Complex Care

Step 1 of 13

Welcome to MCO Healthcare, we look forward to working with you!

Section One: PERSONAL INFORMATION

Title (Mr./Miss/ Mrs./ etc.):(Required)

Name:(Required)

Surname:(Required)

Gender:(Required)

Nationality:(Required)

Address:(Required)

Post Code:(Required)

Home Telephone Number:

Mobile Number:(Required)

Email Address:(Required)

Confirm Email Address:(Required)

NMC/Professional Body Pin:

NI Number:

Next of Kin name:(Required)

Relationship(Required)

Contact Number:(Required)

Email:(Required)

Relationship:(Required)

Address:(Required)

Are you related by blood, marriage or civil, domestic, or legal partnership to any employee, director or board member or MCO Healthcare or any affiliated or subsidiary company?(Required)

Yes

If Yes, please give details:

Section Two: YOUR TRAVEL & WORK PREFERENCES

Are you a driver?(Required)

Yes

How far are you willing to travel?(Required)

Would you relocate for work (with accommodation)?(Required)

Are you currently in regular work?(Required)

Which Shift Patterns do you prefer? (Any/Days/Nights/Weekends)(Required)

Preferred Days:(Required)

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Do you have any allergies?(Required)

Are you happy to work within a home that has pets?(Required)

Yes

If yes, please state:(Required)

Dogs

Cats

Section Three: Citizenship / Immigration Status

Are you a United Kingdom (UK), European Community (EC), European Economic Area (EEA) Citizen?(Required)

Yes

If no, please detail your current immigration status and the relevant visa currently held (including Visa Number):(Required)

Section Four: Equality, Professional Conduct, Rehabilitation of Offenders

Under the Equality Act 2010, the definition of disability is if you have a physical or mental impairment that has a “substantial” and “long-term adverse effect” on your ability to carry out normal day-to-day activities. Further information regarding the definition of disability can be found at www.gov.uk/definition-of-disability-under-equality-act-2010.

For the purposes of this application and interview stage only, is there anything you would like us to be aware of so that we can make reasonable adjustments during the process?(Required)

Yes

Prefer not to say

Have you ever been the subject of an investigation or professional misconduct proceeding or disciplinary action from an employer or is such threatened or pending against you either in the UK or abroad?(Required)

Yes

If Yes, please supply details:

Have you ever been suspended or removed from the register of any professional body such as the Nursing and Midwifery Council. General Social Care Council, General Medical Council or their equivalents in other countries?(Required)

Yes

If Yes, please supply details:

Have you ever been permanently or temporarily placed on a Sex Offenders Register, the Protection of Vulnerable Adults or the Protection of Children Lists or the Register of Persons Banned from working with Children or Vulnerable Adults kept by the ISA or the Disclosure and Barring Service or similar?(Required)

Yes

If Yes, please supply details:

Disclosure Of Criminal Convictions (Spent and unspent) All applications must disclose details of any spent or unspent criminal convictions or police cautions, reprimands, or final warnings they may have received in the UK or aboard. This is because jobs within the organisation are covered by the Rehabilitation of Offence Act 1974 (Exceptions) Orders 1975 (Amended) 1986. You are required to include information about convictions which may be otherwise considered ‘spent’. However, you may omit details omit details of anything which (in line with current guidance) will be filtered out from a disclosure and barring service DBS enhanced disclosure. The information you provide will be treated as strictly confidential and will only be considered where it seems a reasonable relevant to the appointment for which you are applying for. Disclosure of any information does not necessary mean that you will not be considered for appointment First option healthcare will take in account (among other things) the ACAS code of guidance. A main consideration will be there whether the offence is 1 which would make an applicant unsuitable to work with children or vulnerable adults and the type of work to be done. However please note that we may be contractual obliged to reveal the content of the disclosure to customers and by signing this application form you give your consent for us to do this and for us to continue with yearly updates. In accordance with care sector regulations if you do not have suitable personal registration with the DBS update service you will need a new enhanced disclosure before you can work for MCO healthcare. We will help you obtain this. Once received you must forward your original copy of your disclosure to us. This will be copied and the original returned to you. You also need to show us the result of any checks of the courts and police records from other countries in which you have lived. The information you declare below will be compared with the results of these disclosures. Each will be necessary for disclosure checks to be obtained at your own expenses. DBS disclosures and update service checks will include checks of the list of persons banned from working with children and vulnerable adults.

Information about Convictions etc (Please read the above before answering)

Date

Outcome

Information about Convictions etc (Please read the above before answering)

Date

Outcome

Are you providing any information in a separate letter or email?

