Policy for the Management, Investigation and Resolution of Complaints

Transcription

1 Policy for the Management, Investigation and Resolution of Complaints Version 5.2 Approved Date Date Ratified 4th November 2013 Ratified by Chairman s action on behalf of the Policy Group Review Date 5 November 2014 Author Interim Associate Director- Patient Experience Policy for the Management, Investigation and Resolution of Complaints version 5.2 Page 1 of 27

2 CONTENTS Page Title 1 Contents 2 1 Introduction 3 2 Purpose 3 3 Responsible Officers and Duties 4 4 Policy 6 5 Concerns 8 6 Communication and Publicity 9 7 Complaint Management Process 9 8 The Parliamentary and Health Service Ombudsman 14 9 Service Improvement And Lessons Learned Analysis And Reporting Of Complaints Complaint Training Whistleblowing Dissemination and Implementation Document Control Monitoring Compliance Standards/KPIs 16 Monitoring of Policy 17 Change Control 17 Policy Development Team 18 Amendment History 18 Distribution Plan 19 Training Implications 19 Equity & Diversity Impact Assessment 20 References 21 Glossary and Definitions 21 Appendix 1 Complaints Process 22 Appendix 2 Complaints Flow Chart 23 Appendix 3 Risk Rating of Complaints 24 Appendix 4 Advice on Handling Unreasonable, Regular and Persistent Complaints 25 Policy for the Management, Investigation and Resolution of Complaints version 5.2 Page 2 of 27

3 1 Introduction 2 Purpose This document reflects the legal requirement placed upon all NHS organisations to have written procedures in place which highlight the arrangements for handling of complaints in accordance with the 2009 NHS Complaints Regulations Complaints are a means of identifying the users perspective of the service we provide. They can act as an early indicator of problems within a system and trend analysis of the factors causing the complaint can help to identify areas where improvements may be necessary. An important element of governance is to detect, analyse and learn from patients experiences, including adverse events and system failures. A complaint is any expression of dissatisfaction with the services, care or facilities provided by the Trust that requires a response. In line with the Principles of Good Complaint Handling published by the Parliamentary and Health Service Ombudsman (PHSO) the Trust aims to: Get it right Be customer focused Be open and accountable To act fairly and proportionately To put things right Seek continuous improvement University Hospitals Morecambe Bay Hospitals Foundation Trust is committed to the early resolution of complaints and believes that all staff have a duty to recognise an expression of dissatisfaction at the earliest stage and to resolve it personally or if not able to resolve it personally refer the matter promptly to the appropriate (more senior manager) person or service (i.e. PALS). Every effort should be made to resolve complaints as they arise, particularly those involving relatively minor criticisms. Comments, queries, concerns and suggestions are not complaints but staff should endeavour to respond to these promptly and to give appropriate advice and information in order to prevent them escalating and becoming complaints. This policy stipulates the mandatory arrangements for the investigation and resolution of complaints. The purpose of this policy is to inform our staff and service users of the process for complaints handling within the Trust. Furthermore we will ensure that all appropriate complainants will be able to access the Trust s Complaints Procedure and will be treated sympathetically and with respect throughout the process. Implementation of the policy will lead to: Complaints being investigated in line with the requirements of the statutory regulations A patient focussed, consistent approach to investigating complaints Providing a detailed written response to complainants as promptly as possible Equitable and non-discriminatory treatment for service users who complain. Policy for the Management, Investigation and Resolution of Complaints version 5.2 Page 3 of 27

4 Identification of necessary service improvements that arise from complaints. Implementation of necessary service improvements that arise from complaints.. 3 Responsible Officers and Duties This section outlines the roles and responsibilities of individual postholders in relation to the investigation of complaints. All staff have a responsibility to listen and respond to patient and visitor complaints, ensuring timely and effective resolution where appropriate. Complaint books are available in wards and departments to enable recording of complaints made verbally where the complainants wish is for this matter to be escalated through the trusts complaints management process. Complaint and PALS information is available within wards and departments and should be made available to patients and visitors when informal, timely resolution is not possible or appropriate. 3.1 The Chief Executive is responsible for signing off the complaint response. On occasions where they are not available to do so another member of the executive team will sign the response on their behalf. The Chief Executive has overall accountability for ensuring compliance with the Statutory Regulations and this policy to ensure that appropriate action is taken at the conclusion of a complaint investigation. 3.2 Executive Directors are responsible for deciding whether or not it is appropriate to inform the police, and at what stage, if it is reported to them that a complaint alleges, or it becomes apparent during the investigation, that a criminal offence may have been committed. 3.3 The Director of Governance is the Executive Lead for the management of complaints and has responsibility for the co-ordination and oversight of the complaints management process. 3.4 The Head of Patient Experience is the Trust s Complaints Manager and is responsible for the management of all complaints received by the Trust, in accordance with the Regulations and this policy. Where it is apparent, either on receipt of a complaint or during the investigation that a serious untoward incident has, or may have, occurred the Head of Patient Experience ensures that it is reported to the Head of Patient Safety and Effectiveness or the Health & Safety Manager as appropriate. Should it be alleged, or become apparent, during the complaint investigation that a criminal offence may have been committed, the Head of Patient Experience will report this immediately to the Director of Governance or another Executive Director. If the Head of Patient Experience becomes aware during any complaint investigation that patients or complainants are being discriminated against the Head of Patient Experience will take appropriate action to ensure that the discrimination is addressed immediately and that this is taken up with staff members involved via relevant procedures. Policy for the Management, Investigation and Resolution of Complaints version 5.2 Page 4 of 27

5 3.5 Case Officers - Upon receipt of a complaint, Case Officers will contact their Divisional Governance Lead and where necessary relevant Divisional Managers. The Case Officer and Governance lead will make an initial assessment of the complaint to determine if additional information is required from outside of the Division. Should this be necessary, the Case Officer will make that approach. A copy of the complaint and investigation request will be provided and Divisional Governance leads will then liaise with Divisional Managers / Matrons and or Service Managers to initiate an investigation into the issues raised within the complaint. Close liaison will be maintained with the relevant Case Officer at all times. The Governance Lead will advise the Case Officer if they believe this target may be compromised. The Case Officer will endeavour to progress the completion of the investigation in liaison with any staff necessary. Should the 15 days target be at risk of breaching, the Case Officer will escalate to the Head of Patient Experience for further action. 3.6 Divisional Management Teams - The Divisional Management teams are responsible for co-ordinating complaint investigations within their Divisions ensuring that necessary service improvements identified as a result of a complaint investigation are implemented. Upon completion of a complaint investigation the Divisional Management Teams are responsible for feeding back to the relevant Case Officer to provide assurance that actions have been completed. Divisional Management teams will receive regular reports from the Customer Care Department detailing complaints received during a specific period and incorporating information in relation to the cause of a complaint, location, staff groups involved, and target response date etc. This will support the Division to manage their complaints effectively and will enable the Divisions to target interventions where themes in complaints present themselves. Divisional Management teams will be copied in on complaints received and on requests for information made by Case Officers. It is expected that these individuals will advise the Case Officer if they have relevant information relating to the complaint or if they believe that the Case Officer should be seeking additional information from personnel other than those approached. 3.7 Consultants, matrons, service managers and specialty leads are responsible for investigating those elements of the complaints relating to them and their staff and for providing the Case Officer with appropriate statements, overviews and action plans within the specified time frame of 15 working days from receipt of complaint. 3.8 Every member of staff has a responsibility for prompt and effective resolution of complaints within their area as they arise. All staff also have a responsibility to provide any information reasonably requested from them during the investigation of a complaint. All staff must be aware of the Patient Advice & Liaison Service (PALS) and their role in helping to resolve concerns quickly. Contact details are available on the PALS leaflet and on the Compliments, Comments and Complaints leaflet. Policy for the Management, Investigation and Resolution of Complaints version 5.2 Page 5 of 27

6 4 Policy A complaint is defined for the purposes of this policy as any expression of dissatisfaction against any of our services. In 2003, the Department of Health published a consultation document Making Amends. The document detailed the need to communicate well with patients and relatives when a moderate to severe incident had occurred or if something had gone wrong with their care. University Hospitals of Morecambe Bay NHS Foundation Trust aims to provide all complainants with an honest, open response to the concerns which they raise. It is common practice for complainants to be offered local resolution meetings to discuss their concerns or any unresolved issues as appropriate and for a record of such meetings to be written up and provided to the complainant. Where a complaint identifies a serious patient safety incident or it is considered by the Head of Patient Experience to highlight serious concerns in relation to the care received, University Hospitals of Morecambe Bay NHS Foundation Trust Being Open policy will be invoked. 4.1 Supporting Staff Involved In Complaints University Hospitals of Morecambe Bay NHS Foundation Trust recognises that staff whose actions are the subject of a complaint may be upset and distressed and require support during the process. Details of the way in which this support is provided are available in University Hospitals of Morecambe Bay NHS Foundation Trust policy for supporting staff involved in traumatic or stressful incidents. NHS staff may complain about the way they have been dealt with when involved in a complaint investigated within the Complaints Procedure via University Hospitals of Morecambe Bay NHS Foundation Trust Grievance Procedure. 4.2 Prevention Of Discrimination As A Result Of Complaints University Hospitals of Morecambe Bay NHS Foundation Trust expects all staff to treat patients and complainants with respect at all times and will not tolerate discrimination against them as a result of a complaint being made. During any complaint investigation, if it becomes apparent that patients or complainants may be being discriminated against, the Head of Patient Experience will take appropriate action to ensure that the discrimination is addressed and appropriate action taken in relation to the staff members involved. All staff should be aware that documentation relating to complaints should not be filed in patients case notes as this causes concern that it may give rise to future discrimination. Medical Secretaries should maintain a separate folder for complaints as Consultants will require the information annually when undergoing appraisal. 4.3 Exclusion Criteria Under section 8a h of the legislation the following complaints are not required to be dealt with: Policy for the Management, Investigation and Resolution of Complaints version 5.2 Page 6 of 27

7 4.4 Data Protection complaint made by a responsible body complaint made by an employee of a local authority or NHS body about any matter relating to that employment complaint which is made orally and is resolved to the complainant s satisfaction not later than the next working day after the day on which the complaint was made a complaint the subject matter of which is the same as that of a complaint that has previously been made and resolved in accordance with sub-paragraph c a complaint the subject matter of which has previously been investigated under these regulations; the 2004 regulations; the 2006 regulations; or a relevant complaints procedure in relation to a complaint made under such a procedure before 1 April 2009 a complaint the subject matter of which is being or has been investigated by a local commissioner under the Local Government Action 197(a) or a health service commissioner under the 1993 Act a complaint arising out of the alleged failure by a responsible body to comply with a request for information under the Freedom of Information Act 2000 (b) a complaint which relates to any scheme established under section 10 (superannuation of persons engaged in health services etc.) or section 24 (compensation for loss of office etc.,) of the Superannuation Act 1972 or to the administration of those schemes. If complaints received allege a breach or suspected breach of the Data Protection Act 1998, the Head of Patient and Service Experience should inform the Trust s Data Protection Manager. Complaints are recorded on the Trust s Risk Management database and associated documents are scanned and attached to the electronic file. Hard copy files containing the original documentation will be retained for 8 years from the date of closure. The archive is reviewed annually and files closed more than 8 years previously are destroyed in accordance with the Trust s arrangements for confidential waste. No information or correspondence relating to a complaint will be kept the patient record. 4.5 Complaints which may lead to Litigation or Criminal Proceedings Complainants may pursue a complaint under the Trust s Policy and make a clinical negligence claim simultaneously, however, when legal action is being pursued at the same time that a complaint relating to the same matter is made, or when an investigation is on-going into a criminal offence, the Trust should consult with its legal advisors and/or the Police in order to determine whether progressing with the complaint might prejudice subsequent legal or judicial action. If this is deemed to be the case the Trust will notify the complainant, in writing, that further investigation is not possible. Policy for the Management, Investigation and Resolution of Complaints version 5.2 Page 7 of 27

8 4.6 Complaints Where A Patient s Death Has Been Referred To The Coroner 5 Concerns The fact that a death has been referred to the Coroner does not mean that investigations into any complaint about the patient s care should be suspended. Appropriate investigations should be undertaken, regardless of the Coroner s enquiries, but it is advisable to notify the Head of Legal Services, who is the Coroner s point of contact with University Hospitals of Morecambe Bay NHS Foundation Trust, and that they are kept informed of the progress of the complaint investigation. Minor criticisms can often be addressed immediately. Concerns raised should be listened to sympathetically and it is frequently possible for the member of staff to whom these are expressed, or the person in charge at the time, to provide an acceptable answer or explanation. The patient, relative, friend or carer should be made aware of the Patient Advice and Liaison Service (PALS) In addition if staff require support in order to resolve an informal complaint they should contact the ward or department manager, the appropriate Matron, Service Manager, Consultant or the PALS service. All staff should be aware of the correct procedure to follow should a patient or relative wish to make a complaint. A flow-chart for ease of reference is available (see Appendix 2). Where the matter is resolved, staff should make a record of the concerns, the outcome and any action taken on a verbal complaint form. Staff should complete a verbal complaint form giving details of the complaint and the top copy should be sent to the Customer Care Department. A complainant whose concerns cannot be resolved verbally and/or who wishes to make a formal complaint should be advised to write to the Chief Executive. Information is available in the Compliments, Concerns and Complaints leaflet. If a complainant is unable or unwilling to put their concerns in writing the person to whom the complaint is made should do so on their behalf and have the document signed by the complainant to confirm the content and sign it themselves. The document should then be forwarded to the Customer Care Team. If concerns are raised out of hours and the staff are unable to resolve them, or the matter is considered serious, then the senior manager on-call should be informed via the switchboard operator. Details should be accurately recorded and the Head of Patient and Service Experience should be informed of the matter on the next working day. 5.1 PALS (Patient Advice and Liaison Service) The Patient Advice and Liaison Service (PALS) will provide to patient, relatives, carers and friends: help to resolve their concerns quickly, often within 24/48hours. support should they require help navigating NHS services support information requests Policy for the Management, Investigation and Resolution of Complaints version 5.2 Page 8 of 27

9 signposting to external services such as those provided by voluntary, charitable or private sector. All wards and departments should have PALS leaflets and contact details available. 5.2 Independent Complaint Advocacy Services Should a patient or service user wish to seek independent advice when making a complaint there are a number of Independent bodies who can be contacted to provide support and advocacy services to patients going through the NHS complaints process. They can be contacted on: N-Compass- for Lancashire residents People First for Cumbria resident Communication And Publicity Compliments, Concerns and Complaints leaflets and PALS leaflets must be available in all wards and departments in the Trust. Ward and department managers are responsible for maintaining stocks at all times and replacements can be obtained from PALS officers or the Customer Care Department. Staff can access the procedure via the Trust s intranet. Information relating to UHMB NHS FT s Complaints Procedure is available on the Trust s public website which can be found at An accompanying poster is also on display in public areas. 7 Complaints Management Process 7.1 Who can complain A patient Any person who is affected by or likely to be affected by the action, omission or decision of the Trust A complaint may be made by a person acting on behalf of another person mentioned above in any case where that person: Has died Is a minor Is unable by reason of physical or mental incapacity to make the complaint themselves or Has authorised the representative to act on his/her behalf. 7.2 Consent It is preferable if the complaint is made by the person affected, however, if this is not possible a complaint can also be made by someone who has been asked by the patient to act on their behalf. When a representative is complaining on behalf of a patient, care must be taken to ensure that the patient is aware of the complaint, has asked the representative to act on their behalf and has provided written consent for details of their case to be divulged to the third party, this may include medical information. If the written consent is not included with the complaint the Customer Care Team, when acknowledging receipt, will send a consent form requiring completion by the patient. This Policy for the Management, Investigation and Resolution of Complaints version 5.2 Page 9 of 27

10 must be returned before the complaint investigation can commence. If consent is not received within 1 month of the request, the Customer Care Team will consider withdrawing the complaint and will write to the complainant to confirm their decision. In the case of a patient or person affected who has died or who is incapable, the representative must be a relative or other person who, in the opinion of the Head of Patient Experience, has or had sufficient interest in the patient s welfare and is a suitable person to act as representative. If the Head of Patient Experience is of the opinion that a representative does not or did not have sufficient interest in the patient s welfare, or is unsuitable to act as a representative, the Head of Patient Experience must notify that person in writing, stating the reasons for their decision. In the case of a minor, the representative must be a parent, guardian or other adult with parental responsibility. Minors who are, in the opinion of the Head of Patient and Service Experience to be Fraser competent may make a complaint and, where the complaint, is made by an appropriate adult it is good practice to request the minors authority when they are believed to be Fraser competent. 7.3 Governor / Constituent Complaints Any patient/carer may make a complaint or raise a concern via their Foundation Trust Governor. Information and consent forms support this process and further information can be obtained by contacting your local foundation trust governor or alternatively the Membership Services office telephone University Hospitals of Morecambe Bay NHS Foundation Trust endeavours to protect patient information and applies strict criteria regarding who may receive clinical information related to patients. Any third part making a complaint about the care of a particular patient can only receive a response to their complaint provided the consent of the patient is given or, in the case of a deceased patient; the patient s named next of kin or the executor/executrix of their estate. In the event that a patient lacks the capacity to consent, due to the nature or severity of their illness, University Hospitals of Morecambe Bay NHS Foundation Trust will release information only to the individual with whom the clinical staff are liaising/liaised regarding the patient s care during their admission. 7.4 Making a complaint-time limits A complaint must be made within: Twelve months of the date on which the matter, which is the subject of the complaint, occurred. or Twelve months of the date on which the matter, which is the subject of the complaint, came to the notice of the complainant. Where a complaint is made after the expiry of the mentioned above, the Head of Patient Experience may agree to investigate if they are of the opinion that the complainant had good reasons for not making the complaint within the time period and it is still possible to investigate the matter effectively and efficiently. Where it is decided not to investigate a complaint which has not been made within the time limit, the Head of Patient Experience must write to the complainant, informing them that their concerns cannot be dealt with Policy for the Management, Investigation and Resolution of Complaints version 5.2 Page 10 of 27

11 under the complaints procedure. The Trust should, however, endeavour to provide as much information as possible but will make the limit of any investigation clear to the complainant. 7.5 Responding to a complaint All formal complaints must be acknowledged within 3 working days by the Customer Care Team by letter or (where this is indicated as the preferred method of contact/no postal address available) and entered onto the Safeguard Risk Management database. The acknowledgment letter must include information regarding advocacy services together with their contact details. In all cases the Customer Care Case Officer will make contact by telephone with the complainant. This ensures the complainant has a dedicated Case Officer to liaise with and establishes a relationship for any future communication necessary. 7.6 Investigation of complaints On receipt in the Customer Care Department, complaints are assessed and graded according to severity and likelihood of recurrence (see Appendix 3). Formal complaints will be allocated to the Case Officer aligned to the Division involved or, in the case of cross-divisional complaints, to the Case Officer of the Division on whom the majority of the complaint is focused. The Case Officer will in conjunction with the relevant Governance Lead, identify the issues to be addressed and the appropriate senior staff. e.g. Consultant, Matron, Head of Department, and Service Manager who will initiate the investigation into the issues raised within the complaint. The Case Officer and Governance Lead will identify the 15 days working target within which the investigation should be completed. The relevant Divisional staff will be made fully aware of this target date. Divisional staff must ensure completion of the investigation and provision of reports, to enable the Customer Care staff to produce a draft response. This draft needs to be checked and approved within the Division before a finalised letter is provided to the Chief Executive for signature within the 35 working day time-frame. In exceptional circumstances an extension to this target may be agreed, but only with full agreement of the Head of Patient Experience and the complainant. The Case Officer will also arrange for the medical records to be forwarded to the senior personnel being asked to provide comments. On receipt of a complaint those asked to provide comments should identify members of their staff from whom they will require statements and/or whom they will need to interview and make prompt arrangements for this work to be undertaken. The Divisional Governance lead will be made aware of all staff involved in the investigation process. Having investigated the complaint they should review the information collected to ensure it addresses in detail all the issues raised and, where appropriate, should provide an overview relating to the care complained about, informing the Case Officer and Governance Lead of any shortfalls which they believe have occurred, of any necessary remedial action that has been, or is intended to be, taken, completing the lessons learned/action taken section of the complaint investigation proforma. Should there be an unavoidable delay in carrying out enquiries the Case Officer must be informed promptly so that, if necessary, an extension of the response time can be requested from the Policy for the Management, Investigation and Resolution of Complaints version 5.2 Page 11 of 27

12 complainant and a holding letter sent. Guidance on statement writing is available on the Trust s intranet. It is recognised that staff who delivered the care complained of may be distressed to learn of the receipt of a complaint and may need support. This should be arranged by the Senior Manager investigating the complaint within the specialty and normally comes from line managers or the peer group but may require the involvement of the Occupational Health Department. (See University Hospitals of Morecambe Bay NHS Foundation Trust policy on staff support). On receipt of the information from the individual specialties the Case Officer drafts a response incorporating the information provided and forwards it to the specialties for checking before the finalised version is provided to the Chief Executive for signature. The response should address all issues raised by the complainant, be written in terms which can easily be understood by people with a non-clinical background and include any information regarding action taken or recommended. The letter should also explain what the complainant should do if they have further questions or are dissatisfied with the responses this will normally be a request for them to contact the Case Officer whose details should be included in the letter If a complainant contacts the Customer Care Team requesting further action the Case Officer should discuss options with them, taking appropriate senior advice as required. Possibilities for further action include the opportunity to meet with appropriate senior staff, reinvestigation of outstanding concerns, review by clinical staff not involved in the patient s care etc. If a meeting takes place notes will be taken at the meeting and a copy provided to the complainant once the staff who attended have confirmed they are a satisfactory record of the proceedings. Once further action has occurred a letter should be sent to the complainant, from the Chief Executive, detailing the further action and the outcome and advising the complainant that, if they remain dissatisfied, they can either contact the Case Officer again or may refer their complaint to the PHSO. There is no time limit set for responding to revisited complaints but staff must aim to respond within 3 months and, where this is not possible a holding letter should be provided to the complainant updating them as to the progress of the investigation. When a meeting is to take place between the complainant and Trust staff finalised arrangements for the meeting must be communicated to the complainant within 25 working days of agreement to arrange the meeting and the meeting itself should take place within two months of the agreement to arrange the meeting. On closure of a complaint file, the risk rating should be reviewed and, if necessary, amended. A record should be made as to whether or not the complaint has been upheld (partially or totally). The formal written response to a complaint should be sent within 35 working days, from the date on which the complaint is received. This deadline can be extended; with the agreement of the complainant (the Complaint Regulations 2009 allow a period of 6 months). Case Officers will negotiate with a complainant and keep them fully informed of this. Policy for the Management, Investigation and Resolution of Complaints version 5.2 Page 12 of 27

13 Complainants have the right to refer their complaint to the PHSO if it has not been answered six months after it has been made. The Trust therefore has a responsibility to ensure that letters of response go out promptly and that meetings are arranged and take place as quickly as possible in order that the time available to address the issues raised at local level is used to best effect. It is imperative that all complaints are fully investigated and a formal response (signed by the Chief Executive) which answers every issue raised, is sent to the complainant within 35 working days of receipt. Any exceptions to the 35 working day target will be monitored by the Head of Patient Experience and a report formulated for ongoing review and monitoring at the Governance and Quality Committee. All investigations will be carried out in line with the deadlines specified in this policy unless the content of a complaint relates to a Serious Incident Requiring Investigation that has not previously been reported. In this instance the investigation will be undertaken in line with the deadlines set out in the Trust policy for the reporting and investigation of incidents. In this instance it remains the responsibility of the Complaints Team to maintain contact with the complainant. Exceptions of this kind will be monitored by the Head of Patient Experience. 7.7 Complaints Involving Other service providers Complaints involving other service providers should be handled in accordance with the relevant Lancashire or Cumbria joint complaints management protocol. When a complaint also involves other Trusts or GPs the Customer Care Team must contact the complainant, ideally by telephone, to establish whether the complainant is happy for their letter to be copied to the relevant Trusts or GP s. If the complainant confirms that they are happy for this to occur, the complaint letter should be faxed or e- mailed to the other providers involved within three working days and discussion should take place with them to establish which organisation will take the lead in co-ordinating the complaint response; this will generally be the provider on whom most of the complaint is focused. The lead provider will co-ordinate the handling of the complaint, ensure the complainant is kept informed of the progress of the investigation and will ensure a comprehensive response is sent. When it is decided that University Hospitals of Morecambe Bay NHS Foundation Trust is to take the lead in a multiple NHS provider complaint the Customer Care Team will write to the complainant immediately to advise that this Trust is taking the lead and will be obtaining and including comments from other service providers. The draft response must be shared with other NHS providers involved and their agreement obtained before the response is signed by University Hospitals of Morecambe Bay NHS Foundation Trust Chief Executive. If a complainant does not wish their complaint to be shared with other providers involved in the patient s care the Customer Care Team will write to the complainant advising them of the issues which UHMBT can investigate and giving details of how to contact other providers involved directly should the complainant wish to do so. Policy for the Management, Investigation and Resolution of Complaints version 5.2 Page 13 of 27

14 7.8 Regular, Unreasonable and Persistent Complaints In a small number of cases, complainants may become unreasonably persistent despite reasonable attempts having being made to resolve their concerns. This can lead to disproportionate amount of time and resources being spent on them and may also cause unacceptable strain to the staff dealing with them. See Appendix 4 regarding the identification of such complainants and advice regarding dealing with them. Appendices 1 & 2 are a summary of the process and a flowchart 8 The Parliamentary and Health Service Ombudsman If a complainant remains dissatisfied after local resolution has taken place they can ask the Ombudsman to investigate their case. The Ombudsman is not obliged to investigate every complaint put to him/her and will generally not take on a case which has not first been through the NHS complaints procedure. The Head of Nursing will act as the point of contact for the Ombudsman s Officers. At the end of an Ombudsman s investigation the Trust receives a report detailing the findings and recommendations. In conjunction with Divisional Management Teams, the Head of Nursing will co-ordinate a response to the complainant and the production of an action plan as appropriate. Progress of these actions plans will be included in the Quarterly Report provided to the Governance and Quality Committee. 9 Service Improvement And Lessons Learned Following investigation of the complaint the Case Officer should include any lessons learned, and action taken, within the response to the complainant. In cases where future action is intended the Case Officer should record the action plan on the Safeguard System and ensure that information is provided to the Divisional Governance Lead on a weekly basis and monthly to the Divisional Management Teams to support the implementation of actions. Monitoring of actions relating to service improvements will be monitored monthly at the Divisional Governance Committees and quarterly at the Governance and Quality Committee.. Some complaints identify actions required to resolve the individual issue but it is also important to monitor complaints received for trends developing which need to be taken up with Divisional Governance Teams or via the Governance and Quality Committee. Lessons learned will be reported in the quarterly complaints report and reported monthly to divisions for inclusion in divisional governance reporting arrangements. In addition, the quarterly complaints report will be shared with the Trust Lessons Learned Group. Lessons learned may be shared to relevant external bodies if appropriate. 10 Analysis And Reporting Of Complaints The Customer Care Department will provide regular reports to: Divisional Governance Leads (weekly) Divisional Management Teams (monthly) Governance and Quality Committee(quarterly) Policy for the Management, Investigation and Resolution of Complaints version 5.2 Page 14 of 27

15 An annual report will be produced on adherence to the complaint management process which will be provided to the Trust Board, NLPCT and NHS Cumbria. Additional reports will be provided to commissioners in accordance with agreed quality monitoring arrangements. The Head of Patient Experience will inform the Head of Legal Services of any complaints where it is believed likely a clinical negligence will ensue. 11 Complaint Training Complaint training will be delivered in line with the Trust Training Needs Analysis (TNA) The Customer Care team will work with divisions to ensure appropriate training provision is made to support staff involved in complaints handling. Complaints/PALS information is provided to all junior medical staff at the twice yearly induction days. Induction of new staff includes basic information on complaints handling. Complaints/PALS information is contained within the annual Mandatory Training Handbook. 12 Whistleblowing Any staff who observe colleagues, or suspect colleagues of, behaving inappropriately towards a patient(s) should raise their concerns with their line manager at the earliest opportunity. If, however, there is a reason why they feel unable to do so they should refer to the Trust s Whistle Blowing policy, available on the Trust s intranet and follow the advice therein. 13 Dissemination and Implementation 13.1 Dissemination The policy will be distributed and communicated as outlined in the distribution plan. A copy of the policy will be available to all staff on the Intranet through the Library Service Implementation It is expected that any policy will be fully operational by the training and implementation dates identified. 14 Document Control Library of Procedural Documents All current approved documents are kept on the Library System which is available through the Trust Intranet Archiving An electronic archive of strategies, policies, protocols, SOPs and guidelines is maintained by the Library Service 14.2 Process for retrieving archived documents Requests for access to archived documents should be made to the Head of Library & Policy for the Management, Investigation and Resolution of Complaints version 5.2 Page 15 of 27

16 Knowledge Service 15 Monitoring Compliance Adherence to this policy will be reported in reports to the Governance and Quality Committee (CGQC). The quarterly Governance and Quality Committee report will include: the total number of complaints received details of complaints by division details of complaints by category details of complaints by speciality details of any action to improve the service percentage of divisional responses within 15 working days percentage of responses within 35 working days/agreed timescale The annual report will include: the number of complaints received analysis by division any significant trends arising actions taken to improve services number of complaints referred to the PHSO adherence to the process milestones identified in this policy an evaluation of the effectiveness of the current process 16 Standards/ KPIs The standards that will be audited as part of the monitoring of compliance with this policy include: Compliance with acknowledging complaints within 3 working days Compliance with the 15 working day investigation target within Divisions Compliance with agreed 35 working day response target Customer satisfaction measure of complaints process Number of complaints referred to the Ombudsman Action taken on identified lessons learned Number of revisited complaints Number of complaint resolution meetings Monitoring arrangements are indicated in the table below. Policy for the Management, Investigation and Resolution of Complaints version 5.2 Page 16 of 27

17 Monitoring of the policy: Requirement Method Frequency Lead Monitoring Group 2.3Duties Policy review Annual Head of Patient Experience % compliance with Agreed response date 2.3 b & 2.3dCustomer satisfaction Measure of complaints process Number of complaints Referred to ombudsman 2e % of complaint response templates received where lessons learned / action taken has been completed 2.3c Annual audit of adherence to Cumbria and Lancashire joint complaints management protocols % compliance with 3 day acknowledgement requirement % compliance with 15 day target for division investigation stage % compliance with 35 day target for resolution Number of revisited complaints as a proportion of total received Safeguard report Questionnair e National PHSO report Audit of investigation templates Audit of joint complaints Safeguard report Safeguard report Safeguard report Safeguard report monthly 2x yearly Annual Quarterly Annual Quarterly Quarterly Quarterly Annual Head of Patient Experience Head of Patien Experience Head of Patient Experience Head of Patient Experience Head of Patient Experience Head of Patient Experience Head of Patient Experience Head of Patient Experience Head of Patient Experience Governance and Quality Committee (CGQC) Governance and Quality Committee (CGQC) CGQC CGQC Governance and Quality Committee Governance Quality committee Governance and Quality Committee Governance and Quality Committee Governance and Quality Committee Governance and Quality Committee Action Plan Lead Head of Patient Experience Customer Care Secretary Customer Care Secretary Head Patient Experience Customer Care Secretary Customer Care Secretary Customer Care Secretary Customer Care Secretary Customer Care secretary Customer Care Secretary Committee/ group overseeing Action Plan Governance and Quality Committee (CGQC) Governance and Quality Committee (CGQC) Governance and Quality Committee (CGQC) Governance and Quality Committee (CGQC) Governance and Quality Committee (CGQC) Governance and Quality Committee (CGQC) Governance and Quality Committee (CGQC) Governance and Quality Committee (CGQC) Governance and Quality Committee (CGQC) Number of Audit of Annual Head of Customer complaint complaint Patient Governance Care Governance and resolution meeting Experience and Quality Secretary Quality Committee meetings dates Committee (CGQC) arranged within policy timescales Policy for the Management, Investigation and Resolution of Complaints version 5.2 Page 17 of 27

18 CHANGE CONTROL SHEET This is a Controlled Document. The definitive version is on the intranet. Printed versions should be verified as valid with the intranet version. DEVELOPMENT TEAM Name L Logan M Aubrey Job Title Interim Associate Director Patient Experience Director of Governance AMENDMENT HISTORY Revision Date of No. Issue st November 2013 Page/Section Changed Description of Change Review Date Policy for the Management, Investigation and Resolution of Complaints version 5.2 Page 18 of 27

19 DISTRIBUTION PLAN Dissemination lead: Is a previous document already being used? If yes, in what format and where? Action to retrieve out-of-date copies of the document: Actions to communicate the document contents to staff: Head of Patient Experience Yes Electronic - Trust Intranet Replace document on the Trust Intranet Policy Library Include in the UHMB Weekly News To be disseminated to: Library Service Chairperson of approving committee Divisional General Managers Divisional Nurse or AHP Divisional Director Directors All staff For Policy Library and Archive For information For action TRAINING IMPLICATIONS Is training required to be given due to the introduction of this policy? Yes Action by Action required Implementation Date The Customer Care team will work with divisions to ensure appropriate training provision is made to support staff involved in complaints handling. Consultants and front line staff to receive advisory written information. Junior doctors trained at induction and via Foundation Programme. A programme of training to be developed for Ward Managers, Matrons, Heads of Departments. Training contained in Mandatory Training Handbook 2013/2014. Policy for the Management, Investigation and Resolution of Complaints version 5.2 Page 19 of 27

20 EQUALITY & DIVERSITY IMPACT ASSESSMENT TOOL Yes/No Comments 1. Does the policy/guidance affect one group less or more favourably than another on the basis of: Race Ethnic origins (including gypsies and travellers) Nationality Gender Culture Religion or belief Sexual orientation including lesbian, gay and bisexual people Age Disability - learning disabilities, physical disability, sensory impairment and mental health problems 2. Is there any evidence that some groups are affected differently? 3. If you have identified potential discrimination are there any exceptions - valid, legal and/or justifiable? 4. Is the impact of the policy/guidance likely to be negative? No No No No No No No No No No N/A No 4.a If so can the impact be avoided? N/A 4.b What alternative are there to achieving the policy/guidance without the impact? 4.c Can we reduce the impact by taking different action? N/A N/A If you have identified a potential discriminatory impact of this procedural document, please refer it to the HR Equity & Diversity Specialist, together with any suggestions as to the action required to avoid/reduce this impact. For advice in respect of answering the above questions, please contact the HR Equity & Diversity Specialist, Extension Policy for the Management, Investigation and Resolution of Complaints version 5.2 Page 20 of 27

21 REFERENCES (Include references to all relevant Trust Policies and Guidelines) Number References 1 The Local Authority Social Services and National Health Services Complaints (England) Regulations 2009 (309) 2 Principles of Good Complaints Handling Parliamentary and Health Service Ombudsman Making amends: a consultation paper setting out proposals for reforming the approach to clinical negligence in the NHS Department of Health Being Open Policy. National Patient Safety Agency May Records Management NHS Code of Practice Department of Health The Health & Social Care (Community Health and Standards) Act Patient Safety Incident Investigation Policy 8 Freedom of Information Policy 9 Being Open Policy 10 Analysis of Claims, Complaints and Incidents Policy 11 Claims Policy 12 Supporting Staff following traumatic or stressful incidents policy 13 Whistle Blowing Policy GLOSSARY and DEFINITIONS Abbreviation or Term PALS ICAS UHMB NHS FT KPI NHS Cumbria NLPCT PHSO Definition Patient Advice and Liaison Service Independent Complaints Advocacy Service The University Hospitals of Morecambe Bay NHS Foundation Trust Key Performance Indicator NHS Cumbria North Lancashire Primary Care Trust Parliamentary & Health Service Ombudsman Policy for the Management, Investigation and Resolution of Complaints version 5.2 Page 21 of 27

22 Appendix 1 Complaints Process Actions Receipt and acknowledgement Consider whether complaint falls within jurisdiction Record/log complaint and create complaint file Acknowledge the complaint - verbally or in writing Obtain consent if appropriate Agree process with complainant investigation and timeframe for response Advise of the availability of the advocacy services Consider offering meeting Assessment Investigation Response Resolution Assess complaint including Risk Assessment Investigate with relevant staff Obtain any relevant information from other sources Collate, analyse and evaluate information Draft response Request/arrange action plan where appropriate Consider offering meeting Advise of the right to refer to the PHSO but invite to contact Trust again, in first instance. Consider further resolution if dissatisfied Offer meeting Confirm follow up action Advise of the right to refer to the PHSO Policy for the Management, Investigation and Resolution of Complaints version 5.2 Page 22 of 27

23 Policy for the Management, Investigation and Resolution of Complaints version 5.2 Page 23 of 27 Appendix 2

24 Appendix 3 Assessment and Risk Rating Initial Complaint Assessment This process will ensure that any subsequent handling and any associated investigation are proportionate to the severity of the complaint and the related risks. Figure 1 Initial Assessment Initial assessment of complaint Low level - formal complaint Medium level formal complaint High level formal complaint Type of complaint Simple, non-complex complaints Cancelled outpatient appointment/admission Waiting time Several issues relating to clinical care Complex complaint involving several divisions or more than one organisation. Issues may have been investigated as a serious untoward incident or may have the potential for a legal action. Level of investigation and response period Low level of investigation required. Response may be provided verbally or in writing by the Customer Care Team/PALS/Matron/Departmental Head, with the complainant s agreement. Response period within 35 working days from receipt of complaint by Customer Care team, or within timescale agreed with the complainant. More detailed investigation involving clinical matters. Response signed by Chief Executive Response period within 35 working days from receipt of complaint by Customer Care team or within timescale agreed with the complainant. Investigation by clinicians with option to obtain advice from Associate Medical Director/Lead Clinician. Response signed by Chief Executive Response period negotiated with complainant Risk Rating of Complaints This involves an estimate of the likelihood of the risk associated with the complaint occurring and the impact or severity if it does. An assessment of the risks attached to a particular complaint or concern will be undertaken using the Trust s Risk Matrix by mapping the likelihood of occurrence against the severity/impact to determine the risk grading/score. The Risk Matrix is contained within the Trust Risk Management Strategy. This can be used as the basis of identifying acceptable and unacceptable risk, in line with 'Listening, Acting, Improving', the guidance supporting the 2009 Regulations and NPSA advice. Policy for the Management, Investigation and Resolution of Complaints version 5.2 Page 24 of 27