continuing healthcare questionnaire

Care Home Payments UK Healthcare Questionnaire

Dear Sir/Madam

Thank you for choosing to complete the Care Home Payments UK Healthcare Questionnaire. Please note that completion of the Questionnaire does not obligate you to use our services. No formal relationship exists between us until both sides have entered into a written and signed contract.

If a contract is entered into we will act on your behalf to obtain NHS ContinuingHealthcare going forward and/or retrospectively obtaining NHS Continuing Healthcare.

To start the process, please return the following to our office:

1. Completed QuestionnairePlease return the completed questionnaire by email or to our office address,which can be found on the last page of the Questionnaire.

2. Proof of Authority to ActPlease send a copy of your authority to act on behalf of the patient.

For a Living Patient please send a copy of your Power of Attorney orDeputy Order.

For a Deceased Patient please send a copy of the Grant of Probate, LastWill or Letters of Administration.

After receiving the above documentation we will conduct a free assessment of the patients healthcare needs, and contact you as soon a possible.

All information provided to us will be kept strictly confidential as required under the Data Protection Act.

Yours faithfully

Care Home Payments UK

Care Home Payments UK is a trading name of Hale Homes Limited,

Registered in England and Wales with Company Registration Number 5302790.

Registered office is at Cardinal House, 20 St Marys Parsonage, Manchester, M3 2LG.

Registered under the Data Protection Act 1998 with Registration Number Z306740X 1 of 19

www.carehomepayments.co.uk

Hale Homes Limited

QUESTIONNAIRE

1. Full Name of Patient

2. Patients Date of Birth

3. Patients Date of Death(If applicable)

4. Patients NHS Number

5. Name and address of General Practitioner (GP)

6. Home address prior to going into care home

7. Have any of the following assessments taken place?

Continuing Healthcare Checklist

Continuing Healthcare Assessment (Decision Support Tool)

Nursing Care Assessment

Current or Last Prior to entering into care

Section A Patient Details

Type of Assessment Date Outcome (Eligible or Not Eligible)

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Yes NoPlease Tick


Hale Homes Limited

8. If found to be not eligible has an appeal been lodged?

9. Please state whether the Patient suffers/suffered from any illnesses or health condition.

For example: Diabetes, Epilepsy, Parkinsons disease, Dementia, Cancer, Arthritis, Stroke, Lung Disease.

Illness Date of Diagnosis

10. Has the Patient ever been detained under Section 3 of the Mental Health Act 1983?

11. If yes, please provide the date this occurred.

Please provide details of the type of appeal, such as Local Resolution or Independent Panel.

Yes No

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12. Please provide details of medical attention received by a Specialist Nurse (for exampleParkinsons, Epilepsy, Diabetic, Community, Psychiatric or Continence nurse, Dietician or any other

healthcare professional from outside the care home).

13. Please provide details of any hospitals the patient attended prior to going into care.

Name and Address of Hospital

Reason for admission Admission Date

Discharge Date

14. Do you feel the patients needs are/were complex, intense or unpredictable?

Please provide details.

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Hale Homes Limited

Section B - Care Home Details

15. Please give details of current and/or past care homes the patient has attended.

Name and Address of Care Home From: To:

1. Please give date Please give date



16. Please tick the type of home that most accurately describes the current / last home.

Residential home

Nursing home

Residential home for the elderly mentally infirm

Nursing home for the elderly mentally infirm

17. If the care home is a dual registered home, please state whether the patient has aresidential or nursing bed.

Residential Bed Nursing Bed

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18. Please confirm the amount paid per week or month for care?

19. Please confirm the total amount paid to date to the Care Home(s) for the care of thePatient.

20. How much if any, has been paid by a Deferred Payment*?

*Deferred Payment: The local authority will put a legal charge (similar to a mortgage) on thecare home residents property, and then pay the residential care fees in full. The resident is

assessed to see whether they're able to pay a weekly charge to the authority. Their ability

to pay is based on their income less the personal expenses allowance. Repayment of the

money borrowed is deferred until the property is sold or the resident dies.

/ week / month

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Section C Healthcare

21. Challenging BehaviourThis could include verbal or physical aggression, noisiness, restlessness, disruption or refusal/resistanceto care interventions.

Please tick the description that most accurately describes the patients behaviour.

Description Please Tick

No evidence of Challenging Behaviour.

Incidents of Challenging Behaviour; The patient is always compliant with care.

Incidents of Challenging Behaviour; The patient is mostly compliant with care.

Challenging Behaviour with variable compliance.

Challenging Behaviour posing a High Risk, requiring a prompt response.

Challenging Behaviour posing a Severe Risk, requiring an immediate response at all times..

Please provide below the reason(s) for your selection and describe the actual needs of the

patient, including frequency, intensity and unpredictability.

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Hale Homes Limited

22. Cognitive Impairment

Cognitive impairment could include memory loss, confusion and disorientation.

Please tick the description that most accurately describes the patients cognitive abilities.


No impairment, confusion or disorientation.

Occasional difficulty with memory and decisions

Cognitive impairment, yet the patient can make some choices regarding their care.

Frequent short-term memory issues and/or disorientation to time and place. The individual has

awareness of only a limited range of needs and basic risks.

Severe cognitive impairment including marked short-term memory issues and/or long-term

memory loss and/or severe disorientation to time, place or person.

