Complaints Policy. Version: 1.1. NHS Bury Clinical Commissioning Group Governing Body. Ratified by: Date ratified: 27 th March 2013

Transcription

1 Version: 1.1 Ratified by: NHS Bury Clinical Commissioning Group Governing Body Date ratified: 27 th March 2013 Name of originator /author (s): Responsible Committee / individual: Gareth Webb Quality and Risk Committee Date issued: 1 st April 2013 Review date: September 2013 Target audience: Impact Assessed: NHS Bury Clinical Commissioning Group Members and Staff Yes 1

2 Further information regarding this document Document name Category of Document in The Policy Schedule Author(s) Contact(s) for further information about this document This document should be read in conjunction with This document has been developed in consultation with Published by Copies of this document are available from CCG.GOV Governance Gareth Webb, Board Secretary PALS Policy, Incident Reporting Policy Quality and Risk Committee NHS Bury Clinical Commissioning Group 21 Silver Street Bury BL9 OSN The corporate PA office Version Control Version History: Version Number Reviewing Committee / Officer Date 0.1 = draft = Policy once ratified 2.1 = policy once reviewed NHS Bury Clinical Commissioning Group NHS Bury Clinical Commissioning Group 26 th September th March

3 Contents 1. Introduction 1.1 Status 1.2 Purpose & Scope 2. General Policy Statement 3. Definitions 3.1 Complaint 3.2 Policy 3.3 Corporate Policy 3.4 Patient Advice & Liaison Service (PALS) 3.5 Independent Complaints Advocacy Service (ICAS) 3.6 NHS Bury Clinical Commissioning Group Quality and Risk Committee 3.7 Parliamentary & Health Service Ombudsman (PHSO) 3.8 CCG Clinical Governing Body Member 3.9 NHS Bury Clinical Commissioning Group Complaints Manager 4. Duties and Responsibilities 4.1 Legal and Statutory duties and responsibilities 4.2 Specific duties and responsibilities within NHS Bury Clinical Commissioning Group Accountable Officer NHS Bury Clinical Commissioning Group Governing Body Managers NHS Bury Clinical Commissioning Group Complaints Manager Staff (permanent & temporary) Monitoring arrangements Ensuring patients or relatives are not disadvantaged Safeguarding Patients Panel 5. Procedures 6. Training Requirements 7. Implementation, Monitoring and Reviewing Appendix A: Complaints policy & procedure Appendix B: Timescales Appendix C: Policy To Deal With Vexatious Behaviour Appendix D: The Role of the Lay Conciliator Appendix E: Guidance Notes For Investigating A Complaint Appendix F: Template for producing an investigation report Appendix G: Protocol for Joint Working on Health and Social Care Complaints 3

4 1 Introduction 1.1 Status This is a Corporate Policy document. 1.2 Purpose & Scope This policy has a dual purpose: a. to ensure appropriate and timely response to the complaint and complainant; b. to ensure the organisation learns the causes of complaints and acts to prevent recurrence and improve the patient service. 2 General Policy Statement NHS Bury Clinical Commissioning Group is committed to implement the NHS Complaints Procedure. The patient will be at the centre of an impartial, fair and easily accessed system for dealing quickly and effectively with complaints. Complaints are an important source of feedback about the quality of NHS services and provide the organisation with an opportunity to continuously improve its services to patients, relatives and carers. The focus of this procedure is on prevention of recurrence and shared learning rather than apportionment of blame. This policy is reviewed and its content agreed and approved by the NHS Bury Clinical Commissioning Group Governing Body or its delegated Committee. The CCG will commission the processing of complaints from the Commissioning Support service (CSU); however accountability for managing and resolving complaints and ensuring lessons learned are implemented remains with the CCG. General Principles a. All complaints for which NHS Bury Clinical Commissioning Group is responsible, whether written or verbal, will receive a full response. b. All staff will be aware of NHS Bury Clinical Commissioning Group s Complaints Procedure and information about the procedure will be rolled out at staff induction programs. c. All staff will be able to advise and inform service users about the procedure and will be able to signpost complainants on to the NHS Bury Clinical Commissioning Group Complaints Manager. d. Staff directly cited in the complaint will be included in all correspondence with the complainant, as this has been shown to increase staff confidence in a low blame culture. 4

5 e. To promote a learning, low blame culture the procedure will be: (i) obvious and easily accessed; (ii) quick and efficient; (iii) open and transparent and not defensive; (iv) responsive by effecting improvements. f. Patient information leaflets explaining the NHS Complaints Procedure will be available on all NHS Bury Clinical Commissioning Group sites. g. All practices and community premises in Bury will display information in suitable places, informing users of their right to complain, how to use the relevant complaints procedure and who else may help e.g. Independent Complaints Advocacy Service (ICAS) and Patient Advice and Liaison Service (PALS). h. If errors have been made this should be acknowledged and, if appropriate, an apology given in accordance with the National Patient Safety Agency Being Open document. i. All complaints will be logged on to a confidential and secure database. j. Ensure robust complaints systems and processes are in place that provides reasonable assurance of compliance against the Standards for Better Health domains. k. To ensure lessons are learnt and patients are central to the sharing of this knowledge.' 3 Definitions 3.1 Complaint NHS Bury Clinical Commissioning Group defines a complaint as an expression of dissatisfaction requiring a response. All complaints whether oral or written, should receive a positive and full response, with the aim of satisfying the complainant that his/her concerns have been heeded. An apology should be offered, if appropriate at this point and an explanation provided and referral to any remedial action that is to follow. 3.2 Policy A policy is a statement representing a principle or course of action adopted by the organisation. It enables management and staff to make decisions and take action consistently and effectively, in line with relevant legislation, guidance, national service frameworks, organisation rules and good working practices. Compliance with relevant policies is required from all permanent and temporary employees, contractors and sub-contractors 5

6 3.3 Corporate Policy A policy applicable to corporate matters, generally defined as corporate governance, business and operational matters. A corporate policy is approved by the NHS Bury Clinical Commissioning Group Governing Body, and can only be changed by agreement of the Governing Body. 3.4 Patient Advice & Liaison Service (PALS) This is a patient-centred service to provide confidential and on the spot help. PALS have the duty to negotiate immediate solutions and provide relevant information and support to help resolve service users concerns quickly and efficiently. PALS provide a gateway to appropriate independent advice and advocacy support. 3.5 Independent Complaints Advocacy Service (ICAS) Independent Complaints Advocacy Services to assist individuals making complaints against the NHS. NHS Bury s Patients Forums commission and/or provide ICAS for their local population. ICAS function is to ensure complainants have access to the support they need to articulate their concerns and navigate the complaints system, thereby maximising the chances of their complaint being resolved more quickly and effectively. 3.6 NHS Bury Clinical Commissioning Group Quality and Risk Committee By their subjective nature complaints do not automatically reveal concerns about performance, but occasionally they may raise issues that come within the scope of the performance and disciplinary processes. For this reason the NHS Bury Clinical Commissioning Group s Quality and Risk Committee will regularly review reports containing information about patient experience including complaints as part of routine surveillance. The Group consists of a least one Executive Group Member, one Lay Member and CCG Clinical Governing Body Member. If a complaint raises immediate concern, the NHS Bury Clinical Commissioning Group Complaints Manager will inform the Accountable Officer so that appropriate action can be taken. 3.7 Parliamentary & Health Service Ombudsman (PHSO) Second stage complaints procedures; The PHSO carry out independent investigations into complaints about unfair or improper actions or poor service by UK government departments and their agencies and the NHS in England. Their aim is to put things right where they can and share lessons learned to improve public services. 3.8 CCG Clinical Governing Body Member From time to time complaints of a complex clinical nature may be received. In the event that such a complaint is received, the NHS Bury Clinical Commissioning Group Complaints Manager will seek advice and assistance from the designated CCG Governing Body Member. Furthermore, any clinical complaints causing the NHS Bury Clinical Commissioning Group Complaints Manager any concern should be referred in the first instance to the designated CCG Clinical Governing Body Member for consideration. 6

7 3.9 NHS Bury Clinical Commissioning Group Complaints Manager The authorised officer working on behalf of the CCG and Accountable Officer in the management and resolution of CCG complaints. 4 Duties and Responsibilities 4.1 Legal and Statutory duties and responsibilities The following general (Statutory) duties apply: a. Directions made by the National Health Service Act 1977, as subsequently amended, require NHS Trusts and Health Authorities to have written procedures for dealing with complaints within their organisation in line with the framework set out in the Directions. b. Every NHS Organisation is required to have a designated individual to respond to complaints. For the purpose of this document this person will be known as the NHS Bury Clinical Commissioning Group Complaints Manager. 4.2 Specific duties and responsibilities within NHS Bury Clinical Commissioning Group The following specific duties and responsibilities apply within NHS Bury Clinical Commissioning Group: Accountable Officer The Accountable Officer has overall responsibility for ensuring that there is a corporate response to all concerns raised, and for responding in writing to all complaints NHS Bury Clinical Commissioning Group Governing Body The Governing Body or its designated Committee will adopt the written complaints policy and supporting procedures. The Governing Body or its delegated Committee will receive quarterly and annual reports on complaints in order to: a. monitor arrangements for local complaints handling; b. consider trends in complaints; c. consider any lessons which can be learned from complaints, particularly for service improvement. d. Ensure lessons learned are implemented and monitored via the Quality and Risk Committee Managers If required managers are responsible for acting as first line of enquiry for complainants or staff seeking advice regarding a complaint, and providing a full and detailed written report 7

8 to the NHS Bury Clinical Commissioning Group Complaints Manager to enable the Accountable Officer to respond NHS Bury Clinical Commissioning Group Complaints Manager The NHS Bury Clinical Commissioning Group Complaints Manager will: Receive all complaints Ensure all complaints are logged on a central system Man a complaints advice line (This covers specific complaints process advice and information, PALS, general enquiries and providing info). Triage complaint Investigate complaint Draft a respond to complaint for the CCG to review and approve Develop a report for the CCG of learning s of complaints Dealing with outstanding issues / dissatisfied complaints Support onward referral to Ombudsman investigation Ensure On-going performance monitoring of complaints Provide the CCG with regular data regarding complaints handling to feed into formal reports considered by the Board or its designated Committee Provide data in relation to complaints to satisfy formal data returns Staff (permanent & temporary) Are responsible for co-operating with the implementation of this policy as part of their normal duties and responsibilities and for ensuring that any concern raised is dealt with appropriately Monitoring arrangements A monitoring form will be sent to a complainant with the acknowledgement letter to establish the age group and ethnicity of complainants. The ethnicity monitoring information is a requirement of the statutory complaints return to the Department of Health. Information relating to age is an area of good practice outlined within the NSF for Older People to ensure that local services do not indicate a disparity for older people ensuring compliance with Equality Act Ensuring patients or relatives are not disadvantaged The process set out in Appendix A is designed to ensure the handling of a complaint is in accordance with national guidance to maintain the confidentiality of the patient s information. The process for ensuring that patients, relatives and their carers are not treated differently as a result of raising a complaint is as follows:- Patients will be given a detailed verbal explanation of the process to ensure that they, and any others involved, are aware how any information related to the complaint will be handled. All enquiries will be carried out by the designated NHS Bury Clinical Commissioning Group Complaints Manager to ensure the separation of the service provider who is 8

9 directly providing the treatment from any involvement in the information collection relevant to the complaint. No information will be recorded in the patient s health records relating to the complaint being made Safeguarding All adults and children at risk of abuse and neglect should be able to access public organisations to obtain appropriate interventions which enable them to live a life free from fear, violence and abuse. During a complaint investigation, it may become apparent that such a vulnerable person may have been abused or may have made allegations of abuse. In these circumstances, it is essential that appropriate pathways are accessed in order that appropriate personnel can intervene to alleviate any distress being experienced and to progress the matter in line with NHS Bury Clinical Commissioning Group Safeguarding Policies and Procedures. The NHS Bury Clinical Commissioning Group Complaints Manager and all Investigating Officers should be made fully aware that if they suspect that a vulnerable person may have been abused or is experiencing abuse that they should immediately contact the Clinical Commissioning Group Safeguarding Lead Patients Panel Headlines and lessons learnt emanating from the complaints service will be central to the consideration of the Patients Panel who will ensure that appropriate issues are escalated to relevant agencies. 5 Procedures The Complaints Procedures for use by NHS Bury Clinical Commissioning Group staff is included at Appendix A. 6 Training Requirements NHS Bury Clinical Commissioning Group will ensure that all staff receive relevant training at the appropriate level. This will include, as a minimum: a. awareness raising/induction training; general training for all staff to enable them to respond appropriately to comments, questions and complaints; b. Detailed training in complaints handling for the NHS Bury Clinical Commissioning Group Complaints Manager plus other staff identified as regularly involved in dealing with complainants and/or their representatives. 7 Implementation, Monitoring and Reviewing 7.1 CCG Governing Body members are responsible for ensuring that this Policy is implemented. 9

10 7.2 The Clinical Support Unit (CSU) complaints management service will support the CCG in ensuring that this document is reviewed and, if necessary, revised in the light of legislative, guidance or organisational change. 7.3 This Policy will be reviewed no later than one year after issue or in light of any changes. 7.4 Any revisions to this document shall be agreed through the approval process. 10

11 COMPLAINTS POLICY & PROCEDURE APPENDICES 11

12 Appendix A Complaints Requirements This procedure has a dual purpose: (a) To ensure appropriate response to the complaint and complainant. (b) To ensure the organisation learns from the causes of complaints and acts to prevent recurrence and to improve the patient service. CONFIDENTIALITY Care will be take at all times to protect patient confidentiality and any patient identifiable information will be used on a need to know basis and then only that which is relevant to the investigation of the complaint. Patients will be advised that information from their health records may be disclosed to relevant staff members in order to resolve the complaint. When it is necessary to use patient s personal information to investigate a complaint it is not necessary to obtain patient s express consent. However, care must be taken at all times throughout the complaints procedure to ensure that any information disclosed about the patient is confined to that which is relevant to the investigation and only disclosed to those people who have a demonstrable need to know it for the purpose of investigating the complaint. Even so, it is good practice to explain to the patient that information from his/her health records may need to be disclosed to the manager concerned. If the patient objects to this, then the effect on the investigation will need to be explained. The patient s wishes should always be respected, unless there is an overriding public interest in continuing with the matter. (Taken from Complaints, Listening, Acting, Improving 1996) FREEDOM OF INFORMATION ACT 2000 Under the Freedom of Information Act 2000 NHS Bury Clinical Commissioning Group will make available information about the general operation of the policy and supporting procedures. Patient confidentiality will at all times be of paramount importance; if NHS Bury Clinical Commissioning Group considers that the information that has been requested may lead to identification of an individual or cause significant harm then the information may be withheld. In the case where information is requested and there are sections of the information that are exempt then the document should be clearly marked to show where exempt information is withheld. If all information is withheld, then NHS Bury Clinical Commissioning Group will have to give full reasons as to why the information has been withheld. There is a right of appeal to the Information Commissioner against any decision to withhold information if the person requesting access is not satisfied with the reasons. These actions are in line with the rights and responsibilities of the Freedom of Information Act

13 Key elements of The Local Authority Social Services and National Health Service Complaints (England) Regulations 2009 The new regulations introduced on the 1 st April 2009, take a more flexible approach towards handling individual complaints, which focuses on the needs and wishes of the people involved. It simplifies things so that it is much easier for people to share their experiences and for the organisations concerned to respond and make sure that the people s experience helps to improve services. The key changes are:- A complaint must be made within 12 months of the matter which is the subject of the complaint, unless there is good reason for not making it earlier and it is still possible to investigate Complaints received should be acknowledged within three working days. The CSU Complaints Manager/Investigating Officer liaises with the complainant to negotiate an agreed response time to the complaint. A complainant dissatisfied with the response can request the Parliamentary and Health Service Ombudsman to consider the complaint. Who can make a complaint? Anyone who is receiving, or has received, NHS treatment or services can complain. A complaint may be made by a person (referred to as a representative) acting on behalf of a person where that person has died; is a child; is unable by reason of physical incapacity or lack of capacity within the meaning of the Mental Capacity Act 2005 (a) or Has requested the representative to act on his/her behalf and provided written consent. How Complaints Will be Handled A Complaints concerning Independent Contractors (General Practitioners, Dentists, Pharmacists and Optometrists) i. Practices are responsible for resolving their own complaints and must have a complaints procedure. ii. Complainants will normally be referred back to the practice complaints system. iii. If the matter cannot be resolved at practice level, the Practice Manager will ensure that the complainant is advised of their right to pursue the matter further via the NHS Commissioning Board. B Complaints concerning NHS Bury Clinical Commissioning Group (including commissioning decisions), and employed staff (see Flowcharts at Appendix H) 13

14 i. Complaints received by NHS Bury Clinical Commissioning Group may be verbal or written (including electronic). ii. Complaints will be logged by the NHS Bury Clinical Commissioning Group Complaints Manager. iii. Complaints must be acknowledged within 3 working days. iv. All complaints will be entered onto the complaints database. v. Progress of complaints to be monitored on database (NHS Bury Clinical Commissioning Group Complaints Manager) C Complaints concerning Out of Hours Service i. Practices are responsible for resolving their own complaints and must have a complaints procedure. ii. Complainants will normally be referred back to the practice complaints system. iii. If the matter cannot be resolved at practice level, the Practice Manager will ensure that the complainant is advised of their right to pursue the matter further via the NHS National Commissioning Board.. How A Complaint Should be Made A complaint may be made orally or in writing (including electronic) to: i. The NHS Bury Clinical Commissioning Group Complaints Manager ii. The Accountable Officer. However, if a complaint is directed to any other individual in NHS Bury Clinical Commissioning Group, this can be processed by the NHS Bury Clinical Commissioning Group Complaints Manager on receipt of details. Raising Issue through PALS People with complex concerns and issues should be informed of what PALS can offer and be put in touch with the PALS Manager who will explain the various options available including pursuit of a formal complaint. Making a Verbal Complaint A person may wish to raise a complaint verbally with a member of staff. The member of staff should try to resolve the concern on the spot. If resolution is not possible this should be brought to the attention of the line manager who will try to resolve the issue or inform the complainant of the option of making a complaint in writing to the NHS Bury Clinical Commissioning Group Complaints Manager or the Accountable Officer. While members of staff should always encourage complainants to be forthcoming in expressing concern or dissatisfaction, the complainant should be given the option of making the complaint, in writing, to the NHS Bury Clinical Commissioning Group Complaints Manager or the Accountable Officer. Staff in key areas of contact, eg headquarters reception, should have easy access to complaints information leaflets. 14

15 Complainants should also be informed of the role of the Independent Complaints Advocacy Service. Where a complaint is made verbally, staff must make a written record of the complaint which includes the name of the complainant, the subject matter of the complaint and the date on which it was made. A copy of this information should be forwarded to the NHS Bury Clinical Commissioning Group Complaints Manager to respond to the complainant within three working days of the date on which the complaint was made with an invitation for the complainant to sign and return. Making a Written Complaint A person may prefer to make their initial complaint to someone who has not been involved in their care and therefore may wish to make their complaint in writing to the NHS Bury Clinical Commissioning Group Complaints Manager or to the Accountable Officer. All written complaints, however addressed, should be passed immediately to the NHS Bury Clinical Commissioning Group Complaints Manager to be responded to within the required timescales (see Appendix B). Habitual and or vexatious complainants Appropriate staff are trained to respond with patience and sympathy to the needs of all complainants but there are times when there is nothing further which can be reasonably done to assist complainants who make multiple or repeated complaints. Only after all reasonable measures have been taken to try to resolve the complaint should this be brought to the attention of the Accountable Officer who will review the issues in line with NHS Bury Clinical Commissioning Group s Vexatious Complainants Policy (Appendix C) and decide on a way forward. Complaints about Other Providers Complaints about Medical Practices, Dental Practices, Opticians and Pharmacists should be directed to the Practice Manager or Business Manager in the first instance. Complaints about other healthcare organisations should be directed to the appropriate complaints department at the relevant organisation. TIME SCALE It is important that complaints are made as soon as possible after the event occurs. Usually, complaints can only be investigated if they are: made within 12 months of the event or; made within 12 months of the complainant realising that he or she has something to complain about. There is discretion to extend the time limits, where it would be unreasonable in the circumstances of a particular case for the complaint to have been made earlier. When a complaint is made outside the time limits, it will be at the discretion of the Accountable Officer or responsible Director to consider an extension of the time limit. 15

16 In any case where NHS Bury Clinical Commissioning Group has decided not to investigate a complaint on the grounds that it was not made within the time limit, the complainant may request that the Parliamentary & Health Service Ombudsman consider it. Monitoring Complaints NHS Bury Clinical Commissioning Group Governing Body NHS Bury Clinical Commissioning Group has a statutory duty to monitor its clinical standards and complaints are an important indicator, which will inform the process of continuous service improvement. The NHS Bury Clinical Commissioning Group Governing Body or its designated Committee (Quality & Risk Committee) will receive quarterly reports on complaints summarising the causes and trends underlying complaints, and making recommendations for action. These reports will be copied to the relevant people responsible for implementing the recommendations. Lessons Learned and Shared Informal comments, surveys and complaints can provide a valuable opportunity to assess the services we commission. It is essential that we use that opportunity to see whether lessons can be learned by the service in question, and for the CCG as a whole. Directors are responsible for: - Disseminating lessons learned to colleagues within their division. - Sharing lessons learned with colleagues in other Divisions where appropriate. - Providing feedback to the NHS Bury Clinical Commissioning Group Complaints Manager on lessons learned and whether further action is needed. The NHS Bury Clinical Commissioning GroupComplaints Manager is responsible for: - Disseminating lessons learned to other organisations where the complaint has been made to more than one organisation. - Ensuring that external stakeholders such as MPs, councillors and other healthcare professionals raising complaints on a patient s or carer s behalf are made aware of lessons learned. - Producing pro forma documents, where actions are to be taken following complaints, and sending these to the appropriate managers. Following up on these documents to ensure the appropriate actions have been taken. - Ensuring that changes in practice are implemented where this is found to be appropriate. 16

17 Resolution of Complaints Stage 1 All complaints should be resolved in an open, fair, flexible and conciliatory fashion with Local Resolution of complaint at practice level, community team level, or by relevant Head of Service and managers. Where a complaint is made verbally staff must make a written record of the complaint which includes the name of the complainant, the subject matter of the complaint and the date on which it was made. A copy of this information should be forwarded to the NHS Bury Clinical Commissioning Group Complaints Manager to acknowledge the complaint within three working days of the date on which the complaint was made with an invitation for the complainant to sign and return. A copy of all information regarding the complaint should be forwarded to the NHS Bury Clinical Commissioning Group Complaints Manager. If the verbal complaint has been resolved on the spot and the complainant is happy with the outcome of their complaint, the NHS Bury Clinical Commissioning Group Complaints Manager should be advised accordingly. All complaints must be acknowledged within three working days of receipt, with a full written response produced within an agreed period of time (to be negotiated with the Complainant on receipt of the complaint). NHS Bury Clinical Commissioning Group will ensure that every effort is made to meet the agreed deadline for response, however if it becomes apparent that there is likely to be a delay in responding, the NHS Bury Clinical Commissioning Group Complaints Manager will re-negotiate the timescale for response. NHS Bury Clinical Commissioning Group hopes that as many complaints as possible will be resolved quickly through an immediate response or through subsequent investigation and/or with the use of NHS Bury Clinical Commissioning Group s Lay Conciliator (see Appendix D). Investigating a Complaint (see Appendix E) It is essential that all investigations be conducted in a manner that is supportive to those involved and takes place in a blame free atmosphere. The process is best described as listening, learning and improving. This includes providing anyone identified as the subject of a complaint with a full account of the reasons for the investigation, giving them an opportunity to talk to the NHS Bury Clinical Commissioning Group/CSU CSU Complaints Manager and ensuring they are kept informed of progress. All involved will be informed of the support services that are available to them. It is good practice for staff involved in the complaint to be interviewed by the investigating officer and written statements taken. This is to ensure that information is relayed correctly. In addition, to ensure that evidence which may be required at a later stage by the Parliamentary & Health Service Ombudsman is available, a record of the questions and answers at these interviews must also be kept. 17

18 NHS bodies now have a legal obligation to ensure conciliation and mediation services are available. NHS Bury Clinical Commissioning Group should make the services of the lay conciliator available to all branches of the organisation including Primary Care contractors. Responding to a Complaint It is important that a timely and effective response is provided in order to resolve the complaint, and to avoid escalation, eg 25 working days. The complainant should be kept informed of progress and, if appropriate, reasons for any delay and revised timeframe given. Responses to complainants should be clear, accurate, balanced, simple, fair and easy to understand. They should avoid technical terms wherever possible, but where technical terms must be used to describe a situation, event or condition, an explanation of those terms should be provided. All points raised in the complaint should be addressed. Where the investigation finds that something should have been done differently, or identifies an area of improvement, this should be clearly stated in the response, together with an explanation and outline of the action point if applicable. Once the formal response has been sent it will be shared with those involved in the investigation and named in the complaint. Complaints, which relate to individual members of staff, will not be kept on personal files, unless the complaint results in any sort of capability or disciplinary action in which case the rules of the disciplinary procedure will apply. Equally, complaints from patients will not be kept in their health records. NOTE: Verbal and written replies to the complainant should identify actions taken, lessons learned, implementation of actions, and monitoring compliance and outcome. Stage 2 Parliamentary & Health Service Ombudsman (PHSO) If a complainant is not satisfied with the outcome of local resolution of a complaint against a primary care contractor or against NHS Bury Clinical Commissioning Group, then a complainant can request that the matter be referred on to the second stage of the complaints procedure, the Parliamentary and Health Service Ombudsman. From 1 st April 2009, the PHSO took over the responsibility for the second stage of the NHS Complaints Procedure. Applications to the PHSO can be made either orally or in writing and the Complainant will be supplied with contact details of the PHSO in the response letter. Points to Note The Complaints Procedure The Complaints Procedure is a local application of the Local Authority Social Services and National Health Service Complaints (England) Regulations 2009, which came into force on 1 st April

19 These regulations emphasised the requirement for quick and efficient responses and resolutions of complaints with robust actions from recommendations providing individual, service and organisational learning to prevent reoccurrence. The need for good communication with the complainant and better understanding of their issues, coupled with resolution and learning, means closer working with the complainant by establishing first contact early and efficiently. The main objectives of this complaints procedure are: i. to provide a simple procedure with common features, for complaints about any services commissioned by NHS Bury Clinical Commissioning Group, as part of the NHS; ii. ease of access for patients and complainants; iii. more rapid, open processes; iv. emphasis on local resolution; v. fairness for staff and complainants alike; vi. to provide an approach that is honest and thorough with the prime aim of satisfying the concerns of the complainant; vii. To improve the quality of services by acting on lessons learned. What can and cannot be dealt with in the Complaints Procedure? The complaints procedure applies to anything connected with services or treatment provided by the NHS. Some things that cannot be dealt with under the NHS complaints system include: a. Complaints about private treatment unless it has been commissioned by NHS Bury Clinical Commissioning Group; b. Complaints about Independent Sector/Partnerships; c. Events requiring investigation by a professional disciplinary body; d. Complaints regarding an NHS Body s alleged failure to comply with data subject request under the Data Protection Act 1998 or a request for information under the Freedom of Information Act 2000 are to be dealt with separately from the NHS Complaints Procedure. Processes are in place for patients who wish to make a complaint about these subjects and they should be referred on to the appropriate Service Lead for action. e. Whistleblowing - if staff feel that they need to raise a concern, in confidence, under this procedure then they should contact the NHS Bury Clinical Commissioning Group Governing Body Secretary. The NHS Bury Clinical Commissioning Group Complaints Manager will be able to clarify whether the complaint is about the NHS if an individual is unsure. Complaints not required to be dealt with A complaint which is made orally and is resolved to the complainant s satisfaction not later than the next working day after the day on which the complaint was made shall not be deemed to be regarded as a complaint but will be recorded separately from the complaints database. 19

20 Complaints involving Independent Sector/Partnerships A framework for responding to complaints delivered by more than one organisation has been produced jointly with the Local Authority Social Services Department, Pennine Acute Hospitals NHS Trust and Pennine Care NHS Foundation Trust (see Appendix G). However, where NHS Bury Clinical Commissioning Group receives a complaint that relates solely to the local authority, the NHS Bury Clinical Commissioning Group Complaints Manager will:- Within 5 working days of receipt, seek to obtain the consent of the complainant to referring the complaint to the local authority. Where the complainant does not want the complaint to be forwarded to the relevant local authority, they will be advised that NHS Bury Clinical Commissioning Group is unable to deal with the complaint further and that if they wish to pursue it further they must contact the local authority. Separation of Complaints from Disciplinary Procedures The purpose of the Complaints Procedure is to investigate complaints with the aim of satisfying the complainant whilst being scrupulously fair to staff. It is, however, inevitable that in some cases information will be identified which indicates the need for disciplinary investigation. A complaint about which NHS Bury Clinical Commissioning Group is taking or is proposing to take disciplinary proceedings in relation to the substance of the complaint will be excluded from the Complaints Procedure. It will not be a function of the Complaints Procedure to investigate disciplinary matters. Where a complaint indicates prima facie case for referral to any of the following: i. Investigation under the disciplinary procedure; ii. A professional regulatory body; iii. An independent enquiry into a serious incident (Section 84 NHS Act 1977); iv. Investigation of a criminal offence; The NHS Bury Clinical Commissioning Group Complaints Manager will not be responsible for the decision to initiate investigation or action under any of the above. Where such referral or action is taken the Complaints Procedure will cease. The NHS Bury Clinical Commissioning Group Complaints Manager will: i. ensure the relevant information is passed to the appropriate manager to determine if such action is to proceed; ii. Inform the complainant if investigation is to be initiated under the above alternative arrangements. Investigation under the Complaints Procedure of all aspects of the complaint relevant to the alternative procedure will then be suspended; 20

21 iii. iv. proceed with a complete investigation and management of aspects of the complaint which are not the subject of an alternative procedure; Ensure that upon completion of any alternative procedure any outstanding aspect of the Complaints Procedure is addressed. This may include informing the complainant in general terms of any disciplinary sanction which might be imposed. 21

22 APPENDIX B TIMESCALES EVENT Original Complaint TIME ALLOWED 12 months from event, or 12 months of becoming aware of a cause for complaint. There is discretion to extend the time limits for making a complaint within reason. Local Resolution Written and Verbal Complaints Acknowledgement Full response by NHS Bury Clinical Commissioning Group / Practice Dealt with on the spot or referred. 3 working days of receipt To be negotiated with the complainant upon receipt of the complaint. However, if NHS Bury Clinical Commissioning Group is unable to contact the complainant then we will aim to provide a response within 25 working days of receipt. Advise complainant of the Second Stage Complaints Procedure Parliamentary & Health Service Ombudsman (PHSO) - providing contact telephone number, website information and postal address details Currently there is no information regarding timescales for investigation with the PHSO 22

23 APPENDIX C Policy to Deal with Vexatious Behaviour DEFINITION Vex: Vexatious: To harass, to distress, to annoy, to tease, to trouble, agitate, disturb, to discuss to excess. Vexing, wantonly troublesome. Why Do We Need A Policy? A small number of complainants use a disproportionate amount of time (and resources) in pursuing complaints causing undue stress for all concerned. Sadly they usually achieve nothing positive at the end of it, often ending up more dissatisfied. Although NHS Bury Clinical Commissioning Group must ensure that the NHS complaints procedure is accessible, and that all complaints are fully investigated and answered, it is in everyone s interests that ongoing communication continues to be effective, and also that communication should not be continued when nothing further can reasonably be done to resolve the complaint or to rectify a real or perceived problem. The aim of a vexatious behaviour policy is to encourage a modification of vexatious behaviour to help the parties to resolve the complaint. People may show vexatious behaviour for several reasons and they may be completely unaware that their behaviour is causing distress to others. For example, vexatious behaviour may be more often shown by people who:- are aggressive have a personality disorder/mental health problem have social or emotional problems lack family or other support Although this policy refers to complainants, it is equally applicable to any person contacting NHS Bury Clinical Commissioning Group whose behaviour meets the criteria. What is Vexatious Behaviour? It is accepted that in the initial contact from anyone making a complaint to NHS Bury Clinical Commissioning Group the complainant may act out of character, for example aggressively, and staff should make allowances for such behaviour. However, unacceptable behaviour that continues through several contacts should be considered against the background of this policy. Whilst there is no one feature of vexatious behaviour, and all types of such behaviour may be appropriate in certain circumstances, the following criteria may be indicative of vexatious behaviour:- Continuing to pursue a complaint that has been completed outside the statutory steps provided for complainants. 23

24 Prolonging contact with NHS Bury Clinical Commissioning Group by continually raising further concerns or questions that are a repetition of already answered questions. Unwilling to accept the evidence provided, but have no contra evidence. Will not identify the precise subject matter of the complaint. Harassing or being personally abusive or verbally aggressive. Threatening or using actual physical violence. Making an excessive number of contacts with NHS Bury Clinical Commissioning Group. Secretly recording meetings or conversations without consent. Making unreasonable demands or having unreasonable expectations and failing to accept that these demands might be unreasonable. Conviction of conspiracy theories. Complete unwillingness to comply with the NHS complaints procedure yet determination to proceed on their own agenda. Can We Prevent Complaints From Becoming Vexatious? Within the first few contacts, staff can usually identify complaints that may become vexatious. We therefore propose a two stage procedure aimed at trying to prevent this and to help all involved. Stage 1 At an early stage, complainants who are identified by staff as demonstrating vexatious behaviour should be responded to within a framework outlined in this policy. The specific actions to be taken should be agreed at a case conference involving those staff likely to be contacted by the complainant. This case conference should involve others as appropriate, e.g. CCG Governing Body members. Action should be specifically targeted to try and help the complainant and staff involved depending on the type of behaviour the complainant is exhibiting. For example:- Challenge threats, unreasonable demands and manipulation, e.g. if you put me under emotional pressure/threaten me I cannot help you with your complaint. I must remain objective and fair to both parties. State to the complainant how the complaint will be handled, and that the procedure will be followed. Time limit on telephone conversations (number and duration). Use of recorded delivery postage. Refusal to meet with complainant unless meetings are pre-arranged. Imposing and strictly adhering to deadlines for responses etc. One person to be identified as the sole contact point for the complainant. Stage 2 24

25 If this does not have the desired effect and the situation deteriorates, then a report on complainants who continue to act vexatiously and in a way that prevents fair operation of the complaints procedure should be prepared, together with a note of action already taken for the Accountable Officer or their deputies, for a decision on further action. The decision will be notified to members of staff likely to be contacted by the complainant and each case is available or review if appropriate. Possible actions at stage 2 any actions at stage 1 plus:- Inform the complainant why their behaviour is preventing any possible resolution of the complaint. Draw up 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. Notify the complainant in writing that the points raised have been fully responded to and that to continue contact on this matter would serve no useful purpose. Take solicitors advice if appropriate. 25

26 APPENDIX D NHS Bury Clinical Commissioning Group The Role of the Lay Conciliator The Lay Conciliator Who Am I? I am an independent lay person who can assist with handling complaints in the early stages of the NHS Complaints Procedure. I try to find common ground and a way to resolve problems. It is important that I do not take sides but it is not my role to cover up poor practice. Any information given to me by either party is completely confidential between me and the parties and I do not report any information to anywhere unless both parties are in agreement for me to do so. What I cannot do I cannot help a patient who seeks to get financial compensation. Also I cannot be involved in complaints about private treatment, or when legal action has been started or with complaints which involve criminal activity. When do I become involved? I can become involved at any point in the complaint. Either a patient or a practitioner can ask me to take a look at the problem but both parties must agree to my involvement. What is my aim? Ideally all complaints should be dealt with by the party complained against but I can provide an independent service for both parties. My aim is to resolve the problem, enable relationships to continue and to improve the services offered to all patients. How Do I Work? The initial letter It helps if a patient s concerns can be put in writing with an indication of what they would like the outcome of a complaint to be. For example this can be a full explanation about what has happened, what steps have been taken to put the matter right or an explanation of what steps have been taken to try to ensure that it does not happen again. A letter of explanation The appropriate representative of the relevant service will be asked if they wish to submit any initial comments on the letter and this will be forwarded to the complainant for information. If satisfied with the explanation, the complainant may choose not to take any further action. An informal meeting If you are not satisfied you may have an informal meeting with those involved, along with me. Meetings will take place at a mutually convenient place near to where the patient lives and any records need to be readily available. 26

27 I meet the patient just before the meeting to see if they wish to ask the questions or for me to ask their questions for them. At the meeting the only people present are the person who the complaint is against, the complainant, myself and an independent practitioner whom I may ask to come along. I try to select someone not known to the practitioner and their role is to answer any questions the patient may have. They also clarify any clinical terms for myself and the complainant. The meeting is kept as informal as possible. Patients sometimes bring a relative or neighbour with them, but it does help if they ask first. After the informal meeting Within a few days of the meeting you will receive a letter from me with a brief outline of the issues discussed. If you are not happy with the outcome of the meeting the NHS Bury Clinical Commissioning Group Complaints Manager will advise of the options available to you. A brief description of the term conciliation is set out below: Conciliation is the use of discussion, persuasion and communication skills, particularly listening, by a lay person who has no previous involvement in the matter in dispute or of the parties involved. The conciliator will not adopt any stance or personal view, but will attempt to assist the parties to achieve their own agreement. 27

28 APPENDIX E Guidance Notes for Investigating A complaint The following information is provided to assist investigating officers in conducting a complaints investigation. 1. Consider who has made the complaint and why: There may be a genuine reason for the complainant making the complaint The complainant may have a personal vendetta The complainant may be a vexatious complainer 2. Identify who is being complained about. There may be more than one person being complained about. 3. Read through the complaint and identify the specific allegations. Identify what the complainant is asking for, a complainant often only wants an apology. Consider the seriousness of the complaint. If serious allegations have been made about an NHS Bury Clinical Commissioning Group employee, you may need to consider contacting the HR Consultant for advice. 4. Contact who is being complained about and ask them to provide a written account of their version of events. This statement must be signed and dated by the author. 5. If other people witnessed the incident, ask them to provide a signed, written witness statement. 6. Gather documentary evidence, for example clinical/nursing records, which may assist in the investigation. When considering the records you need to be mindful of the following: Errors Inconsistences with statements Ommissions Overwriting Non-chronological entries Deviation from usual procedures of protocols 7. Upon receipt of all the evidence, invite the person being complained about to have an investigation interview to clarify any outstanding points and satisfy yourself that you are able to make an informed decision about the outcome. 8. It is the Investigating Officer s duty to provide the NHS Bury Clinical Commissioning Group Complaints Manager with a written report (see attached template at Appendix G). Following completion of the investigation: REMEMBER the complainant may request a copy of the Investigating Officer s Report. Please ensure that you are happy with the content and its presentation! 28

29 APPENDIX F TEMPLATE FOR PRODUCING AN INVESTIGATION REPORT NATURE OF COMPLAINT Identify and list the allegations contained in the letter of complaint. ANALYSIS Analyse all of the information received from written statements, interviews and any documentary evidence produced during the investigation. Any conflicting information should also be identified and raised as a point of concern in the report. It would be useful for the Investigating Officer to include a sequence of events of their investigation, for example: date of receipt of complaint date of request for statement from employee date of receipt of statement from employee date of receipt of clinical notes or other documentary evidence date of interview and who was present Please note it would be helpful if you did not use jargon. If you do, please provide an explanation. CONCLUSION It is the Investigating Officer s responsibility to come to a conclusion for each allegation made. That conclusion is made on the weight of evidence provided. The Investigating Officer may fully support the member of staff complained about, or be sufficiently concerned to believe the account of the complainant. This is an opportunity for the Investigating Officer to identify what went wrong, if anything, and if anything did go wrong, why? The Investigating Officer must be able to satisfy themselves at this point that their investigation process was robust and they have gained all the facts necessary to make an informed decision. 29

30 RECOMMENDATIONS The Investigating Officer should identify any recommendations that are to be made as a result of the investigation. You may wish to consider one or more of the following options:- No action required Apologise and offer a remedy Are there lessons to be learned from the complaint and if so, what action is to be taken Does the complaint identify a gap in services Does the complaint identify that policies/procedures/services need to be tightened Do staff need training/re-training If recommendations are to be made, the Investigating Officer must provide an action plan detailing the timescale for completion of the recommendation and advise the name of the person responsible for ensuring the task is completed. The Investigation Report should be signed off by the Investigating Officer or the Director level officer of the service complained about. NB At the conclusion of the complaint and based on the timescales identified in the report, it will be the duty of the NHS Bury Clinical Commissioning Group Complaints Manager to contact the Investigating Officer or Director level officer to ensure that any actions taken as a result of the recommendations are fully implemented and working. 30

31 APPENDIX G Protocol for Joint Working on Health and Social Care Complaints This protocol relates to the Pennine Acute Hospitals NHS Trust, Pennine Care NHS Foundation Trust, NHS Bury Clinical Commissioning Group, NHS Community Services Bury and Bury Metropolitan Borough Council when completing a joint complaint investigation. Document Number and Version: EDG015 1 Authorised by: Gavin Barclay Date authorised: Next review date: Document Author: Sara Renwick Main Revisions from previous issue Name of Previous Document: Document Number: Protocol for Joint Working on Health/ Social Care Services Complaints EDG015 Version Number: 2 Reason for Revision: Introduction of Statutory Instrument 2009 No. 309 Bury Council Protocol for Joint Working on Health and Social Care Complaints (Draft Version 3) 31