Complaints Procedure

5.1  Summary of the NHS Complaints Process

  • When a complaint is received by a staff member, they will endeavour to resolve the issue immediately (or within 24 hours) to the satisfaction of the complainant if it is within their role and realm of responsibility, or involve another colleague or more senior staff member if it is not within their role and realm of responsibility
  • Staff will explain the complaints process as described in the procedure steps, and give the complainant a copy of the Complaints Leaflet and Complaints Form at Claremont and Holyport Surgery, which are available in the Forms section of this policy
  • Staff will report the complaint to Mr Scott Ridley where it will be assessed for further action and logged
  • If a complaint can be resolved to the complainant's satisfaction within 24 hours, it is not necessary to go through the formal complaints process
  • If it cannot be resolved to the complainant's satisfaction within 24 hours, the complaint will be recorded as a formal complaint. If the complainant is not the Patient, consent to investigate and resolve the complaint must be obtained from the Patient
  • Acknowledgement of the complaint will be made to the complainant in writing within three working days detailing the complaint and that an investigation will be undertaken
  • Where possible and appropriate, a discussion will take place with the complainant to understand their expectations and preferred outcome(s) and aim to manage their concerns to their preferred outcome (s), dependent on the nature of the complaint. An action plan and timescale will be agreed along with the complainant's preferred method of communication
  • The complaint will then be investigated after which the complainant will receive a reply and response as agreed in the plan and a meeting offered if necessary and appropriate
  • Should the complainant be dissatisfied with the response, further discussion and efforts must be made to resolve the complaint, including local mediation and arbitration where appropriate, for example via the Patient Advice and Liaison Service (PALS) services-and-treatments/what-is-pals-patient-advice-and-liaison-service/
  • Where all attempts to resolve the complaint locally have been unsuccessful, details of the CCG's complaints team and Parliamentary and Health Service Ombudsman (PHSO) will be shared with the complainant

5.2  Receiving a Complaint

A complaint can be received either verbally or in writing and can be made by:

  • Patients
  • Someone acting on behalf of a Patient with their written consent, for example a relative, advocate or Member of Parliament
  • Someone acting on behalf of a Patient who is unable to represent his or her own interests provided this does not conflict with the Patient’s right to confidentiality or a previously expressed wish of the Patient

Once a complaint is received, it must be managed using the formal process. Claremont and Holyport Surgery will acknowledge the complaint in writing within three working days of the complaint being received.

The acknowledgement is not required to address any of the issues relating to the detail of the complaint itself but is to advise and reassure the complainant that the matter will be investigated.

Claremont and Holyport Surgery will establish a practical plan and direction for the investigation at an early stage as this will be beneficial for all involved in the long run, assisted by the complaints handling planning tool at




5.3  Investigating Complaints

Before beginning an investigation, Claremont and Holyport Surgery will assess the seriousness of the complaint. If a complainant does not wish to pursue an issue, Claremont and Holyport Surgery will investigate the issue to identify what led to the complaint so that Claremont and Holyport Surgery can use complaints as part of the learning and improvement cycle to assist in service improvement.

Claremont and Holyport Surgery will find helpful information and a checklist for managing the complaint in the NHS England Assurance of Good Complaints Handling for Primary Care (November 2015) and the Primary Care Complaints Consortium document Complaints: A Guide for General Practices

The complainant may be invited to meet with Mr Scott Ridley to discuss the complaint. This may be done face to face, online, or over the telephone if appropriate. It is important to establish, at the earliest opportunity, what outcome the complainant expects, and to let the complainant know whether this is a realistic and possible expectation.

Claremont and Holyport Surgery will support all members of staff involved in the complaints process.

When a complainant goes directly to NHS England with a complaint about Claremont and Holyport Surgery, NHS England will seek permission from the complainant to share the details of the complaint with Claremont and Holyport Surgery. If permission is not granted, the complainant will be informed that the matter cannot be taken further.

If the complainant gives NHS England permission to pass their complaint on to Claremont and Holyport Surgery, then Claremont and Holyport Surgery will deal with the complaint as if it had been received directly. NHS England is, however, permitted to take on the investigation itself on behalf of the complainant. Complaints can be made either by Patients or by someone who is affected, or likely to be affected, by the action, omission or decision of the responsible body that is the subject of the complaint. This means that potential complainants can be almost anyone, which in turn can present the risk of a vexatious complaint. Vexatious complaints that come directly to Claremont and Holyport Surgery can be rejected with confirmation of the rejection and the reasons for the rejection being communicated to the Patient.

Claremont and Holyport Surgery has the option of informing the Local Medical Committees (LMC) if there is a concern about abuse of the complaints system or about the way NHS England is treating the complaint. Further guidance is available in 5.5 about dealing with vexatious complaints.

Where Claremont and Holyport Surgery has any concerns about handling a complaint support can be sought from its medical defence organisation or the LMC.

When a complaint is made on behalf of a child, Claremont and Holyport Surgery must be satisfied that there are reasonable grounds for the complaint being made by the complainant, rather than the child. Claremont and Holyport Surgery must also be satisfied that the complaint is being made in the best interests of the child. If Claremont and Holyport Surgery is not satisfied that this is the case, written notification of this decision must be sent to the complainant.

As there is a single complaints procedure for all health and social care services, it is usual for

the organisation with the largest part in the complaint to be considered the lead responder and, therefore, to be responsible for co-ordinating the investigation and responses. Further information can be found on the Parliamentary and Health Service Ombudsman website

NHS England regional complaints managers can advise on Practice procedures as well as on dealing with individual complaints if the problem persists or is particularly complex. The NHS complaints manager can discuss the options with Claremont and Holyport Surgery, including whether the complaint is suitable for conciliation.

Complaints managers may provide support to Practice Team members, such as:

  • Advice and help with handling difficult situations
  • Help with wording letters and Patient information
  • Obtaining feedback from Patients on particular Practice issues
  • Patient focus/customer care training
  • Arranging for a conciliator
  • Acting as an ‘honest broker’

5.4  Anonymous Complaints

Anonymous complaints received online via the NHS website (formerly NHS Choices), the website of Claremont and Holyport Surgery etc., will be investigated in the same way as named complaints. They will be logged and any corrective action necessary will be taken and recorded and, if appropriate, the



response will be displayed in reply to the complaint that appeared on the NHS website, Claremont and Holyport Surgery website etc.

5.5  Vexatious Complaints

Occasionally, Claremont and Holyport Surgery may receive complaints that are vexatious in that they cause considerable disruption to the work at Claremont and Holyport Surgery, disproportionate cost and time to handle and impact the wellbeing of staff (because of the way the complaint is made or because of its repetitive nature).

Claremont and Holyport Surgery will ensure that it meets the requirements of the Equality Act 2010 to make ‘reasonable adjustments’ for disabled customers. In some circumstances, customers may have a disability that makes it difficult for them to either express themselves or communicate clearly and/or appropriately.

Where there is an indication that this may be the case, Claremont and Holyport Surgery will consider the needs and circumstances of the Patient or complainant in the first instance and use this information to inform any decisions that are made.

Where appropriate, Claremont and Holyport Surgery will consider complaints to be vexatious but would not label an individual complainant as vexatious. Even if Claremont and Holyport Surgery decides that an individual’s complaint about the service is vexatious, that does not preclude that person from making a formal complaint. Claremont and Holyport Surgery would still consider any such complaints in line with the usual procedures.

To help decide whether a complaint is vexatious, Claremont and Holyport Surgery will consider the full history and context of interactions with the individual making the complaint and will look at both the nature of the complaint and the manner in which it is made. The particular issues that will inform a decision will include whether:

  • The primary purpose and/or effect of the complaint is to disturb, disrupt and/or pressurise Claremont and Holyport Surgery, its staff or an individual member of staff
  • The primary purpose and/or effect of the manner in which the complaint is made is to disturb, disrupt and/or pressurise Claremont and Holyport Surgery, its staff or an individual member of staff
  • The complaint is otherwise clearly unreasonable

If at any point in the handling of a complaint, a member of staff believes it meets the criteria to be deemed vexatious it must be referred to Mr Scott Ridley with a summary of why it is thought to be vexatious.

Mr Scott Ridley will consider the complaint, seek external advice if appropriate, and will either declare the complaint as being vexatious, or not. Where a complaint is not deemed to be vexatious it will be returned to the appropriate point in the complaints handling process.

If a complaint is deemed to be vexatious, Mr Scott Ridley will respond directly to the complainant explaining why it is thought to be so and explain that the complaint will be closed with no further action. Mr Scott Ridley will also consider if the making of a vexatious complaint also requires the application of a restriction on communication following unreasonable behaviour.

The decision to declare a complaint as vexatious will be recorded in the complaints register for future reference.

Any declaration that refers to the specific complaint being vexatious and any further complaints from the same individual will still be considered.

If any individual wishes to challenge a decision made in relation to this policy, and all attempts to resolve the complaint locally have been unsuccessful, details of the CCG's complaints team and Parliamentary and Health Service Ombudsman (PHSO) will be shared with the complainant.

5.6  The Complaints Register

This will contain all correspondence from each complaint received including the following:

  • Details of the complaint including subject matter, date of receipt and method of receipt
  • Date and method of acknowledgement
  • Notes from any meetings with the complainant wherever possible agreed with the complainant by countersignature
  • Details of any reason for delay where investigations took longer than any agreed response period and evidence of keeping the complainant informed of any delay
  • The date the response letter was sent to the complainant
  • Dates when the complaint was discussed in Claremont and Holyport Surgery internal meetings
  • Changes or developments made in response to the complaint as a result of the complaints



investigation, including how and when these were shared

  • Learning from the complaint to improve quality of care
  • Dates of formal complaints reviews

Where complaints are raised by telephone, the log will include the date and time of the call and the content of the conversation.

Complaints to be shared for learning purposes will be anonymised by removing all identifiable Patient information or details and information pointing to the identity of the complainant.

A complaints register, which will also assist the completion of the KO41b Primary Care (GP and Dental) Complaints Collection, is available in QCS resources.

5.7  PALS and Healthwatch

NHS England and NHS trusts have a Patient Advice and Liaison Service (PALS) that is available to help Patients sort out any problems if they are unhappy about something but do not want to lodge a complaint. Patients can be put in touch with PALS or may contact PALS independently to ask for help.

The main aims of PALS is to:

  • Help resolve problems when they arise by working with the staff concerned to negotiate a mutually agreed solution
  • Provide information about local health services

Local Healthwatch was introduced by the Health and Social Care Act 2012 with the aim of building on the existing functions of LINks (Local Involvement Networks), including the provision of information and advice to help people make choices about health and care services as well as the possibility of providing an advocacy service for people making a complaint using the NHS complaints process.

5.8  Parliamentary and Health Service Ombudsman (PHSO)

The PHSO is the final stage for unresolved complaints and usually expects complainants to complain to the organisation they are unhappy with first and is only likely to get involved if the initial approach proves unsuccessful. The PHSO does not investigate every complaint that it receives and is not required to do so, and it has legal criteria that must be satisfied before it can take any complaint forward.

If it does proceed, the PHSO will check whether the local complaints process has been completed. Public organisations are given the opportunity to put things right before the PHSO will consider the matter. If they have not had that opportunity, the investigation is usually declined at that point and the complainant asked to make full use of the Practice complaints process. The PHSO will consider:

  • If the complainant has been affected personally by what happened
  • Whether the complainant contacted the PHSO (or an MP) within a year of knowing about the issue
  • Whether the complainant has (or had) the option of taking legal action instead
  • Whether Claremont and Holyport Surgery potentially got things wrong that have had a negative effect on the complainant that has not been put right

If these preliminary checks are satisfied a formal investigation will follow.

The PHSO may talk to the Practice to try and resolve the issue or it may carry out an investigation and look in detail at the event or occurrence that led to the complaint. The steps taken will vary depending on the nature of the complaint which may involve gathering additional evidence and information by speaking to the complainant and the Practice, or they might obtain expert advice.

The following are the possible outcomes from the PHSO:

  • The Practice has acted correctly
  • That there was a problem, but the Practice has already done enough to put things right, or
  • The Practice has been found to have done something wrong that needs to be put right in which case the PHSO will work with the Practice to achieve This may mean asking the Practice to acknowledge the mistake, apologise, pay compensation and prevent any recurrence of the same error or omission

5.9  Time Limits for Submitting a Complaint

Complaints will normally be made within 12 months after the incident that gave rise to the complaint, or from the time the complainant was made aware thereof. It is possible to extend this timescale if there are good reasons for the complainant not to have raised the matter sooner, and a fair investigation can be carried out.

5.10  Complaints About Locums, Agency or Temporary Staff

Claremont and Holyport Surgery will obtain agreement from locum GPs, locum nurses and other temporary staff members for them to participate in the complaints procedure if required, as it is possible that



complaints will arise after the locum or temporary member of staff has moved on.

Claremont and Holyport Surgery will give locums and temporary members of staff involved in the complaints process every opportunity to respond to complaints with no discrepancy between the way the

process treats locums, temporary staff, salaried GPs, GP partners or permanent staff members.

5.11  Complaints Files and Records

A separate file will be kept for complaints records and letters. These must never appear in a Patient's electronic or paper medical records or that of a complainant who is not the Patient who is a registered Patient of Claremont and Holyport Surgery.

Any complaint resolved by the Practice via the formal complaints procedure will be kept on record for 10 years - the same length of time as for litigation cases.

Claremont and Holyport Surgery will comply with Data Protection legislation and General Data Protection Regulations in relation to complaint handling, recording, storing and archiving.

5.12  Suggestions

Suggestions can be made verbally or in writing using all the feedback and communication channels

at Claremont and Holyport Surgery (Friends and Family Tests, NHS Choices, Patient participation or other engagement groups, direct to Claremont and Holyport Surgery). These are usually made by Patients or users seeking to improve Claremont and Holyport Surgery, meet needs or respond to changes and trends. Suggestions are not complaints. However, they will be recorded, reviewed and actioned to prevent any risk of a future complaint in relation to the suggestion made. Suggestions will be managed in the same way as other feedback and informal complaints and included in reports to Practice meetings together with other feedback.

5.13  Compliments

Receiving compliments via any Practice feedback or ad hoc voluntary method is an opportunity to celebrate and recognise success. Claremont and Holyport Surgery will ensure:

  • All compliments are shared with members of the Practice Team formally or informally
  • Compliments will be anonymised, or permission sought from the Patient or representative before being published, put on display or shared via Practice communication channels
  • Numbers of compliments received are logged as with complaints and other feedback via the Practice register
  • Verbal positive feedback from Patients and users will be recorded and shared. The Patient or representative can be asked if their compliments can be reproduced on a named basis with their consent, or anonymously
  • Compliments, together with complaints, suggestions and other feedback, will be taken as a standing agenda item at relevant Practice meetings

5.14  Friends and Family Test (FFT)

Since 1 December 2014, it has been a contractual requirement for every Practice in England to offer Patients the Friends and Family Test (FFT). The FFT is a quick and simple feedback tool which enables Patients to indicate how likely they would be to recommend Claremont and Holyport Surgery to their friends and family if they required similar care or treatment. Patients can also provide a free text comment to explain the reason for their response. The FFT is not a replacement for the complaints procedure.

The NHS website displays published provider FFT scores for General Practice and other providers using the FFT data collected and submitted.

There is flexibility in how the FFT can be offered to Patients (e.g. completion of a postcard, SMS text message, website, touchpads, tablets or kiosks, smartphone app or online) as different methods work better in different types of Practice and enable the FFT to fit in with existing Practice Patient engagement activities.

All Patients are provided with the opportunity to provide feedback via the FFT regardless of their needs. The NHS England published guidance contains resources to help Practices make the FFT accessible for Patients with different needs (e.g. dementia, hearing loss, children and young people), and the FFT is available in 20 of the most commonly spoken languages.

The FFT offers the facility for Patients and users to leave free-text comments which provide real-time feedback for Claremont and Holyport Surgery to analyse and act upon. FFT free-text can be used as an element of the overarching Practice feedback system to monitor positive and negative feedback,   identify notable trends and inform Practice and service development.

