“The management team maintained oversight of the quality and safety of the service by completing a range of checks each month. The new electronic system [Care Control] alerted managers to tasks that had not been completed, for example care plan reviews, updates of risks assessments and completion of maintenance checks. This supported them to identify any areas for improvement, to ensure the service remained safe and of a high-quality.”
“Staff were supported by the providers electronic care planning system [Care Control] to ensure they met people’s needs. We saw there were effective systems that ensured people had their air mattresses set correctly and were repositioned at regular intervals as required.
The providers electronic care planning system ensured reviews of records were completed and updated when required. Records evidenced that identified risks were updated within care records when required.
People’s records were personalised, and staff knew the history and background of people. There were systems to ensure care was responsive.”
“Staff told us care plans were informative and gave them the guidance they needed to care for people. Staff were informed about people’s changing needs through effective shift handovers, with the nurse in charge, and by accessing up-to-date electronic records [Care Control]. This helped ensure people received consistent care and support.”
“The provider had introduced an electronic care planning system [Care Control]. This helped reduce paperwork and improve risk management systems.
An electronic system for medicines management [Care Control eMAR] helped to reduce risk to a minimum.”
“The new electronic care planning system [Care Control] was going well with staff receiving alerts when care tasks were due and recording care regularly. [Care Control] enabled staff to access information at all times and update care plans as they worked.
The electronic care plans contained very detailed information and it was easy to follow a health concern through to completion showing who was involved, what actions had been taken and how the person was feeling.
People received person-centred care which was responsive to their specific needs and wishes. Each person had an up to date, personalised electronic care plan, which set out how their care and support needs should be met by staff.”
“Information was easily accessible to staff who had their individual passwords to access the electronic care system [Care Control] which ensured people received the care required. Staff said they found the care plans helpful and were able to refer to them at times when they recognised changes in a person’s physical or mental health.
Medicines administered were well documented on the provider’s computerised system [Care Control eMAR]. This system had a fail-safe that would not allow staff to administer medicines until the designated time.”
“The provider had recently introduced a new electronic system [Care Control] for storing people’s care records. This was securely accessible to staff and they told us this ensured they had up to date information about how to keep people safe and meet their needs. Staff reported, ‘the care plans explain risks. The new system is a lot better – it means I can read care plans before going in.’ Care records also showed appropriate environmental risk assessments of people’s homes.
[Care Control] also meant that care plans could be altered and issued immediately to ensure staff were kept up-to-date with any changes.”
“People’s care plans were held electronically and staff were able to log what people had eaten, drunk, activities completed and people’s wellbeing. This technology proved effective in monitoring people’s fluid/food intake which supported staff in helping people to maintain good health.
The registered manager was then able to log on and see at any time that each person, who required any of their care or mental health needs monitored, had been provided the support and care needed to remain well. This was particularly important if people were going through a difficult time with their mental health status or end of life care and was vital to people’s care and welfare.”
“Staff were able to gain instant access to information to inform the delivery of people’s care on electronic hand-held devices [Care Control], in addition to the information provided at staff shift handovers. People also had an electronic summary and ‘fast facts’ page, which provided key information such as significant risks to them and their fluid intake for the past 24 hours.”
“The provider and registered manager had started to use technology to continuously improve and innovate the care provided. The provider had recently implemented a new electronic system [Care Control] which was used to ensure people’s care needs were met, for example, a reminder was sent to staff to offer medicines or drinks. Records were then completed using a mobile telephone so staff and the registered manager could see if a person had received their morning medicines, for example. This also meant that the registered manager was always aware of any issues whilst they were not in the home.”
“The provider had developed its IT systems since our comprehensive inspection in 2018. Care records were operational in an electronic format [Care Control] which were accessible by staff through terminals and hand-held, wi-fi enabled devices. Electronic records enabled managers to see recent changes and up to date information about people’s care needs as well as trends and changes over time. For example, electronic care records provided the registered manager with graphical information such as people’s weight or malnutrition risks. Staff entries into people’s electronic care records were time stamped and monitored to ensure they were accurate and sufficiently detailed. The system was protected by passwords to keep people’s information safe and secure.”
“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’s care records were comprehensive and up to date. Care plans included details for staff about the support each person needed. For example, that a person can become confused and resistant to care at times but responded well to one to one interactions with staff. Care staff praised the electronic records [Care Control] and said they were easier to read and kept them up to date and communicated any changes quickly within the staff team. “
“The provider has created an electronic care system [Care Control] which was originally trialled at Spring House and has been sold to other providers. The registered manager provided examples where they had influenced how the care system had been enhanced based on feedback from staff and her own experience of audits and monitoring the well-being and health of people.”
“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.
“Staff were able to easily access the computerised care plans, risk assessments and any updated information immediately on computers located around the home. Staff said they found the care plans helpful and were able to refer to them when required. Staff recorded all interactions with people and the support provided as quickly as possible after they took place. This included people’s dietary and fluid intake, if they were assessed as being at risk. The registered manager and senior staff could access this system [Care Control] at any time during the day and assess what was happening with people.”
“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.”