COMPLAINTS - Policy and Procedure

Position

Named individual

Complaints Lead

Milaine Borthwick-Ezekiel

Supported by Senior Administrator

Olivia Papics

The purpose of this document is to ensure all staff understand that all patients have a right to have their complaint acknowledged and investigated properly. The practice takes complaints seriously and ensures that they are investigated in an unbiased, transparent, non-judgemental and timely manner. The organisation will maintain communication with the complainant (or their representative) throughout, ensuring they know their complaint is being taken seriously.

In accordance with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (Regulation 16), all staff at this organisation must fully understand the complaints process. Supporting information including legislative requirements and additional reading on complaints management can be found at Annex A.

Status

In accordance with the Equality Act 2010, the organisation has considered how provisions within this policy might impact on different groups and individuals. This document and any procedures contained within it are non-contractual, which means they may be modified or withdrawn at any time. They apply to all employees and contractors working for the organisation.

Requirements: Complaints management team

The responsible person for complaints is the Practice Manager (Complaints Lead) who is responsible for maintaining both legislative and regulatory requirements. This role is supported by the Senior Administrator and Medical Secretarial team who are responsible for the day-to-day management of any complaint that may be received. For example, all complaints received via email or in person are responded to by either the Medical Secretaries or the Senior Administrator. Both named persons are detailed within the Complaints Leaflet.

As stated in A Guide to Effective Complaints Resolution (England), the responsible person for Complaints and the Practice Manager can be the same person.

Definition of a complaint versus a concern

A concern is generally something that a service user is worried or nervous about and this can be resolved at the time the concern is raised, whereas a complaint is a statement about something that is wrong or that the service user is dissatisfied with, that requires a response.

Should a service user be concerned and raise this as such, if they believe that it has not been dealt with satisfactorily, then they may make a complaint about that concern. A concern may also be called a criticism.

Formal or informal?

There is no difference between a ‘formal’ and an ‘informal’ complaint; both are an expression of dissatisfaction. Unless the complainant specifically requests that their issue is raised as a complaint, the Practice Manager (Complaints Lead) will consider whether it is logged as either a concern or a complaint should they believe that it can be resolved quickly.

The CQC’s GP mythbuster 103: Complaints management states that a verbal complaint or concern does not have to be logged if resolved within 24 hours.

Complaints information

This practice has prominently displayed notices detailing the complaints process. This information is also on the website. Furthermore, a complaints leaflet is available at Annex B and at reception. Any complainant will be provided with a copy of the complaints leaflet as this details the process, who to address the complaint to, advocacy support information and how to escalate their complaint if they are not content with the findings or outcome.

A desktop aide-memoire for staff on the complaints management process is detailed at Annex C. Should a patient or their representative wish to complete a complaints form, then templates for both are available at Annex D and Annex E.

Duty of candour

The duty of candour is a general duty to be open and transparent with the people using the organisation’s services whether something has gone wrong or not. 

For further detailed information, see the organisation’s Duty of Candour Policy and the CQC’s GP mythbuster 32: Duty of Candour and General Practice (regulation 20)

Public Service Ombudsman (PSO)

The role of the PSO is to make final decisions on complaints that have not been resolved locally by either the organisation or the Integrated Care Board (ICB). The PSO will look at complaints when someone believes there has been an injustice or hardship because an NHS provider has not acted properly or has given a poor service and not put things right.

The PSO can recommend that organisations provide explanations, apologies and financial remedies to service users and that they take action to improve services. Prior to any complaint to the PSO, the complainant should ensure that their complaint has followed the correct process. This can be achieved by them completing the PSO

Complaint Checker

Important notes:

  • The name of the Public Service Ombudsman changed on 1 October 2026 from its former name of Parliamentary and Health Service Ombudsman or PHSO. Further information can be found on its webpage titled A new name for a new chapter

As at the update of this policy, the addresses and contact details for PSO remain the same: Email: phso.enquiries@ombudsman.org.uk Telephone: 0345 015 4033

Complainant options

The complainant, or their representative, can complain about any aspect of care or treatment they have received at this practice following this complaints procedure:

Stage 1

The complaint may be made to either the practice or directly to the local ICB. Specific details of how to complain to the local ICB can be found on its webpage.

While there is no requirement for a complaint to be sent to South West London PALS, a complaint may still be received by them directly. Refer to BMA guidance and support for dealing with complaints made against a GP as this provides further information.

Stage 2

Should the complainant be dissatisfied with the response from either the ICB or the organisation then the next steps are to:

  • If complainants receive no response within six months of their complaint being received, they can go straight to the PSO

For a data concern, should a complainant not be content with the initial response, the complainant may direct their complaint to the Information Commissioner’s Office (ICO). Further reading including the actions required and how to respond to a data complaint can be found in the ICO guidance titled What are data protection complaints?

Responding to a complaint

While each concern or complaint merits its own response, the outcome is always to ensure the best response is provided. The following are the considered communication responses to any complaint:

  • Should a patient be complaining in person, then this should be discussed face-to-face with them
  • If via telephone, then it is acceptable to call back should the issue not be immediately resolved
  • If by email/letter, then any response should be in writing

Immediate response

Should a patient, or the patient’s representative, wish to discuss a complaint or a concern, then this can be deemed to be a less formal approach. These are often simply a point to note or a concern and can be dealt with at this time.

Longer term response

This is normally when a more formal approach has been taken, although the concern or complaint could still be via a face-to-face discussion or telephone as it does not require to have been in writing to be considered.

Timescales

The Senior Administrator or medical secretarial Team will provide patients will provide an initial response to acknowledge any complaint within three working days after the complaint is received. Following any complaint, a full investigation will be undertaken by the Practice Manager (Complaints Lead). While a deadline for a response might be suggested, there is no obligation to do so.

NHS England’s Complaints Policy states that it will attempt to complete any complaint within 40 working days. This timescale only supports complaints that have been made directly to NHS England.

Meeting with the complainant

To support the complaints process, BMA guidance suggests a meeting should be arranged between the complainant and the Complaints Lead. While not a CQC requirement, having a meeting is considered as being best practice due to there often being a more positive outcome.

Data complaints

The ICO requires that each organisation that processes data must have an internal policy on how to support data complaints. In its guidance titled How to deal with data protection complaints, there are specific rules regarding a data complaint.

Importantly, whilst both the ICO and the NHS response timescales differ, the process as detailed in this policy is more stringent and as such should be followed, and the acknowledgement of any data complaint should still be within three working days. The full investigation must, as for any other complaint, commence without any undue delay.

Verbal complaints

If a patient wishes to complain verbally and they are content for the person dealing with them to handle the complaint (and if appropriate to do so), then complaints should be managed at this level. After this conversation, the patient may suggest that no further action is needed, then the matter can be deemed to be closed.

If the matter demands immediate attention, the Complaints Manager should be contacted who may offer the patient an appointment or may see the complainant at this stage. Staff are reminded that when internally escalating any complaint to the Practice Manager (Complaints Lead), a full explanation of the events leading to the complaint is to be given to allow an appropriate response. Verbal complaints that are not resolved within 24 hours should be added to the Complaints Log.

Written complaints

When a written complaint is received, a full investigation and response will always be provided. As part of the investigation process, other clinical governance tools will be used to complete this action such as meetings, audit, significant event and training etc. Should the complaint not be upheld, this organisation will scrutinise the event in the desire to improve patient outcomes.

Lengthy or AI compiled complaints

It has been widely reported that there is an ongoing trend in the number of complaints received by general practice that are being compiled by artificial intelligence (AI). Whilst simple for any complainant to raise, these are often multi-faceted and lengthy resulting in it being much more time-consuming for the organisation to compose its response.

Should a letter be received that is excessively long, repetitive, unclear or raises several matters, then the guidance at Section 12 to NHS England’s Complaints Policy will be considered. In these instances, the practice may engage with the complainant to ensure that their complaint is fully understood and that the specific issues being referred to are clarified and, importantly, what outcome the complainant wishes to seek.

