​​​​​​This policy outlines the importance Terrence Higgins Trust (THT) places on receiving feedback from service users and carers and learning from this feedback. It sets out the process to be followed when a service/charity user wishes to make a complaint, share a concern, or pass on a compliment.

We provide a number of  services to both the National Health Service (NHS) and Local Authorities and are expected to operate a complaints policy that is at least equivalent to that required of the public sector. This policy aims to fulfil our obligations to NHS and Social Services complaints regulations and procedures whilst adapting these to the operating realities of a Third Sector organisation. This means, for instance, that THT requires specific arrangements for independent review when complainants remain dissatisfied with the outcome of an investigation.

Where the complaint is about a THT service funded by the NHS or Local Authority, the complainant can complain directly to the NHS funding body. In addition, complainants do have the right to refer the complaint to the ombudsmen if unhappy with the investigation carried out by the NHS body.

The overall aim of this policy is to ensure that:

  • complaints are resolved as quickly, appropriately and as close to the source of the problem as possible;
  • information gained is used to improve our services;
  • service/charity users have an easy-to-use complaints process which enables them to express any dissatisfaction they might have, obtain an explanation about what happened, and, where appropriate, receive an apology.



​​​​​​This policy aims to implement a process which promotes a Trust-wide culture of openness and learning from service/charity user feedback.

Being open includes:

  • Acknowledging and apologising where distress has been caused, and providing explainations when things have gone wrong;
  • Conducting a thorough investigation into complaints and reassuring service users, their families, and carers that lessons learned will help prevent the same thing occurring again;
  • Providing support for all involved.

Key Principles

  • The complaints procedure will be accessible and well-publicised to service/charity users
  • The procedure will ensure effective links with other bodies involved in the same complaint
  • The procedure applies to all THT Directorates directly or indirectly providing services to the public
  • The procedure will be fair to complainants and staff
  • THT will respond in a timely and conciliatory manner
  • Responses will be open and transparent
  • The complaints procedure will be supportive of those who find it difficult to complain
  • Lessons will be learnt from complaints and used to improve services and other areas of the Charity’s work
  • Changes as a result of lessons learnt will be recorded and auditable
  • THT will ensure that making a complaint will not harm or prejudice the care that is given to service/charity users
  • All complaints will be dealt with confidentially and securely
  • All complaints will be signed off by a member of the Executive Team




The definition of a complaint is as follows:

Any expression of dissatisfaction about any action, omission, or decision of THT; whether made in writing, over the telephone, or in person; in connection with delivering services and undertaking the Charity’s business”.

What may be complained about?

The complaints process is designed to allow people to express any concern about services they receive or actions, omissions, or decisions by Terrence Higgins Trust in pursuit of its business. Complaints may relate to direct service provision, health promotion, fundraising activities, estates and infrastructure services, marketing, communications, or policy initiatives. Complaints may involve several different areas of the Charity; but, regardless of the origin or nature of the complaint, the policy and procedure is to be applied in the same manner.

What is exempt from this policy?

This policy does not apply when:

  • The same complaint has already been investigated in accordance with THT formal procedures;
  • The complaint falls outside the set time limits (see section 3.9); 
  • A complaint is made by an NHS body, Local Authority, or other funding body about any matter relating to contracts or arrangements with THT;
  • A complaint is made by an employee about matters relating to his/her employment (a grievance);
  • Matters that should be dealt with under other procedures, such as the Disputes Resolution (disciplinary, grievance) Policy, Expression of Genuine Concern (whistle-blowing) Policy, or Bullying and Harassment Policy;
  • A complaint received from a third party in relation to a THT service/charity user where they have not been authorised to act on the service/charity user’s behalf. If a complaint originates from a third party guidance should be sought from the Company Secretary. The key principle is that there must be informed consent from the service user for the third party to act on their behalf.



A complaint may be made by any person who is affected by or likely to be affected by the action, omission, or decision of THT, which is the subject of the complaint. Complaints may be made by carers and relatives/partners about issues that affect them in their role as a carer or relative.

A complaint can be made by a representative acting on behalf of an existing or former service/charity user where that person:

  • Has died
  • Is a child
  • Is unable by reason of physical or mental incapacity to make the complaint themself; or
  • Has requested the representative to act on their behalf

In the case of a service/charity user who has died or is incapable, the representative must be a relative, partner, or other person who has sufficient interest in that service user’s welfare. If the representative is considered not to have sufficient interest the Company Secretary shall notify the person in writing stating the reasons.

