Dignity in Care Thurrock Survey

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* 1. Where do you receive your care?

At my home

At a care home

Other (please specify)

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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?

Yes

Somewhat

Don't know or didn't answer

Other (please specify)

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

Yes

Sometimes

Don't know or didn't answer

Other (please specify)

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

Yes

Sometimes

Don't know or didn't answer

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

Yes

Sometimes

Don't know or didn't answer

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

Yes

Sometimes

Don't know or didn't answer

Other (please specify)

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* 8. Are your religious or cultural beliefs respected?

Yes

Sometimes

Don't know or didn't answer

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

Yes

Sometimes

Don't know or didn't answer

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

Yes

Sometimes

Don't know or didn't answer

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

Yes

Sometimes

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

Yes

Sometimes

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

Yes

Sometimes

Other (please specify)

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

Yes

Sometimes

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

Yes

Sometimes

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

Yes

Sometimes

Other (please specify)

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

Yes

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

Yes

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

Yes

Yes, but would like more

There is too much

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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?

Word 1

Word 2

Word 3

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* 22. Address

Name

Postal Code

Email Address

Phone Number

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* 23. What is your gender?

Female

Male

Transgender

Other, please describe

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* 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

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* 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)