ASHINGTON HOUSE SURGERY
CARERS QUESTIONNAIRE
This questionnaire is to help the surgery recognize the areas where people need more help, support, answers or guidance, and to see if there are any common themes that we need to focus on.
By filling in this sheet you are registering yourself with the Practice as a Carer. All the information you give on this questionnaire will remain confidential.
Please hand this sheet to the reception staff when completed and we will send you out some further information which may be of help and support to you.
ABOUT YOU
Name …………………………………………….Date Of Birth ……………………...
Address :………………………………………………………………………………......
Post Code: ………………………………………. Tel No : ……………………………
Mobile No.: ……………………………………….Email : ……………………………..
ABOUT THE PERSON YOU CARE FOR
Are they a patient at Ashington House Surgery?Yes No
Their name ……………………………………Their Date of Birth ………………..
The main reason they need care ……………………………………………………….
Do they wish to give consent to share their health Yes No
information with you?
REGISTERING YOUR CARING RESPONSIBILITIES
Can we note your caring responsibilities :
On your health record?Yes No
On the cared for persons health record?Yes No
Can we pass your details to Swindon Carers Centre so Yes No
that they can contact you with further information and
the support services available locally to you?
RELATIONSHIP TO THE PERSON YOU CARE FOR (please tick ONE)
My spouse/partner My parent/guardian
My grandparent My child
Another relative My friend/neighbor
I am a professional paid carer
REASONS FOR NEEDING A CARER (please tick ALL that apply)
Has a physical disability Has a learning disability
Has a sensory impairment Has a mental health problem
Frail and/or has limited mobility
Has a long term illness,is recovering from illnessor is terminally ill
Other
AMOUNT OF TIME IN THE WEEK YOU ARE A CARER
1 – 19 hours per week 20 – 34 hours per week
35 – 49 hours per week 50+ hours per week
HOW CAN WE SUPPORT YOU?
Please comment on what we can do to make accessing our services easier for you.
………………………………………………………………………………………………
………………………………………………………………………………………………
………………………………………………………………………………………………
………………………………………………………………………………………………
Your Signature ………………………………………..Date ………………………..
Cared Person’s Signature ……………………………Date ………………………..
(This is necessary if they are a patient of the surgery)
For Admin Use Only (please check, action and tick each box below)
Entered information onto patient record
Made a note of support needs in patient record
Added Carer status in appointment system
Added consent to yellow reminders as appropriate
Sent information to Swindon Carer Centre in requested
Sent Carer’s Information Pack
ASHINGTON HOUSE SURGERY
CARERS INFORMATION PACK
FACT SHEET ()
- The vast majority of carers are of a working age.
- 3 million carers already combine work and care.
- Carers make up over 12% of the total UK workforce, 1 in every 8 employees.
- Every year, over 2 million people become carers, some overnight, some more gradually – so there is a new population of carers in the workforce every day.
- 3 in 5 people will become carers at some point in time.
- Many carers find their job being affected in ways such as not being able to get the replacement services they need, not being able to get the time off work and not being able to get the flexibility they need.
Human Rights Act
Carers, like everyone else in the UK, are entitled to rely on the protection of the Human Rights Act 1998, which should ensure that public bodies take account of their human rights when they provide services. Public services play a critical role in guaranteeing carers’ human rights. They can ensure that carers have the support they need to maintain a normal life. However, a new report commissioned by Carers’ UK shows that reality falls a long was short of this ideal.
There are several articles of the Human Rights Act in which Carers UK believes carers’ rights may be being violated. These are:
- A right to life,
- A right to be free from inhuman or degrading treatment,
- A right to respect for private and family life.
The right to life may seem extreme, but Carers UK research has uncovered carers who have to delay urgent medical treatment because of inadequate support.
To view the complete Human Rights Act 1998 please go to
ASHINGTON HOUSE SURGERY
CARERS INFORMATION PACK
CONTACT SHEET
Swindon Carers Centre
1 Wood Street, Old Town, Swindon, SN1 4AN 01793 531133
Carers UK : The voice of carers’ : Carers’ UK is a membership organisation of carers’ that campaigns to improve recognition services and support for carers and provides information and advice.
0808 808 7777
Macmillan Cancer Relief
0808 808 2020
Counsel and Care : Provides advice and information to older people, their relatives and carers. Uniquely they have the capacity to provide personal support until a solution is found.
0845 450 0350
Multiple Sclerosis Society
0808 800 8000
Crossroads caring for carers’ : The leading provider of practical support for carers’. The service is about improving the lives of carers’ by giving them time to be themselves and have a break from their caring responsibilities.
0845 450 0350
rethink – severe mental illness
0845 456 0455
Help the Aged
0808 800 6565
The Princess Royal Trust for Carers’ : Provides quality information, advice and support services to carers’ of all ages through a network of carers’ centres, young carers’ services and interactive websites.
020 7480 7788