Comments, Compliments and Complaints Policy
CONTENTS
1. Policy Statement and Purpose
2. Scope
3. General Principles
4. Responsibilities
5. How to submit feedback or a formal complaint
6. Actions and Outcomes
7. Time limits for raising a complaint
8. Recording, Monitoring and Review
9. Legal Protection and Regulatory Compliance
10. Supporting Policies and Procedures
1. Policy Statement and Purpose
Nexus is committed to delivering high-quality, person-centred services and ensuring that everyone who interacts with our organisation can confidently provide feedback. We recognise that comments, compliments and complaints are essential for improving our services, strengthening accountability and building public trust.
This policy reflects the requirements of relevant regulatory bodies including: Charity Commission for Northern Ireland (CCNI) and Northern Ireland Public Services Ombudsman (NIPSO). In doing so, it ensures a consistent two-stage approach to complaint handling and emphasises early resolution, learning and transparency.
The purpose of this policy is to:
- Provide clear guidance on how feedback is received, acknowledged, and responded to
- Ensure concerns are addressed promptly, fairly and professionally in line with regulatory guidance such as; Charity Commission for Northern Ireland and NIPSO
- Promote early and effective resolution wherever possible (within 5 working days)
- Ensure a thorough investigation and response to complex or unresolved complaints (within 20 working days)
- Clarify roles and responsibilities for acknowledging, recording and responding to comments, compliments and complaints
- Recognise and record positive feedback about work well done
- Protect the privacy and confidentiality of individuals providing feedback, in line with data protection and data minimisation principles
- Ensure feedback is systematically recorded, reviewed and used to inform continuous service improvement
Nexus views feedback as a valuable source of insight and commits to using it constructively to improve the quality, accessibility and effectiveness of our services.
2. Scope
This policy and its associated procedures outline how Nexus manages feedback relating to all the services and support it provides.
The Comments, Compliments and Complaints Policy applies to all personnel acting on behalf of Nexus including:
- Employees
- Associate Providers
- Volunteers
- Students
- Board Members.
Feedback may be received from:
- Clients / Service-users* (anonymous or named)
- Individuals supporting a client/service user (with consent where possible)
- Professionals or partner organisations
- Funders
- Members of the public
*Where a client/service-user is under 16 or is considered a vulnerable adult, feedback may be submitted by a parent, guardian or appointed health and social care provider on behalf of a client/service-user.
This policy applies to complaints about:
- Conduct, communication, or behaviour of staff
- Quality or appropriateness of support
- Service accessibility or inclusivity
- Confidentiality or data protection concerns
- Safeguarding practice
- Operational issues (availability, waiting times, etc.)
- Organisational decisions or failures to act.
This policy applies to all service users, including those who remain anonymous.
To ensure complaints can be investigated effectively, they should normally be raised:
- Within 3 months and
- No later than 6 months of the issue occurring.
Complaints raised outside this timeframe may still be considered where there is a valid reason for the delay.
3. General Principles
Nexus implements this policy in accordance with the principles embedded in NIPSO Model Complaints Handling Procedure, which promotes accessibility, fairness, consistency, clear expectations, person-centred and learning-oriented complaints culture.
All aspects of this policy and its implementation are grounded in trauma-informed practice. We recognise that many people using our service have experienced interpersonal violence, coercion, control, and systemic harm.
We commit to the following principles:
3.1 Openness to Feedback
- Nexus actively welcomes comments, compliments and complaints as opportunities to improve services
- Clients/service users, partners and stakeholders are regularly encouraged to share feedback on their experience
3.2 Accessibility and clarity
Nexus will ensure that individuals clearly understand:
- how to provide feedback
- how complaints will be handled
- what outcome they can expect
Information about the feedback process will be communicated in a clear and accessible way.
3.3 Early resolution (Stage 1)
Where appropriate, frontline staff will attempt to resolve concerns quickly and informally within 5 working days.
This approach aims to address issues promptly and prevent escalation where possible.
3.4 Investigation (Stage 2)
Where early resolution is not possible or appropriate, Nexus will undertake a formal investigation, ensuring it is fair, impartial, and completed within 20 working days wherever possible.
3.5 Learning and development
Feedback trends and complaints outcomes will be reviewed regularly to identify opportunities for service improvement, staff development and organisational learning.
3.6 Data protection
Only the minimum personal data necessary to manage and resolve feedback will be collected and retained, in accordance with GDPR data minimisation principles and the Nexus Data Protection Policy (NEXUS/G/002).
3.7 Fairness, respect and confidentiality
An individual providing feedback will be treated with dignity, respect, and impartiality.
Confidentiality will be maintained wherever possible, except where disclosure is required to safeguard individuals or comply with legal obligations.
3.8 Cultural, Historical and Gender Awareness
We recognise the impact of discrimination, inequality, and social context, including gender-based violence, disability, race, sexuality, migration status, and poverty.
3.9 Choice and control
Individuals decide what to share, whether to remain anonymous and what outcome they seek where possible.
4. Responsibilities
All personnel across all Nexus services share responsibility for implementing this policy and contributing to a positive feedback culture.
4.1 All personnel
All staff, associates, volunteers, students and board members must:
- Welcome feedback and respond empathetically and professionally
- Ensure individuals are aware how they can submit comments, compliments and complaints
- Forward feedback promptly to the appropriate person
- Support efforts to resolve concerns constructively
4.2 Managers and senior staff
Managers are responsible for:
- Ensure responses are provided within the required timeframes
- Escalating complaints appropriately from Stage 1 to Stage 2 where required
- Support fair and effective investigations
- Ensuring complaints are accurately recorded for monitoring and organisational learning
4.3 Governance and compliance
Nexus senior leadership will:
- Monitor feedback trends across the organisation
- Ensure complaints are reported in accordance with NIPSO standards
- Oversee learning and service improvements arising from complaints
- Ensure personnel have access to relevant training materials and resources
5. How to submit feedback or a formal complaint
Nexus welcomes all forms of feedback – comments, compliments and complaints – as opportunities to resolve any issues and strengthen our services. We aim to make the process easy, accessible and transparent, in line with NIPSO framework.
Ways to submit feedback:
· By email: feedback@nexusni.org with the title “Complaint”
· By phone: 028 9023 6803 - By speaking to a member of our Therapeutic Support Team
· By post:
Business Support Manager
NEXUS
59 Malone Road
Belfast
BT9 6SA
· In person: By speaking to a member of the Therapeutic Support Team at Nexus Headquarters
What to include when raising a complaint
To help us respond promptly and effectively, please include:
- Name and preferred contact details
- Details of the issue (what happened, when, where, and who was involved)
- How you have been affected
- What outcome are you seeking (if known?)
Anonymous complaints will be considered where sufficient information is provided, especially given the anonymous DSA Helpline service provision.
6. Actions and Outcomes
When the organisation receives comments, compliments and complaints the following actions will be taken and target outcomes to be achieved:
6.1 Compliments
- What we do
- Thank the individual, group or organisation for their compliment
- Share the positive feedback with relevant staff/team and their manager
- Forward to Business Support Manager (BSM) at the central feedback mailbox to record the compliment in the Comments, Compliments and Complaints Log
- Responsible
- Person who received the compliment (compliment response, sharing feedback and forwarding to BSM)
- Business Support Manager (recording and monitoring)
- Intended outcomes
- The individual knows their feedback was received and valued
- Personnel contributions are recognised and encouraged
- Positive feedback supports organisational learning and staff morale
6.2 Comments and Suggestions
- What we do
- Acknowledge and thank the individual for their comments/suggestions
- Share the comment/suggestion with relevant team members and their manager
- Forward to Business Support Manager (BSM) for recording the compliment in the Comments, Compliments and Complaints Log
- Responsible
- Person receiving the comment/suggestion (comment/suggestion response, sharing feedback and forwarding to BSM)
- Business Support Manager (recording and monitoring)
- Intended outcome
- The individual feels heard and valued
- Staff consider suggestions for potential improvement
- Leadership reviews ideas that may enhance service delivery
6.3 Complaints
Stage 1 – Early resolution
At this stage, personnel aim to resolve the complaint quickly and locally where possible.
A response will be provided within 5 working days, with a possible extension of a further 5 working days where necessary.
- What we do
- Written acknowledgment that complaint has been received and outline of the next steps to offer reassurance that the complainant will be addressed in a timely manner
- Notify the Business Support Manager (BSM) and forward a record of the complaint to the central feedback mailbox if received elsewhere
- The BSM assigns the relevant manager to investigate the issue
- Attempt to resolve the complaint promptly
- Responsible
- Personnel member receiving the complaint (notify BSM and forward details of complaint)
- Service area manager/coordinator (written acknowledgement to complainant)
- Business Support Manager (recording and monitoring)
- Intended outcome
- The complainant receives a timely and clear response
- The issue is resolved without escalation where possible
If the complaint cannot be resolved at this stage or is unsuitable for early resolution, it will proceed to Stage 2.
Instances when a complaint is escalated directly to Stage 2 (unsuitable for Stage1):
- Complexity: The complaint requires in-depth investigation rather than a quick resolution
- Seriousness/risk: The issue is deemed high-risk or severe.
- Refusal to engage: The client/service user refuses to engage in Stage 1
- Previous failure: The complaint is a follow-up to a previously failed, unresolved or unsatisfactory Stage 1 investigation.
Any complaint which raises concerns of a serious nature including those of a potential breach of a code of ethics must be dealt with under the Formal Complaints Process from the outset and formal consideration will be given as to whether the complaint needs to be referred to the Charity Commission in line with their guidance on serious incident reporting.
Stage 2 – Formal investigation
A complaint is acknowledged within 3 working days and full response provided within 20 working days, with a possible extension of a further 20 working days when justified and clearly communicated.
What we do
- Provide written acknowledgement within 3 working days
- Refer to the Charity Commission for Northern Ireland, as appropriate
- Appoint an impartial investigator – person not previously involved in the matter
- Conduct a fair and thorough investigation
- Provide a written response within 20 working days
- Inform the complainant if an extension of further 20 working days is required
- The full written response will outline:
- investigation process
- findings
- decisions
- corrective actions to resolve the issue and/or prevent future occurrences
- further learning or service improvements identified and implemented right to escalate the complaint to NIPSO, when appropriate
- Record the outcome and organisational learning
- Notify Charity Commission of Northern Ireland of outcome, as appropriate.
Responsible
- Service Area Manager / Coordinator (written acknowledgement of complaint)
- HoS or Nominee (appoint an impartial investigator)
- Business Support Manager (recording and monitoring)
- Assigned impartial investigator - person not previously involved in the matter (investigation and full written response)
- CEO (refer to and update Charity Commission for Northern Ireland)
Intended outcome
- A fair and thorough investigation which includes:
- agreeing parameters of the investigation
- reviewing all relevant records
- collating evidence
- engaging with complainant and all other relevant parties
- A clear and transparent response which includes:
- overview of investigation process
- findings
- decisions
- corrective actions taken
- further learning or service improvements to be implemented
- Organisational learning and improvement service delivery
- Compliance with regulatory and legislative requirements
Internal escalation
Internal escalation is used when the complaint cannot be fully resolved within the Stage 2 process or when its seriousness requires senior-level oversight.
When internal escalation occurs:
- Complex issues requiring extended investigation
- Allegations against senior staff or matters affecting senior leadership
- Significant organisational risk, reputational harm, safeguarding or regulatory implications
- Potential systemic failures requiring wider organisational review
- Situations that require CEO oversight and sign-off
How internal escalation works:
- Oversight transfers to the CEO or a senior leader appointed by the CEO
- The complainant is promptly informed of:
- The reason for escalation
- Who will now handle the matter
- Any revised response timescales
- Additional investigation steps may be taken where needed
- Referral to Charity Commission for Northern Ireland, as appropriate
- The Stage 2 response timeframe may be extended by up to further 20 working days, where justified
- The final written response is reviewed and approved at senior leadership level to ensure fairness and accountability
Responsible
- CEO or nominee (appointment of senior leader to further investigation, refer to Charity Commission for Northern Ireland, decision on additional investigation steps, review and approval of final written response)
- Appointed Senior Leader (written update to complainant, lead further investigation and compile final written response for review, approval and subsequent communication to complainant)
- Business Support Manager (recording and monitoring)
Internal escalation ensures:
- High-risk or unresolved complaints receive appropriate senior attention
- A reliable, accountable and transparent final written response
- Identification and action on any systemic issues
- Clear, timely communication with the complainant
- Compliance with legislative and regulatory requirements
- Robust governance, learning and continuous improvement across the organisation
If you remain dissatisfied after stage 2
As required by NIPSO standards, if you remain dissatisfied after receiving the Stage 2 response, you may be referred to contact the Northern Ireland Public Services Ombudsman, who can independently review your complaint.
Nexus will provide clear information on how to contact NIPSO when issuing the Stage 2 response, if appropriate.
For further information, see NIPSO website https://www.nipso.org.uk/
7. Time limits for raising a complaint
To ensure effective investigation, complaints should normally be raised:
· Within 3 months, and
· No later than 6 months after the issue occurred
8. Recording, Monitoring and Review
All feedback is recorded in the Comments, Compliments and Complaints Log (NEXUS/F/003) to ensure timescales are upheld, information is captured accurately for analysis and organisational learning.
The Log is maintained by the Business Support Manager and stored securely within the organisation’s document management system. Access is restricted to authorised personnel.
Complaints outcomes are monitored anonymously through organisational governance processes, including organisational Risk Register where appropriate.
This policy will be reviewed bi-annually by the Business Support Manager and approved by the Leadership team.
9. Legal Protection and Regulatory Compliance
To comply with the conditions of Nexus` Professional Indemnity Insurance Policy, insurance brokers must be informed immediately if:
· a written complaint is received that may give rise to legal action
· a third-party solicitor becomes involved
Legal advice will be sought before issuing any formal response where appropriate.
Where a complaint meets the criteria for a “serious incident”, it will be reported to the Charity Commission for Northern Ireland in accordance with its Guidance on Serious Incident Reporting.
The Charity Commission regards a serious incident as an adverse event, whether actual or alleged, which results in, or risks, a significant:
- loss of charity money or assets
- damage to charity property, or
- harm to the work of the charity, its beneficiaries or reputation.
10. Supporting Policies and Procedures
This policy is supported by other organisational policies and procedures aimed at promoting safe and healthy working practices.
These include:
CS/G/001 Clinical Governance Policy
CS/G/002 Clinical Note Taking Policy
CS/G/003 Confidentiality Policy
NEXUS/G/002 Data Protection Policy
NEXUS/G/003 Privacy Notice
NEXUS/G/008 Safeguarding Policy
NEXUS/G/006 Whistleblowing Policy
APPENDIX 1 – Complaints Handling Flowchart
This flowchart outlines the step-by-step process for receiving, assessing, responding to and closing a complaint in line with this policy, ensuring consistency, fairness and timely resolution.
Complaints handling flow:
1. Complaint received
Once the complaint has been received via any channel (email, phone, post, in person, anonymous), it must be:
· Acknowledged
· Forwarded to the Business Support Manager for tracking and recording.
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2. Initial assessment
The initial assessment determines how the complaint will be managed.
- Is the issue a complaint (comment or suggestion)?
- If NO – manage as comment
- If YES – proceed
- Assess:
- Risk level
- Safeguarding concerns
- Complexity and seriousness
- Decide appropriate complaint stage
Determining complaint severity and stage
Severity Typical Features Examples Appropriate Stage
Low One-off Delays Stage 1
Minimal impact Communication issues
Medium Repeated concerns Ongoing service concerns Stage 1 or Stage 2
Delays
Moderate impact
High Serious risk Data breach Stage 2
Safeguarding Discrimination
Misconduct
⬇
STAGE 1 – Early resolution (Informal)
Where appropriate:
- Suitable for low-level, non-complex complaints
- Managed locally by Service Manager/Coordinator in collaboration with the BSM
- Written acknowledgement issued centrally
- Attempt early and proportionate resolution
Stage 1- Timeframe and extensions
Standard response time
- 5 working days
Permitted extension:
- One-off extension of up to 5 additional working days where justified and communicated
Justifiable circumstances for extension:
- Key personnel member unavailable (leave or sick)
- Clarification required from complainant
- Limited additional fact-finding required
- Reasonable adjustments needed
- Complaints requests time to provide information
Requirements if extension required:
- Extension communicated before day 5
- Reason recorded
- New deadline confirmed in writing
Outcome of Stage 1
- Resolved – Confirm outcome in writing, record learning, close complaint
- Not resolved or unsuitable – Escalate to Stage 2
⬇
STAGE 2 – Formal Investigation
Eligible to investigate:
- CEO
- Head of Service/SLT
- Senior Manager/Coordinator
- Manager from another service area
- Nominee appointed by SLT
Not eligible to investigate:
- Anyone directly involved in the matter
- Anyone involved in Stage 1
- Line managers where independence may be questionable
Requirements:
- Acknowledgement issued within 3 working days
- Impartial investigator appointed (no previous involvement)
- Fair, thorough and trauma-informed investigation undertaken
- Safeguarding, regulatory or Charity Commission referral considered where appropriate
Stage 2 – Timeframes and extensions
Standard response time:
- 20 working days
Permitted extensions:
- Up to 10 additional working days where justified and clearly communicated
Justifiable circumstances:
- Complexity or multiple parties involved
- Safeguarding or regulatory processes running alongside
- Volume of information to review
- Availability of complainant or witnesses
- Requirement for external professional input
Requirements if extension required:
- Extension communicated before day 20
- Clear explanation provided
- Revised timescales confirmed in writing
⬇
Final response and Closure
- Formal written response issued centrally, including findings, decisions, learning and actions
- Right to escalate to NIPSO explained where applicable
- Complaint outcome recorded by BSM
- Learning shared to support service improvement
APPENDIX 2 – Complaints guidance matrix
This appendix provides practical examples and a complaints matrix to support personnel in assessing the severity and complexity of complaints and applying the policy consistently.
It helps personnel to:
- determine the appropriate stage of a complaint
- understand when and why response timeframes may be extended
- identify who is eligible to investigate complaints at Stage 2 to ensure independence, fairness and compliance with regulatory standards.
STAGE 1 – Early Resolution (Informal)
The characteristics of an informal complaint are:
- Low risk
- One-off issue
- Limited impact
- No safeguarding, discrimination or serious professional conduct concerns
Examples:
· “My appointment was cancelled and I was not told in advance”
· “I did not receive a follow-up call when I was told I would”
· “The information I was given about the service was unclear”
· “I felt a staff member spoke abruptly to me during a call”
· “There was a delay in responding to my email”
· “I want to change my counsellors as I want a female one instead”
Complaints escalated directly to Stage 2 (Unsuitable for Stage 1)
There are various reasons why a complaint may be unsuitable for Stage 1 or moved from Stage 1 to Stage 2:
a) Complexity
· “My complaint involves several staff across different departments/services”
· “There are conflicting accounts of what happened”
· “The issue relates to multiple decisions made over time”
b) Seriousness /Risk
· “I felt unsafe during an interaction with a member of staff”
· “My personal information was shared without my consent”
· “I experienced discriminatory behaviour”
· “A safeguarding concern was not acted upon appropriately”
c) Refusal to engage in Stage 1
· “I do not want this handled informally”
· “I want an independent investigation”
d) Previous failure
· “I am unhappy with how my Stage 1 complaint was handled”
· “No action was taken following my earlier complaint”
· “I have complained about something previously and it has happened again”
Stage 2 – Formal Investigation
The following characteristics of a complaint establish its suitability for Stage 2 Investigation:
- Serious or high-risk issues
- Allegations requiring evidence gathering
- Complaints involving professional conduct or systemic concerns
Examples:
· Allegations of staff misconduct, inappropriate behaviour or boundary breaches
· Repeated complaints suggesting a potential service delivery failure
· Complaints requiring detailed review of clinical notes or organisational records
· Complaints that may have regulatory, legal or reputational implications for the organisation
The following characteristics of a complaint establish its suitability for Stage 2 investigation:
a) Seriousness or high-risk issues
· “I felt intimidated and unsafe during my session with a member of staff”
· “A safeguarding concern I raised was not followed up”
· “I believe my personal data was shared without consent, putting me at risk”
b) Allegations requirements requiring evidence gathering
· “I dispute the account provided by staff and want my records reviewed”
· “What I was told verbally does not match what is written in my notes”
· “There are emails and records that contradict the explanation I was given”
c) Complaints involving professional conduct or systemic concerns
· “I believe a staff member acted unprofessionally and breached expected boundaries”
· “This issue has affected other clients, not just me”
· “There appears to be a pattern, and it happened again following my last complaint”