nhs continuing healthcare online questionnaire17. please indicate whether the current care home is...

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NHS Continuing Healthcare Online Questionnaire

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S O L I C I T O R S L T D

© Farley Dwek Solicitors Ltd 2014

Online Questionnaire

1. Full name of patient

2. Home address (prior to transfer into care home if applicable)

3. Patient’s Date of Birth

4. Patient’s Place of Birth

5. Patient’s Surname at birth

6. Patient’s NHS Number

7. Name of Patient’s General Practitioner

Address

8. Name of Patient’s Social Worker

Address

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Section 1 - Medical History

9. Has the patient ever been detained under Section 3 of the Mental Health Act 1983 for treatment?

If yes, how long ago or for what reason this occurred.

Yes No

Place X appropriate box

10. Please state the Patient’s past and current medical history and physical illnesses in particular whether the Patient has suffered from Diabetes, Epilepsy, Parkinson’s Disease, Cancer, Arthritis, Stroke etc (please give dates where possible of diagnosis)

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Section 1 - Medical History

11. Name and address of any hospitals attended by the Patient and approximate dates.

12. Is the patient attended by a Specialist nurse (for example Parkinsons, Epilepsy, Diabetic, Community, Psychiatric or Continence nurse), a Dietician, Consultant or other healthcare professional from outside of their home environment?

Yes No


If yes, how often are the visits by the above professional (e.g. daily, weekly, fortnightly, monthly etc)?

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Section 2 - Care Home Details

Please complete this section if the patient is or has been in a residential care setting. If residing in their own home, or currently in hospital, please move to Section 3.

13. Address of current Care Home

14. On what date did the Patient become resident of the above Care Home?

15. Could you please give an estimate of how much has been paid to date

to the Care Home(s) to provide care for the Patient?

And/or the current weekly or monthly Care Home Fee

16. Please provide any information with relation to previous Care Home(s) where the Patient has resided and exact or approximate dates (if applicable).

Care Home Address

From

To

Please give as much detail as possible the more exact the data the better, if you need more space you can include a separate sheet of paper.

17. Please indicate whether the current Care Home is one of the following:

A residential home.

A nursing home.

A residential home for the elderly mentally infirm.

A nursing home for the registered elderly mentally infirm.

If the care home is a dual registered home, please let us know if the Patient has a residential or nursing bed.

Yes No

Place X more than one if appropriate

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Section 3 - Care Needs

We need to know whether the Patient needs assistance and supervision on a daily basis to help with activities of daily living. Please can you answer the following questions providing as much information as possible continuing on a separate sheet if required.

18. Personal Care

What personal care does the Patient require? (i.e. assistance with washing, bathing, brushing teeth/dentures, dressing/undressing, hair care, nail care)

19. Eating and drinking

What assistance does the Patient need with eating or drinking? Can they eat independently or require supervision, reminding, coaching or encouragement?

Please tick all of the below statements that apply to the patient:

They refuse food

They require their food cutting up

They require a plate guard

They use adapted cutlery

The require thickeded fluids

They require mashed up/soft foods

They require liquidized food

The have got a PEG feeding tube/naso gastric feeding tube

They have a fortified diet

They require supplement drinks

They are under the care of Speech and Language Therapy

They are under the care of a dietician

They have swallowing difficulties

They are losing weight

They have choking episodes. If so, how often (please give details below)

Yes No

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20. Mobility

Please tick all of the below statements that apply to the patient: Yes No

They are able to walk independently

They walk with a walking stick

They walk with a Tripod

They walk with a Zimmer frame

They use a wheelchair

The can bear weight (take weight on their legs either with assistance or without)

They can stand alone

They use a stand aid

They use a hoist

Staff assist them when getting in and out of bed

The experience falls

They are under the falls service

They require pressure mats to alert staff to their movements

Is there a history of falls, and if so how often? Has the Patient sustained injury as a result of falls and was any medical treatment or hospitalisation required as a result? Do they require additional staff in the home due to attempts to mobilise on their own?

21. Skin Integrity

Please tick all of the below statements that apply to the patient: Yes No Eczema

Psoriasis

Dry skin

Lesions

Oedema

Ulcers on the skin

Pressure areas

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Is the Patient under the care of the Tissue Viability Service/nurse? Do they have dressings regularly done by the nursing home nurse and/or district nurse? Do they have a pressure relieving mattress and/or cushion?

22. Continence Please tick all of the below statements that apply to the patient: Yes No They are self-caring/take themselves to the toilet

They are incontinent of urine

They are incontinent of faeces

They wear incontinence pads

They suffer regularly from urinary tract infections

They suffer from constipation

They suffer from loose stools

They are under the care of the Continence Service

They have a self-retaining catheter in place

They are intermittently catheterised

23. Communication Can the Patient speak? Can they communicate effectively? Can they make their needs known? (i.e. can they ask for a drink or to go to the toilet?) Do they speak in a confused manner? Can they communicate non-verbally (i.e. point to things, make gestures) Does the patient have a sight or hearing impediment?

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24. Medication Please tick all of the below statements that apply to the patient: Yes No They are not prescribed any medication

They depend on staff to administer their medication

They require medication for pain control

They refuse their medication

They require regular blood tests

Does the patient see their GP regularly and, if so, how often? Do they require regular injections? If so, what for and how often?

25. Psychological wellbeing Does the Patient suffer from any mental health problems (i.e. depression, anxiety, distress)? If they are distressed, how to they indicate distress and how often? Do they hallucinate and, if so, how often? Do the hallucinations cause distress? Is the patient often tearful? How do they respond to reassurance? Are they under the care of any local mental health services/practitioners?

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26. Cognition

Please tick all of the below statements that apply to the patient: Yes No They have not got capacity to make simple decisions

They are confused

They cannot assess risk

They do not know where they are

They do not know the time of day

They do not recognise family

They do not know the difference between other residents and staff

They do not have any short term memory

They do not have any long term memory

27. Behaviour Does the Patient demonstrate any behavioural problems? Do they demonstrate difficult behaviour (i.e. verbal or physical aggression, noisiness, restlessness or disruption)? Do they display disinhibited behaviour (i.e. use of bad language, taking their clothes off inappropriately, making unwanted advances to others)? Does the Patient refuse or resist care or medication? How often does this behaviour occur?

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28. Breathing Please tick all of the below statements that apply to the patient: Yes No They require inhalers

They require medication prescribed for breathing

They have recurrent chest infections

They are breathless on sitting

They are breathless when walking

They are prescribed oxygen

29. Altered States of Consciousness Please tick all of the below statements that apply to the patient: Yes No They suffer from epilepsy

They have fainting attacks

They have vacant attacks

They have had a stroke

They suffer from TIAs

They are in a coma

They are unresponsiv

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Section 4 - Claim Details

30. Have you or anyone else contacted the NHS/Primary Care Trust or Strategic Health Authority about the funding of the patient’s care?

Yes No


If yes, please provide as much details as you can including the date you first contacted the Health Authority, the date you received a response and details of that response.

31. Is the person completing this questionnaire the Patient?

If YES, please sign and date the end of the Form.

If NO, continue to question 32 and provide us with your contact details.

32. Your Full Name

33. Your Full Address

34. Contact Telephone Number(s)

35. Your Date of Birth

36. Your National Insurance Number

37. Please give details of your relationship to the patient

Yes No


38. If the Patient cannot complete the Questionnaire themselves please give details as to why.

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39. Has the patient appointed you to act on their behalf using an Enduring Power of Attorney or Lasting Power of Attorney, or are you acting as a Receiver/Deputy on the patient’s behalf? A. Yes Copy of Enduring Power of Attorney enclosed

Copy of Lasting Power of Attorney enclosed

Copy of letter of appointment as a Receiver enclosed

Copy of Deputyship enclosed B. No If we believe that you are eligible to make a claim for NHS Continuing Healthcare Funding, a member of our team will contact you to discuss how the patient can legally appoint you to pursue the claim on their behalf.

40. Does the patient have a current, valid Will in place? Yes No It is important that the patient has a Will in place so that if anything happens during the claim, there are executors who can continue with the claim. If we are unable to proceed with this claim having assessed the patient’s circumstances, you and they will still qualify for our Free Will writing service and a member of our team will contact you to discuss how our service works.

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Declaration

I DECLARE THAT THE INFORMATION I HAVE GIVEN IN ANSWER TO ALL THE QUESTIONS IN THIS QUESTIONNAIRE IS CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF.

Signed

Print name

Relationship to client

Dated

Please return this completed questionnaire to:

Farley Dwek Solicitors Limited Suite 1.2, First Floor One Universal Square Devonshire Street North Manchester M12 6JH

If you have any queries, please contact us on: 0161 272 5222

We will assess the information you have provided and contact you to discuss your eligibility for Funding as soon as possible.

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nhs continuing healthcare online questionnaire17. please indicate whether the current care home is...

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