E8: Complaints Handling Procedure

Complaints Handling Procedures: Overview

ComplaintsHandlingProcedure01Part A: What is a Complaint?


  • This Complaints Handling Procedure applies to all enrolled students of Outreach MedicSkills Ltd., (‘ORMS’) and members of the public. The Complaints Handling Procedure does not apply to ORMS staff. This Complaints Handling Procedure reflects ORMS’ commitment to valuing complaints. ORMS aims to resolve issues of dissatisfaction as close to the initial point of contact as possible and to conduct thorough and fair investigations of complaints so that, where appropriate, we can make evidence-based decisions on the facts of each individual case.
  • Resolving complaints early saves time and resource and contributes to the overall efficiency of ORMS. Concentrating on achieving an early resolution of a complaint as close to the point of contact as possible will free up the time of academic and support staff and ultimately contribute to the continued positive experience of our students and members of the public, including applicants.


2.1 For the purposes of this procedure, a complaint shall be defined as:

“An expression of dissatisfaction by one or more individuals about the standard of a service, action or lack of action by or on behalf of ORMS, as experienced in the physical and/or virtual environment”

A complaint may relate to [though is not limited to] the following:

  1. The quality and standard of service;
  2. failure to provide a service;
  3. the quality of facilities or learning resources;
  4. treatment by or attitude of a staff member, student or contractor;
  5. inappropriate behaviour by a staff member, student or contractor;
  6. the failure of ORMS to follow an appropriate administrative process;
  7. dissatisfaction with ORMS’ policy, although it is recognised that policy is set at the discretion of ORMS.

Not every concern raised with ORMS shall constitute a complaint and the following provides an indicative [though not exhaustive] list of concerns which are not classed as complaints:

  1. a routine, first-time request for a service;
  2. a request under the Freedom of Information Act or Data Protection Act;
  3. a request for information or an explanation of policy or practice;
  4. a request for compensation only;
  5. a response to an invitation to provide feedback through a formal mechanism such as a questionnaire or committee membership will generally not be treated as a complaint;
  6. an insurance claim;
  7. an issue which is being, or has been, considered by a court or tribunal;
  8. an attempt to have a complaint reconsidered where the ORMS’ procedure has been completed and a decision has been issued;
  9. a grievance by a member of staff;
  10. an appeal about an academic decision of an Assessment Board relating to assessment, progression and/or award;
  11. an academic decision relating to admission to a course of study at ORMS.

These issues will be dealt with under the alternative appropriate processes rather than under the Complaints Handling Procedure. It should be noted, however, that some situations can involve a combination of issues, some are complaints and others are not, and each case should be assessed on a case by case basis.


Please also refer to paragraphs 6: Stage 1: Frontline Resolution and 7. Stage 2: Investigation.


The Complaints Handling Procedure applies to complaints from anyone who receives, requests or is affected by the services of ORMS. This may include [though is not limited to]:

  • a student’s experience during their time at ORMS (all referred to as ‘students’ through the remainder of this Complaints Handling Procedure;
  • members of the public, where they have a complaint about matters which are (or which were at the time the issue arose) the responsibility of ORMS; and
  • members of the public who are applying for admission to ORMS and whose complaint does not relate to academic judgement.
    • The basic processes for investigating complaints are the same for students, members of the public and applicants to ORMS.
    • A person can make a complaint in writing, in person, by telephone, by email, on an official social media platform or by having someone complain on their behalf.
    • Sometimes individuals may be unable or reluctant to make a complaint on their own. ORMS will accept complaints brought by third parties, as long as the individual affected has given their personal consent under the requirements of the Data Protection Act (1998); please refer to ORMS’ website for guidance: http://intranet.orms247.co.uk/ This usually means that the individual affected must give clear written authority for the third party to act on their behalf. Complaints made by a third party with the explicit permission of the complainant will be handled in accordance with the timescales detailed within this Complaints Handling Procedure.

Anonymous complaints

  • Complaints submitted anonymously will only be considered where there is sufficient information in the complaint to enable ORMS to make further enquiries. If, however, an anonymous complaint does not provide such information then ORMS may decide not to pursue it further. However, ORMS may give consideration to the issues raised, and will record the complaint so that corrective action can be taken as appropriate.
  • Any decision not to pursue an anonymous complaint will require authorisation by ORMS’ Board of Directors (‘the Board’). If an anonymous complaint contains serious allegations, it shall be referred to the Board immediately.

Complaints involving more than one academic or service Department

  • If a complaint relates to the actions of two or more Departments, the staff member receiving the complaint will confer with the other area(s) to decide who will take the lead on the complaint. The complainant will be told to whom the complaint is being passed and given their contact details. Coordination may still be required between different areas of ORMS to ensure that the complaint is fully addressed in a single response. The nature of the complaint may also require parallel procedures to be initiated (such as the Academic Appeals or Student Misconduct Procedure).

Complaints involving other organisations or contractors who provide a service on behalf of ORMS

  • If an individual complains to ORMS about the service of another organisation, but ORMS has no involvement in the issue, the individual should be advised to contact the appropriate organisation directly.
  • Where a complaint relates to an ORMS service and the service of another organisation the complaint will be handled through the Complaints Handling Procedure and the normal timescales will apply.
  • Such complaints would relate to services provided on ORMS’ behalf, such as partner institutions and contractors, or to those provided by a separate organisation, such as award agencies. If enquiries to an outside organisation in relation to the complaint are required, care will be taken to comply with data protection legislation and the guidance on handling personal information. Such complaints include [though not limited to] the following:
    • (a) A complaint made about a service that is contracted out, such as catering services, accommodation or car parking.
    • (b) A complaint made in relation to provision of third-party services, which may include scribes and certain software.
    • (c) A complaint made to ORMS about a student loan where the dissatisfaction relates to the service ORMS has provided and the service that a Student Awards Agency has provided.

Please also refer to paragraphs 6: Stage 1: Frontline Resolution and 7. Stage 2: Investigation.


  • Complaints should be raised with ORMS as soon as problems arise to enable prompt investigation and swift resolution. Complaints should be raised within six months from when the complainant first became aware of the problem, unless there are special circumstances for requesting consideration of a complaint beyond this time.
  • Consideration of any complaints submitted outwith the six month period will be at the discretion of ORMS.
  • Complaints lodged outwith the six month period must be submitted in writing using the Complaint Form. On receipt of a late complaint, the member of staff receiving the complaint will immediately forward it to the relevant member of the Board and Complaints Investigator and they shall decide whether failure to meet the standard timescales was due to verifiable circumstances which were outwith the control of the complainant. Where the member of the Board and the Complaints Investigator are satisfied that:
  • (a) there are verifiable circumstances then the complaint shall be accepted and the complaint shall be considered under the Complaints Handling Procedure and the normal timescales shall apply.
  • (b) there are no verifiable circumstances then the complaint shall be dismissed.

The member of the Board shall notify the complainant in writing of the decision to either accept or dismiss the complaint within 10 working days of receipt of the complaint.


This Complaints Handling Procedure is intended to provide a quick, simple and streamlined process with a strong focus on early resolution by empowered and well-trained staff. The Complaints Handling Procedure has two stages:

  • Stage 1 – Frontline Resolution: Frontline resolution seeks to resolve straightforward complaints swiftly and effectively at the point at which the complaint is made, or as close to that point as possible.
  • Stage 2 – Investigation: Investigation is appropriate where a complainant is dissatisfied with the outcome of frontline resolution, or where frontline resolution is not possible or appropriate due to the complexity or seriousness of the case.


  • Stage 1: Frontline Resolution will normally be completed within five working days. Anyone who has a complaint is encouraged to raise it initially at the point of, or as close to the point of, becoming aware of it as possible and to raise it with the Department in which the issue arose. Complaints at this stage may be made face-to-face, by phone, in writing, by email or on an ORMS official social media platform.
  • The purpose of frontline resolution is to attempt to resolve as quickly as possible complaints which are straightforward and require little or no investigation. Complaints at this stage of the process may be addressed by any relevant member of ORMS staff and may be handled by way of a face-to-face discussion with the complainant, or by asking an appropriate member of staff to deal with the complaint. The date on which the member of staff receives the complaint shall be taken as the date of lodgement. On receipt of the complaint the member of staff will record the details, including date of lodgement, on ORMS’ Complaints System.
  • Members of staff to whom complaints are made will consider some key questions, including:
    • Is this a complaint or should the individual be referred to another procedure?
    • What specifically is the complaint(s) about and to which area(s) of ORMS does it relate?
    • What outcome is the complainant hoping for and can it be achieved?
    • Is this complaint straightforward and likely to be resolved with little or no investigation?
    • Can the complaint be resolved on the spot by providing an apology, an explanation and/or an alternative solution?
    • Can another member of staff assist in seeking a frontline resolution?
    • What assistance can be provided to the complainant in taking this forward?
  • Resolution may be achieved by providing an on-the-spot explanation of why the issue occurred and/or an apology. In addition, where appropriate, the complainant will be provided with an indication of any corrective action to prevent any future recurrence of the issue(s).
  • If responsibility for the issue being complained about lies in the staff member’s area of work then every attempt will be made to resolve the issue at source. If responsibility lies elsewhere, the staff member receiving the complaint will liaise with the relevant area rather than simply passing the complainant onto another office.

Extension to the five day timeline

  • Frontline resolution shall normally be completed within five working days, though a resolution may be achieved more quickly. In exceptional circumstances a short extension of time may be necessary to increase the possibility of resolving the complaint at the frontline resolution stage. For example, information may need to be obtained from other areas where no single area of ORMS is responsible for the issue(s) being complained about. Where an extension is required this must be signed off by an appropriate Director. The complainant will be informed of the reasons for extending the deadline and be advised of the new timescale for resolution. The maximum extension which can be granted is five working days (i.e. not more than 10 working days in total from the date of receipt of the complaint).

Closing the complaint at the Frontline Resolution Stage

  • The complainant will be informed of the outcome of the complaint. This may be face-to-face, by phone, in writing, by email or via an ORMS official social media platform. There is no requirement to send out written communication to the complainant although the staff member may decide to do so. The response will address all areas of the complaint and explain the reasons for the decision.
  • Once the outcome has been issued, the record of the complaint will be updated on ORMS’ Complaints System, including details of the decision reached. The complaint will then be closed.


  • The Stage 2: Investigation will normally be completed within 20 working days of the complaint being received for Stage 2 Investigation. Such complaints may already have been considered at the frontline resolution stage, or they may be complaints identified upon receipt as appropriate for immediate investigation. A complaint will proceed to Stage 2: Investigation when:
  • frontline resolution was attempted, but the complainant remains dissatisfied. This may be after the case has been closed following the frontline resolution stage;
  • the complainant refuses to recognise or engage with the frontline resolution process and is insistent that the issue be addressed by a more senior officer;
  • the issues raised are complex and will require detailed investigation;
  • the complaint relates to issues that have been identified by ORMS as high risk or high profile. Such complaints may:
  • involve a death or terminal illness;
  • involve serious service failure, for example major delays in service provision or repeated failures to provide a service;
  • generate significant and on-going press interest;
  • pose a serious operational risk to ORMS;
  • present issues of a highly sensitive nature.
    • A person can make a complaint in writing, in person, by telephone, by email, on an ORMS official social media platform or by having someone complain on their behalf. Where it is clear that a complaint will be immediately considered at the investigation stage, the complainant may be encouraged to complete the appropriate Complaint Form to provide full details of the complaint and any relevant documentation. If they choose not to write it down and would prefer to complain in person, then exceptionally a Complaint Form can be completed with them and a letter to confirm the scope of the complaint issued to them.
    • The purpose of conducting an investigation is to establish all of the facts relevant to the points made in the complaint and to provide a full, objective and proportionate response to the complainant that represents the Institution’s definitive position.

ORMS response to Stage 2: Investigation Complaints

  • ORMS will allocate the complaint to a Complaints Investigator. The Complaints Investigator shall provide the complainant with a signed and dated acknowledgement of receipt within three working days of ORMS receiving the complaint. The date the complaint was received for investigation shall become the date of lodgement and shall be recorded within ORMS’s Complaint Record System. It is important to be clear from the start of the investigation stage exactly what is being investigated, and to ensure that both the complainant and the Complaints Investigator understand the scope of the investigation. The Complaints Investigator shall have a discussion with the complainant, either face to face or by other means, and, three key questions shall be considered:
  • What specifically is the complaint (or complaints)?
  • What does the complainant want to achieve by complaining?
  • Do the complainant’s expectations appear to be reasonable and achievable?

If the complainant’s expectations appear to exceed what ORMS can reasonably provide or are not within ORMS’s power to provide, the complainant will be advised of this as soon as possible in order to manage expectations about possible outcomes.


  • The following timescales will apply for Stage 2: Investigation:
  • the complaint will be acknowledged in writing by the Complaints Investigator within 3 working days of receipt of the complaint for investigation;
  • ORMS will provide a full response to the complaint as soon as possible but not later than 20 working days from the time that the complaint was received for investigation.

Extension to the timeline

  • Stage 2: Investigations will normally be completed within 20 working days. However, in some cases it may not be possible to meet this deadline. For example, some complaints may be so complex that they will require careful consideration and detailed investigation beyond 20 working days. Where there are clear and justifiable reasons for extending the timescale, the appropriate Director will exercise judgement and will set time limits on any extended investigation, with the agreement of the complainant. If the complainant does not agree to an extension but it is unavoidable and reasonable, then the Director will consider and confirm the extension. In such circumstances, the complainant will be informed in writing of the reasons for the extension and advised of the new timescale for bringing the investigation to a conclusion. Such extensions will be the exception and ORMS will always strive to conclude Stage 2: Investigations within 20 working days.
    ORMS’s Complaint Record System will be updated to record any extended deadlines and such information will be included in the annual statistical report.


  • Some complex complaints (where, for example, the complainant and/or other involved parties have become entrenched in their position) may benefit from a different approach to resolving the complaint. Using mediation can help both parties to understand what is driving the complaint, and may be more likely to result in a mutually satisfactory conclusion being reached. Where ORMS and the complainant agree to mediation, revised timescales should be agreed.

Closing the complaint at the Investigation Stage

  • The member of the Board will ensure the complainant is provided with written notification of the outcome of the investigation and will advise the complainant of any right to refer the matter to any other appropriate body, the time limit for doing so, and how to contact the respective organisation.
  • The member of the Board will be responsible for ensuring that the outcome, and details of how and when it was communicated to the complainant, is recorded on ORMS’s Complaint Record System.



8.1 ORMS has mechanisms in place to ensure that all staff are aware of:

  • the Complaints Handling Procedure;
  • how to handle and record complaints at the frontline resolution stage;
  • who they can refer a complaint to if they are unable to handle the matter personally;
  • the need to try and resolve complaints early and as locally (within their Department) as possible;
  • their clear authority to attempt to resolve any complaints they may be called upon to deal with.

8.2 ORMS will ensure that:

  • ORMS’s final position on a complaint investigation is signed off by an appropriate member of the Board in order to provide assurance that this is the definitive response of ORMS and that the complainant’s concerns have been taken seriously;
  • it maintains overall responsibility and accountability for the management and governance of complaints handling within ORMS;
  • it has an active role in, and understanding of, the Complaints Handling Procedure (although not necessarily involved in the decision making process of complaints handling);
  • mechanisms are in place to ensure a consistent approach to the way complaints handling information is managed, monitored, reviewed and reported at all levels in ORMS;
  • complaints information is used to improve services, and this is evident from regular publications.

8.3 The role and responsibilities of individual staff members are as follows:

  1. The Board of Directors

Members of the Board may be involved in the investigation. As senior officers they may be responsible for signing off response letters to complainants and therefore must be satisfied that the investigation is complete and that their response addresses all aspects of the complaint.

  1. Complaints Investigator

The Complaints Investigator is a suitably trained staff member responsible for the conduct of the complaints investigation and is involved in the investigation and the co-ordination of all aspects of the response to the complainant. This may include preparing a comprehensive written report, including details of any recommended procedural changes to service delivery. Complaints Investigators must have a clear remit to investigate effectively and reach robust decisions on more complex complaints. This also requires clear direction and support from senior management on the extent and limits of discretion and responsibilities in investigating and resolving complaints, including the ability to identify failings, take effective remedial action and apologise, where it is appropriate to do so.

  1. All staff

A complaint may be made to any member of staff. All staff must, therefore, be aware of the Complaints Handling Procedure and how to handle and record complaints at the frontline resolution stage. They should also be aware of whom to refer a complaint to, in case they are not able to personally handle the matter. We encourage all staff to try to resolve complaints early, as close to the point of service delivery as possible, and quickly to prevent escalation.


Complaints about members of the Board can be difficult to handle as there may be a conflict of interest for the staff investigating the complaint. The Complaints Investigator for complaints concerning a member of the Board will be another Director or a nominee appointed by him/her.



10.1 Valuable feedback may be obtained through complaints. One of the objectives of the Complaints Handling Procedure is to identify opportunities to improve provision of services across ORMS.

10.2 Staff will record all complaints and ORMS will use the complaints data for analysis and management reporting. By recording and using complaints information in this way, the causes of complaints can be identified, addressed and, where appropriate, training opportunities can be identified and improvements introduced.


11.1 It is important that ORMS ensures that complaints are fully recorded and, as a minimum, ORMS shall record the following:

  • name and contact details of the complainant and student enrolment number (if applicable);
  • date of receipt of the complaint;
  • how the complaint was received;
  • category of complaint;
  • staff member responsible for handling the complaint;
  • department to which the complaint relates;
  • action taken and outcome at frontline resolution stage;
  • date the complaint was closed at the frontline resolution stage;
  • date the investigation stage was initiated (if applicable);
  • action taken and outcome at investigation stage (if applicable);
  • date the complaint was closed at the investigation stage (if applicable);
  • underlying cause and remedial action taken (if applicable);
  • response times at each stage. Details of any extensions to time scales and the relevant authorisations to these extensions.

11.2 ORMS has structured systems for recording complaints, their outcomes and any resulting action. The data collected shall be used for the internal reporting as described in paragraph 12 of this Complaints Handling Procedure.


12.1 ORMS has a system for the internal reporting of complaints information. Regularly reporting the analysis of complaints information helps to inform management of where improvements are required. Information reported internally will include:

  • performance statistics, detailing complaints volumes, types and key performance information, for example on time taken and stage at which complaints were resolved;
  • the trends and outcomes of complaints and the actions taken in response including examples to demonstrate how complaints have helped improve services.

12.2 This information will be reported at least quarterly to ORMS’s Board of Directors. In addition, ORMS’s Quality Manager and Administration Team Manager shall have a role in monitoring complaints and outcomes with a view to learning from complaints (refer paragraph 14 of this Complaints Handling Procedure).


13.1 ORMS will publish on a quarterly basis a summary of complaint outcomes, trends and actions taken to improve services, with a focus on case studies and examples of how complaints have helped improve services. This may also include positive feedback from students and members of the public.

13.2 This demonstrates ORMS’s approach to improving services on the basis of complaints and shows that complaints can influence our services. It also helps ensure transparency in ORMS’s complaints handling service and will help to demonstrate to students and members of the public that ORMS values their complaints.

13.3 ORMS will report on complaints handling performance annually. This includes performance statistics showing the volume and type of complaints and key performance details, for example on the time taken and the stage at which complaints were resolved.


14.1 The Complaints Investigator will always satisfy themselves that all parties involved understand the findings of the investigation and any decisions made. ORMS has procedures in place to ensure that any identified issues are acted upon. These procedures facilitate:

  • using complaints data to identify the root cause of complaints;
  • taking action to reduce the chance of this happening again;
  • recording the details of corrective action in the complaints file;
  • systematically reviewing complaints performance reports to improve performance.

14.2 The analysis of management reports detailing complaints performance will help to ensure that any trends or wider issues which may not be obvious from individual complaints are quickly identified and addressed. Where ORMS identifies the need for service improvement:

  • an officer (or team) will be designated the ‘owner’ of the issue, with responsibility for ensuring that any identified action is taken
  • a target date will be set for the action to be implemented, and followed up on to ensure delivery within this timescale
  • where appropriate, performance in the service area will be monitored to ensure that the issue has been resolved.


15.1 Confidentiality is an important factor in conducting complaints investigations. ORMS will always have regard to any legislative requirements; for example, data protection legislation and also internal policies on confidentiality and the use of complainant information. Complaints will be handled with an appropriate level of confidentiality and information released only to those who need it for the purposes of investigating or responding to the complaint. No third party will be told any more about the investigation than is strictly necessary in order to obtain the information required from them.

15.2 Where a complaint has been raised against a student or member of staff and has been upheld, the complainant will be advised of this. However, it would not be appropriate to share specific details affecting specific students or staff members, particularly where disciplinary action is taken.


  1. 1 It is recognised that people may act out of character in times of trouble or distress. The circumstances leading to a complaint may result in the complainant acting in an unacceptable way. Complainants who display difficult behaviour may still have a legitimate grievance, and the Institution must therefore treat all complaints seriously and assess them properly.

16.2 The actions of complainants who are angry, demanding or persistent may result in unreasonable demands on time and resources or unacceptable behaviour towards ORMS’s staff. ORMS will, therefore, put into place policies and procedures to protect staff from such unacceptable behaviour. These policies and procedures will include the requirement to inform the complainant of any decision to restrict their access, their right of appeal, and any procedures for reviewing such a decision to restrict contact.


Anyone who receives, requests or is directly affected by the services the Institution provides has the right to access ORMS’s Complaints Handling Procedure. Complainants who do not have English as a first language may need help with interpretation and translation services. Other complainants may have specific needs which the Institution will seek to address to ensure easy access to the Complaints Handling Procedure by making reasonable adjustments to help the complainant. There are a number of support services available which can provide helpful support to those who wish to pursue a complaint with ORMS.