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You might be finding it difficult to cope at home, perhaps because you are disabled or because you are getting more frail, or you or your relative might be in hospital and know that returning to live at home will be difficult. In either case there are various possibilities that might make your life easier. Residential care is one. There are also services which may allow you to go on living in your own home, or there are various sorts of housing that may suit you better. If you are not sure, it is worth considering what options you have before taking steps to find a suitable home. There is no doubt that selecting a care or service provider for a partner or relative is a difficult task. However, identifying their particular needs before beginning the search process will help you explore the available alternatives and make an informed decision. The following Needs Assessment Survey will assist you in your search and prepare you to answer the many questions that will be posed by a facility's staff. |
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Needs Assessment Why do you need a Care Home? Individual can no longer care for him/herself Individual requires more care than can be provided by our family Individual has extensive medical needs Doctor recommends Discharged from hospital and needs short term care before returning Home Individual Currently has the following care needs (Tick as many as apply) Supervision only Assistance with the activities of daily living Therapy 24-hour care Intensive nursing care Other Medical Conditions Alzheimer's Disease Cancer Cardiovascular Disease Chronic Pain Dementia Learning Disability Head Injury Hematologic condition Mental Infirmity Neurological Disease Neuromuscular Disease Orthopaedic / skeletal problems Arthritis Pulmonary Disease Para / quadraplegic Stroke Trauma Ulcers / Pressure Sores / Wounds Other Therapies Recommended by GP Physiotherapy Occupational Therapy Speech Therapy Respiratory Therapy Reality Therapy Other Equipment and Medical Supplies Required Wheel chair Prosthetics Ventilator Special Bed Intravenous Drugs Prescription Drugs Continence Supplies Oxygen Syringe Driver PEG Feed Other Other Support Needed on a Regular Basis Dentist Optician Dietician GP Chiropodist Other Individual Requires Help with the following Activities of Daily Living Personal care Bathing Continence (urine) Continence (faecal) Dressing Feeding Sight Mobility Using the telephone Shopping Preparing meals Housekeeping Laundry Transportation Taking medications Handling finances Other Cultural and Social Needs Special Needs Special Diet Culturally-based special diet Language (if not English) Other Religion Any religious affiliation Social Activities Preferred Cards and games Watching Videos Listening to the radio Watching television Reading Arts and crafts Social events Pet therapy Outdoor activities Interaction with others Other Facility Preferences Single Room En-suite facilities Shared Room Small size home (less than 10 rooms) Medium size home (less than 20 rooms) Large size home ( more than 20 rooms) Family Needs Spouse / Family is current care provider Is home-based care an option? Are short-term breaks in a care home an option? Is day care an option? Family lives locality Family lives out of locality. Location Near family and friends Near a hospital Within the practice area of your GP Locality preferred Town preferred Village preferred Rural location preferred Other Financial - How Will You Pay For Care? Private pay Part private / part Social Services (Top Up) Fully funded by Social Services Private long-term care insurance Other Transportation Who will transport the individual to off-site appointments if necessary? Family will provide Care Home must provide Client Information (optional) Client Name Date of Birth GP's Name Contact Information (optional) Contact Name Address Town County Post Code Contact Telephone Number: Contact e-mail: Print out this form and keep it by you as you visit your selected care providers. |
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