Application for Registration As A

Applications under section 12 of Care Standards Act 2000

This form must only be used by:
Individuals applying to register as a service provider.
It must not be used by:

Individuals that are already registered as a service provider (‘provider’) for any purpose.
Organisations for any purpose.

Registration entitles you to provide a registered service as defined by the Section 2 of the Care Standards Act 2000 and by the Independent Health Care (Wales) Regulations 2011. You can read continuously updated versions of the Act and regulations on our website:

Any person who carries on or manages an establishment or agency which provides a relevant independent healthcare service without being registered with HIW in respect of it, commits a an offence under Section 11(1) of the Care Standards 2000 for which they risk prosecution. For more information see Section 3 of the Application Guidance.

Before you complete this form you should read the document ‘Guide to the application process’ which can be found on our website.

Fees

You should also read our guidance for providers about fees. This document is available on our website.

You must check or tick the boxes for the services you are looking to provide. The service type(s) you select are used to calculate your annual fee. The service types you declare should match the description of your service in your Statement of Purpose. You can read more information about annual fees on our website.

Managers

If you will not be in day to day management of the service then you must have a Registered Manager. Any registered manager applications that are required must be submitted with this application.
Confidential personal information

Please make sure that your application does not include any confidential personal information about the people who will use your service or your staff. This includes any information that can identify a person. We will reject any application form that includes such information.

Filling in this form

You must fill in an answer to every field marked with an asterisk (*). Other fields are optional but if you have the information please provide it. We will have to reject an incomplete application and return it.

You must complete the declaration of compliance section.

You can fill in and submit this form on paper or on a computer. If you fill it in on a computer you can submit it by attaching it to an email; this is the best way to make applications to the Healthcare Inspectorate Wales (HIW).

This form has been prepared as a ‘protected’ Word document. That means that if you use a computer you can easily move from answer to answer using your ‘tab’, down arrow, and page down keys. You can also click from answer to answer using a mouse. You can put an ‘X’ in checkboxes using your space bar or mouse. You can go backwards to change your answers using your page up key, up arrow key, or mouse.

Spell check and formatting text with bullets cannot be used in protected Word documents. If you want to check your spelling or use bullets you can type the text into a blank new document first, and then copy your text and paste it into the application form when you have finished.

You can fill in this form on a computer using ‘Microsoft Word’ or ‘Open Office’. Open Office is a free programme you can download from The spaces for answers increase in size if this is needed while you are typing.

If you are filling in this form on paper and need more space to answer any questions please submit additional clearly numbered sheets and mark them with the question number from this form.

Managers

If you will not be in day to day charge of carrying on the service stated within this application you must have a registered manager. Any registered manager application that is required must be submitted with this application. A manager application form can be found at or contact HIW for a copy.

Contents Page

Data Protection Act 1998 information5

Section 1: Details about the applicant6

Section 2: Other information11

Section 3: Service type(s)15

Section 4: Application declaration21

Section 5: Application Fee23

How to submit this application24

Application for registration as a new service provider – Individual – October 20121

Data Protection Act 1998 Information

We will use the information provided within this form and any supporting documentation submitted with your application to make a decision about your application for registration. We may need to verify some of the information you provide.

We may share information you give us as permitted by law, for example with other regulatory bodies and law enforcement agencies and with others within the Welsh Government. The information you give us may also be subject to disclosure under the Freedom of Information Act 2000.

Your personal data may be used to:

Maintain a public register of Independent Healthcare establishments or agencies in accordance with the Care Standards Act 2000 (as amended).
Arrange a programme of inspections
Monitor compliance with regulatory requirements
Take enforcement action

Section 1: Details about the applicant

1.1 Service provider’s name and contact details
*Title
*First name
Middle name (if applicable)
*Last name
Previous name (If applicable)
*Date of Birth (dd/mm/yy)
*The name you will trade under if not your own name
*Address line 1
*Address line 2
*Town/City
*Postcode
*Email address
Website
*Main business telephone
Business Fax

Note: This address will be printed on the registration certificate and published on the internet as the provider details.

This address will also be used for all correspondence during the registration process, though please see final Application Declaration at the end of this form.

If you want us to use a different address for correspondence about this application, please provide the details below. We will use this address to ask for more information, and to return incomplete applications and unnecessary documents.

1.2 Alternative correspondence address
Name
Address line 1
Address line 2
Town/city
County
Postcode
*1.4 Administration and bankruptcy
Have you ever been declared bankruptor involved in an organisation that went into administration?
Yes
No
If yes, please give details.
*1.5 Financial viability
Do you take all reasonable steps to remain financially viable in order to achieve its aims and objectives (set out in the statement of purpose)?
Yes
No
If no, please give details.
*1.7 Statement of purpose
You must send us a copy of your statement of purpose. If you don’t we will have to return your application.
Every service provider is required by law to have a statement of purpose for the registerable service they carry on.
By law, the statement of purpose must include

The aims and objectives of the service
The name, address, telephone, fax and email contact details (if any) of the registered provider and any registered manager.
The relevant qualifications and relevant experience of the registered provider and any registered manager.
Details of the responsible individual’s role and responsibilities within the organisation.
The number, relevant qualifications and experience of staff working in the service.
The registered provider’s organisational structure.
The kinds of treatment, facilities and all other services provided, including details of the range of needs which those services are intended to meet and which are available for the benefit of patients.
The arrangements for seeking patients’ views about the quality of services provided.
The arrangements made for contact between any in-patients and their relatives, friends and representatives including any limitations on visiting hours.
The arrangement for dealing with complaints as set out in Regulation 24 of the 2011 Regulations.
The arrangements for respecting the privacy and dignity of patients.
The date the statement of purpose was written and, where revised in accordance with Regulation 8(1) of the 2011 Regulations, the date of such revision.

Statements of purpose should provide:

An overview of the provider's service alongside the formal line of accountability and contact details for them.

Information that is detailed enough to enable us to understand what happens at each location, so that we can assess the risks involved. For example, instead of saying 'we carry out surgery at hospital x' the statement should say what type of surgery is provided and who it is for: ''The surgery we carry out at xx includes specialist surgery such as cardiac and neurosurgery. Cardiac surgery is provided for children as well as adults’.

*1.8 Patient Guide
You must send us a copy of your patient guide. If you don’t we will have to return your application.
Every service provider is required by law to have a patient guide for the registerable service they carry on.
By law, the patient guide must include

A summary of the Statement of Purpose
the terms and conditions in respect of services to be provided for patients, including as to the amount and method of charges by patients for all aspects of their treatment
a standard form of contract for the provision of services and facilities by the registered provider to patients
a summary of the complaints procedure
a summary of the views of patients and others obtained
the address and telephone number of the appropriate office of the registration authority (HIW)
the most recent inspection report prepared by the registration authority of information on how to obtain a copy.

A patient guide should provide:

Information for patients on the service they are to receive. The guide should be provided to every patient and any person acting on behalf of a patient.

*1.9 Start date
It takes HIW up to twelve weeks to process most applications, sometimes more. You must not begin to provide the registerable service until you are registered. To do so is an offence under the Care Standards Act 2000 for which you risk prosecution.
*When would you like to begin carrying on the service in this application (dd/mm/yy)?
*1.10 Invoice and financial contact details
(If your invoice and financial contact details are different from the address provided at 1.1 or 1.2 above, please fill in the details below)
*Role/title
*Last name
*Business address line 1
*Business address line 2
*Town/city
*County
*Postcode
*Email
*Main business telephone
Fax

Section 2: Other information

*2.1 Purchase or transfer of an existing service
Is this application the result of the sale or transfer of a service for which a different provider is already registered as provider under the Care Standards Act 2000?
Yes
No
*2.2 Financial interests in other registered services
Do you have any current financial or work interests in any other registered service provider?
Yes
No
If ‘Yes’, please provide details of the other service(s).
*2.3 Previous registration history
Have you ever been registered or licensed for, or been the owner of any service registered or licensed under any of the following?
(check / tick for yes, leave blank for no)
The Registered Homes Act 1984
The Registered Homes (Amendment) Act 1991
The Children Act 1989 (including childminding and day care for children
The Nurses Agencies Act 1957
The Care Standards Act 2000
Health and Social Care Act 2008
If ‘Yes’, please provide details below.
*2.4 Refused applications and cancellations
Have you ever had an application refused or a registration cancelled by a regulator under any of the Acts in 2.3 above?
Yes
No
If ‘Yes’, please provide details below.
*2.5 Disclosure and Barring (DBS) Check(s)
Please confirm that you have carried out one of the following:
Signed up to the DBS update service and have included your disclosure certificate with this application
Completed the DBS form and have included it within this application along with the relevant documents
If you have not done so we will have to return your application.
Please list the DBS number and date of disclosure.
*2.6 Checklist for information that must be available
Please confirm that the following information is available if required by HIW in relation to the service you are intending to provide.
(Check / tick to show that the information is available)
If any information is not available we will have to return your application
Evidence of insurance arrangements for the regulated activity which must include cover for employees, premises and public liability
Policies, procedures and protocols where required – an index of these must be provided with the application
Staffing details and personnel records
Staffing rotas (if applicable)
Contract arrangements for equipment and services necessary
Confirmation that where planning permission or buildings approval is required, it has been obtained
*2.7 Views and experiences
How will you ensure the views and experiences of people who use services are listened to and acted upon when you are running the service?
Please give details including how you have taken into account the needs of the people who will use your service before you made this application.
*2.8 Equality, diversity and human rights
How will you ensure that peoples’ equality, diversity and human rights are actively promoted in how you carry on your service?

Section 3: Service types

*3.1 Regulated services
Please check / tick the services you are applying to carry on. These are defined in the National Minimum Standards for Independent Health Care in Wales.
If you have any queries regarding what services you should tick please contact HIW before you submit the form.
Termination of Pregnancy
Obstetrics
Accommodation for persons who require treatment for substance abuse
Palliative Care (Hospice) for Adults
Palliative Care (Hospice) for Children
Assessment or medical treatment for persons detained under the Mental Health Act
Dental treatment under general anaesthesia
Cosmetic Surgery
Acute
Non-Acute
In-Vitro Fertilisation
Class 3B or 4 Laser for a surgical purpose
Class 3B or 4 Laser for a non-surgical/cosmetic purpose
Intense Light machine
Dialysis
Endoscopy
Hyperbaric Oxygen Therapy
Circumcision of male children
Independent Clinic
Independent Medical Agency
*3.2 Overnight beds
Will your service be providing beds for patients to stay overnight?
Yes
No
If ‘Yes’, please provide details on how many
*3.3 Service user bands
Please check or tick all of the descriptions / service user bands for the people that will use this service. If you will provide a service to everyone you can check or tick ‘The whole population’.
Adults aged 18-65 / Adults aged 65+
Mental health / Sensory impairment
Physical disability / People detained under the Mental Health Act
Dementia / People who misuse drugs or alcohol
People with an eating disorder / Learning difficulties or autistic spectrum disorder
Children aged 0 – 3 years / Children aged4-12 / Children aged 13-18
The whole population / Other (please specify below)
*3.4 Service readiness
Is the service ready to meet the needs of the people who will use it?
Yes
No
If ‘No’, please describe any building work, conversions, or planning applications that are currently under way, and the date this is expected to be finished.
*3.5 Accessibility
Is the service accessible to all people, including people with disabilities?
Yes
No
If ‘No’, please describe in what way it does not do so, why it is impossible to make the premises fully accessible, and the reasonable adjustments that you have been able to make.
*3.6 Other businesses
Are any other businesses carried on or going to be carried on at the premises?
Yes
No
If ‘Yes’, please describe the other business carried on and the impact this has or will have on people.
*3.7 Security of records
Will records be kept in a way that meets the requirements of the Data Protection Act 1998?
Yes
No
If ‘No’, please describe how records are processed and stored.
*3.8 Security of the premises
Are the premises secure and do not allow access to people with no reason to be there?
Yes
No
If ‘No’, please describe how people are kept safe and their privacy and property protected.
3.9 Declaration of compliance
Before you make this declaration you must refer to the Care Standards Act 2000 and the Independent Health Care (Wales) Regulations 2011, which set out the legal obligations on a person or organisation registered to provide registerable services. You must be sure you have understood their requirements.
The National Minimum Standards for Independent Health Care in Wales shows how the requirements of the Independent Health Care (Wales) Regulations 2011 can be met.
You may decide to comply with relevant regulations in another way. If you do you should be ready to explain how and why you comply with the relevant regulation(s), and provide evidence where necessary about how your alternative approach will be just as or more effective in making sure that the regulations are met.
You must declare compliance with all of the requirements of the Independent Health Care (Wales) Regulations 2011 in relation to the registerable service you will carry on.
I declare that I will comply with the Independent Health Care (Wales) Regulations 2011 in relation to the service that I will carry on:
Yes
No

Section 4: Application declaration

This declaration must be signed by the applicant.