Oral Patches Injections Syringe driver Peg Home Environment Accommodation House Bungalow Flat Warden Controlled Other □ □ □ □ □ Detail any problems with e.g. parking, key safe details access Safety Factors Are there any smokers in Are there any pets in the the home? home? Yes □ No □ Yes □ No □ Details of facilities for staff within the home: Yes No Toilet Heating Telephone Access Is Wi-Fi available Is appropriate seating available Are parking / tea / coffee making facilities available For H@H Office use only Priority Highlight need RED urgent needs /rapid input required rapid change in – – condition, complex symptoms in the last hours or days of life, rapid discharge, carer crisis, pre-admission rapid response to need – within 30 minutes -1hour AMBER deterioration in the last days or weeks of high priority – – life, awaiting care package, potential breakdown foreseen, respite for carers planned care respond to referral in 2 hours with a – planned assessment within 24-48 hours GREEN may not be appropriate for H@H at this stage, or the – team can make contact and hold on file Fax number for completed referrals: 01625 665697
Oral Patches Injections Syringe driver Peg Home Environment Accommodation House □ Bungalow □ Flat □ Warden Controlled □ Other □ Detail any problems with access e.g. parking, key safe details Safety Factors Are there any smokers in the home? Yes □ No □ Are there any pets in the home? Yes □ No □ Details of facilities for staff within the home: Yes No Toilet Heating Telephone Access Is Wi-Fi available Is appropriate seating available Are parking / tea / coffee making facilities available For H@H Office use only Priority Highlight need RED – urgent needs /rapid input required – rapid change in condition, complex symptoms in the last hours or days of life, rapid discharge, carer crisis, pre-admission – rapid response to need within 30 minutes -1hour AMBER – high priority – deterioration in the last days or weeks of life, awaiting care package, potential breakdown foreseen, respite for carers – planned care respond to referral in 2 hours with a planned assessment within 24-48 hours GREEN – may not be appropriate for H@H at this stage, or the team can make contact and hold on file Fax number for completed referrals: 01625 665697