FILING - Healthcare Documentation & Care Products ... easy to use care planning handbook offers a step by step guide to care planning for nurses and carers. The handbook explains what

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Comprehensive Care Planning System

… a comprehensive care planning system, easy for staff to use … it promotes the opportunity to ensure that all care plans are individualised and person centred. During the last three inspections CQC were happy with every one of our care plans … the nurse assessors from the local PCT have commented about the high quality of our care plans and that all of the information they require is accurately recorded and easy to find. The documentation guide helps staff to understand the relevance of each form and how each can be used to evidence that the outcomes are being met …

Jo Turner (Manager) Chester Lodge

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ADMISSIONASSESSMENT & CARE PLANNING

DEMENTIA & MENTAL CAPACITY INFORMATION

DAY TO DAY RECORDING

MANDATORY ASSESSMENTS/RECORDS

OPTIONAL / NURSING INFORMATION

DAILY REPORTING & COMMUNICATION

DOMICILIARYCARE

ContentsADMISSION21.049 Pre Assessment 8

21.026 Hospital Transfer Record 9

21.050 Re-Assessment 9

21.051 Admission 9

ASSESSMENT & CARE PLANNING21.052 Support Plan 10

21.053 Care Plan 11

21.054 Care Plan Evaluation 11

21.055 Activity Plan 12

21.056 Activity Plan Evaluation 12

21.057 Social Activity 12

21.058 Social Activity Comments 12

DEMENTIA & MENTAL CAPACITY INFORMATION21.059 Personal History 13

21.060 Support Network 13

21.061 Mental Capacity Assessment 14

21.062 Deprivation of Liberty 14

21.063 Lasting Power of Attorney 15

21.064 Future Wishes 15

DAY TO DAY RECORDING21.065 Personal Care 16

21.066 Bowel Chart 16

21.067 Food Chart 17

21.068 Weight Chart 17

21.069 Body Chart 18

21.070 Epilepsy Chart 18

21.071 Oral Assessment Tool 19

21.072 Record of Behaviour 19

MANDATORY ASSESSMENTS/RECORDS21.075 Manual Handling 20

21.074 Falls Risk Assessment 21

21.073 MUST Tool 22

21.097 MUST Poster 22

21.077 Infection Risk Assessment 23

21.076 Pressure Ulcer Assessment 23

21.078 Bedrail Assessment 24

21.079 General Risk Assessment 25

21.080 General Risk Evaluation 25

OPTIONAL / NURSING INFORMATION21.081 Pain Chart 26

21.082 Wound Chart 26

21.083 Depression Scale 27

21.084 Medication Record 27

21.089 Dependency Profile 28

21.265 Review Timeline 28

21.267 Dependency Profile Review 28

21.085 Observations and Monitoring 29

21.086 Diabetic Chart 29

21.088 Fluid Balance 29

21.087 Repositioning Chart 29

21.260 Catheter Change 30

21.261 Catheter Care 30

21.090 Deterioration Scale 30

DAILY REPORTING & COMMUNICATION21.091 Keyworker 31

21.092 Communication Sheet 31

21.093 Multidisciplinary Notes 31

21.094 Doctors Notes 32

21.095 Family Communication 32

21.096 District Nurse Notes 32

21.142 Staff Sign in Sheet 32

20.768 Daily Report 33

20.025 Daily Report - Single 33

20.019 Nursing Report 33

21.278 Audit Tool 34

21.319 Audit Tool Quick Checklist 34

21.280 Visitors Book 34

DOMICILIARY CARE21.133 Service User Details 35

21.134 Support Plan 35

21.135 Care Plan AM Visit 35

21.136, 21.137, 21.138 Care Plan Lunch, PM and Night Visit 36

21.139 + 21.140 Manual Handling and Personal Plan 36

21.141 Medication Record 37

21.143 Financial Transactions 37

21.144 Daily Log 37

RESPITE20.929 Respite Booklet 38-39

2 Email: [email protected] Phone: 01604 646 633

Company Overview

Fax: 01604 644 646 Web: www.standexsystems.co.uk 3

Standex Systems have been providing care planning systems to the care sector for over 40 years. Part of an international group with over 18,000 satisfied clients which includes 2,500 in the UK alone.Standex in the UK specialise in providing care planning systems to care homes, nursing homes, hospices and hospitals.At Standex Systems Ltd we always strive to be ahead of your documentation needs. By keeping a close eye on the requirements of the Care Quality Commission, we are able to develop and update care planning systems in line with the regulations.As a company we provide a wide range of filing and storage solutions to compliment our care planning system to create a one stop shop for your care planning needs.

Other product ranges available:• Files & Storage• Waste & Laundry

• Treatment Trolleys• Medication Trolleys

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Thank you for your interest in Standex Systems Care Planning Documentation. We design, develop and implement care planning documentation for care homes and domiciliary care settings. Lucy Caldwell (RGN) is our Nurse Advisor and ensures that all the documentation is up to date, evidence-based and in line with the requirements of the Care Quality Commission (CQC) and Local Authorities (LA). She also provides ongoing support and advice for all our customers.

Some of the products that we produce:

• Care Home Care Planning System – All assessments including holistic, mental capacity and deprivation of liberty along with all mandatory and risk assessments. Person centred care planning (including advanced care planning for end of life), evaluation and reports. The system allows staff to evidence that they are meeting all CQC and LA requirements. See below for an example.

• Care Planning Handbook – an introduction to care planning with prompts for the need, goal and support required for each activity of daily living. Includes examples of how to write a care plan for each activity and a guide to how you should assess for mental capacity and deprivation of liberty. See below for information.

• Documentation Guide – a comprehensive guide explaining each form in depth.

• Training – training sessions on how to use the care planning system correctly and to its full potential.

Audit Tool – enables staff to identify forms within a service user care plan being filled out incorrectly, missing or used inappropriately together with actions required to achieve excellent care planning. In line with CQC audit requirements.

• Domiciliary Care Planning System – holistic assessments; mandatory assessments and risk assessments (inside and outside the home). Person centred care planning for each visit, evaluation and reports. Allows staff to evidence that they are meeting all CQC and LA requirements.

• Files – to store all the service user’s documents in one place

• Storage – many storage solutions including lockable trolleys to securely store each service user file

Standex Systems products are:

• Cost effective• Fully compliant• Up to date and evidence based• In line with best practice• In line with the requirements of the Care

Quality Commission and Local Authorities

...a comprehensive care planning system, easy for staff to use…it promotes the opportunity to ensure that all care plans are individualised and person centred. During the last three inspections CQC were happy with every one of our care plans….the nurse assessors from the local PCT have commented about the high quality of our care plans and that all of the information they require is accurately recorded and easy to find…

Jo Turner (Manager) Chester Lodge

For further details and to arrange a no-obligation quote please contact us on: 01604 646 633


www.standexsystems.co.uk 5Fax: 01604 644 646 Web: www.standexsystems.co.uk 5

2014© Standex Systems LtdDO NOT PHOTOCOPY FOR ANY OTHER REASON THAN LEGAL39 Charter GateQuarry Park Close - Moulton Park Ind. EstateNorthampton - NN3 6QBPhone (01604) 646 633Fax (01604) 644 646Web www.standexsystems.co.uk

CARE PLAN

PERSONAL HISTORY

PERSONAL CARE

MANUALHANDLING

MEDICATION RECORD

KEY WORKERNOTES

ACTIVITY PLAN

MENTAL CAPACITY ASSESSMENT

FOOD CHART

MUST TOOL

DIABETICCHART

MULTIDISCIPLINARY NOTES

SUPPORT NETWORK

BOWEL CHART

FALLS RISK ASSESSMENT

OBSERVATIONS & MONITORING

COMMUNICATION SHEET

DEPRIVATION OF LIBERTY

WEIGHT CHART

INFECTION RISK ASSESSMENT

FLUID BALANCE

DOCTORS NOTES

LASTING POWER OF ATTORNEY

BODY CHART

PRESSURE ULCER ASSESSMENT

REPOSITIONING CHART

FAMILY COMMUNICATION

EPILEPSYCHART

BEDRAIL RISK ASSESSMENT

CATHETER CHANGE

DISTRICT NURSE NOTES

ORAL ASSESSMENT TOOL

GENERAL RISKASSESSMENT

PAIN CHART

WOUNDCHART

DEPENDENCY PROFILE

STAFF SIGN SHEET

DEPRESSION SCALE

REVIEWS

DAILY REPORT

RECORD OF BEHAVIOUR

FUTURE WISHES

SOCIALACTIVITY

Name: Date of Birth: Room Number: System No: 21.053

Care PlanDate Assessment of Need Review signature(s)

1/5/14 Tom has dementia and sometimes becomes confused due to this. This can affect his capacity to make decisions regarding day to day activities.

Tom says he often feels more confused in the mornings, however in the afternoon he is less confused. Sue Smith (S. SMITH)

Goal/Expected Outcomes

1/5/14 Tom would like to be involved in all decision making where possible regarding his care. He wishes to be as independent as possible and should he

not have capacity to make a decision at a particular time, and this decision cannot wait, then he wishes his daughter (who has written Lasting

Power of Attorney) to be contacted. Sue Smith (S. SMITH)

Note: All support required, focusing on what Tom can do to remain as independent as possible, is then recorded overleaf.

Nursing Care Plan Y / N Need

1. Mental Capacity

2. Washing & Dressing

3. Mobility

4. Sleeping/Night Care

5. Medication

6. Spirituality

7.

8.

9.

10.

11.

12.

Note: Each care plan sits on top of the other. These tabs are cut to give a quick reference guide to all the care plans required for that particular service user.

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This easy to use care planning handbook offers a step by step guide to care planning for nurses and carers.

The handbook explains what a care plan is and why they are so integral to the delivery of excellent care within the home.

It looks at:

• What is a care plan?

• Mental capacity and care planning.• Lasting Power of Attorney (LPA) and Deputies.• Deprivation of Liberty Safeguards (DoLS).• The care planning process.

• Elements of a good care plan.

• Elements of a poor care plan.

Prompts are given for the need, goal and interaction required in

each care plan along with an example of how to write a care plan for each of the following areas:

• Mental Capacity and Cognition.• Communication.• Psychological Well being.• Mobility and Falls.• Washing and Dressing.• Eating and drinking.• Continence.• Personal Safety and Risk.• Breathing.• Skin.• Pain.• Infection Risk.• Medication and Symptom Control.• Sleeping and Nightcare.• Social Activities.• Final Days.

Introducing our new Care Planning HandbookA step by step guide to care planning for nurses and carers

Ideal for all keyworkers, new starters and staff involved in care planningPocket sized with a handy Off Duty at the back for staff member to record their shift pattern


www.standexsystems.co.uk 7

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Goal

• For all personal hygiene needs to be met whilst receiving the support required to maintain as much independence as possible?

• For all dressing needs to be met whilst receiving the support required to maintain as much independence as possible?

Support and Interactions

• Does the service user require a Personal Care Chart?

• Does the service user require an Oral Assessment (see Oral Assessment Tool)?

• What are their preferences? e.g. bath or shower?

• Does the service user prefer a male or female carer?

• What are the service users personal preferences with washing (e.g time of wash, favourite soap)?

• What assistance do they require?

• What can they do for themselves?

• Does the service user wish to have a daily shave?

• If the service user is totally dependent what can you do to ensure the bathroom is warm, inviting and secure?

• Can you talk through each activity using a calm tone and speaking slowly?

• What clothing preference does the service user have?

• What are the service users personal preferences with dressing (e.g time to dress, favourite clothes)?

• What is required to ensure the mouth is clean and fresh? e.g. checking daily, four hourly, assistance required etc.

• How often should the service user’s feet be checked? e.g for broken skin.

• Does the service user require assistance with cutting toe nails?

• Are there any hazards associated with this area that need a General Risk Assessment?

Washing and Dressing Care Plan

Need

• Is the service user able to look their hygiene? (e.g. nails, teeth, hair, mouthcare).

• Is the service user able to dress themselves?

• Is the service user able to manage zips, buttons, laces etc?

• Does the service user have their own teeth?

• Does the service user wear dentures?

• Are the dentures correctly fitted?

• Does the service user need to see a Chiropodist/Dentist/Podiatrist.

• Does the service user have any problems with their feet? e.g. dry skin, bunions, diabetic ulcers, swelling etc.

• Any special footwear required?

An example of the prompts given for Washing and Dressing with a person centred care plan worded in a way that is accessible to both service user and staff.

Daily Reporting, Care Plan Evaluation and Reviews

The handbook has a chapter on Daily Reporting and looks at the importance of recording in the correct manner:

• Examples of good practice.

• Examples of poor practice.

• Terminology to use and to avoid, with examples.

The handbook finishes with a look at Care Plan Evaluations and Reviews:

• Why the need for evaluating and reviewing.

• Acknowledging that care plans are always evolving.

Finally it explains the need for auditing of the care plans to ensure that all information is up to date within the care plans and that staff are recording effectively and in the correct manner.

Care Plan - Washing and DressingAssessment of Need

Tom has had a stroke and has weakness on his left side. He also hasarthritis in his knees. As a result of this he finds it difficult to attend to his hygiene and dressing needs. He has difficulty getting in and out of the bath but prefers a bath to a shower. He also has difficulty in dressing especially with buttons and zips which he finds fiddly and he doesn’t always remember to do these up due to him sometimes being confused, so needs prompting and support from staff.

Goal/Expected OutcomesTom takes great pride in his appearance and it is very important to himto have all his hygiene needs met and to be dressed smartly during the day. He would like to remain as independent as possible.

Interactions and Support required (including level of ability to engage)

In order to help Tom get in and out of the bath he needs to use a bath chair and will need the assistance of one carer to do this. Tom is able towash himself however he sometimes needs prompting. For example ifyou give Tom a flannel and a simple clear sentence such as ‘you can usethis to wash your face’ then Tom will respond and be able to wash his face on his own. He likes to wash his hair every other day and uses a mild shampoo. He doesn’t like aftershave but likes to use deodorant.Tom likes to dress himself but again may need prompting for ‘fiddly’ areas like zips and buttons. If he doesn’t have these prompts he will often forget and this may cause embarrassment which is a concern for Tom and his family. Tom likes to wear smart clothing including his armymedals on a blazer. He likes to pin these on himself but may need somehelp with the smaller ones.

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21.049 Pre Assessment

• Demographics, medical history, medication, allergies, resus status.

• Holistic Assessment (including a section about whether service user has mental capacity at time of assessment).

• LPA details if applicable.• Infection status. • Reasons for acceptance/

non acceptance.• This form allows evidencing that the

needs, wishes , preferences and decisions of the service user are placed at the centre of assessment, planning and delivery of care, treatment and support. Whilst promoting independence.

• The very first form that is used before the service user has even entered the home. It evidences that safe and appropriate care is given because individual needs are established from when they are referred. It can be recorded that all aspects of their individual circumstances, and their immediate needs are recorded prior to admission (or non admission as the case may be).


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21.050 Re-Assessment

• A smaller version of Pre-Assessment to document any changes in service user’s condition on return to the home.

• Can document whether the home can still cater for service user’s needs.

21.026 Hospital Transfer Record

• Hospital Transfer Record should be used if the service user is taken into hospital.

• Provides ambulance crew and staff at the hospital with vital information regarding the service user’s health and support required.

• The principal concern of the care home is to maintain the service user’s well-being, provide optimal care during the transfer period, and to deliver the service user safely to the receiving unit.

• The care home can keep the top copy for their records, the 2nd and 3rd copies can be given to the hospital and ambulance crew for their records.

• You may attach photocopied care plans and the latest daily report if you feel this will better inform nursing staff of support required.

21.051 Admission

• Service user details on admission.• Designed to go in front pocket

of the file where it can be seen quickly and easily.

• Quick ‘at a glance’ view of service user’s details.


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21.052 Support Plan

• Based on Roper, Logan and Tierney’s Activities of Daily Living with further categories for a more robust assessment.

• Any problems trigger a care plan.• This can be done on a monthly

basis or more frequently if needs change. Here we have the review section where the service user/advocate can sign to say they have been involved in the assessment.

• The holistic assessment looks at Cognition, Psychological, Physical, Social and End of Life.


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21.053 Care Plan

• Generated from the Support Plan.• Looks at need, goal and support required.• Each plan needs to be person centred

(blank for you to do this).• Our Documentation Guide gives you

prompts for each area and encourages staff to think in a ‘person-centred way’.

• There is a larger care plan available to sit at the back if preferred - 21.129

21.054 Care Plan Evaluation

• To be used to document the evaluation of the care plans.

• There is a larger care plan evaluation available to sit at the back if preferred - 21.130


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21.055 Activity Plan

• To be used as the care plan but specifically for social activity.

• Useful for use by Social Activity Co-ordinators.

21.056 Activity Plan Evaluation

• To be used to document the evaluation of the activity plans.

21.057 Social Activity

• Can be used to plot dates of social activities.

• There is a year on a form.

21.058 Social Activity Comments

• Can be used to write comments about the social activity in conjunction with the activity care plans or on their own.


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21.059 Personal History

• Personal Story.• Useful for reminiscence, especially

in those with dementia.• Person-centred.

21.060 Support Network

• Quick glance document can be used to document service user’s support.

• Can be used for any out of hours contacts such as Macmillan Nurse etc. Therefore supporting End of Life documentation.


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21.061 Mental Capacity Assessment

• To be used if a service user needs to make a decision and their mental capacity is in question.

• Assists staff in assessing capacity in line with the Mental Capacity Act 2005.

• Details of action taken in service user’s best interests to be recorded on the reverse

21.062 Deprivation of Liberty

• Will assist manager in deciding whether an application to deprive a service user of their liberty is required.

• Document the outcome of the decision.


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21.063 Lasting Power of Attorney

• For details of any Written Lasting Power of Attorney and/or advocates.

• Can document any Advance Decisions/refusal of treatment if they become incapacitated (i.e. advance care planning).

21.064 Future Wishes

• Looks at wishes of the service user at end of life (ie advance care planning).

• What is important?• What would they like to happen?• What would they not like to happen?• Worries, concerns and special wishes.• Also looks at what they wish to happen after death.


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21.065 Personal Care

• Used to replace a bath book.

• Year on a form.

21.066 Bowel Chart

• To record bowel movements and complications.

• Uses Bristol Stool Chart (poster provided).


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21.067 Food Chart

• Enables detailed recording of food intake.• Sits above MUST Tool in system.

21.068 Weight Chart

• Can document monthly weight on graph to show clearly any dips in weight (and vice versa).

• New version will allow you to monitor as and when required (ie daily or weekly).

• Year on form based on monthly review.


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21.069 Body Chart

• Can be used to map any bruising or markings that have no explanation but are a concern to staff.

• Could also be used when service user is admitted to hospital and on their return as a safeguard for both service user and staff.

21.070 Epilepsy Chart

• Allows recording of seizures.• An accurate and comprehensive record.


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21.071 Oral Assessment Tool

• Scoring tool to ascertain condition of mouth.• Suggested actions on reverse to assist care planning.• Year on form based on monthly review.

21.072 Record of Behaviour

• Allows recording of any behaviour that may be deemed inappropriate and harmful.

• Enables staff to clearly see patterns and triggers etc.


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21.075 Manual Handling

• Staff can clearly document which type of handling is appropriate for which movement.

• Any constraints, environmental concerns etc can be recorded.

• Year on form based on monthly review.


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21.074 Falls Risk Assessment

• Has questions and necessary actions to prevent the risk of falling.• Year on a form based on monthly review.• By identifying risks staff can then state in the care plans how they will be managed

and reviewed.


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The ‘Malnutrition Universal Screening Tool’ (‘MUST’) is reproduced here with the kind permission of BAPEN (British Association for Parenteral and Enteral Nutrition). The ‘MUST’ was developed by the Malnutrition Advisory Group (MAG) of BAPEN and first produced in November 2003.

‘MALNUTRITION UNIVERSAL SCREENING TOOL’ (‘MUST’)

SCORE 0Wt Loss

< 5%

SCORE 1 Wt Loss 5-10%

SCORE 2Wt Loss > 10%

5st 4lb <4lb 4 - 7lb > 7lb5st 7lb <4lb 4 - 8lb > 8lb5st 11 lb <4lb 4 - 8lb > 8lb6st <4lb 4 - 8lb > 8lb6st 4lb <4lb 4 - 9lb > 9lb6st 7lb <5lb 5 - 9lb > 9lb6st 11lb <5lb 5 - 10lb > 10lb7st <5lb 5 - 10lb > 10lb7st 4lb <5lb 5 - 10lb > 10lb7st 7lb <5lb 5 - 11lb > 11lb7st 11lb <5lb 5 - 11lb > 11lb8st <6lb 5 - 11lb > 11lb8st 4lb <6lb 6 - 12lb > 12lb8st 7lb >6lb 6 - 12lb > 12lb8st 11lb <6lb 6 - 12lb > 12lb9st <6lb 6 - 13lb > 13lb9st 4lb <7lb 7 - 13lb > 13lb9st 7lb <7lb 7 - 13lb > 13lb9st 11lb <7lb 7lb - 1st > 1st10st <7lb 7lb - 1st > 1st10st 4lb <7lb 7lb - 1st > 1st 10st 7lb <7lb 7lb - 1st 1lb > 1st 1lb10st 11lb <8lb 8lb - 1st 1lb > 1st 1lb11st <8lb 8lb - 1st 1lb > 1st 1lb11st 4lb <8lb 8lb - 1st 2lb > 1st 2lb11st 7lb <8lb 8lb - 1st 2lb > 1st 2lb11st 11lb <8lb 8lb - 1st 3lb > 1st 3lb12st <8lb 8lb - 1st 3lb > 1st 3lb12st 4lb <9lb 9lb - 1st 3lb > 1st 3lb12st 7lb <9lb 9lb - 1st 4lb > 1st 4lb12st 11lb <9lb 9lb - 1st 4lb > 1st 4lb13st <9lb 9lb - 1st 4lb > 1st 4lb13st 4lb <9lb 9lb - 1st 5lb > 1st 5lb13st 7lb <9lb 9lb - 1st 5lb > 1st 5lb13st 11lb <10lb 10lb - 1st 5lb > 1st 5lb14st <10lb 10lb - 1st 6lb > 1st 6lb14st 4lb <10lb 10lb - 1st 6lb > 1st 6lb14st 7lb <10lb 10lb - 1st 6lb > 1st 6lb14st 11lb <10lb 10lb - 1st 7lb > 1st 7lb15st <11lb 11lb - 1st 7lb > 1st 7lb15st 4lb <11lb 11lb - 1st 7lb > 1st 7lb15st 7lb <11lb 11lb - 1st 8lb > 1st 8lb15st 11lb <11lb 11lb - 1st 8lb > 1st 8lb16st <11lb 11lb - 1st 8lb > 1st 8lb16st 4lb <11lb 11lb - 1st 9lb > 1st 9lb16st 7lb <12lb 12lb - 1st 9lb > 1st 9lb

SCORE 0Wt Loss

< 5%

SCORE 1 Wt Loss 5-10%

SCORE 2Wt Loss > 10%

34kg < 1.7 kg 1.7 - 3.4 kg > 3.4 kg36kg < 1.8 kg 1.8 - 3.6 kg > 3.6 kg38kg < 1.9 kg 1.9 - 3.8 kg > 3.8 kg40kg < 2 kg 2 - 4 kg > 4 kg42kg < 2.1 kg 2.1 - 4.2 kg > 4.2 kg44kg < 2.2 kg 2.2 - 4.4 kg > 4.4 kg46kg < 2.3 kg 2.3 - 4.6 kg > 4.6 kg48kg < 2.4 kg 2.4 - 4.8 kg > 4.8 kg50kg < 2.5 kg 2.5 - 5 kg > 5 kg52kg < 2.6 kg 2.6 - 5.2 kg > 5.2 kg54kg < 2.7 kg 2.7 - 5.4 kg > 5.4 kg56kg < 2.8 kg 2.8 - 5.6 kg > 5.6 kg58kg < 2.9 kg 2.9 - 5.8 kg > 5.8 kg60kg < 3 kg 3 - 6 kg > 6 kg62kg < 3.1 kg 3.1 - 6.2 kg > 6.2 kg64kg < 3.2 kg 3.2 - 6.4 kg > 6.4 kg66kg < 3.3 kg 3.3 - 6.6 kg > 6.6 kg68kg < 3.4 kg 3.4 - 6.8 kg > 6.8 kg70kg < 3.5 kg 3.5 - 7 kg > 7 kg72kg < 3.6 kg 3.6 - 7.20 kg > 7.2 kg74kg < 3.7 kg 3.7 - 7.4 kg > 7.4 kg76kg < 3.8 kg 3.8 - 7.6 kg > 7.6 kg78kg < 3.9 kg 3.9 - 7.8 kg > 7.8 kg80kg < 4 kg 4 - 8 kg > 8 kg82kg < 4.1 kg 4.1 - 8.2 kg > 8.2 kg84kg < 4.2 kg 4.2 - 8.4 kg > 8.4 kg86kg < 4.3 kg 4.3 - 8.6 kg > 8.6 kg88kg < 4.4 kg 4.4 - 8.8 kg > 8.8 kg90kg < 4.5 kg 4.5 - 9 kg > 9 kg92kg < 4.6 kg 4.6 - 9.2 kg > 9.2 kg94kg < 4.7 kg 4.7 - 9.4 kg > 9.4 kg96kg < 4.8 kg 4.8 - 9.6 kg > 9.6 kg98kg < 4.9 kg 4.9 - 9.8 kg > 9.8 kg100kg < 5 kg 5 - 10 kg > 10 kg102kg < 5.1 kg 5.1 - 10.2 kg > 10.2 kg104kg < 5.2 kg 5.2 - 10.4 kg > 10.4 kg106kg < 5.3 kg 5.3 - 10.6 kg > 10.6 kg108kg < 5.4 kg 5.4 - 10.8 kg > 10.8 kg110kg < 5.5 kg 5.5 - 11 kg > 11 kg112kg < 5.6 kg 5.6 - 11.2 kg > 11.2 kg114kg < 5.7 kg 5.7 - 11.4 kg > 11.4 kg116kg < 5.8 kg 5.8 - 11.6 kg > 11.6 kg118kg < 5.9 kg 5.9 - 11.8 kg > 11.8 kg120kg < 6 kg 6 - 12 kg > 12 kg122kg < 6.1 kg 6.1 - 12.2 kg > 12.2 kg124kg < 6.2 kg 6.2 - 12.4 kg > 12.4 kg126kg < 6.3 kg 6.3 - 12.6 kg > 12.6 kg

Height (feet and inches)

Height (m)Note: The black lines denote the exact cut off points (30, 20 and 18.5 kg/m2), figures on the

chart have been rounded to the nearest whole number

Plate 1 Composite LEICESTER HOSPITAL 20XXX 07/08/06

University Hospitals of LeicesterNHS Trust

System No.: 20.952

'MUST'TOOL

“Derived from forms developed by Standex Systems Ltd in conjunction with University Hospitals of Leicester” ©2007 STANDEX SYSTEMS Ltd. Phone (01604) 646 633 · Fax (01604) 644 646 www.standexsystems.co.uk

COMPLETE ON FIRST SCREEN - DATE:

'Malnutrition Universal Screening Tool' ('MUST') Score

Current Weight

Measured / RecalledPLEASE CIRCLE

Height

Measured / RecalledPLEASE CIRCLE

Body Mass Index (BMI) Weight 3-6 months ago

Measured / Recalled /Don't know

PLEASE CIRCLE

% Weight Loss

Change in weightover last 3-6 monthsYes / No / Don't know

A BMI Less than 18.5kg/m2 = 2Between 18.5kg/m2 and 20kg/m2 = 1More than 20kg/m2 = 0

More than 10% = 2Between 5% and 10% = 1Less than 5% = 0

Patient acutely ill and there has been NO or likelyto be NO nutritional intake for > 5 days:YES = 2NO = 0

