02 QG Complaints and Compliments Policy

02 QG Complaints and Compliments Policy Policy number: Version 3.6 Approved by Name of author/originator Owner (director) 02 QG Date of approval July 2014 Date of last review 03/07/13 Next due for review 03/07/16 Quality and Clinical Governance Committee Samantha Chalmers, Risk and Governance Manager Elaine Newton, Director of Governance and Compliance Page 1 of 24

Version control sheet Version Date Author Status Comment 1.0 October 2012 Lucy Botting Draft As provided for authorisation 2.0 June 2013 Wendy Lockwood 2.1 July 2013 Wendy Lockwood 3.0 May 2014 Samantha Chalmers 3.1 June 2014 Samantha Chalmers 3.2 June 2014 Samantha Chalmers 3.3 June 2014 Samantha Chalmers 3.4 July 2014 Samantha Chalmers Draft Final Draft Draft Draft Draft Draft Updated for legislation and organisational structure For approval Revised following end of year complaints audit Appendices added With amendments For consultation With amendments 3.5 July 2014 Liz Patroe Final With amendments 3.6 November 2014 Liz Patroe Final With amendments Page 2 of 24

Equality statement NHS Guildford and Waverley aims to design and implement services, policies and measures that meet the diverse needs of our service, population and workforce, ensuring that none are placed at a disadvantage over others. We take into account the Human Rights Act 1998 and promote equal opportunities for all. This document has been assessed to ensure that no employee receives less favourable treatment on the protected characteristics of their age, disability, sex (gender), gender reassignment, sexual orientation, marriage and civil partnership, race, religion or belief, pregnancy and maternity. Members of staff, volunteers or members of the public may request assistance with this policy if they have particular needs. If the member of staff or complainant has language difficulties and difficulty in understanding this policy, the use of an interpreter will be considered. We embrace the four staff pledges in the NHS Constitution. This policy is consistent with these pledges. Page 3 of 24

Equality Impact Assessment tool Stage One: Screening for Relevance to Equality Strands and Prioritising. To be completed and attached to any procedural document as part of main document sited between version control sheet and contents page. 1 Name of the strategy / policy / proposal / service function 2 Who is the strategy / policy /proposal / service function aimed at? 3 What are the main aims and objectives? 4 Identify the data / information you have regarding the use of the strategy / policy / proposal / service function by diverse groups? Complaints and Compliments Policy All CCG staff and members of the public Delivery of a user friendly complaints policy that meets all statutory requirements Complaints and compliments Use qualitative, quantitative and anecdotal information e.g. Demographic data, results of consultations, research and surveys. Local authority monitoring data, PALS, complaints, public enquiries, audits & reviews. 5 Is the strategy / policy / proposal / service function relevant to any of the protected characteristics below? Please include negative and positive impact. If YES please indicate if the relevance is low, medium or high. (See description below) Equality strands Patient, carer or family Staff Age Low Low Sex (male, female, gender reassignment) Race / Ethnic communities / groups Disability learning disabilities, physical disability, sensory impairment and mental health problems Low Low Mediu m Low Low Low Nationality Low Low Religious / other beliefs Low Low Low The policy may not be relevant to the Equality Duty as stated by law Little or no evidence is available that different groups may be affected differently Little or no concern raised by the communities or the public about the policy etc when they are consulted (recorded opinions, not lack of interest) Medium The policy may be relevant to parts of the Equality Duty in the policy etc regarding differential impact There may be some evidence suggesting different groups are affected differently Page 4 of 24

Marriage and civil partnership Pregnancy and maternity Sexual Orientation, bisexual, gay, heterosexual, lesbian Low Low There may be some concern by communities and the public about Low Low the policy Low Low Human Rights Low Low Carers Low Low High There will be relevance to all or a major part of the Equality Duty in the policy regarding differential impact. There will be substantial evidence, data and information that there will be a significant impact on different groups There will be significant concern by the communities and relevant partners on the potential impact on implementation of the policy 6 Are there barriers which could inhibit access to the benefits of the strategy / policy / proposal / service function? E.g. Communication / information, physical access, location, sensitivity etc. Method of communicating and publicising this policy is via the website which will mean that it is not readily available to people with no internet access. Paper copies can be posted on request. 7 Does the strategy / policy / proposal / service function relate to an area where there are known inequalities? If so which and how? 8 Please identify what evidence you have used / referred to in carrying out this assessment. 9 Identify any minor changes to the strategy / policy / proposal / service function which will reduce potential adverse impacts at this stage. 10 Please indicate if a Full Equality Impact Assessment is recommended. NO YES 11 If you are not recommending a Full Impact assessment please explain why: 12 Signature of lead or Director Date completed 13 Submitted to Head of Communications for approval Names of people carrying out the assessment Date submitted 1.Samantha Chalmers 2 3 Name of lead manager / director Elaine Newton Please leave blank to allow continuation of equalities impact assessment Page 5 of 24

Contents Contents... 6 1 Introduction... 7 2 Objective... 7 3 Scope... 8 4 Definition of complaint and compliment... 8 5 Duties... 8 5.1 The Governing Body, Chief Officer and Director of Governance and Compliance... 8 5.2 The Complaints Manager (Policy & Engagement Manager)... 8 5.3 CCG leads/ Senior Managers/Line Managers... 9 5.4 All staff... 10 6 Procedure... 11 6.1 Process summary... 11 6.2 The principles of remedy... 12 7 Confidentiality... 14 7.1 Safeguarding... 14 7.2 Fair Processing Notice... 14 8 Parliamentary and Health Services Ombudsman (PHSO)... 15 9 Implementation plan for this policy... 15 10 Monitoring NHSLA Monitoring Table... 16 10.1 Qualitative information... 16 11 Appendix 1 Practical Guidance for Handling Verbal Complaints (telephone or in person)... 17 12 Appendix 2 Response letter checklist... 19 13 Appendix 3 Demographic data collection form... 20 14 Appendix 4 Mail/e-mail confirmation of receipt... 21 15 Appendix 5 Process for passing complaints to other organisations (to be carried out by Complaints Manager)... 22 16 Appendix 6 Template response letter... 23 Page 6 of 24

1 Introduction This policy has been formulated to ensure the CCG responds to complaints to a satisfactory standard, respectfully and efficiently, and complies with the requirements contained within The Local Authority Social Services and National Health Service Complaints (England) Regulations 2009. Our complaints approach is structured around the Parliamentary and Health Service Ombudsman s Principles of Good Complaints Handling 2009. Getting it right Being customer focused Being open and accountable Acting fairly and proportionately Putting things right Seeking continuous improvement. This policy also takes into consideration the Putting Patients First and Foremost: the initial government response to the Francis Report 2013. The Francis report recommendations include: Openness, transparency and candour throughout the system Importance of narrative as well as numbers within the data Complaints amounting to Serious Untoward Incidents should trigger an investigation 2 Objective The CCG recognises complaints and compliments as being valuable tools for improving the quality of health services we commission and provide. The objective of this policy is: To provide a fair complaints procedure which is clear, accessible and easy to use for anyone wishing to make a complaint To publicise the existence of the complaints procedure so that people know how to contact the CCG to make a complaint To make sure everyone at the CCG knows what to do if a complaint is received To make sure all complaints are investigated fairly and in a timely way To make sure that complaints are, wherever possible, resolved and that relationships are repaired To gather information which helps the CCG to improve Page 7 of 24

