Complaints - Integrated Policy and Procedures for Health & Adult Social Care. Making Experiences Count

Transcription

1 Complaints - Integrated Policy and Procedures for Health & Adult Social Care Making Experiences Count NHS Swindon is the brand name for the organisation legally known as Swindon Primary Care Trust Note: Note: This This document is is electronically controlled. The The master master copy copy is is maintained by by the Clinical the Governance Clinical Governance Department. Department. If this document If this document is printed is it printed becomes it becomes uncontrolled. 1

2 Document Control Purpose This Policy brings together a new single complaints policy for health and social care. The policy commits the organisations to providing a consistent, unambiguous approach to the handling of complaints that is fair and encourages communication between all parties Author Judith Blackstock, Assistant Director, Quality &Clinical Governance Annie Naji, Head of PALS, Complaints and PPI Linda Baxter Interim Complaints Manager Application Swindon Primary Care Trust, Swindon Borough Council Adult Social Care & Children and Family Services Implementation November 2009 date Date of review November 2010 Expiry date November 2012 Link to Care Quality Outcome 17 Complaints Commission Essential Also outcomes 1, 2, 4, 6, 7 and 16 Standards of Quality & Safety Link to NHSLA Risk Standards 1 & 5 Standard(s) Responsibility for All Directors, Managers and staff within the organisations implementation Document Reference No: (allocate from Policy Register) Equality and Diversity Date of Equality Impact Assessment This policy has been assessed against the Equality Impact Assessment Tool as required by the Race Relations (Amendment) Act October

3 Links with other documents Policy Statement PCT - Being open policy PCT - Guidelines on conducting investigations SBC Complaints Policy It is the responsibility of staff at all levels to ensure that they are working to the most up to date and relevant policies and procedures. By so doing, the quality of services offered will be maintained and the chances of staff making erroneous decisions, which may affect patient, staff or visitor safety, will be reduced. Review and Approval History Version Reviewer/Approver R/A Outcomes Date Directors, managers from health, children & family, adults social care and commissioning Audit & Assurance Committee R R Comments received and incorporated Ratified for publication August- October 2009 November 2009 Consultation and Revision History Version Status Outcome Date Name and Title 3

4 Part 1 Complaint Policy Contents 1. Purpose 5 2. Background 6 3. What is a complaint? 7 4. What can be complained about? 7 5. Exclusions Who can complain? Letters from MPs Duties of the organisations The organisations responsibilities Director s responsibilities Service manager s responsibilities Staff s responsibilities Reporting on Complaints Quality Monitoring 13 Page 4

5 1. Purpose 1.1 This document brings together and new single complaints policy for health and social care. The policy commits the organisations to providing a consistent, unambiguous approach to the handling of complaints that is fair and encourages communication between all parties. 1.2 Swindon Primary Care Trust (PCT) and Swindon Borough Council (SBC) recognise that suggestions, constructive comments and complaints can be valuable aids to improving services. Both organisations welcome feedback from service users and place a high priority on the resolution of complaints. 1.3 The PCT and Swindon Borough Council are committed to managing the new complaints system across health, which includes children s health and adult social care and will focus on local resolution by working with the complainant. Throughout the course of the investigation of the complaint it is the intention to fully address the concerns raised in a manner that is fair to all parties involved in the complaint. The PCT and Swindon Borough Council are committed to ensuring that service users are not adversely affected in the provision of their service as a result of making a complaint. The complaint will be treated as confidential and information only disclosed to those involved in the complaints procedure. 1.4 The primary objective of the health & adult social care complaints policy and procedure is to provide a timely, open process for investigation and resolution of complaints, to the satisfaction of the service user wherever possible. The learning from complaints will be linked with risk management and clinical governance processes to disseminate lessons learned, influence service redesign and improve services. 2. Background 2.1 The 2009 NHS Constitution explains that complainants have the right to: Have a complaint dealt with efficiently and have it properly investigated Know the outcome of any investigation into a complaint Take the complaint to the Parliamentary and Health Service Ombudsman if they are not satisfied with the way the complaint was dealt with at local resolution level. 5

6 2.2 The Local Authority Social Services and National Health Service Complaints (England) Regulations 2009 provides a framework to which NHS organisations must comply. These regulations came into force on the 1st April NHS organisations and Local Authorities are required to have a well defined procedure which provides clarity to recording, investigating and resolving complaints. 2.4 NHS complaints regulations were amended following the White paper, Our Health, Our Care, Our Say which gave commitment to developing a single, comprehensive complaints procedure across health and social care. This document has been produced in line with the new Complaints Regulations: The Local Authority Social Services and National Health Service Complaints (England) Regulations 2009 and specifically relates to Swindon PCT, Adult Social Care and health services provided to Children and Young People. 2.5 Note: Any person who wishes to express dissatisfaction with any of the Council s other services can complain through Swindon Borough Council s complaint procedure. 2.6 This complaints policy is concerned only with the management of complaints and not disciplinary matters. 2.7 For reference, the full version of the legislation can be found at: Statutory Instruments 2009 No. 309 National Health Service, England Social Care, England 3. What is a complaint? 3.1 A complaint is an expression of dissatisfaction about a service that is being delivered or the failure to deliver a service by Health Services or Social Care. In addition a representation, concern or comment that requires action and a response will also be dealt with according to this document (the term complaint/complainant is used for ease throughout this document but should be taken to apply to these other representations). 6

