Support Planning (Service Commencement)

Enquiry Record Sheet

Details of the Enquirer

Name:*

Telephone number:*

Address:

Re. Prospective Service User

Name (if different from above):

Relationship of Service User to enquirer:

Address or location of Service User:*

Telephone number:

Date of Birth:

Age Now: Brief Details Of Needs:* Personal care (he must be taken for a walk please – he has a walking stick), serve him lunch and make him a cup of tea.

Agreed Dependency Level:*

Agreed Service and Charge Level:*

Long or Short Term Service:*

Potential Service Commencement Date:*

GP Name Address and Telephone: Where did you Hear of Us?

Enquiry taken by:

Date of enquiry:

Further action Required?

Send Information Pack?

Other Action? (specify) Essential Information*

Premises And Environmental Risk to Staff

IF THIS ASSESSMENT INDICATES AN UNMANAGEABLE RISK TO STAFF ATTENDING, DO NOT PROCEED WITH THE ASSESSMENT AND REJECT THE SERVICE. GIVE THE COMMISSIONER THE REASONS. Risk Area
1. Property surroundings; lighting, isolation, approach roads etc.

Risk Description

Management Protocol

Next Review Date
2. Risk of Attendance Identifying Occupant as Vulnerable

Risk Description

Management Protocol

Next Review Date
3. Parking; risks to Vehicle; Risk Travelling to and From

Risk Description

Management Protocol

Next Review Date 4. Property Entrance and Corridors

Risk Description

Management Protocol

Next Review Date
5. Gender Associated Risks

Risk Description

Management Protocol

Next Review Date 6. Other Occupants Risks

Risk Description

Management Protocol

Next Review Date 7. Flooring, Trips, Skids

Risk Description

Management Protocol

Next Review Date
8. Electrical Installation, Fittings, Appliances

Risk Description

Management Protocol

Next Review Date
9. Gas Appliances Risk

Risk Description

Management Protocol

Next Review Date
10. Unstable/Dangerous Furniture

Risk Description

Management Protocol

Next Review Date
11. Hygiene Risks

Risk Description

Management Protocol

Next Review Date

Service Commencement - Personal Details

SU Name: Marital Status MarriedUnmarried Address:

Date of Birth:

Start date:

Proposed Date:

Actual Date:

General Practitioner:

Next of Kin: Name:

Next of Kin: Address: Telephone number: Wish to be contacted?

Second contact: Name:

Next of Kin:

Address:

Telephone number:

Home Telephone Number:

Work Telephone Number:

Social Worker:

Community

Speech Therapist:

Dietician:

Minister of religion:

Religion:

Solicitor:

Ethnic origin:

Nat. Ins number:

NHS number: Names of practitioners involved with Service User in previous twelve months: Has the Service User completed a Preferred Priority of Care or do they have an Advance Care Plan in place? Accountability Signature:
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Date:
Service Commencement - Health Assessment

SU Name:

Service Start date

Brief description of current general health state:

Brief description of current medical treatment:

Mobility:

Specialist aids and equipment used: walking stick

Accountability Signature:
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Date:
Service Commencement - Medical History

GP/Consultant involvement:

Medication – Current:

Controlled drugs administered:

Medication – Significant Previous:

Dietary Requirements and allergies:

Current Weight (In Pounds):

Sight:
Service Commencement- Health Assessment

Hearing:

Communication:

Mobility and Dexterity:

Wheelchair User?

Self Propelled YesNo

Continence:

Confusion:

History of Involvement With Multi-disciplinary Agencies:
Skin Marks/Brusing Record

SU Name:

Date of Assessment

Area Assessed:

Reason For Assessment:

Cause of Marks/Bruising Identified? Support Plan Created: YesNo Key worker/ Named Nurse: Accountability Signature:
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Date: To be used to conduct reviews, unless changes are sufficient to call for a full repeat of risk assessment
Service User Compatibility Assessment

Service User Compatibility Assessment

Suitable Staff Available:

Staff Pool Allocated to Service User:

Staff Introduced to Service User:

The Perception of the Service User and Service User's Family
The perception of the Service User’s family/nominated informal carer in relation to the Service User’s proposed transition into a support package: Perception of the Service User or their advocate about their potential service: Service User’s religious, cultural and terminal Care matters (note: normally this section is completed after service start).

