Validation Date: 29/11/2013. Ratified Date: 14/01/2014. Review dates may alter if any significant changes are made

Transcription

1 Document Type: PROCEDURE Title: Complaints Management Scope: Trust Wide Author/Originator and title: Eleanor Carter, Patient Experience Facilitator Paul Jebb, Assistant Director of Nursing (Patient Experience) Replaces: Version 5, CORP/POL/015, Complaints Policy Name Of: Divisional/Directorate/Working Group: Validated by: Clinical Governance Management Team Meeting Ratified by: Marie Thompson, Director of Nursing and Quality Unique Identifier: CORP/PROC/633 Version Number: 1.1 Status: Ratified Classification: Organisational Responsibility: Clinical Governance Directorate Description of amendments: Author Trust format Version 1.1 minor typo errors and missing links rectified Date of Meeting: Validation Date: 29/11/2013 Ratified Date: 14/01/2014 Review dates may alter if any significant changes are made Risk Assessment: Not Applicable Financial Implications Not Applicable Which Principles of the NHS Constitution Apply? 1-4 Issue Date: 14/01/2014 Review Date: 01/12/2016 Does this document meet the requirements of the Equality Act 2010 in relation to Race, Religion and Belief, Age, Disability, Gender, Sexual Orientation, Gender Identity, Pregnancy & Maternity, Marriage and Civil Partnership, Carers, Human Rights and Social Economic Deprivation discrimination? Initial Assessment

2 CONTENTS 1 PURPOSE SCOPE PROCEDURE Introduction Raising a Complaint Definition and Terminology Who Can Raise A Complaint? Raising a Complaint On Behalf Of A Patient Complaints Which Can Be Addressed Raising a Complaint At The Point Of Service Delivery Raising a Formal Complaint Timeframes For Raising A Formal Complaint Timescales for the Resolution of Formal Complaints Raising a Complaint about More Than One Area of The Trust Raising a Complaint outside the Remit of the Trust Roles and Responsibilities in the Resolution of Complaints Trust Board Patient Experience Involvement Committee Patient Champion Complaints Review Panel Chief Executive Medical Director Director of Nursing and Quality Executive Directors Deputy Directors of Operations Assistant Director of Nursing (Patient Experience) Directorate Managers Quality / Patient Experience Managers Medical Consultants Matron/ Ward/ Service Manager Divisional Complaints Manager Patient Relations Team Communications Manager All Staff Internal Management of Complaints Receipt and Acknowledgement of Complaints Receipt and Acknowledgement of a Formal Complaint Assessing the Severity of a Complaint Possible Claims for Negligence Equality and Diversity Investigation Contents of the Formal Response Communication with the Complainant Complaints Escalation Procedure Issuing the Final Response Support for Staff Involved In Complaints Parliamentary Health Service Ombudsman (PHSO) Vextatious Complainants Lessons Learned Page 2 of 39

3 3.9 Awareness and Publicity Organisational Development and Training ATTACHMENTS ELECTRONIC AND MANUAL RECORDING OF INFORMATION LOCATIONS THIS DOCUMENT ISSUED TO OTHER RELEVANT/ASSOCIATED DOCUMENTS SUPPORTING REFERENCES/EVIDENCE BASED DOCUMENTS CONSULTATION WITH STAFF AND PATIENTS DEFINITIONS/GLOSSARY OF TERMS AUTHOR/DIVISIONAL/DIRECTORATE MANAGER APPROVAL Appendix 1: Complaints Procedure Flow Diagram Appendix 2: Every Voice Counts > Person Centred Check List Appendix 3: Patient Consent Form Appendix 4: E-Complaint Referral Form Appendix 5: Complaints Management Plan Appendix 6: Staff Statement Template Appendix 7: Executive Director Escalation Procedure Appendix 8: Support For Staff Involved In A Complaint, Claim Or Incident Appendix 9: Complaints Evaluation Survey Appendix 10: Equality Impact Assessment Form Page 3 of 39

4 1 PURPOSE The Complaints Management Procedure was produced to give clear guidance on how the Trust deals with complaints and assist all involved in providing a quick but thorough response from those who know the most about the complainant s care. The policy and procedure will: Ensure that the Trust is compliant with the Health and Social Care Act (DOH, 2008), the NHS Constitution (DOH, 2009) and the Local Authority Social Service and National Health Service Complaints Regulations Ensure that all complaints are reviewed for seriousness of consequence on receipt. Serious clinical complaints will be highlighted with the Medical Director, Director of Nursing and Directorate / Service Managers to ensure that appropriate immediate action is instigated. Describe the principles of the Trust which will include the standards of conduct expected of Trust staff and individual roles and responsibilities when dealing with complaints. Ensure that complainants receive a high quality service throughout the process in accordance with the Department of Health s Listening, responding and improving A Guide to Better Customer Care (2009). Ensure that no patient or their representative will experience any adverse action or discrimination as a result of making a complaint and relevant equalities legislation are followed to ensure that no one is discriminated against for their gender, age, disability, gender reassignment, marriage or civil partnership, maternity or pregnancy sexual orientation, race, belief or religion. Ensure that integrated working practices are in place to deal with complaints which span across both acute and community healthcare sectors of the Trust and across divisions. Ensure that an action plan will be completed for all complaints including those which have been deemed serious, evidencing practical changes and progress to complainants, Directorate / Service Managers and the Complaints Review Panel. 2 SCOPE This Policy applies to all staff employed by Blackpool Teaching Hospitals NHS Foundation Trust and is applicable for all of our service users. Page 4 of 39

5 3 PROCEDURE 3.1 Introduction is committed to ensuring that our patients, their relatives and carers, have an excellent experience whilst using our services. Should patients or their representatives be dissatisfied with the standard of care provided by the Trust they have a right to be heard and for their concerns to be dealt with promptly and courteously as set out in the NHS Complaints Procedure. Complaints often act as an early warning sign of failings in systems and processes which need to be addressed, the Trust, therefore, welcomes this form of feedback to monitor, change and improve the services it provides to the local community, preventing problems from re-occurring in the future. This policy explains how the Trust handles complaints, operating with transparency, openness and in collaboration with the complainant to address their issues and provide detailed answers which are full, frank and honest. It also stipulates how under no circumstances complainants will be treated adversely as the result of making a complaint. 3.2 Raising a Complaint Definition and Terminology Complaint - Any expression of dissatisfaction or grievance by a patient, carer or family member rose verbally or in written / electronic format which requires an investigation and response under the NHS Complaint Regulations. There is a national two stage process for handling complaints, consisting of local resolution and referral to the Parliamentary Health Service Ombudsman (PHSO). This Trust tries to resolves all complaints locally within relevant departments, only escalating to the PHSO if all internal modes of enquiry have been exhausted Who Can Raise A Complaint? Complaints can be raised by: People who are receiving or who have received services from the Trust; People affected or likely to be affected by the actions, errors or decisions of the Trust; Staff members if they have a concern relating to patient care; A third party acting on behalf of a person who is unable to raise a concern e.g. a young child or someone who lacks capacity to act on their own behalf; or because that person wants someone else to represent them and has provided written consent; A third party on behalf of a person who has died and who has a sufficient involvement with the patient s welfare and is a suitable person to act as a representative. A Member of Parliament (MP) or other advocate who has evidence of contact from the patient expressing their request to be involved. Page 5 of 39

6 3.2.3 Raising a Complaint On Behalf Of A Patient Care must be taken not to disclose any personal health information without first seeking the patient s authority to do so via the Patient Relations Team using the patient consent form (Appendix 3). If a patient has not authorised someone to act on their behalf, or if the Patient Relations Team is of the opinion that the person seems unsuitable to act as a representative, he / she will notify that person over the telephone or in writing, giving the reasons for his / her decision for the complaint not to be investigated. The Trust will however, ensure the patient is receiving the correct care and that any issues raised in the complaint are investigated and rectified. If a patient has died or through physical or mental incapacity the patient is unable to give consent the complaint can be investigated through the NHS Complaints Procedure. In this situation staff will give particular attention to respecting patient confidentiality and to any requirement expressed by the patient on disclosing information to third parties. In the case of a child, the representative must be a parent, guardian or other adult person who has care of the child. 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 Complaints Which Can Be Addressed Patients or their representatives can raise complaints about any service, decision and / or care and treatment that has been provided by Blackpool Teaching Hospitals NHS Foundation Trust. Staff members can not investigate complaints which are: Made by an employee of a local authority or NHS body about any matter relating to that employment; Relating to a commissioning care provider; Being or has been investigated by the Public Health Services Ombudsman; or an MP or other parliamentary advocate; Already resolved to the complainant s satisfaction no later than the next working day after the day on which the complaint was made; A formal complaint previously made and resolved satisfactorily by clinical leaders, unless the Trust considers it needs to look into the issue again and then it must follow the formal process for handling and investigation; Relating to an NHS body s alleged failure to comply with a data subject request under the Data Protection Act, 1998(a), or a request for information under the Freedom of Information Act, 2000(b) Raising a Complaint At The Point Of Service Delivery When something is not right the best time to deal with it is at the time it happens e.g. criticisms about care on the ward or department, waiting times, meals or transport arrangements, can often be cleared up at the time they occur. All patients and their representatives are encouraged to raise a complaint of this type at the point of service delivery because a number of benefits can be achieved, such as: the issue being dealt with promptly, locally as most complaints are easy to address; Page 6 of 39

7 a reduced likelihood of similar issues arising again; an improvement in patient safety; a reduced number of complaints that are escalated through the formal complaint process; a better experience for people wishing to raise a complaint; a better standard and quality of care; potential reduction in the cost of legal fees; increased public confidence in the services provided by the Trust and NHS overall. All complaints given at the point of service delivery will be resolved as quickly as possible in accordance with national guidelines and preferably within 24 working hours. The clinical member of staff who is addressing the complainants concerns needs to document the issue on the e-complaints referral form (appendix 4) on SharePoint which can be accessed on the homepage of the Intranet site or in the patient experience section: The clinical member of staff will set out the issues which required investigation and list all actions taken and the outcome, before getting it approved by the ward / service manager or matron for the area so it can be submitted. If appropriate the form should also be printed out and shown to the complainant, so it can be agreed as being a true reflection of their complaint. It will then need to be submitted to the Patient Relations Team to be logged on the Ulysses Safeguard Customer Service database. If the complainant was happy with the outcome no further action is required. If the complainant indicates that they are unhappy with the outcome, the Patient Relations Team will initiate the formal complaints process or refer them onto the Parliamentary Health Service Ombudsman if local resolution has been exhausted. The Patient Relations Team will escalate any complaints they receive to the area involved, if they can be resolved within 24 working hours, ensuring that area logs the grievance on the e-complaint system Raising a Formal Complaint Patients and their representatives can raise a formal complaint about the Trust by: By telephone or in person if the complaint is given verbally or the complainant is either unable or unwilling to make a written statement, a written record must be made by the Patient Relations Team setting out the issues requiring investigation. This must be agreed with the complainant and ideally signed. A refusal by the complainant to sign a statement is in no way a reason not to investigate the complaint fully. The complainant must be given a copy of any statement he / she signs. In writing - a complaint can be sent directly to the Patient Relations Team via the Trust s website, using the online complaint form which can be accessed at: Letters or s can also be sent in setting out the key areas of concern they want investigating. Page 7 of 39

8 3.2.7 Timeframes For Raising A Formal Complaint A formal complaint should be made no later than 12 months after the date on which the matter occurred, or no later than 12 months after the date on which the matter came to the notice of the complainant. Where a complaint falls outside of this, the Patient Relations Team may extend the timescales, if they are of the opinion that the Complainant had good reasons for not making the complaint sooner. The Patient Relations Team will also have to consider whether or not, despite the passage of time, it is still possible to investigate the complaint effectively and efficiently. Where it is refused to extend these time limits, the complainant will be informed of this decision by the Chief Executive or Executive Directors and they will be informed of their right to ask The Parliamentary Health Service Ombudsman to consider the decision Timescales for the Resolution of Formal Complaints Any complaint should be dealt with efficiently and be investigated properly and appropriately. It is best practice and Trust policy to send the final response to the complainant in an average time of 25 working days. However the actual time to respond will be determined by the Patient Relations Team s risk assessment on receipt of the complaint. This could be extended to 35 working days with the agreement of the complainant if a lot of preliminary work is needed before moving on to investigate the complaint under the Regulations or if the complaint is complex in nature and involves more than one division or responsible NHS body Raising a Complaint about More Than One Area of The Trust If a formal complaint is made which is multi-divisional, investigation leads from each division will be nominated by the Patient Relations Team at the beginning of the process to provide a response. It is the responsibility of all divisions involved to ensure that their investigation leads receive full cooperation so a coordinated, timely and thorough response can be drafted. If it is necessary to change the lead this must be agreed between the divisions and the Patient Relations Team. The complainant must be kept informed of any changes to the management of their complaint and be told from the outset they will receive their complaint within 35 working days Raising a Complaint outside the Remit of the Trust Where a complaint involves concerns that are outside the management responsibility of the Trust, the Patient Relations Team will contact the complainant and obtain consent to forward a copy of the complaint to the relevant organisation asking that they investigate the aspects of the complaint that are pertinent to their organisation and respond directly to the complainant. If a complaint is received that crosses services provided by the Trust and other organisations the Trust must attempt to coordinate a full response for the complainant. In order to achieve this it will be necessary to obtain consent from the complainant to share the complainant s information with the other organisations. The Patient Relations Team will request authorisation in writing from the complainant prior to registering the complaint. On receipt of authorisation from the complainant the complaint letter / form will be Page 8 of 39

9 forwarded to the organisations for them to investigate concerns, with a copy stored electronically in the complaint file. The complainant must be told from the outset they will receive their complaint within 35 working days. 3.3 Roles and Responsibilities in the Resolution of Complaints Key organisational duties are identified as follows: Trust Board Receives monthly reports on complaints and the action taken. Receives reports from the Parliamentary Health Service Ombudsman and from Independent Reviews, addressing any identified areas of weakness. Develops and monitors action plans to ensure learning from complaints and service improvement. Monitors the complaints policy and handling arrangements, taking action to address any failings Patient Experience Involvement Committee Has responsibility for developing, implementing and monitoring the Trust s Complaints Management Policy and Procedure, the Complaints Review Panel and quarterly patient experience reports Patient Champion Ensures that the Director of Nursing and Quality and the Assistant Director of Nursing (Patient Experience) communicate with patients and their families to obtain feedback about their experiences, reporting it to the relevant committees. Suggest patient complaint stories for Board meetings and Governors Patient Experience Committee meetings. Provide a detailed report to the Patient Experience Involvement Committee on a quarterly basis Complaints Review Panel Review selected divisions upheld complaints on a monthly basis. Address if the divisions complaints have been managed in line within the agreed timeframe; if they were investigated thoroughly and proportionally; if the response was appropriately coordinated and delegated. Review evidence from directorate / service managers to show that lessons learned have been embedded in practice and disseminated locally and across the organisation as appropriate. Discover what emerging themes / trends are arising from upheld complaints at the Trust. Review vexatious complainants cases and agree a suitable response Chief Executive Overall responsibility for ensuring that effective controls are in place to support the management of complaints. Receives a monthly report on complaints and the action taken, including an evaluation of the effectiveness of the action. Receives written complaints and is responsible for agreement and signature on all formal responses. Page 9 of 39

10 3.3.6 Medical Director Ensure that immediate action is instigated as the result of a serious clinical complaint. Provides advice and assistance in relation to a complaint investigation. Resolve difficulties on any aspect of Medical issues raised in a complaint. Liaise with clinicians when appropriate to ensure they will supply comprehensive answers to the divisional complaints manager within 5-10 working days of receipt Director of Nursing and Quality Receive and reviews the monthly complaint report and the quarterly Patient Experience report to understand the learning points for the Trust and actions completed or required. Provide a copy of the above report to the Trust Board. Ensure that immediate action is instigated as the result of a serious clinical complaint. Offers to meet with complainant following receipt of Parliamentary Health Service Ombudsman reports, or those where such action is felt appropriate Executive Directors Have responsibility for ensuring that appropriate mechanisms for reporting, managing and learning from complaints are in place. Enforce the zero tolerance complaint escalation procedure (appendix 7) if a complaint looks like it will breach the target date. Agree any compensation payments to be made and confirmation of appropriate budget, in accordance with the appropriate service team Deputy Directors of Operations Have responsibility for ensuring all complaint investigations are timely and comprehensive and that corrective actions are implemented by the Divisional Management team, enforcing zero tolerance escalation procedure if the complaint looks like it will breach. Meet with complainants where necessary. Approves and signs off final complaints responses before they are submitted to the Chief Executive or Executive Directors for final signature Assistant Director of Nursing (Patient Experience) Has lead responsibility for management of all concerns and complaints, ensures that operational procedures and protocols are in place to facilitate the NHS Complaints Procedure in accordance with the regulations. Responsible for producing information for the monthly complaint reports and quarterly Quality Reports regarding formal complaints, including information regarding complaints being upheld by the Ombudsman. Also responsible for producing an annual report for trend comparison and patient satisfaction surveys. Page 10 of 39

11 Directorate Managers Ensure all staff working within the Directorate is familiar with the Trust s formal Complaints Management Procedure CORP/POL/633. Arrange complaints training for staff within the division and where necessary identify new / additional training. Review every formal complaint that is received in relation to the service they are responsible for, to maintain an overview of the service. Ensure staff are delivering concise and accurate responses addressing all concerns, within 5-10 working days, including immediate remedial action taken. Review the final written response prior to the investigation report being sent to the Chief Executive, ensuring it s robust, effective and patient centred, answering all the questions of the complainant. Monitor staff performance and manage performance following a formal complaint. Fully support all members of staff who are involved in a formal complaint. This support may be immediate or ongoing in nature depending upon the circumstances and individual needs of that member of staff. Occupational Health may be used for counselling and stress management if required. Ensure that all formal complaint action plans have been implemented by sourcing evidence of practical changes and reviewing complaint numbers to identify if similar concerns continue to be raised. Report progress at the monthly Complaints Review Panel Quality / Patient Experience Managers Ensure action plans are developed as a result of complaints and concerns are monitored appropriately. Ensure individual complaints and trend data are considered at directorate and group level to ensure all learning is identified and implemented. Ensure that all completed action plans are discussed at the relevant directorate governance meetings and ensure sign off of action plans is documented in the meetings minutes Medical Consultants Assist with a full investigation of a complaint providing comprehensive answers to the Divisional Complaints Manager within 5-10 working days of receipt of the letter of complaint. Ensure where this is not possible that the Divisional Complaints Manager is notified of the reasons and a date when the information can reasonably be provided. Provide an objective evaluation of the complaints they ve received to the Complaints Review Panel. Ensure patients who raise a concern in their care are aware of the options available to them to pursue their concern, try and deal with them informally and promptly. Ensure to take immediate action where failures have been identified to reduce the likelihood that further harm to other patients/carers will occur in the future Matron/ Ward/ Service Manager Respond to all concerns/ complaints at the point of service delivery within 24 working hours overseeing all actions taken on the e-complaints referral form. Assist with a full investigation of a formal complaint providing comprehensive answers to the divisional complaints manager within 5-10 working days of receipt of Page 11 of 39

12 the letter of complaint. Ensure where this is not possible that the Patient Relations Team is notified of the reasons and a date when the information can reasonably be provided. Empower all staff in area to be familiar with the Trust s Complaints Management Procedure CORP/POL/633. Ensure to take immediate action where failures have been identified to reduce the likelihood that further harm to other patients / carers will occur in the future. Notify the Patients Relations Team as soon as possible if they have been involved in any event likely to give rise to a formal complaint. Meet with newly appointed staff to ensure appreciation of the complaints process, their role and responsibility. Be responsible for providing information on how to take a complaint forward and ensure complaint literature is easily accessible to patients within the clinical area Divisional Complaints Manager Co-ordinate an investigation into the issues raised following the Trust s Complaint Procedure. Safeguard the complaint file adhering to Trust policies for confidentiality. Ensure full details of the complaint are not kept in the patient s medical file. Keep the complaint file up to date on the system and that all contacts made during the investigation are clearly recorded. Link closely with the Directorate or Divisional Manager to ensure seamless communication throughout the process and make arrangements for meetings if necessary. Liaise and obtain relevant information for the investigation from the division to draft a response to the complaint, ensuring that any matters of medical care or clinical judgement is agreed by the consultant or clinician concerned before it is sent out. Assist the Parliamentary and Health Service Ombudsman (PHSO) with any investigation undertaken within the stated timescales. Review department s written responses / statements, alerting Directorate or Divisional Managers if they are not robust, effective and patient centred, or do not answer all the questions of the complainant within 10 days of the final response being needed. Enforce the Executive Director Escalation Procedure (Appendix 7) if they are having trouble getting a response/statement from the clinical area involved in the complaint to ensure it doesn t breach the specified time frame Patient Relations Team Liaise with Matrons or Ward / Service Managers to manage complaints that can be resolved within 24 working hours. Support staff in raising a complaint about their clinical area. Inform the divisional complaints managers and Trust litigation staff of any formal complaints as appropriate. Notify Assistant Director of Nursing (Patient Experience) of any complaint which relates in whole or part to an incident. Agree who will take lead responsibility for coordination of the investigation of all aspects of the complaint. Provide information, and listen to the concerns of the patient/carer/relative, as well as liaising with health professionals, statutory organisations and voluntary groups. Page 12 of 39

13 Be the liaison person between client and hospital teams to resolve complaints. Take a proactive approach to resolve complaints without a formal written response wherever possible. This may involve inviting the complainant in for a meeting with those involved in their care or the use of external conciliation services if necessary. Link closely and regularly with the complainant throughout the process, as appropriate, and ensure that all correspondence is noted within the complaint file. Actively raise awareness of the complaint process through promotional materials, presentations and attendance at local events. Monitor and report activity to the Patient Experience Involvement Committee and Complaints Review Panel. Provide the divisions with monthly performance data. Refer complainants onto the Complaints Review Panel or Parliamentary and Health Service Ombudsman (PHSO) when they raise issues which have already been investigated and answered by the Trust. Deliver complaints training to staff through sessions arranged by the patient experience team and according to the induction policy and the Mandatory Training policy. Such sessions will provide details of the complaints procedure and focus on a number of issues such as process, investigations, preventing discrimination and improving services. Further responsibilities are listed in the CORP/PROC/403 Operational Procedure Patient Relations Department Communications Manager The Communications Manager will ensure that media interest is managed if they become involved in a complaint. She / he will decide, in collaboration with the Director of Nursing or Medical Director, whether any information will be disclosed to the press, the content of a press statement, who will answer press enquiries and whether media access to the area will be given. The Communications Manager will draft material as appropriate, discuss with Chief Executive (or nominated Executive), and issue material / prepare for interviews etc. as appropriate All Staff Encourage patients and carers to raise any concerns they may have about their care and treatment at the earliest opportunity, adhering to the Trust s Person Centred Checklist (see appendix 2). Make every effort to deal with issues as they arise, informally and promptly within 24 working hours. Ensure the person raising the issue is consulted about how they wish their complaint to be handled and clearly record this on the e-complaint referral form on share point. Read and be familiar with the Complaints Management Procedure CORP/POL/633. All staff have a responsibility for ensuring that the principles outlined within this document are universally applied. Attend complaints training as identified in the mandatory training policy. Inform ward / service managers and more senior clinicians where it has not been possible to resolve a complainant s concerns. Make sure the complainant is fully informed of what is being done to resolve their concerns and if they are a patient that their immediate needs are met. Page 13 of 39

14 Where the complainant wishes to make a formal complaint, staff should ensure that they give them the appropriate complaints leaflet and support and that the Patient Relations Team are notified of the complaint immediately. 3.4 Internal Management of Complaints Receipt and Acknowledgement of Complaints Every staff member must deal with any serious issue raised promptly; making a record of all actions taken using the e-complaint referral form (appendix 4) on Share Point. Where issues are sent from a member of the Patient Relations team, the e-complaint referral form must still be completed by the ward / service manager or matron so the Patient Relations team can identify how the matter was resolved. The complainant must be informed when it is not possible to adhere to the 24 working hour s time scale and be given a reason for the delay along with a realistic deadline for the response. If a member of staff has to deal with a complaint about another department, the relevant manager should be contacted and invited to see the complainant to see if the problem can be resolved. The Trust information leaflet Compliment s, Concerns and Complaints should be given to the person with the concerns so they can decide how they would like their issue taken forward Receipt and Acknowledgement of a Formal Complaint On receipt of a complaint the patient relations team will make contact and provide an acknowledgment to the Complainant within three working days. This will be accompanied by the Trust information leaflet Compliment s, Concerns and Complaints (PL/790) which includes information on the complaint process and the Independent Complaints and Advocacy Service (ICAS). They will also discuss with the complainant: The manner in which the complaint is to be handled. The complainant may want a phone call from the manager in charge of the service, a meeting to talk about their concerns or they may require a full investigation with a written response. The period of time in which the investigation into the complaint is likely to be completed. Through a risk assessment the Trust will agree a reasonable timescale which allows a thorough investigation to be carried out. Any extended timeframe for responding will be confirmed with the patient verbally or in writing. Their expectations, it s essential to ascertain what key issues they want addressing in a response to their complaint Assessing the Severity of a Complaint All complaints will be recorded on the Trust s Customer Service Database, Ulysses, and the Patient Relations Team will risk assess and grade them in order to determine the level of investigation required using the Complaint Management Plan (appendix 5). If a complaint is graded moderately or above then the investigation should involve senior staff from within the division. Any complaint that receives a high categorisation will be Page 14 of 39

