‘We checked two people’s fluid balance charts. These had been fully completed electronically and showed appropriate levels of fluid were provided. The charts were checked and monitored by senior staff to ensure people were provided with enough to drink, and to maintain their health.’
‘We looked at three people’s care plans. They were maintained and updated electronically and were specific to the individual and person centred. All contained a range of information that covered all aspects of the support people needed. They included clear information on the person’s identified need, interests, hobbies, likes and dislikes so that these could be respected. The plans gave clear details of the actions required of staff to make sure people’s needs were met. This showed important information was recorded in people’s plans, so staff were aware and could act on this. The plans seen had been regularly reviewed to keep them up to date.’
‘All people’s care records were held on Person Centred Software [PCS]. This was an electronic system and staff used a small hand-held device to record every intervention and interaction provided for people. These included such things as assisting people with diet and fluids and assisting people with their hygiene needs. This meant a full and accurate record of the support provided could be kept electronically.’
‘Staff said, “We have now got use to using the electronic system, it’s good really”, “All staff now do electronic records. We have had more training in record keeping” and “Our records are closely monitored by the managers to make sure they are accurate and up to date.”‘
