Building Resilient Families and Communities

Building Resilient Families and Communities

Accreditation Scheme

Application Form

Version 2: 09/07/2015

SECTION A: COMPANY PROFILE
NOTES TO APPLICANT
This section refers to a sole trader, partnership, incorporated company or other business entity.

A1. Company name in which the Application would be submitted (registered name as shown on your accounts) or acting as lead contact where a consortium Application is being submitted:

A2. Main address for correspondence:

(a) Address
(b) Post code
(c) Telephone number
(d) Fax number
(e) Email address
(f) Website address

A3. Registered Office (as shown at Companies House):

(a) Address
(b) Post code
(c) Telephone number
(d) Fax number
(e) Email address
(f) Website address

A4. Point of contact for enquiries about this submission:

(a) Name
(b) Designation
(c) Telephone number
(d) Fax number
(e) Out of hours telephone number
(f) Email address
(g) Website address

A5. Address from which the Service will be provided (if different from the

above):

A6. Organisation’s Legal Status (please select):

Soletrader Partnership Private Limited Company
Public Limited Company Registered Charity Franchise
Non-profit Subsidiary Consortium
Other, please specify:

A7. Has or is any Director, Partner, Proprietor or Associate (been) employed by this

County Council? If “YES” please give details:

Yes No
If “YES” please give details here:

A8. State if any Director, Partner, Proprietor or Associate has a relative(s) who is/are employed by the County Council at a senior level or is a Councillor. If “YES” please give details here:

If “YES” please give details here:

A9. State Incorporation registration date under Companies Act 2006:

Companies House registration number, or Charity registration number:

A10. Attach a copy of the Certificate of Incorporation of the Applicant under the Companies Act 2006 (if applicable) and any Certificate of change of name:

Attached? Yes No

A11. List any Trade or Professional Associations that the Applicant belongs to, with names and registration numbers:

A12. What are the main day-to-day trade/business activities of the Applicant which is submitting this document?

A13. Consortia and Subcontracting – please indicate either (a), (b) or (c):

(a)Your organisation is applying to provide the services required by itself

(b)Your organisation is applying in the role of prime contractor and intends to use third parties to provide some services

(c)The potential provider is a consortium

A14.Sub-Contract Element -what proportion and nature of the activities involved in this proposed contract/agreement for which your organisation is now applying? Would there be an intention to sub-contract to others and why:

SECTION B: QUESTIONS

Please note that Applicants are required to answer the questions below concisely and factually. The responses provided will assist in the selection of a suitable provider, depending on the specific individual need of the family.

All Applicants are required to submit no more than one side of an A4 sheet for each question.

1. Describe how your organisation will deliver against the five key elements (See section 4 “The Model”).(provider to make reference to their experience and knowledge of the DCLG Operating Model and the three levels of intervention …..)

1. Describe how you will ensure that Key Workers are able to deliver the minimum requirements identified in section 4.5 “The Key Worker.”(provider to make reference to experience and skills of the Key Worker(s) to support and engage families …..)

1. Explain how your organisation would ensure families are fully supported. Developing a relationship with the family, supporting them to identify and implement a programme of change is vital in order to deliver successful outcomes. (provider to make reference to what support their organisation would provide to their Key Worker/s to build an effective relationship with the families and ensure that outcomes are achieved, ….)

1. Explain how you will engage and build relationships with appropriate partners.(provider to make reference to the types of relationships they already have with partners e.g. including BRFC, how effective these relationships are / have been in improving outcomes for families…)

1. Describe what experience your organisation has of supporting families via a named Key Worker. (Provider to make reference to how they have supported troubled / vulnerable families, how they have taken a whole family approach to the support offered, how they have provided a named Key Worker for families….)

The above will be scored by a central panel. The scoring matrix is outlined below:

Category / Definition / Score
Unacceptable / No response to the question or the response is highly inadequate/inappropriate/incorrect or irrelevant. Insufficient information. / 0
Poor / has made some reference but with no supporting knowledge or evidence and/or only partially addresses the question. / 1
Acceptable / Addresses the question with some limited supporting knowledge evidenced. Some omissions of important issues or negative indications that reduce the extent to which the service requirements will be achieved,. More detail and relevance required. / 2
Good / A good response in terms of detail and relevance and clearly meets the requirements. Good use of supporting knowledge and evidence to support the response. / 3
Comprehensive / A comprehensive response in terms of detail and relevance. Clearly exceeds the requirements with no negative indications. / 4

Any answers to questions 1 to 5 which score either 0 (Unacceptable) or 1 (Poor) will result in a failed application.

SECTION C: CURRENT CONTRACT/S WITH STAFFORDSHIRE COUNTY COUNCIL
Do you have any current contracts with Staffordshire County Council? Yes No
If “YES”, please complete the relevant sections below.
Name of Contact (at SCC):
Telephone:
Email:
Address:
Services provided / name of contract:
Dates: / Start: / End:
Value of Contract:
Any other Details:
SECTION D: INSURANCE REQUIREMENTS
NOTES TO APPLICANT
Minimum Requirements:

• £5 million - Public Liability Insurance is required in respect of each and every claim.
• £5 million - Employers Liability Insurance is required in respect of each and every claim.
• £2 million - Professional Indemnity Insurance is required in respect of each and every claim.

THIS SUBMISSION MAY BE REJECTED IF THE APPLICANT IS NOT PREPARED TO COMPLY WITH THIS REQUIREMENT
The above are the main requirements. It is also expected that the Applicant will have, where required, any additional insurance cover(s) which would be applicable to discharge the contract if necessary.

D1. Do you currently have all the relevant levels of insurance in place?

Yes No

D2. Proof of current insurance levels attached to this submission?

Yes No
SECTIONE: EQUALITY & DIVERSITY

E1.Does your organisation have an equal opportunities policy to avoid discrimination. It must follow the recommendations within the statutory codes of practice on age, gender, race and disability, equality and employment. Your policy must comply with the Equalities Act 2010 and Equalities Legislation.

Yes No

E2. If you have answered “NO” please explain how you promote and communicate Equality in employment and service delivery

Please provide details:

IF THE RESPONSE TO E1IS “NO” THE SUBMISSION MAY BE REJECTED.

SECTION F: SAFEGUARDING

F1.Does your organisation have a written Safeguarding policy which complies with Working Together to Safeguard Children (HM Government, 2013) and Staffordshire Safeguarding Children Boards Inter-agency Procedures? (

Yes No
If “YES”, please confirm it has been attached?Yes No

F2.Does your organisation have a safer recruitment policy and does your Organisational Lead have Level 1 and Level 2 Safeguarding and Safer Recruitment training?

Yes No
If “YES”, please confirm it has been attached?Yes No

F3. We recommend that it is best practice for the organisation’s Safeguarding Lead to have the Level 4 training for a Designated Lead. Does your Organisation’s Safeguarding Lead have this training?

Yes No
If “YES”, please confirm it has been attached?Yes No

F4. Does your organisation have a Whistleblowing policy which includes a process around reporting concerns of child abuse?.

Yes No
If “YES”, please confirm it has been attached?Yes No

The Staffordshire Safeguarding Children’s Board Child Protection Policy document can be found at

YOUR SUBMISSION MAY BE REJECTED IF YOU DO NOT POSSESS A SAFEGUARDING POLICY THAT MEETS THE REQUIREMENTS OF THE TEMPLATE POLICY FOUND ON THE WEBLINK BELOW (APPENDIX 1 DEVELOPING A CHILD PROTECTION POLICY) OR WHERE A POLICY IS REQUIRED IN LAW OR IF YOU DO NOT ATTACH A COPY OF IT (PLEASE NOTE YOUR POLICY MUST BE SIGNED AND DATED.)

SECTION G: HEALTH & SAFETY

G1. Does your organisation have a full Health and Safety policy?

Yes No

The contents of the Health and Safety policy must include:

1. A general statement
2. The organisational Health and Safety structure
3. Individual Health and Safety responsibilities
4. Arrangements for Health and Safety

Please provide evidence of the Health and Safety policy endorsed by the Chief Executive Officer that is regularly reviewed. The policy should be relevant to the nature and scale of the work and sets out responsibilities for Health and Safety management at all levels in the organisation.

If “YES”, please confirm it has been attached?Yes No

YOUR SUBMISSION MAY BE REJECTED IF YOU DO NOT POSSESS A HEALTH & SAFETY POLICY WHERE REQUIRED TO DO SO IN LAW OR YOU DO NOT ATTACH A COPY OF IT.

BRFC Accreditation Scheme Page 1 of 22

SECTION H: DISCLOSURE AND BARRING SERVICE

It will not be permitted for any member of the County Council to view disclosures by any of the Applicant’s personnel. Therefore, you are required to provide details of such personnel assigned to the performance of the Accreditation Scheme confirming on your organisation’s headed paper and signed by a duly authorised senior member of staff, the following:

1. The required enhanceddisclosure, along with the registration number and date of issue which has been received from the DBS for that individual

1. Confirmation that they have no offence which bars them from working on a regulated site
   
2. That the individual will be removed immediately from the Contract if an offence becomes known as this contravenes the DBS legislation

1. The County Council requires that the Applicant has the necessary DBS clearance in place at the time of contract award. If you are successful in this application process, this information will be required to be forwarded to the nominated representative of the County Council prior to the date of contract award

DECLARATION

I/We the undersigned have read and agree to abide by the above.

For DBS Information, refer to

Name of Organisation:
Name (typed):
Name (signature):
Position in Organisation:
Date:

YOUR SUBMISSION MAY BE REJECTED IF YOU ARE NOT PREPARED TO COMPLY WITH THIS REQUIREMENT

SECTION I: INFORMATION SHARING

The 'One Staffordshire Information Sharing Protocol' and Data Sharing Agreement deal with the emerging issues surrounding information sharing between agencies in light of the changing nature in which organisations are delivering services for the social, economic and environmental wellbeing of the community.

The protocol and agreement outline the purposes for sharing information, the powers that organisations have to share information, the role of partners and what can be expected from them, the process for sharing and scheduled review dates.

For detailed information about our Information Sharing Protocol, refer to:

DECLARATION

I/We the undersigned have read and agree to abide by the aboveprotocol and agreement and have completed and signed the Form of Acceptance (Appendix 5).

Name of Organisation:
Name (typed):
Name (signature):
Position in Organisation:
Date:

YOUR SUBMISSION MAY BE REJECTED IF YOU ARE NOT PREPARED TO COMPLY WITH THIS REQUIREMENT

SECTION J: SUPPORTING REFERENCES

J1. Supporting references detail experience and ability to deliver services of this nature.

Please list major contracts currently and recently held in public and private sectors for services of a similar type to the Services to be provided in the last three years from whom references may be solicited to testify to your technical capacity, standards and quality of service.

Where an Applicant has a mixture of reference sites, please list in order the priority of Local Authority and public sector sites. Please note that these must represent sites where the services performed are exactly aligned to those requested by this Application.

NOTES TO APPLICANT
The County Council will seek references for the Applicant in relation to work or approaches which are similar to the services and which are currently being provided by, or have been undertaken previously, by the Applicant in the last three (3) years. A minimum of two (2) references must be received and references received must be satisfactory.
Please note that the Applicant’s referees must be at a senior level with responsibility for services/contracts. It is the responsibility of the Applicant to ensure that the referee provided is relevant to the services that are the subject of this Application and the referee will be prepared to provide a reference. The County Council shall notify the Applicant when a request for references is made. Following a request made by the County Council for references a response will only be followed up once. If no references are provided upon request then the submission may be rejected. Therefore, it is imperative that referees are contacted prior to Application submission to ensure that these are completed when a request is made and to avoid any delays in the process.
The County Council’s personnel directly involved in the Application exercise will be unable to supply references.
Reasons that may lead to this submission being rejected:
(a) Failure to provide references of similar nature expected of this Application
(b) If less than two references are received
(c) If references are unsatisfactory
References shall be considered to be unsatisfactory if any of the responses to the questions relating to Performance & Quality are ticked as “YES” and the detail does not provide satisfactory resolution or satisfactory remedial action to failure of any of the obligations under the contract.
A sample of the Application Reference Questionnaire form that will be issued to the referees nominated is attached. Please see Appendix 2 entitled “Reference Questionnaire Template.”
SECTION K: REFERENCES

The Applicant must supply contact details of three (3) referees who are prepared to vouch for their performance of such work (please ensure that this section is completed in full to enable references to be requested)

Name and Address of Referee 1:
Point of Contact:
Telephone:
Fax:
Email:
Title of Contract:
Value of Contract:
Start date & Period of Contract:
State the proportion, value and nature of the activities that you subcontracted to other firms:
What was the reason for sub-contracting?
Detail of work comparable to the County Council’s requirements:
Name and Address of Referee 2:
Point of Contact:
Telephone:
Fax:
Email:
Title of Contract:
Value of Contract:
Start date & Period of Contract:
State the proportion, value and nature of the activities that you subcontracted to other firms:
What was the reason for sub-contracting?
Detail of work comparable to the County Council’s requirements:
Name and Address of Referee 3:
Point of Contact:
Telephone:
Fax:
Email:
Title of Contract:
Value of Contract:
Start date & Period of Contract:
State the proportion, value and nature of the activities that you subcontracted to other firms:
What was the reason for sub-contracting?
Detail of work comparable to the County Council’s requirements:
Reasons for failure to provide required number of reference sites:
SECTION L: DECLARATION
NOTES TO APPLICANT
When you have completed the Application, please ensure that:

• All questions have been answered
• All documents have been providedas requested
• The declaration here is understood and signed

I/We certify that the information submitted within and appended to this Application is accurate and correct and that I/we hold full responsibility for the entire contents.
I/We accept the conditions and undertakings requested in the Application.
I/We understand and accept that false information could result in rejection of the Application to be selected to take part in the Application process.
I/We understand that the information will be used to assess my organisation’s suitability to become a prospective Applicant to the County Council and that information will be held on computer and manually for this purpose in accordance with the Data Protection Act 1998.
I/We also understand that it is a criminal offence, punishable by imprisonment, to give or offer any gift or consideration whatsoever as an inducement or reward to any servant of a public body.
I/We also understand that any such action will result in rejection of my/our Application to take part in the Accreditation Scheme and empower the Authority to cancel any contract currently in force.
I/We understand and agree that if my/our Application is successful, the Applicant will purchase insurances as required if such insurance is not already held.

Please insert your scanned signature as authority. It is not acceptable to simply type your name only.

Name of Organisation:
Name (Signature):
Name (Typed)
Position in Organisation:
Date:
Once completed do not forget to return this application in accordance with the instructions given in the Section 11 – Guidance Notes.

APPENDIX 3: REFERENCE QUESTIONNAIRE TEMPLATE(references to be requested, from those referees detailed within Section K, by Staffordshire County Council)

BRFC Accreditation Scheme Page 1 of 22

STAFFORDSHIRE PROCUREMENT
REFERENCE QUESTIONNAIRE
CONFIDENTIAL
Name and Address of Organisation that the Reference is required for:
Contract area for which they have applied: /
BRFC Accreditation Scheme
PERIOD/VALUE OF CURRENT CONTRACT(S).
How long has your organisation had dealings with this company? / up to 1 yr 1-3 yrs 3-5 yrs over 5 yrs
Current Contract Period: / Contract Value:
What services does this company provide to your organisation?

PERFORMANCE ADDITIONAL COMMENTS (if applicable)

1 / Have this company ever failed to achieve targets for any performance indicators to which they are contracted to deliver? / Yes
No
2 / Has your organisation ever issued a default notice to this company as a result of their failure to perform against the contract in place? / Yes
No
3 / Has your organisation ever suspended a contract with this company? / Yes
No
4 / Has your organisation ever terminated a contract early with this organisation ? / Yes
No
5 / Have your organisation ever had any complaints about this organisation regarding the service they deliver from service user or anyone else? / Yes
No

QUALITY

1 / Has this company ever had any Adult/Child Protection investigation upheld whilst contracted with your organisation? / Yes
No
2 / Has this company ever failed any quality rating systems/inspections that your organisation has in place? / Yes No
Referee Details
The above information has been supplied by:
Company/organisation: Staffordshire County Council
Name:
Position:
Tel: Fax No :
Email:

Please note: Should it be requested, the contents of this reference may be supplied to the person or organisation to which the reference relates.