PATIENT COMPLAINT FORM

If you have a complaint or concern about the service you have received from the doctors or any of the personnel working in this practice, please let us know.  We operate a practice complaint procedure as part of an NHS complaints system, which meets national criteria.

HOW TO COMPLAIN

We hope that we can sort most problems out easily and quickly, often at the time they arise and with the person concerned. If you wish to make a formal complaint, please do so AS SOON AS POSSIBLE - ideally within a matter of a few days. This will enable us to establish what happened more easily.  If doing that is not possible, your complaint should be submitted within 12 months of the incident that caused the problem; or within 12 months of discovering that you have a problem. You should address your complaint in writing to the Practice Manager, use the form below or go on to our complaint section of the website.  He/she will make sure that we deal with your concerns promptly and in the correct way. You should be as specific and concise as possible.

COMPLAINING ON BEHALF OF SOMEONE ELSE

We keep strictly to the rules of medical confidentiality (a separate leaflet giving more detail on confidentiality is available on request).  If you are not the patient, but are complaining on their behalf, you must have their permission to do so.  An authority signed by the person concerned will be needed unless they are incapable (because of illness or infirmity) of providing this. A Third-Party Consent Form is provided below.

WHAT WE WILL DO

We will acknowledge your complaint within 3 working days and aim to have fully investigated within 20 working days of the date it was received.  If we expect it to take longer, we will explain the reason for the delay and tell you when we expect to finish. When we look into your complaint, we will investigate the circumstances; make it possible for you to discuss the problem with those concerned; make sure you receive an apology if this is appropriate and take steps to make sure any problem does not arise again.

You will receive a final letter setting out the result of any practice investigations
 
TAKING IT FURTHER

Please ensure before raising your concerns to the Integrated Care Board that you have made a complaint to the surgery directly in writing. This will allow the surgery to investigate the complaint and respond accordingly. 

Please see below information for the Northants Integrated Care Board:

Tel:  01604 476777
E-mail:  northantsicb.patientexperience@nhs.net
Write to us:  Patient Experience Team, Francis Crick House, Summerhouse Road, Moulton Park, Northampton, NN3 6BF

Please give us as much information as you can, including your name and address, telephone number and a brief description of the issues you would like answered.  
A complaint can be made on behalf of a child, a person assessed under the Mental Capacity Act 2005, consent provided for another person to handle their complaint and if a person has died. 
What happens next?
•	Your complaint will be acknowledged within three working days
•	We will make enquiries or undertake a full investigation into your concerns; this will depend on the type of issues you raise
•	You will receive a full response from us within an agreed timescales
•	If we are unable to complete the investigation within the agreed timeframe, we will let you know 
Support when making a complaint
If you require support or assistance to make a complaint about the NHS you may wish to seek advice from VoiceAbility, an independent advocacy service.  Please see their contact information details below:
Doddridge Centre, 109 St James Road, Northampton, NN5 5LD
•	Tel:  0300 303 1660 (Mon-Fri, 9am-5pm)
•	Text:  0786 002 2939
•	E-mail:  helpline@voiceability.org
Parliamentary and Health Service Ombudsman
If you are not satisfied with the response from us and all local resolution has finished, you can contact the Parliamentary and Health Service Ombudsman at:
The Health and Service Ombudsman, Millbank Tower, Millbank, London, SW1P 4QP
•	Tel:  0345 015 4033
•	E-mail:  phso.enquiries@ombudsman.org.uk
•	Website:  www.ombudsman.org.uk

COMPLAINT FORM

Patient Full Name: ………………………………………………………………………………………………………………………………

Date of Birth: ………………………………………………………… Ethnicity:   ……………………………………………………….….

Address: ……………………………………………………………………………………………………………………...........................

Complaint details: (Include dates, times, and names of practice personnel, if known)

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SIGNED…………………………………………………..Print name……………………………..……(Continue overleaf if necessary)

PATIENT THIRD-PARTY CONSENT

PATIENT'S NAME: _____________________________________________________________

TELEPHONE NUMBER: __________________________________________________________

ADDRESS: ____________________________________________________________________

_____________________________________________________________________________

ENQUIRER / COMPLAINANT NAME: ________________________________________________

TELEPHONE NUMBER:	__________________________________________________________

ADDRESS: _____________________________________________________________________

______________________________________________________________________________

IF YOU ARE COMPLAINING ON BEHALF OF A PATIENT OR YOUR COMPLAINT OR ENQUIRY INVOLVES THE MEDICAL CARE OF A PATIENT THEN THE CONSENT OF THAT PATIENT WILL BE REQUIRED. PLEASE OBTAIN THE PATIENT’S SIGNED CONSENT BELOW.

I fully consent to my Doctor releasing information to, and discussing my care and medical records with the person named above in relation to this complaint, and I wish this person to complain on my behalf.

This authority is for an indefinite period / for a limited period only (delete as appropriate)

Where a limited period applies, this authority is valid until…………………………………….. (Insert date) 

Signed: ………………………………………………………………………... (Patient only)

Date: ……………………………………………………………………………