Complaints Policy
Contents
2. Policy Statement / Purpose 4
4. Terminology and Definitions 5
6. Concerns Management Procedure 6
14. Unreasonable Complainant Behaviour 10
15. Confidentiality and Consent 11
16. Complaint Monitoring and Lessons Learned 12
19. Policy Monitoring / Records Management 12
21. Key Legal Principles / Legislation 13
23. Reference Documents and Guidance 14
Controls
Document Control
Target audience:
All staff and clinicians working at the clinic
Document Author:
My Compliance Clinic Ltd
Approved By:
Dr Amy Law
Approval Date:
December 2025
Implementation Date:
December 2025
Reviewed By (First review due December 2026)
Reviewer:
Review Date:
Next Review Date:
Change Log
Last Amended:
Reason for Review:
Changes Made
(if any):
Version History
Version:
Date:
Author:
Reason:
V1
December 2025
My Compliance Clinic Ltd
New Clinic
Equality Impact Statement
This policy has been equality impact assessed and it is assured to be fair and does not present any barriers to participation or disadvantage any protected groups.
Introduction
Dr Amy Law Clinic is committed to providing high-quality healthcare services to all our patients. Our aim is to understand and assess the needs and desires of each of our patients, to create bespoke treatment plans, within a safe and comfortable environment that promotes the privacy and dignity of every patient.
Dr Amy Law Clinic recognises that there will be times when patients, their families or carers, staff and others are dissatisfied with aspects of the care and services provided. Dr Amy Law Clinic is committed to dealing with any issues that may arise as quickly and effectively as possible.
The potential effects on patients, relatives and staff when things go wrong, can be devastating. The duty of candour, implemented under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Regulation 20, outlines the principles that staff should use when communicating with patients, relatives and/or carers following an incident where harm has occurred, or where there is a risk or possibility that the incident could lead to or result in harm. It underpins a culture of honesty, openness, and transparency, and is a duty on everyone at Dr Amy Law Clinic. (For more information on duty of candour, see the separate Duty of Candour Policy).
When Dr Amy Law Clinic makes sure that concerns and complaints are dealt with in a timely manner, the risk of escalation is minimised. Also, the opportunity to find satisfactory resolution to the problem is maximised.
We value your feedback and appreciate you bringing any concerns or complaints to our attention and will ensure that this Complaints Policy is fair and accessible to all.
The Complaints Lead in Dr Amy Law Clinic is the Registered Manager, Dr Amy Law.
Policy Statement / Purpose
All concerns and complaints will be treated seriously and investigated promptly in accordance with the procedures outlined in this policy. Staff will receive training to deal with concerns and complaints. Dr Amy Law Clinic will ensure that everyone including staff and patients has access to this policy in order to raise a concern or make a complaint. Dr Amy Law Clinic is committed to ensuring that no-one is prevented from highlighting concerns or complaints.
Dr Amy Law Clinic will also make sure that all lessons learned from feedback are used to improve the quality of care and services provided. Recommendations from feedback will be shared at 1:1 supervision session, to ensure changes take place business-wide, and implemented where appropriate. Dr Amy Law Clinic recognises its legal responsibility to respond appropriately and effectively to complaints (Health and Social Care Act 2008 (Regulated Activities) Regulations 2014).
Scope
This policy outlines our commitment to handling complaints about services at Dr Amy Law Clinic and ensures that complaints are resolved promptly and fairly.
This policy applies to all staff at Dr Amy Law Clinic and to patients.
Terminology and Definitions
Complainant:
The person who makes a complaint.
Complaint:
An expression of dissatisfaction about an act, omission or decision, either verbal or written, and whether justified or not which requires a response. A complaint is also negative feedback that patients provide about Dr Amy Law Clinic’s products, services or support experience.
‘Just Culture’:
“Just Culture” refers to a system of shared accountability in which organisations are accountable for the systems they have designed and for responding to the behaviours of their employees in a fair and just manner. This means that employees are not apportioned unconstructive guilt or blame for genuine mistakes, but that they always remain accountable for deliberate policy deviations.
Complaints Lead:
A senior member of staff appointed to handle complaints
Patient:
An individual seeking or undergoing treatment, investigation or examination at Dr Amy Law Clinic. The patient may also be known as a person or people.
Staff / Team / Employee:
All individuals involved with examination, treatment or investigation under employment within Dr Amy Law Clinic.
Submitting Feedback
Concerns can be given verbally or in writing to any staff.
Complaints must be submitted in writing (via email, letter or text) to the Complaints Lead. Where the complainant is unable to submit a complaint in writing, they will need to raise the complaint with the Complaints Lead, who will then record the complaint.
Comments on social media websites will not normally be seen as formal complaints unless submitted in writing as outlined above.
Dr Amy Law Clinic will ensure full information is provided, in different styles and languages where this is required, about this Policy in the form of leaflets and posters that are available throughout the business premises, including areas accessible to the public, and on the Dr Amy Law Clinic website.
Compliments
All compliments received in writing are to be documented and circulated amongst relevant staff. This way staff remain aware of the specific topics raised, and the number of compliments received. Staff are not required to record verbal compliments, but this is encouraged when possible.
Concerns Management Procedure
This protocol applies to all complaints related to the services provided by Dr Amy Law Clinic including:
Clinical care
Administrative procedures
Staff conduct
Facilities, and
Equipment.
Concerns can arise out of a lack of understanding or lack of information. Very often matters are resolved by the provision of advice, an apology or by further information. Therefore, many concerns can often be dealt with at the time of their raising. Sometimes staff can take swift action to resolve a concern straightaway or find the most appropriate staff to help. Staff at Dr Amy Law Clinic should feel empowered to deal with concerns promptly and informally without the need for a more in-depth investigation.
On receipt of a concern staff will:
Ensure that the immediate health care needs of the person affected by the concern are being met (where the person affected is still in Dr Amy Law Clinic’s care)
Offer the person raising the concern the opportunity to discuss their concern further
Make sure that the person raising the concern does not wish to make a formal complaint
Undertake any enquiries required to resolve the matter, and
Respond to the person raising the concern with the appropriate information, advice, an apology and /or explain what has been done to resolve the matter.
Staff should aim to ensure that concerns are resolved as soon as possible upon being raised. At this stage, excellent communication is essential to prevent the concern from escalating into a formal complaint. Verbal communication either face-to-face or via telephone should be used primarily at this stage. However, if preferred by the person raising the concern, this can also be in writing, via email or text.
All concerns must be recorded on the incident management system, and should include details of the concern, how it was resolved, and any further actions required.
When concerns cannot be resolved as stated above, forwarded these concerns to the Complaints Lead, who will discuss the issue with the person raising the concern and initiate the formal complaints process (outlined below), if required.
Making a Complaint
Complaints can be made in writing to [email protected], by phone on 0151 329 3940 or in person at the clinic. Please provide as much detail as possible about your complaint including:
Your name and contact details
The date and time of the incident
A full description of what happened, and
The impact of the incident on you.
Acknowledgement
We will acknowledge receipt of your complaint within three working days.
Once a complaint has been received, it should be recorded on the incident management system. The acknowledgement should normally be in writing but if appropriate, can be given verbally.
The person responsible for handling complaints at Dr Amy Law Clinic is Dr Amy Law, Registered Manager.
Investigation
The Complaints Lead will then investigate the complaint’. The complainant must be informed of the name and contact details of the Complaints Lead, or the Nominated Individual at Dr Amy Law Clinic if the complaint is about the Complaints Lead.
The Complaints Lead will ensure that it is resolved without undue delay. Complainants should ordinarily receive a written response within 28 working days from the date of receipt. A timely response and one that is informed by comprehensive local action, will provide the best response to the complainant and the best opportunities for learning within the business.
The complainant should be sent regular updates on the progress of the investigation and likely timescales for receiving the formal response. If agreed timescales cannot be met, it is essential that the Complaints Lead informs the complainant of the reason for the delay and mutually agree new timescales. In conducting the investigation, Complaints Lead may undertake any of the following:
Contact the complainant to identify the outcome that they are seeking
Develop a timeline of what occurred
Identify any shortfalls in the level(s) of care provided
Identify clear and assigned actions that will prevent recurrence and improve care quality
Interview any staff involved in the incident
Provide the complainant the opportunity to give their account and views of what occurred
Review the relevant documentation, checking for evidence regarding issues raised, and
When appropriate, using a root cause analysis, identify the causes/contributory factors/validity of the concerns that have been raised.
The Complaints Lead will then:
Decide whether the complaint should be upheld in full, upheld in part or not upheld, and
Make a record of investigation details, outcomes, and actions to be taken on the incident management system.
It is essential that every stage of the investigation is based on the best available evidence. The formal response from the Complaints Lead should be structured as follows:
Describe how any action as a result of the complaint was or is proposed to be taken
Explain how conclusions about the complaint were reached, whether it was upheld in part, in full or not upheld
Explain an internal appeal if patients are not happy with the findings
Outline how the complaint has been considered, and
Provide details of the regulatory body, if the complainant is still unhappy and wishes for their complaint to undergo external review.
The Complaints Lead will ensure that a full written response is filed alongside the initial complaint on the incident management system.
Complaint Time Limit
A complaint must be made not later than 6 months after the date the matter, which is the subject of the complaint, occurred. Or, if later, a complaint can be made the date on which the matter, which is the subject of the complaint, came to the notice of the complainant.
Complaint Response
We will aim to provide you with a full and final response to your complaint within 20 working days.
Complaint responses must:
Conclude and evidence how a decision was reached
Outline our findings
Any action taken to address the issue
Include a meaningful apology where it is due
Include an explanation of how the complaint was considered
Provide information about who was involved in the investigation
Refer to any documents, guidelines or records that were considered
Tell the complainant what has been done to put things right, where appropriate.
Before sharing a response with the complainant, consideration should be given to any response which may contain sensitive, unexpected, and/or potentially harmful information or which may be delivered at a sensitive time (such as the anniversary of a death).
If, after receiving the formal response, the complainant is not happy with the outcome, they may write to the Complaints Lead to request an internal appeal.
Appeal Process
Upon receipt of an appeal the Complaints Lead will:
Carefully review the details of the initial investigation and outcome
Contact the complainant to understand the reason(s) why they are unhappy with the initial investigation outcome
Appoint an appropriate independent (non-biased) individual to carry out the appeal investigation
Provide the complainant with the name and contact details of the independent investigator.
The Independent Investigator will:
Review the initial investigation and outcome
Contact or meet with the complainant to discuss their continuing concerns
Carry out further investigation, if necessary
Decide whether the initial investigation outcome should be upheld or not, and
Provide the complainant with relevant feedback and inform them of the appeal outcome.
Once completed, the Independent Investigator will ensure that the incident management system is updated with the details of the appeal, including outcomes and actions taken. The Independent Investigator will also report their findings to the Complaints Lead.
Independent Review
At Dr Amy Law Clinic, our service is registered with the UK Healthcare Regulator, the Care Quality Commission (CQC). Service users can also escalate their complaint to the Care Quality Commission who will make note of the complaint and use it as part of their inspection process. They do not have an active role in dealing with complaints, however.
The CQC can be contacted at:
Care Quality Commission,
National Correspondence,
Citygate, Gallowgate,
Newcastle upon Tyne
NE1 4PA,
Tel: 03000616161, Monday to Friday 8.30am to 5.30pm
https://www.cqc.org.uk/contact-us/how-complain/complain-about-service-or-provider
Unreasonable Complainant Behaviour
Many complainants can feel angry and very aggrieved, sometimes with good cause. Although most complainants behave appropriately, a small number may make complaints that are malicious, vexatious or they may make complaints that try to make life difficult for others. This may involve making serial complaints about different matters or persisting with the same complaint when nothing further can be done to assist them.
Distinguishing between people who make several complaints, because they genuinely believe something has gone wrong, and people who are simply trying to make life difficult is important. Complainants will often be frustrated and aggrieved. Therefore, it is important to consider the merits of the complaint rather than their attitude.
The fact that a complainant has made a malicious complaint in the past, for example, does not necessarily mean that the next complaint is automatically malicious. Each complaint must be considered individually, and a decision made as to whether it is malicious or genuine. Complainants will be deemed to be malicious or habitual if they have met two or more of the following criteria:
Being unable to identify specific issues they wish to be investigated despite all reasonable efforts to assist them.
Being unwilling to accept documented evidence of care given as being factual, including denying receipt of an adequate response to their complaint.
Displaying unreasonable demands or expectations and failing to accept that these may be unreasonable despite a clear explanation having been provided as to what constitutes unreasonable.
Focusing on a trivial matter that is out of proportion to its significance (careful judgement should be used in using this criterion as it requires a subjective judgement).
Frequently bringing up further concerns and questions to prolong contact with Dr Amy Law Clinic. (Staff at Dr Amy Law Clinic must not dismiss new issues, if they are significantly different from the original complaint. This new issue may be addressed as a separate complaint.)
Harassing or being abusive on more than one occasion to the person dealing with the complaint. If the behaviour is sufficiently severe this may be sufficient to classify it as vexatious.
Recording conversations or meetings electronically without the prior knowledge or consent of all parties involved.
Persistence with pursuing a complaint despite Dr Amy Law Clinic complaints procedure (outlined above) having been fully exhausted.
Placing unreasonable demands on Dr Amy Law Clinic’s staff. (Discretion is required by Dr Amy Law Clinic’s team to determine how many contacts constitute excessive, along with good judgement based on the specific circumstances of each individual case.), and
Threatening or using physical violence towards staff. This will automatically cause verbal contact with the complainant to cease, with any further communication being solely in written format. Report any violence on the incident management system.
Careful judgement and discretion must be used to identify habitual and vexatious complainants and to decide the actions to take, including:
Declining further contact with the complainant, either in person, by telephone, letter, email, or text whilst ensuring that at least one route of contact remains available.
Inform complainants that in extreme circumstances Dr Amy Law Clinic reserves the right to refer unreasonable or vexatious complainants to the police, if appropriate.
Informing the complainant that they are at risk of being classified as habitual or vexatious. A copy of this Complaints Policy should be sent to them. The complainant should also be advised to consider the criteria outlined when dealing with Dr Amy Law Clinic in the future.
Notify the complainant in writing that the senior management team has responded fully to the points raised and has tried to resolve the complaint, and that there is nothing more to add and that continuing contact on the matter will serve no useful purpose, and that correspondence is at an end, and further communications will not be acknowledged or answered.
These measures should only be implemented following agreement and written notification of the course of action by the Complaints Lead to the complainant. The written notification should also include the reasons why the complaint was classified as habitual or vexatious, and it should be copied to those involved in the complaint.
Habitual or vexatious status can be withdrawn by the Complaints Lead if a complainant demonstrates a more reasonable approach or submits a separate complaint for which the standard complaints procedure would appear to be appropriate.
Confidentiality and Consent
Dr Amy Law Clinic has a legal duty to maintain the confidentiality of personal information. Dr Amy Law Clinic will not access or share information pertaining to complaints outside standard operating procedures at Dr Amy Law Clinic.
All personal data received is recorded and stored on a secure server with limited authorised access. Information is retained in accordance with Dr Amy Law Clinic’s Information Governance Policy.
Complaint Monitoring and Lessons Learned
Dr Amy Law Clinic regards all forms of feedback as an opportunity to improve the levels of care offered to patients. Dr Amy Law Clinic operates within the ‘just culture in’ framework (see definition). The culture within Dr Amy Law Clinic is a supportive one, and any learning identified in feedback will be addressed.
The Complaints Lead is responsible for ensuring that everyone at Dr Amy Law Clinic is kept informed of issues arising from complaints and lessons learned and proposed service improvements with staff.
Support for Staff
The investigation of a complaint involving assault, allegations of malpractice, etc., can be stressful for the staff involved. Sensitivity and support at this time is required. An independent mentor (e.g., a manager from another area from the staff involved), will be identified to provide advice and support to the staff concerned during this difficult time.
Staff may be asked to prepare statements or attend interviews when a complaint investigation takes place. The Complaints Lead will ensure that:
Good information governance practice is maintained and information about specific individuals is treated with respect and confidentiality. Information sharing will only take place if required to conduct the investigation.
Guidance is given pertaining to areas of information required from staff in a timely manner, allowing time for staff to gain support from colleagues and/or unions.
Interviews are conducted in a professional and supportive manner.
Staff know that the review is being conducted as part of a learning and safety culture, as opposed to the apportioning of blame.
Staff are kept up to date on review progress.
Responsibilities
The Complaints Lead, Dr Amy Law, has the ultimate responsibility for guiding and supporting Dr Amy Law Clinic when dealing with complaints, the complaints process and the resulting actions.
The Complaints Lead is also responsible for ensuring that this policy is implemented and adhered to across Dr Amy Law Clinic.
Dr Amy Law speaks on behalf of Dr Amy Law Clinic as the Nominated Individual.
The Nominated Individual is responsible for supervising the management of regulated activity within the clinic. This is in line with Care Quality Commission (CQC) regulations.
The Nominated Individual is also responsible for notifying the CQC, as soon as reasonably possible for
Absence of a registered individual: If a registered individual is absent for 28 days or more, the CQC must be notified in writing
Allegations of abuse: including abuse or alleged abuse involving anyone who uses the service, whether as a victim or abuser
Changes to registered details: including changes to contact details or an individual's name
Changes to the running of a service: including changes for the person who manages the service, or if the service closes
Changes to the statement of purpose: including changes to the statement of purpose that must be notified within 28 days
Death of any person using the service: The CQC must be notified of the death of anyone using the service, and
Serious injury to a person using the service: The CQC must be notified of any serious injuries to anyone using the service.
Additionally, the Nominated Individual is also responsible for notifying the CQC and alerting the local safeguarding authority for children or adults, and the police if a crime has been or may have been committed.
Policy Monitoring / Records Management
This policy will be monitored and reviewed and amended annually by the Complaints Lead.
Records Management
All feedback paperwork will be retained for a minimum of 3 years. Any archived paper files will be stored in a secure manner, in order to preserve confidentiality.
Feedback related correspondence should not, in any circumstances, be retained in the care record of a person; this should only record information that is strictly relevant to their health.
The security and retention of information on the incident management system is the responsibility of the Complaints Lead.
Governance
This policy is owned and maintained by the Complaints Lead, Dr Amy Law.
The document owner, Dr Amy Law, is responsible for monitoring and reviewing the effectiveness of this policy document. This will be achieved at the point this Complaints Policy requires a review e.g. changes in legislation, findings from incidents or document expiry.
An audit of the complaints process is to be reviewed annually.
Key Legal Principles / Legislation
Key legislation and case law:
Care Act 2014
Compensations Act 2006
Data Protection Act 2018
Human Rights Act 1998
Mental Capacity Act 2005, and
The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
Other Related Policies
This policy should be read in conjunction with the following Dr Amy Law Clinic policies:
Duty of Candour Policy
Information Governance
Safeguarding Policy, and
Whistleblowing Policy.
Reference Documents and Guidance
In the event of conflict between the contents of the referenced documents and this document, this document shall take precedence.
Complaints Matter, CQC, December 2014 20141208 complaints matter, report.pdf (cqc.org.uk).
CQC Receiving and acting on Complaints Regulation 16: Receiving and acting on complaints | Care Quality Commission (cqc.org.uk).
Complaints Matter, CQC, December 2014.
Mental Capacity Act Code of Practice.
Report of the Mid Teamordshire NHS Foundation Trust Public Inquiry, Francis, 2013. https://www.gov.uk/government/publications/report-of-the-mid-teamordshire-nhs-foundation-trust-public-inquiry, and
The Local Authority Social Services and National Health Service Complaints (England), Regulations 2009.
Contents
2. Policy Statement / Purpose 4
4. Terminology and Definitions 5
6. Concerns Management Procedure 6
14. Unreasonable Complainant Behaviour 10
15. Confidentiality and Consent 11
16. Complaint Monitoring and Lessons Learned 12
19. Policy Monitoring / Records Management 12
21. Key Legal Principles / Legislation 13
23. Reference Documents and Guidance 14
Controls
Document Control
Target audience:
All staff and clinicians working at the clinic
Document Author:
My Compliance Clinic Ltd
Approved By:
Dr Amy Law
Approval Date:
December 2025
Implementation Date:
December 2025
Reviewed By (First review due December 2026)
Reviewer:
Review Date:
Next Review Date:
Change Log
Last Amended:
Reason for Review:
Changes Made
(if any):
Version History
Version:
Date:
Author:
Reason:
V1
December 2025
My Compliance Clinic Ltd
New Clinic
Equality Impact Statement
This policy has been equality impact assessed and it is assured to be fair and does not present any barriers to participation or disadvantage any protected groups.
Introduction
Dr Amy Law Clinic is committed to providing high-quality healthcare services to all our patients. Our aim is to understand and assess the needs and desires of each of our patients, to create bespoke treatment plans, within a safe and comfortable environment that promotes the privacy and dignity of every patient.
Dr Amy Law Clinic recognises that there will be times when patients, their families or carers, staff and others are dissatisfied with aspects of the care and services provided. Dr Amy Law Clinic is committed to dealing with any issues that may arise as quickly and effectively as possible.
The potential effects on patients, relatives and staff when things go wrong, can be devastating. The duty of candour, implemented under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Regulation 20, outlines the principles that staff should use when communicating with patients, relatives and/or carers following an incident where harm has occurred, or where there is a risk or possibility that the incident could lead to or result in harm. It underpins a culture of honesty, openness, and transparency, and is a duty on everyone at Dr Amy Law Clinic. (For more information on duty of candour, see the separate Duty of Candour Policy).
When Dr Amy Law Clinic makes sure that concerns and complaints are dealt with in a timely manner, the risk of escalation is minimised. Also, the opportunity to find satisfactory resolution to the problem is maximised.
We value your feedback and appreciate you bringing any concerns or complaints to our attention and will ensure that this Complaints Policy is fair and accessible to all.
The Complaints Lead in Dr Amy Law Clinic is the Registered Manager, Dr Amy Law.
Policy Statement / Purpose
All concerns and complaints will be treated seriously and investigated promptly in accordance with the procedures outlined in this policy. Staff will receive training to deal with concerns and complaints. Dr Amy Law Clinic will ensure that everyone including staff and patients has access to this policy in order to raise a concern or make a complaint. Dr Amy Law Clinic is committed to ensuring that no-one is prevented from highlighting concerns or complaints.
Dr Amy Law Clinic will also make sure that all lessons learned from feedback are used to improve the quality of care and services provided. Recommendations from feedback will be shared at 1:1 supervision session, to ensure changes take place business-wide, and implemented where appropriate. Dr Amy Law Clinic recognises its legal responsibility to respond appropriately and effectively to complaints (Health and Social Care Act 2008 (Regulated Activities) Regulations 2014).
Scope
This policy outlines our commitment to handling complaints about services at Dr Amy Law Clinic and ensures that complaints are resolved promptly and fairly.
This policy applies to all staff at Dr Amy Law Clinic and to patients.
Terminology and Definitions
Complainant:
The person who makes a complaint.
Complaint:
An expression of dissatisfaction about an act, omission or decision, either verbal or written, and whether justified or not which requires a response. A complaint is also negative feedback that patients provide about Dr Amy Law Clinic’s products, services or support experience.
‘Just Culture’:
“Just Culture” refers to a system of shared accountability in which organisations are accountable for the systems they have designed and for responding to the behaviours of their employees in a fair and just manner. This means that employees are not apportioned unconstructive guilt or blame for genuine mistakes, but that they always remain accountable for deliberate policy deviations.
Complaints Lead:
A senior member of staff appointed to handle complaints
Patient:
An individual seeking or undergoing treatment, investigation or examination at Dr Amy Law Clinic. The patient may also be known as a person or people.
Staff / Team / Employee:
All individuals involved with examination, treatment or investigation under employment within Dr Amy Law Clinic.
Submitting Feedback
Concerns can be given verbally or in writing to any staff.
Complaints must be submitted in writing (via email, letter or text) to the Complaints Lead. Where the complainant is unable to submit a complaint in writing, they will need to raise the complaint with the Complaints Lead, who will then record the complaint.
Comments on social media websites will not normally be seen as formal complaints unless submitted in writing as outlined above.
Dr Amy Law Clinic will ensure full information is provided, in different styles and languages where this is required, about this Policy in the form of leaflets and posters that are available throughout the business premises, including areas accessible to the public, and on the Dr Amy Law Clinic website.
Compliments
All compliments received in writing are to be documented and circulated amongst relevant staff. This way staff remain aware of the specific topics raised, and the number of compliments received. Staff are not required to record verbal compliments, but this is encouraged when possible.
Concerns Management Procedure
This protocol applies to all complaints related to the services provided by Dr Amy Law Clinic including:
Clinical care
Administrative procedures
Staff conduct
Facilities, and
Equipment.
Concerns can arise out of a lack of understanding or lack of information. Very often matters are resolved by the provision of advice, an apology or by further information. Therefore, many concerns can often be dealt with at the time of their raising. Sometimes staff can take swift action to resolve a concern straightaway or find the most appropriate staff to help. Staff at Dr Amy Law Clinic should feel empowered to deal with concerns promptly and informally without the need for a more in-depth investigation.
On receipt of a concern staff will:
Ensure that the immediate health care needs of the person affected by the concern are being met (where the person affected is still in Dr Amy Law Clinic’s care)
Offer the person raising the concern the opportunity to discuss their concern further
Make sure that the person raising the concern does not wish to make a formal complaint
Undertake any enquiries required to resolve the matter, and
Respond to the person raising the concern with the appropriate information, advice, an apology and /or explain what has been done to resolve the matter.
Staff should aim to ensure that concerns are resolved as soon as possible upon being raised. At this stage, excellent communication is essential to prevent the concern from escalating into a formal complaint. Verbal communication either face-to-face or via telephone should be used primarily at this stage. However, if preferred by the person raising the concern, this can also be in writing, via email or text.
All concerns must be recorded on the incident management system, and should include details of the concern, how it was resolved, and any further actions required.
When concerns cannot be resolved as stated above, forwarded these concerns to the Complaints Lead, who will discuss the issue with the person raising the concern and initiate the formal complaints process (outlined below), if required.
Making a Complaint
Complaints can be made in writing to [email protected], by phone on 0151 329 3940 or in person at the clinic. Please provide as much detail as possible about your complaint including:
Your name and contact details
The date and time of the incident
A full description of what happened, and
The impact of the incident on you.
Acknowledgement
We will acknowledge receipt of your complaint within three working days.
Once a complaint has been received, it should be recorded on the incident management system. The acknowledgement should normally be in writing but if appropriate, can be given verbally.
The person responsible for handling complaints at Dr Amy Law Clinic is Dr Amy Law, Registered Manager.
Investigation
The Complaints Lead will then investigate the complaint’. The complainant must be informed of the name and contact details of the Complaints Lead, or the Nominated Individual at Dr Amy Law Clinic if the complaint is about the Complaints Lead.
The Complaints Lead will ensure that it is resolved without undue delay. Complainants should ordinarily receive a written response within 28 working days from the date of receipt. A timely response and one that is informed by comprehensive local action, will provide the best response to the complainant and the best opportunities for learning within the business.
The complainant should be sent regular updates on the progress of the investigation and likely timescales for receiving the formal response. If agreed timescales cannot be met, it is essential that the Complaints Lead informs the complainant of the reason for the delay and mutually agree new timescales. In conducting the investigation, Complaints Lead may undertake any of the following:
Contact the complainant to identify the outcome that they are seeking
Develop a timeline of what occurred
Identify any shortfalls in the level(s) of care provided
Identify clear and assigned actions that will prevent recurrence and improve care quality
Interview any staff involved in the incident
Provide the complainant the opportunity to give their account and views of what occurred
Review the relevant documentation, checking for evidence regarding issues raised, and
When appropriate, using a root cause analysis, identify the causes/contributory factors/validity of the concerns that have been raised.
The Complaints Lead will then:
Decide whether the complaint should be upheld in full, upheld in part or not upheld, and
Make a record of investigation details, outcomes, and actions to be taken on the incident management system.
It is essential that every stage of the investigation is based on the best available evidence. The formal response from the Complaints Lead should be structured as follows:
Describe how any action as a result of the complaint was or is proposed to be taken
Explain how conclusions about the complaint were reached, whether it was upheld in part, in full or not upheld
Explain an internal appeal if patients are not happy with the findings
Outline how the complaint has been considered, and
Provide details of the regulatory body, if the complainant is still unhappy and wishes for their complaint to undergo external review.
The Complaints Lead will ensure that a full written response is filed alongside the initial complaint on the incident management system.
Complaint Time Limit
A complaint must be made not later than 6 months after the date the matter, which is the subject of the complaint, occurred. Or, if later, a complaint can be made the date on which the matter, which is the subject of the complaint, came to the notice of the complainant.
Complaint Response
We will aim to provide you with a full and final response to your complaint within 20 working days.
Complaint responses must:
Conclude and evidence how a decision was reached
Outline our findings
Any action taken to address the issue
Include a meaningful apology where it is due
Include an explanation of how the complaint was considered
Provide information about who was involved in the investigation
Refer to any documents, guidelines or records that were considered
Tell the complainant what has been done to put things right, where appropriate.
Before sharing a response with the complainant, consideration should be given to any response which may contain sensitive, unexpected, and/or potentially harmful information or which may be delivered at a sensitive time (such as the anniversary of a death).
If, after receiving the formal response, the complainant is not happy with the outcome, they may write to the Complaints Lead to request an internal appeal.
Appeal Process
Upon receipt of an appeal the Complaints Lead will:
Carefully review the details of the initial investigation and outcome
Contact the complainant to understand the reason(s) why they are unhappy with the initial investigation outcome
Appoint an appropriate independent (non-biased) individual to carry out the appeal investigation
Provide the complainant with the name and contact details of the independent investigator.
The Independent Investigator will:
Review the initial investigation and outcome
Contact or meet with the complainant to discuss their continuing concerns
Carry out further investigation, if necessary
Decide whether the initial investigation outcome should be upheld or not, and
Provide the complainant with relevant feedback and inform them of the appeal outcome.
Once completed, the Independent Investigator will ensure that the incident management system is updated with the details of the appeal, including outcomes and actions taken. The Independent Investigator will also report their findings to the Complaints Lead.
Independent Review
At Dr Amy Law Clinic, our service is registered with the UK Healthcare Regulator, the Care Quality Commission (CQC). Service users can also escalate their complaint to the Care Quality Commission who will make note of the complaint and use it as part of their inspection process. They do not have an active role in dealing with complaints, however.
The CQC can be contacted at:
Care Quality Commission,
National Correspondence,
Citygate, Gallowgate,
Newcastle upon Tyne
NE1 4PA,
Tel: 03000616161, Monday to Friday 8.30am to 5.30pm
https://www.cqc.org.uk/contact-us/how-complain/complain-about-service-or-provider
Unreasonable Complainant Behaviour
Many complainants can feel angry and very aggrieved, sometimes with good cause. Although most complainants behave appropriately, a small number may make complaints that are malicious, vexatious or they may make complaints that try to make life difficult for others. This may involve making serial complaints about different matters or persisting with the same complaint when nothing further can be done to assist them.
Distinguishing between people who make several complaints, because they genuinely believe something has gone wrong, and people who are simply trying to make life difficult is important. Complainants will often be frustrated and aggrieved. Therefore, it is important to consider the merits of the complaint rather than their attitude.
The fact that a complainant has made a malicious complaint in the past, for example, does not necessarily mean that the next complaint is automatically malicious. Each complaint must be considered individually, and a decision made as to whether it is malicious or genuine. Complainants will be deemed to be malicious or habitual if they have met two or more of the following criteria:
Being unable to identify specific issues they wish to be investigated despite all reasonable efforts to assist them.
Being unwilling to accept documented evidence of care given as being factual, including denying receipt of an adequate response to their complaint.
Displaying unreasonable demands or expectations and failing to accept that these may be unreasonable despite a clear explanation having been provided as to what constitutes unreasonable.
Focusing on a trivial matter that is out of proportion to its significance (careful judgement should be used in using this criterion as it requires a subjective judgement).
Frequently bringing up further concerns and questions to prolong contact with Dr Amy Law Clinic. (Staff at Dr Amy Law Clinic must not dismiss new issues, if they are significantly different from the original complaint. This new issue may be addressed as a separate complaint.)
Harassing or being abusive on more than one occasion to the person dealing with the complaint. If the behaviour is sufficiently severe this may be sufficient to classify it as vexatious.
Recording conversations or meetings electronically without the prior knowledge or consent of all parties involved.
Persistence with pursuing a complaint despite Dr Amy Law Clinic complaints procedure (outlined above) having been fully exhausted.
Placing unreasonable demands on Dr Amy Law Clinic’s staff. (Discretion is required by Dr Amy Law Clinic’s team to determine how many contacts constitute excessive, along with good judgement based on the specific circumstances of each individual case.), and
Threatening or using physical violence towards staff. This will automatically cause verbal contact with the complainant to cease, with any further communication being solely in written format. Report any violence on the incident management system.
Careful judgement and discretion must be used to identify habitual and vexatious complainants and to decide the actions to take, including:
Declining further contact with the complainant, either in person, by telephone, letter, email, or text whilst ensuring that at least one route of contact remains available.
Inform complainants that in extreme circumstances Dr Amy Law Clinic reserves the right to refer unreasonable or vexatious complainants to the police, if appropriate.
Informing the complainant that they are at risk of being classified as habitual or vexatious. A copy of this Complaints Policy should be sent to them. The complainant should also be advised to consider the criteria outlined when dealing with Dr Amy Law Clinic in the future.
Notify the complainant in writing that the senior management team has responded fully to the points raised and has tried to resolve the complaint, and that there is nothing more to add and that continuing contact on the matter will serve no useful purpose, and that correspondence is at an end, and further communications will not be acknowledged or answered.
These measures should only be implemented following agreement and written notification of the course of action by the Complaints Lead to the complainant. The written notification should also include the reasons why the complaint was classified as habitual or vexatious, and it should be copied to those involved in the complaint.
Habitual or vexatious status can be withdrawn by the Complaints Lead if a complainant demonstrates a more reasonable approach or submits a separate complaint for which the standard complaints procedure would appear to be appropriate.
Confidentiality and Consent
Dr Amy Law Clinic has a legal duty to maintain the confidentiality of personal information. Dr Amy Law Clinic will not access or share information pertaining to complaints outside standard operating procedures at Dr Amy Law Clinic.
All personal data received is recorded and stored on a secure server with limited authorised access. Information is retained in accordance with Dr Amy Law Clinic’s Information Governance Policy.
Complaint Monitoring and Lessons Learned
Dr Amy Law Clinic regards all forms of feedback as an opportunity to improve the levels of care offered to patients. Dr Amy Law Clinic operates within the ‘just culture in’ framework (see definition). The culture within Dr Amy Law Clinic is a supportive one, and any learning identified in feedback will be addressed.
The Complaints Lead is responsible for ensuring that everyone at Dr Amy Law Clinic is kept informed of issues arising from complaints and lessons learned and proposed service improvements with staff.
Support for Staff
The investigation of a complaint involving assault, allegations of malpractice, etc., can be stressful for the staff involved. Sensitivity and support at this time is required. An independent mentor (e.g., a manager from another area from the staff involved), will be identified to provide advice and support to the staff concerned during this difficult time.
Staff may be asked to prepare statements or attend interviews when a complaint investigation takes place. The Complaints Lead will ensure that:
Good information governance practice is maintained and information about specific individuals is treated with respect and confidentiality. Information sharing will only take place if required to conduct the investigation.
Guidance is given pertaining to areas of information required from staff in a timely manner, allowing time for staff to gain support from colleagues and/or unions.
Interviews are conducted in a professional and supportive manner.
Staff know that the review is being conducted as part of a learning and safety culture, as opposed to the apportioning of blame.
Staff are kept up to date on review progress.
Responsibilities
The Complaints Lead, Dr Amy Law, has the ultimate responsibility for guiding and supporting Dr Amy Law Clinic when dealing with complaints, the complaints process and the resulting actions.
The Complaints Lead is also responsible for ensuring that this policy is implemented and adhered to across Dr Amy Law Clinic.
Dr Amy Law speaks on behalf of Dr Amy Law Clinic as the Nominated Individual.
The Nominated Individual is responsible for supervising the management of regulated activity within the clinic. This is in line with Care Quality Commission (CQC) regulations.
The Nominated Individual is also responsible for notifying the CQC, as soon as reasonably possible for
Absence of a registered individual: If a registered individual is absent for 28 days or more, the CQC must be notified in writing
Allegations of abuse: including abuse or alleged abuse involving anyone who uses the service, whether as a victim or abuser
Changes to registered details: including changes to contact details or an individual's name
Changes to the running of a service: including changes for the person who manages the service, or if the service closes
Changes to the statement of purpose: including changes to the statement of purpose that must be notified within 28 days
Death of any person using the service: The CQC must be notified of the death of anyone using the service, and
Serious injury to a person using the service: The CQC must be notified of any serious injuries to anyone using the service.
Additionally, the Nominated Individual is also responsible for notifying the CQC and alerting the local safeguarding authority for children or adults, and the police if a crime has been or may have been committed.
Policy Monitoring / Records Management
This policy will be monitored and reviewed and amended annually by the Complaints Lead.
Records Management
All feedback paperwork will be retained for a minimum of 3 years. Any archived paper files will be stored in a secure manner, in order to preserve confidentiality.
Feedback related correspondence should not, in any circumstances, be retained in the care record of a person; this should only record information that is strictly relevant to their health.
The security and retention of information on the incident management system is the responsibility of the Complaints Lead.
Governance
This policy is owned and maintained by the Complaints Lead, Dr Amy Law.
The document owner, Dr Amy Law, is responsible for monitoring and reviewing the effectiveness of this policy document. This will be achieved at the point this Complaints Policy requires a review e.g. changes in legislation, findings from incidents or document expiry.
An audit of the complaints process is to be reviewed annually.
Key Legal Principles / Legislation
Key legislation and case law:
Care Act 2014
Compensations Act 2006
Data Protection Act 2018
Human Rights Act 1998
Mental Capacity Act 2005, and
The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
Other Related Policies
This policy should be read in conjunction with the following Dr Amy Law Clinic policies:
Duty of Candour Policy
Information Governance
Safeguarding Policy, and
Whistleblowing Policy.
Reference Documents and Guidance
In the event of conflict between the contents of the referenced documents and this document, this document shall take precedence.
Complaints Matter, CQC, December 2014 20141208 complaints matter, report.pdf (cqc.org.uk).
CQC Receiving and acting on Complaints Regulation 16: Receiving and acting on complaints | Care Quality Commission (cqc.org.uk).
Complaints Matter, CQC, December 2014.
Mental Capacity Act Code of Practice.
Report of the Mid Teamordshire NHS Foundation Trust Public Inquiry, Francis, 2013. https://www.gov.uk/government/publications/report-of-the-mid-teamordshire-nhs-foundation-trust-public-inquiry, and
The Local Authority Social Services and National Health Service Complaints (England), Regulations 2009.
Dr Amy Law, specialising in natural looking results.