The partners at Ammonite Health are always looking for ways to improve the services offered to patients. To do this effectively, the practice needs to know what you think about the services you receive.
We welcome constructive feedback - tell us what we do best, where we don’t meet your expectations plus any ideas and suggestions you may have. Only by listening to you can the practice continue to build and improve upon the service it offers.
1.2 This procedure sets out how we handle complaints and the standards we will follow. This procedure follows the relevant requirements as given 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).
1.3 It should be read in conjunction with the more detailed guidance modules available on the Parliamentary and Health Service Ombudsman website.
2. Accountability, roles, and responsibilities
2.1 Overall responsibility and accountability for the management of complaints lies with the ‘Responsible person’. In our organisation this is Dr Robert Neame, GP Partner, Complaints Lead.
2.2 We have processes in place to ensure that our senior managers regularly review complaints alongside other forms of feedback. They will make sure action is taken on all identified learning arising from complaints so that improvements are made to our service.
2.3 Our senior managers demonstrate this by:
- leading by example to improve the way we deal with compliments, feedback and complaints
- understanding the obstacles people face when making a complaint, and taking action to improve the experience by removing them
- knowing and complying with all relevant legal requirements regarding complaints
- making information available in a format that people find easy to understand
- promoting information about independent complaints advocacy and advice services
- making sure everyone knows when a complaint is a serious incident or safeguarding or a legal issue and what must happen
- making 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
- making sure we listen and learn from complaints and improve services when something goes wrong.
2.4 Our Complaints Co-Ordinator is Carla Roberts, Office Services Manager. They are responsible for managing this procedure and for overseeing the handling and consideration of any complaints we receive.
Roles and responsibilities
2.5 The 2009 Regulations allow us to delegate the relevant functions of the Responsible Person and Complaints Manager to our staff where appropriate. We do this to ensure we can provide an efficient and responsive service. The roles and responsibilities of staff within our organisation and relevant delegated functions when dealing with complaints are set out in the Annex.
3. Identifying a complaint
Everyday conversations with our users
3.1 Our staff speak to people who use our service every day. This can often raise issues that our staff can help with immediately. We encourage people to discuss any issues they have with our front of house 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. Our next point of contact would be our Patient Services Managers, who lead each site.
When people want to make a complaint
3.2 We recognise that we cannot always resolve issues as they arise and that sometimes people want to make a complaint. A complaint is 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
3.3 People may want to provide feedback instead of making a complaint. In line with DHSC’s NHS Complaints Guidance 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.
People do not have to use the term ‘complaint’. We will use the language chosen by the 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.
3.4 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.
3.5 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 signposting information.
3.6 Complaints can be made to us:
- in person
- by phone
- in writing, by email or online.
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.
3.7 We will acknowledge complaints within three working days of receiving it. This can be done in writing or verbally.
3.8 We may receive an anonymous or a general complaint that would not meet the criteria for who can complain. 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 do so.
4. Who can make a complaint
4.1 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 affected or likely to be affected by any action, inaction, or decision by our organisation.
4.2 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 the representative to raise and discuss the complaint with us and to see their personal information.
4.3 If the person affected has died, is a child or is otherwise unable to complain because of physical or mental incapacity, then the complaint may be made on their behalf by a representative. 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.
4.4 If a complaint is brought on behalf of a child we will need to be satisfied that there are reasonable grounds for a representative bringing the complaint rather than the child. If we are not satisfied, we will share our reasons with the representative in writing.
4.5 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. In such circumstances we will advise the representative that they may complain to the Parliamentary and Health Service Ombudsman if they are unhappy with our decision.
5. Timescale for making a complaint
5.1 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.
5.2 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.
5.3 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. We will also explain that, if they are dissatisfied with that decision, they can complain to the Parliamentary and Health Service Ombudsman.
6. Complaints and other procedures
6.1 We make sure our complaints staff are properly trained to identify when it may be not be possible to achieve a relevant outcome through the complaint process on its own. Where this happens, staff will inform the person making the complaint and give them information about any other process that may help to address the issues and has the potential to provide the outcomes sought.
6.2 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
- 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.
6.3 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.
6.4 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, which includes any relevant outcomes where appropriate. Our complaints staff will engage with other staff or organisations who can provide advice and support on the best way to do this.
6.5 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.
6.6 If we consider that a staff member should be subject to remedial or disciplinary procedures or referral to a health professional regulator, we will advise the person raising the complaint. We will share as much information with them as we can. Where the person raising the complaint chooses to refer the matter to a health professional regulator themselves or where 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.
7. Confidentiality of complaints
7.1 We commit to maintaining confidentiality and protecting 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.
7.2 Complaint outcomes may be anonymised and shared within our organisation and may be published on our website to promote service improvement.
8. How we handle complaints
Making sure people know how to complain and where to get support
8.1 We publish clear information about our complaints process and how people can get advice and support with their complaint through their local independent NHS Complaints Advocacy service (seAp Advocacy) and other specialist independent advice services that operate nationally.
8.2 We will make sure that everybody who uses our services (and those that support them) know how they can make a complaint by having our complaints policy 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.
8.3 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
8.4 We want all 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, or to our Patient Advice and Liaison Service if this is applicable, to see if we can resolve the issue promptly.
8.5 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.
8.6 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 you to make sure they understand the issue(s)
- ask how you have been affected
- ask what you 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 can’t do this
- capture any learning if something has gone wrong, to share with colleagues and improve services for others.
Complaints that can be resolved quickly
8.7 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.
8.8 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 that we have resolved the issues for them.
8.9 If we cannot resolve the complaint, we will handle it in line with the rest of this procedure.
8.10 For all other complaints, our staff will acknowledge them (either verbally or in writing/email) within three working days. Staff will also discuss with the person making the complaint how we plan to respond to the complaint.
8.11 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 complaint that may be resolved quickly. If staff consider that the issues cannot be resolved quickly, we will take a closer look into the issues (see section 8.16 onwards).
8.12 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.
8.13 If we think a complaint can be resolved quickly, we aim do this in around 10 working days. However, this can take longer if the additional time means the complaint is more likely to be resolved for the individual. 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
8.14 If we can answer or address the complaint, 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.
8.15 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 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
8.16 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
8.17 Not every complaint can be resolved quickly (due to its complexity or seriousness). In these cases, we will ensure that the complaint is allocated to a 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.
8.18 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 protected time in place to carry out the investigation, according to the complexity of each case.
8.19 Where possible, complaints will be looked at by someone not involved in the events 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
8.20 The Complaint Handler 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 subject to a complaint are made aware at the earliest opportunity (see ‘Support for staff’ below)
- agree a suitable timescale for how long the investigation will take with the person raising the complaint, depending on:
- the complexity of the complaint
- the work that is likely to be involved
- keep the person (and any staff subject to the complaint) regularly informed and engaged throughout
explain how they will carry out the closer look into the complaint, including:
- what evidence they will seek out and consider
- who they will speak to
- who will be responsible for the final response
- how the response will be communicated.
Carrying out the investigation
8.21 Staff who carry out investigations will give a clear, balanced explanation of what happened and what should have happened. They will reference relevant standards, policies, and guidance to clearly identify if something has gone wrong.
8.22 The Complaint Handler 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 in the investigation. If the complaint raises clinical issues the Complaint Handler 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.
8.23 We will complete our investigation within the timescale set out at the start of the investigation. Should circumstances change we will:
- notify the person raising the complaint immediately
- explain the reasons for the delay
- provide a new target timescale for completion.
8.24 If we cannot conclude the investigation and issue a final response within 6 months (unless we have agreed a longer timescale with the person raising the complaint within the first 6 months) the 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.
8.25 Before sending a final written response to the complaint, the Complaint Handler 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 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. The Complaint Handler will always consider any comments they receive before issuing a final written response.
Providing a remedy
8.26 If, following the investigation, the Complaint Handler 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. 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.
8.27 In order to put things right, the following remedies may be appropriate:
- an acknowledgement and a meaningful apology for the error
- reconsideration of a previous decision
- expediting an action
- waiving 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
8.28 As soon as practical after the investigation is finished, the Complaint Handler will co-ordinate a written response, signed by our Responsible Person (or their delegate). 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 something went wrong that sets out what happened compared to what should have happened, with reference to relevant standards, policies, and guidance
- if something did go 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 until all action has been carried out
- confirmation that we have reached the end of our complaint procedure
- details of how to contact the Parliamentary and Health Service Ombudsman if the individual is not satisfied with our final response
- a reminder of where to obtain independent advice or advocacy.
Support for staff
8.29 We will make sure all staff who look at complaints have the appropriate: training, resources, support, and protected time to respond to and investigate complaints effectively.
8.30 We will make sure staff being complained about are made aware and will give them advice on how they can get support from within our organisation, and external representation if required.
8.31 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.
8.32 The Complaint Handler 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.
Referral to the Ombudsman
8.33 In our response on every complaint we will clearly inform the person raising the complaint that if they are not happy with the outcome of our investigation, they can take their complaint to the Parliamentary and Health Service Ombudsman.
9. Complaints involving multiple organisations
9.1 If we receive a complaint that involves other organisation(s) (including cases that cover health and social care issues) we will make sure that we investigate in collaboration with those organisations. Complaint Handlers for each organisation will agree who will be the ‘lead organisation’ responsible for overseeing and coordinating consideration of the complaint.
9.2 The Complaint Handler for the lead organisation will be responsible for making sure the person who raised the complaint is kept involved and updated throughout. They will also make sure that the individual receives a single, joint response.
10.Monitoring, demonstrating learning and data recording
10.1 We expect all staff to identify what learning can be taken from complaints, regardless of whether mistakes are found or not.
10.2 Our Senior Managers 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.
10.3 We maintain a record of:
- each complaint we receive
- the subject matter and 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.
10.4 We measure our overall timescales for completing our consideration of all complaints against these targets:
Timescale for completion (from date of receipt to issue of our final response)
95 % within 3 months
100% within 6 months
Complex/multiple issue or multiple organisations
50% within 3 months
80% within 6 months
10.5 We monitor all feedback and complaints over time, looking for trends and risks that may need to be addressed.
10.6 In keeping with the Regulations section 18, as soon as practical after the end of the financial year, we will produce and publish a report on our complaints handling. This will include how complaints have led to a change and improvement in our services, policies, or procedures.
11. Complaints about a private provider of our NHS services
11.1 This complaint handling procedure applies to all NHS Services we provide.
11.2 Where we outsource the provision of NHS Services to a private provider we will ensure that they follow these same complaint handling procedures.
12. Complaining to the commissioner of our service
12.1 Under section 7 of the Regulations, the person raising the complaint has a choice of complaining to us, as the provider of the service, or to the commissioner of our service NHS England South (Southwest). If a complaint is made to our commissioner, they will determine how to handle the complaint in discussion with the person raising the complaint.
12.2 In some cases it may be agreed between the person raising the complaint and the commissioner that we, as the provider of the service, are best placed to deal with the complaint. If so, they will seek consent from the person raising the complaint. If that consent is given, they will forward the complaint to us and we will treat the complaint as if it had been made to us in the first place.
12.3 In other cases, the commissioner of our services may decide that it is best placed to handle the complaint itself. It will do so following the expectations set out in the Complaint Standards and in a way that is compatible with this procedure. We will co-operate fully in the investigation.
Roles and responsibilities
The roles and responsibilities of staff within our organisation, when dealing with complaints, are set out below. Regulations 4(2) and 4(3) of the 2009 Regulations allow us to delegate any complaints handling function to relevant staff where appropriate.
The Responsible Person has overall responsibility for making sure we:
They are also responsible for:
In cases where an early resolution is possible, we delegate responsibility for responding to the complaint to staff who are coordinating the resolution.
Senior Managers are responsible for:
Senior Managers retain ownership and accountability for the management and reporting of complaints. They are responsible for preparing, quality assuring or signing the final written response. They should therefore be satisfied that the investigation has been carried out in accordance with this procedure and guidance, and that the response addresses all aspects of the complaint.
Senior Managers will review the information gathered from complaints regularly (at least quarterly) and consider how services could be improved or internal policies and procedures updated. They will report on the outcomes of these reviews via the organisation’s governance structure.
Senior Managers are also responsible for ensuring that complaints are central to the overall governance of the organisation. They will make sure that staff are supported both when handling complaints and when they may be the subject of a complaint.
The Complaints Manager is responsible for the overall management of the procedures for handling and considering complaints.
The Complaints Manager, in conjunction with other senior manager(s) acting on his or her behalf (as above), will be involved in a review of the quarterly reports. They will use this review to identify areas of concern, agree remedial action and improve services.
In larger organisations the Complaints Manager may also be responsible for the management and oversight of a complaints team.
The Complaints Manager may also act as a Complaint Handler and Complaint Lead.
The Complaint Handler is the person allocated to oversee and co-ordinate the investigation of the complaint and for the response to a complaint which has not been resolved at Early resolution (stage 1).
They are responsible for making sure that there is a closer look into the issues raised, with the support and input of others. They will make sure that the information and responses they receive from the person making the complaint, and from staff being complained about, clearly addresses all of the issues raised.
The Complaint Handler will be trained in investigative techniques. Where possible they will also be trained in advanced dispute resolution skills. This will enable them to seek a mediated resolution to the concern or complaint at any time during the investigation of the issues.
The Complaint Handler may also act as a Complaint Lead and may also delegate their responsibilities as set out in this procedure to the Complaint Lead.
As appropriate and when required, the Complaint Handler will call for the input of a designated Complaint Lead(s) with knowledge of the care or services complained about. The Complaint Lead will carry out an investigation, as set out in this procedure, and provide the Complaint Handler with:
We expect all staff to proactively respond to service users and their representatives and support them to deal with any complaints raised at the ‘first point of contact’. We will provide training so they can do this.
We expect all of our staff who have contact with patients, service users, or those that support them, to deal with complaints in a sensitive and empathetic way. This includes making sure that people are aware of our local independent advocacy provider and/or national sources of support and advice.
We expect all staff to listen, provide an answer to the issues quickly, and capture and act on any learning identified.