Application Form New Providers
Registration under the Health and Social Care Act 2008
(as amended)
Application for registration as a new provider of regulated activities
For all applicants
April 2015
‘How to fill in the application form for registration……….’
If you roll your cursor over any (See Guidance) and left click your mouse it will take you to the guidance for that section. When you are completing your application form on line it is recommended that you have the guidance open for each section when completing it.
The guidance should be considered as an important part of the application process and it will be presumed that the applicant has read and followed it on submitting the application.
Contents / Page
Statement on Data Protection Act 1998 / 3
Statement of purpose / 4
Section 1: Organisation / 5
Section 2: Individual application / 16
Section 3: Partnership application / 25
To be completed by all applicants
Section 4: Financial information / 43
Section 5: The regulated activities you want to provide / 46
Section 6: The location(s) you want to provide regulated activities at or from / 47
Section 7: How you will provide your service / 60
Section 8: Checklist of information that must be available to CQC on request / 63
Section 9: Partnerships only - Agreement to conditions of registration / 64
Section 10: Supporting notes / 65
Section 11: Application declaration / 66
How to submit this application / 68
Please “click” on the above title to go to that section
20150526 900026 2.0 Application for registration as a new provider of regulated activities1
Statement on the Data Protection Act 1998
You must sign the statement below. If you don’t, we will return your application.
The person who signs below must be one of the following: -
Organisation: Any individual authorised to do so by the Organisation
Partnership: Must be a member of the partnership identified in section 3.4
Individual: Must be the individual
If you are submitting this form electronically we will accept a typed-in name as your signature.
I/We understand that CQC will use the information provided on this form (including personal data), and other relevant information that CQC obtains or receives, for the purposes of performing its regulatory functions.In particular, this information will be used to make regulatory judgements about the registration of providers and managers and in relation to meeting the regulations.
This includes publication of:
- A register of providers
- Conditions of registration
- Reports about meeting the regulations
- Other information that we may publish to assist the public in understanding the quality of services and the regulatory actions of the Commission.
Registration application forms are processed on behalf of CQC. Personal data is processed in accordance with the Data Protection Act 1998.
*Applicant’s signature
*Applicant’s full name / Title / First / Middle / Last
*Date of signing (dd/mm/yyyy)
*Statement of Purpose
You must draft and send us a Statement of Purpose with this application form. If you do not, we will return your application to you.The guidance to filling in this form contains a summary about what the law says must be included in your Statement of Purpose. There is also separate detailed guidance on Statements of Purpose on our website.
Section 1: Where the applicant is an organisation
If you are NOT applying as an organisation please go to section 2 (individual) or
section 3 (partnership) as appropriate.
*Organisation’s name
Name you trade under if different to the above
The registered office of the organisation (if applicable) or its principal office:
*Address line 1
*Address line 2
*Town/city
County / *Postcode
*Email address
Website
*Business telephone number
Mobile telephone number
*Please specify the legal status of the provider organisation e.g. (public limited company/limited company/charity/ limited liability partnership/joint venture/ subsidiary/ other)
If ‘other’ has been selected as the legal status above, please give particulars (for example a franchise)
*Registered company number (if applicable)
*Registered charity number (if applicable)
* Any other number (if applicable)
By submitting this application you are confirming the provider’s willingness, if its application for registration is granted, for CQC to use the email address shown at 1.1 above for service of notices and other documents including draft and final inspection reports and for sending all other correspondence.
If you DO NOT want to receive these by email please check or tick the box below.
We do NOT wish to receive notices and other documents including draft and final inspection reports and correspondence from CQC by email
1.2 Alternative temporary correspondence address
Do not complete this section if it is the same as the above address.
If you wish to provide an alternative temporary correspondence address we will only use this whilst processing your application. (See Guidance)
Contact Name
Address line 1
Address line 2
Town/city
County / Postcode
Telephone
Email address
*1.3 Is your organisation a subsidiary of another company?
(See Guidance)
Yes / No
If ‘No’, please go to Section 1.7
If ‘Yes’, please provide the name and address of the parent/holding company
*Name
*Property name (if any)
*Business address line 1
*Business address line 2
*Town/city
County / *Postcode
*Email address
Website
*Business telephone number
*Registered company number (if applicable)
*Registered charity number (if applicable)
1.4 More information about parent and subsidiary companies
(See Guidance)
Please detail the financial relationship between your organisation and any parent and/or subsidiaries. In particular does your organisation rely financially on any other organisations within the group?
Do you share a brand name with other organisations?
If ‘Yes’, what is the financial relationship between your organisation and other organisations within the brand, in particular does your organisation rely financially on any other organisations within the brand?
*1.5 Is your organisation a franchise?
