Client Personal Details

MCare Client Personal Details

Client Details

Client’s Name:

Address:

Telephone No:

Date Of Birth:

Care Manager/Social Worker Details

Name:

Address:

Telephone No:

Next of Kin Details

NOK 1 (Next of Kin) Name:

Relationship:

Address:

Telephone No:

Mobile No:

Work No:

NOK 2 (Next of Kin) Name:

Relationship:

Address:

Telephone No:

Mobile No:

Work No:

Professionals Involved

G.P:

District Nurse:

Surgery:

Contact No:

Telephone No:

Mobile No:

In the event of an emergency this client would be deemed:

Red

Amber

Green

Red = urgent needs assistance – must access

Amber = family present – try to access

Green = would manage in emergency

Medical History

Write any medical history in the field above.

Start Date:

Access Arrangements:

Call made to service user before service commences by:

Date:

Mcare Service User Agreement

1. To Whom It May Concern, I

Clear

have been consulted with and I am in agreement with my Care Plan and HST TRUST Risk Assessment (where provided) and acknowledge receipt of the following:

Contact details / Out of Hrs emergency numbers

Service user guide/including complaints procedure/terms and conditions/relevant policies

Access to Records Policy

Gifts and Bequests Policy

Health and Safety requirements of my home

2. I agree that M Care LTD Can/Cannot have keys to my home to ensure staff can gain access. In the event of my package of care ending I wish any keys to be returned to Myself / N.O.K / Representative Access arrangements are as follows: BUZZER/INTERCOM/KEYPAD/OR KEYS ISSUED

3. I am aware and agree M Care staff are permitted to manage medication as directed by HSS trust as per Care Plan provided, my medication will be stored in

4. I am aware and agree M Care staff will complete written notes in relation to the services I may receive, these notes may be viewed by anyone that has a common interest in my care i.e. other service providers, G.P and D.N. These notes should be stored in

5. I am aware that it is MY/MY/NOK/OR REPRESENTATIVES Responsibility to ensure my home is safe for staff to provide my services. I agree to the written Risk Assessment being completed by M Care LTD, made available to M Care staff and reviewed as necessary.

6. I am aware that confirmation is held on file and that the commissioning HSS trusts are responsible for the monitoring and maintenance of all supplied equipment. M Care will notify the relevant trust if they become aware of any defects with supplied equipment.

7. I am aware my care will be reviewed and monitored and accept that at times this may need to be unannounced visits, my chosen method of monitoring would be: BY PHONE/VIA HOME VISIT.

8. I am aware that this agreement will not be reviewed, however if there was a substantial change to this agreement it will be amended and agreed with: MYSELF/MY NOK/REPRESENTATIVE and M Care LTD.

9. I request that I AM/I AM NOT consulted when M care policies are being reviewed.

10. I agree my care commenced on:

11. I acknowledge this agreement has been discussed and explained to me on

I have also been provided with my own copy for ease of reference.

12. Invoice Arrangements: HSC TRUST/PRIVATE. Details of private arrangement if applicable:

If at any stage either party would like to terminate the agreement, this can be done by having discussions with your trust representative. Should this agreement end, M Care reserve the right to visit your home and collect the home file.

Service user / N.O.K signature:

Clear

Service User / N.O.K Signature Date:

Manager Signature:

Clear

Manager Signature Date:

Service End Date:

Signature:

Clear

Mcare Risk Assessment

Service User Name:

Date:

Trust Risk Assessment Provided:

Requested:

Number Of Care Staff Required:

Internal Home Assessment

Working Smoke Alarm

Yes

Working Carbon Monoxide Alarm

Yes

Level Access

Yes

Stairs In Use

Yes

Handrails In Use

Yes

Stair Lift In Use

Yes

Space Restricted

Yes

Flooring Satisfactory

Yes

Lighting Satisfactory

Yes

Heating Satisfactory

Yes

Kitchen Fit For Purpose

Yes

Bathroom Fit For Purpose

Yes

External Home Assessment

Easily Accessed

Yes

Noticeable Restrictions

Yes

Adequate Outdoor Lights

Yes

Trust Provided Ramp

Yes

Outside Steps

Yes

Noted Risks

Environment Inside

High

Medium

Low

Environment Outside

High

Medium

Low

C.DIFF POSITIVE

MRSA POSITIVE

Equipment In Use

Hoist In Use

Yes

Service

Type

Sling

Yes

Service

Type

Profiling Bed

Yes

Service

Type

Cot Sides In Use

Yes

Service

Type

Person Centered Assessment

Smoker

Yes

Poor Mobility

Yes

Prone To Falls

Yes

Bed:

Where is the Home File Stored:

Service Required

Current Calls in Place:

Food / Fluid Preferences:

Current Staff Required? (Include Level of Assistance):

Equipment in Place? (Include Service Dates):

Toileting / Continence:

General Notes

Previous Employment / Interests:

Family Involvement:

Use of Restraint? (i.e. Cot Sides / Wheelchair Belt, etc..):

Speech:

Hearing:

Eyesight:

Method of Communication:

Medical History:

Cognition (Intact or Impaired):

Pain Noted:

Action in case of Emergency:

Special Requests (i.e. Waiting, Early/Later Calls, etc..):

Manager’s Signature:

Clear

Client’s Signature:

Clear

N.O.K (Next of Kin) Signature:

Clear

(NOK must be named on Care Plan and be authorised to sign on the Client’s behalf).

If you are human, leave this field blank.

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