BOARD OF DIRECTORS PAPER COVER SHEET Meeting Date: 29 July 2009 Agenda Item: 7 Paper No: D Title: ANNUAL POLICY REVIEW REPORT: POLICY AND PROCEDURE FOR THE MANAGEMENT OF COMPLAINTS Purpose: To provide assurance to the Board of Directors that complaints are being managed in accordance with NHSLA requirements Summary: Annual policy reviews are to be conducted in respect of all policies relating to the 50 NHSLA standards and reported to the Trust committee responsible for monitoring these policies. The report concludes that complaints are being managed in accordance with the Trust s policy and NHSLA requirements. The report makes recommendations to improve the reporting of complaints. Recommendation: For discussion and noting Prepared by: CARRIE STONE ROBERT TALBOT Presented by: ROBERT TALBOT Medical Director This report covers: (Please tick relevant box) Assurance Framework Healthcare Standards: CORE/DEV T Please specify which standard Business Planning Local Delivery Plan Complaints Finance Performance Management Strategic Development Foundation Trust Compliance Financial implications YES / NO Other (Please specify) Legal implications YES / NO
POLICY AND PROCEDURE FOR THE MANAGEMENT OF COMPLAINTS ANNUAL POLICY REVIEW REPORT 2009 Date: July 2009 Presented to: Board of Directors Action Plan: Yes Date of Next Annual Report: July 2010 Author: Legal Services Manager
CONTENTS 1 INTRODUCTION 3 2 RESULTS OF MONITORING AND AUDIT 3 2.1 Aims and Objectives 3 2.2 Methodology 3 2.3 Results 4 2.3.1 Management of the Complaints Process 4 2.3.2 Internal and external communication and collaboration 5 with other organisations when necessary 2.3.3 The procedure to ensure that patients, relatives and 5 their carers are not treated differently as a result of a complaint 2.3.4 Process by which the organisation aims to make 5 changes as a result of formal complaints 2.4 Conclusions 5 3 AREAS OF GOOD PRACTICE 6 4 NEW STANDARDS/LEGISLATION 6 5 RECOMMENDATIONS 6 6 ACTION PLAN 6 7 APPENDICES 6 7.1 Appendix 1: Action Plan 7 3
1 INTRODUCTION This is the second annual monitoring report relating to the Policy and Procedure for the Management of Complaints. Quarterly reports detailing trends and actions in relation to formal complaints are provided to the Board of Directors and the Risk Management and Safety Committee. An annual report is also provided to the Board of Directors. Aggregated data arising from complaints, claims, incidents and PALS issues are presented to the Complaints, Claims, Incidents and PALS Review Group and the Clinical Governance Committee on a quarterly basis. The Policy and Procedure for the Management of Complaints was approved by the Trust Board and subsequent amendments approved by the Medical Director and recorded in the policy document. The policy underwent significant amendment in May 2009, following the publication of SI 2009 No 309 NHS England, Social Care England: The Local Authority Social Services and NHS Complaints (England) Regulations 2009 and was approved by the Board of Directors in May 2009. 2 RESULTS OF MONITORING AND AUDIT 2.1 Aims and Objectives The aim of the monitoring and audit of the effectiveness of this policy is to provide assurance to the Trust that complaints are being managed in accordance with SI 2009 No 309 and the NHSLA requirements. 2.2 Methodology The audit and monitoring criteria for the policy is listed below. Management of the complaints process: NHSLA Standard 5 Learning from Experience 5.3. The acknowledgement times and response times for complaints are provided on a quarterly basis in the reports to the Board of Directors, CCIP Review Group and the Risk Management and Safety Committee. This information is obtained using data held on the Datix complaints system. Accessibility of the complaints procedure to patients, relatives and carers is reported in a similar manner. Internal and external communication and collaboration with other organisations when necessary. The number of complaints that cross multi-agencies is obtained by the review of individual complaints files. The revised policy includes a flow chart describing the process for multi-agency/external agency complaints. The procedure to ensure that patients, relatives and their carers are not treated differently as a result of a complaint. Paragraphs 11.15 and 11.16 of the Policy states that complainants must not be discriminated against and that correspondence pertaining to the complaint will not be filed in the patient s healthcare records. A random selection of healthcare records pertaining to clinical care complaints were reviewed by the Legal Services Manager. 4
Process by which the organisation aims to make changes as a result of formal complaints. 2.3 Results The number, nature and trends of complaints together with the identification of remedial actions are provided on a quarterly basis to the Board of Directors, Risk Management and Safety Committee and the CCIP Review Group. The report is developed using data held on the Datix system for complaints. Summary reports identifying the number, nature and actions taken are provided to the Clinical Care Groups on a quarterly basis for inclusion in the Quarterly Performance Reviews. Following the 2008 Annual Policy Review Report the recommendation that action plans to monitor progress against individual complaints would be developed has been implemented. The specific results for each criterion are given below: 2.3.1 Management of the Complaints Process 355 formal complaints were received by the Trust. The response times for the acknowledgement of complaints for the financial year 2008/2009 was 96%. The response to complaints was 85% within the 25 day time-scale. 51 complaints were responded to outside the timescale. The following table demonstrates the reasons for this: Total Delay due to Clinical Care Group 17 Delay due to further investigation/complex complaint 16 Delay due to Consultant 15 Delay due to Legal Services Department 3 Totals: 51 The amended Regulations, in place in 2008/2009, governing the NHS Complaints procedure, allowed for extensions beyond the recommended 25 working days, following discussion with the complainant. Data on requests for extensions has been included in the Quarterly Complaints Reports to the Board of Directors since approval of the 2008 APRR in July 2008. When it became apparent that the response was likely overrun by more than five working days, 32 requests for extensions were made. Response times within Care Groups are monitored through the Quarterly Performance Reviews and discussed at the Complaints, Claims, Incidents and PALS Review Group. 15% of complaints were received by email, 11% via fax, 3% were received in person and 71% by letter. All complaints are graded according to severity by the Legal Services Manager according to consequence and likelihood utilising the grading of complaints tool (Appendix A of the policy) and a summary of all red and amber complaints are provided in the quarterly complaints report. The Complaints, Claims, Incidents and PALS Review Group have recently received summaries of red and amber complaints. 5
All complaints are categorised by subject and the numbers, trend analysis and outcomes are provided in the quarterly reports to the Board of Directors, the Risk Management and Safety Committee and the CCIP Review Group. All Independent Review requests, outcomes and recommendations made by the Healthcare Commission are reported in the quarterly reports to the Board of Directors, the Risk Management and Safety Committee and the CCIP Review Group. 2.3.2 Internal and external communication and collaboration with other organisations when necessary Collaboration with, and/or referral to other agencies eg., Primary Care Trusts, Foundation Trusts and Social Services has taken place in 12 instances. Where appropriate, complainants have been offered the opportunity of a joint response, but these offers have not always been taken up. 4 complainants received joint responses with collaboration between the Trust, The Royal Bournemouth Hospital, Bournemouth and Poole Primary Care Trust, Social Services and Ambulance Service. The Trust s annual complaints report 2008/2009 will be shared with Bournemouth and Poole Primary Care Trust following approval by the Board of Directors. The report will also be placed on the Trust s website. 2.3. The procedure to ensure that patients, relatives and their carers are not treated differently as a result of a complaint The policy states that correspondence pertaining to the complaint will not be filed in the patient s healthcare records. 144 complaints related to clinical care: a review of healthcare records indicates that 3 sets of case notes contained complaints correspondence. 2.3.4 Process by which the organisation aims to make changes as a result of formal complaints The number, nature and trends of complaints together with identification of remedial actions are provided on a quarterly basis to the Board of Directors. The Clinical Care Groups receive a report on a quarterly basis for the Quarterly Performance Reviews, indicating the number and nature of complaints, together with actions taken or to be taken in respect of individual complaints. The Complaints, Claims, Incidents and PALS Review Group and the Clinical Governance Committee receive quarterly reports identifying organisational and departmental learning and key themes from aggregated analysis. All the reports are developed using data held on the Datix system for incidents, complaints, claims and PALS issues. Organisational learning and recommendations arising from Serious Untoward Incidents are reported to the Board of Directors, the Clinical Governance Committee, Risk Management and Safety Committee and the Complaints, Claims, Incidents and PALS Review Group with subsequent outcome reports to ensure that recommendations and remedial actions are completed within the time-scales set down. 2.4 Conclusions The monitoring and audit of this policy has provided assurance to the Trust that formal complaints are being managed in accordance with the NHSLA requirements and in accordance with this policy. 1
3. AREAS OF GOOD PRACTICE Non-discriminatory practice of ensuring complaint correspondence is not filed in the patient s healthcare records. National Audit Office Feeding back Learning from complaints handling in Health and Social Care. This report identified that the Trust had above average outcomes for our comparator group. 4. NEW STANDARDS/LEGISLATION 4.1 NHS Complaints Reform The way in which complaints are dealt with by health and social care bodies has been the subject of consultation. The Department of Health published its response: Making Experiences Count and undertook a consultation exercise. A more simplified two stage complaints system has been introduced with the focus on local resolution and resolution by Health or Local Government Ombudsmen in those cases where complaints remain unresolved. This has meant that the role of the Healthcare Commission/Care Quality Commission in complaint reviews ceased. 5 RECOMMENDATIONS The new complaints regulations no longer stipulate a time-scale for responding to complaints. Despite this, the Trust will continue to monitor this time-scale through the quarterly complaints reports to the Board of Directors. 6 ACTION PLAN The recommendations detailed above are included in the action plan at Appendix 1. 7 APPENDICES Appendix 1: Action Plan 2
Appendix 1 POOLE HOSPITAL NHS FOUNDATION TRUST Annual Policy Review Report Action Plan for: Lead for Action Plan: Legal Services Manager Reviewing Committee: Board of Directors Date Action Plan Initiated: July 2009 Policy and Procedure for the Management of Complaints Code: Red Amber Green Issue Identified Action Lead Target Date Progress Review Date Green To ensure timeliness of responses to complaints, the 25 day time-scale should continue to be monitored by the Board of Directors on a quarterly basis. Response times to continue to be reported in the quarterly complaints reports to the Board of Directors and through the Care Groups Quarterly Performance Review Reports Carrie Stone With immediate effect. 3