Name of Service: Orchard Care Services - Coventry

Full Name: Interview Questionnaire - Carer Standards______

In order to guide the interview process, we would like you to indicate your personal philosophy of care by completing the following statement:

I believe the purpose of care from a care service is:
If I were a Service User of the Orchard Care Services, I would like:
I believe that the Service Users family and relatives would like from the Orchard Care Services:
I believe that I can support a Service User of the Orchard Care Services because:
As a member of the Orchard Care Services care team, I feel valued when:
I believe a good relationship between me and the Service User depends on :
I believe that I learnt best when:
I believe that a good working team is made by:
I believe that my role in relation to the Service User is:
My other benefits and values of relevance to my job are:

ORCHARD CARE SERVICES

As part of the selection process we consider where applicants live and their availability to work core hours. Core hours are those you are available to work each week and once agreed we would anticipate calls that are rota’d during these times are honoured each week.

The rota’s are issued each week on a Wednesday for calls commencing the following week. The week runs from Monday to Sunday. Once you have received your Rota any requests to change planned calls must be agreed by 5pm on the Friday.

Could you please indicate the hours you are available to work on the chart below.

CORE WORKING HOURS – Name : ………………………………………………

Day / Morning / Lunch / Evening
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

There may be occasions that you are approached to carry out calls outside of these hours, especially in emergency situations when a colleague is off sick. Rota’s also vary when colleagues book holidays and their regular calls need to be picked up by other staff. We would hope that some additional hours could be rota’d and covered by yourself in these situations, in the same way as your colleagues would cover for your time off.

Signed ……………………………………………………………………………..

Date ………………………………………………………………………………..

APPLICATION FORM

ORCHARD CARE SERVICES

Bayley House, Room 3,

The Business Centre, 22-23 Bayley Lane,

Coventry, CV1 5RN

Tel: 02476 433410

The recruitment process within this organisation has a minimum of two stages.

The completion of this application form is part of stage one. This application will be reviewed and a decision made as to whether to proceed to stage two, the interview, based on this information.

PLEASE COMPLETE FULLY AND IN CAPITALS

Position Applied for: Support Worker
Approx. no. of hours required per week:
Surname: / First name(s):
Previous surnames:
(supply documentary evidence e.g. marriage certificate, deed of name change etc.)
Date of Birth: / Email:
Telephone No home: / Mobile:
Work No.(will use with discretion)
Current Address:
Postcode: / Date moved to this address:
Own Transport Yes/No
How long has licence been held? / Clean Current driving licence Yes/No
Endorsements? Details:
Do you have any unspent convictions? / If yes, give details.

EDUCATIONORCHARD CARE SERVICES

Schools/College/University / Please supply copies of certificates
Qualifications & Dates:
TRAINING HISTORY/PROFESSIONAL STATUS
Date of Graduation/Qualification/Location / Notes: Please supply copies of certificates/membership details
Qualifications & Dates:
SHORT COURSES ATTENDED
Subjects: / Location:
Qualifications & Dates

EMPLOYMENT HISTORYORCHARD CARE SERVICES

Current/last first. You must cover the whole of your working life to date. State the reasons for any breaks in employment. Use a separate sheet if required: please sign the sheet(s).

Name & address of your most recent/last employer:
Date employed:
Nature of business:
Position held and reason for leaving:
Salary / Rate:
Name & address of employer prior to the employer listed above:
Date employed:
Nature of business:
Position held and reason for leaving:
Salary / Rate:
Name & address of employer prior to the employer listed above:
Date employed:
Nature of business:
Position held and reason for leaving:
Salary / Rate:
Other Roles (use additional sheet)

Please give details of relevant experience. This may be taken from the work situation, voluntary work, charity or your own home. Please use separate sheet if insufficient space is available.

ORCHARD CARE SERVICES

Please state below your reasons for applying for this position.

REFEREESORCHARD CARE SERVICES

In all instances, two references are required. You must provide references from your most recent employers. If you are unable to provide two employers references then one of the references can be a character reference. In the case of no previous employment, please provide two character references. All will be contacted, therefore, please inform the referees of the fact that you have used their name. If you are unable to provide the required references, please discuss the matter with us.

CURRENT OR MOST RECENT EMPLOYER

Contact Name:
Organisation’s Name:
Address:
Post Code:
Tel No:
Job Title:

PREVIOUS EMPLOYER TO THE ONE ABOVE

Contact Name:
Organisation’s Name:
Address:
Post Code:
Tel No:
Job Title:

CHARACTER REFERENCE

Contact Name:
Address:
Post Code:
Tel No:
Relationship to you:

CHARACTER REFERENCEORCHARD CARE SERVICES

Contact Name:
Address:
Post Code:
Tel No:
Relationship to you:

NEXT OF KIN

Contact Name:
Address:
Post Code:
Tel No:
Relationship to you:

IDENTITY DETAILSORCHARD CARE SERVICES

Nursing & Midwifery Council PIN number:
(Nurses only)
National Insurance Number
(All applicants)

CAPACITY TO WORK IN THE UNITED KINGDOM

Are their any restrictions to your residence in the UK with might affect your right to take up employment in the UK? / Yes / NO
Delete as appropriate
If yes, please provide details: