Policy on the Effective Handling of Complaints and Concerns (including the Procedural Guidance for Staff on Handling Complaints and Concerns

Transcription

1 Policy on the Effective Handling of Complaints and Concerns (including the Procedural Guidance for Staff on Handling Complaints and Concerns Version Number: V10.1 Name of originator/author: Head of PALS, Complaints and Legal Services Name of responsible committee: Name of executive lead: Clinical Governance Committee Director of Nursing and Therapies Date V1 Issued: September 2010 Last Reviewed: October 2013 Next Review date: October 2015 Scope: MMHSCT Policy Code Trust Wide CO-05 1

2 Document Control Sheet Policy on the Effective Handling of Complaints and Concerns (including the Procedural Guidance for Staff on Handling Complaints and Concerns) Lead Executive Director Author and Contact Number Type of Document Document Purpose Director of Nursing and Therapies Head of PALS, Complaints and Legal Services Policy To provide clear guidance to staff, service users and members of the public as to how the Trust will manage complaints, concerns, comments and compliments, in line with the Local Authority Social Services and NHS Complaints (England) Regulations 2009, No Scope of Document Trust Wide Version V10 Number Consultation Executive Directors/ Risk Manager/Head of Patient Experience/Head of Patient Safety/ Head of Regulation, Compliance and Quality Improvement/Mental Health Law Manager/Care Group Governance Leads/Lead Consultants/Deputy Director of HR/Deputy Director of Finance/Heads of Profession/Matrons/Care Group Managers/Information Governance Team/Outpatients Managers/Local Counter Fraud Specialist, Equality and Diversity Adviser/Patient Experience Committee Members/Communications/CPA Lead/Safeguarding Lead Length of Consultation Period (minimum of 2 weeks) Approving Committee Patient Experience Committee Approval 3 September 2012 Date Ratification and Date Trust Management Board Date of Ratification 25 September 2012 Re- ratification Lead Executive 20 October 2013 V1 Valid from Date September 2010 Date of Last Review October 2013 Date of Next Review The Trust standard is 3 years. September 2014 Procedural Documents to be read in conjunction with this document: Training Requirements There Choose an item. Training requirements for this procedural document Specify additional requirements if applicable/delete Financial Resource Impact There Choose an item. Financial resource impacts Specify additional requirements if applicable/delete Document Change History Changes to this document in different versions must be detailed below. Rationale for the change should also be given 2

3 Version Number / Name of procedural document this supersedes All Procedural guidance Type of Change i.e. Review / Legislation / Claim / Complaint Update of post titles through the policy and procedure Risk Grading Matrix Date Details of Change Head of PALS, Complaints & Legal Services Complaints /Enquiries Lead Updated version Procedural guidance Updated Action Plan on investigation form Update version Policy section 12 Update of arrangements for learning All Procedural guidance Update of post titles through the policy and procedure Risk Grading Matrix Head of PALS, Complaints & Legal Services Complaints /Enquiries Lead Updated version V10 Review September Changes made to Patient Association Standards 2013 External references used in the creation of this document: Equality Impact Assessment Initial Assessment Yes/No Comments Does this document affect on group less or more favourably than another on the basis of: Race No Ethnic Origins (including No gypsies or travellers) Nationality No Gender No Culture No Religion or Belief No Sexual Orientation No Age No Disability - Learning disabilities, No sensory impairment and mental health Is there evidence that some No groups are affected differently? If you identify any potential discrimination, are there any valid exceptions, legal / justifiable? Choose an item. 3

4 Is the impact of the document likely to be negative? Can this impact be avoided? Have we considered alternatives to implementing the document without the impact? Can we reduce the impact by No N/A N/A N/A taking different action? If this initial screening assessment has led to identification of an adverse or negative impact a full Equality impact Assessment will need to be completed and approval of our Equality and Diversity Lead given. Date of Full EIA 06 August 2012 Date of Approval 21 August 2012 E&D Lead Fraud Proofing submitted Any issues? Choose an item. Privacy Impact Assessment Any issues? Choose an item. submitted If not relevant to this procedural document give rationale: If you are unclear on any of the above requirements please quality.admin@mhsc.nhs.uk 4

