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Complaints policy


The scope of the complaints procedure is to ensure effective implementation of the event reporting policy; to adequately capture and respond to any concerns or complaints raised by patients accessing the service. Lyphe strives to ensure that legislative processes are adhered to and effectively managed, to support patient safety and patient experience.

Lyphe’s ethos on complaints are: –

– To ensure transparency with patients; notifying them of their rights to make a complaint if they feel they are having a negative experience.

– Patients will be supported through the complaints procedure, and reminded that complaints are healthy for the organisation, as it allows for improvements of service delivery.

– Patients will not be penalised for making a complaint, and their care will not be impacted as a result.

– Patients have a right to their complaint being thoroughly investigated. – Patients have the right to be updated regarding the various stages of the complaints.

– Patients have the right to appeal the complaints decision, if they are unsatisfied with the outcome.

– Patients have the right to escalate their complaints to an independent review board, if they feel they were not adequately supported by the service.

– We have a duty of candour to rely any and all information to our patients, regarding their complaint and the outcome of their complaints, in line with confidentiality and data protection.

– Patient’s complaints to be utilised as lessons learnt for the organisation, and improvement of patient care, safety and experience.

The procedure outlines how complaints are managed within the organisation.


All staff at Lyphe Clinic including contractors


  • Lyphe Quality Assurance Policy
  • Lyphe Incident reporting policy
  • Lyphe Governance and Monitoring Policy
  • Safeguarding Policy


All patients are entitled to a positive health care experience, where their needs are met and they are treated with dignity and respect. In order to monitor clinical governance and patient experience, complaints are necessary to reviewing areas of improvements and provide the organisation with early warning signs of shortcomings in service provisions.

Initial Steps

  • Step 1 – Concern/complaint has been identified by staff.
  • Step 2 – Staff attempt to resolve the matter.
  • Step 3 – If staff are unable to resolve the matter, staff are to record the complaint on RADAR: event reporting | report new event | fill in details including actions taken (include patient ID no).
  • Step 4 – the staff member sends out “acknowledge letter stage 1”
  • Step 5 – the complaint is sent to the registered manager & resolution officer (RO), who either address the matter or allocate according.

Once allocated the resolution officer follows the stages of the complaint’s procedure, and document every stage:

Complaints procedure

Stage 1 – Local Resolution – Assistance Service Manager

  • The complaints handler is responsible to responding to the patient within 3 working days, to schedule a date and time to complete a fact find
  • The complaints handler will review all the patient records, listen to calls, & emails etc pertaining to the complainant’s matter
  • A fact find will be completed, where the complaints handler will interview all parties involved in the matter – use fact find complaints template.
  • The handler has 20 days to complete and respond to the complainant, if they are unable to achieve this deadline, the patient is to be updated via phone/email and a new deadline set. – use Stage 1 template (to respond)
  • If the complainant is unhappy with the outcome, then they can appeal – use appeals template

Stage 2 – Internal Appeal – Service Manager

  • Once the appeals template has returned, the RO will write to the patient acknowledging receipt of their appeal – use acknowledgement template S2.
  • The complaint is escalated to the service manager, who reviews all the information gathered at the fact find, and if they require additional information, can re-interview all relevant parties. (it’s good practice to re-interview).
  • The service manager updates the assistant manager and has 28 working days to respond to the appeal – use stage 2 template.
  • If the patient is not happy with the resolution, then they can appeal for it to go to stage 3 – use appeals template.

Stage 3 – Registered Manager

  • If the patient is still unhappy with their complaint, they can escalate their complaint to the registered manager for review.
  • The registered manager will email the patient within 3 working days to acknowledge receipt of complaint and arrange a date to meet within a fortnight.
  • The registered manager will review the complaint and gather all the fact find information pertaining to the complaint (2 weeks for review).
  • The registered will meet with the patient and discuss the finale outcome of the patient’s complaint and explore solutions moving forwards.
  • The registered manager then writes to the complaint outlining the final outcome – use stage 3 template.

Stage 4 – Independent external mediation / Director of Governance

  • If the complainant continues to feel unheard and unsupported, then they can signpost their complaint for mediation to Centre for Effective Dispute Resolution (CEDR); an independent mediation service.
  • Complainants cannot access stage 3 without going through stages 1 & 2, and CEDR will redirect them back to their care provider.
  • Once we received the appeal letter, then a final letter is sent to the patient with all the information required to liaise with CEDR regarding the complaint.
  • If the complainant wishes to engage in a mediation with the organisation, this can be conducted by either the director of governance or director of operations. 


All staff are responsible for escalating any complaints and concerns once made known and adequately document on RADAR. All staff are responsible for attempting to resolve concerns escalated to support the patient, prior to their concern impacting their welfare and resulting in a complaint.

The CQC registered manager is responsible for ensuring the development, implementation and review of the complaint’s procedure, as well as monitor its compliance and effectiveness.

The resolution officer is responsible for ensuring that all complaints are responded to in a timely manner, and that processes are adhered to, and all documentation is on the systems (Pabau/RADAR). All complaints are to be brought and discussed at the patient safety advisory meeting, outlining the stages of the complaints, actions taken and exploring with the wider senior management team, the barriers to supporting the patient and where applicable utilising the feedback to improve service delivery.


  1. Health and Social Care Act 2008; regulations 2012
  2. Relevant CQC Fundamental Standard/H+SC Act Regulation (2014) • Regulation 17: “Good governance”.
  3. Relevant CQC Fundamental Standard/H+SC Act Regulation (2014) • Regulation 20: ‘duty of candour’
  4. Relevant CQC Fundamental Standard/H+SC Act Regulation (2014) • Regulation 9: ‘person centred care’
  5. Relevant CQC Fundamental Standard/H+SC Act Regulation (2014) • Regulation 10: ‘dignity and respect’
  6. Relevant CQC Fundamental Standard/H+SC Act Regulation (2014) • Regulation 12: ‘safe care and treatment’
  7. Relevant CQC Fundamental Standard/H+SC Act Regulation (2014) • Regulation 13: ‘safeguarding service users from abuse & improper treatment’
  8. Relevant CQC Fundamental Standard/H+SC Act Regulation (2014) • Regulation 16: “receiving and acting on complaints”.
  9. Relevant CQC Fundamental Standard/H+SC Act Regulation (2014) • Regulation 17: “Good governance”.
  10. Equality & Diversity Act 2010
  11. Human Rights Act 1983
  12. Mental Capacity Act 2005
  13. Data Protection Act 2018
  14. UK GDPR
  15. Safeguarding Vulnerable Adults Act 2006