COMPLAINTS, CONCERNS, COMMENTS & COMPLIMENTS POLICY AND PROCEDURE

COMPLAINTS, CONCERNS, COMMENTS & COMPLIMENTS POLICY AND PROCEDURE Version: Approved by: Date approved: Date ratified by Governing Body: Name of originator/author: Name of responsible committee/individual: Date issued: Review date: Target audience: Final Governing Body Diane Hampshire, Director of Quality and Nursing, Leeds North CCG, on behalf of the Leeds CCG Network Richard Gibson, Head of Governance on behalf of the Leeds CCG Network Governance, Risk & Performance Committee To remain in place until June 2015 or sooner if there national policy or legislation changes All Directors, All Senior and Middle Managers and Staff Representatives of the Leeds CCG network - 1 -

Contents SECTION 1 COMPLAINTS POLICY 1. Policy Introduction 3 2. Definition 4 3. Aims 4 4. Scope of Policy 5 5. Equality Impact Assessment (EIA) 5 6. Exemptions 5 7. Roles and Responsibilities 6 8. Time limits 7 9. Habitual Complainants 7 10. Review Approval and Ratification Process 7 11. Implementation and Dissemination 7 12. Reporting and Performance 8 13. General Principles of the Policy 8 Annex A Flowchart of Complaints Handling for Leeds CCGs 9 via the network Governance Team SECTION 2 GUIDANCE FOR MANAGING COMPLAINTS 1. Stage 1: Local Resolution 10 2. Receiving Complaints 17 3. Acknowledging Complaints 17 4. Investigating Complaints 19 5. Agreeing Contacts regarding Progress of the Complaint 21 6. Meetings 21 7. Responses 21 8. Compensation and Ex-Gratia Payments 23 9. Reporting Arrangements 23 10. Compliments 23 11. The Pals and Complaints Interface 23 STAGE 2: Parliamentary and Health Service Ombudsman 25 Review Review of Complaints procedure 25 Other Related Policies 25 SECTION 3 COMPLAINTS RESOURCE PACK Appendix 1 Guidance on Handling Verbal Concerns & Complaints 27 Appendix 2 Guidance on Writing a Response 28 Appendix 3 Investigating a Complaint 31 Appendix 4 Mediation 33 Appendix 5 Complaints, Comments & Compliments Form 34 Appendix 6 Flow Chart Complaints Handling Process 35 Appendix 7 Complaint Investigation Form 36 Appendix 8 Key Personnel & Useful Contacts 41 Appendix 9 Habitual Complaints Procedure 42 Appendix 10 Process for Complaints Involving a Member of Parliament 47-2 -

SECTION 1 POLICY Equality Statement This policy applies to all Leeds North CCG employees irrespective of age, race, colour, religion, disability, nationality, ethnic origin, gender, sexual orientation or marital status, domestic circumstances, social and employment status, HIV status, gender reassignment, political affiliation or trade union membership. All employees will be treated in a fair and equitable manner and reasonable adjustments will be made where appropriate, e.g. interpreter or signing provision, access arrangements, induction loop, etc. Leeds North CCG will ensure that this policy is monitored and evaluated by the Governance, Performance & Risk Committee. 1. Introduction The purpose of the policy is to provide an open, fair and accessible process for complaints about NHS care provided by or resulting from commissioning decisions by Leeds North CCG. The policy also includes the process for handling complaints, comments and concerns and outlines the action to be taken at each stage of the process. Leeds North CCG is firmly committed to continuously improving the quality of care and the services it provides, to ensure the satisfaction of its customers and users. Complaints, Comments and Concerns are one way of receiving feedback from the users perspective of the service provided and this policy therefore encourages the views, comments and suggestions of its service users. Leeds North CCG welcomes feedback, both positive and negative about the quality of services. Competent handling of complaints can assist in improving the quality of care and minimising claims by listening to the service user and using this as an opportunity for learning. It is therefore important that Leeds North CCG has a consistent and orderly process for receiving and handling complaints, concerns and comments appropriately and makes positive use of the information gained to avoid similar occurrences and to improve services. This policy and its procedure is written in consideration with the Local Authority Social Services and National Health Service Complaints (England) Regulations 2009, which came into force on 1 April 2009, the NHS Constitution and the principles set by the Parliamentary and Health Service Ombudsman. The arrangements herein are designed to be accessible and allow for people to complain in a variety of ways including by telephone, in writing, by email etc and be provided with a considered and prompt response. - 3 -

2. Definition For the purpose of this policy Leeds North CCG adopts the following definition: A complaint is an expression of dissatisfaction received from a patient, carer or service user about any aspect of services requiring a response. 3. Aims Leeds North CCG complaints policy and procedure aims to meet the following criteria. Ensure that the Complaints Procedure is flexible and meets the needs of patients Meets the principles laid down by the Parliamentary and Health Service Ombudsman and The Local Authority Social Services and National Health Service Complaints (England) Regulations 2009 To use information from complaints, concerns and comments to improve services where appropriate Be well publicised and easy to access so that complainants are helped to make complaints Be simple to understand and use Be fair and impartial, and be seen to be so Allow complaints to be managed promptly and as close to the point where they arise as possible Provide answers or explanations quickly and within established time limits Ensure that rights to confidentiality and privacy are respected Provide a thorough and effective mechanism for resolving complaints and also investigating matters of concern and comments Enable lessons learned to be used to improve the quality of services Ensure patients care actively promotes their privacy and dignity and protects their modesty Ensures that the unique needs of children and young people are met in terms of compliments and complaints Ensure the complainants are treated courteously and sympathetically Regularly reviewed and amended if found to be lacking in any respect Be consistent with national guidance For Staff To support staff who may be subject of a complaint For Leeds North CCG To ensure the essential information is obtained to respond fully to the service user, to monitor response timescales and report externally to the Department of Health Lessons are learnt from complaints, concerns and comments to improve the quality of services - 4 -

4. Scope of the Policy This policy must be followed by all staff who are employed by Leeds North CCG and those on temporary or honorary contracts, secondments, pool staff and students. This policy will also apply to complaints received by Leeds North CCG concerning local providers of NHS services. Under the Local Authority Social Services and National Health Service Complaints (England) Regulations 2009 complainants have the choice of making a complaint to either the provider or the commissioner of services Independent Contractors are responsible for the development and management of their own procedural documents and for ensuring compliance with the Local Authority Social Services and National Health Service Complaints (England) Regulations 2009 and best practice guidelines. Leeds North CCG will provide advice and support as required. 5. Equality Impact Assessment (EIA) Screening for the Equality and Impact Assessment reveals that a full assessment is unnecessary, as the impact of this policy on staff or members of the public is medium. The equality impact of the guideline will be measured by monitoring any comments or complaints relating to the contents of the document. 6. Exceptions The complaints policy and procedure is for patients, users of the service or their representatives. The following issues do not fall within this policy: Staff Grievances Staff grievances should be followed up via the Human Resources policy on staff grievances Staff Complaints about Patient Care Staff concerns about patient care or services should be followed up via Clinical Governance Procedures and Policies Disciplinary Procedure Disciplinary matters must be kept separate from the complaints procedure. The Governance Team is only concerned with resolving complaints and not investigating disciplinary matters. Criminal Matters Where there are allegations relating to assault or other serious criminal matters, these should be reported to the Counter Fraud and Security manager immediately. The Accountable Officer must be informed for a decision to be taken on whether to refer the matter to the Police. - 5 -

Complaints by Independent Contractors This policy cannot be used for complaints by independent contractors against Leeds North CCG policy. Dispute resolution procedures are in place for this and can be obtained from an Executive Director This policy cannot be used for complaints about the conduct of Leeds North CCG employees This policy cannot be used for complaints concerning locum reimbursement. Freedom of Information/Data Protection Act Complaints relating to Freedom of Information and Data Protection should be sent to the Complaints Manager who will log details of the complaint. The complaint will be passed on to the Information Governance Team for action. The Complaints Manager will be informed of, and will log details of the outcome. 7. Roles and Responsibility The Chief Officer is the person with overall responsibility for the complaints process. Prime responsibility and accountability for Complaints management must remain part of Leeds North CCG general management structure with Executive Directors, General Managers, Directorate Managers and other senior professional staff responsible for the maintenance of standards in their area. Designated Board Member The Director of Quality and Nursing is the Governing Body lead responsible for ensuring that complaints are processed in line with the Local Authority Social Services and National Health Service Complaints (England) Regulations 2009 and that action is taken in light of the outcome of any complaint investigations. They will also be responsible for ensuring that the Board is informed and ultimately assured, that the Complaints policy and procedures are effective. Head of Governance, Leeds West CCG The Head of Governance at Leeds West CCG is responsible for the complaints process for each CCG in Leeds on behalf of the Leeds CCG Network. The Head of Governance is responsible for ensuring that the Complaints Policy and Procedures are followed and that complaints are actioned in line with the policy. Governance Team, Leeds West CCG The Governance Team at Leeds North CCG has responsibility for administering the complaints process for each CCG in Leeds on behalf of the Leeds CCG Network. The Governance team will acknowledge all complaints and is responsible for all aspects of the administration of the complaints process within the policy requirements and maintaining the complaints database. The Governance Team will support the investigation of complaints. - 6 -

Directors and Heads of Service Directors and Heads of Service are responsible for ensuring that all complaints are managed in a timely and sensible manner. Action plans must be developed in order that lessons can be learnt and changes are made to improve services as a result of the complaint. Line Managers Line Managers should ensure staff involved with a complaint are offered support and time to reflect on the situation and the opportunity to debrief in line with the Incident Management Policy. In the event of staff being asked to give witness statements in relation to a complaint then the line manager must ensure that the staff member has access to appropriate advice with this regard. 8. Time Limits A complaint should normally be made within twelve months from the incident that caused the problem or within twelve months of the date of discovering the problem. Complaints which relate to an incident that took place more than twelve months ago may be impossible to investigate to the depth required in order to fully answer the issues raised due to the time lapse involved. Leeds North CCG has the discretion to extend this time limit where it would be unreasonable in the circumstances of a particular case for the complainant to have made their complaint earlier, and where it is still possible to investigate the facts of the case. The Governance Team, in consultation with the relevant Head of Service/Lead Manager, will make a decision on individual cases. 9. Habitual Complainants Leeds North CCG is committed to treating all complaints equitably and recognises that it is the right of every individual to pursue a complaint. Leeds North CCG will endeavor to resolve all complaints to the complainant s satisfaction. Where it is considered that a complainant is habitual i.e. the complainant and/or anyone acting on their behalf meet any of the criteria in Appendix 9, the Governance Team will follow the Leeds North CCG policy and procedure on Habitual Complaints. 10. Review Approval and Ratification Process The Complaints policy will remain in place until June 2015, or will be reviewed earlier in the event of changes to the legislation. This policy will be authorised by the Governance, Performance & Risk Committee and approved and ratified by the Leeds North CCG Governing Body 11. Implementation and Dissemination The Complaints policy will be disseminated via the CCG internal communications systems. - 7 -

12. Reporting and Performance It is important that changes and improvements made as a result of a complaint are communicated to the Governance Team to ensure dissemination of good practice. A reporting sheet will be provided to the relevant Investigating Officer for completion and is included at Appendix 7. The Governance Team will produce regular reports on complaints to the Governance, Performance & Risk Committee in line with its work programme. The Governance Team will provide an annual report and commentary of the Complaints for inclusion in the CCG Annual Report. 13. General Principles of the Policy The policy and procedures herein must be followed to ensure that complaints are managed in accordance with national requirements and expectations. The policy will be implemented by all employees that are likely to receive and manage complaints. Complaints are one mechanism for feedback about quality of services provided and commissioned and provides information for ongoing improvement and development. Health Service Providers have a responsibility to do all that is possible to reduce the likelihood of similar complaints recurring. Great emphasis will be placed on resolving complaints quickly and thoroughly. If complaints are not resolved at the Local Resolution stage, including conciliation, complainants have the right to request an Independent Review by the Parliamentary and Health Service Ombudsman. Violence or abuse against NHS staff is unacceptable; therefore, all complainants are required to behave in accordance with the NHS Policy for Zero Tolerance. - 8 -

Flowchart of Complaints Handling for Leeds CCGs via the network Governance Team ANNEX A Email from complainant (generic email address) Patient Letter (Addressed to Complaints ) Telephone call via PALS signposted to formal complaints process Leeds North CCG office Leeds West CCG office Leeds South & East CCG office Governance Team (Leeds West) Send acknowledgement to complainant on behalf of receiving CCG Liaise directly with the complainant Link with the appropriate manager across the network to investigate Compile the final response Pass to Accountable Officer (AO) of receiving CCG for review and sign off. Copy Copy Copy Leeds North CCG office Leeds West CCG office Leeds South & East CCG office Complainant - 9 -

SECTION 2 GUIDANCE FOR MANAGING COMPLAINTS Introduction The following Parliamentary and Health Service Ombudsman s principles will be applied to the management of all complaints. Getting it right Being customer focused Be open and accountable Acting fairly and proportionately Putting things right Seeking continuous improvement This guidance will also take into consideration the NHS Constitution, which advises that: Complainants have the right to: Have any complaints made about NHS services dealt with efficiently and to have it properly investigated Know the outcome of any investigation into their compliant Take their complaint to the independent Health Service ombudsman, if they are not satisfied with the way their complaint has been dealt with by the NHS Make a claim for judicial review if they think they have been directly affected by an unlawful act or decision of an NHS body and Compensation where they have been harmed by negligent treatment Leeds North CCG also commits: To ensure complainants are treated with courtesy and receive appropriate support throughout the handling of a complaint; and the fact that a complaint has be made will not adversely affect any future treatment When mistakes happen, to acknowledge them and apologise, explain what went wrong and put things right quickly and effectively promoting a climate of openness in accordance the Being Open approach advocated by the National Patient Safety Agency and the Leeds North CCG Being Open Policy and Procedures Stage 1: Local Resolution General Principles The local resolution stage of the complaints procedure refers to the period when Leeds North CCG seeks to resolve the issues raised in a complaint locally to the satisfaction of the complainant. The majority of complaints received by Leeds North CCG are resolved at this local resolution stage. A complaint is an expression of dissatisfaction received from a patient, carer or service user about any aspect of Leeds North CCG services requiring a response. - 10 -

1.1 Time Limits A complaint should normally be made within twelve months from the incident that caused the problem, or within twelve months of the date of discovering the problem. Leeds North CCG has the discretion to extend this time limit where it would be unreasonable in the circumstances of a particular case for the complaint to have been made earlier and where it is possible to investigate the facts of the complaint. Where Leeds North CCG decides not to investigate a complaint because it is out of time the complainant must be informed of their right to refer this to the Parliamentary and Health Service Ombudsman (PHSO). 1.2 Provision of care whilst a complaint is in progress It is recognised that, on rare occasions, the relationship between a patient and a member of staff providing the care may break down and the patient may feel cause to complain about that individual. This may happen in any discipline and within the services provided by Leeds North CCG. It is Leeds North CCG policy not to withdraw clinical treatment or support as a result of a complaint. If a patient complains verbally to a member of staff, in accordance with the local resolution procedure, the recipient of the complaint should try and resolve the matter to the complainant s satisfaction at the time or within a very short period, so as to minimise any ill effect on the patient s continuing care. If a patient complains in writing, the investigating officer will endeavour to resolve matters quickly, also having regard to the patient s need for continuing care. If either side feels that the matter cannot be resolved and the complaint is impacting on the relationship between the patient member of staff, then the member of staff must contact their line manager and appropriate head of service as a matter of urgency (i.e. within 24 hours) to discuss the most appropriate way to resolve the matter. The line manager will inform the complaints department so the complaint can be appropriately recorded. 1.3 Types of Complaints Leeds North CCG will receive complaints in any format, which the complainant wishes to forward details relating to the complaint. Written Complaints The Chief Officer, Governance Team, Head of Service or any member of staff working within Leeds North CCG could receive written complaints. All written complaints should be forwarded to the Governance Team at Leeds West CCG for acknowledging as soon as they are received. - 11 -

Verbal complaints A verbal complaint should be viewed as seriously as written complaints. Any member of staff who is approached by a patient or their representative with a complaint should endeavour to resolve the matter there and then. Whenever possible complaints should be resolved at the time. Any verbal complaints that cannot be resolved at the time should be handled in the same timescales as written ones. If the matter remains unresolved after 48 hours, the member of staff receiving the complaint should complete then re-grade the issue as a complaint if it has not already been done so. Complaint via Email Complaints received via email should be viewed as seriously as written complaints and processed in the same manner. Patients sensitive information will not be sent by email. Acknowledgement or response letters should be sent by post. Leeds North CCG has an email address: leeds.complaints@nhs.net specifically for the receipt of complaints. Consent Complaints via a Third party There are many occasions where a complaint is made indirectly through a third party (e.g. GP s parent or sibling, MP s). The process and investigation will normally follow the same procedure as a complaint that is made directly by a patient. In all cases, when a letter of complaint is received by a third party, the Governance Team will acknowledge the letter and gain consent from the patient to investigate. When drafting the response the investigating manager should always be aware of the confidential nature of the response. All final responses will be copied to the patient. Exceptions include requests from a parent of a patient under the age of 16 (although under Data Protection if a child is considered capable of understanding the implications of their decisions then their wishes should be followed) and complainants who have guardianships or power of attorney that has been registered with the Court of Protection. In all cases the status of the complainant should be confirmed and each request should be considered on a case-by-case basis. If it is evident from the complaint that the patient is unable to consent to the investigation, the CGovernance Team will decide whether to proceed, following discussion with the complainant. When a complaint is received relating to a deceased patient, a response should be sent to the next of kin only. - 12 -

Occasionally, a complaint will be received where the complainant has no apparent connections with the patient concerned. In such cases, before any investigation can commence the following points should be clarified: a) Does the patient know a complaint has been made on their behalf? b) Has the patient authorised the complainant to make enquiries or can an acceptable connection be established? Letters received from solicitors raising a complaint on behalf of an individual should be dealt with in the same way as all other complaints unless it is explicit that legal action is intended. The Head of Governance should be informed of all such instances. 1.4 Closure of Complaints in the absence of Consent If consent is not given, the Governance Team will determine whether the patient would like to receive a response to the complaint or if the complaint is to be closed as in some cases an investigation cannot be carried out without consent. Any deadline for the return of consent will be detailed in the letter of acknowledgement. However, the decision to reopen a complaint can be reviewed by the Governance Team at any time. 1.5 MP letters and Letters to the Accountable Officer Complaints and letters requesting information relating to individuals received through Members of Parliament must be forwarded to the Chief Officer Office who will then liaise with the Governance team to determine ongoing process. As in all other complaints, the Chief Officer will sign the reply. However, in some cases the complaint will be handled directly with the complainant and, in such cases, a letter stating that this is happening may be an appropriate reply to the MP. The Leeds North CCG process for managing complaints involving members of parliament is presented in Appendix 10. 1.6 Complaints by a disabled person Leeds North CCG encourages complaints from disabled people and will seek to assist as appropriate to that individual s disability. For example if a complainant has a sight disability the complainant should be invited to submit details in Braille, or on tape and the Governance Team should arrange for this communication to be transcribed and verified by the complainant. 1.7 Complaints involving Independent Practitioners (IP s) e.g. GPs, dentists, opticians, pharmacists & commissioned services IP s are independent contractors and not employees. The NHS Complaints procedure is based on local resolution. In this case the Practitioners are obliged to investigate their own complaints at local resolution stage. Leeds North CCG is obliged to support the NHS Complaints procedure by giving advice to both patients and practitioners and facilitating the next stage, which is called independent review. - 13 -

Where a complainant wishes to raise a formal complaint against an Independent Practitioner services then they should be directed to NHS England who are the commissioner of these services. 1.8 Complaints involving treatment provided by any provider of NHS services Complainants can choose whether to complain to the provider or the commissioner of NHS services. In the case of the NHS services for Leeds residents this would be their local Clinical Commissioning Group. Where a complaint is received, then the Governance team will facilitate the investigation and response. Where a serious complaint is received about any NHS commissioned service for Leeds patients the Governance Team will ensure that there is a full review of the complaint asking appropriate clinicians to comment. In most cases this will be a handling role, but if it wishes, under the 2009 complaints regulations, Leeds North CCG may choose to investigate any complaint concerning a provider of NHS Services directly. 1.9 Complaints about a continuing care decision/special referrals decision It is important to recognise that the review procedure for continuing care or special referrals is not part of the complaints procedure. The fact that someone has had their case considered by a continuing care review panel or special referrals panel, does not affect their rights under the NHS complaints procedure. They can complain about the original decision on discharge, or the continuing care review. Special referrals process, through the NHS complaints procedure. 1.10 Mixed Sector Complaints A requirement of the Local Authority Social Services and National Health Service Complaints (England) Regulations 2009 is that complainants should receive one coordinated response if their complaint concerns a number of organisations. Where a complaint involves more than one NHS provider, or one or more other bodies (e.g. Social Services), there should be full co-operation in seeking to resolve the complaint as agreed through the Complaints Inter-Agency protocol and the Local Authority Social Services and National Health Service Complaints (England) Regulations 2009. If a complaint is made to Leeds North CCG regarding more than one provider the Governance Team will liaise with each organisation and request that a response is forwarded to Leeds North CCG who will then arrange a combined response. Where complaints are about both NHS and Local Authority services. The Governance Team will liaise with the Local Authority to co-ordinate a joint response. If the complaint cannot be resolved within 2 working days it should be referred to the appropriate Head of Service to take action to resolve the complaint. The Head of Service will risk assess the complaint to ascertain whether it can be managed locally or whether to refer it to the Governance Team. - 14 -

1.11 Complaints concerning a possible Criminal Offence, Alleged Physical Abuse of Patients or Serious Untoward Incident involving harm to a Patient Where a complaint concerns either: a) a possible criminal offence; b) the alleged abuse of patients; c) A serious untoward incident involving harm to a patient or d) A matter which should be referred to one of the professional regulatory bodies the appropriate investigating manager must be informed immediately. This notification may be made at any point during any stage of the complaints process. In this instance the Allegations of Abuse against Staff Policy should be invoked. The investigating manager must refer to the multi agency adult protection policy in relation to the alleged issues, which fall under the definition of adult abuse and follow the agreed procedure. Other matters may need to be referred to the police and the Chief Officer if a possible criminal offence had been committed. This should be reported to the next Confidential Governing Body Meeting. If an issue is referred to the police, any investigation must stop. The investigating manager must involve the Chief Financial Officer of any possible financial offence. 1.12 Complaints involving Litigation or requiring Legal Advice Legal advice on particular aspects of a complaint should be sought if there is the possibility of litigation ensuing. Where a complaint is already a cause of possible litigation and particularly where the approach is made by solicitors acting on behalf of the patient, the matter should be referred immediately to the Governance Team who will seek legal advice if necessary. Following consultation, the investigating manager may wish to explore with the complainant the options available, which could prevent the possibility of litigation ensuing (e.g. an apology, admission of liability, offer of compensation), Copies of the letter will be passed to the clinician and other professional staff involved informing them that the case has been referred for legal advice and advising them to contact their defense union or professional organisation and, if appropriate, the solicitor acting on behalf of Leeds North CCG. The Governance Team will refer complaints to the Head of Governance where a complainant explicitly indicates an intention to take legal action. Complaints received where litigation is being followed are not excluded from the NHS complaints procedure. Where complaint investigation is being undertaken in parallel with a claim investigation advice will be sought from the NHS Litigation Authority. 1.13 Correspondence from the Press If correspondence is received from the press regarding a complaint, the Head of Communications & Engagement should be contacted in the first instance. 1.14 Freedom of Information Act - 15 -

The complaints procedure cannot deal with complaints about non-disclosure under the Freedom of Information Act. These are dealt with under a separate policy and should be referred to the Information Governance Manager. 1.15 Staff Grievances Staff Grievances should not be reported through the complaints procedure but should be dealt with through Leeds North CCG Grievance procedure. Further advice can be obtained from Workforce Team. 1.16 Unreasonable Complaints (Habitual Complaints) Leeds North CCG is committed to treating all complainants equitably and recognises that it is the right of every individual to pursue a complaint. Leeds North CCG therefore endeavours to resolve all complaints to the complainant s satisfaction. However, on occasions, staff may consider that a complaint is unreasonable in nature, e.g. the complainant raises the same or similar issues repeatedly, despite having received full responses to all the issues they have raised. Unreasonable complainants can often be symptomatic of an illness and the complaints procedure may not be the most appropriate means of dealing with the issues involved. There may also be occasions when staff may receive telephone calls from complainants where the complainant is abusive and /or threatening or use bad language. In such cases, the recipient of the call should remain calm and inform the caller that the call cannot be continued if the caller cannot modify his/her language and that the call will have to be terminated. The member of staff should document the call and fill out an incident form. If it is considered that a complainant is becoming unreasonable, the member of staff should refer to the Habitual Complaints procedure for guidance (Appendix 9). 1.17 Mediation Leeds North CCG will consider mediation as a method to resolve complaints during stage one. If it is considered appropriate, and with the agreement of the complainant Leeds North CCG will make arrangement for mediation for the purpose of resolving the complaint. 1.18 The Role of an independent advocate Advonet is an independent advocacy service that provides information, advice and support to people wishing to make a complaint about NHS services. Its aim is to ensure complainants have access to the support they need to articulate their concerns and navigate the complaints system. Their service is free and confidential and their details are included in the Leeds North CCG Patient Advice and Liaison Service Leaflet. 1.19 Urgent Care Complaints A process has been established for the handling of urgent care complaints concerning Leeds residents. The West Yorkshire PALS service will manage these issues and a - 16 -

member of the PALS team will liaise with either NHS Direct or Local Care Direct who provide the service. 1.20 Complaints concerning NHS Choice The NHS Constitution sets out choice as a right and includes the right to information to support that choice. If a patient complains to Leeds North CCG that he/she has not been offered a choice, and the complaint is upheld, Leeds North CCG is required to make sure the patient gets that choice. This does not apply to prisoners, serving members of the armed forces and persons detained under the Mental Health Act 1983. 1.21 Counter Fraud Measures Where a complainant raises a concern about potentially fraudulent activity or practice, than the Governance Team should, in accordance with the Local Counter Fraud agreement, inform the Local Counter Fraud Specialist (LCFS). The LCFS will make sufficient enquiries to establish whether or not there is any foundation to the suspicion that has been raised. If the allegations are found to be malicious, they will also be considered for further investigation to establish their source. Staff should always be encouraged to report reasonably held suspicions directly to the LCFS An employee should not ignore their suspicions, investigate themselves or tell colleagues or others about their suspicions. 1.22 Mental Capacity In the case of a complaint regarding a patient or person affected who has died or who is incapable by reason of physical or mental capacity, the representative of the patient must be a relative or other person who, in the opinion of the Governance Team, had or has a sufficient interest in the patient s welfare and is a suitable person to act as representative. Where a complaint arises concerning a patient lacking capacity and there is no one to act on the patients behalf, the Mental Capacity Act should be consulted as an Independent Mental Capacity Advocate may need to be appointed to act on their behalf. 2. Receiving Complaints Any member of staff receiving a complaint must notify the Governance Team and a copy of all correspondence should be forwarded immediately. All written complaints should be stamped with the date of receipt. There have been occasions where acknowledgements have been delayed due to post not being opened in the absence of the person to whom the complaint has been addressed. Arrangements should be in place to ensure that delays do not occur for this reason. - 17 -

The Governance Team will maintain a database (currently Datix) in which each complaint is recorded and given a unique number. This number will serve as a future identifier for the management of the complaint. 3. Acknowledging Complaints All complaints must be acknowledged within 3 working days of receipt by the Governance Team. The acknowledgement letter should be sent along with a form requesting ethnic monitoring information and should include details of how records will be used and issues regarding confidentiality. A stamped addressed envelope should be enclosed to aid reply. A nominated member of the Governance Team will co-ordinate the acknowledgement of the complaint and complete the entry onto Datix. The nominated member of the Governance Team must offer to discuss the details of the complaint with the complainant. If a contact telephone number is not available, the acknowledgement letter must ask the complainant to contact the complaints office within five working days. A discussion must take place with the complainant agreeing how their complaint will be investigated, who will lead the investigation and by when they should expect a response. If the complaint is to be forwarded to another organisation the complainant s consent must be provided for this to take place. This information must be recorded on the datix file for each case. If the complainant does not contact the Complaints office after five working days a letter will be sent to the complainant outlining how their complaint will be investigated An investigation form will be completed outlining the issues agreed with the complainant and sent to the nominated investigating manager. The investigating manager is responsible for handling the complaint and for ensuring that the complaint is investigated thoroughly and that a response is sent to the Governance Team. 3.1 Ethnic Monitoring All NHS organisations have been asked to complete ethnic category details of complainants and staff complained against. The collection of ethnic category data on written complaints will be valuable in gauging fair and equal access to health care across ethnic groups. There is no obligation on patients or staff members to respond to the ethnic category question and no pressure should be put on them to answer, or on staff to obtain the answer. Should the patient or staff member not respond to the question, this should be classified as not stated. 3.2 Patient Confidentiality - 18 -

Health Service Circular 1998/059 NHS Complaints Procedures: confidentiality states the use of the patient s personal information to investigate a complaint is a purpose for which it is not necessary to obtain the patient s express consent. Care must be taken at all times throughout the complaints procedure to ensure that any information disclosed about the patient is confined to that which is relevant to the investigation of the complaint and only disclosed to those people who have a demonstrable need to know it for the purpose of investigating the complaint. It is good practice to explain to the patient that information from his/her health records may need to be disclosed to the Investigating Manager and to staff involved in the complaint. If the patient objects to this, then the effect on the investigation will need to be explained. 4. Investigating Complaints The investigation must be independent and the Investigating Manager must have the relevant skills to undertake the task and be selected according to the importance and seriousness of the complaint. The Investigating Manager will determine how the complaint is to be investigated and by whom. It is anticipated that the Investigating Manager will normally be the Senior Manger responsible for the area concerned. It is desirable that the complaint is dealt with as close to the point of delivery as possible, to ensure a prompt reply and that appropriate remedial action is taken. The investigation form should be fully completed with action plans completed. If a complaint directly concerns an individual this person must not be the Investigation Manager. If a member of staff is implicated in a complaint and the allegations is serious and could lead to disciplinary action, the member of staff will be informed by the Investigating Manager and will be advised of their right to seek the help and advice of a professional association or trade union before commenting on the complaint. Consideration as to whether or not disciplinary action is warranted is a separate matter for management, outside the complaints procedure, and must be subject to a separate process of investigation. The level of the investigation will be determined by the triage process. If indicated by the seriousness of the complaint, a full root cause analysis will be carried out in accordance with the Serious Incident Policy. For less serious complaints a concise investigation should be carried out in accordance with root cause analysis principles and the Incident Management Policy. On completion of the investigation the Investigating Manager should send a draft response to the Governance Team. The full details of the investigation should also be provided including notes, minutes of meetings, statements and all information included as part of the investigation. This information will be retained by the Governance Team. 4.1 Grading of Complaints Complaints will be assessed to determine the severity of the issues raised. This will enable Leeds North CCG to ascertain the potential level of investigation required and the timescale for the response. The grading of complaints will be as follows: - 19 -

1. Negligible 2. Minor 3. Moderate 4. Major 5. Catastrophic Likelihood Matrix 5. Almost Certain 5 10 15 20 25 4. Likely 4 8 12 16 20 3. Possible 3 6 9 12 15 2. Unlikely 2 4 6 8 10 1. Rare 1 2 3 4 5 Seriousness Complaint resolved within 5 to 10 days A concise investigation to be carried out Complaint resolved within 11 to 25 days A concise investigation to be carried out Complaint resolved over 25 days up to a maximum of 6 months A full root cause analysis to be carried out Further aspect in assessing timescales will be if other agencies are involved. For example, an issue classed as moderate may take longer to resolve if a response is required from multiple agencies such as Social services or Leeds Teaching Hospitals NHS Trust. The Governance Team will have the discretion to determine the timescales to ensure that realistic timescales for a response are established. 4.2 Actions Plans An action plan must be completed as part of the investigation. The finding of the investigation in consideration with the issues raised by the complainant may give rise to changes that need to be made to prevent recurrence and/or to improve services. The action plan will identified the action, the individual responsible for taking the action and the timescale for completion of the action. Audit of the action plans are carried out by Internal Audit to determine if actions proposed have been implemented. 4.3 Documentation - 20 -

All aspects of the investigation should be clearly recorded and all documentation, including staff statements, how the facts have been ascertained etc, should be forwarded to the Governance Team and retained within the complaints file. In the event that the complainant subsequently requests an independent review, Leeds North CCG will require copies of all documentation. Staff should be aware that, should the matter proceed to litigation, all the complaints documentation is subject to disclosure. Copies of complaints correspondence should not be held on the patient s health records. In addition to ensuring good patient care, complete, accurate and timely records allow a clear picture of events to be obtained which is imperative for managing complaints, and for auditing practice. 5. Agreeing Contacts regarding Progress of the Complaint Once a timescale has been agreed and established with the complainant for a response, the complainant must be informed of progress. Where it is not possible to respond within the agreed timescales, the complainant must be contacted by the Governance Team to give an explanation for the delay and an indication given of when the response is likely to be available. The complainant must be offered an interim reply if requested. 6. Meetings The Governance Team will, in consultations with other senior staff involved, decide whether it is appropriate to offer the complainant an interview or mediation meeting. When a meeting has been arranged, the staff involved will be consulted to determine how the meeting will be structured. The Governance Team will conduct the meeting and will ensure that notes are taken. The complainant should be offered the opportunity to have someone else present at the meeting to assist them. A copy of the notes from the meeting should be forwarded to the complainant. If required by the complainant, meetings should take place on neutral premises or at the complainant s residence and at a location with suitable access and to accommodate any carer. If necessary, the complainant can request for an interpreter to be present. 7. Responses 7.1 Draft Responses Wherever practical, replies to all complaints (i.e. written and verbal) should be agreed with the relevant Head of Service before a reply is sent. Where it is clear that there has been a mistake or failure in procedures, this should be clearly stated and an apology given. The Investigating manager will forward the draft response to the complaints department who will organise sign off and signature. Staff who may be the subject of a complaint can be anxious about the progress with the investigation by the investigating officer and should be offered the opportunity to discuss the matter with a professional colleague. Wherever possible, they should have the - 21 -

opportunity to comment on the accuracy of the draft response to the complainant and they should be shown a copy of the final response to make them aware of its content. 7.2 Interim Responses In exceptional circumstances, where it has not been possible to contact all those involved to enable a full response, an interim response should be sent from the Accountable Officer, the Head of Service or the Governance Team on their behalf. It is essential, however, to remain objective at all times and present a fair reply to all complainants. 7.3 Final Responses Procedure All written complaints concerning Leeds North CCG (and any verbal complaints, which are felt to be sufficiently serious) must receive a formal response in writing depending on the risk grading of the complaint. Other than in exceptional circumstances, the final letter should be dispatched depending on the agreed timescale with the complainant. If the complainant agrees to a longer period, the response may be sent within this longer period. The Investigating Manager will forward the draft response to the Governance Team who will review the file to ensure that all the complainant s concerns have been addressed. The file will also be reviewed against a quality checklist to ensure key components of a final response letter are included. The Governance Team will organise sign off and signature by the Accountable Officer or the appropriate deputy. Complainants who have agreed for the complaint to be investigated by an independent contractor or providers of NHS Services will normally receive a response directly from that practitioner or organisation. A copy of the response will be requested to be forwarded to Leeds North CCG Governance Team. Where complaints concern a number of organisations, Leeds North CCG will send one co-ordinated response, also either by agreement, or if Leeds North CCG investigates the complaint directly. A copy of the signed response will be returned to the Investigating Manager and the relevant Executive Director. The final response should invite the complainant to let the Accountable Officer know if they have any outstanding concerns and inform the complainant of the next stage of the complaints procedure should the complainant be dissatisfied. In such cases, consideration should be given to any further action which might resolve the complaint, including offering a meeting. All responses should indicate that if the complainant remains dissatisfied following the completion of local resolution they may contact the Parliamentary and Health Service Ombudsman. 8. Compensation and Ex-Gratia Payments There may be occasions when, having investigated the complaint, the Investigating Manager believes there are grounds for making an ex-gratia payment (without accepting - 22 -

liability). An apology and gesture of goodwill may avoid subsequent litigation and offers the opportunity to deal with certain circumstances in a fair and responsible manner. The Head of Governance and the Director of Finance should approve all ex-gratia payments. It is recommended that, before any compensation is offered in respect of a complaint involving a member of staff, that member of staff should be involved in the discussions when the subject of compensation is raised, to ensure that he/she does not feel compromised by the decision to award compensation. Any ex-gratia payments should be made having regard to Leeds North CCG Standing Orders and Standing Financial Instructions. Any claim for legal fees in relation to complaints is not covered by this policy and will be managed via the Leeds North CCG s claims policy. 9. Reporting Arrangements The Governance Team will produce regular reports on complaints to the Governance, Performance & Risk Committee in line with its work programme. A complaints report will also be included in Leeds North CCG annual report. On an annual basis returns to the Department of Health (KO41 s) are completed. 10. Compliments The Governance Team and PALS Team maintain a record of all letters of praise and compliments received. Departments and Services who received compliment should forward this information to be formally recorded. 11. The PALS Complaints Interface It should be the choice of the individual to use either Patients Advice and Liaison Service (PALS) or the NHS Complaints Procedure; there should be no requirement for service users to use the PALS service first if they wish to make a formal complaint. There is close collaboration between the PALS service and the Governance Team to ensure a coherent and seamless approach to resolving patients concerns. There is a clear differentiation between the roles of the PALS and Governance Teams. PALS will not investigate complaints and their role is to inform and support people to access the complaints procedure when requested. PALS will act as a gateway to the complaints service in Leeds North CCG. PALS provides assistance to members of the public, patients and carers with queries about health related matters when patients first have a concern or issue they wish to raise. Their first point of contact will often be with a member of staff or PALS. - 23 -

A key PALS role is to help people to talk through their concern so that they can identify the nature of the problem and work out various options, including use of the formal complaints procedure, for resolving the issue and explaining the potential consequences of each option. Where an individual approaches PALS and subsequently decides to make a formal complaint, this is referred to the Governance Team. There may be occasions when patients, their carers or relatives contacting PALS have previously made a formal complaint, or taken other action to gain resolution regarding an issue. Patients should not use PALS to pursue a concern once the complaints procedure has been exhausted. PALS staff may decide that no action they can take will provide an effective and speedy resolution, and that the issue is outside their remit. PALS should provide information regarding appropriate independent advocacy or alternative means of pursuing the matter. It is important that PALS are able to work in an independent way and inform people of all their options and rights. Contacts with PALS may initially frame their concern in the form of a complaint but the PALS staff should seek to identify if the concern can be dealt with informally through PALS. In all cases the choice of action should be agreed with the person raising the concern or issue. Using PALS will not remove the right of patients to pursue the complaints option at any stage; however, it would not be appropriate to use PALS and the Governance Team simultaneously to address the same problem. PALS will act as a gateway to the complaints service in Leeds North CCG. - 24 -

STAGE 2: Parliamentary and Health Service Ombudsman (PHSO) Review The independent review stage of the complaints procedure is the second and final stage of the complaints procedure when the complainant has exhausted the local resolution stage. Leeds North CCG must inform the complainant within the final response of the next stage of the complaints procedure should they be dissatisfied and give details of how to contact the PHSO. Complainants who remain dissatisfied following the completion of local resolution may contact the PHSO, requesting an independent review of their case. This must be done within a year after the day on which the person aggrieved first had notice of the matters alleged in the complaint, unless the PHSO considers that it is reasonable to review the complaint outside of this timescale. This request can be made in the following ways: Contact the PHSO on 0345 015 4033, email at Phso.enquiries@ombudsman.org.uk Or write to them at: The Parliamentary and Health Service Ombudsman Millbank Towers Millbank London SW1P 4QP Visit their website at www.ombudsman.org.uk The PHSO can conduct independent investigations of complaints about NHS providers and practitioners. The Ombudsman has established three sets of six principles which outline the approach it believes public bodies should adopt when delivering good administration and customer service, and how to respond when things go wrong. Leeds North CCG has adopted the six principles for Good Complaints Handling as part of this policy and procedures. If a complaint is referred back or upheld by the PHSO the Complaints and Claims Manager will co-ordinate any points of action required with either the Director or Head of Service, Independent Practitioners and/or Commissioned Service and ensure that a response is made within the set deadline established by the PHSO. REVIEW OF COMPLAINTS PROCEDURE A review of the Complaints Comments Concerns and Compliments Policy and Procedure will be undertaken every two years or earlier if there has been any legislative changes. - 25 -

SECTION 3 RESOURCE PACK APPENDIX 1 GUIDANCE ON HANDLING VERBAL CONCERNS AND COMPLAINTS Good communication skills and a personable manner are vital in the successful handling of complaints, concerns and compliments. With regard to the early resolution of complaints locally it is important to: be positive - the complaint is offering valuable information and should not be viewed as unwelcome. - reassure the complainant that s/he will be taken seriously. - remain objective and try not to take the complaint personally, imagine putting yourself in the complainant's shoes and look favourably on their motives. make the complainant feel relaxed - where possible offer a private, calm environment. - offer a cup of tea/coffee, etc. - remain calm and in control, this will encourage the complainant to be calm. - reassure the person about the confidentiality of their Complaint. actively listen - let the person explain the problem before you comment. - show empathy e.g. I can see how upsetting this was. - give signs of acknowledgement to indicate you are listening. - make sure that you have heard and understood what the complaint is about. Ask questions to clarify the problem. - do not be defensive accept that complainants have a valid point of view which may be different from your own. take immediate action if possible - try to resolve the complaint as quickly and satisfactorily as possible. Often an empathic response and apology is all that is necessary to satisfy the complainant. - it could be beneficial to bring the complainant and the person complained about together to discuss the problem through if both parties are in agreement. - 26 -

APPENDIX 2 GUIDANCE ON WRITING A RESPONSE TO A COMPLAINANT Surveys have shown that the majority of complainants when making a complaint are seeking: An acknowledgement of their complaint. An explanation of what happened. An apology (occasionally it may be just to acknowledge their feelings). An assurance that their complaint has been taken seriously. That measures have been taken to prevent a similar occurrence from happening to them or other patients in the future. Steps to compiling good response Read the complaint thoroughly and identify the key issues, contact the complainant to clarify if necessary Address each issue as identified by the complainant. Give explanations. Include details that demonstrate that an investigation has been undertaken. Give reasons why it has not been possible to comment on a particular issue e.g. it is out of the jurisdiction of Leeds North CCG and suggest how that can be managed Avoid using technical language. Apologise where appropriate. Outline action taken to prevent the event occurring again. Leave the complainant feeling that they have been taken seriously and their concerns have been listened to and acknowledged. Avoid being patronising or too defensive. Ensure that all facts are correct. Use conciliatory language. Acknowledge any positive comments. Apologise if the response is delayed with an explanation for the delay. Good practice is to include an action plan where appropriate How to ensure the tone of your response is right Take time to check the response. Put yourself in the shoes of the complainant to see if you have satisfactorily answered the complaint. Would you be satisfied with the response? You may find it helpful to allow someone else to read your response to see if they have any comments or suggestions. - 27 -

Remember to address the reader directly. Keep sentences short and simple use plain English Explain any abbreviations. And avoid technical language, jargon or clinical terminology. Useful phrases for written response I was sorry to hear that you were unhappy with I am sorry if you found x to be upsetting as this was not the intention I would like to apologise if x appeared rude at any time during the conversation with you. He/she have asked me to assure you that this was not his/her intention. The normal practice is.. I am sorry that in this instance this did not occur I apologise for any additional anxiety this has caused. As a result of your letter.. It is always our intention to provided excellent and responsive care for patients and I am sorry if this was not the case Your experience of our services fell short of the standards we set for patient care and I would like to apologise for the stress and anxiety this experience has caused you. What leaves the complainant dissatisfied? Taking too much time to reply Not addressing the complainant correctly. Not addressing or answering key points. Not acknowledging feelings or perceptions. Not offering an apology where appropriate. Responses which are too technical, patronising or defensive. Response with a chronology of care not relevant to the concerns raised. Factually inaccurate and mistakes such as spelling mistakes. No details of appropriate changes or improvements given. - 28 -

COMPLAINT RESPONSE TEMPLATE (To be used for all written responses to complaints) Our ref: Date PRIVATE AND CONFIDENTIAL Patients name and address Dear I am writing to you following the Leeds North CCG investigation into your complaint concerning... The investigation has been co-coordinated by [title] and is now complete. The investigation involved.[brief description of the investigation e.g. staff interviewed. The issues you have raised have been taken very seriously and thoroughly investigated and I am now able to respond to the issues you have raised. Main body of response to each issue raised and to include - a brief outline of what happened. - an apology if the complaint is justified or apology to acknowledge the complainant s perception of events. - any action that will be taken to prevent a future re-occurrence, improve or change systems/policies and where possible include timescales. I am sorry that you felt the need to complain. We are always grateful of the comments made by patients and their relatives. Such feedback prompts us to review the way our services are provided and creates a learning opportunity from which we are able to improve our services. [Standard paragraph to be added by Governance Team regarding next steps if they remain unhappy]. Yours sincerely Accountable Officer - 29 -

APPENDIX 3 INVESTIGATING A COMPLAINT Once a formal complaint has been received an investigation must be undertaken to be able to fully answer the concerns raised by the complainant. The investigation should be carried out using Root Cause Analysis principles. The following steps should be considered as part of your investigation: - The collection of relevant papers. - Evaluate the letter of complaint. - Interview the staff concerned and/or obtain written statements. - Produce a summary investigation report outlining the findings of the investigation. Collect the relevant papers As part of your complaints file you will need to collect any relevant papers starting with the letter of complaint, any other correspondence, the appropriate section of the patient s records and any other supporting information, e.g. appointment books, telephone message books. Evaluate the letter of complaint Using the Investigation Form (Appendix 9) it is CRITICAL to identify all the aspects of the complaint raised by the complainant that require investigation and response and which managers are best placed to reply. If any aspect of the complaint is not clear an appropriate course of action would be to contact the complainant by telephone where they have provided their telephone number in order to clarify any issues raised. A note of the telephone conversation should be recorded on the Investigation form. From the letter of complaint you will need to identify staff involved with the complainant or patient at the time of the events complained about. Arrangements should be made to interview or obtain written statements from each member of staff identified in the complaint. Interview the staff concerned and/or obtain written statements Many staff are deeply affected by complaints. It is important to advise them as to where they can get help and support; sometimes staff can become very upset and this can affect their work. You should emphasise that the process of managing complaints is to listen, learn and improve and that it takes place in a blame free, learning atmosphere. Interviews should be conducted in private and the interviewee should be allowed time to read the letter of complaint and gather their thoughts before answering any questions. You may wish to give them access to the complaints letter and relevant papers prior to the interview. The member of staff can have someone with them providing it does not in any way prejudice the responses of the staff member and that they understand that their role is purely supportive. Staff need to know that you are trying to establish what happened and are seeking their version of events. Do not be surprised if they do not remember the patient or incident - 30 -

referred to in the complaint. Ensure appropriate records and papers are available to help jog their memory. If staff do not recall the event and the comments given are from referring to the records only, this should be stated in the summary investigation report. Each issue raised in the complaint should be taken in turn. Where information is backed up by records this should be stated and quotes from records made where possible. Staff should be encouraged to make a written statement of their recollection and the events in question and ask them to date and sign it. Statements should give their version of events chronologically and in their own words. They may find this useful should further questions arise. If they do not wish to provide a written statement you should take a note of the points they make during their interview. Produce a summary investigation report The production of a summary investigation report will provide the basis of the draft response. An effective way of producing a summary report would be to list all the complainants concerns and use them as headings. For each concern the relevant finding should be placed under each heading. You may find it useful to produce a chronology of events surrounding the complaint. Any action taken to prevent similar occurrence should also be included in the report. Investigating Formal Complaints The Investigating Officer will be the senior manager responsible for the area / service concerned to ensure that the complaint is managed as close to the point of delivery as possible, to ensure a prompt reply and that appropriate remedial action is taken. The investigation must be, and be seen to be, independent and objective. The Investigating Officer must have the relevant skills to undertake the task and be selected according to the importance and seriousness of the complaint. Where complaints concern matters of clinical judgment these should be agreed with the clinician involved. The Investigating Officer will, in consultation with their Head of Service/Line Manager and any other senior employees involved, decide whether it is appropriate to offer the complainant an interview or meeting. The Governance Team should be informed of any meetings arranged. Where the Investigating Officer arranges a meeting with the complainant, the professionals involved will determine how the meeting will be structured. The Head of Service/ Line Manager will chair the meeting and ensure that notes are taken. Two Leeds North CCG employees will attend any interview or meeting and the complainant should be advised of the opportunity to have someone else present to assist them. The meeting must be formally recorded and the notes agreed with the complainant and a copy supplied to them. - 31 -

