‘Tilsley House had previously used written care files, had changed to one electronic system of recording , and then changed to another. The registered manager explained that since they had begun to use the current system, records had improved. This was because staff recorded events such as, incidents, re-positioning, food and fluid intake straight away without waiting to hand write in care files. Staff told us the system was “great” and “a real benefit as you can record yourself and it will write for you if your English isn’t great – like mine!” The care files on the system contained information about people’s individual medical needs, together with evidence of on- going monitoring and involvement from a range of health professionals, such as GPs, district nurses and other specialists to ensure their well-being was promoted. We saw regular evaluations of people’s support, together with updates and details where changes in their health status had been noted. We found people’s files were organised well to enable information to be easily found.’
