Complaints, Concerns and Compliments Policy
Author:
Melanie Coombes, Director of Nursing and
Quality / Amber Woolner, Complaints Officer
Sponsor/Executive:
Director of Nursing and Quality
Responsible committee:
Quality, Governance and Safety Committee
Ratified by:
Clinical Governance and Patient Safety
Committee
Consultation & Approval:
(Committee/Groups which signed off the
policy, including date)
This document replaces:
Complaints Policy
Date ratified:
23 April 2015
Date issued:
May 2015
Review date:
1 May 2017
Version:
2
Policy Number:
CP03
Purpose of the Policy:
To provide clear and concise guidance on
how the Trust manages formal complaints,
concerns and compliments.
If developed in partnership with
another agency, ratification details
of the relevant agency
Policy in-line with national
guidelines:
NHS Complaints Regulation 2009
Signed on behalf of the Trust: …………………………………………………..
Aidan Thomas, Chief Executive
Elizabeth House, Fulbourn Hospital, Fulbourn, Cambs, CB21 5EF Phone: 01223 726789
Page 1 of 41
Version Control Page
Version
1.0
Date
22/08/2013
2.0
3.0
28/04/2013
Author
Comments
Melanie
Coombes
Approved by Quality and Performance
Committee 22 August 2013
Amber
Woolner
The sections of the policy were reorganised for flow. PALS and Complaints
teams
were
separated.
Additional
information
regarding
PALS
and
compliments was added. Stop the Clock
was added and
Amber
Woolner
Following
the
agreement
of
a
recommendation made to the Board of
Directors the policy has been changed to 30
working days to respond to a complaint
instead of 25.
Policy Circulation Information
Notification of policy release:
All recipients;
Staff Notice Board;
Intranet;
Key words to be used in DtGP
search.
CQC Standards
Other Quality Standards
Page 2 of 41
Contents
Section
Page
1
Introduction
4
2
Purpose
5
3
Scope
5
4
Definitions
5
5
Duties
6
6
Complaints Process
10
7
Complaints Management
11
8
Complaints Procedure
14
9
Unreasonable and Persistent Complainants
18
10
Parliamentary and Health Service Ombudsman (PHSO) (Stage 2)
18
11
PALS Management
20
12
Compliments
20
13
Confidentiality and Data Protection
20
14
PREVENT Strategy
21
15
Whistle Blowing
21
16
Being Open and Duty of Candour Policy
21
17
Support for Staff
22
18
Education and Training Requirements
22
19
Process for Monitoring Effective Implementation
22
20
Links to Other Documents
22
21
References and Acknowledgements
22
Appendix 1
Useful Contacts
24
Appendix 2
Informal Complaints/Concerns Feedback Form
26
Appendix 3
Formal Complaints Handling Flow Chart
28
Appendix 4
Risk Grading
29
Appendix 5
Advice Sheet – Investigating Complaints
30
Appendix 6
Guidance for Managers Interviewing Staff who are involved in a
Complaint
32
Appendix 7
Management of Complaints Satisfaction Questionnaire
34
Appendix 8
Joint Protocol between the Trust and the Local Authority for the
Management of Complaints
35
Appendix 9
Guidance for handling Unreasonable Persistent Complainants
38
Appendices
Page 3 of 41
1.
Introduction
Complaints, Concerns and Patient Experience are one way of identifying the
service users’ perspective of the service provided. They can act as an early
indicator that a system may not be functioning effectively or may be placing
patients at risk. Appropriate trend analysis of the factors which prompted
complaints, concerns and enquiries can provide invaluable insight into areas
where improvements may be required.
The Local Authority Social Services and National Health Service Complaints
(England) Regulations 2009 set out to sustain public confidence in the
regulation of healthcare professionals. These regulations are the Legislative
framework for managing complaints against NHS bodies, all statutory
providers of NHS care (including Foundation Trusts and Primary Care
providers), Voluntary and Independent Sector organisations who provide
services under contract to the NHS, and to Local Authorities who provide
Adult Social Services and incorporates the need for effective handling of
concerns about healthcare professionals.
The NHS Constitution (DOH, 2012) outlines to the public their rights when
making a complaint.
The policy contains detailed guidance in relation to the stages of the NHS
Complaints procedure:
Local Resolution
Investigation by the Parliamentary and Health Service Ombudsman
The Health Service Ombudsman considers six principles in relation to
management of complaints, these principles are listed below:
Getting it Right
Being Customer Focused
Being open and accountable
Acting fairly and proportionately
Putting things right
Seeking continuous improvement
Cambridgeshire and Peterborough NHS Foundation Trust (the Trust) must,
under the regulations, make arrangements for the handling and consideration
of complaints. The arrangements must ensure that:
Complaints are dealt with efficiently
Complaints are properly investigated
Complainants are treated with respect and courtesy
Complainants receive as far as is reasonably practical
Assistance to enable them to understand the procedure in relation to
complaints
Advice on where they can obtain such assistance
Complainants receive a timely and appropriate response
Complaints are told the outcome of the investigation of their complaint and
actions are taken if necessary in the light of the outcome of a complaint
The arrangements will be accessible and such as to ensure that complaints
are dealt with speedily and efficiently, that complainants are treated
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courteously and sympathetically, and as far as possible involved in decisions
about how their complaints are handled and considered.
The Trust takes all complaints very seriously. In addition, it welcomes all
feedback, including concerns, suggestions and compliments, because it
provides opportunities for service development and forms an important part of
the Trust’s plans for improving the quality of services.
2.
Purpose
This policy describes the procedure by which the Trust will meet the statutory
legislation and describes the means by which patients; relatives, carers and
members of the public can make formal complaints, raise concerns and make
suggestions and compliments. It also provides information for all Trust staff
regarding their responsibilities should they receive a complaint.
The policy outlines the process which will be followed by the Trust in response
to such feedback and in addition, the process by which the Trust aims to
make improvements to services as a result of the feedback.
The purpose of the Complaints Procedure is not to apportion blame amongst
staff but to investigate complaints to the satisfaction of the complainant whilst
being scrupulously fair to staff and to learn any lessons for improvement in
service delivery. However some complaints will identify information about
serious matters which indicates a need for disciplinary investigation.
Consideration as to whether disciplinary action is warranted must be subject
to a separate process of investigation. Papers that have accumulated during
the investigation of the complaint may be passed to the appropriate person
who will be considering the need for disciplinary or any other form of
investigation.
Care must be taken by the Trust to bear in mind the right of staff to
confidentiality and to avoid disclosure to the complainant of any disciplinary
action that has taken place as a result of a complaint.
The policy takes into account information from complainants who have given
anecdotal feedback of the complaints handling process as well as a number
of relevant public documents (refer to section 21).
3.
Scope
This policy applies to all CPFT staff and volunteers.
4.
Definitions
4.1.
Complaint – is defined as:
Any expression of dissatisfaction, about a Trust service or member of staff,
who is undertaking duties on behalf of the Trust. Complaints can be made
orally or in writing
Complaints are either locally resolved by no later than the next working
day or they are dealt with under the NHS Complaints Procedure. Either
way all complaints must be forwarded to the Complaints Department to be
recorded and monitored
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Where the person would prefer support to resolve an issue rather than
make a complaint they can be referred to the Patient Advice and Liaison
Service if a member of staff is unable to assist
Full details of types of complaint which fall outside this procedure can be
found in Regulation 8 of the Local Authority Social Services and National
Health Service Complaints (England) Regulations 2009. Refer to section
7.6.
4.2.
Responsible Body – means a Local Authority, NHS Body, Primary Care
Provider or Independent Provider
4.3.
Local Resolution – investigation and resolution of complaints under the first
stage of the NHS Complaints Procedure
4.4.
Confidentiality – non-disclosure of personal information to a third party
4.5.
Investigation – the act or process of investigating; a careful search or
examination in order to discover facts
4.6.
PALS – Patient Advice and Liaison Service is a service available to patients,
relatives and carers that offers confidential advice, support and information,
and can assist in resolving informal complaints or concerns.
4.7.
Concerns/Informal Complaint – concerns are written or verbal expressions
of dissatisfaction with a service or a staff member which can be resolved
locally or by the PALS team without the need for a formal investigation.
4.8.
Compliments – an expression of thanks and satisfaction with a service or
members of staff.
4.9.
Working day – a working day in this context is a day from Monday to Friday
excluding bank holidays.
4.10. Upheld – means a high majority or all of the elements were investigated and
found to be substantiated
4.11. Partially Upheld – means a majority (over a third) of the elements
investigated were found to be unsubstantiated
4.12. Not Upheld – means a majority or all of the elements investigated were found
to be unsubstantiated.
4.13. Undetermined – means that following investigation the elements of the
complaint could not be evidenced as upheld or not upheld.
5.
Duties
5.1.
The Chief Executive
The Chief Executive is ultimately accountable for the quality of care within the
organisation, and therefore, as part of governance arrangements, needs an
overview of all recorded dissatisfaction being expressed by service users and
Page 6 of 41
carers. The results of all complaint investigations will be submitted to the Chief
Executive who will sign the final letter of response to the complainant. Where
for good reason the Chief Executive is not able to sign the letter, it will be
countersigned by a nominated person acting on the Chief Executive’s behalf.
The Chief Executive is made aware of all breaches in the timescale for
providing a final response to complainants and the reasons for these.
5.2.
Director of Nursing and Quality
The Director of Nursing Quality has been designated by the Trust Board to
take overall responsibility for the Trust Complaints and Concerns Policy and
for ensuring that it complies with NHS Complaints Regulations.
The Director of Nursing and Quality is also ultimately responsible for ensuring
that action is taken if necessary in the light of the outcome of a complaint. The
Director of Nursing and Quality will, in turn, delegate to the Patient Safety and
Complaints Lead the responsibility for the operational management of the
Trust’s complaints handling in line with its Complaints and Concerns Policy.
5.3.
Patient Safety and Complaints Lead
The Patient Safety and Complaints Lead is responsible for operational
management of the Trust’s complaint handling in line with the Complaints and
Concerns Policy.
5.4.
Complaints Officer
The Complaints Officer manages the Complaints Department which is
overseen by the Patient Safety and Complaints Lead. The Complaints Officer
is responsible for:
Overseeing the operation of complaints procedure including providing
support in ensuring staff awareness
Providing support in ensuring public awareness, through the provision of
leaflets and posters
Collating and recording of all complaints
Ensuring that all formal complaints are dealt with and registered in
accordance with the Complaints Procedure
Liaising with the relevant Director/General Manager/Directorate Head of
Nursing where necessary regarding the appointment of an appropriate
Investigating Manager
Ensuring complaints are acknowledged within 3 working days
Ensuring complaints are answered within the agreed timescale and ensure
non-compliance with timescales escalated to the Chief Executive together
with the reasons for this
Completion of the Statutory Monitoring Forms (KO41A), for monitoring the
Trust Register of Complaints
Prepare the Annual Report on Complaints for the Trust Board and the
Care Quality Commission
Maintaining records of all outcomes and recommendations
Monitoring action taken as a result of complaints and that where
appropriate lessons learned are shared across the Trust
Liaising with the Ombudsman in relation to complaints that cannot be
resolved locally to the complainants satisfaction
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Ensuring that where relevant, complaints are highlighted as possible
claims, safeguarding concerns or serious incidents
Ensuring Directorates are sent monthly reports on complaints data
Complete a yearly audit on a random sample of 25% of the complaints
received to establish compliance with the policy
5.5.
Head of Patient Experience
The Head of Patient Experience is responsible for the operational
management of the Patient Advice and Liaison Service and leads on the
Trust’s patient experience agenda.
5.6.
Patient Experience Officer / PALS Team
The Patient Experience Officer is responsible for:
First point of contact for Patient, Carers and the Public to listen to their
concerns and issues, ensuring that learning and actions are implemented.
Visit wards and have PALs drop in sessions across the Trust’s sites
Log all PALs enquiries and compliments on Datix system
Help to resolve PALs enquiries and concerns locally escalating to the
formal complaint process where necessary
Signpost concerns to the relevant place or teams
Collate PALS / compliments data as part of the Trust’s reporting for quality
and safety
5.7.
Role of Directors and General Managers
Directors and General Managers have overall responsibility for the operation
of this policy within their specific area. This involves ensuring that all staff are
fully conversant and compliant with the policy, procedure and in completing
the Risk Grading Matrix (Appendix 4).
The General Managers will, where appropriate, be responsible for ensuring
the implementation of any service improvements that have been identified as
a result of a complaint.
5.8.
Directorate Heads of Nursing / Deputy General Managers
Directorate Heads of Nursing and Deputy General Managers have been
delegated responsibility from the General Managers to operational manage
the complaints process within their Directorate. This involves the coordination
and appointment of Appointing Officers and Investigating Managers.
Reviewing and approving action plans and recommendations from complaints.
They are responsible for acting as a central point of contact within the
Directorate for formal complaints.
5.9.
Role of Appointing Officers
Appointing Officers are responsible for ensuring the appointment of suitable
Investigating Managers with the relevant training and experience who have
not been involved in the complaint. Where possible, good practise suggests
Investigating Managers should not be from the same service area indicated in
the complaint.
Page 8 of 41
5.10. Role of Investigating Manager (Refer to section 8.3)
The Investigating Managers will be responsible for liaison with the
complainant, ensuring that they carry out a thorough, fair and factual
investigation into the complaint (see Appendix 5). They should ensure that
they complete the report template provided to them to prepare an appropriate
response letter detailing their findings, including a suggested response and
complete the Risk Grading Matrix (Appendix 4) provided to them. All formal
complaint investigations are completed within set timescales stated in this
policy and agreed with the complainant.
5.11. Role of all Staff
To make sure they have read the policy and know what their individual
responsibilities are for handling complaints and concerns.
All staff should be aware of the correct procedure to follow should a patient or
relative wish to make a formal complaint, raise a concern or pass on a
compliment.
All staff, regardless of their role and seniority, are responsible for supporting
complainants with help and information about the procedure and for trying to
resolve complaints and concerns quickly and appropriately as they arise. This
will be done in line with the Trust’s own values and with particular emphasis
on treating complainants with respect and dignity.
All staff should request advice and guidance from the Complaints Department
or PALS if they are unsure of what action to take.
On receipt of a complaint or concern, all staff will follow the procedure outlined
in Appendix 2.
Suggestions and compliments also provide useful feedback and these should
be sent to PALS who will register the feedback.
5.12. Clinical Governance and Patient Safety Committee
The Clinical Governance and Patient Safety Committee has responsibility for
ensuring that complaint handling throughout the Trust is monitored on behalf
of the Trust Board, including:
Reviewing and revising the Complaints Policy, ensuring that it:
Is easily accessible and well publicised
Is applied
Meets legal and other requirements
Remains up-to-date in terms of regulations and Trust structural and
organisational factors
Receives and approves the quarterly thematic review on complaints
management including:
Numbers of opened, closed and re-opened complaints
Subject matter
Trends
Response times
Lessons learnt and actions taken as a result of complaints
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Details of complaints referred to the Ombudsman and the outcome of
these
Ensure that there is a robust system for auditing and sharing the lessons
learned from complaints for service employment. Should remedial action be
required, an action plan will be formulated and monitored by the Clinical
Governance and Patient Safety Committee.
5.13. Governance Forums
Governance Forums will receive a monthly report detailing the complaints, to
include the recommendations, actions taken and the lessons learnt (if
indicated).
5.14. Service Managers
The Operational Services will be expected to provide confirmation that
identified actions relating to complaints management have been completed, or
identify action plans about how issues arising from complaints will be
addressed.
Service Managers will ensure that staff, service users and carers are kept fully
informed of the complaints process, taking into consideration the assistance
required to support those complainants who may not be able to read or write,
may not have English as their first language or may suffer from disabilities
which make formal written complaints difficult. The Trust has access to
interpretation at Translation Services and assistance in putting complaints in
writing is available from the Complaints Departments.
5.15. PALS and Complaints
The Patient Advice and Liaison Service (PALS) and Complaints Department
are separate services within the Trust.
There is a clear differentiation between PALS and Complaints. PALS do not
investigate formal complaints and their role is to help resolve issues and
concerns locally as quickly as possible and support people to access the
complaints procedure when requested. However, the issues raised through
PALS forms an important component of service user and carer feedback
which helps us to improve our services.
PALS provides assistance to members of the public, patients, service users
and carers with queries about health related matters when they first have a
concern or issue they wish to raise.
6
Complaints Process
6.1
Stage 1 – Local Resolution (Stage 1)
6.1.1 Informal Complaints and Concerns
Informal complaints and concerns can often be resolved at the source.
Concerns raised should be listened to sympathetically and it will frequently
be possible for the member of staff to whom these were expressed, to
provide an acceptable answer or explanation on the day where possible.
Page 10 of 41
Where remedial action has been or is to be taken, its nature should be
explained to the person raising the concern. A record of the informal
complaint and any action taken, if appropriate, should be documented
using the Trust’s Informal Complaints/Concerns Feedback form (Appendix
2) and sent to the PALS team via email at [email protected].
Staff should always attempt to deal with informal complaints/concerns
swiftly at the informal stage so that the issue is resolved more quickly for
the complainant. Staff should apologise and inform the patient/relative what
can be done to address their concerns.
If you need help/support with handling an informal complaint you should
contact PALS team ([email protected]).
6.1.2 Formal Complaints
Who may complain?
Complaints may be made directly to the Trust by:
A patient
Any person who is affected by or likely to be affected by the action,
omission or decision of Trust
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 incapacity to make the
complaint themselves
Has requested the representative to act on his behalf and provides
consent to allow this
How can a complaint be made?
Complaints can be made directly to the Trust by:
Letter
Email
Telephone
In person
6.2
Stage 2 – Parliamentary and Health Service Ombudsman (PHSO)
If, after all attempts at local resolution the complainant remains dissatisfied
with the response to their formal complaint they have the right to ask the
Parliamentary and Health Service Ombudsman to investigate their complaint.
7
Complaints Management
7.1
Contacting the Complaints service
The CPFT Complaints Department can be contacted by Freephone 0800
0521411, via email: [email protected] or in writing to:
Complaints Department
Elizabeth House
Fulbourn Hospital
Fulbourn
Cambridge, CB21 5EF
Response Times
7.2
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The team operates within normal office hours Monday to Friday excluding
bank holidays. The team will aim to respond to complaints or contact
regarding complaints within two working days.
7.3
Complaints made by a person other than a patient
If the patient has capacity to give consent and wishes a representative to act
on their behalf, then signed authorisation will be sought by the Complaints
Department. The Complaints Department will request consent and allow four
weeks for the form to be returned. If, however, the form is not received the
Complaints Department will close the complaint.
If the patient has died, or is incapacitated, the Complaints Officer in
conjunction with the Caldecott guardian must decide whether the complainant
is a suitable person to pursue a complaint.
Consideration must be given to all relevant factors such as the closeness of
the complainant’s involvement with the patient over the time they had known
them and the nature and frequency of their contact.
Where the complainant has Lasting Power of Attorney (LPA) on behalf of a
patient, the Complaints Department will ensure that this is valid, registered
with the Office of the Public Guardian and the extent of the powers held, in
order to decide whether consent from the patient is required. A copy of the
LPA will be kept on the complaint file.
Where the complaint is made on behalf of a child aged 16-18 years, the
Complaints Officer will check with the clinician to get an opinion as to whether
the child has competency to give consent for the complaint to be made on
their behalf by a parent or carer. If a child aged 16-18 years makes a
complaint in their own right the Complaints Officer will check with the clinician
regarding their competency and the appropriateness of this.
7.4
Complaints made by Member of Parliament on behalf of Constituent
Complaints, concerns or information requests from MP’s are usually
addressed to the Chief Executive and where this is the case, the Chief
Executive will send acknowledgment that the letter or email has been
received and pass to the Complaints Department.
The Complaints Department will review the letter in-conjunction with PALS
and determine the best route for addressing the issues raised.
If the letter or email is a formal complaint, this will be dealt with in the line with
the Trust’s Complaints Procedure. Consent from the person concerned must
be obtained if correspondence is to be copied to the MP (refer to section 7.3).
All responses to MP’s are signed by the Chief Executive.
7.5
Time limits for making complaints
A complaint should be made within twelve months from the incident that
caused the problem or within twelve months of the complainant becoming
aware of the incident. The Complaints Officer has discretion to extend this
time limit when the complainant had good reason for not making a complaint
Page 12 of 41
within that time limit; and it is still possible to investigate the complaint
effectively and fairly.
When the timescale is not extended, complainants will be advised of their
right to refer the complaint to the Parliamentary and Health Service
Ombudsman for a review of this decision.
7.6
Matters excluded under the complaints procedure
Some complaints fall outside of the remit of the NHS Complaints Procedure:
A complaint made by a Trust employee about any matter relating to
his/her employment.
A complaint arising out of the alleged failure by the Trust to comply with
a request for information under the Freedom of Information Act.
A complaint which has already been investigated in accordance with
the Trust’s formal complaints procedure.
A complaint that is or has already been investigated by the
Parliamentary Health Service Ombudsman.
A complaint that is raised by another NHS Trust, Clinical
Commissioning group, local authority or independent provider. These
concerns are dealt with in accordance with the Healthcare Professional
Feedback procedure.
7.7
Complaints, Legal Action & Criminal Proceedings
Where a complainant states they are commencing legal action against the
Trust in relation to their complaint, the Complaints Department will notify the
Trust Legal Team, and information collated during an investigation of a
complaint, may have to be disclosed when legal action is taken.
It should be noted that the updated Complaints Regulations 2009 no longer
states that the complaint should be halted where legal action has started.
It should also not necessarily be assumed that a complaint made via a
Solicitor means that the complainant has decided to take legal action. If
consent has been received, a response should be made in the normal matter.
An apology is not necessarily an admission of liability.
If the subject of the complaint is a matter being referred to the police, the
complaints procedure will be suspended pending the outcome of that
investigation and the complainant will be informed of the reasons for this
delay. Once the outcome is known the complaint may continue if appropriate.
7.8
Complaints and Disciplinary Action
Complaints can be investigated even if disciplinary action is being considered
or taken against a member of staff. However, the confidentiality of the
member of staff concerned must be respected.
7.9
Discrimination
Complainants need to feel confident that their care will not be affected as a
result of their having made a complaint. This commitment will be
communicated to patients throughout the Complaints Process.
Complainants will be invited to complete a questionnaire (which is currently
under review – Appendix 7) at the end of the procedure and results will be
Page 13 of 41
monitored to identify any discrimination and action to be taken. The
questionnaire will also provide reassurance that internal complaint handling
processes are being followed and that complainants are satisfied with this.
8
Complaints Procedure
8.1
Acknowledgments
All formal complaints must be acknowledged within 3 working days. If the
complaint is addressed to a member of staff outside the Complaints
Department, the addressee will send an acknowledgment confirming that the
complaint has been referred to the Complaints Department.
If a complaint is received outside of office hours or at the weekend the
complaint will be recorded as being received on the next working day and the
acknowledgement will be 3 working days from this date.
The Complaints Department will send an acknowledgment of complaints
received whether they were received directly from the complainant or via a
member of staff. When a complaint is made orally which requires investigation
as a formal complaint, the acknowledgment must be accompanied by a
written account of the complaint, with an invitation to the complainant to
confirm the accuracy by signing and returning it.
When the complainant is not the patient and written authority from the patient
for the complainant to pursue the matter on their behalf has not been
supplied, the completion of a consent form will be requested. Where consent
cannot be obtained for a third party to make a complaint about the care and
treatment of a patient, no response will be given which includes specific or
confidential information about the patient.
The acknowledgment will contain information about support available from
POhWER (Independent Complaints Advocacy Service – see Appendix 1) and
information on the complaints process and about disclosure of information.
Any disclosure must be confined to that which is relevant to the investigation
of the complaint and only disclosed to those people who have a demonstrable
need to know it for the purpose of investigating the complaint.
8.2
Complaints relating to Local Authority or other NHS Body (App 5)
In cases when the complaint relates in part to a Local Authority, or another
NHS body, the involved organisations must co-operate in coordinating the
handling of the complaint and ensuring that the complainant, with their
agreement, receives a coordinated response to the complaint. This includes
agreeing which organisation takes the lead in coordinating the handling of the
complaint and communicating with the complainant. This discussion will take
place within a target of 2 working days of receipt of a complaint. Staff will
endeavour to work with private organisations/agencies in the same way.
Each organisation must provide information relevant to the complaint and
attend any meeting required in connection with the complaint.
When the complaint relates entirely to services provided by another NHS
body, or local authority, the Complaints Department will seek the consent of
Page 14 of 41
the complainant to forward the complaint to the relevant body within a target
of 3 working days.
8.3
Investigation
The Complaints Department will liaise with the Appointing Officer to ensure
the allocation of an appropriate Investigating Manager. The Investigating
Manager will be someone independent of the area(s) and staff that are
subject of the complaint. This will be the start of the complaints handling
process outlined in Appendix 3.
The aim of an effective investigation is to gather a sufficient amount of
relevant clinical, factual and other information to be able to determine what
has occurred and to identify any appropriate action required (Appendix 5).
Guidance of completing a complaints investigation can be sought from the
Complaints Department.
The Risk Assessment Matrix (Appendix 4) will assist in determining the level
of investigation required. It can assist in ensuring that the process is
proportionate to the seriousness of the complaint and the likelihood of
recurrence.
The investigation will be fair to all parties. Investigating Managers will ensure
that anyone who is the subject of a complaint is given a proper opportunity to
talk to them and is kept informed of progress.
The Investigating Manager will need to complete the Complaints Investigation
Pack and ensure all information relevant to the investigation is recorded, and
this is sent back to the Complaints Department to be kept in the complaint file.
This will include records of interviews and telephone conversations. The case
file will be forwarded to the Complaints Department at the end of the
investigation, as it may be required at a later stage by Commissioners or the
Ombudsman.
It is the Investigating Manager’s responsibility to determine if the elements of
the complaint are upheld, partially upheld, not upheld or undetermined. The
Complaints Department are responsible for providing a check on the outcome
and recording this in the complaints database (refer to section 4.10 to 4.13 for
outcome definitions).
Where the complaint involves clinical issues, the findings and the response
must be shared with the relevant clinicians to ensure factual accuracy in
respect of those clinical issues.
The Complaints Department may, where appropriate and with the agreement
of the complainant, make arrangements for conciliation, mediation or other
assistance for the purposes of resolving the complaint.
The Investigating Manager is responsible for ensuring that the complainant is
kept up to date with progress at intervals agreed with them at the start of the
complaint process.
Page 15 of 41
Where a complaint relates to the actions of the Chief Executive or Chairman
of the Trust, special arrangements will be made to ensure a fair investigation.
This may be for example via a neighbouring NHS Trust or Local Authority.
8.4
Stop the Clock
At times there may be reason to ‘stop the clock’ on the 30 working day
standard timeframe and a revised timeframe is used.
Reason to Stop the Clock
Consent is required as the complaint
relates to more than one organisation
Where elements of the complaint
relate to an on-going serious incident
investigation.
Where the complaint raises issues of
a safeguarding nature
Rule
Consent is requested when the
acknowledgement is sent. If consent
is not received within 4 weeks the
complaint is closed.
The 30 working day response time will
be calculated from the date the
Serious Incident investigation report is
submitted to the Clinical
Commissioning Group.
The complaint will be suspended and
will commence once the Safeguarding
Investigation has concluded and the
findings shared with the
patient/relative, or confirmation has
been received a safeguarding review
is not required.
If during the course of the investigation the complainant wishes to suspend
their complaint, the Complaints Department will record the complaint as
closed. If the complainant wishes to recommence their complaints
investigation within two months of the suspension the complaint will be reopened. If the complainant wishes to complain about the same circumstances
again in the future this will be recorded as a new complaint.
8.5
Response to Complainants
A final response letter will be sent out at the end of the investigation. In all
cases the Investigating Manager will agree with the complainant, at the
beginning of the complaint process, the date that they will receive their
response. The Trust aims to provide a response within 30 working days from
receipt of the complaint.
If a complaint is received outside of office hours or at the weekend the
complaint will be recorded as being received on the next working day and the
response will be 30 working days from this date.
There are circumstances when this is not possible and in this case the
Investigating Manager will agree timescales with the complainant and will then
notify the Complaints Department (refer to section 8.6).
Page 16 of 41
The final response letter will be signed by the Chief Executive. If for good
reason the Chief Executive is not able to countersign the final response, it will
be signed by a Director acting on behalf of the Chief Executive.
The response will be in the format of a letter and will include a summary of the
nature and substance of the complaint, an open and honest description of the
investigation and its findings and any recommendations to be taken as a
result of the complaint. It will also include appropriate apology for any
omissions by the Trust and the distress caused.
The response will also include the offer of further opportunities to clarify or
discuss remaining concerns and advice to complainants, regarding the right to
refer the complaint to the Parliamentary and Health Service Ombudsman (see
Appendix 1) if they remain dissatisfied following the Trust’s conclusion of the
complaint.
8.6
Exceptional Circumstances
An exceptional circumstance refers to a reason why the complaints procedure
may not be adhered to and there is a delay in the complainant receiving their
response. Examples of these reasons are:
The patient is in acute phase of their illness/in hospital and the
complaint is unclear and requires clarification with them, contact should
be made with relevant clinician to establish this and must be
documented.
The complaint is very complex e.g. involves a death, serious harm or
goes back more than 12 months. This is likely to also fall under the
Incident Management Policy including Serious Incidents and Near
Misses.
Key witnesses whose statements are required are on annual leave or
sick – this should be identified at the start of the investigation and
explained to the complainant – if a member of staff is on long-term
leave it may not be possible to wait. In these circumstances advice
should be sought from the Complaints Officer.
The Investigating Manager goes on sick leave after starting an
investigation – in this case the complaint should be reallocated
immediately and any delays kept to the minimum.
