Making sure your organisation meets the Complaint Standards: guide for senior leaders

As a senior leader you must make sure your organisation is meeting the legal requirements of the NHS Complaint Regulations.  

The Regulations say your organisation must appoint a ‘responsible person’ who should be the chief executive, sole proprietor or partner. 

The responsible person must make sure your organisation meets the Regulations. They should make sure your organisation takes any necessary action as a result of a complaint and must sign the final response letter to the complaint. 

The Complaint Standards set out expectations that you should also fulfil. These are: 

• Senior staff make sure every employee knows how they can create and deliver a just and learning culture for handling complaints. All staff can demonstrate how they contribute to this culture through practical examples.
• Senior staff make sure appropriate structures are in place to deliver fair and robust complaint investigations.
• Senior staff make sure staff are supported and trained in all aspects of dealing with complaints, from identifying a complaint to issuing a response, so that they meet the expectations set out in the Complaint Standards. This should include how to manage challenging situations.
• Appropriate governance structures are in place so that senior staff regularly review information that arises from complaints and are held accountable for using the learning to improve services. There are clear processes in place to show how organisations do this and this information is included in their annual report. 

As a senior leader, and particularly if you are the responsible person, you should also familiarise yourself with: 

• what is expected when investigating a complaint under the Complaint Standards (Carrying out the investigation guide)
• what to include in a good final response letter (Writing and communicating your final response guide).  

Checklist: ten things to look for in a complaint response 

This checklist sets out what you should look for when approving a complaint response. There is more information in our step-by-step guide to writing a final response letter. Ask yourself, does it: : 

• set out the issues and what the complainant wanted to achieve
• set out how you have investigated the complaint
• explain if something has gone wrong or not: ‘what happened’ vs ‘what should have happened’
• give your conclusion on the care or service provided
• explain any failings and the impact they have had
• give a meaningful apology if there are failings
• explain how you will put things right for the person who made the complaint
• explain how you will put things right for future service users, if relevant
• explain how you will keep the person involved and updated about the action you are taking
• make it clear that it is your final response and signpost to the Ombudsman.

As a senior leader it is important to lead by example. They way you behave and the things you do will set the tone and culture for your organisation. Use the personal cultural assessment tool to reflect on your current performance and identify any actions you need to take. 

You will find more help in the Complaint Standards guide on promoting a just culture. This sets out what senior staff should do to create the right culture and to make sure that: 

• service users see how your organisation proactively and openly responds to complaints and uses learning to improve services
• colleagues know to be open and accountable when mistakes happen and feel confident to speak up when things go wrong
• colleagues are empowered to learn from the insight that comes from complaints, and are supported to be accountable and use learning to improve
• colleagues are trained to know what a just and learning culture looks like in practice and how they should promote it in their work
• people who complain to your organisation agree that they have been listened to and have had their concerns looked at openly, thoroughly and fairly.

After completing your organisational assessment you should have identified the areas you would like your organisation to improve and develop.  

To make sure your senior leadership team takes ownership of those actions, you should meet to discuss the assessment and what you have found. 

To help with that work and to make sure you have the full commitment of your team you may want to hold a workshop to reflect on your organisation’s culture around dealing with complaints. You can use this workshop to: 

• identify the barriers and challenges you face when delivering a good complaints service and what is expected under the NHS Complaint Standards
• communicate what you would like your complaints service to be
• identify goals and actions for developing your complaints service, governance, reporting and learning.  

The workshop outline and action plan templates will help you do this. 

The Complaint Standards say that as a senior leader you should make sure: 

‘Appropriate governance structures are in place so that senior staff regularly review information that arises from complaints and are held accountable for using the learning to improve services. There are clear processes in place to show how [your organisation does] this and this information is included in [your] annual report.’ 

You should read the guide on capturing and reporting on learning from complaints and discuss it with your leadership team to make sure you have the right governance and procedures in place. The guide includes a template form to capture insight and learning that you can use to make sure you are capturing the right data from all your sources of feedback. 

The guide explains what you are legally required to do. It shares good practice on: 

• capturing the right data
• learning from complaints  
• sharing that learning with others.  

Ideally you should appoint a senior member of your organisation, such as a board member, senior partner or equivalent, who will be responsible for overseeing your complaints service and making sure your organisation learns from complaints. The guide explains how they should carry out that role.  

One of the most important parts to get right is showing your service users that your organisation has learned from the complaints you receive. This can be difficult and may need new ideas. Any actions you take or plans you make should include how you will show you have learned and improved services. 

Sharing learning more widely to help others improve what they do is a sign of a mature learning organisation and will increase your reputation. Think about how you can do this through your: 

• annual report
• networks and forums
• Integrated Care Board, local Healthwatch and advocacy providers
• website, local press and social media using the hashtag #MakeComplaintsCount.