In the case of a child, the representative must be a parent, guardian, or other adult who has care of the child. Where the child is in the care of the local authority or a voluntary organisation, the representative must be a person authorised by that body.

Staff/Volunteers who have complaints about other staff or service users and/or relatives/partners should take forward their concerns using THT policies/procedures for:

  • Grievance (Disputes Resolution)
  • Bullying and Harassment
  • Expression of Genuine Concern (Whistle blowing)

-as appropriate. Staff may seek advice in the first instance from their line manager or Human Resources. Where staff/volunteers are making a complaint as a THT service user, this would be covered by this policy.



Complaints may be made verbally, by telephone or in person; or, in writing, by email or post.

Information on how to complain has been made available through leaflets, posters, THT Direct, and THT’s website Complainants should have access to language and sign interpreters when needed.

A complaint taken verbally, over the telephone or during a face-to-face meeting, is just as valid as a written complaint and will be treated with the same consideration and sensitivity.

LEVEL 1 COMPLAINTS: Every effort should be made locally by staff to put right quickly any complaints or concerns highlighted by any users of THT services. THT encourages staff to say sorry for inconvenience or upset caused at the time matters are brought to their attention or mistakes have been made.

LEVEL 1 complaints should be responded to within 2 working days and reported to the relevant Director on a quarterly basis to feed into reporting to trustees.

If the issues cannot be resolved by the staff in the service the complaint may be escalated to the Board Governance Manager (via email at [email protected]) who will co-ordinate a response. The final decision as to whether a complaint or concern is dealt with informally by staff within the service (level 1) or as a formal complaint (level 2) will be the complainant’s. This decision will be based upon information, provided by staff, about the options available.

LEVEL 2 COMPLAINTS: Once elevated to the Board Governance Manager, all complaints will be acknowledged within three working days and complainants will be directed to THT’s complaints procedure in a suitable format.

LEVEL 2 complaints will be investigated by a member of the Executive Team (designated by the Board Governance Manager or Company Secretary as appropriate) who may further designate an investigator from the Leadership Team.

The director responsible for the complaint will respond directly to the complainant within 20 working days. The response will include:

Whether the complaint has been upheld;

The reasons why the complaint has / has not been upheld;

What THT intends to do as a result of the investigation findings (if anything);

Details of how the complaint can be elevated if the complainant is dissatisfied with the outcome.

If the nature of the investigation is overly complex, or involves staff who are on leave, and the timeframe will not be met, either the director responsible or the Board Governance Manager must communicate this to the complainant within the original 20 working days timeframe and a new timeframe must be provided.

The executive team member who carried out the investigation will summarize the findings of the investigation, and any lessons learned, and add this to the complaints register.

If the complainant is dissatisfied with the outcome of the LEVEL 2 investigation they may request to elevate their complaint to LEVEL 3. This request will be acknowledged by the Board Governance Manager within 3 working days and a new timeframe for the Level 3 complaint will be given.

LEVEL 3 COMPLAINTS will be reviewed by the Chief Executive Officer (CEO), and the outcome of this investigation will be communicated to the complainant within 20 working days. If, for any reason, this timeframe cannot be met, this must be communicated to the complainant by the CEO or Board Governance Manager within the original 20 working days timeframe and a new timeframe must be provided.

If the complainant is dissatisfied with the outcome of the LEVEL 3 investigation they may request to elevate their complaint to LEVEL 4.

LEVEL 4 COMPLAINTS are investigated by the Chair of the Board of Trustees. It is important to note that the Chair will not investigate the merits of the complaint; only that the correct procedures and timelines as set out in this policy were abided to, and that the investigations were carried out in a fair, unbiased, and reasonable manner. It is important to communicate this to the complainant, and advise them that a level 4 investigation will not change the outcome of previous investigations unless it is found that the previous investigations were not carried out properly.

The outcome of LEVEL 4 investigations will be communicated to the complainant via a letter from the Board Chair (usually issued via email by the Board Governance Manager) within 20 working days. If this timeframe cannot be met for reasons beyond our control (ie. The absence of related staff or availability of the board chair) this will be communicated to the complainant within the original timeframe and a new timeframe must be provided.

If the complainant is dissatisfied with the outcome of the LEVEL 4 investigation they should be directed to lodge a complaint with the Charities Commission, and current information on how this can be done must be provided, including up-to-date contact details.



THT will be supportive of those who may find it difficult to complain or raise a concern and will ensure that service/charity users, their relatives and carers are not discriminated against as a result of raising a concern or complaint. We will try to communicate with people contacting us in their preferred manner. This may be by telephone, email, writing, or a combination of all of these, or by meeting with them in-person. Communication may need to be in a language other than English; or in another format, for example Easy Read or Braille. We will provide an interpreting and translation service to assist people where required.


Anonymous complaints fall outside the scope of the formal procedure. However, where an anonymous complaint raises serious concerns the Company Secretary and/or CEO will be advised and will decide on the most appropriate course of action.

Where a complainant alleges serious misconduct or a criminal offence this will always be treated as a formal complaint. It must be immediately reported as an incident in accordance with THT’s Incident Management Procedure. Examples of serious complaints include but are not limited to:

  • Clinical malpractice or any other form of malpractice;
  • Physical abuse;
  • Sexual abuse;
  • Financial misconduct;
  • Breach of confidentiality
  • Breach of professional boundaries.

When a person discloses any of the above it must be reported even if that person does not wish to complain. In all of the above circumstances the matter must be reported to the CEO immediately. Allegations of Physical or Sexual abuse will be reported to the appropriate external authority from the CEO’s office. In case of internal financial misconduct concerts, involving staff and/or volunteers, this would initially be reported in accordance with the Expression of Genuine Concern (Whistle-blowing) policy. It would then be subject to THT’s Incident Management Policy.

Concerns regarding children and vulnerable adults must follow THT’s Safeguarding  policies, which require referral to and independent investigation by Social Services.

Contact our Safeguardintg team.


Complaints that include accusations of discrimination based on protected characteristics should be dealt with in the usual way but also flagged with the Director of EDI who will decide if further investigation is warranted.


A complaint should be made as soon as possible after the event, or within 6 months of finding out the problem – provided this is within 12 months of the event. There is discretion to extend this time limit where it would be unreasonable in the circumstances of a particular case for the complaint to have been made earlier and where it is still possible to investigate the facts of the case effectively. Any complaint falling outside these limits will be referred to the Company Secretary and/or CEO for guidance.


Care must be taken throughout the complaints procedure to act in accordance with THT’s Confidentiality and Information Security policies. It is both good practice and essential to explain to the complainant that information from their clinical/social records (where relevant) may need to be disclosed in the course of the investigation. This disclosure will usually be to the Investigating Officer and the complainant should give their express consent to this where necessary. Complainants’ records must be kept separately from clinical/social care records. Such records must be treated with the same degree of confidentially as clinical/social care records. They are open to disclosure in legal proceedings. Where a complaint is received from a family member, partner, carer, or other appropriate person about the care or treatment of a service/charity user, the written consent is required from the service user before personal information about them is disclosed to the named complainant. Complaints files relating to THT complaints investigations will be retained for 6 years.


Particular care must be taken where the service/charity user’s records contain information provided in confidence by or about a third party. Only information which is relevant to the complaint should be considered for disclosure and then only to those within THT who, in connection with the complaint, have a right to know. It must not be disclosed to the service/charity user unless the person providing the information has expressly consented to disclosure. Disclosure of information provided by a third party outside THT also requires the express consent of the third party.



THT is committed to learning from all forms of feedback and we welcome compliments about our staff and our services. It is extremely rewarding for our hard working staff to receive such compliments and expressions of thanks. Compliments and expressions of gratitude from service/charity users, relatives, stakeholders and carers will be shared with the relevant team involved and forwarded to the Executive Team to ensure that teams learn from examples of best practice. Concerns and complaints are also a positive aid to informing and influencing improvements to services.

All compliments will be recorded and reported to the Board of Trustees. The overall purpose of this reporting is to:

  • enable THT to demonstrate that compliments, comments, concerns, and complaints are taken seriously
  • provide a record of how complaints have been resolved and what action plans are in place
  • enable Directorates to monitor the action plans from complaints and share learning
  • ensure that feedback from compliments, comments enquiries, and complaints lead to improvements in the planning and delivering of services
  • enable themes and trends from complaints, concerns, and compliments to be shared with commissioners and others.