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{{org_field_name}}

Registration Number: {{org_field_registration_no}}

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Safe, Secure and Suitable Premises, Facilities and Equipment Policy

1. Purpose

The purpose of this policy is to ensure that {{org_field_name}} provides a safe, secure, and well-maintained environment for service users, staff, and visitors. It outlines the measures taken to protect individuals, property, and sensitive information while complying with Care Inspectorate Wales (CIW) regulations and health and safety legislation. This policy aims to prevent unauthorised access, ensure emergency preparedness, and maintain a comfortable living and working environment for all.

This policy aligns with:

• The Regulation and Inspection of Social Care (Wales) Act 2016, which provides the legal framework for the regulation and inspection of social care services in Wales.
• The Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, as amended, including Regulations 43, 44, 47, 48, 55, 56 and 57, which require the provider to ensure that premises, facilities, equipment, supplies, hygiene arrangements and health and safety systems are suitable, safe, properly maintained and appropriate for the regulated service.
• Welsh Government Statutory Guidance for service providers and responsible individuals on meeting service standard regulations, Version 3, March 2024, which sets out how care home providers may comply with the 2017 Regulations.
• Care Inspectorate Wales inspection framework for care home services, secure accommodation services, residential family centres and domiciliary support services, including the Environment theme for accommodation-based services.
• The Health and Safety at Work etc. Act 1974 and associated health and safety legislation, requiring the provider to protect the health, safety and welfare of staff, individuals, visitors and others affected by the service.
• The Regulatory Reform (Fire Safety) Order 2005, as amended, and the Fire Safety Act 2021, as applicable in Wales, requiring suitable and sufficient fire risk assessment and fire safety arrangements.
• The Equality Act 2010, requiring reasonable adjustments and non-discriminatory access to premises, facilities and equipment.
• The Human Rights Act 1998, the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards, where security measures may affect liberty, privacy, autonomy or freedom of movement.
• UK GDPR and the Data Protection Act 2018, requiring personal information and surveillance information to be processed lawfully, fairly, securely and transparently.
• The Regulated Services (Inspection Ratings) (Wales) Regulations 2025, where applicable, requiring care home services to comply with CIW rating publication and display requirements.

2. Scope

This policy applies to:

• All staff members, ensuring they understand their responsibilities for security and safety.
• Service users, ensuring their environment is comfortable, safe, and secure.
• Visitors and contractors, ensuring controlled access and adherence to safety protocols.
• Equipment, documentation, and property, ensuring proper security and maintenance.

The policy covers:

• Physical security measures, including access control and surveillance.
• Health and safety procedures, including risk assessments and compliance with regulations.
• Fire safety and emergency planning.
• Confidentiality and data protection within the premises.

This policy also covers the suitability, safety, cleanliness, accessibility, maintenance and security of the premises, facilities, furnishings, adaptations, outdoor areas and equipment used to provide the care home service. It applies to all areas used by individuals, staff, visitors, contractors and professionals, including bedrooms, communal areas, bathrooms, kitchens, laundry areas, offices, medication storage areas, records storage areas, gardens, external grounds, entrances, exits, car parking areas, lifts, stairways, corridors and storage areas.

3. Principles of Safe and Secure Premises

3.1 Ensuring a Safe, Suitable and Well-Maintained Environment

At {{org_field_name}}, the premises, facilities and equipment used for the provision of the care home service must be suitable for the service described in the Statement of Purpose and appropriate to the care and support needs, personal outcomes, dignity, privacy, safety and well-being of individuals.

The Registered Manager will ensure that the premises are:

• accessible, adequately lit, heated and ventilated;
• secure from unauthorised access without unnecessarily restricting individuals’ rights, autonomy, liberty or freedom of movement;
• suitably furnished, equipped and adapted to meet the assessed needs of individuals;
• of sound construction and kept in good structural repair, internally and externally;
• organised so that equipment is appropriately located, safely stored and available when required;
• free from hazards to the health and safety of individuals, staff, visitors and contractors, so far as reasonably practicable;
• properly maintained, clean and comfortable;
• designed and managed to support privacy, dignity, confidentiality, independence and personal choice;
• suitable for people with physical, sensory, cognitive, communication or mobility needs, including wheelchair users where applicable.

Premises risk assessments will include internal areas, external grounds, access routes, bedrooms, bathrooms, communal areas, kitchens, laundry areas, medication storage areas, records storage areas, equipment storage areas, lifts, stairs, windows, doors, lighting, heating, ventilation, water systems, infection prevention arrangements and fire safety arrangements.

