NOTTINGHAM UNIVERSITY HOSPITALS NHS TRUST. MANAGEMENT OF COMPLAINTS, CONCERNS, COMMENTS AND COMPLIMENTS POLICY Documentation Control

Transcription

1 NOTTINGHAM UNIVERSITY HOSPITALS NHS TRUST MANAGEMENT OF COMPLAINTS, CONCERNS, COMMENTS AND COMPLIMENTS POLICY Documentation Control Reference GG/CM/002 Approving Body Trust Board Date Approved 26 Implementation Date 26 Summary of Changes from Previous Version Reference to process for Duty of Candour incidents added in appendix 5, process for complaint management Supersedes NUH version 3 (August 2011) Consultation Undertaken PPI Steering Group Clinical Leads Matrons Directors Group Communications Team Date of Completion of Equality Impact Assessment Date of Completion of We Are Here for You Assessment Date of Environmental Impact Assessment (if applicable) February 2014 February 2014 February 2014 Legal and/or Accreditation Implications NHSLA CQC Target Audience All Trust Staff Review Date March 2018 Lead Executive Mandie Sunderland, Director of Nursing & Midwifery Author/Lead Manager Alison Cargill, Complaints Lead Extension Further Guidance/Information Alison Cargill, Complaints Lead Extension

2 CONTENTS Paragraph Title Page 1. Introduction 2. Executive Summary 3. Policy Statement 4. Definitions (including Glossary as needed) 5. Roles and Responsibilities 6. Policy and/or Procedural Requirements 7. Training, Implementation and Resources 8. Impact Assessments 9. Monitoring Matrix 10. Relevant Legislation, National Guidance and Associated NUH Documents Appendix 1 Flow Charts Relating to Process for Handling Compliments Appendix 2 Flow Charts Relating to Process for Handling Comments Appendix 3 Flow Charts Relating to Process for Handling Concerns Appendix 4 Flow Charts Relating to Process for Handling Complaints Appendix 5 Equality Impact Assessment Appendix 6 Appendix 7 Appendix 8 Environmental Impact Assessment Here For You Assessment Certification Of Employee Awareness 2

3 1.0 Introduction 1.1 The Complaints, Concerns, Comments and Compliments (4C s) Policy aims to ensure that: Staff have access to relevant information to support patients, their relatives and carers in giving feedback via access to this policy, leaflets displayed at the Trust and via information accessible on the Trust s internet and intranet sites. The information received as a result of 4C s feedback is used to improve services provided to patients, relatives and carers. The Trust s response to complaints and concerns is fair and equitable to both the complainant and staff involved. Investigations of complaints and concerns are performed in a thorough and timely manner, facilitating resolution in an open and conciliatory way. The information gained forms an essential element of the Trust s approach to governance. 2.0 Executive Summary 2.1 The continually changing healthcare environment poses a number of challenges to the management of compliments; comments; concerns; and complaints resulting in the need for a responsive process, particularly in relation to concerns and complaints. Through this policy the Trust recognises the importance of accurately capturing; responding; sharing; and learning from the 4Cs; and ensuring this is undertaken in a timely manner. 3.0 Policy Statement 3.1 The Trust will ensure the views of patients, relatives and carers are heard and acted upon, this reflects the Trust s behavioural standards, in that we want our patients and their families to feel safe, cared for and confident in their treatment. 3

4 This policy has been written to comply with the Local Authority Social Services and National Health Service Complaints (England) Regulations The NHS complaints legislation requires a single approach for handling of complaints across health and social care. Every member of staff is responsible for supporting people who wish to provide feedback or raise concerns. The Complaints and PALS Team will provide a comprehensive service within the Directorates to ensure management of the 4C s. The Trust will ensure that information gained is acted upon to improve, plan, develop and evaluate the services delivered. 4.0 Definitions 4.1 Compliment: A compliment is positive feedback which may be provided in writing (often in the form of a thank-you card) or verbally regarding the service received by patients, their relatives and carers. Patients, relatives and carers may have valuable feedback relating to an observation they made and are willing to share with the Trust as a comment. Comment: Patients, relatives and carers may have valuable feedback relating to an observation they made and are willing to share with the Trust as a comment. Concern: A concern is an informal complaint that may be raised by a patient, relative or carer, either in writing or verbally to any member of staff within the Trust. These may relate to concerns about the service provided or propose ways of improving the service for patients, their relatives and carers. Complaint: A complaint is an expression of dissatisfaction, either in writing or verbally to any member of staff within the Trust about services provided which requires a formal response. 5.0 Roles and Responsibilities 4

