The State Hospital s Board for Scotland

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1 The State Hospital s Board for Scotland PATIENT & CARER FEEDBACK Procedure for Feedback; Comments, Concerns, Compliments and Complaints (Incorporating the NHS Can I Help you Guidance) Policy Reference Number RM05 Issue: 7 Lead Author Feedback and Complaints Officer Contributing Authors Risk Management Team Leader IES Lead Advisory Group Involvement and Equality Strategy Approval Group Senior Management Team Implementation Date May 2014 Review Date May 2017 Responsible Officer (SMT) Finance and Performance Director Page 1 of 14

2 CONTENT 1. Background 2. Feedback 2.1 Active Listening 3. Complaints 3.1 Principles for an effective Complaints Procedure 3.2 Who can Complain 3.3 What can be Complained about 3.4 Exceptions to Procedure 3.5 When can a Complaint be made 3.6 Joint Complaints 4. Roles and Responsibilities 4.1 The State Hospitals Board for Scotland 4.2 The Clinical governance Committee 4.3 The Senior Management Team 4.4 The Chief Executive 4.5 The Finance and Performance Management Director 4.6 The Complaints Officer 4.7 The Risk Management Team 4.8 Staff and Line Managers 4.9 Patients Advocacy Service 5. Dealing with a Complaint 5.1 Recording the Complaint 5.2 Acknowledging the Complaint 5.3 The Investigation 5.4 Completing the Complaints Process 5.5 Withdrawn Complaints 5.6 Unreasonably Demanding or Persistent Complaints 5.7 Disciplinary Investigation 5.8 Support framework - Staff - Patients - Patient Advice & Support Services (PASS) 6. Role of Scottish Public Services Ombudsman (SPSO) 7. Learning from Complaints 8. Monitoring of Complaints 8.1 Informing the Board 8.2 Annual Reports 8.3 National monitoring 9. Audit and Review 10. Format Page 2 of 14

3 THE STATE HOSPITAL PATIENT & CARER FEEDBACK SYSTEMS INCORPORATING THE NHS COMPLAINTS PROCEDURE 1. Background The State Hospital is a person centred organisation that welcomes feedback from all users of its services. Feedback may be received in the form of a compliment, a comment, a concern or a complaint. All forms of feedback provide opportunities for reflection, learning and where appropriate, change. Within The State Hospital this feedback process is referred to as the 4 C s, developed on the principles of the NHS Can I help you? guidance for handling and responding to feedback, comments, concerns and complaints in relation to health care in accordance with the Patients Rights (Scotland) Act FEEDBACK (Comments, Concerns, Compliments) 2.1 Active Listening The hospital is continually developing feedback systems that encourage users of the service to express their views and have an opportunity to share their views in a variety of ways. The following processes have been developed and are continually being reviewed to enable patients carers and volunteers to have a wider opportunity to voice their views on service delivery, particularly when they do not wish to engage in the NHS Complaints Procedure. These include: Community Meeting: any patient can raise an issue, either directly or through the elected patient chair, which is discussed with a view to resolving the matter at the time. There are times when the issue cannot be resolved at that time and may require to be referred to the Patient Partnership Group for a wider discussion. Patient Partnership Group (PPG): any issue raised by a patient representative will be actioned by the Group or one of the Sub Groups and feedback will be passed back to the wards via the patient representative and via the dissemination of approved minutes and patient notice boards. Involvement and Equality Strategy (IES): on occasion when the PPG are unable to effect a satisfactory outcome, the matter is tabled by the PPG Patient Chair for discussion at the IES Steering Group. Comment/Suggestion Box: are located in each ward, Carer s Reception Centre, Family Centre and Skye Centre. Patients are encouraged to comment about the services the hospital provides. The comment can be anonymous, however if feedback is required patients are aware that contact details will be required. The box is locked and emptied weekly by IES staff with the issues being recorded and raised/actioned at the appropriate fora. Concerns: there will be occasions where a patient, carer or volunteer does not wish to enter into the formal complaints procedure but nonetheless wishes to raise and receive feedback on an issue. A response should be provided within 3 working days. The person raising the concern can, if they are unsatisfied with the response, enter the formal complaints procedure at this stage. Compliments: are welcomed as it helps inform the hospital of the positive things that users are saying about staff and services. These are recorded and shared with the appropriate services and/or specific staff. Page 3 of 14

4 The Complaints Officer monitors the types of issues raised via these processes to provide a wider perspective on user feedback. Statistics are reported to the Clinical Governance Committee, IES Steering Group, PPG, Carers Service Group and Volunteer Service Group. Frontline staff are actively encouraged to resolve any issues or concerns as they arise although there will be occasions when an individual or family will be dissatisfied with the explanation given and want to raise the issue as a formal complaint. When this happens the service provider will attempt to resolve the complaint as directly and quickly as possible, with the primary aim of being fair to both the person making the complaint and where appropriate to the staff to who the complaint relates. Addressing complaints earlier and more informally may avoid the need to access the formal complaints procedure. It is acknowledged that this may result in formal complaints being restricted to more difficult, complex or challenging issues. 3. COMPLAINTS A Complaint is an expression of dissatisfaction requiring a response. As there is a very fine line between a complaint and a concern, there should be an opportunity for the person to decide if they wish the matter they are raising to be considered under the NHS Complaints Procedure or through one of the other less formal feedback processes Principles for an effective complaints procedure The aim of the State Hospital is to operate a complaints procedure which is credible, easy to use, demonstrably objective, effective and sensitively applied. Making a complaint can be stressful both for those making the complaint and for the staff involved. Arrangements should be fair to both sides, supporting the person making the complaint and any staff named in the complaint. The procedure also ensures that the State Hospital can learn and grow positively from the experience Who can complain? Complaints can be made by a patient or former patient, any appropriate person in respect of a patient who has died (e.g. the next of kin or their agent), someone on behalf of an existing or former patient (e.g. a patient s parent, carer, guardian or a visitor; an MP, MSP or local Councillor), or an advocate or member of an independent advice and support organisation. Where someone other than the patient or their authorised agent wishes to make a complaint, they should be advised that they must be able to demonstrate that they have obtained the patient's (normally written) consent to: make a complaint on their behalf. allow members of staff to examine the patient s health records, if this should prove necessary as part of the investigation of the complaint. The Complaints Officer in discussion with the Chief Executive will determine whether the person making a complaint is appropriate to represent a patient. This decision will depend, in particular, on the need to respect the confidentiality of the patient, for example, the patient may have made it known that their information should not be disclosed to third parties. If it is decided that a person is not appropriate to act as the patient s representative, they must be provided with an explanation in writing outlining the reasons for that decision. Should the complainant be anonymous then a decision will be made as to whether or not an investigation is initiated by the Complaints Officer, in consultation with the Chief Executive What can be complained about? The potential subject of a complaint is wide and not just related to medical care. A complaint may be about a decision taken by the State Hospital that is likely to affect the person making Page 4 of 14

5 the complaint or the person on whose behalf the complaint is made. Each complaint must therefore be taken on its own merit and responded to appropriately. The NHS complaints procedure primarily deals with concerns about patient or former patients care provided by the State Hospital including the contracted Primary Care Services and Social Work Services (See 9 - Joint Complaints) Exceptions to the Procedure Members of the public, including patients, may raise concerns with the State Hospital which the organisation needs to address, but which are not appropriate for investigation under the NHS Complaints Procedure. Other appropriate management processes are in place to deal with these concerns. Complainants should be informed that complaints which fall within the following areas are dealt with under other policies and procedures: a complaint from another NHS board a complaint made by an employee relating to the employment contract a complaint that is being, or has been investigated by the Scottish Public Services Ombudsman (SPSO) a complaint about an alleged failure to comply with a request for information under the Freedom of Information Act 2002 a complaint which states the complainant intends to take legal proceedings a complaint in which the hospital is proposing to take disciplinary proceedings in relation to the substance of the complaint or person who is the subject of the complaint. If a complaint is receive on any of these matters they should immediately be referred to the appropriate person. The Complaints Officer will be able to advise on who this is. The complainant must be informed in writing as soon as reasonably practicable that the complaint will not be investigated under the NHS Complaints Procedure and informed of the appropriate procedure for raising such a complaint. In these circumstances, investigation of other aspects of the complaint will only be taken forward if they do not, or will not compromise or prejudice the matter under investigation. There will be occasions when the allegations made by a complainant are considered to be of a serious nature that is unsuitable for investigation under this procedure. The Mental Welfare Commission suggests that significant complaints might be: alleged, actual or intended physical or sexual abuse; allegations of other ill treatment or cruelty, neglect or abuse; failure to comply with statutory provisions, including improper detention and unlawful treatment; maladministration of patient funds or property; or failure to make satisfactory arrangements for care after discharge from the Hospital. Where a complaint is considered to fall within these categories, the Complaints Officer will refer the matter for investigation to the appropriate route: Adult Support & Protection Serious Untoward Incident Critical Incident Review Police Scotland Referral Page 5 of 14

6 3.5. When can a Complaint be made Complaints are normally made at the time a patient, carer or volunteer becomes aware of an issue or a concern and wherever possible they should be dealt with immediately. However, it is recognised that it is not always possible for the patient to make a complaint immediately. Given the difficulties that the passage of time can make to the resolution of a complaint the recommended timescale for accepting a complaint is: within 6 months of the event you want to complain about, or within 6 months of finding out that you have a reason to complain but no longer than 12 months after the event. The State Hospital operates these guidelines flexibly and may accept a complaint where it would have been unreasonable for the patient to make it earlier and where they believe it is still possible to investigate the facts. A decision not to extend these timescales must be agreed by the Chief Executive. Where a decision is taken not to extend these timescale and the person raising the complaint is dissatisfied with this decision, they may appeal to the Scottish Public Services Ombudsman Joint Complaints Where a complaint relates to a patient receiving health and social care services, the State Hospital and the Local Authority responsible for the Social Work Services will agree who will take the lead and work together to ensure that all matters raised are investigated. The person making the complaint should be informed about which matters are being dealt with under which procedure. 4. Roles and Responsibilities 4.1 The State Hospitals Board for Scotland All staff that provides services on their behalf should be aware of and trained in the procedures to be followed. As well as induction awareness training, dedicated training workshops are provided as required. All staff have a responsibility to try to resolve issues as they arise but when this is not possible they should provide the complainant with a range of options available (see 1.1 Active Listening). 4.2 The Clinical Governance Committee The Clinical Governance Committee will receive quarterly Learning from Compliments, Comments, Concerns and Complaints (The 4C s); improving patient safety reports. The Clinical Governance Committee will be assured of the effectiveness of the complaints process. Reports from the Scottish Public Services Ombudsman relating to complaints against the State Hospitals Board for Scotland will be referred to this committee when received. 4.3 The Senior Management Team The Senior Management Team will receive regular quarterly incident reports which will include a section on Learning from comments, concerns, complaints and compliments. This group will ensure that risks are systematically identified, recorded, reported, managed and analysed through incident reporting and investigation and the process of the 4Cs. 4.4 The Chief Executive The Chief Executive is responsible for signing off all complaint responses. In the absence of the Chief Executive the responsibility will be delegated to the Deputy Chief Executive. Should both the Chief Executive and the Deputy Chief Executive be absent, the Chief Executive will nominate a Director to sign off the complaints during the period of absence. Page 6 of 14

