CARE STANDARDS ACT 2000 
APPLICATION TO REGISTER AS AN ADOPTION SUPPORT AGENCY - PART 1
Mae’r ffurflen gais hon hefyd ar gael yn Gymraeg / This application form is also available in Welsh

Name of proposed Agency:	     	

Address of proposed Agency:	     	
Post code:	     	

Tel no:	     	

Fax no:	     	

E mail address:	     	

The form is in 3 parts as follows;

SECTION A		Organisation Information
SECTION B		Responsible Individual Application
SECTION C		Manager Application

Please ensure that the form is signed, by the necessary persons, in all the relevant places.

SECTION A    ORGANISATION INFORMATION
Name of Organisation:
	     	

The full address of registered or principal office:
	     	
Post code:	     	

Company Registration No:	     	

Tel no:	     	

Fax no:	     	

Mobile no:	     	

E mail/Website address:	     	

Language provision of proposed service:                                                          
(please tick one box only)	Welsh
	
English
	
Bilingual

	

Preferred language of inspection 
Please note that Welsh medium services will normally be assigned a Welsh speaking inspector to carry out your inspection so that they will be able to speak with people who use your service. 

For English medium and bilingual services only
Welsh
	
English

If your application is successful and you intend to provide an English medium or bilingual service, in which language would you like your inspection to be carried out?  
(please tick one box only)	

Language of published inspection report
In line with our publication policy, all inspection reports for Welsh and bilingual services are published in Welsh and English on our website. For English medium services we publish in English only unless requested.   

For English medium services only 
If your application is successful and you intend to provide 
an English medium service, please tick the box if you will     
also require your reports to be published in Welsh?       	

Date of establishment of the Agency or proposed date:	     	

If the organisation is a subsidiary of a holding company provide the name and address of the registered or principal office of the ultimate holding company and of any other subsidiary of that holding company.
Name of Holding Company:	     	

The full address of registered or principal office:	     	
Post code:	     	

Tel no:	     	

Fax no:	     	

Mobile no:	     	

E mail/Website address:	     	

Name of Holding Company:	     	

The full address of registered or principal office:	     	
Post code:	     	

Tel no:	     	

Fax no:	     	

Mobile no:	     	

E mail/Website address:	     	

Please attach a separate sheet if insufficient space is provided for all changes of address within the last five years.  Please tick this box if a separate sheet is attached	

Please provide details of the Director, Manager, Secretary or other similar officer of the organisation below.
Name of officer of organisation	Position held	
     
	     	
     
	     	
     
	     	
     
	     	
     
	     	
Is the Agency currently registered for any other purpose:	Yes		No	

If yes describe the nature of the current registration:
     

	

The name address and telephone number of the Registration Authority 
     

	

The person dealing with the regulation of your service
     

	

Is any other service provided from the premises used for the Adoption Support Agency?	Yes		No		

If yes provide details
     

	

Name of proposed manager, or if an application for a transfer of ownership, the name of the existing registered manager*	     

	
*If an existing registered manager is in place a Section C application is not required 

SECTION B      RESPONSIBLE INDIVIDUAL WITHIN ORGANISATION
This section should be completed by the person nominated as “the responsible individual”. Theymust be an individual who is a director, manager, secretary or other officer of the organisation who is responsible for supervising the management of the Agency.  All personal information relates to the nominated responsible individual.	
Attach photo here.

Personal details
Please insert full name of Responsible Individual completing this application:	     	

Position held by the Responsible Individual within the organisation:	     	

Date of birth:
(dd/mm/yyyy)	     	Place of birth:	     	

Current address of the responsible individual: 	     	
Post code:	     	

Tel no:	     	
Fax no:	     	
Mobile no:	     	
E mail address:	     	

Preferred language of communication 
for telephone calls: (please tick one box only)	Welsh
	
English

	

Preferred language of written communication 
(including emails and letters): 
(please tick one box only)	Welsh
	
English
	
Both

	

If your application is accepted a fit person's interview* will take place as part of the registration process. In which language would you like your interview to be conducted?  (please tick one box only)	Welsh
	
English

	
*Please complete the fit person's interview questionnaire (see annex 3) and submit with your application.

