Complaints

Controls 

Document Control

Target audience:	All staff and clinicians working at the clinic
Document Author:	Aesthetics Comply Ltd
Approved By:	Dr Samet Sendur	Approval Date:	August 2024
Implementation Date:	August 2024	Reference Number:	AC103

Reviewed By (First review due Aug 2025)

Reviewer:	Dr Samet Sendur	Review Date:
Next Review Date:

Change Log

Last Amended:
Reason for Review:
Changes Made  (if any):

Version History

Version:	Date:	Author:	Reason:
V1	August 2024	Aesthetics Comply

Equality Impact Statement

This policy has been equality impact assessed and it is assured to be fair and does not present any barriers to participation or disadvantage any protected groups.

1. Introduction

Mayclinik is committed to providing high-quality healthcare services to all our patients. Our aim is to understand and assess the needs and desires of each of our patients, to create bespoke treatment plans, within a safe and comfortable environment that promotes the privacy and dignity of every patient.

Mayclinik recognises that there will be times when patients, their families or carers, staff and others are dissatisfied with aspects of the care and services provided. Mayclinik is committed to dealing with any issues that may arise as quickly and effectively as possible.

The potential effects on patients, relatives and staff when things go wrong can be devastating. Duty of candour, implemented under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Regulation 20, outlines the principles that staff should use when communicating with patients, relatives and/or carers following an incident where harm has occurred or where there is a risk or possibility that the incident could lead to or result in harm. It underpins a culture of honesty, openness, and transparency, and is a duty on everyone at Mayclinik. (For more information on duty of candour, see the separate Duty of Candour Policy).

When Mayclinik makes sure that concerns and complaints are dealt with in a timely manner, the risk of escalation is minimised. Also, the opportunity to find satisfactory resolution to the problem is maximised.

We value your feedback and appreciate you bringing any concerns or complaints to our attention and will ensure that this Complaints Policy is fair and accessible to all.

The Complaints Lead in Mayclinik is the Registered Manager, Dr Samet Sendur.

1. Policy Statement / Purpose

All concerns and complaints will be treated seriously and investigated promptly in accordance with the procedures outlined in this policy. Staff will receive training to deal with concerns and complaints. Mayclinik will ensure that everyone including staff and patients has access to this policy in order to raise a concern or make a complaint. Mayclinik is committed to ensuring that no one is prevented from highlighting concerns or complaints.

Mayclinik will also make sure that all lessons learned from feedback are used to improve the quality of care and services provided. Recommendations from feedback will be shared at 1:1 supervision session, to ensure changes take place business-wide, and implemented where appropriate. Mayclinik recognises its legal responsibility to respond appropriately and effectively to complaints (Health and Social Care Act 2008 (Regulated Activities) Regulations 2014).

1. Scope

This policy outlines our commitment to handling complaints about services at Mayclinik and ensures that complaints are resolved promptly and fairly. 

This policy applies to all staff at Mayclinik and patients.

1. Terminology and Definitions 

Complainant:	The person who makes a complaint.
Complaint:	An expression of dissatisfaction about an act, omission or decision, either verbal or written, and whether justified or not which requires a response. A complaint is also negative feedback that patients provide about Mayclinik’s products, services or support experience.
‘Just Culture’:	“Just Culture” refers to a system of shared accountability in which organisations are accountable for the systems they have designed and for responding to the behaviours of their employees in a fair and just manner. This means that employees are not apportioned unconstructive guilt or blame for genuine mistakes, but that they always remain accountable for deliberate policy deviations.
Complaints Lead:	A senior member of staff appointed to handle complaints
Patient:	An individual seeking or undergoing treatment, investigation or examination at Mayclinik. This patient may also be known as a person or people.
Staff / Team / Employee:	All individuals involved with seeking consent to examination, treatment or investigation under employment within Mayclinik.

1. Submitting Feedback

Concerns can be given verbally or in writing to any staff.

