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Learners promote a culture where attitudes and approaches ensure concerns and complaints directly influence service improvement


This page is designed to answer the following questions:

NOTE: This page has been quality assured for 2023 as per our Quality Assurance policy.

As mentioned in the previous section, a barrier to making a complaint or raising a concern is the belief that doing so will not result in any improvements. For this assessment criterion, you will be required to show that you can promote a culture where attitudes and approaches ensure that concerns and complaints directly influence service improvement. Some of the ways that this could be achieved are discussed below.


All concerns and complaints are acted upon promptly and recorded in line with organisational processes without compromising consent and confidentiality


Whenever a complaint or concern reaches you, it should be dealt with as matter of urgency to maintain trust in the process. Similarly, if complaints do not come directly to you, processes should be in place to ensure that they are acted on swiftly. Your complaints policy should have set timescales for the investigation to take place, for reporting the findings and for the complainant to appeal the decision. Safeguards should also be included in the policy and procedure to prevent consent and confidentiality from being compromised.

All concerns and complaints are investigated using systems and processes and outcomes are logged and reported to appropriate bodies


Your organisation’s complaints and concerns policy and procedure should detail how investigations should be conducted and who can conduct them. The findings of all complaints should be recorded – this is a regulatory requirement because if CQC requests a service provider’s complaint log, they must provide it within 28 days. This can be found in Regulation 16 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (excerpt below):

  1. The registered person must provide to the Commission, when requested to do so and by no later than 28 days beginning on the day after receipt of the request, a summary of—
    1. complaints made under such complaints system,
    2. responses made by the registered person to such complaints and any further correspondence with the complainants in relation to such complaints, and
    3. any other relevant information in relation to such complaints as the Commission may request.

Using information on any concerns or complaints as a regular agenda item at team meetings

Reported concerns and complaints should form part of the agenda during team meetings to support the development of staff and the improvement of the service. Failings in care provision should be discussed and any changes as a result of the complaint/concern should be communicated effectively.


Making explicit use of lessons learnt from concerns or complaints, trends and areas of risk in annual service reviews

As well as disseminating the findings of investigations into complaints and concerns to team members, this knowledge should also inform annual service reviews so that lessons can be learned and services can improve. It is useful to reflect back on what has happened over the previous 12 months during an annual review and how positive action has been taken to raise the standard of care your organisation provide.


Making explicit use of lessons learnt from concerns or complaints in service improvement plans, setting SMART targets and monitoring their achievement

Going forward, knowledge learned from concerns and complaints should be used to inform service improvement plans. To be able to measure improvements effectively SMART targets should be used – these are objectives that are specific, measurable, achievable, realistic and time-bound. By setting targets using this system, you will be able to evaluate progress when you review their progress.

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