Carevia Knowledge Centre · Governance and assurance

Does the registered manager have to complete every audit?

The registered manager does not have to personally complete every audit. Audits can be delegated to suitably skilled, trained and competent colleagues, while the manager remains accountable to make sure the governance schedule is completed, findings are reviewed and concerns are acted on.

It is difficult to balance as a registered manager. There seems to be a never-ending list of tasks, and each feels as important as the other. You’ve probably already heard “work smarter, not harder”, but that can be easier said than done. As a manager you have your exacting standards and trusting or coaching others to meet them can feel more of a challenge than all the tasks you must complete.

However, sharing audits can make good use of expertise within the team, it can help colleagues develop, and form part of succession planning within your service. Empowering the right people can be motivating for others and rewarding for you too.

Clear allocation, support and monitoring help the manager keep a reliable view of what is happening. These decisions also connect with how you manage your time as a registered manager, including what you delegate and where your own attention is most needed.

If you are deciding what audits to include in your governance schedule, see our guide: What audits should a care home manager complete each month? It provides a starting schedule to help you plan coverage before allocating individual audits.

Who can complete an audit?

A deputy, nurse, team leader, trained champion or another colleague may be suitable, depending on the audit and their competence. Match the person’s knowledge and skills to the area being reviewed.

For example, for someone to complete a medicines audit, the person needs to understand the relevant medicines standards, recognise gaps and explain the significance of their findings. They should demonstrate competence that evidences they can identify compliance and unsafe practice within the scope of the medication audit. This means the person can demonstrate they are able to identify gaps between policy-procedure and practice.

Before allocating an audit, ask them to talk you through what they would check, how they would recognize gaps in practice and how they would test the evidence. In addition, they could shadow you or another competent colleague before completing the audit on their own.

For a practical guide to what the audit should cover, read Medication audits in adult social care: what good looks like and common pitfalls.

What should you agree before delegating?

Give the person a clear brief and enough time, information and support to complete it properly. Agree:

• Define the task: You should record what the task is, what needs to be done and by when.
• Test competence before delegating: Document what makes the person competent. What training they have completed, how experienced they are in the area, have you observed them undertaking the auditing task.
• Set the monitoring plan: It is important to agree regular check-ins until you and the person are assured the task can be effectively completed. Check-ins can be short and should reflect the importance of the task delegated.
• Keep oversight: Make sure you can see progress and intervene where the task is not going as planned. Agree with the person the findings that mean the person must escalate to you.
• Record the outcome: Ensure there is a record of the completion of the task, any areas of improvement identified, and next steps.
• Sample: Agree that to support the person’s development and gain assurance you will sample the completed task. If there are any discrepancies you can correct these and add to the persons development plan.

Effective delegation is not passing the buck. It is creating additional time for you to complete the tasks that can’t be delegated. It means when you are not in the service it can still run effectively when you are not there. When it is done properly, effective delegation is part of your development infrastructure.

What remains the manager’s responsibility?

The manager remains accountable for ensuring the audit schedule is completed to the required standard, issues identified have an appropriate action, and improvements are followed through. The provider also retains responsibility for effective governance under Regulation 17: Good governance.

As the registered manager it is sensible to review and sample findings from audits that have been delegated. Explore what the auditor found, how they reached their conclusions and whether the evidence supports them. Record the auditor and reviewer separately so the audit trail shows who did what. This provides an opportunity to coach and supports the auditor’s development if you identify any discrepancies.

Should the manager still check practice personally?

Direct observation, conversations and short checks help managers maintain their own understanding of the service. Use RAOF™: Read, Ask, Observe and Feedforward to explore selected findings and test whether they reflect people’s experiences and everyday practice.

Where someone audits an area they also oversee, a sample check by another competent person can bring useful challenge. This helps the team recognise things that familiarity or assumptions may have hidden.

For more on how expectations and the desire for reassurance can influence findings, read Why audits fail, and why they don’t need to.