Care Services Referral Form

To access one of the Kaleidoscope Plus Group Care Services please complete this form. We will then arrange for a full assessment of need/eligibility to be undertaken.

First and Last Name
DD/MM/YYYY
Street Address Line 1
Risk to themselves
First and Last Name
DD/MM/YYYY
Click or drag a file to this area to upload.
We normally need to see copies of CPA and Risk Assessment documentation as part of our assessment process - it is helpful if you can supply this information with the completed referral form whenever possible. This will help to process the application quicker.

Information for Care Homes

2.1 New service users are admitted only on the basis of a full assessment undertaken by people competent to do so, involving the prospective service user, using an appropriate communication method and with an independent advocate as appropriate.

2.2 For individuals referred through Care Management, the registered manager obtains a summary the Care Programme Approach (CPA) for people with mental health problems – and a copy of the single Care Plan.

2.3 For individuals who are self-funding and without a Care Management

Assessment/Care Plan, the home carries out a needs assessment (meeting the person in his/her own living environment where possible) covering:

i. suitable accommodation and personal support;

ii. meaningful education, training and/or occupation;

iii. family/social contact;

iv. assessment and management of risk;

v. adequate income;

vi. cultural and faith needs;

vii. physical and mental health care;

viii. specific condition-related needs and specialist input;

ix. provision of disability equipment, including arrangements for payment and supply;

x. treatment/rehabilitation programme;

xi. method of communication; and

xii. compatibility with others living in the home.

2.4 The Service develops with each prospective service user an individual Service User Plan based on the Care Management Assessment and Care Plan or the home’s own needs assessment

2.5 Any potential restrictions on choice, freedom, services or facilities – based on specialist needs and risk and/or required by a treatment programme – likely to become part of a prospective service user’s individual Plan, are discussed and agreed with the prospective service user during assessment.

2.6 The registered nursing input required by service users in homes providing nursing care is determined by NHS registered nurses using a recognised assessment tool, according to Department of Health guidance.

2.7 Rehabilitation and therapeutic needs are assessed by state registered health professionals using regulated assessment methods.

2.8 Family carers’ interests and needs are taken into account, subject to the service user’s agreement.

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