Complaints Project FINAL REPORT THE PATIENTS ASSOCIATION. in collaboration with ROYAL FREE LONDON NHS FOUNDATION TRUST

Transcription

1 Complaints Project FINAL REPORT THE PATIENTS ASSOCIATION in collaboration with ROYAL FREE LONDON NHS FOUNDATION TRUST Authors: Jane Stephenson, Celia Turnbull, Project Managers The Patients Association August

2 Contents 1. EXECUTIVE SUMMARY RECOMMENDATIONS FOREWORD INTRODUCTION PROJECT OUTLINE METHODOLOGY FINDINGS AND OUTCOMES OVERVIEW MANAGING COMPLAINTS... Error! Bookmark not defined MANAGING AND ENGAGING WITH COMPLAINANTS. Error! Bookmark not defined. 7.4 INVOLVING STAFF GOVERNANCE SYSTEMS AND REPORTING SHARING THE LEARNING: PATIENT AND STAFF ENGAGEMENT CONCLUSION REFERENCES APPENDIX

3 1. EXECUTIVE SUMMARY 1.1 The Patients Association was commissioned by the Royal Free London NHS Foundation Trust to undertake a small scale investigation, to review the complaints policies and practice following the trust acquisition of Barnet and Chase Farm Hospitals. The project sought to complement work already in place, to explore existing policies and ways of working in the two previous organisations and to gather views of staff and patients to inform the trust strategy regarding the alignment of the current services. 1.2 A project management approach was taken to deliver the review. The project was facilitated by two Patients Association project managers, based on the benefits offered by the Patients Association organisational membership. This was carried out in July and August The review covered five aspects of complaints management, namely: o managing complaints o managing and engaging complainants o involving staff o governance systems and reporting o sharing the learning. 1.4 A paper review of complaints policies and key documents was undertaken, including an overview of a small sample of complaints files. Informal interviews were held with key complaints, PALS and clinical staff. Site visits were made to the three main hospital sites. Observation and informal conversations were held on a selection of wards and outpatients with staff, patients and carers, this gave a snapshot on the day. Corroboration of evidence gathered by the two project managers was undertaken at the end of the data gathering phase and used to prepare the final report. 1.5 The findings demonstrated a number of areas of good practice at each trust, together with areas for improvement. Noteworthy good practice at the Royal Free is the comprehensive analysis and reporting of complaints data; and the complaints training programmes stood out at Barnet and Chase Farm. 1.6 Areas for improvement include the need for visible, up-to-date, patient-facing information on concerns and complaints, together with the need for a much clearer delineation between complaints and PALS at Barnet and Chase Farm. 1.7 Some excellent examples of service improvement and learning from complaints were noted but there is a need for greater visibility and sharing across the trust, together with greater involvement of patients and carers in this work. 3

4 1.8 From this investigation, we believe the trust is well placed to making decisions about the future shape and scope of the complaints service and to take positive aspects from each organisation for adoption in the unified approach. 1.9 The recommendations offer guidance on improving standards in line with best practice, with some practical solutions and a greater engagement with patients and complainants in taking this forward. 2. RECOMMENDATIONS Managing Complaints 2.1 Consider immediate implementation of Royal Free Datix categories and report templates at Barnet and Chase Farm so that joint data can be more easily correlated, reported on and monitored across the sites. 2.2 Consider holding a workshop for divisional complaints managers (DCMs) and complaints facilitators to develop elements of a new complaints policy. Use the findings from this report to inform the discussions, with the aim of retaining and expanding the focus on patient experience and staff guidance. 2.3 Consider an immediate revision of timescales, particularly for complex complaints. 2.4 Introduce a simple and consistent risk assessment for complaints and ensure training for staff. 2.5 Streamline the checking process for final complaints responses. To ensure that this does not affect quality, a formal peer review process could also be introduced. 2.6 Ensure a clear process across the trust for reviewing cases referred to the Ombudsman and monitoring their outcomes. 2.7 Draft a clear definition of what constitutes a PALS concern and how that differs from a complaint, in conjunction with the PALS managers and head of complaints and implement across both sites immediately. Ensure the definitions are easy to understand and are communicated to patients and staff across the trust.* Managing and Engaging with Complainants 4

5 2.8 Reintroduce complaints posters and leaflets in a variety of formats. Consider using a patient focus group to test the final designs.* Until this has been completed, correct the errors on the current leaflets. 2.9 Develop easy read website information on complaints and PALS for access by a wider audience.* 2.10 Introduce the complainant feedback questionnaires at Barnet and Chase Farm and review actions after 6 months.* 2.11 Ensure that a review of the PALS service at Barnet and Chase Farm includes service accessibility for Chase Farm patients.* Involving Staff 2.12 Undertake a staff training needs analysis for DCMs, complaints facilitators and investigator roles. Develop and implement a training programme, to include a section for staff induction, using good practice examples from Barnet and Chase Farm. Governance Systems and Reporting 2.13 Set up a project group to look at how service level improvements from complaints can be shared*: Reporting across the trust more visibly to promote learning; and Outside the trust to engage the wider public, Healthwatch etc. Sharing the Learning Patient and Staff Engagement 2.14 Continue to raise awareness through events such as in Your Shoes and Patient Voices.* 2.15 Invite patient involvement in seminars, training and workshop groups.* 2.16 Develop the website further to include patient stories and learning from complaints* (* indicates actions where patients and carers should be consulted and directly involved) 5

