Download Assessment Document - Families Information Service (FIS) and

Name:
DOB:
NHS DONCASTER CLINICAL COMMISSIONING GROUP
CHILDREN’S CONTINUING CARE (DECISION SUPPORT TOOL)ASSESSMENT
DOCUMENT
DETAILS OF CHILD / YOUNG PERSON
Child / Young Person Name:
DOB:
NHS Number:
Permanent Address:
Current Address (if applicable):
Telephone Number:
School Details:
Parental responsibility status:
Ethnicity:
Mother:
Father:
First Language:
Is an interpreter required?
Name & address of nursery/school/college
Parent / Carers Full Names:
Relationship: mother
Contact Number:
Address if different from above
Relationship: Father
Contact Number:
Address if different from above:
ECHP Domain
Funding
Stream
Health
Continuing
Care
Aiming High
DP/Sessional
SEND
Social Care
Current Package of Care
(Total hours allocated
provision/name of provider)
Start
Date
Last
Review
Date
Education
Any additional
care provider
Date assessment request received from Doncaster CCG:
Date of Completion of assessment:
Initial Assessment/ Review assessment
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Name:
DOB:
Completed by:
Designation:
Telephone contact:
Date assessment submitted to Doncaster CCG:
Decision Panel date:
PERMISSION TO SHARE INFORMATION
The information recorded during this assessment may be shared with others involved in
your child’s care assessment and will be used for consideration of your child’s eligibility
for NHS Continuing Care.
Do you and your child give consent for information of your child,
recorded during this assessment, being shared with other involved
in your care?
Yes
No
Is there any specific information about your child you would NOT
wish to be shared? (please give details below):
INFORMATION NOT TO BE SHARED:
Yes
No
Are there any agencies or individuals with whom you would NOT
wish information about your child to be shared? (please give details Yes
below):
INFORMATION NOT TO BE SHARED:
Service user / patient able to give consent? (please give details
below in respect to Fraser Competent):
Signature of service use / patient or their representative Parental
responsibility:
Name:
Relationship:
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Yes
No
No
Date:
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Name:
DOB:
NHS CHILDREN’S CONTINUING CARE ASSESSMENT DOCUMENT
HEALTH HISTORY
Relevant Medical History including primary and secondary diagnosis
 Dates of significant health events and current health status
 Previous diagnosis, Current diagnosis, Allergies, Previous admission (including when
and where), etc.
 Any recent changes including any improvement or deterioration
FAMILY CIRCUMSTANCES
Include the family structure



Has a social care assessment been made? Yes/No
Support received from the family circle [relations &friends], do any siblings have health
or care needs
Parent/carers occupation, effect of child’s condition on the parents ability to work

HOUSING
Housing – issues, adequacy, include adaptation requirement assessments

EDUCATION, PLAY & LEISURE
Recreation & leisure what are their interest and are they able to choose and
participate

Education/Play & Learning ability to access recreation and education able to access
curriculum, what provision is in place to support continuity of learning. If the child is too
ill to access a setting , what other provision is in place to ensure continuity of learning?
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 Transport - issues & adequacy

Views and aspirations of child/young person – issues, concerns, anxieties,
preferences about care deliver
Is the child / young person attending school Y/ N
Does the child have :
a Statement of Special Educational Need or
Education Health Care Plan?
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Name:
DOB:
NHS CHILDREN’S CONTINUING CARE ASSESMENT DOCUMENT
EQUIPMENT IN PLACE:
SUPPLIED BY:
1.Disposable equipment
2.Permanant equipment
1.
2.
EQUIPMENT OUTSTANDING:
TO BE SUPPLIED BY:
1.
1.
TREATMENT NEEDS:
Symptom management
Are there times when specific interventions
are required?
Is an assessment required by another
service?
CARE NEEDS
Interventions who provides and monitors care
plans?
What is the 24hr daily care routine
TRANSITION
( Age 14 and over)
Has transition commenced?: YES/NO
Please include Future plans for:
 education,
 accommodation package including whether they can be assisted to achieve
independent living
 will their parent/carer need extra emotional and/or practical support
Has the Adults Continuing Healthcare referral and assessment been completed? Y/N
If so when and what is the outcome?
If no please make referral at aged 16+
Name & contact details of Lead Professional for transition:
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Name:
DOB:
NHS CHILDREN’S CONTINUING CARE ASSESSMENT DOCUMENT
PROFESSIONALS AND SERVICES INVOLVED IN THE CARE
Contact Number:
GP:
Location:
Consultant :
Contact Number:
Location:
Community Paediatrician:
Contact Number:
Location:
Psychologist:
Contact Number:
Location:
Community Children’s Nurse :
Contact Number:
Location:
CAMHS:
Contact Number:
Location:
Health Visitor or School Nurse:
Contact Number:
Location:
Social Worker:
Contact Number:
Location:
Occupational Therapist:
Contact Number:
Location:
Speech and Language Therapist:
Contact Number:
Location:
Physiotherapist:
Contact Number:
Location:
Other Therapist:
Contact Number:
Location:
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DOB:
Teacher:
Contact Number:
Location:
Short Break Services:
Contact Number:
Location:
Other
Contact Number:
Location:
Lead Professional / Key Worker:
Contact Number:
Location:
MULTI AGENCY ASSESSMENTS
Please list any assessments that have been undertaken:
Type of Assessment
Completed By
Date of Completion
MULTI AGENCY REFERRALS
Please list any referrals made that are outstanding:
Type of Referral
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Made to
Date of Referral
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Name:
DOB:
NHS CHILDREN’S CONTINUING CARE ASSESSMENT DOCUMENT
Challenging Behaviour
Culturally abnormal behaviours of such intensity, frequency, or duration that the physical safety
of the person or others is likely to be placed in jeopardy or behaviour which is likely to seriously
limit use of or result in the person being denied assess to ordinary community facilities.
A specialist assessment of an individual with serious behavioural issues will usually be required
which included an overall assessment of the risk(s) which are likely to impair a child’s growth,
development and family life.
Describe the actual needs of the individual, including any episodic needs, such as the
times and situations which the behaviour is likely to be performed across a range of
typical daily routines and the frequency, duration and impact of the behaviour.
 Identify the child’s concerns & anxieties
 What is the effect of the persons condition on each member of the family
 Consider levels of cognitive impairment & communication overlap here
Provide the evidence that informs the decision overleaf on which level is appropriate.
This will include behaviour charts and school reports, incident logs, etc to support this
domain.
Circle the assessed level overleaf.
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Name:
DOB:
NHS CHILDREN’S CONTINUING CARE ASSESMENT DOCUMENT
Challenging Behaviour
Description
No incidents of behaviour which challenge
parents/carers/staff
Some incidents of behaviour which challenge
parents/carers/staff but which do not exceed behaviours for
age or stage of development and which can be managed in
mainstream services ( e.g. early years support, health visiting,
school)
Occasional challenging behaviour which are more frequent,
more intense or more unusual than those expected for age or
stage of development, which are having a negative impact on a
child and their family/everyday life:
Level of
Need
No additional
needs
Low
Moderate
Regular challenging behaviours such as aggression (hitting,
kicking, biting, hair pulling) destruction(ripping clothes,
breaking windows ,throwing objects),self-injury (head
banging, self-biting, skin picking) or other behaviours(running
away, eating inedible objects) despite specialist health
intervention and which have a negative impact on the child
and their family/everyday life .
High
Frequent, intense behaviours such as aggression, destruction,
self-injury, despite multiagency support, which have a
profoundly negative impact on quality of life for the child and
their family, and risk exclusion from the home or school
Behaviours of high frequency and intensity despite intense
multiagency support, which threaten the immediate safety of
the child or those around them and restrict every day
activities (e.g exclusion from school or home environment)
Severe
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Supporting
Reports
Priority
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Name:
DOB:
NHS CHILDREN’S CONTINUING CARE ASSESSMENT DOCUMENT
Communication
This section is related to difficulties with receptive and expressive language, both verbal and
non-verbal, or technology assisted that is not commensurate with age and developmental
milestones. It does not include those children that do not speak English as their first language
but are able to communicate in other languages.
Describe the actual needs of the individual, including any episodic needs. Provide the
evidence that informs the decision overleaf on which level is appropriate, including the
frequency and intensity of need, unpredictability, deterioration and any instability.
Circle the assessment level overleaf.
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Name:
DOB:
NHS CHILDREN’S CONTINUING CARE ASSESSMENT DOCUMENT
Communication
Description
Able to understand or communicate clearly, verbally or nonverbally within their primary language, appropriate to their
developmental level. The child / young person’s ability to
understand or communicate is appropriate for their age and
developmental level within their first language.
Level of
Need
Supporting
Reports
No additional
needs
Needs prompting to communicate their needs. Special effort may
be needed to ensure accurate interpretation of needs, or may
need additional support visually, either through touch or with
hearing.
Family / carers may be able to anticipate needs through nonverbal signs due to familiarity with the individual.
Expressive or receptive language.
Low
Communication of emotions and fundamental needs is difficult to
understand or interpret, even when prompted, unless with familiar
people, and requires regular support. Family/carers may be able
to anticipate and interpret the childs needs due to familiarity
Moderate
Support is always required to facilitate communication, for
example, the use of choice boards, signing and communication
aids.
Ability to communicate basic needs is variable depending on
fluctuating mood; or the child / young person demonstrates
severe frustration about their communication, for example,
through challenging behaviour or withdrawal.
Even with frequent or significant support from family / carers and
professionals, the child / young person is rarely able to
communicate basic needs, requirements or ideas,.
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High
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NHS CHILDREN’S CONTINUING CARE – DECISION SUPPORT TOOL DOCUMENT
Mobility
Describe the actual needs of the individual, providing the evidence that informs the
decision overleaf on which level is appropriate.
Assessments should be submitted along with any therapy assessments / reports.
Describe the frequency and intensity of need, unpredictability, deterioration and any
instability.
Circle the assessed level overleaf.
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Name:
DOB:
NHS CHILDREN’S CONTINUING CARE ASSESSMENT DOCUMENT
Mobility
Description
Mobility typical for age and development.
Able to stand, bear their weight and move with some
assistance, and mobility aids
Difficulties in standing or moving even with aids: although
some mobility with assistance
Or
Sleep deprivation ( as opposed to wakefulness) due to
underlying medical related need (muscle spasms, dystonia)
occurring three times a night, several nights per week.
Or
Unable to move in a way typical for age; cared for in a single
position, or a limited number of positions ( e.g. bed
supportive chair) due to the risk of physical harm, loss of
muscle tone, tissue viability or pain on movement, but is able
to assist
Unable to move in a way typical for age; cared for in single ,
or a limited number of positions (bed or supportive chair) and
due to risk of physical harm, loss of muscle tone, tissue
viability, or pain on movement; needs careful positioning and
is unable to assist or needs more than one carer to reposition
or transfer;
Or
At a high risk of fracture due to poor bone density, requiring a
structured management plan to minimise risk, appropriate to
stage of development;
Or
Involuntary spasms placing themselves and carers at risk;
Or
Extensive sleep deprivation due to underlying medical /
mobility related needs, occurring one to two hours (and at
least four nights per week).
Completely immobile and unstable clinical condition such that
on movement or transfer there is a high risk of serious
physical harm;
Or
Where positioning is critical to physiological functioning or life.
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Level of
Need
No
additional
needs
Supporting
Reports
Low
Moderate
High
Severe
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Name:
DOB:
NHS CHILDREN’S CONTINUING CARE ASSESSMENT DOCUMENT
Nutrition, Food and Drink
Describe the actual needs of the individual, providing the evidence that informs the
decision overleaf on which level is appropriate. Including the frequency and intensity of
need, unpredictability, deterioration and any instability.
Circle the assessed level overleaf.
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Name:
DOB:
NHS CHILDREN’S CONTINUING CARE ASSESSMENT DOCUMENT
Nutrition, Food and Drink
Description
Level of
Supporting
need
Reports
Able to take adequate food and drink by mouth, to meet all
No additional
nutritional requirements. Typical for their age.
needs
Some assistance required above what is appropriate for their age;
Low
Or
Needs supervision, prompting and encouragement with food and
drinks above their typical requirement for their age;
Or
needs support and advice about diet because the underlying
condition gives greater change of non-compliance, including
limited understanding or the consequences of food or drink intake;
Or
Needs feeding, when this is not typical for age, but is not time
consuming or not unsafe if general guidance is adhered to
Needs feeding to ensure safe and adequate intake of food;
Moderate
feeding (including liquidised feed) is lengthy; specialised feeding
plan developed by speech and language therapist;
Or
unable to take sufficient food and drink by mouth, with most
nutritional requirements taken by artificial means, for example, via
a non problematic tube feeding device, including nasogastric
tubes.
Faltering growth, despite following specialised feeding plan by a
High
speech and language therapist and/ or dietician to manage
nutritional status;
Or
dysphagia, requiring a management plan developed by speech
and language therapist and multidisciplinary team, with additional
skilled intervention to ensure adequate nutrition or hydration and
to minimise the risk of choking, aspiration and to maintain a clear
airway (or example, suction);
Or
problems with intake of food and drink, (which could include
vomiting) requiring skilled intervention to manage nutritional
status; weaning from tube feed dependency and/ recognised
eating disorder, with self-imposed dietary regime or self-neglect,
for example, anxiety and/ or depression leading to intake
problems placing the child / young person at risk and needing
skilled intervention;
Or
problems relating to a feeding device(e.g. nasogastric tube) which
require skilled risk assessment and management plan undertaken
by a speech and language therapist and multidisciplinary team
and requiring regular review and re assessment. Despite the plan,
there remains a risk of choking and review.
The majority of fluids and nutritional requirements are routinely
Severe
taken by intravenous means.
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Name:
DOB:
NHS CHILDREN’S CONTINUING CARE ASSESSMENT DOCUMENT
Continence and Elimination
Where continence problems are identified, a full continence assessment should be undertaken,
any underlying conditions identified and the impact and likelihood of any risk factors evaluated.
Describe the actual needs of the individual, providing the evidence that informs the
decision overleaf on which level is appropriate. Including the frequency and intensity of
need, unpredictability, deterioration and any instability.
Take into account any aspect of continence are associated with behaviour in the
behaviour domain.
Circle the assessed level overleaf.
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Name:
DOB:
NHS CHILDREN’S CONTINUING CARE – DECISION SUPPORT TOOL DOCUMENT
Continence and Elimination
Description
Continence care is routine and typical of age
Incontinent of urine but managed by others means, for example,
medication, regular toileting, pads, use of penile sheaths;
Or
Is able to maintain full control over bowel movements or has a
stable stoma, but may have occasional faecal incontinence;
Has a stoma requiring routine attention.
Or doubly incontinent but care is routine;
Or
Self-catheterisation;
Or
Difficulties in toileting due to constipation, or irritable bowel
syndrome, requires encouragement and support
Continence care is problematic and requires timely intervention
by a skilled practitioner or trained carer;
Or
Intermittent catheterisation by a trained carer or care workers;
Or
Has a stoma that needs extensive attention every day.
Or
requires haemodialysis in hospital to sustain life
Requires dialysis in the home to sustain life.
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Level of
Need
No
additional
needs
Low
Supporting
Reports
Moderate
High
Priority
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Name:
DOB:
NHS CHILDREN’S CONTINUING CARE ASSESSMENT DOCUMENT
Skin and Tissue Viability
Stomas should be considered under Continence or elimination and tracheostomies
under Breathing
Describe the actual needs of the individual, providing the evidence that informs the
decision overleaf on which level is appropriate. Including the frequency and intensity of
need, unpredictability, deterioration and any instability.
Circle the assessed level overleaf.
Please include any tissue viability reports with this document.
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Name:
DOB:
NHS CHILDREN’S CONTINUING CARE ASSESSMENT DOCUMENT
Skin and Tissue Viability
Description
No evidence of pressure damage or condition affecting the skin.
Evidence of pressure damage and pressure, or a minor wound
requiring treatment;
Or
Skin condition that requires clinical reassessment less then weekly
Or
Well established stoma which requires routine care.
Or
has a tissue viability plan which requires regular review
Open wound(s), which is (are) responding to treatment;
Or
Active skin condition requiring a minimum of weekly reassessment
and which is responding to treatment;
Or
High risk of skin breakdown that require preventative intervention
from a skilled carer several times a day, without which skin integrity
would break down.
Or
High risk of tissue breakdown because of stoma (gastrostomy,
tracheostomy, colostomy stomas) which require skilled care to
maintain skin integrity
Open wound(s), which is (are) not responding to treatment and
require a minimum of daily monitoring / reassessment;
Or
Active skin condition, which requires a minimum of daily monitoring
or reassessment;
Or
Specialist dressing regime, several times weekly, which is
responding to treatment and requires regular supervision.
Life-threatening skin conditions or burns requiring complex, painful
dressing routines over a prolonged period.
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Level of
Need
No
additional
needs
Low
Supporting
Reports
Moderate
High
Severe
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Name:
DOB:
NHS CHILDREN’S CONTINUING CARE ASSESSMENT DOCUMENT
Breathing
Describe the actual needs of the individual, providing the evidence that informs the
decision overleaf on which level is appropriate. Including the frequency and intensity of
need, unpredictability, deterioration and any instability.
Circle the assessed level overleaf.
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Name:
DOB:
NHS CHILDREN’S CONTINUING CARE ASSESSMENT DOCUMENT
Breathing
Description
Breathing typical for age and development
Routine use of inhalers, nebulisers, etc;
Or
Care plan or management plan in place to reduce aspiration
Episodes of acute breathlessness, which do not respond to selfmanagement and need specialist recommended input;
Or
intermittent or continuous low level oxygen therapy is needed to
prevent secondary health issues;
Or
Supportive but not dependant non-invasive ventilation which may
include oxygen therapy which does not cause life threatening
difficulties if disconnected;
Or
Has profoundly reduced mobility or other conditions which lead to
increased susceptibility to chest infection( Gastroesphagael Reflux
Disease and Dysphagia);
Or
Requires oral suction (at least weekly) due to the risk of aspiration
and breathing difficulties.
Or
requires daily physiotherapy to maintain optimal respiratory
function:
Or
requires oral suction (at least weekly) due to the risk of aspiration
and breathing difficulties;
Or
has a history within the last three to six months of recurring
aspiration/chest infections
Requires high flow air/oxygen to maintain respiratory function
overnight or for the majority of the day and night;
Or
Is able to breathe unaided during the day but needs to go onto a
ventilator for supportive ventilation. The ventilation can be
discontinued for up to 24 hours without clinical harm;
Or
Requires continuous high level oxygen dependency, determined by
clinical need;
Or
has a high need for daily oral pharyngeal and or / nasopharyngeal
suction with a management plan undertaken by a specialist
practitioner
Or
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Level of
Need
No
additional
need
Low
Supporting
Reports
Moderate
High
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DOB:
stable tracheostomy that can be managed by the child or young
person or only requires minimal and predictable suction/care from
carer
Has frequent, hard-to-predict apnoea’s( not related to seizures);;
Or
Severe, life-threatening breathing difficulties, which may require
essential oral pharyngeal and / or naso pharyngeal suction, day or
night;
Or
A tracheostomy tube that requires frequent essential interventions
(additional to routine carer) by a fully trained carer, to maintain an
airway;
Or
Requires ventilation at night for very poor respiratory function; has
respiratory drive and would survive accidental disconnection, but
would be unwell and may require hospital support.
