Quality assurance questionnaire (annual) - CQC Registered Care Specialist

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

Do you have any suggestions of how it could be improved?

Yes
No

Please comment on any improvement we can make :

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 “No" answers : *

Are they polite, courteous and respectful? :

Always
Most of the time
Sometimes
Not at all

Do you think our carers understand your needs? :

Always
Most of the time
Sometimes
Not at all

Do you find them helpful?

Always
Most of the time
Sometimes
Not at all

Do you find them friendly and interested in you?

Always
Most of the time
Sometimes
Not at all

Do they listen when you ask them to do something? :

Always
Most of the time
Sometimes
Not at all

Do they follow the Care Plan

Always
Most of the time
Sometimes
Not at all

Please provide further detail of answers :

Do the care-workers come at times that suit you?

Always
Most of the time
Sometimes
Not at all

Have they ever not turned up? (copy)

Always
Most of the time
Sometimes
Not at all

When they have been delayed, have you been informed? :

Always
Most of the time
Sometimes
Not at all

Do they have enough time to complete the tasks?

Always
Most of the time
Sometimes
Not at all

Do they seem to be in too much of a rush?

Always
Most of the time
Sometimes
Not at all

Are they thorough in what they do for you?

Always
Most of the time
Sometimes
Not at all

If they assist with medication, do they follow correct procedures?

Always
Most of the time
Sometimes
Not at all

Do they treat your home in a respectful manner? :

Always
Most of the time
Sometimes
Not at all

If you have had a change of worker, do they always know what to do?

Always
Most of the time
Sometimes
Not at all

Are you confident that they will not harm you and keep you safe? :

Always
Most of the time
Sometimes
Not at all

Do you agree that they are well trained?

Always
Most of the time
Sometimes
Not at all

Do you agree that all information about you is handled in confidence?

Always
Most of the time
Sometimes
Not at all

Are you satisfied that carers will not breach confidentiality?

Always
Most of the time
Sometimes
Not at all

Do you agree that our carers seem to know what they are doing?

Always
Most of the time
Sometimes
Not at all

Are you confident that any complaint you make will be investigated?

Always
Most of the time
Sometimes
Not at all

When you have had to make contact with us have you been dealt with promptly?

Always
Most of the time
Sometimes
Not at all

When you have had to make contact with us have you been dealt with promptly? (copy)

Always
Most of the time
Sometimes
Not at all

Do we make the changes to your service as required?

Always
Most of the time
Sometimes
Not at all

Please provide further detail of answers :

Does the service help you to keep your independence? :

It helps a lot
it helps a little
it doesn't help at all
N/A

Does the service help you to be clean and comfortable?

It helps a lot
it helps a little
it doesn't help at all
N/A

Does the service help you to feel safe in your own home?

It helps a lot
it helps a little
it doesn't help at all
N/A

Does the service assist in keeping contacts with other people as you want?

It helps a lot
it helps a little
it doesn't help at all
N/A

Does the service assist with your leisure and interest activities?

It helps a lot
it helps a little
it doesn't help at all
N/A

Does the service the service enable you to remain at home?

It helps a lot
it helps a little
it doesn't help at all
N/A

Please provide further detail of 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? :

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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