Topline Care Solutions Ltd

Client Consent Form


Dear ,

This document serves as an official confirmation of the consent areas you have agreed to, as well as any areas where consent was not provided or was not applicable. Below, we have detailed your responses as per the consent form:

 

1. Care and Support

No. Consent Area Yes / No / N/A
1 Carry out a Needs Assessment
2 Carry out a Risk Assessment
3 Provide Personal Care and Support as outlined in the Care Plan
4 Assist with Medication Administration
5 Use Restraint or Restrictive Practices
6 Provide End-of-Life Care

2. Information Sharing and Data Protection

No. Consent Area Yes / No / N/A
7 Share Personal Information with Relevant Agencies or Professionals
8 Contact Your GP to Introduce Ourselves as Your Care Provider
9 Share Information with Safeguarding Authorities if Concerns Arise
10 Store and Process Personal Data in Compliance with GDPR

3. Documentation and Record-Keeping

No. Consent Area Yes / No / N/A
11 Record Information on Daily Care Logs
12 Access Records for Auditing and Inspection Purposes
13 Document and Report Any Incidents or Accidents

4. Monitoring and Quality Assurance

No. Consent Area Yes / No / N/A
14 Monitor and Review Care Package Regularly
15 Conduct Spot-Checks on Care and Support Workers
16 Collect and Use Feedback to Improve Care

5. Specific Care Interventions

No. Consent Area Yes / No / N/A
17 Use a Lap Safety Belt on Your Wheelchair
18 Use Bed Side Rails for Safety
19 Hold a Key to Your Property for Emergency Access

6. Advance Care Planning

No. Consent Area Yes / No / N/A
20 Discuss and Document Your Advance Care Plan
21 Follow Your End-of-Life Care Preferences

7. Capacity to Consent

No. Statement Yes / No
22 Confirm You Have the Capacity to Consent
23 If You Lack Capacity, a Representative Has Been Appointed

8. Client Awareness and Documentation

No. Document Yes / No
24 Statement of Purpose for Topline Care Solutions Ltd. Provided
25 Care and Support Plan Provided
26 Emergency Plan Provided
27 Complaints Procedure Provided

9. Complaints and Feedback

No. Statement Yes / No
28 You Can Raise Complaints or Concerns About Your Care
29 Your Feedback Will Be Used to Improve the Quality of Care

 


This document confirms the consent provided for each specific area and ensures that your preferences and needs are fully understood and respected. We will adhere to the information you have provided, and your data will be processed in accordance with the GDPR, ensuring your privacy and safety at all times.

Please review the details above, and once you are satisfied, kindly sign below to confirm your consent. This signed document will serve as your formal agreement with the care plan and services provided by Topline Care Solutions Ltd.

If you have any questions or require clarification, please do not hesitate to contact us.

Client Signature:

Leave this empty:

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Signed by Maria Podolean
Signed On: 02/04/2025


Signature Certificate
Document name: Client Consent Form
lock iconUnique Document ID: 62f4b56d1d606d50defc22c1ee174ac2bba4a004
Timestamp Audit
01/04/2025 5:45 PM BSTClient Consent Form Uploaded by Maria Podolean - info@toplinecare.solutions IP 62.30.221.119
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