POLICY & PROCEDURE FOR THE MANAGEMENT OF COMPLIMENTS, PALS ENQUIRIES AND COMPLAINTS INCLUDING UNREASONABLE OR PERSISTENT COMPLAINANTS APPROVED BY: South Gloucestershire Clinical Commissioning Group Quality and Governance Committee DATE Feb 2015 Date of Issue: 25 February 2015 Version No: 6.0 Date of Review: February 2017 Author, title: Lucy Jones - Corporate Support Officer / Board Secretary Lindsey Perryman Head of Governance and Risk 1
Document status: Current Version Date Comments 1.0 16.09.09 New CCG policy written in line with regulations implemented in April 2009. 2.0 25.02.13 Revised policy in light of CCG responsibilities 3.0 19.06.13 Amended in line with comments from Head of PPI and PALS manager 4.0 14.08.13 Reviewed by JR added section on vexatious complainants and cross referenced with NHS England document Guide to good handling of complaints for CCGs 5.0 26.02.14 Amended by KA contact telephone number for PALS amended. 5.1 26.02.14 Amended by KA change to South West Commissioning Support 5.2 25.11.14 Updated following review by Corporate Support Officer 5.3 04.12.14 Amendments made by Head of Governance 5.4 08.01.15 Amendments made by PALS 5.5 02.02.15 Amendments following Policy Review Group 6.0 25.02.2015 Final approved at Quality and Governance Committee If you need further copies of this document please contact the Corporate Support Officer. South Gloucestershire Clinical Commissioning Group has made every effort to ensure this policy does not have the effect of discriminating, directly or indirectly, against employees, service users, contractors or visitors on grounds of race, colour, age, nationality, ethnic (or national) origin, sex, sexual orientation, marital status, religious belief or disability. This policy will apply equally to full and part time employees. All South Gloucestershire Clinical Commissioning Group policies can be provided in large print or Braille formats if requested, and 2
language line interpreter services are available to individuals of different nationalities who require them. Contents Section Summary of Section Page Cont Contents 3 1 Introduction 4 2 Scope 4 3 Principles and Purpose 4 4 Definitions 4 5 Roles and Responsibilities 6 6 Consultation 8 7 Confidentiality and Service User Consent 8 8 Types of Feedback and How these are Handled 9 9 Implementation Plan 12 10 Audit 13 11 Unreasonable and Persistent Complainants 13 12 Equal Opportunities/Equalities Impact Assessment 13 13 Review Date 13 14 References to other CCG Documents 13 Appendix Appendix 1 Contact Details 14 Appendix 2 Unreasonable and Persistent Complainants 15 3
1. INTRODUCTION 1.1. South Gloucestershire Clinical Commissioning Group (CCG) is fully committed to ensuring that the services in South Gloucestershire meet, and exceed, the expectations of our local population. To help us know how well we are doing, and to enable us to understand where the processes do and do not work, we rely on feedback from our local population. We therefore actively encourage feedback, both positive and negative, so that we can use this to improve and if appropriate, change the services we commission. 1.2 Wherever the acronym CCG is mentioned in this document, it shall be understood to be South Gloucestershire Clinical Commissioning Group. 1.3 When referring to users of health services in the CCG the words service user have been used. 2 SCOPE (Including Stakeholders) 2.1 This policy details the processes to be followed when a compliment, concern or complaint is received by the CCG. It is applicable to all CCG employees and to all stakeholders e.g. Members of the public and service users within South Gloucestershire. 3 PRINCIPLES AND PURPOSE 3.1 The purpose of this policy is to ensure all staff and stakeholders understand how the CCG will manage and use any feedback it is given to improve healthcare services locally. It seeks to inform service users how valuable their feedback is and to provide reassurance that the care received will not be compromised as a result of contacting us. 3.2 The principles of the complaints process are based on those of the Parliamentary and Health Service Ombudsman which are: 1 Getting it right 2 Being Customer Focused 3 Being Open and Accountable 4 Acting fairly and proportionately 5 Putting things right 6 Seeking continuous improvement 4 DEFINITIONS Compliment Concern Complaint Informal Complaint Praise for a service provided / commissioned An indication that something may go wrong if a system, process or action is not changed Where someone expresses explicit dissatisfaction in relation to their experiences of the healthcare system. A matter that can be dealt with on the spot by a member of staff or the most senior person on duty, or one that can be satisfactorily resolved no later than the end of next working day. 4
Formal Complaint PALS HealthWatch Stakeholders A matter that cannot be satisfactorily resolved on the spot or within 24 hours Patient Advice and Liaison Service Advisory and signposting service commissioned by the Local Authority and provided by The Care Forum. Also provides the opportunity for local people to have a say about, and influence the design and delivery of, local health and social care services. A person, group, professional body or organisation with an interest in the service being provided, for example, members of the public including service users, GPs, Dentists, Opticians, Pharmacists and the Local Authority Investigating Officer The person assigned to investigate a complaint or concern. Corporate Support Officer/ The person who is coordinating the complaints process Senior PA Receiving Organisation The Organisation who first receives the complaint The Regulations Local Authority Social Services and National Health Service Complaints (England) Regulations 2009 Learning Outcome Form The form which upon completion of an investigation documents the actions to be taken by the Investigating Officer as a result of the complaint made Parliamentary & Health Service an independent body established to provide a service to Ombudsman the public by undertaking independent investigations into complaints that public bodies, including the NHS in England, have not acted properly or fairly or have provided a poor service. 5 ROLES AND RESPONSIBILITIES 5.1 The CCG 5.1.1 The CCG is responsible for commissioning services for the population of South Gloucestershire and for ensuring that these services are accessible for patients. The CCG is not responsible for the actual provision of these services and in respect of complaints handling, cannot investigate any complaints in this regard. In such circumstances it will be necessary for the CCG to pass the details on to the correct Organisation for investigation, unless there were circumstances where this would be inappropriate. Details of how a complaint will be processed can be found under section 9.3. 5.2 Corporate Support Officer/Head of Governance and Risk 5.2.1 The Corporate Support Officer is the main contact within the CCG and is responsible for managing the complaints process. However the Senior PA supports this function and assumes responsibility in the absence of the Corporate Support Officer. The Corporate Support Officer is responsible for: Acknowledging receipt of a compliment and sharing the feedback as appropriate 5
Processing a complaint in accordance with the regulations and section 9.3 of this policy Disseminating a populated Shared Learning Outcomes Form when a complaint is investigated and responded to by the CCG Sending out feedback questionnaires and equality monitoring forms upon conclusion of each complaint Feeding back the learning identified from complaints to the CCG Quality & Governance Committee at regular intervals, usually quarterly. Completing an annual complaints report (regulation 18 annual complaints report) 5.3 Patient Advice and Liaison Service 5.3.1 The Patient Advice and Liaison Service is responsible for handling all service user and Member of Parliament contacts received by the CCG other than those defined as a formal complaint. The Patient Advice and Liaison Service is commissioned from South West Commissioning Support and contact details for the service can be found in section 10. 5.4 Complaints Investigating Officer 5.4.1 An Investigating Officer is identified for each formal complaint received and is responsible for: 1. Ensuring that all the facts surrounding the complaint are established which may include interviewing staff involved as necessary. 2. Drafting an initial response in the form of a letter based on the facts found and sending this to the Corporate Support Officer for amendment / sign off by the Chief Officer. 3. Ensuring that any learning identified from the complaint that has been investigated and responded to by the CCG is implemented within two months and the Learning Outcomes Form is signed and returned to the Corporate Support Officer along with supporting evidence. 5.5 Complaints Advocacy 5.5.1 The Care Forum will provide Complaints Advocacy as part of its advocacy service. Contact details for The Care Forum can be found in section 10. 5.6 CCG Staff 5.6.2 All CCG staff members have a responsibility to ensure that any concerns brought to their attention by stakeholders or service users are handled quickly and appropriately. Every effort should be made to resolve the concern at the time however if this is not possible, this should be escalated to either the PALS Manager or the Corporate Support Officer. Where the concern is resolved at the time, all details, including any action taken must be sent to the Corporate Support Officer. 6
5.7 Parliamentary and Health Service Ombudsman 5.7.1 The Ombudsman aims to provide a service to the public by undertaking independent investigations into complaints where government departments, a range of other public bodies in the UK, and the NHS in England have not acted properly or fairly or have provided a poor service. Contact details for the Ombudsman can be found in Appendix A. 5.7.2 Therefore a complaint must have been processed through the local procedure in the first instance and contact with the Ombudsman must be made within 12 months of the final response from the Chief Officer being received. 6 CONSULTATION 6.1 The CCG Board Lay Representative for Patient & Public Involvement and Equalities, the CCG Patient & Public Involvement Manager and the Patient Advice & Liaison Manager have been asked to comment on this policy. 6.2 The policy has also been developed in conjunction with: Guide to good handling of complaints for CCGs: NHS England May 2013 NHS complaints procedures in England: House of Commons Library SN/SP/5401 April 2013 Local Authority Social Services and National Health Service Complaints (England) Regulations 2009 7 CONFIDENTIALITY AND SERVICE USER CONSENT 7.1 Sometimes when a compliment, concern or a complaint is received, it will be necessary for the details to be shared outside of the CCG. In such circumstances, consent from the service user will be sought in the first instance and no information will be shared in the absence of this. We would like to provide reassurance that raising a concern or complaint will not impact on any future care that the person(s) involved may receive. 7.2 Any member of staff involved in the complaint or enquiry or with whom the information is shared is expected to maintain service user confidentiality at all times. Any breaches of this that are brought to the attention of the CCG will be investigated and may be treated as a disciplinary matter. 7.3 The CCG appreciates that there are often circumstances when a service user is unable to, or may feel uncomfortable making a complaint themselves and a friend or relative raises this on their behalf. In such circumstances, unless the person making the complaint holds Lasting Power of Attorney for the service user s welfare or is a Court Appointed Deputy with the relevant decision making power, a service user s consent will always be requested before any information is divulged. Without service user consent, the CCG may be unable to provide a personal response, however we will consider the information given and where possible, attempt to address the situation anonymously. 7.4 Where a complaint has been made on behalf of a child, i.e. somebody under 18, the CCG will not consider the issues unless it is satisfied that there are reasonable grounds for this not being made by the child themselves. Likewise, if the service user is a child or 7
is a person who lacks capacity within the meaning of the Mental Capacity Act 2005 and the CCG believes that the representative is not conducting the complaint in the service user s best interest, the complaint will not be considered further. In such circumstances, an explanation of the reasons will be provided in writing to the representative who will need to contact the Health Service Ombudsman if they are unhappy. 7.5 Any information regarding a person who lacks capacity to consent to share information will only be shared on the basis that it is in that person s best interests. A clear record of the best interests determination process will be made, including details of how the views of the person and relevant others have been taken into consideration. 8 TYPES OF FEEDBACK AND HOW THESE ARE HANDLED 8.1 Compliments 8.1.1 The CCG strives to meet and exceed the expectations of its service users and it is extremely rewarding for managers and their staff to know when they have achieved this. 8.1.2 If a service user or a member of their family would like to tell us about a positive experience that they have had, this can be done via the Corporate Support Officer using the details in Section 10. Any compliments received, including thank you cards will be acknowledged wherever possible by the Corporate Support Officer and will be shared with the service lead / staff member involved and their line manager. This information will then be retained on file and shared with the Quality & Governance Committee as part of the quarterly reporting process. 8.2 PALS enquiries 8.2.1 If a service user, friend or relative has a concern or query that they would like to bring to the CCG s attention, this can be done via the Patient Advice and Liaison Service using the contact details in section 10. 8.2.2 Upon receipt of the concern or query, the PALS Manager will discuss with the person the most appropriate way to assist them and will either signpost them to the correct place or liaise with the most appropriate people in order to provide a response. All information will be treated confidentially, however, details will be retained on file and themes, changes and actions are reported regularly to the Quality Group. 8.3 How will the CCG learn from PALS enquiries 9.3.1 Any serious concerns received through PALS will be raised with the individual commissioner at the time. PALS will input into the monthly Quality Meetings held with providers of CCG commissioned services and will also share a quarterly report with the CCG Quality and Governance Committee. This quarterly report will include examples of cross boundary learning across Bristol North Somerset and South Gloucestershire where appropriate. 8.4 Complaints 8.4.1 Informal Complaints 8
8.4.1.1The CCG understands that sometimes things go wrong and the matter can be rectified swiftly and without the need to commence the formal complaints process. As long as the CCG is able to put the problem right, and the outcome meets the stakeholder s satisfaction by the end of the next working day, this will be recorded as an informal complaint. 8.4.1.2 In the event the problem cannot be resolved within this timescale it will be taken forward in line with the formal complaints process detailed under Section 8.4.6, unless the complainant prefers a less formal route, in which case the details will be passed on to PALS. 8.4.1.3 For recording purposes, any complaint received which is not directly investigated or responded to by the CCG will be logged as an informal complaint. The Organisation to which the complaint relates will record this as a formal complaint and will take the issues forward in line with the NHS Complaint Regulations 2009. 8.4.2 Formal complaints 8.4.2.1 There are times when things go wrong and the nature of the problem causes an individual to pursue a more formal process in order for their concerns to be addressed. On such occasions where the complaint is investigated and responded to directly by the CCG, these, will be recorded as formal complaints and will be handled them as per Section 8.4.6 and in line with the NHS Complaint Regulations 2009. 8.4.2.2 There are some instances however, where a complaint cannot be investigated under the current regulations. In particular, any formal complaint, the subject matter of which has already been investigated either under the current Regulations or previous complaint Regulations cannot be registered a second time. In such situations, the Corporate Support Officer will need to be contacted for further advice. 8.4.3 Who can make a complaint? 8.4.3.1 Anybody can make a complaint; however in some circumstances when the complaint is not being made directly by the service user, their consent will be required. 8.4.3.2 In the event that a person discloses abuse to a member of staff, the CCG Safeguarding Children and Vulnerable Adults policy must be followed and/or the CCG lead for Safeguarding must be consulted. This action is required even if the person does not wish to make a formal complaint. In instances where financial misconduct is disclosed, the Chief Finance Officer must be consulted in the first instance. 8.4.3.3 The aforementioned policies can found on the CCG website: www.southgloucestershireccg.nhs.uk. 8.4.4 Timescales for making a Formal Complaint 8.4.4.1 A complaint must be made not later than 12 months after: The date on which the matter which is the subject of the complaint occurred; or If later, the date on which the matter which is the subject of the complaint came to the attention of the complainant. 9
8.4.4.2 Any complaints falling outside of the above criteria will need to be discussed with the Corporate Support Officer. 8.4.5 How should a formal complaint be made? 8.4.5.1 A formal complaint can be made to the Corporate Support Officer by letter, email or telephone using the contact details at the end of this policy. 8.4.6 What is the process for handling a formal complaint? 8.4.6.1 If a complaint is made by letter or by email and it is appropriate for the CCG to take this forward, upon receipt of the details, the Corporate Support Officer will: 1. Acknowledge receipt of the complaint within three working days, offering the opportunity to discuss the concerns further with a view to agreeing how the complaint will be handled and agreeing an appropriate timescale for response 2. Seek consent from the necessary parties if required 3. Upon receipt of consent, assign the complaint to an Investigating Officer and/or if necessary, share the details with an appropriate person from any other Organisation involved. The timescale for response will also be included in the details shared. 4. Ensure the response(s) received fully address the issues raised and pass this to the Chief Officer for approval 5. Ensure the signed response is posted out within the agreed timescale and in the event this cannot be achieved, contact will be made with the complainant 6. Ensure that details of the Parliamentary and Health Service Ombudsman are clearly given should the complainant wish to escalate their concerns to the next stage 7. Ensure any learning identified is captured within a Learning Outcomes Form and actions are carried out within two months of the response date or a plan of action is in place if this is not possible. This step will only apply if the CCG has investigated and responded to the complaint directly. For complaints made verbally, a statement will be taken at the time by the Corporate Support Officer, which will be typed up and sent to the complainant for approval / amendment. At the same time, consent will also be sought if necessary. Upon receipt of the signed consent form and the statement the process above will be followed, with the exception of any duplication i.e. step 2. Not all formal complaints relating to services within South Gloucestershire will be for the CCG to respond to and it may be necessary for the details to be passed on to another organisation for response back to the complainant. In such situations, the Corporate Support Officer will discuss this with the complainant at step 1 before seeking consent to pass the information on and any response provided by the organisation to which the complaint relates will be shared with the CCG. 8.4.7 Complaints made that involve more than one organisation 8.4.7.1 We understand how complex the NHS can be and recognise that it is often difficult for stakeholders to know who to direct their complaint to, particularly when more than one service is involved. Therefore, when the CCG receives a complaint which relates to it 10
but also requires input from other organisations, upon receipt of service user consent, the details will be shared and a single overall response will be coordinated. The Organisation responsible for coordinating the response will be the one to which the complaint mostly relates and where this is not the CCG, confirmation will be provided at the time the complaint is acknowledged. 8.4.8 From where can service users seek support during the complaints process? 8.4.8.1 If any support or advice is required before, during or after the complaints process the Patient Advice & Liaison Service can be contacted using the details at the end of this policy. This service is completely confidential and no information will be shared without service user consent, or for someone who lacks mental capacity to consent, a determination that to share the information would be in the person s best interests. For information regarding Advocacy Support please see section 5.5. 8.4.9 How will the CCG learn from complaints? 8.4.9.1 Learning from feedback is an important step to enabling the CCG to improve the services it provides and commissions. Therefore, upon conclusion of a complaint directly investigated and responded to by the CCG, any actions identified will be recorded on a Learning Outcomes Form and will be passed to the Investigating Officer for implementation within 2 months. This process will be overseen by the Corporate Support Officer and the details will be reported to the CCG Quality & Governance Committee. 8.4.9.2 For complaints coordinated by the CCG but not investigated by them, the individual organisation will be responsible for ensuring any learning identified is implemented. The CCG will monitor this through the contract monitoring arrangements that are already in place. 8.4.9.3 Overall complaint trends will be monitored on a quarterly basis and this detail will be used to inform future commissioning decisions. 8.4.10 What if the complaint outcome is felt to be unsatisfactory? 8.4.10.1Understandably, there will be times when despite the best efforts made, the complaint outcome will not be considered satisfactory by the complainant. In such instances, further discussions can be had with the Corporate Support Officer with a view to the outcome/s being revisited, if this would be appropriate. However, if it is felt that the CCG is unable to help any further the next stage is for the Health Service Ombudsman to be contacted, using the details in Appendix A. 8.4.10.2Based on the findings of the Ombudsman s investigation, suggestions may be made as to how they think the situation could be resolved, taking into account the Ombudsman Principles (see Section 3) and these will be communicated to each party as appropriate. 9 IMPLEMENTATION PLAN (Including training, resources) 9.1 The complaint regulations have been effective since the 1 April 2009 and this policy provides a formal description of the process now in place. Upon approval of the policy, it will be published on the CCG website and all staff will be made aware that it is available. 11
Advice is always available from either the Corporate Support Officer or PALS Manager and training may be provided upon request. 10 AUDIT 10.1 The Corporate Support Officer will write to all complainants two weeks after a full response being provided from the CCG Chief Officer to request feedback on the process. This feedback will then be used to inform how the complaints process is adjusted to ensure it adequately fulfils its purpose. 10.2 The learning identified from complaints will be reviewed on a six monthly basis to ensure that the same issues are not repeated. Action will be taken as necessary. 11 UNREASONABLE OR PERSISTENT COMPLAINANTS 11.1 All complaints are handled in line with NHS complaints procedures. However, there are times that despite this process being followed, complainants can be unreasonably persistent and inappropriately direct their anger and unhappiness at the organisation or the staff trying to help them. The way the CCG will manage such contacts is described in Appendix B. 11.2 This process is not restricted to the Complaints Process alone and can be followed for unreasonable and persistent contacts in other areas of CCG business eg Freedom of Information and Continuing Healthcare. 12 EQUAL OPPORTUNITIES/EQUALITIES IMPACT ASSESSMENT 12.1 An Equality Impact Assessment has been completed for this policy and procedure and it does not marginalise or discriminate minority groups. 13. REVIEW DATE 13.1 This policy and procedure will be reviewed after 2 years, or earlier at the request of either staff or management side, or in light of any changes to legislation or National Guidance. 14 REFERENCES TO OTHER CCG DOCUMENTS Incident Reporting policy Safeguarding Children and Vulnerable Adults Policy 12
Contact Details APPENDIX 1 Name: Job title: Address: Lucy Jones Corporate Support Officer South Gloucestershire Clinical Commissioning Group Suite 11-14, Corum 2 Corum Office Park Crown Way Warmley South Gloucestershire BS30 8FJ Telephone: 0117 947 4426 Email: lucy.jones@southgloucestershireccg.nhs.uk Name: Job title: Address: Louise Carthy Senior PA South Gloucestershire Clinical Commissioning Group Suite 11-14, Corum 2 Corum Office Park Crown Way Warmley South Gloucestershire BS30 8FJ Telephone: 0117 947 4417 Email: louise.carthy@southgloucestershireccg.nhs.uk Name: Job Title: Address: Sarah Jenkins or Marylee Cass Patient Advice & Liaison Service Suite 15, Corum 2 Corum Office Park Crown Way Warmley South Gloucestershire BS30 8FJ Telephone: 0800 073 0907 Email: sarah.jenkins@swcsu.nhs.uk or Marylee.cass@swcsu.nhs.uk Name: The Care Forum NHS Complaints Advocacy Address: The Care Forum Vassall Centre Gill Avenue Fishponds BS16 2QQ Telephone: 0808 808 5252 Name Parliamentary & Health Services Ombudsman Address: Millbank Tower Millbank London SW1P 4QP Telephone: 0345 015 4033 Email: phso.enquiries@ombudsman.org.uk Website: www.ombudsman.org.uk 13
Unreasonable or Persistent Complainants APPENDIX 2 1 Introduction 1.1 Persistent complainants are becoming an increasing problem for NHS staff. The difficulty in handling such cases is placing a strain on time and resources and is causing undue stress for staff who may need support in such situations. Whilst staff are trained to be patient and understanding, there are times when the local process has been completely exhausted and despite making every effort to fully investigate and respond to the concerns raised, there is nothing further that the CCG, or the Organisation involved in the complaint can reasonably do to rectify the issue. 1.2 The aim of this policy is to therefore identify situations where the complainant might be considered persistent or unreasonable and to determine appropriate ways to manage this which are fair to all involved. 1.3 In determining arrangements for handling such situations, the CCG will consider the following: Has the complaints policy been correctly implemented and followed as far as possible Have all the material elements of the complaint been addressed Have all reasonable measures been taken to try and resolve the complaint and manage the situation with the complainant Habitual complainants may have grievances which contain some genuine substance Has an equitable approach been taken to addressing the concerns raised 2 Definition of a Persistent Complainant 2.1 Complainants (and/or anyone acting on their behalf) may be deemed to be persistent where previous or current contact with them shows that they meet at least two of the following criteria: Persist in pursuing a complaint where the NHS complaints procedure has been fully and properly implemented and exhausted Seek to prolong contact by changing the substance of a complaint or continually raising new issues and questions whilst the complaint is being investigated. (It is important not to discard new issues which are significantly different from the original complaint. It may be necessary to take these forward as a new complaint) Are unwilling to accept documented evidence of treatment given as being factual Deny receipt of a response despite evidence of correspondence specifically answering the complaint Unwilling to accept that facts can sometimes be difficult to verify when a long period of time has elapsed Do not clearly identify the issues to be investigated, despite reasonable efforts of the CCG and where appropriate advocacy services being made to obtain these Do not accept that the issues to be investigated are not the responsibility of the CCG and are not willing to consent to the details being shared with the appropriate organisation to take forward 14
Focus on an immaterial / trivial matter to an extent which is out of proportion to its significance and continue to focus on that point (careful judgement must be applied used when applying this criteria) Displays attention seeking behaviour by raising the same issues through different agencies when a response has already been provided or is in the process of being investigated In the course of making a complaint have had an excessive number of contacts with the CCG making unreasonable demands on staff. (A contact may be in person, email, letter, fax or telephone call. Discretion must be used in determining what constitutes as excessive contacts and a judgement should be made based on the specific circumstances of each individual case) Are known to have recorded meetings or face to face/telephone conversations without the prior knowledge and consent of the other parties involved Display unreasonable demands or expectations and fail to accept that these are unreasonable eg. Insist on a more urgent response to a complaint than is reasonable or recognised normal practice Have threatened or used actual physical violence towards staff or their families or associates at any time. This alone will cause personal contact with the complainant and/or their representative to be discontinued and the complaint will, thereafter, only be pursued through written communication (Any incidents of this nature must be documented in line with the CCG s Incident Reporting Policy Have harassed or been personally abusive or verbally aggressive on more than one occasion towards staff dealing with their complaint or their families or associates. 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. Have made personal contacts with any member of staff outside of the workplace. Any personal and threatening behaviour outside of the workplace will be reported to the police. 3 Procedure for dealing with anybody who meets TWO or more of the above criteria 3.1 There are several steps as to how to deal with service users who meet TWO or more of the criteria described in Section 2. Each step must be followed in turn and the next step implemented only if the behaviour continues to be unacceptable or unreasonably persistent. 1. Check that the complainant and/or their representative meets two or more of the above criteria 2. Advise the complainant and/or their representative that their behaviour is considered to be unreasonably persistent or unacceptable. Explain the reasons why and give them the opportunity to stop that behaviour. If it is appropriate and they haven t been given them already, give them the contact details for an advocate 3. Ensure that full and accurate records are kept of all contacts with the complainant and/or their representative. Where unacceptable behaviour has occurred, any comments made by the service user should be recorded as accurately as possible and all records should include the date, time and type of contact. Where appropriate these records should be shared with the service user 4. Where the investigation is on-going, and the unreasonable behaviour continues, the Chief Officer should write to the complainant setting out a clear code of behaviour and advising of the lines of future communication ie letter only 15
5. Where the investigation is complete, the Chief Officer should write to the complainant explaining that the points raised have been fully addressed and the CCG / other Organisations involved are unable to provide any further response to the issues raised. If necessary, direct the complainant to the Ombudsman. If the Ombudsman has already been approached and has declined to investigate further, the CCG will need to reiterate that they are unable to help any further and will not be providing any further responses in regard to this specific complaint 6. The Chief Officer may wish to state that any future correspondence relating to the same issues will be acknowledged but not responded to 7. All relevant staff will need to be advised of the action taken and of the agreed approach in dealing with any further contact from the complainant in respect of the same issue 8. In extreme cases, the CCG should reserve the right to seek legal advice in respect of the matter or to take legal action against the individual. 4 Review of the agreed code of behaviour and communication methods 4.1 When codes of behaviour and stipulated communication methods have been implemented, it is only applicable to the issues and the difficulties being experienced at the time. Should the same complainant and/or their representative then contact the department regarding a completely separate issue the code of behaviour and communications methods will need to be reviewed at the time rather than implemented immediately. 4.2 If following review it is felt that the previous agreement needs to remain in place, the Chief Officer will need to write to the complainant and/or their representative to clearly explain the reasons for this, and to reiterate the agreed acceptable methods of communication. 16