Placement Plan Record
A Placement Plan Record should be completed for all children and young people looked after away from home. Wherever possible the Placement Plan should be prepared prior to placement but where this is not practicable it should be completed within five working days of the start of the placement.
CHILD/YOUNG PERSON’S DETAILSFamily name: / Given names:
DOB or expected due date:
Gender: Male FemaleUnborn
Home address:
Post code: / Tel:
Child/young person’s first language or preferred means of communication:
Is an interpreter/signer required?: Yes No / Social services team:
CHILD/YOUNG PERSON’S ETHNICITY
Black or Black British / Asian or Asian British / White / Mixed / Other ethnic groups
Caribbean
African
Any other Black background / Indian
Pakistani
Bangladeshi
Any other Asian background / White British
White Irish
Any white background / WhiteBlack Caribbean
WhiteBlack African
WhiteAsian
Any other Mixed background / Chinese
Any other ethnic group
Not given
If other please specify:
Further details regarding child/young person’s ethnicity:
Child/young person’s religion:
FAMILY DETAILS
Birth Parents
Name / Relationship to child/young person / Ethnicity / First language / Parental responsibility
Yes No
Yes No
Is an interpreter/signer required?: Mother - Yes No and/or Father - Yes No
Other main family carers
Name / Relationship to child/young person / Ethnicity / First language / Parental responsibility
Yes No
Yes No
PLACEMENT DETAILS
Reason for placement (state if new admission of change of placement):
Date placement (or series of short breaks) began:
If a series of short breaks, what is the period covered by this placement?:
Date this form was first completed:
Details of carers/care providers:
Placement address:
Post code: / Tel:
Type of placement/placement code
1. / Placement with parent(s) / 7. / Specialist residential placement (therapeutic)
2. / Placement with relatives/friends (Emergency Regulation 24) / 8. / Specialist residential placement (residential school)
3. / Placement with relatives/friends (Approved) / 9. / Specialist residential placement (health, including CAMHS)
4. / Foster Placement / 10. / Secure accommodation
5. / Placement with adopters / 11. / Supported lodgings
6. / Residential Placement (Children’s home) / 12. / Other, (please specify)
Is there anyone whom the child/young person’s address should not be given?: Yes No
Name / Address / Relationship to child
What arrangements have been made for the child/young person to visit prior to placement?
Date:
Arrangements:
Social worker details
Name:
Address:
Post code: / Office Tel:
e-mail: / Mobile Tel:
Supervising fostering officer details
Name:
Address:
Post code: / Office Tel:
e-mail: / Mobile Tel:
Frequency of fostering officer’s visits to the placement: Daily Weekly Monthly Other
Independent reviewing officer details
Name:
Address:
Post code: / Office Tel:
e-mail: / Mobile Tel:
Independent visitors details
Name:
Address:
Post code: / Office Tel:
e-mail: / Mobile Tel:
Circumstances under which this placement may be terminated?:
OUT OF HOURS CONTACT
Name: / Tel:
Have the carers and the child’s parents been given the dates and venues of all reviews and planning meetings concerning the child? / Carers: Yes No None yet arranged
Parents: Yes No None yet arranged
If no, information will be given before date:
PLACEMENT ROUTINES
Communication - Include details of how the child/young person make their wishes and feelings known:
Mealtimes - Include details of any likes and dislikes, whether there are dietary requirements through reasons of religion, health, culture or choice, whether the child/young person requires assistance and whether the child/young person has any behaviours that need to be managed at mealtimes. For disabled children and young people it may be important to record the position in which they eat and details of any specialist equipment:
Bedtimes - It is important to record details of the child/young person’s bedtime routine; times, stories, light on or off, door open or closed, teddy or comforter and whether the child/young person wakes during the night, has nightmares, wets the bed, is upset through the night:
It is important to maintain the child/young person’s routines wherever possible. Will these routines be followed in the placement?: Yes No
If not, why and what will be the key changes for the child/young person?:
EMOTIONAL AND BEHAVIOURAL DEVELOPMENT
Summarise the behaviour patterns of the child/young person including details of any abusive incidents to self to others that have been of concern to current or previous carers,this could include aggression, anxiety/withdrawal, self-harm, inappropriate sexual behaviour, offending, substance misuse, lack of awareness of personal safety:
How are difficult behaviours managed?:
Has/is the child/young person receiving support to deal with these issues?:
Are there additional resources required or available to assist the carers in meeting the needs of the child/young person?:
It is important that carers’ are provided with information about positive aspects of a child or young person’s behaviour and development and how to reward positive behaviour. Is there further information about the child or young person’s behaviour that the carer(s)’ need to know at this time?:
HEALTH
Has the child/young person had a health assessment?: YesNo
Arrangements and actions - If no, who is responsible for arranging a health assessment?