3 Scope This policy covers complaints and compliments that have been received either first hand or through a third party regarding the operation, commissioning intentions, organisation or relationships of the CCG. This policy does not cover complaints raised by a member of CCG staff, or complaints raised about the quality or operation of services provided by other organisations (i.e. complaints about a provider). The protocol for passing on complaints to other organisation is set out in appendix 5. 4 Definition of complaint and compliment Both complaints and compliments can be used to improve services provided. A complaint is an expression of dissatisfaction that may be made in writing, in person or over the phone, which requires a response. A compliment is defined as a polite expression of praise or admiration that may also be made in writing, in person or over the phone. Compliments should be passed to the Complaints Manager to be collated and passed on to the relevant service or commissioning manager. Complaints and compliments may be made by patients, their relatives or advocates and by GPs or MPs on behalf of their patients and constituents. The remainder of this policy deals with complaints handling. 5 Duties 5.1 The Governing Body, Chief Officer and Director of Governance and Compliance The above are responsible for: Ensuring that the CCG handles complaints according to the regulations and good practice. Ensuring that there is a designated staff member who manages complaints who will be accessible to the public and to staff and who will be responsible to the Director of Governance and Compliance and Chief Officer for the handling of all complaints made against the CCG. 5.2 The Complaints Manager (Policy & Engagement Manager) The Complaints Manager is responsible for: Recording and acknowledging within 3 working days, all complaints received by the CCG and ensuring that they are dealt with in accordance with this policy. Page 8 of 24

Liaising as required with other organisations to ensure that the appropriate information is available to enable full and open responses to be drafted within the appropriate timescale. Maintaining suitable records, including the logging of complaints and ensuring regular updates are recorded of progress being made in resolving complaints. Liaising with colleagues from other health and/or social care organisations to produce a joint response, when required. Producing reports for the CCG Governing Body, Quality and Governance Committee and other relevant committees on the number and type of complaints, lessons learnt, actions taken and reflecting trends. The outcome of investigations and any corrective action taken should be used to improve future service. Producing annual statistics to the NHS Information Centre for the KO41a and b returns. Providing training and support to staff in handling complaints and investigations, including assistance with drafting responses. Providing induction training for new members of staff. Responding to and monitoring the implementation of any recommendations made by the Ombudsman. 5.3 CCG leads/ Senior Managers/Line Managers Leads/ Senior Managers/Line Managers are responsible for: Reporting complaints received directly to them to the Complaints Manager on the same day that the complaint is received. Ensuring that the investigation is carried out as soon as possible, bearing in mind the need to respond respectfully and efficiently. Ensuring that findings are sent to the Complaints Manager within the deadline set on the day the complaint has been received. Agreeing with the Complaints Manager how each complaint will be investigated. Undertaking complaint investigations and root cause analysis of complaints. Informing staff involved in the complaint. Ensuring that any written statements made by staff as part of the investigation process are accurate, legible, signed, dated and emailed promptly to the Complaints Manager to be saved in the Complaints folder on the X:\drive. Providing a draft response letter or a statement addressing all points raised by the complainant in the order in which they were raised in the initial complaint communication. Advising on the lessons learnt through investigating the complaint so that this can be recording for reporting purposes. Page 9 of 24

Using complaints/findings as a learning opportunity for staff by cascading good and poor practice identified, and ensuring actions are taken to minimise and prevent future complaints, including: o review of practice and systems in place o action plan o training o preparation of a protocol/guidance o redress and remedy o advising relevant staff of the outcome of a complaint against them Ensuring that all their staff are familiar with the NHS Complaints Procedure and are supported to investigate complaints. 5.4 All staff All staff are responsible for: Ensuring that they are familiar with and follow the NHS Complaints Procedure. Knowing where to access the complaints policy or relevant information. (e.g. line manager, complaints manager, portal, extranet and intranet). Page 10 of 24

6 Procedure 6.1 Process summary 6.1.1 All complaints received should be passed immediately to the Complaints Manager (Policy & Engagement Manager). 6.1.2 Complaints are recorded on the log by the Complaints Manager. 6.1.3 The Complaints Manager identifies the appropriate director, who assigns an Investigating Manager and informs the Complaints Manager who this is. 6.1.4 The complaint is acknowledged within three working days of receipt by the Complaints Manager either by phone (using the template in appendix 1) or by mail (using the template in appendix 4). The demographic data collection form (appendix 3) should be sent with the response letter. 6.1.5 Copies of the completed templates should be filed and the timescale of the complaint investigation if it is anticipated that it will exceed 20 days recorded on the log. 6.1.6 The Investigating Manager will advise the complainant and the Complaints Manager of any delays or issues. 6.1.7 The Complaints Manager will update the log with the progress of the complaint. 6.1.8 When the investigation is complete, the Investigating Manager will pass his/her draft response to the Director for approval. 6.1.9 When approved, the response will be sent to the Complaints Manager for checking prior to sign-off by the Chair or Chief Officer. 6.1.10 When the response is signed off, the Complaints Manager will record dispatch/closure of the complaint on the log. 6.1.11 The Complaints Manager will advise the Director of any outstanding, overdue or delayed responses and escalate to the Chair if required. Page 11 of 24

6.2 The principles of remedy The CCG will adopt the following principles of remedy in responding to its complaints: 6.2.1 Getting it right Act in accordance with the law and with regard for the rights of those concerned. Act in accordance with the public body s policy and guidance (published or internal). Taking proper account of established good practice. Provide effective services, using appropriately trained and competent staff. Take reasonable decisions, based on all relevant considerations. Ensure information governance procedures are observed at all times to maintain patient confidentiality. 6.2.2 Being customer focused Ensure people can access services easily. Inform customers what they can expect and what the CCG expects of them. Keep to its commitments, including any published service standards. Page 12 of 24

Deal with people helpfully, promptly and sensitively, bearing in mind their individual circumstances. Respond to customers needs flexibly, including, where appropriate, co-ordinating a response with other service providers. 6.2.3 Being open and accountable Be open and clear about policies and procedures and ensuring that information and any advice provided, is clear, accurate and complete. State the criteria for decision making and giving reasons for decisions. Handle information properly and appropriately. Keep proper and appropriate records. Take responsibility for actions. 6.2.4 Acting fairly and proportionately Treat people impartially, with respect and courtesy. Treat people without unlawful discrimination or prejudice, and ensuring no conflict of interests. Deal with people and issues objectively and consistently. Ensure that decisions and actions are proportionate, appropriate and fair. 6.2.5 Putting things right Acknowledge mistakes and apologising where appropriate. Put mistakes right quickly and effectively. Provide clear and timely information on how and when to appeal or complain. Operate an effective complaints procedure, which includes offering a fair and appropriate remedy when a complaint is upheld. 6.2.6 Seeking continuous improvement Review policies and procedures regularly to ensure they are effective. Ask for feedback and use it to improve services and performance. Ensure that the CCG learns lessons from complaints and uses these to improve services and performance. Page 13 of 24

7 Confidentiality Confidentiality should be maintained at all times. Particular care will be taken when a patient s records contain information provided in confidence by, or about a third party. Only that information which is relevant to the complaint will be considered for disclosure and then only to those within the CCG who have a demonstrable need to know in connection with the complaint investigation. The Complaints Manager will be responsible for determining who should be in receipt of information and at what level. Information provided by a third party will not be disclosed to the complainant unless the person who provided the information has expressly consented to the disclosure, however, a summary of the information used in the investigation will be provided. If the third party objects, then it can only be disclosed where there is an overriding public interest in doing so as determined by the Complaints Manager. 7.1 Safeguarding Should a complaint give rise to concern regarding the safety or welfare of the complainant or the subject of the complaint then the following process must be followed by the person receiving the complaint to ensure confidentiality: Receiver must not act unilaterally Receiver should alert the Complaints Manager. In the absence of the Complaints Manager, the Receiver should contact the designated cover for complaints The Complaints Manager should request expert advice from the appropriate lead for safeguarding (adult or children s lead). Approval must be sought from the Executive Nurse Director for decisions and actions arising from this collective review, unless in an absolute emergency 7.2 Fair Processing Notice In accordance with good practice for Information Governance, the CCG has a fair processing notice to advise complainants how their information will be managed. This is presented below: Who we may share information with We work with patients and health and social care partners (e.g. local hospitals, local authorities, local community groups etc.) to provide healthcare services and may share information with them. We may also share de-identified statistical information with them for the purpose of improving local services. We may need to share your information with other commissioning organisations to allow us to effectively support the purpose for which you have provided the information, for example to manage a complaint or investigation. Page 14 of 24

We may also contract with other organisations to provide a range of services to us such as analysis of data, Human Resource and IT services. In these instances we ensure that our partner agencies handle our information under strict conditions and in line with the law. 8 Parliamentary and Health Services Ombudsman (PHSO) If a complainant remains dissatisfied following Local Resolution, they can approach the Ombudsman to request a review. The Ombudsman is independent of the NHS. The Ombudsman will only usually consider complaints, which have been through the NHS complaints procedure. Complaints should usually be referred to the Ombudsman within 12 months of the complainant raising the complaint. There is no appeal against a decision made by the Ombudsman, although a complainant is able to seek a legal remedy e.g. judicial review. The Ombudsman s office has published a series of Principles of good administration, of remedy and of good complaint handling (listed above in 5.2). Further information on the role and work of the Ombudsman is available from: The Parliamentary and Health Service Ombudsman Millbank Tower Millbank London SW1P 4QP Tel: 0345 015 4033 / Website: www.ombudsman.org.uk 9 Implementation plan for this policy Action Implementation plan Person responsible Timescale Evidence of implementation Publish on the internet Web manager Immediate Policy available on Website Advise all staff of change at team meeting Remind all investigating manager of new process Complaints Manager Complaints manager Within 1 month of approval Within 1 month of approval Minutes from team brief and senior leadership team Copy of policy attached to each complaint notification Page 15 of 24

10 Monitoring NHSLA Monitoring Table Criteria Measurable Frequency Getting it right Compliance with complaints process: Timeliness Quality of response Appropriateness of sign off Annual Reporting to Quality and Governance Committee Action Plan/ Monitoring Audit Being customer focused E&D assessment Accessibility Annual Quality and Governance Committee Audit Open and accountable Acting fairly and proportionately Putting things right Seeking continuous improvement Report Quarterly Quality and Governance Committee Report Quarterly Quality and Governance Committee Annual statement Annual Governing Body Completion of actions Annual Quality and Governance Committee Report: including number of staff completing being open and/or customer care training Report Annual statement Audit 10.1 Qualitative information Qualitative information regarding the complaints received will be presented in the quarterly report. Page 16 of 24

11 Appendix 1 Practical Guidance for Handling Verbal Complaints (telephone or in person) 1. Remain calm and respectful throughout the conversation. 2. Listen - allow the person to talk about the complaint in their own words. 3. Sometimes a person just wants to "let off steam". 4. Don't debate the facts in the first instance, especially if the person is angry. 5. Show an interest in what is being said. 6. Obtain details about the complaint before any personal details. 7. Ask for clarification wherever necessary. 8. Show that you have understood the complaint by reflecting back what you have noted down. 9. Acknowledge the person's feelings (even if you feel that they are being unreasonable) - you can do this without making a comment on the complaint itself or making any admission of fault on behalf of the organisation e.g. "I understand that this situation is frustrating for you". 10. If you feel that an apology is deserved for something that was the responsibility of your organisation, then apologise. 11. Ask the person what they would like done to resolve the issue. They may want a full investigation (provide advice on the process) or they may wish for their issues to be noted and not to go further. 12. Be clear about what you can do, how long it will take and what it will involve (refer to the Process timeline). 13. Don t promise things you can t deliver. 14. Give clear and valid reasons why requests cannot be met. 15. Make sure that the person understands what they have been told. 16. Wherever appropriate, inform the person about the available avenues of review or appeal. 17. Make sure you have noted down preferred contact details (telephone and email address). 18. Complete the record on the following page and send to the Complaints Manager. Page 17 of 24

Name of complainant: Record of Verbal Complaint Date of call: Address: Home telephone: Mobile telephone: Postcode: Email: Is the complainant complaining on behalf Ref: (For complaints manager) of another person? Yes/No GP Practice (to confirm that person to whom the complaint applies is registered within the CCG; if not NHS G&W CCG, the Complaints Manager can pass to the relevant CCG): Summary of discussion: Issues to be investigated: Response date: Consent required? Yes / No Outcome requested: Informed about how SEAP (Support Empower Advocate Promote) can help? Yes / No Any other information: Page 18 of 24

12 Appendix 2 Response letter checklist Thank the complainant for raising the issues Apologise State how you carried out your investigation (who did you talk to, what record did you review) Refer to and answer each issue raised (bullet points or use numbers if this is how it was presented in the complaint) Use the same language as the complainant (Plain English) Explain any acronyms State any changes in practice that have been made as a result Say how you will learn from their complaint Check that the correct address has been applied Check that the response is addressed to the right person (if the complainant was the patient, address the reply to the patient, but if the complainant was the GP or MP, address the reply to the GP or MP) Page 19 of 24

13 Appendix 3 Demographic data collection form This form should be sent out with the confirmation of receipt to the complainant. All information provided is confidential. *This information is voluntary. Please return the completed form to Guildford and Waverley CCG, 3 rd Floor Dominion House, Guildford, GU1 4PU Page 20 of 24

14 Appendix 4 Mail/e-mail confirmation of receipt Our Ref: Date: Complaints Manager Guildford and Waverley CCG 3 rd Floor Dominion House Woodbridge Road Guildford GU1 4PU TEL: 01483 405450 Private and Confidential Complainant s name Complainant s address Dear (Name), I am writing to acknowledge your letter/e-mail/call of (date) which the Clinical Commissioning Group (CCG) received on (date). I was sorry to learn of the problems which you have experienced with XXXXXXXXXXXXX. I would welcome the opportunity to talk to you in order to obtain further information and clarify your concerns and to agree with you the way in which the CCG will handle your complaint. I would therefore be grateful if you could contact me on the above number so that we can have this discussion or, alternatively, so that we can arrange a time to meet and discuss this matter in person. You may also wish to contact an independent advocacy service such as Support Empower Advocate Promote (SEAP), as they are able to provide support for people wishing to make a complaint about the NHS. Further information about SEAP can be found at http://www.seap.org.uk/local-authority/surrey.html. Yours sincerely (Name and Signature) Page 21 of 24

15 Appendix 5 Process for passing complaints to other organisations (to be carried out by Complaints Manager) *The complaint cannot be considered closed until the external organisation has acknowledged that they have received the complaint and have accepted responsibility for investigating the issues raised. Consent may be required when the individual complaining is not the patient and the patient can be considered to have capacity. Page 22 of 24

16 Appendix 6 Template response letter Complaints Manager Guildford and Waverley CCG 3 rd Floor Dominion House Woodbridge Road Guildford GU1 4PU TEL: 01483 405450 Our Ref: Date: Private and Confidential Complainant s name Complainant s address Dear (Name), The response should include: Greeting and apologies where required Reference to (including the date of) the original complaint and any explanations of delays Reason for writing (ie to advise you of the results of my investigation...) Each point raised and addressed in the order that the complainant made them Any comments or information provided by external organisations that assisted in the investigations A description of any actions being undertaken to improve What to do if they are not satisfied (see below) If you remain dissatisfied, you can approach the Parliamentary and Health Services Ombudsman to request a review. The Ombudsman is independent of the NHS. The Ombudsman will only usually consider complaints, which have been through the NHS complaints procedure. Complaints should usually be referred to the Ombudsman within 12 months. Page 23 of 24

Further information on the role and work of the Ombudsman is available from: The Parliamentary and Health Service Ombudsman Millbank Tower Millbank London SW1P 4QP Tel: 0345 015 4033 / Website: www.ombudsman.org.uk Yours sincerely, (Name and Signature) Chair or Chief Officer Page 24 of 24