Partnership and Multi-Agency Working Audit - Care Homes

Evidence to check

• • Partnership working policy or framework is current and accessible
• • Policy covers health, social care, safeguarding, pharmacy, commissioners, advocacy and community partners
• • Staff can explain when and how to involve external professionals
• • Partnership working is linked to resident outcomes, not only communication tasks

Evidence to check

• • Staff can explain the roles of GPs, social workers, district nurses, therapists, SALT, pharmacists and mental health teams
• • Care records identify which professionals are involved and why
• • Responsibilities are clear where tasks are shared between the home and external professionals
• • Gaps or confusion about professional responsibility are escalated promptly

Evidence to check

• • Current contact list for GPs, pharmacies, district nurses, social workers, commissioners, emergency contacts and specialist teams
• • Out-of-hours and urgent escalation contacts are included
• • Staff know where to find contact details during shifts
• • Contact information is reviewed and updated regularly

Evidence to check

• • Care plan reviews include professional input where relevant
• • Examples include mobility, nutrition, swallowing, wounds, dementia, mental health, end-of-life care or safeguarding
• • Professional advice is reflected in the care plan
• • Actions from professional input are followed up and reviewed

Evidence to check

• • MDT meeting minutes or notes
• • Resident or representative views are included where appropriate
• • Actions have named owners and timescales
• • Care plans and risk assessments are updated after MDT discussions

Evidence to check

• • Protocols or pathways are available to staff
• • Staff know escalation routes for safeguarding, deterioration, discharge issues and crisis situations
• • Records show protocols were followed during relevant events
• • Learning from joint working issues is reviewed and shared

Evidence to check

• • Records of referrals or contact with district nurses, GP, SALT, podiatry, dietitian, tissue viability, falls team or mental health services
• • Reason for referral and urgency are clearly recorded
• • Advice received is acted on and added to care plans
• • Delayed responses are escalated where resident risk remains

Evidence to check

• • Consent to share information is recorded in care plans
• • Mental capacity and best-interest records are in place where the resident lacks capacity
• • Rationale is recorded where information is shared without consent due to risk or legal duty
• • Information shared is relevant, proportionate and secure

Evidence to check

• • Hospital discharge summary is available and reviewed
• • Medication changes are checked, reconciled and clarified where needed
• • Care plan, risk assessments and MAR charts are updated promptly
• • Follow-up appointments, equipment and referrals are tracked

Evidence to check

• • Records of pharmacy communication, medication queries and supply issues
• • Medication changes are confirmed and documented
• • Missed, delayed or unavailable medicines are escalated
• • Pharmacy-related themes are reviewed through medication audits or governance

Evidence to check

• • Records of delays, missed calls, conflicting advice or unclear professional responses
• • Escalation to senior staff, commissioners or professional leads where needed
• • Impact on residents is considered and mitigated
• • Themes are reviewed for learning and system improvement

Evidence to check

• • Consent or best-interest rationale for involving relatives or representatives
• • Attorney, deputy or advocate status is verified where relevant
• • Resident's own views remain central where possible
• • Communication with relatives or representatives is recorded clearly

Evidence to check

• • Records of decisions such as DNACPR, capacity assessments, SALT guidance, mobility plans or wound care advice
• • Care plans are updated after professional input
• • Staff handovers include key changes
• • Staff can explain current professional guidance for sampled residents

Evidence to check

• • Appointment records, transport arrangements and escort plans
• • Resident preferences, communication needs and dignity are considered
• • Outcomes from appointments are recorded and actioned
• • Missed or cancelled appointments are followed up and risk-assessed

Evidence to check

• • Records of attendance at local forums, provider meetings or network events
• • Learning from external forums is shared with staff
• • Local updates influence policies, pathways or practice
• • Engagement supports better resident outcomes or service quality

Evidence to check

• • Commissioner, NHS partner or external audit reports
• • Actions from external reviews are added to improvement plans
• • Progress is tracked and reported through governance
• • Feedback is used for learning rather than defensiveness

Evidence to check

• • Records of reassessment or funding review requests
• • Changes in need are clearly evidenced in care records
• • Residents and representatives are involved where appropriate
• • Delays in reassessment are escalated where care needs cannot be safely met

Evidence to check

• • Governance meeting minutes include partnership themes
• • Barriers such as delayed referrals, poor communication or unclear responsibilities are reviewed
• • Actions are agreed with owners and timescales
• • Impact on residents is monitored

Evidence to check

• • Records of notifications to GP, social worker, commissioner, family, safeguarding team or other professionals
• • Communication is timely and appropriate to the level of risk
• • Advice received is recorded and followed
• • Care plans are updated after significant changes

Evidence to check

• • Mental capacity assessment completed for the specific decision
• • Best-interest meeting notes include relevant professionals and representatives
• • Resident's wishes, feelings, beliefs and values are considered
• • Decision and least restrictive option are recorded in the care plan

Evidence to check

• • Staff can describe escalation routes
• • Records show delayed professional responses were chased or escalated
• • Managers support staff who challenge poor or delayed responses
• • Resident safety and dignity are protected while awaiting professional input

Evidence to check

• • Referral records to specialist services
• • Specialist advice is reflected in care plans
• • Staff are briefed on specialist guidance
• • Outcomes from specialist involvement are reviewed

Evidence to check

• • Safeguarding policy reflects local authority procedures
• • Referral records include dates, actions and outcomes
• • Multi-agency safeguarding actions are tracked
• • Care plans and risk assessments are updated after safeguarding outcomes

Evidence to check

• • Professional reports, prescriptions and guidance are compared with care plans and daily records
• • Changes are added promptly and checked for accuracy
• • Unclear advice is clarified before being implemented
• • Staff handovers confirm important updates are communicated

Evidence to check

• • Team meeting minutes, newsletters or supervision records include positive partnership examples
• • Good practice is shared with staff while maintaining confidentiality
• • Successful approaches are repeated or embedded
• • Residents' outcomes are used to show the value of partnership working

Evidence to check

• • Referral tracker or communication log
• • Referral date, reason, response and outcome are recorded
• • Delayed or rejected referrals are followed up
• • Resident and representative are kept informed where appropriate

Evidence to check

• • Records of conflicting advice or professional disagreement
• • Escalation to senior clinicians, commissioners, safeguarding or management where needed
• • Interim risk controls are documented
• • Final agreed plan is recorded and communicated to staff

Evidence to check

• • Audit reviews referral quality, timeliness, advice implementation and outcomes
• • Resident or representative feedback is included where possible
• • Audit checks whether professional advice was followed in practice
• • Actions from audits improve coordination and resident experience