CARE STANDARDS ACT 2000
APPLICATION TO REGISTER AN
ADULT PLACEMENT SCHEME: PART 1
Mae’r ffurflen gais hon hefyd ar gael yn Gymraeg / This application form is also available in Welsh

Contents of Part 1
Please fully complete this document, providing additional information sheets where appropriate. In Section B the appropriate selection should be made by applicants. Section D 4.6 does not apply to Unitary Authorities. 

Section A		General information

Section B1		Individual application
Section B2		Organisation application
Section B3		Unitary Authority application

Section C		Applicant Information

Section D		Details of business and premises

Section E 		Proposed Registered Manager

Section F 		Staffing details

Section G		Other requirements

Name of Scheme:	     	

APPLICATION TO REGISTER AN ADULT PLACEMENT SCHEME: PART 1

Attach

Photo

Here

CIW will require a passport sized recent photograph, 
which is a “true likeness”. This will be kept as part of 
your application.

You are also required to provide your birth certificate and originals of your professional, educational and occupational qualifications. You may make your application in person and bring these documents with you. It will help if you make an appointment with CIW and allow about an hour for this process.  Your documents will be photocopied and returned to you. 

If you prefer to send your application to CIW please enclose your documents which will be photocopied and returned to you securely.
SECTION A	General Information
This section should be completed by all applicants
A 1.1	 
Name and address of proposed Scheme:
	     	
Post code:	     	
Telephone number:	     	
Fax Number: 	     	
Email address:	     	
Proposed date for commencement of operation:	     	

A 1.2	Which of the following do you intend to provide?

Medium/long term placements 			

Short Break or Respite Placement		

A 1.3	Please tick the categories of service user you intend to support 
a)	People with learning disabilities					

b)	People with physical disabilities				

c)	People with sensory loss/impairment				

d)	Other (please give details)	     	

e) 	Age group:		18 to 64  		65+ 	
A 1.4	Please answer either (a) (b) or (c)

a)	Are you making this application as an 	individual provider?			
							Or: 	in partnership with others? 	

If so complete section B1

or 

b)	On behalf of an organisation? 								

If so, complete section B2

or

c)	 On behalf of a Unitary Authority?							

If so, complete section B3

SECTION B1	INDIVIDUAL APPLICATION

If the Scheme is a partnership each partner is required to provide this information.  Please photocopy and complete this section.

B1 	1.1
Please insert full name:	     	

Please state any other names by which you have been known:	     	

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

Address: 
	     

Post code:	     	

Tel no:	     	

Mobile telephone 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 3) and submit with your application.	
B1 	1.2	Do you intend to manage the Scheme? 				Yes   No 
If ‘no,’ please provide details of your proposed registered manager in Section E.
A separate Registered Manager application form (Form 1A) is also required to be completed.

If ‘yes’ you should complete Form 1A yourself, although you will not be required to be registered as the manager.

B2.	ORGANISATION APPLICATION: CHARITY, VOLUNTARY 	ORGANISATION OR REGISTERED COMPANY 

If you are making an application on behalf of an organisation please provide the following details:
B2 	1.1
The full address of the registered or principal office:	     	
Post code:	     	

Company or Charity Registration no.	     	

Tel no:	     	

Mobile no:	     	

Fax 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 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 will        
also require your reports to be published in Welsh?       	
If the organisation is part of a National Charity/Voluntary Organisation or Private Holding Company please provide the name and address of the registered or principal office. Please also provide this information in the form of a flow chart. 

Please tick if details attached	

B2 	1.2	Please provide details of the Director/s, Manager/s and Company Secretary or other similar officers of the organisation below (continue on additional sheets if required)
Name of officer of organisation	Location	Position and role within the Organisation	
     	     	     	
     	     	     	
     	     	     	
     	     	     	
     	     	     	

B2 	1.3	Responsible Individual within the Organisation

Please insert full name of Responsible Individual:	     	

Position held by the Responsible Individual within the Organisation:	     	

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

Address (if different from Scheme 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

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

B2 	1.4	 Are you currently registered as a manager or provider under the Care Standards Act 2000 or have you applied to be a Responsible Individual in respect of any other Scheme or care setting? 									Yes 	No  

 If YES please provide details:
     	

B2 	1.5 Do you or your organisation have a business or financial interest in any other service or Scheme registered under the Care Standards Act 2000 at this time? 	Yes 	No  

 If YES please provide details:
     

	

B3 	UNITARY AUTHORITY APPLICATION
B3 	1.1
Name of Unitary Authority:	     	

Responsible Department of the Authority:	     	

Name and title of Chief Officer:	     	

Main address of the responsible department:	     	
Post code:	     	

Telephone no:	     	

Fax:	     	

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 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?       	

B3 	1.2	Responsible Individual within Unitary Authority

Please insert full name of Responsible Individual:	     	

Position held by the Responsible Individual within the Unitary Authority:	     	

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

Address (if different to the Scheme Address): 
	     	
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.	

B3 	1.3	Are you currently registered under the Care Standards Act 2000? 	Yes   No or 
Have you applied to be a Responsible Individual in respect of any other 
Scheme or care setting? 									Yes   No 

If YES please provide details:
     
	
SECTION C	APPLICANT INFORMATION
This section should be completed by individual applicants, Responsible Individuals within Organisations and Unitary Authorities and where the Scheme is a partnership, by each Partner.  Please photocopy as required.

C 	1.1	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. The 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. 

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

Signature:	     	Date:	     	
C1.2	Occupational History 
Please provide a list of the names and addresses of all your employers covering the period between leaving school and now, starting with your current employer. If you have previously worked with children or vulnerable adults, please explain in full why your employment came to an end. Where there are gaps in employment please give enough detail in your explanation of the circumstances to enable checks to be made if necessary. Include details of any business (es) which you carry on or have at any time previously carried on. 

An up to date Curriculum Vitae can be attached, however this section must also be completed.
Occupation
Including job title and range and scope of responsibility	From

(mm/yy)	To

(mm/yy)	Name, address and telephone number of employer	Reason for leaving	
     	     	     	     	     	
     	     	     	     	     	
     	     	     	     	     	
     	     	     	     	     	
     	     	     	     	     	
     	     	     	     	     	
Continue on separate sheets as necessary
Attached are [     ] extra sheets    CV attached  
C1.3	Educational, Professional or Occupational Qualifications
Please make sure you list all of your relevant qualifications.
Qualifications gained	Awarding Body	Date of award
(dd/mm/yyyy)	
     	     	     	
     	     	     	
     	     	     	
     	     	     	
     	     	     	

Continue on a separate sheet if necessary. 
[     ] separate sheet(s) attached covering period [     ] to [     ]
C1.4	Details of membership or registration with professional or other relevant organisations or bodies, including the Care Council for Wales.
Organisation or professional body	Date:	Type or level of Membership/ Registration	
	Admitted/registered
(dd/mm/yyyy)	Expiry date

(dd/mm/yyyy)		
     	     	     	     	
     	     	     	     	
     	     	     	     	
     	     	     	     	

Continue on a separate sheet if necessary. 

[     ] separate sheet(s) attached covering period [     ] to [     ]
C1.5	Referees
Please supply the names and addresses of two individuals from whom we will take up references. You should give the name of your current and most recent employers (‘Current employer’ means who you are employed by at the time you submit this application). Neither of these may be a relative. Both of these referees must be able to comment on your fitness and professional skills and competence relevant to the operation of the proposed Scheme. At least one of these referees must have employed you for at least three months.  

	Name and job title	Address and telephone number	Capacity in which known to the referee	
1.	     

	     	     	
2.	     

	     	     	
C 	1.6	If any of the following are applicable please provide details below.
•	If you own or have ever owned or managed another registered care establishment or Scheme
•	If you have been refused registration 
•	If you have had your registration cancelled
Owned	Managed	
The nature and dates of the registration decision[s]:	     	     	
The name[s] by which the services were known:	     	     	
Please provide contact details for each registration authority involved:	     	     	
Name of person dealing with regulation of your service: 	     	     	

SECTION D	DETAILS OF BUSINESS AND PREMISES 
D1.1	Please complete the following table and attach to your application copies of the relevant policies or certificates of insurance: 
Insurance	Insurer	Sum Insured	Expiry date
(dd/mm/yyyy)	Copy (tick)	
Employers Liability: 	     	     	     		
Public Liability:	     	     	     		
Professional Indemnity:	     	     	     		

D1.2 	If the application is on behalf of an organisation please provide copies of the last two annual reports. 				Copies attached  

D1.3	If you are intending to run your business from a specified business address, please provide details of the consultations with other Regulators (if applicable).

Date proposals approved by  Environmental Health:
(dd/mm/yyyy)	     

Documentary proof attached		
Date proposals approved by Fire Authority:
(dd/mm/yyyy)	     

Documentary proof attached		
Date planning permission was granted: (dd/mm/yyyy)	     

Documentary proof attached		
Date proposals approved by Building Control:
(dd/mm/yyyy)	     

Documentary proof attached		

D1.4 	Is any person currently registered to provide any other care service from or
in connection with the proposed Scheme premises?			Yes     No  

If Yes describe the nature of the current registration:
     	

Is there any other application pending?					Yes      No  

Please provide the name, address and telephone number of the Registration Authority:	     	

Name of the person dealing with regulation of your service:	     

D1.5	Is any part of the premises used for any other purpose?	Yes       No  

If “Yes” then please state ALL purposes to which any part of the premises is put and details of how access by other occupiers is restricted.
     	
D1.6	Property Ownership (not applicable to Unitary Authorities)
Please provide details of the status of the Scheme’s premises.

Are the premises:

a)	Owned by the Scheme/Organisation?			Yes       No  	
b)	Mortgaged by the Scheme/Organisation?		Yes       No  	
c)	Rented by the Scheme/Organisation?			Yes       No  	
d)	Leased by the Scheme/Organisation?			Yes       No  	

If Yes, to a) or b) please attach details of purchase and mortgage.		Attached 

If Yes, to c) or d) please provide details of terms and conditions including duration and renewal arrangements along with a copy of the lease/tenancy agreement.	Attached 

     
	
D1.7 	Facilities
Please detail the availability of the following at your Scheme premises.

•	Interview/meeting room						Yes 	No 

•	Training room							Yes 	No 

•	Access for disabled staff/service users/visitors		Yes 	No 

•	Security alarm system						Yes 	No 

•	Open during normal office hours				Yes 	No 

•	Arrangements for out of hours emergency contact		Yes 	No 

•	Facilities for storage of records				Yes 	No 

D1.8 	Please provide details of any other facilities available

     

SECTION E	PROPOSED REGISTERED MANAGER

N.B. A separate Registered Manager application will also need to be submitted on Part 1A
E1.1
Please insert full name:
	     	

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

Home address: 

	     	
Post code:	     	

Office Address (if different from Scheme Address):
	     	
Post code:	     	

Tel no:	     	

Mobile no:	     	

Fax no:	     	

E mail address:	     	
E1.2	Management Arrangements
Please describe and provide a flow chart of the managerial relationship between the Responsible Individual and the Registered Manager of the Scheme (if the Responsible Individual is not also the Registered Manager)

     

	

SECTION F	Staff details
F1.1	Please provide the total number of staff who are to be employed.        
F1.2
Name of staff member and date of birth	Qualifications
and experience	Job title
Roles and responsibilities	Full/Part time & hours of work

(FT/PT)	Information as required [by Schedule 3 of the Adult Placement Schemes (Wales) Regulations 2004]
Y/N	
     	     	     	     	     	
     	     	     	     	     	
     	     	     	     	     	
     	     	     	     	     	
     	     	     	     	     	
     	     	     	     	     	
     	     	     	     	     	
     	     	     	     	     	
     	     	     	     	     	
Please provide additional pages if required.   [     ] Extra pages attached 

PLEASE NOTE - As the person carrying on the Scheme you must screen all your staff to the required standard. In order to do this you will need to be registered with the Disclosure and Barring Service. They can be contacted at either Disclosure and Barring Service Registration Team, PO Box 110 Liverpool L69 3JD Registration Information Line 0870 90 90 811 or 
https://www.gov.uk/government/organisations/disclosure-and-barring-service/about 

Alternatively you may register with an “umbrella” body which is DBS registered and make your checks via them. Your national or local Trade Association should be able to give you details of any local arrangements. CIW may at any time require you to demonstrate that you have checked all staff backgrounds to the required standard.  

You should also be aware of the provisions of Part VII of the Care Standards Act 2000 in relation to the list, kept by the Disclosure and Barring Service, of individuals who are considered to be unsuitable to work with vulnerable adults.  It is an offence to knowingly apply for, offer to do, accept or do any work in a care position if included on this Disclosure and Barring list.

A record of DBS certificates should be retained until inspected by CIW. 

F1.3	Please sign the following declaration:
I confirm that I have read and understood the requirements set out in Paragraph 10 of Schedule 2 to the Registration of Social Care and Independent Health Care (Wales) Regulations 2002, and that I understand that it is my responsibility to ensure that the required DBS disclosures are obtained in respect of every person who works or is intended to work at the scheme. I will retain a record of DBS checks and make this available for inspection by the Welsh Government if so required.  
Signed:	     
	Date:	     	

SECTION G	OTHER REQUIREMENTS
Please note: Applications for all individual persons must be supported by a completed medical declaration form DBS and 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 us 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.

You are required to bring the information referred to in the enclosed DBS letter so that we can fulfil the countersigning requirements of the Disclosure and Barring Service. If you make your application in person you may be able to do this at the same time.  

Confirmation of your ID check will need to be submitted along with your completed application. You will need to present your original DBS certificate.

G1.1	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. 

•	Part 1A
•	Part 2

This will be specific to your proposed service category and is a means of providing evidence that you can meet all the relevant Regulations.

•	A fully completed Disclosure and Barring Service application form     Enclosed	
•	A fully completed Medical Declaration authorisation form 	Enclosed	

•	Required financial information  (Not Applicable to Unitary Authorities) 
(see Annex 1 & 2/2a)

Two Years Annual Accounts 	Enclosed	
Business Plan 	Enclosed	
Authorisation for Bankers Reference 	Enclosed	

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

Please bring your completed application form with all requested documentation to your nearest CIW office.
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 Scheme which I / we are applying to be registered to carry on. I / We 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.

In making this application for Registration under the provisions of the Care Standards Act 2000 I agree to comply with the Regulations which apply to the Scheme and the relevant National Minimum Standards.

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:	     	

Signed:	     	Date:	     	

Individual Applicant/s or Responsible Individual on behalf of the organisation

Annex 1
Care Standards Act 2000 – Registration Process
Adult Placement Schemes (Wales) Regulations 2004
Financial Information
Regulation 27 of the Adult Placement Schemes (Wales) Regulations 2004 requires the registered provider to ensure that the scheme is financially viable for the purpose of achieving its aims and objectives. 

As part of the 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.	If the applicant is an incorporated organisation, 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 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 Scheme’s Statement of Purpose along with the letter(s) 

(Annex 2)
Care Inspectorate Wales
Financial Information (Individual Provider)
Strictly Confidential
To       (Name of bank)

      (Address)

I have applied to carry on an Adult Placement Scheme under the Care Standards Act 2000.

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

I therefore authorise you to provide CIW with the following information:

•	An opinion as to my financial standing.
•	A statement as to whether the responsible person (that is me as the applicant) has been adjudged bankrupt, or sequestration of his/her estate has been ordered or he or she has made a composition or arrangement with or granted a trust deed for, his or her creditors.
•	A statement as to my ability to ensure the financial viability of the establishment for the purpose of achieving the aims and objectives of the establishment as set out in its Statement of Purpose.

Signed:      

Print Name:      

Date:      

Name of Individual or Company:      

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 (Incorporated Organisation)
Strictly Confidential

To       (Name of Bank)

      (Bank Address)

(Applicant: Insert full name of incorporated organisation here)      
has applied to carry on an Adult Placement Scheme under the Care Standards Act 2000.

Care Inspectorate Wales (CIW) 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 CIW with an opinion as to the organisation’s financial standing.

Signed:      

Print Name:      

Date:      

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.