1. Introduction

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

1.2 Co-developed with organisations from across the health sector and advocacy and advice services, the NHS Complaint Standards provide a single vision of good practice for complaint handling. This complaint handling procedure describes how we put the core expectations given in the Standards into practice for any complaints we receive from our patients or their representatives.

1.3 The Complaint Standards and this procedure also support delivery of our values:

Trust: By prioritising trust, we can create a culture of mutual respect, safety, and lifelong collaboration, where clients and staff can thrive and reach their full potential.

Discovery: By embracing the value of guided discovery, we can cultivate a mindset of curiosity and creativity, leading to new insights, growth and opportunities for our clients and our staff.

Accessibility: Our accessible services will create a more inclusive and equitable society removing barriers and valuing all individuals.

Belonging: By valuing and fostering a sense of belonging, we can celebrate the unique needs of our clients and create a more inclusive, supportive, and cohesive community that benefits everyone involved.

2. Accountability, roles and responsibilities

2.1 Overall responsibility and accountability for management of complaints lies with the ‘Responsible person’ (as defined by the 2009 Regulations). In our organisation this is Mr. Jesse James, our Managing Director.

2.2 We have processes to make sure the responsible person and relevant senior manager(s) regularly review insight from the complaints we receive, alongside other forms of feedback on our care and services. They will make sure action is taken on learning from complaints so that improvements are made to our service.

2.3 They 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 to us, 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 the Centre of Excellence for Dispute Resolution.

making sure everyone knows when a complaint is a serious incident, or a safeguarding or legal issue and what must happen

making sure 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 Complaints management, roles and responsibilities

2.4.1 Our Complaints Manager (as defined by the 2009 Regulation) is Mrs Ashleigh Thompson, Clinic Manager. She is responsible for managing this procedure and for overseeing the handling and consideration of any complaints we receive.

2.4.2 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.

3. Identifying a complaint

3.1 If you want to raise a concern or make a complaint

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

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

an act, omission or decision we have made

the standard of service we have provided.

3.2 Feedback and complaints

3.2.1 People may want to provide feedback instead of making a complaint. In line with the NHS Complaints Guidance, you 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.

3.2.2 You do not have to use the term ‘complaint’. We will use the language chosen by you or your representative, when you describe the issues you 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.

3.2.3 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.

3.2.4 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 advise you in writing and provide any relevant explanation and signposting information.

3.2.5 Complaints can be made to us:

in person

by telephone: 0161 560 5901

in writing: FAO The Clinic Manager, Unit 12 Quays Reach Business Park, Carolina Way, Salford, Greater Manchester, M50 2ZY

by email: [email protected]

3.2.6 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.

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

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

4. Who can make a complaint

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

4.2 If you do not wish to deal with the complaint yourself, you can appoint a representative to raise the complaint on your behalf. There is no restriction on who may represent you. However, you will need to provide us with your consent for your representative to raise and discuss the complaint with us and to see your personal information (including any relevant medical records).

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

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 escalate the matter to Emily Harrison, Director of Governance and Patient Safety for review if they are unhappy with the 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 think it is not possible to properly consider the complaint (or any part of it), we will write to you to explain this. If you are dissatisfied with the decision, you can request your complaint be escalated to the Director of Governance and Patient Safety for review.

6. Complaints and other procedures

6.1 Staff who deal with complaints are properly supported and trained to identify when it may not be possible to achieve a relevant outcome through the complaint process on its own.

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

trigger our safeguarding procedure

involve a coroner investigation or inquest

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

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

6.3 When another process may be better suited to cover other potential outcomes, our staff will seek advice and provide you with clear information. We will ensure you understand why this is relevant and the options available. We will also signpost you to sources of specialist independent advice.

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

6.5 If you are already taking part or choose to take part in another process but wish to continue with your complaint as well, this will not affect the investigation and response to the complaint. The only exceptions to this are if:

you request or agree 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 you of this. We will share as much information with you as we can while complying with data protection legislation. If you choose to refer the matter to a health professional regulator yourself, or if you subsequently choose to, it will not affect the way that your complaint is investigated and responded to. We will also signpost to sources of independent advice on raising health professional fitness to practise concerns.

6.7 If the person dealing with the complaint identifies at any time that anyone involved in the complaint may have experienced, or be at risk of experiencing, harm or abuse then they will discuss the matter with relevant colleagues and initiate our safeguarding procedure.

7. Confidentiality of complaints

7.1 We will maintain confidentiality and protect privacy throughout the complaints process in accordance with UK General Protection Data Regulation and Data Protection Act 2018. We will only collect and disclose information to those staff who are involved in the consideration of the complaint. Documents relating to a complaint investigation are securely stored and kept separately from medical records or other patient records. They are only accessible to staff involved in the consideration of the complaint.

