Gloucestershire Hospitals

Gloucestershire Hospitals NHS Foundation Trust TRUST POLICY In the case of hard copies of this policy the content can only be assured to be accurate on the date of issue marked on the document. The Policy framework requires that the policy is fully reviewed on the date shown, but it is also possible that significant changes may have occurred in the meantime. The most up to date policy will always be available on the Intranet Policy web site and staff are reminded that assurance that the most up to date policy is being used can only achieved by reference to the Policy web site. 10 December 2013 Management of Complaints, Concerns, Comments and Compliments (4 Cs Policy) Keywords: Complaints, comments, concerns, compliments This document may be made available to the public and persons outside of the Trust as part of the Trust's compliance with the Freedom of Information Act 2000 Date of Issue February 2013 Review Date February 2016 COMPLAINTS POLICY V2.3 (MINOR AMENDMENT DECEMBER 2013) PAGE 1 OF 24

Gloucestershire Hospitals NHS Foundation Trust 4 Cs POLICY Introduction 1 Purpose 2 Roles and Responsibilities 3 Definition 4 Who can complain 5 Matters excluded from consideration 6 Time limits 7 Procedure 8 Consent and Confidentiality 9 Parliamentary & Health Service Ombudsman 10 Independent Complaints Advocacy Service 11 Legal implications 12 Media interest 13 Redress 14 Meetings 15 Being Open 16 Mediation 17 Equality and diversity 18 Complaints regarding private care 19 Fraud and corruption 20 Reporting, monitoring compliance and effectiveness 21 Process local resolution 22 References 23 Appendix 1 Unreasonable persistent complainants Appendix 2 Counter fraud flow chart Appendix 3 Process for complaints Appendix 4 Process for complaints from GP s / Community Appendix 5 Complaints regarding FOI / Data Access requests Appendix 6 Guidelines for front line staff in dealing with complaints COMPLAINTS POLICY V2.3 (MINOR AMENDMENT DECEMBER 2013) PAGE 2 OF 24

Gloucestershire Hospitals COMPLAINTS POLICY NHS Foundation Trust 1 INTRODUCTION The Gloucestershire Hospitals NHS Foundation Trust is committed to listening, responding and learning from the views and experiences of patients and the public about the care and services provided. The Patient Experience Team (Complaints, PALS, and PPI) actively seeks the views of patients and the public about the quality of our services, feeds back this information to the Trust and staff and ensures appropriate action is taken to improve services. Compliments, comments, concerns and complaints (4Cs) from patients, carers and the public are encouraged and welcomed. Should patients, carers or the public be dissatisfied with the care provided, they have a right to be heard and for their concerns to be dealt with promptly, efficiently and courteously. Under no circumstances should patients, relatives or carers be treated any differently as a result of raising a concern / complaint. We welcome all forms of feedback and use this to improve the services we provide. 2. PURPOSE This policy describes the process by which the 4Cs are handled within the organisation according to the national regulations. The process described in this policy seeks to facilitate good local resolution and service development. Links between the Patient Advice & Liaison Service (PALS) and Complaints have been strengthened to ensure a consistent approach for anyone wishing to raise comments, compliments, concerns and complaints. The policy also recognises that the Trust has a duty to act fairly towards staff involved in concerns and complaints. The aim is to encourage and be open to feedback from all users of our services; investigate concerns fully; and respond in a proportionate, appropriate and fair manner. 3. ROLES AND RESPONSIBILITIES Post/Group Details Chief Executive Ensuring compliance with NHS Complaints Regulations 2009 Overall responsibility for actions taken as a result of patient complaints Executive Director Reviewing serious complaints reported to Executive level Promoting a quick response culture to complaints Divisional Management Team Ensuring complaints are investigated, including formal investigations Providing detailed and timely responses Preparation of action plans and learning outcomes to complaints Progressing action plans and learning outcomes Ensuring complaints are reviewed at Divisional quality meetings Other managers responsible Provide specialist advice to the organisation according to area of expertise for risk controls Ensuring that relevant complaints are reviewed and followed up (e.g. Security Specialist, Medical Engineering, Infection Control, Liaising with other risk management specialists Risk Dept, Legal Dept, Human Resources Head of Patient Experience Accountable to the Chief Executive for the investigation and resolution of complaints Patient Experience Manager Operational responsibility for management of Complaints and PALS teams Complaints and PALS teams Administering the 4Cs process Ensuring replies and responses are provided within agreed timescales COMPLAINTS POLICY V2.3 (MINOR AMENDMENT DECEMBER 2013) PAGE 3 OF 24

4. DEFINITION Compliment: An expression of gratitude, thanks and positive comments directed at the Trust, services and staff by a patient, relative, carer visitor or member of the public. Comment: A comment / suggestion made about any services the Trust provides. Positive comments are treated as compliments. Concern: An expression of dissatisfaction that can either be resolved quickly or where the individual raising the concern clearly says they are not making a complaint. Complaint: An expression of dissatisfaction that requires a more detailed investigation or where the individual clearly states that they are making a complaint. SERG Safety and Experience Review Group. PALS Patient Advice & Liaison Service. PHSO Parliamentary and Health Service Ombudsman. ICAS Independent Complaints Advocacy Service. DMT Divisional Management Team. SUI Serious Untoward Incident PPI Patient and Public Involvement Theme a particular issue raised in a single ward / department / division Trend a combination of themes in a single ward / division or across the Trust 5. WHO CAN COMPLAIN A complaint may be made by: A patient of the Trust, or Any person affected by or likely to be affected by the action, omission or decision of Gloucestershire Hospitals NHS Foundation Trust. A complaint may be made by a person (representative) acting on behalf of another person in any cases where that individual: Has died. Is a child (16 years or younger). Is unable to by reason of physical or mental incapacity to make a complaint themselves. Has requested the representative to act on their behalf. In the case of a patient or person affected who has died or who is incapable, the representative must be a relative or other person who, in the opinion of the Complaints Manager, had or has a sufficient interest in their welfare and is a suitable person to act as a representative. If in any case the Complaints Manager (in conjunction with the Head of Complaints & PALS) is of the opinion that a representative does or did not have a sufficient interest in the person s welfare or is unsuitable to act as a representative, they must notify the person in writing, stating the reason. In the case of a child, the complaint must not be considered unless the Trust is satisfied that there are reasonable grounds for the complaint being made by the representative instead of the child i.e. why can t the child make the complaint? The representative must be a parent, guardian or other adult person who has care of the child and where the child is in the care of a local authority or a voluntary organisation, the representative must be a person authorised by the local authority or the voluntary organisation. ` 6. MATTERS EXCLUDED FROM CONSIDERATION The following complaints are excluded from the scope of the arrangements: - A complaint made by an NHS or Local Authority Social Care body which relates to the exercise of its functions by another NHS or Local Authority Social Care body. A complaint made by an employee of Gloucestershire Hospitals NHS Foundation Trust about any matter relating to their contract of employment. COMPLAINTS POLICY V2.3 (MINOR AMENDMENT DECEMBER 2013) PAGE 4 OF 24

A complaint that is made verbally and resolved to the complainant s satisfaction not later than the next working day after the day on which the complaint was made. A complaint that has been or is being investigated under the previous complaints regulations, or by the Healthcare Commission or the Parliamentary and Health Service Ombudsman. A complaint arising out of an NHS body s alleged failure to comply with a data subject request under the Data Protection Act 1998 or a request for information under the Freedom of Information Act 2000 (see Appendix 5 for details on how to raise a complaint about data subject requests or freedom of information requests). Complaints that suggest performance issues of an individual, these issues must be investigated and dealt with outside of the complaints procedure, in order to ensure that individuals rights to representation and support are met through appropriate procedures and processes. 7. TIME LIMITS A complaint must be made not later than 12 months after the date on which the matter occurred or the date at which the subject of the complaint came to the notice of the complainant. This timescale will not apply when or if the Trust is satisfied that either the complainant had good reasons for not raising the complaint within the time limit, or if, notwithstanding the delay, it is still possible to investigate the complaint effectively and fairly. 8. PROCEDURE A complaint may be made verbally, in writing or electronically. Where a complaint is made verbally the Trust will make a written record of the complaint and provide a copy of this record to the complainant for signature. The investigation will commenced once the signed confirmation is received in the Complaints Department confirming the issues to be investigated. The Trust will acknowledge complaints within 3 working days after the day on which it receives the complaint. This acknowledgment can be verbal or written and will include the manner in which the complaint is to be handled and the timescales in which the investigation will be completed. If the complainant does not agree with the way the Trust will investigate their complaint or the timescales involved, the Head of Complaints will review the timescales and notify the complainant in writing. The Trust will keep the complainant informed of progress of their complaint investigation where possible and will notify the complainant in writing where the agreed timescales cannot be achieved. 9. CONSENT & CONFIDENTIALITY The information about the 4Cs and the people involved is strictly confidential and is only disclosed to those with a demonstrable need to know. 4Cs records are kept separate from health records, and any correspondence about the 4Cs is not included in a patient s health records. Informal discussion about concerns can be documented in a patient s health records. It is not necessary to obtain the patient s express consent to use personal information when investigating a complaint. It is good practice to explain that information from health records may need to be disclosed to those involved. When a concern / complaint is made on behalf of an existing or former patient, consent must be obtained from the patient to disclose personal health information and the results of any investigation in order to uphold the duty of confidentiality to the patient. Matters of a nonpersonal or a non-clinical nature may be investigated and a response provided to the complainant. COMPLAINTS POLICY V2.3 (MINOR AMENDMENT DECEMBER 2013) PAGE 5 OF 24

