Fact-finding questionnaire to request an insurance quote

for A CARE HOME or Nursing home

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Contact name

Phone

Business insurance renewal date or policy start date required:

Current insurer (If applicable)

1. GENERAL BUSINESS INFORMATION

Business name

Trading name

Status of entity

Business description:

Company registration number

Date established

Years of experience:

How many Directors and/or Partners this business have in total?

1) Full name / Date of Birth / Position in the company:

2) Full name / Date of Birth / Position in the company:

3) Full name / Date of Birth / Position in the company:

4) Full name / Date of Birth / Position in the company:

Please indicate if any director, or partner has ever:

had an insurance policy cancelled
had a policy renewal refused
had a proposal refused or declined
had special terms imposed on an insurance policy
Not applicable (No adverse insurance history)

Please indicate if any director, or partner has ever:

been disqualified from holding company directorship
been declared bankrupt or insolvent
had a County Court Judgment awarded against them
had any conviction or criminal offence
been served with prohibition or improvement order under Health and Safety regulation
been convicted or, charged with or officially cautioned for a breach of any Health and Safety or Welfare or Environmental Protection legislation
Not applicable (No disqualifications or legal history)

Business address: (Property Name, Building Number, Street Name, Town, Post Code)

Would you like to provide a different address for correspondence?

Correspondence address: (Property Name, Building Number, Street Name, Town, Post Code)

Is the business registered with the CQC or other regulatory body?

Date of the last CQC inspection:

Rating received on the most recent CQC inspection?

Outstanding
Good
Requires improvement
Inadequate

Have you completed all actions points identified during any previous regulator CQC inspections?

Yes
No
Not applicable

Have there been objections to any applications for registration or complaints lodged with the regulatory body in respect of your business?

Yes
No
Not applicable

Are there any outstanding requirements which might affect future applications or continuation of your certificate?

Yes
No
Not applicable

Are you aware of any reasons why there might be objections to future applications or continuation of your certificate?

Yes
No
Not applicable

Have you experienced any losses or incidents giving rise to losses in the last 5 years?

Are you aware of any incidents in respect of your activities which might reasonably be expected to give rise to a claim for abuse or professional negligence?

Please provide details:

Business Total Annual Turnover (£)

Business Gross Profit (£)

2. EMPLOYMENT INFORMATION

Number of Registered Managers:

Their Annual Wage-roll

Number of Senior Carers

Their Annual Wage-roll

Number of Day carers:

Their Annual Wage-roll

Number of Night carers:

Their Annual Wage-roll

Number of Admin staff:

Their Annual Wage-roll

Number of Other Staff (Maintenance, Kitchen, Housekeeping etc)

Their Annual Wage-roll

Employer PAYE No:

Are all employees paid below PAYE threshold?

(inc. LOSC, trainees, apprentices)

Total number of (Full Time) employees:

Total number of (Part Time) employees:

3. WORKING ARRANGEMENTS:

How many staff are on each day shift?

What are the arrangements for night care?

Is there always a senior member of staff on duty?

What percentage of operational roles are currently vacant?

What is the current level of staff turnover?

For the last 5 years

What is the turnover of Home Managers?

For the last 5 years

Do you have a minimum staffing level for all of your facilities and suitable arrangements if this can't be meet?

Please provide details below:

Has there been any movement in the staff to service user ratio in the last year?

Please provide further information in respect of how this has changed and any reasons for this movement:

Is any principal, director or person in charge a qualified medical or dental practitioner?

Does this practitioner hold Professional Indemnity insurance?

4. MANAGEMENT & TRAINING INFORMATION:

Please provide details of qualifications and experience of Managers / Senior Carers?

Do you have any qualified Nurses with experience in this sector? Please provide details:

Details of qualifications and experience of Carers:

Are all new employees required to complete a written application form?

Does the management verify the identity of all new applicants prior to employment?

Are written references requested and independently verified for all employees?

Are all qualification independently verified?

Do all staff have to complete a medical questionnaire form prior to commencing employment?

Does the management undertake DBS checks on all employees prior to employment?

Does the management undertake DBS checks on all existing employees at least every 3 years?

Are all prospective employees required to declare if they have any convictions, cautions, reprimands or final warnings that are not "protected" as defined by the rehabilitation of Offenders Act 1974 (Exceptions) order 1975 (as amended in 2013) or local equivalent?

Can you confirm that none of your business employees (past or present) have ever been interviewed in connection with, or been the subject of any investigation or enquiry into, abuse or other inappropriate behaviour?

Does your induction and ongoing training for employees include awareness of the Protection of Service Users?

Does the business have a designated person to whom all complaints or concerns regarding abuse, neglect or other inappropriate behaviour are reported?

Does the business record the receipt, including signature by employees of all policy procedures and guidelines?

Does the business have a written Health and Safety Policy in place, which is reviewed regularly?

Who compiled this policy?

Is the H&S Policy in operation and made clear to all those working within your business?

Are external companies / consultants used for any aspects of Health and Safety, personnel or training purposes?

Are staff and residents all familiar with the Emergency Fire Procedure? Please also state how this is achieved.

Does the business include a whistle-blower policy whereby unacceptable conduct of Employees can be reported without recrimination?

Does the business include guidelines on how to respond to allegations or concerns regarding abuse, neglect or other inappropriate behaviour?

Does the business have a formal procedure for dealing with complaints or concerns regarding abuse or neglect?

Are all the complaints or concerns regarding abuse or neglect recorded?

Does the business have a written Policy Statement on the Protection of Service Users?

Does the business have documented instructions on the protection of Service Users?

Does the business have a written Anti-Bullying Policy?

Does the business have written instructions on Managing Behaviour and acceptable restraint?

Please select all training provided to staff in the following aspects of care:

Aggression and Anger Management
Restraint and Control
De-escalation
Food hygiene
First Aid
Fire safety

What are Procedures for dispensing prescribed drugs:

Does the business have a documented employee disciplinary and grievance procedure?

Does the business have a designated person responsible for all issues regarding the Protection of Service Users?

Does the business have written guidelines on the roles and responsibilities of all employees and other persons providing services on your behalf?

Do you have a documented method to ensure continued compliance with regulations and guidance on the Protection of Service Users?

Does the business have all sufficient and suitable risk assessments undertaken and documented?

Does the business you have written guidelines on the supervision of Service Users during activities away from your main premises?

Does the business have written Standards of Good Practice for Acceptable Behaviour?

Are those written standards of Good Practice for Acceptable Behaviour include guidelines on intimate care or appropriate contact?

Do you have separate and secure means to store material relating to allegations or concerns?

Is smoking allowed in the home and how is this controlled? Please provide a date of the last inspection.

Do you securely retain the following records for the legally required period, with contingency arrangements in place for long-term retention should you cease to operate?

Training records
Employment application forms
Records of your historical liability insurance policies
Service user files including referral, assessment and care plans
Background checks, references and identity verification documents
Accident and incident registers including records of abuse and notification to relevant authorities

5. PREMISES INFORMATION

Does the business own the premises?

Name is on the Land Registry Title Deeds

Date of purchase

Please select the property type in which the care is provided:

Converted manor
Purpose built
Converted other

Is the building listed?

Please provide details:

Year the property was built (YYYY)

Year the business established at this address (YYYY)

Please select any of the following that apply to the premises:

The property has been extended
The business is not self contained with its own means of access
The business is not the sole occupant (if other than offices or private dwellings)
The business is closed for more than 3 consecutive months
The property is unoccupied, or has not been used in the last 30 days
No additional risk factors regarding premises

Please select any of the following that apply to the premises:

The property has walls or roofs constructed of composite panels
The property has walls of roofs containing combustible linings
The property is erected on made up ground or has been underpinned
The property or adjacent property has suffered from, or shows any visible signs of damage from subsidence, landslip or ground heave
The premises is in area with history of flooding
The property is unduly exposed to storms or high winds
No additional risk factors regarding premises

Please select any of the following that apply to the premises:

The property is close to sloping site
The property is close to mines/underground workings
The property is surrounded by the trees or shrubs, which are more than 5 meters in height and within 10 meters of the property
The property is close to cliffs, embankments, railway cuttings, tunnels, quarries or other excavations
The property is close to vibrations from major roads/ railways
No additional risk factors regarding premises

Is staff in attendance at the premises 24 hours a day?

Do you or any any employee live on the premises?

Are service users able to gain access to the private dwelling area?

Is there a separate entrance to the private dwelling area which is used by you or your employees to gain access?

What are the main materials used in the construction of the property walls?

Please provide percentage split, if the walls are made of more than one material

What are the main materials used for the roof of the property?

Please provide percentage split, if the roof is made of more than one material

Is there any area of flat roofing?

If yes, please state the approximate percentage of the roof being flat?

Number of storeys where floor is of concrete construction

Number of storeys where floor is of wooden construction

Do you use any cellars or floors below street level?

Type of door locks?

Type of window locks?

Type of heating:

Heating fuel:

Any portable heaters?

If so, please confirm the type and let us know when do you use them?

Any cooking facilities beyond the kitchen?

Is the premises in a good state of repair and free from damage?

Please select risk management features that are relevant:

Current IEE electrical certificate
Electrical inspection in the last five years
Smoke detectors mains connected
Fire Alarm
Fire extinguishers in place to scale
Fire blankets in kitchen
Intruder Alarm
Electrics checked and certified by NEICC contractor
Sprinklers

6. SERVICE USERS INFORMATION

Type of home:

Care home
Care home with nursing
Care home with shared lives scheme
Other

Maximum number of Service Users:

How many of these Service Users receive nursing care?