The individual is unable to assess basic risks even with supervision, prompting or assistance.



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23. Psychological and Emotional Needs

Please tick the description that most accurately describes the patients Psychological / Emotional Needs.


Psychological and emotional needs do not have an impact on the patients health.

Anxiety symptoms or periods of distress are having an impact on health, but the patient does

responds to prompts and reassurance.

The individual has withdrawn from most attempts to engage them in support or daily activities.

The individual has withdrawn from all attempts to engage them in support or daily activities.



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24. Communication

Please tick the description that most accurately describes the patients level of communication.


Able to communicate clearly, verbally or non-verbally.

Needs assistance to communicate their needs.

Communication about needs is difficult to understand.

Unable to reliably communicate their needs at any time, and in any way.



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Hale Homes Limited

25. Mobility

Please tick the description that most accurately describes the patients mobility.


Independently mobile.

Able to weight bear but needs assistance.

Not able to consistently weight bear, but can assist with transfers and /or repositioning.

Completely unable to weight bear and unable to assist with transfers and /or positioning.

Completely immobile, where there is a High Risk of physical harm during movement/transfer.



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Hale Homes Limited

26. Eating and Drinking

Please tick the description that most accurately describes the patients ability to eat and drink.


Able to take adequate food and drink by mouth to meet all nutritional requirements.

Needs supervision, prompting with meals, or may need feeding and/or a special diet.

Unable to take any food and drink by mouth.

All nutritional needs maintained by artificial means, such as a non-problematic PEG.

Significant weight loss or gain due to identified eating disorder.

Risk of Choking.

Problems relating to a feeding device, such as a PEG, requiring skilled intervention.

All nutritional requirements taken by artificial means requiring ongoing skilled professional

intervention over a 24 hour period to ensure nutrition/hydration, for example I.V. fluids.



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27. Continence

Please tick the description that most accurately describes the patients continence.


Continent of urine and faeces.

Incontinence of urine managed through medication and regular toileting.

Continence care requires supervision due to urinary catheters, double incontinence, chronic

urinary tract infections and/or the management of constipation.

Continence care is problematic and requires timely and skilled intervention, such as bladder

wash outs and frequent re-catheterisation.



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28. Skin Condition

Please tick the description that most accurately describes the patients skin condition.


No risk of pressure damage or skin condition.

Risk of pressure damage and /or ulcers requiring intervention once a day or less.

.

Risk of pressure damage and /or ulcers requiring intervention several times a day.

Pressure damage or open wounds not responding to treatment.

Open wound(s), pressure ulcer(s) and /or multiple wounds not responding to treatment.



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29. Breathing

Please tick the description that most accurately describes the patients breathing.


Normal breathing, no issues with shortness of breath.

Shortness of breath requiring use of inhalers, which has no impact on daily living activities.

Shortness of breath requiring use of inhalers, which limits some daily living activities.

Breathlessness due to a condition not responding to treatment and limits all daily living activities

Severe breathing difficulties at rest, in spite of maximum medical therapy

Unable to breathe independently, requires invasive mechanical ventilation.



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30. Medication

Please tick the description that most accurately describes the patients use of medication.


Symptoms are managed effectively and without any problems.

Requires administration of medication but patient is compliant.

Requires registered nurse or carer to administer medication

Requires specially trained registered nurse to administer medication

Recurrent pain which is not responding to treatment.

Overwhelming pain despite all efforts to control pain effectively.



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31. Altered States of Consciousness

Altered state of consciousness is any state where the sense perceptions are different than normal. This caninclude Transcient Ischemic Attacks (TIA's) , Epilepsy and Fainting.

Please tick the description that most accurately describes the patients Altered States of Consciousness.


No evidence of altered states of consciousness (ASC).

History of ASC but it is effectively managed and there is a low risk of harm.

Occasional (monthly or less frequently) episodes of ASC that require the supervision of a

carer or care worker to minimise the risk of harm.

Frequent episodes of ASC that require the supervision of a carer or care worker to minimise

the risk of harm.



32. Other significant care needs

Please provide details of any other significant care needs.

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Hale Homes Limited

Section D - Information about you (The applicant)

33. Your Full Name

F 34. Your Full Address

35. Date of Birth

36. Relationship with Patient

37. Home Telephone Number

38. Mobile Number

39. Email address

If the patient is Living please confirm you have legal responsibility by ticking theappropriate box below and sending a copy of the document.

If the patient is deceased please go straight to Question 41.

Lasting/Enduring Power of Attorney

Court of Protection

If the patient is Deceased please confirm that you are the executor or administrator of the deceased persons estate by ticking the appropriate box below and sending a copy of the document.

Grant of Probate

Last Will

Letters of Administration

Please Tick

Please Tick

40.

41.

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Hale Homes Limited

Declaration

I DECLARE THAT THE INFORMATION I HAVE GIVEN IN ANSWER TO ALL THE QUESTIONS IN THIS QUESTIONNAIRE IS CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF.

Signed

Print name

Date

Or return by post to:

Care Home Payments UKMirwell House Carrington Lane Sale Manchester M33 5NL

If you have any queries, please contact us on: 0800 193 1965

Or email us at:

[email protected]

To submit this form by email click below

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continuing healthcare questionnaire

Documents

home address

care section

care home7

completed questionnaire

living patient

deceased patient

patients healthcare

patients date of birth3