Complaints Policy & Procedure

  1. Policy Statement
    Casadh is committed to taking seriously any complaint that concerned individuals have about the service
  2. Purpose
    This policy is intended to ensure that complaints are dealt with properly and addressed in a professional manner and that improvements are made as a result of complaints. This policy covers all actions to be taken in respect to a complaint by a concerned individual.
  3. Scope
    3.1. This policy covers all actions to be taken in respect to a complaint by a concerned individual. Complaints can be made against any aspect of Casadh’s ’s service delivery
    3.2. This policy applies to all staff members and representatives from other agencies conducting in-reach services
  4. Glossary
    4.1. Complaint: In line with the Health Act 2004, “complaint” means a complaint about any action of the organisation that
    A. it is claimed, does not accord with fair or sound administrative practice, and
    B. adversely affects the person by whom or on whose behalf the complaint is made
    For the avoidance of doubt, complaints may only be made in respect of actions which have already been taken.
    4.2. Concerned individuals: Includes anyone who is directly affected by the actions of the organisation, but excludes anyone who works for the organisation either in a paid or voluntary capacity, such as staff members or volunteers. These groups should use internal management structures and / or the organisation’s grievance procedure in the event that they wish to complain about a decision affecting them.
    4.3. Staff member: Should be construed broadly, and includes, for the purposes of this policy, staff members, volunteers, interns and locums
    4.4. Executive: The Health Service Executive (HSE)
  5. Roles and Responsibilities
    5.1. Management are responsible for:
    5.1.1. Ensuring all staff members are aware of this policy and are able to advise concerned individuals on same.
    5.1.2. Ensuring that all complaints received are handled in line with this policy.
    5.1.3. Regularly monitoring the number, nature and outcome of complaints as part of the continuous quality improvement process.
    5.2. Staff members are responsible for;
    5.2.1. Ensuring that all service users are informed of the complaints policy as part of their introduction to the service
    5.2.2. Ensuring that any other concerned individual is made aware of the complaints policy as appropriate
    5.2.3. Assisting concerned individuals to make a complaint as outlined in this policy when requested to do so.
    5.2.4. Following all other steps regarding complaints as outlined in this policy
    5.2.5. Ensuring they keep themselves informed in relation to this policy
    6.1. All complaints should be dealt with promptly, and within the timescales outlined.
    6.2. As far as possible all complaints should be resolved as quickly and efficiently as possible.
    6.3. Complainants should be consulted about what they would like to happen about their complaint.
    6.4. Complainants should be supported and given appropriate assistance throughout the procedure. They should be given the opportunity to be supported by an advocate. For the purposes of this policy an advocate is taken as being anyone who has the complainant’s written permission to complain on their behalf, excluding staff members. A parent or guardian may complain on behalf of a child.
    6.5. The complaints procedure should be well publicised. A template is included in appendix I of this policy document and should be displayed prominently in the project. All new service users will be given a brief explanation of the complaints procedure as part of their induction.
    6.6. All complaints must be properly recorded. A Complaints Record Form template is included in appendix II of this policy document. The Manager is responsible for ensuring that complaints are properly recorded and signed by the complainant, the staff member recording the complaint and the manager. Alterations to the complaint this should be recorded and signed and dated.
    6.7. A complaints file should be maintained and regularly monitored by the Manager
  6. Basic Information
    Who can make a complaint?
    Any person who is being or was provided with a health or personal social service by the Service Provider or who is seeking or has sought provision of such service may complain, in accordance with the procedures established under this Part, about any action of the Executive or Service Provider that-
    (a) it is claimed, does not accord with fair and sound administrative practice,
    (b) adversely affects or affected that person.
    7.1. An advocate may also complain on a concerned individual’s behalf provided they have the concerned individual’s written consent.
    7.2. A parent / guardian may complain on behalf of a child.
    What can they complain about?
    7.3. Any action of the organisation that has directly affected them. This might include:
    7.3.1. The manner in which the organisation has treated them
    7.3.2. Being denied a service
    7.3.3. A change in service provision
    7.3.4. The actions of a specific member of staff
    How can complaints be made?
    7.4. Complaints may be made either in writing or verbally.
    7.5. A verbal complaint may be made in the first instance to the complaints manager. This may be done in person or by telephone on 01-4548419 by asking for the complaints manager.

    Project Name Complaints Policy
    7.6. However, once a complaint moves to Stage 2 (see Section 8, below), it must be recorded in writing (this may be done by the complainant or a person designated by the complainant)
    Written complaints may be made in the first instance to the:
    Complaints Manager,
    Casadh 45 Crumlin Road
    Dublin 12
    Or by email to

    A written complaint may also be handed in in person to the reception area and a written receipt obtained.
    7.6.1 Advocacy
    All complainants have the right to appoint an advocate who, if a person is unable to make a complaint themselves can assist them in making the complaint. The Citizen Information (Comhairle 2005) defines advocacy as a means of empowering people by supporting them to assert their views and claim their entitlements and where necessary, representing and negotiating on their behalf.
    Acknowledgement of written complaints
    7.7. Casadh will notify, the complainant in writing within 5 working days of an written complaint being received:
    7.7.1 That the complaint has been so received
    7.7.2 An outline of the steps that the organisation proposes to take in investigating the complaint
    7.7.3 A proposed time limit for the completion of the investigation
    7.7.4 A contact person for the complainant
    Complaints involving staff
    7.8. If the complaint is about a member of staff, the complainant should immediately be referred to a more senior person than the person about whom they wish to complain1. In the event that the complaint cannot be resolved locally, the complainant:
    7.8.1. may be supported to put the complaint in writing
    7.8.2. will be told that the staff member will be notified of the complaint against them
    7.8.3. will be told that their complaint will be acknowledged as per section 7.6
    7.9 What are the time limits for complaints?2
    Time limits for complaints are set out in Section 47, Part 9 of the Health Act 2004, which requires that:
  7. A complaint must be made within 12 months of the date of the action giving rise to the complaint or within 12 months of the complainant becoming aware of the action giving rise to the complaint.
  8. The manager/complaints officer may decide to extend the time limit for making a complaint if in the opinion of the manager/complaints officer special circumstances make it appropriate to do so.
  9. Special circumstances may include but are not limited to the following:
  10. If the complainant is ill or bereaved
  11. If new relevant, significant and verifiable information relating to the action becomes available to the complainant
  12. If it is considered in the public interest to investigate the complaint
  13. If the complaint concerns an issue of such seriousness that it cannot be ignored
    1 Or to a board member in the event of the complaint being against the most senior employee
    2 Guidelines for Voluntary Organisations and Hospitals in Drafting Complaints Procedures. 2015. HSE.
  14. Diminished capacity of the service user at the time of the experience e.g. mental health, critical/long-term illness
  15. Where extensive support was required to make the complaint and this took longer than 12 months
    The manager/complaints officer must notify the complainant of the decision to extend /not extend the time limits within 5 working days
    7.10 Are there any matters excluded from the complaints process3?
    According to Section 48(1), Part 9 of the Health Act 2004 A person is not entitled to make a complaint about any of the following matters:
  16. A matter that is or has been the subject of legal proceedings before a court or tribunal;
  17. A matter relating solely to the exercise of clinical judgement by a person acting on behalf of the service provider;
  18. An action taken by the service provider solely on the advice of a person exercising clinical judgement in the circumstance described in 7.9.2;
  19. A matter relating to the recruitment or appointment of an employee by the service provider;
  20. A matter relating to or affecting the terms or conditions of a contract of employment that the service provider proposes to enter into or of a contract with an advisor that the Service provider proposes to enter into under Section 24;
  21. A matter relating to the Social Welfare Acts;
  22. A matter that could be the subject of an appeal under Section 60 of the Civil Registration Act 2004;
  23. A matter that could prejudice an investigation being undertaken by the Garda Síochána;
  24. A matter that has been brought before any other complaints procedure established under an enactment
  25. Redress
    According to HSE guidelines on complaints, Redress should be consistent and fair for both the complainant and the service against which the complaint was made. The HSE or service provider should offer forms of redress or responses that are appropriate and reasonable where it has been established that a measurable loss, detriment or disadvantage was suffered or sustained by the claimant personally.
    This redress could include:
    .1. Apology
    .2. An explanation
    .3. Refund
    .4. Admission of fault
    .5. Change of decision
    .6. Replacement
    .7. Repair/rework
    .8. Correction of misleading or incorrect records
    .9. Technical or financial assistance
    .10. Recommendation to make a change to a relevant policy or law
    .11. A waiver of debt
    3,4 Guidelines for Voluntary Organisations and Hospitals in Drafting Complaints Procedures. 2015. HSE

