Name______Date of Birth______

In this section you will need to describe the actual needs of the patient. Give examples of frequency, intensity, duration and the type of intervention required. Where a Care Domain is felt to be complex or intensive give examples. In addition provide copies of Risk Assessments and Incident Forms completed as evidence of this.

Care Domain 1 - Behaviour / Assessment
Challenging Behaviour –
  • describe the nature of the behaviour e.g. verbal and/or physical

Care Domain 2 - Cognition

  • Evidence of cognitive impairment e.g. difficulties in retrieving short-term memory

Care Domain 3 – Psychological and Emotional Needs
  • Are psychological needs having an impact on the patient’s health and wellbeing

Care Domain 4 - Communication (Verbally or Non-Verbally)

Care Domain 5 – Mobility
  • i.e. mobile, immobile, weightbearing or hoist transfer
  • History of falls

Care Domain 6 – Nutrition/Food and Drink
  • Is the patient able to take adequate food and drink. do they require prompting, supervision or feeding.
Note : Give details if NBM – associated to end of life care. Give details if Artificial feeding – such as N/G, Peg, Sub Cut Fluids, IV Fluids.

Name______Date of Birth______

Care Domains / Assessment
Care Domain 7 - Continence (Urinary and Faecal)
  • is the patient incontinent of urine and faeces and how is this managed

Care Domain 8 - Skin (including tissue viability)
Note: If dressings are required give details regarding how often redress takes place and if condition is responsive to treatment. / Pressure Risk Assessment Tool & Score______

Care Domain 9 - Breathing

Care Domain 10 - Drug Therapies and Medication: Symptom Control – List of drugs.

Care Domain 11 - Altered States of Consciousness
Other Significant Care Needs

On completion of this document please return to: NHS Continuing Healthcare/NHS-funded Nursing Care Team, West Suffolk Clinical Commissioning Group, Rushbrook House, Paper Mill Lane, Bramford, Ipswich, IP8 4DE –Fax No. 01473 770202.