Consent & Declarations SERVICE USER CONSENT & DECLARATIONS (QMS-F059) Contact Document Ref: QMS-F059 (Service User Consent) Version: 1.0 Confidentiality Level: HIGH (Restricted Access) CQC Alignment: Effective (Consent to Care) ISO 9001:2015 Requirement: Section 8.2.3 (Review of Requirements for Services) Service User Full NameService User ID NumberOperating Local Authority- Select -HaringeyIslingtonWaltham ForestBarnetOtherCare Funding & Financial Arrangements- Select -Local Authority Managed (Direct Commissioning)NHS Funded (Continuing Healthcare - CHC)Direct Payments (Personal Budgets)Self-Funded (Full Cost)OtherSECTION 1 - Care Provision & AccessGeneral Care Consent I consent to Mutima Care staff providing the care and support detailed in my Care Plan. I consent to Mutima Care staff entering my home at the agreed times to deliver this service. I consent to Mutima Care taking appropriate emergency action, including contacting 999, my GP, or my Next of Kin, if I am found unwell or unresponsive. I consent to Mutima Care sharing my relevant health and social care records with third-party professionals (e.g., District Nurses, Social Workers) when strictly necessary for my safety and continuity of care. I understand that I can withdraw or amend this consent at any time by contacting the Registered Manager.Does the Service User require Mutima Care staff to administer or prompt medication?- Select -YesNoMedication Consent- Select -I consent to Mutima Care staff supporting me with my medication as detailed in my Medication Administration Record (MAR)Does the Service User require Mutima Care staff to handle cash, bank cards, or shopping?- Select -YesNoFinancial Consent- Select -I consent to Mutima Care staff handling my finances for specific agreed tasks, and I understand all transactions will be recorded and receipted.Primary Home Access & Security Permission- Select -Key SafeManual EntryCommunal Door / IntercomPhysical Key HeldHigh-Risk Security Protocol- Select -Management Alert: I confirm that a formal Key Holding Risk Assessment and Key Receipt Log will be completed and signed before the physical key is accepted by Mutima Care.SECTION 2 - Information Sharing (GDPR)Medical & Emergency Data Sharing- Select -I consent to Mutima Care sharing relevant personal data with my GP, District Nurses, and emergency services (Ambulance/Police) if my health or safety is at direct risk.Local Authority & Commissioning Data Sharing- Select -I consent to Mutima Care sharing my records with the Local Authority Commissioning Team for auditing and funding purposes.N/A - My care is entirely privately funded.Family & Next of Kin Sharing- Select -I give full consent for Mutima Care to discuss my care, health, and finances with my nominated Next of Kin.I give partial consent for Mutima Care to discuss my care with my Next of Kin, BUT NOT my finances.I DO NOT give consent for Mutima Care to discuss my care with anyone without asking me first.Custom/Specific Boundaries Apply (Please Specify)Specific Data Sharing BoundariesSECTION 3 - Specific Delegated ConsentsMedication Support & Administration- Select -Agency SupportSelf-AdministrationThird-Party AdministrationFinancial Transactions & Shopping Consent- Select -Consent GrantedConsent Declined / Not RequiredSECTION 4 - Declarations & SignaturesWho is completing this declaration?- Select -The Service UserA legally appointed representative (e.g., Power of Attorney / Deputy)Representative Name & Legal StatusService User Guide & Terms- Select -I confirm I have received, read, and understood the Mutima Care Service User Guide, Complaints Procedure, and Terms & Conditions.Name of Service User / Representative (Digital Signature)Date of AssessmentMutima Care Assessor Declaration- Select -I confirm I have discussed these consent declarations with the Service User/Representative, verified any legal authority documents, and authorize this consent profile for Mutima Care.Submit Legal Consent
