Audit

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

Mobility

Description

Diagnosis

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

Diagnosis

Symptoms

Treatment

Variability

Who diagnosed?

Date of diagnosis

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

Transfers

Transfers
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

Bathroom

Bathroom/Toilet
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

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

Lever Taps?

Household Tasks

Notes

Shopping

Notes

Cooking

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

Conclusions

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

Notes

Internal Stairs

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

Actions

Agreed Action

Notes

Priority
Priority

Permission

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?

Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.