CARE STANDARDS ACT 2000 
APPLICATION TO REGISTER AS THE MANAGER
OF AN ADULT PLACEMENT SCHEME - PART 1A

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

Please fully complete this document, providing additional information sheets where appropriate.

Name of Scheme:	     	

Name of Applicant:	     	

Manager Application Form

Attach

Photo

Here

(This section is for information on, and is to be completed by, any proposed manager)

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 send your application in by post and use the Post Office Document Certification Service to provide confirmation of these documents – we will need to see the originals at some point in the registration process. Alternatively you can submit 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. 
SECTION A – GENERAL INFORMATION

Name of (proposed) Adult Placement Scheme:	     	

Full name of the (proposed) Registered Provider: 
(This will either be an organisation or an individual)	     	
Full address of the (proposed) scheme: 	     	
Post code:	     	

Tel no:	     	
Mobile no:	     	
Fax no:	     	
E mail address:	     	

Please specify the address of your head office: 

Full address: 	     	
Post code:	     	
Tel no:	     	
Mobile no:	     	
Fax no:	     	
E mail address:	     	

Name of the Responsible Individual:	     	

A 1.1 Please tick the categories of Service User the scheme is intended to support 

a)	People with learning disabilities			

b)	People with physical disabilities			

c)	People with sensory loss/impairment			

d)	Other (please give details)

     

Age group		18 – 64			65+	

A 1.2 How many adult placement settings are you proposing to manage? [     ]	

SECTION B – DETAILS OF APPLICANT
Please insert title and full name:	     	

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

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

	
*Please complete the fit person's interview questionnaire (see annex 1) and submit with your application.	

Please record here ALL names or aliases by which you have been known 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 [     ]

If any of the following are applicable, please provide the details below:

•	If you own or have ever owned or managed another care establishment or agency
•	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:	     	     	

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. In addition 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 currently 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
including job title	From

(dd/mm/yyyy)	To

(dd/mm/yyyy)	Name, address and telephone number of employer	Reason for leaving	
     	     	     	     	     	
     	     	     	     	     	
     	     	     	     	     	
     	     	     	     	     	
     	     	     	     	     	
     	     	     	     	     	
Continue on separate sheets as necessary.		Attached are [     ] extra sheets
Relevant Educational, Professional or Occupational Qualifications
Qualification(s) gained	Awarding body	Date of award
(dd/mm/yyyy)	
     	     	     	
     	     	     	
     	     	     	
     	     	     	
     	     	     	
     	     	     	
Continue on a separate sheet if necessary. 		Attached [     ] extra sheets.
Details of membership or registration with 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	
     	     	     	     	
     	     	     	     	
     	     	     	     	
     	     	     	     	
     	     	     	     	
     	     	     	     	
Continue on a separate sheet if necessary. 		Attached [     ] extra sheets.
Training/courses relevant to this application 
Dates
(from and to)	Title	Is this course accredited?
Y/N	Training provider	
     	     	     	     	
     	     	     	     	
     	     	     	     	
     	     	     	     	
     	     	     	     	
     	     	     	     	
Continue on a separate sheet if necessary.	Attached [     ] extra sheets.
Relevant work experience
Please give details of the relevant experience and ability you have which will enable you to manage the Adult Placement Scheme

Management of this specific type of service
     

	

Experience of work with proposed service user group
     

	

Management and support of adult placement carers
     

	

Day-to-day administration
     

	
Continue on a separate sheet if necessary.		 Attached [     ] extra sheets.
SECTION C – REFEREES
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 an 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.	     

	     	     	

SECTION D – DISCLOSURE AND DECLARATIONS
Declaration of Interests
Do you have any current financial or managerial interests in 
any other establishment/agency?						Yes 	No 
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 or cautions 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 form 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 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 pay the cost of their DBS application.

Completed DBS application form submitted?   				Yes    	No 

Do you currently subscribe to the DBS Update Service?		Yes  	No 

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. 

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 establishment/agency and the relevant National Minimum Standards.

I confirm that I will be responsible for the day-to-day operational management of the agency.

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:	     	

SECTION E - OTHER REQUIREMENTS

E 1.1	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. 

A fully completed Disclosure and Barring Service application form
Enclosed 	

A fully completed Medical Declaration authorisation form
Enclosed	
Please also complete the fit person's interview questionnaire (see annex 1) and submit with your application.

You may submit your application by post and use the Post Office Document Certification Service to provide confirmation of any supporting documents – we will need to see the originals at some point in the registration process. Alternatively you can submit 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. 

 

(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.