Complaints Policy and Procedures
Change History
Version Date Name Revision Description
0.1 Draft September 2013
Rebecca Cornish
1.0 September 2013
Julie Andrews Quality Assurance
1.1 October 2013
Julie Andrews Email address change
This document sets out the policy and the procedures for managing complaints throughout East and North Hertfordshire Clinical Commissioning Group (ENH CCG).
Document Owner Sheilagh Reavey, Director of Nursing and Quality
Document Author Sheilagh Reavey, Director of Nursing and Quality
Version 1
Directorate Nursing and Quality
Authorised By (Approval body/Manager) Quality Committee
Date of Approval
Contents Page
Section Heading Page
Executive Summary 3
1 Introduction 4
2 Guiding Principles 5
3 Confidentiality 5
4 The NHS Complaints Regulations 6
5 Patient Advice and Liaison Service 6
6 Health Service Ombudsman’s Principles for Remedy 7
7 Roles and Responsibilities 8
8 What Is A Complaint 9
9 Who Can Make a Complaint 9
10 Timescales for making a complaint 10
11 Complaints relating to Individual Funding Requests and Continuing Healthcare
10
12 Framework for dealing with complaints 10
13 Guidance and Support for Members of the Public 13
14 What Cannot be Complained About 13
15 Learning and sharing lessons 14
16 Discriminatory complaints 15
17 Monitoring and audit 15
18 Training 16
19 Communication 16
20 Litigation 17
21 APPENDIX A – Recommendations from The Francis Report 17 APPENDIX B – Procedure for dealing with complaints
Risk Rationale
Complaints involving other organisations Correspondence from MPs
18
APPENDIX C – Complaints Action Plan 19
APPENDIX D – Equality & Diversity Statement - The Human Rights Act 1998
Executive Summary
This policy reflects the legal requirement placed upon NHS organisations to have written procedures in place which highlight the arrangements for the handling of complaints in accordance to the National Health Service (Complaints) Regulations. This Policy has been developed for the East and North Hertfordshire Clinical
Commissioning Group (ENCCG) for the use from April 2013 to provide guidance on how complaints will be managed.
This Policy takes into account the Mid Staffordshire NHS Foundation Trust Public Enquiry, also known as the Francis Report, which was published on 6th February 2013.
“A complaint that is not heard by an organisation is more damaging than a complaint that is received, acknowledged and remedied.”
This Policy also takes into account the ‘Guide to good handling of complaints for CCGs’, published by NHS England in May 2013.
1. INTRODUCTION
ENCCG is responsible for the local NHS budget and for commissioning healthcare for the patients of East and North Hertfordshire providing a high standard of care and service that is flexible and responsive to the needs of patients and service users. This policy details the procedure for managing complaints received by ENCCG. This policy applies to services commissioned by ENCCG including;
• Commissioning and funding decisions
• NHS funded services that are accountable to ENCCG • Services provided by ENCCG and its staff
The Department of Health published new Regulations (Local Authority Social
Services and NHS Complaints (England) Regulations 2009), which were introduced on 1st April 2009. The Regulations provide the statutory basis for the single approach to complaints handling in health and social care. The new complaints approach is structured around three main principles;
• Listening – taking a more active approach to asking for people’s views by working in partnership
• Responding – dealing with complaints more effectively by finding out what the complainants want to happen
• Improving – using the information received to learn and improve services by agreeing a clear plan of action
ENCCG understands that unless it listens, its response will not address the key issues raised by complainants and valuable opportunities to improve commissioned services will be lost. Complaints and the outcomes of investigations will form part of ENCCG’s continuous quality improvement process with providers.
Aims and Objectives
1.1 This policy and procedure is compliant with current legislation/guidance and reflects the vision of the NHS Complaints Procedure by providing a service that delivers the following aims and objectives;
• Provides an identified person that any member of the public can turn to if they wish to make a complaint or require information on the complaints regulations
• Involves the public and patients in healthcare through its direct role in dealing with complaints
• Is open, easy to access and responsive by being flexible about the ways people can complain
• Is fair and impartial providing an appropriate and proportionate response with an honest, open and fair investigation, without fear of discrimination • Peoples desire for confidentiality is respected and the respect and
• Learns and develops ensuring complaints are reviewed as a positive opportunity to learn from patient’s experiences to drive continual improvement in service delivery
2. GUIDING PRINCIPLES
2.1 Mid Staffordshire NHS Foundation Trust Public Enquiry – The Francis Report 2013
In February 2013 Robert Francis QC dedicated one chapter in his report to the subject of complaints and the importance of learning from patient’s
experiences of the care and services received. The Francis Report set out 14 recommendations for NHS organisations to follow and ENCCG will be working to ensure that those recommendations are adhered to. The 14
recommendations can be found in Appendix 1.
