GUARDIAN HOMECARE by c17gf7Uo

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									                      EAST MIDLANDS HOMECARE
                                        APPLICATION FOR CARE WORKER


TITLE:          FIRST NAMES:                                        SURNAME:
ADDRESS:



                                                               POST CODE:
TELEPHONE NUMBER:                                   MOBILE NUMBER:
E-MAIL:                        D.O.B:                          NATIONAL INSURANCE NUMBER:

NATIONALITY:                   PLACE OF BIRTH:                    RELIGION:
DATE MOVED IN CURRENT          GENDER MALE / FEMALE:              LANGUAGES SPOKEN:
ADDRESS:
DO YOU HOLD FULL               DO YOU OWN CAR:                    IS IT INSURED FOR BUSINESS USE:
DRIVING LICENCE:

                                              DETAILS OF ALL
                                           EDUCATION & TRANING
                                                                                     FROM          TO




                                               EMPLOYMENT
                                             PAID & VOLUNTRY
                                              DETAILS OF ALL
                          STARTING WITH CURRENT - GAPS WILL NEED TO BE EXPLAINED
FROM       TO      EMPLOYERS NAME & ADDRESS     JOB TITLE      MAIN DUTIES         REASON FOR LEAVING




NB: CONTIUE ON SEPARATE SHEET OR INCLUDE YOUR CV IF REQUIRED


Revised by East Midlands Homecare East Midlands Feb 2011
                                                PRACTICAL EXPERIENCE
                                 PLEASE INDICATE WHERE MOST OF YOUR EXPERIENCE IS FROM
PRIVATE HOUSE ◊           NURSING/RESIDENTIAL HOME ◊ HOSPITAL ◊ NO EXPERIENCE ◊
               RELEVANT COURSES ATTENDED/QUALIFICATION GAINED                                              DATE




                                                        REFERENCES
  PLEASE GIVE THE DETAILS OF 2 REFEREES WHO CAN PROVIDE INFORMATION ON YOUR COMPETENCE IN A CARING ROLE -ONE
                 SHOULD BE YOUR PRESENT OR LAST EMPLOYER-WE CAN’T ACCEPT A RELATIVE OR FRIEND
1. NAME:                                                COMPANY:
POSITION:                                               E-MAIL:
ADDRESS


                                                                                 POST CODE:
TELEPHONE NUMBER:                                       KNOWN FOR                YEARS             MONTHS
2. NAME:                                                COMPANY:
POSITION:                                               E-MAIL:
ADDRESS


                                                                                 POST CODE:
TELEPHONE NUMBER:                                       KNOWN FOR                YEARS             MONTHS

Rehabilitation of Offenders Act 1974 & Theft Act 1968

By virtue of the Rehabilitation of Offenders Act 1974 (Exceptions) (Amendments) Order 1986, the provisions of section 4.2 of
the Rehabilitation of Offenders Act 1974 do not apply to any employment which is concerned with the provision of health
services and which is of such a kind as to enable the holder to have access to persons in receipt of such services in the course of
his/her normal duties.

Because of the nature of our business you are required to submit to a Criminal Records Bureau check. The UKHCA (United
Kingdom Homecare Association) will assist in the obtaining of your CRB check and they will ensure that any disclosures made
by the CRB remain strictly confidential.

 HAVE YOU EVER BEEN CONVICTED IN A COURT OF LAW AND/OR CAUTIONED IN RESPECT OF ANY
                                     OFFENCE
NO ◊     YES ◊ - PLEASE GIVE DETAILS




                                             GENERAL INFORMATION
DO YOU BELONG TO A UNION OR PROFESSIONAL ORGANISATION OFFERING                                   YES □            NO □
INDEMNITY INSURANCE
UNIFORM SIZE -         WHERE DID YOU FIRST HEAR ABOUT US -


Revised by East Midlands Homecare East Midlands Feb 2011
Declaration of Health
If the answer is YES to any of the questions in this section, please give full details including:- date, duration and outcome of the
illness or condition. If EM Home Care has concerns about your fitness to work any contract offer may be subject to a
satisfactory medical report.

                                                 ARE YOU DISABLED
                                 PLEASE GIVE DETAILS OF ANY SPECIAL REQUIREMENTS ETC
NO ◊           YES ◊




                  HAVE YOU EVER HAD:                                 NO                      YES (give details)
Tuberculosis, asthma, bronchitis or chest complaints?

Heart condition, chest pain or raised blood pressure?

A history of stroke, dizziness, blackouts or epilepsy?

Mental health problems such as anxiety, depression,
psychosis or schizophrenia?
Back injury or problems?

Dermatitis or skin problems?

Do you have any allergies (pets, food etc)?

Have you any reason to believe that you may be infected
by any communicable disease?
Any other current medical condition or treatment, which
may affect your attendance or performance at work?
Any illness or medical condition that prevented you from
attending work or your normal duties or activities for
more than one week during the last year?
Any physical disabilities including sight or hearing
problems?
Have you ever undergone any surgical operations?

Do you smoke?


Please give the date of your immunisation for Hepatitis B……………………………………………….




Revised by East Midlands Homecare East Midlands Feb 2011
                                             WORK AVAILABILITY
              PART TI E                                                       F LL TI E
E     Y   O NN S           DAYS              EVENIN S         NI    TS                   WEE ENDS
DO YOU HAVE ANY OTHER WORK                                    YES                        NO
COMMITMENTS
WHEN WOULD YOU BE ABLE TO START                       COMMENTS
         ____ / ____ / ____



     PASSPORTS AND WORK PERMIT DETAIL (OVERSEAS APPLICANTS ONLY)
DO YOU NEED A WORK     YES □   NO □ EXPIRY DATE ___ / ___ / ___
PERMIT -
PASSPORT NATIONALITY - PLACE OF ISSUE -  PASSPORT NUMBER -

DATE OF ISSUE -                         EXPIRY DATE -                    KNOWN RESTRICTIONS-




                                                   DECLARATION
I hereby declare that the information provided on this form is complete and correct and any untrue or misleading information
will give my employer the right to terminate any employment contract offered.

I agree that EM Homecare reserves the right to require me to undergo a medical examination.
I agree that EM Homecare may apply for a criminal records bureau check.


SIGNED. …………………………………..…NAME …………………………………..……………DATE ___ / ___ / ___

Should we require further information and wish to contact your doctor with a view to obtaining a medical report, the law
requires us to inform you of our intention and obtain your permission prior to contacting your doctor.




                                            EQUAL OPPORTUNITES
East Midlands Homecare is an employer embracing equality in race and opportunities for all staff and are selected on
 merit irrespective of race, sex, disability, etc. In order to monitor the effectiveness of our Racial Discrimination and
 Equal Opportunities Policy we would ask all applicants to provide the following information by indicating the broad
                                             ethnic group to which you belong.
WHITE □               BANGLADESHI □                                          BLACK AFRICAN □

INDIAN □               CHINESE □                                            BLACK CARIBBEAN □

PAKISTANI □            BLACK OTHER □ (PLEASE SPECIFY)                       OTHER □ (PLEASE SPECIFY)




Revised by East Midlands Homecare East Midlands Feb 2011
     APPLICANT PRACTICAL ABILITY CHECKLIST
     The following is a comprehensive practical ability list of tasks that the applicant will need to be able to
     undertake. Please tick the tasks that you have experience in providing: -
    Personal Care                                                                            ANY DETAILS
    Supporting service users in dressing/undressing
    Bathing/showering/strip washing
    Bed bathing
    Care of feet (excluding toe nails)
    Mouth care (including dentures)
    Shaving
    Care of hair
    Care of eyes (including spectacles)
    Cleaning of hearing aids
    Changing incontinence pads
    Care of bladder and bowels
    Use of bedpans and commodes
    Emptying catheter bags
    Ensure pressure areas are healthy
    Prompting medication has been taken
    Mobility
    Transferring service users
    Use off hoists (specify manual or electric)
    Use of walking aids
    Use of bathing aids
    Date of last Moving & Handling course you attended
    Nutrition
    Preparing meals for service users
    Following dietary guidelines
    Supporting service users in eating their meals
    General
    Washing laundry
    Bed making
    Changing a draw sheet/bottom sheet with a service user in bed
    Light housework
    Shopping
    Report writing/giving
    Observing a service users well being, any changes, and reporting to the
    appropriate person
    Recording instructions given by a District Nurse of GP
    Service user group experience
    With people affected by dementia
    With Terminal Illness
    With Challenging behaviour
    With elderly people
    With people with learning difficulties
    With Mental Health problems
    With people with Physical disabilities
    With people with Sensory disabilities
    With Children

APPLICANT’S NA E…………………………….. APPLICANT’S SI NAT RE ………………………….DATE ___ / ___ / ___




     Revised by East Midlands Homecare East Midlands Feb 2011
Previous Names:

Due to the information required for a CRB check we are required to submit candidates
previous names and dates of the changes.

                                                                Date of Name Change
Surname at Birth
Name Change
Name Change
Name Change


Previous Addresses:

Please provide all addresses you have lived at in the last 5 years

Address (including post code)                             Date From        Date To




Revised by East Midlands Homecare East Midlands Feb 2011
                    EAST MIDLANDS HOMECARE
                               JOB DESCRIPTION – Care worker

Responsible to: Supervisors, Office Manager and Care Managers

Main Purpose of the Post
You will be working with a professional team of carers working in the community to assist people to live
independent lives in their own homes. Our aim is to promote independence and choice to encourage
people to achieve their full potential and lead a fulfilled and valued life within the community. We
consider and respect each person’s privacy, dignity and rights at all times. We treat all people in society
equally regardless of cultural background, gender, sexuality, religion, gender, age, disability or social
class.


Requirements
      You need not have experience in social care but experience in caring for others in a non
       professional situation may be helpful. You must however have a desire to learn and have a caring
       nature.
      You must be reliable, honest, have good time-keeping skills and be able to follow written and
       verbal instructions.
      You must be able to provide contact details for two referees who should provide a favourable
       reference within 2 weeks of the start of your employment.
      You must consent to a full enhanced CRB check being applied for which should come back clear.



Main Duties and Responsibilities
      To attend to the personal needs of the service user as detailed in the service user’s Care Plan. Tasks
       will include personal care, toileting, assisting in / out of bed, use of hoisting equipment, meal
       preparation, cleaning, washing, shopping, administering of medication.
      To ensure that company policies and procedures are adhered to at all times.
      To ensure that the service provided is of a high standard and maintains service users and carers
       routines and allocated times, therefore not disrupting their normal pattern of living.
      To report any changes in the service user’s circumstances, as soon as practicable, to the manager.
      To ensure that service users receive the necessary support, both socially and emotionally, in a way
       that is culturally and ethnically sensitive, and reflects the service users needs in relation to their
       age, gender, sexuality, social class, disability or religious belief.
      To maintain written records in accordance with East Midlands omecare’s established procedure.




Revised by East Midlands Homecare East Midlands Feb 2011
Induction Training
      You will be employed for a probationary period of 3 months.
          o You will be required to complete induction training. This will involve
          o Several office based sessions
          o A 2.5 day moving and handling course
          o Shadowing of more experienced staff

Ongoing Training
      In order to ensure and maintain a safe working environment, you will be required to attend specific
       training sessions relating to Health and Safety and Moving & Handling.
      You will be required to complete an NVQ2 in Health & Social Care within the first two years of
       employment.
      You will be required to attend ongoing training sessions, which will include training in all aspects
       of care.

Supervision
      You will regularly be spot checked to ensure you are performing all aspects of your job to an
       adequate standard and to also offer you support
      You will be required to attend regular supervision sessions with your supervisor
      You will be required to attend an annual appraisal with the manager

General
This job description provides a guideline only and should not be considered exhaustive and may be
amended after consultation and agreement.


I ……………………………. confirm that I have read understood and agreed the conditions and
requirements outlined above


Signed by …………………………………………………. Date ……………………
(Employee)




Revised by East Midlands Homecare East Midlands Feb 2011

								
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