This policy ensures that all feedback and concerns are considered, and that complaints are handled fairly, promptly, and confidentially. It provides a safe and confidential process for employees, subtenants and interested parties to report suspected unethical, illegal, or fraudulent activities without fear of reprisal or retaliation.
POLICY STATEMENT
The Providence Village Board of Directors is committed to upholding the highest standards of integrity, ethics, and accountability and supporting accessible and trusted mechanisms for reporting concerns. Individuals reporting concerns in good faith will be protected from any form of retaliation. Complaints and whistleblowing disclosures will be taken seriously, handled respectfully, and investigated promptly, fairly, and impartially. Confidentiality will be protected through all reporting and investigation processes to the greatest extent possible, except where PVI is legally required to disclose due to suspected criminal activity or other mandatory reporting obligations. While anonymous reports can be received, this may limit our ability to follow-up. PVI views all feedback and complaints as valuable opportunities for learning, improvement, and strengthening our organization’s governance and culture.
SCOPE
The process to make a report applies to all employees, contractors, subtenants, supervisors, managers, senior leadership, members of the Board of Directors, and interested parties.
DUTY TO REPORT AND GOOD-FAITH EXPECTATIONS
All employees, supervisors, managers, senior leadership, and members of the Board of Directors share a responsibility to uphold the integrity, ethical standards, and legal obligations of Providence Village. False or malicious reports may result in disciplinary action, up to and including dismissal. Each individual has a duty to promptly report any suspected wrongdoing, misconduct, breach of policy, unethical behaviour, or violation of legal or regulatory requirements and fully cooperate with investigations. Providence Village subtenants and contractors are encouraged to report any concerns.
Providence Village expects that all concerns will be raised in good faith, meaning they are brought forward with honest intent and based on genuinely held concerns, even if they are later determined to be unsubstantiated. Individuals are not expected to prove wrongdoing—only to report situations or behaviour they reasonably believe may be improper.
Failure to report known or suspected wrongdoing may itself be considered a breach of responsibility.
Providence Village is committed to fostering an environment where speaking up is encouraged, supported, and free from retaliation or reprisal.
The subject of the complaint will be informed of the process and outcome.
The Executive Coordinator in their role as Privacy Officer is responsible for confidentially receiving and responding to reports.
Where the CEO, Privacy Officer, or Board members are involved, concerns will be escalated to the Board Chair. Where the Chair is the subject of the concern, the Privacy Officer is the contact, through to the CHSO Designate, who will work with the Board Executive (excluding the Chair). Catholic Health Sponsors of Ontario (CHSO), our sponsor, may be involved if the report is substantiated.
Reports include, but are not limited to:
- Fraud, theft, or financial misconduct.
- Breach of laws or regulations.
- Health and safety violations.
- Harassment, discrimination, or unethical behavior.
- Any activity that could harm the organization’s reputation or interested parties.
PROTECTION AGAINST REPRISAL OR RETALIATION
Any reprisal or retaliation is strictly prohibited and will result in disciplinary action up to and including termination.
PROCEDURE TO REPORT
Regular board and employee feedback will be sought through a variety of mechanisms, including staff surveys, and subtenant partnership engagement. In the event of a complaint or concern, more direct feedback or complaints can be provided.
- How to provide feedback, make a complaint, or report a concern
Feedback and complaints can be submitted to the Privacy Officer (currently the Executive Coordinator):
- In writing by letter, to the attention of the Executive Coordinator
- Secure email privacyoffice@providencevillage.ca
- By phone to 613-544-4525 Extension 125
Reports should include the complainant’s name and contact information unless anonymity is preferred, the details of the concern (the concern, what happened, when, who was involved) and any supporting evidence (if available).
- Response and Investigation
- Feedback will be acknowledged and shared internally with the responsible Manager or may be escalated to the CEO for consideration and follow-up. Where the CEO or Privacy Officer are involved, concerns will be escalated to the Board Chair.
- Complaints will be acknowledged within 5 business days.
- The complainant will be informed of the next steps and expected timelines.
- Complaints will be reviewed on receipt, with an investigation (if required) to be completed within 30 business days, where possible.
- If the complaint is about a specific individual (or individuals) they will be informed that a complaint has been registered, and the nature of the complaint, without disclosing the name of the complainant. They will also be advised once a resolution or decision has been reached.
- All parties may be interviewed, and relevant documents reviewed.
- Where a complaint may escalate or relate to a governance level or significant partnership matter, the Chair of the Board will be consulted. For matters related to sponsorship, Catholic Health Sponsors of Ontario (CHSO) will be consulted.
- Follow-up and Resolution
- The outcome will be communicated in writing to the complainant by the Executive Coordinator.
- If the complaint is substantiated, corrective actions will be taken by the CEO.
- If not substantiated, reasons will be provided to the complainant.
- Consideration will be given to risk management implications and Board notification (e.g., financial risk, legal implications, reputational harm)
- Appeal
- The complainant or the individual against whom a complaint was made may request an appeal using the reporting process if they believe the complaint outcome was incorrect, incomplete, or unfair.
- Appeals must be submitted in writing within 10 business days from receiving the original decision.
- The appeal should state the specific reasons for requesting reconsideration—such as new evidence, procedural concerns, or factual inaccuracies.
- A senior leader who was not involved in the original decision, or committee designated by the CEO, will conduct the review to ensure impartiality.
- In the case of complaints about the Board or individual Board members, the Board Chair and/or Vice Chair will determine next steps.
- The reviewer will assess the original complaint, the decision, and any new information submitted, and may request additional clarification if needed.
- A written outcome will be provided within a set timeframe, and the appeal decision will be considered final.
- Confidentiality
- All complaints will be handled confidentially.
- Information will only be shared on a need-to-know basis.
- Continuous Improvement
- Feedback will be tracked and shared for consideration as policies, procedures and services are reviewed.
- Complaints data will be analyzed periodically to identify trends and improve processes in consultation with the Management Team.
- Reporting
- Quarterly reporting of complaints, including nature and number of complaints, will be provided to the Board of Directors without revealing confidential information.
- The Board will be advised immediately if the complaints are around abuse, fraud or other serious areas that have significant impact the organization.
- Accessibility
- For assistance with accessibility needs, please contact the Executive Coordinator directly
DEFINITIONS
Feedback: Feedback is information provided to improve services, processes, or relationships. It can be positive or constructive and does not necessarily require formal investigation. Examples may include suggestions for improvement, praise for good service, or general comments.
Complaint: A complaint is an expression of dissatisfaction about a service, decision, behavior, or process that directly affects the individual or organization. Examples may include poor communications, access to or delivery of service, cost effectiveness, unfair treatment, or a breach of organizational policy.
Whistleblowing: Whistleblowing involves reporting suspected illegal, unethical, or fraudulent activities that could harm the organization, its interested parties, or the public. It typically relates to serious misconduct rather than personal dissatisfaction. Examples include fraud or financial misconduct, breach of laws or regulations, health and safety violations, or harassment or discrimination.
Retaliation: Refers broadly to any adverse action taken because an individual reported wrongdoing or participated in a complaint or investigation. This includes behaviours such as harassment, intimidation, exclusion, negative changes to work duties, or subtle actions intended to punish or discourage someone from speaking up.
Reprisal: Reprisal is often used to describe more formal or tangible actions taken in response to someone raising a concern. Examples include termination, demotion, pay reduction, loss of opportunities, or other official employment consequences tied to the disclosure of wrongdoing.