1. Purpose

1.1 To ensure that Care Counts Ltd has an effective system in place to manage complaints, suggestions and compliments.
1.2 To ensure that Care Counts Ltd complies with any legal requirements, regulations, guidelines and best practice.
1.3 To support Care Counts Ltd in meeting the following Key Lines of Enquiry:

Key Question – CARING
Key Lines of Enquiry – C2: How does the service support people to express their views and be actively involved in making decisions about their care, support and treatment as far as possible?

Key Question – RESPONSIVE
Key Lines of Enquiry – R2: How are people’s concerns and complaints listened and responded to and used to improve the quality of care?

Key Question – CARING
Key Lines of Enquiry – S1: How do systems, processes and practices keep people safe and safeguarded from abuse?

1.4 To meet the legal requirements of the regulated activities that Care Counts Ltd is registered to provide:

  •             Compensations Act 2006.
  •             The Care Act 2014.
  •             The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
  •             Human Rights Act 1998.
  •             The Local Authority Social Services and National Health Service Complaints (England) Regulations 2009.
  •             Mental Capacity Act 2005.
  •             Mental Capacity Act Code of Practice.
  •             Data Protection Act 2018.


2. Scope

2.1 The following roles may be affected by this policy:

  • All staff.

2.2 The following Service Users may be affected by this policy:

  •             Service Users.

2.3 The following stakeholders may be affected by this policy:

  •             Family.
  •             Advocates.
  •             Representatives.
  •             Commissioners.
  •             External health professionals.
  •             Local Authority.
  •             NHS.

3. Objectives

3.1 To improve the quality of the Service User’s experience.
3.2 To ensure that all complaints and suggestions are promptly addressed, resolved and shared within the agreed timescales to ensure that lessons are learned and that the learning improves service quality and delivery.

4. Policy

4.1 Complaints

  • Care Counts Ltd understands complaints to be an expression of dissatisfaction requiring a response, communicated verbally, electronically, or in writing. Complaints may be made by any Service Users, their family or advocate acting on their behalf, with their consent or in their best interests.
  • Care Counts Ltd takes complaints seriously. We will aim to put things right that have gone wrong and learn lessons to avoid the problem happening again. This policy sets out the framework for how Care Counts Ltd will achieve this. The detail of how Care Counts Ltd will do this will be found in the associated procedures.
  • Care Counts Ltd will comply with legislation, national guidelines, regulation and best practice when managing complaints and suggestions. A systematic approach will be taken with all aspects of complaints and suggestions.
  • Complaints or concerns by staff will be addressed via the grievance process if the complaint or concerns relates to them individually or the Whistleblowing procedure where a protected disclosure is made.
  • Care Counts Ltd understands our statutory obligations in respect of the Duty of Candour and will ensure we follow the agreed policy and procedure.

4.2 Care Counts Ltd will ensure that the complaints and compliments process at Care Counts Ltd is fair and transparent and does not discriminate directly or indirectly because of the following:

  • Age.
  • Being or becoming a transsexual/transgender person.
  • Being married or in a civil partnership.
  • Being pregnant or on maternity leave.
  • Disability.
  • Race including colour, nationality, ethnic or national origin.
  • Religion, belief or lack of religion/belief.
  • Sex.
  • Sexual orientation.

The complainant will feel free to complain without fear of reprisals and will be treated with courtesy, respect and compassion. Care Counts Ltd will ensure that the process of how to make a complaint and the feedback is provided in a way that meets the Accessible Information Standards and is in a format that the Service User can understand.

4.3 Seeking Views and Engaging with Service Users
Care Counts Ltd will seek out opportunities to obtain feedback from Service Users and stakeholders. Care Counts Ltd will act with sensitivity, integrity and professionalism by treating individuals who do complain or raise a suggestion with compassion, courtesy and respect.
The service will protect the Service User’s right to confidentiality. Care Counts Ltd will ensure that alternative methods of communication are available so that the complaints and suggestions procedures are accessible for Service Users who experience difficulties with communication or whose first language is not English.
Staff will undertake training on how to manage complaints in line with their role and responsibilities.

4.4 Care Counts Ltd understands that it can be difficult to separate a complaint from a concern, therefore, Care Counts Ltd will follow this policy when any dissatisfaction arises with the service.

4.5 A full record will be held of all complaints received regardless of the level of seriousness and means of communication. This approach allows an open and transparent culture around raising concerns in the earliest stage to allow resolution. A record of the complaint will also be held in the Service User’s Care file and reported in line with contractual or regulatory requirements.

4.6 Safeguarding Concerns
Where a complaint or concern is raised that relates to a Service User being harmed or likely to be harmed, Care Counts Ltd will follow its Safeguarding Policy and Procedures in addition to the complaints procedures, seeking advice and guidance from the Kirklees Council (KMC) Safeguarding Adults team and escalating concerns in line with Kirklees Council (KMC)         procedure. Care Counts Ltd will also notify CQC in line with our statutory duty.