(See Guidance)
Yes / No
If ‘No’, please go to Section 1.7
If ‘Yes’, please provide the name and address franchisor
*Name
*Property name (if any)
*Business address line 1
*Business address line 2
*Town/city
County / *Postcode
*Email address
Website
*Business telephone number
*Registered company number (if applicable)
*Registered charity number (if applicable)
1.6 More information about the franchisor
(See Guidance)
Please detail the financial relationship between your organisation and any franchisee. In particular does your organisation rely financially on any other organisations within the group?
Do you share a brand name with other organisations?
If ‘Yes’, what is the financial relationship between your organisation and other organisations within the brand, in particular does your organisation rely financially on any other organisations within the brand?
*1.7 Directors or equivalent
Under roles and responsibilities please record any professional registration numbers and professional body/s. Please also tell us about any specific roles they have in relation to quality and safety within this organisation. Please tell us about any roles or responsibilities with other organisations.
(See Guidance)
*Chair / Title / First / Middle / Last
*Date of birth (dd/mm/yyyy) / Business/mobile telephone number
Email address
*Roles and responsibilities
*Secretary (or equivalent) / Title / First / Middle / Last
*Date of birth (dd/mm/yyyy) / Business/mobile telephone number
*Email address
*Roles and responsibilities
*Chief Executive (or equivalent) / Title / First / Middle / Last
*Date of birth (dd/mm/yyyy) / Business/mobile telephone number
*Email address
*Roles and responsibilities
Member 4 / Title / First / Middle / Last
Job Title/Role
Date of birth (dd/mm/yyyy) / Business/mobile telephone number
Email address
*Roles and responsibilities
Member 5 / Title / First / Middle / Last
Job Title/Role
Date of birth (dd/mm/yyyy) / Business/mobile telephone number
Email address
*Roles and responsibilities
Member 6 / Title / First / Middle / Last
Job Title/Role
Date of birth (dd/mm/yyyy) / Business/mobile telephone number
Email address
*Roles and responsibilities
Member 7 / Title / First / Middle / Last
Job Title/Role
Date of birth (dd/mm/yyyy) / Business/mobile telephone number
Email address
*Roles and responsibilities
Member 8 / Title / First / Middle / Last
Job Title/Role
Date of birth (dd/mm/yyyy) / Business/mobile telephone number
Email address
*Roles and responsibilities
Member 9 / Title / First / Middle / Last
Job Title/Role
Date of birth (dd/mm/yyyy) / Business/mobile telephone number
Email address
*Roles and responsibilities
Member 10 / Title / First / Middle / Last
Job Title/Role
Date of birth (dd/mm/yyyy) / Business/mobile telephone number
Email address
*Roles and responsibilities
Member 11 / Title / First / Middle / Last
Job Title/Role
Date of birth (dd/mm/yyyy) / Business/mobile telephone number
Email address
*Roles and responsibilities
Member 12 / Title / First / Middle / Last
Job Title/Role
Date of birth (dd/mm/yyyy) / Business/mobile telephone number
Email address
*Roles and responsibilities
Member 13 / Title / First / Middle / Last
Job Title/Role
Date of birth (dd/mm/yyyy) / Business/mobile telephone number
Email address
*Roles and responsibilities
Member 14 / Title / First / Middle / Last
Job Title/Role
Date of birth (dd/mm/yyyy) / Business/mobile telephone number
Email address
*Roles and responsibilities
*1.8 Declaration on meeting regulation 5 (See Guidance)
The Chair (or equivalent) of this service provider must complete this section of the form
I declare that all relevant checks and enquiries have been carried out in the appointment of the directors listed above. I confirm that all directors are fit and none meet any of the unfitness criteria specified in Part 1 of Schedule 4 to the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
*Chair’s signature
*Chair’s full name / Title / First / Middle / Last
*Date of signing (dd/mm/yyyy)
*1.9 Nominated individual(s) (See Guidance)
Provide details of the nominated individual (NI) for each regulated activity in this application.
The first person listed will be the main NI to whom we will send notices
Download additional nominated individual sections from the website page where you found this form if you intend to provide more than one regulated activity and plan to have more than one nominated individual.
If you don’t submit a form for each nominated individual, we will return your application.
The information below is for nominated individual number: / 1 / of a total of: / nominated individuals
*Details of a nominated individual for regulated activities
*Regulated activity(s)
(From the list of regulated activities checked or ticked at Section 5 below)
*Full name / Title / First / Middle / Last
Previous name (if applicable)
*Date of birth (dd/mm/yyyy)
*Business address line 1
*Business address line 2
*Town/city
County / *Postcode
*Email address
*Business telephone
Mobile telephone
Please confirm that the Nominated Individual is:
- Of good character.
- Physically and mentally fit to supervise the management of the carrying on of the regulated activity.
- Has the necessary qualifications, skills and experience to do so; and
- Has supplied the registered person, or arranged for the availability of, the information specified in Schedule 3 to Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
Yes / No
Have you applied for and received an enhanced DBS disclosure for the person shown (if you have not done so we will return your application).
Yes / No
DBS disclosure number / Date of disclosure (dd/mm/yyyy)
*1.10 Professional body disciplinary proceedings, other investigations, or bars on activity by the Disclosure and Barring Service (DBS) (See Guidance)
Are or have any members of the board or similar group at 1.7, or Nominated Individuals proposed at section(s) 1.9 been subject to any safeguarding investigation, criminal investigation or any investigation by a previous employer? Please either check or tick ‘yes’ or ‘no’. Please provide details below
Yes / No
If ‘Yes’, please provide details below.
Are any of the members of the board or similar body at 1.7 or any Nominated Individuals proposed in section(s) 1.9 subject to any professional disciplinary action, current proceedings, investigations or restrictions or bars on activity by a health or care professional regulator or the Disclosure and Barring Service?
Yes / No
If ‘Yes’, please provide details below.
*1.11 Previous registration history (See Guidance)
Has your organisation, any parent organisation, franchisee or subsidiary, or any of the directors or equivalent ever been registered or licensed for, or been the owner of any service registered or licensed under any of the following Acts of Parliament?
(check / tick for ‘Yes’, leave blank for ‘No’)
The Registered Homes Act 1984
The Registered Homes (Amendment) Act 1991
The Children Act 1989 (including child-minding and day care for children)
The Nurses Agencies Act 1957
The Care Standards Act 2000
Health and Social Care Act 2008
If ‘Yes’, please provide details below.
Was the registration of the organisation ever cancelled?
If ‘Yes’, please provide details below.
You will need to submit a registered manager application. Please see our website here.
Please proceed to section 4 to continue completing your application.
Section 2: Where the applicant is an individual
If you are NOT applying as an individual please go to section 1 (organisation) or
section 3 (partnership) as appropriate
*Full name / Title / First / Middle / Last
*Date of birth (dd/mm/yyyy)
Previous name (if applicable)
Name you will trade under if not your name
*Address line 1
*Address line 2
*Town/city
County / *Postcode
*Email address
Website
*Business telephone
Mobile telephone
By submitting this application you are confirming your willingness for CQC to use the email address shown at 2.1 above for service of notices and other documents including draft and final inspection reports and for sending all other correspondence to you.
You will be required to provide proof of your identity as part of this application, this must include a recent photo. DO NOT send this with your application, you will be asked to provide this information during the assessment of your application.
If you DO NOT want to receive these by email please check or tick the box below.
I do NOT wish to receive notices and other documents including draft and final inspection reports and correspondence from CQC by email
2.2 Alternative temporary correspondence address
Do not complete this section if it is the same as the above address.
If you wish to provide an alternative temporary correspondence address we will only use this during your application period. (See Guidance)
Contact Name
Address line 1
Address line 2
Town/city
County / Postcode
Telephone
Email address
*2.3 Previous history as a registered person (See Guidance)
Have you ever been registered as manager, provider or nominated individual of an establishment, agency or service registered under any of the following Acts of Parliament?
(check/tick for ‘Yes’, leave blank for ‘No’)
The Registered Homes Act 1984
The Registered Homes (Amendment) Act 1991
The Children Act 1989 (including child minding and day care for children)
The Nurses Agencies Act 1957
The Care Standards Act 2000
Health and Social Care Act 2008
If you have answered ‘Yes’ to any of the above, please include details in section 2.4
If you have ever been registered as a manager, provider or nominated individual of an establishment, agency or service registered under any of the following Acts of Parliament. Has your registration ever been cancelled? If ‘yes’ please provide the reasons below.
* 2.4 Employment History (including previous history as a registered person) (See Guidance)
Please provide details of your full employment history, if applicable please indicate where you were a registered person and the dates you were registered.
- Please say why you left each post.
- Please explain any gaps in employment.
Start date / End date / Employer
Job title and brief description
Reasons for leaving
Registered person (check/tick for ‘Yes’, leave blank for ‘No’)
Dates of registration: / From: / To:
Start date / End date / Employer
Job title and brief description
Reasons for leaving
Registered person (check/tick for ‘Yes’, leave blank for ‘No’)
Dates of registration: / From: / To:
Start date / End date / Employer
Job title and brief description
Reasons for leaving
Registered person (check/tick for ‘Yes’, leave blank for ‘No’)
Dates of registration: / From: / To:
Start date / End date / Employer
Job title and brief description
Reasons for leaving
Registered person (check/tick for ‘Yes’, leave blank for ‘No’)
Dates of registration: / From: / To:
Start date / End date / Employer
Job title and brief description
Reasons for leaving
Registered person (check/tick for ‘Yes’, leave blank for ‘No’)
Dates of registration: / From: / To:
Start date / End date / Employer
Job title and brief description
Reasons for leaving
Registered person (check/tick for ‘Yes’, leave blank for ‘No’)
Dates of registration: / From: / To:
Start date / End date / Employer
Job title and brief description
Reasons for leaving
Registered person (check/tick for ‘Yes’, leave blank for ‘No’)
Dates of registration: / From: / To:
Reasons for gaps in employment
*2.5 Day-to-day management of regulated activities (See Guidance)
If you will be in full-time day to day charge of the carrying on of the regulated activities, you do not need to complete a registered manager application.
Will a registered manager or managers be in day-to-day charge of regulated activities at any of the locations in Section 6 below?
Yes / No
If ‘Yes’, their applications must be submitted with this form. If they are not, we will return your application
*2.6 Medical history (See Guidance)
Do you have any physical or mental health conditions that are relevant to your ability to carry on the regulated activities in this application for registration?
Yes / No
If you answered ‘Yes’, please provide details below Please describe any arrangements you have put in place, including any reasonable adjustments, to enable you to do your job.
Please note: you should tell CQC of any significant changes to your health after you are registered.
*2.7 Your GP (See Guidance)
We may need to contact your doctor about your application. Please supply their contact details below.
*GP’s name / Title / First / Middle / Last
*Surgery name
*Address line 1
*Address line 2
*Town/city
County / *Postcode
*I give permission for the Care Quality Commission to contact my doctor or their surgery.
Yes / No
*2.8 Qualifications, skills and experience (See Guidance)
If you plan to manage the regulated activities in this application on a day-to-day basis, and will be in full-time day-to-day charge of the carrying on, please give details of your relevant qualifications, skills and experience.
Please note: If you will not be in full-time day-to-day charge of the carrying on of any of the regulated activities you are applying for, you will need a registered manager for those activities and they must submit the relevant form.
*2.9 Declarations by a health or social care professional (See Guidance)
Professional Body name
Professional registration number
Professional Body name
Professional registration number
Are you currently the subject of, or have you ever been subject of, any investigation or proceedings by any professional body with regulatory functions in relation to health or social care professionals (including by a regulatory body in another country)?
Yes / No
If ‘Yes’, please provide details below.
Are you currently the subject of, or have you ever been subject of any safeguarding investigation?
Yes / No
If ‘Yes’, please provide details below.
Have you ever been disqualified from the practice of a profession or required to practice subject to specified limitations following a fitness to practice investigation by a regulatory body in the UK or another country?
Yes / No
If ‘Yes’, please provide details below.
*2.10 Disclosure and Barring Service criminal records disclosure (See Guidance)
Have you applied for and received an enhanced DBS disclosure within the last six months, and was the application for the disclosure countersigned by CQC? (Please provide your most recent disclosure number)
Yes / No
NB: If you have not done so, we will return your application
DBS disclosure number
Date of disclosure (dd/mm/yyyy)
*2.11 Reference (See Guidance)
We will need to contact a referee about your application. Please supply contact details for a suitable referee below
Your referee must be your last employer. If you do not have a last employer, your referee:
- Must not be related to you.
- Must be able to provide a reference as to your competence to provide the service.
- Must have employed or worked with you for a period of at least three months (unless this will be your very first job).
*Referee’s name / Title / First / Middle / Last
*Address line 1
*Address line 2
*Town/city
County / *Postcode
*Email address
*Telephone no.
*I give permission for the Care Quality Commission to contact my referee.
Yes / No
*2.12 Is your business a franchise?
(See Guidance)
Yes / No
If ‘No’, you do not need to complete section 2.12 or section 2.13
If ‘Yes’, please provide the name and address franchisor
*Name
*Property name (if any)
*Business address line 1
*Business address line 2
*Town/city
County / *Postcode
*Email address
Website
*Business telephone number
*Registered company number (if applicable)
*Registered charity number (if applicable)
2.13 More information about the franchisor
(See Guidance)
Please detail the financial relationship between your organisation and any franchisee. In particular does your organisation rely financially on any other organisations within the group?
Do you share a brand name with other organisations?
If ‘Yes’, what is the financial relationship between your organisation and other organisations within the brand, in particular does your organisation rely financially on any other organisations within the brand?
Unless you intend to be in full time day to day charge of the regulated activity you will need to submit a registered manager application. Please see our website here.