Name
*
First Name
Last Name
Name of Care Home
*
I am a...
*
Resident
Relative
Other
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Daytime telephone number
Format: (000) 000-0000.
Email
Catering & Food (required)
How satisfied are you with the quality of food provided?
Very Satisfied
Quite Satisfied
Not Very Satisfied
Not Satisfied At All
How satisfied are you with the variety of food provided?
Very Satisfied
Quite Satisfied
Not Very Satisfied
Not Satisfied At All
How satisfied are you with the amount of food provided?
Very Satisfied
Quite Satisfied
Not Very Satisfied
Not Satisfied At All
How satisfied are you with the efforts made to satisfy your individual requirements (including any religious and cultural requirements)?
Very Satisfied
Quite Satisfied
Not Very Satisfied
Not Satisfied At All
How satisfied are you with the way in which menus are planned?
Very Satisfied
Quite Satisfied
Not Very Satisfied
Not Satisfied At All
How satisfied are you with the way in which food is presented? (eg to make it attractive or easy to eat)
Very Satisfied
Quite Satisfied
Not Very Satisfied
Not Satisfied At All
How satisfied are you with the starting times for meals?
Very Satisfied
Quite Satisfied
Not Very Satisfied
Not Satisfied At All
How satisfied are you with the time taken over meals? (eg too rushed or too slow)
Very Satisfied
Quite Satisfied
Not Very Satisfied
Not Satisfied At All
How satisfied are you with seating and table arrangements?
Very Satisfied
Quite Satisfied
Not Very Satisfied
Not Satisfied At All
How satisfied are you with the general atmosphere at mealtimes?
Very Satisfied
Quite Satisfied
Not Very Satisfied
Not Satisfied At All
How satisfied are you with additional snacks and drinks provided?
Very Satisfied
Quite Satisfied
Not Very Satisfied
Not Satisfied At All
Personal Care & Support (required)
How satisfied are you with how the staff look after you?
Very Satisfied
Quite Satisfied
Not Very Satisfied
Not Satisfied At All
How satisfied are you with staff availability - do they come to help you when you? (eg when you ring for help)
Very Satisfied
Quite Satisfied
Not Very Satisfied
Not Satisfied At All
How satisfied are you with how they carry out their work?
Very Satisfied
Quite Satisfied
Not Very Satisfied
Not Satisfied At All
How satisfied are you with their attitudes and general manner?
Very Satisfied
Quite Satisfied
Not Very Satisfied
Not Satisfied At All
How satisfied are you with the nursing and medical care that you receive?
Very Satisfied
Quite Satisfied
Not Very Satisfied
Not Satisfied At All
How satisfied are you with any additional services or treatment arranged? (eg chiropodist, hairdresser)
Very Satisfied
Quite Satisfied
Not Very Satisfied
Not Satisfied At All
Daily Living (required)
How satisfied are you with the arrangements you have for getting up and going to bed?
Very Satisfied
Quite Satisfied
Not Very Satisfied
Not Satisfied At All
How satisfied are you with the arrangements for your personal care? (eg forwashing, bathing, going to the toilet etc)
Very Satisfied
Quite Satisfied
Not Very Satisfied
Not Satisfied At All
How satisfied are you with the arrangements for cleaning and tidying your room or flat?
Very Satisfied
Quite Satisfied
Not Very Satisfied
Not Satisfied At All
How satisfied are you with the social activities provided or arranged?
Very Satisfied
Quite Satisfied
Not Very Satisfied
Not Satisfied At All
How satisfied are you with efforts to help you keep up with your personal interests and hobbies?
Very Satisfied
Quite Satisfied
Not Very Satisfied
Not Satisfied At All
How satisfied are you with how residents in general get on with each other?
Very Satisfied
Quite Satisfied
Not Very Satisfied
Not Satisfied At All
How satisfied are you with how residents and staff get on with each other?
Very Satisfied
Quite Satisfied
Not Very Satisfied
Not Satisfied At All
Premises (required)
How satisfied are you with the home’s decorations and furnishings?
Very Satisfied
Quite Satisfied
Not Very Satisfied
Not Satisfied At All
How satisfied are you with the facilities and amenities?
Very Satisfied
Quite Satisfied
Not Very Satisfied
Not Satisfied At All
How satisfied are you with the accessibility of lounges, dining room and other public areas?
Very Satisfied
Quite Satisfied
Not Very Satisfied
Not Satisfied At All
How satisfied are you with the general cleanliness and tidiness of the building and grounds?
Very Satisfied
Quite Satisfied
Not Very Satisfied
Not Satisfied At All
How satisfied are you with how well repairs and general maintenance are carried out?
Very Satisfied
Quite Satisfied
Not Very Satisfied
Not Satisfied At All
Management (required)
How satisfied are you with the the availability of the home’s manager to discuss any problems when you need to?
Very Satisfied
Quite Satisfied
Not Very Satisfied
Not Satisfied At All
How satisfied are you with the way they get things done when asked?
Very Satisfied
Quite Satisfied
Not Very Satisfied
Not Satisfied At All
How satisfied are you with the management’s efforts to create a good atmosphere?
Very Satisfied
Quite Satisfied
Not Very Satisfied
Not Satisfied At All
Submit
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