Client / Service User Feedback Form

We value your feedback.
By sharing your experience, you help us monitor and improve the care and support we provide. Your comments contribute directly to our ongoing commitment to high‑quality, person‑centred care.

Section 1: About You

Your Name (Optional)

First

Last

You are the: *

• Service User
• Family Member / Representative

Relationship to service user – if applicable (e.g., client, spouse, son/daughter, friend)

Area of service (select all that apply) *

• Domiciliary care
• Companionship
• 24 hour care / Live in

Client’s name (or initials) *

Date of feedback *

Section 2: Quality of Care

Overall satisfaction with the domiciliary care service *

Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5

Please rate the following areas of care (Strongly disagree to Strongly agree) *

	Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree
Care staff treat the client with dignity and respect	Strongly disagreeCare staff treat the client with dignity and respect Strongly disagree	DisagreeCare staff treat the client with dignity and respect Disagree	Neither agree nor disagreeCare staff treat the client with dignity and respect Neither agree nor disagree	AgreeCare staff treat the client with dignity and respect Agree	Strongly agreeCare staff treat the client with dignity and respect Strongly agree
Care staff communicate clearly and listen	Strongly disagreeCare staff communicate clearly and listen Strongly disagree	DisagreeCare staff communicate clearly and listen Disagree	Neither agree nor disagreeCare staff communicate clearly and listen Neither agree nor disagree	AgreeCare staff communicate clearly and listen Agree	Strongly agreeCare staff communicate clearly and listen Strongly agree
Care staff arrive on time / keep the client informed of delays	Strongly disagreeCare staff arrive on time / keep the client informed of delays Strongly disagree	DisagreeCare staff arrive on time / keep the client informed of delays Disagree	Neither agree nor disagreeCare staff arrive on time / keep the client informed of delays Neither agree nor disagree	AgreeCare staff arrive on time / keep the client informed of delays Agree	Strongly agreeCare staff arrive on time / keep the client informed of delays Strongly agree
Care staff are competent and follow the care plan	Strongly disagreeCare staff are competent and follow the care plan Strongly disagree	DisagreeCare staff are competent and follow the care plan Disagree	Neither agree nor disagreeCare staff are competent and follow the care plan Neither agree nor disagree	AgreeCare staff are competent and follow the care plan Agree	Strongly agreeCare staff are competent and follow the care plan Strongly agree
The service supports privacy and confidentiality	Strongly disagreeThe service supports privacy and confidentiality Strongly disagree	DisagreeThe service supports privacy and confidentiality Disagree	Neither agree nor disagreeThe service supports privacy and confidentiality Neither agree nor disagree	AgreeThe service supports privacy and confidentiality Agree	Strongly agreeThe service supports privacy and confidentiality Strongly agree
The service responds to changing needs	Strongly disagreeThe service responds to changing needs Strongly disagree	DisagreeThe service responds to changing needs Disagree	Neither agree nor disagreeThe service responds to changing needs Neither agree nor disagree	AgreeThe service responds to changing needs Agree	Strongly agreeThe service responds to changing needs Strongly agree
The service is well managed and reliable	Strongly disagreeThe service is well managed and reliable Strongly disagree	DisagreeThe service is well managed and reliable Disagree	Neither agree nor disagreeThe service is well managed and reliable Neither agree nor disagree	AgreeThe service is well managed and reliable Agree	Strongly agreeThe service is well managed and reliable Strongly agree
I would recommend this domiciliary care service	Strongly disagreeI would recommend this domiciliary care service Strongly disagree	DisagreeI would recommend this domiciliary care service Disagree	Neither agree nor disagreeI would recommend this domiciliary care service Neither agree nor disagree	AgreeI would recommend this domiciliary care service Agree	Strongly agreeI would recommend this domiciliary care service Strongly agree

Section 3: Your Experience

Were needs, to

1. What works well about our service?

2. What could we improve?

3. Were your needs, wishes, and preferences respected?

• Yes
• Mostly
• No
• Not sure

4. Were any concerns raised, and if so, were they handled appropriately?

• Yes
• No
• Not applicable

If no, please explain:

Section 4: Recommendation

Would you recommend SV Premier Healthcare Ltd to others? *

• Yes
• No
• Not sure

Section 5: Compliments, Concerns or Complaints

If you wish to raise a formal complaint, this will be managed in line with SV Premier Healthcare Ltd’s Complaints Policy and RQIA guidance.If you wish to raise a formal complaint, this will be managed in line with SV Premier Healthcare Ltd’s Complaints Policy and RQIA guidance.

Does your feedback include a complaint, concern, or safeguarding issue? *

• Complaint / concern
• Safeguarding concern (risk of harm, abuse, neglect)
• No

Please describe the complaint/concern/safeguarding issue (include dates, times, and what happened)

Do you give permission for us to share your feedback with relevant staff to investigate and improve the service? *

• Yes
• No

Do you want us to contact you about your feedback? *

• Yes
• No

If yes, please tell us the best way to contact you and any times to avoid

Signature (optional)

Clear Signature

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