4.7 Roles and Responsibilities

All Staff
It is acknowledged that all staff working within Care Counts Ltd may be presented with an individual wishing to raise a concern or complaint at any time, therefore staff need to be able to manage this in a sensitive, structured and timely manner. In order to do this staff will:

  • Be trained on induction and as a routine measure to ensure knowledge is embedded and refreshed around the complaints procedure.
  • Have access to the complaints procedure.
  • Be provided with the opportunity to reflect and learn from complaints as a          means of developing and driving quality care.
  • Appreciate that any feedback from Service Users or their representatives that is of concern needs immediate resolution, where possible, to their satisfaction. Care Plans will be updated to reflect the planned changes to care and the Registered Manager informed of the feedback. Failing to do this may result in a complaint.
  • Be clearly advised that on presentation of a complaint, swift escalation to management is necessary and purposefully withholding or concealing of concerns expressed by Service Users or their representatives may lead to disciplinary action.

Care Counts Ltd Management Team

  • The management team at Care Counts Ltd is responsible for ensuring compliance with this policy, regulations, improvement planning and having arrangements in place to provide relevant reports and information regarding complaints.
  • Mrs Samantha Burrows is the main point of contact for the receipt, investigation and management of complaints within Care Counts Ltd. However, this may be delegated to a senior member of staff within Care Counts Ltd who holds the experience, knowledge and competence to investigate and manage complaints.
  • Care Counts Ltd will ensure the procedure for raising a complaint is accessible and displayed prominently in Care Counts Ltd on the website of Care Counts Ltd and within the Service User information and guides. Alternative languages and formats will be available on request.

4.8 Compliments and Suggestions
Care Counts Ltd welcomes compliments and suggestions and recognises their importance in celebrating and recognising the success of our service and opportunities for improvement. We will engage with a wide range of stakeholders in addition to Service Users to support service development and improvement. We will share feedback with our staff.

4.9 One Complaint, One Response
Care Counts Ltd will follow the Local Government and Social Care Ombudsman best practice [insert hyperlink: https://www.lgo.org.uk/assets/attach/4355/Single%20comms2%20- %20v2.pdf] and where Service Users are receiving services for more than one organisation, we will ensure they can make a complaint to anyone and be provided with a single response following a joint investigation.

5. Procedure

5.1 Raising Complaints
A complaint can be received by Care Counts Ltd either verbally or in writing and can be made by:

  • Service Users.
  • Someone acting on behalf of a Service User and with their written consent, e.g. an advocate, relative, Member of Parliament.
  • Someone acting on behalf of a Service User who is unable to represent his or her own interests, provided this does not conflict with the Service User’s right to confidentiality or a previously expressed wish of the Service User.

Care Counts Ltd will ensure that Service Users are given information on how to make a complaint and the process once a complaint has been made, including any agreed timescales.

5.2 Time Limits for Submitting a Complaint
Complaints should be submitted within 12 months of the incident or concern arising. The time limit, however, can and should be waived, if:

  • It is still practical and possible to investigate the complaint (the records still       exist and the individuals concerned are still available to be questioned, etc.)
  • The complainant can demonstrate reasonable cause for delay in making the complaint It is at the discretion of the manager of the service if the time limit can be set aside.

5.3 Complaints Procedure:

Step 1
When a complaint is raised to staff, staff will make an effort to resolve it immediately to the satisfaction of the complainant.
Step 2
Staff will apologise for the fact that there was the need to complain in the first instance and explain the complaints process as described in the procedure steps.
Step 3
Staff will report the complaint to the most senior member of staff on duty and the complaint will be logged.
Step 4
Formal acknowledgment of all complaints received (whether verbal or written) will be sent within 3 working days to the complainant. This could be via letter or email. Care Counts Ltd will have a local system in place to manage out-of-hours and weekend complaints received.

The acknowledgment will include:

  • An invitation to meet and discuss the complaint.
  • Who will be investigating the complaint?
  • How the investigation will be handled – the response should state what the investigation will be focused on.
  • A time limit for the investigation to be concluded. This should be 28 days; however, some cases may take longer and the complainant will be made aware of this.
  • The complaints procedure and contact details of bodies that can be accessed in the event of dissatisfaction with the outcome of the investigation.

Step 5
Following a full investigation, a response letter will be sent and this will include the following:

  • A summary of the issue from the complainant’s point of view.
  • Details of the evidence and sources consulted in order to investigate the issue fully and fairly.
  • A presentation of the findings for each issue clearly and concisely described.
  • A conclusion, stating clearly whether the issue is “upheld”, “partially upheld” or “not upheld”; unless it is ineligible, in which case the reason for this will be given, e.g. out of time or out of the jurisdiction.
  • An explanation of the outcome and whether any remedial action or learning points arising from the investigation of that issue.
  • An apology where the issue is upheld and shortcomings or failings have been found.
  • The complainant’s rights if not satisfied with the outcome to refer to The Local Government and Social Care Ombudsman.
  • A signature from the responsible individual or sent by email in their name.

Step 6

The complaint will be closed once confirmation has been received that there is satisfaction with the outcome. In the event of dissatisfaction, Care Counts Ltd will support the complainant to access further support (refer to section 5.6).

5.4 The Complaints Log
A record will be held of all complaints raised and contain the following       information:

  • Each complaint received.
  • Subject matter and outcome.
  • Details of any reason for delay where investigations took longer than the agreed response period.
  • The date the report of the outcome was sent to the complainant.

Where complaints relate to a Service User, a copy of the complaint will be held in their care records so that the Service User can reflect on the recommendations.
Where complaints are raised by telephone, the log will include the date and time of the call and this will be followed up with written confirmation of the areas discussed.
Where a complaint indicates the potential abuse of Service Users, safeguarding policies will be followed as per local authority expectation and necessary notifications made to the regulatory body. Where Care is commissioned by Kirklees Council (KMC) their reporting procedure for notifying them of complaints will be followed.
Where complaints are to be shared as part of learning, the complaint will be anonymised so there is no identifiable Service User information.

5.5 Investigations
All investigations will be managed by using the following approach:

  • Investigating the fact.
  • Assessing evidence.
  • Review of records.
  • Interviewing those involved.

Where necessary, advice and support will be sourced via senior managers within the organisation. The complaint must be investigated by a member of staff with the knowledge, experience, and seniority to undertake the investigation robustly.
Confidentiality of information will be considered at all times and staff will adhere to the confidentiality policies and relevant codes of practice.
If an investigation of a complaint results in disciplinary action of staff within Care Counts Ltd, the complaint will continue to its conclusion. The complainant will be informed that the investigation has led to the disciplinary process, but the details of the outcome or ongoing investigation will remain confidential.

5.6 Unresolved Complaints
There are many bodies that can support or will need to be informed of       unresolved complaints:

1 Care Quality Commission
Individuals can escalate their complaint to the Care Quality Commission via:

Citygate, Gallowgate Newcastle upon Tyne NE1 4PA
Tel: 03000 616161
Fax: 03000 616171

2 The Local Government and Social Care Ombudsman (for those Service Users that are funded by local authority-funded social services care or self-funded)
Individuals have the right to raise their complaints to the Local Government and Social Care Ombudsman.
This is a free service and individuals can contact their Local Government and Social Care Ombudsman via: The Local Government and Social Care Ombudsman.
PO Box 4771
Coventry CV4 0EH
Tel: 0300 061 0614
Email: advice@lgo.org.uk
Website: https://www.lgo.org.uk/
Complaint form: https://www.lgo.org.uk/complaint-form
Individuals must be advised that the Local Government and Social Care Ombudsman will not investigate the complaint until the provider has had the opportunity to respond and resolve the matter in the first instance.

3 Parliamentary and Health Service Ombudsman (For Service User that are NHS funded)

Individuals have the right to raise a concern about a service that is NHS funded. This is a free service and individuals can contact via:

Mrs. Samantha Burrows can also signpost individuals to Healthwatch and the local independent complaints advocacy services (ICAS).

4 Clinical Commissioning Groups

Individuals can make a complaint about a health service they are receiving or have received and can discuss this with the commissioner of the service. Local contact details can be located here. [insert hyperlink: http://www.england.nhs.uk/ccg-details/#ccg-e ]

5 Local Authority Complaints Teams

Individuals have the right to raise concerns and complaints about adult social care regardless of whether or not they pay for their own Care or if the Council funds it. Individuals can make a complaint about organisations who provide services on the Council’s behalf. The contact details for the Local Authority Complaints Team are:
Local Authority Complaints Team.

6 Professional Bodies
If a complaint involves the serious misconduct of a healthcare professional, their relevant professional body can be informed and this is determined on an individual case basis in discussion with the Registered Manager.
For any external bodies managing complaints, Care Counts Ltd will work with the external body providing information as requested within any agreed timescales expected.

5.7 Compliments
Receiving compliments is an opportunity to celebrate and recognise success. Care Counts Ltd will ensure that:

  • All compliments are shared with staff and displayed in a public area to highlight good practice.
  • Compliments are anonymised or permission sought before displaying.
  • Numbers of compliments received are logged as part of a quality assurance programme.
  • Verbal positive feedback from Service Users and relatives is also deemed as compliments and will be recorded and shared with colleagues.
  • Compliments form a core agenda item at staff, Service User, and relative meetings.