6 3. FOREWORD 3.1 The Patients Association is an independent healthcare charity which campaigns for improvements in health and social care. The Association's willingness to listen to patients and the public has always informed our work, research and campaigns. Our Helpline, which answers dozens of calls, letters and s every day provides a valuable insight into what is of current concern to patients. 3.2 For over 50 years, the Patients Association has always been there to listen to patients and speak up for change. The Association has spoken up for change through many campaigns and has acted as a critical friend to the Department of Health, voicing concerns, advising about current and future policy, and providing solutions. 3.3 The Patients Association believes that patients and carers should be at the heart of the health and social care system, and that they should be given the opportunity to be actively involved in decisions about their health and social care. Since 2011, The Patients Association has worked with a number of NHS Trusts and organisations to take forward a range of projects to address the "C.A.R.E. Challenge" 1 which focuses on key aspects of care and concerns, raised by patients and carers themselves. 3.4 In 2011, the Health Foundation funded "Speaking Up" project 2 was set up as a key part of this work. The Patients Association developed tools aimed at improving the quality of complaints handling at Mid Staffordshire NHS Foundation Trust and elsewhere. A set of good practice standards for complaints handling was developed based on feedback and concerns raised by patients and carers themselves 3. This was tested out using a Peer Review process to review samples of complaints case files and a complainant questionnaire. 3.5 The complaints standards were specifically recommended for wider use by Robert Francis, QC, in the public inquiry into Mid Staffordshire NHS Foundation Trust 4. This further emphasised that good quality complaints handling is vital to ensuring continuous improvement in the quality and safety of care. The standards provide a tangible and measurable reflection of an organisation s commitment to an open and responsive safety culture. 3.6 Since then, the Patients Association has developed the range of tools and supported a number of organisations in the NHS to improve complaints handling, using the standards and providing training to meet local needs. 6

7 3.7 All projects carried out by the Patients Association aim to fit the following criteria, in order to maximise their impact: Sustainability projects should be sustainable in some way beyond the lifetime of the Patients Association Project; Replicable it should be possible to replicate the projects elsewhere with similar results; Improve the patients and carers' experience the projects should make a real difference to the experience of patients and carers, and Leave a legacy projects should result in permanent improvements in the patients experience and increased staff knowledge about best practice. 7

8 4. INTRODUCTION 4.1 This project focuses on a small scale investigation to review the complaints policies and practice of the former Barnet and Chase Farm Hospitals Trust (Barnet and Chase Farm) and the Royal Free London NHS Foundation Trust (the Royal Free). 4.2 The project sought to complement work already in place, to explore existing policies and ways of working in the two previous organisations, and to gather views of staff and patients to inform the trust strategy regarding the alignment of the current services. 4.3 On 1 st July 2014 acquisition of Barnet and Chase Farm was made by the Royal Free. There are implications for the alignment of many of the services now provided across the new organisation in developing a unified approach to care provision. 4.4 The Patients Association was commissioned to review the existing complaints services and make recommendations on the development of a single service providing consistent patient support across all sites. 8

9 5. PROJECT OUTLINE 5.1 As an independent charity, the Patients Association offers independence and anonymity for patients and carers feeding back their experiences and giving their views about services. The complaints project was led by two Patients Association project managers who have a wide range of experience working with the NHS and in the field of complaints. The project managers worked closely with staff and patients to make recommendations on the way forward. 5.2 Project Aim To undertake a review of the complaints policies and practice for the former Barnet and Chase Farm and the Royal Free in order to inform an eventual merger of the two complaints services. 5.3 Project Objectives To access current information about the two hospital trust complaints systems and outputs in order to undertake a paper-based analysis and comparison. To access staff working in the complaints services of both hospital trusts to explore their experiences of implementing the complaints policies and working with trust staff and patients in resolving complaints. To determine similarities and differences in the complaints practice of the two hospital trusts in relation to openness and a responsiveness in the approach to receiving complaints and using these to learn and improve services. To highlight best complaints handling practice in both trusts based upon the findings of the review and drawing upon current national policy for complaints handling. The objectives were reviewed during the preparatory phase and it was agreed that the project would run over ten days and not include a formal review of closed complaints files. 5.4 Outputs A document detailing the process, mechanisms and outcomes of the current complaints systems for both hospital trusts and highlighting best practice. 9

