: Complaints and Service Concerns Handling Policy NHS Erewash Clinical Commissioning Group Chair: Dr Avi Bhatia Chief Officer: Mr. Rakesh Marwaha Better Care. Better Health. Better Value The aim of this policy is to set out NHS Erewash Clinical Commissioning Group s (CCG) approach to receiving, handling and responding to complaints made under the provisions of the Local Authority Social Services and National Health Service Complaints (England) Regulations 2009 (SI 20009/309)
Document History Version Date: 21 August 2012 Version Number: 2.0 Status: FINAL Next Revision Due: July 2014 Developed by: Lisa Butler Review Date: 01 July 2014 Reviewed/revised by: Approved by: Heidi Scott-Smith Governing Body Date approved: August 2013 To help ensure that this policy is as accessible as possible, it has been left-aligned and is available in alternative formats and languages. To obtain a copy of the policy in large print, audio, Braille (or other format) or in an alternative language please contact 01332 868901.
THE SEVEN PRINCIPLES OF PUBLIC LIFE The Governing Body of NHS Erewash Clinical Commissioning Group has signed up to the seven Principles of public life as set out in the first report of the Committee on Standards in Public Life. These principles are reproduced below to provide support and guidance to staff when conducting business on behalf of NHS Erewash Clinical Commissioning Group. Selflessness Holders of public office should act solely in terms of the public interest. They should not do so in order to gain financial or other benefits for themselves, their family or their friends. Integrity Holders of public office should not place themselves under any financial or other obligation to outside individuals or organisations that might seek to influence them in the performance of their official duties. Objectivity In carrying out public business, including making public appointments, awarding contracts, or recommending individuals for rewards and benefits, holders of public office should make choices on merit. Accountability Holders of public office are accountable for their decisions and actions to the public and must submit themselves to whatever scrutiny is appropriate to their office. Openness Holders of public office should be as open as possible about all the decisions and actions that they take. They should give reasons for their decisions and restrict information only when the wider public interest clearly demands. Honesty Holders of public office have a duty to declare any private interests relating to their public duties and to take steps to resolve any conflicts arising in a way that protects the public interest. Leadership Holders of public office should promote and support these principles by leadership and example i
Contents The Seven principles of Public Life Page i 1. Introduction Page 3 2. Scope Page 3 3. Guiding Principles Page 3 4. Area for implementation Page 4 5. Organisational accountability and responsibility Page 4 6. Equality impact statement/due regard Page 4 7. Complaints handling procedure Page 5 7.1. Receiving a complaint Page 5 7.2. Acknowledging the complaint Page 6 7.3. Investigating the complaint: CCG handled complaints Page 6 7.4. Investigating the complaint: Provider handled complaints Page 6 7.5. Responding to the complaint Page 7 8. Time limit for making complaints Page 7 9. How to make a complaint Page 7 10. Consent and who can complain Page 7 11. Members of Parliament Page 8 12. Complaints that ECCG won t manage Page 8 13. Mediation Page 9 14. Possible claims for clinical negligence Page 9 15. Criminal investigations Page 9 16. Parliamentary and Health Service Ombudsman Page 9 17. Learning the lessons of complaints Page 9 18. Working in partnership Page 10 18.1. Multi- agency complaints Page 10 18.2. Patient Advice and Liaison Service (PALS) Page 10 18.3. NHS Complaints Advocacy Service Page 11 19. Monitoring and performance management of the policy Page 11 20. Ensuring the policy is accessible to all Page 11 21. Support and additional contacts Page 12 22. Persistent or unreasonable complaints Page 12 23. Service concerns Page 13 24. Associated documents Page 14 Appendix 1 Complaint form Appendix 2 - Verbal complaint form Appendix 3,4,5 consent form Appendix 6 Service concerns process Appendix 7 Service concerns form Appendix 8 Service concerns flowchart
1. Introduction This policy sets out NHS Erewash Clinical Commissioning Group s (ECCG) approach to receiving, handling and responding to complaints made under the provisions of the Local Authority Social Services and National Health Service Complaints (England) Regulations 2009. These regulations stipulate that: a concern is when a complaint is made orally and is resolved to the satisfaction of the complainant not later than the next working day after the day on which the concern was raised. All other cases must be managed as a complaint in accordance with this policy, a complaint can be made orally, in writing or electronically. A complaint is an expression of dissatisfaction, however made, about the standard of the service, actions or lack of action affecting an individual, for which a response must be provided. ECCG welcomes complaints as a valuable means of receiving feedback on the services it commissions for the people of Erewash and also on the way ECCG goes about its business. ECCG will identify lessons learnt from complaints as a means of improving services and the effectiveness of the organisation as every person s experience counts. We will use this valuable intelligence about the services we provide and commission to ensure that quality, patient focussed services are at the heart of our work. ECCG s complaints procedure will ensure that the complainant is at the centre of the process, and every effort will be made to resolve the complaint as fairly and as quickly as possible using the Being Open principles. 