ENCCG will ensure that patients and their families have the opportunity to raise concerns at all times. ENCCG will also ensure that lessons are learnt from those experiences in order that there is continual service improvement. 2.2 Duty of Candour
ENCCG welcomes the government’s commitment to introducing a duty of candour within the NHS. This recommends that all providers of NHS care should owe a duty of candour to their commissioners under which they provide, amongst others;
• Timely reports, prepared to an agreed protocol, of all complaints made by NHS patients;
• In cases when complaints are upheld, Complaints Action Plans to address the weaknesses that have been identified;
• Progress reports in relation to implementation of complaints action plans
The Patient Safety and Experience Co-ordinator will review and monitor the
reports received from Providers and will report to the Quality Committee to ensure that the quality of services provided is of a high standard and that they continually strive for further improvement. This will be addressed with Providers through the existing quality monitoring mechanisms.
2.3 The NHS Constitution 2012
As well as capturing the purpose, principles and values of the NHS, the
Constitution brings together a number of rights, pledges and responsibilities for patients and staff . These rights and responsibilities are the result of extensive discussions and consultations with staff, patients and the public. Further details can be found from www.dh.gov.uk/nhsconstitution
3. CONFIDENTIALITY
Patient confidentiality will be maintained when handling a complaint. The Patient Safety and Experience Co-ordinator will keep all related records in a confidential
and secure manner which is completely separate from any patient records. It will be explained to complainants that information from their health record may need to be disclosed for the purpose of an investigation, when appropriate. The Patient Safety and Experience Co-ordinator will ensure that consent is obtained from the patient.
There may be very rare occasions that, when for the sake of patient safety, it is necessary to breach confidentiality. This action would only be taken if the complainant, the patient or any other person is at risk of harm. Any such action will be taken with advice from the appropriate senior manager.
3.1 Any persons subject to, or involved in an investigation should be aware that, unless legally exempt, the contents of any information held as part of an investigation may be subject to public disclosure under the NHS Code of Openness or the Freedom of Information Act 2000.
4. NHS COMPLAINTS REGULATIONS
ENCCG will work to the national performance targets/timescales for acknowledging complaints involving their services as follows;
Event Time Allowed Who is responsible for action
Oral, comment, concern or complaint (PALS)
Dealt with and resolved to the persons
satisfaction within 3 working days
Any member of staff with whom the issue is raised. ENCCG will address any patient safety issues Oral, electronic or written complaint requiring an organisation response Acknowledged within 3 working days offering the complainant an opportunity to discuss the issues. Oral
concerns or complaints will be noted and a copy sent to the complainant for their agreement
Patient Safety and Experience Co-ordinator
Full
organisational response
Timescales to be agreed with the
complainant. The aim is to respond to all
complaints within 25 working days
Patient Safety and Experience Co-ordinator
5. THE PATIENT ADVICE AND LIASION SERVICE (PALS)
The PALS service will listen and provide relevant information and support to help resolve concerns quickly and efficiently, on the spot if possible. They will liaise with staff and managers and where appropriate with other PALS services, local
health and social care organisations to help resolve issues in a timely manner and avoiding the need for patients to make a formal complaint.
6. HEALTH SERVICE OMBUDSMAN’S PRINCIPLES FOR REMEDY
ENCCG will follow the principles of good administration outlined by the Parliamentary and Health Service Ombudsman and will consider the impact of the organisation's actions on the individual concerned. The key principles are as follows:
i. Getting it right
• Acting in accordance with the law and with due regard for the rights of those concerned
• Acting in accordance with the public body's policy and guidance (published or internal)
• Taking proper account of established good practice
• Providing effective services, using appropriately trained and competent staff • Taking reasonable decisions, based on all relevant considerations
ii. Being customer focused
• Ensuring people can access services easily
• Informing customers what they can expect and what the public body expects of them
• Keeping to its commitments, including any published service standards • Dealing with people helpfully, promptly and sensitively, bearing in mind
their individual circumstances
• Responding to customers' needs flexibly including, where appropriate, co-ordinating a response with other providers
iii. Being open and accountable
• Being open and clear about policies, procedures and decisions, and ensuring that information and any advice provided is clear, accurate and complete • Stating its criteria for decision making and giving reasons for decisions • Handling information properly and appropriately
• Keeping proper and appropriate records • Taking responsibility for its actions iv. Acting fairly and proportionately
• Treating people impartially, with respect and courtesy
• Treating people without unlawful discrimination or prejudice, and ensuring no conflict of interests
• Dealing with people and issues objectively and consistently
• Ensuring that decisions and actions are proportionate, appropriate and fair v. Putting things right
• Acknowledging mistakes and apologising where appropriate • Putting mistakes right quickly and effectively
• Providing clear and timely information on how and when to appeal or complain
• Operating an effective complaints procedure, which includes offering a fair and appropriate remedy when a complaint is upheld
vi. Seeking continuous improvement
• Reviewing policies and procedures regularly to ensure they are effective • Asking for feedback and using it to improve services and performance
• Ensuring that the public body learns lessons from complaints and uses these to improve services and performance.
7. ROLES AND RESPONSIBILITIES
a. The Chief Executive (the responsible person) is ultimately accountable for the quality of care commissioned by ENCCG.
The Chief Executive of ENCCG, or any other person authorised by the
responsible body to act on behalf of the responsible person, is accountable for responding in writing to all complaints whether they have been made verbally, electronically or in writing. The Director of Nursing and Quality has delegated responsibility for complaints management within ENCCG.
b. The Patient Safety and Experience Co-ordinator will;
• Be readily accessible to the public and members of staff providing advice on any aspect of complaints resolution
• Co-ordinate the complaints investigation
• Provide training and advice to staff on complaints handling
• To ensure all complaints are recorded on DATIX, or an appropriate alternative database, and an electronic complaints file is established and held securely
• To ensure the complaints files is accessible to the complainant under the Access to Health Records Policy
• To ensure records management is in line with the Data Protection Act 1998
• To prepare regular reports on performance and issues raised through complaints
• To ensure appropriate operating procedures are in place to deliver the Complaints Policy
• To ensure that actions identified to improve services are implemented quickly
• To ensure recommendations made by the Health Service Ombudsman are carried out and completed
c. All Directors are responsible for ensuring that the Complaints Policy and Procedure is implemented across their Directorates.
d. Directors, Service Heads and Leads are responsible for disseminating the Complaints Policy and Procedures and ensuring that staff understand the procedure.
e. All staff are expected to assist the Patient Safety and Experience Co-ordinator to ensure complaints are properly investigated and seize the opportunity to improve patient care.
8. WHAT IS A COMPLAINT
f. A complaint is any expression of dissatisfaction regarding any aspect of service relating to patient care, clinical or non-clinical, relating to attitudes or behaviour, the environment, facilities or systems that requires an
organisational response. Complaints can be made verbally, in writing and electronically and are included under this term along with formal complaints raised by Members of Parliament (MPs) on behalf of their constituents. g. Complaints are managed to enable patients, services users (or their
representatives) to give feedback on the services they have received in as easy a way as possible.
h. Equally important is that the Complaints Service is able to feed learning from complaints into commissioning decisions.
9. WHO CAN MAKE A COMPLAINT a. A complaint may be made by;
• A patient or service user
• Any person who is effected by or likely to be affected by the action, omission or decision of ENCCG
• A representative of either of the above in a case when that person-
- Has died - Is a child
- Is unable by reason of physical or mental capacity to make the complaint themselves
- Has requested a representative to act on their behalf (a representative may include a parent, guardian, relative, civil partner or friend, and, in these cases consent will be required b. 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 Patient Safety and Experience Co-ordinator had or has sufficient interest in their welfare and is a suitable person to act as a representative.
c. If in any case it appears that a representative does not have sufficient interest in the person’s welfare or is unsuitable to act as a
representative, the Patient Safety and Experience Co-ordinator will notify the person in writing, stating the reasons why.
d. In the case of a child or young person aged under 16, the
representative must be a parent, guardian or other adult person who has care of the child and where the child is in care of a Local Authority or a voluntary organisation, the representative must be a person authorised by the Local Authority or the voluntary organisation.
e. Anonymous complaints will be accepted (e.g. telephone call, letter) but if possible the person should be encouraged to provide their name and
other relevant details. If the person is unwilling to provide contact details, the Patient Safety and Experience Co-ordinator will record the complaints and investigate if appropriate and possible.
10. TIMESCALES FOR MAKING A COMPLAINT
A complaint must be made no later than 12 months after the date on which the matter occurred or no longer than 12 months after the incident came to the notice of the complainant. There is discretion to waive the time limit if the complainant can demonstrate exceptional circumstances about why the complaint was not raised sooner. The Patient Safety and Experience
Co-ordinator has to be satisfied that it is still possible and practical to investigate the complaint and whether the reason for the delay is acceptable.
If the Patient Safety and Experience Co-ordinator decides that the reasons are not acceptable or if it is clear that the complaint cannot be investigated, the complainant will be informed in writing of the reasons why and their right to approach the Health Service Ombudsman to consider this decision.
11. COMPLAINTS REGARDING INDIVIDUAL FUNDING REQUESTS (IFR) AND CONTINUING HEALTHCARE
If a complaint is received about an IFR or a Continuing Healthcare (CHC) decision the complainant will be advised that they are entitled to appeal the decision and a copy of the appeals process will be provided if requested. If the complainant still wishes to make a formal complaint this will be investigated under the NHS
Complaints Procedure but the complainant must be made aware that only the IFR or CHC process will be investigated and not the actual funding or CHC decision, which would have been made by the appropriate Panel.