Where consent is needed, the investigation will not commence until the consent has been received. Where a complaint has been made on behalf of a patient by a Member of Parliament (MP), it will be assumed that implied consent has been given by the patient. If however, the complaint relates to a third party, consent will need to be obtained from the patient prior to release of personal information. Where it is known that a concern / complaint involves a vulnerable adult or child the Trust lead for safeguarding adults / children will be informed. All letters regarding the 4Cs will be marked private and confidential. All internal e-mails regarding the 4Cs must be marked confidential and should not contain any patient identifiable information in the e-mail header, but use the appropriate reference number. By ensuring that all concerns and complaints are dealt with in the strictest of confidence the scope for patients, relatives or carers being treated differently as a result will be minimised. In accordance with data protection, all files related to the 4Cs will be kept for 10 years. If the complainant wishes any response via e-mail, this can be done if the complainant gives their consent and accepts the risks that it is not secure once it leaves the hospital server. Responses cannot be sent via e-mail if the staff are unable to verify the e-mail address and recipient. 10. HANDLING AND CONSIDERATION OF COMPLAINTS BY THE PARLIAMENTARY & HEALTH SERVICE OMBUDSMAN (PHSO) Where a complainant is not satisfied with the results of an investigation and the Trust cannot resolve the complaint under local resolution, the complainant will have the option of taking their complaint to the PHSO for review. Full copies of any relevant files, including the complaint file and the patient s medical notes, will be made available to the PHSO on their request and production of a valid consent form. All files sent to the PHSO shall be sent via Special Delivery to ensure it can be tracked throughout its journey and signed for upon delivery. 11. INDEPENDENT COMPLAINTS ADVOCACY SERVICE (ICAS) All complainants have access to information about independent complaints advocacy services which offer independent help, guidance or support when making a complaint. This information is available from PALS or the Complaints Team directly via the complaints leaflet or via the ICAS website - http://www.seap.org.uk. All complaint acknowledgement letters will also have a copy of the complaints leaflet enclosed. ICAS is only available to support people in making complaints about the NHS and is not available to support people with complaints about social care. 12. LEGAL IMPLICATIONS If the complainant has either instigated formal legal action or notified the Trust in writing that he or she intends to do so, the Complaints Manager should seek the advice of the Trust s Legal Department via the Head of Complaints & PALS and if it is considered that the complaint investigation would prejudice the legal claim, the complaint should be stopped. The complainant will be notified in writing on this decision as necessary. COMPLAINTS POLICY V2.3 (MINOR AMENDMENT DECEMBER 2013) PAGE 6 OF 24

If the police become involved at any stage during a complaint, the complaint will be suspended until the police have confirmed that continuation of the hospital s investigation will not prejudice their own investigation. The complainant will be notified in writing of this decision. 13. MEDIA INTEREST The Trust s Communication Team should be briefed where the complainant expresses their intention to contact the media. 14. REDRESS Under the new national guidelines from the PHSO, the Trust has a responsibility to put people back in the position they were in prior to complaining. Redress could mean numerous different resolutions from appointments, changes in policy right through to re-imbursement for any financial loss incurred. For any financial reimbursements if, during the course of the complaint investigation, the Trust is found to be at fault and the complainant has suffered financial loss, the complainant s details will be forwarded to the Legal Department which already has robust systems in place to assess each case and in turn will provide any financial re-imbursements as appropriate. The Legal Department will make contact with the complainant, assess the claim for re-imbursement and make a decision accordingly. 15. MEETINGS As part of being open (see section 16 below), where complaint meetings take place with staff to help in local resolution of concerns or complaints, it is important to record accurately the outcome and actions agreed at that meeting. The Complaints Team will arrange the meeting and organise a senior manager to chair the meeting. The complainant will be asked to provide a clear list of issues they wish to discuss at the meeting and the Complaints Manager will brief those staff involved in the meeting to ensure everyone is aware of the purpose of the meeting and the issues to be discussed and resolved. This preparation must take place before the actual meeting with the complainant. 16. BEING OPEN COMMUNICATING FOLLOWING A COMPLAINT Being Open is a set of principles, developed by the National Patient Safety Agency, that healthcare staff should use when communicating with patients, their families and carers following a patient safety incident in which the patient was harmed. Being Open supports a culture of openness, honesty and transparency. For further guidance see Incidents Action Card AIR6 Being Open involves: acknowledging, apologising and explaining when things go wrong conducting a thorough investigation into the incident and reassuring patients, their families and carers that lessons learned will help prevent the incident recurring providing support for those involved to cope with the physical and psychological consequences of what happened. It is important to remember that saying sorry is not an admission of liability and is the right thing to do. The Trust are fully committed to the principles of Being Open when dealing with patient safety incidents, complaints and claims and this is reflected in related policies. A copy of the NPSA Being Open Framework can be found at www.nrls.npsa.nhs.uk/beingopen COMPLAINTS POLICY V2.3 (MINOR AMENDMENT DECEMBER 2013) PAGE 7 OF 24

17. MEDIATION In certain circumstances where the views of the Trust and the complainant are different, it may be appropriate to use local mediation (independent negotiation to resolve differences) to resolve a complaint and this should be seen as a positive way forward to resolving complaints locally. Mediation can be requested by staff, the complainant or their representative, but all parties have to agree to mediation and abide by their decision. If all parties agree to mediation, this will be arranged via the Complaints Team. Any charges involved will be picked up by the Division leading on that individual complaint. Mediation may be offered via appropriately trained internal mediators, or using external mediators. Any arrangements for mediators must be discussed with the Head of Complaints & PALS in the first instance. 18. EQUALITY AND DIVERSITY The Trust is committed to make its complaints procedure as easily accessible as possible for everyone. With this in mind, the complaints information can be translated into any language as necessary. In addition, the following is available: Standard leaflet explaining how to comment and complain. 4Cs posters for public areas throughout the hospital. Easy read leaflets. PALS leaflet in 23 languages. Combined Health & Social Care complaints leaflet 4C s can be made verbally, in writing, via e-mail and via text messaging. Complaint responses can also be translated into any language as necessary for non-english speakers including Braille. Any issues that the Trust needs to consider with regards to equality and diversity will be documented in the complaint plan. 19. COMPLAINTS REGARDING PRIVATE CARE This policy will cover any complaint made about the Trust s nursing staff or facilities relating to their care in the Trust s private beds. However, it does not allow for complaints about the private medical care provided by the consultant. In these situations, complaints should be sent to the consultant directly. Where a complaint is raised about an individual consultant s private care and they are employed by the Trust, details of the complaint will be forwarded to their Divisional Medical Director to discuss at their appraisal. 20. FRAUD AND CORRUPTION Any complaint which concerns possible allegations of fraud and corruption is passed immediately to the counter fraud and management service in accordance with the Trust policy on Fraud and Corruption (Appendix 2). 21. MONITORING OF COMPLIANCE (M o C) FORM Criteria (objective to be measured) Monitoring methodology Lead responsible Timescales Reporting arrangements 2.3 (b) how the organisation listens an responds to concerns and complaints from patients, their relatives Annual Aggregated report from Patient Experience and complaints. Tracey Martin Annual June Quality Committee Trust Board COMPLAINTS POLICY V2.3 (MINOR AMENDMENT DECEMBER 2013) PAGE 8 OF 24

and carers Divisional Reports Tracey Martin Quarterly Divisions 2.3 (c) how joint complaints are handled between organisations Annual Aggregated report from Patient Experience and complaints. Tracey Martin Annual June Quality Committee Trust Board 2.3 (e) how the organisation makes improvements as a result of a concern or complaint. Divisional Quarterly Report Divisional Annual Report Divisional Risk Managers Quarterly Annual H&S Committee Quality Committee 2.5( c) different levels of investigation appropriate to the severity of the event. Complaints included in Annual Review of Serious Incidents Tracey Martin and Trust Risk Manager Annual Quality Committee 2.5 (e) how action plans are followed up Divisional Quarterly Report Divisional Annual Report Divisional Risk Managers Quarterly Annual H&S Committee Quality Committee COMPLAINTS POLICY V2.3 (MINOR AMENDMENT DECEMBER 2013) PAGE 9 OF 24

22. PROCESS LOCAL RESOLUTION 22.1 COMPLIMENTS Compliments can be made verbally, via our website or in writing directly to the staff involved, to the department manager, the senior management teams, the Complaints team, PALS teams or the Chief Executive. By the 28 th of each month, each ward / department will complete a compliment form detailing all the compliments received that month. This form will be sent to the Head of Complaints & PALS via e-mail. All compliments are recorded on the 4Cs database, fed through to the staff concerned and reported in the monthly divisional 4Cs reports and the quarterly 4Cs quality reports. 22.2 COMMENTS Comments can be made via the Trust comment cards, the Trust s website or verbally / in writing to the PALS team. All comments are recorded on the 4Cs database and reported in the monthly divisional 4C s report and the quarterly 4Cs quality reports. 22.2 CONCERNS AND COMPLAINTS Patients and relatives are encouraged to raise concerns or make complaints as soon as possible and directly to the staff involved in their care or the manager of the department / ward. The complainant s concerns should be addressed constructively and where possible will be dealt with immediately by the staff member approached (Appendix 6). The complainant will be cared for sensitively and in an open and constructive manner. If the staff member approached is unable to deal with the issue, they should promptly refer this to the more senior member of staff on duty at the time i.e. ward manager, lead nurse, matron, general management team or duty management team. Where it is not possible to deal with the concern / complaint immediately, or if the complaint requires a fuller investigation, or if the complainant wishes to address their concerns to somebody not involved, the complainant should be referred to the PALS team. The PALS team will then assist the client in raising their concerns / complaints by the most appropriate method. Whether the concern or complaint is being dealt with by the staff / department concerned or the PALS team, the complainant should be given a contact name and telephone number and must be kept informed of progress and when they can expect to receive a response. Accurate records must be made and kept regarding the concerns, actions taken and any communications. This information must be forwarded to PALS for logging. Where the complainant wants a written response, the concern / complaint should be referred to the Complaints Team which can administer the process and launch an investigation. When complaints arrive they will be date stamped and passed on to the Complaints team as soon as possible. The Complaints Team will record the complaint and risk assess it (in line with the Trust s risk assessment policy), create a file and allocate a Complaints Manager. The risk score will also be reviewed by the Head of Complaints & PALS Where the complaint has been risk assessed as orange or red, the Head of Complaints must be notified and a root cause analysis investigation must take place. Where the complaint has been risk assessed as red, the Complaints Manager will also notify the Risk Manager and a decision taken whether to hold a concurrent SUI investigation. COMPLAINTS POLICY V2.3 (MINOR AMENDMENT DECEMBER 2013) PAGE 10 OF 24

