Wound Care Audit - Care Homes

Evidence to check

• • Wound care policy is current and aligned with NICE, NHS tissue viability and local clinical guidance
• • Policy covers assessment, dressing changes, infection control, escalation, photography, consent, documentation and reporting
• • Staff can explain their responsibilities in wound care and escalation
• • Observed practice and sampled records match the policy

Evidence to check

• • Wound record includes date first noted, site, wound type and suspected cause
• • Body map or wound chart is completed where appropriate
• • Measurements are recorded consistently
• • Care plan clearly identifies each wound separately where more than one wound is present

Evidence to check

• • Wound assessment tool or framework, such as TIME, is used consistently
• • Assessment includes tissue type, infection or inflammation, moisture or exudate and wound edge condition
• • Assessment records surrounding skin, odour, pain and deterioration signs
• • Assessments are completed by staff with appropriate competence

Evidence to check

• • Wound care plan states treatment aim, such as healing, protection, comfort or infection control
• • Dressing type, frequency and technique are clearly recorded
• • Plan includes when to escalate, such as deterioration, infection, pain or no improvement
• • Staff can explain the current wound care plan for sampled residents

Evidence to check

• • Consent for wound photography is recorded
• • Photographs are dated, labelled and stored securely
• • Images are used to support clinical review, not stored on personal devices
• • Photography is reviewed if the resident withdraws consent or lacks capacity

Evidence to check

• • Referral records show date, reason and urgency
• • Advice from TVN, community nurse, GP or specialist is recorded
• • Delayed responses are followed up where risk remains
• • Care plan is updated after professional advice

Evidence to check

• • Training records include skin integrity, wound awareness and escalation
• • Staff can describe signs of pressure damage, infection and wound deterioration
• • Staff know who to report concerns to and when
• • Escalation examples show concerns are acted on promptly

Evidence to check

• • Dressing change records match the wound care plan
• • Staff completing dressing changes have relevant training and competency sign-off
• • Missed or delayed dressing changes are recorded and escalated
• • Dressing frequency is reviewed when wound condition changes

Evidence to check

• • Wound care records include date, time, staff name or signature and products used
• • Clinical observations include wound appearance, exudate, odour, bleeding, pain and surrounding skin
• • Records are completed contemporaneously and not from memory
• • Any concerns or changes are escalated and documented

Evidence to check

• • Staff can describe signs of infection such as redness, heat, swelling, odour, increased exudate, pain or fever
• • Records show prompt escalation to nurse, GP, TVN or community nurse
• • Observations and infection monitoring are completed where required
• • Antibiotic or treatment changes are recorded and followed up

Evidence to check

• • Assessment identifies whether the wound is pressure-related, traumatic, vascular, surgical, diabetic or moisture-related
• • Underlying causes such as pressure, poor circulation, diabetes, nutrition, continence or mobility are addressed
• • Risk assessments and care plans are updated to prevent recurrence or deterioration
• • Professional input is sought where cause is unclear

Evidence to check

• • MUST or nutrition screening is current
• • Care plan includes nutrition and hydration actions linked to wound healing
• • Food and fluid charts are used where required
• • Dietitian, GP or SALT referral is made where intake, weight loss or swallowing affects healing

Evidence to check

• • Wounds are measured and reviewed at the agreed frequency
• • Progress is compared over time using measurements, assessment and photographs where used
• • Lack of improvement or deterioration triggers escalation
• • Treatment plan is changed where current approach is not effective

Evidence to check

• • Pressure ulcers are categorised correctly, including unstageable or suspected deep tissue injury where relevant
• • Moisture lesions, skin tears and pressure damage are differentiated where possible
• • Clinical review is sought where grading is uncertain
• • Incorrect grading is corrected and learning shared

Evidence to check

• • Dressing stock is clean, organised and in date
• • Products are stored to protect sterility and prevent contamination
• • Staff use products according to the wound care plan or clinical instruction
• • Out-of-date or inappropriate products are removed from use

Evidence to check

• • Staff prepare the environment before wound care
• • Clean or aseptic technique is used according to wound type and clinical guidance
• • Resident privacy and dignity are protected during wound care
• • Contaminated surfaces, equipment or interruptions are managed safely

Evidence to check

• • Hand hygiene is completed before and after wound care
• • Appropriate PPE is used and disposed of safely
• • Clinical waste is managed correctly
• • Reusable equipment is cleaned or decontaminated after use

Evidence to check

• • Pain assessment is recorded for residents with wounds
• • Residents with communication difficulties have pain indicators recorded
• • Analgesia is offered or timed before dressing changes where needed
• • Pain concerns are escalated to GP, nurse or prescriber

Evidence to check

• • Local wound formulary or guidance is accessible
• • Staff know which products can be used and which require specialist advice
• • Non-formulary or specialist products are supported by clinical rationale
• • Product changes are documented and communicated to relevant staff

