Feedback Survey
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In-Patient 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 patient's experience with us.
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Who is completing this survey?
Patient
Family member / Carer
What is the patient's age?
Select age
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1. The welcome you received was 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
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 at St Luke's
NOTE: Please do not identify yourself or our staff
5. The ward accommodation (e.g. bay areas and single rooms) are comfortable and clean
Always
Most of the time
Sometimes
Hardly ever
Never
Always
Most of the time
Sometimes
Hardly ever
Never
6. I felt able and supported to use your outdoor spaces
Always
Most of the time
Sometimes
Hardly ever
Never
Always
Most of the time
Sometimes
Hardly ever
Never
7. Please use this space to provide any comments about St Luke's environment
NOTE: Please do not identify yourself or our staff
8. I was able to talk to the 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
9. I felt safe in your care
Always
Most of the time
Sometimes
Hardly ever
Never
Always
Most of the time
Sometimes
Hardly ever
Never
10. 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
11. Please use this space to provide any comments about St Luke's staff
NOTE: Please do not identify yourself or our staff
12. a. I particularly liked ……..
b. It would have been better if ………….(no matter how small )
13. If you would like someone to contact you regarding your feedback, please leave your contact details below
14. 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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