If the complaint relates to more than one NHS or Social Care organisation, the investigation will be conducted according to the South West Complaints Managers Regional Protocol (copy available from the Complaints Team) in conjunction with this policy. Staff s first responsibility on receipt of a complaint is to ensure that the patient s immediate health care needs are being met. This may require urgent action before any matters relating to the complaint are dealt with. The Complaints Manager will allocate an appropriate Investigating Manager(s) and send the complainant an acknowledgement letter detailing the process and timescales and inviting the complainant to contact them should they be unhappy with the investigation proposed. This acknowledgement letter should be sent out within 3 working days of the complaint arriving with the Complaints team. The 4Cs leaflet will be included in this acknowledgement letter which details the complainant s rights under the NHS Constitution, information on ICAS and the PHSO. The complaint will be sent by the Complaints Manager directly (via e-mail) to the appropriate Investigating Manger(s) and the divisional management teams for investigation within the specified timescales. The allocated Investigating Manager(s) will either personally investigate the complaint or allocate members of their teams to undertake the investigation. If any details of the complaint need clarifying then it is appropriate for either the Complaints Manager or Investigating Manager to make contact with the complainant directly. If appropriate, a meeting could be offered at this stage. The Investigating Manager(s) may delegate aspects of the investigation as appropriate but remains wholly responsible for the investigation and the response to the Complaints team. The Investigating Manager(s) must ensure that where necessary they have appropriate clinical input as part of their investigation. Where staff are directly involved in complaints, written accounts will be taken at the time of the investigation as an accurate record of events. These accounts must be submitted with the results of the investigation by the Investigating Manager(s). The Investigation Manager(s) will submit their response to the Complaints Manager within the specified timescales together with any supporting evidence and a complaint checklist. The Complaints Manager is responsible for producing a draft response in the form of a letter from the Chief Executive in conjunction with appropriate staff involved and ensure that: All the issues raised have been fully addressed. The information provided is accurate. A full and honest explanation is provided. An apology (apologies) if appropriate is provided. The actions that have / will be taken to improve the situation (action plans can be included where appropriate) are explained. The Complaints Manager will send the draft response to the Investigating Manager and the DMT for checking and approval. The Investigating Manager(s) and the DMT will clear the response within 2 working days and add further details as necessary to the response. The Complaints Managers will then finalise the response and submit the response and complaints file for review by the Head of Complaints & PALS. The Head of Complaints & PALS (or in their absence, the Head of Patient Experience) will review the complaint, the investigation and response to ensure that it has been thorough, prior to briefing the Chief Executive. COMPLAINTS POLICY V2.3 (MINOR AMENDMENT DECEMBER 2013) PAGE 11 OF 24

The Chief Executive receives a briefing for each complaint and once assured that the investigation has been thorough and the response addresses all the issues raised, a reply will be sent within the timescales specified in the acknowledgement letter. Where the Chief Executive is unavailable this function will be undertaken by the Acting Chief Executive. We will seek to resolve all complaints within the agreed timescales set out in the acknowledgement letter, however, there is variation in the level and complexity of complaints and some may require longer to thoroughly conclude the investigation and provide a full response. If a longer response time is required, this will be identified as soon as possible and an extension of time agreed with the complainant. The complainant will also be kept informed of the progress of their complaint. If a complainant is not happy with the response, any subsequent replies will have timescales agreed with the complainant. The Complaints Team ensures that all information relevant to the investigation of the complaint is recorded and kept in the case files and is available without unnecessary delay to the PHSO if requested. A copy of the signed final response from the Chief Executive will be sent to the Complaints Team, who will forward to the Investigating Manager(s), who will then ensure that all those involved in the investigation and named in the final response will have the opportunity to see it, with any necessary support. A formal debrief can be offered for the staff involved in the complaint. The DMT is responsible for ensuring the action plan is implemented within the agreed timescales. Progress on action plans together with learning outcomes will be discussed at the Divisional Quality Assurance meetings and will be included in the quarterly quality reports to the Trust s quality committee. Where agreed with the complainant, they should be kept informed on the progress of the actions by the Complaints Team. All complaint responses are sent using second and first class post as necessary. All trends and themes that result from concerns and complaints are reported through the monthly 4Cs report to the DMT. All trends and themes will be coded Red (a trend has occurred for three consecutive months), Amber (a trend has occurred for two consecutive months) and Green (a trend has occurred for a single month). 23. REFERENCES The Local Authority Social Services and National Health Service Complaints (England) regulations 2009, available at http://www.doh.gov.uk Publications from the Office of the Parliamentary and Health Service Ombudsman, all available at http://www.ombudsman.org.uk Principles of Good Administration (March 2007) Principles for Remedy (March 2007) Principles for Good Complaint Handling (November 2008) COMPLAINTS POLICY V2.3 (MINOR AMENDMENT DECEMBER 2013) PAGE 12 OF 24

