Client Visit Pack

Office Details:

Date Visit Pack Completed:(Required)

Manager Completing Visit Pack:(Required)

Senior Carers Name:

Visit Pack Completed by:(Required)

Referral Details:

H&C Number:

SOS Care Number:

Client Details:

Service Area Client Will be Based:(Required)

The 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)

Address(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

Additional NOK

NOK Name

Relationship

Contact Number

Email

If the client wishes to name more than one NOK please detail information below.

Trust Details

Trust Care Manager Name:(Required)

First Last

Trust Care Manager Contact Number:(Required)

GP Details

GP Surgery:

GP's Name:(Required)

First Last

GP Contact Number:(Required)

Package Details

Total Hours per week:(Required)

Hours per day:(Required)

Number of calls:(Required)

Care Commencement Date:(Required)

If you have any additional information to add about the client not defined above please detail below:

Service User Guide issued and explained

Service 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 discussed

What 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 noted

Detailed:(Required)

Health & Safety responsibilities discussed

Detailed:(Required)

Call times delays and cancellations discussed and agreed

Detailed:(Required)

Client agreement to delivery of Care Services by Lydian Care

Detailed:(Required)

Financial Transactions required?(Required)

Yes

No

Detailed:(Required)

Care Plan Review Date:(Required)

Risk Assessment Review Date:(Required)

Care Plan

Clients 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)

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)

Risk Assessments

Has a risk assessment taken place for this client or scheduled within the next 72 hours?(Required)

1. Fire Safety/Risk Assessment

Is 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)

Decision to refer to Northern Ireland Fire & Rescue Service?(Required)

Yes

No

2. Internal risk assessment

Area Internal(Required)

Hallways /Passageways, Rooms

Potential Hazards(Required)

Obstruction /Mats/Tripping

Risk(Required)

Upstairs carpet,etc..

Potential risk to:(Required)

Care Staff/Client

3. Client Movement Assessment/Mobility Assessment

Does the client have equipment in their home?(Required)

Yes

No

Detail all equipment in client's home

Equipment

Checked Date

Due Maintenance on

enter each equipment item in the text box above - then click the plus button to add more.

Is the equipment maintained and checked?(Required)

Yes

No

Movement - 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)

Call us: 028 43 725 385

Lydian Care

New Client Visit Pack

Office Details:

Referral Details:

Client Details:

Next of Kin/ POA Details:

Trust Details

GP Details

Package Details

Service User Guide issued and explained

Lydian Care Plan and risk assessment discussed

Health & Safety responsibilities discussed

Call times delays and cancellations discussed and agreed

Client agreement to delivery of Care Services by Lydian Care

Care Plan

Risk Assessments

1. Fire Safety/Risk Assessment

2. Internal risk assessment

3. Client Movement Assessment/Mobility Assessment

As this visit pack has been completed remotely no signature is required.

Useful Links

Our Offices

Phone

Email

Client Visit Pack

Lydian Care

New Client Visit Pack

Office Details:

Referral Details:

Client Details:

Next of Kin/ POA Details:

Trust Details

GP Details

Package Details

Service User Guide issued and explained

Lydian Care Plan and risk assessment discussed

Health & Safety responsibilities discussed

Call times delays and cancellations discussed and agreed

Client agreement to delivery of Care Services by Lydian Care

Care Plan

Risk Assessments

1. Fire Safety/Risk Assessment

2. Internal risk assessment

3. Client Movement Assessment/Mobility Assessment

As this visit pack has been completed remotely no signature is required.

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