Concerns and Complaints Policy and Procedure

Concerns and Complaints Policy and Procedure This policy and procedures may evoke safeguarding adults concerns and as such please refer to the Safeguarding Adults Policy or contact the Trust Safeguarding Adults Team for guidance. Author: Marilyn Thirlway, Head of Patient Experience Owner: Chief Nurse Publisher: Compliance Unit Date of first issue: 1996 Version: 9 Date of version issue: June 2013 Approved by: Risk and Assurance Committee Date approved: June 2010 Review date: June 2015 Target audience: All Trust staff Relevant Regulations and Standards Statutory Instrument 2009 No. 309, The Local Authority Social Services and National Health Service Complaints (England) Regulations 2009 RMSAT Standard 2.3: Concerns and Complaints Care Quality Commission Outcome 17: Complaints Regulation 19 of the Health &Social Care Act 2008 (Regulated Activities) Regulations 2010 0

Version History Log This area should detail the version history for this document. It should detail the key elements of the changes to the versions. Version Date Approved Version Author Status and location Details of significant changes 4 29/09/04 P Goff Incorporates The NHS (Complaints) Regulations 2004 5 29/09/04 Reviewed November 2006 P Goff Reviewed in the light of The NHS (Complaints) Amendment Regulations 2006 6 P Goff Incorporates the Trust Policy Template issued in October 2007 7 P Goff Although compliant with RM standards, the assessor requested more explicit info on how the Trust ensures that patients, relatives and carers are not treated differently as a result of a complaint. 8 M Thirlway 9 M Thirlway Horizon Incorporates The NHS (Complaints) Regulations 2009 and aims to comply with RMSAT Standards Horizon Incorporates Regulation 19 of the Health & Social Care Act 2010, changes to RMSAT standards and CQC outcomes, and updates to the Trust management structure and commissioning arrangements. 1

Contents Section Page Process Flowchart 1 1 Introduction & Scope 1 2 Definitions 4 3 Policy Statement 4 4 Equality Impact Assessment 5 5 Accountability 6 6 Consultation, Approval and Ratification Process 7 6.1 Consultation Process 7 6.2 Quality Assurance Process 7 6.3 Approval Process 7 7 Review and Revision Arrangements 7 8 Dissemination and Implementation 7 8.1 Dissemination 7 8.2 Implementation of this policy 8 9 Document Control including Archiving Arrangements 8 9.1 Register/Library of Policies 8 9.2 Archiving Arrangements 8 9.3 Process for Retrieving Archived Policies 8 10 Monitoring Compliance With and the Effectiveness of Policies 8 10.1 Process for Monitoring Compliance and Effectiveness 8 10.2 Standards/Key Performance Indicators 14 11 Training 15 12 Trust Associated Documentation 15 13 External References 15 14 Appendices 16 2

Process Flowchart See flowcharts on pages 24 and 32 of the Concerns and Complaints Procedure 1 Introduction and purpose 1.1 Purpose 1.1.1 The purpose of this policy is to ensure that York Teaching Hospital NHS Foundation Trust complies with the NHS complaints regulations and Regulation 19 of the Health & Social Care Act 2008 (Regulated Activities) Regulations 2010, meets NHS Litigation Authority (NHSLA) Risk Management Standards for Acute Trusts (RMSAT) and Care Quality Commission (CQC) Outcomes, and supports Sections 2a and 3b of the NHS Constitution. 1.2 NHS complaints regulations 1.2.1 The NHS complaints procedure is currently regulated by Statutory Instrument 2009 No. 309, The Local Authority Social Services and National Health Service Complaints (England) Regulations 2009, effective from 1 April 2009. 1.3 Risk Management Standards for Acute Trusts 1.3.1 The current relevant RMSAT standard for concerns and complaints is Standard 2.3: Concerns and Complaints, which states: All organisations must have an approved documented process for listening, responding and improving when patients, their relatives and carers raise concerns and complaints. (NHSLA Risk Management Standards 2013-14, p60) Currently RMSAT Standard 2.3 has three levels, the requirements of each are shown below. Level 1 Your documented process must include: a) duties b) how the organisation listens and responds to concerns and 1

complaints from patients, their relatives and carers c) how joint complaints are handled between organisations d) how the organisation makes sure that patients, their relatives and carers are not treated differently as a result of raising a concern or complaint e) how the organisation makes improvements as a result of a concern or complaint f) how the organisation monitors compliance with all of the above Level 2 You must evidence implementation of your documented process in relation to: - how the organisation listens and responds to concerns and complaints from patients, their relatives and carers - how the organisation makes improvements as a result of a concern or complaint Level 3 You must evidence monitoring of your documented process in relation to: - how the organisation listens and responds to concerns and complaints from patients, their relatives and carers - how the organisation makes improvements as a result of a concern or complaint. Where your monitoring has identified shortfalls, you must evidence that changes have been made to address them. 1.4 Care Quality Commission (CQC) Outcomes CQC Outcome 17: Complaints states that providers who comply with the regulations will: Have systems in place to deal with comments and complaints, including providing people who use services with information about that system. Support people who use services or others acting on their behalf to make comments and complaints. Consider fully, respond appropriately and resolve, where possible, any comments and complaints. 1.5 The NHS Constitution 2

1.5.1 Section 2a (page 8) of the NHS Constitution lays down the rights of patients and the public and the commitment of NHS organisations in terms of complaint and redress. Section 3b (page 11) lays down the responsibility of NHS staff to welcome and listen to feedback and address concerns promptly and in the spirit of cooperation. 1.6 PALS Standards 1.6.1 Because RMSAT Standards 2.3 includes concerns and complaints, PALS standards are integral to this policy. 1.6.2 PALS core standards are outlined in Patient Advice and Liaison Service (PALS) National Core Standards and Evaluation Framework, Department of Health, 2003. They are: 1. The PALS service is identifiable and accessible to the community served by the Trust 2. PALS will be seamless across health and social care 3. PALS will be sensitive and provide a confidential service that meets individual needs 4. PALS will have systems that make their findings known as part of routine monitoring in order to facilitate change 5. PALS enables people to access information about Trust services, and information about health and social care issues 6. PALS plays a key role in bringing about culture change in the NHS placing patients at the heart of service planning and delivery 7. PALS will actively seek the views of service users, carers and the public to ensure effective services 3

2 Definitions 2.1 The Regulations The Regulations are The Local Authority Social Services and National Health Service Complaints (England) Regulations 2009. 2.2 A service user In terms of concerns and complaints policy and procedure, a service user is anyone receiving services from the Trust or anyone affected or likely to be affected by the behaviour of the Trust. Commonly, this means patients, carers, relatives and visitors. 2.3 A concern A concern is an issue raised by a service user that is not serious or complex, which can be addressed promptly with minimal intervention. It could require a written response. 2.4 A complaint A complaint is an expression of dissatisfaction from a service user that requires investigation and usually a written response. 3 Policy Statement 3.1 This policy provides a framework for the Trust s procedure for handling concerns and complaints in accordance with The Local Authority Social Services and National Health Service Complaints (England) Regulations 2009, Regulation 19 of the Health & Social Care Act 2008 (Regulated Activities) Regulations 2010, RMSAT Standard 2.3: Concerns and Complaints, CQC Outcome 17: Complaints, and the rights of patients and the public laid down in Section 2a of the NHS Constitution. It sets out the requirements of the policy and the roles of those involved with lines of accountability. It helps to underpin the Trust s organisational values, in particular, Listening in order to improve. 3.2 The aims of this policy are: 1. to support an honest, open, thorough and non-discriminatory approach to handling concerns and complaints (RMSAT Standard 2.3, CQC Outcome 17), 2. to resolve concerns and complaints in a timely manner to the satisfaction of complainants (Regulation 14, The Local 4

Authority Social Services and National Health Service Complaints (England) Regulations 2009), and 3. to improve services through concern and complaint action plans (Regulations, RMSAT Standard 2.3, CQC Outcome 17). 3.3 The Trust values the information it receives through service users concerns and complaints, and will use it to improve its services. The information collected will be used in conjunction with knowledge from other sources, for example, serious incidents (SIs), adverse incident reports (AIRs), claims for compensation, and patient and public involvement (PPI) activities. 3.4 The Trust is committed to the fair treatment of everyone, regardless of age, colour, disability, ethnicity, gender, gender reassignment, nationality, race, religion or belief, responsibility for dependants, sexual orientation, trade union membership or non membership, working patterns or any other personal characteristic. This policy and procedure will be implemented consistently and everyone will be treated with dignity and respect (CQC Outcome 17). Consequently, an equality impact assessment has been completed on this policy (Section 10). 3.5 This commitment also applies to service users who fear that they will receive adverse treatment from staff if they make a complaint (RMSAT Standard 2.3, CQC Outcome 17). 3.6 This document replaces the Trust s Complaints Policy and Procedure Version 8 dated June 2010 and the Trust s Patient Advice and Liaison (PALS) Policy and Procedure Version 1 dated February 2008. 4 Equality Impact Assessment 4.1 The Trust aims to design and implement services, policies and measures that meet the diverse needs of our service users, population and workforce, ensuring that none are placed at an unreasonable or unfair disadvantage over others. 4.2 In the development of this policy, the Trust has considered its impact with regard to equalities legislation and a copy of that assessment is attached at Appendix 1. 5

5 Accountability 5.1 In accordance with Regulation 4(1)(a), the Chief Executive is the person responsible for ensuring compliance with the arrangements made under the Regulations, and in particular for ensuring that action is taken if necessary in the light of the outcome of a complaint. 5.2 In accordance with Regulation 4(1)(b), the Trust must have a complaints manager, responsible for managing the procedures for handling complaints in accordance with the arrangements made under the Regulations. This Trust s complaints manager is the Head of Patient Experience, who also manages PALS. The Head of Patient Experience is accountable to the Lead Nurse For Patient Experience for all aspects of the concerns and complaints policy and procedure. 5.3 It is the responsibility of all staff to adhere to this policy and the procedures supporting it. 5.4 The Patient Experience Team (PET) will provide support and advice to staff to ensure: 1. complaints are handled in accordance with the NHS complaints procedure, 2. the relevant Risk Management and CQC standards are met, and 3. Regulation 19 of the Health & Social Care Act 2008 (Regulated Activities) Regulations 2010 5.5 The Patient Advice and Liaison Service (PALS), which is part of PET, will offer assistance to service users experiencing difficulty in resolving concerns and complaints. In accordance with PALS core standards outlined in Supporting the Implementation of Patient Advice and Liaison Services: A resource pack, Department of Health, 2002, PALS will try to resolve concerns quickly with appropriate intervention. 5.6 The PET, including PALS, will support staff to resolve oral complaints by the end of the next working day to the satisfaction of the complainant, in accordance with Regulation 8(1)(c) of The Local Authority Social Services and National Health Service Complaints (England) Regulations 2009. 6

