Audits Action Plans Audit - Care Homes

Q1 | Unanswered

Is there a standardised approach/template for audit action plans (issue, risk rating, root cause, action, owner, deadline, evidence, review date)?

Q2 | Unanswered

Is there a central Quality Improvement Plan (QIP) or Action Log that consolidates actions from all audits into one tracked system?

Q3 | Unanswered

Is there a named lead responsible for overseeing audit actions (e.g., Registered Manager/Quality Lead) with clear accountability?

Q4 | Unanswered

Are audit findings and action plans reviewed routinely in governance/quality meetings with minutes and decisions recorded?

Q5 | Unanswered

Are actions prioritised based on risk to residents (safety, safeguarding, medicines, IPC, staffing) rather than convenience?

Q6 | Unanswered

Is there a clear escalation route for overdue or high-risk actions (provider escalation, resource approval, external support)?

Q7 | Unanswered

Are audit tools linked to CQC KLOEs and Regulation 17 (Good Governance) expectations for continuous improvement?

Q8 | Unanswered

Are audits planned within an annual audit programme with defined frequency, scope, and responsible persons?

Q9 | Unanswered

Are audits completed by suitably competent staff with a clear understanding of standards and what ‘good’ looks like?

Q10 | Unanswered

Are audit findings evidence-based (records reviewed, observations, interviews) and not just checklist ticks?

Q11 | Unanswered

Are audits risk-rated (e.g., high/medium/low) and do they clearly explain the impact of each finding?

Q12 | Unanswered

Are root causes explored for repeated findings (training gaps, unclear policy, staffing levels, equipment issues)?

Q13 | Unanswered

Are findings translated into measurable actions rather than vague statements (e.g., ‘improve documentation’)?

Q14 | Unanswered

Are residents’/families’ feedback and experience considered as part of audit conclusions where relevant?

Q15 | Unanswered

Does every significant audit finding have a corresponding action (no unaddressed ‘red’ items)?

Q16 | Unanswered

Are actions SMART (specific, measurable, achievable, relevant, time-bound) with clear deliverables?

Q17 | Unanswered

Is each action assigned to a named owner (not just ‘team’) with accountability and authority to deliver?

Q18 | Unanswered

Are deadlines realistic and aligned to risk level (urgent actions completed rapidly; longer-term projects scheduled)?

Q19 | Unanswered

Are required resources identified (training time, equipment purchases, contractor works) and escalated for approval promptly?

Q20 | Unanswered

Are interim risk controls documented while longer-term actions are pending (temporary measures to keep people safe)?

Q21 | Unanswered

Are communication plans included where changes affect staff practice (briefings, competency checks, supervision topics)?

Q22 | Unanswered

Is there a live tracker showing action status (not started/in progress/completed/overdue) with dates and evidence links?

Q23 | Unanswered

Are action plan updates reviewed at a defined frequency (weekly/monthly) with clear accountability for progress?

Q24 | Unanswered

Are overdue actions escalated and challenged (revised deadlines with rationale, additional support, provider escalation)?

Q25 | Unanswered

Are actions only signed off as complete when evidence is provided (not just verbal confirmation)?

Q26 | Unanswered

Is the quality of evidence assessed (e.g., spot checks confirm practice change, not just updated documents)?

Q27 | Unanswered

Are completion notes recorded explaining what was done and how it addresses the original finding?

Q28 | Unanswered

Are follow-up audits scheduled to verify sustained improvement (30/60/90 day checks where appropriate)?

Q29 | Unanswered

Are repeat findings flagged automatically and treated as a governance concern (why did it recur)?

Q30 | Unanswered

Are outcome measures defined for key actions (e.g., reduction in falls, improved MAR accuracy, fewer pressure ulcers, faster call bell response)?

Q31 | Unanswered

Is pre/post comparison used to demonstrate improvement where possible (baseline vs post-intervention data)?

Q32 | Unanswered

Are improvements sustained over time (not a one-off compliance spike), evidenced through repeated sampling?

Q33 | Unanswered

Are unintended consequences considered (e.g., increased paperwork reducing care time) and mitigated?

Q34 | Unanswered

Are learning points captured and fed back into training, policies, or systems to prevent recurrence?

Q35 | Unanswered

Are successes shared with staff to reinforce good practice and maintain engagement in quality improvement?

Q36 | Unanswered

Are audit actions linked to incident analysis (e.g., falls audit informs falls action plan) and vice versa?

Q37 | Unanswered

Are audit actions translated into training needs and added to the training matrix with completion tracking?

Q38 | Unanswered

Are audit findings used to shape supervision/appraisal focus for teams/individuals where relevant?

Q39 | Unanswered

Are policies updated in response to audit findings, and are staff informed with evidence of understanding/competency?

Q40 | Unanswered

Are environmental/equipment actions linked to maintenance/PPM logs and contractor management systems?

Q41 | Unanswered

Are safeguarding-related findings escalated appropriately and reflected in safeguarding improvement plans?

Q42 | Unanswered

Does the provider (where applicable) have visibility of the home’s audit action plan progress and high-risk issues?

Q43 | Unanswered

Are provider audits/visits used to validate closure evidence and challenge progress objectively?

Q44 | Unanswered

Is there independent verification for high-risk areas (medicines, IPC, safeguarding) where internal assurance is weak?

Q45 | Unanswered

Are external recommendations (CQC, local authority, commissioners, HSE) integrated into the same action tracking system?

Q46 | Unanswered

Can the home produce an annual audit plan showing what audits are due/completed and who completed them?

Q47 | Unanswered

Can the home provide a consolidated action log showing status, owners, deadlines, evidence, and follow-up dates?

Q48 | Unanswered

Are action plans easy to follow and not fragmented across multiple spreadsheets/emails/paper files?

Q49 | Unanswered

Is there evidence of version control and updates to action plans (date-stamped changes, rationale for deadline shifts)?

Q50 | Unanswered

Are closed actions still accessible for inspection (evidence retained, audit trail preserved)?

Q51 | Unanswered

Can the home show a sample of recent audit findings and the full lifecycle: finding → action plan → implementation → evidence → follow-up audit?

Q52 | Unanswered

Can the home demonstrate that high-risk audit findings are actioned first and within appropriate timescales?

Q53 | Unanswered

Are there examples where follow-up checks identified actions were ineffective and the plan was strengthened?

Q54 | Unanswered

Can staff describe recent changes made as a result of audits and how they know practice has improved?