Complaint Policy


Complaints are a valuable source of feedback; they provide an early warning of failures in service delivery. When handled well, complaints provide an opportunity for organisations to improve their service and reputation. All patients who attend Chase Lodge Hospital Ltd (CLH) will have access to the complaints’ procedure.

The objectives for this complaints policy are therefore to reflect the Principles of Good Complaint Handling (ISCAS, 2017)

  • • Getting it right: Quickly acknowledging and putting right cases of maladministration or poor service that led to injustice or hardship. Considering all the factors when deciding the remedy with fairness for the complainant and where appropriate others who also suffered
  • • Being customer focused: Apologising and explaining, managing expectations, dealing with people professionally and sensitively and putting in place remedies that consider individual circumstances. Duty of Candour is applied in our complaints process.
  • • Being open and accountable: Clear about how decisions are made, proper accountability, delegation and keeping clear records
  • • Acting fairly and proportionately: Fair and proportionate remedies, without bias and discrimination
  • • Putting things right: Consider all forms of remedy such as apology, explanation, remedial action or financial offer
  • • Seeking continuous improvement: Using lessons learned to avoid repeating poor service and recording outcomes to improve services, one of the mechanisms for this is through our audit timetable and the complaints annual review.

This policy outlines the different stages of the complaints procedure and includes arrangements to identify, receive, record, handle and respond to any complaint.

This policy is to be read along with our Duty of Candour Policy.

Please note: The distinction between a complaint and an incident can be subjective. It is for this reason that all incidents (irrespective of level of harm) and verbal complaints will be captured on the same form. A senior manager will decide whether the event will be categorised as an incident, significant event or complaint and therefore which policy it should be managed in line with.

Roles and Responsibilities

Hospital Manager

The Hospital Manager is accountable for:

  • • ensuring complaints are managed in line with this policy
  • • ensuring staff have access to appropriate training to be able to address verbal complaints and concerns appropriately
  • • contacting complainants who have made a written complaint to confirm the issues to be investigated and establish complainant’s expected outcome
  • • liaising with third party providers as appropriate
  • • reviewing all complaints correspondence, relevant investigations and ensuring that the draft response addresses all issues raised before signing off the final version on behalf of CLH.
  • • reporting on individual complaints and trends in complaints at monthly clinical governance meetings.
  • • liaising with the Independent Doctors Federation should a complaint escalate to Stage 2 and ISCAS in the event of a Stage 3 complaint.
  • • Maintaining the updated Complaints’ Log and conducting an annual complaints review.
  • • Patients are able to speak to the CQC regarding any matters, both positive and negative that may arise from their treatment at Chase Lodge Hospital.


Investigators are responsible for ensuring:

  • • they work in a timely manner to ensure their investigation is completed in time for the PA to be draft the complaints response before submitting to the Registered Manager
  • • they investigate all areas of the complaint assigned to them and submit a written response to the Executive PA.

All staff including locums and associates

All staff are responsible for ensuring they:

  • • attend training on induction to ensure they understand the role they perform in complaints management.
  • • make every effort to rectify the situation where possible as soon as it arises to find a satisfactory solution, preventing a formal complaint.
  • • understand the complaints process and know how to advise patients or carers on how to proceed.
  • • maintain accurate, contemporaneous and legible notes.
  • • liaise with relevant staff i.e.: line manager / senior manager / senior doctor when a patient or relative expresses dissatisfaction with the level of service.

N.B. ISCAS (Nov 2018) state ‘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 that continue to permit multiple points of communication and responses to be forwarded to the complainant will be deemed to be 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.


A complaint is defined as a concern or grievance raised by a user, or family member, or carer of a user of independent healthcare facilities and can be described as an expression of dissatisfaction requiring a formal response. The complaint may be raised by the client or the authorised representative of the client, their relative, friend or carer or their insurer. To be compliant with GDPR, consent must be sought if a complaint is raised by a third party. These can be made orally or in writing. 

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


Occasionally, patient’s expectations may not be met and may result in a verbal or written complaint. Understanding the issue as seen through the complainant’s eyes offers CLH valuable insight and is to be welcomed and used to improve patient’s experience.

All complaints should be raised directly with CLH in the first instance (Stage 1). Complaints should normally be made as soon as possible and within 6 months of the date of the event complained about, or as soon as the matter first came to the attention of the complainant. The time limit can sometimes be extended (so long as it is still possible to investigate the complaint). An extension might be possible, such as in situations where it would have been difficult to complain earlier, for example, when someone was grieving or traumatised.

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

Complaints made on behalf of the Patient and Consent

If a patient is anxious about making a complaint themselves, they can ask a relative or friend to do so on their behalf. In the event of receiving a complaint made on behalf of a patient, CLH will seek the patient’s permission in writing. By doing this the patient waives their right to confidentiality of their own clinical information, by sharing this with the person acting on their behalf.

Where someone does not have 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 still needed in situations where the person is very young, too ill or if the person has died, when the Access to Health Records Act 1990 applies. There are limited access rights for the personal representative of a deceased relative under the Access to Health Records Act 1990.

Access to health records

Patients have a right to see their health records under the Data Protection Act 1998. However, access to health records can be refused if disclosure is likely to cause mental or physical harm to the patient or someone else.

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

The complaints process, litigation and clinical negligence

Where the complainant has stated that it is their intention to seek legal advice, CLH should continue to follow the complaints procedure (whether at stage one or two). Wherever feasible CLH will attempt to resolve the complaint and not abandon the use of the complaints procedure due to a potential legal claim.

Where a legal claim has been made, then those areas of the complaint that are central to the legal claim (i.e. clinical negligence and issues of causality) will not be considered under the complaints procedure but other areas may.

How we collect compliments and complaints

Chase Lodge Hospital is committed to collect, investigate and analyse patient feedback including complaints as parts of its quality improvements plans. Patients can provide us with feedback both positive and negative via the following methods:

  • • Notices in the waiting and clinical rooms of how patients can complain by emailing the Hospital Manager
  • • Patients can email our reception team
  • • Verbal feedback/ complaints either over the phone or face to face
  • • Feedback forms given out by staff
  • • Digitalised anonymous Doctify QR codes
  • • Google reviews

Stage 1 complaints

Complaints management

All complaints will be treated in confidence and the details shared only with those who need to be made aware of the complaint.

All complaints (verbal and written) and concerns will be recorded on the complaints log.

The complaints log contains:

  • • the date and time the complaint was received
  • • a description of the complaint
  • • details of the investigation carried out
  • • any actions taken, and
  • • whether or not the complaint was upheld.

Verbal complaints

Verbal complaints are to be managed by the person being complained to, with the aim of swift resolution, their line manager or the most senior, appropriate member of staff available at the time. Details of the complaint must be recorded on the incident / complaints / significant event form (Appendix 1) before that staff member goes off duty and forwarded to the Senior Manager for confirmation the matter is to be treated as a complaint (rather than an incident) and on to the Exec PA for logging.

Written complaints

All written complainants will receive a written acknowledgement of their complaint within two (2) working days.

The Registered Manager will ring and /or offer to meet with the complainant to discuss how the complaint is to be handled and how the issue/s might be resolved.

At this meeting, the following information will be obtained and/or provided (as far as is reasonably possible):

  • • how the complainant wishes to be addressed
  • • how the person wishes to be kept informed e.g. in writing by letter or email, by telephone, or through an agreed third party representative or advocate
  • • confirm with the person if they give their consent to access healthcare records (where appropriate) for the purposes of investigating the complaint
  • • confirm if the person has any disabilities or language issues that need to be taken into account during the process
  • • advise the person that they can have a representative to support them through the complaints process.
  • • ask the person what they are seeking as an outcome to the complaints investigation e.g. an apology, new appointment, reimbursement for costs or loss of personal belongings, or an explanation.
  • • agree a plan of action, including when and how the complainant will hear back from the Practice.
  • • Duty of Candour is applied in all cases of a complain, where appropriate.

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 the complaint being received. The draft complaint response is to be shared with the staff involved with the complaint to confirm accuracy, before being reviewed and signed by the Registered Manager.

If a full response cannot be given within twenty (20) working days of receiving the complaint, the Registered Manager will write to the complainant to explain the reason for the delay. A full written response will be made within five (5) days of a conclusion and outcome being reached.

If a complainant is not satisfied with the outcome, CLH will provide further information to the complainant about how to escalate the complaint to Stage 2, which is through the Independent Doctors Federation. Alternatively, complainants can take their complaint to professional registrant bodies namely the NMC and GMC. Complaints can also be sent to the Care Quality Commission however the CQC will not investigate complaints on behalf of a complainant.

The Registered Manager, on behalf of CLH will co-operate with any independent review of a complaint that has been escalated.

Anonymous complaints

Where a complaint is received anonymously, CLH will use discretion and carry out an investigation as far as is reasonable.

Stage 2 complaints

If a complainant remains dissatisfied at the end of Stage 1, they may proceed to Stage 2.Stage 2 is where the complainant will need to write to one of the Directors namely Natasha Cherrett or Dr Sarah Lotzof who will re-evaluate the issues raised by the complainant.

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

Natasha Cherrett

Chase Lodge Hospital

Page Street

Mill Hill 


The letter should include the following:

  • • Adequate details of the complaint and their reasons for requesting escalation
  • • Copies of all documents, correspondence and/or clinical records that the Directors should consider
  • • What outcome they would like to achieve.

Stage 3 complaints

In the event that the complainant is still not satisfied with Stage 1 or Stage 2 of the complaints process or any of the alternative resolution offered – the complainant has the right to refer the matter to independent external adjudication. This needs to happen within six months of receiving the Hospitals final letter in which they will reminds the complainant of this right. If it is after this time, the complainant may not be able to access the adjudication service. The procedure is for the complainant to write to the ISCAS Secretariat to request Stage Three at:

Independent Sector Complaints Adjudication Service

70 Fleet Street



020 7536 6091

There is no appeal from the independent external adjudication procedure.

The Independent Adjudicator’s decision, although final in terms of the complaints procedure does not affect the complainants statutory rights.

References, guidance and further reading

CQC (2022) GP mythbuster 103: Complaints management (last accessed 29.04.22)

CQC (2015) Guidance for providers on meeting the regulations (last accessed 12.08.19)

DoH (2009) Listening, improving, responding: a guide to better customer care (last accessed 12.08.19)

ICO (2018) General Data Protection Regulation (GDPR)

Data protection

Independent Doctors Federation (2016) (last accessed 12.08.19)

ISCAS (2013) Code of practice (last accessed 12.08.19)

MIND (2016) Complaining about health and social care (last accessed 12.08.19) 

NPSA (2009) Saying sorry when things go wrong Being open – communicating patient safety incidents with patients and their carers (last accessed 12.08.19)

PHSO (2009) Principles of Good Complaint Handling (last accessed 12.08.19)

UK Government (1988) Data Protection Act 1998 (last accessed 12.08.19)

UK Government (2015) NHS Constitution (last accessed 12.08.19)

UK Government (1998) Public Interest Disclosure Act 1998 (last accessed 12.08.19)

Appendix 1

Guidance for managing unacceptable behaviour by Complainants – ISCAS (May 2019)

ISCAS acknowledges Priory Healthcare for sharing its organisational policy in the publishing of this ISCAS guide.

Services will, from time to time, encounter a small number of complainants who absorb a disproportionate amount of staff resource in dealing with their complaint. It is important to identify those situations in which a complainant might be behaving unacceptably and to suggest ways of responding to those situations which are fair to both staff and complainant.

1. The IHP should make clear its expectations of complainants in terms of behaviours, which should help to avoid any complainant behaving in a way that is not acceptable.

2. Handling unacceptable behaviour by complainants places a great strain on time and resources and causes undue stress for the complainant and staff who may need extra support. A complainant who behaves in a way that is unacceptable should be provided with a response to all their genuine grievances and be given details of independent organisations that can assist them, e.g. Citizens Advice Bureau, Patient Organisation, independent advocacy.

3. Although staff are trained to respond with patience and empathy to the needs of all complainants, there can be times when there is nothing further which can reasonably be done to assist them or to rectify a real or perceived problem.

4. In determining arrangements for handling such complainants, staff are presented with the following key considerations:

a) To ensure that the complaints process has been correctly implemented as far as possible and that no material element of a complaint is overlooked or inadequately addressed.

b) To appreciate that a complainant who behaves in a way that is unacceptable may believe they have grievances which contain some genuine substance.

c) To ensure a fair, reasonable and unbiased approach.

d) To be able to identify unacceptable behaviours.

Examples of unacceptable behaviours include:

a) Persistent refusal to accept a decision made in relation to a complaint and that

the complaints process has been fully and properly implemented and exhausted.

b) Seeking to prolong contact by changing the substance of a complaint or persistently raising the same or new issues with multiple members of staff not involved in the investigation of the complaint and questions whilst the complaint is being addressed. (Care must be taken not to discard new issues which are significantly different from the original complaint. These might need to be addressed as separate complaints.)

c) Unwillingness to accept documented evidence of treatment given as being factual e.g. drug records, medical records, nursing notes.

d) Denying receipt of an adequate response despite evidence of correspondence specifically answering their questions.

e) Refusing to accept that facts can sometimes be difficult to verify when a long period of time has elapsed.

f) Demanding a complaint is investigated but that their identity is kept anonymous and without communicating with key persons involved in the complaints incident.

g) Refusing to clearly identify the precise issues which they wish to be investigated, despite reasonable efforts by staff to help them specify their concerns, or where the concerns identified are not within the remit of the service to investigate.

h) Focusing on a trivial matter to an extent that is out of proportion to its significance and continuing to focus on this point. (Determining what is a ‘trivial’ matter can be subjective and careful judgement must be used in applying this criteria).

i) Having, while a complaint has been registered, an excessive number of contacts with the service, placing unreasonable demands on staff, including leaving an excessive number of voicemails or emails. 

(Discretion must be used in determining the precise number of “excessive contacts” applicable under this section using judgement based on the specific circumstances of each individual case).

j) Recording meetings or face to face/telephone conversations without the prior knowledge and consent of the other parties involved.

k) Making unreasonable demands or expectations and failing to accept that these may be unreasonable (e.g. insisting on responses to complaints or enquiries being provided more urgently than is reasonable or normal recognised practice and refusing to engage with and meet/speak directly with the IHP, thereby limiting the ability of the IHP to resolve issues raised).

l) Threatening or using actual physical violence towards staff or their families or associates at any time – this will in itself cause personal contact with the complainant or their representatives to be discontinued and the complaint will, thereafter, only be pursued through written communication.

Harassing or being abusive or verbally aggressive on more than one occasion towards staff dealing with their complaint or their families or associates, including the use of social media i.e. seeking to contact staff involved outside of the working environment or obtaining personal information via social media channels to intimidate staff. Complainants may be intimidating without being ‘abusive’. (Staff must recognise that complainants may sometimes act out of character at times of stress, anxiety or distress and should make reasonable allowances for this.)

Where a complaint investigation is ongoing – the appropriate manager should write to the complainant setting parameters for a code of behaviour and the lines of communication. If these terms are contravened, consideration will then be given to implementing other action.

Where a complaint investigation is complete – at an appropriate stage, the appropriate manager should write a letter informing the complainant that:

a) they have responded fully to the points raised, and

b) have tried to resolve the complaint, and

c) there is nothing more that can be added, therefore, the correspondence is now at an end.

d) (Optional) state that future letters will be acknowledged but not answered.

In extreme cases, the appropriate manager should reserve the right to take legal action against the complainant

Resuming regular interactions – Once complainants have ceased behaving unacceptably there needs to be a mechanism for stating that the policy on unacceptable behaviours no longer applies if, for example, the complainant subsequently demonstrates a more reasonable approach or if they submit a further complaint for which the normal complaints process would appear appropriate.

As staff use discretion in identifying unacceptable behaviours discretion should similarly be used when recommending that the policy on unacceptable behaviour no longer applies

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