Survey Form
(RESIDENTS)
Name:
Address:
Contact No.:
- Are your needs being met?
| YES |
|
| NO |
|
- Does the staff let you make choices? (e.g. About what you wear or eat)
| Always |
|
| Nearly always |
|
| Sometimes |
|
| Never |
|
| Didn’t answer |
|
- Does the staff treat you with respect?
| Always |
|
| Nearly always |
|
| Sometimes |
|
| Never |
|
| Didn’t answer |
|
- “The quality of the service I receive is….”
| Excellent |
|
| Good |
|
| Average |
|
| Poor |
|
- Does the support you receive from Joseph’s Care home allow you to be independent?
| Strongly agree |
|
| Agree |
|
| Disagree |
|
| Strongly disagree |
|
- Do you feel that staff understands your needs?
| YES |
|
| NO |
|
| Didn’t answer |
|
- Does the facility clean and well organized?
| YES |
|
| NO |
|
- Do you find with communication either with phone service or individual that it is clear?
| YES |
|
| NO |
|
| Didn’t answer |
|
- Overall how satisfied are you with the support you receive from Joseph’s Care Facility?
| Very satisfied |
|
| Quite satisfied |
|
| Neither satisfied or dissatisfied |
|
| Quite dissatisfied |
|
| Very dissatisfied |
|
| Didn’t answer |
|
- Is there any way in which you see our service could be improved? If yes please comment in the space below.
| YES |
|
| NO |
|
| Didn’t answer |
|
Comment: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________________________________________________________________
The outcomes we wish to achieve through our service are:
Personal Centered Care ♦ To Improve quality of life ♦ To make a positive contribution ♦
To give you the choice & control of your life ♦ Improve your health & well-being ♦
Freedom from discrimination ♦ To maintain your personal dignity
(FOR FAMILY)
Name:
Address:
Contact No.:
- Are your needs being met?
| YES |
|
| NO |
|
- Does the staff treat you with respect?
| Always |
|
| Nearly always |
|
| Sometimes |
|
| Never |
|
| Didn’t answer |
|
- “The quality of the service I receive is….”
| Excellent |
|
| Good |
|
| Average |
|
| Poor |
|
6. Do you feel that staff understands your needs?
| YES |
|
| NO |
|
| Didn’t answer |
|
7. Does the facility clean and organized?
| YES |
|
| NO |
|
- Do you find the answer phone service clear? If no how this could
| YES |
|
| NO |
|
| Didn’t answer |
|
- Overall how satisfied are you with the support you receive from Joseph’s Care Facility?
| Very satisfied |
|
| Quite satisfied |
|
| Neither satisfied or dissatisfied |
|
| Quite dissatisfied |
|
| Very dissatisfied |
|
| Didn’t answer |
|
- Is there any way in which you see our service could be improved? If yes please comment in the space below.
| YES |
|
| NO |
|
| Didn’t answer |
|
Comment: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
The outcomes we wish to achieve through our service are:
Personal Centered Care ♦ To Improve quality of life ♦ To make a positive contribution ♦ To give you the choice & control of your life ♦ Improve your health & well-being ♦ Freedom from discrimination ♦ To maintain your personal dignity