CONSENT

We need to keep a record of our work with you so that we know what actions we have taken, and why, and to ensure we can continue to support you

People we may need to share information with include other professionals such as a district nurse, providers of support services, Cumbria Fire and Rescue Service, your family. We will only share information as needed.

Do you consent for relevant information to be stored and shared as needed?
Yes
Yes with Limitations
No
Unable to give Consent
What limitations to consent would you like recorded?

For example you may wish to ask us not to share certain information with health staff, or a family member, or to state exactly who you are happy for us to share information with.

If you are unable to give consent, is there someone who could do this on your behalf?

Yes No

If Yes:

Name
Relationship

In some circumstances our local policy may enable us to continue with an assessment, and share information without your consent. The reason we have continued without your consent is

COMMUNICATION

What Language would you prefer to communicate in?

Do you have any communication needs? For example problems with talking, or understanding what people say to you? Yes No Not agreed

Do you have problems with speaking?Yes No

Do you have problems understanding speech?Yes No

Does memory loss, confusion or anxiety affect your ability to communicate? Yes No

If you answer yes to any of these communication issues then consider whether an advocate/interpreter/family member is required

SENSORY IMPAIRMENT

Do you have problems with your eyesight?Yes No

Does this affect your ability to read and /or write? Yes No

Are you Registered Visually Impaired? Yes No

Do you have problems with your hearing?Yes No

Do you have dual sensory loss?Yes No

Do you have any other sensory loss/Issues? E.g. Autism related.

Yes No

PHYSICAL HEALTH AND WELLBEING

Do you have any physical health conditions, disabilities or allergies which affect your daily life?

Yes No Not agreed

If so, how long have you had these for?

Have you spoken to anyone about this recently e.g. GP/Nurse?

Yes No

Have you recently been in hospital including the Accident & Emergency department? Yes No

MENTAL HEALTH AND EMOTIONAL WELLBEING

Do you have any mental health conditions which affect your daily life or your emotional wellbeing? This could include feeling anxious or low in mood, some confusion or memory loss, or a diagnosed mental health condition.

(Practitioner guidance - There may be concerns that other people have raised or that you as a practitioner observe but which the individual does not acknowledge, this may be a difference in perception. This should be recorded using the comments field and you should be explicit about whose opinion it is)

Yes No Not agreed

How long have you had these for?

Have you spoken to anyone about this such as a G.P, specialist nurse?

Yes No

Have you had an assessment from mental health services?Yes No

Did your assessment result in a diagnosis? Yes No

Were you diagnosed with Dementia?

Please note that dementia is the generic term for a number of conditions - Alzheimer's disease, Lewy body dementia, Pick's disease, Fronto-temporal dementia, Vascular dementia

Yes No

If Yes, please give details:

Were you given another diagnosis?

Yes No

CONTINUING HEALTH CARE

CONTINUING HEALTH CARE

Is a Continuing Health Care Assessment required? Yes No

If yes, please ensure continuing health care guidelines are followed. Complete continuing health care screening and consider whether a further assessment is required.

Has the Service User previously had a Continuing Care Assessment?

YES / NO
If yes; please give details below
Date of previous assessment :

MEDICATION

Are you on any prescribed medication? Yes No

Observed Reported verbally Pharmaceutical list provided

How do you manage yourmedication?

1. Independent / 2. Independent with Equipment / 3. With Difficulty and/or Need Personal Help / 4. Unable to do / N/A / Observed / stated
O/S
Medication

PERSONAL CARE

Do you have difficulty with managing your personal care?This could be things such as washing and dressing yourself, getting to the toilet, having a bath or a shower?

Yes No Not agreed

1. Independent / 2. Independent with Equipment / 3. With difficulty and/or Need Personal Help / 4. Unable to do / N/A / Observed / stated
O/S
Washing
Bathing
Showering
Dressing yourself
Grooming
Going to the toilet/Continence

MOBILITY

Falls –

Are you at risk of Falls Yes No Don’t Know

Have you fallen once in last 12 months
Have you fallen several times in last 12 months
Does your risk of falls prevent you from leaving your home?
No falls in last 12 months

If person has fallen please consider referring for a falls assessment.

Do you have difficulty with your mobility – this includes moving around both inside and outside your home?

