NEW!! - CARE PLAN AUDIT: Lindridge Care Home

• Site conducted

  Select

• Conducted on

  Date

• Prepared by

• Room Number

FRONT SHEET

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

  Yes

  No

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

  Yes

  No

  N/A

• A DNACPR/RESPECT form is in place if appropriate which is reflected by the rose on the side of the folder (Green = for resus / Red = Not for resus)

  Yes

  No

  N/A

• Allergy status is recorded on front sheet

  Yes

  No

  N/A

ADMISSION PAPERWORK/INFORMATION

• Pre-admission assessment completed (in folder)

  Yes

  No

  N/A

• GP summary care record is on file (in folder)

  Yes

  No

  N/A

• A care plan index is in place and completed (in folder)

  Yes

  No

  N/A

• NEWS observations have been correctly recorded (PCS or Physical NEWS chart in folder)

  Yes

  No

  N/A

• A life history/'This is Me' or 'Who I am' on PCS is available and completed

  Yes

  No

  N/A

• A permissions/best interest form has been completed and signed (On paper in folder)

  Yes

  No

  N/A

• Personal belongings inventory has been completed (On paper in folder)

  Yes

  No

  N/A

• A body map on admission has been completed (On paper in folder)

  Yes

  No

  N/A

• A dietary form has been completed (On paper in folder)

  Yes

  No

  N/A

RISK ASSESSMENTS

• A pain risk assessment has been completed (PCS)

  Yes

  No

  N/A

• Bed Rails risk assessment completed and up to date (PCS)

  Yes

  No

  N/A

• Continence assessment completed and up to date (PCS)

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• A chocking risk assessment has been completed (PCS)

  Yes

  No

  N/A

• A Eton constipation risk assessment has been completed (PCS)

  Yes

  No

  N/A

• Falls Risk assessment completed and up to date (PCS)

  Yes

  No

  N/A

• A mental capacity assessment has been completed on admission (PCS)

  Yes

  No

  N/A

• Mobility and function risk assessment completed and up to date (PCS)

  Yes

  No

  N/A

• MUST Score completed and up to date (PCS)

  Yes

  No

  N/A

• A nutrition risk assessment has been completed (PCS)

  Yes

  No

  N/A

• Oral care assessment completed and up to date (PCS)

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Waterlow Score Completed and up to date (PCS)

  Yes

  No

  N/A

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

  Yes

  No

  N/A

CARE PLAN: COMMUNICATION

• 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: CONTINENCE

• 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?

CARE PLAN: 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 evaluated at least monthly

  Yes

  No

CARE PLAN: DEATH AND DYING

• 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

• Is 'My Wishes and Preferences for Future Care' document completed

  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

CARE PLAN: FINANCE

• 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

CARE PLAN: MAINTAINING A SAFE ENVIRONMENT

• 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

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/medications

  Yes

  No

• The care plan is evaluated 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

CARE PLAN: MENTAL CAPACITY

• 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

• 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: MOBILITY

• 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: NUTRITION/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: PAIN

• 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: PERSONAL CARE

• 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: SEXUALITY

• 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: SKIN INTEGRITY

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

  Yes

  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

• There is evidence of a wound care plans in place for wounds identified

  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 evaluated at least monthly

  Yes

  No

GENERAL DOCUMENTATION

• A hospital pack is available to print from PCS

  Yes

  No

  N/A

• 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 in the residents folder or scanned onto person centred 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

  Yes

  No

• 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