Is there a 'Life History' or 'About Me' section completed?
Are the resident's personal preferences (likes/dislikes) clearly documented?
Is there evidence that the resident or their representative was involved in the care planning?
Is there a current MUST (Nutrition) assessment completed within the last month?
Is the Falls Risk Assessment up to date and reflective of recent incidents?
Is the Waterlow (Skin Integrity) score calculated and recorded correctly?
Do daily notes reflect the care specified in the care plan?
Is there a signed consent form for care and treatment?
Are DNACPR and ReSPECT forms clearly visible and correctly dated?