MyCareAudit Logo
All samples
Regulation 16Duty of CandourComplaints HandlingLearning from Feedback

Complaints Policy and Procedure

A regulation-mapped complaints policy and procedure aligned to the Local Authority Social Services and NHS Complaints Regulations 2009, Regulation 16 of the Health and Social Care Act 2008, and CQC expectations.

6,800+ words Regulation-mapped Full text below

Complaints Policy and Procedure

For use by [Provider Organisation Name] Ltd, a CQC-registered adult social care service.

Document Control

Document reference [Insert reference]
Version [Insert version number]
Service type(s) this document applies to CQC-registered adult social care service
Regulatory framework / standard [Insert applicable framework/standard]
Author/Owner (role) [Insert author/owner role]
Approved by (role) [Insert approver role]
Date approved [Insert approval date]
Next review date [Insert review date]
Distribution [Insert distribution details]

Scope: This policy applies to all CQC-registered adult social care services provided by [Provider Organisation Name] Ltd, across all regulated settings and for all adults supported by the organisation.
Not in scope: Services or activities not regulated by the Care Quality Commission (CQC).

1. Purpose

The purpose of this Complaints Policy and Procedure is to establish a clear, accessible, and effective framework for addressing and resolving complaints raised by or on behalf of the people we support. This policy reflects the organisation’s commitment to fostering a culture of openness, accountability, and continuous improvement, where feedback — including complaints — is valued as an essential tool for enhancing the quality of care and support provided. By ensuring that all complaints are handled fairly, transparently, and in a timely manner, the organisation aims to build trust and confidence among the people we support, their families, and other stakeholders.

This policy aligns with the requirements of Regulation 16 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, which mandates that service providers must have an effective system for identifying, receiving, recording, handling, and responding to complaints. It also supports the CQC’s key question of whether services are responsive, particularly in relation to listening to and acting on feedback. Failure to handle complaints appropriately can lead to dissatisfaction, reputational damage, regulatory non-compliance, and missed opportunities for learning and improvement. Conversely, a robust complaints process demonstrates a commitment to person-centred care, promotes transparency, and ensures that individuals feel heard and respected.

To achieve these aims, this policy ensures that:

  • Complaints are welcomed as an opportunity to improve services and outcomes for the people we support.
  • The process for raising and resolving complaints is straightforward, accessible, and well-communicated to all stakeholders.
  • Complaints are handled impartially and without discrimination, with a focus on achieving resolution and learning.
  • Complainants are supported throughout the process, including access to advocacy where needed, and are protected from any form of reprisal.
  • Lessons learned from complaints are systematically reviewed and used to inform service improvements.

This policy applies to all complaints, whether they are raised verbally, in writing, electronically, or through a third party. It covers complaints made by the people we support, their families, advocates, professionals, or members of the public. By embedding this policy into practice, the organisation ensures that complaints are not only resolved effectively but also contribute to the ongoing development of high-quality, person-centred care.

2. Scope & Applicability

This policy applies universally across all regulated activities undertaken by the organisation, ensuring a consistent and transparent approach to managing complaints. It is designed to provide clarity and accessibility for all individuals who interact with the service, regardless of the setting in which care and support are delivered. This includes persons we support, their representatives, and staff members, as well as external stakeholders such as advocates, commissioners, and regulatory bodies. The policy ensures that everyone has the right to raise concerns, provide feedback, or make formal complaints without fear of reprisal, and with the assurance that their concerns will be addressed fairly, promptly, and in line with regulatory expectations.

The scope of this policy is intentionally broad to reflect the diverse nature of adult social care services. It applies to all persons we support, whether they receive care in their own homes, in supported living arrangements, or in any other setting where the organisation provides regulated activities. It also extends to their families, carers, and representatives, recognising that these individuals often play a critical role in advocating for the person’s needs and rights. Additionally, the policy applies to all staff members, from frontline care workers to senior management, ensuring that everyone within the organisation understands their role in fostering a culture of openness and accountability.

Who the Policy Applies To

  • Persons we support: Any adult receiving care or support from the organisation, regardless of the setting or type of service provided.
  • Family members, carers, and representatives: This includes relatives, friends, legal guardians, and anyone else acting on behalf of the person we support.
  • Advocates: Independent advocates or advocacy services acting in the interests of the person we support, particularly where the individual may lack capacity or confidence to raise concerns themselves.
  • Staff members: All employees, contractors, and volunteers involved in delivering or supporting the organisation’s regulated activities.
  • External stakeholders: This includes commissioners, local authorities, and other professionals who may wish to raise concerns or provide feedback about the service.

Key Considerations for Applicability

  • The policy applies equally across all care settings, including care provided in a person’s own home, supported living environments, and other community-based settings. Where specific procedures or adjustments are required for a particular setting, these are detailed within the relevant sections of the policy.
  • Complaints or feedback may be raised verbally, in writing, electronically, or through third parties, ensuring accessibility for all individuals, including those with communication difficulties or disabilities.
  • The organisation acknowledges that complaints may arise from a wide range of issues, including but not limited to the quality of care, staff behaviour, communication, or decisions made by the organisation. All such concerns fall within the scope of this policy.
  • Safeguarding concerns raised as part of a complaint are subject to immediate escalation under the organisation’s safeguarding procedures, ensuring compliance with statutory duties.

Evidence of Compliance

To demonstrate compliance with this scope, the organisation maintains the following:

  • Accessible information: Easy-read guides, translated materials, and alternative formats are available to ensure all individuals understand their right to complain and how to do so.
  • Training records: Evidence that all staff have received training on the complaints policy and their role in supporting its implementation.
  • Complaint logs: A centralised system for recording and tracking complaints, including details of the complainant, the nature of the complaint, and the resolution process.
  • Feedback mechanisms: Regular opportunities for persons we support and their representatives to provide feedback, such as surveys, meetings, or suggestion boxes.

By defining a clear and inclusive scope, this policy ensures that all individuals connected to the organisation’s services are empowered to raise concerns and contribute to continuous improvement. This approach aligns with the organisation’s commitment to person-centred care and regulatory standards, fostering trust and accountability across all activities.

3. Legal & Regulatory Framework

The handling of complaints in CQC-registered adult social care services is governed by a robust legal and regulatory framework designed to ensure transparency, accountability, and responsiveness. Compliance with these requirements is not optional; it is a statutory duty under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, specifically Regulation 16, which mandates that all complaints are investigated thoroughly and resolved in a timely manner. Failure to adhere to these standards can result in regulatory action, reputational damage, and, most importantly, a failure to uphold the rights and dignity of the people we support.

Good complaints management is integral to meeting the Care Quality Commission’s (CQC) Key Lines of Enquiry (KLOEs) under the Responsive domain, particularly R2: "How are people’s concerns and complaints listened and responded to, and used to improve the quality of care?" Effective complaints handling demonstrates that the organisation values feedback, learns from mistakes, and places the person at the centre of its processes. It also ensures compliance with broader legislative requirements, such as the Equality Act 2010, which requires organisations to make reasonable adjustments to ensure accessibility for all individuals, including those with disabilities or communication needs.

Key Legal and Regulatory Requirements

The following laws, regulations, and guidance underpin complaints handling in adult social care services:

  • Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 – Regulation 16 (In force):
    Requires providers to establish and operate an effective complaints system that ensures complaints are investigated and appropriate action is taken in response. Providers must also ensure that complainants are not treated unfairly as a result of raising a concern.

  • Care Quality Commission (CQC) Guidance on Regulation 16 (Regulator guidance):
    Outlines the expectations for complaints systems, including accessibility, timeliness, and the need for learning from complaints to improve service quality.

  • Local Authority Social Services and National Health Service Complaints (England) Regulations 2009 (In force):
    Sets out the statutory framework for complaints handling in health and social care, including the requirement to acknowledge complaints within three working days and provide a full response within six months unless otherwise agreed.

  • Equality Act 2010 (In force):
    Requires providers to ensure that complaints processes are accessible to all, including making reasonable adjustments for individuals with disabilities or language barriers.

  • Data Protection Act 2018 and UK GDPR (In force):
    Mandates that personal data related to complaints is handled securely, confidentially, and in compliance with data protection principles.

  • Human Rights Act 1998 (In force):
    Protects the right to a fair process (Article 6) and the right to respect for private and family life (Article 8), both of which are relevant to complaints handling.

  • NICE Guideline NG86: People’s Experience in Adult Social Care Services (Good practice):
    Recommends that providers actively seek feedback, including complaints, and use this to drive service improvements.

Operationalising the Framework

To meet these legal and regulatory requirements, the organisation must:

  • Ensure Accessibility:
    Complaints processes must be easy to understand and accessible to all individuals, including those with disabilities, sensory impairments, or limited English proficiency. This includes providing information in alternative formats, such as large print, braille, or translated materials, and offering support through interpreters or advocates.

  • Timely Acknowledgment and Response:
    Acknowledge receipt of complaints within three working days and provide a full written response within 20 working days. If a resolution requires more time, the complainant must be informed and provided with regular updates.

  • Impartial Investigation:
    Appoint a suitable individual to investigate complaints, ensuring they are not involved in the matter being complained about. Investigations should be thorough, evidence-based, and focused on resolving the issue to the satisfaction of the complainant wherever possible.

  • Confidentiality and Data Protection:
    Maintain confidentiality throughout the complaints process and ensure that all records are stored securely in compliance with the Data Protection Act 2018 and UK GDPR. Only share information on a need-to-know basis.

  • Learning and Improvement:
    Analyse complaints data to identify trends and areas for improvement. Use this information to inform staff training, update policies, and improve service delivery. Evidence of learning from complaints should be documented and shared with relevant stakeholders, including the people we support.

Evidence of Compliance

To demonstrate compliance with the legal and regulatory framework, the organisation must maintain:

  • A clear, written complaints policy and procedure that aligns with Regulation 16 and other relevant legislation.
  • Records of all complaints, including the nature of the complaint, actions taken, and outcomes, stored securely and retained in line with data protection laws.
  • Evidence of timely acknowledgment and resolution of complaints, including correspondence with complainants.
  • Documentation of any service improvements or changes made as a result of complaints.
  • Training records showing that staff have received appropriate training in complaints handling and related legal requirements.

By adhering to this framework, the organisation ensures that it meets its legal obligations, fosters trust and transparency, and continuously improves the quality of care provided to the people it supports.

4. Definition and Types of Complaints

A complaint is defined as any expression of dissatisfaction or concern raised by a person we support, their representative, or any other stakeholder, about the quality of care, services provided, decisions made, or actions taken (or not taken) by the organisation or its staff. Complaints may relate to a wide range of issues, including but not limited to, the standard of care received, the behaviour or attitude of staff, delays in service provision, or the handling of a previous complaint. It is essential to recognise that complaints can be verbal, written, or communicated through alternative means, including through a third party or advocate, and all must be taken seriously and addressed appropriately.

It is important to distinguish between complaints, concerns, and feedback to ensure that each is managed in a way that reflects its nature and significance. A concern is typically an issue raised informally, often with the intention of seeking clarification or resolution without invoking a formal process. Feedback, on the other hand, can be positive or negative and is often shared to provide general observations or suggestions for improvement. While concerns and feedback may not always require formal investigation, they should still be acknowledged, recorded, and acted upon where appropriate. Failing to address concerns or feedback effectively can escalate them into formal complaints, which may have regulatory implications and impact the organisation’s reputation and the trust of the people we support.

Examples of Complaints

Complaints can be categorised into informal and formal types, depending on their nature, severity, and the desired resolution process. Examples include:

Informal Complaints:

  • A person we support expresses dissatisfaction with the quality of meals provided.
  • A family member raises concerns about the timeliness of staff responses to a non-urgent request.
  • A person we support feels that their preferences for daily activities are not being considered.

Formal Complaints:

  • Allegations of neglect or poor care practices by staff.
  • A person we support or their representative disputes a decision made about their care plan.
  • A complaint about discriminatory behaviour or language by a staff member.
  • Concerns about breaches of confidentiality or data protection.

Distinguishing Between Concerns, Feedback, and Complaints

To ensure appropriate handling, staff must be able to differentiate between concerns, feedback, and complaints. The table below provides a summary of these distinctions:

Category Definition Examples Action Required
Concern An informal expression of worry or dissatisfaction, often seeking clarification or resolution. A person we support asks why their care worker was late for a scheduled visit. Address immediately where possible. Record and escalate if unresolved or recurring.
Feedback General comments or suggestions, which may be positive or negative, about the service. A family member suggests a change to the activities schedule to better suit their relative’s needs. Acknowledge and record. Share with relevant staff or management for consideration.
Complaint A formal expression of dissatisfaction requiring investigation and resolution. A person we support alleges that their care needs are not being met, resulting in distress. Follow the formal complaints procedure. Ensure acknowledgment, investigation, and resolution.

Operational Considerations

Staff must be trained to recognise and appropriately respond to all forms of communication from the people we support, their representatives, and other stakeholders. This includes being able to identify when a concern or feedback may escalate into a formal complaint if not addressed promptly and effectively. All complaints, whether informal or formal, must be logged in the organisation’s complaints register, with clear documentation of the issue raised, actions taken, and outcomes achieved.

Common Pitfalls and How to Avoid Them

  1. Failure to acknowledge concerns or feedback: Ignoring or dismissing concerns can escalate the issue into a formal complaint. Staff should always listen actively and respond empathetically to any issues raised.
  2. Misclassifying complaints as concerns or feedback: Staff must not downplay the seriousness of a complaint by treating it as a minor concern. If in doubt, escalate the issue to the Registered Manager for guidance.
  3. Inadequate documentation: All complaints, concerns, and feedback must be recorded accurately, including the actions taken and the outcomes achieved. Inspectors will expect to see evidence of this during audits.
  4. Delays in response: Timely acknowledgment and resolution are critical to maintaining trust. Ensure that all complaints are addressed within the timescales outlined in the complaints procedure.

By clearly defining complaints and distinguishing them from concerns and feedback, the organisation can ensure that all issues are managed appropriately, fostering a culture of openness, accountability, and continuous improvement. This approach not only supports compliance with Regulation 16 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 but also strengthens relationships with the people we support and their representatives.

5. Complaints Procedure

A clear, accessible, and robust complaints procedure is essential to ensure that individuals we support, their families, and other stakeholders can raise concerns about the quality of care or services provided. This process not only ensures compliance with Regulation 16 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 but also demonstrates our commitment to transparency, accountability, and continuous improvement. A well-structured complaints procedure helps to identify and address issues promptly, preventing escalation and fostering trust in the organisation’s ability to respond effectively. Failure to manage complaints appropriately can lead to dissatisfaction, reputational damage, and regulatory action.

The complaints procedure is designed to be person-centred, ensuring that individuals feel heard, respected, and supported throughout the process. It is underpinned by principles of fairness, confidentiality, and a no-blame culture. Complaints can be raised by the person we support, their representatives, staff, or other stakeholders, and can be made verbally, in writing, electronically, or through a third party. The process is structured into three stages: informal resolution, formal investigation, and independent review or escalation. Each stage is designed to ensure timely and effective resolution, with clear roles, responsibilities, and timescales.

Step-by-Step Complaints Procedure

Stage 1: Informal Resolution

  1. Raising the Concern:

    • A person or their representative may raise a concern directly with any staff member. Staff must listen actively, acknowledge the concern, and document the details.
    • If the concern is raised verbally, staff should confirm their understanding of the issue with the complainant to ensure accuracy.

  2. Immediate Action:

    • The staff member receiving the complaint should attempt to resolve the issue promptly and informally, where appropriate.
    • If the concern is resolved at this stage, the staff member must document the issue and resolution in the complaints log within 1 working day.

  3. Escalation:

    • If the complainant is not satisfied with the informal resolution or if the issue is complex, sensitive, or cannot be resolved informally, the complaint must be escalated to Stage 2.

Stage 2: Formal Investigation

  1. Logging the Complaint:

    • The complaint must be formally logged with the Registered Manager or their delegate.
    • A written acknowledgment of the complaint must be sent to the complainant within 2 working days, outlining the next steps and expected timescales.

  2. Assigning an Investigator:

    • The Registered Manager will appoint an investigator who is independent of the issue raised. In some cases, the Responsible Individual may appoint an external investigator.

  3. Investigation Process:

    • The investigator will gather all relevant information, including statements from the complainant, staff involved, and any witnesses.
    • The investigation will be conducted impartially, ensuring that all parties are treated fairly and that confidentiality is maintained.

  4. Outcome and Response:

    • A formal written response, including the findings of the investigation and any actions to be taken, must be provided to the complainant within 20 working days.
    • If the investigation cannot be completed within this timeframe, the complainant must be informed of the delay, provided with an explanation, and given a revised timescale.

Stage 3: Independent Review / Escalation

  1. Request for Review:

    • If the complainant is dissatisfied with the outcome of the formal investigation, they may request an independent review. This request must be made within 20 working days of receiving the Stage 2 outcome.

  2. Escalation Pathways:

    • The Registered Manager will escalate the complaint to the Responsible Individual or an external body, such as the Local Authority Complaints Manager, CQC, or the Local Government and Social Care Ombudsman (LGSCO), depending on the nature of the complaint.
    • The complainant will be informed of the escalation process and provided with contact details for the relevant external body.

  3. Independent Review Process:

    • The independent reviewer will reassess the complaint, review the evidence, and provide a final decision within 28 working days of the escalation request.
    • The outcome of the review will be communicated in writing to the complainant, along with any further actions to be taken.

Additional Considerations

  • Anonymous Complaints: These will be investigated to the extent possible, with findings recorded in the complaints log.
  • Safeguarding Concerns: Any complaint that raises safeguarding issues must be immediately referred to the Designated Safeguarding Lead (DSL) and handled in line with the organisation’s safeguarding policy.
  • Support for Complainants: Complainants will be offered support, including access to advocacy services, to ensure they can fully participate in the process.

Records and Monitoring

  • All complaints, regardless of their nature or outcome, must be recorded in the Complaints Log.
  • The log must include the date of the complaint, the nature of the issue, actions taken, timescales, and the final outcome.
  • Complaints data will be reviewed monthly by the Registered Manager to identify trends and inform service improvements.

Example Scenario

A person we support raises a concern that their care plan is not being followed. A staff member listens to their concern and confirms their understanding. The staff member immediately informs the person’s key worker, who reviews the care plan and identifies a scheduling issue. The key worker resolves the issue within 2 days and informs the person of the changes made. The resolution is documented in the complaints log. If the person remains dissatisfied, the complaint is escalated to the Registered Manager for a formal investigation.

Common Pitfalls

  • Failure to Acknowledge Complaints: Not sending a written acknowledgment within 2 working days can lead to dissatisfaction and non-compliance with Regulation 16.
  • Delays in Resolution: Exceeding the 20-working-day timeframe for formal investigations without communication can erode trust.
  • Lack of Documentation: Failure to document complaints and their outcomes may result in regulatory breaches and missed opportunities for learning.

By adhering to this procedure, the organisation ensures that complaints are handled effectively, respectfully, and in compliance with regulatory requirements.

6. Safeguards and Support for Complainants

Ensuring that individuals feel safe and supported when raising a complaint is fundamental to fostering a culture of openness and continuous improvement within adult social care services. The organisation is committed to treating all complainants with dignity and respect, ensuring they are not subject to discrimination, victimisation, or reprisal as a result of voicing their concerns. This commitment aligns with Regulation 16 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, which requires providers to establish accessible, transparent, and fair complaints systems. Failure to safeguard complainants can undermine trust, deter individuals from raising legitimate concerns, and expose the organisation to regulatory breaches and reputational damage.

Good practice in safeguarding complainants involves creating an environment where individuals feel confident that their concerns will be taken seriously, handled impartially, and resolved in a timely manner. It also requires proactive measures to identify and address any barriers to making a complaint, such as communication difficulties, fear of retaliation, or lack of awareness about the complaints process. Staff must be trained to recognise and address these barriers, and the organisation must provide appropriate support mechanisms to ensure that complainants feel heard, valued, and protected throughout the process.

Measures to Safeguard Complainants

  • Non-Retaliation Policy: The organisation operates a strict non-retaliation policy. Any form of discrimination, victimisation, or adverse treatment of a complainant is considered a serious breach of conduct and will be investigated under the organisation’s disciplinary procedures. This includes ensuring that the person we support does not experience any change in the quality of care or support as a result of raising a complaint.

  • Confidentiality: All complaints are handled in line with the UK GDPR and the Data Protection Act 2018. Information is shared only on a “need-to-know” basis, and complainants are informed about how their data will be used. Records of complaints are stored securely and access is restricted to authorised personnel.

  • Equality and Diversity: The organisation ensures that the complaints process is accessible to all, regardless of age, disability, gender, race, religion, sexual orientation, or any other protected characteristic. Reasonable adjustments are made to support individuals with specific needs, such as providing information in alternative formats or offering translation and interpretation services.

  • Advocacy Support: Complainants are informed of their right to access independent advocacy services. Where appropriate, the organisation will assist in arranging advocacy support to help individuals articulate their concerns and navigate the complaints process.

  • Anonymity: Complainants have the option to raise concerns anonymously. While this may limit the scope of the investigation, the organisation will take all reasonable steps to address the issues raised without compromising the complainant’s anonymity.

Support for Complainants

  • Clear Communication: The organisation ensures that all complainants are provided with clear and accessible information about the complaints process, including expected timescales, the steps involved, and how they will be kept informed of progress.

  • Emotional Support: Staff are trained to provide empathetic and non-judgmental support to complainants. Where necessary, referrals can be made to counselling services or other appropriate support networks.

  • Regular Updates: Complainants are kept informed of the progress of their complaint at regular intervals, with updates provided at least every 10 working days during the investigation process. This helps to build trust and demonstrates the organisation’s commitment to resolving the issue.

  • Feedback on Outcomes: At the conclusion of the complaints process, complainants are provided with a clear explanation of the findings, any actions taken, and how these actions will address their concerns. Where appropriate, they are also informed of their right to escalate the complaint if they remain dissatisfied.

Example Scenario

A person we support raises a complaint about the behaviour of a staff member, expressing fear of reprisal. The staff member responsible for receiving complaints reassures the individual that their concerns will be taken seriously and handled confidentially. The complaint is logged, and the Registered Manager is notified immediately. The complainant is offered the support of an independent advocate and provided with written information about the complaints process. Throughout the investigation, the complainant is kept informed of progress and reassured that their care will not be affected. Upon resolution, the complainant is given a written summary of the findings and actions taken, along with details of how to escalate the complaint if they are dissatisfied with the outcome.

Common Pitfalls to Avoid

  • Failure to communicate effectively: Not providing regular updates can lead to frustration and a lack of trust in the process.
  • Perceived or actual retaliation: Any change in the complainant’s care or support following a complaint can be perceived as punitive and must be avoided.
  • Lack of accessibility: Failing to provide reasonable adjustments or advocacy support can prevent individuals from effectively raising their concerns.
  • Inadequate training: Staff who are not trained in handling complaints sensitively may inadvertently discourage individuals from coming forward.

By implementing these safeguards and support mechanisms, the organisation ensures that all complainants feel safe, respected, and empowered to raise concerns, contributing to a culture of continuous improvement and high-quality care.

7. Roles & Responsibilities

The effective implementation of this Complaints Policy and Procedure relies on the clear definition and understanding of roles and responsibilities across all levels of the organisation. Each individual within the organisation has a critical part to play in ensuring that complaints are handled promptly, fairly, and in line with regulatory requirements. Failure to adhere to these responsibilities can result in poor outcomes for the person we support, reputational damage, and regulatory non-compliance under Regulation 16 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. A robust understanding of roles also ensures that complaints are seen as opportunities for learning and improvement, fostering a culture of openness and accountability.

Good practice in complaints handling requires a collaborative approach, where all staff are empowered to respond to concerns appropriately, and senior leaders actively promote a culture of transparency and responsiveness. This includes ensuring that all staff are trained in the complaints process, that complaints are treated confidentially and without bias, and that outcomes are used to drive service improvement. The following outlines the specific responsibilities assigned to staff, managers, and senior leaders within the organisation.

Staff Responsibilities

  • Frontline Staff:

    • Act as the first point of contact for receiving complaints, whether verbal or written, and ensure the person we support feels heard and respected.
    • Attempt to resolve minor concerns informally and promptly, escalating to a manager if resolution is not possible or if the complaint is of a serious nature.
    • Record all complaints, including informal ones, in the organisation’s complaints log or system within [insert timeframe, e.g., 24 hours].
    • Maintain confidentiality and ensure that no person is treated unfairly or experiences reprisal for raising a complaint.
    • Signpost the person to advocacy services or other support mechanisms where appropriate, particularly if the person has communication difficulties or lacks capacity.
    • Participate in training on complaints handling and demonstrate understanding of the organisation’s policy.

  • Specialist Staff (e.g., Safeguarding Leads, Advocates):

    • Provide additional support to individuals making complaints, particularly where safeguarding concerns are raised.
    • Ensure that complaints involving potential abuse or neglect are immediately escalated in line with the organisation’s safeguarding policy.

Manager Responsibilities

  • Line Managers:

    • Oversee the informal resolution of complaints within their team and ensure that all concerns are addressed in a timely and effective manner.
    • Review complaints logged by staff to ensure accuracy and completeness, and determine whether escalation to a formal investigation is required.
    • Provide guidance and support to staff in handling complaints and ensure that they have access to appropriate training and resources.
    • Monitor trends in complaints within their area of responsibility and report recurring issues to senior management for further action.
    • Ensure that complainants are kept informed of progress and outcomes in line with the organisation’s stated timescales (e.g., acknowledgment within 2 working days, full response within 20 working days).

  • Registered Manager:

    • Take overall responsibility for the formal investigation of complaints at Stage 2 of the procedure, ensuring impartiality and adherence to regulatory requirements.
    • Assign an investigator who is not directly involved in the subject of the complaint, where possible, to ensure objectivity.
    • Ensure that all complaints are logged, tracked, and resolved within the specified timescales, and that outcomes are communicated clearly and respectfully to the complainant.
    • Escalate unresolved complaints to the Responsible Individual or external bodies (e.g., local authority, CQC) where necessary.
    • Analyse complaints data to identify patterns, risks, and areas for improvement, and ensure that lessons learned are implemented across the service.

Senior Leadership Responsibilities

  • Responsible Individual:

    • Provide strategic oversight of the complaints process and ensure that the organisation complies with Regulation 16 and other relevant legal and regulatory requirements.
    • Review and sign off on complaints that are escalated to Stage 3 or involve significant risks to the organisation or the person we support.
    • Ensure that sufficient resources, including training and systems, are in place to support effective complaints handling across the organisation.
    • Promote a culture of openness and continuous improvement by encouraging feedback and ensuring that learning from complaints is embedded into practice.
    • Liaise with external stakeholders, such as commissioners or regulatory bodies, in cases of complex or high-risk complaints.

  • Board or Governance Body:

    • Monitor the organisation’s complaints performance through regular reports and audits, ensuring that trends and risks are identified and addressed.
    • Hold the Responsible Individual and Registered Manager accountable for the effective implementation of the complaints policy.
    • Ensure that the complaints process is reviewed regularly and updated in line with changes in legislation, guidance, or organisational needs.

Evidence and Records

  • All staff must ensure that complaints are documented accurately and stored securely in line with the UK GDPR and Data Protection Act 2018.
  • Managers must maintain a centralised complaints log, which includes details of the complaint, actions taken, and outcomes.
  • Senior leaders must ensure that complaints data is analysed and reported at governance meetings, with evidence of actions taken to address identified issues.

Common Pitfalls

  • Failing to acknowledge complaints within the required timescales, leading to dissatisfaction and escalation.
  • Lack of clarity in roles, resulting in delays or duplication of effort.
  • Inadequate training for staff, leading to inconsistent handling of complaints.
  • Not using complaints data effectively to drive service improvements.

By clearly defining and adhering to these roles and responsibilities, the organisation ensures that complaints are handled effectively, fairly, and in a manner that promotes trust and continuous improvement.

8. Monitoring, Audit & Review

Effective monitoring, auditing, and review of complaints data are essential to ensuring that the organisation remains responsive to the needs and concerns of the people we support. This process not only ensures compliance with Regulation 16 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 but also drives continuous improvement in service quality. Monitoring complaints enables the organisation to identify trends, recurring issues, and areas requiring systemic change, while audits ensure that the complaints process is being followed consistently and fairly. Regular review of this policy ensures it remains current, effective, and aligned with regulatory requirements and best practice.

Good practice in monitoring and auditing complaints involves a structured approach to data collection, analysis, and reporting. Complaints data should be reviewed regularly to identify patterns, such as repeated concerns about specific aspects of the service or particular settings. This information should be used to inform quality assurance activities, staff training, and service development. Additionally, the organisation must ensure that the complaints process itself is functioning effectively, with clear evidence of timely responses, appropriate resolutions, and learning outcomes. Policy reviews should be scheduled and evidence-based, incorporating feedback from people we support, staff, and external stakeholders.

Monitoring Complaints Data

  • Frequency: Complaints data will be monitored on a monthly basis by the Registered Manager or a designated senior staff member.
  • Data Collection: All complaints, including informal concerns and formal complaints, must be logged in the organisation’s complaints register. This register must include:
    • Date of the complaint.
    • Name (or anonymised identifier) of the complainant.
    • Nature of the complaint.
    • Actions taken and timescales.
    • Outcome and resolution status.
    • Any learning or changes implemented as a result.
  • Analysis: Complaints data will be analysed to identify:
    • Trends or recurring themes.
    • Service areas or settings with higher complaint volumes.
    • Timeliness of complaint handling.
    • Effectiveness of resolutions and satisfaction levels of complainants.

Auditing the Complaints Process

  • Audit Schedule: A formal audit of the complaints process will be conducted quarterly by the Responsible Individual or a delegated quality assurance officer.
  • Audit Scope: The audit will assess:
    • Compliance with the complaints procedure, including adherence to timescales.
    • Quality and clarity of communication with complainants.
    • Evidence of impartiality and fairness in investigations.
    • Documentation and record-keeping standards.
    • Implementation of learning outcomes and service improvements.
  • Audit Records: Findings from the audit will be documented in an audit report, which will include:
    • Summary of compliance levels.
    • Identified gaps or weaknesses.
    • Recommendations for improvement.
    • Actions taken to address any deficiencies.

Using Complaints Data to Improve Service Quality

  • Reporting: A summary of complaints data and learning outcomes will be presented at monthly management meetings and quarterly governance meetings.
  • Feedback Loop: Learning from complaints will be shared with staff through team meetings, supervision sessions, and training. Where appropriate, feedback will also be shared with the people we support to demonstrate how their concerns have led to positive changes.
  • Service Development: Complaints data will inform updates to policies, procedures, and staff training programmes. It will also guide strategic planning and resource allocation to address identified service gaps.

Policy Review

  • Review Schedule: This policy will be reviewed annually or sooner if:
    • There are significant changes to legislation, regulation, or guidance.
    • Feedback from complaints or audits highlights deficiencies in the policy.
    • Organisational changes necessitate updates.
  • Review Process: The policy review will be led by the Responsible Individual in consultation with the Registered Manager, staff, and, where appropriate, representatives of the people we support.
  • Approval and Dissemination: Once reviewed, the updated policy will be approved by [Responsible Person] and disseminated to all staff. Staff will be required to confirm their understanding of any changes.

Evidence for Regulators

To demonstrate compliance and effectiveness, the organisation will maintain:

  • A complete and up-to-date complaints register.
  • Audit reports with documented findings and actions.
  • Minutes of meetings where complaints data and learning outcomes were discussed.
  • Records of policy reviews, including dates and participants.
  • Evidence of changes implemented as a result of complaints, such as updated procedures or training records.

By embedding robust monitoring, auditing, and review processes, the organisation ensures that complaints are not only resolved but also used as a powerful tool for learning and continuous improvement.

9. References and Live Links

This section provides a comprehensive list of the legal, regulatory, and good practice frameworks underpinning this policy. These references ensure that the organisation’s complaints handling processes align with statutory requirements, regulatory expectations, and sector best practices. Compliance with these frameworks is critical to safeguarding the rights of the people we support, promoting transparency, and maintaining the organisation’s registration with the Care Quality Commission (CQC). Staff must be familiar with these references to ensure that complaints are managed lawfully, fairly, and effectively. The live links provided (or placeholders where applicable) enable verification of the most current versions of these documents.

Statutory Legislation

The following legislation underpins the legal duties and rights related to complaints handling in adult social care services:

Regulatory Guidance

The following guidance documents issued by regulatory bodies provide essential standards and expectations for complaints handling:

Good Practice Guidance

The following resources provide additional best practice recommendations for effective complaints management:

Sector-Specific Resources

These resources support the organisation in maintaining a person-centred approach to complaints handling:

  • Social Care Institute for Excellence (SCIE): Complaints in Health and Social Care

  • Advocacy Services

    • Information on independent advocacy for individuals making complaints (Good practice).
    • URL: [Insert Local Advocacy Service URL or National Advocacy Service URL]

Internal References

The following internal documents and procedures must be cross-referenced to ensure consistency in complaints handling:

  • [Organisation’s Safeguarding Policy]
  • [Organisation’s Data Protection and Confidentiality Policy]
  • [Organisation’s Quality Assurance Framework]

Staff must ensure they access the most up-to-date versions of these documents. Where a URL is unavailable or subject to change, staff should verify the reference through the issuing body’s official website or contact the compliance lead for support.

Download this policy as a Word document

Get a fully formatted, editable .docx file you can customise with your organisation’s details — just enter your email below.

This is one of 590+ policies in the MyCarePolicy library

View all free samplesBrowse individual policies