If you have changed your name, please provide 
•	your given names at time of birth  and
•	ALL former names or aliases you have been known by
Known as	From
(dd/mm/yyyy)	To
(dd/mm/yyyy)	Reason for change	
     	     	     	     	
     	     	     	     	
     	     	     	     	
     	     	     	     	
     	     	     	     	
Continue on a separate sheet if necessary 
 separate sheet attached covering period  [     ]  to  [     ]
Previous full addresses in the last five years:
From:
(dd/mm/yyyy)	     	To:
(dd/mm/yyyy)	     	
Address:	     	
Post code:	     	
From:
(dd/mm/yyyy)	     	To:
(dd/mm/yyyy)	     	
Address:	     	
Post code:	     	
From:
(dd/mm/yyyy)	     	To:
(dd/mm/yyyy)	     	
Address:	     	
Post code:	     	
Please attach a separate sheet if insufficient space provided for all changes of address within the last five years.  Please tick this box if a separate sheet is attached	

If you have ever carried on or managed an establishment or agency, or been refused or had cancelled a registration of an establishment or agency, please provide details below:

An establishment means a children’s home, a care home, an independent hospital, an independent clinic, or a residential family centre.  An agency means a domiciliary care agency, a nurses’ agency, a fostering agency or a voluntary adoption agency.

The name[s] by which the services were known	The nature and dates of the registration decision[s]
(dd/mm/yyyy)	Contact details for each Registration Authority involved	Person dealing wit the regulation of that service	
     	     	     	     	
     	     	     	     	
     	     	     	     	
     	     	     	     	

Have you ever carried on, or been a Responsible Individual or managed another care service (including as a child minder), registered under the Care Standards Act 2000, Registered Homes Act 1984, Children Act 1989 or The Children and Families (Wales) Measure 2010?								Yes     No  

Please provide details
     	

Do you have, or have you previously had, a business or financial interest in any other registered service?  Please provide details
     	

Has the responsible individual ever been disqualified from any
of the roles included within the Disqualification from Caring for 
Children Regulations 2004 (England or Wales Regulations)?	Yes  	No  

Has the responsible individual ever been adjudged bankrupt or 
had an estate sequestrated?						Yes  	No  

Has the responsible individual ever made a composition or 
arrangement with creditors, or been granted a trust deed 
for creditors?									Yes  	No  

If yes to any of the above, please supply details
     	
References
Please supply the names and addresses of two individuals from whom we may take up references.  You must give the name of your current or most recent employer as one reference (‘Current employer’ means who you are employed by at the time you submit this application).  Neither of these referees may be a relative.

Both of these referees must be able to comment on your professional skills and competence relevant to the proposed service.  At least one of these referees must have employed you for at least three months. Please supply both address and telephone number.
	Name and job title	Address and telephone number	Capacity in which known to the referee.	
1.	     	     	     	
2.	     	     	     	
Qualifications
Please provide details of any qualification (including awarding body and date of award) and professional training relevant to the provision of Adoption Support Services.
Qualifications gained	Awarding Body	Date of award
(dd/mm/yyyy)	
     	     	     	
     	     	     	
     	     	     	
     	     	     	
Continue on a separate sheet if necessary; tick if continued 

Other relevant information including evidence of competency against the National Minimum Standards
Standards 5.1 and 5.2 of the National Minimum Standards for Adoption Support Agencies highlight the skills and experience required.  Please outline how you feel you meet these requirements, including any work or training experience you consider to be relevant, whether paid or not.
     

	

Occupational history
Please provide an occupational history covering the period between leaving school and now.  Starting with when you left school, provide the year and month of each change of occupation.  Include the name and address of any present employer and the names and addresses of any previous employers together with details of the business, which they carried on. If any of your previous duties involved working with children or vulnerable adults, in giving the full reasons why your employment or position ended, please explain how this can be verified.

Where there are any gaps in employment, please give enough detail in your explanation of the circumstances to enable us to make checks if we need to. 
Occupation
Including job title	From

(mm/yy)	To

(mm/yy)	Name, address and tel. no. of employer	Reason for leaving	Indicate of this was working with Adults (A) or Children(C)	
     	     	     	     	     	     	
     	     	     	     	     	     	
     	     	     	     	     	     	
     	     	     	     	     	     	
     	     	     	     	     	     	
Please use continuation sheets if necessary - tick if enclosed  

Have you ever been subject to any disciplinary action, formal warning, suspension and / or dismissal from a place of employment	

Yes  	No  	

If yes please provide details
     	

Are you registered with any organisation that regulates your profession e.g. Social Care Wales, General Social Care Council, NMC, GMC?  If so please give details
Regulatory body	Registration Number	Date due to be renewed
(dd/mm/yy)	Revalidation date if applicable
(dd/mm/yy)	Other information e.g. part / specialist register	
     	     	     	     	     	
