Policy for the Management of Complaints/Concerns

Transcription

1 Document Title Policy for the Management of Complaints/Concerns Document Description Document Type Policy Service Application Trust Wide Version 1.0 Name Dawn Clift Phao Hewitson Garry Perry Lead Author(s) Job Title Director of Governance and Trust Secretary Head of Governance Patient Safety and Patient Relations Patient Relations Manager Change History Version Date Comments 0.1 May 2012 Draft Policy - Update to reflect merged organisation Walsall Healthcare NHS Trust. 0.2 May 2012 Draft Policy Amendments following consultation 1.0 June 2012 Draft Policy Amendments following consultation Supersedes the following policies: November 2010 Links with External Standards The Local Authority Social Services and National Health Service Complaints (England)Regulations 2009 NHSLA Acute Trust Standards Management of Complaints and Concerns Walsall Hospitals NHS Trust Key Dates DATE Ratification Date Trust Management Board 17 th July 2012 Minute Number 214/12 Review Date July

2 Document Title: Executive Summary Sheet Policy for the Management of Complaints/Concerns Please Tick ( ) as appropriate This is a new document within the Trust This is a revised document within the Trust What is the purpose of this document? The Local Authority Social Services and National Health Service Complaints (England) Regulations 2009 came into force on 1 April Every health service user, relative or carer, has the right to bring to the attention of Walsall Healthcare NHS Trust any aspects of a patient s care and treatment, about which they are dissatisfied. All staff must be aware of an individual s right to comment on the standards and quality of services provided by the Trust. Ideally, frontline staff must try to resolve all concerns and issues brought to their attention immediately to avoid escalation and further distress for patients, their relatives and carers. Patients, relatives and carers must be encouraged by staff to speak openly about any concerns they have or if they wish to make a complaint. What key Issues does this document explore? The Complaints/Concerns Policy will enable the Trust to: ensure fairness to complainants and staff learn from experience listen to and use patients and users views to improve services Who is this document aimed at? All staff working within Walsall Healthcare NHS Trust. What other policies, guidance and directives should this document be read in conjunction with? Incident Reporting Policy Root Cause Analysis Policy Claims Handling Policy How and when will this document be reviewed? This policy will be subject to review every three years by the Director of Governance, or nominated deputy. If any legislation / changes in practice occur prior to this review, the policy will be subject to a minor review to ensure compliance with the latest legislation / best practice. 2

3 CONTRIBUTION LIST Key individuals involved in developing the document Name Garry Perry Phao Hewitson Dawn Clift Designation Patient Relations Manager Head of Governance Patient Safety and Relations Director of Governance and Trust Secretary Circulated to the following for consultation Name / Committee / Group Walsall Healthcare NHS Trust web forum Policies and Procedures Group Divisional Quality Boards Version Control Summary Significant or Substantive Changes from Previous Version A new version number will be allocated for every review even if the review brought about no changes. This will ensure that the process of reviewing the document has been tracked. The comments on changes should summarise the main areas/reasons for change. When a document is reviewed the changes should use the tracking tool in order to clearly show areas of change for the consultation process. Version Date Comments on Changes Author 0.1 Apr 12 Draft Policy Developed 0.2 May 12 Amendments following consultation 3

4 Document Index Pg No 1.0 Introduction Scope Statement of Intent Procedure Roles and Responsibilities Monitoring, Control and Audit Arrangements Training Definitions Legal and Professional Issues References Related Policies 22 Appendices Pg No 1 Complaints Investigation Toolkit 23 2 CLIPs Report Template 41 4

5 1.0 Introduction This Policy sets out Walsall Healthcare NHS Trust s approach to the handling of complaints about its provision of services and members of staff. The Policy is relevant in answering complaints at all levels and is applicable to all staff who have responsibility for ensuring that complaints are handled positively and competently. Walsall Healthcare NHS Trust wants to ensure that complaints, concerns and issues raised by patients, relatives and carers are used as learning opportunities and trends are analysed and reported on. Learning from complaints is shared at all levels of the organisation, from Board to Floor, through Divisional Quality Structures, Quality and Safety Committee, Trust Board and Patient Experience Groups. Walsall Healthcare NHS Trust has implemented a new procedure to handle complaints, concerns and issues from patients, relatives and carers which aims to be less rigid and process driven, bringing it into line with the Local Authority Social Services and NHS Complaints (England) Regulations Walsall Healthcare NHS Trust will be able to respond in a way that is the most appropriate to the individual and their circumstances emphasising local resolution, personalised action plans and remedial outcomes. We will also make it easier for people to make comments, compliments and complaints or to raise concerns, and we will have robust systems for learning from the experience of patient s relatives and carers and making changes and service improvements. The underlying principles of this complaints system are: To get it right To be customer focussed To be open and accountable To act fairly and proportionately To apologise and to put things right To seek continuous improvement It is the aim of Walsall Healthcare NHS Trust to ensure that patients, relatives and their carers will not be treated differently as a result of making a complaint. This will be achieved by ensuring that complaints are dealt with fairly and openly and by the maintenance of confidential complaints records kept separate from a patient s health records where this applies. In addition Walsall Healthcare NHS Trust s 'For One and All' programme has been designed to ensure that the Trust does the right thing - provide a consistently first class experience for all of those who use Walsall Healthcare's services. Following an important listening exercise with both staff and patients, we were able to develop 'Our Vision' - To provide first class, integrated health services for the people we serve in the right place at the right time. Six very important promises have also been launched - the first three promises are to those people who use our services and these are to set out 5

