Hey readers, you find me a couple of weeks into my new rotation in a community team based in a hospital. It’s a completely new experience for me, I’ve not yet had the opportunity to be in the community full-time, not even on placement. So as you can imagine a lot of new challenges for me to explore and reflect on in my blog.
So last week I was asked if I felt OK to do an environmental assessment on my own. Actually, I felt apprehensive about it as the last time I did one was 2 years ago as a student. Not that I’ve shied away from them, an opportunity has just never come up on the rotations that I’ve done so far. One of the things we say to patients is ‘if you don’t use it, you lose it’, it definitely applies to us therapists as well! I explained this to my seniors and was paired with someone more experienced so I could brush up on my environmental assessment skills.
Not wanting environmental assessments to get the better of me, that night I went home and promptly engaged in some ‘self directed learning’ (i.e.Googled it). Not much came up (cheers Google). So this made me want to put something on the blog, because if I’ve Googled it, others may be doing the same.
What is an environmental assessment?
An environmental assessment takes place at the patient’s home, usually with a relative present. If a relative cannot be there, you may be able to get written consent from the patient and go alone. This is where it may differ from organisation to organisation so check your local procedures on how to go about it. Some organisations may insist on a relative being there, others may specify it is a visit with 2 members of staff, and some places may have a special form for signed consent .
The purpose of the environmental assessment is to have a look at (assess) the patient’s home and to see what equipment they have in situ and the environment-space, size, doors, steps and stairs and identify any equipment or adaptations that may be needed for discharge.
There may be certain questions that need to be answered which will direct your investigations such as;
- Is there room for a piece of equipment? For example; hoist, a bed downstairs, bariatric equipment, hospital bed, commode, perching stool or a walking aid.
- Will this person be able to go up the stairs or is downstairs living recommended?
- Heights of chair, bed and toilet are needed for patients who have had a total hip replacement
- Are there any falls hazards or safety concerns?
How to do it
If anything, this guide probably has too many questions but then it can cover all eventualities that you may come across. I actually wrote this as a prompt sheet for myself and have been using it, you’ll find a pdf document The OT process Blog final env ax, if you would like to print it off and use it yourself.
Before the visit:
- Establish the purpose of the visit
- Gain consent and arrange for a relative to be present. Make sure that you write down the relatives name and what relation they are to the patient.
- Some organisations may have a proforma that you need to fill in that guides your assessment so make sure you’ve got a copy. You’ll be writing down lots.
During the visit
Don’t forget to ask the relative questions on your way around the house such as; where does the patient normally eat? Which one is the patient’s bedroom (if it’s not obvious). Does the patient use the back door? Which armchair does the patient normally sit in? Do they normally get a shower or a bath (the patient, not the relative).
What to write
Access to property
Is there a pathway?
Are there stairs up to the property?
Do they have a communal entrance with intercom?
Is there a slope on the pathway? Does it slope downwards or upwards to path?
Are there any grab rails? How many? What do they look like? For example horizontal, vertical, wall to floor rail.
Is there a key safe?
Are there any steps or stairs up to the property?
Take down measurements including height (including any lips on the doorway), tread and threshold into hallway.
Are there any ramps or lifts?
Mobility and Circulation Space
What walking aid is the patient currently using? You’ll need to factor this into your assessment.
Will they have enough circulation space to mobilise with that aid? (i.e. room to move around)
Are there any narrow areas in the property that may be difficult to use that aid? note if there is any limited room anywhere in the house where a patient would regularly walk around. If it’s a second bedroom that they never go in then it’s no problem.
Can any furniture be moved to improve the circulation space? For example moving an armchair so the patient can get their delta frame between the sofa and armchair so they can go into the kitchen.
This can be important to know whether the patient can get through in their wheelchair, if they use it inside the house so more specific measurements may be needed, otherwise I have seem ‘standard door widths’ written in environmental assessments.
“1981 x 838 mm in most circumstances provides the required opening width for wheelchair access under the Part ‘M’ mobility requirements. You may also hear this door size being referred to as a 2’9”. So it gives an extra 76mm (3″) width
Describe flooring in each room if needed. This can be important for walking aids and hoists. It’s also important for falls risks e.g if there are loose rugs or carpet, holes or rips in the floor. Note any hazards.
Stairs are very important to us OT’s so you want to make some detailed observations here.
Location of the stairs (e.g. on immediate entry through the front door, is it an open staircase in the living room)
How many steps
How many rails (left or right ascending). Are there any bits where the rail stops and there are still stairs?
Describe the staircase. Is it a straight flight? Does it turn? Is it a split staircase? Are there any landings? You may want to say something like; there is a straight flight of 10 steps with a banister rail left ascending. There is then small landing the staircase then turns with 4 steps up with no rail onto the first floor landing
Take some measurements. Steps heights, widths and tread depth. If width is going to be an issue take a measurement at the widest and the narrowest points of the staircase.
Is there a falls alarm system, lifeline or other assistive technology?
Heights of furniture
If it’s an armchair or sofa that the patient normally sits on, you’ll need to get the height of it when you’re sat down on it, as they squish down lower and that’s the height that the person will be doing their sit to stand transfer from. How many legs or castors does the chair/sofa have? What are the legs of the furniture like; you’re looking here at what type of chair raisers will be needed. See this blog post on chair and bed raisers. Describe if they are square or circular. If it’s a sofa, you’ll need to report whether it’s a 2 or 3 seater as this is needed for ordering spreader bars for chair raisers.
You’ll need to know which side of the bed they sleep on if you need to put a bed lever in. You’ll need the height of the bed once sat on
How many legs or castors, what are the legs like?
Type of bed: single or double, divan base or slatted (this is for bed levers and spreader bars for bed raisers). Is the base sprung if it’s a Divan (as you can’t put bed levers in these types of beds).
Is there any equipment on the bed already? E.g. bed levers, mattress variators, back rests. Is it a hospital/profiling bed?
Is the toilet upstairs or downstairs or both?
What’s the height of the toilet?
Are there any equipment or rails in situ? Name them.
Is there room for a toilet frame?
Is there a boxed in unit behind the toilet? This can make certain toilet frames difficult to install.
Is there anywhere to put a grab rail by the toilet? Is the wall solid or studded?
Is there a commode? Where is it?
Is there somewhere to put a commode, if needed?. State where.
What have they got? Shower cubicle/shower over bath/walk in shower
Is there a step up to the shower? If so, what’s the height?
Is there any equipment or rails in situ? Describe them.
Is there anywhere to put a grab rail in or outside the shower? Is the wall solid or studded?
If you’re considering a shower stool, is there enough room for one? If so, which one?
Describe the bath. Roll top? Standard? Corner bath? P shaped bath?
What material is it? E.g enamel or plastic
Are there any equipment or rails in situ? Describe them.
Measure the bath from outside edge to outside edge-handy to know for bath and shower boards? Is there enough edge for a bath board/swivel bather (usually need 1 ½ inches)
What’s the height differential from the inside to the outside of the bath (useful to know if you’re thinking of a bath step so you know what height you’ll need.
Is there anywhere to put a grab rail by the bath? Is the wall solid or studded?
- Do they have a kitchen trolley? If they need one, is there enough space for one?
- Is there enough room for a perching stool in either kitchen or bathroom?
- Are there any other mobility aids or equipment that you can see?
- Are there any other falls hazards that you have noted? I’ve found the GEM environmental assessment helpful for identifying potential falls hazards to watch out for E.g clutter, loose wires, e.g. inadequate lighting or dark areas of house or items on the floor.
- Is there a smoke alarm? Carbon monoxide alarm? When was the last time they were checked? By whom?
- Note that if someone is downstairs living and there is a gas fire in the room that there will need to be a carbon monoxide detector.
- Are there any other steps. Some houses have steps up into bathrooms or bedrooms, get the measurements.
- Presence of any other grab rails.
- If downstairs living is being considered is there enough room for a bed downstairs? Where could it go? A standard single bed is 3 feet wide and 6 feet 3 inches long (91cm x 190cm for metric-lovers).
- Are there any especially narrow areas of the house that the person will have to navigate, measure them at the narrowest point.
- How is the home heated? Can the patient control the heating themselves?
- Does the patient own the property or is it rented, if so-is it housing association or private landlord. You’ll need to get permission to put rails in if the patient doesn’t own the property.
Although I spoke about one environmental ax being about establishing if there is any room for a hoist. I’ve not done that yet, so can’t comment but I’ll definitely do a blog post when I do. Apologies if I’ve missed anything out, let me know-as I mentioned it’s been a while since I last did them so I’m trying to brush up on this myself. We are always learning.
See you soon