Governance and Quality Monitoring Audit - Supported Living

Evidence to check

• • Governance framework or structure chart
• • Named leads for quality, safeguarding, health and safety, medicines, data protection and compliance
• • Responsibilities are clear between local managers, senior leaders, nominated individual and registered manager
• • Framework reflects supported living risks, including tenancy rights, housing partners, lone working and community-based support

Evidence to check

• • KPI dashboard or quality report
• • Measures include safeguarding, incidents, complaints, missed visits, staff training, audits, tenant feedback and outcomes
• • Data is reviewed for trends and action
• • KPIs include supported living priorities such as independence, choice, community inclusion and tenancy-related risks

Evidence to check

• • Annual or rolling audit schedule
• • Audits cover safeguarding, medicines, health and safety, care planning, MCA, IPC, recruitment, training, complaints and governance
• • Audits include staff questioning, tenant feedback, observation and record sampling where appropriate
• • Missed or overdue audits are escalated and rearranged

Evidence to check

• • Completed audit reports
• • Action plans include named owners and deadlines
• • Actions are followed up until completed
• • Evidence shows actions improved practice, not just that tasks were closed

Evidence to check

• • Current Quality Improvement Plan
• • QIP actions link to evidence from audits, incidents, complaints, feedback or inspections
• • Actions have owners, timescales and progress updates
• • QIP includes supported living themes such as rights, independence, housing issues and community inclusion

Evidence to check

• • Lessons learned records
• • Changes made to support plans, risk assessments, training, policies or rota arrangements
• • Learning shared through team meetings, supervision or briefings
• • Follow-up checks show learning has been embedded

Evidence to check

• • Team meeting minutes
• • Meetings include quality themes, incidents, complaints, safeguarding, tenant outcomes and good practice
• • Staff have opportunities to raise concerns and ideas
• • Actions from meetings are recorded and followed up

Evidence to check

• • Current risk register
• • Risks are rated, reviewed and assigned to responsible leads
• • Controls and further actions are recorded
• • Risk register reflects supported living-specific risks, not only generic provider risks

Evidence to check

• • Incident and near-miss records
• • Analysis by theme, location, tenant, staff group, time or cause
• • Root causes and contributory factors considered
• • Actions are taken to reduce recurrence and improve safety

Evidence to check

• • Named senior leads for data protection, quality and compliance
• • Compliance monitoring records
• • Data breaches, quality risks and regulatory issues are reviewed
• • Senior leaders can evidence action taken in response to risks or gaps

Evidence to check

• • Tenant feedback, surveys, reviews or accessible feedback tools
• • Family, advocate, staff and professional feedback records
• • Feedback methods are adapted for communication needs
• • Feedback is analysed and used to improve the service

Evidence to check

• • Action plans show source of each action
• • Inspection and audit findings are transferred into improvement plans
• • Feedback themes lead to specific actions
• • Progress is reviewed and overdue actions are escalated

Evidence to check

• • Policies are current and version-controlled
• • Training matrix is up to date
• • Audit results, action plans and quality reports are accessible
• • Records are stored securely and can be retrieved promptly

Evidence to check

• • Compliance checks or regulatory monitoring records
• • Regulatory updates are reviewed and communicated
• • Training and supervision reflect compliance learning
• • Practice changes are made where compliance gaps are identified

Evidence to check

• • MCA and consent audit records
• • Capacity assessments and best-interest decisions are sampled for quality
• • Restrictions are reviewed for proportionality, consent and legal basis
• • Community deprivation of liberty concerns are escalated appropriately where identified

Evidence to check

• • Implementation or evaluation records for new initiatives
• • Tenant consent, accessibility, privacy and impact are considered
• • Staff feedback and tenant feedback are reviewed
• • Changes are adjusted if they do not improve quality or outcomes

Evidence to check

• • Compliments log or good practice records
• • Positive outcomes are shared with staff where appropriate
• • Tenant consent is considered before sharing personal examples
• • Good practice is used in training, supervision or quality improvement

Evidence to check

• • Team meeting minutes, briefings or quality updates
• • Staff receive information about audit findings, incidents, complaints and improvements
• • Data is explained in practical terms
• • Staff understand how their practice contributes to quality outcomes

Evidence to check

• • Service improvement priorities mapped to CQC expectations
• • Goals include safety, effectiveness, caring, responsiveness and leadership
• • Supported living values such as rights, choice, independence and inclusion are included
• • Progress against goals is reviewed through governance

Evidence to check

• • Policy review schedule
• • Version control and review dates
• • Policy changes reflect learning, guidance or regulatory updates
• • Staff are informed of policy changes and expected practice

Evidence to check

• • Manager walkaround records, spot checks or service visits
• • Leaders speak with tenants and staff about quality and safety
• • Managers observe real practice, not only review paperwork
• • Issues identified through visible leadership are followed up

Evidence to check

• • Governance or quality meeting minutes
• • Actions include owners, deadlines and progress updates
• • Outstanding actions are carried forward or escalated
• • Meeting records show review of risk, quality, outcomes and compliance

Evidence to check

• • Internal benchmarking between services, teams or locations
• • External standards or sector guidance considered where relevant
• • Benchmarking is used to identify variation and good practice
• • Actions are taken where one service performs less well than others

Evidence to check

• • Risk reports include health, safety, safeguarding, wellbeing, rights and independence themes
• • Tenant-specific risks are escalated where patterns emerge
• • Rights and independence are considered alongside safety
• • Governance records show action where risk remains high

Evidence to check

• • Review of audit programme and governance effectiveness
• • Checks compare audit findings with incidents, complaints and tenant feedback
• • Repeated issues trigger review of monitoring methods
• • Improvements are made where audits are too paperwork-focused or not identifying real risks

Evidence to check

• • External findings are reviewed by senior leaders
• • Long-term plans include workforce, digital systems, training, property, equipment or partnership needs
• • Investment decisions are linked to quality and tenant outcomes
• • Progress against long-term plans is monitored

Evidence to check

• • Governance reports include repairs, landlord issues, tenancy risks, environmental hazards and shared-area concerns
• • Responsibilities between housing provider and care provider are clear
• • Unresolved housing risks are escalated
• • Tenant impact is considered when housing issues remain unresolved

Evidence to check

• • Quality reports include tenant outcomes, independence goals and lived experience feedback
• • Tenant voice is reviewed alongside audits and KPIs
• • Examples show quality monitoring has improved daily life for tenants
• • Poor outcomes trigger review even where paperwork is complete

Evidence to check

• • Audits and feedback check dignity, choice, rights and staff culture
• • Managers review warning signs such as repeated complaints, low feedback, high restrictions or staff cliques
• • Whistleblowing and speaking-up routes are monitored
• • Actions are taken where practice becomes controlling, closed or institutional