Royal Borough of Kensington and Chelsea

Adult Social Care

Grant Application 2010/2011

Threshold 3: £20,001 and over

Name of Organisation: ______

______

Please tell us the amounts you are applying for:

Business Group – Adult Social Care

Adult Social Care – Social Care / £
Adult Social Care –
Transport / £ / Adult Social Care –
Carers / £

Please tell us the amount/s you are applying for it is from another Business Group:

Corporate Services / £ / Family and Children’s Services / £
  1. CONTACT DETAILS

A1 Name of Organisation:
A2 Address of Organisation:
A3 Contact Name and Position Held:
A4 Telephone: / A5 Mobile:
A6 Fax: / A7 Email:
A8 Website:
  1. LEGAL STATUS

B1 Charity Registration Number:
B2 Limited Company Registration:
B3 Other:
B4 Data Protection Act Registration Number (if applicable):
B5 Are you registered with the Criminal Records Bureau? Yes/No
Or with an Umbrella Body (give name of umbrella body)? Yes/No
Do all staff who have direct contact with children, young people, and/or vulnerable adults have a current CRB disclosure reference? Yes/No

First Stage of Application Form

  1. YOU MUST PROVIDE THE FOLLOWING INFORMATION WITH THE APPLICATION

Funding for £20,001 and over:

Tick if attached
C1 A copy of the audited accounts (or equivalent) 2008/2009.
If small organisation, Independent Examiners Report
C2 A copy of the Annual Report 2008/2009
C3 List of current Committee Members (include addresses and
telephone numbers)
C4 Minutes of the last Annual General Meeting
C5 Minutes of the last Management Committee Meeting
C6 If you do not currently receive a grant from the Royal Boroughof Kensington and Chelsea, a copy of the Organisation’s governing document

Finance:

Tick if attached
C7 Attach a breakdown of the organisation’s anticipated incomeand expenditure budget for 2010/2011
C8 Attach a breakdown of the anticipated income/expenditure
budget 2010/2011for each service and/or separate core costsapplied for. (See D1)
C9 Attach a breakdown budget for the transport and carers grant applications (if applicable). (See D2 and D3)

Policies and Inspection Reports

Please tell us if you have the following policies in place:

Tick if in place
C10 Copy of Financial Policies
C11 Copy of User Consultation Policy
C12 Copy of Complaints Procedure
C13 Copy of Equal Opportunities Policy

If grant application is successful, the Royal Borough of Kensington and Chelsea may request to inspect these policies and procedures. Only tick if the

organisation has the relevant policies in place.

Tick if applicable
C14 Copy of the latest reports (if applicable)
OFSTED
Commission for Social Care Inspection/Care Quality Commission
Charity Commission reports

C15 Have you signed up to the Compact and Codes Yes/No

of Practice?

D SUMMARY OF COSTS 2010/2011

D1 Anticipated income 2010/2011 for each service/project and/or separate core costs, including expected income from other sources:

Total Royal Borough of Kensington and Chelsea Grant Application: / £
Other Income Sources:
Total:

D2 Anticipated income 2010/2011 for transport (if applicable):

Total Royal Borough of Kensington and Chelsea Grant Application: / £
Other Income Sources:
Total:

D3Anticipated income 2010/2011 for carers (if applicable):

Total Royal Borough of Kensington and Chelsea Grant Application: / £
Other Income Sources:
Total:

(Please photocopy and fill in a separate Section D for every service/project you are requesting funding for)

E GOVERNANCE

Governance, Management and Finance

E1 The Council needs to ensure the organisation is well governed and has good management and financial systems in place.
Please tell us how you demonstrate the following:
(Maximum 200 words in total)
a)Leadership:
b)Management Committee meetings (tell us how often meetings are held, how decisions are made, and agenda items discussed, for example, health and safety, staffing and finance).
c)Financial Management:
E2 How does the organisation ensure that the trustees and staff are competent and have the necessary skills? (Maximum 100 words)

F CURRENT FINANCIAL INFORMATION

F1 Do you currently receive an annual grant from the Council (2009/2010)? Yes/No
F2 Value of Grant/s: / Adult Social Care: £
Transport: £
Carers: £
Corporate Services: £ / Family and Children’s Services £
F3 What was the total audited income for the organisation in 2008/2009?
£
F4 What was the total audited expenditure for the organisation in 2008/2009?
£
F5 Anticipated total income for the organisation in 2010/2011:
£
F6 Anticipated expenditure for the organisation in 2010/2011:
£
F7 Are there any major issues which may affect income/expenditure in 2010/2011?