7 4.5 The Finance and Performance Director The Chief Executive has appointed the Finance and Performance Director as the executive lead with responsibility for Risk Management including patient, carer and volunteer feedback and complaints. 4.6 The Complaints Officer The Complaints Officer is part of the Risk Management Team and should be readily accessible to patients and stakeholders. The Complaints Officer works with staff involved in the Involvement and Equality Strategy agenda in order to develop ways of encouraging effective patient feedback and to: develop processes to record the handling and consideration of each complaint. develop processes to ensure organisational learning from the operation of the Board s patient feedback and complaints process, including statistical and trend analysis. ensure that a complete record is kept of the handling of each complaint. ensure complaints records are kept separate from health records. ensure that appropriate clarification is sought where a complainant wishes to withdraw a complaint (see Withdrawn Complaints). The Complaints Officer manages the operation of the NHS Complaints Procedure within the Hospital to ensure that: staff have the training, support and help they need to deal effectively with feedback and complaints, including those which are unreasonably demanding or persistent. staff know when to seek advice from senior Staff a register is kept of staff who have undergone formal training where an investigator has not received formal training appropriate guidance will be given to ensure that good investigation principles are adhered the person making the complaint receives advice about how it will be dealt with, including a copy of Health Rights Information Scotland s leaflet Your heath, your rights: Feedback and Complaints and about the role, availability and how to contact the relevant advice and support services for example those that provide information, translation, interpretation etc. there is access to advice and support on associated issues, for example patient consent; confidentiality; the operation of related legislation such as the Data Protection Act, access to medical records, Freedom of Information, etc. The Complaints Officer should continually look at ways of capturing feedback from users of the service and where appropriate meet with groups of carers and patients on a regular basis. 4.7 Risk Management Team Members of the Risk Management Team will assist in the complaints process where necessary by providing support for investigations, monitoring action plans, identifying risks and providing specialist advice on Health and Safety issues. 4.8 Staff and Line Managers All staff and line managers will: be responsive to frontline issues endeavour to resolve these issues locally, as they arise provide support where appropriate to patients and carers and who have complained as well as staff complained against. be responsible in ensuring that lessons are learned and ensure that identified actions are followed through. Page 7 of 14

8 4.9 Patients Advocacy Service (PAS) An Advocate is recognised as an important way of enabling patients to make informed choices about, and remain in control of, their own health care. Should a patient so wish the Patients Advocacy Service can provide a supporting role for them when they wish to complain about their care and treatment and can provide support during the investigation process and through later stages of the complaints process. Where possible the Advocate should consider encouraging patients to resolve issues with front line staff in accordance with the NHS Complaints Procedure Guidelines. 5. Dealing with a Complaint A complaint can be made in writing, by , by phone or in person. There may be the possibility that the person wishing to make the complaint may still, at this stage, wish to have the matter resolved without entering the formal complaints process. This option should, where possible, be explored with the complainant. Where a complaint is made to a member of staff their first responsibility is to ensure that the patient's immediate health care needs are being met. Secondly they should try to resolve the issue locally prior to contacting the Complaints Officer. If the complaint is made on behalf of somebody else, the Complaints Officer will ensure patients consent has been obtained, as outlined previously. Where the person wishes to proceed, the Complaints Officer should agree the details of the complaint and confirm them in a letter of acknowledgement. 5.1 Recording a Complaint Complaints are recorded on Datix, which allocates a reference number for each complaint entered and allows for an electronic complaint file to be created. The system generates dates for acknowledging, receiving feedback and sending out the final response in keeping with national timescales. Copies of correspondence and updates relevant to the complaint can be recorded and stored on the database. Datix allows reports to be produced based on data captured. A paper file of each complaint is also kept. 5.2 Acknowledging a Complaint Complaints will be acknowledged or an initial response issued in writing within 3 working days of receipt. The letter will: outline the proposed course of action to be taken, or offer the opportunity to discuss issues either with the Complaints Officer or, if appropriate, senior member of staff. All such communications will be marked Private and confidential. Written communication to patients will be clearly marked to ensure patients receive the information confidentially. 5.3 Investigating a Complaint It is important that a timely and effective response is provided in order to resolve a complaint, and to avoid escalation. An investigation of a complaint should be completed, wherever possible, within 20 working days following the date of receipt of the complaint. Where it appears the 20 day target will not be met, the person making the complaint, and anyone named in the complaint, must be informed of the reason for the delay with an indication of when a response can be expected. The investigation should not, normally, be extended by more than a further 20 working days. Page 8 of 14

9 While it may be necessary to ask the person making the complaint to agree to the investigation being extended beyond 40 working days, for example because of difficulties caused by staff illness, they should be given a full explanation in writing of the progress of the investigation, the reason for the requested further extension, and an indication of when a final response can be expected. The letter should also indicate that the Ombudsman may be willing to review the case at this stage should they deem the reasons for the requested extension not acceptable. The Chief Executive may decide, in discussion with the Complaints Officer, on a case by case basis, that other action would be helpful. A record will be kept of all meetings and discussions and a letter issued setting out the agreements reached and any action to be taken. The Chief Executive, in discussion with the Complaints Officer, will commission the relevant ward/service manager or Responsible Medical Officer to undertake the investigation and to provide their finding/comments to allow a response to be prepared. There are occasions, however where this may not be appropriate, in these cases an alternative investigator will be appointed. Impartiality is crucial to the success of any investigation. The investigating officer must approach the complaint with an open mind, being fair to all parties. The investigation must not be adversarial and must be conducted in a supportive atmosphere that demonstrates the principles of fairness and consistency. Anyone identified as the subject of a complaint should be provided with a full account of the reasons for the investigation and a proper opportunity to talk to the investigating officer who should ensure they are kept informed of progress. The complainant and the person complained against should be informed of the support services that are available to them. (See also Incident Reporting and Review Policy). The Complaints Officer will ensure that all information relevant to the investigation is recorded and kept in a case file. If, subsequently, the complaint is referred to the Ombudsman, this may result in a request for all relevant papers and other information to be provided in good time to the Ombudsman s office. Complaint records will be kept separate from health records, subject only to the need to record information which is strictly relevant to the patient s health in their health record. Where the complaint involves clinical issues, the draft findings and response will be shared with the relevant clinicians to ensure the factual accuracy of any clinical references. 5.4 Completing the Complaints Process The complaints process is completed by the Chief Executive reviewing the case to ensure that all necessary investigations and actions have been taken. If the Chief Executive is satisfied that the complaints process is complete, they will issue a letter to the person making the complaint. The letter will be clear and easy to understand and: address all issues raised and show that each has been fully and fairly investigated reflect accurately the findings from the investigation include an apology where things have gone wrong report actions taken and/or proposed to prevent any recurrence indicate the outcome of the complaint highlight any area of disagreement and explain why no further action can be taken indicate, where appropriate, that a named member of staff is available to clarify any aspect of the letter indicate that if dissatisfied with the outcome the complainant may seek a review by the Scottish Public Services Ombudsman. Details of how to contact the Ombudsman office is included with the formal complaint response. Page 9 of 14

10 Once the final response has been signed and issued, the Complaints Officer files all correspondence, liaises with local senior managers to ensure that all necessary follow-up action is taken. and report to the Board s Clinical Governance Committee when this has been done. The Line Manager will also ensure that where staff are the subject of a complaint that they receive feedback. Actions taken as a result of issues identified in formal complaints will be reported to the Senior Management Team via the relevant section of the quarterly 4Cs Report. 5.5 Withdrawn Complaints Where a complainant wishes to withdraw a formal complaint, written notification should be sent to the Complaints Officer. This should adequately describe how the issues have been resolved. There may be occasions when the Complaints Officer will require further clarification to be satisfied that all the issues have been resolved. Should there be outstanding issues, further investigation will take place and the complainant will be informed. 5.6 Unreasonably Demanding or Persistent Complaints Staff should be trained to respond with patience and empathy to the needs of people who make a complaint, however there will be times when there is nothing further which can reasonably be done to assist them or rectify a real or perceived problem. Where this is the case and further communications would place inappropriate demands on staff and resources, consideration may be given to classifying the person making the complaint as unreasonably demanding or persistent complainant. On occasions it may be considered appropriate to meet with the complainant and members of the appropriate clinical team to endeavour to support and manage the individual s concerns, thus preventing the classification of the individual as an unreasonably demanding or persistent complainant. Classifying a person making a complaint as unreasonably demanding or persistent will only occur in exceptional circumstances when it can be shown that: the complaints procedure has been correctly implemented all reasonable measures have been taken to resolve the complaint no material element of the complaint has been overlooked or inadequately addressed a full written case has been submitted to and approved by the Chief Executive and Chair of the Board. Before agreeing to classify a correspondent as unreasonably demanding or persistent, consideration should be given to dealing with future correspondence in one or more of the following ways: by drawing up a signed agreement with the correspondent (if appropriate involve any relevant practitioner in a 2-way agreement) which sets out a code of behaviour for the parties involved if the complaint is to continue to be processed. If this is contravened, consideration would then be given to either: a) declining contact either in person, by telephone, by letter, by , by fax or any combination of these, provided that one form of contact is maintained. b) temporarily suspending all contact with the correspondent or investigation of a complaint whilst seeking legal advice or guidance from other relevant agencies. Page 10 of 14

11 Where a decision is taken to classify a correspondent as an unreasonably demanding or persistent complainant, the Chief Executive will notify the person in writing of the reasons why they have been so classified and the action which will be taken with future correspondence or calls. The letter will provide a summary of the Hospital s position relating to their complaint indicating: that we have responded fully to the points raised and, as there is nothing more to add, continuing contact on the matter will serve no useful purpose, and further correspondence received will simply be acknowledged unless it raises a new matter of substance. In extreme cases the correspondent might also be advised that the Hospital reserves the right to pass future correspondence to their solicitors. This notification letter may be copied for the information of others involved in the process. A record will be kept of the reasons why a complainant has been classified as unreasonably demanding or persistent. It is important when considering classifying an individual as an unreasonably demanding or persistent complainant that appropriate checks are undertaken to ensure that the decision is in no way based on institutional discrimination or on a lack of knowledge of the specific needs of that individual. The decision to classify a complainant as unreasonably demanding or persistent will be reviewed should they subsequently demonstrate a more reasonable approach. The decision to withdraw this classification is subject to the approval of the Chief Executive and Chair of the Board. 5.7 Disciplinary Investigation If as a result of a complaint a disciplinary investigation is considered appropriate the complaints investigation will cease, except for any issues not covered by the disciplinary investigation. The complainant will be informed in writing of this decision and assured that the matter will be dealt with under a different procedure and that feedback will not be routinely be provided on the outcome of the investigation Staff concerned about the way in which they have been dealt with under the complaints procedure should make use of the State Hospital Grievance Policy (HR12). 5.8 Support Framework The Hospital acknowledges the stress that an investigation as a result of a complaint can have on staff, patients, carers and volunteers and support frameworks will be developed for stakeholders. The main points of contact for staff during the complaints process include: Line management; Staff representatives; Occupational Health Human Resources (Staff Experience Facilitator) and Independent Counselling and Advisory Service (ICAS). The main points of contact for patients during the complaints process include: Patients Advocacy Service; Patient Involvement Facilitator; IES Lead Next of Kin, Named Person, Carer; any other appropriate support depending on patients needs, and any other specified person. Page 11 of 14

