Wound Care Audit - Care Homes

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  • Is there an up-to-date wound care policy based on national guidance (e.g., NICE, NHS Tissue Viability standards)?
  • Are all wounds accurately documented in the care plan with clear type, size, location, and date first noted?
  • Is a wound assessment tool used consistently to evaluate wound type, stage, and progress (e.g., TIME framework)?
  • Are wound care plans developed with clear objectives, dressing regimes, and frequency of review?
  • Are wounds photographed with consent, where appropriate, to monitor healing and provide visual records?
  • Are residents with wounds referred promptly to the tissue viability nurse (TVN) or appropriate clinical support?
  • Are care staff trained in identifying and escalating skin breakdown, pressure damage, or signs of infection?
  • Are wound dressings changed at the correct frequency and by staff with appropriate competencies?
  • Are all wound care interventions recorded accurately, including date, time, products used, and clinical observations?
  • Are signs of infection (e.g., redness, odour, increased exudate, temperature) promptly recognised and acted upon?
  • Is the cause of the wound clearly identified (e.g., pressure, trauma, vascular, surgical, diabetic) and addressed?
  • Are residents’ nutritional and hydration needs assessed and supported to aid wound healing?
  • Is there a system for monitoring healing progress (e.g., weekly measurements, photo reviews, escalation where no improvement)?
  • Are wounds graded or staged appropriately (e.g., pressure ulcers categorised from Stage 1–4 or unstageable)?
  • Are wound dressing products stored safely, in-date, and used in accordance with manufacturer's instructions and protocols?
  • Are wound care activities performed in a clean environment using aseptic or clean technique as per guidance?
  • Are infection control measures followed during dressing changes (e.g., PPE, hand hygiene, waste disposal)?
  • Are pain assessments conducted during wound care, and appropriate analgesia offered or recorded?
  • Are staff aware of local formulary products and when specialist products or escalation is required?
  • Are chronic or deteriorating wounds reviewed with the GP, community nurse, or TVN in a timely manner?
  • Is the need for pressure-relieving equipment (e.g., specialist mattresses, cushions) reviewed and documented?
  • Are residents and families involved in discussions about wound care, comfort, prognosis, and treatment options?
  • Are records of wound care secure, legible, signed, and in line with NMC record-keeping standards?
  • Are repositioning charts used where relevant to wound care plans and pressure ulcer prevention strategies?
  • Are pressure ulcers and wounds included in internal audits and reported externally where required (e.g., CQC, safeguarding)?
  • Is there a clinical oversight system in place to review all wounds weekly or as part of the clinical governance round?
  • Are unstageable or suspected deep tissue injuries escalated and reviewed as per safeguarding and clinical protocols?
  • Are staff supervisions or observations used to ensure correct wound care technique and adherence to protocols?
  • Are wound-related incidents (e.g., dressing omissions, incorrect product use) recorded, reviewed, and used for learning?
  • Are wound-related outcomes (e.g., healing time, reduction in pressure ulcers) monitored at service level?
  • Are wounds at risk of delayed healing (e.g., diabetic foot ulcers, leg ulcers) appropriately assessed and managed with MDT input?
  • Is continuity of wound care maintained during weekends, holidays, or staff absences with clear documentation?
  • Are dressings removed only by trained staff, and is wound assessment performed before re-dressing when required?
  • Is the emotional and psychological impact of chronic wounds considered and addressed with residents?
  • Are outcomes of wound care audits discussed in team meetings or quality forums to improve practice?
  • Are TVN or clinical nurse specialist recommendations documented and followed through with evidence of implementation?
  • Is the service proactive in engaging with external training or updates on wound care and tissue viability?