CARE STANDARDS ACT 2000
APPLICATION TO REGISTER AS A VOLUNTARY ADOPTION AGENCY PART 1 - Organisation 
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:	     	

Telephone No:	      	Fax No:	      	

Email address:	      	

This application is required to be lodged in person by the proposed responsible individual on behalf of the organisation.  

You will be asked to present your application in person bringing your birth certificate, other documents relating to changes of name and a positive proof of identity such as a passport, driving licence etc. This is to enable us to complete identity check procedures required by the Disclosure and Barring Service (DBS) before requesting a disclosure and to evidence other aspects of the registration process.  Copies will be retained only for the purpose of registration.

We will also require a passport size photograph of the proposed responsible individual and manager which is a current true likeness; this will be retained as part of your application for the purpose of registration.

Please bring with you the originals of all certificates of qualification upon which your application is based. These will be photocopied and returned to you. You are advised to make an appointment for the purpose of lodging your application and to allow at least an hour for the process.

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 of establishment:	        (dd/mm/yyyy)	
If the organisation is not a company please provide details of the means by which the organisation was incorporated and the date of incorporation
     

If the organisation is a subsidiary of a holding company please 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
     	

The full address of registered or principal office:	     	

Address of any other subsidiaries of the holding company:	      	
Post code:	      	

Tel no:	      	Fax no:	      	

Mobile no:	      	

Email/Website address:	      	

If the holding company has had a change of address in the last 5 years please provide details below
      	

If the organisation is a registered charity, please provide the registered charity number	      	

Please provide details below of the Director, Manager, Company Secretary or other relevant officers of the organisation
Name of officer of organisation	Position held	
     
	     	
     
	     	

     
	     	
     
	     	
     
	     	
Is the agency currently registered for any other purpose:		Yes  	No  

If ‘Yes’ please describe:  

i.	the nature of the current registration
     

ii.	the name address and telephone number of the registration authority
     

iii.	the person dealing with the regulation of your service
     

Is any other service provided from the premises used for the voluntary adoption agency?	Yes  	No  	

If ‘Yes’ please provide details
     	

Please provide details below of any branch offices of your voluntary adoption agency
     	

Do you intend setting up any additional branch offices?		Yes  	No  

If 'Yes' please provide details including address
     

	

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 Part 1a application is not required. 

Attach
photo 
here.

SECTION B	Responsible individual within organisation
This section should be completed by the person nominated
 as “the responsible individual”.  He or she must be an
 individual who is a director, manager, company secretary
 or other senior officer of the organisation who is responsible
 for supervising the management of the agency.  All personal
 information relates to the nominated responsible individual
Personal details
Please insert full name of the 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

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

If you have ever 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:	     	
Address:	     	
Post code:	     	
From:   (dd/mm/yyyy)	      	To:	      	
Address:	     	
Post code:	     	
From:   (dd/mm/yyyy)	      	To:	       	
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	

Have you ever carried on or managed an 
establishment, service or agency*? 					Yes  	No   

If 'Yes' please provide details below
      

	

Have you ever been refused or had cancelled a registration of an establishment, service or agency registered under the Care Standards Act 2000, Registered Homes Act 1984, The Children and Families (Wales) Measure 2010 or Children Act 1989? 

Yes  	No     

If yes, please provide details in the table 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, an adoption support agency or a voluntary adoption agency. A service includes any day care service for children under 12 years old.)
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	
     	     	     	     	
     	     	     	     	
     	     	     	     	

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

Have you ever been disqualified from any of the roles included within the Disqualification from Caring for Children (Wales) Regulations 2004?	
Yes  	No  	

Have you ever been adjudged bankrupt or had an estate sequestrated?	Yes  	No  	

Have you 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 can 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 Voluntary Adoption Agencies.

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 fitness and competency as prescribed by regulations 5 & 8 of the Voluntary Adoption Agencies and the Adoption Agencies (Miscellaneous Amendments) Regulations 2003 and the Adoption National Minimum Standards 2003 NMS 14, 15 & 16:

Please outline below 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.  Please start with when you left school and 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 and how this can be verified, if applicable.	Indicate if 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/yyyy)	Revalidation date if applicable	Other information e.g. part / specialist register	
     	     	     	     	     	
     	     	     	     	     	
     	     	     	     	     	
     	     	     	     	     	

Details of membership or registration with other professional or relevant bodies
Organisation or professional body	Date: (dd/mm/yyyy)	Type or level of membership/registration	
	Admitted/ registered	Expiry date		
     	     	     	     	
     	     	     	     	
     	     	     	     	
     	     	     	     	
     	     	     	     	
Disclosure and Barring Service 

Due to the nature of the role of responsible individual, 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 a CIW office.
Applicants must always contact a CIW office to request a DBS application form on the telephone number below:
0300 7900 126
Important: From April 1 2018 all applicants will be required to meet the cost of their DBS application.

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

Please attach completed:
Disclosure and Barring Service application form 	 completed, date: 

Medical Declaration authorisation				 completed, date: 

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:	      	
Proposed responsible individual

SECTION C	Manager Application
Attach photo here
	
This section is 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 and retained on file if 
registration is granted? 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	
     	     	     	     	
     	     	     	     	
     	     	     	     	
     	     	     	     	
     	     	     	     	

Previous full addresses in the last five years:
From: (dd/mm/yyyy)	      	To:	      	
Address:	     	
Post code:	     	
From: (dd/mm/yyyy)	      	To:	      	
Address:	     	
Post code:	     	
From: (dd/mm/yyyy)	      	To:	      	
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 owned or managed another registered care establishment or agency, please provide details: 
(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, an adoption support agency or a voluntary adoption agency. A service includes any day care service for children under 12 years old.)
Owned	Managed	
Are you currently registered to provide any other care service from or in connection with the proposed agency premises?	Yes  	No  
	Yes  	No  

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

Have you ever carried on or managed an establishment, service or agency?	Yes  	No  
	Yes  	No  

Have you ever been refused or had cancelled a registration of an establishment, service or agency registered under the Care Standards Act 2000, Registered Homes Act 1984, Children Act 1989 or The Children and Families (Wales) Measure 2010?													Yes  	No  
(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, an adoption support agency or a voluntary adoption agency. A service includes any day care service for children under 8 years old.)

If yes, please provide details in the table below:
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 been disqualified from any of the roles included within the Disqualification from Caring for Children (Wales) Regulations 2004?

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 can 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 Voluntary Adoption Agencies
Qualifications gained	Awarding body	Date of award
(dd/mm/yyyy)	
     	     	     	
     	     	     	
     	     	     	
     	     	     	
Continue on a separate sheet if necessary.  Please tick this box if a separate sheet is attached 

Other relevant information including evidence of fitness and competency as prescribed by Regulations 7 & 8 of the Voluntary Adoption Agencies and the Adoption Agencies (Miscellaneous Amendments) Regulations 2003 and the Adoption National Minimum Standards 2003 NMS 14, 15 & 16:

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.  Please start with when you left school and 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 and how this can be verified, if applicable.	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. Social Care Wales, General Social Care Council, NMC, GMC?  If so please give details
Regulatory body	Registration number	Date due to be renewed
(mm/yyyy)	Revalidation date ( if applicable)
(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 a 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 April 1 2018 all applicants will be required to meet the cost of their DBS application.

Please attach completed:

Medical Declaration authorisation			  completed, date: 

Disclosure and Barring Service application form  completed, date: 

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

*Please 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:	      	
Proposed registered manager

The following items must also 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 any)	
(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)		                    					

Now please complete Part 2 of the application form, which enables you to provide evidence that you are familiar with and can meet all of the service specific regulations and National Minimum Standards.

Part 2 application								

SECTION B:  (The responsible individual)

DBS enhanced 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 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)
Financial Information
The Voluntary Adoption Agencies and Adoption Agencies (Miscellaneous Amendments) Regulations 2003

The Registration of Social Care and Independent Health Care (Wales) Regulations 2002
Regulation 20(1) of the Voluntary Adoption Agencies and Adoption Agencies (Miscellaneous Amendments) Regulations 2003 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, and regulation 4 and Schedules1 and 2 to the Registration of Social Care and Independent Health Care (Wales) Regulations 2002 lists the documents and information that must be provided with an application. 

With particular relevance to compliance with regulation 20(1) 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.	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) and the annual accounts 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. {Regulation 20(2)(b)}

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 (Individual Applicant)
Strictly Confidential

To       (Name of Bank)

      (Address of Bank)

I have applied to carry on a Voluntary Adoption 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 Company Number:      

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 2a)
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 a Voluntary Adoption 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 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.