Complaints Policy and Procedures

Transcription

1 s Policy/Procedure GOV 03 March 2012 NHS MK&N -COM-GOV Page 1 of 41

2 Document Management Title of document s Type of document Policy GOV 03 Description Target audience Author Department Directorate This document outlines the policy and procedure for handling complaints throughout NHS Northamptonshire (Northamptonshire teaching PCT) and NHS Milton Keynes (Milton Keynes Primary Care Trust) known as NHS MK&N Cluster Organisation. All PCT staff, Independent Contractors, service users and advocates, partner organisations Claira Ferreira Complaints Manager -Francis Crick House, Moulton Park, Northampton NN3 6BJ. Tel: [email protected] Complaints Service Safeguarding and Quality Approved by Date of approval NHS MK&N Board TBC Version Number Version 1.1 Next review date Related documents Superseded documents 1 year from date of Approval Risk Management Strategy The The Patient Advice and Liaison Policy NHS Northamptonshire Advice and Information Service Complaints and Concerns Policy NHS Milton Keynes Internal distribution External distribution Availability Directors, Non Executive Directors, Associate Directors, Heads of Department, other staff, Clinical Commissioning Groups Stakeholder organisations, LINks, ICAS, local representative committees, PCT staff, Independent Contractors, NHS Trusts, Local Authorities All ratified policies, strategies, procedures and protocols are published on NHS MK&N Internet and Public Website NHS MK&N -COM-GOV Page 2 of 41

3 Contents 1 Introduction/aims and objectives 5 2 Guiding principles, and confidentiality 6 & 7 3 Roles and responsibilities 8 4 What is a complaint? 10 5 Who can make a complaint? 11 6 Timescales for making a complaint 12 7 Framework for dealing with complaints 13 8 Learning and sharing lessons 14 9 Guidance and support for patients Vexatious/habitual complaints Discriminatory complaints Monitoring and audit Training Communication Litigation Relationship with disciplinary and other issues Supporting staff Review of Policy and Procedure 22 Appendix A - Procedure for dealing with complaints 23 Appendix B Guidance for staff handling oral complaints 28 Appendix C- Guidance on handling joint organisation complaints 29 Appendix D Complaints Service Map 32 Appendix E Advice & Information Service Guidelines 33 NHS MK&N -COM-GOV Page 3 of 41

4 Appendix F- Equality Impact Assessment 36 Appendix G- RSM Tenon s Local Counter Fraud Specialist/Complaints Department and Advice & Information Service Working Protocol 38 NHS MK&N -COM-GOV Page 4 of 41

5 1. INTRODUCTION NHS Milton Keynes and NHS Northamptonshire Cluster Organisation is responsible for the local NHS budget and commissioning healthcare for the residents of Milton Keynes and Northamptonshire, providing a high standard of patient care and service that is flexible and responsive to the needs of patients and service users. This policy details the procedure for managing complaints received by NHS Milton Keynes and NHS Northamptonshire Cluster Organisation. The Cluster will be referred to as NHS MK&N from this point forward. This policy applies to services commissioned by NHS MK&N including: commissioning and funding decisions services provided by Independent Contractors (GPs, Dentists, Pharmacists, Opticians and other Independent Contractors) who have a contract to provide NHS services and are accountable to NHS MK&N NHS funded services provided by private or overseas hospitals for our patients services provided by NHS MK&N and its staff From 1 April 2009, The Local Authority Social Services and National Health Service Complaints (England) Regulations 2009 came into force. The Regulations provide a single complaints procedure across Health and Social Care which promotes a person centred approach to handling complaints. Each NHS Provider will have their own policy for handling complaints that reflects the NHS Complaints Regulations. The complaint investigation is carried out by an appointed person and response provided directly to the complainant. The regulations allow for Commissioning Organisations to take part in investigations, if the Commissioners deem it appropriate to do so. Clinical Commissioning Groups Within the life of the current NHS Complaints Regulations, our local Clinical Commissioning Groups (Corby Clinical Commissioning Group, Nene Clinical Commissioning Group, Milton Keynes Commissioning) will become authorised and take over the delegated commissioning responsibilities from NHS MK&N, acting as a subcommittee of NHS MK&N Board. Accountability will ultimately lay with NHS MK&N until April 2013 when Government legislation determines that Primary Care Trusts will be abolished. AIMS AND OBJECTIVES 1.1 This Policy and Procedure is compliant with current legislation/guidance and reflects the vision of the NHS Complaints Procedure by providing a service that delivers the following aims and objectives: NHS MK&N -COM-GOV Page 5 of 41

6 provides an identifiable person that any member of the public can turn to if they wish to make a complaint or require information on the complaints regulations involves the Public and Patients in Healthcare through its direct role in dealing with complaints is open, easy to access and responsive by being flexible about the ways people can complain is fair and impartial providing appropriate and proportionate response with an honest, open and fair investigation, without fear of discrimination. people s desire for confidentiality is respected and the respect and confidence of staff is commanded learns and develops ensuring complaints are viewed as a positive opportunity to learn from patients experience to drive continual improvement in service delivery 1.2 Equality and Diversity Statement NHS MK&N is firmly committed to the principles of equality and diversity in all areas of our work. We believe that we have much to learn from diverse cultures and perspectives and that diversity will make our cluster organisation more effective in meeting the needs of all our patients and stakeholders. We are committed to developing and maintaining an organisation in which differing ideas, abilities, backgrounds and needs are fostered and valued, and where people with diverse backgrounds and experiences are able to participate and contribute. 1.3 Staff will treat patients and/or patients nominated representatives with dignity and respect when dealing with their complaint. We will assure complainants that raising concerns will not prejudice the treatment and care provided. We will not discriminate on the grounds of gender, marital status, race, ethnic origin, colour, nationality, national origin, disability, sexuality, religion or age. We will oppose all forms of unlawful and unfair discrimination. 1.4 NHS MK&N recognises that staff provide professional care, often under challenging circumstances and are affected by complaints made against them. It is important that all staff receive training, support and feedback to enable them to deal with complaints in an open, courteous manner whilst at the same time being supported by the organisation they work for. 2. GUIDING PRINCIPLES 2.1 The Human Rights Act NHS MK&N has considered The Human Rights Act and the equality benefits of a Human Rights based approach when handling complaints. These include: an improved quality of health services patients treated with fairness, respect, equality and dignity more person-centred care NHS MK&N -COM-GOV Page 6 of 41

7 a reduced risk of complaints and litigation improved decision making overall a broader range of marginalised groups being involved and considered more meaningful engagement of patients, carers and families Information about the complaints process can be made available in a range of languages and formats. 2.2 The NHS Constitution As well as capturing the purpose, principles and values of the NHS, the Constitution brings together a number of rights, pledges and responsibilities for staff and patients. These rights and responsibilities are the result of extensive discussions and consultations with staff, patients and the public. Further details can be obtained from Confidentiality Patient confidentiality will be maintained when handling a complaint. The Complaints Service will keep all related records in a confidential and secure manner which is completely separate from any patient records. It should be explained to patients that information from their health record may need to be disclosed for the purposes of an investigation. The Complaints Service will ensure that consent is obtained from the patient. There may be times when for the sake of patient safety, it is necessary to breach confidentiality. Any such action will be taken with advice from the appropriate Senior Manager Any persons subject to, or involved in an investigation should be aware that, unless legally exempt, the contents of any information held as part of an investigation may be subject to public disclosure under the NHS Code of Openness or the Freedom of Information Act Reports or statements provided by staff to the Complaints Service will be kept confidential within the complaints process except as necessary to implement improvements to procedures. Staff should be aware, however, that their reports and any covering letters, will not be legally privileged (i.e. cannot be withheld) and may be disclosed to the complainant and his/her solicitor if the complaint is pursued as a legal claim against NHS MK&N. Reports should therefore be frank but factual NHS Complaints Regulations NHS MK&N will work to the national performance targets/timescales for acknowledging complaints involving their services as follows: NHS MK&N -COM-GOV Page 7 of 41

