We saw the service used an electronic system to record care plans, risk assessments and other records relating to people’s care and treatment. We saw all the staff on duty had a hand held devise with their own unique log on which was used to record all activities throughout their shift. This meant any changes in people’s care and treatment were recorded as they happened, which ensured the information available to staff was accurate and up to date. In addition, if a person needed to go into hospital staff were able to log onto the system and print off a hospital pack to go with them. This ensured the hospital staff received all the essential information they required.
We saw the registered manager and the office administrator carried out a range of meaningful audits to include care plans, medication, infection control, staff training and supervision, environmental and accidents and incidents. We saw where shortfalls in the service had been identified action had been taken quickly to address the concerns and a lesson learnt exercise carried out to reduce the risk of a similar incident occurring again. The registered manager was also able to quickly review the care, treatment and support people received on a daily basis due to the ‘live’ electronic care record system.