Home Visiting Safety Checklist

• Home Safety Checklist ACRPC Division

• Conducted on

  Date

• Author: Gill Bartley

• Person Completing Audit

Patient Details

• CHIS number

• Address

• Street name and number

• Suburb

• Post Code

1.0 - Previous Alerts / Flags

• 1.1 - Is there a known alert placed on the property, individual or other inhabitants of the property?

  Yes

  No

  Not Known

• Detail the nature of the alert and the source

2.0 - Communication from site

• 2.1 Does the site have NO mobile phone coverage (Optus)? <br> Yes = the site has no / limited mobile phone coverage

  Yes

  No

  Not Known

• 2.2 Does the site have NO landline which is connected and operational?<br> Yes = the site has NO 'phone

  Yes

  No

  N/A

3.0 - Pets and animals

• 3.1 - Are there any dogs or pets that may present a risk to staff members?

  Yes

  No

  Not Known

• Detail the animal and safety concerns

• 3.2 - Are there NO means of controlling the animal(s) if required during the duration of the visit?

  Yes

  No

  Not Known

  Not Applicable

4.0 - Parking

• 4.1 - Street parking is NOT available

  Yes

  No

  Not Known

• 4.2 - Parking is NOT secure?

  Yes

  No

  Not Known

5.0 - Access

• 5.1 - There is reduced access to the property

  Yes

  No

  Not Known

• Provide Details

• 5.2 - Entry and walkways DO NOT provide safe access

  Yes

  No

  Not Known

• Provide Details

• 5.3 - Entry and Walkways DO NOT allow safe transportation of equipment

  Yes

  No

  Not Known

• Provide Details

6.0 - Premises

• 6.1 - Site is NOT powered

  Yes

  No

  Not Known

• 6.2 - Structural condition of premises

  Good

  Average

  Poor

• Provide Details

• 6.3 - Hygiene

  Good

  Average

  Poor

• Provide Details

• 6.4 - Infestation

  None

  Some

  Moderate

  Severe

• Provide Details

• 6.5 - Squalor

  No squalor

  Minor squalor

  Moderate squalor

  Severe squalor

• Provide Details

• 6.6 - Hoarding

  None

  Minor

  Moderate

  Severe

• Provide Details

7.0 - Appliances

• 7.1 - Gas

  Yes

  No

  Not Known

• Is there NO safety switch

  Yes

  No

  Not Known

  Not Applicable

8.0 - Medical Alerts

• 8.2 - Allergies

  Yes

  No

  Not Known

• Provide details including management plan

• 8.3 - Multi Resistant Organism(s)

  Yes

  No

  Not Known

• Provide details including type of MRO(s) and management plan(s)

• 8.4 - Adverse drug reactions()

  Yes

  No

  Not Known

• Provide details including drug name, reaction and management plan

• 8.5 - Serious medical condition(s)

  Yes

  No

  Not Known

• Detail condition(s) and any management plans

• 8.6 - Drug seeking behaviours

  Yes

  No

  Not Known

• Provide details

9.0 - Consent

• 9.1 - Level of consent provided

  Full

  Partial

  Not yet obtained

• Provide details including any special conditions

10.0 - Other

• Firearms / weapons

  Known Firearm(s)

  Suspected Firearm(s)

  Not known

  None reported

• 10.1 - Smokers on premises

  Yes

  No

  Not Known

• Provide details

• 10.2 - Hazardous substances on site

  Yes

  No

  Not Known

• Provide details

Sign Off

• Date

  Sign

• Staff Member's Name

  Sign