Personal Details

Your Personal Details

Full Name inc. Title:

Date of Birth:

How would you like to be addressed:

Address:

Home Telephone Number:

Mobile Telephone Number:

Preferred Language:

Do you require a Translator?

Religion / Beliefs:

Next of Kin Details

Name:

Relationship to you:

Address:

Home Telephone Number:

Work Telephone Number:

Mobile Telephone Number:

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

Are they the same as 'Next of Kin'?

SEE NEXT OF KIN DETAILS

Name:

Relationship to you:

Primary Contact Number:

Secondary Contact Number:

GP Details

GP Name:

Surgery Name:

Surgery Address:

Telephone Number:

Out of Hours Telephone Number:

Care Manager / Social Worker Details

Name:

Address:

Office Telephone:

Out of Hours Telephone:

Funding Details
Date Paperwork Received:
Social Services Review Date:

Funding Sources:

Total Care / Support Hours Required:

Existing Support

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)

Details:

About You and Your Life History

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):

Details:

Medical and Medication

Medical and Medication Information

Known Allergies

Medical History

Does the Service User take Medication?

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')

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

Medication Dispensing:

Does the Service User Self Medicate?

Complete a 'Medication Self Assessment' form

Are Staff Required To have involvement with Service User Medication?

What Level of Input will be required by Staff?

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

Specialist Training Requirements:

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

Local Authority Requirements:

Is a MAR Chart in Place and Ready for use?

CONTACT OFFICE TO ARRANGE FOR MAR CHART BEFORE COMPLETING THIS SECTION

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

Details of any Difficulties:

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

Details of any Potential Risks:

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

Details of requirements:

Are there any 'Controlled Drugs' on the premises?

Are they Adequately Stored?

Details of Storage Improvement Requirements:

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

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

Any Relevant Notes or Information:

Skin Care

Skin Care and Pressure Care

Are there any Skin Care Concerns at this time?

Describe Skin Care Concern:

CLEARLY IDENTIFY ON BODY CHART (Photograph if possible)

Select Chart

Complete chart when Printed

Female Chart

Complete Chart when Printed

Male Chart
Media

Skin Care Products to use:

Describe Skin Care Routine:

Any Relevant Notes or Information:

Are there any Pressure Care issues at this time?

Describe Pressure Care concern:

CLEARLY IDENTIFY ON BODY CHART (Photograph if possible)

Select Chart

Complete chart when Printed

Female Chart

Complete Chart when Printed

Male Chart
Media

What pressure Care Aids are to be used?

Describe Pressure Care Routine:

Is a 'Turns Monitoring' Form Required?

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

Any Relevant Notes or Information:

Sight - Hearing - Communication

Sight - Hearing - Communication
Sight

Service Users Sight is:

Does the Service User Wear Glasses?

Glasses required:

Other Relevant Information: (contact lenses etc)

Any Relevant Notes or Information:

Hearing

Service Users Hearing is:

Is a Hearing Aid or Hearing Device Used?

Details of Devices Used:

Any Relevant Notes or Information:

Communication
Service Users Levels of Verbal Communication and Conversation are:

Do they Respond Well to YES / NO Type Questions?

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

Any Relevant Notes or Information:

Mobility and Dexterity

Mobility and Dexterity

Able to Walk Unaided?

Requires the use of the following items:

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

MOBILITY AID RISK ASSESSMENT and MANAGEMENT PLAN COMPLETED?

Able to answer the Door to Allow Care Staff In?

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

Able to Go Out Alone?

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

Complete an 'EXTERNAL RISK ASSESSMENT' Form

Any Relevant Notes or Information:

Falls

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

Record Details and complete a 'Falls Risk Assessment' Form

Any Relevant Notes or Information:

Showering/Bathing/Grooming

Personal Hygiene Routines
Showering / Bathing
Service User Prefers:

Service User is:

Bathing Risk Assessment Completed?

Details of Preferred Frequency & Day / Time:

Showering / Bathing Aids:

Details of Other:

Details of Preferred Toileteries:

Any Relevant Notes or Information:

Hair Care
Service User is:

Hair Dresser Frequency and Details:

Facial Hair

Service User Prefers:

Details of Other:

Shaving Frequency and Details:

Details of any Other Hair Removal Requirements:

Any Relevant Notes or Information:

Oral Hygiene Routine

Own Teeth:

Details of Teeth:

Dentures:

Details of Dentures:

At Night, Dentures are to be:

Any Relevant Notes or Information:

Foot Care
Service User is:

Details of Foot Care Routines & any Specialist Treatment:

Any Relevant Notes or Information:

Dressing / Undressing

Dressing and Undressing Requirements

Service User is:

Details of All Assistance Required:

Any Relevant Notes or Information:

Continence Needs

Continence Requirements
Toileting Regime:
Bladder Management

Service User is:

Management Aids:

Details of Incontinence:

Catheter Management Plan:

Toileting Aids:

Details of Specific Toilet Times / Routines:

Any Relevant Notes or Information:

Bowel Management

Service User is:

Management Aids:

Details of Incontinence:

Details of Specific Toilet Times / Routines:

Any Relevant Notes or Information:

Eating and Drinking

Eating and Drinking Requirements

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

Give detailed information as to requirements:

Prefers to have Meals in their:

Details:

For Eating, the Service User is:

Service User is:
Type of Diet is:

Details:

Is there a requirement for a 'Special Diet'? (Low Fat, High Fibre etc)

Details of 'Special Diet'

Are there any foods the Service User SHOULD NOT Consume?

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

Is there a requirement for and specific Eating Aids?

Give Full Details:

For Drinking, the Service User is:

Do they have a 'Preferred' drink?

Details of Drinks:

Is there a requirement to use a 'Thickener' ?

Details of Thickener required:

Are any 'Drinking Aids' required?

Give Details of Drinking Aids:

Any Relevant Notes or Information:

Domestic Needs

Domestic Needs - Meals and Meal Preperation

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

Are there any known Food Allergies:

Give details of foods to avoid:

Details of Preferred Meals and Times:

For preparing Drinks, the Service User is:

Details of Preferred Drinks and Times:

Domestic Needs - Housework

Will Staff be required to undertake General Cleaning duties?

Details all Cleaning duties:

COSHH Risk Assessment Completed?

Any Relevant Notes or Information:

Domestic Needs - Beds

Will Staff be required to make / change beds?

Details of Routine and Requirements:

Any Relevant Notes or Information:

Domestic Needs - Laundry

Will Staff be required to undertake Laundry duties?

Details of Routine / Detergents / Drying etc.

COSHH Risk Assessment Completed?

Any Relevant Notes or Information:

Domestic Needs - Shopping

Will Staff be required to undertake Shopping duties?

Is a 'Financial Record' form in place?

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

Any Relevant Notes or Information:

Sleeping and Settling

Sleeping and Settling Requirements
Usual Time to Rise:
Usual Time to Bed:

Daytime Rest Routine:

Preferred Sleeping Position:

Preferences for Bed Coverings / Pillows etc.

Sleeping Aids:

Sleeping Aids Details:

Room Preferences:

Complete a Bed Rail Risk Assessment

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

Details of any Night Time Checks Required:

Any Relevant Notes or Information:

Finances

Finances and Advanced Decisions

Does the Service User manage their own finances

Contact details for Finance Management:

Have they made any Advanced Decisions?

Contact details of responsible Person:

Have they prepared a Will?

Contact details of responsible Person:

Emotional Wellbeing

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

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

Has a 'Triggers and Precipitating Factors' form been completed

Who is at Risk?

Give Full Details:

What is the Level of Risk?

Complete a 'Risk Management Plan'

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

Has a 'Triggers and Precipitating Factors' form been completed

Who is at Risk?

Give Full Details:

What is the Level of Risk?

Complete a 'Risk Management Plan'

Is there a risk of 'Wandering'?

Details:

Is a Full Risk Assessment and Management Plan completed?

Risk Assessments

Risk Assessments
General and Physical Health

Do you have any General or Physical Health Considerations?

Details:

Do the above considerations have the potential to cause Risk?

Details:

Is there a Risk of Injury from Slips or Falls?

Details:

Falls Risk Assessment

Age:

Mobility:

History of Falls?

Sensory Impairment:

Other Factors

Medication Side Effects?

Loss of Sensation?

Oedema Lower Limbs?

Short of Breath?

Dizzy or Light-Headedness?

Pain?

Muscle Wastage or Weakness?

Incontinence and tries to rush to toilet?

Problems with Balance?

Confusion or Aggression?

Poor Fitting Footwear?

Wanderer?

Trip Hazards around home?

Select Total Score:

Is the Score Lower than 14?

Service User is Low Risk and No Management Plan is required at this time.

Is the Score Lower than 8?

Service Users with a score of 8 or BELOW ARE AT HIGH RISK..!!!
Review Care Plan provision and consider the person to be a High Dependency Service User
Review Staffing input requirement..

Complete a Falls Risk Management Plan for a HIGH RISK Service User.

Complete a Falls Risk Management plan for a MEDIUM RISK Service User

Service Users with a score of 13 or BELOW ARE AT RISK..!!!
Condition and Care Plan should be monitored closely and staff should ensure that the Service User has all necessary personal items close to hand to minimise risks.

Select date
Staff Member Completing:

Is there a Risk Relating to the use of Mobility Aids?

Complete a MOBILITY AID RISK ASSESSMENT

Is there a requirement for a Moving & Handling Risk Assessment?

Complete a MOVING & HANDLING RISK ASSESSMENT

Is there a requirement to Assist with Bathing & Showering?

Complete a BATHING & SHOWERING RISK ASSESSMENT

Is there a Risk from Smoking?

Complete a SMOKING RISK ASSESSMENT

Is there a requirement for an 'External Activities' Risk Assessment?

Complete an EXTERNAL ACTIVITIES RISK ASSESSMENT

Any relevant Notes or Information

Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.