Listening to and involving people

Are the complaints procedure and safeguarding information accessible to people with communication needs?

What we look for: Check the service user guide and complaints policy. Good practice is having easy-read and pictorial versions readily available to clients. A fail is only having a dense, legalistic complaints procedure that clients cannot understand.

Evidence: Easy read complaints policy, audio guide to safeguarding, visual service user guide, complaints log

Are all complaints (both formal and verbal) logged centrally and acknowledged within the timeframe specified in the provider's policy?

What we look for: Review the central complaints log for the last month. Check that every entry has a recorded date of receipt and an acknowledgement sent within the policy timeframe (usually 2-3 days). Fail if verbal grumbles are not being captured as informal complaints.

Evidence: Central complaints log, Acknowledgement letters/emails, Policy document

Are complaints investigated thoroughly, objectively, and do investigations include interviews/statements from all relevant parties?

What we look for: Deep dive into 2 closed complaints. Verify that the investigator gathered robust evidence (e.g., timesheets, care notes) rather than just taking one person's word. Fail if investigations are superficial or conducted by someone directly involved in the complaint.

Evidence: Investigation reports, staff statements, call logs, interview notes

Can frontline staff confidently explain how they would support a person to make a complaint and handle a verbal grievance raised during a visit?

What we look for: Interview 3 care workers. Ask them what they would do if a client expressed dissatisfaction with their care. Staff must know to log it, report it to the office, and not take it personally. Fail if staff say they would just tell the client to ring the office themselves.

Evidence: Staff interviews, spot check records, supervision notes, induction workbooks

Is there a structured and proactive system in place to routinely collect feedback and compliments from people using the service, their relatives, and involved professionals?

What we look for: Sample the last 3 months of surveys or feedback requests. Good practice involves sending regular, structured requests for feedback (not just waiting for it). A fail would be a lack of any proactive feedback collection mechanism.

Evidence: Feedback policy, annual/quarterly survey results, feedback forms, evidence of feedback requests in care review minutes

Can the service demonstrate a 'You Said, We Did' approach, showing tangible changes or improvements made as a direct result of service user feedback?

What we look for: Look for a documented loop of feedback leading to action. Good practice is communicating these changes back to the service users so they know they are heard. A fail is collecting feedback but never taking action or adjusting service delivery.

Evidence: You Said We Did posters/newsletters, updated care plans, revised policies, service improvement plans

Are people who use the service regularly asked for their feedback specifically regarding the reliability and consistency of their care team?

What we look for: Review 5 recent quality assurance phone calls or surveys. Questions should explicitly address punctuality, carer consistency, and whether they feel their care is reliable. A fail is failing to capture or act upon feedback about poor continuity.

Evidence: Quality assurance calls, spot check records, service user surveys, care review meeting minutes

Are complaints logged, acknowledged within policy timeframes, fully investigated, and used to drive improvements in care delivery?

What we look for: Sample recent complaints. Good looks like empathetic, timely responses with clear investigations and lessons learned. Fail if complaints are dismissed, responses are delayed beyond policy timelines, or no learning is recorded.

Evidence: Complaints log, Investigation reports, Written responses to complainants, Changes in care plans following complaints

Are complaints and informal concerns regarding poor timekeeping or clipped visits logged, investigated, and responded to appropriately?

What we look for: Review the complaints log for themes around late or short calls. Management must investigate these thoroughly, check ECM data, and provide an honest response and apology if at fault. A fail is dismissing client concerns about timekeeping.

Evidence: Complaints register, Investigation outcomes, Duty of Candour letters, Service user feedback forms

Are complaints and concerns effectively managed, responded to within policy timeframes, and used to drive continuous improvement?

What we look for: Sample 2 recent complaints. Good looks like empathetic, timely responses with clear outcomes and evidence of service changes where applicable. Fail if complaints are ignored, defensive responses are sent, or timeframes are breached without communication.

Evidence: Complaints log, response letters, complaints policy, quality improvement plan

Is the Complaints policy provided in accessible formats to people using the service and their relatives?

What we look for: Check the information pack given to people at the start of their care. The complaints process must have clear timescales and detail how to escalate to the Ombudsman. A fail is if the policy is only available upon request or lacks escalation options.

Evidence: Service user guide, Easy Read complaints procedure, website, welcome pack

Are actions generated from complaints or service user feedback explicitly tracked and followed up with the person who raised the concern?

What we look for: Trace 2-3 recent complaints or negative feedback surveys. Good looks like a logged action, evidence of the change being made, and a closure letter/call to the complainant explaining the outcome. Fails if actions are taken but the person is never informed.

Evidence: Complaints log, feedback survey action plan, letters to service users, contact logs

Are people using the service informed in advance about who will be visiting them and any unavoidable changes to their scheduled rota?

What we look for: Check communication logs or call clients to verify if they receive their rotas in advance in an accessible format. Verify the procedure for notifying them of last-minute sickness. A fail is clients consistently reporting they do not know who is turning up or when.

Evidence: Weekly schedules sent to clients, communication logs, complaint records, client feedback surveys

Are complaints regarding safety or care quality handled transparently, with outcomes and actions clearly communicated back to the service user?

What we look for: Review 3-5 recent complaints to see if the service user was kept informed throughout the process. Good looks like clear timelines met, a formal response letter, and evidence of a follow-up call. A fail is a complaint marked 'resolved' with no evidence the complainant is satisfied or informed.

Evidence: Complaints log, Complaint response letters, Service user feedback forms, Action plans

Does the review documentation evidence the active involvement of the service user and/or their chosen representatives?

What we look for: Check the review documentation for the person's own words and signatures from them or their family/LPA. Fails if reviews appear to be done solely by staff in the office without consulting the person.

Evidence: Review meeting minutes, Signed review documents, Feedback forms from family

Does the spot checking process include gathering immediate, private feedback from the person receiving care about the care worker's performance?

What we look for: Look for evidence that the supervisor spoke directly to the client (and/or relatives) during or immediately after the spot check to ask if they are happy with the carer. Spot checks that only evaluate tasks without capturing the client's voice are ineffective.

Evidence: Spot check forms (service user feedback section), client survey records