ALHomecare

ALHomecare - Respite Application Form

Important Data Protection Notice: Once completed, this application form will be used only for the purpose of matching a Carer with a Client of ALHomecare.

If you have any questions, please contact:

ALHomecare Data Protection Officer

Contact dpo@alhomecare.ie

Tel: +353877440729

By completing and submitting this application, you are confirming that you have the consent of the Person described in this application who needs care to submit their information on their behalf and that you have their permission to provide this information to ALHomecare for the purposes of sourcing a suitable Carer for them.

If you are submitting this application on your own behalf, you agree that ALHomecare will use the information you have provided for the purposes of sourcing a suitable Carer for you.

By completing and submitting this application, you are confirming that you have read and accepted our Terms & Conditions which are included in our information booklet.

This application form can be completed in a range of formats including Google Forms. If you are completing this through Google Forms, you will see a message from Google immediately below this showing your email address and giving you the option to switch account. If the email address shown is the email address you normally use, then there is no need to switch account and you can disregard that message. If it is not the email address you normally use (perhaps you have more than one email address), click on switch account and choose the email address you wish to use.

Full name of the person(s) needing care *

Please write their official/legal name, not a nickname or any other variant of their official/legal name.
If there is more than one person needing care (e.g. a married couple), a second application form will need to be completed for that second person.

Name of the city, town, village where the Client(s) lives? * Important: If you live in a city, please name the suburb. If you live in the countryside, please name the village nearest you and the distance from your house to that village?

Type of location? *

Countryside

Village

Town

City

Address Line 1 *

Address Line 2 Apartment, suite, unit, building, floor etc.

County *

Eircode *

For countryside placements where a car is not provided for the carer's use and the bus stop is not within walking distance, will a member of your family (or a family representative) help the Carer to get to and from a bus stop on her/his day(s) off? *

Yes

N/A

If you answered No or N/A to the above question, can you explain your answer:

Are you applying for care for yourself? *

Contact Information

Your name *

Phone number *

E-mail(Please provide us with your private/personal email address. For Client and Carer confidentiality, we cannot accept a business/work email address.) *

Preferred contact method *

Where did you hear about ALHomecare? * Please tick all that apply

Social Media

Google

Friend/Family Referral

Newspaper / Radio

Hospital / Nurse / Doctor

Leaflet/Poster

Roadside Billboard

Please give us some more information about how you heard about us? Name of person who told you about ALHomecare or where you saw our leaflet or name of hospital or healthcare professional told you about us or what google search terms did you use?. We really appreciate this information.

If you are applying for care on someone else's behalf, what is your relationship to the person who needs care? (i.e. spouse, child, other)

Client Information

Describe the domestic situation (who lives in the house with the person requiring at the moment?) When the Carer arrives will this situation be the same or different? Do you have relatives living nearby? If yes, how many kilometres away? *

If there is a couple, do both need care?

If you answered yes to the above question, are you willing to pay the 15% supplement for care of 2 people?

What is the Client's age? *

What is the Client's height and weight? * Please provide these measurements in centimetres and kilos

Is active night time care required? i.e. Will the Carer need to routinely get up at night to attend to your relative's care needs during the night e.g. toilet assistance, pad change, turning to prevent bedsores, encourage them back into bed if they wander etc? *

Remember

The Carer will need 11 hours of uninterrupted rest every 24 hours. This means that she/he will be available during a 13 hour window of time every 24 hours to do her/his 7 or 8 hours of work, with breaks in between blocks of work. Carers can provide active daytime or active night time care. One Carer can straddle the late afternoon to early night or early morning to early afternoon....but must still have his/her 11 hours of uninterrupted rest every 24 hours. If active night and active day care (i.e. active 24 hour care) is required then 2 live-in Carers can be supplied or 1 live-in Carer and other visiting care supports may be sufficient to cover active day and active night care.

Does the Client avail of HSE Home Support? (if yes, how many hours per week)? *

Does the Client smoke? *

What are the Client's hobbies & interests *

What medical condition(s) does the Client have? How does their condition affect them day-to-day? Please include any short term or long term infectious condition(s) that your relative may have. * For example heart disease, rheumatism, cancer, dementia, Alzheimer’s, asthma, sight loss, physical condition as result of an accident etc.

If the Client has Alzheimer’s / dementia, please specify: symptoms, type of dementia and stage *

How would you describe the Client’s overall health? *

Good

Slightly Impaired

Substantially impaired

Severely impaired

What is the progression of the Client's condition? *

Stable

Improving

Disimproving

Palliative Care

Which of the below best describes the Client's mobility? *

Very good

Good

Poor

Immobile/stay in bed

Are there stairs in the house? If yes, how does the Client manage with the stairs? *

Does the Client require any aid for walking/moving? * (walking stick, frame, wheelchair etc)

Does the Client have any special equipment to assist them?

Electrically Adjustable Bed

Stair Lift

Walking Frame

Adapted Bathroom with Handrails

Commode

Nebuliser

Hoist

Specially Adapted Car

Which of the above pieces of equipment will the Carer be expected to use (or assist with the use of) during their working day?

