COMPLIMENTS, COMMENTS, CONCERNS AND COMPLAINTS POLICY AND PROCEDURES

Transcription

1 COMPLIMENTS, COMMENTS, CONCERNS AND COMPLAINTS POLICY AND PROCEDURES Lead Responsible: Responsible Person: Review Date: Document type: Date Issued: Ratified by: Reference: Version Helen Hirst - Director of Primary Care and Public Engagement Lorraine Kennedy - Complaints Manager 1 April 2011 Policy March 2010 One Supersedes Approving Body Supporting Procedure(s) Contact for further details Distribution Investigation of Incidents, Complaints and Claims Incident Reporting Policy Being open policy Lorraine Kennedy Complaints Manager lorraine.kennedy@bradford.nhs.uk All areas

2 Contents Section Topic Page SECTION 1 - POLICY 1 INTRODUCTION 4 2 SCOPE 4 3 AIM 4 4 PRINCIPLES OF GOOD COMPLAINTS HANDLING 5 5 THE KEY FUNCTIONS OF THE COMPLAINTS PROCESS 5 6 NHS COMPLAINTS REGULATIONS Exclusions 6 7 OPEN AND FAIR CULTURE 6 8 LEVELS OF RESPONSIBILITY Chief Executive Responsible Member of the Board of Directors Directors Deputy Directors / Heads of Service Complaints Manager Service Managers Front Line Staff Patient Advice and Liaison Service (PALS) 10 9 PALS AND COMPLAINTS INTERFACE CONFIDENTIALITY / DATA PROTECTION COMPLAINTS INVOLVING LITIGATION OR REQUIRING LEGAL ADVICE REDRESS Compensation / Ex-Gratia Payments 12 SECTION 2 - PROCEDURES 13 COMPLAINTS PROCEDURES Making a complaint Persons who can make a complaint Anonymous complaints Time limits for making complaints Acknowledgement and record of the complaint Response time frames Investigation of complaint Grading of complaints Decide how serious the issue is Root cause analysis Content of responses to complaints Conciliation Complaints likely to involve misconduct/breach of disciplinary rules 19 1

3 13.14 Completion of the complaints process Complaints record keeping Actions arising to improve services and share the learning COMPLAINTS ABOUT COMMISSIONED SERVICES AND/OR OTHER AGENCIES / OTHER PROVIDERS COMPLAINTS INVOLVING INDEPENDENT CONTRACTORS GPs, Dentist Pharmacist and Opticians PARLIAMENTARY & HEALTH SERVICE OMBUDSMAN (PHSO) 2 nd Stage) 21 SECTION 3 ADDITION INFORMATION 17 ADVOCACY / INDEPENDENT HELP AND SUPPORT FOR COMPLAINANTS SUPPORT FOR STAFF HABITUAL OR PERSISTENT COMPLAINANTS CORRESPONDENCE RECEIVED FROM LOCAL MEMBERS OF PARLIAMENT (MPs) AND COUNCILLORS MONITORING STAFF TRAINING PUBLICITY AND ACCESSIBILITY OF THE PROCEDURES (PALS and Complaints Procedures) IMPLEMENTATION OF THIS POLICY EQUALITY IMPACT ASSESSMENT MONITORING COMPLIANCE AND EFFECTIVENESS OF THE POLICY AND PROCEDURES FURTHER INFORMATION 25 2

4 Appendices Appendix Topic Page 1a. 1b Summary complaints procedure Complaints procedure flow chart Patient Advice and Liaison Service (PALS) - responsibilities /process Support offered by NHS Bradford and Airedale to assist the resolution process between complainants and independent contractors. (Version 4) West Yorkshire Health and Social Care Protocol for handling health and social care inter-agency complaints. Useful contacts Key references Equality impact assessment tool

5 1. INTRODUCTION The NHS does whatever it can to make sure patients are treated properly and promptly. Sometimes things do go wrong and when they do patients have every right to raise a concern, comment or make a complaint, have it considered and receive a response from the NHS organisation concerned. NHS Bradford and Airedale is committed to patient centered care and to continuous service improvement. As a part of this process, NHS Bradford and Airedale will deliver an effective process to deal with patient concerns, comments and complaints. The organisation is also keen to receive compliments which can also be used to build on good practice. This policy has been reviewed and revised and is based on the The Local Authority Social Services and National Health Service Complaints (England) Regulations 2009, (statutory instruments 2009 No 309) which came into force on 1 April 2009 and the guidance issued to support these, Listening Responding and Improving, a guide to better customer care. This policy outlines the process by which complaints, concerns, comments and compliments are handled when raised by or on behalf of our patients. Some of the patients/clients we serve may have difficulty in expressing their concerns. All staff are encouraged to try and make it easier for patients to express their opinions. It is recognised that many informal complaints, concerns and comments made or raised on behalf of our patients are effectively dealt with on the spot by staff, managers and by the Patient Advice and Liaison Service (PALS). Where this is not possible, or on the persons request, staff ensure that patients, carers or their relatives are able to access the formal complaints procedure. 2. SCOPE The framework for handling complaints is a two stage process. The fundamental objective for handling complaints is to facilitate effective complaints handling at local level, including the resolution of informal concerns raised, and to encourage organisational learning. If unresolved then the complainants would have a right to approach the Parliamentary and Health Service Ombudsman (PHSO). This policy and the procedures, outlined within this document, apply to all staff in relation to any complaints, concerns, comments or compliments raised by patient s and/or their relatives/carer s about services provided or commissioned by NHS Bradford and Airedale. 3. AIM The most satisfactory outcome to complaints is achieved when complaints are dealt with fully and effectively at local resolution, i.e. within the organisation where the complaint occurred. The intention of this Policy for handling NHS Complaints, Concerns, Comments and Compliments is to ensure that there are efficient and effective arrangements in place to be compliant with statutory obligations and ensure the process is open and easily understood by all staff and anyone who may wish to raise an issue about any aspect of their care and treatment provided. The new arrangements that came into effect from 1 April 2009 were to; ensure that complainants/patients/carers or their relatives are treated in a positive manner by all staff when they make a complaint or raise a concern, comment or compliment Make it easier and simpler for people wishing to make a complaint Achieve early resolution by providing responses that are proportionate to the concerns or complaint made and meet the needs of the complainant 4

6 Provide an opportunity for learning and development NHS Bradford and Airedale will ensure that patients, relatives or their carers receive a high quality service in respect of processing their complaints, concerns, comments and compliments; NHS Bradford and Airedale will record and deal with all complaints, concerns, comments and compliments brought to notice. Concerns and complaints will be taken seriously and will be dealt with efficiently in a conciliatory fashion with the main aim of satisfying the complainant. NHS Bradford and Airedale will demonstrate its intention to put the needs of its patients first. NHS Bradford and Airedale will use the information from complaints, concerns, comments, and compliments as an opportunity to influence learning from issues that have been raised and take actions to continuously improve and monitor its standards of care. 4. PRINCIPLES OF GOOD COMPLAINTS HANDLING The Parliamentary and Health Service Ombudsman has published a set of Principles of Good Administration. NHS Bradford and Airedale is committed to these principles which should be taken into account in its handling of complaints: 1. Getting it right 2. Being customer focused 3. Being open and accountable 4. Acting fairly and proportionately 5. Putting things right 6. Seeking continuous improvement A full set of the Principles, together with supporting information, can be found at: 5. THE KEY FUNCTIONS OF THE COMPLAINTS PROCESS The systems and arrangements in place should; Be simple, conciliatory and flexible Treat each case according to individual nature and the complainants expected outcome Focus on satisfactory outcomes, with swift early resolution Ensure there is joint working across organisational boundaries to resolve complaints that involve one or more organisation, involving both NHS and Social Care. The system to centre on people s needs and wishes; The processes for raising concerns or complaints be accessible to patients, relatives or their carers, from front line staff, service managers, to PALS and Complaints functions Encourage and empower people to come forward with complaints and concerns Communicate early with patients/complainants Open early dialogue with complainants to discuss and agree the manner in which the complaint will be dealt with, i.e. how their issues are handled and by who and by exploring what will help resolve the matter The systems set up should seek to; Ensure lessons are learnt from individual concerns and complaints and that those lessons lead to service improvement and/or reduce patient harm 5

7 Develop action planning to ensure implementation, collate evidence of the improvements and changes made, share these in the response to complainants Share the lessons organisation wide and not just in the area where the complaint was made 6. NHS COMPLAINTS REGULATIONS The Local Authority Social Services and National Health Service Complaints (England) Regulations 2009) The following complaints are excluded from the formal complaints regulations: The subject of the complaint is such that it can quickly and effectively be resolved by a member of staff or by the relevant Directorate; A complaint made by an NHS body, which relates to the exercise of its function by another NHS body; A complaint made by a member of staff about matters relating to their contract of employment; A complaint made by an independent provider about any matter relating to arrangements made by an NHS body with that independent provider; A complaint that has been investigated previously by the Healthcare Commission or the Parliamentary Health Service Ombudsman; When a complainant wishes to pursue legal action or a claim has been made; A complaint arising out of the alleged failure by an NHS organisation to comply with a request for information under the freedom of information act 2000 (20) When an NHS organisation decides that it is not required to consider the complaint under these regulations. However all complaints received should be investigated and response made by the appropriate Manager, Director or Chief Executive when necessary. 7. OPEN AND FAIR CULTURE NHS Bradford and Airedale make every effort to promote an open and fair culture and is keen to support all service areas in being open with patients, the public and with staff when concerns have been raised or complaints have been made. (refer to Being Open Policy) The complaints process was set up as a fair, flexible and conciliatory process to give patients the opportunity to raise issues of concern, but also to give NHS organisations and it s staff the chance to provide an appropriate explanation, apology and details of the lessons learned, actions taken as a result to improve patient care and/or to reduce patient harm. Patients, carers or relatives should not be discriminated against as a result of making a complaint and their care and treatment should not be affected. (NHS Standards for Better Health (C14b). Staff are briefed within induction and mandatory training sessions to prevent or minimise the chances of discrimination being raised as an issue. Complaints are not recorded or filed within patients records which limits the number of staff being aware that a complaint has been made (see para 12.15). In addition confidentiality is maintained and the complaint is only shared with the appropriate managers and staff involved. 6

8 8. LEVELS OF RESPONSIBILITY 8.1 Chief Executive The Chief Executive, of Bradford and Airedale Teaching Primary Care Trust ( NHS Bradford and Airedale) has overall accountability for of the management of complaints and to provide a written response to any complaint made in relation to the staff or services provided. 8.2 Responsible Member of the Board of Directors The Director of Primary Care and Public Engagement, is the nominated Director responsible for ensuring that there are structures and processes in place to comply with the NHS Complaints Regulations for NHS Bradford and Airedale, in particular ensuring there are effective management, handling processes in place and that action is taken if necessary in the light of the outcome of complaint. The Director of Primary Care and Public Engagement will ensure that the Board receives assurance reports in accordance with clinical governance arrangements, via the Clinical Governance Sub-Committee. 8.3 Directors The Lead Director retains responsibility and accountability for investigations in relation to Complaints or issues raised within their area of work. The Director is responsible for sign off of the investigation, report findings, the action plan and response prior to sending this to the Chief Executive. The Lead Director should ensure that any risks identified as a result of an investigation should be assessed and recorded on the risk register as appropriate. 8.4 Deputy Director / Head of Service The Deputy Director / The Head of Service will determine the individual who will act as the complaints investigator for the complaint received and to ensure that the investigator is a senior/service manager of the team who is appropriately trained. In some cases, where appropriate the investigator maybe independent to the service complained about. The Deputy Director / Head of Service is responsible for ensuring that the complaint is fully investigated in accordance with the complaints procedures, for the sign off of the investigation, the report findings, the action plan and response prior to sending this to the Chief Executive for approval. The Deputy Director / Head of Service should escalate complaints to the Director when they consider this to be appropriate and seek their approval of the draft written response. The Deputy Director / Head of Service should ensure that the lessons are learned as a result of complaints and that these are shared via appropriate channels. In addition The Head of Service should ensure that any risks identified as a result of an investigation should be assessed and recorded on the risk register as appropriate. Director/ Head of Service should read this policy in conjunction with the procedure for the investigation of incidents, complaints and claims and of the relevant polices set out appendix Complaints Manager The Complaints Manager is the designated Complaints Lead for ensuring complaints are dealt with across NHS Bradford and Airedale, in accordance with the NHS Complaints Regulations 7

9 and taking into account the Department of Health guidance issued to support these, Listening Responding and Improving. The Complaints Manager is responsible for the effective and efficient day to day operation and management of all matters relating to the complaints procedures. The Complaints Manager will receive, record, acknowledge all formal complaints and ensure they are passed on to the relevant Director, Manager to be dealt with in accordance with the regulations. The Complaints Manager will ensure that the appropriate consent is obtained for example if the complainant is not the patient or consent if required from next of kin, including consent to share the complaint with other agencies where appropriate. The Complaints Manager or a member of the Complaints Team will have the initial discussion with the Complainant, following the acknowledgment of the complaint, in order to agree the manner in which the complaint will be dealt with and to initiate a local resolution plan. However this may be done by the appropriate Manager in some cases where this has been agreed. The Complaints Manager will support and advise Directors and Senior Managers throughout the process. The Complaints Manager will liaise and co-ordinate where appropriate with other agencies in the case of a multi-agency complaint and will deal with these in accordance with the West Yorkshire protocol for handling such complaints (appendix 3) The Complaints Manager has direct access to the Chief Executive Office and will consult with the Chief Executive throughout the investigation if necessary. The Complaints Manager will ensure that the Chief Executive has all the relevant information in order for him/her to authorise and sign off of the final response. The Complaints Manager will co-ordinate the information gathering in relation to complaints that are made to the Parliamentary Health Service Ombudsman and ensure that the Heads of Service are aware of the outcome in such cases in order for them to address any actions as a result. The Complaints Manager will deliver a range of complaints training for staff, including induction sessions, mandatory training and advanced training for senior/service managers and any other sessions that are requested or required by individual teams. The Complaints Manager will ensure that complaints information is reported to the relevant groups/committees, including the numbers and types of complaints, actions taken and lessons learnt. 8.6 Service Managers Senior / Service Managers have an important role in resolving any concerns and issues that are raised within their service area or supporting staff or PALS in doing so. Senior / Service Managers are responsible for the investigation of issue raised or any formal complaint made relating to their service area or any investigation to be undertaken at the request of the Director, Deputy Director or Head of Service. Senior / Service Managers should liaise with the Complaints Manager in each individual complaint to agree the way forward in order to develop the resolution plan, which will include the manner in which the complaint will be dealt with and the timeframe involved. 8

10 Senior / Service Manager will take ownership of the complaint and undertake a proportionate investigation into the issues raised. The Senior / Service Manager should refer to the procedure for the investigations of incidents complaints and claims in order to carry out the appropriate level of investigation (see section ) Senior / Service Managers will report the outcome and conclusion of the investigation to the appropriate Deputy Director / Head of Service. Senior / Service Managers are responsible in preparing a draft written response to the complaint which sumarises the investigations, provides an appropriate apology and explanations to the issues raised and details of the lessons learned, actions taken as a result to improve services or prevent reoccurrence (if appropriate). Senior / Service Managers should be mindful of the complainant s desired outcome. The Complaints Manager will advise and support this process. Senior / Service Managers will offer to meet with Complainants to discuss their complaint, the outcome of investigations or when they remain dissatisfied with the aim to resolve the matter. Senior / Service Managers should ensure that there are written notes of any meeting that has taken place. Senior / Service Managers are responsible for identifying any immediate or longer term action plans to improve services and should report these to the Deputy Director / Head of Service. The Senior / Service Manager will ensure that the actions are implemented and should monitor the progress. Service Managers should ensure that the lessons are learned as a result of complaints and that these are shared via appropriate channels with the Head of Service. In addition, Service Managers will report details of any service changes or improvements made as a result of a complaint, in the form of an action plan, to the Complaints Manager within 20 working days of the final response letter to the patient which will identify actions taken as a result of the complaint. Service Managers are responsible for identifying any risks resulting from the investigation of a complaint and should report any such risks to the Deputy Director / Head of Service in order for them to be dealt with in accordance with Risk Management Systems and processes. The Complaints Manager will support and advise Senior / Service Managers throughout the process. 8.7 Front line staff Patient, relative s or carers may contact front line staff in the first instance to raise their concerns or to say they want to make a complaint. NHS Bradford and Airedale encourages staff to discuss with patients any concerns raised. This will give the opportunity to sort out problems immediately, informally, at the place of delivery with the aim of early resolution and without the need for a formal (verbal or written) complaint to be made. Ideally the matter should be resolved on the spot or within 1 working day. Front line staff should refer any case to their line manager if the matter cannot be resolved quickly or easily to the patient s satisfaction or to the Complaints Manager where there is a written complaint or when the patient states that they want to formally complain. This should be done as soon as possible within 1 working day. In any event all concerns raised should be recorded and passed to the PALS Officers as part of patient feedback systems. Complaints should not be recorded within the patient s medical/clinical records. 9

11 Front line staff should, if in any doubt or in the event of having any difficulties in dealing with any particular case, take advice from their Line Manager/Service Manager, the PALS Manager and/or the Complaints Manager. All staff should contact their Senior / Service Manager and the Complaints Department at Douglas Mill immediately if they receive a written complaint to ensure that the complaint is dealt with in accordance with procedures set out. 8.8 Patient Advice and Liaison Service (PALS) Patients, relatives or their carers also contact the Patient Advice and Liaison Service to raise their concern or make a complaint. Appendix 2 details the PALS procedures, the roles and responsibilities of PALS Officers and frontline staff when concerns are raised informally. PALS have a central point of contact and take all PALS telephone queries, responding, signposting or passing on to relevant appropriate members of staff or senior/service managers as appropriate for informal resolution. PALS Officers do not deal with formal complaints, although they can explain the NHS Complaints procedures and may also be able to resolve any concerns informally prior to a formal complaint being pursued. PALS officers liaise with the appropriate service or providers of service in order to try and resolve concerns at the earliest opportunity. The PALS Officers will refer cases to the Complaints Manager, where the matter has not been resolved to the patient s satisfaction or if the patient expresses their desire to pursue a formal complaint. PALS cases are recorded centrally; this includes details of the case, any actions or learning as a result when advised by the service involved. PALS Officers, as front line staff, should, if in any doubt or in the event of having any difficulties in dealing with any particular case, take advice from the PALS Manager or Complaints Manager or the Service Manager involved. 9. PALS AND COMPLAINTS INTERFACE It would be the patient, carer or relative s choice whether they wish for their concerns / issues to be dealt with by a PALS Officer, front line staff or a Service Manager in the first instance to assist them to achieve informal resolution. PALS Officers and front line staff would in discussing any matter with a client would agree an acceptable way forward with them. If the client is not happy with the outcome of the informal resolution with PALS, with front line staff or Senior / Service Managers then the patient may wish to pursue a formal complaint. PALS staff / front line staff or the Senior / Service Manager should refer the matter to the Complaints Manager immediately within 1 working day. Where, at the initial contact stage, a patient, carer or relative wishes for a complaint to be handled through the formal complaints procedure (as opposed to informal complaints which are technically problems that can be resolved quickly) PALS can; Provide information about the complaints procedure, the process and who to contact Where appropriate ask the Complaints Manager or a Complaints Officer to contact the complainant direct Help the complainant access independent advocacy, PALS do not support complainants through the complaints procedure 10

12 Where a complaint has been through the complaints procedure and there is dissatisfaction with the outcome, Complaints staff will discuss any outstanding issues, and agree a way forward with the complainant. PALS officers should not become involved. Formal written complaints received should be dealt with by the Complaints Manager or a Complaints Officer in accordance with these Complaints procedures in consultation with the appropriate Deputy Director / Head of Service. Any formal complaints received by staff should be directed immediately to the Complaints Manager. It should be noted that not all letters received from patients, relatives or cares are formal complaints, the service area where these are received should agree the way forward with the person who submitted the correspondence so that the matter can either be resolved in the service area or passed to the Complaints Manager if required. 10. CONFIDENTIALITY / DATA PROTECTION The requirement to maintain confidentiality is absolute during the complaints process. Information about any complaint should only be shared with the complained against or those involved in any way or with any member of staff with responsibilities in the investigations, unless appropriate consent if obtained in individual cases. The Data Protection Act prohibits information use and disclosure without consent, effectively providing individuals with a degree of control over who sees information they provide in confidence. This duty could be overridden only if there was a statutory requirement, a court order or, in exceptional circumstances, a robust public interest justification. The PALS Team is also bound by confidentiality and the Data Protection act. PALS Officers are client led and will only take actions with their clients consent, keeping them involved in the process. Any concerns or comments which clients may have are treated in confidence. In instances where any member of staff are in any doubt regarding confidentiality, they should seek the advice of an Information Governance Officer and/or the Caldicott Guardian There may be instances whereby confidentiality should be disregarded for example; When client threatens to injure another person Poses any risk to him/herself or others When client discloses details about abuse of children or adults When client expresses strong suicidal tendencies However advice should be taken from Information Governance, the Caldicott Guardian and/or the appropriate Risk Manager. 11. COMPLAINTS INVOLVING LITIGATION OR REQUIRING LEGAL ADVICE The Complaints Manager will seek advice from the Claims Manager for NHS Bradford and Airedale where a complaint carries potential for litigation. The possibility of litigation should not prevent an immediate investigation to discover any failures in systems or procedures and prevent re-occurrence. The Complaints Manager will explore with the complainant their expectation with regard to their desired outcome of the complaints procedures and offer the options available, which could prevent the possibility of litigation. The Head of Service will decide whether it is possible to 11

13 respond to the complaint. Legal advice will be sought and clinicians will be advised to consult their defense organisation if appropriate. Complaints received where litigation is being followed are not excluded from the NHS Complaints Procedure. Where complaints investigation is being undertaken in parallel with a claim investigation advice will be sought from the NHSLA. If the police are involved legal advice will be sought to seek to ensure no prejudice to any criminal proceedings 12. REDRESS Compensation / Ex-Gratia Payments There may be occasions when having investigated the complaint there are grounds for making an ex-gratia payment (without accepting liability) or compensation where failures have been identified. An apology, gesture of goodwill or compensation payment may gives the opportunity to deal with certain circumstances in a fair and responsive manner. The Head of the Service will approve all ex-gratia payments. Any ex-gratia payments should be made having regard to NHS Bradford and Airedale Standing Orders and Standing Financial Instructions. Legal advice should be taken in relation to cases where compensation is an option to resolve the complaint. The Parliamentary and Health Service Ombudsman (PHSO) has set out a number of principles for remedy, which should be read in conjunction with their Principles of Good Administration and Principles of Good Complaints Handling. A full set of the Principles, together with supporting information, can be found at: The PHSO expects public bodies to be fair and take responsibility for failures and apologise for them to make amends and to use the opportunity to improve services. The PHSO refers to a range of responses to a complaint that has been upheld, these including both financial and nonfinancial remedies. It is accepted that in the majority of cases an apology and explanation may be a sufficient and appropriate response. Where maladministration or poor service has led to injustice or hardship NHS Bradford and Airedale should offer a remedy that returns the complainant/patient to the position they would have been in otherwise. If that is not possible the remedy should compensate them appropriately. The complainant/patient should not make profit or gain an advantage from remedies. There are no automatic or routine remedies for injustice or hardship resulting from maladministration or poor service, remedies maybe financial or non-financial. Legal advice will be sought in individual cases It is recommended that, before any compensation is offered in respect of a complaint involving a member of staff, the member of staff should be involved in the discussions when the subject of compensation is considered to ensure that he/she does not feel compromised by the decision to award compensation. 13. COMPLAINTS MANAGEMENT PROCEDURES 12

14 Details of the Complaints procedures and processes are outlined in this section. Appendix 1a and 1b set out the procedures and responsibilities for ease of reference Making a complaint Formal complaints should be made to the Complaints Manager or Chief Executive of NHS Bradford & Airedale about its services and/or its staff. It is accepted that formal complaints can be received at any premise, by anyone within the organisation. However in any event formal complaints must be referred immediately to the Complaints Manager to ensure that they are dealt with in accordance with the complaints procedures. NHS Bradford and Airedale will also receive complaints about its commissioned services and other agencies and/or providers, details of the procedure are set out at paragraph 13 / 14. The emphasis is to try and resolve complaints in a conciliatory fashion, quickly and as close to the source of complaint as possible using the most appropriate way forward in each individual case. It should be acknowledged that face to face or telephone contact can often diffuse situations and rectify misunderstandings. However, if it has not been possible to rectify the matter informally to the complainant s satisfaction, then the local resolution continues and the formal complaints process should be followed. People who want to complain can do so in a number of ways including verbally, in writing, by , by fax. All front line staff or the PALS Officers should refer any person wishing to exercise their right in making a formal complaint (oral or written) to the Complaints Manager as soon as possible and within 1 working day. Where the complaint is made orally then a written record will be made by the Complaints Manager or Complaints Officer, which will include the name of the complainant, the subject of complaint and the date on which it was made. Complaints Manager will require the patient s/complainant s signature to confirm the details are accurate. However complainants will be encouraged to write complaints personally where they are agreeable. Equally with complaints received by , electronically, the complainant will need to sign and authorise the statements received. Where a complainant requires additional support to make a complaint this can be provided by the Independent Complaints Advocacy Service (ICAS). Complainants will be given details of how to obtain independent help and support from ICAS, which can include offering assistance in the writing of letters. (see section 15) In addition arrangements can be made with language line and/or the interpreting and translation services where this is required, requested or there is an identified need. Where a complaint is made in writing, the Complaints Manager must ensure that there is a written record of the date on which it was received, taking the received date as the date the complaint was made Persons who can make a complaint A complaint can be made by a patient or a person affected or likely to be affected by the action, omission or decision of NHS Bradford and Airedale. A complaint can also be made about service provided by another NHS body in which NHS Bradford and Airedale commission, (see paragraph 13). A complaint can also be made by someone acting on behalf of the patient or a person with their written consent. 13

15 Consent would not be possible and/or needed in cases where the patient has died, is a child or is unable by reason of physical or mental incapacity to make the complaint themselves. In cases where the patient has died or is incapable the representative must be a relative or other person who, in the opinion of the Complaints Manager has or had sufficient interest in the person s welfare and is a suitable person to act as representative. Consent may also need to be sought when the complainant is not the patient s next of kin in order to disclose personal confidential information relating to the patients care and treatment within any response made. The correspondence received from Members of Parliament MPs, and Councillors, Cllrs is detailed at section Anonymous Complaints If anyone wishes to remain anonymous whilst making a complaint, NHS Bradford and Airedale will consider whether there is enough information to carry out an investigation. The Complaints Manager will discuss with the appropriate Deputy Director, Head of Service or Senior Manager to consider what action should be taken with regard to the issues raised in any individual case. In any event the information would be captured as feedback and be included within the information contained within Complaints/PALS reports Time limits for making complaints A complaint must be made within 12 months after; The date on which the matter, which was subject of complaint occurred; or if later, the date on which the matter, which is subject of complaint came to notice of the complainant. Where a complaint has not been made within the timescales, the Complaints Manager and/or the Deputy Director / Head of Service will consider the issues raised and may decide to investigate the complaint if he/she are of the opinion that: having regard to all the circumstances, the complainant had good reasons for not making the complaint within the time limits set out or not withstanding the time that had elapsed it is still possible to investigate the complaint effectively and efficiently Acknowledgement and record of the complaint The Complaints Manager must send a copy of the written complaint or statement to the Deputy Director / Head of Service within 2 working days of receipt. The appropriate Director will also be notified of the complaint received at this stage. The Deputy Director / Head of Service will then pass the complaint to the appropriate the Senior / Service Manager to instigate an investigation immediately. The Complaints Manager will ensure there is a log to record the complaint and will send an acknowledgment to the complainant within 3 working days of the date on which the complaint was received. The acknowledgement can be made orally or in writing and must include an offer to discuss with the complainant; The manner in which the complaint will be handled; 14

16 and the response period the investigation is likely to be completed and the response likely to be sent to the complainant. Early dialogue should take place with the complainant to agree the way forward with them. Where the Complainant does not respond or does not wish to take up the offer of a discussion, the Complaints Manager will ensure that the complainant is informed, in writing, details of the manner in which the complaint will be handled and the likely timeframe involved. The Complaints Manager will discuss each individual case with the Deputy Directory / Head of Service and/or Senior / Service Manager in order to fulfill the above requirement and to develop a local resolution plan, an agreement with the complainant of the way forward. Where the complaint was made orally, the acknowledgement must be accompanied by the written record asking the complainant to sign and return the transcript as an accurate record. In addition acknowledgments to the complainant should include information about where the complainant can obtain independent advocacy services. The complainant should also be sent a leaflet which outlines the complaints procedures so that they have information about the process and what they can expect Response Time frames The response period is the timescale for the likely completion of the investigation and the response to be sent to the complainant. The response period should be negotiated and agreed with the Complainant as noted above. The level of the investigation should assist in the determination of the timeframes involved. The Complaints Manager will in consultation with the Senior / Service Manager determine the timeframe which will be agreed with the complainant. It will depend in each individual complaint whether it is the Complaints Manager or the Senior / Service Manager that negotiates and reaches the agreement with the Complainant. In cases where agreements are not made the Chief Executive should aim to respond within 25 working days of receipt of the complaint, or the timeframe determined by the level of investigation undertaken by the Service Manager. Inevitably there will be occasions when the timeframe in dealing with a particular complaint cannot be met; for example when the individual complained against is absent or on leave, or where health records have been requested from another NHS organisation or simply because conciliation meetings have been arranged. If there are delays in the process the Complaints Manager or Senior / Service Manager, whichever is the named contact for the complainant, should advise the complainant and renegotiate and agree further period of time in which the response should be made. The complainant should be sent written notification. The investigations and the response to complaints should in any event be made within 6 months from the date the complaint was received, unless an extension to this period is agreed with the complainant Investigation of Complaint The Deputy Director / Head of Service and the Senior / Service Manager will assess the seriousness of the complaint on receipt and consider the extent of the investigation and the manner which appears to be the most appropriate way forward to resolve the complaint speedily and efficiently in consultation with the Complaints Manager. 15

17 The Deputy Director / Head of Service together with the Service Manager should; Grade the complaint (see section 12.8 below) and undertake a proportionate investigation, and in doing so refer to the Procedure for the investigation of incidents, complaints and claims to assist and guide them through the process and undertake a Root Cause Analysis (RCA) where this is necessary. Collate and gather documentation in relation to the complaint, including taking written, signed statements from relevant staff Liaise with the Complaints Manager throughout the process and with the Complainant where this has been agreed. Compile a report which sets out the findings/evidence and the conclusions reached Draft a response to the complainant in consultation with the Deputy Director / Head of Service and Complaints Manager Complete an action plan, which will identify the issues raised, the lessons learned and the actions to be taken, by who and by when to prevent reoccurrence where necessary. Submit the action plan to the Complaints Manager within 20 days of the Chief Executive s final response sent to the complainant. In addition, the Senior / Service Manager should inform the Complaints Manager about the progress of the complaint and give the reasons for any delay, in order for the Complaints Manager to keep the Complainant informed if this has been agreed. Where the Senior / Service Manager is dealing directly with the Complainant then the Senior / Service Manager should communicate with the Complainant throughout the process and keep the Complaints Manager informed Grading of Complaints Different levels of investigation are required dependent on the type of complaint and the issues that are raised. By correctly assessing the seriousness of a complaint, the right course of action can be taken. The complaint should be graded on receipt and reviewed based on the results of the investigation. The grading of complaints is achieved by assessing the seriousness and the likelihood of reoccurrence. It is important to remember that a complaint can have a very different effect on an organisation compared with any individual. It is for each directorate to ensure that systems are in place to grade all complaints on receipt. The grading will be recorded on the complaints file and the complaints recording system. The level of the complaints investigation will depend on the outcome of the grading. For complaints graded low, following an investigation a formal written response will be required. The level of investigation for complaints graded medium will be dependent on the severity of the incident/issues raised. However all Complaints graded high or extreme will require a full investigation using root cause analysis. (refer to the Incident Reporting Policy) In addition to the final response, a full report including an action plan will be required in high or extreme cases. Action plans will be required in all cases where lessons have been learned and actions are to be taken as a result Decide how serious the issue is: The following guidance has been extracted from the Department of Health document entitled Listening, Responding and Improving of which complaints handling is a part and includes specific guidance, set out below, in relation to the assessment of the seriousness of complaints received. 16

18 Seriousness Description Example of incident Unsatisfactory service or experience Low not directly related to care. No impact or risk to provision of care. OR Medium/moderate High Extreme OR Unsatisfactory service or experience related to care, usually a single resolvable issue. Minimal impact and relative minimal risk to the provision of care or the service. No real risk of litigation. Decide how likely the issue is to recur: Service or experience below reasonable expectations in several ways, but not causing lasting problems. Has potential to impact on service provision. Some potential for litigation. Significant issues regarding standards, quality of care and safeguarding of or denial of rights. Complaints with clear quality assurance or risk management issues that may cause lasting problems for the organisation, and so require investigation. Possibility of litigation. Possibility of adverse local publicity. Serious issues that may cause longterm damage, such as grossly substandard care, professional misconduct or death. Will require immediate and in-depth investigation. May involve serious safety issues. A high probability of litigation. Possible adverse national publicity. Simple non-complex issues; Delayed or cancelled appointments, Event resulting in minor harm (e.g. cut, strain), Loss of property, Lack of cleanliness, Transport problems, Single failure to meet care needs, Medical records missing. Event resulting in moderate harm (e.g. fracture), Delayed discharge, Failure to meet care needs, Miscommunication or misinformation, Medical errors, Incorrect treatment, Staff attitude or communication. See moderate list. Event resulting in serious harm (e.g. damage to internal organs) Events resulting in serious harm or death, Gross professional misconduct, Abuse or neglect, Criminal offence(e.g. assault) Likelihood Rare Unlikely Possible Likely Description Isolated or one off slight or vague connection to service provision. Rare unusual but may have happened before. Happens from time to time not frequently or regularly. Will probably occur several times a year. 17

19 Almost certain Recurring and frequent, predictable. Catorgorise complaint (A guide to better customer care, DOH 2009) Root cause analysis Where a patient safety incident has been identified, or when a complaint relates to an incident that has been reported, then it may be necessary to carry out a root cause analysis. Service Managers should refer to the Procedure for the Investigation of Incidents, Complaints and Claims to determine the depth and type of investigation required. Any serious untoward incident identified within a complaint must be managed in accordance with the Serious Untoward Incident (SUI) policy Content of Responses to Complaints When an investigation has been completed, the Senior / Service Manager will prepare a draft response for approval by the Deputy Director / Head of Service. The response should include the following; Explanation of how the complaint was considered appropriate apology an explanation of all issues raised the reasons for any failure in service lessons learned and/or any steps taken improve services or to prevent a recurrence and or reduce patient harm Offer of conciliatory meeting or further discussion the complainant must be informed of the their next steps and their right to approach the Parliamentary and Health Service Ombudsman if they remain dissatisfied with the outcome of Local Resolution; and that any request must be made within 12 months. The Complaints Manager will support and advise the Senior / Service Manager in the preparation of the draft response. Once the response has been approved by the Deputy Director / Head of Service the complaints file is passed to the Chief Executive for consideration and sign off. The complaint should be escalated to the Director if necessary. 18

20 In some circumstances, where there is good reason, a response maybe signed off by a person acting on the Chief Executive s behalf Conciliation Complainants will be offered opportunities to discuss their concerns at a conciliatory meeting with appropriate managers. The purpose of the meeting would be for the complainant to openly discuss their issues and/or any outstanding grievances they may have to try and resolve their concerns or any dissatisfaction following the outcome of their complaint. Notes of the meeting will be taken as a record of the discussions that take place. These will not be verbatim records. NHS Bradford and Airedale will also offer an independent mediation/conciliation service to assist the complaints local resolution process where deemed appropriate by the Complaints Manager and Deputy Director / Head of Service. The main aim of independent medication is to try to achieve reconciliation between the parties, although it is accepted that this will not always be possible. The mediation process is seen to be useful in that it: provides an opportunity for both sides to air their points of view allows the opportunity of a face-to-face discussion, if this is what both sides want provides an opportunity for the person against whom the complaint has been made to offer an explanation of events leading to the complaint (and an apology if this is felt to be appropriate). The Complaints Manager, where appropriate, with the agreement of the Deputy Director / Head of Service, will make arrangements for independent mediation to take place between the complainant and the complained against or will provide any other assistance for the purpose of resolving the complaint. Both parties must be agreeable to participate in conciliation / mediation Management of Staff involved in Complaints and Incidents that have occurred The complaints procedure must remain separate from any disciplinary procedures. The complaint must first be investigated under the complaints procedure and a decision will be taken as to whether there may have been misconduct or a breach of disciplinary rules. If appropriate the issue will then be investigated under the organisation s disciplinary procedure. Complainants will be informed but the wording will be that the issue is being pursued via the NHS Bradford and Airedale human resource procedures. Further details will not be given in order to protect staff confidentiality Completion of the complaints process The Complaints Manager, in consultation with the Deputy Director / Head of Service and Senior / Service Manager, will ensure that every effort is be made to ensure that the complaints local resolution process has been fully exhausted to try and resolve the complaint. The outcome of all complaints will be recorded and monitored to ensure actions are taken to improve services as appropriate Complaints record keeping All complaints will be registered on the day of receipt, or as soon as possible thereafter, by the Complaints Manager. The Senior / Service Manager will ensure that full records of the investigation are kept, including copies of correspondence/documents records of any telephone calls and interviews held. Records will also be held to document the actions to be taken to improve services in future where necessary and the dates that the changes are implemented. 19