5.7 The description of these responsibilities supports the Regulations, RMSAT Standard 2.3 duties, CQC Outcome 17 and Regulation 19 of the Health & Social Care Act 2008. 5.8 All members of staff are responsible for trying to resolve service user s concerns and complaints in a welcoming manner when they are raised. 5.9 The Chief Nurse is the designated Trust board member responsible for this policy and procedure. The Chief Nurse is accountable to the Trust Board and the Chief Executive for the development, implementation, evaluation and review of all policies and procedures relating to the handling of concerns and complaints. 6 Consultation, Assurance and Approval Process 6.1 Consultation Process 6.1.1 This policy has been developed in consultation with the members of the Complaints Support Group, senior managers and the Chief Nurse. Members of the Complaint Support Group include Directorate Managers, Matrons and senior managers involved in handling complaints. 6.2 Quality Assurance Process 6.2.1 The Quality and Safety Committee is responsible for the quality assurance of this policy. 6.3 Approval Process 6.3.1 Following completion of the Quality Assurance Process this policy has been approved by the Risk and Assurance Committee. 7 Review and Revision Arrangements 7.1 This policy will be reviewed by the Head of Patient Experience when the Regulations or standards change or at least every two years. It will be considered by the Quality and Safety Committee and the Risk and Assurance Committee. 8 Dissemination and Implementation 8.1 Dissemination 8.1.1 Copies of the policy and procedure will be distributed by e- mail to members of the Complaints Support Group, who are responsible for handling complaints on behalf of their areas and 7

directorates. It will be placed on the Trust intranet. Senior managers will be notified of the policy and procedure by e-mail and asked to ensure all staff are made aware of it. Directors and Associate Directors are required through the Executive Board to ensure the policy is brought to the attention of staff in their areas and directorates. Notice of its publication will be included in Team Brief. 8.1.2 This policy and procedure is available in alternative formats, for example, Braille or large font, on request to the author of the policy. 8.2 Implementation of the policy 8.2.1 This policy will be supported by the Chief Nurse, the Medical Director, Lead Nurse for Patient Experience and PET. PET will provide training for staff handling complaints. Staff handling complaints for the first time are required to undertake this training. 9 Document Control including Archiving Arrangements 9.1 Register/Library of Policies 9.1.1 The policy and procedure will be registered and held by the Trust Compliance Unit. 9.2 Archiving Arrangements 9.2.1 Archiving arrangements are managed by the Compliance Unit. 9.3 Process for Retrieving Archived Policies 9.3.1 To retrieve a former version of this policy from the Trust intranet, the Compliance Unit should be contacted. 10 Monitoring Compliance with and the Effectiveness of Policies Monitoring arrangements for compliance with Regulations and standards are specified in this section. 10.1 Process for Monitoring Compliance and Effectiveness 10.1.1 This policy and its associated procedure will be monitored in accordance with the Regulations and NHSLA RMSAT Standard 2.3 as shown in Tables A and B below, which will also ensure compliance with the relevant CQC standard and Regulation 19 of the Health & Social Care Act 2008. 8

Table A: Compliance with The Local Authority Social Services and National Health Service Complaints (England) Regulations 2009 What Who How When Assurance Arrangements for handling and considering complaints (Regulation 3) Head of Patient Experience Production and implementation of policy and procedure For every complaint Weekly, monthly and quarterly monitoring, and quarterly reviews Responsibility for complaints arrangements (Regulation 4) Duty to co-operate (Regulation 9) Procedure before investigation (Regulation 13) Chief Executive Head of Patient Experience Head of Patient Experience Delegated to Head of Patient Experience Quarterly and monthly reports Production and implementation of policy and procedure For every complaint Quality and Safety quarterly report, annual report For every complaint Monthly monitoring reports and quarterly reviews of action plans Executive Board Weekly, monthly and quarterly monitoring, and quarterly reviews Concerns and complaints policy Version 9 June 2013 9

Investigation and response (Regulation 14) Publicity (Regulation 16) Monitoring (Regulation 17) Annual reports (Regulation 18) On request reports (Regulation 19 of the Health & Social Care Act 2008) Head of Patient Experience Head of Patient Experience Head of Patient Experience Head of Patient Experience Production and implementation of policy and procedure Production and distribution of information leaflets, information on the Trust web site Production and implementation of policy and procedure Production of report For every complaint Always For every complaint Annual and as requested Weekly, monthly and quarterly monitoring, and quarterly reviews Review at least every two years Weekly, monthly and quarterly monitoring, and quarterly reviews Reports to Commissioners Concerns and complaints policy Version 9 June 2013 10

Table B: Compliance Monitoring Table for RMSAT Standard 2.3 and CQC Outcome 17 What Who How When Assurance The organisation has an approved documented process Head of Patient Experience Review Concerns and Complaints Every two years or more Approval by Executive Board for listening, responding and improving when patients, their relatives and carers raise concerns/complaints that is implemented and monitored. Policy and Procedure frequently as required a. duties Chief Executive Quarterly and Annual report Executive Board b. process for listening and responding to concerns/complaints of patients, their relatives and carers c. process for the handling of joint complaints between organisations d. process for ensuring patients, their relatives and carers are not treated differently as a result of raising a complaint Head of Patient Experience Head of Patient Experience Head of Patient Experience monthly reports Quarterly and monthly reports Quarterly and monthly reports Quarterly and monthly reports Annual report Annual report Annual report Executive Board and NHS North Yorkshire and York Executive Board Executive Board Concerns and complaints policy Version 9 June 2013 11

e. process by which the organisation aims to improve as a result of concerns/complaints being raised f. process for monitoring compliance with all of the above Head of Patient Experience Head of Patient Experience Quarterly and monthly reports Quarterly and monthly reports Annual report Annual report Executive Board Executive Board Concerns and complaints policy Version 9 June 2013 12

10.1.2 The Executive Board and the Board of Directors will receive quarterly information on the nature, volume and trends in concerns and complaints from the Quality and Safety Committee. The meeting minutes from these groups and the Quality and Safety quarterly report will provide evidence of compliance. (RMSAT Standard 2.3) 10.1.3 The Chief Executive and Chief Nurse will receive monthly reports from PET showing the current status of complaints and concerns, and any issues arising. (Regulations and RMSAT Standard 2.3) 10.1.4 The PET will monitor every complaint to ensure it is handled in accordance with the Concerns and Complaints Policy and Procedure and complies with the Regulations. If non-compliance is found, PET will take appropriate steps to remedy it immediately, if possible. PET will review complaints as necessary to ensure that lessons are learned and performance is improved. The complaint audit sheet and any complaint handling review reports will provide evidence of compliance with standards and Regulations. (Regulations and RMSAT Standard 2.3) 10.1.5 The PET will carry out quarterly reviews of each directorate s complaints to highlight any issues in their handling and to monitor progress on action plans to improve services resulting from complaints. Notes from these reviews will provide evidence of compliance. (Regulations and RMSAT Standard 2.3) 10.1.6 The PET will ask service users who raise concerns and complaints if they are satisfied with the Trust s handling of their issues. This will include asking service users if they have experienced discrimination of any kind in the way they were treated or how their concerns or complaints were handled. Service user questionnaires and any resulting action plans will provide evidence of compliance. (RMSAT Standard 2.3) 10.1.7 The Internal Audit service will undertake independent audit reviews to ensure that concerns and complaints are managed in accordance with Trust policy and procedure. These reviews will seek to provide assurance to management and the Board that: 1. Required standards for managing concerns and complaints are embodied in policy and procedure, and adhered to. Concerns and complaints policy Version 9 June 2013 13

2. Learning from concerns and complaints ensures continuous service improvements. 3. Complainants and those who raise concerns are satisfied with the management of their issues. 10.1.8 During the audit review, the current system for managing complaints will be ascertained and documented, and controls identified and evaluated. A representative sample of complaints will be selected and testing will be undertaken to seek evidence of compliance with policy. Any information that might identify a patient, carer, relative or member of staff will be removed or obliterated from these complaints by PET. This is to comply with CQC Outcome 17 and to ensure the Trust meets data protection requirements. 10.1.9 Evidence will be sought that action arising from previously investigated complaints has been implemented, and a process is in place to provide assurance of such. The audit report will provide the evidence of compliance. (Regulations and RMSAT Standard 2.3) The 2012 internal audit review of the Trust s management of concerns and complaints found high compliance with this policy and procedure. 10.2 Standards/Key Performance Indicators 10.1.2 The standards applying to this policy are specified in Section 1 of this report. 10.1.3 In terms of key performance indicators, the Trust must: 1. Acknowledge a complaint not later than three working days after the day on which it was received 2. Send the complainant a written response, signed by the Chief Executive, including a report on the investigation, findings and any action required 3. Monitor each complaint by recording its subject matter and outcome, and noting if the response date was met 4. Produce an annual report for the Commissioners, and other reports on request. Concerns and complaints policy Version 9 June 2013 14

11 Training 11.1 PET will provide training for staff who handle complaints when it is required. PET will provide updates and support as necessary, either through the Complaints Support Group or with staff on a one to one basis. Staff who have not received training from PET should not investigate complaints. 12 Trust Associated Documentation o Procedure for Concerns and Complaints Policy, York Hospitals NHS Foundation Trust, Version 1, March 2010. Appendix 3 of this policy. o Process for the Handling of Joint Complaints between Organisations, York Hospitals NHS Foundation Trust. Appendix 2 of this policy. o Inclusivity Scheme, York Hospitals NHS Foundation Trust, 2009. o Safeguarding Adults Policy and Procedure, York Hospitals NHS Foundation Trust, 2010 o Adults with Learning Difficulties Policy and Procedure, York Hospitals NHS Foundation Trust, 2010 13 External References o Statutory Instrument 2009 No. 309, The Local Authority Social Services and National Health Service Complaints (England) Regulations 2009. o Health & Social Care Act 2008 (Regulated Activities) Regulations 2010. o NHSLA Risk Management Standards for Acute Trusts 2013-14 o CQC: Guidance about compliance, Essential standards of quality and safety, March 2010. o Patient Advice and Liaison Service (PALS) National Core Standards and Evaluation Framework, Department of Health, 2003. o Supporting the Implementation of Patient Advice and Liaison Services: A resource pack, Department of Health, 2002. o The NHS Constitution, the NHS belongs to us all (for England, 21 January 2009), Department of Health, January 2009. o Listening, Responding, Improving A guide to better customer care, Department of Health, 26 February 2009. Concerns and complaints policy Version 9 June 2013 15

