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CH180-Refurbishment and Building Structure Works Policy

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Registration Number: {{org_field_registration_no}}

Refurbishment and Building Structure Works Policy

1. Purpose

The purpose of this policy is to ensure that any refurbishment, maintenance, repair, redecoration, installation, infrastructure change or building structure works carried out at premises managed by {{org_field_name}} are planned, approved, risk assessed, monitored and completed in a way that protects people’s safety, dignity, privacy, wellbeing, independence and continuity of care. This policy supports compliance with the Health and Social Care Act 2008, the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, including Regulation 9 (Person-centred care), Regulation 10 (Dignity and respect), Regulation 11 (Need for consent), Regulation 12 (Safe care and treatment), Regulation 13 (Safeguarding service users from abuse and improper treatment), Regulation 15 (Premises and equipment), Regulation 17 (Good governance), Regulation 18 (Staffing), and Regulation 20 (Duty of candour), where applicable. It also supports compliance with the Care Quality Commission (Registration) Regulations 2009, including statutory notification requirements, and relevant health and safety, fire safety, construction, asbestos, legionella, planning and building control requirements. The aim is to ensure that works improve or maintain the quality of the care environment while minimising disruption, preventing avoidable harm, safeguarding people, and maintaining clear records that demonstrate effective governance and regulatory compliance.

2. Scope

This policy applies to all refurbishment activities, building structure works, repairs, installations, redecoration, or infrastructure changes occurring at any location operated by {{org_field_name}}. It applies to all staff, maintenance personnel, contractors, agency workers, and management involved in or affected by such works. It also covers temporary adjustments to care arrangements and health and safety controls to protect the people we support during the planning and implementation of such works.

This policy applies whether works are undertaken by internal maintenance staff, external contractors, landlords, managing agents, designers, surveyors, utility providers, insurers, emergency repair services or any other person carrying out work on or affecting the premises. It applies to planned, urgent and emergency works, including works outside normal working hours. Where {{org_field_name}} does not directly control the works, the Registered Manager must still ensure that risks to people using the service are identified, escalated, mitigated and monitored, and that the provider holds sufficient evidence that the premises remain safe and suitable for the regulated activity.

3. Related Policies

This policy should be read in conjunction with:

4. Legal and Regulatory Requirements

Refurbishment and building structure works must be managed in accordance with all legal and regulatory requirements relevant to the nature, scale and risk of the works. This includes, but is not limited to:

The Registered Manager and provider must ensure that the correct approvals, competent advice, risk assessments, method statements, permits, statutory notifications, building control approvals, planning permissions, fire risk assessment reviews, infection prevention controls and completion evidence are obtained before areas are used again for care delivery. All decisions must be recorded.

5. Planning and Approval Process

All refurbishment, maintenance, repair, installation and structural works must be approved before commencement by the Registered Manager, {{org_field_registered_manager_first_name}} {{org_field_registered_manager_last_name}}, and the company director {{org_field_company_director_first_name}} {{org_field_company_director_last_name}}, unless the works are emergency works required to remove an immediate risk. For emergency works, verbal approval may be given, but this must be documented as soon as practicable. A written project plan must be completed for all non-minor works and must include the scope of works, reason for the works, affected rooms and facilities, planned start and finish dates, contractor details, responsible persons, access arrangements, impact on people using the service, staffing implications, fire safety implications, infection prevention controls, communication arrangements, waste management, security controls, contingency arrangements and handover requirements.

Before works begin, the Registered Manager must determine whether planning permission, building control approval, landlord approval, insurer notification, fire service consultation, local authority consultation, environmental health input, infection prevention advice, or CQC notification is required. CQC must be notified where the works result in, or are connected with, a notifiable change to the Statement of Purpose, registered details, regulated activity, registered location, service user bands, accommodation arrangements, capacity, provider details, registered manager arrangements, or where an event stops or may stop the service running safely and properly. The decision about whether CQC notification is required must be recorded, including the reason for the decision.

