Relative Visitor Assessment Form
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1
2Dignity
in Care
Relative/Visitor Assessment Form – Care Home
(Friend – GP – Nurse – Other Health Professional)
Name of care home
Date
D
D
M M
Y
Y
1. Have a zero tolerance of all forms of abuse
Have you ever needed to make a complaint?
Yes
No
If yes, were you kept informed of progress during the investigation?
Yes
No
2. Support people with the same respect you would want for yourself or another member
of your family.
Call your relative/friend by their chosen name?
Yes
No
Ask your relative/friend what they want to wear on a daily basis?
Yes
No
Ensure that your relative/friend is not left in pain, feeling isolated or
Yes
No
Do care staff:
alone?
Use personal mobile phones during work time?
Yes
No
Support your relative/friend to do tasks rather than do them for
Yes
No
them?
Are care staff polite and courteous to your relative/friend even when they are
Yes
No
under pressure?
3. Treat each person as an individual by offering a personalised service.
Support your relative/friend whilst respecting their beliefs and values? Yes
No
Regularly ask your relative/friend if they need anything?
Yes
No
Do care staff:
Assist your relative/friend with cleaning their teeth/glasses/changing
Yes
No
batteries in their hearing aid?
Know your relative/friends likes and dislikes?
Yes
No
4. Enable people to maintain the maximum possible level of independence, choice and control.
Deliver care and support at your relative/friend’s pace?
Yes
No
Do care staff:
Make assumptions about what your relative/friend wants or what is
good for them?
5. Listen and support people to express their needs and wants.
Do care staff listen to your relative/friend with an open mind, enabling them to express
Yes
No
their needs and preferences in a way that makes them feel valued?
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Parent category: Medical