This procedure sets out LIPS HEALTHCARE’s approach to the handling of complaints and is intended as an internal guide who should be made readily available to all staff and also a summary setting out the approach to complaint handling should be available at reception for any patient requesting a copy.

From 1^st April 2009 a common approach to the handling of complaints was introduced across health and adult social care. This procedure complies with this.

LEGAL AND REGULATORY FRAMEWORK

The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (Regulation 16: Receiving and Acting on Complaints).
Care Quality Commission (CQC) Standards on Complaints Handling
UK GDPR and the Data Protection Act 2018
Duty of Candour (Regulation 20, HSCA 2008 Regulations)

POLICY

LIPS HEALTHCARE will take reasonable steps to ensure that patients are aware of:

The complaints procedure.
The time limit for resolution.
How it will be dealt with.
Who will deal with it?
Responsible Officer for handling complaints.
Right of appeal
Further action they can take if not satisfied.
The fact that any issues will not affect any ongoing treatment from LIPS HEALTHCARE and they will continue to be treated.

PROCEDURE

Receiving complaints: complaints can be made by

Any current or former patient of LIPS HEALTHCARE.
A person acting on behalf of a patient, with the patient’s consent.
Where a patient is incapable of making a complaint, or has died, a relative or another adult who has an interest in their welfare.

Complaints raised by consultants, staff, or other stakeholders on behalf of a patient must have the patient’s consent to proceed under this policy. Staff concerns relating to employment or whistleblowing should follow the appropriate HR or whistleblowing procedures

Period within which complaints can be made

The period for making a complaint is normally 6 months from the date of the event, or 6 months from the date the complainant became aware of the issue. Complaints received outside this timeframe may still be considered where it is still possible to investigate them fairly and effectively

All complaints will be acknowledged no later than three working days after the day the complaint is received (the acknowledgement will usually be in writing but can be verbally in some circumstances although this should be the exception rather than the norm).

An offer should be made to discuss with the complainant the following:

The handling of the complaint
Timescales for responding
Expectations and desired outcome if unclear

If the complaint has been made verbally, the complainant should be given a copy of their verbal statement which is considered the formal complaint and asked to confirm that it represents the issues they wish to raise

Nada Salama, the Complaints Manager, has the discretion to extend the time limits if the complainant has good reason for not making the complaint sooner, or where it is still possible to properly investigate the complaint despite extended delay.

When considering an extension to the time limit it is important that the Complaints Manager or the Clinician takes into consideration that the passage of time may prevent an accurate recollection of events by the clinician concerned or by the person bringing the complaint. The collection of evidence, Clinical Guidelines or other resources relating to the time when the complaint event arose may also be difficult to establish or obtain. These factors may be considered as suitable reason for declining a time limit extension.

Action upon receipt of a complaint

It is always better to try and deal with the complaint at the earliest opportunity and often it can be concluded at that point.
If it is not possible or the outcome is not satisfactory the patient should be asked to put it in writing. This ensures that each side are well aware of the issues for resolution. If the patient does refuse to put it in writing then it is advisable for LIPS HEALTHCARE to put it in writing and check that the patient is happy with the detail of the complaint.
On receipt of a written complaint, an acknowledgement will be sent within 3 working days. We aim to provide a full written response within 20 working days. It should also say who is dealing with it i.e. manager.
We aim to provide a full written response within 20 working days of receiving the complaint. If this is not possible, we will provide a written update at 20 working days and then at least every 20 working days thereafter until the final response is issued
A full investigation should take place with written notes and a log of the progress being made.
It may be that outside sources will need to be contacted and if that is the case then a patient consent form will need to be signed to make such a request.

Safeguarding

Safeguarding is a key element of complaints management and review. It may be necessary to identify if any of the following elements are evident in the information/complaint:

Safeguarding concerns to the person, to include their ability to manage with daily living
Safeguarding concerns regarding the adequacy of care/support being provided to the person
Safeguarding concerns regarding the behaviour of a professional to a patient or carer
Safeguarding concern regarding the behaviour of the person/complainant to professional staff

All complaints staff must have at least Level 2 training in safeguarding to enable them to identify the key safeguarding concerns.

All complaints handlers from will require a DBS check as part of their recruitment process.