5.1 Construction Design and Management Regulations 2015

Where works fall within the Construction (Design and Management) Regulations 2015, {{org_field_name}} will ensure that its duties as a client are met. This includes making suitable arrangements for managing the project, ensuring sufficient time and resources are allocated, appointing competent contractors and, where required, a principal designer and principal contractor, ensuring relevant pre-construction information is provided, checking that a construction phase plan is in place before works begin, and ensuring that arrangements are maintained and reviewed throughout the project.

For works involving more than one contractor, a principal designer and principal contractor must be appointed in writing where required. For notifiable projects, the required notification to the Health and Safety Executive must be completed by the appropriate duty holder before work begins. The Registered Manager must retain evidence of CDM appointments, contractor competence checks, construction phase plans, risk assessments, method statements, permits to work, site inductions, daily monitoring records and handover documentation.

Contractors must not begin works until the Registered Manager, or delegated project lead, is satisfied that the arrangements are suitable to protect people using the service, staff, visitors and contractors.

6. Risk Assessment and Health & Safety

Before any works begin, a comprehensive written risk assessment must be completed and signed off by the Registered Manager and the Health and Safety Lead. The assessment must consider risks to people using the service, staff, visitors, contractors and others who may be affected. It must include, as relevant, risks relating to dust, fumes, noise, vibration, restricted access, falls, slips and trips, sharp objects, tools, plant, vehicles, scaffolding, ladders, work at height, hot works, electrical safety, gas safety, water safety, legionella, asbestos, fire safety, blocked escape routes, temporary loss of utilities, disruption to heating or ventilation, infection prevention, waste, security, safeguarding, privacy, dignity, mental capacity, communication needs, sensory needs, mobility needs, distress, confusion and behavioural support needs.

The risk assessment must include person-specific controls for anyone who may be at increased risk because of frailty, cognitive impairment, dementia, learning disability, autism, sensory impairment, mobility difficulty, respiratory illness, mental health need, distress caused by noise or change, or any other relevant care need. Where people’s rooms, routines, communal areas, bathing facilities, dining areas, medicines arrangements, call bells, hoists, pressure care equipment, oxygen equipment or evacuation arrangements are affected, their care plans and risk assessments must be reviewed and updated.

A method statement, safe system of work and control measures must be in place before work starts. Controls may include physical segregation, locked barriers, signage, dust suppression, ventilation, negative pressure or containment where required, safe storage of tools and substances, supervised contractor access, temporary walkways, additional staffing, revised cleaning schedules, temporary fire arrangements, alternative facilities and enhanced welfare checks. Daily site checks must be completed during the works and recorded. Work must stop immediately if there is an uncontrolled risk to people using the service, staff, visitors or contractors.

6.1 Asbestos, Hazardous Materials and Structural Safety

Before any intrusive works, refurbishment, demolition, drilling, chasing, ceiling void access, floor disturbance, pipework disturbance or structural works, the Registered Manager and provider must confirm whether asbestos-containing materials may be present. The asbestos register and asbestos management plan must be checked before works are approved. Where the location or condition of asbestos-containing materials is unknown, suitable asbestos surveys and competent advice must be obtained before works proceed.

Contractors and maintenance staff must be given relevant asbestos information before they start work. No person may disturb suspected asbestos-containing materials. If suspected asbestos is discovered or damaged, work must stop immediately, the area must be isolated, access must be prevented, and competent asbestos advice must be obtained. People using the service must be protected from exposure and disruption. Any required notifications, air testing, clearance certification, waste documentation and reoccupation approval must be retained.

The same precautionary approach must be taken for other hazardous materials or structural risks, including lead paint, mould, contaminated materials, fragile surfaces, hidden services, unstable ceilings, damaged floors, unsafe glazing, compromised load-bearing structures or any other defect that may affect safe occupation.

6.2 Water Safety and Legionella

Where works affect hot or cold water systems, bathrooms, showers, pipework, storage tanks, thermostatic mixing valves, outlets, drainage, heating systems, water pressure, water temperatures or areas that may be unused during works, the legionella risk assessment and water safety arrangements must be reviewed before the area is returned to use. The Registered Manager must ensure that flushing, temperature checks, cleaning, disinfection, sampling, commissioning or recommissioning are completed where required by the risk assessment or competent water safety advice.

