Felton Surgery. Complaints Policy and Procedure

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1 Felton Surgery Complaints Policy and Procedure Policy Statement Felton Surgery is committed to providing a high quality, patient-focused service. Complaints and comments from patients are taken very seriously, as we want every patient to feel satisfied with the services we provide. Felton Surgery has a procedure for dealing with complaints, to ensure that every complaint is handled fairly and transparently. When handling complaints, Felton Surgery is committed to being fair to staff while seeking to resolve complaints promptly. Essential Standards Compliance (Until April 2015) Felton Surgery complies with current NHS complaints procedures and with Outcome 17 of Guidance about Compliance: Essential Standards of Quality and Safety, published by the Care Quality Commission, which describes the requirements of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 as they relate to complaints. The outcome requires providers to have in place an effective system for identifying, receiving, handling and responding appropriately to complaints. Fundamental Standards Compliance (from April 2015) From April 2015, subject to Parliamentary approval, the draft Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 will apply, replacing the Essential Standards. Felton Surgery understands that, with regard to arrangements for complaints handling, Regulation 16 requires Felton Surgery to have an effective complaints procedure in place and for any complaint received to be investigated and necessary and proportionate action taken in response to any failure identified by the complaint or investigation. Procedure 1. All complaints will be dealt with by Felton Surgery in the first instance. 2. If a complainant is dissatisfied with the response they receive, they then have the right to take their complaint to the Ombudsman for independent review. Complaints will be accepted from: Any patient Any person acting on behalf of a patient with the patient's consent Any person acting on behalf of a patient where consent is not required Complaints may be made: Verbally in person face to face Verbally over the telephone By By letter REVIEW DATE: JUNE 2016 Page 1 of 12

2 Complaints should ideally be made within twelve months of the event that gave rise to the complaint, or within twelve months of the complainant becoming aware of it. Where a person could not reasonably have complained within this timescale, Felton Surgery will consider the complaint anyway. Felton Issues raised that do not constitute Complaints It is accepted that people may want to raise issues or matters with the Practice that do not constitute a complaint. These issues may be matters that contain important points from which lessons may be learnt. It is also accepted that people may raise issues which concern them but they do not wish to make a formal complaint. The Practice recognises that it is important that this information and that the potential for learning from it is not lost. Suggestions for making improvements in the future are always actively sought by the Practice. In order to record such information the Practice has implemented a Patient Feedback Log. This log must be updated with any such information that is received by any member of staff whether verbal or in writing. Each matter recorded must be discussed at the Practice weekly Management Meeting and then taken to the monthly Clinical Governance Meeting so that any lessons learnt from it may be implemented at the earliest opportunity. When a person raises an issue verbally at the Surgery or by telephone to the Surgery the First Person receiving the matter should respond positively to the person and resolve the issue there and then if possible. An explanation of the Patient Feedback Log may be given as a solution to the raised issue If resolved, the First Person will take sufficient details of the issue for accurate recording on the log. The details must be recorded on the log and the issue must be discussed at the next the Practice weekly Management Meeting and then taken to the monthly Clinical Governance Meeting. If the First Person is unable to resolve the issue there and then they should explain that they will now report the matter to the Head Receptionist. If the person is reporting face to face then they may be asked to take a seat while the First Person speaks with the Head Receptionist who will then come to see the person in timely fashion. If the matter has been made by telephone then the person may be told that the First Person will now report to the Head Receptionist who will ring them back in a timely fashion The Head Receptionist will try to resolve the matter there and then if possible. If the issue is resolved by the Head Receptionist then an explanation of the Patient Feedback Log will be given to the person and sufficient details taken for accurate recording on the log. The details must be recorded on the log and the issue must be discussed at the next. The Practice Weekly Management Meeting and then taken to the monthly Clinical Governance Meeting REVIEW DATE: JUNE 2016 Page 2 of 12

