Care and Social Services Inspectorate Wales

CARE STANDARDS ACT 2000

APPLICATION TO REGISTER AN

ADULT PLACEMENT SCHEME: PART 1

Contents of Part 1

Please fully complete this document, providing additional information sheets where appropriate. In Section B the appropriate selection should be made by applicants. Section D 4.6 does not apply to Unitary Authorities.

Section AGeneral information

Section B1Individual application

Section B2Organisation application

Section B3Unitary Authority application

Section CApplicant Information

Section DDetails of business and premises

Section E Proposed Registered Manager

Section F Staffing details

Section GOther requirements

Name of Scheme:

APPLICATION TO REGISTER AN ADULT PLACEMENT SCHEME: PART 1

CSSIW will require a passport sized recent photograph, which is a “true likeness”. This will be kept as part of your application.

You are also required to provide your birth certificate and originals of your professional, educational and occupational qualifications. You may make your application in person and bring these documents with you. It will help if you make an appointment with CSSIW and allow about an hour for this process. Your documents will be photocopied and returned to you.

If you prefer to send your application to CSSIW please enclose your documents which will be photocopied and returned to you securely.

SECTION AGeneral Information

This section should be completed by all applicants

A 1.1

Name and address of proposed Scheme:
Post code:
Telephone number:
Fax Number:
Email address:
Proposed date for commencement of operation:

A 1.2Which of the following do you intend to provide?

Medium/long term placements

Short Break or Respite Placement

A 1.3Please tick the categories of service user you intend to support

a)People with learning disabilities
b)People with physical disabilities
c)People with sensory loss/impairment
d)Other (please give details)
e) Age group:18 to 64 65+

A 1.4Please answer either (a) (b) or (c)

a)Are you making this application as an individual provider?

Orin partnership with others?

If so complete section B1

or

b)On behalf of an organisation?

If so, complete section B2

or

c)On behalf of a Unitary Authority?

If so, complete section B3

SECTION B1INDIVIDUAL APPLICATION

If the Scheme is a partnership each partner is required to provide this information. Please photocopy and complete this sheet.

B1 1.1

Please insert full name:
Please state any other names by which you have been known:
Date of birth: / dd/mm/yyyy / Place of birth:
Address:
Post code:
Tel no:
Mobile no:
Fax no:
E mail address:

B1 1.2Do you intend to manage the Scheme?Yes No

If ‘no,’ please provide details of your proposed registered manager in Section E.

A separate Registered Manager application form (Form 1A) is also required to be completed.

If ‘yes’ you should complete Form 1A yourself, although you will not be required to be registered as the manager.

B2.ORGANISATION APPLICATION: CHARITY, VOLUNTARY ORGANISATION OR REGISTERED COMPANY

If you are making an application on behalf of an organisation please provide the following details:

B2 1.1

The full address of the registered or principal office
Post code:
Company or Charity Registration no.
Tel no:
Mobile no:
Fax no:
E mail/Website address:

If the organisation is part of a National Charity/Voluntary Organisation or Private Holding Company please provide the name and address of the registered or principal office. Please also provide this information in the form of a flow chart.

Please tick if details attached

B2 1.2Please provide details of the Director/s, Manager/s and Company Secretary or other similar officers of the organisation below, continue on additional sheets if required.

Name of officer of organisation / Location / Position and role within the Organisation

B2 1.3Responsible Individual within Organisation

Please insert full name of Responsible Individual:
Position held by the Responsible Individual within the Organisation:
Date of birth: / Place of birth:
Address (if different from Scheme address):
Post code:
Tel no:
Mobile no:
Fax no:
E mail address:

B2 1.4 Are you currently registered as a manager or provider under the Care Standards Act 2000 or have you applied to be a Responsible Individual in respect of any other Scheme or care setting? Yes No

If YES please provide details:

B2 1.5 Do you or your organisation have a business or financial interest in any other service or Scheme registered under the Care Standards Act 2000 at this time? Yes No

If YES please provide details:

B3 UNITARY AUTHORITY APPLICATION

B3 1.1

Name of Unitary Authority:
Responsible Department of the Authority:
Name and title of Chief Officer:
Main address of the responsible department:
Post code:
Telephone no:
Fax:
E mail address:

B3 1.2Responsible Individual within Unitary Authority

Please insert full name of Responsible Individual:
Position held by the Responsible Individual withinthe Unitary Authority:
Date of birth: / Place of birth:
Address (if different to the Scheme Address):
Post code
Tel no:
Fax no:
Mobile no:
E mail address:

B3 1.3Are you currently registered under the Care Standards Act 2000?Yes No or

have you applied to be a Responsible Individual in respect of any other

Scheme or care setting? Yes No

If YES please provide details:

SECTION CAPPLICANT INFORMATION

This section should be completed by individual applicants, Responsible Individuals within Organisations and Unitary Authorities and where the Scheme is a partnership, by each Partner. Please photocopy as required.

C 1.1Rehabilitation of Offenders Act 1974

Due to the nature of an application for registration, applicants are exempt from s.4(2) of the Rehabilitation of Offenders Act 1974. The Rehabilitation of Offenders Act 1975 (Exceptions) Order 1975 (as amended) provides that applicants are not entitled to withhold information about convictions which for other purposes are ‘spent’ under the 1974 Act.

I confirm that on behalf of the Organisation I have read and understood the requirements set out in paragraph 10 Schedule 2 of the Registration of Social Care and Independent Health Care (Wales) Regulations 2002

Signature: / Date: / dd/mm/yyyy

C1.2Occupational History

Please provide a list of the names and addresses of all your employers covering the period between leaving school and now, starting with your current employer. If you have previously worked with children or vulnerable adults, please explain in full why your employment came to an end. Where there are gaps in employment please give enough detail in your explanation of the circumstances to enable checks to be made if necessary. Include details of any business(es) which you carry on or have at any time previously carried on.

An up to date Curriculum Vitae can be attached, however this section must also be completed.

Occupation
Including job title and range and scope of responsibility / From / To / Name, address and telephone number of employer / Reason for leaving
mm/yy / mm/yy
mm/yy / mm/yy
mm/yy / mm/yy
mm/yy / mm/yy
mm/yy / mm/yy
mm/yy / mm/yy
mm/yy / mm/yy

Continue on separate sheets as necessary

Attached are extra sheets

CV attached

C 1.3Educational, Professional or Occupational Qualifications

Please make sure you list all of your relevant qualifications.

Qualifications gained / Awarding Body / Date of award
dd/mm/yyyy
dd/mm/yyyy
dd/mm/yyyy
dd/mm/yyyy
dd/mm/yyyy

Continue on a separate sheet if necessary.

separate sheet(s) attached covering period to

C 1.4Details of membership or registration with professional or other relevant organisations or bodies, including the Care Council for Wales.

Organisation or professional body / Date: / Type or level of Membership/ Registration
Admitted/registered / Expiry date
dd/mm/yyyy / dd/mm/yyyy
dd/mm/yyyy / dd/mm/yyyy
dd/mm/yyyy / dd/mm/yyyy
dd/mm/yyyy / dd/mm/yyyy

Continue on a separate sheet if necessary.

separate sheet(s) attached covering period to

C1.5Referees

Please supply the names and addresses of two individuals from whom we will take up references. You should give the name of your two most recent employers. Neither of these may be a relative. Both of these referees must be able to comment on your fitness and professional skills and competence relevant to the operation of the proposed Scheme. At leastone of these referees must have employed you for at least three months.

Name and job title / Address and telephone number / Capacity in which known to the referee
1.
2.

C 1.6If any of the following are applicable please provide details below.

  • If you own or have ever owned or managed another registered care establishment or Schemer
  • If youhave been refused registration
  • If you havehad your registration cancelled

Owned / Managed
The nature and dates of the registration decision[s]:
The name[s] by which the services were known:
Please provide contact details for each registration authority involved:
Name of person dealing with regulation of your service:

SECTION DDETAILS OF BUSINESS AND PREMISES

D 1.1Please complete the following table and attach to your application copies of the relevant policies or certificates of insurance:

Insurance / Insurer / Sum Insured / Expiry date / Copy (tick)
Employers Liability: / dd/mm/yyy
Public Liability: / dd/mm/yyy
Professional Indemnity: / dd/mm/yyy

D 1.2If the application is on behalf of an organisation please provide copies of the last two annual reports. Copies attached

D 1.3If you are intending to run your business from a specified business address, please provide details of the consultations with other Regulators (if applicable).

Date proposalsapproved by Environmental Health: / dd/mm/yyyy
Documentary proof attached
Date proposals approved by Fire Authority: / dd/mm/yyyy
Documentary proof attached
Date planning permission was granted: / dd/mm/yyyy
Documentary proof attached
Date proposals approved by Building Control: / dd/mm/yyyy
Documentary proof attached

D 1.4Is any person currently registered to provide any other care service from or

in connection with the proposed Scheme premises?Yes No

If Yes describe the nature of the current registration:

Is there any other application pending?Yes No

Please provide the name, addressand telephone number of the Registration Authority:
Name of the person dealing with regulation of your service:

D 1.5Is any part of the premises used for any other purpose?Yes No

If “Yes” then please state ALL purposes to which any part of the premises is put and details of how access by other occupiers is restricted.

D 1.6Property Ownership (not applicable to Unitary Authorities)

Please provide details of the status of the Scheme’s premises.

Are the premises:

a)Owned by the Scheme/Organisation?Yes No

b)Mortgaged by the Scheme/Organisation?Yes No

c)Rented by the Scheme/Organisation?Yes No

d)Leased by the Scheme/Organisation?Yes No

If Yes, to a) or b) please attach details of purchase and mortgage.Attached

If Yes, to c) or d) please provide details of terms and conditions including duration and renewal arrangements along with a copy of the lease/tenancy agreement. Attached

D 1.7 Facilities

Please detail the availability of the following at your Scheme premises.