A holding time-period may be given to suggest that the complaint will not be investigated until a summary is given. This must be a reasonable timeframe. Should no further response be received following the request to summarise the complaint, then the normal complaint process is to be continued as detailed at Section 2.19.

Who can make a complaint?

A complaint may be made by the person who is affected by the action. There is no minimum age requirement; if a child is capable of understanding and making a complaint and has shown ‘Gillick competence’, they can do so themselves. However, a complaint made be made by a person acting on behalf of a patient, such as when:

  • It is a child (in the UK, a child is defined as being individual who has not attained the age of 18)

In the case of a child, this organisation must be satisfied that there are reasonable grounds for the complaint being made by a representative of the child and furthermore that the representative is making the complaint in the child’s best interests.

  • The patient has died

In the case of a person who has died, the complainant must be the personal representative of the deceased. This organisation will require to be satisfied that the complainant is the personal representative.

When appropriate, the organisation may request evidence to substantiate the complainant’s claim to have a right to the information.

  • The patient has a physical or mental incapacity

In the case of a person who is unable by reason of physical capacity or lacks capacity within the meaning of the Mental Capacity Act 2005 to make the complaint themselves, the organisation needs to be satisfied that the complaint is being made in the best interests of the person on whose behalf the complaint is made.

  • The patient has given consent to a third party acting on their behalf

In the case of a third party pursuing a complaint on behalf of the person affected, the organisation will request the following information:

    • Name and address of the person making the complaint
    • Name and either date of birth or address of the affected person
    • Contact details of the affected person so that they can be contacted for confirmation that they consent to the third party acting on their behalf

The above information will be documented in the file pertaining to this complaint and confirmation will be issued to both the person making the complaint and the person affected.

  • A person has delegated authority to act on their behalf, for example in the form of a registered Power of Attorney which must cover health affairs
  • It is an MP, acting on behalf of and by instruction from a constituent
  • The ICO in the instance of a data compliant

Should the Practice Manager (Complaints Lead) believe a representative does or did not have sufficient interest in the person’s welfare, or is not acting in their best interests, they will discuss the matter with either medico-legal defence or NHS Resolution to confirm prior to notifying the complainant in writing of any decision.

Complaints advocates

Details of how patients can complain and how to find independent NHS complaints advocates are detailed within the complaints leaflet at Annex B. Additionally, the patient should be advised that the local Healthwatch can help to find an independent complaints advocacy service in the area.

Investigating complaints

This organisation will ensure that complaints are investigated effectively and in accordance with extant legislation and guidance. Furthermore, it will adhere to the following standards when addressing complaints:

The complainant has a single point of contact in the organisation and is placed at the centre of the process. The nature of their complaint and the outcome they are:

  • The complainant has a single point of contact in the organisation and is placed at the centre of the process. The nature of their complaint and the outcome they are seeking are established at the outset
  • The complaint undergoes initial assessment, and any necessary immediate action is taken. A lead investigator is identified
  • Investigations are thorough, when appropriate obtain independent evidence and opinion, and are carried out in accordance with local procedures, national guidance and within legal frameworks
  • The investigator reviews, organises and evaluates the investigative findings
  • The judgement reached by the decision maker is transparent, reasonable and based on the evidence available
  • The complaint documentation is accurate and complete. The investigation is formally recorded with the level of detail appropriate to the nature and seriousness of the complaint
  • Both the complainant and those complained about are responded to adequately
  • The investigation of the complaint is complete, impartial and fair
  • The complainant should receive a full response or decision within six months following the initial complaint being made. If the complaint is still being investigated, then this would be deemed to be a reasonable explanation for a delay

Conflicts of interest

During any response, staff should consider and declare if their ability to apply judgement or act as a clinical reviewer could be impaired or influenced by another interest that they may hold. This could include, but is not limited to, having a close association with or having trained or appraised the person(s) being complained about, and/or being in a financial arrangement with them previously or currently.

In such circumstances, the organisation must seek to appoint another member of staff as the responsible person with appropriate complaint management experience.

Final formal response to a complaint

A final response should only be issued to the complainant once the letter has been agreed by medico-legal defence* if appropriate. Following this, and upon completion of the investigation, a formal written response will be sent to the complainant and will include the information detailed within NHS Resolution’s Responding to complaints guidance.

The full and final response should be completed within six months and signed by the responsible person. If it is likely that it will go beyond this timescale, the Practice Manager (Complaints Lead) will write to the complainant to explain the reasons for the delay and outline when they can expect to receive the response. At the same time, the practice will notify the complainant that they have a right to approach the PSO without waiting for local resolution to be completed.

 

Confidentiality in relation to complaints

Any complaint is investigated with the utmost confidentiality, and all associated documentation will be held separately from the complainant’s medical records.

Complaint confidentiality will be maintained, ensuring only managers and staff who are involved in the investigation know the particulars of the complaint.

Persistent and unreasonable complaints

The management of persistent and unreasonable complaints at this organisation will follow the organisation’s Dealing with Unreasonable, Violent or Abusive Patients Policy. Advice will be sought from the ICB prior to acknowledging persistent, unreasonable or vexatious complaints.

Complaints citing legal action

If a complaint is received that states legal action has been sought, the responsible person will consider contacting the organisation’s defence union for guidance on how best to manage the complaint.

Should any complainant cite legal action that refers to an incident after 1 April 2019, contact NHS Resolution and they will assist under the Clinical Negligence Scheme for General Practice (CNSGP).

While detailed records will always be maintained following any complaint, it is of particular importance when a complaint cites legal action. This is to ensure that all information can be forwarded for medico-legal defence support as required.

Multi-agency complaints

The Local Authority Social Services and NHS Complaints (England) Regulations 2009 state that organisations have a duty to co-operate in multi-agency complaints.

If a complaint is about more than one health or social care organisation, there should be a single co-ordinated response. Complaints Managers from each organisation will have to determine who the lead organisation will be, and they will then be responsible for co-ordinating the complaint, agreeing timescales with the complainant.

If a complaint becomes multi-agency, the organisation should seek the complainant’s consent to ask for a joint response. The final response should include this and, as with all complaints, any complaint can be made to the provider/commissioner but not both.

Complaints involving external staff

If a complaint is received about a member of another organisation’s staff, then this is to be brought to the attention of their Complaints Manager as soon as possible. The Practice Manager(Complaints Lead) will then liaise with the other organisation’s manager.

Complaints involving locum staff

This organisation will ensure all locum staff are aware of the complaints process and that they will be expected to partake in any subsequent investigation, even if they have left the organisation. Locum staff will receive assurance that they will be treated equally, and the process will not differ between locum staff, salaried staff or partners. 

Additional governance requirements

When a complaint is raised, it may prompt other considerations such as a significant event (SE), audit or identify training requirements. For further detailed information, see the Practice  Employment Handbook, the Significant Event Policy and the Quality Improvement and Clinical Audit Policy.

The complainant, their carers and/or family can be involved in the SE process as this helps to demonstrate that the issue is being taken seriously

Any remedial training considerations are supported within the organisation’s Training Handbook and Training Evaluation Form.

Fitness to practise

If the complaint is of a clinical nature, the Senior Partner Dr Joy Nwufoh will be responsible for discussing this with any clinician cited in the complaint. Should the complaint merit a fitness to practise referral, advice is to be sought from the relevant governing body.

Staff rights to escalate to the PSO

It should be noted that any staff who are being complained about can also take the case to the PSO. An example may be that they are not satisfied with a response given on their behalf by the practice or the commissioning body.

Logging and retaining complaints

Following the receipt of any complaint, the record then has to be retained for 10 years. Further guidance can be sought in NHS England’s Records Management Code of Conduct and the organisation’s Record Retention Schedule.

Complaints will be added to the Complaints Log and the evidence required includes:

  1. Initial logging and then updates as required. Consideration is to be given to trends and patterns
  2. Details of all dates of acknowledgement, holding and final response letters and the timely completion of all correspondence relating to the complaint
  1. Compliance with complaints in the categories that are required to be completed for the annual KO14b submission to NHS Digital

This data is submitted to NHS England within the KO14b complaints report annually and then published by NHS Digital. The reporting period is from 1 April until 31 March.