210

210

20

210

210

210

210

210

210

20

20

20

kg m kg/m2 kg

'MALNUTRITION UNIVERSAL SCREENING TOOL' ('MUST')

If score 1 or more start Nutrition careplan (seeright). If no improvement or if score > 4 refer toDietitian

B % Unplannedweight lossover last3-6 months

C Acute diseaseeffect score

Total Add scores to give RISKRecord total score:

Nutritional care plan started?YES NO NOT NEEDED

Please circle score

RISK:Low = 0Medium = 1High = 2 or more

Please circle

WEIGH PATIENT TWICE WEEKLY AND DOCUMENT ON WEIGHT CHART

Repeat 'MUST' weekly or if condition changes - using new weight and on discharge as part of discharge care planning

34 kg36 kg38 kg40 kg42 kg44 kg46 kg48 kg50 kg52 kg54 kg56 kg58 kg60 kg62 kg64 kg66 kg68 kg70 kg72 kg74 kg76 kg78 kg80 kg82 kg84 kg86 kg88 kg90 kg92 kg94 kg96 kg98 kg100 kg102 kg104 kg106 kg108 kg110 kg112 kg114 kg116 kg118 kg120 kg122 kg124 kg126 kg

<1.70<1.80<1.90<2.00<2.10<2.20<2.30<2.40<2.50<2.60<2.70<2.80<2.90<3.00<3.10<3.20<3.30<3.40<3.50<3.60<3.70<3.80<3.90<4.00<4.10<4.20<4.30<4.40<4.50<4.60<4.70<4.80<4.90<5.00<5.10<5.20<5.30<5.40<5.50<5.60<5.70<5.80<5.90<6.00<6.10<6.20<6.30

1.70 - 3.401.80 - 3.601.90 - 3.802.00 - 4.002.10 - 4.202.20 - 4.402.30 - 4.602.40 - 4.802.50 - 5.002.60 - 5.202.70 - 5.402.80 - 5.602.90 - 5.803.00 - 6.003.10 - 6.203.20 - 6.403.30 - 6.603.40 - 6.803.50 - 7.003.60 - 7.203.70 - 7.403.80 - 7.603.90 - 7.804.00 - 8.004.10 - 8.204.20 - 8.404.30 - 8.604.40 - 8.804.50 - 9.004.60 - 9.204.70 - 9.404.80 - 9.604.90 - 9.805.00 - 10.005.10 - 10.205.20 - 10.405.30 - 10.605.40 - 10.805.50 - 11.005.60 - 11.205.70 - 11.405.80 - 11.605.90 - 11.806.00 - 12.006.10 - 12.206.20 - 12.406.30 - 12.60

>3.40>3.60>3.80>4.00>4.20>4.40>4.60>4.80>5.00>5.20>5.40>5.60>5.80>6.00>6.20>6.40>6.60>6.80>7.00>7.20>7.40>7.60>7.80>8.00>8.20>8.40>8.60>8.80>9.00>9.20>9.40>9.60>9.80>10.00>10.20>10.40>10.60>10.80>11.00>11.20>11.40>11.60>11.80>12.00>12.20>12.40>12.60

B - Weight loss score

5st 4lb5st 7lb5st 11 lb6st6st 4lb6st 7lb6st 11lb7st7st 4lb7st 7lb7st 11.lb8st8st 4lb8st 7lb8st 11lb9st9st 4lb9st 7lb9st 11lb10st10st 4lb10st 7lb10st 11lb11st11st 4lb11st 7lb11st 11lb12st12st 4lb12st 7lb12st 11lb13st13st 4lb13st 7lb13st 11lb14st14st 4lb14st 7lb14st 11lb15st15st 4lb15st 7lb15st 11lb16st16st 4lb16st 7lb

<4lb<4lb<4lb<4lb<4lb<5lb<5lb<5lb<5lb<5lb<5lb<6lb<6lb<6lb<6lb<6lb<7lb<7lb<7lb<7lb<7lb<7lb<8lb<8lb<8lb<8lb<8lb<8lb<9lb<9lb<9lb<9lb<9lb<9lb<10lb<10lb<10lb<10lb<10lb<11lb<11lb<11lb<11lb<11lb<11lb<12lb

4lb - 7lb4lb - 8lb4lb - 8lb4lb - 8lb4lb - 9lb5lb - 9lb5lb - 10lb5lb - 10lb5lb - 10lb5lb - 11lb5lb - 11lb6lb - 11lb6lb - 12lb6lb - 12lb6lb - 12lb6lb - 13lb7lb - 13lb7lb - 13lb

7lb - 1st.0lb7lb - 1st 0lb7lb - 1st 0lb7lb - 1st 1lb8lb - 1st 1lb8lb - 1st 1lb8lb - 1st 2lb8lb - 1st 2lb8lb - 1st 3lb8lb - 1st 3lb9lb - 1st 3lb9lb - 1st 4lb9lb - 1st 4lb9lb - 1st 4lb9lb - 1st 5lb9lb - 1st 5lb10lb - 1st 5lb10lb - 1st 6lb10lb - 1st 6lb10lb - 1st 6lb10lb - 1st 7lb11lb - 1st 7lb11lb - 1st 7lb11lb - 1st 8lb11lb - 1st 8lb11lb - 1st 8lb11lb - 1st 9lb12lb - 1st 9lb

>7lb>8lb>8lb>8lb>9lb>9lb>10lb>10lb>10lb>11lb>11lb>11lb>12lb>12lb>12lb>13lb>13lb>13lb

>1st.0lb>1st 0lb>1st 0lb>1st 1lb>1st 1lb>1st 1lb>1st 2lb>1st 2lb>1st 3lb>1st 3lb>1st 3lb>1st 4lb>1st 4lb>1st 4lb>1st 5lb>1st 5lb>1st 5lb>1st 6lb>1st 6lb>1st 6lb>1st 7lb>1st 7lb>1st 7lb>1st 8lb>1st 8lb>1st 8lb>1st 9lb>1st 9lb

A BMI score (& BMI) Height (feet and inches)

Height (m)Note: The black lines denote the exact cut off points (30,20 and 18.5 kg/m2), figures on the chart have been rounded to the nearest whole number.

Wei

ght b

efor

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eigh

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g)

Wei

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efor

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eigh

t los

s (s

t lb)Wei

ght (

kg)

Weight (stones and pounds)

SIGN

The Nutrition screening tool is based on 'MUST' and reproduced here with kind permission of BAPEN (the British Associationfor Parenteral and Enteral Nutrition). Further information on 'MUST' is available on the BAPEN website www.bapen.org.uk

USE CHART TO CALCULATE FROMCURRENT WEIGHT

AND HEIGHT (See bottom) IF YES USE CHART TO CALCULATE %USING CURRENT AND PREVIOUS

WEIGHT (see bottom)

DATE

SCORE 0Wt Loss

<5%

SCORE 1Wt Loss5-10%

SCORE 2Wt Loss>10%

SCORE 0Wt Loss

<5%

SCORE 1Wt Loss5-10%

SCORE 2Wt Loss>10%

Order a special diet if appropriate e.g. gluten free, pureed diet

Assist with ordering suitable meal choices (suggest high energy/high calorie main courses and puddings and'Chef's Specials')

Encourage the patient to request additional items for snacks between meals

Encourage milk and milky drinks

Offer 1 Build Up drink per day (savoury or sweet) Unless contraindicated e.g. renal disease, lactose intolerant, milk allergy or patientsfollowing low residue diets. Contact ward dietitian for advice

Offer assistance with eating and drinking, when required. Instigate red tray if indicated

Treat underlying conditions such as nausea, vomiting, diarrhoea

Commence food and drink record charts for all meals and snacks

REVIEW INTAKE AFTER THREE DAYS, if intake remains minimal, refer to your ward dietitian

Refer to your ward dietitian if:

Repeat 'MUST' weekly - if weight drops >1kg/week refer to your ward dietitian

MEDIUM / HIGH RISK

∨**

***

***

*

*

'MUST' score is 4 or moreEnteral tube feeding is requiredNBM > 5 days'MUST' score increases or there is no improvement on medium/high risk nutrition care planSpecialist advice is required following diagnosis, or a full nutritional assessment is required in response toclinical judgementPatient requires assessment and provision of a therapeutic diet e.g. allergy, metabolic

*****

*

Name: Hospital No: Ward: Site:

Weight (stones and pounds)

Wei

ght (

kg)

STEP 1 - Body Mass Index (BMI) ScoreMeasure height and weight to get BMI and document score in service user file. If un-able to obtain height and weight, use the alternative procedures shown below.

STEP 3Acutely ill and no nutritional intake or unlikelihood of no nutritional intake for more than 5 days

STEP 4Add scores from step 1, 2 and 3 together to obtain an overall score for risk of malnutrition

STEP 5Use management guidelines and/or local policy to develop care plan

STEP 2 - Weight Loss ScoreNote percentage of unplanned weight loss and document score in service user file

2011 Standex Systems LtdDO NOT PHOTOCOPY FOR ANY OTHER REASON THAN LEGAL39 Charter GateQuarry Park Close - Moulton Park Ind. EstateNorthampton - NN3 6QB

Phone (01604) 646 633Fax (01604) 644 646Web www.standexsystems.co.ukSystem Number: 21.097

Body Mass Index and Weight Loss Table

Estimating height from ulna length - use if you cannot measure service user’s actual height

Estimating BMI category from mid upper arm circumference (MUAC)

- use if you cannot measure service user’s actual weight or height

Measure between the point of the elbow (olecranon process) and the midpoint of the prominent bone of the wrist (styloid process) (left side if possible).Find the ulna length in cm in the white row in the table below.Choose the appropriate height in metres from the age and gender in the options above or below the white bar.

