Evidence: Incident log with outcome/root cause analysis · Minutes showing learning shared with staff · Named improvement from each incident type

Evidence: Discharge and transfer protocols · Hospital liaison records · Handover documentation standards

Evidence: Policy reviewed ≤12 months · 100% staff training record · DoLS authorisation tracker · Safeguarding referral log · DOLS register and expired authorisations reviewed

Evidence: Person-specific risk assessments in care plans · Evidence residents/families involved in risk decisions · Mental Capacity Act documentation

Evidence: Fire safety certificate + drill records · COSHH assessments · Legionella risk assessment ≤12 months · Environmental audit in last 6 months · Equipment servicing records

Evidence: Dependency assessments used for staffing decisions · Monthly agency usage log with rationale · Training compliance report (all staff) · Supervision and appraisal records current

Evidence: IPC audit ≤3 months · Named IPC lead · Infection outbreak log · PPE availability check · Hand hygiene audit results

Evidence: MAR charts audited monthly · PRN protocols are person-specific · Medication storage check on record · Medication error log and response documentation · GP medication review records

Evidence: Pre-admission assessments completed · Care plans current and specific · Named keyworker per resident · Regular care plan review dates in use

Evidence: NICE-aligned care approaches documented · Clinical tools in use (e.g. Waterlow, MUST, MUST scores) · Pressure ulcer prevention protocols

Evidence: MDT/GP review records · Referral pathway documentation · Handover records · Hospital liaison protocols

Evidence: Health promotion activities documented · Falls prevention programme · Oral health assessment records · Activity logs linking to wellbeing outcomes

Evidence: Monthly outcome data tracked (falls, pressure ulcers, infections, weight loss) · Trends reported to board · Evidence of changes made in response to data

Evidence: Mental Capacity Act assessments on record · Best interest decisions documented · Consent forms for all relevant treatments · DOLS conditions recorded where relevant

Evidence: Dignity and respect policy · Staff training on person-centred care · Observation records / inspection conversations with residents

Evidence: Life history / "This is Me" documents in care plans · Personal preferences documented · Cultural and religious needs recorded and respected

Evidence: Positive risk-taking documented · Advance care planning in place · Evidence residents make daily choices · Financial autonomy supported

Evidence: Call bell response time records · Responsive support for emotional distress documented · Out-of-hours cover protocols

Evidence: Staff satisfaction survey results · Supervision records showing wellbeing discussed · Sickness absence rates and management · Staff recognition programme

Evidence: Individual care plans reviewed ≤3 months · Residents' preferences actively incorporated · Activity programme tailored to individual interests

Evidence: Discharge and transition protocols · Coordination with NHS and social care documented · Out-of-hospital care plans

Evidence: Service user guide available · Information provided in accessible formats · Language/communication needs documented and supported

Evidence: Resident/family meetings with minutes · Complaints log with response times and outcomes · Satisfaction survey results with named actions taken · Evidence feedback changed something

Evidence: Equality and diversity policy ≤12 months · Equality monitoring of residents and staff · Evidence of reasonable adjustments made · Accessible communication tools available

Evidence: Advance care plans in place · End-of-life care discussions documented · DNACPR decisions appropriately recorded · Gold Standards Framework or equivalent

Evidence: Mission and values statement · Staff awareness of organisational values (inspectors ask staff) · Culture survey results with actions

Evidence: Registered manager registered with CQC · Manager appraisal on file · Manager development plan · Deputy/cover arrangements documented

Evidence: Whistleblowing policy ≤12 months · Named freedom to speak up guardian · Log of concerns raised and outcomes · No-blame incident reporting evidenced

Evidence: EDI policy ≤12 months · Equality monitoring data · Evidence of equitable access to development opportunities · Reasonable adjustments for staff

Evidence: Live risk register reviewed monthly · Monthly board report with governance data · 12 months of board minutes referencing quality and safety · Action plan with named owners, dates, and status updates

Evidence: External partnership records · Community involvement documented · Involvement with ICB / local authority governance · Referral network documentation

Evidence: Completed quality improvement projects with measured outcomes · Evidence of learning from incidents, complaints, and audits · Improvement initiatives named and owned by staff

Evidence: Energy reduction initiatives documented · Waste management policy · Procurement sustainability evidence

Evidence: EOL care policy · Named lead for EOL · Evidence of coordination with palliative care teams · Family communication protocols at EOL