Unable to breath independently and requires permanent
mechanical ventilation;
or
Has no respiratory drive when asleep or unconscious and requires
ventilation, disconnection could be fatal;
or
A highly unstable tracheostomy, frequent occlusions and difficult to
change tubes.
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Severe
Priority
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Name:
DOB:
NHS CHILDREN’S CONTINUING CARE ASSESSMENT DOCUMENT
Drug Therapies and Medicines
Describe the actual needs of the individual, providing the evidence that informs the
decision overleaf on which level is appropriate. Including the frequency and intensity of
need, unpredictability, deterioration and any instability.
Circle the assessed level overleaf.
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Name:
DOB:
NHS CHILDREN’S CONTINUING CARE ASSESSMENT DOCUMENT
Drug Therapies and Medicines
Description
Medicine administered by Parent, carer or self as appropriate for
age.
Requires a suitably trained family member, formal carer, teaching
assistant, nurse or appropriately trained other to administer medicine
due to:
 Age
 Non-compliance
 Type of medicine
 Route of medicine; and / or
 Site of medication administration
Level of
Need
No
additional
needs
Low
Supporting
Reports
Requires administration of medicine regime by a registered nurse,
Moderate
formal employed carer, teaching assistant or family member
specifically trained for this task, or appropriately trained other;
and monitoring because of potential fluctuation of the medical
condition that can be non-problematic to manage;
or sleep deprivation due to essential medication management –
occurring more than once a night (and at least twice a week).
Drug regime that requires management by a registered nurse (within
High
prescription) at least weekly, due to a fluctuating and / or unstable
condition;
or
Sleep deprivation caused by severe distress due to pain requiring
medication management – occurring four times a night (and four
times a week).
or
Requires monitoring and intervention for autonomic storming
episodes
Has a medicine regime that requires daily management by a
registered nurse and reference to a medical practitioner to ensure
effective symptom management associated with a rapidly changing /
deteriorating condition;
or
Extensive sleep deprivation caused by severe intractable pain
requiring essential pain medication management – occurring every
one to two hours.
or
Requires continuous intravenous medication, which if stopped would
be life threatening (e.g. epoprostenol infusion)
Has a medicine regime that requires at least daily management by a
registered nurse and reference to a medical practitioner to ensure
effective symptom and pain management associated with rapidly
changing / deteriorating condition, where one-to-one monitoring of
symptoms and their management is essential?
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Severe
Priority
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Name:
DOB:
NHS CHILDREN’S CONTINUING CARE DOCUMENT
Psychological and Emotional Needs
Describe the Psychological and Emotional Needs that are beyond what is normally
expected from a child / young person of this age.
Please include cognition impairment in this section.
Cognition applies to disturbances of higher mental processes that can be measured by
suitable psychological tests. This may apply to individuals when a learning disability acquired
and degenerative disorders. Where cognition impairment is identified consideration should be
made for referral to an appropriate specialist if one is not already involved
Note that there is a domain that separately considers challenging behaviour
Describe the actual needs of the individual, providing the evidence that informs the
decision overleaf on which level is appropriate. Including the frequency and intensity of
need, unpredictability, deterioration and any instability.
Circle the assessed level overleaf.
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Name:
DOB:
NHS CHILDREN’S CONTINUING CARE ASSESSMENT DOCUMENT
Psychological and Emotional Needs
Interpretation point : assessors should avoid double counting the same need with behaviour domain
Description
Psychological or emotional needs apparent but age appropriate
and similar to those of peer group.
Periods of emotional distress (anxiety, mildly lowered mood) not
dissimilar to those of age-appropriate peer group, which subside
and are self-regulated by the child / young person, with prompts /
reassurance from peers, family members, carers and / or key
frontline staff with the children and young people’s workforce.
Require prompts or support to remain within existing infrastructure;
periods of variable attendance in school / college; noticeably
fluctuating levels of concentration; noticeable deterioration in selfcare (outside prolonged intervention from additional key staff;
intentional self-harm but not generally high risk;
Or
Evidence of low moods, depression, anxiety or periods of distress;
reduced social functioning and increasingly solitary, with a marked
withdrawal from social situations; limited response to prompts to
remain within existing infrastructure (marked deterioration in selfcare outside or cultural / peer group norms and trends).
Rapidly fluctuating moods of depression, necessitating specialist
support and intervention, which have a severe impact on the child /
young person’s health and well-being to such an extent that the
individual cannot engage with daily activities such as eating,
drinking, sleeping or which place the individual at risk;
Or acute and / or prolonged presentation of emotional /
psychological deregulation, poor impulse control placing the young
person or others at serious risk, and / or symptoms of serious
mental illness that places the young person at risk to his / her self
and others; this will include high-risk, intentional self-harming
behaviour.
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Level of
Need
No
additional
needs
Low
Supporting
Reports
Moderate
High
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Name:
DOB:
NHS CHILDREN’S CONTINUING CARE ASSESSMENT DOCUMENT
Seizures
This encompasses the whole range of types of seizures and any associated risks
Describe the actual needs of the individual, providing the evidence that informs the
decision overleaf on which level is appropriate. Including the frequency and intensity of
need, unpredictability, deterioration and any instability.
Circle the assessed level overleaf.
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Name:
DOB:
NHS CHILDREN’S CONTINUING CARE ASSESSMENTDOCUMENT
Seizures
This encompasses the whole range of types of seizures and any associated risks
Description
No evidence of seizures.
History of seizures but none in the past three months; medication
(if any) is stable.
or
Occasional absent seizures and there is low risk of harm
Occasional seizures including absences that have occurred within
the last three months which require the supervision of a carer to
minimise the risk of self-harm.
or
Upto three tonic – clonic seizures every night requiring regular
supervision
.
Tonic-clonic seizures requiring rescue medication on a weekly
basis;
Or 4 or more tonic-clonic seizures at night
Severe uncontrolled seizures, occurring at least daily,
Seizures often do not respond to rescue medication and the child
needs hospital treatment on a regular basis.
This results in a high probability of risk to his / her self or others.
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Level of
Supporting
Need
Reports
No additional
needs
Low
Moderate
High
Severe
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Name:
DOB:
NHS CHILDREN’S CONTINUING CARE ASSESSMENT DOCUMENT
PERSONAL DETAILS
Summary of child / young person’s situation,
 relevant history and current needs
 clinical summary
 identified significant risks drawn from multi-disciplinary assessment:
 Other identified needs to be identified with analysis of severity& impact
Child / young person’s or parent / carers view of care needs
Do they consider that the multi-disciplinary assessment accurately reflects their need?
Child /young person’s view
What the aspiration for this child/young person?
What are their issues, anxieties and concerns about care delivery?
What are their preferences about care delivery?
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Name:
DOB:
NHS CHILDREN’S CONTINUING CARE ASSESSMENTDOCUMENT
CARE DOMAINS
Transfer all the assessed Levels of need onto the matrix below to identify level of need
Either 3 “high” ratings, 1 “severe” or 1 “priority” rating is likely to indicate continuing care needs
Priority
Severe
High
Moderate
Low
No Need
Challenging behaviour
Communication
Mobility
Nutrition, food and drink
Continence and elimination
Skin and tissue viability
Breathing
Drug therapies and medicines
Psychological and emotional
Seizures
Other
Total
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Name:
DOB:
NHS CHILDREN’S CONTINUING CARE ASSESSMENTDOCUMENT
Was the child / young person involved in the completion of the assessment? YES
/ NO.
