Care Planning and Personalisation Audit - Care Homes

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  • Are care plans developed with input from the resident and/or their representative wherever possible?
  • Do care plans reflect the individual’s preferences, history, routines, and lifestyle choices?
  • Are care plans reviewed regularly (at least monthly or when needs change) and updated accordingly?
  • Do care plans include clear goals and outcomes that are meaningful to the resident?
  • Are care plans holistic, covering physical, emotional, psychological, cultural, and spiritual needs?
  • Are residents involved in reviewing and approving their care plans where they have capacity?
  • Are care plans accessible to all relevant staff and referenced during care delivery?
  • Are there clear risk assessments integrated into care plans for mobility, nutrition, falls, pressure ulcers, and mental health?
  • Are changes in health, behaviour, or preferences promptly reflected in the care plan?
  • Are communication needs identified and supported within the care plan (e.g., hearing aids, speech support, visual aids)?
  • Do care plans include guidance on how to maintain the resident’s independence and promote wellbeing?
  • Are mental capacity assessments recorded for decisions requiring consent or best interest determinations?
  • Are consent forms completed for care, medications, data sharing, and use of photographs or monitoring?
  • Do care plans include information about end-of-life preferences or advance care decisions where appropriate?
  • Is support for cultural, religious, and spiritual practices clearly identified and embedded in the care plan?
  • Are personal routines and preferences such as bathing time, meals, and clothing reflected in daily care notes?
  • Are residents’ social, emotional, and activity needs documented and met through person-centred planning?
  • Is there evidence that staff follow and implement care plans in daily practice?
  • Do care plans contain up-to-date information on medications, including allergies and administration needs?
  • Are family, carers, and professionals’ inputs captured and reflected in the care plan when relevant?
  • Are reviews of care plans documented with a record of discussions, changes, and future actions?
  • Is the care plan used to monitor the achievement of agreed goals and adjust care when outcomes are not met?
  • Are dietary needs, preferences, and nutritional risks clearly recorded and regularly reviewed?
  • Is there a section in the care plan that identifies and respects the resident’s dignity and privacy preferences?
  • Are residents with dementia or cognitive impairments supported with personalised tools (e.g., memory boxes, life stories)?
  • Are behavioural support plans used appropriately for residents with challenging behaviour?
  • Do staff receive training in creating, understanding, and using person-centred care plans effectively?
  • Are digital care planning systems secure, accessible, and used consistently across the service?
  • Is there evidence of co-production, with residents setting or shaping aspects of their own care plan?
  • Are care plans audited regularly to ensure completeness, relevance, and personalisation?