employment application form - 4life-healthcare.co.uk · 4life healthcare ltd office t6 howitt...

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.

mailto:[email protected]

http://www.4life-healthcare.co.uk/


Telephone – 0115 9984902, 07464706271


1. VACANCY DETAILS POSITION APPLIED FOR

VACANCY REFERENCE NO.

2. PERSONAL DETAILS

TITLE FIRST NAME

SURNAME/

FAMILY NAME

ADDRESS

POSTCODE

TELEPHONE NUMBER 1 BEST TIME TO CONTACT

am / pm / eve

TELEPHONE NUMBER 2 am / pm / eve

EMAIL ADDRESS NATIONAL

INSURANCE NO.

3. PRESENT EMPLOYER (Please State if Unemployed)

EMPLOYER NAME ADDRESS

JOB HELD

BRIEF DESCRIPTION OF DUTIES

DATE EMPLOYED FROM CURRENT SALARY NOTICE PERIOD

4. NURSES

PIN No. EXPIRY

RNA / RN1: Adult nurse

RNMH / RN3: Mental health nurse

RNC / RN8: Children's nurse

RNLD / RN5: Learning disabilities nurse

NAR: Nursing associate

Employment Application Form (V 1.3)

NOTE TO APPLICANTS

Data Protection – this application will be used for management and administration purposes as well as

monitoring the application of 4Life Healthcare Equal Opportunities policy in employment. By providing any

information on this form you give your consent to allow this information to be processed.




Telephone – 0115 9984902, 07464706271


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)

DATE OBTAINED

Employment Application Form




Telephone – 0115 9984902, 07464706271


7. SUPPORTING STATEMENT

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?

Reference 1 YES NO Reference 2 YES NO





Telephone – 0115 9984902, 07464706271


9. ADDITIONAL INFORMATION

Do you own or have access to a motor vehicle?

Yes No Do you hold a full current driving

license? Yes No

Do you have any driving endorsements?

Yes No

Licence No:

Do you know or have any relationship with any other 4Life Healthcare Ltd member of staff?

If yes, please state name and job title:

YES NO

In the last 5 years, have you lived or worked outside of the UK for more than 3 months? Yes No

If yes, please give details (please provide official

documents where possible)

10. ELIGAGBILIY TO WORK IN THE UK

Are you currently eligible to work in the UK? YES NO

Please state below what documentation you can provide in order to demonstrate this (e.g. British passport/birth

certificate/European Economic Area identity card/travel document, showing an authorization to reside and work in the UK etc.)

DOCUMENT COUNTRY OF ISSUE ISSUE DATE

EXPIRY DATE

DOCUMENT NUMBER

11. STATEMENT To the best of my knowledge and belief, the information contained in this form is accurate. I understand that any false declaration or

misleading statement or any significant omission may disqualify me from employment and render me liable to dismissal. I understand the

job offer is subject to satisfactory pre-employment checks including references and satisfactory Enhanced DBS Clearance. I accept that 4Life

Healthcare Ltd will take reasonable steps to verify the accuracy of the information I have provided.

PRINT NAME DATE

SIGNATURE





Telephone – 0115 9984902, 07464706271


NAME: DOB:

POSITION APPLIED FOR:

QUESTIONS YES NO COMMENTS

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.

SIGNED: DATE:




Telephone – 0115 9984902, 07464706271


EQUALITY AND DIVERSITY MONITORING

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.

Signature: Date:




Telephone – 0115 9984902, 07464706271


DBS PERSONAL DETAILS FORM

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 -:

Applicant signature: Date:




Telephone – 0115 9984902, 07464706271


DBS Personal Details Form (cont.)

Address History:

Address 2

Postcode

Move in date (mm/yyyy) Move out date (mm/yyyy)

Address 3

Postcode


Address 4

Postcode


Previous Surnames:

Surname

From (mm/yyyy)

To (mm/yyyy)

Surname

From (mm/yyyy) To (mm/yyyy)

If you need to add more addresses, please use a separate sheet and attach to this form.

