Title Page

  • Conducted on

  • Prepared by

  • Assessment Location
  • What is the main user group for this location?

Bedrooms & Bays

  • Room Designations/ Numbers

Windows

  • Window Frame

  • Window Handles

  • Window Hinges

  • Window Restrictors

  • Other Ligatures (specify)

  • Notes

Window Coverings

  • Curtains

  • Louvre Blinds

  • Venetian Blinds

  • Hanging Track

  • Other (specify)

  • Notes

Doors

  • Frame

  • Handle

  • Hinges

  • Closer

  • Lock

  • Other (specify)

  • Notes

Ceilings

  • Solid Plaster

  • False/ Suspended Ceiling & Tiles

  • Air Vents/ Diffusers

  • Light Fittings

  • Alarm Detector Heads

  • Hatches

  • Pull Switches

  • Other (specify)

  • Notes

Walls

  • Wall Lights

  • Pictures

  • Mirrors

  • Switches

  • Plug Sockets

  • Call Bells

  • Gas Supply Pipes

  • Radiators and Pipes

  • Vents/ Extractors

  • Alarm Housings

  • Grab Rails

  • TV Brackets

  • Bed Bumpers

  • Shelves

  • Cabinets

  • Hooks

  • Other (specify)

  • Notes

Sinks

  • Sink

  • Taps

  • Soap/ Cleaner Dispensers

  • Towel Holder

  • Plug

  • Pipework

  • Other (specify)

  • Notes

Bed

  • Make and Model

  • Can bed be upended?

  • Power Cables

  • Control Cables

  • Headboard

  • Footboard

  • Linen Tray

  • Bed rails

  • Bed Base

  • Drawers

  • Bed frame

  • Other (specify)

  • Notes

Wardrobes/ Cupboards/ Cabinets

  • Furniture types

  • Door

  • Handle

  • Hinge

  • Lock

  • Rail

  • Coat Hook

  • Shelves

  • Hangers

  • Other (specify)

  • Notes

Other Furniture

  • Chairs

  • Tables

  • Bean bags

  • Other (specify)

  • Notes

Electrical Equipment

  • Equipment Present

  • Cables

  • Other (specify)

  • Notes

Bathrooms, En-Suites, Shower Rooms & Toilets

  • Room Designations/ Numbers

Windows

  • Window Frame

  • Window Handles

  • Window Hinges

  • Window Restrictors

  • Other Ligatures (specify)

  • Notes

Window Coverings

  • Curtains

  • Louvre Blinds

  • Venetian Blinds

  • Hanging Track

  • Other (specify)

  • Notes

Doors

  • Frame

  • Handle

  • Hinges

  • Closer

  • Lock

  • Other (specify)

  • Notes

Ceilings

  • Solid Plaster

  • False/ Suspended Ceiling & Tiles

  • Air Vents/ Diffusers

  • Light Fittings

  • Alarm Detector Heads

  • Hatches

  • Pull Switches

  • Other (specify)

  • Notes

Walls

  • Wall Lights

  • Pictures

  • Mirrors

  • Switches

  • Plug Sockets

  • Call Bells

  • Gas Supply Pipes

  • Radiators and Pipes

  • Vents/ Extractors

  • Alarm Housings

  • Grab Rails

  • TV Brackets

  • Bed Bumpers

  • Shelves

  • Cabinets

  • Hooks

  • Other (specify)

  • Notes

Sinks

  • Sink

  • Taps

  • Soap/ Cleaner Dispensers

  • Towel Holder

  • Plug

  • Pipework

  • Other (specify)

  • Notes

Baths

  • Bath

  • Grab rails/ Handles

  • Taps

  • Soap/ Cleaner Dispensers

  • Towel Holder

  • Plug

  • Pipework

  • Other (specify)

  • Notes

Shower

  • Shower

  • Grab rails/ Handles

  • Shower controls

  • Shower Head

  • Shower Head Hose

  • Soap/ Cleaner Dispensers

  • Towel Holder

  • Pipework

  • Shower Chair/ Seat

  • Other (specify)

  • Notes

Shared Rooms [Lounges, therapy rooms, dining rooms, etc]

  • Room Designations/ Numbers

Windows

  • Window Frame

  • Window Handles

  • Window Hinges

  • Window Restrictors

  • Other Ligatures (specify)

  • Notes

Window Coverings

  • Curtains

  • Louvre Blinds

  • Venetian Blinds

  • Hanging Track

  • Other (specify)

  • Notes

Doors

  • Frame

  • Handle

  • Hinges

  • Closer

  • Lock

  • Other (specify)

  • Notes

Ceilings

  • Solid Plaster

  • False/ Suspended Ceiling & Tiles

  • Air Vents/ Diffusers

  • Light Fittings

  • Alarm Detector Heads

  • Hatches

  • Pull Switches

  • Other (specify)

  • Notes

Walls

  • Wall Lights

  • Pictures

  • Mirrors

  • Switches

  • Plug Sockets

  • Call Bells

  • Gas Supply Pipes

  • Radiators and Pipes

  • Vents/ Extractors

  • Alarm Housings

  • Grab Rails

  • TV Brackets

  • Bed Bumpers

  • Shelves

  • Cabinets

  • Hooks

  • Other (specify)

