4Life Healthcare Ltd, T6 Howitt Building, Nottingham Business Centre, Lenton Boulevard, Nottingham, 2BY Telephone – 0115 9984902, 07464706271 E-mail – [email protected]Website – www.4life-healthcare.co.uk Dear Applicant, Thank you for requesting an application form. Included in this pack you will find the application form, equality and diversity monitoring form, health questionnaire, the code of conduct, confidentiality agreement and bank details. If you need a new DBS certificate then please ask us for a DBS information request form. Once you have fully completed the form's please return to the following address: HR Recruitment Team 4Life Healthcare Ltd Office T6 Howitt Building Nottingham Business Centre Lenton Boulevard Nottingham, NG7 2BY 0115 9984902 Or alternatively please scan the completed application form to the following email on [email protected]All the best with your application, HR Recruitment Team.
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4Life Healthcare Ltd, T6 Howitt Building, Nottingham Business Centre, Lenton Boulevard, Nottingham, 2BY
Included in this pack you will find the application form, equality and diversity monitoring form, health questionnaire, the code of conduct, confidentiality
agreement and bank details. If you need a new DBS certificate then please ask us for a DBS information request form. Once you have fully completed the form's please return to the following address:
HR Recruitment Team
4Life Healthcare Ltd
Office T6 Howitt Building
Nottingham Business Centre
Lenton Boulevard
Nottingham,
NG7 2BY
0115 9984902
Or alternatively please scan the completed application form to the following email on
5. EMPLOYMENT HISTORY Please provide us with details of your employment history from when you left compulsory education. Please start with the most recent, ensuring that all gaps in employment are accounted for. Dates should be provided in DD/MM/YY format. Please provide details of the position held with a brief description of duties, alongside reasons for leaving.
EMPLOYER’S NAME AND ADDRESS
DATES FROM & TO
JOB HELD AND BRIEF DESCRIPTION OF DUTIES
REASON FOR LEAVING
6. EDUCATION AND TRAINING
Please give details about any education and training received in this country or abroad and qualifications obtained, with dates.
TRAINING ESTABLISHMENT COURSE FULL OR
PART TIME QUALIFICATION (With grades if applicable)
Please provide any supporting information, outlining any experience, skills and knowledge relevant to the post which you are applying for as described on the person specification/ job description. (Please use a continuation sheet if necessary).
8. REFERENCES Please give the names of 2 people who are prepared to provide 4Life Healthcare Ltd with a reference regarding your suitability for the post which you are applying for. One reference should be from someone who you have worked for and is in a senior position.
REFERENCE 1 REFERENCE 2
Name: Name:
Post Held: Post Held:
Relationship to Referee: Relationship to Referee:
How Long Known: How Long Known:
Company Name: Company Name:
Date Employed: Date Employed:
Address: Address:
Telephone Number: Telephone Number:
Email Address: Email Address:
Do you object to your referees being contacted before an offer of employment is made?
Tuberculosis, asthma, bronchitis or chest problems?
Chest pain, heart condition or raised blood pressure?
Blackouts, fits or attacks of giddiness?
Depression, mental illness or nervous breakdown?
Rheumatism or arthritis?
Back trouble?
Typhoid, paratyphoid or other infectious disease?
Digestive or bowel disease?
Diabetes, thyroid or other gland trouble?
Bladder or kidney trouble?
Dermatitis or skin trouble?
Varicose veins?
Vision or Hearing problems?
Any other accident, operation or illness?
Have you any reason to believe you may be infected with any communicable disease?
Any other current or recent medical condition or treatment which might affect your attendance or performance at work?
Do you intend to work night duties on a regular basis?
Any illness or medical condition that prevented you from attending work on your normal duties or activities for more than one week during the past year?
Any physical or mental impairment which has a substantial and long term effect on your ability to carry out day to day activities? If yes, please specify any special adjustments required in relation to work.
Do you smoke?
How many units of alcohol do you drink per week?
Health Questionnaire PRIVATE AND CONFIDENTIAL
I confirm that the information I have provided on this form is true and to the best of my knowledge. I have
declared all the medical conditions which may affect my ability to carry out my duties effectively and reliably.
