Hospice at Home Service Evaluation

Hospice at Home Evaluation Form

Which service did you receive?(Required)

Hospice at Home - nursing care at night

Hospice at Home - nursing care during the day

Roaming Nurse Service

How you heard about us

Who referred you to our Hospice at Home Service?(Required)

District Nurse

Palliative Care Nurse

Hospital

Other (please state below)

I found out about the service from:

Thinking about timings, do you think the referral was:(Required)

Information about our Service

Did you receive an information pack from us?(Required)

I found the information pack:(Required)

Were your calls to our coordination team in the office dealt with sensitively?(Required)

The care you received

Did receiving support from Treetops enable your loved one to be cared for in their preferred place of care (at home)?(Required)

Hospice at Home - nursing care at night(Required)

Hospice at Home - nursing care during the day(Required)

Roaming Nurse Service(Required)

Our nurses

How did it feel to have a Treetops nurse in your home?(Required)

How did you feel about the way we cared for your loved one?(Required)

Did the nurses have the appropriate knowledge to care for your loved one effectively?(Required)

Did the nurses take time to listen to your concerns?(Required)

We value any further comments or suggestions you would like to make regarding the Hospice at Home or Roaming Nurse Service:

Your details (optional)

The form is anonymous however if you are happy to share your feedback further, please complete the sections below.

Would you like the Hospice at Home Manager to contact you regarding your feedback?

Are you happy for us to share your feedback with the Hospice at Home nurses?

Are you happy for us to share your comments anonymously in publicity?

Would you be happy to share your feedback more widely - to help us promote our services in the local press or through social media?

Name (optional)

First Last

Phone number (optional)

Email (optional)

Your privacy is very important to us, so we will always keep your details secure and your details will not be passed onto any third parties. For information about how we use your data, please see our Privacy Notice.