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This Policy is designed to enable a permanent record to be provided of the service user’s consent for a plan of bespoke care and treatment services to be delivered by the Organisation’s appropriate care staff.


1. For an appropriate plan of care and treatment to be delivered to the service user, it is critical that the service user (or advocate where the service user lacks mental capacity) is involved at all stages of the service user Baseline Assessment of Needs for Daily Living, reference Form No: 3-002. This will result in an appropriate Care Plan (Form No: 3-013) which the service user or advocate is required to sign as being acceptable, and will be supplemented by two additional Consent Forms which will be included in the service user Care Plan records.


2. Accordingly, records of Consent to Care and Treatment will be found in the following three documents in the service user records:


2.1 Form No: 3-013: Care Plan - Service User:


2.1.1 The Care Plan is structured into the following 15 sections:


1. Waking & Dressing

2. Undressing, Retiring & Sleeping

3. Food, Drink & Diets

4. Medication

5. Mobility

6. Health & Medical Care

7. Personal Hygiene

8. Daily Lifestyle & Activities

9. Social Needs & Relationships

10. Psychiatric & Mental History

11. Communication Needs

12. Religion, Culture & Beliefs

13. Awareness & Reality Orientation

14. Behaviour & Risks

15. Money & Finance


2.1.2 For each section there is provision for the following signatories:


  • the service user or advocate signifying their consent to their care and treatment as set out in their Individual Care Plan.

  • the authorised representative of the Organisation responsible for delivering the care as set out in the Care Plan.


2.2 Form No: 3-011: Consent to Care and Treatment - Service User:

Additional consent will be required for the following situations relating to service user care:

  • Call for a GP to visit where required.

  • Administer First Aid.

  • Call for an ambulance / paramedics to visit where required.

  • Obtain prescriptions for the service user where necessary.

  • Arrange for the service user to be taken to a hospital A&E Unit where necessary.


2.3 Form No: 3-307: Consent to Administer Medication - Service User:


Additional consent will be required for the following situations relating to service user medication, where the medication is administered by appropriately trained staff, reference Policy No: 3302. Medication can be of the following types:

  • Oral (tablets, pills, capsules, liquids, suspensions, syrups).

  • Topical (creams, ointments, lotions, powders, plasters, transdermal patches).

  • Respiratory (oxygen, inhalers).

  • Rectal (suppositories).

  • Injections (intravenous, intramuscular).



FORMS REFERENCES:


Form No: 3-002 Baseline Assessment of Needs for Daily Living - Service User

Form No: 3-011 Consent to Care and Treatment - Service User

Form No: 3-013 Care Plan - Service User

Form No: 3-307 Consent to Administer Medication - Service User

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