15 checks for care records

Care records checklist

Compare assessments, care plans and daily notes to find missing or out-of-date information.

Start checklist
3 review stages15 practical checksPrivate working copy
Reviewed against published CQC guidance · 3 September 2026
Before you start

How to use this checklist

Choose a varied sample across different people, staff, days, visits and levels of risk. Start with each person’s assessed needs and preferences. Then check whether planned support was delivered, changed when needed and reviewed by leaders.

Do not copy personal information into this tool. Use anonymous sample codes and short evidence references only. Complete the actual audit within your organisation’s secure, authorised record system.

  1. 01
    Choose a varied sample

    Include different people, staff and dates. Note why the sample was chosen and anything left out.

  2. 02
    Compare related records

    Follow assessed needs through the care plan, daily notes and reviews. Select a status and add an anonymous note.

  3. 03
    Record the next actions

    Use the action plan to record what needs to change, who will act and how you will check the result.

Records are only one part of the picture. This independent tool is not an official CQC checklist, a complete legal or data-protection review, or a replacement for seeing care and hearing people’s experience. Follow safeguarding, clinical, data-protection and emergency procedures whenever a serious concern appears.

Working copy0 of 15 reviewedSaved only in this browser
Review stage 01

Person and plan

Does the record begin with the individual rather than the template?

5 checks

The assessment covers all important needs, is current and appears in the plan.

Important physical, emotional, social, communication, cultural and environmental needs, strengths and preferences are covered. Gaps and professional advice are followed up.

Sample: initial assessment, professional information, home-environment risks, care plan and review history.
Status for C1

The person’s voice, strengths and desired outcomes are recognisable.

Preferences and goals are specific enough to guide support; the record separates the person’s view from family, professional and provider input; generic wording is avoided.

Sample: “about me” information, goals, review discussion, feedback and person-centred daily entries.
Status for C2

Consent, capacity and decision-making records fit the specific decision.

Consent is current and meaningful. Where needed, records show the mental-capacity assessment, lawful authority, consultation, best interests decision and review for that specific decision. Capacity is not assumed for everything.

Sample only where applicable: consent, decision-specific capacity assessment, authority, best interests record and review.
Status for C3

Risks, choices and safety steps form one clear plan.

Known risks are specific to the person, balanced with choice and independence, and linked to clear steps to prevent harm and respond when something changes. The plan says what staff should notice, do and report.

Sample: risk assessments, positive-risk decisions, care plan controls, daily evidence, incidents and reviews.
Status for C4

Communication and accessibility needs shape the record and support.

Preferred language, sensory needs, communication methods, cultural context and any reasonable adjustments are clear, available to staff and reflected in how involvement is evidenced.

Sample: communication plan, accessible information, staff explanations, feedback and review records.
Status for C5
Review stage 02

Delivery and change

Do day-to-day records show what happened, what changed and what followed?

5 checks

Daily entries are timely, factual and person-specific.

Records identify the care and support provided, relevant observations, the person’s response or outcome, exceptions and actions. They avoid unexplained abbreviations, copied phrases and subjective labels.

Sample: different staff, visit types, days and times; compare electronic timestamps with expected delivery.
Status for C6

Planned support can be compared with what was delivered.

Required tasks, timing, duration, sequence or two-person arrangements are evident. Missed, late, shortened, declined or otherwise changed support has an explanation and appropriate response.

Sample: care plan, rota, call monitoring, daily notes, exception log, on-call response and feedback.
Status for C7

Change, deterioration and concern have a visible response trail.

The record links an observation or concern to immediate action, suitable professional advice, communication, referral, plan changes and follow-up. Unresolved concerns remain visible.

Sample: daily notes, body maps or monitoring where applicable, calls, referrals, handovers and review.
Status for C8

Specialist or extra records agree with the main record.

Where used, medicines, nutrition, hydration, skin, behaviour, repositioning, finance or other targeted records align with assessed need, the plan, daily notes, how concerns were raised and results.

Sample only what applies: charts, protocols, daily narrative, audit results, incidents and review records.
Status for C9

Reviews happen when planned and when circumstances require them.

Routine and event-triggered reviews involve the right people, revisit needs, preferences, risks and outcomes, update linked records and communicate the current version to staff.

Sample: scheduled reviews, post-incident or post-discharge reviews, version history, handover and feedback.
Status for C10
Review stage 03

Record quality and leadership checks

Are records accurate, secure, reviewed and used to improve care?

5 checks

Records are complete, accurate, made at the right time and show who wrote them.

Entries are readable, dated or timed when required and show who made them. Corrections keep the original entry visible, and unexplained gaps are found and followed up.

Sample: paper and electronic records, delayed entries, amendments, signatures or user IDs and gap reports.
Status for C11

Contradictions, duplicate text and obsolete versions are actively controlled.

The service can identify conflicting instructions, outdated risks, copied person-centred detail and parallel records that could mislead staff; corrections are communicated and verified.

Sample: cross-document comparison, template fields, version control, archived plans and staff access.
Status for C12

Access, sharing, storage, how long records are kept and deletion are controlled.

Approved people can get the current information needed for safe support. Access is limited to what each person needs, records are secure and keeping or deleting them follows the rules that apply.

Sample: permissions, access logs, device controls, home-folder arrangements, record-keeping timetable and proof of safe deletion.
Status for C13

Checks use a varied sample and several sources.

The sample is chosen according to risk and includes different people, staff, times and types of record. Findings are checked against people’s experience, feedback, observation, processes and results where relevant.

Sample: audit method, reason for the sample, feedback, observations, results and leadership review.
Status for C14

Findings lead to named actions and proven improvement.

Important gaps are ordered by risk, assigned and dated. Leaders keep proof of completion, use a fresh sample to check what worked, and use repeated themes to improve training, supervision and systems.

Sample: findings log, action plan, proof of completion, repeat audit, leadership meeting notes and shared learning.
Status for C15
Turn review into action

Record your next actions

Keep the priority list short enough to manage. State what must change, who owns it, when it is due and what will prove it worked.

Priority 01
Priority 02
Priority 03
Priority 04
Check the current source

Good records support good care; they do not replace it.

CQC guidance connects personal assessment and planning, consent and effective leadership with records that are accurate, complete, timely and secure. CQC also looks beyond processes to people’s experience, feedback, observation and results.

Check what applies to your regulated service, record systems, service agreements and the people you support before relying on an internal audit tool.

01
Regulation 9: Person-centred careAssessment, preferences, involvement and adjustment
02
Regulation 11: Need for consentConsent, capacity and lawful decision-making
03
Regulation 17: Good governanceRecords, audit, risk and improvement
04
CQC evidence categoriesSix types of evidence CQC may use

Need a fresh view of the records behind the service?

GR Safi can check an agreed sample of assessments, plans, risks and day-to-day records.

View care-record audit supportRequest an audit