Standard 24: Home Care (Version 11)

Why it matters. When care is given in someone’s own home, the home belongs to the client. The provider is a guest there, and the client’s choices about routine, visitors and space must be respected.

Sample. Review the care plans and visit notes for 10 clients, and observe 3 visits.

1. Care follows the client’s routines and possessions.

Method. Check each sampled plan and observed visit for the routine followed.

Evidence to show. The client’s home and household routines (HC-POL-001).

Pass when. Every sampled visit follows the client’s routine.

2. Changes to the routine are agreed with the client first.

Method. Check each recorded change for the client’s agreement.

Evidence to show. Individual care plan (CLN-FRM-003).

Pass when. Every change shows the client agreed.

3. Cultural and religious practices are respected.

Method. Check each plan for the practices recorded and followed.

Evidence to show. The client’s home and household routines (HC-POL-001).

Pass when. Every plan with a practice shows it followed.

Immediate fail (any one means the criterion is not met). A caregiver deciding the client must eat at a set time against their wishes.

Why it matters. A client who does not know their rights cannot use them. A written statement, given before care starts and read through with the client, makes the rights real.

Sample. Review the statement of rights records for 10 clients, including clients who cannot read.

1. The written statement of rights is given before care begins.

Method. Check each sampled record for the date given against the first visit.

Evidence to show. Statement of rights acknowledgement (HC-FRM-001).

Pass when. Every sampled client has the statement before the first visit.

2. Clients who cannot read have it read aloud in their language.

Method. Check each record where reading aloud applies.

Evidence to show. Statement of rights acknowledgement (HC-FRM-001).

Pass when. Every such record shows it read aloud.

3. Understanding is confirmed.

Method. Check each record for the understanding confirmed.

Evidence to show. Statement of rights acknowledgement (HC-FRM-001).

Pass when. Every record shows understanding confirmed.

Immediate fail (any one means the criterion is not met). A client receiving care for months with no statement of rights.

Why it matters. A client may not get on with a caregiver, and a relationship that is not working can harm the care. The client should be able to ask for a different caregiver without a fight.

Sample. Review the caregiver replacement requests made in the last 12 months.

1. Clients can request a replacement caregiver.

Method. Check the policy and the intake for the route to request.

Evidence to show. Caregiver replacement request (HC-SOP-001).

Pass when. The route is stated in the policy and given at intake.

2. Each request is answered within the set time.

Method. Check each request for the response date.

Evidence to show. Caregiver replacement request record (HC-FRM-002).

Pass when. Every request is answered in time.

3. The request is not treated as a complaint about care quality.

Method. Check each outcome for any penalty to the client.

Evidence to show. Caregiver replacement request record (HC-FRM-002).

Pass when. No client is penalised for a request.

Immediate fail (any one means the criterion is not met). A client who asked for a change and was told no.

Why it matters. If the caregiver is the only contact, a client who has a problem with them, or who cannot reach them, is left without help. A direct line to the agency or a supervisor is needed.

Sample. Review the client contact records for 10 clients, and test the out-of-hours route.

1. Each client has a direct route to the agency or supervisor.

Method. Check each sampled record for the contact given.

Evidence to show. Client contact and out-of-hours access record (HC-FRM-003).

Pass when. Every sampled client has a contact recorded.

2. The route works out of hours.

Method. Test the out-of-hours route outside business hours.

Evidence to show. Client contact and out-of-hours access record (HC-FRM-003).

Pass when. The test reaches a person.

3. The client knows how to use it.

Method. Check each record for the client’s confirmation.

Evidence to show. Client contact and out-of-hours access record (HC-FRM-003).

Pass when. Every record shows the client knows how.

Immediate fail (any one means the criterion is not met). A client with no way to reach anyone but the caregiver.

Why it matters. Abuse and neglect of a client in their own home often goes unseen, because the home is private. Active checks, rather than trust, are needed to protect the client.

Sample. Review the independent check-in records for 10 clients over the last 6 months.

1. Each client is checked by someone independent of the caregiver on schedule.

Method. Check each sampled client for check-ins on the schedule.

Evidence to show. Independent check-in record (HC-FRM-004).

Pass when. Every sampled client is checked on schedule.

2. The check covers abuse and neglect.

Method. Check each record for the topics covered.

Evidence to show. Independent check-ins for abuse and neglect (HC-SOP-002).

Pass when. Every record covers abuse and neglect.

3. A concern is reported the same day.

Method. Check each concern for the report date.

Evidence to show. Incident reporting and management (INC-POL-001).

Pass when. Every concern is reported the same day.

Immediate fail (any one means the criterion is not met). A client neglected for weeks with no one noticing.

Why it matters. A criminal record check that matches only a name can miss a person or pick up the wrong one. A check against a unique identifier, such as an ID number, is reliable.

Sample. Review the screening records for 10 caregivers hired in the last 12 months.

1. Each caregiver’s criminal record check is verified against a unique identifier.

Method. Check each sampled record for the identifier used.

Evidence to show. Caregiver screening record (HC-FRM-005).

Pass when. Every sampled record shows a unique identifier.

2. No caregiver is screened on a name match alone.

Method. Check each record for the name-only method.

Evidence to show. Caregiver background screening, registries and recheck (HC-SOP-003).

