Communication Able to communicate clearly, verbally or non-verbally. Has a good understanding of their primary language. May require translation if English is not their first language. OR Needs assistance to communicate their needs. Special effort may be needed to ensure accurate interpretation of needs or additional support may be needed either visually, through touch or with hearing. Communication needs is difficult to understand or interpret or the individual is sometimes unable to reliably communicate, even when assisted. Carers or care workers may be able to anticipate needs through non-verbal signs due to familiarity with the individual. Unable to reliably communicate needs at any time and in any way, even when all practicable steps to assist them have been taken. The individual has to have most of their needs anticipated because of their inability to communicate them. Brief description of need and source of evidence to support the chosen level Write A, B or C below: Name of individual Date of completion
Brief description of need and source of evidence to support the chosen level Write A, B or C below: Name of individual Date of completion C B A Behaviour* No evidence of ‘challenging’ behaviour. OR Some incidents of ‘challenging’ behaviour. A risk assessment indicates that the behaviour does not pose a risk to self, others or property or create a barrier to intervention. The individual is compliant with all aspects of their care. ‘Challenging’ behaviour that follows a predictable pattern. The risk assessment indicates a pattern of behaviour that can be managed by skilled carers or care workers who are able to maintain a level of behaviour that does not pose a risk to self, others or property. The individual is nearly always compliant with care. ‘Challenging’ behaviour of type and/or frequency that poses a predictable risk to self, others or property. The risk assessment indicates that planned interventions are effective in minimising but not always eliminating risks. Compliance is variable but usually responsive to planned interventions.
Brief description of need and source of evidence to support the chosen level Write A, B or C below: Name of individual Date of completion C B A Drug therapies and medication: symptom control* Symptoms are managed effectively and without any problems, and medication is not resulting in any unmanageable OR Requires supervision/administration of and/or prompting with medication but shows compliance with medication regime. OR Requires the administration of medication (by a registered carer or care worker) due to: – non-compliance, or – type of medication (for example insulin); or – route of medication (for example PEG). OR Moderate pain which follows a predictable pattern; or other symptoms which are Requires administration and monitoring of medication regime by a registered nurse, carer or care worker specifically trained for this task because there are risks associated with the potential fluctuation of the medical condition or mental state, or risks regarding the effectiveness of the medication or the potential nature or severity of side-effects. However, with such monitoring the condition is usually non-problematic to manage. OR