5 Trust Board The Trust Board is required to receive assurance that robust systems are in place that enables feedback to be heard, actioned and lessons learned in order to provide the best possible care leading to an improved patient experience / service. The Trust Board will receive monthly data on the number of complaints and timeliness of responses in the Trust Integrated Performance Report and the annual 4C s report Quality Assurance Committee (a committee of the Trust Board) The Quality Assurance Committee will receive quarterly assurance reports about complaint numbers, themes, trends and relevant actions; this report will also include details of concerns, comments and compliment feedback. The committee will monitor performance of key performance indicators (appendix 1) and ensure the dissemination of complaint trends and required actions Directorates will produce reports in line with the reporting schedule above. 5.2 Individual Officers The Chief Executive Is the named officer with responsibility for ensuring that the Trust complies with the statutory obligation to ensure that patients, relatives and carers views are heard, acted upon and that complaints are dealt with in compliance with the Department of Health directives The Director of Nursing Has overall responsibility delegated from the Chief Executive for ensuring that effective systems and processes are in place to deal with complaint, concern, comment and compliment feedback and ensure this is shared and acted upon to continually improve the quality of care provided. 5

6 5.2.3 Clinical Directors or Executive Directors [as Heads of Corporate Function] Clinical Directors or Executive Directors [as Heads of Corporate Function] are accountable to the Chief Executive for ensuring directorate compliance with this policy. They are responsible for implementing and monitoring their systems as part of governance activity to manage and ensure learning from the 4C s The Directorate Management Team accountable for ensuring that their directorate complies with all aspects of this policy. They will provide quarterly reports to their Directorate and Specialty Governance Forums. Their responsibility includes: Reviewing all complaints that relate to the directorate; Ensuring that all investigations are robust and consistent; Ensuring that all responses to complainants are fair, consistent and meet the agreed quality and address all issues; Ensuring that themes are identified across the directorate as a result of the 4C s feedback, and that action plans are produced that demonstrate improvement to service provision. They will ensure that staff within the directorate receive sufficient support and training to ensure they are competent to respond to 4C s feedback appropriate to their level of involvement Communications Team The Communications Team will be informed by the PALS Team or by relevant staff across the Trust where it has been identified that there may be media interest in relation to a complaint. The Communications Team are responsible producing and ensuring appropriate sign-off of all media statements released by the Trust (see Media & PR Policy) Complaints Lead Accountable to the Director of Nursing, the Complaints Lead is responsible for the overview and Trust-wide monitoring and 6

7 evaluation of this policy. This Complaint Lead is responsible for ensuring effective reporting systems are in place between the Directorates, Quality Assurance Committee and the Trust Board in compliance with this policy. The reports will identify themes, trends and actions taken to improve services across the Trust Complaints and PALS The Complaints and PALS Deputy Complaint Lead reporting to the Complaints Lead will ensure all new concerns and complaints are processed according with the complainant s wishes. They will ensure the co-ordination of all aspects of the 4C s in support of delegated Directorates. Directorate Complaint and PALS Coordinators will support Directorates in the co-ordination of the 4C s processes by ensuring that complaints and concerns are consistently reviewed and responded to within the agreed timescales. Directorate Complaint and PALS Officers will receive and work with the co-ordinator to allocate incoming media to the appropriate clinician or manager within the Directorate. They are responsible for the upkeep of DATIX for designated directorate 4C s activity and provide PALS support for the Directorate. Senior PALS Officer will co-ordinate PALS Services across the Trust and PALS Officers will deliver the provision of PALS Services. All team members report to the Deputy Complaints Lead and provide support to facilitate compliance with this policy. The Deputy Complaint and PALS Lead reports to the Complaint and PALS Lead Directorate Specialty Matron/ Head of Service/Department Manager 7

8 Named individuals will be responsible for leading the complaint investigation, responding to the complainant and developing and implementing action plans Ward and Department Managers Each ward and department manager will be responsible for ensuring that all staff within their team have read and understood the Trust s Policy. They must also ensure that all team members have received any identified training and understand their responsibilities when responding to the specific needs and concerns of patients, relatives and carers. Staff should aim to resolve matters locally wherever possible All Staff All Trust employees have a responsibility to respond to complaints, concerns, comments and compliments from patients, their relatives and carers. This will include promptly assisting them if possible, directing them to additional help if required and signposting to the Trust PALS or the complaints procedure if needed. 6.0 Policy and/or Procedural Requirements Compliments, Comments, Concerns, Complaints Processes The Trust receives feedback by the following methods: Verbally to any member of staff Staff are encouraged and expected to discuss any compliment, comment, concern or complaint raised to facilitate where appropriate/possible an immediate action and fast resolution of any problems raised. In the event that the staff member cannot resolve issues immediately or answer questions, the member of staff and the person giving feedback can jointly decide to either escalate to a more senior member of staff or refer the issue to the Trust PALS or complaints procedure. Your views are important to us leaflets The Your views are important to us leaflets are available in all 8

