Care Planning Audit

Rows	Met	Not Met	Action Required	Responsibility	Target Date	Completed Date
Is a Consent to Care Form in place?
Has the Consent to Care Form been signed?

Rows	Met	Not Met	Action Required	Responsibility	Target Date	Completed Date
Has a Care Plan been completed?
Does the Care Plan record all current needs?
Has the client been involved in the development of the Care Plan?
Is the Care Plan person centred?
Does the Care Plan contain some evidence of supporting or encouraging the client to be independent?
Is there evidence that mental capacity has been considered?
Does the Care Plan clearly show a description of the action to be taken and by whom?
Is the Care Plan well written and presented?
Is the Care Plan up to date?
Is there a review date in place?
Has the Care Plan been signed and dated?
Has a signed copy of the Care Plan been given to the client?

Rows	Met	Not Met	Action Required	Responsibility	Target Date	Completed Date
Has a Risk Assessment been completed?
Does the Risk Assessment document all current risks?
Has the Risk Assessment been fully completed?
Does the Risk Assessment correspond with the Care Plan?
Is the Risk Assessment up to date?
Is there a review date in place?
If a reference is unsatisfactory has this been discussed with the staff member?

Rows	Met	Not Met	Action Required	Responsibility	Target Date	Completed Date
Does the Moving and Handling Plan describe the aids required?
Does the Moving and Handling Plan state the number of staff required to support the client?
Does the Moving and Handling Plan state any environmental considerations?
Does the Moving and Handling Plan state any specific needs of the client?

Rows	Met	Not Met	Action Required	Responsibility	Target Date	Completed Date
If the client has a Deprivation of Liberty in place is this recorded in the Care Plan?
If a Lasting Power of Attorney (LPA) is in place is this recorded in the Care Plan?
Does the Care Plan reflect the information in the PEEP?
Does the Care Plan reflect the information in the Moving and Handling Plan?
Does the Care Plan reflect the information in the Food and Drink Profile?
Does the Care Plan reflect the client’s end of life wishes?
If the client has an Advanced Decision in place does the Care Plan reflect this?
Does the Care Plan reflect the information in the Medication Profile?
Does the Care Plan reflect the information in the Communication Profile?
Does the Care Plan reflect the information in the ‘One Page Profile’?
Does the Care Plan reflect the information in the ‘About Me’ profile?

Rows	Met	Not Met	Action Required	Responsibility	Target Date	Completed Date
Do records of care clearly state dates and times?
Is the recording legible?
Is recording comprehensive?
Are care records fully completed?
Does the recording promote dignity?
Have care records been signed and dated?
Where Body Maps are in place have these been fully completed?

Rows	Met	Not Met	Action Required	Responsibility	Target Date	Completed Date
Where concerns have been identified and recorded have these been actioned? If not what is being done to prevent this occurring again?
Consider if further action is required in relation to the following areas: Routine health checksHealth referralsOral Health CareFoot CareFallsMoving and HandlingWeight loss/gainNutritional/hydration needsDietician referralSwallowingChokingSkin/Tissue viabilityEquipment requiredContinenceMedication managementEnd of life careMental CapacityDOLBest Interest decisionsAdvanced decisionsPowers of AttorneyActivitiesAspirationsCultural needsSpiritual needs