Important — please read before completing this form

Quality Staffing Care recruits in line with the standards of the Care Inspectorate Wales (CIW) and the Care Quality Commission (CQC). To meet our safer-recruitment duties we must collect a full employment history, two professional references, satisfactory DBS clearance, and confirmation of your right to work in the UK. Any false or omitted information may result in withdrawal of any offer of work.

All required fields are marked *. Your data is processed in line with the UK GDPR — see Section 13.

Position applied for *

Date of application *

Section 1 — Personal details

Title *

Surname *

Forename(s) in full *

Any previous names / known by

Date of birth *

National Insurance number *

Nationality *

Country of birth

Mobile number *

Alternative number

Email address *

Current home address *

Postcode *

Time at this address

Previous address (if less than 5 years at current)

Emergency contact

Full name *

Relationship to you *

Contact number *

Alternative number

Section 2 — Right to work in the UK

CIW and CQC require evidence of your right to work in the UK before you can start. You will be asked to bring your document or share code to interview.

Do you have the legal right to work in the UK? *

YesNo

Do you require sponsorship to continue working in the UK? *

YesNo

Document type

Document number

Visa type (if applicable)

Visa expiry date

Home Office share code

Restrictions on hours / conditions

Section 3 — Position applied for

Role(s) applying for *

Care AssistantSupport WorkerSenior CarerRegistered Nurse (RGN/RMN)Other
If other, please specify:

Employment basis *

Full-timePart-timeBank / FlexibleEmergency cover only

Areas willing to work *

CardiffVale of GlamorganRhondda Cynon TafCaerphillyNewportBridgendSwanseaOther
Other area:

Hours available per week

Earliest start date

Notice period required

How did you hear about us?

Section 4 — Full employment history

Please list ALL employment in date order, most recent first, including any periods of unemployment, study, travel, or caring responsibilities. CIW and CQC require a complete history with no unexplained gaps.

Employer 1 (most recent)

Employer name

Job title

Employer address

From (MM/YYYY)

To (MM/YYYY)

Salary / hourly rate

Reason for leaving

Manager / supervisor name & contact

Key duties & responsibilities

Employer 2

Employer name

Job title

Employer address

From (MM/YYYY)

To (MM/YYYY)

Salary / hourly rate

Reason for leaving

Manager / supervisor name & contact

Key duties & responsibilities

Employer 3

Employer name

Job title

Employer address

From (MM/YYYY)

To (MM/YYYY)

Salary / hourly rate

Reason for leaving

Manager / supervisor name & contact

Key duties & responsibilities

Employer 4 (or earlier history)

Employer name

Job title

Employer address

From (MM/YYYY)

To (MM/YYYY)

Salary / hourly rate

Reason for leaving

Manager / supervisor name & contact

Key duties & responsibilities

Explanation of any gaps in employment

Please account for any periods of more than four weeks where you were not in paid employment, education, or training.

Gap details

Section 5 — Qualifications, training & professional registration

Education and qualifications

List your school / college / university qualifications (most recent first)

Care-specific qualifications

Tick all that apply

Care Certificate (15 standards)QCF / RQF Level 2 in Health & Social CareQCF / RQF Level 3 in Health & Social CareQCF / RQF Level 4 / 5 in Leadership & Management for CareNMC registration (Registered Nurse)Social Care Wales registration

NMC PIN

NMC expiry

Social Care Wales reg. number

Other care qualification

Mandatory training (last 12 months)

Tick training completed

Safeguarding adults (and children)Manual handling / moving and positioningMedication administrationInfection prevention and controlBasic life support / first aidFood hygiene and safetyHealth and safety / fire safetyMental Capacity Act and DoLS / LPSEquality, diversity and human rightsDementia awarenessOliver McGowan training (LD & autism)GDPR and data protection

Section 6 — Skills and areas of care experience

Tick all areas in which you have hands-on experience

Elderly careDementia / Alzheimer'sEnd-of-life / palliative careLearning disabilitiesAutism supportChallenging behaviour / PBSMental health supportAcquired brain injuryPhysical disabilitiesChildren & young people with special needsComplex care / 1:1 supportStoma, catheter and continence carePEG feedingTracheostomy / suctioningEpilepsy management (incl. buccal midazolam)Diabetes / insulinDomiciliary / home careResidential / nursing homeSupported living

Personal statement

Briefly tell us why you are applying to Quality Staffing Care, the values you bring to care work, and any relevant skills (max 300 words).

Section 7 — Driving and transport

Do you hold a full UK driving licence?

YesNo

Any current endorsements / penalty points?

NoYes (give details below)

Details of endorsements (if any)

Do you have access to your own vehicle for work?