A full premises and environmental risk assessment will be completed at least quarterly, or sooner where there is a change in the premises, equipment, use of rooms, needs of individuals, staffing arrangements, accident trends, inspection findings, external professional advice or any safety concern. Findings will be recorded, prioritised according to risk, allocated to a named responsible person and monitored until completed.

Where improvements are identified, action will be taken according to the level of risk. Immediate action will be taken where there is a risk of harm to individuals, staff or visitors.

3.2 Access Control, Security and Freedom of Movement

{{org_field_name}} will maintain proportionate security arrangements to protect individuals, staff, visitors, property, medication, records and confidential information. Security measures must be necessary, proportionate, risk assessed and the least restrictive option available.

Access control arrangements include:

• controlled entry and exit systems appropriate to the layout and purpose of the service;
• visitor sign-in and sign-out procedures;
• verification of the identity of contractors, professionals and unfamiliar visitors;
• restricted access to medication storage areas, staff-only areas, plant rooms, cleaning chemical storage, records storage and other sensitive areas;
• secure arrangements for personal property, valuables and money, where the service accepts responsibility for safekeeping;
• clear procedures for staff to challenge, redirect or report unauthorised persons in a safe and professional manner.

Security arrangements must not be used to unlawfully restrict an individual’s liberty, movement, contact with others or access to the community. Where an individual’s movement needs to be restricted because of a risk of harm, this must be supported by a current risk assessment, the individual’s personal plan, mental capacity and best interests documentation where applicable, and lawful authorisation where required.

Staff must ensure that doors, windows and access points are managed safely. Fire exits must never be blocked or locked in a way that prevents safe emergency evacuation, unless a suitable lawful fire safety system is in place and has been approved through the fire risk assessment process.

3.3 CCTV, Surveillance and Privacy

Where CCTV or any surveillance system is used, it will be used only where necessary, proportionate and justified by risk assessment. CCTV must support safety and security without compromising individuals’ dignity, privacy, confidentiality or human rights.

CCTV will not be used in bedrooms, bathrooms, toilets, changing areas or other areas where individuals can reasonably expect privacy, unless there are exceptional circumstances, a clear lawful basis, documented risk assessment, consultation, best interests decision where applicable, and senior management approval.

The Registered Manager will ensure that:

• a CCTV/privacy impact assessment is completed and reviewed regularly;
• individuals, representatives, staff and visitors are informed where CCTV is in operation;
• clear signage is displayed;
• CCTV footage is accessed only by authorised persons;
• footage is stored securely and retained only for the approved retention period;
• requests to view or disclose footage are managed in line with UK GDPR, the Data Protection Act 2018 and safeguarding procedures;
• any use of CCTV by individuals, families, staff or third parties is risk assessed and authorised before use;
• CCTV is not used as a substitute for appropriate staffing, supervision, engagement or care planning.

Any covert surveillance must be exceptional, time limited, legally justified, authorised by senior management and handled in accordance with data protection, safeguarding, employment and human rights requirements.

3.4 Fire Safety and Emergency Preparedness

Fire safety is a core part of maintaining safe and secure premises. {{org_field_name}} will comply with applicable fire safety legislation and fire authority advice.

The Registered Manager and Fire Safety Lead will ensure that:

• a suitable and sufficient fire risk assessment is completed by a competent person and reviewed at least annually, or sooner following any significant change, incident, near miss, fire safety concern, building alteration, change in dependency levels or professional advice;
• fire alarms, emergency lighting, fire doors, fire extinguishers, fire detection systems, fire suppression systems where installed, and other fire safety equipment are tested, serviced and maintained in line with legal requirements, manufacturer guidance and competent person advice;
• fire escape routes, corridors, stairways, exits and assembly areas are kept clear and accessible;
• fire doors are not wedged open unless approved automatic closing devices are fitted;
• Personal Emergency Evacuation Plans or equivalent evacuation support arrangements are in place for individuals who require assistance to evacuate;
• staff receive fire safety training during induction and refresher training at planned intervals;
• fire drills are carried out at least every six months, including consideration of day and night staffing arrangements;
• lessons from fire drills, false alarms, incidents and professional visits are recorded and acted upon;
• emergency plans cover evacuation, progressive horizontal evacuation where applicable, shelter arrangements, temporary relocation and business continuity.

In the event of a fire or suspected fire, staff must follow the fire procedure, raise the alarm, support individuals according to their evacuation plans, contact emergency services and report the incident in line with internal procedures and CIW notification requirements where applicable.

