Person-centered FRA

• Site conducted

  Select

• Document No.

• Resident Name

• Full Address

• Conducted on

  Date

• Prepared by

• Review Date

  Date

Hazard and risk factors - Smoking

Cicumstances

• Smoking concerns

  Non-smoker

  Smokes but no concerns

  Smoker with concerns

• Evidence

  Select Discarded cigarettes and matches Burn marks on carpets Burn marks on clothes Burn marks on furnishings Multiple burn marks on carpets Burn marks in bedroom area

  • Discarded cigarettes and matches
  • Burn marks on carpets
  • Burn marks on clothes
  • Burn marks on furnishings
  • Multiple burn marks on carpets
  • Burn marks in bedroom area

• Existing control measures

• Outstanding risk

  No

  Yes

  N/A

• Additional actions required

• No further action required

Hazard and risk factors - Cooking

Circumstances

• Cooking concerns

  Select No cooking facilities Cooking - no concerns Cooking - with concerns

  • No cooking facilities
  • Cooking - no concerns
  • Cooking - with concerns

• Evidence

  Select Inappropriate use of equipment Cooking left unattended History of alarm signals Heat damaged pots and pans Burn/scorch marks on prep area Burn/smoke marks on walls/ceilings

  • Inappropriate use of equipment
  • Cooking left unattended
  • History of alarm signals
  • Heat damaged pots and pans
  • Burn/scorch marks on prep area
  • Burn/smoke marks on walls/ceilings

• Existing control measures

• Outstanding risk

  No

  Yes

  N/A

• Additional control measures

• No further action required

Hazard and risk factors - Electrical

Circumstances

• Electrical concerns

  Select Equipment safely used Extension leads & adapters safely used Lack of maintenance or signs of wear and tear

  • Equipment safely used
  • Extension leads & adapters safely used
  • Lack of maintenance or signs of wear and tear

• Evidence

  Select Cube adapters Overloading of circuits Worn equipment Worn or damaged cables Electric blanket worn or damaged

  • Cube adapters
  • Overloading of circuits
  • Worn equipment
  • Worn or damaged cables
  • Electric blanket worn or damaged

• Existing control measures

• Outstanding risk

  No

  Yes

  N/A

• Additional control measures

• No further action required

Hazard and risk factors - Portable heaters

Circumstances

• Portable heater concerns

  Select No portable heaters Oil rads or convector heaters Fan, bar or paraffin heaters

  • No portable heaters
  • Oil rads or convector heaters
  • Fan, bar or paraffin heaters

• Evidence

  Select Close to combustible materials Could be moved next to combustible materials Drying clothes Cooking or heating food/drinks

  • Close to combustible materials
  • Could be moved next to combustible materials
  • Drying clothes
  • Cooking or heating food/drinks

• Existing control measures

• Outstanding risk

  No

  Yes

  N/A

• Additional control measures

• No further action required

Hazard and risk factors - Candles

Circumstances

• Candle concerns

  Select No candle use Used with precautions Used without precautions

  • No candle use
  • Used with precautions
  • Used without precautions

• Evidence

  Select Inappropriate holder positioned near combustible materials Excessive amount

  • Inappropriate holder
  • positioned near combustible materials
  • Excessive amount

• Existing control measures

• Outstanding risk

  No

  Yes

  N/A

• Additional control measures

• No further action required

Hazard and risk factors - Deliberate ignition

Circumstances

• Ignition concerns

  Select No history of No history but some potential History of deliberate ignition

  • No history of
  • No history but some potential
  • History of deliberate ignition

• Evidence

  Select Previous history of deliberate ignition History of false alarms Ignores preceeding control measures

  • Previous history of deliberate ignition
  • History of false alarms
  • Ignores preceeding control measures

