Policy and Procedure for Management of Concerns and Complaints

MAIDSTONE AND TUNBRIDGE WELLS NHS TRUST Policy and Procedure for Management of Concerns and Complaints Requested/ Required by Main author: Quality & Safety Committee Amanda Bedford, Quality Manager for Patient Concerns Other contributors: Document lead: Amanda Bedford, Quality Manager for Patient Concerns Contact Details: 01622 226404 Supersedes: Review of systems and Processes for Complaint Management 2008 Complaints Policy 2007 Complaints Procedure 2007 Handling of informal concerns raised by patients/relatives carers (PALS) 2007 PALS processes 2006 Procedure for instigating formal investigations from serious issues raised with PALS 2006 Approved by: Ratified by: Standards Committee TBC Quality & Safety Committee TBC Review date: November 2013 Policy and Procedure for Management of Concerns and Complaints Page 1 of 37

Document History Requirement for document: Cross References / Associated Documents: NHSLA standards 5.2, 5.3 and 5.5 Care Quality Commission: Standards for Better Health Core standard C 14a, C14b, C14c The Data Protection Act 1998. London: The Stationery Office. Freedom of Information Act 2000. London: The Stationery Office. Department of Health. (2003). NHS complaints reform: making things right. London: Department of Health. The National Health Service (Complaints Regulations) 2004 SI 2004/1768. London: The Stationery Office. Department of Health. (2004). Guidance to support implementation of the National Health Service (Complaints) Regulations 2004. London: Department of Health. The National Health Service (Complaints) Amendment Regulations 2006 SI 2006/2084. London: The Stationery Office. Department of Health. (2006). Supporting Staff, Improving Services - Guidance to support implementation of the: National Health Service (Complaints) Amendment Regulations 2006. London: Department of Health. Department of Health. (2007). Making Experiences Count: The proposed new arrangements for handling health and social care complaints: Detailed policy background. London: Department of Health. Department of Health. (2008). Reform of health and social care complaints Proposed changes to the legislative framework. London: Department of Health. Health Bill 2009. London: UK Parliament. Department of Health. (2009). Listening, responding, improving: a rough guide to better customer care. London: Department of Health. Department of Health. (2009).The NHS Constitution: the NHS belongs to us all. London: Department of Health. Health and Social Care Act 2008. London: The Stationery Office. Healthcare Commission (HCC). (2009). Spotlight on complaints: A report on second-stage complaints about the NHS in England. London: HCC. Local Government Ombudsman London. Policy on unacceptable behaviour. Local Government Ombudsman London. Policy on unreasonably persistent complainants. National Audit Office. (2008). Feeding back? Learning from complaints handling in health and social care. London: The Stationery Office. National Patient Safety Agency (NPSA). (2005). Being Open Communicating Patient Safety Incidents With Patients and Their Carers. London: NPSA. National Patient Safety Agency (NPSA). (2005). Patient Briefing - Saying Sorry When Things Go Wrong. London: NPSA. Parliamentary and Health Service Ombudsman. (2008). Parliamentary and Health Service Ombudsman s draft Principles of Good Complaint Handling. Parliamentary and Health Service Ombudsman. (2009). Parliamentary and Health Service Ombudsman s Principles of Good Administration. London: Parliamentary and Health Service Ombudsman. Policy and Procedure for Management of Concerns and Complaints Page 2 of 37

Parliamentary and Health Service Ombudsman. (2009). Parliamentary and Health Service Ombudsman s Principles for Remedy. London. The Local Authority Social Services and National Health Service Complaints (England) regulations 2009, available at http://doh.gov.uk Department of Health Homepage: http://www.dh.gov.uk Independent Complaints Advocacy Service Homepage: http://www.icasresources.com/ Independent Regulator of NHS Trusts Homepage: http://www.monitor-nhsft.gov.uk/index.php Information for Local Government from Central Government: http://www.info4local.gov.uk/ Comments, Compliments and Concerns (MTW patient information leaflet COR/COM/6) Version Control: Issue: Description of changes: Date: 1.0 New document combining and reviewing the documents November 2009 it supersedes (listed on the front cover) and incorporating legislative changes for 2009. 1.1 Added Appendix 14 November 2009 2.0 Revision of Version 1 TBC Policy and Procedure for Management of Concerns and Complaints Page 3 of 37

Policy Statement for Policy and Procedure for Management of Concerns and Complaints Maidstone and Tunbridge Wells NHS Trust is committed to responding to all concerns and complaints, however and wherever raised by users of the service and their carers in accordance with the legislation and national guidance in place at the time. This policy also provides: clarification of the duties and responsibilities of all Trust staff involved in resolving issues at all levels of the organisation agreed definitions of terminology used to describe the various stages of the process evidence of compliance with CQC Standards for Better Health, C14a, 14b, 14c assurance required to meet the NHSLA Level 2 risk management requirements regarding the process for responding to concerns or complaints Policy and Procedure for Management of Concerns and Complaints Page 4 of 37

