Service User/Relative's Feedback Questionnaire

This sample model questionnaire indicates the sorts of questions to ask in obtaining residents' and relatives' views on quallty issues. It should be adapted for individual purposes and the specific questions amended accordingly. Ask individuals to answer the following questions in terms of whether they are very satisfied, quite satisfied, not very satisfied or not satisfiedat all.

You can fill in the form below or alternatively download the feedback questionnaire here.

A. Catering and Food - How satisfied are you with:
The choice of food provided: The variety of food provided:
The amount of food provided: Additional snacks and drinks provided?
The efforts made to satisfy your individual requirements (including any religious and cultural requirements)?
The way in which menus are planned? The starting time for meals?
The time taken over meals (e.g. too slow)? Seating and table arrangements?
The way in which food is presented? The general atmosphere at meal times?
B. Personal Care and Support - How satisifed are you with:
The way staff try to help? How the staff look after you?
Staff availability - do they come to help you when you need them?
How they carry out their work? Their attitudes and general manner?
The nursing and medical care that you have receive? Any additional services or treatments arranged (e.g. chiropodist, hairdresser)?
C. Daily Living - How satisfied are you with:  
The arrangements that you have for getting up and going to bed? The arrangements for your personal care (e.g. for washing, bathing, etc)?
The arrangements for cleaning and tidying your room or flat? Efforts to help you keep up with your personal interests and hobbies?
How residents in general get along? The social activities provided or arranged?
How the residents and staff get along?  
D. Premises - How satisfied are you with:  
The home's decorations and furnishings? The facilities and amenities?
The accessibility of lounges, dining room and other public areas? The general cleanliness and tidiness of the building and grounds?
How well repairs and general maintenance are carried out?  
E. Management - How satisifed are you with?
The availability of the home's managers to discuss any problems when you need to? How they involve residents and families in the affairs of the home?
The management's efforts to create a good atmosphere? The way that things get done when asked?