o Clinical Governance and Adult Safeguarding: An Integrated Process, Department of Health, February 2010 14 Appendices Appendix 1: Equality Impact Assessment Appendix 2: Process for the Handling of Joint Complaints between Organisations Appendix 3: Procedure for Concerns and Complaints Policy Concerns and complaints policy Version 9 June 2013 16

Appendix A: Equality Impact Assessment Tool To be completed when submitted to the appropriate committee for consideration and approval. Name of Policy: Concerns and Complaints Policy and Procedure 1. What are the intended outcomes of this work? To provide guidance on how to handle concerns and complaints 2 Who will be affected? e.g. staff, patients, service users etc Staff, Patients, Relatives/patient advocates etc 3 What evidence have you considered? Best Practice and NHSLA requirements a b c d e f g h i j Disability the policy is inclusive. Sex the policy is inclusive. Race the policy is inclusive. Age the policy is inclusive. Gender Reassignment the policy is inclusive. Sexual Orientation the policy is inclusive. Religion or Belief the policy is inclusive. Pregnancy and Maternity. the policy is inclusive. Carers the policy is inclusive. Other Identified Groups the policy is inclusive. Concerns and complaints policy Version 9 June 2013 17

4. Engagement and Involvement a. Was this work subject to consultation? b. How have you engaged stakeholders in constructing the policy c. If so, how have you engaged stakeholders in constructing the policy Discussion and circulation of document d. For each engagement activity, please state who was involved, how they were engaged and key outputs See secton 6 5. a Consultation Outcome Now consider and detail below how the proposals impact on elimination of discrimination, harassment and victimisation, advance the equality of opportunity and promote good relations between groups Eliminate discrimination, harassment and victimisation The policy is inclusive. b Advance Equality of Opportunity The policy is inclusive. c Promote Good Relations Between Groups The policy is inclusive. d What is the overall impact? The policy is inclusive. Name of the Person who carried out this assessment: M Thirlway Date Assessment Completed June 2013 Name of responsible Director Chief Nurse If you have identified a potential discriminatory impact of this procedural document, please refer it to the Equality and Diversity Committee, together with any suggestions as to the action required to avoid/reduce this impact. Concerns and complaints policy Version 9 June 2013 18

Appendix B Checklist for the Review and Approval To be completed and attached to any document which guides practice when submitted to the appropriate committee for consideration and approval. Title of document being reviewed: 1 Development and Management of Policies Is the title clear and unambiguous? Is it clear whether the document is a guideline, policy, protocol or procedures? 2 Rationale Are reasons for development of the document stated? 3 Development Process Is the method described in brief? Are individuals involved in the development identified? Do you feel a reasonable attempt has been made to ensure relevant expertise has been used? Is there evidence of consultation with stakeholders and users? Has an operational, manpower and financial resource assessment been undertaken? 4 Content Is the document linked to a strategy? Is the objective of the document clear? Is the target population clear and unambiguous? /No/ Unsure Comments Concerns and complaints policy Version 9 June 2013 19

Title of document being reviewed: Are the intended outcomes described? Are the statements clear and unambiguous? 5 Evidence Base Is the type of evidence to support the document identified explicitly? Are key references cited? Are the references cited in full? Are local/organisational supporting documents referenced? 5a Quality Assurance Has the standard the policy been written to address the issues identified? Has QA been completed and approved? 6 Approval Does the document identify which committee/group will approve it? If appropriate, have the staff side committee (or equivalent) approved the document? 7 Dissemination and Implementation Is there an outline/plan to identify how this will be done? Does the plan include the necessary training/support to ensure compliance? 8 Document Control Does the document identify where it will be held? /No/ Unsure N/A Comments Concerns and complaints policy Version 9 June 2013 20

Title of document being reviewed: Have archiving arrangements for superseded documents been addressed? 9 Process for Monitoring Compliance Are there measurable standards or KPIs to support monitoring compliance of the document? Is there a plan to review or audit compliance with the document? 10 Review Date Is the review date identified? Is the frequency of review identified? If so, is it acceptable? 11 Overall Responsibility for the Document Is it clear who will be responsible for coordinating the dissemination, implementation and review of the documentation? /No/ Unsure Comments Individual Approval If you are happy to approve this document, please sign and date it and forward to the chair of the committee/group where it will receive final approval. Name Elizabeth McManus Date June 2013 Signature Elizabeth McManus Committee Approval If the committee is happy to approve this document, please sign and date it and forward copies to the person with responsibility for disseminating and implementing the document and the person who is responsible for maintaining the organisation s database of approved documents. Concerns and complaints policy Version 9 June 2013 21

Name Quality and Safety Group Date June 2013 Signature Concerns and complaints policy Version 9 June 2013 22

Appendix C Plan for dissemination of policy To be completed and attached to any document which guides practice when submitted to the appropriate committee for consideration and approval. Title of document: Concerns and Complaints Policy and procedure Date finalised: August 2013 Previous document in use? Dissemination lead M Thirlway Which Strategy does it relate to? Risk Management If yes, in what format and where? Staff room Proposed action to retrieve out of date copies of the document: Dissemination Grid Compliance Unit will hold archive To be disseminated to: 1) All staff 2) Method of dissemination Via Staffroom who will do it? Healthcare Governance Directorate and when? August 2013 Format (i.e. paper Electronic or electronic) Dissemination Record Date put on register / library 12 August 2013 Review date June 2015 Disseminated to Staff via Staff room Format (i.e. paper or electronic) Electronic Date Disseminated 12 August 2013 No. of Copies Sent N/A Contact Details / Comments Policy Manager Concerns and complaints policy Version 9 June 2013 23

Appendix 2: Process for the Handling of Joint Complaints between Organisations 1 The lead will normally be taken, by agreement, by the agency against whom most of the complaint is made 2 Each agency will have a contact officer(s) for liaison, who will coordinate any requests for information with the protocol and inform of right to an advocate 3 Complaints will be acknowledged by the receiving agency, which will also give the details of who will respond 4 Agencies will comply with the timescales laid down within the complaints procedure of the lead agency and complainants will be informed of the timescales involved 5 Response letters will be signed by the Chief Executive (or Director if appropriate) of the lead agency. All contributions to joint letters will be approved by the Chief Executive (or Director) of the relevant agency 6 If during the handling of the complaint, criticism of another agency is identified, the way forward will be determined through consultation with that agency 7 Issues of confidentiality, for example, between agencies or involving consent or data protection authorisation from a complainant, should be the responsibility of the complaints managers 8 Should stage two of the NHS/Social Services/Corporate procedure be requested (Ombudsman), the agencies will liaise and separate if necessary, keeping the complainant informed Concerns and complaints policy Version 9 June 2013 24

Appendix 3: Procedure for Concerns and Complaints Policy Procedure for Concerns and Complaints Policy Author: Marilyn Thirlway, Head of Patient Experience Owner: Elizabeth McManus, Chief Nurse Associated Policy: Concerns and Complaints Date of first issue: June 2010 Version: 2 Date of version issue: June 2013 Approval body: Quality and Safety Committee Date approved: June 2010 Review date: June 2015 Concerns and complaints policy Version 9 June 2013 25

Contents Page 1 Introduction 21 2 Overview 21 3 Responsibilities 23 4 Procedure 25 5 Training 44 6 Document control and archiving 45 7 Monitoring compliance with and effectiveness of the procedure 45 Appendix 1: Procedure for handling serial complaints 46 Concerns and complaints policy Version 9 June 2013 26

1 Introduction The purpose of the Concerns and Complaints Policy and Procedure is to ensure that York Teaching Hospital NHS Foundation Trust complies with the NHS complaints procedure and Regulation 19 of the Health & Social Care Act 2008, meets NHS Litigation Authority (NHSLA) Risk Management Standards for Acute Trusts (RMSAT), Care Quality Commission (CQC) standards and supports Sections 2a and 3b of the NHS Constitution. The relevant regulations and standards are specified in the Trust s Concerns and Complaints Policy. 2 Overview It is Trust policy that dissatisfied service users should be encouraged to tell the Trust about their concerns when they arise. Whenever possible, their concerns should be handled at ward, department or area level by the staff caring for or in contact with them. Staff must offer reassurance and respond to matters of concern raised by service users as they arise. If these attempts to resolve concerns fail, or service users approach the Patient Advice and Liaison Service (PALS) directly, PALS will try to facilitate a resolution appropriate and acceptable to the service user. This requires effective co-operation between all staff involved and PALS. When service users raise complaints rather than concerns, these will be addressed through a complaints procedure that: 1. is easy for service users to access, without fear of discrimination 2. informs the complainant of any assistance available to them throughout the process 3. encourages direct communication with complainants through meetings with staff or telephone calls 4. protects patient confidentiality 5. can handle complainants about any NHS or local authority social services 6. is fair to service users and staff 7. supports thorough investigation of complainants concerns Issue Date: 2013 27

8. keeps the complainant updated on the progress of their complaint 9. provides a timely, honest and open response that satisfies the complainant 10. considers any appropriate redress, including correcting any wrongs that can be put right 11. informs the complainant about the procedure if they remain dissatisfied 12. provides a mechanism for service improvement The Trust will support staff to handle complaints in an open, courteous manner, providing an opportunity for them to satisfy complainants and restore confidence in Trust services. The Trust recognises that being involved in a complainant can be a traumatic experience for staff. Staff will therefore be fully supported in handling complaints by their line managers and the Patient Experience Team (PET). The Patient Experience Team will provide training for staff who handle complaints. Staff who have not had or who are not receiving training should not handle complaints. It is Trust policy to ensure that patients, relatives and their carers are not treated differently as a result of a complaint. However, complainants should not benefit unfairly from complaining, for example, by receiving an earlier appointment or treatment, unless their clinical condition indicates this is necessary. The Trust values the information it receives through service users concerns and complaints, which it will use it to improve its services. The information collected will be used in conjunction with knowledge from other sources, for example, serious incidents (SIs), adverse incident reports (AIRs), claims for compensation, and patient and public involvement (PPI) activities. The Chief Executive is responsible for ensuring compliance with the concerns and complaints policy and procedure, and in particular for ensuring any action arising from complaints is completed. Issue Date: 2013 28