     	     	     	     	     	
     	     	     	     	     	
     	     	     	     	     	

Details of membership or registration with other professional or relevant bodies
Organisation or professional body	Date admitted/ registered
(dd/mm/yyyy)	Expiry date

(dd/mm/yyyy)	Type or level of Membership/Registration	
     	     	     	     	
     	     	     	     	
     	     	     	     	
     	     	     	     	

Rehabilitation 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.  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. 
What happens if there is a criminal background? 
Any convictions, conditional discharges or cautions will be revealed on your DBS certificate which will be sent to you. In order to determine your application to register we will need to see the original certificate. Where a DBS certificate contains any relevant information, we will consider the information and its impact on the application. In deciding what action to take, CIW will take account of the nature of the information itself and full details of the relevant circumstances 

Please note it is an offence to knowingly make a statement in an application which is false or misleading. Failure to fully and accurately complete an application may result in the application being refused or subsequently cancelled.
Please note: Applications for all individual persons must be supported by a completed medical declaration and DBS application (unless the applicant has a DBS certificate countersigned on behalf of Welsh Ministers and is signed up to the DBS Update Service). 
The medical declaration form is available from our website www.careinspectorate.wales or by contacting the relevant CIW office.
Applicants must always contact a CIW office to request a DBS application form on the telephone number here: 0300 7900 126
Important: From 01 April 2018 all applicants will be required to meet the cost of their DBS application.

Please attach completed forms otherwise this will delay your application being processed:

Medical Declaration authorisation						Attached  
Disclosure and Barring Service application form			Attached  

Do you currently subscribe to the 
DBS Update Service?		Yes  	No  
Responsible individual: Please complete the fit person's interview questionnaire (see annex 3) and submit with your application.

Declaration
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.

The information I have provided in this application form and in any attached documents is, to the best of my knowledge and belief, true and complete.  I give my permission for CIW to contact relevant persons / organisations to verify the information provided and gather any additional information necessary to progress this application.  I 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.

Important: 
We process any personal and/or sensitive information we hold about you fairly and lawfully, and we only ask for such information where it is necessary for us to carry out our role. For more information about how we process your personal data, and your rights in relation to this, please see our Privacy Notice at https://careinspectorate.wales/how-we-use-your-information, or contact us for a paper copy.

Signed:	     	Date:	     	
		Responsible Individual

Attach photo here

SECTION C	MANAGER APPLICATION
This section to be completed by the proposed manager of the agency. We will require a passport sized recent photograph, which is a “true likeness”. This will be kept as part of your application.  Please bring with you originals of your technical and professional qualifications, which will be photocopied and returned to you.	
Personal details
Please insert full name:	     	

Address:	     	
Post code:	     	

Date of birth:
(dd/mm/yyyy)	     	Place of birth:	     	

Tel no:	     	Fax no:	     	

Mobile no:	     	

E mail address:	     	

Preferred language of communication 
for telephone calls: (please tick one box only)	Welsh
	
English

	

Preferred language of written communication 
(including emails and letters): 
(please tick one box only)	Welsh
	
English
	
Both

	

If your application is accepted a fit person's interview* will take place as part of the registration process. In which language would you like your interview to be conducted?  (please tick one box only)
	Welsh
	
English

	
*Please complete the fit person's interview questionnaire (see annex 3) and submit with your application.

If you have changed your name, please provide 
•	your given names at time of birth and
•	ALL former names or aliases you have been known by
Known as	From
(dd/mm/yyyy)	To
(dd/mm/yyyy)	Reason for change	
     	     	     	     	
     	     	     	     	
     	     	     	     	
     	     	     	     	
     	     	     	     	
Continue on a separate sheet if necessary 
 separate sheet attached covering period [     ] to [     ]
Previous full addresses in the last five years:
From:
(dd/mm/yyyy)	     	To:
(dd/mm/yyyy)	     	
Address:	     	
Post code:	     	

From: (dd/mm/yyyy)	     	To:
(dd/mm/yyyy)	     	
Address:	     	
Post code:	     	

From:
(dd/mm/yyyy)	     	To:
(dd/mm/yyyy)	     	
Address:	     	
Post code:	     	
Please attach a separate sheet if insufficient space provided for all changes of address within the last five years.    Please tick this box if a separate sheet is attached	

Are you currently registered to provide any other care service from or in connection with the proposed agency premises?	
Yes  	No  	

Do you have any current financial or managerial interest in any other establishment/agency?	
Yes  	No  	

