Advocacy & Complaints Access Audit - Care Homes

Evidence to check

• • Current complaints policy is available and reviewed
• • Policy includes how to complain, acknowledgement timescales, investigation process, outcome letters, escalation and learning
• • Policy is accessible to residents, families, staff and visitors
• • Staff can explain the complaints process in simple terms

Evidence to check

• • Advocacy policy or statement is available and reviewed
• • Policy explains independent advocacy, IMCA and other relevant advocacy routes
• • Policy explains when advocacy should be offered or considered
• • Residents and families are given advocacy information proactively

Evidence to check

• • Named registered manager, deputy manager or complaints lead is documented
• • Lead is responsible for complaints log, investigations, advocacy referrals, action tracking and governance reporting
• • Deputy arrangements are in place
• • Lead can explain current complaint themes and advocacy access arrangements

Evidence to check

• • Governance minutes include complaints, concerns, compliments and advocacy themes
• • Trends are analysed by theme, severity, location, shift, staff group and resident experience where appropriate
• • Actions have owners and deadlines
• • Learning is reviewed for impact and recurrence prevention

Evidence to check

• • Team meeting, supervision or briefing records show learning shared from complaints
• • Confidential resident or complainant information is protected
• • Practice changes are explained to relevant staff
• • Staff understand how complaint learning applies to daily care

Evidence to check

• • Policy explains provider-level escalation and external escalation routes
• • Information includes commissioner, local authority, ICB, Local Government and Social Care Ombudsman or relevant route where applicable
• • Complainants are told how to escalate if dissatisfied
• • Escalation communications are recorded

Evidence to check

• • Complaints are screened for safeguarding concerns, abuse, neglect, serious incidents and duty of candour triggers
• • CQC notifications are considered where required
• • Rationale is recorded where safeguarding, duty of candour or notification is considered
• • Staff know complaints may require immediate safeguarding action

Evidence to check

• • Complaints information is visible in reception, lounges or other suitable areas
• • Welcome packs include complaints information
• • Information is clear, up to date and easy to understand
• • Residents know they can complain verbally as well as in writing

Evidence to check

• • Easy-read, large print, translated, audio or digital formats are available where required
• • Residents with communication or cognitive needs receive information in a suitable way
• • Interpreter support is available where needed
• • Accessibility needs are reviewed and acted on

Evidence to check

• • Advocacy leaflets or posters are visible and current
• • Advocacy is discussed during admission, reviews and key decision points
• • Residents without family or representatives are proactively supported
• • Staff do not treat advocacy as a last resort only

Evidence to check

• • Residents and families receive reassurance that complaints will not affect care
• • This message is included in welcome information, meetings or reviews
• • Staff reinforce openness when concerns are raised
• • Leadership monitors for any signs of victimisation or defensiveness

Evidence to check

• • Quiet private spaces are available
• • Residents can be supported to write, call, email or speak to someone
• • Interpreter or communication support is arranged where needed
• • Staff avoid discussing complaints publicly or in front of others

Evidence to check

• • Information includes relevant commissioners, local authority, ICB, ombudsman and CQC feedback routes
• • Contact details are current
• • Residents and families know they are not limited to internal complaints
• • Staff can direct people to external options without being defensive

Evidence to check

• • Families can raise concerns by phone, email, in person, meeting or written form
• • Named contact or manager details are clear
• • Response times are explained
• • Family concerns are logged and followed up appropriately

Evidence to check

• • Displayed materials are current and dated where appropriate
• • Advocacy provider details are correct
• • Commissioner and complaints escalation contact details are correct
• • Outdated materials are removed promptly

Evidence to check

• • Staff can explain advocacy in plain language
• • Staff understand advocacy is independent support for the resident's voice and rights
• • Staff know advocacy may be needed for care reviews, safeguarding, best-interest decisions or complaints
• • Staff do not confuse advocacy with family involvement only

Evidence to check

• • Staff know where local advocacy contact details are kept
• • Staff can describe the referral route
• • Staff know who in the home can make or support referrals
• • Staff understand expected timescales and follow-up responsibilities

Evidence to check

• • Staff can explain informal concern, complaint and compliment recording
• • Informal concerns are not dismissed or hidden
• • People are offered formal complaint route if dissatisfied
• • Records show concerns are reviewed for themes

Evidence to check

• • Staff use communication aids, interpreters, family input, advocates or observation where appropriate
• • Care plans identify communication preferences
• • Residents with dementia, sensory impairment or learning disability are supported to express dissatisfaction
• • Concerns are not ignored because the person communicates differently

Evidence to check

• • Training records include complaints handling, duty of candour and customer care where relevant
• • Staff understand how to respond calmly and professionally
• • Staff know when to escalate immediately
• • Training impact is reviewed through complaint quality and feedback

Evidence to check

• • Staff can describe internal and external whistleblowing routes
• • Whistleblowing information is accessible
• • Staff understand they must escalate unsafe practice
• • Leaders promote a safe speaking-up culture

Evidence to check

• • Staff report concerns about care, staffing, environment or communication early
• • Early concerns are logged and acted on
• • Managers respond constructively
• • Recurring early concerns are reviewed through governance

Evidence to check

• • Information is adapted to communication and cognitive needs
• • Staff check understanding rather than only handing out leaflets
• • Residents are reminded of their rights over time
• • Accessible communication methods are documented

Evidence to check

• • Care review records show advocacy considered where needed
• • Safeguarding records include advocacy consideration
• • Best-interest decisions record whether advocacy was needed
• • Referrals are made promptly where appropriate

Evidence to check

• • Residents can identify named staff, key worker or manager
• • Night, weekend and agency staff know how to respond to concerns
• • Information is consistent across staff teams
• • Residents are not passed around without support

Evidence to check

• • Residents are asked directly where possible
• • Advocacy is offered where independent support would help
• • Family involvement is based on consent or best-interest arrangements
• • Residents without active family are not disadvantaged

Evidence to check

• • Residents with limited or no family involvement are identified where appropriate
• • Advocacy and IMCA routes are known
• • Care reviews and significant decisions consider independent representation
• • Referrals and outcomes are recorded

Evidence to check

• • Resident meetings, surveys, key worker sessions or one-to-one conversations are recorded
• • Questions include safety, dignity, care, food, activities, environment and staff approach
• • Feedback is analysed and acted on
• • Residents are told what changed as a result

Evidence to check

• • Records identify residents with substantial difficulty participating
• • Appropriate representative availability is considered
• • Independent advocacy or IMCA referral is made where required
• • Decisions are not made without considering the resident's right to representation

Evidence to check

• • DoLS records include representative or advocacy arrangements
• • Residents and representatives are informed of rights where appropriate
• • Conditions or restrictions are explained in accessible ways
• • DoLS remains current framework for care homes; LPS is not treated as implemented practice

Evidence to check

• • Best-interest records include who was consulted
• • Advocacy consideration is recorded where the resident lacks capacity and has limited support
• • Decision-making records reflect the resident's wishes and feelings
• • Referrals are followed up and outcomes recorded

Evidence to check

• • Residents and representatives receive information about review or appeal routes
• • Advocacy is offered where understanding or communication support is needed
• • Restrictions are reviewed and challenged where no longer needed
• • Records show how rights were explained

Evidence to check

• • Advocacy referral log includes date, reason, provider and outcome
• • Follow-up actions are recorded
• • Recommendations or advocacy feedback are added to care planning where relevant
• • Unsuccessful or delayed referrals are chased

Evidence to check

• • Complaint log records date received and date acknowledged
• • Timescales match policy
• • Delays are explained and communicated
• • Complainants are kept informed if investigations take longer

Evidence to check

• • Complaint files include investigation plan or summary
• • Evidence includes statements, care records, timelines, CCTV where lawful, rotas or audit records as relevant
• • Investigation is balanced and not defensive
• • Findings are supported by evidence

Evidence to check

• • Communication log shows updates provided
• • Preferred contact method is respected where possible
• • Delays or changes in timescale are explained
• • Tone of communication is respectful and supportive

Evidence to check

• • Outcome letter or meeting record addresses each complaint point
• • Language is clear, compassionate and easy to understand
• • Apology is offered where appropriate
• • Actions and learning are explained

Evidence to check

• • Records show openness, apology, explanation and actions to prevent recurrence where duty of candour applies
• • Relevant people are informed promptly
• • Written follow-up is provided where required
• • Duty of candour records are linked to incident and complaint files

Evidence to check

• • Complaint log includes categories such as dignity, medication, staffing, communication, environment, safeguarding or meals
• • Severity or risk level is recorded
• • Themes are reviewed over time
• • High-risk themes are escalated through governance

