COMPLAINTS POLICY & PROCEDURE

COMPLAINTS POLICY & PROCEDURE Last Review Date April 2014 Approving Body Governing Body Date of Approval April 2014 Date of Implementation May 2014 Next Review Date November 2015 Review Responsibility Chief of Corporate Services Version 1.1

Date of Review October 2012 Amendment Details CCG Complaints policy developed using PCT policy as a template. Version control re-set to version 0.1. Will be held in draft until April 2013. November Approved by CCG Committee November 2012. Version control 2012 re-set to v1.0. April 2014 Amended to clarify the procedure where complaint cases may be subject to litigation, inquests or serious investigations (Procedure section 1.5 and 1.6) as per guidance from NHSE March 2014 Amend approved by Lead Office Chief of Corporate Services Page 2 of 24

CONTENTS Definitions 4 Section A Policy 5 1. Policy Statement, Aims & Objectives 5 2. Legislation & Guidance 6 3. Scope 6 4. Accountabilities & Responsibilities 6 5. Dissemination, Training & Review 7 Page Section B Procedure 10 1. Overview 10 2. What is a complaint 11 3. Who can make a complaint 11 4. Complaints outside the scope of this policy 12 5. Time limits for making a complaint 13 6. How to make a complaint 14 7. Complaints investigation Local Resolution 14 8. The Parliamentary and Health Service Ombudsman 16 9. Complaints which span more than one organisation 17 10. Unreasonably persistent complainants 18 11. Publicising the policy 21 Appendices Appendix A: Inter-agency complaints procedure 23 Appendix B: Staff operational guidance for handling habitual or 24 unreasonably persistent complainants Page 3 of 24

DEFINITIONS Term Clinical Commissioning Group (CCG) Complaint Complainant Concern Gillick Competence Policy Procedure Definition The local clinically-led organisation that commissions community and secondary care. An expression of dissatisfaction that requires a response. The complaint can be received orally or in written form via letter, email or fax. Refers to the individual who raises or makes the complaint. A matter that engages a person's attention or interest, or that affects a person's welfare or happiness A term used in medical law to decide whether a child (16 years or younger) is able to consent to his or her own medical treatment, without the need for parental permission or knowledge. A plan of action adopted or pursued by an individual organisation A way of acting or progressing a course of action, an established method for performing a task. Page 4 of 24

SECTION A POLICY 1. Policy Statement, Aims & Objectives 1.1. NHS Doncaster Clinical Commissioning Group (CCG) is committed to providing the public, patients and carers with the opportunity to raise concerns or to complain about any services it provides or commissions. Patient experience feedback is essential to service improvement and NHS Doncaster CCG will take a proactive approach to asking for people s views, dealing with complaints effectively and efficiently and using the information received to improve the quality of services that we commission. 1.2. This policy and procedure outlines the statutory regulations all staff must adhere to regarding the handling, reporting and investigation of any complaint, concern, comment or compliment received within NHS Doncaster Clinical Commissioning Group (CCG) about the actions of the organisation, its staff and services. NHS Doncaster CCG will adopt a transparent approach to all its activities, which are undertaken in line with the Nolan Principles. 1.3. The complaints procedure aims to meet the following: Getting it right Being customer focused Being open and accountable Acting fairly and proportionately Putting things right Seeking continuous improvement 1.4. It is imperative that patients, relatives and carers feel able to raise both complaints and concerns as appropriate and are comfortable that any concerns or complaints that are raised will not lead to them receiving a detrimental service in any way. 1.5. To ensure continuous improvement in the management of standards of business conduct and conflicts of interests and to monitor the effectiveness of this policy, NHS Doncaster CCG has the following key performance indicators (KPIs): No Key Performance Indicator Method of Assessment 1 Complaints Annual Report. Publication of Complaints Annual Report. 2 Provision of a simple, clear procedure for managing complaints that is accessible to all. Publication of Complaints Annual Report including feedback from complainants. Page 5 of 24

