1. Procedure
1.1 Raising complaints
A complaint can be made to Clubhouse Support Ltd by:
Persons
Someone acting on behalf of the person and with their written consent, e.g. an advocate, relative, Member of Parliament
Someone acting on behalf of the person who is unable to represent his or her own interests, provided this does not conflict with the person’s right to confidentiality or a previously expressed wish of the person
Complaints can be received either verbally or in writing, and could be:
In person
By telephone
In writing
Through a member of our staff
Through an advocate or representative
Where someone complains verbally, Clubhouse Support Ltd will make a written record and provide a copy of it within 3 working days:
By letter
By email
Complaints can be sent to:
The Operations Director
Clubhouse Support Ltd
Old Georgian Clubhouse
Weybridge Road
Addlestone
Surrey
KT15 2QT
Verbal complaints can be made in person or via:
Clubhouse Support Ltd Telephone Number: 01932 988708
Clubhouse Support Ltd Email: Hello@Clubhouse.Support
On Call Telephone Number: 07983 386086
Accessibility - Including Support for persons with a Learning Disability or Autism
Clubhouse Support Ltd recognises that there are times where some persons will need additional support to be able to provide feedback to the service. Clubhouse Support Ltd commits to offering information in various accessible formats such as easy read documents, audio versions, and translated materials through interpreters.
Clubhouse Support Ltd provides easy read versions of the Complaints, Suggestions and Compliments policy and procedure and ensures that persons are given information on how to make a complaint and the process once a complaint has been made, including any agreed timescales.
Clubhouse Support Ltd will ensure that persons are given information on how to make a complaint and the process once a complaint has been made, including any agreed timescales.
Clubhouse Support Ltd will support individuals who wish to lodge a complaint by ensuring accessibility and providing the necessary assistance in line with the Accessible Information Standard.
Additionally, for persons who require further support, Clubhouse Support Ltd will help to arrange advocacy services to assist individuals in navigating the complaint process, ensuring their concerns are heard and addressed effectively. This is to support the complaint process and ensure it is as inclusive and supportive as possible for everyone.
Further information on supporting persons with communication needs can be found in the:
Supporting Communication and Sensory Needs Policy and Procedure
Person-Centred Care and Support Planning Policy and Procedure
Advocacy support information can be found in the Advocacy Policy and Procedure of Clubhouse Support Ltd.
1.2 Time Limits for Submitting a Complaint
Complaints should be submitted within 12 months of the incident or concern arising.
The time limit, however, can and should be waived, if:
It is still practical and possible to investigate the complaint (the records still exist and the individuals concerned are still available to be questioned, etc.) and
The complainant can demonstrate reasonable cause for delay in making the complaint
It is at the discretion of the manager of the service if the time limit can be set aside.
1.3 Complaints Procedure
Step 1 When a complaint is raised to staff, staff will make an effort to resolve it immediately to the satisfaction of the complainant.
Step 2. Staff will apologise for the fact that there was the need to complain in the first instance and explain the complaints process as described in the procedure steps.
Step 3 Staff will report the complaint to the most senior member of staff on duty and the complaint will be logged. If the complaint relates to that individual, the staff member will report the complaint to the member of staff who is next in line in seniority.
Step 4 Formal acknowledgement of all complaints received (whether verbal or written) will be sent within 3 working days to the complainant. This could be via letter or email. Clubhouse Support Ltd will have a local system in place to manage out-of-hours and weekend complaints received.
The acknowledgement will include:
An invitation to meet and discuss the complaint if appropriate
Who will be investigating the complaint
How the investigation will be handled - the response should state what the investigation will be focused on
A time limit for the investigation to be concluded. This should be 28 working days. However, some cases may take longer and the complainant will be made aware of this
The complaints procedure and contact details of bodies that can be accessed in the event of dissatisfaction with the outcome of the investigation. Where the complaint relates to the processing of personal information, confidentiality or data protection matters, the response will also advise the complainant of their right to contact the Information Commissioner's Office (ICO) if they remain dissatisfied following completion of the complaints process at Clubhouse Support Ltd
Step 5 Following a full investigation, a response letter will be sent and this will include the following:
A summary of the issue from the complainant’s point of view
Details of the evidence and sources consulted in order to investigate the issue fully and fairly
A presentation of the findings for each issue clearly and concisely described
A conclusion, stating clearly whether the issue is 'upheld', 'partially upheld' or 'not upheld'; unless it is ineligible, in which case the reason for this will be given, e.g. out of time or out of jurisdiction
An explanation of the outcome and whether any remedial action or learning points arise from the investigation of that issue
An apology where the issue is upheld and shortcomings or failings have been found
The complainant's rights if not satisfied with the outcome, and how to appeal.
Where applicable, information regarding the complainant's right to escalate data protection concerns to the Information Commissioner's Office (ICO)
A signature from the appointed investigator or sent by email in their name
Step 6 The complaint will be closed once confirmation has been received that there is satisfaction with the outcome. In the event of dissatisfaction, Clubhouse Support Ltd will support the complainant to access further support. (Refer to section 5.9 and 5.10)
1.4 The Complaints Log
A record will be held of all complaints raised and contain the following information:
Each complaint received
Subject matter and outcome
Details of any reason for delay where investigations took longer than the agreed response period
The date the report of outcome was sent to the complainant
If no action is taken this will also be recorded
Where complaints relate to a particular person, a copy of the complaint will be held in their care records so that the person can reflect on the recommendations.
Where complaints are raised by telephone, the log will include the date and time of the call and this will be followed up with written confirmation of the areas discussed.
Where a complaint indicates the potential abuse of persons, safeguarding policies will be followed as per local authority expectation and necessary notifications made to the regulatory body. Where Care is commissioned by Surrey County Council, their reporting procedure for notifying them of complaints will be followed.
Where complaints are to be shared as part of learning, the complaint will be anonymised so there is no identifiable person information, in line with UK GDPR and data protection law.
1.5 Investigations
All investigations will be managed by using the following approach:
Investigating the fact
Assessing evidence
Review of records
Interviewing those involved
Where necessary, advice and support will be sourced via senior managers within the organisation. The complaint must be investigated by a member of staff with the knowledge, experience and seniority to undertake the investigation robustly.
Confidentiality of information will be considered at all times and staff will adhere to the confidentiality policies and relevant codes of practice.
Appropriate action will be taken without delay to respond to any failures identified by a complaint or the investigation of a complaint.
If an investigation of a complaint results in disciplinary action against staff within Clubhouse Support Ltd, the complaint will continue to its conclusion. The complainant will be informed that the investigation has led to the disciplinary process, but the details of the outcome or ongoing investigation will remain confidential.
Clubhouse Support Ltd conducts investigations impartially and without discrimination, the approach to a person's support will remain unchanged in this way and indiscriminate treatment will be provided.
1.6 One Complaint, One Response
Where more than one organisation is involved in the person's Care, they, or their representative, will be able to complain to any of them and Clubhouse Support Ltd will contact the other organisations, carry out a joint investigation and provide a single joint response. persons must not have to contact each organisation separately.
If someone complains and Clubhouse Support Ltd is not responsible for the care or service complained about, rather than turning the complainant away, Clubhouse Support Ltd will share the concerns with the correct organisation(s). It will be necessary to obtain the individual’s permission to do this. If the person prefers that their complaint is not shared with another organisation (or organisations), Clubhouse Support Ltd will signpost them to the right organisation instead and provide the person with their contact details.
Clubhouse Support Ltd will follow Local Government Ombudsman (LGO) guidance for managing this.
1.7 Who is Responsible for Complaints Resolution at Clubhouse Support Ltd?
All efforts will be made by Operations Director to resolve all complaints within Clubhouse Support Ltd. If a particular person does not wish to raise a complaint directly with management within Clubhouse Support Ltd, in the first instance, staff will try and sensitively establish their reasons why and aim to resolve and address any concerns that present.
Clubhouse Support Ltd recognises the importance of persons being able to speak freely and raise a concern or complaint regarding anyone in the organisation, including the Operations Director. persons are provided with information relating to who to contact in the event that this is necessary.
1.8 Anonymous Complaints
Anonymous complaints will be investigated in the same way as named complaints. They will be logged and any corrective action necessary will be taken and also logged.
1.9 The Right to Appeal a Decision and Internal Review
Following the outcome of the investigation, if the complainant is dissatisfied with the response or handling of information, they have the right to appeal the decision by Clubhouse Support Ltd. Upon being notified of this Clubhouse Support Ltd will conduct an internal review of how the complaint was handled. The investigation will be conducted by a member of staff with suitable standing that is not the original responder to the complaint, such as the Operations Director.
When to Appeal:
You believe that the outcome of a complaint was incorrect and disagree with the initial decision
You disagree with the initial decision as you suspect there was a failure in the complaint process
Such as insufficient investigation
A misunderstanding of your complaint
A misinterpretation of evidence
You can provide new evidence or information that wasn't available during the initial complaint that affects the outcome
You feel the decision is unfair or unreasonable
An appeal should be submitted within 10 working days and provide new evidence that can be considered as part of the appeal process
A further 5 days will be granted if deemed appropriate
If the following timescales are not followed the complaint will be closed
Clubhouse Support Ltd recognises that as a key part of transparency and continuous improvement, conducting an internal investigation of this process is necessary before signposting the complainant to an external body.
1.11 Unresolved Complaints & Independent Review
Following the initial handling of the complaint and the appeal process, in the event that the person feels their complaint is unresolved, there are many bodies that can support or will need to be informed to assist with this (to ensure there is no bias). These services may conduct an independent review on how the complaint has been handled and will consider if the complaint has been:
Handled fairly
Investigated thoroughly and efficiently, exploring all the facts
Handled objectively
They will issue a final report that outlines their findings and recommendations.
Clubhouse Support Ltd will fully cooperate with this process and provide the independent reviewer all the information required to ensure transparency. We have a commitment to continuously improve, as part of that commitment we fully understand the importance of learning from the outcomes of this process.
The following external bodies can assist with a complaint that a person feels remains unresolved:
1. The Local Government and Social Care Ombudsman (for those persons that are funded by local authority-funded social services care or self-funded)
Individuals have the right to raise their complaint with the Local Government and Social Care Ombudsman. This is a free service and individuals can contact their Local Government and Social Care Ombudsman via:
The Local Government and Social Care Ombudsman
PO Box 4771
Coventry CV4 0EH
Tel: 0300 061 0614
Email: advice@lgo.org.uk
Website: https://www.lgo.org.uk/
Complaint form: https://www.lgo.org.uk/complaint-form
2. Self-Funded Care
The Local Government Ombudsman (LGO) may investigate complaints from people who arrange their own care. Self-funders will have the right to complain to an independent and impartial Ombudsman.
Individuals must be advised that the Local Government and Social Care Ombudsman will not investigate the complaint until the provider has had the opportunity to respond and resolve the matter in the first instance.
3. Parliamentary and Health Service Ombudsman (for persons that are NHS funded)
Individuals have the right to raise a concern about a service that is NHS funded. This is a free service and individuals can make contact via:
• Telephone 0345 0154033
• Email phso.enquiries@ombudsman.org.uk
• Website www.ombudsman.org.uk
• Address: Parliamentary and Health Service Ombudsman, Millbank Tower, 30 Millbank, Westminster, London, SW1P 4QP
Operations Director can also signpost individuals to Healthwatch and the local Independent Complaints Advocacy Service (ICAS).
4. Integrated Care Systems
Individuals can make a complaint about a health service they are receiving or have received and can discuss this with the commissioner of the service.
5. Local Authority Complaints Teams
Individuals have the right to raise concerns and complaints about adult social care regardless of whether or not they pay for their own Care or if the Council funds it. Individuals can make a complaint about organisations that provide services on the Council's behalf. The contact details for the Local Authority Complaints Team are:
Surrey County Council Local Authority Complaints Team:
Adult Social Care: Email asc.customerrelations@surreycc.gov.uk or call 01483 518300.
6. Professional Bodies
If a complaint involves the serious misconduct of a healthcare professional, their relevant professional body can be informed and this is determined on an individual case basis in discussion with the Operations Director.
For any external bodies managing complaints, Clubhouse Support Ltd will work with the external body providing information as requested, within any agreed timescales expected.
Decisions to raise complaints outside of Clubhouse Support Ltd will be fully respected and the person will be supported to raise their complaint with the commissioner of the service or to seek the support of an independent advocate or representative. Staff can also refer to section 5.6 for a further list of organisations that can be accessed. Persons can also be signposted to Citizens Advice guidance.
1.12 Vexatious Complaints
Occasionally, Clubhouse Support Ltd may receive complaints that are vexatious in that they cause considerable disruption to the work at Clubhouse Support Ltd, disproportionate cost and time to handle, and impact the wellbeing of staff (because of the way the complaint is made or because of its repetitive nature).
Clubhouse Support Ltd will ensure that it meets the requirements of the Equality Act 2010 to make ‘reasonable adjustments’ for disabled persons. In some circumstances, persons may have a disability that makes it difficult for them to either express themselves or communicate clearly and/or appropriately. Where there is an indication that this may be the case, Clubhouse Support Ltd will consider the needs and circumstances of the person or complainant in the first instance and use this information to inform any decisions that are made.
Where appropriate, Clubhouse Support Ltd will consider complaints to be vexatious, but would not label an individual complainant as vexatious. Even if Clubhouse Support Ltd decides that an individual’s complaint about the service is vexatious, that does not preclude that person from making a formal complaint. Clubhouse Support Ltd would still consider any such complaints in line with the usual procedures, as outlined in this policy.
To help decide whether a complaint is vexatious Clubhouse Support Ltd will consider the full history and context of interactions with the individual making the complaint and will look at both the nature of the complaint and the manner in which it is made. The particular issues that will inform a decision will include whether:
The primary purpose and/or effect of the complaint is to disturb, disrupt and or/pressurise Clubhouse Support Ltd, its staff or an individual member of staff
The primary purpose and/or effect of the manner in which the complaint is made is to disturb, disrupt and or/pressurise the Clubhouse Support Ltd, its staff or an individual member of staff
The complaint is otherwise clearly unreasonable
If at any point in the handling of a complaint a member of staff believes it meets the criteria to be deemed vexatious, it must be referred to the Operations Director with a summary of why it is thought to be vexatious.
The Operations Director will consider the complaint, seek external advice if appropriate, and will either declare the complaint as being vexatious or not. Where a complaint is not deemed to be vexatious it will be returned to the appropriate point in the complaints handling process.
If a complaint is deemed to be vexatious, the Operations Director will respond directly to the complainant explaining why it is thought to be so and will explain that the complaint will be closed with no further action. The Operations Director will also consider if the making of a vexatious complaint also requires the application of a restriction on communication following unreasonable behaviour.
The decision to declare a complaint as vexatious will be recorded in the complaints register for future reference.
Any declaration that refers to the specific complaint being vexatious and any further complaints from the same individual will still be considered.
If any individual wishes to challenge a decision made in relation to this policy, and all attempts to resolve the complaint locally have been unsuccessful, details of the Complaints Team of Surrey County Council and Parliamentary and Health Service Ombudsman (PHSO) will be shared with the complainant.
1.13 Compliments
Receiving compliments is an opportunity to celebrate and recognise success. Clubhouse Support Ltd will ensure that:
All compliments are shared with staff and displayed in a public area to highlight good practice
Compliments are anonymised or permission is sought before displaying them
The number of compliments received is logged as part of a quality assurance programme
Verbal, positive feedback from persons and relatives is also deemed a compliment and will be recorded and shared with colleagues
Compliments form a core agenda item at staff, person and relative meetings
1.14 Suggestions
Suggestions can be made verbally or in writing and generally are in response to seeking a means of changing practice for the better.
Suggestions are not complaints, but in some circumstances, if they are not considered or actioned, they could lead to a complaint
When suggestions are raised in meetings or as part of a conversation, these will be documented and then outcomes of such suggestions recorded to show consideration
Staff will be encouraged to share their suggestions, or suggestions received by relatives and persons, with Operations Director
Operations Director will consider implementing a suggestions system to encourage comments from persons, staff and visitors
1.15 Audit and Evaluation
Clubhouse Support Ltd will monitor, review and analyse all information received about the service as a means of continuously reviewing performance, quality and safety.
Clubhouse Support Ltd operates with an ethos of continuous improvement and will:
Ensure all complaints are logged as described in section 5.4
Identify themes and trends
Create actions to improve any identified themes and trends
Share themes, trends and actions with Care Workers working for Clubhouse Support Ltd
Ensure that staff are trained to deal with complaints and understand the procedure for managing complaints
Conduct audits on the complaints process to evaluate timescales, outcomes and feedback
Using Feedback from Complaints to Improve the Service at Clubhouse Support Ltd
Clubhouse Support Ltd values feedback from complaints as a critical tool for continuous improvement. It commits to thoroughly analysing all complaints received to identify patterns and areas for enhancement. Specific actions or changes that may be implemented based on complaints include revising policies, providing additional staff training, updating procedures, and enhancing communication channels. Each complaint will be documented and actionable insights and lessons learnt will be shared with relevant stakeholders to ensure that corrective measures are taken promptly to prevent recurrence and improve overall service quality.
Reviewing the Effectiveness of the System at Clubhouse Support Ltd
As part of the commitment of Clubhouse Support Ltd to good governance, the complaints process will remain effective and responsive, using a process of regular reviews and assessments. This includes audits of complaint records to evaluate response times, resolution rates, and customer satisfaction post-complaint resolution. Clubhouse Support Ltd will also gather feedback from complainants on their experience with the complaints process. Findings from these reviews will be used to refine the complaints handling procedures, ensuring they are user-friendly, efficient, and aligned with best practices. Regular staff training will be conducted to keep all team members updated on any changes and to reinforce the importance of effective complaint management.
Independent Review
Clubhouse Support Ltd is committed to the growth and development of the service. As such we recognise that concerning trends identified over time or processes that do not seem to be working may benefit from an independent review. Clubhouse Support Ltd will seek external support from an independent consultant should it be deemed necessary.
For more details, staff should also refer to the following policies and procedures:
Good Governance Policy and Procedure
Quality and Quality Assurance Policy and Procedure
Auditing Policy and Procedure
1.16 Continuous Improvement and Development
Without feedback it is impossible to improve our service. We have a strong ethos on embracing the feedback we receive be it a compliment or concern to enhance our service.
As part of our commitment to create and maintain a positive culture, we embed this ethos in our staff training from induction onwards to make sure that any feedback is viewed as a catalyst for improvement. If we do not know about it, we cannot do anything to improve or change it.
We share our overarching identified lessons learned and outcomes with both staff and persons to make sure that they feel part of this process, are kept informed and are invested in our commitment for the betterment of the service.