Service Start Pack B – Support Plan Day Support Plan (Summary) Service User’s Name: Likes to get up at: Likes to get Washed/Dressed at: Likes to have Shower/Bath at: Likes Lunch at: Likes Tea at: Likes Supper at: Receives Medication? At what Times: Requires Help With Repositioning? How often? Requires Help With Mobility? How Often? Other Daily Activities and Support Required: Plan completed By: Date: Waking Night Support Plan (Summary) Service User’s Name: Brief Synopsis Of Needs: Receives Night Medication: Sleep Pattern: Likes to go to bed at: Likes to get up at: Sleeps Through the Night: UsuallyOftenRarely Support Regime:UndressingDressingBoth Incontinent: Toilet2/4 Hourly Requires Help:UndressingDressingBoth Require Turning 1 hours2 hours4 hoursOther [group requires-turning-other] If require turning other [/group] Requires Checking 1/2 hourly1 hourly2 hourly4 hourlyOther [group requires-checking-other] If require checking other [/group] Social History Support Plan Social Networks Major Life Events and Life Course History Current and Former Lifestyle Education and Occupation Cultural Family Access to Sexual Health Advice and Support Religion Current and Former Recreational Activities Significant Relationships Accountability Signature [signature* signature-754 cols:200 rows:100 background:#e8ebed] Life History : Pen Picture Service User's Preferred Activities : What They Want to do (Part 1) Service User’s Name: Date Writing Letters Range of Activities Possible by Service User Allocation of Carers to Facilitate Activity Set in Progress Date Flower Arranging Range of Activities Possible by Service User Allocation of Carers to Facilitate Activity Set in Progress Date Going to Church Range of Activities Possible by Service User Allocation of Careers to Facilitate Activity Set in Progress Date Knitting Range of Activities Possible by Service User Allocation of careers to Facilitate Activity Set in Progress Date Listening to Music Tapes or Records Range of Activities Possible by Service User Allocation of Careers to Facilitate Activity Set in Progress Date Reading Aloud Range of Activities Possible by Service User Allocation of Careers to Facilitate Activity Set in Progress Date Washing Up Range of Activities Possible by Service User Allocation of Careers to Facilitate Activity Set in Progress Date Doing jigsaws Range of Activities Possible by Service User Allocation of Careers to Facilitate Activity Set in Progress Date Indoor Gardening Range of Activities Possible by Service User Allocation of careers to Facilitate Activity Set in Progress Date Shoe cleaning Range of Activities Possible by Service User Allocation of Careers to Facilitate Activity set in Progress Date Shopping Range of activities possible by Service User Allocation of Careers to Facilitate Activity set in Progress Date Going to Theatre or Cinema Range of Activities Possible by Service User Allocation of Careers to Facilitate Activity set in Progress Date Dusting Range of Activities Possible by Service User Allocation of Careers to Facilitate Activity Set in Progress Date Entertaining Visitors Range of activities possible by Service User Allocation of Careers to Facilitate Activity Set in Progress Date Using a Library Range of Activities Possible by Service User Allocation of Careers to Facilitate Activity Set in Progress Date Playing Cards or Board Games Range of Activities Possible by Service User Allocation of Careers to Facilitate Activity Set in Progress Date Looking After a Pet Range of Activities Possible by Service User Allocation of Careers to Facilitate: Activity Set in Progress Date Taking Photographs Range of Activities Possible by Service User Allocation of Careers to Facilitate Activity Set in Progress Date Making Tea or Coffee Range of Activities Possible by Service User Allocation of Careers to Facilitate Activity Set in Progress Date Basket Making Range of Activities Possible by Service User Allocation of Careers to Facilitate Activity Set in Progress Date Buying Presents Range of Activities Possible by Service User Allocation of Careers to Facilitate Activity set in Progress Date Playing Bingo Range of Activities