“The care plans had been transferred onto a computerised system [Care Control]. This included people’s specific needs and a flagging system for when a specific task was due. For example, if a person required repositioning or if they had not met their specific hydration target. Senior staff and nurses were able to monitor an overview of what was occurring on each shift. The quality and performance manager also had 24-hour access to monitor what was happening in the home. Staff told is they thought the system [Care Control] was an improvement on the previous paper system.
Some people were having their food and fluid intake monitored. The electronic recording system [Care Control] in place meant there was real time information available to show how much people had eaten and drunk. Monitoring records we looked at showed that people had either met or exceeded their daily targets. When people refused a drink or food, staff had documented this. One member of staff said, “The new [recording] system is great. It means I can see at a glance if people have had enough to drink and if they haven’t, we can act on it straight away.”
“People received personalised care from a stable staff team who knew them well and understood the care they needed. The home used a computerised care planning system [Care Control] which provided a wide range of information about each person’s health and personal care needs. The system [Care Control] enabled the senior staff to monitor people’s care and ensure essential tasks were carried out in accordance with the care plans.
There were systems in place to record and monitor accidents and incidents. A ‘post incident employer log’ was used to record learning from any incidents, and monthly audits of accidents and incidents were used to identify any themes or trends.
The home used an electronic medicine administration system [Care Control eMAR] which reduced the risk of errors and omissions…The system provided additional safeguards to alert staff to any errors or missed dosages.”
“The service had recently implemented an electronic care recording system [Care Control]. This provided a system to store care plans, risk assessments and other important information. The system was also used to record care tasks which had been completed by staff.
Management were provided with real-time information on when reviews of risk assessments and care plans were due, what care tasks had been completed and for whom; amongst other information. Management used this information to ensure records were up to date and to monitor staff performance.
The service had a system [Care Control] to record and analyse any accidents or incidents. This helped to identify and trends or themes.”
“…They had also introduced an electronic care plan system [Care Control]. Staff had trialled some systems before finding the care plan system they felt was right for the home. Care staff we spoke with thought the system [Care Control] was excellent and gave them good information. Care plans we saw were up to date and personal. There was an alert system which helped to make sure people received the care and treatment they needed. For example, if people needed prescribed creams applied, staff were alerted to this until the task had been carried out. There were simple ways for staff to record the food and drink people had and it calculated how much people had each day. Management could easily see the records and make adjustments to care, or seek medical advice, if it was felt there was an issue.
People had their nutritional needs assessed and meals were provided in accordance with their needs and preferences. The staff monitored people’s food and fluid intake and regularly weighed people, with their consent, to gauge people’s well-being. The home used an electronic care plan system [Care Control] which alerted staff to anyone who had lost or gained a significant amount of weight. This enabled staff to promptly seek support and advice from other professionals to make sure people received the correct support.”
“The registered manager explained how care planning had recently been moved from a paper based system to an electronic format. They explained they had piloted the move within one floor of the home before extending it out further so that they could understand if any improvements were needed. The registered manager told us this helped to monitor care being delivered in the home because the system [Care Control] had in-built systems that would flag up any anomalies to support continual improvements to people’s care experiences.”
“The registered manager was committed to delivering high-quality care and support for people. They had introduced an electronic care management system [Care Control] which was used by all staff. This system recorded people’s needs, tasks for staff to complete and records of all care and support provided. Staff entered each episode of care and support contemporaneously for example, a meal eaten, a medical appointment and support with personal care. The registered manager was therefore able to check at any time the support provided to each person that day. The system [Care Control] was used on the wellbeing coordinator’s mobile phone so that it could be used at medical appointments. This helped them give up to date information to professionals. The registered manager was committed to continually developing use of the system to provide responsive care.”
“Care plans were computerised, easily accessible for staff on password protected electronic tablets to keep up to date and very comprehensive records.
Each person had their nutritional needs assessed and met. The home monitored people’s weight in line with their nutritional assessment. Care plans included nationally recognised nutritional assessment tools to ensure staff knew who was at high risk of weight loss for example and what action to take. Recording of nutritional needs was computerised and showed very clearly how staff monitored people’s input and took action if there was a risk of weight loss. There were graphs to show food and fluid and weight trends and details showing how staff could encourage food in a person-centred way such as offering finger foods. Monitoring of people’s needs was excellent.
There was good communication, with shift handover notes kept on the computer system [Care Control], where a red flag alerted staff to any recent changes in people’s needs since the last shift.”
“People’s personal information and the relevant people involved in their care, such as their GP, optician and chiropodist was recorded in the care plan. This meant that when staff were assisting people they had information about the person’s choices, likes and dislikes; staff used this information to provide appropriate care and support. Staff said they found the care plans helpful and were able to refer to them when required. The staff were required to record all interactions with people and the support provided on the computer tablets [Care Control].”
“We saw excellent records of communication with both relatives and professionals and relatives told us that staff were approachable and that they always had time to listen. Where residents had given their consent, relatives had online access [Care Control] to information within their relatives care plan and could follow how they were feeling, what they had been doing, activities, outings etc. Relatives stated that this helped them feel involved in the care of their loved ones and it was particularly helpful for family members and friends living a distance away or overseas.”
