POLICY AND PROCEDURE FOR MANAGING COMPLAINTS, COMMENTS, CONCERNS AND COMPLIMENTS

Transcription

1 TITLE: POLICY AND PROCEDURE FOR MANAGING COMPLAINTS, COMMENTS, CONCERNS AND COMPLIMENTS VALID FROM: January 2014 EXPIRES: January 2016 This procedural document supersedes the previous procedural document (Policy and Procedures for Managing Complaints, Comments, Concerns and Compliments December December 2013)

2 Version: 1.0 Policy reference and description of where held. Title, name and contact details for author: Responsible director: Approved by originating committee, executive or departmental management group TBC Tony Fishenden Customer Service Manager Louise Ashley, Chief Nurse & Director of Quality Governance TBC Ratified by Policy Ratification Group Review date: June 2016 Target audience: All staff working for or on behalf of the Organisation and includes those staff on honorary contracts, contractors/ agency workers and students. Page 2 of 72

3 CONTENTS: Section Page 1. Introduction 2. Aims and objectives 3. Definitions (explanation) of terms used. 4. Duties 5. Managing Complaints, Comments, Concerns and Compliments 6. Consultation 7. Approval and ratification process 8. Dissemination and implementation 9. Archiving 10. Training 11. Monitoring and auditing compliance with this procedural document 12. Review arrangements 13. Associated documentation 14. References 15 Appendices Appendix A Appendix B Appendix C Monitoring and compliance tool Equality Impact Assessment Management of complaints flow chart Appendix D Management of complaints for partner organizations flowchart Appendix E Management of complaints for partner organizations where CLHC is not the lead partner Appendix F Complaint investigation report form Appendix G Guidance for staff writing a statement Appendix H Guidance for meetings with complainants Appendix I Appendix J Appendix K Appendix L Acknowledgement letter template Letter of findings template Management of compliments flow chart Unreasonable and persistent complainants Page 3 of 72

4 Section Page 15. Appendices contd. Appendix M Consent / Authority form Appendix N Customer Service Feedback Appendix O Customer Service Feedback Easy read leaflet Appendix P Appendix Q Appendix R Customer Service Satisfaction Questionnaire Equality monitoring form Complaint Severity Assessment Matrix Page 4 of 72

5 1. Introduction This Policy is Trust-wide, and integrates the capturing of comments, concerns and compliments as well as the formal complaints process. Central London Community Healthcare NHS Trust (CLCH) has a responsibility to ensure that users of the services provided by the Trust have easy access to information about how to raise a concern or make a complaint and that the issues are responded to promptly, fairly and justly without prejudice to the care and treatment of the service user. CLCH accepts that in a service as large and complex as the NHS, things will sometimes go wrong. When they do, the response should not be one of blame and retribution, but of learning, a drive to reduce risk for future patients, and concern for staff who may suffer as a consequence. CLCH promotes good complaint handling because it is an important way of ensuring customers receive the service they are entitled to expect. CLCH also understand that complaints are a valuable source of feedback, provide an audit trail and can be an early warning of trends in failures of service delivery. CLCH is also aware that prompt and efficient complaints handling can also save time and money by preventing a complaint from escalating unnecessarily. 2. Aims and Objectives CLCH believes everyone has the right to expect a good service and to have things put right if they go wrong. When they do, CLCH aims to manage complaints properly so customers concerns are dealt with appropriately and without unnecessary delay. Specifically this policy aims to Set forth CLCH s approach to receiving, acknowledging, investigating and closing complaints received from the users of CLCH services. Describe the support provided to complainants. The policy also aims to ensure that the complaints procedure can be accessed on a fair and equal basis by all patients and carers regardless of their race, language, culture, disability, religion or belief, age, gender, sexual orientation or marital status. The policy aims to ensure that any barriers faced by complainants are minimized when using the complaints process. The policy aims to ensure that CLCH, as a provider of health services, manages complaints in accordance with both the NHS Complaints Procedure 2000 and the NHS Constitution (See also paragraph 14 references). This explains how patients or service users when making a complaint, have the following rights: Page 5 of 72

6 o o o o o o to have their complaint acknowledged and properly investigated to discuss the manner in which the complaint is to be handled and know the period of when the complaint response will be sent to be kept informed of the progress and to know the outcome including an explanation of the conclusions and confirmation that any action needed has been taken on to take their complaint to the independent Parliamentary and Health Service Ombudsman if they are not satisfied with the way the NHS has dealt with their complaint to make a claim for judicial review if they believe they have been directly affected by an unlawful act or decision of an NHS body to receive compensation if they have been harmed by negligent treatment 3. Definitions of any terms used Complaint: A complaint is defined as an expression of dissatisfaction received verbally or in writing that requires a response. All complaints require Investigating, requiring someone to explore the situation on behalf of the complainant and responded to. CLCH will seek to distinguish between requests for assistance in resolving a concern or problem and an actual complaint. All issues will be dealt with in a flexible manner, which is appropriate to their nature. Whenever there is a specific statement of intent on the part of the caller/correspondent that they wish their concerns to be dealt with as a complaint, they will be treated as such. Concerns: These are issues that are of interest or importance affecting the person raising them. Concerns will be registered locally but will not require a full investigation because the issues can be resolved quickly either via clarification with the person (such as meeting talking or explaining) or by immediate action (offering alternative appointments, agreeing further action). It is not intended that every minor concern should warrant a full-scale complaints investigation. The spirit of the complaints procedure is that front-line staff are empowered to resolve minor problems and queries immediately and informally whenever this is possible. Any person, who is dissatisfied with the preliminary response to a matter which has been dealt with outside of the complaints process, will be advised of their right to pursue the matter through the complaints procedure and offered support through independent advocacy. In the following circumstances, concerns received by staff must be passed within 1 working day to the Customer Service Team for the opportunity to make the matter a formal complaint: Page 6 of 72

7 If the person who has raised the issue verbally requests their complaint to be treated formally. Concerns received in writing which expressly state that they wish to complain or make a complaint Concerns that are risk graded as moderate or higher Concerns that require a written response. If it is unclear whether the issue is a complaint or not advice, must be sought from the Customer Service Team to establish this with the service user or their representative. Compliments: These are where positive feedback has been received about HRCH services. CLIPS group: Complaints, Litigation, Incidents, PALS, Serious Incidents meeting. 4 Duties 4.1 All staff working for/ on behalf of CLCH have the following responsibilities for ensuring that: As highlighted in Legislation, Professional Codes of Conduct and the Organisation s Whistle Blowing Policy, all staff have a duty to report complaints & co-operate in investigative processes. To be aware of the requirements of this policy and can understand its requirements. Staff must consult their line manager if they have difficulty following this guidance or have concerns about their ability to report and/ or co-operate with the complaints process. Where any doubt exists about what constitutes a complaint, staff are encouraged to contact the Customer Service team. They try to deal with minor complaints or concerns they may receive locally, where practical and if skilled to do so. A member of staff who is unsure of how to respond to a complaint should immediately seek help from their line manager or the Customer Service Team. In line with statutory & professional responsibilities, co-operate with complaint investigation processes. These duties also extend to the timely and appropriate writing of investigation reports and raising of risks to CLCH s risk registers for monitoring progress towards minimisation. Staff based within external organisations but employed or working on behalf of CLCH have a duty to comply with the complaints processes of the host organisation. If staff employed under these conditions do not have access to the Datix system, then details of the complaint must also Page 7 of 72

8 be reported to CLCH by or by telephone to the Customer Service Team for capture on Datix system. Any staff who require clarification of this condition must contact the Customer Service Team. 4.2 All Managers Managers have the following responsibilities for ensuring that: Reporting Investigating They are aware of the requirements of this policy and can understand their role in identifying, reporting, investigating & following- up complaints. All complaints received within services are reported via the Datix system to the Customer Service Team. Conduct a thorough investigation of the complaint. Complete the investigation within the agreed timescale. Produce an investigation report. Ensure the outcome of the investigation highlights any learning as a result of the complaint and improvement actions required as a result of the complaint. Required changes to practice will be identified and actioned within a specific time frame. A lead member of the team will be identified to take each change forward where appropriate. Lessons will be shared with all the relevant stakeholders. Manage implementation of any improvement actions resulting from learning, and provide timely feedback to the service and the Customer Service Team. Organise a deputy when unavailable Communicating The employing agency is informed of complaints involving temporary workers at the time of complaint identification. All relevant leads associated with the complaint are informed. The Customer Service Manager is kept informed of investigation progress. The results of risk assessments is communicated to all those who may be at risk in line with the Organisations Risk Management Strategy. The complainant must be kept informed about progress and, where appropriate, a written response sent by the manager explaining the Page 8 of 72

