Live-in Carer Application Form

Looking for satisfying work and being able to work with a diverse range of clients? Apply today.

    Carer Application Form

    Key information document

    This document sets out the key information about your relationship with us, should your application be successful, including details about pay, holiday entitlement and other benefits.

    Further information can be found on our website, by following this link: Cheriton Homecare.

    The Employment Agency Standards (EAS) Inspectorate is the government authority responsible for the enforcement of certain agency workers rights.

    You can raise a concern with them directly or through Acas helpline.

    Your name (please fill out this field):
    Your email (please fill out this field):
    Name of Employment Business: Cheriton Homecare Limited
    Your employer(if different from the employment business):Self Employed
    Type of contract you will be engaged under: Contract for Services
    Who will be responsible for paying you (if different from the employment business): N/A
    How often will you be paid?: Weekly
    Expected or minimum rate of pay: Minimum of £100 per day / £700 per week
    Deductions from your pay required by law: None
    Any fees for goods or services: None
    Holiday entitlements and pay: None
    Additional benefits: None


    Example Pay

    Example rate of pay: £100 per day
    Deductions required by law: £0
    Any other deductions or costs from your wage: £0
    Any fees for goods or services: £0
    Example net take home pay: £700 per 7 day week

    Application for Registration as a Self Employed Care Assistant


    Personal details

    Passport and work permit details




    Data Barring Service (DBS)



    General Information




    Industry Related References

    Please give the names, occupation and contact addresses / details of 3 people we can contact for references. One of which must be your current or most recent employer. If you have not been employed please provide the name of a professional person who can comment on your suitability for this position.

    Reference 1


    yesno

    Reference 2


    yesno

    Reference 3


    yesno

    Professional Experience


    Personal Hygiene


    Bath / shower / strip washCare of hairCare of feetDressing / undressing


    Bed bathCare of eyesCare of fingernailsMouth careUse of bath aids



    Toileting


    Applying a conveenAttaching a night bagBedpans / commodesChanging a catheter bag


    Continence careEmptying a catheter bagStoma careOther (please specify below)



    Care Duties


    Assisting with medicationPressure area carePhysical restraint skills


    Simple dressing proceduresPalliative careOther (please specify below)



    Nutrition


    FeedingPreparing meals


    Food handlingOther (please specify below)



    Mobility


    Moving and handling clientsUse of hoists


    Use of walking aidsOther (please specify below)



    Practical Tasks


    BedmakingCollecting benefitsLight housework


    Recording temperatureShoppingOther (please specify below)



    Administrative Abilities


    ConfidentiallityObserving/recording changesSign language


    Report writingArranging appointmentsRecording instructions from GP


    Training Received


    Manual handling (adult)




    YesNo


    Infection control




    YesNo


    Fire safety




    YesNo


    First aid




    YesNo


    Essential food hygiene




    YesNo


    Observational skills




    YesNo


    Lone worker




    YesNo


    Management of aggressive or violent behaviour




    YesNo


    Abuse awareness (POVA)




    YesNo


    Abuse awareness (POCA)




    YesNo


    Safeguarding Training (Adult)




    YesNo


    Health & safety (incl COSHH and RIDDOR)




    YesNo


    Basic life support (Adult)




    YesNo


    Medication




    YesNo


    Other certification



    Do you consent to the use and processing by Cheriton Homecare of personal data for the purpose of farthing your application for a position as a self employed care assistant with the company?


    yesno

    Do you agree to our privacy policy, so that we can contact you about your application?


    yesno

    Declaration


    The information that I have given in this application form is, to the best of my knowledge, complete and accurate in all respects, and I am not aware of any reason why I am not fit for this work. I understand that knowingly giving false information will disqualify me from registration with the agency.