Step 1 of 12 8% Please note that this is a long form that may take some time to complete. You can save your progress at any time by using the orange 'SAVE YOUR PROGRESS AND CONTINUE LATER' button towards the bottom. This will allow you to save your progress and return to complete the form at a later time/date.Name*Known asDate of BirthTelephone NumberAddress Street Address Address Line 2 Town or City Postcode Social Worker DetailsCare First NumberContractFamily/Next of KinEmergency Contact DetailsUseful advice telephone numbersOther ContactsPersonal CircumstancesMy Strengths and capabilitiesOutcomes/What Matters Morning CallTime (Morning Call)Tasks (Morning Call)Lunch CallTime (Lunch Call)Tasks (Lunch Call)Tea CallTime (Tea Call)Tasks (Tea Call)Night CallTime (Night Call)Tasks (Night Call) Assessment and agreed action to achieve your outcomesFamily involvement and other personal / social contactFamily involvement - Description of Services to be providedFamily involvement - Plans needed (Risk plan/support plan)Family involvement - Date of assessment review Date Format: DD slash MM slash YYYY Sight and hearingSight and hearing - Description of Services to be providedSight and hearing - Plans needed (Risk plan/support plan)Sight and hearing - Date of assessment review Date Format: DD slash MM slash YYYY CommunicationCommunication - Description of Services to be providedCommunication - Plans needed (Risk plan/support plan)Communication - Date of assessment review Date Format: DD slash MM slash YYYY ContinenceContinence - Description of Services to be providedContinence - Plans needed (Risk plan/support plan)Continence - Date of assessment review Date Format: DD slash MM slash YYYY Diet & NutritionDiet & Nutrition - Description of Services to be providedDiet & Nutrition - Plans needed (Risk plan/support plan)Diet & Nutrition - Date of assessment review Date Format: DD slash MM slash YYYY MobilityMobility - Description of Services to be providedMobility - Plans needed (Risk plan/support plan)Mobility - Date of assessment review Date Format: DD slash MM slash YYYY Mental health and cognitionMental health and cognition - Description of Services to be providedMental health and cognition - Plans needed (Risk plan/support plan)Mental health and cognition - Date of assessment review Date Format: DD slash MM slash YYYY Medical requirementsMedical requirements - Description of Services to be providedMedical requirements - Plans needed (Risk plan/support plan)Medical requirements - Date of assessment review Date Format: DD slash MM slash YYYY Community & Social inclusionCommunity & Social inclusion - Description of Services to be providedCommunity & Social inclusion - Plans needed (Risk plan/support plan)Community & Social inclusion - Date of assessment review Date Format: DD slash MM slash YYYY TransportationTransportation - Description of Services to be providedTransportation - Plans needed (Risk plan/support plan)Transportation - Date of assessment review Date Format: DD slash MM slash YYYY Behaviours & TriggersBehaviours & Triggers (Is there a behavioural plan in place/needed?)YesNoBehaviours & Triggers - Description of Services to be providedBehaviours & Triggers - Plans needed (Risk plan/support plan)Behaviours & Triggers - Date of assessment review Date Format: DD slash MM slash YYYY Lone WorkingAggressive Behaviour from the service userAggressive Behaviour from the service user - DetailsPlease describe anything the care and support workers should be careful of.Aggressive Behaviour from the service user - Risk implication and Control MeasuresAggressive Behaviour from the service user - RiskHighMediumLowCommunication (Signal/WI-FI)Communication - DetailsPlease describe anything the care and support workers should be careful of.Communication - Risk implication and Control MeasuresCommunication - RiskHighMediumLowEmergency backup (Alarms/call response/on-call)Emergency Backup - DetailsPlease describe anything the care and support workers should be careful of.Emergency Backup - Risk implication and Control MeasuresEmergency Backup - RiskHighMediumLowRota notification (Clock in/out)Rota notification - DetailsPlease describe anything the care and support workers should be careful of.Rota notification - Risk implication and Control MeasuresRota notification - RiskHighMediumLowOther concerns (Specific to the service/location/travel)Other concerns - DetailsPlease describe anything the care and support workers should be careful of.Other concerns - Risk implication and Control MeasuresOther concerns - RiskHighMediumLow Home Assessment A home risk assessment should be completed to identify any hazards around the home and how these may relate to the service provided by the worker(s). If the support requirements are community based it would still be beneficial for us to undertake a home risk assessment so that we have the future option of home sit in sessions.Are you happy for us to undertake a home risk assessment?YesNoLocation (Levels of street lighting and parking availability)Location - DetailsPlease describe anything the care and support workers should be careful of.Location - Risk implication and Control MeasuresLocation - RiskHighMediumLowEntrance / Exit (Approach, trees, gates, slopes, ramps or steps)Entrance / Exit - DetailsPlease describe anything the care and support workers should be careful of.Entrance / Exit - Risk implication and Control MeasuresEntrance / Exit - RiskHighMediumLowEntry System (key code pad / burglar alarm, door /garage keys)Entry System - DetailsPlease describe anything the care and support workers should be careful of.Entry System - Risk implication and Control MeasuresEntry System - RiskHighMediumLowKitchen and or Utility roomKitchen and or Utility room - DetailsPlease describe anything the care and support workers should be careful of.Kitchen and or Utility room - Risk implication and Control MeasuresKitchen and or Utility room - RiskHighMediumLowLiving AreasLiving Areas - DetailsPlease describe anything the care and support workers should be careful of.Living Areas - Risk implication and Control MeasuresLiving Areas - RiskHighMediumLowHall / Stairs / LandingHall / Stairs / Landing - DetailsPlease describe anything the care and support workers should be careful of.Hall / Stairs / Landing - Risk implication and Control MeasuresHall / Stairs / Landing - RiskHighMediumLowBathrooms / ToiletsBathrooms / Toilets - DetailsPlease describe anything the care and support workers should be careful of.Bathrooms / Toilets - Risk implication and Control MeasuresBathrooms / Toilets - RiskHighMediumLowSleeping areas (that carers may enter)Sleeping areas - DetailsPlease describe anything the care and support workers should be careful of.Sleeping areas - Risk implication and Control MeasuresSleeping areas - RiskHighMediumLowOutside areas (Gardens/ Balconies/ Sheds/Garage, etc.)Outside areas - DetailsPlease describe anything the care and support workers should be careful of.Outside areas - Risk implication and Control MeasuresOutside areas - RiskHighMediumLow Fire Safety - Fire Hazards Sources of ignition are not always as obvious as a naked flame and some may only be a problem if misused or they malfunction. Please inform us of anything that you consider could be a source of ignition within your home.Sources of ignition List anything that you consider could be a source of ignition within your home (Oxygen cylinders / smokers in the household).Sources of ignition - DetailsPlease describe anything the care and support workers should be careful of.Sources of ignition - Risk implication and Control MeasuresSources of ignition - RiskHighMediumLowSmoke alarms and escape plan in placeSmoke alarms and escape plan in place - DetailsPlease describe anything the care and support workers should be careful of.Smoke alarms and escape plan in place - Risk implication and Control MeasuresSmoke alarms and escape plan in place - RiskHighMediumLow UtilitiesGas / Electric meterGas / Electric meter - DetailsPlease describe location.Gas / Electric meter - Risk implication and Control MeasuresGas / Electric meter - RiskHighMediumLowWater StopcockWater Stopcock - DetailsPlease describe location.Water Stopcock - Risk implication and Control MeasuresWater Stopcock - RiskHighMediumLow Food and Drink handlingPreparation, cooking and reheatingPreparation, cooking and reheating - DetailsPlease describe anything the care and support workers should be careful of.Preparation, cooking and reheating - Risk implication and Control MeasuresPreparation, cooking and reheating - RiskHighMediumLowAre appliances in a suitable state of repair?Are appliances in a suitable state of repair - DetailsPlease describe anything the care and support workers should be careful of.Are appliances in a suitable state of repair - Risk implication and Control MeasuresAre appliances in a suitable state of repair - RiskHighMediumLow Pets/AnimalsAre there pets on the premises? Do they pose a risk?Are there pets on the premises? Do they pose a risk? - DetailsPlease describe anything the care and support workers should be careful of.Are there pets on the premises? Do they pose a risk? - Risk implication and Control MeasuresAre there pets on the premises? Do they pose a risk? - RiskHighMediumLowLevel of staff involvement with pets, e.g. walking, feedingLevel of staff involvement with pets, e.g. walking, feeding - DetailsPlease describe anything the care and support workers should be careful of.Level of staff involvement with pets, e.g. walking, feeding - Risk implication and Control MeasuresLevel of staff involvement with pets, e.g. walking, feeding - RiskHighMediumLow COSHHStorage of cleaning materialsStorage of cleaning materials - DetailsPlease describe anything the care and support workers should be careful of.Storage of cleaning materials - Risk implication and Control MeasuresStorage of cleaning materials - RiskHighMediumLowStorage of medication belonging to service userStorage of medication belonging to service user - DetailsPlease describe anything the care and support workers should be careful of.Storage of medication belonging to service user - Risk implication and Control MeasuresStorage of medication belonging to service user - RiskHighMediumLowInfection Control - PPE available?Infection Control - PPE available? - DetailsPlease describe anything the care and support workers should be careful of.Infection Control - PPE available? - Risk implication and Control MeasuresInfection Control - PPE available? - RiskHighMediumLowSuitable refuse containersSuitable refuse containers - DetailsPlease describe anything the care and support workers should be careful of.Suitable refuse containers - Risk implication and Control MeasuresSuitable refuse containers - RiskHighMediumLow Mobility Aids in use in the homeMobility Aids in use in the homePlease enter one per line.Serial Numbers of mobility aidsPlease enter one per line.Manufacturer/ Model/ responsibility for maintenance of mobility aidsPlease enter one per line.Who is responsible for servicing of mobility aidsPlease enter one per line.Date of last service of mobility aidsPlease enter one per line. Risk Assessment Summary Having considered the information and recommendations of the overall risk assessment, I am of the opinion that, at the time this assessment was carried out, the situation is that:Risk Assessment Level*No risk has been identifiedThe overall a medium risk was assessed but there are adequate precautions are in place to mitigate the riskThe Risk is significant and actions have been recommended as detailed in the summaryUnacceptable levels of risk have been assessed and some areas of care cannot be undertaken until significant changes have been made as detailed in the summary belowRisk Assessment SummaryRisk assessment statement All tasks assessed within this process must be carried out in accordance with Family Support Wales policy and guidance. No unnecessary risks will be taken that may jeopardise the Service User / Support Workers well being. Community Support Workers to notify Family Support Wales of any changes that may have occurred since the last risk assessment. If required, a new assessment may be undertaken.Assessors name*Assessors positionDate (signed by Assessor)* Date Format: DD slash MM slash YYYY I have read and agree to the support plan outlined in this document. I understand that the plan will be reviewed annually or sooner if circumstances change. Service User name*Date (signed by Service User)* Date Format: DD slash MM slash YYYY Advocate nameDate (signed by Advocate)* Date Format: DD slash MM slash YYYY FSW Manager name*Date (signed by FSW Manager)* Date Format: DD slash MM slash YYYY PhoneThis field is for validation purposes and should be left unchanged.
