Complaints Policy. Controlled Document Number: Version Number: 6 Controlled Document Sponsor: Controlled Document Lead: Approved By:

Transcription

1 Complaints Policy CONTROLLED DOCUMENT CATEGORY: CLASSIFICATION: PURPOSE Controlled Document Number: Version Number: 6 Controlled Document Sponsor: Controlled Document Lead: Approved By: Policy Governance To set out the principles and framework for complaints management, investigation, and learning from complaints. 21 Executive Chief Nurse Patient Services Team Leaders Board of Directors On: 26 January 2012 Review Date: January 2015 Distribution: Essential Reading for: Information for: All Directors, Senior Managers, Department leads All Trust Staff Document Control Number: 21 1

2 Contents Paragraph 1 Policy Statement 3 2 Scope 3 3 Framework 3 4 Duties 6 5 Implementation and Monitoring 9 6 References 9 Page 7 Associated Policy and Procedural Documentation 10 Appendices Appendix 1 Monitoring of Compliance 12 Appendix 2 Model Matrix for Risk 13 Document Control Number: 21 2

3 1 Policy Statement 1.1 The Trust is committed to providing the best in care. 1.2 The Trust will resolve concerns at point of contact where possible. 1.3 The Trust will ensure that concerns which cannot be resolved at point of contact or via PALS are investigated and managed appropriately and in accordance with the wishes of the individual raising the concern. 1.4 The Trust welcomes complaints, as it seeks to learn from them in order to improve its patients experience of care. 1.5 The Trust will ensure that it complies with current legislation and guidance from the Parliamentary and Health Service Ombudsman when dealing with complaints. 1.6 Complainants/patients will not be treated differently as a result of a complaint having been made. This is ensured by complaint documentation not being held within a patient s medical records. 2 Scope 2.1 This policy applies to complaints that are dealt with in line with the NHS Complaint Regulations in relation to the Trust s services, including any satellite services, and all individuals acting on behalf of the Trust including: employees, contractors, volunteers, students, locum/agency staff and those employed on honorary contracts. 2.2 This policy applies to concerns that cannot be resolved at the point of contact or through PALS (Patient Advice and Liaison Service). Please see the PALS Policy and Procedure documents for the process applying to concerns from service users. 2.3 The complaints policy is not designed for staff to use against other staff, except where a member of staff is making a complaint as, or on behalf of, a patient about services provided by the Trust. 3 Framework 3.1 This section describes the broad framework for the Complaints Policy. Detailed instructions are provided in the associated procedural documents. 3.2 Operational instructions for complaints handling, investigation of complaints, and learning from complaints are detailed in the Complaint Procedure and Complaint Procedure (Habitual or Vexatious Complainants). Document Control Number: 21 3

4 3.3 A complaint is defined as an expression of dissatisfaction requiring a response made orally, in writing or electronically which cannot be resolved at point of contact or through PALS and which falls within the scope of the NHS Complaints Regulations. Where complaints fall outside of this scope because they are out of time and cannot be resolved at the point of contact, the Patient Services Department (PSD) will deal with them as enquiries, providing relevant documents can be accessed, following the spirit of the Complaints Process. 3.4 Complaints shall be managed by the PSD. 3.5 Complaints Process Every complaint shall be properly recorded on Datix Where complaints are received orally, a record will be made, and a written summary of the issues will be provided to the complainant Complaints will be acknowledged either orally or in writing within three working days of receipt The Trust will ensure that all complaints receive an appropriate, thorough, specific and timely investigation Timescales for completion will be negotiated between PSD and complainant. Where the original timescales cannot be achieved PSD will contact the complainant explaining the reasons for the delay and renegotiate a completion date Information regarding complaints that may involve incidents, inquests or claims will be shared between the Risk Management Department, Legal Services and PSD Where it is felt that a complaint investigation may prejudice a legal outcome, the complaint investigation may be suspended. Decisions to suspend shall be taken by the Chief Nurse, having taken appropriate advice Where a complaint relates in whole or in part to an incident that could potentially be considered a serious incident, PSD will ensure this is reported to the Risk Management Department Complaints that involve more than one NHS body will be investigated independently but may receive either separate responses from each organisation or a single co-ordinated response in line with NHS Complaint Regulations and subject to negotiation with the complainant. Document Control Number: 21 4

5 3.6 Response and Being Open The Trust will observe the principles of Being Open as set out in the Being Open Policy by offering full and honest explanations. An apology will be provided where appropriate to do so The complainant will be provided with information about the complaints process, including how to access an advocacy service All complainants are given details of the Parliamentary and Health Service Ombudsman (PHSO) as they have the right to request an independent review Where the Trust s response has not satisfied the complaint, the original investigation will be reviewed and, if incomplete, further investigation will be undertaken within an agreed timescale and another response will be issued Where the Trust s response has not resolved the complaint to the complainant s satisfaction and there is no scope for further investigation or a different result, the Trust will explain that local resolution is complete and will remind them of their right to access an independent review through the PHSO. The Trust may decide itself to refer the case to PHSO The Trust will ensure that there is learning from complaints and that this is disseminated across the Trust via relevant staff and forums as well as being shared with complainants. 3.7 Habitual or Vexatious Complainant Where complainants are considered to be habitual or vexatious, the complainant will be handled in accordance with the Complaints Procedure (Habitual or Vexatious Complainants). 3.8 Supporting Staff The line manager is responsible for the provision of primary support for staff involved in a complaint For longer term support the line manager can offer Staff Support Services. This service is independent of the management structure and is completely confidential. Document Control Number: 21 5

6 3.8.3 Staff Support Services offer one-to-one counselling and long term support. This service is independent of the management structure and is completely confidential. The Line Manager should ensure the member of staff is aware of the Staff Support Service and give them the appropriate information leaflet. The Line Manager can obtain Staff Support Leaflets from the Occupational Health and Safety Department If a staff member is experiencing difficulties associated with an event, which have not been resolved following the process above, discussion should be considered by their line manager, in consultation with the member of staff and a Human Resources Manager using the appropriate policy or procedure. 3.9 Staff performance issues The Trust investigates complaints to establish what went wrong rather than who did wrong During the course of an investigation if it is identified that there may be concerns regarding the performance, capability or competence of any individual the appropriate Divisional Management Team should consider a further investigation in accordance with the Trust s Managing Poor Performance Policy and associated procedure. 4 Duties 4.1 Chief Executive The Chief Executive will review, approve, and sign all final responses to complaints. In the absence of the Chief Executive, complaints will be reviewed and final responses signed by the person with delegated authority. 4.2 Executive Chief Nurse The Executive Chief Nurse is responsible for ensuring that: the policy and its associated procedures are complied with; all complaints are investigated appropriately and responded to in an effective and professional manner, so that the complainant s desired outcome is acknowledged and the Trust s investigation and response meets that objective wherever appropriate; and Document Control Number: 21 6

7 4.2.3 the Ombudsman and other responsible bodies are provided with appropriate information when requested every complaint is referred to The Executive Chief Nurse (or her appointed deputy) at the outset for her to triage, i.e. determine the appropriate response to the complaint, whether it should be dealt with formally through the complaints process or whether a more informal, immediate response is considered to be more appropriate. 4.3 Executive Directors Executive Directors are responsible for ensuring complaints in their corporate areas of responsibility are responded to and that learning is implemented. 4.4 Patient Services Department The Patient Services Department is responsible for: Receiving formal complaints Logging correspondence on a post log Referring new complaints to the Chief Nurse for triaging in accordance with above Inputting new complaints on Datix linking to existing records for the same patient including claims, incidents, PALS records or inquests Acknowledging receipt of written concerns and complaints Compiling hard copy complaint file to include the complaint, correspondence to date, relevant patient data obtained from Lorenzo, cover sheet (see Appendix 1 of Procedure document), and a copy of the signed response Risk assessing complaint cases (see Appendix 2 for guidance used) Ensuring serious complaints (see definition in Procedure Document) are copied to the Risk and Legal Departments Deciding whether a complaint is deemed out of time under the NHS Complaints Regulations, and whether the Trust will investigate as a complaint, an enquiry outside of the regulations, or reject it. Document Control Number: 21 7

8 Assessing whether a complaint should be managed under the Complaint Procedure (Habitual or Vexatious Complainants) see associated procedure for details Co-ordinating the management of all complaints in line with the Complaints Policy and Complaints Procedure Ensuring contact with the complainant to acknowledge the complaint and to agree a plan for investigation and response Escalating overdue complaint responses to Divisional Management Teams Ensuring contact with the complainant throughout the life of the complaint Reviewing draft final responses within agreed timeframes, ensuring that all the questions raised in the original complaint have been adequately addressed Acting as point of contact for the PHSO Copying complaint files for potential PHSO complaints when requested by PHSO Keeping PHSO tracking document up-to-date Monitoring complaint activity and highlighting non-compliance via reports as requested by Trust groups or committees Monitoring response timescales and ensuring deadlines are met wherever possible. 4.5 Divisional Management Team The above are responsible for ensuring that: Support is provided to staff involved with complaints Complaints are appropriately investigated, in a timely manner Final responses are signed-off and that any actions or improvements agreed are implemented in their areas of responsibility Any service improvements or learning outcomes that have arisen as a result of the investigation are identified within the response. Document Control Number: 21 8

9 4.5.5 Serious cases which require a separate investigation will have issues identified and learning outcomes and proposed actions will be detailed in the summary of the investigation. A copy of this should be sent to Patient Services Actions and learning from complaints are implemented within the Divisions and monitored through Divisional Clinical Quality Groups. 4.6 Line Managers, Matrons, Ward and Departmental Managers and Heads of Departments Must ensure that staff for whom they have responsibility are: Supported when involved with complaints Familiar with policies and associated procedures for handling concerns Aware that concerns should be resolved locally where possible; and that they should refer to the PALS Policy and Procedure documents for further details Informed about the action to take if a patient or their representative wishes to make a formal complaint to the Trust Aware of their responsibility for informing line managers promptly, where concerns cannot be resolved at point of contact. 5 Implementation and Monitoring 5.1 Implementation A copy of the Complaints Policy will be made available to all staff via the Trust Intranet will be disseminated through the Trust s management structure Complaints awareness training will be delivered to all staff on induction and ad hoc training tailored to individual needs is available on request. 5.2 Monitoring Appendix 1 provides full details on how the policy will be monitored by the Trust. Document Control Number: 21 9

10 6 References 6.1 Legislation.gov.uk (February 2009) The Local Authority Social Services and National Health Service Complaints (England) Regulations 2009, [Online], Available: ade [ ] London: The Stationery Office. 6.2 The Parliamentary and Health Service Ombudsman (PHSO): PHSO (February 2011) Care and Compassion? Report of the Health Service Ombudsman on ten investigations into NHS care of older people, [Online], Available: n.org.uk/ data/assets/pdf_file/0016/7216/care-and- Compassion-PHSO- 0114web.pdf [ ] London: The Stationary Office PHSO (November 2011) Information Promise Framework, [Online], Available: data/asset s/pdf_file/0003/13494/information-promise-framework.pdf [ ] PHSO (November 2011) Information Promise Statement, [Online], Available: data/asset s/pdf_file/0020/13493/information-promise-statement.pdf [ ] PHSO (October 2010) Listening and Learning: the Ombudsman s review of complaint handling by the NHS in England , London: The Stationary Office PHSO (February 2009) Principles for Good Complaint Handling, [Online], Available: data/assets/pdf_file/0005/1040/principles-of-good-complaint- Handling.pdf [ ] PHSO (February 2009) Principles for Remedy, [Online], Available: data/assets/pdf_file /0009/1035/Principles-for-Remedy.pdf [ ] PHSO (February 2009) Principles of Good Administration, [Online], Available: data/asset s/pdf_file/0013/1039/principles-of-good-administration.pdf [ ] PHSO (October 2011) Report on Complaints about Disability Issues, [Online], Available: da ta/assets/pdf_file/0020/11369/report-on-complaints-aboutdisability-issues-final-web-version.pdf [ ]. Document Control Number: 21 10

11 7 Associated Policy and Procedural Documentation 7.1 Being Open Policy 7.2 Claims Handling Policy and Procedure 7.3 Complaints Procedure 7.4 Complaints Procedure (Habitual or Vexatious Complainants) 7.5 Governance Interface Protocol 7.6 PALS Policy and Procedure 7.7 Policy for the Reporting and Management of Incidents including Serious Incidents Requiring Investigation 7.8 Training Catalogue Document Control Number: 21 11

12 Appendix 1 MONITORING OF COMPLIANCE MONITORING LEAD REPORTED TO PERSON/GROUP Process for listening and responding to complaints Chief Nurse Chief Executive s Advisory Group Audit Committee Care Quality Group Patient Experience Group MONITORING PROCESS Trustwide summary report on complaint numbers, subjects (issues) and responses services/locations Formal reports Formal reports Formal reports MONITORING FREQUENCY Monthly Quarterly Monthly Quarterly Compliance with this policy and associated procedures, this will include looking at the handling of joint complaints, ensuring that patients relatives and their carers are not treated differently and that complaints have been listened to and responded to accordingly Chief Nurse Divisional Clinical Quality Group Care Quality Group Formal reports Six-monthly audit of a sample of complaints files Quarterly Six-monthly Annual report on complaints Chief Nurse Board of Directors Formal reports Annually Document Control Number: 21 12

13 Compliance with the investigation process and learning of lessons outlined in the policy and procedure Chief Nurse Executive RCA group Review of a sample of complaint cases By exception Document Control Number: 21 13

14 Appendix 2 Model matrix For the full Risk matrix for risk managers, go to Table 1 Consequence scores Choose the most appropriate domain for the identified risk from the left hand side of the table Then work along the columns in same row to assess the severity of the risk on the scale of 1 to 5 to determine the consequence score, which is the number given at the top of the column. Consequence score (severity levels) and examples of descriptors Domains Negligible Minor Moderate Major Catastrophic Quality/complaints/audit Peripheral element of treatment or service suboptimal Overall treatment or service suboptimal Formal complaint Treatment or service has significantly reduced effectiveness Non-compliance with national standards with significant risk to patients if (stage 1) unresolved Informal complaint/inquiry Local resolution Single failure to meet internal standards Minor implications for patient safety if unresolved Reduced performance rating Formal complaint (stage 2) complaint Local resolution (with potential to go to independent review) Repeated failure to meet internal standards Major patient safety Multiple complaints/ independent review Low performance rating Critical report Totally unacceptable level or quality of treatment/service Gross failure of patient safety if findings not acted on Inquest/ombudsman inquiry Gross failure to meet national standards Document Control Number: 21 14

15 if unresolved implications if findings are not acted on Human resources/ organisational development/staffing/ competence Short-term low staffing level that temporarily reduces service quality (< 1 day) Low staffing level that reduces the service quality Late delivery of key objective/ service due to lack of staff Unsafe staffing level or competence (>1 day) Low staff morale Uncertain delivery of key objective/service due to lack of staff Unsafe staffing level or competence (>5 days) Loss of key staff Non-delivery of key objective/service due to lack of staff Ongoing unsafe staffing levels or competence Loss of several key staff Statutory duty/ inspections No or minimal impact or breech of guidance/ statutory duty Breech of statutory legislation Reduced performance rating if unresolved Poor staff attendance for mandatory/key training Single breech in statutory duty Challenging external recommendations/ improvement notice Very low staff morale No staff attending mandatory/ key training Enforcement action Multiple breeches in statutory duty Improvement notices No staff attending mandatory training /key training on an ongoing basis Multiple breeches in statutory duty Prosecution Complete systems change required Low performance rating Zero performance rating Adverse publicity/ reputation Rumours Potential for public concern Local media coverage short-term reduction in public confidence Elements of public expectation not Local media coverage long-term reduction in public confidence Critical report National media coverage with <3 days service well below reasonable public expectation Severely critical report National media coverage with >3 days service well below reasonable public expectation. MP concerned (questions in the House) Document Control Number: 21 15

16 being met Total loss of public confidence Business objectives/ projects Finance including claims Service/business interruption Environmental impact Insignificant cost increase/ schedule slippage Small loss Risk of claim remote Loss/interruption of >1 hour Minimal or no impact on the environment <5 per cent over project budget Schedule slippage Loss of per cent of budget Claim less than 10,000 Loss/interruption of >8 hours Minor impact on environment 5 10 per cent over project budget Schedule slippage Loss of per cent of budget Claim(s) between 10,000 and 100,000 Loss/interruption of >1 day Moderate impact on environment Non-compliance with national per cent over project budget Schedule slippage Key objectives not met Uncertain delivery of key objective/loss of per cent of budget Claim(s) between 100,000 and 1 million Purchasers failing to pay on time Loss/interruption of >1 week Major impact on environment Incident leading >25 per cent over project budget Schedule slippage Key objectives not met Non-delivery of key objective/ Loss of >1 per cent of budget Failure to meet specification/ slippage Loss of contract / payment by results Claim(s) > 1 million Permanent loss of service or facility Catastrophic impact on environment Document Control Number: 21 16

17 Table 2 Likelihood score (L) What is the likelihood of the consequence occurring? The frequency-based score is appropriate in most circumstances and is easier to identify. It should be used whenever it is possible to identify a frequency. Likelihood score Descriptor Rare Unlikely Possible Likely Almost certain Frequency How often might it/does it happen This will probably never happen/recur Do not expect it to happen/recur but it is possible it may do so Might happen or recur occasionally Will probably happen/recur but it is not a persisting issue Will undoubtedly happen/recur,possibly frequently Note: the above table can be tailored to meet the needs of the individual organisation. Some organisations may want to use probability for scoring likelihood, especially for specific areas of risk which are time limited. For a detailed discussion about frequency and probability see the guidance notes. Table 3 Risk scoring = consequence x likelihood ( C x L ) Likelihood Likelihood score Rare Unlikely Possible Likely Almost certain 5 Catastrophic Major Moderate Minor Negligible Document Control Number: 21 17

18 Note: the above table can to be adapted to meet the needs of the individual trust. For grading risk, the scores obtained from the risk matrix are assigned grades as follows 1-3 Low risk 4-6 Moderate risk 8-12 High risk Extreme risk Instructions for use 1 Define the risk(s) explicitly in terms of the adverse consequence(s) that might arise from the risk. 2 Use table 1 (page 13) to determine the consequence score(s) (C) for the potential adverse outcome(s) relevant to the risk being evaluated. 3 Use table 2 (above) to determine the likelihood score(s) (L) for those adverse outcomes. If possible, score the likelihood by assigning a predicted frequency of occurrence of the adverse outcome. If this is not possible, assign a probability to the adverse outcome occurring within a given time frame, such as the lifetime of a project or a patient care episode. If it is not possible to determine a numerical probability then use the probability descriptions to determine the most appropriate score. 4 Calculate the risk score the risk multiplying the consequence by the likelihood: C (consequence) x L (likelihood) = R (risk score) 5 Identify the level at which the risk will be managed in the organisation, assign priorities for remedial action, and determine whether risks are to be accepted on the basis of the colour bandings and risk ratings, and the organisation s risk management system. Include the risk in the organisation risk register at the appropriate level. Document Control Number: 21 18