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Carer Survey

If you have used our Carer Liaison Officer Support Service, please take a moment to complete this survey to help us improve our service for carers.

All information gathered is confidential.

How was the patient admitted?

Admission Ward

A&E

Pre Admission/Assessment

I was involved in the assessment of the patient’s needs

Strongly agree

Agree

Neutral

Disagree

Strongly Disagree

I was informed of what would happen to the person I care for

Strongly agree

Agree

Neutral

Disagree

Strongly disagree

I feel I was recognised as a Carer

Strongly agree

Agree

Neutral

Disagree

Strongly disagree

How did your experience of pre admission/assessment make you feel as a Carer?

What could have been done to make your experience as a Carer better?

Inpatient Stay (if applicable, otherwise please go to the next question)

I was invited to be involved in the patient’s care

Strongly agree

Agree

Neutral

Disagree

Strongly disagree

I was informed of visiting times and given options of different times

Strongly agree

Agree

Neutral

Disagree

Strongly disagree

I was informed about the patient's treatment during their stay

Strongly agree

Agree

Neutral

Disagree

Strongly disagree

I was informed of changes to their needs or treatment during their stay

Strongly agree

Agree

Neutral

Disagree

Strongly disagree

I was informed about support with the costs of visiting e.g. transport, parking

Strongly agree

Agree

Neutral

Disagree

I feel I was recognised as a Carer

Strongly agree

Agree

Neutral

Disagree

Strongly disagree

How did your experience during the patient’s inpatient stay make you feel as a Carer?

What could have been done to make your experience as a Carer better?

Which ward was the patient in?

If the patient passed away before discharge please tick this box

If the patient passed away before discharge please tick this box

Discharge Planning

I was involved in the discharge planning

Strongly agree

Agree

Neutral

Disagree

Strongly disagree

I feel my own health and capacity to care was taken into account during the discharge process

Strongly agree

Agree

Neutral

Disagree

Strongly disagree

I was given information about the support the patient would need after discharge

Strongly agree

Agree

Neutral

Disagree

Strongly disagree

I was given information on support available for Carers after discharge

Strongly agree

Agree

Neutral

Disagree

Strongly disagree

I feel I was recognised as a Carer

Strongly agree

Agree

Neutral

Disagree

Strongly disagree

How did your experience during the patient’s discharge planning make you feel as a Carer?

What could have been done to make your experience as a Carer better?

OPTIONAL: Patient’s Health Conditions. Please tick those applicable

Alzheimer’s / Dementia

Mental Health Condition

Child under 18

Physical Disability

Old Age / Frailty

Learning Disability

Stroke

Visually impaired

Hearing Impaired

Other (please state)

Privacy Policy

I agree to the privacy policy

The Herbert Protocol form
Referral to Derbyshire Carers Association

Chesterfield Royal Hospital NHS Foundation Trust
Calow
Chesterfield
Derbyshire
S44 5BL

Tel: 01246 277 271

Call 111 when it's less urgent than 999

National Health Service

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Copyright © 2023 Chesterfield Royal NHS Foundation Trust

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