6 2.0 Scope what they can expect from us. These Promises are for our patients to feel, Welcomed, Cared for and In Safe Hands. It is clearly not always possible for the complainant to receive the outcome they hoped for, but if they feel that their complaint has been dealt with appropriately and that they have had a fair hearing, then this is a positive outcome. This policy has been written in accordance with the Local Authority Social Services and National Health Service Complaints (England) Regulations 2009 and Walsall Healthcare NHS Trust will also make reference to the DoH Guidance in Complaints Handling Listening,Responding, Improving and the Parliamentary Health Service Ombudsman Principles of Good Complaints Handling. Our Patient Advice and Liaison Service also deals with concerns and issues from patients on a daily basis. This Policy and Procedure will also apply to those working within the integrated Complaints and PALS team referred to as Patient Relations. The Complaints/Concerns Policy will enable the Trust to: ensure fairness to complainants and staff learn from experience listen to and use patients and users views to improve services 3.0 Statement of Intent Walsall Healthcare aims to resolve concerns and complaints quickly and as close to the source as possible through: 4.0 Procedure(s) 4.1 Introduction an immediate, often oral, first line response through Local Resolution investigation/conciliation in an open and non-defensive way action endorsed by the Chief Executive and learning from the complaint This procedure is based on the Local Authority Social Services and National Health Service Complaints (England) Regulations 2009 and meets the standards set in NHSLA Standard 2 criterion 3 (Concerns/Complaints) 2012/13 Local Resolution Health Service Ombudsman 4.2 Staff Awareness All managers have a responsibility to ensure that all staff are aware of 6

7 the contents of the Complaints and Concerns Policy and how to access this document. If service users seek help in raising a concern or making a complaint then they must be made aware that they can do so without fear of repercussion, discrimination or victimisation. The emphasis of this procedure is on resolving complaints at local level quickly and effectively and, wherever possible, through the actions of front line staff. Guidance notes for staff are included in Appendix One 4.3 The Procedure Local Resolution The Trust s aim is to resolve the majority of complaints through this process. Action upon receipt of a complaint/concern where the issue can be dealt with promptly: The member of staff receiving the complaint should determine if the issue is capable of being resolved promptly. If so, there should be an immediate response from the member of staff. It is important that staff listen attentively and obtain a full picture of the issue/concern and that they check with the complainant that their understanding is accurate. A simple apology may be all that is required by the complainant, together with an explanation of what happened and why. If the member of staff cannot resolve it, they should speak with their line manager who may be able to do so. If the matter can be resolved to the complainant s satisfaction no later than the next working day after the day on which the complaint was made, this issue does not need to be dealt with as a formal complaint. These issues/concerns should be recorded on the form attached at page 38. This ensures that the concern is recorded and any learning can be gained, shared and implemented Concerns / Complaints Made to the Patient Relations (PALS and Complaints) Team Any concern or complaint dealt with to the satisfaction of the complainant within 24 hours will not require a written response. The Patient Relations Team (PALs & Complaints) will: Provide informal on-the-spot help, advice and support for patients, relatives carers and visitors listening to their concerns and suggestions 7

8 Signpost concerns brought to their attention by a patient, relative, carer or visitor to the appropriate member of staff for resolution Provide feedback to the Trust via the Divisional Quality Boards and other quality structures including the Trust Board highlighting where service changes and improvements may be appropriate Provide monthly reports of the main points of activity and concerns raised. This information is incorporated within the Patient Experience Report, Divisional Quality Board Trust Board and the Performance and Quality Board Report Complaints Needing Further Investigation The Patient Relations Team will acknowledge the complaint, issue or concern within 3 working days of receipt. At the time of acknowledging the complaint, or concern the Patient Relations team must: a) offer to discuss with the complainant: i) an action plan for handling the complaint ii) when the investigation is likely to be completed iii) what reasonable outcome is desired iv) when the response is likely to be sent b) arrange an early meeting if appropriate c) advise the complainant of advocacy services available such as ICAS d) complete the Case Management Record on the Safeguard database including the Risk Assessment to determine the seriousness of the complaint. If the complainant does not take up the offer of a discussion, the Patient Relations Team should determine the response period and notify the complainant of that in writing. The agreed action plan and timescales for response should be confirmed to the complainant in writing. Walsall Healthcare NHS Trust has a local resolution target of 30 working days and where possible this target should be met The Investigation and Role of the Investigating Officer Where a complaint demonstrates a clear intention to seek compensation, the complainant will be informed that an investigation will be carried out, but that the compensation aspect will be addressed separately by the Patient Safety Department. The complaint response will require approval by the Head of Governance Patient Safety and Relations. The investigation will be conducted speedily and efficiently, and in a manner proportionate to the seriousness of the complaint. 8

