CARE STANDARDS ACT 2000 
APPLICATION TO REGISTER AS A FOSTERING AGENCY - PART 1

Mae’r ffurflen gais hon hefyd ar gael yn Gymraeg / This application form is also available in Welsh

Name of Applicant:  	     	

This application is required to be lodged in person by the proposed Responsible Individual (for an incorporated body) or by the proposed Registered Provider.  They will be asked to present at this time their complete application and their birth certificate and a positive proof of identity such as their passport, driving licence etc.  This is to enable us to complete identity check procedures required by the Disclosure and Barring Service before requesting a disclosure.  We will also require a passport size, or larger, photograph which is a current true likeness; this will be retained as part of your application.  Please bring with you the originals of all certificates of qualification upon which your application is based, which 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.

Name of the Agency:	      	

The address of the Agency:	      	
Post code:	      	

Tel No:	      	

Fax No:	      	

E mail 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 and bilingual services only
Welsh

English

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

For English services only 
If your application is successful and you intend to provide an English medium service, please tick the box if you also require your reports to be published in Welsh?     
	
Are these premises currently registered for any care 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
     

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 manager application is not required. 

Responsible Individual/Registered Person 

Full name of the proposed Responsible Individual (for an incorporated body) or the proposed Registered Provider
     

Job Title:	      	

Role within the organisation:	      	

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

C.C.W./G.S.C.C. No:	      	

Category:	      	

Expiry date:	      	

Current full address (if different from the address of the Agency):	     

	
Post code:	      	

Tel No:	      	

Fax No:	      	

Email 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.	

Record here ALL former names or aliases by which you have been known at any time.  Please start by providing your family name and your given names at time of your birth:  
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 [     ]
References
Please supply the names and addresses of two individuals from whom we may take up references in respect of the Responsible Individual (for an incorporated body) or the proposed Registered Provider. 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. 
	Name	Address	Tel. No.	
1.	     

	     	     	
2.	     

	     	     	
Involvement in any past or present regulated service 
If you have ever owned or managed a care service of any description or been refused or had cancelled a registration of a care service, please provide details of:

The nature and dates of the registration decision[s] 
     

The name[s] by which the services were known
     

	

The contact details for each Registration Authority involved
     

The person(s) dealing with regulation of your service
     

Occupational history
Remember that CIW will use the information you provide on this page and the next page as its starting point in judging whether you meet the National Minimum Standards requirements on qualifications and experience. 

Please provide an occupational history covering the period between leaving school and now.  Beginning 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.  Where previous employment involved working with children or with vulnerable adults, you should state your reasons for leaving and indicate how this could 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.  Please be sure to highlight any experience you consider to be relevant to the present application including any previous work involving caring for people, whether paid or not. 

Occupation	From
(mm/yyyy)	To
(mm/yyyy)	Name and tel. no.
of person to contact	Reason for leaving	
     	     	     	     	     	
     	     	     	     	     	
     	     	     	     	     	
     	     	     	     	     	
     	     	     	     	     	
Continue on separate sheets as necessary.  		Attached are [     ] extra sheets
Training and qualifications
Professional training and
qualifications gained	Awarding body	Date
(dd/mm/yyyy)	
     	     	     	
     	     	     	
     	     	     	
     	     	     	
     	     	     	
     	     	     	
Continue on separate sheets as necessary.  	Attached are [     ] extra sheets.

Staffing
About the staff you employ.
Please note that Regulation 20 of The Fostering Services (Wales) Regulations 2003 prevents a fostering agency from employing a Foster Parent they have approved - or the member of such a person’s household - in a management, social work or other professional (subject to certain exemptions) capacity. In the case of a position which is not a management or a social work position, then such a position is permissible if the work is undertaken occasionally or voluntarily or for less than 5 hours per week. Regulation 52 provides for exceptions to this rule which allow for the continuation of such employment if commenced before 01 April 2003

Please outline your staffing (or proposals):
Description of
position[s] and duties	Level of qualification and experience	Total proposed hours	
     	     	     	
     	     	     	
     	     	     	
     	     	     	
     	     	     	
     	     	     	
     	     	     	

Please attach a list of all staff employed by the agency and their working hours.  Please supply a copy of your on call rota.  Also attach a copy of the job description and person specification you intend to use when recruiting to each type of post.  

Every member of staff will need to be DBS checked prior to commencing work. 

List of all staff employed attached					
On Call rota attached  						
Set of job descriptions and person specifications attached	
Staffing details and records 
Please provide an operational structure chart which sets out the individual roles and accountabilities of each staff position identified

Structure chart attached	

N.B.  You will need to provide, at the time of your fit person interview, a list of the actual staff you intend to employ following 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. 
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:      

Information on submitting a Disclosure and Barring Service application is available from your local CIW office

Have you ever been adjudged bankrupt or 
had your 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 either or both of the above, please supply details.
     

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

Now please complete Part 2 of the application form
This is specific to your application to register a fostering agency and enables you to provide evidence that you can meet all of the relevant National Minimum Standards

Please sign and date this declaration:
Declaration
The information I have provided in parts 1 & 2 of this application form and in any attached documents is, to the best of my knowledge and belief, a true and complete description of the service, which I am applying to be registered to carry on.  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:	     	

Enclosures:
The following items must also accompany parts 1 & 2 of this application for registration, failure to provide all the requested items will result in a delay in processing your application.

•	The applicant’s fully completed Disclosure and Barring Service application form
•	The applicant’s fully completed Personal Health Information enquiry authorisation form 
•	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 annex2/2a)      
•	Part 2 application                                                                                          
   
Please return your completed application form with all requested documentation to a CIW office.

(Annex 1)
Care Inspectorate Wales
Fostering Agency
Financial Information

Regulation 44 of the Fostering Services (Wales) Regulations 2003 requires the registered provider to ensure that the agency is financially viable for the purpose of achieving its aims and objectives. 

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.	For an existing agency, if the applicant is an individual, copies of the last annual accounts of the agency.

3.	Copies of last two annual reports (if any) of any holding company and or 
any other subsidiary of that holding company

4.	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 (Individual Applicant)
Strictly Confidential

To       (Name of Bank)

      (Address of Bank)

I have applied to carry on a Fostering 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 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 Fostering Agency under the Care Standards Act 2000.

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

On behalf of the 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 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 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.