CARE PLANNING AUDIT
Please complete the form below.
Date of audit:
-
Day
-
Month
Year
Date
Name of person completing audit:
*
First Name
Last Name
Residents Name:
First Name
Last Name
Admission Date:
-
Day
-
Month
Year
Date
CARE PLANNING
The Resident was involved in the completion of the Care Plan.
Yes
No
Comment:
There is evidence of consent from the Resident in relation to their care requirements.
Yes
No
Comment:
Where the Resident has been unable to participate, a best interest decision has been made in line with the Mental Capacity Act 2005 and advocates / representatives have consented:
Yes
No
Comment:
The overall Care Plan meets the current needs of the Resident:
Yes
No
Comment:
Assessments are completed and in place for:
Allergies
Barthel Index
Bedrail
Choking
Continence
Dehydration
Falls Risk
Mental Capacity
Mental Health
Mouth Health Protocol
Moving And Handling
Must
Peep
Reclining Arm Chair
Waterlow
Skin integrity
Comment:
The Care Plan is person-centered to the resident:
Yes
No
Comment:
The Care Plan has been fully completed – all aspects of care needs are completed:
Yes
No
Comment:
Where the resident has a health need there is clear evidence of how this is supported and managed?:
Yes
No
Comment:
Robust individual Care Plans are in place, that clearly highlight the requirements of the Resident:
Yes
No
Comment:
Robust individual risk assessments are in place, that clearly highlight the requirements of the resident:
Yes
No
Comment:
Goals/outcomes have been set for the Resident as part of the Care Planning process:
Yes
No
Comment:
The goals/outcomes are achievable and in line with the care requirements of the Resident:
Yes
No
Comment:
Supporting communication logs and MAR charts, where applicable, are in evidence with the Care Plan:
Yes
No
Comment:
The Care Plan is in date and has been reviewed regularly in line with policy requirements:
Yes
No
Comment:
Staff who have carried out the review are trained to complete this task:
Yes
No
Comment:
Staff receive regular update training in Care Planning:
Yes
No
Comment:
Staff have received additional training (where required) to support the residents health needs – e.g – dementia, diabetes:
Yes
No
Comment:
END OF LIFE
There is clear evidence that has been communicated to the team in relation to DNACPR?:
Yes
No
Comment:
Is there a RESPECT form in place?:
Yes
No
Comment:
Is the EOL care plan detailed and includes preferences in relation to their death and pain management?:
Yes
No
Comment:
Clear evidence of advanced decisions?:
Yes
No
Comment:
Evidence of clear collaborative working during end of life care delivery?:
Yes
No
Comment:
Where family members require communications this is clearly documented and the order in which to contact family?:
Yes
No
Comment:
ACTION PLAN
Action plan
Action required
Comments
Person responsible
Date action to be completed by
Action plan
Action required
Comments
Person responsible
Date action to be completed by
Action plan
Action required
Comments
Person responsible
Date action to be completed by
Action plan
Action required
Comments
Person responsible
Date action to be completed by
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