COMPLAINTS POLICY AND PROCEDURE TWC7

Transcription

1 COMPLAINTS POLICY AND PROCEDURE TWC7 Version: 3.0 Ratified by: Complaints Group Date ratified: July 2011 Name of originator/author: Name of responsible committee/ individual: Date issued: July 2011 Review date: Target audience: Document Reference: Complaints Manager Chief Operating Officer, Executive Lead for Complaints and Complaints Group Chair July 2013 (or if legislation changes) All Trust Staff TWC7 1

2 Version Control Summary Version Date Status Comment/Changes 1.0 FINAL 2.0 May 2009 FINAL Amended to reflect revised national guidance on the complaints procedures 3.0 July 2011 FINAL Amended to reflect governance changes and learning from previous policy Contents Page Number Executive Summary Page 4 1. Introduction Page 4 2. Purpose Page 4 3. Duties Page 5 4. Ratification Process Page 7 5. Definitions Page 7 6. Equality and Diversity Page 8 7. Scope Page 8 8. Complaints Involving Services Provided by Agencies Other than the Trust Page 9 9. Complaints about the Chief Executive 10.Record Keeping 11. Third Party Complaints and Consent Page 11 Page 11 Page Principles in Complaints Handling Page Complaints Resolved by the Following Day Page Complaints Handling Process Page Aggregation Analysis and Improvement 16. Conciliation and Mediation Page 16 Page Out of Hours Arrangements Page Complaints Review Panel Page Vexatious Complaints Page Complaints Grading and Root Cause Analysis Page Where Complaint indicates the need for Investigation under the Disciplinary Procedure Page Complaints Requiring further investigation and follow up by other bodies Page Coroner s Inquests Page Second Stage Review by the Ombudsman Page Monitoring Compliance and Effectiveness with this policy Page Compliments and General Feedback Page Review 28. Associated Documentation Page 22 Page References Page 23 2

3 Appendix 1: Complaints resolved by the following day Page 24 Appendix 2: Complaint Record Form Page 25 Appendix 3: Acknowledgement letter Page 26 Appendix 4: Obtaining Consent Letter Page 28 Appendix 5: Investigating Officer s Initial Letter Page 29 Appendix 6: Delay Letter Page 30 Appendix 7: Complaints Investigation Flow Chart Page 31 Appendix 8: Initial Complaint Contact Form Page 32 Appendix 9: Investigation Report Page 34 Appendix 10: Follow Up Sheet Page 37 Appendix 11: Guidelines for Investigations Page 39 Appendix 12: Guidance on conducting Complaint Meetings Page 44 Appendix 13: Guidelines for Writing a Statement Page 47 Appendix 14: Vexatious Complainants: Guidance and Policy Page 49 Appendix 15: Complaint Response Template Page 53 Appendix 16: Case Examples on Complaints Handling Page 56 Appendix 17: Trust Risk Matrix Appendix 18: Audit Tool Page 59 Page 62 Appendix 19: Equality Impact Assessment Page 63 3

4 Executive Summary This policy has been reviewed in response to new legislation governing the handling of complaints: the Local Authority Social Services and National Health Service Complaints (England) Regulations 2009 ( the 2009 Regulations ) which came into effect from 1 April This policy sets out the complaints handling process to take account of the 2009 Regulations. This policy also formally adopts the Parliamentary and Health Service Ombudsman s Principles of Complaints Handling, Administration and Remedy. 1. INTRODUCTION 1.1 This policy sets out the Trust procedure for complaints handling: listening, responding to and learning from complaints from service users and carers or from third parties acting on their behalf or any person who is affected by or likely to be affected by the action, omission, or decision of the Trust. 1.2 The Trust aims to provide a high standard of care but accepts that sometimes things go wrong and there will always be improvements we can make to our services. For this reason all complaints will be listened to and taken seriously and viewed as a positive means of gaining feedback from people who use our services. We will endeavour to respond to all complaints in a way that is, consistent, open, fair timely with a focus on resolution and service improvements. 1.3 The Trust is committed to the early resolution of complaints either by an immediate informal response from front line staff, or by subsequent investigation and conciliation by staff empowered to deal with complaints. 1.4 The Trust will handle all complaints in accordance with the NHS complaints procedure as currently set out in the Local Authority Social Services and National Health Service Complaints (England) Regulations 2009 ( the 2009 Regulations ) and the Parliamentary and Health Service Ombudsman ( the Ombudsman ) Principles of Complaints Handling being: (1) Getting it right (2) Being customer focussed (3) Being open and accountable (4) Acting fairly and proportionately (5) Putting things right (6) Seeking continuous improvement 1.5 This procedure also adopts the Ombudsman s Principles of Administration and Remedy. 2. Purpose 2.1 Where someone makes a complaint the Trust has two key aims: (1) To listen to the complaint and do everything reasonably possible to resolve that complaint to the satisfaction of the person or people who have made it; and (2) To learn from what has happened and, where appropriate, make demonstrable improvements to the service. It is important that the Trust is able to identify service improvements and other issues, e.g. lack of resources or staff shortages, arising from complaints. It is the responsibility of the appropriate Investigating Officer to ensure that actions identified as a result of the complaint are implemented, either by taking action personally or by referring to other managers/clinicians. Any service improvements, which could be, or are made, as a result of a complaint must be reported to the Complaints Manager. 4

5 3. Duties 3.1 Trust Board is responsible for making arrangements for dealing with complaints in accordance with the 2009 Regulations and to publicise those arrangements Monitor the implementation of the procedure and review complaints in order to make service improvements where necessary Ensure that appropriate procedural guidance is available to staff Identify an Executive Lead for complaints 3.2 Chief Executive Is the responsible person for ensuring compliance with the arrangements made under the 2009 Regulations and will respond in writing to complaints if a written response is required by the complainant 3.3 Executive Lead for Complaints Present regular complaints reports to the Trust Board Respond in writing to all formal complaints in the absence of the Chief Executive Chair the Complaints Committee Inform the police, coroner, professional regulatory body or other agency as appropriate should a complaint or subsequent investigation reveal that a criminal offence or other serious incident has occurred. Initiate a critical incident process should a complaint or subsequent investigation reveal that a criminal offence or other serious incident has occurred. Arrange for the handling of any media interest arising from a complaint or subsequent investigation with the Trust public relations service. 3.4 Service Directors In respect of complaints arising in their respective boroughs (or complaints investigated on behalf of another borough) Investigate or appoint an appropriately trained Investigating Officer to investigate a complaint in accordance with the complaints procedure Ensure that complaints are investigated properly and in an efficient, timely and evidenced based manner Ensure that complainants receive a timely and appropriate response and ensure that local resolution is sought Ensure that identified actions, recommendations and learning from complaints is disseminated and acted on in their service areas and reported to their clinical governance structures. Support and guide staff including Investigating Officers 3.5 Assistant Service Directors, General/Service Managers, Associate Directors of Nursing and Modern Matrons (and their delegates) To act as Investigating Officers when allocated Ensure that learning from complaints is disseminated and acted on their service area Support and guide staff who are the subject of a complaint 5

6 3.6 Investigating Officers To be at least the level of Service Manager (or equivalent) or above and to conduct investigations and draft proposed responses appropriately, thoroughly ensure that they are evidenced based and in accordance with this policy To consider whether any other policy or procedure requires to be considered such as the Safeguarding Vulnerable Adults procedure and if an alert needs to be made under that procedure To maintain good communication with the complainants keeping them informed throughout the complaints process. When the complaints process goes on hold to allow another process to take priority they are required to keep in contact on progress and update them of when it is likely for the complaint process to be resumed. Endeavour to reach local resolution for all complaints and to find conclusions to the complaint and recommend whether any action is taken as a result of it. If an action plan or recommendations are made by the Investigating Officer they reported it the service director Ensure that learning from complaints is disseminated and acted upon Support and guide staff who are the subject of or involved in a complaint Undertake all specific duties allocated to them as part of this policy and procedure 3.7 Emergency teams relevant to the Borough Provide support for staff to respond to complaints received out of hours. Decide where necessary to inform the on-call General/Service Manager 3.8 On call General/Service Manager Provide support for staff to respond to complaints received out of hours Decide where necessary to call the on-call Director, Police, Coroner or other appropriate agency should a complaint be of a sufficiently serious nature 3.9 Assistant Director of Nursing Provide support and supervision for the Complaints Manager Ensure that information and lessons learned from complaints are integrated into overall risk management arrangements Ensure that the complaints function is adequate and meets 2009 Regulations 3.10 Complaints Manager Manage the complaints procedure for the Trust in accordance with the 2009 Regulations and this policy Ensure that staff have appropriate support and training to enable them to respond positively to complaints and comments. Ensure that complainants are supported in making a complaint Decide whether a communication is a complaint or not Provide the Trust Board and Directorates with regular monitoring reports Support Investigating Officers, reviewers and other staff by providing advice and guidance on Trust policy. Maintain up to date knowledge about emerging Government policy, Inspection body requirements and best practice concerning complaints handling, recommending changes as required in Trust policy in order to comply with these. Grade complaints according to Trust risk management procedures. Inform the Claims Manager of any potential claims arising from complaints Inform the Executive Lead for Complaints if any complaint is of such a serious nature as to potentially require investigation under the Serious Untoward Incident Policy Inform the Executive Lead for complaints if a complaint or subsequent investigation reveals a possible criminal offence or incident that may require referral to a professional regulatory body has occurred. 6

7 Maintain a database and record of complaints Review written responses on behalf of the Chief Executive Overview reports that are prepared to the Complaints Group and Complaints Review Panel Make any required statutory returns Report quarterly to the Integrated Governance Committee and annually to the Board May delegate certain functions to the Assistant Complaints Manager 3.11 Performance Managers Manage the timeliness of investigations and liaise with the Investigating Officers and Complaints Department 3.12 All staff: Treat complainants with respect and courtesy and take steps to ensure that service users and carers are not treated adversely as a result of making a complaint Develop an understanding of the complaints procedure and where to get further advice and support regarding it Try and resolve complaints fully and quickly as they arise Ensure all service users and their carers have access to the complaints procedure and to support them to use it Co-operate fully and promptly in complaints investigations Put learning from complaints into practice in their work 4. Ratification process Key Area Lead Director Working Group Ratification Body Complaints Chief Operating Complaints Group Officer 5. DEFINITIONS a complaint 5.1 A complaint is an expression of dissatisfaction about our services and or facilities however made, by an existing or former service user (or their representative) or by any person affected by or likely to be affected by the action, omission, or decision of the Trust, requiring a response. 5.2 A complaint is not: a request for a service a petition or circular letter a request for clarification an isolated incident immediately resolved by the following day to the satisfaction of the complainant a staff grievance or disciplinary issue a request for access to health records 5.3 Advice from the Complaints Manager must be sought if there is uncertainty about whether an issue should be dealt with (and recorded) under the complaints procedure or at which stage it should enter this procedure. 5.4 Members of staff can raise their concerns or grievances via the Raising Concerns or Grievance procedures that can be found on the Trust s bulletin board under Human Resources policies and procedures or can be obtained in hard copy from the Human Resources Department. 7

8 a service user 5.5 A service user is anyone who is currently or who was formerly in receipt of Trust services. a third party acting on behalf of a service user 5.6 A third party may refer to: Relatives/carers (a partner, relative or friend who provides practical or emotional support) Individuals with parental or statutory responsibility for children receiving care from the Trust (e.g. parents, carers, teachers, social workers, health visitors) Advocacy Services Service Users Forum Independent Complaints Advocacy Service (ICAS) or other advocacy services General Practitioner Care Quality Commission Members of Parliament Legal representative. A Person Affected 5.7 A person affected or likely to be affected could include a complaint made by carers concerning services they received from the Trust in respect of their role as carers (e.g. carers assessments). Decision 5.8 If a person is unsure whether a communication is a complaint that falls within the 2009 Regulations and whether it should be treated under this policy, the mater should be referred to the Complaints Manager who will make the determination. 6. EQUALITY AND DIVERSITY 6.1 All service users should have equal access to the complaints system. This may require providing additional assistance and support such as help to prepare or express the complaint or through provision of an interpreter or advocate. Communication needs should be assessed for all service users as part of the care planning process and where support is needed it should be provided both to ensure all service users know about the complaints system and to help them use it. 7. SCOPE 7.1 A complaint can be made orally, in writing or electronically. 7.2 Any complaint that falls within the definition at paragraph 2.1 above will be subject to the complaints process unless it has been excluded (see below) or other direction has been given by the Complaints Review Panel and approved by the Chief Executive. 7.3 A complaint should normally be made within twelve months of the date on which the matter which is the subject of the complaint occurred or within twelve months of the date on which the matter which is the subject of the complaint came to the notice of the complainant. The Trust has discretion to extend this time limit where it is satisfied that the complainant had good reason for not making the complaint within that time and notwithstanding the delay it is still possible to investigate the complaints effectively and fairly. 7.4 The following matters are specifically excluded from the scope of this policy by virtue of the 2009 Regulations: (1) a complaint made by a local authority, NHS body or primary care or independent provider; or 8

9 (2) a complaint made by an employee of a local authority or NHS body or primary care or independent provider about any matter relating to their contract of employment; or (3) a complaint which is made orally and is resolved to the complainants satisfaction not later than the next working day after the day on which the complaint was made; or (4) a complaint the subject of matter of which has previously been investigated under the 2009 Regulations (or their predecessor regulations); or (5) a complaint which is being or has been investigated by the Health Service Commissioner or Local Commissioner; or (6) a complaint arising out of an NHS body s alleged failure to comply with a request for information under the Freedom of Information Act 2000; or (7) a complaint which relates to any scheme established under s10 or s24 of the Superannuation Act 1972 or to the administration of those schemes the subject matter of which has already been investigated under the NHS Complaints Regulations. 7.5 Where a complaint is specifically excluded the Trust will not consider further save that if it falls within 7.3 it will write to the complainant as soon as is reasonable to inform them of the decision and the reasons for it. 7.6 The Trust has procedures for complaints received regarding the Data Protection Act 1998 and the Freedom of Information Act contained The Trust may consult with the Information Commissioner regarding these complaints. 7.7 Access to health records should not be confused with access to the 2009 Regulations, which are both separate processes. However, it will often be the case that a complaint will relate to a clinical issue and will therefore require disclosure of health records to the service user or their representative. Requests for access to records should be handled in accordance with the Trust s Access to Medical Records Policy. 7.8 If the representative for a service user competent to consent wishes to have access, or discuss any aspect of their health records, they must supply a written statement from the service user authorising the hospital and the medical/nursing staff to reveal to, or discuss with, the representative any and all clinical information. 7.9 Complainants also have a right to request access to their complaints file. These requests should also be handled in accordance with the Trust s Access to Medical Records Policy. 8. COMPLAINTS INVOLVING SERVICES PROVIDED BY AGENCIES OTHER THAN THE TRUST Complaints received and sent regarding other parties 8.1 Where complaints are sent to other NHS bodies, Local Authorities or Primary Care Providers but relate to the exercise of the functions of the Trust, they shall be handled under these procedures once it has been received. The Trust shall handle the complaints as if it had been received directly. 8.2 If a complaint is received by the Trust but relate to the another NHS body, Local Authority or Primary Care Provider the Complaints Manager shall seek the consent of the complainant to pass the complaint on to the third party for dealing. Once that consent has been received the Complaints Manager shall pass on the complaint to the third party and inform the complainant of doing so. If consent is not received then the complainant will be informed that the Trust is not able to investigate the complaint. 8.3 Where complaints are received which involve shared Social Service Care provisions, the Trust s Complaints Manager will liaise with the appropriate Local Authority on investigating and producing a response. On receipt of a complaint of this kind the Trust must seek to obtain permission from the complainant prior to sending details of the complaint to the Local Authority. If consent for information sharing is withheld then the Trust must advise the complainant on the 9

10 parts of the complaint that it is able to deal with adding that should the complainant wish to pursue the Local Authority for part of the complaint, they should approach the Local Authority directly. If consent is received there is a clear duty for all parties to fully co-operate in the investigation of the complaint, this includes Sharing relevant information Attending joint meetings to consider the complaint Ensuring a comprehensive and appropriate response is sent Coordination of the complaint procedures Keeping the complainant informed throughout the process 8.4 The two bodies should seek to agree which organisation should take the lead in co-ordinating the handling of the complaint and dealing with the complainant. The lead body s Complaints Manager must: Coordinate the handling of the complaint by working closely with all those involved; Ensure a comprehensive and appropriate response is sent, and Ensure that they keep the complainant informed and, where possible, coordinate a single reply. 8.5 The bodies should consider a joint meeting with the complainant if this will facilitate a more effective outcome. 8.6 The coordinated response must identify which parts relate to the relevant aspects of the complaints letter. The response should advise the complainant of their right to pursue the complaint further and provide details of which regulatory organisation would deal with each aspect of the complaint. 8.7 Notwithstanding which body is the lead agency, the Trust s Chief Executive should sign the response, except where there are good reasons for them not being able to do so. Further, each body retains its duty of care to the complainant and must handle its part of the complaint in accordance with its own regulated procedures. Safeguarding children and vulnerable adult procedures 8.8 Local authorities have a key role and legal powers in safeguarding children and vulnerable adults. The Trust also has procedures in place for dealing with concerns about safeguarding children and protection of vulnerable adults. 8.9 The Complaints Manager and Investigating Officers should be aware of the need to identify any safeguarding children or vulnerable adult issues arising out of complaints and to liaise with relevant staff and agencies, and to work to the relevant procedures The Complaints Manager will separate out complaints that should be dealt with under other procedures and cases where joint action is required. There should be effective coordination between the agencies involved and complainants should be provided with clear information as to how inter-agency matters will be dealt with In considering a complaint that is subject to concurrent investigation under safeguarding children or vulnerable adult procedures, the Trust should be careful not to do anything that may compromise or prejudice the other investigation. The independent sector 8.12 Where the Trust makes arrangements for the provision of services with an independent provider, it must ensure that the independent provider has in place arrangements for the handling and consideration of complaints about any matter connected with its provision of services as if the 2009 Regulations applied to it. 10

11 Care Quality Commission 8.13 Where complaints are made that might relate in part to a matter for the Care Quality Commission (CQC), the Complaints Manager should advise the complainant of the ability to complain to the CQC. 9. COMPLAINTS ABOUT THE CHIEF EXECUTIVE 9.1 The Chief Executive shall be the Responsible Person in respect of all complaints received but this can be delegated. If a complaint is received about the conduct or actions of the Chief Executive, the role of Responsible Person shall be delegated to the Trust Chairman for that complaint. 10 RECORD KEEPING 10.1 Investigation Officers and the Complaints Manager should ensure that all information relevant to the investigation of the complaint is recorded and kept in a case file. They should always bear in mind that should the complaint progress to an independent review; the Ombudsman will request a copy of the case file and will expect it to be delivered to them without unnecessary delay All complaints should be sent to the Complaints Department. 11. THIRD PARTY COMPLAINTS AND CONSENT 11.1 It is necessary under the Data Protection Act 1998 to obtain the service user s consent to use or exchange personal or clinical information as determined by the requirements of the Data Protection Act. Care must be taken when a third party makes the complaint and the response may involve disclosure of such information. Where written consent is not supplied by the third party, the Complaints Manager will arrange for an acknowledgement to be sent as well as arranging for consent to be obtained. If no consent is received the Complaints Manager may set a timeframe within which it is to be received, if it is not received by this time it will be assumed that consent has been refused. 12. PRINCIPLES IN COMPLAINTS HANDLING Introduction 12.1 This section sets out the general principles the Trust will apply in responding to complaints, they are in conjunction with the Ombudsman s Principles that have been adopted at paragraph 1 above. This section should be read with the case examples at appendix 16. (1) An open and flexible approach that supports listening and learning from experience 12.2 All problems, difficulties and complaints must be listened to and handled in an open and constructive manner. Actions taken should be of benefit to the person or people making the complaint, to the staff involved and to the Trust as a whole. An open, learning approach is of particular importance if service users, relatives and families are to have confidence in the organisation. Openness of staff is integral when handling complaints by discussing aspects of the complaint promptly, fully and compassionately and can help service users cope better with the after-effects. Openness when things go wrong is fundamental to the partnership between service users and those who provide their care Directorates and Corporate Services within the Trust must take follow-up action to improve services based not only on individual complaints but on trends that emerge. Information about these improvements will be included in Trust Board reports. 11

12 (2) Providing ease of access 12.4 Those wishing to make a complaint must be assisted in doing so. Staff need to ensure that they have an up to date knowledge of the complaints process and that they are able to supply service users with appropriate information and literature about how the complaints procedure operates. (3) Providing high standards of assistance 12.5 Trust staff should adopt a sensitive and sympathetic approach when handling complaints, giving help and assistance in a constructive way. Where services have failed to reach the required standards a clear apology should be given Staff should resolve complaints as speedily as possible to prevent matters escalating, since delays will lead to frustration, lack of confidence and possibly even complaints about the process itself. The Trust s performance on the speed with which it substantively responds to complaints is carefully monitored for this reason. (4) Support for those making a Complaint 12.7 Making a complaint can be a daunting task, particularly when it involves matters of personal health and care. People who make a complaint should be encouraged to seek support if they feel it would help Support from family, friends, Complaints Department, and Advocacy services should also be encouraged. The Independent Complaints Advocacy Services (ICAS) will also play a role in helping individuals pursue complaints. Information about them, including contact details, is included in the Trust complaints leaflet and on the Trust website and the Complainant is informed of ICAS in their acknowledgement letter. (5) No adverse treatment 12.9 Any service user, carer or representative making a complaint are to be reassured as appropriate that making a complaint will not have any adverse consequences to service user s or carer s care. To support this principle, complaints and their responses will not be held with service users medical records (unless they specifically request that it is in which circumstance it can be considered) and if a service user or carer wishes to raise an issue regarding adverse treatment this will handled as a separate complaint and investigated in accordance with these procedures. This principle shall be highlighted in the Trust s mandatory Induction training. (6) Supporting Staff Being involved in a complaint can be stressful for staff, especially if they are being personally criticised. Staff should receive support from their manager, the Complaints Manager or Staff Support Advisory Network. Staff may also wish to obtain support from their Professional Organisation or Trade Union Staff should be advised that this complaints policy is quite separate from the Trust Disciplinary Procedure and that the process of considering whether the disciplinary procedure should be invoked is also quite separate. (7) Training Training in complaints handling will be provided within the Trust as part of its training programme in risk management. All new members of staff will be given guidance about the policy and procedure as part of their mandatory induction. 12

13 (8) Training Needs Analysis In order to ensure the health, safety and wellbeing of our service users and staff, the Trust aims to address the needs and impact of its corporate, mandatory and statutory training with a comprehensive and robust training needs analysis procedure. To this end, all Trust policies which have risk management training needs for permanent staff are included in the Training and development policy which includes comprehensive Training Needs Analysis for all staff as managed by the Training and Development Department. This document is available on the Trust intranet, under Training and Development. Policy Author Responsibility: Management Responsibility: Staff Responsibility: Training and Development Department Responsibility: to inform the Training and Development Department of amendments to policy training needs. to ensure all permanent staff are adequately trained as appropriate to the employees duties and work location and to follow up on refresher training needs. to ensure that they attend all relevant training as detailed in their induction and annual Performance Appraisal and Development Review (PADR). to provide access to training for all permanent staff. To maintain monitoring, reporting and review systems as per the Training and Development Policy. (9) Effectiveness Staff who are involved in all aspects of complaints handling must be thorough in their approach. They can demonstrate this by, for example, carefully analysing letters of complaint, ensuring that investigations are carried out that involve all the appropriate areas of the Trust, meeting early with the complainant and completing the Initial Contact Form and Investigation Report and responding with the right level of detail and openness and ensuring that appropriate actions are taken and that learning is developed Where staff need to develop skills to achieve this then this should be identified in their personal development plans with their line managers and appropriate training given. (10) Listening, Learning and Improving from complaints The Trust is committed to listening and learning from Complaints and that those lessons lead to service improvement It is the role of the Investigating Officer to find conclusions to the complaint and recommend whether any action is taken as a result of it. If an action plan or recommendations are made by the Investigating Officer it is reported to the service director and it is their responsibility that the actions or recommendations are taken and that any relevant issues are reported to the borough clinical governance committee All complaints, learning and service improvements are to be reported to the Complaints Group every quarter by their respective directorates for monitoring and any outstanding actions yet be taken are to be highlighted for direction from the Complaints Group. A summary of the lessons learned and service improvements are to be reported to the Integrated Governance Committee via a quarterly report from the Complaints Manager and Annual Report to the Board 13

14 13. COMPLAINTS RESOLVED BY THE FOLLOWING DAY 13.1 Many complaints will be initiated with front-line staff and may be resolved immediately, or by no later than the following day, to the satisfaction of the complainant. The responsibility of the complaint recipient is to ensure that the complaint is dealt with as quickly as possible in an informal and sensitive manner. They must also complete the form at Appendix 1 (or completed by the person who is resolving the complaint) and sent to the Complaints Manager immediately Examples of early resolution are complaints about a particular aspect of care might be resolved promptly through organising a review of the Care Plan, involving the Ward Manager and Care Co-ordinator and any other relevant members of the clinical team. Concerns of a more general nature (e.g. ward environment) might be resolved quickly through ward community meetings or discussion with the Ward Manager Young people in the Child and Adolescent Mental Health Service, as well as their parents or carers, should be encouraged to discuss complaints with the appropriate member of the clinical team in the first instance (e.g. Clinical Team Leader, Care Co-ordinator, Key Worker, Consultant Psychiatrist) Complaints made by clients living in the community are often about particular aspects of care and treatment and might be resolved promptly through setting up a case review meeting with the clinical team The Manager of the service (e.g. Service Manager) should be contacted where this might assist in deciding the most appropriate approach to dealing with a complaint If the complaint is not capable of resolution by the following day or it has not been resolved to the complainant s satisfaction the complainant should be provided with any necessary assistance to pursue a complaint through the normal process and the complaint passed to the Complaints Manager. This may also include practical assistance and help with contacting an appropriate advocacy service or the appropriate local ICAS Examples of when it is not possible to resolve the complaint adequately can include. For example: When it is not possible to give the assurances that the complainant is looking for. Where the severity of the complaint requires formal investigation and especially where disciplinary action should be considered (e.g. accusations of verbal or physical abuse by a member of staff, accusations of theft). Where there is any doubt as to how to proceed. Where the complainant remains, or appears to remain, dissatisfied, or where the nature of the complaint requires further investigation If the complainant does not wish to complain but still has a concerned enquiry they can be directed to the to staff at an operational level with direct knowledge and experience of the issues as the Patient Advice and Liaison Service () will no longer operate as a separate function. Remaining concerns will be rapidly escalated through to our complaints department. All staff have duties in patient advice and liaison. As its now an NHS wide requirement that issues raised move into the complaints process if not resolved within 24 hours, a dedicated function has become a 'step' in the process which is no longer required If the complaint cannot be resolved the complainant should be offered the choice of detailing his/her concerns in writing to the Chief Executive or the Complaints Manager or help given to 14

15 them to complete a Complaint Record Form (Appendix 2) which should be kept available on wards and which if completed by a member of staff should, if possible, be checked with the complainant for accuracy. This must then be faxed immediately to the Complaints Department within 1 working day. 14. COMPLAINTS HANDLING PROCESS Receipt and Acknowledgement Any complaint that has been received by the Trust is to be sent to the Complaints Department within 1 working day. The complaint will be acknowledged by the Chief Executive within 3 working days. In the form of Appendix 3 (with any other additional information or expressions, such as condolences, that may be appropriate). The Complaints Department will telephone the complainant where possible and offer to discuss the complaints handling process and anticipated timing and notify them of the Investigating Officer s further contact with them. In respect of any complaint that is received verbally, a written record must be made of it and a copy provided to the complainant The Complaints Manager, or delegate, will send a copy of the complaint to the Borough Performance Manager who will ensure that the Service Director appoints an appropriately skilled Investigating Officer. Initial Steps 14.3 Upon receipt of the complaint the Investigating Officer should: (1) consider whether any immediate remedial action needs to be taken and action if appropriate (this would include, for example, raising a safeguarding alert under the Safeguarding Vulnerable Adults procedure); (2) pass on the complaint to all those relevant including the person (s) named in the complaint; (3) contact the complainant by telephone (if known) and offer meeting to discuss how the complaint is to be handled, including the response time and clarify and/or resolve the issues, to confirm what the complainant is seeking by way of outcome and whether a response from the Chief Executive is required. Whether telephone contact is made or not the Investigating Officer is to write to the Complainant in the template attached at Appendix 5 and complete and Initial Contact Form at Appendix 8 within 5 days of the complaints receipt and send a copy to the Complaints Department straightaway (any time frame for a written response should build in a 10 working day review period with the Complaints Department). The Investigation 14.4 The Investigating Officer will commence and conduct the investigation in accordance with the Guidance for Investigations at Appendix11, Guidance on Meetings at Appendix 12 and ensure that all relevant documents are obtained and reviewed and that statements are obtained in the form set out in Appendix 13. Statements will need be gathered from all relevant staff members and provided to the Investigating Officer promptly, within 5 days (unless greater urgency is indicated), together with any relevant supporting documentation (e.g. care plans, nursing notes, incident forms) The investigation shall be carried out in time to enable a response to be sent to the Complainant within the time frame agreed with them, and if no time frame is agreed within 25 working days of receipt of the complaint (allowing for reviews). If there is a delay in meeting the time frame the Investigating Officer shall endeavour to agree a new time frame (explaining reasons for delay and apologising if appropriate) and a letter will be sent to the complainant in the form of Appendix 5 15

16 setting out an alternate timescale. The Investigating Officer should keep the complainant informed during the investigation process as far as is reasonably practicable When concluding the investigation the Investigating Officer shall complete an Investigation Report (Appendix 7) ensuring that the investigation is evidence based, cogent and supports the response. Where there are actions recommended an Action Plan with named staff responsible with timings for completion should be prepared. In drafting the proposed response the following points should be taken into account: the details of the complainant, such as name and address, must be checked for accuracy. It should be documented if the complainant is on a section of the Mental Health Act and information regarding pursuing a complaint to the Care Quality Commission should be given. all issues and grievances within the complaint should be responded to. A description of the investigation, including any interviews and statements, should be included and any action resulting from the investigation should be explained. It should be clear whether a complaint has been upheld (a complaints can be partially upheld). the response should be in plain English and grammar and spelling accurate. It should be free of jargon, with any technical terms fully explained. an apology or other redress or remedy should be included in the response where appropriate. the response should offer the opportunity for the complainant to discuss the final response with the relevant Investigating Officer (and member(s) or the clinical team, where appropriate). if the complainant is still dissatisfied, s/he should be advised in the response how they can pursue their complaint further. The response letter should therefore include details on how to contact the Ombudsman Once the investigation and associated documentation have been completed, the Investigating Officer shall send all the papers to the Complaints Department. The Complaints Manager, or delegate, will review the response. Where this is felt to be unsatisfactory the Investigating Officer will be asked to go through the investigation once more or reconsider the proposed response When considered satisfactory the proposed response and complaint file will be sent to the Chief Executive for consideration and to sign the response. If any amendments are recommended by the Chief Executive they are to be taken in by the Complaints Manager, or delegate. Once the response is finalised and sent to the complainant, a copy will be sent to the Borough Performance Manager for dissemination to all those involved in the complaint and the service user s consultant if appropriate The Investigating Officer shall ensure that any follow-up action identified in the response is carried out and that the Directorate report into the Complaints Committee on quarterly basis. Follow up 14.10If the complainant is not happy with the response the Investigating Officer is to reconsider the investigation and response together with the additional issues raised by the complainant. A further meeting should be considered and the form at appendix 10 be completed as appropriate. Advice should be sought form the Complaints Manager as this stage as whether a referral to the Ombudsman would be appropriate or further work on the complaints is needed. 15. AGGREGATION ANALYSIS AND IMPROVEMENT 15.1 The Director of Corporate Affairs, Head of Clinical Risk, Clinical Risk Manager and Complaints Manager meet quarterly to review serious incidents, complaints and claims. A quarterly report on 16

17 serious incidents, complaints and claims is presented at the Clinical Governance Group and Integrated Governance Committee. This report includes an identification of themes and lessons learned shared Trust-wide with staff responsible for providing patient care and ensuring patient safety. Further information about analysis and learning is outlined in the Trust Learning from Experience Policy. 16. CONCILIATION and MEDIATION 16.1 Conciliation should be considered throughout the course of the investigation and advice from the Complaints Manager should be sought as to whether a conciliator independent of the service complained of could be used to resolve any outstanding concerns. The Conciliators role is to talk to both parties, either separately or together, in order to identify areas of conflict, ensure that all issues are fully discussed and aired, and help bring the situation to a satisfactory conclusion and resolution The Complaints Manager may, in any case where he/she thinks it would be appropriate to do so (taking into any cost considerations) and with the agreement of the complainant, make arrangements for external mediation for the purposes of resolving the complaint Whether mediation or conciliation is used, all those involved in conciliation need to be made aware of what such a process involves. Inevitably it will mean that both parties will need to enter such a process willing to compromise Confidentiality must be strictly observed during the conciliation or mediation. 17. OUT OF HOURS ARRANGEMENTS FOR COMPLAINTS HANDLING 17.1 Most complaints can be dealt with during normal working hours. When a person makes a complaint out of working hours and it cannot be resolved at the time, staff should tell the complainant that the complaints response process will start on the next working day. If unsure what to do, the person receiving the complaint should contact the On Site Nurse Advisor for the relevant site for advice Occasionally a complaint may be of such a serious nature that immediate action needs to be taken. Examples might include an allegation of assault or other criminal act. In this case the person receiving the complaint should call the on call General Manager. 18. COMPLAINTS REVIEW PANEL 18.1 A Complaints Review Panel shall meet at the request of the Chief Executive or Complaints Manager to consider complaints placed before to provide direction as to their handling and also make any declaration regarding vexatious complainants. 19. VEXATIOUS COMPLAINTS 19.1 Vexatious complaints are an increasing problem for NHS staff. Staff are expected to respond to all complainants with patience and understanding. However, in exceptional circumstances, there may be times where nothing further can be reasonably done to assist them or to rectify a real or perceived problem. In such circumstances staff should refer to the Appendix 14 guidance for responding to vexatious complainants 20. COMPLAINTS GRADING AND ROOT CAUSE ANALYSIS 20.1 In accordance with Trust risk management procedures, the Complaints Manager or delegate, must categorise and grade each complaint according to the Trust risk matrix (see appendix 17), to identify the level of investigation required and if other personnel need to be alerted (e.g. Risk Manager). 17

18 20.2 The Complaints Manager will notify the Clinical Risk Manager of any complaints received that indicate that a serious incident has occurred, to ensure that proper reporting and investigation of serious incidents takes place All complaints graded Red (15 or above) will be subject to full root cause analysis. The Complaints Manager will notify the relevant staff (such as the Clinical Risk Manager and Investigating Officer) if a full root cause analysis is required Root cause analysis is a process that aims to discover the root cause of the incident resulting in a complaint. The root causes of complaints usually lie in the organisational and management systems and processes that support the delivery of care. The primary purpose of investigating complaints is to identify and address the root causes and to improve systems and processes (where this is indicated) to reduce the likelihood of the events leading to the complaint recurring. Investigations will focus on identifying the following: what happened (or nearly happened) Where, when and to whom it happened Persons involved The root cause(s) of the events (systems, policies, procedures, processes) Any lessons which can be learnt which might prevent a reoccurrence or Reduce the impact 20.5 The use of root cause analysis is essential in ensuring that whilst not detracting from personal accountability, a just culture is established which acknowledges the importance of identifying the systemic factors which can lead to complaints and acts to remove or mitigate these factors to improve care. Further details of the use of root cause analysis and triggers for using root cause analysis can be obtained form the National Patient Safety Agency website On occasions where a full root cause analysis is already being undertaken via another procedure (e.g. Serious Untoward Incident), then no additional root cause analysis will be required provided it is copied to the Complaints Manager. 21. WHERE A COMPLAINT INDICATES THE NEED FOR INVESTIGATION UNDER THE DISCIPLINARY PROCEDURE 21.1 The complaints process is only concerned with resolving complaints and not with investigating disciplinary matters. The disciplinary process is separate. Where a complaint reveals the need for disciplinary action, this need not prevent investigation under the complaints procedure of other aspects of the complaint as long as this does not prejudice or compromise the concurrent investigation. The complainant should be kept informed of the timeframe of the other investigative process and sent a full response on its conclusion, outlining the outcome and actions taken and being mindful of patient and staff confidentiality issues. If disciplinary action is taken as a result of a complaint this will not necessarily be disclosed to the complainant. 22. COMPLAINTS REQUIRING FURTHER INVESTIGATION AND FOLLOW-UP BY OTHER BODIES 22.1 Some complaints will require further investigation under other procedures. These would include complaints requiring disciplinary action, a serious issue that should be reported to a professional body for further investigation and an allegation of a criminal offence. These issues will be referred to the appropriate body if that action is agreed by the Chief Executive. 23. CORONER S INQUESTS 23.1 Where a complaint is also subject to a Coroner s inquest, the Trust will continue to investigate the complaint and respond as per these procedures. 18

19 23.2 However, where a complaint relates to the cause of death, the Trust will only formally respond in writing after the Coroner has delivered its verdict. Complaints investigations should also be extended if the Coroner so requests Where the Coroner s Court requests statements from staff, it is advised that the Trust use these statements as the basis for any internal complaints investigation The Complaints Manager should consult with the Coroner s Office as appropriate. 24. SECOND STAGE REVIEW BY THE OMBUDSMAN Referral 24.1 If the complainant is not satisfied they can ask for the Ombudsman to investigate the case for them. Before the Ombudsman will look into a complaint, they will expect that the complaints process has been exhausted, unless it is judged that in the particular circumstances this would be unreasonable to do so The Ombudsman is independent of the NHS and the government and there is no charge for the service. The Ombudsman s office can investigate complaints about: poor service failure to provide a service that a patient has a right to receive administrative failures such as, avoidable delay, not following proper procedures, rudeness or discourtesy, not answering a complaint fully and properly, including refusing to set up an Independent Review Panel complaints about the care and treatment provided by a hospital doctor, GP, nurse, dentist or other health professional, providing that the events complained about occurred after 31st March Initial Action 24.3 If the Ombudsman contacts the Complaints Manager to inform the Trust of a potential referral, the Complaints Manager shall consider (with the Investigating Officer or Complaints Review Panel if appropriate) whether the complaints process has been exhausted or not and notify the Ombudsman If the Chief Executive receives a letter from the Ombudsman, enclosing a summary of the complaint referral, he/she will delegate responsibility for dealing with issues arising from the letter to the Complaints Manager The Complaints Manager will collate the schedule of documents requested by the Ombudsman and arrange for them to be sent to the Ombudsman together with any comments about the investigation as appropriate. Investigation 24.6 After reviewing the Trust's documentation the Ombudsman's Office will notify the Trust if they intend to conduct their own investigation, or not If the Ombudsman's office intends to conduct their own investigation, they will confirm which witnesses their investigating officer requires to see. Those witnesses involved in the events complained about will be informed by the Complaints Manager of the details of the impending investigation and those aspects of the complaint which involve him/her, and will be provided with a copy of 'Notes for Witnesses' The Complaints Manager will ensure that a room is made available for the use of the Ombudsman's investigating officer during the investigation and will arrange attendance of 19

20 witnesses at the investigating officer's interview. Statute does give the Ombudsman the power to compel the attendance of witnesses. Witnesses may have someone with them to act as a support and reduce their anxiety. Final Report and Subsequent Action 24.9 Once the Ombudsman's investigation is complete, the investigating officer will send a copy of the draft final report to the Chief Executive The Complaints Manager, on behalf of the Chief Executive, may circulate the draft report (which is confidential at this stage) to the minimum people necessary to enable any comments to be made on the presentation of the factual evidence, and also to confirm that the facts given in evidence by the Trust staff are correctly stated On receipt of the Final Report from the Ombudsman, the Chief Executive will delegate the responsibility of collating the necessary action to implement the recommendations in the report within the stated time scale to the relevant Clinical Director and Service Manager The Complaints Manager will arrange for copies of the report to be sent to staff directly concerned with the complaint Relevant senior members of staff within the Trust will be requested to initiate action that will be implemented in relation to the recommendations made in the report. Details of this action will be returned to the Chief Executive to enable him/her to write a response to the Ombudsman within the time scale specified, informing the Ombudsman of all action taken by the Trust A letter will also be sent from the Chief Executive to the complainant, informing him/her of the actions taken following the Ombudsman's recommendations. 25. MONITORING COMPLIANCE AND EFFECTIVENESS WITH THIS POLICY Element to be monitored That all That All complaints are acknowledged within 3 working days of receipt Lead Tool Frequency Reporting arrangements Complaints Manager Appendix 18 Every two years Report to Complaints Group and Integrated Governance Committee Acting on recommendation and Lead(s) Required actions will be identified by the Executive Lead for Complaints and completed in a specified timeframe. Change in practice and lessons to be shared Required changes to practice will be identified and actioned within a specific time frame. A lead member of the team will be identified to take each change forward where appropriate. Lessons will be shared with all the relevant stakeholder 20