This policy outlines procedures and responsibilities within MC Clinic Ltd (“the Organisation”) for handling any concerns, issues or complaints that may arise.


  • Regulation 16: “Complaints”


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

MC Clinic Ltd, although an independent body aspires to meet the principles set out in the NHS Constitution which are:

  • The right to have any complaint made about our services dealt with efficiently and to have it properly investigated.
  • The right to know the outcome of any investigation into a complaint.
  • The right to take a complaint to independent review if the complainant is not satisfied with the way their complaint has been dealt with by us
  • The commitment to ensure service users are treated with courtesy and receive appropriate support throughout the handling of a complaint; and 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.
  • Demonstrating a commitment to ensure that the organisation learns lessons from complaints and claims and uses these to improve our services.

This policy serves to indicate how issues concerning service user concerns or complaints should be managed within the organisation.


The CQC Registered Manager holds overall responsibility for ensuring the development, implementation and operation of this policy regarding complaints. This will include appointment of a designated Complaints Manager.

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

Our designated Complaints Manager will be:

  • Responsible for managing the procedures for handling and considering complaints.
  • Ensuring that replies are drafted and signed by the CQC Registered Manager or other authorised person.
  • Responsible for ensuring that action is taken if necessary in the light of the outcome of a complaint or investigation.
  • Responsible for the effective management of the complaints procedure.


Everyone has the right to expect a positive experience and a good treatment outcome. 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, MC Clinic Ltd 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
  • We support a culture of openness and willingness to learn from incidents, including complaints.


  • 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 on a confidential basis or anonymously if they wish, and be assured that their identity will be protected.
  • Service users will not to be discriminated against or suffer any unjust adverse consequences as a result of making a complaint about standards of care and service.


  • 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.


  • All complaints should be raised directly with the Clinic Manager in the first instance and should normally be made as soon as possible / within 6 months of the date of the event complained about, or as soon as the matter first came to the attention of the complainant.
  • The Patient will be given a copy of our complaints procedure and invited to attend a face to face meeting with the Clinic Manager and other relevant parties to talk through their concerns and to try and resolve the issue at an early stage.
  • The Clinic Manager will go through a thorough process of investigation to include reviewing the case in detail and taking statements from all staff members / doctors concerned. The Clinic 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 or e-mail to 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 Clinic Manager will acknowledge receipt of a written complaint, to the complainant’s postal address provided (or via email) within 3 working days of receipt (unless a full reply can be sent within 5 days).
  • The Clinic Manager or their 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 within 20 working 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 20 working days. The aim should be to complete stage 1 in most cases within three months.
  • In the event that 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 Stage 1.


  • If the complainant escalates their complaint to Stage 2, the Clinic Manager will provide a written acknowledgement to complainants within 3 working days of receipt of their complaint at stage 2 (unless a full reply can be sent within 5 working days).
  • The Clinic 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 with the IHP, 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 for a stage 3 process.
  • Provide a review of the investigation and the response made at stage 1.
  • Invite the hospital or clinic that responded at stage 1 to make a further response, where there is an 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 20 working 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 20 working days.
  • The aim should be to complete the review at stage 2 in most cases within three months.
  • In the event that the complainant is dissatisfied with the response to their complaint they may escalate their complaint to Stage 3.


If the complainant remains unsatisfied after Stage 2, complainants have the right to an independent external mediation of their complaint. Requests for independent external mediation should be made to CENTRE for EFFECTIVE DISPUTE RESOLUTION (CEDR), in writing, within 6 months of receipt of the Stage 2 decision letter.

Complainants cannot access mediation until they have gone through Stages 1 and 2 and CEDR will direct complainants back to Provider where appropriate. To access mediation, complainants are asked to complete this application form, on the CEDR website thereby agreeing to the parameters of mediation.

CEDR contact details are as follows:

By Post:
CEDR, 100 St Paul’s Churchyard, London, EC4M 8BU
Email: [email protected]
Telephone: 0207 520 3800  


  • All staff will be appropriately trained to manage complaints competently.
  • Regular reviews are conducted by the complaints manager to check understanding of the complaints process among our staff.


  • Information is provided about the complaints policy in a variety of ways, including some or all of the following:
  • On our website;
  • Through our service user feedback brochure;
  • Publicity about the service;
  • Posters in reception;
  • Discretely located suggestion boxes; and by staff inviting feedback and comments.


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


Formal complaints are normally resolved by direct negotiation with the complainant, but some complaints are better resolved with the assistance of an alternative disputes resolution provider.

The complaints manager will signpost the complainant to an appropriate external 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 or in person within 48 hours.
  • 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 28 days.
    If the complaint is not resolved within that time period days, the complainant will be provided with an update.


  • The complaints manager maintains a complaints 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 secure filing cabinet in the complaints manager’s office and in a restricted access section of the computer system’s file server.
  • Service users are provided with access to their medical records in accordance with our Subject Access policy. Others requesting access to a service users’ medical records as part of resolving a complaint are provided with access only if the service user has provided authorisation in accordance with the Subject Access policy.


  • 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.


The complaints manager carries out investigations of complaints to identify what happened, the underlying causes of the complaint and preventative strategies.

Information 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.


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


The complaints 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 complaints manager periodically prepares 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 as a result of service user complaints and suggestions in its general publicity.


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.