ISSUED BY

OFFICE

Housing for Older People Application form FOR OFFICE USE ONLY

Application for Housing Reference Number

Applicant has expressed interest in the following areas:

1 2 3 4 5

Has a Health and Disability Assessment application been submitted? YES: NO:

2 Housing for Older People: Application for Assessment Guidance Notes Please ensure you read and understand the following information before completing the Housing for Older People application. What you should do: • Complete all questions on the application form, giving as much detail as possible. Failure to do so could result in the application being returned. • Please remember that you must submit a recent ‘Assessment of Need and a Care Plan’ from the Care Manager from the Health & Social Care Partnership • If further assistance is required to complete this application please contact your local housing office. • Sign and date the form • Return the form in person to your local housing office or by post to East Council who will deal with your application on behalf of the SEARCH partners: Council Housing Register Team Housing Service P.O. Box 13 John Dickie Street KA1 1HW What happens next? • The information you provide will be used to make an assessment of your housing need by the Housing Occupational Therapist •The Housing Occupational Therapist may contact or visit you at home in order to gain a better understanding of your needs. • Following the assessment we will write to you when a decision regarding your application has been made.

Housing for Older People: Application for Assessment 3 Please be aware Housing for Older People is subject to additional support charges. Please see attached leaflet Information ‘Charging for Council funded or provided Support Services’. What is housing for Older People? How do I Apply for Housing for Housing for Older People are small, easy to manage Older People? properties grouped together in a community designated for people over the age of 60. They are aimed at enabling You need to complete this Housing for Older People people over the age of 60 with care needs to remain living Application. You will need to provide details of your current with in their community for as long as possible in a safe circumstances and return the form to your local housing environment. office for assessment. It is very important that you complete all the questions on the application and give us as much Type of Accommodation information as possible; this will help us to carry out an accurate assessment of your circumstances. All the properties across East Ayrshire are designed to be easily accessible, with all properties either being bedsits, flats You are not required to complete a Health and Disability or bungalows. All properties are self-contained providing Application if you are only interested in Housing for Older tenants with their own private living space and front door. People. Each of the communities are designated either low or high needs units depending on the facilities and services available. Who will assess my Housing for Please see Section 7 for list of available Housing for Older Older People Application? People communities in East Ayrshire. The assessment will be completed by the Housing Services available within Housing Occupational Therapist. The Housing Occupational Therapist will contact you or your representative to discuss your for Older People Accommodation circumstances in more detail. This may be carried out by Each property is installed with a community alarm and linked telephone, home visit or office appointment. On completion in smoke detector providing a 24 Hour response service. A of the assessment the Housing Occupational Therapist will few of our communities also have communal areas for the make recommendations in relation to your house type opportunity for social interaction with other tenants and requirements as well as awarding a priority level. Housing for people living in the local community. The social activities are Older People are not allocated on a point’s system and as organised by the Well-Being Development Officers who are such no points will be awarded to your application following linked to all our Housing for Older People communities. The this assessment. Following the assessment we will write to Well-Being and Development Officers are generally available you when a decision regarding your application has been Monday to Friday 9am-5pm. made. Please be aware the Well-Being Development Officers do If interested in applying for Housing for Older People owned not provide a warden service. by one of the Registered Social Landlords (Bield, Hanover Housing, Trust or West of ) this form is also If you are interested in Applying for our Housing for Older applicable as request nominations for East Ayrshire Council. People please read the following criteria. However we recommend you register an application form with them directly. Criteria Housing for Older People is applicable to people over the age of 60 and who are experiencing functional difficulties around their home and social isolation as a result of their health condition or disability.

4 Housing for Older People: Application for Assessment Application for Housing for Older People All information provided will be treated in the strictest confidence Please answer all the questions as fully as possible to help us consider this application. If this form is not fully completed we will not be able to carry out an assessment. This form should be completed by you, or someone who cares for you. If you require assistance to fill in the form, contact the address on the back and someone will call to your home and help. Your Application for Housing for Older People will not be considered until this form has been completed and returned to the Council.

Housing for Older People: Application for Assessment 5 Section 1: Information about the household member(s) applying for supported accommodation

Name of main applicant Date of birth

Current address

Telephone number(s)

Name of GP

Address of GP

Telephone number of GP

Please detail any health conditions or disabilities including physical and mental health

Are you a wheeelchair user? YES: NO: If YES, where do you use it? Indoors: Outdoors: Both:

6 Housing for Older People: Application for Assessment Name of joint applicant Date of birth

Current address

Telephone number(s)

Name of GP

Address of GP

Telephone number of GP

Please detail any health conditions or disabilities including physical and mental health

Are you a wheeelchair user? YES: NO: If YES, where do you use it? Indoors: Outdoors: Both:

Housing for Older People: Application for Assessment 7 Section 2: Existing Support Services

Do you, or your partner, receive help from a Social Worker or YES: NO: Health Professional?

