Care and Social Services Inspectorate Wales

Application for Variation or Removal of a Condition of Registration

/

Care Standards Act 2000 Section 15(1)(a)

Registration of Social Care and Independent Health Care (Wales)

Regulations 2002 – regulation 12(2)

Name of service
Address of service including post code
Tel Number
Fax Number
E-mail address
Your name

Please tick as appropriate: I am the

Registered Provider Registered Manager Responsible Individual

Please note that the form must be completed, and the declaration on page 6 signed, by the registered persons to whom the conditions relate. In most cases this is likely to be both the registered provider (or responsible individual) and the registered manager.
Please list any other Registered Persons

For providers who are not organisations (organisations see below)

Name of Registered Provider (if different from applicant named above)
Address of provider including post code
Tel Number
Fax Number
E-mail address

For applications from organisations

Name of Responsible Individual (if different from applicant named above)
Organisation Name
Address of provider including post code
Tel Number
Fax Number
E-mail address

Proposed Conditions of Registration

1.  Provide details of the new condition/s sought and/or condition/s to be removed (Use additional sheet if necessary.)
2.  What are your reasons for making the application? (Use additional sheet if necessary.)
3.  Provide details of the changes proposed.
Include details of any proposed structural changes, additional staff, facilities or equipment, or changes in management that are required to ensure the proposed changes are carried into effect. CSIW may require further details from you to arrive at a decision. (Use additional sheet if necessary.)
4.  Details of any discussions/inspections by other agencies
(e.g. Fire, Planning, Environmental Health etc.) if appropriate, including copies of any permissions or certificates. If changes are to be made to the premises, please enclose two copies of plans drawn to a minimum scale of 1:100. The drawings should clearly show the existing accommodation and the proposed alterations/extensions. (Please see the enclosed Schedule of information for plans for new registrations and variations.)
5.  Detail any proposed changes to documentation that may be necessary as a result of the proposed changes.
This would normally include a revised statement or purpose, and may include other documents such as admission procedure, risk assessments etc. (Please attach copies.)
6.  Proposed effective date of variation or removal of a condition of registration / Date:

Declaration

The information provided in this application form for a variation or removal of a condition, and attached documents is, to the best of my knowledge and belief, a true and complete description of the service. It also reflects accurately the changes proposed to be made in relation to the setting.

I/we understand that it is an offence knowingly to make a statement which is false or misleading in a material respect in relation to an application for the variation of any condition. CSSIW may take enforcement action if information which is material to this application is found to have been deliberately concealed or omitted. .

Signed (registered provider / responsible individual*l):
Name:
Signed (registered manager):
Name:
Date:
Name of Service

*delete as appropriate

Variation form V2, 11/2012 1