ACTIVITY PLANNING TOOL

To plan to do an activity safely it is necessary quickly and fully assess the risk associated with the activity by considering 3 inter-relating areas – the activity and the venue (including instructors/staff) and then match to the client(s) capacity (more than only client may be considered on the form).

Activity: ______

Activity Requirements Low Medium High N/A Comments Eye/hand coordination Strength Balance Standing/Walking Prolonged sitting Climbing Follow instructions Communication skills Visual demands Memory Concentration Money handling Social interaction Noise/lighting Eat/drink Other comments:

Venue Features Present Location Risk (H,M,L) Comments (Y/N/NA) Travel requirements Parking Accessible entry Terrain/surface flat and non-slip Accessible toilets Internal Stairs Accessible lifts First aid facilities Strobe lighting High noise levels Unguarded water features Animals/birds Sun exposure Qualified staff Relevant quals/ accreditation sighted Insurance sighted Other comments Control measures required

Person completing form:

______/__/__

Name Signature Date

Information read by:

Name Signature Date Service User Profile

Service User Name 1 2 3 4 5 6 Chair/bed transfers Ambulation – walking Ambulation – wheelchair Stair climbing Toilet transfers Bowel control Bladder control Bathing Dressing Personal hygiene – grooming Feeding Eyesight Communication Cognitive status Behaviour status Transport Staffing level required Other comments:

Scoring Staffing levels Suitability for Proposed See Activity Risk profile for activity potentially suitable activities Less than 60 1-2 80 1-1 80-100 2-1 More than 100 4-1 If in Red or Orange potentially suitable for Green activities also.

Service User Name 1 2 3 4 5 6 Suitable for activity Service User Profile Scoring definitions 2 Assistance for all aspects required 5 Assistance to managed clothing, Chair/bed transfer or wash hands transfers 8 Supervision required and assistance 0 Require 2 people or equipment to empty/clean night commode 3 Require 1 person to assist in all 10 Independent and able to manage aspects clothing and clean commode or 8 Require 1 person to assist in some urinal if used at night aspects of transfer 12 Require 1 person for confidence or Bowel control supervision 0 Incontinent and dependent 15 Fully independent 2 Help required to adopt position and with bowel movement facilitation Ambulation – techniques walking 5 Able to adopt position but not use 0 Dependent aids or clean self without assistance 3 Requires one or more persons and has frequent accidents constantly 8 Requires supervision with 8 One person to reach aids or suppository or enema and has manipulation occasional accidents 12 Independent up to 50 metres but 10 Good bowel control and able to use requires supervision for confidence suppository or enema as required or safety 15 Independent up to 50 metres and Bladder control no assistance for use of aids etc 0 Dependent, incontinent or has needed indwelling catheter 2 Incontinent but able to assist with Ambulation – application of internal or external wheelchair device 0 Dependent 5 Incontinent at night and needs 3 Able to self-propel over short assistance with devices distances on flat surfaces but 8 Occasional accidents and minimal assistance otherwise required assistance with devices 8 One person needed and constant 10 Continent or able to use devices assistance to manipulate to table independently etc 12 Independent generally but may Bathing require assistance around tight 0 Dependent corners or to negotiate kerb 2 Full assistance but contributes 100mm high 5 Assistance to transfer or with 15 Push wheelchair at least 50 metres washing or drying and negotiate a kerb and 8 Supervision to adjust temps or manoeuvre to table, around transfers corners etc 10 Independent in all areas

Stair climbing Dressing 0 Unable 2 Assistance required in all aspects 0 Dependent including aids 2 Dependent but participates in some 5 Independent but needs assistance degree to carry aids or supervise 5 Assistance to put on and/or remove 8 but requires supervision for safety clothing due to morning stiffness or SOB 8 Assistance to fasten clothing 10 Independent for one flight and no 10 Independent with clothing, corsets assistance for use of aids etc or bracing needed Personal hygiene Toilet transfers 0 Dependent 0 Dependent 1 Dependent but participates in some 8 Able to follow simple verbal and degree written instructions and retain 3 Assistance required in one or more them steps 10 Able to follow complex verbal and 4 Independent but requires written instructions assistance before or after 5 Independent with shaving, washing Behaviour status hands/face, makeup, comb hair, 0 History of use of weapons or clean teeth projectiles against people 2 History of physical assault Feeding 5 History of verbal abuse or 0 Dependent needing to be fed or intimidation nasogastric administered 8 History of property damage or at 2 Can manipulate spoon but active risk or challenging behaviours assistance during meals required 10 Able to socially interact 5 Able to feed self and assistance independently with associated tasks such as Transport adding milk/sugar to tea, salt and 0 Needs to be transported alone and pepper etc required away from the driver in bus – safety 8 Assistance to open milk carton or equipment such as screens may be lid or cut up food otherwise required independent 2 Requires full assistance to 10 Independent when food put within access/leave vehicle and requires reach supervision in rear of vehicle to keep to seat etc Eyesight 5 Requires some assistance to 0 Dependent transfer and allocated seating 2 Independent internally with aids 8 Requires supervision in transfers and supervision but cannot read and use of seat belt 5 Independent internally without aids 10 Able to be transported without but requires assistance/supervision assistance on own or with others externally with mobility and reading 8 Independent with aids for mobility and reading of large print – over 20pt 10 Independent without aids for mobility and 12pt print

Communication 0 Non-verbal and non- communicative 2 Able to make needs known through signs 5 Able to verbalise some needs but inconsistent in appropriateness or difficult to understand 8 Verbalises short phrases appropriately 10 Independent with conversations

Cognitive status 0 Dependent 2 Able to follow simple sign language 5 Able to understand simple verbal instructions but needs them repeated regularly