• Existing control measures

• Outstanding risk

  No

  Yes

  N/A

• Additional control measures

• No further action required

Hazard and risk factors - Alcohol or drug use

Circumstances

• Alcohol/drug use concerns

  Select None Usage but not high fire risk Excessive usage, high fire risk

  • None
  • Usage but not high fire risk
  • Excessive usage, high fire risk

• Evidence

  Select Issues when smoking Issues when cooking Issues when using candles Issues with electrical items

  • Issues when smoking
  • Issues when cooking
  • Issues when using candles
  • Issues with electrical items

• Existing control measures

• Outstanding risk

  No

  Yes

  N/A

• Additional control measures

• No further action required

Hazard and risk factors - Hoarding (access)

Circumstances

• Hoarding concerns

  Select No hoarding Hoarding levels between 1-4 Hoarding levels between 5-9

  • No hoarding
  • Hoarding levels between 1-4
  • Hoarding levels between 5-9

• Evidence

  Select Hoarding in single room Hoarding in more than one room Hoarding in escape route

  • Hoarding in single room
  • Hoarding in more than one room
  • Hoarding in escape route

• Existing control measures

• Outstanding risk

  No

  Yes

  N/A

• Additional control measures

• No further action required

Hazard and risk factors - Oxygen

Circumstances

• Oxygen concerns

  Select No oxygen used Oxygen used no issues Oxygen used with issues

  • No oxygen used
  • Oxygen used no issues
  • Oxygen used with issues

• Evidence

  Select Smoker High alcohol/drug use Inappropriate cylinder storage Excessive cylinders

  • Smoker
  • High alcohol/drug use
  • Inappropriate cylinder storage
  • Excessive cylinders

• Existing control measures

• Outstanding risk

  No

  Yes

  N/A

• Additional control measures

• No further action required

Hazard and risk factors - Sensory impairment

Circumstances

• Impairment concerns

  Select None Hard of hearing Partially sighted Deaf or blind

  • None
  • Hard of hearing
  • Partially sighted
  • Deaf or blind

• Evidence - extent of impairment

• Existing control measures

• Outstanding risk

  No

  Yes

  N/A

• Additional control measures

• No further action required

Hazard and risk factors - Capacity to respond to fire alarm

Circumstances

• Capacity concerns

  Select Fully able to respond May be slow to respond Need staff assistance

  • Fully able to respond
  • May be slow to respond
  • Need staff assistance

• Evidence

  Select Limited decision making ability Learning difficulties Dementia Inability to make decisions Severe learning difficulties

  • Limited decision making ability
  • Learning difficulties
  • Dementia
  • Inability to make decisions
  • Severe learning difficulties

• Existing control measures

• Outstanding risk

  No

  Yes

  N/A

• Additional control measures

• No further action required

Hazard and risk factors - Ability to evacuate

Circumstances

• Evacuation concerns

  Select None - fully able Limited - slow to evacuate No mobility without assistance

  • None - fully able
  • Limited - slow to evacuate
  • No mobility without assistance

• Evidence

  Select Can evacuate - slowly Can move from room not building Can move from fire but not room No mobility

  • Can evacuate - slowly
  • Can move from room not building
  • Can move from fire but not room
  • No mobility

• Existing control measures

• Outstanding risk

  No

  Yes

  N/A

• Additional control measures

• No further action required

Hazard and risk factors - Other factors

Circumstances

• Other concerns

  Select No Yes N/A

  • No
  • Yes
  • N/A

• Details

• No further action required

Risk Level

• Grade

  Low

  Medium

  High

• Have all existing and additional controls measures been explored and introduced before recording this level?

Photographic evidence

Permission

• Does the tenant agree to photographs being taken?

  Yes

  No

• Tenant name and signature

  Sign

• Smoking

  Media

• Cooking

  Media

• Electrical

  Media

• Portable heater

  Media

• Candles

  Media

• Hoarding

  Media

• Oxygen

  Media

• Other

  Media

Assessor(s) details

• Name & Job Title

  Sign

• Name & Job Title

  Sign