Procedure for Management of Concerns and Complaints Section 1.0 Introduction and Scope 6 2.0 Definitions 7 3.0 Duties 8 4.0 Training / Competency Requirements 10 5.0 Procedure for Responding to Concerns and Complaints 10 6.0 Monitoring and Audit 14 Appendices Appendix 1 Process Requirements 16 1.0 Implementation and Awareness 16 2.0 Review 16 3.0 Archiving 16 Appendix 2 Consultation Table 17 Appendix 3 Equality Impact Assessment 18 Appendix 4 Flow chart 20 Appendix 5 Guidelines for front line responses to concerns raised by the public Appendix 6 Informal resolution 26 Appendix 7 Formal resolution 27 Appendix 8 Role of complaint co-ordinator 29 Appendix 9 Investigation by Divisions 30 Appendix 10 Local resolution meetings 32 Appendix 11 Following Our Investigation 33 Appendix 12 Cross organisational complaints, PHSO, Financial recompense 34 Appendix 13 Joint Working Protocols 35 Appendix 14 Complaints action plan template 38 Page 23 Policy and Procedure for Management of Concerns and Complaints Page 5 of 37

1.0 Introduction and Scope 1.1 Introduction Maidstone and Tunbridge Wells NHS Trust has a responsibility to ensure that users of the services provided by the Trust, or their authorised representatives have easy access to information about how to raise a concern or make a complaint and that all issues are responded to fairly, promptly and justly without prejudice to the care and treatment of the service user. This is the first Trust wide integrated policy embracing both the Patient Advice and Liaison Service (PALS) and the formal complaint process and strengthens the integrated working between the two teams. The policy describes how staff are expected to respond to concerns and complaints raised by users of the service, their relatives and their friends. It is in keeping with the Trust core values of: putting the needs of patients at the centre of Trust business taking pride in delivering quality services engaging in honest communication with and involving people, and the people we serve in all decisions about their healthcare being open when things go wrong The policy advocates adherence to the principles of good complaint handling as defined by the Parliamentary and Health Service Ombudsman (PHSO): Getting it right Being customer focused Being open and accountable Acting fairly and proportionately Putting things right Seeking continuous improvement The Trust guidance accompanying this policy found in the appendices is underpinned by these principles. 1.2 Purpose This document describes the means by which the patients or their representative can raise a concern or make a formal complaint. It outlines good practice at each stage of the process, details the responsibilities of staff involved and ensures the Trust learns from concerns and complaints and is committed to changing practice as a consequence of issues raised. The policy helps the Trust to seek continuous improvement from concerns and complaints and ensures our decisions are proportionate, appropriate and fair. 1.3 Scope This policy applies to all staff employed by Maidstone & Tunbridge Wells NHS Trust, either directly or indirectly. It specifically covers all issues of concern raised by patients or service users, or those acting with the patient s authorisation and includes seemingly minor issues to those which are major with potential or actual serious outcomes. Sections 8 a - h of the NHS Complaint Regulations state that the following complaints are not required to be dealt with under those regulations: Policy and Procedure for Management of Concerns and Complaints Page 6 of 37

a. complaint made by a responsible body b. complaint made by an employee of a local authority or NHS body about any matter relating to that employment c. a complaint which is made orally and is resolved to the complainant s satisfaction not later than the next working day after the day on which the complaint was made d. a complaint the subject matter of which is the same as that of a complaint that has previously been made and resolved in accordance with sub-paragraph c e. a complaint the subject matter of which has previously been investigated under these regulations; the 2004 regulations; the 2006 regulations; or a relevant complaints procedure in relation to a complaint made under such a procedure before 1 April 2009 f. a complaint the subject matter or which is being or has been investigated by a local commissioner under the Local Government Act 197(a) or a health service commissioner under the 1993 Act g. a complaint arising out of the alleged failure by a responsible body to comply with a request for information under the Freedom of Information Act 2000 (b) h. a complaint which relates to any scheme established under section 10 (superannuation of persons engaged in health services etc or section 24 (compensation for loss of office etc) of the Superannuation Act 1972 or to the administration of those schemes. Guidance for many aspects of complaint handling can be found within the appendices at the end of this document. 2.0 Definitions The following definitions apply for terms used in this policy: Patient: the person whose care and treatment is the subject of the concerns or complaint. Potential or actual complainant: the person who is raising the concern or complaint. Redress: supplying remedy whereby, if injustice or hardship has been suffered as a result of maladministration or poor service, the person so affected is returned to the position they were in before the maladministration or poor service took place or, if that is not possible, compensate them appropriately. The Regulations: The Local Authority Social Services and National Health Service Complaints (England) Regulations 2009 An investigation: the process of discovering and evidencing what the actually happened in relation to the issue raised. A complaint is defined as an expression of dissatisfaction with the care, services or facilities provided by the Trust that requires a written response. Informal resolution occurs when an investigation and response is possible within 5 working days after the complainant has consented to this process. All low risk grade complainants should be offered this process. Please see Appendix 4 and 6. Policy and Procedure for Management of Concerns and Complaints Page 7 of 37

Formal resolution occurs when the complaint requires a written response following an investigation including those low risk concerns where the complainant rejects the opportunity for informal resolution. All complaints assessed as medium or high risk grade will be investigated formally. Please see Appendix 4 and 7. 3.0 Duties The following staff fulfil specific duties under the Regulations within the procedures that follow: 3.1 Chief Executive: Responsible Person under section 4.(1)a of the legislation to ensure compliance with arrangements made under the Regulations and in particular ensuring that action is taken if necessary in the light of the outcome of a complaint. The Chief Executive (or in his absence, the Deputy Chief Executive) signs all responses investigated under the procedure for formal complaints, including all correspondence addressed to Members of Parliament and the Parliamentary and Health Service Ombudsman. 3.2 Director of Nursing: designated Responsible Person under section 4 (2) of the legislation. In the absence of the Chief Executive, the Director of Nursing or Chief Operating Officer may sign responses to formal complaints, on his behalf. 3.3 Head of Quality and Governance: has responsibility for corporate and clinical governance functions. They oversee the performance management aspects of the process and the aggregated analysis of concerns and complaints as part of the Trust commitment to learning from all forms of adverse incidents. 3.4 Quality Manager for Patient Concerns: is responsible for overseeing the administrative system and procedures for ensuring the Trust meets its obligations for handling and considering complaints under the Regulations and fulfils the role of Complaints Manager under section 4.(1)b of the legislation. S/he will also manage the correspondence and process concerning the Parliamentary and Health Service Ombudsman and maintain a Trust overview of all red or major complaints, and lead on training associated with the management of complaints for the Trust. 3.5 Complaints Case Manager: in conjunction with the PALS lead, reads all written complaints correspondence upon receipt and assigns each to the correct pathway for investigation. Provide assurance to the Executive team on the quality and accuracy of all complaint responses leaving the Trust. S/he also monitors and supervises the first stage of the formal complaint process, confirms the integrity of the electronic data stored and used for reporting and produces the regular performance reports for all Trust and divisional meetings. Policy and Procedure for Management of Concerns and Complaints Page 8 of 37

3.6 PALS Lead: together with the Complaint lead, reads all formal complaint correspondence upon receipt and assigns each to the correct pathway for investigation. Provide the first point of contact with the complainant and ensure their agreement to the process for investigation and response. Ensure the PALS service is identifiable and accessible providing information, advice and a first point of contact for those who are unhappy and wish to raise concerns and complaints about Trust services. Ensure that on the spot help is provided to service users and where possible will negotiate immediate solutions or speedy resolution of problems so that concerns do not escalate. Identify those issues that require a formal complaint investigation and escalate to the Complaints Lead. Ensure service users are sign-posted to appropriate independent advice and advocacy support from local and national sources i.e. ICAS 3.7 Complaint Lead and Complaint Administrator: responsible for receiving and logging all new complaints, tracking the process of investigation and prompting service colleagues when deadlines are approaching; also maintain paper complaint file and electronic DATIX record. 3.8 PALS Officers supported by PALS Administrator: Receive, log and respond to comments and concerns about Trust services. Facilitate the speedy resolution of concerns by listening, providing information, liaising and negotiating with staff colleagues as appropriate. Identify issues requiring a formal investigation and support service users to access the formal complaint process. 3.9 Associate Directors of Operations/Divisional Directors and Associate Directors of Nursing: ensure that systems are in place to meet the Division s responsibilities detailed in the policy including thorough and robust investigation, ensure lessons are learned and preparation of non-judgemental and proportionate response. 3.10 Corporate Complaint and PALS teams, Divisional governance/complaint leads, managers and co-ordinators: to understand and adhere to the guidance given in relation to front line and structured responses to concerns and complaints at all times ensuring that the complainant is treated as a partner in the process. Co-ordinate the local investigation and prepare a draft response for sign off within division prior to handing to the Corporate complaint team for signing by the Chief Executive. (Appendix 4 and 7). 3.11 All staff: should introduce themselves at the start of any interaction with patients or visitors and offer to resolve any concerns as they arise. Information leaflets about the roles of PALS and Complaints staff should be widely available in clinical areas. Where a patient or carer expresses a preference for speaking with someone away from the clinical setting, they should be encouraged to either phone or visit PALS for advice and support. All staff should understand and adhere to the guidance on front line responses to concerns and complaints (Appendix 5) and respond immediately to concerns and complaints raised directly with them, apologise and try and provide resolution. Be aware that PALS can support staff to achieve satisfactory resolution and should be familiar with the process available to patients for raising concerns and complaints. Policy and Procedure for Management of Concerns and Complaints Page 9 of 37

