Quality Assurance Framework Audit

Q1 | Unanswered

Is there a defined governance structure (organogram) showing accountability from frontline to provider/board level?

Q2 | Unanswered

Are roles and responsibilities for quality, safety, and compliance clearly defined (Registered Manager, clinical lead, nominated individual, provider)?

Q3 | Unanswered

Is there a current Quality Assurance Framework document describing the home’s approach to monitoring, assurance, and improvement?

Q4 | Unanswered

Is there a schedule of governance meetings (clinical, quality, health & safety, IPC, medicines, safeguarding) with clear terms of reference?

Q5 | Unanswered

Are governance meetings minuted with actions, owners, deadlines, and follow-up evidenced?

Q6 | Unanswered

Is there clear leadership visibility and oversight across all shifts (including nights/weekends) and units?

Q7 | Unanswered

Is the culture open, transparent, and improvement-focused (psychological safety, no-blame reporting, learning culture)?

Q8 | Unanswered

Is the QA framework explicitly aligned to CQC KLOEs (Safe, Effective, Caring, Responsive, Well-led) and associated quality statements?

Q9 | Unanswered

Does the QA framework demonstrate compliance with Regulation 17 (Good Governance) through structured monitoring and improvement?

Q10 | Unanswered

Is there a system to monitor compliance against Regulations, fundamental standards, and provider policies?

Q11 | Unanswered

Are CQC notifications, safeguarding, and duty of candour built into governance reporting and oversight?

Q12 | Unanswered

Is inspection readiness maintained through ongoing evidence capture rather than reactive preparation?

Q13 | Unanswered

Are external recommendations (CQC feedback, commissioner visits, HSE, fire authority) tracked within governance systems?

Q14 | Unanswered

Is there a current Quality Improvement Plan (QIP) with clear priorities, milestones, owners, and measurable outcomes?

Q15 | Unanswered

Are quality priorities informed by data (incidents, complaints, audits, feedback, staffing, outcomes) and risk assessment?

Q16 | Unanswered

Are residents and families involved in shaping quality priorities (forums, surveys, co-production) with evidence of impact?

Q17 | Unanswered

Are quality objectives communicated to staff and embedded into everyday practice (briefings, supervision, team meetings)?

Q18 | Unanswered

Is there evidence of continuous improvement cycles (Plan-Do-Study-Act or equivalent) for key initiatives?

Q19 | Unanswered

Is there an annual audit programme covering all key domains (care plans, meds, IPC, safeguarding, environment, staffing, training, MCA/DoLS)?

Q20 | Unanswered

Are audits completed to schedule with clear scope, sampling, findings, and risk ratings?

Q21 | Unanswered

Are audit findings translated into robust action plans (SMART actions, owners, deadlines) and tracked centrally?

Q22 | Unanswered

Are follow-up audits undertaken to verify sustained improvement and prevent ‘tick-box’ completion?

Q23 | Unanswered

Is there triangulation across assurance sources (audits + incidents + complaints + feedback) to validate findings?

Q24 | Unanswered

Are quality walkarounds/observations conducted (including out-of-hours) with documented outcomes and actions?

Q25 | Unanswered

Is there independent/provider-level auditing to validate local assurance and reduce ‘marking own homework’ risk?

Q26 | Unanswered

Is there a quality dashboard with defined KPIs (falls, pressure ulcers, meds errors, safeguarding, call bell response, staffing, training compliance)?

Q27 | Unanswered

Are KPIs reviewed routinely with trend analysis, benchmarks where possible, and clear actions when performance deteriorates?

Q28 | Unanswered

Are rates normalised where appropriate (e.g., per 1,000 bed days) to support meaningful trend interpretation?

Q29 | Unanswered

Is data quality assured (accurate, consistent definitions, timely entry) and reconciled across logs (incidents vs notifications vs safeguarding)?

Q30 | Unanswered

Are leading indicators monitored (near-misses, audit compliance, supervision frequency) as well as lagging indicators (harm outcomes)?

Q31 | Unanswered

Are performance reports shared with staff in an understandable way to drive engagement and improvement?

Q32 | Unanswered

Is there a live risk register that includes clinical, operational, environmental, staffing, and compliance risks?

Q33 | Unanswered

Are risks scored (likelihood/impact), assigned owners, and reviewed at defined intervals with mitigation actions tracked?

