Complaints Policy (PART 2)

2.9       Timescale

The time constraint on bringing a complaint is 12 months from the occurrence giving rise to the complaint or 12 months from the time that the complainant becomes aware of the matter about which they wish to complain.

If, however, there are good reasons for complaints not being made within the timescale detailed above, consideration may be afforded to investigating the complaint if it is still feasible to investigate the complaint effectively and fairly. Should any doubt arise, further guidance should be sought from NHS England by the practice/complaints manager

Should any doubt arise, further guidance should be sought from Surrey Heartlands ICB by the Complaints Manager at TWHS.

2.10    Responding to a concern

Should the complaints manager become aware that a patient, or the patient’s representative, wishes to discuss a concern, there is no ‘hard and fast’ rule as to timescales to discuss the matter with them:


Points that should be considered are that:

·         Should the patient be on the premises, then there will need to be a degree of interaction sooner than if it was a telephone call or email

·         Many of the concerns raised are not a true complaint, simply a point to note or a ‘grumble’. Although there is no official guidance on this matter, by discussing the concern with the complainant soonest, there is a potential that this could reduce any escalation to a more formalised complaint

·         All facts need to be ascertained prior to any conversation

·         Should an angry complainant be contacted too soon, this may inflame the situation further if they not receive the outcome that they desire

·         Consider any potential precedence that may be established and will any future concern be expected to always be dealt with immediately should any response be given too soon

·         Time management always needs to be considered

·         Many of the concerns raised are not a true complaint, simply a point to note or a concern and this will still be investigated, and an answer ordinarily given within 10 working days. In doing this and with agreement with the enquirer, this would not need to be logged as a complaint as it can be dealt with as a concern.


Whilst each concern will warrant its own response, generally at TWHS the outcome will always be to ensure that the best response is always provided.

2.11    Responding to a complaint

The complainant has a right to be regularly updated regarding the progress of their complaint. The complaints manager at TWHS will provide an initial response to acknowledge any complaint within seven working days after the complaint is received.

All complaints are to be added to the complaints log.

There are no timescales when considering a complaint, simply that it must be investigated thoroughly and that the complainant should be kept up to date with the progress of their complaint. We do however try to answer all complaints with a final response within 40 days if possible.

At TWHS should any responsenot have been provided within six months, we 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, we will notify the complainant of their right to approach the PHSO without waiting for local resolution to be completed.


The MDU advises in its document titled How to respond to a complaint that a response or decision should be made within six months with regular updates during the investigation. If it extends beyond this time then the complainant must be advised.


CQC GP Mythbuster 103 states the following:


·         The tone of a response needs to be professional, measured and sympathetic


·         Patient confidentiality should be considered and timescales agreed


·         A complaint can be either written or verbal, practices cannot insist that complainants put their complaints into writing.

·         Verbal complains not resolved within 24 hours should be written up by the provider. They should share this with the complainant to agree content.


2.12    Verbal Complaints

If a patient wishes to complain verbally and if the patient is content for the person dealing with the complaint to deal with this matter 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. If this should be the case, then the matter can be deemed to be closed, although the complaints manager should still be informed as this needs to be added to the complaints log.

This local resolution is the quickest method of resolving a complaint and will negate the requirement for the complaint to proceed through the formal complaint process.

An acknowledgement of the verbal complaint will suffice and therefore the complaints manager does not need to subsequently respond in writing, although the verbal complaint must be recorded in the complaints log. This will enable any trends to be identified and improvements to services made if applicable. The complaints manager should record notes of the discussion (for reference only) which may be used when discussing complaints at meetings.

If the matter demands immediate attention, the complaints manager should be contacted who may then offer the patient an appointment or may offer to see the complainant at this stage.

Staff are reminded that when internally escalating any complaint to the complaint’s manager then a full explanation of the events leading to the complaint is to be given to allow any appropriate response.

Note a verbal complaint may simply be a concern. Should this be a less formal concern and, in an agreement with the enquirer then the process in section 2.10 should be followed.


2.13    Written Complaints

Whilst this is not the preferred option due to the timescales involved in compiling a letter of complaint and any subsequent response for both the patient and the complaints manager, an alternative option can be offered for any complaint to be forwarded by letter or email to the complaints manager.