5.8 Suggestions
Suggestions can be made verbally or in writing and generally are in response to seeking a means of changing practice for the better.

  • Suggestions are not complaints, but in some circumstances, if they are not considered or actioned they could lead to a complaint.
  • When suggestions are raised in a meeting or as part of a conversation, these will be documented and then outcomes of such suggestion recorded to show consideration.
  • Staff will be encouraged to share their suggestions or suggestions received by relatives and Service Users to the Registered Manager.
  • Mrs. Samantha Burrows at Care Counts Ltd will consider implementing a suggestion system to encourage comments from Service Users, staff, and visitors.

5.9 Audit and Evaluation
Care Counts Ltd will monitor, review, and analyse all information received about the service as a means of continuously reviewing performance, quality, and safety.
Care Counts Ltd will also:

  • Share themes and trends with Care Workers working for Care Counts Ltd.
  • Ensure that staff are trained to deal with complaints and understand the procedure for managing complaints.

5.10 Anonymous Complaints
Anonymous complaints will be investigated in the same way as named complaints. They will be logged and any corrective action necessary will be taken and also logged.

5.11 One Complaint, One Response
Where more than one organisation is involved in the Service User’s Care they, or their representative, will be able to complain to any of them and Care Counts Ltd will contact the other organisations, carry out a joint investigation and provide a single joint response. Service Users must not have to contact each organisation separately.
If someone complains and Care Counts Ltd is not responsible for the care or service complained about, rather than turning them away, Care Counts Ltd will share the concerns with the correct organisation(s). You will need the individual’s permission to do this. If the person prefers that their complaint is not shared with another organisation (or organisations), Care Counts Ltd will signpost them to the right organisation instead and provide the person with their contact details.
Care Counts Ltd will follow LGO guidance [insert hyperlink: https://www.lgo.org.uk/adult-social-care/adult-social-care-resources ] for managing this.
5.12 All efforts will be made by Mrs Samantha Burrows to resolve all complaints within Care Counts Ltd. If a Service User does not wish to raise a complaint directly to management within Care Counts Ltd, in the first instance, staff will try and sensitively establish their reasons why and aim to resolve and address any concerns that present.
Decisions to raise complaints outside of Care Counts Ltd will be fully respected and the Service User will be supported to raise their complaint to the commissioner of the service or to seek the support of an independent advocate or representative. Staff can also refer to section 5.6 for a further list of organisations that can be accessed.
Service Users can also be signposted to the Citizens advice guidance. [insert hyperlink: https://www.citizensadvice.org.uk/health/nhs-and-social-care-complaints/complaining-about-social-care-services/who-you-can-go-to- when-you-have-a-problem-with-an-adult-social-care-service/]

6. Definitions

6.1 Compliment

  • A compliment is an expression of satisfaction about a service the Service User has received.
  • Compliments are positive feedback that can be received verbally or in writing and can include expressions of praise, admiration, congratulation, and encouragement.

6.2 Complaint

  • A complaint is an expression of dissatisfaction, disappointment or discontent. This could be in response to an act of omission, decision or act.
  • Complaints can be made in various ways and include:
  • Verbally.
  • Electronically.
  • Local feedback channels.
  • Writing.

6.3 Self-Funded Care

  • Self-funded care is defined as care that is paid for entirely by the person receiving it.

Key Facts – Professionals
Professionals providing this service should be aware of the following:

  • Receipt of complaints, suggestions and compliments is everyone’s responsibility and therefore you will know what to say and how to respond. You need to be able to promote an open, honest and transparent service to encourage people to feel able to feedback and raise concerns.
  • You will be involved in quality improvement planning in response to themes from both compliments and complaints received by the service. Compliments will be recognised and celebrated and staff will be supported during any complaints investigations.
  • Any feedback received from Service Users or their representatives can influence positive change and quality delivery of care and must be discussed with your manager.

Key Facts – People affected by the service
People affected by this service should be aware of the following:

  • You have the right to feel confident to raise a concern, make a suggestion or give a compliment.
  • The process for you to raise a concern, make a suggestion or give a compliment will be simple and you will feel listened to and understood.
  • Your concerns, suggestions and compliments will make a positive difference to future care at Care Counts Ltd.

Further Reading
As well as the information in the ‘underpinning knowledge’ section of the review sheet we recommend that you add to your understanding in this policy area by considering the following materials:
LGO Resources for Letter Templates, etc:
Parliamentary and health service ombudsman: Principles of good complaint handling, 2009.
Care Quality Commission: Complaints Matter Report 2014.
Local Government and Social Care Ombudsman (2019) Caring about complaints: lessons from our independent care provider investigations: https://www.lgo.org.uk/information-centre/news/2019/mar/ombudsman-issues-good-practice-guide-for-care-providers