If yes, please advise who provides your service and how often?

Do you, or your partner, receive help from Community Nursing Staff? YES: NO: If yes, please advise what help is received and how often?

8 Housing for Older People: Application for Assessment Please tell us if the person has any difficulty with any of the following daily tasks I can manage Yes I receive If yes, who How often do indpendently help helps you? they help you? Washing self

Dressing self

Cleaning and maintaining my home Preparing meals

Taking prescribed medication

Going out shopping

Attending social groups/clubs

Keeping in touch with family and friends Managing my money, paying bills

Managing mail and correspondence

Housing for Older People: Application for Assessment 9 Section 3: Information about the person’s current accommodation

Current accommodation type (please tick all that apply) Sheltered Housing/Housing for Maisonette (Ground floor) Older People Amenity Housing Maisonette (Upper floor)

Flat (ground floor) House (three-storey)

Flat (upper floor) House (end-terrace)

Multi-storey flat House (mid-terrace)

Basement flat House (semi-detached)

Attic flat House (detached)

Bedsit upper Bungalow

Bedsit lower Other (please give details)

Four in a Block (Ground floor)

Four in a Block (upper floor)

How many bedrooms does your current accommodation have? (If you have a separate dining room you should count this as a bedroom)

Layout of current accommodation (please tick all that apply)

Bathroom upstairs Bedroom upstairs

Bathroom downstairs Bedroom downstairs

Toilet upstairs Curved internal stairs

Toilet downstairs Straight internal stairs Number of external steps: Front door Number of external steps: Back door

10 Housing for Older People: Application for Assessment What does the person’s current home have? (please tick all that apply)

Level access entrance Stair lift

Ramped entrance Tracking hoist fixed to the ceiling

Door entry system Handrails inside over stairs (not a communal one)

Handrail(s) outside over steps Adapted kitchen (e.g. lowered worktops, special sink etc)

External lift Adaptation(s) for people with a hearing impairment

Community Alarm/Telecare Adaptation(s) for people with a visual impairment

Walk-in shower Other (please give details) (wet floor area or level shower base)

Step-in shower

Over-bath shower

Specialist toilet/bath

Wider doors for wheelchair access

Specialist Equipment: Please detail any medical equipment, for example hospital bed, mobile hoist, ventilator, oxygen etc and/or other specialist equipment, for example, bathing, showering or toileting equipment, special seating, walking aid, that is currently used in the accommodation.

Housing for Older People: Application for Assessment 11 Please tell us if the person has any difficulty within their current property with any of the following (please tick all that apply)

Climbing outside steps Getting into rooms due to the width of the doors or hallways

Getting in/out bath or shower Climbing the stairs inside the accommodation

Getting on/off toilet Other (please give details below)

12 Housing for Older People: Application for Assessment Please tell us why you wish to be considered for supported accommodation.

Housing for Older People: Application for Assessment 13 Section 4: Consent to Disclosure of Information

For the purpose of planning care and / or treatment, I agree to information being shared with staff from other agencies who may be involved in assisting with my care and support:

East Ayrshire Council Council

South Ayrshire Council NHS Ayrshire & Arran

Applicant’s Signature Date:

Joint Applicant’s Signature Date:

Section 5: Declaration

If the person wants us to deal with someone else on their behalf (a representative) about this application please give their details below.

Name

Address

Relationship to you (if any)

Telephone number(s)

Representative’s Signature Date:

14 Housing for Older People: Application for Assessment Please read this declaration carefully

•I confirm that the details I have given on this application form are true and accurate. •I understand that if my circumstances change, I must tell East Ayrshire Council. •I understand that if I give any false or misleading information, or do not provide relevant information, that any points awarded to my application can be withdrawn. •If I get a tenancy based on false or misleading information, I understand that the landlord may take court action to evict me. •I understand that East Ayrshire Council can ask for additional information from other agencies and health and social services professionals in connection with my application. •I authorise these agencies and Health and Social Services Professionals to disclose any information needed in connection with my housing application to East Ayrshire Council . • I understand that the information provided on this form, the assessment and any supporting evidence will form part of my housing application and may be shared with any or all of the SEARCH partners.

Applicant’s Signature Date:

Joint Applicant’s Signature Date:

Housing for Older People: Application for Assessment 15 Section 6: Housing for Older People Service Agreement

This document is an Agreement between us, East Ayrshire Council, Council Headquarters,

London Road, Kilmarnock (the “Council”) and…………………………………………………………………………… (You) and we Hereby Agree as follows:-

Should you be allocated a tenancy in Housing for Older People the Council will provided housing support services to you. These services will as a minimum include a community alarm and linked in smoke detector providing a 24 Hour response service.

