- NON CLINICAL NON CLINICAL NON CLINICAL NON CLINICAL NON CLINICAL NON CLINICAL NON CLINICAL NON CLINICA CLINICAL NON CLINICAL - CLINICAL CLINICAL Complaints Policy Incorporating Compliments, Comments, Concerns, Complaints and PALS NON-CLINICAL POLICY ACE 154 Version number: 05 Policy Owner: Lead Director: Complaints Manager Director of Clinical & Corporate Governance Date Approved: June 2014 Approved By: Management Executive Committee (MEC) Review Date: June 2015 Target Audience: All staff
Contents Section/Paragraph Description Page Number 1. 2. 3. 4. 5. 6. 6.1 6.2 6.3 6.4 6.4.1 6.4.2 6.4.3 6.4.4 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 16.1 17. 18. Appendices Introduction Purpose Scope Equality Impact Assessment Duties within The Organisation Explanation of Terms and Management Processes Compliments, Comments and Concerns Complaints Informal Complaints Formal Complaints Receiving a Formal Complaint Acknowledgement of Formal Complaints Investigating a Formal Complaint Responding to the Complainant The Parliamentary Health Ombudsman Service Joint Complaints Intractable Complaints Time Limits for Making Complaints Sources of Support for Complainants Learning lessons from Complaints Support for Staff involved in Complaints Police and Disciplinary Investigations Training Monitoring and Compliance Audit of Complainant Feedback References Associated Documents and Policies 1. Record of Informal Complaint (form) 2. Informal Complaint Flow Chart 3. Formal Complaint Process and Timescale (flow chart) 3 3 3 3 3 4 4 5 5 6 6 6 7 7 7 8 8 8 9 9 9 9 9 10 10 10 10 11 12 13 2
COMPLAINTS MANAGEMENT POLICY AND PROCEDURE 1. Introduction Anglian Community Enterprise, Community Interest Company (ACE CIC) is committed to listening to the views of patients and the public about the care we provide. We value comments on our services as a mechanism for learning and improving and we are committed to ensuring that patients, their relatives and carers are not treated differently as a result of raising a complaint or a concern. Compliments, comments, complaints and suggestions from patients, carers and the public are encouraged and welcomed and we ensure that whatever their background or circumstances people should find it easy to tell us what they think or to make a complaint. Should anyone be dissatisfied with the care we provide, we believe they have a right to be heard and for their concerns to be dealt with promptly, effectively and courteously. 2. Purpose The purpose of this document is to provide an explanation of the terms and to detail how ACE CIC acknowledges and implements the Local Authority Social Services & NHS Complaints Regulations (2009) in addition to good principle documents in relation to complaints handling i.e. Ombudsman guidance. 3. Scope This policy applies to all staff employed by ACE. 4. Equality Impact Assessment This document has been assessed for equality impact and it is applicable to every member of staff within ACE and every patient; or their nominated representative, cared for by ACE irrespective of their race, ethnic origin, nationality, gender, culture, religion or belief, sexual orientation, age or disability. 5. Duties within the Organisation The Managing Director (MD) The MD has overall responsibility for this policy and has delegated to the Director of Clinical and Corporate Governance the authority to ensure ACE is fully compliant with this policy. The MD, Director or delegated deputy will review investigation reports and sign formal responses to complaints. The Complaints Team The Complaints Team comprises the Complaints Manager who is responsible for concerns and informal complaints and the management of all formal complaints received by ACE. The PALS and Patient Experience officer who is responsible for helping patients and their carers to resolve informal problems or concerns quickly; to provide advice or support; to signpost you to other useful sources of information. The Complaints Team also monitors and responds to comments about ACE posted on NHS Choices and other service user feedback web sites. 3
Service Managers The role of all service managers is to manage the resolution of verbal complaints made to front-line staff and respond promptly to requests by senior managers or the Complaints Team when investigations or enquiries are made about formal complaints. Service Managers will provide support and guidance to junior members of staff in how to manage both informal and formal complaints and provide guidance to patients and their carers about how to make comments or complaints if the need arises. Managers will ensure that all serious oral and written complaints are forwarded to the Complaints Team office immediately on receipt and act as an Investigating Officer for complaints if requested to do so. All staff All staff are required to act in accordance with this policy in addressing and managing the resolution of concerns and complaints. Complaints Investigator An investigator will be appointed by the service manager; or in some circumstances such as highly complex cases or to provide a higher degree of independence, by the MD or Director for C&CG. The investigation will be conducted in accordance with the Local Authority Social Services & NHS Complaints (England) Regulations 2009 using the approved documentation templates within 10 working days unless otherwise agreed by the Complaints Team. 6. Explanation of Terms and Management Processes 6.1 Compliments, Comments and Concerns. We actively