Title Page
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Site conducted
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Conducted on
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Prepared by
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Location
Resident Care Plans
FIRST IMPRESSIONS & GDPR
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Have you documented the Resident Initials and Room Number
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Is there a grab file in place and is it in correct order and stored securely?
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Is the grab file up to date with the latest plan of care/hospital passport and medication list?
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If there is a DNACPR or ReSPECT document in place, is it current (check expiry date), original and held at the front of the grab file and copy located on LOG MY CARE?
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Medical information including current conditions are completed, up to date on resident profile sheet?
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Is there a photo taken in the last 12 months on LOG MY CARE?
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If the resident is living with a cognitive impairment, do they have a 'This is Me' form in place, fully completed, updated and held in the front of the resident’s GRAB FILE?
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Is the care plan complete, up to date and evidence Residents involvement?
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Risk assessments are in place, robust, reflect current Resident assessed needs and are reviewed as per schedule?
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Has each individual plan reviewed had an in-depth summary of care over the month period and reflect care provided in that time period?
RESIDENT INVOLVEMENT & CONSENT
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Consent form is completed, accurate and reviewed annually. (Consent form relevant to residents’ current capacity-having capacity and lacking capacity)
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Mental Capacity assessments are fully completed and up to date if applicable for Resident who may require decision specific assessments
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Best interest decisions are in place, evidenced and promote least restrictive person-centred approaches
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Is there a separate plan of care for MCA/BI and DoLS? (If applicable)
Mandatory monthly Plans
MOBILITY
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Resident has a moving & handling risk assessment in place and is reviewed monthly
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There is a log of all equipment issued to Resident that includes serial number and sizing that is reviewed monthly
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Resident equipment is in a good state of repair, fit for purpose and used by them only
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Resident has a PEEPS in place and is reviewed monthly
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There is a falls diary log that is up to date and reviewed monthly for trends
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All risk assessments within mobility plan are in place and reviewed monthly
EATING & DRINKING
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Has the MUST and BMI risk assessment and weight been completed in full, scored accurately, reviewed as a minimum monthly (or as needs change) and reflects the resident's current MUST score?
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Are the relevant risk assessments in place: Choking, Hydration, Nutritional Care Communication Tool? Have these been reviewed monthly or sooner where a change as been identified and reflects the residents current needs?
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Weight checks are documented at weekly/monthly (define which).
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Does the resident's Eating and drinking support plan clearly state their nutrition and hydration support needs and how best to support the resident to maintain their nutritional and hydration to the required level? (Plan should reflect how to support person with their nutrition and hydration needs including level of support required to eat and drink, dietary needs (e.g. texture-modified diet, thickened fluids, fortified, supplements, food first), specialist equipment to promote independence, allergies, likes and dislikes, where they like to eat, any requirement around seating position, cultural requirements, any safety issues e.g. cross-reference to choking risk assessment, SLT guidance, dietician)
SKIN
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There is a waterlow in place that identifies Resident skin integrity and is reviewed monthly or sooner where needed for significant changes
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If the resident has a current wound (including bruising / skin tears) is there a wound plan in place which is accurate, updated with current treatment advice and evidences any referrals to external professionals (e.g. TVN / District Nurse)? (Cross-reference with incident report reference to ensure accuracy, appropriate investigation (Stage 3 and above, ungradable, multiple stage 2 pressure ulcers home acquired). Is this included in 'Wound Wednesday'.
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Does the resident's Skin support plan clearly state their skin integrity support needs and how best to support the resident to maintain their skin integrity? (Plan should reflect how to support person with all appropriate equipment and clearly indicate what a person can do for themselves and when they may require staff support (e.g. support with and frequency of repositioning, topical cream application, airflow mattress settings, TVN / District Nurse advice), cross-references to nutrition, moving and handling, continence etc., the plan should accurately reflect their current level of risk, ensure plan reflects any wound / bruising / skin tear investigation outcomes)
LIVING SAFELY & TAKING RISKS
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Is there an health and safety risk assessment in place and reviewed monthly or sooner where needed?
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Where a specific risk is identified such as bedrails, smoking, behaviours that may impact on health and safety etc. Is there a detailed risk assessment in place to identify risks and how to mitigate this and reviewed monthly or sooner where needed?
PERSONAL CARE
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Has the Oral risk and personal care risk been completed in full, scored accurately, reviewed as a minimum monthly (or as needs change) and reflects the resident's current oral hygiene risk?
