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Reference number: INF001

Approved by: Management Board

Date approved: 15 October 2013

Version: 1.5

Last revised: December 2019

Review date: December 2020

Category: Information Management

Owner: Head of Information Compliance and Equality

Target audience: All council employees and members of the public

After the Review Date has expired, this document may not be up-to-date. Please contact the document owner to check

the status after the Review Date shown above.

Access to Information Policy and Procedure

Formal Complaints, Freedom of Information (FOI), Subject Access Requests

(SAR), Environmental Information Regulations (EIR), and Data Protection (DP)

This policy should be read in conjunction with the Data Protection policy, and

Information Security policy.

If you would like help to understand this document, or would like it in another format

or language, please contact the document owner.

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PART 1 - POLICY

1. INTRODUCTION

1.1. This policy covers all formal complaints, requests made under the Freedom of Information (FOI) Act 2000, subject access requests (SAR),requests made under the Environmental Information Regulations 2004(EIR), and data protection breaches regarding Herefordshire Council. It sets out how a request for information will be dealt with, the timescales, and who should be involved in handling the request. This policy covers all forms of requests for information regarding, adult social care, children and young people and all council services.

1.2. Formal Complaints about Herefordshire Council will be handled by the

Information Access Team (IAT) within the Corporate support services which will be the single point of contact for the customer. An IAT officer will acknowledge the complainant, agree a timescale, assign an investigating officer, assess risk, ensure that a fair investigation takes place either by a service manager or by a complaints manager, quality check all responses, and communicate with the customer.

1.3. Complaints about Children’s Services and Children’s Social Care will be dealt

with under a separate statutory procedure (“Children’s Representations & Complaints Procedures”).

1.4. Complaints about schools will be managed by the school and they should be

contacted directly to follow the school’s complaint procedure.

1.5. Complaints about council services provided by the 2gether Mental Health Foundation Trust will be managed and responded to by 2gether Mental Health Foundation Trust, and monitored through the contract compliance and commissioning framework.

1.6. Complaints regarding other organisations carried out on the council’s behalf may be investigated by the organisation concerned or the council team commissioning that service in the first instance, however final stages of the complaints process will be managed by the information access team. This includes organisations such as Hoople, Balfour Beatty, FCC, ACE adoption and bailiffs.

1.7. The policy seeks to create a positive approach to complaints and other

information requests. Complaints are valued as a means to continuously review and improve the services we offer. By listening to customers and using insight into peoples experiences mistakes can be resolved faster, new ways to improve can be learned and the same problems can be prevented from happening in the future.

1.8. Our customers may find it difficult to talk about their views or concerns, they may

be worried that complaining will lead to a reduction in services or care; equally they may find it difficult to speak out because of things like how their disability affects them, their language or their level of communication skills, or how their racial, cultural or religious background, age, gender or sex are viewed. The IAT will ensure that all of these issues are taken into account and will provide a

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service that is fair and equitable, irrespective of an individual’s needs, beliefs, age, sexual orientation or race.

2. OBJECTIVES

2.1. To provide an effective means for a customer to make a formal complaint about how services could be improved in the future.

2.2. To provide an effective means for customers and their representatives to

complain if they are dissatisfied with the service they receive.

2.3. To ensure complaints are dealt with in a courteous and efficient manner and are resolved without avoidable delay.

2.4. To provide the public with access to information so that we are open and

transparent in our dealings with the community and, to inform future policy and service planning.

2.5. There are 6 overriding principles to good complaints handling that will be followed

at all times:

1. Being customer focused 2. Getting it right 3. Acting fairly and proportionally 4. Being open and accountable 5. Putting things right 6. Improving services as a result

3. DATA PROTECTION PRINCIPLES

3.1. The principles relating to processing personal data under the GDPR:

1. Processed lawfully, fairly and in a transparent manner in relation to the data subject (lawfulness, fairness and transparency)

2. Collected for specified, explicit and legitimate purpose and not further processed in a manner that is incompatible with those purposes; further processing for archiving purposes in the public interest, scientific or historical research purposes or statistical purposes shall, in accordance with Article 89(1), not be considered to be incompatible with the initial purpose (purpose limitation)

3. Adequate relevant and limited to what is necessary in relation to the purposes for which they are processed (data minimisation)

4. Accurate and, where necessary, kept up to date every reasonable step must be taken to ensure that personal data that are inaccurate, having regard to the purpose for which they are processed, are erased or rectified without delay (accuracy)

5. Kept in a form which permits identification of data subjects for no longer than is necessary for the purposes for which the personal data are processed; personal data may be stored for longer periods insofar as the personal data will be processed solely for archiving purposes in the public interest, scientific or historical research purposes of statistical purposes in accordance with Article 89(1) subject to implementation of the appropriate technical and organisational measures required by this regulation in order to safeguard the

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rights and freedoms of the data subject (storage limitation) 6. Processed in a manner that ensures appropriate security of the personal

data, including protection against unauthorised or unlawful processing and against accidental loss, destruction or damage, using appropriate technical or organisational measures (integrity and confidentiality)

3.2. Complaints give us valuable feedback in our continuing bid to develop high

quality services and help to give customers confidence that they will be given a fair hearing within agreed timescales.

3.3. Any informal complaints, comments or compliments should be resolved and

recorded locally, so that they can be recorded and monitored by the service area. The Assistant Director responsible for the service area should be informed of informal complaints, comments or compliments so that learning and service improvement can be shared.

3.4. All formal complaints will be referred to the IAT to ensure that they are recorded,

tracked and monitored, and that any learning can be shared across the Council. 4. WHAT IS COVERED BY THE IAT TEAM AND THIS POLICY

4.1. Formal Complaint: A complaint, for the purpose of this policy, is defined as:

An expression of dissatisfaction about the standard of service, actions or lack of action by Herefordshire Council, our staff or contractors.

4.2. Freedom of Information Requests (FOI): Information covered by the Freedom of Information Act is any recorded information which is not “personal data” within the meaning of the Data Protection Act 2018 or which is not “Environmental Information” as defined by Regulation 2 of the Environmental Information Regulations (EIR) 2004. The information may be held by Herefordshire Council, or by one of its contractors on the council’s behalf.

4.3. Environmental Information Requests (EIR): This gives the public the right to access environmental information which is held by the council or one of its contractors on the council’s behalf. This includes subjects like: state of the elements, natural sites (eg. wetlands), factors like radiation, energy noise, waste, state of human health including the contamination of the food chain, cultural sites and built environment.

4.4. Subject Access Requests (SARs): The data subject has the right to obtain confirmation as to whether or not personal data concerning him or her are being processed and where that is the case access to their personal data.

4.5. Proof of Life: A request from the police to check for a named individual’s contact

with council services. This is part of a criminal case in which the police need to prove that the named individual is dead.

5. WHAT IS NOT COVERED BY THIS POLICY AND PROCEDURE

5.1. Internal complaints and compliments are not covered by this policy and procedure.

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5.2. Complaints that employees may have about Herefordshire Council as an employer should be made through the grievance procedure, or other internal channels. However, members of staff have the same rights to complain about our actions or services as other residents or members of the public.

5.3. The following are covered by different procedures and are exemptions to the

complaints policy and procedure, so we may not accept these types of complaints.

Complaints from organisations that we commission and the complaint is about

their funding or related issues Children’s complaints (see separate policy) Complaints about schools From employees about issues relating to their employment From councillors, unless they are complaining as ordinary members of the

public or as an ‘advocate’ (representing the interests of someone else) Where legal limits are in place, for example:

o refusing planning permission o cases where legal action has already started

o cases covered by our insurance procedures o compensation claims o parking and traffic offences; penalty charge notices o refusing to issue disabled badges for parking exemption o where the complaint has already been dealt with in another way

6. HOW TO MAKE A COMPLAINT

6.1. It is for the customer to decide whether or not to make a complaint. Any employee however should remember that reporting a fault or a problem is not necessarily a complaint, but may be simply a request for service. Some examples of complaints may be:

we have not achieved the standard we say we will provide we have not provided the service to the standard which the customer/service

user thinks is reasonable we are doing something which the customer did not want us to do we are carrying out our duties in an unsatisfactory way our staff or contractors are behaving in an unacceptable way (including

rudeness, violence or aggression) we fail to do something which we have been asked to do we fail to do something which the customer thinks we should have done, even

if we were not actually asked to do it

6.2. Generally speaking, a complaint has to be made within 12 months from the date on which the matter occurred, or the matter came to the notice of the complainant.

6.3. Where a complaint is made direct to the IAT about an organisation providing

Adult Social Care services, the IAT will discuss with the complainant how the complaint will be handled. Decisions will be based on the complainant’s wishes, but no information will be shared with the provider unless consent has been given by the complainant.

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6.4. Where the IAT decides to manage the complaint, they will notify the complainant and the provider.

6.5. If the IAT decides it is more appropriate for the complaint to be handled by the

provider organisation, with the consent of the complainant it will notify the provider and the complainant.

When the provider receives the notification: the provider must handle the complaint in accordance with this policy the complainant is deemed to have made the complaint to the provider the IAT should be informed of the outcome

6.6. Where the complainant wishes the IAT to investigate the complaint this will be

commenced in conjunction with the provider once consent has been received from the complainant to share the information. The provider must have the opportunity to respond to the complainant. Once the investigation is complete, the IAT will inform the complainant of the outcomes.

6.7. Where the services are provided by Herefordshire Council, the formal complaint must be managed by the IAT.

7. SUPPORT AND ADVOCACY

7.1. If our customers feel or appear to be at any sort of disadvantage in being able to express themselves, we will offer them the help and support they need to have their concerns listened to and understood. This may include translation or interpreting services, or referral to sources of local independent advocacy and advice. Advocacy for children will be made available via Children’s Services. If a child is “Looked After”, leaving care, or involved in child protection processes and/or subject to a child protection plan, and aged 10 or over, then this service will be provided under contract.

7.2. Anonymous complaints will be investigated and may be acted upon at our

discretion. Should the complainant fear that we will withhold services or care, or treat them less favourably if they complain openly, we will, if required, assist in finding support outside the service.

8. RIGHTS

8.1. Customers have the right:

to be treated with dignity and respect to confidentiality (if an investigation cannot proceed without the complainant

being identified, the complainant will be given the option whether or not to continue)

to have any complaint dealt with efficiently and have it properly investigated within agreed timescales and to be updated and consulted if those timescales need to change

to be offered a face to face meeting to go through the detail of the complaint whenever appropriate

to know the outcome of any investigation into their complaint to be kept informed of the progress of their complaint to receive an apology if a complaint is upheld

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to be informed of any changes to our policies or procedures arising from a complaint

to take their complaint to the Local Government and Social Care Ombudsman if they are not satisfied with the way their complaint has been dealt with

to refer their request to the Information Commissioner’s Office if they are not happy with the response they have received regarding an FOI or EIR or if they feel that we have a data protection issue or breach

8.2. This complaints policy does not affect the right of an individual or organisation to

approach a local councillor or Member of Parliament for advice or assistance. If this results in a complaint being made by or on behalf of an individual, it will be dealt with using this procedure.

8.3. Everyone has the right to be treated with respect and courtesy and to be spoken

to without the use of abusive language at all times by both customers and staff.

8.4. Where a complaint forms part of, or relates to any legal action being undertaken, we reserve the right to delay or suspend investigation of the complaint if it could have an impact on the legal process.

9. CONFIDENTIALITY

9.1. All customer information, whether held on paper, computer, visually or audio recorded, or held in the memory of the professional, must not normally be disclosed without the consent of the customer. It is irrelevant how old the customer is or what the state of their mental heath is; the duty still applies.

9.2. There are three circumstances making disclosure of confidential information

lawful:

where the individual to whom the information relates has consented where disclosure is in the public interest where there is a legal duty to do so, for example: a court order, or

safeguarding concern

9.3. Data protection legislation prohibits the obtaining or sharing of information with third parties without an appropriate condition for processing, such as consent. Conditions for consent are: Where processing is based on consent the controller shall be able to

demonstrate that the data subject has consented to processing of his or her personal data.

If the data subject’s consent is given in the context of a written declaration which also concerns other matters, the request for consent shall be presented in a manner which is clearly distinguishable from the other matters, in an intelligible and easily accessible form, using clear and plain language. Any part of such a declaration which constitutes an infringement of this regulation shall not be binding.

The data subject shall have the right to withdraw his or her consent at any time. The withdrawal of consent shall not affect the lawfulness of processing based on consent before its withdrawal. Prior to giving consent, the data subject shall be informed thereof. It shall be as easy to withdraw as to give consent.

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When assessing whether consent is freely given, utmost account shall be taken of whether, inter alia, the performance of a contract, including the provision of a service, is conditional on consent to the processing of personal data that is not necessary for the performance of that contract.

9.4. Herefordshire Council will take care at all times throughout the complaints

procedure to ensure that any information disclosed about the customer is confined to that which is relevant to the investigation of the complaint, and is only disclosed to those people who have a demonstrable need to know it for the purpose of investigating the complaint.

9.5. Customers will be made aware of the effect it will have on the investigation if they

object to their information being disclosed, but the wishes of the customer will be respected, unless there is overriding public interest in continuing the investigation.

9.6. Complaints will be kept securely by the council for 6 years after final resolution of the complaint.

10. RISK MANAGEMENT

10.1. One of the key aims of this policy and procedure is to minimise risk to safety and enhance the quality of services and care provided to customers. This policy therefore is a crucial part of the overall strategy and approach to the management and minimisation of risks identified or arising from information access requests and complaints.

10.2. Specific risks related to the application of this policy and procedures are:

Delay or failure to respond appropriately to complaints or information requests

in accordance with regulations, leaving the organisation open to potential action by the LGSCO or the Information Commissioner

Not addressing concerns raised resulting in loss of public confidence Failing to identify risk or safety issues and address or reduce them Failing to identify trends or recurrent themes identified from complaints and

other forms of service user feedback The need for confidentiality vs the requirement to refer safeguarding concerns

appropriately

10.3. In accordance with risk management procedures, all complaints will be graded according to the seriousness of the risk. The grading system will consider the severity or impact of risk identified within the complaint and the likelihood of this occurring in the future producing an assessment of low, medium, high to significant risk. Any risk identified will be managed in accordance with risk management procedures. All risks identified will be placed onto the risk register.

11. COMPLAINTS AGAINST STAFF

11.1. If a complaint regarding staff actions or behaviour is found to be valid, then the issue will be referred to the appropriate corporate human resource policy/ procedure such as the capability or disciplinary procedure and investigated. This will be regarded as an outcome for the complaints procedure.

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11.2. For complaints regarding standards of spoken English, the Code of Practice on the English Language Requirements for Public Sector Workers states that for the purposes of the fluency duty, a legitimate complaint is one about the standard of spoken English of a public sector member of staff in a customer-facing role. A complaint about accent, dialect, manner or tone of communication, origin or nationality would not be considered a legitimate complaint about the fluency duty. Complaints that are without foundation and/or which are intended to result in harsh or wrongful treatment of the person who is the subject of the complaint must not be taken forward.

12. STAFF AWARENESS AND TRAINING

12.1. All employees should have information about dealing with customer feedback and complaints at induction and Data Protection, and Information Governance is part of the mandatory training for all new starters.

12.2. The IAT will provide training to employees on how to deal with complaints, FOI,

SARs EIR, and Data Protection as and when required. 13. MONITORING, EVALUATION AND REPORTING

13.1. The IAT will keep a record of all formal complaints, including dates received, acknowledged, responded, category of complaint, actions taken and lessons learned.

13.2. All complaints will be recorded on a single system (CRM) for tracking and

monitoring and reporting purposes.

13.3. Regular reports will be sent to service areas and senior management indicating numbers of information access requests including complaints received, how many are dealt with within the agreed timescale, what service improvements and changes have been made as an outcome to complaints received.

14. HANDLING UNREASONABLE COMPLAINTS

14.1. We operate a zero tolerance policy with regards to physical, verbal or written abuse towards our staff.

14.2. Where, despite best efforts to resolve a complaint, the complainant becomes

abusive, unreasonable or vexatious, staff will follow the separate policy for dealing with unreasonable complainant behaviour.

14.3. Where a complaint is deemed vexatious, they will be informed of the decision in

writing and given clear information about how they should contact the council in the future.

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PART 2 - PROCEDURE

15. FORMAL COMPLAINTS

15.1. Anyone who wishes to make a formal complaint may do so in writing (by using a complaints form, letter, or e-mail). Formal Complaints should normally be sent to the IAT, but if they are received directly into any service area covered by this policy they will be redirected to the IAT immediately.

15.2. On receipt of a written complaint that is passed on in person, the customer

should be advised that it will be sent to the IAT who will contact them to arrange how the complaint will be managed.

15.3. Once received, we will normally acknowledge any formal complaint within five

working days. 16. FREEDOM OF INFORMATION REQUESTS

16.1. Anyone who wishes to make an FOI request must do so in writing. All FOI requests will be dealt with by the IAT. If an FOI relating to service delivery is received by any employee, then the individual should forward details of the request to the IAT for recording (and response if required) as soon as is practical; this would normally be within 5 working days. All FOI requests will be logged and monitored to ensure that the response is made within the statutory timescales.

16.2. If a customer is not satisfied with the Council's handling of their request or if a

customer disagrees with the application of an exemption, they may request a review of the request through the IAT. The Review Procedure is available from here.

17. SUBJECT ACCESS REQUESTS

17.1. The council encourages people to submit requests via the Subject Access Request Form on the council website. All requests should be sent to the Information Governance Team who will log the request and ensure that the request is valid.

17.2. For a subject access request to be valid, it must meet the following criteria:

Be made in writing Be supported by sufficient identification of the requester Be enough information to identify the applicant and to locate the information

18. ENVIRONMENTAL INFORMATION REGULATION REQUESTS

18.1. Anyone who wishes to make an EIR request can do so in writing or verbally. All EIR requests will be dealt with by the IAT. If an EIR request is received by any employee, then the individual should forward details of the request to the IAT for recording (and response if required) as soon as is practical; this would normally be within 5 working days. All EIR requests will be logged and monitored to ensure that the response is made within the statutory timescales.

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19. DEALING WITH A FORMAL COMPLAINT

19.1. Where a formal, serious or complex complaint is received by an employee other than IAT staff, the employee should report the complaint to IAT immediately, ensuring that all the relevant details are recorded and forwarded to the IAT team. In the case of Customer Services, this would be via the CRM system.

19.2. The IAT will send a written acknowledgement to the complainant normally within

5 working days of receipt into the Council, if necessary and appropriate with an offer to discuss the complaint over the telephone or in person, to identify and agree the points for investigation and the complainant’s desired outcomes. Where complaints involve a simple investigation and response, the acknowledgement letter from the IAT will outline the proposed action and this will be the complaints handling plan.

19.3. The IAT will then appoint an investigating officer. The investigating officer will in

most cases be the manager of the service being complained about because of their specialist knowledge. The IAT will liaise with the Assistant Director (AD) responsible for the appropriate department if it is inappropriate to use an investigating officer in the service area concerned.

19.4. The investigating officer will undertake an investigation in line with the timescale

agreed with complainant and recorded by the IAT.

19.5. The IAT will maintain contact with the complainant to give advice on progress at regular intervals.

19.6. The IAT will review the response and outcome before providing a formal

response to the complainant (this may involve the IAT requesting further clarification or additional information from the investigating officer or the service involved).

19.7. The IAT will send out the response to the complainant with a covering letter

stating that at this stage that the complainant will have 10 working days to respond if they remain dissatisfied with the outcome.

19.8. If there is no further communication after the specified 10 working days, the IAT

will close the complaint.

19.9. If the complainant is dissatisfied with the response and responds within the 10 working days, the IAT will review the complaint in light of any ongoing issues. This may involve a further investigation and/or a meeting with the complainant and the relevant representative(s) from the service(s) involved.

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19.10. We will make every effort to resolve customers’ complaints and ensure that they are investigated fully and fairly. In each response we will provide the complainant with details of the Local Government and Social Care Ombudsman should they wish to refer the issue.

19.11. Where we have investigated and taken all available actions and the complaint

remains unresolved, we will write to advise the complainant that the case will be closed and clarify what options of further redress are available to them.

19.12. The IAT will record action and learning resulting from complaints and these will

be reported at Directorate management meetings and shared with directors and senior managers on a regular basis.

20. THE OMBUDSMAN

20.1. If the complaint is unable to be resolved, or a person is not satisfied with the handling of the complaint (at any stage), they can ask for the Local Government and Social Care Ombudsman to review the matter.

20.2. For monitoring purposes, the IAT will log the date of receipt by the Council of the

LGSCO request and the date the information is returned to the LGSCO. 21. WITHDRAWAL OF A COMPLAINT

21.1. The complaint may be withdrawn verbally or in writing at any time by the complainant. The IAT must write to the complainant to confirm the withdrawal of the complaint. In these circumstances, the council will decide on whether or not it wishes to continue considering the issues that gave rise to the complaint through an internal management review. The council will then use this work to consider the need for any subsequent actions in the services it delivers.

21.2. Should the complainant then seek to reinstate the complaint, the council can use

the review to produce a response as necessary.

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22. DOCUMENT CLASSIFICATION

Author Name and Role Equality Information and Records Manager

Date Created September 2013

Date Issued May 2014

Description Access to Information Policy

File Name Access to Information Policy

Format Microsoft Word / 2010

Geographic Coverage Herefordshire

Master Location

Publisher Herefordshire Council

Rights Copyright Copyright of Herefordshire Council

Security Classification Unclassified

Status Final

Subject Information Governance

Title Access to Information Policy

Version Log

Version Status Date Description of Change Pages affected

0.01 Draft Creation of document

1.0 Final May 2014

Updated all

1.1 Final July 2014 Updated to include reference to FOI/EIR Review Procedure

All

1.2 Final October 2015

Updated web links 4, 9

1.3 Final September 2017

Change of name for LGO All

1.4 March 2018

Updates 3, 4, 7, 8, 10

1.5 December 2019

Update to include reference to children’s complaints process and other organisation’s complaints proceses.

All

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23. APPENDICES Appendix 1

Formal Complaints Flow Chart

esponse s

Request for Information or

formal complaint comes into

the service area.

IAT log on system and initiate process – If

formal complaint normally acknowledge

within 5 working days

IAT contact service area. Service area identify

appropriate investigating officer and agree

time scales

IAT confirm timescales with complainant

and identify if consent required.

Consent

required

Consent to share details within

council gained and logged

No

consent

IAT write to complainant

to clarify that the

complaint has been

closed Investigation carried out by investigating

officer.

Written response sent to IAT. IAT send

out response with covering letter,

informing complainant that if no further

action complaint will be closed in 10

working days

Response

inadequate or

unclear IAT contact service area for

further information or

clarification

Complainant not happy with

response

Complainant refers case to Local

Government Ombudsman

Complaint closed

Forward to

IAT

Complainant

satisfied with

response

Consent gained

Day

1 -5

6

6-10

10-

15

20

20 -

25

30

30 + Learning and actions from complaints

reported and discussed at Directorate

Management Teams on a regular basis.

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Appendix 2

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Appendix 3: Learning Template – Monitoring and Quality Assurance

The Local Authority should monitor the operation and effectiveness of the complaints procedure as well as how information about complaints is being used to improve services and delivery. The Local Authority should ensure that their quality assurance systems include a cycle of planning with outcomes fed back into operational delivery. All local authorities should provide a system for:

the dissemination of learning from complaints to line managers the use of the complaints procedure as a measure of performance and means of

quality control information derived from complaints to contribute to practice development,

commissioning and service planning

Annual report Local authorities must, each financial year, publish an Annual Report (regulation 13(3)). This should draw upon the information already gathered for recording purposes. However, this Annual Report is a separate requirement and should not contain personal information that is identifiable about any individual complainant.

The Annual Report should be arranged by the Complaints Manager and should provide a mechanism by which the local authority can be kept informed about the operation of its complaints procedure. The report should be presented to staff, the relevant local authority committee, and should be made available to the regulator and the general public. It should provide information about:

representations made to the local authority the number of complaints at each stage and any that were considered by the

Local Government and Social Care Ombudsman which customer groups made the complaints the types of complaints made the outcome of complaints details about any advocacy services provided under these arrangements compliance with timescales, and complaints resolved within extended timescale

as agreed learning and service improvement, including changes to services that have been

implemented and details of any that have not been implemented a review of the effectiveness of the complaints procedure

In order to demonstrate learning from complaints, analysis of trends and closer working with relevant bodies (such as the NHS), individual local authorities may wish to agree a common format for their reports and reporting cycles with relevant key agencies.

Monitoring Monitoring should also highlight how effective communication is within the authority and to the people receiving their services, where staff training is required and whether resources are targeted appropriately. This should be fed back into the system in order to facilitate and improve policy and practice.

Learning Template

Case number Has an advocate been involved Y/N

What category the complaint was about (Service failure/ Delay / Poor Communication/ Staff Attitude / Wrong Information Given)

Outcome of complaint (Up-held, Not up-held)

What were the underlying causes of the complaint?

(eg poor record keeping)

What has changed? How will we ensure that this doesn’t happen again?

Was the complaint resolved within agreed timescales?