Home Safe Environment Checklist V1

Location - Address *

Street address *Street address line 2

City *

State *

Postcode *

Country

ENVIRONMENT *

YesNoN/A

Fire and smoke alarms

YesNoN/A

High-risk location (e.g. isolated or remote location, high rise flat)

YesNoN/A

Pets/animals

YesNoN/A

Furniture and equipment are in good repair (check for broken seating, accessories, etc.).

YesNoN/A

Hardware in furniture/equipment is recessed and securely fastened

YesNoN/A

Furniture has no sharp edges at a level to injure the participant.

YesNoN/A

Presence of weapons in the home

YesNoN/A

External services for gardening, general maintenance

YesNoN/A

If pesticides are used, is information provided to workers for safe use

YesNoN/A

Hot water temperature checked (review state requirements)

YesNoN/A

Temperature control devices such as thermostatic mixing valves (TMV) or tempering valves control the output temperature of the water at the tap

YesNoN/A

MEDICATION *

YesNoN/A

Medication stored on premises

YesNoN/A

Medication in a locked cabinet

YesNoN/A

Should medication be in a locked cabinet?

YesNoN/A

ELECTRICAL *

YesNoN/A

Electrical cords on equipment and appliances are not frayed;

YesNoN/A

Cords are secured

YesNoN/A

No exposed wiring

YesNoN/A

Regular inspections are completed to re-assess electrical hazards

YesNoN/A

EXPOSURE TO FUMES *

YesNoN/A

Smoker/smoking fumes

YesNoN/A

Chemicals used have ammonia or similar

YesNoN/A

Toxic gases or vapours

YesNoN/A

Fumes/Dust

YesNoN/A

control cleaning products used in participants' homes

YesNoN/A

SLIPS/TRIPS/FALLS *

YesNoN/A

Uneven, slippery or steep surfaces

YesNoN/A

Poor housekeeping

YesNoN/A

Obstacles being placed in the vicinity

YesNoN/A

Loose rugs, carpets

YesNoN/A

Inappropriate or poorly maintained floor or walking surfaces (i.e. lack of a slip-resistant surface, unprotected holes, penetrations or gaps?)

YesNoN/A

Stairs or ramps

YesNoN/A

Guardrails or other suitable edge protection

YesNoN/A

MANUAL HANDLING *

YesNoN/A

Transporting the participant equipment available

YesNoN/A

Carrying equipment required

YesNoN/A

Equipment available to move participants as needed

YesNoN/A

Repetitive or twisting body movement is limited

YesNoN/A

Frequent lifting of participant or equipment is required

YesNoN/A

Lifting or moving participant or equipment over long distances or up steps or stairs

YesNoN/A

Inadequate or poorly placed lighting while lifting or moving participant or equipment

YesNoN/A

Interference of the employee's clothing or personal protective equipment with manual handling performance

YesNoN/A

OCCUPATIONAL VIOLENCE *

YesNoN/A

Known history of violence

YesNoN/A

Previous assaults/threats/verbal violence

YesNoN/A

A criminal record for violence or sexual assault

YesNoN/A

Reports from affiliated agencies/stakeholders

YesNoN/A

Use of firearms in the past

YesNoN/A

History of mental health issues

YesNoN/A

Substance abuse

YesNoN/A

The impact of the intervention causing stress or aggression in participant

YesNoN/A

The occurrence of any incident in the participant/family situation could increase the risk to the employee's safety

YesNoN/A

Indicators of violence ,e.g. voice tone, mood swings, physical presentation/ behaviour

YesNoN/A

Unknown adults in the home

YesNoN/A

History of mental health issues

YesNoN/A

History of substance abuse

YesNoN/A

Security issues

YesNoN/A

Participant presenting in an escalating state of crisis

YesNoN/A

COMMUNICATIONS *

YesNoN/A

Employees informed the process in an emergency (e.g. mobile phones, duress alarms)?

YesNoN/A

Regular contact is maintained with workers to ensure safety and supervision

YesNoN/A

System to always ensure knowledge of the location of all workers during work shifts

YesNoN/A

Reporting mechanisms if any hazards

YesNoN/A

EMPLOYEE PREPARATION *

YesNoN/A

sharps procedure in place to manage the handling of sharps in participant's homes

YesNoN/A

Provided with adequate information on communicable diseases? (e.g. symptoms, long term health effects, risk factors and controls to minimise risk, including immunisation)

YesNoN/A

Trained in relevant policies and procedures

YesNoN/A

Trained in hazard and risk management

YesNoN/A

Trained in incident management

YesNoN/A

Trained in complaints and feedback procedures

YesNoN/A

Trained in universal infection control procedures

YesNoN/A

Trained in hot water safety risk management

YesNoN/A

Provide adequate PPE (e.g. range of gloves for both personal and domestic support workers)

YesNoN/A

HappinessFirst Staff Name *

HappinessFirst Staff Signature *

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Date *

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Home Safe Environment Checklist

Hazard Inspection

OFFICE USE