Co-operate with the PALS and the Complaints team to facilitate resolution of concerns or formal complaints in a timely manner. Provide statements when required to any authorised staff member within five days of request in response to an issue of complaint. 4.0 Training / Competency Requirements Corporate Complaint and PALS team will receive training as required in line with personal development plans to ensure they have the required knowledge and skills to fulfil their roles. Additional training will be provided to ensure they are kept up to date with any legislative changes. Introductory training in relation to the management of complaints and PALS will be provided to all new staff at Trust Welcome Days. The Trust Corporate Complaints and PALS team, in conjunction with Brachers solicitors provide update training days which are accessible to all staff throughout the year. 5.0 Principles and procedure for responding to concerns and complaints The national complaints legislation requires that concerns raised by the public are responded to personally and positively and that lessons are learnt by the organisation. Patients, relatives and their carers must not be treated any differently as a result of raising concerns or making a complaint. Where the complainant is not the patient, authorisation should be obtained prior to disclosure of information covered by the Data Protection Act (1998) which supersedes information accessible under the Freedom of Information Act (2000). 5.1 Two Stage Process The process described by the 2009 Regulations requires for a two stage process as follows: Local resolution working with the potential or actual complainant to understand and resolve their concerns in a timely and proportionate fashion Referral to the Parliamentary and Health Service Ombudsman (PHSO) if local resolution is unsuccessful, the client can refer their complaint to the PHSO for review. The Trust has agreed an internal procedure to ensure full and robust investigation of complaints, wherever possible at local (Trust) level. This is described in more detail below and expanded within the appendices of this document. 5.2 Local Resolution Front of house PALS offices are located on site at Maidstone Hospital and Tunbridge Wells Hospital at Pembury. They provide a point of contact for those wishing to raise concerns or comment on services provided, or make complaints. Staff will work in partnership with Divisional colleagues to achieve immediate or swift resolution wherever possible, and with Complaint colleagues, where the issue requires formal investigation in accordance with the requirements of the NHS Complaint Regulations (2009). Key to all issues raised is the local learning from investigation and resolution and Trustwide learning whenever possible. Policy and Procedure for Management of Concerns and Complaints Page 10 of 37

The boundary may not always be clear between a concern brought to PALS and a complaint. PALS and Complaints processes offer flexibility and choice that is in line with the needs and wishes of service users and the severity of each particular problem. Issues raised will be managed in accordance with risk assessment of the concern or complaint and the wishes of the complainant. There are therefore two initial routes for Local Resolution. Immediate, informal resolution by front-line staff (Appendix 5 and 6) Structured, directorate led response (Appendix 7) Where Local Resolution is unsuccessful or the complaint is red or severe/major, the Trust has a process for the review of serious or complex complaints. These are described in more detail below. 5.2.1 Informal resolution procedure by front line staff Problems raised verbally with front line staff should be resolved quickly and locally at the time they are notified, by the member of staff who is made aware of the issue. It is better to act quickly to prevent a problem from escalating. Members of staff are expected to take ownership and resolve problems brought to them personally if they have the necessary knowledge and experience. If not, the member of staff is responsible for passing the matter on to a colleague who can help. Where resolution is not possible, and the patient remains dissatisfied, the patient or their representative should be referred to PALS (Appendix 5 and 6). A judgement about the nature of the issues being raised must be made and senior managers must be involved immediately with serious problems. Senior managers should ensure that their staff recognise the type of problems which might escalate and must ensure that effective Divisional processes are in place to ensure appropriate handling and recording of such situations. This guidance must specifically include action to be taken where concerns have been raised in writing with a named member of staff. More detailed information about dealing with informal complaints and concerns at the front line level is given in the associated guidance document (Appendix 7). The PALS team is available for telephone advice from 9.00am 5.00pm, Monday to Friday or in person between 10.00am and 4.00pm on the same days. Service users can raise concerns with PALS by telephone, in person or by e-mail. 5.2.2 Structured Divisional led responses Not all situations can be resolved immediately, and these situations need a more structured approach. Guidance relating to the structured response to complaints, concerns and comments is laid out in Appendix 7-11. All Divisions must agree local systems and processes for dealing with complaints, concerns and comments which meets this guidance. The systems must include mechanisms for linking into Divisional governance arrangements. The PALS and Complaints teams will provide support and assistance to staff responding to difficult or pressured situations. People raising issues through clinical services (outpatients departments, wards etc) should not be referred to the corporate teams when they can respond directly from local knowledge. Policy and Procedure for Management of Concerns and Complaints Page 11 of 37