Q34 | Unanswered

Are high-risk issues escalated promptly to provider level with evidence of support and decision-making?

Q35 | Unanswered

Is there a clear system for managing serious incidents (SI) including investigation, duty of candour, notifications, and learning dissemination?

Q36 | Unanswered

Are contingency and business continuity plans in place and tested (staffing crises, utilities failure, outbreak, evacuation)?

Q37 | Unanswered

Is there a workforce plan linking dependency/acuity to staffing establishment, skill mix, and recruitment?

Q38 | Unanswered

Are staffing shortfalls, agency use, and overtime monitored with risk mitigation and cost controls?

Q39 | Unanswered

Is training compliance monitored via a live matrix, including role-specific competencies (meds, M&H, IPC, safeguarding)?

Q40 | Unanswered

Are supervisions and appraisals completed to schedule, with quality assurance of content and follow-up actions?

Q41 | Unanswered

Is competence assessed and recorded for high-risk tasks, with remedial plans where gaps are identified?

Q42 | Unanswered

Are staff wellbeing, retention, and culture indicators monitored (turnover, sickness, surveys) with improvement actions?

Q43 | Unanswered

Are care plans and risk assessments reviewed regularly and audited for person-centred quality and outcomes?

Q44 | Unanswered

Are clinical pathways monitored (falls prevention, pressure care, nutrition/hydration, medicines, oral care, behaviours support)?

Q45 | Unanswered

Are DNACPR, escalation plans, and end-of-life care governance robust and audited for legality and person-centred practice?

Q46 | Unanswered

Are hospital admissions and re-admissions reviewed for avoidability and learning?

Q47 | Unanswered

Are GP/MDT engagement and professional involvement monitored for effectiveness and timeliness?

Q48 | Unanswered

Is evidence-based practice promoted (guidance updates, training refreshers, clinical leads support)?

Q49 | Unanswered

Are residents’ meetings held regularly, minuted, and actions followed up with feedback to residents?

Q50 | Unanswered

Are family forums/surveys conducted and used to improve services, with outcomes communicated?

Q51 | Unanswered

Are complaints, concerns, and compliments analysed for themes and linked to improvement plans?

Q52 | Unanswered

Are dignity, privacy, choice, and involvement monitored through observation and feedback mechanisms?

Q53 | Unanswered

Are activities and meaningful occupation audited for inclusion, choice, and impact on wellbeing?

Q54 | Unanswered

Are equality and inclusion monitored to ensure protected groups have equitable experience and access?

Q55 | Unanswered

Are documentation systems reliable and auditable (care records, MARs, training records, incident logs, audit trails)?

Q56 | Unanswered

Are information governance controls in place (GDPR compliance, access controls, secure storage, confidentiality)?

Q57 | Unanswered

Are records complete, contemporaneous, and reflective of care delivered (not retrospective or generic)?

Q58 | Unanswered

Is there a document control system for policies and procedures (owners, review dates, version control, staff awareness)?

Q59 | Unanswered

Are internal and external reports stored and retrievable for inspection (certificates, audits, meeting minutes, action logs)?

Q60 | Unanswered

Is there evidence the QA framework identifies issues early (before harm/complaints/CQC intervention) and drives improvement?

Q61 | Unanswered

Are improvements sustained over time (repeat audits show maintained compliance, not short-lived fixes)?

Q62 | Unanswered

Are there examples where governance resulted in measurable quality gains (reduced falls, improved MAR compliance, fewer complaints)?

Q63 | Unanswered

Are ‘stuck’ actions (overdue/high risk) rare, and when they occur are they escalated and resolved with provider support?

Q64 | Unanswered

Is there evidence that staff at all levels understand quality priorities and their role in delivering them?

Q65 | Unanswered

Can leaders demonstrate triangulation: how they combine different evidence sources to make decisions?

Q66 | Unanswered

Can the home provide a single ‘governance pack’ showing: audit programme, QIP/action log, KPI dashboard, risk register, meeting minutes, and improvement evidence?

Q67 | Unanswered

Can the home evidence how issues move through the governance cycle: identification → risk rating → action → implementation → review → sustainment?

Q68 | Unanswered

Can staff describe recent quality improvements and how governance processes led to those changes?

Q69 | Unanswered

Are provider/board oversight records available showing challenge and support for quality performance?