7 3.2 Often patients/service users do not wish to make a formal complaint but do have things to say about our services. Patients/service users and their representatives do not have to make a complaint to have these issues addressed and in these circumstances should be encouraged to use Patient Advice Liaison Service (PALS). Staff handling complaints will work closely with the Patient Advice & Liaison Service (PALS), which provides wherever possible on the spot resolution of queries and concerns raised by services users and the general public. PALS offers a less formal way of resolving concerns and will be offered as a choice when issues are raised. 3.3 A complaint/representation can be made in person, in writing, by telephone or . Every effort should be made to assist people in raising their concerns and any member of staff can take a complaint, if that is what the complainant wishes. A verbal complaint should be summarised in writing and the content agreed with the complainant before proceeding with the investigation. 4. What can be complained about? 4.1 A person is eligible to make a complaint about health and/or adult social care where the local authority has a power or a duty to provide, or to secure the provision of, a service for them or the person they care for. This includes a service commissioned by the National Health Service or the Local Authority. In relation to Independent Contractors (e.g. GP practices, dental practices) or organisations awarded a contract to provide services under the banner of the NHS, complaints can be made either directly to the service provider or to the PCT for investigation. Complaints made directly to an Independent Contractor providing NHS services are reported quarterly to the PCT. Serious incidents should be reported immediately to the PCT 4.2 Complaints may relate to the following: an unwelcome or disputed decision concern about the quality or appropriateness of a service, whether provided by local authority, health services or on our behalf by an independent provider or agency delay in decision making or provision of services delivery or non-delivery of services including complaints procedures quantity, frequency change or cost of a service attitude or behaviour of staff 7

8 application of eligibility and assessment criteria the impact on an individual of the application of a local authority or health policy assessment, care management and review 5. Exclusions 5.1 Complaints do not apply when: the person wishing to complain does not meet the requirements of who may complain, and is not acting on behalf of such an individual the complaint is not in regard to the actions or decisions of the local authority complained to or of any body acting on its behalf the same complaint has already been dealt with the same complaint has already been investigated by a local commissioner the complaint relates to a cross-boundary issue, but has been fully investigated and concluded, through the full complaints procedure of a partner agency the complaint is frivolous or the complainant is unreasonably persistent (as defined in Complaint Procedure ) The complaint is about a person that the service user employs to provide care, using direct payments Patients opt to receive private health care matters should be dealt with under other proceedings such as: disciplinary proceedings grievance procedure complaints from staff about personnel issues complaints should be considered under the local authority s corporate complaints procedure, the children s and young people s complaints procedure applies an alternative statutory appeals process already exists criminal investigation has been undertaken and Court action is pending 5.2 When a complaint is received that relates to issues already under investigation through other procedures, the Complaints Manager has the discretion to decide whether to accept this complaint, or to consider that to do so may prejudice the outcome of such investigations e.g.: 8

9 Court proceedings Tribunals Disciplinary proceedings Criminal proceedings 5.3 Complaints from Self-funded users of Independent Services cannot be considered under the local authority complaints procedures. The Care Standards Act, 2000 requires service providers to have their own complaints procedure in place, and these service users can access that procedure. 5.4 Anonymous Complaints fall outside of the scope of the statutory procedure and it is the responsibility of the Complaints Manager to decide what action if any should be taken. This could include passing the information to the relevant manager for further consideration within the service area concerned. 5.5 Mental Health Act 1983 A decision made by an Approved Mental Health Professional regarding the making of an application under the Mental Health Act, 1983, is an action taken independently of the local authority and therefore falls outside of the complaints procedure. However, complaints made about the process of the assessment and the Approved Mental Health Professionals actions during the process are covered by this guidance 6. Who can complain? A patient or service user A patient or service user s representative. Where a complaint is received from a representative acting on behalf of a patient / service user, (e.g. their advocate) they must have the consent of the patient / service user. A recognised representative acting in the best interest of the patient / service user who does not have capacity. The complaint manager, best interest assessor and / or independent mental capacity advocate (IMCA) can be used to establish this. Anyone who is affected by a decision made by the service provider Where the service user lacks capacity to give consent then an Independent Mental Capacity Advocate or a Court appointed Welfare Deputy can act as a representative in the individuals best interests. 9

10 7. Letters from MPs 7.1 Letters from MPs should be passed to the Complaints Department immediately on receipt and will be dealt with through either the Complaints Procedure or through PALS depending on the issues raised. 8. Duties of the organisations 8.1 The organisations should: Provide timely and accessible publicity and information on the complaints process Provide translation of publicity / information on request Provide information on organisations that could provide appropriate support to the person raising concerns e.g. Independent Complaints Advocacy Service (ICAS). Advise complainants of their right to access an advocate. If an advocate is requested at any point in the complaints procedure then the complainant must be referred to an appropriate advocacy provider Accept each organisation has a duty to cooperate with all other agencies involved in a complaint, in order to best resolve the issues raised (see Procedures Appendix 4) Ensure Data Protection and Freedom of Information guidance requirements are followed Enable complainants to make their complaint in the most appropriate format for them which may be verbally, electronically or in writing Provide access to interpreting and translation services if required Ensure learning from complaints is built into future service developments and risk management systems Accept employer duty of care towards staff by ensuring appropriate support is provided to individuals and teams. 8.2 Directors of services remain responsible for ensuring that: The investigation of the complaint is allocated to the most appropriate manager and that a thorough investigation is carried out Any re-negotiation of agreed timeframes is completed as soon as a potential delay is identified by contacting the complaint manager who will facilitate agreement with the complainant 10

11 Should the need for a meeting be identified relevant staff are available to attend The response letter is written in an appropriate manner, answering all points raised and ready for sign-off by the Chief Executive/Group Director Data Protection and Freedom of Information guidance and requirements are followed Actions required as a result of the complaint are appropriately prioritised, followed through and monitored to completion In consultation with the complaints manager they assess the potential need for undertaking a Serious Investigation procedure or disciplinary action which may arise out of the investigation Outcomes are reported to the Complaints Department for inclusion on the database and subsequent reporting Learning from the complaint is shared within the Directorate and across other service areas of the PCT and SBC Adult Social Care if appropriate 8.3 Service Managers are responsible for: Thoroughly investigating the complaint or responding to a PALS enquiry in a timely manner and within the timeframes agreed with the Complaints Manager Ensuring that all aspects of the complaint as identified on the front sheet are investigated Providing a full record of the investigation, including notes, s, conversations and statements from interviews with staff Identifying the learning from the complaint and including this in the response Developing an action plan with projected completion dates to rectify system errors and include this in the response Ensuring that the relevant Director has a copy of the response, details of the investigation and the front sheet signed off and dated Appropriately disseminating the learning from the complaint within the team and other service areas if relevant 8.4 Staff are responsible for: Informing patients/service users that their comments, compliments and complaints are welcomed 11

12 Being open to receiving complaints and enabling patients/service users to make their complaint (if necessary) by noting their concerns and passing them on to their line manager Informing patients/service users about how to make a comment or complaint Co-operating fully with a complaint investigation or PALS enquiry Undertaking relevant training on Complaints Policy and Procedures Taking on the learning from comments and complaints to improve their practice where relevant 8.5 Independent Contractors are responsible for: Providing an effective in-house complaints system Producing an annual report for the PCT / SBC on complaints received and the learning outcomes However should a complainant choose to ask the Commissioning Organisation to investigate their complaint about a commissioned service this complaints policy and procedure will apply. In addition the Independent Contractor will: Undertake an initial investigation into the complaint Comply with requests from the Complaints Manager for further information or further investigation Provide a draft written response to the complaint, subject to Chief Executive approval and sign off 9. Reporting on Complaints 9.1 Reporting on complaints will be completed on a quarterly basis for the PCT Board, Swindon Borough Council Lead member, Director and management teams. 9.2 A quarterly report will be presented to the Clinical Governance Forums with any exceptions reported at the following month s meeting. 12

13 9.3 Reports on complaints will be prepared on a quarterly basis for individual service providers and commissioners. The reports will use anonymised data to preserve the confidentiality of complainants. The reports will include: number of complaints received nature (category) of complaint compliance with agreed timescales for responding learning outcomes actions taken / action plans confirm when action plan completed identification of emerging trends success of local resolution / or referral to Parliamentary and Health Service Ombudsman 10. Training PALS and Complaints session is included in the PCT Induction programme for all new staff. The PALS and Complaints service deliver an ongoing programme of training about the complaints policy and procedures across Health and Adult Social Care services. 11. Quality Monitoring 11.1 Evaluation of the complaints process itself will be achieved by sending an evaluation form to each complainant after the final response has been sent out. Adverse comments about the complaint process will be reviewed and acted upon as appropriate An annual audit of a sample of completed complaints will be undertaken for quality assurance purposes. Performance indicators will include: Complaint processed within agreed timescales Action plan monitoring Outcome and service improvements achieved Improvements to the complaint process based on returned evaluation forms 13

14 Complaints Policy Audit Tool YES NO N/A Was the complaint acknowledged within 3 working days of receipt by complaints service? Was the appropriate consent requested within 3 working days of receipt by complaints service? Was a complaint plan agreed with the complainant? Was the investigation timetable agreed with the complainant? Was the investigation completed within the timescale agreed? Was a time extension required? Did local resolution require a meeting to take place? Was a further investigation required? Does the response to the complaint cover all the issues raised? Does the response set out what will be done by way of remedy and the timescales for these actions? Was the response clearly written, free of jargon and with full explanations? Was the complainant satisfied with the outcome? Was the complaint referred to the Ombudsman? Did the Ombudsman uphold the whole complaint? Did the Ombudsman uphold part of the complaint? Did the Ombudsman send the complaint back for further local resolution? Was an action plan received from the service provider? Was the action plan monitored by the complaints service within the agreed timescale? Were all of the service improvements achieved? Were some of the service improvements achieved? Were any of the service improvements achieved? 14

15 Part 2 Complaints Procedure Contents 1.0 Introduction Complaints process Local resolution Flow chart Response letters Learning from complaints Dealing with difficult situations Indentify persistent complainants Dealing with persistent complainants Cross boundary complaints Investigation process Complaint plan Complaints resolution Links 25 Page Appendices Appendix 1 Complaints Process Form 26 Appendix 2 Provider Services Flowchart 27 Appendix 3 Commissioning Flowchart 28 Appendix 4 Factors to Determine Lead Organisation 29 Appendix 5 Consent form 31 Appendix 6 Eight Data Protection Principles 32 15

16 1.0 Introduction Swindon Primary Care Trust (PCT) and Swindon Borough Council (SBC) Adult Social Care Services recognise the importance of listening to our service users experiences and views about our services particularly if they are unhappy and we want to make it as easy as possible for them to let us know their views. The new complaints system aims to be flexible and to respond in a way that is the most appropriate to the individual complainant taking account of their circumstances. Key aspects include local resolutions, personalised actions plans and remedial outcomes and service improvements. The underlying principles of this complaints system are: To get it right To be customer focussed To be open and accountable To act fairly and proportionately To apologise and put things right To make service changes based on the learning from complaints To seek continuous improvement Under normal circumstances the concerns must be raised within a year of the incident. Under exceptional circumstances complaints outside this limit will be investigated at the discretion of the Complaints Manager in conjunction with the relevant Director. 2.0 The Complaints process The complaints process has 2 stages: Local resolution Ombudsman Parliamentary & Health Service Ombudsman Emphasis is placed on achieving local resolution. Should a complaint be taken to the second stage the Ombudsman will consider whether significant effort has been made to resolve the complaint locally before agreeing to review the complaint. The Ombudsman is able to send the complaint back to the 16

17 organisation for further attempts at resolution if they consider more can be achieved. The Ombudsman may investigate when a complainant: Is not satisfied with the handling of the investigation Feels that their concerns have not been resolved The complaint was not investigated as the complaint was not made within the required time limit Should a complainant take their case to the Parliamentary and Health Service Ombudsman the Ombudsman can award the payment of compensation for time and trouble in bringing the complaint. 2.1 Local Resolution The role of the Complaint Manager is to facilitate the complaint process, ensure adherence to the complaint policy and maintain an overview for each complaint. 1. Complaint received by letter, verbally or electronically. Any member of staff can receive a complaint. If the complaint is made orally the recipient should make a written record of the complaint and ask the complainant to sign it. Contact the Complaints Manager for help with accessing interpreting / translation services or advocacy services. 2. Either to palscomments@swindon-pct.nhs.uk or fax to Safe Haven Fax number immediately after receipt of the complaint. 3. The Complaint Manager is responsible for ensuring complaint is logged on database (to provide a unique number identifier) and that acknowledgment is made (either verbal or by letter) within 3 working days. The Complaint Manager will discuss with the complainant appropriate timescales for the investigation; agree key issues; offer a meeting to discuss the findings of the investigation. 4. The Complaint Service will send a copy of the complaint with a front sheet which outlines action required, key issues, negotiated timescales and response deadline to the appropriate Director and service manager (see Appendix 1). If a meeting is required by the complainant the complaint manager is responsible for arranging this. Please note that all meetings between the complainant and staff will be digitally recorded for accuracy in producing notes. The complainant will be offered a CD recording of the meeting. 5. The lead Director is responsible for ensuring a timely investigation is undertaken by the appropriate manager and for returning an appropriately worded response letter to the Complaints Manager ready for Chief 17

18 Executive sign-off. If relevant, an action plan for service improvement, with timescales, should be returned to the Complaints Service. 6. Chief Executive signs off letter. 7. Complaint response letter returned to complaint department for closure on the database and sending out. 8. Complaint Service to monitor completion of service improvement action plans for reporting purposes. 2.2 Procedure flowcharts: General flowchart see next page Provider services flowchart see Appendix 2 Commissioning flowchart see Appendix 3 18