2. Scope This policy describes ECCG s approach to managing, monitoring and learning from complaints and concerns. This policy applies to all employees of ECCG and those that act in the capacity of employees. 3. Guiding Principles This policy is guided by the Principles of Good Complaints Handling published by the Parliamentary and Health Service Ombudsman for public bodies: Getting it right Being customer focussed Being open and accountable Acting fairly and proportionately Putting things right Seeking continuous improvement This is how we interpret these principles and how we will handle complaints: Complainants will be treated with respect and courtesy; The CCG will have a fair, open and transparent process in the handling of complaints; Complainants will receive a timely and appropriate response; Complaints will be properly investigated, monitored and recorded; Complainants will receive a sympathetic and caring response and will be told of the outcome of the investigation of their complaint and action taken, if necessary, in the light of the outcome of a complaint; 3 P a g e
Complainants will not be discriminated against for making a complaint and making a complaint will not adversely affect future treatment; Complaints will be dealt with efficiently and confidentially; The CCG will ensure ease of access for patients and complainants and, so far as reasonably practicable, assist them to understand the policy and procedures or advice on where assistance should be available The CCG will ensure lessons are identified and there is evidence of learning to improve services for patients and staff; Complaints involving more than one NHS organisation and joint complaints relating to health and social care will be handled in a coordinated manner. Staff will receive appropriate training in handling complaints 4. Area for implementation This policy covers complaints connected with ECCG s function of commissioning health care or other services under an NHS contract, or making arrangements for the provision of such care or services with an independent provider. It also covers those complaints where ECCG agrees with another organisation to take the lead in handling a complex, multi-agency complaint. 5. Organisational accountability and responsibilities The Accountable Officer holds corporate responsibility for ensuring ECCG has arrangements in place that comply with the regulations, and that appropriate action is taken arising from complaints. The person responsible for managing ECCG s complaints procedures in accordance with the arrangements made under the regulations is the Complaints Manager. 6. Equality Impact Statement/Due Regard We welcome feedback on this policy and the way it operates. We are interested to know of any possible or actual adverse impact that this policy may have on any groups in respect of gender or marital status, race, disability, sexual orientation, religion or belief, age, deprivation or other characteristics. This policy has been screened to determine equality relevance. The policy is considered to be high in equality relevance particularly in relation to: age, disability, race, gender, religion/belief, sexual orientation, transgender and deprivation. It is important for staff to remember that complainants may not be able to read or write, may not have English as their first language or may have disabilities which make it difficult for them to express their complaint. There are many groups in our communities that find it hard to access the services that they need. Therefore, it is important that NHS Erewash Clinical Commissioning Group has in place mechanisms to ensure that all groups are given the opportunity to access proper health care services. Staff have access to an interpretation and translation service who can also provide advice on the translation of literature into languages relevant to Derbyshire s communities. The Equality and Human Rights Commission (EHRC) promotes equality and human rights to create a fairer Britain. It does this by providing advice and guidance, working to implement an effective legislative framework and raising awareness of a person s rights. 4 P a g e
This policy embraces diversity, dignity and inclusion in line with statutory requirements and human rights guidance. NHS Erewash Clinical Commissioning Group recognises, acknowledges and values differences across all people. Every person will be treated with respect, courtesy and with consideration for their individual backgrounds. NHS Erewash Clinical Commissioning Group will ensure that everyone is treated fairly and it conveys equality of opportunity in service delivery and employment practice. Practically, this means that NHS Erewash Clinical Commissioning Group will: not tolerate any actions which obstruct access to, or delivery of, the services we provide and which lead to unfair treatment on the grounds of religion or belief, gender, race, disability including learning disability, age, sexual orientation, gender reassignment, marriage or civil partnership, pregnancy or maternity, nationality, ethnic or national origin, domestic circumstances, social and employment status, HIV status, political affiliation or trade union membership, or because they have complained; ensure provision of services adhere to the principles of treating people the way they expect to be treated and are in line with equality legislation and the Human Rights Act; ensure people are treated with fairness, dignity, respect and equality; take appropriate action to remove any discrimination and promote equal opportunities; monitor a wide range of our activities in order to make sure our commitment is being effectively delivered throughout the organisation; ensure fairness for all by developing a robust system for collecting equalities monitoring data when complaints are received about commissioned services, to address any gaps or lack of service provision identified. 7. Complaints handling procedure This section sets out NHS Erewash Clinical Commissioning Group s approach to handling complaints made to it under the complaints regulations. 7.1 Receiving a complaint When ECCG receives a complaint an initial assessment will be completed to see if it can be handled under the complaints regulations. If the complaint is excluded from the complaints regulations, ECCG will contact the complainant to inform them, and provide appropriate advice. This advice will be confirmed in writing. If a complaint is reported as per the regulations and is about a provider that ECCG commissions services from, then ECCG will contact the complainant to obtain consent for details of the complaint to be passed onto the provider. If it transpires during this initial step that the complaint has already been dealt with by the provider then ECCG will advise the complainant to contact the Parliamentary and Health Service Ombudsman. If the subject matter of the complaint relates to a service or function that NHS Erewash Clinical Commissioning Group is directly responsible for then it will handle the complaint in line with the regulations and notify the complainant accordingly. 5 P a g e
7.2 Acknowledging the complaint Complaints will be acknowledged either by letter, electronically or verbally within 3 working days, and will explain how the complaint will be handled and agree the proposed time scale for responding. This letter also includes details of the NHS Advocacy Service if the complainant requires independent support during NHS complaints process. The complaints regulations do not impose a time frame for responding to a complaint but in most cases ECCG will seek agreement for the response to be sent within 25 working days. There may be occasions where a longer timescale is required to ensure an appropriate level of investigation is completed. Should this be required ECCG will keep the complainant fully informed of the progress of the complaint and give estimates as to when a response can be expected. If it has not been possible to contact the complainant within the 3 working day timescale then a written acknowledgement will still be sent requesting for the complainant to contact ECCG to discuss how the complaint will be handled. 7.3 Investigating the complaint: CCG-handled complaints The Complaints Manager will send the complaint to the manager accountable for the provision of the service or function being complained about for investigation. The manager will be asked to fully investigate and address issues raised in the complaint. Upon receipt of the manager s response the complaints manager will scrutinise the response to ensure it answers the concerns raised in the complaint. If it is felt that the response does not adequately address the concerns raised then further information shall be sought from the relevant party before a final response is compiled. When the final response is compiled it will be quality assured by the Head of Quality at Erewash CCG and signed off/approved by the Director of Nursing. 7.4 Investigating the complaint: Provider-handled complaints This applies to those complaints where it has been decided that they shall be handled by the provider responsible for the service complained about. When a complaint is passed to a provider for handling it is expected that the provider will conduct a full investigation into the complaint and provide a response direct to the complainant that meets the requirements of the complaints regulations. ECCG will request a copy of the response so that lessons learnt from the complaint can be used to improve the quality of services that ECCG commissions, and to aid with future commissioning decisions. 7.5 Responding to the complaint ECCG will strive to ensure that a complaint is fully responded to within the time limit agreed with the complainant. Where it becomes evident that the agreed deadline cannot be met, the complaints manager handling the case will contact the complainant at the earliest opportunity to inform them of the delay, the reasons for it, and agree a new deadline for responding. ECCG s response will be based on the outcome of the investigation conducted by the relevant manager, and will seek to answer the questions raised in the complaint truthfully and comprehensively. The response will also include how they can contact the Parliamentary Health Ombudsman if the complainant remains dissatisfied with the response. 6 P a g e