3 The Patient Suggestion procedure is not a substitute for the Complaints procedure but is to be considered a safety net for matters which fall outside a formal complaint or Significant Event so that valuable information is not lost. If the First Person and Head Receptionist are unable to resolve the issue and the person wishes to make a formal complaint then a Statement of Complaint form will be completed by the Head Receptionist. The Statement of Complaint Form (Appendix 1) will include a summary of the complaint which should be completed accurately. Read the summary out to the complainant and ask them to sign this as a true and accurate summary of their complaint. Explain to the Complainant that the matter will now be dealt with by the Practice Manger and that he/she will contact the complainant within three working days. The Statement of Complain Form will be given to the Practice Manager that day. Where a person raises an issue to the surgery in writing and it is felt that this issue may be resolved by use of the Patient Feedback Log system then the Head Receptionist will contact the person by telephone on the day the correspondence is received to acknowledge receipt of it. The Head Receptionist may resolve the matter there and explain the Patient Feedback Log procedure. If this is the case then the Patient Feedback Log must be completed accurately and the issue must be raised at the next Practice meeting. If the Head Receptionist is unable to resolve the issue then he/she will explain to the Complainant that the matter will now be dealt with by the Practice Manger and that he/she will contact the complainant within three working days. Where service users might lack the confidence or the capacity to make a complaint, staff should provide whatever help they require or help them to contact the appropriate advocacy services: ADAPT (North East) Burn Lane Hexham Northumberland NE46 3HN T: F: E: W: This service applied for those who may have a learning disability / autism etc. If the person does want to use the complaints procedure, the team member should: Explain the procedure to the Complainant. Take a note of the details of the complaint on a Statement of Complaint Form as above. REVIEW DATE: JUNE 2016 Page 3 of 12

4 Check that the person wishes to make the complaint verbally or whether they wish to put it in writing (if they have not already done so). Pass the details of the complaint to the Practice Manager together with the Statement of Complaint form that working day. The Practice Manager is the nominated Complaints manager for Felton Surgery. All Complaints should be directed to the Practice Manager in the first instance. The Practice Manager will record the Complaint on the Complaints Log that working day. The Complaint must be added to the agendas for the weekly Management Meeting with the Partners, and the Monthly Clinical Governance Meeting. The Practice Manager must acknowledge the Complaint within three working days of receipt. This acknowledgement will include the offer of a discussion to agree the investigation process (Appendix 2). When a person complains on behalf of a patient, before proceeding to investigate the complaint, the Practice Manager will: Verify the person's identity Verify that the person has the patient's written consent. The Practice Manager will investigate the complaint. He or she will: Speak with staff involved Review any systems and processes involved Discuss with the partners the appropriate response to the complaint Discuss with the partners any changes required to working practices or systems Discuss the response with involved staff before contacting the complainant. Following agreement of the appropriate response, the Practice Manager will write to the complainant to explain the outcome of the investigation. If the complainant is not happy with the response, the Practice Manager will advise them how to take their complaint to the next stage. (Appendix 3 Complaint Response Template) The Practice Manager will keep a full record of all complaints, responses, actions taken and meetings held as a result of complaints. This will be stored on the Shared Drive. It may be that a Complaint also falls under the guise of a Significant Event. If this is the case then this file will also be updated by the Practice Manger. A hyperlink to the Significant Event document will be placed on the Complaints Register. The Practice Manager will discuss the Practice response to complaints at the Monthly Clinical Governance Meeting. The Compliance Officer will audit the register of complaints for ALL LIVE complaints on a weekly basis to ensure that the policy is being adhered to and to identify trends. If non-compliance is identified this should be reported to a GP partner. This analysis will be presented at Clinical Governance Meetings for review REVIEW DATE: JUNE 2016 Page 4 of 12

5 The Practice Manager will be responsible for leading on actions for Practice development as a result of complaints and matters that do not constitute complaints. ALL documentation regarding Complaints will be kept for 10 years, Under no circumstances will any documentation regarding a complaint be attached to a patient file. REVIEW DATE: JUNE 2016 Page 5 of 12

6 Appendix 1 STATEMENT OF COMPLAINT FORM Patient Person Making Complaint Name: Address: Name: Address: Telephone No: Telephone No: Ethnicity of Patient: Gender: Any relevant disabilities or religious beliefs Date of Birth: AREA OF COMPLAINT: Organisation Felton Surgery Name of staff involved (if Date of Incident if known known) Summary of complaint:- Desired Outcome:- I certify that this is a true and accurate account of the verbal complaint I raised with: Name Role Signed Dated For completion by Felton Surgery staff only Date received Name of staff member who took complaint Signature of staff member Completed forms to be returned to: Appendix 2 REVIEW DATE: JUNE 2016 Page 6 of 12

7 COMPLAINT ACKNOWLEDGE TEMPLATE Felton Surgery Middle Farm, Main Street, Felton Northumberland NE65 9PR Tel: [Today...] [Title/Initial/Surname] [Patient Address Block] [Post Code] Dear [Title] [Surname] Re Complaint I am writing in response to the concerns that you raised and would like to thank you for taking the time to raise this issue concerning (Enter Nature of Complaint Here) with our practice. Firstly, I do appreciate how difficult it has been for you to raise your concerns at this very sad and difficult time and am so sorry that your grief has been compounded by the need to do so. Please accept my deepest sympathies on your loss. (Delete as appropriate) I would like to reassure you that Felton Surgery is committed to providing the highest possible standards of care to all of our patients. However, we do appreciate that unfortunately at times things can go wrong and recognise that complaints provide a unique opportunity for us to view our services from the patient s perspective. Due to the nature of your complaint it will involve input from NHS employees outside of my control and as such it may be between four and eight weeks before I can write to you with an update. (Delete as appropriate). If you would like a discussion regarding your complaint or this letter then please call me at the surgery. Yours sincerely Practice Manager REVIEW DATE: JUNE 2016 Page 7 of 12

8 COMPLAINT RESPONSE TEMPLATE Appendix 3 Felton Surgery Middle Farm, Main Street, Felton Northumberland NE65 9PR Tel: [Today...] [Title/Initial/Surname] [Patient Address Block] [Post Code] Dear [Title] [Surname] I am writing in response to the concerns that you raised and would like to thank you for taking the time to raise these issues with (Enter Nature of Complaint Here) Firstly, I do appreciate how difficult it has been for you to raise your concerns at this very sad and difficult time and am so sorry that your grief has been compounded by the need to do so. Please accept my deepest sympathies on your loss. (Delete as appropriate) I would like to reassure you that the Felton Surgery is committed to providing the highest possible standards of care to all of our patients. However, we do appreciate that unfortunately at times things can go wrong and recognise that complaints provide a unique opportunity for us to view our services from the patient s perspective. During my investigation, I have considered the medical records, taken statements from the staff identified below and referred to (refer here to any policies / procedures / protocols / guidance / legislation / good practice that you have relied upon) and unfortunately this has taken longer than originally anticipated. Please accept my sincere apologies for the delay in responding to your concerns. Dr A Another - Consultant Physician Mr J G - Consultant Orthopaedic Surgeon Mrs A J.. - Nurse Practitioner Miss A B.. - Staff Nurse Mr T J.. - Healthcare Assistant Your complaint highlighted a number of issues which have been addressed individually later in my letter. Having had the opportunity to reflect on the issues raised and the documentation available to me I have found your complaint to be well founded in respect of points 1) 3) and 5). I have not found your concerns well founded regarding points 2) and 4). I have set out below my findings and the rationale behind the decisions that I have reached. REVIEW DATE: JUNE 2016 Page 8 of 12

9 I feel that it would be beneficial to provide a summary of the circumstances surrounding your care. (Print off a Summary) I will now address each of your issues in turn as follows:- 1) Delay in referral to the... service. This complaint was well founded. I have liaised with the GP practice and received confirmation that a referral was faxed to the service on (Enter Date Here). It is clear from the medical records that this was received on however, it was passed to the consultant for review and unfortunately he was unavoidably absent from work due to unforeseen circumstances for a period of three weeks. At the time there was no formal process for review by an alternative consultant and I feel that it would have been reasonable to have expected this to occur. Clearly this led to a delay in the referral being acted upon for a period of three weeks. Please accept my sincere apology for this shortcoming. I have discussed your concerns within the Medical Business Unit Governance Meeting and a number of actions were identified as a result. A protocol has been developed and was immediately implemented, whereby in the absence of an individual consultant it is the responsibility of the consultant s secretary to ensure that any referrals are flagged up with the clinical director who will allocate them to another consultant to deal with. I am confident that this will prevent a recurrence of the situation that you experienced. I note that you had received an appointment for 27 May 2009 and am pleased to confirm that you have now been placed onto the waiting list at the point that you would have been, had the referral been acted upon immediately and your appointment has therefore been rearranged for 6 May ) Failure to adequately treat broken finger following your fall. I have not upheld this complaint. I understand from staff nurse B that on the evening of the 18 January 2009 that you got up, to go to the toilet and whilst passing the nurses station, you slipped and fell. The fall was witnessed by staff nurse Brown who was completing documentation at the nurse s station at the time. I understand that you were wearing socks without any slippers and your socks were slipping on the floor. Staff nurse B was unable to reach you before you fell to the floor. She sought the assistance of the healthcare assistant and Dr Another was called to review you. Dr Another arrived within a couple of minutes and you were immediately examined for injury. You were alert and orientated and able to provide an outline of the circumstances surrounding your fall and to confirm that your ribs were tender. You denied any other discomfort. Dr Another examined you and found you to be tender over the lower rib area and x-rays were requested. The x rays identified a hairline fracture to your rib. This injury can cause significant discomfort and I am pleased to note that from the documentation in your medical records that you were given regular analgesia to manage your pain. I can find no evidence to suggest that any concerns were raised in respect of an injury to your finger at the time of your fall. However, I have reviewed the documentation for the remainder of your stay and note that you did indicate that you felt some discomfort over your fingers the following day, which were then showing signs of bruising. I have asked the consultant to confirm how this injury should have been treated had it been identified at the time of your fall. Mr G has explained that as it was your little finger, it is not possible to apply a plaster to this area and the treatment would have been to provide you with analgesia. As you had already been provided with analgesia for the pain in the rib area and the treatment you received did not therefore differ from that which I would expect had the broken finger been identified at the time of your fall, I have not upheld this complaint. 3) Etc... REVIEW DATE: JUNE 2016 Page 9 of 12

10 In summary, I acknowledge that there was an initial delay in acting appropriately on the referral to the (Enter Department) service and in respect of points 1) 3) and 5) our services have fallen below our usual high standards and would like to convey a sincere apology to you in that respect. I am however very pleased to note your very kind comments regarding the actions of staff nurse B. at the time of your fall and the empathy showed to you by the whole team on ward 4 and confirm that your positive comments have been shared with them. Finally, once again, I would like to take this opportunity of thanking you for taking the time to raise your concerns and providing me with an opportunity of commenting on them. I do hope that the explanations provided above, have gone some way towards alleviating your concerns. However should you wish to clarify any of the above further either by telephone or in a meeting, I would be happy to do so. I can be contacted on If you remain dissatisfied at the end of local resolution you can put your complaint to the Health Services Ombudsman. The Ombudsman can carry out independent investigations into complaints about poor treatment or service provided through the NHS in England, The Ombudsman s services are free. If you have any questions about whether the Ombudsman may be able to help you or about how to make a complaint please contact their helpline on , or fax Or you can write to them at: The Parliamentary and Health Service Ombudsman Millbank Tower Millbank London SW1P 4QP Further information about the Ombudsman can be found on Should you require any direct help or advice making your complaint you can contact your local Independent Complaints Advocacy Service (ICAS): ICAS Churchill House 12 Mosley Street Newcastle upon Tyne NE1 1DE Tel: ICAS provides independent advocacy to people making complaints under the NHS complaints procedure. Regards Practice Manager REVIEW DATE: JUNE 2016 Page 10 of 12

11 Felton Surgery Complaints Investigation plan Complaint reference number: Patient name including title Ethnicity of patient: Gender: Any relevant disabilities or Disabilities Religious Beliefs religious beliefs Complainants name including title Date complaint received Date acknowledged & investigation Acknowledged Investigation plan agreed plan agreed Consent required / date received Yes No Date Received Joint organisation complaint - person co-ordinating complaint Person investigating complaint Holding letter / update due Response due Brief overview of concerns / issues raised: 1) 2) 3) 4) 5) Desired outcome 1) 2) 3) 4) 5) REVIEW DATE: JUNE 2016 Page 11 of 12

12 Appendix 4 Audit Date Audit By Complaint Number Date of Complaint 3 Day Acknowledgement adhered to? Is complaint on agenda for next monthly management meeting? This may be ongoing if the complaint is discussed at several meetings. Is the next date recorded on the Complaints Log. Is complaint included in the minutes of the monthly Management Meeting as having been discussed? This may be ongoing if the complaint is discussed at several meetings. Is the outcome of the meeting recorded on the Complaints Register and X-Ref'd with Sig Events Log where necessary? Have decisions made at meeting been complied with? Is a computer file up to date with scanned documents relating to the complaint? Are documents and records stored separately from the patient file? If answer to any of these questions is no then this must be brought to the attention of Dr Waite or Dr Lees REVIEW DATE: JUNE 2016 Page 12 of 12

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