CARE STANDARDS ACT 2000
APPLICATION TO REGISTER AN ADULT PLACEMENT SCHEME: Part 2
Mae’r ffurflen gais hon hefyd ar gael yn Gymraeg / This application form is also available in Welsh

Name of Scheme:
	     	

Name of Applicant:
	     	

Date:
	     	

Care Inspectorate Wales
Structure and approach of Part 2 of the application form
This section of your application is your primary opportunity to demonstrate that you have understood the principles and requirements in the Regulations and National Minimum Standards for Adult Placement Schemes and that the arrangements and resources you are proposing to employ in your Adult Placement Scheme will result in those Regulations and Standards being consistently met or exceeded.

Whilst broad in scope, the Regulations and Standards acknowledge the unique and complex needs of individuals and the additional specific knowledge and skills required in order to deliver a service that is tailored to the needs of each person. They will ensure that placements provide good quality care, meet the needs of people who live in placements and are otherwise carried on in accordance with regulatory requirements. 

The Standards focus on achievable outcomes for service users and are grouped under the following key topics:

•	Section 1: Choice of Placement (Standards 1-5)
•	Section 2: Individual Needs and Choices (Standards 6-8)
•	Section 3: Lifestyles (Standards 9-15)
•	Section 4: Personal Support (Standards 16-19)
•	Section 5: Role and Conduct of Adult Placement Carers (Standards 20-24)
•	Section 6: Concerns, Complaints and Protection (Standards 25-26)
•	Section 7: Environment (Standards 27-29)

These Standards establish the minimum required; i.e. they state a standard of service provision below which an adult placement scheme must not fall. The applicant should note however that although the Standards will be used as a measure of the organisation’s performance it is primarily in relation to the Regulations that any enforcement action will be taken.

Each of the Standards is preceded by a statement of the overall outcome that is intended to be secured for service users. The Standards have been designed to achieve the required outcomes and to be enforceable through relevant regulations.

When completing your application you must demonstrate that you will run the proposed service in every respect to the requirements of the Regulations and the Standards. Appendix A of the Notes for Applicants document provides examples of possible evidence that you may wish to submit as part of your application. This is not meant to be a prescriptive list. The self-assessment documentation in Part 2 of the application to register an Adult Placement Scheme follows the Standards and is set out on each page in the following way:

•	Title and number of the Standard
•	The overall outcome of the Standard
•	Reference to the Regulations against which your application will be measured
•	Space for you to list the evidence you have attached to Part 2 of the application
•	Space for the inspector assessing your application to make notes

It will be necessary for you to refer to the full set of Adult Placement Scheme Regulations and National Minimum Standards when conducting the self-assessment activities. The submission of the evidence should enable you to demonstrate that you have either met or exceeded the expectation of the Standard. If you are submitting a piece of evidence which covers more than one Standard, or part of a Standard, please identify all aspects it is intended to cover, by including it in the list of evidence for each relevant Standard. You do not need to submit the same piece of evidence more than once.

The Standards are based on certain fundamental principles. In applying the Regulations and these Standards, regulators will look for evidence that the day-to-day operation of adult placement schemes reflects the following key values:

•	Autonomy – promotion of individual autonomy, self-determination and choice, and control over decision-making.
•	Attainment – recognition of individual ability and potential for personal development, and of the social and environmental barriers to achieving potential.
•	Citizenship – maintenance of entitlements associated with citizenship under the law, including protection from discrimination, harassment and degrading or inhuman treatment.
•	Individuality – respect for individuality, privacy and dignity, and maintenance of self-esteem in all situations.
•	Diversity – respect for age, ethnic and cultural diversity, and promotion of equal opportunity.
•	Well-being – promotion of physical, emotional and spiritual well-being.
•	Inclusion – promotion of social and economic inclusion and participation in community life.

As already emphasised in the Notes for Applicants document, a well thought out and clearly worded Statement of Purpose for the proposed agency is an essential basis for working through the practical details of all aspects of the agency’s operation.  It will also be the starting point for CIW`s evaluation of your proposals under each Standard.
 
To help us process your application as efficiently as possible, will you please list and mark each document provided by reference to the Standard.  Although not a requirement, CIW would find it helpful if you would submit your documents in lever arch files with an index of sections and contents.

Finally, it is essential that in preparing your evidence you read the Regulations and the Standards together. CIW believe that it is essential that you base your proposals on a consideration of all the legal requirements. 

We look forward to receiving your completed proposals.

NATIONAL MINIMUM STANDARDS FOR ADULT PLACEMENT SCHEMES
STANDARD 1: INFORMATION
OUTCOME
Prospective service users have the information they need to make an informed choice about where to live.	

See the following Regulations: 
	4 Statement of Purpose 
	5 Adult Placement Scheme Guide 
	6 Review of Statement of Purpose	
Please list evidence supporting your application
     

	

	

NATIONAL MINIMUM STANDARDS FOR ADULT PLACEMENT SCHEMES
STANDARD 2: NEEDS ASSESSMENT
OUTCOME
Prospective service users’ individual aspirations and needs are assessed.	

See the following Regulations: 
	18 Adults’ plans	
Please list evidence supporting your application
     

	
NATIONAL MINIMUM STANDARDS FOR ADULT PLACEMENT SCHEMES
STANDARD 3: MATCHING AND PLACEMENT
OUTCOME
Prospective service users know that the placement they choose will meet their needs and aspirations.	

See the following Regulations: 
	13 Making of placements and Adult Placement agreements 
	16 Fitness of Adult Placement Carers 
	17 Training
	18 Adults’ Plans	
Please list evidence supporting your application
     

	

NATIONAL MINIMUM STANDARDS FOR ADULT PLACEMENT SCHEMES
STANDARD 4: TRIAL VISITS
OUTCOME
Potential service users have an opportunity to visit and ‘test drive’ the placement.	

See the following Regulations: 
	13 Making of placements and Adult Placement agreements
	19 General conduct of Adult Placement Scheme 
	20 Records	
Please list evidence supporting your application
     

	

NATIONAL MINIMUM STANDARDS FOR ADULT PLACEMENT SCHEMES
STANDARD 5: ADULT PLACEMENT AGREEMENT
OUTCOME
Each service user has an individual written Placement Agreement which reflects the service user’s assessed needs and personal goals.	

See the following Regulations: 
	13 Making of placements and Adult Placement agreements
	14 Monitoring and review of placements
	20 Records	
Please list evidence supporting your application
     

	

NATIONAL MINIMUM STANDARDS FOR ADULT PLACEMENT SCHEMES
STANDARD 6: PARTICIPATION AND DECISION-MAKING
OUTCOME
Service users participate in family life at the placement and make decisions about their lives with assistance as needed.	

See the following Regulations: 
	  5 Adult Placement Scheme guide
	13 Making of placements and Adult Placement agreements
	16 Fitness of Adult Placement carers
	19 General conduct of Adult Placement Scheme
	21Complaints  	
Please list evidence supporting your application
     

	

NATIONAL MINIMUM STANDARDS FOR ADULT PLACEMENT SCHEMES
STANDARD 7: RISK TAKING
OUTCOME
Service users are supported to take risks as part of an independent lifestyle.	

See the following Regulations: 
	17 Adult Placement Carers – Training 
	19 General conduct of Adult Placement Scheme	
Please list evidence supporting your application
     

	
NATIONAL MINIMUM STANDARDS FOR ADULT PLACEMENT SCHEMES
STANDARD 8: CONFIDENTIALITY
OUTCOME
Service users know that information about them is handled appropriately and that their confidences are kept.	

See the following Regulations: 
	  4 Statement of Purpose
	14 Monitoring and review of placements 
	17 Adult Placement carers – training
	19 General conduct of Adult Placement Scheme
	20 Records
	26 Staff handbook and code of conduct	
Please list evidence supporting your application
     

	

NATIONAL MINIMUM STANDARDS FOR ADULT PLACEMENT SCHEMES
STANDARD 9: PERSONAL DEVELOPMENT
OUTCOME
Service users have opportunities for personal development.	

See the following Regulations: 
	11 Registered person – general requirements and training 
	13 Making of placements and Adult Placement agreements 
	18 Adults’ plans 
	19 General conduct of the Adult Placement Scheme	
Please list evidence supporting your application
     

	

NATIONAL MINIMUM STANDARDS FOR ADULT PLACEMENT SCHEMES
STANDARD 10: EDUCATION AND EMPLOYMENT
OUTCOME
Service users are able to engage in education, training and employment opportunities which help them to explore their full potential.	

See the following Regulations: 
	13 Making of placements and Adult Placement agreements
	18 Adults’ plans
	19 General conduct of Adult Placement Scheme	
Please list evidence supporting your application
     

	

NATIONAL MINIMUM STANDARDS FOR ADULT PLACEMENT SCHEMES
STANDARD 11: COMMUNITY LINKS AND SOCIAL INCLUSION
OUTCOME
Service users are part of the local community.	

See the following Regulations: 
	  4 Statement of Purpose
	13 Making of placements and Adult Placement agreements	
Please list evidence supporting your application
     

	

NATIONAL MINIMUM STANDARDS FOR ADULT PLACEMENT SCHEMES
STANDARD 12: LEISURE
OUTCOME
Service users engage in a range of leisure activities, which reflect their individual choices.	

See the following Regulations: 
	  4 Statement of Purpose
	13 Making of placements and Adult Placement agreements
	18 Adults’ plans
	19 General conduct of Adult Placement Scheme	
Please list evidence supporting your application
     

	
NATIONAL MINIMUM STANDARDS FOR ADULT PLACEMENT SCHEMES
STANDARD 13: RELATIONSHIPS
OUTCOME
Service users are helped to maintain their existing personal family and sexual relationships and to develop new ones as appropriate.	

See the following Regulations: 
	  4 Statement of Purpose
	13 Making of placements and Adult Placement agreements
	18 Adults’ plans
	19 General conduct of the Adult Placement Scheme	
Please list evidence supporting your application
     

	

NATIONAL MINIMUM STANDARDS FOR ADULT PLACEMENT SCHEMES
STANDARD 14: DAILY ROUTINES
OUTCOME
Service users live ordinary domestic lives and their rights are respected and responsibilities recognised.	

See the following Regulations: 
	13 Making of placements and Adult Placement agreements
	18 Adults’ plan
	19 General conduct of Adult Placement Scheme
	22 Visits by registered provider
	20 Records
	27 Financial position	
Please list evidence supporting your application
     

	

NATIONAL MINIMUM STANDARDS FOR ADULT PLACEMENT SCHEMES
STANDARD 15: MEALS
OUTCOME
Service users are offered a healthy diet and enjoy their meals and mealtimes.	

See the following Regulations: 
	13 Making of placements and Adult Placement agreements
	18 Adults’ plan
	19 General conduct of Adult Placement Scheme
	20 Records	
Please list evidence supporting your application
     

	

NATIONAL MINIMUM STANDARDS FOR ADULT PLACEMENT SCHEMES
STANDARD 16: PERSONAL CARE
OUTCOME
Service users receive personal support in the way which they prefer and require.	

See the following Regulations:
	13 Making of placements and Adult Placement agreements
	14 Monitoring and review of placements
	18 Adults’ plans
	19 General conduct of Adult Placement Scheme
	22 Review of quality of scheme’s operation	
Please list evidence supporting your application
     

	
NATIONAL MINIMUM STANDARDS FOR ADULT PLACEMENT SCHEMES
STANDARD 17: HEALTH CARE
OUTCOME
Service users’ physical and emotional health needs are met.	

See the following Regulations:
	13 Making of placements and Adult Placement agreements
	14 Monitoring and review of placements
	18 Adults’ plans
	19 General conduct of Adult Placement Schemes
	22 Review of quality of scheme’s operation	
Please list evidence supporting your application
     

	

NATIONAL MINIMUM STANDARDS FOR ADULT PLACEMENT SCHEMES
STANDARD 18: MEDICATION
OUTCOME
Service users retain, administer and control their own medication.	

See the following Regulations:
	17 Adult placement carers - training
	19 General conduct of Adult Placement Scheme
	20 Records	
Please list evidence supporting your application
     

	

NATIONAL MINIMUM STANDARDS FOR ADULT PLACEMENT SCHEMES
STANDARD 19: AGEING AND DEATH
OUTCOME
The ageing, illness and death of a service user is handled with respect and as the individual would wish.	

See the following Regulations:
	17 Adult Placement carers - training
	18 Adults’ plans
	19 General conduct of the Adult Placement Scheme	
Please list evidence supporting your application
     

	

NATIONAL MINIMUM STANDARDS FOR ADULT PLACEMENT SCHEMES
STANDARD 20: ROLES AND RESPONSIBILITIES
OUTCOME
Service users benefit from clarity of Adult Placement Carer roles and responsibilities.	