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Does the resident's Personal Care support plan clearly state their personal and oral care support needs and how best to support the resident to maintain their personal and oral care to the required level? (Plan should reflect how to support person with personal care including their preferences around bathing and showering, what they can do for themselves and how we can support them in order to maintain as much independence as possible, preferences around toiletries, privacy and dignity choices, how we can support the resident to make daily decisions and choices (e.g. clothing, make-up, grooming), preferences around oral health, appropriate referrals for dental support)
HEALTH & MEDICATION
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Has every effort been made to support this resident to self-medicate and the medication risk has been completed in full and reviewed at the required intervals monthly? (Review of all medication as may be able to partially self-medicate, may be able to medicate with minimal assistance, confirm that the assessment has been completed by the Home Manager)
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Are all risk assessments in place to support health and medication (Health Conditions, Deterioration pathway etc) and reviewed monthly or sooner?
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Is the 'Dependency Assessment' an accurate reflection of the resident's current support needs and is this reflected throughout the support plan?
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Are there any PRN medications in place and if so have protocols been put in place. This also includes variable dose medications. Check whether PRN medications have needed to be administered and whether these have been followed up and if effective to needs. Have protocols been reviewed monthly or sooner where needed as part of the medication support plan review process.
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Is there evidence that the resident's medication has been reviewed within the last 12 months for regular medication, and 3 months for anti-psychotic and sedative medication?
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Does the resident's Medication support plan clearly state their medication support needs and how best to support the resident with their medication? (Plan should reflect how to support person with taking their medication with emphasis on promoting independence and informed choice, should include preferences on how the resident likes to take their medication, any known allergies to medication, how to take their medication safely (e.g. thickened fluids), any timed or high risk medications, cross reference to any health condition risks, PRN protocols and covert medication pathways if in place)
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Does the resident's Medication support plan clearly state their pain management support needs and how best to support the resident with pain? (Plan should reflect how to support person with pain management including how the resident expresses pain with use of the Abbey Pain Scale evidenced if required, all residents who experience pain should have their individual symptoms clearly documented this can be verbal or non-verbal indicators, include detail of pain management medication, detail whether resident experiences chronic, acute or acute-on-chronic (breakthrough) pain)
BEHAVIOUR (This should be monthly for residents who display escalated behaviours, take medications for low mood or prescribed antipsychotics/sedatives)
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If the resident has a history of depression or is displaying signs of a low mood, has the Cornell Depression in Dementia been completed with evidence of any action taken where there is a risk identified?
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Does the resident's Behaviour support plan clearly state their mental health and well-being support needs and how best to support the resident with their mental health and well-being? (Plan should reflect how to support person with their mental health and well-being including document how staff can support the resident when they are displaying signs of stress or distress. Describe what stress and distress looks like for this resident. The plan should include known triggers for stress or distress, specific instructions on how to support the resident (e.g. what works well, what doesn't work as well), known distraction techniques and activities the resident enjoys, how to prevent the resident experiencing stress or distress. how to recognise early signs that the resident is beginning to experience stress or distress. Identify any medication to support the resident, identified medication as last resort, cross referenced to medication Support Plan and/ or PRN protocol. Avoid generic statements such as ‘give reassurance’ and instead describe what this means to the resident. Detail whether ABC charts are to be completed via LOG MY CARE and where they are held Detail any external professionals involved.)
3 MONTHLY REVIEWS & ADDITIONAL PLANS OF CARE
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Have 3 monthly reviews been completed on the remaining plans of care and attached risk assessments? (Where a resident is actively end of life and/or prescribed anticipatory medications, this would change to monthly)
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For any clinical risks identified, is there a risk assessment in place and is this reviewed as per schedule-e.g transdermal patches, catheter risk, epilepsy, vacant episodes, diabetes etc. (This list is not exhaustive and any clinical risk should be evidenced in the appropriate plans of care)
DAILY ENTRIES & ACTIVITIES
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Daily notes evidence person centred approach, are dignified and legible (Refer the last 28 days entries)
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Residents are offered a shower/bath even if they chose not to and this is evidenced (as per personal care plan detail of preference)
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Resident care logs are completed and reflect individual choices and decisions related to care
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Is there evidence within LOG MY CARE of meaningful activity which the resident has been involved in and this is included in the Community, Learning & Leisure plan of care?
COMMUNICATION LOGS WITH RELATIVE AND EXTERNAL PROFESSIONALS
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Is the Health visits section on LOG MY CARE evidencing all external professional visits?
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Is there evidence that keep relatives informed regarding the resident?