10 5.5 Outcomes Outcomes agreed at the outset of this project were: Changes will be identified that will facilitate the development of a single unified complaints service across all hospital sites for the new hospital trust. This will include the positive aspects from each organisation s complaints procedures which will be highlighted for adoption in the unified approach. Complainants will receive the same service whichever part of the trust they receive their care. Reporting of complaints will take a unified approach using the same categories and classifications whichever part of the trust they originate. There will be consistency in the complaints teams, their roles and responsibilities and staff complements with regard to size and cover of the services provided. 5.6 Timescales June 2014 Agree proposal for project Invoice and payment Appoint Project Managers Acquire documentation around complaints and PALS (the Patient Advice & Liaison Service) for analysis July 2014 Commence scoping of current practice Set dates for staff interviews Interviews with a range of staff dealing with complaints Site visits and conversation with patients, carers, visitors Interviews with former complainants (if enough time). August 2014 Analyse data and write up report of findings. 10

11 6. METHODOLOGY Project management 6.1 A project management approach was taken to deliver the review. The project was facilitated by two Patients Association project managers, based on the benefits offered by the Patients Association organisational membership; Framework for Review 6.2 The review covered five aspects of complaints management: o managing complaints o managing and engaging complainants o involving staff o governance systems and reporting o sharing the learning 6.3 The Patients Association Good Practice Standards in NHS Complaints Handling 3 were used as a basis alongside the Complaints Regulations and good practice guidance from the Department of Health (DH) and the Parliamentary & Health Service Ombudsman A list of supporting documents to review from each trust was drawn up. A list of people to interview was adapted to fit the former and current trusts' organisational structures. A semi structured interview format was revised and tailored to fit the specific requirements of the project. 6.5 Site visits were arranged to the three main hospital sites, to include observation of the complaints and PALS services, and a sample of clinical areas. Data collection 6.6 A paper review of two trusts' complaints policies and current practice was undertaken using the Patients Association Good Practice Standards in NHS Complaints Handling 3 and associated national guidance. 6.7 We reviewed a range of complaints data, from trust reports, documents and complaints files to gain insight into how the processes were working, this included: identifying key service areas involved; types of complaints and categorisation; the engagement of complainants and staff; follow up work and ombudsman cases. Interface with PALS and patient experience work was also looked at. 11

12 6.8 Interviews were carried out with key complaints staff, senior leads, directors and a sample of clinical staff from both previous organisations (Appendix 1), using a semi structured interview format. Most interviews were face to face; the complaints managers and facilitators were interviewed as groups, and where face to face was not possible, telephone interviews were carried out. Notes were taken at the time and written up at the end of each interview. 6.9 Site visits were made to Royal Free, Barnet and Chase Farm and general observation of the complaints and PALS services, their environments and information provided on site were carried out. On each of the three sites, visits were made to outpatients and a number of wards. Informal conversations were held with patients and families using the service at the time. Informal interviews were held with a range of ward staff including matrons, ward sisters, physiotherapists, health care assistants and reception staff (Appendix 1) Corroboration of evidence gathered by the two project managers was undertaken at the end of the data gathering phase. 12

13 7. FINDINGS AND OUTCOMES 7.1 OVERVIEW 7.11 The document review, interviews and site visits were carried out during July and August We recognise that this was during the early stages of the acquisition of Barnet and Chase Farm by the Royal Free and that the findings need to be seen in the light of this. We recognise also that the need to maintain safe standards and good communication is even more critical during the transition The findings and outcomes have been presented under five key themes, and examples of good practice together with areas for improvement have been highlighted Trust complaints data indicates that the Royal Free had a total of 653 complaints in 2013/14, down from 710 in 2012/13. Barnet and Chase Farm had a total of 338 complaints, up from 295 in 2012/13. Whilst the core services at the two trusts are different, it would appear that Barnet and Chase Farm have a lower than expected number of complaints. The service has been run very closely with PALS and has different categories of complaints, so direct comparison not possible. 25% of complaints come from the Chase Farm site which now takes elective care only The most common reasons for complaints are broadly consistent for the two trusts and with the national picture, namely: o Clinical treatment o delays o staff attitudes o communication 7.15 We noted that from the CQC inspections of the Royal Free and Barnet sites in 2014 both met the standard for complaints, with some specific areas for improvement being taken forward. Chase Farm was not specifically assessed for complaints but was reassessed by the CQC following serious lapse in care on one ward in 2013, and patient care was found to have improved in During 2013, the Patients Association Helpline had also received an increase in complaints about Chase Farm which may have reflected the same issues Both trusts have commendably carried out self assessments against the Patients Association and other good practice complaints standards with areas identified for action. This work has also informed this current review. 13

14 7.2 MANAGING COMPLAINTS 7.21 In reaching our findings on this section we reviewed both trusts complaints policies and reports and spoke to divisional complaints managers (DCMs), complaints facilitators and PALS. We also looked at a few complaints on the two main sites, however, a comprehensive file review was not part of the final agreed brief. Barnet and Chase Farm Complaints & PALS Policy 7.22 The policy is very comprehensive with a clear policy statement referencing the Regulations, the NHS constitution, the CQC and the Health Service Ombudsman. Responsibilities and roles are also clearly defined and there is a helpful section on risk assessment. It is also written in an accessible way in plain English Our main concern with the policy was the overlap between PALS and complaints such that Barnet and Chase Farm have a PALS complaints category which is neither a PALS concern nor a complaint. Ideally PALS and complaints should work closely together but have separate and clear functions: the former being to resolve straightforward concerns. (These do not have to be resolved in 2 days, contrary to the policy s assertion- the '2 days' relates to complaints which do not then have to be dealt with under the Regulations). The review of the NHS Hospitals Complaints System 7 made a clear recommendation that Patient services and patient complaints support should remain separate so patients do not feel they have to go through PALS first before they make a complaint. Barnet and Chase Farm: managing complaints in practice 7.24 The following points were noted primarily through discussions with staff: Emphasis on initial contact with the complainant and local resolution meetings, which are recorded and then sent to the complainant; Investigation is often done by complaints facilitators (contrary to the page 7 of the complaints policy) but there is no clear system and it varies between divisions; No formal analysis or chronologies No system for recording evidence of actions 14

15 Royal Free Complaints Policy and Procedure 7.25 The Royal Free policy gives a clear step-by step guide to handling complaints in the Trust, referencing the Regulations, the Ombudsman s Principles and roles/responsibilities etc. It offers much less clarity on Action Plans and learning. Overall the policy has quite a technical feel and is not as readable or accessible as the Barnet Chase policy. Excellent guidance in the Appendices includes extracts from the Department of Health s Listening, Responding, Improving' 9 and guidance on financial redress. We heard that divisional complaints managers (DCMs) had not been consulted when the complaints policy was reviewed and it was clear that they were not all familiar with the detailed content of the policy, in particular the useful guidance. They may well have spotted the out of date reference to ICAS (page 21) which was replaced by individual NHS Complaints Advocacy organisations in April This will of course need to be changed in the new policy. Royal Free: managing complaints in practice 7.26 The following points were noted from interviews with staff: The discontinuation of paper files for complaints in 2012 appears to have led to more rigorous Datix recording, hence more accurate reporting; All draft complaint responses are checked with contributors, then the divisional director of nursing, then the head of complaints and finally the director of nursing. Whilst this checking process is commendable, it takes time and we learned that it had already slowed the response time down notably since the acquisition. It is recommended that the signing off process be reviewed to involve fewer people, and ensure rigour with quality checks undertaken by peer review. Complaint Response Deadlines 7.27 Both trusts have a set a 25 day deadline for response which is not mandated by the Regulations. This has placed a pressure on compliance and there were differing views on how this should be handled from the DCMs and facilitators in the two trusts Barnet and Chase Farm s policy references the Department of Health s complaint reforms (page 5) as enabling a more flexible, patient-focussed approach, but this is not reflected in the trust target response time of 25 working days. However, the Your Experience Matters leaflet for Barnet and Chase Farm (this is headed up as the Royal Free, so we assume it was recently reviewed), states: Complaints investigated with the help of a Complaint Facilitator should be fully resolved within 25 working days. However, on more complex issues this could be extended to 45 working days and up to 60 working days if other agencies are involved and it is particularly complex. 15

16 7.29 This suggests that on the ground a more flexible, pragmatic approach has been taken at Barnet and Chase Farm and we would support this approach However, it is important that patient information and operational policies are in alignment The Royal Free policy states that the trust s default position is to respond to complaints in writing within 25 working days, but the timescale can be negotiated with the complainant. It is commendable that the Royal Free policy acknowledges the importance of working with the complainant (page 10), but our impression was that in reality the 25 working day timescale is viewed fairly rigidly by the trust Our view is that the 25 day deadline should be reviewed particularly for the management of more complex complaints. This would better reflect the tailored, flexible, patient-focussed approach which was integral to the revised 2009 Regulations. Working closely with the complainant on timescale and managing complainant s expectations remains key to how this is taken forward. Although 25 working days is a common complaint response target in NHS trusts, it is not universal and some trusts use 35 days, others 40. Risk Assessment The Royal Free does not undertake formal risk assessments on receipt of complaints, despite risk assessment being recommended by the Department of Health in their guidance 9. Our experience is that risk assessment is commonly used in complaints handling at both trust and ombudsman level, to flag any patient safety issues, and to assist in planning a proportionate investigation. We note that risk assessment is mentioned in the Royal Free complaints policy (page 9) under the role of the patient affairs team, although no further information is given. Whilst some Royal Free staff consider that risk assessment is inherent in their work, this leaves room for vastly different interpretations and there was no evidence on the Datix files we viewed of even an informal risk assessment In contrast, the Barnet and Chase Farm policy includes risk assessment and a risk rating matrix (page 19) to produce a numerical complaint risk scoring with a range for each (low, medium & high) risk rating. The numerical figure (but not the rating) is then included in a Complaint Summary and Risk Assessment form. However, we found inaccuracies and inconsistencies in how the rating was being applied such that the reporting of risk in complaints at Barnet and Chase Farm over the past few years cannot be relied on. Barnet and Chase Farm have now been asked to no longer review risk, although that did not seem to be fully translated into practice. Furthermore not all complaints facilitators were familiar with how to apply the trust s risk rating system We recommend that the trust introduces a process for risk rating, following clear guidance and training. 16

17 Complaints to the Health Service Ombudsman It was difficult to draw any conclusions from the data relating to Ombudsman cases. The Royal Free provided a very comprehensive complaints report to their Board, showing a decline in the number of cases formally investigated by PHSO. However, those are shown by complaints received in a particular reporting year and subsequently escalated to the Ombudsman. Many cases will be received by the Trust in one reporting year, and go to the Ombudsman in the subsequent reporting year. For example the Royal Free report shows that 13 complaints received in 2012 (we assume ) went to the Ombudsman with 3 upheld. The current case list provided by the Royal Free shows 15 complaint reference numbers during that period, with 2 upheld. The Ombudsman s published figures 10 state that 84 complaints were received about the Royal Free in of which only 1 was accepted for investigation. It states the trust's number of published NHS complaints that year as 711 (i.e. 12% went on to the Ombudsman). However, it is likely that the Ombudsman s figures also include telephone contact about complaints about the Royal Free, hence the significant discrepancy. The Ombudsman figures are expected to be published in September or October The Barnet and Chase Farm complaints & PALS annual report contained no data about Ombudsman cases, although we were provided with a list of open Ombudsman cases showing 4 complaints. The Ombudsman s published figures state that they received 76 complaints from Barnet and Chase Farm in , of 293 written NHS complaints (i.e. 26% went on to the Ombudsman), with 3 accepted for investigation. The much higher proportion of complaints that went to the Ombudsman from Barnet and Chase Farm in is on the surface a cause for concern and is worth exploring further. Complaints' Responses Five complaints files were accessed on Datix at random at the Royal Free site, including one complex case. The key findings were as follows: Responses were generally well written and in the main addressed all the issues raised with suitable apologies; The standard acknowledgement letter does not have a contact name, just the Central Team, although the director of nursing is mentioned as overseeing the process. When a complainant was unhappy with the first response (to a very distressed complainant), the trust had gone to considerable lengths to address the outstanding concerns, and the final response was notably more empathetic than the original. Datix did not contain all the information used to respond to the complaint, for example a few cases contained no clinical advice, though advice had clearly been sought and used in the response. 17

18 Two cases acknowledged and apologised for errors made by clinicians but neither response said that the trust would feedback to the individual (though they did say that they would share learning more widely). There was no evidence on Datix that responses were checked by a divisional director as described by the DCMs and one response contained no record that the initial draft had been approved by anyone (though it was signed off by the director of nursing). None of the final responses included information about the Ombudsman as required under the Regulations, nor did they refer to any enclosed leaflet which is apparently sent out and includes (incorrect) information about the Ombudsman. Best practice would be to include this as a paragraph in final response letters Complaints files at Barnet and Chase Farm were difficult to access because until the acquisition, complaints facilitators had used a shared (S) drive to store information, as well as occasionally storing documents on their own personal drives. We therefore saw only a few final, post-acquisition responses, and were unable to conduct a full audit trail from the documents provided. Due to the difficulty of viewing documents on cases electronically, our observations were limited to the following: No clear audit trail with very few documents on Datix. Although Barnet and Chase Farm have now moved to adding all files to Datix, this is a significant change and regular audit will be needed to ensure that it happens in practice. Final responses [small sample only] covered the main issues but tended towards being factual rather than empathetic. No reference to the Ombudsman in final responses as required by the Regulations. Complainants invited to contact the complaints co-ordinator [facilitator] to discuss the options available under the NHS complaints procedure. One file had no clinical evidence on Datix or the S drive. Several files had nothing on Datix or the S drive to indicate who the clinical investigator was. Although we saw statements from staff relating to an investigation on the S drive, they did not contain the staff member s job title. 18

19 7.219 MANAGING COMPLAINTS: Summary Managing Complaints: Areas of Good Practice Royal Free Good practice guidance in complaints policy appendices Clear drive to improve complaints handling recording on Datix Comprehensive and effective reporting and analysis of data. Clear role of DCMs and good relationships between DCMs and divisional staff Clear delineation between PALS & complaints Good PALS accommodation Barnet and Chase Farm Easy to read complaints policy Clear policy statements. Good use of local resolution meetings. Managing Complaints: Areas for Improvement Royal Free More patient focus in complaints policy Risk assessment Opportunity to more clearly define difference between concerns (PALS) & complaints (and move away from using the terms formal and informal ) Barnet and Chase Farm Difference between policy and practice e.g. use of formal and informal complaints in reporting Lack of clear boundaries between PALS and complaints. Lack of clear boundaries between the investigating officer and complaints facilitator roles Risk assessment- some errors and inconsistency. Lack of audit trail in complaints management (use of S and personal drives to store documents) Lack of rigor in Datix recording Both Trusts 25 day deadline impeding complex complaints Final response letter and Ombudsman information 19

20 7.3 MANAGING & ENGAGING WITH COMPLAINANTS Complaints & PALS publicity 7.31 We found that written information on the complaints process was not readily available on any of the three sites. There was a noticeable lack of publicity material (posters or leaflets around the hospital) encouraging feedback via complaints and PALS. This was reflected in our conversations with patients and carers, few of whom were aware how to make a complaint. Several patients said they would 'look it up' or 'go to the top'; others mentioned their MP. Few also had heard of PALS or knew how to access the service. We did find an old Your Views Count poster in Outpatients at Barnet Chase but this referred to an electronic feedback machine which was no longer in use Of the staff we spoke to, none were able to easily locate any complaints guidance for patients, but most were clear on how to advise a complainant and all were aware of PALS. One staff nurse pointed out the complaints information on the ward TV screens, but we did not find a patient who recalled seeing this and we observed that a number of patients had moved the TVs to one side. Although a Senior Matron at the Royal Free told us that the TVs could be used for quick surveys, there was no information around the ward about this. Complaints Leaflets 7.33 Royal Free staff gave us two leaflets: Compliments, concerns and complaints and Did we measure up? The former is colourful, straightforward and easy read, although it needs updating to reflect the new NHS Complaints Advocacy Service rather than ICAS (which has not existed since April 2013) The Did we measure up? leaflet is a more comprehensive version of the first leaflet but needs designing to be less text-dense and more eye catching. It also contains some errors, referring to NHS Direct (dissolved in March 2014) and stating that complainants have 12 months from the end of local resolution to request a review by the Ombudsman (requests should be made as soon as possible after the end of local resolution). We have now informed both PALS (who copy this leaflet for distribution around wards at the Royal Free) and DCMs that this needs updating as soon as possible. We did not see copies of either of these leaflets around the Royal Free site Barnet and Chase Farm gave us a third leaflet: Your experience matters which had been updated with a Royal Free header. Again, this contained information about ICAS. The section entitled What we will do for you reflects the lack of clarity between the PALS and complaints roles at Barnet and Chase Farm We realise that the project visits took place very soon after trust acquisition and that there will be a need to revise a range of patient information across the sites. 20

21 Patient Advice & Liaison Service (PALS) 7.37 Whilst it was beyond our remit to look in any detail at the PALS service, it is clearly integral to patient feedback and resolution of issues raised by patients and is seen by many as a gateway for complaints The PALS drop-in service located at the Royal Free Hospital is clearly very accessible and well used and nursing staff on-site told us they were encouraged to go to the PALS office to resolve issues as they arose, where possible. Whilst the line between complaints and concerns is relatively well drawn at the Royal Free, PALS across the newly integrated trust would still benefit from a clear definition of what constitutes a concern as opposed to a complaint. Furthermore, the terms informal and formal complaints appear to be in common use across both sites, despite the Barnet and Chase Farm complaints policy having a specific reference to those terms no longer being in use Whilst PALS data at the Royal Free is regularly reported to the user experience committee, the most recent data we found on the website was from 2007/08. External reporting of PALS concerns and resolutions is essential to ensure that the patience voice is heard We noted that the PALS service at Barnet and Chase Farm is based and accessible on the Barnet site, and commend the recent increase in hours given to this service. We were told that the on-site service at Chase Farm has been discontinued and whilst staff and patients we spoke to had not found this a problem, we would urge a review of access to PALS at Chase Farm. Indeed the trust may wish to consider a range of PALS outreach arrangements for the smaller sites It was clear from the Barnet and Chase Farm complaints and PALS policy and from talking to staff that there has been some overlap between the PALS & complaints services and although it was indicated that this was being tackled, we did not see evidence that this had been resolved. We also noted that some staff at Barnet referred to PALS when we asked what they would do if a complaint was raised, which indicates that the service may have been used as a gateway for complaints. We can only reiterate the importance of having clearly understood definitions of 'concerns' to be dealt with by PALS and 'complaints' which need to be dealt with by the complaints function. One staff member gave a useful definition of a concern as an issue which is current and containable. 21

22 The current Royal Free website It is encouraging to see a Patients and Visitors tab on the front page of the website, with an Advice and Support section first on the website (access to PALS and complaints information is then another click away). We looked at the trust website which gave standard advice on how to make a complaint and we recommend that this could be expanded to include an 'easy read' version available to a wider audience We were told about various ways that patient feedback was encouraged, for example, use of the PET tracker at Barnet, use of comments books on the wards at Royal Free and the focus on learning from the friends and family test 8. We commend the work being undertaken in both trusts to listen to patients, for example the Focus Groups at Royal Free, the Patient and Relative Advisory Group at Barnet and Chase Farm,. This work could be advertised even more widely. Keeping Complainants Informed At both trusts we heard about the process for early telephone contact with the complainant to discuss the complaint. This appeared to be a more rigorous process at Barnet and Chase Farm. We commend the focus on early personal contact with the complainant to establish the desired outcomes, particularly where complex or distressing issues have been raised. Complainant Satisfaction with the Complaints Process The scope of the review did not include specific feedback from complainants, however we are able to comment on the information available to us We spoke to 3 patients who had previously made a complaint. In one case the daughter of an elderly lady at Royal Free described a quite serious complaint and the process that she felt had been investigated and acted on appropriately. In another at Chase Farm, the son of a patient felt a complaint he had made had also been handled properly. Two patients regularly attending outpatients at Royal Free had reported being unhappy about the attitude of staff members; one felt this had been dealt with well in the department, the second had been directed to PALS but remained unclear of the outcome and very anxious. We advised her to contact PALS again We commend the recent use of complainant feedback questionnaires at the Royal Free. We looked at the responses for June (which had not at that time been analysed) and noted both excellent and very poor feedback. One respondent said that the trust had looked at the wrong admission and another said that the trust hadn t really understood the complaint. Clearly this learning from complaints is work in progress and the introduction of the questionnaire to Barnet and Chase Farm will be of benefit. We would recommend that the complainants could also be invited to contribute to future learning events. 22

23 7.318 We heard about the use of face to face resolution meetings at Barnet and Chase Farm, and whilst we were not able to speak to a complainant, we heard from a number of staff about the real benefits of this way of resolution which was recorded and shared on disc. This was described as of particular benefit in distressing situations allowing time for difficult issues to be explored MANAGING & ENGAGING WITH COMPLAINANTS: Summary Managing and Engaging with Complainants: Areas of Good Practice Both Trusts Patients generally find staff friendly and approachable. Early telephone contact with complainant Royal Free Open and accessible PALS service Complainant feedback questionnaires Barnet and Chase Farm Face to face resolution meetings Meetings recorded on disc with a copy sent to the complainant Managing and Engaging with Complainants: Areas for Improvement Both Trusts Most patients do not know how to complain & many had not heard of PALS. No recent information seen as posters and leaflets on any site. Website has no 'easy read' complaints information. Using complainant feedback questionnaires across the Trust Lack of PALS access on Chase Farm site 23

24 7.4 INVOLVING STAFF 7.41 The matrons and ward sisters we spoke to at each of the three sites all talked about their strong focus on early intervention, and resolution, talking to the patient and family when concerns and complaints are raised. Overall they indicated a clear understanding of the complaints process and were used to supporting their staff and others in the team when appropriate e.g. junior doctors. The role of the matron in coordinating complaints handling appears well established in both trusts, including working with the complaints manager/facilitator Other staff members we spoke to appeared to have adequate knowledge about how to direct a complainant - this included a receptionist who received good support from her manager (Royal Free) and a physiotherapist who had experience working on complaints within her team (Chase Farm) We heard from the complaints managers and facilitators about improvements in clinicians engaging in the complaints process and a growing sense of openness in responding to complaints. Opportunities for sharing these improvements across site were also highlighted With regard to training, the majority of staff we spoke to did not recall having had recent training in complaints. This included some of the complaints managers and facilitators who felt strongly that further training was needed to carry out their roles effectively. Two staff members at Barnet who had received training in investigation from a complaints facilitator felt this had improved their investigatory skills and report writing We saw excellent complaints training materials used at Barnet and Chase Farm for induction, and for a range of in-house staff training emphasising communication, attitude and improving patient experience. There is currently no complaints element in induction training at the Royal Free. Development of the Barnet and Chase Farm training would be of benefit across the new trust. 24

25 7.46 INVOLVING STAFF: Summary Involving Staff: Areas of Good Practice Both Trusts Senior staff interviewed had clear focus on managing and resolving complaints. Good support for junior staff. Examples of learning shared at ward/dept level Barnet and Chase Farm Range of complaints training at induction and to different staff groups. e.g. Investigation training to support senior clinical staff. Involving Staff: Areas for Improvement Royal Free Complaints training at all levels 25

