Complaint Handling Procedure

Updated May 2025

Contents

         Policy Statement

1. Identifying a Complaint

2. Who can make a complaint

3. Timescale for making a complaint

4. Complaints and other procedures

5. Confidentiality of complaints

6. How we handle complaints

7. Monitoring, demonstrating learning and data recording 

First Line Complaints Handler: Victoria Leese-Wood

Second Line Complaints Handler: Christina Param-Phillips

Policy statement

This procedure sets out how we handle complaints and the standards we will follow. This procedure follows the relevant requirements in the Local Authority, Social Services and National Health Service Complaint Regulations 2009 and the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (the 2009 and 2014 Regulations). 

We have processes in place to make sure that the responsible person and relevant staff regularly review insight from the complaints we receive, alongside other forms of feedback on our care and service. They will make sure action is taken on learning arising from complaints so that improvements are made to our service. 

The purpose of this procedures is:

• To lead by example to improve the way we deal with compliments, feedback and complaints.

• To understand the obstacles people face when making a complaint to us and to take action to improve the experience by removing them

• To know and comply with all relevant legal requirements regarding complaints

• To make information available in a format that people find easy to understand

• To make sure all staff know when a complaint is a serious incident, or a safeguarding or legal issue and what must happen

• To make sure that there is a strong commitment to the duty of candour so there is a culture of being open and honest when something goes wrong

• To make sure we listen and learn from complaints and improve services when something goes wrong.

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1. Identifying a complaint

Everyday conversations with our users 

Our staff speak to people who use our service every day. This can often raise issues, requests for a service, questions or worries that our staff can help with immediately. We encourage people to discuss any issues they have with our staff, as we may be able to sort the issue out to their satisfaction quickly and without the need for them to make a complaint. 

When people want to make a complaint 

We recognise that we cannot always resolve issues as they arise and that sometimes people will want to make a complaint. The NHS Complaint Standards define a complaint as: an expression of dissatisfaction, either spoken or written, that requires a response. It can be about: 

• an act, omission or decision we have made 

• the standard of service we have provided. 

Feedback and complaints 

Patients may want to provide feedback instead of making a complaint. People can provide feedback, make a complaint, or do both. Feedback can be an expression of dissatisfaction (as well as positive feedback) but is normally given without wanting to receive a response or make a complaint. 

Patients do not have to use the term ‘complaint’. We will use the language chosen by the patient, service user, or their representative, when they describe the issues they raise (for example, ‘issue’, ‘concern’, ‘complaint’, ‘tell you about’). We will always speak to people to understand the issues they raise and how they would like us to consider them. 

For more information about the types of complaints that are and are not covered under the 2009 Regulations please see The Local Authority Social Services and National Health Service Complaints (England) Regulations 2009. 

If we consider that a complaint (or any part of it) does not fall under this procedure we will explain the reasons for this. We will do this in writing to the person raising the complaint and provide any relevant explanation and signposting information.

Complaints can be made to us: 

• in person 

• by telephone 

• in writing 

• by email

• via social media/web messages/chats

We will consider all accessibility and reasonable adjustment requirements of people who wish to make a complaint in an alternative way. We will record any reasonable adjustments we make. 

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We will acknowledge a complaint within three working days of receiving it. This can be done in writing, electronically or verbally. 

We may receive an anonymous or general complaint that would not meet the criteria for who can complain (see below). In this case we would normally take a closer look into the matter to identify if there is any learning for our organisation unless there is a reason not to. 

1. Who can make a complaint 

As set out in the 2009 Regulations, any person may make a complaint to us if they have received or are receiving care and services from our organisation. A person may also complain to us if they are not in direct receipt of our care or services but are affected, or likely to be affected by, any action, inaction or decision by our organisation. 

If the person affected does not wish to deal with the complaint themselves, they can appoint a representative to raise the complaint on their behalf. There is no restriction on who may represent the person affected. However, they will need to provide us with their consent for 

their representative to raise and discuss the complaint with us and to see their personal information (including any relevant medical records). 

If the person affected has died or is otherwise unable to complain because of physical or mental incapacity, a representative may make the complaint on their behalf. There is no restriction on who may act as representative but there may be restrictions on the type of information we may be able to share with them. We will explain this when we first look at the complaint. 

If at any time we see that a representative is not acting in the best interests of the person affected we will assess whether we should stop our consideration of the complaint. If we do this, we will share our reasons with the representative in writing. 

1. Timescale for making a complaint 

Complaints must be made to us within 12 months of the date the incident being complained about happened or the date the person raising the complaint found out about it, whichever is the later date. 

If a complaint is made to us after that 12 month deadline, we will consider it if: 

• we believe there were good reasons for not making the complaint before the deadline, and 

• it is still possible to properly consider the complaint. 

If we do not see a good reason for the delay or we think it is not possible to properly consider the complaint (or any part of it) we will write to the person making the complaint to explain this.

1. Complaints and other procedures 

We make sure staff who deal with complaints are properly supported and trained to identify when it may not be possible to achieve a relevant outcome through the complaint process on its own. When this happens, the staff member dealing with the complaint will inform the person making the complaint and give them information about any other process that may help address the issues and has the potential to provide the outcomes sought. 

This can happen at any stage in the complaint handling process and may include identifying issues that could or should: 

• trigger a patient safety investigation 

• trigger our safeguarding procedure 

• involve a coroner investigation or inquest 

• trigger a relevant regulatory process, such as fitness to practice investigations or referrals 

• involve a relevant legal issue that requires specialist advice or guidance. 

When another process may be better suited to cover other potential outcomes, our staff will seek advice and provide clear information to the individual raising the complaint. We will make sure the individual understands why this is relevant and the options available. We will also signpost the individual to sources of specialist independent advice. 

This will not prevent us from continuing to investigate the complaint. We will make sure that the person raising the complaint gets a complete and holistic response to all the issues raised. This includes any relevant outcomes where appropriate. The staff member dealing with the complaint will engage with other staff or organisations who can provide advice and support on the best way to do this. 

If an individual is already taking part or chooses to take part in another process but wishes to continue with their complaint as well, this will not affect the investigation and response to the complaint. The only exceptions to this are if: 

• the individual requests or agrees to a delay 

• there is a formal request for a pause in the complaint process from the police, a coroner or a judge. 

In such cases the complaint investigation will be put on hold until those processes conclude.

If we consider that a staff member should be subject to remedial or disciplinary procedures, we will advise the person raising the complaint. We will share as much information with them as we can while complying with data protection legislation. If the person raising the complaint chooses to refer the matter to a health professional regulator themselves, or if they subsequently choose to, it will not affect the way that their complaint is investigated and responded to. We will also signpost to sources of independent advice on raising health professional fitness to practise concerns. If the person dealing with the complaint identifies at any time that anyone involved in the complaint may have experienced, or be at risk of experiencing, harm or abuse then they will discuss the matter with relevant colleagues and initiate our safeguarding procedure. 

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1. Confidentiality of complaints 

We will maintain confidentiality and protect privacy throughout the complaints process in accordance with UK General Protection Data Regulation and Data Protection Act 2018. 

We will only collect and disclose information to those staff who are involved in the consideration of the complaint. Documents relating to a complaint investigation are securely stored and kept separately from medical records or other patient records. They are only accessible to staff involved in the consideration of the complaint. 

Complaint outcomes may be anonymised and shared within our organisation and may be published on our website to promote service improvement.

1. How we handle complaints 

Making sure people know how to complain and where to get support 

• We publish clear information about our complaints process and how people can get advice and support with their complaint.

• We will make sure that everybody who uses (or is impacted by) our services (and those that support them) know how they can make a complaint by having our complaints procedure and/or materials that promote our procedure visible in public areas and on our website. We will provide a range of ways to do this so that people can do this easily in a way that suits them. This includes providing access to our complaints process online. 

• We will make sure that our service users’ ongoing or future care and treatment will not be affected because they have made a complaint. 

What we do when we receive a complaint 

• We want all people, patients, their family members and carers to have a good experience while they use our services. If somebody feels that the service received has not met our standards, we encourage people to talk to staff who are dealing with them and/or to contact us to see if we can resolve the issue promptly. 

• We want to make sure we can resolve complaints quickly as often as possible. To do that, we train our staff to proactively respond to service users and their representatives and support them to deal with any complaints raised at first point of contact. 

• All of our staff who have contact with patients, service users (or those that support them) will handle complaints in a sensitive and empathetic way. Staff will make sure people are listened to, get an answer to the issues quickly wherever possible, and any learning is captured and acted on. 

Our staff will: 

• listen to the service user to make sure they understand the issue(s) 

• ask how they have been affected 

• ask what they would like to happen to put things right 

• carry out these actions themselves if they can (or with the support of others) 

• explain why, if they cannot do this, and explain what is possible 

• capture any learning to share with colleagues and improve services for others. 

Complaints that can be resolved quickly 

Our frontline staff often handle complaints that can be resolved quickly at the time they are raised, or very soon after. We encourage our staff to do this as much as possible so that people get a quick and effective answer to their issues. 

In keeping with the 2009 Regulations, if a complaint is made verbally (in person or over the phone) and resolved by the end of the next working day, it does not need go through the remainder of this procedure. For this to happen, we will confirm with the person making the complaint that they are satisfied we have resolved the issues for them. If we cannot resolve the complaint within that timescale we will handle it in line with the rest of this procedure. 

Acknowledging complaints 

For all other complaints, we will acknowledge them (either verbally or in writing/email) within three working days. We will also discuss with the person making the complaint how we plan to respond to the complaint. 

Focus on early resolution 

When we receive a complaint, we are committed to making sure it is addressed and resolved at the earliest opportunity. Our staff are trained to identify any complaints that may be resolved at the time they are raised or very soon after. If staff consider that the issues cannot be resolved quickly, we will take a closer look into the matter. 

When our staff believe that an early resolution may be possible, they are authorised to take action to address and resolve the issues raised, and put things right for the person raising them. This may mean giving a quick explanation or apology themselves or making sure a colleague who is more informed of the issues does. Our staff will resolve complaints in person or by telephone wherever possible. 

If we think a complaint can be resolved quickly, we aim to do this in a matter of days. We will always discuss with those involved what we will do to resolve the complaint and how long that will take. 

If we can resolve a complaint 

If we can answer or address the complaint early, and the person making the complaint is satisfied that this resolves the issues, our staff have the authority to provide a response on our behalf. This will often be done in person, over the telephone, or in writing (by email or letter) in line with the individual circumstances. 

We will capture a summary of the complaint and how we resolved it and we will share that with the person making a complaint. This will make sure we build up a detailed picture of 

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how each of the services we provide is doing and what people experience when they use these services. We will use this data to help us improve our services for others. 

If we are not able to resolve a complaint 

If we are unable to find an appropriate way to resolve the complaint to the satisfaction of the person making it, we will look at whether we need to take a closer look into the issues. 

A closer look into the issues 

Not every complaint can be resolved quickly and sometimes we will require a longer period of time to carry out a closer look into the issues and carry out an investigation. In these cases, we will make sure the complaint is allocated to an appropriate member of staff (or Complaint Handler), who will take a closer look into the issues raised. This will always involve taking a detailed and fair review of the issues to determine what happened and what should have happened. 

We will make sure staff involved in carrying out a closer look are properly trained to do so. We will also make sure they have: 

• the appropriate level of authority and autonomy to carry out a fair investigation 

• the right resources, support and time in place to carry out the investigation, according to the work involved in each case. 

Where possible, complaints will be looked at by someone who was not directly involved in the matters complained about. If this is not possible, we will explain to the person making the complaint the reasons why it was assigned to that person. This should address any perceived conflict of interest. 

Clarifying the complaint and explaining the process 

The staff member (or Complaint Handler) dealing with the complaint will: 

• engage with the person raising the complaint (preferably in a face- to-face meeting or by telephone) to make sure they fully understand and agree: 

• the key issues to be looked at

• how the person has been affected

• the outcomes they seek 

• signpost the person to support and advice services, including independent advocacy services, at an early stage 

• make sure that any staff members specifically complained about are made aware at the earliest opportunity (see ‘Support for staff’ below) 

• share a realistic timescale for how long the investigation is likely to take with the person raising the complaint, depending on:

• the content and complexity of the complaint 

• the work that is likely to be involved 

• agree how they will keep the person (and any staff specifically complained about) regularly informed and engaged throughout 

• explain how they will carry out the closer look into the complaint, including: 

o what evidence they will seek out and consider
o who they will speak to
o how they will decide if something has gone wrong or not o who will be responsible  for the final response
o how the response will be communicated. 

Carrying out the investigation 

Staff who carry out investigations will give a clear and balanced explanation of what happened and what should have happened. They will reference relevant legislation, standards, policies, procedures and guidance to clearly identify if something has gone wrong. 

They will make sure the investigation clearly addresses all the issues raised. This includes obtaining evidence from the person raising the complaint and from any staff involved or specifically complained about. 

If the complaint raises clinical issues, they will obtain a clinical view from someone who is suitably qualified. Ideally, they should not have been directly involved in providing the care or service that has been complained about. 

We will aim to complete our investigation within the timescale shared with the person making the complaint at the start of the investigation. Should circumstances change we will: 

• notify the person raising the complaint (and any staff involved) immediately 

• explain the reasons for the delay 

• provide a new target timescale for completion. 

Unless we have agreed a longer timescale with the person raising the complaint within the first 6 months, we will inform them if we cannot conclude the investigation and issue a final response within 6 months. Our Responsible Person or a Senior Manager will write to the person to explain the reasons for the delay and the likely timescale for completion. They will then maintain oversight of the case until it is completed and a final written response issued. 

Before sending a final written response to the complaint, the staff member carrying out the investigation will share and discuss (by telephone, in a meeting or in writing) the outcome of our investigation and the actions we intend to take, with all of the key parties to the complaint. This will be decided on a case-by-case basis and will be based on the complexity of the issues and the identified impact. We will always consider any comments they receive before issuing a final written response. 

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Providing a remedy 

Following the investigation, if the person investigating the complaint identifies that something has gone wrong, they will seek to establish what impact the failing has had on the individual concerned. Where possible they will put that right for the individual and any other people who have been similarly affected. If it is not possible to put the matter right, they will decide, in discussion with the individual concerned and relevant staff, what action can be taken to remedy the impact. 

In order to put things right, the following remedies may be appropriate: 

• an acknowledgement, explanation and a meaningful apology for the error 

• reconsideration of a previous decision 

• expediting an action 

• waiving (or recompensing) a fee or penalty 

• issuing a payment or refund 

• changing policies and procedures to prevent the same mistake(s) happening again and to improve our service for others. 

The final written response 

As soon as practical after the investigation is finished, the person carrying out the investigation will co-ordinate a written response. They will send this to the person raising the complaint and any other interested parties. 

The response will include: 

• a reminder of the issues investigated and the outcome sought 

• an explanation of how we investigated the complaint 

• the relevant evidence we considered 

• what the outcome is

• an explanation of whether or not something went wrong that sets out what happened compared to what should have happened, with reference to relevant legislation, standards, policies, procedures and guidance 

• if something went wrong, an explanation of the impact it had 

• an explanation of how that impact will be remedied for the individual 

• a meaningful apology for any failings 

• an explanation of any wider learning we have acted on/will act on to improve our service for other users 

• an explanation of how we will keep the person raising the complaint involved and updated on how we are taking forward all systemic learning or improvements relevant to their complaint 

• confirmation that we have reached the end of our complaint procedure 

• a reminder of where to obtain independent advice or advocacy. 

Support for staff 

• We will make sure all staff who look at complaints have the appropriate: training, resources, support and time to investigate and respond to complaints effectively. This includes how to manage challenging conversations and behaviour. 

• We will make sure staff specifically complained about are made aware of the complaint and we will give them advice on how they can get support from within our organisation, and externally if required. 

• We will make sure staff who are complained about have the opportunity to give their views on the events and respond to emerging information. Our staff will act openly and transparently and with empathy when discussing these issues. 

• The person carrying out the investigation will keep any staff complained about updated. These staff will also have an opportunity to see how their comments are used before the final response is issued. 

1. Monitoring, demonstrating learning and data recording 

We expect all staff to identify what learning can be taken from complaints, regardless of whether mistakes are found or not. 

We take an active interest and involvement in all sources of feedback and complaints, identifying what insight and learning will help improve our services for other users. 

We maintain a record of: 

• each complaint we receive 

• the subject matter 

• the outcome 

• whether we sent our final written response to the person who raised the complaint within the timescale agreed at the beginning of our investigation. 

To measure our overall timescales for completing consideration of all complaints, we seek feedback on our service from: 

• people who have made a complaint and any representatives they may have 

• staff who have been specifically complained about 

• staff who carried out the investigation. 

We monitor all feedback and complaints over time, looking for trends and risks that may need to be addressed. 

In keeping with the 2009 Regulations section 18, as soon as practical after the end of each financial year, we will produce and publish a report on our complaint handling. This will include how complaints have led to a change and improvement in our services, policies or procedures.

If you need to raise a complaint