19 Complaint Procedure Flowchart Complaint comes in If complaint made verbally, the recipient should make notes and send to the complainant to sign as an accurate account of their complaint Immediately on receipt of the complaint, either to or fax to the Safe Haven Fax on for the attention of the Complaint s Service Complaints Manager to ensure complaint is logged on the database and an acknowledgement is made (within 3 working days) to the complainant Complaints Manager to phone complainant to discuss their complaint, agree key issues and timescales, and the method of response Complaints Service to send copy of complaint and front sheet outlining action required to the appropriate Service Director and Service Manager Complaint response letter returned to Complaints dept for recording and sending out CE/Group Director signs off letter Lead Director is responsible for ensuring a timely investigation and for returning a relevantly worded letter back to the Complaints Manager, ready for the CE /Group Director to sign off. Lead Director to provide copy of any service Improvement Action Plans. Complaint Service monitors completion of Improvement Action Plans 19

20 2.3 Response letters It is important that the response letter is written in a way that is easy to understand and avoids the use of jargon or complex terminology. The letter should include: an apology a full explanation of the findings of the investigation a response to each question or issue raised in the complaint what the service has changed as a result of the issues raised e.g. change to way service provided, staff training, policy review (if appropriate) a thank you to the complainant for taking the time to raise their concerns which will help the organisation to improve services a reference to the relevant documents should national guidance or policy affect the content of the response It is important to note that making an apology is not an admission of liability or wrongdoing (for further guidance refer to NPSA Being Open ). The lead Director is responsible for ensuring that an appropriately worded response is returned to the Complaints Service in an electronic format within the agreed timescales. Letters will then be logged on the database and signed off by the Chief Executive/Group Director. A final version of the letter signed by the Chief Executive/Group Director (or deputy) will be sent to the complainant and the lead Director. 2.4 Learning from Complaints Swindon PCT and SBC Adult Social Care are committed to learning from complaints and positively encourage people who use our services to comment on the quality of the service they have received. The lead Director is responsible for implementing any learning from complaints and for producing an action plan with reasonable timescales for completion. The action plan must be copied to the complaints manager for monitoring purposes. When the action plan is completed the lead Director must inform the Complaint Manager as part of the compliance and reporting procedures. 20

21 2.5 Dealing with difficult situations People may demonstrate behaviours which can be difficult to deal with during the complaint process. The substance of the complaint must be investigated thoroughly regardless of the manner in which it is presented and pursued. However staff are not expected to tolerate abusive, threatening or persistent behaviours and steps will be taken to protect staff in these situations. Measures such as requiring the person to have only one point of contact (normally the Complaints Manager) and only accepting a specified method of communication will be invoked as necessary. Refusal to respond to communications is only permitted when all reasonable and practical possibilities of resolution have been exhausted, in negotiation with the lead Director. A complainant who displays very difficult behaviours will be informed that these behaviours are not acceptable and asked to amend their conduct. Staff who are subject to these behaviours from a complainant will be offered support throughout the process. People who raise prolific concerns/issues can be difficult to deal with and regardless of whether they are right to persist they need appropriate support from staff to resolve their concerns/issues. Ensuring that such concerns/issues are resolved relies on how staff manage the individual and the labelling of a patient/service user as annoying or persistent could interfere with the ability of staff to understand the patient/service user s needs and may prolong the time taken to reach a mutually agreeable solution. Staff should consider whether a patient/service user with multiple concerns/issues or who raises the same or similar concerns/issues repeatedly despite having a full response may have underlying reasons for their persistence. Staff should regard concerns/issues raised by patients/service users as an opportunity to review and possibly improve service provision. 2.6 Identifying persistent complainants Patient/service users who present prolific concerns/issues are likely to display certain types of behaviour by: 21

22 Raising concerns about various parts of health and/or social care services regardless of the concern/issue Seeking attention by contacting several agencies and individuals and always repeating the full concern/issue Automatically responding to every communication from the organisation Insisting that they have not received an adequate response Focusing on a trivial matter Being abusive or aggressive 2.7 Dealing with persistent complainants Role of Complaints Service Staff receiving any direct contact from complainants regarding the complaint should contact the Complaints Service for help and support. The Complaints Service will be responsible for co-ordinating any action needed to manage the situation to enable the investigation to be completed. However should the complainant continue with inappropriate behaviours, despite all reasonable attempts to communicate effectively, a decision may be taken to discontinue the complaint process. The decision to treat a patient/service user as unreasonably persistent should be taken by the Chief Executive/Group Director (or Deputy) or the relevant Director of Service. The Chief Executive/Group Director or Director will communicate in writing with the patient/service user specifying the reasons why assistance is being refused. 2.8 Cross boundary / interagency complaints Where a complaint involves several organisations the cross boundary protocol will be followed to determine the lead organisation (see Appendices 4 and 7). The role of the lead organisation will be discussed with the person raising concerns. 22

23 When a cross organisation complaint is received, permission to share the concerns with the other organisations involved must be received before proceeding with sharing information (see Appendix 5). This is the responsibility of the Complaint Manager. The Complaint Manager will be responsible for ensuring that the response from the PCT and/or SBC Adult Social Care is sent to the lead organisation for inclusion in the joint response letter. Organisations must be mindful of Freedom of Information and Data Protection Legislation (Appendix 6) Process for investigating interagency complaints The lead organisation must agree the time-scale with the other organisations and the person raising the concerns. In the event that consent is denied, the complainant will need to be informed that separate complaints must be made to those agencies involved and that this is the responsibility of the complainant. If the complaint is solely for another organisation then the Complaints/PALS Manager should seek permission from the complainant to pass the complaint onto the relevant organisation on their behalf or signpost the person raising the concerns to that organisation Agreeing the issues and the complaint plan The lead organisation and the person raising the concerns will agree a plan of how their issues will be dealt with. For example this might include resolution, mediation, meeting with clinicians, and formal investigation with a report or negotiation. From the initial discussions, the Complaints/PALS Managers will need to agree the following: Which body will discuss the complaint plan with the person raising concerns, thereby acting as the lead? (Please refer to Appendices 4 and 7 for guidance with this). The named point of contact for the complainant The timescales for completion of response The milestone deadlines for sharing information during the process Identify any elements that may be more appropriately dealt with by other routes e.g. legal proceedings, Safeguarding or grievance disciplinary procedures, serious untoward incidents. 23

24 Where national guidance or policy is implicated in a response, the relevant document should be quoted. The person raising concerns will need to sign the complaints plan. If an appropriate timescale cannot be agreed, the organisations involved will set a timescale and will inform the person raising concerns in writing Complaint resolution A coordinated response must be communicated by the lead organisation to the person raising concerns in the agreed manner e.g. in writing or orally. If one organisation is having difficulty meeting the agreed timescale this should be discussed at the earliest opportunity. The lead will then contact the complainant to agree an extension with them and keep updating all involved. A draft response needs to be shared with the appropriate authorised person for signing off. Each body will agree to the draft but only authorised person of the lead organisation needs to formally agree the findings. The response will make it clear that it is on behalf of all the organisations involved. If the person raising the concerns considers that any of the issues have not been fully addressed, further negotiation will take place to try to reach a satisfactory resolution. Should a satisfactory resolution not be achieved, the person raising the concerns must be informed about their right to take the matter to the Ombudsman. The lead organisation is responsible for sharing the final outcomes of the complaint with all the organisations involved. Each organisation is responsible for the implementation and monitoring of any learning related to System management Contractual issues Policy review Communication with the public Clinical care Attitudes and behaviours 24

25 A nominated person from each organisation will have responsibility for collating and reporting on ongoing improvements as an outcome of the complaint. 3.0 Links The Complaints Policy and Procedure links to the following legislation and Swindon PCT Policies: Swindon Primary Care Trust Request for Incident Investigation Swindon Primary Care Trust Being Open Policy link Data protection principles Mental Capacity Act Mental Health Act Freedom of Information Act Swindon Primary Care Trust Records Management Policy Disciplinary Procedures NHS Constitution Best practice guidance - Department of Health document A guide to better customer care, February

26 COMPLAINT PROCESS FORM Appendix 1 Date complaint received Ulysses Number Details of complainant On behalf of Acknowledged on Service Director complaint forwarded to and date Response requested by Please address the following parts of the complaint Complainant Outcomes Wanted Service Manager investigation Service Manager draft letter sent to Service Director Service Director reviewed/ amended letter Letter to be sent back to Complaints Service Final letter sent to Chief Executive for signature Letter sent out By whom Date Complet 26

27 Appendix 2 DRAFT COMPLAINTS PROCEDURE (FOR PROVIDER SERVICES) MP/ICAS letters to Group Director (Civic Offices ) or Chief Executive (PCT HQ) (1) Complaint letters to Joint Director (2) Complaint via Service and Team Managers Telephone Complaints PALS Your Comments Count Fax details to Complaints Service safe haven fax asap, or if electronic. Received by Complaints Service (9) Letter to Complaint Team to post Informal PALS Process PALS or Complaints Complaints Manager contacts complainant - formal/informal? - expectations/outcomes - timescales Final draft to Chief Executive/ Group Director for signature FORMAL COMPLAINT Draft response to Director for approval Draft response to Complaints Team for formatting (3) Acknowledged by Complaints Service within 3 days. Unique ID database number, month and year logged on Ulysses (ie, 106Jul09) (4) Consent requirement established and forms sent out with acknowledgement letter (5) Details ed to Directors, Head of Service and Team Manager from Complaints Service (logged onto Provider Services spreadsheet) Head of Service leads investigation supported by Complaints Team (7) Team Manager undertakes investigation in conjunction with Complaints Team response letter drafted (6) T I M E F R A M E M O N I T O R E D 27

