CARE STANDARDS ACT 2000 
APPLICATION TO REGISTER AS THE
MANAGER OF A FOSTERING AGENCY

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

	Name of Applicant:	     	

Organisation Information
Name of the Fostering Agency:
	     	

Full name of the Registered Provider (this will either be an organisation or individual):	     	

Full address of the agency:	     	

Post code:	     	

Tel. no:	     	

Fax no:	     	

Email address:	     	

Proposed Manager - Personal Details
Full name of the proposed Manager:	     	

Maiden name:	     	

Date of birth:
(dd/mm/yyyy)	     	

Place of birth:	     	

Home address:	     	
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

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

Please record here ALL names or aliases by which you have been known by at any time.  Please start by providing your family name and 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  [     ]

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 the first 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 provide comment on your professional skills and competence relevant to managing a fostering agency.  At least one of these referees must have employed you for at least 3 months (if it is impracticable to obtain such a reference, please explain why).
	Name	Address	Tel. No.	
1.	     	     	     	
2.	     	     	     	

If you have ever owned or managed a care setting of any description or been refused or had cancelled a registration of a care setting, please provide details of:

The nature and dates of the registration decision[s]  
     

The name[s] by which the services were known
     

Provide contact details for each Registration Authority involved 
     

The person dealing with regulation of your service
     

Please provide an occupational history covering the period between leaving school and now.  Starting with your first occupation provide the year and month of each change of occupation.  Alternatively you may attach a Professional CV - attached  

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.  Include the name and address of any present employer and the names and addresses of any previous employers together with details of any business, which you carry on or manage or have carried on or managed.  If any of your previous duties involved working with children or vulnerable adults, you should give the full reasons for leaving and explain how this could be verified

Occupation	From
(mm/yyyy)	To
(mm/yyyy)	Name and tel. no. of employer	Reason for leaving	
     	     	     	     	     	
     	     	     	     	     	
     	     	     	     	     	
     	     	     	     	     	
     	     	     	     	     	
     	     	     	     	     	
     	     	     	     	     	
     	     	     	     	     	
Continue on separate sheets as necessary. Attached are [     ] extra sheets

Qualifications and Training
Please provide details of qualifications (including Awarding Body and date of Award) and Professional training
Qualification gained/ professional training	Awarding body	Date
(dd/mm/yyyy)	
     	     	     	
     	     	     	
     	     	     	
     	     	     	
     	     	     	
     	     	     	
     	     	     	
     	     	     	
Continue on separate sheets as necessary.	Attached are [     ] extra sheets

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: 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 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 attach completed:

Medical Declaration authorisation				 completed, date: 

Disclosure and Barring Service application form 	 completed, date: 
Please also complete the fit person's interview questionnaire (see annex 1) and submit with your application.

Declaration
I am applying for registration under the Care Standards Act 2000 and certify that the information given in this application is to the best of my knowledge and belief complete and correct.  If registered, I agree to comply with the registration requirements specified.  I am aware that if it is discovered that I have withheld, omitted or misrepresented any facts in this application, any Registration granted would be liable to cancellation and I may be 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 Manager

(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.