8. Time limit for making complaints There is a statutory time limit for making a complaint, which is 12 months from the date on which the matter being complained about occurred, or 12 months from the date on which the complainant became aware that they have grounds for complaint, whichever is the later. A complaint made outside of the time limit can be considered if NHS Erewash Clinical Commissioning Group decides there are good reasons for the complaint not being made within the time-limit and the case can still be properly investigated. 9. How to make a complaint NHS Erewash Clinical Commissioning Group has engaged the Greater East Midlands Commissioning Support Unit (GEM CSU) to provide a complaints handling service to our residents and users of the services ECCG commissions. Under this arrangement the complainant s details will be provided to GEM CSU for them to manage the complaint once the complainant has provided consent for this as it may involve GEM CSU accessing case records in order to ensure the complaint is investigated thoroughly. Personal identifiable information will be used to process the complaint to enable the service provider to investigate and respond to the issues raised so that the complainant will receive a comprehensive response. If the complainant does not provide consent for their information to be used by GEM CSU the complaint will not be able to be processed. 10. Consent and who can complain A complaint can be made by: A service user or any person affected by, or likely to be affected by, the action, omission or decision of the NHS body, independent provider or local authority, that is the subject of the complaint; Someone acting on behalf of another person may make a complaint where that person is unable to make the complaint herself/himself or has asked the person to make the complaint on his/her behalf. A complaint may be made by a person acting on behalf of a person as described above where that person: Has died, Is a child, Is unable by reason of physical or mental incapacity to make the complaint himself/herself, Has requested that a representative act on his/her behalf. The complainant s written (or their representative s) consent is required before sharing confidential information with another body or organisation. With regards to children and people without capacity, the complaints regulations permit the responsible body for the complaint to decide whether the person is acting in the patient s best interests. If it is felt that this is not the case then the responsible body can refuse to handle a complaint made by that person. NHS Erewash Clinical Commissioning Group should not automatically assume that a parent or guardian can make a complaint on behalf of a child if it is felt that the child has sufficient maturity and capacity to make, or withhold, the complaint on their own behalf. In any case 7 P a g e
where ECCG is considering exercising this power it will only do so after full and proper consultation with relevant other parties 1. If an adult with capacity consents to a third person acting on their behalf, and the appointed person can provide a valid and acceptable form of consent, ECCG shall regard the appointed person as a representative for the patient in the complaint process. However, where a third person claims to be making a complaint on behalf of someone with capacity and does not have that person s valid consent in place, NHS Erewash Clinical Commissioning Group will contact the patient and request their consent for the complaint to proceed. If consent is not provided the complaints regulations prevent the complaint from being processed further, as it is the complainant s consent that is required in order for the details to be passed onto the provider. 11. Members of Parliament Where a Member of Parliament (MP) acts on behalf of a service user who is a constituent, who has, whether in writing, by telephone or in person sought that MP s assistance, written consent should be sought from the service user in the usual way. The constituent will be informed that, unless they advise otherwise, ECCG will be responding to their concerns via the MP. 12. Complaints that ECCG won t manage The CCG will decline to handle any complaints the subject matter of which is covered by one of the exclusions set out in Regulation 8 of the 2009 Complaints Regulations. These include: A complaint from another responsible body, e.g. a hospital trust, GP practice, or independent provider; Matters relating to the employment arrangements of an employee of an NHS body; A complaint the subject matter of which has been previously dealt with under complaint regulations; Matters that are either under investigation or have been investigated by the Health Service Ombudsman; and A concern that has been dealt with and resolved to the complainant s satisfaction within a working day of the complaint being voiced. Additionally ECCG will consider declining to handle a complaint: That is made beyond the time limit for making complaints and for which a reasonable explanation of the delay has not been given, or accepted by ECCG; In which ECCG is not satisfied that a third party is a suitable person for making a complaint on behalf of the patient; Where it is made by an adult on behalf of a child who is capable of making the complaint themselves and has chosen not to do so, or has not given consent for the complaint to be made on their behalf. 1 Relevant other parties will be determined based on the circumstances of the particular case under consideration and could include the Courts; a social worker; health care professional; or legal advocate. 8 P a g e
In all cases where ECCG declines to handle a complaint the complainant will be notified in writing of the decision and the reasons for it. 13. Mediation NHS Erewash Clinical Commissioning Group is not in a position to provide a formal mediation service for providers and complainants who are having difficulty resolving a complaint. However, it may be able to provide advice on how to resolve a complaint to either party but this will not involve an ECCG officer attending meetings between complainant and provider. Where it is appropriate NHS Erewash Clinical Commissioning Group will advise the complainant of the Independent Complaints Advocacy Service that is established to assist complainants with the management of their complaint. 14. Possible claims for clinical negligence If a complainant reveals that they wish to seek compensation or pursue legal action due to negligence, the Complaints Manager will advise that the complaint will be investigated but will not be able to address the issues related to compensation. Where possible, the complaint will continue if an investigation is not likely to prejudice the outcome of any legal case. 15. Criminal investigations If ECCG becomes aware that the subject of a complaint is also the subject of a criminal investigation, advice will be sought from Legal Services Support. It may be necessary to adjourn investigation of a complaint to ensure any actions taken do not affect the criminal investigation. However every effort will be made to continue with a complaints investigation. 16. Parliamentary and Health Service Ombudsman The role of the Health Service Ombudsman in the complaint procedure is to find out why a complaint about the NHS has not been resolved locally and to identify actions needed to achieve resolution. The Health Service Ombudsman may also choose to investigate the substance of the complaint themselves and make recommendations as to how the case might be resolved. The Health Service Ombudsman base their decisions on principles of Good Complaint Handling. NHS Erewash Clinical Commissioning Group welcomes the closer involvement that the Health Service Commissioner (Ombudsman) has with regards to complaints as a result of the 2009 regulations. The Ombudsman is in a position to take an independent view of how ECCG has handled and responded to a complaint, and whether we have provided sufficient redress where an injustice has taken place as a result of the matters being complained about. There will be one of two outcomes from a referral to the Ombudsman: it will either be decided that an appropriate response has been provided and no further action will be taken; or the Ombudsman will investigate and provide a view on the handling and outcome of the complaint. If the Ombudsman should choose to investigate and find failings or omissions in ECCG s response then that will provide learning opportunities that can be put to use in future investigations. 17. Learning the lessons of complaints Each quarter the complaints team will provide a learning and outcomes based report to the Head of Quality in NHS Erewash Clinical Commissioning Group. This report will: outline the number of complaints received 9 P a g e
identify the subject matters detail achievement against performance standards identify themes, trends and areas of concern highlight any improvements put into place resulting from lessons learnt from complaints contain details of any complaints referred to the Parliamentary and Health Services Ombudsman, if these were upheld and any recommendations made to the trusts. Where a complaint identifies risks that NHS Erewash Clinical Commissioning Group needs to record on its risk register the Complaints Manager will request the investigating manager to complete a risk assessment and ensure appropriate actions are taken to mitigate or eliminate the risk. 18. Working in partnership 18.1 Multi-Agency complaints Note: This section is predicated on regulation 9 duty to co-operate and will only apply where a section of the complaint is about ECCG s exercise of its functions. If ECCG receives a multi-agency complaint and no element of ECCG s functions can be identified in it then ECCG will pass it on to the agency that has the majority of the content of the complaint. Complaints can feature more than one service or organisation and the 2009 regulations permit responsible bodies to agree that one body should take the lead in the handling of a complaint. Where it is appropriate for the circumstances of the case 2 for NHS Erewash Clinical Commissioning Group to take the lead in handling a multi-agency complaint it will do so, and will work closely with the other agencies involved to ensure that the complaint is properly investigated and the issues raised are addressed. Where NHS Erewash Clinical Commissioning Group is not the lead agency but a party to the complaint it will ensure full co-operation and relevant sharing of information with the lead agency. Where NHS Erewash Clinical Commissioning Group is the lead agency in handling a complaint and for any reason finds an agency to be uncooperative in assisting with the proper handling of the complaint, it will firstly remind the agency of its obligations under the regulations and any relevant legislation. If this does not resolve the issue then it will be clearly identified in the complaints response, those matters that it has not been possible to resolve because of this lack of co-operation. It will then be a matter for the complainant to decide if they wish to raise these matters with the Ombudsman or other relevant body. 18.2 Patient Advice and Liaison Service (PALS) PALS service can provide a rapid intervention service in tackling concerns with the aim of resolving them quickly and to the complainant s satisfaction, preventing the need to follow the complaints process. If at any time during this intervention the patient or his/her representative indicates that they wish to escalate the concerns to a complaint, it will be treated as such. 2 Such circumstances could include whether the complaint is predominantly about a health service; or if another organisation is not able to handle the complaint because of a particular conflict of interest; or if ECCG is the majority or lead commissioner. This is not an exhaustive list but provides examples of where the CCG may agree to take on the lead role in handling a multi-agency complaint. 10 P a g e
It may sometimes be necessary, due to the urgent nature of some issues (i.e.booking ambulance transport) to allow a PALS enquiry to be handled alongside the investigation of a formal complaint. All reported concerns and lessons learnt will be recorded as a means of improving services. 18.3 NHS Complaints Advocacy - POhWER The Independent Complaints Advocacy Service, POhWER provides complainants with an advocacy service that can assist with writing letters, preparing for and attending meetings, explore options at each stage of the complaint, and help with making decisions on the complaint. The POhWER service can be contacted at: Post:POhWER, PO Box 14043. Birmingham B6 9BL T: 0300 200 0084 F: 0300 456 2365 Minicom 0300 456 2364 E: pohwer@pohwer.net Skype pohwer.advocacy (8am 6pm Monday Friday) Text: send the word powher with your name and number to 81025 Website: www.powher.net 19. Monitoring and performance management of the policy In addition to quarterly reports NHS Erewash Clinical Commissioning Group will publish an annual report on its website regarding: Number of complaints received; Subject matters Detail achievement against performance standards Identify trends and areas of concern Highlight any improvements put into place resulting from lessons learned from complaints; Contain details of any complaints referred to the Parliamentary and Health Service Ombudsman, if these were upheld and any recommendations made to the trusts. Number of reopened complaints. 20. Ensuring the policy is accessible to all The CCG is committed to ensuring that the guidance in this policy is accessible to all. Additional support will be provided as required, to help ensure that the information in this policy can be understood and its guidance followed. This support includes (but is not limited to): The provision of the policy and any associated documents in alternative formats. Enabling individuals to have an advocate or interpreter involved for support with communication Making reasonable adjustments, in discussion with individuals or their representative, to procedures where these are necessary to ensure their accessibility All staff involved in the implementation of this policy will need to proactively consider the additional actions that might be required to ensure that individual needs can be met. Actions to improve communication could include: 11 P a g e
Using easy read, Braille, pictures and symbols, or other formats when explaining information Providing a translator/interpreter for people for whom English is not their first language Providing information using picture communication symbols Supplying correspondence and leaflets in alternative languages and formats, including easy read Ensuring the client can access advocacy if needed Providing telephone advice and support using alternative languages and formats Using an Induction Loop when communicating with clients with hearing loss Using Augmented and Alternative Communication aids (AAC) for people with speech or writing difficulties 21.Support and additional contacts Further advice on this policy and its content can be obtained from: Complaints Manager 01332 868736 22. Persistent or unreasonable complainants There will be occasions when complainants remain dissatisfied following the investigation of their complaint. Whilst their frustrations can be acknowledged, some complainants will pursue their complaint in what is deemed to be an unreasonable manner. The Ombudsman s Office describes this as complainants who, because of the frequency or nature of their contacts with an agency, hinder the consideration of their or other people s, complaints. Unreasonable or vexatious complaints may include the following: The same complaint with minor differences but the complainant will not accept the outcome of any investigation into their complaint. Matters where the complainant is seeking an unrealistic outcome. The complaint arises from a historic and irreversible decision or incident. Frequent, lengthy, and complicated contact which is stressful for staff. Refusal to specify the grounds of the complaint despite offers of help from staff. The complainant behaves in an aggressive manner to staff when presenting their complaint. The complainant changes aspects of their complaint partway through the investigation. The complainant continually makes or breaks contact with the agency. Making unnecessarily excessive demands on the time and resources of staff whilst a complaint is being looked into e.g. excessive telephoning or sending emails to numerous staff, writing lengthy complex letters every few days and expecting immediate responses. The complainant persistently approaches the agency through different routes about the same complaint, in the hope that they will secure a different response. This list is not exhaustive but covers some of the main kinds of behaviours and actions that come to the agency s attention. Where a complainant is deemed to be persistent, vexatious or unreasonable, this will be considered on a case by case basis and an individual management plan will be agreed with the Governing Body. 12 P a g e
23. Service Concerns - Quality and Patient Safety Concerns, Incidents and Issues This process is not included within the Local Authority Social Services and National Health Service Complaints Regulations, 2009. This process has been developed as a response to national drivers, such as learning from the Francis Report and evidence based good practice. It provides a single point of access for independent contractors such as GPs and all stakeholders in services commissioned by NHS Erewash Clinical Commissioning Group to raise quality and patient safety issues and will be used to identify areas/services that need to improve patient safety and experience. All issues and the subsequent outcomes will be recorded and monitored so as to identify trends and themes, which will aid in data triangulation, and inform commissioning decisions. Concerns, incidents or issues related to quality and/or patient safety could be: Inappropriate patient pathways Dispensing errors Delays to patient treatment Referral issues Poor discharges, communication and information governance etc. This list is not exhaustive and further advice on what to report can be sought from ECCG Clinical Quality Team. Each concern, incident and issue will be assessed and investigated to set timescales as outlined in the flowchart in Appendix 8. This may result in signposting to a more appropriate system such as complaints, incidents and serious incidents. Consent will need to be obtained as appropriate as per section 10. The process flowchart and attached reporting form will be available on the ECCG website and intranet. The use of the form is not compulsory, however the minimum data set required is marked with * as follows: * Date of incident; *Location (where it happened) *Description of incident *Remedial action undertaken *Interpretation of incident (why investigation is required) *Reporter details. All electronic correspondence relating to this process will be dealt with confidentially via a dedicated nhs.net account using the following email address: Erewashccg.qualityissues@nhs.net For further advice on service concerns the Head of Quality or Clinical Facilitator can be contacted on: 0115 931 6157 or 0115 931 6187 13 P a g e
24 Associated Documents This policy was drafted with reference to the following: The Local Authority Social Services and National Health Services Complaints (England) Regulations 2009 Department of Health Listening, Responding, Improving: A guide to better customer care (February 2009) Being Open NHS Constitution Francis Report 14 P a g e
Appendix 1 COMPLAINT FORM Date of complaint: Complaint ref. no: Details of person making complaint: Full name: Address: Postcode: Telephone number: Patient s name (if not complainant) Address: Date of birth: Summary of complaint: Signature of complainant.... 15 P a g e
Continuation Sheet Signature of complainant... 16 P a g e
Appendix 2 VERBAL COMPLAINT FORM Date of complaint: Complaint ref. no: Details of person making complaint: Full name: Address: Postcode: Telephone number: Patient s name (if not complainant) Address: Date of birth: Complaint relating to: Summary of complaint: Advice given: 17 P a g e
Appendix 3 CONSENT FORM THIRD PARTY AUTHORITY TO ACT When a complainant is not the patient, consent is required from the patient for us to proceed with the investigation of a complaint. Please ask the patient to complete and sign the form below: I authorise the complaint reference.. to be made on my behalf by.. and I agree that confidential information may be disclosed to this person (only insofar as is necessary to answer the complaint). Furthermore, I authorise the release of my records to the Complaints Investigating Officer at NHS Erewash Clinical Commissioning Group to enable them to carry out a full investigation into the issues raised in the complaint. Signed (patient) Date of birth:. Full name and address IF FOR ANY REASON YOU ARE UNABLE TO COMPLETE THIS FORM, PLEASE CONTACT THE COMPLAINTS TEAM ON 01332 868736 Please return in the No stamp needed envelope provided. 18 P a g e
Appendix 4 CONSENT FORM TRANSFER TO PROVIDER ORGANISATION I,.., give consent for NHS Erewash Clinical Commissioning Group to forward my complaint to.. to enable an investigation to be undertaken into my concerns. Signed: Date:.. Please return in the No stamp needed envelope provided. 19 P a g e
Appendix 5 CONSENT FORM RELEASE OF RECORDS To obtain a copy of this form in large print, audio, Braille, easyread (or other format or language) please contact 01332 868901 I authorise the release of my relevant records to the Complaints Investigating Officer of NHS Erewash Clinical Commissioning Group to enable a full investigation to be carried out into the issues raised in the complaint. Signed: Full name: Address: IF FOR ANY REASON YOU ARE UNABLE TO COMPLETE THIS FORM, PLEASE CONTACT THE COMPLAINTS TEAM ON 01332 868736 Please return in the No stamp needed envelope provided. 20 P a g e
