ABC Audit - Care Homes (Antecedent, Behaviour, Consequence)

Evidence to check

• • Current policy is available and reviewed
• • Policy explains ABC recording, behaviour support planning, restrictive practice, MCA, DoLS and safeguarding links
• • Staff can explain when ABC charts should be started
• • Observed practice and records match the policy

Evidence to check

• • Policy or guidance defines behaviours of concern using respectful language
• • Staff can describe behaviours in observable terms rather than labels
• • Staff understand distress may link to pain, fear, confusion, trauma, communication, environment or unmet need
• • ABC charts are used when patterns need to be understood, not only after serious incidents

Evidence to check

• • Named behaviour support lead, registered manager, clinical lead or PBS lead is documented
• • Lead reviews ABC data, behaviour plans, restrictive practice and incidents
• • Lead follows up audit actions
• • Staff know who to approach for behaviour support guidance

Evidence to check

• • Clinical, quality or governance meeting minutes include ABC or behaviour themes
• • Actions from ABC reviews have owners and deadlines
• • Progress is reviewed at later meetings
• • Governance considers resident outcomes, staff support and restrictive practice reduction

Evidence to check

• • Incident analysis includes behaviour-related events
• • Themes are reviewed by resident, unit, time of day, activity, staffing and environment
• • Learning is shared through handover, team meetings, supervision or training
• • Care plans are updated following learning

Evidence to check

• • Behaviour audit action plan is current
• • Actions have named owners, deadlines and priority ratings
• • Completion is evidenced, not just marked as done
• • Impact on distress, incidents, PRN use or quality of life is reviewed

Evidence to check

• • Behaviour-related incidents are reviewed for safeguarding, CQC notification and external reporting requirements
• • Rationale is recorded where notification or referral is or is not made
• • Notifications are completed within required timescales where applicable
• • Learning from safeguarding or notification outcomes is shared

Evidence to check

• • Care plan records usual mood, communication, routine, sleep, appetite and interaction patterns
• • Baseline includes what is normal for the resident and what indicates change
• • Staff use baseline information to recognise deterioration or distress
• • Baseline is updated when the resident's needs change

Evidence to check

• • Records show checks for pain, constipation, UTI, delirium, dehydration, infection, hunger, fatigue or injury
• • GP, nurse or clinical review is requested where needed
• • Pain assessment tools are used for residents who cannot verbalise pain
• • Behaviour plans are updated when physical health causes are identified

Evidence to check

• • Assessment considers dementia progression, delirium, depression, anxiety, psychosis, trauma and confusion
• • Mental health or dementia specialist input is requested where needed
• • Records show changes in cognition or mood are escalated
• • Staff adapt approaches based on cognitive and emotional needs

Evidence to check

• • Medication review considers behaviour changes and distress
• • Recent medication changes, missed doses or side effects are reviewed
• • PRN use is monitored for frequency, reason and effectiveness
• • GP, pharmacist or prescriber input is sought where medication may contribute to distress

Evidence to check

• • Assessment considers hearing, vision, aphasia, learning disability, autism, sensory processing and trauma history
• • Communication aids, glasses, hearing aids or visual prompts are available where needed
• • ABC records consider whether communication breakdown contributed to distress
• • Care plan includes resident-specific communication strategies

Evidence to check

• • Records consider sleep disturbance, pain, toileting, hunger, noise, sundowning or medication effects
• • Night-time ABC patterns are reviewed separately where relevant
• • Sleep routines and comfort strategies are included in the care plan
• • Night staff contribute to ABC records and reviews

Evidence to check

• • ABC analysis considers noise, lighting, crowding, temperature, signage, layout, clutter and lack of quiet space
• • Environmental changes are trialled where triggers are identified
• • Residents with dementia or sensory needs have adapted environments where possible
• • Effectiveness of environmental changes is reviewed

Evidence to check

• • Policy defines when formal assessment or ABC charting should begin
• • Staff know escalation thresholds
• • Repeated low-level distress is not ignored
• • Formal assessment is started promptly when thresholds are met

Evidence to check

• • Functional assessment is completed for residents with repeated or complex distress
• • Assessor has suitable skills, training or professional role
• • Assessment identifies possible function or unmet need behind behaviour
• • Findings lead to practical support strategies

Evidence to check

• • ABC charts are completed close to the time of the event
• • Records include lower-level or repeated distress, not only serious incidents
• • Charts are completed across day, night, weekend and agency shifts
• • Retrospective entries are clearly identified and explained

Evidence to check

• • ABC records include date and time of event
• • Location is specific, such as bedroom, bathroom, dining room or corridor
• • Staff names or roles are recorded
• • Records allow patterns by place, time and staffing to be analysed

Evidence to check

• • Records describe what was happening before the behaviour
• • Entries avoid assumptions such as 'for no reason' or 'attention-seeking'
• • Antecedents include activity, interaction, environment, personal care, pain or change in routine where relevant
• • Staff are coached where antecedents are vague or judgemental

Evidence to check

• • Records describe what was seen or heard, such as shouting, pacing, hitting out or refusing care
• • Language avoids unsupported labels such as aggressive, difficult, manipulative or challenging
• • Resident dignity is maintained in records
• • Managers challenge poor recording language

Evidence to check

• • ABC or incident records include intensity rating where required
• • Scale criteria are defined so staff rate consistently
• • Intensity is reviewed alongside duration, frequency and impact
• • Ratings are used to plan support, not to label the resident

Evidence to check

• • Records show how long the behaviour lasted
• • Repeated episodes are tracked over days or weeks
• • Frequency trends are reviewed during behaviour meetings
• • Reduction or increase in frequency is used to evaluate support plans

Evidence to check

• • Records describe staff actions after the behaviour
• • Records note whether the resident gained, avoided or escaped something, such as personal care, noise or interaction
• • Resident outcome is recorded, such as settled, still distressed, injured or needed medical review
• • Consequences are analysed to avoid unintentionally reinforcing distress

Evidence to check

• • Records consider pain, fear, confusion, boredom, loneliness, hunger, sensory overload or communication difficulty
• • Resident is asked what happened where possible
• • Non-verbal cues are considered for residents who cannot explain
• • Care plan reflects identified unmet needs

Evidence to check

• • Incident forms are completed where harm, injury, near miss or property damage occurs
• • ABC chart references the related incident record
• • Injuries to residents, staff or others are recorded and followed up
• • Safeguarding and external reporting are considered where relevant

Evidence to check

• • Records are legible, dated and attributable to staff
• • Entries are factual and respectful
• • Records are stored securely in line with information governance
• • Incomplete or poor-quality records are followed up

Evidence to check

• • Staff receive guidance or training on ABC recording
• • Night, weekend, bank and agency staff know how to complete charts
• • Managers check for reporting bias or gaps by shift
• • Support is given where staff lack confidence in recording

Evidence to check

• • ABC review frequency is defined
• • Summaries identify patterns, triggers and effective responses
• • Analysis leads to care plan changes
• • Reviews are completed sooner where risk escalates

Evidence to check

• • ABC analysis includes time and shift trends
• • Staffing levels and skill mix are considered
• • Environmental triggers are reviewed alongside staffing data
• • Actions address system factors, not only resident behaviour

Evidence to check

• • ABC analysis reviews activities linked to distress
• • Personal care, bathing, mealtimes, medication rounds and transitions are considered
• • Care routines are adapted where specific activities trigger distress
• • Staff are briefed on activity-specific prevention strategies

Evidence to check

• • Analysis considers whether certain staff, residents, visitors or approaches are linked to distress
• • Interaction style, tone, pace, gender of staff and familiarity are considered
• • Staff receive coaching where their approach contributes to distress
• • Findings are used constructively, not to blame

Evidence to check

• • ABC analysis is compared with clinical notes and health records
• • Pain, bowel, fluid, infection and sleep records are reviewed where relevant
• • Clinical escalation occurs where health triggers are suspected
• • Care plan includes prevention and monitoring for identified health triggers

Evidence to check

• • ABC analysis considers boredom, loneliness and lack of stimulation
• • Activity records and social engagement are reviewed
• • Care plan includes meaningful occupation and choices
• • Effectiveness is reviewed through wellbeing and incident trends

Evidence to check

• • ABC reviews consider how staff communicated before distress
• • Staff pace, clarity, tone and use of communication aids are reviewed
• • Care plan includes communication strategies
• • Staff are coached where communication contributes to distress

Evidence to check

• • Noise, lighting, busy areas, smells, touch and lack of sensory input are considered
• • Sensory preferences are recorded in care plans
• • Quiet spaces, sensory tools or environmental changes are trialled
• • Impact of changes is reviewed

Evidence to check

• • Care plan records known trauma-informed approaches where relevant
• • ABC analysis considers whether care actions or environment may trigger trauma responses
• • Staff use choice, predictability, consent and reassurance
• • Specialist support is sought where trauma responses are complex

Evidence to check

• • Behaviour plans are updated after ABC analysis
• • Plans include trigger prevention and early intervention
• • Staff change routines, environment or communication before distress escalates
• • Reactive responses are not the only strategy

Evidence to check

• • Behaviour support plan is current and resident-specific
• • Plan is linked to ABC findings
• • Plan is accessible to staff providing care
• • Plan is reviewed after incidents or changes in need

