Enabling Research in Care Homes Network - full application

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* 1. Name of Care Home

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* 2. Address

Address

Address 2

City/Town

County

Post Code

Email Address

Phone Number

Website address

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* 3. Name of Owner/Company

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* 4. Manager's Name

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* 5. Main Contact Information

Name

Job title

Email Address

Phone Number

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* 6. Type of Home (indicate all that apply)

Nursing

Residential

Intermediate

Care village/assisted living

Other (please specify below)

Other (please specify)

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* 7. Are you registered for Dementia?

Yes

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* 8. Number of all beds?

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* 9. Date of last CQC?

Date

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* 10. What was your CQC rating?

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* 11. Number of care staff?

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* 12. Number of registered nurses?

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* 13. Number of ancillary staff?

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* 14. Other healthcare regular staff? (indicate all that apply)

Occupational Therapist

Speech and Language Therapist

Dietician

Other (please specify below)

Volunteers

Other (please specify)

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* 15. Does the care home have specific clinical and/or research relationships with name clinicians/hospital departments/Universities or others?

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* 16. GP Practices - please give the name of the practice, the Care Home or residence are linked to. This is because sometimes the research methodology means the GP may be asked to be involved. If there is an assigned GP it would be helpful to have their name and practice too.

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* 17. Does the Care Home have any previous experience of supporting research/research studies?

Yes (if Yes please provide more information below e.g. name of study/role/when etc)

If yes, please specify

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* 18. Are residents care home healthcare records/notes centrally held?

Electronic

Paper

Both

Don't know

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* 19. Are there any specific areas of research that your care home would like to be involved in? Perhaps you have a research question or aspect we could share with potential researchers?

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* 20. Can we share your information (only) with appropriate research teams? This will help speed up the time for the research teams to contact you. Remember you can decide not to join a research activity without it affecting your service in any way. Please don't hesitate to contact us at the CRN KSS if you have any concerns or questions

Yes

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* 21. Please note, membership is free of charge and you are free to withdraw at any time if you wish to do so. Please note below that you confirm you understand the aims and requirements of participation in the network

Yes, I confirm I understand

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* 22. NIHR ENRICH is the data controller and is committed to protecting the rights of individuals in line with the data protection act 1998 (DPA) and the new general data protection regulation (GDPR). The relevant legal basis for processing your personal data is consent provided by the data subject.
I agree to NIHR ENRICH using my information for the following purposes:

To invite you to relevant research seminars and networking events

To provide information about research, questionnaires, newsletters and training opportunities

To share your data with relevant university research teams and to be contacted from time to time by research teams to consider taking part in research

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* 23. Name/Date

Name

Job Title

Date