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* 1. Where do you receive your care?

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* 2. Name of care home or provider of care

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* 3. Do you feel included in decisions about your care and treatment?

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* 4. Do you feel you are listened to and understood?

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* 5. Do you have a choice on what to eat and when?

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* 6. Do you have a choice on what level of personal assistance you have and by whom?

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* 7. Do you feel in control of your independence?

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* 8. Are your religious or cultural beliefs respected?

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* 9. Do you feel supported to live the life you want?

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* 10. Do you feel confident to complain if you are not happy with something?

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* 11. Do you feel your personal possessions are respected?

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* 12. Do you have enough privacy when using the bathroom, being examined or discussing your care?

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* 13. Are you given assistance when you need it and not when you don’t? ie: eating, dressing etc?

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* 14. Do you have pain relief when you need it?

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* 15. Do you feel the care home feels like home or the next best thing?

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* 16. Do you have access to equipment to maintain your independence?

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* 17. Do you feel the washing and bathroom facilities are clean and adequate?

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* 18. Are you able to maintain contact with friends and family?

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* 19. Are there enough cultural, recreational and social activities?

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* 20. Is there anything you would change about your care or experiences within the care home

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* 21. What three words would you use to explain how you feel about living here?

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* 22. Address

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* 23. What is your gender?

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* 24. What is your age?

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* 25. Which race/ethnicity best describes you? (Please choose only one.)

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