Comments, Compliments and Complaints Policy. Document Title NTW(O)07. Reference Number. Medical Director. Lead Officer

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1 Document Title Reference Number Comments, Compliments and Complaints Policy NTW(O)07 Lead Officer Medical Director Author(s) (name and designation) Ratified by Keeley Brickle Complaints and PALS Manager Senior Management Team Date ratified October 2012 Implementation Date October 2012 Date of full implementation December 2012 Review Date October 2015 Version number V04.1 Version Type of change Date Description of change Review and Amendment Log V04 Review Oct 12 Reviewed policy documents From November 2012, Trust wide Policy Group approve policy documentation V04.1 Update Nov 13 Minor updates to content and standard appendices This policy supersedes: Reference Number NTW(O)07 V04 Title Comments, Compliments and Complaints Policy

2 Comments, Compliments and Complaints Section Contents Page No. 1 Introduction 1 2 Purpose 1 3 Duties 2 4 Consultation and communication with stakeholders 5 5 Definitions of terms used 5 6 Process for registering Comments and Compliments 6 7 Principles of Complaints Handling 6 8 Eligibility 7 9 Time Limits 8 10 Information for Complainants 8 11 Complainants rights 9 12 Support and advice for complainants 9 13 Making a complaint Resolving a complaint Request for review Capacity and Consent Confidentiality Complaints involving more than one Health or Social Care Organisation 19 Complaints about Private Practice Protecting Service Users Supporting Staff Handling unreasonable demands Equality impact assessment Training Implementation Monitoring and compliance Learning Fraud and Corruption Fair Blame Leaflets for Comments, Compliments and Complaints Policy Associated documentation References 21 15

3 Appendices within policy A Equality Impact Assessment tool 22 B Communication and Training Needs Information 25 C Audit/Monitoring Tool 26 D Policy Notification Record Sheet 28 Appendix No: Appendices - listed separate to policy Description Issue No: Issue Date Review Date 1 Complaints resolution process 2 Oct 13 Oct 15 2 Guidance for handling complaints involving 2 Oct 13 Oct 15 more than one organisation Joint Protocol 3 Action planning process 1 Oct 12 Oct 15 Practice Guidance Note listed separate to policy Document No Description Issue within V04 CCC-PGN-01 Comments, Compliments and Complaints Date issued Review Date Issue 1 Oct 2012 Oct 15 Appendix 01 Leaflet Have your say Issue 1 Oct 2012 Oct 15 Appendix 02 Leaflet - Have your say (how to complain) Easy to Read version Issue 1 Oct 2012 Oct 15 Appendix 03 Feedback form Issue 1 Oct 2012 Oct 15 Appendix 04 Compliment recording form Issue 1 Oct 2012 Oct 15 Appendix 05 Complaints Resolution Plan Issue 1 Oct 2012 Oct 15 Appendix 06 Sample resolution letter Issue 1 Oct 2012 Oct 15 Appendix 07 Sample Sign off Letter Issue 1 Oct 2012 Oct 15 Appendix 08 Complaints handling evaluation Issue 1 Oct 2012 Oct 15 Appendix 09 Follow Up Action Plan for Complaints Issue 1 Oct 2012 Oct 15 Appendix 10 Poster Have your say Updated May 12 Issue 1 Oct 2012 Oct 15 Advice Sheet 1 Investigating complaints Issue 1 Oct 2012 Oct 15 Advice sheet 3 Dealing with serious complaints Issue 1 Oct 2012 Oct 15 CCC-PGN-02 Vexatious Complainants Issue 1 Oct 2012 Oct 15

4 1 Introduction NTW(O)07 1.1, (the Trust) encourages all service users to give feedback on their experience. Comments, compliments and complaints are considered to be valuable learning tools and provide information that enables services to develop. 1.2 In 2006, the Government committed to helping NHS and adult social care organisations to improve the way they dealt with complaints, in order to make services more effective, personal and safe. To achieve this, it was decided that a single approach would be introduced for dealing with complaints, to give organisations greater flexibility to respond and encourage a culture that seeks and then uses people s experiences of care to improve quality. 1.3 Other reforms have since helped to strengthen this policy. The NHS Constitution makes clear what people should expect when they complain. The combined health and social care regulator, the Care Quality Commission (CQC), will require registered providers of services to investigate complaints effectively and learn lessons from them. 1.4 After extensive consultation and testing on the ground by early adopter sites, the new approach started from April When a mistake has happened, it is important to acknowledge it, put things right quickly and learn from the experience. This has been highlighted in many reports on NHS and social care complaints. (Making Things Better report 2005, Department of Health Commissioned survey 2005, Department of Heath Consultation document 2007, National Audit Office Learning from complaints handling in health and social care 2008, Healthcare Commission review 2009) 1.6 Government policies, such as those outlined in the NHS Constitution are already helping people understand their rights when it comes to making a complaint. However, this is not the only reason services need to get better at customer care. By listening to people about their experiences of health and social care services, managers can resolve mistakes faster, learn new ways to improve and prevent the same problems from happening in the future. In short, by dealing with complaints more effectively, services can get better, which will improve things for the people who use them as well as for the staff working in them. 1.7 From April 2009, a single approach was introduced for dealing with complaints about NHS and adult social care services. Organisations are encouraged to ask people what they think of their care, to sort out problems more effectively and to use the opportunities to learn. The new approach is designed to bring real benefits for health and care organizations and for the staff working in them and ensure that the Trust continues to comply with Care Quality Commission Essential Standards of Quality and Safety Outcome 17 2 Purpose 2.1 The receipt of comments and compliments is a valuable means of establishing service users feedback. 1

