Client Personal Details

MCare Client Personal Details

Client Details

Care Manager/Social Worker Details

Next of Kin Details

Professionals Involved

In the event of an emergency this client would be deemed:
Red = urgent needs assistance – must access
Amber = family present – try to access
Green = would manage in emergency
Write any medical history in the field above.

Mcare Service User Agreement

have been consulted with and I am in agreement with my Care Plan and HST TRUST Risk Assessment (where provided) and acknowledge receipt of the following:

2. I agree that M Care LTD Can/Cannot have keys to my home to ensure staff can gain access. In the event of my package of care ending I wish any keys to be returned to Myself / N.O.K / Representative Access arrangements are as follows: BUZZER/INTERCOM/KEYPAD/OR KEYS ISSUED

5. I am aware that it is MY/MY/NOK/OR REPRESENTATIVES Responsibility to ensure my home is safe for staff to provide my services. I agree to the written Risk Assessment being completed by M Care LTD, made available to M Care staff and reviewed as necessary.

6. I am aware that confirmation is held on file and that the commissioning HSS trusts are responsible for the monitoring and maintenance of all supplied equipment. M Care will notify the relevant trust if they become aware of any defects with supplied equipment.

7. I am aware my care will be reviewed and monitored and accept that at times this may need to be unannounced visits, my chosen method of monitoring would be: BY PHONE/VIA HOME VISIT.

8. I am aware that this agreement will not be reviewed, however if there was a substantial change to this agreement it will be amended and agreed with: MYSELF/MY NOK/REPRESENTATIVE and M Care LTD.

9. I request that I AM/I AM NOT consulted when M care policies are being reviewed.

I have also been provided with my own copy for ease of reference.

If at any stage either party would like to terminate the agreement, this can be done by having discussions with your trust representative. Should this agreement end, M Care reserve the right to visit your home and collect the home file.

Mcare Risk Assessment

Internal Home Assessment

Working Smoke Alarm
Working Carbon Monoxide Alarm
Level Access
Stairs In Use
Handrails In Use
Stair Lift In Use
Space Restricted
Flooring Satisfactory
Lighting Satisfactory
Heating Satisfactory
Kitchen Fit For Purpose
Bathroom Fit For Purpose

External Home Assessment

Easily Accessed
Noticeable Restrictions
Adequate Outdoor Lights
Trust Provided Ramp
Outside Steps

Noted Risks

Environment Inside
Environment Outside

Equipment In Use

Hoist In Use
Profiling Bed
Cot Sides In Use

Person Centered Assessment

Poor Mobility
Prone To Falls

Service Required

General Notes

(NOK must be named on Care Plan and be authorised to sign on the Client’s behalf).