Please select the types of Service Users relevant to the business:

Elderly (including those with dementia)
Physically disabled
Mental Health disorder (but not Sectioned under the Mental Health Act 1983)
Aged under 18 years
With learning disability
Other

What is the minimum staff-to-resident ratio during the daytime?

What is the minimum staff-to-resident ratio overnight?

Percentage of Service Users who are elderly (65+)

(Including those with Dementia)

Percentage of Service Users that are physically disabled

Percentage of Service Users aged under 18

Percentage of Service Users (18+) with learning disability

Percentage of Service Users with mental health disorders

(But not sectioned under Mental Health Act 1983)

Percentage of Service Users that are not described above

Number of service user aged under 18:

Number of service user aged 19 to 64:

Number of service user aged 65+

Select the genders of your Service Users:

Women
Men
Mix

Select any of the following behavioural history items that apply to your Service Users:

Challenging aggressive or violent behaviour
Drug or alcohol dependence
Service users with a history, committing or attempting sexual or violent offences or arson attacks
Services users liable to be Sectioned under the provisions of the Mental Health Act 1983 or local equivalent of such legislation
Service users with a history of schizophrenia
Services users detained under the provisions of the Mental Health Act 1983 or local equivalent of such legislation
Not applicable

Do you have secure units, including detention centres?

Are the service users' rooms inspected daily and defects remedied?

How long have the individuals been residing at the home?

Do Service Users suffer with Dementia/Alzheimer’s?

Describe the procedures in place in-order to ascertain whether an individual will be accepted (including details of any risk assessments carried out):

Description of type of individuals accepted

Do you provide Pre and/or Post Operative Care?

8. REGULATORY COMPLIANCE INFORMATION

Do you have written Safeguarding Policy to guard against abuse of your Service Users?

Is this Safeguarding Policy reviewed at least annually and when legislation requires?

Are the provisions of the Manual Handling Operations Regulations 1992 complied with?

Are the provisions of the Management of Health & Safety at Work Regulations 1999 complied with?

Are the provisions of the Control of Substances Hazardous to Health Regulations 2002 complied with?

Are the provisions of the Personal Protective Equipment at Work Regulations 1992 complied with?

Are the provisions of the Workplace (Health, Safety, and Welfare) Regulations 1992 complied with?

Are the provisions of the Regularly Reform (Fire Safety) Order 2005, The Fire (Scotland) Act 2005, or The Fire & Rescue Services (Northern Ireland) Order 2006 - as appropriate - compliant with?

Do you comply with the HSE Approved Code of Practice and Guidance L8 (2002): Legionnaires Disease: the control of Legionella bacteria in water systems?

Is an accident book kept recording all incidents including, but not limited to back injuries to Employees?

Is the medical history of new staff checked with specific reference to back and neck injuries or dermatitis, and a record of such retained on each employee personnel file?

Are staff trained in manual handling and records retained recording such training?

Are lifting aids provided, used, and maintained where possible and staff trained in their use?

Are lifting aids used in preference to manual handling?

At all times are suitably qualified competent and experienced person working in such numbers as are appropriate for the health and safety of the Service Users?

Do you provide domiciliary care services (Care in the homes of Service Users)?

Do you provide any other Care in the Community?

Is smoking allowed in the home?

Yes, in designated area
No

Do you provide any Sheltered Accommodation?

Can you confirm that the administration of drugs in the other circumstances is only undertaken at Homes registered as providing nursing and by trained medical and nursing personnel?

In respect of any doctors, surgeons or dentist working in connection with your business, are they all suitably qualified and registered and hold their own relevant insurance?

Do you regularly review and update your infection protection control risk assessments and procedures in line with Government guidelines and record when any changes have been made?

Can you formally demonstrate that you communicate these changes to your employees and or volunteers?

SUM INSURED & FINANCIALS

Reinstatement sum of the building (If owned by the business)

Reinstatement sum of Tenants Improvement (If building is rented)

Reinstatement sum of Furniture, Fixtures, Office equipment, all other contents

Sum of Computer & Electronic Equipment

Reinstatement sum of Resident Clothing and Personal Effects

Sum of Business Stock and Material in Trade

Number of fridges and freezers, along with the maximum reinstatement sum of stock in each

Do you use a safe or strongroom on the premises? If yes, please provide: • Safe’s make and model • Description of how it is secured • Maximum reinstatement sum

Required length of indemnity period for Business Interruption cover

12 months
24 months
36 months
Not required

The period that begins after an insured event occurs and ends when the business is back to normal or when the policy's maximum period expires.

Required Limit of indemnity for Public Liability

Required Limit of indemnity for Employers' Liability

Required Limit of Professional Indemnity

Required Limit of Abuse Cover

Additional information:

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