Office Use Verification of ID Documents:

Passport Number Issue Date

Driving License

Driver Number Issue Date

For all other ID Documents — Please check that they are within 3 months of current date

Signature Date




Telephone – 0115 9984902, 07464706271


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.

Signed: Name: Date:




Telephone – 0115 9984902, 07464706271


CODE OF CONDUCT

Policy brief and purpose Our code of conduct company policy outlines our expectations regarding employee’s behavior towards their

colleagues, clients, supervisors and overall organizations. We promote freedom of expression and open

communication. But we expect all employees to follow our Code of Conduct. They should avoid offending,

participating in serious disputes and disrupting any workplace they are in. We also expect them to foster a well-

organized, respectful and collaborative environment.

Scope This policy applies to all our employees regardless of agreement or rank.

Policy elements Company employees are bound by their contract to follow our employee Code of Conduct while performing their

duties. We outline the components of our Code of Conduct below.

Compliance with the law

All employees must protect our companies and clients legality. They should comply with all environmental,

safety and fair dealing laws. We expect employees to be ethical and responsible when dealing with our

company’s products, partnerships, clients and the public image of our company and our clients.

Respect in the workplace

All employees should respect their colleagues. We won’t allow any kind of discriminatory behavior,

harassment or victimization. Employees should conform with our equal opportunity policy in all aspects of

their work, from recruitment and performance evaluation to interpersonal relations.

Protection of company property

All employees should treat our companies or clients property, whether material or intangible, with respect

and care.

Employees:

Should not misuse company or clients equipment or use it frivolously.

Should respect all kinds of our companies or clients property, this includes information, reports,

uniform, equipment, etc.

Professionalism

All employees should show integrity and professionalism in the work place such as personal appearance, all

employees must follow our dress code and personal appearance guidelines.

Corruption

We discourage employees from accepting gifts from clients or residents. We prohibit briberies for the

benefit of any external or internal party.




Telephone – 0115 9984902, 07464706271


Job duties and authorities

All employees should fill their duties with integrity and respect towards our clients and other members of

staff. Supervisors and managers must not abuse their authority. We expect them to delegate to their team

members taking into account their competence and workload. Likewise, we expect team members to follow

their team leader’s instructions and complete their duties with skill, compassion, care, dignity and respect

for the clients. We encourage mentoring and shadowing throughout our company.

Absenteeism and tardiness

We expect employees to be punctual when attending a client, if designated a shift that you are unable to do

you must let us know as soon as possible.

Collaboration

All employees should be friendly and collaborative. They should not disrupt the workplace or present

obstacles to their colleagues at work.

Communication

All employees must be open for communication to their colleagues, supervisors or team members.

DISIPLINARY ACTIONS Our company may have to take disciplinary action against employees who repeatedly or intentionally fail to follow

our Code of Conduct. Disciplinary actions will vary depending on the violation.

Possible consequences:

Reprimand

Supervision

Suspension

Termination

We may take legal action in cases of corruption, theft, embezzlement or other unlawful behaviour.

I have read and agree to the terms stated in the agreement above

Print Name ____________________________________________

Signature ____________________________________________

Date ____________________________________________




Telephone – 0115 9984902, 07464706271


Confidentiality Agreement

Confidentiality Contract

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

7) Staff Guidance on Data Breaches

Print Name:

Signature:

Date:




Telephone – 0115 9984902, 07464706271


Recruitment Privacy Consent Statement

By submitting an application to us whether directly to the Recruitment Team, via our

applicant tracking system or a referral you are authorising us to use your personal

data provided to us, in relation to the role that you are applying for.

You are also authorising us to hold your personal data within our candidate

database for reference to future roles with 4Life Healthcare Ltd, and to contact you

regarding any such roles.

Any data submitted will be used for recruitment purposes, and any other sales or

marketing activities which we feel would be relevant to you. We may share your

information with our clients and other third parties, such as government bodies, in

order to provide you with work placements and to allow the monitoring of our

compliance to contractual and legislative requirements.

As a candidate who has supplied their personal details you have the right to be

forgotten. At any time you can therefore request, that your personal data be

removed from our systems by emailing

[email protected] if however, you commence work with

the Company, then we retain the right to decline any request to be forgotten, as we

may need to retain your personal data for regulation purposes.

□ I consent to 4Life Healthcare Ltd holding and processing my personal data as

specified in the statement

□ I do not consent to 4Life Healthcare Ltd holding and processing my personal data

as specified in the

Name:____________________________________________________

Signature:_________________________________________________

Date: _______________________





Telephone – 0115 9984902, 07464706271


Dress code

Whilst we aim to ensure that all 4Life healthcare employees adhere to a smart /casual dress code, if the

client requires particular dress code 4Life healthcare we will inform you as soon as possible.

All employees must be aware of the following standard dress code:

• Smart /casual black trousers

• No jeans

• Polo shirt with company logo, this will be supplied

• Smart black flat shoes

• No trainers

• No jewellery, apart from a wedding band

• No offensive logos or pictures




Telephone – 0115 9984902, 07464706271


Last Reviewed: 02/04/2019

Job Description – CARER

Version: 1.3




Telephone – 0115 9984902, 07464706271


Responsibilities and Duties of the Job

Role Specific Duties:

Ensure Service Users are at the heart of care delivery and their wishes and preferences enhance

their wellbeing

To contribute to the efficient running of the service

Support Service Users to maintain their relationships and connections with the local community

Ensure Care Plans and other information about how to support Service Users are followed

Be responsible for informing the Senior Carer/Nurse of any changes in the needs of Service Users

Be responsible for promoting and safeguarding the welfare of those individuals they support

Working with Others:

Develop effective working relationships with other employees within 4Life Healthcare Ltd

Work in cooperation with members of the multi-disciplinary teams to maximise opportunities for

Service Users

If desired by the Service User, maintain and develop relationships with family, friends and other people important in their life

Leading by Example:

Seek opportunities for personal and professional growth

Be a role model for other carers and be an ambassador for the service

Be professional, polite and reasonable at all times

Values Based Job Description and Person Specification

Job Title: Domiciliary Carer

Reports to: Senior Carer / Nurse / Registered Manager

Job Overview: (Note: In addition to these functions employees are required to carry out such duties as may reasonably be required)

To provide care in accordance with best practice and legislative requirements, reflecting policies and procedures and agreed standards

under the direction of the Senior Carer/Nurse

To support and enable Service Users to maintain skills and personal

interests whilst delivering person-centred care unique to each individual

To maintain skills at a current level, undertake such training and development as required from time-to-time to maintain and progress knowledge

Location: 4Life Healthcare Ltd, but you may be required to work from other locations at the discretion of the company and with appropriate notice.

Working Hours: 5 days over 7-day period, with varying shift patterns as agreed with the manager.

Job Description - Carer




Telephone – 0115 9984902, 07464706271


Personal Responsibilities:

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

YES




Telephone – 0115 9984902, 07464706271



VALUE BASED PERSONAL QUALITIES

Area Specific Requirement

Working

Together

Involve Service Users, family, external agencies & colleagues

Speak up when things go wrong

Respect and

Dignity

Understand person-centred care and can demonstrate treating people as individuals and respecting choices

Promoting independence and encouraging appropriate risk taking

Everybody

Counts

Ensuring no one is discriminated against or excluded

Understand human rights and impact on care delivery

Facilitating people to ‘speak up’ about concerns and acting upon them

Commitment

to Quality of

Care

Striving for quality in everything we do recognising and understanding what quality in care means for people using the services

Being accepting about criticism and focusing on improvement

Being open to new opportunities for learning and identifying the limits of skills and knowledge

Compassion

Treating people with kindness Understanding the importance of empathy in all areas of

employment Understanding the values of others and always providing a

caring service

Improving Lives

Focus on how things could be done better and sharing ideas

Understanding of wellbeing and what is important to people using the service

Improving outcomes for people Ensuring appropriate services are provided for people using

the services




Telephone – 0115 9984902, 07464706271



Declaration

I declare that I have read and understood the job description (Version 1.3) and agree to work in

accordance with the description of this role. I also declare that I have read and understood the ‘Values

Based Personal Qualities’ and agree to abide by the principles as stated.

Print Name: Date:

Signature:

