Personal Details
Name:
Address:
Telephone Number:
SWIF T/ Hospital Number:
Date Of Birth:
Assessment Date:
Assessment Time:
Location:
Height: Weight:
Any other Measurements, eg hip width, back length, knee to ankle:
Religious /Cultural considerations:
Name of Assessor:
Department:
Position:
Contact Number:
Any existing equipment or issued in past:
Has the use of this equipment been demonstrated to the person?
Person’s Name: SWIFT/Hospital Number:

Physical Assessment
Status
1.Present Medical Details
2. Relevant Medical History
3. Ability to weight bear
4. Ability to transfer
Bed (include in/out, rolling, repositioning)
Chair
Toilet
(include repositioning)
Wheelchair
Shower / Bath
5. Stairs
6. Pain
7. Hearing / Vision
8. Speech (include language, communication)
9. Skin conditions
10. Seizures / involuntary movements
11. Postural stability (include sitting, standing, balance, head control)
12. Muscle tone/ contractures
Comments
13. Attachments / Prosthetics
14. Continence
15. Cognitive / behavioural
(include capacity issues)
16. Day / Night Variations
Person’s Name: SWIFT/Hospital Number:

Environmental considerations
Status
Space Constraints / Is the environmental space constricted? (for handler and equipment)
Is the temperature, Humidity and Lighting adequate?
Are the floor coverings appropriate to allow ease of movement of equipment to be used?
(i.e corridors / thresholds)
Pets at property?
Comments / Hazards identified
Sleeping in room with a gas fire?
Access (e.g. to bed, bath, W/C and passage ways)
Equipment power supply
Is furniture appropriate to allow transfers to be undertaken with ease and safely? (i.e circulation space and access under furniture with hoist)
Carer / Handler Considerations
Status
Social Situation/Support
Have all informal carers received appropriate demonstrations of use of equipment?
Have all formal carers received appropriate training?
Is special training required for equipment to be issued? (in addition to foundation training)
Is special equipment and or clothing required?
(i.e. gloves, apron)
Are the carers at risk of poor posture during the activity ? (bending, twisting, stooping, reaching etc)
Are there specific hazards to those with existing health problems (or pregnancy)?
Comments
Person’s Name: SWIFT/Hospital Number:

Risk Matrix for continuing with the current situation
Note: You must assess the risk against the likelihood of an incident occurring and should it happen the severity of the consequences.
Likelihood – Please indicate taking into account the controls in place and their adequacy, how likely is it that such an incident could occur? Apply a score according to the following scale:
Level
5
4
3
2
1
Descriptor
Almost Certain
Likely
Possible
Unlikely
Rare
Description
Likely to occur on many occasions, a persistent issue
Will probably occur but it is not a persistent issue
May occur occasionally
Do not expect it to happen but it is possible
Can’t believe that this will ever happen
Severity – Please indicate taking into account the controls in place and their adequacy, how severe would the consequences be of such an incident? Apply a score according to the following scale:
Level
5
4
3
2
1
Descriptor
Catastrophic
Major
Moderate
Minor
Insignificant
Actual or Potential Impact on Individual (s) Actual or Potential Impact on Authority
Death National adverse publicity. HSE investigation. Litigation expected/certain
Permanent Injury: eg RIDDOR reportable/ill health/retirement/redeployment
Semi-Permanent Injury/Damage: e.g. injury that takes up to one year to resolve or requires Occupational Health / rehabilitation
Short term injury/damage: e.g. injury that has been resolved within one month
No injury or adverse outcome
RIDDOR reportable. Long term sickness.
Litigation expected/certain
RIDDOR reportable. Long term sickness.
Litigation possible but not certain
Minimal risk to Council. Short term sickness.
Litigation likely
No risk to Council, litigation remote
RISK SCORE / ACTION TO BE TAKEN: (Likelihood level x Severity level) Please circle
Likelihood
LEVEL
1
2
3
4
5
1
1
2
3
4
5
2
2
4
6
8
10
Severity
3
3
6
9
12
15
4
4
8
12
16
20
5
5
10
15
20
25
Low
Medium/Further action required
High / Urgent action
Risk Score............................................ Rating..............................................
Person’s Name: SWIFT/Hospital Number:

OT Risk Reduction Plan
Concern/Difficulty/Hazard
Identified
Action Required By Whom Date Completed Review Date
Have other options been considered and rejected, if so, please state reasons
1.
2.
3.
Eligibility Criteria Outcome
Critical Low Moderate Substantial
Have direct payments been offered to person?
Yes No
If No, state reason why
Person’s Name: SWIFT/Hospital Number:

Hoist & Sling Compatibility Tool
Does a Hoist and sling compatibility tool need to be completed?
Yes State reason why: No State reason why:
(If No, go to Handling Plan)
Hoist Description:
Sling Description:
Yes No Comments
Does the Hoist and sling keep the person at a good & safe angle
Is good posture for the person maintained by the hoist and sling?
Is the distance from the spreader bar to the person acceptable?
Is the environment conducive to using this hoist and sling?
Are there any issues with the dimensions of the hoist and sling?
Is there equal weight distribution of the person in the hoist and sling?
Hazard Yes No Likelihood score
Severity score
Risk
Rating score
Is the person’s weight within normal limits of sling and hoist?
Person’s sling needs identified
Person’s hoist needs identified
Spreader bar and loop compatible
Carers knowledge of sling and hoist use is adequate
Is there a compatibility statement from either the sling or hoist manufacturer?
Yes No
If yes please attach to this form.
Person’s Name: SWIFT/Hospital Number:

Date: ….……………………………..
IMPORTANT NOTE
Carers to consider working height of bed, brakes applied as appropriate according to handling plan on equipment and the person is comfortable at the end of each transfer.
Carers to ensure before every use the structural integrity of the hoist and sling and that slings are in a good state of
repair and the hoist is fully charged and within the service date.
Transfer / Task Method Equipment /
Staff
Review Date
OT Supported Equipment Details
Hoist/Standaid Used:
Make, Model and Size
Type of Sling:
(Make, Model and Size)
Serial number of sling:
Method of fitting:
Loop fitting:
Shoulders
Waist
Leg
Slide Sheet Serial number:
Method of fitting:
Additional Comments:
Person’s Name: SWIFT/Hospital Number:

Risk Matrix for situation after implementation of Manual Handling Plan
Date Completed: …………..………………………..
Note: You must assess the risk against the likelihood of an incident occurring and should it happen the severity of the consequences.
Likelihood – Please indicate taking into account the controls in place and their adequacy, how likely is it that such an incident could occur? Apply a score according to the following scale:
Level
5
4
3
2
1
Descriptor
Almost Certain
Likely
Possible
Unlikely
Rare
Description
Likely to occur on many occasions, a persistent issue
Will probably occur but it is not a persistent issue
May occur occasionally
Do not expect it to happen but it is possible
Can’t believe that this will ever happen
Severity – Please indicate taking into account the controls in place and their adequacy, how severe would the consequences be of such an incident? Apply a score according to the following scale:
Level
5
4
3
2
1
Descriptor
Catastrophic
Major
Moderate
Minor
Insignificant
Actual or Potential Impact on Individual (s)
Death
Permanent Injury: eg RIDDOR reportable/ill health/retirement/redeployment
Semi-Permanent Injury/Damage: e.g. injury that takes up to one year to resolve or requires Occupational Health / rehabilitation
Short term injury/damage: e.g. injury that has been resolved within one month
No injury or adverse outcome
Actual or Potential Impact on Authority
National adverse publicity. HSE investigation. Litigation expected/certain
RIDDOR reportable. Long term sickness.
Litigation expected/certain
RIDDOR reportable. Long term sickness.
Litigation possible but not certain
Minimal risk to Council. Short term sickness.
Litigation likely
No risk to Council, litigation remote
RISK SCORE / ACTION TO BE TAKEN: (Likelihood level x Severity level) Please circle
Likelihood
LEVEL
1
2
1
1
2
2
2
4
Severity
3
3
6
4
4
8
3
4
5
3
4
5
6
8
10
9
12
15
12
16
20
5
5
10
15
20
25
Low
Medium/Further action required
High / Urgent action
Risk Score............................................ Rating..............................................
Person’s Name: SWIFT/Hospital Number:

Signatures
Name of Assessor:.............................................................................
Signature:..........................................................................................
Date:........................................................... Time:……………………………………………..
Person’s Agreement
I have seen a copy of and understood the implications of the manual –handling plan that has been prepared for carers to assist me to be cared for safely. I will co-operate with their requirements and assist as much as I possibly am able.
Signature:...........................................................................................
Date:...................................................................................................
Managers Signature
(Managers signature required unless previously agreed and competencies have been met and signed off through professional accountability process.)
Signature:................................................................................................
Date:........................................................... Time:……………………………………………..
If a review of the Handling Plan identifies no changes are needed, an Updated Risk
Matrix for continuing with the current Manual Handling Plan may be inserted here and completed.
Person’s Name: SWIFT/Hospital Number:

CONSENT to SHARE INFORMATION
NHS No: .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. Local Authority No: .. .. .. .. .. .. .. .. .. .. .. ..
Hospital No; .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. Other No: .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ..
Surname: .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. Forename(s): .. .. .. .. .. .. .. .. .. .. .. .. .. .. ..
Address: .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .
Information recorded during this assessment process may be shared with others involved in your care. This will help them understand your needs and avoid having to repeat some parts of the assessment. I understand that at times sharing of information will be undertaken in the best interests of my care and that consent may not always be necessary.
Consent to Share Information: tick as appropriate
( ) I understand that the information collected in this assessment process will be used to
provide care for me. I agree that it may be shared with other health and social care
professionals, including GPs and appropriate voluntary organisations, in order to
provide care for me.
( ) I understand the above; but there is specific personal information that I do not want
information to be shared with. Please give details below.
( ) The person is unable to give consent; e.g. unable to sign. Please give details below.
( ) Person does not give consent
Details:
Does person want relatives informed of assessment / condition / treatment ? Y ( )

N ( )

If yes, person authorised to receive information:

Name: .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. Relationship: .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ..
Name: .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. Relationship: .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ..
Signature:
Person’s Name:
Date:
SWIFT/Hospital Number:

Demonstration Confirmation Form
Person’s Name: D.O.B SWIF T/ Hospital Number:
Task Observed
1.
2.
3.
4.
5.
I/we confirm that the task as detailed above has been demonstrated to me/us and that I/we have also demonstrated ability to carry out the above mentioned transfers.
I/we understand how to use the equipment correctly and understand how to safely maintain the equipment. If any defect is noticed or my needs change, I will notify the Newport City Council Contact
Centre immediately by telephoning 01633656656 (opening times: - 8:00am-8:00pm Monday to Friday
(except bank holidays) and 9:00am -1:00pm Saturday) and I will not use the equipment until it has been checked / repaired / replaced.
Person / carers (s): ..................................................................................
(print name and signature)
...................................................................................
...................................................................................
Date: ....................................................................................
I confirm that I have witnessed the above named safely and effectively carry out the above mentioned task
(s)
Occupational Therapist: ....................................................................................
(print name and signature)
...................................................................................
...................................................................................
Date: ...................................................................................
Occupational Therapy Department Copy
Person’s Name: SWIFT/Hospital Number:

Person’s Name: SWIFT/Hospital Number:

Demonstration Confirmation Form
Person’s Name: D.O.B SWIF T/ Hospital Number:
Task Observed
1.
2.
3.
4.
5.
I/we confirm that the task as detailed above has been demonstrated to me/us and that I/we have also demonstrated ability to carry out the above mentioned transfers.
I/we understand how to use the equipment correctly and understand how to safely maintain the equipment. If any defect is noticed or my needs change, I will notify the Newport City Council Contact
Centre immediately by telephoning 01633656656 (opening times: - 8:00am-8:00pm Monday to Friday
(except bank holidays) and 9:00am -1:00pm Saturday) and I will not use the equipment until it has been checked / repaired / replaced.
Person / carers (s): ..................................................................................
(print name and signature)
...................................................................................
...................................................................................
Date: ....................................................................................
I confirm that I have witnessed the above named safely and effectively carry out the above mentioned task
(s)
Occupational Therapist: ....................................................................................
(print name and signature)
...................................................................................
...................................................................................
Date: ...................................................................................
Persons Copy
Person’s Name: SWIFT/Hospital Number: