Application number

Department to complete

2014 AGED CARE APPROVALS ROUNDRESIDENTIAL AGED CARE PLACES AND A

CAPITAL GRANT Applicant organisation

Aged care service

Aged care planning region

Complete a separate application for each service for which you are seeking residential aged care places and a capital grant.

If you are seeking only a capital grant in respect of the service use the ‘Capital Grants Only’ application

If you are seeking only residential aged care places in respect of the service use the ‘Residential Aged Care Places’ application.

Detailed information about completing this application is included in the 2014 ACAR Essential Guide.

Submit your application to the Department of Social Services. Address details can be found at page 4, Section 1 of the 2014 ACAR Essential Guide.

The closing time for the 2014 Aged Care Approvals Round is2.00pm, 4 July 2014.

This form is approved under paragraph 13-1(c) and paragraph 71-1(c) of the Aged Care Act 1997 Page 1 of 24

PART 1: APPLICANT DETAILS*

1.1 Applicant:

Organisation (if approved provider, insert approved provider name)

ABN

NAPS ID (if known)

1.2 Applicant postal address:

Street name and number ORPO Box number

Suburb/Town

State/Territory Postcode

1.3 Contact Details:

Primary contact Alternate contact

Name of contact person

Position in organisation

Telephone ( ) ( )

Mobile

Best hours to ring

Email

* These details will be used as the official address for all notices related to the 2014 ACAR from the Department for this process.

This form is approved under paragraph 13-1(c) and paragraph 71-1(c) of the Aged Care Act 1997 Page 2 of 24

PART 2: SERVICE DETAILS

2.1 Service details:

Name of service(existing or new)

RAC service ID(existing service only)

2.2 Physical address of the service:(if known)

Street number

Street name

Street Type (Street/Avenue etc)

Suburb/Town

State/Territory Postcode

This form is approved under paragraph 13-1(c) and paragraph 71-1(c) of the Aged Care Act 1997 Page 3 of 24

PART 3: RESIDENTIAL AGED CARE PLACES BEING SOUGHT

3.1 Residential aged care places sought.

To complete this table, refer to Section 4 of the 2014 ACAR Essential Guide.

Total residential aged care places soughtSpecify the total number of residential aged care places sought for this service

Number of places Max

Number of places Min

Of the total residential aged care places sought, how many are for general access and/or priority of access?NOTE: General access places + Priority access places MUST EQUAL total residential aged care places

General access places soughtNumber of places Max

Number of places Min

Priority of access places sought

Geographic Location Special needs group

CALD community

(if applicable)

Identified key issue (if any)

Number of places Max

Number of places Min

3.2 How many new residential respite bed days per annum will be provided at this service?

Days

3.3 When will the places that are the subject of this application be made operational?

From date of allocation Number of new places

Immediate

Within 1 month

2-3 months

4-6 months

7-12 months

13-18 months

19-24 months

TOTAL

This form is approved under paragraph 13-1(c) and paragraph 71-1(c) of the Aged Care Act 1997 Page 4 of 24

PART 4: SERVICE PROPOSAL

4.1 Provide a detailed description of your proposal for this service.

A. Features of the proposal. B. What need(s) is/are being met? C. What evidence has been relied on to determine need(s)? D. How will the service proposal address the need(s)?

Word limit 1000

This form is approved under paragraph 13-1(c) and paragraph 71-1(c) of the Aged Care Act 1997 Page 5 of 24

4.2 Provide the configuration of your service, both BEFORE and AFTER the proposal for this service is implemented.

BEFOREthis proposal is implemented

New construction

Upgrading of existing rooms

Unchanged rooms after this

proposal is implemented

AFTERthis proposal is implemented

E=B+C+DA B C D E

Single rooms -en-suites

Number of rooms

Number of residents

Single rooms -shared bathrooms

Number of rooms

Number of residents

Single rooms -common ablutions

Number of rooms

Number of residents

Double rooms -en-suites

Number of rooms

Number of residents

Double rooms -shared bathrooms

Number of rooms

Number of residents

Double rooms -common ablutions

Number of rooms

Number of residents

Multi-bed wardsNumber of rooms

Number of residents

Common ablution areas

Number of showers

Number of baths

Number of toilets

Additional toilets off common areas

Other areas No m2 No m2 No m2 No m2 No m2

Laundry

Kitchen

Lounge

Dining

Other recreational areas

Administration areas

This form is approved under paragraph 13-1(c) and paragraph 71-1(c) of the Aged Care Act 1997 Page 6 of 24

PART 5: SERVICE PLANNING AND DEVELOPMENT

5.1 Describe your proposal to extend, refurbish or develop new buildings for the delivery of aged care services.

Word limit 500

5.2 Provide the key milestones in the development of the capital works project.

Key Milestone Date achieved Date to be achieved

Have you attached evidence?

Finalise land purchase/lease Y/N

Approval of finance Y/N

Development Application approved Y/N

Building Application approved Y/N

Arrangements for existing residents Y/N

Commencement of building work Y/N

Completion of building work Y/N

Approval from appropriate state/territory and/or local government authorities Y/N

Admission of residents Y/N

5.3 Identify any known risks that may affect your ability to meet the above key milestones.

A. Identify risks. B. How are you going to manage identified risks?

Word limit 500

This form is approved under paragraph 13-1(c) and paragraph 71-1(c) of the Aged Care Act 1997 Page 7 of 24

PART 6: CAPACITY OF APPLICANT TO DELIVER RESIDENTIAL AGED CARE SERVICES

A. Management and ability to provide appropriate care

6.1 Describe your organisation’s expertise and experience in providing residential aged care or similar services.

Word limit 750

6.2 Describe the systems in place which enable your organisation to deliver appropriate care in accordance with the legislation.

Word limit 750

6.3 Describe how you will provide appropriate care to people with dementia.

Word limit 500

This form is approved under paragraph 13-1(c) and paragraph 71-1(c) of the Aged Care Act 1997 Page 8 of 24

6.4 Does this proposal involve specialisation in dementia care?

No (go to 6.7)

Yes (go to 6.5)

6.5 How will the building design and external environment address the particular care needs of people with dementia?

Word limit 500

6.6 Describe the specific strategies your organisation has in order to provide specialised dementia care.

Word limit 500

B. Provision of appropriate care for people with special needs

6.7 Describe how you will provide appropriate care for people with special needs.

Word limit 500

This form is approved under paragraph 13-1(c) and paragraph 71-1(c) of the Aged Care Act 1997 Page 9 of 24

Have you identified any places which would provide priority of access for a special needs group in your response to question 3.1?

No (go to 6.9)

Yes (go to 6.8)

6.8 For each of the special needs groups identified at 3.1, provide details of:

A. Evidence of need in the region/geographic location for residential aged care for the special needs group. B. Organisational experience and/or expertise in the provision of care for the special needs group. C. Any tailored approaches you plan to take to meet this group’s particular care needs.

Word limit 500 for each special needs group identified

C. Continuity of care

6.9 How will you ensure continuity of care to current and future care recipients?

Word limit 500

D. Compliance with responsibilities

Protecting the rights of care recipients

6.10 Describe the measures you will implement to protect the rights of care recipients.

Word limit 500

This form is approved under paragraph 13-1(c) and paragraph 71-1(c) of the Aged Care Act 1997 Page 10 of 24

PART 7: CAPITAL WORKS

7.1 Capital grant project details - Provide a description of the proposed capital works.

Word limit 300

7.2 Describe the issues the proposed capital works will address.

Word limit 300

7.3 If the proposed capital works are regarded as urgent, explain the reasons for this urgency.

Word limit 300

7.4 Describe why you are unable to fund the proposed capital works project.

Word limit 300

This form is approved under paragraph 13-1(c) and paragraph 71-1(c) of the Aged Care Act 1997 Page 11 of 24

7.5 Provide details of any temporary accommodation and/or care arrangements you will need to put in place during the construction or redevelopment work.

Word limit 300

7.6 Concessional, supported, assisted & low-means care recipients.

Concessional, supported, assisted & low-means care recipients

Current number(as at 1 June 2014)

Expected number(upon completion of works)

7.7 If you have identified as part of your overall proposal, a significant increase in the numbers of concessional, supported, assisted or low-means care recipients, describe the steps you will take to achieve this outcome.

Word limit 300

7.8 Is the primary purpose of this capital works project to facilitate the provision of care to people from one or more of the special needs groups?

No (go to 7.14)

Yes

If the primary purpose of the capital works project is the provision of care to people from one or more identified special needs group, this may be reflected in the conditions of any grant.

You may identify more than one special needs group which will benefit from this capital works project. While it is recognised that a care recipient may be a member of more than one special needs group, for the purposes of Questions 7.9 – 7.13 a care recipient should only be included in only one special needs group.

NOTE: Complete one set of Questions 7.9 – 7.13 for EACH special needs group which will be provided with care as a result of the capital works project.

7.9 Specify the special needs group, as defined in the Aged Care Act 1997.

7.10 How many people from this group do you provide care to at the service now?

This form is approved under paragraph 13-1(c) and paragraph 71-1(c) of the Aged Care Act 1997 Page 12 of 24

7.11 How many people from this group will you provide care to at this service at the conclusion of this project?

7.12 If you have forecast a significant increase in the numbers of people from the special needs group, describe the steps you will take to achieve this outcome.

Word limit 300

7.13 Describe how the building design and external environment will meet the particular care needs of the identified special needs group.

Word limit 300 per special needs group

This form is approved under paragraph 13-1(c) and paragraph 71-1(c) of the Aged Care Act 1997 Page 13 of 24

7.14 Cost Certificate

$DO NOT INCLUDE GST

A. Land costs

(a) Site acquisition (only include costs if land is not already acquired)

(b) Site preparation

(c) Fencing and road-works

(d) Demolition

(e) Connecting mains to property boundary (water, sewerage and/or electricity)

(f) Landscaping

(g) Survey fees re: sub-division costs

B. Estimated capital works (building) cost for the project

C. Costs of furniture, furnishings and fittings

D. Other cost of works NOT included in the above estimate

(h)

(i)

(j)

E. Fees

(k) Architect fees @ ……. % on $ ………..

(l) Other professional consultants’ fees

(m) Describe any other fees:

(n) Contingency sum(s)

TOTAL PROJECT COST

I declare this is my best estimate of the total project costs of the capital works described in Question 7.1 and is based on the configuration of the service as described in Question 4.2.

Name of company

Name of Architect or Design or Construction professional

Signature Qualification Date

This form is approved under paragraph 13-1(c) and paragraph 71-1(c) of the Aged Care Act 1997 Page 14 of 24

PART 8: FINANCIAL INFORMATION

APPROVED PROVIDER/APPLICANT ORGANISATION

8.1 Statement of Organisational Financial Position and Projections – Assets.

NOTE: Organisations must provide 2012-13 Audited Financial Statements. This information will be used to assess your organisation’s financial viability for this application.

A B C D

Forecast situationas at 30 June 2014

Forecast situation immediately

BEFORE commencement of

capital works

Forecast situation immediately AFTER completion of capital

works

Forecast situation AFTER completion of the capital works and when maximum

occupancy is achieved

Month Year Month Year Month Year

CURRENT ASSETS $ ‘000 $ ‘000 $ ‘000 $ ‘000

Cash and bank accounts

Investments

Receivables

- Residents

- Parent/related organisation

- Other (provide detail in ‘Other Assets’)

Total current assets

NON-CURRENT ASSETS $ ‘000 $ ‘000 $ ‘000 $ ‘000Land and buildings

Plant and equipment

Investments

Intangibles

Receivables

- Residents

- Parent/related organisation

- Other (provide detail in ‘Other Assets’)

Total non-current assets

TOTAL ASSETS

Other assets:

Other Current assets

Other Non-Current assets

Word limit 150Liabilities

This form is approved under paragraph 13-1(c) and paragraph 71-1(c) of the Aged Care Act 1997 Page 15 of 24

NOTE: Organisations must provide 2012-13 Audited Financial Statements. This information will be used to assess your organisation’s financial viability for this application.

A B C DForecast situation

as at 30 June 2014Forecast situation

immediately BEFORE

commencement of capital works

Forecast situation immediately AFTER completion of capital

works

Forecast situation AFTER completion of the capital works and when maximum

occupancy is achieved

Month Year Month Year Month Year

CURRENT LIABILITIES $ ’000 $ ‘000 $ ‘000 $ ‘000Bank overdraft Creditors and accruals Employee entitlements Debt/Loans Accommodation bonds, refundable accommodation deposits and refundable accommodation contributions

Bridging finance Bank/financial institution Parent/related organisation Zero real interest loan Other (provide detail in ‘Other Liabilities’)

Total current liabilities

NON-CURRENT LIABILITIES $ ‘000 $ ‘000 $ ‘000 $ ‘000Employee entitlements Debt/Loans Accommodation bonds, refundable accommodation deposits and refundable accommodation contributions

Bridging finance Bank/financial institution Parent/related organisation Zero real interest loan Other (provide detail in ‘Other Liabilities’) Total non-current liabilities TOTAL LIABILITIES TOTAL ASSETS less TOTAL LIABILITIES (A)

Reconciliation of movement in Net Assets to Operating Surplus (Deficit)Opening NET ASSETS Operating surplus/(Deficit) Other changes to equity- Contributed capital received- Dividend payments- Other (provide detail below)

Closing NET ASSETS (A)

This form is approved under paragraph 13-1(c) and paragraph 71-1(c) of the Aged Care Act 1997 Page 16 of 24

Other liabilities:

Current liabilities Non-Current liabilities

Word limit 150

Other changes in equity:

Nature of the transaction(s) Reason why not included in the operating surplus (deficit), contributed capital or dividend payments.

Word limit 150

This form is approved under paragraph 13-1(c) and paragraph 71-1(c) of the Aged Care Act 1997 Page 17 of 24

FINANCIAL INFORMATION - SERVICE LEVEL

8.2 Operating surplus (deficit) – projections for the residential aged care service.

Forecast situation after the capital works are completedYear 1 Year 2 Year 3 Year 4

2012-13 Year Year Year Year $ ‘000 $ ‘000 $ ‘000 $ ‘000

Income

Expenditure

AOperating surplus (deficit) (income-expenditure) before depreciation and debt interest payments

B Less: Depreciation on buildings

C Less: Depreciation on plant and equipment

D Less: Zero real interest loan interest payments (equal to CPI)

E Less: Other debt interest payments

FOperating surplus (deficit) AFTER depreciation and debt interest payments

G Less: Zero real interest loan principal repayments

H Less other debt principal repayments

I Add back: Depreciation on buildings

J Add back: Depreciation on plant and equipment

K Less: New capital expenditure

LNET Accommodation bonds, refundable accommodation deposits and refundable accommodation contributions

M Cash surplus (deficit)

N Total number of operational places

O Total number of provisional places

P Total number of places

This form is approved under paragraph 13-1(c) and paragraph 71-1(c) of the Aged Care Act 1997 Page 18 of 24

8.3 Advise of any significant changes in your operating results.

Word limit 150

8.4 Advise how your organisation will fund any operating deficit.

Word limit 150

Capital works financial details

8.5 Capital works costs associated with this application.

Existing places(Operational or offline)

Provisionally allocated places

Project element New Construction

$Upgrading

$New Construction

$Upgrading

$

Do not include GST Do not include GST Do not include GST Do not include GSTAcquisition of land (include costs only if land has not already been acquired)

Construction of new building

Fit out of new building

Upgrading of existing premises

Refurbishment/fit out of upgraded existing premises

Landscaping and road works

Other (provide detail at “Other Capital Works Costs”)

Total capital works costs

Number of existing operational places to be accommodated.

Number of places applied for in 2014 ACAR to be accommodated

Number of existing offline places

Number of provisionally allocated places from previous ACARs to be accommodated.

This form is approved under paragraph 13-1(c) and paragraph 71-1(c) of the Aged Care Act 1997 Page 19 of 24

Other Capital Works Costs:

Word limit 150

8.6 Sources of funds for the capital works.

Applicant organisation’s contributions $ ‘000Internal sourcesDrawn from reserves (excluding any amounts from accommodation bonds, refundable accommodation deposits and refundable accommodation contributions)Provide detail at 8.7 Reserve Funds

Internal borrowings from within the applicant organisation or a parent/allied group – repayable Describe:

Contributions from parent/allied group – non-repayable Sale of assetsDescribe:

Resident sourcesAccommodation bonds – existing places (do not include any provisionally allocated places)

Refundable accommodation deposits and refundable accommodation contributions – any provisionally allocated placesProvide detail at 8.8 Bridging Finance

External sourcesBorrowings from an external organisation, including loans from financial institutions

Other sourcesSpecial fund raising activitiesDescribe:

OtherDescribe:

Total applicant contribution Additional sources of funding

Capital funding from state/territory government

Capital grant(s) allocated in previous ACAR(s)

Zero real interest loans allocated in previous ACAR(s)

Other additional sources of fundingDescribe:

Total funds

8.7 Where do “Funds drawn from reserves” appear in the Statement of Financial Position (Balance Sheet)?

This form is approved under paragraph 13-1(c) and paragraph 71-1(c) of the Aged Care Act 1997 Page 20 of 24

Funds drawn from: $Cash and bank accounts

Investments

OtherDescribe:

TOTAL RESERVES to be used for the capital works identified in this application

8.8 Bridging finance to be used for the capital works identified in this application.

Annual amount to be repaid 2014-15$

2015-16$

2016-17$

2017-18$

2018-19$

2019-20$

Principal

Interest

Date bridging finance is to be repaid in full

8.9 Current status of funds negotiations.

Discussions held

Agreement in-principle

Contract in place

Other (provide detail below)

Have you attached

evidence?

Internal sources

External sources

Bridging finance

This form is approved under paragraph 13-1(c) and paragraph 71-1(c) of the Aged Care Act 1997 Page 21 of 24

Projections for the residential aged care service

8.10 Service overview.

Forecast situation after the capital works are completedYear 1 Year 2 Year 3 Year 4

2012-13 Year Year Year Year

A Number of allocated places

B Number of unfunded places

C Total places

D Total residents

E Occupancy rate (%)

F

Number of residents paying accommodation bonds,refundable accommodation deposits and refundable accommodation contributions

GTotal collected from accommodation bonds, refundable accommodation deposits and refundable accommodation contributions ($)

HLiability for accommodation bonds, refundable accommodation deposits and refundable accommodation contributions ($)

I Reserve funds for the service ($)

This form is approved under paragraph 13-1(c) and paragraph 71-1(c) of the Aged Care Act 1997 Page 22 of 24

8.11 Assumptions underlying the projections.

Word limit 100

8.12 Required attachments.

Document

Audited 2012-13 financial reports, including any notes and/or auditor’s opinions(to confirm the starting position for your financial projections).

This form is approved under paragraph 13-1(c) and paragraph 71-1(c) of the Aged Care Act 1997 Page 23 of 24

Have you attached evidence?

PART 9: ENDORSEMENT OF APPLICATION

This application can be signed only by those persons who are legally empowered to give assurances and enter into contracts and commitments on behalf of the applicant.

In signing this endorsement, you are affirming that this proposal has the full consent and support of your organisation’s Board of Directors, or other relevant authority.

Giving false or misleading information is a serious offence.

There are offences established by the Aged Care Act 1997 and the Criminal Code Act 1995relating to providing false or misleading information.

Approvals based on false or misleading information may be revoked.

I am aware of my responsibilities as prescribed in the Aged Care Act 1997 and the Aged Care Principles.

I have read the 2014 ACAR Essential Guide.

I declare that the information provided in this application and associated attachments is true and complete.

I declare that the key personnel in the applicant organisation are, and will continue to be, suitable to provide aged care and are not disqualified individuals.

I consent to the Secretary of the Department of Social Services providing relevant information in respect of this application to other persons or organisations, in order to obtain their advice as necessary to assist in assessing this application or in assessing other applications submitted by the applicant in the 2014 ACAR. These organisations may include, but are not limited to, the Australian Aged Care Quality Agency and state, territory or Australian Government Departments and/or other relevant sources, such as independent financial analysts.

I consent to the persons or organisations that are contacted releasing information to the Department of Social Services.

Company seal and citation

This form is approved under paragraph 13-1(c) and paragraph 71-1(c) of the Aged Care Act 1997 Page 24 of 24

Full name

(print)

Signature

Position held

Date / /

How many hours did your organisation take to complete this form?