Complaints must be submitted in writing (via email, letter or text) to the Complaints Lead. Where the complainant is unable to submit a complaint in writing, they will need to raise the complaint with the Complaints Lead, who will then record the complaint.

Comments on social media websites will not normally be seen as formal complaints unless submitted in writing as outlined above.

Mayclinik will ensure full information is provided, in different styles and languages where this is required, about this Policy in the form of leaflets and posters that are available throughout the business premises, including areas accessible to the public, and on Mayclinik website. 

Compliments

All compliments received in writing are to be documented and circulated amongst relevant staff. This way staff remain aware of the specific topics raised, and the number of compliments received. Staff are not required to record verbal compliments, but this is encouraged when possible. 

1. Concerns Management Procedure

This protocol applies to all complaints related to the services provided by Mayclinik including:

• Clinical care
• Administrative procedures
• Staff conduct
• Facilities, and 
• Equipment.

Concerns can arise out of a lack of understanding or lack of information. Very often matters are resolved by the provision of advice, an apology or by further information. Therefore, many concerns can often be dealt with at the time of their raising. Sometimes staff can take swift action to resolve a concern straightaway or find the most appropriate staff to help. Staff at Mayclinik should feel empowered to deal with concerns promptly and informally without the need for a more in-depth investthe igation. 

On receipt of a concern staff will:

• Ensure that the immeda iate health care needs of the person affected by the concern are being met (where the person affected is still in Mayclinik’s care)
• Offer the person raising the concern the opportunity to discuss their concern further 
• Make sure that the person raising the concern does not wish to make a formal complaint 
• Undertake any enquiries required to resolve the matter, and
• Respond to the person raising the concern with the appropriate information, advice, an apology and /or explain what has been done to resolve the matter.

Staff should aim to ensure that concerns are resolved as soon as possible upon being raised. At this stage, excellent communication is essential to prevent the concern from escalating into a formal complaint. Verbal communication either face-to-face or via telephone should be used primarily at this stage. However, if preferred by the person raising the concern, this can also be in writing, via email or text.

All concerns must be recorded on the incident management system, and should include details of the concern, how it was resolved, and any further actions required.   

When concerns cannot be resolved as stated above, forwarded these concerns to the Complaints Lead, who will discuss the issue with the person raising the concern and initiate the formal complaints process (outlined below), if required.

1. Making a Complaint

Complaints can be made in writing to samet.sendur@mayclinik.com or by phone 07754 700249or in person at the clinic. Please provide as much detail as possible about your complaint including:

• Your name and contact details
• The date and time of the incident
• A full description of what happened, and
• The impact of the incident on you.

1. Acknowledgement

We will acknowledge receipt of your complaint within three working days. 

Once a complaint has been received, it should be recorded on the incident management system. The acknowledgement should normally be in writing but if appropriate, can be given verbally. 

The person responsible for handling complaints at Mayclinik is Dr Samet Sendur, Registered Manager.

1. Investigation

The Complaints Lead will then investigate the complaint.’ The complainant must be informed of the name and contact details of the Complaints Lead at Mayclinik if the complaint is about the Complaints Lead.

The Complaints Lead will ensure that it is resolved without undue delay. Complainants should ordinarily receive a written response within 28 working days from the date of receipt. A timely response and one that is informed by comprehensive local action, will provide the best response to the complainant and the best opportunities for learning within the business. 

The complainant should be sent regular updates on the progress of the investigation and likely timescales for receiving the formal response. If agreed timescales cannot be met, it is essential that the Complaints Lead informs the complainant of the reason for the delay and mutually agree on new timescales. In conducting the investigation, the Complaints Lead may undertake any of the following:  

• Contact the complainant to identify the outcome that they are seeking
• Develop a timeline of what occurred  
• Identify any shortfalls in the level(s) of care provided
• Identify clear and assigned actions that will prevent recurrence and improve care quality
• Interview any staff involved in the incident
• Provide the complainant the opportunity to give their account and views of what occurred
• Review the relevant documentation, checking for evidence regarding issues raised, and
• When appropriate, using a root cause analysis, identify the causes/contributory factors/validity of the concerns that have been raised.

