Date: April 2017
Each staff member had an i-pod which allowed them to access people’s records only accessed via a password. These included care plans for personal care, safety and the environment, nutrition, activities, communication, continence needs, mobility, medication, emotional support and sleeping patterns. Staff were also able to access the handover notes for each shift and add to them if a GP had been called, for example and could also log any concerns raised by a person or their family. As staff had the i-pod with them they were able to refer instantly to the records which meant it was better for the person as they could remain with them while checking their records.
Care records resulted from the initial assessment and were person-centred. They included all key aspects of a person’s needs such as communication, lifestyle preferences, emotional support needs, mobility, nutrition skin integrity and medication. Each assessment discussed the present situation for a person, what their needs were and how these were to be met with very specific guidance for staff. The level of support required for people was highlighted according to the activity or decision they were undertaking. In one care record we saw ‘[Name] can communicate their needs but gets confused when people ask them questions. They may need more assistance making choices that are in their best interest…They sometimes find it easier to make decisions if given a choice of two or more.’ On each assessed need the person’s risk assessment scores were noted helping staff to see instantly how other aspects of their abilities may impact on their care need.