Yes No Not agreed

1. Independent / 2. Independent with Equipment / 3. With difficulty and/or Needs Personal Help / 4. Unable to do / N/A / Observed / stated
O/S
Indoor mobility
Outdoor mobility
Steps
Stairs
Chair
Bed
toilet
Bath
Shower
Into/out of car
(as passenger)
On/off public transport

If equipment is used, please state what equipment is used and how:

Further details (only complete if required for equipment purposes)

Are you left or right Handed / Left Right
Height
Weight
Property Information – For Use as required and when major or minor adaptations being considered which could affect the fabric of the building
Property Owner & details
Access Issues
Rooms / Lounge Dining Kitchen
Number of bedrooms
Bathroom / Ground Floor First Floor
Toilet / Ground Floor First Floor
Shower / Over Bath Cubical Level Access

PREPARING AND EATING MEALS AND DRINKS

Are you able to manage your nutritional needs? This includes preparing food and drink including cooking safely and ability to eat and drink.

Yes No Not agreed

1. Independent / 2. Independent with Equipment / 3. with difficulty and/or Need Personal Help / 4. Unable to do / N/A / Observed / stated
O/S
Preparing food
Preparing drinks
Eating
Drinking
Cooking

DOMESTIC ACTIVITIES

Are you able to manage your practical domestic activities such as shopping, laundry, cleaning, gardening, managing your money and keeping your home warm: -

Yes No Not agreed

1. Independent / 2. Independent with Equipment / 3. With difficulty and/or Needs Personal Help / 4. Unable to do / N/A / Observed / stated
O/S
Shopping
Laundry
Cleaning
Gardening
Managing your money
Staying warm/heating your home

Benefits -

Do you receive benefits? Yes No

If Yes, please give details:

Would you like to be referred for assessment of whether you would be entitled to any benefits, or further benefits? Yes No

Who has this been referred to e.g. DWP, Financial assessment Officer, Prevention service?

ASSISTIVE TECHNOLOGY/TELECARE

Assistive Technology and Telecare is the name given to advanced community alarm services.

Community alarms plug into your telephone line and come with a call button which you can attach to yourself or your clothing. Using the button, you can summon help from anywhere in your home. Telecare systems can operate as community alarms but can also have more sensors around your home so they can automatically detect things like:

• Fires and smoke;

• Extremes of heat;

• Carbon monoxide and natural gas;

• Flooding

• Falls.

Do you have a community alarm? Yes No

If Yes – who is the provider?

Do you have other assistive technology/telecare equipment?

Yes No If yes please say what?

Would you like to explore the use of assistive technology/telecare equipment to help you?

Yes No

Just Checking

Just Checking provides a chart of daily living activity, via the web.

If your family/friends/carers are concerned about you because you live alone and are becoming forgetful then Just Checking will give an insight into how best to support you

Has “Just Checking” been used as part of this assessment?

Yes No

CUMBRIA FIRE AND RESCUE HOME SAFETY CHECK

The free home fire safety check service operated by Cumbria Fire & Rescue Service is more than just putting up a smoke detector. It’s about assessing general fire risk and providing advice and equipment to the household. We even provide fire retardant bedding, portable sprinkler systems and alarms for people with hearing impairment. It’s about getting the right solution for the right people.

Your details will be sent to Cumbria Fire and Rescue Service unless you indicate you do not wish this.

Do not send my details

Reason: I have had a safety check in the last 12 months

Other reason please state

Are there any issues the fire service should consider when visiting or contacting you?Do you want a friend or family member with you when they visit, do you want to make them aware of any communication issues?

Do you have working smoke alarms? Yes No Don’t Know

Do you smoke? Yes No

Do you consider yourself at high risk of fire? Yes No

MEETING OTHER PEOPLE AND SOCIAL ACTIVITIES

Can you access social activities, work and education both in and out of your home as you would like?

Yes No Not agreed

Can you access? / 1.
Independent / 2. Independent with Equipment / 3. With Difficulty and/or Needs Personal Help / 4. Unable to do / N/A / Observed / stated
O/S
The social activities/contact/ hobbies and interests you want to in your home?
The social activities/contact/
hobbies and interests you want to outside your home?
Educational opportunities you would like to?
Leisure activities you would like to
Work in the way you would like to

CULTURAL ISSUES

Are there any cultural factors which are important to you?This could be attending a local place of worship, socialising with friends and family, accessing hobbies, dietary issues, how you would want any support organised, your wishes at death.

Yes No

MAKING DECISIONS AND HAVING CHOICES

Do you feel you have choice and control over the way you live your life?

Yes No

Are you able to make decisions about your life?

Yes I am independent with all decision making

Yes I can make all decisions with the help and guidance of friends and family

Yes I can make some decisions with the help and guidance of friends and family

No I require help with all decisions

Consider whether assessment of capacity or best interests assessment is required

Staying Safe

Do you feel safe? / Yes No
Are you in urgent danger or need? / Yes No
Do you have concerns about how others treat you / Yes No
Are there any risks or priorities that need to be addressed urgently? / Yes No

What are the risks or priorities?What are they? How are you coping now? Are there people who can help you in the time being?

