Management agement of Complai. nts, Concerns, Comments

Transcription

1 Policy: C1 Management agement of Complai nts, Concerns, Comments & Com pliments Po licy Version: C1 / 09 Ratified by: TMT Date ratified: 12 th December 2012 Title of Author: Title of responsible Director Governance Committee Head of Governance Director of Nursing & Patient Experience Date issued: 12 th December 2012 Review date: July 2015 Target audience: NHSLA relevant? Disclosure Status Service User and Carer Experience / Trust Board All staff Trust wide Yes B Can be disclosed to patients and the public EIA / Sustainability Implementation Plan Monitoring Plan Other Related Procedure or Documents: EIA form for C1 implementation plan G:\Trust Policies and West London Mental Health NHS Trust Page 1 of 29

2 Equality & Diversity statement The Trust strives to ensure its policies are accessible, appropriate and inclusive for all. Therefore all policies will be required to undergo an Equality Impact Assessment and will only be approved once this process has been completed Sustainable Development Statement The Trust aims to ensure its policies consider and minimise the sustainable development impacts of its activities. All policies are therefore required to undergo a Sustainable Development Impact Assessment to ensure that the financial, environmental and social implications have been considered. Policies will only be approved once this process has been completed West London Mental Health NHS Trust Page 2 of 29

3 Version Control Sheet Version Date Title of Author Status Comment C1/01 April 2001 Head of Complaints New Policy Withdrawn in September 2003 issued C1/02 September Head of Complaints Revised Policy Revision made to Section issued and 11 of Policy C1/03 January Head of Complaints Revised Policy Revision made to Sept 03 Policy 2006 issued in Section 10 and 11 C1/04 24/10/07 Head of Complaints Revised Policy As a result of a review to the issued Policy in May 2007 C1/05 08/07/09 Head of PALS, Policy Consultation period ending Complaints & TPL substantially 07/08/09 revised and approved for consultation at Version 5 not approved CSSG meeting C1/06 26/10/09 Head of PALS, Revised Policy Following consultation, revised Complaints & TPL issued policy approved by Operational Delivery Group on 24/09/09 On 16/04/10 ED lead changed from Medical Director to Director of Nursing & Patient Experience no other changes made to policy Version 6 not approved C1/07 July 2010 Head of PALS, Under Substantial revisions made to Complaints & TPL consultation ending 3 rd Sept 2010 policy highlighted Version 7 not approved C1/08 1 st October 2010 Associate Director, Clinical Governance Revised Policy issued Sept 10 - Inclusion of comments / additions from consultation. As well as additions from NHSLA Consultant to ensure Level 1 compliance. Approved at PRG C1/09 20 th Interim Head of Updated following review of February 2012 Governance process and procedure in line with organisational restructure (& title amended slightly) C1/09 11 th May 2012 Broadmoor Performance Updated following seeding and to take account of different job Improvement titles in each CSU! Manager C1/09 To be presented to TMT, December 2102 West London Mental Health NHS Trust Page 3 of 29

4 Content Page No. 1. Introduction (includes purpose) 4 2. Scope 7 3. Definitions 7 4. Duties 7 5. Feedback 9 6. Consent Confidentiality Complaints Process Stage one Complaints Process Stage two Complaints Process Stage three Ombudsman Review Support for Complainants Being Open Situations where the complainant s mental health Managing unreasonable complainants Training Monitoring References Supporting documents Glossary of Terms/Acronyms Appendices 23 West London Mental Health NHS Trust Page 4 of 29

5 INTRODUCTION To enable the Trust to provide a responsive, quality public service it is ess ential to actively seek the views of those people who use our services. This policy responds to a number of key initiatives aimed at ensuring organisations seek out views and respond appropriately to feedback: Listening, Responding, Improving A guide to better Customer Care (DoH, 2009) outlined plans to ensure a single health and adult social care approach to the handling of feedback. The statutory obligation to involve and consult the public about services (DoH, 2008) with organisations held to account for actions taken as a result of public participation and feedback. The NHS Constitution (DoH, 2009) outlines the public s rights when making a complaint. The Health and Social Care Act (DoH, 2008) sets out to sustain public confidence in the regulation of Health Care Professionals. This incorporates the need for effective handling of concerns about healthcare professionals CQC essential standards outcome 17 requires NHS organisations to provide evidence of good practice in relation to complaints management NHSLA standard 2, criterion 3 requires NHS organisations to have, as a minimum, approved documented processes for listening, responding and improving when service users, their relatives and carers raise concerns or complaints, and these processes must be implemented and monitored. 1.2 Experience shows that what we learn from listening to service users, relatives and carers promptly and can openly add considerable value to the quality of care provided. 1.3 Ensuring that all service users and carers have the opportunity to feed back their views and experiences of care is an essential part of how we ensure people have a say in our services. The West London Mental Health NHS Trust (WLMHT) has an established framework of reporting and activity to facilitate feedback about all aspects of services and ensure any lessons learned are acted upon. An important element of this framework is information received and action taken as a consequence of concerns and complaints. 1.4 Dealing with feedback in a transparent and responsive way demonstrates a commitment to improving the service user experience and to ensuring that service users gets the best possible support. WLMHT will build an evidence base to demonstrate how the lessons learned from dealing appropriately with issues raised will contribute to improving the quality of the current service, and lead to an increased level of service user satisfaction with services. 1.5 Failure to deal with complaints appropriately presents a risk to the organisation. In particular it could have an adverse effect on the Trust s public reputation either directly through service users own experience or as West London Mental Health NHS Trust Page 5 of 29

