Co-ordinate-My-Care for Residents in Care Homes

New Resident Change in circumstances

Please confirm that the ‘Information for patients and their carers’ has been given to the NOK/resident

YES NO

Please indicate method of authorisation you have to share this patient's information electronically?

Resident agrees to the creation of a Personalised Urgent Care Plan;the sharing of the care plan with legitimate health and social care providers, and administrative staff as necessary;and to secondary use of their anonymised data for audit and research.

Write full name of staff member obtaining verbal consent …………………………………………………………………………………...

OR

Resident lacks mental capacity but a clinical decision has been made in their ‘best interests’ toshare their

end of life care information. This hasbeen discussed with the following NOK who gives their permission.

Write full name of NOK who gives their permission

…………………………………………………………………………………….

NOTE if present the Lasting Power of Attorney for Health and Welfare must give consent.

OR

Consent given by appointed person with lasting power of attorney for health and welfare (MCA 2005) for

sharing end of life care information. Please supply name:

Please confirm you have a copy of the LPA for health and welfare in the care home? YES

Has the resident/family member requested a copy of the CMC record? YES NO

Resident’s details: / Care Home:
Title: / Surname: / Address:
Post Code:
Preferred name: / Forename:
Gender: / DOB:
Religion: / NHS Number: / Tel:
Ethnicity: / Preferred language: / Fax:
Does the resident have Next of Kin? Yes No Not Known
Name: / Relationship:
Address: / Telephone Number (s):
Lasting Power of Attorney (property and financial) Yes No Don’t Know
If yes, givedetails………………………………………………………………
Lasting Power of Attorney (Health and Welfare) without authority for life sustaining decisions
Yes No Don’t Know If yes, give details……………………………………………………………
Lasting Power of Attorney (Health and Welfare) with authority for life sustaining decisions
Yes No Don’t Know If yes, give details……………………………………………………………

If yes, please confirm that you have given them a copy of the CMC record? YES

GP surgery
Name of GP:
Telephone: / Fax:

Diagnosis (please circle all that apply)

Cardiac / Angina; Atrial Fibrillation; Congestive Cardiac Failure; Ischaemic Heart Disease; Left Ventricular Failure; Myocardial Infarction
Other – please specify:
Dementia / Alzheimer’s; Lewy Body;
Vascular; Unspecified / Elderly / Frail
Endocrine / Adrenal Disorders; Diabetes Type 1; Diabetes Type 2; Hyperthyroidism; Hypothyroidism; Pituitary Disorders
Other – please specify:
Neurological / Epilepsy; Motor Neurone Disease; MS; Parkinson’s Disease
Other – please specify:
Renal / Acute Kidney Injury; Chronic Renal Failure (CKD); End Stage Renal Failure; UTI
Other – please specify:
Respiratory / Asthma; Bronchitis (chronic); COPD; Emphysema; Pneumonia
Other – please specify:
Vascular / Hypertension; Hypotension; Peripheral Vascular Disease; Stroke/Cerebrovasacular Accident – all; Transient Ischaemic Attack
Other – please specify:
Cancer / Please state type:
Other

Is resident aware of their diagnosis / condition? YesNo Don’t Know

Is next of kin aware of diagnosis / condition?YesNo Don’t Know

Prognosis/Coding (please circle): A/Blue/Years B/Green/Months C/Yellow/Weeks D/Red/Days

Date: Estimated by (name):

Is resident aware of prognosis Yes Not able to discuss Not yet discussed with the resident

Resident not wanting to know this information

Is the family aware of prognosis? Yes Not yet discussed with family/carer

Does the resident have any disabilities?

Hearing loss / Mental impairment / Lacks safety awareness
Visual impairment / Other disabilities / Unable to summon help in an emergency
Communication difficulties / No known disability / Person reports no current disability

World Health Organization (WHO) Performance Status: Date of WHO assessment __/__/201_

(How does the resident generally function?)

1 – Cannot carry out heavy physical work lifting but can do anything else

2 – Up and about for more than half the day, you can look after yourself but not able to go to work

3 – In bed /chair for more than half the day and will need some looking after

4 - In bed / chair all the time and will need a lot of looking after

Resident/NOK preferences:

Resident’s Preferred Place of Care: Care Home Hospice Hospital Not yet discussed

Resident not able to discuss Resident not wanting to state preference Other……………………………………

Resident’s Preferred Place of Death: Care Home Hospice Hospital Not yet discussed

Resident not able to discussResident not wanting to state preference

Other……………………………………

Cardiopulmonary Resuscitation (CPR) discussion:

Has resuscitation been discussed with resident? Yes Not yet discussed Resident not able to discuss

Resident not wanting to discuss

Has resuscitation been discussed with family? Yes Not yet discussed Family not wanting to discuss

No family / carer to discuss with

Should cardio-pulmonary resuscitation commence?Yes Not yet discussed No

Date decision made:…………………………………

Who made this decision………………………………

Is a signed Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) order in the home? Yes No

**(Please fax a copy with this CMC form)

Detail location ……………………………………………………………………….

Emergency Treatment plan

Ceiling of treatment if further deterioration (please tick one relevant box below):

Full, active treatment including CPR

Full, active treatment including admission to hospital

Treatment of any reversible conditions including hospital setting if needed but not for any ventilation or CPR

Treatment of any reversible conditions but only in a home/hospice setting – keep comfortable

Symptomatic treatment only – keep comfortable

Is the resident known to a hospice community palliative care team? YES NO

COMMUNITY CONTACTS e.g.: District Nurses / Hospice /Palliative Care Contacts

Name / Organisation Name / Telephone No. / Mobile No.

If resident is in their last 2 weeks of life please state date,the Doctor’s name and the date that Dr last reviewed:

Name:

Date: __/__/201_

Is there a Statement of Preferences / Wishes re treatment? Yes No Don’t Know Not yet discussed

(Also known as Advance Care planning)

Check if there is a PEACE plan? Yes No Don’t Know Not yet discussed

Is there an Advance Decision to Refuse Treatment? Yes No Don’t Know Not yet discussed

**Please fax a copy of the ADRT with this CMC form

Has the resident expressed any wishes for organ or tissue donation? Yes No Don’t Know

If yes, give details or fax a copy of the documentation ………………………………………………

(NHS donor line 0300 1232323 – 24hr number)

MEDICATION

Allergies: No

Yes Details of allergies …………………………………………………………………………..

We do not know if they have any allergies

Has the resident been prescribed opioids for use now? (For example: Morphine). YesNo

Please give details …………………………………………………………………………………………

If yes, are the opioids currently being administered? YesNo

Have emergency drugs been left in the home Yes (please detail below) No

(Please be aware there should be a dated prescription for these drugs).

Drug name / Route

Is a syringe pump / syringe driver:Currently in useNot needed at present Needed

Where can a syringe pump / syringe driver be located, if needed?

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Name of staff completing form: ………………………………. Designation: ...…………………… Date: __/__/2016

Manager’s Approval: Name……….……………………………Signature …………………………Date: __/__/2016

CMC checklist

Please ensure all sections are completed as fully as possible.

In particular, please check you have:

Completed the consent section at the start of the form
Supplied patient’s name, DOB and NHS number
Completed the diagnosis section
Completed the prognosis / coding
Completed the disabilities section
Completed the WHO assessment
Indicated patient’s PPC and PPD
Completed the Cardiopulmonary resuscitation section
If the patient has a DNaCPR order, have you faxed a copy with the form?
Completed the allergy section
Signed and dated the form at the end

THANK YOU

Coordinate-My-Care for Residents in Care Homes – Updates
Care plans should be reviewed every 3 months. If there has been no change in the resident’s circumstances, please complete, sign and date this sheet.
If there has been a change, please complete a revised Co-ordinate-My-Care form.
Please fax completed updated sheets, or revised forms to 020 8778 6049
Resident’s name: / DOB: / NHS No.:
Resident’s DOB: / Gender:
Care Home: / Tel.:
We have reviewed the urgent care plan for the above resident and can confirm that there have been no changes in circumstances.
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Name of staff completing form: ……………………………………………………………………
Designation: ...…………………… Date: __/__/2016
Manager’s Approval: Name……….………………………………………………………………
Signature …………………………Date: __/__/2016

Please fax form to 020 8778 6049

AFTER DEATH INFORMATION

Resident’s details: Name of Care Home

Title: Address:

Surname:

Forename:

Gender:Post Code:

Resident ethnicity: Tel:

DOB:Fax

NHS number:

Date of Death: __/__/2016

Place of Death:

Was preferred place of death (PPD) achieved? Yes No

Reason for not achieving PPD- please indicate from list below;

Resident changed mind

Family changed mind

Care package breakdown

Hospice bed not available

Sudden deterioration/ sudden death

Other, please specify:

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Name of staff completing form………………………………. Designation...…………………… Date: __/__/2016

RESIDENT’S NAME:

DOB: