Care and Nursing Home Survey

‘Healthwatch Portsmouth is working with Portsmouth City Council to find out about people’s experiences of care and nursing homes across the city. Please tell us your feedback which we will anonymise’.

1. Please tell us the name of the service *

Date of your experience

2. Are you *(the person) or a carer providing feedback on the experience of care received?

Person
Carer

3. How would you rate your experience?

	Very dissatisfied	Dissatisfied	Neutral	Satisfied	Very satisfied
😠 Very poor	😠 Very poor [IMG_S5] Very dissatisfied	😠 Very poor [IMG_S4] Dissatisfied	😠 Very poor [IMG_S3] Neutral	😠 Very poor [IMG_S2] Satisfied	😠 Very poor [IMG_S1] Very satisfied
🙁 Poor	🙁 Poor [IMG_S5] Very dissatisfied	🙁 Poor [IMG_S4] Dissatisfied	🙁 Poor [IMG_S3] Neutral	🙁 Poor [IMG_S2] Satisfied	🙁 Poor [IMG_S1] Very satisfied
😐 Neutral	😐 Neutral [IMG_S5] Very dissatisfied	😐 Neutral [IMG_S4] Dissatisfied	😐 Neutral [IMG_S3] Neutral	😐 Neutral [IMG_S2] Satisfied	😐 Neutral [IMG_S1] Very satisfied
🙂 Satisfied	🙂 Satisfied [IMG_S5] Very dissatisfied	🙂 Satisfied [IMG_S4] Dissatisfied	🙂 Satisfied [IMG_S3] Neutral	🙂 Satisfied [IMG_S2] Satisfied	🙂 Satisfied [IMG_S1] Very satisfied
😀 Very Satisfied	😀 Very Satisfied [IMG_S5] Very dissatisfied	😀 Very Satisfied [IMG_S4] Dissatisfied	😀 Very Satisfied [IMG_S3] Neutral	😀 Very Satisfied [IMG_S2] Satisfied	😀 Very Satisfied [IMG_S1] Very satisfied

Please provide detail about your experience that you wish to share.

4. Please provide your contact details if you wish to be contacted.

Name:
Email Address:
Telephone Number:

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