Complaints Policy

Serenity Baby Clinic

Park View Business Centre
Combermere
Nantwich
SY13 4AL

This policy explains how patients, parents, carers and others can raise concerns or complaints about Serenity Baby Clinic and how the clinic will investigate, respond, learn and improve. Raising a complaint will not adversely affect a family’s care, access to services or treatment by the clinic.

The clinic will operate an effective, accessible and proportionate complaints system. Complaints will be acknowledged, investigated without avoidable delay, answered openly and used to improve safety and quality. Where Katherine Williams is personally involved, she will not control the investigation or outcome.

1 Purpose and outcomes

Serenity Baby Clinic welcomes feedback and takes complaints seriously. The purpose of this policy is to make it easy to speak up, resolve concerns locally where possible, establish what happened, provide a clear explanation, apologise where appropriate, take proportionate action and identify learning. The process is intended to be fair to the complainant and to any person complained about.

2 Scope

This policy applies to all services and activities delivered by or on behalf of Serenity Baby Clinic, including clinical consultations, infant-feeding support, tongue-tie assessment and any frenulotomy service, paediatric appointments, baby massage and movement sessions, first-aid and antenatal education, messy play, stay-and-play, events, retail activity, home visits, telephone or online support, administration and conduct.

It applies to both Managing Directors and to any future employees, self-employed practitioners, contractors, students and volunteers working under the clinic’s arrangements. A complaint may concern care, communication, consent, dignity, discrimination, confidentiality, records, charges, access, premises, delays, behaviour or any other aspect of the service.

A complaint is an expression of dissatisfaction requiring a response. A concern may be resolved immediately but must be recorded as a complaint if the person asks for a formal response or if the issue is serious, repeated or indicates a safety or governance risk.

3 Legal and regulatory framework

The clinic will apply this policy consistently with:

• Regulation 16 of the Health and Social Care Act 2008 Regulated Activities Regulations 2014, requiring an effective and accessible system for identifying, receiving, recording, handling and responding to complaints; proportionate investigation; necessary and proportionate action; and protection from discrimination for making a complaint;
• Regulation 17 on good governance, including accurate records, monitoring and improvement;
• Regulation 20 and the statutory duty of candour where a notifiable safety incident occurs;
• the Equality Act 2010, UK data-protection law, professional duties under the NMC Code, safeguarding duties and the clinic’s related policies.

4 Who may complain and support available

A patient, parent, person with parental responsibility, carer, family member, advocate or representative may complain. Where a representative acts for another person, the clinic will normally confirm consent or lawful authority before sharing confidential information. This will not delay urgent action needed to protect a baby, child or adult at risk.

Complaints may be made verbally or in writing. The clinic will provide reasonable adjustments, including help to put a complaint in writing, extra time, accessible formats, communication support or acceptance through an advocate. Anonymous complaints will be considered as far as the available information allows.

5 How to make a complaint

A person does not have to use legal or clinical language. It is helpful to give their name and preferred contact details, what happened, when and where it happened, who was involved, the effect on them or their child, and what outcome they are seeking. The clinic will not refuse a complaint merely because some information is missing.

6 Time limit

Complaints should normally be made within 12 months of the event or of the complainant becoming aware of it. The Registered Manager may accept a later complaint where there is a good reason for delay and it remains possible to investigate fairly. Safeguarding, serious safety or professional concerns will be considered regardless of when they are raised.

7 Immediate safety safeguarding and candour

On receipt, the person handling the complaint will first consider whether anyone needs urgent clinical care or protection. Allegations of abuse, neglect, unsafe practice, serious harm, criminal conduct or an immediate risk will be escalated without waiting for the routine complaints process. The clinic will follow its safeguarding, incident reporting, duty of candour, whistleblowing and notification procedures as applicable.

A complaint investigation does not replace emergency action, safeguarding referral, police reporting, CQC notification, professional-regulator referral or insurer notification. These processes may run in parallel and information will be shared lawfully and proportionately.

8 Acknowledgement and agreed handling

The clinic will acknowledge a complaint within three working days. The acknowledgement will identify the person handling it, confirm the issues understood, invite clarification where needed, explain confidentiality and consent requirements, offer a discussion about the desired outcome and state the planned response date.

The clinic aims to provide a full written response within 20 working days. If this is not possible because of complexity, absence of key evidence, safeguarding or another investigation, the complainant will be told why, what is being done and when a response is expected. Progress updates will be provided at least every 10 working days unless another interval is agreed.

9 Triage and investigator allocation

The person complained about may be informed and invited to respond, but only information necessary for a fair investigation will be disclosed. No person will investigate their own conduct or determine an appeal about their own conduct.

10 Investigation standard

The investigation will be proportionate to seriousness, risk and complexity. The investigator will:

• confirm the complaint issues and desired outcome;
• secure relevant Cliniko records, consent forms, communications, booking and payment information, policies, audit evidence and other records without altering the original clinical record;
• obtain accounts from relevant people and give a person complained about a fair opportunity to respond;
• consider clinical standards, the NMC Code, clinic policy, contractual information and applicable law or guidance;
• separate evidence, findings and recommendations and decide each issue on the balance of probabilities;
• identify actual or potential harm, duty of candour, safeguarding, notification and referral considerations;
• record learning, corrective action, responsible owners and completion dates.

Where specialist clinical or technical judgment is required, the clinic will obtain advice from a suitably qualified person who is independent of the events. The complainant will be told if part of the investigation must be paused to avoid prejudicing a safeguarding, police, regulatory or legal process.

11 Written response

The final response will be clear, respectful and understandable. It will summarise the complaint, describe how it was investigated, address each issue, explain the evidence and findings, acknowledge uncertainty, apologise where appropriate, set out action already taken or planned, explain any limitation on information that can lawfully be shared, and state how to request a review or contact an external body.

An apology is not to be withheld solely because liability is possible. Where Regulation 20 applies, the clinic will follow the statutory duty of candour process in addition to the complaint response.

12 Internal review

If dissatisfied, the complainant should request a review within 20 working days of the final response and explain what they believe was not addressed or was procedurally unfair. The review will not simply repeat the first investigation. It will consider whether the process was fair, relevant evidence was considered, conclusions were reasonable and actions were appropriate.

A review will be undertaken by the other Managing Director where independent and not involved. If either condition is not met, Serenity RN Ltd will appoint a competent independent reviewer. The clinic aims to conclude the review within 20 working days and will explain any delay. The review response is the end of the clinic’s internal process, but it does not restrict any right to contact CQC, the NMC, legal advisers or another appropriate body.

13 Contacting CQC and the NMC

A complainant may contact CQC about concerns regarding the safety or quality of the regulated service, including where a complaint concerns either or both Managing Directors. CQC uses information to regulate services but does not have powers to investigate or resolve an individual complaint on the complainant’s behalf. The clinic will never state or imply that contacting CQC is prohibited while the local process is ongoing.

Where the clinic itself is considering a professional referral, it will follow NMC employer guidance and seek advice from the NMC Employer Link Service where appropriate: 020 7462 8850 or employerlinkservice@nmc-uk.org. Referral decisions will be documented, fair and based on risk and the relevant regulatory threshold.

14 Fairness confidentiality and data protection

No patient, baby, child, parent, carer or representative will be discriminated against, disadvantaged or treated adversely because they complained, supported a complaint or contacted a regulator. Care decisions will remain based on clinical need and safety. Any breakdown in therapeutic relationship will be managed fairly, with safe continuity and appropriate signposting.

Complaint information will be shared only with those who need it to investigate, protect people, comply with law or improve care. The clinic cannot promise absolute confidentiality where disclosure is necessary for safeguarding, serious risk, professional referral or a legal duty. The complainant will be informed where lawful and practicable.

Clinical records in Cliniko must remain contemporaneous and unaltered. A factual note that a complaint exists may be added only where relevant to ongoing care; opinion and investigation material will not be inserted into the clinical record. Complaint files and the complaints register will be stored securely with restricted access in accordance with the clinic’s data-protection and records-retention arrangements.

15 Learning governance and CQC evidence

Katherine Williams, as Registered Manager, will maintain oversight of all complaints except where she is the subject of the complaint. In those cases Caroline Tunley or the independent investigator will provide governance assurance without disclosing unnecessary confidential detail to Katherine.

The Managing Directors will review complaint themes, response times, upheld findings, safety issues, equality concerns, referrals, duty of candour, repeated concerns, actions and evidence of completed improvement. Learning will be shared with relevant workers and incorporated into policies, training, risk registers, audits and service design. CQC will be given access to records and evidence within its lawful powers.

The clinic will not use confidentiality clauses to prevent lawful disclosure to CQC, the NMC, safeguarding bodies, police, legal advisers or whistleblowing channels.

16 Monitoring and review

This policy will be reviewed at least annually and sooner following a serious complaint, identified procedural weakness, complaint about either Managing Director, safeguarding or duty-of-candour event, external investigation, CQC or NMC feedback, change to services or staffing, or relevant legal or regulatory change. The review will confirm that public-facing information and regulator contact details remain current.