NHS Nottingham North and East, Nottingham West and Rushcliffe Clinical Commissioning Group

NHS Nottingham North and East, Nottingham West and Rushcliffe Clinical Commissioning Group Patient Experience Team Complaints and Concerns Policy and Procedure Ratified V6 June 2013 Page 1 of 25

Patient Experience Team Complaints and Concerns Policy and Procedure Ratified version v6 June 2013 Title: Author/Nominated Lead: Approval Date: Approving Committee: Review Date: Target Audience: Circulation List: Complaints and Concerns Policy and Procedure Dr Cheryl Crocker, Director of Quality and Patient Safety June 2013 Quality and Risk Committee June 2014 All Staff and all members of the public who use, access or come in contact with any services provided or commissioned by The CCG All Staff Cross Reference: Risk Management Strategy and Policy, Persistent and Unreasonable complainants Policy, Incident Reporting Policy, Equality and Diversity Policy, Capability Policy and Procedure, Information Governance Policy, Complaints Procedure, Voicing Your Concerns Policy. Superseded Documents: Complaints and Concerns Policy and Procedure v5.5 Action Required: Contact Details: Version Control: 1.0 (Ratified version 6) Dr Cheryl Crocker Director of Quality & Patient Safety, Executive Nurse NHS Nottingham North & East Clinical Commissioning Group Byron Court Brookfield Gardens Brookfield Road Arnold Nottingham NG5 7EW Page 2 of 25

Contents Page Number Introduction 4 1 Scope 5 2 NHS England complaints 5 3 Equality and Human Rights Impact Statement 5 4 Definition 6 5 Policy Statement 6 6 What Complainants can expect from our Complaints process 7 7 Responsibilities and Accountabilities 7 8 Clinical Commissioning Group Policy principles 8 9 Who can complain 8 10 Complaints not covered by this policy 9 11 Conciliation and mediation 10 12 Joint Complaints 10 13 Advice, support and guidance 11 14 The Complaints Procedure 16 15 Learning from complaints and concerns 18 16 Related policies 18 Concerns Resolution Timescales Response Time According to Complexity Appendices A) Complaint/ concerns categorisation Grading matrix B) Formal Complaint - Front sheet C) Equality and Diversity Personal Data verification form 20 21 23 25 Note: This policy is written on behalf of three Clinical Commissioning Groups (CCG) collectively referred to within this document as The CCG. Page 3 of 25

Introduction The CCG is committed to providing a high quality and professional service at all times. However, it is recognised that there may be occasions when patients or their representatives feel that their expectations have not been met. The CCG takes a positive view of being informed of any concerns about any of our services. In return we will be open and honest, providing a full explanation and where appropriate we will take remedial action and will offer an apology. We will learn from complaints and incorporate that learning into our service improvement process in order to commission better services for all patients and the public. In receiving and handling complaints we will, as a minimum, comply with the Local Authority Social Services and National Health Service (NHS) Complaints (England) Regulations 2009 (hereafter referred to as the Regulations ) Principles of Good Complaint Handling (Parliamentary and Health Service Ombudsman, 2009) are outlined below and are our guiding principles: Getting it right Being customer focused Being open and accountable Acting fairly and proportionately Putting things right Seeking continuous improvement The CCG will make no distinction between complaints and concerns received in person, by telephone or in writing (including by email). Each will be reviewed and prioritised, to determine the level of action required. This may involve early contact with the person or organisation raising the issue, to ascertain their wishes, prior to being dealt with as a formal complaint through the complaints process or as a concern placed with the Patient Advice and Liaison Service (PALS). All complaints will be given a commitment that they will receive a formal response by a specified and agreed date. This will usually be 30 working days from receipt of the complainant s authorised consent. If a complaint is complex and/or involving a number of providers, to ensure a robust investigation it may be necessary to allow a longer investigation period. However we will always ensure the complainant is kept fully updated and receives a formal response to their complaint without undue or unreasonable delay. The CCG will ensure that no one is discriminated against as a result of them making a complaint or raising a concern. The Clinical Commissioning Group (CCG) recognises that suggestions and complaints provide valuable insights into services. Every person s experience counts. Therefore 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. In order to achieve this there are three steps to our policy: 1. Listening 2. Responding 3. Improving We will place equal emphasis on each of the three. We are aware that unless we listen our response will not address the key issues raised by the complainants and valuable Page 4 of 25

