Signpost to NKCCG28. NHS North Kirklees Clinical Commissioning Group. Complaints Policy

Transcription

1 Signpost to NKCCG28 NHS North Kirklees Clinical Commissioning Group Complaints Policy

2 North Kirklees CCG Complaints Policy Version Date Author Draft / Final Status th October 2012 Jan Randall Draft Legacy from NHS Kirklees PCT plus localisation pre development th October 2012 Jan Randall Draft First read through and amend in line with Healthwatch / CSU provision nd October 2012 Jan Randall Draft Update following comments from Chair Dr Kelly

3 Contents 1. History of Document and Background POLICY 2. Introduction 3. Associated Policies and Procedures 4. Aims and Objectives 5. Accountabilities 6. Definition of a Complaint 7. Who Can Make a Complaint 8. Time Limits 9. Child Protection/Vulnerable Adult Issues 10. Complaints from Mentally Ill and Clients with Learning Disabilities 11. Complaints Alleging a Criminal Offence 12. Clinical Judgement 13. Legal Action 14. Patient Authorisation (Third Party Consent) 15. Confidentiality 16. Complaints Received Out of Office Hours 17 Anonymous Complaints 18. Complaints Concerning Services Managed by Other Providers 19. Support Available to staff 20. Training 21. Communication with Stakeholders 22. Assessing how serious the complaint is 23. Family Health Service disciplinary procedures 24. Monitoring arrangements 25. Responsibility for complaints arrangements 26. Regional and national returns 27. Annual Report

4 28. Monitoring the ethnicity of patients 29. Learning from experience 30. Sharing lessons learnt across the health community 31. Conciliation 32. Serious complaints 33. Serious Untoward Incidents (SUI) 34. Complaints of a disciplinary nature 35. Complaints leading to litigation 36. Complaints arising from an incident 37. Complaints requiring redirection 38. Joint working with other organisations 39. Stage 2: Health Service Ombudsman s review 40. Storage and retention of complaint files 41. Support for complaints 42. Complaints made to the CCG regarding FHS Practitioners 43. Health Service Ombudsman review of complaints against non-nhs providers 44. Equality impact assessment 45. Policy review 46. Dissemination and implementation

5 Appendices A Verbal Complaint Form B Writing a Statement C Learning Lessons from Complaints Form D Conciliation Leaflet E Equality Impact Assessment

6 1 History of Document and Background CCG Version: Taken from the legacy of the NHS Kirklees Complaints Policy, V0.4 April 2010 This policy has been developed for the NHS North Kirklees Clinical Commissioning Group (NKCCG) for use from 1 April 2013 pending authorisation. Until that time, NHS Kirklees Primary Care trust Complaints Policy and Procedure is in use. NHS North Kirklees CCG recognises that suggestions and complaints provide valuable insights into services that they commission. We will use this information about the services we commission to ensure that they are high quality, safe and accessible and responsive to patients as we place patients and quality at the heart of what we do. In order to achieve this, our approach to complaints is to: Listen Respond Learn and Improve The outcomes of the complaints investigation will form part of our continuous quality improvement process and these outcomes and learning will be shared through our NHS North Kirklees CCG Website: NKCCG will be buying its PALS and complaints service from the West Yorkshire Commissioning Support Unit (CSU) through an SLA arrangement. The overall responsibility and accountability for complaints remains that of the Chief Officer and Chair of NHS North Kirklees CCG, with quality and learning from the complaints being championed by the Head of Quality and Safety. The relationship management for this area at the CSU will be held by the Head of Governance and the Complaints and PALS Manager. Information on how to make a complaint will be readily available to patients and their relatives and carers on the NHS North Kirklees CCG website as well as available as a leaflet and is presently available on the NHS Kirklees website. With the implementation of Local Healthwatch, the CCG will also be signposted to and from this organisation, to ensure that the population of North Kirklees is provided the most appropriate advice and resolution in the right location. POLICY 2 Introduction The aim of NHS North Kirklees Clinical Commissioning Group (NKCCG) policy is to ensure complaints are resolved promptly, effectively and that complainants are treated sympathetically and with respect throughout the process of making a complaint. The policy supports the principle that complaints should positively influence the way services are delivered in the future. The guidance and procedure defines a complaint, explains who is entitled to make a complaint and how the complaint will be dealt with from the initial receipt to its conclusion. Anyone involved in the handling of a complaint, at any level, has an obligation to comply with this policy and procedures and to ensure confidentiality of information at all times. The PALS

7 and Complaints Officers and Managers in the CSU will process complaints that cannot be handled at the point of receipt, in liaison with other key people In accordance with national guidance, the procedure is made up of two stages 1. Local Resolution 2. Review by the Health Service Ombudsman The emphasis will be on taking action to resolve the complaint as quickly as possible, as close as possible to the point of service delivery, whilst at the same time ensuring complaints provide the CCG with an opportunity to take learning from the complaints and improve working practices. At Local Resolution stage, they will provide a formal written response to the complainant within twenty-five days or by a mutually agreed date. Sometimes a patient/user will need a problem resolving, these will be handled by the PALS or Complaints Officers. It is the CCG policy to ensure that patients, relatives and their carers are not treated differently as a result of raising a concern or complaint. 3 Associated Policies and Procedures This policy should be read and used in conjunction with the following: Confidentiality Code of Practice Consent Policy Claims Policy and Procedure PALS Policy and Procedure Depending upon the nature of the complaint the following documents may be helpful: Vexatious and Habitual Complaints Procedure Incident, Complaint and Claims Investigation Policy and Toolkit Serious Untoward Incident (SUI) Procedures Procedure for Handling Access Requests for Health Records Child Protection Procedures Disciplinary Procedure FHS Disciplinary Procedure Freedom of Information Policy Vulnerable Adult Procedures Whistle-blowing Policy 4 Aims and Objectives The CCG wishes to enable and support patient and public feedback on services; this includes ensuring that the process of making a complaint or compliment is as easy as possible. The CCG also recognises the effect that complaints have on individuals and teams and that they may require support during any complaint investigation. That information gained during a complaint investigation is used to instigate and support service change as appropriate and that this information forms part of the report to the Board.

8 This document is intended to provide useful guidance on handling all types of feedback received by the CCG. It is intended to help staff view complaints in an objective way, avoiding concerns about blame and also ensuring that feedback can be used to further develop and improve services. The CCG recognises, and will at all times adhere to, the NHS complaints procedure for the resolution of complaints, in the interests of: Encouraging a climate of openness and transparency when something has gone wrong with a patient s treatment or the patient is dissatisfied with that treatment and/or the outcome. Encouraging the adoption of a constructive approach to complaints and claims, and accepting that concerned patients are entitled to an explanation and an apology if warranted. 5 Accountabilities The policy must be complied with by all groups of staff directly employed by the CCG, together with those with any organisation that the CCG has commissioned to provide support including; the CSU, locum and agency staff and independent contractors. Complaints must be dealt with as set out set out in this document; failure by staff to comply with these may lead to disciplinary action. All Members of Staff One of the main objectives of the Complaints Procedure is to resolve complaints and grievances as quickly as possible. Any member of staff receiving a complaint should attempt to seek solutions to complaints brought to their attention. The organisation encourages staff to do this, as informal resolution at an operational level is regarded as the best way of dealing with most cases. If the complaint cannot be investigated adequately or necessary reassurances given, the complaint should be referred a senior manager or the Complaints Manager. Governing Body Members If a complaint is made known to a Governing Body Member or a letter of complaint is forwarded to them, this information should be passed immediately to the Complaints Manager to deal with. Line Manager If a member of staff does not feel able to deal with the complaint/grievance then they can contact their line manager or Complaints Manager at the CSU for assistance. Complaints that have been dealt with by staff should be reported to the line manager who, in turn, will report to the CCG s commissioned service lead. Chief Officer All complainants have the right to receive a full and prompt reply from the Chief Officer to any written complaint or to oral complaints. The Chief Officer or his/her deputy in his/her absence will sign all written responses and be responsible for ensuring there is appropriate local policy and procedural guidance available to all staff.

9 The Chief Officer will take responsibility for ensuring compliance with the arrangements made under the National Health Service (Complaints) Regulations 2004 and ensure that action is taken in the light of the outcome of any investigation. CSU Complaints Manager All written and oral complaints that front line staff and Complaints Officers cannot resolve on an informal basis are passed to the Complaints Manager. The Complaints Manager oversees and monitors the complaints procedure, acknowledging and co-ordinating timely responses and services the Health Ombudsman reviews. The Complaints Manager monitors all complaints received are recorded and analyses the complaint trends. The Parliamentary and Health Service Ombudsman The Health Ombudsman will consider whether or not to investigate unresolved complaints or complaints that have been denied a Healthcare Commission review or denied an investigation because they were made outside the time limits. PALS and Complaints Service The Service focuses on improving the service to NHS patients. The service aims to: Provide advice and support to patients, their families and carers. Provide information on NHS services. Listen to patients concerns, suggestions or queries. Help sort out problems quickly. PALS and Complaints Officers will assist a patient/family concerns, liaising with staff, managers and, where appropriate, relevant organisations to negotiate immediate or promote solutions. If necessary, the Officers can also refer patients and families to specific local or national-based support agencies. Independent Complaints Advocacy Services (ICAS) ICAS offers free, ongoing advice about how to make a complaint regarding NHS treatment. ICAS assist complainants at each stage of the process, interpreting and explaining matters to and on behalf of the complainant. 6. Definition of a complaint The NHS Executive has suggested that one definition of a complaint is An expression of dissatisfaction that requires a response. Clearly this is an extremely wide definition and it is not intended that every minor concern should warrant a full-scale complaints investigation. Rather, the spirit of the complaints procedures is the front line staff are empowered to resolve minor comments, grumbles and problems immediately and informally or to offer the assistance of the Customer Liaison Service. The CCG will therefore seek to distinguish between requests for assistance in resolving a perceived problem and an actual complaint. All issues will be dealt with in a flexible manner, which is appropriate to their nature and the latter will be dealt with strictly in accordance with the complaints procedure.

10 Whenever there is a specific statement of intent on the part of the complainant that they wish their concerns to be dealt with as a complaint, they will be treated as such. Any complainant who is dissatisfied with the preliminary response to a matter which has been dealt with as a problem solving issue will be advised of their right to pursue the matter further through the complaints procedure. 7. Who can make a complaint? A complaint is defined as an expression of dissatisfaction with care, services or facilities provided or commissioned by the CCG, where any of the following apply: Action by the CCG or someone commissioned to working for the CCG has detrimentally affected the experience of a patient or carer in using our service. Examples might include concerns about health visiting treatment, the quality of the podiatry service or the attitude of staff. The complainant believes there has been a mistake or an error of judgement. For example, if a complainant indicated that a district nurse had failed to visit them following discharge from hospital, it would be necessary to investigate what follow-up care was requested and provided. The complainant brings to the attention of the CCG/CSU something that they expect the CCG to put right. For example, a carer may complain about a shortage in occupational therapy services, with the expectation that this service will be increased. The following are not complaints: Requests for information or advice about services. Requests for changes to medication or a care plan. Reports of lost or stolen items. In such cases callers can be directed to the service on: NUMBER TO BE ADDED. Any person who has received care or treatment from the CCG and is dissatisfied with the care or treatment they have received is entitled to make a complaint. If the person has died or is otherwise unable to act for him or herself, a close relative or friend, or an independent advocate may register a complaint on their behalf. An informal carer may also lodge a complaint if the quality of care provided to the person for whom they are caring detrimentally affects them. Complainants requiring access to medical records should be handled with care and advice should be sought from the Complaints Manager in such circumstances due to the complexities resulting from the application of various procedures. Refer to Procedure for Handling Access Requests for a Health Record. Written and verbal requests for access to medical records should be addressed/forwarded to the Corporate Governance Manager. All communication arising from a complaint verbal or written will be documented in the complaints file. 8. Time limits A complaint must be made within twelve months of the incident or within twelve months from the point of discovery of the problem, as long as this is no more than twelve months since the incident.

11 The Complaints Manager has the discretion to extend this time limit if the circumstances show that the complaint could not have been made earlier and if it is still possible to investigate the complaint. The Complaints Team, on behalf of the Chief Officer will seek to respond appropriately to the complainant within 25 working days of receipt of the complaint or by the mutually agreed date. This limit can be extended further if the complainant agrees. If the complaint is not resolved after 6 months, the complainant can go directly to the Health Ombudsman. The response letter must be signed by the Chief Officer, or nominated Deputy. 9. Child Protection/Vulnerable Adult issues Complaints which include allegations of abuse/neglect of a child or vulnerable adult should be dealt with under joint agency protocols for Child Protection or Vulnerable Adults which are outlined in separate procedures. 10. Complaints from mentally Ill and clients with learning disabilities It is appreciated that staff may have some difficulty in assessing whether complaints from mentally ill or learning disability clients should be investigated as set out in this procedure. Complaints may be made which appear confused, imagined or unfounded. All complaints from mentally ill or learning disability clients should be taken seriously and processed as set out in the procedure. 11. Complaints alleging a criminal offence There may be occasions when it is necessary to involve the Police (and other agencies) in investigating complaints. Such decisions will normally be taken on the grounds of the investigation being outside of the CCG s jurisdiction e.g. an alleged criminal offence. Referral to the Police (or other statutory organisations) would normally be undertaken by the CSU Head of Governance who will be responsible for consulting with the CCG Chief Officer. The involvement of the Police (or other statutory agencies) will lead to the investigation being handed over from the Complaints Manager to the Head of Governance. In addition there may be occasions when the behaviour of a person is so intimidating or threatening to members of staff that the Police are involved. The CCG have made a commitment to Zero Tolerance. 12. Clinical judgement Any part of the complaint which refers to matters of clinical judgment should be investigated in conjunction with the clinician(s)/practitioner(s) concerned, as appropriate. Any findings or recommendations from an investigation relating to clinical judgement must be agreed with the clinician(s)/practitioner(s) concerned. If there is any doubt as to the clinical judgement of a specific clinician/ practitioner in relation to a complaint, this matter should be raised with the Director responsible for Clinical Governance or Clinical Chair by either the investigating officer or the Complaints Manager. 13. Legal Action If at any stage during the investigation, the complainant indicates in writing of their intention to pursue legal action, the Trust will seek legal advice on how to proceed with the complaint and may choose to cease any further action under the complaints procedure. This is consistent with the guidance in the national NHS complaints policy.

12 The Complaints Manager should inform the Head of Governance and CCG Chief Officer as soon as possible that legal action has been instigated or is being anticipated. The policy and procedure for handling a claim received by the CCG will be followed from this point onwards. If the complainant s initial communication is via a solicitor s letter, the inference should not necessarily be made that the complainant has decided to take legal action. An inappropriate response from the CCG in these circumstances is more likely to encourage the complainant to seek legal redress. It should be remembered that at no point should any legal action prevent a full explanation being given and if appropriate an apology offered to the complainant. An apology is not an admission of liability. Staff should be aware that all documentation generated through this process is open to legal disclosure. 14. Patient authorisation (third party consent) When the complainant is not the patient, patient authorisation is required in order to respond to the complaint. If the patient is unable to give their authorisation, this is not a reason to deny an investigation into the issues raised on their behalf under the complaints procedure. Authorisation is required from the patient s representative for example spouse, relative, friend, MP or ICAS etc. This must be done before confidential or information of a sensitive nature is released to a third party. Forms will be sent from the Complaints Team to the complainant to obtain authorisation from the patient. The Complaints Team will ensure that the Procedure for Handling Access Requests for a Health Record is complied with. If authorisation has not been received by the time the investigation has been completed and the response to the complaint is ready, a reminder will be sent to the complainant by the Complaints Team restating why it is required and asking for it to be returned, giving a threeweek deadline. This situation will be discussed with the Head of Governance as how best to proceed if the authorisation is not forthcoming. 15. Confidentiality All complainants will be dealt with in line with the CCG s Confidentiality Code of Practice, the Data Protection Act and Caldicott principles. Should any information need to be divulged to those handling the complaint, this should be made clear to the complainant. Any complaint will also be dealt with in line with the up to date guidance on child protection or adult abuse issued between the NHS and other agencies. 16. Complaints received out of office hours If a complaint is received out of office hours (Monday to Friday time to be confirmed in SLA), it should be referred to the most senior member of staff on duty and to the Complaints Manager as

13 soon as is practical. Complaints can be received at any time by staff and not necessarily on the CCG or CSU premises (e.g. when working in private homes, residential homes). 17. Anonymous complaints All anonymous complaints received by the CCG or CSU will be investigated if there is enough information to carry out such an investigation. Investigating officers will be requested to report to the appropriate director and make appropriate recommendations based on the allegations raised. 18. Complaints concerning services managed by other providers A complaint concerning a service not managed within the CCG or CSU will be passed to the relevant service by the Complaints Team. If the patient is a resident of the CCG geographical area, a copy of the final response will be requested. The Complaints Team will also notify the complainant of the action taken. 19. Support available to staff Leaflets outlining the complaints procedure will be made available to all staff to give out to the public. Leaflets outlining the PALS services and ICAS will be made available to all staff to distribute to the public. The complaints policy and procedures are intended to allow effective complaints management for users whilst remaining fair to staff. The majority of complaints should not result in staff feeling uncomfortable with the process. The CCG and CSU will, as far as possible, resist assigning blame. In the case of a complaint being made in person, the member of staff receiving the complaint may request a colleague (who is more knowledgeable about the particular issue and therefore in a better position to ensure that the complainant is provided with a full response) to liaise directly with the complainant. Staff may also call on the Complaints Manager for advice and assistance in dealing with a complaint. Staff will be informed of the details of any complaints made against them and have the opportunity to answer the complaint. They will be kept informed of the progress of the complaint and its outcome by their manager. The CCG does not expect staff to tolerate any form of abuse from service users or others during complaint management. Staff are not expected to put themselves in situations where they feel they may be at risk when dealing with complaints. Abuse, harassment or violence of any kind towards members of staff will not be tolerated and personal contact may be withdrawn from any individual who acts in this way. Staff will not be expected to undertake home visits or to meet people on their own if they feel themselves to be at risk. Alternative, CCG premises will be made available for any meeting and a colleague to accompany with them. However, should CCG staff require support as a result of a complaint being made against them or investigation, this will be provided in confidence. Staff can self-refer in the strictest of confidence by contacting the Occupational Health Service on or

14 If the outcome of the complaint suggests disciplinary action is needed, this will be handled under the disciplinary procedure. Staff who feel they have been treated badly under the complaints procedure have the right to invoke the grievance procedure or complain directly to the Health Service Ombudsman. 20. Training Staff will receive training in handling and investigating complaints as part of the CCG and CSU s induction process. All Managers through the staff appraisal system will be responsible for identifying staff within their service that need training in the handling or investigation of complaints. 21. Communication with stakeholders During the complaint process the organisation may consider involving external agencies such as: Enforcing agencies, e.g. H M Coroner External stakeholders, e.g. other Trust, CCG, Local Authority External advisors, e.g. clinical experts providing advice. 22. Assessing how serious the complaint is The CCG uses a three-step process to gauge the impact of complaints on the people involved, the potential risks to the organisation and the response required. The complaint is first reviewed when it is received, and then reviewed on the results of any investigation by the Complaints Team. It is also important to remember that a complaint can have a very different effect on an organisation compared with an individual. This is especially important if someone is vulnerable such as poor health, communication difficulties or recent bereavement. Step 1: Decide how serious the issues is Seriousness Description Low Medium High Unsatisfactory service or experience not directly related to care. No impact or risk to provision of care. OR Unsatisfactory service or experience related to care, usually single resolvable issue. Minimal impact and relative minimal risk to the provision of care or the service. No real risk of litigation. Service or experience below reasonable expectations in several ways, but not causing lasting problems. Has potential to impact on service provision. Some potential for litigation. Significant issues regarding standards, quality or care and safeguarding of or denial of rights. Complaints with clear quality assurance or risk management issues that may cause lasting problems for the organisation and so require investigation. Possibility of litigation. OR Serious issues that may cause long-term damage, such as grossly substandard care, professional misconduct or death. Will require immediate and in-depth investigation. May involve serious safety issues. A high probability of litigation and strong possibility of adverse national publicity.

15 Step 2: Decide how like the issue is to recur Likelihood Rare Unlikely Possible Likely Almost certain Description Isolated or one off slight or vague connection to service provision. Rare unusual but may have happened before. Happens from time to time not frequently or regularly. Will probably occur several times a year. Recurring and frequent, predictable Step 3: Categorise the risk Seriousness Likelihood of recurrence Rare Unlikely Possible Likely Almost certain Low Low Medium Medium Medium Medium Extreme Examples of different types of incidents Low Moderate High Simple, non-complex issues Several issues relating to a short period of care Multiple issues relating to a longer period or care, often involving more that one Delay or cancelled appointments. Event resulting in minor harm e.g. cut, strain. Loss of property Lack of cleanliness. Single failure to meet care needs e.g. missed call-back bell. Event resulting in moderate harm e.g. fracture. Failure to meet care needs. Miscommunication or misinformation. Medical errors. Incorrect treatment. Staff attitude or communication. See moderate list. Event resulting in serious harm e.g. damage to internal organs.

16 Extreme organisation or individual Multiple issues relating to serious failures, causing serious harm Events resulting in serious harm or death. Gross professional misconduct. Abuse or neglect. Criminal offence e.g. assault. 23. Family Health Service disciplinary procedures The decisive factor as to whether or not disciplinary action should be taken would be the adherence by the practitioner to his/her terms of service. The employer with whom the practitioner has a contract with may refer allegations of breaches of the terms of service for local disciplinary action based on the final complaint report. 24. Monitoring arrangements Reports to the CCG from the CSU A report setting out anonymised details of complaints lodged against the CCG or commissioned services will be provided to the CCG on a monthly basis. The content will be reviewed by the Senior Management Team of the CCG and also submitted to the Governance Committee and the Operational Performance Committee, where Quality and Safety is reviewed, including any learning opportunities. This report will be made at the end of each quarter. Quarterly reports will specify the number of complaints received, identify the subject matter, summarise the handling of the complaint including the outcome and identify any cases dealt with the by the Health Ombudsman. Significant risks resulting from incidents, public enquiries, complaints and claims are recorded on the CCG s Risk Register and reports are presented to the Governance Committee. Aggregated reports on incidents, complaints, claims and PALS enquiries are presented to the relevant Governance Committee (quarterly). An annual complaints report will also be produced covering the year April to March and will be discussed in the public part of the appropriate Board meeting. The Board will support services in making any necessary change as identified following an investigation, to a level it considers reasonable. A copy of this report should be submitted to the Strategic Health Authority as soon after the end of the year as possible. 25. Responsibility for complaints arrangements The Chief Officer is the person ultimately accountable for the quality of care within the organisation and is responsible for responding in writing to all complaints. The Board will designate through the SLA with the CSU for day to day responsibility with sign off through the CCG. The Board will also delegate the local responsibility to one of the Heads of Service in the CCG to take responsibility for ensuring compliance with the Complaint Regulations and procedure. The designated Head of Service will also be responsibility for ensuring action is taken in light of the outcome of any investigation. 26. Regional and national returns The CCG annual complaints report will be copied to NHS Commissioning Board. The Korner (KO41) returns will be provided annually on request to the Department of Health.

17 27. Annual report The Complaints Manager will prepare an annual report on the handling and consideration of complaints and send a copy to:- the Chief Officer of the CCG the CCG Board the CSU Business Support Services Director the NHS Commissioning Board; and the Health Ombudsman. 28. Monitoring the ethnicity of patients The CCG monitors complaints to meet the requirements of the Race Relations Amendment Act and the Disability Discrimination Act. 29. Learning from experience The CCG is committed to learn and make changes to practice to improve services as a result of complaints. A systematic approach to the analysis of incidents, PALS enquiries, complaints and claims on an aggregated basis will be developed as part of the risk management integrated process, which will include: Organisational sharing of learning Local implementation of action plans Links between claims, PALS enquiries, complaints and incidents management Identification of risks and inclusion on risk register Reviewing and implementing best practice from other Trusts and organisations. Complaints will be viewed in conjunction with claims, PALS enquiries and incidents and the Complaints Manager will report back any learning to the Head of Quality and Safety through Quarterly and Annual reports. Learning from complaints will also be shared as widely as possible in the CCG as appropriate. 30. Sharing lessons learnt across the health community The CCG is represented at the West Yorkshire Complaints Manager Group. This group aims to ensure cross organisational learning and sharing of safety lessons. The CCG also reports serious adverse events through the STEIS reporting system to the NHS Commissioning Board providing a further opportunity to contribute to cross organisational learning. The CCG utilises the DATIX electronic reporting system which links to the National Patient Safety Agency (NPSA), National Learning and Reporting System (NRLS) to ensure that incidents reported within the organisation are fed into a central system and further analysis and trend identified performed at a National level to enable National learning.

18 31. Conciliation If the complainant is dissatisfied with the explanation/outcome, the complainant and the complained against may be invited to a voluntary conciliation meeting. An explanation of the conciliation process is attached at D. 32. Serious complaints An immediate referral to the Head of Corporate Services will be made if it becomes clear that there are serious issues that may require: An investigation under the disciplinary procedure. The need for referral to one of the professional regulatory bodies. An investigation into a Serious Untoward Incident. An investigation of a criminal offence. The potential for significant adverse publicity. 33. Serious Untoward Incidents (SUI) Some complaints will also be subject to a SUI investigation. When this is the case, it is often not possible to respond to the complaint until the SUI investigation of the complaint is complete, as the issues raised in the complaint will be similar to those raised in the SUI inquiry. However, throughout the SUI investigation, it should be remembered that the issues raised in the complaint would not always be exactly the same as those raised in the SUI investigation. A separate and full response to the complaint will therefore generally be required (please refer to the SUI procedures). 34. Complaints of a disciplinary nature The purpose of the Complaints Procedure is not to apportion blame. Where the initial complaint alleges negligence or malpractice on the part of an individual member of staff, details of the allegation will be passed to the appropriate Head of Service who will consider whether a disciplinary investigation is appropriate. If a disciplinary investigation is considered to be appropriate, the investigation will be separate from the investigation into any other aspect of the complaint. The disciplinary investigation will be carried out strictly in accordance with the CCG s Disciplinary Procedure. A decision to refer all or part of the complaint for consideration as a disciplinary matter may be taken at any time during the investigation into the complaint. Investigations will continue simultaneously into any aspect of the complaint not subject to the disciplinary investigation and a response should, where possible, be provided within the standard timescale of twenty-five days or as mutually agreed. The complainant will be advised that those specific aspects of the complaint are being dealt with as a disciplinary matter but, for reasons of confidentiality, will not be advised of the outcome. The person managing the investigation into the complaint will play no part in deciding whether to carry out a disciplinary investigation or in determining any disciplinary action arising out of the complaint. 35. Complaints leading to litigation

19 The Chief Officer will be informed of any possible litigious complaints. Complaints where financial redress is sought will be forwarded to Chief Finance Officer of the CCG. 36. Complaints arising from an incident The Health and Safety Risk Manager will be informed of any complaint arising from an incident such as a fall on CCG premises. The Health and Safety Risk Manager will forward any public complaints on to the Complaints Manager following an incident. (Incident Reporting Policy) 37. Complaints requiring redirection All written complaints received concerning other Trusts must be passed to the Complaints Team for redirection. 38. Joint working with other organisations The Complaints Managers of all organisations involved in the complaint, will agree which organisation is to lead on the investigation. Normally, the organisation where the main essence of the complaint falls will take the lead and will ensure that it is clear what aspects each organisation is to address and milestones will be set up for monitoring progress. The complainant will ideally have one point of contact and be kept informed of progress. Where possible, there will be a single response to the complainant but, if one aspect is more complicated than another and this is not practicable, then the complainant will be kept informed as to who will be responding and by when. Good examples of Joint working on complaint see Department of Health Listening, Responding, Improving A guide to better customer care. 39. Stage 2: Health Service Ombudsman s review If complainants remain dissatisfied following the completion of local resolution, they have the right to ask for a review by the Health Service Ombudsman. The Health Service Ombudsman on receipt of a request from a complainant will: 1. Ensure that the complaint is with 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. 2. 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? 3. if the Ombudsman believes there is a case to answer, they will direct the organization to put things right. 40. Storage and retention of complaint files

20 All files and documentation relating to complaints will be stored centrally. The Complaints team will be responsible for ensuring that complaints records are afforded the same confidentiality as clinical records and that records are easily accessible should further investigation be required. Complainants will have the right to request access to records relating to a complaint made by them. Requests will be made and processed through the CCG s Procedure for Handling Access Requests for a Health Record and release of records will be subject to approval by either the CCG s Clinical Chair or the Chief Officer. Complaints files relating to CCG and those prior for registered patients of North Kirklees previously made to NHS Kirklees complaint investigations will be held by the CCG for a minimum of 10 years. These can be held in their behalf by the CSU. 41. Support for complainants The Complaints team will work with the Yorkshire and Humberside Independent Complaints and Advocacy Service (ICAS) to ensure complainants are adequately supported through the process. 42. Complaints made to the CCG regarding FHS Practitioners The responsibility for these complaints will be held with the NHS Commissioning Board. This section refers to NHS work carried out by Family Health Service Practitioners such as Doctors, Dentists, Opticians and Pharmacists. Under regulations, the practitioners are required to co-operate fully in handling complaints. The provider s Governance Lead is required to inform the CCG s Clinical Chair as soon as is practicable of complaints which indicate: Serious complaints for example sexual assault. Police involvement. An investigation under disciplinary procedures. Referral to a professional regulatory body. An alleged criminal offence or potential investigation of a criminal offence. Civil litigation. An independent inquiry into a serious incident under Section 84 of the NHS Act Health Service Ombudsman review of complaints against Non-NHS providers The CCG will specify in the contracts with independent providers, for example independent nursing care, that the provider must set up and run a local resolution process. This should be as close as possible to the Local Resolution that NHS providers operate and they must cooperate with the Health Service Ombudsman Procedure. 44. Equality impact assessment The Trust aims to design and implement service, policies and measures that meet the diverse needs of our services, population and workforce, ensuring that none are placed at a disadvantage to others. Appendix E. 45. Policy review

21 This policy will be reviewed every three years or sooner should the need arise. This policy is to be read in conjunction with the NHSLA reporting guidelines and procedures and the following CCG policies and procedures: Claims Management Procedure Incident Reporting Procedure Records Management Policy Risk Management Policy 46. Dissemination and implementation Complaint Policy will be disseminated in line with the Policy for the development of Procedural Documents. References The National Health Service (Complaints) Regulations 2004 The Local Authority Social Services and National Health Service Complaints (England) Amendment Regulations 2009

22 Appendix A VERBAL COMPLAINT RECORD - FORMAL/INFORMAL/ANONYMOUS This form must be completed upon receipt of any/all complaints received by telephone or in person and must be forwarded to the Complaints Manager (CSU). If FORMAL complaint please forward as a matter of urgency to Complaints Manager (no to be confirmed). Date received... Time... Received by... Contact tel no. Complaint received in person or by phone? Complainant's name... Telephone no Address Postcode... Complainant's Status: Patient/Relative/Other (please specify) (If the complainant is the patient s representative patient authorisation may be required) Patient's Name... Telephone No Date of Birth Address Postcode Complained against (name and contact details)... Which service does the complaint relate to? (ie District Nursing)... Does the complaint relate to a specific date and time? If so, please state

23 Brief description of complaint COMPLAINTS POLICY Complaint Resolved Yes / No Would you say the complaint was Justified/Partially Justified/Not Justified? Have you identified any areas for service improvement? Please outline Date, time and nature of further action/contact agreed with complainant Please forward a copy of completed form to Complaints Manager, West Yorkshire Clinical Support Unit, in order that the complaint can be logged. Complaints will be analysed with a view to identifying and sharing good/best practice.

24 W R I T I N G A S T A T E M E N T Appendix B In the event of an enquiry, complaint, incident or litigation, staff may be required to make a statement regarding their involvement with a particular patient or relative. These guidelines should be used when preparing a statement. Seek advice from a Senior Manager, Head of Corporate Governance if you have any difficulties writing the statement. 1. Write your full name, address, job title, contact details and service area. In the case of litigation, professional qualifications should be given. 2. Remind yourself of the situation through a careful reading of the relevant notes. 3. State your role in relation to the event (eg District Nurse covering weekend); detailing day, dates on which events took place (and, ideally, times). If you were under supervision, state by whom. 4. Establish the sequence of events (dates should be set out in full, eg ) and write a narrative of precisely what you recall of the events. Comment on every point in the situation concerning your involvement. Keep to the facts. Where there is any disagreement between your recollection of events and other accounts please specify this. 5. If a decision was made then this should be set out in the statement, noting what action was agreed. Write reasons for your actions and also record anything that you omitted to do and your reasons for the omission. 6. List facts only the content should be objective. Do not include hearsay or any personal feelings/opinions about the event or matters outside your expertise. 7. Identify staff involved. Give full details of their involvement. This should be on the basis of what you saw and heard, recording what they did or did not do. State their job titles. 8. If patient records/notes and other documents are relevant then it may be helpful to refer to these in the statement. If hand-written notes are being referred to or any notes are being referred to, then it is usually helpful to have a transcript of those notes incorporated into the statement. 9. If any shorthand notes or abbreviations are being referred to these should be explained fully. 10. If you discover any inaccuracies in the notes then explain these as part of the statement and prepare an amendment note for the patient s notes, which must be signed and dated. Under no circumstances alter notes after the event. 11. Where possible, the statement should be typed. A handwritten statement should be legible and written in a pen that will allow photocopying (ie black ink). 12. Sign and date the statement when you are happy with it. Ask a senior colleague to read it through and approve it. 13. Keep a copy of the statement. 14. Do not store the statement in the patient s notes. Note: If the matter is taken further through a legal route, any information contained in this statement may need to be disclosed.

25 Appendix C L E A R N I N G L E S S O N S F R O M C O M P L A I N T S Complaint Reference: Service: Action identified as a result of the complaint Responsibility for action (name) Timescale for completion Signed off completion (Signature) (Printed) (Dated) (Tel) Please forward a copy of completed form to the Head of Quality and Safety at NHS North Kirklees CCG.

26 Appendix D C O N C I L I A T I O N An explanatory leaflet for patients and practitioners What is Conciliation? Conciliation is part of local resolution and aims to resolve the problem between the complainant and practitioner in a safe, constructive and confidential environment. The lay conciliator will assist you to identify the issues of concern and make sure these are aired through full and open discussion. Who are Lay Conciliators? The lay conciliators are specially trained and independent. They are non-judgmental and have no formal connections with the Clinical Commissioning Group (CCG), or any of the people involved in the complaint other than acting as a conciliator. Confidentiality Conciliation is a confidential process between the complainant, practitioner and conciliator and no formal records are kept; however, the conciliator will provide the CCG s Complaints Manager with a record of any actions agreed by both parties at the conclusion of the conciliation meeting. If no actions are agreed the conciliator will provide a statement to this effect to the CCG s Complaints Manager. If the complaint is not resolved at local resolution, then any information obtained by the conciliator or any other party cannot be used at the next stage of the complaints procedure. This process is without prejudice to any subsequent proceedings. How Do I Request a Conciliator? Either the complainant or practitioner can ask the CCG to appoint a conciliator at any time during local resolution. Requests for conciliation should be addressed to:- TBC

27 What Happens Next? The CCG will need to make sure that both parties agree to participate before conciliation can commence and that any consent to release medical records/relevant correspondence to the conciliator has been obtained. The Complaints Manager will then arrange a mutually convenient date, time and venue for both the complainant and the practitioner. You may choose to be accompanied at the conciliation meeting by a relative or friend to provide you with support. The complainant may find it helpful to focus on the main issues of concern prior to the meeting taking place. The Lay Conciliator will meet with the complainant to discuss the issues of concern, inviting them to address the question What do I hope to achieve from these proceedings? The Conciliator will then meet the practitioner to outline the concern(s), receive the response and then report back to the complainant. Only at that stage will the Conciliator invite both parties to meet together in the same room, led by the Conciliator, to try and resolve the matter(s). However, if the parties do not wish to meet together the Conciliator will continue to act as intermediary. Under normal circumstances the whole process lasts about 2-2½ hours. Occasionally the conciliator may draw on the help of an independent clinician/adviser to give an explanation on the medical, dental or other specialist issues. When the discussions are finished, the conciliator will ask the complainant if they are satisfied with the outcome or if they wish to take the complaint further. Hopefully the issues and questions will have been dealt with. Either way, the Complaints Manager will write formally to advise the complainant that they have six months in which to implement the next stage of the complaints procedure, if they feel there are areas of their complaint that remain unresolved. The practitioner will be kept informed by the CCG of progress. Who Can Help Me Pursue a Complaint? You can get independent help and advice from the Independent Complaints Advocacy Service (ICAS), which is provided by the Carers Federation telephone (local rate).

28 Appendix E NHS North Kirklees CCG - EQUALITY IMPACT ASSESSMENT To be completed and attached to any procedural document when submitted to the appropriate committee for consideration and approval. Yes / no comments 1. Does the policy / guidance affect one group less or more favourably that another on the basis of: Race Ethnic origins (including gypsies and travellers) Nationality Gender Culture Religion or belief Sexual orientation including lesbian, gay and bisexual people Age 2. Is there any evidence that some groups are affected differently? 3. If you have identified potential discrimination, are any exceptions valid, legal and / or justifiable? 4. Is the impact of the policy / guidance likely to be negative? 5. If so can the impact be avoided? 6. What alternatives are there to achieving the policy / guidance without the impact? 7. Can we reduce the impact by taking different action? If you have identified a potential discriminatory impact of this procedural document, please refer it to Head of litigation and complaints, together with any suggestions as to the action required to avoid / reduce this impact. For advice in respect of answering the above questions, please contact Complaints Manager.