Catalogue of Social Care Data

Anxiety or depression

I am not anxious or depressed
I am moderately anxious or depressed
I am extremely anxious or depressed

Please place a tick in the box that best describes your abilities for each of the following questions.

For each of the below, the responses are:
I can do this easily by myself
I have difficulty doing this myself
I can’t do this by myself

Questions:
Do you usually manage to get around indoors (except steps) by yourself?
Do you usually manage to get in and out of a bed (or chair) by yourself?
Do you usually manage to feed yourself?
Do you usually deal with finances and paperwork – for example, paying bills, writing letters – by yourself?

Please place a tick in the box that best describes your abilities for each of the following questions.

For each of the below, the responses are:
I can do this easily by myself
I have difficulty doing this myself
I can’t do this by myself

Do you usually manage to wash all over by yourself, using either a bath or shower?
Do you usually manage to get dressed and undressed by yourself?
Do you usually manage to use the WC/toilet by yourself?
Do you usually manage to wash your face and hands by yourself?

How well do you think your care home is designed to meet your needs?

My care home meets my needs very well
My care home meets most of my needs
My care home meets some of my needs
My care home is totally inappropriate for my needs

Thinking about getting around outside of your care home, which of the following statements best describes your present situation?
You can include getting around by yourself or with help from someone else

I can get to all the places in my local area that I want
At times I find it difficult to get to all the places in my local area that I want
I am unable to get to all the places in my local area that I want
I do not leave my care home

Do you receive any practical help on a regular basis from your husband/wife, partner, friends, neighbours or family members?

Yes, from someone living in my household
Yes, from someone living in another household
No

Do you buy any additional care or support privately or pay more to ‘top up’ your care and support?

Yes, I buy some more care and support with my own money
Yes, my family pays for some more care and support for me
No

Did you have any help from someone else to complete this questionnaire?

No, I did not have help
I had help from a care worker
I had help from someone living in my household
I had help from someone living outside my household

What type of help did you have?

I didn’t have any help
Someone else read the questions to me
Someone else translated the questions for me
Someone else wrote down the answers for me
I talked through the questions with someone else
Someone answered for me, without asking me the questions

Please use the space provided below to describe any other experiences you would like to tell us about, or to write any other comments you would like to make

Free text response

OPTIONAL QUESTION – Councils should remove this question if they do not want to include it in the questionnaire. Any data collected from this question does not need to be returned to NHS England.
We may be asking some people to take part in follow-up research for this study in the next year or so.
Would you be happy to be invited to take part in more research?

Yes, I have written my name, address and phone number in the space below
No

Which of the following statements best describes how much control you have over your daily life?

I have as much control over my daily life as I want
I have adequate control over my daily life
I have some control over my daily life but not enough
I have no control over my daily life

Do care and support services help you in having control over your daily life?
By ‘care and support services’ we mean any equipment or care provided by staff who are paid to help you. The staff could be from [Social Services], an agency or bought by you using money you receive from [Social Services], using a Direct Payment.

I do not need care and support services to help me have control over my daily life
Yes
No

Thinking about keeping clean and presentable in appearance, which of the following statements best describes your situation?

I feel clean and am able to present myself the way I like
I feel adequately clean and presentable
I feel less than adequately clean or presentable
I don’t feel at all clean or presentable

OPTIONAL QUESTION – Councils should remove this question if they do not want to include it in the questionnaire. Any data collected from this question does not need to be returned to NHS England.
Do care and support services help you in keeping clean and presentable in appearance?

I do not need care and support services to help me keep clean and presentable
Yes
No

Thinking about the food and drink you get, which of the following statements best describes your situation?

I get all the food and drink I like when I want
I get adequate food and drink at OK times
I don’t always get adequate or timely food and drink
I don’t always get adequate or timely food and drink, and I think there is a risk to my health

OPTIONAL QUESTION – Councils should remove this question if they do not want to include it in the questionnaire. Any data collected from this question does not need to be returned to NHS England.
Do care and support services help you to get food and drink?

I do not need care and support services to help me get food and drink
Yes
No

Which of the following statements best describes how clean and comfortable your care home is?

My care home is as clean and comfortable as I want
My care home is adequately clean and comfortable
My care home is not quite clean or comfortable enough
My care home is not at all clean or comfortable

OPTIONAL QUESTION – Councils should remove this question if they do not want to include it in the questionnaire. Any data collected from this question does not need to be returned to NHS England.
Do care and support services help you in keeping your care home clean and comfortable?

I do not need care and support services to help me keep my home clean and comfortable
Yes
No

Which of the following statements best describes how safe you feel?
By ‘feeling safe’ we mean how safe you feel both inside and outside the home. This includes fear of abuse, falling or other physical harm.

I feel as safe as I want
Generally I feel adequately safe, but not as safe as I would like
I feel less than adequately safe
I don’t feel at all safe
If you have said you don’t feel safe, can you please tell us why?
-open text response-

Do care and support services help you in feeling safe?

Yes
No

Thinking about how much contact you’ve had with people you like, which of the following statements best describes your social situation?

I have as much social contact as I want with people I like
I have adequate social contact with people
I have some social contact with people, but not enough
I have little social contact with people and feel socially isolated

OPTIONAL QUESTION – Councils should remove this question if they do not want to include it in the questionnaire. Any data collected from this question does not need to be returned to NHS England.
Do care and support services help you in having social contact with people?

I do not need care and support services to help me have social contact with people
Yes
No

Which of the following statements best describes how you spend your time?
When you are thinking about how you spend your time, please include anything you value or enjoy including leisure activities, formal employment, voluntary or unpaid work and caring for others.

I’m able to spend my time as I want, doing things I value or enjoy
I’m able to do enough of the things I value or enjoy with my time
I do some of the things I value or enjoy with my time but not enough
I don’t do anything I value or enjoy with my time

OPTIONAL QUESTION – Councils should remove this question if they do not want to include it in the questionnaire. Any data collected from this question does not need to be returned to NHS England.
Do care and support services help you in the way you spend your time?

I do not need care and support services to help me in the way I spend my time
Yes
No

Which of these statements best describes how having help to do things makes you think and feel about yourself?

Having help makes me think and feel better about myself
Having help does not affect the way I think or feel about myself
Having help sometimes undermines the way I think and feel about myself
Having help completely undermines the way I think and feel about myself

Which of these statements best describes how the way you are helped and treated makes you think and feel about yourself?

The way I’m helped and treated makes me think and feel better about myself
The way I’m helped and treated does not affect the way I think or feel about myself
The way I’m helped and treated sometimes undermines the way I think and feel about myself
The way I’m helped and treated completely undermines the way I think and feel about myself

How often do you feel lonely?

Often or always
Some of the time
Occasionally
Hardly ever
Never

In the past year, have you generally found it easy or difficult to find information and advice about support, services or benefits?
Please include information from different sources, such as voluntary organisations, and private agencies as well as [Social Services].

I’ve never tried to find information or advice
Very easy to find
Fairly easy to find
Fairly difficult to find
Very difficult to find
If you found it difficult to find information and advice, please tell us why and what we can do to make it easier for you
-open response-

How is your health in general?

Very good
Good
Fair
Bad
Very bad

By placing a tick in one box in each group below, please indicate which statements best describe your own health state today.

I have no pain or discomfort
I have moderate pain or discomfort
I have extreme pain or discomfort

Which of these statements best describes how having help to do things makes you think and feel about yourself?

Having help makes me think and feel better about myself
Having help does not affect the way I think or feel about myself
Having help sometimes undermines the way I think and feel about myself
Having help completely undermines the way I think and feel about myself

Which of these statements best describes how the way you are helped and treated makes you think and feel about yourself?

The way I’m helped and treated makes me think and feel better about myself
The way I’m helped and treated does not affect the way I think or feel about myself
The way I’m helped and treated sometimes undermines the way I think and feel about myself
The way I’m helped and treated completely undermines the way I think and feel about myself

How often do you feel lonely?

Often or always
Some of the time
Occasionally
Hardly ever
Never

In the past year, have you generally found it easy or difficult to find information and advice about support, services or benefits?
Please include information from different sources, such as voluntary organisations, and private agencies as well as [Social Services].

I’ve never tried to find information or advice
Very easy to find
Fairly easy to find
Fairly difficult to find
Very difficult to find
If you found it difficult to find information and advice, please tell us why and what we can do to make it easier for you
-open response-

How is your health in general?

Very good
Good
Fair
Bad
Very bad

By placing a tick in one box in each group below, please indicate which statements best describe your own health state today.

I have no pain or discomfort
I have moderate pain or discomfort
I have extreme pain or discomfort

Anxiety or depression

I am not anxious or depressed
I am moderately anxious or depressed
I am extremely anxious or depressed

Please place a tick in the box that best describes your abilities for each of the following questions.

For each of the below, the responses are:
I can do this easily by myself
I have difficulty doing this myself
I can’t do this by myself

Questions:
Do you usually manage to get around indoors (except steps) by yourself?
Do you usually manage to get in and out of a bed (or chair) by yourself?
Do you usually manage to feed yourself?
Do you usually deal with finances and paperwork – for example, paying bills, writing letters – by yourself?

Please place a tick in the box that best describes your abilities for each of the following questions.

For each of the below, the responses are:
I can do this easily by myself
I have difficulty doing this myself
I can’t do this by myself

Do you usually manage to wash all over by yourself, using either a bath or shower?
Do you usually manage to get dressed and undressed by yourself?
Do you usually manage to use the WC/toilet by yourself?
Do you usually manage to wash your face and hands by yourself?

How well do you think your home is designed to meet your needs?

My home meets my needs very well
My home meets most of my needs
My home meets some of my needs
My home is totally inappropriate for my needs

Thinking about getting around outside of your home, which of the following statements best describes your present situation?
You can include getting around by yourself or with help from someone else

I can get to all the places in my local area that I want
At times I find it difficult to get to all the places in my local area that I want
I am unable to get to all the places in my local area that I want
I do not leave my home

Do you receive any practical help on a regular basis from your husband/wife, partner, friends, neighbours or family members?

Yes, from someone living in my household
Yes, from someone living in another household
No

Do you buy any additional care or support privately or pay more to ‘top up’ your care and support?

Yes, I buy some more care and support with my own money
Yes, my family pays for some more care and support for me
No

Did you have any help from someone else to complete this questionnaire?

No, I did not have help
I had help from a care worker
I had help from someone living in my household
I had help from someone living outside my household

What type of help did you have?

I didn’t have any help
Someone else read the questions to me
Someone else translated the questions for me
Someone else wrote down the answers for me
I talked through the questions with someone else
Someone answered for me, without asking me the questions

Please use the space provided below to describe any other experiences you would like to tell us about, or to write any other comments you would like to make

Free text response

OPTIONAL QUESTION – Councils should remove this question if they do not want to include it in the questionnaire. Any data collected from this question does not need to be returned to NHS England.
We may be asking some people to take part in follow-up research for this study in the next year or so.
Would you be happy to be invited to take part in more research?

Yes, I have written my name, address and phone number in the space below
No

Overall, how satisfied or dissatisfied are you with the care and support services you receive?

I am extremely satisfied
I am very satisfied
I am quite satisfied
I am neither satisfied nor dissatisfied
I am quite dissatisfied
I am very dissatisfied
I am extremely dissatisfied

Thinking about the good and bad things that make up your quality of life, how would you rate the quality of your life as a whole?

So good, it could not be better
Very good
Good
Alright
Bad
Very bad
So bad, it could not be worse

Do care and support services help you to have a better quality of life?

Yes
No

Are you male or female?

Male
Female
Other

How old are you?

________________ years

To which of these groups do you consider you belong?

English / Welsh / Scottish / Northern Irish / British
Irish
Gypsy or Irish Traveller
Any other White background
White and Black Caribbean
White and Black African
White and Asian
Any other Mixed / Multiple background
Indian
Pakistani
Bangladeshi
Chinese
Any other Asian background
African
Caribbean
Any other Black / African / Caribbean background
Arab
Any other background

Overall, how satisfied or dissatisfied are you with the care and support services you receive?

I am extremely satisfied
I am very satisfied
I am quite satisfied
I am neither satisfied nor dissatisfied
I am quite dissatisfied
I am very dissatisfied
I am extremely dissatisfied

Thinking about the good and bad things that make up your quality of life, how would you rate the quality of your life as a whole?

So good, it could not be better
Very good
Good
Alright
Bad
Very bad
So bad, it could not be worse

Do care and support services help you to have a better quality of life?

Yes
No

Which of the following statements best describes how much choice you have over the care and support services you receive?
By ‘choice’ we mean being able to choose from a range of care providers and services and make changes as and when required

I do have enough choice over care and support services
I don’t have enough choice over care and support services
I don’t want or need choice about care and support services

Which of the following statements best describes how much control you have over your daily life?

I have as much control over my daily life as I want
I have adequate control over my daily life
I have some control over my daily life but not enough
I have no control over my daily life

Do care and support services help you in having control over your daily life?
By ‘care and support services’ we mean any equipment or care provided by staff who are paid to help you. The staff could be from [Social Services], an agency or bought by you using money you receive from [Social Services], using a Direct Payment.

I do not need care and support services to help me have control over my daily life
Yes
No

Thinking about keeping clean and presentable in appearance, which of the following statements best describes your situation?

I feel clean and am able to present myself the way I like
I feel adequately clean and presentable
I feel less than adequately clean or presentable
I don’t feel at all clean or presentable

OPTIONAL QUESTION – Councils should remove this question if they do not want to include it in the questionnaire. Any data collected from this question does not need to be returned to NHS England.
Do care and support services help you in keeping clean and presentable in appearance?

I do not need care and support services to help me keep clean and presentable
Yes
No

Thinking about the food and drink you get, which of the following statements best describes your situation?

I get all the food and drink I like when I want
I get adequate food and drink at OK times
I don’t always get adequate or timely food and drink
I don’t always get adequate or timely food and drink, and I think there is a risk to my health

Which of the following statements best describes how clean and comfortable your home is?

My home is as clean and comfortable as I want
My home is adequately clean and comfortable
My home is not quite clean or comfortable enough
My home is not at all clean or comfortable

OPTIONAL QUESTION – Councils should remove this question if they do not want to include it in the questionnaire. Any data collected from this question does not need to be returned to NHS England.
Do care and support services help you in keeping your home clean and comfortable?

I do not need care and support services to help me keep my home clean and comfortable
Yes
No

Which of the following statements best describes how safe you feel?
By feeling safe we mean how safe you feel both inside and outside the home. This includes fear of abuse, falling or other physical harm.

I feel as safe as I want
Generally I feel adequately safe, but not as safe as I would like
I feel less than adequately safe
I don’t feel at all safe
If you have said you don’t feel safe, can you please tell us why?
-open response-

Do care and support services help you in feeling safe?

Yes
No

Thinking about how much contact you’ve had with people you like, which of the following statements best describes your social situation?

I have as much social contact as I want with people I like
I have adequate social contact with people
I have some social contact with people, but not enough
I have little social contact with people and feel socially isolated

OPTIONAL QUESTION – Councils should remove this question if they do not want to include it in the questionnaire. Any data collected from this question does not need to be returned to NHS England.
Do care and support services help you in having social contact with people?

I do not need care and support services to help me have social contact with people
Yes
No

Which of the following statements best describes how you spend your time?
When you are thinking about how you spend your time, please include anything you value or enjoy including leisure activities, formal employment, voluntary or unpaid work and caring for others.

I’m able to spend my time as I want, doing things I value or enjoy
I’m able to do enough of the things I value or enjoy with my time
I do some of the things I value or enjoy with my time but not enough
I don’t do anything I value or enjoy with my time

OPTIONAL QUESTION – Councils should remove this question if they do not want to include it in the questionnaire. Any data collected from this question does not need to be returned to NHS England.
Do care and support services help you in the way you spend your time?

I do not need care and support services to help me in the way I spend my time
Yes
No

Do you receive any practical help on a regular basis from your husband/wife, partner, friends, neighbours or family members?

Yes, from someone living in my care home
Yes, from someone living outside my care home
No

Do you buy any additional care or support privately or pay more to ‘top up’ your care and support?

Yes, I buy some more care and support with my own money
Yes, my family pays for some more care and support for me
No

Did you have any help from someone else to complete this questionnaire?

No, I did not have help
I had help from a care worker
I had help from someone living in my care home
I had help from someone living outside my care home

What type of help did you have?

Someone else read the questions to me
Someone else translated the questions for me
Someone else wrote down the answers for me
I talked through the questions with someone else
Someone answered for me, without asking me the questions

Please use the space provided below to describe any other experiences you would like to tell us about, or to write any other comments you would like to make?

Open response

Thinking about the food and drink you get, which of the following statements best describes your situation?

I get all the food and drink I like when I want
I get adequate food and drink at OK times
I don’t always get adequate or timely food and drink
I don’t always get adequate or timely food and drink, and I think there is a risk to my health

OPTIONAL QUESTION – Councils should remove this question if they do not want to include it in the questionnaire. Any data collected from this question does not need to be returned to NHS England.
5b. Do care and support services help you to get food and drink?

I do not need care and support services to help me get food and drink
Yes
No

Which of the following statements best describes how clean and comfortable your care home is?

My care home is as clean and comfortable as I want
My care home is adequately clean and comfortable
My care home is not quite clean or comfortable enough
My care home is not at all clean or comfortable

OPTIONAL QUESTION – Councils should remove this question if they do not want to include it in the questionnaire. Any data collected from this question does not need to be returned to NHS England.
6b. Do care and support services help you in keeping your care home clean and comfortable?

I do not need care and support services to help me keep my home clean and comfortable
Yes
No

Which of the following statements best describes how safe you feel?
By ‘feeling safe’ we mean how safe you feel both inside and outside the home. This includes fear of abuse, falling or other physical harm.

If you have said you don’t feel safe, can you please tell us why?

Part 1:
I feel as safe as I want
Generally I feel adequately safe, but not as safe as I would like
I feel less than adequately safe
I don’t feel at all safe

Part 2:
Open response

Do care and support services help you in feeling safe?

Yes
No

Thinking about how much contact you’ve had with people you like, which of the following statements best describes your social situation?

I have as much social contact as I want with people I like
I have adequate social contact with people
I have some social contact with people, but not enough
I have little social contact with people and feel socially isolated

OPTIONAL QUESTION – Councils should remove this question if they do not want to include it in the questionnaire. Any data collected from this question does not need to be returned to NHS England.
8b. Do care and support services help you in having social contact with people?

I do not need care and support services to help me have social contact with people
Yes
No

Which of the following statements best describes how you spend your time?
When you are thinking about how you spend your time, please include anything you value or enjoy including leisure activities, formal employment, voluntary or unpaid work and caring for others.

I’m able to spend my time as I want, doing things I value or enjoy
I’m able to do enough of the things I value or enjoy with my time
I do some of the things I value or enjoy with my time but not enough
I don’t do anything I value or enjoy with my time

OPTIONAL QUESTION – Councils should remove this question if they do not want to include it in the questionnaire. Any data collected from this question does not need to be returned to NHS England.
9b. Do care and support services help you in the way you spend your time?

I do not need care and support services to help me in the way I spend my time
Yes
No

Which of these statements best describes how having help to do things makes you think and feel about yourself?

Having help makes me think and feel better about myself
Having help does not affect the way I think or feel about myself
Having help sometimes undermines the way I think and feel about myself
Having help completely undermines the way I think and feel about myself

Which of these statements best describes how the way you are helped and treated makes you think and feel about yourself?

The way I’m helped and treated makes me think and feel better about myself
The way I’m helped and treated does not affect the way I think or feel about myself
The way I’m helped and treated sometimes undermines the way I think and feel about myself
The way I’m helped and treated completely undermines the way I think and feel about myself

How often do you feel lonely?

Often or always
Some of the time
Occasionally
Hardly ever
Never

In the past year, have you generally found it easy or difficult to find information and advice about support, services or benefits?

Please include information from different sources, such as voluntary organisations, and private agencies as well as [Social Services].

If you found it difficult to find information and advice, please tell us why and what we can do to make it easier for you

Part 1:
I’ve never tried to find information or advice
Very easy to find
Fairly easy to find
Fairly difficult to find
Very difficult to find

Part 2:

How is your health in general?

Very good
Good
Fair
Bad
Very bad

By placing a tick in one box in each group below, please indicate which statements best describe your own health state today.

a. Pain or discomfort
b. Anxiety or depression

Responses for a:
I have no pain or discomfort
I have moderate pain or discomfort
I have extreme pain or discomfort

Responses for b:

Please place a tick () in the box that best describes your abilities for each of the following questions.

a. Do you usually manage to get around indoors (except steps) by yourself?

b. Do you usually manage to get in and out of a bed (or chair) by yourself?

c. Do you usually manage to feed yourself?

d. Do you usually deal with finances and paperwork – for example, paying bills, writing letters – by yourself?

Repeated response scale for all categories:
I can do this easily by myself
I have difficulty doing this myself
I can’t do this by myself

Please place a tick () in the box that best describes your abilities for each of the following questions.

a. Do you usually manage to wash all over by yourself, using either a bath or shower?

b. Do you usually manage to get dressed and undressed by yourself?

c. Do you usually manage to use the WC/toilet by yourself?

d. Do you usually manage to wash your face and hands by yourself?

Repeated response scale for all categories:
I can do this easily by myself
I have difficulty doing this myself
I can’t do this by myself

How well do you think your care home is designed to meet your needs?

My care home meets my needs very well
My care home meets most of my needs
My care home meets some of my needs
My care home is totally inappropriate for my needs

Thinking about getting around outside of your care home, which of the following statements best describes your present situation?

I can get to all the places in my local area that I want
At times I find it difficult to get to all the places in my local area that I want
I am unable to get to all the places in my local area that I want
I do not leave my care home

In the past year, have you generally found it easy or difficult to find information and advice about support, services or benefits?

Please include information from different sources, such as voluntary organisations, and private agencies as well as [Social Services].

If you found it difficult to find information and advice, please tell us why and what we can do to make it easier for you

Part 1:
I’ve never tried to find information or advice
Very easy to find
Fairly easy to find
Fairly difficult to find
Very difficult to find

Part 2:

How is your health in general?

Very good
Good
Fair
Bad
Very bad

By placing a tick in one box in each group below, please indicate which statements best describe your own health state today.

a. Pain or discomfort
b. Anxiety or depression

Responses for a:
I have no pain or discomfort
I have moderate pain or discomfort
I have extreme pain or discomfort

Responses for b:

Please place a tick () in the box that best describes your abilities for each of the following questions.

a. Do you usually manage to get around indoors (except steps) by yourself?

b. Do you usually manage to get in and out of a bed (or chair) by yourself?

c. Do you usually manage to feed yourself?

d. Do you usually deal with finances and paperwork – for example, paying bills, writing letters – by yourself?

Repeated response scale for all categories:
I can do this easily by myself
I have difficulty doing this myself
I can’t do this by myself

Please place a tick () in the box that best describes your abilities for each of the following questions.

a. Do you usually manage to wash all over by yourself, using either a bath or shower?

b. Do you usually manage to get dressed and undressed by yourself?

c. Do you usually manage to use the WC/toilet by yourself?

d. Do you usually manage to wash your face and hands by yourself?

Repeated response scale for all categories:
I can do this easily by myself
I have difficulty doing this myself
I can’t do this by myself

How well do you think your care home is designed to meet your needs?

My care home meets my needs very well
My care home meets most of my needs
My care home meets some of my needs
My care home is totally inappropriate for my needs

Thinking about getting around outside of your care home, which of the following statements best describes your present situation?

I can get to all the places in my local area that I want
At times I find it difficult to get to all the places in my local area that I want
I am unable to get to all the places in my local area that I want
I do not leave my care home

Do you receive any practical help on a regular basis from your husband/wife, partner, friends, neighbours or family members?

Yes, from someone living in my care home
Yes, from someone living outside my care home
No

Do you buy any additional care or support privately or pay more to ‘top up’ your care and support?

Yes, I buy some more care and support with my own money
Yes, my family pays for some more care and support for me
No

Did you have any help from someone else to complete this questionnaire?

No, I did not have help
I had help from a care worker
I had help from someone living in my care home
I had help from someone living outside my care home

What type of help did you have?

Someone else read the questions to me
Someone else translated the questions for me
Someone else wrote down the answers for me
I talked through the questions with someone else
Someone answered for me, without asking me the questions

Please use the space provided below to describe any other experiences you would like to tell us about, or to write any other comments you would like to make?

Open response

Overall, how satisfied or dissatisfied are you with the care and support services you receive?

