Active Service Users
142
6 new this month
Care Plans Due Review
9
4 overdue > 7 days
Open MDT Referrals
17
5 awaiting GP response
Safeguarding Flags
2
1 requires escalation today
Priority Alerts & Risk Signals (AI-Triaged)
| Service User | Alert Type | Source | Priority | Raised | Status | |
|---|---|---|---|---|---|---|
| Margaret O'Sullivan SR-00142 · 86F · Drumcondra |
Falls risk escalation — 2nd fall in 14 days | RGN Visit Note + Wearable | Critical | Today, 08:12 | Action Required | |
| Thomas Brennan SR-00098 · 79M · Coolock |
Weight loss >5% in 4 weeks — nutrition risk | Dietitian Module / MUST Score | High | Yesterday, 16:40 | Under Review | |
| Brid Casey SR-00077 · 91F · Raheny |
Suspected financial abuse — disclosure during visit | Social Worker Module — Safeguarding | Critical | Today, 07:55 | Escalate Now | |
| Liam Fitzgerald SR-00115 · 74M · Santry |
Medication review overdue — 3 PRN errors logged | eMAR / Documentation | High | 2 days ago | Scheduled | |
| Ann Doyle SR-00133 · 83F · Clontarf |
Cognitive decline trend — possible delirium onset | AI Assessment Trend Analysis | Medium | 3 days ago | GP Notified |
Today's Visit Schedule
Live carer GPS & visit-completion feed
Visits scheduled68
Completed on time59
In progress6
Late / missed3
Governance Snapshot
HIQA / HSE audit readiness index
Care plans GDPR-compliant100%
Staff CORU/NMBI verified100%
Mandatory training current94%
Open incidents (30 days)4
AI Insight of the Day
Generated from aggregated assessment & visit data
Falls incidence across the North Dublin cluster has risen 18% over 4 weeks, concentrated among service users on benzodiazepines. Recommend a targeted medication review cycle with the Consultant Geriatrician and Pharmacist for 11 affected service users.
Overview
Physical Health
Cognitive & Mental Health
Functional & OT/Physio
Social & Environmental
AI Risk Synthesis
Service User Profile
NameMargaret O'Sullivan
DOB / Age86 years
MRN / GPSR-00142 / Dr. P. Hennessy
AddressDrumcondra, D9
Care Package3x daily, 14 hrs/wk
Consent / GDPROn file ✓
Assessment Completion
Biopsychosocial domains completed: 9 / 10
interRAI-HCComplete
Barthel ADL IndexComplete
GDS-15 (mood)Complete
MoCA / 6-CITDue
Overall Risk Summary
Falls Risk (FRAT)Very High
Pressure Ulcer (Waterlow)Moderate
Malnutrition (MUST)Low
Depression (GDS-15)Possible (score 7)
SafeguardingNo concerns
Assessment Timeline
12 Jun 2026, 09:20 — Community RGN
Comprehensive interRAI-HC reassessment completed following 2nd fall. Skin integrity check: Waterlow 16 (moderate risk), sacral redness noted.
10 Jun 2026, 14:05 — Advanced Nurse Practitioner
Post-fall clinical review. No fracture on examination; GP informed; physio referral initiated.
28 May 2026, 11:30 — Occupational Therapist
Home hazard assessment completed. Recommended grab rails, raised toilet seat, removal of loose rugs.
14 May 2026, 10:00 — Consultant Geriatrician (virtual MDT)
Medication review: discontinued zopiclone due to falls risk; commenced melatonin.
What matters most to Margaret
Captured directly in service user's own words during assessment
"I want to stay in my own home, near my garden. I'm frightened of falling again — I just want to feel steady on my feet and not be a bother to my daughter."
Care Plan Status
Plan versionv4 — effective 12 Jun 2026
Co-produced withMargaret O'Sullivan + daughter Eithne
Next review24 Jul 2026
Sign-offANP + Service User ✓
Goals & Interventions
| Goal (SMART) | Linked Risk | Interventions / Owner | Target Date | Progress |
|---|---|---|---|---|
| Reduce falls risk — no further falls over next 8 weeks | FRAT: Very High | Physio falls programme (2x/wk); OT home modifications; medication review (Geriatrician) | 07 Aug 2026 | |
| Improve mobility confidence — walk to garden independently with frame | TUG 26s; Berg 32/56 | Graded mobility plan (Physio); confidence-building (OT); carer prompts each visit | 20 Aug 2026 | |
| Maintain skin integrity — no progression of sacral redness | Waterlow 16 | 2-hourly repositioning; pressure-relieving cushion (OT); RGN weekly skin checks | Ongoing | |
| Improve mood & social engagement — resume day centre attendance | GDS-15: 7 | Psychiatry of Later Life review; SW-coordinated transport; carer encouragement | 30 Aug 2026 | |
| Establish Advance Care Plan | No ACP on file | Social Worker-facilitated family meeting; document wishes per ADM Act 2015 | 15 Jul 2026 |
Daily Care Schedule (Carer Instructions)
| Visit | Tasks |
|---|---|
| 08:00 | Personal care, medication prompt, repositioning check, breakfast + fluids |
| 13:00 | Lunch + fluids, mobility walk with frame (as tolerated), skin check |
| 19:00 | Evening medication, dinner + fluids, repositioning, safety check before bed |
AI Care Plan Assistant
Drafting Support
Based on the latest assessment, the AI assistant has proposed updates to Goal 1 (falls reduction) and flagged that the ACP goal has had no activity in 7 days. Suggested next action: Social Worker to schedule family meeting this week.