G If the organisation has not received a grant from the Royal Borough of Kensington and Chelsea within the last two years, give the name of an independent referee who knows about the organisation.

G1 Name:
G2 Organisation:
G3 Position:
G4 Address:
G5 Telephone Number: / G6 Email:
G7 Has the referee been told that they will be approached? Yes/ No

HSUMMARY OF COSTS 2010/2011

Business Group – Adult Social Care Only.

Give a breakdown of the service/project costs and/or core costs, including expected income from other sources for each service/project.

Service/project description funding breakdown – Income 2010/2011:

(1) ADULT SOCIAL CARE
Name of service/project:
£Amount
i)
ii)
iii)
iv)
v)
Total Requested from Adult Social Care:
Funding from other sources: / £Amount
i)
ii)
iii)
Total funding expected from other sources:
(2) ADULT SOCIAL CARE
Name of service/project:
£Amount
i)
ii)
iii)
iv)
v)
Total Requested from Adult Social Care:
Funding from other sources: / £Amount
i)
ii)
iii)
Total funding expected from other sources:
(3) ADULT SOCIAL CARE
Name of service/project:
£Amount
i)
ii)
iii)
iv)
v)
Total Requested from Adult Social Care:
Funding from other sources: / £Amount
i)
ii)
iii)
Total funding expected from other sources:
(4) ADULT SOCIAL CARE
Name of service/project:
£Amount
i)
ii)
iii)
iv)
v)
Total Requested from Adult Social Care:
Funding from other sources: / £Amount
i)
ii)
iii)
Total funding expected from other sources:

(Please photocopy if you have more services/projects to tell us about)

Adult Social Care – Transport Only

(1) ADULT SOCIAL CARE - Transport
Name of service/project:
£Amount
i)
ii)
iii)
iv)
v)
Total Requested from Adult Social Care– Transport:
Funding from other sources: / £Amount
i)
ii)
iii)
Total funding expected from other sources:

Adult Social Care – Transport Only

(1) ADULT SOCIAL CARE - Transport
Name of service/project:
£Amount
i)
ii)
iii)
iv)
v)
Total Requested from Adult Social Care– Transport:
Funding from other sources: / £Amount
i)
ii)
iii)
Total funding expected from other sources:

(Please photocopy if you have more services/projects to tell us about)

Adult Social Care – Carers Grant Only

(1) ADULT SOCIAL CARE - Carers
Name of service/project:
£Amount
i)
ii)
iii)
iv)
v)
Total Requested from Adult Social Care – Carers:
Funding from other sources: / £Amount
i)
ii)
iii)
Total funding expected from other sources:

Adult Social Care – Carers Grant Only

(1) ADULT SOCIAL CARE - Carers
Name of service/project:
£Amount
i)
ii)
iii)
iv)
v)
Total Requested from Adult Social Care – Carers:
Funding from other sources: / £Amount
i)
ii)
iii)
Total funding expected from other sources:

(Please photocopy if you have more services/projects to tell us about)

Business Group – Corporate Services

(1) CORPORATE SERVICES
Name of Service
£Amount
i)
ii)
iii)
iv)
v)
Total Requested from Corporate Services:
Funding from other sources: / £Amount
i)
ii)
iii)
Total funding expected from other sources:

Second Stage of Application Form

I Outline the overall aims and objectives of the organisation

I1 Aims and Objectives (Maximum 150 words)

J Service Detail: Describe the service/project for which funding is requestedfrom Adult Social Care.