Pass when. No record is screened on a name match alone.

3. Identity checks are on file for each caregiver.

Method. Check each file for the identity check result.

Evidence to show. Staff verification register (STF-FRM-001).

Pass when. Every file shows the identity check.

Immediate fail (any one means the criterion is not met). A caregiver hired on a name match with a different person’s record.

Why it matters. A caregiver may have worked abroad, where an abuse record is held in another country. Checking the registries of every country where they lived or worked finds those records.

Sample. Review the registry checks for 10 caregivers who have worked in more than one country.

1. Abuse and neglect registries are checked for each country worked.

Method. Check each caregiver with a multi-country history for each registry.

Evidence to show. Caregiver screening record (HC-FRM-005).

Pass when. Every country worked has its registry checked.

2. Where no registry exists, another reliable check is recorded.

Method. Check each country without a registry for the alternative.

Evidence to show. Caregiver background screening, registries and recheck (HC-SOP-003).

Pass when. Every such country has an alternative recorded.

3. The check is on file before the first visit.

Method. Check each file for the date of the check against the start date.

Evidence to show. Caregiver screening record (HC-FRM-005).

Pass when. Every check is dated before the first visit.

Immediate fail (any one means the criterion is not met). A caregiver with an abuse record abroad, hired without a check.

Why it matters. Some countries keep a list of people barred from working in care. Those lists are separate from the criminal record and must be checked on their own.

Sample. Review the exclusion registry checks for 10 caregivers.

1. Every caregiver is checked against the exclusion registry where one exists.

Method. Check each caregiver record for the exclusion registry check.

Evidence to show. Caregiver screening record (HC-FRM-005).

Pass when. Every caregiver record shows the check.

2. Where no registry exists, the service verifies history with prior employers.

Method. Check each country without a registry for the employer verification.

Evidence to show. Caregiver background screening, registries and recheck (HC-SOP-003).

Pass when. Every such case has an employer verification.

3. A general criminal record check is not used as a substitute.

Method. Check the procedure for the separate exclusion check.

Evidence to show. Caregiver background screening, registries and recheck (HC-SOP-003).

Pass when. The procedure requires the separate check.

Immediate fail (any one means the criterion is not met). A barred caregiver hired because the exclusion list was never looked at.

Why it matters. A caregiver who was clear when hired may not be clear later. Screening repeated on a set schedule keeps the checks current.

Sample. Review the screening schedule and the recheck records for 10 active caregivers.

1. Screening is repeated on a defined schedule.

Method. Check the schedule against each caregiver’s last check.

Evidence to show. Caregiver background screening, registries and recheck (HC-SOP-003).

Pass when. The schedule is defined.

2. Each active caregiver is rechecked on schedule.

Method. Check each sampled caregiver against the schedule.

Evidence to show. Caregiver screening record (HC-FRM-005).

Pass when. Every sampled caregiver is rechecked on schedule.

3. The next recheck date is recorded.

Method. Check each record for the next date.

Evidence to show. Caregiver screening record (HC-FRM-005).

Pass when. Every record shows the next recheck date.

Immediate fail (any one means the criterion is not met). A caregiver working for five years on a check from hiring.

Why it matters. A criminal record does not always mean a person cannot work safely. Each finding should be looked at individually, for its real relevance to the job, rather than an automatic refusal.

Sample. Review every criminal history finding in the last 12 months and the decision recorded.

1. Each finding is assessed for its relevance to care work.

Method. Check each finding for the assessment recorded.

Evidence to show. Individualised assessment of criminal history findings (HC-POL-002).

Pass when. Every finding has an assessment.

2. The assessment considers nature, age and relevance.

Method. Check each assessment for the three factors.

Evidence to show. Individualised assessment of criminal history findings (HC-POL-002).

Pass when. Every assessment covers the three factors.

3. No refusal is automatic.

Method. Check each refusal for the individual reasoning.

Evidence to show. Caregiver screening record (HC-FRM-005).

Pass when. Every refusal has individual reasoning recorded.

Immediate fail (any one means the criterion is not met). A person refused automatically for an old, unrelated finding.

Why it matters. A home that has loose rugs, poor lighting or a slippery bathroom is a risk to the client before care even starts. A structured assessment before the first visit finds those risks.

Sample. Review the home safety assessments for 10 clients, and walk through 3 homes.

1. A structured assessment is done before care begins.

Method. Check each sampled home for the assessment date against the start date.

Evidence to show. Home safety assessment record (HC-FRM-006).

Pass when. Every sampled home is assessed before care begins.

2. The assessment covers flooring, lighting, stairs, bathroom and pathways.

Method. Check each assessment for the five areas.

Evidence to show. Home environment safety assessment and remediation (HC-SOP-004).

Pass when. Every assessment covers the five areas.

3. The walk-through matches the assessment.

Method. Compare the walk-through with the assessment for hazards.

Evidence to show. Home safety assessment record (HC-FRM-006).

Pass when. No hazard seen on the walk-through is missing from the assessment.

Immediate fail (any one means the criterion is not met). Care started in a home with stairs and no handrail, no assessment done.

Why it matters. A hazard found in a home that is noted and then forgotten still puts the client at risk. Each hazard needs a named action and a check that it was fixed.

Sample. Review the hazard remediation register for the last 12 months.

1. Each hazard leads to a specific action.

Method. Check each hazard for the action recorded.

Evidence to show. Home hazard remediation register (HC-REG-001).

Pass when. Every hazard has an action.

2. Each hazard has a responsible person and a deadline.

Method. Check each hazard for the person and deadline.

Evidence to show. Home hazard remediation register (HC-REG-001).

Pass when. Every hazard has a person and a deadline.

3. Hazards are remediated within the deadline.

Method. Check each hazard against its deadline and remediation date.

Evidence to show. Home hazard remediation register (HC-REG-001).

Pass when. At least 90% are remediated on time.

Immediate fail (any one means the criterion is not met). A loose stair rail noted on three visits and never fixed.

Why it matters. A fall at home is a turning point. It often means the client needs a different level of care. A structured reassessment after each fall finds the cause and what must change.

Sample. Review the falls records for 10 clients who fell in the last 12 months.

1. Each fall triggers a structured reassessment.

Method. Check each fall for the reassessment recorded.

Evidence to show. Falls Risk Assessment and Prevention (PSF-SOP-001).

Pass when. Every fall has a reassessment.

2. The reassessment covers the home environment and client risk factors.

Method. Check each reassessment for both.

Evidence to show. Falls Risk Assessment Tool (PSF-FRM-002).

Pass when. Every reassessment covers both.

3. The care plan is changed after repeated falls.

Method. Check each client with repeated falls for the plan change.

Evidence to show. Falls Log (PSF-FRM-001).

Pass when. Every client with repeated falls has a changed plan.

Immediate fail (any one means the criterion is not met). A client falling three times in a month with the care plan unchanged.

Why it matters. A home changes over time: a new rug, a new bed, a new family member. A periodic reassessment, not only at the start, catches new hazards.

Sample. Review the reassessment records for 10 long-running clients.

1. The home is reassessed on a defined schedule.

Method. Check the schedule against each home’s reassessment dates.

Evidence to show. Home environment safety assessment and remediation (HC-SOP-004).

Pass when. The schedule is defined.

2. Each sampled home is reassessed on schedule.

Method. Check each sampled home against the schedule.

Evidence to show. Home safety assessment record (HC-FRM-006).

Pass when. Every sampled home is reassessed on schedule.

3. Changes in the home are recorded.

Method. Check each reassessment for changes recorded.

Evidence to show. Home safety assessment record (HC-FRM-006).

Pass when. Every reassessment records any change.

Immediate fail (any one means the criterion is not met). A home unchecked for two years while the client’s needs grew.

Why it matters. If a client collapses in a home where the door is locked or the code has changed, the ambulance may not get in. A verified plan for emergency access saves minutes that matter.

Sample. Review the emergency access arrangement for 10 clients.

1. A verified access arrangement exists for each home.

Method. Check each sampled home for the arrangement recorded.

Evidence to show. Emergency access arrangement record (HC-FRM-007).

Pass when. Every sampled home has an arrangement.

2. The arrangement is checked.

Method. Check each record for the date it was checked.

Evidence to show. Emergency access arrangement record (HC-FRM-007).

Pass when. Every arrangement has a recent check date.

3. Responders can enter when the client cannot reach the door.

Method. Test the access route for a sample of homes with the agency.

Evidence to show. Emergency access arrangement record (HC-FRM-007).

Pass when. The test shows access is possible.

Immediate fail (any one means the criterion is not met). An ambulance crew unable to enter a home for ten minutes.

Why it matters. Reminding a client to take a medicine is different from giving it. A non-clinical caregiver may remind, but only a trained person may give or manage a medicine. Confusing the two causes harm.

Sample. Review the task list for each caregiver and observe 3 medicine tasks.

1. Reminders and administration are separated in the policy.

Method. Check the policy for the separation.

Evidence to show. Medication reminders and administration in the home (HC-POL-003).

Pass when. The policy separates the two.

2. Each caregiver performs only tasks within their scope.

Method. Check each observed medicine task against the scope.

Evidence to show. Medication reminders and administration in the home (HC-POL-003).

Pass when. Every observed task is within scope.

3. Tasks beyond scope are refused and reported.

Method. Check each recorded refusal for the report.

Evidence to show. Incident reporting and management (INC-POL-001).

Pass when. Every refusal is reported.

Immediate fail (any one means the criterion is not met). An untrained caregiver giving an injection.

Why it matters. When a client’s medicines are on several lists, the GP, the pharmacy and the caregiver may each have a different version. One current list, shared with everyone, prevents the mix-ups that cause harm.

Sample. Review the shared medication list for 10 clients, against the medicines at home.

1. One current medication list exists for each client.

Method. Check each sampled client for one list.

Evidence to show. Shared medication list (HC-FRM-008).

Pass when. Every sampled client has one list.

2. The list is shared with everyone involved.

Method. Check each list for the people it is shared with.

Evidence to show. Shared medication list (HC-FRM-008).

Pass when. Every list shows the people it is shared with.

3. The list matches the medicines in the home.

Method. Compare each list with the medicines found in the home.

Evidence to show. Medicine reconciliation form (LTC-FRM-002).

Pass when. No mismatch is found in the sample.

