Home Visiting Safety Checklist - No Limitts

• Home Safety Checklist

• Conducted on

  Date
• Address of checklist completed
  Address

• Author: Andrew Thomas

• Person Completing Audit

Patient Details

• Participant's Name

• 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

• undefined

• Detail the nature of the alert and the source

2.0 - Consent

• 2.1 Does the client consent to the Home Visit?

  Yes

  No

  N/A

• 2.2 Has the Home Visit Check been completed with client / carer present?

  Yes

  No

  N/A

• Type of residence

  Select

3.0 - Communication from site

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

4.0 - Pets and animals

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

  Yes

  No

  N/A

• Detail the animal and safety concerns

• 4.2 - There are means of controlling the animal(s) if required during the duration of the visit?

  Yes

  No

  N/A

• Please rate the risk

  Select

5.0 - Parking

• 5.1 - Street parking is NOT available

  Yes

  No

  N/A

• Please rate the risk

  Select

• 5.2 - Parking is NOT secure?

  Yes

  No

  N/A

• Please rate the risk

  Select

6.0 - Access

• 6.1 - There is reduced access to the property

  Yes

  No

  N/A

• Please rate the risk

  Select

• Provide Details

• 6.2 - Entry and walkways provide safe access

  Yes

  No

  N/A

• Please rate the risk

  Select

• Provide Details

• 6.3 - Entry and Walkways allow safe transportation of equipment

  Yes

  No

  N/A

• undefined

  Select

• Provide Details

7.0 - Premises

• 7.1 - Site is powered

  Yes

  No

  N/A

• Please rate the risk

  Select

• 7.2 - Structural condition of premises

  Good

  Average

  Poor

• undefined

  Select

• Provide Details

• 7.3 - Hygiene

  Good

  Fair

  Poor

  N/A

• Please rate the risk

  Select

• Provide Details

• 7.4 - Infestation

  None

  Some

  Moderate

  Severe

• Please rate the risk

  Select

• Provide Details

• 7.5 - Squalor

  No squalor

  Minor squalor

  Moderate squalor

  Severe squalor

• Please rate the risk

  Select

• Provide Details

• 7.6 - Hoarding

  None

  Minor

  Moderate

  Severe

• Please rate the risk

  Select

• Provide Details

• 7.7 Is there adequate lighting inside?

  Yes

  No

  N/A

• Please rate the risk

  Select

• 7.8 Are there any trip or slip hazards

  Yes

  No

  Not Known

• Please rate the risk

  Select

• 7.9 The gas and electric appliance are well maintained

  Yes

  No

  N/A

• Please rate the risk

  Select

• 7.10 There are Fire hazards?

  Yes

  No

  Not Known

• Please rate the risk

  Select

• 7.11 There are smoke detectors present and well maintained?

  Yes

  No

  N/A

• Please rate the risk

  Select

• 7.12 Have there been any known infectious illnesses in the house in the last two weeks? Including Covid-19

  Yes

  No

  Not Known

• Please rate the risk

  Select

8.0 - Medical Alerts

• 8.1 - Allergies - anything that can serious risk to health and well being? i.e. anaphylaxis

  Yes

  No

  Not Known

• Provide details including management plan

• 8.2 - Multi Resistant Organism(s)

  Yes

  No

  Not Known

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

• 8.3 - Adverse drug reactions(s)

  Yes

  No

  Not Known

• Provide details including drug name, reaction and management plan

• 8.4 - Serious medical condition(s)

  Yes

  No

  Not Known

• Detail condition(s) and any management plans

• 8.5 - Drug seeking behaviours

  Yes

  No

  Not Known

• Provide details

9.0 Occupants

• 9.1 Does the client have a positive behaviour support plan?

  Yes

  No

  Not Known

• Are Restrictice Practices used in the home?

  Yes

  No

  N/A

• Have you provided {insert company / representative} with a copy?

  Yes

  No

  N/A

• Yes

  No

  N/A

• 9.2 - Smokers on premises

  Yes

  No

  Not Known

• Are you aware that you will not be able to smoke whilst {insert company/representatives} are in your home?

  Yes

  No

  N/A

• Does the client have mobilites issues? e.g. wheelchair or other?

  Yes

  No

  N/A

• undefined

• 9.3 Does the client speak English?

  Yes

  No

  N/A

• Is an interpreter required?

  Yes

  No

  N/A

• 9.4 Are there any religious or cultural sensitivities to be aware of?

  Yes

  No

  N/A

• 9.5 Firearms / weapons

  Known Firearm(s)

  Suspected Firearm(s)

  Not known

  None reported

• undefined

• 9.6 Is there any known substance abuse amongst or visitors?

  Substance

  Suspected substance

  No substance

• Any details please provide

10.0 History

• 10.1 Does the client , or other occupants have a history of vioulent or aggresive behaviour? e.g. domestic violence, elder abuse or family violence

  Yes

  No

  N/A

• 10.2 Will the Violent / Aggresive person be present at the visit (if it is not the client)?

  Yes

  No

  N/A

• Can you provide assurances as to the safety and potential impact to the safety of others

  Yes

  No

  N/A

11.0 - Consent

• 11.1 - Level of consent provided

  Full

  Partial

  Not yet obtained

• Provide details including any special conditions

12.0 Sign Off

• Date

  Date

• Staff Member's Name

  Sign