Initial Assessment of Needs

INITIAL ASSESSMENT OF NEEDS

NAME:

ADDRESS:

REFERENCE:

NAME OF ASSESSOR: RACHEL AITKENSIGNATURE:DATE:

Care Plan

Client’s name:
Preferred name:
D.O.B:
Address:
Contact number:
ID number:
Next of kin:
Next of kin contact number:
Doctor:
Collections/pension/
shopping:
Client information:
Medical information:
Home entry requirements:
Care package:

PLEASE ENSURE THAT YOU READ NEXT PAGE TO VIEW VISITING HOURS, BATH DAYS AND EXTRA ACTIVITIES.

Visit Times

Day / Morning / Lunch / Teatime / Bedtime
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
PLEASE BE AWARE THAT ALTHOUGH YOU MAY HAVE BEEN GIVEN A TIME FOR YOUR VISIT, THIS CAN WAIVER BY HALF AN HOUR AT OUR DISCRETION
BY ACCEPTING THIS CARE PLAN, YOU ARE AGREEING THAT THE INFORMATION IS CORRECT.
YOU ARE ALSO PERMITTING UNICARE TO SPEAK TO OTHER AGENCIES IF NECESSARY (E.G. GP, DISTRICT NURSES, CARE DIRECT PLUS, NEXT OF KIN ETC) TO ENSURE THAT WE MEET YOUR NEEDS, AND IN YOUR BEST INTERESTS.
PLEASE ADVISE UNICARE OF ANY INDIVIDUALS/AGENCIES THAT YOU WOULD PREFER US NOT TO CONTACT.
CARER’S SIGNATURE:
CLIENT’S SIGNATURE:
DATE OF CARE PLAN:
UNICARE DEVON LTD 145 QUEEN STREET, NEWTON ABBOT, TQ12 2BN
TEL: 01626 355619 EMAIL: WEBSITE:

NAME OF ASSESSOR: RACHEL AITKENSIGNATURE:DATE:

NAME: REFERENCE:

ASSISTANCE WITH GETTING UP/WASHED/DRESSED
UNICARE / ANOTHER / INDEPEN-DENT / COMMENTS
1 / Help needed to get out of bed?
2 / Help needed to wash?
3 / Help needed to dress?
4 / Help needed to choose clothes?
5 / Help needed to get to the bathroom/ commode?
(state which)
6 / Help needed to bathe/ shower?
(state which)
7 / Help needed to clean dentures/teeth?
(state which)
8 / Help needed to brush hair?
9 / Help needed with a deodorant?
10 / Help needed to apply creams?
(state what and where)
11 / Help needed/required to apply makeup?
(state what)
12 / Help needed with shaving?
(give details)
13 / Support needed with nail care?
(give details- NOT FEET)
14 / Detail routine:
ASSISTANCE WITH PREPARING FOR/ GOING TO BED
UNICARE / ANOTHER / INDEPEN-DENT / COMMENTS
1 / Help needed to get in to bed?
2 / Help needed to wash?
3 / Help needed to undress?
4 / Help needed to choose clothes?
5 / Help needed to get to the bathroom/ commode?
(state which)
6 / Help needed to bathe/ shower?
(state which)
7 / Help needed to clean dentures/teeth?
(state which)
8 / Help needed to brush hair?
9 / Help needed to apply creams?
(state what and where)
10 / Detail routine:
ASSISTANCE WITH MEAL PREPARATION
UNICARE / ANOTHER / INDEPEN-DENT / COMMENTS
1 / Help needed to prepare breakfast?
(state what help)
2 / Help needed to prepare lunch?
(state what help)
3 / Help needed to prepare evening meal?
(state what help)
4 / Help needed to prepare drinks?
(state what help)
5 / Help needed to prepare snacks?
(state what help)
6 / Help needed to cut up food?
7 / Help needed to eat food?
8 / Help needed to manage drinks?
(state what help)
9 / Adapted cutlery or crockery needed?
(state what)
10 / Dietary requirements?
11 / Favourite food?
12 / Particular dislikes?
13 / Food allergies?
(state what)
14 / Preferred place to eat meals?
(state where)
15 / Preferred meal times
(ie. Main meal at lunch/evening)
16 / Help needed to get shopping?
(state what)
ASSISTANCE WITH USING THE BATHROOM
UNICARE / ANOTHER / INDEPEN-DENT / COMMENTS
1 / Help needed to get to the bathroom?
(State what help)
2 / Help needed to empty a catheter?
3 / Help needed to cleanse after using the toilet?
4 / Help needed to empty and change a stoma/ colostomy bag?
(where stored)
5 / Help needed to change a catheter bag?
(where stored)
6 / Help needed to attach a night bag?
7 / Pads worn?
(state what pads)
8 / Yellow bag in place?
(state day to be collected and where stored)
9 / Prefer to use the toilet or commode?
10 / Continence issues
OTHER ASSISTANCE
UNICARE / ANOTHER / INDEPEN-DENT / COMMENTS
1 / Help with finances?
(state what help)
2 / Help to access benefits?
(state what help)
3 / Help needed to go out of the house shopping?
(state what help)
4 / Help needed to attend a place of worship?
(state what help)
5 / Help needed to attend appointments?
(state what help)
6 / Do you have a pet? If so, do you need help with it?
7 / Assistance to make the bed?
8 / Assistance to change the bed?
9 / Assistance to do the laundry?
10 / Assistance to keep the house tidy?
11 / Assistance to put the bins out?
(state the day)
12 / Assistance to wash up?
COMMUNICATION
1 / Language spoken?
2 / Glasses worn?
3 / Contact lenses worn?
4 / Hearing aids worn?
5 / Communication equipment used?
6 / Able to use a standard telephone? Amplifier/ large keys needed?
7 / Communication affected by illness?
(explain)
8 / Are you able to write?
MOBILITY AIDS/AIDS TO DAILY LIVING USED
AID USED / SERVICE DATE AND CONTACT / COMMENTS
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
OTHER SERVICES USED
SERVICE / CONTACT / DETAILS
1 / HAIRDRESSER
2 / CHIROPODIST
3 / OT
4 / PHYSIOTHERAPIST
5 / DIETICIAN
6 / SOCIAL WORKER
7 / DISTRICT NURSE
8 / COMMUNITY PSYCHIATRIC NURSE
9 / GP
10 / SPEECH THERAPIST
11 / OPTICIAN
12 / AUDIOLOGIST
13 / DENTIST
14
15
16
17
18
19
20
HEALTH/ MEDICATION
UNICARE / ANOTHER / INDEPEN-DENT
1 / Assistance required with medication?
(state what)
2 / Cream required?
3 / Eye drops required?
4 / Ear drops required?
5 / Prescription medication used?
6 / Homely remedies?
7 / Alternative remedies?
8 / Drug sensitivity?
(state what)
9 / Able to consent to medication? / YES / NO
10 / Effect of medication on mobility?
11 / Do you smoke?
If so, how many a day?
12 / Do you drink alcohol?
If so, how many units a day?
Medical conditions:

CREAM APPLICATION

FRONT /
BACK

1. ......

1. ......

1. ......

1. ......

1. ......

1. ......

PLEASE MAKE SURE THAT YOU NUMBER ON THE BODY WHERE CREAMS ARE PUT.