“Accidents and incidents were recorded and regularly reviewed to ensure any learning could be discussed and shared with staff to reduce the risk of similar events happening. For example following a number of incidents and minor errors relating the management of people’s medicines, the registered manager and staff explored the need for a more robust system to support staff and also reduce the number of medicine incidents. As a result, the provider and registered manager introduced the use of electronic medicines recording system [Care Control eMAR]. The impact of this was that there were no further incidents relating to the management of medicines. This was because the Electronic medicine administration records [Care Control eMAR] had a safety feature that enabled staff to clearly identify if people had not received their medicines. Therefore people were less likely to not receive their medicine.”
“Since the last inspection the home had introduced an electronic care plan system [Care Control]. The system was password protected to protect people’s personal details…The new care plan system enabled the provider to keep up to date with people’s needs even if they were not at the home. The system also alerted them when accidents or incidents had occurred. This allowed them to constantly monitor people’s care.”
“The new computer system was comprehensive and working well… Health professionals could input directly into the computerised care plan system [Care Control]. This information was then included in an updated care plan for staff to follow. Care plans and daily records were easy to follow showing progress. Staff said, ‘The care plan system is fantastic. We use electronic tablets so we can record as we go. We now have more time to care and it’s easy to share any new information or changes with the team as a pop-up alert too.’
The deputy manager said the district nurses loved the new [Care Control] system as they could enter and find information easily. Body maps were used to identify and monitor areas requiring topical creams or bruises.
Care plans were individualised and comprehensive ensuring staff had up to date information in order to meet people’s individual needs effectively. Care plans were person centred and comprehensively reflected people’s needs when we spent time with them.
[Care Control’s] care plans had details of what social activities people liked and who was important to them. For example, staff knew when people regularly had visitors or not and about family dynamics and whether people needed to be assisted to get ready to go out. An ‘alert’ could be put on the system, for example one person was getting ready to go to a specialist day centre related to their medical condition. People’s care plans showed how they liked to be addressed and then went on to detail people’s past experiences.
Care plan overall risk assessment results included falls, self-neglect, manual handling and possibility of behaviour which could be challenging for staff. Each care plan section also included an assessment of people’s level of need such as continence, oral health and mental health.
Staffing numbers were determined by using a dependency tool, which looked at people’s level of need in areas such as mobility, nutrition and maintaining continence.”
“We saw the service had recently introduced an electronic document recording system [Care Control] on which people’s care plans were now recorded…The activities co-ordinator, who had been employed at the service for a week, having replaced the previous co-ordinator, showed us how they were populating the new ‘My Life’ section of the electronic care records. This was intended to replace the previous ‘This is Me’ information on the paper-based files and we found the format provided the opportunity to document a comprehensive amount of person-centred information. ‘This is Me’ is a document produced by the Alzheimer’s Society which allows people, their relatives and staff to document their life history, interests and preferences. The ‘My Life’ section on the service’s electronic care records allowed for similar information to be documented.”
“At the time of the inspection the provider was introducing a new electronic care plan system [Care Control]…The system enabled photographs to be up loaded directly into care plans and daily records which would help to make them more meaningful to people who found it difficult to read lengthy documents.”
“An electronic care planning system [Care Control] enabled the manager and staff to access and input information at all times and be made aware of any alerts to people’s well-being.”
“Care plans were personalised and helped staff provide person centred care. Care plans were constructed on an IT system and the home had a range of tablets that staff could use to update care records. The care plans covered a number of areas such as continence, hearing, nutrition and hydration, oral, sight, skin condition, sleep, physical health, medication, communication, general, dressing, and end of life.”
“The service had introduced new electronic records, which were being developed and personalised further. For example, the activities co-ordinator was helping people to complete their life history. The new system enabled relatives to access certain parts of the care plan and they were encouraged to add relevant information about their loved one. A health professional said, ‘The new system of records is really helpful…’
Staff used hand held devices to access the care records and to record the care and support provided. Staff said although it had taken some getting used to, they found it very useful to have easily accessible information about each person.”
“The home used [Care Control] to produce care plans which were accessed by all staff. The provider/registered manager could also access the system externally to check up on progress and input. All were personal to the individual which meant staff had details about each person’s specific needs and how they liked to be supported.
The daily records were excellent and gave clear information about how people were so that staff on each shift would know what was happening.
Staff used clear body maps to monitor people’s skin and to show why and where topical creams were required.”
“A new computerised system [Care Control] had been implemented since the last inspection which prompted staff to regularly update people’s care plans. The provider told us, ‘This has been accepted very positively and with enthusiasm by all staff.”
“Staff monitored how much food and drink people had to help ensure they were staying healthy. A staff member told us, ‘The new (computer based) system is more accurate and tallies it up so we can see if they haven’t had enough. The nurses have an overview and will ask us if there is a reason if someone’s food and drink is low. They then ask certain staff to focus on encouraging the person to eat or drink.”
“Where people needed regular visits from healthcare professionals, these were added to the computer system, which highlighted them to staff when they were due. This helped ensure people received the correct support from external professionals when they needed it. Professionals confirmed appropriate referrals were made in a timely way.”
“People were supported by staff who recognised any changes to their needs, quickly. One staff member confirmed, ‘Things are reported very quickly. We recognise the smallest of signs and the nurse is informed. The care is very good.’ Any changes to people’s needs prompted an update to their records. Another staff member confirmed, ‘Changes are updated in the care plans, then they are flagged on the system and we have to read them.”
“Computerised care records contained risk assessments about each person which identified measures taken to reduce risks as much as possible. These included risk assessments for falls, skin integrity, nutrition and manual handling.”