Complaints Policy
1.0 Introduction
MyGynae Limited believes that if a patient or their relatives are unhappy about any element of the care we provide; or if they feel that we can improve in some way, that the patient or their relatives are fully entitled to complain.
We welcome feedback in any form and believe that feedback provides the opportunity to learn, improve and develop the service we are providing. Any complaints, comments or feedback will be taken seriously and dealt with appropriately.
We will always investigate complaints; and appropriate action will be taken in response to issues that are identified.
2.0 Scope
This policy applies to all individuals who receive care and support from MyGynae Limited including patients ,their families, advocates, and representatives. It also applies to any member of the public or stakeholder who wishes to raise a concern about the service provided.
3.0 Roles and Responsibilities
The Registered Manager:
Has overall responsibility for the complaints process and ensuring compliance with regulatory requirements.
Ensures that all complaints are logged, investigated, and responded to within required timeframes.
Reviews complaint outcomes and ensures appropriate corrective and preventive actions are taken and produces a monthly report for the governance meeting.
Produces an annual report about trends and outcomes of complaints to governance meetings and relevant external bodies as required (e.g. CQC, ).
Staff:
Must report any complaints or expressions of dissatisfaction received during service delivery to the Registered Manager immediately.
Must cooperate fully and honestly in any complaint investigation.
Should handle complaints with empathy, professionalism, and without defensiveness.
Patients, Families, and Representatives:
Are encouraged to raise concerns or complaints without fear of discrimination or negative consequences.
Have the right to be supported by an advocate or representative during the complaints process.
Should receive clear information on how to make a complaint and what to expect in terms of timescales and outcomes.
4.0 Complaints Procedure (Step by step Procedure for Staff)
MyGynae Limited is committed to providing high-quality, safe, and effective care. We encourage anyone who is dissatisfied with any aspect of the service or care they have received to inform us as soon as possible. Early notification enables us to investigate promptly, provide explanations, offer an apology where appropriate, and take corrective action. In many cases, concerns raised at the earliest opportunity can be resolved quickly and effectively.
This section sets out the step-by-step process all staff must follow when a concern or complaint is received about MyGynae Limited . The aim is to resolve issues quickly where possible, record and investigate appropriately, and provide a timely, fair response in line with Regulation 16 (Receiving and Acting on Complaints) and Regulation 20 (Duty of Candour).
Managing a Concern Informally (where appropriate)
Concerns can be made verbally or in writing, including by email. Where a complaint is made verbally, staff will make a written record and confirm the details with the complainant.
MyGynae Limited is committed to responding promptly, aiming to address all inbound queries within 1 working day and, where possible, to resolve issues quickly through clarification, explanation, or appropriate corrective action.
If the matter cannot be resolved at this stage, it will be escalated to the Registered Manager for further review.
A concern is an issue that can be resolved immediately or within 24 hours without a formal investigation. Where safe and appropriate, the staff member who receives the concern should:
1. Understand and acknowledge the concern with empathy and respect.
2. Clarify what outcome the person is seeking (e.g., explanation, apology, change to arrangements).
3. Take immediate practical steps to put things right where possible and within your role.
4. If you cannot resolve the issue straight away, escalate to the Registered Manager without delay.
Staff must offer support to anyone who needs help to raise an issue (for example, due to communication needs) and must involve the Registered Manager to agree to any reasonable adjustments.
Representation and Consent
If a complaint is raised by a representative on behalf of a patient, staff must ensure appropriate consent is in place before sharing any personal information. If consent is unclear (or the person may lack capacity), escalate to the Registered Manager before discussing details, and record what checks/actions were taken.
Formal Complaint Resolution Procedure-overview
If an informal resolution cannot be achieved, or if the complainant prefers to make a formal complaint, they may do so in writing through MyGynae Limited’s Complaint Resolution Procedure. This process is structured to meet the requirements of the Independent Sector Complaints Adjudication Service (ISCAS) and reflects the principles of the ISCAS Code of Practice.
The Complaint Resolution Procedure consists of three stages:
● Stage 1 - Local Resolution:
The complaint is reviewed and investigated at service level by the Registered Manager. A full, written response will be provided, addressing the issues raised and outlining any actions taken.
● Stage 2 – Internal Review:
If the complainant remains dissatisfied, they may request a further internal review. This involves the Nominated Individual examining the handling and outcome of Stage 1 to ensure fairness, transparency, and compliance with our governance standards.
● Stage 3 – Independent Adjudication (ISCAS):
If the matter remains unresolved following Stages 1 and 2, the complainant may request an independent external review through ISCAS. This stage provides impartial adjudication and marks the conclusion of the complaints process.
Please note that all three stages are governed by the ISCAS Code of Practice for Complaints Management, which MyGynae Limited adheres to in full.
Stage 1
Step 1: Receiving a Complaint
• Complaints may be received verbally, in writing, via email.
• Staff receiving complaints must remain calm, show empathy, and thank the complainant for raising the issue.
• Do not argue, dismiss concerns, or apportion blame.
• Check whether the issue is a concern (can be resolved within 24 hours) or a formal complaint (requires investigation and a written response). If unsure, treat it as a complaint and advise the patient that formal complaints can be made verbally or in writing, including by email. Where a complaint is made verbally, staff will make a written record and refer it to the Registered Manager.
• Record key details (name/contact details if provided, date/time, what happened, staff/ desired outcome) and report to the Registered Manager as soon as possible (same day where feasible).
1.1 Complaints from Representatives
We will only accept complaints from a patient’s representative/relative if they have the consent of the patient; or when the patient cannot complain unaided. The representative must always be acting in the patient’s best interests.
Step 2: Immediate Resolution (Where Possible)
• Where appropriate, attempt to resolve the issue immediately (within your role and without compromising safety).
• If resolved, inform the Registered Manager and agree any follow-up actions required.
• The Registered Manager will ensure the complaint is recorded in the complaints log for learning and trend analysis.
Step 3: Safeguarding Check
If the complaint raises concerns about:
• Abuse or neglect
• Safety risks
• Capacity or coercion,
The matter must be escalated immediately in line with the Safeguarding Policy.
Step 4: Recording the Complaint and Acknowledgement
• All formal complaints must be recorded on the complaints log by the Registered Manager.
• An acknowledgement must be issued within 3 working days by the Registered Manager.
• The acknowledgement must confirm who will be investigating the complaint.
• It must set expected timescales (including any interim updates).
• It must explain the next steps and how the complainant can provide further information.
• A copy of the Complaints Procedure must be offered (and in an accessible format if requested) (See Appendix)
Step 5: Investigation
The Registered Manager must:
• Gather all relevant evidence
• Obtain factual statements from relevant staff (as soon as possible while details are fresh).
• Review relevant policies, records, and procedures to assess whether standards were met.
Investigations must be fair, objective, and proportionate. Complainants must be kept informed by the Registered Manager of the progress preferably in writing so there is a clear audit trail.
If the complaint is about a clinician, the Registered Manager will write to the clinician within 2 days and ask for a response within 7 days. Repeated complaints about any clinician will be escalated by the Registered Manager to the Clinic Lead to review.
Step 6: Response
A full written response (or in a different format if requested) must be issued within 20 working days of receipt of the complaint (or within an agreed extended timeframe where the complaint is complex). The response must include:
• A summary of the complaint and the issues investigated.
• The investigation findings (what was established and, where appropriate, what could not be established).
• An apology.
• Any actions taken and/or planned, including learning and service improvements.
• How the complainant could escalate the matter if dissatisfied (including next stage and contact details where applicable).
Step 7: Duty of Candour
Where a complaint identifies actual or potential harm, or where a notifiable safety incident may have occurred, the Registered Manager must assess whether the Statutory Duty of Candour applies and follow the Duty of Candour requirements where the threshold is met. The service will also maintain a culture of openness, explanation and apology where things have gone wrong, even where the statutory threshold is not met.
• Prompt notification to the relevant person, including an offer of a meeting where required or appropriate.
• Offer a sincere apology.
• Be open and transparent about what is known at the time.
• Explain what went wrong (in clear, accessible language).
• Explain what immediate actions have been taken and what will be done to prevent recurrence.
• Document the discussion, decisions, and actions taken.
• Promptly report to the CQC where the relevant notification threshold is met.
Stage 2
Step 8: Escalation – Stage 2 Internal Review
If the complainant remains dissatisfied, then:
•The Registered Manager must record the escalation request in the complaints log and confirm they can send to the Nominated Individual.
Nominated Individual Contact Details:
Name: Vidyuth Manu
Address: 25 St John Street, Deansgate, Manchester, M3 4DT
Phone: 0161 956 2770
Email: vmanu@mygynaec.co.uk
• Where possible, the complainant should submit the Stage 2 request within 6 months of receiving the Stage 1 response (unless there is a valid reason for delay).
• The Registered Manager must compile a complete case file for the review (complaint record, acknowledgements, investigation notes, evidence, statements, correspondence, outcomes, actions, and learning).
• The Registered Manager will update the complaints log with the Stage 2 outcome, actions, and learning, and confirm any service improvements/training required.
• If the complainant remains dissatisfied, the Stage 2 response must clearly explain how to access Stage 3
Stage 3
Step 9: Escalation – Stage 3 Independent External Review
• The Registered Manager must provide the complainant with details of the applicable independent external review route, Independent Sector Complaints Adjudication Service
• The Registered Manager must compile a complete case file for external review (complaint record, acknowledgements, investigation notes, evidence, statements, correspondence, outcomes, actions, and learning).
• All staff must cooperate fully with any external review, providing timely factual statements and any requested documents, and maintaining confidentiality in line with data protection requirements.
• Where the complainant also wishes to share concerns with the CQC, staff should explain that the CQC does not investigate individual complaints but welcomes information to support monitoring; signpost to the contact details in Appendix 1.
• Any recommendations or required actions arising from an external review must be recorded, implemented, and shared for learning (e.g., team briefing/training), and the complaints log updated accordingly.
When requested by the Care Quality Commission, the service will provide a summary of complaints, responses, and relevant correspondence within 28 days, or within any other timeframe specified by the CQC.
5.0 Complaints regarding the Registered Manager
In most cases, the Registered Manager is responsible for receiving, investigating, and responding to complaints. However, to maintain transparency and impartiality, any complaint made about the Registered Manager will follow an alternative, independent process.
Escalation
If a complaint is made against the Registered Manager, it will be escalated to the Nominated Individual
Nominated Individual Contact Details:
Name: Vidyuth Manu
Address: 25 St John Street, Deansgate, Manchester, M3 4DT
Phone: 0161 956 2770
Email: vmanu@mygynaec.co.uk
This ensures that the Registered Manager has no involvement in investigating complaints about their own conduct, in line with Regulation 16 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
Acknowledgement and Communication
The complaint will be acknowledged within 3 working days, with confirmation that the Registered Manager will not be involved in the investigation due to a conflict of interest.
The complainant will be informed who will oversee the investigation and how to contact them.
All communications will be made in accessible formats and with reasonable adjustments if required, in accordance with the Equality Act 2010.
Investigation Process
The complaint will be investigated by a either the Nominated Individual or delegated to a suitably senior, trained individual who has no personal involvement in the issues raised.
If required, an external independent investigator may be appointed to maintain impartiality.
The investigation will be conducted fairly, objectively, and with regard to the rights of both the complainant and the Registered Manager, in line with principles of natural justice and UK GDPR.
Outcome and Response
A full written response will be provided within 20 working days of receipt of the complaint. If the investigation takes longer, an update will be provided with a revised timescale.
The response will include:
A summary of the investigation and findings
Any actions taken or planned as a result
An apology or explanation where appropriate, in line with the Duty of Candour
Details of how to escalate the complaint if the outcome is not satisfactory
Escalation Options
If the complainant remains dissatisfied with the outcome, they may escalate the matter to If the matter is still unresolved, after these stages, the complainant must be given support and details on how to contact the Independent Sector Complaints Adjudication Service (ISCAS) for an impartial review and/or the Care Quality Commission (CQC) (for concerns about safety, regulation or leadership)
Confidentiality, Fairness and Protection from Retaliation
All complaints will be handled confidentially, and in accordance with our Data Protection and Whistleblowing policies.
The Registered Manager will be informed of the complaint and given a right to respond, unless this compromises the safety or integrity of the process.
All parties involved will be treated fairly and with respect. No person will suffer detriment for raising a concern or making a complaint in good faith.
6.0 Complaints from Employees
If an employee wishes to make a complaint about MyGynae Limited; or any aspect of our work, this must be raised as a grievance and not via this complaints policy. Please speak to the Registered Manager who can provide you with a copy of the Grievance Procedure.
7.0 Anonymous Complaints
Any complaints that are made anonymously will be taken seriously and the details of the complaint documented. If you make an anonymous complaint, it will be investigated but we will not be able to provide you with details of the outcome.
8.0 Support for Complainants & Advocacy
MyGynae Limited is committed to ensuring that everyone can raise concerns without fear of discrimination or disadvantage. We will provide:
Accessible Information: Complaint information will be made available in formats that meet the Accessible Information Standard upon request. The service can provide large print and access to translation support.
Advocacy Services: Information on independent advocacy services will be provided to individuals who require support in making a complaint upon request
Reasonable Adjustments: Adjustments will be made for individuals with disabilities or communication needs, in line with the Equality Act 2010. Where a person is unable to make a complaint independently, we will accept complaints from a representative acting in their best interests.
Clear Contact Points: Complaints can be made verbally or in writing, including by email to f.assar@mygynaec.co.uk and support will be provided throughout the process where required.
9.0 Data Management
Finalised complaints are kept at our office; and the details of all individual complaints are logged on our Complaints Control Spreadsheet. All complaints and associated personal data will be recorded and stored securely in accordance with the UK General Data Protection Regulation (UK GDPR). This includes ensuring that data is processed lawfully, fairly, and transparently; is used only for the purpose of managing and learning from complaints; and is retained for 10 years or more if legally necessary. Individuals have the right to access their data, request corrections, and understand how their data is used. Access to complaint records is restricted to authorised staff only.
10.0 Learning from Complaints
MyGynae Limited will:
• Log all complaints in the central complaints log and maintain accurate records of actions taken.
• Monitor complaints monthly to ensure policy procedure has been followed and all complaints have been appropriately addressed
Analyse trends annually as part of our governance and quality assurance processes
• Use feedback from complaints to improve service delivery, including updating policies, revising procedures, and providing targeted staff training.
• Review all complaints received at monthly governance meetings to ensure the process is effective, accessible, and compliant with regulatory requirements.
• Share lessons learned with staff through team meetings, supervision, and training sessions to prevent recurrence and promote continuous improvement.
• Annually Review: Complaints data will be analysed to identify trends, recurring issues, and opportunities for improvement. We specifically consider the following:
• The type and number of complaints received
• The subject matter of the complaints
• The outcomes of the complaints
Continuous Improvement: Findings will inform staff training, policy updates, and feed into our annual Quality Improvement Plan
11.0 Training requirements
All staff will be required to undertake an induction that includes mandatory training in complaints handling. This will then need to be updated annually.
12.0 Legislation and Guidance
Regulation 16: Receiving and acting on complaints - Care Quality Commission (cqc.org.uk)
Complaints matter - Care Quality Commission (cqc.org.uk)
CQC (2025) Regulation 20: Duty of Candour
CQC (2024) Meeting the Accessible Information Standard
The Equality Act 2010
Data Protection Act 2018
Data protection: The UK's data protection legislation - GOV.UK
UK General Data Protection Regulation (UK GDPR)
Equality Act 2010
Updated As Of: 2026-08-28
Date of Next Review: 2027-06-30