Admissions and Discharge/Transition Audit - Care Homes

Evidence to check

• • Admissions policy is current, reviewed and accessible.
• • Policy covers pre-assessment, capacity to meet needs, resident involvement, risk assessment and emergency admissions.
• • Managers can explain how they decide whether the home can safely admit someone.
• • Admission decisions are based on evidence, not only bed availability.

Evidence to check

• • Welcome pack, brochure, website or pre-admission information is available.
• • Information covers fees, services, staffing, visiting, complaints, activities, rooms and what the home can and cannot provide.
• • Accessible formats are offered where needed.
• • Residents and families have opportunities to ask questions before admission.

Evidence to check

• • Pre-admission assessment is completed before admission wherever possible.
• • Assessment includes mobility, falls, nutrition, skin, medication, continence, cognition, mental health, communication and personal preferences.
• • Information is gathered from the resident, family, hospital, social worker or other professionals where appropriate.
• • Assessment identifies whether the home has the skills, equipment and staffing to meet needs.

Evidence to check

• • Pre-admission risk information is recorded clearly.
• • Immediate risk controls are in place from the first day.
• • Staff are briefed about high-risk needs before the resident arrives.
• • Equipment, staffing or professional input is arranged before or immediately after admission where needed.

Evidence to check

• • Records of communication with hospital, social worker, GP, district nurse, commissioner or other professionals.
• • Transition plan includes medication, equipment, appointments, risks and support needs.
• • Outstanding actions are allocated and followed up.
• • Care staff receive a clear handover before supporting the resident.

Evidence to check

• • Consent records are completed where the resident has capacity.
• • Mental capacity assessments are decision-specific where capacity is in doubt.
• • Best-interest decisions are recorded where the resident lacks capacity.
• • LPA, deputyship, advocate or representative involvement is verified where relevant.

Evidence to check

• • Admission plan includes arrival time, room preparation, staff welcome and immediate needs.
• • Resident is introduced to key staff and supported at their own pace.
• • Room is clean, ready and personalised where possible.
• • Staff check comfort, pain, hunger, thirst, anxiety and immediate safety needs on arrival.

Evidence to check

• • Settling-in plan or early review notes.
• • Staff support the resident to learn routines, find key areas and meet others if they wish.
• • Residents with dementia, anxiety or sensory needs receive adapted support.
• • Daily records show emotional wellbeing and settling-in needs are monitored.

Evidence to check

• • Initial care plans and risk assessments are completed within required timescales.
• • Plans include immediate guidance for personal care, mobility, medication, nutrition, continence, skin and communication.
• • Staff handover confirms key risks and preferences are known.
• • Care plans are updated as more information becomes available.

Evidence to check

• • Medication list, discharge summary, MAR chart and medicines received are checked against each other.
• • Allergies, time-critical medicines, controlled drugs and high-risk medicines are identified.
• • Discrepancies are escalated to GP, pharmacy, hospital or prescriber promptly.
• • Medication changes are communicated to staff and recorded clearly.

Evidence to check

• • Life history, personal preferences and routines are recorded.
• • Resident's own voice is included where possible.
• • Family or representative input is used where appropriate and agreed.
• • Staff can explain what matters to the resident and how this shapes care.

Evidence to check

• • Consent or best-interest rationale for involvement is recorded.
• • Family or advocate input is included in admission planning where appropriate.
• • Relatives or representatives are updated during the settling-in period.
• • Resident's own wishes remain central.

Evidence to check

• • Initial review or 6-week review record.
• • Resident and family feedback is included where appropriate.
• • Care plans and risk assessments are updated following review.
• • Concerns from the settling-in period are acted on promptly.

Evidence to check

• • Discharge plan is completed before the resident leaves where possible.
• • Receiving service or family receives relevant care, risk, medication and equipment information.
• • Resident consent and preferences are considered.
• • Discharge arrangements are confirmed before transfer.

Evidence to check

• • Records of coordination with relevant external services.
• • Transport, equipment, medicines and follow-up appointments are arranged.
• • Community nursing, GP or social care involvement is confirmed where required.
• • Outstanding actions are clearly handed over.

Evidence to check

• • Care records show emotional support and preparation for transition.
• • Resident preferences about saying goodbye, belongings, routines or memory items are respected.
• • Families or advocates are involved where appropriate.
• • Residents with dementia, anxiety or communication needs receive adapted transition support.

Evidence to check

• • Discharge or transfer summary includes care needs, risks, medication, allergies, mobility, nutrition, skin, continence, communication and safeguarding information.
• • Records are sent securely to the correct recipient.
• • Information is current and checked for accuracy before transfer.
• • Copies are retained appropriately in the resident record.

Evidence to check

• • Discharge planning records identify unresolved risks.
• • Safeguarding, commissioner, social worker or professional escalation is recorded where needed.
• • Rationale is recorded if discharge proceeds despite identified risks.
• • Protective actions are agreed before the resident leaves.

Evidence to check

• • Consent to share information is recorded.
• • Mental capacity and best-interest records are completed where relevant.
• • Only relevant information is shared securely.
• • Resident or representative understands who information is shared with where possible.

Evidence to check

• • Discharge review or closure record.
• • Resident, family or receiving service feedback is sought where appropriate.
• • Reasons for discharge and outcomes are recorded.
• • Learning is identified and added to improvement actions where needed.

Evidence to check

• • Records of admission or discharge delays, documentation issues, medication discrepancies or poor handovers.
• • Themes are reviewed by managers.
• • Actions are taken to improve admission and discharge processes.
• • Learning is shared with staff and relevant partners.

Evidence to check

• • Emergency admission checklist or process.
• • Immediate information includes medication, allergies, mobility, risks, next of kin and urgent care needs.
• • Temporary care plans are created until full assessment is completed.
• • Early review is completed once full information is available.

Evidence to check

• • Admission decision records consider staffing and dependency.
• • Manager reviews whether specialist needs can be met before accepting admission.
• • Equipment, training or professional input is arranged before admission where needed.
• • Admissions are paused or delayed where safe care cannot be assured.

Evidence to check

• • Admission and discharge audit records.
• • Audit checks assessment quality, medication reconciliation, care plan completion, consent, handover and resident experience.
• • Findings are discussed in governance meetings.
• • Actions have owners, deadlines and evidence of completion.

Evidence to check

• • Resident and family feedback records.
• • Feedback covers welcome, communication, care planning, emotional support and transition safety.
• • Feedback from people with communication needs is sought in accessible ways.
• • Changes are made and reviewed following feedback.

Evidence to check

• • Admission records show missing or unclear information is identified.
• • Medication, discharge summary, infection status, mobility and equipment needs are verified.
• • Hospital or professionals are contacted promptly to clarify gaps.
• • Interim risk controls are recorded while awaiting information.

Evidence to check

• • Audits review whether admission was appropriate and safe.
• • Audit checks whether the resident settled well and received personalised care.
• • Discharge audits check continuity and outcome after transition where possible.
• • Findings lead to practical improvements in assessment, communication and planning.