PSYCHIATRIC, MENTAL HISTORY, BEHAVIOUR AND RISKS
1 / History of eating disorders?
2 / History of alcohol dependency?
3 / History of drug dependency?
4 / History of epilepsy?
5 / History of inappropriate sexual behaviour?
6 / History of depression?
7 / History of aggression?
8 / History of challenging behaviour?
9 / Trigger factors?
10 / Effect of medication on mood?
11 / Impact of family members on mood?
12 / Specific dates that impact mood?
13 / Other
14 / Awareness of place, time, date?
15 / Awareness of self and significant others
16
FALLS: RISK FACTORS
Tick box if applicable and explain
Visual/ sight problems / History of fits/ seizures
Hearing problems / Confusion/ disorientation
Speech impediment / Arthritis of knees/ hips
Cognitive impairment / Cardiac disease
Limited/ impaired mobility / Arterial disease
History of falls / Parkinson’s disease
Fear of falls / High/ low blood pressure
Urinary incontinence / Use of sedatives
Faecal incontinence / Use of anti-depressants
History of smoking / Peripheral neuropathy
History of alcohol abuse / Controlled drugs prescribed
FALLS CONTRIBUTORY FACTORS
CRITERIA / CONSIDERATIONS
Previous history of falls
Limited mobility or movement or unsteady gait
Confusion, disorientation, effects of medication or other type of altered mental state
Impaired vision, hearing, other sensory loss
Frequency of urination, defecation or incontinence
Recent cardiovascular accident or neurological impairment
EASE OF MOVEMENT
ACTIVITY / NORMAL CAPABILITY / ABNORMAL CAPABILITY / AIDS USED
1 / Rising from chair
2 / Stand for 30 seconds after rising
3 / Stand with eyes closed for 15 seconds
4 / Walk 15ft and back
5 / Walk 5 ft and turn around
6 / Sitting down in a chair
7 / Negotiating steps/stairs
8 / Going to bed
9 / Rising from bed
10 / Bed rails needed
11
12
13
14
WORKPLACE RISK ASSESSMENT
Are all floors and flooring in good condition even? / Yes / No / N/A
Is there suitable handrails/banisters and are they all securely fitted? / Yes / No / N/A
Are all rooms, hallways and stairs adequately lit? / Yes / No / N/A
Do all windows and doors lock securely? / Yes / No / N/A
Are all rooms and walkways free from clutter and obstacles? / Yes / No / N/A
Does the bath/shower have a non-slip surface or bath mat? / Yes / No / N/A
Are there suitable arrangements in place to control pets during visits? / Yes / No / N/A
Are care workers able to exit the property quickly and safely in the case of an emergency? / Yes / No / N/A
Where is the gas main tap located? and is it easily reached? / Yes / No / N/A
Where is the water stopcock located? and is it easily reached? / Yes / No / N/A
Where is the fuse box located? and is it easily reached? / Yes / No / N/A
Are smoke alarms fitted and working? / Yes / No / N/A
Are carbon monoxide detectors fitted and working? / Yes / No / N/A
Are all electrical appliances, plugs and wires in safe working order? / Yes / No / N/A
Are all portable heaters kept away from furniture and out of walkways? / Yes / No / N/A
Is the house well ventilated and a comfortable temperature? / Yes / No / N/A
Are all used fireplaces in good condition and swept regularly? / Yes / No / N/A
Is the house kept in a generally clean and hygienic state? / Yes / No / N/A
Where clients smoke, is the house kept well ventilated to prevent the air from becoming polluted? / Yes / No / N/A
Is household waste regularly disposed of regularly? / Yes / No / N/A
Are cleaning fluids available? / Yes / No / N/A
Are all cleaning products stored in safe locations in there original containers? / Yes / No / N/A
Is there basic first aid material at the house? / Yes / No / N/A
Is all medications on record, kept in original containers, in date and stored in a safe location? / Yes / No / N/A
Is all food in within its date and stored hygienically? / Yes / No / N/A
Are oven gloves available to handle hot dishes? / Yes / No / N/A
Are kitchen sharps stored safely? / Yes / No / N/A
Are there proper facilities (e.g. yellow clinical waste bags) to dispose of clinical waste and sharps? / Yes / No / N/A
Are outside paths/steps well lit, in good condition and not too steep? / Yes / No / N/A
GENERAL SAFETY AWARENESS
1 / Smoking / Smokes in home
Discards cigarettes butts appropriately
2 / Going out / Sense of danger
Sense of time
Sense of location
Sense of direction
3 / Electricity / Can reach power points easily
Can reach light switches/ manipulate lamp switches easily
Can reach telephone easily
Sense of danger of overloading power points
AREA OF RISK / WHO IS AT RISK? / ACTIONS/ PRECAUTIONS TO TAKE

