POLICY AND PROCEDURE FOR MANAGING COMPLAINTS, COMMENTS, CONCERNS AND COMPLIMENTS

TITLE: POLICY AND PROCEDURE FOR MANAGING COMPLAINTS, COMMENTS, CONCERNS AND COMPLIMENTS VALID FROM: January 2014 EXPIRES: January 2016 This procedural document supersedes the previous procedural document (Policy and Procedures for Managing Complaints, Comments, Concerns and Compliments December 2010- December 2013)

Version: 1.0 Policy reference and description of where held. Title, name and contact details for author: Responsible director: Approved by originating committee, executive or departmental management group TBC Tony Fishenden Customer Service Manager tony.fishenden@clch.nhs.uk Louise Ashley, Chief Nurse & Director of Quality Governance TBC Ratified by Policy Ratification Group Review date: June 2016 Target audience: All staff working for or on behalf of the Organisation and includes those staff on honorary contracts, contractors/ agency workers and students. Page 2 of 72

CONTENTS: Section Page 1. Introduction 2. Aims and objectives 3. Definitions (explanation) of terms used. 4. Duties 5. Managing Complaints, Comments, Concerns and Compliments 6. Consultation 7. Approval and ratification process 8. Dissemination and implementation 9. Archiving 10. Training 11. Monitoring and auditing compliance with this procedural document 12. Review arrangements 13. Associated documentation 14. References 15 Appendices Appendix A Appendix B Appendix C Monitoring and compliance tool Equality Impact Assessment Management of complaints flow chart Appendix D Management of complaints for partner organizations flowchart Appendix E Management of complaints for partner organizations where CLHC is not the lead partner Appendix F Complaint investigation report form Appendix G Guidance for staff writing a statement Appendix H Guidance for meetings with complainants Appendix I Appendix J Appendix K Appendix L Acknowledgement letter template Letter of findings template Management of compliments flow chart Unreasonable and persistent complainants Page 3 of 72

Section Page 15. Appendices contd. Appendix M Consent / Authority form Appendix N Customer Service Feedback Appendix O Customer Service Feedback Easy read leaflet Appendix P Appendix Q Appendix R Customer Service Satisfaction Questionnaire Equality monitoring form Complaint Severity Assessment Matrix Page 4 of 72

1. Introduction This Policy is Trust-wide, and integrates the capturing of comments, concerns and compliments as well as the formal complaints process. Central London Community Healthcare NHS Trust (CLCH) has a responsibility to ensure that users of the services provided by the Trust have easy access to information about how to raise a concern or make a complaint and that the issues are responded to promptly, fairly and justly without prejudice to the care and treatment of the service user. CLCH accepts that in a service as large and complex as the NHS, things will sometimes go wrong. When they do, the response should not be one of blame and retribution, but of learning, a drive to reduce risk for future patients, and concern for staff who may suffer as a consequence. CLCH promotes good complaint handling because it is an important way of ensuring customers receive the service they are entitled to expect. CLCH also understand that complaints are a valuable source of feedback, provide an audit trail and can be an early warning of trends in failures of service delivery. CLCH is also aware that prompt and efficient complaints handling can also save time and money by preventing a complaint from escalating unnecessarily. 2. Aims and Objectives CLCH believes everyone has the right to expect a good service and to have things put right if they go wrong. When they do, CLCH aims to manage complaints properly so customers concerns are dealt with appropriately and without unnecessary delay. Specifically this policy aims to Set forth CLCH s approach to receiving, acknowledging, investigating and closing complaints received from the users of CLCH services. Describe the support provided to complainants. The policy also aims to ensure that the complaints procedure can be accessed on a fair and equal basis by all patients and carers regardless of their race, language, culture, disability, religion or belief, age, gender, sexual orientation or marital status. The policy aims to ensure that any barriers faced by complainants are minimized when using the complaints process. The policy aims to ensure that CLCH, as a provider of health services, manages complaints in accordance with both the NHS Complaints Procedure 2000 and the NHS Constitution (See also paragraph 14 references). This explains how patients or service users when making a complaint, have the following rights: Page 5 of 72

o o o o o o to have their complaint acknowledged and properly investigated to discuss the manner in which the complaint is to be handled and know the period of when the complaint response will be sent to be kept informed of the progress and to know the outcome including an explanation of the conclusions and confirmation that any action needed has been taken on to take their complaint to the independent Parliamentary and Health Service Ombudsman if they are not satisfied with the way the NHS has dealt with their complaint to make a claim for judicial review if they believe they have been directly affected by an unlawful act or decision of an NHS body to receive compensation if they have been harmed by negligent treatment 3. Definitions of any terms used Complaint: A complaint is defined as an expression of dissatisfaction received verbally or in writing that requires a response. All complaints require Investigating, requiring someone to explore the situation on behalf of the complainant and responded to. CLCH will seek to distinguish between requests for assistance in resolving a concern or problem and an actual complaint. All issues will be dealt with in a flexible manner, which is appropriate to their nature. Whenever there is a specific statement of intent on the part of the caller/correspondent that they wish their concerns to be dealt with as a complaint, they will be treated as such. Concerns: These are issues that are of interest or importance affecting the person raising them. Concerns will be registered locally but will not require a full investigation because the issues can be resolved quickly either via clarification with the person (such as meeting talking or explaining) or by immediate action (offering alternative appointments, agreeing further action). It is not intended that every minor concern should warrant a full-scale complaints investigation. The spirit of the complaints procedure is that front-line staff are empowered to resolve minor problems and queries immediately and informally whenever this is possible. Any person, who is dissatisfied with the preliminary response to a matter which has been dealt with outside of the complaints process, will be advised of their right to pursue the matter through the complaints procedure and offered support through independent advocacy. In the following circumstances, concerns received by staff must be passed within 1 working day to the Customer Service Team for the opportunity to make the matter a formal complaint: Page 6 of 72

If the person who has raised the issue verbally requests their complaint to be treated formally. Concerns received in writing which expressly state that they wish to complain or make a complaint Concerns that are risk graded as moderate or higher Concerns that require a written response. If it is unclear whether the issue is a complaint or not advice, must be sought from the Customer Service Team to establish this with the service user or their representative. Compliments: These are where positive feedback has been received about HRCH services. CLIPS group: Complaints, Litigation, Incidents, PALS, Serious Incidents meeting. 4 Duties 4.1 All staff working for/ on behalf of CLCH have the following responsibilities for ensuring that: As highlighted in Legislation, Professional Codes of Conduct and the Organisation s Whistle Blowing Policy, all staff have a duty to report complaints & co-operate in investigative processes. To be aware of the requirements of this policy and can understand its requirements. Staff must consult their line manager if they have difficulty following this guidance or have concerns about their ability to report and/ or co-operate with the complaints process. Where any doubt exists about what constitutes a complaint, staff are encouraged to contact the Customer Service team. They try to deal with minor complaints or concerns they may receive locally, where practical and if skilled to do so. A member of staff who is unsure of how to respond to a complaint should immediately seek help from their line manager or the Customer Service Team. In line with statutory & professional responsibilities, co-operate with complaint investigation processes. These duties also extend to the timely and appropriate writing of investigation reports and raising of risks to CLCH s risk registers for monitoring progress towards minimisation. Staff based within external organisations but employed or working on behalf of CLCH have a duty to comply with the complaints processes of the host organisation. If staff employed under these conditions do not have access to the Datix system, then details of the complaint must also Page 7 of 72

be reported to CLCH by email or by telephone to the Customer Service Team for capture on Datix system. Any staff who require clarification of this condition must contact the Customer Service Team. 4.2 All Managers Managers have the following responsibilities for ensuring that: Reporting Investigating They are aware of the requirements of this policy and can understand their role in identifying, reporting, investigating & following- up complaints. All complaints received within services are reported via the Datix system to the Customer Service Team. Conduct a thorough investigation of the complaint. Complete the investigation within the agreed timescale. Produce an investigation report. Ensure the outcome of the investigation highlights any learning as a result of the complaint and improvement actions required as a result of the complaint. Required changes to practice will be identified and actioned within a specific time frame. A lead member of the team will be identified to take each change forward where appropriate. Lessons will be shared with all the relevant stakeholders. Manage implementation of any improvement actions resulting from learning, and provide timely feedback to the service and the Customer Service Team. Organise a deputy when unavailable Communicating The employing agency is informed of complaints involving temporary workers at the time of complaint identification. All relevant leads associated with the complaint are informed. The Customer Service Manager is kept informed of investigation progress. The results of risk assessments is communicated to all those who may be at risk in line with the Organisations Risk Management Strategy. The complainant must be kept informed about progress and, where appropriate, a written response sent by the manager explaining the Page 8 of 72

Supporting staff outcome and including any necessary remedial action taken as a result of the complaint. The Organisation recognises that staff may be adversely affected by complaints- regardless of their involvement in the event or the risk grading/ severity. Staff experiencing distress are encouraged to discuss their concerns with line managers, the occupational health team and counselling services provided by CLCH. Discussions with the above groups will be held in confidence. Incident management debriefings/ supervision may also be provided by the Organisation s specialist staff. When a complaint is graded as moderate or above and involves members of staff, support should be provided to the staff concerned by Human Resources and the investigating managers. Ensure that staff are adequately trained, supervised and supported to deal with complaints effectively. The investigating manager will ensure that witness statements/ statements of involvement are obtained from staff involved or witness to accidents/ incidents. The investigating manager will ensure feedback is provided to staff involved in complaints. The incident reporter and Customer Service Team are kept informed of any progress. Managing Risk All documents are managed in accordance with the Organisation s Records Management Policy and Clinical Record Keeping Standards. All relevant actions are undertaken following the complaint. Identified risks are added to the relevant risk registers in line with the CLCH Risk Management Policy 4.3 Customer Services Team Complaints and concerns can also be established through the Customer Service Team. Its responsibilities include: Helping resolve concerns or problems when using the NHS Providing information about the NHS complaints procedure and how to get independent help if it is decided to make a complaint Page 9 of 72

Providing information and help introduce agencies and support groups outside the NHS Improve the our services by listening to complaints, concerns, suggestions and experiences and ensuring that people who design and manage services are aware of the issues raised Provide an early warning system for the Trust and monitoring bodies by identifying problems or gaps in services and reporting the Provide advice, training and support to individuals or teams as required. 4.4 The Customer Service Manager Is accountable to the Head of Patient and Public Engagement and is responsible for the day to day management and facilitation of the complaints service. The Customer Service Manager is also responsible for providing statistical information on trends and types of complaints for submission to the appropriate committee or group to assist in the decision making process. The Customer Service Manager will: Monitor and supervise the informal process of responding to concerns and any low risk-grade complaints that the enquirer agrees can be resolved through this route. Line manage the Customer Service Team to ensure the service is identifiable and accessible, providing information, advice and a first point of contact for those who have queries about or are unhappy and wish to raise concerns and complaints about Trust services. Provide training, support and advice to staff regarding the process for the investigation and management of concerns or complaints. Ensure feedback is provided to staff involved in complaints Ensure that on-the-spot help is provided to service users and, where possible, will negotiate immediate solutions or speedy resolution of problems where possible so that concerns do not escalate Identify those issues that require a formal complaint investigation and comply with the complaints procedure (unless the person raising the concern explicitly requests that they do not do so) Ensure service users are sign-posted to appropriate independent advice and advocacy support from local and national sources Be mindful of the need to offer complainants any additional support or reasonable adjustments to meet disability-related or other support needs and to deal with any barriers arising from language or culture Page 10 of 72

Produce data for reports as required helping identify trends from complaints, comments, concerns and feedback. Ensure that the Customer Service Team assist the Learning and Development team on complaints training for staff and lead on staff inductions. 4.5 Customer Service Officer The Customer Service Officer is accountable to the Customer Service Manager. Their role is to provide advice, support and information to users of the service. They help to resolve any concerns about Trust services where appropriate. They provide information and support to those who need help to make a formal complaint. The Customer Service Officer duties are:. To receive, log and respond to complaints, comments, concerns and compliments about Trust services. To facilitate the speedy resolution of concerns by listening, providing information, liaising and negotiating with staff colleagues as appropriate. To identify issues requiring a formal investigation and support service users to access the formal complaint process (unless they explicitly request that they do not wish to make a formal complaint). To provide information to patients in alternative formats as required; including an easy-read guide for people with learning disabilities and in other formats/languages as appropriate 4.6 Directors and Associate Directors Directorate leads have the following responsibilities: For ensuring the timely and effective investigation and resolution of complaints that fall within their areas of responsibility and for ensuring that the procedures outlined in this policy are followed within their directorate. Making suitable arrangements to assure both the investigation process and the outcome, and approve the directorate report provided to the Customer Service Manager. 4.7 Chief Nurse and Director of Quality Governance The Chief Nurse and Director of Quality Governance is charged with overseeing the Trust s systems for quality, safety & effectiveness and is responsible for reviewing and approving the investigation and final response letter prior to sign off by the Chief Executive. Page 11 of 72

4.8 Medical Director The Medical Director will review and approve those investigations and final response letters where the complaint is regarding clinical treatment and/or involve a medical doctor prior to sign off by the Chief Executive. 4.9 Chief Executive The Chief Executive retains accountability of the quality, safety & effectiveness of services provided on behalf of CLCH to staff and service users and is responsible for ensuring that: This policy is implemented within CLCH Reviewing & signing the final response letter wherever possible. 4.10 CLCH Board The Board has a duty to ensure that the requirements of the complaints policy are upheld. The Board will receive a complaints report at least quarterly. The Board will also receive the annual complaints report that the Trust is required to prepare in accordance with Regulation 18 of the Local Authority Social Services and National Health Service Complaints Regulations. 4.11 CLIPS (Complaints, Litigation, Incidents, PALS and Serious Incidents) Group The CLIPS Group has been established to provide a dedicated forum for CLCH to share lessons learned following investigation into all significant complaints, legal claims, adverse incidents, near misses or PALS concerns arising from the activities of CLCH and partnerships, thereby improving risk management and service delivery 4.12 Quality Committee The Quality Committee will be provided with the annual complaint report prior to its submission to the Trust Board. Page 12 of 72

5. Management of Complaints, Comments, Concerns & Compliments. A. Complaints 5.1 Who can complain? A complaint may 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. Complaints can be made by health care and social care professionals on behalf of patients, their carers and relatives. 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: Has died Is a child Is unable by reason of physical or mental incapacity to make the complaint Has requested that a representative act on his/her behalf. 5.2 How a complaint can be made Complaints can be made to any employee of CLCH, or to any member of staff who provides a service commissioned by CLCH. Complaints can be via a third party. For example there are a number of independent groups and bodies that can provide helpful advice and support to a complainant, dependent upon their individual needs. Complaints can be made verbally or in writing (including electronic means such fax, e-mail, telephone or via the CLCH website). Complaints may also be received via Customer Service Feedback Forms which are widely available at Trust sites. All complaints will be forwarded to Customer Service Manager. In accordance with regulations, complaints made by other health and social care professionals (from a responsible body, commissioners, a local authority, NHS body, primary care provider or independent provider) falls outside of the NHS complaints procedure. The Customer Service team will help to produce any written responses to external organisations as necessary. These complaints will be recorded and Page 13 of 72

investigated in the same way as a formal complaint but logged as an Organisation or Commissioner complaint as appropriate. 5.3 Exceptions to the complaints process A definition of what is excluded from this policy is set out in the Statutory Instrument 2009 No. 309 The Local Authority Social Services & National Health Services Complaints (England) Regulations. In summary these include: Complaints or concerns raised verbally which are resolved to the satisfaction of the person who has raised the issue within one working day after the complaint or concern was made Complaints which have been previously investigated under this or previous NHS complaints regulations A complaint by an employee relating to their employment. Employees should follow guidance given by the CLCH Grievance Procedure NHS and Provider professionals wishing to make a complaint about care provision in general should refer to the CLCH Raising Concerns at Work policy, which is available online through the organisation s intranet site or the relevant HR department A complaint made by a responsible body such as commissioners, an NHS employee or partner organisation about another NHS employee or partner organisation. A complaint made by a Local Commissioner under the Local Government Act 1974 (a) or a Health Service Commissioner under the 1993 Act Complaints about Freedom of Information Requests and Access to Information Requests. These should be directed to the Freedom of Information Policy. A complaint that is being investigated by the Health Ombudsman Should there be any doubt about whether a complaint will prejudice any other formal proceedings then the person who has received the complaint should immediately pass the relevant information to the Customer Service Manager, who will then make a decision with regard to when to initiate any action by taking appropriate professional advice. If a complaint does include in part any of the exceptions noted above during any stage of the Complaints Procedure, this should not delay any investigation of unrelated issues raised within the complaint Page 14 of 72

5.4 Procedure to ensure that complainants are not treated differently as a result of their complaint CLCH is committed to ensuring that people are not treated differently as a result of making a complaint. Complainants must not be discriminated against because they have made a complaint about any service commissioned / provided by CLCH. As such, documentation regarding a complaint will be held separately from the patient s medical records, and only those staff participating in the investigation will be party to the full details. If there is evidence that someone has been treated differently by staff as a result of raising a complaint, this will be discussed with Human Resources for action to be taken as appropriate. Additional controls to ensure people are not treated any differently as a result of making a complaint include: Ensuring that individuals can raise concerns anonymously if they wish, via the Customer Service Team Ensuring that investigations are standardised across CLCH with procedures in place that comply with external standards. Ensure any documentation relating to investigations regarding concerns/complaints are not filed within the service users health records. If an individual does report that they have been treated differently as a result of raising a concern or registering a formal complaint, this would be investigated. 5.5 Types of Complaints 5.6 Informal complaints (Comments and Concerns) Service users often raise issues about which they are unhappy, without wishing to make a formal complaint. In many instances, they will simply be concerned and wish to receive an explanation and if something has gone wrong an apology. As these suggestions may be made to any member of staff, it is important that all staff are trained to welcome patient's views and see them as an opportunity to improve their local service. This training is provided through the Trust s induction process and bespoke customer service training. Expressions of concerns and comments are to be passed to the Customer Service Team who will record and investigate as necessary. If a concern is not resolved to the satisfaction of the person concerned they should be given the opportunity to make the matter a formal complaint. Expressions of concern and comments which are of medium of high risk, or require a written response, must be referred to the Customer Service Team. Page 15 of 72

5.7 Anonymous Complaints Complaints made anonymously fall outside the scope of this process. However, wherever possible, these types of complaints will be recorded, reviewed and investigated as appropriate. 5.8 Bereavement complaints Wherever possible a meeting will take place between CLCH and the complainant in order to take a detailed history, record the issues raised and ascertain how they wish the complaint to be handled. Attendance by the Service Associate Director, Chief Nurse and Director of Quality Governance, Chief or Deputy Chief Executive (Operations) may be appropriate in certain circumstances. 5.9 Commissioner complaints The commissioners of CLCH services reserve the right to investigate complaints received by them about provider services. Complaints arising from CSU/CCGs or other NHS Groups on behalf of a patient will be recorded and tracked by the Customer Service Team as described in the complaints process and within CLCH corporate mechanisms. 5.10 Offender Complaints Healthcare services at HMP Wormwood Scrubs are provided by CLCH. Complaints from prisoners about healthcare are dealt with initially through the Prison Service s local complaints procedure. If dissatisfied with the outcome of this first stage the complaint can be passed CLCH for investigation. 5.11 Other complaints Where complaints involve, or may need to be referred to, external bodies such as the Police or other organisations, advice should be sought from the Chief Nurse and Director of Quality Governance. 5.12 Counsellor complaints If a counsellor is acting on behalf of a patient, then consent must be obtained from the patient. Information must not be disclosed without the permission of the patient. If the counsellor has obtained this consent, they must provide evidence of this. When the consent form is received careful note must be made as to where the service user would like the response to be sent to. All complaints and concerns raised by are to be forwarded to the Chief Executive CLCH. 5.13 Complaints regarding safeguarding or an incident An incident is any event that has, or may have, impacted upon the safety of patients, staff, and delivery of service or health improvement. Incidents include hazards, accidents, dangerous occurrences, significant events and near misses. For an explanation of these terms please the Incident Reporting and management Policy. Page 16 of 72

If an incident is identified in the complaint it must be reported it via the incident reporting module on Datix. Serious incidents, must be escalated to the divisional senior management team and a senior member of the Quality and Assurance Team (or its successor team). The reporter will be notified as to whether or this will be progressed as a complaint, or whether it will be removed from the complaint process and managed through the incidents process. If a there is an urgent concern about a child or an adult at risk of harm should be acted on immediately to protect the person at risk, by calling the relevant CLCH safeguarding lead during business hours. The CLCH on-call staff must be notified after hours.if there is no risk of immediate harm, discuss your concerns with a line manager or the Trust s safeguarding lead or advisor at the time of identification. 5.14 Joint organisation and partner complaints When a complaint is received by CLCH which also involves services provided by another organisation we will work together with them to provide a seamless complaints process for the complainant and not to create additional burden. When a complaint is regarding the services of different organisations not in a partnership, CLCH will: Contact the complainant to discuss and agree how the complaint will be managed and obtain appropriate consent for information sharing. Liaise with the other organisations to agree who will lead on the complaint and co-ordinate a response. Ensure that a single response is provided if this is requested by the complainant. Where a complaint is made regarding a service provided in partnership with CLCH the investigation will be led by the lead organisation. Where a complaint is made to CLCH that relates entirely to another organisation or local authority CLCH complaints will: Liaise with the complainant to determine whether they want the complaint be sent to the local authority to which it relates and If the complainant consents to this, send that material to that local authority as soon as is reasonably practicable. 5.15 Consent 5.16 Complaints made by the service user If the complainant is the service user, consent to investigate their complaint is not normally required unless the investigation requires their personal information to be shared with or requested from other organisations outside CLCH. Page 17 of 72

In these circumstances the complainant will be informed that investigation of their complaint may require sharing of information with other organisations and that their consent is required. Consent is assumed for investigations involving only clerical and clinical staff within CLCH. Should they not consent to this then an explanation of the limits this may put on the ability to fully investigate their complaint will be given. For example, by not being able to share their personal details may mean it is not possible to identify the staff involved in their complaint. 5.17 Complaints made by a third person Another person can pursue the complaint on behalf of the service user. In order to do this the written consent of the service user must be sought and received on whose behalf a complaint has been made before any confidential information can be disclosed to them. This includes next of kin, relative, friend, carer, counsellor, advocate or solicitor or other persons claiming to represent a service user. (Please also see Appendix M the consent form) 5.18 Complaints made by a child In the case of a child (under 16), a parent or guardian may make the complaint. However in some cases it may be appropriate to obtain consent from a child if that child is considered to be capable of understanding the situation and can give informed consent. The decision as to whether he/she is capable will need to be assessed on an individual basis and in line with CLCH policy. Children who received NHS treatment have the right to make a complaint in their own right and have the right to use the NHS complaints process. If the service user is a minor and unable to give consent the complaint should be discussed with the organisations Caldecott Guardian. 5.19 Complaints made by MPs on behalf of their constituents If a patient has visited an MP in their surgery or written to them requesting their representation in making a complaint or raising a concern, consent is not required (Statutory Instrument 2002 No 2905). If the MP states that they have received their constituent s permission then it should be assumed to be the case and the complaint investigated as per normal. Information should only be disclosed on a need to know basis. Nothing more than the relevant information pertaining to a complaint should be given in the final response. All complaints and concerns raised by MPs are to be forwarded to the Chief Executive of CLCH. 5.20 Third party complaints made by MPs on behalf of their constituents If an MP is representing a constituent who is acting on behalf of a patient, then consent must be obtained from the patient. Information must not be disclosed without the permission of the patient. If the MP has obtained this consent, then the MP must Page 18 of 72

provide evidence of this. When the consent form is received careful note must be made as to where the service user would like the response to be sent to. 5.21 Complaints in respect of a deceased service user If the service user has died then information can only be released to a patient s personal representative and any person who may have a claim arising out of that patient s death. A personal representative is the executor or administrator of the deceased person s estate. If the person making the complaint cannot provide required proofs they will be notified in writing stating the reasons for this decision. A list of requirements is provided in Appendix M Consent/Authority Form. 5.22 Capacity issues If there are concerns about whether the service user has capacity to consent (i.e. if the service user is too ill or otherwise incapacitated) this matter should be discussed with the organisations Caldicott Guardian and guidance taken from the Senior Manager for Primary Care Mental Health. If the service believes that the person making the complaint does not have sufficient interest in the person s welfare, or is not suitable to act as a representative, then the person will be notified in writing stating the reasons for this decision. An example of the above could be where the case relates to a Protection of Vulnerable Adult. 5.23 Circumstances where consent is not required There may be circumstances where service user consent is not required to pass on information, for example: When not revealing such information would be breaking the law. When the service user reveals any matter which CLCH considers may constitute a criminal offence. Where there is clear indication that a serious crime has been or is about to be committed. Where there is a risk of harm to an individual or themselves. Information is requested by H.M. Coroner, a court or a tribunal. There are reasonable grounds to suspect abuse of a child or vulnerable adult. 5.24 Commencement of investigations without consent To assist in the speed of resolution of a complaint, investigations may commence for those aspects of the complaint which do not require the divulging of confidential information. Refer also to the CLCH Consent to Treatment or Examination Policy Page 19 of 72

5.25 Screening of complaints The list below covers those topics which may highlight any potential safety issues for service users. These are individually annotated below. Where complaints contain these topics which have their own policy and procedures, the responsible departments must also be made aware of the complaint directly. Incidents see Incident Reporting and Management Policy Clinical risks see Incident Reporting and Serious Incident Policy Safeguarding Adults and Children see Safeguarding Adults and Children Policy Deprivation of Liberties see Deprivation of Liberty Policy Fitness to Practice see Fitness to Practice Policy Human Rights and Discrimination Policy Claims Policy All complaints will be assessed upon receipt by the Customer Service Team. Complaints will also be cross referenced via the Datix system to check for any associated incidents. 5.26 When should complaints be investigated? It is important that complaints are made as soon as possible after the event has occurred. Usually, complaints can only be investigated if they are: Made within 12 months of the event; or Made within 12 months of the date on which the matter which is the subject of the complainant came to the notice of the complainant. If a complaint is made after the 12 months timescale, CLCH may investigate at the discretion of the Customer Service Manager where the complainant had good reasons for not making a complaint within that period; it is still possible to investigate the complaint effectively and efficiently. 5. 27 Process for investigation of formal complaints and timescales (First Stage) All complaints received must be sent to the Customer Service Team within one working day; this should be done by scanning and sending by secure e-mail to facilitate same-day receipt. Receipt must be confirmed. A verbal or written acknowledgement to the complainant will be made by the Customer Services Team no later than 3 working days from the day the complaint was received. (An example template is attached at appendix J). The acknowledgement must include the following information: Page 20 of 72

An apology Clarification of all the issues to be investigated. Offer a meeting to discuss concerns. Agree the type of response required (writing, meeting, phone, or email) Agree customer s desired outcomes Will advise of their right to independent support e.g. an advocate or interpreter. Advise who will carry out the investigation, and Agree timescales for the final response If the complaint was made verbally, the complainant must be asked if they require a written summary to be sent to them together with an invitation to agree or amend the information. If a telephone number has not been provided the complainant will be sent a brief acknowledgement letter, within 3 working days, asking them to contact the Customer Service Team to discuss their complaint in more detail. The letter will also advise that if no contact is made the Trust will assume they wish for their complaint to be responded to in writing, unless their complaint advised differently. 5.28 Assessment of seriousness of complaint: Correct assessment of the seriousness of a complaint will ensure that the right course of action can be taken. Each complaint will be reviewed by the Customer Service team according to the assessment matrix which can be found in Appendix R. The complaint will also be reviewed following the outcome of the investigation and re graded if appropriate. The assessment grading will be recorded on the Complaint Resolution Investigation Report (Template at appendix F). 5.29 Complaints graded as moderate or above: If a complaint is graded moderately or above then the investigation should involve senior staff from within the division. If it involves members of staff, support should be provided to the staff concerned by Human Resources as well as the investigating managers 5.30 Complaint Investigation The appropriate Service Manager is responsible for investigating the complaint, together with support and guidance available from the Customer Service Manager. The Complaint Resolution Investigation report can be found at appendix F. The template will contain all of the information required which will then be shared with the relevant Division for dissemination to staff who are tasked with investigating the complaint. Page 21 of 72

If the service is unable to meet the report completion deadline please inform the Customer Service team as soon as you are aware and no later than 3 working days before the deadline date if possible. The staff directly involved in the complaint will not be nominated to investigate the complaint although if required they will be approached to provide a statement in relation to the complaint. (Guidance is provided at appendix G) The complaint investigation will include some or all of the following actions: requests for statements from staff analysis of the relevant health records staff interviews root cause analysis impartial advice or opinion from other Trust staff that are independent of the clinical team providing the care complained about. 5.31 Complaints graded as high or above: These complaints will be investigated using the Root Cause Analysis (RCA) method level 2/3. They will also be shared with the relevant Directorate Lead, Medical Director and Chief Nurse and Director of Quality Governance. 5.32 Investigation timescales: The following timetable gives suggested timescales and guidance for investigation completion times: Table 1: Timescales and guidance on complaint investigation and response times Category Assessment level Indicative investigation time (working days) Response time to complainant (working days) PALS enquiry Low/ Medium High Very Low Risk and/ or straightforward resolution An investigation will usually be led by the Line Manager and, where appropriate, in conjunction with the relevant Clinical Lead. May involve one or more services/ organisation, requiring, more in depth investigation and will be overseen by a Service Head of Service or Service Manager/ Director. Highly complex and sensitive complaints. Most likely involve two or more organisations and will require in depth investigation overseen by a Service Director. Such complaints will normally be an integral part of an incident and a full RCA investigation would take place. Up to 5 Up to 10 Up to 60 5 (1 week) 25 (5 weeks) 75 (15 weeks) Page 22 of 72

5.33 Response timescales: The Health and Local Authority Adult Social Care Complaints Regulations 2009 require that it is agreed with the complainant a timeframe within which the investigation of the complaint is likely to be completed. Although the legislation allows the response time to be flexible, CLCH aims to provide a response in as timely a manner as possible setting an internal benchmark of 25 working days for low to medium risk graded complaints. The 25 day deadline will commence from the date the complaint is received by the service or any employee of the Trust. Those complaints made on behalf of a patient which require their consent to be investigated, the 25 day deadline will commence from the date the consent is received. Within this timeframe, 5 days is allowed for from the Customer Service Team receiving the investigation report and obtaining approval of the draft response from the service. A further 7 days allowed for the Chief Nurse or the Medical Director for approval and being signed by the Chief Executive or nominated deputy. Once the investigation has been completed a review of all moderate to high complaints will be analysed by the service. If a complaint theme is occurring frequently the Customer Service Manager may review and inform the CLIPS Group. 5.34 Conduct of investigations Investigations will employ the National Patient Safety Agency s (NPSA) best practice on conducting investigations using Root Cause Analysis (RCA) methodologies to include: Care and service delivery problems: Contributory factors Root causes Lessons learned Recommendations Arrangements for shared learning These are also referred to at appendix F. Further detailed information on RCA investigations can also be found at the following link: http://www.nrls.npsa.nhs.uk/rca/. Page 23 of 72

5.35 Independent investigations An independent investigation may be carried out in agreement with the Chief Nurse, Senior Managers and the complainant in circumstances where, for example: A complaint amounts to an allegation of a serious incident; Subject matter involving clinically related issues is not capable of resolution without an expert clinical opinion; A complaint raises substantive issues of professional misconduct or the performance of senior managers. A complaint involves issues about the nature and extent of the services commissioned. The Chief Nurse will appoint an Independent Investigator, who will take on the role of Investigating Manager who will lead the investigation and prepare a written report for adjudication by a senior manager. 5.36 Responding to complainants At the conclusion of the investigation, a Letter of findings response will be prepared by the Customer Service Team and passed to the Chief Nurse, or the Medical Director regarding clinical treatment and/or involve a medical doctor, for approval prior to being signed by the Chief Executive or nominated deputy. (The letter of findings template can be found at appendix J). The response will include: A detailed explanation, in light of the investigation findings, regarding the questions raised in the complaint from the service involved. An apology. Conclusions reached in relation to the complaint including remedial action and lessons learned. Information on how complainants can proceed if they are not satisfied with the reply, and will specifically mention the complainant s right to refer the complaint to the Health Service Ombudsman. A copy of the Customer Satisfaction Questionnaire for the complainant to complete. The outcomes of the complaint must also be recorded in the Complaints Database as either being Upheld, Partially Upheld or not Upheld as required by NHS Information Centre for Health K041a submission. This is an annual mandatory collection of complaints made by (or on behalf of) patients. Page 24 of 72

If the investigation s findings agree with the customer s complaint it is upheld. If the investigation s findings disagree with the customer s complaint it is not upheld. If the investigation s findings agree with some parts of the customer s complaint it is partly upheld. Where appropriate all action plans and learning will be evidenced and tracked by the Division involved. Where a complainant is dissatisfied with the outcome of an investigation, and response, the customer service manager will take such further reasonable steps to provide a local resolution to the complaint, and will consider whether it would be appropriate to undertake further investigation. Complainants not satisfied with the outcome have the right to refer their complaint to the Health Service Ombudsman. 5.37 Meeting with complainants Misunderstandings and miscommunication is often the root cause of most complaints. Meetings can therefore be a good way of resolving complaints. If a meeting is to take place with the complainant and their representatives, CLCH staff should refer to Appendix G Guidance for meeting with a complainant. CLCH follows the Department of Health principles of Being Open and endeavour to include service user, family or carers in setting the scope of any investigation and the investigation itself if appropriate. The organisation will give consideration to the provision of information and support to service users, relatives & carers and staff involved in the complaint in accordance with the Being Open policy. 5.38 Mediation and Conciliation Independent mediation and conciliation arrangements can be made available on a case-by-case basis. The Head of Patient and Public Engagement (or their successor) will review requests made to access these services and approve funding for independent mediation and conciliation services when appropriate. 5.39 Disciplinary procedure The complaints procedure will be kept separate from the staff disciplinary procedure. The purpose of the investigation carried out under the complaints procedure is to resolve complaints and not apportion blame or to make recommendations regarding disciplinary action against members of staff. In the event of a complaint being received that involves serious allegations of misconduct about a member (s) of staff warranting a management investigation, Page 25 of 72

involvement of a professional regulatory body or a criminal investigation, the Customer Service Manager should immediately inform the HR Manager and the relevant Service Director. If a formal management investigation is initiated and, in particular, in these circumstances if instigation of the disciplinary procedure is required, there is a need to balance obligations relating to confidentiality of staff with reassuring the complainant. It will be explained to the complainant that details of any subsequent disciplinary action against members of staff cannot be divulged but that they will receive an appropriate explanation, apology and any action take to prevent recurrence. 5.40 Re-opended Complaints If the complainant is not satisfied with the response their remaining concerns will be passed to the service for a response. The Deputy Chief Nurse and /or the Medical Director as required will also be consulted for a decision as to whether the further reponse from the Trust can be issued by the service or if the response is to be escalated to Director level. 5.41 Withdrawn Complaints Where a complainant requests that a formal complaint to be withdrawn, CLCH will record the complaint and will undertake a review as per normal procedure if there is sufficient information to do this. This is so that issues can still be captured and any 5.42 Duty of confidentiality Care must be taken at all times throughout the complaints procedure, to ensure that any information disclosed about the service user is confined to that which is relevant to the investigation of the complaint. Information will only be disclosed to those people who have a demonstrable need to know it for the purpose of investigating the complaint or ensuring that the complaints procedure is followed. It is good practice to explain to the service user or complainant that information from his/her health records may need to be disclosed to staff involved in managing the complaint including the Ombudsman should it be required. If the service user objects to this then the effect on the investigation will be explained learning identified. 5.43 Parliamentary and Health Service Ombudsman (PHSO) When complainants are not satisfied with the final response from CLCH they have the right to refer their complaint to the PHSO. CLCH will always proactively advise complainants of this right and provide them with the necessary contact details. CLCH will co-operate in full with any requests made by the PHSO. Recommendations received from the PHSO will be recorded by the Customer Service Manager and the Chief Executive s Office and then provided in full to the relevant directorate or service provider for implementation. Where recommendations Page 26 of 72

are made these are normally made to reduce the risk of a similar adverse event occurring again. Progress of any recommendations made by the Ombudsman will be monitored by the Customer Service Manager and included in reporting to the CLIPS Group. 5.44 Unreasonable and persistent Complainants In the event that a complainant is deemed as unreasonably persistent and/or repetitive, it is important that any decisions are made with reference to this policy; in conjunction with the Service Director in whose area the complaint falls, Chief Nurse and Director of Quality Governance and the Chief Executive (if necessary), and that it can be shown that all attempts to resolve the issue locally have been made. Guidance is contained in Appendix L. 5.45 Payment of Financial Remedy CLCH will establish redress policy derived from guidance issued by the Health Service Ombudsman s Principles of Remedy and Principles of Good Administration 5.46 Communication 5.47 Electronic communication of complaints information Within the complaints process it is essential for information to be conveyed in a speedy and secure way. E-mailing of service user identifiable information, for the purpose of complaints resolution, is permitted between email addresses within the same domain name, which is identified by the section of the address following the @ symbol, which is secure. If these are the service user identifiable material should not be emailed to other NHS, Local Authority Social Care departments, or other organisations as part of the complaints process unless the sender and receiver are both using nhs.net accounts. Emails containing patient identifiable information should be sent from and to an nhs.net account. To minimise the risk of confidential information being lost or stolen, e-mails must not include the name of the service user, the person making the complaint or any other identifiers within the subject header. Wherever possible, information should be presented within a word document and information, such as address and contact details, should be removed unless this is essential to the purpose of the e-mail. Password protecting the document is not necessary. The Customer Services team will store all emails related to the complaint on the complaint file in the DATIX database; therefore once an e-mail has been sent to the Customers Services team it can be deleted. Page 27 of 72

If details are sent by fax, then the relevant person within the Customer Services team should be informed prior to the fax being sent. The complaints fax is a safe haven facility and therefore secure and not accessible to non-customer Service personnel. The receipt of the fax must be confirmed to the sender by the Customer Service team. 5.48 Internal Communication For complaints requiring the involvement of the following departments, there will be an additional communication to that department: or lead. Infection Control Team Local Security Management Specialist Adult and Children Safeguarding Leads Occupational Health Quality Assurance and Safety Deprivation of liberties Equality and Diversity 5.49 Media Involvement If the complaint is likely to receive media interest, the appropriate lead in the communications team must be informed immediately upon receipt or notification of the complaint. CLCH will publicise this policy and provide further information on how to complain through appropriate means, which may include the CLCH website, posters, leaflets and through partnership working with key stakeholders. Internal communication channels will be used to ensure staff is fully informed of the policy and their responsibilities. 5.50 Organisational Learning A fundamental aspect of the complaints process is ensuring that the organisation learns and improves from the experience of receiving and managing complaints. Each complaint investigated will have recorded, as a feature of the final outcome, the lessons learned and what action has been, or will be taken as a result of the investigation. The resulting actions will be monitored through the Risk Register and the lessons learned disseminated throughout the organisation. The Customer Service Manager will analyse complaints and the subsequent investigations to identify emerging themes or trends and, where appropriate, will highlight these for urgent attention. Lessons learned and emerging themes will be presented to the Patient Experience Group as per the schedule of that group. Where Page 28 of 72

required learning bulletins can be quickly disseminated via email or through the appropriate governance structure. Feedback on trust wide lessons learned from formal complaints will be circulated via the CLIPS and TIPS newsletter. B. Comments and concerns 5.51 Process for responding to comments and concerns Service users often raise issues about which they are unhappy, without wishing to make a formal complaint. In many instances, they will simply be concerned and wish to receive an explanation and if something has gone wrong an apology. As these suggestions may be made to any member of staff, it is important that all staff are trained to welcome patient's views and see them as an opportunity to improve their local service. As described above, expressions of concerns and comments that are risk graded as moderate or higher, or require a written response, must be passed to the Customer Service Team. If a concern is not resolved to the satisfaction of the person concerned they should be given the opportunity to make the matter a formal complaint. Staff should respond positively and appropriately if a patient or other person affected by a service raises a concern. Staff should: Ensure that the patient s immediate health care needs are being met before dealing with the suggestion or comment rapidly, sensitively and confidentially. Discuss the matter of concern with the patient, encouraging them to speak freely. Provide an honest and objective response. The response should be given verbally, unless the patient has requested a written reply or the member of staff considers a letter is appropriate. Oral responses should be given on the spot or, where this is not possible, a timescale for a way forward should be agreed with the patient. The response should include an explanation, an apology where appropriate and indicate what is being done to avoid the problem happening again. Any oral or written response about a clinical matter should be agreed with an appropriate clinician. Where a patient has requested it, issue a written response, approved where appropriate by a clinician or senior member of staff. Details of the concern and a copy of the written response must be sent to the Customer Service team prior to sending to the enquirer. Consider, based on their assessment of the situation, the nature of the concern, and their knowledge of any previous similar situation(s), what Page 29 of 72

action is appropriate to share the information and ensure that the organisation learns from the process. Clinical Business units should hold local complaints logs of verbal complaints that had been resolved locally. Staff should also understand that where they feel unable to respond themselves that they can: Call on the support of an appropriate senior member of staff, or offer the patient the option of discussing the matter with someone not directly involved in their care, for example someone from another team or department, the practice manager or contact the Customer Service team. When asked to provide this type of support, staff should, ideally, respond immediately, but where this is not possible a timescale for a way forward should be agreed with the patient. If the patient remains unhappy after receiving an oral or written response, they should be advised of the next appropriate step and given a copy of the CLCH Customer Service Feedback leaflet. This may involve the offer of speaking with a more senior member of staff or contacting organisation s Customer Service team who will be able to assist the patient or, if they wish, put them in touch with an independent advice and support service. C. Compliments 5.52 Recording of compliments The potential value of complimentary remarks should not be underestimated. Local arrangements should be put in place to receive, identify, recognise and pass onto the intended recipient. If a compliment is received verbally their name, address and post code should be obtained if possible. Compliments should then be passed on to the Customer Service Team, following the guidance in Appendix K for recording and where appropriate for sharing the learning from good individual or team practice. Compliments are reported to the Trust via weekly, monthly and quarterly reports. These reports do not divulge the staff member s name, but staff details are captured so that they can be used in an appropriate way. For example, to support evidence for staff recognition awards and staff appraisals if required. Page 30 of 72

6. Consultation This document was developed in consultation with the Organisation s internal stakeholders and includes an Equalities Impact Assessment.The following stakeholders were consulted by email in the creation of this policy and comments incorporated as appropriate. Chief Nurse and Director of Quality Governance All Directors, Associate Directors. All Heads of Services All staff who receive the weekly complaints and compliments reports NHS CLCH Joint Staff Consultative Committee Patients representatives 7. Approval and Ratification This document was reviewed by the Quality Committee before being approved by Trust Board, and thereafter ratified by the Policy Ratification Group. 8. Dissemination & Implementation This policy document will be implemented as follows: This procedural document will be placed on the intranet by the QAS team. The QAS team will provide a reference number for this policy. It will be therefore be available to all staff via the CLCH NHS Trust intranet. Furthermore the document will be uploaded on the CLCH intranet after ratification and will also be circulated to all managers by an email from the Customer Service Manager. They will be required to cascade the information to members of their teams and to confirm receipt of the policy and destruction of the previous policy which this supersedes. Managers will ensure that all staff are briefed on its contents and on what it means for them. 9. Archiving The QAS Team will undertake the archiving arrangements. 10. Training The organisation recognises that if the reporting and investigation of complaints is to be successful and beneficial, then staff training must be available and supported by regular updates. The organisation will provide training through staff inductions and Page 31 of 72

briefings directly to service teams to assist with the implementation of this policy, which will be included in the staff induction process. Induction training, which is mandatory for all staff, will include a section on handling complaints. The Customer Service Manager will ensure that this element is kept upto-date, as well as ensuring that communications materials (for example. leaflets, briefing and intranet content) are made available and that all staff are advised of their availability The Customer Service Manager in conjunction with the Training/Learning and Development team will develop and arrange annual targeted training for Service Managers and their teams who take part in the management or investigation of complaints, and to ensure that staff have skills appropriate to their level of involvement. An e-learning module, which provides further training in complying with this policy, will be available from the 2nd quarter 2014. 11. Monitoring and auditing compliance with this policy Please see appendix A 12. Review arrangements The policy will be reviewed at least every two years; the next review is due in January 2016. It will be reviewed earlier by the Customer Service Manager or their successor subject to: Receipt of updated legislation, and/ or guidance issued by regulators. Learning identified through the on-going use & deployment of the Datix system. Page 32 of 72

13. References 1. Department of Health Listening, Responding, Improving: A guide to better customer care. 2. The Parliamentary Health Service Ombudsman Principles of Good Complaints Handling guide. 3. The Parliamentary Health Service Ombudsman Principles of Remedy guide. 4. The Parliamentary Health Service Ombudsman Principles of Good Administration guide 5. Care quality commission (2009) Guidance about compliance with the Health and Social Care Act 2008 registration requirements regulations 2009: A consultation. [online] London: Care Quality Commission. Available at <http://www.cqc.org.ukl 6. Department of Health Good Practice' Guide 7. The NHS Constitution 8. The NHS Litigation Authority Standards <http://www.nhsla.nhs.uk/> Patient Safety Agency. Available at <http://www.npsa.nhs.uk> 9. National Patient Safety Agency. (2005c). Safer Practice Notice - Being Open When Patients are Harmed. London: National Patient Safety Agency. Available at: <http://www.npsa.nhs.uk> 10. National Patient Safety Agency. (2009). National framework for reporting and learning from serious incidents requiring investigation: A consultation. London: National Patient Safety Agency. Available at <http://www.npsa.nhs.uk> 11. NHS Litigation Authority (2009) NHSLA risk management handbook. [online] London: NHSLA. Available from <http://www.nhsla.nhs.uk/> [accessed 15 May 2013]. 12. The Mid Staffordshire NHS Foundation Trust Public Inquiry (The Francis Report- Effective Complaints Handling). Available at http://www.midstaffspublicinquiry.com/ 13. Report of handling of complaints by NHS hospitals in England by Ann Clwyd MP and Professor Tricia Hart. 14. The Local Authority Social Services and National Health Services Complaints (England) Regulations 2009 http://www.legislation.gov.uk/uksi/2009/309/contents/made 15. Reform of Complaints Handling in Health and Social Care key messages for boards, members and senior management teams (DH 2009) 16. Data Protection Act 1998 17. Freedom of Information Act 2000 18. Human Rights Act 1998 Page 33 of 72

14. Associated documentation CLCH Violence and Aggression at Work Policy CLCH Incidents Reporting Policy CLCH Records Management Policy CLCH Risk Management Policy CLCH Claims policy CLCH Raising Concerns at Work Policy CLCH Equality and Diversity Policy CLCH Counter Fraud and Corruption Policy CLCH Being Open Policy CLCH Induction and Statutory and Mandatory Refresher Training Policy 15. Appendices Appendix A Appendix B Appendix C Appendix D Appendix E Appendix F Appendix G Appendix H Appendix I Appendix J Appendix K Appendix L Appendix M Appendix N Appendix O Appendix P Appendix Q Appendix R Monitoring and compliance tool Equality Impact Assessment Management of complaints flow chart Management of complaints for partner organizations flowchart Management of complaints for partner organizations where CLHC is not the lead partner Complaint investigation report form Guidance for staff writing a statement Guidance for meetings with complainants Acknowledgement letter template Letter of findings template Management of compliments flow chart Unreasonable and persistent complainants Consent / Authority form Customer Service Feedback Customer Service Feedback Easy read leaflet Customer Service Satisfaction Questionnaire Equality monitoring form Complaint Severity Assessment Matrix Page 34 of 72

Appendix A: Monitoring and auditing compliance. Element to be monitored NHSLA Risk Management Standard 2.3:Concerns and Complaints Lead How Trust will monitor compliance(data and audit) Frequency of monitoring Reporting arrangements Acting on recommendations and Lead(s) Change in practice and lessons to be shared How will changes be implemented and lessons learnt/ shared Duties Head of HR The duty of individual staff to respond to patient feedback including complaints will be monitored locally via appraisals. The duty of senior Trust officers in relation to this Policy will be monitored via the Board accountability. Process. How the organisation listens and responds to concerns and complaints from patients (including joint complaints) their relatives and carers (NHSLA requirement) Via the annual complaints audit. This will include information regarding numbers, types and response times (as compared with this policy) Annually. Quarterly Patient Experience Group and Quality Committee which reports to the Board. Quality Account AGM Patient Experience Group The Quality Committee Patient Experience Group Themes, Learning and changes to practice will be identified and actioned within by the Patient Experience Group. A lead member of the team will be identified to take each change forward where appropriate. Lessons will be shared with all the relevant stakeholders including the operations manager, responsible managers and duty holder.

Element to be monitored NHSLA Risk Management Standard 2.3:Concerns and Complaints Lead How Trust will monitor compliance(data and audit) Frequency of monitoring Reporting arrangements Acting on recommendations and Lead(s) Change in practice and lessons to be shared How will changes be implemented and lessons learnt/ shared How the organisation makes sure that patients, their relatives and carers are not treated differently as a result of raising a concern or complaint Customer Service Manager The complaints audit will review this and identify any difference in treatment. Any differences will be reported. Annually As above Patient Experience Group How the organisation makes improvements as a result of a concern or complaint Customer Service Manager Concerns and complaints and associated action plans will be monitored via risks registers. Divisional team meetngs will review informal complaints/concerns logs and report on these to the Patient Experience Group Trust wide themes are shared at CLIPS and appropriate learning will be disseminated via the CLIPS and TIPs newsletters Quarterly CLIPS group Patients Experience Group PEG As above Page 36 of 72

Element to be monitored NHSLA Risk Management Standard 2.3:Concerns and Complaints Lead How Trust will monitor compliance(data and audit) Frequency of monitoring Reporting arrangements Acting on recommendations and Lead(s) Change in practice and lessons to be shared How will changes be implemented and lessons learnt/ shared How the organisation monitors compliance with all the above Customer Service Manager As described in this table Annually Page 37 of 72

Appendix B: Equalities Impact Assessment NAME OF POLICY OR STRATEGY Equality Analysis for Policies Screening form CLCH as a public authority has a legal requirement to analyse the impact of the policy on the protected characteristics of staff and patients. This helps us to check if there is a negative impact, how we can reduce that impact. Does the policy affect groups of people based upon their protected characteristic? Think about the delivery of the procedural document and how it will be applied. 1. Protected characteristic Positive impact Neutral Impact Negative Impact Reason for impact and action required. People of different ages (e.g. Children, young or older people). People of different religions / beliefs People with disabilities (physical, sensory or learning). People from different ethnic groups Men or women Transgendered people People who are gay, lesbian, and bi-sexual Refugees and asylum seekers

2 Please describe engagement and consultation process and the key feedback. E.g. with teams, unions. Consultation is described in paragraph 6 of the report 3. If there are negative impacts upon people s protected characteristics. Does the policy in its current form need a full Equality Analysis Assessment to be completed? No 4. Have you signed this off with the Equality and Diversity team? Yes Page 39 of 72

Appendix C Management of complaints flowchart 3 w o r k i n g d a y s Key: CST: Customer Service Team SM: Service Manager AD Associate Director If risk is moderate or above copy to Service AD If risk is high or above pass to Chief Nurse If a safeguarding/incident has been identified follow Safeguarding /Incident procedure. Pass to Customer Service Team within 1 working day. Receipt must be confirmed. CST acknowledges complaint and agrees timeframe and issues to be investigated Yes Complaint /concern received Service Triage complaint. Is it risk assessed as moderate or higher? No 10 working days CST to send Investigation Report Form to SM with agreed report completion date No Can it be resolved within 1 working day? 5 working days 5 working days CST receives investigation report and sends draft response to SM for review and sign off Draft response letter and forward to Service Manager for factual accuracy checks. CST forwards draft response to Chief Nurse (or Medical Director for clinical issues) or deputy for review prior to sending to Chief Executive Office Yes Record issue and outcome locally and review at local CLIPS meeting Chief Executive Office to send final response to CST for sending to complainant together with Customer Service Questionnaire CST sends copy of response to SM. Page 40 of 72

Appendix D: Management of complaints for partner organisations flowchart: CLCH is the lead partner 3 w o r k i n g d a y s If risk is moderate or above copy to Service AD. If risk is significant or above also pass to Chief Nurse 10 working days for low risk. 10-30 days for medhigh risk Complaint /concern received regarding PO. Pass complaint to SM within 1 working day (cc PO). CST acknowledges complaint and sends Investigation Report Form to CLCH Service Manager with agreed report completion date. Note; All communications from PO must be via SM The SM will co-ordinate completion of Investigation Report Form with PO 5 working days SM sends investigation report to CST who then sends draft response to SM for review and sign off with PO. 5 working days CST forwards draft response to CLCH Chief Nurse (or Medical Director for clinical issues) for review prior to sending to Chief Executive Office. Key: CST: Customer Service Team PO: Partner Organisation SM: Service Manager AD: Associate Director Chief Executive Office to send letter of findings to CST for sending out. CST sends copy of response to SM to pass to PO. Page 41 of 72

Appendix E: Management of complaints for partner organisations flowchart: CLCH is not the lead partner 3 w o r k i n g d a y s If risk is moderate or above copy to Service AD If risk is significant or above pass to Chief Nurse 10 working days for low risk. 10-30 days for medhigh risk Complaint /concern received regarding CLCH Service. Pass complaint to PO Complaints Team within 1 working day (cc SM). PO Complaints Team acknowledges complaint and sends their investigation report template to CST cc Service Manager with agreed report completion date. Note; All communications with CST and complainant is led by the PO Complaints Team The CST will co-ordinate completion of Investigation Report Form with SM SM send report template to CST. 5 working days CST checks investigation report template and send to CLCH Chief Nurse (or Medical Director for clinical issues) for review prior to sending to PO Complaints Team Key: CST: Customer Service Team PO: Partner Organisation SM: Service Manager AD: Associate Director CST sends investigation template to PO Complaints Page 42 Team of 72 for response to the complainant. PO sends copy of response to CST for file. CST sends copy to SM.

Appendix F Complaint Resolution Investigation Report Agreed response date by Investigating Manager: Low-Mod risk: Up to 10 working days Med-High Up to 30 working days Extreme: 30-60 working days where agreed to have an extension at Director level Customer s (complainant) details Name: Complaint Datix Ref : CLCH Cxxx Address: Date of Birth: Telephone number: (Home): (Mobile): Email: Preferred method of contact with customer: (e.g. telephone, letter, email) Advocacy / interpreter or additional support required e.g. VoiceAbility, MIND Service User details (if different from complainant) Name (include title): Address: Date of birth: Telephone number: (Home): (Mobile): Details of staff member(s) named in complaint NB The staff member should be asked to submit a written statement using the pro-forma in the Complaints Policy (Appendix G) and that staff have opportunity to review the investigation findings before it is forwarded for approval. If agency staff has the agency been informed of the complaint Y/N? Name: Please advise Job Title: Speciality: Site: Contact No: Line Manager: Details of Investigating service manager Name: Service: Job Title Contact No: Site Based: Page 43 of 72

Any further issues following contact with complainant? E.g. Awaiting Consent, Local resolution Meeting required (Use pro-forma for meetings guidance in the Complaints Policy (Appendix H). Other organisations/services involved? If yes, give details and actions taken: May be a joint complaint against CLCH and another Trust. Will need to agree who is leading on complaint. Outcome of Datix check for other incidents or complaints re staff member: Service to check if datix logged in connection with complaint incident. Summary of complaint: (Give brief, factual account and dates of circumstances and complaint -use separate sheet if required See email/letter or summary of verbal complaint. Desired outcomes: (What the customer would like to happen as a result of their complaint): For example They want to know what went wrong and why What has/is being done to rectify the problem that occurred They don t want the same issue to reoccur for other patients/carers Want an apology To know if there is any learning or actions being taken as a result of their complaint Is CCTV footage required? N (E.g. cases where behaviour of Reception/Complainant is in question) if yes, has it been requested (note records are deleted by 31 days of recording. Preferred method of feedback following investigation: (Tick as appropriate) Initial triage completed by (Complaints team) Triage after investigation completed by investigating manager: Meeting Letter Phone Call Email Triaged and assessed as: (Consequence x Likelihood Use the risk matrix in Complaints Policy-Appendix R Triaged and assessed as: (Consequence x Likelihood) Use the risk matrix in Complaints Policy-Appendix R Page 44 of 72

Considerations for Investigation Manager s report Care and service delivery issues A themed list of the key problem points. (Where many problems have been identified the full list should be included in the appendix) Contributory factors List the following factors which could have contributed to the issues. For example, 1.The occurrence happened towards the end of a shift so there was a delay in the family being informed. 2.There is no 24 hour doctor cover on the ward and this contributed to the delay in an x ray being carried out. 3.The staff member did not follow the moving and handling guidelines. Root Causes These are the most fundamental underlying factors contributing to the incident that can be addressed. For example 1. The staff member did not follow moving and handling guidance. 2. The staff member left the patient on her own. 3. As the fall did not result in a fracture there was no written report carried out Lessons learned Key safety and practice issues identified which may not have contributed to this incident but from which others can learn. For example: 1. The nurse in charge should check that staff know how to use the equipment in the ward. 2. This incident has highlighted the importance of keeping a patient s family informed of care and treatment and ensuring that information is shared in a timely way. Recommendations: These should be directly linked to root causes and lessons learned. They should be clear but not detailed (detail belongs in the action plan). It is generally agreed that key recommendations should be kept to a minimum where ever possible. For example: 1. To ensure that all staff in the future know how to use the equipment on the ward an induction program to be developed to be used on staff s first shift on the ward. 2. When the CLCH Temporary Staffing Office use agencies to find staff to work in CLCH the quality of their training should be checked. 3. Families to be provided with clear outcomes, e.g. if there is not going to be a written report they should be told that they will be provided with verbal feedback and have an opportunity to respond.. 4. Outcome of the investigation to be shared with the agency so that they discuss action with their staff. Arrangements for sharing and learning For example: This report will be shared with the Service Manager and Modern Matron for the ward. Actions taken Page 45 of 72

Chronology (timeline) of events (use more pages if required) Date & Time Event Page 46 of 72

Appendix G: Guidance for staff writing a statement A template for writing a statement is included below along with the following key points which need to be considered:- Write simply and avoid jargon and abbreviations. If your statement cannot be typed then it needs to be handwritten as clearly as possible. Please ensure that your report is typed or written in black ink, is dated and signed and includes your name, designation and contact work address. Always refer to the relevant documents to assist you in providing an accurate report including the patient s health records. Include as many facts as possible dates, times, patient names, staff present, location, drugs and equipment used etc. Facts only (not opinions) the statement must be accurate. Avoid making judgements or coming to conclusions stick to the facts rather than your analysis of them. Detail the sequence of events as you saw them that led to the alleged complaint occurring. Write short concise paragraphs. When mentioning policies, procedures or standards, describe them clearly. Always refer to policies, procedures, standards that are currently available, at the time. When referring to people, be precise in using their full name and title. Assume the reader is not familiar with the way in which the Trust provides treatment and care. Always assume that a statement could be read by the complainant. Page 47 of 72

Staff Statement Name: Job Title: Service/Area concerned: Contact number: Response to the issues raised in the complaint: Other witnesses to incident(s): Signed: Date: Page 48 of 72

Appendix H: Guidance for a meeting with the complainant. Misunderstandings and miscommunication is often the root cause of most complaints. Meetings can therefore be a good way of resolving complaints. Make sure before organising the meeting that the meeting and/or type of meeting are appropriate for the complaint. 1. Before the meeting clarify: Purpose: Be clear to the complainant what the meeting is for; explain it is to establish facts. Manage expectations and be clear about what the meeting can and cannot offer. Prior to meeting complainant may wish to identify a list of questions which if shared before meeting can aid in all getting the most out of the process. Venue (home, health centre or other) This can be a Health Centre or other venue; however the patient/complainant may wish to meet in a more neutral venue. Meeting in persons home often allows for a more relaxed environment, where the person making the complaint feels more comfortable. If the meeting is at the complainant s home a risk assessment must be carried by CLCH staff out prior to the meeting Attendees: Depending on the complaint issue may want to look at the numbers attending. Complaints meetings which are small are less intimidating to the complainant and less likely to end in defensive responses. CLCH Complaints representation can help in meetings which require chairing. Having a lay conciliator present can aid in facilitating the meeting, however there are few lay conciliators and so tend to be used only in bereavement complaints or difficult to resolve issues. Complainants should always be informed of their right to advocacy or to bring a friend or family member. Both complainant and a CLCH representative present should be aware of who is attending and why before the meeting. The person complained about would not normally be present unless they specifically feel this would benefit resolution and the complainant/patient is happy for the person to be there. Time: This really depends upon the nature of the complaint; however it is advisable to ensure that 1 hour is provided for the meeting as a minimum. Any meeting longer than 3 hours will need an allocated break. Evidence: Copies of appropriate sections of medical records should be available, alongside any policies and procedures relevant to the complaint in hand (e.g. NICE guidance). These should be available for the complainant to review in the meeting and ideally copies to take away Page 49 of 72

Minutes/record: Ensure that the meeting will be documented in a way that is appropriate, for example, only actions might be recorded. If the meeting response is not particularly complex these actions could be recorded by someone who is part of the meeting (so as not to increase attendees unnecessarily. For meetings involving a more complex response it may be necessary to bring outside administrative support. Consideration also might be given to the use of sound recording equipment in order to aid writing up of minutes, in which case permission to do so by the attendees must be sought. 2. At the meeting: This is an advised structure for complaints meeting; however each meeting may be different: Introductions, thanks, clarification of purpose and boundaries, information about complaints process Complainant highlights issues, summarises questions/list so form an agenda basis. Go through each point and respond with questions and answers. Summarise after each point covering all the issues raised, explain clearly why a course of action was taken. Apologise for mistakes made and discuss what actions will be taken to prevent a reoccurrence. Concluding, go through action points, acknowledge any differences reiterate options for taking complaint forward, thank person again. Try to be non-defensive: It is very easy to become defensive especially if you are being blamed. Be open and honest, the complainant will often only be trying to understand, if defensive this will antagonise the situation and jeopardise the meeting. If there are points of disagreement acknowledge these, state these are noted and move on. 3. Following the meeting: Complete actions and/or minutes and send copy to all present (with option to alter if wish), these can be in draft copy, ensuring that when returned with alterations the final copy can be sent via CLCH Customer Service Team from the Managing Director with a sign off letter Ensure details of next stage provided (these will be provided in the sign off letter as well) Carry out actions and monitor action plan Page 50 of 72

Appendix I Acknowledgment letter template Private and Confidential Customer Service Team Public and Patient Engagement Our reference: CLCH C FREEPOST RSLS-RCUA-XZAX 6 th Floor 64 Victoria Street London Name SW1E 6QP Address Address Tel: 08003680412 Post Code Fax: 02077980891 E-mail: clchcomplaints@nhs.net Web: www.clch.nhs.uk DD Month 201X Dear Mr/Ms/Mrs (or other title) Surname, I am writing in response the concerns expressed in your letter of DD Month Year, addressed to the Customer Service Team/ Manager...I was very sorry to learn of the problems you experienced with our xx Service at XXXXXX and for the inconvenience caused OR Thank you for taking the time to speak with me regarding the concerns expressed in your recent letter addressed to xxxxxx, which was received by Central London Community Healthcare (CLCH) on DD MONTH YEAR. I was very sorry to learn of the problems you experienced with our xx Service at XXXXXX and for the inconvenience caused For your information, CLCH provides this service and we will therefore investigate your concerns. I should explain that on receiving such concerns it is normal procedure to forward the complaint to the relevant Service Manager and ask them to investigate the issues raised. I have therefore passed your concerns/ letter and supporting documents to XX, Service Manager for XXX Service, for investigation. (As agreed,) I aim to complete an investigation into your concerns and a formal response to be sent from the Chief executive, James A. Reilly by DD Month Year, or earlier if possible. Page 51 of 72

Please let me know if this proposal is acceptable to you, or if you prefer not to contact me, I will then assume you are agreeable. In order to ensure that I respond fully to your concerns, I have summarised my understanding of your concerns below: Details of complaint If you disagree with my understanding or feel that you have further concerns that you wish to be investigated please contact me at the above address or call me on 020 7798 1436. Alternatively you can email me at clchcomplaints@nhs.net. If you prefer not to contact me I will assume that my understanding is correct. Please be advised that should you need any help or advice from an independent body in presenting your complaint please contact VoiceAbility the Independent NHS Complaints Advocacy Service, on 0300 330 5454 OR Please be advised that should you need any help or advice from an independent body in presenting your complaint I have pasted a link to their website below explaining their services/ provided by VoiceAbility the Independent Complaints Advocacy Service, and whom you can also contact on as follows: Helpline: 0300 330 5454 Textphone: 0786 002 2939 Fax: 0330 088 3762 Email: nhscomplaints@voiceability.org Website: www.voiceability.org OR (FOR THIRD PARTY REQUESTS) As explained in my telephone call, in order respond to your concerns regarding the treatment provided to your relative, and provide the medical notes requested, I will require your relative s consent and relevant proof of their identity. I have attached a copy form for him/her to complete, and return to me in the Freepost envelope provided. I should also explain that we have a legal duty to eliminate discrimination and to promote equality for all our patients, service users and their carers. Therefore, I would be grateful if you could complete the enclosed form and send it back to us using the Freepost envelope. We use this information to help assess whether we are providing equal access and treatment for different groups of people Yours sincerely, Name Page 52 of 72

Job Title Central London Community Healthcare NHS Trust Appendix J: Letter of findings template Private and Confidential Our reference: CLCH CXXX Office of the Chief Executive 7 th Floor 64 Victoria Street London Name Address Address Post Code SW1E 6QP Tel: 020 7798 1436 Fax: 020 7798 0891 E-mail: clchcomplaints@nhs.net Web: www.clch.nhs.uk Date DD Month YYYY Dear Mr/Mrs/Ms (or other title) I am writing in response to the concerns you raised in your letter/email/telephone call of xx Month YYYY regarding Having received your letter, xxx, xxx Manager was asked to undertake a comprehensive investigation into the issues which you raised. As part of the investigation he/she has reviewed the relevant medical notes and held discussions with the healthcare professionals involved. Investigation findings. Yours sincerely, James A. Reilly Chief Executive Central London Community Healthcare NHS Trust Enc. Health Service Ombudsman Leaflet Page 53 of 72

Please note: Receiving complaints is one way that we, at Central London Community Healthcare NHS Trust, can understand where processes have gone wrong and helps us to remedy gaps in our services. Please feel free to contact Tony Fishenden, Customer Service Manager, on 020 7798 1436 who will be happy to assist you if there is anything you would like clarified or investigated further. If you are unhappy with my response to your complaint, you may ask us to review your remaining concerns again. If you are then still unhappy, you have the right to ask the Health Service Ombudsman for an independent review of your case within twelve months from the time that you made your complaint. The Ombudsman can carry out independent investigations into complaints about poor treatment or service provided through the NHS in England. I am enclosing their leaflet which explains their service more fully. Page 54 of 72

Appendix K: Management of compliments flowchart Verbal or written received by Service Verbal or written received by CST If verbal compliment try to obtain name, address and post code of person making compliment and pass to CST. Acknowledge compliment and pass to CST within 3 working days CST acknowledges compliment and logs in Datix Inform relevant team or staff they have received compliment. CST reports compliments to the Trust (These reports do not divulge the staff member s name, but staff details are captured so that it can be used in an appropriate way. For example, it could be used to support evidence for staff recognition awards and staff appraisals if required. ) Key: CST: Customer Service Themes and learning reviewed at CLIPS meeting Page 55 of 72

Appendix L: Unreasonable and persistent complainants 1. A complaint the subject matter of which is the same as that of a complaint which has been previously investigated under the complaints legislation, and under these new legislative arrangements try to reopen or represent previously investigated cases by another organisation, and have been classified as being unreasonable, inappropriate or unreasonably persistent will not be considered. 2. If a complainant begins to demonstrate behaviours which could be classified by the lead or secondary organisations as unreasonable and persistent as described below, the lead organisation will advise the complainant and issue a letter of concern. 3. If the complainant persists then the lead organisation in consultation with any other secondary organisations involved in the complaint will make a decision to classify the complainant as unreasonable and or persistent. 4. During the complaints process CLCH staff might have contact with a small number of complainants who absorb a disproportionate amount of NHS resources in dealing with their complaints. The aim of this policy is to identify situations where the complainant might be considered to be persistent and to suggest ways of responding to these situations which are fair to both staff and complainant. It is emphasised that this policy should only be used as a last resort and after all reasonable measures have been taken to try to resolve complaints following the NHS complaints procedures, for example through local resolution, conciliation, and involvement of independent advocacy as appropriate. 5. Judgement and discretion must be used in applying the criteria to identify potential habitual complainants and in deciding the action to be taken in specific cases. This policy should only be implemented in relation to a specific complainant, following careful consideration by, and with the authorisation of, the appropriate Non-Executive Director and/or Chief Executive of CLCH 6. Complainants (and/or anyone acting on their behalf) may be deemed to be persistent where previous or current contact with them shows that they meet at least TWO of the following criteria: The same complaint with minor differences but the complainant will not accept the outcome of any investigation into their complaint after it has been fully and properly implemented and exhausted. Seek to prolong contact by changing the substance of a complaint or continually raising new issues and questions whilst the complaint is being addressed. (Care must be taken not to discard new issues which are significantly different from the original complaint. These might need to be addressed as separate complaints). Are unwilling to accept documented evidence of treatment given as being factual 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. Have harassed or been personally abusive or verbally aggressive on more than one occasion towards staff dealing with their complaint or their families or associates. (Staff must recognise that complainants may sometimes act out of character at times of stress, anxiety or distress and should make reasonable allowances for this.) Staff should document all incidents of harassment in line with the Violence at Work Procedures, completing an incident form. The complainant changes aspects of their complaint partway through the Investigation. Page 56 of 72

Deny receipt of an adequate response despite evidence of correspondence specifically answering their questions. The complainant continually makes or breaks contact with the agency/ complaint investigation lead organisation. 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 council staff, writing lengthy complex letters every few days and expecting immediate responses. The complainant persistently approaches the agency/ complaint investigation lead organisation through different routes about the same complaint, in the hope that they will secure a different response. This list is not exhaustive and so only covers some of the main kinds of behaviours and actions that come to the agency s/ lead organisations attention. 7. Check to see if the complainant meets sufficient criteria to be classified as an unreasonable or persistent complainant. Where there is an ongoing investigation The Non-Executive Director* should write to the complainant setting parameters for a code of behaviour and the lines of communication. If these terms are contravened consideration will then be given to implementing other action. * It would be inappropriate for the Chief Executive to set these parameters at this stage as s/he will be involved in the ongoing complaints process. Where the investigation is complete At an appropriate stage, the Chief Executive or Non-Executive Director should write a letter informing the complainant that: - the Chief Executive has responded fully to the points raised, and - has tried to resolve the complaint, and - there is nothing more that can be added, therefore, the correspondence is now at an end. - The Trust may wish to state that future letters will be acknowledged but not answered. 8. In extreme cases the PCT should reserve the right to take legal action against the complainant. WITHDRAWING PERSISTENT STATUS 9. Once complainants have been determined as persistent there needs to be a mechanism for withdrawing this status at a later date if, for example, complainants subsequently demonstrate a more reasonable approach or if they submit a further complaint for which normal complaints procedures would appear appropriate. Staff should previously have used discretion in recommending persistent status and discretion should similarly be used in recommending that this status be withdrawn. Page 57 of 72

Appendix M: Consent/Authority Form (complaint on behalf of a patient) This form is for you to gain consent from the patient, or another legally responsible party, for you to progress a complaint against Central London Community Healthcare NHS Trust (CLCH). You should include a copy of this form when making the complaint. You are giving signed consent informing CLCH that you wish a named person, e.g. an advocate, spouse, family member, solicitor or friend, to submit a complaint on your behalf. It may be necessary, in order to answer the complaint fully to refer to your past/present medical history. By signing this Consent Form, you are agreeing that your medical information may be shared with your nominated person, if appropriate to do so, unless you express a specific request to the contrary. Section A Your Details Title (Mr, Mrs, Ms etc.): Full name: Address: Post Code: Daytime telephone number: Email address: Mobile Number: Section B - Patient Details Full name of patient: Patient s date of birth: Patient s address (if different from above): Post Code: (Date/ Month/Year) Your relationship to the patient: Section C - Patient Consent Has the patient agreed to this complaint? Yes No Deceased Page 58 of 72

C1 - If the patient is able to consent to the complaint being progressed by you as a representative, please complete the following: I am the patient I agree to the person named in this form, making this complaint on my behalf. I agree they may see my medical records and any other information that might be relevant to this complaint. Signature: Date: C2 - If the patient is under 16 years old, a parent or guardian must fill in this section: My name is: Who I am: (for example: patient, patient s relative, patient s next of kin, patient s solicitor, etc.) I give my permission for (representative s name) to make a complaint on s behalf. I also agree that they be shown any medical records which are relevant to this complaint. Signature: Date: C3 - If the patient has died, their next of kin or legal representative must fill in this section: My name is: Who I am: (for example: patient s next of kin, legal representative, etc. You may need to provide evidence of this, for example, power of attorney) I give my permission for (representative s name) to make a complaint on s behalf. I also agree that they be shown any medical records which are relevant to this complaint. I confirm that I have the legal authority to give this permission. Signature: Date: Page 59 of 72

C4 - If the patient is NOT able to consent to the complaint being progressed by you as a representative, please complete the following: I am the patient s representative Signature: Date: The patient is not able to give their direct permission because: Once completed, please return this form to: Customer Service Team Freepost RSLS-RCUA-XZAX 7 th Floor 64 Victoria Street London SW1E 6QP Email: clchcomplaints@nhs.net Tel: 0800 368 0412 Page 60 of 72

Appendix N Customer Service Feedback Leaflet Page 61 of 72

Appendix O: Customer Service Feedback Leaflet-Easy Read version Page 62 of 72

Appendix P: Customer Service Feedback Leaflet-Easy Read version Customer Satisfaction Survey: Customer Services Team Please read each question and tick the box which best describes your experience of our service. There are no right or wrong answers, it is your experience we are interested in. All information you provide is strictly confidential and will be used to improve Central London Community Healthcare (CLCH) NHS Trust services. Please answer every question. When you have finished the survey, please return it to us using the envelope provided. Q1. Where did you learn about how to raise your concerns? (Please tick all that apply) fec Saw a poster and read information cfe Telephoned switchboard at the Trust ecf Asked for a leaflet cfe Contacted another department within the Trust cef Asked a member of staff what I should do cfe Asked a friend, relative or colleague what I should do Contacted another organisation (e.g. NHS efc Westminster, Imperial College, ICAS) fec I already knew how to make a complaint fec Contacted Customer Services fec Other (please specify) Q2. How easy did you find it to access Customer Services to raise your concerns? fec Very easy fec Fairly easy fec Fairly difficult cfe Very difficult Q3. How easy to understand was the information you were given about how to raise your concerns? fec Very clear fec Fairly clear fec Fairly unclear cfe Very unclear Q4 Were you satisfied with the amount of time Customer Services took to respond to your concerns? fec Yes fec No Page 63 of 72

Q4.1 If NO to Q4, please give detail Q5. Did our response answer all the issues you raised? efc Yes => Go to Q6 fec Some but not all => Go to Q5.1 cfe No => Go to Q5.1 Q5.1 If you answered NO or SOME BUT NOT ALL to Q5 please specify in the box below: Q6. How would you rate the help and support provided by Customer Services? fec Very helpful fec Fairly helpful fec Fairly unhelpful cfe Very unhelpful Q7. Do you feel that the service concerned has changed, or been altered, as a result of raising your concerns? efc Yes =>Go to Q7.1 cfe No =>Go to Q8 cfe Not sure / Don't know => Go to Q8 Q7.1 If you answered YES to Q7, how would you describe the changes to the service? (Please give details below) fec An improvement fec Became worse Q8. Overall how satisfied are you with the way we dealt with your concerns? efc Very satisfied fec Satisfied fec Unsatisfied cfe Very Unsatisfied Q8.1 If you would like to provide further details regarding your answer to Q8 please provide in the box below: Q9. CLCH NHS Trust aims to improve and develop services in the future by involving patients and service users through our Foundation Trust Membership. Would you agree to your details being shared with our Membership Team for this purpose? fec Yes fec No Page 64 of 72

Q10. Would you like to make any further comments? If so, please enter them into the box below. Page 65 of 72

Appendix Q: Equality Monitoring Form We have a legal duty to eliminate discrimination and to promote equality for all our patients, service users and their carers. We use the following information to help assess whether we are providing equal access and treatment for different groups of people. What we would like you to do Please take a moment to fill in the information below. If you do not wish to answer any questions please state that you would rather not say. This information will be treated in the strictest confidence. Your cooperation in this matter is greatly appreciated. I enclose a freepost envelope for you to return this information. Please tick a box/ boxes as appropriate for each question Patient s name: 1. Please tell us your Age: 16-21 21-29 30-39 40-49 50-59 60-69 70 or above Rather not say 2. Do you consider yourself to have a disability? Yes No Rather not say 2b. If yes do you have a: Physical Impairment Sensory Impairment Learning Disability Mental Health Condition (Long Term) Other Health Condition (Long Term) 3. Ethnicity Asian or Asian British Bangladeshi Indian Pakistani Any Other Asian Background (please state) Black or Black British African Caribbean Any Other Black Background (please state) Mixed White and Asian White and Black African White White British White Irish Any Other White Background (please state) Other Ethnic Group Chinese Any Other Ethnic Group (please state) Rather not say Page 66 of 72

White and Black Caribbean Any Other Mixed Background (please state) 4. Gender Female Male Rather not say 5. Religion or Beliefs Atheism Agnosticism Buddhism Christianity Hinduism Humanism Islam 6. Sexual Orientation Bisexual Gay Man Heterosexual Jainism Judaism Sikhism Any Other Religion/Belief (please state) No Religion or Belief Rather not say Lesbian/Gay Woman Other Rather not say In complying with the Data Protection Act 1998 CLCH confirm that it will process data gathered from this form only for the purposes relating to ensuring the organisation meets its NHS equality and diversity requirements For more information contact Lesley Soden, Head of Equality & Human Rights by emailing Lesley.Soden@clch.nhs.uk Page 67 of 72

Appendix R Complaint Severity Assessment Matrix STEP ONE: SEVERITY - HOW SEVERE ARE THE CONSEQUENCES? Choose the most appropriate domain for the identified risk from the left hand side of the table Then work along the columns in same row to assess the severity of the risk on the scale of 1 to 5 to determine the consequence score, which is the number given at the top of the column. Table 1: Severity / Impact Categories Consequence score (severity levels) and examples of descriptors 1 2 3 4 5 Domains Negligible Minor Moderate Major Catastrophic Impact on the safety of patients, Minimal injury requiring Minor injury or illness, requiring Moderate injury requiring Major injury leading to longterm staff or public (physical/ psychological harm) no/minimal intervention or treatment. minor intervention professional intervention Requiring time off work for <3 days incapacity/disabilit y No time off work Increase in length of hospital stay by 1-3 days Requiring time off work for 4-14 days Increase in length of hospital stay by 4-15 days Requiring time off work for >14 days Increase in length of hospital stay by >15 days RIDDOR/agency reportable incident Mismanagement of patient care with An event which long-term effects impacts on a small number of patients Incident leading to death Multiple permanent injuries or irreversible health effects An event which impacts on a large number of patients Quality/complaints/ audit Peripheral element of treatment or service suboptimal Informal complaint/inquiry Overall treatment or service suboptimal Formal complaint (stage 1) Local resolution Single failure to meet internal standards Minor implications for patient safety if unresolved Treatment or service has significantly reduced effectiveness Formal complaint (stage 2) complaint Local resolution (with potential to go to independent review) Repeated failure to meet internal standards Non-compliance with national standards with significant risk to patients if unresolved Multiple complaints/ independent review Low performance rating Critical report Totally unacceptable level or quality of treatment/service Gross failure of patient safety if findings not acted on Inquest/ombudsma n inquiry Gross failure to meet national standards Page 68 of 72

Reduced Major patient performance rating safety implications if unresolved if findings are not acted on Human resources/ organizational development/ staffing/ competence Short-term low staffing level that temporarily reduces service quality (< 1 day) Low staffing level that reduces the service quality Late delivery of key objective/ service due to lack of staff Unsafe staffing level or competence (>1 day) Low staff morale Uncertain delivery of key objective/service due to lack of staff Unsafe staffing level or competence (>5 days) Loss of key staff Non-delivery of key objective/service due to lack of staff Ongoing unsafe staffing levels or competence Loss of several key staff Statutory duty/ inspections Adverse publicity/ reputation No or minimal impact or breech of guidance/ statutory duty Rumours Potential for public concern Breech of statutory legislation Reduced performance rating if unresolved Local media coverage short-term reduction in public confidence Elements of public expectation not being met Poor staff attendance for mandatory/key training Single breech in statutory duty Challenging external recommendations/ improvement notice Local media coverage long-term reduction in public confidence Very low staff morale No staff attending mandatory/ key training Enforcement action Multiple breeches in statutory duty Improvement notices Low performance rating Critical report National media coverage with <3 days service well below reasonable public expectation No staff attending mandatory training /key training on an ongoing basis Multiple breeches in statutory duty Prosecution Complete systems change required Zero performance rating Severely critical report National media coverage with >3 days service well below reasonable public expectation. MP concerned (questions in the House) Total loss of public confidence Page 69 of 72

Business Insignificant cost <5 per cent over 5 10 per cent over Non-compliance Incident leading objectives/ projects increase/ project budget project budget with national 10 >25 per cent over schedule 25 per cent over project budget slippage Schedule slippage Schedule slippage project budget Schedule slippage Schedule slippage Key objectives not Key objectives not met met Finance including claims Small loss Risk of claim remote Loss of 0.1 0.25 per cent of budget Claim less than 10,000 Loss of 0.25 0.5 per cent of budget Claim(s) between 10,000 and 100,000 Uncertain delivery of key objective/loss of 0.5 1.0 per cent of budget Claim(s) between 100,000 and 1 million Purchasers failing to pay on time Non-delivery of key objective/ Loss of >1 per cent of budget Failure to meet specification/ slippage Loss of contract / payment by results Claim(s) > 1 million Service/business interruption Environmental impact Loss/interruption of >1 hour Minimal or no impact on the environment Loss/interruption of >8 hours Minor impact on environment Loss/interruption of >1 day Moderate impact on environment Loss/interruption of >1 week Major impact on environment Permanent loss of service or facility Catastrophic impact on environment STEP 2: Likelihood What is the likelihood of the consequence occurring? Likelihood may need to be assessed in a different manner depending on the nature of risk. For example, the likelihood that a particular incident will occur in a particular team is best suited to a likelihood measure that is based on frequency (Table 2). If, however, we look at the risks associated with visiting a service user at home, it is sensible to focus on the probability that the risk will be actualized given existing controls that are in place (Table 3). It is for this reason that the measure of likelihood has been split into two tables, either of which may be used as appropriate. Table 2: Likelihood / Frequency Scale The frequency-based score is appropriate in most circumstances and is easier to identify. It should be used whenever it is possible to identify a frequency. Likelihood score 1 2 3 4 5 Descriptor Rare Unlikely Possible Likely Almost certain Frequency Not expected to Expected to occur Expected to occur Expected to occur Expected to occur occur for years. at least annually. at least monthly. at least weekly at least daily Page 70 of 72

Table 3: Likelihood / Probability Scale Likelihood score 1 2 3 4 5 Descriptor Rare Unlikely Possible Likely Almost certain Frequency This will probably never happen/recur Do not expect it to Might happen or happen/recur but it recur occasionally is possible it may do so Will probably Will undoubtedly happen/recur but it happen/recur, is not a persisting possibly frequently issue STEP 3: The Risk Matrix (Likelihood x Consequence) - In order to calculate the risk score, the likelihood is multiplied by the severity/impact using the matrix in Table 4. Table 4: The Risk Matrix Likelihood Consequence 1 2 3 4 5 Rare Unlikely Possible Likely Almost certain 5 Catastrophic 5 10 15 20 25 4 Major 4 8 12 16 20 3 Moderate 3 6 9 12 15 2 Minor 2 4 6 8 10 1 Negligible 1 2 3 4 5 STEP 4: Risk Treatment Decide on a course of action which is relative to the level of risk. Risk Rating Degree of Risk Action required to reduce the risk (1-3) Low A risk at this level may be acceptable. If not acceptable, existing controls should be monitored or adjusted. No further action or additional controls are required. (4-6) Moderate Not normally acceptable. Efforts should be made to reduce the risk, provided this is not disproportionate. Establish more precisely the likelihood of harm as a basis for determining the need for improved control measures. (8-12) Significant Very unlikely to be acceptable. Significant resources may have to be allocated to reduce the risk. Where the risk involves work in progress urgent action should be taken. (15-25) High Unacceptable. Immediate action must be taken to manage the risk. Control measures should be put into place which will have the effect of reducing the impact of an event or the likelihood of an event occurring. A number of control measures may be required. Page 71 of 72

Instructions for use 1. Define the risk(s) explicitly in terms of the adverse consequence(s) that might arise from the risk. 2. Use table 1 to determine the consequence score(s) (C) for the potential adverse outcome(s) relevant to the risk being evaluated. 3. Use tables 2 or 3 to determine the likelihood score(s) (L) for those adverse outcomes. If possible, score the likelihood by assigning a predicted frequency of occurrence of the adverse outcome. If this is not possible, assign a probability to the adverse outcome occurring within a given time frame, such as the lifetime of a project or a patient care episode. If it is not possible to determine a numerical probability then use the probability descriptions to determine the most appropriate score. 4. Calculate the risk score the risk multiplying the consequence by the likelihood: C (consequence) x L (likelihood) = R (risk score) 5. Identify the level at which the risk will be managed in the organisation, assign priorities for remedial action, and determine whether risks are to be accepted on the basis of the colour bandings and risk ratings, and the organization s risk management system. Include the risk in the organisation risk register via Datix at the appropriate level. Page 72 of 72