Men (<65 years) 1.94 1.93 1.91 1.89 1.87 1.85 1.84 1.82 1.80 1.78 1.76 1.75 1.73 1.71 1.69 1.67 1.66 1.64 1.62 1.60 1.58 1.57 1.55 1.53 1.51 1.49 1.48 1.46

Men (>65 years) 1.87 1.86 1.84 1.82 1.81 1.79 1.78 1.76 1.75 1.73 1.71 1.70 1.68 1.67 1.65 1.63 1.62 1.60 1.59 1.57 1.56 1.54 1.52 1.51 1.49 1.48 1.46 1.45

Ulna Length (cm) 32 31.5 31 30.5 30 29.5 29 28.5 28 27.5 27 26.5 26 25.5 25 24.5 24 23.5 23 22.5 22 21.5 21 20.5 20 19.5 19 18.5

Women (<65 years) 1.84 1.83 1.81 1.80 1.79 1.77 1.76 1.75 1.73 1.72 1.70 1.69 1.68 1.66 1.65 1.63 1.62 1.61 1.59 1.58 1.56 1.55 1.54 1.52 1.51 1.50 1.48 1.47

Women (>65 years) 1.84 1.83 1.81 1.79 1.78 1.76 1.75 1.73 1.71 1.70 1.68 1.66 1.65 1.63 1.61 1.60 1.58 1.56 1.55 1.53 1.52 1.50 1.48 1.47 1.45 1.44 1.42 1.40

The subject’s left arm should be bent at the elbow at a 90 degree angle, with the upper arm half parallel to the side of the body. Measure the distance between the bony protrusion on the shoulder (acromiom) and the point of the elbow (olecranon process).

Mark the mid-point.

Ask the subject to let arm hang loose and measure around the upper arm at the mid-point, making sure that the tape measure is snug but not tight.

If MUAC is < 23.5cm, BMI is likely to be < 20 kg/m2

If MUAC is > 32cm, BMI is likely to be > 30 kg/m2

21.097 MUST Poster

• Reference guide for MUST Tool showing BMI chart, Weight Loss table and alternative measurements.

21.073 MUST Tool

• Enables MUST score to be documented.

• Over two and a half years on a form based on monthly review.

• Accompanied by poster with BMI, weight loss table and alternative measurements for quick reference.


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21.077 Infection Risk Assessment

• Evidences that systems are in place to monitor and manage infection control.

21.076 Pressure Ulcer Assessment

• Waterlow Score.• Body map.• Year on a form based on monthly review.• Waterlow Manual accompanies form.


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21.078 Bedrail Assessment

• Asks risk balance questions.• Staff get a recommendation via

the Risk Matrix Tool.• Can document your rationale for

using (or not), bedrails.• Consent signature column.


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21.079 General Risk Assessment

• One form per risk. • Trigger questions regarding level of risk

and actions to be taken.• In the style of the care plans with tabs.• Can use evaluation form to evaluate plan

without having to re-write.

21.080 General Risk Evaluation

• To be used to document the evaluation of the risk assessment.


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21.081 Pain Chart

• Numeric Pain Scale (for those who can verbalise pain).

• Doloplus2 (for those with a cognitive impairment, ie dementia, who cannot verbalise their pain).

• Can assess acute and chronic pain.

• Body Map.

21.082 Wound Chart

• One chart per wound for more detailed documentation.

• Accompanies care plan if one is required.


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21.083 Depression Scale

• Questions to ascertain whether service user has depression.

• Soon to be one for those with cognitive impairment such as dementia.

21.084 Medication Record

• Document all medication on arrival including short term meds such as antibiotics and any changes to medications.


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21.089 Dependency Profile

• Scoring tool to ascertain dependency levels.

• Can be plotted on graph to show patterns of dependency levels.

• Can be used as evidence if applying for continuing healthcare funding (has the same domains).

• Designed to be a monthly assessment and in line with Outcome 21: Records, it can be evidenced on that assessments are updated, monitored and reviewed to ensure records are kept and maintained for each service user.


21.267 Dependency Profile Review

• Sits behind the Dependency Profile enabling staff to record the outcomes of a monthly review.

21.265 Review Timeline

• A snapshot of reviews and those involved over the year.

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21.085 Observations and Monitoring

• To record temp, pulse, resps, blood pressure, fluid intake, output and input.

• Can record any relevant comments.

21.086 Diabetic Chart

• Document time, blood sugar and insulin given.

21.088 Fluid Balance

• Document intake and output over 24 hours.

• Two weeks on one form.

21.087 Repositioning Chart

• Document repositioning of service user.

• Two weeks on one form.


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21.090 Deterioration Scale

• Recommended by Dr Jo Hockley in line with Gold Standards Framework.

• Can be used to record periodic review of deterioration and required action.


21.260 Catheter Change

• To be used to detail information regarding a new catheter.

21.261 Catheter Care

• To be used for recording all catheter maintenance.

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21.091 Keyworker

• Enables keyworkers to document their notes.

21.092 Communication Sheet

• Can be used for general communication purposes.

• Can be used to replace the Communication book.

21.093 Multidisciplinary Notes

• Enables the multidisciplinary team to document their notes.


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21.094 Doctors Notes

• Enables Doctors to document the outcome of their visit.

21.095 Family Communication

• Enables family to document any concerns they may have and any communication they wish to get across to staff.

• Recommended by Dr Jo Hockley.

21.096 District Nurse Notes

• Allows District Nurses to document the outcome of their visit.


21.142 Staff Sign in Sheet

• A document that allows staff to sign in to say they have read the contents of the service user’s care plan including risk assessments and tasks required.

• Also useful for documenting staff member’s initials for identification elsewhere in the system.

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20.025 Daily Report

• Sits at the back so can be changed very easily.

• A form on which day to day occurrences should be recorded.

• A4 in size.

20.768 Daily Report

• Sits at the back so can be changed very easily.

• A form on which day to day occurrences should be recorded.

• A3 in size.

20.019 Nursing Report

• For use by nursing staff.• Sits at the back so can be

changed very easily.• A form on which day to

day occurrences should be recorded.

• A3 in size.


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21.278 Audit Tool

• Audits of care plans are to be done to ensure all staff are recording effectively and that care plans are meeting the requirements of the Care Quality Commission.

• One audit tool should be used per service user care plan. It is best to pick a selection of care plans at random (e.g. 4 in a 40 bedded home = 10%).

• Each audit identifies any documents missing from the care plans, any documents in the care plan that don’t need to be and what percentage of each form is being used correctly.

• Has an area to record the final scores and any action that needs to take place such as further training.

21.319 Audit Tool Quick Checklist

• As above but a quick view checklist for use monthly on all service users if required.

21.280 Visitors Book

• A record of all visitors to the home.• Includes details such as Date,

Name, Company/Car Reg, Who is being visited, Reason, Arrival/Departure Time and Signature.

Name: Date of Birth: System No: 21.134

SUPPORT PLAN (for daily living and long term outcomes)All requirements must be met through positive, individualised support and be person centred based on dignity, equality, fairness, autonomy and respect

CARE PLAN REVIEWSIf the service user does not have mental capacity at time of assessment/review please indicate below and involve advocate(s).

The service user and anyone involved in the care planning must sign in the boxes below.

Date

Mental Capacity

Does the service user have capacity at the time of assessment? Y / N




Comments

Consent Signatures

Names of those involved in care planning:

Staff name: ...........................................................................

Signature: .............................................................................

Service user: ........................................................................

Signature: .............................................................................

Advocate: .............................................................................

Signature: .............................................................................


Staff name: ...........................................................................

Signature: .............................................................................

Service user: ........................................................................

Signature: .............................................................................

Advocate: .............................................................................

Signature: .............................................................................


Staff name: ...........................................................................

Signature: .............................................................................

Service user: ........................................................................

Signature: .............................................................................

Advocate: .............................................................................

Signature: .............................................................................


Staff name: ...........................................................................

Signature: .............................................................................

Service user: ........................................................................

Signature: .............................................................................

Advocate: .............................................................................

Signature: .............................................................................

©2013 Standex Systems LtdDO NOT PHOTOCOPY FOR ANY OTHER REASON THAN LEGAL39 Charter Gate - Quarry Park Close - Moulton Park Ind. EstateNorthampton - NN3 6QBPhone (01604) 646 633 - Fax (01604) 644 646www.standexsystems.co.uk System Number: 21 278

Documentation AuditName of Care Home: Date of Audit:

Signature of Auditor: Name of Auditor (print): Service user/Identification:

Aims and Objectives

The audit enables the provider to have a system in place to:

• achieve consistency of professional practice in the documentation throughout the home(s)• ensure compliance of the home’s required standards• continually monitor the quality of care that is being given, meeting the audit requirements of the Care Quality Commission• record what actions are required to improve in care planning with dates to be achieved by

This documentation audit will highlight:

• What percentage of each form is being used correctly• What percentage of forms are missing from the care plan• What percentage of forms in the care plan are not required

Guidance on completion

• One audit booklet per service user care plan• We suggest doing the audit on 10% of the service user population e.g. on 4 service user care plans for an occupancy of 40, at a frequency you feel appropriate• Each form is scored to enable you to work out what percentage of each form is being used correctly• Once completed and percentages calculated, action plans with time scales must be put in place and communicated to staff• Full audits should be completed periodically by a competent member of staff

Scoring

• Each form scores one point per question (marked with a tick under either ‘yes’, ‘no’ or ‘n/a’), and each form has a possible score• Percentages are calculated by dividing the amount of ‘yes’ and ‘n/a’ answers by the possible score and multiplying by 100 to ascertain the percentage• The percentage will reflect how much of the form has been used correctly, how many forms are missing and how many forms are not required in the care plan

Documentation Audit

Action Plan

ScoringCare Planning Yes No n/a CommentsSupport Plan (Possible Score - 12)

1 Name and date of birth of service user recorded?

2 Document completed with no gaps?

3 Entries legible and easy to understand with no jargon/abbreviations?

4 Entries factual and objective?

5 Entries free from meaningless and offensive phrases?

6 Signed and dated?

7 Each category (cognition, Psychological, Physical, Social and End of Life) is signed and dated by service user/advocate on a monthly basis to evidence that the plan has been reviewed monthly/as required?