Have you ever carried on or managed an establishment or agency, or been refused or had cancelled a registration of an establishment or agency*, please provide details below:
(*An establishment means a children’s home, a care home, an independent hospital, an independent clinic, or a residential family centre.  An agency means a domiciliary care agency, a nurses’ agency, a fostering agency or a voluntary adoption agency).
The name[s] by which the services were known	The nature and dates of the registration decision[s]
(dd/mm/yyyy)	Contact details for each Registration Authority involved	Person dealing with the regulation of that service	
     	     	     	     	
     	     	     	     	
     	     	     	     	
     	     	     	     	
     	     	     	     	

Have you ever carried on, or been a Responsible Individual or managed another care service (including as a child minder), registered under the Care Standards Act 2000, Registered Homes Act 1984, Children Act 1989 or The Children and Families (Wales) Measure 2010?  Please provide details
     

	

Have you ever been disqualified from any of the roles included within the Disqualification from Caring for Children Regulations 2004 (England or Wales versions)?	

Yes  	No  	

If yes please supply details
     	
References
Please supply the names and addresses of two individuals from whom we may take up references.  You must give the name of your current or most recent employer as one reference (‘Current employer’ means who you are employed by at the time you submit this application). Neither of these referees may be a relative.

Both of these referees must be able to comment on your professional skills and competence relevant to the proposed service.  At least one of these referees must have employed you for at least three months. Please supply both address and telephone number.
	Name and job title	Address and telephone number	Capacity in which known to the referee	
1.	     	     	     	
2.	     	     	     	
Qualifications
Please provide details of any qualification (including awarding body and date of award) and professional training relevant to the provision of Adoption Support Services.
Qualifications gained	Awarding Body	Date of award
(dd/mm/yyyy)	
     	     	     	
     	     	     	
     	     	     	
     	     	     	
Continue on a separate sheet if necessary. 	Attached  

Other relevant information including evidence of competency against the National Minimum Standards

Standards 5.1 and 5.2 of the National Minimum Standards for Adoption Support Agencies highlight the skills and experience required.  Please outline how you feel you meet these requirements, including any work or training experience you consider to be relevant, whether paid or not.
     

	
Continue on a separate sheet if necessary. 	Attached  

Occupational history
Please provide an occupational history covering the period between leaving school and now.  Starting with when you left school, provide the year and month of each change of occupation.  Include the name and address of any present employer and the names and addresses of any previous employers together with details of the business, which they carried on. If any of your previous duties involved working with children or vulnerable adults, in giving the full reasons why your employment or position ended, please explain how this can be verified.

Where there are any gaps in employment, please give enough detail in your explanation of the circumstances to enable us to make checks if we need to. Continue on separate sheets as necessary.
Occupation
including job title	From
(mm/yy)	To
(mm/yy)	Name, address and tel. no. of employer	Reason for leaving	Indicate of this was working with Adults (A) or Children(C)	
     	     	     	     	     	     	
     	     	     	     	     	     	
     	     	     	     	     	     	
     	     	     	     	     	     	
     	     	     	     	     	     	
     	     	     	     	     	     	
Please use continuation sheets - tick if continuation sheet included 

Have you ever been subject to any disciplinary action, formal warning, suspension and / or dismissal from a place of employment	
Yes  	No  	

If yes please provide details
     

	

Are you registered with any organisation that regulates your profession e.g. Social Care Wales, General Social Care Council, NMC, GMC?  If so please give details
Regulatory body	Registration number	Date due to be renewed

(dd/mm/yyyy)	Revalidation date ( if applicable)
(dd/mm/yyyy)	Other information e.g. part / specialist register	
     	     	     	     	     	
     	     	     	     	     	
     	     	     	     	     	
     	     	     	     	     	

Details of membership or registration with other professional or other relevant organisations or bodies
Organisation or professional body	Date admitted/registered and expiry date (dd/mm/yyyy)	Type or level of Membership/Registration	
     	     	     	
     	     	     	
     	     	     	
     	     	     	

 Rehabilitation 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.  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. 