The Complaints Lead will then: 

• Decide whether the complaint should be upheld in full, upheld in part or not upheld, and
• Make a record of investigation details, outcomes, and actions to be taken on the incident management system. 

It is essential that every stage of the investigation is based on the best available evidence. The formal response from the Complaints Lead should be structured as follows: 

Describe how any action as a result of the complaint was or is proposed to be taken

Explain how conclusions about the complaint were reached, whether it was upheld in part, in full or not upheld

Explain an internal appeal if patients are not happy with the findings

Outline how the complaint has been considered, and  

Provide details of the regulatory body, if the complainant is still unhappy and wishes for their complaint to undergo external review. 

The Complaints Lead will ensure that a full written response is filed alongside the initial complaint on the incident management system. 

1. Complaint Time Limit

A complaint must be made not later than 12 months after the date the matter, which is the subject of the complaint, occurred. Or, if later, a complaint can be made, the date on which the matter, which is the subject of the complaint, came to the notice of the complainant.

1. Complaint Response

We will aim to provide you with a full and final response to your complaint within 20 working days. 

Complaint responses must:

• Conclude and evidence of how a decision was reached
• Outline our findings
• Any action taken to address the issue 
• Include a meaningful apology where it is due
• Include an explanation of how the complaint was considered
• Provide information about who was involved in the investigation
• Refer to any documents, guidelines or records that were considered
• Signpost the complainant to the next steps including details of the Local Government Ombudsman and

Tell the complainant what has been done to put things right, where appropriate.

Before sharing a response with the complainant, consideration should be given to any response which may contain sensitive, unexpected, and/or potentially harmful information or which may be delivered at a sensitive time (such as the anniversary of a death).

If, after receiving the formal response, the complainant is not happy with the outcome, they may write to the Complaints Lead to request an internal appeal.

1. Appeal Process

Upon receipt of an appeal the Complaints Lead will: 

• Carefully review the details of the initial investigation and outcome
• Contact the complainant to understand the reason(s) why they are unhappy with the initial investigation outcome
• Appoint an appropriate independent (non-biased) individual to carry out the appeal investigation
• Appoint an Independent Investigator, and
• Provide the complainant with the name and contact details of the independent investigator. 

The Independent Investigator will: 

• Review the initial investigation and outcome
• Contact or meet with the complainant to discuss their continuing concerns 
• Carry out further investigation, if necessary
• Decide whether the initial investigation outcome should be upheld or not, and
• Provide the complainant with relevant feedback and inform them of the appeal outcome. 

Once completed, the Independent Investigator will ensure that the incident management system is updated with the details of the appeal, including outcomes and actions taken. The Independent Investigator will also report their findings to the Complaints Lead.

1. Independent Review

If the complainant remains unsatisfied with the outcome of the internal appeal, they can refer their complaint to the Local Government Ombudsman or to Healthwatch Westminster.

Healthwatch Westminster contact details:

Phone: 07985461766 Monday to Friday 9am to 5pm

Email; info@healthwatchwestminster.org.uk.

At Mayclinik, our service is registered with the UK Healthcare Regulator, the Care Quality Commission (CQC). Service users can also escalate their complaint to the Care Quality Commission who will make note of the complaint and use it as part of their inspection process. They do not have an active role in dealing with complaints, however.

The CQC can be contacted at: 

Care Quality Commission, 

National Correspondence, 

Citygate, Gallowgate, 

Newcastle upon Tyne 

NE1 4PA, 

Tel: 03000616161, Monday to Friday 8.30am to 5.30pm

https://www.cqc.org.uk/contact-us/how-complain/complain-about-service-or-provider

1. Unreasonable Complainant Behaviour

Many complainants can feel angry and very aggrieved, sometimes with good cause. Although most complainants behave appropriately, a small number may make complaints that are malicious and vexatious, or they may make complaints that try to make life difficult for others. This may involve making serial complaints about different matters or persisting with the same complaint when nothing further can be done to assist them.

Distinguishing between people who make several complaints because they genuinely believe something has gone wrong and people who are simply trying to make life difficult is important. Complainants will often be frustrated and aggrieved. Therefore, it is important to consider the merits of the complaint rather than their attitude. 

The fact that a complainant has made a malicious complaint in the past, for example, does not necessarily mean that the next complaint is automatically malicious. Each complaint must be considered individually, and a decision made as to whether it is malicious or genuine. Complainants will be deemed to be malicious or habitual if they have met two or more of the following criteria:

• Being unable to identify specific issues they wish to be investigated despite all reasonable efforts to assist them.
• Being unwilling to accept documented evidence of care given as being factual, including denying receipt of an adequate response to their complaint.
• Displaying unreasonable demands or expectations and failing to accept that these may be unreasonable despite a clear explanation having been provided as to what constitutes unreasonable.
• Focusing on a trivial matter that is out of proportion to its significance (careful judgement should be used in using this criterion as it requires a subjective judgement).
• Frequently bringing up further concerns and questions to prolong contact with Mayclinik. (Staff at Mayclinik must not dismiss new issues, if they are significantly different from the original complaint. This new issue may be addressed as a separate complaint.)
• Harassing or being abusive on more than one occasion to the person dealing with the complaint. If the behaviour is sufficiently severe this may be sufficient to classify it as vexatious.
• Recording conversations or meetings electronically without the prior knowledge or consent of all parties involved.
• Persistence with pursuing a complaint despite Mayclinik complaints procedure (outlined above) having been fully exhausted.
• Placing unreasonable demands on Mayclinik’s staff. (Discretion is required by Mayclinik’s team to determine how many contacts constitute excessive, along with good judgement based on the specific circumstances of each individual case.), and
• Threatening or using physical violence towards staff. This will automatically cause verbal contact with the complainant to cease, with any further communication being solely in written format. Report any violence on the incident management system.

Careful judgement and discretion must be used to identify habitual and vexatious complainants and to decide the actions to take, including: 

• Declining further contact with the complainant, either in person, by telephone, letter, email, or text whilst ensuring that at least one route of contact remains available. 
• Inform complainants that in extreme circumstances Mayclinik reserves the right to refer unreasonable or vexatious complainants to the police, if appropriate.
• Informing the complainant that they are at risk of being classified as habitual or vexatious. A copy of this Complaints Policy should be sent to them. The complainant should also be advised to consider the criteria outlined when dealing with Mayclinik in the future.
• Notify the complainant in writing that the senior management team has responded fully to the points raised and has tried to resolve the complaint, and that there is nothing more to add and that continuing contact on the matter will serve no useful purpose, and that correspondence is at an end, and further communications will not be acknowledged or answered.

These measures should only be implemented following agreement and written notification of the course of action by the Complaints Lead to the complainant. The written notification should also include the reasons why the complaint was classified as habitual or vexatious, and it should be copied to those involved in the complaint. 

Habitual or vexatious status can be withdrawn by the Complaints Lead if a complainant demonstrates a more reasonable approach or submits a separate complaint for which the standard complaints procedure would appear to be appropriate. 

1. Confidentiality and Consent

Mayclinik have a legal duty to maintain the confidentiality of personal information. Mayclinik will not access or share information pertaining to complaints outside standard operating procedures at Mayclinik. 

All personal data received is recorded and stored on a secure server with limited authorised access. Information is retained in accordance with Mayclinik’s Data Protection Policy.

1. Complaint Monitoring and Lessons Learned

Mayclinik regards all forms of feedback as an opportunity to improve the levels of care offered to patients. Mayclinik operates within the ‘just culture in’ framework (see definition). The culture within Mayclinik is a supportive one, and any learning identified in feedback will be addressed. 