Electrically Adjustable Bed

Stair Lift

Walking Frame

Adapted Bathroom with Handrails

Commode

Nebuliser

Hoist

Specially Adapted Car

Is the Client able to walk outside the house or only within the house? *

Does the Client require personal care? * Assisted Daily Living Activities (ADL's) including: (Washing/bathing/hygiene, Grooming, Dressing, Eating/Feeding, Toileting/Continence Care)

What activities can the Client do without assistance? *

Drive their car

Shop for themselves

Do their laundry

Cook for themselves

Take their medication themselves

Client is unable to do any of the above themselves

Does the Client or anyone else in the house drink alcohol? If yes, please give clear details (including level(s) of consumption & how it can affect their behaviour) *

Is their level of alcohol consumption known to their doctor and/or community nurse?

Please leave blank if you the Client does not drink alcohol

Is there any surveillance device in the Client's home? *

If YES, where in the Client's home are the devices located? Note: We are asking you these questions because Carers expect to know this information in advance before accepting the placement.

Does the Client have pets and, if yes, would the Carer be responsible for their care? *

Does the Client have any special dietary requirements? * (allergies, food intolerances etc)

Has the Client had a live-in Carer before? *

Please tell us what your experience was like having a live-in Carer before?

Please leave blank if you did not have a live-in Carer before.

Which grade of Carer do you want? *

ALH Carer Plus

ALH Advanced Carer

Nurse

Carer Requirements

When do you want the Carer to start (approx date)? *

Please note that it takes approximately 2 - 4 weeks, depending on the requirements of the placement from receipt of your application to have a Carer in place. So please allow for this when you are putting in your desired start date below

Do you have a preference for a male or female Carer? *

Female

Male

Open to either

Is there a DNR order in place for the Client? *

DNR Order (do-not-resuscitate order) is a medical order written by a doctor. It instructs health care providers not to do cardiopulmonary resuscitation (CPR) if a patient's breathing stops or if the patient's heart stops beating.

Would you/the Client mind if the Carer smoked? *

(Outside the house only)

Do you require a driver? *

If a driver is required, are you willing to provide a car for the Carer's use and are you prepared to provide car insurance cover for the Carer? *

If a driver is required and driving is part of the Carer's work duties, will the Carer also be allowed to use the car for their personal use in their free time on a work day? *

Will the Carer be allowed to use the car for their personal use on their day(s) off? *

Carer Timetable

We understand that the Carer's duties can change over time. We will use your answers below as a guide for the Carer so she/he knows what will be expected of her.

What days would you like the Carer to work? *

The Carer can work up to 6 days per week but needs a minimum of 1 day off per week.

Note: There is the option, if the Carer wants, to work up to 12 days without a free day and then take 2 days break before continuing on in that same placement or before they start a new placement.

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Which time period during 24 hours do you want the Carer to work? *

Daytime Care Role

The Carer will be working during the day and they will be completely off duty at night and they will just be a passive presence in the house up to 7 nights per week, in case of an emergency.

Night-time Care Role or Active Night Care

The Carer will be working on an on call basis during the night and will be completely off duty during the day.

Please Note:

The Carer must have 11 hours of uninterrupted rest every 24 hours. This means that she/he will be available during a 13 hour window of time every 24 hours to do her/his 7 or 8 hours of work, with breaks in between blocks of work. Carers can provide active daytime or active night-time care. One Carer can straddle the late

afternoon to early night or early morning to early afternoon but must still have her/his 11 hours of uninterrupted rest every 24 hours. If active night and active day care (i.e. active 24 hour care) is required then 2 live-in Carers can be supplied or 1 live-in carer and other visiting care support may be sufficient to cover active day and active night care.

What time do you expect/estimate that the carer will start their work each day? *

What time do you expect/estimate the Carer will finish their work each day (i.e. no more than 13 hours after the Carer's start time above)? *

Note: Bear in mind the 11 hours of uninterrupted rest every 24 hours. So your Carer will need to finish their work, at the latest, 13 hours after they start working that day.

How many hours per day do you expect the Carer will need to work? *

Note: The Carer can work 35 hours work per week across a maximum of 5 days per week with the option to expand the working hours up to a maximum of 48 hours work across a maximum of 7 days per week. The Employee is then entitled to 48 hours rest in the following 7 day period.

Please describe the bedroom which will be provided for the Carer *

(will she share toilet/shower with the Client or has she a separate bathroom/toilet?)

Photos of the Client and their home

As part of the application form, we kindly ask you to upload photos of the Client and their home. These photos will greatly help the Carer to fully understand the nature of the placement. They will be able to see what the Client looks like and what their living environment will be like. From ALHomecare's experiences, providing photos to the Carer gives her the confidence and reassurance that she is making the right decision to accept the placement. If you are not in a position to upload the photos at this time, you can skip this section and submit your application without the photos. However, you should email us the photos to placementdepartment@alhomecare.ie as soon as possible with the name of the Client as the subject of the email and the word "photos".

Please Note: Please upload only photos (not videos) and along with photos of the inside of the Client's house, upload a photo of the Client (but not photos of any other people other than the Client themselves).

We assure you that your application will be password protected and will be shared only with candidates for the live-in carer position.

Please attach a photo of the Client

1 or 2 photos

Please attach a photo of the living room

Please attach a photo of the kitchen

Please attach a photo of the Carer's bathroom or the shared bathroom

Please attach a photo of the Carer's bedroom

Please attach a photo of second bathroom (if applicable)

For Respite placements that are longer than 12 days, the Carer will need regular days off. What supports are in place during the respite placement? (i.e. family, friends, neighbours, HSE Home Support etc.)? *

Anything else you would like us to know about the placement?