January 2018
‘The provider had implemented an electronic care planning system which provided clear, detailed and very comprehensive care plans for each person. These had been developed with the involvement of people and/or their relatives and provided up to date guidance for staff about how people wanted to be supported. The care plans were clearly laid out which made them very easy for staff to read and to find the information they required in order to provide person centred care for people. All aspects of people’s physical care and support were planned for including; mobility; continence; skin integrity; personal care and any health conditions. Each person also had a care plan outlining the emotional support they required which included how they may deal with loss or illness and how staff should support them at this time. ‘
‘The registered manager showed us how the system ‘prompted’ when reviews were due which enabled them to keep everything up to date. Notes were written on the ‘home page’ of people’s electronic care plans which ensured important information was ‘flagged’ to staff. For example, one person was allergic to two medicines and had vulnerable pressure areas. The provider and registered manager had invested a great deal of time to ensure the care planning system was fit for purpose, was well maintained and reflected people’s current needs. ‘
‘People’s electronic care plans were comprehensive and focused on their individual needs, rights, choices and preferences.’
‘Electronic care plans were detailed and current and all relevant information, such as medical history, mobility and communication needs, could be immediately transferred into a hospital passport when required. This ensured clinical staff would have important information about the person at the time of admission to hospital to enable them to know how to support them appropriately during their stay. ‘
‘Drinks were offered to people throughout the day and we observed staff topping up people’s glasses with a choice of flavoured drinks and water. We noted that staff had recorded in people’s electronic daily records when and what they had eaten or drunk. ‘
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