Service User’s Wishes in Respect of Cultural and Religious Matters:

Service User’s wishes in Respect of Terminal Care (Preferred Priority of Care and/or Advance Care Plan):

Next review date:
Support Needs (ADL) Assessment Tool
Service User’s Name: Key Worker Name Accountability Signature:
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Communication Low DependencyHigh DependencyMedium Dependency
Comments Bath Low DependencyHigh DependencyMedium Dependency
Comments Washing Low DependencyHigh DependencyMedium Dependency
Comments Dressing Low DependencyHigh DependencyMedium Dependency Comments Grooming Low DependencyHigh DependencyMedium Dependency Comments Toilet Low DependencyMedium DependencyHigh Dependency Comments Continence Low DependencyMedium DependencyHigh Dependency Comments Eating Low DependencyMedium DependencyHigh Dependency Comments Drinking Low DependencyMedium DependencyHigh Dependency comments Pressure Sore Care Low DependencyMedium DependencyHigh Dependency Comments Social & Recreational Low DependencyHigh DependencyMedium Dependency Comments Moving and Handling Low DependencyMedium DependencyHigh Dependency Comments Memory Low DependencyMedium DependencyHigh Dependency Comments Personality Low DependencyMedium DependencyHigh Dependency Comments Moods Low DependencyMedium DependencyHigh Dependency Comments Pain Low DependencyMedium DependencyHigh Dependency Comments Sleep Low DependencyMedium DependencyHigh Dependency Comments
Support Needs Assessment Tool
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
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Review Details – Support Needs Assessment Tool

Name:

Date:

Assessor:
Mental Health Assessment Tool
Depression 0123 Comments Mood 0123 Comments Anxiety 0123 Comments Memory 0123 Comments Aggression 0123 Comments Challenging Behaviour – Moderate 0123 Comments Challenging Behaviour – Severe 0123 Comments Self-Harm 0123 Comments Self-Neglect 0123 Comments Comments From Others, Professional Or Informal Carer: Behavioural issues and strategies to cope:
Mental Health Assessment Tool
Date: Signature
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Now complete a full review using the original risk assessment.
Service User Risk Assessment
Service User Name:

Relative/Advocate:
InvolvedInformed
Diagnosis

Key Worker:
InvolvedInformed
Diagnosis

Assessor InvolvedInformed Diagnosis
To be used to conduct reviews, unless changes are sufficient to call for a full repeat of risk assessment, Review Details – Service User’s Risk Assessment Generic Risk Assessment
To be used for risk areas not covered by specific assessments (not to be used where a specific assessment tool is available in this pack). Date: Internal Risk Assessment
Service User Name: Address of assessed premises: Service start date (if new check) Smoke alarms (if fitted) Cleanliness Lighting Temperature Ventilation Window opening checks Sanitary conveniences Washing facilities Drinking water Alarm/Call bell – bed (if fitted) Alarm/Call bell – chair (or extension lead) (if fitted) Chair height Toilet height Grab rails (if fitted) Flooring (check for loose or worn carpet) Bed safety rail (if fitted) Doors and gates Radiator surface temperature Tripping hazards (i.e. trailing wires/cables) Condition of external paths and steps Date: Signature [signature signature-854 cols:200 rows:100 background:#e8ebed] Review Details – Service User’s Risk Assessment Pre Service start checklist

Service User Name:

Date and time of arrival:

Action

Progress

Enquiry sheet:

Information pack sent (enter date sent):

Brochure given to Service User:

Service User’s Handbook sent (enter date sent):

Personal details:

Service commencement health assessment:

Skin/bruising record:

Service User and support worker compatibility assessment:

Support needs assessment tool:

Mental Health assessment:

Service User Risk Assessment:

Letter of offer of service:

Client accommodation assessed for suitability (risk assessed):

Obtain recent photograph for Service User Support Plan:[mfile* My-File-Upload limit:10485760 filetypes:jpeg|gif|png|jpg min-file:5 max-file:6]

Contact name and telephone number given to Service User:

Person responsible for financial affairs of Service User identified:

Person responsible for financial affairs made fully aware of financial matters concerning service:

Comments:
Service Consent Record

Service User name:

For your protection and privacy, your consent is required before we request information from you, or carry out any examination or procedure.

Please read the questions below, or ask someone to read them to you, and indicate clearly YES or NO to each question. You will be asked to sign against each answer.

Note to staff: the Service User must be given sufficient time to consider their responses to these questions. Do not pressurerise the Service User into answering, and be prepared to leave the form with them and return.
Date Consent Form given to Service User: Date Consent Form given to Service User: YesNo Date Consent Form given to Service User: [signature signature-243 cols:200 rows:100 background:#e8ebed] 1. Do you consent to answering questions, giving information, and having that information recorded for the purposes of an assessment of your needs? [signature signature-1989 cols:200 rows:100 background:#e8ebed] 2. Do you consent to the service consulting with other professionals concerned with your Care or support for the sole purpose of obtaining information for the completion of this assessment? [signature signature-2022 cols:200 rows:100 background:#e8ebed] 3. Do you consent to having information recorded of any wounds or skin lesions for the purposes of considering your Care needs? [signature signature-2021 cols:200 rows:100 background:#e8ebed] 4. Do you consent to this assessment being read by staff who are or may provide Care and support for you (and only those staff)? [signature signature-2020 cols:200 rows:100 background:#e8ebed]
Used to conduct reviews of current assessment, unless sufficient changes require full risk re-assessment.
Service User's Name: Service start date:
Review notes:
Consents requires repeating? YesNo Date of review: Next review date
Note: All DCSS Policies are reviewed annually, more frequently, or as necessary.