Intentionally left blank. COMPLAINTS POLICY V2.3 (MINOR AMENDMENT DECEMBER 2013) PAGE 13 OF 24

Gloucestershire Hospitals NHS Foundation Trust Learning & Development Department Redwood Education Centre Training Needs Analysis for COMPLAINTS POLICY Completed on 23 rd July 2009 By Carl Beech *Level of training required Staff Group / s Division / Department A Divisional Management Team All Divisions Yearly A Divisional Risk Managers All Divisions Yearly A All staff All Divisions Yearly Frequency of training / update Method of training delivery Attendance at Divisional meetings Attendance at Divisional meetings Via appropriate Divisional meetings Lead and department responsible for provision of training Complaints Managers Complaints Managers Head of Departments *Levels of Training A = Awareness (Micro-teach, drop in session, e-learning) B= ½ day (2.5 3 hours) (workshop, training event, e-learning) C = Full day (5-6 hours) (workshop, training event) D= Course (more than one day training) COMPLAINTS POLICY V2.3 (MINOR AMENDMENT DECEMBER 2013) PAGE 14 OF 24

Gloucestershire Hospitals NHS Foundation Trust TRUST POLICIES Authorisation Form DOCUMENT: DEPARTMENT/DIVISION (WHERE APPROPRIATE) AND TITLE Authorisation Name and Position Date Approved Responsible Author Tracey Martin Head of Complaints & PALS Policy Sponsor Maggie Arnold Director of Nursing & Midwifery Policy Assurers Consideration at authorised groups (e.g. Board, Board sub committees, Policy Group, Clinical Policies Sub Group, Departmental meetings etc.) Name of Group Minute Details Date considered Clinical Policy Group 10 th November 2009 Trust Policy Approval Group 26/02/2013 approved COMPLAINTS POLICY V2.3 (MINOR AMENDMENT DECEMBER 2013) PAGE 15 OF 24

Gloucestershire Hospitals NHS Foundation Trust EQUALITY IMPACT ASSESSMENT INITIAL SCREENING 1. Lead Name : Tracey Martin Job Title : Head of Complaints & PALS 2. Is this a new or existing policy, service strategy, procedure or function? New Existing 3. Who is the policy/service strategy, procedure or function aimed at? Patients Carers Staff Visitors Any other Please specify: 4. Are any of the following groups adversely affected by this policy: If yes is this high, medium or low impact (see attached notes): Disabled people: No Yes Race, ethnicity & nationality: No Yes Male/Female/transgender: No Yes Age, young or older people: No Yes Sexual orientation: No Yes Religion, belief & faith: No Yes If the answer is yes to any of these proceed to full assessment. If the answer is no to all categories, the assessment is now complete. Date of assessment: 25 th February 2013 Completed by: Tracey Martin Signature: Director: Job title: Head of Complaints & PALS Signature: This EIA will be published on the Trust website. A completed EIA must accompany a new policy or a reviewed policy when it is confirmed by the relevant Trust Committee, Divisional Board, Trust Director or Trust Board. Executive Directors are responsible for ensuring that EIA s are completed in accordance with this procedure. COMPLAINTS POLICY V2.3 (MINOR AMENDMENT DECEMBER 2013) PAGE 16 OF 24

Unreasonably Persistent Complainants Appendix 1 The Trust treats complaints very seriously, it is also accountable for the proper use of public money and must ensure that that money is spent wisely and achieves value for complainants and the wider public. We are committed to dealing with all people fairly and impartially and to providing a high quality service. However, there are a small number of complainants who, because of the frequency of their contact with the Trust, hinder our consideration of their, or other people s complaints. We refer to such complainants as exhibiting unreasonable persistent behaviour and, where this level of contact is unreasonable, we will take action to limit their contact with the Complaints Office and / or the Trust. Complainants may be deemed to be unreasonably persistent where previous or current contact with them shows that they meet two or more of the criteria. Where complainants have: Refused to accept the remit of the process to be undertaken as described to them in the complaint plan. Continually raised new issues or seek to prolong contact by continually raising further concerns or questions upon receipt of a response or whilst the complaint is being investigated, when they have already agreed to the complaints plan. Not accepted the response and / or where the concerns identified are not within the remit of the Trust (despite the best endeavour of staff to confirm and answer the complainants concerns and, where appropriate involving ICAS). In the course of addressing a complaint, had an excessive number of contacts with the Trust, which have placed unreasonable demands on staff. Discretion is used in determining the precise number of excessive contacts in each individual case. Failed to engage with staff in a manner which is deemed appropriate e.g. repeatedly using unacceptable language, secretly recording conversations without consent (in contravention of the Data Protection Act 1998), refusing to adhere to previously agreed communication plans or behaving in an otherwise threatening or abusive manner on more than one occasion. Repeatedly focused on conspiracy theories and / or will not accept documented evidence as being factual. Focused on a matter to an extent which is out of proportion to its significance and continuing to focus on this point. Requested actions that are not compatible with the process or place unreasonable demands on staff. Threatened or used actual physical violence towards staff. Sent indecent or offensive items to staff either in person or via the post / e-mail. When we consider that an individual s level of contact is unreasonably persistent we will tell them why we believe that their behaviour falls into this category, and ask them to change it. If the behaviour continues, we will take further action. The decision to restrict access to our Complaints Office and / or the Trust will be taken by the Head of Patient Experience following discussions and agreement with the Chief Executive. Any restrictions imposed will be appropriate and proportionate. The options we are most likely to consider are: Drawing up a signed agreement with the complainant which sets out a code of behaviour for the parties involved if the Trust is to continue progress the complaint. If these terms are contravened, consideration would then be given to implementing other action as indicated in this section. Restrict or decline contact with the complainant either in person, by telephone, by fax, by letter or by any combination of these. COMPLAINTS POLICY V2.3 (MINOR AMENDMENT DECEMBER 2013) PAGE 17 OF 24