Immediate fail (any one means the criterion is not met). Two different medicine lists in the home and the client taking the wrong dose.

Why it matters. The most dangerous moments for medicines are changes: a hospital discharge, a new prescriber, a change of dose. Reconciling the list at those points catches the error.

Sample. Review 10 medicine changes and care transitions in the last 12 months.

1. Each change or transition triggers a structured review.

Method. Check each change for the review recorded.

Evidence to show. Medication changes, transitions and missed doses (HC-SOP-005).

Pass when. Every change has a review recorded.

2. The review covers the complete regimen.

Method. Check each review for the full regimen.

Evidence to show. Medicine reconciliation at admission, transfer and discharge (LTC-SOP-002).

Pass when. Every review covers the full regimen.

3. The shared list is updated at each change.

Method. Check the list date against each change.

Evidence to show. Shared medication list (HC-FRM-008).

Pass when. Every change is on the list on the same day.

Immediate fail (any one means the criterion is not met). A hospital discharge with a new drug not added to the home list.

Why it matters. Medicines for different people in the same home can be mixed up, especially by an aide who is not familiar with the household. Storing each person’s medicines separately prevents that.

Sample. Review the medicine storage in 5 multi-person households.

1. Each person’s medicines are stored separately.

Method. Observe the storage in each sampled home.

Evidence to show. Medicines in multi-person households (HC-SOP-006).

Pass when. Every sampled home stores them separately.

2. Medicines are labelled with the owner’s name.

Method. Check each sampled label.

Evidence to show. Medicines in multi-person households (HC-SOP-006).

Pass when. Every sampled label shows the owner.

3. Controlled medicines are stored securely and recorded.

Method. Check the controlled medicines register for each home.

Evidence to show. Controlled medicines register (PHM-FRM-002).

Pass when. Every controlled medicine is recorded.

Immediate fail (any one means the criterion is not met). A husband’s heart tablets given to his wife.

Why it matters. A missed dose can cause serious harm, and an uncertain dose can lead to a double dose. A clear follow-up for each missed or uncertain dose protects the client.

Sample. Review the missed-dose records for the last 6 months.

1. Each missed or uncertain dose is followed up.

Method. Check each missed dose for the follow-up recorded.

Evidence to show. Medication changes, transitions and missed doses (HC-SOP-005).

Pass when. Every missed dose has a follow-up.

2. The follow-up is the same day.

Method. Check each follow-up for the time against the missed dose.

Evidence to show. Medication changes, transitions and missed doses (HC-SOP-005).

Pass when. At least 95% are followed up the same day.

3. Anticoagulant and other high-risk doses are prioritised.

Method. Check each high-risk missed dose for the priority follow-up.

Evidence to show. Incident reporting and management (INC-POL-001).

Pass when. Every high-risk missed dose is followed up at once.

Immediate fail (any one means the criterion is not met). An anticoagulant missed for a week with no one noticing.

Why it matters. Before a caregiver goes into a home, the risk to them and to the client must be known: who lives there, whether there is violence, and what is in the home. The assessment comes first.

Sample. Review the pre-visit risk assessments for 10 new assignments.

1. Each home is risk-assessed before the first visit.

Method. Check each assignment for the assessment date against the first visit.

Evidence to show. Pre-visit home risk assessment (HC-FRM-009).

Pass when. Every assignment is assessed before the first visit.

2. The assessment covers household members and known risk.

Method. Check each assessment for household and known risk.

Evidence to show. Caregiver safety in private homes (HC-POL-004).

Pass when. Every assessment covers household and known risk.

3. No caregiver is sent to a home with a known risk and no assessment.

Method. Check each known risk for an assessment on file.

Evidence to show. Caregiver safety in private homes (HC-POL-004).

Pass when. Every known risk has an assessment.

Immediate fail (any one means the criterion is not met). A caregiver sent to a home with a known violent member and no assessment.

Why it matters. Caregivers work alone in homes they do not control, and violence is a real risk. A prevention programme that fits the home setting, not a hospital, protects them.

Sample. Review the violence prevention programme and its training records.

1. A violence prevention programme exists for the home setting.

Method. Check the programme for home-based adaptation.

Evidence to show. Caregiver safety in private homes (HC-POL-004).

Pass when. The programme covers the home setting.

2. Caregivers working alone are trained.

Method. Check the training records for each caregiver.

Evidence to show. Violence and aggression prevention and response (WRK-SOP-006).

Pass when. Every caregiver has training recorded.

3. Incidents are tracked and reviewed.

Method. Check the incident log for the review.

Evidence to show. Violence and aggression incident record (WRK-FRM-003).

Pass when. Every incident is tracked and reviewed.

Immediate fail (any one means the criterion is not met). A caregiver attacked in a home with no programme and no training.

Why it matters. A caregiver alone in a home who feels threatened needs a way to ask for help without the client or family knowing. A discreet signal, and a plan for it, keeps them safe.

Sample. Review the distress signal arrangements for 10 caregivers.

1. Each caregiver has a discreet way to signal distress.

Method. Check each caregiver record for the signal arrangement.

Evidence to show. Caregiver safety and distress signalling (HC-POL-005).

Pass when. Every caregiver has a signal.