    A Manager/complaints officer may not, following the investigation of a complaint, make a recommendation the implementation of which would require or cause-
    The service provider to make a material amendment to its approved service plan, or
    The service provider and the Executive to make a material amendment to an arrangement under section 38.
    If, in the opinion of the relevant person, such a recommendation is made, that person shall either-
    (a) Amend the recommendation in such manner as makes the amendment to the applicable service plan or arrangement unnecessary, or
    (b) Reject the recommendation and take such other measures to remedy, mitigate or alter the adverse effect of the matter to which the complaint relates as the relevant person considers appropriate
  26. Complaints Management
    There are four stages to the complaints procedure:
    Stage 1 Local resolution at the point of contact
    Stage 2 Managing a written complaint
    Stage 3 Local Review
    Stage 4 Independent review

    9.1. Stage 1 Local resolution at the point of contact
    9.1.1. If a complainant has a problem with an aspect of the service they should inform a staff member. The staff member will make every effort to resolve the problem locally at first point of contact. The staff member may seek assistance from management at this stage in resolving the problem.
    9.1.2. In the event that the problem cannot be resolved locally it must be recorded as a formal complaint to be progressed further.
    9.2. Stage 2 Managing a written complaint
  27. Informal resolution of a complaint
    a. The manager/complaints officer taking into account the nature and circumstance of the complaint, may seek the consent of the complainant and any third party to whom the complaint applies to finding an informal resolution of the complaint by the parties concerned.
    b. Where an informal resolution is not applicable or not successful, the manager/complaints officer will initiate a formal investigation.
  28. Formal resolution of a complaint
    a. The complaint should be reviewed by manager/complaints officer, to confirm that they are in possession of a written record of the complaint, which is signed and dated by the complainant and clearly sets out the nature of the compliant, why the initial response was unsatisfactory and what the complainant’s desired outcome is.
    b. The manager/complaints officer will write to the complainant in line with 7.6.
    c. The manager/complaints officer will investigate the complaint and may draw on appropriate expertise, skills etc. as required.
    d. The complainant and any third parties involved will be given the opportunity to discuss the complaint with the manager/complaints officer individually in private.
    e. The manager/complaints officer will complete investigation of the complaint within 30 working days of acknowledging the complaint. If this is not possible, within 30 working days of acknowledging the complaint, the complainant must be informed of the delay and given an indication of the time it will take to complete the investigation. The complainant and relevant third parties must be updated every 20 working days.
    f. Where the investigation passes the 30 working days timeframe, the complainant must be informed of the delay and the manager/complaints officer must endeavour to complete the investigation within 6 months.
    g. Where deadlines are not met, the complainant must be informed that they can chose to move to stage 3 (if relevant) / stage 4 of the complaints management process
    h. The manager/complaints officer will inform the complainant and any relevant third parties of the outcome of the investigation in writing. The letter must state whether the complaint has been upheld, and whether any further action will be taken.
    i. If the complainant is not satisfied with the outcome of the investigation, they should be informed of Stage 3 and 4 reviews.
  29. Stage 3 Local (independent) Review
    If a complainant is not satisfied with the outcome of the investigation at stage two, an independent review will be offered. This will be a person nominated by the board of management (In senior standing of the complaints officer/manager) of Casadh who will review all documentation and determine the appropriateness of the determinations of the complaints officer.
    10.1. The Independent Review Officer’s function is to: determine the appropriateness of a recommendation made by the Complaints Officer, having regard to the two elements:
  30. All aspects of the complaint
  31. The investigation of the complaint
    Having determined the appropriateness of the recommendation to uphold it, vary it, or make a new recommendation if he/she considers it appropriate to do so. Implementation of Recommendations made by Review Officers
    a. Within 30 working days the Accountable Officer will write to the Complainant and the Review Officer detailing recommendation.
    b. Where a recommendation, the implementation of which would require or cause the Executive to make a material amendment to its approved service plan, the relevant Head of Service (Accountable Officer) may amend or reject the recommendation.
    c. Where the recommendation is being amended or rejected or where alternative measures are being taken, the relevant Head of Service (Accountable Officer) must give the reasons for their decisions.
    d. The relevant Head of Service (Accountable Officer) must put an action plan in place for the implementation of the recommendations of the investigation. The action plan, persons responsible and timeframes are to be identified and recorded
  32. Stage 4 Further (Independent review)
    11.1.1. If the complainant is not satisfied with the outcome of the complaints management process in stage 2 or stage 3, the complainant may seek a review of the complaint by the Ombudsman or Ombudsman for Children. The complainant must be informed of their right to seek an independent review from the Ombudsman or Ombudsman for Children at any stage of the complaint management process.
    11.1.2. All requests for reviews may be addressed to the Office of the Ombudsman, 18 Lower Leeson Street, Dublin 2. Tel: +353-1-639 5600. Lo-call: 1890 223030. Fax: (01) 639 5674.
    Ombudsman for Children’s Office, Millennium House, 52-56 Great Strand Street, Dublin 1. Tel: 01-8656800.
    Project Name Complaints Policy
  33. Refusal to Investigate or further investigate:
    A complaints officer shall not investigate a complaint if— the person who made the complaint is not entitled under section 46 to do so either on the person’s own behalf or on behalf of another.
    The complaint is made after the expiry of the period specified in section 47(2) or any extension of that period allowed under section 47(3)
    A complaints officer may decide not to investigate or further investigate an action to which a complaint relates if, after carrying out a preliminary investigation into the action or after proceeding to investigate such action, that officer— (a) is of the opinion that—
  34. the complaint does not disclose a ground of complaint provided for in section 46,
  35. the subject-matter of the complaint is excluded by section 48,
  36. the subject-matter of the complaint is trivial, or
  37. the complaint is vexatious or not made in good faith, or (b) is satisfied that the complaint has been resolved.
    A complaints officer shall, as soon as practicable after determining that he or she is prohibited by subsection (1) from investigating a complaint or after deciding under subsection (2) not to investigate or further investigate a complaint, inform the complainant in writing of the determination or decision and the reasons for it.
  38. Unreasonable or vexatious complainant behaviour
    Where a complainant’s behaviour could be considered abusive, unreasonable or vexatious, Casadh may consider invoking their Policy for Dealing with Vexatious Complaints.
    A vexatious complaint would be categorised as follows:
    • The claimant Persist in pursuing a complaint and the Casadh complaints procedure has been fully and properly implemented and exhausted
    • Persistently change the substance of a complaint or continually raise new issues or seek to prolong contact by continually raising further concerns or questions upon receipt of a response whilst the complaint is being addressed.
    • Care must be taken, however, not to disregard new issues which are significantly different from the original complaint as they need to be addressed as separate complaints;
    • Are repeatedly unwilling to accept documented evidence given as being factual or deny receipt of adequate response in spite of correspondence specifically answering their questions or do not accept that facts can sometimes be difficult to verify when a long period of time has elapsed;
    • Repeatedly do not clearly identify the precise issues which they wish to have investigated, despite reasonable efforts of Casadh or persons appointed by casadh within the complaints procedure to help them specify their concerns, and/or where the concerns identified are not within the remit of Casadh to investigate.
    Procedure: Complainant will be notified in writing that Casadh has responded fully to the points raised and has tried to resolve the complaint but there is nothing more to add and continuing contact on the matter will serve no useful purpose.
    The complainant should also be notified that the correspondence is at an end and that further letters received will be acknowledged but not answered.
    Inform the complainant that in extreme circumstances Casadh reserves the right to pass unreasonable or vexatious complaints to its solicitors/report to Gardai.
    Temporarily suspend all contact with the complainant or investigation of a complaint whilst seeking legal advice.
    13.2 If found to be vexatious; Casadh will not pursue the complaint any further.
    Project Name Complaints Policy
    However, this does not remove the complainant’s right to submit their complaint to independent agencies, such as the Ombudsman or the Ombudsman for Children. If a complaint is found to be vexatious, there will be no record of the complaint in the file of the staff member/service about which the complaint was made.
  39. Anonymous Complaints
    In the event that an anonymous complaint is received Casadh will note the issues raised and, where necessary try and resolve them appropriately. An anonymous complaint may be referred for investigation:
    9.1 If there was good reason why the complaint was being made on an anonymous basis, for example, if there was a concern by the complainant that if their identity was revealed it could lead to negative consequence on their health or well-being. This may depend on the seriousness of the allegation being made, and should be at the discretion of the manager. If the allegation involves the manager, it should be referred to the chair of the management committee.
    9.2 If the allegation can be properly investigated either by talking to a third party witness, or with evidence provided with the complaint, and where there is no need for further contact with the anonymous complainant.
    9.3 Any complaint involving a minor will be investigated and handled in a confidential manner according to the Child Protection Policy.
    9.4 In the case that a complaint cannot be fully investigated, the complaint will not be referred to in the staff file or will not in any other way impact upon working process or roles etc., except where this has been agreed by all involved including the person named in the complaint.
    9.5 If the complaint relates to the general service delivery this will be referred to the Director/CEO and remedial action will be implemented if appropriate.
    9.6 A record of all complaints will be retained on file.
    9.7 The organisation will continue to promote the complaints procedure and ensure appropriate supports are in place to facilitate complaints.
    Project Name Complaints Policy
    Reporting to the HSE5 (if applicable)
    Service providers who has entered into a Service Level Agreement (SLA) or Grant Aid Agreement with the HSE under Section 38 or Section 39 of the Health Act 2004 are obliged to report to the HSE on complaints as requested and on the templates/format provided by the HSE. The report should include
    • The total number of complaints
    • The nature of complaints
    • The number of complaints resolved by informal means
    • The outcome of any investigations into the complaints
    Complaints Process – Information for Service Users
    Who can complain?
    1) Anyone who is a user of the service.
    2) An advocate may complain on the service user’s behalf provided they have the service user’s written consent.
    3) A parent / guardian may complain on behalf of a child.
    What can you complain about?
    1) Any part of the service that you have received
    2) A decision made about you that affects you
    3) Being denied a service
    4) A change in service provision
    5) A member of staff
    Important things to note:
    1) You have the right to complain when you are unhappy with the service.
    2) If staff cannot address your issue then they will help you write down your complaint so it can go to the manager.
    3) If you make a complaint then you will not be treated differently following the complaint. The service sees complaints as a way to improve what we do.
    Complaints involving staff:
    If you wish to make a complaint about a staff member
  • Tell one of the team and you will be referred to a manager, who will help you follow the process.
  • Note that the staff member will be informed that a complaint has been made against them.
  • If you want to complain about the manager then the complaint can go to someone more senior, again let a member of staff know.
    Complaint Process
  • All complaints will be taken seriously.
  • If you tell a staff member about a complaint, the staff member will try to resolve the issue with you. If this does not happen and you are still unhappy then the staff member will help you complete a Complaints Record Form or write a complaint letter, which will be given to the manager.
  • Once you have written down the complaint the manager will investigate the problem and get back to you in 30 working days with a response.
    5 Guidelines for Voluntary Organisations and Hospitals in Drafting Complaints Procedures. 2015. HSE
    Project Name Complaints Policy
  • If you are unhappy with the response, let the manager know and a meeting can be set up with someone more senior in the organisation within four weeks.
  • You can bring a family member or other advocate to this meeting. Following this meeting you will be informed of an outcome after three days.
    Project Name Complaints Policy
    Complaints record form (template)
    Date of complaint: _____________________________________________
    Complaint made by: _____________________________________________
    Complaint received by: _____________________________________________
    Complaint made by: Telephone
    Letter (attached)
    In person
    Complainant details
    Name of complainant(s): _____________________________________________
    Address of complainant/s:

Contact phone number of complainant/s: _________________________________________________________________
If a complaint is being made on behalf of someone else:

  1. Who is the complaint on behalf of: _______________________________
  2. Who is making the complaint: _______________________________
  3. What is their relationship _______________________________
  4. Does the representative have the complainant’s written consent to represent their interests? Yes
    Details of the complaint (If insufficient space, attach extra pages)

Project Name Complaints Policy
The complainant’s desired outcome is:

Complainant: ____________________ Date: ____________________
manager: ____________________ Date: ____________________
Details of investigation (To be completed by manager/complaints officer)

Outcomes (to be reported by manager/complaints officer)

Project Name Complaints Policy