9 patient areas to ensure patients, relatives and carers have a method of providing written comments about our services to the ward, department and Trust. Patient Advice and Liaison Service (PALS) Feedback can be given via the Trust PALS service either in person, by telephone on , text phone ( ), fax ( ), (pals@nuh.nhs.uk) or referral by a member of staff. When a concern is raised the Complaint and PALS Team will support the patient, relative or carer throughout the process and provide any support they require. No confidential information will be shared without first gaining the patient s permission (where appropriate). The PALS leaflet is available in standard format and an easy read version. In addition this can be provided in a range of alternate formats and languages on request to PALS. In writing to the relevant ward or department or Chief Executive Compliments, comments, concerns and complaints may be received in any area of the Trust. Complaints will be forwarded directly to the Chief Executive and referred into the complaint process. Comments, concerns and compliments may be responded to by the manager (or senior member of staff) of the ward or department by telephone and/or in writing (whichever is identified as most appropriate) to the patient, relative or carer with a response if contact details are supplied in the letter. Electronically via the patient feedback page offered on the Trust s website ( the give us your feedback section which is accessible via the home page Feedback received electronically will be received into the PALS account. The PALS Team will forward the feedback to the appropriate ward or department or into the complaints process as appropriate. The ward or department will provide a response directly to the patient, relative of carer who has raised comment and concern. 9

10 Patients, relatives and carers can submit feedback about the Trust via a number of websites. The two main websites are NHS Choices and Patient Opinion. ( and Feedback posted on the Patient Opinion website is automatically syndicated on NHS Choices. All feedback is reported to the Communications Team and the PALS Team. There is an agreed process with clear timescales for responding to online patient feedback Social media Patients, relatives and carers regularly post their feedback and complaints on social media forums, such as Twitter and Facebook. The Communications Team is responsible for responding to such comments both in and out of hours and for reporting to the PALS Team. Compliments If the feedback is a compliment the feedback will be sent from PALS to the relevant ward or department and the Communication Team will post a thank you message on the NHS choices website. Concerns If the feedback is a concern the a member of the PALS Team will liaise with the Directorate Complaint and PALS Coordinator to ensure the relevant Directorate Clinical Lead, Clinical Director or Head of Department provides a response. When the response is received a member of the PALS Team will forward to the Communication s Team who will arrange for this to be posted onto the NHS Choices website. The feedback will be categorized and the trend recorded on DATIX using the relevant theme code The Trust will assure patients, relatives and their carers who give feedback regarding service or raise a concern or 10

11 complaint, that they will continue to be treated according to their clinical needs and care will not be compromised. Equally, relatives/carers will not be treated any differently. This assurance will be offered by the Trust through relevant communications, included in Trust feedback leaflets, the complaints leaflet and outlined in acknowledgement letters for all complaints. Complainants who may be concerned that discrimination may occur will be offered the support of PALS. If a complainant reports a concern that they have been treated differently this will be reported to the Directorate Clinical Lea, Clinical Director or General Manager who will ensure corrective actions are implemented. All reports regarding actual or potential discrimination will be recorded by the Patient Experience Team on DATIX, and reported anonymously in reports to the Quality Assurance Committee A complaint is an expression of dissatisfaction about services provided which requires a formal response. Under the NHS Complaint s Legislation (2009) a complaint can be made by; A person who receives or has received services from the Trust. A person who is affected, or likely to be affected, by the action, omission or decision of the Trust. A complaint may be made by a person who is acting on behalf of a person, if the person has died, is a child, is unable to make the complaint themselves because of physical incapacity or mental incapacity (Mental Capacity Act, 2005) or if they have requested the representative to act on their behalf. This process does not apply to:- Private patients being treated at NUH who wish to complain about the competence or conduct of a privately paid practitioner. Patients should be advised to address such complaints directly to the privately paid practitioner. However, the policy does apply where a private patient wants to complain about any other aspect of their care/treatment at NUH. 11

12 Staff who wish to voice concerns or grievances in relation to their work. These should be raised through appropriate line management and Human Resource processes. Complaints should be made within twelve months of the incident or becoming aware of the incident that has caused concern. However, this timescale can be extended if the Complaints Lead is satisfied that there is good reason for the time delay and that it is possible to investigate the complaint effectively. When a complaint is made by a representative the Complaints Lead must be satisfied that there are reasonable grounds for a complaint to be made by a representative on behalf of another person. Consent should be obtained where there does not appear to be reasonable grounds Separate procedures have been developed for the management of the 4C s processes. These can be found in appendix 2(Compliments), appendix 3 (Comments), appendix 4 (Concerns) and appendix 5 (Complaints). The Complaints Procedure provides detailed operational guidance and should be read in conjunction with this policy Reporting Feedback within Directorates The Speciality Governance Forums will be expected to report (verbally and in writing) to the Directorate Governance Forums on a regular basis, on the following as detailed below: Numbers of 4C s (monthly) Achievement of timescales for complaints response (monthly) Themes of complaints and concerns (quarterly) Evidence to demonstrate that lessons have been learned as a result of 4C s feedback (quarterly) 6.3 Learning from Feedback 12

13 6.3.1 All Directorates and Departments must have systems in place as part of their governance arrangements to ensure feedback is reviewed and acted upon. As a result of complaints, concerns, comments and compliments they will ensure that:- themes emerging from feedback are identified that action is taken that demonstrates changes have been made to benefit patients, relatives and carers that lessons have been learned, and the patient experience has improved organisational learning is utilised when reviewing processes and policies The Directorate Management Team will develop directorate action plans to demonstrate that appropriate changes and/or service improvements have been implemented The Corporate Governance Leads will interrogate the DATIX system to identify themes and trends in accordance with the Trust s Investigating, Analysing & Learning from Incidents, Complaints and Claims Procedure. The Quality Assurance Committee will receive Quarterly reports. The reports produced will detail key issues for the Committee to debate and agree action. The Committee will ensure that lessons learned from the analysis translate into tangible changes in practice thereby influencing a positive organisational culture. 7.0 Training and Implementation 7.1 Training Please refer to the Trust s Training Needs Analysis for details of training to support delivery of this document. Staff will receive training in accordance with the Statutory and Mandatory Training Policy (HR/T&D/006) and the associated training needs analysis 13

14 7.2 Implementation 7.2.1The Complaint and PALS Lead is responsible for implementing the Management of Complaints, Concerns, Comments and Compliments Policy and ensuring Corporate and Directorate Clinical Leads, Clinical Directors, General Managers, Matrons and Head of Service are aware of the Policy All Trust staff will be made aware of the Policy through team brief and new staff will be informed at corporate induction The Complaint and PALS Lead will continuously review the complaint process across the Trust. This will incorporate the consistency of the complaint process, internal quality of the investigation, responses, actions taken and the satisfaction of complainants The Directorate Management Team, supported by the Directorate Complain/PALS Coordinator, will ensure that identified complaint investigators are competent to respond to complaints and concerns. They will also ensure staff are aware of the need to report comment and compliment feedback. The Directorate Management Team will also encourage the involvement of patients and public and are able to demonstrate improvements to services for patients, relatives and carers Advice on the application of this Policy is available from the Complaint and PALS Lead. 7.3 Resources No additional resources are required. USEFUL CONTACTS: Help (Employee Assistance Helpline):

15 8.0 Trust Impact Assessments 8.1 Equality Impact Assessment An Equality Impact Assessment has been undertaken on this document (Appendix 6) and has not indicated that any additional considerations are necessary. 8.2 Environmental Impact Assessment An Environmental Impact Assessment has been undertaken on this document (Appendix 7) and has not indicated that any additional considerations are necessary. 8.3 Here For You Assessment A Here For You Assessment has been undertaken on this document (Appendix 8) and has indicated the need for additional considerations which have been duly incorporated. 15

16 9.0 Policy / Procedure Monitoring Matrix Minimum requirement to be monitored Acknowledgement of complaints within 3 working days Provision of final response to complainant within agreed timescale Action plans to be implemented for upheld complaints to demonstrate learning Referrals to Parliamentary & Health Service Ombudsman Responsible individual/ group/ committee Complaint and PALS Team Directorate Team Directorate investigators Complaint and PALS Team Process for monitoring e.g. audit Frequency of monitoring Responsible individual/ group/ committee for review of results Reports Quarterly Monitoring quarterly by QUAC Reports Monthly Monitoring monthly by Trust Board Reports Quarterly Monitoring quarterly by QUAC Reports Quarterly Monitoring quarterly by QUAC Responsible individual/ group/ committee for development of action plan Complaint and PALS Lead Directorate Clinical Lead/Clinical Director Directorate Clinical Lead/Clinical Director Complaint and PALS Lead Responsible individual/ group/ committee for monitoring of action plan QUAC Trust Board QUAC QUAC 16

17 10.0 Relevant Legislation, National Guidance and Associated NUH Documents Legislation The Local Authority Social Services and National Health Service Complaints (England) Regulations 2009 HMSO 2. National Guidance DOH (2009) Listening, Responding, Improving - A Guide to Better Customer Care DOH (2009) NHS Constitution DOH (2008) Duty to Involve DOH (2008) Health and Social Care Act PHSO (2009) Principles of Remedy PHSO (2009) Principles of Good Administration PHSO (2009) Principles of Good Complaint Handling 3. Associated NUH Documents Aggression, Violence and Harassment Policy (HS/SP/012) Being Open Policy (GG/CG/003) Claims Handling Policy and Procedure (GG/CM/006) Scheme Of Delegation And Reservation (Corporate Governance Framework Chapter 4) Disciplinary Policy (HR/PC/011) Incident Reporting and Management Policy (GG/CM/021) Information Governance Policy (GG/INF/001) Investigation, Analysing and Learning from Incidents, Complaints and Claims Procedure (GG/CM/028) Media and Public Relations Policy (GG/CM/022) Patient Advice and Liaison Service (PALS) Policy (GG/CM/004) Personal Property Claims Procedure (GG/FIN/006) Losses and Special Payments Policy and Procedure (GG/FIN/001) Serious Untoward Incident Policy (GG/CM/019) Single Equity Scheme (HR/E&D/002) Whistle Blowing Policy (Corporate Governance Framework Chapter 11) The Complaint Process v5 04/06/14 We are here for you Behavioural Standards 17

18 APPENDIX 1 Key Performance Indicators Performance against the three day acknowledgement letter target (target 100%) Performance against the 25 day response timescale (target 90%) Average time to response to responses over 25 days Reported measures Number of complaints referred to and investigated by the PHSO Top 5 compliment and complaint themes 18

19 APPENDIX 2 Process for Handling Compliments A compliment is positive feedback which may be provided in writing (often in the form of a thank-you card) or verbally regarding the service received by patients, their relatives and carers. Compliments can be provided to any member of staff. If a compliment is provided in writing to the relevant ward/department the manager will respond by telephone and/or in writing. Any member of staff receiving a compliment should log this on the ward/department s compliment log. The compliment log will be submitted to the Directorate Complaints and PALS Team on a monthly basis. The Complaint / PALS Officer will input the information submitted on the compliment logs into the database for inclusion in specialty and directorate monthly and quarterly 4C s reports. The database log will include all wards/departments for the directorate. On a monthly basis the Directorate Complaint Coordinator will review the log to identify gaps in submission. Thank you letters received by the Chief Executive will be responded to in writing by the Chief Executive s Office. A copy of the letter will then be sent to the appropriate department, ward or manager. In conducting this process all staff will be attentive to the Here for You standards 19

20 WARD/DEPARTMENT COMPLIMENT LOG Ward/Department: Month: Contact Name: Tel No: Cards/letters Gifts Other Please return at the end of each month to the Patient Experience Team, c/o Trust Headquarters, City Campus Thank you 20

21 Process for Handling Comments APPENDIX 3 Patients, relatives and carers may have valuable feedback relating to an observation they made and are willing to share with the Trust as a comment. Comments can be made verbally or in writing to any member of staff. The Your views are important to us leaflet is available in all wards, departments and public areas of the Trust and can be used to provide anonymous feedback. Completed leaflets can be handed to staff (or) placed in the collection box within the wards and departments where available. Alternatively they can be returned to the Trust via the FREEPOST address quoted in the leaflet. The leaflet can be provided in alternate formats and languages on request to PALS. All leaflets submitted by post are received by the Complaint and PALS Team. The Team will send the feedback to the appropriate department or ward manager who will acknowledge receipt if contact details are provided. Each department or ward is responsible for ensuring the comments they receive are reviewed and actioned accordingly. They will also provide a response directly to the patient, relative or carer who has made comments on the service. The member of staff receiving the comment should log this on the ward/department s comment log. The comment log will be submitted to the Directorate Complaint and PALS Team on a monthly basis. The Directorate Complaint and PALS Team will input the information submitted on the comment logs into the database for inclusion in specialty and directorate monthly and quarterly 4C s reports. In conducting this process all staff will be attentive to the Here for You standards 21

22 WARD/DEPARTMENT COMMENT LOG Ward/Department: Month: Contact Name: Tel No: Comments Action Outcome/Learning Please return at the end of each month to the Patient Experience Team, c/o Trust Headquarters, City Campus Thank you 22

23 Process for Handling Concerns APPENDIX 4 A concern is an informal complaint that may be raised by a patient, relative or carer, either in writing or verbally to any member of staff within the Trust. These may relate to concerns about the service provided or propose ways of improving the service for patients, their relatives and carers. Verbal Concerns Verbal concerns can be provided to any member of staff, the relevant ward or department is responsible for ensuring any concerns they receive are resolved. The Trust s Concern Report Form will be completed by any member of staff when they provide on the spot resolution to a concern. If it has not been possible to provide resolution to the concern, the member of staff should seek support and advice from their line manager or PALS to ensure a satisfactory resolution is achieved. Upon resolution of the concern the completed form will then be forwarded to the Directorate Complaint and PALS Team. The Directorate Complaint and PALS Team will input the information to DATIX. PALS Concerns Concerns that are received by PALS that require a response but where the patient, relative or carer does not wish to complain may be received verbally, by or in writing will be handled as PALS concerns. The PALS officer will liaise with the ward or department to ensure any issues are resolved and that feedback is provided to the person raising the concern. The PALS concern will be input to Datix by the handler within two working days. Written Concerns Correspondence received by the Trust through the Chief Executive s Office will be triaged by the relevant Directorate Complaint and PALS Team. This will include completion of the grading assessment and the triage assessment tool (found in the Complaint Procedure) and contacting the person raising the concern to discuss what resolution they are seeking and how they want the Trust to achieve this. 23

24 The method of feedback will be agreed with the patient, relative or carer and may be by telephone, face to face, electronically or in writing. The Directorate Complaint and PALS Team will pass the details of the concern to the relevant ward or department manager who will be responsible for facilitating the response and any corrective action. If a written response is required this will be prepared by the ward or department and provided to the Directorate Complaint and PALS Team who will ensure a copy is input to DATIX before forwarding it to the person who raised the concern. All concern feedback is input to DATIX and will be collated by speciality and reported in monthly directorate reports. Responses to all concerns received by MP s will be signed off by the Chief Executive. In conducting this process all staff will be attentive to the Here for You standards. 24

25 Concern Report Form Date received.contact Details... Name of person raising concern Patient Name Ward/Dept. Hospital No: Date of Birth:... DETAILS OF CONCERN (Please indicate by placing an X) Admission Cleanliness Attitude Incontinence/bowel care Food & Nutrition Communication Medical Care Nursing Care Tissue Viability Privacy & Dignity Patient Safety Infection Car Parking Health Records Signage Transport Portering Medical Equipment Patient Property Discrimination Other Specify: Discharge Waiting Time OUTCOME (Please indicate what you did to resolve the concern/s above) Was the client satisfied with your actions YES NO (Refer to Line Manager or PALS) Completed by:- Sign. Print name Designation Return completed forms to Patient Experience Team, c/o Trust Headquarters, City Campus 25

26 Process for Handling Complaints APPENDIX 5 The Complaint Procedure providing detailed guidance and template documents will be utilised by all staff responsible for handling or investigating complaints. Verbal Complaints Response to verbal complaints should be on the spot when possible and a Concern Report Form completed (Appendix 3). If it is not possible for the member of staff to resolve the complaint, assistance should be sought from their line manager. If the verbal complaint can be resolved within one working day the response does not need to be in writing. However, the nature of the complaint and resolution should be documented by the member of staff responsible for resolution using the Concern Report Form (Appendix 3). If the verbal complaint has not been resolved within one working day then it must be referred to the Directorate Complaint and PALS Team and handled in accordance with written complaint procedure. During office hours (8.30am-4.30pm Monday to Friday except Bank Holidays) the Directorate Complaint and PALS Team may be accessed for assistance as required. Out of Hours (4.30pm 8.30am Monday to Friday, Saturdays, Sundays and Bank Holidays) the Duty Nurse Manager can be contacted through switchboard. The Duty Nurse Manager will gain assistance and guidance from Silver-on-Call if required. Written All complaints should be sent to the Chief Executive. If a complaint is received directly by an individual, ward or department it should be forwarded to the Chief Executive Office within one working day Written complaints will require a formal investigation and full response in accordance with the procedure detailed Complaint Procedure. Every effort must be made to support people who wish to make a complaint. This could include obtaining interpreters, assisting in putting the complaint into writing, signposting to an Independent Complaint Advisory Service or providing mediation. 26

27 If the complainant requires access to medical records in accordance with the Data Protection Act, an application form will be forwarded to them by contacting the Administrator, Patient Records Services, B Floor, QMC campus, ext If the complaint includes a request for information under the Freedom of Information (FOI) Act the request should be passed immediately to the Trust s FOI Administrator who will be responsible for processing the request with the Directorate FOI Lead in accordance with the FOI Policy and responding to the person making the request. If the complaint makes reference to a claim for compensation, advice should be sought from the Complaint and PALS Lead. All records relating to complaint investigations are confidential and must be kept in one master complaint file separate, from any medical records. Care should be taken with accuracy, legibility and language used. In accordance with the Data Protection Act (1998) a complainant has the right to access all correspondence within the complaint file. All complaint records must be kept by the Trust in a secure environment for ten years. The archive system will be administrated and maintained by the Directorate Complaint and PALS Teams. The Matron/Head of Service/Department Manager, with support from the Directorate Complaint and PALS Coordinator, will coordinate the investigation and ensure a response is drafted; action plan developed and implemented. The Matron/Head of Service/Department Manager will review every complaint and make a decision as to the complaint complexity and seriousness, If the Matron/Head of Service/Department Manager thinks that the complaint is actually a patient safety incident with a degree of harm of moderate or above, then the complaint process needs to be suspended and the incident investigation process followed. The severity grading assessment must also be reviewed and taken into account. In understanding this assessment the following points need to be considered: If the complaint involves issues that could potentially compromise public or patient safety the Directorate Clinical Lead/ Clinical Director for the relevant 27

28 directorate and the Medical Director/Director of Nursing should be informed immediately. Any complaints that could fall into the Serious or High Level Incident category must be referred for advice to the Clinical Lead / Clinical Director and, if necessary, the Governance Lead for Safety. Any complaint that is thought to fall into the category of moderate harm or above (thus fall under the Duty of Candour Policy) must be checked on DATIX to see if recorded as an incident. If it is the complaint process should be suspended and complaint investigation procedure followed. If it is not recorded, this must be referred for advice to the Clinical Lead / Clinical Director and, if necessary, the Governance Lead for Safety. Any complaints about members of staff that involve accusation of misconduct should be referred to Human Resources for advice/action (see Disciplinary Policy [HR/P&C/001]). Any issues that could potentially involve the media need to be discussed with the Trust Communications Team. Issues relating to safeguarding should be discussed with the Trust safeguarding leads, for Vulnerable Adults and for Children & Young People. All complaint responses should adhere with the negotiated timescale. However if the Matron/Head of Service/Department Manager identifies that the investigation will not be finalised within the agreed timescale due to complexities identified within the investigation they will inform the Directorate Complaint and PALS Coordinator at the earliest opportunity. A member of the Directorate Complaint and PALS Team will then contact the complainant (by telephone whenever possible) to explain the reason for the delay. They will discuss with the complainant a new anticipated target response date. A letter will then be sent to the complainant by the member of staff to confirm the discussion. The Directorate Clinical Lead/Clinical Director/General Manager will assess the quality of the response to ensure all concerns have been addressed in a comprehensive and appropriate way before signing the directorate response. 28

29 The response will then be presented to the Chief Executive or nominated deputy who will review the response and sign the covering letter. All responses to complaint letters received by Members of Parliament (MPs) will be reviewed and signed by the Chief Executive. The response can be provided in different formats or languages, the Patient Experience Team will arrange this as required. When the Trust has undertaken comprehensive attempts to respond to a complaint the response letter must inform the complainant of their right to ask the Parliamentary and Health Service Ombudsman to review their complaint if they remain dissatisfied with the Trust s complaint management. Complaint Redress When dealing with complaints the Trust s main purpose is to remedy the situation as soon as possible and wherever possible ensure the individual is satisfied with the response and feels that they have been fairly treated. The redress offered will be proportionate to the service failing, suitable for the complaint and designed where possible to put the complainant back in the position they would have been had the failings in the service not occurred. In most cases an apology, explanation or evidence to demonstrate action will be taken to prevent recurrence will be sufficient. In all cases where a complaint has been upheld, the responsible Directorate Clinical Lead, Clinical Director or General Manager will consider the approach of redress, whether or not the complainant has asked for a specific form of redress. Financial redress may be considered where no other form of redress is proportionate and suitable. The NHS Finance Manual provides guidance for NHS bodies on "special payments", including ex-gratia payments. This guidance enables an NHS body to make such ex-gratia payments, generally where the complainant has incurred financial loss following the actions or omissions of the relevant NHS body. However, it also makes provision for payments where there has been no financial loss but clarifies that such payments should only be made in exceptional circumstances. 29

30 Financial redress may be offered to the complainant where: A complaint has been upheld, and There has been maladministration by or on behalf of the Trust, and The maladministration has directly caused injustice to the complainant or their relative or carer, and No other form of redress is proportionate or suitable. Parliamentary and Health Service Ombudsman Review If a complainant remains dissatisfied after local resolution they can ask the Parliamentary and Health Service Ombudsman (PHSO) to undertake a review of their case. The PHSO will assess the complaint using the Principles of Remedy, Good Administration and Good Complaint Handling (2009). These principles provide guidance to organisations on how they should handle complaints. The overarching principles are: Getting it right Being customer focused Being open and accountable Acting fairly and proportionately Putting things right Seeking continuous improvement The PHSO review will seek to demonstrate that the Trust has acted appropriately when assessing the complaint to identify if there is evidence of maladministration or service failure. The PHSO will request the Trust to provide a copy of the complaint file and health care records. After undertaking the review the PHSO will inform the Trust whether the review has upheld the complaint and the corrective action that the Trust must implement. Complaints referred to the PHSO will be monitored by the Complaints Lead and reported to the Quality Assurance Committee. The responsible Directorate Clinical Lead/Clinical Director/General Manager will develop a response and action plan to demonstrate learning in response to any complaint being upheld by the PHSO. All correspondence to the PHSO in relation to responding to upheld and partially upheld complaints will be reviewed and signed off by the Chief Executive. The response and action plan will be scrutinised and implementation monitored by the Quality Assurance Committee. PHSO responses and action plans to be shared with external stakeholders only after agreement by the Quality Assurance Committee 30

31 Unreasonable or persistent complainants Most complainants are entirely reasonable. However a minority are not. Some may, for example, behave in a way that impedes or deters an investigation, or may hinder staff from undertaking routine work activities. Behaviours and Action which may be displayed include: Avoiding specifying the grounds of a complaint, despite offers of assistance with this from Trust staff and being informed about Advocacy Services. Insisting on the complaint being dealt with outside of the complaints procedure. Refusing to accept that issues are not within the remit of the complaints procedure or despite having been provided with information about the procedure s scope. Changing the basis of the complaint as the investigation proceeds and/or denying statements he or she made at an earlier stage. Introducing trivial or irrelevant new information which the complainant expects to be taken into account, or raising large numbers of detailed but unimportant questions and insisting they are all fully answered. Making unnecessarily excessive demands on the time and resources of staff whilst a complaint is being investigated by, for example, excessive telephoning or sending s to numerous members of staff, writing numerous lengthy complex letters and expecting immediate responses. Making what appear to be groundless complaints about the staff dealing with the complaints, and seeking to have them replaced. Electronically recording meetings and conversations without the prior knowledge and consent of the other persons involved. Adopting a 'scattergun' approach: pursuing a complaint or complaints with the Trust, at the same time, with a Member of Parliament/a councillor/the Care Quality Commission/the Strategic Health Authority/solicitors/the Ombudsman. Submitting repeat complaints, after the complaints processes have been completed, essentially about the same issues, with additions/variations which the complainant insists make these 'new' complaints which should be put through the full complaints procedure. Refusing to accept the decision repeatedly reframing the issue and complaining about the decision. Submitting repeated complaints about a variety of issues of different issues about the same individual. 31

32 Displaying violence, aggression or foul language towards members of staff. Making untoward comments or threats towards about staff or their families If a Matron/Head of Service/Department Manager becomes concerned that a complainant is becoming unreasonable they must seek assistance from the Directorate Clinical Lead/Clinical Director/General Manager and Complaints Lead. All members of staff with contact with the complainant must ensure fully comprehensive notes of conversations and actions are placed in the complaint file. In conducting this process all staff will be attentive to the Here for You standards 32

33 Complaint Process (Assuming 25 day response agreed with complainant) Day 1 Day 1-3 Complaint received by Directorate PET Coordinator: Complaint Management Plan commenced; risk assessment. Phone complainant / patient to acknowledge the complaint. Identify and notify lead clinician / manager (Matron / HOS/ AGM) Lead Clinician/manager and PET Coordinator agree proposed course of action and liaise with patient / complainant in each case to agree course of action and timescale: 1. Action required (eg apt to be arranged) Day 3-10 Action to be taken, letter to clarify outcome to be sent, complaint resolved, no further action 2. Information required: meeting to be offered / suggested and arranged; if letter preferred information to be provided and sent to patient / complainant (as per complaint process) Day 3-20 Day 20 Meeting to be arranged with appropriate clinicians to provide the information Letter to be written post meeting to summarise outcome Meeting refused manage as below: provide facts as opposed to investigate 3. Investigation Required: Poor Experience - investigation to take place Day 4-15 Day 16 Day 18 Day 20 Day 21 Day Investigate obtaining statements from key individuals / reviewing medical & nursing records Share investigation report / draft letter with PET Coordinator / specialty management team / other specialties / Directorates as required Draft response to be prepared by the PET Coordinator from the investigation Letter to be presented to the CL/CD/GM for signature Presentation to CEO / nominated deputy for signature of covering letter Changes required back to PET Coordinator / amend CEO Sign off 33

34 APPENDIX 6 Equality Impact Assessment (EQIA) Form (Please complete all sections) Q1. Date of Assessment: February 2014 Q2. For the policy and its implementation answer the questions a c below against each characteristic (if relevant consider breaking the policy or implementation down into areas) Protected Characteristic a) Using data and supporting information, what issues, needs or barriers could the protected characteristic groups experience? i.e. are there any known health inequality or access issues to consider? The area of policy or its implementation being assessed: b) What is already in place in the policy or its implementation to address any inequalities or barriers to access including under representation at clinics, screening c) Please state any barriers that still need to be addressed and any proposed actions to eliminate inequality Race and Ethnicity Gender Positive impact identified None identified Information is available in alternate formats and languages Translation and interpretation services are available as required none Age None identified 34

35 Religion None identified Disability Positive impact identified Information is available in alternate formats Sexuality None identified none Pregnancy and None identified Maternity Gender None identified Reassignment Marriage and None identified Civil Partnership Socio-Economic None identified Factors (i.e. living in a poorer neighbour hood / social deprivation) Area of service/strategy/function Q3. What consultation with protected characteristic groups inc. patient groups have you carried out? Consultation has been taken with Patient Partnership Group, including Directorate Patient Groups Q4. What data or information did you use in support of this EQIA? Complainant data captured on datix Q.5 As far as you are aware are there any Human Rights issues be taken into account such as arising from surveys, questionnaires, comments, concerns, complaints or compliments? No 35

36 Q.6 What future actions needed to be undertaken to meet the needs and overcome barriers of the groups identified or to create confidence that the policy and its implementation is not discriminating against any groups What By Whom By When Resources required Q7. Review date 36

37 APPENDIX 7 Environmental Impact Assessment The purpose of an environmental impact assessment is to identify the environmental impact of policies, assess the significance of the consequences and, if required, reduce and mitigate the effect by either, a) amend the policy b) implement mitigating actions. Area of impact Waste and materials Soil/Land Water Environmental Risk/Impacts to consider Is the policy encouraging using more materials/supplies? no Is the policy likely to increase the waste produced? no Does the policy fail to utilise opportunities for introduction / replacement of materials that can be recycled? no Is the policy likely to promote the use of substances dangerous to the land if released (e.g. lubricants, liquid chemicals) no Does the policy fail to consider the need to provide adequate containment for these substances? (e.g. bunded containers, etc.) no Is the policy likely to result in an increase of water usage? (estimate quantities) no Is the policy likely to result in water being polluted? (e.g. dangerous chemicals being introduced in the water) no Does the policy fail to include a mitigating procedure? (e.g. modify procedure to prevent water from being polluted; polluted water containment for adequate disposal) no Action Taken (where necessary) 37