Where concerns raised involve other organisations the Corporate Complaint Team will liaise with those organisations. Where the organisations are within the Kent and Medway area, investigations will adhere to the principles agreed by the Kent and Medway Complaints Managers Forum and formally adopted by the organisations involved, as detailed in Appendix 13. The corporate team will also be responsible for liaising with NHS Kent where individuals have raised their issues directly with the Commissioner. There are three possible conclusions to local resolution: The complainant and Trust agree that local resolution has ended. At this stage, all issues have been resolved - ideally to the satisfaction of the complainant, or there maybe agreement to disagree The complainant, but not the Trust, decides that local resolution has come to an end: there is nothing further to be done but the matter remains unresolved The Trust, but not the complainant, decides that local resolution has come to an end: there is nothing further to be done but the matter remains unresolved Irrespective of the conclusion reached, local resolution will be completed by sending a final letter from the Chief Executive summarising the steps that have been taken, the outcomes from the process (including any changes that have been made) and confirming the conclusion reached. Accompanying this letter will be information for the service user about taking their complaint further should they wish to do so (Appendix 12). In the event of further correspondence being received from the complainant, it must be actioned following the same process as described under the formal resolution procedure. In addition the nominated Divisional lead may consider either verbally answering questions from the complainant (documented in a file note added to DATIX), provide another response letter or offer a local resolution meeting. If the complainant remains dissatisfied after exhausting local remedies a review of how the complaint handling or the clinical issues involved may be considered. Where requested by the complainant, they must clearly state the reasons for their dissatisfaction. This must be done within two months of the final response letter being sent. A complainant should be asked to demonstrate that there are clear grounds that require further investigation. A paper review of the file to date will be undertaken to determine whether the complaint will benefit from further investigation. If agreed, the second stage review will be monitored as detailed for serious or complex complaints. (Appendix 4). 5.2.3 Trust review of serious or complex complaints Where the issue is categorised red or severe on the DATIX risk matrix, the details are immediately circulated to the Medical Director, Director of Nursing, the Head of Quality Governance and the senior management team in the Division concerned. On completion of the investigation the draft reply is reviewed by the Medical Director, if the concerns raised are of a clinical nature, and/or the Director of Nursing if the complaint includes nursing issues. The Division will produce an action plan which will be monitored by the Central Complaints team. Outcomes and monitoring of red cases will be reported at the monthly Complaints, Litigation, Policy and Procedure for Management of Concerns and Complaints Page 12 of 37

Incidents and PALS (CLIP) meetings which report into Quality and Safety, and thereby to Board level, via a quarterly Clinical Governance Overview Committee. Terms of reference for the committes will generally seek to undertake the following: Review the complaint, considering whether the Trust has fully and reasonably responded and has done all it can do to resolve the issues Answer the following questions: Has the investigation and response answered each of the points raised? Is the response and action customer focussed? Does the response demonstrate openness and accountability? Has the complaint been dealt with fairly and proportionately? Does the response demonstrate that things have been put right? Does the response demonstrate continuous improvement in terms of learning out comes and practice change? 5.3 Referral to the Parliamentary and Health Service Ombudsman (PHSO) Following referral to the Parliamentary and Health Service Ombudsman the process is managed by the Quality Manager for Patient Concerns (Appendix 11). 5.4 Document Control Paperwork gathered in the course of an investigation will be scanned and stored electronically wherever possible. Paper files will be stored in accordance with the policy for storage of management of paper Health Records files, and retained for 7 years following closure, with the exception of maternity, paediatric, blood transfusion and chemotherapy cases which will be retained in accordance with national guidance. 6.0 Monitoring and Audit The Director of Nursing is the Director with executive responsibility for the operation of the complaints arrangements and together with the Chief Operating Officer and Medical Director, are required to ensure that lessons learned are implemented. Performance with respect to responding to complaints, concerns and comments will be monitored together with assurances on actions taken, themes and trends and learning will be reported to the Patient Experience Committee (PEC) and Complaints, Litigation, Incidents & PALS Committee (CLIP). Reports on the performance of complaints handling will be discussed at the Monthly Performance Review meetings. Policy and Procedure for Management of Concerns and Complaints Page 13 of 37

Quarterly Reports on activity and learning as discussed at PEC and CLIP will be provided to the Quality and Safety Committee. An annual report to the Trust Board covering the management of concerns and complaints will be produced to show: the numbers and type of contacts made and service areas involved a summary of the subject matter of the complaints received and any matters of general importance arising out of those complaints or the way they have been handled proportion of complaints considered to be well-founded the quality of the response - as measured against specific performance and quality measures number of cases that were referred to the Parliamentary and Health Service Ombudsman the changes made within the Trust s processes and systems in response to issues raised Regular audits will be undertaken by the Quality Manager for Patient Concerns which will measure the effectiveness of the procedures, whether the processes are being properly applied, whether case records are being kept correctly, and to measure the robustness of data entry. A monitoring report will be presented to the Quality and Safety Committee annually (as part of the Clinical Governance report submitted by the Head of Quality and Governance) detailing compliance with the policy and including: Duties are staff fulfilling their roles? This can be demonstrated through the complaint response times. Process for raising concerns (informal complaints or through PALS) Complaints management process, which includes internal and external communication, and collaboration with other organisations when necessary Process for involving and communicating with internal and external stakeholders to share safety lessons Process/procedure for ensuring patients, relatives or carers are not treated differently as a result of raising concerns or making a complaint. Process by which the organisation aims to make changes as a result of concerns/complaints being made. Process for monitoring compliance with the above Organisation s expectations in relation to staff training, as identified in the training needs analysis Different levels of investigation as detailed in Appendix 4 appropriate to the severity of event Process for following up relevant action plans In the event of deficiencies being identified, action plans will be passed to the relevant team corporate, division etc, including appropriate time frames and recommendations. Compliance with the action plan and recommendations will be reported by the division to the next quarterly meeting of the committee. Policy and Procedure for Management of Concerns and Complaints Page 14 of 37

Process Requirements APPENDIX ONE 1.0 Implementation and Awareness Dissemination and implementation arrangements will meet the requirements of Trust policy. Dissemination to the public: Information about making complaints, concerns or comments will be widely available on the Trust website and by way of leaflets in all public areas. The PALS offices will also provide detailed verbal information to visitors or callers. Leaflets will use accessible language and help will be provided through the PALS services for people with different language or special needs. Patient Experience Matrons will support the Trust commitment to ensure that all users of Trust services have access to appropriate advice and information when wishing to raise concerns. Dissemination to Trust staff: the usual internal communication plan designed to inform staff of the new policy and of their personal responsibilities within the policy will be used. The policy and associated guidance will be available within DATIX Guidelines on the Trust intranet site. Training sessions will be made available for Divisional leads with responsibility for handling concerns and complaints and to those in key roles in the new process. The policy will be highlighted within the Trust s induction programme. Implementation: the draft policy will be used as a working document as soon as possible as it reflects the principles of the 2009 legislation. It will become effective as soon as it has been ratified. The competency and skills of the staff in the corporate teams will be assessed as part of the formal appraisal process. Training will be provided to meet identified gaps. The Quality Manager for Patient Concerns will ensure that the wider corporate team is aware of all national changes and developments and that where necessary, training is provided to those staff requiring additional skills in order to achieve the standards required. 2.0 Review The policy will be reviewed every two years, or at any other time when changes are made to the governing legislation and/or national guidance. The outcome of each review will be noted in the Version Control Sheet at the front of the document and version numbers amended accordingly. Major changes to the policy will be ratified by the Trust Executive. 3.0 Archiving The Clinical Governance Assistant will take responsibility for ensuring earlier versions of the policy are archived in addition to the published versions on the documents management system, DATIX Guidelines (Trust Intranet). Policy and Procedure for Management of Concerns and Complaints Page 15 of 37

APPENDIX TWO CONSULTATION ON: Policy and Procedure for Management of Concerns and Complaints Consultation process Use this form to ensure your consultation has been adequate for the purpose. Please return comments to: By: Name: List key staff appropriate for the document under consultation. Select from the following: Date sent Date reply received Modification suggested? Y/N Modification made? Y/N Director of Nursing Medical Director Chief Operating Officer Deputy Director of Nursing Chair of Quality & Safety Committee Non-Executive Director, Complaints Corporate Quality and Governance Leads Associate Directors of Nursing Associate Divisional Directors Clinical Governance Assistant Staff Side chair Trust website for public consultation The role of those staff being consulted upon as above is to ensure that they have shared the policy for comments with all staff within their sphere of responsibility who would be able to contribute to the development of the policy. Policy and Procedure for Management of Concerns and Complaints Page 16 of 37

APPENDIX THREE Equality Impact Assessment In line with race, disability and gender equalities legislation, public bodies like MTW are required to assess and consult on how their policies and practices affect different groups, and to monitor any possible negative impact on equality. The completion of the following Equality Impact Assessment grid is therefore mandatory and should be undertaken as part of the policy development and approval process. Please consult the Equality and Human Rights Policy on the Trust intranet, for details on how to complete the grid. Please note that completion is mandatory for all policy development exercises. A copy of each Equality Impact Assessment must also be placed on the Trust s intranet. Title of Policy or Practice What are the aims of the policy or practice? Identify the data and research used to assist the analysis and assessment Analyse and assess the likely impact on equality or potential discrimination with each of the following groups. Males or Females People of different ages People of different ethnic groups People of different religious beliefs People who do not speak english as a first language People who have a physical disability People who have a mental disability Women who are pregnant or on maternity leave Single parent families People with different sexual orientations People with different work patterns (part time, full time, job share, short term contractors, employed, unemployed) Policy and Procedure for Managing Concerns and Complaints To ensure that all concerns are dealt with in an open fair and equitable way, according to a set of principles and with guidance provided for staff The policy aims to ensure that the patient is at the centre of the process it is designed to be accessible and suited to all. The policy will be available on the website in order to be as accessible as possible to those affected. The principles of the policy and procedure specifically require staff to consider throughout the life of a complaint, whether the complainant has any special needs. The policy also recognises the rights of staff within the process. Consultation process Is there an adverse impact or potential discrimination (yes/no). If yes give details. No No No No Potential but support of interpreting and translation services must be sought Potential for people with sensory loss or mobility restrictions Potential but support provided No No No Internet access to information about the complaint handling process Policy and Procedure for Management of Concerns and Complaints Page 17 of 37

People in deprived areas and people from different socio-economic groups Asylum seekers and refugees Prisoners and people confined to closed institutions, community offenders Carers If you identified potential discrimination is it minimal and justifiable and therefore does not require a stage 2 assessment? When will you monitor and review your EqIA? Where do you plan to publish the results of your Equality Impact Assessment? No No Some limitation due to Home Office rules on sharing confidential patient information No Minimal and justifiable When policy is reviewed in October 2011 As an appendix to this policy/procedure on Datix Guidelines (Trust intranet) Policy and Procedure for Management of Concerns and Complaints Page 18 of 37

