Suggestions and Complaints

We welcome suggestions for improvements to our services.

We strive to provide the best possible care to all our patients and we always welcome your views or suggestions to help us improve our service to you.

If you have any suggestions for us on how our service could be improved please speak with one of the reception staff who will be more than happy to make a note and pass it on to the relevant staff.

Complaints Procedure: Summary

Complaints can be addressed to our Practice Manager, or to the Health Professional that you see, or to NHS England. Full details are further down this page.

Contact our Practice Manager:

Every complaint we receive will be acknowledged in writing and it will be explained to you when you can expect a further response once an initial investigation has taken place.

We will try our best to fully understand every point of view and will notify you of the outcome.

If you're not satisfied with this we will invite you to attend the surgery, with a friend or companion if you would like as well, to discuss the complaint and the findings of our internal investigation.

Where necessary the practice will consider any internal action required to ensure a similar incident does not occur in the future.

Advocacy Together Hub

Complainants can request free advice from here.

Advocacy Together Hub - Castlemere Community Centre, Tweedale Street, Rochdale OL11 1HH

Telephone: 01706 645830 or 07867 459340


Complaints Policy in Detail

Reviewed: September 2021


This document explains the manner in which Hope Citadel Healthcare will handle any complaints it receives and confirms that the company understands and will comply with the relevant NHS complaints legislation including from the Parliamentary and Health Service Ombudsman.

All practice staff will be provided with training at induction so that they fully understand their role and responsibilities as a result of this policy.

Definition of a 'complaint'

A complaint is defined as "an expression of dissatisfaction that requires a response" (NHS Executive, 1996). It should be noted that the complainant will not always specifically use the word 'complaint', and staff will be aware that 'comments' that should be treated as 'complaints' will be dealt with as such.

All 'comments' made by patients should be passed on to the practice manager so that action can be taken to improve the patient experience and prevent them from escalating into complaints.


Hope Citadel actively encourages feedback from its patient population through regular patient questionnaires, suggestion boxes and Practice Patient Participation Groups. However when a patient wishes to make a complaint the practice will seek to ensure that patients are aware of its complaints procedure.

Specifically this will ensure patients understand:

  • Hope Citadel Healthcare's desire to continuously improve its service, and welcome patient's comments and complaints.
  • Their right to approach an independent complaints advocacy service (ICAS) for assistance with their complaint. (an example is free advocacy from Advocacy Together Hub, Castlemere Community Centre, Tweedale Street, Rochdale, OL11 1HH. Telephone: 01706 645 830 or 07867 459 340. Email:
  • Their right to complain to NHS England instead of complaining to the practice if they so wish
  • Any patient facing information needs
  • Who may make a complaint.
  • That there is a named complaints manager whom they can contact.
  • How they may complain and within what period of time.
  • The process that will be followed and when they can expect a response.
  • That they may complain either to Hope Citadel or directly to NHS England.
  • That if they remain dissatisfied with the response it is their right to refer their complaint to the Health Service Ombudsman for review.

This will be achieved by publicising the procedure within the practice leaflet, on a poster within the waiting room, on its website and by providing a separate 'complaints procedure' leaflet (see Appendix A). All materials will be free of charge and available to anyone who requests it.

If the patient wishes to complain to NHS England rather than the practice, they can use the following details:

By post to:
NHS England
PO Box 16738
B97 9PT

By email to:

If you are making a complaint please state: 'For the attention of the complaints team' in the subject line.

By telephone: 0300 311 22 33

Opening hours are 9am to 3pm Monday to Friday, except Wednesdays when they open at the later time of 9.30am. Closed on bank holidays.

Responsibility for complaints

Responsibility for compliance with the NHS complaints regulations and for ensuring any action as a result of investigating a complaint is implemented, will rest with the Executive Management Team. The day to day management, including implementing the complaints procedure and investigating complaints will be handled by the Practice Manager.

The Complaints Procedure

Who may complain?

  • A patient who is receiving treatment from the practice or a former patient who has received treatment from the practice; or
  • The representative of a dead patient, where in the opinion of the complaints manager the representative had sufficient interest in the deceased patient's welfare (for example a family member); or
  • A child, where the representative is

    • The child's parent, guardian or other adult who has care of the child; or
    • Where the child is in the care of the Local Authority (LA) or voluntary organisation (VO), the representative must be authorised by the LA or VO as appropriate
    • A patient who has asked the representative to act on their behalf and has given their consent; or
    • The representative of a patient unable to complain personally due to mental or physical incapacity, where in the opinion of the complaints manager the representative has sufficient interest in the incapacitated patient's welfare (for example a family member).

Period within which Complaints can be made

Complaints must be made within 12 months of the incident happening. Where a complaint falls outside of the above time frame the Complaints Manager may still decide to investigate it if the complainant has a good reason for the delay and if given the delay the matter may still be investigated effectively.

Handling of Complaints

A complaint may be made verbally or in writing (including electronically via email or on websites such as NHS Choices) and upon receipt, will be forwarded to the Practice's Complaints Manager immediately. The Complaints Manager will:

  • Acknowledge the complaint in writing within 3 working days of receiving it, either verbally or in writing. If it is acknowledged verbally, this must be recorded. The acknowledgement should include timescales for a response and details of local advocacy services.
  • In exceptional circumstances, where it is not possible to reply within 3 working days, the reply will be sent at the earliest opportunity with an apology and explanation for the delay. The acknowledgement will be copied to any person or member of staff who is identified as the subject of the complaint.
  • The complaints manager will assess the complaint to ascertain if it contains material that, had it been sent to the Local Authority, would have been dealt with under the Social Services Complaints Regulations. Should this be the case the Complaints manager will write within 10 working days of receipt of the complaint to enquire whether the complainant would like the details forwarding to the Local Authority. In these circumstances the complainant will be informed as to which aspects of the complaint are being dealt with under the NHS regulations and which under the Social Services Regulations. Hope Citadel Healthcare will co-operate with the Local Authority to ensure the complainant receives a co-ordinated response.
  • Fully investigate the complaint to the extent necessary, establishing facts, involving the Lead GP at each site especially where clinical opinion and input is required, and keeping the complainant informed of progress made. Each complaint will be assessed and a level of 1. Seriousness, 2. Likelihood of recurrence and 3. Risk level will be undertaken ("complaints regulations February 2009")
  • Send a detailed written response to the complainant within a reasonable timeframe from the date of the complaint and within 6 months at the very latest. Where the investigation is especially complex the response will be sent as soon as is practicable and the complainant will be informed of when a response can be expected. This response will be copied to any person or member of staff who is identified as the subject of the complaint.
  • If a response cannot be provided within 6 months from the date of receipt then the complainant will be informed of their right to approach the Health Service Ombudsman, along with being given an explanation for the delay.
  • Ensure that full records regarding the complaint and all subsequent investigations and correspondence are kept. These records will be kept separate from the patient's medical records.
  • If the complaint includes issues about another provider as well as the practice, all parties complained about should decide who will take the 'lead' on the complaint. The lead organisation will be responsible for acknowledging the complaint and liaising with the complainant, and the other parties involved should send their complaint responses for the issues about them to the lead organisation. It this then the lead organisation's responsibility to write the final response letter incorporating the responses from the other providers involved.

Where appropriate the response may offer the complainant a formal meeting with the Complaints Manager alone, or with the Lead GP and/or other clinical and administrative staff where involvement deems appropriate to discuss the findings. Consideration will be given to the use of independent conciliation services at this meeting. All post will be sent by recorded delivery.

The Written Response will include (NHS Executive, 1996):

  • A summary of the complaint;
  • An explanation of the practice's view of events;
  • An apology, where appropriate;
  • The outcome of any meetings;
  • Details of what actions have been taken to prevent any future reoccurrence of the incident, where appropriate;
  • Information about NHS complaints procedures and what can happen next - perhaps a meeting to discuss the findings;
  • An explanation that the complaint can be referred to the Parliamentary and Health Service Ombudsman for review should the complainant remain unhappy about Hope Citadel Healthcare's response.

Unreasonable complaints

Where a complainant becomes aggressive or despite effective complaint handling, unreasonable in their promotion of the complaint, some or all of the following formal provisions will apply and be communicated with the patient:-

  • The complaint will be managed by one named individual at senior level who will be the only contact for the patient. This could be a senior manager or a member of the Executive Management Team.
  • Contact will be limited to one method only (e.g. in writing);
  • A time limit will be placed on each contact;
  • The number of contacts in a time period will be restricted;
  • A witness will be present for all face to face contacts;
  • Repeated complaints about the same issue will be refused;
  • Only acknowledge correspondence regarding a closed matter and not respond to it;
  • Set behaviour standards;
  • Return irrelevant documentation;
  • Keep detailed records.


All complaints must be treated in the strictest confidence. Where the investigation of the complaint requires consideration of the patient's medical records the Complaints Manager must inform the patient or person acting on his/her behalf if the investigation will involve disclosure of information contained in those records to a person other than the Practice or an employee of the Practice.

The practice must keep a record of all complaints and copies of all correspondence relating to complaints, but such records must be kept separate from patients' medical records.

Review of Complaints

Hope Citadel Healthcare is committed to using all comments and complaints made by patients as a learning tool to improve the patient experience of its services. Responses to complaints are written by the Practice Manager alongside the Clinical Lead, and complaints that have been sent to NHS England will additionally be reviewed by the CEO.

At the monthly practice staff meeting the outcomes of any patient complaints and any actions being taken to prevent the incident reoccurring will be communicated.

Annually the practice Complaints Manager will conduct a thorough review of any complaints received in the previous 12 months to ascertain any apparent trends or additional learning points. This will be documented in a report and shared with the Executive Management Team to be presented to the board.

"Being Open" Policy

The concept of an open approach to communication of patient safety incidents to patients, families and carers was first introduced into the NHS in 2005 and was further reviewed in 2008.

An open dialogue with patients or their representatives following an incident can ease the impact, stress and concern. An effective method of formalised, honest, timely and open communication with patients, their families and carers is a vital part of the process of dealing with patient safety incidents in healthcare, helping patients to accept mistakes and medical errors and reach a state of forgiveness more readily. It will also:

  • Ensure that the communication with patients, their families and carers has been handled in the most appropriate way:
  • Enable the clinician to develop a good professional reputation for handling difficult situations well:
  • Improve the clinician's understanding of incidents from the perspective of the patient, their family and carers.

The practice will:

  • Ensure that all staff are aware of the requirements to be open and remind them on a regular basis of the practice approach to patient concerns. This will usually entail:
  • An immediate apology.
  • The original clinicians are involved in the resolution process.
  • Clinicians or staff have good communication skills and are able to relate to the patient or families.
  • There is a meaningful dialogue in which the concerns of the patient are respected and listened to.
  • Patients and families can have confidence in the process.
  • There is careful pre-planning, responsive disclosure, a proper system of follow-up and internal, as well as independent, counselling support.

Patient safety incidents can have major consequences for patients, their families and carers and can similarly be distressing for the clinicians involved. Being open and dealing with issues in the right way can help to prevent formal complaints legal action.

1. Acknowledge the incident

Patient safety incidents should be acknowledged and reported as soon as they are identified.

In cases where the patient, their family and carers inform healthcare staff when something untoward has happened it must be taken seriously from the outset. Any concerns should be treated with compassion and understanding by all clinicians.

The recognition that a patient has suffered harm or has died as a result of a patient safety incident is a major event and rare in primary care. The incident may however arise elsewhere as a result of care in the practice. The Being Open process and the investigation and analysis of a patient safety incident should normally occur in the healthcare organisation where the incident took place, and inter-care cooperation may be required.

Take immediate action to prevent of further harm or recurrence. Where additional treatment is required this should occur whenever reasonably practicable after a discussion with the patient and with appropriate consent.

2. Investigate the incident

Investigate in an open and non-threatening way. Encourage participation and document the findings.

The multidisciplinary team, including the most senior health professional involved in the patient safety incident, should meet as soon as possible after the incident to:

  • Establish the clinical and other facts.
  • Assess the incident to determine the level of immediate response.
  • Nominate who will be responsible for discussion with the patient, their family and carers.
  • Consider the appropriateness of engaging patient support at this early stage. This includes the use of a facilitator, a patient advocate or a healthcare professional who will be responsible for identifying the patient's needs and communicating them back to the clinical team.
  • Identify immediate support needs for the staff involved.
  • Ensure there is a consistent approach by all team members around discussions with the patient, their family and carers.

3. Ensure truthfulness, timeliness and clarity of communication

Information about a patient safety incident must be given to patients, their families and carers in a truthful and open manner by an appropriately nominated person with appropriate skills. Patients should be provided with a clear explanation of what happened delivered in a timely, open and honest way. Patients and their families/ carers should be provided with information about what happened as soon as practicable.

Any information given should be factual as known the time, and be updated as new information may emerge as the matter is investigated. Establish one point of contact - a staff member who will communicate with them on all aspects.

4. Apologise where you need to

Provide a face-to-face apology delivered by the most appropriate member of staff to patients, their families and carers as soon as possible. Consider both seniority and the relationship to the patient and experience and expertise in the type of patient safety incident that has occurred when nominating an individual. This should be the most senior person responsible for the patient's care and/or someone with experience and expertise in the type of incident that has occurred. This could either be the patient's own clinician or the Lead GP. They should be:

  • Known to, and trusted by, the patient, their family and carers;
  • Have a sound knowledge of the incident;
  • Be senior;
  • Be able to offer an apology and an explanation of the facts;
  • Be able to maintain a relationship with the patient or their family where possible.

The initial discussion is the first part of an ongoing communication process. The patient, their family and carers should be advised of the identity and role of all people attending any open discussion beforehand, allowing them to state their own preferences about which staff they would prefer to be present, or omitted. The meeting may:

  • Offer genuine sympathy and an apology.
  • State the facts that are known as agreed by the multidisciplinary team. Where there is disagreement, this may be deferred until further investigations have taken place.
  • Take patient's or family's views into account.
  • Ensure that communication and terminology are appropriate to the needs of the family, with jargon avoided.
  • Give an explanation about what will happen next in the short through to long-term treatment plan and investigation.
  • Give information on likely short and long-term effects of the incident. The long term effects may have to be considered later.
  • Offer support for the patient, their family and carers. This may involve getting help from third parties such as charities and voluntary organisations, as well as offering more direct assistance.

Follow-up discussions with the patient, their family and carers will be required as part of the Being Open process. A written record of each discussion should be maintained and a copy provided to the patient's representatives.

A written apology can follow, which clearly states the healthcare organisation is sorry for the suffering and distress resulting from the incident and what the next steps are, and should be issued quickly.

5. Recognise patient/family expectations

Patients, their families and carers can reasonably expect to be fully informed of the issue surrounding a patient safety incident in a face-to-face meeting with a representative from the practice and this should be facilitated. Determine what expectations they have in the resolution process.

They should be treated sympathetically, with respect and consideration and should be offered support appropriate to their needs.

6. Professional support

Practices should encourage a culture where staff feel able to report patient safety incidents without worry. Staff should also feel supported throughout the incident investigation process as they may be suffering or stressed by the events.

Staff should not be unfairly exposed to punitive disciplinary action, increased medico-legal risk or any threat to their registration, however where there is potentially a reason to believe a member of staff has committed a punitive or criminal act, they should be advised at an early stage to enable them to obtain separate legal advice and/or representation, perhaps from a defence organisation. This may be done in a supportive and sensitive way and should not be accusative.

7. Risk Management and Systems Improvement

The practice Significant Event Procedure should be used to examine the underlying causes of a patient safety incident. These investigations should focus on improving systems of care and the discussion of learning points. Document the discussions and formalise changes to procedure. Communicate changes to the patient as part of the Openness policy.

8. Multidisciplinary Responsibility

All staff in the practice involved in patient care should be aware of the incident and the issues or changes arising. Major incidents often arise from a systems failure over a period of time or a culmination of minor lapses rather than from the single action of an individual.

Investigate and correct any deficiencies in practice systems or risk control measures which may have contributed to the error.

9. Clinical Governance

Being open requires the support of clinical governance frameworks through which patient safety incidents can be investigated and analysed to find out what can be done to prevent their recurrence. These findings should be treated as learning points and discussed. Incorporate the risk and the resultant actions in the practice Risk Management Framework

10. Confidentiality

Policies should comply with the patient's, their family's and carers' rights and also staff rights to privacy and confidentiality. Details of a patient safety incident should be considered as confidential. The consent of the individual concerned should be sought prior to disclosing information beyond the clinicians involved in treating the patient. Rules of confidentiality apply.

11. Continuity of care

Patients are entitled to expect that they will continue to receive all usual treatment and continue to be treated with dignity, respect and compassion. If a patient expresses a preference for their healthcare needs to be taken over by another team the appropriate arrangements should be made for them to receive treatment elsewhere.

An Open Culture

A culture of openness is where:

  • Staff are open about incidents they have been involved in.
  • Staff are accountable for their actions.
  • Staff feel able to talk to their colleagues about an incident.
  • Organisations are open with patients, the public and staff when things have gone wrong and explain what lessons will be learned.
  • Staff are treated fairly and are supported when an incident happens.

Resulting Death

It is important to consider the emotions bereaved relatives. The patient's family and carers will probably need information on the processes that will be followed to identify the cause(s) of death. Establishing open channels of communication may also allow the family and/or carers to indicate if they need bereavement counselling or assistance at any stage.

The Being Open discussion and any investigation may occur a coroner's inquest, but consider whether it may be better to wait until after the coroner's report, to help focus on the facts of the incident.


Relationships with the family may break down as a result of a perceived error. They may not accept information and may refuse to be involved in any discussion:

  • Attempt to deal with this as soon as possible.
  • Involve family where you can.
  • Provide details of support services.
  • Use an alternative clinician to mediate, e.g. another partner or external PCT or PALS liaison.
  • Provide details of the formal NHS complaints procedure.

Blame Free Culture (BFC)

The purpose of a BFC is to generate an open and fair environment where errors and near misses are reported and examined and where lessons are learned and established into new day to day practices, without the fear from staff that their mistakes will "count against them" in some way. The establishment of a BFC will not however override the need for proper professional or regulatory control or clinical accountability which may be implemented over and above BFC procedures as the need may arise. Practice staff and clinical professionals will be made aware of the nature of the BFC culture and the limits under which this will operate in normal circumstances. It is expected that as part of their professional status that they will be aware of the professional and regulatory/contractual issues under which they must operate and the nature of items which must be referred to regulatory bodies.

Patient and staff safety hinges on the safe design, operation and maintenance of equipment, systems and procedures, together with awareness of the human factors from which errors may arise.

  • Staff are encouraged to report incidents using the Significant Event reporting procedure.
  • Reported events will be documented by each person directly involved with the event, and reported to the practice manager who will carry out an initial review.
  • Where the Practice Manager considers that there may be regulatory or other significant reporting issues involved he/ she may terminate the normal review process (below) and seek advice from external sources or GP partners as appropriate. At this point the matter will become confidential and controlled subject to management discretion.
  • Where the event reported is regarded as a "normal" event involving genuine error or learning issues the matter will be discussed at an appropriate meeting of clinicians with the following key objectives:
  • Encourage any staff members directly involved to present the item.
  • Encourage an honest and open discussion without a consideration of fault.
  • Identify the nature and cause of the incident.
  • Identify any actions required immediately to rectify the situation and to prevent a similar recurrence.
  • Discuss and document the nature of the incident, how processes and procedures may be changed to improve safety or efficiency.
  • Discuss how and when changes may be implemented. Agree implementation and a suitable review period to ensure that any changes have been firmly embedded within normal practice.


Department of Health (2004), Statutory Instrument 2004 No. 1768: The National Health Service (Complaints) Regulations 2004, HMSO: London

Complaints Regulations (February 2009)

Department of Health (2006), Statutory Instrument 2006 No. 2084: The National Health Service (Complaints) Amendment Regulations 2006, HMSO: London

NHS Executive (1996), Practice-based Complaints Procedures: Guidance for General Practices, HMSO: London


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The Kingsway Practice_White
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285a Kingsway
Greater Manchester
OL16 4AT

Tel: 01706 664120