What happens when there is a criminal background? 
Any convictions, conditional discharges or cautions will be revealed on your DBS certificate which will be sent to you. In order to determine your application to register we will need to see the original certificate. Where a DBS certificate contains any relevant information, we will consider the information and its impact on the application. In deciding what action to take, CIW will take account of the nature of the information itself and full details of the relevant circumstances 

Please note it is an offence to knowingly make a statement in an application which is false or misleading. Failure to fully and accurately complete an application may result in the application being refused or subsequently cancelled.
Please note: Applications for all individual persons must be supported by a completed medical declaration and DBS application (unless the applicant has a DBS certificate countersigned on behalf of Welsh Ministers and is signed up to the DBS Update Service). 
The medical declaration form is available from the CIW website or by contacting the relevant office
Applicants must always contact a CIW office to request a DBS application form on the telephone number here: 0300 7900 126
Important: From April 1 2018 all applicants will be required to meet the cost of their DBS application.

Please attach completed forms otherwise this will delay your application being processed:

Medical Declaration authorisation:					Attached  

Disclosure and Barring Service application form:			Attached  

Are you currently subscribing to the 
DBS Update Service?		Yes  	No  

Please also complete the fit person's interview questionnaire (see annex 3) and submit with your application.

Declaration
The information I have provided in this application form and in any attached documents is, to the best of my knowledge and belief, true and complete.  I give my permission for CIW to contact relevant persons / organisations to verify the information provided and gather any additional information necessary to progress this application.  I 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.

Important: 
We process any personal and/or sensitive information we hold about you fairly and lawfully, and we only ask for such information where it is necessary for us to carry out our role. For more information about how we process your personal data, and your rights in relation to this, please see our Privacy Notice at https://careinspectorate.wales/how-we-use-your-information, or contact us for a paper copy.

Signed:	     	Date:	     	
		Manager

The following items must accompany this application for registration, failure to provide all the requested items will result in a delay in processing your application.
SECTION A 
Business Plan for first (or next) 2 years of operation (See annex 1)	

Copies of last two annual reports if applicable (See annex 1)          	

Copies of last two annual reports (if any) of any holding company and or 
any other subsidiary of that holding company (See annex 1)             	

Financial reference request form - to be forwarded to your bank(s) 
(See annex 2/2a)                                                                                    	

Part 2 application                                                                                          
SECTION B:  (The responsible individual)
DBS enhanced disclosure application form	

Passport, birth certificate and other documents relating to a change of name 	

Medical declaration form	

Evidence of relevant qualifications	

Recent photograph, which should be a true likeness	
Please complete the fit person's interview questionnaire (see annex 3) 
and submit with your application.
SECTION C: (The Manager)
DBS enhanced disclosure application form 	

Passport, birth certificate and other documents relating to a change of name	

Medical declaration form	

Evidence of relevant qualifications	

Recent photograph, which should be a true likeness	
Please complete the fit person's interview questionnaire (see annex 3) 
and submit with your application.

(Annex 1)
Care Inspectorate Wales
Financial Information
Care Standards Act 2000 – Registration Process
Adoption Support Agencies (Wales) Regulations 2005

Regulation 28 of the Adoption Support Agencies (Wales) Regulations 2005 requires the registered provider to ensure that the agency is financially viable for the purpose of achieving the aims and objectives set out in the statement of purpose. 

As part of the registration process the following documentation must be provided:

1.	A business plan covering the first (or next) two years of operation of the proposed service, including cash flow projections.
2.	Copies of the last two annual reports and accounts that the organisation was required to produce.  Where the incorporated organisation is a subsidiary of a holding company, the name and address of the registered or principal office and the last two annual reports (if any) of the holding company and of any other subsidiary of that holding company. 
3.	A copy of an insurance certificate that provides cover in respect of any liability that may be incurred in respect of death, injury, public liability, damage or other loss.

Please enclose the above documents when you submit your application.

In addition can you please complete and sign the attached draft letter(s) to your Banker(s) and post them to the bank without delay (See annex 2/2a below). 

N. B. Please remember to enclose a copy of the agency’s Statement of Purpose along with the letter(s). 

(Annex 2)
Care Inspectorate Wales
Financial Information (Incorporated Organisation)
Strictly Confidential

To       (Name of Bank)

      (Address of Bank)

(Applicant: Insert name of organisation here)      
has applied to carry on an Adoption Support Agency under the Care Standards Act 2000.

Care Inspectorate Wales needs to be satisfied that the above named organisation is financially secure and has full consultation with its financial backers.

On behalf of the above named organisation, I therefore authorise you to provide Care Inspectorate Wales with an opinion as to the organisation’s financial standing.

