Your Care Options Report | Rowan Care Advisory
Share details about the care you’re researching so we can begin and tailor suitable options.
Before you begin
This form gives us everything we need to begin your research, so we won't need to come back with questions. It takes around 40 minutes. You can save it and come back at any time, and "not sure" is always a useful answer.
Your name
*
Your email address
*
example@example.com
Your reference
How should we contact you during the research?
*
By email
By email, and a phone call is fine if it's quicker
Phone number, and good times to call
Please enter a valid phone number.
Format: (000) 000-0000.
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Who and what
Who is the care for?
*
Myself
Myself and my partner
Someone else, for example a parent, relative or friend
Two people, for example my parents
Someone I act for under a power of attorney or as a deputy
Your relationship to them
*
Do you hold any legal authority for them?
None
Lasting power of attorney for health and welfare
Lasting power of attorney for property and financial affairs
Enduring power of attorney
Court-appointed deputy or delegate
Not sure
Is the power of attorney registered?
Yes
No
Not sure
Do they know about and agree to this research?
*
Yes, they know and agree
They know, but haven't agreed yet
They don't know yet
They can't make this decision themselves
That's fine for now. Before we speak to any provider about them by name, we'll need their agreement, so it's worth talking with them soon. We're happy to suggest how.
Thank you. We'll work with you in their best interests. Anything that needs signing will need whoever holds the legal authority.
What do you need to decide?
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Whether staying at home can still work
Which type of care is right
Which care home or care provider to choose
How care will be paid for
Care needed quickly, for example after a hospital stay
How two people can stay together
Something else
In your own words, what decision are you trying to make?
*
What has happened recently that has led you to look for care now?
*
Who else is involved in decisions?
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About the person needing care
Needs, health and daily life. This is what decides which types of care, and which places, are really suitable. Answer as well as you can; "not sure" is fine.
Their first name
*
Age
*
Living situation now
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Please Select
At home, alone
At home, with a partner
With family
Sheltered housing or retirement living
In a care home
In hospital
Somewhere else
Which hospital, and the expected discharge date if known?
Current postcode
*
Is the current situation safe for now?
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Yes, for now
Just about, but it's under strain
No, something needs to change soon
Not sure
The health picture, in your own words
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Over the last 6 to 12 months, care needs have:
*
Stayed about the same
Got gradually worse
Got suddenly worse, after an illness, fall or other event
Gone up and down
Improved
Not sure
Are needs expected to increase?
Yes, a doctor or nurse has said so
Probably
Probably not
Not sure
Conditions that apply
Dementia (diagnosed)
Memory problems (not diagnosed)
Stroke
Parkinson's
MS or motor neurone disease
Heart condition
Breathing condition, such as COPD
Diabetes
Cancer
Frailty or repeated falls
Sight loss
Hearing loss
Learning disability
Mental health condition
Receiving end-of-life care
None of these
Not sure
Other
Other conditions
Memory and understanding
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No concerns
Some forgetfulness, but manages day to day
Needs reminders and some supervision
Often confused, or needs someone nearby most of the time
Not sure
Mobility
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Walks without help
Walks with a stick or frame
Uses a wheelchair some of the time
Uses a wheelchair all of the time
Needs one person to help with transfers
Needs two people or a hoist
Mostly in bed
Stairs
Manages stairs alone
Manages stairs with help
Can't manage stairs
Not sure
Falls in the last six months
None
One
Two or three
Four or more
Not sure
Washing, dressing and personal care
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Manages independently
Needs prompting or some help
Needs full help
Continence
No help needed
Occasional accidents
Uses pads regularly
Catheter or stoma
Prefer not to say
Nights
Sleeps through
Up in the night but manages alone
Needs help during the night
How often, and what help is needed?
Eating and drinking
Independent
Needs some help or encouragement
Needs a modified diet (soft, puréed or thickened fluids)
Tube-fed (PEG)
Medication
Manages own medication
Needs reminders
Needs medication given
Not sure
Any nursing tasks?
None
Wound or pressure-sore care
Catheter care
Insulin injections
Other injections
Oxygen
PEG feeding
Palliative care or a syringe driver
Not sure
For each, how often, and who does it now?
Wellbeing and behaviour needs
None
Walking with purpose or trying to leave
Distress or agitation
Declining care
Verbal or physical aggression
Unsettled at night
Low mood or withdrawal
Other
What tends to cause distress, and what helps them settle?
Which of these are a struggle now?
Cooking or preparing food
Shopping
Housework and laundry
Managing money and post
Using the phone or calling for help
Using the cooker and appliances safely
Going out alone
None of these
Language, hearing or sight needs
What does a good day look like?
What has been said about what's wanted, or not wanted?
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About the second person
The same questions, for the second person.
First name (second person)
Age (second person)
Living situation now (second person)
At home, alone
At home, with a partner
With family
Sheltered housing or retirement living
In a care home
In hospital
Somewhere else
Which hospital, and the expected discharge date if known? (second person)
Current postcode (second person)
Is the current situation safe for now? (second person)
Yes, for now
Just about, but it's under strain
No, something needs to change soon
Not sure
The health picture, in your own words (second person)
Over the last 6 to 12 months, care needs have: (second person)
Stayed about the same
Got gradually worse
Got suddenly worse, after an illness, fall or other event
Gone up and down
Improved
Not sure
Are needs expected to increase? (second person)
Yes, a doctor or nurse has said so
Probably
Probably not
Not sure
Conditions that apply (second person)
Dementia (diagnosed)
Memory problems (not diagnosed)
Stroke
Parkinson's
MS or motor neurone disease
Heart condition
Breathing condition, such as COPD
Diabetes
Cancer
Frailty or repeated falls
Sight loss
Hearing loss
Learning disability
Mental health condition
Receiving end-of-life care
None of these
Not sure
Other
Other conditions (second person)
Memory and understanding (second person)
*
No concerns
Some forgetfulness, but manages day to day
Needs reminders and some supervision
Often confused, or needs someone nearby most of the time
Not sure
Mobility (second person)
*
Walks without help
Walks with a stick or frame
Uses a wheelchair some of the time
Uses a wheelchair all of the time
Needs one person to help with transfers
Needs two people or a hoist
Mostly in bed
Stairs (second person)
Manages stairs alone
Manages stairs with help
Can't manage stairs
Not sure
Falls in the last six months (second person)
None
One
Two or three
Four or more
Not sure
Washing, dressing and personal care (second person)
*
Manages independently
Needs prompting or some help
Needs full help
Continence (second person)
No help needed
Occasional accidents
Uses pads regularly
Catheter or stoma
Prefer not to say
Nights (second person)
Sleeps through
Up in the night but manages alone
Needs help during the night
How often, and what help is needed? (second person)
Eating and drinking (second person)
Independent
Needs some help or encouragement
Needs a modified diet (soft, puréed or thickened fluids)
Tube-fed (PEG)
Medication (second person)
Manages own medication
Needs reminders
Needs medication given
Not sure
Any nursing tasks? (second person)
None
Wound or pressure-sore care
Catheter care
Insulin injections
Other injections
Oxygen
PEG feeding
Palliative care or a syringe driver
Not sure
For each, how often, and who does it now? (second person)
Wellbeing and behaviour needs (second person)
None
Walking with purpose or trying to leave
Distress or agitation
Declining care
Verbal or physical aggression
Unsettled at night
Low mood or withdrawal
Other
What tends to cause distress, and what helps them settle? (second person)
Which of these are a struggle now? (second person)
Cooking or preparing food
Shopping
Housework and laundry
Managing money and post
Using the phone or calling for help
Using the cooker and appliances safely
Going out alone
None of these
Language, hearing or sight needs (second person)
What does a good day look like? (second person)
What has been said about what's wanted, or not wanted? (second person)
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Current support and assessments
Support in place now
None yet
Family or friends
Visiting carers
Live-in carer
Day centre
Respite stays
Already in a care home
How many visits a day, and who arranges them?
Roughly how many hours a week of help do family or friends give?
None
Under 5
5 to 20
20 to 35
More than 35
Not sure
What isn't working, or has gone wrong?
If someone is the main carer, how are they coping?
Which assessments have happened?
Council needs assessment
Carer's assessment
Financial assessment (means test)
Jersey Long-Term Care assessment
NHS Continuing Healthcare checklist
NHS Continuing Healthcare full assessment
Occupational therapy assessment
Hospital discharge assessment
None yet
Not sure
What did they conclude, and roughly when?
Professionals involved
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What you're looking for
Where will care be arranged?
*
England
Wales
Jersey
Not decided yet
Types of care being considered
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Care at home (visiting carers)
Live-in care
Residential care home
Nursing home
Specialist dementia care
Assisted living or extra-care housing
A short stay or respite first
Not sure, please advise
Open to other options?
Yes, if you think something else would suit better
No, the type of care is decided
Staying together
Must share a room
Same home, separate rooms is fine
Nearby is fine
Needs are different, open to advice
Where should care be? Postcode or town
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Where do the main visitors live? Postcode or town
Longest reasonable journey for regular visits
Up to 15 minutes
Up to 30 minutes
Up to 45 minutes
Up to an hour
Distance isn't the main factor
Anything else about location?
Areas to avoid, a reason to move closer to family, a church or community to stay near.
When does care need to start?
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As soon as possible
Within a month
In one to three months
In three to six months
Planning for later
Is a date driving this?
For example a discharge date, a carer's operation or a house sale.
Essentials
En-suite
Ground floor or lift
Garden or outdoor space
Room for own furniture
Pets welcome
Smoking area
Flexible visiting
Good activities
Near public transport
Wi-Fi and video calls
Anything that would rule a place out? And any nice-to-haves?
Faith, cultural, dietary or language needs
Places already visited, considered or ruled out
Names and what you thought. It saves us calling somewhere you've already ruled out.
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Funding and money
Money questions use ranges, not exact figures. They decide which funding rules apply and which options are realistic. Everything is confidential. "Prefer not to say" is always fine, though the funding part of your report will then be more general.
For two people, give combined figures, and use the last box on this page to tell us how things are split.
Savings and investments, not counting the home
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Under £14,250
£14,250 to £23,250
£23,250 to £50,000
£50,000 to £100,000
£100,000 to £250,000
Over £250,000
Not sure
Prefer not to say
Home
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Owned outright
Owned with a mortgage
Owned jointly with a partner
Owned jointly with someone else
Rented from the council or a housing association
Rented privately
Already sold
No property of their own
Plans for the home
Keep it
Sell it
Rent it out
Undecided
Rough value of the home
Under £200,000
£200,000 to £400,000
£400,000 to £700,000
Over £700,000
Not sure
Will anyone else still live in the home?
Nobody
A partner or spouse
A relative aged 60 or over
A relative with a disability
A child under 18
Someone else
Regular income
State pension
Private or workplace pension
Attendance Allowance
Pension Credit
PIP or DLA
Jersey Long-Term Care benefit
Jersey income support
Other income, such as rent or an annuity
Not sure
Total income, roughly, per week
Under £250
£250 to £400
£400 to £600
Over £600
Not sure
Prefer not to say
Council funding
Not involved yet
Waiting for an assessment
Assessed: the council will contribute
Assessed: self-funding
Not sure
NHS Continuing Healthcare
Never raised
Checklist done, waiting
Assessed and eligible
Assessed and not eligible
Challenging a decision
Not sure
Jersey Long-Term Care scheme
Not applied yet
Assessed, waiting for the outcome
Receiving support
Not sure
What weekly amount could be paid comfortably, from all sources?
*
Under £800
£800 to £1,000
£1,000 to £1,200
£1,200 to £1,400
£1,400 to £1,600
£1,600 to £2,000
Over £2,000
Not sure
And the most that could be paid each week, if the right place needed it?
*
Under £800
£800 to £1,000
£1,000 to £1,200
£1,200 to £1,400
£1,400 to £1,600
£1,600 to £2,000
Over £2,000
Not sure
How much could family contribute each week as a top-up, if needed?
Nothing
Up to £100
£100 to £250
£250 to £500
Over £500
Not sure
Anything else about money?
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Your priorities
Your answers here shape what the report focuses on and how it's written.
What have you already tried, or been told?
What worries you most?
What would make this report most useful to you?
Who is likely to read the report?
*
Just me
My partner
The person the care is for
Other family members or friends
A professional, such as a solicitor or social worker
Not sure yet
Anything else we should know?
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Check and send
Use Back to check any answer. Once you send, we'll begin straight away.
The information I've given is accurate to the best of my knowledge.
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I agree
I agree to Rowan Care Advisory using the health and personal information in this form to research and prepare my report, as set out in the privacy notice at rowancareadvisory.co.uk/#privacy.
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I agree
I confirm that the people this form is about have agreed to me sharing it, or that I'm acting with the authority, or in the best interests, described earlier.
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I agree
I've read and accept the terms of engagement.
*
I agree
I'd like the research to start straight away. I understand that I lose my right to cancel once my report has been delivered, and that if I cancel before then, I pay for the work already done.
*
I agree
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