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