Customer Services (Enquiries/Concerns/Complaints) Framework 2012/13

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1 Customer Services (Enquiries/Concerns/Complaints) Framework 2012/13 Version: One Responsible Committee: The Audit & Governance Group Date approved: Name of author: JANET SMART Name of responsible director/ assistant Penny Woodhead, Head of Quality director: Date issued: Next review to be complete by: Post 31 March 2013 Target audience: All staff Practices Public Other providers 1

2 CONTENTS Section 1 Forward 3 2 Definition 3 3 Aims 3 4 Objectives 4 5 Interpretation 5 6 Policy 5 General Principles Being Open 5 7 Communication with the Complainant 6 8 Complaints Handling Procedure 7 9 The Role of the Independent Complaints Advocacy Service (ICAS) 8 10 Independent Practitioner Complaints 8 Facilitating Independent Practitioner Complaints 8 11 Receiving PCT Complaints 8 Verbal Complaints 8 Written Complaints 9 12 Patient Authority / Consent Time Limits Management of Complaints Files/Good Practice Guidance Multi-Agency Complaints Investigating Complaints Holding Letters Final Response Letter After the Final Response 14 Conciliation 14 Mediation 14 Health Service Ombudsman Habitual & Vexatious Complaints Issues Not Suitable For The NHS Complaints Procedure Monitoring Mechanisms Training and Support Review of The Complaints Policy Other Related PCT Policies Equality Impact Risk Assessment Dissemination and Implementation 18 Page 2

3 28 Monitoring Compliance and Effectiveness References 18 3

4 1. FOREWORD 1.1 This policy is based on the Local Authority Social Services and National Health Service Complaints (England) Regulations 2009, which were introduced on 1 April The regulations set out an outcome based approach to complaints handling and cover both NHS services and social care 1.2 By listening to people about their experiences of health and social care services, managers can resolve mistakes faster, learn new ways to improve and prevent the same problems from happening in the future. In short, by dealing with complaints more effectively, services can get better, which will improve things for the people who use them as well as for the staff working in them. Listening, Responding and Improving a guide to better customer care It is important that NHS Calderdale has a robust process in place for receiving and handling complaints appropriately and makes positive use of the information gained to avoid similar occurrences and to improve the services it commissions. The arrangements must be accessible and allow for people to complain in a variety of ways (by telephone, in writing, etc) and expect a detailed, considered and prompt response in languages and formats that reflect the people and communities served by the organisation. 2. DEFINITION 2.1 A complaint is any expression of dissatisfaction whether justified or not. 3. AIMS 3.1 NHS Calderdale s complaints procedure aims to meet the following criteria. Be well publicised and easy to access Be simple to understand and use Be fair and impartial Allow complaints to be dealt with promptly Provide answers or explanations quickly and within established time limits. Ensure that rights to confidentiality and privacy are respected Provide a thorough and effective mechanism for resolving complaints and also investigating matters of concern. Enable lessons learned to be used to improve the quality of services Be regularly reviewed and amended if found to be lacking in any respect. Be consistent with national guidance 4. OBJECTIVES 4.1 NHS Calderdale aims to provide a high quality service, but occasionally things can go wrong. When they do, we seek to put them right and learn from the experience to improve our services. Complaints are one way of identifying people s perspective of the service provided. NHS Calderdale therefore values the views, comments and suggestions of patients, carers, staff and the general public. The objective is to provide an open, fair and accessible service for patients or their representatives for complaints about: NHS Calderdale; primary care independent practitioners; or services we commission with hospital and 4

5 independent providers (including nursing homes). This framework explains how NHS Calderdale will handle complaints. The procedure sets out the process (Appendix 1). It also outlines the action to be taken and offers guidance on good practice at each stage of the process. It provides staff with clear guidance about referring concerns arising from complaints to professional regulatory bodies, the police, the coroner, and raising complaints involving vulnerable children and vulnerable adults to the appropriate protection agency. It provides staff with clear guidance about NHS Calderdale s procedures for investigating matters that fall outside the NHS complaints procedure (for example complaints about other patients; complaints about care provided by the independent sector; complaints pursued through legal action; complaints made about the application of the Data Protection Act and the Freedom of Information Act); and matters that will be investigated alongside the complaints procedure (for example a related disciplinary process). 5. INTERPRETATION 5.1 The procedure applies to any complaint, whether it is received from a user of the service or their representative, or a member of the community who comes into contact with the service by other means. All complaints are investigated (subject to consent where primary care practitioner complaints are raised directly with NHS Calderdale), and responses to them are structured in an appropriate way (i.e. complex medical terminology is avoided or fully explained). 6. POLICY 6.1 General Principles Being Open and Accountable It is important that the correct procedures are followed. All employees that are likely to receive complaints will be made aware of this document. Adherence must also be made to the National Patient Safety Agency (NPSA s) strategy to improve communication between healthcare organisations and patients and/or carers. This also forms part of the Government s initiative to establish a safer and better healthcare service in its report Building a Safer NHS for Patients. All NHS Calderdale staff must therefore take into account the guidance available in the NPSA s policy on openness and honesty following patient incidents, Being Open, when handling and responding to complaints. Openness when things go wrong is fundamental to the partnership between patients and those who provide their care. Being Open and Accountable involves: acknowledging, apologising and explaining when things go wrong. conducting a thorough investigation of the complaint reassuring the complainant that any lessons learned will help prevent the experience from happening again. providing support to cope with the physical and psychological consequences of what happened. 6.2 Complaints should be viewed positively; using them to identify where improvement in service provision is necessary. 5

6 6.3 All NHS employees have a responsibility to do all that is possible to reduce the need for complaints by patients, their relatives and advocates. 6.4 All complaints are treated confidentially. The right to confidentiality is not absolute and it can be waived or over-ridden in a number of circumstances, for example: where a patient has expressly or implicitly consented to information being disclosed, e.g. when a victim makes a witness statement and details the injuries suffered; regardless of consent, it can be over-ridden by primary or secondary legislation, e.g. Directions, The Public Health (Control of Diseases) Act 1984 etc regardless of consent, if disclosure is in the public interest, then the duty of confidence can be over-ridden. 6.5 Senior Management is responsible for ensuring that complaints are investigated and handled following the Local Authority Social Services and National Health Service Complaints (England) Regulations 2009 and that appropriate action is taken to learn from the findings of any complaint investigations. The Customer Services Manager of NHS Calderdale has responsibility to acknowledge, handle and refer for investigation complaints which have been directed to NHS Calderdale, The appropriate senior Director/Head of Service is responsible for responding in writing to all Level 3 and 4 complaints received by NHS Calderdale. 6.6 Great emphasis is placed on providing a comprehensive response as quickly as possible and in meeting staff members needs for support and guidance while any investigation is taking place. 6.7 There are two main stages involved in making a complaint (1) Local Resolution, and (2) Parliamentary and Health Service Ombudsman It is hoped that most complaints will be resolved within Stage 1 known as Local Resolution. This aims to provide a fast, informal and satisfactory response to the complainant. However if the complainant feels their complaint remains unresolved, they have the option of referring it to the Parliamentary and Health Service Ombudsman. 7. COMMUNICATING WITH THE COMPLAINANT 7.1 The following principles will be applied in any communication with the complainant. Friendly and polite Show empathy Listen to what is being said Be apologetic where appropriate Ask clarifying questions to ensure the issue has been understood Be prompt and follow the established time limits for reply (if a comprehensive response is not possible within the set Level, then it will be necessary to agree an extension of time with the complainant.) 6