3 Responsibilities All staff have a responsibility to resolve service users concerns promptly. PALS will provide support for staff when necessary. All staff have a responsibility to resolve service users complaints in accordance with The Local Authority Social Services and National Health Service Complaints (England) Regulations 2009, supported by PET and senior managers. There are no exact definitions of concerns and complaints, and common sense must prevail in identifying them. For the purpose of this policy and procedure a concern is defined as an issue raised by a service user that is not serious or complex, which can be addressed promptly with minimal intervention. A complaint is an expression of dissatisfaction from a service user that requires investigation and usually a written response. There is no distinction between formal and informal complaints. All complaints must be handled in accordance with the Regulations unless they are made orally and resolved to the service users satisfaction not later than the next working day on which the complaint was made. The following flow chart outlines how staff should identify and address concerns and complaints. Issue Date: 2013 29

Flow chart for identifying and addressing concerns and complaints Is the issue a concern or a complaint? Is it simple and can be addressed promptly with minimal intervention? No Is it an oral complaint that can be resolved not later than the next working day? No Is it serious or complex, and requires an investigation and written response? Resolve to the service user s satisfaction. Resolve to the service user s satisfaction and note any learning for the organisation. Handle in accordance with the complaints regulations. Issue Date: 2013 30

4 Procedure 4.1 Procedure for resolving concerns through PALS Service users concerns should be resolved promptly in the most effective manner. Service users raising concerns or staff requiring support to resolve concerns can contact PALS by telephone, email, letter, or face to face by arrangement. Alternatively, service users can provide details of their concerns on a feedback leaflet, which can be left in a box in the hospital main entrance or posted to the hospital using a freepost address. PALS will handle concerns as follows: 1. all concerns will be identified and clarified, and the relationship between the inquirer and the patient established 2. verbal consent to access personal information will be obtained and documented 3. any immediate need will be identified and addressed 4. outcomes for resolution that are achievable will be agreed with the service user 5. a reasonable timescale will be agreed 6. contact details will be clarified 7. confidentiality will be maintained in respect of any information gathered during the course of the inquiry 8. PALS will reassure service users that they will not be treated differently by the Trust as a result of raising a concern 9. PALS will carry out any necessary enquiries and take appropriate steps to resolve concerns 10. if possible and practical, the same PALS advisor will handle a concern throughout its course 11. PALS will update service users on the progress towards resolving their concern 12. Electronic records of concerns and details of action taken will be held on the PALS database (Datix) 13. The effectiveness of PALS involvement in resolving concerns will be evaluated from the service users point of view 4.2 Procedure for PALS handling of oral complaints not later than the next working day PALS will handle these complaints as follows: Issue Date: 2013 31

1. all aspects of the complaint will be identified and clarified, and the relationship between the complainant and the patient established 2. verbal consent to access personal information will be obtained and documented 3. any immediate need will be identified and addressed 4. PALS will evaluate the complaint and make initial checks to ensure it can be resolved within one working day 5. if it cannot, PALS will forward details to the complaints team who will register the complaint and handle it in accordance with the Regulations, PALS will explain this to the complainant 6. otherwise, the process for handling oral complaints within one working day will be explained to the complainant 7. confidentiality will be maintained in respect of any information gathered during the course of the inquiry 8. PALS will reassure service users that they will not be treated differently by the Trust as a result of raising a concern 9. PALS will carry out any necessary enquiries and take appropriate steps to resolve the complaint to the complainant s satisfaction 10. if PALS are unable to resolve the complaint within one working day they will refer it to the complaints team who will handle it in accordance with the Regulations. 11. PALS will confirm that the complaint is resolved to the complainant s satisfaction 12. PALS will make a note of any learning for the organisation 13. Details of the complaint will be recorded in the PALS database 4.3 Learning from concerns and oral complaints handled by PALS PALS will keep the Trust informed of concerns and oral complaints raised by service users by: 1. quarterly reporting on the nature, volume and trends in concerns to areas and directorates 2. introducing improvement plans when required 3. discussing concerns, volume and trends at PET weekly team meetings Issue Date: 2013 32

