CARE STANDARDS ACT 2000 
Application to register as a Manager of 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 agency to which this application applies:	     	

Full address of the agency:	     	

Post code:	     	

Tel. no:	     	

Fax no:	     	

Email address:	     	

Attach photo 
here

Personal details:

Please insert full name:	     	

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

Address:	     	

Post code:	     	

Tel no:	     	

Mobile no:	     	

Fax 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 1) and submit with your application.

N.B. You must provide us with 
•	your family name
•	given names at time of your birth, and
•	ALL former names and aliases you have been known by at any time: 
Known as	From
(dd/mm/yyyy)	To
(dd/mm/yyyy)	Reason for change	
     	     	     	     	
     	     	     	     	
     	     	     	     	
     	     	     	     	
     	     	     	     	
Continue on a separate sheet if necessary 
 separate sheet attached covering  [     ] to [     ]

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*? Pease 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 nurse’s 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 Part 2 of the Children and Families (Wales) Measure 2010/The Child Minding and Day Care (Wales) Regulations 2010?  

If yes, 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 provide details
     

References
Please provide 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. 

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. 

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/yyyy)	To
(mm/yyyy)	Name, address and tel. no. of employer	Reason for leaving	Indicate if 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. Care Council for Wales, General Social Care Council, NMC, GMC?  If so please give details.
Regulatory body	Registration Number	Date due to be renewed
(dd/mm/yyyy)	Re-validation 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
(dd/mm/yyyy)	Expiry date

(dd/mm/yyyy)	Type or level of Membership/
Registration	
     	     	     	     	
     	     	     	     	
     	     	     	     	
     	     	     	     	
Criminal Disclosure 
Due to the nature of the role of manager, the post-holder is exempt from s.4(2) of the Rehabilitation of Offenders Act 1974. 

Rehabilitation of Offenders Act 1975 (Exceptions) Order 1975 (as amended) provides that post-holders are not entitled to withhold information about convictions which for other purposes are ‘spent’ under the 1974 Act. 	

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 your local CIW office.
Applicants must always contact their 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.

Do you have a current DBS Certificate contersigned by 
the Welsh Ministers (CIW) that is registered with the 
DBS Update Service?		 				Yes  	No  

Are you currently subscribing to the DBS Update Service?	Yes  	No  
Please also complete the fit person's interview questionnaire (see annex 1) 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:	     	

(Annex 1)

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.