Title Page

  • Document No.

  • Audit Title

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

Tenant Details

  • Name

  • Date of birth

  • Address
  • Post code

  • Phone number

  • Alternate contact

  • Email address

  • Reason for referral

  • Name of referrer

  • Present during visit?

  • Tenancy start date?

Propert Details

Property Details

  • General Property Photo

  • Type of property

  • Number of bedrooms

  • Ground Floor

  • First Floor

  • Other

  • Household

External Access

External Access

  • Photo of entrance

  • Description

  • Steps

  • Rails

  • Slopes

  • Communal

  • Door entry system

  • Key safe

  • Sketch

  • Threshold mm

  • Door clear opening width mm

Equipment in situ

Equipment in situ

  • Description

  • Photo

Falls in last month/care line?

  • Description


  • Description


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

  • Diagnosis

  • Symptoms

  • Treatment

  • Variability

  • Who diagnosed?

  • Date of diagnosis


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

  • Treatment

  • Symptoms

  • Diagnosis

  • Variability

  • Who diagnosed?

  • Date of diagnosis

Client information

Client information

  • Height cm (As reported by client)

  • Weight Kgs

  • Is weight stable?

  • Is weight increasing?

  • Is weight decreasing?

  • Lower leg measurement cm

Limitations to functions

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

  • Limitations to Back

  • Limitations to Upper limbs

  • Limitations to Upper Limbs Right

  • Limitations to Upper Limbs Left

  • Limitations to Lower Limbs Right

  • Limitations to Lower Limbs Left



  • Chair Height cm

  • Bed Height cm

  • Toilet Height cm

  • Photos

Bathing Assessment

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

  • Bathing Assessment Notes

Assessment of Equipment Trialled

Assessment comments if equipment trialled?

  • Equipment Trialled?

  • Photo of equipment



  • Photo

  • Bathroom Sketch

  • Height of WC cm (Upstairs)

  • Door clear opening mm (Upstairs)

  • Door opening type

  • Height of WC cm (Downstairs)

  • Door clear opening mm (Downstairs)

  • Door opening type

  • Able to operate flush?

  • Independent Toilet Hygiene?

  • Basin Lever Taps?


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

  • Photo

  • Kitchen Sketch

  • Lever Taps?

Household Tasks

  • Notes


  • Notes


  • Notes

Living Room

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

  • Sketch of stairs

Suitable for stairlift/through floor lift/transfer space?

  • Suitable for stair/through floor lift?

  • Notes


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

  • Notes

Internal Stairs


  • 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


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

  • Occupational Therapist

  • Date and Time

Westward Wise Account

  • Does Tenant have a Westward WISE account?

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

  • 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?

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.