CQC Quality Statement

Theme 4 – Leadership: Learning, improvement and innovation 

We statement

We focus on continuous learning, innovation and improvement across our organisation and the local system. We encourage creative ways of delivering equality of experience, outcome and quality of life for people. We actively contribute to safe, effective practice and research.

1. Introduction

A complaint can be made by an adult who has applied for or is in receipt of a service in relation to care and support, including a carer, or a person acting on their behalf. A service should not be delayed, withdrawn or suspended because a person has made a complaint.

The local authority’s complaints procedure should aim to achieve the best outcome for the

  • adult receiving the service,
  • the complainant (if different)
  • and the service.

Each complaint should be seen as an opportunity to improve the service offered.

There is a single complaints procedure for adult social care and the National Health Service (NHS). Where a complaint involves these two organisations or more, the complainant should receive a coordinated response.

2. Principles of Good Complaint Handling

Responding appropriately to complaints includes:

  • getting it right (legally and procedurally);
  • being customer focused;
  • being open and accountable;
  • acting fairly and proportionately;
  • putting things right;
  • seeking continuous improvement.

See Principles of Good Complaint Handling (Parliamentary and Health Service Ombudsman).

3. Complaints Criteria

The local authority’s complaints procedure may be used in relation to:

  • service quality or appropriateness of the provision;
  • delays in decision making or service provision;
  • failure to provide a service;
  • attitude or behaviour of staff;
  • application of eligibility or assessment criteria.

The local authority’s complaints procedure does not apply when the complaint:

  • relates to the actions of another local authority or an independent provider;
  • has already been investigated;
  • relates to an event that took place more than 12 months before (although discretion may be used in relation to this period if there is good reason why the person did not make an earlier complaint);
  • is about a Court decision;
  • should be dealt with under court proceedings, criminal proceedings, disciplinary proceedings, grievance proceedings or a tribunal.

4. Action to be taken on receiving a Complaint

The initial contact the service has with a person who is unhappy with the service they have been given is key.

4.1 Informal Resolution

Any person expressing a concern about a service should be listened to, so that the nature of the complaint is properly understood and wherever possible the issue causing concern can be quickly resolved locally and informally for example by a change in arrangements which can be managed easily within the person’s overall plan.

Where a quick resolution is possible without further investigation, for example through an apology, this should be done with the agreement of the relevant operational team manager so long as the complainant is happy with this outcome and there are no risks to others using services, for example because the complaint raises serious issues (see Section 7, Assessing Seriousness of the Complaint).

Any complaint received should be recorded and the Adult Social Care Complaints Unit should be notified even where a quick resolution is achieved.

4.2 Formal Complaints

If it is clear that the person wishes to make a formal complaint, this should be passed to the relevant operational team manager or equivalent. It is crucial for this manager to obtain all information that will allow the seriousness of the complaint to be assessed correctly (see Section 7, Assessing seriousness of the Complaint) and to enable the complaint to be resolved quickly if possible.

After receiving a complaint where a quick resolution is not possible, the Adult Social Care Complaints Unit should be notified within one working day and the complaint should be acknowledged within 3 working days.

The Adult Social Care Complaints Unit, in conjunction with the relevant General Manager, will identify a lead person to respond to the complaint and inform the complainant of the name of the lead person who will be contacting him or her about the complaint.

Where the complaint relates to two organisations, it should be agreed between the relevant organisations which of them will take the lead and a single point of contact should be given to the complainant.

The lead person will then be responsible for liaising with the other organisation throughout the duration of the complaint.

The lead person should contact the person making the complaint to arrange a face-to-face meeting to discuss the complaint and what the investigation can achieve.

Complaints can be resolved more effectively if it has been made clear from the outset what the person complaining expects as an outcome. If this is not a feasible or realistic outcome, then this must be explained to the complainant.

The lead person should agree a Complaints Plan with the complainant about the action required in relation to any support to be provided to the person making the complaint, and the process of the investigation including how and when the complainant will receive progress reports and the timescale for a final response (usually 10 to 25 working days but in exceptional circumstances this may be longer).

The Complaints Plan should be notified to the Adult Social Care Complaints Unit.

4.3 Safeguarding

Where any safeguarding issues are identified, the member of staff or manager should immediately refer the concerns under the Local Safeguarding Adults Board procedures, as appropriate.

5. Publicising the Complaints Procedure

See also Trafford Council’s Adult Social Care Complaints Procedure

People using services should be informed of the Complaints Procedure and how they can use it.

People must have access to advice and information about making complaints including how to complain and who to. Information should be jargon free, user friendly, available in different formats and languages and give advice on how to obtain more information and support.

Translation and interpretation facilities should be available if needed (see Interpreting, Signing and Communication Needs chapter).

People using services should also be advised that they can make a complaint directly to the Local Government Social Care Ombudsman.

6. Giving People Support and Advice when they Complain

There are many reasons why someone might need support (e.g. disability, language, age) and there are a number of services that help.

  • The Adult Social Care Complaints Unit can provide advice and support to people who receive services and their representatives (see Contact)
  • Advocacy can be used to help some people to make a complaint and to provide support given during the investigative process (see Independent Advocacy chapter).

7. Assessing Seriousness of Complaints

In order to ascertain the best course of action, it is essential to assess the seriousness of the complaint using a three step process (see How to Complain, Local Government and Social Care Ombudsman).

Step 1: Decide how serious the issue is


  • Unsatisfactory service or experience not directly related to care;
  • No impact or risk to provision of care or of not meeting persons eligible needs;


  • Unsatisfactory service or experience related to care, usually a single resolvable issue. Minimal impact and relative minimal risk to the provision of care or the service. No real risk of litigation.
  • Examples – cancelled appointments, missed call.


  • Service or experience below reasonable expectations in several ways, but not causing lasting problems. Has potential to impact on service provision; and some potential for litigation.
  • Examples – delayed discharge from hospital, miscommunication or misinformation.


  • Significant issues regarding standards, quality of care and safeguarding of or denial of rights. Complaints with clear quality assurance or risk management issues, which may cause lasting problems for the organisation and therefore require investigation. Possibility of litigation and adverse local publicity;


  • Serious issues that may cause long-term damage, such as grossly sub-standard care, professional misconduct or death. Will require immediate and in-depth investigation. May involve serious safety issues. A high probability of litigation and strong possibility of adverse national publicity.
  • Example – event resulting in serious harm, multiple failures, abuse or neglect, gross professional misconduct.

Step 2: Decide how likely the issue is to recur


  • rare: isolated or ‘one off’ -slight or vague connection to service provision;
  • unlikely / rare: unusual but may have happened before;
  • possible: happens from time to time – not frequently or regularly;
  • likely: will probably occur several times a year;
  • almost certain: recurring, frequent, predictable.

Step 3: Categorise the Risk

  • This will be determined by taking account of the seriousness of the complaint and the likelihood of its recurrence.

8. Investigating the Complaint

The purpose of the investigation into the circumstances and nature of the complaint is to establish the facts of what occurred. This should include – where appropriate – reviewing records, interviewing staff, conducting visits to the location involved and receiving specialist advice.

The person appointed as complaints investigator should be independent of the service to which the complaint relates and appropriately experienced and trained. Some serious cases will warrant the appointment of an independent external investigator.

Once evidence has been collated and analysed the investigator should produce a written report setting out a summary of the complaint, methodology used during the investigation, key findings, conclusions and recommendations for action. The decision made by the investigator should be fair and reasonable.

It should be noted that mediation may be useful in some cases.

9. The Outcome

Following the production of the report from the investigation findings, a written summary / explanation should be given to the complainant outlining:

  • the complaint;
  • how it was considered;
  • lessons learned;
  • proposed resolution of the complaint;
  • recommendations for action which have either already been taken or are proposed.

Prior to the letter to the complainant being sent, the outcome should be agreed with the relevant manager, who should also sign the letter.

It may be agreed that an invitation to the complainant for a meeting in person to go through the points in the letter would be useful.

The complainant should also be informed of their right to take the matter to the Local Government and Social Care Ombudsman, if they are not satisfied.

10. Unreasonable or Vexatious Complainants

Sometimes, complainants can be persistent or vexatious, for example by:

  • Making a series of complaints about a range of different issues;
  • Making the same complaint in different ways trying to achieve the outcome they want;
  • Raising a series of peripheral issues relating to a core complaint;
  • Having an unrealistic expectation about the outcome.

Just because someone is a persistent complainant, however, does not mean that their complaint is not valid. There should be no limit on the number of complaints someone can make. All should be dealt with positively, to try and find a satisfactorily resolve the situation with the complainant.

A vexatious or persistent complaint should be dealt with through the usual complaints process, as above. The complaints manager and service manager however, can take a view on ‘proportionality’ if it is clear that:

  • the complaint is made as a result of a difficult relationship the complainant has with the service / individual professional;
  • seeking a resolution is not the main outcome the sought by the complainant;
  • the complaint is not raising significant concerns about issues of practice;
  • the service may wish to satisfy itself in relation to the nature of the complaint, but needs to spend a proportionate amount of time and effort in doing so.

The managers involved should make a decision in relation to proportionality, recording both the decision and the reasons for making it on the complaint file.

10.1 Unreasonable Behaviour

On occasion, a complainant may become obstructive to the process, abusive or threatening to staff including those who are investigating the complaint.  In such circumstances restriction of access to the process can be considered, including:

  • Requiring communication only in writing;
  • Requiring communication through a designated officer;
  • Putting time limit on contact;
  • Placing restrictions on the number of contacts;
  • Reaching an agreement on acceptable conduct.

In extreme circumstances risk assessments may be conducted and the police involved (see Risk Assessments chapter). It may be necessary to seek early referral to the Local Government and Social Care Ombudsman should the relationship between the complainant and the local authority staff become too challenging.

11. Learning Lessons

The Complaints Unit should ensure a record of complaints is kept, including outcomes and lessons learned, together with any actions taken to improve services.

This information will be regularly shared with all managers.

An annual report must be produced by the Complaints Unit and presented to senior managers, including:

  • the number of complaints received;
  • analysis of the issues raised by the complaints;
  • the number of complaints upheld;
  • actions taken to improve services as a result; and
  • the number of cases referred to an Ombudsman.

12. Further Reading

12.1 Relevant information

Principles of Good Complaint Handling (Parliamentary and Health Service Ombudsman)

How to Complain (Local Government and Social Care Ombudsman)

Adult Social Care Resources (Local Government and Social Care Ombudsman) 

Was this helpful?
Thanks for your feedback!
Reading Confirmation
  • This form allows staff to confirm they have read chapters in this APPP. This can be useful for newly employed staff as part of their induction, supervision, CPD and for team discussions for example.

    When you complete and submit the form, the confirmation will be emailed to you at the address provided.

  • Hidden