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Return To FormNHS and Social Services Confidential Information about a patient
Printed Assessment Details
Printed By: / Kathryn Bryant
Print Date: / 13-Feb-2009
Draft Common Assessment Tool
Service User: / Pink Panther, 01-Jan-1940 (SAP Ref: 14411)
Lead Assessor: / Kathryn Bryant - Cumbria
AssessmentType: / Common Assessment Tool
Assessment Date: / 13-Feb-2009 15:00
Copy to Briefcase
Common Assessment Tool
This form is a Common assessment tool.
It can be completed where urgent care is required prior to the completion of the short-assessment questionnaire, or can be completed in conjunction with the short-assessment questionnaire where it is felt a more complex assessment is required. In all cases a short assessment questionnaire must be done within 4 weeks (PI)
In completing this assessment if the information is not from the person being assessed or is someone else’s opinion please be sure to reference this and evidence all statements.
Consent
The County council web site provides guidance to service users on why we keep records, what we keep, how they can access their record and how we safely store the record.
Click this link to access
Have consent issues been discussed with the client?
/ Yes / / No / / Unable to give consent
If 'Yes', was consent given for information to be shared as needed?
/ Yes / / Yes, with limitations / / No / / Not applicable
Requested limitations in information sharing
Please indicate below any limitations requested by the person.
If the Service User is unable to give consent, please state why:
In some circumstances your local policy may enable you to continue with an assessment without the service user's consent. If you need to override consent you must record a valid reason.
Common Assessment Tool
Your Life
This part is about you and your life and asks you to consider how your life is, what are the strengths in your life and what are the important relationships. What are the current concerns you have, and what do you want to change in your life?
What’s important to you?
- Please consider personal, practical, social and cultural aspects of your life.
- What are your interests, who are the people in your life who are important to you? Who visits you regularly?
- What are your interests and hobbies?
- What do you like to do with your time?
- Are there end of life issues you want to consider?
What Personal strengths do I have to help me with the changes I want to make?
Achievements, current support and community networks, assertiveness, abilities
Making Decisions and Having choice
Do you need help or support to make decisions about your life?
This part is about how you decide important things in your life – things like where you live, who supports you and how your money is spent. Do you need support with making decisions? Do you need someone to make decisions for you?
Do you need help or support with making decisions about day to day things: -
Include decisions around health care, where you live, what you do day-to-day.
/ Yes / / No
If yes; what help do you need? Does anyone help you now?
/ Need Identified- Support with making decisions and having choice
Developing and Keeping Relationships and Involvement in Activities
This part is about doing things in your community, like going to work, accessing learning opportunities, using the local library, going to a club, community centre, or a place of worship, visiting friends, or being involved in local organisations.
Do you need help or support with doing things in your community, like using the local library, going to a club, community centre, or a place of worship, visiting friends, or being involved in local organisations. Please identify if there are things you would like to do now but are unable.
/ Yes / / No
If yes; what help or support do you need? Does anyone help you now?
/ Need Identified- Support with accessing community activities
Do you need help or support with getting or keeping a job?
/ Yes / / No
If yes; what help or support do you need? Does anyone help you now?
/ Need Identified- Support with getting/keeping a job
Do you need help or support Accessing education or learning opportunities?
/ Yes / / No
If yes; what help or support do you need? Does anyone help you now?
/ Need Identified- Support with accessing education or learning opportunities
Do you need help or support forming or maintaining relationships/friendships?
/ Yes / / No
If yes; what help or support do you need? Does anyone help you now?
/ Need identified - Support with forming or maintaining relationships/friendships
Accommodation
This part is about where you live. Do you need help with your present living arrangements? Is your current home suitable for your needs? If you need alternative accommodation, what has changed and what type of housing do you feel you need?
/ Need Identified- Alternative accommodation required
/ Need Identified- Adaptations to property
Finance
This section is about managing your finances and paying your bills.
Do you need help or support with managing your money, such as paying your bills?
/ Yes / / No
If yes; what help or support do you need? Does anyone help you now?
/ Need Identified- Managing your money
Have you nominated someone as your Enduring Power of Attorney?
Please ensure this person is recorded in the personal relationships in SAP.
/ Yes / / No
Have you nominated someone as your Lasting Power of Attorney (LPA)?
Please ensure this person is recorded in the personal relationships in SAP.
/ Yes / / No
Does your LPA have financial decisions delegated to them?
/ Yes / / No
Does your LPA have life decisions delegated to them?
/ Yes / / No
Is this power registered?
You may wish to discuss seeking EPA or registering.
/ Yes / / No
You may want to tell us whether you receive any benefits related to your needs e.g. attendance allowance/disability living allowance.
Do you think you need a benefits check?
/ Yes / / No
/ Need Identified- Benefits check
Daily living tasks
This part is about day to day life; things like shopping, cleaning, cooking, doing the laundry, managing finances, paying bills and maintaining your home.
Do you need help or support with managing domestic tasks such as cooking, shopping, cleaning, and laundry?
/ Yes / / No
If yes; what help or support do you need? Does anyone help you now?
/ Need Identified- Meal Preparation
/ Need Identified- Cooking
/ Need Identified- Shopping
/ Need Identified- Cleaning
/ Need Identified- Laundry
Mobility
This part is about your mobility. Do you need aids to assist you with your mobility? Do you have any needs moving around your home or outdoors
Number of Falls
Please tick which applies:
/ No Falls
/ Fallen once in last 48 hours
/ Fallen several times in last 48 hours
/ Fallen once in last 12 months
/ Fallen several times in last 12 months
Please tick all that apply:
/ Fell at home
/ Fell outside the home
/ Resulted in attendance at hospital
/ Resulted in referral to falls management programme
/ Resulted in referral to physiotherapist
/ Resulted in referral to community Nurse
/ Resulted in referral to Occupational Therapy
Additional Comments:
/ Need identified- Falls Assessment
If Service User has fallen please consider referring for a falls assessment.
Click here to view details and criteria for local falls prevention clinics.
Going to Bed
/ I am independent and can manage easily unaided
/ I am independent and can manage with difficulty unaided
/ I need some help
/ I need lots of help
/ I can not do at all
Additional information to assist us to understand the help you need, including equipment and Assessor’s comments:
/ Need identified - Help going to bed
Getting out of Bed
/ I am independent and can manage easily unaided
/ I am independent and can manage with difficulty unaided
/ I need some help
/ I need lots of help
/ I can not do at all
Additional information to assist us to understand the help you need, including equipment and Assessor’s comments:
/ Need identified - Help getting out of bed
Standing / bending down
/ I am independent and can manage easily unaided
/ I am independent and can manage with difficulty unaided
/ I need some help
/ I need lots of help
/ I can not do at all
Additional information to assist us to understand the help you need, including equipment and Assessor’s comments:
/ Need identified - Standing / Bending down
Walking Indoors
/ I am independent and can manage easily unaided
/ I am independent and can manage with difficulty unaided
/ I need some help
/ I need lots of help
/ I can not do at all
Additional information to assist us to understand the help you need, including equipment and Assessor’s comments:
/ Need identified - Help to walk indoors
Managing stairs
/ I am independent and can manage easily unaided
/ I am independent and can manage with difficulty unaided
/ I need some help
/ I need lots of help
/ I can not do at all
Additional information to assist us to understand the help you need, including equipment and Assessor’s comments:
/ Need identified - Help managing stairs
Transferring from Chair / Hoist / Wheelchair/ Toilet
/ I am independent and can manage easily unaided
/ I am independent and can manage with difficulty unaided
/ I need some help
/ I need lots of help
/ I can not do at all
Additional information to assist us to understand the help you need, including equipment and Assessor’s comments:
/ Need identified - Help with transferring
Do you have any additional mobility needs?
Personal Care
This part is about looking after you – things like washing, dressing and going to the toilet.
Do you need help or support with personal care tasks such as washing and dressing/undressing yourself, bathing/showering, shaving and personal grooming and going to the toilet?
/ Yes / / No
If yes; what help or support do you need? Does anyone help you now?
/ Need Identified- Washing
/ Need Identified- Dressing / Undressing
/ Need Identified- Bathing / Showering
/ Need Identified- Personal Grooming
/ Need Identified- Going to Toilet
Do you need help or support with managing your continence?
/ Yes / / No
If yes; what help or support do you need? Does anyone help you now?
/ Need Identified- Managing continence
Do you have any personal care support needs through the night?
/ Yes / / No
If yes; what help or support do you need? Does anyone help you now?
/ Need Identified- Personal Care (night)
Eating and Drinking
This part is about staying well nourished including needing help or support with prompting to eat or drink.
Do you need help or support with eating and drinking. Do you have any specialist dietary requirements? Do you need any specialist equipment around your dietary needs?
/ Yes / / No
If yes; what help or support do you need? Does anyone help you now?
/ Need Identified- Support with eating/drinking
Sensory Impairment
This section is about help you might need as a result of sensory loss e.g. sight or hearing loss.
Do you have a sensory impairment or problems with:
Sight:
/ Yes / / No
Speech/Communication:
/ Yes / / No
Hearing:
/ Yes / / No
Touch/Sensitivity:
/ Yes / / No
Taste/Eating:
/ Yes / / No
Balance:
/ Yes / / No
Sense of Smell:
/ Yes / / No
What problems do you have?
/ Need Identified- Sensory Impairment
What equipment (if any), do you have? Please record types of glasses, do you wear them, hearing aids etc if known.
Do you have any additional needs relating to your sensory impairment?
Physical Health and Wellbeing
This part refers to support you may need to manage a long-term physical condition such as diabetes, heart or respiratory failure, stroke or epilepsy; or to manage a short-term physical condition.
Do you have any physical health conditions, or disabilities, which affect your daily life?
/ Need identified- Support to manage health condition
Do you need help or support with collecting prescriptions?
/ Yes / / No
If yes; what help or support do you need? Does anyone help you now?
Do you need prompting to take your medication?
/ Yes / / No
If yes; what help or support do you need? Does anyone help you now?
Do you need help or support to apply ointments or to give you your medication?
/ Yes / / No
If yes; what help or support do you need? Does anyone help you now?
Do you need help or support getting to appointments?
/ Yes / / No
If yes; what help or support do you need? Does anyone help you now?
/ Need Identified- Managing medication
Please tick the frequency that best applies:
/ Occasional (less than one appointment per month)
/ Regular (one or two appointments per month)
/ Frequent (one or more appointments per week)
Do you receive regular visits from a specialist nurse, District Nurse or other health professionals?
If "Yes" please record details in professional relationships on SAP.
/ Yes / / No
Is a continuing health care assessment required?
If yes, please ensure continuing health care guidelines are followed. Complete a continuing health care assessment.
/ Yes / / No
/ Need Identified- Continuing care assessment required
Do you have any additional needs around maintaining your physical wellbeing?
Mental health and emotional wellbeing
This part refers to support you may need to manage a mental health condition including dementia, depression, acute anxiety, bereavement or memory loss.
Do you have any concerns about your mental health? Do you have any memory loss, periods of confusion, depression? Do you feel you put yourself at risk? Are others concerned you are at risk because of your mental health? Does anyone support you with these issues?
Have you had a formal diagnosis and by whom. Who else was involved in this assessment? Has an assessment been done under the mental capacity act? Is one required?
Please record legal status in special factors on SAP.
/ Need Identified- Support to manage mental health
/ Need Identified- Support to manage emotional wellbeing
Do you receive regular visits from a specialist nurse (including Community psychiatric nurse), or other health professionals in respect of your emotional or mental health.
If "Yes" please record details in professional relationships on SAP.
/ Yes / / No
Learning Disability
This part is for if you have a learning disability. If so, do you have a formal diagnosis, did you/do you attend specialist schooling? What are your support needs around managing your learning disability? Do you have support needs around your behaviour?
/ Need Identified- Support to manage learning disability
Staying Safe
This section is about keeping safe. It could be about going out on a bus, using a cooker or using stairs etc. Staying safe is different things to different people.
Do you think you are at any risk, or danger? Do others think you are at risk? How do you cope with these risks and does anyone help you manage these risks. Do you feel other people put you at risk?
/ Need Identified- Support to stay safe
Does anyone help you with staying safe now?
/ Yes / / No
Please say how they help?
Are there safeguarding adults issues to be considered?
If yes please ensure Safeguarding Adults Procedures are followed.
/ Yes / / No
Supporting choice and control - Are there things you would like to be able to do, but feel unable to do because of the risk? Are there potential solutions (positive risk taking)?
/ Need Identified - Supporting choice and control
Is a multidisciplinary risk assessment needed?
/ Yes / / No
/ Need Identified - Multidisciplinary Risk Assessment Required
Cumbria Fire and Rescue Home Safety Check
The totally free home fire safety check service operated by Cumbria Fire & Rescue Service is more than just putting up a smoke detector. It’s about assessing general fire risk and providing advice and equipment to the household. We even provide fire retardant bedding, portable sprinkler systems and alarms for people with hearing impairment. It’s about getting the right solution for the right people.
Are you happy to have a home safety check from Cumbria Fire and Rescue Service?
Please note where you answer yes this information will be given direct to the fire and rescue service.
/ Yes / / No
If yes:
Are there any issues we should consider when visiting or contacting you? Please note if someone else e.g. if a carer or advocate should be contacted in the first instance, or if there are any communication issues.
Does the property have working smoke alarms?
Do you smoke?
/ Need Identified - Home Safety Check Required
Is there considered to be a high risk of fire?
/ Yes / / No
Telecare Assessment
Some situations where there are high risks can be managed by using technology. If you need support to manage risks you should ask what telecare is available in your area.
Do you already have Telecare equipment installed? If so please list equipment, e.g. falls detector or flood detector:
Are you connected to a Community Alarm Service?
(e.g. Careline)
/ Yes / / No
If “yes” who is the provider?
Summary