Client Visit PackLydian CareNew Client Visit PackStep 1 of 616%Office Details:Date Visit Pack Completed:(Required) DD dash MM dash YYYY Manager Completing Visit Pack:(Required)Emma BrownNadine CheeversJulie DuffyElaine FlanaghanDawn ShankeltonHollie TateCarol SavageRachel DeeryFiona KaneSenior CarerSenior Carers Name:Visit Pack Completed by:(Required)TelephoneIn personSenior CarerOtherReferral Details:H&C Number:SOS Care Number:Client Details:Service Area Client Will be Based:(Required)1. Ballygowan2. Ballynahinch3. Castlewellan4. Comber5. Crossgar6. Downpatrick7. Drumaness8. Killyleagh9. Newcastle10. Saintfield11. Seaforde12. South Belfast13. DundonaldThe form will be sent to the rota co-ordinator for the area to record as completed - important to select the correct area.Title:(Required)Client's Name:(Required) First Last Client's DOB:(Required) Day Month YearAddress(Required) Address Line 1: Address Line 2: Town/City: Postcode: Clients Contact Number:(Required)How will carers gain access to client's home?Keypad Number (if applicable)Next of Kin/ POA Details:Name First Last Relationship to Client:(Required)Contact Number:(Required)Email(Required) To provide access to the family portal an email address is required.Permission to share information: Client gives permission.Client Gives permission for information to be shared with this person.Additional NOKNOK NameRelationshipContact NumberEmail Add RemoveIf the client wishes to name more than one NOK please detail information below.Trust DetailsTrust Care Manager Name:(Required) First Last Trust Care Manager Contact Number:(Required)GP DetailsGP Surgery:GP's Name:(Required) First Last GP Contact Number:(Required)Package DetailsTotal Hours per week:(Required)Hours per day:(Required)Number of calls:(Required)Care Commencement Date:(Required) DD slash MM slash YYYY If you have any additional information to add about the client not defined above please detail below:What is Important To The Service User (Personalised Care Plan)Ask the below questions and get the feedback from the service user on what is important to them about their care package.1. Tell me a hobby or interest of yours that you still like to do?(Required)2. What would you like from the care that you will receive?(Required)3. Tell me about your support system i.e. family and friends(Required)4. What would you like our carers to know about you, and how do you feel they can maintain your dignity when assisting you with your care needs?(Required)5. How will you manage your support and stay in control?(Required)6. How can we facilitate this to make it happen?(Required)Care PlanClients known allergies. I know I am allergic to: -(Required)Client’s physical needs. The assistance I need with physical activities of living.(Required)Client’s medical needs. My known medical conditions and the needs arising from this condition(Required)Clients medication support. The support I require with my medication and by whom(Required)Only if it is detailed on the care plan and timetable if we can provide any assistance with this.Clients mental health assistance I require with orientation and self determination(Required)Client’s personal care. The assistance I require with my personal care.(Required)Nutrition and Hydration. The support I require with preparation and serving of meals and drinks(Required)Service User Guide issued and explainedService User Guide issued and explained (Explain Lydian Care complaints procedure, If carers run over 15 mins to call office and problems to call office, all details are in the care book at the clients house)Detailed:(Required)Lydian Care Plan and risk assessment discussedWhat Equipment do you have at Home? Do you have Tiled/Carpet/Wooden floors or any mats? Asking this just because it may be a fall risk/risk to staff and to have this notedDetailed:(Required)Health & Safety responsibilities discussedDetailed:(Required)Call times delays and cancellations discussed and agreedDetailed:(Required)Client agreement to delivery of Care Services by Lydian CareDetailed:(Required)Financial Transactions required?(Required) Yes NoDetailed:(Required)Care Plan Review Date:(Required) DD slash MM slash YYYY Risk AssessmentRisk Assessment Review Date:(Required) DD slash MM slash YYYY Following this assessment - when should the risk assessment be reviewed?1. Fire Safety/Risk AssessmentIs this person at greater risk from fire; • Aged 60 or older • Have a disability or impaired mobility - • Have a health condition that would impact upon their ability to acknowledge or respond to an emergency within the home - Referral criteria to NIFRS Evidence of; • No working smoke alarm - • History of fires - • Are not careful with smoking materials - • Scorch marks on bedding, clothing and/or carpets • Leaving cooking unattended • Large quantities of loose papers/stored/hoarded items in rooms • Use of candles unguarded/close to combustible materials.Detail:(Required)Is the service user aged 60 or above?(Required)YesNoDo they have a working smoke alarm in their home?(Required)YesNoDo they have a health condition that would impact upon their ability to acknowledge or respond to an emergency within the home?(Required)YesNoIf Yes please detail and consider whether a referral to NIFRS is required.(Required)Decision to refer to Northern Ireland Fire & Rescue Service?(Required) Yes No2. Internal risk assessmentArea Internal(Required)Hallways /Passageways, RoomsPotential Hazards(Required)Obstruction /Mats/TrippingRisk(Required)Upstairs carpet,etc..Potential risk to:(Required)Care Staff/Client3. Client Movement Assessment/Mobility AssessmentDoes the client have equipment in their home?(Required) Yes NoDetail all equipment in client's homeEquipmentChecked DateDue Maintenance on Add Removeenter each equipment item in the text box above - then click the plus button to add more.Is the equipment maintained and checked?(Required) Yes NoMovement - Walking(Required)Movement - Washing(Required)Movement - Chair to standing(Required)Movement - Transfers Chair to bed, Bed to chair, Chair to toilet/commode(Required)Movement - Bed to standing(Required)Movement - Rolling bed(Required)Movement - Positioning in bed(Required)Movement - Wheelchair Transfers(Required)4. Other Risk FactorsDoes the service user have any pets?(Required)YesNoIf yes please detail:Does the outside of the client's home have sufficient lighting for carers entering and leaving the home?(Required)YesNoIf no please detail:5. Risk RatingPlease evaluate and confirm the risk rating assigned to this client. This is an internal rating and not to be shared with the client. RED – High - Service users who do not have support networks that could take on any aspect of domiciliary care calls and all care calls are critical, e.g. personal care, medication administration, meals. AMBER – Medium - Service users who would be able to cope without a call temporarily or a reduction in call length due to support networks who could carry out part of care calls. The care being undertaken by a member of their support network should be clearly communicated. GREEN Low/Minimal - Service users who receive task calls – cleaning, laundry and shopping. These could be moved to another day, frequency reduced or canceled if family/carers can carry them out. Service users who receive sitting services. These should be considered for removal or reduction in time unless it is part of a protection or risk management plan and the removal of service could lead to significant harm to service users or care. Risk Rating(Required) Low Risk Medium Risk High RiskPlease detail why you have assigned the risk rating based on your assessment.(Required)Client Signature:(Required)