APPENDIX 4 MEDIATION Mediation is a way of resolving a problem or a complaint or a difference of opinion of two parties using the skills of a mediator to facilitate the process. It involves using an independent, impartial person to liaise between the conflicting parties with the aim of achieving a clearer understanding of events from both sides and good relations between the two parties restored. A mediator is someone not personally connected with either party. Mediators have been trained to do this work and work confidentially. A Mediator doesn t take sides and is concerned only to reach a resolution acceptable to both parties in the dispute. Either the complainant or Leeds North CCG/Independent Practitioner can suggest it. If the other party agrees then either may ask the Governance Team to arrange for the involvement of a mediator. The Governance Team will copy the complaint and any responses already sent to the mediator. The Mediator will contact the parties to establish whether it is appropriate to have a meeting with both parties together or to liaise between the two. Following the mediation process, the mediator writes to both parties outlining the outcome. It is hoped that a satisfactory outcome will be achieved for both parties. - 32 -

APPENDIX 5 COMPLAINTS COMMENTS AND COMPLIMENTS FORM Please complete this form on receipt of a verbal compliment, comment or concern. All written complaints received should be forwarded to the Governance Team immediately for processing under the CCG Formal Complaints Procedure. Date and time of comment received: Name and address and daytime telephone number of contact (if given): Patient name, address and date of birth (if different from above): Details of comments made: If compliment received was it communicated to relevant staff Yes members? Please circle yes or no. No Complaints - please provide details of any action taken on the spot to resolve the issue (continue overleaf if necessary): If the matter is judged to be more serious, please refer it your Service Manager. Please outline any action taken by the service manager to resolve the complaint (continue overleaf if necessary). If the matter remains unresolved, please advise the complainant of the Leeds North CCG formal complaints procedure and if possible provide them with a copy of the complaints leaflet. Inform the Governance Team immediately by emailing this form to leeds.complaints@nhs.net. Your name: Title: Service/Department: Base: Tel no: Please return the form to: Governance Team, Suite 2-4 Wira House, West Park Ring Road, Leeds, LS16 6EQ - 33 -

APPENDIX 6 Working Days 24 hours 3 working days Forward within Leeds North CCG Flow Chart - Complaints Handling Process Role Who Written/formal complaint received by any member of staff Governance Officer/ Team determine if appropriate for investigation cc. Executive Director and Service Manager Investigation Manager 1. Send to Governance Team URGENTLY by email to leeds.complaints@nhs.net 1. Determine if appropriate for Leeds North CCG to investigate 2. Create complaints file 3. Input details onto DATIX system 4. Send acknowledgement letter to complainant 5. Obtain consent if necessary 6. Contact Complainant to agree issues of concern to be addressed and list precisely on investigation form 7. Triage complaint and agree timescales with complainant and agree contact arrangements 8. Send investigation form to Head of Service / function to initiate investigation cc. to Executive Director 1. Head of appropriate commissioning area for commissioning complaints decides which manager will investigate. 2. Investigation Manager requests relevant clinical records/other relevant documents. 3. Interview and/or obtain written statements from staff involved 4. Investigate complaint and complete investigation form 5. Contact Governance Team if investigation is not meeting agreed timescales or if significant delays are likely e.g. staff sickness 6. Provide draft response agreed by Director to relevant complaints manager 7. Develop corrective action plan and build learning into quality improvement plans 3 agreed No of Working Days following Triage using Risk Matrix 2 Working Days Head of appropriate commissioning area &.c.c Executive Director Governance Officer/Team If response at risk of breaching target notify Head of Governance / deputy immediately Quality assurance check to be carried out on response letter, Executive Director 1. Executive Director will approve the draft response and will send to Governance Team to quality assure the response. Inform external body as necessary. 1. Check the response and return if necessary 2. Send interim response letter if required 3. Identify other agencies to be copied in to response 4. Request any further information required/check for accuracy 5. Develop action plan further where required 6. Quality assure the response 7. Pass response to Exec Director for approval 1. Review investigation and draft response 2. Agree draft response & return to relevant Complaints Officer/Team who will email to Accountable Officer for signing 1. Sign response 2 Working Days Chief Officer Governance Officer /Team - 34-1. Send response 1 st class to complainant 2. Send copy to anyone named in the complaint 3. Copies sent to other agencies as appropriate e.g. Advocate 4. Update DATIX and close file 5. Retain and store file

APPENDIX 7 A COMPLAINT INVESTIGATION FORM 1 REF NO: Date Received: Draft response due: Director: Manager: Response from : B Name of Complainant: Name of Patient: As above (if not complainant) Department: Names of staff: (identified in complaint) C Safeguarding Concerns Are you aware of any safeguarding concerns? Yes / No If Yes, ensure that an IR1 form is completed and safeguarding referral made if appropriate. Please indicate nature of concern: Physical Financial Sexual Neglect Institutional Discrimination Emotional/Psychological Has a safeguarding investigation been triggered as part of this case? Yes / No D Key issues to be investigated: Please could you look into the relevant key issues and questions to your service raised in this complaint and provide information for inclusion in a response by [Deadline date]. If you have any further questions you feel are necessary to address, please include these in Section E Please see the attached file note for any other information that you may need to include. The complaint response will require: Apologies were appropriate Explanation of issues raised Details of any action taken or lessons learned as a result of this complaint if it is established that things could/should have been done differently. PLEASE ALSO REFER TO THE ORIGINAL LETTER OF COMPLAINT - 35 -

PLEASE ALSO NOTE THAT THE COMPLAINT RESPONSE WILL ALSO REQUIRE ANY COPIES OF CLINICAL NOTES OR MEDICAL RECORDS USED IN THE INVESTIGATION E Outline in chronological order phone calls/meetings during the investigation of the complaint and attach any completed complaints/supporting statement forms: - 36 -

ACTION PLAN Action identified as a result of the complaint. (This should cover any specific actions promised to the complainant in the letter of response and action on general issues raised by the complaint. Where action is not applicable, please indicate this.) Responsibility for taking action (named individual) Timescale for completion - 37 -

Name of Investigating Officer (print): Position: Base Tel: (0113) Date: COMPLAINT SUPPORTING STATEMENT FORM (to be attached to the Complaint Investigation Form) Rec d All statements should be made on a separate statement form. returned by Ref No: Date Complaint Date to be Please write clearly in black ink. Record facts or make it clear when you are stating your view/opinion of a situation. Detail events in chronological order. Do not abbreviate or use jargon. - 38 -

Please continue on the reverse side of this form if required. Full Name of person completing this form (PRINT): (Signature): Position: Date: Tel.No. Base: - 39 -

APPENDIX 8 KEY PERSONNEL AND USEFUL CONTACTS Governance Team Complaints contact Telephone 0113 8435236 Email leeds.complaints@nhs.net Patient Advice and Liaison Service (PALS) CCG PALS office Telephone 0800 0525 270 Independent Advocacy Service (Advonet) Leeds Independent Health Complaints Advocacy Telephone 0113 244 0606 Leeds Teaching Hospitals Trust Complaints Patient Relations Manager Telephone 0113 2066261 Leeds Mental Health Trust Complaints Complaints Manager Telephone 0113 3055973/4-40 -

APPENDIX 9 PROCEDURE FOR HANDLING HABITUAL COMPLAINANTS - 41 -

PROCEDURE FOR HANDLING HABITUAL COMPLAINANTS 1 INTRODUCTION 1.1 Complaints about Leeds North CCG services are processed in accordance with NHS complaints procedures. During this process Leeds North CCG staff inevitably have contact with a small number of complainants who continue to challenge the complaints process or service or whose complaints and requests absorb a disproportionate amount of NHS resources in managing their concerns. Complainants may also become aggressive, abusive or violent towards those involved in the complaints process. The aim of this procedure is to set out the criteria and options for managing complainants who behave in this way at any point in the complaints process. 1.2 It is emphasised that the identification of a complainant as habitual 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 procedure. The decision must be taken by the Accountable Officer, or their deputy in their absence, with advice from the Head of Corporate Governance and the Governance Team 1.3 The aim of this procedure is to set out the criteria and options for managing habitual complainants. NHS staff should respond with patience and sympathy to the needs of all complainants but there are times when there is nothing further which can reasonably be done to assist them or to rectify a real or perceived problem. This procedure will be followed when a complainant is considered to be habitual i.e. the complainant and/or anyone acting on their behalf meet any of the criteria in this procedure. 2 CRITERIA FOR HABITUAL COMPLAINANTS Complainants fulfilling any one of these criteria will be managed as habitual:- 2.1 The complainant threatens or uses actual physical violence towards staff or their families or associates at any time. 2.2 The complainant changes the substance of a complaint or continually raises new issues or seeks to prolong contact by continually raising further concerns or questions upon receipt of a response whilst the complaint is being addressed. 2.3 The complainant is unwilling to accept documented evidence of treatment given as being factual, e.g. drug records, General Practitioner manual or computer records, nursing records. 2.4 The complainant denies receipt of an adequate response in spite evidence of correspondence specifically answering their questions being supplied. - 42 -

2.5 The complainant does not accept that facts can sometimes be difficult to verify when a long period of time has elapsed. 2.6 The complainant does not clearly identify the precise issues which he/she wishes to be investigated. 2.7 The complainant does not accept that the concerns identified are not within the remit of Leeds North CCG to investigate. 2.8 The complainant persists in pursuing a complaint where the NHS complaints procedure has been fully and properly implemented and exhausted (for e.g. where Leeds North CCG has not investigated a complaint because it is outside the time limits. 2.9 The complainant has harassed or been personally abusive or verbally aggressive on more than one occasion towards staff managing their complaint or their families or associates. This will include racial harassment. (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. They should document all incidents of harassment). 2.10 The complainant makes an excessive number of contacts with Leeds North CCG placing unreasonable demands on staff. 2.11 The complainant is known to have recorded meetings or face-toface/telephone conversations without the prior knowledge and consent of other parties involved. 2.12 The complainant makes unreasonable demands and fails to accept that these may be unreasonable (e.g. insists on responses to complaints or enquiries being provided more urgently than is reasonable or normal recognised practice). 3 OPTIONS FOR MANAGING HABITUAL OR POTENTIAL HABITUAL COMPLAINANTS Where complainants have been identified as habitual in accordance with the above criteria or where complainants are becoming habitual but do not fully satisfy the above criteria the Chief Officer (or appropriate deputy in their absence), the Head of Governance and the Governance Team will agree the actions to be taken appropriate to the individual case. Once they are satisfied that the complaints procedure has been properly followed and that the response covers all the issues raised the Chief Officer will inform the complainant in writing: A) That if they persist with the approach they are taking, and explaining their actions causing concern, they will be classed as a habitual complainant. Consideration will be given to the need for a signed agreement with the complainant which sets out a code of behaviour for the parties involved if Leeds North CCG is to continue processing the complaint. If necessary or appropriate, for example where the - 43 -

complainant may require alternative communication formats other than writing, the complainant will be invited to meet with Leeds North CCG and be issued with a verbal notification. This meeting will explain that all previous issues have been addressed and there is no further resolution. A copy of this procedure will be included so that they understand the next stage of the process if they persist. Or B) Inform the complainant, in writing, that that they have been classified as a habitual complainant, the reasons for this and the actions that Leeds North CCG will take. A copy of this procedure will be included. These communications may be copied for the information of others involved in the complaint e.g. practitioners, conciliator, advocate, Members of Parliament One, a combination or all of the following actions may be adopted by Leeds North CCG for habitual complainants: 3.1 The Chief Officer will write to the complainant clearly explaining that there is nothing further for Leeds North CCG to do, and remind the complainant of their right to contact the Ombudsman or suggest that the complainant seeks advice in processing their complaint for e.g. through independent advocate. The complainant will be notified that the correspondence is at an end and that further letters will be acknowledged but not answered. 3.2 Inform the complainant that Leeds North CCG will pass unreasonable complaints to their solicitors or the police. 3.3 Remind the patient of their right to ask for an Independent Review by the Parliamentary Health Service Ombudsman. 3.4 Restrict or decline all communication to one channel, (for example correspondence with the Chief Officer) and all staff who are contacted by the complainant should give the same message and a record of the contact by the complainant retained in the complaint file. If necessary an incident form should be completed. Staff will be provided with a standard statement to use in the event of such contacts. The complainant should be reassured that the complaint is being managed. 3.5 The Chief Officer will write to the complainant clearly stating that he/she can not investigate the complaint. If possible, give the name of any organisation that can investigate the matter or provide advice. 3.6 The Chief Officer will inform the complainant that they are being treated as being habitual, stating the reasons why and suspending all contact with the complainant or investigation of a complaint and seek legal advice 3.7 Temporarily suspend all contact with the complainant or investigation is a complaint while legal or other agency advice or guidance is sought. - 44 -

3.8 The Chief Officer will inform the complainant of arrangements to protect staff. These will reflect the severity of the case but examples include: restricting complainant to correspondence only; informing the police; asking for correspondence to be sent via the Leeds North CCG solicitor or securing an injunction. 4 WITHDRAWING HABITUAL OR ITERATIVE STATUS 4.1 Once a complainant has been determined as habitual there needs to be a mechanism for withdrawing this status at a later date if, for example, the complainant subsequently demonstrates 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 habitual status at the outset and discretion should similarly be used in recommending that this status be withdrawn when appropriate. Where this appears to be the case, discussion will be held with the Chief Officer, Head of Governance and the Governance Team. Subject to their approval, normal contact with the complainants and application of NHS complaints procedures will then be resumed. 5 REVIEW OF PROCEDURE This procedure will be reviewed and revised as appropriate in line with the Complaints, Concerns, Comments and Compliment Policy and will remain in place until June 2015 or sooner if there are any changes to legislation. - 45 -

APPENDIX 10 PROCESS FOR COMPLAINTS INVOLVING A MEMBER OF PARLIAMENT - 46 -

Managing MP Letters at Leeds CCGs Members of Parliament will write to CCG Chief Officers on behalf of their constituents with general queries regarding health services and also in relation to a specific patient complaint. Each CCG executive office should receive, log and track each MP letter to ensure an appropriate response has been collated and returned to the MP within a reasonable timeframe. MP queries tend to fall into 1 of 3 categories: 1. General queries in relation to health services. E.g. Why is a certain service not provided? 2. Freedom of Information (FOI) requests. 3. Acting on behalf of a specific constituent to make a formal complaint. General queries should be responded to by the most appropriate manager for the query. For example if it is relating to the commissioning of acute mental health beds then the lead commissioner for mental health services should provide a response. N.B. The appropriate manager may not necessarily be a staff member of the CCG that initially received the query e.g. Leeds North CCG receive a MP query in relation to Community Health Service Commissioning. Formal complaints and FOI requests should be directed to the appropriate team to ensure the strict criteria and timescales for these issues are followed appropriately: FOI requests West and South Yorkshire and Bassetlaw Commissioning Support Unit Formal Complaints Leeds North CCG Governance Team In all cases the final response to the MP should be signed-off by the Chief Officer who received the initial query. - 47 -

Managing MP Letters MP Accountable Letter to Chief Officer Officer Office Receipt & Sort by Executive Office Direct Patient Care Complaint e.g. Named Patient issue General query e.g. commissioning decisions Freedom of Information Request Governance Team at Leeds West CCG Appropriate CCG Manager (Commissioning/Contracting etc) for response. This may be outside of the CCG that received the query Information Governance Team Managed within Complaints Policy & strict timescales Appropriate CCG Manager to draft response Managed within Freedom of Information Policy & strict timescales Final written response checked by appropriate Director - 48 - MP