28 Appendix 3 DRAFT COMPLAINTS PROCEDURE (FOR COMMISSIONING) MP/ICAS letters to Chief Executive/Group Director (1) Complaint letters to Director (2) Complaint via Service and Team Managers Telephone Complaints PALS Your Comments Count Fax details to Complaints Service safe haven fax asap, or if electronic. Received by Complaints Service (9) Letter to Complaint Team to post Informal PALS Process PALS or Complaints Complaints Manager contacts complainant - formal/informal? - expectations/outcomes - timescales Final draft to Chief Executive/Group Director for signature FORMAL COMPLAINT Draft response to Director for approval Draft response to Complaints Team for formatting (3) Acknowledged by Complaints Service within 3 days. Unique ID database number, month and year logged on Ulysses (ie, 106Jul09) (4) Consent requirement established and forms sent out with acknowledgement letter (5) Details ed to Directors, Head of Service and Team Manager from Complaints Service (logged onto Provider Services spreadsheet) Head of Service leads investigation supported by Complaints Team (7) Team Manager undertakes investigation in conjunction with Complaints Team response letter drafted (6) T I M E F R A M E M O N I T O R E D 28

29 Appendix 4 Factors to Determine the Lead Organisation The following factors should be taken into account when determining which organisation will take the lead role with any cross boundary complaint: The organisation that manages integrated services Having carried out a risk assessment, the organisation that has the most serious complaints relating to it If a disproportionate number of the issues in the complaint relate to one organisation compared to the other organisation(s) The organisation that originally receives the complaint (should the seriousness and number of complaints prove roughly equivalent) If the complainant has a clear preference for which organisation takes the lead If the complainant has an established relationship with one of the agencies The organisations can agree separately from the above should other factors be pertinent. For example, if the impact on the individual organisation s governance arrangements. Agreement for interagency complaint handling Agreement between: Avon and Wiltshire Mental Health Partnership Great Western Ambulance Trust Great Western Hospital NHS Foundation Trust Swindon PCT Swindon Borough Council Principles: The organisations agree to adopt a no blame approach to the investigation to encourage openness and transparency. With the agreement of the person raising concerns the lead role for liaison will fall to the person responsible for complaints within the organisation where contact/rapport has already been established.

30 Appendix 4 contd. However if no contact has been established the lead role will be taken by the organisation with the most concerns raised about them. The liaison manager will: - Acknowledge the complaint and send a consent form for access to medical records / information sharing / acting on behalf of another person for signing - Within two days of the return of the consent form agree the way forward and timescales - For complex or serious incidents offer a meeting with representatives from all organisations involved Sign-off is the responsibility of the lead organisation. However it is the responsibility of each organisation to formally agree the content of the joint response letter. Should an independent investigation be required e.g. serious untoward incident, this investigator must have access to the relevant records. The investigator must present their report to the organisation(s) for confirmation of accuracy before passing back to the complaint process. Learning outcomes will be shared between all organisations involved in the complaint. 30

31 Appendix 5 Statement of consent for the disclosure of personal records Complainant s name: Complainant s address: Telephone number: I hereby give my consent for the organisations listed below to share any relevant information in order to complete the investigation into my complaint. I understand that this may include disclosure of my personal or medical records. (Lead organisation) (Organisation) (Organisation) This will assist the investigation of my joint organisation complaint, which is being co-ordinated by: (Name of complaints manager) of (Organisation) The reason for, and the implications of, this have been explained to me by the above-named complaints manager. I understand that information exchanged as agreed by me must be used solely for the purpose for which it was obtained. 31

32 Signed: Date: 32

33 Appendix 6 The Eight Data Protection Principles Anyone processing personal information must comply with eight enforceable principles of good information handling practice. These say that data must be: 1. Fairly and lawfully processed 2. Processed for limited purposes 3. Adequate, relevant and not excessive 4. Accurate and up to date 5. Not kept longer than necessary 6. Processed in accordance with the individual's rights 7. Secure 8. Transferred to countries outside European Economic area only where that country has adequate protection for the individual. The lead organisation must agree the time-scale with the other organisations and the person raising the concerns. In the event that consent is denied, the complainant will need to be informed that separate complaints must be made to those agencies involved and that this is the responsibility of the complainant. If the complaint is solely for another organisation then the Complaints/PALS Manager should seek permission from the complainant to pass the complaint onto the relevant organisation on their behalf or signpost the person raising the concerns to that organisation. 33

34 Appendix 7 West Country Health and Social Care Complaints / Feedback Network Protocol for Managing Customer / Patient Feedback Date June 2009 Review date April

