Care and Social Services Inspectorate Wales

Application for an Individual to register as a Provider or Provider/Manager in respect of a Care Home (Younger Adult) - Part 1

NB - For your application to become a registered manager to be considered by CSSIW you are required to be registered as a Manager with the Care Council for Wales.

Note

  1. Where the home is to be carried on by an organisation (a body corporate) please contact Care and Social Services Inspectorate who will provide you with the correct application form.
  2. This application is required to be lodged in person at which time you will be asked to present your complete application AND your birth certificate and your passport. This is to enable us to complete identity check procedures required by the Disclosure and Barring Service prior to requesting disclosure of information. We will also require a passport sized photograph which is a current true likeness which will be retained as part of your application. Please bring with you originals of your technical and professional qualifications, 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 proposed Home
Address of the proposed Home
Post code
Tel. no
Fax no
Email address

Please tick preferred language of written communication:

English Welsh Both

Page 1 of 26

Care Home Younger Application Individual Part 1 09/2013

Are these premises currently registered for any care purpose? Yes No

If ‘Yes’, describe the nature of the current registration.

Name of the person dealing with the regulation of your service.

Please provide the date on which the establishment was established or is proposed to be established / dd/mm/yyyy

Is it proposed to provide nursing at the care home? Yes No

Specify number of proposed service users in each category.

Number / Gender / Category / Age / Category code
For office use
Select:MaleFemale
Select:MaleFemale
Select:MaleFemale
Select:MaleFemale
Select:MaleFemale
Select:MaleFemale
Select:MaleFemale
Select:MaleFemale
Select:MaleFemale
Your current full address (if different from the address of the proposed home)
Post code
Tel no
Fax no
Email address
Your full name
Date of birth / dd/mm/yyyy
Place of birth

If you are a registered nurse:

NMC Registration No
Part/s of the register
Expiry date / dd/mm/yyyy

If you are a registered medical practitioner:

GMC Registration No
Specialist Register
Re-validation date / dd/mm/yyyy
Renewal Date / dd/mm/yyyy

Care Council for Wales details

Please enter your registration number
Please enter the registration date / dd/mm/yyyy
Please enter the expiry date / dd/mm/yyyy
Do you have a current DBS certificate countersigned by the Welsh Ministers (CSSIW) that is registered with the DBS Update Service? / Yes No

N.B. Please provide us with your family name and given names at the time of your birth and ALL former names and aliases you have been known by at any time: -

Known as / From
(mm/yyyy) / To
(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. 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 your proposed service. At least one of these referees must have employed you for at least three months. (If it is impracticable to obtain such a reference, please explain why).

Name and Title / Full Address / Tel. No.
1
2

If you have ever carried on or managed an establishment or agency or have been refused or had cancelled a registration of an establishment or agency please provide details below:

An establishment means a children’s home, a care home for adults, an independent hospital, an independent clinic, or a residential family centre.

An agency means a domiciliary care agency, a nurses agency, a fostering agency or a voluntary adoption agency.

The name[s] by which the services were known

The nature and dates of the registration decision[s]. Date

dd/mm/yyyy
dd/mm/yyyy
dd/mm/yyyy
dd/mm/yyyy

Contact details for each Registration Authority involved.

Have you ever carried on or managed any other form of care service registered under the Care Standards Act 2000, Registered Homes Act 1984, Children Act 1989 or Part 2 of the Children and Families (Wales) Measure 2010? Please provide details

Do you have, or have you had, a business or financial interest in any other registered service? Please provide details.

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 provide an occupational history covering the period between leaving school and now. Provide the year and month of each change of occupation.

Professional CV attached

Make sure you list all of your qualifications. 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. Starting with your current employer include the names and addresses of all your employers since leaving school. Include details of any business(es) which you carry on or have at any time previously carried on. If you have previously worked in a position where your duties involved working with children or vulnerable adults, please explain in full why your employment came to an end.