If no please state why the child / young person did not contribute to this
assessment
Was the parent / carer involved in the completion of the assessment? YES / NO
Is the child / young person and their parent / carer happy with the
recommendations made? YES / NO
Please note below any views of the individual that have not been recorded elsewhere in
this document.
Please include whether the child/young person and or parent/carer agree with the domain
levels selected.
Where they disagree, this should be recorded below, including the reasons for the
disagreement. Where the individual is represented or supported by a parent / carer or advocate
their understanding of the individual’s views should be recorded.
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Name:
DOB:
NHS CHILDREN’S CONTINUING CARE ASSESSMENT DOCUMENT
RECOMMENDATION
Please now give a recommendation as to whether or not the individual is eligible for NHS
continuing healthcare.
Take into account the range and levels of need previously recorded and the
individual’s primary need is for healthcare.
Please indicate whether needs are expected to change (in terms of deterioration or
improvement) before the case is next reviewed. If so, please state why and what
needs you think will be different and therefore whether you are recommending that
eligibility should be agreed now or that an early review date should be set
Any disagreement on levels used or areas where needs have been counted against
more then one domain should be highlighted here.
Reach a recommendation on whether the individual’s primary needs are health
need should include consideration of:




Nature: This describes the particular characteristics of an individual’s needs (which can
include physical, mental health, or psychological needs), and the type of those needs.
This also describes the overall effect of those needs on the individual, including the type
(quality) of interventions required to manage them.
Intensity: this related to both the extent (quality) and severity (degree) of the needs and
the support required to meet them, including the need for sustained / ongoing care
(continuity)
Complexity: This is concerned with how the needs present and interact in increase the
skill needed to monitor the symptoms, treat the condition(s) and / or manage the care.
This can arise with a single condition or can also include the presence of multiple
conditions or the interactions between two or more conditions.
Unpredictability: this describes the degree to which needs fluctuate, creating challenges
in managing them. It also related to the level of risk to the person’s health if adequate and
timely care is not provided. Someone with an unpredictable healthcare need is likely to
have either a fluctuating, or unstable or rapidly deteriorating condition.
.
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Name:
DOB:
NHS DONCASTER CHILDREN’S CONTINUING CARE ASSESSMENT DOCUMENT
RECOMMENDATION
Recommendation on eligibility for NHS continuing healthcare detailing the conclusions on
the issues outlined on the previous pages:
Please note that this application will not be processed unless this section is completed
and a recommendation is provided.
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Name:
DOB:
NHS DONCASTER CHILDREN’S CONTINUING CARE ASSESSMENT DOCUMENT
REQUESTED CARE PACKAGE
Request future care package and likely location(s)
The decision on eligibility for NHS Continuing Healthcare is separate to any decision to
commission a particular package.
REQUESTED CARE PACKAGE/PLAN:

START DATE :
Please indicate the actual or expected start date of the package (where this is unknown, the
lead professional must confirm it with the continuing care team as soon as possible).
Outcomes to be achieved from delivery of care package/plan.
Health:


Name, designation & signature of the person completing this
assessment
Date completed:
Name and designation of professionals that have participated
in the completion of this assessment :
Contact details
Please forward this typed assessment via:
Secure email: [email protected]
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Name:
DOB:
For office use only:
ECHP Domain
Panel Date:
Panel decision:
Funding Stream Agreed Package of Care/Provision Review period Cost per
(Total hours allocated
Hour/week of
Provision & Name of Provider)
provision
Health
Social care
Education
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Cost per
year to
NHS