Complaints Policy

Chase Lodge Hospital Complaints Policy

Objectives

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

The objectives of this policy are to ensure good complaint handling by reflecting the following principles adopted by CLH:

  • Getting it right: Quickly acknowledge and rectify service failures or maladministration that led to injustice or hardship. Fairly determine remedies by considering all relevant factors.

  • Being customer-focused: Apologise, explain, and manage expectations professionally and sensitively, applying the Duty of Candour where necessary.

  • Being open and accountable: Maintain transparency in decision-making, clear accountability, proper delegation, and robust record-keeping.

  • Acting fairly and proportionately: Provide fair and unbiased resolutions without discrimination.

  • Putting things right: Offer suitable remedies, including apologies, explanations, corrective action or financial redress.

  • Seeking continuous improvement: Use complaints as learning opportunities. Record outcomes and incorporate findings into regular audits and an annual review process.

This policy details the stages of the complaints procedure and how CLH identifies, receives, records, handles, and responds to complaints. It must be read in conjunction with the Duty of Candour Policy.


Policy Scope

CLH recognises that the distinction between a complaint and an incident can be subjective. Therefore, all incidents and verbal complaints are captured on the same form. A senior manager will determine if the matter is to be managed under the incident, significant event, or complaints policy.


Roles and Responsibilities

Hospital Manager

The Hospital Manager is accountable for:

  • Ensuring complaints are handled in line with this policy.

  • Providing staff with training on managing verbal complaints.

  • Contacting complainants of written complaints to confirm the issues raised and understand the outcome they seek.

  • Coordinating responses from third-party providers, where applicable.

  • Reviewing investigation findings and signing off final responses.

  • Reporting on complaint trends at monthly governance meetings.

  • Managing the Complaints Log and annual complaints review.

  • Liaising with relevant regulatory bodies or professional associations if required.

  • Informing patients of their right to contact the Care Quality Commission (CQC).

Investigators

Responsible for:

  • Timely completion of complaint investigations.

  • Providing a written report of findings to the Executive PA for inclusion in the complaint response.

All Staff (including Locums and Associates)

Responsible for:

  • Completing complaint training during induction.

  • Attempting informal resolution of issues to avoid escalation.

  • Understanding the complaint process and advising patients accordingly.

  • Documenting accurate and contemporaneous notes.

  • Involving appropriate managers or senior clinicians when concerns are raised.

Note: CLH policy mandates a single coordinated response to complaints that includes feedback from all relevant clinicians and staff. No separate individual responses are permitted.


Definitions

  • Complaint: A formal expression of dissatisfaction requiring a response, made by a patient or someone authorised on their behalf.

  • Authorised representative: A person with written consent to act on behalf of the patient. Consent is required for complaints involving clinical information.

  • Comment: A general observation (positive or negative) not requiring a formal response.

  • Concern: A minor issue that may be resolved informally and not necessarily requiring escalation to a formal complaint.


Complaints and Consent

Patients can nominate someone to complain on their behalf. Written consent is required before the complaint can proceed. For those lacking capacity, consent must be provided by a legally appointed representative.

In cases involving deceased patients, consent is limited to individuals with a legal right under the Access to Health Records Act 1990.


Access to Health Records

Under the Data Protection Act, patients have the right to access their medical records unless it would cause harm. A fee of £50 is charged for record access.


Complaints vs. Legal Claims

If a complaint indicates potential legal action, CLH will continue to follow the complaints process unless legal proceedings formally commence. Only the elements under legal scrutiny (e.g. negligence) will be excluded from review.


How Feedback is Collected

Patients can submit feedback through:


Complaint Management Process

Stage 1 – Internal Review

  • All complaints are treated confidentially and recorded in the Complaints Log with:

    • Date/time received

    • Complaint summary

    • Investigation details

    • Actions taken

    • Outcome status

Verbal Complaints
Handled directly by the person involved or their line manager. Must be documented and submitted to the Senior Manager for classification.

Written Complaints
Acknowledged within 2 working days. The Registered Manager will contact the complainant to:

  • Clarify preferred communication method

  • Seek consent to access records

  • Identify accessibility needs

  • Understand desired outcomes

  • Agree on an investigation plan

Investigation and Response
A full written response is sent within 20 working days. If a delay occurs, a holding letter is issued. Final response is sent within 5 working days of outcome conclusion.

If dissatisfied, the complainant may proceed to Stage 2.

Anonymous Complaints
Investigated as far as reasonably possible at CLH’s discretion.


Stage 2 – Director Review

Complainants not satisfied with the Stage 1 response may escalate by writing to:

Chase Lodge Hospital
Page Street, Mill Hill, NW7 2ED

Include:

  • Details of the complaint and reasons for escalation

  • Supporting documents

  • Desired outcome


Stage 3 – Independent External Adjudication

If dissatisfaction remains following Stage 2, complainants may request an independent adjudication. Requests must be made within 6 months of the final Stage 2 decision. Details of the adjudication body will be provided by CLH upon request.

There is no appeal after this adjudication. This process does not affect statutory legal rights.


Managing Unacceptable Behaviour

Occasionally, a small number of complainants may act unreasonably or aggressively. CLH maintains the right to set behavioural expectations and manage communication accordingly.

Unacceptable behaviour includes:

  • Persistently disputing resolved complaints

  • Excessive, unfocused, or aggressive communication

  • Making unreasonable demands

  • Refusing to engage appropriately with the complaints process

  • Harassment, threats, or abuse towards staff (including on social media)

  • Covert recording of conversations

Management actions:

  • Issue a letter setting boundaries

  • Limit communication methods

  • End further contact if resolution has been reached

  • Take legal action where necessary

Reinstating regular communication: Should the complainant’s behaviour become reasonable again, CLH may resume standard handling protocols.


References and Further Reading

  • Care Quality Commission: Guidance on complaints handling

  • Department of Health: Listening, Improving, Responding

  • Information Commissioner’s Office: Data protection and GDPR guidance

  • NHS Constitution: Rights and responsibilities in healthcare

  • Public Interest Disclosure Act

  • Access to Health Records Act 1990