Responding to Feedback Policy -

Transcription

1 - Management of Complaints, Claims, Concerns and Compliments Job Title of Author Approved by Ratified By Ratification Date Version 4.0 Issue Date Review Date April 2018 Target Audience All staff Complaints Manager Director of Governance and Risk Patient Safety Committee Revision History Version Revision Date Summary of Changes 2 January 2010 External Communications and Review Request Guidelines for People who use our services. 3 August 2013 Complete review. 4 April 2015 Policy name change; update to reflect national policy and internal process changes

2 CONTENTS EXECUTIVE SUMMARY OBJECTIVES SCOPE DEFINITIONS ROLES AND RESPONSIBILITIES PROCEDURE EVALUATION MEASURES REVIEW REFERENCES DISTRIBUTION RELATED POLICIES LEGISLATION LIST OF APPENDICES APPENDIX 1 - CONCERN REPORT FORM APPENDIX 2A: STANDARD OPERATING PROCEDURE COMPLAINTS MANAGEMENT APPENDIX 2B - STANDARD OPERATING PROCEDURE FLOWCHART APPENDIX 3 TRIAGE CRITERIA FOR CONCERN/COMPLAINT GRADING APPENDIX 4 - RISK GRADING ASSESSMENT CATEGORISATION APPENDIX 5 PART A - TEMPLATE ACKNOWLEDGEMENT LETTER WHEN CONTACT MADE APPENDIX 5, PART B TEMPLATE ACKNOWLEDGEMENT WHEN CONTACT UNSUCCESSFUL APPENDIX 6 - TEMPLATE LETTER COMPLAINT RELATING TO ANOTHER ORGANISATION APPENDIX 7, PART A - TEMPLATE - REQUEST FOR CONSENT COVER LETTER APPENDIX 7, PART B - CONSENT REQUEST FORM APPENDIX 8 - COMPLAINT MANAGEMENT PLAN APPENDIX 9 - TEMPLATE EXTENSION TO COMPLAINT TIMETABLE APPENDIX 10 PART A - TEMPLATE FINAL RESPONSE COVER LETTER APPENDIX 10 PART B - TEMPLATE FINAL RESPONSE LETTER APPENDIX 11 UNREASONABLY PERSISTENT COMPLAINANTS APPENDIX 12 - COMPLAINTS SERVICE EVALUATION QUESTIONNAIRE APPENDIX 13 - SAYING SORRY APPENDIX 14 - LETTER TO STAFF INVOLVED IN AN INVESTIGATION APPENDIX 15 - INTERVIEW RECORD APPENDIX 16 STAFF STATEMENT TEMPLATE Document Type: Policy Page 2 of 46 Version: 4.0

3 EXECUTIVE SUMMARY The provision of feedback whether received from the people who use our services, their family/carers or those purchasing services on behalf of the local population - is a gift. It allows us to see ourselves as others see us and to identify areas in which we need to improve as well as identifying areas of service where we are exceeding expectations. When a person complains about us personally, it can be hard to accept, especially when we know how hard we have been working whilst juggling multiple commitments. Similarly, when a person tells us that our services have not been provided to an acceptable standard, our initial reaction may be one of denial or even irritation. However, when we successfully put aside any hurt feelings we may have and reflect on what people tell us, we can learn valuable lessons that help us to be better at what we do. It is only when we take the time to listen and consider another person s perception and experience that we can find information we didn t previously know. The NHS, and Hinchingbrooke Health Care NHS Trust, is a public service, primarily funded by the taxation system. This places a number of obligations on us: to spend that money wisely and protect it from fraud to make best use of the resources we are trusted with to meet or exceed standards of service and behaviour that meet legal regulations and clinical standards to exhibit the values set out in the NHS Constitution This policy sets out the Trust s expectations on staff when feedback is received, whether this is positive or negative. Document Type: Policy Page 3 of 46 Version: 4.0

4 1. OBJECTIVES 1.1. Hinchingbrooke Health Care NHS Trust [ the Trust ] recognises that feedback, in the form of complaints, concerns, comments and compliments, received from people who use our services, their families/ carers and those commissioning or referring into our services, provide a valuable source of information about the quality of the care we provide. It is essential that feedback is received positively by all our staff and that concerns or allegations are investigated thoroughly and responded to promptly with corrective/ improvement actions when this is indicated The Trust is committed to reaching and maintaining the highest possible standards of care and experience. All staff within the Trust, both clinical and nonclinical, may have contact with people who use our services, carers, family members, stakeholders and external organisations who wish to make a comment, raise a concern or make a formal complaint or allegation regarding the services provided. It is therefore essential that all staff read, understand and follow this policy and its related procedures, to ensure our stakeholders have access to an impartial and rigorous complaints system The way in which we investigate complaints and concerns ensures fairness to all involved. We ensure that people who raise complaints and provide us with vital feedback on our performance are not discriminated against and their care is not compromised. Equally, the family or carers complaining on behalf of a person being treated will continue to be treated with respect. If any complainant tells us that they are concerned that they have been adversely treated because of raising the complaint, this will also be investigated. 2. SCOPE 2.2. This policy is applicable to all services managed or operated by Hinchingbrooke Health Care NHS Trust and, therefore, applies equally to both NHS and privately funded patients This policy applies to all individuals undertaking duties on behalf of Hinchingbrooke Health Care NHS Trust, including agency, bank and locum workers and contractors. The generic term staff will be applied to this group of workers This policy considers best practice with regards to complaint handling and has been created to ensure that it meets all legislative and regulatory standards. The content of this policy reflects the requirements from the recommendations from the Francis Report, including the principles of openness, transparency and candour, the Clywd-Hart Report on NHS Complaints and best practice standards outlined by The Patient Association This policy will establish a standardised approach to complaint handling across the Trust in order to ensure fairness and rigour of investigation, and to guarantee that all departments deliver an accessible and impartial complaints management service without detriment to any person s on-going care. Document Type: Policy Page 4 of 46 Version: 4.0

5 3. DEFINITIONS For the purpose of this policy, the following definitions will be applied Feedback means any comment provided, whether verbal or in writing, that gives an opinion about our services or the treatment or experience received Complaints, Concerns, Comments and Compliments means any structured feedback, communicated orally or in writing, that individual members of staff or the facility receives from people who use our services, their carers or public about the services it provides, whether or not this requires a formal response. It should be noted that not all expressions of dissatisfaction should be regarded or labelled as a complaint ; a tangible distinction therefore needs to be made between issues of concern and complaints. Concerns are usually dealt with in a flexible and less formal manner, whereas complaints are treated in strict accordance with the established procedures for handling complaints Complaints Lead individual[s] responsible for managing the procedures for handling and considering complaints in accordance with regulations 3.5. Complaint means expression of dissatisfaction requiring a formal response in accordance with regulations Complainant means an individual raising a formal complaint regarding the services provided by the Trust whether they are a patient, carer, family member, stakeholder or external organisation Concern means minor criticisms, expressions of dissatisfaction or discontent that may require a response, and which may need to be pursued through a formal route Comment means a helpful observation, whether positive or negative Compliment means an expression of appreciation Claim means an application for compensation Correspondent means an individual raising a concern, providing a comment or passing a compliment regarding the services provided, whether they are a patient, carer, family member, stakeholder or external organisation Lead Investigator individual responsible for planning and undertaking the investigation into a formal complaint Decision Maker individual responsible for reviewing complaint investigation and concluding the outcome and any actions Ex-gratia / goodwill payment means a payment made when there was no obligation or liability to pay it. Any such payments made are not an admission of liability Local Resolution means the first stage of the complaint resolution process, which involves investigation and action at facility level PALS [Patient Advice and Liaison Service] means a service that offers advice, support and information on health-related matters. PALS provides a point of contact for people who use our services, their families and/or carers Person who uses services any individual accessing a service from the Trust, for example, a patient. Document Type: Policy Page 5 of 46 Version: 4.0

6 4. ROLES AND RESPONSIBILITIES For the purpose of this policy the following individuals and groups shall have the following responsibilities: 4.2. Trust Board responsible for the overall monitoring of the quality and timeliness of complaints, concerns, claims and PALS management. Accountable for ensuring that the Trust operates accessible, impartial and rigorous processes for reviewing, investigating and responding to feedback Sub Committee of the Trust Board with responsibility for quality and risk receiving and reviewing reports from the Trust in respect of received feedback, with such reports to include complaint rates, themes, trends and lessons learned, at organisational and divisional levels; ensuring robust systems are in place to enable feedback to be considered and acted upon, lessons learned to be cascaded and for actions to be implemented so as to provide the best possible care going forward Chief Executive Officer [CEO] has overall accountability for the day to day running of the Trust and, specifically, for ensuring that written complaints are investigated fully and responded to honestly and in writing. Responsible for authorising and signing complaints responses or delegating this duty to an appropriate Executive colleague Director of Governance and Risk has delegated authority to authorise and sign complaints responses or claims decisions in accordance with the Scheme of Delegation. Is operationally responsible for complaints and claims management and for the provision of performance and quality reports to the Trust s Committees and Board Director of Nursing, Midwifery and Quality has delegated authority to authorise and sign complaints responses or claims decisions in accordance with the Scheme of Delegation. Is operationally responsible for corporate nursing input into investigations and for the management of the Trust s PALS provision Medical Director has delegated authority to authorise and sign complaints responses or claims decisions in accordance with the Scheme of Delegation. Is operationally responsible for corporate medical input into investigations Complaints Lead is operationally responsible for the day to day management and processing of complaints and claims, monitoring compliance with legislation, regulation, policy and procedure and for escalating any non-compliance Investigation Lead is responsible for collating all relevant information in order to consider the concerns raised, recommend whether to uphold the concerns, develop an action plan and prepare the draft response to the person providing feedback Decision Maker is the senior member of a Directorate with responsibility to approve the recommendations, action plan and draft response provided by an Investigation Lead Service Leads [Directors and Associates, Divisional Heads and Senior Managers]: accountable for ensuring that the management of complaints, concerns, claims and PALS procedures is effectively and efficiently implemented in Document Type: Policy Page 6 of 46 Version: 4.0

7 accordance with this policy within the departments and services under their leadership. This includes the assignment of investigation and response responsibilities within their teams and ensuring that all staff members within the teams understand how to manage feedback initially received by them; assist with investigations relating to their service area / department, to include supporting the Lead Investigator to interview staff, collect statements, review clinical notes and produce reports where appropriate; ensuring that lessons learned are identified and cascaded to staff and that any actions required are implemented within their departments/teams in a timely manner and are monitored for ongoing compliance All staff clinical and non-clinical staff in all services may have contact with people who use our services, carers, family members, stakeholders and external organisations who wish to give feedback. It is therefore essential that all staff read, understand and follow this policy and its related procedures, to ensure our stakeholders have access to an impartial and rigorous complaints system, including co-operating with the implementation of this policy and, specifically, any investigation in which they are involved; reporting complaints in the relevant form / template and escalating where appropriate. 5. PROCEDURE 5.2. Who can give feedback? Any individual can give feedback to any staff member at the Trust Complaints can be made by: a person who receives or has received services from the Trust a person who is affected, or is likely to be affected, by an act, omission or decision of the Trust a person who is acting as a representative on behalf of someone who: has died, is a child, is unable to make the complaint themselves due to physical capacity or lack of mental capacity [within the meaning of the Mental Capacity Act 2005], or has requested that the person act on their behalf a Member of Parliament, councillor or solicitor may write on behalf of the person who has used our services 5.3. How can feedback be given to the organisation? All staff should encourage people who use our services, relatives and carers to provide feedback wherever possible. The Concern Report Form [Appendix 1] should be made readily available for people in all clinical areas Information for the people who use our services, their relatives and carers regarding processes for complaints, claims, concerns or compliments and how to provide feedback to the organisation are available via the following means: leaflets displayed in areas across the Trust; Document Type: Policy Page 7 of 46 Version: 4.0

8 directly from members of staff; the Trust s website When an individual wishes to provide feedback, they should be encouraged and supported to do so. This could include helping them to write a complaint, obtaining interpreters or signposting them to an advocacy service What is the process for handling feedback? All feedback received should be forwarded to the Complaints Lead at the Trust All feedback should be logged onto the integrated risk management software by the staff members formally delegated to do so When a complaint is made by a representative [i.e. not the person directly using our services], consent should be obtained from the person on whose behalf the complaint is made. Where possible, boundaries of communication should be established with the person affected, for example, does the person wish to be copied in to correspondence and what amount of personal clinical information would they wish to be shared with their representative. Consent is not required when it is felt that there are reasonable grounds for a complaint to be made by a representative of another person Compliments Compliments can be provided to any member of staff by any member of the public. Verbal compliments should be relayed to the relevant staff. Where a compliment is provided in writing the relevant manager will respond by telephone or in writing; an electronic copy should be forwarded to the relevant manager for cascade to their teams and to the Governance and Risk Directorate staff for logging Comments Comments can be made be made in writing in a number of formats, including via the Concern Report Form [Appendix 1] All comments received or completed forms should be forwarded to the Complaints Lead The Complaints Lead will arrange for feedback to be provided to the appropriate department lead on comments made in respect of their area and/or incorporated into the complaints process where relevant Each department is responsible for ensuring comments they receive are reviewed and actioned accordingly, a written copy of the actions taken should be forwarded to the Complaints Lead If appropriate, the relevant department will provide a response directly to the person who has made comments informing them what actions have been taken. Comments and suggestions received from people who use our services will be acknowledged within three working days of receipt and useful suggestions will be acted upon wherever possible Verbal Complaints and Concerns Where possible, all verbal complaints and concerns should be dealt with on the spot and the staff member receiving the feedback should attempt to establish what resolution is being sought and determine whether or not this can be delivered and, if so, within what timeframe. If the resolution to the verbal Document Type: Policy Page 8 of 46 Version: 4.0

9 feedback can be delivered in full within one working day then this can be recorded as a concern and no written response is required. However, the nature of the verbal feedback and the resolution reached should be documented by the member of staff responsible for resolving the matter using the Concern Report Form [Appendix 1] If the staff member is unable to resolve the verbal feedback then this should be escalated to their line manager The Matron or Divisional Head of Nursing can be asked for assistance as required If the decision is to handle the matter as a concern, this should be clearly communicated, with corrective action taken and a response provided to the person raising the concern within an agreed timeframe If the decision is to handle the matter as a complaint then the process set out in clauses 5.8 to 5.12 [inclusive] should be followed Complaints in writing Grading the Complaint [triage] The Complaint Lead will review every complaint and make a decision as to the complexity and seriousness, taking into the Concern / Complaint Risk Grading Assessment [Appendix 4]. The following needs to be considered: if the complaint involves issues that could potentially compromise public or individual safety or involve the media, or if the complaint is graded as high or extreme, the Executive of the Day should be informed immediately and this should be recorded as evidence; Complaints that could fall into the Serious Incident category must be discussed with the Executive of the Day in the first instance before any action is taken; and Complaints about members of staff that involve allegation of misconduct or abuse should be referred to the Director of Human Resources for advice / action [refer Disciplinary and Grievance Policy] Where a Complaint is about clinical care, an appropriate clinical member of staff should be involved in the risk assessment. Timeframe for submission of a complaint Complaints should be made within twelve months of an incident occurring or of the complainant becoming aware of the incident. This timescale can be extended if the Complaint Lead or their deputy is satisfied that there is good reason for the time delay and that it is possible to investigate the complaint effectively. Process for managing a complaint 5.9. Written complaints Complaints regarding NHS-funded services follow a two stage resolution process. Document Type: Policy Page 9 of 46 Version: 4.0

10 5.10. Stage one Local Resolution All stage one complaints should be managed using the Complaints Standard Operating Procedure [Appendix 2] All complaints received in hard copy must be stamped and dated on the day of receipt to the Trust. All complaints should be forwarded to the Complaints Lead immediately If a complaint is received electronically, the Complaints Team must obtain the complainant s official mailing address and telephone number. It should then be explained to the complainant that the final response to the complaint will be sent in hard copy via the postal system, unless the complainant specifically requests the response be sent electronically, in this situation, evidence of this instruction must be documented in the complaint file All complaints will be logged within the integrated risk management system and shall include address, age and gender of the complainant, the relationship of the complainant to the person using our services, where relevant, and the source of the complaint. This is the responsibility of the Complaints Team The Complaints Lead will ensure that the complaint is risk graded and triaged before contacting the complainant to discuss the handling of the complaint. The Complaint Management Plan [Appendix 8] will be developed by the Investigation Lead and will include the complainant s specific resolution expectation and the agreed timescale for the investigation Whenever possible, a conciliatory approach should be taken; this should include telephone or direct contact with the complainant. This is especially important if the complaint is particularly complex. The Complaints Lead will also support the nominated Investigation Lead to set up an initial meeting with the complainant if deemed appropriate in assisting the investigation The complaint will be acknowledged within three working days [either verbally or in writing]. A letter of acknowledgement [Appendix 10] will always be sent Maximum response timescales (working days) are: Low: 0-20 Moderate 0-40 High/Extreme For each complaint, the Lead Investigator will ensure the investigation is proportionate to the level of the complaint. The Lead Investigator will most usually be a senior manager from the service that is being complained about, with independent challenge of responses being offered from within the Governance and Risk Directorate and Corporate Medical and Nursing Directorates. The investigation will include: meeting with the complainant if appropriate; taking statements from the staff involved; ensuring staff involved in complaints are aware of support mechanisms and how to access these; Document Type: Policy Page 10 of 46 Version: 4.0

11 reviewing medical records, policies and procedures as appropriate [whenever possible, documented evidence to support statements should be sought]; seeking independent expert advice where indicated; formulating a draft response [as if replying to the complainant], ensuring that the response addresses all the issues recorded in the Complaint Management Plan; re-assessing the risk grading of the complaint at the end of the investigation; provisionally conclude whether the complaint is upheld or not; recommend actions for improvements and draft an action plan for every complaint [even if the action plan states that no action is required]; ensuring all relevant documents, including staff statements, policy documents and file notes are collated for inclusion into the complaint file and reviewed by the decision maker; keeping contemporaneous records of the investigation within the Complaint Management Plan; return the draft response and action plan to the decision maker by the required timeframe; For each complaint, the decision maker will be independent to the part of the service that is being complained about. The decision maker will review the Lead Investigators investigation and conclude: whether the complaint is upheld, partially upheld or not upheld; confirm actions for improvements and finalise action plan for every complaint [even if the action plan states that no action is required]; finalise the response to complainant. the draft response will then be sent to the relevant Executive Director for approval and signature Clinical, department, divisional, or service leads should ensure that any staff involved in complaints are supported during the investigation process. They should also support staff when they are required to provide statements, be interviewed or when there is escalation to the Human Resources Directorate. Consideration also needs to be given to the potential effect of the complaint on the staff member During the investigation and following the conclusion of the complaint, the staff member[s] involved should be kept fully informed of progress and given details of the outcome of the complaint Staff in the Directorate of Governance and Risk will record the progress of the complaint investigation within the integrated risk management system. Hard copy documents will be scanned and uploaded to the system, with retention of the hard copy in accordance with requirements. This includes copies of any correspondence to the complainant or staff, logging of telephone calls made or face-to-face conversations and any electronic correspondence. The Complaint Management Plan must be maintained, including documentation of each contact Document Type: Policy Page 11 of 46 Version: 4.0

12 made in the complaint investigation. This is the responsibility of the Lead Investigator The Complaints Lead will monitor the progress of the investigation on a weekly basis; any complaints that are proving difficult to resolve should be discussed with the Director of Governance and Risk and with the Executive and/or Clinical Leads for the relevant service to determine action. The opportunity to discuss these approaches at an early stage may help to prevent a complaint from requiring escalation to an external reviewer All records relating to complaint investigations are confidential and must be kept separate from any medical records and in a secure environment for eight years from the date of the last contact. Care must be taken with the accuracy, legibility and language used within all correspondence. In accordance with the Data Protection Act [1998] a complainant has the right to access all correspondence within the complaint file An appropriate Executive Director, with delegated authority from the Chief Executive Officer, will sign the final response to a complainant after checking that the response addresses all of the points recorded in the Complaint Management Plan All complaint responses should comply with the negotiated time-scale; however, if a response is not going to be available within the pre-agreed timescale, staff from within the Directorate of Governance and Risk will contact the complainant to negotiate an extension. This must be confirmed in writing If the complainant remains dissatisfied, the Complaints Lead should pursue alternative means of local resolution. This could include initiating further investigation or organising for staff to meet directly with the complainant A complainant has the right to have issues investigated under the complaint process at the same time as they are pursuing a claim for clinical negligence; however, it is not within the remit of the complaints process to investigate clinical negligence and this should not be commented on within the complaint response. Complaints relating to another organisation incorrectly sent to the Trust If it becomes apparent that the complaint relates to another organisation and does not involve the Trust, the Complaints Lead will telephone the complainant to advise them that the complaint relates to another organisation. The Complaints Lead will request permission to forward the correspondence to the relevant organisation or will seek confirmation that the complainant will contact the correct organisation themselves. If consent for forwarding has been obtained, a summary record of the conversation and a scanned copy of the complaint letter should be made and uploaded into the integrated risk management system, the original letter can then be forwarded to the relevant organisation. If contact cannot be made with the complainant by telephone, then the Complaints Lead will write to the complainant advising them that attempts have been made to contact them and that the complainant needs to redirect their letter to the correct organisation, details of which will be included in the letter. Complaints involving more than one organisation Where a complaint spans more than one organisation, attempts should be made to identify the organisation that will lead the complaint management. The leading organisation will most usually be the organisation associated with the majority of issues or the most severe issue. The leading organisation should Document Type: Policy Page 12 of 46 Version: 4.0

13 facilitate one response that encompasses all of the investigation outcomes. For clarity, the response should be clear about which organisation has investigated what elements of the complaint. MP letters When a complaint is received from a Member of Parliament on behalf of an individual, consent to investigate the complaint and respond to the MP is required from the person using our services. This may be included within the letter if the MP has arranged this It is important that boundaries of communication are established, for example whether the person affected wishes to be copied in to correspondence and what degree of personal clinical information they wish to be shared with the MP. A response to the MP s letter must be provided within 10 working days. Solicitor letters When a complaint is received from a solicitor on behalf of an individual, consent to investigate the complaint and respond to the solicitor is required from the person using our services. This may be included within the letter if the solicitor has arranged this It is important that boundaries of communication are established, for example whether the person affected wishes to be copied in to correspondence and what degree of personal clinical information they wish to be shared with the solicitor. A response must be provided within the agreed timescale. Requests that are not required to be managed under the complaints process If the complainant makes reference to a Freedom of Information or Access to Medical Records request, this request will be managed separately by the Medical Records Department If the complaint makes reference to a claim for compensation, the complainant must be informed that the complaint and claims processes are independent of each other and that if they wish to pursue a claim, rather than a complaint, they must instruct a solicitor Stage 2 Independent Review If a complainant remains dissatisfied with attempts at local resolution they can, depending on their funding arrangements, ask either of the following to review their case: in the case of privately funded services the Independent Healthcare Advisory Services [IHAS]; or in the case of NHS-funded funded services the Parliamentary and Health Services Ombudsmen [PHSO] The external agency will seek to identify whether the Trust has acted appropriately when assessing the complaint in order to identify if there is evidence of maladministration or service failure The relevant external agency will request the Trust to provide a copy of the complaint file and health care records. After undertaking the review, the external agency may undertake an investigation that may include a review of clinical care and/or complaint management; the agency will also normally write and formally ask for relevant information to be provided by a specific date. After completing their review they will send a final report informing the organisation whether they uphold the complaint or not and any corrective action that the organisation must Document Type: Policy Page 13 of 46 Version: 4.0

14 implement. Complaints referred to either external agency will be monitored by the Complaints Team and reported to the Executive Board Unreasonably persistent complainants The Trust is committed to dealing with all complaints as quickly, fairly and impartially as possible; however, it is acknowledged that some complaints are difficult to resolve. Complainants may remain dissatisfied no matter how comprehensive and honest a response is provided and, as a result, they may choose to continue to contact the Trust about their complaint. There is a low number of complainants who may, because of the frequency and nature of their contact with the complaints service/pals, hinder the consideration of their own, or other people s, complaints Most complainants are entirely reasonable and are merely seeking to find out the facts of a situation and, in cases where we have wronged them or made error, receive an apology and some form of assurance that others will not experience the same thing. Rarely, a complainant may not have this agenda and may, for example, abuse or threaten individual members of staff and/or continue to raise new or repeated issues when their previously stated complaints have been investigated and addressed. An unreasonably persistent complainant is someone who repeatedly submits complaints and/or allegations, despite their complaint having been rigorously and comprehensively investigated and truthfully and fully responded to If the Complaints Lead becomes concerned that a complainant is behaving in an unreasonable manner, they must initially seek advice from the Director of Governance and Risk, who may in turn seek advice from another Executive colleague. It is vital that any restrictions placed on correspondence with the complainant should be as a result of fair and consistent application of policy, taking into consideration whether the complainant has legitimate complaint. In exceptional circumstances, the Director of Governance and Risk may authorise correspondence to the complainant advising them that no further correspondence on a particular matter will be entered into and respectfully asking that they desist from further correspondence on the issue. In such a circumstance, this correspondence will include alternative routes for complaint review, such as the PHSO. Threats and/or abusive comments made to staff will not be tolerated and the complainant may be reported to the Police. Refer to [Appendix 11] for further information on unreasonably persistent complaints. 6. EVALUATION MEASURES 6.2. Responsibilities The Director of Governance and Risk will be responsible for reviewing the complaint process across the organisation. This will include a review of the consistency of application of the complaint process, in line with policy, internal quality of investigations and responses, appropriateness of actions taken and the satisfaction of complainants Directorate-level assurance needs to be given that all staff are competent to respond to feedback, and that lead investigators and decision makers have the skills and confidence to undertake rigorous and comprehensive investigation and to formulate a response meeting expected standards of grammar, tone and content. Each Directorate must also have clear evidence of involving people who Document Type: Policy Page 14 of 46 Version: 4.0

15 use our services and the public and to be able to demonstrate quality improvements made as a result of feedback To ensure compliance with this policy:- the Complaints Team will provide a quarterly report to the relevant Sub- Committee of the Trust Board, which will in turn submit an annual report on feedback, including volume, service type, trends and themes along with actions taken to improve services for people using our services; the Director of Governance and Risk will annually monitor relevant activity to ensure that the policy and its implementation are fully compliant with the National Minimum Standards The Associate Directors of Operations will be accountable for: ensuring that operational staff involved in an investigation and complaint response comply with this policy and the data recording required therein; ensuring that complaints and incident investigations are undertaken and concluded within agreed timescales ensuring that lead investigators within their Directorate provide responses that meet expected standards of grammar, tone and content providing evidence to demonstrate that lessons have been learned as a result of feedback and that agreed actions have been implemented in accordance with the specific action plan and timelines per complaint 6.3. Learning from feedback The Trust is required to have a system in place as part of its governance arrangements to ensure feedback is reviewed for lessons and that the findings are cascaded across the Trust to support continuous improvement. Clinical Directorate-level action plans will be produced and submitted to the Patient Safety Committee on a quarterly basis to demonstrate what service improvements are planned as a result of the receipt of feedback. 7. REVIEW Subject to change in regulations and legislation which would result in the need for earlier review, this policy will be reviewed and approved by the Director of Governance and Risk every three years, and ratified in accordance with Trust Policy. 8. REFERENCES The Local Authority Social Services and National Health Service Complaints [England] Regulations Care Quality Commission Essential Standards of Quality and Safety NHS Constitution Document Type: Policy Page 15 of 46 Version: 4.0

16 Parliamentary and Health Service Ombudsman [PHSO] Independent Sector Complaints Adjudication Service [ISCAS] Patient Association Good Practice Standards for NHS Complaints Handling Public Inquiry chaired by Robert Francis QC NHS Hospitals Complaints System Review by Right Honourable Ann Clywd MP and Professor Tricia Hart DISTRIBUTION 9.2. This policy will be made available to all staff via the Trust s Intranet and sent directly to Directors, Associate Directors and Senior Managers, for onward cascade throughout Directorates The Trust s e-communications will be used to alert staff to an update in policy. 10. RELATED POLICIES Raising Concerns at Work Policy Adverse Incidents Policy Discrimination, Bullying and Harassment Policy Disciplinary Policy Grievance Policy Equality and Diversity Policy 11. LEGISLATION In developing this policy the following legislation has been duly considered: Data Protection Act 1998 Data Protection issues have been considered with regards to this policy. Adherence to this policy will therefore ensure compliance with the Data Protection Act 1998 and internal Data Protection Policies. Diversity & Equality Policies Equality issues have been considered with regards to this policy. Adherence to this policy will therefore ensure compliance with Equal Opportunity legislation and internal Equal Opportunity policies. Document Type: Policy Page 16 of 46 Version: 4.0

17 Freedom of Information Act 2000 Freedom of Information issues have been considered with regards to this policy. Adherence to this policy will therefore ensure compliance with the Freedom of Information Act 2000 legislation and internal Freedom of Information policies. Health and Safety Act 1974 Health and Safety issues have been considered with regards to this policy. Adherence to this policy will therefore ensure compliance with Health and Safety legislation and internal Health and Safety policies. Human Rights Act 2004 The Human Rights Act 1998 has been considered with regards to this policy. Proportionally has been identified as the key to Human Rights compliance. This means striking a fair balance between the rights of the individuals and those of the rest of the community. There must be a reasonable relationship between the aim to be achieved and the means used. Race Relations Amendment Act 2000 The Race Relations Amendment Act 2000 has been considered with regards to this policy. Adherence to this policy means that the company will eliminate discrimination on the grounds of race and will promote race equality and good race relations. The Employment Equality [Age] Regulations 2006 Hinchingbrooke Health Care NHS Trust acknowledges that the age profile of the United Kingdom and therefore the local community is changing. The company is committed to equality of opportunity both in service delivery and employment and we have made a commitment to promoting age diversity by. Adherence to this policy means that the company will challenge the general acceptance of ageism in order to eliminate age stereotyping. The Mental Capacity Act 2005 Has been considered when developing this policy to ensure the guiding principles of the act are adhered to with reference to testing and assessment of capacity, consulting others and protecting the best interests of the Service User. The Mental Capacity Act provides a statutory framework to empower and protect vulnerable people who are not able to make their own decisions. It makes it clear who can take decisions, in which situations, and how they should go about this. It enables people to plan ahead for a time when they may lose capacity. Document Type: Policy Page 17 of 46 Version: 4.0

18 List of Appendices APPENDIX 1 Template Concern Report Form APPENDIX 2 Standard Operating Procedure and Flowchart for Complaints Management APPENDIX 3 Triage Criteria for Establishing a Concern/ Complaint APPENDIX 4 Risk Grading Assessment Categorisation APPENDIX 5 Parts A and B - Template Acknowledgement Letters APPENDIX 6 Template Complaint Referral to Other Organisation APPENDIX 7 Parts A and B - Template - Request for Consent Letter And Form APPENDIX 8 Complaint Management Plan APPENDIX 9 Template Extension to Complaint Timetable APPENDIX 10 Template Consent Request Form APPENDIX 10 Parts A and B Template letter response cover and response final APPENDIX 11 Unreasonably Persistent Complainants APPENDIX 12 Complaints Service Evaluation Questionnaire APPENDIX 13 Saying Sorry APPENDIX 14 Letter to staff involved in an investigation APPENDIX 15 Interview record form APPENDIX 16 Staff Statement template Document Type: Policy Page 18 of 46 Version: 4.0

19 APPENDIX 1 - Concern Report Form Please use BLOCK CAPITALS. If you have any difficulties completing this form, or any questions about the complaints process that you would like to discuss, please call the Complaints Team on If you would like someone to act on your behalf [perhaps a friend of relative] please provide us with their details and your written permission. If you are not the person in receipt of our services and are making a complaint on someone else s behalf, please ask the patient to sign the declaration at the end of this form to give his/her permission for you to act as their representative. If there is anything which makes it difficult for you to pursue your complaint, for example if English is not your first language or you have a disability that makes it hard, please use the space below to tell us how we might help you or ring us on Your details [the person making the complainant] Title Complainant e.g. Miss, First Name Mrs, Ms, Mr Complainant Surname Complainant Date of Birth Complainant Address Complainant Postcode Daytime contact telephone number: [09:00 hrs to 17:00 hrs] Complainant address: Document Type: Policy Page 19 of 46 Version: 4.0

20 Complainant details: Please indicate if you are the person in receipt of services who is raising this complaint: YES / NO If No, please state your relationship to the person affected: Patient details: Title eg Miss, Mrs, Ms, Mr Last name First Name Date of Birth Address of the patient affected Postcode of the patient affected The NHS or Hospital Number of the patient affected, where known Daytime contact telephone number [9am to 5pm] address of the patient affected Service details Which area is your complaint about? Where did the incident[s] happen that led to your complaint? Please be as specific as you can When did the incident[s] happen that led to your complaint? If more than one date, please specify when the incidents occurred below. Date Time Or indicate the time period[s] when the incident[s] occurred. Document Type: Policy Page 20 of 46 Version: 4.0

21 From From From To To To Your complaint Please describe the circumstances that have led you to complain Please include the below details if you are able to: Who was involved What was said and/or done How it has affected you What you think the service failed to do, or did wrongly If there is not enough space, please continue on a separate sheet of paper and attach it to this form. Please state the areas that you wish to be investigated Document Type: Policy Page 21 of 46 Version: 4.0

22 Please state any other information that we may find useful Please state what outcome you are seeking Apology Explanation / answers to questions Further appointment Other [please specify] How would you like us to respond to the concerns that you have raised? In the first instance, it may be necessary for us to contact you to discuss your complaint. Therefore please confirm if you would initially like us to contact you either in writing or on the telephone to discuss the complaint and to agree how you would like us to respond you following the completion of our investigations this may be in writing or in a meeting with staff if you prefer. I would initially like you to WRITE TO ME / RING ME [delete as appropriate] to discuss my complaint and how you will respond to the concern[s] that have been raised. Address [if different from above] Postcode Telephone number [if different from above] Please contact me between [please state convenient dates and times] Document Type: Policy Page 22 of 46 Version: 4.0

23 APPENDIX 2a: Standard Operating Procedure Complaints Management Receipt of complaint 1. Complaint received in Directorate of Governance and Risk; consent received, if complaint submitted by a person other than the person affected Actions to be taken by Complaint Lead: 2. Triage and grade the complaint 3. Record the complaint within the designated system 4. Contact the complainant to discuss a plan to resolve the complaint. This may include a local resolution meeting, conciliation or mediation services. 5. Acknowledge the complaint in writing within three working days of receipt of the complaint. Offer assistance to ensure the complainant understand the complaints process. Enclose the Complaints Leaflet 6. Identify the appropriate Investigation Lead and the Decision Maker 7. Forward the complaint to the Investigation Lead, copying in the Decision Maker. Include templates and a confirmation of deadlines for each stage of the investigation. Actions to be taken by the Lead Investigator: 8. Complete the Complaint Management Plan, identifying each person involved in the complaint 9. Commence the investigation, requesting a written statement from each person involved in the complaint and conducting and recording interviews with the individuals concerned. 10. Collate the information gathered and review the casenotes of the affected person if this is relevant and appropriate. 11. Analyse the information available and formulate a recommendation for each element of the complaint [fully upheld, partially upheld, not upheld]. 12. Identify actions required to resolve the complaint and/or prevent recurrence. 13. Complete an action plan and ensure all responsible owners are made aware of the actions and deadlines for completion. 14. Draft the written response letter to the complainant, ensuring each element of their complaint is set out and a full response provided beneath. 15. Forward the draft response and action plan to the Decision Maker, for consideration. Include a reminder of the deadline for their decision and provision of response to the Complaint Lead. Actions to be taken by the Decision Maker: 16. Review the response letter and recommendations received from the Lead Investigator. 17. Revise the letter, where appropriate, and confirm your decision. 18. Where additional or alternative actions are identified, forward these to the Investigation Lead for cascade to responsible owner[s]. Document Type: Policy Page 23 of 46 Version: 4.0

24 19. Forward the completed letter to the Complaint Lead in the Directorate of Governance and Risk. Actions to be taken by the Complaint Lead: 20. Provide the relevant Executive Director with the final draft response, for approval and signature. 21. Complete any final amendments. 22. Send the letter. 23. Ensure all correspondence is uploaded into the designated system. Document Type: Policy Page 24 of 46 Version: 4.0