Care Costing - Resident

• Site conducted

  Select

• Costing Completed on

  Date

• Costing Prepared by Name

• Resident Name

• Bedroom Number (Existing or Proposed)

• Placement Type

  Permanent

  D2A / Spot Purchase

  Respite

• Social Worker or Discharge Contact Name (NOK if Privately funded with no SW)

• Social Worker or Discharge Contact Phone Number (NOK if Privately funded with no SW)

• Social Worker or Discharge Contact Email (NOK if Privately funded with no SW)

Care Cost to Funder

• Care Cost to Funder (Code 16) (£/Week)

• FNC (Code 15)

  FNC Not Applicable

  + FNC

Description of Resident Care Needs

• Please provide a description of residents care needs (or attach assessment)

Care Costing

• Bedroom / Hotel Cost (Code 1) (£/per week)

• Special Room Cost (£/per week)

  Yes

  No

• Special Room Cost (Code 2) (£/per week)

• Description of Special Room Requirements

• Food Cost (Code 3) (£/per week)

• Any Additional Specialist Dietary Requirement Cost or Food Cost

  Yes

  No

• Specialist Dietary Requirement Cost or Food Cost (Code 4) (£/Week)

• Specialist Dietary Requirement Cost or Food Cost Description

• Ancilliary Costs for Catering, Cleaning, Laundry, Reception, Admin and Management (Code 5) (£/Week)

• Any Additional Ancilliary Cost

  Yes

  No

• Additional Ancilliary (Code 6) (£/Week)

• Additional Ancilliary Cost Description

• Total Care Hours Per Day (In accordance with Depensys - Dependency System)

• Total Care Cost (Code 7) (£/ Week)

• Are any one 2 one Care hours required?

  Yes

  No

• One 2 one Care required (hours / per day)

• Total Skilled / Nursing Hours Per Day (In accordance with Depensys - Dependency System)

• Total Skilled / Nursing Cost (Code 9) (£/ Week)

• Are any one 2 one Nursing hours required?

  Yes

  No

• One 2 one Nursing hours required (hours / per day)

• Any Specialist Equipment Costs

  Yes

  No

• Specialist Equipment Cost (Code 11) (£/Week)

Care Cost Totals

• Total Care Cost (Code 12) (£/ Week)

• Funding Type

  Privately Funded

  Local Authority

  CCG / CHC

• NOK Name responsible for Funding

• Relationship to Resident

• Name of Local Authority Funding

• Discount Applicable? (Code 13)

  Select 0% 5% 10% 15% 20% 25%

  • 0%
  • 5%
  • 10%
  • 15%
  • 20%
  • 25%

• Total Care Cost After Discount Applied (Code 14) (£/Per Week)

• Name of CCG Funding

• Discount Applicable? (Code 13)

  Select 0% 5% 10% 15% 20% 25%

  • 0%
  • 5%
  • 10%
  • 15%
  • 20%
  • 25%

• Total Care Cost After Discount Applied (Code 14) (£/Per Week)

• Is FNC to be applied for? (Code 15)

  Yes

  No

• FNC Amount (Code 15) (£/Week)

  £209.19

• Total Cost with FNC deducted (Code 16) (£/Week)

• If FNC (Funded Nursing Care) is not awarded the Full Total Cost will be applied to the resident funder.