Audits Action Plans Audit - Care Homes

Evidence to check

• • Action plan template includes finding, risk rating, root cause, action, owner, deadline, evidence required and review date
• • Template is used consistently across audit areas
• • Template distinguishes between immediate risk controls and longer-term improvement actions
• • Staff completing audits understand how to create a meaningful action plan

Evidence to check

• • Central QIP or action tracker is current and accessible to authorised managers
• • Actions from medicines, IPC, care plans, falls, safeguarding, staffing, environment and other audits are included
• • Actions are not scattered across multiple untracked spreadsheets, emails or paper notes
• • The tracker clearly shows status, owner, deadline, evidence and follow-up

Evidence to check

• • Named registered manager, quality lead, deputy manager or governance lead is documented
• • Responsibilities include maintaining the action log, chasing owners, escalating risks and reporting progress
• • Deputy arrangements are in place
• • Lead can explain current high-risk actions, overdue items and completed improvements

Evidence to check

• • Governance meeting minutes show review of audit findings and action progress
• • Decisions, risks and escalations are recorded
• • High-risk actions are prioritised and challenged
• • Progress is reviewed until actions are completed and embedded

Evidence to check

• • High-risk findings relating to safety, safeguarding, medicines, IPC, staffing or serious care failures are prioritised
• • Risk rating influences deadline and escalation level
• • Lower-risk cosmetic or administrative actions do not displace urgent safety actions
• • Rationale for prioritisation is documented

Evidence to check

• • Escalation process identifies when to involve provider, senior leadership, commissioners or external support
• • Overdue high-risk actions are discussed promptly
• • Resource barriers are escalated rather than left unresolved
• • Escalation outcomes and decisions are recorded

Evidence to check

• • Audit programme reflects safe, effective, caring, responsive and well-led areas
• • Audit tools support continuous improvement and not only checklist compliance
• • Governance arrangements show how audit findings inform service improvement
• • Managers can explain how audits support inspection readiness

Evidence to check

• • Annual audit schedule is available
• • Audit frequency is risk-based and covers all core areas
• • Each audit has a named responsible person
• • Missed or delayed audits are recorded with recovery plans

Evidence to check

• • Auditors have suitable knowledge, training or role competence
• • Specialist audits, such as medicines, IPC, clinical care or health and safety, are completed by appropriate people
• • Auditors understand what good practice looks like
• • Audit quality is reviewed by senior staff

Evidence to check

• • Audits include record review, observation, staff discussion and resident or family feedback where relevant
• • Findings reference specific evidence sampled
• • Audits identify both compliance and quality of practice
• • Scores are supported by comments and examples

Evidence to check

• • Findings are rated high, medium or low risk, or equivalent
• • Risk rating reflects potential or actual impact on residents
• • Serious findings are clearly highlighted
• • Risk rating determines timescale and escalation

Evidence to check

• • Repeated findings trigger root cause review
• • Root causes consider training, staffing, policy clarity, equipment, systems, culture and leadership oversight
• • Actions address the reason the issue occurred
• • Repeat findings are not simply reissued with the same action

Evidence to check

• • Actions describe exactly what will be changed
• • Actions avoid vague wording such as 'improve documentation' without detail
• • Expected evidence of completion is stated
• • Actions are clear enough for another manager to verify

Evidence to check

• • Audits include resident or family feedback where the topic affects experience
• • Feedback from people with communication needs is sought using suitable methods
• • Feedback influences findings and actions
• • Actions reflect both compliance and lived experience

Evidence to check

• • High-risk or red findings are not left without action
• • All significant shortfalls are transferred to the action log or QIP
• • Where no action is taken, rationale is documented
• • Audit sign-off checks that all findings are addressed

Evidence to check

• • Actions are specific, measurable, achievable, relevant and time-bound
• • Deliverables are clear
• • Expected outcome is defined
• • Actions can be objectively checked for completion

Evidence to check

• • Each action has one named accountable owner
• • Actions are not assigned vaguely to 'the team' without accountability
• • Owner has the authority, knowledge or support required
• • Shared actions still have one lead owner

