2. Ward Information Sheet For completion at the beginning of each ward visit. The purpose of this sheet is to collect information that gives context to the feedback obtained. This sheet can be adapted to suit the information you want to collect. Early shift:Late shift: S/NHousekeepersS/NHousekeepers HCAsOtherHCAsOther Therapists Total number of beds on ward?Number of closed or empty beds? How many patients? Time of day and what was going on during visit? General ward observations: Other comments: (e.g. “1pm – 5pm – visit captured the end of lunch, afternoon visiting and afternoon tea round”) (e.g. whether ward seemed very busy, calm, chaotic, well ordered, cluttered, tidy, Doctor round in progress etc) Page 1 Hospital: Ward: Date: Author:

3. Other patient comments not captured on the questionnaire: Ward feedback: (State who you fed back info to e.g. verbal feedback to staff on duty and anyone you emailed this information to. Ask how the feedback is shared / displayed / discussed with staff. Ask if staff are aware / seen feedback report) Page 2

4. Page 3 Questions & Prompts 1050NULLComments 1 How clean is the ward? (including toilets) Very cleanFairly clean Not very clean Don’t know / no opinion (whatever reason) Comments 2 As far as you know, do staff wash or clean their hands between touching patients? (Is patient confident staff clean their hands?) Yes always No / Sometimes No Don’t know / can’t remember Comments 3 Do you like the food? Yes, it’s very good It’s OK / not bad Not much / not very good Not applicable (e.g. NBM) Comments 4 Do you get enough to eat and drink? Yes alwaysYes usually Not usually / never Not applicable (e.g. NBM) Comments 5 Do you get help from staff to eat your meals? (If independent still ask re cutting up food, opening packets, spreading jam etc) Yes always Sometimes / to some extent No I don’t need any help Comments 6 Are you ever bothered by noise at night? (If yes, noise from patients or noise from staff? Time he lights go out? Bothered by TVs?) NoSometimes Yes frequently I haven’t stayed overnight Comments 7 Have you ever shared a sleeping area with a member of the opposite sex? No Not applicable Yes Not applicable Comments Patient Experience Questions and Response Data Collection Tool Hospital / ward:Data:Male / Female / Relative

5. Page 4 Questions & Prompts 1050NULLComments 8 How quickly is your bell usually answered? (Has patient ever been worried or anxious about getting to the toilet on time?) Usually answered promptly It varies Usually takes too long I haven’t used my call bell Comments 9 Do you think the staff do all they can to help control your pain? Yes definitely To some extent No I don’t have any pain Comments 10 Have staff talked to you about your discharge from hospital? (Discharge leaflet given on admission?) Yes To some extent Not at all Not applicable (e.g. EoLC) Comments 11 Do you feel involved in decisions about your care and treatment? Yes always / completely Sometimes / to some extent No I don’t want to be (e.g. prefers to leave it to family) Comments 12 Do you have enough privacy?(Whether for talking or for physical care) Yes always Sometimes / to some extent No Not applicable Comments 13 Do you feel you have been treated with respect and dignity while you’ve been on this ward? Yes always / by everyone Yes mostly / by most of the staff No Not applicable Comments

6. Patient Experience Feedback Report Early shift:Late shift: S/NHousekeepersS/NHousekeepers HCAsOtherHCAsOther Therapists How many beds?Empty beds? How many patients?How many patients interviewed? Time of day visited and what was going on during the visit: General ward observations: Other comments: Other patient comments not captured on the questionnaire: Ward feedback: Page 5 Hospital: Ward: Date: Author:

7. Patient Experience Feedback Report (Additional comments) QuestionsComments 1 How clean is the ward? (including toilets) Comments 2 As far as you know, do staff wash or clean their hands between touching patients? (Is patient confident staff clean their hands?) Comments 3 Do you like the food?Comments 4 Do you get enough to eat and drink? Comments 5 Do you get help from staff to eat your meals? (If independent still ask re cutting up food, opening packets, spreading jam etc) Comments 6 Are you ever bothered by noise at night? (If yes, noise from patients or noise from staff? Time he lights go out? Bothered by TVs?) Comments 7 Have you ever shared a sleeping area with a member of the opposite sex? Comments Page 6

8. QuestionsComments 8 How quickly is your bell usually answered? (Has patient ever been worried or anxious about getting to the toilet on time?) Comments 9 Do you think the staff do all they can to help control your pain? Comments 10 Have staff talked to you about your discharge from hospital? (Discharge leaflet given on admission?) Comments 11 Do you feel involved in decisions about your care and treatment? Comments 12 Do you have enough privacy?(Whether for talking or for physical care) Comments 13 Do you feel you have been treated with respect and dignity while you’ve been on this ward? Comments Page 7