Report a Concern About Care Quality

For professionals and members of the public to report any concern, issue, omission or error in care by an adult social care provider.

Please note this form will be shared with the Provider so they can address any issues raised.

Our Privacy Notice explains more about how we use the data you give us in this form.

Risk Level*
1. High
2. Medium
3. Low
High Risk - Please complete The Safeguarding Alert form on the website.
Serious harm or criminal act. Has occurred regularly or many times. Wider impact. Probably to re-occur.
Medium - Some harm. Occurred once or more. Could be wider impact. May recur. May be more than one person exposed to risk
Low - No harm. Not a criminal act. No wider impact. Occurred once and unlikely to re-occur. One person exposed to risk
Your details
1. Title
2. Other Title
3. First Name
4. Last Name
5. Email*
6. Telephone / Mobile
Client Address
1. 1. Postcode*
    
    Address
2. 1. Number
  2. Name
  3. Street
  4. Area
  5. Town/City
  6. County
  7. Postcode
Client Details
1. Name
  1. Title
  2. Other Title
  3. First Name
  4. Last Name
2. Date of Birth
  1. For example, 20 03 1976
  2. Label
    DD
    
    Label
    MM
    
    Label
    YYYY
    
    date
  3. *Please enter a valid Date of Birth.
3. Date of Birth
4. If known
  1. RAISE ID
  2. NHS Number
1. * Please correct any of the validation issues highlighted above