Initial Care Needs and Risk Assessment - Residential Care v.3.0

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Your Personal Details

• Full Name inc. Title:

• Date of Birth:

  Date

• How would you like to be addressed:

• Current Address:

• Contact Telephone Number:

• Preferred Language:

• Do you require a Translator?

  No

  Yes

• 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'?

  Yes

  No

• 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:

  Date

• Social Services Review Date:

  Date

• Funding Sources:

• Total Care / Support Hours Required:

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)

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

• Does the Service User take Medication?

  No

  Yes

• 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

• Does the Service User Self Medicate?

  Yes

  No

• Complete a 'Medication Self Assessment' form

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

  No

  Yes

• 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'?

  No

  Yes

• Specialist Training Requirements:

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

  No

  Yes

• Local Authority Requirements:

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

  Yes

  No

• ARRANGE FOR MAR CHART BEFORE COMPLETING THIS SECTION

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

  No

  Yes

• Details of any Difficulties:

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

  No

  Yes

• Details of any Potential Risks:

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

  Yes

  No

• Details of requirements:

• Are there any 'Controlled Drugs'?

  No

  Yes

• Are they Adequately Stored?

  Yes

  No

• Details of Storage Improvement Requirements:

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

  No

  Yes

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

• Any Relevant Notes or Information:

Skin Care and Pressure Care

• Are there any Skin Care Concerns at this time?

  No

  Yes

• Skin Care Products to use:

• Skin Care Routine:

• CLEARLY IDENTIFY ON BODY CHART

• Select Chart

  Male

  Female

• Complete Chart when Printed

  

• Complete Chart when Printed

  

• Any Relevant Notes or Information:

Pressure Care Concerns

• Are there any Pressure Care issues at this time?

  No

  Yes

• Pressure Care Aids:

• Pressure Care Routine:

• CLEARLY IDENTIFY ON BODY CHART

• Select Chart

  Male

  Female

• Complete Chart when Printed

  

• Complete Chart when Printed

  

• Any Relevant Notes or Information:

Turns Monitoring requirements

• Is a 'Turns Monitoring' Form Required?

  No

  Yes

• Completed and included with the Care Plan?

• Any Relevant Notes or Information:

Communication

• 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)

• Any Relevant Notes or Information:

Sight

• Service Users Sight is:

  Full

  Partial

  No Sight

• Does the Service User Wear Glasses?

  No

  Yes

• Glasses required:

  Occasionaly

  Reading Only

  Always

• Other Relevant Information: (contact lenses etc)

• Any Relevant Notes or Information:

Hearing

• Service Users Hearing is:

  Full

  Partial

  No Hearing

• Is a Hearing Aid or Hearing Device Used?

  No

  Yes

• Details of Devices Used by Service User:

• Any Relevant Notes or Information:

Mobility and Dexterity

• Able to Walk Unaided?

  Yes

  No

• Requires the use of the following items:

  Select Wheelchair Frame Stick Calliper Brace Other

  • Wheelchair
  • Frame
  • Stick
  • Calliper
  • Brace
  • Other

• Details of Other Equipment or Device:

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

  No

  Yes

• COMPLETE A MOBILITY RISK ASSESSMENT

• Able to Go Out Alone?

  Yes

  No

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

  No

  Yes

• Details:

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

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

  No

  Yes

• Details:

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

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

  No

  Yes

• Details:

• Complete a 'Falls Risk Assessment' Form

• Any Relevant Notes or Information:

Personal Hygiene Routines

Showering / Bathing

• Service User Prefers:

  Select Shower Bath Bed Sponge Flannel Wash Other

  • Shower
  • Bath
  • Bed Sponge
  • Flannel Wash
  • Other

• Details:

• 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 Toiletries:

• Any Relevant Notes or Information:

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

  No

  Yes

• 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:

• Any Relevant Notes or Information:

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

• Any Relevant Notes or Information:

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 & Specialist Treatment:

• Any Relevant Notes or Information:

Dressing and Undressing Requirements

• Service User is:

  Independent

  Prompted

  Supervised

  Some Assistance

  Fully Assisted

• Details of All Assistance Required:

• Any Relevant Notes or Information:

Bladder Management

• Service User is:

  Continent

  Incontinent

  Catheterised

• 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

• Management Aids:

  Select Pads Pants Kylie Sheets Other Catheter

  • Pads
  • Pants
  • Kylie Sheets
  • Other
  • Catheter

• Catheter Management Plan:

• Details:

• Details of Specific Toilet Times / Routines:

• Any Relevant Notes or Information:

Bowel Management

• Service User is:

  Continent

  Incontinent

  Catheterised

• Management Aids:

  Select Pads Pants Kylie Sheets Other Catheter

  • Pads
  • Pants
  • Kylie Sheets
  • Other
  • Catheter

• Details of Incontinence:

• Details of Specific Toilet Times / Routines:

• Any Relevant Notes or Information:

Eating and Drinking Requirements

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

  No

  Yes

• Give detailed information as to requirements:

• Prefers to have Meals in:

  Select Dining Room Bedroom Other

  • Dining Room
  • Bedroom
  • Other

• Details:

• 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

• Requires a 'Special diet'?

  Yes

  No

• Type of Diet is:

  Select Normal Soft Modified Soft (minced) Puréed High Fibre Low Fat High Fat Gluten Free Other

  • Normal
  • Soft
  • Modified Soft (minced)
  • Puréed
  • High Fibre
  • Low Fat
  • High Fat
  • Gluten Free
  • Other

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

  No

  Yes

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

• Is there a requirement for and specific Eating Aids?

  No

  Yes

• Give Full Details:

• For Drinking, the Service User is:

  Independent

  Prompted

  Supervised

  Some Assistance

  Fully Assisted

• Do they have a 'Preferred' drink?

  No

  Yes

• Details of Drinks:

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

  No

  Yes

• Details of Thickener required:

• Are any 'Drinking Aids' required?

  Yes

  No

• Give Details of Drinking Aids:

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

• Contact details for Finance Management:

• Have they made any Advanced Decisions?

  No

  Yes

• Contact details of responsible Person:

• Have they prepared a Will?

  No

  Yes

• Contact details of responsible Person:

General and Physical Health

• Do you have any General or Physical Health Considerations?

  No

  Yes

• Details:

• Do the above considerations have the potential to cause Risk?

  No

  Yes

• Details:

• Is there a Risk of Injury from Slips and Falls?

  No

  Yes

• Details:

Falls Risk Assessment

• Age:

  Under 70 4

  Over 70 3

• Mobility:

  Steady on Feet 5

  Walks with Aid 4

  Unsteady 3

• History of Falls?

  None 5

  Fallen in Past 12 Months 3

• Sensory Impairment?

  None 5

  Single 4

  Multiple 3

• Other Factors

• Medication Side-Effects?

  No 0

  Yes -1

• Loss of Sensation?

  No 0

  Yes -1

• Oedema Lower Limbs?

  No 0

  Yes -1

• Shortness of Breath?

  No 0

  Yes -1

• Dizziness or Light-headedness?

  No 0

  Yes -1

• Pain?

  No 0

  Yes -1

• Muscle Wastage or Weakness?

  No 0

  Yes -1

• Incontinence and tries to Rush to toilet?

  No 0

  Yes -1

• Problems with Balance?

  No 0

  Yes -1

• Confusion or Aggression?

  No 0

  Yes -1

• Poor Fitting Footwear?

  No 0

  Yes -1

• Wanderer?

  No 0

  Yes -1

• Trip Hazards around the Home?

  No 0

  Yes -1

• Select Total Score:

  Select -1 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19

  • -1
  • 0
  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10
  • 11
  • 12
  • 13
  • 14
  • 15
  • 16
  • 17
  • 18
  • 19

• Is the score LOWER than 14?

  No

  Yes

• Service User is LOW RISK - NO Management Plan required at this time

• Is the Score LOWER than 8?

  No

  Yes

• Service Users with a Score of 8 or Below ARE AT HIGH RISK..!!!
  Review Care Plan provision and consider the person to be HIGH DEPENDENCY
  Review Staffing input requirement.

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

• Service Users with a Score of 13 or Below ARE AT MEDIUM RISK..!!
  Their Condition and Care Plan should be Monitored Closely and staff should ensure that the person has all necessary personal items close to hand to minimise risk.

• Complete a Falls Risk Management Plan for MEDIUM RISK Service User.

• Select date

  Date

• Staff Member Completing Risk Assessment:

  Sign

• Is there a Risk Relating to Mobility Aids?

  No

  Yes

• Complete a MOBILITY AID RISK ASSESSMENT

• Is there a Requirement for a Moving & Handling Assessment?

  No

  Yes

• Complete a MOVING & HANDLING RISK ASSESSMENT

• Is there a Requirement to Assist with Bathing & Showering?

  No

  Yes

• Complete a BATHING & SHOWERING RISK ASSESSMENT

• Is there a Risk from Smoking?

  No

  Yes

• Complete a SMOKING RISK ASSESSMENT

• Is there a Requirement for an 'External Activities' Risk Assessment?

  No

  Yes

• Complete an EXTERNAL ACTIVITIES RISK ASSESSMENT

• Any relevant Notes or Information:

Mental Health & Emotional Wellbeing

• Do you have any Mental Health considerations?

  No

  Yes

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

  No

  Yes

• Details of the Risks:

• Who is likely to be at Risk?

  Select Self Staff Residents Visitors N / A

  • Self
  • Staff
  • Residents
  • Visitors
  • N / A

• Complete a 'Triggers & Precipitating Factors' Form

• What is the 'Level of Risk'?

  LOW

  MEDIUM

  HIGH

• Complete a 'Risk Management Plan'

• Do you have any Emotional Wellbeing considerations?

  No

  Yes

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

  No

  Yes

• Details of the Risks:

• Who is likely to be at Risk?

  Select Self Staff Residents Visitors N / A

  • Self
  • Staff
  • Residents
  • Visitors
  • N / A

• What is the 'Level of Risk'

  LOW

  MEDIUM

  HIGH

• Complete a 'Risk Management Plan'

• Complete a 'Triggers & Precipitating Factors' Form

• Are there any Risk of the Service User 'Wandering'?

  No

  Yes

• Details:

• What is the 'Level of Risk'?

  LOW

  MEDIUM

  HIGH

• Complete a 'Risk Management Plan'

Considerations on the use of Bedrails

• Is there a likelihood of Falling Out of Bed?

  No

  Yes

• Consider the use of Bedrails after using the Risk Matrix Tool

• Would the Service User feel 'Anxiuos' if they DID NOT have Bedrails?

  No

  Yes

• Consider the use of Bedrails after using the Risk Matrix Tool

• Are Bedrails Likely to Reduce Independence?

  No

  Yes

• Consider the Safety aspect of use after using the Risk Matrix Tool

Bedrail Safety

• Are Bedrails to be used?

  No

  Yes

• Is there a likelihood that the Service User may 'Climb Over' the rails?

  No

  Yes

• Complete a Risk Management Plan

• Is the Bed and Mattress suitable for the Rails?

  Yes

  No

• Arrange for suitable equipment before using bedrails

• Are there any 'GAPS' between the rail and any part of the bed that the Service User could potentially 'Trap' parts of their body?

  No

  Yes

• Arrange for suitable equipment before using rails

• Are the Bedrails in good condition?

  Yes

  No

• Details:

• Arrange for Rails to be Serviced / Replaced