2. Legislation & Guidance 2.1. The following legislation and guidance has been taken into consideration in the development of this policy and procedure: Local Authority Social Services & National Health Service Complaints (England) Regulations 2009. The Principles of Good Complaint Handling (Parliamentary and Health Service Ombudsman, 2008). Listening, Improving, Responding a Guide to Better Patient Care (Department of Health, 2009). NHS Constitution. 3. Scope 3.1. This policy applies to those members of staff that are directly employed by NHS Doncaster CCG and for whom NHS Doncaster CCG has legal responsibility. For those staff covered by a letter of authority / honorary contract or work experience this policy is also applicable whilst undertaking duties on behalf of NHS Doncaster CCG or working on NHS Doncaster CCG premises and forms part of their arrangements with NHS Doncaster CCG. As part of good employment practice, agency workers are also required to abide by NHS Doncaster CCG policies and procedures, as appropriate, to ensure their health, safety and welfare whilst undertaking work for NHS Doncaster CCG. 4. Accountabilities & Responsibilities 4.1. Overall accountability for ensuring that there are systems and processes to effectively manage all complaints received by NHS Doncaster CCG and for responding to complaints about the actions and / or commissioning responsibilities of the organisation lies with the Accountable Officer, who is known as the Chief Officer. The responsibility for the management of complaints is delegated to the following individuals: Chief of Corporate Services (or equivalent) Has delegated responsibility for: Organisational compliance with the Local Authority Social Services & National Health Service Complaints (England) Regulations 2009. Ensuring that action is taken following the outcome of any complaints investigations. Ensuring an organisational Complaints Policy is in place. Page 6 of 24

Chief Nurse Has delegated responsibility for: Providing clinical input to complaints investigations. Patient Experience Team Have delegated responsibility for: Provision of advice and/or support to staff regarding complaints. Acknowledging and facilitating the investigation of complaints that have been directed to the organisation. Arrangement of training on complaints handling where appropriate. Co-ordination of complaints investigations. Maintenance of the complaints database. Proposing policy changes in response to revisions to complaints regulations. Liaising with complaints teams in other organisations where appropriate. Staff Responsibilities of Staff (including all employees, whether full/part time, agency, bank or volunteers) are: Forwarding all complaints and compliments to the Complaints Team. All complaints must be notified to complaints staff as soon as possible in order to ensure a full and accurate complaint register is held within NHS Doncaster CCG. Cooperating with and responding appropriately to any complaints investigations in line with this policy and procedure. 5. Dissemination, Training & Review 5.1. Dissemination 5.1.1. The effective implementation of this Policy and Procedure will support openness and transparency in decision making. NHS Doncaster CCG will: Ensure all staff and stakeholders have access to a copy of this Policy and Procedure via the organisation s website. Communicate to staff any relevant action to be taken in respect of complaints issues. Ensure that relevant training programmes raise and sustain awareness of the importance of effective complaints management. Page 7 of 24

5.1.2. This Policy & Procedure is located in the General Policy Manual. A set of hardcopy Procedural Document Manuals are held by the Governance Team for business continuity purposes and all procedural documents are available via the organisation s website. Staff are notified by email of new or updated procedural documents. 5.2. Training 5.2.1. All staff will be offered relevant training commensurate with their duties and responsibilities. Staff requiring support should speak to their line manager in the first instance. Support may also be obtained through their union representative or HR Department. Managers should contact the Patient Experience Team if there are specific training needs. 5.3. Review 5.3.1. As part of its development, this policy and its impact on staff, patients and the public has been reviewed in line with NHS Doncaster CCG s Equality Duties. The purpose of the assessment is to identify and if possible remove any disproportionate adverse impact on employees, patients and the public on the grounds of the protected characteristics under the Equality Act. 5.3.2. The Policy & Procedure will be reviewed every three years, and in accordance with the following on an as and when required basis: Legislatives changes Good practice guidelines Case Law Significant incidents reported New vulnerabilities identified Changes to organisational infrastructure Changes in practice 5.3.3. Complaints management will be performance monitored to ensure the following and the results will be published in the Complaints Annual Report: The CCG is aware of its compliance with response timescales and in accordance with equality duties. Appropriate management processes are being undertaken. Patients, relatives and their carers are not being treated differently as a result of submitting complaints/concerns. Changes are being made as a result. Page 8 of 24

5.3.4. Complaints returns will be made in line with requirements of the Department of Health. This currently comprises the number and cause of written complaints dealt together with the ethnic category of both complainant and complained against. Page 9 of 24

SECTION B - PROCEDURE 1. Overview 1.1. The Department of Health published new Regulations (Local Authority Social Services and NHS Complaints (England) Regulations 2009) which were introduced on 1 st April 2009. The Regulations provide the statutory basis for the new single approach to complaints handling in health and social care. 1.2. The new complaints approach is structured around the three main principles of listening, responding and improving: Listening Taking a more active approach to asking for people s views and working in partnership Responding Dealing with complaints more effectively by finding out what the complainant wants to happen Improving Using the information received to learn and improve services by agreeing a clear plan of action 1.3. Comments, suggestions and complaints about the CCG and health services commissioned by the CCG are welcomed. It is important for staff to acknowledge all comments and suggestions and to let the person making them know that they will be treated constructively and confidentially. 1.4. Complaints will be handled in strict confidence at all times. Care will be taken that information is only disclosed in line with the Data Protection Act 1998 and information will not be disclosed to patients or complainants unless the person who has provided the information has given consent to disclosure. 1.5. Where the complainant is taking, or plans to take, legal proceedings, a complaint may only be put on hold where there are exceptional reasons to justify it, or the complainant has requested that investigation be delayed. Exceptional circumstances for putting a complaint on hold may include formal requests to do so by the police, a coroner or a judge 1.6. Any concerns about continuing with the investigation of a complaint shoud be raised during the discussion with the complainant of how the complaint is to be handled in order to allow the complainant s view to be heard. If, exceptionally, the CCG decides to put a complaint on hold against the wishes of the complainant, the complainant should be informed of this as soon as is practicable and provided with a full explanation (in writing, unless request not to) of the reasons for this. Page 10 of 24

Any decision to put the complaint on hold in these circumstances would be made by the Chief Officer. 2. What is a complaint? 2.1. A complaint is an expression of dissatisfaction or concern about a CCG staff member, about a service which is commissioned by NHS Doncaster CCG or about an action, omission or decision of the CCG that requires a response. The complaint can be received orally or in written form via letter, email or fax. 2.2. The term complainant refers to an individual who raises or makes the complaint. 2.3. Not all issues raised are formal complaints and it is important that staff who are handling complaints understand the difference. Staff must be able to recognise when a person is making an enquiry, asking for advice or making a constructive suggestion and not to misconstrue this as a complaint. Many concerns can be sorted out by the member of staff in direct communication with the contact. This should be the normal practice and staff will be empowered to resolve these quickly (on the spot or within 1 working day) without the need for them to go through a more formal complaints process. 3. Who can make a complaint? 3.1. A complaint can be made by any person who has received or is receiving NHS treatment or services or any person who has been affected by an action, omission or decision of the CCG. 3.2. A complaint can also be made by a representative acting on another person s behalf, if that person: Has requested the representative to act on their behalf; Is a child; Is unable to make the complaint themselves because of physical incapacity or lack of capacity within the meaning of the Mental Capacity Act 2005; Has died. 3.3. If a complaint is made by a representative then consent will be required so that a full investigation can be commenced. In the case of an individual being unable to provide consent (for example, due to physical or mental capacity or in the case of a minor), their legal guardian, parent or other verified appropriate representative will be accepted to act on their behalf. Page 11 of 24