12. FRAMEWORK FOR DEALING WITH COMPLAINTS
The guiding principle for good complaints management is that any expression of dissatisfaction about the service provided requires a response. The emphasis is on early resolution through an immediate informal response where possible. The NHS Complaints Procedure has 2 stages;
12.1 Stage 1 – Local Resolution – Investigation & Response
The first stage of the NHS Complaints Procedure allows for complaints to be dealt with locally. The aim of this stage is for a complaint to be acknowledged, investigated and responded to. This will involve;
• Written acknowledgement within 3 working days offering the
complainant the opportunity to discuss, at a mutually convenient time, how the complaint is to be handled and an opportunity to clarify the issues to take forward for an investigation
• Agreement of the response timeframe
• Obtaining appropriate consent from the patient/complainant • The formulation of a Complaints Action Plan (See Appendix B)
• Investigation by the service complained about with the aim of resolve the complaint speedily and efficiently
• The complainant being offered the opportunity to contact the if Patient Safety and Experience Co-ordinator or an update at any time during the course of the complaint
• Within the initial timeframe agreed with the complainant or within an agreed extension, a written signed response by the ‘responsible body’ – i.e. the Chief Executive of ENCCG (or any person authorised by the responsible body to act on behalf of the responsible person)
• The response should include;
- An explanation of how the complaint has been
considered and who has investigated the complaint with appropriate apologies
- The conclusions reached in relation to the complaint including any matters that require remedial action
- Confirmation of any action needed as a consequence of the complaint
- Details of the complainant’s right to take their complaint to the Parliamentary and Health Service Ombudsman Where appropriate, a meeting can be offered to the complainant to clarify or explain any issues within the written response.
12.2 Stage 2 – The Parliamentary and Health Service Ombudsman
If the complainant remains dissatisfied after the local resolution process has been completed, a request can be made to the Parliamentary and Health Service Ombudsman for an independent investigation into any outstanding issues.
The Parliamentary and Health Service Ombudsman for England Millbank Tower Millband London SW1P 4QP Telephone helpline: 0345 015 4033 Website: www.ombudsman.org.uk Email: [email protected]
1. Complaint
received 2 Acknowledgement 3. Investigation 4. Collation
Received by the Patient Safety and Experience Co-ordinator (by phone, email, letter). Complaint is acknowledged by the Patient Safety and Experience
Co-ordinator within 3 working days and agreement is made
with complainant regarding timescales. All details are added to
the database Consent is requested if relevant
The Patient Safety and Experience Co-ordinator will
instigate investigation and write to all parties concerned seeking response to the complaint. A lead investigator will be appointed to prepare the response
The Patient Safety and Experience
Co-ordinator collates the responses and any
other information relevant to the complaint for the complaints file (i.e.
telephone notes etc.) 5. Response The Patient Safety and Experience Co-ordinator forwards the response and complaint file for
signing
6. Learning
The Patient Safety and Experience
Co-ordinator updates the database with the
outcomes and learning and when action is due to be
completed
13. GUIDANCE AND SUPPORT FOR MEMBERS OF THE PUBLIC
The Patient Safety and Experience Co-ordinator will publish information on how to make a complaint.
Patients, their families and carers can contact the Patient Safety and Experience Co-ordinator for advice on how to make a complaint with the appropriate
organisation and provide advice and guidance on the complaints process and regulations.
The Patient Safety and Experience Co-ordinator is sometimes able to assist a complainant without recourse to the formal complaints procedure if this is the complainants wish. If the complaint requires an organisational response, the Patient Safety and Experience Co-ordinator will discuss with the complainant how the complaint is to be handled and the timeframe in which to seek resolution. Contact Details;-
Patient Safety and Experience Co-ordinator Charter House
Parkway
Welwyn Garden City Hertfordshire
AL8 6JL
Telephone: 01707 369697
Email: [email protected]
The Independent Complaints Advocacy Service (ICAS) can assist members of the public who wish to make a complaint about NHS services.
Contact details; POhWER Hertlands House Primett Road Stevenage Hertfordshire SG1 3EE Telephone: 0300 456 2370
14. WHAT CANNOT BE COMPLAINED ABOUT
In accordance with the regulations governing NHS complaints ENCCG cannot investigate complaints which relate to;
• Services provided by Independent Contractors (GPs, dentists,
pharmacists, Opticians and other independent contractors) who have a contract to provide NHS services
• An oral complaint which has been resolved to the patients satisfaction by the end of the next working day after receipt
• A complaint that has been previously investigated where no additional significant information is supplied
• A complaint being investigated by the Parliamentary and Health Service Ombudsman
• A complaint regarding the failure to comply with a Freedom of Information request
• A complaint regarding the administration of superannuation schemes • A complaint regarding treatment outside of the NHS
• A complaint which is being or has been investigated by a Local Commissioner under the Local Government Act 1974, or the Health Service Commissioner under the 1993 Act
• A dispute being raised by one organisation about another
Where ENCCG receives a complaint relating to the above, the Patient Safety and Experience Co-ordinator will write to the complainant explaining the reason why the complaint cannot be investigated and, if appropriate, advising them of the relevant organisation which can assist and their contact details.
If a complainant approaches ENCCG to investigate a complaint already handled by a provider, the Patient Safety and Experience Co-ordinator will write to the complainant to advise that under the NHS Complaints Regulations ENCCG cannot reinvestigate a closed complaint. The complainant will be signposted back to the provider and details of the Health Service Ombudsman will be provided.
15. LEARNING AND SHARING LESSONS
ENCCG recognises that complaints are a meaningful way to understand the concerns of patients and members of the public and encourages all staff to recognise complaints as a learning opportunity. The Patient Safety and Experience Co-ordinator has developed a mechanism which enables the tracking of outcomes from complaints. This will ensure that a robust mapping mechanism is in place to create results and is able to demonstrate learning and improved service delivery as a result of patient feedback.
a. Monitoring Improvements
Where complaints are upheld and actions subsequently required the Patient Safety and Experience Co-ordinator will seek to ensure that these actions are addressed and seek assurance of implementation. Where there is a failure to implement actions or relevant improvements are not made ENCCG will invoke the process for remediation through the appropriate Quality Monitoring
committees. In addition;
• The Patient Safety and Experience Co-ordinator will use existing communication channels to provide staff with feedback on any actions taken as a result of reported complaints
• The Patient Safety and Experience Co-ordinator will report any findings or intelligence as appropriate
16 DISCRIMINATORY COMPLAINTS
16.1 These are complaints made against an individual because of their racial background, gender, marital status, race, ethnic origin, colour, nationality, national origin, disability, sexuality, religion or age. Some will be easily identifiable from the outset; others may come to light during the complaints process.
16.2 At an early stage the Patient Safety and Experience Co-ordinator will endeavour to identify any complaints which amount to harassment and ensure that the employee concerned is not put through the process of an investigation. Any complaints made purely on the basis of race will be considered to be harassment and will not be tolerated.
16.3 The Patient Safety and Experience Co-ordinator will discuss any possible discriminatory complaints with an Executive Director and/or Service Lead and determine whether the complaint should be progressed through the complaints process.
16.4 If the decision is taken not to progress the matter through the complaints process the complainant will be notified in writing that the complaint will not be progressed and informed that harassment against any member of staff will not be tolerated.
16.5 ENCCG will offer and arrange support to the employee who is the subject of the complaint.
16.6 Any complaints couched in discriminatory language that raise legitimate issues about clinical practice, procedures and communications will be investigated using the complaints system, without prejudice to the outcome of the investigation.
16.7 Where a complaint is investigated that is couched in discriminatory language the complainant will be advised that discriminatory language will not be tolerated. The employee will also be offered support.
17.MONITORING AND AUDIT
ENCCG pays particular importance to monitoring of complaints. Repeated
complaints/concerns relating to a particular area or service can be an indicator of serious and systemic failings. There are arrangements in place to address this and are set out below;
• A database will be held centrally to record and monitor all complaints. Information gathered for the purposes of Annual Reporting will be anonymised.
• An annual report of complaints handling will be written to monitor ENCCG performance in respect of the following;
- Number of complaints received
- Number of complaints ENCCG were informed were referred to the Health Service Ombudsman
- Summary of subject matter
- Summary of general matters of importance arising from complaints or the way in which they were handled
- Summary of actions to improve services as a result of the complaints
17.1 The Patient Safety and Experience Co-ordinator will prepare a quarterly report that will demonstrate;
- Number of complaints received
- Achievements of Key Performance Indicators - Trends and areas of concern
- Actions taken to improve services as a result of complaints - Complaints that have been facilitated by the Patient Safety and
Experience Co-ordinator but dealt with via another Provider, i.e. East and North Herts NHS Trust
17.2 The Patient Safety and Experience Co-ordinator will provide the Annual Report to the ENCCG Board. The Annual Report will be available to any person on request.
17.3 The Patient Safety and Experience Co-ordinator will seek to actively maintain formal routes for feeding back emerging themes to ENCCG. Outcomes from complaints assist in advising commissioners and providers on changes and service improvements which will improve patient experience.
18. TRAINING
Complaints handling training is available to all ENCCG staff. When required staff will also receive specific training on the Complaints Policy and Procedures and this is accessible via the Patient Safety and Experience Co-ordinator.
19. COMMUNICATIONS
The Complaints Policy and Procedure is available to staff on the intranet and hard copies are available from the Patient Safety and Experience Co-ordinator. The policy is also available on the external website for members of the public and made available when requested.
20. LITIGATION
If the complaint reveals a possible case of negligence or if there is a likelihood of litigation the Patient Safety and Experience Co-ordinator will immediately inform the Manager with the responsibility for legal claims. If the complainant expresses in writing their intention to take legal action, the Patient Safety and Experience Co-ordinator will discuss with the complainant that the relevant authority will be
Complaints Procedure will prejudice subsequent legal or judicial action. If so, the complaint will be put on hold and the complainant advised accordingly. If not, the NHS Complaints Procedure will continue. Any patient safety issues with wider implications will be investigated and actioned where appropriate.
21. REVIEW
The Complaints Policy and Procedure will be reviewed annually, or sooner, if changes occur in legislation. The effectiveness of the policy will be reviewed in the light of performance against response timeframes; numbers resolved and referred complaints as well as implementation of lessons learned.
The Procedure will also be reviewed in the light of any audit recommendations learning and developments cycles or changes to organisational structure that may have an impact on how the procedures operate.
