Dignity in Care Thurrock Question Title * 1. Where do you receive your care? At my home At a care home Other (please specify) OK Question Title * 2. Name of care home or provider of care OK Question Title * 3. Do you feel included in decisions about your care and treatment? Yes No Somewhat Don't know or didn't answer Other (please specify) OK Question Title * 4. Do you feel you are listened to and understood? Yes No Sometimes Don't know or didn't answer Other (please specify) OK Question Title * 5. Do you have a choice on what to eat and when? Yes No Sometimes Don't know or didn't answer OK Question Title * 6. Do you have a choice on what level of personal assistance you have and by whom? Yes No Sometimes Don't know or didn't answer OK Question Title * 7. Do you feel in control of your independence? Yes No Sometimes Don't know or didn't answer Other (please specify) OK Question Title * 8. Are your religious or cultural beliefs respected? Yes No Sometimes Don't know or didn't answer OK Question Title * 9. Do you feel supported to live the life you want? Yes No Sometimes Don't know or didn't answer OK Question Title * 10. Do you feel confident to complain if you are not happy with something? Yes No Sometimes Don't know or didn't answer OK Question Title * 11. Do you feel your personal possessions are respected? Yes No Sometimes OK Question Title * 12. Do you have enough privacy when using the bathroom, being examined or discussing your care? Yes No Sometimes OK Question Title * 13. Are you given assistance when you need it and not when you don’t? ie: eating, dressing etc? Yes No Sometimes Other (please specify) OK Question Title * 14. Do you have pain relief when you need it? Yes No Sometimes OK Question Title * 15. Do you feel the care home feels like home or the next best thing? Yes No Sometimes OK Question Title * 16. Do you have access to equipment to maintain your independence? Yes No Sometimes Other (please specify) OK Question Title * 17. Do you feel the washing and bathroom facilities are clean and adequate? Yes No OK Question Title * 18. Are you able to maintain contact with friends and family? Yes No OK Question Title * 19. Are there enough cultural, recreational and social activities? Yes Yes, but would like more There is too much No OK Question Title * 20. Is there anything you would change about your care or experiences within the care home OK Question Title * 21. What three words would you use to explain how you feel about living here? Word 1 Word 2 Word 3 OK Question Title * 22. Address Name Postal Code Email Address Phone Number OK Question Title * 23. What is your gender? Female Male Transgender Other, please describe OK Question Title * 24. What is your age? 18 to 24 25 to 34 35 to 44 45 to 54 55 to 64 65 to 74 75 or older OK Question Title * 25. Which race/ethnicity best describes you? (Please choose only one.) White/White British Black/Black British Asian/Asian British Mixed race Rather not say Another race or ethnicity (please specify) OK DONE