3.4. If a parent or guardian complains on behalf of their child and that person is sixteen years old or older, then their consent will be sought prior to further action. Complaints made on behalf of children and young people under the age of sixteen will be considered on an individual basis (subject to Gillick competence) and according to the nature and subject of the complaint before consent is requested. 3.5. In the case of a representative acting on behalf of a deceased patient, the relationship of the representative to the deceased must be clarified and confirmed as either the next of kin or Executor / Administrator. 3.6. If a Member of Parliament makes a complaint on behalf of a constituent, it will be considered that the MP has obtained consent prior to contacting NHs Doncaster CCG (In line with requirements of the Data Protection Act 1998 processing of Sensitive Personal Data Elective Representatives Order 2002). 4. Complaints outside the scope of this policy and procedure 4.1. The following types of complaint are outside the scope of this policy: A complaint which is made orally and resolved to the complainant s satisfaction by the end of the working day following receipt of the complaint. A complaint which has already been investigated under the complaints regulations; A complaint which has been or is being investigated by the Health Service Ombudsman; A complaint arising out of the CCG s alleged failure to comply with a data subject request under the Data Protection Act 1998 or a request for information under the Freedom of Information Act 2000; A complaint made by an employee or potential employee of the CCG about any matter relating to their employment; A complaint made by CCG staff about colleagues or managers, which will normally be dealt with under the CCG s Grievance Policy and Procedure or Whistleblowing Policy; A complaint made by another NHS body, Independent Provider, health organisation or Local Authority; A complaint from a Member Practice which is eligible to be managed under the Dispute Resolution process contained in the NHS Doncaster CCG Constitution; Complaints about private services or treatment unless provided under commissioning arrangements with the NHS. 4.2. Complaints solely regarding Independent Contractors (General Practices, Dental Practices, Pharmacies, Opticians), Prison Healthcare and Specialised Commissioning should, wherever possible, be directed by the complainant to the Complaints Lead for the organisation responsible for delivering that care or to the South Yorkshire & Page 12 of 24

Bassetlaw Local Area Team of the NHS Commissioning Board. If these complaints are received by NHS Doncaster CCG, the complainant will be contacted and their consent sought to pass their complaint onto the appropriate lead. NHS Doncaster CCG does not commission these services and therefore cannot investigate complaints relating to them. 4.3. Complaints solely regarding a single Provider such as our local Acute Trust (Doncaster & Bassetlaw Hospitals Foundation Trust) and local Community & Mental Health Trust (Rotherham Doncaster & South Humber NHS Foundation Trust) should, wherever possible, be directed by the complainant to the Complaints Lead for the organisation that is responsible for delivering that care. If these complaints are received by NHS Doncaster CCG, the complainant will be contacted for a discussion regarding the handling of their complaint and their consent sought to pass their complaint onto the appropriate lead. NHS Doncaster CCG will not undertake an investigation into a complaint solely regarding care provided by a provider organisation. It is the responsibility of the organisation providing the services to investigate the complaint under local resolution arrangements. It should be noted that no complaint will be investigated without the provider of the service being involved and having the opportunity to respond. 4.4. Complaints which span multiple Providers should, however, be directed to NHS Doncaster CCG s Patient Experience Team (see below for further details). 4.5. Full details of all types of complaint which fall outside this procedure can be found in regulation 8 of the Local Authority Social Services and NHS Complaints (England) Regulations 2009. There are also circumstances where further discussions will take place before determining whether or not to investigate a complaint and these include: Where the Police are involved; Where legal action is being taken or the intent to take legal proceedings has been stated in writing 5. Time limits for making a complaint 5.1. A complaint must be made within 12 months from the date on which a matter occurred or the matter came to the notice of the complainant, unless there are exceptional circumstances. The time limit will not apply if the CCG is satisfied that the complainant had good reasons for not making the complaint within the time limit and, notwithstanding the delay, it is still possible to investigate the complaint effectively and fairly. Page 13 of 24

6. How to make a complaint 6.1. All formal complaints should be directed to the Chief Officer at NHS Doncaster CCG s Headquarters (full details available on our website or by telephone 01302 565656). 7. Complaints Investigation Local Resolution 7.1. Any member of staff approached verbally by a complainant should try and resolve the issue or concern. If the complainant is satisfied at this stage no further action need be taken. The complaint should be recorded and sent to the Patient Experience Team for logging. These will not be recorded as a formal complaint, however NHS Doncaster CCG will ensure that these issues are logged and tracked to ensure resolution and that the organisation captures all concerns of service users. 7.2. If the issue cannot be quickly resolved it should be forwarded to the Patient Experience Team for action. Any complaint that is received that could be potentially serious or include possible litigation must be reported the Patient Experience Team immediately. 7.3. The Patient Experience Team upon receiving the complaint shall: Record the complaint via a written record; Risk assess the complaint where appropriate using NHS Doncaster CCG s Integrated Risk Management Framework, Strategy, Policy & Procedure. Acknowledge the complaint raised by the complainant and confirm contact preferences and deal with any issues of consent where relevant; Agree with the complainant: o The manner in which the complaint is to be handled; o The period of time in which the investigation is expected to be completed; o The complainant s desired outcomes from the complaint. Confirm the above agreement with the complainant in writing. 7.4. If, following repeated attempts verbal contact with the complainant, contact is unable to be made or the complainant rejects the offer of a discussion in relation to the above, the response period will be determined by the Patient Experience Team and notified to the complainant in writing. 7.5. Independent Complaints Advocacy Services (ICAS) are available locally and play an important role in supporting individual complainants and particularly in representing the needs of vulnerable groups when making complaints. If appropriate, complainants should be advised about how the local services can be accessed. Page 14 of 24

7.6. NHS Doncaster CCG will ensure that complaints are investigated in an appropriate manner aiming to resolve it as soon as possible. All complaints should be investigated to ensure lessons are learnt. During the investigation complainants will be kept informed, as far as is practical, as to the progress in respect of their complaint. Investigation may take the form of gathering of documents, interviewing relevant staff, review of policies and procedures, and will be co-ordinated by the Patient Experience Team, who will stipulate timescales in accordance with each case. 7.7. If a complainant wishes to meet with an appropriate member of NHS Doncaster CCG staff or complaints department staff to discuss their complaint, this will be facilitated by the Patient Experience Team. Notes will be taken of all meetings and the Patient Experience Team will endeavour to ensure that these are confirmed by all involved before being accepted as a file copy. 7.8. Any member of staff named or implicated in a complaint should be informed of the complaint and fully supported by their line manager. The management style and culture within NHS Doncaster CCG will be to promote a positive attitude towards dealing with complaints. Where appropriate, staff will also be signposted to other forms of support such as Occupational Health and professional colleges or indemnity organisations. Where a Chief is associated with a complaint, the matter will be investigated directly by the Chief Officer. 7.9. If a complaint is received that involves a serious allegation of misconduct about a member or members of staff warranting a management investigation will be handled separately through line management arrangements, Human Resource policies and Fraud and Whistleblowing Policies. 7.10. Following a complaint or investigation of a complaint, if it appears or is alleged that a criminal offence may have been committed, the matter should be reported immediately to the Chief Officer (or the most senior manager available) who will give advice on whether the Police should be called. On conclusion of any criminal proceedings or, having been brought in, the Police decide not to institute criminal proceedings, the organisation must then itself consider what further investigation is required. 7.11. In its investigations, NHS Doncaster CCG should take care not to prejudice police enquiries or court proceedings. If there appears to be any risk that investigations by the CCG may prejudice or potentially prejudice police enquiries or court proceedings, NHS Doncaster CCG should consult the Police and their own legal advisers before proceeding. Page 15 of 24

7.12. If appropriate, Doncaster CCG will review what action needs to be taken to reduce the risk of a recurrence of the incident leading to the complaint. Where appropriate, action plans should therefore form part of the conclusion of a complaint, highlighting what steps will be taken, by when and to what timescale. 7.13. Following completion of the investigation, a response will be sent to the complainant signed by the Chief Officer, which should include: An explanation of consideration of the complaint An honest explanation Conclusions reached in respect of the complaint Any remedial action that is considered to be appropriate Confirmation that the action has been taken or satisfaction that it will be actioned 7.14. If a complainant remains dissatisfied following receipt of the investigation response, Conciliation and/or Mediation is a way of dealing with complaints that helps to avoid adversarial situations. By bringing the two sides together with a neutral Conciliator/Mediator it aims to achieve a satisfactory conclusion for both the complainant and the CCG. The Conciliator s/mediator s role is to identify any outstanding issues of complaint, establish what is hoped to be achieved by pursuing the complaint and to try and assist in addressing these issues in discussions or in a meeting with the complainant and staff involved. The Conciliator/Mediator is a lay person who is used by the CCG on an ad hoc basis and they are not employees of the CCG. The Conciliator/Mediator is not an advocate for either party. Their role is to give impartial support to both parties. The Conciliator/Mediator will adopt procedures that are most appropriate for conducting the conciliation/mediation process. Conciliation/Mediation can be joint, both parties present or a separate meeting for each party with feedback from the Conciliator/Mediator. 7.15. Complainants who remain dissatisfied at the end of local resolution will be informed of their right to ask the Health Service Ombudsman to review their complaint. 8. The Parliamentary and Health Service Ombudsman 8.1. A complainant can ask the Parliamentary and Health Service Ombudsman to review a complaint if they remain dissatisfied following local review. Contact details for the Parliamentary and Health Service Ombudsman will be provided with all complaint responses. 8.2. The Parliamentary and Health Service Ombudsman provides a service to the public by undertaking independent investigations into complaints that the NHS in England has not acted properly or fairly, or has provided a poor service. The Parliamentary and Health Service Page 16 of 24