I am extremely satisfied
I am very satisfied
I am quite satisfied
I am neither satisfied nor dissatisfied
I am quite dissatisfied
I am very dissatisfied
I am extremely dissatisfied

Thinking about the good and bad things that make up your quality of life, how would you rate the quality of your life as a whole?

So good, it could not be better
Very good
Good
Alright
Bad
Very bad
So bad, it could not be worse

Do care and support services help you to have a better quality of life?

Yes
No

Which of the following statements best describes how much choice you have over the care and support services you receive?

By ‘choice’ we mean being able to choose from a range of care providers and services and make changes as and when required

I do have enough choice over care and support services
I don’t have enough choice over care and support services
I don’t want or need choice about care and support services

Which of the following statements best describes how much control you have over your daily life?

I have as much control over my daily life as I want
I have adequate control over my daily life
I have some control over my daily life but not enough
I have no control over my daily life

Do care and support services help you in having control over your daily life?

I do not need care and support services to help me have control over my daily life
Yes
No

Thinking about keeping clean and presentable in appearance, which of the following statements best describes your situation?

I feel clean and am able to present myself the way I like
I feel adequately clean and presentable
I feel less than adequately clean or presentable
I don’t feel at all clean or presentable

OPTIONAL QUESTION – Councils should remove this question if they do not want to include it in the questionnaire. Any data collected from this question does not need to be returned to NHS England.
4b. Do care and support services help you in keeping clean and presentable in appearance?

I do not need care and support services to help me keep clean and presentable
Yes
No

Overall, how satisfied or dissatisfied are you with the care and support services you receive?

I am extremely satisfied
I am very satisfied
I am quite satisfied
I am neither satisfied nor dissatisfied
I am quite dissatisfied
I am very dissatisfied
I am extremely dissatisfied

Thinking about the good and bad things that make up your quality of life, how would you rate the quality of your life as a whole?

So good, it could not be better
Very good
Good
Alright
Bad
Very bad
So bad, it could not be worse

Do care and support services help you to have a better quality of life?

Yes
No

Which of the following statements best describes how much control you have over your daily life?

I have as much control over my daily life as I want
I have adequate control over my daily life
I have some control over my daily life but not enough
I have no control over my daily life

Do care and support services help you in having control over your daily life?

I do not need care and support services to help me have control over my daily life
Yes
No

Thinking about keeping clean and presentable in appearance, which of the following statements best describes your situation?

I feel clean and am able to present myself the way I like
I feel adequately clean and presentable
I feel less than adequately clean or presentable
I don’t feel at all clean or presentable

OPTIONAL QUESTION – Councils should remove this question if they do not want to include it in the questionnaire. Any data collected from this question does not need to be returned to NHS England.
4b. Do care and support services help you in keeping clean and presentable in appearance?

I do not need care and support services to help me keep clean and presentable
Yes
No

Thinking about the food and drink you get, which of the following statements best describes your situation?

I get all the food and drink I like when I want
I get adequate food and drink at OK times
I don’t always get adequate or timely food and drink
I don’t always get adequate or timely food and drink, and I think there is a risk to my health

OPTIONAL QUESTION – Councils should remove this question if they do not want to include it in the questionnaire. Any data collected from this question does not need to be returned to NHS England.
5b. Do care and support services help you to get food and drink?

I do not need care and support services to help me get food and drink
Yes
No

Which of the following statements best describes how clean and comfortable your care home is?

My care home is as clean and comfortable as I want
My care home is adequately clean and comfortable
My care home is not quite clean or comfortable enough
My care home is not at all clean or comfortable

OPTIONAL QUESTION – Councils should remove this question if they do not want to include it in the questionnaire. Any data collected from this question does not need to be returned to NHS England.
6b. Do care and support services help you in keeping your care home clean and comfortable?

I do not need care and support services to help me keep my home clean and comfortable
Yes
No

Which of the following statements best describes how safe you feel?
By ‘feeling safe’ we mean how safe you feel both inside and outside the home. This includes fear of abuse, falling or other physical harm.

If you have said you don’t feel safe, can you please tell us why?

Part 1:
I feel as safe as I want
Generally I feel adequately safe, but not as safe as I would like
I feel less than adequately safe
I don’t feel at all safe

Part 2:
Open response

Do care and support services help you in feeling safe?

Yes
No

Thinking about how much contact you’ve had with people you like, which of the following statements best describes your social situation?

I have as much social contact as I want with people I like
I have adequate social contact with people
I have some social contact with people, but not enough
I have little social contact with people and feel socially isolated

OPTIONAL QUESTION – Councils should remove this question if they do not want to include it in the questionnaire. Any data collected from this question does not need to be returned to NHS England.
8b. Do care and support services help you in having social contact with people?

I do not need care and support services to help me have social contact with people
Yes
No

Which of the following statements best describes how you spend your time?
When you are thinking about how you spend your time, please include anything you value or enjoy including leisure activities, formal employment, voluntary or unpaid work and caring for others.

I’m able to spend my time as I want, doing things I value or enjoy
I’m able to do enough of the things I value or enjoy with my time
I do some of the things I value or enjoy with my time but not enough
I don’t do anything I value or enjoy with my time

OPTIONAL QUESTION – Councils should remove this question if they do not want to include it in the questionnaire. Any data collected from this question does not need to be returned to NHS England.
9b. Do care and support services help you in the way you spend your time?

I do not need care and support services to help me in the way I spend my time
Yes
No

Which of these statements best describes how having help to do things makes you think and feel about yourself?

Having help makes me think and feel better about myself
Having help does not affect the way I think or feel about myself
Having help sometimes undermines the way I think and feel about myself
Having help completely undermines the way I think and feel about myself

Which of these statements best describes how the way you are helped and treated makes you think and feel about yourself?

The way I’m helped and treated makes me think and feel better about myself
The way I’m helped and treated does not affect the way I think or feel about myself
The way I’m helped and treated sometimes undermines the way I think and feel about myself
The way I’m helped and treated completely undermines the way I think and feel about myself

How often do you feel lonely?

Often or always
Some of the time
Occasionally
Hardly ever
Never

In the past year, have you generally found it easy or difficult to find information and advice about support, services or benefits?

I’ve never tried to find information or advice
Very easy to find
Fairly easy to find
Fairly difficult to find
Very difficult to find

How is your health in general?

Very good
Good
Fair
Bad
Very bad

By placing a tick in one box in each group below, please indicate which statements best describe your own health state today.

a. Pain or discomfort

b. Anxiety or depression

Responses for a.
I have no pain or discomfort
I have moderate pain or discomfort
I have extreme pain or discomfort

Responses for b.
I am not anxious or depressed
I am moderately anxious or depressed
I am extremely anxious or depressed

Please place a tick in the box that best describes your abilities for each of the following questions.

a. Do you usually manage to get around indoors (except steps) by yourself?

b. Do you usually manage to get in and out of a bed (or chair) by yourself?

c. Do you usually manage to feed yourself?

d. Do you usually deal with finances and paperwork – for example, paying bills, writing letters – by yourself?

I can do this easily by myself
I have difficulty doing this myself
I can’t do this by myself

Please place a tick in the box that best describes your abilities for each of the following questions.

a. Do you usually manage to wash all over by yourself, using either a bath or shower?

b. Do you usually manage to get dressed and undressed by yourself?

c. Do you usually manage to use the WC/toilet by yourself?

d. Do you usually manage to wash your face and hands by yourself?

I can do this easily by myself
I have difficulty doing this myself
I can’t do this by myself

In the community care questionnaire:
How well do you think your home is designed to meet your needs?

In the residential and nursing care questionnaire:
How well do you think your care home is designed to meet your needs?

In the community care questionnaire:
My home meets my needs very well
My home meets most of my needs
My home meets some of my needs
My home is totally inappropriate for my needs

In the residential and nursing care questionnaire:
My care home meets my needs very well
My care home meets most of my needs
My care home meets some of my needs
My care home is totally inappropriate for my needs

In the community care questionnaire:
Thinking about getting around outside of your home, which of the following statements best describes your present situation?

In the residential and nursing care questionnaire:
Thinking about getting around outside of your care home, which of the following statements best describes your present situation?

I can get to all the places in my local area that I want
At times I find it difficult to get to all the places in my local area that I want
I am unable to get to all the places in my local area that I want
I do not leave my home

Do you receive any practical help on a regular basis from your husband/wife, partner, friends, neighbours or family members?

Yes, from someone living in my household
Yes, from someone living in another household
No

Do you buy any additional care or support privately or pay more to ‘top up’ your care and support?

Yes, I buy some more care and support with my own money
Yes, my family pays for some more care and support for me
No

Did you have any help from someone else to complete this questionnaire?

What type of help did you have?

No, I did not have help
I had help from a care worker
I had help from someone living in my household
I had help from someone living outside my household

I didn’t have any help
Someone else read the questions to me
Someone else translated the questions for me
Someone else wrote down the answers for me
I talked through the questions with someone else
Someone answered for me, without asking me the questions

Overall, how satisfied or dissatisfied are you with the care and support services you receive?

I am extremely satisfied
I am very satisfied
I am quite satisfied
I am neither satisfied nor dissatisfied
I am quite dissatisfied
I am very dissatisfied
I am extremely dissatisfied

Thinking about the good and bad things that make up your quality of life, how would you rate the quality of your life as a whole?

So good, it could not be better
Very good
Good
Alright
Bad
Very bad
So bad, it could not be worse

Do care and support services help you to have a better quality of life?

Yes
No

Which of the following statements best describes how much choice you have over the care and support services you receive?

I do have enough choice over care and support services
I don’t have enough choice over care and support services
I don’t want or need choice about care and support services

Which of the following statements best describes how much control you have over your daily life?

I have as much control over my daily life as I want
I have adequate control over my daily life
I have some control over my daily life but not enough
I have no control over my daily life

Do care and support services help you in having control over your daily life?

I do not need care and support services to help me have control over my daily life
Yes
No

Thinking about keeping clean and presentable in appearance, which of the following statements best describes your situation?

I feel clean and am able to present myself the way I like
I feel adequately clean and presentable
I feel less than adequately clean or presentable
I don’t feel at all clean or presentable

Do care and support services help you in keeping clean and presentable in appearance?

I do not need care and support services to help me keep clean and presentable
Yes
No

Thinking about the food and drink you get, which of the following statements best describes your situation?

I get all the food and drink I like when I want
I get adequate food and drink at OK times
I don’t always get adequate or timely food and drink
I don’t always get adequate or timely food and drink, and I think there is a risk to my health

Do care and support services help you to get food and drink?

I do not need care and support services to help me get food and drink
Yes
No

Which of the following statements best describes how clean and comfortable your home is?

My home is as clean and comfortable as I want
My home is adequately clean and comfortable
My home is not quite clean or comfortable enough
My home is not at all clean or comfortable

Do care and support services help you in keeping your home clean and comfortable?

I do not need care and support services to help me keep my home clean and comfortable
Yes
No

Which of the following statements best describes how safe you feel?

I feel as safe as I want
Generally I feel adequately safe, but not as safe as I
would like
I feel less than adequately safe
I don’t feel at all safe

Do care and support services help you in feeling safe?

Yes
No

Thinking about how much contact you’ve had with people you like, which of the following statements best describes your social situation?

I have as much social contact as I want with people I like
I have adequate social contact with people
I have some social contact with people, but not enough
I have little social contact with people and feel socially isolated

Do care and support services help you in having social contact with people?

I do not need care and support services to help me have social contact with people
Yes
No

Which of the following statements best describes how you spend your time?

I’m able to spend my time as I want, doing things I value or enjoy
I’m able to do enough of the things I value or enjoy with my time
I do some of the things I value or enjoy with my time but not enough
I don’t do anything I value or enjoy with my time

Do care and support services help you in the way you spend your time?

I do not need care and support services to help me in the way I spend my time
Yes
No

Which of these statements best describes how having help to do things makes you think and feel about yourself?

Having help makes me think and feel better about myself
Having help does not affect the way I think or feel about myself
Having help sometimes undermines the way I think and feel about myself
Having help completely undermines the way I think and feel about myself

Which of these statements best describes how the way you are helped and treated makes you think and feel about yourself?

The way I’m helped and treated makes me think and feel better about myself
The way I’m helped and treated does not affect the way I think or feel about myself
The way I’m helped and treated sometimes undermines the way I think and feel about myself
The way I’m helped and treated completely undermines the way I think and feel about myself

OPTIONAL QUESTION – Councils should remove this question if they do not want to include it in the questionnaire. Any data collected from this question does not need to be returned to NHS Digital.

Do care and support services help you to get food and drink?

Yes
No

General health
Anxiety
Depression

In the community care questionnaire:
Which of the following statements best describes how clean and comfortable your home is?

In the residential and nursing care questionnaire:
Which of the following statements best describes how clean and comfortable your care home is?

In the community care questionnaire:
My home is as clean and comfortable as I want
My home is adequately clean and comfortable
My home is not quite clean or comfortable enough
My home is not at all clean or comfortable

In the residential and nursing care questionnaire:
My care home is as clean and comfortable as I want
My care home is adequately clean and comfortable
My care home is not quite clean or comfortable enough
My care home is not at all clean or comfortable

General health
Anxiety
Depression

OPTIONAL QUESTION – Councils should remove this question if they do not want to include it in the questionnaire. Any data collected from this question does not need to be returned to NHS Digital.

In the community care questionnaire:
Do care and support services help you in keeping your home clean and comfortable?

In the residential and nursing care questionnaire:
Do care and support services help you in keeping your care home clean and comfortable?

Yes
No

General health
Anxiety
Depression

Which of the following statements best describes how safe you feel?

By feeling safe we mean how safe you feel both inside and outside the home. This includes fear of abuse, falling or other physical harm

I feel as safe as I want
Generally I feel adequately safe, but not as safe as I
would like
I feel less than adequately safe
I don’t feel at all safe

General health
Anxiety
Depression

Do care and support services help you in feeling safe?

Yes
No

General health
Anxiety
Depression

Thinking about how much contact you’ve had with people you like, which of the following statements best describes your social situation?

I have as much social contact as I want with people I like
I have adequate social contact with people
I have some social contact with people, but not enough
I have little social contact with people and feel socially isolated

General health
Anxiety
Depression

OPTIONAL QUESTION – Councils should remove this question if they do not want to include it in the questionnaire. Any data collected from this question does not need to be returned to NHS Digital.

Do care and support services help you in having social contact with people?

Yes
No

General health
Anxiety
Depression

Which of the following statements best describes how you spend your time?

When you are thinking about how you spend your time, please include anything you value or enjoy including leisure activities, formal employment, voluntary or unpaid work and caring for others.

I’m able to spend my time as I want, doing things I value or enjoy
I’m able to do enough of the things I value or enjoy with my time
I do some of the things I value or enjoy with my time but not enough
I don’t do anything I value or enjoy with my time

General health
Anxiety
Depression

OPTIONAL QUESTION – Councils should remove this question if they do not want to include it in the questionnaire. Any data collected from this question does not need to be returned to NHS Digital.
Do care and support services help you in the way you spend your time?

Yes
No

General health
Anxiety
Depression

Which of these statements best describes how having help to do things makes you think and feel about yourself?

Having help makes me think and feel better about myself
Having help does not affect the way I think or feel about myself
Having help sometimes undermines the way I think and feel about myself
Having help completely undermines the way I think and feel about myself

General health
Anxiety
Depression

In the past year, have you generally found it easy or difficult to find information and advice about support, services or benefits?

Please include information from different sources, such as voluntary organisations, and private agencies as well as [Social Services].

I’ve never tried to find information or advice
Very easy to find
Fairly easy to find
Fairly difficult to find
Very difficult to find

General health
Anxiety
Depression

How is your health in general?

Very good
Good
Fair
Bad
Very bad

General health
Anxiety
Depression

By placing a tick in one box in each group below, please indicate which statements best describe your own health state today.

a. Pain or discomfort

b. Anxiety or depression

Responses for a.
I have no pain or discomfort
I have moderate pain or discomfort
I have extreme pain or discomfort

Responses for b.
I am not anxious or depressed
I am moderately anxious or depressed
I am extremely anxious or depressed

General health
Anxiety
Depression

Please place a tick in the box that best describes your abilities for each of the following questions.

a. Do you usually manage to get around indoors (except steps) by yourself?

b. Do you usually manage to get in and out of a bed (or chair) by yourself?

c. Do you usually manage to feed yourself?

d. Do you usually deal with finances and paperwork – for example, paying bills, writing letters – by yourself?

