COMPLAINTS POLICY AND PROCEDURES

COMPLAINTS POLICY AND PROCEDURES First issued by/date Wirral PCT November 2006 Issue Version Purpose of Issue/Description of Change 3 Revised update to unify procedure across Local Authority Social Services and NHS Complaints. Planned Review Date April 2010 Named Responsible Officer:- Approved by Date Complaints Manager General Policy Group July 2009 Policy file: General Policy Impact Assessment Screening Complete October 2006 Full impact Assessment Required No Policy No. GP1 Key Performance Indicators: 1. Time scales for responding monitored by the Complaints Department.. 2. Service Improvements reported to PCT Board in quarterly activity report. Page 1 of 32

NHS WIRRAL COMPLAINTS PROCEDURE Contents Page Policy Statement 4 Introduction 4 Aim & Objectives 5 Definition of a complaint 5 Recording 5 Support Mechanisms for Staff 6 Who May Complain? 6 Complaints relating to Local Authority 6 Patient Confidentiality 7 Access to Health Records 7 Patient Advice and Liaison Service 7 Independent Complaints Advocacy Service 8 Referral to Professional Bodies 8 Vulnerable Adults/Child 8 Fairness and Equality 8 Learning from Experience 9 Dissemination of the Complaints Procedure 9 Implementation of the Complaints Procedure 9 Monitoring 9 Archiving 10 The Complaints Procedure General Overview 10-12 Responsibilities 12-13 Role and Responsibility of all staff 14-16 Role and Responsibility of Investigating Manager 16-17 Role and Responsibility of Senior Manager, 18-19 Head of Service and Director of Primary Care & Provider Services Disciplinary Issues 19 Page 2 of 32

Legal Matters/Issues 19 Other procedures 19 Other providers 19 Compliments 20 Legal Framework 21 Appendices Appendix 1 Service User Feedback Form 22 Apppendix 2 Complaints Procedure Time Limits 23 Appendix 3 Parliamentary and Health Service Ombudsman 24 Appendix 4 Habitual/or Vexatious Policy 25-29 Appendix 5 Policy Audit Tool 30 Appendix 6 Conciliation Service 31 Flow Chart Complaints Procedure Page 3 of 32

POLICY STATEMENT NHS WIRRAL COMPLAINTS POLICY & PROCEDURE This policy and procedure has been formulated to ensure all staff respond to complaints in a satisfactory manner and comply with the requirements contained within The Local Authority Social Services and National Health Service Complaints (England) Regulations 2009. The policy covers all issues related to what the Department of Health refers to as the 4 C s; - Compliments - Comments - Concerns - Complaints NHS Wirral will all also follow the guidance contained in the Standards for Better Healthcare (2004), and guidance issued by the National Patient Safety Agency on Being Open. NHS Wirral recognizes the 4 C s as being a valuable tool for improving the quality of health services we commission and provide. The objectives of this policy are: To endeavor to achieve resolution of a complaint. To ensure that complaints are handled efficiently and in a timely manner. To identify any areas of risk and take appropriate action where necessary. To learn from outcomes of complaints and share good practice throughout the Trust. A simple procedure common to all complaints about any services commissioned and provided by NHS Wirral. An open and honest process that is fair to complainant and staff. INTRODUCTION NHS Wirral recognises the importance of the views of service users in helping to improve the quality of services provided. This policy and procedure is to be applied when service users complaints are received. There may also be occasions when a communication is critical of a service or the quality of care, but is not intended as a complaint. Therefore, it is also important that a record of suggestions, comments and compliments is maintained, in order that areas of practice exceeding customer expectations can be identified and, where possible, good practice shared across the Trusts. It is the responsibililty of all NHS Wirral staff to be receptive to all forms of patient feedback, including complaints, and appreciate that such information is Page 4 of 32

an essentail element of clinical governance. The way our service users perceive the services NHS Wirral provides is critical to the success of the service delivery. AIM AND OBJECTIVES It is important to deal with service users concerns as early as possible. It is recognised that the longer it takes to try and resolve problems and concerns, the more difficult it becomes for both staff and those making complaints. Therefore, the overall aim of all complaints handling is early local resolution following a process that is: Timely Accessible Accurate Confidential Fair Honest Impartial Non-defensive Simple It is expected that in many cases, an immediate informal response by a front line member of staff or practitioner, will resolve the issues as they arise. In cases where an immediate response is not sufficient, or where the response does not resolve the complaints and a further investigation is required, then this must be undertaken as quickly as possible, in an open and non-defensive way in accordance with this procedure. The role of front-line staff is critical in dealing with complaints and satisfying complainants early on. Directorates and departments need to ensure that staff dealing with services users are equipped with the skills required for dealing with the public, including handling complaints. DEFINITION OF A COMPLAINT A complaint is defined as an expression of dissatisfaction. (written or verbal) about a service provided or which is not provided, which requires a response. Examples of complaints include: Concerns about the quality of service provided, the following of standard procedures and good practice, poor communication and the attitude or behaviour of a member of staff. RECORDING All complaints, including those resolved informally on the spot, must be recorded for monitoring purposes. This will demonstrate that NHS Wirral is responsive to comments, complaints, concerns and compliments and will provide management information for monitoring the current quality of service provision and to inform furture service changes and developments. A register Page 5 of 32

of all complaints received will be maintained by the Complaints Department. Service users verbal comments, concerns, complaints and compliments are to be recorded by staff on the Service Users Feedback form. This form is attached as Appendix 1 and copies may be obtained from the Complaints Department or by photocopying. SUPPORT MECHANISMS FOR STAFF Related NHS Wirral policy Management of Work Related Stress Policy HRP29. It is important to consider not only how the complainanat feels in such situations, but also those in the organisation being complained against as this can be an extremely stressful experience. Staff will be supported by their Line Manager, in the first instance, and if required the PCT will provide confidential counselling (MEDRA) for staff involved in complaints. WHO MAY COMPLAIN? Existing or former patients who receives or has received services from NHS Wirral; A person who is affected or likely to be affected by the action, omission or decision of NHS Wirral; Complaints may be made on behalf of patients by anyone who has the patients consent. Where a patient is unable to act, his or her consent shall not be required; A person who is acting on behalf of a patient who has died, is a child, or unable to make the complaint themselves because of physical incapacity; or lack of capacity within the meaning of the Mental Capacity Act 2005 (18). Patients, relatives and carers must be assured that if they have to raise any concerns regarding treatment and care that these issues will be dealt with in a professional and caring manner; and that by raising such concerns, their future treatment and care willnot be compromised. Staff must also be aware that to discriminate against a patient who has raised concerns could result in dsiciplinary action being taken against them. COMPLAINTS RELATING TO LOCAL AUTHORITY SOCIAL SERVICES (PART/WHOLE) Where a complaint is received that contains material which relates wholly or in part to a Local Authority Social Services (LASS) complaint NHS Wirral will ask the complainant whether s/he consents to details of the complaint being sent to the relevant adult social care provider; and if the complainant so consents, send details of the complaint as soon as reasonably practicable. Where the responsible body receives a complaint via NHS Wirral in the circumstances referred to above, then the LASS must co-operate for the purpose of co-ordinating the handling of the complaint and ensuring that the complainant receives a co-ordinated response to the complaint. Page 6 of 32

PATIENT CONFIDENTIALITY The use of the patient s personal information to investigate a complaint is a purpose for which it is not necessary to obtain the patient s express consent. Care must be taken at all times throughout the complaints procedure to ensure that any information disclosed about the patient is confined to that which is relevant to the investigation of the complaint and only disclosed to those people who have a demonstrable need to know it for the purpose of investigation the complaint. Where a complaint is made on behalf of a patient who has not authorised someone to act for him/her, care must be taken not to disclose personal health information to the complainant, unless the patient has expressly consented to its disclosure.¹ Complaints records will be held by the Complaints Department. Complaints records must be kept separate from health records, subject to the need to record any information which is strictly relevant to his or her health in the patient s health records. ACCESS TO HEALTH RECORDS Related NHS Wirral policy - General Policies & Procedures, GP6. Access to relevant records is very important in the context of complaints and a potential source of difficulty in some cases. NHS Wirral operates in accordance with the provisions of the Access to Health Records Act 1990 (for deceased patients); Data Protection Act 1998; and the Freedom of Information Act Policy. The Cheshire & Wirral Partnership NHS Trust, Trust Records Manager, is responsible for oganising release of the relevant records and x-rays, on completion of the appropriate documentation. PATIENT ADVICE AND LIAISON SERVICE Related NHS Wirral policy General Policies & Procedures, GP23. The Patient Advisory Liaison Service (PALS) is a service provided by all primary and secondary care NHS trusts. The key aim for PALS is to continually improve the patient experience of health care services, effect change and improve quality. PALS will act as a facilitator to handle concerns of patients, family and carers, who do not wish to pursue matters through the NHS Complaint Procedures, with the power to negotiate immediate soultions when it is possible to do so. ¹Complaints. Listening Acting Improving Guidance on implementation of the NHS Complaints Procedure, 1996 Page 7 of 32

INDEPENDENT COMPLAINTS ADVOCACY SERVICE The Independent Complaints Advocacy Service (ICAS) currently provides external independent advocacy to people wishing to complain about the treatment or care they received under the NHS. There is a statuory requirement to provide advice on where complainants may obtain assistance. Therefore, this service must be signposted to the complainant no matter what level their complaint is being dealt with. Trained advocates with knowledge of the NHS Complaint Procedures help clients to understand whether they wish to pursue a complaint and where needed advocates provide support to clients in doing so. The support offered ranges from helping the client with initial preparation in ordering their thoughts and thinking about what a good resolution would look like to them, through to attendance at resolution meetings and helping people with correspondence. REFERRAL TO PROFESSIONAL BODIES Related NHS Wirral policy Disciplinary & Dismissal Procedure, HRP1; Standards of Conduct Policy, HRP3. NHS Wirral is commited to nurturing an honest and open ethos within the organisation, therefore complaints and disciplinary actions must be kept separate. However, should the manager of the staff member concerned have concerns arising from complaints that he/she feels should be referred to either the professional regulatory bodies, the police or the cornoner clear guidance on referral procedures can be gained from the Standards of Conduct Policy. It must be said however, that the staff have a right to confidentiality and under the complaints process the outcome of any disciplinary process will not be disclosed. VULNERABLE ADULTS/CHILD Related NHs Wirral policy Vulnerable Adults Policy, GP12; Child Protection Policy, GP19. When a member of staff has concerns regarding a vulnerable audlt/child, principals of best practice can be gained from the Vulnerable Adult Policy and/or the Child Protection Policy and Procedure. FAIRNESS AND EQUALITY Related NHS Wirral policy RES GP27. Making a complaint does not mean that a patient/complainant will receive less help or that things will be made difficult for them. Everyone can expect to be treated fairly and equally regardless of age, disability, race, culture, nationality Page 8 of 32

and sexual orientation. NHS Wirral staff must also ensure that patients and their carers are not discriminated against when a complaint is made and that their ongoing treatment will be unaffected. Complaint records must be kept separate from clinical records. LEARNING FROM EXPERIENCE Related PCT policy Risk Management Strategy, GP5 Lessons learnt from complaints are an important tool to assist quality and responsiveness. The Complaints Manager will report the lessons learned were appropriate at the quarterly Patient Safety and Learning from Experience Group and to appropriate managers within NHS Wirral to ensure that any idenfified risk management lessons are shared. The Clinical Effectivenss Manager will also be notified so that any organisation or clinical risks may be added to NHS Wirral s Risk Register. Lessons learned will also be reported to NHS Wirral s Risk Management Working Group which meets bi-weekly and PALs. DISSEMINATION OF THE COMPLAINTS PROCEDURE This procedure will be available to staff on the Intranet under the General Policy File. IMPLEMENTATION OF THE COMPLAINTS PROCEDURE NHS Wirral will provide awareness training on complaints handling procedures quarterly to all NHS Wirral staff. The Complaints Manager will also make her/himself available for training sessions as and when required by individual services. REPORTING STRUCTURE/MONITORING It will be the responsibility of the Complaints Manager to ensure that there is a minimum of quarterly monitoring of complaint files. Quarterly reports will be submitted to internal stakeholders ie NHS Wirral Board, Primary Care Management Board, Risk Management Working Group and the Patients Safety and Learning from Experience group and to external stakeholders, ie LINks, Strategic Health Authority, Care Quality Commission and the Parliamentary Health Service Ombudsman, as and when required. Reports will include information on the service area, subject of complaint and service improvements and positive outcomes. The Risk Management Working Group and the Patient Safety and Learning from Experience Group will be responsible for initiating any further Trust wide actions and for ensurig the Heads of Services progress any outstanding actions by monitoring service through performance review. The Risk Management Working Group when reviewing reports should Page 9 of 32

consider recommending high risks for inclusion in the Risk Register. The compliance of this policy will be monitored by the following auditable Key Performance Indicators prior to review in a year or earlier in response to changes in legislation. ARCHIVING 1. Chief Executive response forwarded to complainant within agreed timescales. 2. Service improvements reported to NHS WIRRAL Board in quarterly activity report. This procedure will be archived locally by the procedure author. THE COMPLAINTS PROCEDURE GENERAL OVERVIEW There are two stages of the complaints procedure; Local Resolution and Review by the Parliamentary Health Service Ombudsman. Complaints Process The principal objective of local resolution is to provide the fullest opportunity for investigation and resolving issues and concerns in an open, fair, flexible and conciliatory manner. A complaints training programme Complaints Made Easy is available to support staff. Time Frames All complaints that are raised with either staff or the Complaints Department will be risk assessed/triaged jointly by the Head of Service and the Complaints Department to determine how they are best managed. In all cases a complaint must by acknowledged within three working days after the day on which it receives the complaint. The acknowledgment may be made orally or in writing. At the time the complaint is acknowledged the manner in which the complaint is to be handled and the period within which the investigation is likely to be completed and response sent should also be discussed with the complainant. Once agreed details of the actions to be taken should be recorded in an Action Plan. If a complainant does not accept the offer of a discussion to discuss the handling of the complaint, NHS Wirral will determine the response period and notify the complainant in writing. The opportunity for the timeframe to be re-assessed during the investigation will remain open. Page 10 of 32

A complaint which is made orally; and is resolved to the complainant s satisfaction not later than the next working day after day on which the complaint was made is not required to be dealt with in accordance with these arrangments. 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 notice of the complainant. The time frame shall not apply if NHS Wirral is satisifed that the complainant had good reasons for not making the complaint within the time limit, and notwithstanding the delay, it is still possible to investigage the complaint effectively and fairly. Complaints about the provision of health services. The new arrangements apply to complaints which are made to NHS Wirral about the services provided by an NHS Body or Provider under arrangments with NHS Wirral. NHS Body means, a Strategic Health Authority; a Primary Care Trust; an NHS Trust managing a hospital or other establishment or facility in England; NHS Direct or an NHS Foundation Trust. Provider means a Primary Care Provider, ie general medical practitioner; general dental practitioner; general ophthalmic services contractor or pharmaceutical serives contractor. An Independent Provider means a person or a body who provides health care in England under arrangments made with an NHS Body; and is not an NHS Body or Primary Care Provider. When a complaint is received by NHS Wirral and it is considered that it is more appropriate for the complaint to be dealt with by the provider, NHS Wirral must ask the complainant whether the complainant consents to details of the complaint being sent to the provider; and if consent is obtained, NHS Wirral must as soon as reasonably practicable send details of the complaint to the provider. If NHS Wirral considers that it is more appropriate for NHS Wirral to deal with the complaint, the provider and the complainant must be notified. Arrangements for the handling and consideration of complaints. Stage one, Local Resolution. Complaints received in writing addressed to any member of staff must be faxed, without delay, to the Complaints Department for immediate action. All complaints whether verbal or in writing are dealt with under local resolution. Page 11 of 32

A verbal complaint resolved to the complainant s satisfaction not later than the next working day after the day on which the complaint was made does not have to be dealt with under the arrangments. However, the complaint should be recorded, by the person who has dealt with the issue, on the Service Users Feedback form and copied to the Complaints Department. Verbal complaints that need further investigation and all written complaints must be handled in accordance with the Regulations. Appendix 2. All written complaints and unresolved verbal complaints will receive in writing a response from the Chief Executive. It is important that those dealing with complaints feel confident that, in every case, everything reasonable and fair has been done to resolve a complainant s concern at this stage. Review by the Parliamentary and Health Service Ombudsman. Stage two, Independent Investigation. When a complainant remains dissatisified, following receipt of the final response from the Chief Executive, they may request the Parliamentary and Health Service Ombudsman to consider undertaking an independent investigation into the handling of their complaint by the responsible organisation. On receipt of the complaint the Parliamentary and Health Service Ombudsman will assess the nature and substance of the complaint and decide, with the help of expert advice if necessary, how it should be handled. Further details of the remit of the Parliamentary and Health Service Ombudsman are available in Appendix 3. RESPONSIBILITIES NHS Wirral will ensure that there is a designated responsible person responsible for ensuring compliance with the arrangements made under the Regulations. The responsible person in the case of NHS Wirral is the Chief Executive. NHS Wirral will ensure that there is a Complaints Manager who will be responsible for managing the procedures for handling and considering complaints in accordance with the arrangments. The Complaints Manager will record all complaints received by NHS Wirral and ensure that they are dealt with in accordance with this policy, reporting as necessary to the Chief Executive. S/he will liaise, as required, with other NHS Wirral staff and Providers at all levels to ensure that the appropritate information is available to enable full and open responses to be drafted within the agreed timescale for the Chief Executive to consider. Page 12 of 32

The Complaints Manager is responsible for: Managing the complaint from start to conclusion Updating the Chief Executive on the progress of the complaint Ensuring that target dates and deadlines are achieved Producing quarterly reports to the NHS Wirral Board, Primary Care Management Board and Risk Management Working Group and the Patient Safety and Learning from Experience Group on the number and type of complaints as well as lessons learned and action taken Producing an annual report for the Chief Executive and NHS Wirral Board reflecting trends over the last year Liaising closely with Directors and other Senior Managers to ensure they are regularly updated on issues of particular interest and learning from complaints Producing annual statistics to the DoH for their KO41a and b returns Providing training and support to staff in handling complaints and investigations, including assistance with drafting responses Providing induction training to new members of staff Ensuring conciliation is available to complainants and practitioners, if required Ensuring the recommendations made by the Parliamentary and Health Service Ombudsman are implemented Heads of Service/Senior Managers are responsible for: Undertaking or delegating complaint investigations Root Cause Analysis of complaints Informing staff involved in the complaint Ensure that all their staff are familiar with the NHS Complaints Procedure Ensuring that all written statements made by staff as part of the investigation process are accurate, legible and signed and dated Reporting complaints to the Complaints Manager on the same day they receive them, (Telephone, Fax or Email) and followed up by sending the original letter of complaint to the Complaints Manager Ensuring that the investigation is carried out as soon as possible and findings are sent to the Complaints Manager within deadlines given Providing a draft response letter Liaising information sharing and feedback where the investigation indicates that external partner agencies should be involved e.g Health & Safety Executive, Police Using complaints/findings as a learning opportunity process for staff by cascading good and bad practice identified, and ensuring actions are taken to minimise and prevent future complaints to include review of practice and systems in place, training. Page 13 of 32

ROLE AND RESPONSIBILITY OF ALL STAFF Stage One Local Resolution Comments, Compliments, Complaints and Suggestions verbal and written. All staff, and particularly those working directly with service users, should familiarise themselves with the Complaints Policy and receive feedback, openly and honestly. All staff, including contracted staff, are responsible for treating patients, relatives, carers, visitors and colleagues with empathy, dignity and respect. They should also recognise that the way the service is perceived by service users is critical in measuring the quality of service delivery. Feedback may be comments, compliments, suggestions or complaints. Verbal comments, suggestions, compliments and complaints should be received in a non-defensive way and each one recorded on the Service Users Feedback forms. This includes complaints and concerns that are resolved to the complainant s satisfaction not later than the next working day after the day on which the complaint made. Once completed, this form must be faxed to the Complaints Department without delay and copied to the Head of Service or Senior Manager. The original forms should then be sent to the Complaints Department. 1. The first responsibility of a person receiving a complaint is to ensure the patient s immediate health care needs are being met. This may require action before any matters relating to the complaint are tackled. 2. Staff should deal with any complaint in an informal and sensitive manner. An apology that a person is dissatisfied with the service and an explanation as to what happened may resolve the complaint. It may be that immediate action is taken by the staff member receiving the complaint to resolve the issue or to try to prevent it happening again. Apologies it is both natural and desirable for those involved in treatment which produces an adverse result, for whatever reason, to sympathise with the patient or the patient s relatives and to express sorrow or regret at the outcome. Such expressions of regret would not normally constitute an admission of liability ² Explanantions Patients and their relatives increasingly ask for detailed explanation of what led to adverse outcomes. In this respect they are no different from their equivalents in any ² and³ Apologies and Explanations. The National Health Service Litigation Authority, February 2002 Page 14 of 32

other field. Closely linked to this desire for information in the frequently expressed view that they will feel some consoltation if lessons have been learned for the future. ³ 3. All complaints should receive a positive and full response, with the aim of satisfying the complainant that his/her concerns have been heeded. 4. Staff should recognise where a complaint is too serious to be dealt with on the spot; for example where allegations made by the complainant may lead to a disciplinary investigation or an investigation of a criminal offence. The complainant should be informed that the matter will be brought to the attention of the Head of Service/Senior Manager and Complaints Department immediately. Staff must act quickly on such matters, contacting the Head of Service/Senior Manager by telephone immediately, in addition to completing a Service Users Feedback form. There is no requirement to cease a complaint investigation if a person indicates an intention to bring legal proceedings. Written complaints and compliments. Staff are responsible for ensuring letters of complaint, to whomever addressed, are fowarded immediately to the Complaints Department who, on behalf of the Chief Executive, will acknowledge the letter not later than three working days after the day on which it is received. The acknowledgement may be made orally or in writing and at the time it acknowledges the complaint, the complaints manager/officer will initially discuss with the Head of Service/Senior Manager on how best to handle the complaint. The Complaints Manager/Officer will then discuss with the complainant the manner in which the complaint is to be handled; and the period within which the investigation of the complaint is likely to be completed ; and the response sent to the complainant. An Action Plan must be formulated, which the complainant is in agreement with. This will clearly demonstrate to the complainant that their concerns are being taken seriously and are acted upon. If a staff member is named or referred to in a complaint then they will receive a copy of it as quickly as possible. All staff are required to assist in the investigation of complaints providing as much information as possible to assist in the investigation and the resolution of the complaint. It is important to remember that the longer complaints take to resolve, the more difficult it is for complainants and staff alike. Page 15 of 32

Any response given to a complainant concerning issues of clinical judgement will be agreed with the clinician concerned. Letters and cards of compliment and thanks should be recorded and forwarded to the Senior Manager/Head of Service on a regular basis. ROLE AND RESPONSIBILITY OF INVESTIGATING MANAGER Stage One Local Resolution The tool provided by the National Patient s Safety Agency for Root Cause Analysis has been agreed as the systematic approach NHS Wirral is adopting when investigating an complaint. Each Department should decide who is to investigate complaints that are not resolved on the spot and those that are received in writing. The managers undertaking this role are referred to as investigating manager in this procedure. When a Service Users Feedback form indicates that a verbal complaint is not resolved or when a letter of complaint is received it will be sent to the Head of Service/Senior Manager for investigation. The Head of Sevice/Senior Manager, if not undertaking this role themselves, will forward the correspondence to the investigating manager. 1. Firstly, it is important to ensure the patient s immediate health care needs are being met before tackling the issues of the complaint. 2. The investigating manager should forward a copy of the complaint to any staff member named or referred to in the correspondence immediately. 3. It is important to investigate complaints rapidly and thoroughly. The investigation should be factual, including a review of the relevant records and documentation, together with discussions with, and if appropriate statements from, staff involved. Clinicians should be asked to advise on clinical issues. 4. The investigating manager should deal with the complaint in the format agreed and documented in the Action Plan. This may involve speaking to the complainant over the telephone; or arranging a meeting with them and the relevant staff to discuss the complaint and the findings of the investigation. When liaising with the complainant it is important, to secure the confidence of the complainant, that the person investigating the complaint is impartial. It is good practice to keep a written record of these meetings/discussions and a copy of issues discussed and agreements reached. The information should be forwarded to the Complaints Department along with the report on the findings Page 16 of 32

following the investigation. After completing the investigation, a follow up letter from the Chief Executive will be sent to the complainant. The letter will include an explanation of how the complaint was considered; and the conclusions reached, including any matter for which the complaint specifies, or NHS Wirral considers, that remedial action is needed, and confirmation as to whether NHS Wirral is satisfied that any action needed in consequence of the complaint has been taken or is proposed to be taken. 5. Conciliation If the investigating manager feels conciliation would be useful, then this should be agreed with the Head of Service/Senior Manager and the Complaints Department contacted. The Complaints Manager will consult with the Head of Service and, if agreed, arrangements will be made to appoint an Independent Lay Conciliator, if the complainant agrees to this approach. See Appendix 8. If the complainant chooses not to meet, or does not want to discuss his or her concerns with the investigating manager, then this should be recorded and respected. The investigation should continue as normal, based on the information available in the written complaint. The investigating manager will provide a full written report to the Senior Manager/Head of Service for forwarding to the Complaints Department, together with copies of records and documentation referred to. The report should include the process of investigation, a full factual explanantion, and details of any action taken to resolve the complaint and/or to prevent a recurrence of the problem. Stage 2 Investigation by the Parliamentary and Health Service Ombudsman. If the Complaint Manager receives notice of a decision from the Parliamentary and Health Service Ombudsman that they are to undertake an independent investigation into a complaint, the staff member or body which is the subject of the complaint will be notified as reasonably practicable. Managers of staff involved in Stage 2 (Investigation by the Parliamentary and Health Service Ombudsman) of the procedure should ensure support is available to the staff member throughout the process. Page 17 of 32

ROLE AND RESPONSIBILITY OF THE SENIOR MANAGER, HEAD OF SERVICE AND DIRECTOR OF PRIMARY CARE AND PROVIDER SERVICES. Stage One Local Resolution The Complaints Department will write to the Senior Manager or Head of Service enclosing a written complaint or an unresolved verbal complaint that the complainant will have been asked to sign. The Senior Manager or Head of Service will arrange for the complaint to be dealt with appropriately. If the Senior Manager or Head of Service is to investigate complaints him or herself, refer to section of this report entitled Role and Responsibilities of the Investigating Manager. The Senior Manager or Head of Service will consider the report of the investigation received from the investigating manager, draw conclusions and consider any further action that may be appropriate. The Senior Manager and Head of Service must be assured that every effort has been made to resolve the complaint including direct contact with the complainant and, if this is not the case, should take further action. The Senior Manager and Head of Service will be responsible for advising the Head of Provider Services of complaints. The Senior Manager or Head of Service will draft a response for the Chief Executive to send to the complainant. This communication should aim to satisfy the complainant that the complaint has been fully and fairly investigated, with an appropriate appology where things have gone wrong, and what is to be done to prevent a recurrence. It should be written in a nondefensive style. Clinical issues should be explained in a way the complainant can understand and be checked with the clinician concerned. The draft letter, together with the report prepared by the investigating manager, must be forwarded to the Complaints Department for the Chief Executive s consideration in accordance with the timescales outlined in this procedure see Appendix 2. If the timescale is to be exceeded then the Senior Manager/Head of Service should write to the Complaints Department, explaining the reason for the delay and when the response can be expected. The Complaints Department will notify the complainant in writing accordingly and explain the reason for the delay and advising when a response will be forwarded. The Senior Manager and Head of Service is responsible for ensuring any action promised is taken and the Complaints Department advised of this by completing the Complaints Investigation Form, which will be forwarded to managers with the letter of complaint. Page 18 of 32

Stage Two Investigation by the Parliamentary and Health Service Ombudsman Senior Managers and Head of Services will be responsible for ensuring staff in their Directorate are fully supported if the Parliamentary and Health Service Ombudsman proposes to conduct an independent investigation. Senior Managers, Heads of Services and/or Head of Provider Services, will be responsible for implementing any recommendations made by the Parliamentary and Health Service Ombudsman. The Director of Primary Care and Provider Services has a responsibility to ensure that complaints form part of the clinical governance agenda and that action is taken within the Trust to ensure quality improvements. Senior Managers and Head of Services are responsible for ensuring quality improvements in relation to complaints are notified to the Complaints Department for reporting appropriately, e.g quarterly report on complaints to NHS Wirral Board and NHS Wirral s Annual Report. DISCIPLINARY ISSUES It is not appropriate to address disciplinary matters through the NHS complaints procedure. However, evidence from complaints may be used as part of a disciplinary process. LEGAL MATTER/ISSUES If formal legal action has been initiated by the complainant, there is no requirement for the NHS complaints procedure to cease. However, if advised by an appropriate body,ie NHS Litigation Authority that to continue with a complaint investigation may jepodise a legal matter, then the complaint investigation will cease and the necessary parties informed. The NHS complaints procedure would not be able to assist complainants with claims for compensation. OTHER PROCEDURES Related NHS Wirral policy Incident Reporting Policy - GP8 and Risk Management Strategy GP5 Where a complaint leads to the identification of a serious untoward incident, NHS Wirral s policy for Incident Reporting and Risk Management Strategy must be followed. OTHER PROVIDERS NHS Wirral should ensure that all NHS Providers and Independent Providers Page 19 of 32

with whom it has a Contract or Service Level Agreement has robust arrangements in place for handling complaints from NHS Wirral s residents about the services they provide. COMPLIMENTS Compliments are as important to NHS Wirral as complaints and should be seen as a means of learning how things have gone well. Compliments should be reported quarterly to the Board and also cascaded to the staff. Compliments are collated by the service the compliment is for and should be sent to the Complaints Manager on a monthly basis. Definition of a recordable compliment: Expressions of appreciation by letter, card, gift or donation. Page 20 of 32

LEGAL FRAMEWORK The complaints procedure is based on: The Local Authority Social Services and National Health Service Complaints (England) Regulations 2009 No. 309; the National Health Service (General Medical Services Contracts) Regulations 2004 No. 291; The National Health Services (Personal Medical Services Agreements) Regulations 2004 No. 627; The National Health Service (Pharmaceutical Services) Regulations 2005 as amended by the National Health Service (Pharmaceutical Services) Amendment Regulations 2006; The National Health Service(General Dental Services Contracts) Regulations 2005; The National Health Service (Perrsonal Dental Services Agreements) Regulations 2005; The National Health Service (General Ophthalmic Services Contracts) Regulations 2008; The Primary Ophthalmic Services Amendment, Transitional and Consequential Provisions Regulations 2008, and the General Dental Srvices, Personal Dental Services and Abolition o fthe Dental Practice Board Transitional and Consequential Provisions Order 2006. Page 21 of 32

Appendix 1 SERVICE USER FEEDBACK FORM This form is to be completed by staff to record any comments, suggestions, compliments and complaints made by, or on behalf of, service users. Your name: Base:....... Tel No:. Department:.. Date: Please indicate whether feedback received was: Compliment Comment Suggestion Complaint Name of person giving feedback, i.e name of patient or relative : Address:... Tel:.. Name of service user: (if different from person giving feedback): Address:.. (It is acceptable if the service user or person giving feedback wishes to remain anonymous) If this is a complaint, is the service user aware of it? Yes No Date of Incident.. Details:. Response and Action Taken:... (please continue on separate sheet if required) If this is a record of complaint, was it resolved? Yes No Fax completed form immediately to Complaints Department on 0151 651 2918 and to your Head of Service/ Senior Managers. Send original to Complaints Department, Wirral NHS WIRRAL, St Catherine s Hospital, Church Road, Birkenhead, Wirral, CH42 0LQ. Page 22 of 32

Appendix 2 COMPLAINTS PROCEDURE TIME LIMITS Time Limits for Stage One Local Resolution Event Original Complaint. Local Resolution Verbal Complaint. Written complaint or unresolved verbal complaint acknowledgment. Senior Manager/Head of Department response to Chief Executive/Complaints Department. Full response by Trust. Time Allowed 12 months from event on 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 notice of the complainant. The time limit shall not apply if the responsible body is satisfied that the complainant had good reasons for not making the complaint within that time frame; and notwithstanding the delay, it is still possible to investigate the complaint effectively and fairly. Time Allowed A complaint which is resolved to the complainant s satisfaction not later than the next working day after the day on which the complaint is made is not dealt with under these Regulations. Within 3 working days after the day the complaint is received. As agreed with complainant and documented in Action Plan As agreed with complainant and documented in Action Plan. Time Limits for Stage Two Investigation by the Parliamentary and Health Service Ombudsman Action Request for independent investigation Acknowledge complaint of Email enquiry Written enquiry Substantive response to enquires Time Allowed Within 12 months of when the complaint was made locally. (However, the HSO do have the discretion to waiver the time limit if appropriate). Within one working day of receipt. Within two working days of receipt 80% within 40 working days Page 23 of 32

Appendix 3 STAGE TWO The Parliamentary and Health Service Ombudsman In any case where a person has made a complaint to an NHS Body, Primary Care Provider or Independent Provider and is not satisfied with the outcome of the an investigation of his/her complaint by the responsible body and after receiving a final formal written response from the organisation he/she may request the Parliamentary and Health Service Ombudsman to consider undertaking an independent investigation into the handling of their complaint by the responsible organisation. The Health Service Ombudsman can carry out independent investigations into complaints about poor treatment or service provided through the NHS in England. The Health Service Ombudsman provides a service to the public by undertaking independent investigations into complaints against NHS services provided by hospitals, health authorities, trusts, GPs, dentists, pharmacists, opticians and other health care practitioners who have not acted properly or fairly or have provided a poor service. They can also investigate complaints against private health providers if the treatment was funded by the NHS. A request must be made in writing (including electronically) and must be made within 12 months from the date on which the matter which is the subject of the complaint occurred, or where that is not possible, as soon as reasonably practicable. When the complaint is received it will be acknowledged within two working days. The Parliamentary and Health Service Ombudsman will look at whether the complaint is one that they can handled, because they can only investigate complaints where they have the legal power to do so. If they decide not to do so, they will let the complainant know why thay have made that decision. Once sufficient information is available, the case manager will recommend a course of action. To ensure consistency, this recommendation will be reviewed by the team leader. The decision will be conveyed to both the complainant and the organisation which the complaint is made. The possible courses of action at this stage include: a) Taking no further action, giving reasons. It may be that there is evidence that the complaint has already been thoroughly investigated and answered locally. b) Referring back to the NHS organisation complained against, suggesting in writing what further action it might take to resolve the complaint or review its procedures and services. c) Referring the case to other procedures, for example statutory professional regulatory bodies. Page 24 of 32

Appendix 4 HABITUAL/OR VEXATIOUS POLICY The vast majority of NHS complainants are responsible in how they act and behave, and act courteously and fairly. Habitual and /or vexatious complainants can cause undue stress for staff. Our staff are trained to respond, with patience and sympathy, to the needs of all complainants but there are times when there is nothing further which can reasonably be done to assist or to rectify a real or perceived problem. This policy document, which has been incorporated into the Complaints Procedure, maybe made available to members of the public to raise its awareness albeit that its primary use is for complaints personnel. It should be recognised, however, that implementation of such a policy will only occur in exceptional circumstances. BACKGROUND In determining arrangements for handling such complaints, complaints staff are presented with two key considerations: 1. To ensure that the NHS Complaints Procedure has been correctly implemented so far as possible and that no material element of a complaint is overlooked or inadequately addressed and to appreciate that habitual or vexatious complaints can have aspects which contain substance. The need to ensure an equitable approach is crucial. 2. To be able to identify the stage at which a complaint has become habitual or vexatious. AIMS AND OBJECTIVES Complaints about services provided by NHS Wirral are considered in accordance with the NHS Complaints Procedure. The aim of our habitual and/or vexatious complaints policy is to: Outline criteria that will be used by NHS Wirral in defining a habitual and/or vexatious complaint. Set out how a complaint will be handled. This policy will be used as a last resort and after all reasonable measures have been taken to try and resolve complaints during the NHS Complaints Procedure, for example, through Local Resolution, Conciliation. Care should be taken because if you label a complainant as vexatious from the start then it will never be anything else. This may get in the way of your ability to understand why the complainant is so persistent and may only prolong the Page 25 of 32

time it takes to reach a conclusion. Judgement and discretion will be used in applying the criteria to identity potential habitual or vexatious complaints and in deciding action to be taken in specific cases. The policy will only be implemented following careful consideration by, and with the authorisation of the Chief Executive or deputy in their absence. Care should be taken before implementing this policy because if a complainant is labelled as vexatious from the start then it will never be anything else. This may get in the way of the NHS Wirral s ability to understand why the complainant is so persistent and may only prolong the time it takes to reach a conclusion. When the Chief Executive is considering its implementation, this policy will be shared with all complainants to give them prior notification of its possible implementation, should the complainant s unreasonable actions/behaviour continue. DEALING WITH HABITUAL AND/OR VEXATIOUS COMPLAINTS Where complaints have been identified as habitual or vexatious in accordance with the criteria (see Definition of Habitual/Vexatious Complaint) the Chief Executive will ultimately determine what action to take. The Chief Executive will implement such action and will notify complainants in writing, of the reasons why their complaint has been classified as habitual or vexatious and the action that will be taken. For completeness, this notification may be copied to any others involved for example a Conciliator. A record will be kept, for future reference, of the reasons why a complaint has been classified as habitual or vexatious. The Chief Executive, in conjunction with NHS Wirral s Chairman may decide to deal with such complaints in one or more of the following ways: Set out in a letter a code of commitment and responsibilities for the parties involved if NHS Wirral is to continue processing the complaint. If these terms are contravened, consideration will then be given to implementing other action as indicated below. Decline contact with the complainant, either in person, by telephone, by fax, by letter, be e-mail or any combination of these, provided that one form of contact is maintained. This may also mean that only one named NHS Wirral officer will be nominated to maintain contact (and a named deputy in their absence). The complainant will be notified of this person. Once a person has been identified as vexatious the Complaints Manager must be kept informed of all communication either written or verbal in order to avoid duplication and time wasting. Notify the complainant, in writing that the Chief Executive has responded fully to the points raised and has tried to resolve the complaint but that there is nothing more to add and continuing contact on the matter will serve no useful purpose. The complainant will be Page 26 of 32