B. Comments and concerns
1. Protected characteristic
Positive impact
Neutral Impact
Negative Impact
Reason for impact and action required.
People of different ages (e.g. Children, young or older people).
√
People of different religions / beliefs
√
People with
disabilities (physical, sensory or learning).
√
People from different ethnic groups
√
Men or women √
Transgendered people
√
People who are gay, lesbian, and bi-sexual
√
Refugees and asylum seekers
√
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2 Please describe engagement and consultation process and the key feedback. E.g.
with teams, unions.
Consultation is described in paragraph 6 of the report
3. If there are negative impacts upon people’s protected characteristics. Does the policy in its current form need a full Equality Analysis Assessment to be completed?
No
4. Have you signed this off with the Equality and Diversity team?
Yes
Page 40 of 72 Appendix C Management of complaints flowchart
Complaint /concern received Service
Record issue and outcome locally and review at local CLIPS
meeting Pass to Customer
Service Team within 1 working day. Receipt
must be confirmed.
CST to send Investigation Report Form to SM with agreed
report completion date CST acknowledges complaint and agrees timeframe and issues to
be investigated
report and sends draft response to SM for review
and sign off Draft response letter and forward to Service Manager for factual accuracy checks.
If risk is moderate or above copy to Service AD If risk is high or above pass to Chief Nurse
CST forwards draft response to Chief Nurse (or Medical Director for clinical issues) or deputy
for review prior to sending to Chief Executive Office
Chief Executive Office to send final response to
CST for sending to complainant together has been identified follow Safeguarding /Incident procedure.
CST sends copy of response to SM.
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Appendix D: Management of complaints for partner organisations flowchart:
CLCH is the lead partner
Complaint /concern received regarding PO.
Pass complaint to SM within 1 working day (cc
PO).
CST acknowledges complaint and sends Investigation Report Form to CLCH Service Manager
with agreed report completion date.
SM sends investigation report to CST who then sends draft response to SM for review and sign
off with PO.
CST forwards draft response to CLCH Chief
Nurse (or Medical Director for clinical issues) for review prior
to sending to Chief Executive Office.
Chief Executive Office to send letter of findings
to CST for sending out.
3
Key: CST: Customer Service Team
PO: Partner Organisation SM: Service Manager AD: Associate Director The SM will co-ordinate
completion of Investigation Report
Form with PO If risk is moderate or
above copy to Service AD. If risk is significant or above also pass to Chief Nurse
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Appendix E: Management of complaints for partner organisations flowchart:
CLCH is not the lead partner
If risk is moderate or above copy to Service AD If risk is significant or above pass to Chief Nurse
Complaint /concern received regarding
CLCH Service.
Pass complaint to PO Complaints Team within 1
working day (cc SM).
SM send report template to CST.
CST checks investigation report template and send to CLCH Chief Nurse (or
Medical Director for clinical issues) for review prior to sending to PO Complaints Team CST and complainant is led by the PO Complaints
Team
The CST will co-ordinate completion of Investigation Report
Form with SM
Key: CST: Customer Service Team
PO: Partner Organisation SM: Service Manager AD: Associate Director
PO sends copy of response to CST for file.
CST sends copy to SM.
Page 43 of 72 Appendix F
Complaint Resolution Investigation Report Agreed response date by Investigating
Manager:
Low-Mod risk: Up to 10 working days Med-High Up to 30 working days Extreme: 30-60 working days where agreed to have an extension at Director level
Complaint Datix Ref : CLCH Cxxx
Customer’s (complainant) details Name:
Date of Birth:
Address:
Telephone number: (Home):
(Mobile):
Email:
Preferred method of contact with customer:
(e.g. telephone, letter, email)
Advocacy / interpreter or additional support required e.g. VoiceAbility, MIND Service User details (if different from complainant)
Name (include title):
Date of birth:
Address:
Telephone number: (Home):
(Mobile):
Details of staff member(s) named in complaint NB The staff member should be asked to submit a written statement using the pro-forma in the Complaints Policy (Appendix G) and that staff have opportunity to review the investigation findings before it is forwarded for approval.
If agency staff has the agency been informed of the complaint Y/N?
Name: Please advise
Details of Investigating service manager Name:
Page 44 of 72 Any further issues following contact with complainant?
E.g. Awaiting Consent, Local resolution Meeting required (Use pro-forma for meetings guidance in the Complaints Policy (Appendix H).
Other organisations/services involved?
If yes, give details and actions taken: May be a joint complaint against CLCH and another Trust. Will need to agree who is leading on complaint.
Outcome of Datix check for other incidents or complaints re staff member:
Service to check if datix logged in connection with complaint incident.
Summary of complaint: (Give brief, factual account and dates of circumstances and complaint -use separate sheet if required See email/Letter or summary of verbal complaint.
Desired outcomes: (What the customer would like to happen as a result of their complaint):
For example
• They want to know what went wrong and why
• What has/is being done to rectify the problem that occurred
• They don’t want the same issue to reoccur for other patients/carers
• Want an apology
• To know if there is any learning or actions being taken as a result of their complaint
Is CCTV footage required? N (E.g. cases where behaviour of Reception/Complainant is in question) if yes, has it been requested (note records are deleted by 31 days of recording.
Preferred method of feedback following investigation: (Tick as appropriate)
Meeting Letter Phone Call Email
Initial triage completed by (Complaints team)
Triaged and assessed as: (Consequence x Likelihood Use the risk matrix in Complaints Policy-Appendix R
Triage after investigation completed by investigating manager:
Triaged and assessed as: (Consequence x Likelihood) Use the risk matrix in Complaints Policy-Appendix R
Page 45 of 72 Considerations for Investigation Manager’s report
Care and service delivery issues
A themed list of the key problem points. (Where many problems have been identified the full list should be included in the appendix)
Contributory factors List the following factors which could have contributed to the issues.
For example,
1.The occurrence happened towards the end of a shift so there was a delay in the family being informed.
2.There is no 24 hour doctor cover on the ward and this contributed to the delay in an x ray being carried out.
3.The staff member did not follow the moving and handling guidelines.
Root Causes These are the most fundamental underlying factors contributing to the incident that can be addressed.
For example
1. The staff member did not follow moving and handling guidance.
2. The staff member left the patient on her own.
3. As the fall did not result in a fracture there was no written report carried out
Lessons learned Key safety and practice issues identified which may not have contributed to this incident but from which others can learn.
For example:
1. The nurse in charge should check that staff know how to use the equipment in the ward.
2. This incident has highlighted the importance of keeping a patient’s family informed of care and treatment and ensuring that information is shared in a timely way.
Recommendations: These should be directly linked to root causes and lessons learned. They should be clear but not detailed (detail belongs in the action plan). It is generally agreed that key recommendations should be kept to a minimum where ever possible.
For example:
1. To ensure that all staff in the future know how to use the equipment on the ward an