Feedback Survey
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Community Service / at Home Survey Form
We will not ask you to identify yourself in the survey. To maintain the privacy of our staff please do not identify them by name. Please rate your satisfaction based on your / the patients experience with us.
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Which service did you access with St Luke's Community?
Specialist Community Nurses at home
Urgent Care service at home (EOLUCS)
Occupational / Physio Therapist
Coordination Hub / Advice Line
Who is completing this survey?
Patient
Family member / Carer
What is the patient's age?
Select age
Prefer not to say
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1. The staff were polite and friendly
Always
Most of the time
Sometimes
Hardly ever
Never
Always
Most of the time
Sometimes
Hardly ever
Never
2. Staff treated me as a whole person rather than focusing only on my condition / Journey
Always
Most of the time
Sometimes
Hardly ever
Never
Always
Most of the time
Sometimes
Hardly ever
Never
3. My individual, spiritual, religious and cultural needs were met
Always
Most of the time
Sometimes
Hardly ever
Never
Always
Most of the time
Sometimes
Hardly ever
Never
4. Please use this space to provide any comments about the care you received from St Luke's
NOTE: Please DO NOT identify yourself or our staff
5. I was able to talk to staff about things that mattered most to me
Always
Most of the time
Sometimes
Hardly ever
Never
Always
Most of the time
Sometimes
Hardly ever
Never
6. I understood the different organisation services providing my care
Always
Most of the time
Sometimes
Hardly ever
Never
Always
Most of the time
Sometimes
Hardly ever
Never
7. I felt safe in your care
Always
Most of the time
Sometimes
Hardly ever
Never
Always
Most of the time
Sometimes
Hardly ever
Never
8. Staff treated me with dignity, respect and privacy
Always
Most of the time
Sometimes
Hardly ever
Never
Always
Most of the time
Sometimes
Hardly ever
Never
9. Please use this space to provide any comments about the care you received from staff
NOTE: Please DO NOT identify yourself or our staff
10. a. I particularly liked ……..
b. It would have been better if ………….(no matter how small)
11. If you would like someone to contact you regarding your feedback, please leave your details below
12. How do you rate your overall care at St Luke's
Highly Satisfied
Satisfied
Neutral
Dissatisfied
Highly Dissatisfied
Highly Satisfied
Satisfied
Neutral
Dissatisfied
Highly Dissatisfied
Confirmation
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