Risk Questionnaire for Nursing & Care Homes

Before you start filling out this questionnaire, please ensure that you have the following documents ready:

Annual accounts for the last 3 accounting periods
Full details for all claims, incidents and circumstances reported in the last 6 years, if applicable.

Nursing & Care Homes Risk Questionnaire

Please enable JavaScript in your browser to complete this form.

Layout

Name of the person providing information:

Email:

Position held within the business:

Phone:

How many Directors and/or Partners this Nursing and/or Care Business have in total?

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

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

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

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

Select any of the following that apply to any proposer, director or partner:

had an insurance cancelled
has a renewal refused
had a proposal refused or declined
had special terms imposed
Not applicable

Select any of the following that apply to any proposer, director or partner:

been disqualified from holding company dictatorship
been declared bankrupt or insolvent or been the subject of bankruptcy proceeding or insolvency proceeding
been the owner or director of, or partner in, any business, company or partnership had a county court judgment awarded against them
had any conviction or criminal offence which are not spent under Rehabilitation of Offenders Act or has any prosecutions pending
Not applicable

Select any of the following that apply to any proposer, director or partner:

been served with prohibition or improvement order under health and safety regulation
been convicted of, (or charged but not yet tried for) any offence other than a driving offence
been the subject of a recovery action by Customs and exercise or the Inland Revenue
been convicted or, charged (but not yet tried) with or officially cautioned for a breach pf any Health and Safety or Welfare or Environmental Protection legislation
Not applicable

Layout

Business name:

Trading name:

Layout

Status of entity:

Date established:

Layout

Business description:

Years of experience:

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

Would you like to add a correspondence address?

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

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

Layout

Date of the last inspection:

What rating did you receive on your last inspection?

Outstanding
Good
Requires improvement
Inadequate

Please provide details:

Have you completed all actions points identified during any previous regulator (CQC or local equivalent) inspections?

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

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

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

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?

Do you have any employees?

Are all employees (inc. LOSC, trainees, apprentices) paid below PAYE threshold?

Layout

Total number of employees:

Employer PAYE No:

What is the Business Total Annual Turnover? (£)

Layout

What is the estimated Annual Wageroll for Manual working employees?

What is the estimated Annual Wageroll for Clerical (non-manual) employees?

Layout

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

Layout

How many staff are on each shift?

What are the arrangements for night care?

Layout

Is there always a senior member of staff on duty?

What percentage of operational roles are currently vacant?

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?

Please provide the numbers of your staff:

Layout

Registered managers:

Senior carers:

Kitchen staff:

Admin staff:

Please provide the numbers of your staff:

Layout

Night carers:

Maintenance staff:

Day carers:

Other staff:

RECRUITMENT DETAILS:

Are all employees required to complete a written application form?

Do you verify the identity of all applicants prior to employment?

Are written references requested and independently verified for all employees?

Are all qualification provided independently verified?

Do you undertake DBS checks on all employees prior to employment?

Do you 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 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/Children?

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

Do you record the receipt, including signature by employees of all policy procedures and guidelines?

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

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

Do you have a formal procedure for dealing with complaints or concerns regarding abuse or neglect?

Are all such concerns or complaints recorded?

Do you have a written Policy Statement on the protection of service users/children?

Do you have documented instructions on the protection of service users/children?

Do you have a written Anti-Bullying Policy?

Do you have written instructions on managing behaviour and acceptable restraint?

Are all staff or care providers are trained in the following aspects of care:

Aggression and anger management
Restraint and control
De-escalation
Food hygiene
First Aid
Fire safety

Do you have a documented employee disciplinary and grievance procedure?

Do you have a designated person responsible for all issues regarding the protection of service users/children?

Do you 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/children?

Are sufficient and suitable risk assessments undertaken and documented?

Do you have written guidelines on the supervision of service users/children during activities away from your main premises?

Do you have written standards of good practice for acceptable behaviour?

Do they include guidelines on intimate care or appropriate contact?

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

Do you securely retain for a legally required period of time the following records with contingency arrangement in place for long-term retention should you cease to operate:

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

Please select applicable

Do you own the business premises?

What name is on the Land Registry Title Deeds?

Please choose the property type:

Converted manor
Purpose built
Converted other

Is the building listed?

Layout

Year the property was built (YYYY)

Year the business established at this address (YYYY)

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

Do you live on the premises?

Does any of your employees live on the premises?

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

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

Please select if any following options apply to the premises:

The business is not self contained with its own means of access
The proposer is not the sole occupant (if other than offices or private dwellings)
The premises is closed for more than 3 consecutive months
The property is unoccupied, or has not been used in the last 30 days
The property has been extended
Not applicable

Please select if any following options 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
Not applicable

Please select if any following options apply to the premises:

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 mines/underground workings
The property is close to cliffs, embankments, railway cuttings, tunnels, quarries or other excavations
The property is close to vibrations from major roads/ railways
The property is close to sloping site
Not applicable

Please indicate correct answer: Are the walls of the building constructed from:

Standard, one type of material
More than one type of materials

Please select the walls material of the building from the options provided below:

Please specify what materials and describe percentage of each material used:

Please indicate correct answer: Does the building have a roof constructed from:

Standard, one type of material
More than one type of materials

Please select the roofing material of the building from the options provided below:

Please specify what materials and describe percentage of each material used:

Is there an area of flat roofing?

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

Layout

Total number of stories:

Number of stories where floor is of wooden construction

Do you use any cellars or floors below street level?

Type of heating:

Layout

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
Fire Alarm
Fire extinguishers in place to scale
Fire blankets in kitchen
Intruder Alarm
Sprinklers
Other
None

Layout

Please specify type of door locks

Please specify type of window locks

SERVICE USERS DETAILS:

Type of home:

Layout

Maximum number of services users:

Of these how many residents receive nursing care?

Please choose type of Service Users relevant to the business:

Elderly (including those with dementia)
Mental Health disorder (but not Sectioned under the Mental Health Act 1983)
Aged under 18 years
Physically disabled
Learning disability
Not described above

What is the minimum ratio of staff to resident? (including overnight)?

Percentage of service users who are elderly (including those with Dementia)

Percentage of service users aged under 18

Percentage of service users aged over 18 who have a 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

Layout

Current number of service user aged under 18:

Current number of service user aged 19 to 64:

Current number of service user aged 65+

Select any of the following behavioural history 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?

Is surgery, endoscopy, haemodialysis, peritoneal dialysis or treatment by lasers undertaken at the Home?

Do you provide Pre and/or Post Operative Care?

Please confirm, that you have written Safeguarding Policy to guard against abuse of your service users by any person which is reviewed at least annually and when legislation requires?

You have written Health and Safety policy which is reviewed regularly

Is a written Health and Safety policy in operation which is made clear to all those working within your business?

Is your organisation audited/accredited by a third-party approving body that includes your Safeguarding Policy?

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?

Do you keep a record of this information on the employee’s 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?

Can you confirm that medicine prescribed by general practitioners to Service Users are administered by trained care workers (including Employees if applicable) sufficiently competent to ensure that required dosage levels are adhered to?

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

Do you provide any other Care in the Community?

Layout

Do you provide any other facilities/activities?

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?

What is the estimated total value of the building? (Including Fixed Glass, Landlords Fixtures/Fitting)

PLEASE INDICATE VALUES OF YOUR BUSINESS CONTENTS:

Layout

Business Equipment:

Resident Clothing and Personal Effects:

Stock and Material in Trade:

Electrical equipment:

Stock Deterioration:

All Other Contents:

Layout

Insurance renewal date:

Current or previous insurer:

Is there anything else you would like us to know about?

GDPR Agreement *

I consent to having this form submitted so Prestige Insurance Brokers (UK) Ltd can respond to my inquiry.

We would like to assure you that we take data protection seriously and your privacy is important to us. We will process your data in accordance with GDPR.

Phone