ExcelCare Agency
In-house inspection checklist
Safeguarding & Rights
CQC key question: Effective/Caring · Reg 11 (consent) · Reg 17 (records)
Care Records, Consent & Mental Capacity audit
Confirms that care plans are current and person-centred, consent is properly sought, and capacity is assessed in line with the Mental Capacity Act.
01Care plans and records
011Each person has a care and support plan that reflects their assessed needs and choices.
Not assessed012Care plans are reviewed at least every 6 months or sooner where needs change.
Not assessed013Daily records are accurate, dated, signed, and written in a respectful tone.
Not assessed014Records are kept securely and respect the person's confidentiality.
Not assessed015Care plans are available to the person and, with consent, to relatives and advocates.
Not assessed
02Consent
021Consent to care and treatment is sought and recorded before care starts.
Not assessed022Consent is reviewed when care changes and is recorded on each occasion where required.
Not assessed023Staff know that consent can be withdrawn at any time.
Not assessed024Where consent is not given, the reason and the action taken are recorded.
Not assessed
03Mental capacity
031A capacity assessment is completed wherever there is doubt about a person's ability to decide.
Not assessed032Best-interests decisions are recorded, with input from the person and those close to them.
Not assessed033Restrictive interventions are the least restrictive option and are documented.
Not assessed034Staff understand the principles of the Mental Capacity Act and Deprivation of Liberty Safeguards.
Not assessed035Where a person lacks capacity, advocacy is considered and offered.
Not assessed
Overall finding
Select the outcome of this audit and record any actions required.
Inspector signature
Registered manager review
ExcelCare Agency · In-house inspection checklist · Care Records, Consent & Mental Capacity audit · Controlled document set v6.0 · Retain the completed audit in the quality file and review at the next governance meeting.