New Visit Note — Margaret O'Sullivan
Audit Trail — Last 10 Entries
| Date/Time | Author | Entry Type | Status |
|---|---|---|---|
| 12/06 09:20 | C. Nwosu, RGN | Visit Note (SOAP) | Signed |
| 11/06 19:05 | HCA — J. Murphy | Care visit log | Signed |
| 11/06 13:10 | HCA — J. Murphy | Care visit log | Signed |
| 10/06 14:05 | C. Nwosu, ANP | Clinical review | Signed |
| 10/06 08:30 | HCA — A. Kowalski | Incident report — fall | Signed |
| 28/05 11:30 | S. Byrne, OT | Home hazard assessment | Signed |
| 14/05 10:00 | Dr. R. Adeyemi, Geriatrician | MDT review note | Signed |
AI Documentation QA
This entry has been checked for completeness against HIQA Regulation 21 fields. All required elements present. Flagged for clinical attention: "irregular pulse" — auto-linked to MDT referral suggestion below.
Incident Reporting (NF01 / HSE-aligned)
| Date | Service User | Incident Type | Severity | Reported To | Status |
|---|---|---|---|---|---|
| 10/06/2026 | Margaret O'Sullivan | Fall — no injury | Moderate | HIQA notification not required (no harm) — logged internally | Closed |
| 08/06/2026 | Margaret O'Sullivan | Fall — minor bruising | Moderate | GP, Clinical Governance Director | Closed — review completed |
| 05/06/2026 | Brid Casey | Safeguarding disclosure | Critical | HSE Safeguarding & Protection Team, An Garda Síochána liaison | Open — investigation ongoing |
Open Referrals
17
Avg. Response Time
3.4 days
Closed-Loop Confirmed
92%
New AI-Drafted Referral
Active Referrals — Status Tracker
| Service User | Referred To | Priority | Status |
|---|---|---|---|
| M. O'Sullivan | Geriatrician — med review | Critical | Sent — awaiting triage |
| M. O'Sullivan | Memory Assessment Service | High | Acknowledged |
| T. Brennan | Community Dietitian | High | Appointment scheduled |
| L. Fitzgerald | GP — medication review | High | Sent — awaiting response |
| A. Doyle | GP — possible delirium / UTI | Critical | Reviewed — closed loop |
| B. Casey | HSE Safeguarding Team | Critical | Investigation ongoing |
Virtual MDT Schedule
Thu 18 Jun, 10:00 — Falls & Frailty MDT
Geriatrician, ANP, Physio, OT — reviewing 11 service users incl. M. O'Sullivan, T. Brennan
Fri 19 Jun, 11:00 — Mental Health of Later Life MDT
Psychiatry of Later Life, Social Worker, ANP — reviewing M. O'Sullivan (mood/cognition), A. Doyle (delirium follow-up)
Mon 22 Jun, 09:00 — Safeguarding Review Panel
Clinical Governance Director, Social Worker, HSE Safeguarding liaison — B. Casey case review
Secure Messaging — Eithne O'Sullivan
Hi, just checking how Mam got on with the physiotherapist today — was she able to manage the exercises?
Hi Eithne, the physio visit went well — your mum completed her seated exercises and managed a short walk with the frame, supervised. We've also brought forward her medication review to this week given the recent falls. I'll update you after that appointment.
Thank you so much, really appreciate the update. Could we also talk about what supports are available — I'm worried about her being on her own so much.
Shared Care Plan Summary
Family-friendly view, auto-generated from clinical care plan (clinical detail simplified)
Current focusReducing falls & rebuilding confidence
Recent changeSleeping tablet stopped — safer alternative started
UpcomingDoctor's medication review this week
How you can helpEncourage fluids & short walks; join family meeting re: future planning
Upcoming Family Meeting
Social Worker has proposed a meeting to discuss future care wishes and available supports.
Notification Preferences (GDPR-Managed Consent)
Consent recorded 02 Apr 2026 by Margaret O'Sullivan with capacity confirmed. Editable by service user or legal representative only.
HIQA Standards Met
96%
GDPR DPIA Status
Current
Staff Registration Checks
100%
Open Safeguarding Cases
2
Compliance Standards
Staff Registration (NMBI/CORU)
Data Protection (GDPR)
Safeguarding Pathway
Audit & Inspection Readiness
| Standard / Regulation | Area | Status | Last Reviewed |
|---|---|---|---|
| HIQA Standard 1 — Person-Centred Care & Support | Care planning co-production | Met | 05 Jun 2026 |
| HIQA Standard 3 — Safe Services | Risk assessment, falls, medication mgmt | Mostly met — falls action plan in progress | 10 Jun 2026 |
| HIQA Standard 4 — Health & Wellbeing | Biopsychosocial assessment coverage | Met | 01 Jun 2026 |
| Regulation 21 — Records | Clinical documentation | Met | 12 Jun 2026 |
| HSE Home Support Service Specification 2023 | Service delivery & review cycles | Met | 30 May 2026 |
| Safeguarding Vulnerable Persons at Risk of Abuse (HSE 2014) | Safeguarding pathway | Active case — pathway followed | 11 Jun 2026 |