Extra Care Accommodation Expression of Interest Form FINAL V3.3

Extra Care Accommodation – Expression of Interest Form FINAL V3.3

Redcar & Cleveland Extra Care Accommodation Expression of Interest Form

If you need help completing this form you can ask for someone to assist you. i.e. a family member or a health/social care representative (They will need to sign the form at the end to say that they filled the form in for you) To Qualify for Extra Care accommodation you must:  Be aged 55 years or over  Have a need for support or more suitable housing  Have a need for help with personal care or your carer needs more support This form must be completed in addition to the registration form for the Housing

provider. Please tick ( ) all schemes you would like to consider. You can also indicate your 1st 2nd and 3rd choice Scheme Housing Provider Choi ce ( ) 1,2,3 St Germains, Vicarage Drive, Marske By The Anchor Sea, Redcar TS11 7AX All apartments have their own level access shower. There is also a bath for assisted bathing Number of Number of Number of Studio Apartments 1 Bedroom Apartments 2 Bedroom Apartments 0 28 3 Barnaby House, Lodge Farm Road, Eston TS6 Thirteen Group 9GA

All apartments have their own level access shower. There is also a bath for assisted bathing Number of Number of Number of Studio Apartments 1 Bedroom Apartments 2 Bedroom Apartments 0 7 33 Jubilee Court, Jubilee Road, Eston TS6 9QQ Anchor All apartments are being converted to have their own level access shower. Number of Number of Number of Studio Apartments 1 Bedroom Apartments 2 Bedroom Apartments 36 6 0 New schemes (Not yet available) Scheme Description Choi ce ( ) 1,2,3 The Dunes, Low Farm Drive, Redcar 64, 1 bedroom apartments for people Estimated completion date Spring over the age of 55 2017

Extension to Barnaby House, 21, 1 bedroom apartments for people Estimated completion date over the age of 55 Autumn 2016

of 12 Other contact Would you prefer us to speak to your carer or a member of your family or other person about your application? If so, please provide details below):

Name: Address: Telephone Number:

What is their relationship to you?

All applicants should complete this form in BLOCK CAPITALS and as fully as possible. Fields marked with * are mandatory and must be completed. All information given on this form is treated in strict confidence. When are you looking to move? (Please circle)

Within the next 6 months Within the next 6 to 12 months Within 12 to 18 months Longer than 18 months Do you have any pets? (Please circle)

Yes No

If so what type of pet? (Please state) What are your reasons for seeking a move? Extra Care Accommodation – Expression of Interest Form FINAL V3.3

Personal details* Please give the following details for you and your household: Title Surname First Name (s) Sex Date of Relationship to Are NHS M/F Birth you, the you a Number applicant carer?

Current address

Postcode:

Telephone Telephone (Mobile) (Home)

Email address: In what year did you move into your current address?

Current property status: Please tick ( ) appropriate box(s) Owner / Occupier Rented Social Renting Private Housing Landlord Other (Please Specify)

of 12 Details of health, care and adaptations you may need Please give details of any health issues you have a diagnosis of Applicant Partner / other (s)

When is care needed? Please circle below as When is care needed? Please circle below as appropriate appropriate Day time Night time Day time Night time Please let us know about any adaptations you have had or state if you need them in your new home as determined by a health/social care professional Extra Care Accommodation – Expression of Interest Form FINAL V3.3

Are you (the applicant) currently receiving care or support packages for any of the following? Please let us know about any other support packages not on the list in the box below Support package for Support package for ( ) ( ) Mobility in the home Wash self Mobility outdoors Bath / shower In & out of bed Toilet Chair/ transfers Dressing / undressing Stairs Cooking Orientation in time / place Eating / drinking Shopping Communication Administer medication Other…

Is your partner currently receiving care or support packages for any of the following? Please let us know about any other support packages not on the list in the box below Support package for Support package for ( ) ( ) Mobility in the home Wash self Mobility outdoors Bath / shower In & out of bed Toilet Chair/ transfers Dressing / undressing Stairs Cooking Orientation in time / place Eating / drinking Shopping Communication Administer medication Other…

of 12 Do you need any help or advice on claiming benefits? Yes No

Do you and everyone to be housed with you have the right of residence in the Yes No UK?

Do you own or have a tenancy at any other property? Yes No

If so, please give details

Do you need any other help to manage a tenancy? Yes No If so, please give details e.g. Help paying household bills, help paying rent, general budgeting help, other… Extra Care Accommodation – Expression of Interest Form FINAL V3.3

Are you a previous tenant of any of the Extra Care Housing providers? i.e. Yes No Anchor or Thirteen Group If so, please give details

Please tell us about any recent hospital admissions Person 1 Person 2 Hospital Hospital

Date admitted Date admitted

Length of stay Length of stay

Reason for admission Reason for admission

of 12 About your mobility Please tell us about your mobility Person 1 Person 2 Ye Yes No No Do you use a walking stick indoors? s Ye Yes No No Do you use a walking stick outdoors? s Ye Yes No No Do you use a walking frame indoors? s Ye Yes No No Do you use a walking frame outdoors? s Ye Yes No No Do you use a self-propelled wheelchair? s Ye Do you use an attendant powered Yes No No wheelchair? s Ye Have you had any falls in the past 6 Yes No No months? s If so, please tell us how many times you have fallen: Extra Care Accommodation – Expression of Interest Form FINAL V3.3

Please use these scores to answer the next 2 questions I am able to do I am able to do I am able to do this I am able to do this I am unable to this but it is this with Equipment with help do this difficult 0 1 2 3 4

Access to your home Please tell us about your mobility Person 1 Person 2 Are you able to get in and out of your property?

Can you get to the front door?

Are you able to manage steps (Internal/External)?

Are you able to manage stairs?

Are you able to get to the toilet?

Are you able to get in and out of the bath?

Are you able to get in and out of the shower?

Other Relevant Information Please use this space to tell us anything else that you think we need to know about in relation to this request

Extra Care Accommodation – Expression of Interest Form FINAL V3.3

About your background Other White – Please British specify Gypsy or Irish White Traveller Irish White and Black Other Mixed/Multiple-Please Caribbean Specify Mixed or multiple ethnic groups White and Asian White and Black African Indian Chinese Other Asian – Please Bangladeshi Specify Asian / British Asian

Pakistani Other Black – Please African Specify Black / British Black Caribbean

Other Ethnicity Prefer not to say

Data Protection Act 1998 Notification Clause The information you have provided will be held safe and securely on both computerised and manual files. The data will only be accessible to those partners involved in the scheme who have a requirement to process your application and consider the allocation of a property to you.

Information given in this application may be shared with other bodies for the prevention of crime, including fraud. Unless otherwise stated, the information will only be used for the purposes of housing services.

By signing this declaration you confirm that you have read and understood this section. In order to make sure you are aware of all of the services available to you a member of Redcar & Cleveland Borough Council or partners of the scheme may wish to contact you from time to time.

Signature We may need to contact your GP or Social Worker/Care Manager to get more information from them to help with your application. We may also be required to share this information with other housing providers and Redcar & Cleveland Borough Council to support your application for Extra Care Accommodation.

By signing below, you are allowing us to share information and contact your GP and/or Social Worker/Care Manager for more information. Page 11 of 12 Signature: (person with support needs)

Date: Please Note: The person requiring the support will need to sign this form. When we receive this form, we may contact you to call out to your home. This will help us to assess your application for Extra Care Accommodation. Person completing this form on behalf of the applicant

Print Name Relationship to applicant

Signature: Date:

What happens next? If you are interested in any of these schemes your expression of interest form will be shared between the relevant partner organisations and providers for each of the schemes you are interested in.

This form is registering your interest in extra care housing so you may be required to complete further information if you are considered for a property. A Care Manager or member of staff may also contact you to discuss your application further as vacancies become available in the scheme (s) of your choice.

Please return this form to Redcar & Cleveland Borough Council e-mail [email protected] or return to: Adult Access Team, People Services Directorate, Redcar & Cleveland Borough Council, Seafield House, Kirkleatham Street, Redcar, Yorkshire, TS10 1SP.