9 The Patient Relations team will: a) send a copy of the complaint and covering letter to the Divisional Lead who will appoint an investigating officer, this will include a breakdown of the issues as far as possible b) identify at an early stage whether it would be helpful to introduce conciliation/mediation c) keep the complainant up to date with progress of the investigation The Investigating Officer will: a) establish what happened, what should have happened and who was involved and make written records of the investigation/staff statements b) make sure an appropriate and sincere apology is made c) identify any lessons learned and where applicable any actions which can be implemented to ensure that there is no recurrence d) draft a report addressing the issues raised by the complainant and comment on what action is being taken to prevent recurrence in the future e) send the draft investigation to the Patient Relations Team via the Divisional Lead who will first review the draft report for accuracy and content, and ensuring the issues raised via the Complainant have been addressed. The staff involved in the complaint: a) should be made aware of the complaint and asked to prepare written accounts as part of the investigation b) are required to co-operate with the complaints procedures as part of their terms of employment c) Where an employee refuses to give an interview or a written account without reasonable grounds, this should be considered a disciplinary offence. Clinical Staff Where the complaint relates to a clinical matter, an investigation officer should be appointed by the relevant Clinical Director and a written report from the appropriate clinician shall be obtained. This report can potentially be disclosed to the complainant and therefore must be written in plain English and medical terminology clearly explained. Walsall Healthcare NHS Trust is expected to release clinicians and staff from other commitments to act as advisers for complaints cases so that delays in the process can be avoided Conciliation and Mediation Experienced conciliators are available from the Walsall Healthcare Patient Relations team. Conciliation can be used at any stage of a complaints investigation but should be used as early as possible where the circumstances of the complaint are likely to be stressful for all parties e.g. where the complaint relates to the death of a patient or the care of an infant 9

10 or child. Where conciliation has been agreed, the relevant managers will be informed and full cooperation from all parties is essential to make it work. 4.4 Complaints Involving More than One Agency The agency receiving the complaint will ask the complainant for consent to pass their concerns on to other agencies involved for investigation. Complaints involving more than one agency will be dealt with in accordance with the protocol agreed between NHS Walsall, Walsall Council, Walsall Healthcare NHS Trust, West Midlands Ambulance Service and the Dudley and Walsall Mental Health Partnership NHS Trust In the event that a different agency who is not a party to the agreed joint protocol is involved in the concern or complaint (for example, hospitals from out-of-borough) the agency receiving the complaint will liaise with them to ensure that, as far as it is possible, the concern or complaint is dealt with in line with these arrangements. 4.5 Complaints Process The Patient Relations Manager will ensure that the following action takes place: Internal Formal Complaint Time Standards Action By, When, Who Letter, , telephone or in person contact to Patient Relations Team. 10

11 4.6 Grading of Complaints In order to understand the impact of complaints on the individuals involved and the organisation a system of risk/severity grading is undertaken, as per the Trust s Risk Management Strategy The system used is outlined below and is essentially assessing the risk to all concerned. The grading is applied initially by the Patient Relations Team (if necessary in consultation with the Risk Department) on receipt of the complaint and can be adjusted following the completion of the investigation if required. The grading is recorded on the database along with any actions identified. 4.7 Serious Complaints Severity 4/5 A Root Cause Analysis will be carried out for all complaints graded 4/5 (in some circumstances severity 3 may warrant this). Individuals who have been trained in Root Cause Analysis will be called upon to lead on serious complaint investigations. The lead will be responsible for establishing the root cause of the complaint and to identify further actions to prevent recurrence. Severity/Risk Score Severity 1 Insignificant Unsatisfactory Patient Experience not directly related to patient care readily resolvable 11

12 Severity 2 Minor Unsatisfactory Patient Experience readily resolvable. Justified complaint peripheral to patient care Severity 3 Moderate Mismanagement of patient, care short term consequences justified complaint involving lack of appropriate care Severity 4 Major Mismanagement of patient care, long term Consequences. Multiple justified complaints/concerns Severity 5 Catastrophic Totally unsatisfactory patient outcome or Experience. Multiple justified complaints leading to claims In accordance with Department of Health Guidance, complaints records must be kept separate from health records. Please note: Complaints correspondence should not be filed within a patient s health record unless specifically requested by the patient. Source: cationspolicyandguidance/browsable/dh Consent, Patient Confidentiality / Sensitivity and Third Party All staff dealing with a concern or complaint are obliged to ensure that it is treated in confidence and with sensitivity. Complainants and the person(s) who are the subject of the complaint must be advised and assured by staff that their complaint will be treated in confidence and with sensitivity. If someone other than the service user or, in the case of a child, the parent with parental responsibility, has made the complaint, the Patient Relations Teams will obtain written consent from the patient/parent of the child. Should this not be possible due to incapacity or refusal, a discussion will take place with the clinician responsible for the patient s care on the best interests of the patient and a response will be made accordingly. Should it not be possible to answer all of the concern/complaint because consent has not been obtained, an explanation will be given. Staff must be fully aware of the Confidentiality: NHS Code of Practice. If the patient does not wish to progress the concern/complaint, once the complaint process has been instigated, they have the right not to continue regardless of the wishes of the third party concerned. However, the third party may still pursue the complaint with regard to issues directly concerning themselves, i.e. unhelpful attitude of staff. 4.9 Other Agencies and Organisations There are a number of external agencies, including other organisations that may be involved in a complaint. The Patient Relations Team will give support and advice about this. They may include: Independent Complaints Advocacy Service (ICAS) (to give support to the complainant throughout a complaint) User Organisations Coroner (in the case of sudden death) NHS Litigation Authority (when a claim arises from a complaint) Parliamentary and Health Service Ombudsman 12

13 Local Authority (where a complaint is about social care) Local Acute Trusts and other health care providers NHS Commissioning organisations Independent Contractors 4.10 Ending the Formal Complaints Process Where the complaint becomes the subject of a disciplinary or capability process the complaints procedure will continue and a copy of all correspondence will be shared with Human Resources and the formats for the relevant procedure followed. Similarly, if the complaint becomes the subject of a claim or other legal process then the relevant procedures will be invoked and the relevant persons will be informed that the process is suspended/concluded. The complainant will be informed of this in writing Out of Hours The Patient Relations Team are ordinarily available during office hours, Monday Friday 8am pm On-site Co-ordinators should report any issues occurring out of office hours to the Patient Relations Team as appropriate, immediately as office hours begin again Independent Review by Parliamentary Health Service Ombudsman Should any complainant express dissatisfaction with the outcome of the Local Resolution and there is nothing more the organisation can do to resolve the complaint to the complainant s satisfaction, they will be advised of their right to request an Independent Review by contacting the HS Ombudsman. Requests for Independent Review may be made orally or in writing, including electronically and should be made within six months of the completion of the Local Resolution Process, or as soon as reasonably practicable. The HSO Ombudsman is contactable at: Parliamentary and Health Service Ombudsman, 11th Floor, Millbank Tower, Millbank, London, SW19 4AP Coroner s Cases The fact that a death has been referred to H M Coroner does not mean investigations into a complaint need to be suspended. It is important to initiate proper investigations regardless of H M Coroners inquiries, and where necessary, to extend these investigations in H M Coroner requests. A copy of the final response letter following completion of the complaints investigation will be forwarded to H M Coroner for information Links with Quality Structure The monthly reports generated by the Patient Relations Team will be used by the Speciality Divisional Quality Teams as a quality improvement tool. Where appropriate the groups will investigate trends and lessons learned will be used in planning improvement work. The Quality Teams will report 13

14 exceptions to the Quality and Safety Committee and any outstanding risk issues will be assessed and added to the appropriate Risk Register Cross Divisional Complaints Where a complaint crosses Divisions, the Patient Relations Manager will liaise with the Heads of Nursing to agree a lead Division Media Enquiries Staff should not respond directly to any enquiries from the media. These should be referred to the Trust s Communications Department Retention of Complaints Files Managers should ensure that in all cases complaints correspondence, which contains patient identifiable and confidential information, should be stored in a secure cabinet which is locked and that information and files are only shared in the groups/directorates on a need to know basis. It is not necessary for managers to keep complaints files once a complaint is closed, as the main copy of the complaint will be retained by the Patient Relations Team preferably electronically and securely on the Safeguard Database. Requests for copies must be made in writing to the Patient Relations Manager clearly stating the reason for the request. Complaints files may be disclosed should a legal claim be made to the organisation following the outcome of a complaint. Complaints files will be kept by the Patient Relations Team for 8 years from date of receipt of the complaint Ethnicity Information The Trust recognises that some complainants may not use English as their first Language, or may have other communication or learning difficulties. In these circumstances the Trust will ensure that such complainants have access to adequate support to enable them to fully participate in the complaints process. The Patient Relations Team will make the necessary arrangements on an individual case-by-case basis, after discussion with the complainant or their advocate or representative. It is Walsall Healthcare NHS Trust policy that no person shall be discriminated against on grounds of race, gender, language, colour, religion or any type of disability when making a complaint or raising a concern. Interpreting services can be provided if required Procedure for Dealing with Habitual Complainants The organisation is committed to dealing with all complainants in a fair and equitable way and seeks to provide a full and comprehensive response to all complaints. However, on rare occasions some complainants may attempt to pursue the Complaints Procedure in a manner which is deemed to be unreasonably persistent abusive or even vexatious. Similarly, from time to time complainants may seek to maintain a relentless communication via the 14

15 raising of serial complaints or a persistent continuation of a complaint that has been dealt with. Examples of such behaviour may include: the persistent pursuit of unrealistic outcomes or demands; attempts to access confidential information, persistently unreasonable (and sometimes aggressive or abusive) behaviour towards the organisation s staff in respect of a complaint or multiple complaints; excessive and disproportionate requests for information in respect of a complaint or multiple complaints; persistent attempts to have complaints which are well out of time investigated, or to have complaints which have previously been the subject of investigation and which may have also been considered by the Parliamentary Health Service Ombudsman reinvestigated. Therefore the Trust has procedures in place to deal with Persistent, Serial or Vexatious complaints in order to ensure that there is equity, fairness and consistency in our response to contacts of this type. It will not always be the case that a complainant who is persistent in their contacts or who raises a number of complaints should be dealt with via this procedure. The organisation believes that the decision to apply the procedure for dealing with a complainant as a persistent, serial or vexatious complainant should be taken only as a last resort. However, in a small number of cases the Trust will use such procedure to limit or restrict an individual s access to the Complaints Procedures. In the event that a decision is taken to limit or restrict a complainant s access to the Complaints Procedure, then they will be informed, in writing. This letter should detail the steps that the organisation has taken in order to attempt to resolve the matter and the nature of the persistent unreasonable or vexatious behaviour being demonstrated by the complainant and details of the restrictions to be put in place. All such letters will be approved and signed by the Chief Executive or in their absence the identified Deputy Chief Executive Guidance for termination of telephone contact when speaking with habitual or vexatious complainants who are aggressive The following form of words (or a very close approximation) should be used by any member of staff who intends to withdraw from a telephone conversation with a complainant. Grounds for doing so could be that the complainant has become unreasonably aggressive, abusive, insulting or threatening to the individual dealing with the call or in respect of other NHS staff. I am sorry but I have to inform you that we have reached a point where your manner has become unreasonable and I have no alternative but to discontinue this conversation. However, your complaint(s) will still be dealtwith by the Trust in accordance with the NHS Complaints Procedure. I am now going to end this conversation. The above, should not be used to avoid dealing with a complainant s legitimate questions/concerns that can sometimes be expressed extremely strongly. Careful judgement and discretion must be used in determining 15

16 whether or not a complainant s approach has become unreasonable Withdrawing Habitual or Vexatious Status Once complainants have been classified as habitual or vexatious, such status will continue to apply for a period of twelve months, at the end of which period, habitual or vexatious status will automatically be withdrawn. However, this may be withdrawn earlier if, for example, complainants subsequently demonstrate a more reasonable approach, they can apply to have this status withdrawn at an earlier date. In addition, if they submit a further complaint, relating to a new matter(s), the normal complaints procedures will apply Complainants Whose Illness May Predispose to Complaints Where it is clear that the complainant s health is predisposing them to make complaints the following steps should be taken: The complaint should initially follow the normal complaints procedure. The concern that the illness is the root cause of the complaint and that responding to it would add to the client s poor health should be discussed with the Patient Relations Manager A decision should be made, in conjunction with the Medical Director and Chief Executive that it would not be in the client s best interests to respond Learning from Experience A procedure is in place to ensure that learning takes place, where necessary, from each complaint. This is achieved by: assessing the severity of the complaint and grading it (Patient Relations Manager), ensuring that, where necessary, corrective action is taken (Heads of Nursing/Investigating Officer) ensuring that a supportive process is in place to enable staff to undertake reflective learning through regular staff/team meetings auditing the action taken in each complaint/concerns and reporting this to the Board and relevant staff, confidentially where appropriate (Divisional Directors/Heads of Nursing) Organisational learning and actions taken will be reported through the Patient Experience Group and Divisional Quality Teams 5.0 Roles and Responsibilities 5.1 Chief Executive The Chief Executive of Walsall Healthcare NHS Trust has overall accountability for Complaints. The Chief Executive is made aware of significant issues and approves and signs the final responses to formal complaints and action taken as a result of the issues raised. 16

17 5.2 Director of Governance and Trust Secretary Has overall responsibility for the Patient Relations Team (Complaints and Patient Advice & Patient Advice and Liaison Service) 5.3 Directors Nursing / Medical and Chief Operating Officer Will ensure that the policy and associated procedures are followed throughout their lines of responsibility and that lessons are identified and acted upon. 5.4 Head of Governance Patient Safety and Relations Has managerial responsibility for the Patient Relations functions and ensures that complaint handling is carried out in accordance with the policy. 5.5 Divisional Directors Ensure all staff are aware of their responsibilities and that they are adhering to relevant procedures Ensure any recommendations identified as a result of complaints received by their Divisions are implemented and monitored in order that lessons can be learned and the standard of care and treatment afforded to patients, carers and relatives improved Ensure any recommendations made following Independent Review by the Health Service Ombudsman are appropriately actioned and are discussed at Divisional Quality Board Meetings. 5.6 Head of Nursing and Midwifery / Associate Medical Directors To be responsible for ensuring all complaints/concerns received are investigated and appropriate responses provided on a timely basis to the Patient Relations Team (Complaints and PALS) To undertake formal investigations as requested by the Patient Relations Team (Complaints and PALS) and appointing an investigation officer to provide a detailed, comprehensive response, addressing all the issues raised in the complaint, with specific reference to action taken to minimise the risk of a recurrence and clearly identifying lessons learned. A formal action plan, detailing actions taken as a result of the complaint should be completed at all times where this is applicable taken to address concerns/complaints To be responsible for ensuring all complaint responses are reviewed and approved before being sent on a timely basis to the Patient Relations Team (Complaints and PALS) To be responsible for ensuring that any action plan sent to Divisional Quality Teams for completion is completed in full and on a timely basis, 17

18 addressing all concerns raised. To ensure Complaints and concerns are a Divisional Quality Team Standing Agenda item Ensure that actions identified are transferred into a robust action plan, with clear timescales and appropriate leads for monitoring purposes To ensure complaints are reviewed regularly and appropriate action. 5.7 Matrons, Ward & Department Managers/Supervisors Ensure all staff receive training on how to deliver effective customer care and handle difficult situations in order to minimise the number of concerns and formal complaints received and to ensure local resolution of concerns and complaints takes place wherever possible Ensure staff are aware of what action to take if a patient, relative, carer or visitor wishes to raise a concern or make a formal complaint to the Trust Contribute towards the completion of an Action Plan for all complaints where relevant and if appointed as an Investigating Officer that the correct process is followed and adhered to Ensure appropriate action is taken to ensure service improvement and minimise the risk of recurrence of issues raised in a concern or complaint Ensure complainants are not treated differently as a result of raising a concern or making a complaint 5.8 Patient Relations Manager (Complaints and PALS) Is the designated Patient Relations Manager for formal complaints as required by the regulations and as such has day to day management of the Patient Relations (Complaints & PALS Team) Assesses the severity and significance of the issues contained in complaints and concerns and escalates information appropriately Ensures the Patient Relations Department is managed efficiently Ensures the administration of the Complaints process is carried out appropriately and in a timely fashion, including dealing with enquiries and concerns and responding to formal complaints Ensures formal written responses to complaints are of an acceptable Standard Ensures training on Customer Services and complaints handling is delivered to front line and administrative staff as part of the Trust Induction Programme and relevant mandatory training as appropriate. 18

19 5.8.7 Ensures all queries around the legalities of dealing with complaints are dealt with appropriately Ensures the Patient Relations Team liaises with appropriate managers in order to initiate and monitor a thorough investigation of matters raised Provides advice where appropriate to services in the formation and development of action plans 5.9 Complaints Team The Patient Relations Team provides day-to-day support to the Patient Relations Manager and has responsibility to ensure that: All complaints are registered on the database (Safeguard) Relevant paperwork and databases are up to date and available for the Patient Relations Manager Acknowledgement letters are sent to complainants within the specified time scale Complaints are sent for investigation to the appropriate Head of Nursing/manager/Clinical Director The complaints process is carried out appropriately, offering support to complainants and the Patient Relations Manager 5.10 Patient Relations ( Patient Advice & Liaison Service) The PALS function will be available and accessible to anyone receiving healthcare within the Trust, and will be dealt with via the integrated Complaints and PALS team now known as the Patient Relations Team Issues brought to the Trust which relate to services of other NHS Trusts/organisations will be signposted to the relevant health contact in the appropriate organisation. The Patient Relations Officers will clarify with patients, relatives, carers and visitors to the Trust, their role and limitations. They provide the following services: Listen to concerns, suggestions or queries Provide information on NHS services Advise and support patients, carers, relatives and visitors Help to sort problems promptly on patients behalf Support patients, relatives, carers and visitors to access the formal complaints process Support patients, relatives, carers and visitors to access independent advocacy Provide information about and support local patient and public involvement activity Act as an interface between Walsall Healthcare NHS Trust and NHS Walsall Provide support and assistance to staff when dealing with difficult situations 19

20 5.11 All Staff Identify trends and gaps in services Provides monthly reports to the Divisional Quality Teams, highlighting themes, types of concerns and concerns by area. Have a responsibility to be aware of the complaints and concerns processes and attend complaints and customer care training sessions as part of induction and mandatory updates. Ensure no patient, carer, relative or visitor to the Trust is treated differently as a result of raising a concern or making a complaint. Any concerns over non-compliance should be raised with the relevant line manager in order that appropriate action is taken. 6.0 Audit / Monitoring Arrangements 6.1 Monitoring Process Requirements Who Head of Governance, Patient Safety and Relations Standards Monitored The organisation listens and responds to concerns and complaints from patients, their relatives and carers How joint complaints are handled between organisations How the organisation makes sure that patients, their carers are not treated differently as a result of raising a concern or complaint How the organisation makes improvements as a result of a concern or complaint When How Presented to Monitored by Completion/Exception reported to Annually Review of data held on Safeguard Review of Investigation Reports Review of Action Plans and Follow Up Review of Complaint Response Letters Quality and Safety Committee Quality and Safety Committee Trust Board Monitoring Process Who Standards Monitored When How Presented to Monitored by Completion/Exception Requirements Learning and Development Department Training Annually Review of training provided against TNA Patient Experience Group Quality and Safety Committee Trust Board 20

21 reported to Reporting Arrangements A six monthly aggregated analysis of Complaints, Litigation, Incidents and PALs (CLIPS) (appendix 2) will be submitted to the Trust Board via the Quality and Safety Committee. This will include a broad overview of: Categories of CLIPs identified during the period Severity of CLIPs identified Divisional origin of CLIPs Analysing trends arising Outcomes of investigations into serious CLIPs Lessons learned Changes made to practice A monthly report to the Patient Experience Steering Group. A monthly Quality report will include analysis of incidents and complaints, highlighting any areas of potential risk. The Quality report will be reviewed by the Quality and Safety Committee before being submitted to the Board. Tailored reports will be tabled at the Divisional Quality Teams on a monthly basis. These will include specific information about complaints, to enable each Quality Team to develop and monitor remedial action plans whose lessons are shared with staff in appropriate wards and departments. Exception reports will be submitted to the Quality and Safety Committee, and in turn to the Board. Risk assessments will be carried out on exceptions and added to the appropriate risk register. The NHS Litigation Authority Risk Management Standards outline a number of minimum requirements and processes that need to be in place to promote safety and quality of care in Acute Trusts in relation to the process for managing complaints and monitoring compliance with the process in relation to investigation, aggregation and demonstration of improvements following incidents, complaints and claims. These are as follows: Process for listening and responding to concerns/complaints of patients, their relatives and carers Process for the handling of joint complaints between organisations Process for ensuring that patients, their relatives and carers are not treated differently as a result of raising a concern/complaint Process by which the organisation aims to improve as a result of concerns/complaints being raised Process for following up relevant action plans Coordinated approach to the aggregation of incidents, complaints and claims Process for communicating this information to the relevant individuals or groups Process for monitoring roles and responsibilities as identified in section 5.0 Compliance of these processes in relation to complaints management will be monitored via a rolling audit programme. An audit against the processes contained within this policy will be audited during the lifetime of the policy 21

22 7.0 Training A selection of complaints covering a period, along with investigations and analysis will form part of the audit process. Customer Care/Complaints Training is provided to all new members of staff as part of the Mandatory Induction process. In addition, staff members, when identified by their Line Manager, will be required to attend further training as necessary. 8.0 Definitions Nil 9.0 Legal and Professional Issues Nil 10.0 References The Local Authority Social Services and National Health Service Complaints (England)Regulations 2009 NHSLA. National Health Services litigation Authority 2012/13 Acute Trust Standard 2 Criterion Related Policies Risk Management Strategy,

23 Appendix 1 Complaints Investigation Toolkit PATIENT RELATIONS SERVICE FORMAL COMPLAINT INVESTIGATION TOOLKIT 23

24 CONTENTS 1. Flowchart for complaint response 2. Guidelines for responding to a complaint 3. Investigation Report and Action Plan Template 4. Guide to statement writing 5. Statement template 6. Letter to complainant template for information 24

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26 Guidelines: Complaint Investigation and Response Letter This guidance has been written to assist staff when they produce responses to complaints. Common shortfalls Great care needs to be taken when drafting responses. Some common shortfalls in complaint responses are that they: - are sometimes poorly written in terms of vocabulary and grammar. - are often defensive rather than constructive. - do not answer all of the points raised in the letter/complaint. - do not include apologies when appropriate. - do not include details that demonstrate that an investigation has been undertaken. - do not reference statements from staff involved. - do not acknowledge statements from complainants. - do not mention any follow up or remedial action taken or to be taken. - for complex complaints there may be no mention of meetings with complainants. - do not include options for further action. This results in: - The Complaints Manager returning the response for redrafting. - Delays in meeting the 30 -working-day target. - Dissatisfied complainants - Potential adverse involvement of the external parties, e.g. media, MP, etc. - Cases being referred to the NHS Ombudsmen or CQC - Further correspondence which in turn leads to more work - The complainant gaining an impression that the organisation does not care. Value of Complaints It is always helpful to think of the positive value of complaints: - they are a measure of quality - they are a catalyst for change - they aid future planning - they reflect opinions and views of users - they project the image of the organisation - they can be an early warning system Steps to a good response - Read the complaint and understand the key issues. - Address each issue as identified by the complainant. - Think of the complainant and respect their strength of feeling - Give explanations. - Avoid using technical language or being too wordy - Apologise appropriately - Outline action taken to prevent the event occurring again. 26

27 - Write as much as possible in active not passive tenses e.g. I will send a report to your doctor. rather than a report will be sent to your doctor. - Leave the complainant feeling that they have been taken seriously and their concerns have been listened to and acknowledged. - Avoid being patronising or defensive. - Ensure that all facts are correct. - If there is a reason why a specific issue cannot be addressed, this should be stated. - Be open and honest Getting the tone of the response right - Remember to: o address the reader directly, o keep sentences short and simple, o explain any abbreviations, o avoid jargon. - Take the time to do a personal check where you step out of your role and put yourself in the shoes of the complainant to see if you have satisfactorily answered the complaint. Look at the situation from their point of view - would you be satisfied with the response? - Ask a colleague to read your response to double check that it is balanced and fair and demonstrates that the organisation welcomes complaints as a mechanism for learning What leaves the complainant dissatisfied? - Not addressing or answering key points. - Not acknowledging feelings / perceptions. - Responses which are too technical, patronising or defensive. - Responses with a chronology of care not relevant to the concerns raised. - Factually inaccuracies and silly mistakes. - Using complex language - No details of appropriate changes / improvements are given. Useful phrases to include in complaint responses The following phrases may prove helpful in writing complaint responses, though it is important to ensure that the content of the letter sounds personal and not a standard response. - Your concerns have been investigated by, who would like to apologise for the delay in responding to your concerns. This was due to. - I was sorry to hear that you were unhappy with. - I am sorry if you found [xx] to be upsetting as this was not the intention. - The normal practice is [xx]. I am sorry that in this instance this did not occur. - I apologise for any additional anxiety this caused. - As a result of your letter,. 27

28 - I trust that my letter has answered the issues you raised and I sincerely regret that this situation arose. - It is always our intention to provide excellent and responsive care for patients and I am sorry if this was not the case. - Your experience of our services falls short of the standards we set for patient care and I would like to apologise, as would all staff concerned, for the stress and anxiety this experience has caused you. - [X] would like to apologise if the [staff member] appeared rude at any time during the conversation with you. [He/She] would like assure you that this was not [his/her] intention. - I will be happy to write to you with further details, discuss your concerns or arrange a meeting with relevant staff. - Finally, I would like to take this opportunity to thank you for bringing this to my attention. The opinions of those who use our services give us valuable insight into the care/services that we provide and areas where improvements are required. Final response checklist Investigating Officer & Complaints Manager - Letter is prepared with the Walsall Healthcare NHS Trust letterhead - Letter is marked 'Private and Confidential'/In Confidence - Name and address are correct. - If original concern was not addressed to Chief Executive, this is acknowledged in the response - Details of who undertook the investigation are given. - An apology is given if the response is overdue and explanation for the delay. - An apology is included - Each of the points the complainant has raised have been addressed with a full explanation or the reason(s) have been given why it is not possible to comment on a specific matter. - Some specific details about the investigation are included, e.g. who was interviewed, and what was discovered - Details of action, improvements or changes made as a result of the complaint are given. - Any positive comments are acknowledged. - An offer for the complainant to meet with the key staff involved is included, when appropriate. - The mandatory paragraph regarding further options open to the complainant - Check the letter for mistakes or inconsistencies e.g. Dr Brown then David Brown. - Ensure the response can be backed by factual evidence - Will the response make sense to the complainant? (Check for complex sentences, grammar and medical jargon). - Is the balance right between being too personal or too factual? - Remember, the response will be signed by the Chief Executive and should be written as a personal letter from him/her - Be mindful of confidentiality constraints if the patient involved has not given consent to the sharing of information, take care to ensure that the complaint does not breach confidentiality, but does not hide behind confidentiality either. 28

29 Tips for achieving the 30 day deadline - Determine a management action plan as soon as the complaint is received: o Call for the health records, if required and rate the severity o Circulate the complaint to all relevant staff, and appoint an investigating officer ensuring they are clear what they are investigating o Seek statements from staff, giving clear deadlines and ensuring they are prepared appropriately o Liaise with partner agencies, other organisations if necessary o Identify other information that may be required o Seek an independent opinion in complex matters o If a delay is likely ensure that this is communicated to the patient relations team urgently with a valid reason in order to keep the Complainant informed - Staff absence is not a reason for delaying a response. If the testimony of a particular staff member is crucial, then ensure the rest of the complaint is answered within the required timescale and give the complainant a timescale when you will respond with the missing information. - If advice is required, then be sure to seek it promptly. 29