8 Event Time Allowed Who is responsible for action Oral, comment, concern or complaint Dealt with and resolved to the person s satisfaction within 24 hours. Any member of staff with whom the issue is raised NHS MK&N will address any patient safety issues or practice concerns Oral, electronic or written complaint requiring an organisational response Full organisational response Acknowledged within three working days, offering the complainant an opportunity to discuss the issues. Oral concerns or complaints will be noted and a copy sent to the complainant for their agreement Timescales to be agreed with the complainant Complaints Manager or Complaints Coordinator Complaints Manager or Complaints Coordinator Health Service Ombudsman s Principles for Remedy Principles for Remedy published by the Parliamentary and Health Service Ombudsman, describes six principles that represent best practice and are directly applicable to the NHS Complaints Procedure. Good Practice according to the document entails: 1. Getting it right 2. Being customer focused 3. Being open and accountable 4. Acting fairly and proportionately 5. Putting things right 6. Seeking continuous improvement A downloadable version of the Principles for Remedy document is available on the Health Service Ombudsman Website at: 3. ROLES AND RESPONSIBILITIES 3.1 The Chief Executive (the responsible person) is ultimately accountable for the quality of care within NHS MK&N (the responsible body). The Chief Executive of NHS MK&N or any person authorised by the responsible body to act on behalf of the responsible person is accountable for responding in writing to all complaints whether they have been made verbally, electronically or NHS MK&N -COM-GOV Page 8 of 41

9 in writing. The Director of Safeguarding and Quality has delegated responsibility for complaints management within NHS MK&N. 3.2 Clinical Commissioning Groups (CCGs) CCGs will be responsible for dealing with complaints about the services they commission when authorisation as a statutory body is completed. 3.3 NHS MK&N Complaints Service The Complaints Service is part of a wide range of services (known as the Commissioning Support Hub) that provides services to NHS MK&N Cluster Organisation and CCGs approaching authorisation. The Hub manages the Complaints Service on behalf of NHS MK&N. The Complaints Service is ultimately accountable to NHS MK&N until such times as the CCGs become the statutory responsible bodies. 3.4 The Complaints Manager s role is to: act as designated Complaints Manager for NHS MK&N be readily accessible to the public and members of staff including other Trusts and Independent Contractors providing advice on any aspect of complaints resolution provide training and advice to staff on complaints handling act as an honest broker between the complainant and Independent Contactors i.e. GPs, Dentists, Pharmacists and Opticians to resolve the complaint at practice level organise the Conciliation Service and provide access to the service for the resolution of complaints when appropriate ensure all complaints are recorded on NHS MK&N database and a written complaints file is established and held securely ensure the complaints file is accessible to the complainant under the Access to Health Records Policy ensure records management is in line with the Data Protection Act 1988 prepare regular reports on performance and issues raised through complaints ensure appropriate operating procedures are in place to deliver the Complaints Policy ensure recommendations made by the Health Service Ombudsman are carried out and completed 3.4 The Complaint s Coordinator s role is to: assist the Complaints Manager with the above functions obtain appropriate consent co-ordinate the investigation and response of written complaints according to NHS MK&N s manage and administer the complaints file NHS MK&N -COM-GOV Page 9 of 41

10 signpost the complainant to the Health Service Ombudsman when local resolution has been completed 3.5 All Directors are responsible for ensuring that the Complaints Policy and Procedure is implemented across their Directorates. 3.6 Clinical Commissioning Group Leaders with the responsibility for policy dissemination will ensure the is distributed amongst their staff group. 3.7 Individual Directors, Service Heads and Leads are responsible for disseminating the by: ensuring that staff understand the policy ensuring that the procedure and associated documentation are available to their staff ensuring that oral complaints are recorded and reported to the Complaints Service assisting the Complaints Manager/Coordinator to ensure complaints are investigated appropriately and action is taken to resolve the problem and prevent reoccurrence assist the Complaints Service in gathering written and signed statements from staff and preparing a written response report addressing all the questions raised ensuring staff against whom a complaint is made are supported through the process sharing complaints monitoring information with staff teams and reporting actions taken and lessons learned 3.8 Each member of staff is responsible for:- advising patients and the public on how to make a complaint or providing contact details of the service (see appendix B) seeking to resolve oral complaints on the spot wherever possible, to the satisfaction of the complainant understanding and following the taking part in investigations following a complaint, as required implementing changes in practice as required 4. WHAT IS A COMPLAINT 4.1 A complaint is any expression of dissatisfaction regarding any aspect of service relating to patient care, clinical or non clinical, relating to attitudes or behaviour, the environment, facilities or systems, that requires an organisational response. Complaints can be made verbally, in writing and electronically and are included under this term along with formal complaints raised by Members of Parliament on behalf of their constituents. NHS MK&N -COM-GOV Page 10 of 41

11 4.2 Complaints are handled to enable patients, service users (or their representatives) to feed back on the services they receive as easily as possible. 4.3 Equally important is that the Complaints Service is able to feedback complaints learning into commissioning decisions. 4.4 Compliments will be fed back to the appropriate managers to be shared with their staff. 4.2 WHAT CANNOT BE COMPLAINED ABOUT In accordance with the regulations governing NHS complaints, NHS MK&N cannot investigate complaints which relate to: any matter concerning employment an oral complaint which has been resolved to the patients satisfaction by the end of the next working day after receipt a complaint that has previously been investigated where no additional significant information is supplied a complaint being investigated by the Parliamentary and Health Service Ombudsman a complaint regarding failure to comply with a Freedom of Information request a complaint regarding the administration of superannuation schemes a complaint regarding treatment outside of the NHS e.g. private GP consultation, private dental treatment a complaint which is being or has been investigated by a Local Commissioner under the Local Government Act 1974, or the Health Service Commissioner under the 1993 Act a dispute being raised by one organisation about another Where NHS MK&N receives a complaint relating to the above, the Complaints Manager will write to the complainant explaining the reason why the complaint cannot be investigated. If a complainant approaches NHS MK&N to investigate a complaint already handled by the provider, the Complaints Manager/Ccoordinator will write to the complainant to advise that under the NHS Complains Regulations, NHS MK&N cannot reinvestigate a complaint. The complainant will be signposted back to the provider and details of the Health Service Ombudsman will be provided. 5. WHO CAN MAKE A COMPLAINT? 5.1 The complaint may be made by: a patient (former or existing); or any person who is affected by, or likely to be affected by the action, omission or decision of the NHS body which is the subject of the complaint NHS MK&N -COM-GOV Page 11 of 41

12 5.2 a person acting on behalf of a person detailed above, in any case where that person has died is a child is unable by reason of physical or mental incapacity to make the complaint him/herself; or has requested the representative to act on his/her behalf 5.3 In the case of a patient or a person affected who has died, consent to progress the complaint will be required from the Next of Kin or Executor of the Will. In the case of a person who lacks capacity, the representative must be a relative or other person who, in the opinion of the Complaints Manager had or has a sufficient interest in his/her welfare and is a suitable person to act as a representative. 5.4 If in any case it appears that a representative does not have sufficient interest in the person s welfare or is unsuitable to act as a representative, the Complaints Manager will notify the person in writing, stating the reason why. 5.5 In the case of a child or young person aged under 18, the representative must be a parent, guardian or other adult person who has care of the child and where the child is in the care of a Local Authority or a voluntary organisation, the representative must be a person authorised by the Local Authority or the voluntary organisation. 5.6 Anonymous complaints will be accepted, (e.g. telephone call, letter) but if possible the person should be encouraged to provide their name and other relevant details. If the person is unwilling to provide contact details, the Complaints Manager will record the complaint and investigate if appropriate and possible. The outcome will be reported to the Head of Quality and Clinical Standards. 6. TIMESCALES FOR MAKING A COMPLAINT A complaint must be made not later than 12 months after the date on which the matter occurred or not longer than 12 months after the incident came to the notice of the complainant. There is discretion to waive the time limit if the complainant can provide the exceptional circumstances why the complaint was not raised sooner. The Complaints Manager has to be satisfied that it is still possible and practical to investigate the complaint and whether the reason for the delay is acceptable. If the Complaints Manager decides that the reasons are not acceptable or if is clear that the complaint cannot be investigated, the complainant will be informed in writing of the reason why and their right to approach the Health Service Ombudsman to consider this decision. NHS MK&N -COM-GOV Page 12 of 41

13 7. FRAMEWORK FOR DEALING WITH COMPLAINTS The guiding principle of good complaints management is that any expression of dissatisfaction about the service provided requires a response. The emphasis is on early resolution through an immediate informal response by a front line member of staff where this is possible. The NHS Complaints Procedure has two stages: 7.1 Stage 1 Local investigation and response The first stage of the NHS Complaints Procedure allows for complaints to initially be dealt with locally i.e. by the provider of the service complained about. The aim of this stage is for a complaint to be acknowledged, investigated and responded to. This will involve:- written acknowledgement within three working days offering the complainant the opportunity to discuss, at a mutually convenient time, how the complaint is to be handled and an opportunity to clarify the issues to take forward for an investigation discussion of timeframe in which to respond seek the appropriate consent from the patient/complainant the formulation of a Complaints Action Plan investigations with or by the service area with the aim to resolve the complaint speedily and efficiently during the investigation the complainant will be offered the opportunity to contact the Complaints Service for an update at any time during the course of the complaint within the initial timeframe agreed with the complainant or within an agreed extension, a written signed response by the responsible body i.e. the Chief Executive of NHS MK&N (or any person authorised by the responsible body to act on behalf of the responsible person), a Senior Partner or Practice/Service Manager of an Independent Contractor Organisation or CEO of another Trust. The response should include: o an explanation of how the complaint has been considered and who has investigated the complaint o the conclusions reached in relation to the complaint including any matters that require remedial action o confirmation of any action needed as a consequence of the complaint o details of the complainant s right to take their complaint to the Parliamentary and Health Service Ombudsman Where appropriate, a meeting can be offered to the complainant to clarify or explain any issues within the written response. NHS MK&N -COM-GOV Page 13 of 41

14 7.2 Conciliation Service: The Complaints Manager/Coordinator will use discretion with regards to the Conciliation Service. In some complex cases, it may be beneficial for the service to be utilised at the outset, to aid the local resolution of a complaint. This can be requested by the complainant or the provider of the service complained about. The complainant can be advised of Conciliation in the formal response, and will be asked to contact the Complaints Manager/Coordinator as soon as possible if they wish to proceed. 7.3 If a complainant requests Conciliation, the Complaints Manager/Coordinator will contact the service provider to gain their agreement to enter into this service, as both parties must agree. If in the unusual circumstance the service provider declines, the Complaints Manager/Coordinator will notify the complainant of the reason why in writing. The complainant then has the option to approach the Health Service Ombudsman if they remain dissatisfied. If the service provider and the complainant have agreed to enter into the process, the Complaints Manager/Coordinator will request consent from the complainant to provide the appointed Conciliator with a copy of the complaint file. The Complaints Manager/Coordinator will write to the complainant, the service provider and the Conciliator, to confirm to all parties that Conciliation can proceed. Note: the complainant has the right to approach the Health Service Ombudsman at any time, although local resolution should be completed. Stage Two The Ombudsman 7.4 If the complainant remains dissatisfied after the local resolution process has been completed, a request can be made to the Parliamentary and Health Service Ombudsman for an independent investigation into any outstanding issues. The Health Service Ombudsman for England Millbank Tower Millbank London SW1P 4QP Telephone helpline: Website: [email protected] 8. LEARNING AND SHARING LESSONS 8.1 NHS MK&N recognises that complaints are a meaningful way to understand the concerns of patients and members of the public and encourages all staff to recognise complaints as a learning opportunity. The Complaints Service has developed a Learning mechanism which enables the tracking of the outcomes from complaints. This will ensure that NHS MK&N has a robust mapping NHS MK&N -COM-GOV Page 14 of 41

15 mechanism to create results and is able to demonstrate learning and improved service delivery as a result of public feedback. When a complaint also meets the serious incident criteria, NHS MK&N may use root cause analysis methodology when reviewing the complaint. This will be undertaken for all incidents with patient safety implications and other serious incidents, at the discretion of the Director responsible for the area in consultation with, to ensure that the appropriate approach is taken. 8.2 Monitoring Improvements Where complaints are upheld and actions subsequently required, NHS MK&N will seek to ensure that these actions are addressed and seek assurance of implementation from providers. Where there is a failure to implement appropriate actions or relevant improvements are not made, NHS MK&N will invoke the relevant processes for remediation through the Clinical Quality Review Groups, Contracting and Commissioning. In addition: the Complaints Service will use existing communication channels to provide staff with feedback on any actions taken as a result of reported complaints the Complaints Service will report any findings or intelligence to NHS MK&N Directorates as appropriate 9. GUIDANCE AND SUPPORT FOR MEMBERS OF THE PUBLIC 9.1 NHS MK&N publishes information on how to make a complaint 9.2 Patients, their families and carers can contact the Complaints Service for advice on how to make a complaint with the appropriate organisation and provide advice and guidance on the complaints process and regulations. The Complaints Service is sometimes able to assist a complainant without recourse to the formal complaints procedure if this is the complainants wish. If the complaint requires an organisational response, the Complaints Manager /Coordinator will discuss with the complainant how the complaint is to be handled and the timeframe in which to seek resolution. Contact details:- NHS MK&N Complaints Service Francis Crick House Summerhouse Road Moulton Park Northampton NN3 6BF Telephone: / [email protected] NHS MK&N -COM-GOV Page 15 of 41

16 9.3 The Independent Complaints Advocacy Service (ICAS) can assist members of the public who wish to make a complaint about NHS services. Contact details:- For Northamptonshire residents contact: ICAS The Business Box 2 Oswin Road Braunstone Leicester LE3 1HR Telephone: [email protected] For Milton Keynes residents contact: ICAS 1st Floor Rear Clarendon House 9-11 Church Street Basingstoke Hampshire RG21 7QG Telephone: VEXATIOUS/HABITUAL COMPLAINTS 10.1 There are exceptional circumstances where NHS MK&N can reasonably do nothing further to rectify a real or perceived problem from a complainant Complainants (and/or anyone acting on their behalf) may be deemed to be vexatious or habitual complainants where previous or current contact with them shows that they meet one or more of the following criteria:- persist in pursuing a complaint where the complaints procedure has been fully and properly implemented and exhausted changed the substance of a complaint or continually raise new issues or seek to prolong contact by continually raising further concerns or questions (care must be taken not to discard new issues which are significantly different from the original complaint) continue to pursue a complaint with NHS MK&N after appropriate consent has been sought to forward the complaint to the provider for investigation are unwilling to accept documented evidence of treatment given as being factual (i.e. records) or deny receipt of an adequate response in spite of correspondence specifically answering their questions or do not accept that facts can sometimes be difficult to verify when a long period of time has elapsed NHS MK&N -COM-GOV Page 16 of 41

