Policies & Procedures Audit - Care Homes

Evidence to check

• • Document control process is documented and current
• • System includes version control, author, owner, reviewer, approver, issue date and next review date
• • Policies are approved before issue
• • Obsolete versions are archived or removed from circulation

Evidence to check

• • Policy Register is current and complete
• • Register includes all clinical, operational, HR, health and safety, governance and care-related policies
• • Each policy has a named owner and next review date
• • Register is used actively to monitor overdue or upcoming reviews

Evidence to check

• • Each policy has a named responsible owner
• • Owners understand their role in review and implementation
• • Policy ownership is reviewed when staff roles change
• • Governance records show owners are held accountable for overdue or poor-quality policies

Evidence to check

• • Review frequency is defined, such as annual, biannual or risk-based review
• • Overdue policies are clearly identified
• • Overdue high-risk policies are risk assessed
• • Escalation and completion plans are documented

Evidence to check

• • Policy review process includes out-of-cycle triggers
• • Incident, complaint and audit learning is considered during policy review
• • Legislative, regulatory and best-practice changes are monitored
• • Evidence shows policies have been updated following learning or external changes

Evidence to check

• • Policies reference relevant legislation, CQC regulations, MCA, safeguarding, health and safety and data protection requirements where applicable
• • Policies reflect current national and local guidance
• • Outdated legal references are removed or corrected
• • Specialist policies are reviewed by competent persons where needed

Evidence to check

• • Policies show approval by registered manager, provider, governance board or relevant senior lead
• • Approval dates are visible
• • Governance minutes record policy approval where required
• • High-risk policy changes are formally approved before implementation

Evidence to check

• • Policies are easy to follow and avoid unnecessary jargon
• • Procedures include step-by-step instructions where needed
• • Roles and responsibilities are clear
• • Staff feedback confirms policies are useful in practice

Evidence to check

• • Policies are available through a digital system, intranet, policy folder, QR code or approved shared location
• • Staff can access policies during shifts without delay
• • Access is available in offices, nurses' stations or relevant service areas
• • Staff know which source contains the current version

Evidence to check

• • Night and weekend staff can access policies without relying on day managers
• • Out-of-hours access arrangements are tested
• • Agency and bank staff know where essential policies are kept
• • Any access barriers are recorded and resolved

Evidence to check

• • Safeguarding, fire, missing person, choking, medication error, IPC and emergency procedures are easy to access
• • Critical procedures are available in relevant areas such as office, nurses' station, medication room or emergency folder
• • Contact numbers and escalation routes are current
• • Staff can find critical information quickly

Evidence to check

• • Staff can demonstrate how to locate a policy or procedure
• • Staff know where emergency procedures are kept
• • Spot checks include day, night, weekend, bank and agency staff
• • Knowledge gaps are addressed through briefing or induction

Evidence to check

• • Plain English summaries are available for key policies where useful
• • Translated summaries, larger print or alternative formats are provided where required
• • Reasonable adjustments are made for staff with literacy, language, disability or neurodiversity needs
• • Accessible versions remain consistent with the approved policy

Evidence to check

• • Obsolete policies are removed from folders, shared drives and local noticeboards
• • Archived policies are clearly marked as superseded
• • Current version is clearly identifiable
• • Staff are not using outdated procedures in practice

Evidence to check

• • Policy update communications are recorded
• • Updates are shared through briefings, memos, handovers, team meetings or digital notifications
• • Key changes are highlighted clearly
• • Night, weekend, bank and part-time staff receive the same updates

Evidence to check

• • Read-and-sign records or electronic acknowledgements are completed
• • Understanding is checked through quizzes, supervision, competency checks or spot questions
• • Staff do not only sign without demonstrating awareness
• • Gaps in understanding lead to coaching or retraining

Evidence to check

• • Meeting minutes show discussion of key policy changes
• • Supervision records reference relevant policy updates
• • Training materials are updated after policy changes
• • Staff can explain how policy changes affect their role

Evidence to check

• • Spot checks and observations confirm staff follow policy
• • Staff can describe key steps without relying only on paperwork
• • Practice matches the current approved procedure
• • Policy awareness is tested across roles and shifts

Evidence to check

• • Staff can explain safeguarding, whistleblowing, medication errors, fire, missing person, choking and serious incident escalation
• • Staff know who to contact and what to record
• • Night and agency staff are included in knowledge checks
• • Incorrect answers trigger immediate briefing

Evidence to check

• • Policy breaches are recorded and reviewed
• • Minor gaps are addressed through coaching or supervision
• • Serious or repeated breaches trigger formal action where appropriate
• • Learning from breaches is shared without creating a blame culture

Evidence to check

• • Agency and bank induction includes safeguarding, IPC, medicines boundaries, emergency procedures and confidentiality
• • Local induction checklists are completed
• • Agency staff know escalation routes and key local procedures
• • Briefings are refreshed where policies or resident risks change

Evidence to check

• • Policies identify required training or competence where relevant
• • Training matrix maps training to key policies such as IPC, MCA, safeguarding, medicines and moving and handling
• • Competency frameworks reflect policy expectations
• • Policy changes trigger review of training needs

Evidence to check

• • Training matrix is current and role-specific
• • Matrix links policies to induction, refresher and competency requirements
• • Training gaps are monitored and escalated
• • Matrix includes clinical, care, governance, emergency and health and safety policies where relevant

Evidence to check

• • Competence assessments are completed for medicines, moving and handling, safeguarding, catheter care, PEG, wound care or other high-risk tasks where relevant
• • Assessments include observation of practice where appropriate
• • Staff are not allocated high-risk tasks until competent
• • Competence gaps are followed up with support and reassessment

