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{{org_field_name}}

Registration Number: {{org_field_registration_no}}

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Gathering Feedback Policy

1. Purpose

The purpose of this policy is to set out how {{org_field_name}} actively, systematically and accessibly gathers, records, reviews, responds to and learns from feedback from people living at the service, relatives, friends, representatives, advocates, staff, visiting professionals, commissioners, regulators and other stakeholders.

Feedback is essential to delivering safe, effective, caring, responsive and well-led care. It helps {{org_field_name}} understand people’s experiences, identify risks, improve quality, promote transparency and ensure that people are involved in shaping the service they receive.

This policy supports compliance with the Health and Social Care Act 2008, the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, including Regulation 9 Person-centred care, Regulation 10 Dignity and respect, Regulation 12 Safe care and treatment, Regulation 13 Safeguarding service users from abuse and improper treatment, Regulation 16 Receiving and acting on complaints, Regulation 17 Good governance and Regulation 20 Duty of candour. It also supports compliance with the CQC assessment framework, the Accessible Information Standard, the Equality Act 2010, UK GDPR and the Data Protection Act 2018.

{{org_field_name}} will use feedback not only to resolve individual issues, but also to identify themes, reduce risks, improve outcomes and demonstrate learning through audits, governance meetings, quality improvement plans and service development.

2. Scope

This policy applies to all individuals involved in or impacted by the delivery of services by {{org_field_name}}. This includes people we support, family members or advocates, staff, volunteers, agency workers, visiting professionals, and commissioners. All team members, including the Registered Manager and senior leaders, have a role in encouraging, collecting, and responding to feedback as part of their daily responsibilities. Feedback may relate to the quality of care, communication, staff behaviour, service responsiveness, or general satisfaction with the support being provided.

This policy applies to all feedback received in any format, including verbal, written, electronic, anonymous, informal and formal feedback. It also applies where feedback indicates a complaint, safeguarding concern, notifiable safety incident, equality concern, communication barrier, staffing issue, environmental risk or potential breach of people’s rights. Where feedback falls under another policy, such as complaints, safeguarding, whistleblowing, Duty of Candour or data protection, it will be managed under that policy while still being recorded as feedback for learning and governance purposes.

3. Related Policies

• CH04 – Good Governance Policy
• CH07 – Person-Centred Care Policy
• CH13 – Safeguarding Adults from Abuse and Improper Treatment Policy
• CH14 – Receiving and Acting on Complaints Policy
• CH27 – Staff Supervision, Training, and Development Policy
• CH42 – Communication and Engagement with Service Users and Families Policy
• CH35 – Duty of Candour Policy

• Whistleblowing Policy
• Data Protection and Confidentiality Policy
• Equality, Diversity and Inclusion Policy
• Mental Capacity Act and Deprivation of Liberty Safeguards Policy
• Advocacy Policy
• Accessible Information and Communication Policy
• Safeguarding Children Policy, where children visit or are involved as relatives or representatives
• Quality Assurance and Audit Policy
• CQC Notifications Policy

4. Types of Feedback Collected

{{org_field_name}} collects both formal and informal feedback through a variety of methods to ensure that all voices are heard. These include:

• Verbal comments during visits or reviews
• Written compliments or concerns
• Satisfaction surveys (quarterly and annual)
• Care plan reviews
• Family and friends questionnaires
• Staff feedback sessions and team meetings
• Exit interviews when staff or people we support leave the service
• Complaints and suggestions logged under CH14
• Digital feedback via email or secure online platforms

• Residents’ meetings, relatives’ meetings and “you said, we did” engagement sessions
• Feedback gathered during keyworker sessions, care plan reviews, best interest discussions and review meetings
• Feedback from people who may communicate non-verbally, through behaviour, body language, emotional presentation or changes in wellbeing
• Feedback from advocates, attorneys, deputies, appointees and representatives
• Feedback from visiting health and social care professionals, including GPs, district nurses, pharmacists, social workers, therapists and commissioners
• Feedback from audits, observations of practice, incident reviews, safeguarding enquiries and lessons learned meetings
• Feedback from CQC, local authority quality teams, Healthwatch and other external bodies
• Online reviews or public comments, where these relate to the service and can be reviewed appropriately

Feedback must be reviewed to identify whether it is a compliment, suggestion, concern, complaint, safeguarding concern, whistleblowing disclosure, equality or accessibility issue, data protection issue, or a matter requiring Duty of Candour. Staff must not dismiss informal comments as unimportant, as informal feedback may identify early warning signs of poor care, closed cultures or unmet needs.

Feedback may be positive, constructive, or critical. All forms are equally valued and reviewed to identify themes, risks, and areas for learning.