Evidence to check

• • Urgent safety actions have short deadlines
• • Longer-term projects have milestone dates
• • Deadlines reflect resident risk and operational reality
• • Deadline extensions require rationale and approval

Evidence to check

• • Action plans identify training time, equipment, staffing, contractor work, IT support or funding needs
• • Resource requests are escalated to the right person
• • Interim controls are used while waiting for resources
• • Resource decisions and approvals are recorded

Evidence to check

• • Temporary controls are recorded for unresolved high-risk findings
• • Controls reduce risk to residents immediately
• • Staff are briefed on interim measures
• • Interim controls are monitored until permanent action is completed

Evidence to check

• • Action plans state how staff will be informed of changes
• • Briefings, handovers, toolbox talks, supervisions or training are used where appropriate
• • Competency checks are planned for high-risk practice changes
• • Staff understanding is checked after communication

Evidence to check

• • Tracker shows status such as not started, in progress, completed, overdue or awaiting verification
• • Dates and evidence links are recorded
• • Tracker is updated regularly
• • Managers can identify open, overdue and high-risk actions quickly

Evidence to check

• • Action progress is reviewed weekly, monthly or according to risk
• • Review dates are recorded
• • Lack of progress is challenged
• • Progress updates are factual and evidence-based

Evidence to check

• • Overdue actions are clearly flagged
• • Revised deadlines include rationale and approval
• • Additional support or provider escalation is used where required
• • Repeated overdue actions are treated as a governance concern

Evidence to check

• • Completed actions include supporting evidence
• • Verbal confirmation alone is not accepted for high-risk actions
• • Evidence is reviewed by an appropriate person
• • Completion date and verifier are recorded

Evidence to check

• • Evidence shows practice has changed, not only that a document was updated
• • Spot checks, observations or record samples are used where appropriate
• • Weak evidence is challenged
• • High-risk actions require stronger verification

Evidence to check

• • Completion notes are specific and linked to the finding
• • Notes explain the action taken and evidence reviewed
• • Completion notes are dated
• • Residual risks or follow-up checks are recorded

Evidence to check

• • Follow-up checks are scheduled for significant or high-risk findings
• • 30, 60 or 90-day reviews are used where appropriate
• • Follow-up audit scope is linked to the original issue
• • Results are documented and reviewed

Evidence to check

• • Tracker identifies recurring findings
• • Repeat failures trigger root cause review
• • Previous actions are reviewed for effectiveness
• • Provider or senior oversight is used where recurrence persists

Evidence to check

• • Actions include expected outcomes such as reduced falls, improved MAR accuracy, fewer pressure ulcers or faster call bell response
• • Measures are relevant and realistic
• • Baseline data is recorded where possible
• • Outcome progress is reviewed after implementation

Evidence to check

• • Baseline data is compared with post-action results
• • Improvement is measured using audit scores, incident rates, complaints, feedback or observation results
• • Managers can explain whether the action worked
• • Where data does not improve, the plan is reviewed

Evidence to check

• • Repeated sampling confirms improvement is maintained
• • Spot checks continue after initial closure
• • Staff practice remains consistent across shifts
• • Actions are embedded into routine systems

Evidence to check

• • Action plans consider whether changes could create new risks
• • Examples include increased paperwork reducing care time, restrictive controls reducing choice, or new processes confusing staff
• • Resident and staff feedback is reviewed after changes
• • Actions are adjusted where unintended impact is identified

Evidence to check

• • Learning from audits is added to training plans, policies, supervision topics or system changes
• • Staff are informed of learning in a practical way
• • Policies or procedures are updated where required
• • Learning is retained for future induction or refresher training

Evidence to check

• • Positive audit findings and improvements are shared with staff
• • Teams are recognised for sustained improvement
• • Good practice examples are used in training or meetings
• • Staff understand the impact of improvement work on residents

Evidence to check

• • Falls, medication, IPC, safeguarding and pressure care audit actions link to incident trends where relevant
• • Incident analysis triggers focused audits where needed
• • Audit and incident findings are reviewed together in governance
• • Actions address shared themes across evidence sources

Evidence to check

• • Audit findings identify staff learning needs
• • Training matrix is updated with required training or refreshers
• • Completion is tracked
• • Training impact is checked through follow-up audit or observation

Evidence to check

• • Supervision topics reflect audit themes
• • Individual practice issues are followed up appropriately
• • Team-wide audit findings are discussed in group learning
• • Appraisal objectives or development plans reflect recurring audit themes where relevant

Evidence to check

• • Policy updates are linked to audit learning where relevant
• • Staff communications explain what changed and why
• • Read-and-understand or competency checks are completed
• • Practice is checked after policy changes

Evidence to check

• • Premises or equipment findings are entered into maintenance systems
• • Contractor work is tracked and evidenced
• • PPM schedules are updated where needed
• • Temporary risk controls are used until repairs or replacements are complete

Evidence to check

• • Safeguarding findings are reviewed against local reporting thresholds
• • Protective actions are taken immediately where needed
• • Safeguarding improvement actions are tracked separately or clearly flagged
• • Learning is shared with staff while maintaining confidentiality

Evidence to check

• • Provider or senior leadership receives regular action plan updates
• • High-risk actions are escalated beyond the home where required
• • Provider challenge and support are recorded
• • Resource decisions are documented

Evidence to check

• • Provider visit reports review action plan progress
• • Closed actions are sampled for evidence and practice change
• • Provider feedback challenges weak assurance
• • Provider actions are added to the same tracker or QIP

Evidence to check

• • External or independent review is considered for medicines, IPC, safeguarding, clinical governance or health and safety where needed
• • Commissioner, pharmacist, IPC nurse, consultant or provider quality team input is used where appropriate
• • External recommendations are tracked
• • Independent findings are not ignored or filed without action

Evidence to check

• • CQC, local authority, commissioner, safeguarding, fire authority, HSE or external audit recommendations are included
• • Recommendations have owners, deadlines and evidence requirements
• • External actions are not tracked separately without oversight
• • Progress is reported through governance

Evidence to check

• • Annual audit programme is available
• • Due and completed audits are clearly marked
• • Responsible auditors are named
• • Delayed audits have recorded reasons and recovery dates

Evidence to check

• • Consolidated action log is current
• • Status, owner, deadline and evidence are visible
• • Follow-up dates are recorded
• • High-risk and overdue actions can be easily identified

Evidence to check

• • Managers can locate current actions quickly
• • Actions are not duplicated or lost across emails, spreadsheets, paper files or meeting notes
• • There is one clear source of truth
• • Staff responsible for actions know where to update progress

Evidence to check

• • Action plan updates are dated
• • Changes to deadlines or actions include rationale
• • Previous versions or audit trail are retained where needed
• • Managers can see progress history over time

Evidence to check

• • Closed actions are archived but retrievable
• • Completion evidence is retained
• • Follow-up audit evidence remains linked
• • Inspection or audit requests can be answered promptly

Evidence to check

• • Sample shows original audit finding
• • Action plan, implementation evidence and completion sign-off are present
• • Follow-up audit or effectiveness check is available
• • The home can explain what changed in practice

Evidence to check

• • High-risk findings have urgent deadlines
• • Immediate safety controls are documented
• • Completion evidence shows timely action
• • Delayed high-risk actions include escalation and risk mitigation

Evidence to check

• • Follow-up audits identify whether actions worked
• • Ineffective actions are revised rather than simply closed
• • Revised plans include stronger controls or different approaches
• • Learning is shared through governance

Evidence to check

• • Staff can give specific examples of audit-driven improvements
• • Examples may include medication practice, care records, IPC, falls prevention, environment or dignity improvements
• • Staff understand why the change was made
• • Staff can describe how improvement is being monitored

Evidence to check

• • Reviews include observation, staff feedback, resident feedback and record sampling where relevant
• • Actions are not closed simply because a form, memo or policy was updated
• • Practice change is verified across shifts
• • Residents experience safer, better or more consistent care as a result

Evidence to check

• • Audit actions feed into the QIP, risk register, training plan, supervision themes and provider reporting
• • Recurring themes are escalated to strategic planning
• • Senior leaders can evidence how audit actions improve quality and compliance
• • The service demonstrates a continuous improvement cycle: identify, act, verify, learn and sustain