Cherry Tree Lodge
Updated: 26/05/2011
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CA11 - Pre-Admission Assessment and Care Planning Pack
Pre-Admission Assessment and Care Planning Pack
Copyright © 2012 Quality Compliance Systems Limited Tel: 0207 1383078 Fax: 0845 2590201
Cherry Tree Lodge
Updated: 26/05/2011
Printed: 13/04/2012
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CA11 - Pre-Admission Assessment and Care Planning Pack
Instructions for Use
The following Care Plan pack may seem overwhelming. There is a lot of information, but a lot of information is needed to
create a totally person centred Care Plan. The following Care Plans will help you develop a comprehensive picture of the
person you are providing care for.
We have divided the Care Plan into several different sections for you. They are:
●
●
●
●
●
●
●
●
●
●
●
Pre-admission
General (consent forms, room risks, care needs, mental health needs)
Mental Capacity
Skin Marks, Bruising, Skin Integrity (including Waterlow Risk Assessment)
Moving and Handling
Nutritional Needs
Falls Risks
Medications
Social History, Activities and Needs (including Dementia Workbook)
Other Risk Assessments and Care Plans
Records
The first section, Pre-admission is used to assess applicants for a match to the service and determine if the service can
meet their needs as required by the Health and Social Care Act 2008 and the attendant Regulations.
The remaining sections are the plans which are completed when an admission takes place, combined with the PreAdmission section they form the complete Care Plan file.
The Service User’s view of their needs and preferences must be obtained and taken into account at every stage of
assessment and Care Planning, and evidence of that involvement generated and recorded. In order to relieve the Service
User of the task of signing many documents, in this pack a “Record of Service User Involvement” is used for staff to record
brief details of each consultation, and for the Service User to sign only once.
© 2010 Quality Compliance Systems Ltd (QCS)
271 Regent Street
London W1B 2ES
Tel: 0208 626 44 52
Email: info@ukqcs.com
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Cherry Tree Lodge
Updated: 26/05/2011
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CA11 - Pre-Admission Assessment and Care Planning Pack
PRE-ADMISSION: Enquiry Form
* Essential information
Name:*
Address:
Telephone number:*
Prospective Service User Information
Name (if different from above, and only if revealed)
Relationship to enquirer
Address or location:*
Telephone number:
Date of birth:*
Age now:
Brief details of needs:*
Agreed dependency level:*
Agreed fee level:*
Long or short stay:*
Single or twin room
Potential admission date:*
GP name address and telephone:
Where did you hear of us? (Circle as appropriate)
Social Services – Hospital staff – GP – Friend – Other
Date of this initial enquiry:
Enquiry taken by:
If required, use the back of this form for further details.
Further action Required:
Date Information Pack sent
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CA11 - Pre-Admission Assessment and Care Planning Pack
PRE-ADMISSION: MENTAL CAPACITY ACT ASSESSMENT
Is the Service User designated and lacking mental capacity under the MCA 2005?
Yes / No
If yes, summary of reasons for designation:
Details of any “best interest” specifications:
Yes / No
Details of any restraint specifications:
Yes / No
Details of Lasting Power of Attorney, if any:
Yes / No
Details of any Court appointed deputies:
Yes / No
Details of any Independent Mental Capacity Advocate:
Yes / No
Details of any Advance decisions to refuse treatment:
Yes / No
Other relevant details:
Yes / No
Next review interval (maximum 1 month)
Therefore next review date:
(use attached review form to note, or if changes are substantial, carry out this full assessment again)
Accountability Signature: (Person completing to print name and sign):
Copyright © 2012 Quality Compliance Systems Limited Tel: 0207 1383078 Fax: 0845 2590201
Date of form
completion:
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CA11 - Pre-Admission Assessment and Care Planning Pack
PRE-ADMISSION: CONSENT RECORD
Resident name:
For your protection and privacy, your consent is required before we request information from you, or carry out any
examination of procedure.
Please read the questions below, or ask someone to read them to you, and indicate clearly YES or NO to each question. You
will be asked to sign against each answer.
You will be asked to sign each answer at the end.
Note to staff: the Service User must be given sufficient time to consider their responses to these questions. Do not pressurise
the Service User into answering, and be prepared to leave the form with them and return.
Date Consent for given to
Date Consent Form received from Service User
Service User
YES or NO (delete as
appropriate)
(Signature)
1 Do you consent to answering questions, giving information, and having that information recorded, for the purposes of an
assessment of your needs?
YES or NO (delete as
appropriate)
(Signature)
2. Do you consent to a physical examination and having that information recorded, for the purposes of an assessment of your
needs?
YES or NO (delete as
appropriate)
(Signature)
3. Do you consent to the service consulting with other professionals concerned with your care or support, for the sole purpose
of obtaining information for the completion of this assessment?
YES or NO (delete as
appropriate)
(Signature)
4. Do you consent to having a photograph taken of any wounds or skin lesions which an examination may show, and having
that information recorded, for the purposes of considering your care needs?
YES or NO (delete as
appropriate)
(Signature)
5. Do you consent to this assessment being read by staff who are or may provide care and support for you (and only those
staff)?
YES or NO (delete as
appropriate)
(Signature)
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CA11 - Pre-Admission Assessment and Care Planning Pack
PRE-ADMISSION: CONSENT – MONTHLY OR MORE FREQUENT REVIEW
Use to conduct reviews of current assessment, unless sufficient changes require full risk re-assessment. Max 6 reviews,
then re-assess.
Service User’s Name:
Admission date:
Review notes:
Consents requires repeating Y / N?
Date of review:
Next review date (maximum 1 month, or less if required, and always if Accountability Signature:
any changes)
Review notes:
Consents requires repeating Y / N?
Date of review:
Next review date (maximum 1 month, or less if required, and always if Accountability Signature:
any changes)
Review notes:
Consents requires repeating Y / N?
Date of review:
Next review date (maximum 1 month, or less if required, and always if Accountability Signature:
any changes)
Review notes:
Consents requires repeating Y / N?
Date of review:
Next review date (maximum 1 month, or less if required, and always if Accountability Signature:
any changes)
Review notes:
Consents requires repeating Y / N?
Date of review:
Next review date (maximum 1 month, or less if required, and always if Accountability Signature:
any changes)
Review notes:
Consents requires repeating Y / N?
Date of review:
Next review date (maximum 1 month, or less if required, and always if Accountability Signature:
any changes)
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CA11 - Pre-Admission Assessment and Care Planning Pack
PRE-ADMISSION: PERSONAL DETAILS
Service User’s Name:
Preferred mode of address:
Home address:
Date of Birth:
Admission date:
Next of Kin: Name:
Partnership Status:
Admitted from:
Relationship:
Address:
Telephone number:
Home:
Work:
Wish to be contact day or night:
Photo:
Second contact: Name:
Relationship:
Address:
Telephone number: Home:
Work:
Maiden name:
General Practitioner:
Social Worker:
Speech Therapist:
Community Nurse:
Dietician:
Minister of religion:
Religion:
Funeral directions:
Solicitor:
Ethnic origin:
Nat. Ins number:
NHS number:
Accountability Signature: (Person completing to print name and sign):
Date of form completion:
Note: on admission move this page to the front of the Care Plan file
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CA11 - Pre-Admission Assessment and Care Planning Pack
PRE-ADMISSION: HEALTH DETAILS – 1
Service User’s Name:
Admission date:
Brief description of current health state/Reason for admission
Brief description of past and present medical health
Spectacles – Reading – Distance
Hearing aids – Left – Right
Dentures: upper / lower / partial
Pacemaker: Y /N. Instructions:
Specialist aids and equipment
Skin
Hair
Nails
Weight
Accountability Signature: (Person completing to print name and sign):
Date of form completion:
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CA11 - Pre-Admission Assessment and Care Planning Pack
PRE-ADMISSION: HEALTH DETAILS – 2
Service User’s Name:
Admission date:
Allergies/aversions
Previous health conditions
GP/Consultant involvement
Medication – current
Medication – previous
Controlled drugs administered
History of falls (see also falls risk assessment for more detailed assessment)
Dietary requirements and allergies. Include current weight
Sight, hearing and communication
Specialist services involvement
Specialist aids used or required (state which)
Accountability Signature: (Person completing to print name and sign):
Date of form completion:
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CA11 - Pre-Admission Assessment and Care Planning Pack
PRE-ADMISSION: HEALTH DETAILS – 3
Service User’s Name:
Admission date:
Oral health
Foot care
Mobility and dexterity
Wheelchair user?
Self-propelled or not?
Continence
Confusion
History of involvement with multi-disciplinary agencies.
Accountability Signature: (Person completing to print name and sign):
Date of form completion:
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CA11 - Pre-Admission Assessment and Care Planning Pack
PRE-ADMISSION: CULTURAL, RELIGIOUS AND PALLIATIVE CARE
Service User’s Name:
Admission date:
Service User’s wishes in respect of cultural and religious matters:
Service User’s wishes in respect of terminal care:
Accountability Signature: (Person completing to print name and sign):
Date of form completion:
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CA11 - Pre-Admission Assessment and Care Planning Pack
PRE-ADMISSION: PERSONAL CARE NEEDS ASSESSMENT TOOL – 1
Service User’s Name:
Admission date:
Low dependency
Communication No problems
Bath
Independent
Washing
Independent
Dressing
Independent
Grooming
Independent
Toilet
Independent
Continence
Independent
Eating
Independent
Drinking
Independent
Medium dependency
High dependency
Comments/Notes
Understands, slow to
Unable to respond
respond.
appropriately.
Can bath with support of
Requires support of two
one carer
carers
Can wash most parts of
Can wash only face and
body, help with feet and
hands.
back.
Needs one carer help with Needs help from two carers
buttons & straps
dressing,
Can shave or make up with Needs two carer help with
one carer.
grooming.
Needs one carer support Needs two carers to cleanse
to cleanse self after toilet self after toilet
Needs one carer support Incontinent, requires two
to use toilet.
carers.
Needs food prepared, can Requires one carer for
then eat independently.
support and
encouragement.
Independent using
Needs full support and 1
adopted drinking utensil. carer encouragement for
drinking.
Next review interval (maximum 1 month)
Therefore next review date:
(use attached review form to note, or if changes are substantial, carry out this full assessment again)
Accountability Signature: (Person completing to print name and sign): Date of form completion:
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CA11 - Pre-Admission Assessment and Care Planning Pack
PRE-ADMISSION: PERSONAL CARE NEEDS ASSESSMENT TOOL – 2
Service User’s Name:
Admission date:
Low dependency
Medium dependency
No problems
Regular pressure relief
and overlay mattress.
Moods
High risk pressure relief
monitoring. Specialist chair
cushions and bed
mattresses. Two carers day
and night.
Independent & sociable. Needs encouragement to Very reluctant to socialise
join activities.
and take part in recreational
pursuits.
Independent & weight
Weight bearing but needs Non-weight bearing, hoist
bearing.
support of staff.
only.
No problems.
Short term memory able to Unable to hold a rational
communicate.
conversation. Disoriented in
time and place.
Socialises well.
Prefers solitude and one to Withdrawn, or Manic
one conversation.
No problems
Tending to depression.
Depressive illness
Pain
No problems
Sleep
No problems
Intermittent, controlled by
medication
Occasional sleeping
difficulty.
Pressure Sore
Care
Social &
Recreational
Moving and
Handling
Memory
Personality
High dependency
Comments/Notes
Severe, requires regular
medication
Poor sleep patterns,
requiring night time care,
intermittent night sedation.
Next review interval (maximum 1 month)
Therefore next review date:
(use attached review form to note, or if changes are substantial, carry out this full assessment again)
Accountability Signature: (Person completing to print name and sign): Date of form completion:
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CA11 - Pre-Admission Assessment and Care Planning Pack
PRE-ADMISSION: MENTAL HEALTH ASSESSMENT TOOL
Service User’s Name:
0
Date
1
2
3
DEPRESSION None at
present.
History of
depression.
Mild depression,
medication.
Severe depression,
specialist services.
MOOD
No mood
disorder.
Predictable mood Unpredictable
change.
mood change.
Unable to be
rationalised.
ANXIETY
Calm under
pressure.
Anxiety after
stress.
Anxiety easily
triggered.
Severe anxiety.
Mild short term
memory loss.
Disoriented at
times.
Unable to form links
with the present.
Isolated history
of aggressive
outbursts.
Aggressive, no
violence.
Random
episodes of
violence.
Abusive
Aggressive
behaviour a regular
occurrence.
Rummaging
Shouting
Invading privacy of
others.
Violent
Destructive
Severe deviance
Screaming
Smearing
Others
Previous history
of deliberate self
harm.
Current
intermittent selfneglect.
Severe risk of self
harm.
MEMORY
Long and
short term
intact.
AGGRESSION No history of
aggression.
CHALLENGING No history
BEHAVIOUR –
MODERATE
CHALLENGING No history
BEHAVIOUR –
SEVERE
SELF HARM
SELF
NEGLECT
No history
Previous history
of accidental self
harm.
No history of Previous neglect
any form.
of diet, hygiene or
appearance.
Comments
Severe current risk
of self harm.
COMMENTS FROM OTHERS, PROFESSIONAL OR INFORMAL CARER
Presentation of behaviour in shaded (heavy text) cells indicates that the potential Service User may be suitable for a
dementia registered the home, but unsuitable for a general registered the home, irrespective of aggregate score. Further
detailed assessment may be necessary to decide appropriate placement.
Next review interval (maximum 1 month). Therefore next review date: _________________________
(use attached review form to note, or if changes are substantial, carry out this full assessment again)
Accountability Signature: (Person completing to print name and sign):
Date of form completion:
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CA11 - Pre-Admission Assessment and Care Planning Pack
PRE-ADMISSION: RECORD OF INVOLVEMENT
Service Users, or their authorised representatives, must have assessment explained to them, be given options for care and
support from which they can choose their preferences, be fully involved in the design of Care Plans, and fully involved in
reviews, including again being given choices from which they can select their preferences. A record must be kept of these
discussions as evidence. Brief details (verbatim records are not required) of every discussion must be recorded on this
record as evidence of the involvement.
Service User NAME:
Record of involvement:
Names of participants:
Date and time:
Record :
Record of involvement:
Names of participants:
Date and time:
Record :
Record of involvement:
Names of participants:
Date and time:
Record :
Record of involvement:
Names of participants:
Date and time:
Record :
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CA11 - Pre-Admission Assessment and Care Planning Pack
PRE-ADMISSION: SKIN MARKS/BRUISING ASSESSMENT TOOL
Service User’s Name:
Admission date:
Examined in person? Y / N. If N, record name and designation of person providing information:
Name:
Date of examination:
Designation:
Signature:
Skin Marks/Bruising Diagram
Area of risk/mark/bruising identified
Description of risk/mark/bruising identified
Cause identified? Specify
Care Plan created Yes/No. If no, why?
OR – No skin lesions apparent: (tick and sign
for accountability. See above if accepting 2nd
hand information)
Next review interval (maximum 1 month).
Therefore next review date: _____ (use attached review form to note, or if changes are substantial, carry out this full
assessment again)
Accountability Signature: (Person completing to print name and sign):
Date of form completion:
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CA11 - Pre-Admission Assessment and Care Planning Pack
PRE-ADMISSION: SAMPLE LETTERS
Sample Letter offering a place in a care home
Date
Address
Dear ,
Thank you for expressing an interest in the services offered by the home.
I confirm that we have carried out an assessment of your needs, and that we are able to provide the services which you
require.
I enclose a copy of our Service User’s Handbook which provides information which we are required to give you under
Statutory Regulations, combined with some useful information about life in the home. The two copies of the Service Users
Agreement have been signed by a representative of the home. Please sign the Provider’s Copy (at the back of the
Handbook), detach it from the Handbook and returned it to us. You should keep the rest of the Handbook for your own
information.
I also enclose a copy of the summary of the latest Service User’s Satisfaction Survey carried out in the home. We are
required to make available to you the latest report from the Care Quality Commission, but, as this is a very lengthy
document this has not been included but is on public display within the home. If you require a personal copy, please contact
me and I will arrange for a copy to be sent to you.
I confirm that we have arranged for admission at about Xam/pm on (date). Our Manager, and/or your proposed Key Worker
will be available to greet you, and help you settle in on your first day. Anyone accompanying you is welcome to take a meal
with you after your arrival, in your room if you prefer. It would assist our catering arrangements if you could inform us prior to
admission if you would like to.
We look forward to seeing you. Please contact the home at any time in the meantime if you have any questions.
Yours sincerely
Registered Manager
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CA11 - Pre-Admission Assessment and Care Planning Pack
PRE-ADMISSION: SAMPLE LETTERS
Sample Letter declining to offer a place in a care home
Date
Address
Dear ,
Thank you for expressing an interest in the services offered by the home. I confirm that we have carried out an assessment
of your needs, and unfortunately I am not able to offer you a place at the home, because we are unable to fully meet the full
range of your needs which were identified during the assessment.
I am sorry that we have been unable to offer you a place. If I can be of any assistance in advising you as to other suitable
placements, please do not hesitate to get in touch.
Yours sincerely
Registered Manager
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CA11 - Pre-Admission Assessment and Care Planning Pack
GENERAL: CONSENT FORM
Resident name:
For your protection and privacy, your consent is required before we request information from you, or carry out any
examination of procedure.
Please read the questions below, or ask someone to read them to you, and indicate clearly YES or NO to each question. You
will be asked to sign against each answer.
You will be asked to sign each answer at the end.
Note to staff: the Service User must be given sufficient time to consider their responses to these questions. Do not pressurise
the Service User into answering, and be prepared to leave the form with them and return.
Date Consent for given to
Date Consent Form received from Service User
Service User
YES or NO (delete as
appropriate)
(Signature)
1 Do you consent to answering questions, giving information, and having that information recorded, for the purposes of an
assessment of your needs?
YES or NO (delete as
appropriate)
(Signature)
2. Do you consent to a physical examination and having that information recorded, for the purposes of an assessment of your
needs?
YES or NO (delete as
appropriate)
(Signature)
3. Do you consent to the service consulting with other professionals concerned with your care or support, for the sole purpose
of obtaining information for the completion of this assessment?
YES or NO (delete as
appropriate)
(Signature)
4. Do you consent to having a photograph taken of any wounds or skin lesions which an examination may show, and having
that information recorded, for the purposes of considering your care needs?
YES or NO (delete as
appropriate)
(Signature)
5. Do you consent to this assessment being read by staff who are or may provide care and support for you (and only those
staff)?
YES or NO (delete as
appropriate)
(Signature)
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CA11 - Pre-Admission Assessment and Care Planning Pack
GENERAL: CONSENT – MONTHLY OR MORE FREQUENT REVIEW
Use to conduct reviews of current assessment, unless sufficient changes require full risk re-assessment. Max 6 reviews,
then re-assess.
Service User’s Name:
Admission date:
Review notes:
Consents requires repeating Y / N?
Date of review:
Next review date (maximum 1 month, or less if required, and always if Accountability Signature:
any changes)
Review notes:
Consents requires repeating Y / N?
Date of review:
Next review date (maximum 1 month, or less if required, and always if Accountability Signature:
any changes)
Review notes:
Consents requires repeating Y / N?
Date of review:
Next review date (maximum 1 month, or less if required, and always if Accountability Signature:
any changes)
Review notes:
Consents requires repeating Y / N?
Date of review:
Next review date (maximum 1 month, or less if required, and always if Accountability Signature:
any changes)
Review notes:
Consents requires repeating Y / N?
Date of review:
Next review date (maximum 1 month, or less if required, and always if Accountability Signature:
any changes)
Review notes:
Consents requires repeating Y / N?
Date of review:
Next review date (maximum 1 month, or less if required, and always if Accountability Signature:
any changes)
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CA11 - Pre-Admission Assessment and Care Planning Pack
GENERAL: PERSONAL DETAILS
Service User’s Name:
Preferred mode of address:
Home address:
Date of Birth:
Partnership Status:
Admission date:
Admitted from:
Next of Kin: Name:
Relationship:
Address:
Telephone number:
Home:
Work:
Wish to be contact day or night:
Photo:
Second contact: Name:
Relationship:
Address:
Telephone number: Home:
Work:
Maiden name:
General Practitioner:
Social Worker:
Speech Therapist:
Community Nurse:
Dietician:
Minister of religion:
Religion:
Funeral directions:
Solicitor:
Ethnic origin:
Nat. Ins number:
NHS number:
Accountability Signature: (Person completing to print name and sign):
Date of form completion:
Note: on admission move this page to the front of the Care Plan file
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CA11 - Pre-Admission Assessment and Care Planning Pack
GENERAL: ROOM RISK ASSESSMENT
Service User’s name:
Location
Fire doors
Admission date:
Fire alarms
Cleanliness
Lighting
Temperature
Ventilation
Windows, skylights,
transparent doors
Window opening checks
Sanitary conveniences
Washing facilities
Drinking water
Call bell – bed
Call bell – chair (or extension
lead)
Chair height
Toilet height
Grab rails
Flooring
Bed safety rail
Doors and gates
Radiator surface temperature
Piping surface temperature
Hot water tap temperature
control
Thermometer
Warning signs
Next review interval (maximum 1 month). Therefore next review date:
(use attached review form to note, or if changes are substantial, carry out this full assessment again)
Signature: (print and sign):
Date of form completion:
Service User or Advocate
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CA11 - Pre-Admission Assessment and Care Planning Pack
GENERAL: ROOM RISK PLAN OF CARE
Service User’s name:
Admission date:
Assessed need and Service User view:
Aim of care:
Staff Instruction(s):
Accountability signature (Person completing to print name and sign):
Date of form completion:
Signature (Service User or Advocate to print name and sign):
Date of form completion:
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CA11 - Pre-Admission Assessment and Care Planning Pack
GENERAL: ROOM RISK – MONTHLY OR MORE FREQUENT REVIEW
Use to conduct reviews of current assessment, unless sufficient changes require full risk re-assessment. Max 6 reviews,
then re-assess.
Service User’s name:
Admission date:
Review notes:
Care Plan requires modifying (Y / N)?
Date of review:
Next review date (maximum 1 month, or less if required, and always if Accountability signature:
any changes)
Review notes:
Care Plan requires modifying (Y / N)?
Date of review:
Next review date (maximum 1 month, or less if required, and always if Accountability signature:
any changes)
Review notes:
Care Plan requires modifying (Y / N)?
Date of review:
Next review date (maximum 1 month, or less if required, and always if Accountability signature:
any changes)
Review notes:
Care Plan requires modifying (Y / N)?
Date of review:
Next review date (maximum 1 month, or less if required, and always if Accountability signature:
any changes)
Review notes:
Care Plan requires modifying (Y / N)?
Date of review:
Next review date (maximum 1 month, or less if required, and always if Accountability signature:
any changes)
Review notes:
Care Plan requires modifying (Y / N)?
Date of review:
Next review date (maximum 1 month, or less if required, and always if Accountability signature:
any changes)
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CA11 - Pre-Admission Assessment and Care Planning Pack
GENERAL: CARE NEEDS – THE SERVICE USER’S VIEW (OR THEIR FAMILY/ADVOCATE’S VIEW)
Service User’s Name
Date
Communication
Bathing & Washing
Care Plan Y/N?
Dressing & Grooming
Care Plan Y/N?
Personality, Moods & Emotions
Care Plan Y/N?
Use of toilet & Continence
Care Plan Y/N?
Eating & Drinking
Care Plan Y/N?
Pressure Area Care
Care Plan Y/N?
Social, Recreational & religious
Care Plan Y/N?
Moving and Handling & Mobility Needs
Care Plan Y/N?
Any Special Routines Required by the Service User
Care Plan Y/N?
Gender of carer
Burial/cremation wishes
Care Plan Y/N?
Memory
Care Plan Y/N?
Resuscitation
Care Plan Y/N?
Next review interval (maximum 1 month):
Therefore next review date:
Care Plan Y/N?
(use attached review form to note, or if changes are substantial, carry out this full assessment again)
Accountability signature (person completing to print name and sign):
Date of form completion:
Service User’s or Advocate’s signature:
Date of form completion:
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CA11 - Pre-Admission Assessment and Care Planning Pack
GENERAL: Personal Care Needs Assessment Tool – 1
Service User’s Name:
Admission date:
Low dependency
Medium dependency
High dependency
Communication No problems.
Understands, slow to respond. Unable to respond
appropriately.
Bath
Independent.
Can bath with support of one
carer.
Requires support of two
carers.
Washing
Independent.
Can wash most parts of body,
help with feet and back.
Can wash only face and
hands.
Dressing
Independent.
Needs one carer to help with
buttons & straps.
Needs help from two carers
dressing.
Grooming
Independent.
Can shave or make up with
one carer.
Needs two carers’ help with
grooming.
Toilet
Independent.
Needs one carer’s support to
cleanse self after toilet.
Needs two carers to cleanse
self after toilet.
Continence
Independent.
Needs one carer’s support to
use toilet.
Incontinent, requires two
carers.
Eating
Independent.
Needs food prepared, can then Requires one carer for
eat independently.
support and
encouragement.
Drinking
Independent.
Independent using adopted
drinking utensil.
Needs full support and 1
carer encouragement for
drinking.
Next review interval (maximum 1 month):
Therefore next review date:
(use attached review form to note, or if changes are substantial, carry out this full assessment again)
Accountability signature (person completing to print name and sign):
Date of form completion:
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Comments/Notes
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Updated: 26/05/2011
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CA11 - Pre-Admission Assessment and Care Planning Pack
GENERAL: Personal Care Needs Assessment Tool – 2
Service User’s Name:
Admission date:
Low dependency
Medium dependency
Regular pressure relief and
overlay mattress.
High dependency
Pressure Sore
Care
No problems.
High risk pressure relief
monitoring. Specialist chair
cushions and bed
mattresses. Two carers day
and night.
Very reluctant to socialise
and take part in recreational
pursuits.
Non-weight bearing, hoist
only.
Social &
Recreational
Independent & sociable. Needs encouragement to join
activities.
Moving and
Handling
Independent & weight
bearing.
Weight bearing but needs
support of staff.
Memory
No problems.
Short term memory able to
communicate.
Personality
Socialises well.
Prefers solitude and one to
one conversation.
Moods
No problems.
Tending to depression.
Depressive illness.
Pain
No problems.
Intermittent, controlled by
medication.
Severe, requires regular
medication.
Sleep
No problems.
Occasional sleeping difficulty.
Poor sleep patterns,
requiring night time care,
intermittent night sedation.
Unable to hold a rational
conversation. Disoriented in
time and place.
Withdrawn, or manic.
Next review interval (maximum 1 month)
Therefore next review date:
(use attached review form to note, or if changes are substantial, carry out this full assessment again)
Accountability Signature: (Person completing to print name and sign):
Date of form completion:
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Comments/Notes
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Updated: 26/05/2011
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CA11 - Pre-Admission Assessment and Care Planning Pack
GENERAL: PERSONAL CARE NEEDS PLAN OF CARE
Service User’s name:
Admission date:
Assessed need and Service User view:
Aim of care:
Staff Instruction(s):
Accountability Signature: (Person completing to print name and sign):
Date of form completion:
Signature (Service User or Advocate to print name and sign):
Date of form completion:
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CA11 - Pre-Admission Assessment and Care Planning Pack
GENERAL: PERSONAL CARE NEEDS – MONTHLY OR MORE FREQUENT REVIEW
Use to conduct reviews of current assessment, unless sufficient changes require full risk re-assessment. Maximum 6
reviews, then re-assess.
Service User’s name:
Admission date:
Review notes:
Care Plan requires modifying (Y / N)?
Date of review:
Next review date (maximum 1 month, or less if required, and always if Accountability signature:
any changes)
Review notes:
Care Plan requires modifying (Y / N)?
Date of review:
Next review date (maximum 1 month, or less if required, and always if Accountability signature:
any changes)
Review notes:
Care Plan requires modifying (Y / N)?
Date of review:
Next review date (maximum 1 month, or less if required, and always if Accountability signature:
any changes)
Review notes:
Care Plan requires modifying (Y / N)?
Date of review:
Next review date (maximum 1 month, or less if required, and always if Accountability signature:
any changes)
Review notes:
Care Plan requires modifying (Y / N)?
Date of review:
Next review date (maximum 1 month, or less if required, and always if Accountability signature:
any changes)
Review notes:
Care Plan requires modifying (Y / N)?
Date of review:
Next review date (maximum 1 month, or less if required, and always if Accountability signature:
any changes)
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CA11 - Pre-Admission Assessment and Care Planning Pack
GENERAL: NIGHT CARE PLAN (SUMMARY)
Service User’s name:
Brief synopsis of needs:
Room number:
Receives night medication (Yes / No):
Sleep pattern:
Likes to go to bed at:
Likes to get up at:
Sleeps through the night:
Care regimen:
Usually / Often / Rarely
Requires help:
Undressing / Dressing / Both
Incontinent (Yes / No):
Requires turning:
Toilet 2 / 4 hourly
1 / 2 / 4 hourly /
Other
½ / 1 / 2 / 4 hourly / Other
Requires checking:
Continence aids used:
Other information:
Accountability signature (person completing to print name and sign):
Date of form completion:
Signature (Service User or Advocate to print name and sign):
Date of form completion:
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CA11 - Pre-Admission Assessment and Care Planning Pack
GENERAL: Mental Health Assessment Tool
Service User’s Name:
Date
0
1
2
3
DEPRESSION
None at
present.
History of
depression.
Mild depression,
medication.
Severe depression,
specialist services.
MOOD
No mood
disorder.
Predictable mood Unpredictable
change.
mood change.
Unable to be
rationalised.
ANXIETY
Calm under
pressure.
Anxiety after
stress.
Anxiety easily
triggered.
Severe anxiety.
MEMORY
Long and
short term
intact.
No history of
aggression.
Mild short term
memory loss.
Disoriented at
times.
Unable to form links
with the present.
Isolated history
of aggressive
outbursts.
Aggressive, no
violence.
Random
episodes of
violence.
Abusive.
Aggressive
behaviour a regular
occurrence.
Rummaging.
Shouting.
Invading privacy of
others.
Violent.
Destructive.
Severe deviance.
Screaming.
Smearing.
Others.
AGGRESSION
CHALLENGING
BEHAVIOUR –
MODERATE
CHALLENGING
BEHAVIOUR –
SEVERE
No history.
No history.
SELF-HARM
No history.
SELF NEGLECT
No history of
any form.
Previous history Previous history
of accidental self- of deliberate
harm.
self-harm.
Previous neglect Current intermittent
of diet, hygiene or self-neglect.
appearance.
Comments
Severe risk of selfharm.
Severe current risk
of self-harm.
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CA11 - Pre-Admission Assessment and Care Planning Pack
GENERAL: Mental Health Assessment Tool (continued)
COMMENTS FROM OTHERS, PROFESSIONAL OR INFORMAL CARER
Presentation of behaviour in shaded (heavy text) cells indicates that the potential Service User may be suitable for a
dementia registered home, but unsuitable for a general registered home, irrespective of aggregate score. Further detailed
assessment may be necessary to decide appropriate placement.
Next review interval (maximum 1 month). Therefore next review date: ______
(use attached review form to note, or if changes are substantial, carry out this full assessment again)
Accountability signature (person completing to print name and sign):
Date of form completion:
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CA11 - Pre-Admission Assessment and Care Planning Pack
GENERAL: MENTAL HEALTH NEEDS PLAN OF CARE
Service User’s name:
Admission date:
Assessed Need and Service User view:
Aim of care:
Staff Instruction(s):
Accountability signature (person completing to print name and sign):
Date of form completion:
Signature (Service User or Advocate to print name and sign):
Date of form completion:
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CA11 - Pre-Admission Assessment and Care Planning Pack
GENERAL: MENTAL HEALTH NEEDS – MONTHLY OR MORE FREQUENT REVIEW
Use to conduct reviews of current assessment, unless sufficient changes require full risk re-assessment. Max 6 reviews,
then re-assess.
Service User’s name:
Admission date:
Review notes:
Care Plan requires modifying (Y / N)?
Date of review:
Next review date (maximum 1 month, or less if required, and always if Accountability signature:
any changes)
Review notes:
Care Plan requires modifying (Y / N)?
Date of review:
Next review date (maximum 1 month, or less if required, and always if Accountability signature:
any changes)
Review notes:
Care Plan requires modifying (Y / N)?
Date of review:
Next review date (maximum 1 month, or less if required, and always if Accountability signature:
any changes)
Review notes:
Care Plan requires modifying (Y / N)?
Date of review:
Next review date (maximum 1 month, or less if required, and always if Accountability signature:
any changes)
Review notes:
Care Plan requires modifying (Y / N)?
Date of review:
Next review date (maximum 1 month, or less if required, and always if Accountability signature:
any changes)
Review notes:
Care Plan requires modifying (Y / N)?
Date of review:
Next review date (maximum 1 month, or less if required, and always if Accountability signature:
any changes)
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CA11 - Pre-Admission Assessment and Care Planning Pack
MENTAL CAPACITY ACT: ASSESSMENT
Each MCA decision should be made as the result of a separate assessment and in compliance with the MCA 2005.
Details of Lasting Power of Attorney, if any:
Yes/No
Details of any Court appointed deputies:
Yes/No
Details of any Independent Mental Capacity Advocate:
Yes/No
Details of any Advance decisions to refuse treatment:
Yes/No
Other relevant details:
Yes/No
Accountability signature (Named Nurse or Key Worker to print name and sign):
Date of form completion:
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CA11 - Pre-Admission Assessment and Care Planning Pack
MENTAL CAPACITY ACT: PLAN OF CARE
Service User’s Name:
Admission date:
Assessed Need and Service User view:
Aim of care:
Staff instruction(s):
Accountability signature (person completing to print name and sign):
Date of form completion:
Signature (Service User or Advocate to print name and sign):
Date of form completion:
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CA11 - Pre-Admission Assessment and Care Planning Pack
MENTAL CAPACITY ACT: ASSESSMENT FORM - ASSESSING A PARTICULAR DECISION
Assessment to ascertain whether or not
_________________________________ (Service User)
has the mental capacity in relation to a particular decision whilst living at:
Cherry Tree Lodge
40 - 42 Knowsley Road
Southport
PR9 0HW
Date of Admission/Commencing Service:
Person Undertaking Assessment:
The Decision being made is:
Position of person completing the form:
Signature:
Date:
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CA11 - Pre-Admission Assessment and Care Planning Pack
MENTAL CAPACITY ACT: ASSESSING MENTAL CAPACITY
Note: You must always act from the assumption that the person has capacity to make the
decision in question. However, if you are not certain that someone has capacity and that they may
regain capacity shortly, then ask yourself the following questions.
Does the decision need to be made without delay?
Yes or No
Is it possible to wait until the person does have the capacity to make the decision
for him or herself? (For example, a person may be drowsy or disorientated
because of the medication they are taking.)
Yes or No
If the answer to the Question 1 is Yes AND Question 2 is No then proceed to the assessment.
If the answer to Question 1 is No then delay the making of the decision and make a diary note to
review the person’s capacity to see if they can then make the decision at a later date.
If the answer to Question 1 is Yes but the answer to Question 2 is Yes revisit the matter to when
a decision is needed and consider if the decision can be delayed.
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CA11 - Pre-Admission Assessment and Care Planning Pack
MENTAL CAPACITY ACT: TEST OF CAPACITY
Part A
1. Is there an impairment of, or disturbance in, the functioning of the person’s mind
or brain (it does not matter if this is permanent or temporary)
2. If yes, does the impairment or disturbance make the person unable to make the
particular decision?
Yes/No
Yes/No
If the answer to both those questions is NO then the person has the mental capacity to make their
own decisions.
If the answer is YES to either question, proceed to part B.
Part B
1. Is the person able to understand the information relevant to the decision, including
understanding the likely consequences of making, or not making the decision?
2. Is the person able to retain that information?
3. Is the person able to use or weigh that information as part of the process of
making the decision?
4. Is the person able to communicate their decision (whether by talking, using sign
language or any other means)?
If the answer to any of these four questions is NO then the person does not have the mental
capacity to make a decision.
Copyright © 2012 Quality Compliance Systems Limited Tel: 0207 1383078 Fax: 0845 2590201
Yes/No
Yes/No
Yes/No
Yes/No
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CA11 - Pre-Admission Assessment and Care Planning Pack
MENTAL CAPACITY ACT: DEMONSTRATING BEST INTEREST IN MAKING THE DECISION
1. How is making this decision in the best interest of the Service User?
2. Who else have you consulted (e.g. family member, doctor or other staff member)?
Decision made:
Person completing this form:
Position of person completing this
form:
Signature:
Date:
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CA11 - Pre-Admission Assessment and Care Planning Pack
SKIN MARKS, BRUISING, SKIN INTEGRITY: ASSESSMENT TOOL
Service User’s name:
Admission date:
Examined in person? (Y / N). If N, record name and designation of person providing information:
Name:
Date of examination:
Designation:
Signature:
Skin Marks/Bruising Diagram
Area of risk/mark/bruising identified
Description of risk/mark/bruising
identified
Cause identified (specify)?
Care Plan created (Yes / No). If no,
why?
OR – No skin lesions apparent (tick
and sign for accountability. See
above if accepting 2nd hand
information):
Next review interval (maximum 1 month):
Therefore next review date: _____ (use attached review form to note, or if changes are substantial, carry out
this full assessment again)
Accountability signature (person completing to print name and sign):
Date of form completion:
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CA11 - Pre-Admission Assessment and Care Planning Pack
SKIN MARKS, BRUISING, SKIN INTEGRITY: PLAN OF CARE
Service User’s name:
Admission date:
Assessed Need and Service User view:
Aim of care:
Staff instruction(s):
Accountability signature (person completing to print name and sign):
Date of form completion:
Signature (Service User or Advocate to print name and sign):
Date of form completion:
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CA11 - Pre-Admission Assessment and Care Planning Pack
SKIN MARKS, BRUISING, SKIN INTEGRITY: MONTHLY OR MORE FREQUENT REVIEW
Use to conduct reviews of current assessment, unless sufficient changes require full risk re-assessment. Maximum 6
reviews, then re-assess.
Service User’s name:
Admission date:
Review notes:
Care Plan requires modifying (Y / N)?
Date of review:
Next review date (maximum 1 month, or less if required, and always if Accountability signature:
any changes)
Review notes:
Care Plan requires modifying (Y / N)?
Date of review:
Next review date (maximum 1 month, or less if required, and always if Accountability signature:
any changes)
Review notes:
Care Plan requires modifying (Y / N)?
Date of review:
Next review date (maximum 1 month, or less if required, and always if Accountability signature:
any changes)
Review notes:
Care Plan requires modifying (Y / N)?
Date of review:
Next review date (maximum 1 month, or less if required, and always if Accountability signature:
any changes)
Review notes:
Care Plan requires modifying (Y / N)?
Date of review:
Next review date (maximum 1 month, or less if required, and always if Accountability signature:
any changes)
Review notes:
Care Plan requires modifying (Y / N)?
Date of review:
Next review date (maximum 1 month, or less if required, and always if Accountability signature:
any changes)
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CA11 - Pre-Admission Assessment and Care Planning Pack
SKIN MARKS, BRUISING, SKIN INTEGRITY: WATERLOW RISK ASSESSMENT (NURSING HOME USE ONLY)
Ring scores in table. Several scores per category can be used.
Service User’s name:
Built/Weight for
Height
Average
Admission date:
*
Special Risks
*
Sex/Age
0
Risk areas/visual
skin type
Healthy
0
Male
1
Above average
1
Tissue paper
1
Female
2
Obese
2
Dry
1
14-49
1
Below average
3
Oedematous
1
50-64
Clammy
1
Discoloured
*
*
Tissue/Malnutrition
e.g. Terminal cachexia
Cardiac failure
8
2
2
Peripheral vascular
disease
Anaemia
65-74
3
Smoking
1
2
75-80
4
Broken/spot
3
81+
5
5
2
Continence
*
Mobility
*
Appetite
*
Neurological deficit
*
Complete/catheterises
0
Fully
0
Average
0
Diabetes/CVA
4-6
Occasional continence
1
Restless/fidgety
1
Poor
1
MS
4-6
Incontinent of faeces
2
Apathetic
2
NG tube
2
Paraplegia
4-6
Double incontinence
3
Restricted
3
Fluids only
2
Medication
Steroids, Cytotoxic /
Anti-inflammatory
4
Inert/Traction
4
Nil by
mouth/Anorexic
3
Chair bound
5
Aggregate score:
SCORE:
10+ AT RISK
20+ VERY HIGH RISK
(Ring appropriate risk level)
Next review interval (maximum 1 month):
Therefore next review date:
(Use attached review form to note, or if changes are substantial, carry out this full assessment again).
Accountability signature (person completing to print name and sign):
Date of form completion:
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CA11 - Pre-Admission Assessment and Care Planning Pack
SKIN MARKS, BRUISING, SKIN INTEGRITY: WATERLOW RISK ASSESSMENT – GUIDANCE NOTE
Remember: tissue damage may start prior to admission, in casualty. A seated patient is at risk (see over) if the
patient falls into any of the risk categories, then preventative nursing is required. A combination of good nursing
techniques and preventative aids will be necessary.
All actions must be documented.
PRESSURE REDUCING AIDS
Special
10+ Overlays or specialist foam mattresses.
Mattress/beds:
15+ Alternating pressure overlays, mattresses and bed systems
20+ Bed systems: Fluidised bead, low air loss and alternating pressure mattresses
Note: Preventative aids cover a wide spectrum of specialist features. Efficacy should be judged, if possible,
based on independent evidence.
Cushions:
No person should sit in a wheelchair without some form of cushioning. If nothing else is available – use the
person’s own pillow. (Consider infection risk)
10+ 100mm foam cushion
15+ Specialist Gel and/or foam cushion
20+ Specialised cushion, adjustable to individual person.
Bed clothing:
Avoid plastic draw sheets, inco pads and tightly tucked in sheet/sheet covers, especially when using
specialist bed and mattress overlay systems
Use duvet – plus vapour permeable membrane
NURSING CARE
General
HAND WASHING, frequent changes of position, lying, sitting. Use of pillows
Pain
Appropriate pain control
Nutrition
High protein, vitamins and minerals
Handling
Correct moving technique – hoists – monkey poles
Transfer devices
Comfort Aids
Bed cradle
Skin Care
General hygiene, NO rubbing, cover with an appropriate dressing
WOUND GUIDELINES
Assessment
odour, exudate, measure/photograph position
WOUND CLASSIFICATION – EPUAP
GRADE 1
Discolouration of intact skin not affected by light finger pressure (non-blanching erythema)
This may be difficult to identify in darkly pigmented skin
GRADE 2
Partial thickness skin loss or damage involving epidermis and/or dermis
The pressure ulcer is superficial and presents clinically as an abrasion, blister or shallow crater
GRADE 3
Full thickness skin loss involving damage of subcutaneous tissue but not extending to the underlying fascia
The pressure ulcer presents clinically as a deep crater with or without undermining of adjacent tissue
GRADE 4
Full thickness skin loss with extensive destruction and necrosis extending to underlying tissue.
DRESSING GUIDE
Use Local dressings formulary and/or www.worldwidewounds.com
IF TREATMENT IS REQUIRED, FIRST REMOVE PRESSURE
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CA11 - Pre-Admission Assessment and Care Planning Pack
SKIN MARKS, BRUISING, SKIN INTEGRITY: SKIN INTEGRITY RISK PLAN OF CARE
Service User’s Name:
Admission date:
Assessed Need and Service User view:
Aim of Care:
Staff Instruction(s):
Accountability Signature: (Person completing to print name and sign):
Date of form completion:
Signature: (print and sign): Service User or advocate
Date of form completion:
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CA11 - Pre-Admission Assessment and Care Planning Pack
SKIN MARKS, BRUISING, SKIN INTEGRITY: SKIN INTEGRITY RISK – MONTHLY OR MORE FREQUENT
REVIEW
Use to conduct reviews of current assessment, unless sufficient changes require full risk re-assessment. Max 6
reviews, then re-assess.
Service User’s Name:
Admission date:
Review notes:
Care Plan requires modifying Y / N?
Date of review:
Next review date (maximum 1 month, or less if required, and always if Accountability Signature:
any changes)
Review notes:
Care Plan requires modifying Y / N?
Date of review:
Next review date (maximum 1 month, or less if required, and always if Accountability Signature:
any changes)
Review notes:
Care Plan requires modifying Y / N?
Date of review:
Next review date (maximum 1 month, or less if required, and always if Accountability Signature:
any changes)
Review notes:
Care Plan requires modifying Y / N?
Date of review:
Next review date (maximum 1 month, or less if required, and always if Accountability Signature:
any changes)
Review notes:
Care Plan requires modifying Y / N?
Date of review:
Next review date (maximum 1 month, or less if required, and always if Accountability Signature:
any changes)
Review notes:
Care Plan requires modifying Y / N?
Date of review:
Next review date (maximum 1 month, or less if required, and always if Accountability Signature:
any changes)
Copyright © 2012 Quality Compliance Systems Limited Tel: 0207 1383078 Fax: 0845 2590201
Cherry Tree Lodge
Updated: 26/05/2011
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CA11 - Pre-Admission Assessment and Care Planning Pack
MOVING AND HANDLING: GENERAL RISK ASSESSMENT
Date
Review
date
Involved
Informed Diagnosis
Service User’s
Name
Relative/Advocate
Key Worker
Assessor
Independent Supervised 1 Carer
2 Carers Hoist (if Wheelchair Other
ticked, Footrest
Aids
note
Y/N
sling
size)
Inside the the
home
Outside the the
home
In and out of bed
Toilet
Transfer
Sit/Stand
Bathing
Stairs
General
movement
Emergency
situation
History of falls?
Yes / No
Falls risk
rating risk
High
Medium
Low
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Fear
Pain
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Updated: 26/05/2011
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CA11 - Pre-Admission Assessment and Care Planning Pack
MOVING AND HANDLING: GENERAL RISK ASSESSMENT (CONTINUED)
General
Comments
Next review interval (maximum 1 month)
Therefore next review date:
(use attached review form to note, or if changes are substantial, carry out this full assessment again)
Accountability Signature: (Person completing to print name Date of form completion:
and sign):
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Updated: 26/05/2011
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CA11 - Pre-Admission Assessment and Care Planning Pack
MOVING AND HANDLING: GENERAL RISK PLAN OF CARE
Service User’s Name:
Admission date:
Assessed Need and Service User view:
Aim of Care:
Staff Instruction(s):
Accountability Signature: (Person completing to print name and sign):
Date of form completion:
Signature: (print and sign): Service User or advocate
Date of form completion:
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Updated: 26/05/2011
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CA11 - Pre-Admission Assessment and Care Planning Pack
MOVING AND HANDLING: GENERAL RISK NEEDS – MONTHLY OR MORE FREQUENT REVIEW
Use to conduct reviews of current assessment, unless sufficient changes require full risk re-assessment. Max 6
reviews, then re-assess.
Service User’s Name:
Admission date:
Review notes:
Care Plan requires modifying Y / N?
Date of review:
Next review date (maximum 1 month, or less if required, and always if Accountability Signature:
any changes)
Review notes:
Care Plan requires modifying Y / N?
Date of review:
Next review date (maximum 1 month, or less if required, and always if Accountability Signature:
any changes)
Review notes:
Care Plan requires modifying Y / N?
Date of review:
Next review date (maximum 1 month, or less if required, and always if Accountability Signature:
any changes)
Review notes:
Care Plan requires modifying Y / N?
Date of review:
Next review date (maximum 1 month, or less if required, and always if Accountability Signature:
any changes)
Review notes:
Care Plan requires modifying Y / N?
Date of review:
Next review date (maximum 1 month, or less if required, and always if Accountability Signature:
any changes)
Review notes:
Care Plan requires modifying Y / N?
Date of review:
Next review date (maximum 1 month, or less if required, and always if Accountability Signature:
any changes)
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Updated: 26/05/2011
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CA11 - Pre-Admission Assessment and Care Planning Pack
MOVING AND HANDLING: RISK ASSESSMENT
Also copy to bedroom.
Service User’s Name:
Admission date:
Weight:
Body shape:
Handling constraints:
kilos
Tall
Pain
Handling constraints:
Increasing/decreasing Obese
Thin
Average weight
Medium
Skin condition
Short
Catheter
Arthritis
Other Specify:
Walking
Toileting
Transferring
Movement in bed
Service User’s
Good
Poor
comprehension:
Handling recommendations and equipment to be used
Walking
History of falls: Yes
No
Score; total
below
Standing
Toileting
Transferring
Moving in bed
Handling risk
category/score:
Moving and handling risk
created by general
condition
Ability to assist
Level of awareness
Ability to Mobilise
Tendency to become easily
tired
Pain
High Score 3
Medium Score 2
Low Score 1
Low Score 1
High (3)
Medium (2)
Low (1)
None (0)
Poor (3)
Poor (3)
Poor (3)
High (3)
Fair (2)
Fair (2)
Fair (2)
Moderate (2)
Good (1)
Good (1)
Good (1)
Slight (1)
Very good (0)
Very good (0)
Very good (0)
No (0)
Severe (3)
Intermittent (2)
Mild (1)
None (0)
Weight
Extra large (3)
Large (2)
Medium (1)
Slight (0)
Total score:
Risk category
High risk
Medium risk
Low risk
Risk Score
17–24
9–16
1–8
Hazard code
Notes
Next review interval (maximum 1 month). Therefore next review date:
(use attached review form to note, or if changes are substantial, carry out this full assessment again)
Accountability Signature: (Person completing to print name and sign):
Date of form completion:
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CA11 - Pre-Admission Assessment and Care Planning Pack
MOVING AND HANDLING: RISK PLAN OF CARE
Service User’s Name:
Admission date:
Assessed Need and Service User view:
Aim of Care:
Staff Instruction(s):
Accountability Signature: (Person completing to print name and sign):
Date of form completion:
Signature: (print and sign): Service User or advocate
Date of form completion:
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Updated: 26/05/2011
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CA11 - Pre-Admission Assessment and Care Planning Pack
MOVING AND HANDLING: RISK – MONTHLY OR MORE FREQUENT REVIEW
Use to conduct reviews of current assessment, unless sufficient changes require full risk re-assessment. Max 6
reviews, then re-assess.
Service User’s Name:
Admission date:
Review notes:
Care Plan requires modifying Y / N?
Date of review:
Next review date (maximum 1 month, or less if required, and always if Accountability Signature:
any changes)
Review notes:
Care Plan requires modifying Y / N?
Date of review:
Next review date (maximum 1 month, or less if required, and always if Accountability Signature:
any changes)
Review notes:
Care Plan requires modifying Y / N?
Date of review:
Next review date (maximum 1 month, or less if required, and always if Accountability Signature:
any changes)
Review notes:
Care Plan requires modifying Y / N?
Date of review:
Next review date (maximum 1 month, or less if required, and always if Accountability Signature:
any changes)
Review notes:
Care Plan requires modifying Y / N?
Date of review:
Next review date (maximum 1 month, or less if required, and always if Accountability Signature:
any changes)
Review notes:
Care Plan requires modifying Y / N?
Date of review:
Next review date (maximum 1 month, or less if required, and always if Accountability Signature:
any changes)
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CA11 - Pre-Admission Assessment and Care Planning Pack
NUTRITIONAL NEEDS: KITCHEN NOTIFICATION (SEND TO KITCHEN FOR ATTENTION)
Service User’s Name:
Admission Date:
Likes
Dislikes
Breakfast
Lunch
Supper
Drinks
Food in general
Special dietary
requirements (including
allergies)
Would like main meal at:
Mid-day Evening (tick as
appropriate)
Assessed by:
Signed:
Information received by:
(catering dept)
Signed:
Catering action as a result of assessment
Chef interview with
Service User
Date:
Signature:
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CA11 - Pre-Admission Assessment and Care Planning Pack
NUTRITIONAL NEEDS: NUTRITIONAL RISK ASSESSMENT
Service User’s Name:
Admission date:
SCORE WEIGHT
APPETITE
4
Usual weight
and steady
Full diet and
fluids
3
Recent weight Eats only ½
loss up to 3.5kg meals
(lbs.)
2
1
ABILITY TO
EAT
Independent
eating and
drinking
Requires
assistance to
be fed
MENTAL
CONDITION
Alert, oriented,
co-operative
MEDICAL
CONDITION
Uncomplicated
medical
condition
Apathetic,
GI conditions
mildly confused e.g.
constipation,
diverticular
disease,
ulcerative colon
Recent weight Poor appetite Has difficulties Confused,
Complicated
loss over 3.5kg and reluctant to chewing and
depressed,
medical
(lbs.)
drink
swallowing
unco-operative condition
affecting food
intake
Extremely thin, Little or no
Unable to take Comatose
Severe
emaciated or appetite,
food or fluid
infection, GI
cachectic
refuses meals orally
disease, leg
or drinks.
ulcers etc
Unable to eat
SKIN
CONDITION
Pressure areas
intact
GUT
FUNCTION
Normal gut
function
Skin quite red
over pressure
areas
Feels
nauseous etc
Superficial
breakdown of
skin
Diarrhoea
and/or vomiting
Breakdown of
skin, wounds
infected and
deep
Profuse D and
V
SCORE
22 –28 LOW RISK
No action necessary
Check weight regularly
16 –21 NEEDS MONITORING 7 –15 HIGH RISK
Check weight weekly
Ask medical staff or GP to refer
to dietician
Encourage eating and drinking Also all patients artificially feed
e.g. NG & gastronomies
Offer little and often
Caution with patients with
diabetes, renal failure, liver
disease.
Repeat score after 1 week if no Please assess appropriateness
action, refer to dietician if no
of referral in last stages of care
improvement
Date
Score
Weight
Next review interval (maximum 1 month). Therefore next review date:
(use attached review form to note, or if changes are substantial, carry out this full assessment again)
Accountability Signature: (Person completing to print name and sign):
Date of form completion:
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Updated: 26/05/2011
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CA11 - Pre-Admission Assessment and Care Planning Pack
NUTRITIONAL NEEDS: NUTRITIONAL RISK PLAN OF CARE
Service User’s Name:
Admission date:
Assessed Need and Service User view:
Aim of Care:
Staff Instruction(s):
Accountability Signature: (Person completing to print name and sign):
Date of form completion:
Signature: (print and sign): Service User or advocate
Date of form completion:
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Updated: 26/05/2011
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CA11 - Pre-Admission Assessment and Care Planning Pack
NUTRITIONAL NEEDS: FOOD AND NUTRITION INTAKE LOG
Service User Name:
Date:
Time
Food
Amount
Comments
Midnight 12:
1:
2
3
4
5
6
7
8
9
10
11
Midday 12
1
2
3
4
5
6
7
8
9
10
11
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Cherry Tree Lodge
Updated: 26/05/2011
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CA11 - Pre-Admission Assessment and Care Planning Pack
NUTRITIONAL NEEDS: NUTRITIONAL RISK – MONTHLY OR MORE FREQUENT REVIEW
Use to conduct reviews of current assessment, unless sufficient changes require full risk re-assessment. Max 6
reviews, then re-assess.
Service User’s Name:
Admission date:
Review notes:
Care Plan requires modifying Y / N?
Date of review:
Next review date (maximum 1 month, or less if required, and always if Accountability Signature:
any changes)
Review notes:
Care Plan requires modifying Y / N?
Date of review:
Next review date (maximum 1 month, or less if required, and always if Accountability Signature:
any changes)
Review notes:
Care Plan requires modifying Y / N?
Date of review:
Next review date (maximum 1 month, or less if required, and always if Accountability Signature:
any changes)
Review notes:
Care Plan requires modifying Y / N?
Date of review:
Next review date (maximum 1 month, or less if required, and always if Accountability Signature:
any changes)
Review notes:
Care Plan requires modifying Y / N?
Date of review:
Next review date (maximum 1 month, or less if required, and always if Accountability Signature:
any changes)
Review notes:
Care Plan requires modifying Y / N?
Date of review:
Next review date (maximum 1 month, or less if required, and always if Accountability Signature:
any changes)
Copyright © 2012 Quality Compliance Systems Limited Tel: 0207 1383078 Fax: 0845 2590201
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Updated: 26/05/2011
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CA11 - Pre-Admission Assessment and Care Planning Pack
FALLS RISK: ASSESSMENT SECTION 1
To be completed for all Service Users
Service User’s Name:
Admission date:
Section 1. Initial assessment (Tick any that apply)
History of falls: (e.g. admitted
as a result of a fall/fall since
admission
Impaired judgement: (e.g.
confused/agitated/forgets
limitations)
Stability concerns: (e.g.
unsteady
gait/imbalance/weakness
Impaired vision:
If any of the boxes are ticked, the Service User is “at risk” – Continue to Section 2: Detailed assessment
None of the above applies * You do not need to fill in any more of this form. (Service User not considered at significant risk of
falling)
Next review interval (maximum 1 month)
Therefore next review date:
(use attached review form to note, or if changes are substantial, carry out this full assessment again)
Accountability Signature: (Person completing to print name and sign):
Date of form completion:
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CA11 - Pre-Admission Assessment and Care Planning Pack
FALLS RISK: ASSESSMENT SECTION 2 – DETAILED ASSESSMENT
To be completed for all at risk Service Users, and a Care & Action Plan initiated at the appropriate level.
Section 2 – Detailed Assessment – to be completed for all at risk Service Users, and a Care & Action Plan
initiated at the appropriate level. Score below as indicated in brackets [ ] for each risk factor. Reassess at least
monthly and whenever Service User falls, or there has been a significant change in risk (e.g. Service User’s
ability/condition has improved)
RISK FACTOR
Date:
Falls:
A fall as the reason for admission [5]
A fall since admission to the home [5 per fall]
Stability:
Dizziness [2]
Unsteady gait [2]
Weakness [2]
Judgement:
Confused [3]
Agitated [3]
Inability to understand or follow directions [2]
Tendency to wander away from area [1]
Tries to mobilise unsafely without assistance [5]
First 3 days in the home [3]
Senses:
Significant visual impairment [3]
Significant hearing impairment [1]
Inability to communicate [2]
Medication:
Diuretics (or urinary frequency) [3]
Strong analgesics/sedatives/general
anaesthetic [2]
Antidepressants [3]
Other factors:
Attached to equipment (e.g. catheter stand etc.)
[3]
Requires mobility aids (e.g. wheelchair etc) [3]
Secondary diagnosis (more than 1 diagnosis in
notes) [2]
TOTAL RISK SCORE
Next review interval (maximum 1 month)
Therefore next review date: (use attached review form to note, or if changes are substantial, carry out this full
assessment again)
Accountability Signature: (Person completing to print name and sign):
Date of form
completion:
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CA11 - Pre-Admission Assessment and Care Planning Pack
FALLS RISK: ASSESSMENT SECTION 3 – ACTION PLAN
Service User’s Name:
Admission date:
Assessed Risk Level Low
Medium
Tick as appropriate
Actions
Tick action
Fall Risk
1. Introduce Service User to the home environment
Score 1 – 10 LOW RISK 2. Involve Service User & care team in own safety
Re-assess and
programme
document on
3. Keep environment free of clutter
condition change
High
Review date
4. Monitor suitability of seating; consider alternative
if necessary
5. Review lighting to ensure it is appropriate at all
times
6. Observe conditions of feet and nails and refer to
podiatrist if necessary. Ensure appropriate
footwear is worn.
7. Ensure any necessary items are in reach e.g.
spectacles, drinks, books, also ensure call bell is
within reach and that Service User knows how to
use it.
8. Ensure bed is kept at lowest level (except when
giving care)
Fall Risk
ALL OF THE ABOVE INTERVENTIONS, PLUS:
Score 11 – 20 MEDIUM 9. Consider the use of bed restraints – see policy
RISK
10. Consider use of bed/chair exit alarm, if
Re-assess and
available
document at least
11. Physiotherapy/OT referral (ensure that the
weekly and on
referral is documented in care notes)
condition change
12. Implement bowel and bladder programme to
decrease urgency and incontinence
13. Check lying & standing BP, if possible, and
document
14. Consider need for regular observation e.g.
acute confusion, dementia etc and ensure this is
recorded as appropriate
15. Consider use of transfer and mobility aids,
ensuring they are in reach at all times.
16. Assess supervision needs in toilet/bathroom
areas
Fall Risk
ALL OF THE ABOVE INTERVENTIONS, PLUS:
Score 21+
17. Accompany and stay with Service User in
Re-assess and
toilet/bathroom areas
document at least
18. Assign Service User to bed/chair (ass
twice weekly and on
appropriate) with high visibility
condition change
19. Consider more appropriate bed (e.g. LowCare
bed if available) or consider placing mattress on
floor
20. Review medication and treatment plan to
ensure adequate focus on falls risk
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Signature
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Updated: 26/05/2011
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CA11 - Pre-Admission Assessment and Care Planning Pack
FALLS RISK: PLAN OF CARE
Service User’s Name:
Admission date:
Assessed Need and Service User view:
Aim of Care:
Staff Instruction(s):
Accountability Signature: (Person completing to print name and sign):
Date of form completion:
Signature: (print and sign): Service User or advocate
Date of form completion:
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Updated: 26/05/2011
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CA11 - Pre-Admission Assessment and Care Planning Pack
FALLS RISK: ASSESSMENT – INCIDENT NOTES
Service User’s Name:
Admission date:
Any further information
Communication notes: Document new falls, changes in condition, notes from physio, OT etc.
Date
Notes
Signature
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Updated: 26/05/2011
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CA11 - Pre-Admission Assessment and Care Planning Pack
FALLS RISK: MONTHLY OR MORE FREQUENT REVIEW
Use to conduct reviews of current assessment, unless sufficient changes require full risk re-assessment. Max 6
reviews, then re-assess.
Service User’s Name:
Admission date:
Review notes:
Care Plan requires modifying Y / N?
Date of review:
Next review date (maximum 1 month, or less if required, and always if Accountability Signature:
any changes)
Review notes:
Care Plan requires modifying Y / N?
Date of review:
Next review date (maximum 1 month, or less if required, and always if Accountability Signature:
any changes)
Review notes:
Care Plan requires modifying Y / N?
Date of review:
Next review date (maximum 1 month, or less if required, and always if Accountability Signature:
any changes)
Review notes:
Care Plan requires modifying Y / N?
Date of review:
Next review date (maximum 1 month, or less if required, and always if Accountability Signature:
any changes)
Review notes:
Care Plan requires modifying Y / N?
Date of review:
Next review date (maximum 1 month, or less if required, and always if Accountability Signature:
any changes)
Review notes:
Care Plan requires modifying Y / N?
Date of review:
Next review date (maximum 1 month, or less if required, and always if Accountability Signature:
any changes)
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CA11 - Pre-Admission Assessment and Care Planning Pack
MEDICATION: PLAN OF CARE
Service User’s Name:
Admission date:
Assessed Need and Service User view:
Aim of Care:
Staff Instruction(s):
Accountability Signature: (Person completing to print name and sign):
Date of form completion:
Signature: (print and sign): Service User or advocate
Date of form completion:
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CA11 - Pre-Admission Assessment and Care Planning Pack
MEDICATION: MONTHLY OR MORE FREQUENT REVIEW
Use to conduct reviews of current assessment, unless sufficient changes require full risk re-assessment. Max 6
reviews, then re-assess.
Service User’s Name:
Admission date:
Review notes:
Care Plan requires modifying Y / N?
Date of review:
Next review date (maximum 1 month, or less if required, and always if Accountability Signature:
any changes)
Review notes:
Care Plan requires modifying Y / N?
Date of review:
Next review date (maximum 1 month, or less if required, and always if Accountability Signature:
any changes)
Review notes:
Care Plan requires modifying Y / N?
Date of review:
Next review date (maximum 1 month, or less if required, and always if Accountability Signature:
any changes)
Review notes:
Care Plan requires modifying Y / N?
Date of review:
Next review date (maximum 1 month, or less if required, and always if Accountability Signature:
any changes)
Review notes:
Care Plan requires modifying Y / N?
Date of review:
Next review date (maximum 1 month, or less if required, and always if Accountability Signature:
any changes)
Review notes:
Care Plan requires modifying Y / N?
Date of review:
Next review date (maximum 1 month, or less if required, and always if Accountability Signature:
any changes)
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CA11 - Pre-Admission Assessment and Care Planning Pack
MEDICATION: PRN Medication Plan of Care
Service User’s Name:
Admission date:
Assessed Need and Service User view:
Aim of Care:
Staff Instruction(s):
Accountability Signature: (Person completing to print name and sign):
Date of form completion:
Signature: (print and sign): Service User or advocate
Date of form completion:
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CA11 - Pre-Admission Assessment and Care Planning Pack
MEDICATION: PRN MEDICATION – Monthly or more frequent review
Use to conduct reviews of current assessment, unless sufficient changes require full risk re-assessment. Max 6
reviews, then re-assess.
Service User’s Name:
Admission date:
Review notes:
Care Plan requires modifying Y / N?
Date of review:
Next review date (maximum 1 month, or less if required, and always if Accountability Signature:
any changes)
Review notes:
Care Plan requires modifying Y / N?
Date of review:
Next review date (maximum 1 month, or less if required, and always if Accountability Signature:
any changes)
Review notes:
Care Plan requires modifying Y / N?
Date of review:
Next review date (maximum 1 month, or less if required, and always if Accountability Signature:
any changes)
Review notes:
Care Plan requires modifying Y / N?
Date of review:
Next review date (maximum 1 month, or less if required, and always if Accountability Signature:
any changes)
Review notes:
Care Plan requires modifying Y / N?
Date of review:
Next review date (maximum 1 month, or less if required, and always if Accountability Signature:
any changes)
Review notes:
Care Plan requires modifying Y / N?
Date of review:
Next review date (maximum 1 month, or less if required, and always if Accountability Signature:
any changes)
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CA11 - Pre-Admission Assessment and Care Planning Pack
SOCIAL HISTORY, ACTIVITIES AND NEEDS: SOCIAL HISTORY
The CC00-Dementia Policy and Procedure includes a Dementia Workbook for the Service User's family or loved ones to
complete. If completed this workbook should be attached to and become part of the Care Plan.
Service User’s Name:
Admission date:
Social Networks
Major live events and life course history
Current and former lifestyle
Current and former recreational activities
Education and occupation
Accountability Signature: (Person completing to print name and sign):
Date of form completion:
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CA11 - Pre-Admission Assessment and Care Planning Pack
SOCIAL HISTORY, ACTIVITIES AND NEEDS: LIFE HISTORY
Service User’s Name:
Admission date:
Accountability Signature: (Person completing to print name and sign):
Date of form completion:
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CA11 - Pre-Admission Assessment and Care Planning Pack
SOCIAL HISTORY ACTIVITIES AND NEEDS: PREFERRED ACTIVITIES – WHAT I WANT TO DO
Service User’s name:
Admission date:
Past interests
Range of activities possible by Allocation of carers to facilitate Activity set in progress date
Service User
Writing letters
Flower arranging
Going to church
Knitting
Listening to music
Reading aloud
Washing up
Doing jigsaws
Indoor gardening
Shoe cleaning
Shopping
Going to theatre or cinema
Dusting
Entertaining visitors
Using a library
Playing cards or board games
Looking after a pet
Taking photographs
Making tea or coffee
Basket making
Buying presents
Playing bingo
Listening to radio
Washing/setting hair
Writing poetry/prose
Embroidery
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CA11 - Pre-Admission Assessment and Care Planning Pack
SOCIAL HISTORY, ACTIVITIES AND NEEDS: PREFERRED ACTIVITIES – WHAT I WANT TO DO
(CONTINUED)
Service User’s name:
Admission date:
Past interests
Range of activities possible by Allocation of carers to facilitate Activity set in progress date
Service User
Outdoor gardening
Attending church services in
the home
Washing clothes
Singing
Watching TV
Ironing
Physical exercises
Painting/drawing
Visiting friends
Polishing silver/ornaments
Yoga
Feeding birds
Reading
newspapers/magazines
Crosswords
Going for walks
Playing an instrument
Stamp collecting
Typing
Expressing views on current
affairs
Mending
Doing odd jobs
Making soft toys
Doing football pools
Keeping a diary
Reading books
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CA11 - Pre-Admission Assessment and Care Planning Pack
SOCIAL HISTORY, ACTIVITIES AND NEEDS: PREFERRED ACTIVITIES – WHAT I WANT TO DO
(CONTINUED)
Service User’s name:
Admission date:
Past interests
Range of activities possible by Allocation of carers to facilitate Activity set in progress date
Service User
Bird watching
Making birthday/ Christmas
cards
Going to adult education
classes
Making phone calls
Going to club/ day
Talking to friends
Any social skills, Psychological health, Physical health limiting range of activity:
Next review interval (maximum 1 month). Therefore next review date:
(use attached review form to note, or if changes are substantial, carry out this full assessment again)
Accountability Signature: (Person completing to print name and sign):
Date of form completion:
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Updated: 26/05/2011
Printed: 13/04/2012
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CA11 - Pre-Admission Assessment and Care Planning Pack
SOCIAL HISTORY, ACTIVITIES AND NEEDS: SOCIAL CARE AND ACTIVITIES PLAN OF CARE
Service User’s Name:
Admission date:
Assessed Need and Service User view:
Aim of Care:
Staff Instruction(s):
Accountability Signature: (Person completing to print name and sign):
Date of form completion:
Signature: (print and sign): Service User or advocate
Date of form completion:
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Updated: 26/05/2011
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CA11 - Pre-Admission Assessment and Care Planning Pack
SOCIAL HISTORY, ACTIVITIES AND NEEDS: SOCIAL CARE AND ACTIVITIES – MONTHLY OR MORE
FREQUENT REVIEW
Use to conduct reviews of current assessment, unless sufficient changes require full risk re-assessment. Max 6
reviews, then re-assess.
Service User’s Name:
Admission date:
Review notes:
Care Plan requires modifying Y / N?
Date of review:
Next review date (maximum 1 month, or less if required, and always if Accountability Signature:
any changes)
Review notes:
Care Plan requires modifying Y / N?
Date of review:
Next review date (maximum 1 month, or less if required, and always if Accountability Signature:
any changes)
Review notes:
Care Plan requires modifying Y / N?
Date of review:
Next review date (maximum 1 month, or less if required, and always if Accountability Signature:
any changes)
Review notes:
Care Plan requires modifying Y / N?
Date of review:
Next review date (maximum 1 month, or less if required, and always if Accountability Signature:
any changes)
Review notes:
Care Plan requires modifying Y / N?
Date of review:
Next review date (maximum 1 month, or less if required, and always if Accountability Signature:
any changes)
Review notes:
Care Plan requires modifying Y / N?
Date of review:
Next review date (maximum 1 month, or less if required, and always if Accountability Signature:
any changes)
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Cherry Tree Lodge
Updated: 26/05/2011
Printed: 13/04/2012
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CA11 - Pre-Admission Assessment and Care Planning Pack
OTHER: RISK ASSESSMENT
To be used for risk areas not covered by specific assessments (not to be used where a specific assessment tool is
available in this pack)
Service User’s Name:
Admission date:
Specific risk or hazard being assessed:
Identification of risk or hazard:
Existing risk control measures:
Further control action required: list any risks or hazards not adequately controlled and the action to be taken, where it is
reasonably practical to do more:
Next review interval (maximum 1 month)
Therefore next review date:
(use attached review form to note, or if changes are substantial, carry out this full assessment again)
Accountability Signature: (Person completing to print name and sign):
Date of form completion:
Copyright © 2012 Quality Compliance Systems Limited Tel: 0207 1383078 Fax: 0845 2590201
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Updated: 26/05/2011
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CA11 - Pre-Admission Assessment and Care Planning Pack
OTHER: RISK PLAN OF CARE
Service User’s Name:
Admission date:
Assessed Need and Service User view:
Aim of Care:
Staff Instruction(s):
Accountability Signature: (Person completing to print name and sign):
Date of form completion:
Signature: (print and sign): Service User or advocate
Date of form completion:
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Updated: 26/05/2011
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CA11 - Pre-Admission Assessment and Care Planning Pack
OTHER RISK: MONTHLY OR MORE FREQUENT REVIEW
Use to conduct reviews of current assessment, unless sufficient changes require full risk re-assessment. Max 6
reviews, then re-assess.
Service User’s Name:
Admission date:
Review notes:
Care Plan requires modifying Y / N?
Date of review:
Next review date (maximum 1 month, or less if required, and always if Accountability Signature:
any changes)
Review notes:
Care Plan requires modifying Y / N?
Date of review:
Next review date (maximum 1 month, or less if required, and always if Accountability Signature:
any changes)
Review notes:
Care Plan requires modifying Y / N?
Date of review:
Next review date (maximum 1 month, or less if required, and always if Accountability Signature:
any changes)
Review notes:
Care Plan requires modifying Y / N?
Date of review:
Next review date (maximum 1 month, or less if required, and always if Accountability Signature:
any changes)
Review notes:
Care Plan requires modifying Y / N?
Date of review:
Next review date (maximum 1 month, or less if required, and always if Accountability Signature:
any changes)
Review notes:
Care Plan requires modifying Y / N?
Date of review:
Next review date (maximum 1 month, or less if required, and always if Accountability Signature:
any changes)
Copyright © 2012 Quality Compliance Systems Limited Tel: 0207 1383078 Fax: 0845 2590201
Cherry Tree Lodge
Updated: 26/05/2011
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CA11 - Pre-Admission Assessment and Care Planning Pack
OTHER: (___________) NEEDS PLAN OF CARE
Service User’s Name:
Admission date:
Assessed Need and Service User view:
Aim of Care:
Staff Instruction(s):
Accountability Signature: (Person completing to print name and sign):
Date of form completion:
Signature: (print and sign): Service User or advocate
Date of form completion:
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Cherry Tree Lodge
Updated: 26/05/2011
Printed: 13/04/2012
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CA11 - Pre-Admission Assessment and Care Planning Pack
OTHER: (___________) NEEDS – MONTHLY OR MORE FREQUENT REVIEW
Use to conduct reviews of current assessment, unless sufficient changes require full risk re-assessment. Max 6
reviews, then re-assess.
Service User’s Name:
Admission date:
Review notes:
Care Plan requires modifying Y / N?
Date of review:
Next review date (maximum 1 month, or less if required, and always if Accountability Signature:
any changes)
Review notes:
Care Plan requires modifying Y / N?
Date of review:
Next review date (maximum 1 month, or less if required, and always if Accountability Signature:
any changes)
Review notes:
Care Plan requires modifying Y / N?
Date of review:
Next review date (maximum 1 month, or less if required, and always if Accountability Signature:
any changes)
Review notes:
Care Plan requires modifying Y / N?
Date of review:
Next review date (maximum 1 month, or less if required, and always if Accountability Signature:
any changes)
Review notes:
Care Plan requires modifying Y / N?
Date of review:
Next review date (maximum 1 month, or less if required, and always if Accountability Signature:
any changes)
Review notes:
Care Plan requires modifying Y / N?
Date of review:
Next review date (maximum 1 month, or less if required, and always if Accountability Signature:
any changes)
Copyright © 2012 Quality Compliance Systems Limited Tel: 0207 1383078 Fax: 0845 2590201
Cherry Tree Lodge
Updated: 26/05/2011
Printed: 13/04/2012
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CA11 - Pre-Admission Assessment and Care Planning Pack
RECORDS: GP/ANCILLARY PROFESSIONAL VISITS AND TESTS
Service User’s name:
Date
Admission date:
GP/other professional visit
Special test
Carer signature
Copyright © 2012 Quality Compliance Systems Limited Tel: 0207 1383078 Fax: 0845 2590201
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Updated: 26/05/2011
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CA11 - Pre-Admission Assessment and Care Planning Pack
RECORDS: WEIGHT, BP AND PULSE
Service User’s name:
Date
Weight
Admission date:
Gain +
Loss –
Action taken on weight
change
BP
Pulse
Signature
Copyright © 2012 Quality Compliance Systems Limited Tel: 0207 1383078 Fax: 0845 2590201
Cherry Tree Lodge
Updated: 26/05/2011
Printed: 13/04/2012
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CA11 - Pre-Admission Assessment and Care Planning Pack
RECORDS: BLOOD SUGAR MONITORING
Service User Name:
Date/initial
Date of admission:
Time
Score
Date/initial
Time
Score
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Updated: 26/05/2011
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CA11 - Pre-Admission Assessment and Care Planning Pack
RECORDS: CARE NEEDS – THE STAFF VIEW
Service User’s Name
Date
Communication
Bathing & Washing
Care Plan Y/N?
Care Plan Y/N?
Dressing & Grooming
Personality, Moods & Emotions
Care Plan Y/N?
Care Plan Y/N?
Use of toilet & Continence
Eating & Drinking
Care Plan Y/N?
Pressure Area Care
Care Plan Y/N?
Social, Recreational & religious
Care Plan Y/N?
Care Plan Y/N?
Moving and Handling & Mobility Needs
Any Special Routines Required by the Service User
Care Plan Y/N?
Gender of carer
Burial/cremation wishes
Care Plan Y/N?
Care Plan Y/N?
Memory
Resuscitation
Care Plan Y/N?
Care Plan Y/N?
Next review interval (maximum 1 month)
Therefore next review date:
(use attached review form to note, or if changes are substantial, carry out this full assessment again)
Accountability Signature: (Person completing to print name and sign):
Date of form completion:
Service User’s or Advocate’s Signature
Date of form completion:
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Cherry Tree Lodge
Updated: 26/05/2011
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CA11 - Pre-Admission Assessment and Care Planning Pack
RECORDS: SUMMARY OF RISK ASSESSMENT RESULTS: LIST ALL RISKS IDENTIFIED BY ANY
ASSESSMENTS OR OTHER PROCESSES
Service User’s Name:
Admission Date:
Source – Risk Risk – note only
Assessment
Date Signature
Date Signature
Date Signature
Care Plan Date
completed
(signature)
Room risk
assessment
Personal care
needs
assessment
tool
Mental health
assessment
tool
Mental
Capacity Act
assessment
Skin
marks/bruising
assessment
tool
Waterlow risk
assessment
General risk
assessment
Moving and
handling risk
assessment
Nutritional risk
assessment
Falls risk
assessment
Medications
Social history,
life history,
activities
Other
Accountability Signature: (Person completing to print name and sign):
Date of form completion:
Copyright © 2012 Quality Compliance Systems Limited Tel: 0207 1383078 Fax: 0845 2590201
Cherry Tree Lodge
Updated: 26/05/2011
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CA11 - Pre-Admission Assessment and Care Planning Pack
RECORDS: DAILY RECORD OF ADL (ACTIVITIES OF DAILY LIVING) AND CARE GIVEN
Service User’s Name:
Date Plan of
care ref:
Admission Date:
Daily report
BO Bath/ Care giver Signature
Shower
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Updated: 26/05/2011
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CA11 - Pre-Admission Assessment and Care Planning Pack
RECORDS: Family or Advocate discussion record
This form should be used for informal contacts only, and the Record of Involvement sheet used for recording choices
given and made
Resident Name:
Date of contact:
Person contacted e.g. family member, advocate.:
Method and time of contact:
Contact notes:
Signed:
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Updated: 26/05/2011
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CA11 - Pre-Admission Assessment and Care Planning Pack
RECORDS: RECORD OF INVOLVEMENT
Service Users, or their authorised representatives, must have assessment explained to them, be given options for
care and support from which they can choose their preferences, be fully involved in the design of Care Plans, and
fully involved in reviews, including again being given choices from which they can select their preferences. A record
must be kept of these discussions as evidence. Brief details (verbatim records are not required) of every discussion
must be recorded on this record as evidence of the involvement.
Service User NAME:
Record of involvement:
Names of participants:
Date and time:
Record :
Record of involvement:
Names of participants:
Date and time:
Record :
Record of involvement:
Names of participants:
Date and time:
Record :
Record of involvement:
Names of participants:
Date and time:
Record :
Copyright © 2012 Quality Compliance Systems Limited Tel: 0207 1383078 Fax: 0845 2590201
Cherry Tree Lodge
Updated: 26/05/2011
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CA11 - Pre-Admission Assessment and Care Planning Pack
RECORDS: Administration Notification
Service User Name
Date of admission
Time of admission
Home Address
Previous Address (admitted from)
Date of birth
Person taking responsibility for contract, finances etc
Self / Next of kin / Advocate / Other (delete as appropriate)
If not self:
Name
Relationship
Address
Telephone (home)
Telephone (work)
Telephone (mobile)
Service User maiden name
Service User pension (National Insurance) number
Funding source
Self / Social services / PCT (delete as appropriate)
If not self, details:
Fee quoted:
Attach copy of signed contract
Accountability signature:
Date:
Copyright © 2012 Quality Compliance Systems Limited Tel: 0207 1383078 Fax: 0845 2590201