17 do not clearly identify the precise issue which they wish to be investigated, despite reasonable efforts and/or where concerns identified are not within the remit of NHS MK&N to investigate focus on a matter to an extent which is out of proportion to its significance and continues to focus on this point (it is recognised that this can be subjective and careful judgement must be used) have in the course of addressing a complaint had an excessive number of contacts with the organisation placing unreasonable demands on staff (this can be by telephone, fax, , letter or in person and discretion must be taken in determining excessive ) are known to have recorded meetings or face-to-face/telephone conversations without the prior knowledge and consent of other parties displayed unreasonable demands or expectations and fail to accept that these may be unreasonable (e.g. insist on responses to complaints or enquiries being provided more urgently than is reasonable or normal recognised practice) used inappropriate verbal or written language against members of staff 10.3 The following procedures will be used in exceptional circumstances and as a last resort, after all reasonable measures have been taken via the complaints procedure. Discretion must be applied. Stage 1: NHS MK&N employees should refer the complainant to the Complaints Manager. The Complaints Manager will take action specifically targeted to try and help the complainant and staff involved, depending on the behaviour the complainant is displaying. This could include: explaining the complaints process informing a limit to the number of and duration of telephone conversations, s and written letters where hand written correspondence is unclear, the complaint will be acknowledged and the opportunity provided to contact the Complaints Service to discuss the concerns. If this is option is not taken, the correspondence will be returned and the complainant signposted to ICAS use of recorded delivery postage seeking help from ICAS to contact and liaise with the complainant where appropriate the Complaints Manager identified as the sole organisational contact point for the complainant informing the complainant that written communication will be the only communication between NHS MK&N and the complainant the Complaints Manager will contact all staff likely to receive contact from the complainant, advising them of the action decided upon and providing a suitable script which staff should read to the complainant (and repeat up to 3 times) in the event of the complainant contacting them before calls are terminated. NHS MK&N -COM-GOV Page 17 of 41

18 Stage 2: If stage 1 does not have the desired effect and the situation deteriorates, then one or more of the following actions may be taken: the Complaints Manager will write to the complainant informing them why their behaviour is preventing any possible resolution of the complaint, and include an agreement setting out a code of behaviour for both parties listing grounds on which the complaint will be dealt with and which it will not the Complaints Manager will write to the complainant informing them that the points raised have been fully responded to and that to continue contact on this matter would serve no useful purpose. The letter will include advice on contacting the Health Service Ombudsman the Complaints Manager will escalate the case to an Executive Director and agree a suitable course of action, which will be communicated to the complainant in writing if the action above does not have the desired effect, the Complaints Manager will compile a report for the Chief Executive, detailing the issues and sequence of events. The Chief Executive will then write to the complainant informing them of NHS MK&N actions 10.4 Once a complainant has been deemed as vexatious or habitual, the status will be withdrawn at a later date if, for example, the complainant subsequently demonstrates a more reasonable approach or, if they submit a further complaint for which the normal complaints procedure would appear appropriate. Discretion should be used in removing the status If it becomes apparent through the course of investigating a complaint that staff have been subjected to inappropriate personal verbal or written abusive comments, the complainant will be advised that this is unacceptable and will not be tolerated with any future communications the person may have with NHS MK&N staff. Staff will be encouraged to report any such incidents to their Line Manager. 11. DISCRIMINATORY COMPLAINTS 11.1 These are complaints made against an individual because of their racial background, gender, marital status, race, ethnic origin, colour, nationality, national origin, disability, sexuality, religion or age. Some will be easily identifiable from the outset, others may come to light during the complaints process At an early stage, NHS MK&N will endeavour to identify any complaints which amount to harassment and ensure that the employee/practitioner concerned is not put through the process of an investigation. Any complaints made purely on the basis of race will be considered to be harassment and will not be tolerated. NHS MK&N -COM-GOV Page 18 of 41

19 11.3 The Complaints Manager will discuss any possible discriminatory complaints with an Executive Director and/or with the Lead Service Provider, and determine whether the complaint should be progressed through the complaints process If the decision is taken not to progress the matter through the complaints system, the complainant will be notified in writing that the complaint will not be progressed and informed that harassment against any member of staff will not be tolerated NHS MK&N will offer and arrange support to the employee/service provider who is the subject of the complaint Any complaints couched in discriminatory language that raise legitimate issues about clinical practice, procedures and communication, will be investigated using the complaints system, without prejudice to the outcome of the investigation Where a complaint is investigated that is couched in discriminatory language, the complainant will be advised that discriminatory language will not be tolerated. The employee/service provider will also be offered support. 12. MONITORING AND AUDIT 12.1 A database will be held centrally to record and monitor all complaints. Information gathered for the purposes of Annual Reporting will be anonymised An annual report of complaints handling will be undertaken to monitor NHS MK&N performance in respect of the following: number of complaints received number of complaints NHS MK&N decided were substantiated number of complaints NHS MK&N has been informed were referred to the Health Service Ombudsman summary of subject matter summary of general matters of importance arising from complaints or the way in which they were handled summary of actions to improve services as a result of these complaints 12.3 The Complaints Service will prepare a quarterly report that will demonstrate Numbers and types of complaints received achievement of Key Performance Indicators trends and areas of concern actions taken to improve services as a result of complaints complaints that have been facilitated by the Complaints Service but dealt with via Independent Contractor practice-based complaints procedure 12.4 The Complaints Service will provide its annual report to NHS MK&N Board, the Strategic Health Authority and Clinical Commissioning Groups. The annual report will be available to any person on request. NHS MK&N -COM-GOV Page 19 of 41

20 12.5 Independent Contractor providers will make available an annual report on complaints as outlined in the complaints regulations. General Practitioners and Dentists return their complaints figures to the Department of Health via the Complaints Manager The Complaints Service will seek to actively maintain clear formal routes for feeding back emerging themes to NHS MK&N. Outcomes from complaints assist in advising contractors/commissioners and providers on changes and service improvements which will improve the patient experience An audit summary is recorded by the Complaints Service to demonstrate that audit action plans have been implemented. 13. TRAINING Complaints handling training is available to all NHS MK&N staff. When required, staff and service managers will also receive specific training on the Complaints Policy and Procedures and this is accessed via the Complaints Manager. Primary Care Independent Contractors will also receive training when required or requested, however independent providers are ultimately responsible for their staff. 14. COMMUNICATIONS The is available to staff on the intranet and hard copies are available from the Complaints Service. The policy is also available on the external website for members of the public and made available when requested. An A4-size summary of this document is available to staff and patients for information. A copy of this can be provided in other languages other than English, or in other formats. 15. LITIGATION If the complaint reveals a possible case of negligence, or if there is a likelihood of litigation, the Complaints Manager will immediately inform the Manager with the responsibility for legal claims. If a complainant expresses in writing their intention to take legal action, the Complaints Manager will discuss with the complainant that the relevant authority will be contacted to determine whether progressing the complaint through the NHS Complaints Procedure will prejudice subsequent legal or judicial action. If so, the complaint will be put on hold and the complainant advised accordingly. If not, the NHS Complaints Procedure will continue. However, any patient safety issues with wider implications will be investigated and actioned as appropriate. NHS MK&N -COM-GOV Page 20 of 41

21 16. RELATIONSHIP WITH DISCIPLINARY AND OTHER ISSUES 16.1 It is a requirement of the regulations that the complaints procedure is kept separate from NHS MK&N disciplinary procedures. The purpose of the Complaints Policy and Procedure is to investigate concerns raised by patients and the public and provide a suitable explanation and apology as appropriate NHS MK&N has approved policies and procedures for dealing with incapability, unsatisfactory work performance, disciplinary matters, whistle blowing and disputes between organisations. These procedures may be invoked as a result of the findings of a complaints investigation but are not part of them The Complaints Service has a close relationship with the department responsible for reviewing Independent Contractor fitness to practice concerns. The Practice Concerns Screening Group (PCSG) routinely reviews complaints about Independent Contractors via its Policy and Procedure Framework for Identifying and Managing Independent Contractor Performance Concerns. If any actions are identified as part of the review of the complaint, these will be overseen by the PCSG. This action does not form part of the complaints procedure. However, there may be occasions where the PCSG considers it appropriate to contact the complainant directly and advise of any recommendations that have been made If a complaint results in a need for referral to any of the following: one of the professional regulatory bodies an independent inquiry into a serious incident under section 84 of the National Health Service Act 1977 a referral to the police if a breach of the law has occurred Advice should be sought immediately from the Complaints Manager before an acknowledgement is sent. The Complaints Manager will ensure that the information is passed to the relevant Executive Director and Chief Executive The Executive Director and Chief Executive will be responsible for deciding whether to initiate any necessary action that deviates from the Complaints Policy and Procedure (for further details refer to NHS MK&N Policy and Procedure Framework for Identifying and Managing Independent Contractor Performance Concerns and Human Resources policies) If disciplinary procedures follow an investigation into a complaint, resolution of the complaint will take precedence over the internal disciplinary procedure. 17. SUPPORTING STAFF NHS MK&N -COM-GOV Page 21 of 41

22 Where an incident or complaint investigation requires staff to prepare a formal statement or where staff may be called to give evidence as a witness, for example, at an inquiry, court case or Coronial Inquest, they are to be actively supported by their Line Manager in accessing appropriate advice. This may be through a professional union, registration body, or the Complaints Manager. Where necessary, the Safeguarding and Quality Director will obtain appropriate external legal advice to support NHS MK&N and its staff. For further information for staff support refer to The Incident and Near Miss Policy. 18. REVIEW The will be reviewed annually, or sooner, if changes occur in legislation. The effectiveness of the policy will be reviewed in the light of performance against response timeframes, numbers of resolved and referred complaints as well as implementation of lessons learned. The procedure will also be reviewed in the light of any audit recommendations, learning and development cycles or changes to organisational structure that may have an impact on how the procedures operate. NHS MK&N -COM-GOV Page 22 of 41

23 APPENDIX A PROCEDURE FOR DEALING WITH COMPLAINTS 1. Complaints can be made verbally, electronically or in writing 1.1 Verbal complaints, comments or concerns can be made to front line staff. NHS MK&N encourages patients, their families and carers to raise and discuss their concerns in the first instance with a member of staff or the person in charge of the service. Many concerns can be resolved by dealing with the issue on the spot and all staff should make every effort to enable this to happen. The Complaints Service can also be contacted if the complainant prefers not to raise an issue directly with staff. 1.2 Where a complaint is made verbally, electronically or in writing to the Complaints Service, the complaint will be acknowledged within three working days of receipt (as outlined in section of the policy), ensuring a complaints leaflet and ICAS leaflet are supplied. The acknowledgment letter will include the opportunity for the complainant to discuss with the Complaints Service how the complaint is to be handled and which organisation is best placed to respond to the complaint. The appropriate consent form will be sent to the complainant/patient. 1.3 If consent to proceed with the handling of the complaint is not received, a reminder will be sent after 21 days enclosing a copy of the consent form and reminding the complainant of the support of ICAS if they wish to approach the provider directly. If no further communication is received, the complaints file will be closed, however the commissioner/contracting manager will be alerted to the concerns raised with the patient/complainant details kept anonymous. 1.4 Any complaint received about ongoing clinical care will be handled with the view to improve the situation and may entail, with the patient s consent, contacting support medical staff or the practitioner/service manager to help resolve the concerns as quickly as possible. The complaint will continue to be handled in line with procedures, with the complainants consent. 2. Risk Rating Rationale The Complaints Manager/Coordinator will ensure all complaints received by NHS MK&N, whether verbally or in writing, are recorded and risk rated. Correctly assessing the seriousness of a complaint can assist in ensuring the right action is taken in addition to the complaints process. Risk rating is determined by assessing both the consequence and the likelihood of recurrence. Risk is then determined by balancing the consequence to the likelihood of recurrence. NHS MK&N -COM-GOV Page 23 of 41

24 2.1 Consequences Negligible/ not Catastrophic / Minor Moderate Major significant Extreme Unsatisfactory experience not affecting immediate patient care. No risk to safety and well being. No injury or harm. Some damage to confidence in service. Significant harm or death of patient directly resulting from acts or omissions of provider. Illegal activity. High potential for national media interest Examples Unsatisfactory experience resolvable with no long term affect on patient care. No immediate harm to patient. No likely media interest. System failures in mainly non clinical areas. Service below expectations and/or significant contractual requirements resulting in actual or risk of harm or potential to impact on service provision. Mismanagement of patient care. Risk of local media interest and reputation damage. Significant lapse of standards or professional conduct leading to potential or real harm. Failure to comply with clinical guidance. Failure to adhere to professional standards. Likelihood of media interest Communication issues, attitude of staff Appointment systems, payment of fess Commissioning decisions, failure to assess/examine Missed diagnosis, failure to refer, prescription error Surgical error 2.2 Likelihood Rare Unlikely Possible Likely Almost certain This will probably never happen/recur Do not expect it to happen/recur but it is possible it may do so Might happen or recur occasionally Will probably happen/recur but it is not a persisting issue Will undoubtedly happen/recur, possibly frequently 2.3 Risk Matrix Likelihood Likelihood score Rare Unlikely Possible Likely Almost certain 5 Catastrophic/ Extreme Medium High Extreme Extreme Extreme 4 Major Medium High High Extreme Extreme 3 Moderate 2 Minor 1 Negligible/ Not significant Low Medium High High Extreme Low Medium Medium High High Low Low Low Medium Medium NHS MK&N -COM-GOV Page 24 of 41

25 2.4 Extreme Risk The Complaints Manager/Coordinator will ensure that the Head of Quality and Clinical Standards is advised and kept informed of the progress when any complaint is classified as major/extreme 3. NHS MK&N Complaints The Associate Director, Head of Department or Service Lead whose service or area of responsibility has been complained against, will usually be identified by the Complaints Manager/Coordinator as the investigating officer. The Investigating Officer will receive a copy of the complaint, specific points to be investigated and responded to and a timescale for completion. 3.1 The appointed senior manager/investigating officer will, after completion of their investigation, provide a draft response in the form of a response report to the Complaints Manager/Coordinator, who will quality check the information written, ensuring it can be easily understood and all the questions have been answered. Any witness statements should be signed and if a patient s clinical record has been accessed, the relevant part thereof, should be returned to the Complaints Manager/Coordinator. 3.2 The Complaints Manager/Coordinator will be responsible for drafting the final response letter for the Chief Executive s signature. The letter will include the opportunity to contact the Complaints Service with any outstanding concerns and signposting to the Health Service Ombudsman should the complainant remain dissatisfied at the end of the local resolution process. 3.4 Once a written response has been provided, the complaint will be recorded as closed unless the complainant contacts the Complaints Service with any outstanding concerns. The Complaints Manager will advise whether it remains practicable to continue the investigation further. 4. Independent Contractor Complaints 4.1 If the Complaints Manager/Coordinator receives a complaint concerning an Independent Contractor (GP, Dentist, Pharmacist, Optician or Other Independent Contractors providing NHS Services for NHS MK&N) a copy of the complaint (with the consent of the complainant) will be sent to the Independent Contractor who will be asked to handle the complaint in line with the complaints regulations and to respond directly to the complainant. The practice/service will be asked to provide the Complaints Service with a copy of the response. In these circumstances, the complainant is deemed to have made the complaint to the provider under NHS Regulations. NHS MK&N -COM-GOV Page 25 of 41

26 4.2 If a complaint is received directly by an Independent Contractor, an investigation will be carried out under the complaints regulations which will be completed in the timeframe agreed with the complainant. If the complainant is not satisfied with the Independent Contractors response, the Complaints Manager/Coordinator can be contacted for further advice about accessing the Conciliation Service. 4.3 Any concerns the Complaints Service receives about Independent Contractors will be routinely passed to Contracting Managers as part of the Complaints Service s role in highlighting issues to NHS MK&N. However, if the complaint is about the performance of a Primary Care Independent Contractor, consent will be sought for the complaint to be reviewed through the Policy and Procedure Framework for Identifying and Managing Independent Contractor Performance Concerns. 5. Complaints Involving Other Organisations 5.1 Where a complaint solely involves another NHS Partner Organisation, NHS MK&N will seek consent from the complainant to forward to the organisation concerned to be handled in accordance with the NHS Complaints Regulations. If the Complaints Manager/Coordinator considers it appropriate and if the complainant consents, a copy of the complaints response will be requested from the Partner organisation. Where a complaint is raised about the services provided under arrangements with NHS MK&N for example an NHS Contracted Service or Social Care Provider, a copy of the complaint (with the consent of the complainant) will be sent to the provider who will be asked to handle the complaint in line with the complaints regulations and to respond directly to the complainant. The provider will be asked to provide the Complaints Service with a copy of the response. In these circumstances, the complainant is deemed to have made the complaint to the provider under NHS Regulations. 5.2 Where a complaint is made about more than one organisation, a discussion will be had with the complainant as outlined in section of the policy to establish the appropriate way the complaint can be handled. Consent will be gained from the complainant/patient before forwarding to all the organisations involved. The NHS organisations involved will work together in line with guidance when dealing with joint organisation complaints (see appendix C). Where NHS MK&N Complaints Manager/Coordinator takes the lead in a complaint as agreed with the complainant, they will work towards sending a response to the complainant within the agreed timeframe as outlined in section of the policy. Where possible, a coordinated response to the complainant will come from the lead organisation. 5.3 If NHS MK&N considers it appropriate to handle a complaint, the complainant and the provider organisation will be notified and the complaint will continue to be handled in accordance with NHS Complaints Regulations. In all cases the Complaints Manager/Coordinator will work towards sending a response to the complainant within agreed timescales. Any delay to this time scale will be agreed with the complainant. All time-sensitive correspondence will be sent Recorded Delivery or with a request that safe receipt is confirmed. NHS MK&N -COM-GOV Page 26 of 41

27 6. Correspondence from Members of Parliament When NHS MK&N receive a correspondence from a Member of Parliament on behalf of a constituent, the Complaints Service are tasked to handle these enquiries. Appropriate consent will be sought from the constituent should it be necessary to contact other organisations involved in their care in order to respond to the enquiry. There are no formal response timescales for an enquiry. However, the Complaints Service will always endeavour to handle correspondence in a timely manner. Should a Member of Parliament make a formal complaint on behalf of their constituent, the correspondence will be handled in line with NHS MK&N Complaints Procedure. NHS MK&N -COM-GOV Page 27 of 41

28 APPENDIX B GUIDANCE FOR STAFF ON HANDLING ORAL COMPLAINTS Remain courteous and calm at all times. Listen carefully to the complainant and give them an opportunity to explain. Apologise that the person has had cause to complain, this is not an admission of liability. Make notes of the conversation and summarise the concerns. Try and establish what the complainant is seeking by way of resolution. Ensure you have all the information you need including the complainants contact details and record in the sections below. Advise the complainant you will be passing their details to the Complaints Service ( ) who will contact them. This form is available on the intranet. Complete and immediately to [email protected] DETAILS OF COMPLAINANT Name: Tel No:.. Address:.. SUMMARY OF COMPLAINT Action complainant would like to see taken (resolution to their concern) NHS MK&N -COM-GOV Page 28 of 41

29 APPENDIX C Guidance on handling Joint Organisation Complaints 1. Purpose This guidance provides a framework when NHS MK&N receives a complaint that involves a combination of NHS Providers and where NHS MK&N acts as the facilitator on behalf of the complainant by acting as the complaints lead. In this role, NHS MK&N will ensure that complainants receive a timely and coordinated response to a complaint whether the complaint relates to Health, Social Care or both. This will eradicate the need for complainants to make separate complaints to individual organisations. NHS MK&N will ensure that there is effective communication between agencies as part of a joint learning and developmental approach to complaints. 2. Principles 2.1 To facilitate a unified approach and timely response to handling joint complaints. 2.2 To provide clear guidance on consent and information sharing and inspire confidence in the process. 2.3 To help facilitate effective complaints handling at a local level to include a clear and comprehensive process for notifying the complainant of the lead agency and discussing how the complaint will be handled. 2.4 To identify and share joint organisational learning where there is consent to do so. 3. Consent 3.1 This guidance recognises the duty to ensure that information relating to individual service users and patients is protected in line with the requirements of the Data Protection Act, Caldicott Principles and the confidentiality policies of each organisation. 3.2 NHS MK&N will obtain consent in order to facilitate the handling of the joint complaint and where this is received verbally, will be clearly recorded and recognised in any acknowledgement letter. NHS MK&N -COM-GOV Page 29 of 41

30 3.3 The complainant shall be entitled to a full explanation of why consent is necessary and the purpose of any information sharing. 3.4 Consent will be required for NHS MK&N to receive complaint investigations from providers which will, in most cases, contain patient information. 3.5 If the complainant withholds consent to the complaint being shared with partner organisations and for NHS MK&N to facilitate the handling of a joint complaint, the Complaints Manager will advise the complainant that the complaint will need to be made directly to the relevant organisations. 4. Assessment and Formulation of a Complaints Action Plan (CAP) 4.1 The Complaints Manager/Coordinator will conduct an initial assessment of the complaint. This will establish if alternative procedures should take precedence e.g. Adult Protection. 4.2 If the complaint relates wholly to another organisation, the complaint will be forwarded to the relevant organisation within 3 working days subject to the consent of the complainant. 4.3 The Complaints Manager/Coordinator will identify which organisations are involved in the complaint. After discussion with the complainant and the other organisations, a decision will be reached as to which organisation will be the lead organisation. In most cases, this will be the organisation with the majority of the complaint. Where NHS MK&N has been identified as the complaints lead, the organisations involved will be provided with: a CAP which will identify the individual questions each organisation is required to investigate timescales will be given for responses to be completed and returned to NHS MK&N the original complaint letter copy of the consent form 4.4 The CAP will identify if the complainant has any special requirements, for example independent advocacy services e.g. and how this can best be provided, subject to the agreement of the complainant. 5. Complaints Investigation 5.1 Where NHS MK&N Complaints Service is acting as the complaints lead, the individual organisations involved in the complaint will be requested to handle their part of the complaints investigation and provide their completed signed off response to the Complaints Manager/Coordinator. NHS MK&N -COM-GOV Page 30 of 41

31 5.2 If the Complaints Manager/Coordinator observes that an investigation is incomplete, the organisation concerned will be approached to discuss the situation with the aim of avoiding complainant dissatisfaction NHS MK&N will provide the individual responses in their entirety to the complainant along with an accompanying letter signed off by the NHS MK&N CEO. 6. Timescales Timescales for the investigation will initially be discussed with the complainant. A deadline will be set by the Complaints Manager/Coordinator for the organisations involved to complete their investigation. If the organisations involved are unable to complete their investigation by the deadline, the Complaints Manager/Coordinator will negotiate a revised completion date with the complainant and advise the participating organisations accordingly. 7. Disputes 7.1 When there is a dispute between organisations on how to deal with a joint organisation complaint, NHS MK&N will endeavor to facilitate wherever possible. However there may be occasions where each organisation will resort to dealing with their element of the complaint according to their procedures. 7.2 This dispute will be reported to the relevant Chief Executive and/or Directors. 8. Learning from Complaints 8.1 NHS MK&N is fully committed to facilitating organisational learning and development through complaint resolution. 8.2 Steps will be taken to identify and rectify, communication, procedural, operational or strategic issues that cross organisational boundaries. If appropriate, this will be raised through NHS MK&N contractual or quality review process. 8.3 Joint organisational learning will be shared with each of the organisations involved in a complaint where ever possible subject to the consent of the complainant. 9. Evaluation 9.1 This working document will be subject to review in light of any developments in joint organisation complaints handling. NHS MK&N -COM-GOV Page 31 of 41

32 APPENDIX D Low/Medium Handle as per process Complaints Map Complaint received Triaged and risk rated by complaints team High/Extreme Risk notify relevant internal staff & external agencies or organisations as appropriate INDEPENDENT CONTRACTORS GP, Dentist, Pharmacy, Optician, Other Independent Contractor or Provider, AQP Complaints. Acknowledge within 3 working days advising of Practice or Service in-house complaints procedure enclose consent, service leaflet and info about ICAS. COMPLAINTS ABOUT NHS MK&N, OTHER PARTNER TRUST OR JOINT ORGANISATION COMPLAINT Acknowledge in 3 working days with request to contact to discuss complaint Agree way to handle complaint and confirm investigation points, discuss possible timescales For solely partner organisation complaints, request consent to forward on to be handled in line with their complaints procedure. Request copy of response if appropriate and complainant agrees Consent received Forward to provider copy of response requested Consent not given? Advise to approach provider directly with the support of ICAS Consent form and confirmation of investigation points confirmed in writing Information useful for Triangulation meeting/clinical Quality Review Response received log learning outcomes If either party wish to utilise NHS MK&N Conciliation Service and both parties agree, arrange as per process Complaint and response forwarded to PCSG for internal review Consent received acknowledged and timescales confirmed in writing Complaint and investigation points forwarded to AD or HoD, service manager, other organisations involved in complaint with deadline Responses received and reviewed by Complaints Team Complaints team to identify areas where further review by clinical, commissioning,, contracting or quality is required. Findings to be compiled on an additional report along with recommendations If appropriate Conciliator prepares final report and signposts to the Ombudsman For NHS MK&N, response report prepared along with response for CEO -both returned to Investigating Officer for final agreement before sending to CEO For joint complaints where NHS MK&N is the complaints lead provider responses are provided in their entiretycovering letter prepared for CEO NHS MK&N -COM-GOV Signed by CEO or Page 32 of 41 assigned Signatory

33 APPENDIX E Advice and Information Service Guidelines NHS MK&N provides an NHS Advice and Information Service for patients, their families/carers/representatives and will be referred to as the service for the purposes of these guidelines. The service listens to concerns, suggestions and queries, with the aim of assisting wherever possible. The service is responsible for: dealing with specific enquiries and providing accurate advice, information and signposting to patients, carers, service users and members of the public ensuring confidentiality; the service will not disclose any information about a named person without prior permission communicating with NHS MK&N staff, Managers and Independent Contractors being identifiable and accessible making referrals when appropriate to independent advice and advocacy support from local and national networks including the Independent Complaints Advocacy Service (ICAS) advising of the complaints process and procedures where appropriate recording enquiries, comments and concerns on NHS MK&N database operating within a local network with other organisations within NHS MK&N providing advice for patients who use different parts of the NHS for the care they need, where this is possible The service is also responsible for: handling written enquires from members of the public that require an organisational response from the CEO providing regular reports as required by NHS MK&N and the emerging Clinical Commissioning Groups maintaining clear formal routes for feeding back themes and trends to NHS MK&N NHS MK&N -COM-GOV Page 33 of 41

34 1. Operational Hours The service is available from Monday to Friday between 9am and 5pm except Bank Holidays. 2. Access to the service There is a variety of ways the service can be contacted. A free phone line with relevant information for both Milton Keynes and Northamptonshire is available 24 hours per day. Callers can leave a message which the service will endeavor to respond to within two working days. The service can also be accessed via and in writing. The service recognises that there are times when issues require immediate attention. However, the service is not for crisis intervention, neither can medical advice be given. Contact Details: Telephone: In writing: [email protected] The Advice and Information Service NHS MK&N Francis Crick House Summer House Road Moulton Park Northampton NN3 6BJ 3. Managing Expectations The service accepts that in some cases patients and their representatives can be upset, angry and frustrated when contacting the service and staff will endeavor to take this into account when handling calls and be as helpful as possible. However, the service works within the framework of the NHS Zero Tolerance Policy and threats of violence or abusive language towards staff will not be tolerated. NHS MK&N reserves the right to remove the service in these cases. Patients/representatives should also be aware that there will be situations where the service is unable to provide the advice, information or signposting required and so the matter cannot be progressed further. In the case of frequent contacts where advice/information/signposting has been exhausted, the service will explain that an appropriate juncture has been reached to close the matter. Advice will be provided on the complaints process if the person wishes to pursue the matter NHS MK&N -COM-GOV Page 34 of 41

35 4. Storage of Information Information will be recorded and stored within a secure database managed and accessible by the service and this will conform to the relevant requirements of the data Protection Act and Caldecott Guidelines for Patient Confidentiality 5. Equality and Diversity The service opposes and challenges discrimination of any kind. Staff will respect and recognise the needs of all patients and clients regardless of age, race, religion, gender, sexual orientation, disabilities, non English speakers and other personal aspects indentifying with a person lifestyle. NHS MK&N -COM-GOV Page 35 of 41

36 APPENDIX F Equality Impact Assessment Questions and Definitions Yes/No Comments Name of document being assessed: Complaints Policy & Procedures Does the document/guidance content affect one group less or more favourably than another on the basis of: Race Religion or belief Refers to the protected characteristic of race. It refers to a group of people defined by their race, colour, nationality (e.g. citizenship), ethnic or national origins (e.g. gypsies and travellers) Religion has the meaning usually given to it but belief includes religious and philosophical beliefs including lack of belief (e.g. atheism). Generally, a belief should affect your life choices or the way you live for it to be included in the definition. No No The complaints leaflet has a translated passage in the County s top 7 languages giving details of how to contact the service. Translation services are available. The Independent Complaints Advocacy Service is available to anyone making an NHS complaint. Gender Refers to eliminating sex discrimination and harassment and to promote equality for women and men. No Sexual Orientation Whether a person's sexual attraction is towards their own sex, the opposite sex or to both sexes. No Gender Identity Whether a person's gender identity is with their own gender or the opposite gender. No Age Disability Socio- Economic This refers to a person belonging to a particular age group, which can mean people of the same age (e.g. 32-year-olds) or range of ages (e.g year-olds, or people over 50) A person has a disability if he or she has a physical or mental impairment which has a substantial and longterm adverse effect on that person's ability to carry out normal day-to-day activities. A group of people who face disadvantage based on their location, background and other protected characteristics e.g. Post Code Lottery - where they live means there life expectancy is lower. No No No The Complaints Policy and Procedures reflects Statutory Regulations in that a complaint must be made by a parent, guardian or representative if a child is age under 18 An A4 Policy Summary can be provided in a variety of formats. The Independent Complaints Advocacy Service is available to anyone making an NHS complaint. People can contact to make a complaint in a variety of ways including via a free phone line. The Independent Complaints Advocacy Service is available to anyone making an NHS complaint. NHS MK&N -COM-GOV Page 36 of 41

37 Carers A person cares for a child under 16 or a disabled child under 18, or if they re a carer for an adult, where it has an effect on that person's ability to carry out normal day-to-day activities. Is there any evidence that some groups are affected differently? If you have identified potential discrimination, are there any exceptions valid, legal and/or justifiable? Is the impact of the document/guidance likely to be negative? If so, can the impact be avoided? What alternative is there to achieving the document/guidance without the impact? Can we reduce the impact by taking different action? No People can contact make a complaint in a variety of ways including , in writing and via a free phone line. The Independent Complaints Advocacy Service is available to anyone making an NHS complaint If you have identified a potential discriminatory impact of this procedural document, please refer it to the HR Department, together with any suggestions as to the action required to avoid/reduce this impact. For advice in respect of answering the above questions, please contact Communications & Human Capital. NHS MK&N -COM-GOV Page 37 of 41

38 NHS Milton Keynes & Northamptonshire Local Counter Fraud Specialist and Complaints Department and Advice and Information Service Working Protocol April 2012 NHS MK&N -COM-GOV Page 38 of 41

39 CONTENTS 1. INTRODUCTION STRATEGY PROTOCOL 41 AS S IGNMENT CONTR OL Draft Protocol issued by LCFS Client Manager to Complaints Officer 26 April 2012 LCFS Client Manager Mark Trevallion Final Protocol Agreed Date 26 April 2012 Complaints Manager Claira Ferreira Director of Finance Gill Scoular 2012 RSM Tenon The information contained herein is of a general nature and is not intended to address the circumstances of any particular individual or entity. Unless otherwise stated copyright in the whole and every part of the information belongs to RSM Tenon, and may not be used, sold, licensed, copied or reproduced in whole or in part in any manner or form or in any media to any person without written consent. Although care has been taken to ensure the content accurate and timely, there can be no guarantee that such information is accurate as of the date it is received or that it will continue to be accurate in the future. RSM Tenon therefore accepts no liability for loss of any kind incurred as a result of reliance on the information or opinions provided in this document. No one should act on such information without appropriate professional advice after a thorough examination of the particular situation. RSM Tenon Limited is an independent member firm of RSM International an affiliation of independent accounting and consulting firms. RSM International is the name given to a network of independent accounting and consulting firms each of which practices in its own right. RSM International does not exist in any jurisdiction as a separate legal entity. RSM Tenon Limited (No ) is registered in England and Wales. Registered Office 66 Chiltern Street, London W1U 4GB. England NHS MK&N -COM-GOV Page 39 of 41

40 1. INTRODUCTION 1.1 It is imperative for the furtherance of successful counter fraud work within the PCT Cluster that the Local Counter Fraud Specialist (LCFS) and the Complaints Department have a good and clear understanding of each other s roles and responsibilities so that they can work closely together in the interests of the Trust and in accordance with all current legislation and Directions. 2. STRATEGY The LCFS recognises that the Complaints Department is responsible for managing the complaints process for the PCT Cluster. The Complaints Department understands that the LCFS has responsibility for investigating any case of alleged fraud, bribery and corruption that may occur within the PCT Cluster in accordance with the guidelines of the Secretary of State Directions and the NHS Counter Fraud and Corruption Manual. This does not mean that the Complaints Policy of the PCT Cluster may not immediately come into play, but that the LCFS and Complaints Manager must liaise very closely to ensure that the actions taken by each Department are complementary to each other. The LCFS and the Complaints Manager must be fully aware of each other s intentions and actions at all times when counter fraud activity involves a contractor (general practitioner, dentist, pharmacist, optometrist), on the PCT Cluster s respective list. The knowledge that the work is undertaken with cooperation and understanding will play a large part in developing and achieving a counter fraud culture and will further aid the prevention and deterrence of fraud, bribery and corruption, all of which are central to the strategy of NHS Protect in countering fraud in the NHS. It is recognised that each case of suspected fraud, bribery and corruption will need to be considered on its own particular merits. In achieving this, account will be given to the following: NHS Counter Fraud and Corruption Manual NHS Protect Policy Statement Applying Appropriate Sanctions Consistently Local employment policies and procedures Local Counter Fraud Policy Local Anti-Bribery Policy Local contracts with contractors Contractor Terms and Conditions of service NHS MK&N -COM-GOV Page 40 of 41

41 3. PROTOCOL RESPONSIBILITIES OF THE LCFS The LCFS will ensure that the Complaints Manager is fully briefed as to the work of counter fraud service in the NHS. The LCFS will ensure that the Advice and information Service is fully briefed as to the work of counter fraud service in the NHS. The LCFS will provide information and guidance as to the progress of a referral arising from a complaint. This liaison will also consider if there is any information and/or statements that can be imparted by the LCFS to the Complaints Manager in order to aid in the Complaints Process. RESPONSIBILITIES OF THE COMPLAINTS MANAGER The Complaints Manager will inform the LCFS as soon as possible if they become aware of any instances where complaints involve suspicious behaviour in respect of fraud, bribery and corruption with regard to any Trust member of staff or contractor. Preliminary enquiries by the Complaints Manager will not be undertaken with regard to complaints involving suspected fraud or instigated prior to consultation with the LCFS in order to avoid the potential loss or contamination of criminal evidence. RESPONSIBILITIES OF The Advice and Information Service (AIS) AIS staff will inform the LCFS as soon as possible if they become aware of any instances where cases involve suspected fraudulent behaviour with regard to any PCT Cluster member of staff or contractor. Problem resolution by the AIS will not be undertaken with regard to issues involving suspected fraud or instigated prior to consultation with the LCFS in order to avoid the potential loss or corruption of criminal evidence. To be read in conjunction with the NHS Milton Keynes & Northamptonshire s. NHS MK&N -COM-GOV Page 41 of 41