APPENDIX 3

INDIVIDUAL SERVICE CONTRACT (ISC) FOR CARE HOME SERVICES

Date of ISC:	Click or tap to enter a date.

This Individual Service Contract (“ISC”) is made under the terms and conditions of the Contract (“the Contract”) for the provision of Care Home Services (April 2020), and includes the Service Specification (“the Service Specification”) made between City and County of Cardiff County Council/ the Vale of Glamorgan Council (“the Council”) and/or the Cardiff and Vale University Health Board (“the UHB”) ,if applicable and Insert name of TPP».

Name of Service User:

Client No:

Date of Birth of Service User:	Click or tap to enter a date.

Name of Care Home:

Address of Care Home:

Category (s) of Care:

Trial Period*

Respite (Social Care)

Respite (Healthcare)

Temporary Placement (Social Care)

Temporary Placement (Healthcare)

Permanent Residential Care (Social Care)

Permanent Nursing Care

Continuing Health Care

* N.B: Unless otherwise notified, at the end of the 6-week trial period the placement will automatically become a permanent placement. An amended ISC will only be sent by the Service Purchaser(s) for signature by the Service Provider and Service User/Service User’s Representative if there is a change to the Rate.

Period of Care (please stipulate if known)	From	Click or tap to enter a date.

Until	Click or tap to enter a date.

Has this service user been assessed as self-funding?

Yes

No

Not applicable (e.g. CHC/FNC)*

Finance assessment not yet complete

Consent to disclose withheld by service user/representative

* Not to be used for placements commissioned by Social Services

Financial Arrangements:

The Weekly Rate (for AA and PIP cases)	£

From: Click or tap to enter a date. to: Click or tap to enter a date.

Resident’s Contribution	£
Third Party Payment	£
UHB Payment	£
Social Services Payment	£
Social Services FNC Payment (nursing placements only)	£

The Weekly Rate	(during property disregard)	£

From: Click or tap to enter a date. to: Click or tap to enter a date.

Resident’s Contribution	£
Third-Party Payment	£
UHB Payment	£
Social Services Payment	£
Social Services FNC Payment (nursing placements only)	£

The Weekly Rate (thereafter)	£

From: Click or tap to enter a date. to: Click or tap to enter a date.

Resident’s Contribution	£
Third Party Payment	£
UHB Payment	£
Social Services Payment	£
Social Services FNC Payment (nursing placements only)	£

Any element of funded nursing care will be paid directly by the Local Health Board

Any Third-Party Payment will be paid directly to the Provider by:

The Provider agrees to provide care to the Service User in accordance with the Contract including the Service Specification and Care and Support Plan.

This ISC will terminate on the Expiry Date and may be terminated in any of the circumstances set out in the Contract.

This ISC may be amended by agreement and upon the issue of a revised Care and Support Plan, and such revised Care and Support Plan shall be deemed to form part of this ISC.

The ISC will be reviewed on an annual basis as a minimum.

Individual Service Contract in respect of:

SIGNATURE for and on behalf of Provider:

………………….………………………………	Print Name :…………………………………

Position :………………………………….…..	Date:………………………………….

SIGNATURE for and on behalf of the Council :

…………………………….…………………..	Print Name : …………………………………

Position : ……………………………………	Date …………………………………

SIGNATURE for and on behalf of the University Health Board (where applicable) :

……………..……………………………..	Print Name:……………………….......

Position: …………………………………	Date:…………………………………

SIGNATURE of Service User/Service User’s Representative :

……………..………………………………	..	Print Name:……………………….......

Legal Status (if applicable): …………………………………..

Date: ………………………………