Ditchburn Place
Extra Care Housing

Application Form

Who is Eligible to apply? 
Extra Care Housing has been specially designed for older people who meet the following criteria:
•	Aged over sixty five.
•	Whom have been assessed by Cambridgeshire Social Care as having a suitable care needs that can be met within the extra care environment. 
•	Priority will be given to those applicants who have a local connection to Cambridge City.  

What you need to do next
In addition to this application, we will need an up to date copy of your social care assessment.  This assessment is required to determine the level of care that you need and that you qualify for extra care housing.
If you do not have one already you will need to arrange for this assessment to be carried out by the local authority Social Services Department where you currently live.  

How to request a Social Care Assessment  

•	If you currently live in Cambridgeshire you need to contact Cambridgeshire social care by phone  0345 0455 202 and request that one of their Care Managers completes a ‘Social Care Assessment’ as you have applied for Extra Care Housing.
•	If you live outside of Cambridgeshire you will need to contact your local authority social care department.

Please note applications cannot go forward without a Social Care Assessment.

Once complete please return this form by post to:

Senior Administrator
Ditchburn Place
Mill Road
Cambridge 
CB1 2DR

Or e-mail it to independent.living@cambridge.gov.uk

If you have any questions about completing the form please call 01223 457199 to speak to a member of the housing team. 

Personal details
You	Joint applicant	

	Mr		Mrs		Ms		Miss				Mr		Mrs		Ms		Miss	
																		
Other (please state)				Other (please state)		
																		
Surname				Surname		
																		
First name				First name		
																		
Middle name								Middle name		
																		
	Male		Female							Male		Female				
																		
Date of birth				Date of birth		

National Insurance No:	Applicant									
	Partner									

Home Address	

			Address 
(if different from main applicant)		
Postcode				Postcode		
						
Phone Nos:	Home				Phone Nos:	Home		
	Mobile					Mobile		
						
Current Address if different from above i.e. temporary						
GP’s Name				GP’s Name		
Address	

			Address		
Postcode				Postcode		
Phone No				Postcode		

About your General Health

Please tell us about your general health and about any conditions which are affecting your ability to cope at home.	

	
	
Have you been treated in hospital in the last 12 months?	Yes 	No 	

If yes, please give details:	

	

Do you need any special features in the home you move to, such as a level access shower, ground floor accommodation etc. 	Yes 	No 	

If yes, please give details:	

	

Please tell us about any aids and equipment you currently use in your home such as wheelchair, walking frame, hospital bed etc.	

	

About your support needs
	
Do you need the support of other people, such as family, friends, paid carers or others, to enable you to manage daily living at home?	Yes 	No 	

If yes, please give details:	

	

Please use the table below to tell us who currently provides your support and how often.

For example, if your partner or a relative provides you with support 3 times a day for very day, write ‘3’ in the box for each day of the week opposite ‘Your partner or a relative’.

Person Providing Support	Mon	Tue	Wed	Thu	Fri	Sat	Sun	
Your partner or relative								
A friend or neighbour								
Home Care Assistant								
Community Nurse								
Community Psychiatric Nurse								
Lunch Club								
Meals on wheals								
Day Centre or Hospital								
Voluntary service								
Social Worker								
Other – please give details:

We would like to discuss your support needs, in confidence, with our staff, Social Services and yourself, to ensure that we know what your needs are.  Please say if you would be happy for us to do this:
Yes 	No 
We would not discuss your needs with other people and organisations unless you give us your permission.	

About you and How You Live Now

Please tell us about yourself and how you live now, in your present situation.

Tell us in general terms, about:
•	Your contacts with neighbours, friends and relatives – your daily home life
•	Visits to local clubs and societies and other activities – your social life
•	What you think about the area where you live, and how you feel about living there.	

	
Tell us about why you want to move to Extra Care Housing

	

Tell us about any family and friends who live near you now, and what support they provide for you

	

What support would your family and friends continue to provide if you move to extra care housing?	

	

Please tell us the names of people who will provide support in an emergency
Name	Relationship to you	Daytime Phone No.	Night-time Phone No.	

Do you have any pets	Yes 	No 	
If yes, please give details:	

Please note, pets are not permitted at Ditchburn Place. 

Connections to Cambridge City Council

Do you work for Cambridge City Council?	Yes 		No		
Are you related to someone who works for Cambridge City Council?	Yes 		No 		
Are you related to a CCC Councillor?	Yes 		No 		
If you answered YES to any of the above questions, please give further details:		

	

Other Information
Please tell us anything else that you think we should know about in connection with your application for extra care housing:

	

Professional Referral on behalf of an Applicant
If you are making a referral for extra care housing on behalf of the Applicants, please complete this section:

Contact Details
Please tell us anything else that you think we should know about in connection with your application for extra care housing:

Your Name		Job Title		
Relationship to Applicant		Phone No:  Work		
Organisation Name		Phone No:  Mobile		
Organisation Address	

Declaration by the Applicant
The information in this application is correct to the best of my knowledge and belief, and I will inform Cambridge City Council if any information changes.  I understand that if I knowingly give false or misleading information, I may lose any housing offered to me.  I understand that it is the policy of Cambridge City Council to seek the eviction of any person who gives false information in order to obtain a tenancy.  I give my permission for Cambridge City Council to request information from current and previous landlords about me.

How we use your personal data
Why are we asking for your personal information?
The Supporting Housing team work with the County Council to provide the care services at Ditchburn Place.  We ask for your personal information to help us ensure that you are suitable to be offered accommodation at Ditchburn Place and so that we can determine the level of care and support that you may need.

You have a number of rights over the personal data you provide us:

Right to Access – You have the right to access (receive a copy) of your personal data and supplementary information.

Right to Rectification – You have the right to have any inaccurate or incomplete personal data rectified

Right to Restriction – You have the right to request a restriction of the processing of your personal data in situations where it is inaccurate, unlawful, and no longer needed for the purposes for which it was originally collected, or if a withdrawal of consent has been made.

Sharing your information

We will work with you and with the other people who may be supporting you such as the social care team,  mental health team, probation workers and medical professions like GPs and support workers to determine your eligibility to be offered accommodation at Ditchburn Place.  We will only do this with your agreement.

If any of the information we have about you is incorrect, or your circumstances change please tell us; we are rely on you assisting us to keep your information accurate and up to date.

Retention of your personal information
We only keep your information as long as necessary, for some items this will be dictated by law. You can find out more by looking at the Councils Retention Policy on the web site.

We do not routinely process any information about you outside the UK. We will not transfer your personal data outside of the EU.	

Cambridge City Council is a registered Data Controller with the Information Commissioners Office. 

You can find out more about how we handle your data by visiting the Councils Privacy Notice page on the web site. If you have a query regarding your rights please contact the Data Protection Officer who can be contacted by emailing infogov@3csharedservices.org or you can write to the Council and mark your letter for the attention of the Data Protection Officer. Alternatively you can call 07864 604221 or 01954 713318.

Signed 1st Applicant 		Date		Signed 2nd
Applicant		Date