  • Notes

Sinks

  • Sink

  • Taps

  • Soap/ Cleaner Dispensers

  • Towel Holder

  • Plug

  • Pipework

  • Other (specify)

  • Notes

Wardrobes/ Cupboards/ Cabinets

  • Furniture types

  • Door

  • Handle

  • Hinge

  • Lock

  • Rail

  • Coat Hook

  • Shelves

  • Hangers

  • Other (specify)

  • Notes

Other Furniture

  • Chairs

  • Tables

  • Bean bags

  • Other (specify)

  • Notes

Electrical Equipment

  • Equipment Present

  • Cables

  • Other (specify)

  • Notes

Corridors & Circulation Spaces

  • Room Designations/ Numbers

Windows

  • Window Frame

  • Window Handles

  • Window Hinges

  • Window Restrictors

  • Other Ligatures (specify)

  • Notes

Window Coverings

  • Curtains

  • Louvre Blinds

  • Venetian Blinds

  • Hanging Track

  • Other (specify)

  • Notes

Doors

  • Frame

  • Handle

  • Hinges

  • Closer

  • Lock

  • Other (specify)

  • Notes

Ceilings

  • Solid Plaster

  • False/ Suspended Ceiling & Tiles

  • Air Vents/ Diffusers

  • Light Fittings

  • Alarm Detector Heads

  • Hatches

  • Pull Switches

  • Other (specify)

  • Notes

Walls

  • Wall Lights

  • Pictures

  • Mirrors

  • Switches

  • Plug Sockets

  • Call Bells

  • Gas Supply Pipes

  • Radiators and Pipes

  • Vents/ Extractors

  • Alarm Housings

  • Grab Rails

  • TV Brackets

  • Bed Bumpers

  • Shelves

  • Cabinets

  • Hooks

  • Other (specify)

  • Notes

Wardrobes/ Cupboards/ Cabinets

  • Furniture types

  • Door

  • Handle

  • Hinge

  • Lock

  • Rail

  • Coat Hook

  • Shelves

  • Hangers

  • Other (specify)

  • Notes

Other Furniture

  • Chairs

  • Tables

  • Bean bags

  • Other (specify)

  • Notes

Electrical Equipment

  • Equipment Present

  • Cables

  • Other (specify)

  • Notes

Any other ligature issues

  • Other (specify)

  • Notes

The Following rooms were found to be unlocked & unsupervised during the visit

  • Room Designations/ Numbers

Windows

  • Window Frame

  • Window Handles

  • Window Hinges

  • Window Restrictors

  • Other Ligatures (specify)

  • Notes

Window Coverings

  • Curtains

  • Louvre Blinds

  • Venetian Blinds

  • Hanging Track

  • Other (specify)

  • Notes

Doors

  • Frame

  • Handle

  • Hinges

  • Closer

  • Lock

  • Other (specify)

  • Notes

Ceilings

  • Solid Plaster

  • False/ Suspended Ceiling & Tiles

  • Air Vents/ Diffusers

  • Light Fittings

  • Alarm Detector Heads

  • Hatches

  • Pull Switches

  • Other (specify)

  • Notes

Walls

  • Wall Lights

  • Pictures

  • Mirrors

  • Switches

  • Plug Sockets

  • Call Bells

  • Gas Supply Pipes

  • Radiators and Pipes

  • Vents/ Extractors

  • Alarm Housings

  • Grab Rails

  • TV Brackets

  • Bed Bumpers

  • Shelves

  • Cabinets

  • Hooks

  • Other (specify)

  • Notes

Sinks

  • Sink

  • Taps

  • Soap/ Cleaner Dispensers

  • Towel Holder

  • Plug

  • Pipework

  • Other (specify)

  • Notes

Baths

  • Bath

  • Grab rails/ Handles

  • Taps

  • Soap/ Cleaner Dispensers

  • Towel Holder

  • Plug

  • Pipework

  • Other (specify)

  • Notes

Showers

  • Shower

  • Grab rails/ Handles

  • Shower controls

  • Shower Head

  • Shower Head Hose

  • Soap/ Cleaner Dispensers

  • Towel Holder

  • Pipework

  • Shower Chair/ Seat

  • Other (specify)

  • Notes

Beds

  • Make and Model

  • Can bed be upended?

  • Power Cables

  • Control Cables

  • Headboard

  • Footboard

  • Linen Tray

  • Bed rails

  • Bed Base

  • Drawers

  • Bed frame

  • Other (specify)

  • Notes

Wardrobes/ Cupboards/ Cabinets

  • Furniture types

  • Door

  • Handle

  • Hinge

  • Lock

  • Rail

  • Coat Hook

  • Shelves

  • Hangers

  • Other (specify)

  • Notes

Other Furniture

  • Chairs

  • Tables

  • Bean bags

  • Other (specify)

  • Notes

Electrical Equipment

  • Equipment Present

  • Cables

  • Other (specify)

  • Notes

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