Evidence to check

• • Plan identifies resident-specific triggers
• • Early warning signs are clearly described
• • De-escalation strategies are practical and individualised
• • Staff can describe what works for the resident

Evidence to check

• • Plan includes prevention strategies, not only crisis response
• • Routine, choice, activity, communication and environment are addressed
• • Strategies are realistic for all shifts
• • Daily records show proactive strategies are used

Evidence to check

• • Plan describes what staff should do in the moment
• • Reactive strategies focus on safety, reassurance and dignity
• • Physical or restrictive interventions are not used as first-line responses
• • Staff understand when to escalate

Evidence to check

• • Staff can explain the resident's behaviour support plan
• • Observation shows staff use the agreed approach
• • Handovers reinforce agreed strategies
• • Inconsistent practice is corrected through supervision or coaching

Evidence to check

• • Care plan records reasonable adjustments
• • Tools or aids are available and used
• • Adjustments are reviewed for effectiveness
• • Staff understand why the adjustments matter

Evidence to check

• • Plan review dates are recorded
• • Incident learning is added to the plan
• • Changes are communicated to staff
• • Follow-up checks whether the revised plan reduced distress

Evidence to check

• • Family or representative input is recorded where appropriate
• • Consent and confidentiality are considered
• • Family knowledge of history, routines and triggers is used
• • Resident's own wishes remain central

Evidence to check

• • Decision-specific capacity assessments are completed where required
• • Best-interest decisions include least-restrictive options
• • Relevant people are consulted where appropriate
• • Decisions are reviewed when circumstances change

Evidence to check

• • Care plan identifies all restrictive practices
• • Restrictions are not hidden within routine care language
• • PRN or sedating medication is considered where it may restrict behaviour
• • Restrictive interventions are logged and reviewed

Evidence to check

• • Risk assessment states why restriction is needed
• • Less restrictive alternatives are considered and documented
• • Restriction is proportionate to the risk
• • Restriction is reviewed and reduced where possible

Evidence to check

• • DoLS application, authorisation, conditions and expiry date are checked where relevant
• • Care plan reflects authorised restrictions and conditions
• • Staff understand DoLS does not remove the need for consent and least-restrictive practice
• • LPS is not treated as active practice; DoLS remains the current care home framework

Evidence to check

• • Restrictions have review dates and reduction plans
• • Reduction attempts are recorded where safe
• • Resident wellbeing and quality of life are reviewed
• • Long-term restrictions are challenged through governance

Evidence to check

• • PRN records include reason, dose, time and outcome
• • Frequency and patterns of PRN use are reviewed
• • Side effects and impact on alertness, mobility and wellbeing are monitored
• • Non-medication strategies are used and recorded where appropriate

Evidence to check

• • Resident debrief or welfare review is recorded where possible
• • Staff debrief is offered after significant incidents
• • Debriefs identify triggers, learning and support needs
• • Learning is reflected in care plans and staff support

Evidence to check

• • Training records and certification are current where physical intervention is used
• • Only trained staff use physical intervention except in immediate emergency to prevent serious harm
• • Competency and refresher training are monitored
• • Use of physical intervention is reviewed for legality, proportionality and harm

Evidence to check

• • Incident forms and ABC charts cross-reference each other
• • Records are completed promptly
• • ABC data adds analysis beyond the incident form
• • Gaps between incident and ABC records are followed up

Evidence to check

• • Post-incident review identifies what happened before, during and after
• • Root causes and unmet needs are considered
• • Prevention strategies are updated
• • Staff receive feedback and learning

Evidence to check

• • Safeguarding threshold is considered during incident review
• • Resident-to-resident incidents are reviewed for safeguarding concerns
• • Neglect, abuse, coercion, exploitation or poor practice is escalated
• • Rationale is recorded where safeguarding is considered but not referred

Evidence to check

• • Injury records include resident and staff harm
• • Investigation reviews environment, staffing, training, equipment and care plan factors
• • Actions are implemented and followed up
• • Occupational health or staff wellbeing support is offered where needed

Evidence to check

• • CQC, safeguarding, RIDDOR, commissioner or other reporting requirements are considered
• • Notifications are completed within required timescales where applicable
• • Rationale is recorded where no notification is made
• • Learning from external feedback is acted on

Evidence to check

• • Staff debrief and supervision records
• • Emotional impact and confidence are discussed
• • Support is offered after distressing or violent incidents
• • Staff support is balanced with resident safety and accountability

Evidence to check

• • Referrals to GP, mental health team, psychiatry, psychology, SALT, OT, physiotherapy or dementia specialist are recorded where needed
• • Referral outcomes are followed up
• • Professional advice is added to care plans
• • Delays are escalated where risk remains

Evidence to check

• • Communication and swallowing needs are reviewed
• • SALT referral is made where appropriate
• • SALT advice is reflected in care plans and staff practice
• • Staff understand communication or dysphagia-related triggers

