Care Records and Record Keeping Audit – Care Homes
Answered 0 / 32(0% complete)
Note: This is the "clipboard" version of the audit. Save as Draft keeps your changes here only. When the audit is complete and accurate, Save & Push to Calendar creates the final version for that month, where you can allocate tasks, upload evidence, and manage actions.
Audit workspace
Score
0%
N/A counts as Yes (full credit). Unanswered reduces the score until completed.
Breakdown
0 Yes •0 No •0 N/A •32 Unanswered
Answers Overview
Questions
0/32 answeredQ1 | Unanswered
Governance: Is there a current record-keeping policy covering paper and electronic records, with clear responsibilities, staff guidance and management oversight?
Evidence to check
- • Current record-keeping policy covering paper and electronic systems
- • Named responsibilities and management reviews of implementation
Supporting NotesNo notes yet.Notes are stamped with your name, date and time.Photographic Evidence
Attach photos for any answer, including positive evidence.
Image filesCameraQ2 | Unanswered
Required records: Has the home identified and maintained the records required by Regulation 59 and Schedule 2, with checks for completeness and availability to CIW on request?
Evidence to check
- • Record inventory or checklist mapped to applicable Regulation 59 and Schedule 2 requirements
- • Sampled required records and evidence gaps or retrieval problems were addressed
Supporting NotesNo notes yet.Notes are stamped with your name, date and time.Photographic Evidence
Attach photos for any answer, including positive evidence.
Image filesCameraQ3 | Unanswered
Identification: Are records clearly linked to the correct person, with current identifying details, contacts and relevant alerts checked to reduce misfiling or wrong-person entries?
Evidence to check
- • Sampled record identifiers, contact details and relevant alerts
- • Checks and correction records for misfiled, duplicated or wrong-person information
Supporting NotesNo notes yet.Notes are stamped with your name, date and time.Photographic Evidence
Attach photos for any answer, including positive evidence.
Image filesCameraQ4 | Unanswered
Assessments: Are admission, needs and risk assessments recorded, dated and reviewed, with relevant professional information and changes reflected in care instructions?
Evidence to check
- • Dated admission, needs and risk assessments and review history
- • Professional reports and evidence changes informed current care instructions
Supporting NotesNo notes yet.Notes are stamped with your name, date and time.Photographic Evidence
Attach photos for any answer, including positive evidence.
Image filesCameraQ5 | Unanswered
Personal plans: Are current personal plans and reviews available to staff, with agreed outcomes, preferences, responsibilities and changes clearly recorded?
Evidence to check
- • Current personal plans, review records and agreed outcomes
- • Staff access checks and examples showing revised instructions are used
Supporting NotesNo notes yet.Notes are stamped with your name, date and time.Photographic Evidence
Attach photos for any answer, including positive evidence.
Image filesCameraQ6 | Unanswered
Daily records: Do daily entries describe the care actually provided, the person's experience and response, any declined or missed support and the follow-up needed?
Evidence to check
- • Sampled daily entries compared with planned care and monitoring records
- • Resident feedback or observations and follow-up on declined or missed support
Supporting NotesNo notes yet.Notes are stamped with your name, date and time.Photographic Evidence
Attach photos for any answer, including positive evidence.
Image filesCameraQ7 | Unanswered
Timeliness: Are entries made promptly after care or events, with late entries clearly identified and no care recorded as completed before it occurs?
Evidence to check
- • Entry timestamps or dated paper records compared with event or care times
- • Late-entry guidance, identified late entries and action on premature recording
Supporting NotesNo notes yet.Notes are stamped with your name, date and time.Photographic Evidence
Attach photos for any answer, including positive evidence.
Image filesCameraQ8 | Unanswered
Attribution: Are entries legible and attributable to an identifiable author, with the date, relevant time and role recorded and electronic entries made through individual accounts?
Evidence to check
- • Sampled entries showing author identity, date and relevant time
- • Signature or staff identity records and individual electronic account arrangements
Supporting NotesNo notes yet.Notes are stamped with your name, date and time.Photographic Evidence
Attach photos for any answer, including positive evidence.
Image filesCameraQ9 | Unanswered
Accuracy and language: Are records factual, respectful and sufficiently specific, distinguishing observations, the person's words, professional advice and staff opinion?
Evidence to check
- • Sampled entries distinguishing facts, direct accounts, advice and opinion
- • Supervision or audit feedback addressing vague, disrespectful or inaccurate language
Supporting NotesNo notes yet.Notes are stamped with your name, date and time.Photographic Evidence
Attach photos for any answer, including positive evidence.
Image filesCameraQ10 | Unanswered
Corrections: Are errors and disputed information addressed through traceable corrections or addenda that preserve the original entry and identify who made the change, when and why?
Evidence to check
- • Correction procedures and examples of traceable amendments or addenda
- • Amendment logs and records of accuracy challenges and their resolution
Supporting NotesNo notes yet.Notes are stamped with your name, date and time.Photographic Evidence
Attach photos for any answer, including positive evidence.
Image filesCameraQ11 | Unanswered
Version control: Are obsolete plans, duplicated records and copied-forward entries managed so staff can identify current instructions and changes without relying on inaccurate information?
Evidence to check
- • Plan version histories and arrangements for identifying current records
- • Checks of duplicated or copied-forward information and action on inconsistencies
Supporting NotesNo notes yet.Notes are stamped with your name, date and time.Photographic Evidence
Attach photos for any answer, including positive evidence.
Image filesCameraQ12 | Unanswered
Changes and escalation: Do records show changes in health, well-being or risk, the action taken, advice sought, escalation decisions and checks of the outcome?
Evidence to check
- • Records of changes, escalation, professional advice and resulting actions
- • Follow-up entries showing outcomes and updates to care or risk plans
Supporting NotesNo notes yet.Notes are stamped with your name, date and time.Photographic Evidence
Attach photos for any answer, including positive evidence.
Image filesCameraQ13 | Unanswered
Monitoring charts: Where monitoring is required, are food, fluid, repositioning, pain, wound, continence and other relevant charts complete, consistent with care plans and reviewed for concerns?
Evidence to check
- • Relevant monitoring charts matched to individual care instructions
- • Review notes, escalation records and action on omissions or concerning trends
Supporting NotesNo notes yet.Notes are stamped with your name, date and time.Photographic Evidence
Attach photos for any answer, including positive evidence.
Image filesCameraQ14 | Unanswered
Medicines records: Are medicines records clear and current, with administration, omissions, refusals, changes and relevant outcomes documented and discrepancies investigated?
Evidence to check
- • Sampled medicines administration records and current prescribing information
- • Records of omissions, refusals, changes, outcomes and investigated discrepancies
Supporting NotesNo notes yet.Notes are stamped with your name, date and time.Photographic Evidence
Attach photos for any answer, including positive evidence.
Image filesCameraQ15 | Unanswered
Consent and decision-making: Are consent, decision-specific capacity assessments, best-interest decisions and any relevant legal authority or restrictions recorded with review arrangements?
Evidence to check
- • Relevant consent, capacity, best-interest and legal-authority records
- • Review dates and checks showing decisions and restrictions match current care
Supporting NotesNo notes yet.Notes are stamped with your name, date and time.Photographic Evidence
Attach photos for any answer, including positive evidence.
Image filesCameraQ16 | Unanswered
Person's voice: Do records reflect the person's wishes, communication needs, preferred language and involvement, including how differences of view or declined choices were addressed?
Evidence to check
- • Records of wishes, communication support, preferred language and participation
- • Examples showing disagreements or declined choices were recorded and followed up
Supporting NotesNo notes yet.Notes are stamped with your name, date and time.Photographic Evidence
Attach photos for any answer, including positive evidence.
Image filesCameraQ17 | Unanswered
Professional input: Are referrals, appointments, professional advice and correspondence recorded, with resulting care changes and outstanding actions followed through?
Evidence to check
- • Referral, appointment, professional advice and correspondence records
- • Action tracking and care updates showing recommendations were followed through
Supporting NotesNo notes yet.Notes are stamped with your name, date and time.Photographic Evidence
Attach photos for any answer, including positive evidence.
Image filesCameraQ18 | Unanswered
Handover and transfer: Do shift handovers and transfers share accurate, current information about needs, risks, medicines and outstanding actions, with receipt and follow-up checked where necessary?
Evidence to check
- • Sampled shift handovers and transfer information matched to current records
- • Evidence of relevant receipt checks and follow-up on outstanding actions
Supporting NotesNo notes yet.Notes are stamped with your name, date and time.Photographic Evidence
Attach photos for any answer, including positive evidence.
Image filesCameraQ19 | Unanswered
Incidents and safeguarding: Are accidents, falls, safeguarding concerns and other incidents recorded consistently, with relevant care entries, actions, referrals and outcomes linked?
Evidence to check
- • Incident and safeguarding records matched with daily notes and relevant assessments
- • Referral, investigation and outcome records with linked care actions
Supporting NotesNo notes yet.Notes are stamped with your name, date and time.Photographic Evidence
Attach photos for any answer, including positive evidence.
Image filesCameraQ20 | Unanswered
Concerns and notifications: Are complaints, concerns and required notifications recorded with decisions, dates, recipients, responses and follow-up, with discrepancies between records investigated?
Evidence to check
- • Complaint, concern and notification records with dates, decisions and recipients
- • Responses, follow-up and checks resolving inconsistencies between records
Supporting NotesNo notes yet.Notes are stamped with your name, date and time.Photographic Evidence
Attach photos for any answer, including positive evidence.
Image filesCameraQ21 | Unanswered
Money and valuables: Are charges and any money or valuables held on a person's behalf recorded accurately, with receipts or acknowledgements, transactions and reconciliation checks?
Evidence to check
- • Charge records, money or valuables logs and relevant receipts or acknowledgements
- • Reconciliation checks and action on missing transactions or discrepancies
Supporting NotesNo notes yet.Notes are stamped with your name, date and time.Photographic Evidence
Attach photos for any answer, including positive evidence.
