Carer’s Agreement

This is a written agreement between you and the nursing staff which sets out the ways you would like to maintain your role as a carer whilst the person you care for is in Kingston Hospital.

The agreement describes in detail the practical ways we can work together for the benefit the person you care for. It specifies the aspects of care that hospital staff will provide along with those that you will give.

Agreeing or wanting to provide care for someone in hospital does not remove any obligation of care from the hospital and it’s staff.

Guidance notes

• Where more than one person acts as a carer for the same patient, they should also sign the agreement in the section called ‘Other carers’. If this applies, please designate a main carer to co-ordinate a carers’ rota in consultation with the nursing staff.
• The agreement of the patient should be recorded if they are able to express their wishes.
• The agreement and its contents may be reviewed at any time at the request of any of the participants.

Patient’s name	MRN (Medical Record Number)
Date of agreement	Review date/s (minimum weekly review)

Arrangements for visiting and / or staying on the ward (e.g. what days / times, overnight)

Personal Care: what carer/s will do (e.g. washes, baths / showers, dressing etc.)

Personal Care: what hospital staff will do

Mealtimes / Feeding: how carer/s will be involved

Medications: how carer/s can help with administering medication

Examination, Treatment & Consultation: how carer/s can be involved (e.g. present at ward round, aids communication, provides reassurance etc.)

Useful Information for staff about patient’s condition & preferences

Discharge Arrangements: how carer/s will be involved in decision-making

Who carer/s should speak to if concerned about the patient or their own role as carer

Signature of patient (if able)

Name of main carer (PRINT)	Signature
1.	1.
Name(s) of other carer/s (PRINT)	Signature
2.	2.
3.	3.
4.	4.
Name / designation of staff member	Signature