Satisfaction of Service Form

Complete on screen and print. Use to gather feedback from people who use services, their families, and representatives about the quality of care received.

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About You

Your feedback helps us improve the quality of care. All responses are confidential. You do not have to give your name if you prefer not to.

Your Experience of Care

Please rate each statement from 1 (strongly disagree) to 5 (strongly agree).

StatementRating 1 to 5Comments
I feel safe and well cared for
Staff treat me with dignity and respect
Staff listen to me and take my views seriously
I am involved in decisions about my care and support
Staff know my needs and preferences
My privacy is respected at all times
I am supported to be as independent as I want to be
The environment is clean, comfortable, and suitable
I receive care at times that suit my needs
Staff respond promptly when I need help
I know how to make a complaint if I need to
I would recommend this service to others

Specific Areas of Care

Tell us about specific aspects of your care experience.

Overall Satisfaction

Follow-Up

For Office Use Only

Feedback forms support CQC Regulation 17 (Good Governance) and the requirement to gather and act on the views of people who use services. Store securely in line with GDPR and your organisation's data protection policy. If you wish to make a formal complaint, please request a copy of the complaints policy or contact CQC directly.