Care Plan – For Ever Young Agency

Care Plan

Name *

Gender:

Date of Birth:

Address:

Phone Number:

Email Address *

Name Of Doctors Surgery

GP Surgery Address:

Name Of GP

GP Phone Number:

Preferred Day/Time Of Visit

Relevant Health Issues To care Requirements

Languages Spoken:

Emergency Contact Details

Name *

Phone Number:

Email Address *

Address:

Pets

Pets In the Home.

Background Information:

Goals And Outcomes Of The Support

Tasks to Be Carried Out During VisitDescriptions of Tasks

Care Needs

1.Personal Care Needs/Specialist Tasks:

2.Management Of Continence:

3. Earing & DrinkingExpected Daily Fluid Intake

4. Mobility (eg. Assistance needed, Supervision/support required/equipmentExpected Daily Fluid Intake

5.Communication, Memory & Sensory

6. Likes & Dislikes:

7. Social, Religious & Culture, Activity:

8. Interests & Hobbies:

9. Activities Outside The Home

Medication

Medication Support Level0 - No Support Required1. General Support (Including Prompting2. Administration Of Medication by care Staff3. Administratyion by Specialist Techniques

Specialist Training RequiredYes ( If Yes give details below)No

If specialist training required, give details below:

Details of where medication is stored:

GP Surgery Address:

Mobility Needs:0 / 180

Special Dietary Requirements:

Use of Medical Equipment:

Care Requirements

Care Required:

Preferred Days

Preferred Times

Specific Needs or Preferences:

Consent

I consent to Forever Young Agency storing and processing my data for careassessment and contact purposes. *Yes

Date:

Location Of Precautions:

Gas Meter

Fuse Box

Electric Meter

Water Stop Cock

Telephone

Lifelines (if applicable)

Appliances

Food Handling

Pets/Animals

COSHH

Infection Control

Mobility

Behaviour Management

Memory

Activities Outside The Home

Cash Handling

I have acknowledge that you have informed me of your lefal obligation to the commisssion and under the Vulnerable Adults and Child Protection Policies.YesNo

I have been given the information and Guidelines for ClientsyesNo

Date And Note Any Changes Made To The Care Plan

Agreement:

Risk Assessment And Care Plan Statement

All tasks assessed within this process must be carried out in accordance with Your Quality Care Policy and guidance.

No unnecessary risks will be taken that may jeopardise the client or care staff members well being. Care staff members will notify Your Quality Care of any changes that may have occred since the last risk assess at least annually.

I have read and understood this risk assessment and care plan. I agree to Your Quality Care providing care as shown on the Care Plan. I will notify Your Quality Care of any changes to the Clients condition or care arrangements and occasional care required by agreement

Would you have any objection to this happening.YesNo

As part of the requirements of the National Care Standards and Qualifications and Credit Framework (QCF) staff training programme, we occasionally need to observe our staff whilst they are working with clients.

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