MENTAL CAPACITY ASSESSMENT

1.Is there an impairment or disturbance in the functioning of the mind or brain? / Yes Impairment is present- record evidence of your decision / No Impairment is not present- record evidence
If NO the person is deemed to have capacity- assessment is now ended

If the answer to Q1 was “YES” proceed to Q2

2a With all possible help given is the person able to understand the information relevant to the decisions? / YES- able to understand info. Record evidence of your decision / NO- unable to understand.
Record evidence of your decision, state why you feel that they did not understand
2b Are they able to retain the information long enough to make the decision? / YES- able to retain the information.
Record evidence of your decision / NO- unable to retain the information
Record evidence of your decision, state why you feel that they are not able to retain it
2c Are they able to weigh the information as part of the decision making process? Are they able to understand the consequences of the decision? / YES- able to weigh information.
Record evidence of your decision / NO- unable to weigh the information
Record evidence of your decision, state why you feel that they are not able to weigh it
2d are they able to communicate the decision in any way? / YES- able to communicate decision
Record evidence of your decision / NO- able to communicate decision
Record evidence of your decision, state why you feel that they are not able to retain it
DATE OF ASSESSMENT
HOW WAS THE ASSESSMENT COMPLETED? Who was present, where did it happen, how did you enable the person to make their decision
CONCLUSION-
If the answer to 1 is yes and the answer to any of 2a to 2d is NO then the person lacks capacity under the Mental Capacity Act 2005 / Fluctuating capacity?:
Outcome:
Signature:

SMOKING POLICY

I acknowledge receipt of Unicare Devon’s smoking policy and the leaflet “Take care of the Carer who takes care of you”

I agree to ensure that Carers are provided with a smoke free working environment.

I accept that any refusal to refrain from smoking during the Carers visit may result in the Carer leaving their working environment i.e. My Home.

I agree to ensure that My Home is well ventilated if I, or another, smoke in the vicinity

Signed:

Dated:

NAME OF ASSESSOR: RACHEL AITKENSIGNATURE:DATE:

NAME: REFERENCE:

MEDICATION DISCLAIMER

1. I am able to take my medication without prompting

The following descriptions define what assisting with medicines means and what administering medicines means.

• ASSISTING

When a care worker assists someone with their medicine, the person must indicate to the care worker what actions they are to take on each occasion. (E.g. hands the box of tablets to you or reminds you to take them)

• ADMINISTRATION

If the person is not able to do this or if the care worker gives any medicines without being requested (by the person)to do so, this activity must be interpreted as administering medicine. (e.g. dispenses the medication into a pot for you or puts in your eye drops)

1. I need help assisting with medicines

1. I need help with administering my medicines

1. Who will help me with my medication?

Should assistance with medication be required as part of the service users package, Unicare Devon cannot be held responsible for the ordering, dosage or collection of any medication.

Medication includes tablets and capsulesin a blister pack, creams, liquids, eye drops and any other medicationwhich is not dispensed in unit doses or blister packs.

The responsibility for measuring the doses remains with the service user, their advocate and/or chemist.

The ordering of medical appliances and/or disposable items remains the responsibility of the service user.

I, the undersigned, certify that all prescription only medication has been prescribed to me by my GP.I accept all risks involved, in the assisting / administration of my medication, to me the service user by staff members who have been trained in administering medication of Unicare Devon.

Name of Service user: Signature: Date:

Address of service user:

Witness Name: Signature: Date:

NAME OF ASSESSOR: RACHEL AITKENSIGNATURE:DATE: