Housing Adaptions Assessment

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Tenant Details

• Name

• Date of birth

  Date
• Address
  Address

• Post code

• Phone number

• Alternate contact

• Email address

• Reason for referral

• Name of referrer

• Present during visit?

• Tenancy start date?

  Date

Property Details

• General Property Photo

  Media

• Type of property

• Number of bedrooms

• Ground Floor

  Yes

  No

  N/A

• First Floor

  Yes

  No

  N/A

• Other

  Yes

  No

  N/A

• Household

  Yes

  No

  N/A

External Access

• Photo of entrance

  Media

• Description

• Steps

  Yes

  No

  N/A

• Rails

  Yes

  No

  N/A

• Slopes

  Yes

  No

  N/A

• Communal

  Yes

  No

  N/A

• Door entry system

  Yes

  No

  N/A

• Key safe

  Yes

  No

  N/A

• Sketch

  Drawing

• Threshold mm

• Door clear opening width mm

Equipment in situ

• Description

• Photo

  Media

Falls in last month/care line?

• Description

Mobility

• Description

Diagnosis (Date of diagnosis, symptoms, illness, history, treatment, prognosis, hospitalisations, consultant input)

• Diagnosis

• Symptoms

• Treatment

• Variability

• Who diagnosed?

• Date of diagnosis

  Date

Diagnosis (Date of diagnosis, symptoms, illness, history, treatment, prognosis, hospitalisations, consultant input)

• Treatment

• Symptoms

• Diagnosis

• Variability

• Who diagnosed?

• Date of diagnosis

  Date

Client information

• Height cm (As reported by client)

• Weight Kgs

• Is weight stable?

  Yes

  No

  N/A

• Is weight increasing?

  Yes

  No

  N/A

• Is weight decreasing?

  Yes

  No

  N/A

• Lower leg measurement cm

Limitations to Function (Pain, joints, restrictions of movement, balance, breathlessness, continence, dominant hand, sensation, cognitive, sensory)

• Limitations to Back

  Yes

  No

  N/A

• Limitations to Upper limbs

  Yes

  No

  N/A

• Limitations to Upper Limbs Right

  Yes

  No

  N/A

• Limitations to Upper Limbs Left

  Yes

  No

  N/A

• Limitations to Lower Limbs Right

  Yes

  No

  N/A

• Limitations to Lower Limbs Left

  Yes

  No

  N/A

Transfers

• Chair Height cm

• Bed Height cm

• Toilet Height cm

• Photos

  Media

Bathing Assessment (Personal Care, Bending/reaching, dressing/undressing, Washing, Hair, Equipment)

• Bathing Assessment Notes

Assessment comments if equipment trialled?

• Equipment Trialled?

  Yes

  No

  N/A

• Photo of equipment

  Media

Bathroom/Toilet

• Photo

  Media

• Bathroom Sketch

  Drawing

• Height of WC cm (Upstairs)

• Door clear opening mm (Upstairs)

• Door opening type

  Select Inwards Outwards Sliding

  • Inwards
  • Outwards
  • Sliding

• Height of WC cm (Downstairs)

• Door clear opening mm (Downstairs)

• Door opening type

  Select Inwards Outwards Sliding

  • Inwards
  • Outwards
  • Sliding

• Able to operate flush?

  Yes

  No

  N/A

• Independent Toilet Hygiene?

  Yes

  No

  N/A

• Basin Lever Taps?

  Yes

  No

  N/A

Kitchen (Suitability to meet clients needs, user profile, hazards)

• Photo

  Media

• Kitchen Sketch

  Drawing

• Lever Taps?

  Yes

  No

  N/A

Household Tasks

• Notes

Shopping

• Notes

Cooking

• Notes

Living Room (Suitability to meet clients needs, user profile, hazards)

• Notes

Control of Environment (Heating, lights, sockets, doors, locks, telephone, contact alarm)

• Notes

Internal Stairs/Winders/Landing (half/quarter)

• Photo of stairs

  Media

• Sketch of stairs

  Drawing

Suitable for stairlift/through floor lift/transfer space?

• Suitable for stair/through floor lift?

  Yes

  No

  N/A

• Notes

General Notes and Summary (Options discussed, other needs identified, advice given, carers support)

• Notes

Benefits

• Income Support

• Pension Credit

• Universal Credit/ Housing Benefit

• Council Tax Benefit

• Incapacity Benefit/ Employment and Support Allowance

• PIP/ DLA - Care

• PIP/ DLA - Mobility

• Pension State/ Occupational

Agreed Action

• Notes

Priority

• Priority

  Select Critical Substantial Moderate Low

  • Critical
  • Substantial
  • Moderate
  • Low

I give my permission for photos to be taken. I give my consent for information to be shared with relevant medical, social care and housing providers.

• Tenant

  Sign

• Occupational Therapist

  Sign

• Date and Time

  Date

Westward Wise Account

• Does Tenant have a Westward WISE account?

  Yes

  No

  N/A

• Would the tenant like to get £10 for keeping a Gas Servicing appointment?

  Yes

  No

  N/A

• Is the Tenant aware they could receive up to £50 a year for paying their rent on time and not being involved in any ASB?

  Yes

  No

  N/A