Complaints policy template

1. What the regulation says

Any complaint received must be investigated and necessary and proportionate action must be taken in response to any failure identified by the complaint or investigation. (Reg 16(1): the headline duty)

The registered person must establish and operate effectively an accessible system for identifying, receiving, recording, handling and responding to complaints by service users and other persons in relation to the carrying on of the regulated activity. (Reg 16(2): the system requirement)

The registered person must provide to the Commission, when requested to do so and by no later than 28 days beginning on the day after receipt of the request, a summary of [complaints, responses, and any other relevant information requested]. (Reg 16(3): CQC request response window)

The full text of the regulation is at https://www.legislation.gov.uk/uksi/2014/2936/regulation/16. Where this policy and the regulation diverge, the regulation wins.

2. Plain-English summary

Every complaint must be investigated and proportionate action taken on anything the complaint or investigation surfaces. You have to run an accessible system for identifying, receiving, recording, handling and responding to complaints from service users and other people. If CQC asks for a summary of complaints, responses, and related correspondence, you have 28 days from the day after the request to provide it.

3. Regulations and standards this policy follows

The Service writes and operates this policy in line with:

• Regulation 16 of the 2014 Regulated Activities Regulations (receiving and acting on complaints), the primary duty set out above.
• Regulation 20 (duty of candour): where a complaint concerns a notifiable safety incident, the Service also follows its duty of candour policy, which runs alongside the complaint.
• The Accessible Information Standard: the Service identifies, records and meets each person's communication and information needs, so that the complaints system is genuinely accessible to people with a disability, impairment or sensory loss.
• The Equality Act 2010: the Service does not treat anyone less favourably for raising a complaint, and makes reasonable adjustments so that anyone can complain.
• The UK GDPR and the Data Protection Act 2018: complaint records hold personal and often special-category data; the Service keeps, shares and retains them lawfully, securely and only as needed.
• For NHS-funded episodes, the Local Authority Social Services and National Health Service Complaints (England) Regulations 2009, which set their own acknowledgement and response requirements.

4. Scope

This policy applies to all employees, contractors, and external parties at who may receive, acknowledge, investigate, draft a response to, or sign off a complaint. It covers complaints from service users, families and representatives, members of the public, advocates, MPs, regulators (where a regulator forwards a complaint), and NHS commissioners. Both private-episode complaints (under Reg 16) and NHS-funded-episode complaints (under the Local Authority Social Services and National Health Service Complaints (England) Regulations 2009) are in scope; the platform records funding source per complaint so the right framework applies per record.

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5. How people can raise a complaint, and the support the Service gives

A person can complain in whatever way suits them. The Service:

• accepts complaints in writing, by email, by telephone, in person or through a representative, and does not require a person to put a complaint in writing before it is acted on
• makes the complaints information available in accessible formats on request, for example large print, easy-read or another language, in line with the Accessible Information Standard
• supports a person who needs help to complain, including help to put their complaint into words, and tells them they may use an advocate (including an NHS Complaints Advocate for an NHS-funded episode) and helps them find one
• reassures people that raising a complaint will never affect the care they receive

Who to contact. Complaints are sent to the Complaints Manager, , at <address, email and telephone>. A person who would rather not contact that person, or who is complaining about them, can use the route in section 8.

(Tenant completes the named contact.)

6. Roles and responsibilities

• Registered Manager: accountable for the complaints system under Reg 16. Reviews every complaint at closure for response quality and change-to-practice. Signs off the quarterly complaints report.
• Nominated Individual: holds provider-side accountability.
• Complaints Manager (named individual; in small services often the Registered Manager): the day-to-day complaints authority. Acknowledges, investigates, drafts the response, tracks the response clock.
• Investigators (assigned per complaint): carry out the complaint investigation, gather evidence, interview involved staff, write findings. May be the Complaints Manager or a separate clinician depending on subject matter.
• Reviewers (assigned per complaint): the second-pair-of-eyes review on the draft response. Often the Registered Manager when the Complaints Manager investigates.
• All staff: know how to receive a complaint (in writing, verbally, by email, by phone), record it the same shift, escalate it to the Complaints Manager.

(Tenant updates the named role-holders.)

7. Procedure

The complaints procedure operationalises Reg 16 (and the 2009 NHS Regulations where applicable) across the lifecycle from receipt to closure.

1. Receive and log. Any staff member who receives a complaint records it on the complaints register the same shift. The record captures the complainant's contact details, the source (in writing, verbal, etc.), the date received, the funding source for the episode complained about, and the complainant's preferred contact method.
2. Acknowledge. The Complaints Manager acknowledges the complaint in writing. For NHS-funded complaints this must happen within 3 working days of receipt per the 2009 Regulations. For private complaints under Reg 16 the provider's own policy sets the window (the platform default is 3 working days to align with the NHS standard).
3. Triage and assign. The Complaints Manager triages the complaint for severity and subject matter, decides whether the case needs a clinical investigator, and assigns ownership. Where the complaint also raises a safeguarding concern, an incident, or a Reg 18 notification trigger, those records are spawned and cross-linked.
4. Investigate. The assigned investigator gathers the clinical records, interviews the involved staff, reviews the policy or procedure under question, and writes the findings. Investigation timescale is per the assigned-on-complaint expectation; the Complaints Manager flags slipping investigations weekly.
5. Draft the response. The investigator (or the Complaints Manager) drafts the written response. For NHS-funded complaints the response must contain: an explanation of how the complaint has been considered, the conclusions reached, confirmation that any necessary action has been taken or is proposed, and notification of the right to take the matter to the Parliamentary and Health Service Ombudsman if dissatisfied. For private complaints the response is in proportionate plain British.
6. Review the draft. A reviewer reads the draft against the policy and against what the investigation actually found. Tone is checked: empathetic, factual, specific, not defensive.
7. Send the response. The signed response is sent through the complainant's preferred channel. The send timestamp, the sender, and a copy of the letter are attached to the record. For NHS-funded complaints this should happen within 6 months of receipt unless extended by written agreement with the complainant. For private complaints under Reg 16, "without unreasonable delay" applies.
8. Keep people updated, and the routes if they are dissatisfied. Throughout, the Service keeps the complainant updated on progress and tells them if a stage will take longer than expected. Where the complainant responds with further questions, a follow-up response is drafted, reviewed, and sent. If the complainant remains dissatisfied:
   • for an NHS-funded complaint, they can ask the Parliamentary and Health Service Ombudsman (PHSO) to review it, and the Service cooperates fully with any PHSO investigation
   • for a private complaint there is no statutory ombudsman. As good practice, not a legal requirement, the Service may subscribe to an independent complaints adjudication scheme such as the Independent Sector Complaints Adjudication Service (ISCAS); where it does, the response tells the person about that route and the Service cooperates with the adjudication. Where the Service does not subscribe to such a scheme, it still confirms the complaint has been fully considered and sets out any further options open to the person.
9. Closure with change. Closure happens when the complainant has accepted the response, the response period has expired with no further contact, or the matter has moved to escalation. The closure paragraph records what changed at the provider as a result of the complaint. Improvement actions are opened where actions are needed; the actions cross-link to the complaint.
10. Quarterly pattern review. The Complaints Manager presents the aggregate complaints view at the monthly governance meeting: count by category, by service line, by site, response times, repeat patterns. Aggregate themes producing more than three complaints in a quarter are escalated.

8. Complaints about the Registered Manager or the Nominated Individual

The Service makes sure that a person can complain about its most senior people, and that such a complaint is handled fairly and never by the person it is about.

• a complaint about the Registered Manager is handled by the Nominated Individual, or another director or senior person who is not the subject, who investigates and responds
• a complaint about the Nominated Individual is handled by the Registered Manager or another senior person who is not the subject
• where the Registered Manager and the Nominated Individual are the same person, or are the only senior people, a complaint about them is referred to an independent person outside the Service (for example a non-executive director, an external professional, or the relevant commissioner or regulator) so that it is considered impartially
• the person is told who is handling their complaint and why, and the independence of the handler is recorded

9. Training requirement

• All staff who may receive a complaint complete complaint-receiving training at induction and every two years.
• The Complaints Manager completes complaints management training at appointment and refresher every two years.
• Investigators complete investigation skills training at appointment and every three years.
• The Registered Manager and Reviewers complete complaint-response writing training at appointment (the 2009 Regulations content requirements; tone and structure of a good complaint response).

Training records held in the tenant's training matrix register.

10. Audit

Compliance with this policy is monitored by the Complaints Manager and the Registered Manager:

• Per-complaint closure sign-off: every closure checked for response-content completeness, change-to-practice capture, and timeliness against the acknowledgement and response clocks.
• Quarterly response-timing audit: all complaints in the trailing 12 months checked against the 3-working-day acknowledgement and the 6-month response window for NHS-funded; against the Reg 16 "without unreasonable delay" for private.
• Quarterly theme pattern review: aggregate by category, site, service line, staff team.
• Annual policy review: the policy is read against the live Reg 16 text and the 2009 NHS Regulations.
• Reg 16(3) preparation: the read-only export of the trailing-12-month complaints summary is generated quarterly so the 28-day Reg 16(3) CQC-request window can be met without scramble.

Audit findings recorded in the tenant's audit register; actions logged in the improvement-actions register.

11. Record-keeping

Complaints records (the complaint itself, acknowledgement, investigation findings, draft response, sent response, any further correspondence, closure paragraph, cross-linked records) are held for a minimum of 8 years from the date of the last entry per the NHS Code of Practice on Records Management. NHS-funded complaints follow the 2009 Regulations 10-year minimum where it applies.

Records relating to children's complaints are retained until the child reaches the age of 25.

Verivius preserves the per-record audit trail indefinitely while the workspace is active.

12. Related policies in this pack

• Duty of Candour Policy
• Good Governance Policy
• Safe Care and Treatment Policy
• Safeguarding Adults Policy

13. Sources and further reading

This template is based on CQC's guidance for providers and managers, the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, and other topic-specific legislation and guidance listed below. It is a starting point for adaptation, not a substitute for legal, clinical, HR, safeguarding or specialist professional advice.

• CQC Regulation 16: Receiving and acting on complaints
• Parliamentary and Health Service Ombudsman
• Local Government and Social Care Ombudsman
• Local Authority Social Services and National Health Service Complaints (England) Regulations 2009 (where NHS-funded episodes apply)
• Accessible Information Standard
• Equality Act 2010 (https://www.legislation.gov.uk/ukpga/2010/15)
• UK GDPR and Data Protection Act 2018
• Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (https://www.legislation.gov.uk/uksi/2014/2936/regulation/16)

14. When to seek further advice

Seek specialist advice where the issue involves serious harm, safeguarding, deprivation of liberty, restraint, children, professional misconduct, controlled drugs, radiation, termination of pregnancy, infection outbreak, water safety, employment dismissal, DBS barring referral, or regulatory enforcement.

15. Document control

This sample policy template was issued by Verivius. It is a template, not a substitute for legal advice or the tenant's own policy-development process. Where this template and live law or regulator guidance diverge, the live source wins.