CSIR35

Children Young People’s Social Care

PLACEMENT AGREEMENT FORM

CHILDREN’S SHORT BREAKS

All sections of this agreement form should be completedat the Placement Agreement Meeting, before the child has an overnight stay,with the following parties:

1. parents/guardian (or by those persons legally designated with parental responsibility),

  1. the child where appropriate,
  2. the child’s social worker,
  3. the foster carer, and the supervisory fostering officer where this is a Family Placement short break
  4. The keyworker where the short break is in a residential establishment

The foster carer or child’s placement should be informed of any changes to telephone numbers, medication or information contained in this agreement. Copies should be kept by the parent/guardian, the child’s social worker, the short breaks carer, and the short breaks service providing the placement.

PART1. ESSENTIAL INFORMATION

Child's name / DOB: / Legal status
Parents/Guardian Name
Home address / 

Emergency Contact/s / 

CYPSC / Emergency Duty Team (EDT) / 01132409536
Child’s social worker and area office / 
Family Placement SFO or establishment keyworker and address of placement / 
GP Name
Surgery / 
School / 
No of days allocated
Who holds parental responsibility?

PART2. MEDICAL ISSUES

(a) Please give full details of child’s medical condition / disability. If the child accesses a particular hospital, or is under the care of a consultant paediatrician,please give details.

b) Medication Prescribed

Medication Name / Strength/Dose / Route / Frequency

When medication is sent to the Placement for the child/young person it must be in the bottle or packaging in which it was prescribed, clearly labelled with the name of the child, the dose and strength of the medication, and the time it should be given.

Parents/guardians must notify Family Placement carers,or the short breaks establishment, of any change to the listed medication on the “Notification of and Consent to Change in Medication Form”. Blank copies of these shouldbe given to parent/guardians and FP carers.

(c) Non prescription medication

Medication Name / Strength / Route / Frequency

A Family Placement carer/ short breaks placement provider, can give the non-prescribed medication outlined aboveif there have been no previous counter-reactions, but must not extend treatment beyond two consecutive doses without seeking medical advice through NHS Direct or the GP.

Only medication listed on this agreement can be administered by Family Placement carers and short breaks providers. It is the CYPSC policy that our carers and short breaks establishments cannot administer herbal or homeopathic remedies because of potential risk of interaction with prescribed medicines.

(d) Details of any nursing care interventions required:

Type of Nursing Intervention / Route / Times and Frequency / Any other relevant information

If nursing care interventions are required the Family Placement carer or residential worker must be trained in these by a qualified nurse, and the Identification of Procedure and Parental Consent Form completed before the placement can commence.

(e)Details of any known allergiesaffecting the child and how they are treated.

(f) Any other relevant information in respect of the child’s health.

If your child becomes ill on placement the Family Placement carer or short breaks establishment will contact you. Where possible and appropriate arrangements should be made for your child to return home. If your child cannot return home medical advice will be sought through NHS Direct or the GP.

PART 3 NEEDS OF THE CHILD

Outline needs of the child / How will these needs be met by the family placement carer or short breaks establishment(include carer’s skills and experience)?
Personal Care(all personal care must be given in accordance with the Intimate Care Policy)
Child’s routine
Feeding and dietary needs (include food likes and dislikes, help required etc)
Specialist Accommodation, Moving and Handling (including equipment and appliances)
Communication Needs
Play and Social Needs
(Cont)
Outline needs of the child / How will these needs be met by the family placement carer or short breaks establishment(include carer’s skills and experience)?
Behaviour
Night Care (include bedwetting, incontinence pads, etc)
Supervision
Cultural, racial, religious needs
Any other needs identified?

PART 4 PLACEMENT ISSUES

What are the arrangements for transport?
Will the child attend school during their short breaks stays? If so what are the arrangements?
Is there anything the child particularly enjoys?
Is there anything which the child dislikes?
The Family Placement Risk Assessment or CYPSC Risk Assessment accompanies this Placement Agreement. Please ensure that it has been completed at the Placement Agreement Meeting.
YES/NO
Does the Family Placement Carer / short breaks establishment, have the essential information/pen picture of the child?
YES/NO
Does the Family Placement Carer or short breaks establishment have a copy of the Appropriate Assessment of the Child’s needs, including attached reports on the health, development and education of the child?
YES/NO
Outline arrangements for introductions, and patterns of placement envisaged, if introductions are successful and all parties are in agreement.

PART 5 PARENT'S REQUEST and AGREEMENT FOR PLACEMENT

Signing this agreement gives parental consent to the placement and enables the Family Placement carer, short breaks establishment, to seek medical attention for the child should this be necessary.

I/ We request that(name of child/young person)…… ………………………………………….

be accommodated by Leeds City Council in accordance with the provision laid down in Regulation 9 of the Foster Placement (Children) Regulations 1991 (short term placements) of the Children Act 1989.

I/ We understand that I/ We retain full parental responsibility for my/our child, and can remove my child from the accommodation provided at any time.

I/ We agree to Leeds City Council, (Family Placement Carer or short breaks establishment)………………...... arranging medical treatment, including emergency treatment and anaesthetics if necessary, for(name of child/ young person)….…………… ………………. while they are looked after by them.

The issue of medical consent has been explained to me/us.

I/we understand and agree that a review of the service provided will be carried out every 6 months or when requested by us.

Signatures of consent:

Parent / Guardian / Child (where appropriate)
Name
Signature
Date

Part 6 DEPARTMENTAL APPROVAL TO THE REQUEST FOR ACCOMMODATION

I agree to this request for accommodation to be provided:

Social Worker/ Team Manager
Signature
Date

PART 7 FOR COMPLETION BY THE FAMILY PLACEMENT CARER OR SHORT BREAKS ESTABLISHMENT

I have received information about the above named child relevant to the placement and agree to care for the above named child for short breaks placements.

Name
Address

Signature / Date
Coordinator Family Placement or establishment manager
Signature / Date

Updated 12.10.09CSIR 35

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Placement Agreement CSIR 35 July 09 File Path G Drive/FAMILY PLACEMENT/All forms/ Children’s Scheme Forms