FQ03 Pre-Inspection Questionnaires for Relatives/Representatives

Hello, the following questions should be answered in accordance with the wishes of your relative or the resident you represent, thank you.

1. What information was made available to help your relative about the centre before going to live in this centre?

Comments:

2. Did your relative have an opportunity to visit the centre prior to their coming to live here? Yes No

Comments:

3. Does your relative have a personal plan that assesses his/herneeds, and if so, was your relative and/or his/her representative involved in its development?

Yes No

Comments:

4. Do you feel that the needs of your relative, identified in the plan above are being met in the centre? Yes No

Comments:

5. Do you feel that your relative’s social and developmental needs are being met? Yes No

Comments:

6. Do you think that your relative is assisted and supported at all times to communicate their needs and wishes?

Yes No

Comments:

7. Do staff assist and enable your relative to be as independent as possible? Yes No

Comments:

8. Do you consider that your relative is supported to make decisions about his/her care and support? Yes No

Comments:

9. Do you consider that your relative is supported to make choices and have control in their daily life? Yes No

Comments:

10. Do you feel that your relative is safe in the centre?

Yes No

Comments:

11. Do you think that there are adequate numbers of staff in the centre to support and care for your relative?

Yes No

Comments

12. Do you think that your relative iscared for in a respectful manner, and is their privacy and dignity respected?

Yes No

Comments:

13. Do you feel that your relative’s health care needs are being met?

Yes No

Comments:

14. Who would you make a complaint to?

If you ever made a complaint was it dealt with to your satisfaction?

Yes No

Tell us about it.

15. Is there anything about the centre that you would like to see changed? Yes No

Comments:

16. Is there anything you would like to tell us about the centre that we have not asked you?

Yes No

Comments:

Thank you for taking the time to fill in the questionnaire. Your views are important to us. A public report will be written following the inspection.You may prefer to speak to an inspector instead of, or as well as filling in the questionnaire. The centre will advise you of the date of our inspection.

Please note that if your identity has to be disclosed for any reason, the Health Information and Quality Authority will discuss this with you first.

On completion of this form

Please post it to your regional Health Information and Quality Authority office or place in an envelop and give to inspectors during the inspection. The address of your regional office is highlighted below:

If you live in:

Cavan, Clare, Donegal, Dublin,

Galway, Kildare, Laois, Leitrim, Longford, Louth, Mayo, Meath,

Monaghan, Offaly, Roscommon,

Sligo, Tipperary North, Westmeath, Wicklow

If you live in:

Carlow, Cork, Kerry,

Kilkenny, Limerick

Tipperary South,

Waterford, Wexford

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