2. Each signal is responded to at once.

Method. Check each recorded signal for the response time.

Evidence to show. Lone-worker check-in log (MOB-FRM-004).

Pass when. Every signal is responded to at once.

3. The signal does not alert the household.

Method. Check the signal method in the policy.

Evidence to show. Caregiver safety and distress signalling (HC-POL-005).

Pass when. The method is discreet by design.

Immediate fail (any one means the criterion is not met). A caregiver threatened with no way to call for help.

Why it matters. A dog that bites, a broken stair or a chemical left on a shelf are hazards that a caregiver meets in homes but never in a hospital. These need to be named and managed.

Sample. Review the home risk assessments for 10 homes with animals or outdoor work.

1. Hostile or unpredictable animals are assessed.

Method. Check each sampled home for the animal assessment.

Evidence to show. Pre-visit home risk assessment (HC-FRM-009).

Pass when. Every sampled home has the animal check.

2. Lighting, walking and temperature hazards are assessed.

Method. Check each sampled home for the environmental hazards.

Evidence to show. Pre-visit home risk assessment (HC-FRM-009).

Pass when. Every sampled home has the hazards checked.

3. Each caregiver is told of the hazards before the visit.

Method. Check each sampled caregiver for the briefing.

Evidence to show. Caregiver safety in private homes (HC-POL-004).

Pass when. Every caregiver is briefed before the first visit.

Immediate fail (any one means the criterion is not met). A caregiver bitten by a dog the agency knew about.

Why it matters. A near-miss is a warning. A caregiver who nearly fell, or nearly gave the wrong medicine, has shown where the risk is. Recording it and changing the risk assessment prevents the real event.

Sample. Review the near-miss reports for the last 12 months and the risk assessments updated.

1. Near-misses are reported by caregivers.

Method. Check the reporting log for near-miss reports.

Evidence to show. Incident reporting and management (INC-POL-001).

Pass when. Near-misses are reported.

2. Each near-miss updates the risk assessment.

Method. Check each near-miss for the assessment update.

Evidence to show. Pre-visit home risk assessment (HC-FRM-009).

Pass when. Every near-miss updates the assessment.

3. Near-misses are reviewed at governance.

Method. Check the governance minutes for the near-miss review.

Evidence to show. Governing Body Minutes Template (GOV-FRM-003).

Pass when. Near-misses are reviewed at each governance meeting.

Immediate fail (any one means the criterion is not met). A caregiver who nearly fell on the same stair three times with no report.

Why it matters. A supervisor who never enters the home cannot see how care is given. Supervisory visits on site, on a schedule, are the only way to check the care that is delivered.

Sample. Review the supervisory visit records for 10 clients over the last 12 months.

1. Supervisory visits are on-site, in person.

Method. Check each visit record for the in-person entry.

Evidence to show. Supervisory visits in the home (HC-SOP-008).

Pass when. Every visit is in person.

2. Visits follow the schedule for the level of care.

Method. Check each client against the schedule.

Evidence to show. Supervisory visit record (HC-FRM-010).

Pass when. At least 95% of visits are on schedule.

3. Visits are not replaced by phone calls.

Method. Check each record for a phone call used as the visit.

Evidence to show. Supervisory visits in the home (HC-SOP-008).

Pass when. No visit is a phone call.

Immediate fail (any one means the criterion is not met). A client with a care plan never visited by a supervisor in a year.

Why it matters. When a client receives only personal care, the aide is alone with them for every task. A supervisor must observe the aide giving that care, not only read about it.

Sample. Review the supervisory visits for 10 clients who receive personal care only.

1. The visit includes observing the caregiver giving care.

Method. Check each visit for the observation recorded.

Evidence to show. Supervisory visit record (HC-FRM-010).

Pass when. Every visit records an observation.

2. The caregiver is present during the observation.

Method. Check each observation for the caregiver present.

Evidence to show. Supervisory visit record (HC-FRM-010).

Pass when. Every observation shows the caregiver present.

3. Care is assessed as delivered.

Method. Check each observation for the measured aspects.

Evidence to show. Supervisory visits in the home (HC-SOP-008).

Pass when. Every observation records the aspects assessed.

Immediate fail (any one means the criterion is not met). An aide giving personal care for a year with no one watching.

Why it matters. A supervision note that says ‘visit went well’ tells no one anything. Objective, measurable observations allow the next supervisor to see a change over time.

Sample. Review 10 supervisory visit records for the quality of observations.

1. Observations are objective and measurable.

Method. Check each record for measured observations.

Evidence to show. Supervisory visit record (HC-FRM-010).

Pass when. Every record has measured observations.

2. General statements alone are not accepted.

Method. Check each record for statements without data.

Evidence to show. Supervisory visit record (HC-FRM-010).

Pass when. No record relies on a general statement alone.

3. The record can be compared with the next visit.

Method. Check each record for comparable measures.

Evidence to show. Supervisory visit record (HC-FRM-010).

Pass when. Records use the same measures over time.

Immediate fail (any one means the criterion is not met). A visit recorded as ‘satisfactory’ with no detail.

Why it matters. A client’s needs change: a service is no longer needed, or a new need appears. The care plan must change with them, or the care no longer fits.

Sample. Review the care plans for 10 clients with a change in need in the last 12 months.