6 a result of negative media coverage. It could also lead to missed opportunities to improve services based on service user feedback. 1.6 Service users and carers have a right to have their views heard and acted upon All staff should be able to advise service users, carers, relatives and visitors to WLMHT on how to access the complaints process. Staff assigned to investigate complaints should be appropriately trained to take the right action in accordance with Trust policy and procedures and in highlighting necessary learning. WLMHT s Complaints Service provides a comprehensive service, recording, managing and reporting on all types of feedback. Service users and others will always be supported to raise issues, regardless of whether their feedback is a complaint, concern, comment or compliment. The Trust will ensure that what is learned from all these processes is acted upon to evaluate, develop, plan and improve the services we deliver. The Patient Advice & Liaison Service (PALS) provides a useful point of contact for enquiries about the Trust and its services and to signpost people to other avenues of support, information and advice. Refer to the Pals policy P9 which should be read in conjunction with this policy. Through implementation of this policy we will ensure that: Staff have access to relevant information to support service users, their relatives and carers in giving feedback; Clear, simple, easy to understand procedures for managing complaints are widely publicised and accessible to all; Investigation of complaints and concerns is performed in a thorough and timely way, with transparency, honesty and understanding; Complainants and staff are provided with support and the necessary guidance throughout the complaints process; All complainants, service users and staff are treated equitably, with dignity, respect and without discrimination in all matters relating to their complaint and concerns. Raising a complaint or concern will not affect a service user s care or treatment nor will they be treated differently as a result. The response to complaints and concerns will be fair and equitable to both the complainant and the staff involved; Insight gained from complaints, concerns, comments and compliments and any other form of feedback will be used to improve the care and services we provide; Information gained through any feedback will form an essential part of WLMHT s approach to Governance WLMHT takes all service user feedback seriously. Every effort will be made by staff to act on feedback at the time it is raised if possible and to try and resolve any concerns promptly. However, care must be taken to ensure no clinical details are disclosed without the written permission of the service user. West London Mental Health NHS Trust Page 6 of 29

7 1.12 The Complaints Service will offer support to complainants who may be concerned that discrimination may occur as a result of them raising issues and any reports of discrimination will be sent to the Complaints Manager to oversee an independent investigation and, where necessary, the implementation of corrective action. All concerns regarding actual or potential discrimination will be recorded and reported to the Quality Committee. 2. SCOPE 2.1 This policy applies to all those who work either for or on behalf of the Trust DEFINITIONS For defining feedback, WLMHT uses the 4 Cs: Compliment positive feedback received verbally or in writing (often in the form o f a thank you card) regarding care or services received by service users, relatives, carers or members of the public to WLMHT staff. Comment - a comment may be made either verbally or in writing to any member of staff. Concern - an issue raised in writing or verbally to any member of staff, identifying issues about a service or proposing ways of improving services. Complaint - an expression of dissatisfaction with care, services or facilities provided by the Trust, where any of the following apply: Action (or inaction) by WLMHT or a staff member has detrimentally affected the experience of the service user or carer The complainant believes that a mistake or error occurred and that this has detrimentally affected them The complainant brings to our attention an issue about WLMHT which could detrimentally affect them or someone else, which they expect the Trust to put right There are other ways we collect feedback too. For example; patient surveys, focus groups, service user groups, workshops and participation in National Patient Surveys as prescribed by the Department of Health. Meridian (software on a handheld device) is also used as a tool to collect feedback from service users. This allows the Trust to have access to real time up to date feedback to enable prompt response and learning. DUTIES Chief Executive As accountable officer, the Chief Executive must ensure that responsibility to manage complaints, including informal complaints / PALS within the Trust is delegated to an appropriate executive lead. West London Mental Health NHS Trust Page 7 of 29

