‘Care and health assessments were undertaken to identify people’s support needs when they moved into the home. The home had introduced a computer based care planning system in July 2015. A unit manager told us that care plans and risk assessments were developed using the assessment information. Care plans included detailed information and guidance for staff on how people’s needs should be met. They described people’s daily living activities, their life history, personal preferences, their communication methods, mobility needs and the support they required with personal and nursing care. We saw that people’s care records were constantly updated throughout the day by health care assistants using iPod’s and nursing staff using iPad’s. For example health care assistants recorded what people ate and drank or if there were any changes in their needs or behaviours that might require medical assistance and unit managers recorded the outcome of appointments with and referrals made to health care professionals.’

‘Most of the information relating to peoples care and support needs were held on the computer system however some paper records were held in individual care files, for example capacity assessments and, where appropriate, Deprivation of Liberty Safeguards authorisations and associated paperwork. The unit manager told us, “The care planning system is easy to use, easy to update and it’s easy to keep people’s needs under review. Staff have more time to spend time with the residents because they are not having to complete lots of paperwork.” A health care assistant told us, “We are all familiar with people’s needs because we read their care plans and assessments. Using the iPod during the day also helps us keep up to date with what people need.” Information contained in the care files indicated that people using the service, their relatives and appropriate healthcare professionals had been involved in the care planning process.’