Ombudsman will normally only take on a complaint after the NHS organisation complained about has first tried to resolve the issues and has responded to the complainant. The Parliamentary and Health Service Ombudsman believes that the CCG should be given a chance to respond and, where appropriate, put things right before they become involved. They are, therefore, the second stage of the NHS Complaints Procedure. 8.3. The Parliamentary and Health Service Ombudsman may investigate a complaint if: The complainant is not satisfied with the outcome of the investigation/does not feel their concerns have been resolved; The complaint has not been investigated on the grounds that it was not made within the required time limit 8.4. When NHS Doncaster CCG is advised that a complainant has approached the Ombudsman it will ensure that: The Ombudsman receives full co-operation and all information requested in relation to the complaint is provided; The Chief Officer is informed Any recommendations from the Ombudsman are appropriately actioned and used as a learning tool for handling future complaints. 8.5. The Chief Officer will contact the complainant informing him/her of any action the CCG is taking as a result of any independent review. 9. Complaints which span more than one organisation 9.1. If the CCG receives a complaint which appears to span both Health and Adult Social Care Services and/or other healthcare organisations, it will work with the other organisation(s) under the Regulations to ensure co-ordinated handling and to provide the complainant with a single response which covers all aspects of the complaint. 9.2. With consent from the complainant a copy of the complaint will be forwarded to the organisation concerned. The lead organisation will be established by discussion with the complainant and organisation/s concerned, which may depend on which organisation has to address the majority of the issues raised and whether the complainant is happy with the proposed lead. Joint complaints can be more complex and may require more time in which to respond and deadlines will be agreed between all parties concerned. 9.3. If a complainant remains unhappy with the other organisation after receiving a joint response, the CCG will endeavour to arrange a meeting with appropriate staff from that organisation for further resolution (a conciliation/mediation meeting may be considered). Page 17 of 24

9.4. A flowchart appended as Appendix A captures the process. 10. Unreasonably persistent complainants 10.1. Unreasonably persistent complainants are an increasing problem for NHS staff. The difficulty in handling such complainants places a strain on time and resources and causes unacceptable stress for staff who may need support in difficult situations. NHS staff are trained to respond with patience and understanding to the needs of all complainants, but there are times when there is nothing further that can reasonably be done to assist them or to rectify a real or perceived problem. 10.2. Any complaints received by the CCG will be processed in accordance with the Complaints Policy & Procedure, and requests for Information will be processed in accordance with the CCG s Freedom of Information Policy. During this process, CCG staff inevitably have contact with a small number of individuals who may take up an unwarranted amount of NHS resources. This section of the Complaints Procedure aims to identify situations where this could be considered unreasonably persistent and to suggest ways of responding to such situations. 10.3. The unreasonably persistent complainants procedure will only be used as a last resort and after all reasonable measures have been taken (i.e. an effort to resolve complaints following the NHS complaints procedures or exhaustion of all reasonable measures under the Freedom of Information Act). 10.4. Complainants or persons requesting information (and / or anyone acting on their behalf) may be deemed to be unreasonably persistent where current or previous contact with them shows that they have met two or more (or are in serious breach of one) of the following criteria: Persisting in pursuing a complaint where the NHS complaints procedure has been fully and properly implemented and exhausted. For example, where investigation is deemed to be 'out of time' or where the Ombudsman has declined a request for independent review Persisting in pursuing a request for information where the Freedom of Information Act Policy has been fully and properly implemented and exhausted. Changing the substance of a complaint or persistently raising new issues or seeking to prolong contact by unreasonably raising further concerns or questions upon receipt of a response whilst the complaint / request is being dealt with. Care must be taken not to disregard new issues, which differ significantly from the original complaint / request - these may need to be addressed separately. Page 18 of 24

Unwillingness to accept documented evidence of treatment given as being factual (e.g. drug records, GP records, nursing records) or denying receipt of an adequate response despite correspondence specifically answering questions / concerns raised. This could also extend to include those persons who do not accept that the facts can sometimes be difficult to verify after a long period of time has elapsed. Focusing on a trivial matter to an extent which is out of proportion to its significance and continuing to focus on this point. It should be recognised that determining what is trivial can be subjective and careful judgement must be used in applying this criterion. Physical violence has been used or threatened towards staff or their families / associates at any time. This will, in itself, cause personal contact to be discontinued and will thereafter, only be pursued through written communication. All such incidents should be documented and reported using the CCG s Incident Policy, and notified as appropriate, to the Police. Staff should also refer to the CCG s Personal Safety Policy. Had an excessive number of contacts with the Trust when pursuing their request or complaint, placing unreasonable demands on staff. Such contacts may be in person, by telephone, letter, fax or electronically. Discretion must be exercised in deciding how many contacts are required to qualify as excessive, using judgement based on the specific circumstances of each individual case. Have harassed or been abusive or verbally aggressive on more than one occasion towards staff - directly or in-directly - or their families and / or associates. If the nature of the harassment or aggressive behaviour is sufficiently serious, this could, in itself, be sufficient reason for classifying the complainant as unreasonably persistent. Staff must recognise that complainants may sometimes act out of character at times of stress, anxiety or distress and should make reasonable allowances for this. All incidents of harassment or aggression must be documented in accordance with the CCG s Incident Policy. Are known to have electronically recorded meetings or conversations without the prior knowledge and consent of the other parties involved. It may be necessary to explain to a complainant at the outset of any investigation into their complaint(s) that such behaviour is unacceptable and can, in some circumstances, be illegal. Displaying unreasonable demands or expectations and failing to accept that these may be unreasonable once a clear explanation is provided to them as to what constitutes an unreasonable demand (i.e. insisting on responses to complaints or enquiries being provided more urgently than is reasonable or recognised practice, presenting similar or substantially similar requests for information). Page 19 of 24

10.5. Careful judgement and discretion must be used in applying the criteria to identify potential unreasonably persistent complaints and requests for information and in deciding what action to take in specific cases. 10.6. This procedure should only be implemented following careful consideration by, and with authorisation of, the Chair and Chief Officer or nominated deputy and subsequently ratified by the Governing Body through the confidential agenda. 10.7. When complainants / persons requesting information have been identified as unreasonably persistent, in accordance with the above criteria, the Chair and Chief Officer (or their nominated deputy) will decide what action to take. The Chief Officer (or deputy / representative) will implement such action and notify the individual(s) promptly, and in writing, the reasons why they have been classified as unreasonably persistent and the action to be taken. 10.8. This notification must be copied promptly for the information of others already involved such as practitioners, conciliator, Independent Complaints Advocacy Service, Member of Parliament, advocates etc. Records must be kept, for future reference, of the reasons why the decision has been made to classify as unreasonably persistent and the action taken. 10.9. Prior to formal classification, once it is clear that one of the criteria above has been breached, it may be appropriate to inform the individuals, in writing, that they are at risk of being classified as unreasonably persistent. A copy of this procedure should be sent to them and they should be advised to take account of the criteria in any future dealings with the CCG and its staff. In some cases it may be appropriate, at this point, to copy this notification to others involved and suggest that complainants seek advice in taking their complaint further (e.g. via the Independent Complaints Advocacy Service). 10.10. The CCG should try to resolve matters before invoking this procedure, and / or the sanctions detailed within it, by drawing up a signed agreement with the complainant / persons requesting information (if appropriate, involving the relevant practitioner) setting out a code of behaviour for the parties involved, if the CCG is to continue dealing with the complaint. If this agreement is breached, consideration would then be given to implementing other actions as outlined below. The CCG can decline further contact either in person, by telephone, fax, letter or electronically, or any combination of these, provided that one form of contact is maintained. Alternatively, a further contact could be restricted to liaison through a third party. A suggested statement has been prepared for use if staff are to withdraw from a telephone conversation. This is shown in the attached staff operational guidance at Appendix B. Page 20 of 24

Notify complainants / persons requesting information in writing that the Chair or Chief Officer (or delegated deputies / representatives) has responded fully to the points raised and has tried to resolve the issues but there is nothing more to add and continuing contact on the matter will serve no useful purpose. This notification should state that that correspondence is at an end and that further communications will be acknowledged but not answered. Inform complainants / persons requesting information that in extreme circumstances the CCG reserves the right to refer unreasonably persistent complaints to the organisation s solicitors/ the Information Commissioner and / or, if appropriate, the police. Temporarily suspend all contact, whilst seeking legal advice or guidance from the NHS Commissioning Board, Information Commissioner s office or other relevant agencies. 10.11. Once classified as unreasonably persistent, there needs to be a mechanism for withdrawing this status if, for example, a more reasonable approach is subsequently demonstrated or if they submit a further complaint/ request for information for which the normal complaints procedures or Freedom of Information Act procedures would be appropriate. Staff should have already used careful judgement and discretion in recommending or confirming unreasonably persistent status and similar judgement / discretion will be necessary when recommending that such status should be withdrawn. Where this appears to be the case, discussions will be held with the Chairman and Chief Executive (or their delegated deputies / representatives) and, subject to their approval, normal contact and procedures will be resumed. Regular monitoring of the application of this procedure will be reported to the confidential section of the Governing Body. 11. Publicising the policy 11.1. It is important that patients and their relatives or carers know about the CCG s Complaints Policy and how to make comments, compliments, suggestions or complaints about services which the CCGs commission and provide. 11.2. Patients and their relatives or carers may contact the Patient Experience Team if they have any questions or concerns about the Complaints Policy & Procedure. 11.3. Patients may also contact the Independent Complaints Advocacy Service (ICAS) if they need help in making a complaint. 11.4. It is important to remember that complainants may be unable to read or write, may not have English as their first language or may suffer from disabilities which make formal written complaints difficult to make. The CCG has access to interpretation/translation services and other Page 21 of 24

services for those unable to put their complaint into writing and details can be obtained from the Patient Experience Team. Page 22 of 24

Appendix A Inter-Agency Complaints Procedure Complaint made to agency Agree lead and identify responsibility for each aspect of complaint *To be requested within five days of receiving complaint Obtain consent* to share complaint with other agencies Consent Obtained Yes No Advise complainant unable to respond to all aspects of the complaint Share complaint with other agencies Agree if response will be joint or separate All agencies to investigate within timescales Respond to complainant within agreed timescale (refer to individual complaint plan) Investigate aspects of complaint within restrictions Page 23 of 24

Appendix B STAFF OPERATIONAL GUIDANCE FOR HANDLING HABITUAL OR UNREASONABLY PERSISTENT COMPLAINANTS The following form of words or a very close approximation should be used by any member of staff who intends to withdraw from a telephone conversation with a complainant. Grounds for doing so could be that the complainant has become unreasonably aggressive, abusive, insulting or threatening to the individual dealing with the call or in respect of other NHS personnel. It should not be used to avoid dealing with a complainant's legitimate questions / concerns which can sometimes be expressed extremely strongly. Careful judgement and discretion must be used in determining whether or not a complainant's approach has become unreasonable. Attention is drawn to the fuller provisions set out in the body of this procedure for handling unreasonably persistent complainants (see section 10). FORM OF WORDS "I am afraid that we have reached the point where your approach has become unreasonable and I have no alternative but to discontinue this conversation. Your complaint(s) will still be dealt with by the CCG in accordance with the NHS complaints procedure. I am now going to put the telephone down but wish to assure you that the situation will shortly be confirmed in writing to you." FOLLOW-UP ACTION The incident should immediately be reported to the Chief Officer / Chief of Corporate Services and agreement reached on future means of communication with the complainant, together with any further action deemed necessary. Page 24 of 24