Complaints Policy

1. Introduction

1.1 Policy statement

The purpose of this document is to ensure all staff at Jaya Life understand that all patients have a right to have their complaint acknowledged and investigated properly. This organisation 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 the complaint is being taken seriously.

In accordance with Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (Regulation 16), all staff at Jaya Life must fully understand the complaints process. Additionally, the BMA has released guidance titled: Responding to concerns: a guide for doctors who manage staff.

1.2 Status

Jaya Life aims to design and implement policies and procedures that meet the diverse needs of our service and workforce, ensuring that none are placed at a disadvantage over others, in accordance with the Equality Act 2010. Consideration has been given to the impact this policy might have regarding the individual protected characteristics of those to whom it applies.

This document and any procedures contained within it are non-contractual and may be modified or withdrawn at any time. For the avoidance of doubt, it does not form part of your contract of employment. Furthermore, this document applies to all employees of the organisation and other individuals performing functions in relation to the organisation such as agency workers, locums and contractors.

This document applies to all patients and employees of the organisation, partners and other individuals performing functions in relation to the organisation, such as volunteers, agency workers, locums and contractors. It also applies to all patients.

1.3 Training and support

Jaya Life will provide guidance and support to help those to whom it applies to understand their rights and responsibilities under this policy. Additional support will be provided to managers and supervisors to enable them to deal more effectively with matters arising from this policy.

2. Overview

2.1 Legislation and guidance

As a CQC Registered Healthcare service, we are required to have a complaints procedure. This process must detail how to complain about any aspect of care, treatment or service. This document has been informed by the following processes:

2.2 Complaints management team

The responsible person, or complaints lead, is the CQC Registered Manager, Jaya Life and they are responsible for ensuring compliance with the complaints regulations making sure action is taken because of the complaint. They will also oversee the management of the complaints procedures and must be readily identifiable to patients / service users.

As recognised in A Guide to Effective Complaints Resolution (England), the responsible person and complaints manager can be the same person.

2.3 Definition of a complaint versus a concern

Best practice guidance defines that a concern is something that a patient 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 patient / service user is dissatisfied with which requires a response.

It should be noted that a patient could be concerned about something and raise this matter, however, should it not be dealt with satisfactorily, then they may make a complaint about that concern.

For the purpose of good governance, we will record all concerns and complaints and ascertain whether or not the complaints process applies on an individual basis.

2.4 Formal or informal?

There is no difference between a “formal” and an “informal” complaint. Both are expressions of dissatisfaction.

It is the responsibility of the complaints manager to consider whether the complaint is informal and therefore early resolution of an issue may be possible. If the complaints manager believes an issue can be resolved quickly then they will aim to do this in around 10 working days and, with the agreement of the enquirer, we will categorise this as a concern and not a complaint.

However, if the enquirer is clear that they wish to formalise the complaint, then the organisation will follow this complaints policy in full.

2.5 Complaints information

Complaints information is available on our website and provided electronically on request. We will provide complaints information in accessible formats in line with the Accessible Information Standard, and will make reasonable adjustments to support people with sensory loss, learning disability, autism, or other communication needs.

Complaints can be made by writing to:

Name: Dr Lucy Mather (Registered Manager / Complaints Lead)
Email: info@jayalife.com
Postal address: Jaya Life, 66 Delaunays Road, Crumpsall, Manchester, Greater Manchester, M8 4RF

2.6 Duty of candour

The duty of candour is a general duty to be open and transparent with people receiving care at this organisation.

Both the statutory duty of candour and professional duty of candour have similar aims, to make sure that those providing care are open and transparent with the people using their services whether or not something has gone wrong.

Further information can be sought from the Duty of Candour Policy and as detailed within CQC GP Mythbuster 32: Duty of Candour and General Practice (regulation 20)

2.7 Independent Sector Complaints Adjudication Scheme (ISCAS)

We will consider membership of an independent adjudication scheme such as ISCAS. Where we are a member, patients will be advised of how to access this service.

2.8 Complainant options

The complainant, or their representative, can complain about any aspect of care or treatment they have received at this organisation to this organisation via the complaints manager.

See below image that further explains the route of any complaint:

Stage 1

The complainant may make a complaint to the organisation. This is classed as a local resolution.

Stage 2

If dissatisfied with the initial Stage 1 response, the complainant may then escalate this to the ISCAS.

The complainant should be provided with a copy of the complaints leaflet at Annex D detailing the complaints process and they should be advised of the two-stage process.

2.9 Timescale

Complaints should ideally be raised within 12 months of the incident (or the date the complainant became aware of it). However, we will consider complaints outside this timeframe where there are good reasons for delay.

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, then this is deemed to be less formal and should be responded to as detailed below.

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
All facts need to be ascertained prior to any conversation
Should the person be angry, contacting them too soon may inflame the situation further if they did not receive the outcome that they desired
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.

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 Jaya Life will provide an initial response to acknowledge any complaint within 3 working days after the complaint is received.

All complaints are to be added to recorded using existing governance systems.

A complaint must be investigated thoroughly, and the complainant should be kept up to date with the progress of their complaint.

At Jaya Life, should any response not 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 that they have a right to approach the ISCAS 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 in writing’;
Verbal complaints (not resolved in 24 hours) should be written up by the provider. They should share this with the complainant to agree content.

2.12 Meeting with the complainant

To support the complaints process, BMA guidance suggests that a meeting should be arranged between the complainant and the complaints lead.

Whilst not a CQC requirement, having a meeting is considered as being best practice due to there often being a more positive outcome.

2.13 Verbal complaints

If a patient wishes to complain verbally and should the patient be 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. Should this be the case, then the matter can be deemed to be closed. Having this acknowledgement of the verbal complaint will be deemed as being sufficient and therefore the complaints manager does not need to subsequently respond in writing. However, the verbal complaint must be recorded in the governance log to 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 agreement with the enquirer, then the relevant process should be followed.

2.14 Written complaints

Although this is not the preferred option due to the timescales involved from both parties, it is the complainant’s choice, and they may either write or verbalise their concerns. Therefore, they are not to be persuaded or dissuaded from putting it in writing and should be processed just like any other complaint.

2.15 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, the organisation 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, 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.
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.

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 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 the MDU to confirm prior to notifying the complainant in writing of any decision.

2.16 Investigating complaints

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

Furthermore, we 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 seeking are established at the outset.
The complaint undergoes initial assessment, and any necessary immediate action is taken. A lead investigator is identified - in the case of Jaya Life this will be the CQC Registered Manager Dr Lucy Mather.
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.
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.

2.17 Conflicts of interest

Where a conflict of interest arises (e.g., a complaint about one Director), the other Director will not act as sole investigator/decision-maker. We will seek independent advice/support from our medical defence organisation and/or an external suitably qualified clinician/complaints advisor to ensure the process is impartial.

2.17a Complaints about the Registered Manager / Nominated Individual

Where a complaint relates to the Registered Manager and/or Nominated Individual, the complaint will not be handled solely by the person complained about. The other Director will acknowledge the complaint and arrange investigation support to ensure fairness and impartiality. We will seek independent advice and/or investigation support from our medical defence organisation and/or an external suitably qualified clinician/complaints advisor. The complainant will be informed of the arrangements and kept updated in line with this policy.

2.18 Final formal response to a complaint

A final response should only be issued to the complainant once the letter has been agreed by the Registered Manager.

Following this, and upon completion of the investigation, a formal written response will be sent to the complainant and will include the following:

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 contact, referring to the clinical notes as required.
Set out what details are based on memory, notes or normal practice.
Explain any medical terminology in a way that is understandable.
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 ISCAS should 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, signed by the responsible person, 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.

A template example of the final response letter can be found at Annex F.

2.19 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.

2.20 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.
It is strongly suggested that organisations make a record of everything involving the complaint.

2.21 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 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.

2.22 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 their complaints manager at the earliest opportunity. The complaints manager will then liaise with the other organisation’s manager.

2.23 Significant events

When a complaint is raised, it may prompt other considerations, such as a significant event (SE). SEs are an excellent way to determine the root cause of an event and Jaya Life can benefit from the learning outcomes because 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 Jaya Life. Further information on the significant event process can be sought from the Significant Event and Incident Policy.

2.24 Fitness to practise

When a complaint is raised, consideration may need to be given to whether the complaint merits a fitness to practise referral and advice may need to be sought from the relevant governing body.

At this organisation, the Registered Manager Dr Lucy Mather will be responsible for firstly discussing the complaint with the clinician involved prior to seeking any guidance from the relevant governing body if applicable.

2.25 Staff rights to escalate to the ISCAS

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

2.26 Logging and retaining complaints

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

Evidence required includes:

Logging, updating and tracking for trends and considerations.
Details of all dates of acknowledgement, holding and final response letters and the timely completion of all correspondence relating to the complaint.

3. Use of complaints as part of the revalidation process

3.1 Outlined processes

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.

4. CQC regulatory complaint assessment during inspection

4.1 Overview

The CQC will inspect the organisation to ensure it is safe, effective, responsive, caring and well-led under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (Regulation 16) and expect all staff to fully understand the complaints process.

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

People feel comfortable, confident and are encouraged to make a complaint and speak up.
The process is easy to use so people understand how to make a complaint or raise concerns.
The practice offers help and support where necessary, using accessible information.
The complaints process involves all parties named or involved in the complaint and they have an opportunity to be involved in the response.
The complaints are handled effectively, including:
- Ensuring openness and transparency
- Confidentiality
- Regular updates for the complainant
- A timely response and explanation of the outcome
- A formal record.
Systems and processes protect people from discrimination, harassment or disadvantage.
Complaints are monitored to assess trends that are used for learning, and shared with the wider team or externally as appropriate to make changes and drive continuous improvement.

The complaints manager will advise the complaints procedure to the complainant or their 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).

5. Summary

The care and treatment delivered by Jaya Life are 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 can 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.