2.14    Who can make a complaint?

A complaint may be made by the person who is affected by the action or it may be made by a person acting on behalf of a patient in any case where that person:

·         Is a child (an 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 best interests of the child.

·         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.

Where appropriate we may request evidence to substantiate the complainant’s claim to have a right to the information.

·         Has 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, this 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.

·         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 we will request the following information:

o  Name and address of the person making the complaint

o   Name and either date of birth or address of the affected person

o   Contact details of the affected person so that we can contact them 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.

·         Has delegated authority to act on their behalf, for example in the form of a registered Power of Attorney which must cover health affairs

·         Is an MP, acting on behalf of and by instruction from a constituent

Should the complaints manager be of the opinion that 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 the defence union or NHS Resolution to confirm prior to notifying the complainant in writing of any decision.

2.15    Complaints Advocates

Details of how patients can complain and also how to find independent NHS complaints advocates are to be detailed within the organisation leaflet.

Additionally, the patient should be advised that the local Healthwatch can help to find an independent NHS complaints advocacy services in the area.

Independent advocacy services include:

1.      POhWER – a charity that helps people to be involved in decisions being made about their care. POhWER’s support centre can be contacted via 0300 456 2370


2.      Advocacy People – gives advocacy support. Call 0330 440 9000 for advice or text 80800 starting message with PEOPLE


3.      Age UK – may have advocates in the area. Visit their website or call 0800 055 6112


4.      Local councils can offer support in helping the complainant to find an advocacy service. Visit

2.16    Investigating complaints

TWHS will ensure that complaints are investigated effectively and in accordance with extant legislation and guidance.

This organisation will adhere to the following standards when addressing complaints:

1.    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.


2.    The complaint undergoes initial assessment and any necessary immediate action is taken. A lead investigator is identified.


3.    Investigations are thorough, where appropriate obtain independent evidence and opinion, and are carried out in accordance with local procedures, national guidance and within legal frameworks.


4.    The investigator reviews, organises and evaluates the investigative findings.


5.    The judgement reached by the decision maker is transparent, reasonable and based on the evidence available.


6.    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.


7.    Both the complainant and those complained about are responded to adequately.


8.    The investigation of the complaint is complete, impartial and fair.


9.    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.


2.17    Final formal response to a complaint

Upon completion of the investigation, a formal written response will be sent to the complainant and will include the following as per NHS Resolution (see extract)


·         Be professional, well thought out and sympathetic

·         Deal fully with all the complainant’s complaints

·         Include a factual chronology of events which sets out and describes every relevant consultation or telephone contact, referring to the clinical notes as required

·         Set out what details are based on memory, contemporaneous notes or normal practice

·         Explain any medical terminology in a way in which the complainant will understand

·         Contain an apology, offer of treatment or other redress if something has gone wrong

·         The response should also highlight what the organisation has done, or intends to do, to remedy the concerns identified to ensure that the problem does not happen again

·         The response should inform the complainant that they may complain to the

Parliamentary and Health Service Ombudsman (PHSO) if they remain dissatisfied

Consideration must be given to the fact that the response is likely to be read by the complainant’s family and possibly legal advisers.

A full explanation and apology may assist in avoiding a claim. However, if a

patient subsequently brings a claim for compensation, the complaint file is likely to be used in those proceedings so it is important that any response to a complaint is clear and well explained and can be supported by evidence.

The full and final response should ordinarily be completed within six months, although should it be likely that this will go beyond this timescale, the complaints manager will contact the complainant to update and give a projected completion timescale.

2.18    Confidentiality in relation to complaints

Any complaint is investigated with the utmost confidence 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.

2.19    Persistent and unreasonable complaints

The management of persistent and unreasonable complaints at TWHS will follow that as detailed by Surrey Heartlands ICB.


2.20    Complaints citing legal action

Should any complaint be received and the content states that legal action has been sought then, prior to any response, consideration should be given to contacting the defence union for guidance.

·         It is strongly suggested that should any organisation receive a complaint that highlights that legal action has been taken then they should be cautious

·         By doing nothing with any complaint of this type, this could affect the outcome of a CQC assessment and/or the relationship with your ICB

·         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). Refer to the NHS Resolution Guidance for general practice document here

2.21    Complaints involving external staff

Should a complaint be received about a member of another organisation’s staff, then this is to be brought to the attention of the complaints manager at the earliest opportunity. The complaints manager will then liaise with the other organisation’s manager.

