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Feedback
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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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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Very satisfied
Satisfied
Neutral
Dissatisfied
Very dissatisfied
Would you recommend our service to others?
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Yes
No
No sure
Please rate the professionalism of the support staff
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Excellent
Good
Fair
Poor
Do you feel the support provided meets your (or the service user’s) individual needs?
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Always
Most of the time
Sometimes
Rarely
Never
How well do staff communicate with you/about the person receiving care?
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Very well
Well
Fair
Poorly
Not applicable
Do staff treat you (or the service user) with dignity and respect?
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Always
Most of the time
Sometimes
Rarely
Never
Do you feel the support staff are well-trained and competent?
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Yes
Mostly
Not sure
No
Are tasks and care activities completed as agreed in the care plan?
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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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Always
Most of the time
Sometimes
Rarely or never
Do staff promote the service user’s independence and wellbeing?
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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?
*
Do you have any concerns or complaints you’d like to raise?
*
Would you like to be contacted to discuss your feedback?
*
Yes
No
Submit