Audit tools for measuring quality

Members of the National Quality Advisory Group have worked together to produce these hospice audit tools. They can be used for quality improvement and evidence towards compliance with CQC essential standards.

Not all of these tools will continue to be supported by the National Quality Advisory Group. These are identified by **.


1. Create a folder for your audit tool

Create a separate local folder for each of the audit tools you intend to download.

2. Download the audit tool

The new tools are on a single spreadsheet however the older tools are in zip folders. To access these, select your audit tool and download it. Do not enter any data into the audit tool whilst it is still in the Zip file.

You must extract the audit tool.

3. Extract the audit tool

  1. Right click on the downloaded zip file (looks like a folder with a zip on it).
  2. Select ‘extract all’.
  3. Click the ‘next’ button.
  4. Click ‘Browse’ and select the folder you created in stage one.
  5. Select the ‘next’ button to extract the audit tool.

4. Using the audit tool

Open the local folder and read the guidance notes which are in the extracted audit tool folder. If you are in any doubt about these instructions, check with your local information technology (IT) staff.


Treatment and care

  • Management of Pressure Ulcers within the Inpatient Unit (April 2016)
  • Inpatient Admission and Initial Assessment **
  • Day Care Admission and Initial Assessment **
  • Pain Management **
  • Nutrition and Hydration **

Medicines management

  • Controlled Drugs; A Self Assessment Tool for the Accountable Officer (August 2016)
  • Management of Controlled Drugs (October 2016)
  • Management of General Medicines (May 2017)
  • Self Administration of Medicines (May 2014)
  • Medical Gases (January 2016)

End of life

  • Pre-Bereavement Care **
  • Bereavement Support Service **

Community Services

  • Referral and Initial Assessment - Clinical Nurse Specialist (CNS) Team **
  • On-going community support - Clinical Nurse Specialist (CNS) Team **

Children's Hospices

  • Referral, Initial Assessment and Admissions **
  • H&SCA 2008, Code of Practice: Self Assessment **
  • General Medicines **
  • Medical Gases **

Prevention and control of infection

  • H&SCA 2008, Code of Practice: Self Assessment (November 2015) 

Infection Control - 16 modules

  • Policies and protocols (August 2014)
  • Hand hygiene (August 2014)
  • Patient areas (August 2014)
  • Clinical rooms (August 2014)
  • Patient bathrooms (August 2014)
  • Patient toilets/bidets (August 2014)
  • Sluice/dirty utility (August 2014)
  • Domestic rooms (November 2014)
  • Care of deceased patients (November 2014)
  • Sharps (Nov 2016)
  • Protective equipment (November 2014)
  • Kitchen Areas (excluding main kitchen) (November 2014)
  • Public Areas (August 2012) 
  • Toilets for Public Use (August 2012) 
  • Offices within Clinical Areas (August 2012) 
  • Visitors’ Accommodation (August 2012)
  • Infection Control Audit Tool (Summary Sheet) (Nov 2016)

What does hospice care mean to you?