Smokers risk assessment form v 1.0.docx.docx

Smokers Risk Assessment Form

Name of Care Centre

This Smokers Risk Assessment Form Was Prepared For

Name of Resident

The content of this document is confidential

© Phoenix Safety Training Services – Unit 21, Redleaf House, Townspark, Longford.
Tel/Fax: +353 (0) 43 3349611 Email:info@phoenixsts.ieWeb:www.phoenixsts.ie
V1.0 – Page 1 of 8


While smoking is no longer permitted in enclosed buildings, there may be some areas where it is
permitted (for example long-stay nursing homes and mental health facilities). In these circumstances, due
regard should be taken of the fire risk this poses. Smoking safety must be listed in the Care Centres Fire
Safety Policy.

This Smokers Risk Assessmenthas been prepared by PHOENIX SAFETY TRAINING SERVICES; its
purpose is to identify the individual risks to a resident with regard to their safe when smoking. The
Smokers Risk Assessment should be completed ONLY by a COMPETENT PERSON as defined in the
Safety Health and Welfare at Work Act 2005. The Smokers Risk Assessmentis not exhaustive and where
additional requirements are identified they should be entered in under “Other Information” showing any
remedial actions deemed necessary. Each resident who is a smoker should have a Smokers Risk
Assessment prepared prior to their arrival or if already a resident within the Care Centre.

It is important to distinguish in the Smokers Risk Assessment whether the area to be accessed will be
used inside or outside of normal working hours. It is likely that certain areas of the Care Centre will be
inaccessible outside of normal working hours e.g. to assure security. The Smokers Risk Assessment needs
to demonstrate that this has been adequately considered.

If the Smokers Risk Assessment deems that a particular area does not meet the general access
requirements for the resident being assessed then alternative management arrangements will need to be
identified. Once these arrangements have been identified then a new Smokers Risk Assessment will need
to be undertaken. The Assessor should complete new Smokers Risk Assessment and send it to the Person
in Charge of the Care Centre.

The Smokers Risk Assessment should be updated at least every 3 months or on finding of a risk
assessment that’s show the previous Smokers Risk Assessmentis out of date.

Phoenix Safety Training Services does NOT accept any responsibility for the misinterpretation or
assessments carried out by any individual completing the Smokers Risk Assessment.

The content of the Smokers Risk Assessmentis subject to COPYRIGHT and cannot be transcribed. If
you require any additional information on the interpretation or use of the Smokers Risk Assessmentplease
contact Phoenix Safety Training Services at info@phoenixsts.ie or on 043 3349611.

For more information on smokers safety in Care Centres visit; http://www.phoenixsts.ie/shop/

For more information on fire safety training in Nursing Home/Care Centres visit;
http://www.phoenixsts.ie/nursing-home-safety/

V1.0 – Page 2 of 8


Assessor
Name of Assessor;Name

Assessor Position; Choose Position Other; If Other

Date of Assessment; Date Time of Assessment;Hour:Mins

What times or daysare covered by this assessment?Assessment Time/Day

Section 1 – Residents Information
Age;Age D.O.B; Date

Nature ofImpairment(s);
Nature ofImpairment(s)

Is the resident a wheelchair user? Yes/No Type; TypeSize;Sizemm
If YES Enter Details

Does the resident use other types of mobility aids? Yes/No Type; Type of Mobility Aid

Has the resident a visual impairment? Yes/No

Has the resident a hearing impairment? Yes/No

Can the resident raise the alarm if they discover a fire (operate the manual call point)? Yes/No
If NO Enter Details

In an emergency can the resident contact staff in the area in which the resident is located? Yes/No
If NO Enter Details

Does the resident required assistance to get in/out of the smoking room/area? Yes/No
If YES EnterDetails

Can the resident move quickly in the event of an emergency? Yes/No
If NO Enter Details

V1.0 – Page 3 of 8


Is the resident on oxygen therapy? Yes/No

Section2– Only forInternal Smoking Room
Is there an internal smoking room?Yes/No

Floor; Floor Room No.Room No.

Is the fire door fitted with fire rated glazing? Yes/No
If No Enter Details

Is smoking room fitted with closed-circuit television (CCTV) (not to record monitor only)?Yes/No
If No Enter Details

If CCTV is in use approximate distance in meters from monitoring station from internal smoking room
Metersm

How long would you estimate that it would take to reach the resident from the monitoring station in the
event of an emergency? Time Minute(s)

Approximate distance in meters from closest Fire Point to internal smoking room Metersm

Is smoking room fitted with fire detection?Yes/No If yes; Type of detection; Type of Detection
If No Enter Details

Is smoking room fitted with emergency lighting?Yes/No
If No Enter Details

Are all Textiles and Furnishings compliant with current Sanders stands?Yes/No
If No Enter Details

Maximum number of resident that could be in the smoking room/area at any time; Number of Resident

Section3– External Smoking Area
Is there an external smoking area?Yes/No

Is smoking area fitted with CCTV (not to record monitor only)?Yes/No

V1.0 – Page 4 of 8


If CCTV is in use approximate distance in meters from monitoring station from external smoking area
Metersm

How long would you estimate that it would take to reach the resident from the monitoring station in the
event of an emergency? Time Minute(s)

Approximate distance in meters from closest Fire Point to external smoking area Metersm

Is smoking area fitted with fire detection?Yes/No If yes; Type of detection; Type of Detection
If No Enter Details

Is smoking area fitted with emergency lighting?Yes/No
If No Enter Details

Are all Textiles and Furnishings compliant with current Sanders stands?Yes/No
If No Enter Details

Maximum number of resident that could be in the smoking room/area at any time; Number of Resident

Section4 – Staff
Has staff practiced appropriate evacuation drill to meet the resident’s needs if in the smoking room/area?
Yes/No
If NO Enter Details

Is there an up-to-date record of staff receiving training in the use of Fire Extinguishers? Yes/No
If NO Enter Details

Section 5 – Control Measures

Risk Assessment
Risk Likelihood Severity Overall Risk
Physical Injury for Smoking Choose Choose Choose

Key Risks
Location of Smoking;
Location of Smoking

V1.0 – Page 5 of 8


Risk Indicators;
Burns to furnishings in smoking room/area;☐ Burns to bedding in resident room; ☐
Burns to upholstered furniture in resident room; ☐ Burns to residents clothing;☐
Burns to furnishingsin resident room; ☐ Burns to floor in residentsroom; ☐

Nature ofResidentImpairment(s);
Resident Health;
Resident Health

ResidentComprehension;
Resident Comprehension

Control Measures
Active Monitoring of Resident when Smoking;☐ Smokers Protective Apron for Resident;☐

Every half-hourInspection of Smoking Room/Area ☐ CiglowFlameless Lighter; ☐

Other Control Measures;
Other Control Measures

Residual Risk Assessment
Risk Likelihood Severity Overall Risk
Physical Injury for Smoking Choose Choose Choose

Other Information;
Other Information

As the Assessor do you denote that the Care Centre can manage the safety of the resident when smoking?
Yes/No

Signed (Assessor) _________________________________

V1.0 – Page 6 of 8


Annex 1

Section 5 – Control Measures
Initial Risk Assessment (Risk = Likelihood + Severity)

Severity
Insignificant = 1 Minor = 2 Moderate = 3 Major = 4 Catastrophic = 5
Likelihood

Almost Certain = 5 6 7 8 9 10
Likely = 4 5 6 7 8 9

Possible = 3 4 5 6 7 8

Unlikely = 2 3 4 5 6 7

Rare =1 2 3 4 5 6

Hazard Rating Number Interpretation

1 – 4 = Low Risk No action required – Manage by routine procedures.

Will not be accepted, additional control measures must be considered and the risks reduced
5= Medium Risk to Low, inform the Person in Charge.

Will not be accepted, smoking will stop additional control measures must be considered
6 – 10 = High Risk and the risks reduced to Low, inform the Person in Charge.

MediumandHighandrisks must be reported to Person in Charge and reduce the risk to Low

V1.0 – Page 7 of 8


Annex 2 Risk Assessment Matrix

Consequence
Injuries or ailments not Serious injury causing Life threatening injury or
People/ requiring medical
Minor injury or First Aid
hospitalisation or multiple multiple serious injuries
Death or multiple life
Resident Treatment Case. threatening injuries.
treatment. medical treatment cases. causing hospitalisation.

Examination required by Intense public, political
Examination required by Assembly inquiry or
internal committees or and media scrutiny. eg:
Reputation Internal Review
internal audit to prevent
external committees or
front page headlines, TV,
Commission of inquiry or
inquest, etc. adverse national media.
escalation. etc.
Critical system failure,
Policy procedural rule Strategies not consistent
Business Process & Minor errors in systems One or more key bad policy advice or on-
occasionally not met or with Government’s
or processes requiring accountability going non-compliance.
Systems services do not fully meet agenda. Trends show
corrective action. requirements not met. Business severely
needs. service is degraded.
affected.

1% of Budget 2.5% of Budget > 5% of Budget > 10% of Budget >25% of Budget
Financial or <€5K or <€50K or <€500K or <€5M or >€5M

Insignificant Minor Moderate Major Catastrophic

Numerical: Historical: 1 2 3 4 5
Is expected to occur in
most circumstances
>1 in 10 Almost Certain 5 6 7 8 9 10
Will probably occur
1 in 10 - 100 Likely 4 5 6 7 8 9
Likelihood

Might occur at some
1 in 100 – 1,000 time in the future Possible 3 4 5 6 7 8
Could occur but
1 in 1,000 –
10,000
doubtful Unlikely 2 3 4 5 6 7
May occur but only in
1 in 10,000 –
100,000
exceptional
circumstances
Rare 1 2 3 4 5 6

V1.0 – Page 8 of 8

Smokers risk assessment form v 1.0.docx.docx

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