Governance & Complaints Policy

Clinical Governance

Clinical Governance is an umbrella term which encompasses arrange of activities in which clinicians should become involved in order to maintain and improve the quality of the care they provide to patients and to ensure full accountability of the system to patients.

Cantourage Clinic has a robust Clinical Governance framework, supporting high quality service delivery and promoting the ethos of continuous service improvement.

An elected heath care professional chairs the Quality, Safety, Quality & Innovation Committee which uses information from a variety of sources to evaluate our service delivery against the current regulatory standards and industry guidance.

This information includes but is not limited to:

o Patient feedback

o Patient reported treatment outcomes

o Team training and development activity

o Clinical and non-clinical incidents

o Internal policy and procedure documents

o Audit and compliance check findings

The notes, actions and outcomes from these meetings are circulated throughout the staff team and reported to the Cantourage Clinic leadership team.


1. Background.

It is important to patients, their supporters, staff &all stakeholders that every complaint is dealt with in a timely, impartial and confidential manner, which is consistent with the standards of the Care QualityCommission (CQC). It is Cantourage Clinic policy to monitor patient relations through patient feedback process and by the analysis of all complaints received. In the event of a matter is not resolved to the satisfaction of theComplainant, Cantourage Clinic will facilitate mediation or adjudication. This policy outlines Cantourage Clinic procedures and responsibilities for handling any concerns, issues or complaints that may arise.


2. Purpose & objectives.

The purpose of this policy is to ensure that any complaints or concerns by service users are correctly managed.

Cantourage Clinic will ensure:

·      All Complaints are dealt with efficiently and are properly investigated.

·      Complainants are provided with an outcome in respect of complaint investigations.

·      Complainants are aware of their right to take a complaint to independent review, if the complainant is not satisfied with the way their complaint has been dealt with by Cantourage Clinic.

·      Any person making a compliant is treated with courtesy and receives appropriate support throughout the handling of a complaint and be aware the fact that they have complained will not adversely affect their future treatment.

·      When mistakes happen, they shall be acknowledged; an apology made; an explanation given of what went wrong; and the problem rectified quickly and effectively.

·      The organisation learns lessons from complaints and uses these to improve our services.


3.Duties and responsibilities

The Registered Manager holds overall responsibility for ensuring the development, implementation and operation of this policy regarding complaints.

The Registered Manager will also lead and oversee the process of the implementation of this policy, as well as monitoring its compliance and effectiveness.

The Registered Manager will review all complaints received and acknowledge within 3 working days.  

The Registered Manager will identify a Cantourage Clinic team member with an appropriate skill set to investigate the compliant. Formal responses will be signed and authorised by the Registered Manager.

In the absence of the Registered Manager the Executive Team will oversee .


The Registered Manager is responsible for the effective management of the complaint’s procedure.

The Registered Manager and/ or  Executive team are responsible for ensuring that action is taken if necessary, in the light of the outcome of a complaint or investigation dependant on the nature of the compliant and outcome.


4. Policy Statement

Everyone has the right to expect a positive experience. In the event of concern or complaint, service users have a right to be listened to and to be treated with respect.

As an authorised provider, Cantourage Clinic will manage complaints properly, so user concerns are dealt with appropriately. Good complaint handling matters because it is an important way of ensuring our users receive the service they are entitled to expect.

Complaints are also a valuable source of feedback; they provide an audit trail and can be an early warning of failures in service delivery. When handled well, complaints provide an opportunity to improve service and reputation.


Our Aims & Objectives.

We aim to provide a service that meets the needs of our service users and we strive for a high standard of care.

We welcome suggestions from service users and from our staff about the safety and quality of service, treatment and care we provide.

We are committed to an effective and fair complaints system and support a culture of openness and willingness to learn from incidents, including complaints.


5. Our Complaints principles.

Service users are encouraged to provide suggestions, compliments, concerns and complaints and we offer a range of ways to do it.

All complainants are treated with respect, sensitivity and confidentiality.

All complaints are handled without prejudice or assumptions about how minor or serious they are. The emphasis is on resolving the problem.

Service users and staff can make complaints anonymously if they wish, however we can not respond anonymous complaints

Service users will not to be  victimised or suffer any unjust adverse consequences because of making a complaint about standards of care and service.


6.Managing Complaints

All staff are expected to encourage service users to provide feedback about the service, including complaints, concerns, suggestions and compliments.

Staff are expected to attempt resolution of complaints and concerns at the point of service, wherever possible and within the scope of their role and responsibility.

Our staff will consult with their manager if addressing the problem is beyond their responsibilities.

Feedback will be categorised as a concern:

When a patient has expressed a difficulty or a doubt over an issue, they consider important  that can be resolved with reassurance and additional explanation.

A complaint will be defined as an expression of dissatisfaction however made, about  action/s taken or the  lack of action taken.



All complaints should be raised  in writing directly with the Registered Manager in the first instance and should normally be made as soon as possible / within6 months of the date of the event complained about, or as soon as the matter first came to the attention of the complainant.

Patient will be given a copy of our complaints procedure and invited to attend a face-to-face or remotely accessed meeting or offered a call(specifically to discuss the issues ) with the Registered Manager (with other relevant parties) . This is  to talk through  concerns and to try and resolve the issue at an early stage.

The Registered Manager will initiate the  process of investigation to include reviewing the case in detail and taking statements from all staff members / doctors concerned. The Registered Manager responds directly to the person who has made the complaint, whether the complaint was made verbally, by letter, text or email, however we do not respond to complainants via email.

To make a formal complaint the complainant should write ore-mail the provider clearly stating the nature of their complaint and as much detail concerning dates, times and if known names of staff members. This will enable us to acknowledge and address the issues raised promptly and effectively.

The Registered Manager will acknowledge receipt of a written complaint, to the complainant’s postal address provided within 3 working days of receipt. The Executive will ensure this is completed in the RegisteredManagers absence

The Registered Manager or other designated person will investigate all complaints. Where Provider is unclear on any point or issue regarding the complaint, it will contact the complainant to seek clarification.

A full response to the complaint will usually be made within28 days or, where the investigation is still in progress, send a letter explaining the reason for the delay to the complainant, at a minimum, every 28days. The aim should be to complete this stage (stage 1) in most cases within three months.

If the complainant is dissatisfied with the response to their complaint, they can escalate their complaint to Stage 2, and must do so in writing, within 6 months of the final response to their complaint at Stage1.

Complaints and concerns will be recorded in a compliant log by the Registered Manager or assigned other.


8. If a complaint is not resolved (Stage 2.)

If the complainant escalates their complaint to Stage 2, theRegistered Manage or designated other will provide a written acknowledgement to complainants within 3 working days of receipt of their stage 2 complaint.

The Registered Manager will have arrangements in place by which to conduct an objective review of the complaint. Normally this will involve a senior member of staff who has not been involved in handling of the complaint at stage 1.

Stage 2 shall involve a review of all the documentation and may include interviews with relevant staff. The records made as part of the stage 2 review should be complete and retained since these may be required fora stage 3 process.

Provide a review of the investigation and the response made at stage 1.

Invite the stage 1 respondent to make a further comment/response to explore the possibility of the opportunity to resolve the complaint, by taking a further look at a specific matter. The complainant should be kept informed where this happens.

Consider whether the review at stage 2 would be supported by facilitating a face-to-face meeting (or teleconference, where acceptable)between the complainant and those who responded to the complaint at stage 1.

Provide a full response on the outcome of the review within 28 days or, where the investigation is still in progress, send a letter explaining the reason for the delay to the complainant, at a minimum, every 28days.

The aim should be to complete the review at stage 2 in most cases within three months.

If the complainant is dissatisfied with the response to their complaint at stage 2, they may escalate their complaint to Stage 3.


9. Centre for effective dispute resolution (Stage 3.)

At Stage 3, complainants have the right to refer to The Centre for Effective Dispute Resolution (CEDR)

Requests for these services should be made via the CEDR web page cannot access Stage 3 until they have gone through Stages 1 and 2


CEDR contact details are as follows:

By Post:

70 Fleet Street, London, EC4Y 1EU


Telephone: 020 7520 38000


10. Staff training

All staff approving & signing complaints will be appropriately trained to manage complaints.

Regular reviews are conducted to check understanding of the complaints process among our staff.


11. Promoting feedback

Information is provided about the complaints policy via our web page


12. Risk assessment.

After receiving a formal complaint, the Registered Manager reviews the issues in consultation with relevant staff to decide what action should be taken, consistent with the risk management procedure.


13.Assessing resolution options.

Formal complaints are normally resolved by direct negotiation with the complainant, but some complaints are better resolved with the assistance of CEDR.

The person managing the complaint will engage an appropriate external individual or body  if:

The complaint is against a senior manager who will be responsible for investigating the complaint, resulting in a perception that there is a lack of independence; or

The complaint raises complex issues that require external expertise.

The complaint cannot be resolved internally to the service user’s satisfaction.



Formal complaints are acknowledged in writing within 3 working days.

The acknowledgment provides contact details for the person who is handling the complaint, how the complaint will be dealt with and how long it is expected to take.

If a complaint raises issues that require notification or consultation with an external body, the notification or consultation will occur within three days of those issues being identified.

Formal complaints are investigated and resolved within 28days.

If the complaint is not resolved within that time days, the complainant will be provided with an update.


15.Records & privacy

Cantourage Clinic maintains a complaint register.

Personal information in individual complaints is kept confidential and is only made available to those who need it to deal with the complaint.

Complainants are given notice about how their personal information is likely to be used during the investigation of a complaint.

Individual complaints files are kept in a restricted access section of the computer system’s file server accessible by the Registered Manager.


16.Disclosure & fairness.

Complainants are initially provided with an explanation of what happened, based on the known facts.

At the conclusion of an inquiry or investigation, the complainant and relevant staff are provided with all established facts, the causal factors contributing to the incident and any recommendations to improve the service, and the reasons for these decisions.


17. Investigation & resolution

The Cantourage Clinic Quality, safety & innovation team, carries out  a review of complaints to identify what happened, the underlying causes and future preventative strategies.Information to investigate a complaint  is gathered from:


·      Talking to staff directly involved.

·      Listening to the complainant’s views.

·      Reviewing medical records and other records; and

·      Reviewing relevant policies, standards or guidelines.


18.Complaints about individuals

Where an individual staff member has been mentioned specifically by a complainant, the matter will be investigated by the relevant manager or supervisor, who will:

·      Inform the staff member of the complaint made against them.

·      Ensure that, if possible, the member of staff does not have any contact with the complainant during the investigation period, or afterwards if deemed appropriate.

·      Ensure fairness and confidentiality is maintained during the investigation; and

·      Encourage the staff member to seek advice from their professional association/body, if desired.

·      The staff members will be asked to provide a factual report of the incident, identify systems issues that may have contributed to the incident and suggest possible preventive measures.


Where the investigation of a complaint results in findings and recommendations about individual staff members, the issues are addressed through the Disciplinary or other appropriate process.


19.Reporting & recording complaints

The Registered Manager prepares regular reports on the number and type of complaints, the outcomes of complaints, recommendations for change and any subsequent action that has been taken. The reports are provided to staff and senior management, and if appropriate, uploaded into personal portfolio for audit and appraisal.


The Registered manager may periodically prepare case studies using anonymised individual complaints to demonstrate how complaints are resolved and followed up, for the information of staff, and for use in audit and appraisal.

Information about trends in complaints and how individual complaints are resolved is routinely discussed at staff meetings and clinical review meetings as part of reflecting on the performance of the service and opportunities for improvement.

Complaints reports are considered and discussed at monthly clinical review meetings and directors’ meetings.

An annual quality improvement report is published that includes information on:

The number and main types of complaints received, common outcomes and how complaints have resulted in changes.

How complaints were managed—how the complaints system was promoted, how long it took to resolve complaints (and whether this is consistent with the policy) and whether complainants and staff were satisfied with the process and outcomes; and

The results of any service user satisfaction survey.

The service promotes changes it has made because of service user complaints and suggestions in its general publicity.


20.Monitoring & evaluation

The complaints manager continuously monitors the amount of time taken to resolve complaints, whether recommended changes have been acted on and whether satisfactory outcomes have been achieved.

The complaints manager annually reviews the complaints management system to evaluate if the complaints policy is being complied with and how it measures up against best practice guidelines. As part of the evaluation, users and staff will be asked to comment on their awareness of the policy and how well it works in practice.












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