  • Interview/meeting roomYes No
  • Training roomYes No
  • Access for disabled staff/service users/visitorsYes No
  • Security alarm systemYes No
  • Open during normal office hoursYes No
  • Arrangements for out of hours emergency contactYes No
  • Facilities for storage of recordsYes No

D 1.8Please provide details of any other facilities available

SECTION EPROPOSED REGISTERED MANAGER

N.B. A separate Registered Manager application will also need to be submitted on Part 1A

E1.1

Please insert full name:
Date of birth: / Place of birth:
Home address:
Post code:
Office Address (if different from Scheme Address):
Post code
Tel no:
Mobile no:
Fax no:
E mail address:

E 1.2Management Arrangements

Please describe and provide a flow chart of the managerial relationship between the Responsible Individual and the Registered Manager of the Scheme (if the Responsible Individual is not also the Registered Manager).

SECTION FStaff details

F 1.1Please provide the total number of staff who are to be employed.

F 1.2

Name of staff memberand date of birth / Qualifications
andexperience / Job title
Roles and responsibilities / Full/Part time & hours of work / All information as required by Schedule 3 of the Adult Placement Schemes (Wales) Regulations 2004
Select:F/TP/T / Yes No
Select:F/TP/T / Yes No
Select:F/TP/T / Yes No
Select:F/TP/T / Yes No
Select:F/TP/T / Yes No
Select:F/TP/T / Yes No
Select:F/TP/T / Yes No
Select:F/TP/T / Yes No
Select:F/TP/T / Yes No

Please provide additional pages if required. Extra pages attached

PLEASE NOTE - As the person carrying on the Scheme you must screen all your staff to the required standard. In order to do this you will need to be registered with the Disclosure and Barring Service. They can be contacted at either Disclosure and Barring Service Registration Team, PO Box 110 Liverpool L69 3JDRegistration Information Line 0870 90 90 811or

Alternatively you may register with an “umbrella” body which is DBSregistered and make your checks via them. Your national or local Trade Association should be able to give you details of any local arrangements. CSSIW may at any time require you to demonstrate that you have checked all staff backgrounds to the required standard.

You should also be aware of the provisions of Part VII of the Care Standards Act 2000 in relation to the list, kept by the Disclosure and Barring Service, of individuals who are considered to be unsuitable to work with vulnerable adults. It is an offence to knowingly apply for, offer to do, accept or do any work in a care position if included on this Disclosure and Barring list.

A record of DBS certificates should be retained until inspected by CSSIW.

F 1.3Please signthe following declaration:

I confirm that I have read and understood the requirements set out in Paragraph 10 of Schedule 2 to the Registration of Social Care and Independent Health Care (Wales) Regulations 2002, and that I understand that it is my responsibility to ensure that the required DBS disclosures are obtained in respect of every person who works or is intended to work at the scheme. I will retain a record of DBS checks and make this available for inspection by the Welsh Government if so required.
Signed: / Date:

SECTION GOTHER REQUIREMENTS

You are required to bring the information referred to in the DBS letter enclosed so that we can fulfil the countersigning requirements of the Disclosure and Barring Service. If you make your application in person you may be able to do this at the same time. If you choose to send your application to CSSIW you will need to make an appointment to have your DBS information checked. You may also use the Post Office ‘Document Certification service’. Confirmation of your ID check will need to be submitted along with your completed application. You will need to present your DBS certificate at some time in the registration process; this is likely to be during a site visit or fit person’s interview.

G 1.1The following items must also accompany Parts 1 & 2 of this application for registration. Failure to provide all the requested items will result in a delay in processing your application.

  • Part 1A
  • Part 2

This will be specific to your proposed service category and is a means of providing evidence that you can meet all the relevant Regulations.

  • A fully completed Disclosure and Barring Service application form

Enclosed

  • A fully completed Medical Declaration authorisation formEnclosed
  • Required financial information (Not Applicable to Unitary Authorities)

Two Years Annual Accounts Enclosed

Business Plan Enclosed

Authorisation for Bankers Reference Enclosed

Please bring your completed application form with all requested documentation to your CSSIW regional or local officeor alternatively you may submit your application by post to the relevant regional office.

Declaration

The information I have provided in parts 1 & 2 of this application form and in any attached documents is, to the best of my knowledge and belief, a true and complete description of the Scheme which I/we are applying to be registered to carry on. I/We understand that the discovery of any deliberate concealment or omission of information could lead to any registration which may be granted as a result of this application being cancelled and may also render me liable to prosecution.

In making this application for Registration under the provisions of the Care Standards Act 2000 I agree to comply with the Regulationswhich apply to the Scheme and the relevant National Minimum Standards.

Signed: / Date:
Signed: / Date:

Individual Applicant/s or Responsible Individual on behalf of the organisation

FOR CSSIW OFFICE USE ONLY

Name of Scheme:

Officer:

DBS ID check completed:[ ] Initials [ ] date / /

Professional registration check completed: [ ] Initials [ ] date / /

Date returned:

QA date: [ ] Initials [ ] date / /

Notes:

Adult Placement Scheme Part 1 Application02/2014

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