Signed:      

Print Name:      

Date:      

Full Name of Incorporated Organisation:       

Registered Company Number:      

Registered or Principal Office Address:      

Account Name(s):      

Account Number(s):       

Please return information to…….. (Applicant: Please delete as applicable)

Care Inspectorate Wales,  
Government Buildings,
Sarn Mynach,
Llandudno Junction.
LL31 9RZ	Care Inspectorate Wales,  
Welsh Government Building, 
Rhydycar Business Park,
Merthyr Tydfil.
CF48 1UZ	Care Inspectorate Wales,  Government Buildings,
Picton Terrace,
Carmarthen.
SA31 3BT	

(Annex 2a)
Care Inspectorate Wales
Financial Information (Individual Applicant)
Strictly Confidential

To       (Name of Bank)

      (Address of Bank)

I have applied to carry on an Adoption Support Agency under the Care Standards Act 2000.

Care Inspectorate Wales needs to be satisfied that I am financially secure and have had full consultation with my financial backers.

I therefore authorise you to provide Care Inspectorate Wales with an opinion as to my financial standing.

Signed:      

Print Name:      
	
Date:      

Full Name of Individual or Company:      

Registered or Principal Office Address:      

Account Name(s):      

Account Number(s):      

Please send this form. Together with the necessary opinion and statements to 
Care Inspectorate Wales at: (Applicant: Please delete as applicable)

Care Inspectorate Wales, Government Buildings,
Sarn Mynach,
Llandudno Junction
LL31 9RZ   	Care Inspectorate Wales, Welsh Government Building,
Rhydycar Business Park
Merthyr Tydfil
CF48 1UZ  
	Care Inspectorate Wales, 
Government Buildings
Picton Terrace
Carmarthen
SA31 3BT	

(Annex 3)					

APPLICANT’S FIT PERSON QUESTIONNAIRE:
Your name:
	     	
The name of service/proposed service:
	     	
The name of the Provider:
	     	

I am the proposed:                                                                                       (Please tick)	

Manager:  	
	
Service Provider: (individual)	
	
Responsible Individual: 	

The type of Service:                                                                   (Please tick)	

Care Home: 	

Children’s Home:	

Domiciliary Care Agency: 	

Nurse Agency:	

Adult  Placement Scheme:	

Foster/Adoption Support Agency:	

Residential Family Service:	

Important: 

This questionnaire forms part of the test of your fitness to provide and/or manage a service. It is important to think carefully about your responses as they will be considered and used as evidence to support your application. 

You are advised to familiarise yourself with the relevant legislation, including the regulations and National Minimum Standards linked to your service area. You should also consider the Code of Professional Practice and the Human Rights Act 1998.

Please complete the following questionnaire and submit along with your completed application. Please note that once submitted, CIW will accept your response as complete and any further amendments or additions will not be possible.

(We recommend that you limit your response for each question to one side of A4 or approximately 300 words).

a. Statement of Purpose* 
*Please include a copy of your current statement of purpose with your response.
	
Q. a1 The Regulations require that each service has a Statement of Purpose. Why is this a key document?
     

	
Q. a2 How do (will) you ensure that the service you provide/manage is consistent with its Statement of Purpose?
     	

b. Wellbeing
	
Q. b1 How do (will) you ensure that people’s rights are promoted and they are safe and protected from abuse and neglect?
      	
Q. b2 How do (will) you ensure that people are supported to keep as healthy as they can be?
     

	

c. Care and Support
	
Q. c1 How do (will) you ensure a person’s individual needs and preferences are understood and anticipated? 
     	
Q. c2 How do (will) you ensure that people are actively engaged in making decisions about the service they receive?
     

	

d. Leadership & Management
	
Q. d1 Describe your role and responsibilities in relation to the recruitment, development and management of your staff?
     	
Q. d2 (i) How has your past work experience equipped you for your current role and (ii) how will you maintain your own personal learning and development?
     	
Q. d3 How do (will) you evaluate the quality of care experienced by people in your service?
     

	

e. Environment 
	
Q.e1 How do (will) you ensure that the service you provide/manage offers an environment that is safe and able to meet the individual and collective needs of people using it?
     

	

Are there any matters that you wish to raise at the Fit Person Interview?
	
     

	

Please sign and date this declaration:
Declaration
The information I have provided in this ‘Fit Person’ questionnaire and in any attached documents, is true to the best of my knowledge and belief.  I make this statement knowing that the discovery of any intentionally false or misleading information could lead to any registration which may be granted as a result of my application, being cancelled, and may also render me liable to prosecution. I confirm that the above responses are my own. 
Signed:	     	Date:
(dd/mm/yyyy)	     	

Reminder: Please include a copy of your current statement of purpose with your response.