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Application Form

East Sussex County Council’s Approved List For The Provision Of Supported Living Services For Working Age Adults

Document 1.a - Application Form

1	BASIC DETAILS OF YOUR ORGANISATION
1.1	Name of Organisation
1.2	Contact Name
1.3	Contact Position (Job Title)
1.4	Correspondence Address
1.5	Telephone Number
1.6	E-mail Address
1.7	Authorised Contract Signatory Name
1.8	Authorised Contract Signatory E-mail Address
1.9	Company Registration Number
1.10	Registered VAT number (if applicable)
1.11	Other Registration Number (please clarify i.e. Charity, Housing Association)
1.12	Date of Registration
1.13	Registration Address if different from 1.4
1.14	Please tick the relevant description of your organisations Legal Entity	i) Public Ltd Company
		ii) Limited Company
		iii) Partnership
		iv) Sole Trader
		v) Registered Charity
		vi) Provident Society
		vii) Other (please specify)

2.	CLIENT GROUP and SERVICES PROVIDED Please tick the relevant box/es
1A	Mental Health – Accommodation and Housing Support
1B	Mental Health – Personal Care
2A	Learning Disability – Accommodation and Housing Support
2B	Learning Disability – Personal Care
3A	Physical Disability, Sensory Impairment – Accommodation and Housing Support
3B	Physical Disability, Sensory Impairment– Personal Care

3	FINANCIAL INFORMATION

3.1 Applicants are required to self-certify that they meet the minimum financial requirements for economic and financial standing as part of the selection process.

3.2 Please complete Document 2A Self Certification Test. The Council will assess the Applicant’s financial suitability by reference to the criteria set out in the provided Approved List Guidance and Instructions document (‘Economic & Financial Standing Criteria’).

Please ensure if the alternative option is selected all alternative evidence is submitted with your application. Any application that selects this option but fails to provide the evidence as part of the completed application will be deemed unsuccessful as it will fail to meet the Council’s submission requirements.

4	REQUIRED CERTIFICATION
Please provide electronic copies of the following documentation with your submission. Tick the relevant boxes to confirm their inclusion.
4.1	CQC Registration (if your organisation is providing Personal Care or direct support with medication)
4.2	Other (please specify)

5	INSURANCE
Please provide details of your current insurance cover:
5.1	Employer’s Liability
5.2	Public Liability Insurance
5.3	Other (please provide details)
5.4	The Council requires a minimum of £10 million for this contract for each and every claim under a company’s Public Liability insurance policy. Please confirm that you will provide this level of cover if successfully awarded entry to the Select List.	YES/NO

