In order to ensure that we are continuing to provide a good quality of Domiciliary Care to meet your needs we would be obliged if you would assist us by completing the following questionnaire. It is by asking about our Care Service, and whether you feel that it meets your needs as you perceive it, that we are able to look at ways of improving and maintaining the standard of care we provide. Please note that there is no provision for you in your name. this is to ensure privacy and confidentiality and to enable you to able you to be totally honest with your answers. For each OBSERVATION listed please tick the appropriate SCORE box according to how you thing we rate and when completed please put the questionnaire into the envelope provided, seal it and pass it to our Domiciliary Care Worker. Thank you for your help.