7 8 PROCEDURE 8.1 Level 1 simple queries (mainly PALS queries e.g. how do I register with a dentist, I have been taken off my GP list etc) Dealt with the same day. Level 2 Simple non complex issues (again mostly PALS queries e.g. loss of property, records missing, transport problems) Acknowledgement within three days Response within 3 5 days Level 3 More complex issue requiring written response and investigation with provider Acknowledgement within three days Response within days Level 4 Multiple issues involving one or more providers Acknowledgement within three days Response time will be with the agreement of the complainant (however, we will aim for 25 days with flex depending on severity and number of providers). 8.2 All patients have the right to have their complaint looked into. The role of the Customer Services Manager is to organise a response to any complaint where the complainant does not wish to raise their concerns with the people directly involved with their care, or where front-line staff are unable to deal with the complaint. 8.4 The Customer Services Manager should be notified immediately of any written or unresolved verbal clinical or non-clinical complaint received by NHS Calderdale staff, to ensure that the full implications for the organisation can be assessed. 8.5 The Customer Services Manager will maintain a database from which all Level 2, 3 and 4 enquiries and complaints will be given a unique reference number. The number will serve as a future identifier for the particular complaint. 8.6 The Customer Services Manager must notify the appropriate commissioner when a complaint is received about their service/area of work. 8.7 If an employee is implicated in a complaint and the allegation is serious and could lead to disciplinary action, the employee will be informed by their line manager and will be advised of their right to seek the help and advice of a professional association or trade union before commenting on the complaint. 8.8 Complainants will be informed of any appropriate independent sources of assistance in respect of making a complaint, for example, the Independent Complaints and Advocacy Service (ICAS). 8.9 All Levels 3 and 4 complaints must be responded to in writing. 7

8 9. THE ROLE OF THE INDEPENDENT COMPLAINTS AND ADVOCACY SERVICE (ICAS) 9.1 This service, provided by the Carers Federation, offers information, advice and support to people wishing to make a complaint regarding NHS services. Their service is free and confidential and details are included in NHS Calderdale s Customer Services Leaflet. 10. INDEPENDENT PRACTITIONER COMPLAINTS 10.1 Complaints against an independent primary care practitioner, (that is a general medical practitioner, dentist, pharmacist or optician) should be directed to them in the first instance. All practices have their own procedure for dealing with problems and complaints. These have to meet the standards set out in Local Authority Social Services and National Health Service Complaints (England) Regulations 2009 and should provide information on making a complaint. Information reflecting this information must be available from the practice. If, however, the complainant does not want to raise their problem or complaint directly with the practice concerned, then the Customer Services Manager for NHS Calderdale will liaise with the practice to investigate the complaint Facilitating Independent Practitioner complaints Where the Customer Services Manager is aware of a potential complaint against an independent practitioner, she will notify the independent practitioner concerned to advise them of the potential complaint and she will also set out the advice available from NHS Calderdale, including conciliation, or mediation together with information on the complaints procedure and best practice In some cases it may be appropriate to act as a broker between the practice and the patient. The Customer Services Manager should remain impartial during this process and only advise parties of the NHS complaints process and options available to them Where Local Resolution is not successful with the Independent Practitioner, the Independent Practitioner or the Customer Services Manager will remind the complainant of their right to contact the Parliamentary and Health Service Ombudsman for a review of their complaint. 11 RECEIVING PRIMARY CARE TRUST ENQUIRIES AND COMPLAINTS 11.1 Verbal enquiries and complaints Where concerns, queries or complaints are received in person or over the telephone, every effort must be made to resolve the situation at the time, usually between one and five working days. Where the individual receiving the complaint is unable to resolve the issue, then assistance from an appropriate line or senior manager within that team or department should be requested In all circumstances where a verbal complaint is taken, a First Contact Log form should be immediately completed. This ensures a comprehensive record of the conversation and concerns is made and that all necessary details (names, addresses, staff involved etc.) are recorded. This information should then be 8

9 forwarded to the Customer Services Manager who will ensure her team log this onto the Datix database Any verbal complaint, which cannot be resolved on the spot should be reported to the Customer Services Manager immediately and then handled in accordance with timescales for complaints. The complainant should be informed of NHS Calderdale s Complaints Procedure The patient or their representative will be asked to put their concerns in writing and advised to send their correspondence to the Customer Services Manager Written Complaints Written complaints received by any member of staff must also be passed to the Customer Services Manager without delay. Written complaints may also be received by fax or and passed to the Customer Services Manager All written complaints must be date stamped on the date received and passed to the Customer Services Manager immediately. Where there is no date stamp on a written complaint, the Complaints Manager will register the complaint when he/she receives it All written complaints must be logged onto Datix and acknowledged within three working days of receipt by the Customer Services Manager. The complaint will be given a unique reference number. If there has been a delay of more than three working days from the date the complaint was received or the date it was received by the Customer Services Manager, the acknowledgement letter will include an apology for the delay in sending the acknowledgement The acknowledgement letter will explain how the complaint will be handled and who will be investigating the issues The acknowledgement letter will also inform the complainant that they will receive a full written response to the issues they have raised in accordance with the respective level given to the complaint. In some more complex cases, the deadline may need to be extended, but only following agreement with the complainant The acknowledgement letter will also give the contact details of the Customer Services Manager in case they have any queries about the investigation or the complaints procedure Once the complaint has been logged and acknowledged, the Customer Services Manager will forward it immediately to the relevant Director/Head of Service, organisation, or Practice Manager, who will be responsible for nominating an Investigating Officer to investigate the issues raised and compile a draft response for submission for the Chief Executive. The target for the response is to be sent back to the Customer Services Manager within 14 working days from receipt of the complaint. The Customer Services Manager will provide a deadline date for the submission of the draft response to ensure that the response target is met Where the Investigating Officer becomes aware that he/she is unable to meet the deadline given, they will notify the Customer Services Manager of the reasons for the delay and give an indication of when the response is likely to be available. 9

10 The Customer Services Manager will contact the complainant to agree an extension to the deadline The appropriate senior Director/Head of Service is responsible for responding in writing to all Level 3 and 4 complaints received by NHS Calderdale 12. PATIENT AUTHORISATION / CONSENT 12.1 There are many occasions where a complaint is made indirectly through a third party (relative/friend/advocate). Where a complaint is being made by a third party, the Customer Services Manager will need to establish that the third party is acting with consent. The receipt of the complaint will be acknowledged to the third party, enclosing a consent form for the patient to sign and return to the Customer Services Manager. The investigation will proceed following receipt of consent. This must be done before confidential or information of a sensitive nature is released to a third party. A response will be sent within the relevant number of days for the level of complaint from receipt of consent In the case of a patient or person affected who has died or who is incapable by reason of physical or mental capacity, the third party must be a relative or other person who, in the opinion of the Customer Services Manager, is the appointed next of kin, or she feels has a sufficient interest in the patient s welfare and is a suitable person to act as representative In the case of a child, the representative must be a parent, guardian or other adult person who has care of the child. Where the child is in the care of a local authority or a voluntary organisation, the representative must be a person authorised by the local authority or the voluntary organisation If authorisation is not received within two weeks, a reminder is sent to the complainant by the Customer Services Manager restating why it is required and asking for it to be returned. Both the Customer Services Manager and the Investigating Officer will need to take into account the patient s wishes and his/her responsibility to investigate matters of concern brought to his/her attention Once consent has been established, the process and investigation will normally follow the same procedure as a complaint, which is made directly. However, the Customer Services Manager will always be aware of the confidential nature of the response and, in some cases, it may be more appropriate to send the reply direct to the patient concerned advising the third party that a reply has been sent. Each case will be considered individually Complaints received through Members of Parliament should be treated in the same way as all other complaints. The appropriate senior Director/Head of Service will sign the reply. The response will be addressed to the MP. However, in some cases the complaint may be handled directly with the complainant and, in such cases, a letter stating that this is happening may be an appropriate reply to the MP Reporting To ensure that the Accountable Officer is aware of general issues being raised as complaints within NHS Calderdale, the Customer Services Manager will provide a monthly report on the numbers and types of complaints (including MP enquiries) 10