I can do this easily by myself
I have difficulty doing this myself
I can’t do this by myself

General health
Anxiety
Depression

Please place a tick in the box that best describes your abilities for each of the following questions.

a. Do you usually manage to wash all over by yourself, using either a bath or shower?

b. Do you usually manage to get dressed and undressed by yourself?

c. Do you usually manage to use the WC/toilet by yourself?

d. Do you usually manage to wash your face and hands by yourself?

I can do this easily by myself
I have difficulty doing this myself
I can’t do this by myself

General health
Anxiety
Depression

In the community care questionnaire:
How well do you think your home is designed to meet your needs?

In the residential and nursing care questionnaire:
How well do you think your care home is designed to meet your needs?

In the community care questionnaire:
My home meets my needs very well
My home meets most of my needs
My home meets some of my needs
My home is totally inappropriate for my needs

In the residential and nursing care questionnaire:
My care home meets my needs very well
My care home meets most of my needs
My care home meets some of my needs
My care home is totally inappropriate for my needs

General health
Anxiety
Depression

In the community care questionnaire:
Thinking about getting around outside of your home, which of the following statements best describes your present situation?

In the residential and nursing care questionnaire:
Thinking about getting around outside of your care home, which of the following statements best describes your present situation?

I can get to all the places in my local area that I want
At times I find it difficult to get to all the places in my local area that I want
I am unable to get to all the places in my local area that I want
I do not leave my home

General health
Anxiety
Depression

Do you receive any practical help on a regular basis from your husband/wife, partner, friends, neighbours or family members?

Yes, from someone living in my household
Yes, from someone living in another household
No

General health
Anxiety
Depression

Do you buy any additional care or support privately or pay more to ‘top up’ your care and support?

Yes, I buy some more care and support with my own money
Yes, my family pays for some more care and support for me
No

General health
Anxiety
Depression

Did you have any help from someone else to complete this questionnaire?

What type of help did you have?

No, I did not have help
I had help from a care worker
I had help from someone living in my household
I had help from someone living outside my household

I didn’t have any help
Someone else read the questions to me
Someone else translated the questions for me
Someone else wrote down the answers for me
I talked through the questions with someone else
Someone answered for me, without asking me the questions

General health
Anxiety
Depression

Which of these statements best describes how the way you are helped and treated makes you think and feel about yourself?

The way I’m helped and treated makes me think and feel better about myself
The way I’m helped and treated does not affect the way I think or feel about myself
The way I’m helped and treated sometimes undermines the way I think and feel about myself
The way I’m helped and treated completely undermines the way I think and feel about myself

In the past year, have you generally found it easy or difficult to find information and advice about support, services or benefits?

I’ve never tried to find information or advice
Very easy to find
Fairly easy to find
Fairly difficult to find
Very difficult to find

How is your health in general?

Very good
Good
Fair
Bad
Very bad

By placing a tick in one box in each group below, please indicate which statements best describe your own health state today.

a. Pain or discomfort

b. Anxiety or depression

Responses for a.
I have no pain or discomfort
I have moderate pain or discomfort
I have extreme pain or discomfort

Responses for b.
I am not anxious or depressed
I am moderately anxious or depressed
I am extremely anxious or depressed

Please place a tick in the box that best describes your abilities for each of the following questions.

a. Do you usually manage to get around indoors (except steps) by yourself?

b. Do you usually manage to get in and out of a bed (or chair) by yourself?

c. Do you usually manage to feed yourself?

d. Do you usually deal with finances and paperwork – for example, paying bills, writing letters – by yourself?

I can do this easily by myself
I have difficulty doing this myself
I can’t do this by myself

Please place a tick in the box that best describes your abilities for each of the following questions.

a. Do you usually manage to wash all over by yourself, using either a bath or shower?

b. Do you usually manage to get dressed and undressed by yourself?

c. Do you usually manage to use the WC/toilet by yourself?

d. Do you usually manage to wash your face and hands by yourself?

I can do this easily by myself
I have difficulty doing this myself
I can’t do this by myself

In the community care questionnaire:
How well do you think your home is designed to meet your needs?

In the residential and nursing care questionnaire:
How well do you think your care home is designed to meet your needs?

In the community care questionnaire:
My home meets my needs very well
My home meets most of my needs
My home meets some of my needs
My home is totally inappropriate for my needs

In the residential and nursing care questionnaire:
My care home meets my needs very well
My care home meets most of my needs
My care home meets some of my needs
My care home is totally inappropriate for my needs

In the community care questionnaire:
Thinking about getting around outside of your home, which of the following statements best describes your present situation?

In the residential and nursing care questionnaire:
Thinking about getting around outside of your care home, which of the following statements best describes your present situation?

I can get to all the places in my local area that I want
At times I find it difficult to get to all the places in my local area that I want
I am unable to get to all the places in my local area that I want
I do not leave my home

Do you receive any practical help on a regular basis from your husband/wife, partner, friends, neighbours or family members?

Yes, from someone living in my household
Yes, from someone living in another household
No

Do you buy any additional care or support privately or pay more to ‘top up’ your care and support?

Yes, I buy some more care and support with my own money
Yes, my family pays for some more care and support for me
No

Did you have any help from someone else to complete this questionnaire?

What type of help did you have?

Part 1:
No, I did not have help
I had help from a care worker
I had help from someone living in my household
I had help from someone living outside my household

Part 2:
I didn’t have any help
Someone else read the questions to me
Someone else translated the questions for me
Someone else wrote down the answers for me
I talked through the questions with someone else
Someone answered for me, without asking me the questions

Overall, how satisfied or dissatisfied are you with the care and support services you receive?

I am extremely satisfied
I am very satisfied
I am quite satisfied
I am neither satisfied nor dissatisfied
I am quite dissatisfied
I am very dissatisfied
I am extremely dissatisfied

General health
Anxiety
Depression

Do care and support services help you to have a better quality of life?

Yes
No

General health
Anxiety
Depression

Which of the following statements best describes how much choice you have over the care and support services you receive?

I do have enough choice over care and support services
I don’t have enough choice over care and support services
I don’t want or need choice about care and support services

General health
Anxiety
Depression

Thinking about the good and bad things that make up your quality of life, how would you rate the quality of your life as a whole?

So good, it could not be better
Very good
Good
Alright
Bad
Very bad
So bad, it could not be worse

General health
Anxiety
Depression

Which of the following statements best describes how much control you have over your daily life?

I have as much control over my daily life as I want
I have adequate control over my daily life
I have some control over my daily life but not enough
I have no control over my daily life

General health
Anxiety
Depression

Do care and support services help you in having control over your daily life?

Yes
No

General health
Anxiety
Depression

Thinking about keeping clean and presentable in appearance, which of the following statements best describes your situation?

I feel clean and am able to present myself the way I like
I feel adequately clean and presentable
I feel less than adequately clean or presentable
I don’t feel at all clean or presentable

General health
Anxiety
Depression

OPTIONAL QUESTION – Councils should remove this question if they do not want to include it in the questionnaire. Any data collected from this question does not need to be returned to NHS Digital.

Do care and support services help you in keeping clean and presentable in appearance?

Yes
No

General health
Anxiety
Depression

Thinking about the food and drink you get, which of the following statements best describes your situation?

I get all the food and drink I like when I want
I get adequate food and drink at OK times
I don’t always get adequate or timely food and drink
I don’t always get adequate or timely food and drink, and I think there is a risk to my health

General health
Anxiety
Depression

Please use the space provided below to describe any other experiences you would like to tell us about, or to write any other comments you would like to make?

Open response

Overall, how satisfied or dissatisfied are you with the care and support services you receive?

I am extremely satisfied
I am very satisfied
I am quite satisfied
I am neither satisfied nor dissatisfied
I am quite dissatisfied
I am very dissatisfied
I am extremely dissatisfied

Thinking about the good and bad things that make up your quality of life, how would you rate the quality of your life as a whole?

So good, it could not be better
Very good
Good
Alright
Bad
Very bad
So bad, it could not be worse

Do care and support services help you to have a better quality of life?

Yes
No

Which of the following statements best describes how much choice you have over the care and support services you receive?

I do have enough choice over care and support services
I don’t have enough choice over care and support services
I don’t want or need choice about care and support services

Which of the following statements best describes how much control you have over your daily life?

I have as much control over my daily life as I want
I have adequate control over my daily life
I have some control over my daily life but not enough
I have no control over my daily life

Do care and support services help you in having control over your daily life?

Yes
No

Thinking about keeping clean and presentable in appearance, which of the following statements best describes your situation?

I feel clean and am able to present myself the way I like
I feel adequately clean and presentable
I feel less than adequately clean or presentable
I don’t feel at all clean or presentable

OPTIONAL QUESTION – Councils should remove this question if they do not want to include it in the questionnaire. Any data collected from this question does not need to be returned to NHS Digital.

Do care and support services help you in keeping clean and presentable in appearance?

Yes
No

Thinking about the food and drink you get, which of the following statements best describes your situation?

I get all the food and drink I like when I want
I get adequate food and drink at OK times
I don’t always get adequate or timely food and drink
I don’t always get adequate or timely food and drink, and I think there is a risk to my health

Do care and support services help you to get food and drink?

Yes
No

Which of the following statements best describes how clean and comfortable your home is?

My home is as clean and comfortable as I want
My home is adequately clean and comfortable
My home is not quite clean or comfortable enough
My home is not at all clean or comfortable

Do care and support services help you in keeping your home (or care home in care home questionnaire) clean and comfortable?

Yes
No

Which of the following statements best describes how safe you feel?

I feel as safe as I want
Generally I feel adequately safe, but not as safe as I
would like
I feel less than adequately safe
I don’t feel at all safe

Do care and support services help you in feeling safe?

Yes
No

Thinking about how much contact you’ve had with people you like, which of the following statements best describes your social situation?

I have as much social contact as I want with people I like
I have adequate social contact with people
I have some social contact with people, but not enough
I have little social contact with people and feel socially isolated

Do care and support services help you in having social contact with people?

Yes
No

Which of the following statements best describes how you spend your time?

I’m able to spend my time as I want, doing things I value or enjoy
I’m able to do enough of the things I value or enjoy with my time
I do some of the things I value or enjoy with my time but not enough
I don’t do anything I value or enjoy with my time

Do care and support services help you in the way you spend your time?

Yes
No

Which of these statements best describes how having help to do things makes you think and feel about yourself?

Having help makes me think and feel better about myself
Having help does not affect the way I think or feel about myself
Having help sometimes undermines the way I think and feel about myself
Having help completely undermines the way I think and feel about myself

Thinking about your personal safety, which of the statements best describes your present situation?

By ‘personal safety’ we mean feeling safe from fear of abuse, being attacked or other physical harm.

I have no worries about my personal safety
I have some worries about my personal safety
I am extremely worried about my personal safety

Thinking about how much social contact you’ve had with people you like, which of the following statements best describes your social situation?

I have as much social contact as I want with people I like
I have some social contact with people but not enough
I have little social contact with people and feel socially isolated

Thinking about encouragement and support in your caring role, which of the following statements best describes your present situation?

I feel I have encouragement and support
I feel I have some encouragement and support but not enough
I feel I have no encouragement and support

Thinking about the other people you have caring responsibilities for, which of the following best describes your current situation? Please exclude the person you spend most time helping.

I don’t have caring responsibilities for anyone else
I always have enough time to care for them
I sometimes have enough time to care for them
I never have enough time to care for them

In the last 12 months, has your health been affected by your caring role in any of the ways listed below?

Feeling tired
Feeling depressed
Loss of appetite
Disturbed sleep
General feeling of stress
Physical strain (e.g. back)
Short tempered/ irritable
Had to see own GP
Developed my own health conditions
Made an existing condition worse
Other
No, none of these

In the last 12 months, has caring caused you any financial difficulties?

No, not at all
Yes, to some extent
Yes, a lot

In the last 12 months, have you found it easy or difficult to find information and advice about support, services or benefits? Please include information and advice from different sources, such as voluntary organisations and private agencies as well as Social Services.

I have not tried to find information or advice in the last 12 months
Very easy to find
Fairly easy to find
Fairly difficult to find
Very difficult to find

In the last 12 months, how helpful has the information and advice you have received been? Please include information and advice from different organisations, such as voluntary organisations and private agencies as well as Social Services.

I have not received any information or advice in the last 12 months
Very helpful
Quite helpful
Quite unhelpful
Very unhelpful

In the last 12 months, do you feel you have been involved or consulted as much as you wanted to be, in discussions about the support or services provided to the person you care for?

There have been no discussions that I am aware of, in the last 12 months
I always felt involved or consulted
I usually felt involved or consulted
I sometimes felt involved or consulted
I never felt involved or consulted

In addition to your caring role, please tell us which of the following also applies to you?

Retired
Employed full-time
Employed part-time (working 30 hours or less)
Self-employed full-time
Self-employed part-time
Not in paid work
Doing voluntary work
Other

Thinking about combining your paid work and caring responsibilities, which of the following statements best describes your current situation?

Not in paid work:
I am not in paid employment because of my caring responsibilities
I am not in paid employment for other reasons (e.g. Retired)

In paid employment:
I am in paid employment and I feel supported by my employer
I am in paid employment but I don’t feel supported by my employer
I do not need any support from my employer to combine my work and caring responsibilities

Self-employed:
I am self-employed and I am able to balance my work and caring Responsibilities
I am self-employed but I am unable to balance my work and caring Responsibilities

About how long have you been looking after or helping the person you care for?

Less than 6 months
Over 6 months but less than a year
Over 1 year but less than 3 years
Over 3 years but less than 5 years
Over 5 years but less than 10 years
Over 10 years but less than 15 years
Over 15 years but less than 20 years
20 years or more

About how long do you spend each week looking after or helping the person you care for?

0-9 hours per week
10-19 hours per week
20-34 hours per week
35-49 hours per week
50-74 hours per week
75-99 hours per week
100 or more hours per week
Varies – Under 20 hours per week
Varies – 20 hours or more per week
Other – if other please specify

Over the last 12 months, what kinds of things did you usually do for the person you care for?

Personal care?
(Things like dressing, bathing, washing, shaving, cutting nails, feeding, using the toilet)
Physical help?
(Such as helping with walking, getting up and down stairs, getting into and out of bed)
Helping with dealing with care services and benefits?
(Things like making appointments and phone calls, filling in forms)
Helping with paperwork or financial matters?
(Such as writing letters, sending cards, filling in forms, dealing with bills, banking)
Other practical help?
(Things like preparing meals, doing his/her shopping, laundry, housework, gardening, decorating, household repairs, taking to doctor’s or hospital)
Keeping him/her company?
(Things like visiting, sitting with, reading to, talking to, playing cards or games)
Taking him/her out?
(Such as taking out for a walk or drive, taking to see friends or relatives)
Giving medicines?
(Things like making sure he/she takes pills, giving injections, changing dressings)
Keeping an eye on him/her to see he/she is all right?
Giving emotional support?
Other help?

Do you have any of the following?

A physical impairment or disability
Sight or hearing loss
A mental health problem or illness
A learning disability or difficulty
A long-standing illness
Other
None of the above

How old are you?

________________ years

Are you male or female?

Male
Female

How many children aged 18 or under do you have parental responsibility for?

0
1
2
3
4+

To which of these groups do you consider you belong?

English / Welsh / Scottish / Northern Irish / British
Irish
Gypsy or Irish Traveller
Any other White background
White and Black Caribbean
White and Black African
White and Asian
Any other Mixed / Multiple background
Indian
Pakistani
Bangladeshi
Chinese
Any other Asian background
African
Caribbean
Any other Black / African / Caribbean background
Arab
Any other background
Prefer not to say

Did someone help you to complete this questionnaire?

Yes
No

In the past year, have you generally found it easy or difficult to find information and advice about support, services or benefits?

Very easy to find
Fairly easy to find
Fairly difficult to find
Very difficult to find
I’ve never tried to find information or advice

How is your health in general?

Very good
Good
Fair
Bad
Very bad

By placing a tick in one box in each group below, please indicate which statements best describe your own health state today.

a. Pain or discomfort

b. Anxiety or depression

Responses for a.
I have no pain or discomfort
I have moderate pain or discomfort
I have extreme pain or discomfort

Responses for b.
I am not anxious or depressed
I am moderately anxious or depressed
I am extremely anxious or depressed

Please place a tick in the box that best describes your abilities for each of the following questions.

a. Do you usually manage to get around indoors (except steps) by yourself?

b. Do you usually manage to get in and out of a bed (or chair) by yourself?

c. Do you usually manage to feed yourself?

d. Do you usually deal with finances and paperwork – for example, paying bills, writing letters – by yourself?

I can do this easily by myself
I have difficulty doing this myself
I can’t do this by myself

Please place a tick in the box that best describes your abilities for each of the following questions.

a. Do you usually manage to wash all over by yourself, using either a bath or shower?

b. Do you usually manage to get dressed and undressed by yourself?

c. Do you usually manage to use the WC/toilet by yourself?

d. Do you usually manage to wash your face and hands by yourself?

I can do this easily by myself
I have difficulty doing this myself
I can’t do this by myself

In the community care questionnaire:
How well do you think your home is designed to meet your needs?

In the residential and nursing care questionnaire:
How well do you think your care home is designed to meet your needs?

In the community care questionnaire:
My home meets my needs very well
My home meets most of my needs
My home meets some of my needs
My home is totally inappropriate for my needs

In the residential and nursing care questionnaire:
My care home meets my needs very well
My care home meets most of my needs
My care home meets some of my needs
My care home is totally inappropriate for my needs

In the community care questionnaire:
Thinking about getting around outside of your home, which of the following statements best describes your present situation?

In the residential and nursing care questionnaire:
Thinking about getting around outside of your care home, which of the following statements best describes your present situation?

I can get to all the places in my local area that I want
At times I find it difficult to get to all the places in my local area that I want
I am unable to get to all the places in my local area that I want
I do not leave my home

Do you receive any practical help on a regular basis from your husband/wife, partner, friends, neighbours or family members?

Yes, from someone living in my household
Yes, from someone living in another household
No

Do you buy any additional care or support privately or pay more to ‘top up’ your care and support?

Yes, I buy some more care and support with my own money
Yes, my family pays for some more care and support for me
No

Did you have any help from someone else to complete this questionnaire?

No, I did not have help
I had help from a care worker
I had help from someone living in my household
I had help from someone living outside my household

What type of help did you have?

I didn’t have any help
Someone else read the questions to me
Someone else translated the questions for me
Someone else wrote down the answers for me
I talked through the questions with someone else
Someone answered for me, without asking me the questions

How old is the person you care for?

Number of years
(If you don’t know the exact age, please give an approximate one – the person cared for should be aged 18 or over)

Does the person you care for have….?

Dementia
A physical disability
Sight or hearing loss
A mental health problem
Problems connected to ageing
A learning disability or difficulty
Long-standing illness
Terminal illness
Alcohol or drug dependency

Where does the person you care for usually live?

With me
Somewhere else

Overall, how satisfied or dissatisfied are you with the support or services you and the person you care for have received from Social Services in the last 12 months?

We haven’t received any support or services from Social Services in the last 12 months
I am extremely satisfied
I am very satisfied
I am quite satisfied
I am neither satisfied nor dissatisfied
I am quite dissatisfied
I am very dissatisfied
I am extremely dissatisfied

Has the person you care for used any of the support or services listed below in the last 12 months?
They may be provided by different organisations, such as a voluntary organisation, a private agency or Social Services.

a. Support or services allowing you to take a break from caring at short notice or in an emergency
b. Support or services allowing you to take a break from caring for more than 24 hours
c. Support or services to allow you to have a rest from caring for between 1 and 24 hours (eg. a sitting service)
d. Personal assistant
e. Home care/home help
f. Day centre or day activities
g. Lunch club
h. Meals Services
i. Equipment or adaptation to their home (such as a wheelchair or handrails)
j. Lifeline Alarm
k. They are permanently resident in a care home

Have you used any of the support or services listed below, to help you as a carer over the last 12 months?

They may be provided by different organisations, such as a voluntary organisation, a private agency or Social Services. Please do not include any unpaid help from family and friends.

a. Information and advice
b. Support from carers groups or someone to talk to in confidence
c. Training for carers
d. Support to keep you in employment

Which of the following statements best describes how you spend your time?

When you are thinking about what you do with your time, please include anything you value or enjoy, including formal employment, voluntary or unpaid work, caring for others and leisure activities.

I’m able to spend my time as I want, doing things I value or enjoy
I do some of the things I value or enjoy with my time but not enough
I don’t do anything I value or enjoy with my time

Which of the following statements best describes how much control you have over your daily life?

I have as much control over my daily life as I want
I have some control over my daily life but not enough
I have no control over my daily life

Thinking about how much time you have to look after yourself – in terms of getting enough sleep or eating well – which statement best describes your present situation?

I look after myself
Sometimes I can’t look after myself well enough
I feel I am neglecting myself

Overall, how satisfied or dissatisfied are you with the care and support services you receive?

By ‘care and support services’ we mean any equipment or care provided by staff who are paid to help you. The staff could be from [Social Services], an agency, a care home or bought by you using money from [Social Services] through a Direct Payment.

I am extremely satisfied
I am very satisfied
I am quite satisfied
I am neither satisfied nor dissatisfied
I am quite dissatisfied
I am very dissatisfied
I am extremely dissatisfied

Thinking about the good and bad things that make up your quality of life, how would you rate the quality of your life as a whole?

So good, it could not be better
Very good
Good
Alright
Bad
Very bad
So bad, it could not be worse

Do care and support services help you to have a better quality of life?

Yes
No

Which of the following statements best describes how much choice you have over the care and support services you receive?

By ‘choice’ we mean being able to choose from a range of care providers and services and make changes as and when required

I do have enough choice over care and support services
I don’t have enough choice over care and support services
I don’t want or need choice about care and support services

Which of the following statements best describes how much control you have over your daily life?

By ‘control over daily life’ we mean having the choice to do things or have things done for you as you like and when you want.

I have as much control over my daily life as I want
I have adequate control over my daily life
I have some control over my daily life but not enough
I have no control over my daily life

Do care and support services help you in having control over your daily life?

By ‘care and support services’ we mean any equipment or care provided by staff who are paid to help you. The staff could be from [Social Services], an agency or bought by you using money you receive from [Social Services], using a Direct Payment.

Yes
No

Thinking about keeping clean and presentable in appearance, which of the following statements best describes your situation?

I feel clean and am able to present myself the way I like
I feel adequately clean and presentable
I feel less than adequately clean or presentable
I don’t feel at all clean or presentable

Do care and support services help you in keeping clean and presentable in appearance?

Yes
No

Thinking about the food and drink you get, which of the following statements best describes your situation?

I get all the food and drink I like when I want
I get adequate food and drink at OK times
I don’t always get adequate or timely food and drink
I don’t always get adequate or timely food and drink, and I think there is a risk to my health

Do care and support services help you to get food and drink?

Yes
No

Which of the following statements best describes how clean and comfortable your home is?

My home is as clean and comfortable as I want
My home is adequately clean and comfortable
My home is not quite clean or comfortable enough
My home is not at all clean or comfortable

Do care and support services help you in keeping your home clean and comfortable?

Yes
No

Which of the following statements best describes how safe you feel?

By feeling safe we mean how safe you feel both inside and outside the home. This includes fear of abuse, falling or other physical harm.

I feel as safe as I want
Generally I feel adequately safe, but not as safe as I
would like
I feel less than adequately safe
I don’t feel at all safe

Do care and support services help you in feeling safe?

Yes
No

Thinking about how much contact you’ve had with people you like, which of the following statements best describes your social situation?

I have as much social contact as I want with people I like
I have adequate social contact with people
I have some social contact with people, but not enough
I have little social contact with people and feel socially isolated

Do care and support services help you in having social contact with people?

Yes
No

Which of the following statements best describes how you spend your time?

When you are thinking about how you spend your time, please include anything you value or enjoy including leisure activities, formal employment, voluntary or unpaid work and caring for others.

I’m able to spend my time as I want, doing things I value or enjoy
I’m able to do enough of the things I value or enjoy with my time
I do some of the things I value or enjoy with my time but not enough
I don’t do anything I value or enjoy with my time

Do care and support services help you in the way you spend your time?

Yes
No

Which of these statements best describes how having help to do things makes you think and feel about yourself?

Having help makes me think and feel better about myself
Having help does not affect the way I think or feel about myself
Having help sometimes undermines the way I think and feel about myself
Having help completely undermines the way I think and feel about myself

Which of these statements best describes how the way you are helped and treated makes you think and feel about yourself?

The way I’m helped and treated makes me think and feel better about myself
The way I’m helped and treated does not affect the way I think or feel about myself
The way I’m helped and treated sometimes undermines the way I think and feel about myself
The way I’m helped and treated completely undermines the way I think and feel about myself