Home Safety Checklist

Home Safety Checklist
Client Name:*

First NameLast Name
Date of Birth:*

DayMonthYear
Date
Client record Number:
Clients Address

Street Address

Street Address Line 2

CityState

Postcode
Contact peron, if not the client:

First NameLast Name
Telephone Number:
Identifying features of the house if isolated or difficult tofind/identify (eg map reference, directions)
Location of entrance door – (tick the box)

FrontSideBackOther
If other please explain here:
Type of dwelling – (tick the box)

HouseFlat/UnitMulti LevelResidential FacilityRural
Section One - To be completed PRIOR to the first home visit.

Suggested – Home visit risk assessment introductory statement (Can be read out over the phone to explain why we need to do the risk assessment)

This agency has a duty of care to make sure that all staff are safe at work – so it is routine for us to ask some questions before we visit you at home. I need to ask you about pets, firearms, smoking, infectious diseases – we ask these questions of all clients.
OCCUPANTS
Do you have religious or cultural needs our staff should be sensitive to?*

YesNoUnsure
Are there others who live at your premises? Please list on client file:*

YesNoUnsure
Do you currently have a nominated authorised representative, Community Treatment order or similar?*

YesNoUnsure
Is anyone living at the premises known to be potentially aggressive or violent?*

YesNoUnsure
Are there any firearms at the property?*

YesNo
If yes are they appropriately secured?*

YesNo
Hazards
Are the clients or others living at the premises smokers? Explain smoking policy*

YesNoUnsure
Does any occupant have or been recently exposed to an infectious disease, eg chicken pox, shingles, influenza, gastro?*

YesNoUnsure
If you would like to take a photograph of any hazards click "Take Photo"

"Take Photo"

Cancelof
Access
Are there any access problems, eg clear pathway, easy to open door/gate?*

YesNoUnsure
Are there any pets/animals on the premises? Explain the policy.*

YesNoUnsure
Is there any difficulty with mobile phone coverage and/or a working landline?*

YesNoUnsure
If you would like to take a photograph of any access issues click "Take Photo"

"Take Photo"

Cancelof
Section 1 Completed by, Name:

First NameLast Name
Agency Name:
Date

DayMonthYear
Date
Please sign here using a soft touch pen:*

Clear
Section Two - To be completed AT first home visit
Occupants
Is there any observable evidence that client/other occupants are involved in substance abuse?*

YesNoUnsure
Is there any evidence that weapons (eg guns), are on the premises?*

YesNoUnsure
Hazards
Smoke detectors – are they installed and operational?

YesNoUnsure
Is there adequate lighting – indoors/outdoors?

YesNoUnsure
Basic amenities – is there access to running water and rubbish disposal?

YesNoUnsure
Pressurised cylinders?

YesNo
Are/is they/it safely positioned away from naked flames?

YesNoUnsure
Is there a biological hazard on the premises, eg body fluids, dressings?*

YesNoUnsure
Is there evidence of immediate danger to the client or staff?*

YesNoUnsure
If you wish to take any photos of any hazards, click "Take Photo"

"Take Photo"

Cancelof
Access
Is entry to the premises free of impediment and visible from the street?

YesNoUnsure
Is parking adequate on the street?

YesNoUnsure
Are there two safe exit points - from the building and property in an emergency?

YesNoUnsure
Are the premises free from clutter and safe for the worker to undertake their duties?

YesNoUnsure
If you wish to take any photos of any access issues, click "Take Photo"

"Take Photo"

Cancelof
Section 2 completed by, Name:

First NameLast Name
Agency Name:
Date

DayMonthYear
Date
Please sign here using a soft touch pen:

Clear
Grampians Region
Agency Risk Report

NB When completing the Check List on Page One ensure that any boxes you tick which are marked with an asterisk are reported in the Agency Risk Report below.
Client Name:

First NameLast Name
Date of Birth:

DayMonthYear
Date
Client Record Number:
Occupants - Concern
E.G. 1: 19/12/08 Client has previously used this service – was verbally abusive to staff
ACTION TAKEN - BY WHOM - REVIEW DATE
E.G. Reviewed with supervisor, agreed to give client another opportunity – assessmentvisit to address issues of abuse and service will be withdrawn if abuse is evident –service delivery staff to advise assessment officer of any abuse
HAZARD - CONCERN
E.G. 1: 19/12/08 Client has a number of loose mats with curled ends – slip hazard.
ACTION TAKEN - BY WHOM - REVIEW DATE
E.G. Discussed with client, alerted her to danger, she will have family remove them forher – service delivery staff to advise this has been done at first visit – mats to beremoved are from lounge, bedroom, passageway.
ACCESS - CONCERN
E.G. 1: 19/12/08 Client in a small unit with only front entry door – no back exit.
ACTION TAKEN - BY WHOM - REVIEW DATE
E.G.Discussed with relevant supervisor – exit via front door clear and easy to use,service delivery staff to be advised to ensure that they do not block the front doorwith equipment during their time at the unit
ASSESSMENT HOME VISIT DECISION
Risk analysis indicates that it will be appropriate for just one staff member to attend the initial visit

YesNo
Risk analysis indicates that it is appropriate for two staff members to attend the initial visit. NB All risks need to be addressed prior to initial visit – two staff attending does not necessarily reduce the risk.

YesNo
Risk analysis indicates that the issues identified above need to be addressed before a staff member can complete the initial visit

YesNo
Agency Risk Report completed by (name):

First NameLast Name
Please sign here using a soft touch pen:

Clear
Agency Name:
Date

DayMonthYear
Date
Client/Carer please sign here using a soft touch pen:

Clear
Present at the assessment:

First NameLast Name
Date

DayMonthYear
Date
Review date for monitoring action taken by client/carer:

DayMonthYear
Date
The Assessment Home Visit Decision above is not a directive or advice for other agencies – it is the opinion of the person completing it – each agency receiving a copy of this form is responsible for its own staff and any consequent decisions as to the risk of visiting this client in their home. The decision as to home visit safety can be amended following a change in client circumstances.

• It is recommended that this checklist be repeated/reviewed annually or when the client situation changes, eg move house.
• This Service Provider Home Safety Checklist and Agency Risk Report was developed by the Ballarat Partnering Project (2008/9).

The original Home Safety Checklist on which this work was based and developed under the auspice of the Central Highlands Primary Care Partnership, Service Coordination Sub-Committee.
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