Quality Assurance Framework Audit - Care Homes

Evidence to check

• • Current organogram shows reporting lines and accountability
• • Governance structure includes frontline staff, seniors, nurses, registered manager, provider and nominated individual where applicable
• • Staff understand who is accountable for quality, safety and compliance
• • Governance structure is reviewed when roles or service arrangements change

Evidence to check

• • Registered Manager, clinical lead, deputy, nominated individual and provider responsibilities are documented
• • Quality, safeguarding, medicines, IPC, health and safety, staffing and governance leads are identified
• • Deputy arrangements are in place
• • Leaders can explain their specific governance responsibilities

Evidence to check

• • Quality Assurance Framework is available, current and approved
• • Framework explains audit, risk management, governance meetings, KPIs, feedback, incident learning and improvement planning
• • Framework applies to the home's actual service model and resident needs
• • Staff and leaders understand how the framework works in practice

Evidence to check

• • Governance meeting calendar is available
• • Meetings include quality, clinical, health and safety, IPC, medicines, safeguarding, staffing and resident experience where relevant
• • Terms of reference define purpose, membership, frequency, reporting and escalation
• • Meetings are held as scheduled or delays are explained

Evidence to check

• • Meeting minutes are complete and dated
• • Actions have named owners and target dates
• • Previous actions are reviewed until closed
• • Minutes show challenge, decision-making and escalation, not only updates

Evidence to check

• • Leadership walkarounds include varied shifts and units
• • Night and weekend staff receive management contact and oversight
• • Leaders speak with residents, relatives and staff during visits
• • Findings from walkarounds are recorded and actioned

Evidence to check

• • Staff report feeling safe to raise concerns, incidents and near misses
• • Leaders respond constructively to errors and concerns
• • Learning is shared without blame where appropriate
• • Whistleblowing, complaints and incident reporting are promoted as routes to improvement

Evidence to check

• • Framework maps assurance activity to safe, effective, caring, responsive and well-led domains
• • Quality statements are reflected in audits, KPIs and governance discussions
• • Evidence is organised to support inspection readiness
• • Gaps against CQC expectations are added to improvement plans

Evidence to check

• • Framework includes systems to assess, monitor and improve quality and safety
• • Risks to residents are identified, assessed and mitigated
• • Records and data are accurate, complete and used for decision-making
• • Improvement actions are tracked and reviewed for effectiveness

Evidence to check

• • Compliance monitoring schedule or checklist is in place
• • Regulatory requirements are linked to audits and governance reports
• • Provider policy compliance is checked through audit and observation
• • Non-compliance is risk rated and actioned

Evidence to check

• • Governance reports include notifications, safeguarding referrals and duty of candour cases
• • Themes and timeliness are reviewed
• • Actions from investigations are tracked
• • Leaders check that statutory duties are not missed

Evidence to check

• • Evidence is kept current throughout the year
• • Governance pack is updated routinely
• • Staff understand current quality priorities
• • The home can evidence improvement without last-minute preparation

Evidence to check

• • CQC, commissioner, local authority, safeguarding, fire authority, HSE and other external recommendations are logged
• • Actions have owners, deadlines and evidence requirements
• • Progress is reviewed through governance
• • External recommendations are not held separately without oversight

Evidence to check

• • QIP is current and risk-based
• • Each action has an owner, deadline, milestone and expected outcome
• • High-risk actions are prioritised
• • Progress is reviewed and updated regularly

Evidence to check

• • Priorities are based on incidents, complaints, audits, feedback, staffing, outcomes and risk register data
• • Rationale for quality priorities is documented
• • Priorities change when new risks emerge
• • Leaders can explain why current priorities matter

Evidence to check

• • Resident meetings, surveys, family forums or co-production activities influence priorities
• • Feedback from people with communication needs is actively sought
• • Residents and families are told what changed as a result
• • Quality plans reflect lived experience, not only management data

