Pre-Admission Self-Assessment

Step 1 of 13

Your details

We understand that filling out these forms can be tiring and frustrating. If you need to take a break and come back, you can always save and continue later. We'll only hold your personal details for 14 days, after which it'll be deleted for your security.

Title

Date of birth

Name

First Last

CHI/NHS number:

Telephone number

Email address

Address

Street Address Address Line 2 City Postcode

Social worker details

Social worker's name

First Last

Social worker's address

Street Address Address Line 2 Postcode

Local authority(Required)

Duty social work contact number

Social worker email address

GP details

GP title and name

GP address

Street Address Address Line 2 Postcode

GP telephone number

District nurse details

Name

Distruct nurse address

Street Address Address Line 2 Postcode

Specialist services (relevant health professionals e.g. MS, MND, OT, PHYSIO)

Name

Specialist service

Service address

Street Address Address Line 2 City Postcode

Next of kin - Emergency contact 1

Title

Relationship

Name

Address

Postcode

Phone

Mobile

Next of kin?

Yes

Emergency contact

Yes

Next of kin - Emergency contact 2

Title

Relationship

Name

Address

Postcode

Phone

Mobile

Next of kin?

Yes

Emergency contact

Yes

Current medical condition

Medical history

Medications currently used

Creams used

Drug allergies

Food allergies

Can the current prescription script be sent along with medications?

Do you smoke?

Yes

If yes, can you smoke independently (light it, hold it, stub it out etc)?

Yes

Do you vape?

Yes

Please note: no smoking or vaping is allowed inside Leuchie House.

Do you drink alcohol

Yes

If yes, how often?

NB please ensure that any medicine brought to Leuchie House is either in a Monitored Dosage System (MDS), Dosette blister pack from a Pharmacy or in an original pharmacy pack/bottle With Name, medication name, and dose to be given. Time to be given. We are unable to make any amendments to any medication and have to follow the Pharmacy labels at all times.

Do you suffer from Epilepsy/fits?

Yes

If yes please comment on any triggers, what happens, and what your treatment is.

Are you diabetic?

Yes

Is you diabetes insulin controlled?

Yes

If yes, please state what your insulin regime plan is:

If no, please give details of your treatment and how it is managed:

Do you require rescue medication?

Yes

If yes, please provide an up to date epilepsy rescue plan:

Mobility

Current weight:

Current height:

Do you use a wheelchair?

Yes

If not, please skip the following part.

Main wheelchair

type

Manual

Electric

Make, model and approximate age

Main use (e.g. outdoors, where it needs to go in a car)

NHS funded or private purchase

NHS

Private

How is it controlled?

Self propelled

Attendant controlled

Both

Do you have a pressure relieving cushion? If so, please state the make

Do you have any extra supports e.g. head rest, lateral supports, pommel etc. Please list them

Can it be used to transport you in a vehicle?

Yes

What other mobility equipment do you use regularly?

Are you able to transfer independently (for example from bed to chair)?

Yes

If no, what transfer aids do you use? (For example, stand turner, stand hoist, full hoist – give the make if possible)

Have you had any falls in the last five years?

Yes

If yes, please give brief details.

Have you had any NHS or private therapy at home in the last two years?

Yes

If yes, please give brief details.

How active are you? Do you take part in any formal exercise?

Yes

Please give brief details.

Do you use therapeutic/exercise equipment at home (or in day groups etc)?

Yes

If so, what and how regularly?

Do you currently have any concerns about your mobility?

Yes

If yes, please give brief details.

Personal care

Do you need assistance with washing and dressing?

Yes

Please give details of assistance required:

Do you need assistance with oral care?

Yes

How often do you wish to have a shower/bath whilst at Leuchie?

Approximately what time would you like to get up in the morning at Leuchie?

Approximately what time would you like to go to bed at Leuchie?

How long, approximately, is your evening personal care routine?

Is there any other aspect of your personal care you would like us to assist with?

Yes

Hair styling, make up, shaving etc. Please give details of assistance required:

Night time care

Do you normally sleep well?

Yes

Would you like staff to check you overnight?

3AM

6AM

Both

None

If you require additional checks please provide details:

Do you wish to have positional changes overnight at Leuchie?

Yes

Please give details of positional change routines:

Do you use a CPAP machine to aid breathing overnight?

Yes

What kind of mattress would you like to use at Leuchie?

Soft form

Repose

Full air mattress

Do you use grab bars on the bed?

Yes

If yes, which side of the bed:

Do you have any special requirements of how you like to be positioned in bed?

Yes

Please give details of position requirements:

Do you normally use the toilet overnight?

Yes

Please give details of routine and assistance required.

Any equipment required? (bed pan, urine bottle, commode):

Continence

Are you fully continent (not requiring the use of a catheter)?

Urine

Yes

Bowels

Yes

Do you have a catheter?

Yes

If yes, which type:

Supra-pubic

Urethral

Size

Date of last change

Are there any problems surrounding your catheter we should be aware of?

Yes

If yes, please provide details:

Do you regularly use a catheter maintenance solution?

Yes

If yes, please provide details:

Can you access and use the toilet independently without staff assistance?

Yes

Do you use continence pads?

Yes

If yes, please provide details of products and routine for changing:

Do you use any continence aids such as a sheath/ileostomy/urostomy/colostomy?

Yes

If yes, please provide details:

Do you require assistance with these continence aids?

Yes

If yes, please provide details:

Have you had a review from your continence nurse?

Yes

If yes, please provide details:

Are you susceptible to UTIs?

Yes

Have you had urosepsis?

Yes

Skincare & Skin Wounds

Is your skin intact at the moment?

Yes

Do you have any bruising/marks on your skin that need treatment?

Yes

If yes, please provide details:

Do you have any wounds that require dressing?

Yes

If yes, please give details on wound area, dressings regime and products used:

Does the district nurse visit to provide wound care?

Yes

If yes, please provide a copy of your wound care plan:

Do you use creams for any areas of your skin?

Yes

If yes, please provide details of creams and where these should be applied:

Do you require a change of position during the day for pressure relief?

Yes

If yes, please provide details:

Do you require assistance with eating at drinking?

Yes

If yes, please give details:

Do you use any adaptive aids such as plate guard/adapted cutlery/beaker with a lid?

Yes

If yes, please give details:

Do you have swallowing difficulties?

Yes

Do you experience episodes of choking?

Yes

Have you been assessed by a speech and language therapist for swallowing?

Yes

Please note if this is yes, a copy of these guidelines is required at assessment stage.

Do you require a soft/moist/pureed diet?

Yes

Please give details of any food allergies.

Do you require thickener to your fluids?

Yes

Are there any foods you should not eat such as a food allergy?

Yes

If yes, please add comments:

Do you follow any specialised diets such as low sugar, gluten free, dairy free etc.?

Yes

If yes, please give details:

What foods do you like to eat?

What foods do you dislike to eat?

What drinks do you like and how do you like them made?

Are you fed or given fluids via a PEG? (a feeding tube)

Yes

Please add comments:

If yes, please add details

CENTRE FOR ENABLING TECHNOLOGY

Currently we offer 1-1 digital skills support if you need help using your phone, tablet or other technology. We can help you learn about operating these devices through your voice and/or using a switch. We will give presentations of the technology we have available to demo and trial during your stay at Leuchie, including Amazon Alexa smart speakers, Environmental controls, Ring doorbell, smart light bulbs and technology mounts/cushions.

Enabling Technology

Do you have or use any voice activated speakers (ie Alexa, Google) at home?

Yes

If yes, what do you use them for?

Do you have an Environmental Control System at home?

Yes

If so, what do you use it to control ie. door, phone, TV, bed, chair and call system? Who funded and set up the system?

Do you have a good memory?

Yes

If so please describe what you need help with.

Memory / emotions / understanding / communication

Do you have a good memory?

Yes

Do you have support methods to help with your memory?

Yes

Please comment:

Do you understand and can make your own decisions?

Yes

Please comment:

Do you have any problems with your speech?

Yes

Please comment:

Do you have any communication difficulties?

Yes

Please comment:

Do you use any support methods/communication aids?

Yes

Please comment:

Do you experience any mental health difficulties?

Yes

Please comment:

Where in your body do you experience pain?

Yes

Please comment:

On a scale of 1-10 please tick (1 being not much pain – 10 being in a lot of pain)

Please enter a number from 1 to 10.

How can we assist with your pain management?

What makes you fatigued?

How can we assist with your fatigue management?

Do you have any social, emotional or behavioural needs that requires frequent staff support?

Yes

If no please give details on who should make these decisions:

Consent and declaration: all consent boxes must be completed

DNACPR:(Required)

Yes

If you have a DNACPR in place please bring the original copy. This will be returned to you when you leave.

POA:(Required)

Yes

If you have an incapacity form or guardianship with power of attorney for welfare and finances, please enclose copies of these forms.

Consent to have photographs taken:

These may be used for marketing literature and for newsletters, are you happy for it to be used in this way?(Required)

Yes

Can we use your name with the photo?(Required)

Yes

Do you consent to photographs being taken for nursing purposes i.e. pictures of wounds?(Required)

Yes

Consent to share information with health care providers:(Required)

Yes

Consent to share person data with organisations associated with health and social care where it is considered there may be potential benefit of my or others health and social care, e.g. doctor, hospitals, local authorities, podiatrist and that I consent for the data to be used securely for 8 years after I leave the service or longer if the Law requires it.

Consent to care provision as detailed in your care plan:(Required)

Yes

Consent to care provision by Leuchie House as detailed in your care plan. Leuchie House will use the information provided in this form and from your admission to compile a care plan which is individualised to your care needs.

We would like to keep in touch by adding you to our email mailing list to keep you up to date with Leuchie news and events and to tell you more about ways you can support Leuchie. If you are happy to receive emails from us, please tick this box.(Required)

Yes

Do you have capacity to make decisions on treatments/therapies such as podiatry, Massage and hairdressing?(Required)

Yes

Please comment:

Leuchie’s Guest Wi-Fi has a set of restrictions in place by default, drawn from 2 sources: The Law Any categories that covers anything illegal in the UK. Regulator Any categories suggested by the Care Inspectorate. Any concerns regarding internet access should be noted here or discussed with us. Concerns regarding internet access: We can restrict internet access on Leuchie iPads further during your stay to remove access to the following categories: gambling, alternative beliefs, nudity and risqué and lingerie and swimsuit. You will still have access to regular guest Wi-Fi on your own devices.

Please check here if you would like to have these additional restrictions applied during your stays with us.

Religion

Practising?

Yes

Do you require assistance to practice your religion while at Leuchie House?

Yes

Do you wish to use the laundry?

Yes

If yes, please ensure that clothes are named or initials placed on the labels.

BLUE MOBILITY BADGE: Do you own a blue badge?

Yes

If yes, bring it to Leuchie House to use for the duration of your stay.

DATA PROTECTION:

Leuchie House will not use or process personal information in any way that contravenes its notified purposes or in any way that would constitute a breach of Data Protection Law. Any new purposes introduced will, where appropriate, be notified to the individual and, if required by law, their consent will be sought. Confidential data, as above, is held under additional security controls.