QUALITY ASSURANCE: QUESTIONNAIRE (Annual) (Domiciliary)

This quality assurance questionnaire is our way of gathering feedback from our service users, their family or representatives. If you need any assistance in the completion of this survey, please contact the office where we will be happy to assist.
Thank you for your cooperation

Name of Person Completing the Form: : *

Name of Service User: : *

Relationship to Service User: : *

Have you received a copy of the service user guide? : * Yes No

Have you read this information? : * Yes No

Was it helpful in informing you about our services? : * Yes No

Is there anything that you did not understand? : * Yes No

Is there anything we seem to have missed? : * Yes No

Do you have any suggestions of how it could be improved? : * Yes No

Please comment on any improvement : *

Do you have a completed care needs assessment? : * Yes No

Is there a care plan within your home? : * Yes No

Did you sign a contract for services? : * Yes No

Are we providing the services detailed on the care plan? : * Yes No

Does the service meet your expectations? : * Yes No

Please detail any “Yes” answers : *

Are they polite, courteous and respectful? : Not at all Sometimes Most of the time Always

Do you think our carers understand your needs? : Not at all Sometimes Most of the time Always

Do you find them helpful? : Always Most of the time Sometimes D Not at all

Do you find them friendly and interested in you? : Always Most of the time Sometimes D Not at all

Do they listen when you ask them to do something? : Always Most of the time Sometimes D Not at all

Do they follow the Care Plan? : Always Most of the time Sometimes D Not at all

Do they follow the Care Plan? : * Always Most of the time Sometimes D Not at all

Please detail any “C and D” answers : *

Do the care-workers come at times that suit you? : Always Most of the time Sometimes D Not at all

Do the care-workers arrive on time at the agreed time? : Always Most of the time Sometimes D Not at all

Have they ever not turned up? : Always Most of the time Sometimes D Not at all

When they have been delayed, have you been informed? : Always Most of the time Sometimes D Not at all

Do they have enough time to complete the tasks? : Always Most of the time Sometimes D Not at all

Do they seem to be in too much of a rush? : Always Most of the time Sometimes D Not at all

Do they spend less time than they should? : Always Most of the time Sometimes D Not at all

Are they thorough in what they do for you? : Always Most of the time Sometimes D Not at all

Do they encourage you to do as much as possible? : Always Most of the time Sometimes D Not at all

If they assist with medication, do they follow correct procedures? : Always Most of the time Sometimes D Not at all

Do they work well as a team where appropriate? : Always Most of the time Sometimes D Not at all

Do they treat your home in a respectful manner? : Always Most of the time Sometimes D Not at all

If you have had a change of worker, do they always know what to do? : Always Most of the time Sometimes D Not at all

Are you confident that they will not harm you and keep you safe? : Always Most of the time Sometimes D Not at all

Do you agree that they are well trained? : Always Most of the time Sometimes D Not at all

Do you agree that all information about you is handled in confidence? : Always Most of the time Sometimes D Not at all

Are you satisfied that carers will not breach confidentiality? : Always Most of the time Sometimes D Not at all

Do you agree that our carers seem to know what they are doing? : * Always Most of the time Sometimes D Not at all

Are you confident in their abilities? : Always Most of the time Sometimes D Not at all

Do you agree that they are given clear instruction about what to do? : Always Most of the time Sometimes D Not at all

Are you confident that any complaint you make will be investigated? : Always Most of the time Sometimes D Not at all

Do carers record accurately in the attendance record? : Always Most of the time Sometimes D Not at all

When you have had to make contact with us have you been dealt with promptly? : Always Most of the time Sometimes D Not at all

Are phone calls returned quickly? : Always Most of the time Sometimes D Not at all

Are office staff polite and courteous? : Always Most of the time Sometimes D Not at all

Do we make the changes to your service as required? : Always Most of the time Sometimes D Not at all

Please detail any “C and D” answers : *

Does it help you to keep your independence? : It helps a lot It helps a little It doesn’t help at all

Does it help you to be clean and comfortable? : It helps a lot It helps a little It doesn’t help at all

Does it help you to feel safe in your own home? : It helps a lot It helps a little It doesn’t help at all

Does it assist in keeping contacts with other people as you want? : It helps a lot It helps a little It doesn’t help at all

Does it assist with your leisure and interest activities? : It helps a lot It helps a little It doesn’t help at all

Does it help you to get up and go to bed at times which suit you? : It helps a lot It helps a little It doesn’t help at all

Does the service enable you to remain at home? : It helps a lot It helps a little It doesn’t help at all

Please detail any “C” answers : *

How satisfied are you in general with the services provided? : Completely satisfied Nearly Satisfied Partly Satisfied Unsatisfied

How satisfied are you in general with the services provided? : Excellent Very Good Good Satisfactory Poor

If you had a friend or neighbour needing support, would you recommend us? : Definitely Probably Not certain Not at all

Print Name to Sign : *

Date : *

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