Complaint Policy

At Chase Lodge Hospital Ltd (CLH), our Complaint Policy serves as a valuable resource for feedback, providing early warnings of failures in service delivery. By handling complaints effectively, we create opportunities to enhance our service and reputation. All patients attending CLH will have access to our comprehensive complaints procedure.

The objectives of this Complaint Policy reflect the Principles of Good Complaint Handling (ISCAS, 2017):

• Getting it right: We quickly acknowledge and rectify cases of maladministration or poor service that lead to injustice or hardship. Our approach considers all relevant factors when determining a remedy, ensuring fairness for the complainant and, where appropriate, for others who may have suffered.
  • Being customer-focused: We apologise and provide clear explanations, manage expectations, and deal with individuals professionally and sensitively. Our remedies take individual circumstances into account, and we apply the Duty of Candour throughout the complaints process.
  • Being open and accountable: We are clear about how decisions are made and maintain proper accountability and delegation, keeping precise records.
  • Acting fairly and proportionately: We ensure our remedies are fair and proportionate, free from bias and discrimination.
  • Putting things right: We explore all forms of remedy, including apologies, explanations, remedial actions, and financial offers.
  • Seeking continuous improvement: We use lessons learned to prevent the recurrence of poor service, recording outcomes to enhance our services. This is part of our audit timetable and annual complaints review.

This Complaint Policy outlines the different stages of the complaints procedure and includes arrangements for identifying, receiving, recording, handling, and responding to any complaint.

This policy should be read alongside our Duty of Candour Policy.

Please note: Distinguishing between a complaint and an incident can be subjective. For this reason, we capture all incidents (regardless of harm level) and verbal complaints in the same form. A senior manager determines whether an event is categorised as an incident, significant event, or complaint, and which policy should be followed.

Roles and Responsibilities

Hospital Manager

The Hospital Manager is accountable for:

• Ensuring complaints are managed according to this Complaint Policy.
  • Ensuring staff receive appropriate training to address verbal complaints and concerns effectively.
  • Contacting complainants who have submitted written complaints to confirm the issues to be investigated and clarify the complainant’s expected outcomes.
  • Liaising with third-party providers as necessary.
  • Reviewing all complaints correspondence and relevant investigations, ensuring that draft responses address all issues before signing off the final version on behalf of CLH.
  • Reporting individual complaints and trends at monthly clinical governance meetings.
  • Collaborating with the Independent Doctors Federation if a complaint escalates to Stage 2 and with ISCAS for Stage 3 complaints.
  • Maintaining the updated Complaints Log and conducting an annual review of complaints.
  • Informing patients that they can speak to the CQC regarding any positive or negative matters related to their treatment at Chase Lodge Hospital.

Investigators

Investigators are responsible for ensuring:

• They work promptly, completing their investigations in time for the PA to draft the complaint response before submission to the Registered Manager.
  • They investigate all areas of the assigned complaint and submit a written response to the Executive PA.

All Staff, Including Locums and Associates

All staff are responsible for:

• Attending induction training to understand their roles in complaints management.
  • Making every effort to resolve issues quickly and satisfactorily to prevent formal complaints.
  • Understanding the complaints process and advising patients or carers on how to proceed.
  • Maintaining accurate, contemporaneous, and legible notes.
  • Collaborating with relevant staff, such as line managers or senior doctors, when patients or relatives express dissatisfaction.

N.B. ISCAS (Nov 2018) states, “It is not acceptable for Consultants with practising privileges, or other persons engaged by the independent healthcare provider, to write separate responses to the complainant. Independent healthcare providers permitting multiple communication points and responses to the complainant will be deemed non-compliant with the ISCAS Code.” A single response to a complaint that incorporates feedback from all relevant clinicians, including registered message consultants with practising privileges, must be submitted.

Definitions

A complaint is defined as a concern or grievance raised by a user, family member, or carer of a user of independent healthcare facilities. It expresses dissatisfaction requiring a formal response. Complaints may be raised by the client or their authorised representative, relative, friend, carer, or insurer. To comply with GDPR, we must seek consent if a third party raises a complaint. Complaints can be made orally or in writing.

An authorised representative is an individual or client advocate who complains on behalf of a client. CLH ensures that the individual is a legitimate representative and that the complaint is made with the client’s knowledge and written consent. A comment is defined as a helpful observation—positive, negative, or simply a compliment made by a patient. A concern is defined as a minor criticism or expression of dissatisfaction that may require a response but may not necessitate a formal route.

Introduction

At times, patients’ expectations may not be met, resulting in a verbal or written complaint. Understanding issues from the complainant’s perspective offers CLH valuable insights that we welcome and use to improve patients’ experiences.

All complaints should be raised directly with CLH initially (Stage 1). Complaints should be made as soon as possible, ideally within six months of the event, or as soon as the matter comes to the complainant’s attention. Time limits can sometimes be extended if it is still possible to investigate the complaint. Extensions may apply in situations where it would have been difficult to complain earlier, such as during periods of grief or trauma.

If the complainant is unhappy with our response, they can escalate their complaint to Stage 2 by bringing it to the CEO of Chase Lodge Hospital. If they remain dissatisfied, they can seek independent external adjudication (Stage 3).

Complaints Made on Behalf of the Patient and Consent

If a patient is hesitant to make a complaint themselves, they may ask a relative or friend to do so on their behalf. In such cases, CLH will seek the patient’s written permission. This waiver allows the patient to share their clinical information with the person acting on their behalf.

When someone lacks the capacity to consent, CLH can only accept consent from an authorised person with Legal Power of Attorney (specifically, a Court of Protection appointed Deputy authorised to make health and welfare decisions).

Consent is also necessary for young children, severely ill individuals, or in cases where the individual has passed away, as outlined by the Access to Health Records Act 1990. Limited access rights apply for the personal representative of a deceased relative under the same Act.

Access to Health Records

Patients have the right to see their health records under the Data Protection Act 1998. However, access may be denied if disclosure could cause mental or physical harm to the patient or another individual.

A fee of £50 will be charged for granting access to health records. This fee represents the maximum charge in England, Scotland, Wales, and Northern Ireland as specified in the Data Protection Act.

The Complaints Process, Litigation, and Clinical Negligence

When a complainant indicates an intention to seek legal advice, Chase Lodge Hospital (CLH) will continue to follow the complaints procedure, whether at Stage 1 or Stage 2. We aim to resolve complaints wherever feasible and will not abandon the complaints process due to the potential for a legal claim.

If a legal claim has been initiated, CLH will not consider the parts of the complaint central to the legal claim (such as clinical negligence and issues of causality) under the complaints procedure. However, other aspects may still be addressed.

How We Collect Compliments and Complaints

Chase Lodge Hospital is dedicated to collecting, investigating, and analysing patient feedback, including complaints, as part of our quality improvement plans. Patients can provide feedback, both positive and negative, through the following methods:

• Notices in waiting and clinical rooms outlining how to submit complaints via email to the Hospital Manager at petros@chaselodgehospital.com
• Emailing our reception team at info@chaselodgehospital.com
• Providing verbal feedback or complaints either over the phone or in person
• Using feedback forms distributed by staff
• Submitting digitalised anonymous feedback via Doctify QR codes
• Posting Google reviews

Stage 1 Complaints

Complaints Management

All complaints will be treated confidentially, with details shared only with those necessary to address the complaint.

Both verbal and written complaints will be recorded in the complaints log, which includes:

• The date and time the complaint was received
• A description of the complaint
• Details of the investigation conducted
• Any actions taken
• Whether or not the complaint was upheld

Verbal Complaints

Verbal complaints should be managed by the staff member being complained about, with the aim of swift resolution. Alternatively, the matter can be addressed by their line manager or the most senior staff member available at that time. Details of the complaint must be recorded on the incident/complaints/significant event form (Appendix 1) before the staff member’s shift ends and forwarded to the Senior Manager for confirmation that it is treated as a complaint rather than an incident, and then on to the Executive PA for logging.

Written Complaints

All written complainants will receive a written acknowledgment of their complaint within two (2) working days. The Registered Manager will contact the complainant to discuss the handling of the complaint and potential resolutions. During this conversation, we will gather the following information as applicable:

• How the complainant wishes to be addressed
• Preferred method of communication (e.g., written letter, email, telephone, or through an agreed third-party representative)
• Consent to access healthcare records for investigating the complaint
• Any disabilities or language issues to consider during the process
• Information about the option for a representative to support them through the complaints process
• Desired outcomes from the complaint investigation (e.g., an apology, a new appointment, reimbursement for costs or personal belongings, or an explanation)
• Agreement on a plan of action, including how and when the complainant will receive updates from the practice

The Duty of Candour will be applied in all relevant cases.

An investigation will be conducted by the most appropriate person, and a full written response will be sent to the complainant by the Registered Manager within twenty (20) working days of receiving the complaint. The draft response will be shared with the involved staff to confirm its accuracy before the Registered Manager reviews and signs the final version.

If a complete response cannot be provided within twenty (20) working days, the Registered Manager will inform the complainant of the delay and provide a full response within five (5) days of concluding the investigation.

If the complainant is dissatisfied with the outcome, CLH will guide them on escalating the complaint to Stage 2 through the Independent Doctors Federation. Alternatively, complainants may approach professional registrant bodies, such as the NMC and GMC. Complaints can also be sent to the Care Quality Commission (CQC), but please note that the CQC does not investigate complaints on behalf of complainants.

The Registered Manager, on behalf of CLH, will cooperate with any independent review of an escalated complaint.

Anonymous Complaints

When an anonymous complaint is received, CLH will use discretion and investigate as far as reasonably possible.

Stage 2 Complaints

If the complainant remains dissatisfied after Stage 1, they may proceed to Stage 2 by writing to one of the Directors, namely Natasha Cherrett or Dr Sarah Lotzof, who will re-evaluate the issues raised.

To proceed to Stage 2, the complainant must write to:

Natasha Cherrett
Chase Lodge Hospital
Page Street
Mill Hill
NW7 2ED

The letter should include:

• Adequate details of the complaint and reasons for requesting escalation
• Copies of all documents, correspondence, and/or clinical records for the Directors’ consideration
• The desired outcome

Stage 3 Complaints

If the complainant remains dissatisfied with the outcomes of Stages 1 or 2 or any alternative resolutions offered, they have the right to refer the matter to independent external adjudication. This referral must occur within six months of receiving the hospital’s final letter, which reminds the complainant of this right. After this period, access to the adjudication service may no longer be possible. The complainant should write to the ISCAS Secretariat to request Stage 3 at:

Independent Sector Complaints Adjudication Service
70 Fleet Street
London
EC4Y 1EU
info@iscas.org.uk
020 7536 6091

Please note there is no appeal from the independent external adjudication procedure. The Independent Adjudicator’s decision is final regarding the complaints procedure, but it does not affect the complainant’s statutory rights.

References, Guidance, and Further Reading

• CQC (2022) GP Mythbuster 103: Complaints Management Link (last accessed 29.04.22)
• CQC (2015) Guidance for Providers on Meeting the Regulations Link (last accessed 12.08.19)
• DoH (2009) Listening, Improving, Responding: A Guide to Better Customer Care Link (last accessed 12.08.19)
• ICO (2018) General Data Protection Regulation (GDPR)
• Independent Doctors Federation (2016) Link (last accessed 12.08.19)
• ISCAS (2013) Code of Practice Link (last accessed 12.08.19)
• MIND (2016) Complaining About Health and Social Care Link (last accessed 12.08.19)
• NPSA (2009) Saying Sorry When Things Go Wrong Link (last accessed 12.08.19)
• PHSO (2009) Principles of Good Complaint Handling Link (last accessed 12.08.19)
• UK Government (1988) Data Protection Act 1998 Link (last accessed 12.08.19)
• UK Government (2015) NHS Constitution Link (last accessed 12.08.19)
• UK Government (1998) Public Interest Disclosure Act 1998 Link (last accessed 12.08.19)

Appendix 1

Guidance for Managing Unacceptable Behaviour by Complainants – ISCAS (May 2019)

Acknowledgment
ISCAS expresses gratitude to Priory Healthcare for sharing its organisational policy, which has contributed to the creation of this ISCAS guide.

Overview
Occasionally, services may encounter a small number of complainants whose behaviour consumes a disproportionate amount of staff resources. It is crucial to identify situations where a complainant might be acting unacceptably and to propose fair responses for both the complainant and the staff involved.

Key Expectations

1. Clarifying Expectations
   The Independent Healthcare Provider (IHP) should clearly articulate its expectations regarding acceptable behaviour from complainants to mitigate the likelihood of unacceptable actions.
2. Impact on Resources
   Dealing with unacceptable behaviour can impose significant strain on staff resources and cause undue stress for both the complainant and the staff. Complainants exhibiting such behaviour should still receive responses to their legitimate grievances and be informed about independent organisations that can assist them, such as the Citizens Advice Bureau, Patient Organisation, or independent advocacy services.
3. Staff Training and Limitations
   While staff are trained to respond with patience and empathy, there may be occasions when no further assistance can be reasonably provided to address a real or perceived issue.
4. Considerations for Handling Complaints
   Staff should keep the following considerations in mind when addressing complainants exhibiting unacceptable behaviour:
   • Ensure the complaints process is implemented correctly and that no essential elements of the complaint are overlooked.
   • Recognise that complainants may genuinely believe their grievances have substantive merit.
   • Maintain a fair, reasonable, and unbiased approach.
   • Be able to identify unacceptable behaviours.

Examples of Unacceptable Behaviours

Unacceptable behaviours may include, but are not limited to:

• Refusal to Accept Decisions
  Persistently refusing to accept the outcome of a complaint, even after the complaints process has been fully exhausted.
• Prolonging Contact
  Attempting to extend interactions by altering the nature of a complaint or persistently raising the same or new issues with different staff members not involved in the investigation. Care should be taken to distinguish new, significantly different issues that may need separate handling.
• Rejection of Documented Evidence
  Unwillingness to accept factual evidence of treatment provided, such as drug records, medical records, or nursing notes.
• Denial of Adequate Responses
  Claiming not to have received an adequate response, despite clear evidence of correspondence addressing their queries.
• Refusal to Acknowledge Verifiability
  Not accepting that certain facts may be challenging to verify, particularly when significant time has passed.
• Anonymity Demands
  Insisting on an investigation while requiring their identity to remain anonymous, without engaging with key individuals involved in the incident.
• Unclear Issues
  Failing to specify the exact issues they wish to be investigated, despite staff efforts to assist them, or raising concerns outside the remit of the service.
• Focus on Trivial Matters
  Concentrating excessively on trivial issues that are disproportionate to their significance.
• Excessive Contacts
  Maintaining an excessive number of contacts with the service during an ongoing complaint, thereby placing unreasonable demands on staff. Determining what constitutes “excessive” requires careful judgement based on individual cases.
• Recording Without Consent
  Recording meetings or conversations without prior consent from all involved parties.
• Unreasonable Expectations
  Making unreasonable demands or having expectations that are clearly inappropriate, such as insisting on urgent responses beyond normal practice or refusing direct communication with the IHP.
• Threatening Behaviour
  Engaging in actual physical violence or making threats against staff or their associates. This behaviour will result in personal contact with the complainant being ceased, with all future communication conducted in writing.
• Harassment or Abuse
  Harassing or displaying abusive or verbally aggressive behaviour towards staff on multiple occasions, including using social media to intimidate or contact staff outside of professional contexts. It is essential to recognise that complainants may sometimes act out of character due to stress or distress.

Managing Ongoing Complaints

• Ongoing Investigations
  When a complaint investigation is in progress, the relevant manager should communicate to the complainant the expected standards of behaviour and the communication protocols. If these terms are breached, further actions may be considered.
• Completed Investigations
  Upon completion of a complaint investigation, the appropriate manager should send a letter to the complainant stating that:
  • Their concerns have been fully addressed,
  • Efforts have been made to resolve the complaint,
  • No further information can be added, thereby concluding the correspondence.
  • (Optional) Future correspondence will be acknowledged but not responded to.

In extreme situations, the manager reserves the right to initiate legal action against the complainant.

Resuming Regular Interactions

If complainants cease unacceptable behaviour, there should be a mechanism to indicate that the policy on unacceptable behaviours no longer applies, particularly if they demonstrate a more reasonable approach or submit a further complaint suitable for the normal process.

As staff exercise discretion in identifying unacceptable behaviours, similar discretion should be applied when recommending that the policy be rescinded.