Feedback and Complaints Policy


1. Policy Statement

Pegasus continuously strives to provide high quality supports and services and recognizes that feedback and complaints from stakeholders play an important role in identifying areas where improvement may be needed.  Feedback and complaints may identify needs for improvement both in the delivery of services and supports, as well as in administrative processes that oversee service delivery.

In order to encourage and facilitate feedback and complaints, Pegasus has developed a process for eliciting and receiving feedback and complaints, and addressing them in a fair, timely and well informed manner. This process provides a timely and effective mechanism for all stakeholders to communicate with Pegasus.

The process guarantees confidentiality and enables Pegasus to respond to a changing environment and to adapt its systems as required.

2. Scope of the Policy

This policy applies to all participants, families, support persons, others acting on their behalf, employees, volunteers, and the general public.

3. Terms of Reference

Pegasus welcomes the opportunity to communicate with all its stakeholders.  As an organization that was founded by community and family members, and that is committed to serving individual needs in a community setting, Pegasus believes that the dynamic interaction amongst all its stakeholders can enhance and improve supports and services.

4. Definitions

4.1. Feedback:

Feedback is an opinion expressed about the services and supports that Pegasus offers.  Feedback can be solicited or unsolicited, and it can be positive or negative.  Examples of solicited feedback include surveys or questionnaires published by the agency. Examples of unsolicited feedback include a conversation, a letter or a phone call to the agency.

4.2. Complaint:

A complaint is expression of dissatisfaction about the service and supports provided by Pegasus. It is negative feedback.  A complaint can be formal, such as a letter, or informal, such as a verbal complaint expressed to a staff person, or board member if about senior management.

5. Fair Review Process

Pegasus is committed to a fair complaints process. All participants and other stakeholders have the right to deliver feedback and complaints free from coercion, intimidation, bias, harassment, threats, fear of losing service, or other negative consequences.  Pegasus upholds this right and will train all its staff and Board of Directors to respond appropriately and professionally to feedback and complaints.

The regular and repeated distribution of this policy to participants and those that act on their behalf also serves to reinforce Pegasus’ commitment to their right to give feedback.

6. Responsibility of Complainants

Complainants must at all times treat Pegasus staff with respect and courtesy. If a person is rude or harasses an employee in the course of delivering a complaint, the employee will ask the complainant to address the Program Manager, if it is program related, or the Executive Director.  Employees will not receive or respond to complaints that are delivered in a disrespectful manner.

7. Invalid Complaints

Pegasus is not obligated to apply this process with complaints that it judges to be vexatious, frivolous, personal in nature, or not made in good faith. However, at its own discretion the agency may address complaints of this nature.

8. Confidentiality

In compliance with agency Privacy Policies and Confidentiality processes, every effort will be made to keep all aspects of the complaint confidential.

9. Conflict of Interest

No staff member, participant or Board member who has a potential or real conflict of interest with the complaint or the complainant should be involved in the review, documentation, investigation, resolution or notification/confirmation of any complaint.

They should declare the conflict of interest immediately, so as to avoid the perception that the decision-making process is not objective. People receiving supports and services from Pegasus should not have to be concerned that their needs are secondary to any individual’s or group’s personal gain.

A conflict of interest is defined as a situation in which a person has a private or personal interest sufficient to appear to influence the objective exercise of his or her official duties as an employee.  Some examples of types of conflict of interest include financial, political, or personal.

10. Procedures

10.1. Eliciting Feedback

Pegasus elicits feedback from its stakeholders on a regular basis as follows:

  • As part of each participant’s annual review process (PGPR/ISP)
  • As part of the Executive Director’s newsletters to families and group homes
  • In surveys of satisfaction with supports and services, sent to all participants, families and support person.
  • In a survey following any new service or support being offered

10.2. Complaints Process

10.2.1  Communicating the existence of the complaints process:

10.2.1.1.    All participants, families, and support persons are informed of this  process, and given a copy of this policy at the time of intake. The process will be reviewed yearly thereafter.

10.2.1.2     Other community members can access this process on the agency website and in general newsletters.

10.2.1.3     Anyone may request a copy of any agency policies and procedures by contacting the administrative offices.

10.2.2     Accessible formats

Pegasus accepts complaints in the following formats: in person, by telephone, email, letter, picture symbols or by use of a diskette or other e-submission format.

Communications support or alternate formats can be arranged upon request. (As per AODA regulation 191/11 Section 11).

10.2.3.       Level 1:

10.2.3.1.    Any staff member can receive a complaint. Complainants should approach the staff member that they judge to be the most appropriate to receive the complaint.

10.2.3.2.    The staff who receives the complaint should tell their immediate Supervisor about it as soon as possible and within the same day.

10.2.3.3.    Staff should not discuss the complaint.  This assures that the complaint is dealt with in a clear fashion and makes it clear to the complainant that the process is followed.  It also reduces the risk of gossip and taking sides.

