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Hospice At Home Service Evaluation
Evaluation Form
1. How quickly did the Hospice at Home team contact you once a referral had been made? (please tick where applicable)
1
2
3
4
5
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9
10
Where 1 is very slow and 10 is very fast
2. How would you rate the communication you had with the Hospice at Home team? (please tick where applicable)
1
2
3
4
5
6
7
8
9
10
Where 1 is very poor and 10 is very good
3. Did you feel the team was able to support you/ your loved one in the way you needed? (please tick where applicable)
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2
3
4
5
6
7
8
9
10
Where 1 is not at all and 10 is always
4. Do you feel having the Hospice at Home team reduced any worries or anxiety that you may have had? (please tick where applicable)
1
2
3
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5
6
7
8
9
10
Where 1 is not at all and 10 is always
5. Do you feel the staff took the time to listen to your concerns/worries? (please tick where applicable)
1
2
3
4
5
6
7
8
9
10
Where 1 is not at all and 10 is always
6. Do you think you would have been able to care for your loved one at home without the help of the Hospice at Home team? (please tick where applicable)
1
2
3
4
5
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7
8
9
10
Where 1 is not at all and 10 is definitely
7.Without the support of the Hospice at Home team do you feel you would have needed more advice/support from other services, such as (please tick where applicable)
GP
Hospital Admission
District Nurse
Specialist Nurses
111
Other
8.Have you ever used the Blythe House Hospice Roaming Car Service?
Yes
No
If yes, what was your experience of it?
Your name
*
Your email
*
We would welcome any additional comments or suggestions you would like to make regarding Blythe House Hospice at Home Service, as we are continuously aiming to improve.
Would you be happy to receive our monthly email newsletter to keep up to date with news, events and information from Blythe House Hospice?
Yes
Would you be happy to share your story of how the hospice has supported you?
Yes
No
If yes, we will pass on your details to our Marketing and Communications team who will get in touch to explain more. If no, please don't worry, there is no pressure or obligation. For more information before you decide, visit: https://blythehousehospice.org.uk/share-your-hospice-story/
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