Occupation / From
(mm/yyyy) / To
(mm/yyyy) / Name & tel. no. of employer / Reason for leaving

Continue on separate sheets as necessary Attached are [] extra sheets

Professional/Technical Qualifications

Qualification gained / Awarding body and date of award / Date of Award
(dd/mm/yyyy)

Continue on separate sheets as necessary Attached are [] extra sheets

Please include in your application the:

Insurance certificate in respect of risks set out in Schedule 2 para.9 of the Registration of Social Care and Independent Health Care (Wales) Regulations 2002.

Effective from date: dd/mm/yyyy

About the premises to be registered as the Home:

Are these existing premises? Yes No

If ‘Yes’ has the building required conversion or extension? Yes No

Alternatively are the premises purpose built? Yes No

Please tick applicable

Will you: own them? lease them? rent them?

If leasing or renting how much notice to quit would have to be given?

Please attach proof of ownership or a copy of the tenancy agreement/lease

attached

Do you intend to register any rooms above

the ground floor? Yes No

If ‘Yes’, be sure to mark these in the tables overleaf using G = Ground Floor, 1 = First floor, 2 = Second floor etc. Also, ensure that you fill in the section headed “passenger lifts”.

Page 1 of 26

Care Home Younger Application Individual Part 1 09/2013

For each room you intend to be registered fill in the following details using metres and centimetres where measurements are required.

Main communal area

Storey / Size / x
G1st2nd3rd4thLwr G / Intended for use by wheelchair users? / Minimum door width [800mm] Yes No
Type of floor covering
Type of wall finish
(painted, papered, artex etc)
Lighting arrangements / Minimum light level Lux
Ventilation arrangements
Type of heating and safety specification
Other facilities:
e.g.
Loop system, TV, video, radio, ‘phone points, call points, furniture, aids and adaptations
Describe ease of access to lifts, toilets and other facilities from this area

Additional communal area

Storey / Size / x
G1st2nd3rd4thLwr G / Intended for use by wheelchair users? / Minimum door width [800mm] Yes No
Type of floor covering
Type of wall finish
(painted, papered, artex etc)
Lighting arrangements / Minimum light level Lux
Ventilation arrangements
Type of heating and safety specification
Other facilities:
e.g.
Loop system, TV, video radio, ‘phone points, call points, furniture, aids and adaptations
Describe ease of access to lifts, toilets and other facilities from this area

Visitors’ room

Storey / Size / x
G1st2nd3rd4thLwr G / Intended for use by wheelchair users? / Minimum door width [800mm] Yes No
Type of floor covering
Type of wall finish
(painted, papered, artex etc)
Lighting arrangements / Minimum light level Lux
Ventilation arrangements
Type of heating and safety specification
Other facilities
e.g.
Loop system, TV, video, radio, ‘phone points, call points, furniture, aids and adaptations
Describe ease of access to lifts, toilets and other facilities from this area

Dining Room[s]

[Please copy before use if you plan to have more than one dining room]

Storey / Size / x
G1st2nd3rd4thLwr G / Intended for use by wheelchair users? / Minimum door width [800mm] Yes No
Type of floor covering
Seating arrangements
(e.g. number of tables, number at each table, choice of social groupings, arrangements for wheelchair users)
Aids and adaptations proposed
Service arrangements
e.g. Plated meals?
Self service at table?
Staff service at table?
Arrangements for ensuring choice and preferences
Type of wall finish
(painted, papered, artex etc)
Lighting arrangements / Minimum light level Lux
Ventilation arrangements
Type of heating and safety specification
Other facilities
e.g. Loop system, TV, video, radio, phone points, call points, furniture, aids and adaptations
Describe ease of access to lifts, toilets and other facilities from this area

Circulation area

Storey / Size / x
G1st2nd3rd4thLwr G / Intended for use by wheelchair users? / Minimum door width [800mm] Yes No
Type of floor covering
Type of wall finish
(painted, papered, artex etc)
Lighting arrangements / Minimum light level Lux
Ventilation arrangements
Type of heating and safety specification
Describe access to lifts, changes of levels. Loop system, phone points, call system points etc.
Describe ease of access to toilets and other facilities from this area. Include aids and adaptations

Circulation area

Storey / Size / x
G1st2nd3rd4thLwr G / Intended for use by wheelchair users? / Minimum door width [800mm] Yes No
Type of floor covering
Type of wall finish
(painted, papered, artex etc)
Lighting arrangements / Minimum light level Lux
Ventilation arrangements
Type of heating and safety specification
Describe
access to lifts,
changes of levels.
Loop system, phone points, call system points & etc.
Describe ease of access to toilets and other facilities from this area. Include aids and adaptations

Circulation area

Storey / Size / x
G1st2nd3rd4thLwr G / Intended for use by wheelchair users? / Minimum door width [800mm] Yes No
Type of floor covering
Type of wall finish
(painted, papered, artex etc)
Lighting arrangements / Minimum light level Lux
Ventilation arrangements
Type of heating and safety specification
Describe
access to lifts,
changes of levels.
Loop system, phone points, call system points & etc.
Describe ease of access to toilets and other facilities from this area. Include any aids and adaptations

Lifts

Shaft Lift / Is a shaft lift provided? / Yes No
How many persons will it accommodate?
Which floors will it serve?
Is there a maintenance contract in place? / Yes No
Please provide a copy of maintenance contract / Attached
Please provide a copy of the commissioning engineers certificate / Attached
Stair Lift / Is a stair lift provided? / Yes No
Which floors will it serve?
Is there a maintenance contract in place? / Yes No
Please provide a copy of maintenance contract / Attached
Please provide a copy of the commissioning engineers certificate / Attached
What in millimetres at the narrowest point of the stairway is the clear distance available to pass the stair lift when it is in the folded position / [] mm
Other / If any other lifting devices are to be installed, please describe

Security arrangements

Describe how the perimeters of the building are secured? / Windows
External doors
Interconnecting doors between different service areas
Doors between general areas and identified hazards [describe please]
Arrangements for restricting access from adjacent premises or, when the premises form part of a building, from other parts of the building.
Internal:
Security
Windows / Are restrictors fitted to all windows above the ground floor level? / Yes No

Continue on separate sheet if necessary additional sheets attached

Proposed number of bedrooms

Single Double

Please copy as necessary prior to use and use one copy of this form for each room

Storey / Bedroom
Number / Size x
G1st2nd3rd4thLwr G / Furniture, floor coverings etc. meet the requirements for the minimum range of provisions set out in the National Minimum Standards for the proposed type of service / Yes No
Required door lock specification / Yes No
Is this room intended for wheelchair use? / Yes No
If ‘yes’ does it comply with minimum door width? / Yes No
Wash hand basin adapted / Yes No
Electricity outlets raised / Yes No
All controls at correct height / Yes No
In double occupancy rooms, are separate washing facilities provided and screened? / Yes No
Does this room have en-suite toilet facilities?
Describe available moving and handling aids /hoists / Yes No
Fully wheelchair compliant? Yes No
Does this room have en-suite bathing facilities?
Describe available moving and handling aids /hoists / Yes No
Fully wheelchair compliant? Yes No
Describe call facilities
Type of floor covering
Type of wall finish
(painted, papered, artex etc)
Do residents have a choice of decor? / Describe arrangements please
Lighting arrangements / Minimum light level Lux
Ventilation arrangements
Type of heating and safety specification
Other facilities
loop system, TV, video, radio, phone points, electricity sockets etc. Include any equipment and adaptations

Kitchen

Storey / Size / x
G1st2nd3rd4thLwr G / List equipment and facilities:
List food-related storage facilities
G1st2nd3rd4thLwr G / Size x
Describe use:
Size x
Describe use:
Size x
Describe use
Size x
Describe use:
Does the kitchen cater for any other service or group? / Yes No
If ‘Yes’, describe nature of service, period[s] of operation and numbers of meals or volume of service provided:

Laundry facilities