Health – regulated service providers declaration Please complete the form below to help us understand if we can refer clients to your for services that you provide. Our privacy notice is available here. Please enable JavaScript in your browser to complete this form.About the businessBusiness name *Business address including postcode *Name of accountable manager *Job title of accountable manager *Business contact number *Business email address *Care Quality Commission (CQC)Are you registered with the CQC? *YesNoInspection date *Inspection rating *InsurancesDo you have employers liability insurance *YesNoHow much cover do you have? *Employers liability insurance expiry date *Please upload your current employers liability insurance certificate (copy) * Click or drag a file to this area to upload. Do you have public liability insurance? *YesNoHow much public liability insurance cover do you have? *Public liability insurance expiry date *Please upload your current public liability insurance certificate * Click or drag a file to this area to upload. Do you have Medical Malpractice Insurance (MMI)? *YesNoHow much MMI insurance cover do you have? *MMI insurance expiry date *Please upload your current medical malpractice insurance certificate * Click or drag a file to this area to upload. Do you have cover for negligence/malpractice within your insurance cover, with cover limits for negligence/malpractice ? *YesNoHow much negligence/malpractice insurance cover do you have? *Negligence/malpractice insurance expiry date *Please upload current written confirmation from your broker/insurer to confirm that any medical/personal care activities you engage in are covered under the scope of your existing public liability insurance * Click or drag a file to this area to upload. Do you and / or your staff use their personal vehicles in the course of their work? *YesNo15. Are those using personal vehicles for work insured for “Social, domestic and pleasure including business use”? *YesNoDon't knowSafeguardingDo you complete an assessment of need and care and support plan in line with CQC regulations prior to/within 48 hours of commencement of service provision? *YesNoDo you conduct a risk assessment prior to commencement of service provision in line with CQC regulations? *YesNoFrom time to time we may require further evidence or paperwork relating to the clients that you have supported on our behalf. Can these be made available on request? *YesNoDo you have policies and procedures in place reflecting the Kent & Medway Multi-agency Safeguarding Adults Policy? *YesNoDo you maintain the relevant standards to assure safeguarding of vulnerable adults, including satisfactory enhanced DBS checks as applicable for staff (and volunteers) in contact with, or accessing data about, vulnerable adults? *YesNoCan you confirm that robust procedures are in place for responding to suspicion or evidence of abuse or neglect to ensure the safety and protection of individuals who access the service? *YesNoCan you confirm that basic training on the prevention of abuse and self-neglect is given to all staff and volunteers within three months of employment commencing and/or engagement in activities with individuals? *YesNoDoes your Safeguarding Policy ensure that all allegations and incidents of abuse are followed up in a prompt, specified timeframe and that all details and actions taken are recorded in a dedicated record / file kept specifically for the purpose, as well as on the Personal file of person in receipt of regulated care provision? *YesNoDo you have a Whistleblowing policy which includes procedures under which staff and volunteers can raise, in confidence, any serious concerns that they may have and do not feel that they can raise in any other way? *YesNoGovernanceAre business continuity plans in place to manage certain situations e.g. adverse weather, staff absence? *YesNoHave you had, in the last three years, any finding of unlawful discrimination made against your organisation by an Employment Tribunal, an Employment Appeal Tribunal or any other court (or in comparable proceedings in any jurisdiction other than the UK)? *YesNoPlease provide details *Have you had, in the last three years, a complaint upheld following an investigation by the Equality and Human Rights Commission or its predecessors (or a comparable body in any jurisdiction other than the UK), on grounds of alleged unlawful discrimination? *YesNoPlease provide details *Have you been convicted of breaching environmental legislation, or had any notice served upon you, in the last three years by any environmental regulator or authority (including local authority).? *YesNoPlease provide details *Do you comply with the Health and Safety at Work Act etc. 1974? *YesNoDo you comply with the Offices, Shops and Railway Premises Act 1963? *YesNoConfirmationsWill you notify Carers' Support East Kent of any safeguarding and risk concerns that you may have? *YesNoDo you agree not to outsource any work commissioned by Carers’ Support East Kent? *YesNoCan you supply documentary evidence of insurances and other documents upon request? *YesNoPlease confirm that you are authorised to provide this information on behalf of your organisation, that the information given is correct, and that you will notify Carers’ Support East Kent of any changes to the above as they happen. *YesNoPrivacy noticePlease tick to confirm that you have read and understood our privacy notice *I have read and understand the privacy notice.WebsiteSubmit