Client Profile and Risk Assessment

Client Profile and Risk Assessment

Surname Title
Forename(s) D.O.B
Marital Status:
Address/Care Site
Post Code: Tel No:
Place of Birth: Ethnic Group:
Religion : Language:
Next of Kin: Relationship:
Address:
Post Code: Home No:
Work:
Mobile:
Emergency Contact:
G.P: Tel No:
Address:
District Nurse: Tel No:
Home Help: Yes /No M.O.W Yes/No
Day Care: Yes/No Sheltered Housing: Yes/No
Medical / Surgical History:

Medication

Yes

No

No Medication
Self Medicates
Needs Medication Dispensed

Requires Supervision

PRN Medication Only

Regularly refuses medication

Medication Taken

Chemist:
Administered By: / Where Stored:
Who gets repeats:
Breathing: /

Yes

No

No Breathing Problems

Occasional Breathing Problems

Severe Problems e.g Bronchitis

Requires Nebuliser/O2

Hearing

Yes

No

Hears Clearly

Partially Deaf

Can hear but not comprehend

Totally Deaf

Uses Hearing Aid

Lip Reads

Uses Sign Language

Sight

Yes

No

Good Sight

Can see with Glasses

Partially Sighted

Can only make out shapes

Registered Blind

Specify Conditions:

Elimination

Yes

No

Full Control

Assistance with Hygiene needs

Occasional incontinence of Urine

Occasional incontinence of Faeces

Regular incontinence of Urine

Regular incontinence of Faeces

Regular Double incontinence

Catheter/Sheath

Other Information:

Mental State

Yes

Alert

Apathetic

Withdrawn

Occasional Forgetfulness

Short Concentration \span

Periods of Confusion

Periods of Agitation

Severe Confusion

Pain

Anxiety

Aggressiveness

Communication

Yes

Speaks clearly and comprehends

Speech impaired

Commutation Aid e.g.

Comprehends but cannot speak

Impaired comprehension

No comprehension or speech

Motivation

Yes

Well Motivated

Needs encouragement

Prefers own Company

Totally Unmotivated

Sleep

Yes

Sleeps Well

Sleeps with Sedation

Difficulty in getting to Sleep

Needs Early Morning Waking

Needs Regular Attention e.g. turning

Nocturnal Wandering

Mobility

Yes

Walks Unaided

Climbs Stairs with Assistance

Walks with Assistance

Needs assistance of 2 or more

Totally dependent on Staff

Requires Aids:

Personal Hygiene

Yes

Able to use Shower/Bath without Assistance
Able to Wash Unaided
Needs Help/Supervision to wash/Bathe
Requires Bed bath
Uses Aids
Specify Equipment:

Service Date: Monitored By:

Care Plan Routine

Morning:
Lunch:
Tea-Time:
Evening Visit:

Dressing

Yes

Able to Dress/Undress unaided

Minimal assistance/supervision

Considerable help required

Needs Full help to dress/undress

Specify any additional Factors:

Eating/Drinking

Yes

Eats / Drinks Unaided

Needs Some Assistance

Needs to be Fed

Swallowing Difficulties

Tube Fed

Specify Medical conditions/Equipment: e.g Diabetes , Tube Fed.

Access;

/ Keysafe;
Key Holders;

Domestic Duties

Yes

Appliances

Cooker

Washing Machine

Dish Washer

Microwave

Other Electrical

Cleaning Materiels (COSHH)
Where Stored:

Environmental Risk Assessment

Services user name :
Address: / Date of Assessment:
Completed By:

Mark the relevant box with a ü

Yes

No

/ Comments &
Actions to be taken
Is the property isolated?
Is there easy access to the property from the highway?
Is the access/egress route adequately illuminated?
Is there a telephone?
Do the doors have security locks or chains fitted?
Is a Manual Handling assessment required?
Locationof Manual Handling issues:
Does the client smoke?
Do all electrical appliances and sockets appear to be safe to use?
Are there adequate fire safety arrangements e.g. smoke alarms?
Do all gas appliances and their controls appear to be safe?
Are there any animals to be aware of?
Location of fuse box:
Location of gas cut off:
Are there any other considerations to be noted:

ACCESS TO PREMISES

/ Yes / No / COMMENTS:
Location
Parking
Pathways
Lighting
Steps
Intercom system/pass code
HALLWAY
Lighting
Flooring
Furniture
Access
Stair lift
KITCHEN
Lighting
Flooring
Electric’s
Gas
Other power sources
Food storage
Preparation area
Cleanliness
Sharp utensils
Water temp.
Pests
LIVING ROOM
Flooring
Access
Furniture
Heating
Electric’s
Lighting
BATHROOM
Flooring
Lighting
Access and space

Handrails

Lifting aids
Heating
Bath or Shower (delete which not applicable)
Non slip mats
Ventilation

ACCESS TO PREMISES

/ Yes / No / COMMENTS:
TOILET
Upstairs/downstairs/both/outside
Access and space
Flooring
Grab rails
Aids
Washing facilities
Lighting
Heating
BEDROOMS
Flooring
Access and space
Furniture
Aids
Heating
Lighting
Electric’s
Access to toilet
OTHER ROOMS:
MAINS SUPPLY
Gas
Electricity
Water
CALL SYSTEM
Telephone
Pendant
Warden
OTHER HAZARDS
Cross infection
Safety and wellbeing of carer

Other environmental hazards

Manual handling
Smoking
Smoke detectors
Pets
Action to be taken / by whom

SIGNATURE:

COPIES TO:

Westminster Homecare / Page 1 of 12 / Assessment Input Records - Updated May 2008 (A Jones)

CLIENT – CENTRED GOAL SETTING

Client’s Name: / Care Worker: / Professionals involved:
Client priorities (as discussed with client):
Initial Date / Client’s Initial status / Goal Date / Rehabilitation Goals / Outcome Date / Client Outcome
Initial Date / Client’s Initial status / Goal Date / Rehabilitation Goals / Outcome Date / Client Outcome
Westminster Homecare / Page 1 of 12 / Assessment Input Records - Updated May 2008 (A Jones)

Home Visit Report

Service User Name:
Address:
Postcode:
Date of Visit: / Time of Visit:
Visit carried out by:
Position:
Discussion and Recommendations:
Signed:
Date:
Westminster Homecare / Page 1 of 12 / Assessment Input Records - Updated May 2008 (A Jones)