FPC Complaints
Statement of complaints This form is for use by service users, relatives, friends, representatives and employees of First Prime Care Ltd who have received a written or an oral complaint. It must be completed within 24 hours of receiving the complaint and forwarded to the Registered Manager, or the Manager on Call in its absence.
Reference Number
Name of person receiving the complaints
*
position
*
Date
*
-
Month
-
Day
Year
Date
Time
*
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Detail of person making complaint
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Status of person making complaint
*
Service user
Relative
Friend/representative
Details Of complaint
*
Details of witnesses
*
Do you give permission for FPC to give relevant information about you toappropriate outside authorities?
*
YES
NO
Do you give permission for FPC to inform your family or next of kin?
*
YES
NO
If service user is not capable of giving their permission or capable to decide, I believe he/she would give permission to the two above questions?
*
YES
NO
Complainant/ represetnative
*
First Name
Last Name
Complainant representative/Signature
What do you realistically want to happen?
AdditionalInformation:
Name of person completing form
*
First Name
Last Name
Signature
Date
*
-
Month
-
Day
Year
Date
Submit
For Registered Manager/ Manager On Call
This is deemed to be a
INFORMAL COMPLAINT
FORMAL COMPLAINT
SAFEGUARDING REFERRAL
Other
Multi Agency safeguarding hub notified
YES
NO
Not required
CQC Notified
YES
NO
Not required
Police Notified
YES
NO
Crime Ref Number
Registered Manager Signature/Manager On Call:
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: