General Information
Please state the number of years you have been trading at these premises:
Please state the number of years you have been trading elsewhere (if applicable):
If you have purchased an existing care home within the last 12 months, do you intend to predominantly continue with the existing staff?
Please Select
N/A
No
Yes
If not, please provide details:
Care Standards Act 2000
Is the home registered under the Care Standards Act 2000?
Please Select
No
Yes
If yes, which category of service are you registered to provide for?
Care home only No Yes
Care home with nursing No Yes
Care home providing adult placement No Yes
Care home not providing medicines or medical treatment No Yes
Details of Residents
Please state the minimum age of residents:
Please state the maximum number of residents that the home can accommodate:
Mental Illnesses
Does the home provide residential accomodation for any persons detained under the provisions of the Mental Health Act 1983?
Please Select
No
Yes
If yes, give details including numbers, ages & cause of detention:
In respect of homes caring for residents with mental health problems or learning disabilities:
(i) Explain the nature and severity of the illnesses/disabilities catered for:
(ii) Does the home accept clients with a history of violence, aggression, sexual offences or arson?
Please Select
No
Yes
If yes, please provide details of they are managed in order to protect other persons from injury:
Have there been any incidents of assault or abuse over the last 5 years?
Please Select
No
Yes
If yes, please provide details:
Additional Risk Information
Does the home offer any surgery post operative care?
Please Select
No
Yes
If yes, please state the percentage: %
Please list arrangements for services made available to service users in the home e.g. physiotherapy, etc.
Are any of the above services provided by you or your employees?
Please Select
No
Yes
If yes, please provide details:
If no, do you ensure that the practitioner holds Public Liability and/or Professional Indemnity Insurance?
Please Select
No
Yes
Do you provide Care in the Community?
Please Select
No
Yes
Do you provide Sheltered Accomodation?
Please Select
No
Yes
Do you provide Day Care?
Please Select
No
Yes
Do you provide any recreational facilities? (e.g. swimming pools, jacuzzis, gymnasiums, etc.)
Please Select
No
Yes
If yes to any of the above, please give details:
Are the residents/patients needs assessed and documented?
Please Select
No
Yes
Number of residents currently in the home:
Are staff in attendance 24 hours a day?
Please Select
No
Yes
Proposers History / Claims Experience
Have you or any other partner or director, been prosecuted under the Health & Safety Act? No Yes
Have you or any other partner or director, ever been declared bankrupt or insolvent? No Yes
Have you or any previous owner, director or partner of the business suffered any loss, damage, injury or liability in the last 5 years at these or any other premises whether insured or not? No Yes
If yes, please provide details i.e. date of claim, description of claim, amount claimed, etc.:
Health & Safety
Does the home comply with Health and Safety, COSHH and other environmental/health regulations? No Yes
Does the home have a written Health and Safety policy and are details of that policy passed to all employees? No Yes
Does the home have a specific action plan with regard to the clearing up of spillages of liquids and water, especially in the kitchen and bathroom environments, and warning notices to cordon off areas that are damp or wet be available and used? No Yes
Are regulators fitted to restrict the temperature of hot water and radiator surfaces/ pipes to a maximum of 43 degrees centigrade? No Yes
Is a pre-employment health questionnaire completed by all prospective employees and, in particular, specific enquiries about back problems made? No Yes
Are all staff properly trained in lifting techniques and is the training recorded in writing and does each member of staff sign a statement to confirm that they have received such training? No Yes
Building Construction
Construction of the walls (e.g. brick, stone, etc.)
Construction of the roof (e.g. tile, slate, etc.) (If flat, state if 'felt/bitumen' or 'concrete')
Percentage of flat roof (if applicable) %
Approximately, what year was the property built?
Is the building purpose built or converted? Purpose Built Converted
Is the property a listed building?(e.g. grade I, II, II* etc.)
- Please Select -
Not Listed
Grade I
Grade II
Grade II*
Has any part of the property ever been affected by any subsidence or flood damage?
- Please Select -
No
Yes
If yes, please provide details:(e.g. type of damage, date of damage, amount of damage, etc.)
How high is the property above the nearest watercourse or tidal waters?