9 Supporting staff outcome and including any necessary remedial action taken as a result of the complaint. The Organisation recognises that staff may be adversely affected by complaints- regardless of their involvement in the event or the risk grading/ severity. Staff experiencing distress are encouraged to discuss their concerns with line managers, the occupational health team and counselling services provided by CLCH. Discussions with the above groups will be held in confidence. Incident management debriefings/ supervision may also be provided by the Organisation s specialist staff. When a complaint is graded as moderate or above and involves members of staff, support should be provided to the staff concerned by Human Resources and the investigating managers. Ensure that staff are adequately trained, supervised and supported to deal with complaints effectively. The investigating manager will ensure that witness statements/ statements of involvement are obtained from staff involved or witness to accidents/ incidents. The investigating manager will ensure feedback is provided to staff involved in complaints. The incident reporter and Customer Service Team are kept informed of any progress. Managing Risk All documents are managed in accordance with the Organisation s Records Management Policy and Clinical Record Keeping Standards. All relevant actions are undertaken following the complaint. Identified risks are added to the relevant risk registers in line with the CLCH Risk Management Policy 4.3 Customer Services Team Complaints and concerns can also be established through the Customer Service Team. Its responsibilities include: Helping resolve concerns or problems when using the NHS Providing information about the NHS complaints procedure and how to get independent help if it is decided to make a complaint Page 9 of 72

10 Providing information and help introduce agencies and support groups outside the NHS Improve the our services by listening to complaints, concerns, suggestions and experiences and ensuring that people who design and manage services are aware of the issues raised Provide an early warning system for the Trust and monitoring bodies by identifying problems or gaps in services and reporting the Provide advice, training and support to individuals or teams as required. 4.4 The Customer Service Manager Is accountable to the Head of Patient and Public Engagement and is responsible for the day to day management and facilitation of the complaints service. The Customer Service Manager is also responsible for providing statistical information on trends and types of complaints for submission to the appropriate committee or group to assist in the decision making process. The Customer Service Manager will: Monitor and supervise the informal process of responding to concerns and any low risk-grade complaints that the enquirer agrees can be resolved through this route. Line manage the Customer Service Team to ensure the service is identifiable and accessible, providing information, advice and a first point of contact for those who have queries about or are unhappy and wish to raise concerns and complaints about Trust services. Provide training, support and advice to staff regarding the process for the investigation and management of concerns or complaints. Ensure feedback is provided to staff involved in complaints Ensure that on-the-spot help is provided to service users and, where possible, will negotiate immediate solutions or speedy resolution of problems where possible so that concerns do not escalate Identify those issues that require a formal complaint investigation and comply with the complaints procedure (unless the person raising the concern explicitly requests that they do not do so) Ensure service users are sign-posted to appropriate independent advice and advocacy support from local and national sources Be mindful of the need to offer complainants any additional support or reasonable adjustments to meet disability-related or other support needs and to deal with any barriers arising from language or culture Page 10 of 72

11 Produce data for reports as required helping identify trends from complaints, comments, concerns and feedback. Ensure that the Customer Service Team assist the Learning and Development team on complaints training for staff and lead on staff inductions. 4.5 Customer Service Officer The Customer Service Officer is accountable to the Customer Service Manager. Their role is to provide advice, support and information to users of the service. They help to resolve any concerns about Trust services where appropriate. They provide information and support to those who need help to make a formal complaint. The Customer Service Officer duties are:. To receive, log and respond to complaints, comments, concerns and compliments about Trust services. To facilitate the speedy resolution of concerns by listening, providing information, liaising and negotiating with staff colleagues as appropriate. To identify issues requiring a formal investigation and support service users to access the formal complaint process (unless they explicitly request that they do not wish to make a formal complaint). To provide information to patients in alternative formats as required; including an easy-read guide for people with learning disabilities and in other formats/languages as appropriate 4.6 Directors and Associate Directors Directorate leads have the following responsibilities: For ensuring the timely and effective investigation and resolution of complaints that fall within their areas of responsibility and for ensuring that the procedures outlined in this policy are followed within their directorate. Making suitable arrangements to assure both the investigation process and the outcome, and approve the directorate report provided to the Customer Service Manager. 4.7 Chief Nurse and Director of Quality Governance The Chief Nurse and Director of Quality Governance is charged with overseeing the Trust s systems for quality, safety & effectiveness and is responsible for reviewing and approving the investigation and final response letter prior to sign off by the Chief Executive. Page 11 of 72

12 4.8 Medical Director The Medical Director will review and approve those investigations and final response letters where the complaint is regarding clinical treatment and/or involve a medical doctor prior to sign off by the Chief Executive. 4.9 Chief Executive The Chief Executive retains accountability of the quality, safety & effectiveness of services provided on behalf of CLCH to staff and service users and is responsible for ensuring that: This policy is implemented within CLCH Reviewing & signing the final response letter wherever possible CLCH Board The Board has a duty to ensure that the requirements of the complaints policy are upheld. The Board will receive a complaints report at least quarterly. The Board will also receive the annual complaints report that the Trust is required to prepare in accordance with Regulation 18 of the Local Authority Social Services and National Health Service Complaints Regulations CLIPS (Complaints, Litigation, Incidents, PALS and Serious Incidents) Group The CLIPS Group has been established to provide a dedicated forum for CLCH to share lessons learned following investigation into all significant complaints, legal claims, adverse incidents, near misses or PALS concerns arising from the activities of CLCH and partnerships, thereby improving risk management and service delivery 4.12 Quality Committee The Quality Committee will be provided with the annual complaint report prior to its submission to the Trust Board. Page 12 of 72

13 5. Management of Complaints, Comments, Concerns & Compliments. A. Complaints 5.1 Who can complain? A complaint may be made by a service user or any person affected by or likely to be affected by the action, omission or decision of the NHS body, independent provider or local authority that is the subject of the complaint. Complaints can be made by health care and social care professionals on behalf of patients, their carers and relatives. Someone acting on behalf of another person may make a complaint where that person is unable to make the complaint herself/himself or has asked the person to make the complaint on her/his behalf. Where people are unable to make a complaint themselves, the representative will need to have or have had sufficient interest in their welfare, and be an appropriate person to act on their behalf. A complaint may be made by a person acting on behalf of a person as described above where that person: Has died Is a child Is unable by reason of physical or mental incapacity to make the complaint Has requested that a representative act on his/her behalf. 5.2 How a complaint can be made Complaints can be made to any employee of CLCH, or to any member of staff who provides a service commissioned by CLCH. Complaints can be via a third party. For example there are a number of independent groups and bodies that can provide helpful advice and support to a complainant, dependent upon their individual needs. Complaints can be made verbally or in writing (including electronic means such fax, , telephone or via the CLCH website). Complaints may also be received via Customer Service Feedback Forms which are widely available at Trust sites. All complaints will be forwarded to Customer Service Manager. In accordance with regulations, complaints made by other health and social care professionals (from a responsible body, commissioners, a local authority, NHS body, primary care provider or independent provider) falls outside of the NHS complaints procedure. The Customer Service team will help to produce any written responses to external organisations as necessary. These complaints will be recorded and Page 13 of 72

14 investigated in the same way as a formal complaint but logged as an Organisation or Commissioner complaint as appropriate. 5.3 Exceptions to the complaints process A definition of what is excluded from this policy is set out in the Statutory Instrument 2009 No. 309 The Local Authority Social Services & National Health Services Complaints (England) Regulations. In summary these include: Complaints or concerns raised verbally which are resolved to the satisfaction of the person who has raised the issue within one working day after the complaint or concern was made Complaints which have been previously investigated under this or previous NHS complaints regulations A complaint by an employee relating to their employment. Employees should follow guidance given by the CLCH Grievance Procedure NHS and Provider professionals wishing to make a complaint about care provision in general should refer to the CLCH Raising Concerns at Work policy, which is available online through the organisation s intranet site or the relevant HR department A complaint made by a responsible body such as commissioners, an NHS employee or partner organisation about another NHS employee or partner organisation. A complaint made by a Local Commissioner under the Local Government Act 1974 (a) or a Health Service Commissioner under the 1993 Act Complaints about Freedom of Information Requests and Access to Information Requests. These should be directed to the Freedom of Information Policy. A complaint that is being investigated by the Health Ombudsman Should there be any doubt about whether a complaint will prejudice any other formal proceedings then the person who has received the complaint should immediately pass the relevant information to the Customer Service Manager, who will then make a decision with regard to when to initiate any action by taking appropriate professional advice. If a complaint does include in part any of the exceptions noted above during any stage of the Complaints Procedure, this should not delay any investigation of unrelated issues raised within the complaint Page 14 of 72

15 5.4 Procedure to ensure that complainants are not treated differently as a result of their complaint CLCH is committed to ensuring that people are not treated differently as a result of making a complaint. Complainants must not be discriminated against because they have made a complaint about any service commissioned / provided by CLCH. As such, documentation regarding a complaint will be held separately from the patient s medical records, and only those staff participating in the investigation will be party to the full details. If there is evidence that someone has been treated differently by staff as a result of raising a complaint, this will be discussed with Human Resources for action to be taken as appropriate. Additional controls to ensure people are not treated any differently as a result of making a complaint include: Ensuring that individuals can raise concerns anonymously if they wish, via the Customer Service Team Ensuring that investigations are standardised across CLCH with procedures in place that comply with external standards. Ensure any documentation relating to investigations regarding concerns/complaints are not filed within the service users health records. If an individual does report that they have been treated differently as a result of raising a concern or registering a formal complaint, this would be investigated. 5.5 Types of Complaints 5.6 Informal complaints (Comments and Concerns) Service users often raise issues about which they are unhappy, without wishing to make a formal complaint. In many instances, they will simply be concerned and wish to receive an explanation and if something has gone wrong an apology. As these suggestions may be made to any member of staff, it is important that all staff are trained to welcome patient's views and see them as an opportunity to improve their local service. This training is provided through the Trust s induction process and bespoke customer service training. Expressions of concerns and comments are to be passed to the Customer Service Team who will record and investigate as necessary. If a concern is not resolved to the satisfaction of the person concerned they should be given the opportunity to make the matter a formal complaint. Expressions of concern and comments which are of medium of high risk, or require a written response, must be referred to the Customer Service Team. Page 15 of 72

16 5.7 Anonymous Complaints Complaints made anonymously fall outside the scope of this process. However, wherever possible, these types of complaints will be recorded, reviewed and investigated as appropriate. 5.8 Bereavement complaints Wherever possible a meeting will take place between CLCH and the complainant in order to take a detailed history, record the issues raised and ascertain how they wish the complaint to be handled. Attendance by the Service Associate Director, Chief Nurse and Director of Quality Governance, Chief or Deputy Chief Executive (Operations) may be appropriate in certain circumstances. 5.9 Commissioner complaints The commissioners of CLCH services reserve the right to investigate complaints received by them about provider services. Complaints arising from CSU/CCGs or other NHS Groups on behalf of a patient will be recorded and tracked by the Customer Service Team as described in the complaints process and within CLCH corporate mechanisms Offender Complaints Healthcare services at HMP Wormwood Scrubs are provided by CLCH. Complaints from prisoners about healthcare are dealt with initially through the Prison Service s local complaints procedure. If dissatisfied with the outcome of this first stage the complaint can be passed CLCH for investigation Other complaints Where complaints involve, or may need to be referred to, external bodies such as the Police or other organisations, advice should be sought from the Chief Nurse and Director of Quality Governance Counsellor complaints If a counsellor is acting on behalf of a patient, then consent must be obtained from the patient. Information must not be disclosed without the permission of the patient. If the counsellor has obtained this consent, they must provide evidence of this. When the consent form is received careful note must be made as to where the service user would like the response to be sent to. All complaints and concerns raised by are to be forwarded to the Chief Executive CLCH Complaints regarding safeguarding or an incident An incident is any event that has, or may have, impacted upon the safety of patients, staff, and delivery of service or health improvement. Incidents include hazards, accidents, dangerous occurrences, significant events and near misses. For an explanation of these terms please the Incident Reporting and management Policy. Page 16 of 72

17 If an incident is identified in the complaint it must be reported it via the incident reporting module on Datix. Serious incidents, must be escalated to the divisional senior management team and a senior member of the Quality and Assurance Team (or its successor team). The reporter will be notified as to whether or this will be progressed as a complaint, or whether it will be removed from the complaint process and managed through the incidents process. If a there is an urgent concern about a child or an adult at risk of harm should be acted on immediately to protect the person at risk, by calling the relevant CLCH safeguarding lead during business hours. The CLCH on-call staff must be notified after hours.if there is no risk of immediate harm, discuss your concerns with a line manager or the Trust s safeguarding lead or advisor at the time of identification Joint organisation and partner complaints When a complaint is received by CLCH which also involves services provided by another organisation we will work together with them to provide a seamless complaints process for the complainant and not to create additional burden. When a complaint is regarding the services of different organisations not in a partnership, CLCH will: Contact the complainant to discuss and agree how the complaint will be managed and obtain appropriate consent for information sharing. Liaise with the other organisations to agree who will lead on the complaint and co-ordinate a response. Ensure that a single response is provided if this is requested by the complainant. Where a complaint is made regarding a service provided in partnership with CLCH the investigation will be led by the lead organisation. Where a complaint is made to CLCH that relates entirely to another organisation or local authority CLCH complaints will: Liaise with the complainant to determine whether they want the complaint be sent to the local authority to which it relates and If the complainant consents to this, send that material to that local authority as soon as is reasonably practicable Consent 5.16 Complaints made by the service user If the complainant is the service user, consent to investigate their complaint is not normally required unless the investigation requires their personal information to be shared with or requested from other organisations outside CLCH. Page 17 of 72

18 In these circumstances the complainant will be informed that investigation of their complaint may require sharing of information with other organisations and that their consent is required. Consent is assumed for investigations involving only clerical and clinical staff within CLCH. Should they not consent to this then an explanation of the limits this may put on the ability to fully investigate their complaint will be given. For example, by not being able to share their personal details may mean it is not possible to identify the staff involved in their complaint Complaints made by a third person Another person can pursue the complaint on behalf of the service user. In order to do this the written consent of the service user must be sought and received on whose behalf a complaint has been made before any confidential information can be disclosed to them. This includes next of kin, relative, friend, carer, counsellor, advocate or solicitor or other persons claiming to represent a service user. (Please also see Appendix M the consent form) 5.18 Complaints made by a child In the case of a child (under 16), a parent or guardian may make the complaint. However in some cases it may be appropriate to obtain consent from a child if that child is considered to be capable of understanding the situation and can give informed consent. The decision as to whether he/she is capable will need to be assessed on an individual basis and in line with CLCH policy. Children who received NHS treatment have the right to make a complaint in their own right and have the right to use the NHS complaints process. If the service user is a minor and unable to give consent the complaint should be discussed with the organisations Caldecott Guardian Complaints made by MPs on behalf of their constituents If a patient has visited an MP in their surgery or written to them requesting their representation in making a complaint or raising a concern, consent is not required (Statutory Instrument 2002 No 2905). If the MP states that they have received their constituent s permission then it should be assumed to be the case and the complaint investigated as per normal. Information should only be disclosed on a need to know basis. Nothing more than the relevant information pertaining to a complaint should be given in the final response. All complaints and concerns raised by MPs are to be forwarded to the Chief Executive of CLCH Third party complaints made by MPs on behalf of their constituents If an MP is representing a constituent who is acting on behalf of a patient, then consent must be obtained from the patient. Information must not be disclosed without the permission of the patient. If the MP has obtained this consent, then the MP must Page 18 of 72

19 provide evidence of this. When the consent form is received careful note must be made as to where the service user would like the response to be sent to Complaints in respect of a deceased service user If the service user has died then information can only be released to a patient s personal representative and any person who may have a claim arising out of that patient s death. A personal representative is the executor or administrator of the deceased person s estate. If the person making the complaint cannot provide required proofs they will be notified in writing stating the reasons for this decision. A list of requirements is provided in Appendix M Consent/Authority Form Capacity issues If there are concerns about whether the service user has capacity to consent (i.e. if the service user is too ill or otherwise incapacitated) this matter should be discussed with the organisations Caldicott Guardian and guidance taken from the Senior Manager for Primary Care Mental Health. If the service believes that the person making the complaint does not have sufficient interest in the person s welfare, or is not suitable to act as a representative, then the person will be notified in writing stating the reasons for this decision. An example of the above could be where the case relates to a Protection of Vulnerable Adult Circumstances where consent is not required There may be circumstances where service user consent is not required to pass on information, for example: When not revealing such information would be breaking the law. When the service user reveals any matter which CLCH considers may constitute a criminal offence. Where there is clear indication that a serious crime has been or is about to be committed. Where there is a risk of harm to an individual or themselves. Information is requested by H.M. Coroner, a court or a tribunal. There are reasonable grounds to suspect abuse of a child or vulnerable adult Commencement of investigations without consent To assist in the speed of resolution of a complaint, investigations may commence for those aspects of the complaint which do not require the divulging of confidential information. Refer also to the CLCH Consent to Treatment or Examination Policy Page 19 of 72

20 5.25 Screening of complaints The list below covers those topics which may highlight any potential safety issues for service users. These are individually annotated below. Where complaints contain these topics which have their own policy and procedures, the responsible departments must also be made aware of the complaint directly. Incidents see Incident Reporting and Management Policy Clinical risks see Incident Reporting and Serious Incident Policy Safeguarding Adults and Children see Safeguarding Adults and Children Policy Deprivation of Liberties see Deprivation of Liberty Policy Fitness to Practice see Fitness to Practice Policy Human Rights and Discrimination Policy Claims Policy All complaints will be assessed upon receipt by the Customer Service Team. Complaints will also be cross referenced via the Datix system to check for any associated incidents When should complaints be investigated? It is important that complaints are made as soon as possible after the event has occurred. Usually, complaints can only be investigated if they are: Made within 12 months of the event; or Made within 12 months of the date on which the matter which is the subject of the complainant came to the notice of the complainant. If a complaint is made after the 12 months timescale, CLCH may investigate at the discretion of the Customer Service Manager where the complainant had good reasons for not making a complaint within that period; it is still possible to investigate the complaint effectively and efficiently Process for investigation of formal complaints and timescales (First Stage) All complaints received must be sent to the Customer Service Team within one working day; this should be done by scanning and sending by secure to facilitate same-day receipt. Receipt must be confirmed. A verbal or written acknowledgement to the complainant will be made by the Customer Services Team no later than 3 working days from the day the complaint was received. (An example template is attached at appendix J). The acknowledgement must include the following information: Page 20 of 72

21 An apology Clarification of all the issues to be investigated. Offer a meeting to discuss concerns. Agree the type of response required (writing, meeting, phone, or ) Agree customer s desired outcomes Will advise of their right to independent support e.g. an advocate or interpreter. Advise who will carry out the investigation, and Agree timescales for the final response If the complaint was made verbally, the complainant must be asked if they require a written summary to be sent to them together with an invitation to agree or amend the information. If a telephone number has not been provided the complainant will be sent a brief acknowledgement letter, within 3 working days, asking them to contact the Customer Service Team to discuss their complaint in more detail. The letter will also advise that if no contact is made the Trust will assume they wish for their complaint to be responded to in writing, unless their complaint advised differently Assessment of seriousness of complaint: Correct assessment of the seriousness of a complaint will ensure that the right course of action can be taken. Each complaint will be reviewed by the Customer Service team according to the assessment matrix which can be found in Appendix R. The complaint will also be reviewed following the outcome of the investigation and re graded if appropriate. The assessment grading will be recorded on the Complaint Resolution Investigation Report (Template at appendix F) Complaints graded as moderate or above: If a complaint is graded moderately or above then the investigation should involve senior staff from within the division. If it involves members of staff, support should be provided to the staff concerned by Human Resources as well as the investigating managers 5.30 Complaint Investigation The appropriate Service Manager is responsible for investigating the complaint, together with support and guidance available from the Customer Service Manager. The Complaint Resolution Investigation report can be found at appendix F. The template will contain all of the information required which will then be shared with the relevant Division for dissemination to staff who are tasked with investigating the complaint. Page 21 of 72

22 If the service is unable to meet the report completion deadline please inform the Customer Service team as soon as you are aware and no later than 3 working days before the deadline date if possible. The staff directly involved in the complaint will not be nominated to investigate the complaint although if required they will be approached to provide a statement in relation to the complaint. (Guidance is provided at appendix G) The complaint investigation will include some or all of the following actions: requests for statements from staff analysis of the relevant health records staff interviews root cause analysis impartial advice or opinion from other Trust staff that are independent of the clinical team providing the care complained about Complaints graded as high or above: These complaints will be investigated using the Root Cause Analysis (RCA) method level 2/3. They will also be shared with the relevant Directorate Lead, Medical Director and Chief Nurse and Director of Quality Governance Investigation timescales: The following timetable gives suggested timescales and guidance for investigation completion times: Table 1: Timescales and guidance on complaint investigation and response times Category Assessment level Indicative investigation time (working days) Response time to complainant (working days) PALS enquiry Low/ Medium High Very Low Risk and/ or straightforward resolution An investigation will usually be led by the Line Manager and, where appropriate, in conjunction with the relevant Clinical Lead. May involve one or more services/ organisation, requiring, more in depth investigation and will be overseen by a Service Head of Service or Service Manager/ Director. Highly complex and sensitive complaints. Most likely involve two or more organisations and will require in depth investigation overseen by a Service Director. Such complaints will normally be an integral part of an incident and a full RCA investigation would take place. Up to 5 Up to 10 Up to 60 5 (1 week) 25 (5 weeks) 75 (15 weeks) Page 22 of 72

23 5.33 Response timescales: The Health and Local Authority Adult Social Care Complaints Regulations 2009 require that it is agreed with the complainant a timeframe within which the investigation of the complaint is likely to be completed. Although the legislation allows the response time to be flexible, CLCH aims to provide a response in as timely a manner as possible setting an internal benchmark of 25 working days for low to medium risk graded complaints. The 25 day deadline will commence from the date the complaint is received by the service or any employee of the Trust. Those complaints made on behalf of a patient which require their consent to be investigated, the 25 day deadline will commence from the date the consent is received. Within this timeframe, 5 days is allowed for from the Customer Service Team receiving the investigation report and obtaining approval of the draft response from the service. A further 7 days allowed for the Chief Nurse or the Medical Director for approval and being signed by the Chief Executive or nominated deputy. Once the investigation has been completed a review of all moderate to high complaints will be analysed by the service. If a complaint theme is occurring frequently the Customer Service Manager may review and inform the CLIPS Group Conduct of investigations Investigations will employ the National Patient Safety Agency s (NPSA) best practice on conducting investigations using Root Cause Analysis (RCA) methodologies to include: Care and service delivery problems: Contributory factors Root causes Lessons learned Recommendations Arrangements for shared learning These are also referred to at appendix F. Further detailed information on RCA investigations can also be found at the following link: Page 23 of 72

24 5.35 Independent investigations An independent investigation may be carried out in agreement with the Chief Nurse, Senior Managers and the complainant in circumstances where, for example: A complaint amounts to an allegation of a serious incident; Subject matter involving clinically related issues is not capable of resolution without an expert clinical opinion; A complaint raises substantive issues of professional misconduct or the performance of senior managers. A complaint involves issues about the nature and extent of the services commissioned. The Chief Nurse will appoint an Independent Investigator, who will take on the role of Investigating Manager who will lead the investigation and prepare a written report for adjudication by a senior manager Responding to complainants At the conclusion of the investigation, a Letter of findings response will be prepared by the Customer Service Team and passed to the Chief Nurse, or the Medical Director regarding clinical treatment and/or involve a medical doctor, for approval prior to being signed by the Chief Executive or nominated deputy. (The letter of findings template can be found at appendix J). The response will include: A detailed explanation, in light of the investigation findings, regarding the questions raised in the complaint from the service involved. An apology. Conclusions reached in relation to the complaint including remedial action and lessons learned. Information on how complainants can proceed if they are not satisfied with the reply, and will specifically mention the complainant s right to refer the complaint to the Health Service Ombudsman. A copy of the Customer Satisfaction Questionnaire for the complainant to complete. The outcomes of the complaint must also be recorded in the Complaints Database as either being Upheld, Partially Upheld or not Upheld as required by NHS Information Centre for Health K041a submission. This is an annual mandatory collection of complaints made by (or on behalf of) patients. Page 24 of 72

25 If the investigation s findings agree with the customer s complaint it is upheld. If the investigation s findings disagree with the customer s complaint it is not upheld. If the investigation s findings agree with some parts of the customer s complaint it is partly upheld. Where appropriate all action plans and learning will be evidenced and tracked by the Division involved. Where a complainant is dissatisfied with the outcome of an investigation, and response, the customer service manager will take such further reasonable steps to provide a local resolution to the complaint, and will consider whether it would be appropriate to undertake further investigation. Complainants not satisfied with the outcome have the right to refer their complaint to the Health Service Ombudsman Meeting with complainants Misunderstandings and miscommunication is often the root cause of most complaints. Meetings can therefore be a good way of resolving complaints. If a meeting is to take place with the complainant and their representatives, CLCH staff should refer to Appendix G Guidance for meeting with a complainant. CLCH follows the Department of Health principles of Being Open and endeavour to include service user, family or carers in setting the scope of any investigation and the investigation itself if appropriate. The organisation will give consideration to the provision of information and support to service users, relatives & carers and staff involved in the complaint in accordance with the Being Open policy Mediation and Conciliation Independent mediation and conciliation arrangements can be made available on a case-by-case basis. The Head of Patient and Public Engagement (or their successor) will review requests made to access these services and approve funding for independent mediation and conciliation services when appropriate Disciplinary procedure The complaints procedure will be kept separate from the staff disciplinary procedure. The purpose of the investigation carried out under the complaints procedure is to resolve complaints and not apportion blame or to make recommendations regarding disciplinary action against members of staff. In the event of a complaint being received that involves serious allegations of misconduct about a member (s) of staff warranting a management investigation, Page 25 of 72

26 involvement of a professional regulatory body or a criminal investigation, the Customer Service Manager should immediately inform the HR Manager and the relevant Service Director. If a formal management investigation is initiated and, in particular, in these circumstances if instigation of the disciplinary procedure is required, there is a need to balance obligations relating to confidentiality of staff with reassuring the complainant. It will be explained to the complainant that details of any subsequent disciplinary action against members of staff cannot be divulged but that they will receive an appropriate explanation, apology and any action take to prevent recurrence Re-opended Complaints If the complainant is not satisfied with the response their remaining concerns will be passed to the service for a response. The Deputy Chief Nurse and /or the Medical Director as required will also be consulted for a decision as to whether the further reponse from the Trust can be issued by the service or if the response is to be escalated to Director level Withdrawn Complaints Where a complainant requests that a formal complaint to be withdrawn, CLCH will record the complaint and will undertake a review as per normal procedure if there is sufficient information to do this. This is so that issues can still be captured and any 5.42 Duty of confidentiality Care must be taken at all times throughout the complaints procedure, to ensure that any information disclosed about the service user is confined to that which is relevant to the investigation of the complaint. Information will only be disclosed to those people who have a demonstrable need to know it for the purpose of investigating the complaint or ensuring that the complaints procedure is followed. It is good practice to explain to the service user or complainant that information from his/her health records may need to be disclosed to staff involved in managing the complaint including the Ombudsman should it be required. If the service user objects to this then the effect on the investigation will be explained learning identified Parliamentary and Health Service Ombudsman (PHSO) When complainants are not satisfied with the final response from CLCH they have the right to refer their complaint to the PHSO. CLCH will always proactively advise complainants of this right and provide them with the necessary contact details. CLCH will co-operate in full with any requests made by the PHSO. Recommendations received from the PHSO will be recorded by the Customer Service Manager and the Chief Executive s Office and then provided in full to the relevant directorate or service provider for implementation. Where recommendations Page 26 of 72