12 The main points of contact for carers during the complaints process include: Carer Engagement Facilitator IES Lead Patient Advice & Support Services (PASS) NHS Scotland [HDL (2006) 13 provides a national framework for PASS which should be available to the patients, carers and service users of all NHS Boards in Scotland, including Special Health Boards and National Services Scotland. The Health Department have been working with Citizens Advice Scotland, the NHS the voluntary sector and Citizens Advice Bureau to develop this national framework which will ensure quality and equity of services across NHS Scotland. The PASS operating in geographical NHS Board areas should provide advice and support for patients, carers and service users who reside in their area and who want to complain about a service provided by the State Hospital. Arrangements have been made with NHS Lanarkshire to provide this service for patients and carers from Northern Ireland. Leaflets are available in the Carer s Centre showing users how to access this service. 6. Role of the Scottish Public Services Ombudsman (SPSO) The Scottish Public Services Ombudsman Act 2002 established a one-stop shop service to deal with complaints formerly handled by the Scottish Health Service Ombudsman and the function of the Mental Welfare Commission of investigating complaints relating to mental health. The Ombudsman can in principle investigate complaints from aggrieved persons that have sustained injustice or hardship as a result of maladministration or service failure on the part of an authority within the Ombudsman's jurisdiction. Such authorities, referred to as listed authorities, include all NHS organisations. The Ombudsman s office can generally only consider complaints only when they have been fully considered under a listed authority s internal complaint procedures - although this requirement can be waived in exceptional circumstances. Complaints should generally be made to the Ombudsman within 12 months of the events giving rise to them, or within 12 months of the complainant becoming aware that there were grounds for complaint, although there is scope to waive this requirement if there are special circumstances. The Scottish Public Services Ombudsman Act 2002 requires listed authorities, such as NHS Boards and family health service providers, to take reasonable steps to publicise - the right conferred by the Act to make a complaint to the SPSO the time limit for doing so how to contact the SPSO SPSO Freepost EH641 Edinburgh EH3 0BR SPSO 4 Melville Street Edinburgh EH3 7NS Advice Line Freephone Fax Website: Online contact form: Online complaints form: Details of how to contact the SPSO, (SPSO Information Leaflet 2) is included with every formal complaint response. Page 12 of 14

13 7. Learning from Complaints Data relating to complaints is collected so that lessons can be learned which can help improve service delivery throughout the organisation. Processes are continually being developed for collecting and disseminating the information, themes and good practice gained from stakeholders views, experiences and complaints and ensuring they are used to improve service quality. The State Hospital is keen to listen to and act on complaints from those who feel let down by the service they have received as well as being quick to learn from what we have been advised worked well for our stakeholders. The Hospital is working to strengthen the voices and influence of people who use our services and use a range of approaches and opportunities to hear their complaints, concerns, comments and compliments, learn from them and change the way in which things are done. The Hospital is committed to working towards encouraging the meaningful involvement of those who know how services are currently delivered, and make a special effort to hear from those whose voice is not normally heard or who would otherwise be excluded. The hospital encourages a culture where complaints, concerns, comments and compliments are welcomed and acted upon by all staff. The Hospital is committed to learn from other organisations where things have gone wrong as well as building on areas of good practice. The SPSO monthly commentary reports are reviewed to ensure that lessons are learned from examples of good and bad practice delivered in similar settings to the State Hospital. Staff will treat all stakeholders politely and with dignity and respect. Violence, racial, sexual or verbal harassment of any stakeholder will not be tolerated within the State Hospital. 8. Monitoring Complaints 8.1 Informing the Board Arrangements are in place to monitor the complaints process with due regard to the principles of equality and diversity in terms of the person making the complaint, the person complained against and the content of the complaint. Quarterly reports to the Senior Management Team and Clinical Governance Committee report on: trends in complaints, concerns, comments and compliments outcomes of complaints received the effectiveness of local complaint handling and service user feedback systems lessons learned and shared and any service improvements made identifying exceptions to performance targets monitoring the stakeholders experiences over the period 8.2 Annual Reports The State Hospital publishes an Annual Report which will contain a section on stakeholder feedback and complaints handling. 8.3 National Monitoring The Information and Statistic Division (ISD) collect and monitor statistics on the number, types, and outcome of all formal complaints received by the State Hospital. This information is input by the Complaints Officer and is the same as the information recorded locally on Datix. 9. Audit and Review The procedure will be reviewed every three years as a minimum, sooner should national guidance be reviewed. Complaints data will be reported to the governance committees on a quarterly basis. Page 13 of 14

14 10. Format The State Hospital is committed to ensuring that, as far as it is reasonably practicable, the way we provide services to the public and the way in which we treat our staff reflects their individual needs and does not discriminate against individuals identified and protected within the Equality Act Should a member of staff or any other person require access to this policy in another language or format (such as Braille or large print) they can do so by contacting the Head of Communications. Page 14 of 14

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