1. A change in need triggers a care plan review.

Method. Check each recorded change for the review.

Evidence to show. Individualised care planning (CLN-SOP-002).

Pass when. Every change has a review.

2. The plan is updated after review.

Method. Check each reviewed plan for the update date.

Evidence to show. Individual care plan (CLN-FRM-003).

Pass when. Every reviewed plan is updated.

3. Responsibility shifts are recorded.

Method. Check each change for the responsibility recorded.

Evidence to show. Individual care plan (CLN-FRM-003).

Pass when. Every shift in responsibility is recorded.

Immediate fail (any one means the criterion is not met). A client with new continence needs given the same plan for three months.

Why it matters. A deficiency found in supervision is only useful if it leads to retraining and a re-check. Without that follow-through the same problem returns.

Sample. Review the caregiver deficiency records and retraining records for the last 12 months.

1. Each deficiency leads to documented retraining.

Method. Check each deficiency for the retraining recorded.

Evidence to show. Annual competency assessment procedure (WRK-SOP-001).

Pass when. Every deficiency has retraining recorded.

2. A competency evaluation is done before independent care resumes.

Method. Check each retrained caregiver for the evaluation before independent work.

Evidence to show. Competency assessment form by role (WRK-FRM-001).

Pass when. Every caregiver is evaluated before independent work.

3. No caregiver works independently without confirmed correction.

Method. Check each caregiver for independent work after a deficiency.

Evidence to show. Competency assessment form by role (WRK-FRM-001).

Pass when. No caregiver works independently without confirmed correction.

Immediate fail (any one means the criterion is not met). A caregiver who failed a technique check three times with no retraining.

Why it matters. A client served by one caregiver who falls sick or goes on leave is left with no care. A written cover plan keeps the client safe in the absence.

Sample. Review the coverage plans for 10 clients served by a single caregiver.

1. A coverage arrangement exists for each solo-caregiver client.

Method. Check each sampled client for the coverage plan.

Evidence to show. Solo caregiver coverage plan (HC-PLN-001).

Pass when. Every sampled client has a plan.

2. A named alternative is recorded.

Method. Check each plan for the named alternative.

Evidence to show. Solo caregiver coverage plan (HC-PLN-001).

Pass when. Every plan names an alternative.

3. The plan is tested.

Method. Check each plan for the test date.

Evidence to show. Coverage for a solo caregiver’s absence (HC-SOP-009).

Pass when. Every plan has a test date.

Immediate fail (any one means the criterion is not met). A client left without any care for two days when the only caregiver was sick.

Why it matters. A client who sees a different caregiver each day is less safe and less well cared for. Tracking continuity and giving priority to clients with the greatest need keeps the same person coming.

Sample. Review the continuity register for the highest-need clients over the last 6 months.

1. Caregiver continuity is tracked for each client.

Method. Check each sampled client in the register.

Evidence to show. Caregiver continuity register (HC-REG-003).

Pass when. Every sampled client is tracked.

2. Priority is given to the highest-need clients.

Method. Check the review order against need level.

Evidence to show. Caregiver continuity register (HC-REG-003).

Pass when. High-need clients are reviewed first.

3. Clients above the agreed number of caregivers are flagged and acted on.

Method. Check each flag for the action recorded.

Evidence to show. Caregiver continuity register (HC-REG-003).

Pass when. Every flag has an action recorded.

Immediate fail (any one means the criterion is not met). A dementia client seeing six caregivers in a week.

Why it matters. New caregivers often leave in the first months, which costs the client continuity and the agency money. Structured attention in those first weeks helps them stay.

Sample. Review the first 100 days records for 10 new caregivers.

1. Each new caregiver has structured support in the first 100 days.

Method. Check each sampled caregiver for the support recorded.

Evidence to show. First 100 days check-in record (HC-FRM-011).

Pass when. Every sampled caregiver has support recorded.

2. Check-ins are held at each set point.

Method. Check each caregiver for the check-in dates.

Evidence to show. New caregiver support in the first 100 days (HC-SOP-010).

Pass when. At least 90% have all check-ins.

3. Reasons for leaving are recorded.

Method. Check each leaver for the reason recorded.

Evidence to show. First 100 days check-in record (HC-FRM-011).

Pass when. Every leaver has a reason recorded.

Immediate fail (any one means the criterion is not met). A new caregiver who left after a week with no contact from the agency.

Why it matters. A caregiver who works alone for hours can become isolated and unsupported, which affects their health and the care they give. Regular supervisor contact and peer support counter the isolation.

Sample. Review the contact records for 10 caregivers who work alone.

1. Each caregiver has regular supervisor contact.

Method. Check each caregiver for the contact log.

Evidence to show. Lone-worker check-in and response (MOB-SOP-002).

Pass when. Every caregiver has regular contact.

2. Peer connection is arranged.

Method. Check each caregiver for peer connection in the period.

Evidence to show. Lone-worker check-in and discreet distress signal (HC-SOP-007).

Pass when. Every caregiver has peer connection in the period.

3. Missed check-ins are followed up the same day.

Method. Check each missed check-in for the same-day follow-up.

Evidence to show. Lone-worker check-in and response (MOB-SOP-002).

Pass when. Every missed check-in is followed up the same day.