See the following Regulations:
	  4 Statement of Purpose
	13 Making of placements and Adult Placement agreements
	19 General conduct of Adult Placement Scheme 
	20 Records
	23 Visits by registered provider
	26 Staff handbook and code of conduct
	27 Financial position
	28 Notification of incidents	
Please list evidence supporting your application
     

	

NATIONAL MINIMUM STANDARDS FOR ADULT PLACEMENT SCHEMES
STANDARD 21: QUALITIES AND QUALIFICATIONS
OUTCOME
Service users are supported by skilled, experienced and competent Adult Placement Carers.	

See the following Regulations:
	16 Fitness of Adult Placement carers
	17 Adult Placement carers - training
	22 Review of quality of scheme’s operation
	26 Staff handbook and code of conduct	
Please list evidence supporting your application
     

	

NATIONAL MINIMUM STANDARDS FOR ADULT PLACEMENT SCHEMES
STANDARD 22: SUPERVISION AND SUPPORT
OUTCOME
Service users benefit from well-supported and supervised Adult Placement Carers.	

See the following Regulations:
	6 Review of Statement of Purpose and Adult Placement Scheme 	 	guide 
	14 Monitoring and review of placements 
	23 Visits by registered provider 
	25 Staff and their training	
Please list evidence supporting your application
     

	

NATIONAL MINIMUM STANDARDS FOR ADULT PLACEMENT SCHEMES
STANDARD 23: RECORDS
OUTCOME
Service users’ rights and best interests are safeguarded by the registered provider’s and Adult Placement Carer’s record keeping policies and procedures.	

See the following Regulations:
	20 Records
	26 Staff handbook and code of conduct	
Please list evidence supporting your application
     

	

NATIONAL MINIMUM STANDARDS FOR ADULT PLACEMENT SCHEMES
STANDARD 24: SAFE WORKING PRACTICES
OUTCOME
The health, safety and welfare of service users are promoted and protected.	

See the following Regulations:
	13 Making of placements and Adult Placement agreements 
	19 General conduct of Adult Placement Scheme
	20 Records	
Please list evidence supporting your application
     

	

NATIONAL MINIMUM STANDARDS FOR ADULT PLACEMENT SCHEMES
STANDARD 25: CONCERNS AND COMPLAINTS
OUTCOME
Service users’ views are listened to and acted on.	

See the following Regulations:
	14 Monitoring and review of placements 
	19 General conduct of Adult Placement Scheme
	21 Complaints	
Please list evidence supporting your application
     

	

NATIONAL MINIMUM STANDARDS FOR ADULT PLACEMENT SCHEMES
STANDARD 26: PROTECTION FROM ABUSE
OUTCOME
Service users are protected from abuse, neglect and self-harm.	

See the following Regulations:
	13 Making of placements and Adult Placement agreements
	19 General conduct of Adult Placement Schemes
	24 Fitness of workers
	25 Staff and their training
	28 Notification of incidents		
Please list evidence supporting your application
     

	

NATIONAL MINIMUM STANDARDS FOR ADULT PLACEMENT SCHEMES
STANDARD 27: PREMISES
OUTCOME
Service users live in a homely, comfortable and safe environment.	

See the following Regulations:
	13 Making of placements and Adult Placement agreements
	22 Review of quality of scheme’s operation	
Please list evidence supporting your application
     

	

USER FOCUSED SERVICES 
NATIONAL MINIMUM STANDARDS FOR ADULT PLACEMENT SCHEMES
STANDARD 28: INDIVIDUAL ROOMS
OUTCOME
Service users’ own rooms suit their needs and lifestyles and promote their independence.	

See the following Regulations:
	13 Making of placements and Adult Placement agreements
	22 Review of quality of scheme’s operation	
Please list evidence supporting your application
     

	

NATIONAL MINIMUM STANDARDS FOR ADULT PLACEMENT SCHEMES
STANDARD 29: ADAPTATIONS AND EQUIPMENT
OUTCOME
Service users have the specialist equipment they require to maximise their independence.	

See the following Regulations:
	13 Making of placements and Adult Placement agreements
	22 Review of quality of scheme’s operation	
Please list evidence supporting your application
•	See standard 27 and 28.
     

	

Declaration and Signature
Declaration
The information we/I have provided in this application form and in any attached documents is, to the best of our/my knowledge and belief, true and complete.  We/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 us/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.

Signature of person(s) completing this form

1) Name:	     	
Status:	     	

2) Name:	     	
Status: