Carevia Knowledge Centre · Governance and assurance
What should a care home audit action plan include?
A care home audit action plan should set out the finding, the risk, the action needed, who will do it and by when. It should also show how you will check that the action worked and that the improvement has lasted.
In a busy service, an entry such as “staff reminded” can feel like progress. It gives you little to follow up, unless it explains what needs to change and how you will check it.
Sometimes, writing an action in a structured action plan can feel like another job to do. In a busy day it is easier to make a note in your little black notebook. You can jot the to-do in your notebook and scribble it out later. Unfortunately, this may be quicker, but crossing it out without an accessible record of ownership, follow-up or effectiveness doesn’t provide assurance of good governance.
What information should I record?
Keep the plan clear enough for another person to pick up and understand. For each finding, include:
01
The finding and evidence
what was identified, where and when, with a reference to the audit or sample.
02
The risk and priority
why it matters, who could be affected and any immediate protective action taken.
03
The action and intended outcome
what will change to address the cause and what improvement should look like. This should consider the whole service. For example, if one person’s care plan does not match their risk assessments, daily notes or observed practice, it makes sense to consider whether the same issue affects other people’s care plans. The scope of the review should reflect the risk and findings.
04
An owner and deadline
who will lead the work, the support they need and the completion date. The owner should have the skills, knowledge and competence to accomplish the action. The deadline should reflect the risk and urgency of the improvement needed.
05
The testing arrangements
who will check effectiveness, how and when, including a later review where needed.
06
Status and evidence
progress, what was completed, what subsequent checks found and any further action.
What needs action first?
If an audit identifies an immediate risk, take appropriate protective action and follow the relevant escalation procedures. Record that response alongside the further work needed.
Set priorities and timescales according to the risk. CQC’s guidance on Regulation 17: Good governance expects providers to monitor improvement plans and act promptly where progress is insufficient.
It can be tempting and motivating to chase “quick wins”, however these should be done alongside high-risk and high-priority actions, not instead of them.
Example: improving daily notes
An audit finds that sampled daily notes describe tasks but provide little detail about people’s choices or responses. Discussion with staff identifies that the recording prompts focus on tasks.
A vague action: “Staff to be reminded in the next team meeting to improve daily notes and include more detail.” This leaves the owner, deadline and expected change unclear.
A more useful plan could record:
Action: revise the recording prompts and coach staff using anonymised examples to record relevant support, choices, responses and changes. Facilitate workshops with staff and include recording scenarios in team meetings. Staff can choose good examples and poor examples. Allow time throughout a shift to keep notes person-centred and chronological.
Owner and deadline: deputy manager, by 6 November 2026.
Intended outcome: sampled notes record relevant support, choices, responses and changes requiring follow-up, consistent with the person’s care plan.
Test: on 13 November, the manager samples 10% of daily-note entries recorded between 7 and 12 November, covering different people, staff and shifts, and compares them with conversations with people and staff.
Embedding review: repeat sampling across different staff and shifts on 11 December to check whether improvement has continued.
Status and evidence: record when the prompts and coaching are completed, then add the findings from both reviews.
This is an illustrative example. Choose dates and samples that reflect your service’s risks, and record the actual findings before confirming effectiveness.
How does SMART-TE™ help?
SMART-TE™ is Carevia’s approach to building testing and sustained improvement into action planning. It extends Specific, Measurable, Achievable, Relevant and Time-bound with Tested and Embedded.
A revised prompt and a completed coaching session show that tasks were done. Testing looks for evidence of improvement; embedding checks whether it continues over time. Our article on closing the loop on actions explains these stages further.
Use RAOF™: Read, Ask, Observe and Feedforward to explore whether records, conversations and practice support the conclusion that an action worked. Feed what you find into the next decision.
What if an action is overdue or has not worked?
It is important to regularly review actions to identify barriers before deadline dates are missed. Where a deadline needs to change, retain the original date and record the rationale, the revised date, who agreed it and how any continuing risk will be managed.
Review the risk and find out what is preventing progress. Record the support, revised action or escalation needed, who is responsible and when it will be reviewed. Repeated extensions should prompt closer scrutiny of whether the action is achievable and whether the underlying concern is being resolved.
Keep findings and actions connected
The Carevia Service Assurance Hub brings audit findings into an overall action plan with owners, due dates, success criteria and evidence. It supports the follow-through that turns an audit finding into a checked improvement in practice.