15 shared with the Litigation Team, Assistant Director of Nursing (Patient Experience), Medical Director and Director of Nursing. Following the outcome of the investigation, the complaint may be re-graded if appropriate Possible Claims for Negligence If a review of a complaint reveals a case of negligence, or if it is thought that there is a likelihood of legal action being taken, the divisional complaints manager will ensure the Claims Department is notified and has access to the appropriate information after the response to the complainant has been provided. They will ensure the National Health Service Litigation Authority (NHSLA) is informed appropriately within the agreed timescales Equality and Diversity All complaints received are treated in an open and unbiased manner in accordance with the Equality Act 2010 and the Public Sector Duty and covers all the protected characteristics and Human Rights Investigation Throughout the investigation process the complainant will be kept informed, as far as reasonably practicable, of the progress of the investigation by the Patient Relations Team. The Divisional Complaints Managers will assume full responsibility for informing those who have been identified in the complaint. They will issue the area involved a copy of the complaint outlining the requirements and timeframe for a response. Requests for statements will also be made if: A member of staff has been named in a complaint, the line manager for the individual will be provided with details of the complaint and the individual will be requested to provide a statement in response to the complaint. If a complaint relates to an agency member of staff then the relevant agency is advised of the complaint and a statement will be requested. All statements and draft responses should follow a set template (appendix 6) and be forwarded to the Divisional Complaints Manager within 5-10 working days. They should answer all aspects of the complaint, identify any contributory causes and include an outline of any agreed action to take following the complaint. Guidelines for investigating and responding to formal complaints can be found in the Better Practice Guide to Complaint Handling. If upon receipt of the complaint, the senior manager from the area involved is of the opinion that the complaint does not relate to them or their department and has been sent in error, it is the responsibility of the Divisional Complaints Manager to amend the database and complaint file accordingly. The Divisional Complaints Manager will ensure that all documentation from staff including correspondence and written statements are contained electronically in the complaints file. For a checklist of what to include in the file please review the Trust s Management of Complaint Files Procedure (CORP/GUID/416). Page 15 of 39

16 3.4.7 Contents of the Formal Response The response to a formal complaint must include: A resume of the complaint. Who has been involved in the investigation of the complaint. A detailed explanation of what has been found during the investigation and where appropriate, apologies given. An explanation as to what will be undertaken to prevent a recurrence. An opportunity to meet to discuss their concerns with the relevant members of staff should they wish to. Details of the complainant s right to request an Independent Review by the Parliamentary Health Service Ombudsman and how to make this request Communication with the Complainant The Patient Relations team must ensure that the complainant is kept updated in a timely manner about the investigation. The Divisional Complaints Manager should give consideration to inviting the complainant to attend meetings with staff and at what stage in the investigation those should most usefully be arranged. It can do more harm for clinical staff to meet a patient too early; neither should things be left so long that the person raising the concern feels they have been forgotten about. Timing should be carefully considered to allow everyone to prepare and for any meeting to be as useful as possible Complaints Escalation Procedure The Trust has a duty to try and resolve all complaints within an average time of 25 working days depending on the complexity of the case. If the Divisional Complaints Manager is having difficulty obtaining statements or comments from a division, or if the division have said they will be unable to meet the target date, then the Executive Director Escalation Procedure (appendix 7) must be implemented. If this is implemented and the complaint still looks like it will breach the target date the Patient Relations Team will need to contact the complainant and negotiate an extended timescale and this will be confirmed in a holding letter to the complainant. The Ulysses system will be updated to reflect these new timescales and information on non-responders will be forwarded to their relevant Manager / Director to be included as part of the annual appraisal process if appropriate Issuing the Final Response The Divisional Complaint Manager will draft the final response to the complaint. The Deputy Director of Operations (DDOP) or nominated divisional manager will then review the response if it is felt that more information is needed they will request that this is provided before the response is forwarded to the Chief Executive for signature. The final response for signing must be passed to the Chief Executive at least 5 working days prior to the target date and must be ed to the Patient Relations Team, along Page 16 of 39

17 with the completed investigation file. If the Division is going to be unable to meet this deadline, thereby jeopardising the Trusts ability to meet the target date, then the Divisional Complaints Manager must be informed immediately to implement the Executive Director Escalation procedure and let the complainant know there will be a delay. 3.5 Support for Staff Involved In Complaints Being the subject of a complaint or even reporting one as a member of staff can be very stressful. In terms of being the subject of a complaint, when an issue is raised, whether by a patient or through a report from a member of staff, the details should be shared with the staff member involved wherever appropriate. This should be done supportively and staff may want to have a member of their professional association or Trade Union representative present in any meetings. Consideration should also be given under the Human Resource (HR) policies as to whether a staff member may need more proactive support such as counselling through Occupational Health. Further details are outlined in the procedure Supporting Staff Involved in a Traumatic / Stressful Incident, Complaint or Claim CORP/PROC/550. In terms of staff who report concerns, consideration should also be given as to whether they may require specific support. If a staff member feels uncomfortable raising a complaint with their line manager, or in their clinical area then they should contact the Patients Relations Team for assistance and advice. A Support for Staff guide involved in a complaint is available to all staff (Appendix 8). This information is also available on the intranet under the complaints web page. Please refer to the Supporting Staff involved in Traumatic/Stressful Incidents, Complaints or Claims Procedure (CORP/PROC/550, see section 7) for further information. 3.6 Parliamentary Health Service Ombudsman (PHSO) Once local resolution has been exhausted with a complaint and the complainant is still not satisfied with the outcome they have a right to request an independent review carried out by the Parliamentary Health Service Ombudsman. After ensuring that the complaint is within their jurisdiction the Ombudsman may check that everything has been done to resolve the issue locally. If they don t investigate they will write to the Trust informing them that they will not uphold the case. If the case is investigated and they think more can be done they will refer the issue back to the Trust to rectify matters. If the PHSO recommends that a financial penalty be paid this will be in cases of any direct or indirect financial loss, loss of opportunity, inconvenience, distress or any combination of these. If the recommended financial penalty is up to 1000, then the Division responsible should pay the stated amount to the complainant. If the recommended amount is over 1000 then the Trust legal advisor will need to be informed by the division and legal advice sought in conjunction with the NHSLA whether Page 17 of 39

18 the payment would be accepted as a potential Clinical Negligence Scheme For Trusts (CNST) claim and as such payment would be made by the NHSLA. If this is not accepted by the NHSLA the legal advisor will refer the matter back to the Division to decide if any payment should be made or refused. The Trust will respond to correspondence submitted by the Ombudsman and action their requests within the timescales specified. Following completion of all recommendations the Patient Relations Team will close the case on Ulysses Safeguard database. 3.7 Vextatious Complainants People raising complaints have the right to be heard, understood and respected and every effort should be made to assure individuals that their complaint will be investigated thoroughly. However, there may be times when the distress of a situation leads to the person acting out of character and becoming determined, forceful, and angry, making unreasonable demands of staff, even resorting to violence. They may also persistently pursue their complaint by phoning, writing, or turning up repeatedly in the Patient Relations office despite being advised on the other avenues available to them. Behaviour like this that escalates into actual or potential aggression towards staff is not acceptable. Please refer to the Vexatious Complaints Policy CORP/POL/153 (see section 7) for guidance. 3.8 Lessons Learned Complaints monitoring is a tool which can help facilitate both local and wider learning within the Trust. Once the response has been sent to the complainant, the Patient Relations Team will forward a copy of the response by to the Directorate Manager. The Directorate Manager must then provide a copy of the response to all staff involved in the complaint for their information and highlight any lessons learned to the Division and the monthly Complaints Review Panel when requested. Quarterly Patient Experience and monthly complaint reports will be produced, containing both qualitative and quantitative data, specifically detailing the number of complaints received by each Division, the percentage of complaints that received a response within the stated deadline, a breakdown of complaints for each department or ward and the number of complaints that related to clinical care and non-clinical care. The reports will be made available to both internal and external stakeholders and NHS organisations where appropriate and will include the actions taken in response to highlighted trends within complaints, to improve services and reduce and eliminate identified risks. Progress against the identified actions will be monitored by the Patient Experience Involvement Committee. A Trust wide adverse events bulletin will also be prepared quarterly that includes information on themes of complaints and issues raised through the Patient Relations Team. This will be circulated throughout the Trust to enhance and inform the personal and professional development of staff and learning from complaints will be included in staff Page 18 of 39

19 appraisals and professional development plans. Quarterly reviews of the Complaints Evaluation Survey (appendix 9) will monitor the effectiveness of the complaint process overall. The complaint survey is issued to all complainants along with their final response and focuses on a number of issues including accessibility to the service, availability of information, timeliness, discrimination, communication and overall process problems. The results of the survey will be captured and shared with each division and included in the quarterly Quality Report. The results will also be discussed at the Patient Experience and Involvement Committee. 3.9 Awareness and Publicity The Trust is obliged to ensure that patients and their representatives know how to raise a complaint. This is will be achieved by: Literature available through the Trust in the form of posters and leaflets. These must be kept in all clinical waiting areas and in the hospital bays and main corridors and will be subject to monitoring through the Patient Experience Team. Information and advice given through the Patient Relations Team. Prominent positioning of information on the Trust s website. Ensuring Trust staff are supplying accurate information through Corporate Induction and further training Organisational Development and Training Front line staff at all levels within the Trust must receive mandatory training to enable them to comply with the Management of Complaints Procedure (CORP/POL/633). They will be shown how to log complaints on SharePoint, respond to complaint enquiries and draft statements. It is envisaged that the delivery of training for the new arrangements will be approached locally and through a selection of national training resources, where applicable. These include: digital patient stories; use of training videos and classroom and e-learning methods. The Patient Relations Team will be required to contribute to the induction and training of all new members of staff, and investigation leads are expected to have attended root cause analysis training and complaints handling training as identified in the Induction and Mandatory Training policy (CORP/POL/045). Directorates can also request further support from the Patient Experience Team who will develop and deliver bespoke training and workshops to assist their staff in dealing with a customer-focused approach. Page 19 of 39

20 4 ATTACHMENTS Appendix Number Title Appendix 1 Complaints Procedure Flow Diagram Appendix 2 Every Voice Counts > Person Centred Check List Appendix 3 Patient Consent Form Appendix 4 E-Complaint Referral Form Appendix 5 Complaints Management Plan Appendix 6 Staff Statement Template Appendix 7 Executive Director Escalation Procedure Appendix 8 Support For Staff Involved In A Complaint, Claim Or Incident Appendix 9 Complaints Evaluation Survey Appendix 10 Equality Impact Assessment Form 5 ELECTRONIC AND MANUAL RECORDING OF INFORMATION Electronic Database for Procedural Documents Held by Policy Co-ordinators/Archive Office 6 LOCATIONS THIS DOCUMENT ISSUED TO Copy No Location Date Issued 1 Intranet 14/01/ Wards, Departments and Service 14/01/ OTHER RELEVANT/ASSOCIATED DOCUMENTS Unique Identifier Title and web links from the document library CORP/GUID/424 Better Practice Guide to Complaint Handling docx CORP/GUID/416 Management of Complaint Files Procedure doc CORP/POL/045 Induction and Mandatory Training Policy docx CORP/POL/155 The Systematic approach for Managing Incidents, Complaints and Claims docx CORP/POL/153 Vexatious Complaints Policy doc CORP/POL/354 Mandatory Risk Management Training Policy docx CORP/PROC/101 Untoward Incident and Serious Incident Reporting Procedure docx CORP/PROC/403 Operational Procedure Patient Relations Department docx Page 20 of 39

21 7 OTHER RELEVANT/ASSOCIATED DOCUMENTS Unique Identifier Title and web links from the document library CORP/PROC/416 Management of Complaint Files (Procedure) doc CORP/PROC/550 Traumatic / Stressful Incident, Complaint or Claim doc CORP/STRAT/006 Risk Management Strategy ( ) docx PL/790 Compliment s, Concerns and Complaints iments,%20complaints%20and%20concerns.pdf 8 SUPPORTING REFERENCES/EVIDENCE BASED DOCUMENTS References In Full Crown. (1998). Data Protection Act Available: Last accessed 14/01/2014. Crown. (2000). Freedom of Information Act Available: Last accessed 14/01/2014. Crown. (2009). The Local Authority Social Services and National Health Service Complaints (England) Regulations Available: Last accessed 14/01/2014. Crown. (2010). Equality Act Available: Last accessed 14/01/2014. Health and Social Care Act (DOH, 2008) Crown. (2012). Health and Social Care Act Available: Last accessed 14/01/2014. Crown. (8 March 2012). NHS Constitution for England. Available: Last accessed 14/01/2014. Department of Health s Listening, responding and improving A Guide to Better Customer Care (2009). NHS Choices. (2013). Making a complaint. Available: spx. Last accessed 14/01/ CONSULTATION WITH STAFF AND PATIENTS Name Designation Marie Thompson Director of Nursing and Quality Mark O Donnell Medical Director Dean Quinn Patient Experience Manager Wendy Thompson Patient Relations Manager Christine McLellan Complaints Manager Karen McLellan Complaints Manager Barbara Becker Assurance and Compliance Manager Jane Roskell Governance Policy Co-ordinator Margaret Forrest Governance Assistant Page 21 of 39

22 10 DEFINITIONS/GLOSSARY OF TERMS CNST Clinical Negligence Scheme For Trusts DDOP Deputy Director of Operations HR Human Resource ICAS Independent Complaints and Advocacy Service MP Member of Parliament NHS National Health Service NHSLA National Health Service Litigation Authority PHSO Parliamentary Health Service Ombudsman 11 AUTHOR/DIVISIONAL/DIRECTORATE MANAGER APPROVAL Issued By Eleanor Carter Checked By Paul Jebb Job Title Patient Experience Job Title Assistant Director of Facilitator Nursing (Patient Experience) Date January 2014 Date January 2014 Page 22 of 39

23 Appendix 1: Complaints Procedure Flow Diagram Complaint received or written letter? In person? Can the complaint be resolved within 24 working hours? No The Patient Relations Team will grade and acknowledge the complaint within 3 working days, discussing the next steps with the client. Ye s Work with the matron or service manager to reply to the client within the time frame, addressing all of their concerns in a polite and patient manner. Complaint will be shared with directorate and complaint manager for a response within an average time of 25 working days. Document the complaint, listing all actions taken on the e- Complaint referral form on SharePoint. A comprehensive response will be provided, ensuring all keys issues are addressed and any remedial actions are taken thoroughly. Print and show the client the form, so it can be agreed as being a true reflection of their complaint before submitting it. Response approved and signed off by the Chief Executive, issued to complainant along with an evaluation survey. Were they satisfied? complainant happy? Ye s No Submit the complaint referral form so it can be taken up by the Patient Relations Team in case any further actions are required. Case closed. Client can request further Trust investigation or contact the PHSO to look into their case. Page 23 of 39

24 Appendix 2: Every Voice Counts > Person Centred Check List is committed to ensuring its processes are more person centred by being responsive, open and accountable when managing all concerns and complaints. The following checklist should be adhered to by all members of staff within the Trust: Principles Accessibility Welcome and encourage all questions, queries, concerns of complaints from staff, patients, their carers or relatives. Openness Be open and clear about how we decide actions and why. Operate a proper system of accountability. Sensitivity Handle all concerns or complaints sympathetically and sensitively to not reduce, deny or marginalise people s feelings. Responsiveness Resolve issues and concerns without the need to trigger a formal complaint in the first place. Acknowledge and put right poor levels of service. Promptness Welcome all complaints, processing and resolving them swiftly to avoid delays. Action taken >Ensure that there is a comprehensive range of support and complaints information available at all times. > Ensure that differences in language, culture and vulnerability are taken into account when handling issues. > Ensure to seek help from the Patient Relations Team or Departmental Manager if uncomfortable addressing the issue. > Ensure a named contact is given of who will be looking into the enquiry. >Ensure to explain process, timescales and possible limitations of the investigation >Ensure patients and their representatives never chase up answers or are left for long periods of time without contact. > Advise the client clearly about the outcome of the investigation and explain any remedial action taken thoroughly. > Ensure to make an admission of responsibility and an apology, offering reassurance that lessons will be learned and sanctions put in place if an individual is clearly at fault. >Respect feelings, what might seem like a trivial or unimportant matter to one person is of great significance to another. > Acknowledge the emotional trauma suffered from poor care, illness and bereavement in the response. >Ensure the approach to the investigation matches the seriousness of the issues involved. > Telephone or facilitate meetings to try and resolve matters quickly and effectively without the need for a formal written response. >Provide an explanation in situations where there might be a delay, agreeing reasonable timescales and informing them of the stage the complaint has reached in the system. >Ensure all responses to investigations are provided within 10 working days. Page 24 of 39

25 Appendix 2: Every Voice Counts > Person Centred Check List Support Promote advocacy, representation and support to those who need and want it. >Ensure they are aware of the NHS Complaints Advocacy Service so they can pursue their complaint effectively. >Provide an interpreter or communication support, if required. >Address what level of support and reassurance staff might need if their involved in Fairness Offer responses that are fair and proportionate. Treat people without bias, prejudice or unlawful discrimination an investigation. > Explain that the Trust will consider what care and treatment was given; > Explain that the investigation will consider the client s suggestions for remedy. > Ensure to discuss and agree the best method of feedback, i.e. meeting or in writing. > Ensure they don t experience any adverse action or discrimination as a result of making a complaint and relevant equalities legislation are followed at all times. Page 25 of 39

26 Appendix 3: Patient Consent Form Patient Relations Team Berry Offices Whinney Heys Road Blackpool FY3 8NR Complaint Reference: A complaint has been made by On behalf of:.. :.... The signed consent of. is required in order that confidentiality is maintained and protected. Therefore please sign and date the sections below marked signed & dated. Please note: We are unable to proceed with releasing any information unless the necessary consent has been obtained. In the event of a complaint being made on behalf of a minor, the consent to proceed must be given by a parent or guardian. In certain circumstances where the patient is a young person, the agreement/consent of the young person may also be sought. I hereby give my consent for the organisation/s listed below to share any relevant information in order to complete the investigation into my complaint. I understand that this is likely to include disclosure of my personal records.. (Lead Organisation). (Organisation). (Organisation) This will assist the investigation of a joint organisation complaint. I understand that the information exchanged must be used solely for the purpose for which it is obtained. Signed Date Once completed, please return this consent form in the freepost envelope provided. Page 26 of 39

27 Appendix 4: E-Complaint Referral Form Page 27 of 39

28 Appendix 4: E-Complaint Referral Form Page 28 of 39

29 Appendix 5: Complaints Management Plan Complainant - Case Number - Patient - Complainant Address & Telephone Number Patient Address - Relationship to Patient Consent Y/N Hospital Number - Proof of Rep Y/N Date of Birth - Date Letter Received Date Contacted and by who Letter Meeting Days to Complete Initial Grading Complainant is seeking? (apology/explanation) Rare Unlikely Possible Likely Almost Certain Low Minor Serious Major Disaster Other Organisations Involved TO BE COMPLETED BY INVESTIGATING DIVISION/MANAGER Summary of Complaint: Investigation Lead: This must include everyone involved and highlight those who have been complained about please so we can register. Staff involved (inc consultant and area if different from above) Page 29 of 39

30 Appendix 5: Complaints Management Plan All of the following to be completed by Directorate Outcome (Tick) Upheld Partially Upheld Not Upheld Withdrawn Was meeting held with Complainant? (Delete as appropriate) Yes No If there were any delays in providing the complainant with a response, please state below the reasons for this: ACTION PLAN Action to be followed up by Clinical Case No. Name Division Governance Issue/Problem Action Progress Lead/Owner Target Date Lessons Learnt Page 30 of 39

31 Appendix 5: Complaints Management Plan Complaints Grading Consequence x Likelihood Rare Unlikely Possible Likely Almost Score Certain Low Descriptor Rare Unlikely Possible Likely Almost Minor Frequency Not expected to occur for years Serious Probability Will only occur in exceptional circumstances Major Disaster Expected to occur at least annually Unlikely to occur Divisional Complaints Grading Consequence & Likelihood (L) C x L x = Expected to occur at least monthly Reasonable chance of occurring Expected to occur at least weekly Likely to occur certain Expected to occur at least daily More likely to occur than not Investigation Lead.Date Directorate Manager..Date Page 31 of 39

32 Appendix 6: Staff Statement Template Full Name: Position and Grade: Location / Ward / Dept / Team: Contact Number: Date and Time of incident: Complaint case number: Main body of Statement/ Account: Other persons present: Background factors: Actions taken to prevent reoccurrence: Page 32 of 39

33 Appendix 6: Staff Statement Template Any other relevant information: Appendices: I believe that the facts stated in this witness statement are true. Signature: Date: Page 33 of 39

34 Appendix 7: Executive Director Escalation Procedure 1-10 working days (1-15 for a complex case) Complaint received by the Patient Relations team Investigation lead decided, comments / statement requested from individuals involved within 5-10 working days Directorate Manager and Matron/ Head of Service to be copied into the request for comments / statement working days (15-25 for a complex case) Comments/ statement not received from individuals involved Divisional Complaints Manager exhausts all options prior to escalation to include phone, and personal contact Divisional Complaints Manager escalates to the Directorate Manager or Matron/ Head of Service working days (25-30 for a complex case) Comments or statement still not received Directorate Manager or Matron/ Head of Service to make contact personally with member of staff from whom comments are awaited, to request by return Where no response is received by the next working day, Directorate Manager or the Matron/ Head of Service follows up advising them of the next stage in the escalation procedure working days (30-35 for a complex case) Comments or statements still not received Executive Director or Deputy Director of Operations informed to send Zero Tolerance letter and request comments by return Information on non-responders to be forwarded to their relevant Manager / Director and to possibly be included as part of the annual appraisal process Page 34 of 39

35 Appendix 8: Support For Staff Involved In A Complaint, Claim Or Incident Support or advice regarding a complaint can be sought from any of the following listed below: Your immediate Line Manager Complaints Department Tel: Local Security Management Specialist Tel: Human Resources Department Tel: (The Human Resources Department is able to provide contact details for union representation) UNISON (member s contact number) Tel: Medical Defence Union (MDU) Tel: British Medical Association (BMA) Tel: Fax: Royal College of Nursing (RCN) Tel: How to Access Counselling Should you require the service of a Counsellor, counselling can be accessed from: Your GP practice, everybody is able to seek Counselling via their GP The Occupational Health Department, offers anonymous and confidential and advice and how to access counselling Occupational Health Department Tel: BMA Counselling and Doctors for Doctors Tel: (local call rate) Page 35 of 39

36 Appendix 9: Complaints Evaluation Survey COMPLAINTS EVALUATION SURVEY Recently you had reason to complain about the services provided by Blackpool Teaching Hospitals NHS Foundation Trust. We are always looking for ways in which our complaints handling service could be improved and would be very grateful if you could spare a few minutes of your time to fill in this short survey telling us about your experience. Once you have completed the questionnaire please post it in the Free Post envelope attached. Thank you for taking the time to do this. 1. Did you receive appropriate information on the NHS Complaints procedure, i.e. the process by which we investigate and respond to your complaint? Yes No 2. Did you feel that your concerns were treated seriously and with sensitivity? Yes No If you answered no, please tell us why below. 3. Did you feel we addressed all the points you made in your complaint? Yes No 4. Did we provide a clear and understandable response? Yes No 5. Did you feel your complaint was responded to within a reasonable period of time? Yes No Page 36 of 39

37 Appendix 9: Complaints Evaluation Survey 6. Did we keep you sufficiently informed if there was a delay in providing you with a response? Yes No Not applicable 7. Did you feel you were treated differently as a result of making a complaint? Yes No If you answered yes, please provide an explanation below. 8. Were you able to easily access the Patient Relations Team whilst your complaint was being investigated? Yes No Not applicable If you found it difficult accessing the Patient Relations Team please tell us why. 9. Overall how do you think your complaint was handled? Very well Well Average Poor Very poor 10. Finally, if you could improve anything about our complaints handling service, what would it be? Page 37 of 39

38 Appendix 10: Equality Impact Assessment Form Department Organisation Wide Service or Policy Procedure Date Completed: December 2013 GROUPS TO BE CONSIDERED Deprived communities, homeless, substance misusers, people who have a disability, learning disability, older people, children and families, young people, Lesbian Gay Bi-sexual or Transgender, minority ethnic communities, Gypsy/Roma/Travellers, women/men, parents, carers, staff, wider community, offenders. EQUALITY PROTECTED CHARACTERISTICS TO BE CONSIDERED Age, gender, disability, race, sexual orientation, gender identity (or reassignment), religion and belief, carers, Human Rights and socio economic/deprivation. QUESTION RESPONSE IMPACT What is the service, leaflet or policy development? What are its aims, who are the target audience? Does the service, leaflet or policy/ development impact on community safety Crime Community cohesion Is there any evidence that groups who should benefit do not? i.e. equal opportunity monitoring of service users and/or staff. If none/insufficient local or national data available consider what information you need. Does the service, leaflet or development/ policy have a negative impact on any geographical or sub group of the population? How does the service, leaflet or policy/ development promote equality and diversity? Does the service, leaflet or policy/ development explicitly include a commitment to equality and diversity and meeting needs? How does it demonstrate its impact? Does the Organisation or service workforce reflect the local population? Do we employ people from disadvantaged groups Will the service, leaflet or policy/ development i. Improve economic social conditions in deprived areas ii. Use brown field sites iii. Improve public spaces including creation of green spaces? Does the service, leaflet or policy/ development promote equity of lifelong learning? Does the service, leaflet or policy/ development encourage healthy lifestyles and reduce risks to health? Does the service, leaflet or policy/ development impact on transport? What are the implications of this? Does the service, leaflet or policy/development impact on housing, housing needs, homelessness, or a person s ability to remain at home? Are there any groups for whom this policy/ service/leaflet would have an impact? Is it an adverse/negative impact? Does it or could it (or is the perception that it could exclude disadvantaged or marginalised groups? The Procedural Document is to ensure that all members of staff have clear guidance on processes to be followed. The target audience is all staff across the Organisation who undertakes this process. Not applicable to community safety or crime Issue Action Positive Negative Raise awareness of the Yes Clear Organisations format and processes identified processes involved in relation to the procedural document. Page 38 of 39 N/A N/A No N/A N/A No N/A N/A Ensures a cohesive approach across the Organisation in relation to the procedural document. The Procedure includes a completed EA which provides the opportunity to highlight any potential for a negative / adverse impact. Our workforce is reflective of the local population. N/A N/A N/A N/A N/A None identified ACTION: All policies and procedural documents include an EA to identify any positive or negative impacts.

39 Appendix 10: Equality Impact Assessment Form Please identify if you are now required to carry out a Full Equality Analysis No (Please delete as Name of Author: Signature of Author: Eleanor Carter appropriate) Date Signed: December 2013 Name of Lead Person: Signature of Lead Person: Name of Manager: Signature of Manager Paul Jebb Date Signed: Date Signed: December 2013 Page 39 of 39