Evidence to check

• • Records show escalation for non-healing, infected, deteriorating or complex wounds
• • Review dates and professional advice are documented
• • Delayed clinical input is chased and escalated
• • Care plan is updated following review

Evidence to check

• • Care plan identifies required mattress, cushion, heel protection or seating support
• • Equipment is provided promptly and set correctly
• • Equipment is checked for faults, cleanliness and suitability
• • Equipment needs are reviewed when wound condition or mobility changes

Evidence to check

• • Resident involvement is recorded in wound care planning
• • Family or representative involvement is recorded where consent or best-interest arrangements allow
• • Information is explained in a way the resident can understand
• • Refusals, preferences and comfort needs are respected and reviewed

Evidence to check

• • Wound records are legible, dated and attributable to the staff member
• • Records are factual, accurate and free from unexplained gaps
• • Confidentiality is maintained
• • Corrections are made transparently and in line with record-keeping policy

Evidence to check

• • Repositioning records match the care plan frequency
• • Entries show actual positions used and any refusal or intolerance
• • Gaps or repeated copied entries are investigated
• • Repositioning effectiveness is reviewed if wounds deteriorate

Evidence to check

• • Wound and pressure ulcer audit records
• • Safeguarding, commissioner, CQC or local reporting requirements are considered
• • Rationale is recorded where external reporting is considered but not made
• • Audit findings are tracked through governance and action plans

Evidence to check

• • Weekly or agreed-frequency wound review records
• • Clinical lead or registered nurse reviews wound progress and risks
• • Deteriorating wounds are escalated promptly
• • Wound review outcomes are discussed in clinical governance or handover where needed

Evidence to check

• • Records show urgent escalation for unstageable or suspected deep tissue injury
• • TVN, community nurse, GP, safeguarding or commissioner involvement is considered
• • Immediate pressure relief and monitoring actions are recorded
• • Care plan and risk assessment are updated promptly

Evidence to check

• • Competency assessments or practice observations are completed
• • Supervision addresses wound care practice where relevant
• • Poor technique or documentation gaps lead to retraining
• • Competency is refreshed after incidents, audit findings or new guidance

Evidence to check

• • Incident records include wound care omissions or errors
• • Root causes and resident impact are reviewed
• • Actions are taken to prevent recurrence
• • Learning is shared with staff and monitored

Evidence to check

• • Wound tracker or clinical dashboard is maintained
• • Data includes new wounds, healed wounds, deteriorating wounds and pressure ulcers
• • Trends are reviewed by managers or clinical governance
• • Actions are taken where outcomes indicate risk or poor practice

Evidence to check

• • Records show referral to GP, podiatry, diabetic foot team, vascular service, district nurse or TVN where needed
• • Underlying conditions are reflected in the care plan
• • Foot checks, circulation concerns or diabetes-related risks are monitored
• • Professional advice is implemented and reviewed

Evidence to check

• • Wound care plans are accessible to all authorised staff
• • Handover includes dressing schedules and high-risk wounds
• • Weekend and bank holiday dressing needs are planned
• • Agency or covering staff receive clear guidance and do not undertake tasks beyond competence

Evidence to check

• • Staff understand who is authorised to remove and replace dressings
• • Wound is assessed before re-dressing according to the care plan
• • Unexpected wound changes are escalated before continuing treatment where needed
• • Residents are not left with wounds exposed unnecessarily

Evidence to check

• • Care plans consider distress, embarrassment, odour, pain, sleep and social impact
• • Residents are offered reassurance and involvement in care decisions
• • Emotional wellbeing concerns are escalated or referred where needed
• • Staff protect dignity and privacy during wound care

Evidence to check

• • Meeting minutes include wound care audit findings and themes
• • Actions are shared with care staff, nurses and managers
• • Learning is translated into practice changes
• • Follow-up checks confirm improvement

Evidence to check

• • Professional recommendations are recorded in the care plan
• • Staff are briefed on changes to dressing, equipment, repositioning or escalation
• • Implementation is evidenced in daily notes and wound records
• • Non-implementation or delays are escalated and explained

Evidence to check

• • Records of external wound care training, TVN updates or clinical guidance reviews
• • New learning is shared with staff
• • Policies, products or practice are updated after relevant guidance
• • Impact of training is checked through audits or competency observations

Evidence to check

• • Audit reviews healing progress, pain, infection, dignity and resident experience
• • Audit compares records with actual wound condition and staff knowledge
• • Residents' comfort and quality of life are considered
• • Actions from audits lead to measurable improvement in wound care outcomes

Evidence to check

• • Refusals are recorded respectfully and promptly
• • Capacity, consent and best-interest considerations are documented where relevant
• • Alternative approaches are explored and reviewed
• • Family, advocate or professional input is sought where risk remains high

Evidence to check

• • Care plan states who is responsible for assessment, dressing changes, review and escalation
• • External professional input is documented with clear actions
• • Staff know when to contact community services or GP
• • Gaps or delays between services are escalated to protect the resident