Name: / Tel:
G.P details
Name:
Address:
Post code: / Tel:
Dentist details
Name:
Address:
Post code: / Tel:
Is the child/young person disabled?: YesNo
If yes, please give all details of disabilities:
Is the child/young person using any medication?: YesNo
Medication / Purpose / Form, e.g cream, tablet / Dose / How given / When given
Does the child/young person have any outstanding medical/dental appointments?: YesNo
Is the child/young person under the care of any specialist consultant?: YesNo
If yes, please give details
Name:
Address:
Post code: / Tel:
Arrangements and actions - Does the child have a parent child health record (PCHR) (Red book)?: YesNo
If yes, please give details of the keeper of the PCHR
Name: / Tel:
If no, please give details of who will receive the PCHR and when?
Name: / Date:
Is the child/young person known to suffer from any allergies?: YesNo
If yes, please give details of the allergies and how they are individually managed?:
Does the child/young person have any other medical conditions to monitor?: YesNo
If yes, please give details of the medical conditions and how they are individually managed?:
Arrangements and actions – Who will take the child/young person for medical and dental treatments, including any outstanding appointments?
Name: / Tel:
If costs are incurred, for example if the appointment is some distance from the placement, how will these be met?:
Does the child/young person use any special equipment, e.g. symbol book, hearing aid, tube feeding aids, special footwear, special cup or bottle?: YesNo
If yes, please give details of the equipment used?:
Arrangements and actions – If necessary have arrangements been made for the carer(s) to receive any essential equipment required by the child/young person?: YesNoNot yet, but within the next 24 hours
What equipment will be needed by the carers and how will training be delivered?:
Who will provide the training?:
Who will fit the equipment?:
Does the child/young person have specific dietary needs or restrictions for health reasons or through their own choice i.e. young person may choose to be vegetarian?: YesNo
If yes, please give details of any dietary requirements?:
Does the child/young person have a health care plan?: YesNo
Arrangements and actions – If no, when will one be completed?:
Can the child/young person remain registered with their own G.P?: YesNo
If no, who will register them with a local medical practice and when?
Name: / Date:
Can the child/young person remain registered with their own dentist?: YesNo
If no, who will register them with a local dental surgery and when?
Name: / Date:
CONSENT TO MEDICAL TREATMENT
I/We have the parental responsibilities for(child/youngperson) and agree to Leeds City Council arranging the following surgical, medical and dental procedures and treatments for the above named child/young person whilst they are looked after by them, if the child/young person is not deemed able to give their own consent by an appropriately qualified medical practitioner
Type of treatment / Yes / No / Please record the name and position of the person the authority has delegated the responsibility for giving consent to medical treatment
Emergency surgical, medical and dental examinations and intervention (including anaesthetics)
Routine medical and dental intervention/treatment deemed by an appropriately qualified medical practitioner to be in the best interests of the child/young person (including immunisations)
Planned surgical intervention/treatment deemed by an appropriately qualified medical practitioner to be in the best interests of the child/young person
The issue of consent to medical treatment has been explained to me
Additional agreements and contents might be required for children and young people with complex health needs. For example, agreement to psychiatric/psychologist assessments, consent to administration of non-prescription medicines such as Calpol or consent to the use and provision of specialist equipment such as tube feeding
Additional Agreement – please specify / Parental consent
Parent(s) or people with parental responsibility may wish to give their views about any of the above treatments of procedures:
Signature of parent(s) or those with parental responsibility
Signature: / Signature:
Name: / Name:
Designation: / Designation:
Date: / Date:
EDUCATION
Current pre-school/nursery/school/college or other educational provision details
Key contact designation,i.e. head teacher, form tutor:
Name:
Address:
Post code: / Office Tel:
Will the child/young person continue to attend this education provision?: YesNo
If the child/young person can not continue at their current education provision, has a new one been identified?: YesNo
If yes, please give details of the new education provision
Key contact designation, i.e. head teacher, form tutor:
Name:
Address:
Post code: / Office Tel:
Is the child the subject of a SEN statement of school action plus?: YesNo
If yes, please give details of the statement?:
How will the child/young person get to and from their place of education?: Walk PublictransportTransport arranged by social services Transport arranged by carers If other, please specify:
Has the child/young person’s school college been informed that s/he has become looked after or changed placement?: YesNo
If yes, please give details of the person
Name: / Tel:
Does the child/young person have a personal education plan (PEP)?: YesNo
If yes, please give details of the date of completion:
If no,please give the date of when it will be completed:
Arrangements and actions – If child/young person cannot continue at his/her present school/college, who is responsible for making alternative arrangements for the child/young person’s education?
Name: / Tel:
When will these arrangements be in place date?:
If necessary, who will inform the child/young person’s pre-school nursery/school/educational establishment that s/he is looked after or has changed placement?
Name: / Tel:
Who will liaise with the school on a day-to-day basis?
Name: / Tel:
Who will receive correspondence/reports from the child/young person’s pre-school nursery/school/educational establishment?
Name: / Tel:
If not carer(s) how will information be shared with them?:
If not parent(s) how will information be shared with them?:
Who will attend parent and open evenings, and other school events?
Name: / Tel:
Permission for the child/young person to go on school day trips may be given by?
Name: / Tel:
Permission for the child/young person to go on longer school journeys may be given by?
Name: / Tel:
Are there any costs associated with the child’s education i.e. school meals, fares, uniform what are they?:
If so, who will meet the costs?
Name: / Tel:
FAMILY AND SOCIAL RELATIONSHIPS
Arrangements and actions - What arrangements for contact have been made? All members of the child/young person’s family and other significant people for the child/young person must be listed, even where contact arrangements are not yet in place
Person / Frequency / Type (face to face, phone, letterbox, overnight) / Arrangements (transport, location, arrangements for supervision)
Where it is intended for a child subject to a care order to stay overnight with parents requirements arising from sections 15-20 of the Care Planning, Placement and Case Review (England) Regulations 2010 must be complied with / Birth mother
Birth father
Step-parent/other main carer
Should include half and step-siblings / Brothers and sisters
Grandparents
Can include extended family members, friends and previous carer(s) / Other significant people for the child/young person
Is there anyone with whom contact with the child/young person is restricted or forbidden?
Relationship:
Name:
Address:
Post code: / Tel:
Has a court made any order or recommendation restricting contact?YesNo
If yes, please give details and indicate whether the carers have a copy of any order?:
Does the child/young person want anyone else to know where they are, in addition to those listed on page 15:YesNo
If yes, please give details and indicate who will contact the child/young person?
Relationship:
Name:
Address:
Post code: / Tel:
To be contacted by:
Please detail any areas where delegated authority is to be given to carers. It is expected that foster children should enjoy the same experiences as all children and should not need formal permission to stay overnight with the carer’s own family or with their friends:
Is the young person a parent?: YesNo
If yes, do they have parental responsibility?: YesNo
Child(ren’s) names and dates of birth
Name / DOB
Do(es) the child(ren) have a social worker?: YesNo
If yes, please provide social worker details
Name: / Team:
Tel: / e-mail:
If the young person is not living with their child(ren) please provide brief details of contact arrangements?:
IDENTITY
Does the child/young person regularly attend a place of worship?: YesNo
If yes, please provide details of their place of worship
Address:
Post code: / Days and times of attendance:
Please give details of any religious practices to be observed:
Does the child/young person have any specific dietary needs for religious or cultural reasons?: YesNo
If yes, please give details of the dietary requirements:
Does the child/young person regularly attend any activities e.g. groups, centres or clubs, which relate to their racial, cultural or linguistic needs?: YesNo
If yes, please give details of the activities/groups
Address: / Days and times of attendance:
Is there any other information in relation to the child/young person’s religious, cultural or linguistic needs that it would be helpful for the carer(s) to know?: YesNo
If yes, please give religious, cultural or linguisticadditional needs/details?:
Arrangements and actions – Will the child/young person attend their regular place of worship?: YesNo
If yes, who will be responsible for taking them?
Name: / Tel:
If no, who is responsible for making alternative arrangements?
Name: / Tel:
When will these arrangements be in place date?:
Will the child/young person continue to attend any activities in relation to their culture or heritage?: YesNo
If yes, who will be responsible for taking them?
Name: / Tel:
If no, who is responsible for making alternative arrangements?
Name: / Tel:
When will these arrangements be in place date?:
These services should be included in the Care Plan for the child/young person. Will any additional services be provided to support the carers to meet the child/young person’s religious or cultural needs?: YesNo
SELF CARE SKILLS AND INDEPENDENCE
Are there any aspects of the child/young persons self care skills that will require specific attention as a result of skills attainment programmes or preparation for independence?:
SOCIAL AND LEISURE ACTIVITIES
Please list the child/young persons current hobbies, special interest and leisure activities
Activity details / Date/day / Time(s) / Location
Social and leisure activities
Arrangements and actions – Provide details of the child/young person’s current hobbies, special interests and leisure activities that will continue in the placement
Activity details / Arrangements
Are any costs involved? (e.g. equipment, fares, subscriptions); YesNo
If so, who will cover these?:
What is the contingency plan if any of the above arrangements fall through or cannot be financed?:
Please identify activities that cannot be continued in the current placement?:
AGREEMENTS FOR CHILD/YOUNG PERSON TO BE ACCOMMODATED
1. Social worker/duty social workerdeclaration
The above information is correct to the best of my knowledge and belief
Signature: / Name:
Designation: / Date:
2. Residential worker declaration
I agree to look after(child/young person) at the below address
Address:
Signature: / Name:
Designation: / Date:
3. Approved foster carers declaration
I/we agree to look after(child/young person) at the placement address and to comply with all aspects of the foster care agreement as stated in Schedule 5 of the Fostering Services Regulations (England) 2011. I/we have received written information concerning these regulations. I/we also agree to co-operate with all arrangements made by Leeds City Council
Signature: / Name:
Date:
Signature: / Name:
Date:
4. Relative/friends declaration
I/we agree to look after(child/young person) at the placement address for a period not exceeding sixteen weeks under Regulation 24 of the Care Planning, Placement and Case Review (England) Regulations 2010 and to comply with all aspects of the foster care agreement as stated in Schedule 5 of the Fostering Services Regulations 2011. I/we have received written information concerning these regulations. I/we also agree to co-operate with all arrangements made by Leeds City Council for him/her
Signature: / Name:
Date:
Signature: / Name:
Date:
5. Young person declaration (if of sufficient age and understanding. If the young person concerned is 16 or over and being accommodated without parental consent s/he should be encouraged to sign this agreement)
Views of the young person:
I agree to be looked after by Leeds City Council
Signature: / Name:
Date:
6. Parent/person with parental responsibility declaration
I/we agree for(child/young person) being accommodated by Leeds City Council
Signature: / Name:
Date:
Signature: / Name:
Date:
7. Social Care Team
Have all sections of the Placement Plan Record been completed at the time the child/young person was placed with carers?: YesNo
If no, when will it be completed date?:
Team manager signature: / Team manager name:
Date:
Date record completed:
Date copied to all parties:
Team manager signature: / Team manager name:
Date:
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