8 Alterations are signed and dated?

9 Mistakes are drawn through with a single line and made clear it is an error?

10 Mistakes are signed and dated?

11 Is a care plan referenced if there is a need?

12 Completed in black ink?

Total number of ‘Yes’ and ‘n/a’ answers ÷ 12 = x 100 = % of Support Plan used correctly

Care Plans and Social Activity Plans (Possible Score - 16)

1 Name and date of birth of service user recorded?

2 Care/Social Activity Plans have needs identified in a clear and objective way evidencing that the service user/advocate was involved in their care plan?

3 Care/Social Activity Plans have Goal and Expected Outcomes identified in a clear and objective way evidencing that the service user/advocate was involved in their Care Plan

4 Care/Social Activity Plans have Interactions and Support required identified in a clear and objective way evidencing that the service user/advocate was involved in their Care Plan.

5 Support and Interactions include what level of ability the service user has to engage

6 Each Care/Social Activity Plan has been signed by the service user/advocate and staff to evidence the service user’s consent to the plan of care?

7 Alterations made to the Care/Social Activity Plan post review are dated, timed and signed?

Scores

Overall percentage of documents being used correctly

Grand total of ‘yes’ and ‘n/a’ answers: ÷ Possible score of all documents: x 100 = % of all documents used correctly

Therefore % used incorrectly

Documents missing from care plan

Number of documents not in care plan but should be: ÷ Total number of documents in care plan: x 100 = % of documents missing from care plan

Please list:

Documents in the care plan but not required

Number of documents in care plan that are not required: ÷ Total number of documents in care plan: x 100 = % of documents in care plan are not required Please list:

Scoring

1 Admission

2 Care Planning

3 Life Story

Action Plan

Section Problem Identified Action Person Responsible

Date to be achieved

Reviewed By

Signature/Print Name

Action Plan

Date Name Company andCar Registration

Who are you visiting? Reason for visit? Arrival

time Signature Departure time

Visitors book

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Domiciliary Care Planning DocumentationMany of our standard documents may be used for Domiciliary Care such as Falls Assessments, Bowel Charts, Food Charts etc. However we have also developed the following documents that are specific to Domiciliary Care, ensuring you can record all the care necessary for the service user in their own home.

21.133 Service User Details

• As well as standard service user details, has such information as house access details and methods of payment

• Designed to sit at the front of the file for quick access

21.134 Support Plan

• A comprehensive assessment of all care required

• Space for reviews• Views of the service user including

their thoughts, wishes and feelings• Thorough internal and external risk

assessment

Service User Details - DOMICILIARY CARE

Surname: Past Medical History (including disabilities): Access details

First Name(s): Knock/Ring bell Y / N

Likes to be called: Walk in Y / N

Maiden Name: Key safe Y / N

Date of Birth: Key safe number Y / N

Place of Birth: Front door Y / N

Marital Status: Back door Y / N

Nationality: MRSA or Clostridium - Any Positive History? Y / N Side door Y / N

Language: Details: Key holder Y / N

Preferred language: Other:

Religion: Allergies:

Address:

Reason for support required: Bill to be sent to:

Tel No: Private Service User? Y / N

Mob No: Direct payments? Y / N

Service User number: Method of payment (delete as applicable) - Standing order / Cash / Cheque / Other:

Other family at residence? Y / N

Details: Communication needs of service user: Does the service user consent to paying money to the carer to bring in to the office? Y / N

Next of Kin / Contact Person 1:

Relationship:

Address:

Does service user self medicate Y / N

Tel No: General Practitioner:

Mob No: Surgery:

Next of Kin / Contact Person 2: Address:

Relationship:

Address: Tel No: RESUSCITATION STATUS:

Date:

District Nurse:

Tel No: Tel No:

Mob No: Other professional (if applicable): Date:

Legal Instructions: Signature of Assessor:

Name of Assessor:

Signature of Service User:

System Number: 21.133

Name: Date of Birth:

SUPPORT REQUIRED

All requirements must be met through positive, individualised support and be person centred based on dignity, equality, fairness, autonomy and respectDate Service user’s wishes and feelings toward their support: Assessor Name Signature

Date How and when would the service user like their care to be delivered:

Date Please detail the service user’s religious or spiritual needs:

Date What level of involvement does the family have?

Date What can carers do to improve the service user’s quality of life and maximise their independence?

21.135 Care Plan AM

• Care Plans for AM visit to detail what tasks are to be done on that particular visit

2014 © Standex Systems LtdDO NOT PHOTOCOPY FOR ANY OTHER REASON THAN LEGAL39 Charter GateQuarry Park Close - Moulton Park Ind. EstateNorthampton - NN3 6QBPhone (01604) 646 633Fax (01604) 644 646Web www.standexsystems.co.uk

AM VISIT


Care Plan - AM Visit. Time and length of stay:Date Need Review signature(s)


Need

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21.136 Care Plan Lunch Visit

• Care Plans for Lunch visit to detail what tasks are to be done on that particular visit.


LUNCH VISIT


Care Plan - Lunch Visit. Time and length of stay:Date Need Review signature(s)


Need

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

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PM VISIT


Care Plan - PM Visit. Time and length of stay:Date Need Review signature(s)


Need

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4.

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6.

7.

8.

9.

10.

11.

12.

21.137 Care Plan PM Visit

• Care Plans for PM visit to detail what tasks are to be done on that particular visit.

21.138 Care Plan Night Visit

• Care Plans for Night visit to detail what tasks are to be done on that particular visit.


NIGHT VISIT


Care Plan - Night Visit. Time and length of stay:Date Need Review signature(s)


Need

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

©2013 Standex Systems LtdDO NOT PHOTOCOPY FOR ANY OTHER REASON THAN LEGAL39 Charter GateQuarry Park Close - Moulton Park Ind. EstateNorthampton - NN3 6QBPhone (01604) 646 633Fax (01604) 644 646Web www.standexsystems.co.uk


MANUAL HANDLING

System No: 21.139

MANUAL HANDLINGPhysical Hazards Y N CommentCould the service user’s weight cause a problem? Weight: Build: Height:Does the service user have swollen limbs? Describe:Are the service user’s feet in a poor state?Is the service user’s skin condition poor? Detail:Does the service user have any pressure sores? Detail (incl. where):Does the service user have any pain? At rest: On movement:Is the service user hearing impaired? Detail:Is the service user’s eyesight impaired? Detail:Does the service user experience seizures/involuntary movements? Detail:Is the service user unstable/uncoordinated? Detail:Are there attachments to consider? e.g. catheters, oxygen cylinders, false limbs etc Detail:Does the service user have any paralysis? Detail:Does the service user have any weak areas? Detail:Does the service user have a history of falls? Detail:Psychological HazardsIs the service user co-operative? Detail:Is the service user unpredictable? Detail:Does the service user have difficulty following instructions? Detail:Is the service user anxious? Detail:Is the service user prone to mood swings? Detail:Does the service user display behaviours which may seem challenging? Detail:Environmental HazardsIs there enough room? If no, complete further risk assessment.Is the lighting adequate? If no, complete further risk assessment.Is the temperature suitable? Detail:Are there constraints on posture due to the room layout/design or any hazards? If yes, complete further risk assessment.Is the bed/chair the correct height? If no, complete further risk assessment.Is there a risk of slips, trips and falls? If yes, complete further risk assessment.Is the environment noisy? Detail:Are there any hazards in the environment? If yes, complete further risk assessment.

21.139 and 21.140 Manual Handling and Personal Plan

• An in-depth look at physical, psychological and environmental hazards.• A section on equipment and dates of inspection.• What the service user can do for themselves to promote independence.• The Personal Plan sits behind the Manual Handling form.• Scoring tool for level of risk.• Personal Handling Plan for each activity.



PERSONAL PLAN

MANUAL HANDLING SCORE TOOLMobility Score Health/Medical History Mental state

Needs assistance into bed 1 A physical disability requires assistance for mobility 5 Able to fully co-operate 0Needs assistance out of bed 1 Amputee 3 Mildly confused/forgetful 2Needs assistance into chair 1 Stroke - limited use of one limb 2 Very confused 3Needs assistance out of chair 1 Stroke - limited use of two limbs 3 Unconscious/semi conscious 5Needs assistance on/off commode 1 Pain/stiffness of joints 2 WeightNeeds assistance in/out of wheelchair 2 Breathlessness 1 Below 8 stone (50 kg) 1Needs assistance up or down stairs 5 Alcohol/drug abuse 3 8 stone - 9 stone 13lb (51 - 63 kg) 2Uses a stick 1 Spasms/severe shaking 5 10 stone - 11 stone 13lb (64 kg - 75 kg) 3Uses a walking frame 1 Poor/limited sight 1 12 stone or above (76 kg +) 4Uses a wheelchair 3 Speech impediment 1

Below 15 = Low risk 15 - 25 = Medium risk 25+ High risk

If the score is over 25 please do additional risk assessment

Uses a stair lift - requires no assistance 1 Vertigo 2Uses a stair lift - requires assistance 5 History of falls 5Able to weight bear and stand without support 2Able to weight bear - requires physical assistance of carer 5Unable to weight bear/uses hoist 5

System No: 21.140

Date

Score

Additional Risk Assessment?

Signature

Hoist Details

Manual or electric:

Make:

Model:

Sling Details

Type of sling:

Size:

Shoulder strap colour: Leg strap colour:

Bath Hoist Details

Manual or electric:

Make:

Model:

Electric Bed Details

Manual or electric:

Make:

Model:

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21.141 Medication Record

• Risk assessment for self-medication.• Looks at mental, physical and

sensory ability.• Medication Profile.

21.143 Financial Transactions

• A document to record any financial transactions.• Amounts given to carer, spent, change returned

and receipt given.• Safeguarding for both carer and service user.


Name: Date of Birth: System No: 21 141

Medication Record

Mental Ability

Y / N / NA Y / N / NADoes the service user remember to take their medication? Is the medication supplied in a medication administration device or compliance aid?

Does the service user always take the right quantity of medicines at the right time? Is a reminder card or compliance aid provided by the pharmacy or nurse?

Does the service user always want to take their medication? Has the Doctor been told the medication is not always taken?

Physical / Sensory AbilityIs the service user able to obtain supplies of medication as needed? Can the family or neighbour collect? Does pharmacy deliver? (please circle)

Does the service user know where all their medication is stored within the home? Can the family tell you where it is stored?

Is there any excess medication stored in the home, which may give rise to confusion or mistakes in administration?

Can the service user or family return all excess or out of date medication to the pharmacy, or are they prepared to store the medication elsewhere for future use?

Can the service user read the label on the medication? Is there a relative, friend or neighbour who could help?

Can the service user get the tablet or capsule out of the bottle, container or packet? Can the pharmacy pack into different containers so that the service user can get the medicines out successfully?

Can the service user pick up the tablets once out of the container? Is there a relative, friend or neighbour who could help?

Is the service user able to swallow their tablets or capsules? Can the pharmacy provide this medicine in another form, such as liquid or soluble tablets?

Can the service user pick up a bottle and pour a dose of liquid medicine? Is there a relative, friend or neighbour who could help? Would a measure cup rather than a spoon help?

Can the service user use an inhaler properly? Is there a relative, friend or neighbour who could help? Would a compliance aid help the service user?

Can the service user use eyedrops properly? Would a compliance aid for eye drops help the service user?

Can the service user reach the part of the body to apply cream/ointment? Does a nurse or family member visit to apply this medicine?

Are there any vulnerable family members at risk? If yes, who and what control measures have been put in place?

If adequate control measures have not been put in place to protect vulnerable family members, it must be explained to the service user the risks that these pose, and that all medication must be stored in a safe place. If a service user refuses to adhere to these recommendations, please get the service user to sign here:Service user signature:......................................................................................................................................................Assessor signature:.............................................................................................................................................................Date:........................................................................................................................................................................................

MEDICATIONRECORD


Financial Transaction Sheet

Date Time Transaction Amount given Service User signature Carer signature Amount spent Receipt given Change returned Service User

signature Carer signature


FINANCIAL TRANSACTIONS

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21.144 Daily Log

• All carers to write on Daily Log after visit• Time In and Time Out• Full name and signature required

System No.: 21 144

Date Time In Time Out Daily Log Signature

20.929 Respite Booklet

• The Standex System in condensed format for those who are having short term respite.


Needs Assessment

Name: Date of birth: Room Number: Date of assessment:

COGNITIONPlease assess each area and formulate a numbered care plan if support is required in that particular area.

Brain impairment:

Refer to care plan no:

Communication and understanding: Memory:

Refer to care plan no:Refer to care plan no:

Orientation:


Behaviour:


Practical Skills:


Recognition and perceptual difficulties:


PSYCHOLOGICALPlease assess each area and formulate a numbered care plan if support is required in that particular area.

Mental state:


Emotional :


Personality:


Response to diagnosis/illness:


Anxiety/Depression:


PHYSICALPlease assess each area and formulate a numbered care plan if support is required in that particular area.

Washing and dressing (including mouth care):


Eating and Drinking:


Communication (including sight and vision):


Mobility and history of falls:


Footcare:


Continence:


Breathing:


Condition of skin:


Pain:


Infection risk:


Personal safety and risk:


Medication:


Sleeping:


SOCIALPlease assess each area and formulate a numbered care plan if support is required in that particular area.

Social Interest/hobbies


Daily routines Likes/Dislikes


Skills, abilities and strengths Religious, cultural and spiritual needs:

Refer to care plan no: Refer to care plan no:

END OF LIFEPlease assess each area and formulate numbered a care plan if support is required in that particular area.

Personal preferences and wishes:


Concerns:


Symptom control:


Religious, cultural and spiritual needs: Final Days:


Page 5

General Risk Assessment

Date Risk

Level of risk

(low, medium,

high)

Who may be affected?

How likely is it to occur?

How important

is the activity?

What are potential

triggers/factors?How could risk be managed? Evaluation and Comments Signature

Page 6 Page 7

Waterlow Pressure Ulcer Assessment ToolA Build/Weight for

HeightB Skin type, visual

risk areas C Continence D Mobility E Sex/Age F Malnutrition Screening Tool (MST)(Nutrition Vol 15 No 6 1999-Australia)

Average BMI = 20 - 24.9

Above average BMI = 25 - 29.9

Obese BMI = > 30

Below average BMI = < 20

BMI = wt (kg) / ht (m)2

Healthy

Tissue paper

Dry

Oedematous

Clammy, Pyrexia

Discoloured Grade 1

Broken / Spots Grade 2 - 4

Complete / Catheterised

Urinary incontinence

Faecal incontinence

Urinary / Faecal Incontinence

Fully Mobile

Restless / Fidgety

Apathetic

Restricted

Bedbounde.g. traction

Chairbounde.g. wheelchair

Male

Female

14 - 49

50 - 64

65 - 74

75 - 80

81+

A) Has patient lost weight recentlyYes - go to BNo - go to CUnsure - go to C and score 2

B) Weight loss0.5 - 5kg5 - 10kg10 - 15kg> 15 kgUnsure

C) Patient eating poorly or lack of appetiteNo Yes

NUTRITION SCOREIf >2 refer for nutrition assessment /

intervention

G Special Risks

TISSUE MALNUTRITION:Terminal cachexiaMultiple organ failureSingle organ failure (resp, renal, cardiac)Peripheral Vascular DiseaseAnaemiaSmoking

NEUROLOGICAL DEFICIT:Diabetes, MS, CVAMotor / SensoryParaplegia (max of 6)

MAJOR SURGERY or TRAUMA:Orthopaedic / SpinalOn table >2hr#On table >6hr#

# Scores can be discounted after 48 hours provided patient is recovering normally

MEDICATION:Cytotoxics, long term / high dose steroids, anti-inflammatory Max. of 4

0

1

2

3

0

1

1

1

1

2

3

0

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2

3

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1

2

3

4

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1

2

1

2

3

4

5

885

521

4-6558

12342

01

SCORE TABLE

Date A B C D E F G Total Signature

Activity Indepen-dent

One carer required

Two carers required Equipment to be used Techniques to be used Environmental

concerns

Sit to stand

Stand to sit

Standing

Walking

Getting into bed

Getting out of bed

Turning in bed

Lying to sitting

Moving wheelchair

Moving hoist

Lifting limbs

Does the manual handling pose a hazard to staff identified as ‘at risk’?Have the risks been reduced to the lowest reasonable level?

Y / NY / N

Is there a need for further assessments to reduce the risk?Do staff need any specialist knowledge or information?

Y / NY / N

Comments (including choices and opinions of the service user/advocate)

Initial review Staff signature: Date:

Review 2 Staff signature: Date:



Falls Risk Assessment

If unknown please put ‘U’ Y/N Suggested actions for YES responses

Service user fallen in last 12 months? No of falls:................ Talk to GP/Nurse about any changes in health or frequency of falls

Taking more than 4 meds? e.g. sedatives, diuretics, bp tablets Have their medicine reviewed by Pharmacist/GP

Inappropriate alcohol use? Use of alcohol to help sleep or control pain may need to be dealt with

Neurological Disease e.g. stroke Talk to GP about changes in condition. Mobility/walking aids required?

Previous fractures or osteoporosis? Talk to GP about medication/supplements for osteoporosis

Dizzy or lightheaded when lying to sitting/sitting to standing? Talk to GP/Nurse if this is a problem

Unable to get up from dining room chair without using arms? Consider exercise to improve strength and balance

Eyesight worsened in last year? Does service user need an eyetest?