encourage people to provide us with feedback on any aspect of the services we provide, be that positive or negative. Regardless of the background or the circumstances of any individual, we endeavour to provide easily understood, accessible and uncomplicated ways in which they can tell us what they feel about the care, treatment or service they have received. Every effort will be made to formally acknowledge receipt of compliments and comments in writing expressing our thanks. Front line staff are expected to receive and resolve minor concerns relating to their services and to clearly inform the individual of the next stages i.e. either informal or formal complaint if they feel that their concern has not been sufficiently handled or resolved. Concerns received at service level do not need to be reported to the Complaints Team but service leads may wish to make a note to be kept at service level and it is good practice and encouraged that managers use this information at team meetings. On some occasions individuals may wish to highlight a concern or informal complaint but do not want to raise this with the service directly. In these cases individuals may use the PALS function to either clarify any queries, or to handle informal complaints. All complaints and concerns that are handled by the PALS Officer are recorded on to the Datix system. The PALS Officer will guide and support the individual should a formal compliant be considered necessary and will follow the processes for formal complaints handling described in this policy. 4
6.2 Complaints A complaint is an expression of dissatisfaction relating to care and services that requires a response. Who can complain? A person who receives or has received services from ACE A person who is affected, or likely to be affected, by the action, omission or decision of ACE which is the subject of the complaint A person acting on behalf of a person detailed above who:- - has died; - is a child; - is unable to make the complaint themselves because of:- - physical incapacity; or - lack of capacity within the meaning of the Mental Capacity Act 2005 (a); or - has requested the representative to act on their behalf. With regards to children and adults without capacity, ACE is permitted in accordance with the regulations to take a view on whether the person is acting in the patients best interests when making a complaint. If it is felt that this is not the case then ACE can refuse to handle a complaint made by that person. In practice this means that ACE should not automatically assume that a parent or guardian can make a complaint on behalf of a child if it is felt that the child has sufficient maturity and capacity to make, or withhold, the complaint on their own behalf. If ACE were considering exercising this power it would only do so after full and proper consultation with relevant other parties who will be determined based on the circumstances of the particular case and could include the Courts, a social worker, healthcare professional or legal advocate. Instances where complaints cannot be made By one responsible body e.g. a hospital trust, GP practice or independent provider against another. A complaint the subject matter of which has already been investigated under the current or previous complaints regulations. Staff working within, or contracted to ACE cannot use this policy to complain about employment, contractual or pension issues. Complaints arising from the alleged failure to comply with a data subject request under the Data Protection Act 1998 or the alleged failure to disclose information under the Freedom of Information Act 2000 6.3 Informal Complaints It is in the interests of all parties that concerns and complaints are resolved as quickly, efficiently and professionally as possible, therefore informal i.e. oral complaints can be resolved on the spot by front line staff. 5
Informal complaints received at service level by any member of staff will normally be resolved immediately or within 2 working days. These complaints should be documented using the template at Appendix 1 and forwarded to the Complaints Team for logging on to Datix. Informal complaints that are potentially serious or require a written response should be deemed as formal and forwarded by safe haven fax on the day of receipt to the Complaints Team who will process and manage them in line with the Local Authority Social Services & National Health Services Complaints (England) Regulations 2009. Any individual who remains dissatisfied following the response to an informal complaint has the right to pursue the matter further through the formal complaints procedure. 6.4 Formal Complaints The right to complain about the service received from ACE and to have your complaint dealt with effectively is contained in the NHS constitution. The Local Authority Social Services and NHS complaints regulations (England) came into force in 2009 and require provisions to be in place to ensure the effective, timely and consistent management of complaints and the treatment of complainants with courtesy and respect. Additional complaints-related obligations for NHS organisations are contained in the CQC standards for quality and safety and within the Ombudsman s Principles of Good Complaint Handling (2009). Service users, relatives and carers should feel able and know how to comment without fear of being treated differently as a result. Complainants will be given assurance that they will not be treated differently as a result of their complaint either by the staff member receiving the complaint or by the service or by the organisation as a whole. If the complainant is an existing patient, they can expect to continue to receive a high standard of care and treatment. Should there be any reports of complainants feeling that the standard of care they are receiving is being compromised because of their complaint, this will be reported to the appropriate senior manager for further investigation and management. From April 2009 there has been a single approach for dealing with complaints about NHS and Adult Social Care Services. In the NHS, a complainant can also choose to complain to the commissioner of the service instead of the service provider. Complaints about ACE services or staff may therefore be received by the ACE Complaints Team from the commissioning body. In these circumstances ACE will work in accordance with the regulations and with the commissioning body to investigate, respond and resolve complaints as quickly as possible and within the prescribed timescales. 6.4.1 Receiving a Formal Complaint The Complaints Manager will receive all written, serious oral and complaints not resolved on the spot on behalf of the Managing Director. An initial assessment will be made to ensure that the complaint can be handled under the complaints regulations. If the Complaints Manager has concerns for the immediate welfare of the patient they will seek advice from the MD, Director of C&CG or their nominated deputy. 6.4.2 Acknowledgement of Formal Complaints The Complaints Manager will; on behalf of the Managing Director, acknowledge receipt of the complaint to the complainant within 3 working days. The acknowledgement will set out in writing how the complaint will be handled, the areas of concerns to be investigated (Terms of 6
Reference) and the proposed timescale for the response. The acknowledgment will also invite the complainant to contact the Complaint Team if they wish to discuss or change the terms of reference or are unhappy about the proposed timescales. The Regulations places an emphasis on personal contact with the complainant so that the complaint can be fully understood and that the response sought by the complainant can be identified. The complainant may therefore be offered the opportunity of either a meeting or telephone consultation to discuss the content of the complaint, the scope of the response they would wish and a timeframe in which this will be achieved. Each complainant, if not represented by an independent advocate will be provided with information on Advocacy Services. In the case of any complaint where consent of the patient is required the Complaints Manager will request the written consent of the patient before proceeding with the complaint. Where consent is refused the complainant will be advised of this in writing. In cases where the capacity to give consent is unknown the Complaints Manager must liaise with professionals who have a sound knowledge of the patient to ascertain capacity. The start date for complaints handling will start once consent is received. 6.4.3 Investigating the Formal Complaint Investigation into a complaint is necessary to provide a review of an incident, complaint or claim in order to identify what, how, and why it happened. The analysis can then be used to identify areas for change and recommendations for improvements and to minimise recurrence in the future. The level of investigation is dictated by the level of severity of harm to the patient/carer/relative or staff member; and the potential for learning (which could include investigating those incidents, complaints or claims which are high frequency, but are of low severity). The greater the risk: the higher the level of investigation and the more senior the investigator will be. In the case of a complex serious complaint, ACE may commission an independent party to undertake the internal investigation. The investigator has a duty to complete the investigation within agreed timescales and to allow sufficient time for a review of their report, compilation of a response and any subsequent queries that may arise. 6.4.4 Responding to the Complainant On receipt of the investigators report and draft response the Complaints Manager will prepare a response letter to the complainant for consideration by the Managing Director. Once the Managing Director is satisfied that the response answers the complaint, the letter will be signed and sent to the complainant. An attachment entitled Advise and Additional Support which explains the process for local resolution meetings, providing feedback to ACE on complaints handling and for accessing the Parliamentary & Health Service Ombudsman will be sent with the response. All complaints will; unless previously negotiated and agreed by the complainant, be responded to within 30 working days. This timeframe will commence from the time the TOR are agreed by the complainant or at the time written consent has been received. 7. The Parliamentary Health Service Ombudsman Complainants have the right to raise their concerns directly with the Ombudsman service. The Ombudsman will be primarily concerned with identifying whether any maladministration has taken place in the matters raised by the complaint, in the handling of the complaint, and whether ACE has failed to provide a service that it is statutorily required to provide. 7
The Ombudsman will not necessarily challenge a decision made by ACE so long as it can be demonstrated that no maladministration or failing has taken place in the process by which the decision was made. The Complaints Manager is responsible for liaising with the Ombudsman in the event of a complaint being referred to their office. The Ombudsman takes an independent view of how organisations has handled and responded to a complaint and whether it has provided sufficient redress where an injustice has taken place. There are two possible outcomes from a referral to the Ombudsman: it will either be decided that ACE have provided an appropriate response and no further action will be taken; or the Ombudsman will investigate and provide a view on the handling and outcome of the complaint. If after investigation the Ombudsman finds fault or omissions with the investigation or response then ACE will be provided with recommendations for improvements. ACE will co-operate fully with the Ombudsman s office on any complaint that is referred to it and will take action on any findings that the Ombudsman makes as a result of a complaint. 8. Joint Complaints Complaints can feature more than one service or organisation and the 2009 regulations permit organisations concerned to agree that one body will take the lead in handling the complaint. ACE will honour the requirement under The Local Authority Social Services and NHS Complaints (England) Regulations 2009 in our duty to co-operate. Each case will be considered individually and in all cases the Complaints Manager will manage the process on behalf of ACE. 9. Intractable Complaints There are a small number of complainants who, for a number of reasons may not accept the final outcome of a response. For example, the complainant may not accept evidence put forward or they may continually change the subject of their complaint or focus on a minor disproportionate issue. Occasionally, complainants may become aggressive or threatening. In these rare cases the MD will consider taking additional actions such as face to face conciliatory meetings or confine further dialogue through a third party. Exceptionally, action will be taken to limit their contact with the Complaints Team. 10. Time limits for making a complaint It is optimal if complaints are raised as soon as an individual feel the need to complain, this enables timely investigation and resolution. The Regulations state that an NHS or Social Care complaint must be made within 12 months from the date on which a matter occurred or the matter came to the notice of the complainant. However, this timescale can be extended in such circumstance that the complainant was too ill or too upset to complain at the time and that the evidence for a proper investigation is still available. Front-line staff receiving a complaint which appears out of time, should contact the Complaints Manager for advice and decision. 8
11. Sources of Support for Complainants All staff should ensure that complainants are advised of the support available to them in making their complaint; namely: ACE Complaints Team including PALS The Independent Complaints Advocacy Service (ICAS) Complainants should be provided with the ACE leaflet Listening, Responding, Improving, copies of which are available in all services and via the Complaints Team. 12. Learning Lessons from Complaints ACE is committed to using complaints as a resource to learn from patient and carer experience to improve the services we provide. Managers should use the issues raised in individual complaints to explore and; where appropriate, initiate service improvements. Issues arising from complaints, problems and other user feedback should be a standard item for discussion at team meetings. The Complaints Team will monitor trends and provide trend and analysis reports for crossorganisational learning. 13. Support for Staff involved in Complaints ACE recognises that complaints will be made and will resist assigning blame. Staff will be informed of the details of any complaints made against them, have the opportunity to answer the complaint and be kept informed of the progress of the complaint and its outcome by their manager. The following additional support is available to ACE staff who are the subject of a complaint. Their duties will be reviewed dependent on the nature of the complaint. The majority of staff continue in their role, although in some cases they may be taken off particular tasks, supervised or in some cases temporarily redeployed to another area. Only in very serious cases staff may be temporarily suspended from duties until the investigation is completed. Immediate and on-going support if required will be made available to staff from Human Resources, their Unions, Occupational Health and their manager. The organisation does not expect staff to tolerate any form of abuse from service users or others during complaint management. Staff are not expected to put themselves in situations where they feel they may be at risk when dealing with complaints. Abuse, harassment or violence of any kind towards members of staff will not be tolerated. Personal contact may be withdrawn from any patient who acts in this way. Staff will not be expected to undertake home visits or to meet people on their own regarding a complaint or concern if they feel themselves to be at risk. 14. Police and Disciplinary Investigations Investigations and responses to complainants may be dealt with concurrently with both police and disciplinary proceedings unless to continue would impede one or both these investigations. If, this is the case the complainant must be advised that the investigation into their complaint is suspended until the completion of the other investigation 15. Training All staff can access additional support and 1-1 coaching during the management of complaints from the Complaints Team. Complaints investigation training is bespoke to named investigators enquiries should be made to the Director of C&CG in the first instance for advice and signposting. 9
16. Monitoring and Compliance The Complaints Team will provide: Monthly reports on the achievement of compliance of the Act in relation to timescale for acknowledgement and response for internal i.e. MEC and Board and for external i.e. commissioner reporting Monthly reports of the number and content, service area and outcome Trend reports for internal action planning to improve performance and patient experience. An annual complaint report. 16.1 Audit of Complainant Feedback The Complaints Team will undertake audit reviews to ensure that concerns and complaints are managed in accordance with the Act and this policy. These reviews will seek to provide assurance to management and the Board that: The required standards for managing concerns and complaints are embedded in practice and adhered to Learning from concerns and complaints ensures continuous service improvements Complainants and those who raise concerns are satisfied with the management of their issues 17. References The Local Authority Social Services and National Health Service Complaints (England) Regulations 2009 Principles of Good Administration Parliamentary and Health Service Ombudsman 2009 Principles of Remedy - Parliamentary and Health Service Ombudsman 2009 Principles of Good Complaints Handling - Parliamentary and Health Service Ombudsman 2009 18. Associated Documents and Policies Financial Remedy Policy (Complaints Handling (ACE 359) PHSO Principles for Remedy 10
Appendix 1 Date complaint received: Details of person making the complaint: Full name Address Record of Informal/Verbal Complaint Postcode Contact telephone number Details of patient if not complainant: Full name Date of birth Service details: Service NHS no Ward/Dept. Site Summary of complaint: continue on separate piece of paper and attach if necessary Response made: continue on separate piece of paper and attach if necessary Resolution reached: YES NO delete as required If resolution is not reached within 2 working days this form must be marked URGENT and faxed or emailed to the Complaints Team Email: ACECIC.patientexperience@nhs.net Learning outcomes: if resolution reached. Continue on separate piece of paper and attach if necessary Complaint handled by: Name Job Title Signature Date completed This form and any attachments must be returned to the Complaints Team @ 659-662 The Crescent, Colchester Business Park Colchester, CO4 9YQ June 2014 V2 11
Informal Complaint Flow Chart Appendix 2 Complaint received by front line staff Take complainant to a private area Is the complainant the patient? Yes No Inform complainant that due to confidentiality you must seek consent from the patient to discuss these issues Explain what will happen as a result of their complaint Yes Is patient able to give consent? No Inform complainant that you will be completing a record of informal/verbal complaint and that details will be recorded on ACE S computerised complaint system (DATIX) Ask complainant for full details of their concerns including dates and times Yes Does complainant have the authority to make the complaint on the patient s behalf; power of attorney or named next of kin No Is the complaint of a serious nature? No Yes Contact Complaints Team for advice Attempt to resolve the complaint Resolved record the outcomes on the verbal/informal complaint form and send to the Complaints Team Unresolved return completed verbal/informal complaints form to the Complaints team who will contact complainant within 3 days Contact complaints team for advice If it cannot be responded to within 2 working days it must be referred to the complaints manager June 2014 V2 12
Formal Complaints Process & Timescales Appendix 3 Complaint received Is consent required? Complainant NOT happy with TOR NO Acknowledgement sent within 3 working days with suggested TOR and timescale (30,60,90 working days) YES Acknowledgement sent within 3 working days with suggested TOR and a consent form to be completed and returned Complainant NOT happy with TOR Complaint on hold until TOR agreed Complainant happy with TOR Complainant happy with TOR and Consent returned Complaint on hold until TOR agreed Complaint sent to Manager for allocation of investigator Complainant happy with TOR and consent returned Investigator allocated and given 10 working days to complete investigation. Complaints Team will provide the relevant investigation report template Investigation report completed on time? Day 10 YES Final Investigation report to Complaints Manager for review NO Interim investigation report either in writing or given verbally to Complaints Manager if more time to investigate is required Days 11-20 Days 20-25 Investigation report reviewed and any outstanding issues discussed with investigator Draft letter passed for clinical check if required New investigation timescale negotiated with Complaints Manager and with Complainant if 30 working day complaint timescale is not achievable Within 10 Working Days Days 25-30 Letter passed to MD for final consideration, amendment and signature June 2014 V2 13