Governance and Quality Monitoring Audit - Care Homes

Evidence to check

• • Governance framework or structure chart
• • Clear roles and responsibilities for provider, nominated individual, registered manager, deputies and leads
• • Staff understand escalation routes and decision-making responsibilities
• • Governance arrangements are reflected in meeting minutes, audits and action tracking

Evidence to check

• • KPI dashboard or quality report
• • KPIs include resident outcomes, incidents, complaints, staffing, training, audits, safeguarding and experience
• • KPI trends are analysed, not only recorded
• • Poor or declining performance leads to timely action

Evidence to check

• • Audit schedule covering medication, safeguarding, IPC, care plans, MCA, environment, nutrition and staffing
• • Audit tools include observation, staff questioning and resident feedback where appropriate
• • Audits identify quality of practice, not only missing signatures
• • Audit frequency reflects service risk and previous findings

Evidence to check

• • Audit action plans
• • Named responsible persons and target dates
• • Evidence of completed actions
• • Follow-up checks confirm whether actions improved practice

Evidence to check

• • Current Quality Improvement Plan
• • Actions linked to audits, incidents, complaints, feedback and CQC quality statements
• • Progress updates recorded regularly
• • Completed actions are checked for sustained improvement

Evidence to check

• • Lessons learned records
• • Team meeting minutes or staff briefings
• • Changes made to care plans, risk assessments, training or procedures
• • Staff can describe recent learning and what changed as a result

Evidence to check

• • Manager or provider walkaround records
• • Records of engagement with residents, relatives and staff
• • Senior leaders review audits, incidents and feedback
• • Staff and residents know who senior leaders are and how to raise concerns

Evidence to check

• • Current risk register
• • Risks are rated, reviewed and assigned to named owners
• • Controls and escalation actions are recorded
• • High or repeated risks are discussed in governance meetings

Evidence to check

• • Resident, family, staff and professional feedback records
• • Feedback themes reviewed collectively
• • External professional or commissioner feedback considered
• • Feedback leads to service development or improvement actions

Evidence to check

• • Resident satisfaction surveys or feedback reports
• • Governance minutes showing resident experience themes
• • Actions taken following feedback
• • Residents are informed about changes made from their feedback

Evidence to check

• • Care plan audit records
• • Cross-checks between care plans, daily notes, risk assessments and observed practice
• • Outdated or contradictory records corrected promptly
• • Findings are escalated where record quality affects care safety

Evidence to check

• • Training compliance reports
• • Competency assessment records
• • Training gaps reviewed against incidents, complaints and audit findings
• • Actions taken where staff knowledge or practice is weak

Evidence to check

• • Policy review schedule
• • Version control and review dates
• • Updates following regulatory, legal or practice changes
• • Staff are briefed on important policy changes

Evidence to check

• • Safeguarding, whistleblowing, incident and concern logs
• • Trend analysis across reporting systems
• • Evidence of escalation where repeated or serious concerns arise
• • Staff feedback on confidence to report concerns

Evidence to check

• • CQC self-assessment records
• • Evidence mapped to Safe, Effective, Caring, Responsive and Well-led
• • Quality statements considered in governance reviews
• • Self-assessment findings lead to improvement actions

Evidence to check

• • Staffing dependency tools or staffing reviews
• • Rota analysis, agency use and vacancy data
• • Incidents, complaints or missed care reviewed against staffing levels
• • Management action taken where staffing risks affect quality or safety

Evidence to check

• • Inspection readiness records or evidence files
• • Staff can explain service strengths, risks and recent improvements
• • Documentation is current and accessible
• • Leaders know the evidence supporting their CQC self-assessment

Evidence to check

• • External audit or inspection reports
• • Action plans linked to external findings
• • Progress updates and evidence of completion
• • Learning shared across staff teams

Evidence to check

• • Evidence folders or digital evidence system
• • Evidence includes practice examples, feedback, audits, actions and outcomes
• • Records are current and not duplicated or outdated
• • Managers can retrieve key evidence promptly

Evidence to check

• • Meeting minutes
• • Actions include named owners and deadlines
• • Previous actions reviewed at later meetings
• • Minutes show decisions and learning, not only discussion

Evidence to check

• • Project plans or change records
• • Risk assessments for service changes
• • Resident and staff feedback on changes
• • Evaluation records showing impact and whether changes were sustained

Evidence to check

• • Named quality or compliance lead
• • Role description or responsibilities
• • Evidence of audits, reporting, escalation and action tracking
• • Lead has access to quality data, records, staff and management support

Evidence to check

• • Post-incident or complaint governance reviews
• • Root cause analysis identifies system issues, not only individual error
• • Changes made to oversight, checks, training or escalation
• • Follow-up confirms the governance weakness has been addressed

Evidence to check

• • Staff briefings, newsletters or meeting minutes
• • Staff know current quality priorities and risks
• • Actions are explained to different staff groups and shifts
• • Staff feedback is invited and acted on

Evidence to check

• • Review of governance effectiveness
• • Comparison of audit findings, incidents, complaints, outcomes and resident feedback over time
• • Governance processes changed where they are not identifying or resolving risks
• • Evidence that quality monitoring leads to sustained improvement