11 and the time being taken to respond. This will act as the report as part of Learning From Experience into the Quality team. 13. TIME LIMITS 13.1 A complaint should normally be made within twelve months of the incident happening Complaints which relate to an incident that took place more than twelve months ago may be impossible to investigate because of the difficulties being able to fully answer the issues raised, due to the time lapse involved. NHS Calderdale has the discretion to extend this time limit where it would be unreasonable, in the circumstances of a particular case, for the complainant to have made their complaint earlier and where it is still possible to investigate the facts of the case. The Customer Services Manager, in consultation with the relevant Head of Service, will make a decision on individual cases. 14 MANAGEMENT OF COMPLAINTS FILES / GOOD PRACTICE GUIDANCE 14.1 A comprehensive and well-maintained record of a complaint that has been received, investigated and responded to will be kept A complaint file has the same status as any other created by a healthcare organisation. It is a public record, its contents are confidential and the Customer Services Manager is responsible for making sure that it is maintained to an appropriate standard Complaints records will be kept separate from health records. Patient s health records should contain only information which is strictly relevant to their care and treatment. Any correspondence relating directly to a patient s complaint that is found in the patient s medical records should be forwarded to the Customer Services Manager The Complaints file will be held and maintained by the Customer Services Manager. This will include any internal or external letters and any other correspondence. A log of action, including details of telephone conversations and personal conversation will be kept in the file The Investigating Officer should forward any additional file notes and statements collated during the investigation to the Customer Services Manager at the end of their investigation, for inclusion in the complaints file The file may be required by the Health Service Ombudsman and all papers must be considered disclosable to the patient, their representative or solicitor (in the case of litigation). The Complaint file will be kept for a minimum of ten years. 15 COMPLAINTS INVOLVING MORE THAN ONE BODY MULTI AGENCY COMPLAINTS - JOINT NHS AND LOCAL AUTHORITY (SOCIAL CARE COMPLAINTS) 15.1 Where two or more organisations are involved, the complaint will be handled and responded to by the receiving organisation on behalf of the others. This is so that the patient only has to deal with one organisation. 11

12 Social care should handle complaints in the same way as the NHS and so complaints crossing health and social care will be investigated and responded to by one organisation. The exception to this is complaints about children s services as local authority children s services are not part of the Local Authority Social Services and National Health Service Complaints (England) Regulations INVESTIGATING COMPLAINTS 16.1 Guidance on investigating complaints is available from the Customer Services Manager It is anticipated that the Investigating Officer will normally be the senior manager responsible for the area concerned. It is desirable that the complaint is dealt with as close to the point of delivery as possible to ensure a prompt reply and that appropriate remedial action is taken The investigation must be open, honest, factual, fair and identify any lessons which need to be learned. The Investigating Officer must have the relevant skills to undertake the task and be selected according to the importance and seriousness of the complaint. Where complaints concern matters of clinical judgement these should be agreed with the clinician involved. NHS Calderdale has access to independent clinical advice for medical, dental, pharmaceutical and ophthalmological issues The Investigating Officer will, in consultation with other senior employees involved, and the Customer Services Manager, decide whether it is appropriate to offer the complainant an interview or meeting Where the Investigating Officer arranges a meeting with the complainant, the professionals involved will determine how the meeting will be structured. The Investigating Officer will conduct the meeting and ensure that notes are taken. Two NHS Calderdale employees should normally attend any interview or meeting and the complainant should be offered the opportunity to have someone else present to assist them, for example from ICAS. The meeting must be formally recorded and the notes agreed with the complainant If the Investigating Officer feels there is likely to be a delay in responding to the complainant, he/she must inform the Customer Services Manager so that a holding letter /extension request can be sent to the complainant to keep them informed. 17. HOLDING LETTERS 17.1 If a response deadline is unlikely to be met, a holding letter will be sent four days before the deadline is due The holding letter will include an apology for the delay and an explanation of the reason. An indication of the date a full response can be expected. The complainant will be asked to agree to the extension A copy of this letter will be kept on the complaint file. Should a complaint response be delayed further, the file will remain under review and further holding letters with clear apologies and explanations for the delay will be sent on a regular basis until the final response is sent. 12

13 17.4 Alternatively the agreement can be reached verbally between the complainant and the Customer Services Manager, a record of these conversations will be kept and confirmation sent to the complainant. 18. FINAL RESPONSE LETTER 18.1 All written complaints must receive a response in writing from the appropriate Senior Director/Head of Service. The final letter should be dispatched within the timescale for the level given to the complaint The Investigating Officer should provide the appropriate Head of Service with a copy of the draft response when the matter has been investigated. It must be checked for factual accuracy prior to the draft reply being submitted to the Customer Services Manager Wherever practical, replies to all complaints should be agreed with staff involved before the draft reply is sent to the Customer Services Manager. If the response cannot be agreed with those involved the Customer Services Manager should be informed, in order to agree the wording of the response. It is essential, however, to remain objective at all times and present a fair reply to all complainants. Where it is clear that there has been a mistake or failure in procedures, this should be clearly stated and an appropriate apology given. Where this could constitute an admission of legal liability the matter should be referred for legal advice. The Customer Services Manager will liaise with the Head of Corporate Affairs for advice on the recommended course of action The Customer Services Manager will check that the response covers all aspects of the complaint raised by the complainant. The Customer Services Manager will follow up any queries regarding the response with the Investigation Officer as soon as possible The final response letter must be factually correct, and; include an apology where appropriate; NB An apology is not necessarily about accepting blame or fault, but will sometimes be an acknowledgement of the complainants feelings about their experience; address each of the points the complainant has raised with a full explanation or give reasons on why it is not possible to comment on a specific matter; give specific details about the investigation, how it was carried out, who was interviewed, what was discovered etc; give details of action taken and learning identified as a result of the complaint; provide the name and telephone number of the Customer Services Manager and or the Investigation Officer for further queries/discussion; include details of further action available to the complainant. (if appropriate, an invitation to meet with staff / details of the Parliamentary and Health Service Ombudsman Once the response is finalised, it is printed off and taken with the complete complaints file to the appropriate Senior Director/Head of Service for agreement and signature. 13

14 18.7 Where appropriate, the Head of Service/Investigating Officer will be advised that the formal response has been sent The final response should also invite the complainant to contact the Chief Executive/Customer Services Manager again if they have any outstanding concerns. In such cases, consideration should be given to arrange further action which might resolve the complaint, including offering a meeting with the appropriate member of staff to which the complaint relates. A response should be sent to the complainant confirming the outcome of any further action and remind them of their right to refer their complaint to the Parliamentary and Health Service Ombudsman. 19. AFTER THE FINAL RESPONSE LETTER 19.1 Conciliation Conciliation is a way of resolving a problem or a complaint or a difference of opinion of two parties using the skills of a conciliator to facilitate the process. It involves using an independent, impartial person to liaise between the conflicting parties with the aim of achieving a clearer understanding of events from both sides and good relations between the two parties restored. A conciliator is someone not personally connected with either party. Conciliators have been trained to do this work and work confidentially. A conciliator does not take sides and is concerned only to reach a resolution acceptable to both parties in the dispute. Either the complainant or the PCT/Independent Practitioner can suggest it. If the other party agrees then either may ask the Customer Services Manager to arrange for the involvement of a conciliator. Following the conciliation process the Complaints Manager will write to the complainant to outline the next stage of the complaints procedure. As conciliation is a confidential process no notes will be taken Mediation An alternative option which provides a similar route to a solution is mediation. Mediation differs from conciliation in that it is the parties that come up with a solution to the issues rather than this being led by the concilitiator. Mediation is facilitative and requires good communication between the parties to achieve a resolution. Mediation is bought in by the PCT on an ad-hoc basis and should only be offered if there is a clear opportunity for resolution at this stage Health Service Ombudsman If the complainant is still dissatisfied after all attempts have been made to resolve their concerns at Local Resolution stage, they can ask the Health Service Ombudsman to investigate their case. 14

15 20. VEXATIOUS COMPLAINTS 20.1 NHS Calderdale is committed to treating all complaints equitably and recognises that it is the right of every individual to pursue a complaint. NHS Calderdale therefore endeavours to resolve all complaints to the complainant s satisfaction. However, on occasions, NHS Calderdale may consider that a complaint is vexatious in nature, i.e. the complaint raises the same or similar issues repeatedly, despite having received full responses to all the issues they have raised. Vexatious complaints may be symptomatic of an illness and the complaints procedure may not be the most appropriate means of dealing with the issues involved. Where a complaint (or informal enquiry) is considered vexatious in nature, the Customer Services Manager will follow NHS Calderdale s policy and procedure on Habitual and Vexatious Complaints. 21. ISSUES NOT SUITABLE FOR THE NHS COMPLAINTS PROCEDURE The complaints procedure is for patients, users of the service or their representatives. The following issues do not fall within the NHS complaints procedure: Staff Grievances Staff grievances should be followed up via the Human Resources policy on staff grievances. Staff Complaints About Patient Care Staff concerns about patient care or services should be followed up via Clinical Governance Procedures and Policies. Compensation & Litigation Once legal action is started, the complaints process should be suspended as the two processes are not compatible Disciplinary Procedure If a complaint is against a family doctor, dentist, pharmacist or optician, any disciplinary action will only be started after the complaint has been completed and/or when the Parliamentary and Health Service Ombudsman has considered the complaint and, if applicable, produced its report. Disciplinary matters can not be investigated under the complaints procedure and a separate disciplinary panel would be set up to investigate and report back to NHS Calderdale. If a complaint is against one of NHS Calderdale s personnel and disciplinary action is indicated, the complaints procedure will be stopped and the matter will be investigated under the Trust s disciplinary procedure. Whistleblowing Staff concerns about the organisation should be considered whistleblowing and referred to the Whistleblowing Policy. 15

16 Criminal Matters Where there are allegations relating to assault or other serious criminal matters the Chief Executive must be informed immediately for a decision to be taken on whether to refer the matter to the Police. Private Treatment Complaints concerning private care or treatment can not be investigated through the NHS complaints procedure. Complainants should be referred to the private organisation involved for investigation and response. Freedom of Information (FOI) / Data Protection Act (DPA) 1998 Complaints concerning FOI or DPA requests should be referred to the Information Governance Manager. Complaints about a commissioned service by staff or volunteers of that service These should be deemed as whistleblowing on the service and should be brought to the attention of the relevant commissioning manager. 22. MONITORING MECHANISM 22.1 The Customer Services Manager will track the complaint using the reminders from the DATIX system A report on lessons learnt from complaints will be produced as part of the learning from experience work and sent to the Quality team The Customer Services Manager will report all complaints to the Risk Management team and all complaints will be recorded as incidents. These will be fed through clinical governance and included in the incident report to the Audit and Governance Group The Regulations require all independent contractors to provide NHS Calderdale with annual complaint activity information stating the number and nature of complaints and identify the lessons learned. The Customer Services Manager will produce an annual report to the Board on complaints. This report will detail turnaround times, amounts, types or subject of complaints, trends and actions taken including lessons learned and improvements made or proposed. A named Non-Executive Director will champion complaints at Board level The Customer Services Manager will conduct a twice yearly satisfaction survey with complainants. Results obtained from such surveys will be fed back into the processes to improve the service. 16

17 23. TRAINING AND SUPPORT 23.1 The Customer Services Manager is available to work with individual departments or family health practitioners to address their specific training and learning needs and managers should contact the Customer Services Manager direct if this is required Staff requiring support after a particularly difficult or stressful complaint should speak to their line manager in the first instance. Alternatively support can be obtained by contacting the Customer Services Manager, union representative or the Occupational Health Department. 24. REVIEW OF COMPLAINTS POLICY 24.1 An annual review of the Complaints Policy will be undertaken by NHS Calderdale. 25. OTHER RELATED POLICIES 25.1 This policy should be read in conjunction with the complaints procedure and resource pack and also the Habitual and Vexatious Complaints Procedure. This policy is also cross referenced with other policies within the PCT. Staff may wish to access the following policies for further information: Habitual/Vexatious Complaints Policy Risk Management Framework Serious Untoward Incident Policy Freedom of Information Policy Training Policy Access to Health Records Safeguarding Children and Adults Commissioning Policy Supervision Policy Appraisal, Grievance and Whistle Blowing Procedures These can be accessed via the NHS Calderdale intranet and website at Being Open The National Patient Safety Agency s Policy on Openness and Honesty Following Patient Safety Incidents EQUALITY IMPACT ASSESSMENT Previously tested approach with a variety of representatives from the protected characteristics. This work need updating however remains relevant Complaints handling includes equality monitoring form which will pick up any issues and learning 17

18 26 DISSEMINATION AND IMPLEMENTATION Complaints information shared through annual complaints report and section in annual report Policy will be shared with staff through weekly bulletin and staff briefing 28 MONITORING COMPLIANCE AND EFFECTIVENESS Complaints information reported to Quality Group Annual complaints report to Audit & Governance Group and CCE Annual return to SHA 29 REFERENCES All the policies related are listed in the document 18

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