Home Visiting Risk Assessment Form

• Client Name

• Contact Number

• Risk Assessment Completed on

  Date

• Person completing Risk Assessment

• Location
  Address

Pre-Visit Case manager confirmation phone call:

• Covid Checklist complete

  Yes

  No

  N/A

• Is the address easy to find?

  Yes

  No

  N/A

• Can the occupant respond to the front door if alone?

  Yes

  No

  N/A

• Is there a recent history of violent aggressive behaviour, history of domestic violence (verbal or physical) or substance abuse

  Yes

  No

  N/A

• Are there known mental health issues?

  Yes

  No

  N/A

• Any known issues with the neighbours or those residing at the property?

  Yes

  No

  N/A

• Presence of firearms? Is the firearm licenced

  Yes

  No

  N/A

• If yes client has agreed to lock firearms away prior to, during & until the staff have left the premises’

  Yes

  No

  N/A

• Does the client live alone?

  Yes

  No

  N/A

• Will others be home for the visit?

  Yes

  No

  N/A

• Do they pose any threat to staff?

  Yes

  No

  N/A

• Whom will be present?

• Are there issues around Infectious diseases or cytotoxic drugs?

  Yes

  No

  N/A

• Are there any unrestrained or aggressive pets/animals on the premises? If so, will the client agree to restraining the animal prior to and during this and subsequent visits?

  Yes

  No

  N/A

• Is car parking available?

  Yes

  No

  N/A

• Is the Property address clearly numbered?

  Yes

  No

  N/A

• Is the house visible from the street with a clear safe path from vehicle to the entry?

  Yes

  No

  N/A

• Is the driveway/road two-wheel drive safe?

  Yes

  No

  N/A

• Is it close to dangerous physical elements e.g. main roads, steep slopes, rivers creeks?

  Yes

  No

  N/A

• In a remote or isolated area?

  Yes

  No

  N/A

• Is there mobile phone coverage?

  Yes

  No

  N/A

• Special entry requirements? (Security, locks, or intercoms)

  Yes

  No

  N/A

• Any Further details regarding access to premises?

• Based on the above answers, should the home visit assessment proceed?

  Yes

  No

  N/A

• If you have concerns regarding home visiting this client, contact your Manager to discuss prior to attending premises.

Hazard Review

Roof Areas

• Any visual guttering not securely attached or leaking onto paths

  Yes

  No

  N/A

• Is the residence single story or split level

  Yes

  No

  N/A

• Does the site have power connected?

  Yes

  No

  N/A

Clothesline

• Stable, adjustable, with suitable access

  Yes

  No

  N/A

• Wires secure and taut

  Yes

  No

  N/A

Balcony/verandah

• Handrail provided when more than 600mm above ground

  Yes

  No

  N/A

Garden/Yard area

• Are access ways clear of branches or debris?

  Yes

  No

  N/A

• Are pathways slippery or have a moss or mildew covering?

  Yes

  No

  N/A

• Are lawns at a level for safe access?

  Yes

  No

  N/A

• Pool on site - is there are fence and lockable gate

  Yes

  No

  N/A

• How are the waste bins taken to the street kerb (will the client need assistance with this)

  Yes

  No

  N/A

Floors/Aisles/Exits

• Are steps even, free from slips hazards, undamaged and are rails in place?

  Yes

  No

  N/A

• Are entry and exit ways obstructed or cluttered?

  Yes

  No

  N/A

• All floors free from slips, uneven surfaces, cracked or broken tiles?

  Yes

  No

  N/A

• Are there non-slip mats in place for slippery areas?

  Yes

  No

  N/A

Kitchen/Dining

• Are floor surfaces free from water and grease?

  Yes

  No

  N/A

• Do kitchen appliances appear to be in safe working order?

  Yes

  No

  N/A

• Is Gas cooking in use?

  Yes

  No

  N/A

• Are chairs and tables in good working order and stable

  Yes

  No

  N/A

• Is this area free from infestation of rodents or insects

  Yes

  No

  N/A

Laundry

• Washing machine/dryer securely fixed in position in a safe working condition?

  Yes

  No

  N/A

• Detergents appropriate for task & stored securely

  Yes

  No

  N/A

Bedroom

• Is there sufficient space for storage & movement?

  Yes

  No

  N/A

• Is the bed height suitable and adjustable if personal care or nursing is required?

  Yes

  No

  N/A

Bathroom

• Enough space for HSW to provide personal care?

  Yes

  No

  N/A

• Is the floor surface slippery?

  Yes

  No

  N/A

• Does the floor have non-slip mats?

  Yes

  No

  N/A

• Shower/toilets not leaking to the floor

  Yes

  No

  N/A

• Is there a handheld shower?

  Yes

  No

  N/A

• Are there grab rails in the shower & toilet? (take photos if permitted)

  Yes

  No

  N/A

• Is there adequate ventilation?

  Yes

  No

  N/A

• Is the bath or shower appropriate for the client’s mobility?

  Yes

  No

  N/A

• Is the water temperature easily adjusted?

  Yes

  No

  N/A

• Is there access to liquid soap, running water & paper towel for staff?

  Yes

  No

  N/A

Passageways

• Wide enough for wheelchair & hoists if applicable?

  Yes

  No

  N/A

• Is a hoist in use. Is it in good condition, free of defects?

  Yes

  No

  N/A

• Has any lifting equipment been serviced in the last 12 months?

  Yes

  No

  N/A

Electrical Risks (Ask Client to confirm)

• Are electrical leads free from kinks, frays, loose or exposed wires?

  Yes

  No

  N/A

• Are plugs, sockets, and switches in safe condition, away from water, and free from obvious defects (loose, broken, overheating)?

  Yes

  No

  N/A

• Any known concerns with lighting i.e. sufficient or free of faults?

  Yes

  No

  N/A

• Are computer and other electrical leads and cables away from aisles and walkways?

  Yes

  No

  N/A

Heating and cooling systems

• Any portable heaters in use? If so, are flammable items more than a meter away?

  Yes

  No

  N/A

• Adequate clearance for ceiling fans?

  Yes

  No

  N/A

Equipment

• Are vacuums suitable for housekeeping - light enough to move (most modern vacuums are between 6-8kg) with an adjustable handle? - free from cord defects?

  Yes

  No

  N/A

• Are mops suitable, functioning and wring out? (if not encourage purchase of spin mop)

  Yes

  No

  N/A

• Is equipment in good working order? Consider -

  Yes

  No

  N/A

• 4WW's

  Yes

  No

  N/A

• wheelchairs

  Yes

  No

  N/A

• walking frames

  Yes

  No

  N/A

• commodes

  Yes

  No

  N/A

• shower chairs

  Yes

  No

  N/A

• Is there an emergency kit (list of emergency Phone numbers, food, water, torch, radio-battery operated)? Where is it located?

  Yes

  No

  N/A

• Brooms in working order with appropriate handle length?

  Yes

  No

  N/A

• Iron and ironing board in good order and safe?

  Yes

  No

  N/A

• Are smoke detectors alarms in working order?

  Yes

  No

  N/A

• Check that the light on the cover flashes. It should flash at least once every 60 seconds

  Yes

  No

  N/A

• Are there fire blankets or fire extinguishers onsite?

  Yes

  No

  N/A

• If yes, please note their location: Add this information to Sandwai for the HSW

  Yes

  No

  N/A

• Encourage clients to store these items away from ignition sources such as stoves that may prevent their access

Chemical/Hazardous substances

• Cleaning chemicals any noticeable risks?

  Yes

  No

  N/A

• Garden chemicals any noticeable risks?

  Yes

  No

  N/A

• Does client choose to use own chemicals for cleaning? if so, record chemical detail, source SDS (Safety data Sheet) upon return forward SDS document to WHS advisor for approval

  Yes

  No

  N/A

• Presence of smokers during visit?

  Yes

  No

  N/A

• Client or other household persons agreed to refrain from smoking during staff visits?

  Yes

  No

  N/A

• Is there excessive mould present on walls, & furnishings

  Yes

  No

  N/A

• If the property address is incorrect in Google maps, please update in the Priority note to alert those visiting

  Yes

  No

  N/A

MSS Home Visiting Risk Assessment Form

• If answers to the questions above have prompted concern regarding ongoing home visiting this client, contact your Manager to discuss

  Yes

  No

  N/A

• Based on the above answers and the Risk level colour, should home visits proceed?

  Yes

  No

  N/A

• Enter an alert in Priority notes in the client’s record if risks or concerns have been identified and control measures are in place to minimise the risk. This alert will be seen on all job cards and to alert HSW to identified risks

Completed & Approved Form

• Form completed by

  Sign

• Manager Approving form

  Sign