OFFICE USE ONLY / Staff Processing Form: / Date card issued:
Emergency Card ID: / New Replacement card
If you need assistanceto complete this form please contact: 020 8960 3033Carers Network Westminsterfor assistance over the phone or to meet in person.
Aftercompletion please return theform using the freepost envelope included.
Carer’s Personal Information:Mr./Mrs./Miss/Other: / First name: / Surname:
Date of birth: / Gender: Male Female / Ethnicity:
Address: / Post code:
Interpreter Required: Yes No(language): / Religion:
Relationship to person cared for: / Receive Carers Allowance: Yes No
Home Tel: / Work Tel: / Mobile No:
Email address: / Carer for an Adult Parent Carer Young Carer
Details of person cared for: / SWIFT ID(OFFICE USE ONLY):
Mr./Mrs./Miss/Other: / First name: / Surname:
Date of birth: / Gender: Male Female / Ethnicity:
Address: / Post code:
Interpreter Required: Yes No(language): / Religion:
Home Tel No: / Mobile No: / Work Tel:
Has Support Package Name of Care Agency: / Receive Direct Payments
GP Name: / TelNo:
GP Address:
Have you had a carer’s assessment?
YesNo / Would you like to have a carer’s assessment if you have not yet had one? Yes No
Is the person you care for known to Social Services/Mental Health Teams? Yes No
Care Manager/Social Worker/Care Coordinator/Case Manager’s name:
Contact number: / Team:
Details for named contact in an emergency:(Up to 3 contacts, if applicable)
First Contact:
Mr./Mrs./Miss/Other: / First name: / Surname:
Address: / Post code:
Relationship to person cared for: / Interpreter: Yes No(language)
Home Tel: / Work Tel: / Mobile No:
Second Contact:
Mr./Mrs./Miss/Other: / First name: / Surname:
Address: / Post code:
Relationship to person cared for: / Interpreter: Yes No(language)
Home Tel: / Work Tel: / Mobile No:
Third Contact:
Mr./Mrs./Miss/Other: / First name: / Surname:
Address: / Post code:
Relationship to person cared for: / Interpreter: Yes No(language)
Home Tel: / Work Tel: / Mobile No:
If no contacts are named/ emergency contacts are not available to provide care, social services will provide appropriate emergency care which may include providing a paid care worker.
Note: All emergency calls made will be notified to the relevant Social Services Team
Access to property:
/Equipment in situ where cared for person live
Cared for person able to open door: Yes No / Key safe installed: Yes No
Has pendant alarm: Yes No / Presence of pets: Yes No Type:
Telecare installed: Yes No Type of Telecare Equipment:
Key holder’s details if different from nominated persons above
Mr./Mrs./Miss/Other: / First name: / Surname:
Relationship to person cared for: / Interpreter: Yes No(language)
Home Tel: / Work Tel: / Mobile No:
You need to make sure named contacts have access to property where the cared for person lives.
Are there any risks that people going to the house should know for their own safety and the safety of the person cared for?e.g. deliberate self harm, person’s behaviourbeing a risk for example verbal/physical aggression, suicide attempts, wandering, risks to others, confusion etc
Do you have the message in a bottle in the cared for person’s house where you keep important information?e.g. medication details, daily routines, care plan etc Yes No
Carers Emergency Card Scheme Care Plan
Does the person you care for have (tick all that apply)
Physical disability,sensory impairment and/or illness / Mental health (not dementia)
Dementia / Substance misuse / Learning disability / Other (specify):
Give details of medical condition(s) or illnesses, health problems or disabilities. Up to date medication details should not be included here but should be stored in the message in a bottle as this may change from time to time
Details of communication, hearing and sight needs if relevant:
Give details of difficulties with mobility and equipment used if available:
Other useful Information: Religious/Cultural needs and considerations
Does the cared for person have known allergies?Yes No. If yes please explain…
Emergency Care Plan
Please use this example to help complete the care plan
Time / Activities or tasks explaining assistance required
0800-0830 daily / Assist John with bathing and dressing, I use equipment (bath lift) for bath transfers
0830-0900 daily / Prepare breakfast of John’s choice – this can be cereal, tea/toast, boiled eggs etc
1000-1600
Monday&Friday / John goesto the day centre as part of therapy, transport is provided. Disruption in attendance may cause agitation as he is used to routine.
1200-1300 daily / Home meal service brings ready made meals, able to feed independently
0700-1800 daily / Supervise taking medication and eating evening meal. Dosage box kept on top of fridge and important medication information is in the message in a box in the fridge
Mondays 09:00 / District nurse (contact number 0207 150 …) comes to give weekly injection
Notes:
In summary John needs my assistance for an hour twice daily in the mornings and evenings and has wheels on meals lunch time independently. Twice weekly he goes to the day centre as part of therapy and this should not be disrupted unless its necessary (include information here if the cared for person lives in a residential placement and comes home for specified periods of time)
Note: Please include specialist medical needs and equipment being used e.g. colostomy bags, peg feeding, medication that requires specialist training to administer etc.
Emergency 24-hour Care Plan(list only essential activities/services to be provided in an emergency)
Time
use 24:00 clock or am/pm to indicate day or night time / Activities or tasks explaining assistance required
Notes:
Use extra sheet if required / Did you use another sheet?Yes No / Date completed:
Is the cared for person aware of this registration and care plan? Yes No
Declaration: I have discussed this registration and care plan (care plan is on pages 3 and 4) with the person I care for and the person I care for has agreed for me to register. We both agree for any emergency call made to the Carers Emergency Card scheme to be referred to Westminster Social Care teams for monitoring and for follow up which may be required. I have also discussed registration and care plan with nominated contacts and they have agreed to provide care on my behalf in an emergency. All nominated contacts are over 18 years old.
Name of Carer: ______
Signature of Carer: ______ Date: ______
Name of person Cared for: ______
Signature of person Cared for:______Date: ______
It is important for us to have up to date records to enable us to provide services effectively for the person being cared for. Please contact us to update these records when there are changes before annual review date. We will also contact you annually to update our records.
Note: Carers are responsible for the suitabilityof the named contacts they nominate. WestminsterCity Council and NHS Westminster do not take responsibility.
Please return completed formsusing freepost envelope provided or to the free post address: Carers Emergency Card Scheme, Carers Network Westminster, Office 8, Beethoven Centre, Third Avenue, LondonW10 4JL
You will be sent your emergency card once you are registered.Copies of the care plan will be sent with the card along withextra copies for distribution to the cared for and nominated contact persons and a ResCard discount booklet.
Thank you for completing the Carers Emergency Card Scheme registration and care plan form.
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