CARE QUALITY COMMISSION -ESSENTIAL STANDARDS OF QUALITY AND SAFETY Outcome 17- Regulation 19 Complaints Self Assessment of Compliance August 2010 CQC 17A 17A(1) Evidence of compliance / People who use services and those acting on their behalf can be confident that their comments and complaints are listened to and dealt with effectively because: There are clear procedures Each comment /complaint is Low Poss Minor Both electronic and paper followed in practice, monitored allocated a complaints manager case files.all details on and reviewed, for receiving, who contacts the complainant DATIX identifying case handling, considering and and manages the case manager, investigating responding to comments and throughout. The service is officer, Head of Service complaints, and a named contact notified of the complaint and an and timescales. who is accountable for doing so. Investigating Officer allocated. Adhere to the The Local Authority Social Services and National Health Service Complaints (England) Regulations 2009 1
17A(2) The complaints process is available, understood and wellpublicised, and reflects established principles of good complaint handling. The process will ensure: that the details of the complaint, and the desired outcome, have been properly understood that advice and advocacy support is available to those who wish or need such support that what is required to resolve the complaint, and the likely timescale, is explained. Information on the process available in leaflet and internet informing the public of the process. Available in other formats via Pearl Linguistics. The Complaints Manager contacts the complainant to discuss and clarify their concerns and explain the process and agree a timescale. Evidence of compliance / Low Poss Minor Patient Leaflet distributed to all Services and included in the acknowledgment letter to the complainant. Available on the Internet and Intranet. ICAS details and leaflet is also included in the acknowledgment letter. The letter also provides the detail of the timescales and the Complaints Manager. 2
17A(3) 17A(4) Investigations are both proportionate and sufficiently thorough. A documented audit trail of the steps taken and the decisions reached is kept. The Service generally relies on staff to investigate the complaint within their own service area. Occasionally for the more complex cases it is possible for another staff member to investigate for example a Matron from another community hospital. The Complaints Team are not involved in the investigations and expect the investigators to be open and thorough.question responses if deemed appropriate and raise concerns to the Head of Service. It would be ideal if there was more capacity within the complaints team or within frontline staff who are trained in RCA to be released to investigate the more complex cases outside of their service area The DATIX Complaints module is populated with all information identifying the complainant, provide a unique identifier and all correspondence and telephone contact with the complainant is recorded and rationale for action. Medium Poss Evidence of compliance / Moderate There is a robust quality assurance process within the checking process giving the opportunity for the Complaints Team, the Head of Service and Managing Director to ask further questions or request another investigation. The organisation has reviewed their investigation policy and there is now a register of qualified individuals providing a pool of investigators to be called upon when required. Audit of the data monthly provides assurance that this is a robust approach and all the complaints team adhere to the procedure Dec 2010 3
17A(5) Consideration of the complaint is undertaken by staff who are competent to address the issues raised, provide honest explanations that are based on facts and include the reasons for the decisions made. All Complaints Managers are appropriately trained with experiences and skills and support the staff investigating the complaint and challenge where necessary. Evidence of compliance / low poss Minor All staff within the Complaints team have attended Conflict Resolution training.head is a qualified mediator. Head and Managers have attained the qualification BTEC Advanced Professional Award in Complaints Handling and Investigations Level 7 17A(6) Whenever possible complaints are reviewed by someone not involved in the events leading to the complaint. This is not always possible. The service is informed of the complaint and it is generally an individual within the service who will investigate.they may not have been involved in the events leading to the complaint but work within that area. The Investigating officer is identified and signs off the investigation report, recommendations and action plans. They are not required to record their title and responsibilities. Medium Poss Moderate Investigations undertaken by an impartial investigator can be identified but only by local knowledge. Again due to capacity allocation of an impartial investigator is requested for complex cases and is not formally documented as such. Action to be taken will be to introduce a system that will enable the organisation to provide this evidence and the rationale for the decision taken. Dec 2010 4
17A(7) 17A(8) Comments and complaints are investigated and resolved to the satisfaction of the person raising the complaint unless: the complaint falls outside the remit of the provider s responsibility the complaint cannot be upheld. The service has clear procedures followed in practice, monitored and reviewed for dealing with unreasonably persistent complainants in a fair and consistent manner, but ensures that the point they make is properly considered. The complaints team have a robust procedure to follow and promote the culture that everything possible will be considered to resolve concerns locally As above. As the culture is to undertake an initial investigation and provide an open and honest response there has been very few cases where the organisation has deemed the complainant to be unreasonably persistent. Evidence of compliance / Evidence of the complaints plan recorded on notepad within the DATIX system Policy written in 2008 for review and ratification in anticipation that DCHS may need to evoke this Marc h 2011 5
17A(9) The service encourages and supports a culture of openness that ensures any comment or complaint is listened to and acted on. 17A(10) The organisation ensures that a full record of the complaint is logged in line with the service s procedures. 17A(11) The information from complaints is used to identify noncompliance, or any risk of noncompliance, with the regulations and to decide what will be done to return to compliance. 17A(12) The person knows how to contact the Care Quality Commission in order to inform the Commission of concerns they may have about the carrying on of the regulated activity. With each complaint received the complainant is invited to speak to the complaint manager to discuss their concerns further and offer a face to face meeting where appropriate All documentation is in paper and electronic format and stored for 10 years. Any cases that are not compliant or at risk of non compliance is addressed by the Head of Complaints with appropriate staff and at relevant forums i.e. governance, Patient Experience.learning lessons The CQC are not referred to generally at the early stages of the complaint. However, on acknowledging their concerns the patient leaflet is enclosed in the correspondence which has the details of the CQCs contact details. Evidence of compliance / action required Low Poss Minor Documented within all case files date of contact with complainant Complaints Officer checks every case file once the final response has been sent and again if additional information needs to be added. Audit of complaints undertaken monthly. Notes within individual case records, minutes of meetings Low Poss Minor The details of the CQC are noted in the patient leaflet 6
17B 17B(1) 17C 17C(1) 17D 17D(1) Evidence of compliance / action required People who use services whose care, treatment and support is shared with more than one provider, or has been transferred to another provider, know that their comments and complaints are listened to because: The provider has agreed All services across the county low poss Minor Protocol ratified and in protocols in place to ensure that including Social Services, use across the county. the services cooperate to provide Ambulance, Foundation Trusts one complete and coordinated and Mental Health Trust have response. developed a county wide protocol Providers who are registered with the Care Quality Commission: Will produce a summary of Awaiting guidance low poss Minor Awaiting guidance complaints at a time and in a format set out by the Care Quality Commission and then send the summary within the time frame specified. People who use services benefit from a service that: Takes into account relevant guidance, including that from the Care Quality Commission s Schedule of Applicable Publications (see appendix B). The management of Complaints adheres to the The Local Authority Social Services and National Health Service Complaints (England) Regulations 2009 and the Ombudsman s Principles low poss Minor Evidenced within the policy/complaint process of individual cases/complaints plan/ financial remedy 7
17E 17E(1) 17E(2) 17E(3) Evidence of compliance / action required People who use services or those acting on their behalf are able to use the comments and complaints process because: They are treated in a manner that All complaints are managed in an low poss Minor Form included in respects their human rights and individual sensitive and acknowledgement diversity in a fair and equal way. confidential manner requesting gender, ethnicity etc. Statement in acknowledgment letter and patient leaflet re discrimination. Satisfaction survey sent 6 weeks after response including question re They know how to obtain or access information about the complaints system. Any comments and complaints are dealt with in a sensitive and timely manner by taking into account the individual circumstances. Staff are aware how to obtain copies of patient leaflet encouraged to display in Service areas and to discuss and resolve if possible concerns as they occur. discrimination. Patient leaflets in all service areas. Information on the internet and intranet. Through PALs and staff. Leaflet for people with disabilities available from Learning Disabilities Services and interpreting services through Pearl Linguistics. Take action on the feedback from the satisfaction survey. See 17E(1) low poss Minor Evidenced in the complaints plan and case files. Ongoing 8
17E(4) 17E(5) Their comments and complaints can be made either verbally, through sign language or in writing. Where they lack confidence or capacity to make a complaint, staff help them through the means the person who uses services finds most supportive. Alternatively, the provider accepts comments and complaints made by others acting on their behalf. The translation/interpretation service is available via Communications also accessible via the Complaints Team. Evidence of compliance / action required Access to Pearl Linguistics as required 9