Health Information and Quality Authority

Health Information and Quality Authority
Application to renew the registration of a designated centre under the Health Act 2007 /
Application by a Company[1]
For office use
Centre Name:
Centre ID:
If not completing electronically, please complete the application form in BLOCK CAPITALS using BLACK INK.
Glossary of terms

Registered provider

The provider of services, referred to in the Health Act 2007 as “the registered provider”, is the person who is registered as carrying on the business of the designated centre.

Applicant

The applicant is the person who makes and is responsible for the application. In most cases the applicant will be the registered provider. In the case of an application by a company, the applicant must nominate a person to be responsible on behalf of the company for the application. He/she must be a senior member of the company involved in supervision of the management of the designated centre, sufficiently senior to make decisions and implement recommendations arising from an inspection of the designated centre.

Person in charge

This is the person whose name is entered on the register as being in charge of or managing the designated centre. As per the Health Act 2007 (Care and Welfare of Residents in Designated Centres for Older People) Regulations 2009 (as amended) the person in charge shall be a nurse with a minimum of three years experience in the area of geriatric nursing within the previous six years.

Designated centre

The term designated centre refers specifically to residential care settings as defined in Section 2(1) of the Health Act 2007. A designated centre does not include any of the following:

§ a centre registered by the Mental Health Commission

§ an institution managed by or on behalf of a Minister of the Government

§ part of an institution in which the majority of persons being cared for and maintained are being treated for acute illness or provided with palliative care

§ an institution primarily used for the provision of educational, cultural, recreational, leisure, social or physical activities

§ a special care unit

§ a children detention school as defined in section 3 of the Children Act 2001.

1. Information about the centre

Centre details

/ For official use
Name of the centre
Address of the centre
Telephone number
Fax number
Email address
When did this centre commence operation? (please state date) / //
Day / month / year
What is the total bed capacity of the centre?
Please state the maximum number of residents who will be accommodated in your centre (i.e. the number of residents you are applying to register).
Current residents
Number of residents
Are you applying to open new beds with this application? / Yes / No
Statement of Purpose / Please tick (√)
I confirm that the attached statement of purpose clearly sets out the services and facilities provided within the designated centre, as required by Schedule 1 of the Health Act 2007 (Care and Welfare of Residents in Designated Centres for Older People) Regulations 2009

2. Information about Applicant (the Company)

For official use

Company name
Company registration number
Number of directors
Business/Trading name
(if applicable)
Address of the principal place of business of the company
Company telephone number
Company Fax number
Company Email address
Is this company a subsidiary company / Yes No
If yes please state the name of the parent company
Please state where the parent company is registered

Chairperson details

For official use

First name
Surname
Address for correspondence
Telephone number
Mobile number
Email address

Company Secretary Details

For official use

First name
Surname
Address for correspondence
Telephone number
Mobile number
Email address

Chief Executive Details

For official use

First name
Surname
Address for correspondence
Telephone number
Mobile number
Email address

Director details

Please provide details for each director. If the company consists of more than three directors, please make copies of the additional director details question to facilitate completion of this question by each director. / For official use
First name
Surname
Address
Telephone number
Mobile number
Email address

Involvement of director in other designated centres

/ For official use
Has this director experience of carrying on the business of a designated centre in Ireland or residential services outside Ireland? / Yes / No
If yes, please provide details below. Please continue on a separate sheet if necessary.
Current name of centre(s) / Previous name of centre(s)- if applicable / Address/contact details of the centre(s) / Name of post held / For official use
Has this director ever managed a designated centre or carried on the business of a designated centre that has been refused registration, had registration cancelled, or had conditions attached to registration in Ireland or outside Ireland in the past? / Yes / No
If yes, please provide details below. Please continue on a separate sheet if necessary.
Current name of centre(s) / Previous name of centre (s) if applicable / Address / contact details of the centre(s) / Details of registration refusal, registration cancellation, or conditions attached to registration as a registered provider of a designated centre or residential facility in Ireland or outside Ireland / For official use

Additional Director Details

/ For official use
First name
Surname
Address
Telephone number
Mobile number
Email address

Involvement of director in other designated centres

Additional Director Details

/ For official use
First name
Surname
Address
Telephone number
Mobile number
Email address

Involvement of director in other designated centres

Details of person responsible on behalf of the company for the registration application

For official use

Title / Ms Mrs Mr
Other Please specify:
First name
Surname
Address for correspondence
Telephone number
Mobile number
Email address
Role of the applicant in relation to the designated centre

RD27 Version1.1 16062011

Involvement of applicant in other designated centres

/ For official use
Have you experience of carrying on the business of a designated centre in Ireland or residential services outside Ireland? / Yes / No
If you answered yes, please provide details below. Please continue on a separate sheet if necessary.
Current name of centre(s) / Previous name of centre(s)- if applicable / Address/contact details of the centre(s) / Name of post held / For official use
Have you ever been refused registration, had registration cancelled, or had conditions attached to registration as a registered provider of a designated centre or residential facility in Ireland or outside Ireland in the past? / Yes / No
If you answered yes, please provide details below. Please continue on a separate sheet if necessary.
Current name of centre(s) / Previous name of centre (s) if applicable / Address / contact details of the centre(s) / Details of registration refusal, registration cancellation, or conditions attached to registration as a registered provider of a designated centre or residential facility in Ireland or outside Ireland / For official use
Have you ever been subject to An Bord Altranais Fitness to Practise proceedings? / Yes / No
If you answered yes, please provide details below.

RD27 Version1.1 16062011

4. Information about the person in charge
Person details / For official use
Title / Ms Mrs Mr
Other Please specify:
First name
Surname
Work address
Telephone number
Mobile number
Email address

Registration with professional organisations

/ For official use
Is the person in charge registered with a professional organisation? / Yes / No
If yes, please provide details below. Please continue on a separate sheet if necessary.
Professional organisation / Registration number / Date of registration

Qualifications

Please list relevant professional qualifications

/ For official use
Qualification / Accrediting body / Date conferred

Employment history

Please provide details of the employment and study history of the person in charge. Include time spent outside Ireland for a duration of more than three months, any time spent working on a voluntary basis, and any period not accounted for in the above. Please continue on a separate page if necessary. Please list in order of most recent employment.
Date from / Date to / Name and address of employer/academic organisation and nature of business / Job title or brief description of work or other activity / Reason for leaving / For official use
Has the person in charge ever been subject to An Bord Altranais Fitness to Practise proceedings? / Yes / No
If yes, please provide details below.
Please detail how the person in charge meets the minimum requirements of the Health Act 2007 (Care and Welfare of Residents in Designated Centres for Older People) Regulations 2009 (as amended) whereby the person in charge shall be a nurse with a minimum of three years experience in the area of geriatric nursing within the previous six years.
Date from / Date to / Name and address of employer and nature of business / Job title or brief description of work

Involvement of person in charge in other designated centres

/ For official use
Has the person in charge experience of managing or carrying on the business of a designated centre in Ireland or residential services outside Ireland? / Yes / No
If yes, please provide details below. Please continue on a separate sheet if necessary.
Current name of centre(s) / Previous name of centre(s)- if applicable / Address/contact details of the centre(s) / Name of post held / For official use
Has the person in charge ever managed a designated centre or carried on the business of a designated centre that has been refused registration, had registration cancelled, or had conditions attached to registration in Ireland or outside Ireland in the past? / Yes / No
If yes, please provide details below. Please continue on a separate sheet if necessary.
Current name of centre(s) / Previous name of centre (s) if applicable / Address / contact details of the centre(s) / Details of registration refusal, registration cancellation, or conditions attached to registration as a registered provider of a designated centre or residential facility in Ireland or outside Ireland / For official use
Has the person in charge previously worked in a position where his/her duties involved work with children or vulnerable adults in Ireland or outside Ireland? / Yes / No
If you answered yes to the above question, please complete the “Verification of Reasons why the Employment or Position Ended Form”
5. Information about other persons who participate in the management of the centre(i.e. members of the management team)[2]
Person details / For official use
Title / Ms Mrs Mr
Other Please specify:
First name
Surname
Work address
Telephone number
Mobile number
Email address

Registration with professional organisations

/ For official use
Is this person registered with a professional organisation? / Yes / No
If yes, please provide details below. Please continue on a separate sheet if necessary.
Professional organisation / Registration number / Date of registration

Qualifications

Please list relevant professional qualifications

/ For official use
Qualification / Accrediting body / Date conferred

Employment history

Please provide details of the employment and study history of this person. Include time spent outside Ireland for a duration of more than three months, any time spent working on a voluntary basis, and any period not accounted for in the above. Please continue on a separate page if necessary. Please list in order of most recent employment.
Date from / Date to / Name and address of employer / academic organisation and nature of business / Job title or brief description of work or other activity / Reason for leaving / For official use

Involvement of persons who participate in the management of the centre in other designated centres

/ For official use
Has this person experience of managing or carrying on the business of a designated centre in Ireland or residential services outside Ireland? / Yes / No
If yes, please provide details below. Please continue on a separate sheet if necessary.
Current name of centre(s) / Previous name of centre(s)- if applicable / Address/contact details of the centre(s) / Name of post held / For official use
Has this person ever managed a designated centre or carried on the business of a designated centre that has been refused registration, had registration cancelled, or had conditions attached to registration in Ireland or outside Ireland in the past? / Yes / No
If yes, please provide details below. Please continue on a separate sheet if necessary.
Current name of centre(s) / Previous name of centre (s) if applicable / Address / contact details of the centre(s) / Details of registration refusal, registration cancellation, or conditions attached to registration as a registered provider of a designated centre or residential facility in Ireland or outside Ireland / For official use
Has this person previously worked in a position where his/her duties involved work with children or vulnerable adults in Ireland or outside Ireland? / Yes / No
If you answered yes to the above question, please complete the “Verification of Reasons why the Employment or Position Ended Form”

6. Premises details