Home Care Quality Topic Group Monday 30 November and Tuesday 1 December 2009 at 9.30Am

Appendix 3

HERTFORDSHIRE COUNTY COUNCIL

CONTRACTED HOME CARE AGENCIES

Name of Agency:……………………………………. Date:……………………………………..…

Name of Client:………………………………………Age………………………………………..…

Address…………………………………………………………………Extra Care Scheme

Client Group:(EPD/OMH/AMH/LD/CSF)……………Visiting Officer……………………………..

Details of package:……………………………………………………….……………………..……

Standard visit (S)/Concerned visit (C)/Project (P) – identify which………………………………

How long have you been receiving services from this agency?

Less than 6 months 6-12 months over 12 months

PAPERWORK

Do you have the agency folder/notes to be looked at now?Yes No

Is there a copy of :

2.The agency’s out of hours contact numberYes No

3.The agency complaints procedureYes No

4.A detailed care plan (date and review……………………..) Yes No

5.Care worker daily record in place & completedYes No

6.If there are manual handling tasks, has an agency Yes No N/A

assessment been completed?

(Check for risk assessment & snr. Staff visit)

Comments:…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

PERFORMANCE

7.Does regular provision comply with contracted package?

Yes No

Comments……………………………………………………………………………..

…………………………………………………………………………………………

8.How many different care workers visit you in an average week – Monday-Friday?

0 1-4 5-7 8-10More than ten

(Evidence with agency diary sheets)

Comments……………………………………………………………………………….

…………………………………………………………………………………………..

8a.How does this feel?

Too many Too few About right N/A

Comments………………………………………………………………………………

………………………………………………………………………………………….

9.How many different care workers visit you in an average weekend?

0 1-4 5-7 8-10 More than ten

(Evidence with agency diary sheets)

Comments………………………………………………………………………………..

……………………………………………………………………………………………

9a.How does this feel?

Too many Too few About right N/A

Comments……………………………………………………………………………….

…………………………………………………………………………………………...

DH1.Do your care workers come at times that suit you?

They always come at times that suit me

They usually come at times that suit me

They sometimes come at times that suit me

They never come at times that suit me

This is not an issue for me

Comments:………………………………………………………………………………

……………………………………………………………………………………………

10.Does the agency inform you if the care worker is to be more than 15

minutes late?

Always Usually Sometimes Never

They are never late

Comments……………………………………………………………………………….

…………………………………………………………………………………………...

11.Does the agency inform you if a new or different care worker is to visit?

Always Usually Sometimes Never

This never happens

Comments…………………………………………………………………………….

………………………………………………………………………………………..

12.Do the care workers show you their ID card the first time they call?

Always Usually Sometimes Never Cannot recall

Not applicable

Comments…………………………………………………………………………….

………………………………………………………………………………………....

13. Does the care worker use the electronic monitoring (EM) system or give you a

Timesheet (TS) to sign at each visit?
EM TS

13.aHow often

Always Usually Sometimes Never

Comments…………………………………………………………………………….

………………………………………………………………………………………...

14.Have there been any occasions when visits have been missed in last 3 months?

(relate to whether the office/care worker have cancelled, or asked if client can manage).

No Once Two-four times Five or more

Comments (evidence from agency diary notes)………………………………

…………………………………………………………………………………………..

Dates missed on diary sheets:………………………………………………………..

15. Does the care plan include administration of medication via HC42?

Yes No

15a. If so, are there properly updated & completed records?

Yes No N/A

Comments (Dates missed)……………………………….…………………………………

………………………………………………………………………………………………….

16. Are there any manual handling tasks?

Yes No

Comments: (e.g. use of equipment)…………………….……………………………………

……………………………………………………………………………………………………

17. If care workers provide personal care do they always wear gloves?

Always Usually Sometimes Never N/A

Comments e.g any other protective clothing?……………………………………….

…………………………………………………………………………………………..

18.Does the care worker ever handle money as part of their duties?

Yes No

18a. If so, do you sign anything and or receive receipt?

Always Usually Sometimes Never N/A

19.Do you get all the help you need within the time of your visit?

Always Usually Sometimes Never

Comments:………………………………………………………………………………..…………………………………………………………………………………………. ………………………………………………………………………………………… ………………………………………………………………………………………….

20.Are you satisfied that the care worker is made aware of your needs
prior to visiting?
Very satisfied Satisfied

Neither satisfied nor dissatisfied Dissatisfied

Very dissatisfied

Comments :………………………………………………………………………………

…………………………………………………………………………………………..
…………………………………………………………………………………………..

21.Are you satisfied that the care workers listen to you and treat you with respect?
Very satisfied Satisfied

Neither satisfied nor dissatisfied Dissatisfied

Very dissatisfied

Comments :……………………………………………………………………………..

22.Are you satisfied that the care workers are competent enough to carry out your care?
Very satisfied Satisfied

Neither satisfied nor dissatisfied Dissatisfied

Very dissatisfied

Comments :…………………………………………………………………..………………..

AGENCY OFFICE

23.Have you had to ring the agency during office hours?Yes No

24.If yes, how satisfied were you with the response?

Very satisfied Satisfied

Neither satisfied nor dissatisfied Dissatisfied

Very dissatisfied

Comments :………………………………………………………………………………

…………………………………………………………………………………………..

25.Have you had to ring the agency out of office hours?Yes No

26.If yes, how satisfied were you with the response?

Very satisfied Satisfied

Neither satisfied nor dissatisfied Dissatisfied

Very dissatisfied

Comments :………………………………………………………………………………

27. Have you had a visit from a senior member of staff/agency office staff in the past year?

Yes No Cannot recall

Comments :………………………………………………………………………………

27a.Is there evidence of a visit in the paperwork Yes No

28.Have you had any concerns or complaints about your home care in past year?

Yes No

28a.If yes, have you reported these issues to the agency?

Once 2-5 times More than 5 times No N/A

Details of complaint:……………………………………………………………………

…………………………………………………………………………………………..

28b. If no, why was this?……………………………………………………………………

………………………………………………………………………………………….

…………………………………………………………………………………………..

28c.If yes, were you satisfied with how your complaint/s was/were dealt with?

Yes No N/A

Comments:……………………………………………………………………………

…………………………………………………………………………………………

29.Are you satisfied with the staff at the agency office?

Very satisfied Satisfied

Neither satisfied nor dissatisfied Dissatisfied

Very dissatisfied

30.If not why not?(a)Poor attitude
(b)Lack of action
(c)Not keeping us informed
(d)Poor scheduling

(e)Other

Comments :……………………………………………………………………………..

…………………………………………………………………………………………..

OVERALL

31.Overall, how satisfied are you with the care that you receive from the agency?

I am extremely satisfiedI am fairly dissatisfied

I am very satisfiedI am very dissatisfied

I am quite satisfiedI am extremely dissatisfied

I am neither satisfied nor dissatisfied

32.Any further comments you would like to make about the agency:………...
…………………………………………………………………………………………..
…………………………………………………………………………………………..

…………………………………………………………………………………………..

33. What difference does having home care make to you and your families lives? ...... ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

34. Is there SAP – RED BOOK paperwork in the home?Yes No

Comments (what use is it to you?)………………………………………………………………….

…………………………………………………………………………………………………………..

35. Is there anything you would like me to take further on your behalf?

Yes No

…………………………………………………………………………………………..

Additional QMO comments:

……………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Ethnic Monitoring

White British White Irish Any other White background

White & Black Caribbean White & Black African White & Asian

Any other mixed background Indian Pakistani

Bangladeshi Any other Asian background

Caribbean African Any other Black background

Chinese Any other ethnic group

Please specify other ethnic group………………………………………………………………..

Information given by:

User Name :………………………………………………………………….………………

Carer – Name & Relationship:……………………………………………………………..

Carer and User together:……………………………………………………………………

ACTIONS –

AgencyConcern

ReferralCompliment

TeamFurther QMO contact

Service Solutions Team

Details………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..