Checklist for Residential/ Nursing Placements

Please complete and save in EDRMS for funding request to Budget Manager and use in conjunction with the Step by Step Guide and Process Guidance on Mosaic:

Name
DOB & Age
Mosaic Number
Stage	Check
Has the SDA been completed and signed off by manager? (Please record date)	☐ Click or tap to enter a date.
If Residential – have you considered Extra care as a provision? (please briefly explain rationale)	Click or tap here to enter text.	If Nursing – please briefly explain rationale (Please ensure Nursing papers/ Consultant Documents are saved on EDRMS)	Click or tap here to enter text.
Referral to Operational Commissioning Referral for vacancies and allocation for Choices Checklist	☐
Options shared with family (Minimum of 2) – family aware to visit and of all financial implications – including top ups Is this residential or nursing?	☐ ☐ Residential ☐ Nursing
Justification for Request for funding (including past medical History)
SDA summary of Worker Opinion Include what needs are too high for placements (if applicable)
COST per Week
Name of Care Home
Care Governance Care Home Rating – Green/ Amber/ Red
Are you progressing a referral to CHC as the SDA indicates the customer has primary health needs? YES – completing/completed checklist NO – the customer does not have significant/primary health needs	☐ Yes ☐ No
Does the customer lack capacity to consent to the placement? Is there an MCA which evidences this assessment Is there a record of the Best Interest decision which evidences the placement is in the customers Best Interest	☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No
If the customer lacks capacity to consent and the care and support arrangements at the placement and these will amount to a deprivation of liberty at the placement, please record the date and that the DOLS team were notified.	☐ Click or tap to enter a date.
Does the person need an Advocate? – (if appropriate please make referral) Name of Informal Advocate - Click or tap here to enter text.	☐ Yes ☐ N/A
Does the person have LPA for: Name of LPA – Click or tap here to enter text. OPG Check Completion Date: Click or tap to enter a date.	Health and Wellbeing ☐ Finance ☐
Are the family looking at Court of Protection/ Deputyship? (looking for funding without prejudice)	☐ Yes ☐ No
Has a Financial Assessment been completed? (Please record date)	☐ Click or tap to enter a date.
Is the person over the threshold?	☐ Yes ☐ No
Are they looking for a 12 weeks property disregard? Are they eligible for 12 weeks property Disregard?	☐ Yes ☐ No ☐ Yes ☐ No
Are they looking for a Deferred Payment Agreement? Are they eligible for Deferred Payment Agreement?	☐ Yes ☐ No ☐ Yes ☐ No
Is a top-up being requested? What evidence has been supplied to confirm both accountability and sustainability.	☐ Yes ☐ No Click or tap here to enter text.
Has Finance confirmed outcome of financial assessment? (Please record date)	☐ Click or tap to enter a date.
List all the options provided including costs (copied from Choices Checklist):
Does the customer have any Aged Debt?	☐ Yes ☐ No
Is the customer aware of this debt?
Does the customer need help with managing their finances, and has this been put in place.
Is there a plan to repay?
Any Further information
Has a risk assessment been completed for Amber or Red?
Date passed/ discussed with Line Manager Name of Manager :	Click or tap to enter a date.
Date passed to Budget manager for decision on Mosaic	Click or tap to enter a date.

Checklist Completed By: Click or tap here to enter text.