YesNo

Business-use insurance in place?

YesNoN/A

Section 8 — Health declaration & reasonable adjustments

Quality Staffing Care is committed to the Equality Act 2010. This information is collected so we can support you safely and make any reasonable adjustments. It will not be used to discriminate against you.

Do you consider yourself to have a disability or long-term health condition?

YesNoPrefer not to say

Are there any reasonable adjustments we should consider for interview or work?

Any health condition, medication, or allergy we must be aware of for safe working?

How many days of sickness absence have you had in the last 12 months?

Section 9 — DBS & criminal record disclosure

Important: This post is exempt from the Rehabilitation of Offenders Act 1974. You must declare ALL convictions, cautions, reprimands and final warnings, including those that would otherwise be considered spent. Failure to disclose may lead to dismissal. Information disclosed will be treated in the strictest confidence and used only for the purpose of assessing suitability for work involving children or adults at risk.

Do you have a current Enhanced DBS certificate?

YesNo

DBS certificate number

Date of issue

Are you registered with the DBS Update Service?

YesNo

Have you ever been convicted of a criminal offence, received a caution, reprimand or final warning?

NoYes (give details below)

Are you currently the subject of any criminal investigation?

NoYes

Are you barred from working with children or adults at risk by the DBS Barred List?

NoYes

Have you been the subject of any safeguarding investigation, disciplinary proceeding, or referral to the DBS, Social Care Wales, NMC or other professional body?

NoYes (give details below)

Details (if you answered Yes to any of the above)

Section 10 — References

Please provide TWO professional references covering at least the last three years of employment. One MUST be your most recent or current employer. Personal referees, family members and friends are not acceptable.

Reference 1 — most recent employer *

Full name *

Job title *

Organisation *

Email *

Telephone *

Relationship to you

Dates known

Address

May we contact this referee before interview?

YesNo — only after conditional offer

Reference 2 *

Full name *

Job title *

Organisation *

Email *

Telephone *

Relationship to you

Dates known

Address

May we contact this referee before interview?

YesNo — only after conditional offer

Section 11 — Availability

Please indicate the days and shifts you are available to work. Quality Staffing Care provides 24/7 emergency cover, so flexibility is highly valued.

Day shifts available

MonTueWedThuFriSatSun

Night shifts available

MonTueWedThuFriSatSun

Sleep-in shifts available

MonTueWedThuFriSatSun

Are you available for emergency / short-notice cover?

YesNo

Notice required to start a shift

Currently working elsewhere?

Average hours worked elsewhere per week

Section 12 — Equal opportunities monitoring (optional)

Anonymously collected for monitoring only and separated from your application before shortlisting. Completing this section is voluntary.

Gender

Age band

Ethnic group

Religion or belief

Sexual orientation

Welsh language ability

Section 13 — Data protection & consent

Quality Staffing Care Ltd is the data controller for the personal information you provide on this form. Your data will be processed under the UK GDPR and the Data Protection Act 2018 for the purposes of recruitment, safer-recruitment checks (including DBS, right-to-work and references), regulatory compliance with CIW and CQC, and the management of your work placements should your application be successful.

If your application is unsuccessful, your data will be retained for six months and then securely destroyed unless you ask us to keep it on file. You may request a copy of your data, or its correction or erasure, at any time.

I consent to Quality Staffing Care holding and processing my personal data for the purposes set out above.
I consent to Quality Staffing Care contacting my referees and verifying the qualifications and registrations declared on this form.
I consent to Quality Staffing Care carrying out an Enhanced DBS check and, where relevant, checks against the DBS Barred List, Social Care Wales register and NMC register.
I consent to Quality Staffing Care retaining my data for six months if my application is unsuccessful, so that I may be considered for future opportunities.

Section 14 — Applicant declaration

I confirm that:

The information given in this application is true, complete and accurate to the best of my knowledge.
I have not omitted any information that is relevant to my suitability for the role.
I understand that any false declaration or omission may result in the withdrawal of an offer of work or, if discovered after appointment, dismissal without notice.
I understand that the role applied for is exempt from the Rehabilitation of Offenders Act 1974 and that I have disclosed all convictions, cautions, reprimands and warnings, whether spent or unspent.
I understand that the offer of work is subject to satisfactory references, Enhanced DBS clearance, evidence of right to work in the UK and confirmation of qualifications and registrations.
I am not aware of any reason, including any safeguarding concern or barring decision, that would make me unsuitable to work with children or adults at risk.

I have read, understood and agree to the declaration above.

Typed signature (full name) — by typing your name you are signing this form *

Date *

Optional — attach your CV

PDF or Word document, max 5MB.