Survelix CQC Compliance Resource
Person-Centred Care Planning Quality Checker
Care plan quality review framework aligned to CQC SAF Effective domain requirements
Author: Cheta Ikemsinachi Ogbuzuru
Published via survelix.co
Review Date: ___________________
HSCA Reg. 9
About this quality checker
Poor care planning is cited in the majority of Requires Improvement ratings. Inspectors consistently find care plans that are copied between service users, use task-oriented rather than person-centred language, fail to reflect mental capacity assessments, and are not updated after changes in need. This quality checker addresses all known failure points. Use it to review a sample of care plans monthly, or to review every plan ahead of inspection. Authored by Cheta Ikemsinachi Ogbuzuru.
3 = Fully met
2 = Partially met
1 = Not met
N/A = Not applicable
Section A: Foundation Information
Every care plan must contain accurate, current foundational information. Inspectors check these elements first as they indicate the quality of assessment and admission processes.
| # | Quality Criterion | Score 1 / 2 / 3 / N/A | Reviewer Notes |
|---|---|---|---|
| A1 | Full legal name, preferred name, date of birth, and NHS number are present and accurate | ||
| A2 | Photograph is current (taken within the last 18 months). Photo reflects the service user's current appearance | ||
| A3 | Named next of kin / emergency contact with current telephone number is recorded | ||
| A4 | GP name, practice address, and contact number are current. Date last verified is recorded | ||
| A5 | Known allergies and adverse reactions are documented with the type of reaction (anaphylaxis, intolerance, rash, etc.) | ||
| A6 | Religion, cultural background, and language preferences are recorded. Communication needs are specified | ||
| A7 | The date of the initial assessment and the date the care plan was first written are documented | ||
| A8 | Consent to care planning is documented. Where the service user lacks capacity, this is noted and a best interest record is referenced |
Section B: Person-Centred Language and Content
This is where most care plans fail. Generic, task-focused language (e.g. "Service user requires assistance with personal care") is not evidence of person-centred care. The care plan must describe the individual as a person, not as a collection of tasks.
| # | Quality Criterion | Score | Reviewer Notes |
|---|---|---|---|
| B1 | The care plan is written in the first person ("I like", "I prefer", "I need help with") or directly describes the individual's own preferences | ||
| B2 | Life history and background are documented (family, occupation, hobbies, significant life events, what matters most to the person) | ||
| B3 | Personal preferences around daily routine are specified (waking time, meal preferences, bathing preferences, activity interests) | ||
| B4 | The care plan describes what the service user can do independently and what they need help with. It does not over-medicalise or imply helplessness | ||
| B5 | Goals and outcomes are documented in the service user's own words where possible. Goals are meaningful to the individual, not generic | ||
| B6 | The care plan does not use institutional or clinical language that depersonalises the individual (e.g. "the patient", "service user requires") | ||
| B7 | Family and carer perspectives are incorporated where relevant and with consent. Disagreements between family and service user wishes are noted | ||
| B8 | The "what matters to me" section (or equivalent) is completed with specific, individual content, not generic statements |
Section C: Risk Assessments
| # | Quality Criterion | Score | Reviewer Notes |
|---|---|---|---|
| C1 | Falls risk assessment uses a validated tool (STRATIFY, Morse, or equivalent). Score is current. High-risk individuals have a falls prevention plan | ||
| C2 | Pressure ulcer risk uses Waterlow score or equivalent. Repositioning frequency is specified in the care plan for at-risk individuals | ||
| C3 | Nutritional risk assessment (MUST or equivalent) is current and linked to a nutrition care plan where indicated | ||
| C4 | Choking and dysphagia risk is assessed where relevant. IDDSI framework is referenced where texture modification is required | ||
| C5 | Moving and handling assessment is current and signed off by a manual handling lead. Specific equipment is named in the plan | ||
| C6 | Behaviour support plans are in place for any service user with behaviours that may be a risk to themselves or others. Plans are positive and therapeutic, not purely restrictive | ||
| C7 | Environmental risks specific to the individual are documented (e.g. wandering, stairs, kitchen access) | ||
| C8 | Risk assessments are dated and version-controlled. All risks have been reviewed within the last 6 months or following any incident |
Section D: Mental Capacity Act Compliance
| # | Quality Criterion | Score | Reviewer Notes |
|---|---|---|---|
| D1 | MCA capacity assessments are decision-specific. Each significant decision has its own documented capacity assessment | ||
| D2 | The five principles of the Mental Capacity Act are evident in how decisions are recorded (presumption of capacity, supported decision-making, least restrictive option) | ||
| D3 | Best interest decisions are documented with a record of who was involved, what was considered, and what the least restrictive option was | ||
| D4 | DoLS application status is recorded where the service user is being deprived of their liberty. Authorisation reference number and expiry date are noted | ||
| D5 | IMCA (Independent Mental Capacity Advocate) referrals have been made where required (e.g. for serious medical decisions with no family involved) | ||
| D6 | Capacity is reviewed and reassessed following any change in cognitive status, health event, or significant decision |
Section E: Review Currency and Evidence of Use
| # | Quality Criterion | Score | Reviewer Notes |
|---|---|---|---|
| E1 | The care plan has been reviewed within the last 12 months, or within 28 days of any significant change in needs | ||
| E2 | Review records include the service user's or their representative's signature or acknowledgement of involvement | ||
| E3 | Care notes are consistent with the care plan. There is no evidence that care described in the notes contradicts the plan | ||
| E4 | The care plan is current following any hospital discharge, falls, illness, or behavioural change in the last 6 months | ||
| E5 | Staff who have read and are working to this care plan have signed it. Evidence that care plan is known to the care team is present |
Care Plan Quality Score
Total Applicable Items
___
/35
Total Score Achieved
___
/105 max
Quality Rating
___
Scoring guide
90%+ = Good / Outstanding quality. 75-89% = Requires improvement. Below 75% = High risk. Any single item scored 1 in Sections C (Risk), D (MCA), or E (Currency) requires immediate action regardless of overall score.
| Ref | Action Required | Lead Person | Target Date | Date Completed |
|---|---|---|---|---|
Authored by: Cheta Ikemsinachi Ogbuzuru
Published via Survelix (survelix.co) for Custoris Ltd
References: HSCA Regulation 9 (Person-Centred Care); Mental Capacity Act 2005; CQC Effective Key Question Guidance