Agitated or confused? Talk to GP if this is a new symptom or review periodically

Incontinence problem and trys to get to toilet? Discuss with GP/Nurse for possible solution

Trip hazards around home/in room? Eliminate trip hazards as much as possible

Poor footwear? Ensure correct size/fitting footwear. May need to see a chiropodist

Is a fear of falling preventing service user form doing tasks? Talk to GP/Nurse about management of fear if it is compromising function

Less than 3 yes responses = Low risk (Support a healthy lifestyle/consider exercise) 4 - 7 yes responses = Medium risk (Take actions as above) 8 - 11 yes responses = High risk (Take actions as above and refer to Falls Prevention Programme if available)

Initial review Staff signature: ............................................................................................................................................................

Review 2 Staff signature: .................................................................................................... ..............................................................

Review 3 Staff signature:....................................................................................................................................................................

Review 4 Staff signature:.....................................................................................................................................................................

Date: .....................................................

Date: .....................................................

Date: .....................................................

Date: ......................................................

Manual Handling

Build: ..............................................................................

Pain: ................................................................................

Sitting Balance: ..........................................................

Skin condition: ...........................................................

Standing balance: .....................................................

Other: ............................................................................

Malnutrition Universal Screening Tool (MUST) - refer to DOC Guide for BMI and Weight loss chart

Step 1 Step 2 Step 3

BMI Score Weight loss Score Acute disease effect score

BMI kg/m2

> 20 (> Obese)18.5 - 20< 18.5

Unplanned weight loss in past 3-6 months< 5 %5 - 10 %> 10 %

If service user is acutely ill and there has been or is likely to be no nutritional intake for > 5

days

Score 2

Step 4 Overall risk of malnutrition

Add scores together to calculate overall risk of malnutrition Score 0 Low Risk - Score 1 Medium Risk - Score 2 or more High Risk

Step 5 Management guidelines

0Low Risk - Routine clinical care

• Repeat screening monthly

1Medium Risk - Observe

• Document dietary intake for 3 days• If improved or adequate intake little concern;

if no improvement - clinical concern - follow home’s policy

• Weigh monthly (consider twice monthly) and recalculate % weight change over the most recent 3 - 6 months

• Note any changes in scores

2 or moreHigh Risk - Treat **

• Refer to dietitian• Improve and increase overall nutritional intak• Monitor and review care plan• Weigh monthly (consider twice monthly) and

recalculate % weight change over the most recent 3-6 months

• Note any changes in scores ** Unless detrimental or no benefit is expected from nutritional support e.g. imminent death

All risk categories:Treat underlying condition and provide help and advice on food choices, eating and drinking when necessary.

Record malnutrition risk category. Record need for special diets and follow local policy

Date Weight STEP 1

BMI ScoreSTEP 2

Weight loss score

STEP 3 Acute disease

score

Step 4 Score / Risk

Step 5Action taken Signature

= 0= 1= 2

= 0= 1= 2

+ +

Page 8

Body Chart

Please number all areas of skin damage or discolouration and list below. The action taken may also include any equipment such as a pressure mattress put in place. You may also use this chart in conjunction with the Pain Assessment (21 271) or Wound Assessment (21 272) ‘add on’.

Date No Location Description Action Taken Signature

Page 9

Personal Inventory

Clothing and shoes Medical equipment/prosthetics

Personal Possessions (TV/Radio) Valuables

Have monies been retained by service user? WARNING: Do not specify name of stone, only descriptive view including colour of ring/chains etc i.e. yellow metal or white metal.

Date:..............................................................................................................................

Staff signature:..........................................................................................................

Service user signature:...........................................................................................

Witness Name:...........................................................................................................

Witness signature:....................................................................................................

Y N

If no, who is reponsible:

Medication RecordStart Date Medication on admission Dose &

frequency Route Selfmedicate?

Stop Date Reason for change Special instructions Signature

page 12

Daily Report (Multidisciplinary)

Date Time Report Signature

A Daily Report Continuation sheet ‘add on’ is available to order: 21 270

There is a Pain Assessment (21 271) and Wound Assessment (21 272) ‘add on’ if required

When archived please record how many ‘add on’ documents were used:

DO

CU

MEN

TATION

FILING

STOR

AG

EA

CC

ESSOR

IESO

THER

S

RESP

ITE

ADMI

SSIO

NAS

SESS

MENT

&

CARE

PLA

NNIN

GDE

MENT

IA &

MEN

TAL

CAPA

CITY

INFO

RMAT

ION

DAY

TO D

AY

RECO

RDIN

GMA

NDAT

ORY

AS

SESS

MENT

S/RE

CORD

SOP

TION

AL / N

URSI

NG

INFO

RMAT

ION

DAILY

REP

ORTI

NG &

CO

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DOMI

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ARY

CARE


Page 4

Care PlanDate No Need Goal Support required Signature

I have been involved with this care plan and all my questions satisfactorily answered.

Service user/Advocate signature:

Nurse/Carer signature:

Print Name: Date:

Print Name: Date:

A Care Plan Continuation sheet ‘add on’ is available to order: 21 269



front

Pain Chart

Please number all pain sites on body chart in Respite booklet

Numeric Rating Scale (for those able to verbalise their pain)

0 1 2 3 4 5 6 7 8 9 10

No Pain Mild Pain Moderate Pain

SeverePain

Very severe pain

Worst pain possible

Score: A ‘Doloplus -2’ score of 5 or more means the service user is likely to be experiencing pain. An appropriate analgesic should be administered dependent on what the person is already/not already taking.

1. PSYCHOSOCIAL REACTIONS

Communication unchangedheightened (the patient demands attention in an unusual manner)lessened (the patient cuts him/herself off)absence or refusal of any form of communication

0123

Social Life participates normally in every activity (meals, entertainment, therapy workshop)participates in activities when asked to do so onlysometimes refuses to participate in any activityrefuses to participate in anything

0123

Problems of behav-iour

normal behaviourproblems of repetitive reactive behaviourproblems of permanent reactive behaviourpermanent behaviour problems (without any external stimulus)

0123

2. PSYCHOMOTOR REACTIONS

Washing &/or dressingusual abilities unaffectedusual abilities slightly affected (careful but thorough)usual abilities highly impaired, washing &/or dressing is laborious and incompletewashing &/or dressing rendered impossible, the patient resists any attempt

0123

Mobilityusual abilities & activities remain unaffected usual activities are reduced (the service user avoids certain movements and reduces his/her walking distance)usual activities and abilities reduced (even with help, the patient cuts down on his/her movements)any movement is impossible, the patient resists all persuasion

0123

3. SOMATIC REACTIONS

Somatic complaints no complaintscomplaints expressed upon inquiry onlyoccasional involuntary complaintscontinuous involuntary complaints

0123

Protective body pos-tures adopted at rest

no protective body posturethe patient occasionally avoids certain positionsprotective postures continously and effectively soughtprotective postures continously and effectively sought, without success

0123

Protection of sore areas no protective action takenprotective action attempted without interfering against any investigation or nursingprotective action against any investigation or nursingprotective actions taken at rest, even when not approached

0123

Expression usual expressionexpression showing pain when approachedexpression showing pain even without being approachedpermanent and unusually blank look (voiceless, staring, looking blank)

0123

Sleep pattern normal sleepdifficult to go to sleepfrequent waking (restlessness)insomnia affecting waking times

0123

Doloplus-2 Scale (Behavioural pain assessment in the elderly for those with a cognitive impairment e.g. dementia)

- Type of wound: (e.g. leg ulcer, pressure ulcer (category 1-4 EPUAP), diabetic foot ulcer etc):

- Location of the wound: Indicate location on the body map

- Factors that may delay healing (e.g. medication, steroid therapy, immunosuppressant, chemotherapy, neurological deficit, malnutrition, anaemia, diabetes, ischaemia, etc):

Dressing Allergies:

Wound Assessment

Initial Assessment Review Review Review

Dimensions (in cm): Width:

Length:

Depth:

Undermining:

Wound Bed/ Colour:

Document as a percentage %

Necrotic (black) %

Infected/Colonised (green) %

Sloughy (yellow) %

Granulating (red) %

Epithelialising (pink) %

Discoloured skin (red/purple) %

Surrounding Skin: Healthy/Intact

Oedematous/Dry/Scaly

Macerated/Excoriated

Other/Describe

Attach any photographs or maps/tracings in the service user file

WOUND ASSESSMENT CHART - (please use one chart per wound)

Care PlanDate No Need Goal Support required Signature

I have been involved with this care plan and all my questions satisfactorily answered.

Service user/Advocate signature:

Nurse/Carer signature:

Print Name: Date:

Print Name: Date:

page 12



A Daily Report Continuation sheet ‘add on’ is available to order: 21 270

There is a Pain Assessment (21 271) and Wound Assessment (21 272) ‘add on’ if required

When archived please record how many ‘add on’ documents were used:

DO

CU

MEN

TATION

FILING

STOR

AG

EA

CC

ESSOR

IESO

THER

SRESPITE







DOMICILIARYCARE

Standex Systems Ltd39 Charter Gate, Quarry Park Close, Moulton Park Industrial Estate, Northampton, NN3 6QBPhone: 01604 646 633 Fax: 01604 644 646www.standexsystems.co.uk

Contact your local business manager for a no obligation care planning consultation for your care home.

For any guidance or advice on all aspects of care planning, please contact our Nurse Advisor, Lucy Caldwell RGN on 01604 646 633

Standex Systems Ltd39 Charter Gate І Northampton NN3 6QB

Tel.: + 44 (0)1604 / 64 66 33 І Fax: +44 (0)1604 / 64 46 46Email: [email protected]

www.standexsystems.co.uk

Lucy CaldwellNurse Advisor

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