10.2.3.4.    Supervisors should respond to the complainant as soon as possible, within 48 hours maximum. A Supervisor may discuss the issue with the Program Manager before approaching the complainant. They should request that the complaint be explained and discuss the issue. If an acceptable solution is found, the complaint is considered resolved.

10.2.3.5.    No staff should respond to a complaint in a casual manner. If a complaint is stated to a staff at a time when the staff is busy working with a participant, the staff should request that the complainant wait a few minutes, and then discuss the complaint in private and in a formal manner.

10.2.3.6.    Record keeping: the Supervisor should keep a record of the complaint, and the way it was resolved, in the Supervisor’s journal.  The record should include date, time, description of the issue, resolution, and any information that would inform policy review and revisions.  The report should include records of conversations. In addition, relevant documentation will be collected, including Incident Reports, Serious Occurrence Reports and electronic correspondence.

10.2.3.7.    If a solution is not found, the complaint proceeds to the Level 2 process.

10.2.4. Level 2

Complaints that are not resolved at Level 1 proceed to the Level 2 process.

Level 2 complaints must be put in writing. If a complainant is unable to put it in writing, communications support or alternate formats can be arranged upon request. (As per AODA regulation 191/11 Section 11).

Level 2 complaints should be handled as follows:

10.2.4.1.    By the Program Manager: if it is from a participant, family, or other support persons regarding a participant.

10.2.4.2.    By the Executive Director: all other complaints, including those from the general public.

10.2.4.3.    By the Board of Directors: All complaints about the Executive Director.

Contact information is made available to all families and members of support networks. In addition, email addresses and phone numbers of the above persons can be found on the agency website.

10.3. Responding to Complaints

The Program Manager, or Executive Director, will review and discuss the complaint with other staff or Board members as needed. Participants may be involved in the review process as frequently as possible and if they consent. Adequate information to prepare the participant using the communication method appropriate for that person will be offered.

A conversation will be set up with the complainant, either in person or on the phone.  During the conversation, further information and clarifications will be sought, and a preliminary solution will be suggested.  If the complainant is satisfied with the solution, it will be put in writing and both parties will sign the document.

10.3.1.Possible Solutions to a Complaint

Staff who are dealing with a complaint should consider many options, which include, but are not limited to, the following:

  • A clarification of the reason behind current agency practices
  • A commitment to review current practices
  • A change to specific services or supports as they affect a specific individual
  • A commitment to additional knowledge transfer to staff
  • A commitment to further investigate, and setting time limits for the investigation
  • A change to current policies and/or procedures
  • A decision can be made to uphold all policies and procedures and that the situation was not in violation of any policies and procedures.

10.3.2.Time limits

Pegasus will meet the following timeframes:

  • 48 hours to contact the complainant to resolve the issue or acknowledge receipt of the complaint.
  • If not resolved within 48 hours, 15 days to formally respond to the complaint after review of documents and to arrange a conversation with the complainant.
  • If not resolved after the conversation with the complainant, both parties will agree to future deadlines.

10.3.3. When a resolution is not found using channels as stated above, the following one or all of the following should occur:

10.3.3.1.    The Board of Directors can carry out an investigation and suggest resolutions.

10.3.3.2.    An outside agency can be requested to review the situation.

10.3.3.3.    Ministry of Community and Social Services can be asked by the Executive Director or Board of Directors to review the situation.

10.3.4. Investigation Process

The investigation will consist of gathering detailed information about the complaint and all circumstances surrounding it.  It may require speaking to other stakeholders and community members.  It may require consulting with other service providers.  A decision should not be made until the investigator is satisfied that all the necessary information and points of view have been obtained.

11. Involvement of External Parties

In certain cases the complaint process will involve the police.  One example that would require Pegasus to contact the police would be if there is an allegation of abuse.

In certain cases Pegasus would file a Serious Occurrence Report to the Ministry of Community and Social Services (MCSS) in accordance with Ministry directives and reporting requirements in the Services and Supports to Promote the Social Inclusion of Persons with Developmental Disabilities Act, 2008.  MCSS would be contacted if there was involvement of the police or if there were other complaints about situations that trigger a Serious Occurrence Report.

12. Training

12.1 Staff training

All staff will be educated on this policy as part of initial orientation and annually thereafter.

12.2 Participant training

All participants will be educated, in plain language, and in an appropriate communication method, on their rights to complain and give feedback.  Training will emphasize that complaining will not threaten their right to receive supports, or their relationships with staff and other stakeholders.

13.  Policy Review

The Board of Directors and Executive Director will conduct an annual review and analysis of the Feedback and Complaints Policies and Procedures to evaluate their effectiveness and make amendments as needed.  Both formal and informal complaints will be reviewed as part of the policy review.