Anonymous Message to Directors

IMPORTANT: This form cannot be used to report any concerns or instances of abuse. In these cases, you must follow correct procedure, reporting it to your manager and if necessary directly to James. Such cases cannot be reported anonymously under any circumstances, as we may need to gather more information from you to investigate the matter fully.

You can contact the directors at any time by phone or email to discuss any issues and we will always aim to maintain confidentiality. Contacting us directly allows us to address your concerns much more effectively as we can get all the relevant details from you.

We do however appreciate that sometimes you may not be comfortable raising issues directly with us. In such cases, you can use the below form to raise issues anonymously.

"*" indicates required fields

Position Applied For

Home Applied for*

In which home are you applying to work?

Which homes would you be willing to work in?

Please tick which homes you are able to travel to for work.

Southside (Hall Green, Birmingham)

Holly House (Acocks Green, Birmingham)

Karenza (Rowley Regis, Birmingham)

The Beeches (Rowley Regis, Birmingham)

Are you currently working?*

Yes

What is your notice period?

How much notice will you need to give your current employer, or when will you be available to start work with us?

Will you continue in any other employment?*

If you obtain this position, will you continue in any other employment?

Yes

Details of other employment

Please give details of any other jobs, including the hours you will work there and whether we will need to schedule your shifts around another job.

Is your ability to perform this job limited in any way?*

Yes

Details of Limitations

Please give details of your limitations, including how we could help you to overcome them.

Special Requirements*

Do you require any special arrangements during the recruitment process, e.g. large print forms or additional time?

Yes

Details of Special Arrangements

Please give details of all special arrangements required.

Restrictions to capacity to work in the UK*

Are there any restrictions to your residence in the UK or working permissions, e.g. a time limited work permit or restrictions to the number of yours you can work?

Yes

Details of UK work restrictions

Please give further details of any restrictions to your residence in the UK or working permissions.

Name*

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone

Mobile Phone

Email*

Do you have a full and current driving license?*

Yes

Do you have any penalty points, convictions or restrictions on your license?

Yes

License Details

Please list all penalty points, convictions and restrictions on your license, including any relevant dates.

Absences

Please list any absences from work (other than annual leave) during the past 12 months.

Reason for Absence

Length of Absence

How many hours per week would you like to work?*

Which shifts are you available to work?*

Tick all shifts that you're willing to work.

Days (8am to 8pm)

Nights (8pm to 8am)

Restrictions

Please list any days or hours during the week which you CANNOT work. If you leave this blank then we will assume that you are available 7 days per week.

Employment History

Do you have a CV?*

Tick yes if you have an up to date CV, cover letter or any other document you want to submit with your application.

Yes

CV Upload

Upload CV, cover letter or any other documents to support your application.

Drop files here or

Max. file size: 100 MB.

Does your CV contain a complete and up to date work history?*

Yes

Employment history

Please list entire employment history

Name of Employer

Start Date

Leave Date

Duties

Reason for Leaving

How many years experience do you have working in Care?*

How many years experience do you have working with people with Dementia?*

How many years experience do you have working with people with Challenging Behaviour?*

How many years experience do you have working in a Senior Role?*

Qualifications and Training

Does your CV contain details of all your qualifications and training?*

Yes

Qualifications

Please list all qualifications you hold, including GCSE, A-Level, Degrees, Diplomas, NVQ/QCF and any others you deem relevant.

Qualification

Date Completed

Result/Grade

Training

Please list all relevant training you hold.

Training Course

Date Completed

Date of Expiry (if applicable)

NVQ/QCF Level*

If you hold an NVQ/QCF or similar vocational qualification, please select which level you hold.

References

Employment Reference

Please give details of your most recent previous employer, and any other employers from whom we can obtain a reference.

Employer Name

Supervisors Name

Email Address

Address

Phone Number

Character Reference

Please give details of at least one responsible person who is not related to you and is over 18.

Name

Relationship to you

Email Address

Address

Phone Number

Criminal Records Check

Workers of The Home are subject to the Health and Social Care Act 2008, and will be subject to a Police Record Check through the DBS. Please declare all criminal convictions, whether spent or not, charges, whether proceeded with or not, and warnings and cautions.Please note, you may not be eligible for work in a care setting if you are on the DBS Register(s).

Do you have any criminal convictions, charges, warnings or cautions to declare?*

Declare all criminal convictions, whether spent or not, charges, whether proceeded with or not, and warnings and cautions.

Yes

Criminal Convictions

Please list all criminal convictions, whether spent or not, charges, whether proceeded with or not, and warnings and cautions below.

Conviction

Date

Further Details

SIGNATURE and DECLARATION – IMPORTANT – READ BEFORE SIGNING*

I declare that to the best of my knowledge and belief the information given by me in this application is true, and I understand that the above information forms the basis of my contract of employment. I understand that if any of the information supplied by me is found to be falsely declared, my contract may have been fundamentally breached and my employment may be terminated immediately. I understand that I may not be offered a post until a satisfactory response has been received with respect to my DBS Register status, and that should I subsequently be offered a post, that offer will be subject to receipt of two satisfactory references, one of which must be from my previous employer, and that confirmation of the employment will be subject to a satisfactory criminal record check from the DBS. I understand that until a satisfactory response is received from the DBS, and my employment is confirmed, I will be supervised at all times at work, and will not seek or have unsupervised access to vulnerable people. If the post I have applied for is as a Registered Nurse, my confirmation of employment will also be subject to a satisfactory search of the Nursing and Midwifery Council records and registers. By my signature, I authorise JW Care Group to request a DBS Register check and a criminal records check from the DBS, on initial employment and at any time during my employment thereafter. I undertake to inform my employer immediately if my DBS Register status or criminal status changes at any time during my employment, such as by being charged with an offence (other than motoring offences), the administering of a warning, criminal conviction, referral to any register of barred care workers, or withdrawal of any registration required by my employment status.

Declaration read and understood

Do you have any more information to provide in support of your application?