Complaints Policy and Procedure

All clinical and non-clinical staff, except Dr Julia Piper

ReferencesGMC: Good Medical Practice 2013  

DoH: Listening Responding Improving 

CQC: Fundamental Standards 

Appendix 3.  IDF Complaint resolution Procedure

Appendix 5.   Complaint Procedure for patients regarding nurse

Appendices1.  Patient Complaint Information Leaflet 

2.  Complaint Form

3.  CEDR Private Healthcare Mediation Scheme Rules

4.  Guidance for managing unacceptable, vexatious behaviour

5.  Complaints regarding the Practice Nurse

ScopeAll individuals in the employ of this establishment 

(‘employ’ means any person who is employed, self-employed, a volunteer, working under practising privileges or contract of service with this establishment)

Definition of complaint

Any communication involving goods or a service that requires an investigation and formal response. Complaints may be made by letter or e-mail or text.   We want to ensure that all patient concerns and complaints are dealt with thoroughly, promptly in accordance with the principles of effective complaints handling:

  • Promoting a just and learning culture
  • Welcoming complaints in a positive way
  • Being thorough and fair
  • Giving fair and accountable responses
  • In a prompt manner

resulting in satisfactory conclusions and improvement in delivery of care where appropriate. accepts the rights of patients (and their relatives or representatives, if appropriate) to make complaints and to register comments and concerns about the services received and that they should find it easy to do so.  We welcome complaints and look upon them as opportunities to learn, adapt, improve and provide better services.

PGP believes that failure to listen to or acknowledge complaints leads to an aggravation of problems, service user dissatisfaction and possible litigation. PGP supports the idea that most complaints, if dealt with early, openly and honestly, can be sorted at a local level between just the complainant and the Practice.


The Registered Manager is responsible for following through complaints for the practice.  The Clinical Governance Committee formally reviews all complaints at least every three months as part of its quality monitoring and improvement procedures, to identify the lessons learned.

Staff must treat all patients, whether complaining or not, with courtesy, politeness, empathy and professionalism.  

All complaints, whether given verbally or in writing, must be taken seriously and acknowledged. The complainant should be directed to the policy and procedure and especially to the patient leaflet at 

Appendix 1.   Written complaints must be acknowledged within three working days.  The acknowledgement should start with a sentence that the member of staff is sorry that the complainant feels that the practice has not acted in a way that they would have expected.  This does not constitute an apology for the issue, nor that the complaint is valid, rather it acknowledges the complainant’s feelings about the issue.

A meeting could be offered to the complainant to which they may bring a friend, relative or a representative such as an advocate.  It would be helpful to know whether the advocate was a lawyer attending as a friend or in a legal capacity on behalf of the patients.

If the complaint is about Dr Julia Piper or another IDF clinician member, the practice manager must be informed and the Complaint Resolution Procedure at Appendix 3 and Appendix 4 followed.

If the complaint is about the practice nurse, the complaints procedure at Appendix 5 must be followed.


If you are unhappy with the facilities or services you have received from any member of staff at, whether clinical or non-clinical, we would like to know about it as soon as possible so we can investigate your concerns and explain, apologise and take positive action where necessary. In most circumstances, if you tell us about your concern quickly, we can resolve matters straightaway. To let us know about something with which you are unhappy please speak with the Operations Manager in the first instance.  If the complaint is against the Operations Manager, please speak with Dr Piper. 

  • All complaints will be acknowledged within three working days of receipt, whether by letter, e-mail or text.  
  • All complaints are investigated and responded to in writing within 20 working days of being made.
  • Should the investigation take longer than 20 working days, the patient (and their representative, if appropriate) will be updated on the progress of the investigation every 20 working days.
  • All complaints are dealt with promptly, fairly and sensitively, with due regard to the upset and worry that they can cause to both service users and staff. 

Complaints against the Practice Nurse

Please see Appendix 5 

Stage 1

Verbal complaints must be written down by the member of staff receiving them, signed and dated.  If the complainant has telephoned the member of staff must read back the complaint to ensure that there is complete understanding of the details of the complaint, names, times and dates.  If possible, the member of staff receiving the complaint should try to resolve the issue themselves.    If the complaint has been resolved by the member of staff to the satisfaction of the complainant, the resolution must be sent to the complainant in writing as a follow up.

If the complaint is in writing, this must be acknowledged within three working days and the investigation to be concluded, if possible, within 20 working days with a letter to the complainant fully explaining the investigation, any meetings held, the outcome and any learning arising from this to be inculcated into the working of the practice.  All actions associated with the investigation must be logged in the complaints record.  Should the investigation take longer than 20 working days, the complainant must be informed in writing and given an indicative date by which the investigation would be concluded and the result produced.  If it is found at this stage that the complaint is complex and may require legal input, then legal advice must be sought and the complainant advised of this.  The complaint may then be moved to Stage 2.

If the complaint is being made on behalf of the patient by a relative or other representative (advocate), it must first be verified that the person has permission to speak for the patient, especially if confidential information is involved. Signed and dated consent by the complainant is required.  It is very easy to assume that the advocate has the right or power to act for the service user when they may not. If in doubt, it should be assumed that the patient’s explicit consent is needed prior to discussing the complaint with the advocate.

The letter advising the complainant of the outcome at Stage 1 must detail what action the complainant should take for resolution.  This is detailed in Stage 2. 

If not, then the complainant must be informed that their complaint will move to Stage 2, that they should complete the form, Appendix 2, and that it will be forwarded to the practice manager.

Stage 2

If following receipt of the letter informing the complainant of the outcome of stage 1, the complainant is not satisfied, the complainant must complete a Complaint Form, Appendix 2, and send it to the practice manager at within 20 days of receiving the outcome of Stage 1.  The Practice Manager or other senior member of staff, with no prior knowledge of the original complaint will be assigned to investigate the complaint, using the documentation from Stage 1.  If appropriate, a meeting will be held with the complainant, accompanied if they wish as above, the member of staff who investigated at stage 1 and any witnesses required by the investigator at stage 2.  The meeting will be called within 15 working days of the receipt of the complaint form, unless the complainant is unable to attend, in which case a second date will be arranged.  Should this date not be convenient for the complainant, the meeting may still go ahead.  The decision will be sent to the complainant within five working days.   

Stage 3

if following receipt of the letter informing the complainant of the outcome of stage 2, the complainant is not satisfied, the complainant should apply to use the Private Healthcare Mediation Scheme run by the Centre for Effective Dispute Resolution (CEDR).  See Appendix 4.  

Vexatious Complainers

PGP takes seriously any comments or complaints regarding its service.  However, there are service users who can be treated as vexatious complainers due to the inability of the practice to meet the outcomes of the complaints, which are never resolved.  The process at Appendix 5 will be used in this case.   See CR26c Guidance for Managing Unacceptable, Vexatious Behaviour by Complainants.

Complaints that involve clinicians or other healthcare professionals

Complaints made about the clinical care delivered at PGP are treated seriously.  The practice manager will immediately seek advice from the medical director who will take advice from the GMC and/or the MDU or other indemnity organisation.  The practice manager will work with the medical director to resolve the complaint.  (Note: if the complaint is made about the medical director, the practice manager will share the complaint with another clinician). 

Complaints that involve children

Complaints involving children are to be treated seriously and investigated with care.  If the complaint is of a safeguarding nature, the safeguarding lead must be contacted immediately and will lead the investigation. Depending upon the circumstances, Gillick competency and/or Fraser Guidelines may or may not have been involved with decision making processes and all clinical staff engaged with looking after or having contact with children must have knowledge of these and have made appropriate documented notes.

Appendix 1

Patient Complaint Information Leaflet

As a practice we strive to provide the best possible service for our patients. However, we recognise that sometimes you may feel that we have not met your needs.

If you have a concern or complaint about the service you have received from the doctors or staff working at this centre, you are entitled to ask for an explanation.

We operate an in-house complaints procedure to deal with your complaint. This procedure does not deal with matters of legal liability or compensation.

Our promise to you

We will: 

  • Listen to your complaint or concern;
  • Respond by establishing a clear, appropriate plan of action, and provide you with relevant support and advice;
  • Improve the service however we can.

How to make your complaint

We hope that we can resolve your problem easily and promptly, often at the time the problem arises and with the person concerned.   If your problem cannot be sorted out in this way and you wish to make a formal complaint, we would like you to do so as soon as possible.  This will enable us to establish what happened more easily.

Please make your complaint in writing to the practice manager. If you would like assistance with making your complaint, a member of staff will be able to help you complete a Complaint Form.

Please be assured that any complaint you make, written or verbal, will be treated in strict confidence and have no effect upon the level of treatment and care that you receive at the practice.

If you would prefer a family member, friend or advocate to make the complaint on your behalf, they may do so and the centre will work with them, and yourself, to resolve the problem. However, whilst we can receive a complaint on your behalf, we cannot provide any medical information to a third party without your authority.  To discuss or provide information about you, we will require a note to this effect signed and dated by you.  A member of our staff would be happy to assist you with this.

What happens next?

Your complaint will be acknowledged within three working days of receiving it.  This may well be a phone call from the practice manager to you (or your advocate) to make sure we fully understand your complaint.  

We aim to make a full response to you within the next twenty working days.  During that time we will conduct an investigation to find out what has happened and whether there is any action that can be taken to put things right. If at the end of those twenty days we are still conducting our investigations, we will notify you of the position and keep you fully informed until our investigations have been concluded.

As a result of the practice investigation we will:

  • Make sure you receive an apology;
  • Find out what has happened and what went wrong;
  • Make it possible for you to discuss the problem with those concerned, if you would like this;
  • Keep you informed of our progress;
  • Identify what we can do to make sure that problem does not happen again.

Getting further help with your complaint

We hope that, through our practice complaints procedure, we can resolve your problem satisfactorily.  We believe that this will give us the best chance to put the matter right with you and the opportunity to improve our services for all our patients.

In the case of nursing staff: 

Where the complaint cannot be resolved between the parties, independent external arbitration will be sought by the NMC.

For those clinicians who are members of the Independent Doctors Federation and will refer to the IDF if internal resolution cannot be achieved.  Should there still be an impasse then the IDF will refer the complaint to the Independent Healthcare Sector Complaints Adjudication Service.  ISCAS and its findings will be final to both parties.

For those clinicians who are not members of the IDF, the complaint will go straight to ISCAS if internal resolution (Stages 1 and 2) cannot be achieved.

You may also contact the Care Quality Commission, if you feel that your complaint is not being dealt with in a satisfactory manner, on 03000 616161.  (Note: the CQC will not arbitrate in a complaint but require the provider to make their (CQC) contact details available to the service user).

Appendix 2

Patient Complaint Form


Patient name: ……………………………………………………

Address: ……………………………………………………………………………………………………………………………….………………………………

Telephone number: …………………………… 

Best time of day to be contacted on phone: ………………

If complaint is being made on behalf of the patient, please note relationship to patient: ……………………….

Where appropriate, a consent letter must be signed and dated by the patient allowing a relative to speak on their behalf.

Telephone number: …………………………… 

Best time of day to be contacted on phone: ………………

Nature of complaint / problem:

*Signed by: ………………………………………… on ……/……../……… Time: …………………..

Referred to: ………………………………………..  on ……/……../……… Time: …………………..

*Please note:  If a patient is unable to put his/her complaint in writing, please use this form to record the complaint and indicate that you are writing it on behalf of the patient and ask them to sign a the end of the statement to confirm it is accurate and you have permission to refer it on.

Appendix 3

Private Healthcare Mediation Scheme Rules


  1. The Mediation Scheme is a method of resolving complaints or disputes between private healthcare providers and their patients that have become deadlocked.
  2. Mediation is a flexible process conducted confidentially in which a Mediator actively assists parties in working towards a negotiated agreement of a dispute or difference, with the parties in ultimate control of the decision to settle and the terms of resolution.
  3. Mediation is voluntary, confidential and ‘without prejudice’ which means nothing said in the Mediation is admissible as evidence in legal proceedings.
  4. A CEDR Accredited Mediator will work with the parties to try and find an agreed solution to the complaint and the Mediator may propose a solution to the parties in an attempt to help them reach a resolution.
  5. Any settlement reached is legally binding once put into writing and signed by the parties. The parties will have a short ‘cooling off’ period after any agreement made orally should they wish to take legal advice before they sign a final document.
  6. The Scheme is provided by the Centre for Effective Dispute Resolution (CEDR) to private healthcare organisations who subscribe to the Scheme. It provides Mediation if requested to do so by a patient who is in dispute with a subscribing company where the parties have not been able to resolve the dispute between themselves through the company’s complaints procedure.
  7. The Scheme will normally take five to six weeks from receipt of the correctly completed application form to the closure of the case.
  8. CEDR have exclusive rights to appoint or withdraw a Mediator under this Scheme.


  1. An application to use the Scheme must be made by the patient on the designated application form which will be accessible on the CEDR website.
  2. Upon receipt of a properly completed application form CEDR will aim to appoint the

Mediator within 5 working days and will inform the parties accordingly.