2.22    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 need to determine which the lead organisation will be and the lead organisation will then be responsible for coordinating 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. 

2.23    Complaints involving Locum staff

TWHS will ensure that all locum staff, be it GPs, nurses or administrative staff, are aware of both the complaints process and that they will be expected to partake in any subsequent investigation, even if they have left the organisation (keeping in mind the 12-month time frame to complain).

Locum staff must receive assurance that they will be treated equally and that there is no difference between locum staff, salaried staff or partners. 

2.24    Significant events

When a complaint is raised it may prompt other considerations, such as a Significant Event. SEs are an excellent way to determine the root cause of an event and TWHS can benefit from the learning outcomes as a result of the SE.

It is advised that the complainant, their carers and/or family are involved in the SE process.  This helps to demonstrate to the complainant that the issue is being taken seriously and investigated by TWHS.  NHS(E) see too many instances where complainants are not involved in the SE process. 

2.25    Fitness to practice

When a complaint is raised, consideration may need to be given to whether the complaint merits a fitness to practise referral. Advice may need to be sought from the relevant governing body such as the GMC, NMC, HCPC etc.

At TWHS the partner mentor will be responsible for firstly discussing the complaint with the clinician involved and then seeking guidance from the relevant governing body where applicable as well as liaising with the complaints lead and manager.


2.26    Staff rights to escalate to the PHSO

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

2.27    Logging and retaining complaints

All organisations will need to log their complaints and retain as per the Records Retention Schedule.

Evidence required includes:

a.    Logging, updating and tracking for trends and considerations

b.    Details of all dates of acknowledgement, holding and final response letters and the timely completion of all correspondence relating to the complaint

c.    Compliance with the complaints in the categories that are required to complete the annual KO14b submission

     This data is submitted by The Practice Manager to NHS E within the KO14b complaints report annually and then published by NHS Digital. Any reporting period cover the period of 1 April to 31 March.



3          As part of the revalidation process, GPs must declare and reflect on any formal complaints about them in tandem with any complaints received outside of formal complaint procedures at their appraisal for revalidation. These complaints may provide useful learning.

The Royal College of General Practitioners (RCGP) has produced appraisal guidance for this purpose.

Nurses may also wish to use information about complaints as part of their NMC revalidation. This feedback can contribute towards submissions about organisation related feedback, and it can also be part of a written reflective account. Likewise, pharmacists and other healthcare professionals may wish to consider using complaints and their management as part of their revalidation process


4          The CQC will inspect the organisation to ensure the organisation is safe, effective, responsive, caring and well-led under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (Regulation 16) and particularly with regard to KLOE R4 concerns and complaints.


When assessing complaints management, the CQC will seek to be satisfied of the following, as directed within the GP Mythbuster 103 – Complaints management:


·         People who use the service know how to make a complaint or raise concerns


·         People feel comfortable, confident and are encouraged to make a complaint and speak up


·         The complaints process is easy to use. People are given help and support where necessary


·         The complaints process involves all parties named or involved in the complaint. They have an opportunity to be involved in the response.


·         The provider uses accessible information or support if they need to raise concerns

·         The complaints are handled effectively, including:

o   Ensuring openness and transparency

o   Confidentiality

o   Regular updates for the complainant

o   A timely response and explanation of the outcome

o   A formal record


·         Systems and processes protect people from discrimination, harassment or disadvantage


·         Complaints are logged and monitored to assess trends and shared with the wider team. They are used to learn and drive continuous improvement. Trends are used to highlight where changes or improvements may be needed.

The complaints manager will advise the complaints procedure to the complainant or t      heir representative. In many cases, a prompt response and, if the complaint is upheld, an explanation and an apology will suffice and will prevent the complaint from escalating (an apology does not constitute an admission of organisational weakness).

CQC will also expect all staff to fully understand the complaints process.



The care and treatment delivered by TWHS is done so with due diligence and in accordance with current guidelines.  However, it is acknowledged that sometimes things can go wrong.  By having an effective complaints process in place, this organisation is able to investigate and resolve complaints in a timely manner, achieving the desired outcome for service users, whilst also identifying lessons learned and ultimately improving service delivery.