The Complaint Policy 

Policy Details

Legal name of provider: ElizabethPharma Ltd
Service: Clinically Supervised Weight Loss Clinic
Regulated activity: Treatment of disease, disorder or injury
Policy owner: Elizabethpharma Ltd
Complaints Lead: Hassan Bhatti
Deputy Complaints Lead: In the absence of the Complaints Lead, the Registered Manager will act as the Deputy Complaints Lead and assume full responsibility for receiving, investigating, and responding to complaints in accordance with this policy
Independent Reviewer: Dr Kamran Ahmed (external, independent clinician)
Date issued: 17-Jan-2026
Review date: [17-Jan-2027]
Version: 1.0

​

​

2. Purpose

ElizabethPharma Ltd is committed to providing safe, effective, and person-centred care.
This policy explains how complaints are received, acknowledged, investigated, responded to, escalated, and used for learning and service improvement.

Complaints are welcomed and treated seriously.
Raising a complaint will NOT affects anyone’s legal rights and will not affect current or future care.

​

​

3. Scope

This policy applies to:

• All current patients and former patients

• Representatives, carers, advocates, or legal proxies

• All staff, clinicians, and contractors working for or on behalf of ElizabethPharma Ltd

 

 

4. Legal and Regulatory Framework

This policy demonstrates compliance with:

• Health and Social Care Act 2008 (Regulated Activities) Regulations 2014

  • Regulation 16 – Receiving and acting on complaints, see Section 2, 4, 6,7, 8,10, 11, 12, 13,  14, 15.

  • This includes the requirement to provide complaint information to the Care Quality Commission within statutory timescales when requested.

  • Regulation 20 – Duty of Candour, see Section 4, 8,9, 12, 13, 15

• Accessible Information Standard, see Section 6,7, 8, 12, 13, 14, 15

• Equality Act 2010, see Section 2,3, 4, 5,6,7, 8, 14, 15

• UK GDPR, see Section 1, 2, 8, 10, 12, 13, 15

• Data Protection Act 2018, see section 1, 2, 8, 10, 12, 13, 15

• Mental Capacity Act 2005, see section 2,4, 5,6, 7, 12, 15

 

 

5. Who Can Make a Complaint

A complaint may be made by:

• Current and former patients

• Current and former staff members

• A relative, carer, or advocate of a complainant

• A person acting on behalf of a complainant who lacks capacity

• An anonymous person

Where capacity is lacking, complaints will be handled in line with the Mental Capacity Act 2005, ensuring actions are taken in the complainant’s best interests.

​

​

6. How to Make a Complaint

Complaints can be made through multiple accessible routes:

• Verbally (in person or by telephone)

• In writing (email or letter)

• Via a dedicated complaints tab on the clinic website

• Anonymously by telephone or in writing ( letter, E-mail, a Note e.t.c)

Anonymous complaints are accepted and will be recorded, investigated, and responded to as far as reasonably possible in the same way as named complaints. Anonymous complaints will not be treated differently or given lesser consideration and will be used for learning and service improvement.

All complaints, including verbal complaints resolved immediately, are logged, investigated and will be formally recorded electronically on a live complaints register.

Complaints contact details:

Complaints Lead: Hassan Akhlaq Bhatti
Email: [Insert]
Telephone: [Insert]
Postal address: 84 Rowan Crescent, Wolverhampton, WV3 7HL

​

​

7. Accessibility, Equality and Support

No individual will be discriminated against, disadvantaged, or treated unfairly for raising a complaint, in accordance with the Equality Act 2010 and the Accessible Information Standard.

ElizabethPharma Ltd will  ensure that :

• The complaints process is accessible to everyone, see section 5.

• Information is written in plain English

• Alternative formats are available for people with visual impairment, including large-print documents (16–18 pt font).

• Reasonable adjustments are made for disability, language, or communication needs

Note: Alternative formats and communication support may include large-print documents, audio formats, accessible electronic documents compatible with screen-reading software, written communication in place of telephone contact, text-based communication, and access to interpreter support (including British Sign Language) where required.

Information and communication needs are identified, recorded, flagged in records, met, and reviewed in line with the Accessible Information Standard.

​

​

8. Complaints Handling Procedure

A. How complaints can be made
Complaints may be made verbally or in writing (including in person, by telephone, email, or letter) by the complainant or an authorised representative.

​​

B. Complaint recording
All complaints are recorded on the electronic complaints register within the ElizabethPharma Medical Record System.

 

C. Unavailability of the electronic register
In the event that the electronic complaints register is temporarily unavailable, complaints will be recorded manually in a secure complaint register and transferred to the electronic system once access is restored.

​

​

Stage 1 — Receipt, logging and triage (Day 0–3 working days)

​

Step 1.1: Receive and log (same day)

• All complaints/concerns are received and recorded immediately by the Complaint Lead (Hassan Bhatti) in the complaints log (date/time, contact details, summary,).

• Any immediate safety risk is escalated the same day.

Step 1.2: Risk screen + duty of candour trigger (same day)

• The complaint is screened for:

  • safeguarding concerns

  • medicine/prescribing risk

  • significant clinical harm or near-miss

• If a notifiable safety incident is identified, duty of candour is initiated without delay alongside the complaint process.

Step 1.3: Acknowledge within 3 working days

• An acknowledgement receipt will be issued within three working days using the complainant’s preferred method of communication, unless it is a verbal concern resolved to the complainant’s satisfaction immediately/within 1 working day.

Acknowledgement will include:

• Confirmation of receipt and date received

• Name/contact details of the Complaints Lead

• Understanding of the complainant’s issue(s) and expectations

• The investigation plan (where applicable) and agreed response timescale

• How complaint updated will be provided on the complainant’s preferred communication method 

 

Stage 2 — Early resolution (target Day 0–2 working days)

Where appropriate, we attempt local resolution quickly:

• apology/explanation where appropriate

• immediate corrective action (e.g., appointment rebooking, clarification of fees, quick correction of admin error)

• confirm resolution in writing if requested

If resolved, outcome will be logged in complaint’s register and learning needs will be identified and actioned.

(If not resolved or complex → Stage 3.)

 

Stage 3 — Formal investigation (target 10–20 working days; up to 30 for complex)

​

Step 3.1: Appoint investigator (within 2 working days)

• A named investigator is appointed (normally the Complaint Lead Hassan Bhatti).

• Where the complaint relates to the appointed investigator, the complaint will be referred to an Independent Complaint Reviewer (Dr Kamran Ahmed) who has agreed to the be the independent reviewer of the complaints.

Step 3.2: Investigation actions (proportionate and documented)

Complaint Lead will investigate by:

• reviewing consultation notes, prescribing records, monitoring records, communications, and relevant SOPs

• obtaining written accounts from involved staff

• undertaking a clinical review where prescribing/clinical judgment is involved

• identifying whether standards were met and what should have happened

This aligns with the Ombudsman’s principles for planning and conducting investigations and producing a clear final response.

Step 3.3: Timescales

• Target response: within 20 working days

• If complex, (up to 30 working days), complainant will be informed the reason will be documented in the complaints register.

​

​

B. Keeping people updated throughout

• Update will be provided:

  • at acknowledgement (plan + timescale)

  • at Day 10 working days if investigation is ongoing

  • immediately if there is any delay or new significant finding

• Updates are given via the complainant’s preferred method and recorded in the complaint file.

 

 

C. How we tell people the outcome

Complaint Lead will issue a final written outcome via the complainant’s preferred method  that includes:

• Summary of the complaint issue(s)

• What was found (facts and conclusions)

• An apology where appropriate (and duty of candour actions if relevant)

• What actions have been and will be taken (immediate and long-term resolution)

• What learning(s) identified and service improvements implemented (SOP/training/audit)

• How to request a review/escalate if dissatisfied

• Contact details of the independent review, General Pharmaceutical Council (GPHC), Citizen’s Advice Bureau, Patients Association

 

 

D. If the person is unhappy with the outcome (Escalation)

Independent Review (acknowledge within 3 working days; respond within 20 working days)

• An Independent reviewer who is not involved in the matter will review:

  • whether the investigation was fair and complete

  • whether conclusions are supported by evidence

  • whether actions are adequate

• Complainant will be informed that this complaint has been forwarded to an Independent Review who’s contact details will be provided in this communication

External signposting

If still dissatisfied, complainant will be signposted to the appropriate route depending on service context.