Evidence to check

• • Quality priorities are shared through team meetings, handovers, supervision or briefings
• • Staff can describe current improvement priorities
• • Objectives are linked to day-to-day practice
• • Communication reaches night, weekend, bank and agency staff where relevant

Evidence to check

• • Improvement work follows Plan-Do-Study-Act or equivalent cycle
• • Baseline, intervention, review and adjustment are documented
• • Learning is used to refine the approach
• • Improvements are sustained and embedded

Evidence to check

• • Audit programme includes care plans, medicines, IPC, safeguarding, environment, staffing, training, MCA/DoLS, dignity and governance
• • Audit frequency is defined and risk-based
• • Responsible auditors are named
• • Missed audits are identified and rescheduled

Evidence to check

• • Audit records show date, auditor, scope and sample size
• • Findings include evidence and risk rating
• • Audit schedule is monitored
• • Delayed or incomplete audits are escalated

Evidence to check

• • Audit actions are SMART with owners and deadlines
• • Actions address root cause and resident impact
• • Actions are tracked centrally
• • Completion evidence is retained

Evidence to check

• • Follow-up checks are scheduled for significant findings
• • Follow-up audits test whether practice changed
• • Repeat findings are investigated
• • Actions are revised where improvements were not sustained

Evidence to check

• • Audits, incidents, complaints, safeguarding, staffing, feedback and observations are reviewed together
• • Contradictory evidence is investigated
• • Triangulation informs risk rating and priorities
• • Leaders can explain how multiple evidence sources support decisions

Evidence to check

• • Walkaround records include observations of care, environment, dignity, staffing and resident experience
• • Out-of-hours visits are completed periodically
• • Findings are actioned and followed up
• • Walkarounds include direct engagement with residents and staff

Evidence to check

• • Provider or external audits are completed at defined intervals
• • Provider audits challenge local findings and closure evidence
• • Findings are integrated into the QIP
• • Independent review is used where internal assurance is weak

Evidence to check

• • Dashboard includes falls, pressure ulcers, medicines errors, safeguarding, complaints, call bells, staffing, agency use, training, supervision and audits where relevant
• • KPIs have definitions and data sources
• • Dashboard is reviewed regularly
• • Deteriorating indicators trigger action

Evidence to check

• • KPI reports show trend over time
• • Performance deterioration is discussed and actioned
• • Benchmarks are used where available and meaningful
• • Actions are followed through to outcome

Evidence to check

• • Indicators such as falls or incidents are considered per occupancy or bed days where useful
• • Changes in occupancy and dependency are considered
• • Leaders avoid misleading interpretation of raw numbers
• • Trend analysis supports accurate decision-making

Evidence to check

• • Incident, safeguarding, complaint, notification and audit logs are reconciled
• • Definitions are consistent
• • Data is entered promptly and accurately
• • Discrepancies are investigated and corrected

Evidence to check

• • Leading indicators include near misses, audit compliance, training compliance, supervision frequency and staffing risk
• • Lagging indicators include harm, complaints, pressure ulcers and serious incidents
• • Leaders act before harm occurs where possible
• • Early warning signs are included in governance reports

Evidence to check

• • Staff receive updates on key quality themes
• • Data is translated into practical learning
• • Staff understand how their role affects performance
• • Improvement progress is shared to maintain engagement

Evidence to check

• • Risk register is current and reviewed regularly
• • Risks include resident safety, staffing, premises, equipment, infection control, safeguarding and compliance
• • Each risk has controls, owner and review date
• • Closed risks include rationale and evidence

Evidence to check

• • Risk scoring includes likelihood and impact
• • Each risk has named owner
• • Mitigation actions are tracked
• • Risk scores are updated when controls improve or risk increases

Evidence to check

• • High-risk items are escalated to provider or senior leadership
• • Provider response and decisions are recorded
• • Resource or support needs are addressed
• • Escalated risks remain under review until reduced

Evidence to check

• • Serious incident process covers investigation, RCA, safeguarding, CQC notification, duty of candour and learning
• • Serious incidents receive senior review
• • Actions are tracked to completion
• • Learning is shared and embedded

Evidence to check

• • Plans cover staffing crisis, utilities failure, outbreak, evacuation, cyber incident and major premises failure
• • Plans are reviewed and tested through drills or scenarios
• • Staff understand their role in emergencies
• • Learning from tests or real events updates the plan

Evidence to check

• • Dependency or acuity data informs staffing establishment
• • Skill mix and shift leadership are considered
• • Recruitment plan addresses vacancies and future needs
• • Workforce plan is reviewed when resident needs change

Evidence to check

• • Staffing dashboard includes vacancies, sickness, agency use, overtime and continuity
• • Shortfalls are risk assessed and escalated
• • Agency use is reviewed for quality and cost
• • Fatigue and wellbeing risks are considered

Evidence to check

• • Training matrix is current and role-specific
• • Mandatory and specialist competencies are tracked
• • Expired or missing training is escalated
• • High-risk tasks are not allocated to untrained staff

Evidence to check

• • Supervision and appraisal trackers are current
• • Record quality is sampled
• • Actions from supervision and appraisal are followed up
• • Themes inform training, wellbeing and performance improvement

Evidence to check

• • Competency records cover medicines, moving and handling, catheter care, PEG, wound care or other relevant tasks
• • Competence is observed and signed off by suitable assessors
• • Gaps trigger retraining or restriction
• • Competence is reviewed after incidents or role changes

Evidence to check

• • Turnover, sickness, exit interviews, staff surveys and morale themes are reviewed
• • Wellbeing risks are included in governance where relevant
• • Actions address workload, support, recognition and retention
• • Impact of wellbeing actions is reviewed

Evidence to check

• • Care plan audit checks quality, accuracy, person-centred detail and review frequency
• • Risk assessments are updated after changes and incidents
• • Resident preferences and outcomes are included
• • Staff practice reflects the written plan

Evidence to check

• • Falls, pressure care, nutrition, hydration, medicines, oral care, continence and behaviour support are monitored
• • Clinical audits and KPIs identify trends
• • Professional input is sought where needed
• • Outcomes improve or plans are revised

Evidence to check

• • DNACPR and escalation plans are legally valid and accessible
• • End-of-life care plans reflect resident wishes and best-interest decisions where applicable
• • Records are reviewed for accuracy and sensitivity
• • Staff know how to access and follow these plans

Evidence to check

• • Hospital transfer log is reviewed
• • Avoidable admissions or readmissions are analysed
• • Learning is linked to care planning, clinical escalation or staff training
• • Outcomes are discussed in governance

Evidence to check

• • Professional referrals and visits are documented
• • Recommendations are added to care plans
• • Delayed responses are followed up
• • MDT input is reviewed for impact on resident outcomes

Evidence to check

• • Guidance updates are monitored and shared
• • Clinical leads support staff to apply best practice
• • Training reflects current guidance
• • Audits check whether evidence-based practice is followed

Evidence to check

• • Resident meeting minutes are available
• • Actions are recorded and followed up
• • Residents are told what changed
• • Alternative feedback routes are available for residents unable or unwilling to attend meetings

Evidence to check

• • Family feedback is collected through surveys, meetings or direct engagement
• • Themes are analysed and actioned
• • Outcomes are communicated to families
• • Feedback influences the QIP where relevant

Evidence to check

• • Complaints and compliments log is current
• • Themes are reviewed through governance
• • Learning is shared with staff
• • Actions are added to the QIP where needed

Evidence to check

• • Observation audits include staff approach, privacy, consent, language and choice
• • Residents and families are asked about dignity and involvement
• • Findings lead to staff coaching or wider actions
• • Improvements are reviewed

Evidence to check

• • Activities audits review individual preference, inclusion and participation
• • Residents who remain in rooms or are less vocal are included
• • Impact on mood, connection and wellbeing is considered
• • Activity planning changes based on feedback and outcomes

Evidence to check

• • Feedback, complaints, outcomes and access are reviewed for equality themes
• • Protected characteristics and communication needs are considered
• • Reasonable adjustments are made and reviewed
• • Discrimination concerns are recorded and acted on

Evidence to check

• • Care records, MARs, training records, incident logs and audit trails are accessible and complete
• • Electronic systems have audit trails where applicable
• • Paper records are stored securely and indexed
• • Managers can retrieve evidence quickly

Evidence to check

• • GDPR compliance, access controls, secure storage and confidentiality expectations are documented
• • Staff receive data protection training
• • Data breaches are reported and investigated
• • Access to sensitive records is role-based and reviewed

Evidence to check

• • Records are completed at the time or as soon as practicable
• • Records are specific, factual and person-centred
• • Generic or retrospective entries are challenged
• • Record audits lead to improvement actions

Evidence to check

• • Policy register includes owners, version numbers, approval dates and review dates
• • Current versions are accessible to staff
• • Obsolete versions are removed
• • Staff awareness of key policies is tested

Evidence to check

• • Certificates, audits, meeting minutes, action logs, visit reports and external reviews are organised
• • Records are retained securely
• • Evidence can be found promptly
• • Closed actions and historical evidence remain accessible

Evidence to check

• • Leading indicators and near misses are monitored
• • Audit and feedback identify emerging issues
• • Actions are taken before risks escalate
• • Examples show early identification prevented deterioration

Evidence to check

• • Repeat audits show maintained compliance
• • Improvement is visible across shifts and units
• • Temporary compliance spikes are identified and addressed
• • Sustained improvement evidence is retained

Evidence to check

• • Examples show reduced falls, improved MAR compliance, fewer complaints, better training compliance or improved resident feedback
• • Baseline and post-improvement data are available
• • Actions taken are linked to outcomes
• • Learning is embedded into routine practice

Evidence to check

• • Overdue action list is reviewed
• • High-risk overdue items are escalated to provider level
• • Reasons for delay and interim controls are documented
• • Provider support or resources are provided where needed

Evidence to check

• • Staff can describe current quality priorities
• • Staff understand how their role contributes to improvement
• • Quality messages are shared across shifts and departments
• • Staff feedback influences improvement work

Evidence to check

• • Leaders can show how incidents, audits, complaints, feedback, staffing and outcomes are combined
• • Decisions are evidence-led rather than based on a single data source
• • Triangulation identifies hidden risks or confirms improvement
• • Examples are documented in governance records

Evidence to check

• • Governance pack includes audit programme, QIP, action log, KPI dashboard, risk register, meeting minutes and improvement evidence
• • Documents are current and consistent with each other
• • Pack is updated routinely
• • Leaders can explain the evidence and current risks

Evidence to check

• • Sample issue shows identification, risk rating, action planning, implementation, evidence, review and sustainment
• • Records are linked across audits, meetings, action logs and follow-up checks
• • Ownership and escalation are clear
• • Outcome is measured and learning is shared

Evidence to check

• • Staff can give specific examples of improvements
• • Examples link to audits, incidents, feedback or governance decisions
• • Staff understand what changed and why
• • Staff can describe how improvement is being maintained

Evidence to check

• • Provider or board reports review quality, risk, staffing and compliance
• • Records show constructive challenge, not only acceptance of local reports
• • Support, resources or decisions are documented
• • Provider oversight follows up previous concerns

Evidence to check

• • Framework includes observation, resident feedback, family feedback and staff feedback
• • Assurance checks whether care is safe, kind, timely and person-centred in practice
• • Resident outcomes and lived experience influence quality priorities
• • Governance decisions lead to visible improvement for residents

Evidence to check

• • Framework review date is recorded
• • Review considers whether audits, dashboards, meetings and action plans are identifying and resolving risks
• • Feedback from staff, residents and provider leadership informs review
• • Framework is updated when it is not working effectively