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

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.