Notify the complainants in writing that the Trust has responded fully in an attempt to resolve the complaint, however, there is nothing more to add and continuing contact on the matter will serve no useful purpose. The complainants should be notified that their correspondence is at an end and that further letters will be filed and not acknowledged or answered. Enforce the Trust s violence and aggression policy. In all cases we will write to tell the individual why we believe their behaviour is unacceptable, what action we are taking and the duration of that action. We will also tell them how they can challenge the decision if they disagree with it. Where an individual continues to behave in a way which is unreasonably persistent, we may decide to terminate contact with that individual. Where the behaviour is so extreme that it threatens the immediate safety and welfare of the Trust staff or others, we will consider other options, for example, reporting the matter to the Police or taking legal action. In such cases, we may not give prior warning of that action. Explaining the decision taken Once a restriction is put in place, a letter should be issued from the Chief Executive to inform the individual about the decision, what it means for their future contact with the organisation and the context of those contacts, how long those restrictions will remain in place and what they can do to have their position reviewed. A copy of this policy needs to accompany that letter. Appeals Where an individual wishes to appeal the action taken by the Trust, they should write in detailing why they wish to appeal. This should be sent in the first instance to the Head of Complaints & PALS who will inform the Head of Patient Experience and seek a review from a senior Trust Manager / Director who has had no involvement with that complaint to review the decision taken. COMPLAINTS POLICY V2.3 (MINOR AMENDMENT DECEMBER 2013) PAGE 18 OF 24

Counter Fraud flow chart Appendix 2 Incident reported to Local Counter Fraud Service Local Security Management Service Ensure details are shared as appropriate Complaint elements investigated by Complaints Dept Fraud elements investigated by LCFS Security elements investigated by LSMS Regular liaison in shared investigations to ensure progress is monitored Closure reports shared when appropriate Quarterly meetings to discuss areas of mutual interest COMPLAINTS POLICY V2.3 (MINOR AMENDMENT DECEMBER 2013) PAGE 19 OF 24

Appendix 3 PROCESS FOR COMPLAINTS Within 3 working days Complaint received into the Complaints Department Same working day Acknowledgement sent to complainant Complaint dated / logged and key respondents of complaint identified and notified sent to DMT 10 working days CM appoints Investigation Manager to investigate complaint, draft response, compile the evidence / action plan IM / DMT to submit their response & evidence to the Complaints team Time extensions may need to be agreed with the complainant if delays occur resulting in not meeting Department of Health timescales Complaints team checks response answers complaint, evidence & action plans as appropriate Any questions not answered or response is not satisfactory, returned to Investigation Manager / DMT Response prepared for the Chief Executive by the CMs Response to be sent within the agreed timescales Letter submitted for signing by Chief Executive Response sent to Complainant/ Respondents COMPLAINTS POLICY V2.3 (MINOR AMENDMENT DECEMBER 2013) PAGE 20 OF 24

Appendix 4 Process for Complaints / Concerns from GP s and other Community Healthcare Professionals Complaint / Concern from GP / PCT / other healthcare professional not employed by Gloucestershire Hospitals NHS Foundation Trust Issue sent by GP etc, directly to appropriate Consultant or Manager to answer. Issue sent by GP etc, directly to appropriate Consultant or Manager to answer, but copied to PALS GP etc, sends issue directly to the PALS team for answers Individual Consultant or Manager investigates and responds directly back to the GP etc PALS will log issue on hospital database (Datix) and monitor for response PALS will acknowledge receipt of issue and log on hospital system (Datix) Copy of all paperwork to be sent to PALS for logging on the Datix system If no response is forthcoming, PALS will chase with individual concerned Issue sent to the most appropriate individual to answer concerns Once the issue has been responded to, PALS will log response and close case Draft investigation report submitted back to PALS within specified timescales All cases will be logged on Datix and fed back anonymously via monthly divisional reports. PALS will provide GP etc with response to their concerns COMPLAINTS POLICY V2.3 (MINOR AMENDMENT DECEMBER 2013) PAGE 21 OF 24