The Complaints Lead is responsible for ensuring that everyone at Mayclinik is kept informed of issues arising from complaints and lessons learned and proposed service improvements with staff.

1. Support for Staff 

The investigation of a complaint involving assault, allegations of malpractice, etc., can be stressful for the staff involved. Sensitivity and support at this time is required. An independent mentor (e.g., a manager from another area from the staff involved), will be identified to provide advice and support to the staff concerned during this difficult time.  

Staff may be asked to prepare statements or attend interviews when a complaint investigation takes place. The Complaints Lead will ensure that: 

• Good information governance practice is maintained and information about specific individuals is treated with respect and confidentially. Information sharing will only take place if required to conduct the investigation. 
• Guidance is given pertaining to areas of information required from staff in a timely manner, allowing time for staff to gain support from colleagues and/or unions.
• Interviews are conducted in a professional and supportive manner.
• Staff know that the review is being conducted as part of a learning and safety culture, as opposed to the apportioning of blame. 
• Staff are kept up to date on review progress.

1. Responsibilities

The Complaints Lead, Dr Samet Sendur, has the ultimate responsibility for guiding and supporting Mayclinik when dealing with complaints, the complaints process and the resulting actions. 

The Complaints Lead is also responsible for ensuring that this policy is implemented and adhered to across Mayclinik.

1. Policy Monitoring / Records Management

This policy will be monitored, reviewed, and amended annually by the Complaints Lead.

Records Management

All feedback paperwork will be retained for a minimum of 3 years. Any archived paper files will be stored in a secure manner, in order to preserve confidentiality. 

Feedback related correspondence should not, in any circumstances, be retained in the care record of a person; this should only record information that is strictly relevant to their health. 

The security and retention of information on the incident management system is the responsibility of the Complaints Lead.

1. Governance 

This policy is owned and maintained by the Complaints Lead, Dr Samet Sendur.

The implementation of this Policy is the responsibility of the Complaints Lead, Dr Samet Sendur.

The document owner, Dr Samet Sendur, is responsible for monitoring and reviewing the effectiveness of this policy document. This will be achieved at the point this Complaints Policy requires a review e.g. changes in legislation, findings from incidents or document expiry.

An audit of the complaints process is to be reviewed annually.

1. Key Legal Principles / Legislation 

Key legislation and case law:

• Care Act 2014
• Compensations Act 2006
• Data Protection Act 2018
• Human Rights Act 1998
• Mental Capacity Act 2005, and
• The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

1. Other Related Policies 

This policy should be read in conjunction with the following Mayclinik policies:

• Data Protection Policy
• Duty of Candour Policy
• Grievance Policy
• Information Governance and Record Keeping Policy 
• Safeguarding Policy, and 
• Whistleblowing Policy. 

1. Reference Documents and Guidance

In the event of conflict between the contents of the referenced documents and this document, this document shall take precedence. 

1. Complaints Matter, CQC, December 2014 20141208 complaints matter, report.pdf (cqc.org.uk).
2. CQC Receiving and acting on Complaints Regulation 16: Receiving and acting on complaints | Care Quality Commission (cqc.org.uk).
3. Complaints Matter, CQC, December 2014.
4. How to complain about a care home or care in your home – self-funded or council-funded, Local Government Ombudsman Home – Local Government and Social Care Ombudsman.
5. Mental Capacity Act Code of Practice.
6. NHS Complaint Standards: Summary of expectations NHS Complaint Standards: Summary of expectations | Parliamentary and Health Service Ombudsman (PHSO).
7. Parliamentary and Health Service Ombudsman: My expectations for raising concerns and complaints My expectations for raising concerns and complaints | Parliamentary and Health Service Ombudsman (PHSO).
8. Report of the Mid Teamordshire NHS Foundation Trust Public Inquiry, Francis, 2013. https://www.gov.uk/government/publications/report-of-the-mid-teamordshire-nhs-foundation-trust-public-inquiry, and
9. The Local Authority Social Services and National Health Service Complaints (England), Regulations 2009.