Evidence to check

• • Sensory and environmental concerns are documented
• • OT referral or advice is sought where appropriate
• • Recommendations are implemented, such as seating, lighting, routines or sensory tools
• • Effectiveness of changes is reviewed

Evidence to check

• • Pain assessment tool is used, including for non-verbal residents
• • Pain relief or clinical review is requested where needed
• • Response to treatment is monitored
• • Behaviour support plan is updated where pain is a trigger

Evidence to check

• • Dementia-related distress is recognised in care planning
• • Specialist dementia advice is sought where needed
• • Staff use dementia-friendly communication and validation approaches
• • Care plan includes life history, routine, comfort and orientation strategies

Evidence to check

• • MDT meeting records include attendees, risks, decisions and actions
• • Resident and family or representative involvement is considered
• • Actions have owners and timescales
• • Review date is set and followed up

Evidence to check

• • Professional advice is recorded in care plans
• • Staff are briefed on recommendations
• • Daily notes and observations show recommendations are followed
• • Non-implementation is escalated and explained

Evidence to check

• • Training records cover relevant behaviour support areas
• • Training is role-appropriate and refreshed
• • Staff can explain de-escalation and trauma-informed approaches
• • Training gaps are addressed through action plans

Evidence to check

• • Supervision records include behaviour support where relevant
• • Managers observe practice and provide feedback
• • Night, weekend, bank and agency staff are included in support
• • Inconsistent practice is addressed promptly

Evidence to check

• • Rota or allocation reflects known behaviour support needs
• • Experienced staff are allocated during high-risk times where possible
• • Two staff support is planned where required for personal care or transfers
• • Staffing changes are reviewed for effectiveness

Evidence to check

• • Handover records include behaviour support information
• • Staff are informed of new triggers, refusals, PRN use or incidents
• • Effective strategies are shared across shifts
• • Changes are not left only in written care plans without verbal handover where risk is high

Evidence to check

• • Observation shows calm tone, patience, pacing and reassurance
• • Staff avoid blame, threats, punishment or shaming language
• • Residents are supported with dignity during distress
• • Managers challenge punitive or controlling practice

Evidence to check

• • Agency induction or shift briefing includes behaviour support needs
• • Agency staff know resident-specific triggers and safe approaches
• • Permanent staff support agency staff with complex residents
• • Agency staff are not allocated beyond competence

Evidence to check

• • Measures include incident frequency, severity, duration, PRN use, injuries and restrictive practice
• • Quality of life indicators are included, such as activity, relationships, sleep, comfort and autonomy
• • Baseline and follow-up data are compared
• • Outcomes inform care plan changes

Evidence to check

• • Before-and-after analysis is available
• • Incident frequency, severity or distress levels are reviewed
• • Reduction is linked to specific changes or strategies
• • Where incidents increase, the plan is reviewed rather than allowed to continue unchanged

Evidence to check

• • Behaviour plan reviews identify strategies that are not working
• • Staff feedback and ABC data inform changes
• • Professional advice is sought where progress is limited
• • Care plans do not repeat ineffective approaches without rationale

Evidence to check

• • Records show improved comfort, activity, relationships, sleep, communication or choice
• • Resident feedback or non-verbal wellbeing indicators are considered
• • Support focuses on quality of life, not only reducing incidents
• • Positive outcomes are reviewed and sustained

Evidence to check

• • Communication records show appropriate updates
• • Consent and confidentiality are considered
• • Family insight is used to understand history, triggers and comfort strategies
• • Feedback is included in reviews where appropriate

Evidence to check

• • ABC analysis has led to changes in environment, routines, staffing, training or activities
• • Learning is shared beyond one resident where relevant
• • Governance records show service-wide themes and actions
• • Impact of service-wide changes is reviewed

Evidence to check

• • Staff can describe a real example
• • Example links antecedent, behaviour and consequence to a change in approach
• • Care plan or routine was updated as a result
• • Resident outcome improved or risk reduced

Evidence to check

• • Senior staff can show ABC trend analysis
• • Action plans show actions, owners, deadlines and outcomes
• • Evidence includes reduced distress, reduced restriction, improved wellbeing or improved staff confidence
• • Reports are discussed through governance

Evidence to check

• • Audit reviews whether ABC records are objective, complete and useful
• • Audit checks whether analysis led to updated support plans
• • Audit considers resident dignity, quality of life and reduction in distress
• • Actions from audits lead to measurable practice improvement

Evidence to check

• • Records avoid judgemental terms such as difficult, manipulative or attention-seeking
• • Language describes observable behaviour and possible unmet need
• • Managers challenge poor language in records and handovers
• • Care plans focus on support, reassurance and prevention