Complaints handling policy (Reg 16)

1. What the regulation says

Any complaint received must be investigated and necessary and proportionate action must be taken in response to any failure identified by the complaint or investigation.

The registered person must establish and operate effectively an accessible system for identifying, receiving, recording, handling and responding to complaints by service users and other persons in relation to the carrying on of the regulated activity.

The registered person must provide to the Commission, when requested to do so and by no later than 28 days beginning on the day after receipt of the request, a summary of [complaints, responses, and any other relevant information requested].

The full text of the regulation is at https://www.legislation.gov.uk/uksi/2014/2936/regulation/16. Where this policy and the regulation diverge, the regulation wins.

2. Plain British summary

Every complaint must be investigated and proportionate action taken on anything the complaint or investigation surfaces. You have to run an accessible system for identifying, receiving, recording, handling and responding to complaints from service users and other people. If CQC asks for a summary of complaints, responses, and related correspondence, you have 28 days from the day after the request to provide it.

3. Scope

This policy applies to all employees, contractors, and external parties at who may receive, acknowledge, investigate, draft a response to, or sign off a complaint. It covers complaints from service users, families and representatives, members of the public, advocates, MPs, regulators (where a regulator forwards a complaint), and NHS commissioners. Both private-episode complaints (under Reg 16) and NHS-funded-episode complaints (under the Local Authority Social Services and National Health Service Complaints (England) Regulations 2009) are in scope; the platform records funding source per complaint so the right framework applies per record.

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4. Roles and responsibilities

• Registered Manager: accountable for the complaints system under Reg 16. Reviews every complaint at closure for response quality and change-to-practice. Signs off the quarterly complaints report.
• Nominated Individual: holds provider-side accountability.
• Complaints Manager (named individual; in small services often the Registered Manager): the day-to-day complaints authority. Acknowledges, investigates, drafts the response, tracks the response clock.
• Investigators (assigned per complaint): carry out the complaint investigation, gather evidence, interview involved staff, write findings. May be the Complaints Manager or a separate clinician depending on subject matter.
• Reviewers (assigned per complaint): the second-pair-of-eyes review on the draft response. Often the Registered Manager when the Complaints Manager investigates.
• All staff: know how to receive a complaint (in writing, verbally, by email, by phone), record it the same shift, escalate it to the Complaints Manager.

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5. Procedure

The complaints procedure operationalises Reg 16 (and the 2009 NHS Regulations where applicable) across the lifecycle from receipt to closure.

1. Receive and log. Any staff member who receives a complaint records it on the complaints register the same shift. The record captures the complainant's contact details, the source (in writing, verbal, etc.), the date received, the funding source for the episode complained about, and the complainant's preferred contact method.
2. Acknowledge. The Complaints Manager acknowledges the complaint in writing. For NHS-funded complaints this must happen within 3 working days of receipt per the 2009 Regulations. For private complaints under Reg 16 the provider's own policy sets the window (the platform default is 3 working days to align with the NHS standard).
3. Triage and assign. The Complaints Manager triages the complaint for severity and subject matter, decides whether the case needs a clinical investigator, and assigns ownership. Where the complaint also raises a safeguarding concern, an incident, or a Reg 18 notification trigger, those records are spawned and cross-linked.
4. Investigate. The assigned investigator gathers the clinical records, interviews the involved staff, reviews the policy or procedure under question, and writes the findings. Investigation timescale is per the assigned-on-complaint expectation; the Complaints Manager flags slipping investigations weekly.
5. Draft the response. The investigator (or the Complaints Manager) drafts the written response. For NHS-funded complaints the response must contain: an explanation of how the complaint has been considered, the conclusions reached, confirmation that any necessary action has been taken or is proposed, and notification of the right to take the matter to the Parliamentary and Health Service Ombudsman if dissatisfied. For private complaints the response is in proportionate plain British.
6. Review the draft. A reviewer reads the draft against the policy and against what the investigation actually found. Tone is checked: empathetic, factual, specific, not defensive.
7. Send the response. The signed response is sent through the complainant's preferred channel. The send timestamp, the sender, and a copy of the letter are attached to the record. For NHS-funded complaints this should happen within 6 months of receipt unless extended by written agreement with the complainant. For private complaints under Reg 16, "without unreasonable delay" applies.
8. Track follow-up. Where the complainant responds with further questions, a follow-up response is drafted, reviewed, and sent. Where the complainant escalates to the Ombudsman (PHSO for NHS), the provider cooperates with the Ombudsman's investigation.
9. Closure with change. Closure happens when the complainant has accepted the response, the response period has expired with no further contact, or the matter has moved to escalation. The closure paragraph records what changed at the provider as a result of the complaint. Improvement actions are opened where actions are needed; the actions cross-link to the complaint.
10. Quarterly pattern review. The Complaints Manager presents the aggregate complaints view at the monthly governance meeting: count by category, by service line, by site, response times, repeat patterns. Aggregate themes producing more than three complaints in a quarter are escalated.

6. Training requirement

• All staff who may receive a complaint complete complaint-receiving training at induction and every two years.
• The Complaints Manager completes complaints management training at appointment and refresher every two years.
• Investigators complete investigation skills training at appointment and every three years.
• The Registered Manager and Reviewers complete complaint-response writing training at appointment (the 2009 Regulations content requirements; tone and structure of a good complaint response).

Training records held in the tenant's training matrix register.

7. Audit

Compliance with this policy is monitored by the Complaints Manager and the Registered Manager:

• Per-complaint closure sign-off: every closure checked for response-content completeness, change-to-practice capture, and timeliness against the acknowledgement and response clocks.
• Quarterly response-timing audit: all complaints in the trailing 12 months checked against the 3-working-day acknowledgement and the 6-month response window for NHS-funded; against the Reg 16 "without unreasonable delay" for private.
• Quarterly theme pattern review: aggregate by category, site, service line, staff team.
• Annual policy review: the policy is read against the live Reg 16 text and the 2009 NHS Regulations.
• Reg 16(3) preparation: the read-only export of the trailing-12-month complaints summary is generated quarterly so the 28-day Reg 16(3) CQC-request window can be met without scramble.

Audit findings recorded in the tenant's audit register; actions logged in the improvement-actions register.

8. Record-keeping

Complaints records (the complaint itself, acknowledgement, investigation findings, draft response, sent response, any further correspondence, closure paragraph, cross-linked records) are held for a minimum of 8 years from the date of the last entry per the NHS Code of Practice on Records Management. NHS-funded complaints follow the 2009 Regulations 10-year minimum where it applies.

Records relating to children's complaints are retained until the child reaches the age of 25.

Verivius preserves the per-record audit trail indefinitely while the workspace is active.

6. Training requirement

All staff in scope complete at induction and at . Records are kept in .

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7. Audit

Compliance with this policy is monitored by on , through <named method, e.g., quarterly file audit of N records>. Audit findings are recorded in the tenant's audit register and reviewed at on .

(Tenant completes.)

8. Record-keeping

The records this policy generates are kept for , in . The retention period reflects <statutory requirement OR Verivius operational default, as applicable>.

9. Related policies in this pack

• Duty of Candour Policy (hscra-reg-20-duty-of-candour)
• Good Governance Policy (hscra-reg-17-good-governance)
• Safe Care and Treatment Policy (hscra-reg-12-safe-care-and-treatment)
• Safeguarding Adults Policy (hscra-reg-13-safeguarding-from-abuse)

10. Document control

This sample policy template was issued by Verivius as part of the Mock Inspection design partner onboarding pack. It is a template, not a substitute for legal advice or the tenant's own policy-development process. Where this template and the live regulation diverge, the live regulation wins.