Appropriate independent escalation routes and advice bodies relevant to the service arrangement for example:

• Patients Association

• Citizens Advice Bureau

• Action against Medical Accidents (AvMA)

• GPHC

• CQC

 

 

E. Cooperation with independent review

ElizabethPharma Ltd/Complaint Lead will cooperate fully with any independent review by:

• providing records, correspondence, SOPs, and audit logs promptly

• facilitating staff statements/interviews where appropriate

• sharing investigation methodology and rationale for decisions

• implementing recommendations and recording evidence of changes made

 

 

F. Learning, governance, and policy review trigger (complaint-driven)

Following resolution, if learning indicates that the complaint arose from:

• a gap in policy/SOP,

• staff training need,

• weakness in the process

• documentation/communication issue

then the relevant policy will be reviewed and updated sooner (not waiting for the annual review cycle). This will be recorded in the complaints register as an action with the completion date, and re-audited where appropriate.

 

 

9. Duty of Candour (Regulation 20)

Where a complaint identifies harm or potential harm:

• Complaint Lead will be open and honest with the complainant

• A sincere apology will be provided via complainants preferred method of contact

• A clear explanation will be given

• Learning(s) will be shared with the complainant

• Actions to prevent recurrence will be documented and shared with complainant

These (Duty of Candour) action(s) will be recorded as part of the complaints process.

​

​

10. Independent Review of Complaints

Where a complaint cannot be resolved through the internal process, or where independence is required, Complaint Lead (Hassan Bhatti) will arrange an independent review.

Complaint Lead will inform the complainant that their complaint has been escalated and to an Independent Reviewer who will respond within 20 working days and to contact the Complaint Lead if not response received from the independent reviewer.

Independent Reviewer

An independent clinician, Dr Kamran Ahmed, may be appointed to review complaints where appropriate.

The independent reviewer:

• will have no involvement in the matter involved.

• will have no managerial or financial control over Elizabethpharma Ltd

• will Provide an impartial and objective review

• will reviews clinical decision-making and complaint handling

• will be impartial and objective

• The complainant will be informed of the outcome of the independent review within 20 working days.

Independent review may be used when:

• A complainant remains dissatisfied

• A complaint involves the Registered Manager or Registered Provider

• There is actual or potential harm

• A conflict of interest exists

• Additional clinical objectivity is required

The complainant will be informed when an independent review is initiated.
Findings are documented and considered in the final response.

​

​

11. Escalation and External Bodies

• If a complainant is dissatisfied with the outcome, they may escalate concerns externally.

 

• A complainant may request an independent review of their complaint.
  Dr Kamran Ahmed (external, independent clinician) has agreed to act as an Independent Reviewer where appropriate.
  Contact details for the Independent Reviewer will be provided in the final response.

 

• They may contact the Care Quality Commission (CQC) regarding safety or quality concerns.

 

• CQC contact details will be provided in the final response.

CQC does not resolve individual complaints but uses information to monitor services.

 

• Where a complaint relates to professional conduct or prescribing practice, complainants may also be advised of their right to contact the General Pharmaceutical Council (GPhC).

 

• For complaints relating to private (non-NHS) care, contact details of organisations such as Citizens Advice, Patient Advice Bureau, AvMA e.t.c will be provided.

 

• When requested by the Care Quality Commission, ElizabethPharma Ltd will provide a summary of complaints, responses, and any related correspondence within 28 days, in accordance with Regulation 16(3) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

 

 

12. Record Keeping and Confidentiality

• All complaints are recorded in an electronic Complaints Register that is password protected and contains encrypted patient data

• Each complaint is assigned a unique reference number

• Records include:

  • Date received

  • Nature of complaint

  • Actions taken

  • Outcome

  • Learning identified

  • Date closed

Complaint Records are:

• Stored securely in electronic register which is password protected and all the dated stored in encrypted form.

• Accessed only by Complaint Lead

• Managed in accordance with UK GDPR and the Data Protection Act 2018

• Will be retained for 10 years in line with health records management guidance, then securely destroyed

​

​

13. Learning and Service Improvement

Complaints will be reviewed every 6 months for themes and trends

ElizabethPharma Ltd:

• will use learning(s) to improve safety, quality, and patient experience

• will Update policies, procedures, and training as part of learnings.

• will monitor effectiveness of actions taken by conducting Annual audits

Evidence of learning is retained and available for inspection for as long as necessary.

​

​

14. Public Access to Complaints Information

Information on how to make a complaint is provided through:

• A dedicated Complaints tab on the clinic website

• Printed complaints leaflets available to patients within the clinics

• Clear signage at the clinic entrance door explaining how to raise a complaint

• Staff signposting on request

 

 

 

15. Policy Review

This policy is:

• Reviewed annually

• Reviewed sooner if a complaint investigation identifies learning or service improvements that require changes to this policy, or if there are changes to relevant legislation, regulations, or guidance.

 

​

END OF POLICY