5. Encouraging an Open Feedback Culture

We foster a culture where giving and receiving feedback is seen as an opportunity to grow and improve. To support this:

• All staff are trained to ask for and receive feedback respectfully and without defensiveness
• The people we support and their families are informed regularly that their opinions are welcomed and valuable
• Feedback opportunities are embedded into care reviews and supervision sessions
• We actively seek input from people who may find it difficult to express themselves through alternative communication tools, advocates, or translation services
• No one will be discriminated against or penalised for raising a concern or sharing feedback

• Managers will promote a psychologically safe culture where people, relatives, staff and professionals feel able to speak up without fear of blame, dismissal or retaliation.
• Staff will be expected to listen to feedback respectfully, thank the person for raising it, record it accurately and escalate it where required.
• The service will actively seek feedback from people who are less likely to speak up, including people living with dementia, people with a learning disability, autistic people, people with sensory impairment, people who do not use English as a first language, people receiving end of life care and people without regular visitors.
• Feedback will be sought in ways that are meaningful to the person, including observation, one-to-one discussion, visual prompts, Easy Read materials, communication aids, interpreters, advocates and involvement of representatives where appropriate.

{{org_field_name}} recognises that a lack of complaints or concerns does not automatically mean that people are satisfied or safe. The Registered Manager will consider whether people have genuine opportunities and confidence to provide feedback, and whether any barriers may prevent people from speaking openly.

6. Accessible Feedback Channels

{{org_field_name}} will ensure that all people are supported to give feedback in a way that meets their communication needs, preferences, mental capacity, language, culture and protected characteristics.

Feedback may be given through:

• face-to-face discussion with staff, the Registered Manager or senior staff;
• residents’ meetings, relatives’ meetings, keyworker sessions and care reviews;
• paper forms, surveys, comment cards and suggestion boxes;
• email, telephone, website forms or other secure digital systems;
• advocacy, representatives, attorneys, deputies, appointees or family members;
• Easy Read documents, large print, translated materials, pictorial tools, communication aids, interpreters or British Sign Language support where required;
• anonymous feedback routes, where this is possible and safe to provide.

{{org_field_name}} will follow the Accessible Information Standard by identifying, recording, flagging, sharing and meeting people’s information and communication support needs. People with a disability, impairment or sensory loss will be supported to access and understand information about the service and to receive the communication support they need.

Reasonable adjustments will be made in line with the Equality Act 2010. Staff must consider whether the person needs extra time, a quiet space, communication support, an advocate, family involvement or another adjustment to help them provide feedback.

Where a person lacks capacity to provide specific feedback or make a specific decision, staff will follow the Mental Capacity Act 2005 and involve relevant representatives, advocates or best interest decision-making processes as required.

7. Responding to Feedback

All feedback will be recorded, acknowledged where contact details are available, reviewed and triaged promptly. Feedback will be reviewed within 48 hours, or sooner where it indicates risk, poor care, safeguarding concerns, a potential complaint, a notifiable safety incident or a matter requiring Duty of Candour.

The person receiving the feedback must consider whether immediate action is needed to keep people safe. Where feedback raises a potential risk of harm, abuse, neglect, discrimination, organisational abuse, unsafe staffing, poor practice or a closed culture, it must be escalated to the Registered Manager or the person in charge without delay.

The following action will be taken, depending on the nature of the feedback:

• immediate action to protect people from harm where safety concerns are identified;
• escalation to the Registered Manager, Safeguarding Lead, nominated individual or provider where required;
• referral into the complaints process where the person is dissatisfied and requires a response or investigation;
• safeguarding referral where abuse, neglect or improper treatment is alleged or suspected;
• Duty of Candour action where a notifiable safety incident has occurred;
• review of the person’s care plan, risk assessments, communication plan or support arrangements;
• staff supervision, competency checks, additional training or disciplinary action where required;
• discussion at governance, quality assurance or lessons learned meetings;
• feedback to the person, relative, representative or stakeholder about action taken, unless feedback was anonymous or there is a lawful reason not to share information.

Where feedback is treated as a complaint, it will be managed under CH14 – Receiving and Acting on Complaints Policy. Where feedback identifies a safeguarding concern, it will be managed under CH13 – Safeguarding Adults from Abuse and Improper Treatment Policy. Where feedback identifies a notifiable safety incident, the Duty of Candour Policy and CQC notification processes will be followed.

8. Using Feedback to Improve Services

All feedback is used as a tool for continuous improvement. Themes and trends are analysed quarterly and shared through:

• Quality and governance audits
• Registered Manager reports
• Staff meetings and supervision
• Service improvement plans

Where recurring issues are identified, a Quality Improvement Plan is developed with SMART objectives, lead responsibility, and timelines. Actions may include additional training, reviewing procedures, or engaging external consultants where needed. Positive feedback is also celebrated and used to recognise and motivate staff.

The Registered Manager will ensure that feedback is analysed for:

• recurring themes or repeated concerns;
• risks to people’s safety, wellbeing, dignity or rights;
• differences in experience or outcomes for people with protected characteristics;
• concerns linked to staffing levels, staff conduct, communication, nutrition, hydration, medicines, infection prevention and control, activities, visiting, environment or leadership;
• evidence of closed culture, poor communication or people feeling unable to speak up;
• actions completed, actions overdue and whether changes have been effective.

Where actions are identified, these will be recorded in the service improvement plan or quality improvement plan. The plan will state the action required, responsible person, target date, progress update, completion date and evidence of impact. The Registered Manager will check that changes have improved people’s experience and will not close actions until there is evidence that the improvement is embedded.

{{org_field_name}} will share learning with staff, people living at the service and relatives where appropriate. This may include “you said, we did” displays, newsletters, meetings, supervision, training updates and care plan reviews.

9. CQC Assessment Framework and Quality Statements

Feedback will be used as evidence within the CQC assessment framework. {{org_field_name}} will consider feedback when assessing whether the service is safe, effective, caring, responsive and well-led.

Feedback will be particularly relevant to the following CQC quality statements:

• Listening to and involving people: making it easy for people to share feedback, ideas and complaints, involving them in decisions and telling them what has changed as a result.
• Person-centred care: ensuring care reflects people’s needs, preferences, choices and outcomes.
• Equity in access: identifying and removing barriers that prevent people from accessing care, support, information or feedback routes.
• Equity in experiences and outcomes: listening to people who may experience poorer outcomes and adapting care and support in response.
• Safeguarding: identifying and responding to concerns about abuse, neglect, discrimination or improper treatment.
• Governance, management and sustainability: using feedback, audits and performance information to improve the service.
• Learning, improvement and innovation: using feedback and incidents to learn and make sustainable improvements.
• Workforce wellbeing and enablement: listening to staff feedback and acting on issues affecting care quality, safety and culture.

The Registered Manager will ensure that feedback evidence is available for CQC assessment, including surveys, meeting minutes, complaints analysis, compliments, action plans, audit outcomes, lessons learned records and examples of changes made because of feedback.

10. Feedback from Staff

Staff are encouraged and expected to provide feedback about the quality and safety of the service through supervision, appraisals, team meetings, handovers, debriefs, surveys, direct discussion with managers and the whistleblowing process.

Staff feedback will be treated as an important source of intelligence about:

• people’s safety and wellbeing;
• staffing levels and deployment;
• training, supervision and competency;
• team culture and communication;
• risks, incidents, near misses and poor practice;
• equality, inclusion and workplace wellbeing;
• practical barriers that prevent staff from delivering good care.

Managers will create a culture where staff can speak up without fear of blame, bullying, retaliation or unfair treatment. Concerns about unsafe, abusive, discriminatory or unlawful practice must be escalated immediately through the relevant safeguarding, whistleblowing, complaints, disciplinary or notification procedures.

The Registered Manager will review staff feedback as part of governance and quality assurance processes and will share learning with the staff team where appropriate.

11. Feedback from External Stakeholders

Feedback is welcomed from external professionals, commissioners, regulators, and advocates. This is gathered through contract monitoring visits, inspections, partnership meetings, and written communication. We maintain open and transparent dialogue with stakeholders and use their input to refine our practice and align with sector standards.

Feedback from external stakeholders will be recorded and reviewed as part of the service’s governance arrangements. Where feedback is received from commissioners, CQC, local authority safeguarding teams, Healthwatch, health professionals or other agencies, the Registered Manager will ensure that actions are agreed, monitored and completed. Any external recommendations, contract monitoring actions or inspection findings will be added to the service improvement plan and reviewed until embedded.

12. Duty of Candour and Transparent Practice

{{org_field_name}} will act in an open and transparent way with people living at the service and their relevant representatives. Where feedback, a complaint, incident, safeguarding concern or review identifies that something has gone wrong, staff must respond honestly, compassionately and without defensiveness.

Where a notifiable safety incident has occurred, {{org_field_name}} will follow CH35 – Duty of Candour Policy and Regulation 20. This includes informing the relevant person as soon as reasonably practicable, providing a truthful account of what is known at the time, offering a sincere apology, explaining what further enquiries will take place, keeping the person updated and providing written follow-up where required.

Apologising is not an admission of liability. It is part of being open, respectful and committed to learning.

Learning from Duty of Candour events will be recorded in the service improvement plan, shared with staff where appropriate and monitored through governance processes to reduce the risk of recurrence.

13. Data Protection, Confidentiality and Records

All feedback records will be managed in line with UK GDPR, the Data Protection Act 2018 and {{org_field_name}}’s Data Protection and Confidentiality Policy.

Feedback records must be accurate, factual, dated and stored securely. Records should include:

• the date feedback was received;
• the name and contact details of the person giving feedback, unless anonymous;
• the person the feedback relates to, where applicable;
• the method of feedback;
• the nature of the feedback;
• immediate action taken;
• whether the matter was escalated to complaints, safeguarding, Duty of Candour, CQC notification or another process;
• the outcome and learning;
• the date the matter was closed;
• evidence that actions were completed and reviewed.

Anonymous feedback will be reviewed and acted on wherever possible. However, staff must explain that anonymity may limit the ability to investigate fully or provide a direct response.

Personal information will only be shared where there is a lawful basis to do so, such as consent, safeguarding, legal obligation, vital interests or legitimate care and governance purposes. Information will be shared on a need-to-know basis.

14. Complaints, Escalation and Independent Review

Feedback must be reviewed to decide whether it is a complaint. A complaint is any expression of dissatisfaction about care, treatment, support, communication, staff conduct, the environment or the running of the service that requires a response.

Where a person wishes to make a complaint, staff must support them to use CH14 – Receiving and Acting on Complaints Policy. The person must be told:

• how to make a complaint;
• who will handle the complaint;
• expected timescales;
• how they will be kept updated;
• how the outcome will be shared;
• what they can do if they are unhappy with the response;
• how to access advocacy or communication support.

If the complaint is about the Registered Manager, the complaint must be referred to the provider, nominated individual or another senior person who is sufficiently independent of the concern. If the complaint is about the provider or nominated individual, {{org_field_name}} must ensure the complaint is reviewed fairly and without conflict of interest.

People must also be informed that they may contact CQC, commissioners, safeguarding teams or the Local Government and Social Care Ombudsman where appropriate. CQC does not usually investigate individual complaints for people, but it uses information from people to monitor and regulate services.

15. Feedback Governance and Management

{{org_field_name}} will manage feedback through clear governance arrangements. The Registered Manager has overall responsibility for ensuring that feedback is collected, recorded, reviewed, acted on and used to improve the service.

A designated Feedback Lead may support this process, but accountability remains with the Registered Manager and provider.

Feedback governance will include:

• a central feedback log;
• secure storage of feedback records;
• monthly management review of feedback, complaints, compliments, concerns and themes;
• quarterly analysis of trends and recurring issues;
• review of feedback alongside incidents, safeguarding, audits, staffing information, care plan reviews and complaints;
• service improvement plans with named leads and deadlines;
• evidence of completed actions and impact;
• reporting to the provider, nominated individual or governance meetings;
• sharing learning with staff, people living at the service and relatives where appropriate;
• retaining evidence for CQC assessment and provider oversight.

Where CQC requests information under Regulation 17, {{org_field_name}} will provide the required written report, action plan or evidence within the required timescale.

16. Displaying and Sharing Feedback Outcomes

{{org_field_name}} will share feedback outcomes in a way that is meaningful, accessible and proportionate. This may include:

• “you said, we did” displays;
• residents’ and relatives’ meeting updates;
• newsletters;
• staff meeting minutes;
• supervision and training updates;
• quality assurance reports;
• individual responses to people who gave feedback.

Information will be anonymised unless the person has consented to being identified or there is another lawful basis for sharing. Feedback outcomes will be shared in accessible formats where required.

Positive feedback, compliments and examples of good practice will be shared with staff to promote morale, learning and continuous improvement.

17. Equality, Diversity and Human Rights Monitoring

{{org_field_name}} will use feedback to identify whether any person or group experiences poorer access, poorer experience or poorer outcomes. This includes considering feedback in relation to age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex, sexual orientation, mental capacity, communication needs, culture, language and social circumstances.

The Registered Manager will review whether people with protected characteristics or communication needs are able to give feedback and whether reasonable adjustments are effective. Where barriers are identified, action will be taken to remove or reduce them.

Feedback that indicates discrimination, harassment, loss of dignity, restriction of rights or failure to make reasonable adjustments will be escalated and investigated.

18. Policy Review

This policy will be reviewed annually or sooner if there are:

• changes to legislation, statutory guidance or CQC requirements;
• changes to the CQC assessment framework or quality statements;
• significant complaints, safeguarding concerns, incidents or Duty of Candour events;
• themes from feedback that show the policy is not effective;
• recommendations from CQC, commissioners, safeguarding teams, Healthwatch or other external bodies;
• changes to {{org_field_name}}’s services, systems or governance arrangements.

The Registered Manager is responsible for ensuring that this policy remains current, implemented and understood by staff. Staff will be informed of changes and, where required, receive training or supervision to support implementation.

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Responsible Person: {{org_field_registered_manager_first_name}} {{org_field_registered_manager_last_name}}
Reviewed on: {{last_update_date}}
Next Review Date: {{next_review_date}}
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