Evidence to check

• • Complaint action plans include specific actions, owners and deadlines
• • Actions are measurable and relevant to the findings
• • Completion evidence is retained
• • Effectiveness is checked after completion

Evidence to check

• • Outcome letters include escalation routes
• • External bodies and contact details are current
• • Time limits are included where relevant
• • Staff do not discourage escalation

Evidence to check

• • Anonymous concerns are logged
• • Concerns are investigated proportionately based on available information
• • Safeguarding or safety concerns are still escalated where needed
• • Learning is recorded even where complainant cannot be contacted

Evidence to check

• • Complaint reviews identify what could improve
• • Learning is shared with staff
• • Apologies and corrective actions are used where appropriate
• • There is evidence of improvement cycles after complaints

Evidence to check

• • Barriers such as fear, language, disability, cognitive impairment, sensory impairment or digital exclusion are considered
• • Alternative routes and support are available
• • Residents who may struggle to complain are proactively checked in with
• • Feedback methods are adjusted to individual needs

Evidence to check

• • Staff observe distress, withdrawal, changes in behaviour, facial expressions and refusal as possible feedback
• • Families, advocates or familiar staff contribute where appropriate
• • Concerns are recorded even when not expressed verbally
• • Care plans are adjusted in response to observed dissatisfaction

Evidence to check

• • Resident meetings, family forums, key worker sessions, suggestion boxes or informal check-ins are used
• • Informal concerns are logged and reviewed
• • Quiet or less vocal residents are proactively included
• • Themes from informal feedback influence service improvement

Evidence to check

• • Interpreter support is available where needed
• • Complaints information can be translated or adapted
• • Cultural expectations around communication, family involvement or authority are considered respectfully
• • No resident is disadvantaged because of language, culture or identity

Evidence to check

• • Leadership checks whether care continues respectfully after complaints
• • Residents are reassured and followed up after raising concerns
• • Any retaliation, coldness or negative treatment is treated as a serious concern
• • Staff understand victimisation is unacceptable

Evidence to check

• • Complaints register is current and complete
• • Register includes receipt date, acknowledgement, investigation, outcome, actions and closure
• • Themes and severity are recorded
• • The log is reviewed by management

Evidence to check

• • Advocacy referral log includes date, reason, provider, outcome and follow-up
• • Patterns are reviewed, such as repeated decision-making or complaint support needs
• • Delays or access issues are escalated
• • Advocacy feedback informs service improvement where appropriate

Evidence to check

• • Files include acknowledgement, investigation evidence, communication records, outcome letter, action plan and follow-up
• • Evidence supports conclusions
• • Any safeguarding, duty of candour or notification decision is documented
• • Incomplete files are followed up

Evidence to check

• • Complaint and advocacy records are stored securely
• • Access is restricted to authorised staff
• • Retention periods are defined and followed
• • Records are available for audit and inspection

Evidence to check

• • Follow-up checks are completed after complaint actions
• • Resident or family feedback is sought where appropriate
• • Audit, observation or record review confirms change has embedded
• • Repeat complaints are reviewed to test whether previous actions worked

Evidence to check

• • Information is physically visible during walkaround
• • Welcome packs include current complaints and advocacy information
• • Accessible versions are available where needed
• • Residents and families know where to find the information

Evidence to check

• • Staff know where advocacy contact details are kept
• • Staff can describe how to refer or who to contact internally
• • Staff understand when advocacy is needed
• • Knowledge gaps are addressed through briefing or training

Evidence to check

• • Sampled complaints show acknowledgement, investigation, outcome and closure within policy timescales
• • Outcome letters are clear and compassionate
• • Learning and action plans are documented
• • Follow-up confirms actions were effective

Evidence to check

• • Residents and families can identify who they would speak to
• • Feedback indicates they feel safe raising concerns
• • Examples show concerns were listened to and acted on
• • Gaps are recorded and used to improve access

Evidence to check

• • Audit includes resident interviews, family feedback, staff questioning, record review and walkaround
• • Audit checks accessible formats, private support, advocacy referrals and outcomes
• • Audit includes people with communication needs or limited family involvement
• • Actions improve real access to voice, rights and resolution

Evidence to check

• • Governance reviews connect complaints and advocacy themes with incidents, safeguarding, MCA, DoLS, staffing and resident experience
• • Themes inform training, supervision, staffing, policy or environmental improvements
• • Senior leaders monitor repeat concerns and unresolved risks
• • The service can evidence openness, learning and continuous improvement