Appendix 6 Service Concerns Process Quality & Patient Safety Concerns, Incidents and Issues Erewash Clinical Commissioning Group (ECCG) has developed a new process for managing quality & patient safety concerns, incidents and issues. This process has been developed as a response to national drivers, such as learning from the Francis Report and evidence based good practice. It provides a single point of access to raise service concerns with regards to quality and patient safety issues and it will be used to identify areas/services that need to improve patient safety and experience. It will also facilitate improved communication, identify themes and trends, and inform commissioning decisions. Anyone who is a stakeholder in services commissioned by Erewash Clinical Commissioning Group (ECCG) has access to this process. Concerns, incidents or issues related to Quality and/or Patient Safety could be: Inappropriate patient pathways, dispensing errors, delays to patient treatment, referral issues (e.g. Choose and Book), e-discharge information, poor discharges, communication and information governance etc. This list is not exhaustive and further advice on what to report can be sought from the Erewash CCG Clinical Quality Team. Each service concern received will be assessed and investigated to set timescales see attached flowchart. This may result in signposting to a more appropriate system e.g. complaints, Incidents and Serious Incident reporting. In order to progress with an investigation into the concern raised it is important that we receive the relevant level of information, and where appropriate consent obtained. The process flowchart and reporting form will be available on the ECCG Website and intranet. The use of the form is not compulsory, however the minimum data set required is marked with * as follows: Date of incident Location (where it happened) Description of incident Remedial Action Undertaken Interpretation of incident (why investigation is required) Reporter details All electronic correspondence relating to the concerns process will be dealt with confidentially via a dedicated nhs.net account using the following email address: Erewashccg.qualityissues@nhs.net The preference for dealing with concerns most efficiently is by email, however, if this is not practicable then paper based correspondence should be sent via the postal system (marked 21 P a g e
confidential) to: The Clinical Quality & Nursing Team Service Concerns, Erewash Clinical Commissioning Group, Toll Bar House, Ilkeston, Derbyshire, DE7 5FH For further advice on the quality concerns process please contact: Quality Concerns - Clinical Quality & Nursing Team Members: Heidi Scott-Smith Head of Quality 0115 931 6157 Margaret Farrow-Johnson Clinical Facilitator 0115 931 6187 22 P a g e
Appendix 7 Service Concerns Quality & Patient Safety Issues Form Please use this form to report areas which you feel need further investigation either in terms of quality and safety or contracting, such as coding / counting / double charging / inappropriate patient pathway used or referrals etc. Please note fields/sections marked with * are essential information requirements in order to progress the concern further: Is your concern relating to: Quality: Contracting: Details of Concern: Date of Incident:* Date of form completion: Time of incident (if known): Location (where identified):* Brief description of Incident:* Please include brief details information must be factual and not personal opinion. If applicable please include the details of the person(s) affected and those present. If more space is required, please use the continuation space on the back of this form: Remedial Action Undertaken or Required:* Describe any safeguarding or actions undertaken to prevent recurrence: Interpretation of incident and why investigation is required:* Include any further information relevant to the incident/concern i.e. patient details if relevant: Details of Reporter:* Name (please print): Location (i.e. practice / clinic): Job Title: Contact details (telephone / email): 23 P a g e
Continuation section: Internal Office Use Only: Form Receipt Date: CCG/Directorate: Result: Further Investigation? Shared with and when: Additional comments: Internal Ref No: Incident Type: Incident Category: Incident Sub-Category: Actual Outcome: Date of feedback to reporter: 24 P a g e
Appendix 8 SERVICE CONCERNS - QUALITY & PATIENT SAFETY ISSUES PROCESS FLOWCHART Concern / Incident identified by Reporting Organisation / Independent Contractor/Stakeholder Complete concern form within 5 working days (see link in the following box) Commissioners are notified of concern as reporting organisation forwards the form to the If dedicated further advice inbox is (Erewashccg.qualityissues@nhs.net) required, please contact the Southern which Derbyshire will automatically CCG, Clinical forward to the Quality email accounts Team on of 01332 relevant 868744 Clinical or via Quality the Quality & Nursing Issues Team inbox members (nhs.net who account will deal to with the be arranged) concern. Forms can also be posted to the Clinical Quality & Nursing Team Clinical Quality & Nursing (CQN) Team will acknowledge the concern within 2 working days Concern / Incident reviewed by CQN Team within 2 weeks and entered onto the Concerns Database. If appropriate, obtain consent. Referred to an appropriate person for investigation providing them with a 45 working day deadline for a response Response / Investigation report to be returned Clinical Quality & Nursing Team via the dedicated inbox (Erewashccg.qualityissues@nhs.net) Response / Investigation report will be reviewed by the Clinical Quality & Nursing Team within 2 weeks of receipt Final response to the Reporting Organisation / Independent Contractor within 2 weeks. Any learning or information to be shared will be submitted to the relevant forum. NB: The aforementioned timescales are the recommended best practice standards, however, the circumstances and requirements of the investigation may require flexibility on a case by case basis. If further advice is required, please contact the Erewash CCG, Clinical Quality & Nursing Team on 0115 9316187 / 9316157 or via the dedicated inbox (Erewashccg.qualityissues@nhs.net) 25 P a g e