Dementia Quality Governance: Audit Cycles That Actually Improve Care (Not Just Paperwork)

Dementia services can produce a lot of paperwork and still miss the point: whether support is safe, consistent and person-centred across every shift. The purpose of dementia audit is not “compliance for its own sake” — it is to make care more reliable, reduce avoidable harm, and prove that learning translates into improved outcomes and experience. If your audits do not change practice, they are activity, not assurance.

This article sits in Dementia – Quality, Safety & Governance and should be used alongside Dementia – Service Models & Care Pathways, because what “good” looks like must reflect the service model (homecare, residential, supported living, step-down, integrated community pathways) while still meeting the same governance expectations.

What a dementia audit cycle should achieve

A defensible dementia audit cycle should be able to answer three questions:

• Are we delivering what we promised? (care planning, routines, meaningful activity, safe medicines, responsive support)
• Are we identifying risk early? (falls patterns, weight loss, dehydration, distress escalation, safeguarding indicators)
• Are we improving? (trend analysis, actions completed, measurable change over time)

To do this, audits must be focused, sampled properly, and linked to action tracking. “Audit completed” is not evidence of quality. “Audit completed, actions implemented, outcomes improved” is evidence.

Commissioner expectation: demonstrable assurance and continuous improvement

Commissioner expectation: commissioners generally expect dementia providers to show that quality assurance is routine and effective. In practical terms this means:

• A planned audit schedule (what, when, who, and how you sample).
• Clear escalation routes when audits identify risk.
• Evidence of learning and improvement (not just findings).
• Outcomes and performance evidence that supports contract KPIs (safety, continuity, stability, avoidable escalation).

If a provider cannot show improvement cycles, commissioners may see the service as “high risk” even if current incidents are low.

Regulator / Inspector expectation: audit findings match observed practice

Regulator / Inspector expectation (CQC): inspectors will compare audit claims with what they observe and what staff describe. CQC confidence increases when:

• Audits are specific to dementia practice (not generic).
• Managers can explain “what changed because of this audit”.
• Actions are tracked to completion with evidence.
• People’s experience is visible in records (not just clinical or task notes).

In dementia services, CQC will often probe distress management, communication approaches, dignity, medicines safety and restrictive practice review, because these are high-impact risk areas.

What to audit in dementia services (the areas that matter most)

Rather than auditing everything, prioritise audits that directly affect safety and quality of life:

1) Care planning quality and personalisation

Sample whether care plans are dementia-specific, describing triggers, routines, communication, meaningful activity, risk enablement and family involvement. Check that plans are updated after significant changes.

2) Distress, behaviour support and de-escalation practice

Audit whether staff record “what happened” and “what worked” — not just “agitated”. Evidence should show proactive support, not reactive containment.

3) Medicines and administration reliability

Audit MAR completion, error reporting, PRN governance (where used), capacity and consent considerations, and how side effects or refusal are managed safely.

4) Falls, frailty and deterioration pathways

Audit fall records for patterns, action taken, and whether clinical escalation is documented. In homecare, this includes environment checks and moving and handling approach.

5) Safeguarding thresholds and follow-through

Audit whether concerns are escalated appropriately, recorded factually, and linked to care plan and risk updates after outcomes are known.

How to sample so audits are credible

Sampling matters. A dementia audit that only reviews “easy” cases will not reassure commissioners or CQC. Practical sampling principles include:

• Rotate across shifts (weekday/weekend, day/night, agency cover periods).
• Include high-risk cohorts (history of falls, distress, safeguarding vulnerability, medicines complexity).
• Mix record review and observation (paper evidence plus what you see staff do).
• Include at least one “edge case” each cycle (complex decision-making where governance is tested).

Small, frequent samples are often more effective than large quarterly audits that arrive too late to prevent harm.

Operational Example 1: Audit cycle that improved dementia care planning quality

Context: A service had care plans that were technically complete but not operationally useful. Staff relied on memory and informal handovers, increasing inconsistency.

Support approach: The provider introduced a monthly dementia care planning audit with a focused scoring rubric.

Day-to-day delivery detail:

• Managers sampled 6 care plans monthly across different teams and shifts.
• They scored specific dementia indicators: triggers, calming approaches, communication, meaningful activity, family involvement, and review dates.
• Where gaps were found, staff received immediate coaching and a clear deadline to update plans.

How effectiveness is evidenced: Within two cycles, audit scores improved, staff reported fewer “unknown triggers” incidents, and records showed clearer personalised routines. The service could evidence an improvement trend rather than one-off fixes.

Operational Example 2: Distress audit that reduced incidents and restrictive responses

Context: A residential service had regular low-level distress episodes. Incidents were recorded, but there was little learning and the same issues repeated.

Support approach: A weekly distress audit was introduced to identify patterns and strengthen proactive support.

Day-to-day delivery detail:

• Managers reviewed all distress incidents weekly, looking for triggers and staff responses.
• They tested whether records described “what worked” and whether care plans were updated accordingly.
• They introduced two practice changes: improved early cues recognition and a structured “calm sequence” approach.

How effectiveness is evidenced: The service saw fewer repeat incidents for the same people, reduced use of reactive containment strategies, and stronger evidence of proactive support in daily notes.

Operational Example 3: Medicines audit that prevented repeated errors

Context: A provider identified minor but repeated medicines documentation errors in dementia care, especially during busy periods and staff changes.

Support approach: A targeted medicines audit with rapid corrective action and prevention controls.

Day-to-day delivery detail:

• Weekly MAR sampling focused on high-risk medicines and PRN documentation.
• Errors were logged with root cause notes (time pressure, unclear handover, training gap).
• Actions included refresher training, peer checking during specific rounds, and updated guidance on refusal and capacity considerations.

How effectiveness is evidenced: Error rates reduced over successive weeks and the service could show action completion evidence, not just “training delivered”.

Action tracking: the piece most services miss

Audit without action tracking is where governance collapses. A workable approach is:

• Each audit produces a short action list (owner, deadline, evidence required).
• Actions are reviewed weekly at a governance huddle.
• Completion evidence is stored (updated care plans, supervision notes, training sign-off, new risk controls).
• Trend lines are reviewed monthly to prove improvement.

This turns audits into a living assurance system — the kind commissioners and CQC trust.

---