Image filesCameraQ22 | Unanswered
Service records: Are required staffing, visitor, fire, equipment-test and other operational records maintained accurately, with authorised updates and evidence of remedial actions?
Evidence to check
- • Sampled operational records, including actual staffing, visitors and fire checks
- • Authorised update histories and records of remedial action
Supporting NotesNo notes yet.Notes are stamped with your name, date and time.Photographic Evidence
Attach photos for any answer, including positive evidence.
Image filesCameraQ23 | Unanswered
Staff competence: Do permanent, agency and new staff receive record-keeping and information-security instruction, with supervision addressing gaps in the quality of their entries?
Evidence to check
- • Induction, agency briefings and training on records and information security
- • Competency checks and supervision showing entry-quality concerns are addressed
Supporting NotesNo notes yet.Notes are stamped with your name, date and time.Photographic Evidence
Attach photos for any answer, including positive evidence.
Image filesCameraQ24 | Unanswered
Confidential storage: Are paper files, screens, handover materials and archived records protected from unauthorised viewing, loss or access while remaining available for authorised care?
Evidence to check
- • Storage and privacy checks for files, screens, handover materials and archives
- • Access arrangements and action on unauthorised visibility, loss or security concerns
Supporting NotesNo notes yet.Notes are stamped with your name, date and time.Photographic Evidence
Attach photos for any answer, including positive evidence.
Image filesCameraQ25 | Unanswered
Electronic access: Are electronic permissions appropriate to each role, individual credentials protected, access removed when no longer needed and access or amendment logs reviewed where concerns arise?
Evidence to check
- • Role-based access lists, account reviews and leaver-access removal records
- • System access or amendment logs and investigation of inappropriate access
Supporting NotesNo notes yet.Notes are stamped with your name, date and time.Photographic Evidence
Attach photos for any answer, including positive evidence.
Image filesCameraQ26 | Unanswered
Information sharing: Is information shared securely and only as necessary under an appropriate lawful basis, with recipient authority checked and decisions documented where needed?
Evidence to check
- • Information-sharing procedures and relevant lawful-basis or recipient-authority records
- • Sampled secure transfers and documented decisions on necessary disclosure
Supporting NotesNo notes yet.Notes are stamped with your name, date and time.Photographic Evidence
Attach photos for any answer, including positive evidence.
Image filesCameraQ27 | Unanswered
Access to records: Are people informed how to access their records, with requests from them or representatives managed promptly, access authority checked and explanations provided in an accessible way?
Evidence to check
- • Accessible information about record access and request-handling procedures
- • Request logs, representative-authority checks and responses with relevant explanations
Supporting NotesNo notes yet.Notes are stamped with your name, date and time.Photographic Evidence
Attach photos for any answer, including positive evidence.
Image filesCameraQ28 | Unanswered
Retention and disposal: Does a documented retention schedule meet applicable Welsh requirements and other lawful obligations, with justified retention, secure disposal and preservation where investigations or claims require it?
Evidence to check
- • Retention schedule with applicable requirements and reasons for retention periods
- • Secure disposal logs and documented preservation decisions for investigations or claims
Supporting NotesNo notes yet.Notes are stamped with your name, date and time.Photographic Evidence
Attach photos for any answer, including positive evidence.
Image filesCameraQ29 | Unanswered
Archives and closure: Can historic records be located and retrieved, with secure custody and access arrangements documented for transfers of responsibility or closure of the service?
Evidence to check
- • Archive index, retrieval checks and custody arrangements
- • Plans for secure record transfer, continued retention and access if the service closes
Supporting NotesNo notes yet.Notes are stamped with your name, date and time.Photographic Evidence
Attach photos for any answer, including positive evidence.
Image filesCameraQ30 | Unanswered
Continuity and breaches: Are backup, recovery and downtime arrangements tested, with temporary records reconciled and lost, compromised or unavailable information escalated and addressed appropriately?
Evidence to check
- • Backup or recovery test records and downtime reconciliation procedures
- • Information incident logs, escalation decisions and corrective actions
Supporting NotesNo notes yet.Notes are stamped with your name, date and time.Photographic Evidence
Attach photos for any answer, including positive evidence.
Image filesCameraQ31 | Unanswered
Audit and follow-up: Do record audits sample different residents, shifts and record types, compare entries with actual care and track corrective actions without obscuring the original record?
Evidence to check
- • Audit sampling plans and findings compared with care observations or resident feedback
- • Action trackers, traceable corrections and rechecks confirming sustained improvement
Supporting NotesNo notes yet.Notes are stamped with your name, date and time.Photographic Evidence
Attach photos for any answer, including positive evidence.
Image filesCameraQ32 | Unanswered
Leadership assurance: Does the Responsible Individual review the accuracy, completeness and security of records under Regulation 78, with findings informing supervision, systems and the quality of care review?
Evidence to check
- • Responsible Individual and management reviews of record accuracy, completeness and security
- • Quality-of-care reviews and resulting supervision or system improvements
Supporting NotesNo notes yet.Notes are stamped with your name, date and time.Photographic Evidence
Attach photos for any answer, including positive evidence.
Image filesCamera
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