These support services will incur a charge which will be payable by you to the Council. This charge is separate from the rent, council tax, or any other service charge for the tenancy. The charge is mandatory to every tenant residing within one of our Housing for Older People communities. The charge varies depending on the services and facilities available within the different Housing for Older People communities and is payable on a monthly basis. Please refer to the Charging for Council funded or provided Support Services leaflet for more details.

However a financial assessment will be carried out to determine whether not you may be eligible for a rebate of the support service charge under the Council non-residential service charging policy. Please note the council’s community alarm service has a flat rate weekly charge which no rebates are awarded.

Should you become a tenant in Housing for Older People; the Council will notify you of the support service charge and consult you about any proposed increases before the Council makes a decision. The Council is entitled to increase the amount of the support service charge as long as we tell you in writing at least four weeks before the beginning of the month when the change is to start from. The Council will not normally change the support service charge more than once a year. You have the right to a request a copy of the Council’s support service charging policy.

Name (on behalf of East Ayrshire Council)

Address

Signature Date:

Name (Applicant)

Address

Signature Date:

16 Housing for Older People: Application for Assessment Section 7: Supported Accommodation in East Ayrshire COMMUNITY NUMBER OF HOUSES OR FLATS LINK CORRIDOR AREA COMMUNAL LAUNDRY ROOMS GUEST KITCHEN LANDLORD TYPE OF SERVICE

Back Rogerton Crescent, 41 x 1 bed bungalows No No No No No EAC Low needs William McComb Court, Auchinleck 12 x 1 bed bungalows No No No No No EAC Low needs Bridge Lane, 20 x 1 bed bungalows No Ye s Ye s Ye s No EAC Low needs 1 x 2 bed bungalow Cowans Row, Crookedholm 10 x 1 bed bungalows No No No No No EAC Low needs James Young Avenue, Netherthird 20 x 1 bed bungalows No No Ye s No Yes EAC Low needs 1 x 2 bed bungalows Glebe Court, Cumnock 10 x bedsit flats Ye s Ye s Ye s No Yes Bield High needs Menzies Court, Cumnock 19 x 1 bed flats Ye s Ye s yes Ye s Yes Bield Low needs Tweedlie Court, Cumnock 6 x 1 bed flats No No No No No Bield Low needs Warrick Court, Cumnock 19 x 1 bed flats Ye s Ye s Ye s No Yes Bield Low needs 8 x2 bed flats Highcrofts, 24 x 1 bed flats Ye s Ye s Ye s Ye s Yes Bield medium needs Hopes Avenue, Dalmellington 13 x 1 bed bungalows No Ye s yes No No EAC Low needs Collins Court, 16 x 1 bed flats No No No No No Trust Low needs Rowantree Court, 33 x 1 bed flats Ye s Ye s Ye s Ye s Yes EAC High needs Boyd Street, Galston 8 x 1 bed flats No No No No No EAC Low needs Craigie Place, Galston 5 x 1 bed flats No No No No No EAC Low needs Ross Court, Galston 23 x bedsit bungalows Ye s No No EAC High needs 2 x 1 bed bungalows Standalane, Galston 4 x 2 bed flats No No No No No EAC Low needs Titchfield Street, Galston 3 x 1 bed flats No No No No No EAC Low needs 12 x 2 bed flats Garven Court, Kilmarnock 28 x 1 bed flats Ye s Ye s Ye s No Yes EAC High needs 3 x 2 bed flats Craigie Court, Kilmarnock 12 x bedsit flats No No Ye s No No EAC Low needs Springhill Gardens, Kilmarnock 24 x 1 bed bungalows No No Ye s No No EAC Low needs COMMUNITY NUMBER OF HOUSES OR FLATS LINK CORRIDOR AREA COMMUNAL LAUNDRY ROOMS GUEST KITCHEN LANDLORD TYPE OF SERVICE

Princess Court, Whatriggs Road, 11 x 1 bed flats No No No No No Hanover Low needs Kilmarnock Housing Forbes Place, New Farm Loch, 10 x 1 bed flats No No No No No Hanover Low needs Kilmarnock Housing MacNichol Place, New Farm Loch, 10 x 1 bed flats No No No No No Hanover Low needs Kilmarnock Housing Creighton Court, Onthank 31 x 1 bed flats Yes Ye s Yes No No Hanover medium Kilmarnock Housing needs Mill Court, Old Mill Road, 30 x 1 bed flats Ye s Ye s Ye s No No Hanover medium Kilmarnock Housing needs Witch Road, Kilmarnock 23 x 1 bed flats Ye s Ye s Ye s Ye s Yes West of High needs 2 x 2 bed flats Scotland St Maurs Gardens, 12 x bedsit flats Ye s Ye s Ye s No Yes EAC High needs Main Street, Kilmaurs 12 x 1 bed flats No No No No No Hanover Low needs Housing Bryce Avenue, Logan 24 x 1 bed bungalows No No No No No EAC Low needs Paterson Avenue, Logan 6 x 2 bed bungalows No No No No No EAC Low needs Ellisland Court, 6 x bedsit flats Ye s Ye s Ye s Ye s Yes EAC High needs 10 x 1 bed flats Loch Road, Mauchline 6 x 1 bed bungalows No Ye s No No No EAC Low needs Main Street, 14 x 1 bed bungalows No No No No No EAC Low needs Afton Court, 20 x 1 bed flats Ye s Ye s Ye s Ye s Yes EAC High needs Afton Bridgend, New Cumnock 10 x 1 bed bungalows No No No No No EAC Low needs 1 x 2 bed bungalows Greenhead Road, New Cumnock 4 x 1 bed bungalows No No No No No EAC Low needs Murdoch Nesbit Court, 10 x 1 bed flats No No No No No Hanover Low needs Housing Lady Flora’s Institute, Newmilns 20 x 1 bed flats Ye s Ye s Ye s Ye s No Trust Medium 5 x 2 bed flat needs Valley Court, Patna 1 x 1 bed flat Ye s Ye s Ye s Ye s Yes Bield High needs 18 x 2 bed flats Hamilton Gardens, 20 x bedsit flats Ye s Ye s Ye s No Yes EAC High needs Lochhead Court, Stewarton 30 x 1 bed flats Ye s Ye s Ye s No No Hanover medium Housing needs

18 Housing for Older People: Application for Assessment Housing for Older People: Application for Assessment 19 DATA PROTECTION East Ayrshire Council Housing Offices SEARCH is a Partnership involving East Ayrshire Council and Registered Social Landlords, Atrium North West Kilmarnock Homes, Cunninghame Housing Association, Irvine Western Road, KILMARNOCK, KA3 1NQ Housing Association and Shire Housing Association. Tel: 01563 555 670 Contact details for all of the Partners can be found at Kilmarnock Central and South the end of this document. Council Offices, John Dickie Street East Ayrshire Council will process your application on KILMARNOCK, KA1 1BY behalf of all of the partners. The Council and partners Tel: 01563 576 618 are data controllers in common. Any data protection Irvine Valley and Ballochmyle queries can be directed to the Council’s Data Protection Officer using the details noted below. If your issues Council Offices, John Dickie Street are not resolved following internal discussions, further KILMARNOCK, KA1 1BY enquiries or complaints can be made to the Information Tel: 01563 554 664 or 554 653 Commissioner’s Office, contact details below: Cumnock

Data Protection Officer: Council Headquarters, London Rothesay House, 1 Greenholm Road Road, Kilmarnock, KA3 7BU CUMNOCK, KA18 1LH Tel: 01563 576094 Tel: 01290 427 727 or 01290 427 728 Email: [email protected] Doon Valley Information Commissioner’s Office: Dalmellington Area Centre, 33 Main Street 45 Melville Street, Edinburgh, EH3 7HL DAMLELLINGTON, KA6 7QL Tel: 03031231115 Tel: 01292 552 887 Email: [email protected] SEARCH Partner Landlords It is necessary to process this information to perform a public task which is of substantial public interest – in other Atrium Homes words to allow us to assess your current accommodation 14 Central Avenue, Shortlees, KILMARNOCK, KA1 4PS against any health issues or disabilities you are suffering to Tel: 01563 528 816 assess what assistance can be provided. Cunninghame Housing Association Your information will be available to all of the SEARCH 42 Campbeltown Drive, KILMARNOCK, KA3 1JX partners. In order to fully assess your application, the Tel: 01294 607 550 SEARCH partners can ask for additional information Irvine Housing Association from other agencies and Health and Social Services 44-46 Bank Street, IRVINE, KA12 0LP professionals in connection with your application. Tel: 0345 112 6600 You have the right to request any data held about you, Shire Housing Association the right to have inaccurate data corrected, the right to Netherthird House, Netherthird restrict or object to the processing of your data and the CUMNOCK, KA18 3DB right to data portability in certain circumstances. Tel: 01290 421 130 Your information will be retained for 5 years following cancellation of your application, or 5 years following the termination of your tenancy agreement if rehoused. Designed and produced by East Ayrshire Council Communications Section ©2018 Ayrshire Council Communications East Designed and produced by