Emergency Contacts/ Key Holders

 Telecare Referral / Assessment A. Personal Details – all information is required

Address Date of Birth Inc. Postcode

Landline Phone No GP Name Mobile Address E-mail Address Phone No.

Ethnicity Religion Next of Kin Next of Kin Relationship Address Phone No Mobile

Handling of Information The information you give us will be held securely and in confidence. We may need to share this information with external health and social care professionals/providers who we may need to consult, in order to advise or provide you with the appropriate services. We may also use your information for service planning, monitoring services and research. Are you in agreement with this? Yes No

Has the person given consent for a referral for Telecare? Yes/No If no, please provide details of person providing consent acting on their behalf Yes No

Does the person give consent for information to be passed to West Midlands Fire Service to undertake a Safe and Well check ? Yes No

Accommodation

Accommodation Type House Flat Bungalow Maisonette

Tenure Housing association Rented Owner occupied Sheltered

Other ( please state )

Name of housing association/supported housing

Telecare Assessment Page 1 of 5 Are there any potential risks in accessing the property? E.g. large dog, person is a hoarder, hidden access doors etc.

Person lives alone? Yes No

Emergency Contacts/ key holders

Emergency contacts / Key holders must live within 30 minutes travelling time of the service user. All details must be completed. 1st Contact 2nd Contact Key holder name Relationship Key holder address Key holder phone no. Key holder mobile no.

If the individual does not have two emergency contacts the responder service will be required. (a keybox would be required if not already in place).

Is the Responder service required? Yes No

Keyboxes will only be installed by the Telecare team where the responder service is required. We cannot fit a keybox if the door has shared entry with other tenants e.g. in flats, unless all tenants have given written agreement to this and also agree to inform their home insurance company that a keybox has been installed.

Is a keybox required?

Already in place Keybox No. if known No Yes ( the telecare team will contact you to discuss details for the keybox referral ) Already being ordered

Communication with service user

Capacity to Respond - In the event of an alert being raised at the call centre, call staff will attempt to speak directly with the person through their telephone. Tick If NO, how would you want the call centre staff to respond? (Who should they contact?) Is the person usually able to Yes No communicate their needs verbally? Is English first language, if not Yes No please indicate what is

Telecare Assessment Page 2 of 5 Is this person visually impaired? Yes No

Is this person hearing impaired? Yes No

Is there another RASS lifeline (neck pendant) alarm already installed at the property? Yes/No Name of pendant provider if known Yes No

Would the service user’s memory enable them to push a button? Yes No

Would the person’s manual dexterity enable them to push a button ? Yes No

Are there any risks associated with falls? Yes No If yes continue to fill out the information below

Details How many times has the person fallen in the past 3 months

The person has fallen due to seizures, dizziness or loss of Yes No consciousness

Are there any significant risks associated with medication? Yes No If yes please explain

Are there any significant risks associated with fire? Yes No If yes continue to fill out the information below

Yes/No If yes, please give details The person's behaviour and/or environment Yes No significantly increases risk of fire occurring The person is unlikely to respond Yes No appropriately in the event of a fire In the event of a fire the person would have Yes No difficulty evacuating the premises

Telecare Assessment Page 3 of 5 Does anyone smoke within the property? Yes No Is there a working smoke detector in the Yes No property?

Are there any significant risks associated with dementia? Yes No If yes continue to fill out the information below

Yes/No Is the person able to orientate to day, date and time? Yes No

Is a care package provided? Yes No If Yes, please provide details of care provider and times of care package

Installation details and contacts (Individual to be contacted to arrange installation visit. Please provide name and daytime telephone no.)

Is there an active telephone line with incoming and outgoing calls? Telecare systems requiring links to the control centre cannot be fitted without a land line

Yes - Telephone Supplier No

Is there a power socket within 2 metres of the phone socket (located on the same wall)? Yes No ( if no the telecare team will contact you to discuss )

Please note that incorrect information can lead to a delay in installation, it is therefore essential that the above details are confirmed.

Referral details

Name of person completing the referral

Relationship

Contact number Email address

Telecare Assessment Page 4 of 5 Date of referral -

Please email form to: [email protected] or ring 07808735440 for postal address

Telecare Assessment Page 5 of 5