Claremont and Holyport Surgery is required to submit the following data through the Calculating Quality



Reporting Service (CQRS):

  • The total number of responses in each response category
  • The number of responses collected through each collection method

Claremont and Holyport Surgery will submit data as soon as possible after the month end and has until the twelfth working day (inclusive) to make the submission. Free text comments are not submitted to

NHS England.

NHS England suspended the FFT for GP Practices from March 2020 to free up time to focus on COVID-

  1. Claremont and Holyport Surgery does not need to keep a count of responses collected during the suspension period and there will be no penalties for not complying with any part of the FFT guidance during this period. Although data submission for acute and community providers (including independent providers) restarted in December 2020 and Dental practices will start submitting data from July 2021, NHS England will make a further announcement about GP practices in due course.

However, Claremont and Holyport Surgery will continue to listen to Patients and enable them to raise any concerns.

5.15  Audit and Evaluation

Claremont and Holyport Surgery will record, monitor, review and analyse all complaints and other feedback received about the service as part of the Practice continuous improvement cycle to identify and inform performance, effectiveness, quality, safety and trends. Claremont and Holyport Surgery will investigate or explore what has been received and act on the findings that emerge.

Claremont and Holyport Surgery will:

  • Share themes and trends with the Practice Team and relevant external stakeholders, for example commissioners, secondary care, community and primary care providers as required by NHS England and as appropriate in the interests of the development and dissemination of best practice
  • Carry out and submit complaints reviews to NHS England and statutory bodies as required
  • Review complaints, compliments and other feedback received, together with the outputs and outcomes from the management process, as a standing agenda item at Practice meetings
  • Ensure that staff members are trained to deal with complaints, compliments, suggestion and feedback and understand the complaints procedure so that they can advise complainants with accuracy

5.16  Annual Complaints Return

Claremont and Holyport Surgery will report all written complaints received via the KO41b Primary Care Data Collection. This information is made available through an annual publication on the NHS Digital website.

The data collection refers to written complaints received between 1 April and 31 March each year. It is a statutory requirement to declare complaints information as detailed in the 2009 Complaints Regulations. Claremont and Holyport Surgery will refer to NHS Digital Guidance Notes for GP collection. The guidance gives information about the data which must be reported including:

  • Complaints brought forward (from the previous period)
  • New complaints
  • Total complaints resolved
  • Number of complaints upheld
  • Number of complaints partially upheld
  • Number of complaints not upheld
  • Total carried forward
  • Age (the number of complainants in each age group)
  • Complainant (the number of new complainants in each complainant type group e.g. Patient, parent, carer)
  • Service area (e.g. GP Surgery)
  • Subject area (e.g. appointment availability or length, clinical treatment errors, confidentiality breach, etc.)
  • Staff Group (e.g. Admin staff, Locum Practitioner, Practice Nurse, )

The template for recording this information, for the submission of the annual complaints return, is available in the User documents section of the KO41b Primary Care (GP and Dental) Complaints Collection webpage.



Following the decision not to conduct the 2019-20 KO41b data collection from GP Practices due to the COVID-19 pandemic, NHS Digital aims to collect the 2020-21 data in May/June 2021.


6.1  Vexatious Complaint

  • A vexatious complaint is one that is pursued, regardless of its merits, solely to harass, annoy or subdue somebody; something that is unreasonable, without foundation, frivolous, repetitive, burdensome or unwarranted

6.2  Compliment

  • A compliment is an expression of satisfaction about a service the Patient has received
  • Compliments are positive feedback that can be received verbally or in writing and can include expressions of praise, admiration, congratulation and encouragement

6.3  Complaint

  • A complaint is an expression of dissatisfaction, disappointment or discontent. This could be in response to an act of omission, decision or act
  • Complaints can be made in various ways and include:
    • Verbally
    • Writing
    • Electronically
    • Local feedback channels

6.4  Suggestion

  • An idea or plan put forward for consideration, usually to achieve some type of improvement, to solve a problem or introduce positive change for service development

6.5  Written Complaint

  • A written complaint is one that is made in writing to any member of staff or is originally made orally and subsequently recorded in writing. Once it is recorded, a complaint should be treated as though it was made in writing from the outset