Evidence to check

• • Competency refresh frequencies are defined
• • Refreshers are recorded in staff files or training systems
• • Incidents or concerns trigger earlier reassessment where needed
• • Managers monitor expired or overdue competencies

Evidence to check

• • Incident reviews and audits identify policy or procedure learning
• • Policies are amended where gaps are found
• • Staff receive updated training or briefing
• • Effectiveness of changes is checked through follow-up audits

Evidence to check

• • Policies include local safeguarding contacts, escalation numbers, local forms and service-specific processes
• • Procedures reflect the home's layout, staffing structure and care model
• • Generic templates have been localised appropriately
• • Staff recognise the policy as relevant to their own home

Evidence to check

• • Policies identify responsibilities for carers, seniors, nurses, managers, providers and external contractors where relevant
• • Deputy and out-of-hours arrangements are clear
• • Staff understand their own responsibilities
• • Role ambiguity is addressed during policy review

Evidence to check

• • Escalation routes include internal managers, on-call, provider, safeguarding, commissioners, emergency services or regulators where relevant
• • Out-of-hours contacts are current
• • Staff know when escalation must be immediate
• • Escalation routes are tested through spot checks or scenarios

Evidence to check

• • Relevant policies include incident forms, body maps, audit tools, referral forms or checklists
• • Templates are current and easy to use
• • Staff know where to find associated forms
• • Completed forms show the template supports good practice

Evidence to check

• • Medicines policy aligns with MAR processes
• • Safeguarding policy aligns with complaints, whistleblowing and incident reporting
• • MCA and DoLS guidance aligns with care planning and restrictive practice procedures
• • Contradictions are identified and corrected

Evidence to check

• • Policies include reasonable adjustments, non-discrimination, dignity, choice and rights-based practice
• • Policies avoid discriminatory language or assumptions
• • Accessible communication and cultural needs are considered where relevant
• • Staff understand equality and human rights in practical terms

Evidence to check

• • Staff feedback is gathered on whether policies are clear and practical
• • Complex policies include summaries or flowcharts where useful
• • Policies are tested through scenarios or spot checks
• • Review process considers whether staff can actually apply the procedure

Evidence to check

• • Policy audits or spot checks are completed
• • Audits include staff questions, observation and record review
• • Findings are documented with actions and deadlines
• • Repeat gaps are escalated through governance

Evidence to check

• • Audit findings are compared with incident, complaint, safeguarding and training data
• • Repeat errors trigger review of policy clarity, staff awareness and systems
• • Actions address implementation, not only paperwork
• • Follow-up checks confirm improvement

Evidence to check

• • Named leads exist for areas such as IPC, safeguarding, medicines, MCA, falls or moving and handling where applicable
• • Leads support staff with practical guidance
• • Leads contribute to reviews, audits and learning
• • Champion roles are supported with time and training

Evidence to check

• • Meeting records show scenario-based policy discussions
• • Topics include high-risk procedures or recent policy updates
• • Staff are encouraged to ask questions
• • Learning from sessions is recorded and followed up

Evidence to check

• • Policy version history references learning from incidents or complaints where relevant
• • Staff communications explain what changed and why
• • Care practice is updated after policy revision
• • Governance minutes track learning through to implementation

Evidence to check

• • Staff can suggest changes through meetings, supervision, digital feedback or manager discussion
• • Feedback is recorded and reviewed
• • Useful suggestions lead to policy clarification or improvement
• • Staff are told when their feedback results in change

Evidence to check

• • Policy Register is immediately available
• • Sampled policies match register details
• • Approval and review dates are clear
• • Managers can identify high-risk policies and their review status

Evidence to check

• • Old version is archived or retired
• • New version is approved and issued
• • Staff are informed of key changes
• • Staff acknowledgement and understanding checks are recorded

Evidence to check

• • Sampled policies include complete document control details
• • Version history explains key changes
• • Reviewer and approver are named
• • Next review date is visible and realistic

Evidence to check

• • Spot questions, supervision discussions, quizzes or competency checks are documented
• • Testing includes high-risk policies and emergency procedures
• • Results are reviewed for themes
• • Knowledge gaps lead to targeted briefing

Evidence to check

• • High-risk policies such as safeguarding, medicines, IPC, MCA/DoLS, fire, missing person and health and safety are current
• • Any overdue high-risk policy has a risk assessment
• • Completion plan includes owner and deadline
• • Interim controls are communicated to staff if needed

Evidence to check

• • Day, night, weekend, bank and agency staff can locate safeguarding information
• • Staff know how to report internally and externally
• • Staff know immediate protection actions where abuse or neglect is suspected
• • Gaps are corrected immediately

Evidence to check

• • Staff can describe a recent update, such as IPC, medicines, safeguarding or MCA
• • Staff know how the change affects practice
• • Communication method is evidenced
• • Staff who missed the original update were followed up

Evidence to check

• • Managers use observation, audits, supervision, competency checks and scenario questions
• • Read-and-sign is not the only assurance method
• • Practice gaps are addressed through coaching or retraining
• • Managers can evidence improvement after awareness checks

Evidence to check

• • Policy owners receive reminders before review dates
• • Governance tracking shows upcoming and overdue reviews
• • Owners report progress or barriers
• • Senior leaders intervene where reviews are delayed

Evidence to check

• • Audit includes policy register review, staff questioning, record sampling and observation
• • Audit checks whether staff follow the procedure during care delivery
• • Findings identify gaps between written policy and real practice
• • Actions improve practical compliance and resident safety

Evidence to check

• • Policy gaps inform the Quality Improvement Plan, training matrix and risk register
• • Governance reviews repeated incidents where policy was unclear or not followed
• • Senior leaders can evidence how policy management improves safety, quality and consistency
• • The home can demonstrate current, accessible, understood and implemented policies during inspection