APPENDIX FOUR FLOW CHARTS to demonstrate the complaint handling process. Accompanying notes: LOCAL SERVICE RESOLUTION (INFORMAL) All concerns and low risk written complaints to be offered this route to effective resolution written complaints triaged by PALS lead/complaint Case Manager - and action by Division. Accountability for resolution rests with Division who should agree timescale (maximum of five working days to achieve resolution to potential complainant satisfaction. Respond as complaint received i.e. telephone, e-mail or letter, but record process in writing and add to DATIX (PALS DATIX if verbal via PALS, or Complaints DATIX informal if response within five working days). FORMAL COMPLAINT INVESTIGATION (2 day acknowledgement, 25 day response, CEO sign off ) All written complaints which cannot be resolved in 5 working days or if informal option is rejected by complainant. Acknowledge centrally. All MP letters to be acknowledged by CEO. Robust investigation within division including file notes/statements to support all aspects of investigation. Written response answering all aspects of the complaint, for signature by CEO within 25 working days. Response and outcome should be proportionate to the complaint. Identify areas for service improvement if appropriate and divisional governance lead to co-ordinate action plan. Medical Director (clinical issues) and Director of Nursing (nursing issues) to review all red or major risk complaints. Monitoring/overview via CLIP and Clinical Governance Overview Committee. Complainant raises new issues or expresses dissatisfaction with initial response. Offer local resolution meeting if complainant agreeable and identify issues and real process for investigation. Share notes of meeting within 10 working days of meeting. Respond to all promised actions within 25 working days of meeting. (Consider mediation if appropriate). If internal review/reinvestigation indicated (particularly for complex complaints), consider membership of a review panel and determine terms of reference for the review. May require independent clinical assessment, oversight from another division, exec lead. Or reciprocal arrangement from another trust? Manage complainant s expectations re outcome and timeframe for review. CEO to send closing letter. REFERRAL TO PARLIAMENTARY AND HEALTH SERVICES OMBUDSMAN All PHSO referred complaints reported monthly to Exec lead panel for oversight of case. Case management by Quality Manager for Patient Concerns Where internal trust process fails or is exhausted, complainant has the right to seek external review from the Health Services Ombudsman. Ombudsman s powers are equivalent to High Court and can impose sanctions, including closure of service, financial remedy and evidence to Parliamentary Select Committee if Trust is found to be failing in duty of care to patients. Policy and Procedure for Management of Concerns and Complaints Page 19 of 37

RESOLUTION PATHWAY COMPLAINT RECEIVED IN TRUST AND SENT TO COMPLAINTS OFFICE ON SAME DAY LOW RISK GRADE Triage & risk assess Cts/PALS Lead MEDIUM/HIGH RISK GRADE Formal investigation PALS to contact potential complainant Negotiate options for resolution by close of business following working day Informal option agreed NO Send to Lead staff in Division for investigation Complaints office acknowledge within 2 working days Red cases escalate d YES GM or Matron (Division) to resolve issue with service user NO Response to Complaints office within 20 working days or agreed timescale for review and signature PALS liaise with staff to ensure resolution RESOLVED? Staff to update DATIX entry with outcome and feedback to PALS for closure Close on PALS DATIX Close on Complaints DATIX YES NO See following page: Policy and Procedure for Management of Concerns and Complaints Page 20 of 37

All high risk or red complaints Reply reviewed by Medical Director (Clinical issues) and/or Director of Nursing (nursing issues). Independent clinical review / review of process. (From previous page) In conjunction with the complainant, consider the following: Conciliation meeting Further letter Telephone call Second stage paper review by Complaints managers & Divisional Lead NO RESOLVED YES Close on DATIX Determine whether grounds for review YES Reply reviewed by Medical Director (Clinical issues) and/or Director of Nursing (nursing issues). Re-investigation or expert clinical advice if required to inform further and final Trust response NO Write to complainant explaining reasons for closing complaint Close on DATIX Write to complainant with further explanations & action points REFER TO OMBUDSMAN Policy and Procedure for Management of Concerns and Complaints Page 21 of 37

1. Summary APPENDIX FIVE Guidelines for Front Line Responses to Concerns Raised by the Public These guidelines provide information about the way in which the Trust expects individual members of staff to respond to concerns raised by the public. They should be read in conjunction with the Trust Policy for Management of Concerns and Complaints 2. Introduction Every member of staff is personally responsible for responding politely and appropriately when approached by a user of the service or visitor to the Trust, expressing a concern or asking for help. Taking a few minutes to respond helpfully gives the user of the service a positive experience and can often avoid a formal complaint being made. It is important to ensure that patients, relatives and carers are not treated differently as a result of raising concerns or making complaints. 3. Individual Responsibilities Where possible, always respond immediately to concerns or questions raised by users of the service. However, first consider whether you are able to reply, and whether it is appropriate for you to do so, or if the matter is serious enough that it should be referred to someone senior to you. Concerns raised in writing are rarely about issues where a front line response is sufficient to resolve the problem and should be passed to a senior manager or direct to the Corporate Complaints team for further advice. If you are able to answer but have another immediate priority, offer to return later to provide the answer and make good on the offer as promised. If you do not have the experience or knowledge to respond, or the issue is of a serious nature and needs escalating, refer the person to a colleague who will able to assist. The hospital environment is unfamiliar to the majority of users but as staff we understand the complexities of the environment in which we work. Patients and visitors inevitably need help to find their way around the system and your support and advice to patients helps to ensure their satisfaction. Being pro-active in communicating with patients is essential. If you are in a position to do so, keep patients informed about events which are affecting them, such as delays in outpatient clinics, so that they can understand what is happening without having to ask. Most people understand as long as they know what is going on. Be factual and avoid passing comment, for example use: I m sorry but the doctor has been held up on his ward rounds and clinic is running about 30 minutes late. Rather than: Policy and Procedure for Management of Concerns and Complaints Page 22 of 37

the Doctor is late again, I m sorry this is always happening; I m sure he will be here soon. Try to be positive and diffuse the situation. For example, it is better to respond to complaints about car parking by saying something like: Yes, it s a real problem here I am sorry you ve been affected. We are trying to make some changes but in the meantime we do make allowances for people who are late arriving. Rather than: I know, it s awful. We keep complaining about it, but they never do anything about it. When you have dealt personally with a concern raised by a user of the service, consider whether you need to let your manager know about it. Trends and themes can only be identified and problems rectified, if information is shared. Do not send any person(s) to the Corporate Complaints and PALS teams, suggesting, You need to make a complaint. This is not helpful and will not end the problem for you the first thing the team will need to do is come back to your area to find out what the answer is. The Teams are there to support staff if the front line response has failed and the situation has become more difficult, and to provide advice and training for staff. Please note: Staff are not expected to tolerate rude or violent behaviour from patients or visitors and guidance in this respect is provided in the Trust s Policy on Managing Violence and Aggression. 4. Managers Responsibilities Lead by example, encouraging staff to respond positively and helpfully to expressions of concern from users. Use the Communication Section of the Knowledge Skills Framework (KSF) in the appraisal process to ensure all members of your team develop strong and effective communication skills. Be confident that your staff are aware that they can expect to be treated with respect and courtesy by patients and visitors to the hospital, and how they should act in situations where their rights are not being observed. Where necessary, make sure that systems exist to keep users informed about what is happening. In patient areas make sure that the environment allows for privacy and dignity to be preserved. If confidential details need to be discussed, try to make sure the discussion cannot be overheard. Ensure your staff are aware of the types of issues raised by users that you expect them to escalate to you. This guidance must specifically deal with concerns raised in writing to named members of staff. Policy and Procedure for Management of Concerns and Complaints Page 23 of 37

5. Summary Take personal ownership when approached by the public raising questions or concerns. Resolve the problem quickly, if possible, or escalate to another colleague who can assist. Be polite, positive and open in responses. Sorting out a problem at the start, when it is small and manageable, saves everyone time and trouble in the long run. Policy and Procedure for Management of Concerns and Complaints Page 24 of 37

APPENDIX SIX Informal Resolution Procedure PALS staff will take the patient/enquirers details and provide the client with their name and contact number PALS will listen to concern/complaint expressed by patient/representative and clarify and record details of the issue as reported PALS will discuss actions that PALS could take and offer and negotiate options for resolution as appropriate. PALS will ascertain whether the client is willing for PALS to seek to resolve the problem informally PALS aim to deal with issues within 48 hours; however, because of the nature and complexity of some cases involving in-depth or multiple staff contact resolution will take longer. An expected timescale for resolution or for reporting back progress will be agreed with the client where possible PALS staff will verbally request permission to access electronic patient information to deal with an enquiry, if appropriate. Verbal consent will be obtained to share information and contact the relevant staff in an attempt to solve the problem PALS staff will identify and then make contact with the relevant staff member(s), who will be able to investigate and respond to the concerns reported The staff member will feedback their actions and response to the patient/representative and PALS team. The member of staff should speak directly to the patient/representative in response to concern. PALS staff will follow up contact with the service user and/or the member of staff to ensure the issue is resolved satisfactorily Where the service user is not satisfied with the outcome they should be asked if they wish PALS to continue to be involved or if they wish the matter to be dealt with through the formal complaints procedure All details, action, interventions and outcomes will be logged on PALS DATIX. Each team member can access the recorded information and so can progress an enquiry if/as necessary in the absence of a colleague PALS refers clients to the formal complaints procedure Where a service user clearly wishes to follow this route When there is an allegation of a serious nature and issues of risk are identified. PALS will provide information about the formal complaints process, including options of redress PALS can acknowledge the complaint raised with PALS and assist complainant in formulating the statement of complaint or help complainant access appropriate independent advocacy services for this purpose and facilitate referral Pass complaint to relevant staff for investigation. APPENDIX SEVEN Policy and Procedure for Management of Concerns and Complaints Page 25 of 37