Date of birth: Database ID:

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1 Patient : f birth: NHS CHC and Cmplex Care Service- Review Dcument All details t be cnfirmed at each review This review dcumentatin shuld be accmpanied by an anntated DST in all cases where a previus MDT assessment and meeting has been held and the DST is available. Where a previus DST is nt available please cmplete the attached NHS review dcument (Appendix 1) Please indicate type and frequency f review: CHC FNC Jint package f care 3 Mnth 12 Mnth Other: The purpse f this review is t: 1. Ensure patient needs are being met in the mst apprpriate way. 2. Ensure patient cntinues t be eligible fr NHS cntinuing healthcare (CHC) funding r Funded Nursing Care (FNC) cntributin. This requires identificatin f current needs and a cmparisn f these t the assessed needs at the time f the eligibility decisin regarding CHC r FNC funding. Please identify any changes and actins taken t ensure prvisin f care meets the needs identified in each dmain and attach any evidence t supprt current needs and interventins Patient : f Birth: Hme Address: Next f Kin Cntact Details (address and Phne number): care package / placement cmmenced: Details f existing package, including csts Current GP Cntact Details (Check at each review t cnsider Respnsible cmmissiner): Rle 1 f 8

2 Patient : f birth: Present at review /s and Relatinship Cnsent cnsideratins: Please indicate which applies. Current infrmed cnsent fr review gained frm patient Current infrmed cnsent fr review gained frm attrney/deputy N capacity t cnsent best interest prcess cmpleted Deprivatin f Liberty (DLS) / Curt f Prtectin status (please check if any recmmendatins included, if applicable) Pwer f Attrney status cnfirmed if applicable: : Health and Welfare / Prperty and Finances (please indicate) Dcuments seen: Yes / N Review Cmpleted: : Time: Perid under review: f last assessment / review: T present date: Review Cmpleted by: Designatin: Equipment in use, please state if maintenance cntracts are in place. Are there additinal equipment requirements? Hw will this be met? List f prfessinals invlved in care prvisin date last seen and utcmes: Rle 2 f 8

3 Patient : f birth: Review summary: Please include: Overall summary f patient s situatin Include details f the current care package prvided. Include details f any additinal care prvisin prvided by family members Any respite care prvisin Any incidents reprted Any safeguarding cncerns raised and utcmes Are the care needs met within the package / placement? Des the care plan reflect the Individual s needs? care plan last reviewed: Is there evidence that the care plan is being delivered effectively? Please describe Is the individual and / r family / representative satisfied with the placement and quality f care delivered? Have there been any reprted SAFA and / r incidents invlving the individual since the last review? Yes / N If yes please give details: Rle 3 f 8

4 Patient : f birth: Patient views/ Family views: Please include: Has a carer s assessment been cmpleted (if patient at hme)? If nt, is this indicated? Is referral t scial services required? Is a Persnal Health Budget (PHB) being used? If yes, indicate current status belw: Yes / N Nt currently used Ntinal Third party Direct payment. Direct payment financial declaratin frm cmpleted and returned? Yes/ N If a PHB is used please cnsider the fllwing and prvide cmments in the review summary: 1. Whether the PHB has been used in line with the agreed care plan. 2. Is the direct payment sufficient t cver the full cst f the package 3. Whether any risks have changed and are current risks managed apprpriately If PHB is nt being used please discuss and ffer t refer t Brkerage team and share leaflet Actins taken: Recmmendatins and actins frm this review: Rle 4 f 8

5 Patient : f birth: Outcme Is any immediate remedial actin required? (if yes please attach actin plan) Yes / N Please indicate utcme frm review: There has been a decrease in the level f needs since the last assessment, therefre a full assessment fr CHC eligibility is required. There has been an increase in care needs, therefre a full care review is required. There has been n change in the care needs and / r level f care required therefre full assessment is nt required Detail f changes t package, if required, including financial elements Any ther cmments: f next scheduled review: Rle 5 f 8

6 Patient : f birth: NHS Review Dcument (Appendix 1) Previus Medical Histry Present Medical Histry Hspital admissins since last review Please prvide dates f admissin and discharge t enable cntracts team t check csts. 1. Breathing: 2. Nutritin: Rle 6 f 8

7 Patient : f birth: 3. Cntinence: 4. Skin integrity: 5. Mbility: 6. Cmmunicatin: 7. Psychlgical and emtinal needs: 8. Cgnitin: Rle 7 f 8

8 Patient : f birth: 9. Behaviur: 10. Drug therapies, medicatin and symptm cntrl: 11. Altered states f cnsciusness: 12. Other significant care needs: Rle 8 f 8