Are there safeguarding issues to be considered?Yes No

If Yes then please follow safeguarding guidance and start a Safeguarding Alert on IAS

Is a Risk Assessment required? Consider positive risk taking for positive outcomes?

Yes No


CARER(S)

Do you currently have any help? This could be formal or paid help, orinformal help you receive from family and friends.

Yes No

Do you get the support you need? Do you have any concerns around this support? For example you may feel you ask for too much help, orthat the help you receive changes the nature of your relationship with friends and family

Young Carer

Is there a young person/young family member (under 19) providing care or support? Yes No

If Yes, please give names and ages and primary address

Hasthe young person considered a Young Carer’s Assessment?

Yes No

Would they like someone to contact them to discuss what support may be available?

Yes No

Where you indicate Yes – then the young person’s details will be sent to a Carers Association for a specialist Young Carer Assessment. Also the name and address of the cared for person will be sent. The young personwill normally hear from the Carers Association within a month.

If No, why not?

If an Adult Carer is identified do they want an assessment?

You have the right to an independent Carer’s Assessment where you can talk about any concerns you have and the impact of your caring role.

No, Carer does not want an assessment
Yes, jointly as part of this the cared for person’s assessment
Yes, a separate assessment by the Carers’ Association (Carers’ and disabled Children’s Act 2000)
Yes, a separate assessment by Adult Social Care (NHS and Community Care Act 1991)
Not applicable – no carer identified

If carer does not want an assessment –please say why?

Name of Carer
Date of Birth or Age of Carer
Has the carer been provided with advice and /or information during this assessment?
Yes No

How does your supporting role affect your life? Does it cause you concern or have a significant impact on your daily life, health and wellbeing?

Do you feel able to continue to providing the help and support you do?

Yes No

EQUIPMENT

Has a prescription for equipment been issued as part of this assessment?

(Practitioner guidance –

If assessment has resulted in a prescription or minor adaptation then their may be no need to complete a support plan. However this should be based on practitioner judgement about what is most useful for the person e.g. may complete support plan if there will be ongoing practitioner support. Maintained equipment will require a support plan and any cases being referred for DFG should have a support plan completed.)

Yes No

Date prescription issued

What Equipment has been advised, prescribed, issued?

Equipment / Advised/prescribed/issued

REABLEMENT

Reablement is an Adult Social Care service which aims to help people (customers and carers) who have a social care need regain their independence following an illness, injury, disability or loss of personal support network. All new customers, and existing customers at unplanned and planned review, should be considered and receive a reablement intervention for any aspect of their social care needs that would increase their quality of life and reduce their long term care needs.
Reablement is for people aged 18 or over and living in Cumbria; who are capable of and would benefit from reablement; and who live in their own home or would be able to live in the community with some support. Carers may also be able to have reablement to help them to continue to look after someone.
Reablement is a free service and is provided for a short period of time, usually up to 6 weeks or less. A reablement episode may extend beyond six weeks where a reablement outcome has not been completed, or a new outcome has been identified during a reablement episode and has not been completed.

Is Reablement Appropriate Yes No

If No then please state why

Quality Of Life Questionnaire

The Quality of life questions are designed to capture information about your social care quality of life. We will do this questionnaire with you if you are likely to need ongoing social care support, including maintained equipment, or are entering the reablement service. This will then mean that we can check that the support we have planned with you is maintaining or improving your quality of life. This is important to us

(If we have recently completed these questions with your, for example within a review or because you had a period of reablement then they may not be required)

Practitioner guidance -

(We are using this to measure the outcomes for customers by taking a baseline for how they feel about their life. This should be repeated at first and annual review, and on starting and leaving reablement service so that we capture information on how successful we are at meeting peoples outcomes)

Are “Quality Of Life Outcome” questions required? Yes No

SELF DIRECTED SUPPORT

Self Directed Support enables people who need socialcare and support services to have greater choice and control over the services they receive.

Once we have assessed your needs then we use the resource allocation questionnaire to provide you with an indication of how much money we could make available to pay for services to meet these needs - this is called yourIndicative Amount.

If your needs have increased we will need to repeat this questionnaire

Is Resource Allocation Questionnaire Required?

Yes No

Summary Section

What would you like to happen next?

SUMMARY (Statement of Needs)

Quality of Life Outcomes Questionnaire

1. Which of the following statements best describes how much control you have over your daily life?

By ‘control over daily life’ we mean having the choice to do things or have things done for you as you like and when you want.