PLEASE COMPLETE ALL SECTIONS COPY to be retained in service users note folder with summary sheet and moving and handling plan on front for carer please tick appropriate box and indicate when action is required. DOB Environment Lighting: is External lighting OK? yesNo Stairways and doors clear and accessible? yesNo Enough space to perform all tasks safely? yesNo Furniture and fittings at the right height and position for tasks? yesNo Any health risk i.e.: sanitation, infestation? yesNo Heating: is this set at a comfortable level for the service user? (refer to hyperthermia policy) yesNo Lighting: is internal lighting OK? yesNo Is flooring in good condition? yesNo Any loose mats or rugs? yesNo Are there any awkward steps or changes in floor level? yesNo Are oxygen cylinders in use? yesNo Does the service user or significant other smoke? yesNo TASKS Will the carer require additional training? yesNo Are there any known infection control issues? Is personal protective equipment required? yesNo Are the task appropriate for a carer to offer? yesNo Will the tasks require two carers? yesNo Any special disposal of waste arrangements needed? yesNo Soiled laundry? yesNo Sharps container? yesNo Medical waste? yesNo Any other comments: ELECTRICAL APPLIANCES Is the cooker electric? yesNo Is the heating electric? yesNo Are there any obvious faults? yesNo Electrical appliances visually checked? yesNo Do sockets, plugs wiring and installation look clean and well maintained? yesNo Are there any trailing cables or cables under carpet? yesNo Any other comments please state: APPLIANCE Use the table below to record visual checks with a tick if satisfactory Washing machine CONDITIONPLUGSOCKET iron CONDITIONPLUGSOCKET Toaster CONDITIONPLUGSOCKET Vacuum cleaner CONDITIONPLUGSOCKET Electric fire CONDITIONPLUGSOCKET Television CONDITIONPLUGSOCKET microwave CONDITIONPLUGSOCKET Kettle CONDITIONPLUGSOCKET Electric blanket CONDITIONPLUGSOCKET Any actions (please specify) GAS APPLIANCES Is the cooker gas? yesNo Are there any obvious faults? yesNo Does it self ignite? yesNo If yes is that working? yesNo Is there a gas fire? yesNo Is there gas central heating yesNo Does the service user have a gas maintenance plan/contract? yesNo Are there any signs of carbon monoxide leaking e.g soot around the boiler or fire? yesNo Is there a working carbon monoxide detector? yesNo Any other comments: WATER Where is the stopcock located? OPEN FIRES Is there an open fire? yesNo Coal burning? yesNo Wood burning? yesNo Is there a fire guard? yesNo Are all fires clear of furniture, curtains, and bedclothes? yesNo Is fuel stored where it can be safely assessed? yesNo Any other comments: SIGNIFICANT OTHERS If there are other people in the working environment are there concerns for safety? yesNo Is the significant other designated as a second care worker for moving and handling? yesNo Are they trained to do so? yesNo If yes do we have a copy of certificate dated within the last 24 months? yesNo Is there any potential for violent/aggressive behaviour from the service user or the significant other? yesNo Any other comments: PETS Are there any domestic animals in the home? yesNo If yes, are they under control? yesNo Has the pet ever injured anyone? yesNo Is the pet(s) house trained? yesNo Any other comments: FIRE SAFETY Does the service user have smoke alarms? yesNo If yes has the service user confirmed they are working? yesNo If no, have you advised the service user of the importance of smoke alarms? yesNo Are fire or heaters used for drying clothes? yesNo Anything in the home to indicate a higher than normal risk of fire eg; smoking, oxygen, piles of paper, chip pans etc? yesNo Is there more than one way to evacuate the building in an emergency? yesNo Are non essential appliances switched off at night? yesNo Does the service user have a telephone? yesNo Is the service user linked to a community alarm? yesNo Does the service user have access to a garden? yesNo Any other comments: FINANCE Can the service user sign documents including time sheets? yesNo Does the service user require assistance with finance? yesNo If yes – pension or benefit? yesNo If yes paying for shopping? yesNo If yes bill payment? yesNo Please give more details: EXTERNAL ENVIROMENT Does the locality pose a risk? yesNo Are there any obvious hazards in the external environment? yesNo Is external access to the property clear – eg no overgrown or hazards? yesNo Does the service user leave their home during care worker visits? yesNo If yes is it appropriate for the care worker to transport the service user? yesNo Is the service user to be transported by the care worker? yesNo If yes is it appropriate for the care worker to transport the service user? yesNo Any other comments: Supervisor: Supervisors Signature Date
