SECTION A: THE REFERRAL PROCESS

1. Who made the referral for you to be part of our Enabling /Befriending project? (Please tick)
a)Self
b)Social Worker
c)Other
If ‘Other’ please state ………………………………………………………..
  1. How long did you have to wait to be accepted onto the scheme? (Please tick)
a) Less than a month
b) More than a month
If you waited more than a month, were you given a reason why you had to wait? Please use the space below to comment.
  1. How long have you been a customer of our Enabling / Befriending project? (please tick)
    a) Less than 6 months
    b) Between 6 months and 1 year
    c) Over 1 year

SECTION B: Staff Support

4. Generally speaking, do you find staff / volunteers polite and helpful?
Always
Sometimes
Rarely
Never
If you have ticked ‘Sometimes’, ‘Rarely’ or ‘Never’ please comment below:
5. Were you involved/consulted in writing your SupportPlan for your service? This is the plan that outlines what you would like to achieve from the service.
Yes No
If you have answered ‘No’ can you please comment on the reasons for this below:

SECTION C: OUT AND ABOUT

6. Does themember of staff / volunteer arrive at your home at the agreed times? (Please tick)
Yes always
Sometimes
Rarely
Never
If you answered ‘Sometimes’, ‘Rarely’ or ‘Never’ please feel free to add additional comments below:
7. When you are out and about in a wheelchair do you feel safe and supported?
Always
Sometimes
Rarely
Never
If you answered ‘Sometimes’, ‘Rarely’ or ‘Never’ please comment below:
8. Is the member of staff / volunteer helpful?
Always
Sometimes
Rarely
Never
If you answered ‘Sometimes’, ‘Rarely’ or ‘Never’ please comment below:

SECTION D: Activities

9. What activities do you currently like to do with our member of staff / volunteer?
10. What activities would you like to be more involved in?
11. Do the visits from staff/volunteers help you achieve what you want from the service?
Yes No
If no, please comment below:

SECTION C: Dignity in Care

12. Do you think staff / volunteers encourage you to retain your independence?
Yes No
If ‘No’ please comment below:
13. Do staff / volunteers address you by your preferred name at all times? (Please tick)
Yes No
If ‘No’ please comment below:
14. Do staff / volunteers respect your dignity when visiting you?
Yes No
If ‘No’ please comment below:
15. Are the staff / volunteers courteous to you, your family or representatives?
Yes No
If ‘No’ please comment below:
16. Do you trust staff / volunteers to support and care for you?
Yes No
If ‘No’ please comment below:
17. Do you think the staff / volunteers have the right experience and skills to provide the service for you? (Please tick)
Yes No
If ‘No’ please comment below:
18. Do you feel confident that the staff / volunteers can deal with any accident or emergency?
Yes No
If ‘No’ please comment below:
19. Did you know that you could pay privately for extra visits from our staff?
Yes No
The current rate is £11.50 per hour. Would you like a member of staff to contact you about arranging extra hours?
Yes No
20. Have you had any problems or complaints with the service?
Yes No
If yes, did you report your concerns and were they dealt with to your satisfaction?
Yes No
21. What difference does being part of our Enabling / Befriending Scheme make, to the quality of your life?
The views of family, carers and friends are also important please ask them to add any comments they may have about the service

Many thanks for taking the time to complete this questionnaire.If you have any questions please do not hesitate to discuss this with

Garry Thompson – on 01912808496

Once you have completed the Questionnaire please return it in the stamped addressed envelope provided.

Thank You

EB001/Annual Service User Survey/July 2012-V1