opportunities for improvement will be lost. Complaints and the outcome of the investigation will form part of our continuous quality improvement process. We also realise that many complaints involve a number of organisations. However the person making the complaint has one experience and wants to be assured that all departments and/or organisations have worked together to ensure that any changes are made in a consistent and sustainable way. Therefore when a complaint is received by us, unless it falls outside the scope of this policy (see below) we will ensure complainants receive a single response. Where the complaint relates predominantly to health concerns, if appropriate we will take a lead role in the investigation. 1. Scope This policy describes the CCGs approach to managing, monitoring and learning from complaints and concerns. This policy applies to all employees of the CCG and those that act in the capacity of employees. This policy does not include Any complaint which either wholly or in part relates to NHS primary care provision. This includes all NHS services provided by independent contractors such GPs, NHS Dentists, Pharmacies and NHS Optometrists. The complaints are the responsibility of NHS England see below Any complaint which relates to Public Health services, Military Health services, and healthcare provided to prisoners. The complaints are the responsibility of NHS England see below. The managing and monitoring and learning from untoward incidents, which is outlined in a separate policy. Staff complaints, grievances or Whistleblowing, which can all be found in separate policies. 2. NHS England complaints From 1 April 2013 responsibility for the investigation of primary care complaints, and those which relate to Public Health, Military Health and Offender Health now rests with NHS England (NHS Commissioning Board). These complaints should be sent to: NHS England PO Box 16738 REDDITCH B97 9PT england.contactus@nhs.net 3. Equality & Human Rights Impact Statement This policy embraces diversity, dignity and inclusion in line with human rights guidance. We recognise, acknowledge and value differences across all people. We will treat every person with respect, courtesy and with consideration for their individual backgrounds. We will ensure that everyone is treated fairly and that we convey equality of opportunity in service delivery and employment practice. 4. Definition Formal complaints may be received orally, in writing or by email from the patient or their representative. A written/email communication may indicate at the outset that a formal Page 5 of 25

complaint is being made. A complainant making an oral complaint may wish the issue to be dealt with formally or in a more informal way through the PALS Procedure, having had the choices explained to them. In line with complaint regulations, to be formally investigated a complaint must be in writing, and if a complaint requires assistance with this, we will ensure they are aware of organisations such as ICAS (Independent Complaints Advocacy Service) who will advocate on their behalf. A complaint may be made by: A patient or their representative Any person who is affected or likely to be affected by the action, omission or decision of the NHS which is the subject of the complaint. A complaint may be made by a representative in any case where a person has died, is a child or minor, is unable by means of physical/mental capacity to make the complaint themselves or has requested the representative to act on their behalf (written consent usually required from the patient in this case). The time limit for a complaint is usually: 12 months from the date the event happened, or 12 months from the date the patient or complainant first became aware of it. A complaint can only be investigated once under the Regulations. There is of course, nothing to prevent a complainant bringing a further complaint about a different incident. This policy will also apply to any complaint received from a Member of Parliament making/forwarding a complaint on a constituent s behalf. Historically, following receipt the complaints manager will liaise directly with the complainant unless they require all contact to be made via their MP. Concerns are a more informal way of raising an issue. They may be received orally, in writing or by email from the patient or their representative. These concerns should be resolved promptly without the need to resort to formal complaint. 5. Policy Statement The CCG staff will ensure that complaints are viewed in a positive way and used to identify any areas for service improvement. Communication with complainants will be open, fair, and conciliatory. All complainants will be treated courteously and sympathetically. An apology will be given whatever the content of the complaint in recognition of the concern caused to the complainant as well as for any shortfall in services experienced. We will work with health and social care colleagues to ensure that the person making the complaint receives one response which addresses all the issues raised and clearly sets out how any required changes will be made. Where changes are planned we will agree a timeframe by which we will update the complainant on the changes made. The complainant is entitled to seek external advice and support to ensure that their complaint is handled in line with national good practice and to refer their complaint to the Parliamentary and Health Service Ombudsman. 6. What Complainants Can Expect From Our Complaints Process Our policy has been developed to ensure that a consistent approach is undertaken with all complaints irrelevant of the issues raised. When a complaint is made the complainant can expect: Page 6 of 25

To be sent within three working days, an acknowledgement that the complaint has been received. To be asked for a consent form to be completed if they are not the person who has received the service. To be asked to complete a consent form if they are the person who has received the service, if the investigation of their complaint will require access to their patient records. An offer to discuss the complaint or concerns. To exercise choice as to which body leads on the handling of the complaint (subject to appropriateness and potential conflicts of interest) The member of staff dealing with the complaint will understand the complaints procedures and comply with this policy. An explanation of options relevant to the content of the complaint in order to ensure resolution which will take into account the complainants views and wishes. A plan (including timescales) for dealing with the complaint to be agreed with the complainant. To receive a written response explaining how the complaint has been resolved and what appropriate action has been taken. This will also include information on their right to refer their complaint to the Parliamentary and Health Service Ombudsman s (PHSO) should they remain dissatisfied. The CCG to uphold the rights set out in the NHS Constitution. To receive information on where support can be accessed such as the Independent Complaints Advocacy Service (ICAS). The offer of a conciliation meeting where there are difficult issues to be resolved Where the content of the complaint covers both health and social care issues we will work with social care colleagues to investigate and provide a single response. If the timescale is likely to be breached then the complainant will be kept informed. 7. Responsibilities and Accountabilities In order to fulfil our responsibilities the CCG Governing Body has nominated the following personnel to deliver the policy. Chief Officers/Chief Operating Officer Have overall responsibility for complaints and concerns. Responsibility for local resolution sign off of complaints is delegated to the Director of Quality and Patient Safety as detailed below. Director of Quality and Patient Safety Responsibility for complaints and concerns handling, for reviewing and signing complaints on behalf of the Chief Officer or Chief Operating Officer. Assistant Director of Quality and Patient Safety Responsibility for ensuring the implementation and delivery of the complaints and concerns process. Patient Experience Team Operational responsibility for the case management of each complaint/concern in line with the complaints and concerns process. Page 7 of 25

All Staff All members of staff will respond to a complaint/concern in a positive manner and comply with the policy and procedure on complaints/concerns handling. There is a duty to co-operate between Social Care and the Clinical Commissioning Groups, as well as all other healthcare providers, in order to co-ordinate one response to a complainant. 8. The CCG Policy Principles are Publicise the complaints and concerns procedure. Ensure complaints/concerns are dealt with efficiently and that investigations are appropriate to enable a response to the complainant and to identify areas for improvement. Ensure a robust procedure is in place in organisations that the CCG commission services from. This will be monitored via our Quality Scrutiny Groups. We will require the organisation to keep us informed at all stages of the investigation if there is a significant concern relating to patient safety. Where appropriate and practicable, ensure that a complainant s choice can be exercised with regard to the lead agency handling the complaint Implement procedures to ensure clarity of roles and responsibilities, including between health and health, and health and local authority organisations Implement a system for grading complaints. Implement a reporting process which enables the Governing Body to understand the issues raised and the improvements made from complaints/concerns. Produce an annual report on complaints/concerns in line with current legislation Provide training on complaints/concerns handling for teams as appropriate. Ensure collection and collation of Equality and Diversity data in line with local and national requirements. Maintain a record of each complaint or concern on the complaints/concerns database in line with current legislation. To complete the annual KO41 returns as required. Escalate any complaints or concerns which may have a safeguarding concern. Escalate any concerns regarding GP performance to the underperformance team. 9. 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 her/his behalf. Where people are unable to make a complaint themselves, the representative will need to have, or have had, sufficient interest in their welfare and be an appropriate person to act on their behalf. A complaint may be made by a person acting on behalf of a person as described above where that person: Page 8 of 25

o o o o 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. 10. Complaints not covered by this policy The Complaints Policy applies to complaints made by or on behalf of patients. The policy does not apply to: Complaints which either wholly or in part relate to NHS primary care provision. This includes all NHS services provided by independent contractors such GPs, NHS Dentists, Pharmacies and NHS Optometrists. Any complaint which relates to Public Health services, Military Health services, and healthcare provided to prisoners. Complaints made by patients relating to funding/commissioning arrangements unless their case has been considered via The CCG Commissioning Appeals Process Complaints about eligibility for NHS Continuing Health Care (CHC) funding, which are addressed via the CHC Disputes process. Complaints and grievances by members of staff relating to their contract of employment. Employees should raise such issues with their Line Manager or with the Director of Workforce and Corporate Services in accordance with the CCG and Collective Grievance and Disputes Procedure. Complaints by primary care practitioners that relate either to the exercise of the CCG functions or to the contract or arrangement under which the practitioner provides primary care services. Complaints made by any other organisation which are not made on the behalf of a patient. Complaints by an independent provider about contracts arranged by the CCG under its commissioning arrangements. Complaints about the non-disclosure of information requested under the Freedom of Information Act 2000 or the failure to comply with a data subject access request made under the Data Protection Act 1998. Applicants will have the right to appeal directly to the Information Commissioner s office. Complaints that are being/have been investigated by the Parliamentary and Health Service Ombudsman s (PHSO). Complaints which have already been investigated, or are currently under investigation by another health body. 11. Conciliation and mediation Independent mediation and conciliation arrangements can be made available on a case-by-case basis. Requests for intervention of this type will be reviewed and considered by the Director of Quality and Patient Safety. 12. Joint complaints 1.1 When a complaint received by the CCG (first body) also involves services commissioned or provided by another body (second body), or commissioned in partnership with another body we will work with other provider/s and commissioner(s) to co-ordinate the handling of the complaint, as per patient choice. This will apply to both health, and social care commissioners and providers. We will contact the complainant to discuss and agree how the complaint will be managed, including whether the patient would like their Page 9 of 25

complaint considered by the provider or commissioner; and ensure that a single response is provided. We will agree which of the two bodies should take the lead in: (i) Co-ordinating the handling of the complaint; and (ii) Communicating with the complainant; In order to provide to the other body information relevant to the consideration of the complaint which is reasonably requested by the other body; and to attend, or ensure it is represented at any meeting reasonably required in connection with the consideration of the complaint. A joint response will be agreed between respective Complaints Managers. A signed response will be issued to the complainant as agreed, reminding the complainant of their right to take the matter to the Health Service Ombudsman or Local Government Ombudsman if they are still unhappy. 1.2 Complaint that covers both health and social care issues On receipt of the complaint (written or oral), the Complaints Manager will acknowledge the complaint and seek consent for the sharing of information for the purposes of the complaints investigation only. The acknowledgement should explain that the organisations concerned will investigate and provide a single joint response and ensure the complainant is aware of advocacy agencies able to offer assistance. The lead agency will be determined by the health and social care agencies, and/or in accordance with the complainant s preferences as far as appropriate. Upon receipt of consent, the Patient Experience Team will action as per 12.1. This information will be communicated to the complainant, including contact details. 1.3 Complainant s consent to the sharing of information between agencies Nothing in this protocol removes the obligation to ensure that information relating to individual service users and patients is protected in line with the requirements of the Data Protection Act, Caldicott principles and the confidentiality policies of each signatory organisation. It is for this reason that the complainant s consent must always be sought before information relating to the complaint is passed between organisations. Moreover, the complainant is entitled to a full explanation of why his/her consent is being sought and the information shared should be treated with respect and in confidence. Consent to the passing on or sharing of information under this protocol should be obtained, in writing, wherever possible. Where this is not possible, the complainant s verbal consent should be recorded and logged and acknowledgement forwarded to the complainant. If the complainant withholds consent to the complaint being passed to the other organisation, the Complaints Manager of the organisation receiving the complaint will seek to engage with him/her to resolve any issues or concerns about remit and responsibility and offer any liaison which could contribute to the resolution of the matter of concern. The complainant should be reminded of his/her entitlement to contact the other organisation direct. Page 10 of 25

The only circumstances in which a complainant s lack of consent could be overridden would arise if the complaint included information which needed to be passed on in accordance with Safeguarding Children, Protection of Vulnerable Adults procedures or any criminal activity. The Lead Partner will ensure that all complaints records are stored and disposed of; in compliance with the Data Protection procedures. 13. Advice, support and guidance In the South CCs the Patient Advice & Liaison Service (PALS) has now been incorporated into the Patient Experience Team (PET); however the team continues to offer support and guidance to patients, carers and their families throughout their contact with the NHS. For the North CCGs the PALS service has remained unchanged. In the South the Patient Experience Team is committed to providing a service that is responsive to the needs, priorities, preferences and experiences of patients, carers and members of the public offering an effective and seamless approach. The PET ensures that health services are more open to patients, carers and family s needs and that patient experience feedback leads to service improvement. The CCG will work to these standards and protocols when dealing with enquiries and issues raised by patients and the public. The PET service will ensure that this is done by challenging: Discrimination Promote equality of access and quality of service. Support the provision of service appropriate to individual needs, preference and choice. Respect and protect Human Rights. Further the NHS reputation as a model service. Enable NHS organisations to contribute to economic success and community cohesion. The PET will be accessible to everyone. The PET will be seamless across health. The PET will be sensitive and responsive and provide a service to meet individual needs. The PET will be effective and the learning from the PET will inform service improvement and development. The PET will be accountable and have systems that make their findings known as part of routine monitoring. The PET will be proactive and will actively seek the views of service users, carers and the public. The PET will be educative and the learning from concerns will influence design and delivery and training. The PET will evaluate its impact for the CCG, patients and the public. The PET is often the first point of contact for residents who live in Nottinghamshire. It aims to:- Provide confidential advice and support to patients, carers and families that meet individual needs. Help resolve any problems or difficulties patient carers and their families may be experiencing with local NHS services. Page 11 of 25

Provide information and advice on local health services on subjects such as location of a GP or Dentist. Listen to patient and public opinions about local health services in order to improve them. Signpost to other services e.g. Social Services departments or support agencies. Provide advice and guidance to patients and public in regard to the Complaints Procedure. Provide training to NHS staff e.g. Induction training and Customer Care Training. Act as an early warning resource for the CCG and Patient and Public Involvement Forums by monitoring trends and gaps in services and reporting these to the CCG management The PET will act independently when handling patient and family concerns, liaising with staff, managers and (where appropriate) relevant organisations, to negotiate immediate solutions and to help bring about changes to the way that services are delivered. If necessary, PET officers can also refer patients and families to local or national based support agencies. The PET does not aim to reduce complaints to the CCG, but to work with the patient, carers and the public to obtain the best outcome for them and to ensure the CCG learn from patient experience. As a result of early intervention, the PET does, however, expect to reduce the number of issues that escalate to more serious problems. It is the choice of the individual to use either the CCG complaints procedure or approach the PET Officer and there is no requirement for service users to use the PET before they can make a formal complaint. 13.1 Objectives and main function of the PET To provide a formalised system by which patients, their families and carers can raise concerns and have issues addressed. To maintain and manage seamless relationships with all health, social care and voluntary organisations where appropriate. To develop and maintain effective links with Senior Management in all respective organisations. To ensure the aims of the PET are clearly communicated to users, their families, carers and providers of health, social, voluntary and other statutory services. To promote the active involvement of service users and carers in shaping health, social care and voluntary services to ensure continuous improvement of service provision. To ensure that users, their families and carers are signposted to formal complaints processes as appropriate. To promote the development of integrated services ensuring that when users, their families and carers interface with other service providers this happens effectively and efficiently. To enable organisational learning by identifying underlying themes raised through the patient s experience. Operational Guidance has been developed to provide guidelines about the overall structure and provision of the PET, the operational guidance is underpinned by protocols covering: Confidentiality Informed Consent Data Protection Page 12 of 25

Freedom of Information Difficult and Complex Calls 13.2 Provision of the PET Service The PET should be visible across the organisation and easy to access, and should not be seen as a separate service but an embedded service within the culture of the organisation. Referrals can be made to the designated PET Officer if: Every effort has been made to resolve issues locally (with help from the Head Nurse/Matron or Practice Manager/Service/Department Lead if necessary) and this has been unsuccessful. The user wishes to speak to someone independent of the department/service concerned. The issues are complex and require liaison between different services and departments. The user requires information that is not available from the different services or departments. The Patient Experience Team may be accessed directly by: 13.3 Access Talking to any NHS staff member Telephoning the PET office By writing to or emailing the PET office The PET offers a core service available between the hours of 9.00 am 5.00 pm Monday to Friday (excluding public holidays) and can be contacted by Freephone telephone, minicom, letter, fax, email, or CCG website. Patients and members of the public can self-refer to the PET by telephoning the service direct (0800 028 3693) or a staff member can contact PET on the patients behalf (with their consent) and ask the PET Officer to contact the patient. Out of hours service is provided by an answer-phone and calls returned within 48 hours. Contact can also be made with the PET via what is still identified as the PALS answerphone, email, or fax. 13.4 Equal Access for All The CCGs are required by the Disability Discrimination Act 1995, Section 21, and the CCGs Equality and Diversity Strategy 2005 to provide a service that is accessible to all service users. Monitoring the age, sex and ethnic group and disability of people contacting PALS will enable a profile to be built up and initiatives planned to redress any under representation. 13.5 What is a PET issue? The PET will seek to offer advice to people who have issue(s) in order to find a resolution and will act as quickly as possible to deal with issue(s) before they escalate. Page 13 of 25

The PET will help people to talk through their issues so that they can identify the nature of the problem and work out various options for resolution, including use of the formal complaints procedure. The PET will respond where a user of a service has identified that a service did not meet their needs, because of (for example) all of any of the following: - Breakdown in communication. Appropriate information is not available. Service is not available, accessible or appropriate. Staff attitude. 13.6 Concerns and Complaints Interface PET work is identified as a separate process from the complaints process and does not replace the formal complaints procedure or restrict patient or carers rights to access it. The PET is: Keen to encourage local resolution of concerns, issues or complaints in the first instance. Separate from the complaints procedure within the CCGs. About providing information about the rights and options available to people who want to complain. Available to help and support people to understand and negotiate the complaints procedure. Able to direct complainants to the NHS Independent complaints advocacy s service POhWER. The PET is not: About investigating complaints. To be used by complainants to pursue a complaint once the complaints process has been initiated or exhausted. About investigating allegations of assault or incidents. A procedure for dealing with concerns that are initially framed as a complaint. PET will not: Give medical advice in any circumstances and will be clear in all publications and public dealings that the service is not staffed by medically trained personnel. Make recommendations regarding comparative treatments or services. If information is sought and advice requested about services or treatments, it will be clear that the PET does not endorse any of the potential options provided as information. A referral protocol has been developed to support the PET to deliver a service that ensures: Consistency of approach. A timely and effective response from other agencies. That the enquirer is kept informed of the progress of their enquiry by the most appropriate PET Officer throughout. Difficulties are highlighted for action in partner agencies or organisations. Page 14 of 25

13.7 Referral Protocol In accessing NHS services, people do not necessarily recognise the geographical and other boundaries between primary, secondary and social care services. Issues and concerns can relate to more than one area of health and social care. The following protocol aims to ensure consistency of approach and timely and effective response from other agencies. Referrals to other services Client aims and boundaries of concerns will be clarified. Option of self-referral and direct client contact with other services will be explained and supported where feasible. Method of referral (e.g. by phone/letter/fax etc.) will be explained and agreed. Standards set out in PET confidentiality protocol for communication of information will be followed. Copies of any written or emailed communication on behalf of the client will normally be made available to them. For other referrals which are not in written form the PET will make sure that the client is informed of the named person to whom the referral has been made, the anticipated time-scale for response (if known) and contact details for the service and individual referred to. The PET may signpost clients to other services; however, this does not constitute a referral. The PET will offer the option for clients to contact the PET again if there is unexpected delay or difficulty in following up the referral made. If the PET receives an enquiry from a person asking for specific information regarding a health condition, they have the option to ring NHS Direct on that persons behalf. The PET Officer will need to explain that the referral will be made to the enquirer and provide compulsory person details, including name, date of birth, address, telephone number and a brief description of the enquiry. The PET Officer will make it clear to the enquirer that an NHS Direct Health Advisor will be calling them back on the phone number they gave in order that the enquiry can be more fully explored. Referrals from other services The PET will acknowledge (to referrer and client if appropriate) receipt within 2 working days if appropriate. The PET will ensure that the referrer and client understand the PET role and boundaries (e.g. interface with complaint procedures). The PET will check that the referrer has client consent both for general referral to the PET and more specifically for the personal information, which is to be shared. PET Officers will try to avoid duplication of requests for consent where possible. For referrals, which are inappropriate the PET will feedback and explain to the client and referrer and signpost to alternative sources of help if that is needed. Referral to and from other PET and PALS services The initially contacted the PET team will advise the receiving PET or PALS team as quickly as possible: By telephone if referral is urgent and can be explained briefly. Page 15 of 25

By email if unavailable by phone. Emails will be marked confidential in the title and password protected and in line with CCG policies to avoid identifiable information where possible. By post marked private and confidential. By safehaven fax. Receiving PET or PALS will acknowledge receipt of the referral. Cases involving the PET or PALS services in more than one NHS organisation To ease the client journey and provide a seamless service one PET or PALS contact will co-ordinate the responses to the client or will agree transfer of coordinating responsibility with the client and another PET or PALS service if that is more appropriate. If the PET Officer needs to contact staff in another NHS organisation this should be discussed with the PET or PALS service in that organisation in advance where possible. 14. Complaints Procedure 14.1 Listening Complaint received - verbally / written/ face to face Complaint recorded and file opened ( electronic and paper Appendix B) Contact made with most complainants to gain more detail from them if required. For complaints which fall outside the scope of this policy once consent is received the complaint will be directed to the appropriate agency who will liaise directly with the complainant. For all complaints which fall within the scope of this policy, where the complaint involves services provided or commissioned by another body or partner (including social care), the patient will be provided with a choice regarding who should lead on the complaint. Lead agency determined in accordance with complainant s preference as far as appropriate and practicable Complaint Graded ( see Appendix A) Timescale for investigation and response to complainant determined and complainant advised Acknowledgement letter sent to complainant ( within 3 days) Consent is requested to proceed with investigation as necessary. 14.2 Consent and confidentiality Written consent will always be sought from the patient before a complaints investigation is undertaken. Likewise, if a complaint needs to be re-directed to another service to respond directly to the complainant, written consent will be obtained before this can occur. If a complaint is made regarding our organisation, and it is not necessary to contact any external organisations in order to provide a full response, written consent is not required. The complaints letter or verbal complaint form will be treated as express consent for us to start an investigation. In the case of a child, the representative must be a parent, guardian or other adult person who has care of the child, in cases where the child is in the care of a local Page 16 of 25

authority or a voluntary organisation, the representative must be a person authorised by the local authority or voluntary organisation. All information in relation to a complaint will be handled in accordance with the Data Protection Act 1998. 14.3 Responding Each case will be investigated and managed by a manager, who for the purposes of the investigation will be referred to as the Complaints Manager. Responsibility for the investigation will be determined by the location of the provider implicated, or where the patient lives (whichever is appropriate), except where a complaint relates to secondary care when responsibility will be determined by the proportional significance of the concerns raised. Where the concerns relating to secondary care are significant case responsibility will be determined by the preexisting lead accountabilities of the CCG. The investigation will commence once all pertinent information is received, complaint issues clarified and (where appropriate) consent is received. The Complaints Manager will contact specific providers and/or commissioning managers, requesting information, records and a full explanation/outline which addresses all concerns and questions highlighted by the complaint This stage can be prolonged and may include phone calls/ interviews/ note reviews - whatever is required to effectively address the complaint. When the concerns highlighted by the complaint are significant, if appropriate the Complaints Manager will request full review of all documents by an independent clinician usually a CCG Clinical Lead. When all the information has been collated and the investigation is complete whenever possible a formal response letter will be sent to the complainant within the agreed timescale. If a robust investigation cannot be completed within the timescale the complainant will be kept updated. The complainant will receive a formal response letter signed by the Director of Quality and Patient Safety on behalf of the Chief Operating Officer/Chief Accountable Officer of the CCG in which the patient lives. 14.4 Improving Where appropriate or necessary we will support providers to learn from complaints handling. When a complaint has highlighted the need for service improvements, actions to achieve those improvements will be identified and agreed with the provider and/or commissioning team. The findings and outcomes of complaints will be monitored by the Quality teams and reviewed at the Learning Review Group. 14.5 Closure of Complaints Each Response Letter will provide information about how to contact the Ombudsman if the complainant remains dissatisfied with the outcome of the complaint investigation and /or the handling of the complaint by the CCG. Local Resolution meetings will be offered when a complainant remains dissatisfied When a case is closed the case review documentation will be completed (see Appendix B) and databases will be updated to ensure accurate and full records are maintained. Page 17 of 25

In the event that all the investigating partners of a complaint are unable to mutually agree the resolution of a complaint, or are unable to unanimously agree a way forward in expediting the resolution of a complaint, the complaint will then be escalated to the next tier of management (line manager, head of a service or director) for arbitration and/or conflict resolution. If again, at this higher level of complaints management a unanimously agreed resolution cannot be achieved then the complaint will be escalated again until this can be achieved. 15. Learning from Complaints and Concerns Key learning from complaints and concerns will be identified at the Learning Review Group, a formal sub-committee of the joint Quality and Risk Committee, and shared across the CCG via a Quality Newsletter. This will facilitate dissemination of best practice and promote service improvement. Arrangements will made to share best practice between health and social care partners as appropriate. Learning will also be sough via the use of the patient s story, with the Governing Body of each CCG being provided each month with a summary outline of a real patient experience. Patient stories will be provided in written format or by the patient themselves or their representative. A regular report on complaints handling is received by the Quality and Risk Committee and the Governing Body. An Annual Complaints Report will be produced on the handling and considering of complaint. A copy will be shared with the Health and Wellbeing Board, Healthwatch and social care partners in order to disseminate learning. In line with Francis recommendations with permission, patient complaints will also be publicised on CCG websites. 16. Related Policies There are a number of policies and procedures which may be useful to read in conjunction with this policy: Equality and Diversity Policy Quality Strategy incorporating the Patient Experience Strategy Voicing Your Concerns (Whistleblowing) Policy Integrated Risk Management Framework Incident Reporting Policy Capability Policy and Procedure Information Governance Policy Risk Matrix Equality Impact Assessment Page 18 of 25

Concerns Resolution Timescales Response Time According to Complexity ENQUIRY RECEIVED BY PET OFFICER Enquiry is clear and easily addressed Simple enquiry, resolved on the spot or with little research Respond within 2 working days Enquiry is clear and easily addressed Simple enquiry relating to one service only Resolve within limited amount of research Requirement for limited specialist input Respond within 5 working days Enquiry raises two or three issues Enquiry may refer to more than one NHS organisation Enquiry can only be resolved via investigation led by service manager/head Initial contact indicates need for a meeting or liaison between person raising enquiry and service involved Respond within 10 working days Page 19 of 25

Appendix A - COMPLAINT / CONCERN CATEGORISATION MATRIX Introduction This matrix has been developed in line with the NHS Nottinghamshire County PCT and CCG s Risk Matrix Serious Incidents (SI) process. The categorisation of complaints and concerns relates to the level of risk that is presented at the outset. Risk levels may be escalated or deescalated during the investigation process as more facts emerge. Category Description Action/Investigation Initial Target for responses Catastrophic 5 Acknowledge within 3 working days - if possible via telephone. If complaint/concern alleges one or more of the following: Results in serious injury, major permanent harm or death; Involves the suspension of a member of staff for reasons associated with their clinical practice and/or Safeguarding. Involves adverse impact upon delivery of service plans and/or serious breach of standards or quality of care; Confirmed transmission of a serious infectious disease between staff and patient; Involves fraud or suspected fraud Caused major breach of patient confidentiality; Has the potential to cause significant damage to the reputation of the organisation or a member of staff Inform the Director of Quality and Patient Safety In case of safeguarding concerns contact MASH 40 working days Major 4 If complaint/concern alleges one or more of the following: Complaints with clear quality assurance or risk management implications Significant issues of standards, quality of care or Inform the Director of Quality and Patient Safety. Acknowledge within 3 working 30 working days Page 20 of 25

denial of rights Professional general misconduct or negligence causing non-permanent injury or illness Possibility of litigation Physical abuse/assault by staff. days In case of safeguarding concerns contact MASH Moderate 3 If complaint/concern alleges one or more of the following: Verbal abuse or discriminatory action by staff Professional misconduct or negligence causing minor injury or illness Acknowledge within 3 working days In case of safeguarding concerns contact MASH 30 working days Minor 2 If complaint/concern alleges one or more of the following: Inappropriate comments/unprofessional conduct by staff causing distress Minimal impact and relative minimal risk to the provision of healthcare or the organisation. Inappropriate clinical care causing distress Acknowledge within 3 working days In case of safeguarding concerns contact MASH 30 working days Negligible 1 If complaint/concern meets one or more of the following: No impact or risk to provision of healthcare: Dissatisfaction or unhappiness with staff attitude Inappropriate driving with no consequences Unprofessional behaviour with no consequences Acknowledgement may be made verbally (make file note) Gather information and facts to determine appropriate level of risk prior to responding back to complainant. 30 working days Inform complainant of outcome Page 21 of 25

Formal Complaint Quality & Patient Safety Team Section A: To be completed on receipt of Formal Complaint by admin Date Received Complainant Name Telephone Contact Correspondence Address Patient Name Relationship to patient ICAS Advocate How received Themes Acknowledgement Date Brief summary of complaint: Service under investigation Service/Independent Contractor Secondary Care provider Patients CCG Investigating Officer Consent required Consent received Date of request: Deceased? Section B: To be completed by the Investigating Officer Contact made with complainant: Form of contact Response timescale: 25/30/40/50/60 Initial grading: Catastrophic Major Moderate Minor (delete) Key concerns 1. 2. 3. 4. Desired outcomes 1. 2. 3. Investigation request sent Provider response due Secondary care response due PCT response due Final response due Delay (days) Reasons for delay Delay letter sent (date) Final response sent Page 22 of 25

Investigation Officer s Record Chronology: Date Action/Event Page 23 of 25

Investigation outcomes: Lessons learned: Service Improvements/ Actions required: WHAT NAME & ORGANISATION DATE Sign Off (include dates) Date response sent to CO/ AO for signing Chief Officer / Accountable Officer to sign Date response signed by CO/AO name / date FORMAL RESPONSE SENT Date for closure Final risk grading Complaint upheld Complaint closed Catastrophic Major Moderate Minor (delete) YES/NO Page 24 of 25

Appendix C Personal data verification form NHS Nottinghamshire County PCT and Nottinghamshire Clinical Commissioning Groups place equality, diversity and human rights at the centre of organisational cultures. The organisations are committed to commissioning services that are of the highest quality and appropriate to its growing, diverse population. Please help us understand whether this service is compliant with Equality legislation in being fully inclusive and accessible, by completing this short form and returning it to your service provider. Please tick those that apply. 1 Gender Male Other (gender identity) Female I do not wish to disclose 2 Ethnic background Asian or Asian British Mixed H Indian D Mixed White & Black Caribbean J Pakistani E Mixed White & Black African K Bangladeshi F Mixed White & Asian L Any other Asian background G Any other mixed background White Black or Black British A British M Caribbean B Irish N African C Any other white background P Any other Black Background Other Ethnic Group R Chinese Z I do not wish to disclose S Any other ethnic group 3 Disability Learning disability/difficulty Mental Health Condition Sensory impairment I do not wish to disclose Long Standing illness Physical impairment Other Page 25 of 25