8 4.2 Accountable Director The Director of Nursing and Patient Experience is the nominated lead executive director who must ensure that there are robust systems in place to manage complaints, concerns and PALS within the Trust. The Director of Nursing and Patient Experience has overall responsibility for ensuring the Trust s compliance with the arrangements of the new Local Authority Social Services and National Health Service Complaints (England) Regulations 2009 and that action is taken in the light of investigations. 4.3 Clinical Service Unit (CSU) Directors CSU Directors will ensure that all complaints are dealt with appropriately within their respective service units by implementing the process outlined in this policy. They will ensure that governance systems are in place to implement and monitor actions following on from complaints. 4.4 Head of Governance The Head of Governance can act as a higher level reviewer for difficult or complex concerns raised. The Head of Governance will act on behalf of the Director of Nursing and Patient Experience as required to consider the report of the investigation for all complaint responses that require Chief Executive sign off The Head of Governance will ensure the production of a quarterly report which includes an aggregated analysis of learning from complaints, compliments, PALS etcetera for the Trust s Quality Committee CSU Governance Leads The CSU Governance leads will act as a contact point for the service and maintains an overview of the CSU Complaints, compliments & comments database, ensuring all feedback is registered on the system. They provide professional advice to the team and manage any complaints that are referred to the next stage of the process (see section 12). They have a responsibility to oversee compliance with policy and process and also to manage the collation of CSU information for inclusion in reports to Trust wide forums collected by the central governance team. 4.6 Policy Author Policy Author is responsible for the development or review of a policy as well as ensuring the implementation and monitoring is communicated effectively throughout the Trust via CSU / Directorate leads and that monitoring arrangements are robust. 4.7 Locality based Complaints Team Within each Clinical Service Unit (CSU) designated Governance teams are in place to implement this policy. See list on Appendix 2. The Governance teams are responsible for providing information on all feedback activity within their CSU. West London Mental Health NHS Trust Page 8 of 29

9 4.8 PALS Co-ordinator The PALS coordinator works Trust wide, Monday to Friday 9am to 5pm. Messages can be left outside of these times. The PALS co-ordinator works with the individual service user / carer / family etc. to seek answers or provide advice in consultation with clinical services, advocates or other agencies as appropriate. The PALS coordinator works closely with the CSU Governance teams to ensure that concerns are escalated to complaints as and when necessary. Refer to PALS policy (P9) for more information. 4.9 All Staff All staff, both clinical and non clinical, contribute to the service user and carer experience to varying degrees and as such must be receptive to all forms of service user feedback, including complaints, and appreciate that such information is an essential element of good governance. 5. FEEDBACK 5.1 Who Can Give Feedback? Any individual can give any type of feedback to any Trust employee or to the Complaints Service. Feedback is most commonly received from service users, those affected by service provision and those acting as a representative of a service user like their carers, relatives, MPs, councillors or advocates If anyone is writing on behalf of a service user, we will have to seek the service user s consent to respond (see section 6). 5.2 How to Give Feedback? WLMHT has a variety of ways to offer feedback:- Leaflets and posters distributed to all areas of the Trust sites, indicating the various ways you can contact us. An audio copy of the leaflet will also be available on the Trust website and intranet along with options to access copies in other languages. All service users receive a hand book on admission to hospital which includes information on the Trust Complaints procedure. Via members of staff - staff are encouraged and expected to discuss any comment, concern or complaint at the time it is raised to facilitate immediate action and fast resolution of any problems. In the event that the staff member cannot resolve issues immediately or answer questions, the member of staff and the person giving feedback can jointly decide to either involve a more senior member of staff or the Complaints Service. West London Mental Health NHS Trust Page 9 of 29

10 Through the Trust Website via the Contact Us section is a Feedback and a PALS page. Feedback can be sent electronically to the Complaints or the Patient Advice & Liaison (PALS) Service. Through the Complaints or the Patient Advice & Liaison (PALS) Service contact can be made by in writing, by telephone, fax, , referral by a member of staff A list of contact information is included in this policy at Appendix How We Handle Feedback Compliments Compliments can be provided to any member of staff by anyone. Compliments and thank you letters / cards received by the Chief Executive will be responded to in writing if the author provides contact details. A copy will be forwarded to the appropriate department / ward / manager / staff member with a covering note from the Chief Executive. If a compliment is provided in writing direct to a ward / department the manager will respond either by telephone or in writing, providing contact details are provided. Recipients must ensure details of all compliments are forwarded to the appropriate Complaints Team (see Appendix 2) who will log them on the Trust s database Comments Comments can be made in writing, electronically or by telephone (in which case a feedback form (as at Appendix 1) should be completed on behalf of the caller). All comments must be forwarded to the appropriate CSU Governance Team who will log them on the Trust database In discussion with the appropriate department, ward or service manager, the Complaints Team will agree the action to be taken in response. Each CSU area is responsible for ensuring that all comments received are reviewed and actioned appropriately, including responding to the person offering the comment Concerns and Complaints Verbal Response to concerns and complaints should be on the spot wherever possible and a feedback form (as at Appendix 1) completed. If the concern or complaint is raised verbally and can be resolved within one working day the response does not need to be in writing. However, the issue should still be documented using the form at Appendix 1. If it is not possible to resolve the concern or complaint straight away, assistance should be sought from line management. When matters can t be resolved straight away, they should be reported to the appropriate Complaints Team, who will triage the issue(s) raised and negotiate with the person raising the concern / complaint to agree West London Mental Health NHS Trust Page 10 of 29

11 how the issue will be dealt with and within what timeframe. They will also ensure the matter is logged on the Trust s database In Writing All written concerns and complaints will be triaged and assessed by the appropriate Complaints Team. They will work with the person raising the issue to determine a handling plan. The complainant will be offered the choice of the concern or complaint being dealt with through a formal route culminating in a written response or, if they would prefer, they will be supported to resolve the issue directly with the relevant department / team. Irrespective of the chosen route, all con cerns and complaints will be logged on the database and investigated. If a written response is required, it will be sent from either the person to whom the original concern or complaint was addressed, or in accordance with WLMHT s process. Written complaints will always require formal investigation and a written response Th e NHS Complaint Procedure encompasses the following: A person who in receipt of or who has received services from the Trust. A person who is affected, or likely to be affected, by an action, omission or decision of the Trust. A person who is acting on behalf of a person who has died, is a child (i.e. under the age of 18), is unable to make the complaint themselves because of physical incapacity or lack of mental capacity (Mental Capacity Act, 2005) or has been requested to act as a service user s representative When a complaint is made by a representative the Complaints Service Manager must be satisfied that there are reasonable grounds for a complaint to be made by a third party on behalf of another person. Consent should be obtained where there does not appear to be reasonable grounds. Complaints should be made within twelve months of the incident or becoming aware of the incident that has caused concern. However, this timescale can be extended if the Complaints Service Manager, in consultation with the appropriate Service Director is satisfied that there is good reason for any delay and that it is still possible to investigate the complaint effectively. All complainants will be informed about the Independent Complaints Advocacy Service (ICAS). All complainants have the option to apply to the Parliamentary and Health Service Ombudsman should they remain dissatisfied following the Trust s management of the complaint In keeping with the NHS regulations, the following are not covered by this policy. West London Mental Health NHS Trust Page 11 of 29

12 Requests for information about services (refer to PALS or Trust web site). Requests for documents (refer to Freedom of Information Procedure). Requests for access to records or an amendment to the clinical record (refer to Access to Records procedure). Requests for a change to care plan or medication (refer to clinical team). Challenges to policy decisions by the Trust Board (refer to Trust Chairman). Complaints made by a member of staff (refer to HR policies). Complaints about services delivered by an independent provider on behalf of the Trust (the Trust is required to ensure independent providers have their own complaints procedure). Complaints which have already been investigated using the NHS procedure (refer to the section of this policy covering Parliamentary and Health Service Ombudsman). 6. CONSENT 6.1 Consent If a representative raises an issue (i.e a concern or complaint) on behalf of a service user, before disclosing any information about the service user, their consent must be sought. Consent can be granted by the service user verbally over the telephone to a member of WLMHT staff or, preferably, written consent can be provided. In cases whereby consent is provided verbally, a written record of this discussion must be recorded and included within the complaints file. 6.2 Refusal to Consent In a case where consent is not received or not granted by the service user, the representative will be advised in writing that WLMHT is unable to disclose any confidential information about the service user because we do not have their permission to do so. However, a general response to the issues raised will be provided by the relevant service, following an investigation if warranted. The timescales for response will depend on the level of triage. 6.3 Capacity to Consent Adults: In circumstances whereby an adult service user (aged 18 years or over) is not deemed to have capacity to consent, as identified under the provisions of the Mental Capacity Act 2005, a check must be made to ascertain whether a Lasting Power of Attorney (LPA) for the service user s personal welfare is in place. If so, consent will be sought from the attorney who is permitted to make decisions on behalf of the patient If there is no LPA and the service user lacks capacity, consent should be sought from the next of kin. If, however, there are concerns that the complainant and/or the next of kin is not acting in the best interests of the service user with respect to the issues of complaint, liaison may take place West London Mental Health NHS Trust Page 12 of 29

13 between the Complaints Team, the Director of Safeguarding and the CSU Director to establish whether the complaints process should proceed Children & Young Adults: A child aged under 16 and a young person aged 16 or 17 should be deemed to have the competence to consent if they have sufficient understanding and intelligence to consent. In relation to the former this is described as being Gillick competent. Where the service user is under 18 years old, WLMHT has a duty to ensure it is satisfied that there are reasonable grounds for the complaint being made by a representative instead of the child There may be circumstances whereby serious concerns are raised, through the complaints process, relating to a safeguarding adult or child issue. In such circumstances, liaison may take place between the Complaints Team, Director of Safeguarding and CSU Director to establish which procedure to instigate, which must be in the best interests of the service user involved. 7. CONFIDENTIALITY 7.1 Complaints will be handled in the strictest of confidence at all times. Care should be taken to ensure that any information about a service user is only disclosed to those within WLMHT who have a demonstrable need to have access to it. Under schedule 3 of Data Protection Act 1998, explicit consent is not required from the service user (or parent if applicable) for WLMHT staff to access relevant records for the purpose of a complaint investigation. This is because a complaint raised must be looked into to ensure that WLMHT satisfies its duty to ensure safe management of healthcare services to the service user. Complaints documentation must be kept completely separate from a service user s medical records THE COMPLAINTS PROCESS STAGE ONE Timeliness All complaints received will be acknowledged within a maximum of 3 working days. However, where possible, we will endeavour to send an acknowledgment letter within 24 (working) hours. Letter will include re- The method of resolution, their desired outcome and a timeframe will be assurance that their concerns are being looked into fairly and service users care and treatment will not be impacted as a result of raising any concerns. agreed with the complainant depending on the complexity of the concerns raised. If the timeframe for the response cannot be met at any point of the process the complainant must be informed immediately with an explanation of the delay and further agreement on the timeframe sought Fo r complaints which require consent, timescales will be counted from the point at which consent is been received. West London Mental Health NHS Trust Page 13 of 29

14 8.1.4 CSU directors / CSU Service Managers will assign a competent investigating manager for any received complaints. This person must not be directly involved in the complaint being made The CSU governance teams will ensure that all complaints are recorded on the trust electronic system and status kept up to date. They will ensure that the investigators are given all the information required to investigate the concerns raised. 8.2 Seeking Resolution Often a prompt explanation and an apology will be appropriate. In deciding on the appropriate remedy an account should be taken of the nature of the complaint, the impact on the individual affected, the length of time it has taken to resolve the complaint and the trouble the complainant was put to in pursuing it. There are a wide range of appropriate responses to a complaint which has been upheld or not upheld, however upheld responses could include financial or non financial remedies The complainant should be reassured that lessons have been learned and given an explanation of the changes that have been made to prevent a reoccurrence of the matters complained about. Possible remedies could be: An apology An assurance that lessons have been learned and improvements made that will benefit the complainant and others Where necessary action to ensure that staff follow policies and receive appropriate training and support A second opinion from outside of the Trust Seeking input from outside of the Trust Mediation Meeting any costs unreasonably incurred due to the Trust s action or omission If a complete breakdown in the relationship has occurred then a change of personnel / location for service provision The focus should be on the outcome for the complainant and, where appropriate, others similarly affected. This will necessitate a flexible response depending on the circumstances of the case and the outcome of the risk assessment. While a full investigation of the facts is important the investigation does need to be proportionate to the issues raised within the complaint and this may need to be explained to the complainant. 8.3 Staff and Complaints It is vital that staff involved or cited in any complaint are fairly treated and this means ensuring that members of staff know that they have been complained about and have the opportunity to respond, and are aware of the outcome of the complaint and the action / resolution plan. In the event that a student on a placement in the Trust is cited in a complaint, then the complaints case manager will notify the relevant Trust placement officer West London Mental Health NHS Trust Page 14 of 29

15 who will in turn contact the relative university / college to appropriate support. ensure 8.4 Complaints in Relation to More than One Organisation The ve ry nature of mental health care means that we often work with other organisations. National guidance on complaints stipulates that a collaborative and shared approach between Health and Social Services is a pre-requisite for an effective complaints process When a complaint relates to more than one organisation it is the responsibility of the CSU Governance Lead/team to liaise with the other care providers, for example, social services, primary care, acute care to agree a host organisation. This agreement should also be discussed with the complainant. Where possible the aim should be to ensure one consistent and shared response to the issues raised from one organisation on behalf of each of those cited in the complaint. This may mean that separate investigations are undertaken but the spirit of joint working and collaboration must be in place Where more than one directorate or organisation (health or social care) is involved, the CSU Governance Lead/team will assist in ensuring appropriate consent is obtained from the complainant to allow appropriate information to be shared and that a lead person is appointed to co-ordinate the investigation and response Complaints in relation to another Trust Where complaints received by the Trust relate to another organisation the complaint will be passed on as appropriate without delay, following receipt of consent from the complainant. Complaints in Relation to Investigations as Part of a Disciplinary Procedures, Professional Misconduct or Criminal Offences If any complaint received by a member or employee of the Trust indicates a prima facie need for referral to any of the following: (i) (ii) (iii) (iv) (v) an investigation under the disciplinary procedure any of the professional regulatory bodies an independent inquiry into a serious incident under Section 84 of the National Health Service Act 1977 an investigation of a criminal offence an investigation where counter-fraud investigators are involved The person in receipt of the complaint should at once pass the relevant information to the Complaints Service Manager, who will ensure that a Director identified in the Trust s Disciplinary Procedures Policy (D4), is informed. The Director will decide whether or not and when to initiate such action. This referral may be made at any point during any stage of the West London Mental Health NHS Trust Page 15 of 29

16 complaints procedure. The Complaints Service Manager and the identified Director must establish whether or not progressing the complaint might prejudice the investigation of the disciplinary, professional misconduct or criminal processes. If this is the case then the complaint will be closed until such time as the relevant investigation is concluded. The complainant will be told this by the Complaints Service Manager and advised about appropriate action. 8.7 Complaint s in Relation to Serious Incident Reviews In the case of associated serious incident reviews the complaints process will be held in abeyance for those issues which clearly fall under the serious incident review terms of reference. However the complainant may be best advised to await the outcome of the investigation before lodging their complaint. Components of the complaint which do not relate to the serious incident review process will be completed within the normal complaints timeframe. Components of the complaint which are being reviewed as part of a serious incident review will be responded to by the Chief Executive upon completion of the serious incident review process. 8.8 Complaints in Relation to Vulnerable Adults or Children Complaints involving vulnerable adults or children must be referred to the appropriate protection agency and the Trust s policies C18 Child Protection or V7 Vulnerable Adults invoked. This must be undertaken in line with the adv ice and key contacts specified in the relevant policies including the responsible Director for Safeguarding. 9. THE COMPLAINTS PROCESS STAGE TWO Mediation Despite our best efforts some complaints are more difficult to resolve, particularly when there is a breakdown in a relationship and in these cases mediation can be useful. Mediation gives everybody a chance to think about how they could put the situation right. It allows all the parties involved to come up with their own ways to rebuild relationships by working tog ether towards the same goal. Mediation can also save time and money an d lead to quicker solutions and crucially, it can prevent the problem from becoming worse. 10. THE COMPLAINTS PROCESS STAGE THREE Final Internal Review Following mediation the Trust has implemented a third step of its process whereby a complaint file can be reviewed by an appropriate, independent senior member of the Trust in order to ascertain their view on whether the Trust has met all the requirements of the principles of good complaints handling. West London Mental Health NHS Trust Page 16 of 29

17 11. OMBUDSMAN REVIEW 11.1 If all reasonable efforts have been made to resolve a complaint and the complainant is still not satisfied, they can ask the Ombudsman to review the matter After ensuring that the complaint is within their jurisdiction, the Ombudsman may check that everything has been done to resolve the issue locally. If they think more can be done, they will refer the issue back to the service Before taking the matter on, the Ombudsman will consider several factors: What has gone wrong? What injustice has this caused? What is the likelihood of achieving a worthwhile outcome? 11.4 If the Ombudsman believes that there is a case to answer, they will direct the organisation to put things right If the issue is about a service provided by the NHS then the complainant can contact the Parliamentary and Health Service Ombudsman (PHSO) by: Visiting mbudsman.org.uk Calling the complaints helpline on ing phso.enquireis@ombudsman.org.uk Faxing Or by writing to; The Parliamentary and Health Service Ombudsman Millbank Tower Millbank London SW1P 4QP 11.6 Tr ust Response to PHSO In circumstances whereby the PHSO contacts WLMHT to advise that they have been asked to review a complaint, the Complaints Service Manager will be informed and will liaise with the relevant service; source all documentation and information in a timely fashion; provide the PHSO with the information requested within the timescale where practicable All complaints assessed and investigated by the PHSO will be reported in WLMHT s quarterly learning from experience report. West London Mental Health NHS Trust Page 17 of 29

18 12. SUPPORT FOR COMPLAINANTS 12.1 It is important to ensure that complainants are effectively supported, they should be offered support should they require it. This can be in the form of commun ication support, such as translation, audio tape or Braille, independent support, usually through referral to Independent Advocacy Services or other methods of support. All requests and offers of support must be documented within the complaints working file whether or not accepted. 13. BEING OPEN 13.1 WLMHT has embedded the principles of the National Patient Safety Agency (NPSA) Being Open guidance into Trust practice. This is outlined in Policy O2 Being Open. This ethos encourages truthfulness, timeliness and clarity of communications between the Trust and other organisations involved in incidents, complaints and claims. In order to facilitate this, the following elements must be present with the Trust s complaints handling: All statements, letters, notes of phone calls and actions relating to a complaint must be kept in the complaint file; All staff named in a complaint should be informed (as detailed in paragraph 11.3 above); All complaints raised with the CSU or service should be forwarded to the relevant Complaints Team within 24 hours of receipt; For all complaints triaged at the higher levels a being open meeting or discussion should be offered to the complainant; Where the level of care has fallen below acceptable standards, an apology should be provided to the service user and / or carer and family, as soon after the event as possible, with assurance that a full explanation of what went wrong will be provided with any learning and / or recommendations to prevent reoccurrence. 14. SITUATIONS WHERE THE COMPLAINANT S MENTAL HEALTH IS STATED AS THE ROOT CAUSE OF A COMPLAINT 14.1 Where it is clear on investigation that the complainant s mental health is predisposing them to make complaints the following steps should be taken:- The concern that the illness is the root cause of the complaint and that responding to it would adversely affect the service user s mental health problems should be considered by the service user s care team. If, based on clinical opinion that is judged to be the case, they will advise the complaint lead on what management arrangements might be made. These could include:- 1. Delaying the investigation until the complainant is well. West London Mental Health NHS Trust Page 18 of 29

19 2. Not pursuing the investigation as the complaint is part of the service user s pathology. 3. Arranging for the service user to meet with a senior member of their care team (e.g. ward manager) to discuss their issues of concern. 4. Advising that it would not be in the service user s best interests to respond to the complaint. This decision must be clearly documented in the complaint file supported by the rationale for it. This decision can only be made by the Complaints Team in conjunction with the service user s care team. It should be noted that not to make any response whatsoever to a complaint is an exception and should only occur after careful consideration and with good reason. 5. Informing the service user of the care team s advice and resulting action unless there is good reason not to Where a clinical team and the Complaints Team agree that such measures need to be implemented for a patient the Complaints Service Manager must be informed, and the date the measure are implemented will be logged and a date for review agreed. all correspondence relating to the patient s complaint(s) must be discussed with them by the nominated senior member of their care team so that the issues can be assessed and where appropriate investigated, to ensure there are no omissions or causes for concern. 15. MANAGING UNREASONABLE COMPLAINANTS (HABITUAL OR VEXATIOUS) 15.1 This process is necessary for responding to the small minority of complainants who are unreasonable in their expectations of the NHS Complaints Procedure This process should only be considered when all other avenues have been exhausted and then always in line with the NHS Complaints Procedure, as outlined within this policy and supporting guidance. In all cases further guidance should always be sought from the Head of Governance and responsible CSU Director All possible assistance will be employed; including advocacy services and PALS before the policy is implemented WLMHT must ensure that making a complaint is not detrimental to a patient s treatment, care or management and must always ensure that the complainant is made aware of this Definition of an unreasonable complainant Complainants (and / or anyone acting on their behalf) may be deemed to be unreasonable where previous or current contact shows that they meet two or more of the following criteria where complainants: West London Mental Health NHS Trust Page 19 of 29

20 persist in pursuing a complaint where the trust complaints procedure has been fully and properly implemented and exhausted OR where the complainant is unwilling to move to the next stage, by referring their complaint to the Ombudsman OR change the substance of a complaint OR continually raise issues or seek to prolong contact by continually raising further concerns or questions upon receipt of a response where the complaint has been addressed. Care must be taken to ensure that new facts are not excluded from the primary complaint where they are genuinely identified late in the process. Care must also be taken not to discard new issues, which are significantly different from the original complaint. These should be considered as separate complaints. The importance of early communication with the complainant and full clarification of the issues to be raised is therefore very important. The responsible managers must consider if the complainant is unwilling to accept documented evidence of treatment given as being factual, e.g. drug records, General Practitioner, manual or computer records, or nursing records, or deny receipt of an adequate response in spite of correspondence specifically answering their questions, or do not accept that facts can sometimes be difficult to verify when a long period of time has elapsed; does not clearly identify the precise issues that they wish to be investigated despite reasonable efforts of staff and where appropriate, ICAS or other agencies to help them specify their concerns, and / or where the concerns identified are not within the remit of the Trust to investigate; focuses on a trivial matter to an extent, which is out of proportion to significance and continues to focus on this point (it is recognised that determining what a trivial matter is can be subjective and careful judgement must be used in applying this criterion - further advice and in these guidance can be sought from the Complaints Service Manager circumstances); has threatened or used actual physical violence during the investigation of complaint and continue to present a danger towards staff or their families or associates; has, in the course of addressing a registered complaint, had an excessive number of contacts with the Trust, placing unreasonable demands on staff (a contact may be in person or by telephone, letter or fax. Again, discretion must be used in determining the precise number of excessive contacts applicable under this section, using judgement based on the specific circumstances of each individual case); has harassed or been personally abusive or verbally aggressive on more than one occasion towards staff dealing with their complaint or their families or associates, (staff must recognise that complainants may sometimes act out of character at times of stress, anxiety or distress and should make reasonable allowances for this. They should document all incidents of harassment); West London Mental Health NHS Trust Page 20 of 29 its

21 are known to have recorded meetings or face to face / telephone conversations without the prior knowledge and consent of the other parties involved; display unreasonable demands or service user / complainant expectations and fail to accept that these may be unreasonable (e.g. insist on responses to complaints or enquiries being provided more urgently than is reasonable or normal recognised practice) Options for dealing with Unreasonable Complainants Where complainants have been identified as unreasonable, in accordance with the above criteria, the Chief Executive and Chairman (or appropriate deputies) will determine what action to take The Chief Executive (or nominated deputy) will implement such action and will notify the complainant in writing of the reasons why they have been classified as unreasonable complainants and the action to be taken. This notification may be copied for the information of others already involved in the complaint, e.g. practitioners, conciliator, ICAS, MP. A record must be kept in the complaints file for future reference of the reasons why a complainant has been classified as unreasonable The Chairman and Chief Executive (or their deputies) may decide to deal with complainants in one or more of the following ways: Once it is clear that complainants meet any two of the criteria above; it may be appropriate to inform them in writing that they may be classified as unreasonable complainants, copy this policy to them and advise them to take account of the criteria in any further dealings with the Trust. In some cases it may be appropriate, at this point, to suggest that complainants seek advice in processing their complaint, e.g. through ICAS or other agencies; Try to resolve matters, before invoking this policy, by drawing up a signed agreement with the complainant (and if appropriate involving the relevant practitioner in a two way agreement) which sets out a code of behaviour for the parties involved in the Trust is to continue processing the complaint. If these terms were contravened, consideration would then be given to implementing other action; Decline contact with the complainants either in person, by telephone, by fax, by letter or any combination of these, provided that one form of contact is maintained or alternatively to restrict contact to liaison through a third party, (if staff are to withdraw from a telephone conversation with a complainant it may be helpful for them to have an agreed statement available to be used at such times); Inform the complainants that in extreme circumstances the Trust reserves the right to pass unreasonable complaints to the Trust s solicitors; Temporarily suspend all contact with the complainants or investigations of a complaint whilst seeking legal advice or guidance from relevant agencies; Issue a correspondence to the complainant outlining the Trust s approach to acceptable behaviour. West London Mental Health NHS Trust Page 21 of 29

22 15.7 Withdrawing Unreasonable Status Once complainants have been determined as unreasonable, there needs to be a mechanism for withdrawing this status at a later date, if for example, complainants subsequently demonstrate a more reasonable approach or if they submit a further complaint for which normal procedures would appear appropriate Staff should previously have used discretion in recommending unreasonable status at the outset and discretion should similarly be used in recommending that this status be withdrawn when appropriate. Where this appea rs to be the case, discussion will be held with the Chairman and Chief Executive (or deputies). Subject to their approval, normal contact with the complainants and application of the NHS Complaints Procedures will then be resumed. Further guidance is available from the Complaints Service Manager. 16. TRAINING 16.1 The re is no mandatory training available on the requirements of this policy. However staff undertaking investigations as part of the complaints process will have access to Root Cause Analysis (RCA) training and support from both the CSU governance team and the central Governance team as required The Head of Governance should be contacted if clarification is required on any aspect of policy interpretation or application. 17. MONITORING 17.1 The CSU governance teams are responsible for maintaining and updating the complaints, compliments, concerns and comments database, overseen by the Head of Governance This process is monitored via Governance team meetings once a month Where action plans are not being implemented or where there are resource or governance issues identified these will be escalated by each of the CSU s governance leads to the Head of Governance On a quarterly basis the Head of Governance will report progress on complaints, compliments, comments and concerns and actions plans / learning to the Quality Committee group. Issues will be discussed and actions forwarded to the clinical services units A report detailing complaints, concerns, comments and compliments activity will be produced annually 17.6 This policy will be reviewed every two years unless there are changes to legislation or national guidance within that period. In this case the policy will be reviewed earlier. West London Mental Health NHS Trust Page 22 of 29

23 18. REFERENCES (EXTERNAL DOCUMENTS) This policy should be read in conjunction with the following: The Local Authority Social Services and National Health Service Complaints (England Regulations 2009) The Crown Prosecution Service 2006 Achieving Best Evidence in Criminal Proceedings: Guidance for Vulnerable or Intimidated Witnesses, including Children NHS Complaints Regulations National Health Service (Complaints) Regulations 2004 No Supporting Staff, Improving Services Guidance to support implementation of the: National Health Service (Complaints) Amendment Regulations 2006 The Health and Social Care Act 2003 Trust Disciplinary Policy Trust Serious Untoward Incident Policy 19. SUPPORTING DOCUMENTS (TRUST DOCUMENTS) D4 Disciplinary Policy O2 Being Open Policy I8 Incident Reporting Policy P9 Patient Advice & Liaison Policy 20. GLOSSARY OF TERMS / ACRONYMS CSU WLMHT MP ICAS PHSO NHS LPA PALS HR DOH CQC NHSLA Clinical Service Unit West London Mental Health NHS Trust Member of Parliament Independent Complaints Advocacy Service Parliamentary Health Service Ombudsman National Health Service Lasting Power of Attorney Patient Advice & Liaison Service Human Resources Department of Health care Quality Commission National Health Service Litigation Authority 21. APPENDICES. Appendix 1 Feedback form Appendix 2 Contact list West London Mental Health NHS Trust Page 23 of 29