Any outlet or facility taken out of use during works must be managed to prevent stagnation and contamination. Records of flushing, temperature monitoring, disinfection, sampling, remedial works and sign-off must be retained with the project file. Bathrooms, showers and clinical or personal care facilities must not be returned to use until the Registered Manager is satisfied that water safety controls have been completed.

7. Communication and Consent

People receiving care, their families, representatives, advocates and staff must be informed in advance of planned works wherever practicable. Information must include the reason for the works, expected start and finish dates, areas affected, expected noise or disruption, temporary changes to access or routines, alternative facilities, safety measures and who to speak to with concerns. Information must be provided in a way each person can understand, including accessible formats where required.

People must be consulted about any change that affects their room, privacy, dignity, routines, meals, bathing, visiting, activities, care delivery, mobility, communication, sleep or wellbeing. Staff must listen to concerns and make reasonable adjustments to reduce anxiety, distress or sensory impact. Where a person lacks capacity to make a specific decision affected by the works, the Mental Capacity Act 2005 must be followed, including best-interest decision-making and consultation with relevant representatives where required.

Where temporary relocation, room changes, restrictions on access, altered care routines or changes to support arrangements are necessary, these must be discussed with the person and their representatives as appropriate, recorded in the care plan, risk assessed, kept under review and ended as soon as safe and practicable. People must be reassured that their safety, dignity, privacy, independence, visiting arrangements and continuity of care remain priorities throughout the works.

8. Infection Prevention and Cleanliness

Building and refurbishment works can increase infection prevention and control risks through dust, debris, water disruption, reduced ventilation, contamination of surfaces, disruption to cleaning schedules and temporary loss of facilities. Before works begin, an infection prevention and control risk assessment must be completed and proportionate controls must be implemented.

Controls may include dust barriers, sealed work areas, safe routes for contractors, enhanced cleaning schedules, safe waste removal, appropriate ventilation, covering or removal of equipment, separation of clean and dirty routes, protection of laundry and catering areas, safe storage of materials, and additional cleaning before areas are returned to use. Where works affect bathrooms, toilets, sluices, kitchens, dining areas, laundry facilities, clinical areas or handwashing facilities, safe temporary alternatives must be arranged before those facilities are taken out of use.

Hand hygiene facilities or suitable alternatives must remain available at all times. Contractors must follow site infection prevention requirements and must not enter care, catering, laundry or medicines areas unless authorised and supervised. Before any room or area is reopened, it must be inspected, cleaned, cleared of dust and waste, and signed off as safe by the Registered Manager or delegated lead. Records of IPC risk assessments, cleaning schedules, environmental checks and reopening sign-off must be retained.

9. Contractor Management and Site Security

Only competent, insured and approved contractors may carry out refurbishment, maintenance, repair or structural works at {{org_field_name}} premises. Before appointment, the Registered Manager or provider must obtain and retain proportionate evidence of contractor competence, which may include insurance, qualifications, professional registrations, references, health and safety policy, risk assessments, method statements, training records, permits, asbestos competence, electrical or gas safety registration, fire safety competence, and previous experience in care or occupied premises.

Contractors must sign in and out, wear identification, receive a site induction and comply with safeguarding, confidentiality, infection prevention, fire safety, security, smoking, parking, waste and conduct requirements. Contractors must be told how to report hazards, incidents, safeguarding concerns and urgent risks. Work areas must be physically separated from people using the service wherever practicable, clearly signed, secured from unauthorised access and checked regularly.

DBS checks must be considered on a role-by-role basis in accordance with DBS eligibility guidance. Contractors must not be asked for a standard, enhanced or barred list check unless the role is legally eligible for that level of check. Where a contractor does not have the required check or where a check is not legally available, the provider must use proportionate safeguards, including supervision, restricted access, signing in and out, escorting, barriers, and preventing unsupervised access to people using the service or their private rooms. Contractors must not provide care, assist with care tasks, handle personal information, enter private rooms, or interact with people using the service unless this has been authorised and risk assessed.

10. Continuity of Care

During refurbishment or building works, {{org_field_name}} will maintain safe, person-centred and continuous care. Before works begin, the Registered Manager must assess whether the works affect bedrooms, communal rooms, bathrooms, toilets, dining areas, kitchens, laundry, medicines storage, call bells, lifts, hoists, pressure care equipment, oxygen, heating, cooling, ventilation, lighting, access routes, visiting arrangements, activities, staffing deployment, night support or emergency evacuation.

Where any room, facility or route becomes temporarily unavailable, safe alternatives must be identified, risk assessed and communicated before the area is removed from use. Staffing levels and deployment must be reviewed to ensure people receive timely support, reassurance, observation, personal care, nutrition, hydration, medicines, continence support, mobility support, activities and emergency assistance during periods of disruption.

If care cannot safely continue in an affected area, temporary relocation within the home, temporary changes to room use, alternative service provision, phased works, out-of-hours works or postponement of works must be considered. Any relocation or significant change must be discussed with the person and their representatives as appropriate, recorded in the care plan and reviewed. The provider must not continue works where the disruption creates an unmanaged risk to people’s health, safety, dignity or wellbeing.

11. Equipment and Furniture Management

Any equipment, furniture, fixtures or fittings affected by refurbishment works must be safely relocated, protected, covered, cleaned, stored or removed to prevent contamination, damage, unauthorised use or obstruction. Care equipment must remain available in sufficient quantity and in safe working order throughout the works, including hoists, slings, pressure care equipment, call bells, mobility aids, beds, mattresses, oxygen equipment and emergency equipment.

Equipment must be cleaned, checked and, where required, serviced, tested or recommissioned before re-use. New furniture, fixtures, fittings and equipment must be suitable for a care environment and must meet relevant requirements for fire safety, infection prevention, accessibility, manual handling, durability, cleaning, safe use and compatibility with people’s needs. Where new equipment affects care delivery, staff must receive information, instruction or training before it is used.

All new or relocated equipment must be added to the premises, equipment, maintenance or asset records as appropriate. Any warranty, commissioning certificate, servicing requirement, safety certificate, user manual or maintenance schedule must be retained.

12. Fire Safety and Emergency Access

Refurbishment or structural works must not compromise fire safety, emergency evacuation, fire detection, fire alarm systems, emergency lighting, fire doors, fire stopping, compartmentation, sprinklers, smoke control, firefighting equipment, evacuation aids, escape routes or emergency service access. The fire risk assessment must be reviewed before works begin where works may affect fire precautions, evacuation arrangements or the layout and use of the premises.

Where any fire alarm, detector, fire door, compartment line, sprinkler, emergency light, evacuation route, refuge point or fire escape is affected, temporary fire safety measures must be agreed and recorded before works proceed. These may include temporary detection, additional staff checks, temporary signage, alternative escape routes, temporary fire doors or barriers, hot works permits, contractor fire watches, restrictions on ignition sources, safe storage of flammable materials and revised evacuation arrangements.

Personal emergency evacuation plans and evacuation risk assessments must be reviewed for people whose rooms, mobility routes, dependency levels or evacuation arrangements are affected. Staff and contractors must be briefed on temporary fire arrangements. Fire doors must not be wedged open unless an approved, risk-assessed automatic hold-open device is used. Any fire-stopping, compartmentation or fire door works must be completed and certified by competent persons before affected areas are returned to use.

Hot works, including welding, grinding, cutting, soldering, torch work, roofing heat work or any activity creating sparks or heat, must only take place under a permit-to-work system and with suitable fire precautions.

12.1 Statutory Notifications and Incident Reporting

The Registered Manager must consider whether any incident, disruption, injury, safeguarding concern, police involvement, service interruption, serious injury, death, allegation of abuse, event affecting safe operation, or other notifiable matter arising before, during or after works must be reported to CQC under the Care Quality Commission (Registration) Regulations 2009. Notifications must be submitted without delay where required and a copy retained.

CQC must be notified where works result in an event that stops, or may stop, the service from running safely and properly, or where an incident affects the health, safety or welfare of people using the service and falls within statutory notification requirements. The provider must also consider whether RIDDOR reporting to the Health and Safety Executive is required for reportable work-related injuries, diseases or dangerous occurrences.

All accidents, incidents, near misses, safeguarding concerns, complaints, defects, contractor breaches, fire safety concerns, infection control breaches, water safety concerns and environmental hazards connected with the works must be recorded, investigated, escalated and reviewed. Lessons learned must be shared with staff and used to improve future works planning.

12.2 Building Control, Planning and Completion Certification

Before works begin, the provider must determine whether planning permission, listed building consent, building control approval, landlord consent, insurer approval, environmental health input, utilities approval or specialist professional advice is required. No work requiring formal approval may begin until the appropriate approval has been obtained, unless emergency action is needed to remove an immediate risk.

On completion, the Registered Manager must obtain and retain all relevant completion evidence before affected areas are returned to use. This may include building control completion certificates, electrical certificates, gas safety certificates, fire alarm certificates, emergency lighting test records, sprinkler certificates, fire-stopping certificates, fire door certificates, asbestos clearance certificates, legionella/water safety records, ventilation commissioning records, lift or hoist certificates, warranties, operation manuals, maintenance schedules and contractor handover documents.

Rooms, facilities or areas affected by works must not be reopened for people using the service until the Registered Manager or delegated competent person has completed and recorded a final safety, cleanliness, infection prevention, fire safety and suitability check.

13. Monitoring, Handover, and Quality Assurance

A designated project lead must monitor all works throughout the project and provide regular updates to the Registered Manager. Monitoring must include daily safety checks where works are active, review of contractor conduct, access control, cleanliness, fire safety, infection prevention, noise, dust, waste, resident impact, staffing impact, complaints, incidents and progress against the project plan.

The Registered Manager must maintain a project file containing approval records, risk assessments, method statements, contractor checks, CDM documents where applicable, permits, communication records, resident impact assessments, care plan updates, fire safety reviews, infection control checks, water safety checks, daily site checks, incident records, complaints, photographs where appropriate, completion certificates, warranties, maintenance information and final sign-off.

On completion, a full inspection must be completed before rooms or spaces are reopened. Any snagging issues must be risk assessed and resolved before use, unless they are minor and do not affect safety, dignity, suitability, infection prevention, fire safety or care delivery. Feedback must be sought from people using the service, relatives or representatives, staff and contractors. Lessons learned must be recorded and used to improve future refurbishment planning.

The provider or senior management team must review significant projects, incidents, delays, complaints, cost overruns, defects, regulatory concerns and lessons learned as part of governance and quality assurance arrangements.

13.1 Evidence for CQC Assessment

The Registered Manager must ensure that records relating to refurbishment and building works are available to evidence compliance with CQC requirements and the current assessment framework. Evidence may include people’s feedback, staff feedback, environmental audits, infection prevention audits, fire safety checks, risk assessments, care plan reviews, governance meeting minutes, contractor documents, completion certificates, maintenance records, incident investigations, complaints and lessons learned.

Evidence must show that risks were identified, people were involved, reasonable adjustments were made, care continued safely, premises and equipment remained suitable, staff were supported, incidents were acted on, and improvements were embedded. Records must be accurate, complete, dated, signed or attributable, stored securely and retained in line with {{org_field_name}}’s record retention requirements.

14. Policy Review

This policy will be reviewed annually or earlier if significant refurbishment is planned, legislation or CQC guidance changes, the provider changes premises, a serious incident occurs, CQC or another regulator raises concerns, fire safety or health and safety advice changes, a project identifies learning, or feedback from people using the service, relatives, staff or contractors indicates that the policy requires improvement. Reviews are led by the Registered Manager in consultation with the Health and Safety Lead, provider representative, maintenance team, infection prevention lead, fire safety competent person and, where appropriate, people using the service and their representatives.

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.

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