BOARD MEETING. The Reporting and Monitoring of Safety and Quality Care Quality Commission Regulation 19 (Outcome 17) Complaints

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1 BOARD MEETING The Reporting and Monitoring of Safety and Quality Care Quality Commission Regulation 19 (Outcome 17) Complaints PRESENTER AUTHOR Rosie Trainor, Associate Director of Quality & Integrated Governance Rachel Housley, Head of Complaints PURPOSE To present the Board with an assurance report on compliance to the Care Quality Commission s Essential Standards of Quality and Safety, specifically in relation to the Management of Complaints Regulation 19, Outcome 17). RECOMMENDATIONS The Board is requested to review, comment on and note the level of minor concerns and that no major concerns have identified through self assessment in the report, which gives assurance that DCHS is complying with the regulation. BACKGROUND The Care Quality Commission (CQC) has published 28 regulations, which all providers of healthcare are required to comply with. The new system is focussed on outcomes, rather than systems and processes, and places the views and experiences of people who use our services at its centre. In order to assess the on-going compliance to these regulations the CQC will frequently review all available information and intelligence that they hold about providers of healthcare (from the NPSA, NHSLA, Audit Commission and other regulators) in order to evidence outcomes for the people who use our services. This will provide on-going assurance to the CQC that we are maintaining compliance with the regulations. By focussing on outcomes the CQC (and DCHS) can concentrate on how individuals are affected by the care they receive, rather than only on the nature of the service. For instance, outcomes for people who use our services include:- Health and clinical outcomes; Have the individuals needs been met; What kind of experience people have when they use our services; Whether people receive care that is safe Complaints (Regulation 19) In relation to complaints, Regulation 19 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010, specifically states that all providers of healthcare must have an effective system in place for identifying, receiving, handling and responding appropriately to complaints and comments made by service users, or persons acting on their behalf. 1

2 Outcome 17 Complaints The CQC has published (see links on page 5 below) a series of outcomes for each of the 28 regulations. These specifically state the expectations of outcomes for the people who use our services. In relation to complaints these are: That people are sure that their comments and complaints are listened to and acted on effectively Know that they will not be discriminated against fro making a complaint. This is because providers who comply with the regulations will: Have systems in place to deal with comments and complaints, including providing people who use services with information about the system Support people who use services or others acting on their behalf to make comments and complaints Consider fully, respond appropriately and resolve, where possible and comments and complaints. The CQC publication Essential Standards of Quality and Safety has a series of prompts that support the regulations and outcomes. These prompts have been used as a tool to self assess our compliance to Regulation 19 (Outcome 17) Complaints - and are reproduced in the first column of Appendix B. In summary these are: CQC Prompts Complaints 17a Are procedures followed in practice, monitored and reviewed, for receiving, handling, considering and responding to comments and complaints and a named contact who is accountable for doing so? Is the complaints process available, understood and well-publicised and reflects established principles of good complaint handling? Does the process ensure that the details of the complaint and desired outcome have been properly understood? Is the advice and advocacy support available to those who wish or need such support? Is what is required to resolve the complaint and the likely timescale explained? Are investigations both proportionate and sufficiently thorough? Is there an audit trail of the steps taken and the decision reached kept? Is consideration of the complaint undertaken by staff who are competent to address the issues raised, provide honest explanations that are based on fact and include the reasons for the decision made? Whenever possible complaints are reviewed by someone not involved in the events leading up to the complaint? Are comments and complaints investigated and resolved to the satisfaction of the person raising the complaint unless: o The complaint falls outside the remit of the provider s responsibility? o The complaint cannot be upheld? Does the service have clear procedures followed in practice,monitored and reviewed for dealing with unreasonably persistent complainants in a fair and consistent manner, but ensures that the point they make is properly considered. Does the service support and encourage a culture of openness that ensures any comment and complaint is listened to and acted on? Does the organisation ensure that a full record of the complaint is logged in line with the service s procedures? Is the information from complaints used to identify non-compliance or any risk of non-compliance with the regulations and to decide what will be done to return to compliance? Does the person know how to contact the Care Quality Commission in order to inform the Commission of concerns they may have about how their complaint was managed? 17b When more than one provider/service is involved in the issues raised: 2

3 Do the providers have agreed protocols in place to ensure that the services cooperate to provide one complete and coordinated response? 17c Providers who are registered with the Care Quality Commission will produce a summary of complaints at a time and in a format set out by the CQC and then send the summary within the time frame specified. 17d DO the people that use the service take into account relevant guidance, including that from the Care Quality Commission s Schedule of Applicable Publications. 17e People who use services or those acting on their behalf are able to use the comments and complaints process and do they know: They are treated in a manner that respects their human rights and diversity in a fair and equal way? How to obtain or access information about the complaints system? Their comments and complaints are dealt with in a sensitive and timely manner by taking into account the individual circumstances Their comments and complaints can be made either verbally, through sign language or in writing? Where they lack confidence or capacity that staff will help them? That by making a compliant they will not be discriminated against or have any negative e4ffect on their care, treatment or support? They will be able to discuss the timescales and process that the provider will follow in responding to their complaints and be kept informed of progress? They can use the NHS complaints process where their care was supported and funded by the NHS whether or not that care was provided within an NHS facility. What steps to take if they are not satisfied with the findings and the outcome once the complaint has been responded to and of their right to refer the matter to the next stage? The CQC Judgement Framework The CQC has published a Judgement Framework (see summary at Appendix A) which has been used by the Head of Complaints to self assess the level of compliance to the regulation 19, outcome 17 and the published prompts detailed in Appendix B. Future CQC assurance reports to the Board will focus on the self assessment, by teams that will champion the specific CQC Regulation, in line with the model contained in this report. Governance arrangements for Complaints in Derbyshire Community Health Services The Head of Complaints reports directly to the Assistant Director Quality and Patient Experience within the Quality & Integrated Governance Directorate. Monthly reports are provided to Heads of Service reporting on the details of complaints received, highlighting trends and themes and hotspots. The report also provides the opportunity to feedback the compliments received too. Quarterly reports are prepared and presented to the Patient Experience Committee also reporting the above and annual reports are reported to the Board, East Midlands Strategic Health Authority and NHS Derbyshire County. A regional meeting is held quarterly at the East Midlands Strategic Health Authority providing the forum for Complaints staff to network and for external speakers to attend. Quality Schedule Issues raised by PALs complaints have been responded to appropriately. FINANCIAL IMPACT There are no direct financial impacts to this report. 3

4 ANALYSIS AND CONCLUSIONS This report builds on the quarterly report to the Patient Experience Committee. The report identifies that there are no Red areas of concern that need to be brought to the Boards attention in relation to the published outcomes required under the CQC regulations for complaints. Where Amber areas have been identified action plans are in place to ensure that controls are in place and reviewed & reported on into the organisation, specifically to the Patient Experience Committee. Reporting relating to Complaints 2009/ /10 Appointments 104 Attitude of staff 93 All Aspects of Clinical Treatment 85 Communications 59 Others 55 Written complaints about NHS hospital and community services in England have seen the biggest annual rise since records began over a decade ago. There were more than 100,000 complaints in 2009/2010, a 13.4% increase on the previous year. For DCHS during this period we have had a decrease of 8.4%. PATIENT, PUBLIC AND STAKEHOLDER INVOLVEMENT There are no direct PPI or Stakeholder implications to this assurance report. EQUALITY AND DIVERSITY IMPACT When a complaint is acknowledged, the complainant is asked to complete an information form which includes details of age, gender, sexual orientation, disability, race and ethnicity, religion and belief. The complaints manager handling the case is then informed to meet individual needs. If the complainant is telephoning then this information can be gathered during the conversation with the complaints manager. LINKS TO DCHS STRATEGY The Complaints Team endeavours to manage all complaints sensitively and efficiently and in accordance with DCHS values of:- Getting the basics right Compassion and Respect Making a difference Everyone matters. 4

5 OPERATIONAL CONSEQUENCES The Head of Complaints will continue to report on the analysis of complaints detailed on the DATIX System to the Patient Experience Committee, Heads of Service Governance Committee and individual Heads of Service. ANALYSIS OF RISK The self assessment of compliance to CQC Regulation 19 (Outcome 17) Complaints has identified a RAG (Red, Amber, Green) assessment of compliance to the CQC Regulations, which will continue to be monitored throughout the year. There are no Red areas of concern in relation to Regulation 19. The risks associated with the complaints are entered onto the risk register for on-going monitoring and review. FURTHER INFORMATION Rachel Housley Head of Complaints Rachel.housley@nhs.net Rachel.housley@derbyshirecountypct.nhs.uk Lyn Barwick Assistant Director Quality and Patient Experience Lyn.barwick@derbyshirecountypct.nhs.uk Further reading:- The Essential Standards of Quality & Safety (CQC March 2010) The Judgement Framework (CQC March 2010) 5