Complete a separate Section J for each service/project applied for

J1 Name of Service/Project Description (Maximum 150 words)
Which of the priorities below does the service meet? Tick box (you can tick more than one)
Improved quality of life / Making a positive contribution
Better health and well-being / Dignity and respect
Choice and control / Freedom from discrimination and
harassment
Economic well-being
Describe how theservice will meet the priorities that have been ticked. (Maximum of 100 words for each priority)
a)Improved quality of life
b)Better health and well-being
c)Choice and control
d)Economic well-being
e)Making a positive contribution
f)Dignity and respect
g)Freedom from discrimination and harassment

People using the service

J2 Which users are targeted by the services you provide?
J3 Give the total number of people expected to use the service.
Monthly______
Yearly______
Percentage expected to be Royal Borough of Kensington and Chelsea residents
%______
Which areas of the borough will the service cover:
All Central North South

J4 Transport Grant

If funding is sought to meet transport costs, answer all the following questions:

Brief description of transport needs (Maximum 50 words)
Give reasons why public transport cannot be used (Maximum 50 words)
Frequency of journeys (e.g. twice daily, weekly)
Do you have your own transport? Yes/No
If no, name the transport provider you intend to use

Outputs

J5 List the service outputs (up to 6)

Monitoring and Evaluation

J6 Describe the ways in which the service you are requesting funding for will be monitored (Maximum 150 words)
J7 Describe the ways in which service you are requesting funding for will be evaluated (Maximum 150 words)
i)
ii)
iii)
iv)

Complete a separate Section J for each service/project applied for

K User involvement/consultation

K1 How does the organisation involve and consult with users? (Maximum 150 words)
K2 Can you give an example in the past 12 months when users were involved in service development, service design and/or service delivery? (Maximum 200 words)

L Equal Opportunities

L1 Can you give three examples of how you have implemented equal opportunities and equal access for users, volunteers, carers and staff? (Maximum 100 words for each example)
i)
ii)
iii)

M Volunteering

M1 How many volunteers work for the organisation (excluding trustees)?

N Quality Assurance

N1 Name the quality assurance system/s the organisation has in place or describe how you ensure the quality of service delivery (Maximum 150 words)

OPublicising to potential service users and carers

O1 How will you promote and publicise the services you provide and reach out to potential users and carers? (Maximum 150 words)

P Additional Added Value

P1 Describe how the services you provide offer value for money (Maximum 150 words)

Q Additional Funding and Fundraising

Q1 What are the general fundraising plans for the organisation? (Maximum 200 words)

RBACS Form

Please ensure that you complete the information below before submitting your application form.

It is the Royal Borough’s policy to make all payments by BACS transfer to reduce administrative costs. Please supply the details of your bank account below so that, if you are successful in your grant application, we can make payments quickly by direct bank transfer.

Please send a copy of a recent bank statement with this form.

Organisation Name: ______

Organisation Address: ______

Fax No______

Tel. No______

Payee’s Bank Account Name______

_ / _

Bank Sort Code

Bank Account

Number

Bank Name and Branch______

Bank Address______

______

Postcode______

Signature______Date______

Print Name______

Job Title______

Office Use Only:

One World Supplier Number:

S DECLARATION

On behalf of the organisation, we the undersigned certify the following:

  1. The organisation wishes to apply for Grant Funding from the Council;
  2. If funding is approved we will adhere to the Funding Agreement and Mandatory Conditions of Funding;
  3. Monitoring information will be provided as required, returned on time, and we acknowledge the Council may impose penalties if this is not done;
  4. To the best of our knowledge the information included in the form is true. We understand that if false statements are made the Council may reduce or withdraw funding and that the Council will treat fraud as a legal matter;
  5. We understand that the contents of the completed application form are confidential between the Council and ourselves and that disclosure to third parties can only be done with permission of the Council and ourselves.

Signed: ______Date: ______

Position: ______

Signed: ______Date: ______

Position: ______

One signatory should be an officer of the Management Committee for example Chairman, Treasurer and the other an appropriate member of staff, for example Executive Director or Manager.

T RETURNING THE APPLICATION FORM

Voluntary Sector Grant Applications 2010/11

Royal Borough of Kensington and Chelsea

Room 139

The Town Hall

Hornton Street

London

W8 7NX

Or email to

Remember to

Apply by the deadline: 23 September 2009 by 12 noon

Complete all sections

Keep a copy of the application for your files

Ensure all the additional information listed in Section C is enclosed with the application form. We will require a hard copy of the signature page and BACS form.

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