Unreasonable Complaints

Where a complainant becomes aggressive or, despite effective complaint handling, unreasonable in their promotion of the complaint, some or all of the following formal provisions will apply and will be communicated to the patient:

The complaint will be managed by one named individual at senior level who will be the only contact for the patient
Contact will be limited to one method only (e.g. in writing)
Place a time limit on each contact
The number of contacts in a time period will be restricted
A witness will be present for all contacts
Repeated complaints about the same issue will be refused
Only acknowledge correspondence regarding a closed matter, not respond to it
Set behaviour standards
Return irrelevant documentation

Keep detailed records

Final Response

This will include:

A clear statement of the issues, investigations and the findings, giving clear evidence-based reasons for decisions if appropriate
Where errors have occurred, explain these fully and state what will be done to put these right, or prevent repetition
A focus on fair and proportionate outcomes for the patient, including any remedial action or compensation
A clear statement that the response is the final one at Stage 1 (local resolution), or that further action or reports will be sent later
An apology or explanation as appropriate
A statement of the right to escalate the complaint, together with the relevant contact details
Advice on the next step in the process if the complainant is still not satisfied, such as:
An offer of a meeting with the Head of Service Delivery (HoSD) to try further reconciliation
Escalation to Stage 2: Complaint review, as outlined below

Stage 1 Local resolution

The complaint is considered locally by LIPS HEALTHCARE, based on the steps outlined in the PROCEDURE section of this policy, following which a response is sent back to the patient.

Stage 1 complaints will ordinarily be concluded within 3 months of receipt.

Stage 2 Complaint review If a complainant is dissatisfied with the initial outcome of their complaint, an internal escalation will take place prior to external referral.

Automatic escalation: Where dissatisfaction is expressed, the complaint will be referred to Ali Alnakeeb, the Head of Service Delivery (HoSD), within 48 hours.
Acknowledgement: The HoSD will acknowledge receipt of the escalation within 3 working days.
Review: The HoSD will review the complaint, the investigation undertaken, and any response provided. Where appropriate, further information may be requested from staff involved or the complainant.

Outcome: A further written outcome will be provided to the complainant within 20 working days of escalation (or sooner if possible). Where this timescale cannot be met, the complainant will be updated in writing with the reason for delay and a revised timescale.

Stage 3 ISCAS independent external adjudication

If the patient is still dissatisfied (s)he can take the complainant to ISCAS for final adjudication.
If, after stages 1 and 2, a patient is still dissatisfied, (s)he may request independent adjudication of the complaint at ISCAS. At this stage, complainants are asked to sign a ‘Statement of understanding and consent’, thereby agreeing to the parameters of Stage 3.
To find out more about ISCAS, including full documentation relating to the patient complaints process, please visit the ISCAS website here.

If at any time during the complaint process the complainant or their representative or advocate decides they would like to withdraw the complaint this request can be made either verbally or in writing. The withdrawal of a complaint will be acknowledged in writing.

Audit and Learning from Complaints

Complaints and complaint themes will be audited on a monthly basis. The findings will be reviewed to identify recurring issues, inform staff training, and support service redesign where required. This ensures that lessons are embedded and improvements to care and patient experience are continuously driven.

LIPS HEALTHCARE will establish an annual complaints report, incorporating a review of complaints received, along with any learning issues or changes to procedures which have arisen. This report is to be made available to any person who requests it, and may form part of the Freedom of Information Act Publication Scheme.

This will include:

Statistics on the number of complaints received
Justified / unjustified analysis
Known referrals to the Ombudsman
Subject matter / categorisation / clinical care
Learning points
Methods of complaints management
Any changes to procedure, policies or care which have resulted

Confidentiality

Complaints will be handled in the strictest of confidence in accordance and will be kept separately from patients’ medical records. Care will be taken that information should only be disclosed to those who have a demonstrable need to have access to it. Suitable arrangements are in place for the handling of patient identifiable data to meet the compliance of GDPR & Data Protection Act 2018 and other legal obligations such as the Human Rights Act 1998 and the common law duty of confidentiality

The Caldicott Report sets out a number of general principles that health and social care organisations should use when reviewing its use of patient or patient information. The designated Caldicott Guardians are responsible for ensuring that confidentiality is maintained. Confidentiality will be maintained in such a way that only managers and staff who are leading the investigation know the contents of the case. Anyone disclosing information to others who are not directly involved in this may be dealt with under disciplinary procedures.

LIPS HEALTHCARE must keep a record of all complaints and copies of all correspondence relating to complaints, but such records must be kept separate from patients' medical records.

Location Address: 349-351 The Power Station 1st Floor Battersea Power Station Turbine Hall Circus Road South , SW11 8DD

Registered Address: Solar House, 282 Chase Road, London, United Kingdom, United Kingdom, N14 6NZ

Policy created, approved, signed, and issued by: Ali Al Nakeeb

Issued and created on: 2025-08-15

Review date: 2026-08-10