35 1. Introduction 1.1. Sometimes a concern or complaint crosses over boundaries between the NHS and a local authority. Where this happens, people who use services should not have to worry about who to approach with complaints about different aspects of the service that they receive. Instead, the complaint can be made in its entirety to any one of the bodies involved. The purpose of this protocol is to set out the arrangements for the successful handling of cross boundary issues within the boundaries of the Great Western Ambulance Trust and Avon & Wiltshire Mental Health Partnership Trust boundaries including the following organisations (the West Country health and social care organisations): Great Western Ambulance Service Avon & Wiltshire Mental Health Partnership Trust South Gloucestershire PCT South Gloucestershire Council Bristol PCT Bristol City Council University Hospitals Bristol North Bristol NHS Trust B&NES PCT B&NES Council Royal United Hospital Bath Royal Hospital for Rheumatic Diseases North Somerset PCT North Somerset Council Weston Area Health Trust Wiltshire PCT Salisbury NHS Foundation Trust Wiltshire County Council Great Western Hospitals NHS FoundationTrust Swindon PCT Swindon Borough Council Gloucestershire PCT Gloucestershire County Council Gloucestershire Hospitals Foundation Trust 2gether Foundation Trust for Gloucestershire 35

36 1.2. This protocol has been developed to formally record the agreement between the West Country health and social care organisations on how to process customer/patient feedback. As such it is produced for those members of staff in these organisations who have responsibility for managing feedback and is not intended as a public document. The aim of this protocol is to ensure that the customer/patient does not need to know who does what but has confidence that their feedback will be appropriately managed. Literature specifically designed for customers/patients has been developed and produced This protocol has been developed in accordance with the Local Authority Social Services and National Health Service complaints (England) Regulations Each organisation has their own systems for recording and reporting of complaints. Each organisation must record the complaint within their own system for tracking, monitoring and reporting on learning within their organisation. 2. Problem solving 2.1. Both the NHS, through the Patient Advice and Liaison Service (PALS), and the local authorities have been developing a more customer / patient focussed way of dealing with complaints. Both services offer an opportunity for people to raise issue or concerns that can be resolved without invoking the complaints process. It is important that each organisation has robust mechanisms to record feedback and to ensure that learning from issues is fed back into the organisation. 3. Making a Complaint Handling issues involving more than one service Lots of people receive care from more than one health and social care organisation. If something goes wrong with that care and a complaint is made, it is important that the organisations involved provide a single point of contact and a single response The regulations require that if the complaint includes matters relating to both the NHS and Social Care, these bodies must cooperate for the purposes of 36

37 a) coordinating the handling of the complaint; and b) ensuring that the complainant receives a coordinated response to the complaint Each organisation has a duty to publicise their complaints procedures and provide details as to how to make a complaint. Provision must be made for complainants to make their complaint in the most appropriate format for them; this may be verbally or in writing. Each organisation has a duty to cooperate with all other agencies involved in a complaint, in order to best resolve the issues raised In some circumstances an advocate may provide support to the person making the complaint and the health and social care organisations publish the arrangements by which Advocacy Services may be contacted. 4. Receiving the Complaint 4.1. Acknowledgements may be oral or written. When a joint complaint is received, the acknowledgement must be made within three working days and permission from the complainant to share the complaint with another body should be sought at this time. The organisations must agree the time scale with the complainant If the complaint is solely for another organisation then the Complaints / PALS Manager should seek permission from the complainant to pass the complaint onto the relevant organisation on their behalf If the complaint is received by one body and it includes elements for another body it will be necessary to alert the complainant to this during the initial contact. Where this is the case then the lead organisation should advise the complainant of this, and agree timescales accordingly The flowchart at appendix 1 sets out the steps to be taken. 5. Consent and Information Sharing 5.1. We will seek consent from the complainant to share information with another body within acknowledgement. Once consent is received, the information will be passed to the other body within three working days. 37

38 5.2. Information should be shared between organisations via secure methods. In some instances it may be necessary to the information, particularly where a joint response is required. Therefore consent to share information via will be obtained from the complainant at the same time as seeking their consent to share information with the other body In the event that consent is denied, the complainant will need to be informed that there is likely to be a limit to what any investigation can consider and respond to. They should be advised that separate complaints must be made to those organisations involved and that this is the responsibility of the complainant. 6. Factors to Determine the Lead Organisation 6.1. The following factors should be taken into account when determining which organisation will take the lead role with any cross boundary complaint: The organisation that manages integrated services The organisation that has the most serious complaints relating to it If a disproportionate number of the issues in the complaint relate to one organisation compared to the other organisation(s) The organisation that originally receives the complaint (should the seriousness and number of complaints prove roughly equivalent) If the complainant has a clear preference for which organisation takes the lead If the complainant has an established relationship with one of the agencies The organisations can agree separately from the above should other factors be pertinent. For example, if the impact on the individual organisation s governance arrangements. 7. Agreeing the issues and the complaint plan 7.1. Where there are elements of complaints for both bodies there will be close cooperation and discussion between Complaints / PALS Managers in identifying which issues are for which organisation. These elements need to be clearly identified and recorded as part of the outline complaint plan. See appendix There may be some elements of a complaint that can be resolved quickly at a local level with the complainant s agreement. This would be agreed with the 38