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Please look at the questions before your appointment and answer them afterwards.
Please do not take the questionnaire with you to the appointment.
Please do not announce yourself as being a mystery shopper or as being from Healthwatch Derby.
Please answer not applicable to any questions that are not relevant to the type of appointment that you had.

Please enter the following information into the box below:

Name of Healthwatcher

Appointment at (add department if relevant)

Date of visit

1. Question 1.

How easy was it to get an appointment?

Very easy

Fairly easy

Not very easy

Not at all easy

2. Question 2.

How far in advance was the appointment?

Same day

Next working day

A few days later

A week or more later

3. Question 3.

What type of appointment were you given?

Face to face

Telephone

Video

4. Question 4.

Were you given a choice about the type of appointment?

Yes

No

Other (please specify):

This is required

Input box for - Other (please specify):

5. Question 5.

How convenient was this for you?

Very convenient

Fairly convenient

Not very convenient

Not at all convenient

6. Question 6.

How did you make your appointment?

In person

By phone

Online

Other (please specify):

This is required

Input box for - Other (please specify):

Comments

7. Question 7.

Is the surgery easily accessible (walking/public transport/driving)?

Very easy

Fairly easy

Not very easy

Not at all easy

Not applicable

8. Question 8.

Is there a ramp or flat access?

Yes

No

Don't know

Not applicable

9. Question 9.

Can wheelchair users and people with mobility issues get in easily?

Very easy

Fairly easy

Not very easy

Not at all easy

Not applicable

10. Question 10.

Is there a wheelchair accessible toilet?

Yes

No

Don't know

Not applicable

Comments

11. Question 11.

Are there signs providing information in your first language?

Yes

No

Don't know

Not applicable

12. Question 12.

Were you acknowledged on arrival (eye contact, smiles, a greeting)?

Yes

No

Don't know

Not applicable

13. Question 13.

Did the reception staff make you feel welcome and at ease?

Yes

No

Don't know

Not applicable

14. Question 14.

Does the environment appear to be clean and well maintained?

Yes

No

Don't know

Not applicable

Comments

15. Question 15.

Is information available clear and visible?

Yes

No

Don't know

Not applicable

16. Question 16.

Is there hand gel available?

Yes

No

Don't know

Not applicable

17. Question 17.

Is there information about the staff members and the person in charge?

Yes

No

Don't know

Not applicable

18. Question 18.

Are security and fire procedures evident?

Yes

No

Don't know

Not applicable

Comments

19. Question 19.

Was your appointment on time?

Yes

No

Don't know

20. Question 20.

If not, how long was the delay?

Less than 10 minutes

10-20 minutes

More than 20 minutes

Comments

21. Question 21.

Was the person you saw/spoke to helpful?

Very helpful

Fairly helpful

Not very helpful

Not at all helpful

22. Question 22.

Did they give you all the information you needed?

Yes

No

Don't know

23. Question 23.

Were you able to ask questions?

Yes

No

Don't know

24. Question 24.

Did they explain your treatment and/or medication and what happens next?

Yes

No

Don't know

Comments

25. Question 25.

How likely are you to recommend this surgery to friends or family if they needed similar care or treatment?

Extremely likely

Likely

Neither unlikely or likely

Unlikely

Extremely unlikely

Don't know

Comments

Anything else?

Comments