3.5 Secure Handling of Personal and Confidential Information

Confidentiality and data protection are key security concerns within the premises. We ensure:

• Service user records are stored in locked cabinets and/or password-protected databases.
• Only authorised staff have access to personal data, following GDPR regulations.
• Visitors and contractors sign confidentiality agreements where necessary.
• Shredding of confidential documents before disposal, preventing data breaches.

Data breaches or unauthorised access to confidential information must be reported immediately to the Data Protection Officer: {{org_field_data_protection_officer_first_name}} {{org_field_data_protection_officer_last_name}}.

The premises will include suitable and secure facilities for the storage of records and confidential information. Records must be stored in a way that protects confidentiality, prevents unauthorised access, supports accurate record keeping and allows records to be made available to authorised persons, including CIW, where required. Staff supervision, confidential meetings and discussions about individuals must take place in a suitable private space wherever practicable.

3.6 Health and Safety Compliance and Risk Management

To ensure the ongoing safety of service users and staff, we:

• Conduct regular risk assessments, identifying hazards and implementing controls.
• Follow infection prevention and control procedures, including cleaning and PPE use.
• Provide staff training on manual handling, first aid, and accident reporting.
• Ensure emergency procedures (fire, power failure, medical emergency) are well-documented and rehearsed.

All incidents, near-misses, and accidents must be reported and logged in line with our Health and Safety Policy.

3.7 Staff Responsibilities and Training

All staff members must adhere to this policy and:

• Complete safety and security training as part of induction and annual refresher courses.
• Follow procedures for access control, fire safety, and data protection.
• Report concerns about security, health hazards, or suspicious behaviour to the Registered Manager.
• Support service users in understanding and following security measures, ensuring their participation in safety protocols.

Managers are responsible for monitoring compliance and ensuring staff receive regular updates on safety measures.

3.8 Facilities, Furnishings and Equipment

{{org_field_name}} will ensure that all facilities, furnishings, adaptations and equipment used for the provision of the service are suitable, safe, clean, properly maintained and appropriate for the purpose for which they are used.

This includes, where applicable:

• beds, mattresses, pressure-relieving equipment and bedroom furniture;
• hoists, slings, stand aids, wheelchairs and mobility equipment;
• bathing, showering and toileting equipment;
• call bell systems and assistive technology;
• kitchen, laundry and cleaning equipment;
• medication storage equipment;
• PPE and infection prevention equipment;
• fire safety equipment;
• lifts, stair lifts, ramps and access equipment;
• outdoor seating, pathways and garden equipment.

The Registered Manager will ensure that:

• equipment is used only for its intended purpose;
• staff are trained and competent before using specialist equipment;
• equipment is cleaned and decontaminated in line with infection prevention requirements and manufacturer instructions;
• servicing, inspection, maintenance and calibration are completed by competent persons at required intervals;
• defects are reported immediately and defective equipment is taken out of use where it presents a risk;
• suitable storage is available so equipment does not create hazards, block access routes or compromise dignity;
• individuals are consulted, where practicable, about facilities and equipment provided for their use;
• records of servicing, repair, replacement, cleaning and safety checks are maintained.

3.9 Outdoor Areas and External Grounds

Outdoor areas and external grounds will be maintained so they are safe, accessible and suitable for individuals using the service. The Registered Manager will ensure that:

• pathways, entrances and outdoor routes are safe, even, well-lit where required and suitable for people using wheelchairs, mobility aids or mobility scooters where applicable;
• outdoor areas are risk assessed and maintained to reduce hazards such as slips, trips, falls, unsafe surfaces, poor lighting, unsafe gates, exposed chemicals, unsafe plants, water hazards or damaged furniture;
• sufficient and suitable seating is available where individuals use outdoor areas;
• garden and recreational equipment is safe, clean and maintained;
• outdoor spaces support independence, well-being, therapeutic activity and sensory needs where practicable;
• individuals can access outdoor areas independently or with support, in line with their needs, wishes, personal plans and risk assessments;
• security arrangements for gardens and grounds are proportionate and do not unlawfully restrict liberty or movement.

3.10 Health, Safety, Hygiene and Environmental Controls

{{org_field_name}} will maintain health, safety, hygiene and environmental control arrangements to protect individuals, staff, visitors and contractors.

