Yes

  No

  N/A

• Choking risk assessment completed and up to date

  Yes

  No

  N/A

• Mental Capacity assessment completed and up to date

  Yes

  No

  N/A

• Nutrition assessment completed and up to date

  Yes

  No

  N/A

• Fluid watch assessment completed and up to date

  Yes

  No

  N/A

Care Plan - Communication

• 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

• The care plan is reviewed at least monthly

  Yes

  No

Care Plan - Continence

• 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

• The care plan is reviewed at least monthly

  Yes

  No

• Does the service user have a catheter?

  yes

  no

• A catheter passport is in place

  Yes

  No

Care Plans - Daily life/lifestyle

• 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 reviewed at least monthly

  Yes

  No

Care Plan - Death and dying

• 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

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

  Yes

  No

  N/A

• The care plan is reviewed at least monthly

  Yes

  No

  N/A

Care Plan - Emotional Support

• 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

• The care plan is reviewed at least monthly

  Yes

  No

  N/A

Care Plan - Medical

• 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

  Yes

  No

• The care plan is reviewed at least monthly

  Yes

  No

Care Plan - Medication

• 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

• The care plan is reviewed at least monthly

  Yes

  No

Care Plans - Mental Capacity

• 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

• The care plan is reviewed at least monthly

  Yes

  No

• Does the person lack capacity?

  yes

  no

• Is there a valid Dols in place

  Yes

  No

• Is this detailed in the care plan and Mental Capacity Risk assessment?

  Yes

  No

Care Plan - Mobility

• 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

• The care plan is reviewed at least monthly

  Yes

  No

Care Plan - Nutrition and hydration

• 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

• The care plan is reviewed 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 - Pain

• 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

• The care plan is reviewed at least monthly

  Yes

  No

Care Plan - Personal Care

• 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

• The care plan is reviewed at least monthly

  Yes

  No

Care Plan - Skin Integrity

• 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

• The care plan is reviewed at least monthly

  Yes

  No

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

  yes

  no

• Repositioning schedules have been added to PCS

  Yes

  No

• Wound treatment plan is available?

  Yes

  No

Care Plan - 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 reviewed at least monthly

  Yes

  No

GENERAL DOCUMENTATION

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Registered nurses complete a daily entry onto Person Centered Software (for Nursing residents)

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

• 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 added onto PCS "plan my care day"

  Yes

  No

  Not required