WESTMEAD HOME SAFETY ASSESSMENT LONG FORM NAME: THERAPIST: DATE OF VISIT: / / TYPE OF RESIDENCE: OWNERSHIP: DIAGNOSIS: AGE: No. FALLS PAST YEAR: FUNCTIONAL VISION: MOBILITY: FUNCTIONAL COGNITION: HOME & COMMUNITY SUPPORTS/ASSISTANCE: SUMMARY AND ACTION PLAN Home Safety Assessment Long Form Page 1 of 6
EXTERNAL TRAFFICWAYS GATES PATHWAYS / DRIVEWAYS STEPS RAMPS surface near gate Uneven surfaces near gate Deep steps near gate at steps near gate Uneven/loose surfaces Narrow Steep gradient Obstructions on pathways Uneven surfaces Steps too high/uneven heights Deep tread Narrow stairway Irregular ground surfaces Obstructions Steep gradient HAND RAILS ACCESS (external steps and ramps) LAWNS / GARDENS / GROUNDS GARAGE DOORMAT DOOR OPENING NIGHTLIGHTING Irregular ground surfaces Irregular lawn surface Steep gradient or lawn Large lawn to equipment Tools hard to use Untidy Inadequate lighting to car Curled edges Worn areas No landing for outward opening doors Stiff/ heavy doors High lock Multiple locks/difficult door handle Threshold Steps/pathways not illuminated Does not eliminate dark, shadowy areas GENERAL INDOORS Steps Ramps Inadequate position ICE / SNOW ON WALKWAYS Inadequate angle Inadequate diameter Inadequate length Not secure Difficulty to see / manoeuvre Footwear inadequate grip LIGHTING Dark / dim Shadowy Abrupt changes Glare Time observed: A.M P.M OT observation TIDINESS / CLEANLINESS Clutter Spills on floor Client self-report Home Safety Assessment Long Form Page 2 of 6
CLEANING EQUIPMENT IRONING AREA Ease of use Difficulty setting up ironing board SPACE in trafficways (furnishings) in trafficways (objects) objects used for support Objects reducing space for mobility & manoeuvrability Proximity of walking aid when not in use Lack of colour contrasts Cords across trafficways TELEPHONE HEATERS / FANS No sitting area to phone books Difficulty switching on/off Inadequate heating COMMONLY OPENED WINDOWS/CURTAINS/SHADES REACHING FOR HIGH PLACES INTERNAL TRAFFICWAYS FLOORS & FLOOR COVERINGS Unsafe when reaching Inaccessible storage of used items Unsafe when climbing furniture / equipment used Slipperiness when wet Worn/loose areas or edges Changes in patterns & textures DOORWAYS RAMPS STAIRS / ELEVATORS APPROACH / DISEMBARKATION STEPS / STAIRS of material Steep gradient Visibility /loose surfaces Uneven coverings Tread coverings Deep tread Steps too high/uneven heights Step overhang Narrow stairway Step contrasts/visual surrounds HANDRAILS INTERNAL STEPS / STAIRS FLOOR MATS Small & lightweight Loose Curled edges LIGHT SWITCHES / POWER POINTS Cords across trafficways Steps Ramps s Inadequate position Inadequate angle Inadequate diameter Not secure Home Safety Assessment Long Form Page 3 of 6
MOBILITY AID PETS LIVING AREA FURNITURE LAMPS SEATING Aid not appropriate Small Large Many dogs/cats Playful/boisterous BEDROOM BED WARDROBES / CUPBOARDS CURTAINS / BED COVERS BED LIGHTING Too low Too high Too soft Worn mattress Difficulty transferring furniture used for transferring Difficulty reaching daily clothing Trailing in trafficways Indicate relevant area (e.g. lounge, kitchen) BEDSIDE TELEPHONE 1. 2. 3. Tow low Too high Too soft No arms Back too sloped unstable Splayed legs Cushions COMMODE FOOTWEAR Inadequate height MEDICATION MANAGEMENT SAFETY CALL SYSTEM to medications Difficulty to open / close containers Reminder aid not in place Instructions not readable/understandable No alarm system / plan of action (E.g. Indoors/outdoors, special occasions, slippers, etc.) 1. 2. 3. Improper fit Open/worn down heel heel/sole High heel Thickness of soles Narrow heel Stocking feet Home Safety Assessment Long Form Page 4 of 6
BATHROOM LOCATION FLOOR SURFACE SHOWER RECESS BATH / OVERHEAD SHOWER Poor proximity Hazardous trafficways en route when wet when dry mats or curled edges Worn floor covering Raised or loose tiles Narrow doorway High hob / sill floor in recess shower mat Uneven floor surface Difficulty reaching toiletries Difficulty reaching taps shower chair or stool bathseat Narrow bathseat High sides bath bathmat Difficulty reaching taps Difficulty turning water heater on/off TOILET Too low Too high Difficulty reaching toilet roll Difficulty reaching flush Inadequate lighting in room GRABRAILS BATHROOM / TOILET Bath Shower Toilet KITCHEN USAGE Inadequate position Drink only Light meals All meals Inadequate angle Inadequate diameter Inadequate length PROXIMITY OF KITCHEN TO EATING AREA Not secure Not directly adjacent to each other Steps en route KITCHEN WORK AREAS / EQUIPMENT TOILET AREA LOCATION Poor proximity Hazardous trafficways en route Inadequate night lighting untidy Working height FLOOR COVERINGS when wet when dry mats or curled edges Worn floor covering Uneven floor surface Workplace Commonly used items Power points Sink Jug/Kettle Fridge Freezer Oven Grill Hot plates Microwave Dishwasher Other Home Safety Assessment Long Form Page 5 of 6
GARBAGE Kitchen tidy access Taking garbage to bin Garbage bin access Garbage bin to street LAUNDRY LOCATION Trafficway from house to laundry Trafficway from laundry to drying area Poor proximity to house Poor proximity to drying area WASHING MACHINE DRIER CLOTHES LINE Taking washing to line Difficult to set up to pegs Home Safety Assessment Long Form Page 6 of 6