Possible by Service User Allocation of Careers to Facilitate Activity Set in Progress Date Listening to Radio Range of Activities Possible by Service User Allocation of Careers to Facilitate Activity Set in Progress Date Washing/Setting Hair Range of Activities Possible by Service User Allocation of Careers to Facilitate Activity Set in Progress Date Writing Poetry/Prose Range of Activities Possible by Service User Allocation of Careers to Facilitate Activity Set in Progress Date Embroidery Range of Activities Possible by Service User Allocation of Careers to Facilitate Activity Set in Progress Date Outdoor Gardening Range of Activities Possible by Service User Allocation of Careers to Facilitate Activity Set in Progress Date Washing clothes Range of Activities Possible by Service User Allocation of Careers to Facilitate: Activity Set in Progress Date Singing Range of Activities Possible by Service User Allocation of Careers to Facilitate Activity Set in Progress Date Watching TV Range of activities possible by Service User Allocation of Careers to Facilitate Activity Set in Progress Date Ironing Range of Activities Possible by Service User Allocation of Careers to Facilitate Activity Set in Progress Date Making Clothes Range of Activities Possible by Service User Allocation of Careers to Facilitate Activity Set in Progress Date Physical Exercises Range of Activities Possible by Service User Allocation of Careers to Facilitate Activity Set in Progress Date Painting/Drawing Range of Activities Possible by Service User Allocation of Careers to Facilitate Activity Set in Progress Date Visiting Friends Range of Activities Possible by Service User Allocation of Careers to Facilitate Activity Set in Progress Date Polishing silver/Ornaments Range of Activities Possible by Service User Allocation of Careers to Facilitate Activity Set in Progress Date Yoga Range of Activities Possible by Service User Allocation of Careers to Facilitate Activity Set in Progress Date Feeding Birds Range of Activities Possible by Service User Allocation of Careers to Facilitate Activity Set in Progress Date Reading Newspapers/Magazines Range of Activities Possible by Service User Allocation of Careers to Facilitate Activity Set in Progress Date Crosswords Range of Activities Possible by Service User Allocation of Careers to Facilitate Activity Set in Progress Date Going for Walks Range of Activities Possible by Service User Allocation of Careers to Facilitate Activity Set in Progress Date Playing an Instrument Range of Activities Possible by Service User Allocation of Careers to Facilitate Activity Set in Progress Date Stamp Collecting Range of Activities Possible by Service User Allocation of Careers to Facilitate Activity Set in Progress Date Typing Range of Activities Possible by Service User Allocation of Careers to Facilitate Activity Set in Progress Date Expressing Views on Current Affairs Range of Activities Possible by Service User Allocation of Careers to Facilitate Activity Set in Progress Date Mending Range of Activities Possible by Service User Allocation of Careers to Facilitate Activity Set in Progress Date Doing Odd Jobs Range of Activities Possible by Service User Allocation of Careers to Facilitate Activity Set in Progress Date Making Soft Toys Range of Activities Possible by Service User Allocation of Careers to Facilitate Activity Set in Progress Date Doing Football Pools Range of Activities Possible by Service User Allocation of Careers to Facilitate Activity Set in Progress Date Keeping a Diary Range of Activities Possible by Service User Allocation of Careers to Facilitate Activity Set in Progress Date Reading Books Range of Activities Possible by Service User Allocation of Careers to Facilitate Activity Set in Progress Date Bird Watching Range of Activities Possible by Service User Allocation of Careers to Facilitate Activity Set in Progress Date Making Birthday/ Christmas Cards Range of Activities Possible by Service User Allocation of Careers to Facilitate Activity Set in Progress Date Going to Adult Education Classes Range of Activities Possible by Service User Allocation of Careers to