26 7.5 GOVERNANCE SYSTEMS & REPORTING 7.51 We looked at the complaints reporting arrangements for the Royal Free and Barnet and Chase Farm which overall appeared satisfactory with clear accountabilities. At both trusts, complaints reporting arrangements were to the director of nursing under the trusts' governance structures. The Barnet and Chase Farm model had greater integration between complaints and patient experience and we would recommend that there are benefits in bringing these two areas closer together. The delineation between PALS and complaints however appears to be more effectively operating in the Royal Free model and the maintenance of objectivity and clear operational separation is advised, as recommended in the Clwyd and Hart review At both trusts there are central complaints or patient affairs teams, with complaints managers or facilitators in the four divisions. We identified some clear reporting arrangements between the teams, collation of data centrally and weekly monitoring of performance to address open complaints and timescales. Both trusts reported on complaints through a Quality Board. We noted also the current patient and staff experience committee has a role in monitoring complaints in the trust There appear to be some good arrangements to manage complaints in the divisions, but a lack of overview centrally of some actions and learning. We learnt about some excellent examples of complaints service improvements and learning from the clinicians that did not appear to be held centrally. For example following a complaint on a ward at the Royal Free, the Senior Matron had set up a welcome board with their contact details and the name of the nurse in charge that day. The same ward had a comments book which was read and responded to daily. The post natal ward at Barnet also demonstrated some service improvements in communication with parents and a subsequent reduction in complaints. The reporting of actions and outcomes through the divisional governance to the Board may need to be strengthened The divisional complaints manager and facilitator is clearly a key role that requires adequate resourcing to be effective. Training for this role is important and there may be a need to balance the good relationships built with clinical colleagues and the ability to challenge and maintain independence. Complaints managers are also well placed to be more involved in review of policy and practice Both trusts reported annually to the Board on complaints, as required in the regulations. The Royal Free annual report for 2013/14 gave significant detail and analysis of complaints, including vulnerability and equality issues. The Barnet and Chase Farm report was less clear in terms of data and included PALS with an additional complaints heading. We agree that the trust should proceed urgently with standardisation of categories and terminology to ensure consistent analysis and monitoring of trends. 26

27 7.56 We noted a Royal Free report on complaints to the Health Scrutiny Committee which clearly addressed some of the wider community issues and could be an effective way of reaching out to the wider public We noted the Barnet and Chase Farm Quality Accounts 2013/14 included complaints reporting to the Board as a trust priority. We commend the focus placed on the interface with patient safety and quality Coordination of complaints across the larger trust will require some clear parameters. We recognise that managing timescales has been a priority for both trusts; however, we heard some concerns about current delays in the completion of investigation and sign off of the response letter(see also 7.26). The review of timescales, reporting processes and a focus on training for senior staff may help to strengthen the process. A review of complaints resources across the trust may also be of benefit GOVERNANCE SYSTEMS & REPORTING: Summary Governance Systems & Reporting: Areas of Good Practice Both Trusts Complaints monitoring and reporting arrangements to the Trust Board. Complaints managed within divisional / directorate governance structures Royal Free Clear and robust complaints reporting and analysis Barnet and Chase Farm Greater integration of complaints with patient experience Governance Systems & Reporting: Areas for Improvement Both Trusts Lack of central complaints overview on action plans and wider learning. Complaints managers / facilitators not involved in policy revision. Complaints managers / facilitators training 27

28 7.6 SHARING THE LEARNING: Patient and Staff Engagement 7.61 Evidence of outcomes and wider learning from complaints initially appeared limited from both trusts. Neither trust website appeared to give any examples of service improvement, learning from complaints or patient stories. The Annual Reports gave individual complaints outcome examples and only the Barnet and Chase Farm Quality Accounts identified complaints as a priority Further information came to light from interviews with clinical staff and we were made aware of some key pieces of work such as the Task and Finish group improvements in maternity at Barnet, also the standardisation of information updates in outpatients at Barnet and Chase Farm. We also saw some impressive outcomes from the 'In Your Shoes Events' at both trusts which involved patients and complainants in shaping learning The 'Patients Voices' at the Trust Board to share complainants' stories is to be commended and could be developed further to involve actual patients. The Barnet and Chase Farm 'Patient and Relatives Advisory Group' gives a good opportunity for wider involvement, but this group would need to be re-launched with perhaps a stronger patient voice. The Royal Free Focus Groups involving different patients also provide a good forum for input and we would support their continuation We support the trust proposals for bringing complaints under the umbrella of patient experience and would urge greater direct engagement of patients and those who have complained to share their experiences and support training and service improvement. This could be achieved through a wider use of volunteers as critical friends. Opportunities for further engagement with community groups and Healthwatch could also be explored. 28