ACS Care Plan - needs tweaking!

• Care Plan For:

• Conducted on

  Date

• Prepared by

Your Personal Details

• Full Name inc. Title:

• Preferred name:

• Date of Birth:

  Date
• Address:
  Address

• Mobile Telephone Number:

• Preferred Language:

Next of Kin Details

• Name:

• Address:
  Address

• Home Telephone Number:

• Work Telephone Number:

• Mobile Telephone Number:

• Relationship to you:

Emergency Contact Details - (if different from Next Of Kin)

• Name:

• Relationship to you:

• Home Number:

• Mobile Number:

GP Details

• GP Name:

• Surgery Name:

• Surgery Address:
  Address

• Telephone Number:

• Out of Hours Telephone Number:

Social Worker

• Name:

• Address:
  Address

• Telephone Number:

• Out of Hours Telephone:

About You and Your Life History

• Note: Consider things such as Birth Place, Growing Up, Work, Family, Relationships, Significant Dates, Interests/Hobbies, TV Programs, Books/Papers, Food & Drink likes/Dislikes):

Medical and Medication Information

• Known Allergies

• Medical History

• Current Types of Medication (Consideration MUST be given to the type of Medication and level of Staff Interaction as some Medication Types and Administration Methods will require 'Specialist Training')

  Select Liquid; Tablet; Inhaler; Patch; Injected; Eye Drops; Ear Drops; Cream; Other;

  • Liquid;
  • Tablet;
  • Inhaler;
  • Patch;
  • Injected;
  • Eye Drops;
  • Ear Drops;
  • Cream;
  • Other;

• List ALL Current Medications: (see MAR Sheet for details etc.)

• Medication Dispensing:

  Select MDS Bottle Measure Doset Box

  • MDS
  • Bottle
  • Measure
  • Doset Box

Medication & Medical Needs

• Does the Service User Self Medicate?

  Yes

  No

• Are Staff Required To have involvement with Service User Medication?

  Yes

  No

• What Level of Input will be required by Staff?

  Select PROMPT ASSIST ADMINISTER

  • PROMPT
  • ASSIST
  • ADMINISTER

• Does any Medication Assistance require Staff to have 'Specialist Training'?

  Yes

  No

• Specialist Training Requirements:

• Are there any 'Special' Training Requirements as per Local Authority?

  Yes

  No

• Local Authority Requirements:

• Is a MAR Chart in Place and Ready for use?

  Yes

  No

• CONTACT OFFICE TO ARRANGE FOR MAR CHART BEFORE COMPLETING THIS SECTION

• Difficulties taking Medication e.g. Swallowing, Spilling Liquid Meds etc?

  Yes

  No

• Details of any Difficulties:

• Does Management of Prescribed or Un-Prescribed Medication(s) have 'Potential' to Cause Risk?

  Yes

  No

• Details of any Potential Risks:

• Is All Appropriate Documentation On File? e.g. MAR Sheets, Controlled Drugs Records, Disposal Forms etc.

  Yes

  No

• Any Relevant Notes or Information:

• Are there any 'Controlled Drugs' on the premises?

  Yes

  No

• Are they Adequately Stored?

  Yes

  No

• Details of Storage Improvement Requirements:

• Is a 'Consent to Treatment' Form required? (Mental Health)

  Yes

  No

• COMPLETE A 'CONSENT TO TREATMENT' FORM BEFORE COMPLETING THIS SECTION

Skin Care and Pressure Care

• Are there any Skin Care Concerns at this time?

  Yes

  No

• Describe Skin Care Routine and Clearly Mark on 'Body Chart':

• Skin Care Products to use:

• Are there any Pressure Care issues at this time?

  Yes

  No

• CLEARLY IDENTIFY ON BODY CHART

• Describe in detail the Pressure Care Routine to use:

• What pressure Care Aids are to be used?

• Is a 'Turns Monitoring' Form Required?

  Yes

  No

• Has the Turns Monitoring form been Completed and included with the Care Plan?

Sight - Hearing - Communication

• Service Users Sight is:

  Full

  Partial

  No Sight

• Does the Service User Wear Glasses?

  Yes

  No

• Glasses required:

  Occasionaly

  Reading Only

  Always

• Other Relevant Information: (contact lenses etc)

• Service Users Hearing is:

  Full

  Partial

  No Hearing

• Is a Hearing Aid or Hearing Device Used?

  Yes

  No

• Details of Devices Used by Service User:

• Service Users Levels of Verbal Communication and Conversation are:

  Select Full Partial None

  • Full
  • Partial
  • None

• Do they Respond Well to YES / NO Type Questions?

  Yes

  No

• What other types of Communication can be used? (Picture/Note Pad/Sign etc)

What Existing Care / Support do you Currently Receive?

• Details of any Existing Care / Support you currently receive: (name of person/organisation - contact details inc address - type of Care/ Support and days/times)

Mobility and Dexterity

• Able to Walk Unaided?

  Yes

  No

• Requires the use of the following items:

  Select Wheelchair Frame Stick Calliper Brace

  • Wheelchair
  • Frame
  • Stick
  • Calliper
  • Brace

• Is there a Risk relating to any of the Mobility Aids?

  Yes

  No

• RISK ASSESSMENT AND MANGE,ENT PLAN COMPLETED?

• Able to Go Out Alone? (If NO give details)

  Yes

  No

  N/A

• Will Staff be required to assist the Service User on External Activities?

  Yes

  No

  N/A

• Please Complete an 'EXTERNAL RISK ASSESSMENT' Form for all external activities

• Has the Service User 'Fallen' in the Past 12 months?

  Yes

  No

  N/A

• Record Details and complete a 'Falls Risk Assessment' Form

• Are you able to answer the Door to Allow Care Staff In?

  Yes

  No

  N/A

• Details of how Care Staff will Gain Entry to the Premises: (e.g. Key Safe, Key Holding, someone present etc)

Showering / Bathing / Washing / Grooming

• Service User Prefers:

  Select Shower Bath Bed Sponge Flannel Wash

  • Shower
  • Bath
  • Bed Sponge
  • Flannel Wash

• Service User is:

  Independent

  Prompted

  Supervised

  Some Assistance

  Fully Assisted

• Bathing Risk Assessment Completed?

• Details of Preferred Frequency & Day / Time:

• Showering / Bathing Aids:

  Select Hoist Shower Chair Bath Seat Other

  • Hoist
  • Shower Chair
  • Bath Seat
  • Other

• Details of Other:

• Details of Preferred Toileteries:

• Hair Care:

• Service User is:

  Select Independent Prompted Supervised Some Assistance Fully Assisted

  • Independent
  • Prompted
  • Supervised
  • Some Assistance
  • Fully Assisted

• Hair Dresser Frequency and Details:

• Facial Hair

• Service User Prefers:

  Select Wet Shave Electric Shave Other

  • Wet Shave
  • Electric Shave
  • Other

• Details of Other:

• Shaving Frequency and Details:

• Details of any Other Hair Removal Requirements:

• Oral Hygiene Routine

• Own Teeth:

  None

  Some

  All

• Details of Teeth:

• Dentures:

  Select None Partial Full Upper Full Lower

  • None
  • Partial
  • Full Upper
  • Full Lower

• Details of Dentures:

• At Night, Dentures are to be:

  Select In Out

  • In
  • Out

• Foot Care

• Service User is:

  Select Independent Prompted Supervised Some Assistance Fully Assisted

  • Independent
  • Prompted
  • Supervised
  • Some Assistance
  • Fully Assisted

• Details of Foot Care Routines & any Specialist Treatment:

Dressing and Undressing Requirements

• Service User is:

  Independent

  Prompted

  Supervised

  Some Assistance

  Fully Assisted

• Details of All Assistance Required:

Continence Requirements

• Toileting Regime:

  Select Independent Prompted Supervised Some Assistance Fully Assisted

  • Independent
  • Prompted
  • Supervised
  • Some Assistance
  • Fully Assisted

• Toileting Aids:

  Select None Over Toilet Frame Raised Seat Commode Bed Pan Uridome

  • None
  • Over Toilet Frame
  • Raised Seat
  • Commode
  • Bed Pan
  • Uridome

• Bladder Management

• Service User is:

  Continent

  Incontinent

  Catheterised

• Management Aids:

  Select Pads Pants Kylie Sheets Other

  • Pads
  • Pants
  • Kylie Sheets
  • Other

• Details of Incontinence:

• Details of Specific Toilet Times / Routines / Aids use:

• Bowel Management

• Service User is:

  Continent

  Incontinent

  Catheterised

• Management Aids:

  Select Pads Pants Kylie Sheets Other

  • Pads
  • Pants
  • Kylie Sheets
  • Other

• Details of Incontinence:

• Details of Specific Toilet Times / Routines:

Eating and Drinking Requirements

• Are there any Enteral (PEG/NGT) Feeding Requirements?

  Yes

  No

• Give detailed information as to requirements:

• Prefers to have Meals in their:

  Select Kitchen Dining Room Lounge Bedroom Other

  • Kitchen
  • Dining Room
  • Lounge
  • Bedroom
  • Other

• Give Detail of Other:

• For Eating, the Service User is:

  Independent

  Prompted

  Supervised

  Some Assistance

  Fully Assisted

• Service User is:

  Select Right Handed Left Handed

  • Right Handed
  • Left Handed

• Type of Diet is:

  Select Normal Soft Modified Soft (minced) Puréed Other

  • Normal
  • Soft
  • Modified Soft (minced)
  • Puréed
  • Other

• Is there a requirement for a 'Special Diet'?

  Yes

  No

• Details of 'Special Diet'

• Are there any foods the Service User SHOULD NOT Consume?

  Yes

  No

• Give full details of food items the Service User may not consume and reasons why:

• Is there a requirement for and specific Eating Aids?

  Yes

  No

• Give Full Details:

• For Drinking, the Service User is:

  Independent

  Prompted

  Supervised

  Some Assistance

  Fully Assisted

• Do they have a 'Preferred' drink?

  Yes

  No

• Details of Drinks:

• Is there a requirement to use a 'Thickener' ?

  Yes

  No

• Details of Thickener required:

• Are any 'Drinking Aids' required?

  Yes

  No

• Give Details of Drinking Aids:

Domestic Needs - Meals and Meal Preperation

• For Preparing / Cooking / Heating Meals, the Service User is:

  Independent

  Prompted

  Supervised

  Some Assistance

  Fully Assisted

• Are there any known Food Allergies:

  Yes

  No

• Give details of foods to avoid:

• Details of Preferred Meals and Times:

• For preparing Drinks, the Service User is:

  Independent

  Prompted

  Supervised

  Some Assistance

  Fully Assisted

• Details of Preferred Drinks and Times:

Domestic Needs - Housework

• Will Staff be required to undertake General Cleaning duties?

  Yes

  No

• Details all Cleaning duties:

Domestic Needs - Beds

• Will Staff be required to make / change beds?

  Yes

  No

• Details of Routine and Requirements:

Domestic Needs - Laundry

• Will Staff be required to undertake Laundry duties?

  Yes

  No

• Details of Routine / Detergents / Drying etc.

Domestic Needs - Shopping

• Will Staff be required to undertake Shopping duties?

  Yes

  No

• Is a 'Financial Record' form in place?

• Details of Shopping Requirements inc. Days / Times / Locations etc:

Sleeping and Settling Requirements

• Usual Time to Rise:

  Date

• Usual Time to Bed:

  Date

• Daytime Rest Routine:

• Preferred Sleeping Position:

  Select No Preference Back Front Left Side Right Side

  • No Preference
  • Back
  • Front
  • Left Side
  • Right Side

• Preferences for Bed Coverings / Pillows etc.

• Sleeping Aids:

  Select Massage Music Radio Hot Pack Other Warm Drink Cold Drink Snack

  • Massage
  • Music
  • Radio
  • Hot Pack
  • Other
  • Warm Drink
  • Cold Drink
  • Snack

• Sleeping Aids Details:

• Room Preferences:

  Select Light On Light Off Night Light Door Open Door Closed Window Open Window Closed Bed Rails Up

  • Light On
  • Light Off
  • Night Light
  • Door Open
  • Door Closed
  • Window Open
  • Window Closed
  • Bed Rails Up

• Night Time Patterns:(e.g. Wanders/Talks/Shouts etc.)

• Details of any Night Time Checks Required:

Finances

• Does the Service User manage their own finances

  Yes

  No

  N/A

• Contact details for Finance Management:

• Have they made any Advanced Decisions?

  Yes

  No

  N/A

• Contact details of responsible Person:

• Have they prepared a Will?

  Yes

  No

  N/A

• Contact details of responsible Person:

Emotional and Mental Wellbeing

• Do you have any Emotional Wellbeing or Mental Health considerations?

  Yes

  No

• Relevant Details:

• Do identified Mental Health considerations have potential to cause a risk?

  Yes

  No

  N/A

• Who is at Risk?

  Select Self Staff Visitors

  • Self
  • Staff
  • Visitors

• Give Full Details:

• Do identified Emotional Wellbeing considerations have potential to cause a risk?

  Yes

  No

  N/A

• Who is at Risk?

  Select Self Staff Visitors

  • Self
  • Staff
  • Visitors

• Give Full Details:

• Has a 'Triggers and Precipitating Factors' form been completed

  Yes

  No

  N/A

• Is there a risk of 'Wandering'?

  Yes

  No

• Is a Full Risk Assessment and Management Plan completed?