Please read the ‘applicant guidance’ booklet before fully completing the application form


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NamePlease read the ‘applicant guidance’ booklet before fully completing the application form
A typeDocumentation
Fair Employment Number (for office use only):


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Spa Nursing Home Group comprises of 6 Nursing Care Homes in Belfast, Ballynahinch, Carryduff & Crumlin.


Job Title

Closing Date & Time
Location

PLEASE READ THE ‘APPLICANT GUIDANCE’ BOOKLET BEFORE FULLY COMPLETING THE APPLICATION FORM.


1. PERSONAL DETAILS

Forenames
Surname


Title Mr/Mrs/Miss

Home Address: …………… ………………………………………………………………………………………….
…………………………………………………………………………………… Postcode: …………………………..

Contact Telephone Numbers (You must provide at least one contact telephone number)
Home ………………………………………………………….. Mobile ……………………………………………….
Email Address: …………………………………………………………..………………………………………………


Email Address: …………………………………………………………..……………………………………………

Please mark an X where appropriate: YES NO


  1. Do you hold a FULL current driving licence?




  1. Do you have access to a form of transport which would enable you to carry out

the duties of the post?

2. Only Nurses & Nursing Care Assistant applicants should complete this section



















































Yes No

Do you have any live sanctions or ongoing referrals to NISCC, NMC or any other regulatory body?
1A) Registered Nurses & Nursing Care Assistants
Care Assistants Northern Ireland Social Care Council (NISCC) Registration Number:
If you are applying for a position as a REGISTERED NURSE please complete this section:
Nursing and Midwifery Council (NMC) PIN:
Date of Birth: _____ / _____ / ________ Renewal Date of PIN: _____ / _____ / ________
Alternatively: I am a newly qualified Nurse and I have not received my PIN.

I am due to qualify / receive my PIN on (date): ______ / ______ / _______
If you are applying for a position as a NURSING CARE ASSISTANT please provide the details below:

NI Social Care Council registration number:

Expiry Date of Registration: _____ / _____ / _____

If you are applying for a position as a REGISTERED NURSE please complete this section:
Nursing and Midwifery Council (NMC) PIN:
Date of Birth: _____ / _____ / ________ Renewal Date of PIN: _____ / _____ / ________
Alternatively: I am a newly qualified Nurse and I have not received my PIN.

I am due to qualify / receive my PIN on (date): ______ / ______ / _______
If you are applying for a position as a NURSING CARE ASSISTANT please provide the details below:

NI Social Care Council registration number:

Expiry Date of Registration: _____ / _____ / _____

Nurses Nursing and Midwifery Council (NMC) Pin Number:
Or date pin expected: ______________


If you are applying for a position as a REGISTERED NURSE please complete this section:
Nursing and Midwifery Council (NMC) PIN:
Date of Birth: _____ / _____ / ________ Renewal Date of PIN: _____ / _____ / ________
Alternatively: I am a newly qualified Nurse and I have not received my PIN.

I am due to qualify / receive my PIN on (date): ______ / ______ / _______
If you are applying for a position as a NURSING CARE ASSISTANT please provide the details below:

NI Social Care Council registration number:

Expiry Date of Registration: _____ / _____ / _____
3. Education & Qualifications


Level of Qualification

(GCSE, A ‘Level, Degree, NVQ/QFC etc.)

Subject

(Maths, English, Nursing, Health & Social Care etc.)

Result(s) Obtained










Please state how you meet the essential criteria or include any additional information you feel is relevant for your applicantion:



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  1. 4. EMPLOYMENT HISTORY


If you have never been in employment please tick here, and proceed to section 5
Please note you must include details for ALL previous employment, even if it is not Care related, or took place outside of the UK.
NOTE: (If your previous work history exceeds the space available, you may use an additional A4 page/s. Please note your name & address at the top of any additional page/s and complete the information as requested above. CV’s will not be accepted)


  1. Current or Last Employer

Please provide a brief Outline of your duties & responsibilities:
………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………

Company Name:
End date: (DD/MM/YY)

Start date: (DD/MM/YY)
FULL Address:
Postcode
Notice Period

Rate of Pay


Job Title

Reason for leaving:

Please provide a brief Outline of your duties & responsibilities:
………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………

End date: (DD/MM/YY)

Start date: (DD/MM/YY)


Company Name:

B) Employment Record


Notice Period

Rate of Pay

FULL Address:

Postcode


Job Title

Reason for leaving:

Please provide a brief Outline of your duties & responsibilities:
………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

C) Employment Record


End date: (DD/MM/YY)

Start date: (DD/MM/YY)


Company Name:


Notice Period

Rate of Pay

FULL Address:

Postcode

Job Title

Reason for leaving:

Please provide a brief Outline of your duties & responsibilities:
………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

D) Employment Record

End date: (DD/MM/YY)

Start date: (DD/MM/YY)


Company Name:

FULL Address:

Postcode

Notice Period

Rate of Pay


Job Title


Reason for leaving:

Please provide a brief Outline of your duties & responsibilities:
………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………


From (Date)

To (Date)

Reason





























5. Employment Gaps
Our governing body, the Regulation & Quality Improvement Authority (RQIA) require all applicants to provide a full and comprehensive employment history. In addition to details regarding all previous periods of employment applicants are required to provide details relating to any periods, longer than one month, when they were not in paid employment.
Examples of such periods may include time away from work to care for a child or relative, time spent in education or training, periods spent travelling or volunteering at home or abroad, time away from work due to ill health, or periods of unemployment when you were actively seeking work.
Please provide details for each period of time spent not in employment below.

6: Availability to work

*** This Section will be used for shortlisting PURPOSES ***

The minimum number of hours I can work per week: ………………………… hours
The maximum number of hours I can work per week ………………………… hours

Please place an X in the boxes below according to the job role you are applying for confirming the hours you wILL be available to work:


Registered General Nurse and Care Assistant applicants

I am available to work

Mon

Tues

Wed

Thurs

Fri

Sat

Sun

Fully flexible – I can work anytime






















8am-8pm (Days)






















8pm-8am (Nights)






















8am-2pm (Mornings)






















2pm-8pm (Evenings)






















GENERAL ASSISTANT applicants

I am available to work

Mon

Tues

Wed

Thurs

Fri

Sat

Sun

Fully flexible – I can work anytime






















9am – 1pm






















9am – 5pm






















8am – 2pm






















Cook applicants

I am available to work

Mon

Tues

Wed

Thurs

Fri

Sat

Sun

8am-5pm






















9am – 6pm






















Activity Therapist and Maintenance / Gardener applicants

I am available to work

Mon

Tues

Wed

Thurs

Fri

Sat

Sun

10am- 1pm






















10am-4pm























Note: You will not be required to work all of the hours / days that you are available - adequate rest days / periods will be scheduled in line with current legislation. If shortlisted your availability will be further discussed with you at interview.
7. REFERENCES

***THIS SECTION WILL BE USED FOR SHORTLISTING PURPOSES***



    • You must provide full contact details for three referees


        • Your referees must not be a partner / spouse / family member / relative
      We reserve the right to approach any past employer for a reference


      • If you have previously been in paid employment one of your referees MUST be your present or most recent employer. The referee you provide must have been responsible for supervising or managing your work.

      • If you have never been in paid employment, please supply the details of three character and / or academic referees. It is preferred that the referees have known you for longer than one year.

      • All referees for qualified nurses must be professionals

      • ALL references must be supplied in English. Where this is not possible it will be the applicant’s responsibility to provide a certified translation.

      • Referees must not be related to you by birth or marriage


SECTIONS MARKED WITH AN * asterisk MUST BE COMPLETED IN FULL

REFEREE 1 - in what capacity are you known to the referee?

Work Character Academic


Company name (if applicable)
……………………………………………………..

*Address: ……………………………………………………………………………………………………………………………………………………………………..

*Postcode ………………………………………..
*Name


Position (if work or Academic)

*Tel No:

.


Email


REFEREE 2 - in what capacity are you known to the referee?

Work Character Academic


*Name

Company name (if applicable)
……………………………………………………..

*Address: ……………………………………………………………………………………………………………………………………………………………………..

*Postcode ………………………………………..

Position (if work or Academic)

*Tel No:


Email

REFEREE 3 - in what capacity are you known to the referee?

Work Character Academic


*Name

Company name (if applicable)
……………………………………………………..

*Address: ……………………………………………………………………………………………………………………………………………………………………..

*Postcode ………………………………………..

