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Individual (skillsforcare)

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Activity provision self-assessment:
Individual
Date: Completed by:
Reference number:
Do the range of activities for each person reect their choice, their social, cultural and religious preferences, and are they available at frequent
and regular intervals throughout the week?
C1.4
R1.3
Yes
Sometimes
No
Yes: please provide evidence
No or sometimes: what further action are you
going to take? Who is responsible? Achieve by
Date
completed Evidence of actions taken
Link to
KLOEs
R1. 2
E 7. 2
R1.2
E7.2
Is biographical information recorded with consent and kept up to date to inform the care plan and activity provision?
D
oes each person have a ‘Life History’ or ‘Cloud Profile/All About Me Book’?
Are these life biographies easily available to all people providing support?
Activity provision self-assessment: Individual 1/4
DD/MM/YYYY
Enter your name
Enter your reference number
Yes
Sometimes
No
Yes: please provide evidence
No or sometimes: what further action are you
going to take? Who is responsible? Achieve by
Date
completed Evidence of actions taken
Link to
KLOEs
Activity provision self-assessment: Individual 2/4
To
comply with care policies about choice and consent, do individuals and relatives share information as appropriate?
I
s there an up-to-date activity care plan?
Are current activity preferences, interes
ts and abilities regularly reviewed, recorded in the care plan and reflected in daily activities?
R1.2
E7.2
E1.1
R1.2
R1.3
E1.1
R1.2
R1.3
Activity provision self-assessment:
Individual
Reference number:
Enter your reference number
Yes
Sometimes
No
Yes: please provide evidence
No or sometimes: what further action are you
going to take? Who is responsible? Achieve by
Date
completed Evidence of actions taken
Link to
KLOEs
Activity provision self-assessment: Individual 3/4
Does the activity planning and documentation include relevant risk assessments?
I
s there evidence of an individual’s life history in their own room, e.g. personalised bedrooms that add to the picture of who the person is?
D
o they have their own furniture/bed linen, photos and ornaments?
S2 .1
C3.5
C1.4
C1.4
Activity provision self-assessment:
Individual
Reference number:
Enter your reference number
Yes
Sometimes
No
Yes: please provide evidence
No or sometimes: what further action are you
going to take? Who is responsible? Achieve by
Date
completed Evidence of actions taken
Link to
KLOEs
Activity provision self-assessment: Individual 4/4
I
s the need for ‘quiet time’ recognised and respected?
A
re daily living tasks adapted to suit the person’s needs at that time, e.g. getting dressed or bathing when they want to?
C1.1
E1.1
R1.2
Activity provision self-assessment:
Individual
Reference number:
Enter your reference number
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Individual (skillsforcare)

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Completed 27 July 2021

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