The Registered Manager will ensure that risk assessments and control measures are in place for:

• safe water temperatures and prevention of scalding;
• water hygiene and legionella control;
• window restrictors and prevention of falls from height;
• slips, trips and falls;
• hazardous substances and COSHH;
• clinical waste, domestic waste and sharps disposal where applicable;
• food storage, preparation and hygiene;
• infection prevention and control;
• laundry arrangements;
• cleaning schedules and cleanliness audits;
• electrical safety;
• gas safety where applicable;
• asbestos management where applicable;
• contractor safety;
• moving and handling equipment;
• environmental temperature, heating and ventilation;
• pest control;
• lift safety and servicing where applicable;
• maintenance work and temporary hazards.

External advice from competent professionals, the fire and rescue service, Health and Safety Executive, environmental health, infection prevention specialists, insurers, contractors or other relevant bodies will be considered and acted upon according to risk.

4. Managing Security and Safety Efficiently

4.1. Leadership and Accountability

• The Responsible Individual has oversight of the safe and effective operation of the service, including assurance that premises, facilities, equipment, risk management, maintenance, fire safety, infection prevention, security and governance arrangements are effective and reviewed.
• The Registered Manager is responsible for overseeing security, health and safety compliance, and risk assessments.
• The Responsible Individual has oversight of the safe and effective operation of the service, including assurance that premises, facilities, equipment, risk management, maintenance, fire safety, infection prevention, security and governance arrangements are effective and reviewed.

• The Fire Safety Lead: {{org_field_the_fire_safety_lead_name}} ensures that all fire prevention measures are in place.
• The Data Protection Officer ensures that confidentiality and GDPR regulations are adhered to.
• All staff members are accountable for following security and safety procedures in their daily work.

4.2. Staff Training and Awareness

• All new staff receive induction relevant to safe and secure premises, including access control, visitor procedures, fire safety, emergency procedures, health and safety, infection prevention, confidentiality, reporting hazards, accident and near-miss reporting, safeguarding concerns and the safe use of equipment relevant to their role.
• Staff receive refresher training at planned intervals and sooner where risks, incidents, inspection findings, new equipment, new procedures or changes in legislation require it.
• Staff must not use specialist equipment, including hoists, slings, mobility equipment, evacuation equipment or specialist bathing equipment, unless they have been trained and assessed as competent.
• Fire drills, emergency exercises and security scenario discussions will be used to test staff knowledge and improve practice.
• Learning from incidents, accidents, near misses, complaints, safeguarding concerns, audits, maintenance issues and CIW inspection findings will be shared with staff through supervision, team meetings, handovers or additional training.

4.3. Monitoring and Continuous Improvement

• Quarterly security audits are conducted to identify risks and improvement areas.
• Feedback from staff, service users, and families is used to enhance safety measures.
• Incident logs and near-miss reports are reviewed regularly to identify trends.
• Annual policy reviews ensure alignment with CIW regulations and legal updates.

Monitoring of the premises and environment will be linked to CIW’s inspection themes, including the Environment theme for accommodation-based services. Audit findings, environmental risks, maintenance records, incidents, complaints, service user feedback, staff feedback, fire safety checks, infection prevention audits and equipment servicing records will be reviewed as part of quality assurance and continuous improvement. Where CIW inspection ratings apply, the service will comply with legal requirements for publication and display of ratings, and any rating or inspection finding relating to the environment will be used to inform the service improvement plan.

5. Related Policies

This policy is supported by:

• CHW11 – Safe Care and Treatment Policy
• CHW16 – Health and Safety at Work Policy
• CHW17 – Infection Prevention and Control Policy
• CHW18 – Risk Management and Assessment Policy
• CHW19 – Emergency and Business Continuity Plan
• CHW20 – Fire Safety and Evacuation Procedures
• CHW34 – Confidentiality and Data Protection (GDPR) Policy

• CCTV and Surveillance Policy
• Maintenance and Repairs Policy
• Environmental Risk Assessment Policy
• Control of Substances Hazardous to Health (COSHH) Policy
• Waste Management Policy
• Legionella and Water Safety Policy
• Food Safety Policy
• Moving and Handling Policy
• Records Management and Retention Policy
• Visitors and Contractors Policy
• Mental Capacity and Deprivation of Liberty Safeguards Policy
• Equality, Diversity and Human Rights Policy
• Quality Assurance and Governance Policy

6. Policy Review

This policy is reviewed annually, or sooner if required due to legislative changes, CIW guidance updates, or security incidents. Updates are communicated to all staff, and additional training is provided as necessary.

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Responsible Person: {{org_field_registered_manager_first_name}} {{org_field_registered_manager_last_name}}
Reviewed on: {{last_update_date}}
Next Review Date: {{next_review_date}}
Copyright © {{current_year}} – {{org_field_name}}. All rights reserved.