Position (if work or Academic)

Email

*Tel No:
If short-listed for interview you will be required to apply for an Enhanced Access NI disclosure. Due to the nature of the work that you have applied for this will result in convictions which may normally be considered as spent being disclosed in addition to unspent criminal convictions, with the exception of filtered information.
Please note: it is a criminal offence for any person who has been ‘barred’ from working with adults to apply for a post which involves carrying out regulated activity with adults.
Are you currently subject to inclusion on the ADULTS BARRED LIST? YES NO
Regulated’ and ‘Previously Regulated’ Activity Positions

For the purposes of our employment, ‘Regulated’ posts include Nurse Managers, Nurses, Care Assistants, General Assistants & Activity Therapists. For these posts, an Enhanced Disclosure and a check of the Adult Barred List will be required.
Posts that are no longer considered ‘Regulated’ activity, include Maintenance Person/Gardener, Cook and Receptionist. Applicants for these posts will require Enhanced Disclosure only.
If an offer of employment is made, and accepted, we will require your consent to process your application for an Enhanced Access NI disclosure and carry out a check of the Adults Barred List (if applicable).
Our policy on the Handling & Assessing of Criminal Conviction information is provided later in the recruitment process. However, if you wish to obtain a copy at this stage, please contact our Head Office.
8. HANDLING & ASSESSING CRIMINAL CONVICTION INFORMATION


in obtaining a post your hours of work will be scheduled in line with current business requirements.


9. DECLARATION OF CONSENT – PLEASE READ CAREFULLY

I consent to the organisation obtaining references and carrying out a check of the Adults Barred List (if applicable) to support this application once an offer has been made and accepted, either verbally or in writing, and release the organisation and referees from any liability caused by giving and receiving information.

I confirm that the information given on this form is, to the best of my knowledge, true and complete. Any false statement or omission may be sufficient cause for rejection or, if employed, dismissal.
Signature / or typed if by email: ………………………………………………………………………………………
Print Name: …………………………………………………………………………………………
Date: ………………………………….
Please return this form to: Spa Nursing Homes Ltd, Human Resources Department,

18 Orby Link, Belfast, BT5 5HW or via email to hr@spanursing.co.uk
If you have any questions about the information requested, or require support in completing your application our HR department can be contacted on:

Tel: 028 90707628 email: hr@spanursing.co.uk


Private & Confidential

Fair Employment Questionnaire





Please write your Fair Employment number in the space provided below:

(If you do not have a Fair Employment Number one will be allocated to your application upon receipt)
Location code Year Batch App

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Fair Employment Number
Position Applied for: ………………………………………………………………. Date: …………………
Equality of Opportunity

We are an equal opportunity employer. We do not discriminate on the grounds of religious belief or political opinion. We practice equality of opportunity in employment and select the best person for the job. To demonstrate our commitment to equality of opportunity in employment we need to monitor the community background of our employees, as required by the Fair Employment and Treatment Order (Amendment) Regulations (NI) 2003
Regardless of whether we practice our religion, most of us in Northern Ireland are seen as either Roman Catholic or Protestant. We are therefore asking you to indicate your sex & community background by ticking the appropriate box below.


I am a member of the Protestant Community




I am a member of the Roman Catholic Community




I am neither a member of the Protestant or Roman Catholic Community
















Please indicate whether you are: Male




Female





If you do not complete this questionnaire, we are encouraged to use the “residuary” method regarding the question relating to community background, which means that we can make a determination on the basis of personal information on file.
Please note: It is not compulsory for you to answer the above questions. However, should you decide to answer the above questions you must do so truthfully, as it is a criminal offence under the Fair Employment (Monitoring) Regulations (NI) 1999 to knowingly give false answers to these questions.
The Disability Discrimination Act 1995 defines a disabled person as a person with ‘a physical or mental impairment which has a substantial and long-term adverse effect on their ability to carry out normal day-to-day activities’


Taking this definition into consideration, would you consider yourself to be disabled?: Yes




No




Please state where you read or heard about the vacancy:




  1. Jobcentre Online

5. Word of Mouth (Please state if from an existing employee)







  1. Jobs & Benefits Office

6. Recruitment Agency:

(Please state which agency)







  1. Enquired at Nursing Home or Head Office

7. Newspaper:

(Please state which paper)







  1. NI Jobs website

8. Other:

(Please state the source)






Please provide your National Insurance Number:

Please complete this form and place it in a sealed envelope marked ‘Monitoring Officer’.

It should then be returned along with your completed Application Form.



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