This template is provided by PSNC and NHS Employers, who have developed it to assist PCTs and pharmacy contractors.

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1 Community Pharmacy Patient Questionnaire Worksheet This template is provided by PSNC and NHS Employers, who have developed it to assist PCTs and pharmacy contractors. Pharmacy contractors using this template will be able to collate and analyse the responses received in the Community Pharmacy Patient Questionnaire, and then use the data to populate a report containing the required information. The Terms of Service requires every pharmacy contractor to undertake a CPPQ and to publish a report. The contents of the report are specified in the Approved Particulars published on the PSNC and NHS Employers websites. Use of the template The first section of this template is where the data is collated. This will provide an analysis of the percentage of the responses rated as satisfied or dissatisfied. There is a highlighted example of how to use the template. Section 2 collates this detail, and allows the different areas of the questionnaire to be ranked in order of how well the pharmacy was rated. Section 3 allows the contractor to reflect on the results, and set out the action, if any, that has been taken or is planned. It is the third section that contains the information that must be published. There is no obligation to use this template, and pharmacy contractors can choose to analyse their data how they think fit, and to publish their report in another format, so long as the contents include the details in the Approved Particulars.

2 Q1 Why did you visit this pharmacy today? To collect a prescription for: Yourself Someone else Both OR for some other reason: (count and list reasons) Total: 56 Total: 5 Total: 2 Total: 6 Grand Total: 69 81% 7% 3% 9% Q2 If you collected a prescription today, were you able to collect it straight away, did you have to wait in the pharmacy or did you come back later to collect it? Straight away Waited in pharmacy Came back later Total: 31 Total:15 Total:6 Grand Total: 52 60% 29% 11% Q3 How satisfied were you with the time it took to provide your prescription and/or any other NHS services you required? Not at all satisfied Not very satisfied Fairly satisfied Very Satisfied Total:0 Total: 0 Total:11 Total:71 Q4. Thinking about any previous visits as well as today's, how would you rate the pharmacy on the following factors? a) The cleanliness of the pharmacy - Total: 1 Total:0 Total: 3 Total: 79 Total:1 Dissatisfied: 1% Satisfied: 98%

3 b) The comfort and convenience of the waiting areas (e.g. seating or standing room) Total:1 Total:0 Total:13 Total:70 Total:0 Dissatisfied: 1% Satisfied: 99% c) Having in stock the medicines/appliances you need - Total: 1 Total:1 Total:12 Total:68 Total:0 Dissatisfied: 2% Satisfied: 98% d) Offering a clear and well organised layout - Total:0 Total:1 Total:13 Total:65 Total:3 Dissatisfied: 1% Satisfied: 95% e) How long you have to wait to be served - Total: Total:2 Total:16 Total:60 Total:0 Grand Total:78 Dissatisfied: 3% Satisfied: 97% f) Having somewhere available where you could speak without being overheard, if you wanted to Total: 1 Total: 5 Total: 16 Total: 46 Total: 13 Grand Total: 81 Dissatisfied: 7% Satisfied: 77%

4 Q5 Again, including any previous visits to this pharmacy, how would you rate the pharmacist and the other staff who work there? a) Being polite and taking the time to listen to what you want - Total: 0 Total: 0 Total:7 77 Total:0 b) Answering any queries you may have - Total: 0 Total: 0 Total: 10 Total: 72 Total: 0 Dissatisfied: 0% Satisfied: 98% c) The service you received from the pharmacist - Total: 0 Total: 0 Total: 5 Total: 78 Total: 1 Dissatisfied: 0% Satisfied: 99% d) The service you received from the other pharmacy staff Total: 0 Total: 0 Total: 6 Total: 78 Total:0 e) Providing an efficient service Total: 0 Total: 0 Total: 6 Total: 78 Total:

5 f) The staff overall Total: 0 Total: 0 Total: 6 Total: 77 Total: 1 Dissatisfied: 0% Satisfied: 99% Q6 Thinking about all the times you have used this pharmacy, how well do you think it provides each of the following services? a) Providing advice on a current health problem or a longer term health condition - Not at all well Not very well Fairly well Very well Never used Total: 0 Total: 0 Total: 7 Total: 31 Total: 43 Grand Total: 81 Dissatisfied: 0% Satisfied: 47% b) Providing general advice on leading a more healthy lifestyle - Not at all well Not very well Fairly well Very well Never used Total: 0 Total: 0 Total: 7 Total: 31 Total: 43 Grand Total: 81 Dissatisfied: 0% Satisfied: 47% c) Disposing of medicines you no longer need - Not at all well Not very well Fairly well Very well Never used Total: 1 Total: 0 Total: 1 Total: 37 Total: 41 Grand Total: 80 Dissatisfied: 0% Satisfied: 47% d) Providing advice on health services or information available elsewhere - Not at all well Not very well Fairly well Very well Never used Total: 0 Total: 0 Total: 5 Total: 29 Total: 45 Grand Total: 79 Dissatisfied: 0% Satisfied: 43%

6 Q7 Have you ever been given advice about any of the following by the pharmacist or pharmacy staff? Stopping smoking - Yes No Total: 4 Total: 73 Grand Total: 77 5% 95% Healthy eating - Yes No Total: 14 Total: 64 Grand Total: 78 18% 82% Physical exercise - Yes No Total: 12 Total: 66 Grand Total: 78 15% 85% Q8 Which of the following best describes how you use this pharmacy? This is the pharmacy that you choose to visit if possible This is one of several pharmacies that you use when you need to Total: 70 Total: 8 Total: 2 Grand Total: 80 88% 10% 2% This pharmacy was just convenient for you today Q9 Finally, taking everything into account - the staff, the shop and the service provided - how would you rate the pharmacy where you received this questionnaire? - Poor Fair Good Very Good Excellent Total: 0 Total: 0 Total: 4 Total: 38 Total: 42

7 Q10 If you have any comments about how the service from this pharmacy could be improved, please write them in here: (list comments) since the current pharmacist was appointed, everything has improved 1005, i.e. organisation, attitude, efficiency, thank you when I called in to collect in the morning, I was informed the pharmacist was in a meeting so the staff member was unable to allow collection. Inconvenient to return, so staff offered home delivery difficult to see other goods they sell one has to ask. But on second thought, maybe that s a good thing with regards to medicine, but what about tissues, cotton wool, mouthwash, toothpaste etc never had a problem with staff or level of service by selling other medicines that are not pharmacy, e.g. vicks, friars balsam, throat lozenges etc excellent in every way we are very fortunate to have you ensuring other person isn t being served beside you, if you are discussing your prescription or something else (more space at the counter) the home delivery service is very good and efficient when required I can t think of any improvement, what with treatment and advice of the staff, quality, a good friendly atmosphere, cleanliness exceptional, who could not ask or expect more when asking a question to the pharmacist (by phone) I ve often been told the pharmacist would phone back but they had forgotten to do so. Bit disappointed the only criticism I have is that my med was changed from weekly to twice weekly (same dose, different brand of patch) without anyone telling me Pharmacist did ask if I d had the medicine before I didn t know I hadn t the service is very good. Staff are very nice and helpful overall, the pharmacy provides an excellent service, especially the delivery staff very friendly and helpful with all my complications I have used this pharmacy to have my drugs dispensed and delivered very pleased with service, thank you all staff are so helpful and nothing is too much trouble difficult to see how it could be improved, its excellent Q11 How old are you? Total: 0 Total: 1 Total: 1 Total: 5 Total: 11 Total: 11 Total: 55 0% 1% 1% 6% 13% 13% 65% Q12 Are you Male Female Total: 30 Total: 51 Grand Total: 81 37% 63%

8 Q 13 Which of the following apply to you: You have, or care for, children under 16 You are a carer for someone with a longstanding illness or infirmity Neither Total: 7 Total: 8 Total: 62 Grand Total: 77 9% 10% 81%

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