Care Planning and Personalisation Audit - Care Homes

Evidence to check

• • Resident or representative involvement recorded in care planning notes
• • Care review notes showing what the resident wanted, refused or preferred
• • Evidence of advocacy involvement where needed
• • Care plan language reflects the resident's voice and choices

Evidence to check

• • Life history or 'This is me' information
• • Personal routines such as preferred waking, bathing, meals and bedtime
• • Interests, hobbies, relationships and what matters to the resident
• • Staff can describe the resident beyond their care needs

Evidence to check

• • Monthly care plan reviews
• • Updates after falls, infections, hospital admissions, weight loss or behaviour changes
• • Review notes showing what changed and why
• • No outdated or contradictory information remaining in the care plan

Evidence to check

• • Goals linked to the resident's wishes, independence or wellbeing
• • Progress notes showing whether goals are being achieved
• • Staff understand what the resident is working towards
• • Goals reviewed and changed where they are no longer relevant

Evidence to check

• • Care plan covers more than basic personal care tasks
• • Emotional wellbeing, mental health and social needs included
• • Cultural, religious or spiritual needs recorded where relevant
• • Daily notes show these needs are considered in practice

Evidence to check

• • Resident signatures or recorded consent where appropriate
• • Review notes showing discussion with the resident
• • Evidence that refusal or disagreement is recorded and respected
• • Accessible formats used where needed

Evidence to check

• • Staff know where to find current care plans
• • Staff can explain key risks, preferences and support needs
• • Care delivery matches the written care plan
• • Temporary, agency or night staff can access relevant information

Evidence to check

• • Risk assessments linked to care plan guidance
• • Observed care matches the assessed risk level
• • Actions taken to reduce identified risks
• • Risk assessments updated after incidents or changes

Evidence to check

• • Care plan updates after changes in need
• • Handover records showing staff were informed
• • Daily notes match the current care plan
• • No delay between identified change and updated guidance

Evidence to check

• • Communication care plan
• • Use of hearing aids, glasses, speech aids, pictures or translation support
• • Staff can explain how the resident communicates pain, distress or choices
• • Accessible information used where needed

Evidence to check

• • Independence goals or enablement guidance
• • Daily notes showing residents are encouraged to do what they can
• • Staff avoid doing tasks unnecessarily for the resident
• • Wellbeing and independence reviewed over time

Evidence to check

• • Decision-specific mental capacity assessments
• • Best-interest records where the resident lacks capacity
• • Evidence of family, advocate or professional involvement where appropriate
• • Care plan reflects the outcome of the capacity or best-interest decision

Evidence to check

• • Consent forms or consent records
• • Resident choices and refusals recorded
• • Staff understand what consent has and has not been given
• • Consent reviewed when circumstances change

Evidence to check

• • End-of-life care plan or advance care planning notes
• • DNACPR or ReSPECT documentation where applicable
• • Evidence of discussion with resident, family or professionals
• • Staff understand the resident's wishes and how to support them

Evidence to check

• • Care plan records cultural, religious or spiritual preferences
• • Daily notes show support with practices, festivals, prayer, diet or community links
• • Resident or family feedback confirms needs are respected
• • Staff can explain how they support these needs

Evidence to check

• • Daily notes reflect individual routines
• • Observed care matches resident preferences
• • Resident feedback about choice and control
• • Care plan updated if preferences change

Evidence to check

• • Activity and wellbeing care plan
• • Records of meaningful engagement, not just group activities
• • Resident feedback about loneliness, boredom or fulfilment
• • Adjustments made where the resident declines or disengages

Evidence to check

• • Direct observation of care where appropriate
• • Daily notes match care plan guidance
• • Staff can explain key care plan instructions
• • No repeated gaps between planned care and delivered care

Evidence to check

• • Medication care plan aligns with MAR chart
• • Allergy information is visible and consistent
• • Guidance on swallowing, timing, refusal or covert medication where relevant
• • Updates after medication changes or adverse reactions

Evidence to check

• • Family or representative input recorded
• • Professional advice included in the care plan
• • Consent for sharing information considered
• • Resident's own wishes remain central to decision-making

Evidence to check

• • Care review notes with dates and attendees
• • Clear record of changes made
• • Actions allocated and followed up
• • Future review dates or triggers identified

Evidence to check

• • Goal progress reviewed in care notes or reviews
• • Outcomes adjusted when not achieved
• • Resident views considered when measuring progress
• • Evidence that care changes in response to outcomes

Evidence to check

• • Nutrition and hydration care plan
• • MUST or nutritional risk assessment where used
• • Food and fluid charts where required
• • Dietary preferences, allergies, texture-modified diets and referrals reflected in practice

Evidence to check

• • Dignity and privacy preferences recorded
• • Observation of doors, curtains, clothing and explanations during care
• • Resident feedback about feeling respected
• • Staff can describe individual dignity preferences

Evidence to check

• • Life story information or dementia care plan
• • Use of memory boxes, photographs, music or familiar objects
• • Staff know triggers, reassurance methods and preferred routines
• • Daily notes show personalised support, not generic dementia care

Evidence to check

• • Behaviour support plan or distress support plan
• • Triggers and early warning signs recorded
• • Staff use de-escalation and least restrictive approaches
• • Incidents reviewed to update the plan

Evidence to check

• • Training or induction records on care planning
• • Supervision notes discussing care plan use
• • Handover records highlighting care plan changes
• • Staff can explain how they use care plans during shifts

Evidence to check

• • Digital access controls and staff permissions
• • Records completed in real time or promptly
• • No shared logins or inappropriate access
• • Staff know how to use the system and escalate technical issues

Evidence to check

• • Resident-led goals or preferences recorded
• • Examples of residents choosing how care is delivered
• • Positive risk-taking decisions documented
• • Care plan uses resident-centred wording and reflects choice

Evidence to check

• • Care plan audit records
• • Audits include resident feedback, staff questioning and observation where possible
• • Actions from audits completed and reviewed
• • Repeated issues or generic care plans escalated through governance

Evidence to check

• • Compare care plans with daily notes and handover records
• • Staff explain current needs consistently
• • Outdated guidance removed or archived
• • Contradictions corrected promptly

Evidence to check

• • Positive risk-taking records
• • Risk assessments balance safety with choice
• • Resident views included in risk decisions
• • Restrictions reviewed and justified where used

Evidence to check

• • Professional advice and correspondence
• • Care plan updated after advice received
• • Staff know and follow the guidance
• • Outcomes or follow-up actions recorded

Evidence to check

• • Review wording used in care plans
• • No disrespectful, blaming or institutional language
• • Resident strengths and preferences included
• • Language focuses on support needs and wellbeing