Complaints and Comments Procedure

A. Confidentiality Notice

This document and the information contained therein is the property of The Sides Medical Practice.

This document contains information that is privileged, confidential or otherwise protected from disclosure. It must not be used by, or its contents reproduced or otherwise copied or disclosed without the prior consent in writing from The Sides Medical Centre.

B. Document Details

Author and Role: Frazer Meadowcroft / Practice Business Manager
Organisation: The Sides Medical Practice
Document Reference: Complaint
Current Version Number: 4
Current Document Approved By: The GP Partners
Date Approved: May 2020

C. Document Revision and Approval History

  • Version 1 created 07/11/2018 by Lorraine Townshend. Version approved by Frazer Meadowcroft.
  • Version 2 created 08/08/2019 by Lorraine Townshend. Version approved by Frazer Meadowcroft.
  • Version 3 created 12/02/2020 by Lorraine Townshend. Version approved by Frazer Meadowcroft.
  • Version 4 created 28/05/2029 by Frazer Meadowcroft. Version approved by Michelle Gilmour.

This Policy and Procedure complies with The Local Authority Social Services and National Health Service Complaints (England) Regulations 2009, introduced on 1st April 2009 across health and social care.


The Practice will take all reasonable steps to ensure that staff are aware of and comply with this procedure.

The Practice has nominated Michelle Gilmour, Administration Manager, and member of the practice management team, as its Responsible Person, ensuring compliance with the policy and procedure, and, in particular, ensuring that action is taken if necessary in the light of the outcome of a complaint. Lorraine Townshend, Practice Operations Manager, or Frazer Meadowcroft, Practice Business Manager, will deputise for Michelle should the need arise.

The Practice will take all reasonable steps to ensure that patients are aware of:

  • The complaints and comments procedure.
  • The roles of the Practice, NHS England, Clinical Commissioning Group (CCG) and the Health Service Ombudsman with regard to patient complaints.
    This includes the alternative facility for the patient to complain directly to the CCG instead of making their complaint to the Practice, as well as their right to escalate their complaint to the Health Service Ombudsman when they are dissatisfied with the initial response.
    N.B. All escalations must be directed to the Health Service Ombudsman (so when a patient is dissatisfied with the Practice response to their complaint, they must escalate their complaint to the Health Service Ombudsman, not the CCG).
  • Their right to assistance with any complaint from the Patient Advice and Liaison Service (PALS); The Independent Complaints Advocacy Service (ICAS); Citizens Advice Bureaux, NHS Direct and the Care Quality Commission.
  • The Practice Complaints Patient Information Leaflet, the Practice Patient Information Booklet and the Practice Website will be the prime information sources for communicating this policy and procedure and will be kept up to date and be made freely available to all patients.
  • All complaints will be treated in the strictest confidence.
  • Patients who make a complaint will not be discriminated against or be subject to any negative effect on their care, treatment or support.
  • If a complaint investigation requires access to the patient’s medical records and involves disclosure of this information to a person outside the practice, the Responsible Person will inform the patient or the person acting on their behalf.
  • The practice will maintain a complete record of all complaints and copies of all related correspondence. These records will be stored in the Management folder of the practice’s N drive and entirely separately from patients’ medical records.


Complaint initiated on Practice Premises

  • In the event that any practice staff member notices that a patient appears to be dissatisfied with an aspect of our service whilst on the practice premises, every effort will be made to identify and resolve the problem immediately. The member of staff should ask the patient to wait in the Interview Room, to the side of the reception area and contact Michelle Gilmour, in the first instance, or in her absence Lorraine Townshend, or if neither are available, Frazer Meadowcroft.
  • If the patient is unable to remain on the premises but wishes to leave their details so as to receive a phone call from the practice, this information should be sent by EMIS task and followed up with an EMIS email.

Receipt and Acknowledgement of Complaints

The Practice may receive the following complaints:

  • A complaint made directly by the patient or former patient, who is receiving or has received treatment at the Practice;
  • A complaint made on behalf of a patient or former patient (with his/her consent), who is receiving or has received treatment at the Practice;
  • Where the patient is a child:
    • By either parent, or in the absence of both parents, the guardian or other adult who has care of the child;
    • By a person duly authorised by a Local Authority into whose care the child has been committed under the provisions of the Children Act 1989;
    • By a person duly authorised by a voluntary organisation, by which the child is being accommodated.
  • Where the patient is incapable of making a complaint, by a representative who has an interest in his/her welfare.
  • All complaints, whether written or verbal will be recorded by Michelle Gilmour in the dedicated complaints record, this will be in the management drive so that it is accessible to all the GP Partners and the management team.
  • All written complaints will be acknowledged in writing within 3 working days of receipt.
  • The practice can only respond to complaints regarding care or services provided by The Sides Medical Centre.

Periods of Time Within Which Complaints can be Made

The periods of time within which a complaint can be made is normally:

  • 12 months from the date on which the event / incident which is the subject of the complaint occurred; or
  • 12 months from the date on which the event / incident which is the subject of the complaint comes to the complainant’s notice.

Initial Action Upon Receipt of a Complaint

All complaints, whether verbal or in writing must be forwarded immediately to Michelle Gilmour, in the first instance. Lorraine Townshend, Practice Operations Manager, or Frazer Meadowcroft, Practice Business Manager, will deputise for Michelle should the need arise.

Where the complaint is made verbally, a written record will be held for reporting and quality improvement purposes.

An acknowledgement of receipt of the complaint must be made as soon as possible and not later than 3 working days after the day on which the Practice receives the complaint.

If it is considered that the matter can be resolved quickly without further investigation, the Practice will do so, providing the complainant agrees and there is no risk to other service users.

In the event the complainant cannot be placated, the practice will itself determine the next steps, including the response period and notify the complainant in writing of that period.

Investigation and Response

Complaints should be resolved within a “relevant period” i.e. 6 months from the day on which the complaint was received.

However, at any time during the “relevant period”, the Responsible Person has the discretion to liaise with the complainant to extend this timeframe to a mutually agreeable date, provided it is still possible to carry out a full and proper investigation of the complaint effectively and fairly.

When an extension to the 6 months timeframe is being considered, it is essential that the Responsible Person takes into account that either party may not be able to remember accurately the essential details of the event / incident and also the feasibility of being able to obtain other essential evidence specific to the time of the event.

The Practice will investigate the complaint speedily and efficiently and as far as reasonably practicable, keep the complainant informed of the progress of the investigation.

After the investigation is completed, the Practice will send the complainant a response within the 6 months “relevant period”, signed by Frazer Meadowcroft (Practice Business Manager) or, the Practice Responsible Person. The response will incorporate:

  • A summary of each element of the complaint
  • Details of policies or guidelines followed
  • A summary of the investigation
  • Details of key issues or facts identified by an investigation
  • Conclusions of the investigation: was there an error, omission or shortfall by your organisation? Did this disadvantage the complainant, and if so, how?
  • What needs to be done to put things right
  • An apology, if one is needed
  • An explanation of what will happens next (e.g. what will be done, who will do it, and when)
  • Confirmation as to whether the Practice is satisfied that any necessary action has been taken or is proposed to be taken;
  • A statement of the complainant’s right to take their complaint to the Parliamentary and Health Service Ombudsman and information on what the person complaining should do if they are still unhappy and wish to escalate the complaint.

If the Practice does not send the complainant a response within the 6 month “relevant period”, it will:

  • Notify the complainant in writing accordingly and explain the reason why; and,
  • Send the complainant in writing a response as soon as reasonably practicable after the 6 month “relevant period”.

In the event that the complaint has been incorrectly sent to the Practice, the Practice will advise the patient of this fact within 3 working days from its initial receipt and ask them if they want it to be forwarded to the correct organisation. If it is sent on, the Practice will advise the patient of the correct organisation’s full contact and address details.

Handling Unreasonable Complaints

In situations where the person making the complaint can become aggressive or
unreasonable, the Practice will instigate the appropriate actions from the list below and will advise the complainant accordingly:

  • Ensure contact is being overseen by an appropriate senior member of staff who will act as the single point of contact and make it clear to the complainant that other members of staff will be unable to help them.
  • Ask that they make contact in only one way, appropriate to their needs (e.g. in writing).
  • Place a time limit on any contact.
  • Restrict the number of calls or meetings during a specified period.
  • Ensure that a witness will be involved in each contact.
  • Refuse to register repeated complaints about the same issue.
  • Do not respond to correspondence regarding a matter that has already been closed, only acknowledge it.
  • Explain that you do not respond to correspondence that is abusive.
  • Make contact through a third person such as a NHS Salford Clinical Commissioning Group.
  • Ask the complainant to agree how they will behave when dealing with your service in the future.
  • Return any irrelevant documentation and remind them that it will not be returned again.
  • When using any of these approaches to manage contact with unreasonable or aggressive people, provide an explanation of what is occurring and why.
  • Maintain a detailed record of each contact during the ongoing relationship.

Annual Review of Complaints

In line with National Guidance, the Practice will supply the following information to NHS England:

  • The number of complaints received;
  • The issues that these complaints raised;
  • Whether complaints have been upheld;
  • The number of cases referred to the Ombudsman.

Reporting a Summary of Complaints to the Care Quality Commission

The Practice will adhere to the Care Quality Commission’s requirement of producing a summary of complaints at a time and in a format set out by the CQC and then send the summary within the timeframe specified.