Complaints regarding FOI and data protection Appendix 5 For any complaint relating to failure to comply with FOI should be addressed to: Trust Freedom of Information Lead Gloucestershire Hospitals NHS Foundation Trust The Management Suite Alexandra House Cheltenham General Hospital Sandford Road Cheltenham GL53 7AN For any complaint relating to failure to comply with data access requests should be addressed to: Head of Legal Services Legal Services Department Cheltenham General Hospital Sandford Road Cheltenham Gl53 7AN Any complaints received by the FOI Lead and the Head of Legal Services will be notified to the Head of Complaints & PALS to ensure that the organisation is aware of the complaints and organisational learning can be monitored. COMPLAINTS POLICY V2.3 (MINOR AMENDMENT DECEMBER 2013) PAGE 22 OF 24

Guidelines for Front Line staff dealing with Concerns or Complaints Appendix 6 Summary These guidelines provide information about the way in which the Trust expects individual members of staff to respond to concerns and complaints raised by patients or the public. They should be read in conjunction with the Trust policy for the Management of the 4Cs (Compliments, comments, concerns and complaints). Introduction Every member of staff is personally responsible for responding politely and appropriately when approached by a user of the service, or visitor to the Trust, expressing a concern, complaint or asking for help. Taking a few minutes to respond helpfully gives the user of the service a positive experience and can often avoid a more formal complaint being made. Individual responsibilities Where possible, always respond immediately to concerns or questions raised by users of the service. However, first consider whether you are able to reply, and whether it is appropriate for you to do so, or if the matter is serious enough that it should be referred to someone senior to you. Concerns and complaints raised in writing are rarely about issues where a front line response is sufficient to resolve a problem and should therefore be referred to the Complaints team for further advice. If you are able to answer, but have another immediate priority, offer to return later to provide the answer and make good on the offer as promised. If you do not have the experience or knowledge to respond, or the issue is of a serious nature and needs escalating, refer the person to a colleague who will be able to assist. Take into account that the hospital environment is unfamiliar to the majority of users. As staff we are accustomed to this world and understand how it works; patients and visitors are not and need help to find their way. If you can help a patient to understand the process they have become involved in and what they can expect to happen to them, they are far more likely to be satisfied with the service they receive. Being pro-active in communicating with patients is essential. If you are in a position to do so, keep patients informed about events which are affecting them, such as delays in outpatient clinics, so that they can understand what is happening without having to ask. Most people are understanding as long as they know what is going on. Be factual and avoid passing comment, for example use: I m sorry but the doctor has been held up on this ward rounds and clinics are running about 30 minutes late Rather than: doctor is late again, I m sorry this is always happening, I m sure he will be here soon COMPLAINTS POLICY V2.3 (MINOR AMENDMENT DECEMBER 2013) PAGE 23 OF 24

Try to be positive and diffuse the situation. For example it is better to respond to complaints about car parking by saying something like: yes, it s a real problem I am sorry you ve been affected. We are trying to make changes and do try and make allowances for people who are late arriving rather than: I know, it s awful. We keep complaining about it, but they never do anything about it When you have dealt personally with a concern or a complaint raised by a user of the service, consider whether you need to let your manager know about it. Trends and themes can only be identified, and problems rectified, if information is shared. Do not send any person(s) to the PALS and Complaints team suggesting you need to make a complaint. This is not helpful and will not end the problem for you the first thing the teams will do is come back to your area to find out what the answer is. The teams are there to support staff if the front line response has failed and the situation has become more difficult, and to provide advice and training for staff. Please note: staff are not expected to tolerate rude or violent behaviour from patients or visitors and guidance in this respect if provided in the Trust s policy on Managing Violence and Aggression. Manager s responsibilities Lead by example, encouraging staff to respond positively and helpfully to expressions of concern from users. Use the communication section of the Knowledge Skills Framework (KSF) in the appraisal process to ensure all members of your team develop strong and effective communication skills. Be certain that your staff are aware that they can expect to be treated with respect and courtesy by patients and visitors to the hospital, and how they should act in situations where their rights are not being observed. Where necessary, make sure that systems exist to keep users informed about what is happening. In patient areas make sure that the environment allows for privacy and dignity to be preserved. If confidential details need to be discussed, try to make sure the discussion cannot be overhead. Ensure your staff are aware of the types of issues raised by users that you expect them to escalate to you. This guidance must specifically deal with concerns raised in writing to named members of staff. Summary Take personal ownership when approached by anyone raising questions, concerns or complaints. Resolve the problem quickly, if possible, or escalate to another colleague who can assist. Be polite, positive and open in responses. Sorting out the problem at the start, when it is small and manageable, saves everyone time and trouble in the long run. COMPLAINTS POLICY V2.3 (MINOR AMENDMENT DECEMBER 2013) PAGE 24 OF 24