5 2.2. It is important that the Trust is aware when things have gone well so it can identify and promote examples of good practice The Trust requires a system to deal quickly and effectively with complaints, promoting collaborative working with the complainant to achieve a satisfactory outcome and to make good use of the information gained, to learn and avoid similar situations occurring in the future The purpose of this policy and accompanying Practice Guidance notes is to provide a framework in which comments, compliments and complaints can be dealt with effectively in accordance with the Local Authority Social Services and National Health Service Complaints (England) Regulations 2009 (2009 Complaints Regulations) and the Ombudsman s principles of: 3 Duties 3.1 Chief Executive 1. Getting it right 2. Being customer focused 3. Being open and accountable 4. Acting fairly and proportionately 5. Putting things right 6. Seeking continuous improvement The Chief Executive has overall responsibility for ensuring compliance with the arrangements made under the 2009 Complaints Regulations and in particular ensuring that action is taken, if necessary, in light of the outcome of a complaint. The Chief Executive may nominate the Medical Director to execute this responsibility in their absence Following resolution of a complaint, the Chief Executive will write to the complainant including:- (i) (ii) an explanation of how the complaint has been considered the conclusions reached in relation to the complaint including any matters for which the complaint specified, or the Trust considers, that remedial action is needed The Chief Executive will confirm that they are satisfied that any action needed in response to the complaint has been taken or is proposed to be taken and inform the complainant of their right to take their complaint to the Parliamentary Health Service Ombudsman. 3.2 Medical Director The Medical Director is responsible for ensuring that procedures are developed, agreed and implemented throughout the Trust and are monitored as appropriate. 2

6 NTW(O) Deputy Director of Clinical Governance / Deputy Medical Director (Quality and Safety) The Deputy Director of Clinical Governance / Deputy Medical Director (Quality and Safety) shall on behalf of the Medical Director ensure a robust system of complaints management is in place underpinned by sound clinical and corporate governance arrangements. 3.4 The Head of Safety / Patient Experience The Head of Safety and Patient Experience will through the safety / patient experience structure ensure that a robust system of complaints management is in place. The safety / patient experience structure has been created to facilitate effective reporting, investigation and communication of all complaint activity both internal and external to the Trust. 3.5 Complaints and PALS (Patient Advice and Liaison Services) Manager The Complaints and PALS Manager is responsible for managing the procedures for handling and considering complaints in accordance with the 2009 Regulations, reporting to the Quality and Performance Committee (assurance group for the Board of Directors) The Complaints and PALS Manager manages the Complaints function and is responsible for the complaints process, policy and procedures. They are also responsible for maintaining the central database for comments, compliments and complaints, producing statistical data to populate the above reports and monitoring action plans. The Complaints and PALS Manager will use the Safeguard electronic system to improve the quality and performance of complaints management The Complaints and Pals Manager will inform the Head of Safety and Patient Experience or the Clinical Risk Manager where a complaint is likely to generate media interest or is related to a serious incident, who will consider the impact and escalate to Directors as appropriate. 3.6 Group Directors It is the responsibility of the Group Directors to allocate complaints to individuals in agreement with the Complaints department, and they will respond to the reporting notification. 3.7 Directorate Managers It is the responsibility to quality check and approve complaint responses and to check against the original complaints letter. 3.8 Service Managers It is the responsibility of Service Managers to ensure that actions from complaints for improvements to the quality and safety of care are implemented in a timely manner, this will include a review of all complaints for their services, so that they can assess whether the complaints also sit in other locations. 3

7 3.9 Complaints Investigators The services will identify suitably skilled individuals to investigate complaints, staff who have not investigated complaints before, but are identified to investigate complaints, will be supported by the complaints team and other staff who have investigated complaints. Training will be available for staff that are asked to investigate complaints Where there are specific complex issues relating to specialist areas of service provision or expertise, then a lead clinician or specialist will be identified to support the Complaints Investigator, an example of this may be information governance due to a breach of confidentiality All nominated clinical and operational staff are responsible for implementing the Complaints Resolution Plan. This may involve resolution at ward/ department level (Category 1) or may require the undertaking of a detailed investigation by a Complaints Investigator (Category 2 and 3) that person is referred to hereafter as The Complaints Investigator The Complaints Investigator will complete a formal response and give preliminary feedback to the complainant in advance of the agreed final response date As part of the feedback the Complaints Investigator must enquire and record whether the complainant is satisfied with the response or whether there maybe further work to do. It must be acknowledged at this point it is not the expectation to re-investigate the same complaint again, and equally if there are new issues there should be consideration of a new complaint, and also consideration in line with Vexatious Complainants PGN The formal response will include: (i) An introduction from the Complaints Investigator. An apology in line with the principles of Being Open The specific agreed areas of concern, with an explanation of how each of the concerns have been considered and addressed and whether they have been upheld or not. (ii) The conclusions reached from the investigation and any improvements that need to be completed The Complaints Investigator is responsible for negotiating any request for extension to the above timeframes with the complainant. An extension can only be agreed with a complainant or someone acting on behalf of the complainant. The Complaints Investigator will inform the Complaints Team and the Service Manager of the area about the extension The completed response letter should be forwarded electronically to the Complaints department in advance of the timeframe for responding to the complainant, consideration must be given to the time needed for quality checks (see section 14.6), within the department and the Chief Executives Office. 4

8 3.10 Employees Every individual employed by the Trust or undertaking work on behalf of the Trust is expected to co-operate fully as required in the handling and investigation of complaints. (This includes staff employed as bank, agency or on honorary contract) This may include providing statements or attending meetings in a timely manner, which will not delay the completion of the response. Ensure that care and treatment is not adversely compromised as a consequence of a complaints 3.11 Quality and Performance Committee The committee will receive a monthly report on all complaints, highlighting any areas of concern Directorate Quality and Performance Groups Directorate Groups will receive complaint information relating to their activity in the form of a CLIPP report (Complaints, Litigation, Incidents, PALS and Points of You). This will bring together all their safety and patient experience activity into a central report. 4 Consultation and Communication with stakeholders 4.1 This is an existing policy with additional / changed content that relates to operational and / or clinical practice and was therefore circulated to the following for a two week consultation period: Senior Management Team Local Negotiating Committee Consultant Psychiatrists Planned Care Specialist Service Urgent Care Psychological Services Clinical Governance and Medical Directorate Safeguarding Trust Allied Health Professions Service Steering Group Finance, IM&T, Estates and Performance Staff-side Trust Pharmacy Workforce Communications 5. Definition of Terms used 5.1 Complaint. A complaint is a generic term for any expression of discontent raised by people using services i.e. patients, service users, their carers, relatives and advocates. The expression of discontent can be verbal, in writing or electronic and a response is required. See Appendix 1 Complaints Resolution Process for further information 5

9 Category 1. (Low in terms of complexity and risk) NTW(O)07 o 20 working days from date of receipt of complaint to date of letter from a Trust representative Category 2. (Moderate in terms of complexity and risk) o 25 working days from date of receipt of complaint to date of letter from the Chief Executive Category 3. (High in terms of complexity and risk) o 35 working days from date of receipt of complaint to date of letter from the Chief Executive Joint Complaint (Cross Organisational Issues) o 35 working days from date of receipt of complaint to date of letter from the Chief Executive in agreement with joint complainants, if NTW is the lead responder. 6 Process for registering Comments and Compliments 6.1 Whenever possible, details of comments received in service areas should be acknowledged by the service area and copied to the Complaints and PALS Manager to be logged onto the central database and included in the CLIPP reports. 6.2 Ward or Department Managers and Team Leaders should submit this information. 6.3 Any comments received in the Complaints Department will be acknowledged by the Complaints Department, logged onto the central database and included in the CLIPP reports. 6.4 Any compliments received in service areas should be acknowledged by the service area and copied to the Complaints and PALS Manager to be logged onto the central database and included in the CLIPP reports. 7 Principles of complaints handling 7.1 In compliance with the 2009 regulations, The Trust has a legal responsibility to Publicise the complaints procedures Acknowledge each complaint received within 3 working days and offer to discuss the matter with the complainant, collaboratively agreeing on the resolution plan and timescales Deal efficiently with complaints and investigate them properly and appropriately Treat complainants with respect and courtesy Write to the person who complained once the complaint has been dealt with, explaining how it has been resolved and what appropriate action has been taken, and reminding them of their right to take the matter to the Parliamentary Health Service Ombudsman if they are still unhappy 6

10 Have someone senior within the organisation who is responsible for both the complaints policy and learning from complaints Help the person who is complaining to understand the complaints procedure Produce an annual report about complaints that have been received and outline what has been done to improve things as a result. Provide or contribute to one, coordinated response if the complaint involves two or more organisations 8 Eligibility 8.1 A complaint may be made by: (a) (b) A person who receives or has received services from the Trust; or A person who is affected, or likely to be affected, by the action, omission or decision of the Trust 8.2 A complaint may be made by a representative acting on behalf of a person mentioned above whom: (a) Has died (b) Is a child (c) Is unable to make the complaint themselves because of: (i) physical incapacity; or (ii) lack of capacity within the meaning of the Mental Capacity Act 2005 or (d) Has requested the representative to act on their behalf Where a parent / guardian makes a complaint on behalf of a child, the Trust must be satisfied that there are reasonable grounds for the complaint being made by a parent / guardian instead of the child. If the Trust is not satisfied of this, the parent / guardian must be notified in writing, giving the reason for this decision Where the representative makes a complaint on behalf of a child; or a person who lacks capacity within the meaning of the Mental Capacity Act 2005, the Trust must be satisfied that the representative is conducting the complaint in the best interests of the person on whose behalf the complaint is made. If the Trust is not satisfied of this, the representative must be notified in writing, giving the reason for this decision. 8.3 Complaints not required to be dealt with under the 2009 Regulations A complaint by another Trust or Healthcare organisation, unless agreed as a joint complaint with the other healthcare organisation A complaint by an employee of the Trust about any matter relating to that employment A complaint which is made orally; and is resolved to the complainant s satisfaction not later than the next working day after the day on which the complaint was made. 7

11 8.3.4 A complaint the subject matter of which is the same as that of a complaint that has previously been made and resolved not later than the next working day after the day on which the complaint was made A complaint the subject matter of which has previously been investigated under these Regulations or the 2004 Regulations A complaint the subject matter of which is being or has been investigated by the Healthcare Commission under the 2004 regulations A complaint arising out of the alleged failure of the Trust to comply with a request for information under the Freedom of Information Act A complaint which relates to any issue of the Superannuation Act Where the Trust decides that it is not required to consider the complaint, the complainant should be notified in writing giving the reason for the decision. 9 Time Limits for making a Complaint 9.1 It is important that complainants make their complaints as soon as possible after the event(s) which led to their complaint. 9.2 A complaint can be made within 12 months of the incident. However, if it has taken the service user some time to discover the problem, then the time limit is within 12 months from the point of discovery. 9.3 Where a complaint is made after the expiry of the period mentioned above, the Complaints and PALS Manager may arrange to have it investigated if he/she is of the opinion that: a) Having regard to all the circumstances, the complainant had good reasons for not making the complaint within that period; and b) Notwithstanding the time that has elapsed, it is still possible to investigate the complaint effectively and efficiently. 9.4 When a complaint is made outside the time limit, the Complaints and PALS Manager in collaboration with the Directorate Manager will decide whether or not to waive the time limit. 9.5 In any case where the Complaints and PALS Manager has decided not to investigate a complaint on the grounds that it was not made within the time limit, he/she must write to the complainant explaining the reasons why the complaint cannot be investigated. 10 Information for Complainants 10.1 It is important to provide information that explains very clearly how people can give their views including how to complain. 8

12 10.1 All wards, departments and teams should ensure that they have sufficient supplies of information leaflets. Additional copies may be obtained from the Complaints Department. The information is also available on the Trust internet and intranet sites Where Service Users require Interpretation or translation services, staff should refer to the Trust Policy for Interpreter/Translation Services. Producing information letters in Braille or languages other than English can be considered by contacting the Equality and Diversity Officer 11 Complainants rights 11.1 Complainants rights in the NHS are articulated by the NHS Constitution which states that any individual has the right to: Have any complaint they make about NHS services dealt with efficiently and have it properly investigated Know the outcome of any investigation into their complaint Take their complaint to the independent Parliamentary Health Service Ombudsman if they are not satisfied with the way the NHS has dealt with their complaint Make a claim for judicial review if they think they have been directly affected by an unlawful act or decision of an NHS body Receive compensation where they have been harmed by negligent treatment. 12 Support and advice for complainants 12.1 Service Users and Carers should be made aware of the services provided by the Patient Advice and Liaison Service (PALS) The role of the PALS officer is to: Listen to concerns, suggestions or queries Advise and support patients, their families and carers Provide information about NHS and social care services Help sort out problems quickly Be visible, approachable and accessible Act as an early warning system for Trusts and Patients Forums The PALS Officers aims are to establish a close working relationship with healthcare service providers, user/carer groups and support agencies. They will be aware of existing organisations offering information and other services, and will work to maintain close liaison with them to refer patients and carers as appropriate. 9

13 The service is confidential and clients written consent is sought at all times before any concern is discussed with others PALS officers are available to sort out problems and complement the complaints system. People may choose to speak to PALS first, especially if the difficulty can be resolved quickly. Effective intervention by PALS may prevent issues needing to become complaints PALS can be considered as an intervention option if someone has made a complaint to the Trust PALS staff do not provide clinical advice and will refer anyone with the need for clinical advice or treatment to the appropriate professional There are PALS officers based in most Hospital sites. North of Tyne PALS South of Tyne PALS Service Users and Carers should be made aware of the services provided by the Independent Complaints Advocacy Service (ICAS) Some people will need help making their complaint, and ongoing support while it is resolved. Independent advocacy support can be invaluable here, in speaking to someone in strict confidence who is independent and impartial. In the NHS, advocacy is provided by the Independent Complaints Advocacy Service (ICAS) ICAS will ensure that patients, their carers and families have access to independent help and support if they think they may have a complaint about their NHS treatment and care: They help service users to identify the courses of action open to them (including complaints procedure) and any other options for addressing problems They provide service users with information, advice, practical assistance and representation, as required and appropriate to support them throughout the complaint process (e.g. helping them write letters, supporting them at meetings, contacting third parties, etc) They ensure that lessons from users experiences of the NHS and complaints procedure are fed back to policy makers, senior managers and those responsible for scrutinising the NHS The contact telephone number for the ICAS North East is Advocacy is also provided by independent advocacy services. 10

14 13 Making a complaint NTW(O) A complaint may be made orally, in writing or electronically via , either by letter or complaints form. An electronic facility to make a complaint on line, is available on the Trust internet site, please click below Where a complaint (that cannot be resolved to the complainants satisfaction within 24 hours) is made orally. A staff member, either clinical staff or from the Complaints Team will need to make a written record and confirm the contents with the complainant Communication to the complainant may be made electronically providing the complainant has given consent for this. 14 Resolving a complaint As described in the role of the complaints investigators Acknowledge All Complaints should be forwarded to the Complaints Team at St Nicholas Hospital as quickly as they are received. All complaints forwarded to or received in the Complaints Team will be acknowledged not later than 3 working days after the date of receipt. The complaint will be logged on to the electronic system and any consent issues will be considered Complaints received directly in the Chief Executive s office will be acknowledged by the Chief Executive s staff and forwarded to the Complaints Team Understand It is important to understand why the person is dissatisfied and to understand the level of seriousness of the situation in order to know the options and agree on the right course of action Listen When a person wishes to make a complaint, the initial contact an organisation has with a person who is unhappy about their service is key in setting the scene for successful resolution. The Complaints Investigator will contact the complainant, whenever possible, to clarify issues, establish outcomes, manage expectations, offer support and commence the Resolution Plan Plan A jointly agreed plan with a realistic outcome and timeframe is crucial in ensuring that services respond in the right way to every complaint and resolution is more likely to be achieved. It also gives the person that is complaining more confidence that their concerns are being taken seriously The complaint should be investigated in a proportionate manner, appropriate to resolve it speedily and efficiently 11

15 The way forward can be selected from a number of options which could include: PALS Meeting or telephone contact with appropriate Trust staff ( e.g. Manager) Meeting with a negotiator Formal complaints investigation Mediation Conciliation Utilising information for any related ongoing investigation (e.g. Serious Incident investigation. Disciplinary investigation, Safeguarding investigation Or, a combination of any of the above 14.5 Act The Complaints Team will send a New Complaint for Allocation to the Group Director asking for a Complaints Investigator to be allocated within 24 hours The Group Director will allocate the complaint to a relevant member of staff, and notify the Complaints Department who will then send out a You have been allocated a complaint to the relevant person with all relevant documents to assist them attached. An evidence wallet will be sent in the post. This will ultimately be scanned onto the database when the complaint is completed for future reference and management The timescales set out in definitions of terms used (Section 5) are the Trust standards and should be met. The Complaints Investigator will need to negotiate any further extensions with the complainant, and advise the Complaints department and the Service Manager of any extensions The Trust will be measured on the extent to which it responds to complainants within the agreed time frames Any complaint that has not been resolved within six months of date of commencement will be subject to a review by the Group Directors Respond The Complaints Investigator will produce a formal response letter and give preliminary feedback to the complainant in advance of the agreed final response date As part of the feedback the Complaints Investigator must enquire and record whether the complainant is satisfied with the response or whether there maybe further work to do. It must be acknowledged at this point it is not the expectation to re-investigate the same complaint again, and equally if there are new issues there should be consideration of a new complaint, and also consideration in line with Vexatious Complainants CCC-PGN

16 The completed response letter should be forwarded electronically to the Complaints Department in advance of the timeframe for responding to the complainant, consideration must be given to the time needed for quality checks as listed below, within the Department and the Chief Executives Office The Complaints staff will electronically forward the response letter, together with the original complaint letter and verification checklist to the Verifying Manager (Directorate Manager or Service Manager) for verification. Any complaints relating to medical staff should also be verified by the Group/Clinical Directors. The Complaints Investigator will post or hand-deliver the evidence wallet to the Complaints Office at St Nicholas Hospital The Complaints staff will make spelling and grammar checks to the response letter within 24 hours of receipt where possible and check the complaints file containing evidence The Head of Safety and Patient Experience will undertake quality checks within 24 hours where possible and send back to Complaints Administrators The Complaints Administrators will send to Chief Executive PA for final checks and signing off by the appropriate Directors / Chief Executive within 5 days where possible. The Chief Executive or nominated deputy will sign the cover letter informing the complainant of their right of appeal. If for any reason, there is a delay on the response letter being sent to the complainant (no signatories available or amendments to be made or further work to be carried out), the Complaints Administrator must be notified and a holding letter will be sent to the complainant Learn and improve If the Complaints Investigator considers that action is required, they should indicate this in the response letter and commence an action plan All proposed action plans should be forwarded electronically with the response letter to the Complaints Department who will send it to the Verifying Manager for verification The Verifying Manager will nominate a Lead Manager who will be responsible for co-ordinating the action plan and ensuring that action has been implemented in the service area The Complaints Department will monitor action plans on an individual basis consistent with the prescribed timeframes The Service Manager will take the completed action plans to the Group Quality and Performance meeting and other appropriate meetings in order to share the learning The Service Manager will then forward the completed action plan to the Complaints Department. It will be formally signed off and closed Themes will be anonymously reported in the CLIPP reports. 13

17 At the conclusion of a complaint, the complainant will be given the opportunity to comment on the experience by way of a feedback form including whether or not they felt they were treated differently as a result of raising a concern 15 Request for Review 15.1 The Chief Executive, in signing off the response to a complainant, will ensure that the complainant is advised of their right to contact the Parliamentary Health Service Ombudsman if they are dissatisfied with the outcome After ensuring that the complaint is within their jurisdiction, the Ombudsman will check that everything has been done to resolve the issue locally. If they think more can be done, they will refer the issue back to the service Before taking the matter on, the Ombudsman will consider several factors: What has gone wrong? What injustice has this caused? What is the likelihood of achieving a worthwhile outcome? 15.3 If the Ombudsman believes there is a case to answer, they will direct the organisation to put things right. 16 Capacity and consent 16.1 As detailed in Section 8.2 of this policy, in certain circumstances, a representative may complain on a service user s behalf 16.2 To protect the service user s right to confidentiality, in circumstances where responding to the complaint requires the disclosure of health information; the service user will need to give consent for their health records to be accessed and for information to be shared with the complainant No assumption should be made regarding whether or not the service user has the mental ability (or capacity) to decide whether or not they wish this information to be shared. Therefore in accordance with the Mental Capacity Act 2006, the Complaints staff will obtain a capacity assessment made by the service user s Consultant Psychiatrist or Care Coordinator regarding whether or not the service user has the ability to make these decisions If the capacity assessment concludes that the service user has the capacity to make these decisions, the Complaints staff will write to the complainant to advise them that consent from the service user will be required. They will also write to the service user to seek that consent enclosing a consent form and a copy of the complaint letter unless that complainant has indicated that there is information contained in the complaint letter that they do not intend to be shared with the service user 16.5 Investigation into the complaint will not commence until consent is obtained. 14

18 16.6 If the capacity assessment concludes that the service user does not have the capacity to make these decisions or, the Complaints and PALS Manager in conjunction with the clinical team, will decide whether or not the complaint should be investigated in the service user s best interest If the service user, who has capacity, decides to withhold consent, the Complaints and PALS Manager will decide whether any general issues can be considered without accessing clinical information 17 Confidentiality 17.1 All correspondence should be marked Confidential Communication to the complainant may be made electronically providing the complainant has given consent for this 17.3 Complaints documentation should not be placed with a service user s clinical record Wherever possible, the exchange and transportation of a complaint file should be made by hand to avoid unnecessary delay. However, it is appreciated that this may not always be possible and the most safe and appropriate method of delivery should be discussed with the Complaints Team. 18 Complaints involving more than one NHS/Social care organisation (Appendix 2) 18.1 A protocol has been agreed between Northumberland Tyne and Wear NHS Foundation Trust and the partner organisations as outlined in Appendix 2 19 Complaints about Private Practice 19.1 When a complaint is made regarding private practice: If the individual was doing work for another designated body when the complaint arose, this needs to be investigated by that designated body. The outcome should be shared with our Trust If the individual was doing work as a private contractor, but on a referral basis, i.e. from social care or a GP practice or a third party then it is the responsibility of social care, GP or the third party to investigate, and share the outcome with the Trust If the individual was doing this work as a private contractor, based purely on the basis of the service user contacting them directly via the yellow pages/website etc, then the service user should be referred to seek advice via the Patient Advice and Liaison Service (PALS) or the Independent Complaints and Advocacy Service (ICAS), or the CQC as the regulators of healthcare. 15

19 20 Protecting Service Users NTW(O) As an employee of the Trust, concern about standards of care, treatment and services provided for users are of paramount importance. During the course of an investigation, concerns may be raised about the care or treatment given to an individual user, or a particular group of users. Staff who find themselves in this position should refer this to their Directorate Manager or Professional Lead for consideration of the implementation of Local Safeguarding Adult or Children procedures (Refer to local Safeguarding Adult and Children policies and Appendix 18) In such circumstances when another Trust procedure is instigated e.g. the Disciplinary Procedure, Serious Incident investigation or Safeguarding Adults or Children procedures, the Investigating Officer will, being mindful of confidentiality, contact the complainant and revise the plan accordingly. 21 Supporting Staff 21.1 Staff have a clear duty to provide assistance in the investigation/resolution of complaints The Complaints Investigator should inform any staff that have been named by the complainant, that a complaint has been made in relation to them. All named staff should be informed at the same time The Complaints Investigator should inform staff named in the complaint and assisting with the investigation of the expected completion date and if the timescale is extended Staff assisting in an investigation of a complaint, have the right to be represented by a trade union official (not acting in a legal capacity) or a colleague, whenever they are interviewed. The Complaints Investigator should ensure that staff are aware of this right 21.5 The Complaints Investigator should ensure that meetings with complainants are held in venues that are away from the staff bases of staff that have been named in the complaint Managers should give consideration to methods of supporting staff who are assisting in the investigation as it is recognised that this can be a stressful time. This may include access to the Trust counselling service and other methods of immediate and ongoing support such as clinical supervision. Managers should maintain regular contact should the Human Resources Department to agree the best plan for supporting staff members who are on sick leave especially if the sickness is related to the complaint On conclusion of the complaint resolution, The Complaints Investigator should inform staff assisting in the investigation of the outcome 22 Handling unreasonable demands 22.1 On rare occasions, despite best efforts to resolve a complaint, the complainant can begin to make unreasonable demands. It is important to know how to handle circumstances such as these. 16

20 There are a number of ways to help manage the situation: o Make sure contact is being overseen by a manager at an appropriate level in the organization o Provide a single point of contact with an appropriate member of staff and make it clear to the complainant that other members of staff will be enable to help them o Ask that they contact you only in one way, appropriate to their needs (e.g. by phone) NTW(O)07 o Place a time limit on any contact with the complainant o Restrict the number of calls or meetings you will have with them during a set period o Ensure that any contact involves a witness o Refuse to register repeated complaints about the same issue o Only acknowledge correspondence you receive about a matter that has already been closed o Explain that you do not respond to correspondence that is abusive o Make contact through a third person such as a specialist advocate o Ask the complainant to agree how they will behave when dealing with your service in the future o See attached Practice guidance note on dealing with vexatious complainants, CCC-PGN Return any irrelevant documentation and remind them that it will not be returned again. When using any of these approaches to manage contact with unreasonable or aggressive people, it is important to explain what you are doing and why, and to keep a detailed record of the ongoing relationship You can read more advice on dealing with unacceptable behaviour and unreasonably persistent complainants at / Publications / guidance-notes / unreasonably persistent -complainants/ 23 Equality Impact Assessment In conjunction with the Trust s Equality and Diversity Officer, this policy has undergone an Equality and Diversity Impact Assessment, which has taken into account all human rights in relation to disability, ethnicity, age and gender. The Trust undertakes to improve the working experience of staff and to ensure everyone is treated in a fair and consistent manner. (See Appendix A). 24 Training Appendix B 24.1 Levels of training are identified in the training needs analysis and are included within the Training Guide which can be accessed via this link 17

21 25 Implementation 25.1 Taking into consideration all the implications associated with this policy and its predecessor s ratification, implementation will be achieved within 3 months of ratification. 26 Monitoring and Compliance of the Complaints Policy and practice guidance notes There are a number of ways in which the compliance to this policy and practice guidance notes will be monitored (see Appendix C): Frequency of Reporting The Trust has in place numerous reporting and monitoring systems for Incidents, Complaints and Claims, these are:- Daily automated update reports into clinical dashboards Weekly updates to Directors relating to serious incidents and complaints Weekly reports to clinical groups on serious incidents and complaints communications to team around complaints activity as it occurs Monthly reports to Quality and Performance Committee on all Incidents, Complaints and Claims activity highlighting any areas of concern, this report includes incidents reported to external agencies to allow for effective monitoring Monthly reports to Directorate Quality and Performance Committees on all Incident, Complaints and Claims activity highlighting any areas of concern Monthly reports shared with Commissioners Bi-monthly reports to Board of Directors on all Incident, Complaints and Claims activity highlighting any areas of concern Annual reports to Board of Directors on all Incident, Complaints and Claims activity Annual submission to NHS Information Centre for Complaints Activity 26.2 Responsibility It is the responsibility of the Head of Safety / Patient Experience to ensure that the above information is provided to the required services within the required timescales. 18

22 26.3 Method The Safety / Patient Experience function of the organisation will facilitate and support the Trust s reporting systems All of the Trusts incident, complaints and claims information is collated using the Safeguard system, this system is utilised to produce the reports listed above, it links externally to both the National Reporting and Learning Service and the Security Incident Reporting System, it also links internally with the Trusts ESR (Electronic Staff Record) system as well as RIO the Trusts Electronic Patient Record, this ensures quality of information The system generates over 30,000 automated electronic reports to named contacts via the Trust s system, some of these reports relate specifically to complaints, and indicates timescales for completion A number of reports are produced manually for corporate groups, with text added to add an assessment to what the information is about and whether there are any concerns The Complaints and PALS Manager will maintain statistical information in relation to Each complaint received The subject matter and outcome of each complaint The expected response time for the complaint That the complainant was informed of this Any amendment to the timeframe Whether the resolution was agreed within the final timeframe The Complaints and PALS Manager will maintain statistical information in relation to The number of complaints received The number of complaints that the Trust decided were well founded The subject matter of each complaint Any matters of significance arising out of complaints The number of cases reported to the Ombudsman Any matters where action has been taken to improve services as a consequence of a complaint The Complaints and PALS Manager will produce monthly reports to Quality and Performance Committee and an Annual Report will be available. This report will demonstrate the level of compliance towards Care Quality Commission Standards of Quality and Safety Outcome 17 19

23 27 Learning NTW(O) As activity is reported and investigated utilising the Trust s corporate systems, a number of actions and learning points can be identified at any point throughout the life of an incident, complaint or claim and as such the actions and learning points are varied appendix E shows the learning points across the pathway of governance activity. 28 Fraud and Corruption 28.1 In accordance with the Trust s policy NTW(O)23 Fraud and Corruption/Response Plan, all suspected cases of fraud and corruption should be reported immediately to the Trust s Local Counter Fraud Specialist or to the Executive Director of Finance 29 Fair Blame 29.1 The Trust is committed to developing an open learning culture whereby mistakes can be acknowledged and learnt from. It has endorsed the view that, wherever possible, disciplinary action will not be taken against members of staff who have been complained about, although there may be clearly defined occasions where disciplinary action will be undertaken. 30 Policy Leaflets for Comments, Compliments and Complaints 30.1 Any information given to patients needs to be in an accessible format, accurate and branded correctly. (the Trust) follows the process around production of this information as outline in the Trust s policy, NTW(O)03 Accessible Information for Patients, Carers and Public Patient Information leaflets will be reviewed every 2 years with the exception to those documents which are reviewed on an annual basis. However, should there be any changes in legislation or practice; all documents will be reviewed immediately irrespective of review date. 31 Associated documentation 31.1 This policy should be read in conjunction with: NTW(O)01 - Development and Management of Procedural Documents Policy NTW(O)03 - The Production of Accessible Information for Patients, Carers and Public Policy NTW(O)05 - Incident Reporting Policy NTW(O)09 - Records Management Policy NTW(HR)04 - Disciplinary Policy NTW(C)04 Safeguarding Children Policy NTW(C)24 Safeguard Vulnerable Adults Policy Local Safeguarding procedures 20

24 32 References Healthcare Commission, Spotlight on complaints: A report on second-stage Complaints about the NHS in England, 2009 The Principles of Good Complaint Handling, Parliamentary and Health Service Ombudsman 2008 Department of Health commissioned survey, 2005 Department of Health, The NHS Constitution, 2009 HM Government, Our health, our care, our say: a new direction for community services, The Stationery Office, Department of Health, Listening, Responding, Improving. A guide to better customer care 2009 National Audit Office, Feeding back? Learning from complaints handling in health and social care, The Stationery Office, Local Authority Social Services and National Health Service Complaints (England) Regulations 2009 The Stationery Office, 2009 NHS Litigation Authority guidance about complaints Being open communicating patient safety incidents with patients and their carers (NPSA, 2009) 21