Statutory notification about a person who lives in a care home

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1 Statutory notification about a person who lives in a care home Please read Guidance for Providers: How to tell us about notifiable events for detailed advice on how and when to make statutory notifications The guidance is available at There is a separate form for notifications about a care home s premises, the registered provider(s), registered manager, staff, or statement of purpose This notification includes personal information. To comply with the Data Protection Act 1998 it should not be sent by or fax Please send this notification by post to: Care Quality Commission National Correspondence Citygate Gallowgate Newcastle Upon Tyne NE1 4PA Fax us on: Or your regional team: Easter Region: London Region: North East Region: North West Region: South East Region: South West Region: West Midlands Region: Please use a separate form for each notification Please do not send in duplicate notifications by or fax: send this notification ONCE, by post only Service numbers can be found on reports and certificates of registration You do not need to send us this page Page 0 of 5

2 Statutory notification about a person who lives in a care home Part 1 Required information: Please note it is important to fill in the service number. You will find this on your registration certificate. The care home Care home name: Care home s address: Postcode: Service number: Form filled in by: Date: The person Title Name Age Date of birth Date of admission The type of event (tick one) Notification timescale A death Serious infectious disease Serious injury Serious illness (in a non nursing care home only) Without delay Event that adversely affects the person s safety & welfare Theft, burglary or accident The termination of accommodation without notice As soon as practicable Where the notification is about a death Date of death Time of death Time of discovery of death Was the death expected? (You must provide additional relevant information Cause of death (if/as recorded on death certificate) Page 1 of 4

3 Where the notification is about a serious infectious disease Date of diagnosis by doctor Type of disease Where the notification is about a serious injury Date of injury Time of injury Where the notification is about a serious illness (non-nursing homes ONLY) Date of diagnosis by medical practitioner Type of illness Other events that adversely affect people s safety and welfare Please tick the type of event Medication error that needed discussion with a doctor or nurse Any incident where the police became involved Loss or theft of controlled drugs Missing persons procedure used Water, gas or electricity cut off for more than 24 hours Significant damage to the premises which affects residents (You must provide additional relevant information Fire detection, call system or lift not working for more than 24 hours Other (specify Theft or burglary Please tick theft or burglary Theft of a person s personal items Burglary Part 2 Additional voluntary information Where the notification involves serious injury Nature of Injury Sprain/strai Cut/bite/ Fracture Bruise n open wound Concussio Vital organ n Where did the injury occur Person s Communal Bath / WC bedroom room shower Garden / Outside the Corridor grounds home Activity: What was the person doing when they were injured? Burn Kitchen Page 2 of 4

4 Receiving Leisure Alone care activity Mechanism: How was the person hurt / how was the injury inflicted? Pressure Fall Fire / heat sore (2+) Intent Accidental Intended unintende assault d Self harm Other If care or medical treatment was required What treatment / care was given and where Care or first aid given within the care home Medical treatment given within the care home Treatment given in a medical setting but person not admitted to hospital Hospital admission If the notification is about alleged abuse or neglect Type of abuse (tick all that apply) Physical abuse Psychological abuse Neglect Sexual abuse Financial/material Discriminatory abuse Alleged abuser(s) relationship with the person (tick all that apply) Care Worker employed at the Relative Volunteer home Visiting care worker or professional Friend Information about a safeguarding investigation Date allegation was reported to registered person: Date Date Date allegation was reported to social services department / police: Page 3 of 4

5 Part 3 Any further information Continue on additional numbered sheets if necessary (box will expand) Page 4 of 4

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