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Feedback
Who is completing this form?
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Who is completing this form?
I am the person receiving support (service user)
A family member or friend of the person receiving support
A healthcare or social care professional
Other
How long have you been involved with our service?
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How long have you been involved with our service?
Less than 1 month
1 - 6 months
6 - 12 months
Over a year
Not applicable
How satisfied are you with the domiciliary support service overall?
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How satisfied are you with the domiciliary support service overall?
Very satisfied
Satisfied
Neutral
Dissatisfied
Very dissatisfied
Would you recommend our service to others?
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Would you recommend our service to others?
Yes
No
No sure
Please rate the professionalism of the support staff
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Please rate the professionalism of the support staff
Excellent
Good
Fair
Poor
Do you feel the support provided meets your (or the service user’s) individual needs?
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Do you feel the support provided meets your (or the service user’s) individual needs?
Always
Most of the time
Sometimes
Rarely
Never
How well do staff communicate with you/about the person receiving care?
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How well do staff communicate with you/about the person receiving care?
Very well
Well
Fair
Poorly
Not applicable
Do staff treat you (or the service user) with dignity and respect?
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Do staff treat you (or the service user) with dignity and respect?
Always
Most of the time
Sometimes
Rarely
Never
Do you feel the support staff are well-trained and competent?
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Do you feel the support staff are well-trained and competent?
Yes
Mostly
Not sure
No
Are tasks and care activities completed as agreed in the care plan?
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Are tasks and care activities completed as agreed in the care plan?
Always
Most of the time
Sometimes
Rarely or never
Do you feel safe (or feel the person receiving care is safe) with the support workers?
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Do you feel safe (or feel the person receiving care is safe) with the support workers?
Always
Most of the time
Sometimes
Rarely or never
Do staff promote the service user’s independence and wellbeing?
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Do staff promote the service user’s independence and wellbeing?
Always
Most of the time
Sometimes
Rarely or never
What do you value most about the service?
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Is there anything we could improve?
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Do you have any concerns or complaints you’d like to raise?
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Would you like to be contacted to discuss your feedback?
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Would you like to be contacted to discuss your feedback?
Yes
No
Submit