North West London Needs-Based Assessment Form

North West London Needs-Based Assessment Form

This form is to be completed for all patients who are being discharged back to their own homes or usual place of residence with a new or changed need for community support.

Please send a completed form to the Single Point of Accessbased in the patients’ usual borough of residence:

BrentShort Term Rehab:Brent D/N:

Ealing Home Ward:

Ealing Enable (stroke):Ealing D/NEmail:

Harrow:Hounslow:

Hammersmith & Fulham:

HillingdonSocial care:.

Hillingdon Rehab & D/N:

Kensington & Chelsea:Westminster:

Section 1: Personal Details(all referrals)
Full Name: / NHS number:
DOB: / Address:
Contact telephone:
Email Address: / Postcode:
Preferred contact method: Phone ☐ Email ☐ Post ☐
Borough of permanent residence: / GP Name:
GP Telephone: / GP Practice Address:
Ethnicity: / First Language: / Interpreter required: / Yes ☐ No ☐
Any other communication requirements (e.g. large print, braille, visual aids etc.) or sensory impairments:
Next of Kin: / Relationship:
Address: / Contact telephone:
Emergency contact (if different): / Relationship:
Address: / Contact telephone:
Are there any cultural, spiritual or religious preferences which need to be taken into consideration:
Is a referral to social services required? Yes ☐ No ☐ / Date of referral (if applicable):
Framework-i/ social services reference number:
Section 2: Summary and Recommendations(all referrals)
Summary of key health and social care concerns: / Details of existing services received (health, social and voluntary sector services):
Is the patient able to attend an appointment in clinic? / Will the patient be discharged with a blister pack or catheter?
Lead staff member(person to be contacted for follow up questions and information): / Expected date and time of discharge(AM or PM): / Service start date and time:
Contact details for lead staff member (include direct phone number):
Details of staff completing this assessment: / Staff signature(s):
Timescale for seeing patient (please advise how long after discharge the patient will need to be seen and what support is required):
Reason for referral (e.g. support required to administer medication) / Type of support required (e.g. nursing, therapy etc.) / Frequency (e.g. morning and evening calls required)
Are other services required to support the patients’ discharge (e.g. patient transport, pharmacy):
Patient/ carer/ relative comments on recommendations:
Section 3: Admission Details(all referrals)
Date of admission: / Other people Involved during assessment (including other professionals):
Reason for admission/ presenting health problems:
Details of relevant health interventions:
Location of patient (name of hospital and ward):
Overview of existing health conditions and disabilities (Provide details of diagnoses including physical health, mental health and Learning disabilities :)
Details of advanced care plan/ co-ordinate my care plan(if known): / Details of any allergies:
Does the patient consent to this assessment? (Explain to the patient how their information will be used, stored and shared) Yes ☐ No ☐
Section 4: Access Details (all referrals)
Details of gaining access to the property (e.g. key safe number, steps into the property):
Are there any risk factors for visiting staff (include details of pets, other family members or relatives who may pose a risk to staff, hoarding etc): / Agreed actions to mitigate/ manage risk:
Section 5: Functional Assessment(if requesting therapy support)
Please list any concerns or potential risk factors for the patient (consider history and risk of falls, risk of wandering, risk of pressure ulcers, malnutrition and diet, whether the patient is or will be bed bound, current cognition and memory, issues with swallowing and risk of stroke, any history or risk of self-harm or neglect and threats of violence):
Activities of Daily Living and Basic Care Activities:(I=INDEPENDENT, AO1=ASSISTANCE OF 1 / AO2=ASSISTANCE OF 2)
Function / Pre-Admission Level / Current Level
Mobility (indoor and outdoor)
Transfers (including stairs, chairs, bed, toilet and bath)
Self-care- washing/dressing
Self-care- Toileting (including night toileting and continence issues)
Self-care- Eating/ drinking
Self-care – Wound care
Self-care – Medicines management
Everyday tasks- Meal preparation(including transporting meals)
Everyday tasks- Shopping / Is there edible food at home? Yes ☐ No ☐
Everyday tasks- Other (including household tasks, laundry, leisure activities and work)
Are there any concerns about the patients’ capacity to make decisions in their best interests/ is a DoLS assessment required?
Yes ☐ No ☐ / Details of who will complete a best interest/ DoLS assessment:
What is the patients’ perception of their current functional abilities?
Cognitive screen performed (date): / Cognitive screen score:
How is the patients current mood, motivation and behaviour (inter- and intra-personal):
Rehabilitation Therapy Goals(Goals must be Specific, Measurable, Achievable, Realistic and Timely). For Short-term rehabilitation please explain how goals will reduce the care package within 6 weeks.
Section 6: Home Environment(if requesting therapy support)
Has a home assessment been completed recently? (please attach supporting documents) Yes ☐ No ☐ / Tenure type:
Overview of home environment(include kitchen, bedroom, bathroom and toilet):
Details of other people living in household (include relationships, age and whether present during daytime/ evenings):
Internal layout (location and number of stairs, toilets etc.):
Details of existing equipment and adaptations: / New items of equipment/ adaptations required(when are they required by):
Details of existing telecare items: / New items of telecare required:
Section 7: Carers and Care Package Information(if requesting a social care package)
Details of care and/or support the patient provides to others (including children and adults as well as informal caring responsibilities): / Is a carers’ assessment required? Yes ☐ No ☐
Details of individuals who provide care and/or support to the patient (formal and informal care arrangements):
Is a social services package of care or Reablement required and does the individual meet the eligibility criteria? Yes ☐ No ☐ / Name of allocated social worker (if applicable):
If yes, please tick the care tasks needed at each care call throughout the day. Please specify timings.
Morn / Lunch / Aft / Eve / Morn / Lunch / Aft / Eve
Getting in/ out of bed / Mobility
Chair transfers / Stairs
Strip wash / Drink/ meal/ snack preparation
Shower / Change bed linen
Bath / Dishes
Grooming / Medication prompt
Dressing / Medication administered
Toileting / Other
Empty Commode / Is a compliance container to be used? / Yes ☐ No ☐
Carers / Single ☐ Double Up ☐ / Male ☐ Female ☐ No Preference ☐