Patient and Carer Feedback Policy
Central and North West London NHS Foundation Trust (CNWL) is committed to providing quality
NHS services and adopting best practice in dealing with all patient and carer feedback. It
recognises the absolute need to listen to, value and respond to feedback from the patients and
carers that use our services.
By carefully listening to people about their experiences, we can identify things that have gone
wrong and put them right, resolve mistakes faster, and learn new ways to improve and prevent the
same problems from happening in the future. By dealing with all types of patient or carer feedback
effectively, services can improve, making things better for the people who use them as well as for
the staff working in them. This policy provides the framework by which the Trust receives feedback
on its services, including both complaints and compliments.
This policy is essential reading for the following groups:






Patient Support Service
Divisional & Borough Directors
Divisional Medical Directors and Divisional Directors of Nursing
Service Managers, Team Managers, Matrons and Ward Managers
Patients and carers.
External Stake holders
Scope
This policy provides the framework by which the Trust receives feedback on its services. This
includes compliments, comments, concerns and complaints.
Key points of the policy





CNWL must adhere to the Local Authority Social Services and NHS (England) Complaints
Legislation 2009 and follow good complaint handling principles.
All individually received feedback (Complaints, Compliments, Comments and Concerns)
will be received by individual members of staff/services and logged on to the Trust’s
electronic feedback data base (Datix).
An initial response/action should be taken by the staff member or service on receipt of
feedback.
Any necessary follow up action will be taken by the service responsible and the service will
communicate this to the patient and/or carer.
CNWL will apologise if we did the wrong thing, do what we can to put things right and make
sure that it doesn’t happen again.
Page 1 of 11
PATIENT AND CARER FEEDBACK POLICY
Policy lead:
Head of Patient and Carer Involvement
Ratifying Committee /
Group:
CNWL Operational Board
Status of policy:
Final
Policy Reference:
Signed:
TW/00338/15-17a
____________________________________________
Andy Mattin
Approval date: ___________27.10.15__________________________
POLICY
IMPLEMENTATION
DATE:
July 2015
DATE POLICY TO
BE REVIEWED:
July 2017
2
Patient and Carer Feedback Policy V1 - July 2015
Contents
1.
Purpose............................................................................................................................... 4
2.
Requirements...................................................................................................................... 4
3.
Responsibilities................................................................................................................... 4
4.
Definitions........................................................................................................................... 6
5.
Patient Support Service...................................................................................................... 7
6.
Complaint Handling Process.............................................................................................. 7
7.
Independent review by the Health Service Ombudsman................................................... 8
8.
Duty of candour................................................................................................................... 9
9.
Confidentiality...................................................................................................................... 9
10.
Consent............................................................................................................................... 9
11.
Capacity............................................................................................................................... 9
12
Complaints related to Deceased patients............................................................................ 9
13
Advocacy and support for patients..................................................................................... 10
14.
Interagency complaints...................................................................................................... 10
15.
Litigation............................................................................................................................. 10
16.
Aggressive and Vexatious Complainants........................................................................... 10
17.
Governance........................................................................................................................ 10
18.
Consultation....................................................................................................................... 10
19.
References........................................................................................................................ 11
3
Patient and Carer Feedback Policy V1 - July 2015
1.
Purpose
The policy outlines how feedback (Compliments, Comments, Concerns and Complaints) can be
received in CNWL. It identifies how staff are expected to provide an initial response to any type of
feedback received, and if possible quickly deal with issues raised. It provides for the recording of
all feedback by the member of staff receiving it on a Feedback database so the capture of real time
individual written and verbal feedback across the Trust is achieved. The opportunity to learn and
do the right thing from feedback is the intention of this policy. It is supported by a more detailed
Patient and Carer Feedback Procedure.
2.
Requirements

All patients and carers will be informed on how to give feedback at their first contact with
CNWL services.

All CNWL sites will display visible information for its visitors on how to give feedback
(posters/leaflets).

All forms of feedback must be recorded on to the Feedback Database (Compliments,
Concerns, Comments and Complaints). See definitions below.

All concerns must be resolved within 3 working days.

All complaints will be acknowledged by the Patient Support Service within 3 working days.

Appointed investigators will contact the complainant to discuss the issues and agree an
investigation plan.

All complaints will aim to be investigated and responded to within 25 working days or a
timescale agreed with the Complainant.

All staff will be trained on how to deal with feedback.

Appointed investigators must contact the Complainant to discuss the issues and agree an
investigation plan and to discuss the findings and outcome of the investigation.

All investigations must be impartial and forensic in approach.

The Patient Support Service will provide support to all staff when required and provide training
on handling/responding to feedback and the investigation of complaints.

The Patient Support Service will review Complainant satisfaction with an agreed methodology
(written/telephone Survey) with in an agreed timeframe.
3.
Responsibilities
Individual
Chief Executive
Key Responsibilities
 Responsibility for ensuring compliance with the NHS Complaints
Legislation and the Patient and Carer Feedback Policy and Procedure.
Executive Director of
Nursing / Associate
Director of Quality
 Responsibility for supporting the development of the Patient and Carer
Feedback policy and its implementation.
 Overall responsibility for ensuring that complaints are handled in line with
the Patient and Carer Feedback Procedure
 Responsibility for providing and presenting reports to the Trust Board
and to the Trust Quality and Performance Committee as necessary.
4
Patient and Carer Feedback Policy V1 - July 2015
Individual
Head of Patient and
Carer Involvement
Key Responsibilities
 Responsibility for managing the Patient Support Service Manager and
overseeing the implementation of the Patient and Carer Feedback Policy
and Procedure.
 Retaining oversight of all complaint reviews that are commissioned,
reporting on these to the Associate Director of Quality.
Patient Support
Service Manager
 Responsibility for managing the Patient Support Service, provision for
providing a single point of access to people wishing to seek advice raise
a concern or make a complaint.
 Responsibility for the implementation of the Patient and Carer Feedback
Policy and Procedure across the Trust.
 Responsibility for ensuring that all complainants receive timely
information on the support they will receive.
 Responsibility for ensuring the attainment of Trustwide targets in relation
to feedback, ensuring that all complaints are acknowledged within 3 days
of receipt, and reporting on whether complaints are responded to within
the agreed timescale.
 Responsibility for overseeing the training of staff in the use of the Patient
and Carer Feedback Procedure.
 Making available Trustwide reports to the Board and other meetings as
required, to aid organisational learning. Also assisting in the provision of
local feedback for Divisions and Boroughs.
 Providing support to staff investigating complaints and some to staff
named in complaints. Support for staff named in complaint is mainly
provided by HR.
Divisional Directors
 Responsibility for ensuring that appropriate systems are in place to
support effective and efficient management of feedback, and compliance
with the requirements of this Policy and Procedure.
 Overall responsibility for complaints raised about the services they
oversee.
 Responsibility for signing off complaints relating to their area of local
responsibility and ensuring that there is a nominated deputy to take
responsibility for this in their absence.
Service / Borough
Directors
 Ensuring that services act on all aspects of feedback outlined in this
policy and monitor its implementation in the services that they are
responsible for.
 Ensuring there is a robust local system for reviewing all complaints within
their sphere of responsibility, so lessons learned are shared across the
Borough / Division, as appropriate.
 Supporting local managers undertaking the investigation of ‘high risk’,
complex or sensitive complaints. Meeting with complainants where
appropriate.
Investigating Leads
 Ensuring that complainants are fully involved in the process of resolving
their complaint.
 Providing an impartial investigation that is open and transparent.
Maintaining regular contact with the complainant throughout the
investigation.
5
Patient and Carer Feedback Policy V1 - July 2015
Individual
All Staff
4.
Key Responsibilities
 Dealing with all feedback, concerns and complaints in a timely / sensitive
manner.
 Ensuring that the individuals raising feedback are provided with the
space and time to talk through any concerns they have.
 Ensuring their compliance with this Policy and the related Procedure,
and cooperating as necessary with any investigations.
 Responsibility for ensuring complainants are listened to and individuals
have opportunities to provide feedback and raise concerns.
 Ensuring an open and transparent approach so that compassion and
respect is at the forefront of the support provided in helping individuals to
provide feedback.
 Responsibility for understanding the process for logging feedback and
receiving any necessary training to achieve this.
 Ensuring all feedback is logged onto the Trustwide Datix web
system.
Definitions
Compliment
Is defined as “an expression of praise” and can be provided both in writing and verbally.
Comment / Enquiry
Is when a patient, carer or member of the public makes a remark relating to the Trust or makes a
request for information. This covers a range of areas and includes, but is not limited to, a specific
period of care and treatment and details of the types of services provided by the Trust.
Concern
Is an expression of dissatisfaction, that is communicated to any member of staff verbally or in
writing. Concerns should be resolved locally before the end of 3 working days or within a timescale
agreed with the person raising the concern.
Some concerns may require a written response from the Trust. This should be sent within 5
working days of resolving the matter.
Any concern that cannot be resolve locally before the end of the next working day or within a
timescale agreed must be escalated to a complaint with the agreement of the person raising the
concern.
Complaint
Is defined as “an expression of dissatisfaction requiring an investigation and written response”,
received from patients, carers and anyone who may be affected by the actions or decisions of the
Trust.
A complaint may be made verbally, or in writing. Local and informal resolution of a complaint
should always be considered in the first instance, as above, if the complaint can be resolved by the
end of the next working day, or within a timescale that is acceptable to the complaint.
6
Patient and Carer Feedback Policy V1 - July 2015
However, complaints will need to be investigated formally if:



The complaint is in the form of a letter or email.
The complaint is verbal, but of a serious nature and judge that it cannot be dealt
with in any other way.
The Complainant makes a verbal request for a matter to be dealt with in this way.
Staff must also be aware that certain comments, concerns, suggestions or enquiries may present
issues that need to be brought to the immediate attention of their Line Manager. This includes
issues relating to patient or staff safety and safeguarding.
5.
5.1
The Patient Support Service
Access to the Patient Support Service is simple and without varied contact points, the
Service has:

One dedicated e-mail address
[email protected]

One dedicated telephone number
0300 013 4799

A freepost postal address
Freepost RSTJ-LART-UBYA
Patient Support Service
CNWL
Stephenson House
75 Hampstead Road
LONDON
NW1 2PL
5.2
The Team will monitor all feedback logged onto Datix; scrutinise all feedback and make
decisions as to whether a concern raised needs to be investigated formally as a complaint;
and alerting the relevant Borough and Divisional Directors where a complaint needs to be
investigated.
5.3
The Team will provide support to Investigators, and advice and input in relation to more
complex and vexatious complaints.
6.
Complaint handling principles
The Trust will ensure that:
6.1
6.2
The Divisional Director, in consultation with the Director responsible for the service in which
a complaint has arisen, will arrange the appointment of a lead investigator for each
complaint capable of ensuring a thorough investigation takes place and that the
Complainant receives ongoing feedback in regards to the status of the complaint. The
Divisional Director will ensure a written response of an appropriate standard is sent at the
end of the process.
All complainants will be offered the opportunity to meet with the lead investigator so they
can discuss the issues of concern and the outcomes they are seeking, understand how the
investigation will be carried out and agree how long the process should take.
7
Patient and Carer Feedback Policy V1 - July 2015
6.3
Every effort will be made to satisfy the Complainant that their concern has been taken
seriously, investigated thoroughly and that they will be responded to honestly throughout
the process.
6.4
Complainants will also be offered the opportunity to meet with the lead investigator towards
the end of the process to discuss the outcome of the complaint and ensure that they are
satisfied with the response being offered.
6.5
All complaints raised with the Trust will receive a written response once the investigation
has concluded. Reponses will acknowledge where mistakes have been made and
apologise whilst also explaining what happened in terms of any care or service delivery
problems. The response will also include details of any actions being taken to facilitate
lessons learnt.
6.7
All closure communications will invite the patient or carer to give feedback on their
experience and satisfaction with the process.
6.8
Where a Complainant remains dissatisfied with the response, the Trust will continue its
efforts to resolve the complaint by offering a meeting with a senior manager from the
service that investigated the complaint. This process will be supported by the Patient
Support Services.
6.9
A Complainant remaining dissatisfied had the option to ask for a management review to
assess whether the complaint investigation has been fair, impartial and robust. Such
reviews are to be carried out by a member of staff not previously involved in either their
care or the complaint.
7.
Independent Review by the Health Service Ombudsman
7.1
If a Complainant is dissatisfied with the outcome of the Trust’s investigation and review
process they have the right to ask the Health Service Ombudsman to independently review
their complaint.
7.2
Information on how to obtain an independent review will be provided to all Complainants by
the Trust. The Health Service Ombudsman will decide how to take such requests forward
but this can include referring the complaint back to the Trust for local resolution or
undertaking its own investigation.
7.3
Staff in CNWL will work the Health Service Ombudsman, and co-operate with any
investigations undertaken, including the disclosure of documentation, reports, statements,
etc. The Trust will also consider and respond to all formal recommendations made in
response to their independent review of a complaint. The Parliamentary and Health
Service Ombudsman can be contacted as follows:
The Parliamentary & Health Service Ombudsman
Millbank Tower
Millbank
London
SW1P 4QP
[email protected]
8
Patient and Carer Feedback Policy V1 - July 2015
8.
Duty of candour
8.1
If any feedback received identifies an incident or serious incident, the Service Manager,
lead investigator or the Patient Support Service must check to see if this has been recorded
as an incident on DATIX.
8.2.
The Service Manager or lead investigator must ensure that this is communicated to their
Service/Borough, and also that the Complainant is informed as soon as is reasonably
practical of the details of the error and the actions that have been taken to prevent such a
situation from happening again.
8.3
Details of the error and actions taken must be included in the written complaint response to
the Complainant, to ensure that all errors are dealt with in an honest and open manner.
9.
Patient confidentiality
9.1
No patient information will be given to a third party without the appropriate consent being
obtained from the patient unless there is a legal requirement to share information.
9.2
Complaints records must be kept separate from health records unless there is a clinical
requirement to record the complaint and/or recommendations.
9.3
Details of complaints made against identifiable employees of the Trust and the investigation
findings will be retained on Datix. Where disciplinary proceedings are undertaken this
information may also be held on the HR records of those staff and will be used as part of
the revalidation process.
10. Consent
Where a concern or complaint is raised by a third party, written consent from the patient will be
obtained for the matter to be investigated and where relevant for disclosure of clinical information.
11. Capacity
11.1
Should a patient lack capacity appropriate actions/steps will be taken to ensure that the
best interests of the patient are pursued. Clinical staff will lead on decisions relating to
capacity and best interest in accordance with the relevant Trust policy and procedure.
11.2
Where proceeding with investigation of the complaint is not considered to be in the patient’s
best interests, they will receive written notification stating the reason for this decision. The
Trust will ensure that the concerns raised are reviewed and reported internally.
12. Complaints relating to the care of a deceased patient
When addressing a complaint relating to the care of a deceased patient, careful consideration will
be given prior to the release of information. In all cases consideration should be given to the
Access to Health Records Act and the Serious Incident Policy. Further advice on this matter can
be obtained from the Head of Information Governance or Head of Safety.
9
Patient and Carer Feedback Policy V1 - July 2015
13. Advocacy & support for patients
If the patient raising the concern/complaint requires the support of an advocate the trust will
provide contact details on receipt of the feedback, and consider any other support needed such as
an interpreter. The local service investigating the complaint will provide a single point of contact for
the complainant, and also access to the Patient Support Service.
14. Interagency complaints
The complainant will be asked to clarify whether they are seeking a single or joint response to their
complaint, and will be asked provide their consent for the sharing of information relating to the
complaint between agencies. Further detail can be found in the Patient and Carer Feedback
Procedure.
15. Litigation
A threat of litigation will not be a barrier to investigation of a complaint. Advice can be sought from
the Patient Support Service
16. Aggressive and Unreasonable Complainants
There may be occasions where complainants may be aggressive or habitual. In these instances
the Patient Support Service will work with clinicians and where appropriate Managers to agree an
appropriate way forward. Further detail can be found in the Patient and Carer Feedback
Procedure.
17. Governance
Board-led Scrutiny of Complaints – The Associate Director of Quality will have responsibility for
the management of complaints performance (ie. response time, patient satisfaction with complaint
resolution).
The Patient Support Service and Quality Governance teams – will work closely together to
drive improvements from handling feedback.
Local investigation – Local experts in service provision should be tasked with investigation of
complaints. An appropriate choice of investigator is key to ensuring that the investigation is seen
as objective and thorough.
Continuous Improvement of the handling of feedback and complaints will be driven by monitoring
the experiences of patients/carers who made a complaint or submitted feedback.
18. Consultation
A broad range of CNWL staff, patient/carer and governor workshops and consultation was
undertaken as part of the Trust’s review of how it handles patient and carer feedback. This policy
has been cross referenced against national review papers with careful consideration of both the
Francis Report and Clwyd review of Complaints Handling to further support best practice.
10
Patient and Carer Feedback Policy V1 - July 2015
19. References

The Local Authority Social Services and National Health Service Complaints (England)
Regulations 2009, Department for Health (2009)

A guide to better customer care, Department of Health, February (2009)

Principles of Good Complaint Handling, Parliamentary and Health Service Ombudsman
(2008)

Access to Health Records Act, 1991

Recommendations made by Francis and Clywd/Hart Reports (2013)
11
Patient and Carer Feedback Policy V1 - July 2015