APPENDIX A FRANCIS REPORT – 14 RECOMMENDATIONS
The Francis report dedicates one chapter to the subject of complaints and makes 14 recommendations. The table below sets out those recommendations;
No Summary of Recommendation
1. Methods of registering a complaint or comments must be readily accessible
2. Actual or intended litigation should not be a barrier to complaining 3. Provider organisations must constantly promote their desire to receive
and learn from comments and complaints
4. Feedback that is not in the form of a complaint but suggests a cause for concern should also be the subject of an investigation
5. Recommendations from the Peer Review should be reviewed and implemented
6. Comments that describe a Serious Incident should trigger an investigation
7. Arm’s length investigations should be initiated by the provider where appropriate
8. Advocacy should be made available for meeting with the complainants 9. ICAS should have the facility for expert advice
10. Some complaints should be published on the website
11. More information on complaints to be given to Overview and Scrutiny Committees
12. Commissioners should require access to all complaints information 13. The CQC should have ready access to information on complaints 14. Clear processes required for large scale failure of clinical services
APPENDIX B PROCEDURE FOR DEALING WITH COMPLAINTS
1. Complaints can be made verbally, electronically or in writing
1.1 Verbal complaints, comments or concerns can be made to any members of staff. ENCCG encourages patients, their families and carers to raise and discuss their concerns in the first instance with a member of staff or the person in charge of the service. Many concerns can be resolved by dealing with the issue on the spot and all staff should make every effort to enable this to happen. The Patient Safety and Experience Co-ordinator can also be contacted if the complainant prefers not to raise an issue directly with staff. 1.2 Where a complaint is made verbally, electronically or in writing to the Patient
Safety and Experience Co-ordinator, the complaint will be acknowledged within three working days of receipt (as outlined in section 2.3.2 of the policy), ensuring a complaints leaflet and ICAS leaflet are supplied. The
acknowledgment letter will include the opportunity for the complainant to discuss with the Patient Safety and Experience Co-ordinator how the
complaint is to be handled and which organisation is best placed to respond to the complaint. The appropriate consent form will be sent to the
complainant/patient.
1.3 If consent to proceed with the handling of the complaint is not received, a reminder will be sent after 10 days enclosing a copy of the consent form and reminding the complainant of the support of ICAS if they wish to approach the provider directly. If no further communication is received, the complaints file will be closed, however the commissioner/contracting manager will be alerted to the concerns raised with the patient/complainant details kept anonymous. 1.4 Any complaint received about on-going clinical care will be handled with the
view to improve the situation and may entail, with the patients consent, contacting support medical staff or the practitioner/service manager to help resolve the concerns as quickly as possible. The complaint will continue to be handled in line with procedures, with the complainants consent.
2. THE COMPLAINTS PROCEDURE
2.1 The Associate Director, Head of Department or Service Lead whose service or area of responsibility has been complained against, will usually be identified by the Patient Safety and Experience Co-ordinator as the investigating officer. The Investigating Officer will receive a copy of the complaint, specific points to be investigated and responded to and a timescale for completion.
2.2 The appointed senior manager/investigating officer will, after completion of their investigation, provide a draft response in the form of a response report to the Patient Safety and Experience Co-ordinator who will quality check the information written, ensuring it can be easily understood and all the questions have been answered. Any witness statements should be signed and if a patient’s clinical record has been accessed, the relevant part thereof, should be returned to the Patient Safety and Experience Co-ordinator.
2. 3 The Patient Safety and Experience Co-ordinator will be responsible for quality assuring the final response letter for the Accountable Officer’s signature. The letter will include the opportunity to contact the Patient Safety and Experience Co-ordinator with any outstanding concerns and signposting to the Health Service Ombudsman should the complainant remain dissatisfied at the end of the local resolution process.
2.4 Once a written response has been provided, the complaint will be recorded as closed unless the complainant contacts the Patient Safety and Experience Co-ordinator with any outstanding concerns. The Patient Safety and
Experience Co-ordinator will advise whether it remains practicable to continue the investigation further.
3. RISK RATING RATIONALE
The Patient Safety and Experience Co-ordinator will ensure all complaints received by ENCCG, whether verbally or in writing, are recorded and risk rated. Correctly assessing the seriousness of a complaint can assist in ensuring the right action is taken in addition to the complaints process. Risk rating is determined by assessing both the consequence and the likelihood of recurrence. Risk is then determined by balancing the consequence to the likelihood of recurrence. 4. COMPLAINTS INVOLVING OTHER ORGANISATIONS
Where a complaint solely involves another NHS Partner Organisation, the Patient Safety and Experience Co-ordinator will seek consent from the complainant to forward to the organisation concerned to be handled in accordance with the NHS Complaints Regulations. If the Patient Safety and Experience Co-ordinator
considers it appropriate and if the complainant consents, a copy of the complaints response will be requested from the Partner organisation. If appropriate, the provider will be asked to provide the Patient Safety and Experience Co-ordinator with a copy of the response. In these circumstances, the complainant is deemed to have made the complaint to the provider under NHS Regulations.
Where a complaint is made about more than one organisation, a discussion will be had with the complainant to establish the appropriate way the complaint can be handled. Consent will be gained from the complainant/patient before forwarding to all the organisations involved. The NHS organisations involved will work together in line with guidance when dealing with joint organisation complaints. Where the Patient Safety and Experience Co-ordinator takes the lead in a complaint as agreed with the complainant, they will work towards sending a response to the complainant within the agreed timeframe as outlined in section 2.3.2 of the policy. Where possible, a coordinated response to the complainant will come from the lead organisation.
If it is considered appropriate to handle a complaint, the complainant and the provider organisation will be notified and the complaint will continue to be handled in accordance with NHS Complaints Regulations. In all cases the Patient Safety and Experience Co-ordinator will work towards sending a response to the
complainant within agreed timescales. Any delay to this time scale will be agreed with the complainant. All time-sensitive correspondence will be sent Recorded Delivery or with a request that safe receipt is confirmed.
5. CORRESPONDENCE FROM MEMBERS OF PARLIAMENT
When ENCCG receive correspondence from a MP on behalf of a constituent, the Patient Safety and Experience Co-ordinator will handle these enquiries.
Appropriate consent will be sought from the constituent should it be necessary to contact other organisations involved in their care and to share potentially personal information with the MP. There are no formal response timescales for an enquiry. However, the Patient Safety and Experience Co-ordinator will always endeavour to handle correspondence in a timely manner. Should a MP make a formal
complaint on behalf of their constituent, the correspondence will be handled in line with the Complaints Procedure.
APPENDIX C
ACTION PLAN
Name of Complainant: Ref: Complained Against:
Lead Investigator Date complaint sent to complained
against
Details of Action & Deadline Date Given
Action Taken Date
APPENDIX D Equality and Diversity Statement
ENCCG is firmly committed to the principles of equality and diversity in all areas of work. ENCCG believes that more could be learnt from diverse cultures and
perspectives and that diversity will make the CCG more effective in meeting the needs of all patients and stakeholders. ENCCG is committed to developing and maintaining an organisation in which differing ideas, abilities, backgrounds and needs are fostered and valued, and where people with diverse backgrounds and experiences are able to participate and contribute.
Staff will treat patients and/or patient’s nominated representatives with dignity and respect when dealing with their complaint and complainant/patients raising concerns will not prejudice the treatment and care provided. The CCG will not discriminate on the grounds of gender, marital status, race, ethnic origin, colour, nationality, national origin, disability, sexuality, religion or age. The CCG will oppose all forms of unlawful and unfair discrimination.
The Human Rights Act 1998
ENCCG has considered the Human Rights Act 1998 and the equality benefits of a Human Rights based approach when handling complaints. These include;
• An improved quality of healthcare services – patients treated with fairness, respect, equality and dignity
• More person-centred care
• A reduced risk of complaints and litigation • Improved decision making overall
• A broader range of marginalised groups being involved and considered • More meaningful engagement of patients, carers and their families Information about the complaints process can be made available in a range of languages and formats.
APPENDIX E VEXATIOUS/HABITUAL COMPLAINTS
There are exceptional circumstances where ENCCG can reasonably do nothing further to rectify a real or perceived problem from a complainant.
Complainants (and/or anyone acting on their behalf) may be deemed to be vexatious or habitual complainants where previous or current contact with them shows that they meet one or more of the following criteria;
• Persist in pursuing a complaint where the complaints procedure has been fully and properly implemented and exhausted
• Changed the substance of a complaint or continually raise new issues or seek to prolong contact by continually raising further concerns or questions (care must be taken not to discard new issues which are significantly different from the original complaint)
• Continue to pursue a complaint with ENCCG after appropriate
consent has been sought to forward the complaint to the provider for investigation
• Are unwilling to accept documented evidence of treatment given as being factual (i.e. records) or deny receipt of an adequate response in spite of correspondence specifically answering their questions or do not accept that facts can sometimes can be difference to verify when a long period of time has elapsed
• Do not clearly identify the precise issue which they wish to be investigated, despite reasonable efforts/and or where concerns identified are not within the remit of ENCCG to investigate • Focus on a matter to an extent which is out of proportion to its
significance and continues to focus on this point (it is recognised that this can be subjective and careful judgements must be used)
• Have in the course of addressing a complaint had an excessive number of contacts with the organisation placing unreasonable demands on staff (this can be by telephone, fax, email, letter or in person and discretion must be taken in determining “excessive”) • Are known to have recorded meetings or face-to-face/telephone conversations without the prior knowledge and consent of other parties
• Displayed unreasonable demands or expectations and fail to accept that these may be unreasonable (e.g. insist on responses to
complaints or enquiries being provided more urgently than is reasonable or normal recognised practice)
• Used inappropriate verbal or written language against members of staff
b. The following procedures will be used in exceptional circumstances and as a last resort, after all reasonable measures have been taken via the
Stage 1
ENCCG employees should refer the complainant to the Patient Safety and
Experience Co-ordinator. The Patient Safety and Experience Co-ordinator will take action specifically targeted to try and help the complainant and staff involved, depending on the behaviour the complainant is displaying. This could include;
• Explaining the complaints process
• Informing a limit to the number of and duration of telephone conversations, emails and written letters
• Where hand written correspondence is unclear, the complaint will be
acknowledged and the opportunity provided to contact the Patient Safety and Experience Co-ordinator to discuss the concerns. If this option is not taken the correspondence will be returned and the complainant signposted to ICAS • Use of recorded delivery postage
• Seeking help from ICAS to contact and liaise with the complainant where appropriate
• The Patient Safety and Experience Co-ordinator identified as the sole organisational contact point for the complainant
• Informing the complainant that written communication will be the only communication between ENCCG and the complainant
• The Patient Safety and Experience Co-ordinator will contact all staff likely to receive contact from the complainant, advising them of action decided upon and provide a suitable script which staff should read to the complainant (and repeat up to 3 times) in the event of the complainant contacting them before calls are terminated. This will be regularly reviewed.
Stage 2
If Stage 1 does not have the desired effect and the situation deteriorates, then one or more of the following may be taken;
• The Patient Safety and Experience Co-ordinator will write to the
complainant informing them why their behaviour is preventing any possible resolution of the complaint, and include an “agreement” setting out a code of behaviour for both parties listing grounds on which the complaint will be dealt with and which it will not
• The Patient Safety and Experience Co-ordinator will write to the complainant informing them that the points raised have been fully
responded to and that to continue to contact on this matter would serve no useful purpose. The letter will include advice on contacting the Health Service Ombudsman
• The Patient Safety and Experience Co-ordinator will escalate the case to an Executive Director and agree a suitable course of action, which will be communicated to the complainant in writing
• If the action above does not have the desired effect, the Patient Safety and Experience Co-ordinator will compile a report for the Chief Executive
detailing the issues and sequence of events. The Chief Executive will then write to the complainant informing them of ENCCG actions
Once a complainant has been deemed as vexatious or habitual, the status will be withdrawn at a later date if, for example, the complainant
subsequently demonstrates a more reasonable approach or if they submit a further complaint for which the normal complaints procedure would appear appropriate. Discretion should be used in removing the status.
If it becomes apparent through the course of investigating a complaint that staff have been subjected to inappropriate personal verbal or written abusive comments the complainant will be advised that this is unacceptable and will not be tolerated with any further communications the person may have with ENCCG staff. Staff will be encouraged to report any such incidents to their Line Manager.
Appendix 1 – Equality Impact Assessment Stage 1 Screening
1. Policy EIA Completion Details
Title: Complaints Policy Names & Titles of staff involved in completing the EIA:
Valerie Penn – Head of Governance
Proposed Existing
Date of Completion: September 2013 Review Date: September 2014
2. Details of the Policy. Who is likely to be affected by this policy?
Staff Patients Public
3. Impact on Groups with Protected Characteristics Probable impact on
group?
High, Medium or Low
Please explain your answers
Positive Adverse None
Age
Being married or in a civil partnership
Disability, inc.learning difficulties, physical disability, sensory impairment etc.
Having just had a baby or being pregnant
Race, ethnicity, nationality,
language etc.
Religion or belief
Sex (inc. being a transsexual person)
Sexual Orientation
Other:
No impact on any of the groups above.
Please explain and provide evidence
4. Which equality legislative Act applies to the policy? Human Rights Act 1998
Equality Act 2010
Health & Safety Regulations
Mental Health Act 1983 Mental Capacity Act 2005 5. How could the identified adverse effects be minimised or eradicated?
Appendix 2 – Privacy Impact Assessment Stage 1 Screening
1. Policy PIA Completion Details
Title: Complaints Policy Names & Titles of staff involved in completing the PIA:
Valerie Penn – Head of Governance
Proposed Existing
Date of Completion: September 2013 Review Date: September 2014
2. Details of the Policy. Who is likely to be affected by this policy?
Staff Patients Public
Yes
No
Please explain your answers
TechnologyDoes the policy apply new or additional information technologies that have the potential for privacy intrusion?
(Example: use of smartcards) Identity
By adhering to the policy content does it involve the use or re-use of existing identifiers, intrusive
identification or authentication? (Example: digital signatures,
presentation of identity documents, biometrics etc.)
Investigations of complaints
required PID data at some level
to appropriate people involved
By adhering to the policy content is there a risk of denying anonymity and de-identification or converting previously anonymous or de-identified data into identifiable formats?
Only to investigating officers
Multiple Organisations Does the policy affect multiple organisations?
(Example: joint working initiatives
with other government departments or private sector organisations)
Multiple organisations are often
involved in one complaint
Data
By adhering to the policy is there likelihood that the data handling processes are changed?
(Example: this would include a more intensive processing of data than that which was originally expected)
If Yes to any of the above have the risks been assessed, can they be evidenced, has the policy content and its implications been
understood and approved by the department?
