COMPLAINTS MANAGEMENT NGH/PO/016

Transcription

1 COMPLAINTS MANAGEMENT NGH/PO/016 Ratified By: Procedural Documents Group Date Ratified: October 2009 Date(s) Reviewed: August 2009 Next Review Date: August 2011 Version No: 3 Responsibility for Review: Complaints Manager Contributors: PALS Manager, Director of Nursing and Midwifery, Deputy Director of Nursing (Governance).NGH/PO/016 Page 1 of 30

2 CONTENTS Section Page Summary 3 1 Introduction 3 2 Purpose 4 3 Scope 4 4 Compliance statements 4 5 Definitions 5 6 Roles and Responsibilities 6 7 Substantive Content 7.1 Procedure Overview 7.2 Stage 1 Local Resolution 7.3 Performance Standards for Complaints 7.4 Stage 2 Investigation by the Health Service Ombudsman 8 Implementation & Training 18 9 Monitoring & Review References and Associated Documents 19 Appendices Appendix 1 Process for handling formal complaints 21 Appendix 2 Comments, Concerns, Complaints, Compliments 22 leaflet Appendix 3 Comments, Concerns, Complaints, Compliments 24 form Appendix 4 Comments, Concerns, Complaints, Compliments 25 form - Action plan template Appendix 5 Action Plan Template 26 Appendix 6 Making a complaint Leaflet 27 Appendix 7 Duty to co-operate with other organisations 28 resolving complaints Appendix 8 Risk Grading Tool 29.NGH/PO/016 Page 2 of 30

3 SUMMARY Northampton General Hospital NHS Trust s Policy and Procedure for the Management of Complaints is based upon the NHS Statutory Regulations governing Health & Social Care (for Adults) 2009 No: 309. The Trust also recognises the six principles of the Health Service Ombudsman: 1. Getting it right 2. Being customer focused 3. Being open and accountable 4. Acting fairly and proportionately 5. Putting things right 6. Seeking continuous improvement The Ombudsman has stated that everyone has the right to expect good service from public bodies and to have things put right if they go wrong. If things do go wrong this Trust aims to manage complaints effectively so that concerns are dealt with appropriately and in a timely manner. Effective handling of complaints will aid the Trust to deliver the service and level of care to patients and their families and/or carers that they are entitled to expect. Complaints can be a valuable source of feedback for the organisation, as, when they are handled well, they can provide an opportunity for the organisation to improve their service and reputation. 1 INTRODUCTION Northampton General Hospital NHS Trust is committed to listening to the views of our patients and members of the public about the care that we provide and we value the experiences of our patients. The Complaints Department, in conjunction with the Patient Advice & Liaison Service (PALS), actively seeks the views of patients and the public about the quality of our services, feedback the information to the Trust and staff and ensure appropriate action is taken to improve services. Compliments, comments, complaints, concerns and suggestions from patients, carers and the public are encouraged and welcomed. Should patients, carers or members of the public be dissatisfied with the care provided by this Trust they have a right to be heard and for their concerns to be dealt with promptly, efficiently and courteously. Under no circumstances should patients, relatives or carers be treated adversely as a result of making a complaint. We welcome all forms of feedback and use this information to improve the service that we provide to our local community. We aim to provide a complainant-led complaints service that meets the needs and objectives of the complainant, whilst at the same time complying with the requirements set out in the NHS and Social Care Complaints Procedure. We recognise that the information derived from complaints provides an important source of data to help make improvements in hospital services. Complaints can act as an early warning of failings in systems and processes which need to be addressed..ngh/po/016 Page 3 of 30

4 The Trust serves a diverse patient population and many different ethnic groups use our services. We are committed to providing a complaints service to all regardless of their ethnicity, gender or sexual orientation, religion or disability. 2 PURPOSE The purpose of this policy is to explain how the Northampton General Hospital NHS Trust acknowledges and implements the National Health Service Complaints regulations. The policy is intended to standardise the handling of complaints Trustwide. The principles that underpin this purpose are: To increase people s confidence that their complaints will be taken seriously and that services will improve as a result of their experiences; To have a flexible approach to resolving people s complaints, which includes effective support To provide a seamless approach to complaints investigations To ensure organisational openness and fairness when dealing with complaints To ensure an approach which is fair to people using and delivering services To place the emphasis on early and effective resolution of complaints To provide excellent local leadership and accountability that supports the resolution of complaints. 3 SCOPE This policy is applicable to all NHS staff including students and contractors and provides information in relation to the complaints handling process in accordance with the NHS (Complaints) Regulations that embrace: All NHS bodies (including Primary Care Trusts and Strategic Health Authorities) All statutory providers of NHS care (including Foundation Trusts and primary care providers) Voluntary and independent sector organisations who provide services under contract to the NHS, and Local authorities who provide adult social services 4 COMPLIANCE STATEMENTS Equality & Diversity This policy has been assessed against the Trust s Equality Impact assessment tool as required by the Service Equality Scheme 2006 and Race Relations (Amendment) Act NGH/PO/016 Page 4 of 30

5 General Statement of Intent This Trust aims to design and implement services, policies and measures that meet the diverse needs of the population it serves and its workforce ensuring that none are placed at a disadvantage over others. Disciplinary Action The Trust takes a non-punitive approach to risk and incident reporting. It encourages an open culture and fair-blame approach. The Trust Board has confirmed that staff will be protected from harassment in a situation where they have openly drawn attention to a risk and those directly involved with an incident will not face disciplinary action unless the member of staff has acted: Illegally - against the law (e.g. assaulting a colleague, committing a theft or fraud); or Maliciously - intending to cause harm which s/he knew was likely to result (e.g. deliberately releasing confidential information); or Recklessly - deliberately taking an unjustifiable risk where s/he either knew of the risk or s/he deliberately closed his/her mind to its existence (e.g. working while under the influence of alcohol or repeatedly making the same careless mistake). A complaint will be investigated even if disciplinary action is being considered against a member of staff. However, good practice must be adhered to around restrictions in providing confidential/personal information to the complainant. Human Resources policies must be adhered to at all times in this respect. 5 DEFINITIONS Formal Complaint Informal on-thespot Any concern or issue either verbal or in writing (including correspondence) about any aspect of service provided by the Trust which the patient or their representative (with the patient s consent) or any person has specifically asked to be addressed formally through the Complaints Procedure. A complaint may be made by any person about concerns they have regarding the quality of service that they have experienced, in accordance with the framework set out in this procedure. Any issue that can be resolved within 36 hours (the next day) is not considered to be a complaint and therefore falls outside of the remit of this procedure. Issues of this nature should be addressed directly with the member of staff involved. If ward staff are unable to resolve the issue then the complainant should be advised of the other options available to them i.e. to speak with the senior nurse on the ward, the Directorate Head Nurse, Modern Matron or department manager. Additionally the complainant may also be offered the option to discuss their concerns with PALS (Patient Advice & Liaison Service-refer to policy number NGH/PO/228). All options should be considered fully before the issue is escalated to the Complaints Team..NGH/PO/016 Page 5 of 30

6 6 ROLES & RESPONSIBILITIES All NHS organisations and local authorities must have a person readily identifiable to service users, who is responsible for managing the complaints handling team within that organisation. Within this Trust this is the Complaints Manager. The Trust also has a designated Executive Lead for Complaints (the Director of Nursing, Midwifery & Patient Services) who is also the identified person designated as being responsible for: The operation of the complaints arrangements, and Ensuring that lessons learned are implemented 6.1 Complaints Manager The responsibilities of this role are as follows: Formulate and regularly review the Trust s Complaints Policy and Procedure in accordance with the NHS (Complaints) Regulations, ensuring that all updates and changes to the Regulations and covered; Review all formal complaints received by the Trust and ensure that they are handled in accordance with the Trust s Policy and Procedure; Manage the complaints handling process within the Trust along with the complaints team and the relevant staff; Ensure that information about the complaints procedure is publicised widely throughout the Trust; Ensure that processes are in place to facilitate the early recognition of emerging trends and themes in complaints so that these can be addressed; Act as the Chairman s and/or Chief Executive s representative in dealing with patients, their relatives or carers who have raised complaints regarding the level of care and/or service provided by the Trust; As required, provide accurate information on complaints and lessons learnt to the Trust Board; On a quarterly basis, provide complaints data to the Clinical Quality & Effectiveness Group (CQEG); Ensure that information on complaints performance versus targets is made available to directorates on a monthly basis utilising the complaints IT system; Highlight problems in the management and organisation of systems that support the delivery of care which are identified as a result of complaints; As the Trust s designated senior manager liaise with the Parliamentary and Health Service Commissioner (the Ombudsman) regarding complaints that have reached the second (final) stage of the NHS Complaints Procedure; Ensure programmes are in place to provide ongoing training in complaints handling for all Trust staff. 6.2 Complaints Team The Trust s Complaints Team ensures that the day-to-day management of the complaints process is effective. Specifically, they will:.ngh/po/016 Page 6 of 30

7 Within 3 working days of receiving a formal complaint: o Acknowledge the complaint and offer the complainant the opportunity to discuss, either by telephone or face-to-face, how the complaint is to be handled. If the complainant declines the invitation to a discussion, the Complaints Team will, on the evidence available, decide how the complaint is to be handled and advise the complainant accordingly. It should be noted that the Trust will not always be able to accommodate the complainant s preferences on how a complaint should be handled as issues such as the appropriate use of resources must be taken into consideration; o Negotiate the expected timescale with the complainant; o Discuss the complainant s desired or expected outcome ensuring that expectations are managed appropriately. Prepare a complaints plan for every formal complaint that is received; Highlight and fast-track complaints of a potentially serious nature; Ensure that responses from staff address the issues raised in the complaint and are received within the necessary timescales; Be available as required to meet with complainants; Assess reopened complaints to determine what further action is required; Prepare/review written responses in preparation for organisational sign-off, ensuring that the letter fully and clearly addresses the issues raised by the complainant; Complete the process within the target timescales agreed between the Trust and the complainant. This process must not exceed 6 months; Maintain accurate data on complaints. Monitor action plans, which have been prepared by the directorates, to ensure that proposed actions are implemented and signed off by the appropriate senior manager/director; As appropriate, liaise with the Risk and Litigation Departments with regard to being open in the investigation of complaints; Assist in the preparation of documentation as required by the Health Service Ombudsman or other relevant external bodies such as the General Medical Council (GMC) or the Nursing & Midwifery Council (NMC)); Participate in Trust induction and away-days to provide information on the complaints procedure and training on the effective management of complaints. 6.3 Clinical Director/Directorate Manager/Head Nurse These personnel have a responsibility to: Ensure that all staff in their directorate are fully aware of their responsibilities in terms of the handling of complaints in line with this procedure; Ensure that formal complaints relating to their directorates are appropriately investigated within the timescales that have been agreed between the complainant and the complaints team; In the event that a complaint has been received about a member of their staff, ensure that the individual is informed of the complaint and supported throughout the investigation; Ensure that the findings of any investigations are conveyed clearly and promptly to the complaints team; Lead the development of action plans to address any changes in practice within the directorate that have been identified through the investigation of a complaint and monitor the effective implementation of the plans;.ngh/po/016 Page 7 of 30

8 Report progress on action plans developed as a result of serious complaints to the CQEG; Report progress on the implementation of recommendations made following any investigation by the Health Service Ombudsman to the CQEG. Clinical Directors, Directorate Managers and Head Nurses may delegate some or all of the above functions to a named individual in their Directorate/department whilst remaining accountable for the responsibilities. In this situation, the complaints team should be advised accordingly. 6.4 All Employees All employees have a responsibility to abide by this procedure and any decisions arising from its implementation. They further have a duty to ensure that: They take immediate action and try their utmost to resolve verbal complaints thus preventing them from becoming a PALS contact or written complaint; Where the complainant accepts the response as being satisfactory and appropriate there is no requirement for further action; If a complainant is not satisfied with the response to a verbal complaint a PALS contact may be made or a written complaint raised that will be dealt with in line with this procedure. Staff should distinguish serious issues that, although raised verbally, should be brought to the attention of senior managers within the Trust; e.g. where raise patient safety issues are involved; Give assistance with the investigation into any complaints and, as required, provide statements that reflect fact not opinions. 7 SUBSTANTIVE CONTENT Who may make a complaint? Complaints may be made by: A patient Any persons who are affected by, or likely to be affected by, an action, omission or decision of the Trust. A complaint may be made by a representative acting on behalf of the above where that person: Has died; Is a child; Is unable by reason of physical or mental incapacity to make the complaint himself/herself; Has requested the representative to act on his/her behalf and given consent for this; A Member of Parliament acting on behalf of a constituents. Where the patient or person affected has died or is incapable, the Complaints Manager will seek advice from the Director of Nursing, Midwifery & Patient Services, or nominated deputy, as to whether the complainant has sufficient interest in the deceased or incapable person s welfare to be suitable to act as a representative. At all times, the need to respect the confidentiality of the patient must be the guiding principle. Should the opinion be formed that a representative does not or did not have.ngh/po/016 Page 8 of 30

9 sufficient interest in the person s welfare or is unsuitable to act as a representative, the individual will be notified of this in writing and given the reasons for the decision. In the case of a child, the representative must be a parent, guardian or other adult person who has care of the child. Where the child is in the care of a local authority or a voluntary organisation, the representative must be a person authorised by the local authority or the voluntary organisation. Exclusions and time limits The procedures laid out in this documentation may not be used: For complaints raised 12 months or more from the date on which the matter occurred, or the matter came to the notice of the complainant (however, the Trust has the discretion to investigate beyond this time if there are good reasons and if it is still possible to investigate the complaint effectively and fairly); By health organisations or local authorities against each other; For issues that may be resolved within 36 hours (the next day); For complaints relating to private health care providers; For complaints that have already been investigated under the Complaints Regulations; For complaints which have been or are being investigated by a Local Authority Commissioner or the Health Service Ombudsman; Complaints arising out of an alleged failure to comply with Data Protection or Freedom of Information requests; Where the complainant has stated that they are taking legal action against the provider. 7.1 Procedure overview (Appendix 1) The NHS formal complaints procedure comprises two stages. The following sections detail how the Trust approaches each of these stages. Stage 1 Stage 2 Local resolution (and review if required) Investigations by the Parliamentary and Health Service Ombudsman 7.2 STAGE 1 - LOCAL RESOLUTION Local resolution of concerns and complaints Patients and relatives are encouraged to raise concerns or make complaints as soon as possible and directly to the staff involved or to the manager of the ward or department. Guidance is provided in the patient information leaflet Comments, Concerns, Complaints, Compliments (Appendix 2). This leaflet gives information to patients, relatives, carers and staff regarding the Trust s streamlined approach to handling issues raised and ensure they have access to the range of options available to them in order to resolve their concerns in a self determined way. The complainant s concerns should be addressed constructively and where possible dealt with immediately by the staff member approached. The complainant should be treated sensitively and in a manner that is open and constructive. If the staff member approached is unable to deal with the issue raised, it should be referred promptly to a more senior member of staff on duty at the time, i.e. ward manager, head nurse or directorate/department manager..ngh/po/016 Page 9 of 30

10 Where it is not possible to deal with the complaint immediately or the complaint requires an involved investigation or the complainant wishes to address their concerns to somebody who has not been involved in the situation, the complainant should be referred initially to PALS who will advise the complainant of the options available i.e. either through a formal or informal process. Irrespective of who is dealing with the matter, the complainant should be given a contact name and telephone number and must be kept informed of progress and advised when a response could be expected. Accurate records must always be made and kept regarding the concerns, actions taken and any communications. Staff must ensure that a Comments, Concerns, Complaints, Compliments form (Appendix 3) is completed and sent to the directorate Manager or department head and copied to the Complaints Manager. Where a decision has been taken to provide a written response, an acknowledgement and a written summary detailing the complaint will be sent to the complainant within three working days. The complainant has 5 working days in which to correct any errors or make additions to the complaint. Verbal complaint forms should only be used by the Complaints Team on receipt of a verbal complaint from a member of the public and received directly in the department. For verbal complaints that require investigation, a copy will be sent to the complainant for their record and signature PALS & complaints interface Close collaboration between the Complaints Department and the Trust s PALS is essential to ensure a coherent and seamless approach to resolving clients concerns. These teams work closely together to establish the most effective means of resolution of patients/relatives concerns. Where complaints include issues that might be dealt with in a more timely way outside the Complaints Procedure these will be handled by PALS in agreement with the complainant Written complaints All formal complaints will receive a letter of acknowledgement within three working days identifying the issues raised. A complaints leaflet (Appendix 6) giving information about the right to request an independent review by the Health Service Ombudsman in the event that local resolution has been exhausted and they are not fully satisfied with the response as well as information about the right to assistance from ICAS will be included with the letter of acknowledgement. The complaint will be sent to the named lead within the Directorate and a copy to the Clinical Director, Directorate Manager and Head Nurse. The named lead will assess the complaint and either personally investigate it or allocate it to an appropriate senior member of their team to undertake the investigation (see paragraph 6.3). Where possible, a draft response in the form of a letter from the Chief Executive including clinical input as required, should be prepared. The draft response may.ngh/po/016 Page 10 of 30

11 be prepared by the investigating manager or an appropriate member of staff from the Complaints Team who will ensure that: all of the issues raised have been addressed; the information contained in the response is accurate; a full and honest explanation of the events is provided; if appropriate, an apology is tendered; an explanation of the actions that have/will be taken to improve the situation is provided. A copy of an action plan may be supplied if appropriate. Where a draft response is prepared within the directorate and where staff are directly involved in the complaint, statements will be taken at the time of the investigation to provide an accurate account of the events. These statements should be submitted together with the draft response by the investigating manager to the Complaints Team Out of hours arrangements The Complaints Department is open between 9:00am and 5:00pm Monday to Friday. When a complaint is raised out of hours, the complainant s details should be taken by the ward or department and passed on to the Complaints Team on the next working day. Should the matter require immediate resolution or the intervention of a senior member of staff, the on-call senior manager or head nurse should be contacted and a Comments, Concerns, Complaints, Compliments form (Appendix 3) completed. The senior manager/head nurse should take the details of the issue and initiate any immediate action. The senior manager/head nurse will then forward the details of the complaint to the Complaints Team if any further investigation or action is required When a complaint is received The Complaints Team will: Acknowledge the complaint and offer the complainant the opportunity to discuss the content of the complaint/how the complaint is to be handled; Agree the expected timescale, in which the Trust will aim to respond, with the complainant; Discuss the complainants desired or expected outcome ensuring that expectations are managed appropriately; Provide the complainant with a copy of the Trust s leaflet How to make a complaint. (Appendix 6) together with an ethnic & age category form (a requirement of the Department of Health); Grade the complaint in accordance with the Trust s Risk Matrix-(Appendix 8); Record the details of the complaint onto the complaints central database; Obtain and review medical records where appropriate; Liaise with the relevant personnel in the investigation of the complaint; Ensure that the relevant directorate manager/head nurse and the clinical director receive copies of all written complaints; Monitor the timescales, which have been agreed between the complainant and the Complaints Team, to ensure compliance; Draft/review the written response to the complainant on behalf of the Trust. This may be in the form of a letter or an investigation report together with a covering letter; Include in the response details of any action which is being taken to implement changes in practice and procedure identified as a result of the.ngh/po/016 Page 11 of 30

12 complaint; Ensure that, where appropriate, letters of response are sent to clinical staff for approval of the clinical content before being sent to the complainant; Ensure that the letter of response is quality checked by a senior manager with an appropriate level of knowledge/experience before being passed to the Chief Executive for signature; Send the approved final response to the complainant within the agreed timescale, as set out at the start of the process; Ensure the complainant is kept informed and a new timescale agreed in the event of unforeseen delays in the issue of the response; Ensure copies of the response to the complaint are sent to the relevant staff; Be responsible for maintaining secure and accurate records of each complaint; Monitor action plans and ensure that evidence is provided by the directorate to show that the actions have been taken and the plan is signed off by a senior manager/director Organisational sign-off All complaints must have organisational sign off when action has been completed at local level. Accountability for sign off will rest with a senior person within the organisation (i.e. the Chief Executive). The actual task of ensuring the necessary actions have been completed, signing the final letter and checking any attachments may be delegated to a designated manager within the Trust, acting on behalf of the Chief Executive Serious complaints Serious complaints are those that are risk rated high with reference to the Trust s risk grading tool, the most serious being where a patient has, or is perceived by the complainant to have, suffered death or permanent disability as a result of action or non-action of Trust staff. Further details about risk management and grading assessments are included in the Trust s Risk Management Strategy and associated Policy. Serious complaints may also involve: identification of a serious clinical incident; medico-legal implications; professional disciplinary or criminal investigation; safeguarding of children or vulnerable adults; a serious breach of health and safety or fire safety arrangements which has resulted in injury to a patient, carer or relative whilst on Trust property. The Complaints Manager will promptly identify those complaints that meet the above criteria and review the complaint with the relevant senior manager/director who will initiate the appropriate action. Complaints which identify a serious clinical incident will be passed to the Risk Manager who will agree who will be responsible for liaising with, and responding to, the complainant. The incident will be logged on the Trust s clinical incident reporting database and also on the complaints database. Copies of documentation relating to the complaint will be filed with the Complaints Team to facilitate ready access if the complainant wishes to pursue the complaint to the next stage of the Complaints Procedure. Complaints which have legal implications will be passed to the Litigation.NGH/PO/016 Page 12 of 30

13 Department upon completion of the investigation. The complaint will remain on the complaints database and documentation will be filed in the Complaints Department. The exception to this will be if the complaint becomes a legal claim, and the complainant advised of this. Information derived from the claim will be actioned through the directorate governance groups and Trust-wide at the CQEG. Details of complaints which warrant professional disciplinary or criminal investigation (such as professional misconduct, poor performance, theft, assault, wilful negligence or abuse) will be passed to Director of Human Resources for action and copied for information to the Medical Director for Medical staff, the Director of Nursing, Midwifery & Patient Services for nursing and therapy staff, and the Director of Operations for all other health professions. Details of complaints which have Safeguarding of Children or Vulnerable Adults concerns will be notified to the SOVA Lead or Safeguarding Children Lead as appropriate. The Lead will then confirm whether the complaint should continue to be handled through the Complaints Procedure or whether a safeguarding notification should be raised. In the event of alleged abuse, the safeguarding procedure will always take precedence. Complaints which have Health and Safety or Fire Safety implications will be passed to the Risk Management Department for recording and investigating. The Risk Management team and Complaints Manager will jointly agree who will liaise with and respond to the complainant. Copies of the documentation relating to the complaint will be kept by the complaints department to facilitate access should the complainant decide to proceed to the next stage of the complaints procedure. Information derived from the complaint will be actioned through the directorate health and safety groups and the Director of Facilities Action plans Where the investigation of a complaint identifies the need to make changes in practice and systems, it is important that all remedial measures are clearly documented, acted upon and monitored. The Directorate Manager/Clinical Director (or the designated investigator for the complaint) must provide an action plan (Appendix 5) clearly identifying the action that has or will be taken. The responsibility for the action plan will remain within the directorate/department. Other than in exceptional circumstances, all action plans should be fully implemented within a maximum of six months. The Clinical Director/Directorate Manager will be responsible for ensuring that agreed actions are taken and monitored. Action plans will be monitored by the Complaints Team to ensure that evidence of implementation has been received along with executive/senior management sign off Cross-directorate and cross-organisational complaints Appendix 7 Duty to co-operate with other organisations in the resolution of complaints..ngh/po/016 Page 13 of 30

14 Complaints about members of staff Where complaints are expressed against named members of staff, there is a process of review to ensure that any shortfalls in performance are identified as impartially as possible and rectified. The following process should be followed (except where professional, disciplinary or criminal investigation is warranted). When a complaint is received against a member of staff, information should be obtained from the member of staff via interview or statement. The member of staff s line manager will then be asked to review this information (e.g. a complaint against a junior doctor will be reviewed by the relevant consultant, a complaint against a ward staff nurse will be reviewed by the ward manager, a complaint against an allied health professional will be reviewed by their professional lead). Following review by the line manager, actions such as counselling, supervision or training should be initiated by the reviewer as appropriate. If, following investigation/review, it is apparent that professional, disciplinary or criminal investigation is warranted, the Complaints Manager and the Director of Human Resources should be informed immediately. The Complaints Manager should follow the actions set out in Serious Complaints. The directorate leads are responsible for ensuring that this process of review has been carried out appropriately and that any member of staff about whom a complaint has been made is appropriately supported during the investigation Written complaints received directly by departments or individual named staff Some complainants may prefer to address their concerns directly to the relevant consultant, director, ward or departmental manager. If this constitutes a complaint the information should be passed to the Complaints Team and investigations and response made in line with this procedure. In cases where it is unclear whether a concern raised directly with a member of staff is a formal complaint or if there is a suggestion of any serious shortcomings, the Complaints Manager, in consultation with the complainant, will decide whether or not the matter should be investigated Help for people wanting to make a complaint Any person making a complaint should be advised that they can seek support from the Independent Complaints Advocacy Service (ICAS) who provide free, impartial, confidential and independent support to people who wish to complain about health care services (Paragraph 7.2.3) Complaints received via the media The Trust will not enter into correspondence with complainants via the media. People who contact the local press to complain about the care they or their relatives have received should be advised to contact the Complaints Team if they wish to pursue a formal complaint against the Trust. Where a complainant has contacted the media because they are dissatisfied with the way in which their complaint has been dealt with by the Trust, they should be reminded of their right to proceed to the second stage of the NHS Complaints Procedure by contacting the Health Service Ombudsman..NGH/PO/016 Page 14 of 30

15 The Complaints Manager will work with the Communications Department to prepare statements on specific issues where this is considered to be appropriate Complaints brought by Members of Parliament (MP) on behalf of constituents Complaints about health services raised in writing by MPs on behalf of their constituents will be addressed in the same manner as any other written complaint. Letter of response will not contain any personal details about the constituent What cannot be investigated as a complaint (See section 7) The formal complaints procedure will not commence or will be stopped if: The complainant expresses an intention to pursue a legal claim against the Trust; Complaints are raised more than 12 months after the event or discovery of the event; The complainant is vexatious or the complaint includes any threat of physical or other harm to staff; The complainant, on behalf of a patient, is not considered to have sufficient interest in the welfare of the patient or is not considered to be a suitable representative. In any of the above circumstances, the complainant will be notified in writing that the complaints procedure has been suspended/not initiated and that the matter is being dealt with in accordance with legal or other procedures. There will be ongoing liaison with the complainant where appropriate. 7.3 Performance Standards for Complaints Complaints Team Complaints must be acknowledged by the Complaints Team within 3 working days of receipt. The target timescale for responding to formal complaints will be agreed in consultation with the complainant. It is the responsibility of the Trust to ensure that agreed timescales are adhered to wherever possible. This will be reported to the Trust Board on a monthly basis as part of the performance report (Balanced Scorecard) and also in the quarterly and annual complaints reports. Timescales will also be monitored via the quarterly complaints reports to the CQEG. The Complaints Team will monitor timescales to identify where they have been, or are in danger of being, breached. Where a response from the directorate is outstanding, the Complaints Team will contact the investigating manager/s to check progress. Where regular breaches in response times from specific directorates become apparent, these will be discussed with the relevant directorate managers initially and escalated to the appropriate director as required Quality of investigations and responses Designated directorate leads are responsible for ensuring that formal complaints are investigated thoroughly and fairly in accordance with Trust guidelines..ngh/po/016 Page 15 of 30

16 They are also responsible for providing information on the outcome of the investigations to the Complaints Team in order for this to be monitored for completion. The Complaints Team will ensure that complaints are tracked and monitored, as appropriate, to ensure compliance with the timescale agreed. It is the responsibility of the directorate governance groups to review and act upon complaints within their relevant areas. The designated investigating manager with assistance from the Complaints Officer is responsible for preparing the written responses to complainants prior to them being approved by a senior manager/director and subsequently presented to the Chief Executive for signature. When these contain clinical or technical information, advice will be sought from the appropriate clinician or other healthcare professional to ensure accuracy. Complainants are always invited to contact the Trust again if they have any queries or concerns about the response to their complaint Conciliation / Mediation Where appropriate, and with the agreement of the complainant, the Complaints Manager may involve a mediator or a conciliator to try to resolve a complaint. Complainants will be offered the opportunity to meet with the Complaints Manager/Complaints Officer and, as appropriate, relevant staff Health Service Ombudsman All complainants must be advised of their right to contact the Health Service Ombudsman if they are not satisfied with the way that their complaint has been dealt with. (Appendix 6) This information should also be provided in the Trust s letter of response Trust s handling of persistent complainants Persistent complainants can cause significant problems for the organisation both in terms of staff time and emotional stress. Such complainants tend to make frequent complaints but each one is distinct. In answering a complaint each issue should be investigated and responded to, however, the amount of time taken to investigate each issue should be determined by the seriousness of the issue, and not by the type of complainant. The Trust has a duty to protect staff against outright abuse of their person or time and it is necessary to identify unreasonably persistent complainants and to have in place a procedure for dealing with them. A persistent/habitual or vexatious complainant may meet one or more of the following criteria: Is in frequent contact with the Complaints Team or another department, sometimes making daily contact; Will contact the department by telephone or in person despite having been given a date for a meeting or advised of the timescale for a written or verbal response; Is aggressive or abusive towards staff; Is adamant that their concerns have not been addressed despite having received detailed responses;.ngh/po/016 Page 16 of 30

17 Having received a response, contacts the Complaints Team immediately with a new set of questions or presents the original problem in a different way; Changes the complaint or what they want to achieve part-way through the process; Dictates who they will speak to and/or meet with; Seeks an unrealistic outcome and express an intention to pursue the complaint until that is achieved. A complainant may meet some or all of the above criteria and the final decision about what action to take will rest with the Chief Executive. In all cases where a complainant is classified as being unreasonably persistent a letter will be sent to them explaining why it is believed that their behaviour falls into that category and what action the Trust is taking. The options are most likely to be: Requesting that they contact the Trust in a particular form (e.g. by letter only); Requesting that they make contact with one particular named person; Restricting their telephone calls to specific days and times; Asking them to enter into an agreement about their future behaviour. Where the complainant fails to comply with the above and continues to behave in a way which is unreasonable, the Trust may decide to terminate further contact with the complainant. The complainant will be advised of this in writing by the Chief Executive. Any further correspondence which is received will be read but not acknowledged unless there are new issues of concern. New complaints received from people who have been dealt with under the persistent complainants section will be assessed by the Complaints Manager and dealt with as appropriate. 7.4 Stage 2 Investigation by the Health Service Ombudsman Role of the Health Service Ombudsman Complainants who remain dissatisfied with the way their complaint has been handled have the right to ask the Health Service Ombudsman to review their complaint. The Ombudsman is authorised to investigate complaints in which a failure in service, or maladministration, has allegedly caused injustice and hardship. The Ombudsman will not usually investigate a complaint, which has not been through the local resolution stage of the NHS Complaints Procedure. Reports and recommendations produced by the Ombudsman will be formally presented to the CQEG What the Ombudsman will do On receipt of a complaint, the Ombudsman will check that it is a complaint that they have the legal power to consider. The Ombudsman can consider complaints about: Unsatisfactory care or treatment; Failure to provide a service that should have been provided; Poor administration, errors, attitude, misleading advice. The Ombudsman cannot consider complaints about::.ngh/po/016 Page 17 of 30

18 Private health care not funded by the NHS; Refusal of access to medical records; Matters on which legal action has been or is about to be taken; Personnel matters relating to recruitment, pay or discipline Role of the Complaints Manager during stage 2 The Complaints Manager will be the Trust s nominated contact for liaising with the Health Service Ombudsman s investigating officer and will be responsible for: Providing copies of documentation and case files as requested by the Ombudsman; Ensuring that all staff involved in the complaint are informed of the Ombudsman s involvement and are updated on developments and decisions; Ensuring that decisions by the Ombudsman are communicated to the appropriate staff and acted upon promptly What the Ombudsman may decide Having completed the investigation the Ombudsman may decide to uphold the complaint in part or in full, or not at all. They will set out their findings and the reasons for those findings in the report. Where the complaint is upheld or partially upheld, they may make recommendations for appropriate redress which might include an apology, an explanation, improvements in practices and systems, or, where appropriate, financial redress. They also have the power to refer clinicians to regulatory bodies in the interests of patient safety. The Ombudsman will expect any recommendations to be fully implemented and the Trust to demonstrate that this has been done. Directorates will be responsible for the development of an action plan to implement the Ombudsman s recommendations and for monitoring adherence to them Implementation of recommendations made by the Ombudsman Other than in exceptional circumstances, all action plans should be implemented within a maximum of 6 months. It is the responsibility of a Senior Nurse or Lead Clinician to draft the action plan. The action plan should then be presented to the Directorate Governance Meeting. A date will be agreed for a progress report on the action plan to be presented to the Trust s CQEG. In the meantime actions plans should be monitored on a regular basis by the divisional/directorate governance groups. Reports produced by the Ombudsman following a review of a complaint will be presented, together with the action plans, to the Trust Board via the Director of Nursing, Midwifery & Patient Services. 8 IMPLEMENTATION & TRAINING The Trust recognises that it is essential that staff receive appropriate training in order to be able to fulfil the responsibilities outlined in this document. All relevant staff will be.ngh/po/016 Page 18 of 30

19 offered training on how to handle complaints positively and also on the principles and requirements of the Trust s Complaints Procedure, including the requirement that complainant s care and service will not be affected by the fact they have made a complaint. All staff involved in the investigation of formal complaints and the preparation of responses should receive appropriate training, including root cause analysis and other relevant skills. A rolling programme of complaints handling training will be provided by the Complaints Department. 9 MONITORING & REVIEW The Trust will be informed quarterly via the Complaints Department about the number of complaints received, any trends and whether Department of Health Targets are being met. Serious complaints will be reviewed and escalated by the Deputy Director of Nursing/Executive Lead for Complaints/Medical Director. Additionally they will also be reviewed via the CQEG who will take responsibility for ensuring that any actions that arise as a result of the complaint are implemented. The Clinical Audit Department will undertake regular surveys of users of the Complaints Department to ensure that the team are meeting its users requirements. 10 REFERENCES & ASSOCIATED DOCUMENTATION The Local Authority Social Services and National Health Service Complaints (England) Regulations 2009 SI 2009/309 [online]. London. HMSO. Available at: [Accessed 27 th October 2009] The National Health Service (Complaints) Regulations 2004 SI 2004/1768 [Online] London. HMSO Available at: [Accessed 27th October 2009] The National Health Service (Complaints) Amendment Regulations 2006 SI 2006/2084 [Online] London. HMSO. Available at: [Accessed 27th October 2009] Parliamentary and Health Service Ombudsman (2009) Ombudsman s principles (Good Administration, Good Complaint Handling, Principles for Remedy) [Online]. London. Parliamentary and Health Service Ombudsman. Available at: [Accessed 27th October 2009] Some additional resources which might be useful: listed on this page: intspolicy/nhscomplaintsprocedure/index.htm includes guidance on helping to improve complaints handling, published 2009: yandguidance/dh_ ngh/po/016 Page 19 of 30

20 Archiving On revision or replacement of this policy the nominated developer, in accordance with the Trust s Policy on Development & Control of Procedural Documents, will request archived copies of the superseded policy. This will be done be completion of a new policy form and in liaison with the Compliance Manager. Associated documents This policy should be read in conjunction with the following Trust policies and procedures: Risk Management Strategy Incident Reporting Policy Being Open Policy Disputes, Inquests and Claims management Policy Guidance to writing statements for clinical & non clinical incidents, complaints & claims Protecting staff against violence, aggression and harassing situations from patients and members of the public policy i.e. the Zero tolerance policy Consent policy Patient Advice & Liaison Service (PALS).NGH/PO/016 Page 20 of 30

21 Appendix 1 Process for handling formal complaints Working day 1 Formal complaint received by Complaints Department Days 1-3 Complaints Department: -Acknowledges the complaint -Grades/risk assesses the complaint Agrees timescale with complainant Complaints Plan developed Day 3 onwards Complaints Department s complaint to directorate/s investigator/s advising of the timescale agreed. Complaint Investigated and statements/evidence collected. Complaints Department check progress with directorate after agreed number of working days, dependent on complexity of complaint Information/draft response/statements must be received in the Complaints Department at least 10 working days before the deadline and, where appropriate, include an action plan. If information/statements not available, appropriate Directorate lead advised and asked to chase outstanding information Draft letter audit checked and where complex clinical information involved, copy of final draft sent to senior manager/clinician for approval Complaints Team liaise with directorate to monitor action plan implementation and evidence of completion. Once approved, letter sent to Chief Executive for signature. Final response sent to complainant within agreed timescales. Correspondence copied to relevant directorate lead.ngh/po/016 Page 21 of 30