5 Monitoring and Compliance Requirements For audit, CQC Registration and NHSLA purposes all procedural documents must have monitoring requirements or key performance indicators set by the authors, Committees or Lead Directors. This allows the Trust to routinely monitor the effectiveness and impact of their procedural documents on a regular basis. Does this procedural document offer support or evidence for the Trusts registered activities and outcomes? Yes Primarily Outcome 17 Complaints Additional Outcome 1 Respecting & Involving People who use Services Additional Outcome 4 Care and Welfare of People who use Services Is this an NHSLA Document? Minimum Requirement / Standard / Indicator to be monitored & Section of document it appears Level 1/a Duties Policy Section 9 Procedural Guidance 2.1 Level 1/b Concerns and Complaints Procedural Guidance Section 2 Level 1/c Joint Complaints. Policy Section 18 Policy Section 28 Yes Which Standard does this relate to? 2 - Learning from Experience Which Criterion Level 1/d Patients, relatives and carers are not treated differently. Policy Section 23, paragraph 4 Procedural Guidance Section Level 1/e Improvements. Policy Section 12 Level 1/f Monitoring. Policy section 23 Process for monitoring Review Review Review Review Review Audit Responsible Individual / Group Head of PALS, Complaints and Legal Services. Patient Experience Committee Head of PALS, Complaints and Legal Services. Patient Experience Committee Head of PALS, Complaints and Legal Services. Patient Experience Committee Head of PALS, Complaints and Legal Services. Patient Experience Committee Head of PALS, Complaints and Legal Services. Patient Experience Committee Head of PALS, Complaints and Legal Services. Frequency of Monitoring Responsible Group for review of results / action plan approval / implementation 2 Years Patient Experience Committee 2 Years Patient Experience Committee 2 Years Patient Experience Committee 2 Years Patient Experience Committee 2 Years Patient Experience Committee Yearly Patient Experience 2/3 Concerns & Complaints Choose an item. Choose an item. Comments 5

6 Patient Experience Committee Committee NB: If you have selected audit you should complete the required audit registration form and standards document and submit these with your expected timescales for completing the audit to as soon as possible and no later than 4 weeks prior to the audit commencing. The Group / Committee should also ensure the monitoring work is added to their yearly schedule of monitoring and action logs as appropriate 6

7 Policy on the Effective Handling of Complaints and Concerns (including the Procedural Guidance for Staff on Handling Complaints and Concerns Contents Section Title Page BRIEFING SHEET FOR MANAGERS 14 1 Overview of the Policy 14 2 Specific issues to be raised with staff 14 3 Manager Action 14 4 Location of electronic copy of the document 15 5 Advice and Support available from the Complaints and Enquiries Lead Policy on the Effective Handling of Complaints and Concerns (including the Procedural Guidance for Staff on Handling Complaints and Concerns 1 Introduction 16 2 Scope of the Policy 16 3 Aim of the Policy 16 4 Parliamentary and Health Service Ombudsman s Principles 17 5 Who can make a complaint 17 6 Time limit for making a complaint 18 7 Assistance for complainants 18 8 Consent of Service User for third party complaints 19 9 Duties and Responsibilities for complaints arrangements Trust Board Chief Executive Head of PALS, Complaints and Legal Services Complaints and Enquiries Lead Managers All Staff

8 9.7 Patient Advice and Liaison Service (PALS) Arrangements for the handling and consideration of complaints Supporting Staff Arrangements for learning and improvements from complaints and concerns Cases subject to litigation Complaints about the provision of Health Services Primary Care Trust Care Quality Commission Ombudsman Care provided in non-nhs facilities Mediation Complaints that do not fall under the regulations Disciplinary Procedure Duty to Co-operate/Joint Handling of Complaints Publicity Dissemination of the Policy Annual Report Habitual and/or vexatious complainants Monitoring Training on Policy References Review, Updating and Archiving of this document Cross referencing of policy Protocol on Joint Working on Complaints 31 APPX 1 Flow chart of handing joint organisation complaints 37 12

9 APPX 2 Statement of Consent for the disclosure of personal records template 39 APPX 3 Complaints managers and other contacts in signatory organisations APPX 1 Procedural Guidance on Handling Habitual or Vexatious Complainants Procedural Guidance on the Effective Handling of Complaints and Concerns (including the procedure for reporting Compliments and Comments) APPX 2 How to respond positively to local concerns 61 APPX 3 APPX 4 APPX 5 APPX 6 APPX 7 APPX 8 APPX 9 APPX 10 APPX 11 APPX 12 APPX 13 How to respond positively to verbal complaints triaged as green / yellow Examples of different types of complaints 63 Complaints Plan of action /investigation form 64 Investigation of written/ e mail / verbal complaints received by Complaints and Enquiries Lead and triaged as Green Investigation of written/ e mail / verbal complaints received by Complaints and Enquiries Lead and triaged as Yellow Investigation of written/ e mail / verbal complaints received by Complaints and Enquiries Lead and triaged as Amber Overall flowchart for complaints received by Complaints Enquiries Lead 76 Guidance for Investigators 77 Guidance on writing a statement 82 Template letter Chief Executive s response to complaints 83 Template letter Chief Executive s response to Mps enquiries If you need to have this information translated into another language please contact the Mental Health Linkwork Scheme on or linkworkers.mentalhealth@nhs.net. If you require it in larger print, Braille, audio or other formats please contact the Communications Team on or communications.admin@mhsc.nhs.uk 13

10 Policy on the Effective Handling of Complaints and Concerns (including the Procedural Guidance for Staff on Handling Complaints and Concerns) BRIEFING SHEET FOR MANAGERS: Policy on the Effective Handling of Complaints and Concerns 1. Overview of the policy 1.1 To provide clear guidance to staff, service users and members of the public as to how the Trust will manage complaints, concerns, comments and compliments, in line with the Local Authority Social Services and NHS Complaints (England) Regulations 2009, No This policy is applicable to complaints from service users, their relatives / carers or anyone acting on behalf of service users who receive or have received services from the Trust. 2. Specific issues to be raised with staff 2.1 Awareness of the policy and importance of resolution of concerns/ complaints at local level where appropriate (see section on duties and responsibilities and flow charts in the procedural guidance). 2.2 Staff to complete the Local Concerns/Complaints Feedback form and send to the Complaints and Enquiries Lead where there has been resolution of the issues by front line staff. 2.3 All written complaints to be sent to the Complaints and Enquiries Lead by fax on immediately they arrive within the Trust to enable the central team to acknowledge receipt within 3 working days. 2.4 Staff to advise service users, their relatives and carers (who wish to make a formal complaint) of the support available to assist them with complaining by signposting them to the Independent Complaints Advocacy or other advocacy services as appropriate. 2.5 All compliments to be reported on the intranet. 3. Manager action 3.1 Managers to cascade information to staff they have a responsibility for. 3.2 To ensure new staff are made aware of the policy and procedure at local induction. 3.3 To ensure staff attend mandatory training on Listening, Responding, Improving. 14

11 3.4 To disseminate learning from Quarterly Patient Experience Reports and Annual reports on Complaints and PALS to staff. 4. Location of Electronic copy of the document 4.1 On Trust Intranet / Internet 5. Advice and support available from the Complaints and Enquiries Lead , Patient Advice and Liaison Service on /5. 15

12 Policy on the Effective Handling of Complaints and Concerns (including the Procedural Guidance for Staff on Handling Complaints and Concerns) 1. Introduction This policy sets out the framework for the management of complaints and concerns within Manchester Mental Health and Social Care NHS Trust (hereafter called the Trust). The Trust welcomes all types of feedback in order to know what is working; help to identify risks and prevent them from getting worse; help identify any potential service problems; highlight opportunities for staff improvement and provide the information we need to review our services and procedures effectively. There is separate procedural guidance for staff that supplements and supports this policy. 2. Scope of the Policy This policy complies with the Local Authority Social Services and National Health Service Complaints (England) Regulations 2009 (hereafter called the Regulations 2009) and relates to all complaints about health and social care services provided by the Trust. This policy applies to all staff employed by Manchester Mental Health and Social Care Trust including agency, bank, students and volunteers. 3. Aim of the Policy The key aims of the policy are:- To ensure that the Trust actively seeks people s views about the service they receive by making information about how to complain, raise concerns, comments and compliments clear and accessible. Support to make a complaint will be provided by the Complaints and Enquiries Lead and Patient Advice and Liaison (PALS) service where necessary. To listen to feedback from service users, carers and relatives and deal with them in a sensitive and a timely manner by taking account of individual circumstances To treat people in a manner that respects their human rights and diversity in a fair and equal way To investigate complaints thoroughly and objectively To provide an equitable approach to all parties involved (staff, service users, their relatives and carers) providing the necessary support throughout the complaints process To be honest and accountable for decisions and actions when responding to complaints To provide a confidential complaints service seeking consent from service users where appropriate. To learn lessons from mistakes and prevent future complaints relative to similar issues To seek continuous service improvement by taking action following a complaint/ concern. 16

13 To ensure that service users care is not adversely affected in any way as a result of making a complaint To have arrangements in place for managing habitual and / or vexatious complainants. 4. Parliamentary and Health Service Ombudsman s Principles The Parliamentary and Health Service Ombudsman has produced three sets of Principles covering Good Complaints Handling, Good Administration and Principles for Remedy which the Trust has adopted to deliver good customer service and how to respond when things go wrong. The principles of this Policy are in accordance with the Ombudsman s guidance, which is as follows: Getting it right Being Customer Focussed Being open and accountable Acting fairly and proportionately Putting things right Seeking continuous improvement The Patient Association Standards are: The Complainant has a single point of contact and is placed at the centre of the process. The complaint undergoes initial assessment and any necessary immediate action is taken. A lead investigator is identified. Investigations are thorough, where appropriate obtain independent evidence and opinion and are carried out in accordance with local procedures, national guidance and within legal frameworks. The investigator reviews, organises and evaluates the investigative findings. The judgement reached by the decision maker is transparent, reasonable and based on the evidence available. The complaint documentation is accurate and complete. Both the complainant and those complained about are responded to adequately. The investigation of the complaint is complete, impartial and fair. The organisation records, analyses and reports complaints information throughout the organisation and to external audiences. Learning lessons from complaints occurs throughout the organisation. Governance arrangements regarding complaints handling are robust. Individuals assigned to play a part in a complaint investigation have the necessary competencies. 5. Who can make a complaint? A complaint may be made by: - 17

14 A person who receives or has received services from the Trust or A person who is affected, by the action, omission or decision of the Trust. A person (representative*) acting on behalf of a person mentioned above who has (i) died, (ii) is unable to make the complaint themselves because of physical incapacity or lacks capacity within the meaning of the Mental Capacity Act 2005 or (iii) has asked the representative* to act on their behalf in order to support a complaint being made. (*A representative could be the Independent Complaints Advocacy, IMCA, family member, the service user s Member of Parliament or local councillor, the service user s advocate). (If the service user is deceased, the Trust has to ensure the complainant has the right to the information before responding by producing e.g. letters of administration). In cases where the service user lacks capacity, if a complaint is made by a representative and the Trust is satisfied that the representative is not conducting the complaint in the service user s best interests the complaint must not be considered under the Local Authority Social Services and National Health Service Complaints (England) Regulations The Trust must notify the representative in writing and state the reasons for its decision. (Regulations a, b) 6 Time limit for making a complaint A complaint must not be made later than 12 months after: - The date on which the matter which is the subject of the complaint occurred If later, the date on which the matter which is subject to the complaint came to the notice of the complainant The time limit shall not apply if the Trust is satisfied that the complainant had good reasons for not making the complaint within the time limit and notwithstanding the delay it is still possible to investigate the complaint effectively and fairly. 7. Assistance for complainants The Complaints and Enquiries Lead can assist complainants making a complaint and can be contacted by phone on , in person or in writing to Chorlton House, 70 Manchester Road, Chorlton cum Hardy, Manchester 21 9UN, christine.trwoga@mhsc.nhs.uk or E mail box complaints@mhsc.nhs.uk or through the website on The Complaints and Enquiries Lead can access and will arrange support for complainants with literacy, language, visual and hearing impairment requirements. 18

15 Complainants must always be notified of the possible assistance that can be offered by ICA (Independent Complaints Advocacy). ICA can be contacted on (free from landlines and mobiles). Web site address There are also service user and carer groups across the city that can offer assistance to complainants. Details are available from the Patient Advice and Liaison Service on /2085. For inpatients the Rethink Advocacy Services can support patients raising concerns, complaints and comments. The Patient Advice and Liaison Service (PALS) can assist with quick resolution to concerns and can signpost service users, their relatives and carers to the complaints procedure where concerns cannot be resolved at front line level and to the ICA / advocacy services. PALS can be e mailed on PALS@mhsc.nhs.uk or contacted on /2085. The CQC can be contacted on , or by post to: Care Quality Commission, Citygate, Gallo gate, Newcastle upon Tyne, NE1 4PA or by at enquiries@cqc.org.uk. 8. Consent of service user for third party complaints If a third party makes a complaint and a response will require divulging confidential details about the service user s care and treatment, it will be necessary to seek their consent in order to fully respond to the complaint. In the case of complaints the Complaints and Enquiries Lead will request the service user s written consent. If a service user lacks the capacity to give informed consent their consultant psychiatrist will be consulted. Where a complaint requires consent that is not forthcoming, a general response may be made without disclosing confidential information. However it is recognised that such a response may be of limited value to the complainant. It is important to acknowledge that a service user s representative or carer can make a complaint in his or her own right without consent having to be sought. Examples might include how they themselves have been treated by staff or concerns about communication, information, carers assessment and hotel services on inpatient wards. 9. Duties and Responsibilities for complaints arrangements 9.1 Trust Board The Trust Board must ensure that organisations that the Trust contracts with (e.g. Creative Support, Jigsaw) have complaints handling arrangements in place. 19

16 9.2 Chief Executive The Chief Executive is the responsible person who will ensure compliance with the arrangements for complaints handling and ensure that action is taken if necessary in light of the outcome of a complaint. 9.3 Head of PALS, Complaints and Legal Services The Head of PALS, Complaints and Legal Services is the designated Complaints Manager and is responsible for the overall management of the procedures for handling and considering complaints in accordance with the arrangements under the Local Authority Social Services and National Health Service Complaints (England) Regulations Complaints and Enquiries Lead The Complaints and Enquiries Lead will maintain a register on DATIX of each complaint and concern received, the subject matter and outcome of each complaint, monitor the progress of investigations, the draft responses from investigating managers and any follow-up action that has been taken as a result of the complaint with the Care Groups affected. 9.5 Managers The responsibility for investigating complaints lies with the appropriate Care Group General Manager who will have overall responsibility for the investigation of the complaint and the preparation of any formal response. Managers are responsible for the implementation of learning from complaints and ongoing improvement to services as a result of feedback. 9.6 All staff All staff are responsible for listening and dealing with complaints and concerns in a sensitive and timely manner and for ensuring that service users care is not adversely affected in any way as a result of making a complaint. The responsibility for handling concerns / local complaints lies with all staff within the service where they are raised. 9.7 Patient Advice and Liaison Service (PALS) Service users, their relatives and carers may raise concerns with the Patient Advice and Liaison Service (PALS) who provide advice and information to try to resolve concerns quickly and in liaison with the service where they originate. The supportive atmosphere of PALS often assists in speedy local resolution of concerns. 10. Arrangements for the handling and consideration of complaints a) The Trust has arrangements in place for dealing with complaints that ensures that: Complaints are dealt with efficiently and in a timely manner Complaints are fully investigated with investigations being proportionate to the complaint made (see b. below) 20

17 Complainants are treated with sensitivity, respect and courtesy at all times Complainants receive, so far as is reasonably practical:- Assistance to enable them to understand the procedure in relation to complaints or Advice on where they may obtain such assistance All complaints will be monitored in relation to equality and diversity as part of meeting the statutory requirements of equality legislation. Complainants receive a timely and appropriate response Complainants are told the outcome of the investigation of their complaints Action is taken in light of the outcome of a complaint where appropriate b) Triage system for complaints All complaints received by the Trust will be triaged so they can be dealt with in the most appropriate way. The level of investigation should be proportionate to the level of risk. The complaint may be regraded following the investigation. Complaints triaged as green are those that are fairly straightforward and require a minimum level of intervention and are simple, non-complex issues. They should be the type of complaint or concern that requires a minimal level of fact finding prior to a prompt remedy or resolution being provided e.g. of complaints triaged as green are:- delayed or cancelled appointments, loss of property, lack of cleanliness, single failure to meet care needs. The majority of complaints triaged as green complaints should be managed and resolved by front line staff and the PALS service and are usually verbal. Complaints triaged as yellow relate to several issues during a short period of care e.g. events resulting in moderate harm, delayed discharge, failure to meet care needs, miscommunication or misinformation, staff attitude or communication. They require a higher level of intervention and it would always be expected that the investigator make contact either by phone or in person with the complainant. Complaints triaged as amber require a higher and more significant level of intervention. An Investigating Manager independent of the service being complained about may also need to be considered to ensure fairness and objectivity. There would be multiple issues relating to a longer period of care often involving more than one organisation or person. Amber complaints require a robust investigation and at all times require a face-to-face meeting with the complainant in addition to a thorough investigation and established plan of action. E.g., Amber complaints could be events resulting in serious harm. Complaints triaged as red are highly complex relating to multiple issues in respect of serious failures causing serious harm. An Investigating Manager 21

18 independent of the service being complained about will be appointed to ensure fairness and objectivity. Red complaints are usually being investigated as SUIs / or with the coroner. These complaints require a very in-depth investigation / root cause analysis. E.g. events resulting in serious harm or death, gross professional misconduct, abuse, criminal offence (assault). 11. Supporting Staff It is vital to support staff that are involved in a complaints investigation. Immediate support for staff must be identified and provided by their line manager. Additional and ongoing support is also available and can be provided internally or externally as required. Managers should refer to the Trust policy on Supporting Staff following Traumatic or Stressful Incidents for guidance. Other support materials are available to support the investigation of concerns and complaints, for example procedural guidance on handling complaints, templates for completion of reports, guidance on how to prepare witness statements, which can be accessed via the intranet or the Complaints and Enquiries Lead. 12. Arrangements for learning and improvements from complaints and concerns One of the major drivers within the Complaints Regulations 2009 is the importance of seeking continuous improvement through learning from complaints and demonstrating changes in practice. Learning from complaints is a powerful way of helping to improve public service, enhance the reputation of a public body and increase trust among the people who use its services. It is therefore important that the Trust regularly reviews lessons learnt from complaints and concerns and has systems in place for demonstrating changes in practice. To ensure the Trust is able to identify changes resulting from feedback and to monitor emerging trends and themes, a variety of reports are produced within the Trust as detailed below: A quarterly Complaints and PALS report to Patient Experience Committee will capture the learning from local complaints and concerns resolved informally, formal complaints, Ombudsman enquiries and from feedback through the community service user meetings. In addition the learning from the You said, we did scheme maintained by the PALS service on inpatient wards will feature in the report. PALS will display the learning from You said, we did scheme each month on posters displayed in each inpatient and outpatient area. The report will include an appendix containing a breakdown of all the actions from formal complaints where learning has been identified, progress on the delivery of the action and evidence of the action being carried out. In addition the report will include a summary of key learning, a breakdown by care group, trends, source of complaint, method of complaint, performance monitoring of achievement of response timescales, equality and diversity monitoring and identify the details of 22

19 local and wider organisational learning. This report will be disseminated to the Quality and Governance Care Group meetings and Matrons meetings for discussion and dissemination. An annual report on Complaints and PALS will be produced and submitted to Patient Experience Committee and Trust Board. Following approval the report will be placed on the Internet / Intranet and a copy sent to LINks, Clinical Commissioning Groups and the Overview and Scrutiny Committee. The report will be cascaded through the organisation through discussion at the Quality and Governance Care Group meetings and Matrons meetings. A quarterly Governance report will triangulate emergent themes through complaints, incidents and litigation and feed into local Care Group Quality Accounts and the Trust Quality account. This report will be disseminated to the care Group Quality and Governance meetings. Complaints triaged as red will be investigated using root cause analysis in line with the Serious Untoward Incident procedure. All red SUIs are fed back to the multi disciplinary team involved and where necessary lesson learned from the review, or required changes in individual practice, are discussed in supervision with individual practitioners. Where applicable, the Chief Executive s letter of response to a complainant must always include the lessons learnt and changes made to services, guidance or policy as a direct result of the issues raised in a complaint. 13. Cases subject to litigation The Department of Health s position is laid out in the consultation document Reform of health and social care complaints: Proposed changes to the legislative framework published in December 2008: The position in cases where legal action is being taken or the police are involved is slightly different. On receipt of a complaint in these circumstances, the Government will expect discussions to take place with the relevant authority (for example, legal advisors, the police, or the Crown Prosecution Service) to determine whether progressing the complaint might prejudice subsequent legal or judicial action. If so, the complaint will be put on hold, and the complainant will be advised of this fact. On receipt of a complaint in these circumstances, good practice is for discussions to take place with the relevant authorities (for example, local legal advisors or the NHS Litigation Authority) to determine whether progressing the complaint might prejudice subsequent legal action. The complaint should be put on hold only if this is so, with the complainant being advised of this and given an explanation. In other words, the default position in cases where the complainant has expressed 23

20 an intention to take legal proceedings would be to seek to continue to resolve the complaint unless there are clear legal reasons not to do so. In all cases, it will be important to ensure the potential implications for patient safety and/or organisational learning are investigated as quickly as possible to allow urgent action to be taken to prevent similar incidents arising. 14. Complaints about the provision of health services 14.1 Primary Care Trust From 1 April 2013, a complaint can be made to either the Trust, the NHS Commissioning Board, or the local Clinical Commissioning Group (whichever body commissioned the service in question). Where the commissioner receives a complaint they must ask the complainant whether they consent to the details of the complaint being sent to the provider and if the complainant consents the commissioner must send details of the complaint to the Trust. (See Regulations ) If the commissioner considers that it is appropriate for them to deal with the complaint they must notify the complainant and continue to handle the complaint in line with the regulations. If the commissioner considers it is more appropriate for the complaint to be dealt with by Manchester Mental Health and Social Care Trust and the complainant consents the commissioner must notify the complainant and the Trust and the Trust must then handle the complaint in line with the Regulations. The complainant is deemed to have made the complaint to the Trust under these circumstances Care Quality Commission Although the CQC do not investigate individual complaints they encourage people to share information with them as they believe involving people who use services in everything the CQC do will help improve services for everyone. The Care Quality Commission (CQC) monitors the care of people whose rights are restricted under the Mental Health Act and make sure their interests are protected. The CQC can provide advice and assistance to service users detained in hospital or on a community treatment or guardianship order who have concerns about their care. The Care Quality Commission require for the purposes of assessing, and preventing or reducing the impact of, unsafe or inappropriate care or treatment, that the Trust must have an effective system in place for identifying, receiving, handling and responding appropriately to complaints and comments made by service users, or persons acting on their behalf, in relation to the carrying on of the regulated activity. The Trust must send to the Commission, when requested to do so, a summary of: - 24

21 (a) Complaints made by service users, or persons acting on their behalf, in relation to the carrying on of the regulated activity and (b) Responses made by the Trust to such complaints Ombudsman If a complainant remains dissatisfied following the local resolution stage they have the right to take their complaint to the Local Commissioner under the Local Government Act 1974 (a) regarding social care complaints or the Health Care Commissioner under 1993 Act regarding health complaints Care provided in non NHS facilities Service Users, carers and relatives can raise concerns about care funded by the NHS but provided in non NHS facilities under the Complaints regulations Mediation There may be exceptional circumstances, for example a breakdown of relationship between the complainant and the Trust, where mediation may need to be considered. In such circumstances the agreement to involve a mediator would be taken by the Chief Executive/ appropriate director in discussion with the Head of PALS, Complaints and Legal Services. 16 Complaints that do not fall under the Regulations A complaint made by a responsible body i.e. a Local Authority, NHS body, primary care provider or independent provider A complaint made by an employee about any matter relating to their employment A complaint which has been made verbally and is resolved to the complainant s satisfaction in one working day A complaint where the subject matter is the same as that under (iii) which has been resolved A complaint, which has been resolved under the Regulations 2009, Regulations 2006 or Regulations A complaint which has been investigated by the Local Commissioners under the Local Governments Act 1974(a) or a Health Service Commissioner under the 1993 Act A complaint arising out of the alleged failure of the Trust to comply with a request for information under the Freedom of Information Act

22 Privately funded healthcare e.g. not being able to complain about services purchased by direct payment. However, a service user can use the new system if they have a complaint about the allocation of the funding or the support provided by the Local Authority to enable them to manage the direct payment The Care Quality Commission has the power to investigate complaints from detained patients. 17 Disciplinary procedure The policy will not be used to apportion blame amongst staff, and will therefore be separate from the Trust s disciplinary procedure. Information gained during the investigation of complaints may, however, indicate a need for a disciplinary investigation, which would then be dealt with under the disciplinary procedure. In the case of complaints, the manager investigating the complaint may be the person who will investigate and present the potential disciplinary case clearly stating this at the start of the investigation under the disciplinary procedure ensuring the member of staff is aware of this. 18 Duty to Cooperate / Joint Handling of Complaints Where complaints are received that are solely regarding other agencies, e.g. GPs, acute services, portering and hotel services they should be referred to the appropriate body by the Complaints and Enquiries Lead who will advise the complainant that this has been done. Where a complaint is made to the Trust, which relates in part to a local authority or another NHS provider then the organisations have a duty to cooperate and coordinate the handling of the complaint and ensure that the complainant receives a coordinated response. See Protocol on Joint Working on Complaints. 19 Publicity Posters and leaflets must be displayed in all departments giving details on how complaints, concerns, comments and compliments can be made. Copies of the Patients Advice and Liaison Service (PALS) leaflet and leaflets on how to raise complaints, concerns and feedback comments and compliments must be accessible and available to all service users, their relatives and carers in all public and service user areas in the Trust. The leaflets are also available on the intranet and internet In addition there is the facility to receive feedback by on pals@mhsc.nhs.uk and complaints@mhsc.nhs.uk and the Trust s website on The leaflets should be made available in different languages, large text, Braille up on request. Staff and the PAL service will support complainants with literacy needs by ensuring that the procedure is explained and can where necessary make arrangements for the ICA (Independent Complaints Advocacy) or the Complaints and Enquiries Lead to phone the complainant to assist with taking their complaint. 26

23 The PALS service distributes leaflets on how to raise complaints, concerns and feedback comments and compliments to each public area and audits the availability of the leaflets on a monthly basis. Inpatient Welcome Packs contain copies of (PALS) leaflet and leaflets on how to raise complaints, concerns. All first appointment letters to service users include the leaflet on how to raise complaints, concerns and feedback comments and compliments. 20 Dissemination of the Policy The approved policy and leaflets on how to raise complaints, concerns and feedback comments and compliments will be disseminated through to all staff and will be available on the Internet and Intranet following approval. 21 Annual Report In line with the Complaints Regulations 2009 the Trust must prepare an annual report each year, which must specify: - The number of complaints received The number of complaint which the Trust decided were well-founded The number of complaints referred to the Ombudsman Summarise the subject matter of the complaints, any matters of general importance arising from the complaints or the way the complaints were handled and any action taken to improve services as a consequence of complaints In addition, the Trust will report on the equality and diversity monitoring of complaints. A copy of the annual report must be sent to the Primary Care Trust and must be available to any person on request. A copy will be sent to the LINks (Local Involvement Network) and Health Scrutiny Committee. 22 Habitual and / or vexatious complainants The Trust reserves the right to refuse to accept a complaint where the complaint is clearly habitual, vexatious, malicious or motivated by discriminatory attitudes on the grounds of race, disability, gender, age, religion /belief, sexual orientation, transsexual or where the complainant threatens or abuses Trust staff. The decision as to whether a complaint is habitual and/or vexatious will be taken by the Chief Executive in consultation with the appropriate Executive Director and the Head of PALS, Complaints and Legal Services. (Refer to procedural guidance on handling unreasonable complainants). 23 Monitoring The Patient Experience Committee will monitor implementation of this policy. A quarterly report, which incorporates equality and diversity monitoring, on 27

24 complaints and PALS will be submitted to the Patient Experience Committee to provide the assurance that all aspects of complaints and PALS activity is monitored including the management of joint complaints. Failure to meet performance indicators as follows will be reported to Patient Experience Committee - complaint acknowledgements that have exceeded 3 working days and where investigations have exceeded 6 months. The quarterly report will monitor the progress of agreed improvements which will included as an appendix detailing each action, progress and evidence of completion. The PALS service will monitor the availability of leaflets and posters on each ward and outpatient department (quarterly) replenish any stocks that are low and report back the audit of results to the Patient Experience Committee, annually. Learning from local complaints and concerns resolved informally will be captured through the completion of the feedback forms and You said we did and will included in the quarterly Complaints and PALS report for Patient Experience Committee. The Complaints and Enquiries Lead will send out a questionnaire following each response from the Chief Executive to monitor the standard of complaints handling and to ensure that service users, their relatives and carers are not treated differently as a result of a complaint. An audit of complaints handling will take place annually and the outcomes and recommendations for improvement reported to the Patient Experience Committee. The Complaints and Enquiries Lead will monitor progress on action plans following complaints investigations in line with the agreed procedure. Failure to comply with agreed recommendations will be reported by the Complaints and Enquiries Lead to the Head of PALS, Complaints and Legal Services for including in the quarterly Patient Experience Committee. An annual complaints return, KO 41a, will be submitted to the Department of Health on 31 st March each year. 24 Training on policy Most concerns and complaints are received by front line staff working in hospital, community and day services. Resolving concerns and complaints is within the Listening, Responding, Improving training programme that is part of the Trust mandatory training programme. The training advises staff how to handle concerns and complaints in an open and fair way. Training for staff is prioritised to ensure that front line staff are offered training in the first instance. Corporate Induction for permanent and temporary staff includes guidance on how staff should handle concerns and complaints to promote good customer care. 28

25 25 References Local Authority Social Services and National Health Service Complaints (England) Regulations 2009 Department of Health the NHS Constitution 2009 Healthcare Commission Spotlight on Complaints: A report on second stage complaints about the NHS in England 2009 The Parliamentary and Health Service Ombudsman for England Principles on Good Complaints Handling; Good Administration and Principles for Remedy 2008 Department of Health: Making Experiences Count: A new approach to responding to complaints 2007 Department of Health: Listening, Responding, improving: A Guide to Better Customer Care 2009 Mental Capacity Act 2005 Code of Practice National Health Service (Complaints) Regulations 2004 National Health Service (Complaints) Amendment Regulations 2006 NHS Litigation Authority Guidance about complaints Being Open communicating patient safety incidents with patients and their cares (NPSA 2009) Department of Health Clarification of the Complaints Regulations 2009, (Gateway Reference Number:13508) Care Quality Commission Regulation 19 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2009 Equality Act 2010 Human Rights Act 1998 Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry (Robert Francis QC) Review, updating and archiving of this document This policy will be the subject of periodic review in the light of local practice and/or the receipt of changes to national procedures or guidelines and initially no later than September 2014, this will be the responsibility of the Head of PALS, 29

26 Complaints and Legal Services. The Head of PALS, Complaints and Legal Services will be responsible for holding the archive copy of the policy. 27 Cross referencing of policy This document should be cross-referenced with the following policies and procedures: - Incident and Critical Incident (Serious Untoward Incident SUI) Procedure and Practice Guidance including Data Incidents Safeguarding Vulnerable Adults Procedure Policy and Procedure for the Management of Clinical Negligence and Personal Injury Claims (including Liabilities to Third Parties scheme and Property Expense Scheme) Disciplinary Policy and Procedure Being Open Policy Mandatory Training Policy Policy for Investigation of Incidents /Complaints/Claims Supporting Staff following Traumatic or Stressful Incidents Policy Single Equality Scheme Procedural Guidance for staff on handling complaints and concerns 30

27 28 Protocol on Joint Working on Complaints Protocol on Joint Working on Complaints For information or advice please contact Head of PALS, Complaints and Legal Services Version Number: Name of originator/author: Head of PALS, Complaints and Legal Services Name of responsible committee: Clinical Governance Committee Name of executive lead: Director of Nursing and Therapies Date V1 Issued: February 2010 Last Reviewed: 3 September 2012 Next Review date: September 2014 Scope: Trust Wide 31

28 Protocol on Joint Working on Complaints Contents Section Title Page 1 Purpose of the Protocol 3 2 The Role of the Complaints Manager 3 3 Who should be the lead organisation? 3 4 Process 4 5 Complaints about one organisation that are addressed to 4 another organisation 6 Complainant s consent about sharing information between 5 organisations 7 Learning from Complaints 5 8 Review, updating and archiving of this document 6 9 References 6 10 Signatory organisations 6 APPX Flow Chart for Handling joint organisation complaints 7 1 APPX Statement of consent for the disclosure of personal 9 2 records APPX 3 Complaints Managers and other contacts in signatory organisations 10 32

29 Protocol on Joint Working on Complaints 1 Purpose of the Protocol If a complaint is made about care delivered by more than one organisation, it is important to provide a single point of contact and a single response to the complainant. Dealing with a wide range of health and social care organisations can be confusing for people. This protocol aims to address this, by bringing together the various health and social care organisations in Manchester to provide a unified, responsive and effective service for complainants. This protocol provides a framework for collaboration in handling complaints, to ensure: A single consistent and agreed contact point for complainants Regular and effective liaison and communication between complaints managers and complainants, and That learning points arising from complaints covering more than one body are identified and addressed by each organisation. 2 The role of the complaints manager The designated complaints manager in each organisation that signs up to this protocol is responsible for: Coordinating whatever actions are required Cooperating with other managers and agreeing who will take the lead role in joint complaints Ensuring that there is someone else to whom any requests for collaboration from other organisations can be addressed when they are absent. If complaints managers are unable to reach agreement about any matter covered by this protocol, they should refer to directors/senior managers in their organisations for resolution. 3 Who should be the lead organisation? When determining which organisation will take the lead role in a joint complaint, he complaints manager in receipt of the complaint should take into account (in discussion with complaints colleagues in other organisations if necessary): 33