Complaints Policy and Procedure

Transcription

1 Hinchingbrooke Health Care NHS Trust NHS Complaints Policy and Procedure Status: Draft Date: November

2 Contents: 1 Introduction General Principles Local Resolution Healthcare Commission Independent Review Recording and Monitoring Support Mechanisms Appendix CHECKLIST FOR WRITING A STATEMENT

3 1 Introduction 1.1. The NHS Plan contains a commitment to create an NHS that puts patients at the heart of everything it does The Trusts appreciates that although staff strive to provide a high quality of care, sometimes things go wrong or there is a perception that the level of quality is below what should be expected. When this occurs, complaints may be made Complaints may be defined as expressions of dissatisfaction with any aspect of the Trust services or staff performance, by a patient or patient group, visitor, carer, member of the general public or a member of staff Every NHS organisation has a statutory obligation to have in place a policy and procedure which allows complaints to be addressed and responded to, in a timely, efficient and effective way The Trust s Complaints Manager has delegated responsibility from the Chief Executive to investigate and manage the complaints process within the Trust. 2 General Principles 2.1. This procedure is applicable to any person making a complaint Complaints can be written or verbal and may be addressed to any level of the organisation. Verbal complaints should be referred to the PALS service in the first instance if Modern Matrons or ward managers cannot resolve, if local resolution can not be achieved at this stage, the All complaints must be referred to the formal complaints procedure Complaints investigations should be seen as constructive and the information should be used, whenever possible, as a process for quality improvement. To facilitate this, copies of complaints and final responses will be sent to the appropriate Clinical Directors and Directorate Managers Associate Directors for action Complaints should be made as soon as possible, normally within 6 months of the complainant becoming aware of the cause for complaint or within 12 months of the date of the event The Trust has discretion to extend these limits where it would have been unreasonable for the complaint to have been made earlier and where it is still possible to properly investigate the facts If the complaint is made by someone other than the patient, confidentiality must be protected and the patient contacted to confirm 3

4 agreement to proceed. Exceptions are if the patient is a child and not capable of pursuing the complaint themselves, or if the patient is incapacitated or has died Clear, concise, accurate documentation must be maintained throughout the whole complaints process If a complaint reveals a likelihood of legal action being taken, the Claims Manager will be kept fully informed by the Complaints Manager and may be handed over to the Claims Manager if appropriate Complaints and disciplinary procedures must be kept separate Correspondence relating to complaints must be kept separate from the patient s health records If formal legal action is instigated or disciplinary procedures apply at any stage, the complaints procedure will be brought to an end and the complainant will be advised in writing If any complaint received by a member of staff indicates the need to refer to any of the following:- a) an investigation under disciplinary procedure b) professional regulatory bodies c) independent enquiry into a serious incident under section 84 of the National Health Service Act 1977 d) investigation of a criminal offence The person in receipt of the complaint should at once pass the relevant information to the Complaints Manager. Where the complaint refers to a. or b. above, the Personnel Human Resources Director will be informed accordingly by the Complaints Manager. 3 Local Resolution 3.1 Many complaints can effectively be handed by informal resolution. This will apply typically to minor matters and staff are encouraged to resolve these locally, as they occur. 3.2 For informal resolutions to apply, the member of staff receiving the complaint must believe that a satisfactory solution can be achieved and that the complainant is happy to have the matter resolved at local level. 3.3 Staff should not refer complainants to the Complaints Manager Formal Complaints Procedure where informal resolution is appropriate. If however, the complainant is dissatisfied with the informal resolution, they should be advised how to make a formal complaint or if there is 4

5 scope for the matter to be resolved without the complaint being formalised, the complainant should be referred to the PALS Manager or Modern Matron in the first instance. 3.4 The PALS Manager is based at the Hospital and is available Monday- Friday 9.00 am-5.00pm and can be contacted on extension The Complaints Manager is also based in the Hospital and can be contacted on extension 6580 between the hours of 9.00 am and 3.00 pm. For urgent issues arising outside these times, the on-call managers can be contacted for assistance by telephoning switchboard who will then contact the appropriate manager by the bleep system 3.5 Details of informal complaints and their resolution should be recorded and filed by the PALS Manager or the Complaints Manager. Informal complaints are not included in the Trust s complaints statistics but the details are recorded and used to identify trends and opportunities for quality improvement. 3.6 Formal complaints will be either written or verbal complaints which have not been resolved informally at local level. This may be due to the seriousness of the complaint or dissatisfaction by the complainant, with the informal resolution process. They require a full written response from the Chief Executive. 3.7 Complainants should be advised to address formal complaints to the Chief Executive or the Complaints Manager. 3.8 Formal complaints received in the Trust, should be forwarded to the Complaints Manager within 2 working days of receipt. 3.9 Formal complaints will be logged centrally by the Complaints Manager and acknowledged, by means of a personalised letter to the complainant, within 2 working days of receipt or within 5 working days, if it is possible to resolve the complaint fully within this timeprovide a full written response within this time If a verbal complaint is received which seems to be particularly complex, the Complaints Manager may ask the complainant to put their concerns in writing. The independent complaints advocacy service PoWher ICAS are available to assist complainants with this. They can be contacted in this locality at POhWER ICAS, Unit 26A, E Space North. 181 Wisbech Road, Littleport Cambs CB6 1RA. Helpline On occasions, it may be appropriate to offer the complainant the opportunity of a personal interview to discuss more complex complaints. In these circumstances, the relevant clinician and/or manager would be invited to attend. The complainant should be advised that a friend/advocate may accompany them. 5

6 3.12 A leaflet explaining the NHS Complaints procedure will be sent to all complainants with the acknowledgement The Complaints Manager will then request responses to the specific issues raised by the complaint. The request for a response will be sent to the appropriate manager who will ensure that any staff named in the complaint, together with all other relevant staff associated with the incidentcomplaint, are requested to supply statements. A copy of the request will also be sent to the relevant Associate DirectorDirectorate Managers and Clinical Directors of the service involved. The Medical Director receives copies of all complaints and copies should also be sent to the Director of Nursing, Midwifery and Operations, and Head of Nursing as appropriate The ward manager, departmental manager or responsible clinician should undertake local investigation of complaints and include: interviews with any staff involved and where appropriate, a request for a written statement should be made. A review of the nursing and medical case notes, and a review of any systems and processes involved with specific reference to Trust Policy and procedures. For complex complaints or those of a serious nature, a full root cause analysis investigation may be required. (Reference to Trust guidance on incident and complaints investigation under construction) 3.15 The responses (statements) should be appropriate, relevant to the issues raised, address all of the issues raised, identify any actions taken or changes made as a result of the compliant investigation, be legible, and be dated and signed. Staff should ensure that they have access to the patient s medical records when preparing statements or responses to ensure accuracy of information including, dates and times. Staff should seek assistance from the appropriate manager when preparing a response or statement and may also find it helpful to seek guidance from their union representative if appropriate. Responses should also be written in a form that can be used as a basis of the draft response. The relevant Modern Matron or Assistant General Manager should review the complaints response and provide an over view of the information collected prior to it being returned to the Complaints Manager. The responses should be returned to the Complaints Manager within the timescale stated on the request (within a maximum of 10 working days). Further guidance on how to prepare statements is included in a checklist in Appendix On receipt of the response(s), a draft response will be prepared by the Complaints Manager in preparation for the Chief Executive to send to the complainant. The draft response will be sent to respondents for their comments. Where appropriate, advice may also be sought from the Clinical Director and/ordirectorate Manager Associate Director and Medical or Nurse Directors. 6

7 3.17 The final response letter will then be signed by the Chief Executive and sent to the complainant within 20 working days of receipt of the original complaint. If it is not possible to provide a full response to the complainant within 20 working days, they will be kept informed All staff involved in providing a statement or response to complaints should have an opportunity to see the final response letter. Copies of the final letter will be sent to all of the managers involved who should share it with the staff. Staff can also request a copy from the Complaints Manager if necessary If the complainant is not satisfied with their letter of response, a meeting with appropriate personnel should be considered, to attempt to resolve the outstanding issues. If they are still dissatisfied, they may ask the Healthcare Commission to review the case the complainant may request (verbally or in writing) consideration for an independent review. This should be done within 28 working days of the final meeting or correspondence. 4 Healthcare Commission Independent Review 4.1 When dissatisfied with the outcome of Local Resolution, a complainant has the right to refer the matter to the Healthcare Commission. 4.2 It is anticipated that complainants will make any referral themselves. A request may be made either orally or in writing (including electronically) and must be made within two months of, or where that is not possible, as soon as reasonably practicable after, the date on which the Trust s response was received by the complainant. The Healthcare Commission can be contacted at Healthcare Commission, Complaints Team, Peter House, Oxford Street, Manchester M1 5AN. Telephone: The Healthcare Commission may request any person or body to produce such information and documents, as it considers necessary to enable a complaint to be considered properly. Any such request must be made in writing and must specify what information is requested and state why it is relevant to the consideration of the complaint. The Healthcare Commission may not make a request for information which is confidential and relates to a living individual unless the individual to whom the information relates has consented, such consent may be either expressed or implied, to its disclosure and use for the purposes of the investigation of the complaint. 4.4 The Healthcare Commission may conduct its investigation in any manner which seems to be appropriate, may take such advice as appears to it to be required and, having regard in particular to views of the complainant and any person who or body which is the subject of the 7

8 complaint, may appoint a panel of three independent lay persons to hear and consider the complaint. Follow up Action by the Trust On receipt of a report following an investigation by the Healthcare Commission, the Chief Executive must write, within four weeks from the publication of the report, to the complainant informing them of any action the Trust is taking as a result of the Healthcare Commission s deliberations and of the right of the complainant to take their grievance to the Health Service Commissioner (Ombudsman) if they remain dissatisfied. The Trust Board is responsible for ensuring that the action taken is communicated quickly and clearly to the complainant 5 Recording and Monitoring 4.5 The Convenor will, with appropriate clinical advice: a)ascertain whether all the opportunities for satisfying the complainant have been fully explored and exhausted; b)decide with a lay Chairman from the regional list, whether an Independent Review Panel should be established; c)ensure that the matter is dealt with impartially. NB It is not the role of the Convenor to further investigate or attempt to resolve the complaint. 4.3.It is the Convenor's ultimate decision whether a Panel should be convened or not. Whatever the decision, the complainant should be informed within 20 working days. Formatted: Bullets and Numbering Formatted: Bullets and Numbering 4.4.If the decision is made to convene a Panel, then members should be appointed within 20 working days of making the decision. 4.5.Where the Convenor considers that a complaint relates in whole or in part to clinical judgement, he/she must take appropriate clinical advice in deciding whether to convene a Panel. 4.6.A Panel will not be convened if: a)legal proceedings have commenced or there is an explicit indication by the complainant of the intention to make a legal claim; b)the Convenor considers that the Trust has already taken all practicable action and establishing a Panel would add no further value to the process; c)further action as part of local resolution is still believed to be appropriate and feasible. 8

9 4.7.The Convenor must inform the complainant, any staff concerned, the Chief Executive, the Chairman and Trust Board members of the decision whether or not a decision has been made to convene a Panel and if there is further action which could be taken as part of local resolution. 4.8.If a Panel is refused, the Convenor will advise the complainant of the option to refer the complaint directly to the Health Service Commissioner. 4.9.Where appropriate, the Convenor will offer Conciliation as a means of resolving complaints. Where conciliation is acceptable to the complainant, an independent conciliator will be contacted If the Convenor decides that a Panel will be convened, the membership must conform to current NHS guidance Where the Convenor decides the complaint is clinical in nature, the Panel will be advised by at least two independent clinical assessors, nominated by the Regional Office The aim of the Panel is to investigate all aspects of the complaint and to issue a report with conclusions and suggestions, whilst maintaining confidentiality throughout the process The Panel will have no executive authority over any action by the Trust and may not make any suggestion that any person should be subject to disciplinary action or referred to any professional regulatory authority The Panel will conduct proceedings within the following rules: a)absolute confidentiality must be maintained; b)the Panel must have access to all the relevant documentation held by the Trust; c)if the complaint is clinical, the Panel must have access to all the relevant parts of the patient s health records; d)the Panel must give the complainant and any person complained against, a reasonable opportunity to express their views on the complaint; e)if any of the Panel members disagrees about how the Panel should go against its business, the chairman s decision will be final; f)the complainant and/or those complained against may be accompanied by a person of their choosing, but not a legally qualified person acting in a legal capacity; g)the independent clinical assessor s role is to advise and make a report to the Panel on clinical complaints The Panel s report should be sent to: 9

10 a)the patient/complainant b)any person named in the complaint c)any person interviewed by the Panel d)the clinical assessors e)the Trust Chairman f)the Trust Chief Executive g)regional Directors of Public Health and Performance Management h)chairman and Chief Executive of the organisation who purchased the service concerned i)where the complaint is about services provided by the independent sector, the Chairman and Chief Executive of the independent service provider The report will be circulated as stated above. The Panel shall not send it to any other person or body. The Panel chairman has the right to withhold any part of the Panel's report and all or part of the assessors' reports in order to ensure confidentiality of clinical information Guidelines of the content of the final report are issued by the Department of Health and the Ombudsman's office and are available from the Complaints Manager The assessor's report (if required) will be attached to the Panel's final report. Appropriate extracts must be sent to any person complained against A draft report may be issued, at the discretion of the Panel The Chief Executive will write to the complainant regarding appropriate action to be taken and the right to proceed to the Health Service Commissioner within 20 working days of the report being published. 5.1 All complaints will be registered by the Complaints Manager on a computerised system. 5.2 Complaints will be included in the quarterly Quality & Risk Management Report and reported to: a) Clinical Governance & Risk Management Steering Group b) Clinical Governance & Risk Management Committee c) Trust Management Executive Board d) All Commissioners and external stakeholders e) Trust Board. 5.3 Complaints will be analysed in the following categories: 10

11 a) Type of complaint; b) time elapsed to acknowledgement; c) time elapsed to final response d) complaints by source and complainant relationship; e) complaints by ward/department; f) time taken to closure from which trends can be identified. 5.4 All Departments Directorates will receive a monthly report detailing the complaints they have received. Departments Directorates should review complaints relating to clinical care in their monthly clinical governance rolling half days. Wards and departments should identify the most appropriate forum for reviewing complaints on a monthly basis to ensure lessons are learnt and shared with the whole team. Trends should be analysed in order to identify the root causes of complaints so that lessons can be learned and the quality of care improved. 5.5 The Trust will undertake a quarterly audit of action taken as a consequence of Trust complaints. Actions taken and lessons learnt are recorded on the ward performance framework documents. This document is reviewed monthly and the recorded actions and changes to practice are sent to the Complaints Manager for reporting through the Governance structure. This will be undertaken by the Complaints Manager. 5.6 The Trust will continue to seek complainants' views on the procedure including liaison with ICAS 6 Support Mechanisms. 6.1 The Community Health Council ICAS and PALS service are sources of support for complainants. Complainants must be informed as soon as possible that this service is available and given information on how to access their help. Support is also available from the Quality & Risk Management department. 6.2 Staff involved in responding to complaints can contact their manager/supervisor or trade union representative if they need guidance or reassurance about the most appropriate way to respond. 6.3 Staff can also contact the Complaints Manager on extension 6580, the Clinical Risk Manager on 6358, the Assistant Director of Quality on extension 3661 or the Nurse Director on extension 6021 for advice and guidance. 11

12 6.4 Immediate actions for line managers to consider when supporting staff involved in a complaint should include: Assess fitness to practice, refer to Occupational Health if necessary Formatted: Bullets and Numbering Debriefing by experienced empathetic staff Keep staff informed Consider additional support ICAS Document all actions taken to support staff 6.4. The Trust will provide training to staff on responding to complaints and on learning lessons from patients complaints and observations for all new staff on induction. Complaints handling training is available on request to meet the requirements of specific staff groups..further information regarding training can be found in the Trust Training Directory. 12

13 Review 7.1 This Policy is due for review in November This policy will also be reviewed and modified when necessary, in line with current guidance and good practice. Author of Policy: Caroline Sheets Complaints Manager Policy Reviewed and Amended in November 2004 Date introduced: December 2001 Date reviewed and updated: January 2003 Date of next Review: November 2005 Approved by Clinical Governance & Risk Management Steering Group: November 2004 Approved by Clinical Governance & Risk Management Committee: December 2004 Approved by Trust Management Executive: Approved by Trust Board 13

14 Hinchingbrooke Healthcare NHS TRUST Appendix 1 8CHECKLIST FOR WRITING A STATEMENT Formatted: Bullets and Numbering 1 Your statement must be legible. It does not have to be typed. If necessary print names or difficult words. WHY? Statements can be misleading or useless if they cannot be read. 2 State your name, designation and grade. WHY? We need to know who is making the statement. 3 State the name, designation and grade of each member of staff mentioned in your statement. WHY? We may not know who Nurse Smith, or John Jones are. 4 Give the name and patient number of any patient involved. Also give names and addresses of any other people involved such as relatives, visitors, or persons who are not employees of the Trust. WHY? We need to know who was involved. 5 Always date the statement. WHY? This will show whether the statement was written at the time when events were fresh in your mind, or some time later. While it is preferable to write it at the time, a retrospective statement is better than no statement. 6 Where possible, include times of the events. If the accuracy of the timing is important, try to state which clock you looked at. WHY? For some incidents and complaints it can be very important to get the timings correct. 7 The statement must be factual: What you did - What you heard. WHY? We need to know WHAT YOU WITNESSED, not what you assume happened or your opinions on what might have happened and why. Ask yourself, if you were questioned about what you wrote, could you justify the information you have written down? 8 Wherever possible avoid phrases such as Dr X was telephoned or the floor was cleaned. Instead try to use I called Dr X or Mrs Y cleaned the floor. 14

15 WHY? This makes it much clearer and avoids misunderstandings. SOME TIPS ABOUT WRITING YOUR STATEMENT: A statement is not a list, but should add to, or explain information on any incident form. It is often easier to write down everything you remember and then put it into order. Do not be rushed into this. Try to find somewhere quiet and take your time. As your statement should be a factual account of your involvement in an incident or a complaint, it is probably a good idea to write it alone. SOME THINGS YOU MIGHT NEED TO INCLUDE: When were you involved? (At the beginning of the incident or complaint, or part way through?) What were you told about the complaint? Who told you? What did you actually see or hear? What exactly did you do? If necessary explain why you did this. Did you give information to patients or relatives? What information? What was documented and where? If you have any concerns about actions of other members of staff, these should not be ignored, but should be discussed with your manager or followed up through the Whistle Blowing procedure. Comments and criticisms should not be written as part of your statement just stick to the facts. In addition to writing a statement there are further actions you may need to take: Inform your manager and complete an incident form. Inform your Union representative. Make an entry in the patient s notes. WHO WILL SEE MY STATEMENT? Initially just your manager and Trust staff who are dealing with incident reporting, complaints or claims, in the case of a claim, the solicitors who are acting for the Trust. 15