Royal Borough of Kensington & Chelsea Social Services Department

NEEDS ASSESSMENT

Title: Forename: Surname:

User No:

Case Paper No./Episode No:
Case Status:

Care co-ordinator:

OT Allocated:

Worker Allocated to NA/FACE:

Other Worker 1
Team:
Worker:

Non-ASCC Workers:

User Category: Risk:
Sub Category: Band:

Does the user have a secondary diagnosis/category? Secondary Category Secondary Subcategory

Assessment Information, Dates and Approval

Assessment Start Date:

Have you had direct contact with the client (i.e. by phone/in person), or if the client is unable to speak for himself or herself, have you had such contact with their next of kin/carer?

Date of client contact

Is this Assessment hospital discharge related?

Has Assessment Information been sent/passed to User?
Enter date

Background Information

Personal Details

No Fixed Abode? Undisclosed Address?

Current Address

Sub-Premise Name/Number:
Street Name:
Town:
County:
Post Code:

Local Authority:
WARD:
PCT:

Previous Address:

Additional Premise Information (Comments):

Permanent Address

Address: Postcode:

Contact Details:

Landline:
Mobile Tel no:
Work Tel No:
Fax:
E-mail:

Date of Birth:
Gender:

Comments on contacting Client:

Is the person the responsibility of RBKC?
Select Responsible Local Authority (only if not RBKC):

Communication

Is an interpreter required?
Is other help needed with communication?

Specific Communication Needs:

Other Information

Ethnicity: Ethnic subcategory: Religion First language

Does the user consider themselves to be disabled?

ASSESSMENT

Current Services
(Community Health, CPN, SSD and Other Services (Including private), including whether user and carer think they are appropriate)

Health
(Consultant, Hospital (in/out patient), diagnosis (if known), disability, impact of Psychological/medical condition)

Daily Living Activities
(self-care, mobility, transport, language, communication, memory, motivation, interests, hobbies, lifestyle)

Does the user experience any travel difficulties?
If so, please give details

Environment
(Housing, including tenure, condition and suitability, access difficulties, harassment)

Finance, are there any special financial arrangements?
(E.g. enduring power of attorney, appointeeship, court of protection) Please give details

Are there any financial difficulties
(e.g. Debts, problems with benefit claims)

Would the user like further financial advice or a benefit check?

Has the service user been offered Self Directed Support?

Risk Factors
(consider issues of Physical safety - including self-harm; safety in the home; abuse - including exploitation, potential for violence; self neglect and danger to self and others)

Any additional information
(e.g, users emotional well-being, cultural/religious needs, personal history, social life, social networks, etc)

Is there a carer?

User's View - further statement from user
Is there anything else you would like to tell us or anything that you've already told us that you wish to emphasise?

Summary of Needs Assessment

Continuing Care agreed?:
Eligible for Services following Assessment/Review (according to FACS risk criteria)?:
Assessment Decision:
Decision Sub Category :

Team of worker completing assessment:
Worker completing assessment:

Document Completed
Signed-Off by
Signed-Off on

Comments