4Life Healthcare Ltd aims to select applicants solely on the basis of merit and ability which are relevant for the role applied for and not on the basis of age, gender, sexual orientation, marital status, disability, religious beliefs, nationality and/or ethnic origin. The information you provide will be held in complete confidence and will only be used to monitor that our equality and diversity policy is fully and fairly implemented. The information you provide will NOT be considered during our recruitment and selection process.
Personal Information AGE <21 21-30 31-40 41-50 51-60 >60
Gender Female Male
Marital Status
Single Married Widowed
Co-Habiting Civil-Partnership Partner
Separated Divorced Prefer not to say
Sexual Orientation
Heterosexual Bisexual Lesbian
Gay Prefer not to say
Do you wish to be considered as having a disability?
Yes
No Prefer not to say
Ethnic Origin
White
British
Black
British
Irish African
European Caribbean
Other (please State) Other (please State)
Asian
British
Oriental Other
Chinese
Indian Japanese
Pakistani Malaysian
Bangladeshi Mauritian
Other (please State) Other (Please State)
Mixed White/Black African White/Asian
White/Black Caribbean Other (Please State
Religion
Agnostic: Atheist: Hinduism:
Christian: Jehovah’s Witness: Sikhism:
Judaism: Buddhist: Other (Please State)
Taoism: Muslim: Prefer not to say:
Vacancy Details
Position applied for: Carer Nurse
Where did you hear about this vacancy?
4Life Staff Member Word of Mouth
Advert (please State) Other (Please State)
Website (please State)
Consent
I agree to the use of this information for monitoring purposes and statistical analysis and returns.
At 4Life Healthcare Ltd we support vulnerable adults and therefore all those having daily contact with our service users will require an Enhanced DBS check prior to starting work. 4Life Healthcare will charge the full cost of this for all new staff (currently £55). If you having your own updated DBS we will require the updated DBS number to verify the status. This is because we feel that we want to show commitment to you, even before you join us, and we hope you will show the same to us with a long and rewarding career at 4Life.
You may not know that, as we apply for your DBS online, you have the option, at a nominal cost, to make this a transferable DBS (DBS will give you more information about this when they send you your certificate). This means that the DBS certificate becomes yours and you can use for all roles requiring a DBS (e.g. voluntary roles) without the cost of having to reapply.
Title
Forename Surname
Middle name (s) Gender
D.O.B (dd/mm/yyyy) Ni Number
Address History (5 yrs required) — PTO for more addresses
C u r r e n t a d d r e s s
Post code
Move in date (mm/yyyy)
Town of birth Nationality at birth
Have you changed your nationality since birth? YES NO
If yes, current nationality
Have you changed your surname since birth? If yes, PTO for more details YES NO
Do you have any unspent convictions? If yes, please give details YES NO
By signing this form agreeing to an enhanced DBS check you are also signing to agree to the deduction of the DBS fee from your pay should you leave 4Life Healthcare Ltd within 6 months PTO -:
Declarations 1. I understand that if I am charged or cautioned after signing this declaration, I must inform 4Life Healthcare Ltd. 2. Have you ever been subject to disciplinary action or are currently being investigated due to alleged misconduct?
Yes
No
3. I acknowledge that I have been given a copy of the Terms and Conditions of Service issued by 4Life Healthcare Ltd, which is mine to keep, and furthermore that I have read those Terms and Conditions and agree to abide by them. 4. I am not aware of any condition, medical or otherwise, which would affect or limit my employment or performance, other than those declared in my Occupational Health Questionnaire. 5. I declare that the information given herein is true and complete and is not presented in a way intended to mislead. I agree that if I have given false or misleading information or omit to give relevant information now or in the future that 4Life Healthcare Ltd may cease to offer me further agency placements without notice, as well as a claim for recovery of any payments I have received, together with a claim for a loss of profit to 4Life Healthcare Ltd. 6. I acknowledge and confirm that 4Life Healthcare Ltd is authorised to apply for and obtain a Disclosure and Barring Service Check (including the online status update service check if applicable) and references from any previous employers and educational establishments. 7. I acknowledge that my personal details will be stored and handled correctly by 4Life Healthcare Ltd in accordance with the Data Protection Act 1998 is the UK’s implementation of the General Data Protection Regulation (GDPR), however; I agree that they may be made available for audit/review by relevant third parties. (This is relevant for all information including all documents – DBS, Occupational Health, References). 8. I understand that if I am on a student visa I can only work for 20 hours per week during term time. I understand that I have a responsibility to monitor this. In addition, if my position as a student changes, I must inform 4Life Healthcare Ltd. 9. I understand that if I am on a Tier 2 Sponsorship Visa, I can only work for a maximum of 20 hours per week at the same professional level as my sponsorship. I understand that I have a responsibility to monitor this. In addition, if my position with my sponsored company changes, I must inform 4Life Healthcare Ltd. 10. I acknowledge that if any of my details stated on this Application Form change, or my circumstances change, which may affect my ability to work for 4Life Healthcare Ltd, I must inform 4Life Healthcare Ltd immediately. 11. I confirm that I am not currently under investigation, or currently suspended, by my professional regulatory body (e.g. NMC) or being investigated by my current or previous employer. I will inform 4Life Healthcare Ltd if I am under investigation or suspended by my professional regulatory body or employer at any point whilst working for 4Life Healthcare Ltd. 12. I confirm that when asked about my working history (primarily, but not exclusively, for the purposes of the Agency Workers Regulations) I will provide accurate information. 13. I acknowledge that should I reach the 12 week Qualifying Period under the Agency Workers Regulations, I may be asked for, and will provide, further documentation as evidence of qualifying weeks, if 4Life Healthcare Ltd deems it necessary
14. I give my permission for 4Life Healthcare Ltd to run a Right to Work check with the Home Office if I provide them a Biometric Residence Card for my Right to work in the UK.
During or after your employment with us, you must not disclose any trade secrets or any information of a confidential or sensitive nature about:
1. 4Life Healthcare Ltd; or
2. any of our service users; or
3. any of our employees.
There is an exception if you need to share this information as part of your job or if you are made to by law.
It is the responsibility of all staff to ensure data security. You will be responsible for the confidentiality, integrity and availability of all data which you have access to in the course of your work.
You must adhere to our Data Protection Policy and associated policies, which will all be made available to you. Failure to adhere to these policies may result in disciplinary action.
I confirm that I have received, read and understood the following documents and agree to abide by the terms and
conditions stated above:
1) An Introduction to Information Sharing for Staff
2) Staff Guidance on Data Sharing
3) Staff Guidance on Subject Access Requests & Individual Rights
4) Data Security and Protection Code of Conduct
5) Staff Guidance on Individual’s Rights under GDPR
6) Staff Guidance on Data Quality & Record Keeping
Knowledge of, and work within, the Fundamental Standards
Understand the regulatory framework that governs the service, including the role of CQC and
their requirements
Commit to achieving the relevant qualifications commensurate with the role
Attend statutory training and any other training as directed by management
Understand and follow all policies and procedures relevant to the role
Be open to learning opportunities
Person Specification
Specific Requirement for Qualifications Essential Desirable
Good English - Written and verbal YES
RQF qualifications in Social Care YES
Specific Requirement for Skills
Proficient Written Skills
Maintain all Care Plans/care records in accordance with 4Life Healthcare Ltd policy YES
Leadership Skills
Ability to induct and orientate new employees to the job role and service
Provide Service Users with support/assistance as they accomplish daily tasks, including bathing, eating, dressing, grooming and using the bathroom
Communicate any problems, concerns or changes to Service Users’ family members as needed
YES
Communication Skills
Carers must build rapport with Service Users by establishing personal connections and showing interest in their lives
Carers must be able to communicate effectively with Service Users
Carers must have the communication skills to inform colleagues, management and professionals about the needs of Service Users
YES
Problem-Solving Skills
Carers need to be able to adapt and address situations quickly
Plan, develop, implement and assess approaches to promote health and well-being, whilst recognising and reporting situations where there might be a need for protection
YES
Specific Requirement for Previous Experience
Previous experience of working in similar environment YES
Previous experience of working in similar role YES
Experience of working with Service Users, in particular, those that may have additional support needs