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

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

8.1.1 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 on 0808 802 3000

VoiceAbility – an independent complaints advocacy service in Manchester can also help: https://www.voiceability.org/support-and-help/services-by-location/manchester

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

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

8.2 What we do when we receive a complaint

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

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

8.2.3 Our staff will:

listen to you (or your representative) 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 cannot do this, and explain what is possible

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

8.3 Complaints that can be resolved quickly

8.3.1 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.

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

8.4 Acknowledging complaints

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

8.5 Focus on early resolution

8.5.1 When we receive a complaint, we are committed to making sure it is addressed and resolved at the earliest opportunity. If we consider that the issues cannot be resolved quickly, we will take a closer look into the matter.

8.5.2 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 wherever possible or by telephone.

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

8.5.4 We will capture a summary of the complaint and how we resolved it, and we will share that with you. This helps us to 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.

8.6 If we are not able to resolve a complaint

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

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

8.6.3 We will make sure staff involved in carrying out an investigation are properly trained to do so. We will also make sure they have:

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

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

8.6.4 Where possible, complaints will be looked at by someone who was not directly involved in the matters complained about. If this is not possible, we will explain the reasons why it was assigned to that person.

8.7 Clarifying the complaint and explaining the process

8.7.1 The complaint handler dealing with the complaint will:

speak with you (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 you have been affected

the outcomes you would like

signpost you to support and advice services, including independent advocacy services, at an early stage

make sure that any staff members specifically complained about are made aware at the earliest opportunity

share with you a realistic timescale for how long the investigation is likely to take, depending on:

the content and complexity of the complaint

the work that is likely to be involved

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

explain how they will carry out the investigation, including:

what evidence they will seek out and consider

who they will speak to

how they will decide if something has gone wrong or not

who will be responsible for the final response

how the response will be communicated.

8.8 Carrying out the investigation

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

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

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

For example, a view will be sought from a clinical director, or a clinician from another team, who was not involved in the care complained about.

8.8.4 We will aim to complete our investigation within the timescale agreed with you at the start of the investigation. Should circumstances change we will:

notify you (and any staff involved) immediately

explain the reasons for the delay

provide a new target timescale for completion.

8.8.5 Our Responsible Person or Clinic Manager will write to you 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. We will issue a final response within six months of the date the complaint was first raised.

8.9 Providing a remedy

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

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

an acknowledgement, explanation and a meaningful apology for the error

reconsideration of a previous decision

expediting an action

waiving (or recompensing) a fee or penalty

issuing a payment or refund

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

8.10 The final written response

8.10.1 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 you and any other interested parties. The response will include:

a reminder of the issues investigated and the outcome sought

an explanation of how we investigated the complaint

the relevant evidence we considered

what the outcome is

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

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

an explanation of how that impact will be remedied

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 you involved and updated on how we are taking forward all systemic learning or improvements relevant to your complaint

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.

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

8.11 If you are dissatisfied with our response

8.11.1 If you are not satisfied with our response at this stage, you may wish to escalate your complaint to Emily Harrison, our Director of Governance and Patient Safety for review.

8.11.2 If this is the case, you can write directly to Emily Harrison at the Aspen Clinic address. Letters should include a summary of why you are unsatisfied with our initial response.

8.11.3 A response will be provided to you within 20 working days.

8.11.4 If following review by the Director of Governance and Patient Safety, you still feel the response is unsatisfactory and all options of resolution have been exhausted, you may wish to escalate your complaint for external mediation. (See section 8.12 below)

8.12 Referral to the Centre of Excellence for Dispute Resolution (CEDR)

8.12.1 If you would like to request external mediation, please advise either the Clinic Manager or the Director of Governance and Patient Safety and we will provide you with more information about the process and what to expect. If you wish to go ahead, we can get the process started.

8.12.2 Alternatively, you can make a complaint directly to the CEDR. Details of how to do this are provided below.

Website: www.cedr.com

Telephone: 020 7536 6000

Email: [email protected]

8.12.3 The CEDR specialises in mediation and alternative dispute resolution. They are an independent, non-profit organisation and registered charity.

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. The people handling the complaint for each organisation will agree who will be the ‘lead organisation’ responsible for overseeing and coordinating consideration of the complaint.

9.2 The person investigating the complaint for the lead organisation will be responsible for making sure you are kept involved and updated throughout. They will also make sure that you receive a single, joint response.

10. Monitoring, 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

the outcome

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

10.4 To measure our overall timescales for completing consideration of all complaints and our delivery of the NHS Complaint Standards, we seek feedback on our service from:

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

staff who have been specifically complained about

staff who carried out the investigation.

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

Useful Links

Healthwatch Manchester: Help making a complaint | Healthwatch Manchester

CEDR: www.cedr.com

The Local Authority Social Services and National Health Services Complaints (England) Regulations 2009: The Local Authority Social Services and National Health Service Complaints (England) Regulations 2009 (legislation.gov.uk)

NHS Complaints Standards: https://www.ombudsman.org.uk/organisations-we-investigate/complaint-standards/nhs-complaint-standards