6 a	GROUNDS FOR EXCLUSION – MANDATORY
Within the past five years, has your organisation (or any member of your proposed consortium, if applicable), Directors or partner or any other person who has powers of representation, decision or control been convicted of any of the following offences?
1. conspiracy within the meaning of section 1 or 1A of the Criminal Law Act 1977 or article 9 or 9A of the Criminal Attempts and Conspiracy (Northern Ireland) Order 1983 where that conspiracy relates to participation in a criminal organisation as defined in Article 2 of Council Framework Decision 2008/841/JHA on the fight against organised crime;		YES/NO
2. corruption within the meaning of section 1(2) of the Public Bodies Corrupt Practices Act 1889 or section 1 of the Prevention of Corruption Act 1906;		YES/NO
3. the common law offence of bribery;		YES/NO
4. bribery within the meaning of sections 1, 2 or 6 of the Bribery Act 2010; or section 113 of the Representation of the People Act 1983;		YES/NO
5. any of the following offences, where the offence relates to fraud affecting the European Communities’ financial interests as defined by Article 1 of the Convention on the protection of the financial interests of the European Communities:		YES/NO
(i) the offence of cheating the Revenue;		YES/NO
(ii) the offence of conspiracy to defraud;		YES/NO
(iii) fraud or theft within the meaning of the Theft Act 1968, the Theft Act (Northern Ireland) 1969, the Theft Act 1978 or the Theft (Northern Ireland) Order 1978;		YES/NO
(iv) fraudulent trading within the meaning of section 458 of the Companies Act 1985, article 451 of the Companies (Northern Ireland) Order 1986 or section 993 of the Companies Act 2006;		YES/NO
(v) fraudulent evasion within the meaning of section 170 of the Customs and Excise Management Act 1979 or section 72 of the Value Added Tax Act 1994;		YES/NO
(vi) an offence in connection with taxation in the European Union within the meaning of section 71 of the Criminal Justice Act 1993;		YES/NO
(vii) destroying, defacing or concealing of documents or procuring the execution of a valuable security within the meaning of section 20 of the Theft Act 1968 or section 19 of the Theft Act (Northern Ireland) 1969;		YES/NO
(viii) fraud within the meaning of section 2, 3 or 4 of the Fraud Act 2006; or		YES/NO
(ix) the possession of articles for use in frauds within the meaning of section 6 of the Fraud Act 2006, or the making, adapting, supplying or offering to supply articles for use in frauds within the meaning of section 7 of that Act;		YES/NO
6. any offence listed—
(i) in section 41 of the Counter Terrorism Act 2008; or		YES/NO
(ii) in Schedule 2 to that Act where the court has determined that there is a terrorist connection;		YES/NO
7. any offence under sections 44 to 46 of the Serious Crime Act 2007 which relates to an offence covered by subparagraph (f);		YES/NO
8. money laundering within the meaning of sections 340(11) and 415 of the Proceeds of Crime Act 2002;		YES/NO
9. an offence in connection with the proceeds of criminal conduct within the meaning of section 93A, 93B or 93C of the Criminal Justice Act 1988 or article 45, 46 or 47 of the Proceeds of Crime (Northern Ireland) Order 1996;		YES/NO
10. an offence under section 4 of the Asylum and Immigration (Treatment of Claimants etc.) Act 2004;		YES/NO
11. an offence under section 59A of the Sexual Offences Act 2003;		YES/NO
12. an offence under section 71 of the Coroners and Justice Act 2009		YES/NO
13. an offence in connection with the proceeds of drug trafficking within the meaning of section 49, 50 or 51 of the Drug Trafficking Act 1994; or		YES/NO
14. any other offence within the meaning of Article 57(1) of the Public Contracts Directive—		YES/NO
(i) as defined by the law of any jurisdiction outside England and Wales and Northern Ireland; or		YES/NO
(ii) created, after the day on which these Regulations were made, in the law of England and Wales or Northern Ireland.		YES/NO
15 Non-payment of taxes Has it been established by a judicial or administrative decision having final and binding effect in accordance with the legal provisions of any part of the United Kingdom or the legal provisions of the country in which your organisation is established (if outside the UK), that your organisation is in breach of obligations related to the payment of tax or social security contributions? (If you have answered Yes to this question, please use a separate Appendix to provide further details. Please also use this Appendix to confirm whether you have paid, or have entered into a binding arrangement with a view to paying, including, where applicable, any accrued interest and/or fines?)		YES/NO

6 b	GROUNDS FOR EXCLUSION - DISCRETIONARY
Within the past three years, please indicate if any of the following situations have applied, or currently apply, to your organisation.
your organisation has violated applicable obligations referred to in regulation 56 (2) of the Public Contracts Regulations 2015 in the fields of environmental, social and labour law established by EU law, national law, collective agreements or by the international environmental, social and labour law provisions listed in Annex X to the Public Contracts Directive as amended from time to time;		YES/NO
your organisation is bankrupt or is the subject of insolvency or winding-up proceedings, where your assets are being administered by a liquidator or by the court, where it is in an arrangement with creditors, where its business activities are suspended or it is in any analogous situation arising from a similar procedure under the laws and regulations of any State;		YES/NO
your organisation is guilty of grave professional misconduct, which renders its integrity questionable;		YES/NO
your organisation has entered into agreements with other economic operators aimed at distorting competition;		YES/NO
your organisation has a conflict of interest within the meaning of regulation 24 of the Public Contracts Regulations 2015 that cannot be effectively remedied by other, less intrusive, measures;		YES/NO
the prior involvement of your organisation in the preparation of the procurement procedure has resulted in a distortion of competition, as referred to in regulation 41, that cannot be remedied by other, less intrusive, measures;		YES/NO
your organisation has shown significant or persistent deficiencies in the performance of a substantive requirement under a prior public contract, a prior contract with a contracting entity, or a prior concession contract, which led to early termination of that prior contract, damages or other comparable sanctions;		YES/NO
your organisation— (i) has been guilty of serious misrepresentation in supplying the information required for the verification of the absence of grounds for exclusion or the fulfilment of the selection criteria; or (ii) has withheld such information or is not able to submit supporting documents required under regulation 59 of the Public Contracts Regulations 2015; or		YES/NO
your organisation has undertaken to		YES/NO
(i) unduly influence the decision-making process of the contracting authority, or		YES/NO
(ii) obtain confidential information that may confer upon your organisation undue advantages in the procurement procedure; or		YES/NO
your organisation has negligently provided misleading information that may have a material influence on decisions concerning exclusion, selection or award.		YES/NO

7	SERVICE SPECIFIC QUESTIONS

Where a maximum word count of 600 words is stated, it is advised that a minimum of 300 words are submitted.

7.1 What does your organisation view as the three most important elements of providing effective care and support services to Working Age Adults?

(Arial 11, maximum 600 words per Client Group)

Learning Disabilities:

Mental Health:

Physical Disabilities, Sensory Impairment and Long Term Conditions:

7.2 How do you/will you ensure that you are able to provide the Service in a cost effective and sustainable way and deliver best value for tax payer’s money? Please provide practical examples.

(Arial 11, maximum 600 words, one response required)

7.3 How do you/will you ensure the services you provide promote independence whilst ensuring the safety, health & well-being of your clients? Please provide practical examples.

(Arial 11, maximum 600 words per Client Group)

Learning Disabilities:

Mental Health:

Physical Disabilities, Sensory Impairment and Long Term Conditions:

7.4 How do you/will you ensure the Clients who use your service have choice and control over the support they receive? Please provide practical examples.

(Arial 11, maximum 600 words per Client Group)

Learning Disabilities:

Mental Health:

Physical Disabilities, Sensory Impairment and Long Term Conditions:

7.5 How will the service you provide enhance peoples’ quality of life and their ability to actively participate in the wider community?

(Arial 11, maximum 600 words per Client Group)

Learning Disabilities:

Mental Health:

Physical Disabilities, Sensory Impairment and Long Term Conditions:

7.6 How will you work with clients and partner agencies to positively manage different types of risk to ensure that the health and wellbeing of clients is upheld and the needs of the local community well considered?

(Arial 11, maximum 600 words per Client Group)

Learning Disabilities:

Mental Health:

Physical Disabilities, Sensory Impairment and Long Term Conditions:

7.7 The Service Provider’s Sub-Contractors: Please complete table:

Identity of Service Provider’s Sub-contractors, if applicable	[Insert details of all permitted sub-contractors, including full legal name, registered address and location where processing of Personal Data will occur and a description of the processing operations undertaken by each sub-contractor. Please note that you are not permitted to engage any sub-contractors to process any personal or special category data without prior written approval of the Councils.]
Purposes for the processing of the data:
Duration of the processing of Council Data by Sub-Contractor:

7.8 Please list the service addresses where the service/s will be provided at for each client Group.

SERVICE SPECIFIC CLARIFICATION QUESTIONS

Please confirm your approval that information including responses to the Service Specification questions from your previous 2015-2018 application will be used as evidence to support this application onto the 2019 Approved List.

8.1 What does your organisation view as the three most important elements of providing effective care and support services to Working Age Adults?	YES/NO
8.2 How do you/will you ensure that you are able to provide the Service in a cost effective and sustainable way and deliver best value for tax payer’s money? Please provide practical examples.	YES/NO
8.3 How do you/will you ensure the services you provide promote independence whilst ensuring the safety, health & well-being of your clients? Please provide practical examples	YES/NO
8.4 How do you/will you ensure the Clients who use your service have choice and control over the support they receive? Please provide practical examples.	YES/NO
8.5 How will the service you provide enhance peoples’ quality of life and their ability to actively participate in the wider community?	YES/NO
8.6 How will you work with clients and partner agencies to positively manage different types of risk to ensure that the health and wellbeing of clients is upheld and the needs of the local community well considered?	YES/NO
If you have answered “No” to questions 8.1-8.6 above, please submit a new response to the relevant question. Any new response will be evaluated in line with the guidance for section 8.

11.

DECLARATION

I declare that to the best of my knowledge the answers submitted in this Application (and any supporting modules) are correct. I understand that the information will be used in the evaluation process to assess my organisation’s suitability to be accepted on the Approved List for Working Age Adult Supported Housing.

FORM COMPLETED BY

Organisation Name:

Name:

Position (Job Title):

Date:

Telephone number:

Signature:

I understand that by signing this Application I accept the following:

Question for Care and Support Providers:

As a provider of care and support you have a duty of care to your clients. Part of this duty of care is to actively monitor the living environment and to report any safety concerns to the landlord and/or statutory enforcement authorities in order that they may discharge their statutory duties. Please tick this box to indicate that you understand this and accept this as part of your wider duty of care to your clients.

Question for Care and Support Providers who are also landlords:

If you are, or it is your intention to, provide care and support services to clients in properties where you are also the landlord, please tick this box to indicate that the physical housing environment is safe, that all certificates in relation to Fire, health and safety and building regulations are in place and up to date and all other regulations and minimum standards as required by your local housing department and all other relevant regulatory authorities, are met.