The Process 

  1. CEDR will acknowledge receipt of a new application for mediation within 14 days of receipt.
  2. The process begins on the date of the acknowledgment of a valid application from the patient. At the same time the patient’s application form and supporting documents will be forwarded to the private healthcare company who may wish to provide a response.44 (0)20 7520 3800 E: 
  3. If a response is received, this will be sent to the patient for information only and CEDR will confirm the identity of the Mediator within 7 days.
  4. All the documents relating to the case that have been provided by the parties will be provided to the Mediator who will endeavour to conclude the Mediation within 28 days of their appointment.
  5. The Mediator will speak to the parties by telephone, Skype, Zoom or communicate in writing (including email) with the parties, either together or individually, to request further information or to explore possible solutions.
  6. If the parties do not reach a solution between themselves after discussions with the Conciliator, then they will suggest to the parties recommendations for settlement in writing.
  7. If a solution is found or is accepted by the parties as proposed by the Conciliator, then the Mediator will record that solution in writing and send it to the parties (via CEDR) in the form of an Outcome Statement (the Statement), for signature via an online portal. The parties must sign the Statement within 14 days of the date on which the Statement is provided. Any amendment to the Statement at this stage, other than for minor clerical errors, will be regarded as notifying a failure to agree.
  8. If the Statement is signed by both parties within the timescale, CEDR will advise the parties accordingly and transmit a copy to both parties. At this point the agreement becomes a binding contract and the parties must then take action to comply with the agreed outcome.
  9. No terms of settlement reached will be legally binding unless or until set out in writing in the Statement and signed by or on behalf of each of the Parties.
  10. If either party chooses not to sign the Statement within 14 days, it will have no effect on either party and CEDR will confirm the Mediation has ended without resolution.
  11. The date on which the Mediation will be deemed to be concluded is the date of the letter from CEDR which confirms the process has ended.


  1. Every person involved in the Mediation:
    1. 23.1.will keep confidential all information arising out of or in connection with the Mediation, including the terms of any settlement, but not including the fact that the Mediation is to take place or has taken place or where disclosure is required by law, or to implement or to enforce terms of settlement or to notify their insurers, insurance brokers and/or accountants; and 
    2. 23.2.acknowledges that all such information passing between the Parties, the Mediator and/or CEDR, however communicated, is agreed to be without prejudice to any Party’s legal position and may not be produced as evidence or disclosed to any judge, arbitrator or other decision- maker in any legal or other formal process, except where otherwise disclosable in law. 

T: +44 (0)20 752000 W: 

  1. Where a Party privately discloses to the Mediator or CEDR any information in confidence before, during or after the Mediation, the Mediator or CEDR will not disclose that information to any other Party or person without the consent of the Party disclosing it, unless required by law to make disclosure. The Parties, and each of them, agree, however, that the Mediator may disclose such information to CEDR provided that such disclosure is made by the Mediator and received by CEDR in confidence.
  2. The Parties understand that the Mediator and CEDR do not give legal advice and agree that they will not make any claim against the Mediator or CEDR in connection with this Mediation.
  3. The Parties will not call the Mediator or any employee or consultant of CEDR as a witness, nor require them to produce in evidence any records or notes relating to the Mediation, in any litigation, arbitration or other formal process arising from or in connection with their dispute and the Mediation; nor will the Mediator nor any CEDR employee or consultant act or agree to act as a witness, expert, arbitrator or consultant in any such process. If any Party does make such an application (as listed above), that Party will fully indemnify the Mediator or the employee or consultant of CEDR in respect of any costs any of them incur in resisting and/or responding to such an application, including reimbursement at the Conciliator’s standard hourly rate for the Conciliator’s time spent in resisting and/or responding to such application.

Legal status and effect of the Mediation 

27. The process is governed by the law of England and Wales and the courts of England and Wales shall have exclusive jurisdiction to decide any matters arising out of or in connection with this Agreement and the Mediation.


  1. The Mediation Scheme will be provided free of charge to the patient unless otherwise advised at time of application.
  2. The costs incurred by the parties in preparation of their claim, including documentation and all other expenses are not recoverable under the Scheme.


30. These Rules may be amended by CEDR from time to time, and current Rules apply to any application on the date of application.

Centre for Effective 

Dispute Resolution  

100 St. Churchyard 

London EC4M 8BU  

T:  020 7520 3800  



T: +44 (0)20 7520 3800 


Registered Charity number 1060369 

Registered in England as  

Centre for Dispute Resolution  

Limited number 2422813 

Appendix 4


Most people who complain about an independent healthcare act entirely reasonably. Occasionally, complainants may act inappropriately towards the staff involved in the investigation of a complaint for several reasons.   A small number of complainants may take up a disproportionate amount of staff time in dealing with their complaint.  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.  This should help to avoid any complainant behaving in a way that is not acceptable.

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, for example, the Citizens Advice Bureau, Patient Organisation, independent advocacy. 

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. 

When dealing with such complainants, staff should consider the following: 

  • 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. 
  • Appreciate that a complainant who behaves in a way that is unacceptable may believe they have grievances which contain some genuine substance. 
  • Ensure a fair, reasonable and unbiased approach. 
  • Be able to identify unacceptable behaviours. 

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

  • they have responded fully to the points raised, and 
  • have tried to resolve the complaint, and 
  • there is nothing more that can be added, therefore, the correspondence is now at an end. 
  • (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. 

Once complainants have ceased behaving unacceptably, they should be informed 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.

Examples of unacceptable behaviours include

  • 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.
  • 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.  New issues which are significantly different from the original complaint should be addressed as separate complaints.
  • Unwillingness to accept documented evidence of treatment given as being factual e.g. drug records, medical records, nursing notes.
  • Denying receipt of an adequate response despite evidence of correspondence specifically answering their questions.
  • Refusing to accept that facts can sometimes be difficult to verify when a long period of time has elapsed.
  • Demanding a complaint is investigated but that their identity is kept anonymous and without communicating with key persons involved in the complaints incident.
  • 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.
  • 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).
  • 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).
  • Complainants who make unreasonable demands or expectations and fail to accept that these may be unreasonable, for example insisting on responses to complaints or enquiries being provided more urgently than is reasonable or normal recognised practice 
  • Complainants who refuse to engage with and meet/speak directly with the member of staff dealing with the complaint, thereby limiting the ability of the practice to resolve issues raised.
  • Complainants threatening or using actual physical violence towards staff or their families at any time.  Should this occur, personal contact with the complainant or their representatives will be discontinued and the complaint will only be contacted via written communication
  • Complainants who harass or are abusive or verbally aggressive on more than one occasion towards staff dealing with their complaint or their families.  This includes the use of social media, for example, to seek to contact the staff involved outside 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.

Appendix 5


Making a complaint to the Practice in no way prejudices the patient’s right to complain to the Nursing & Midwifery Council should the complaint not be resolved to their satisfaction. 

The Practice Manager co-ordinates the complaints procedure on behalf of the Practice.

Complaints should be submitted in writing as soon as possible after the event giving rise to the complaint, ideally within 20 days or at least within 6 months.

The Practice Manager will then ensure that all relevant details are recorded and arrange for the complaint to be investigated.

The Practice aims to report back to the complainant within 20 working days.  If this is not possible the reason for the delay will be explained to them and they will be given a revised date for the completion of the investigation.

An initial ( Stage 1) investigation will take place within the Practice. In the event of the issues not being resolved:

  1. The matter will be referred to the Nursing & Midwifery Council, where the complaint moves into Stage 2.  At stage 2 the referral goes through to their screening team, who are expert at information gathering and fact checking.  A member of their screening team will assess your referral to see whether the concern or complaint you’ve raised needs to be taken to a further stage of investigation or intervention.
  1. Once sent to the investigation team, they will obtain other necessary evidence like documents, witness statements and speak to the nurse and the employer.  You may be asked to give a witness statement.  If you do, you may need to go to a hearing.  They will then write a report for the case examiners to look at.  This can take up to 25 weeks.
  1. The examiners will look at the report and evidence, and if the nurse is fit to practice now. The examiners might decide the case needs to be looked at by a fitness practice panel at a hearing or a meeting.  The panel will make a decision.


  1. If complaints remain unresolved the matter moves to Stage 3: with referral to the Independent Sector Complaints Advisory Service (ISCAS), an independent body.
  1. NMC any ISCAS fees where applicable, including the cost of any expert opinion sought as part of the adjudication process will be payable by the appropriate parties. In addition, they are obliged to abide by any alternative resolution suggested at stage 2 and/or any award made by the ISCAS adjudicator at stage 3.

 CR26  Complaints Policy and Procedure Version 2 21.02.2022 2022. Review due  21.02.2024

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