Appendix 1 Single Assessment Process (SAP) Single Assessment Process (SAP) Contact Form Date Title Family Name First Name Preferred Name Gender M F NHS No Agency No DOB Religion Marital status S M W Practising (tick) Ethnicity Preferred Language Other Language Interpreter needed Other communication needs Home Address Temporary Address Post Code Tel No Lives alone Lives with Relationship Tel No GP Address Post Code Tel No Hazards Access arrangements Emergency Contact Address Tel No Fax No Main Carer Tel No Tick if Carer Name Address / telephone Relationship Next of Kin Significant representatives Name No Referrer/Hospital Ward: Expected Date of Discharge Accommodation Type: Ground floor flat Tenure:
Occupation / Previous Occupation: Reason for referral /Significant history (including weight for dietetics referral): Physical: Medication: Agencies involved/contacted: Consent to share information Written Verbal Assessor Signature Print Name Job Title Assessor s Address:
Care Programme Approach Policy Single Assessment Process Person s Own Views (Overview Form) Anyone contributing to the overview should sign, print name & position and date each entry. Name Start Date of Assessment NHS No Agency No STATEMENT OF PERSON S OWN VIEWS Please tick relevant heading and complete details below Health Senses Personal Care Mobility Relationships Care of the Home Physical Well-Being Accommodation Access to Facilities Mental Well-Being Finances/legal Safety Using the person s own words, wherever possible, give details of the above The person was unable to contribute Name (relationship) has agreed to contribute to this assessment Version 1.0 October 2015 3
Health Allergy: None known Diagnosis / Past Medical History (include hospital admissions in past 12 months) Care Programme Approach Policy Medication (if on 4 or more medications, 6 monthly review recommended) Date of last medication review Type of assistance required with taking medicines Blood pressure: Blood monitoring: Bowels: Urine: Height: Weight/Diet/Nutrition: Nutrition: Breathing: Smoking: Alcohol/illegal drugs: Exercise: Skin condition: Tissue viability: Pain: Immunisation (flu): Version 1.0 October 2015 4
Personal Care (e.g. foot care, washing, dressing): Care Programme Approach Policy Mobility (e.g. transfers, risk of falls): Senses and communication (e.g. changes in speech, altered sensation in face/arms/legs) Mental Health (e.g. sleep pattern, bereavement, emotions, diagnosis by mental health specialist) First specialist mental health contact date Source of referral: Dates mental capacity assessed Specific decision making type Relationships and Carers (e.g. social integration, carers issues, leisure, learning) Carers Assessment Offered Y/N Completed Y/N Refused Y/N DOH leaflet given Y/N Version 1.0 October 2015 5
Personal and Public Safety (e.g. risks, internal/external home safety, VAP1) Care Programme Approach Policy Care of Home (e.g. daily tasks, food preparation, laundry) Access to local facilities (e.g. transport, shops, leisure & health services) Accommodation: Tenure and type of accommodation: Access to Property: Service users can open the door Front/back door Keys needed Steps inside/outside Suitability of the home Adaptations made to the property (including Telecare & environmental controls)) Have you had an Occupational Therapist assessment? Condition of the property specify any apparent safety hazards regarding structure of the property, wiring/plugs/sockets, cooking facilities, heating, others (flooring, carpets etc.). Damp. Ability to maintain the property, repairs, decorating, gardening etc. Which fuel is used to heat the accommodation? Gas Electricity Solid fuel Oil Is it centrally heated? Yes No Is the home adequately heated? Version 1.0 October 2015 6
Care Programme Approach Policy Facilities in relation to living area: Bathroom Upstairs Downstairs Same floor Shower Upstairs Downstairs Same floor Toilet Upstairs Downstairs Same floor Outside Bedroom Upstairs Downstairs Same floor Kitchen Upstairs Downstairs Same floor Finances/Legal (e.g. benefits check required, difficulty paying bills, advance statements/directive) Direct Payments Offered Y/N Requested Y/N Refused Y/N Culture / Religion (e.g. access, relevant needs, appropriate services, beliefs) Version 1.0 October 2015 7
Summary of Needs Care Programme Approach Policy Person s statement of need Risks Actions Version 1.0 October 2015 8
Care Programme Approach Policy Comments (e.g. noted disagreements, additional information) I have read / had read to me the contents of this document. I or my representative, agree that what is written here is a fair reflection of my personal situation. Person Person s Representative Relationship to person Signature Printed Name Date Representative s Address Telephone No Assessor Signature Print Name Job Title Telephone No: 0121 612-8320 Date assessment completed: Assessor s Address: Therapy & Recovery Unit Edward Street Hospital Edward St, West Bromwich, B70 Version 1.0 October 2015 9
Care Programme Approach Policy Single Assessment Process - Consent Form Person s details Title: First/given name: Date of birth: Last/family name: Gender: Statement of Practitioner Can the person understand why their information may be shared and are they able to give informed consent: [ ] Yes (complete page 2) [ ] No [ ] I am unable to judge this and have referred the matter to: [ ] No, but where possible and appropriate I have consulted with the persons representative and those involved in their care, ascertained any advance statements and I consider it to be in their best interests to share their information because: I have explained to the patient/service user: - Why we may need to share information [ ] Yes - Who we may need to share information with [ ] Yes - Their right to decline sharing some or all of the information [ ] Yes - Their right to withdraw consent to share information at any time [ ] Yes - How the information will be stored [ ] Yes Signed: Date: Name: Service/team: Location: Statement of person Please read this form carefully, if you have any concerns please discuss them with the Practitioner before you sign, they will help you. I consent / do not consent to information being shared and; - I understand why my information may need to be shared with other agencies - I understand that I may withdraw my consent to share my information at any time - I understand that I have the right to restrict what information may be shared and with whom. (Please tick box below) No restrictions [ ] Restrictions [ ] Version 1.0 October 2015 10
Care Programme Approach Policy - I understand that these restrictions will be recorded and acted upon accordingly. Restrictions: Signed: Date: A witness should sign below if a competent person is unable to sign but has indicated consent. Signed: Date: Name: Relationship: Statement of Lasting Power of Attorney / Deputy (personal welfare) The person does not have the mental capacity to give consent. I have the legal power to make this decision, and in accordance with the Mental Capacity Act Code of Practice and any advance statement of the person, I sign below that I agree this is in the persons best interests, with any restrictions identified above. Signed: Date: Name: Relationship: Version 1.0 October 2015 11