Application Form QA109

Application Form QA109

Private & Confidential

Personal Details

Title:
Surname:
Forenames:
Maiden Name:
Any other names:
Home Address:
Postcode:
Contact Numbers:-
Home:
Mobile:
Work:
Email Address:
National Insurance Number:
Do you have a current, clean, full UK driving licence:
Do you have a vehicle:
If you answered ‘yes’ to the driver questions please state:
1. The dates your licence is valid from……………………… to………………………..
2. The number of Penalty Points (if any) endorsed on the licence………………..
3. Have you ever been disqualified from driving or had insurance refused?……………………
4. If yes to the above question 3 please provide details……………………………..
……………………………………………………………………………………………………………………….
(You will need to provide us with a copy of both parts of your licence)
Next of kin:
Relationship:
Address:
Contact number:

Caring for our Community

Education/Training/Qualifications (including government training schemes)

School/college/ university/Placement / Dates
From To / Courses taken/ Qualification / Grade / Date

Relevant Non-Qualification courses attended

Organising body / Course Details / Dates
From To

Present/Last employment

Name and address of present or last employer:
Job Title: / Normal Hours worked:
Gross salary/wage: / Start date: Leave Date:
Grade: / Notice Required:
Brief details of duties:

Past employment (most recent first)

(Please complete gaps between employment dates for example: unemployed, housewife/househusband)

Employers name & address / Position held / Dates
From To / Reason for Leaving

References

Please supply names, full postal addresses, status and telephone numbers of two references to whom we may refer to as to your suitability for the post. At least one reference must be from your present/last employer. Other references should be from either a person in authority employed in the care sector, e.g. qualified nurse/social worker, or a professional person registered with a national association body. (Not family members)

Name: / Name:
Position: / Position:
Company Name: / Company Name:
Company/Home address: / Company/Home Address:
Town: Postcode: / Town: Postcode:
Telephone Number: / Telephone Number:
Email Address: / Email Address:

Experience

Please give details of your duties and achievements in previous post. You should indicate experience, special knowledge, skills, personal qualities and motivation, which relates to this particular job. You may also wish to draw attention to information including leisure activities, community or voluntary, domestic or family experience.

Work preferences (Please tick appropriate)

Due to the nature of our work all staff are required to work unsociable/flexible hours between 06.00 and 23.00 Monday through to Sunday (Night sitting service 21.00 – 07.00). Weekends are part of the working week and we DO NOT employ any staff who are unwilling to work Saturdays or Sundays. If you are unable to adhere to this then we are unable to employ you.

From time to time you may be asked to assist in covering calls on your allocated day off if this is agreeable.

Please indicate whether you wished to be employed:

Full time

Part time

Part time only

Am Unavailable at present

Approximate number of hours per week______
Are you staying with your current employer ______
If yes please explain(hours worked) ______
Do you have any commitments that might limit your working hours: YES/NO
If yes please explain ______
Do you have any pre booked holidays: YES/NO
If yes please state dates ______

European Working Time Directives

I am aware that under the European Working Time Directive staff cannot be compelled to work more than 48 hours per week unless they wish to do so.

I wish to exercise my right to work more than 48 hours per week.

If you DO NOT wish to do above 48 hours please DO NOT sign below as it is not necessary.

Signed:……………………………………… Date:……………………………………………

DECLARATION

I CERTIFY THAT TO THE BEST OF MY KNOWLEDGE THE INFORMATION I HAVE GIVEN IS CORRECT (Providing false information or deliberately omitting relevant information will make the candidate liable to dismissal or disciplinary action if appointed)

Signed:……………………………………….Date:…………………………………………….

CARE ASSISTANT JOB DESCRIPTION QP70

1Accountability

Accountable to the Care Manager in the first instance, or his/her supervisor

2Purpose of the Job

Give specific care and attention to the people’s needs, comfort, and personal hygiene following the care plan and individual instruction.

To ensure that the rights and entitlements of the people are respected at all times.

Help develop and maintain individually planned care programmes designed to maximize the people’s independence and quality of life.

To follow and adhere to all Company policies and procedures.

3Responsibilities

3.1At all times staff must demonstrate the highest level of honesty, trustworthiness and reliability.

3.2Maintain at all times the level of personal appearance to a socially acceptable standard; assist the people where necessary

3.3To act as escort for any person to and/or from other places. E.g. Hospital, day trips etc.

3.4To participate and give encouragement with recreational activities

3.5To develop a trusting relationship with people enabling them to express their needs, views and concerns

3.6Be aware of the confidentiality rules and adhere to these at all times.

3.7To respect the people’s right to privacy and ensure their dignity is maintained at all times

3.8Be aware of responsibilities towards people’s valuables and property in accordance with the laid down policy

3.9To communicate effectively recognizing the need for alternative methods of communication

3.10Consult with the Care Manager or his/her deputy on any changes required to the Care plan

3.11Report any changes in the persons circumstances or condition; report any hazards, misuse or abuse of the person/s

3.12Report any unusual circumstances to the Care Manager or his/her deputy. This includes accidents to the people or staff where necessary.

3.13Ensure a safe environment for people and staff. Following instructions when using equipment and check that it is in safe condition.

3.14To take the appropriate action in the event of emergencies, ensuring the Care Manager or his/her deputy is informed promptly.

3.15It is the duty of all employees to ensure that a safe working environment and safe working practices are maintained at all times and that the Company’s Health and Safety policies are adhered to.

3.16Attend all training sessions as required within the expected time frame.

3.17To attend supervision meetings

3.18Deliver the service to meet the people’s needs and conform to Local Authority contract specifications. Ensure documentation is processed in accordance with Company and Local Authority policy and procedures.

3.19To notify the Care Manager if unable to comply with any of the activities as listed on the personal specification.

3.20This Job description indicates the main duties and responsibilities of the post. It is not intended as a complete list and may be subject to periodic review. All activities carried out shall comply with the Company’s policies, contributing to the wellbeing of people.

CARE ASSISTANT PERSONAL SPECIFICATION QP70a

Category / Requirements / Essential / Comments/Definition
Skills and Knowledge /

Enhanced CRB
Hold or working towards NVQ level 2 in care
Manual Handling
Understanding of Adult care
Flexible, reliable, honest and trustworthy
Ability to work without direct supervision in peoples homes

/ Essential
Essential
Physical Skills /

Ability to assist others with the delivery of personal care
Ability to sit, bend, stretch and climb stairs intermittently over any given shift
Fitness to do the job within manual handling policy including kneeling on the floor on both knees
Ability to kneel on the floor on either knee,
Ability to stand the feet shoulder width apart and lunge left to right
Ability to stand in the lunge position and transfer body weight from back to front
Ability to withstand Intermittent static posture during any given shift
Ability to withstand Intermittent pulling, pushing, lifting and lowering of loads during any given shift
Ability to withstand gripping intermittently on any given shift
Ability to have lateral flexion, extension, rotation and hyperextension of the vertical column in any given shift

/ Periods of holding your body in one position during the call/shift
Repetitively bending your back forwards, arching backwards, twisting or bending side wards during one call/shift. E.g. same movement repeated over and over again.
Mental Skills /

A common sense approach to problem solving
Good concentration and observation skills
Ability to deal with changing circumstances
Ability to absorb information
Ability to make decisions

Communication Skills /

Able to communicate routine information that may require tact and persuasive skills
Good interpersonal skills
Ability to deal tactfully and empathetically with people requiring care
Ability to read and write

Working Conditions /

Personal physical contact with people requiring care
Must be able to travel

Physical Resources /

Responsible towards peoples valuables and property
Ensure all equipment is in a safe working condition

Other /

Awareness of equal opportunities

Health Declaration

Do you have the ability to comply with the requirements of the Job Description and Personal Specification? Yes No

If no please give details: ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

G.P Details

Surgery name
Your G.P’s Name
Address of surgery
Telephone Number

WOMEN ONLY TO COMPLETE THIS SECTION

Are you currently pregnant ______

Do you suffer any gynaecological disturbances of sufficient severity to cause absence from work i.e period pain?

______

MEN & WOMEN TO COMPLETE

Are you presently taking any medication or undergoing treatment?______

If so please give details ______

What is you daily consumption of:

Alcohol ______

Tobacco ______

Has either ever exceeded this level ______

How many working days have you been absent from work during the last 12 months (including illness such as cold, flu, upset stomach etc)? ______

What was the reason for these absences ______

Do you expect to ask for time off from work during the next 12 months for medical reasons? ______

Have you ever left or been denied a job on health grounds? ______

This space may be used to provide additional information

______

Immunisation

In order to determine your immunisation status please give the following information:
E.g. Tetanus Child 1968 Adult 2010
Vaccination / Child / Teenager / Adult

Do you have any phobias, allergies or reactions to pets which may affect the service delivery to our clients? YES NO

If yes please give details:…………………………………………………………………………

…………………………………………………………………………………………………………………………………………………………………………………………………………

Do you have any Disabilities? YES NO

If so, please specify

Would you require our Company to make any adjustments to allow you to fulfil the requirements of this post? (If yes please specify):

………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Equal Opportunities Statement

CM Community Care promotes Equal Opportunities; to meet the terms of anti-discrimination, race relations and Equal Opportunities legislation

Gender

Male Female

Ethnic Origin

White

English/Welsh/Scottish/Northern Irish/BritishIrish Gypsy or Irish Traveller Any other white background

Mixed/Multiple Ethnic

White and Black Caribbean White and Asian

White and Black African

Any other mixed/Multiple Ethnic Background

Asian/Asian British

IndianPakistani

BangladeshiChinese

Any other Asian Background

Black/African/Caribbean/Black British

AfricanCaribbean

Any other Black/ African/Caribbean Background

Other

ArabAny other Ethnic Group

If other please specify ______

Nationality

Please state your nationality ______

Eligibility to work in the UK

I can confirm that I am legally entitled to work in the UK, and I am able to supply documents of proof to support this. I acknowledge that if I am not able to supply evidence to prove that I can work in the UK your Company will not be able to employ me, or will terminate my employment with immediate effect.

Do you require a permit to work in the UK? YES NO

Signed: ……………………………………… Date:…………………………………………….

Please read carefully before signing

I declare that the answers given above are true and correct and give a full complete picture of my health in every respect.

I give the company permission to contact my doctor for further particulars of my medical records should the company decide so.

I am prepared to undergo a medical examination if this is required.

I understand and accept that if any of the information given in this document is incorrect or untrue, that the Company reserve the right to immediately terminate my employment with them.

Signed:…………………………………………Date:…………………………………….

Do you have any family members Working for CM Community Care? Yes No
If Yes name of Family member: ……………………………………………………………………………………………………….

Rehabilitation of Offenders Act 1974

Are you currently facing any criminal charges or have you ever been convicted of a criminal offence, received a caution, reprimand or warning Yes No
If yes please give details in full including dates

I understand that my details will be submitted for a Criminal Record Bureau Enhanced Disclosure, and for checking against the ISA. I also understand that giving incorrect details and not declaring a criminal record will render me liable to disciplinary action or dismissal with immediate effect.

Signed:………………………………………Date:……………………………….

Availability

Due to the nature of the job you have been offered, you are required to be flexible and willing to help occasions where your rostered work may need to be changed within your normal expected hours of work. If your application is successful please acknowledge that there may be periods when no work or minimal work is available and the Company has no obligation to provide any employee with any work or to provide a minimal number of hours in any work day or week.

Signed:…………………………………….Date:…………………………………

For both legal and contractual purposes your information will be held on certain databases. The database holds accurate factual information regarding the Care Workers Name, Address, Date of birth, National Insurance Number, Date employment commenced, Date employment ceased and any disciplinary action.

The purpose of the database is for the protection of the service users from unscrupulous Care Workers. There is no concern for genuine Care Workers.

The information will NOT be discussed elsewhere. No other government body, local government department, or any other organisation would have access whatsoever.

Please Sign below.

I understand the above and agree to allow my details to be forwarded and held on any relevant database.

Signed:………………………………………..Date:……………………………….

Our Company policy on the operation of our rota system requires carers to be available seven days per week. However, if you are employed on a full time basis you will only be obliged to work five days minimum out of seven on a rotation.

You will be expected to be available between the hours of 06.00am and 23.00pm. Night sits are from 21.00pm until 07.00am. Full time carers will be expected to deliver between 35 and 45 hours per week, but extra hours could be available through working extra shifts on their days off, or by extra hours during the middle of the day.

The senior care Co-ordinator will decide which days each carer has off in each four weekly cycle. These will be allocated fairly and proportionally. Any carers needing to have a particular day off in any week must make a request at least 11 days in advance of the onset of week one of four weekly cycles. Dates of four weekly cycles in your area can be obtained through the office. No rostered runs can be handed back or refused without prior consultation and ultimate agreement from the Care Co-ordinator.

Part time carers will be expected to be available for five shifts over a seven day week and receive days off as allocated by a senior Care Co-ordinator. From time to time you may be asked to assist in covering calls on your allocated days off if this is agreeable.

DECLARATION

Signature………………………………………………………………….

Dated………………………………………………………………………

FOR OFFICE USE ONLY

Comments ______

Action ______

Further action details ______

Signed ______

Application Form September 2012 11 Pages1