Immediate fail (any one means the criterion is not met). A caregiver alone for a year with no contact with the agency.

Why it matters. In a home where no one else is present, a problem can go unnoticed for days. Incident reporting must allow for that delay, and not assume a problem was reported at once.

Sample. Review the incident records for the last 12 months, including late-discovered incidents.

1. Delayed-discovery incidents are reported on discovery.

Method. Check each late-discovered incident for the discovery date.

Evidence to show. Incident reporting for delayed discovery in the home (HC-SOP-011).

Pass when. Every late-discovered incident is reported on discovery.

2. The estimated time of the event is recorded.

Method. Check each record for the estimated time.

Evidence to show. Incident reporting for delayed discovery in the home (HC-SOP-011).

Pass when. Every record has an estimated time.

3. Delayed discovery is reviewed without blame by default.

Method. Check each review for the blame approach.

Evidence to show. Root cause analysis of serious incidents (INC-SOP-001).

Pass when. Reviews do not assign default blame.

Immediate fail (any one means the criterion is not met). A fall discovered the next morning recorded as the caregiver’s fault for not reporting at once.

Why it matters. A client who has fled violence or displacement may carry trauma that changes how they respond to care in their own home. Care that is adapted to that experience is safer and more respectful.

Sample. Review the care records for 10 clients with a migration or displacement history.

1. Care is adapted to the migration and displacement history.

Method. Check each sampled record for the history and the adaptation.

Evidence to show. Migration history and trauma-aware assessment record (HMG-FRM-001).

Pass when. Every sampled record shows the adaptation.

2. Trauma-informed practice is applied.

Method. Observe a sample of visits for trauma-informed practice.

Evidence to show. Migration-informed, trauma-aware care (HMG-POL-001).

Pass when. Observed visits follow trauma-informed practice.

3. Legal-status barriers to access are identified.

Method. Check each record for the barrier check.

Evidence to show. Migration history and trauma-aware assessment record (HMG-FRM-001).

Pass when. Every record shows the barrier check.

Immediate fail (any one means the criterion is not met). A caregiver entering the room of a traumatised client without asking.

Why it matters. A caregiver who spends every day with a client needs a way to communicate that goes beyond a few words. A plan for language support, that lasts across the whole relationship, keeps care understandable.

Sample. Review language support arrangements for 10 clients with a language need.

1. Language support is planned for daily interaction.

Method. Check each sampled client for the daily language plan.

Evidence to show. Interpreter and mediator use (PTR-SOP-010).

Pass when. Every sampled client has a daily plan.

2. Interpreter access is not limited to occasional use.

Method. Check the support arrangement for daily access.

Evidence to show. Interpreter and mediator use (PTR-SOP-010).

Pass when. The arrangement provides daily access.

3. Pain and symptoms are communicated.

Method. Check each record for the communication of pain.

Evidence to show. Individual care plan (CLN-FRM-003).

Pass when. Every record shows pain is communicated.

Immediate fail (any one means the criterion is not met). A client who could not explain pain to a caregiver for weeks.

Why it matters. A client’s home is their most important space, and their cultural and religious practices belong there. Respecting them, including food, prayer and dress, is part of their dignity.

Sample. Review the care plans for 10 clients with cultural or religious practices.

1. Dietary, prayer and gender preferences are recorded.

Method. Check each sampled plan for the practices.

Evidence to show. The client’s home and household routines (HC-POL-001).

Pass when. Every sampled plan records the practices.

2. The practices are followed in the home.

Method. Observe a sample of visits for the practices followed.

Evidence to show. The client’s home and household routines (HC-POL-001).

Pass when. Observed visits follow the practices.

3. Personal items are not removed.

Method. Check the visit notes for any removal of personal items.

Evidence to show. Non-Discrimination and Equal Access to Care (CON-POL-002).

Pass when. No visit note records removal.

Immediate fail (any one means the criterion is not met). A caregiver removing religious objects from the client’s room.

Why it matters. A caregiver who is not legally authorised to work may be exploited and may put the client at risk if they have to leave. Verifying work authorisation in the same way as for any employee protects both.

Sample. Review the work authorisation checks for 10 caregivers hired in the last 12 months.

1. Each caregiver’s work authorisation is verified.

Method. Check each sampled file for the verification.

Evidence to show. Staff credential verification and recheck (STF-SOP-001).

Pass when. Every sampled file shows verification.

2. The same standard check applies to all applicants.

Method. Compare the checks applied across applicants.

Evidence to show. Staff credential verification and recheck (STF-SOP-001).

Pass when. The same check is recorded for each applicant.

3. No caregiver is scrutinised on origin or accent.

Method. Check the hiring records for any origin-based scrutiny.

Evidence to show. Non-Discrimination and Equal Access to Care (CON-POL-002).

Pass when. No record shows scrutiny on origin or accent.

Immediate fail (any one means the criterion is not met). A caregiver working without authorisation and paid cash.

Why it matters. A caregiver whose own work permit is about to expire can lose their job suddenly, which leaves the client without care. Planning ahead for a change in status protects both.

Sample. Review the authorisation changes for caregivers in the last 12 months.

1. Each authorisation change is tracked before it takes effect.

Method. Check each change for an early tracking date.

Evidence to show. Caregiver work authorisation change: transition support (HC-SOP-012).

Pass when. Every change is tracked early.

2. A transition period and client cover are in place.

Method. Check each change for the transition plan.

Evidence to show. Caregiver work authorisation change: transition support (HC-SOP-012).

Pass when. Every change has a transition plan.

3. No caregiver is stopped the same day without a plan.

Method. Check each stop for a same-day termination.

Evidence to show. Caregiver work authorisation change: transition support (HC-SOP-012).

Pass when. No same-day stop occurs without a plan.

Immediate fail (any one means the criterion is not met). A caregiver’s permit expired and they stopped work the same day, leaving a client alone.

Why it matters. Immigrant caregivers often stay longer in the job than others, which gives continuity to clients. That advantage should be recognised and supported, not overlooked.

Sample. Review the workforce equity register and the turnover data for immigrant caregivers.

1. Retention among immigrant caregivers is measured.

Method. Check the register for the measure.

Evidence to show. Workforce equity register (WRK-REG-003).

Pass when. The register measures retention by group.

2. Precarious employment practices are reviewed.

Method. Check the review record for precarious terms.

Evidence to show. Workforce equity monitoring (WRK-SOP-009).

Pass when. The review covers employment terms.

3. The retention advantage is acted on.

Method. Check the action record for the advantage.

Evidence to show. Workforce equity monitoring (WRK-SOP-009).

Pass when. An action is recorded for the advantage.

Immediate fail (any one means the criterion is not met). A service with high turnover that never looked at who stayed.

Why it matters. Clients may be asylum seekers, refugees, stateless people or migrants, with different rights to care. The service needs to know which groups it serves so the right care is given.

Sample. Review the client records for legal status categories and the rights guidance used.

1. The service names the legal status categories of its clients.

Method. Check the guidance for the categories named.

Evidence to show. Migration-informed, trauma-aware care (HMG-POL-001).

Pass when. The guidance names the categories.

2. Access rights are not assumed uniform.

Method. Check the staff guidance for the different rights.

Evidence to show. Interpreter and mediator use (PTR-SOP-010).

Pass when. The guidance states the different rights.

3. Staff know the rights for each category.

Method. Check the training record for the rights training.

Evidence to show. Migration-informed, trauma-aware care (HMG-POL-001).

Pass when. Staff training covers each category.

Immediate fail (any one means the criterion is not met). A stateless client turned away because staff did not know their rights.

Why it matters. Care must be given to every client, whatever their immigration status. Documenting it fully protects the client and the caregiver who gave it.

Sample. Review the care and documentation records for 10 clients, regardless of status.

1. Care is provided regardless of immigration status.

Method. Check each sampled client for care delivered.

Evidence to show. Non-Discrimination and Equal Access to Care (CON-POL-002).

Pass when. Every sampled client receives care.

2. Documentation is the same for every client.

Method. Compare the documentation across status groups.

Evidence to show. Migration-informed, trauma-aware care (HMG-POL-001).

Pass when. Documentation does not differ by status.

3. No lesser standard applies to undocumented clients.

Method. Check the referral and refusal records for status-based refusal.

Evidence to show. Non-Discrimination and Equal Access to Care (CON-POL-002).

Pass when. No referral or refusal is status-based.

Immediate fail (any one means the criterion is not met). A client refused home care because they had no papers.

Why it matters. Bias can shape how staff treat immigrant caregivers as well as clients. Reflective practice that covers both keeps the workforce and the care fair.

Sample. Review the staff reflective practice records and the rota allocation for immigrant caregivers.

1. Reflective practice covers how immigrant caregivers are treated.

Method. Check the reflective practice agenda for caregiver treatment.

Evidence to show. Speak-up policy (WRK-POL-005).

Pass when. The agenda covers caregiver treatment.

2. Hardest rounds are not given on origin.

Method. Check the rota for the allocation of difficult rounds.

Evidence to show. Workforce equity monitoring (WRK-SOP-009).

Pass when. Allocation shows no origin-based pattern.

3. Caregivers can raise concerns without retaliation.

Method. Check the speak-up records for protection from retaliation.

Evidence to show. Concern handling and protection from retaliation (WRK-SOP-010).

Pass when. Concerns are raised and protected.

Immediate fail (any one means the criterion is not met). Immigrant caregivers given the hardest rounds without reason.

Why it matters. A migrant or refugee client who moves house must keep their care. Losing a caregiver and a service at a move can leave them without care for weeks.

Sample. Review the relocation records for 10 clients who moved in the last 12 months.

1. A portable care summary is given to the client.

Method. Check each sampled relocation for the summary.

Evidence to show. Portable client care summary (HC-FRM-012).

Pass when. Every sampled relocation has a summary.

2. Active handover occurs where the new provider is known.

Method. Check each relocation for the handover record.

Evidence to show. Continuity of care when a client relocates (HC-SOP-013).

Pass when. Every known provider has a handover recorded.

3. Care continues after the move.

Method. Check each relocated client for care in place at the new address.

Evidence to show. Continuity of care when a client relocates (HC-SOP-013).

Pass when. No relocated client is left without care.

Immediate fail (any one means the criterion is not met). A refugee family moved across the city and left without care for a month.