For members of the public, and professionals, 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.

  1. Risk Level *
  2. 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.
  3. Medium - Some harm. Occurred once or more. Could be wider impact. May recur. May be more than one person exposed to risk
  4. Low - No harm. Not a criminal act. No wider impact. Occurred once and unlikely to re-occur. One person exposed to risk
  5. Your details
  6. Client Address
  7. Client Details
    1. Name
    2. Date of Birth
      1. For example, 20 03 1976
        1. DD
        2. MM
        3. YYYY
      2. *Please enter a valid Date of Birth.

    3. If known