1. Medical Information

• Summary of diagnosis and reason for hospital admission
• Details of treatment received during hospital stay
• Discharge letter and medication list
• Follow-up appointments scheduled (GP, physiotherapy, specialist, etc.)

2. Mobility and Equipment

• Current mobility level (e.g., walking independently, using a frame, bedbound)
• Equipment needs arranged (e.g., walking frame, commode, hospital bed)
• Occupational therapy and physiotherapy input assessed
• Home environment assessed for accessibility and safety (stairs, handrails, etc.)

 3. Personal Care and Daily Living

• Level of support needed with washing, dressing, toileting
• Support required for meals, drinks, medication prompts
• Plans in place for shopping, cleaning, laundry (if applicable)
• Contingency plan if family are unable to assist

4. Medications

• Up-to-date list of prescribed medications
• Confirmation of who will collect or deliver prescriptions
• Clear instructions on how and when to take medications
• Need for carer support to prompt/administer medications

 5. Ongoing Health Monitoring

• Signs and symptoms to watch for (e.g., infection, pain, confusion)
• Who to contact if concerns arise (GP, district nurse, Bluebird Care, 111/999)
• Consent given to share discharge information with care provide

6. Care at Home Arrangements

• Family or informal carers briefed and available
• Professional care arranged (e.g., Bluebird Care start date and schedule)
• Personalised care plan created or reviewed
• Review date set to assess progress and adjust support

7. Emotional & Social Wellbeing

• Emotional needs considered - any anxiety, confusion, loneliness?
• Activities and interests discussed (music, hobbies, conversation)
• Plans for social interaction or companionship support

8. Legal & Financial Considerations

• Lasting Power of Attorney (Health & Welfare / Finances) in place if needed
• Funding clarified – NHS, social care, or private care
• Relevant benefits checked (Attendance Allowance, PIP, etc.)