Quality Monitoring Visit Audit - Care Homes
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- Q1: Is there a documented record of the date of visit and previous visit for comparison and follow-up?
- Q2: Is the visit undertaken by an appropriately qualified person and recorded with their details?
- Q3: Are any outstanding action points from the previous visit reviewed, with evidence of completion or progress?
- Q4: Are residents and their families asked if they feel safe in the home, and is feedback documented?
- Q5: Are any current safeguarding issues identified, documented, and followed up appropriately?
- Q6: Are health and safety risk assessments in place for the environment, residents, and staff, with evidence of action on identified risks?
- Q7: Are communal areas and bedrooms clean, clutter-free, and well maintained, with equipment safely stored?
- Q8: Is there evidence of recent incidents (within the last three months) reviewed, investigated, and used for learning?
- Q9: Are fire risk assessments up to date, with evidence of the last fire drill and staff awareness of fire safety procedures?
- Q10: Are infection control practices compliant with guidance (e.g., PPE usage, cleaning audits, zoning practices)?
- Q11: Are hand washing facilities available, with clear hand washing procedures displayed for staff and visitors?
- Q12: Is the service’s continuity plan up to date, accessible, and known by staff, with evidence of training or briefing?
- Q13: Are bed rails and call bells safe and accessible, with bed rail bumpers used and risk assessments in place?
- Q14: Is there evidence of residents and relatives involved in care plan reviews and feeling safe in their environment?
- Q15: Is the medication management system audited for accuracy, missing signatures, stock balances, and record-keeping?
- Q16: Are maintenance checks (e.g., electrical, water, fire, equipment) up to date, with certificates and risk assessments documented?
- Q17: Are care plans reviewed on each floor for key areas (e.g., weight loss, epilepsy, diabetes, wounds, communication needs)?
- Q18: Are staff recruitment records and disciplinary procedures complete and up to date, with evidence of safe recruitment?
- Q19: Are staff rotas and agency usage reviewed for consistency, continuity, and staffing sufficiency?
- Q20: Are accidents and incidents documented and reviewed for patterns, safeguarding triggers, and appropriate responses?
- Q21: Are staff training records up to date, with evidence of completion for mandatory and role-specific courses?
- Q22: Are window restrictors and bed rails safety checks documented and current?
- Q23: Is there evidence of resident and relative feedback on staff conduct, communication, and overall experience?
- Q24: Are mealtimes observed for dignity, choice, and positive staff-resident interactions?
- Q25: Are new and agency staff inductions completed, documented, and regularly reviewed for effectiveness?
- Q26: Are GPs and external professionals (e.g., dietitians, SALT, mental health teams) involved and their input documented?
- Q27: Is communication and documentation (daily notes, charts, care plans) up to date and person-centred?
- Q28: Is there evidence of capacity assessments and best interest decisions being made in line with MCA principles?
- Q29: Are staff supervision and appraisal records up to date, with clear support for staff development and performance?
- Q30: Are staff observed to be caring, respectful, and engaged with residents and families?
- Q31: Are end-of-life care plans (e.g., GSF, advanced care plans) in place and tailored to individual preferences?
- Q32: Are privacy, dignity, independence, and advocacy actively promoted in care delivery and environment?
- Q33: Do staff understand and respect equality, diversity, and human rights in their daily practice?
- Q34: Is there a clear complaints policy, with evidence of actions taken and learning from complaints?
- Q35: Are staff confident in and understand the principles of confidentiality?
- Q36: Are pre-admission assessments and person-centred care plans in place and reviewed for effectiveness?
- Q37: Is resident and family involvement in care planning and communication consistently documented and acted upon?
- Q38: Is there evidence of meaningful activities and social opportunities for residents, including individual interests?
- Q39: Are resident bedrooms personalised, with names, photos, and personal items respected and celebrated?
- Q40: Is there a complaints folder or log, with actions clearly recorded and followed up by management?
- Q41: Do residents and families report positive experiences with home management and leadership?
- Q42: Is the home management team visible, approachable, and engaged in quality assurance processes?
- Q43: Are quality assurance systems robust, with evidence of regular reviews and action plans?
- Q44: Are surveys from residents and families completed, with analysis and responsive action documented?
- Q45: Are minutes from staff, resident, and relative meetings kept, shared, and used to improve care and culture?
- Q46: Are audits (e.g., monthly audits) completed on time, with actions clearly agreed and followed up?
- Q47: Is there a culture of transparency, learning, and proactive improvement evident in all areas of practice?