Facilitate Activity Set in Progress Date Making Phone Calls Range of Activities Possible by Service User Allocation of Careers to Facilitate Activity Set in Progress Date Going to Club/Day Range of Activities Possible by Service User Allocation of Careers to Facilitate Activity Set in Progress Date Talking to Friends Range of Activities Possible by Service User Allocation of Careers to Facilitate Activity Set in Progress Date Any social skills, Psychological health, Physical Health Limiting Range of Activity: Accountability Signature [signature* signature-891 cols:200 rows:100 background:#e8ebed] Assessment Date Service User’s VIEW OF SUPPORT NEEDS (or their family/advocate’s view) Service User’s Name: Key Worker: Communication Support Plan YesNo [group support-plan-yes] If Support Plan Yes [/group] [group support-plan-no] If Support Plan No [/group] Bathing & Washing Gender of Carer MaleFemale Support Plan YesNo [group support-plan-yes-bathing] If Support Plan Yes [/group] [group support-plan-no-bathing] If Support Plan No [/group] Dressing & Grooming YesNo [group yes-support-plan-dressing] If Support Plan Yes [/group] [group no-support-plan-dressing] If Support Plan No [/group] Personality, Moods & Emotions YesNo [group yes-support-plan-personality] If Support Plan Yes [/group] [group no-support-plan-personality] If Support Plan No [/group] Use of Toilet & Continence YesNo [group yes-use-of-toilet] If Support Plan Yes [/group] [group no-use-of-toilet] If Support Plan No [/group] Eating & Drinking YesNo [group yes-support-eating] If Support Plan Yes [/group] [group no-support-eating] If Support Plan No [/group] Pressure Area Care YesNo [group yes-support-pressure-area] If Support Plan Yes [/group] [group no-support-pressure-area] If Support Plan No [/group] Social, Recreational & Religious YesNo [group yes-social] If Support Plan Yes [/group] [group no-social] If Support Plan No [/group] Moving and Handling & Mobility Needs YesNo [group yes-moving] If Support Plan Yes [/group] [group no-moving] If Support Plan No [/group] Any Special Routines Required by the Service User: Memory YesNo [group yes-memory] If Support Plan Yes [/group] [group no-memory] If Support Plan No [/group] Resuscitation YesNo [group yes-resuscitation] If Support Plan Yes [/group] [group no-resuscitation] If Support Plan No [/group] Accountability Signature: [signature* signature-961 cols:200 rows:100 background:#e8ebed] Assessment Date: Review To be used to conduct reviews, unless changes are sufficient to call for a full repeat of risk assessment, or 6 reviews have taken place. Date Signature [signature* signature-688 cols:200 rows:100 background:#e8ebed] Review Details Staff Support Needs Service User’s Name: Key Worker: Communication Support Plan YesNo [group support-plan-staff-communication-yes] If Support Plan Yes [/group] [group support-plan-staff-communication-no] If Support Plan No [/group] Bathing & Washing Gender of Carer MaleFemale Support Plan YesNo [group support-plan-yes-bathing-staff] If Support Plan Yes [/group] [group support-plan-no-bathing-staff] If Support Plan No [/group] Dressing & Grooming YesNo [group yes-support-plan-dressing-staff] If Support Plan Yes [/group] [group no-support-plan-dressing-staff] If Support Plan No [/group] Personality, Moods & Emotions YesNo [group yes-support-plan-personality-staff] If Support Plan Yes [/group] [group no-support-plan-personality-staff] If Support Plan No [/group] Use of Toilet & Continence YesNo [group yes-use-of-toilet-staff] If Support Plan Yes [/group] [group no-use-of-toilet-staff] If Support Plan No [/group] Eating & Drinking YesNo [group yes-support-eating-staff] If Support Plan Yes [/group] [group no-support-eating-staff] If Support Plan No [/group] Pressure Area Care YesNo [group yes-support-pressure-area-staff] If Support Plan Yes [/group] [group no-support-pressure-area-staff] If Support Plan No [/group] Social, Recreational & Religious YesNo [group yes-social-staff] If Support Plan Yes [/group] [group no-social-staff] If Support Plan No [/group] Moving and Handling & Mobility Needs YesNo [group yes-moving-staff] If Support Plan Yes [/group] [group no-moving-staff] If Support Plan No [/group] Any Special Routines Required by the Service User: Memory YesNo [group yes-memory-staff] If Support Plan Yes [/group] [group no-memory-staff] If Support Plan No [/group] Resuscitation YesNo [group yes-resuscitation-staff] If Support Plan Yes [/group] [group no-resuscitation-staff] If Support Plan No [/group] Accountability Signature: [signature* signature-580 cols:200 rows:100 background:#e8ebed] Assessment Date: STAFF VIEW OF SUPPORT NEEDS To be used to conduct reviews, unless changes are sufficient to call for a full repeat of risk assessment, or 6 reviews have taken place. Date Review Details Now complete a full review using the original risk assessment. SUMMARY OF RISK ASSESSMENT RESULTS: LIST ALL RISKS IDENTIFIED BY ANY ASSESSMENTS OR OTHER PROCESSES. NOTE – THE ASSESSMENTS ARE MAINLY CONTAINED IN Pack A. Service User Name: Key Worker: Source Risk Date: Transferred to Plan of Care (Signature)[signature* signature-494 cols:200 rows:100 background:#e8ebed] Service User's Name: Key Worker Source Risk Date: Transferred to Plan of Care (Signature)[signature* signature-9 cols:200 rows:100 background:#e8ebed] Service User's Name: Key Worker: Source Risk Date: Transferred to Plan of Care (Signature)[signature* signature-796 cols:200 rows:100 background:#e8ebed] Service User's Name: Key Worker: Source Risk Date: Transferred to Plan of Care (Signature)[signature* signature-711 cols:200 rows:100 background:#e8ebed] SUPPORT PLAN Service User Name: Assessed Need Aim of Support Named Carer/Key Worker Instruction Signature[signature* signature-552 cols:200 rows:100 background:#e8ebed] Date Review Date Service User Name: Assessed Need Aim of Support Named Carer/Key Worker Instruction Signature[signature* signature-415 cols:200 rows:100 background:#e8ebed] Date Review Date Service User Name: Assessed Need Aim of Support Named Carer/Key Worker Instruction Signature[signature* signature-416 cols:200 rows:100 background:#e8ebed] Date Review Date Service User Name: Assessed Need Aim of Support Named Carer/Key Worker Instruction Signature[signature* signature-25 cols:200 rows:100 background:#e8ebed] Date Review Date Signed by Carer/Key Worker:[signature* signature-26 cols:200 rows:100 background:#e8ebed] Signed to indicate agreement by Service User:[signature* signature-27 cols:200 rows:100 background:#e8ebed] Signed by Advocate: [signature* signature-768 cols:200 rows:100 background:#e8ebed] Daily Record of A(ctivities) of D(aily) L(iving) Activity and Support Given Date Daily Report Time in Time out Carer/ Key worker/ Signature Service User Signature [signature* signature-829 cols:200 rows:100 background:#e8ebed] Date Daily Report Time in Time out Carer/ Key worker/ Signature Service User Signature[signature* signature-750 cols:200 rows:100 background:#e8ebed] Date Daily Report Time in Time out Carer/ Key worker/ Signature Service User Signature[signature* signature-348 cols:200 rows:100 background:#e8ebed] Date Daily Report Time in Time out Carer/ Key worker/ Signature Service User Signature[signature* signature-440 cols:200 rows:100 background:#e8ebed] Service User Name: GP/Ancillary Professional Visits and Tests Service User’s name: BP Date Special Test GP/Other Professional Visit Carer Signature [signature* signature-565 cols:200 rows:100 background:#e8ebed] Service User’s name: BP Date Special Test GP/Other Professional Visit Carer Signature [signature* signature-616 cols:200 rows:100 background:#e8ebed] Service User’s name: BP Date Special Test GP/Other Professional Visit Carer Signature [signature* signature-854 cols:200 rows:100 background:#e8ebed] Service User’s name: BP Date Special Test GP/Other Professional Visit Carer Signature [signature* signature-320 cols:200 rows:100 background:#e8ebed] Record of Reviews, Signatures Key Worker/Manager: Review Date Signature[signature* signature-136 cols:200 rows:100 background:#e8ebed] Service User/Advocate: Review Date Signature[signature* signature-830 cols:200 rows:100 background:#e8ebed] Key Worker/Manager: Review Date Signature[signature* signature-931 cols:200 rows:100 background:#e8ebed] Service User/Advocate: Review Date Signature[signature* signature-757 cols:200 rows:100 background:#e8ebed] Key Worker/Manager: Review Date Signature[signature* signature-189 cols:200 rows:100 background:#e8ebed] Service User/Advocate: Review Date Signature[signature* signature-263 cols:200 rows:100 background:#e8ebed] Key Worker/Manager: Review Date Signature[signature* signature-2000 cols:200 rows:100 background:#e8ebed] Service User/Advocate: Review Date Signature[signature* signature-145 cols:200 rows:100 background:#e8ebed] Record of Weight Service User Name: Weight Date BP Pulse Signature [signature* signature-979 cols:200 rows:100 background:#e8ebed] Service User Name: Weight Date BP Pulse Signature [signature* signature-2001 cols:200 rows:100 background:#e8ebed] Service User Name: Weight Date BP Pulse Signature [signature* signature-394 cols:200 rows:100 background:#e8ebed] Service User Name: Weight Date BP Pulse Signature [signature* signature-708 cols:200 rows:100 background:#e8ebed] Food and Nutrition Intake Log Service User Name: Date: Time Midnight 12 Food Amount Comments 1 AM Food Amount Comments 2 AM Food Amount Comments 3 AM Food Amount Comments 4 AM Food Amount Comments 5 AM Food Amount Comments 6 AM Food Amount Comments 7 AM Food Amount Comments 8 AM Food Amount Comments 9 AM Food Amount Comments 10 AM Food Amount Comments 11 AM Food Amount Comments Midday 12 Food Amount Comments 1 PM Food Amount Comments 2 PM Food Amount Comments 3 PM Food Amount Comments 4 PM Food Amount Comments 5 PM Food Amount Comments 6 PM Food Amount Comments 7 PM Food Amount Comments 8 PM Food Amount Comments 9 PM Food Amount Comments 10 PM Food Amount Comments 11 PM Food Amount Comments Blood Sugar Monitoring Service User Name: Date/Initial Time Score Service User Name: Date/Initial Time Score Service User Name: Date/Initial Time Score Service User Name: Date/Initial Time Score Acknowledgement of Service Request Order Divine Care and Support Services Limited (This form may be used in the absence of written confirmation of service placement from Social Services. Copy onto your letterhead and edit appropriately.) TO: Date Acknowledgement of Service Placement Order We hereby Acknowledge Receipt and Acceptance of the Service Request as follows: Date request made: Request placed by: Name of Service User Rate: £ From to (date, if applicable): Until Further Notice Additional Details of Service Requested: Please Sign this Acknowledgement in the space provided below and Fax the Signed form back to us as Confirmation of the Service Request. Yours Faithfully For and on behalf of Divine Care and Support Services Limited I confirm that the above details are correct and that I am duly authorized to confirm the service details: Signed: [signature* signature-2002 cols:200 rows:100 background:#e8ebed] Name Date: On Behalf of the Addressee Service Start Notification to Administration To be completed and sent to administration as soon as service start is confirmed, fully completed. Name of Service User: Date and Time of Service Start: Date of Birth: Previous Address: Next of kin, address & tel, relationship (must appoint advocate and give details if no family/next of kin): Service start arranged by (e.g. Social Services (name); family member etc): GP Name and Address: Who to be funded by: (name and address) (e.g. Social Services self). Include all funders if more than one. If Social Services funded, who is to complete any benefits applications? – this must be agreed upon with the funding authority or person before service start. Fee level (state £/HOUR agreed): Service start contract given to (name and address): Any other details relevant: Welcome letter given: (by whom to whom, when) Brochure given: (by whom to whom, when) Contract given: (by whom to whom, when) Handbook given: (by whom to whom, when) This form completed by: On (date): Family or Advocate Discussion Record This form should be used for Informal Contacts only, and the Record of Involvement Sheet used for Recording choices given and made. Service User Name: Date of Contact: Person Contacted (e.g. family member, advocate:) Method and Time of Contact: Contact notes:
