QUALITY ASSURANCE COMMITTEE - 22 June

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1 laint QUALITY ASSURANCE COMMITTEE - 22 June QAC: Item: TITLE OF PAPER Complaints Quarterly Report (01 January-31 March 2015) FROM Rosie McHugh Director of Organisation Development/Board Secretary TO BE PRESENTED BY Wendy Hedland Head of Corporate Affairs ACTION REQUIRED For consideration and discussion OUTCOME Consideration, discussion and approval. TIMETABLE FOR DECISION Approval of Complaints Quarterly Report to be sought at July s Board meeting LINKS TO OTHER KEY REPORTS/DECISIONS BAF OBJECTIVE No and TITLE 1.1 Quality & Safety 2.4 Efficiency & Productivity 6.2 Pathways of Care 7.1 Performance LINKS TO THE NHS CONSTITUTION & OTHER RELEVANT FRAMEWORKS BAF, RISK, OUTCOMES ETC The Complaints Quarterly Report links to The Local Authority Social Services and National Health Service Complaints (England) Regulations 2009, the Board Assurance Framework, strategic objectives, corporate (organisational) risk register, Directorate risk registers, Monitor s regulatory framework. HSE MH Act Equality BME Disability Legislation NHS Constitution: Staff Rights Patients Rights Public s Rights Principles Values IMPLICATIONS FOR SERVICE DELIVERY & FINANCIAL IMPACT Implications of individual risks highlighted in the Complaints Quarterly Report and addressed through action plans already in place. CONSIDERATION OF LEGAL ISSUES Failure to produce the Complaints Quarterly Report would constitute a breach of SDD Objectives, BAF and Monitor s regulatory framework. Author of Report Designation Wendy Hedland Head of Corporate Affairs Date of Report June

2 Report to: Quality Assurance Committee SUMMARY REPORT QAC Item Date: 22 June 2015 Subject: Complaints Quarterly Report (01 January-31 March 2015) From: Prepared by: Wendy Hedland Head of Corporate Affairs Wendy Hedland Head of Corporate Affairs 1. Purpose This paper aims to provide the Quality Assurance Committee with a summary of the Complaints Quarterly Report 01 January-31 March Summary In this period, the Trust received 38 formal complaints, 33 oral and Fastrack complaints and 226 compliments. 4 th Quarter 2014 (01/01/15-31/03/15) 3 rd Quarter 2014 (01/10/14-31/12/14) 2 nd Quarter 2014 (01/07/14-30/09/14) 1 st Quarter 2014 (01/04/14-30/06/14) Formal Complaints Oral and Fastrack Complaints Compliments % of complaints responded to within agreed timescales 4 th Quarter 2014 (01/01/15-31/03/15) 3 rd Quarter nd Quarter 2014 (01/10/14-31/12/14) (01/07/14-30/09/14) 74% 80% 82% 87% 1 st Quarter 2014 (01/04/14-30/06/14) Of the 38 formal complaints received, 11 were upheld, 9 were not upheld and 12 were partially upheld. 4 are still outstanding. 1 complaint was transferred into Whistleblowing Procedures and 1 complaint was closed due to lack of response from complainant (this will be re-opened should the complainant make contact). Where appropriate, action plans, including timescales for completion, are compiled by the Complaints & Litigation Lead and these are approved by the Chief Executive when he signs off each formal complaint response. The action plan is monitored on a weekly basis via the complaints monitoring system which is issued to all Service and Clinical Directors, investigating officers and relevant team managers. The system is designed to ensure that necessary lessons are learned and changes implemented. On completion of the action plan, appropriate evidence is filed on the complaints master file to evidence a closing of the loop. 2

3 To note in Quarter 4: Investigation response times in In-patient Directorate = 45% (43% previous quarter); PHSO/LGO findings and financial penalty following investigation. Parliamentary & Health Service Ombudsman/Local Government Ombudsman Findings Directorate Appeal/Issue Findings Community Delay in processing SDS Delay in remedying an upheld complaint; application. Delay in arranging an assessment meeting; Failure to provide the complainant with the opportunity to review and comment on the review questionnaire (SDS); Failure to include decision reasons in the Mental Health Panel s decision; Failure by the Mental Health Panel to take account of the Trust s complaint findings; Failure by the social worker to address complainant s concerns about the review questionnaire and the Mental Health Panel s decision; Failure to treat complainant as an individual; Failure to communicate effectively, both between the two organisations and with the complainant. Recommendations SHSC and SCC to: Write to complainant to apologise for the failings identified and the distress that the failings caused within one month; (completed) Reimburse complainant 14,000 for the costs she incurred in buying in support that should properly have come from her SDS budget, covering the period January 2014 to February 2015 inclusive; (completed) Agree complainant s monthly SDS budget as a matter of urgency and ensure that payments are made within three months at the latest and backdated appropriately; Pay complainant 12,000 to acknowledge the impact on her of not having an adequate SDS budget in place; (completed) Pay complainant a further 1,000 to acknowledge the avoidable stress and frustration, and her justifiable outrage from having to continue to pursue her complaint; (completed) Disregard these payments when assessing the complainant s financial contribution to her SDS budget; Produce an action plan within three months addressing the faults identified, setting out what action has and will be taken to address them. (completed). 3

4 Action plans relating to complaints where recommendations made (Qtr 4) Actions All service users will be asked whether they prefer the louvre panel to be open at night. Status Their choice will be recorded on 24-hour routine checks form, including reminder to staff to close all louvre panels at 6:30am. The Trust to consider whether the policy of 30 minutes observations of all in-patients at night is necessary, or whether night-time observations could be based on individual risk assessment Trust to consider this in light of the new Mental Health Act Code of Practice (references blanket restrictions). Burbage Ward to establish a protocol outlining the requirement for drug screens to be repeated where the service user refutes the result. Ward staff to be reminded that they are required to provide emotional support to service users following an incident and that they should enable/support service users who wish to contact the police. Ward staff to ensure that service users adhere to the ward s admission contracts. Given the serious incident that occurred following discharge and the potential for further such incidents, staff must, in future, communicate with family when the service user takes S17 leave or is discharged. Senior staff on the ward have been made aware of this requirement. The issues the complainants raised to be shared with staff on Rowan Ward and in the SORT team as an opportunity for them to learn from a carer s perspective. The Trust has, as part of its 2015/2016 Training Plan, identified priority training needs for staff based in the Community Mental Health Teams which will focus on working with Autistic Spectrum Disorders. The training will be facilitated by a specialist clinical psychologist and should address awareness of Asperger s Syndrome. A procedure has been put in place to support people eligible for free prescriptions under Section 117. Staff at East Glade have been reminded of the need to be vigilant in picking up messages and returning calls. An Advance Directive to be put in place which clearly outlines the actions and responsibilities should the complainant s daughter s experience another rapid deterioration in her mental health. The complainant to receive a carer s assessment. An agreement to be reached across all agencies involved with the complainant s daughter s care with regard to who is the Lead Agency i.e. who will respond to future crises and assess which services are best to resolve the presentation at the point of crisis. This should be clearly recorded and shared with the complainant s daughter and her family. 4

5 Actions An understanding to be reached (and recorded) between North East Derbyshire CMHT and South West Sheffield CMHT about what each team s responsibilities will be. Status If the complainant s wife is to remain a service user of North East Derbyshire, then this service to be clearly identified as the lead agency. She should expect the same consideration of her mental health care needs as any other North East Derbyshire CMHT service user. The complainant and his wife to request reconsideration of whether the complainant s wife should be placed on CPA so she might benefit from having a care co-ordinator and a multi-disciplinary approach to her continuing care / condition. South West Sheffield CMHT to ensure that an assessment of the complainant s wife s eligible social care needs is undertaken and the assessment questionnaire completed. The manager of South West Sheffield CMHT to ensure that this work is undertaken by an OT from the CMHT in conjunction with the complainant as a carer (if required) as well as his wife. It may be that the manager will need to liaise with the Adult Social Care OT Department at Sheffield City Council if this is deemed necessary; however, such liaison should not delay the work being undertaken within the deadline specified (one month). A carer s assessment to be offered to the complainant. The complainant to be allocated a Care Co-ordinator. The Manager of West CMHT is to remind staff that there should be no references to complaints or the outcome of a complaint on care records. If in doubt, advice should always be sought from the Corporate Affairs Team. The Manager of West CMHT to remind staff that all decisions should be based on clinical need and must not be delayed due to a complaint having been lodged with the Trust. If tasks are to be allocated to trainees in the short term, careful consideration should be given by the allocating professional that the task given is appropriate and can be carried out effectively in the time available. A review to be undertaken of the protocol in place on G1 in relation to informing relatives of incidents, for example, falls. Particular attention to be paid to the circumstances in which relatives should be contacted and at what point A Clinic appointment system to be implemented which allows patients to book appointments while still on the Clinic premises, i.e. up to 3 months or more in advance. A revised letter to be sent to the complainant s GP. The Opiates Service to review how they deliver sensitive feedback to service users, particularly around child safeguarding concerns. The member of staff to be supported to review practice in this area via clinical supervision. The member of staff will not have any involvement in the service user s future care, barring any crisis/emergency contact. All entries on the electronic patient record, including the initial referral, to be removed from the complainant s notes and transferred to the other service user s record. In addition, all entries relating to conversations between the member of staff and the complainant will be removed from the system, together with all records of any contact with the Alcohol Service, including the initial referral. 5

6 Actions Staff have been reminded to be courteous and professional during all interactions. As an indirect result of these events, a full review of services at Woodland View was commissioned by the Directorate resulting in a number of actions. Some staff have left Woodland View in the intervening period. A programme of work has commenced to improve the environment, including replacing carpets with nonslip washable flooring (reducing the risk of offensive odours), redecoration, and the replacing of furniture, including seating for residents. Levels of staff have been increased on the cottages and there is an ongoing recruitment plan which includes four Clinical Educators. It is usual for doctors to contact patients to discuss results by telephone when this is felt to be appropriate. All doctors at Highgate Surgery have been reminded of this at the staff meeting. Status All doctors were also reminded to routinely review medical histories prior to seeing a patient. The complainant s wife s medical notes have been amended to ensure appropriate details are sent to the laboratory when samples are sent to MSU. In an attempt to reduce the number of GPs who may attend end of life cases in the future, it has been recommended that there should be no more than two or three GPs involved in on-going care in these circumstances. In the future, where service users utilise a managed service, the Trust will set up the service user as a debtor in the same way that we would if they were managing their own finances. This change will allow the Trust to issue statements by service user rather than the current system that includes all invoices on one statement. The Finance Department will be working closely with SPACES North staff over the next few months to ensure that such a situation does not recur. Action plan from outstanding complaint from Quarter 3 included in the Quarter 4 report The CMHT to undertake a case review for team learning. The review to include effective communication, supervision (particularly of agency and temporary staff) and situations involving uncooperative and/or reluctant colleagues and what actions staff could take in such circumstances. Protocols relating to transfer of service users from one team to another to be reviewed, particularly in respect of the transfer of medical responsibility and whether the service user will be allocated a care co-ordinator or key worker. Agency social workers and staff on short-term contracts to be more closely supervised especially in relation to communication and the ensuring of good and positive responses from family members. 6

7 Complaints referred to Health Service Ombudsman Complaints investigated by the Health Service Ombudsman 4 th Quarter 2014 (01/01/15-31/03/15) 3 rd Quarter nd Quarter 2014 (01/10/14-31/12/14) (01/07/14-30/09/14) st Quarter 2014 (01/04/14-30/06/14) Next Steps There are no next steps required. 4. Required Actions As all action plans arising from Quarter complaints have been completed or are being actively monitored, no further action is required. This summary report will be placed on the complaints page of the website ( 5. Monitoring Arrangements The Head of Corporate Affairs will continue to monitor response deadlines, themes/trends and the implementation and completion of action plans on a weekly basis and will submit quarterly reports to the Quality Assurance Committee. 6. Contact Details For further information, please contact: Wendy Hedland Head of Corporate Affairs wendy.hedland@shsc.nhs.uk 7