Form – Service audit: is it well led?

Suitable for all providers.

Instructions for use:
  • The aim of this service audit is to check what the current situation is and to identify areas for service improvement.
  • When auditing your service always seek evidence for compliance.
  • Ensure that if you deem an area of your service compliant that the whole of that area is compliant.
  • This audit does not cover all of the potential areas of compliance and users should tailor it to their specific setting.
/ Date of audit:
Audited by:
Audit shared with:
Is it well led?
Area of compliance / Key questions / Response to key questions
Y/N / Evidence to back up your responses (details of evidence and location) / Service improvements identified and how they will be implemented
  • Do you have a mission statement that clearly sets out the purpose and vision of your organisation?
  • Was the service manager involved in the creation of the mission statement?
  • Do your policies and procedures relate to the mission statement?
  • Are policies and procedures consistent with current legislation and best practice?
  • Do you have an effective complaints process which is used to improve service provision?

The registered provider /
  • Does the registered provider have the skills and experience to lead a care provider organisation?
  • Is the registered provider visible and accountable to service users and other key stakeholders?
  • Does the registered provider share key information with the staff team, i.e. financial viability, vision etc.?
  • Does the registered provider seek and listen to the views of the staff team?

The registered manager /
  • Is there a registered manager in post?
  • Does the registered manager have the skills, qualifications and experience to lead and manage your care provision?
  • Does the registered manager spend time observing care being provided?
  • Is the registered manager visible and accessible to staff, service users and other key stakeholders?
  • Does the registered manager believe in the purpose and vision of the organisation?
  • Does the registered manager involve all aspects of the staff team, i.e. care staff, admin staff, catering staff, domestic staff and maintenance staff in shaping the vision for the care service?
  • Does the registered manager undertake training to maintain their knowledge and competence?

Senior care staff /
  • Do senior care staff /team leaders understand and put into practice the vision and ethos of the organisation?
  • Are senior staff committed to following the organisation’s policies and procedures?
  • Do senior staff guide and mentor those who work for them?
  • Do senior staff act as a link between the care team and the management team?

Care plans /
  • Are care plans person centred, focused on outcomes for service users and current?
  • Are service user files neat and tidy, in good order and up-to-date?
  • Do senior staff check records made by care staff and address any concerns?
  • Does the registered manager check and countersign records made by other staff?

Training /
  • Are staff provided with training which is legally required?
  • Have all staff had this training?
  • Is this training up to date?
  • Are staff provided with training which is required to meet the needs of service users, i.e. training on specific conditions?
  • Have all staff had this training?
  • Is this training up-to-date?
  • Are staff provided with training that is required to meet their professional development needs?
  • Is the effect of training on performance assessed via day-to-day observations, formal supervisions and appraisals?

Staffing /
  • Do staff have regular recorded supervision and appraisals with their line manager?
  • Do supervisions focus on the key aspects of their work i.e. ethos and approach, maintaining standards, training and development, work/life balance?
  • Are those people carrying out supervisions trained to do so?
  • Are people carrying out supervisions doing so with a manageable number of staff, i.e. no more than 10?
  • Is there an on-call or out-of-hours support system in place?
  • Is responsibility for out-of-hours support allocated to people who are willing to undertake this part of their job role?
  • Do you have regular recorded team meetings?
  • Do all staff have the opportunity to attend, determine the agenda and contribute to team meetings?
  • Are team meetings effective in improving the quality of service provision?
  • Do staff have an annual appraisal with their line manager which looks at them and their performance holistically with reference to how they contribute to the organisation’s goals?

Records /
  • Do you undertake regular checks of all of the records required under relevant legislation?
  • Are such records used to review and improve the quality of service provision?

Quality assurance /
  • Is your service kept under constant review?
  • Is the review based on best practice and current legislation?

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