Yes

Print Full Name(Required)

Signature(Required)

Date(Required)

MM slash DD slash YYYY

Section Five: Complex Care

Complex Care – please tick any skill that you have had training for or have experience in(Required)

Tracheostomy Care

Medication Administration

Nebuliser Administration

NG Tube Management & Care

NJ Tube Management & Care

Oxygen Saturations

IV Therapy

Bowel Management

PEG- Feeding

Cough Assist

Epilepsy

Invasive Ventilation

Non-Invasive Ventilation

Diabetes and Insulin

Female Catheter Care

Colostomy

Oral Suctioning

Invasive Suctioning

Seizure Management

Dysphasia

Oxygen Therapy

CPAP/BiPAP

Male Catheter Care

lleostomy

Other

If you selected "other", please specify here:

How many months/years of healthcare experience do you have?(Required)

Please tick boxes below to indicate areas that you have experience in

Live-in Care

Domiciliary / Homecare

Nursing Home

Hospitals

Complex Care

Other

If you selected "other", please specify here:

Basic Patient Observation – please tick any skill tht you have had training for or have experience in

Glucose Readings

Skin Integrity

Fluid balance monitoring

Obtain samples- urine, sputum, faeces

Use of Syringes

Correct use of PPE

Pressure sores

Admission/Discharge Planning

Knowledge of Sepsis pathway

Basic wound care

Complex wound care

Incident / Accident reporting

Complex Needs nnd Mental Health – please tick any skill tht you have had training for or have experience in(Required)

Autistic Spectrum Disorders

ADD/ADHD

Makaton/BSL

Eating Disorder

Speech and Language Impairment

Brain Injury

Break away and physical intervention

Psychosis

Addiction

Post-Traumatic Stress

Schizophrenia and Personality Disorder

Obsessive-Compulsive Disorder

Other

If you selected "other", please specify here:

Section Six: Education & Training

Education History

To(Date)

DD slash MM slash YYYY

From(Date)

DD slash MM slash YYYY

Educational Establishment

Course Title

Qualification Achieved

From(Date)

DD slash MM slash YYYY

To(Date)

DD slash MM slash YYYY

Educational Establishment

Course Title

Qualification Achieved

From(Date)

DD slash MM slash YYYY

To(Date)

DD slash MM slash YYYY

Educational Establishment

Course Title

Qualification Achieved

From(Date)

DD slash MM slash YYYY

To(Date)

DD slash MM slash YYYY

Educational Establishment

Course Title

Qualification Achieved

TRAINING COURSES ATTENDED OR COMPLETING (EVIDENCE REQUIRED)

Training 1:

Location:

Details:

Date:

MM slash DD slash YYYY

Training 2:

Location:

Details:

Date:

MM slash DD slash YYYY

Training 3:

Location:

Details:

Date:

MM slash DD slash YYYY

Training 4:

Location:

Details:

Date:

MM slash DD slash YYYY

Organisation Name

Membership Number

Renewal Date

MM slash DD slash YYYY

Details

Organisation Name

Membership Number

Renewal Date

MM slash DD slash YYYY

Details

Section Seven: Employment History

Employment History

From(Date)

DD slash MM slash YYYY

To(Date)

DD slash MM slash YYYY

Name of Organisation

Position Held

Reason for Leaving

From(Date)

DD slash MM slash YYYY

To(Date)

DD slash MM slash YYYY

Name of Organisation

Position Held

Reason for Leaving

From(Date)

DD slash MM slash YYYY

To(Date)

DD slash MM slash YYYY

Name of Organisation

Position Held

Reason for Leaving

From(Date)

DD slash MM slash YYYY

To(Date)

DD slash MM slash YYYY

Name of Organisation

Position Held

Reason for Leaving

From(Date)

DD slash MM slash YYYY

To(Date)

DD slash MM slash YYYY

Name of Organisation

Position Held

Reason for Leaving

Section Eight: Referees

Please provide names, addresses and telephone numbers for referees below who we may approach for a reference. You must provide references from your two most recent employers. In line with CQC requirements, we require references covering your last 5 years of employment. If you have not had more than one employer in the last five years, we require further reference. Please provide 2 character references if you are unable to obtain two professional references, e.g. in the case of an applicant who has been raising children for 10 years. All will be contacted, therefore, please inform the referees of the fact that you have used their name. If you are unable to provide the required references, please discuss the matter with us.

1. Name:(Required)

Company & Address:(Required)

Telephone:(Required)

Email Address:(Required)

Professional Relationship:(Required)

2. Name:(Required)

Company & Address:(Required)

Telephone:(Required)

Email Address:(Required)

Relationship:(Required)

Section Four: DECLARATION – 48 HOUR OPT OUT

THE 48 HOUR MAXIMUM AVERAGE WORKING WEEK The Working Time Regulations 1998 provide that the average working week, including overtime, shall not exceed 48 hours. The Company and the Worker agree that this limit shall not apply to the Worker. This Agreement will remain in force indefinitely. The Worker, or the Company, may terminate this Agreement at any time by giving not less than one months’ written notice to the other. I understand that I may withdraw this consent by giving MCO Healthcare not less than one months’ notice.

48 Hour Opt in/out(Required)

By ticking this box. you opt-in to working in excess of an average of 48 hours per week.

By ticking this box, you opt-out of working in excess of an average of 48 hours per week.

Signature

Date

MM slash DD slash YYYY

Section Nine: Declaration

We will only collect data for specified explicit and legitimate use in relation to the recruitment process. By signing this application form, you consent to holding the information contained within this application form. If successfully shortlisted, data will also include shortlisting scoring and interview records. We would like to keep this data until the vacancy is filled. (We cannot estimate the exact time period, but we will consider this period over when a candidate accepts our job offer for the position for which we are considering you). When that period is over, we will either delete your data or inform you that we would like to keep it in our database for future roles. The information in this application form is true and complete. I agree that any deliberate omission, falsification or misrepresentation in the application form will be grounds for rejecting this application or subsequent dismissal if employed. Where applicable, I consent that the company can seek clarification regarding professional registration details. We have privacy policies that you can request for further information. Please be assured that your data will be securely stored by the Registered Manager and only used for the purposes of recruiting for this vacant post. You have a right for your data to be forgotten, to rectify or access data, to restrict processing, to withdraw consent and to be kept informed about the processing of your data. If you would like to discuss this further or withdraw your consent at any time, please contact the Registered Manager to discuss.

Print Full Name(Required)

Signature(Required)

Date(Required)

MM slash DD slash YYYY

Section Ten: Supporting Statement

It is a statutory requirement that all employees in the healthy sector go through a health check risk assessment for their safety and that of patients. Also, it will help Platinum healthcare staffing to make necessary adjustments to find out your needs in performing the job role better.

Your answers to the following questions are confidential and will not be disclosed to anyone without your written consent.

Please add here your reasons for applying. You should refer to the job description and person specification to guide you. It would also be of value to describe strengths and talents that set you apart from others as well as including skills gained from work, home and other activities.(Required)

Section Eleven: Supplementary

If I were a Service User, I would like:(Required)

I believe that the Service User's family and relatives would like the following:(Required)

I believe that I can support a Service User because: would like the following:(Required)

As a member of the team. I would feel valued when: would like the following:(Required)

I believe that a good relationship between me and the Service User depends upon:ould like the following:(Required)

I believe that I learn best when:(Required)

I believe that a good working team is made by:(Required)

I believe that my role in relation to the Service User is:(Required)

My other beliefs and values relevant to my job role are:(Required)

Declaration

I confirm that all the information and statements l have provided above are all true to the best of my knowledge and do understand that any intentional misrepresentation by myself on any part of the application will result in it being invalid and hence dismissal. I give my consent to the Agency to carry out any checks necessary including;

Giving permission for Platinum Healthcare Staffings to apply for an Enhanced DBS Check/Disclosure or verify my existing DBS certificate via the Update Service, when I register with the agency and on an ongoing annual basis. I give permission for my personal data to be shared with U-Check to process my check.

Giving my permission for Platinum Healthcare Staffings to contact and share my personal data with the UKBA/ Home Office / Embassy to perform any necessary eligibility checks (including but not limited to Biometric Residence Permit / ECS checks) on my right to work in the UK.

Giving my permission for Platinum Healthcare Staffings to contact and share my personal data with any organisation where I have worked in the last three years for the purpose of obtaining or validating a reference and give permission for references to be released to Platinum Healthcare Staffings .

Giving permission for Platinum Healthcare Staffings to contact and share my personal data with any organisation where I have worked in the last three years for the purpose of obtaining or validating a reference and give permission for references to be released to Platinum Healthcare Staffings .

Giving permission for Platinum Healthcare Staffings to share my documentation which holds my personal data to verify and validate my occupational health results, qualifications and training certificates where necessary.

I expressly consent to all the data contained in my personal file being made available to both internal and external auditors and organisations where I have been placed and any prospective clients for audit, review and inspection purposes.

If, during the course of my temporary assignment and a client wishes to employ me directly, I acknowledge that Platinum Healthcare Staffings will be entitled to charge the client a transfer fee.

Name (AS printed on ID):

Signature

Date(Required)

DD slash MM slash YYYY

Section One: PERSONAL INFORMATION

Section Two: YOUR TRAVEL & WORK PREFERENCES

Section Three: Citizenship / Immigration Status

Section Four: Equality, Professional Conduct, Rehabilitation of Offenders

Section Five: Complex Care

Section Six: Education & Training

Section Seven: Employment History

Section Eight: Referees

Section Four: DECLARATION – 48 HOUR OPT OUT

Section Nine: Declaration

Section Ten: Supporting Statement

Section Eleven: Supplementary

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