4. contributing to monthly PET reports and Quality and Safety quarterly reports 5. feeding back to areas and directorates comments from service users received on comments leaflets 6. alerting senior managers to serious concerns and significant incidents 7. raising issues and trends at weekly AIRs meetings. 4.4 Procedure for handling complaints in accordance with the Regulations All complaints will be handled in accordance with The Local Authority Social Services and National Health Service Complaints (England) Regulations 2009. This procedure is designed to ensure that the requirements of the Regulations are met. 4.4.1 Who can complain? Complaints can be made by a patient or anyone who is affected or likely to be affected by the actions of the Trust. If the complainant acts on behalf of someone else, however, confidential information will not be given to the complainant without the patient s written consent unless the patient is unable to act for themselves, for example, if the patient is a child, lacks capacity, is too ill or has died. In giving consent, patients agree to someone making a complaint on their behalf and to the sharing of relevant clinical information with the complainant. If consent is not received from someone able to give it, the Trust will carry out an investigation and respond to the complainant in general terms without breaching patient confidentiality, if this is possible. The Trust will encourage and facilitate the involvement of advocacy services and other agencies to assist people who would like support or who are not able to complain in their own right. 4.4.2 Complaints not required to be handled under the Regulations The Trust is not required under the Regulations to handle a complaint which is made orally, and resolved to the complainant s satisfaction not later than the next working day on which the complaint was made (Regulation 8). Under the Regulations the Trust is not required to Issue Date: 2013 33

deal with a complaint with the same subject matter resolved in this manner. It is Trust policy to take this opportunity to resolve oral complaints promptly. Issues handled under Regulation 8 must be supported with documentation that includes details of any action taken to improve services or learning for the Trust. 4.4.3 Time limits A complaint must be made not later than 12 months after the event or when the complainant first became aware of it. This time limit will not apply if the complainant had good reason for not making the complaint within the time limit and it is still possible to investigate the complaint effectively and fairly. 4.4.4 The complainant s rights Under the NHS complaints procedure the complainant is entitled to the following: 1. A copy of the written record of their complaint. 2. An acknowledgement within three working days of the Trust receiving the complaint, with an offer to discuss how the complaint will be handled, when the investigation and response will be completed, and their preferred method of communication. 3. To receive in a timely manner in relation to all their concerns, a full and complete report explaining what happened, what should have happened, why it did not and what action the Trust will take to rectify any matters. If what happened was appropriate, a clear explanation of the reasons. 4. To be kept updated on the progress of their complaint. 5. To be asked to agree any extension of the response deadline. 6. To be offered an apology and any other appropriate redress. 7. If an error or omission has occurred, the complainant will be given information about the action the Trust has taken, or is proposing to take, to try to prevent it happening again. 8. To request an investigation of their complaint by the Health Service Ombudsman if they remain dissatisfied at the end of the local resolution process. In addition the Trust will undertake to do the following: Issue Date: 2013 34

1. Assure complainants that complaints, comments, suggestions and compliments are all welcome. 2. Ensure complainants know they have a right to complain and that all complaints are taken seriously and treated with respect. 3. Throughout the procedure, make appropriate adjustments to meet the communication and access needs of complainants with a disability, mental health problems, learning difficulties or whose first language is not English. 4. Assure complainants that complaints will lead to positive action and that change and improvements to services will result. 5. Provide the complainant with the name and contact number of the person investigating their complaint. 6. Encourage staff to meet with complainants to discuss their concerns. 7. Ask the complainant about their preferred method of communication. 8. Ensure that advocacy, conciliation and mediation services are available, if required. 9. Explain the options available to the complainant if they remain dissatisfied with the Trust s response. 10. Update the complainant on the progress of action plans when appropriate. 11. Invite the complainant to view any changes to services made as a result of their complaint. 12. Obtain feedback from complainants on how their complaint was handled. 4.4.5 Publicity and accessibility The Trust will ensure that the right to complain, advice on how to use the complaints procedure and the help available from advocacy services is well publicised to all service users. Information about the complaints procedure will be made available in large print, Braille, on audiotape and in other languages on request. Interpretation services will be provided for complainants if necessary. 4.4.6 Confidentiality Patient confidentiality will be protected throughout the complaints process and when the complaint is closed. This will ensure, for Issue Date: 2013 35

example, that the requirements of data protection legislation are met and reduce the likelihood that complainants are discriminated against as a result of making a complaint. All records relating to a complaint will be kept confidential and separate from patient medical records. It is not necessary to obtain the patient s express consent to use their personal information for the purposes of investigating a complaint. However, patients will be made aware when their complaint is acknowledged that, in the course of investigating a complaint, access to clinical information will be required, and this will be shared only with those individuals involved in handling the complaint. It is Trust policy to ensure that any information disclosed about the patient is confined to that which is relevant to the investigation of the complaint and is disclosed only to those who need to know it. The Trust will not disclose personal health information to a complainant acting on behalf of a patient unless the patient has expressly and in writing, consented to its disclosure. Consent is not usually needed in situations where patients are not able to act for themselves. However, in certain circumstances legal advice might be required. The Trust wants to ensure staff can provide open and honest statements about complaints in which they are involved, without fear of them passing into the public domain. Staff reports and statements on complaints are therefore kept confidential within the complaints process and when complaints are closed. Staff should be aware, however, that complaints reports and any covering letters, are not legally privileged, and may be disclosed to the complainant and their solicitor if the complaint is pursued as a legal claim against the Trust. Complainants requests for access to the content of complaints files will be considered on a case by case basis, balancing the Trust s commitment to transparency with our duty of confidence to all parties. No statement will be disclosed in full or part without consultation with the person who made it. Under the Data Protection Act, complainants have the right of access to information about themselves. In practice, decisions about what can be disclosed from complaint files will take into account the Issue Date: 2013 36