Please note: if is it known that the Investigating Manager will be on planned
leave this is not an exceptional circumstance and this must be considered
when allocating a complaint to that person. They must be able to meet the 30
day deadline. The complainant must be informed in all cases of the above and
agreement should be sought on when the complaint will be completed.
Any extensions in excess of the 30 day timescale together with the reason
must be documented and will be monitored closely. This will also monitored
through the annual complaints audit.
8.7
Learning from Complaints
When the investigation is complete, the Investigating Manager will agree with
the Ward/Team Manager, Service Manager or General Manager, the findings
and where appropriate agree achievable recommendations, in the form of an
action plan.
Page 17 of 41
The identified recommendations will be sent by the Complaints Department to
the relevant Directorate Head of Nursing for discussion and monitoring at the
Local Governance meetings. An electronic tracker of the action plans will be
regularly updated with evidence by the Complaints Department.
This information will be reported to the Clinical Governance and Patient
Safety Committee. Directorate Heads of Nursing will receive a copy of action
plan tracker for their Directorate and are responsible for ensuring they are
disseminated, actions are implemented and evidence is provided.
Where lessons from complaints have value, wider than the service concerned
i.e. teaching staff and adoption of good practise, complainants will be
approached to participate in ‘sharing their story’ (with their consent), for ongoing dissemination and spread of lessons learnt across the organisation.
9
Unreasonable and Persistent Complainants
Habitual complainants are becoming an increasing problem for NHS Staff,
causing undue stress and placing a strain on time and resources. Staff are
trained to respond with patience and sympathy to the needs of all
complainants, but there are times when there is nothing further which can
reasonably be done to assist them or to rectify a real of perceived problem.
The Trust will ensure that the Complaints Procedure is followed so far as
possible and that no material element of a complaint is overlooked, as
complaints from unreasonable and persistent complainants may have some
substance.
In cases where an unreasonable and persistent complainant has been
identified, the Complaints Officer will discuss the case with the Chief
Executive and decide what action to take. This may include a review of all the
complaints documentation or seeking legal advice. Once a decision has been
made, the Chief Executive will write to the complainant and a record kept of
the reasons why a complainant has been classed as unreasonable and
persistent. Refer to the Guidance for Handling Unreasonably Persistent
Complainants (Appendix 9).
10
Parliamentary and Health Service Ombudsman (PHSO) (Stage 2)
10.1 The Role of the Ombudsman
The Ombudsman is independent of the National Health Service and the
Government.
The Ombudsman is appointed by the Queen and is answerable to a Select
Committee.
The role of the Ombudsman is to identify cases of genuine hardship or
injustice or any unfairness of complaint management under the NHS
Complaint Procedure.
Page 18 of 41
The Ombudsman may decide to investigate complaints about services
received from the NHS if not resolved to the complainant’s satisfaction locally
through Local Resolution.
The Ombudsman has powers to investigate complaints about NHS providers
and purchasers and non-NHS providers which are funded by the NHS, on
such matters as care and treatment, clinical judgment, maladministration
causing hardship or injustice, service provision and complaints handling.
It is intended that complainants should fully exhaust the complaints procedure
before referring to the Ombudsman. However, the Ombudsman shall have
discretion, exceptionally, to override this requirement.
When investigating a complaint the Ombudsman will require access to all
papers relating to the Local Resolution of the complaint.
The Ombudsman will not investigate complaints about disciplinary or other
personnel matters.
The Trust works to the PHSO ‘Principles of good Complaint Handling’, which
identifies six principles an organisation is expected to understand when
dealing with complaints.
The six principles include:
Getting it right
Being customer focused
Being open and accountable
Acting fairly and proportionately
Putting things right
seeking continuous improvement
10.2 Responding to the PHSO
If the Trust received a notification that a case has been referred to the
Ombudsman the complaints department will:
Ensure the PHSO is sent copies of the complaint investigation file
within the timescale set by the PHSO
Liaise with the offices of the PHSO to provide additional information as
requested
Update the central database in relation to the complaint to indicate its
referral to the Ombudsman
Report any complaint referred to the PHSO via the Integrated Board
Report to the Trust Board
Report any complaint referred to the PHSO to the Patient Safety and
Clinical Risk Group.
Co-ordinate the formulation of an action plan for any actions identified
as needed as a result of the PHSO’s review of the complaint
Communicate the outcomes of the PHSO’s reviews to the
Commissioners and Clinical Governance and Patient Safety Committee
along with any action plans
Submit any action plan produced to the appropriate local governance
group for monitoring
Page 19 of 41
11
PALS Management
11.1 Contacting the PALS team
The PALs team can be contacted by Freephone 0800 376 0775, via email:
[email protected] or in writing to:
Elizabeth House
Fulbourn Hospital
Fulbourn
Cambridge, CB21 5EF
The PALS and complaints teams work very closely together to ensure all
informal and formal concerns are handled effectively and smoothly.
11.2 Response Times
The team operates within normal office hours Monday to Friday excluding
bank holidays. The team will aim to respond to contacts relating to concerns
or enquiries where possible the same day and no later than two working days.
11.3 PALS Drop-In sessions
The PALS team offer drop-in sessions on the wards for inpatients. This
service allows patients to ask for advice or voice concerns in a confidential
and personal manner.
12
Compliments
The PALS team record all compliments received by the Trust on the PALS
database. If the compliments are received directly by the PALS team they will
forward the feedback to the relevant team.
The wards and teams are responsible for forwarding copies of any
compliments they receive to the PALS team so these can be recorded on the
central database and report as part of the Trust’s quality reporting.
13
Confidentiality and Data Protection
13.1 Data Protection Act
It is essential when dealing with complaints that staff comply with the
Confidentiality Policy, Data Protection Policy and Access to Health Records
Policy. Any request to access clinical/medical records will be dealt with under
the Data Protection Act (1998).
As the Data Protection Act only relates to living persons access to deceased
patient’s records is via the Access to Health Records Act (1990). Any
disclosure must be confined to that which is relevant to the investigation of the
complaint and only disclosed to those people who have a demonstrable need
to know it for the purpose of investigating the complaint.
13.2 Record Keeping for PALS and Complaints
All concerns and enquiries will be analysed on arrival by PALS and coded by
main theme, sub theme, staff type and service. This information along with the
personal details of the person raising the concern or enquiry, and details of
Page 20 of 41
the contact, will be entered onto the database, which will be kept up to date
and accurate. Clients may wish their personal details remain anonymous and
these wishes would be respected, however, the issue would be recorded on
the database so as to ensure that trends are identified and reported.
On receipt of a formal complaint the complainants and patients details are
inputted onto the complaints database, and an electronic folder is created.
Information pertaining to the complaint is held within the database and
electronic folder within a secure network.
Records pertaining to a formal complaint or that a patient/relative has made a
formal complaint should not be kept in a patient’s clinical records. The
complaint files are held separately to the patient’s clinical records to ensure
patients are not discriminated against for raising concerns.
13.3 Confidentiality and Consent
Both the Complaints Department and PALS team will treat all information
received about patients and staff in strict confidence. Information about a
caller, including the fact that they have made contact, will not be disclosed to
a third party even to a partner or family member without the express consent
of the caller.
The majority of concerns or enquiries will be received by telephone. In order
to facilitate the speedy response of enquiries, verbal consent will be gained
from enquirers. If the enquiry is on behalf of a child under the age of 16, it is
not necessary to obtain consent from the child.
The process for obtaining consent for formal complaints is outlined in section
7.3 and 7.4.
14
PREVENT Strategy
If a staff member becomes concerned that an adult with risk behaviour
indicates they may be being drawn into terrorist-related activity should contact
the Trust Prevent Lead as soon as possible.
15
Whistle Blowing
The Whistleblowing (Open Practice) Policy should be accessed instead of the
Complaints Policy when an employee or worker provides certain types of
information, usually about illegal or dishonest practises to the employer or a
regulator, which has come to their attention through work.
16
Being Open and Duty of Candour Policy
From April 2013 all NHS organisations will be required to comply with the
Duty of Candour and tell patients if their safety has been compromised. CPFT
will ensure that patients (and their carers if appropriate) receive a prompt
apology for any incidents when this has occurred, whether or not a complaint
has been made or information has been requested and ensure that lessons
are learnt to prevent them from being repeated.
Page 21 of 41
17
Support for Staff
The Trust recognises that complaints made against individual members of
staff can be distressing. Support is available for staff from their Line
Managers, the Occupational Health Department, and Union Representatives.
18
Education and Training Requirements
Complaints information relating to this policy will be provided through Trust
Induction, and Investigating Managers training sessions within service areas.
It is preferable for Investigating Managers to have undertaken Root Cause
Analysis training. The Complaints Department provided in-house complaints
investigation training.
19
Monitoring Compliance
The Trust monitors its management of complaints, concerns and compliments
through:
The production of monthly reports to the Trust Board, a quarterly thematic
review, and annual reports.
An annual complaints audit is undertaken to review the complaint
procedure and the reports are presented to the Clinical Governance and
Patient Safety Committee.
20
Links to Other Documents
Other related Trust procedural documents should be identified here.
Incident Management Policy including Serious Incidents and Near Misses
Being Open and Duty of Candour Policy
Whistleblowing (Open Practice) Policy
Access to Health Records, Personnel Records, and CCTV Data Protection
Act 1988 Policy
Confidentiality Policy
Freedom of Information Policy
Health Records Management Policy
Safeguarding Children Policy
Safeguarding Adults Policy
Supporting Staff Following Traumatic or Distressing Events Policy
Disciplinary Policy and Procedure
21
References and Acknowledgements
The following documents and publications have been directly referenced or
have been considered in the drafting of this policy:
Access to Health Records Act (1990)
Data Protection Act (1998)
The Principles of Good Complaint Handling (Parliamentary and Health
Service Ombudsman, 2008)
Listening, responding, and improving a guide to better customer care. Local
Authority Social Services and NHS Complaints England DH, 2009
Page 22 of 41
NHS Consultation (DH 2012)
NHS Litigation Authority Guidance about Complaints
The Local Authority Social Services and National Health Service Complaints
(England) 2009
Being Open – Communicating Patient Safety Incidents with Patients and their
carers (NSPA, 2009)
Robert Francis Inquiry Report into Mid-Staffordshire NHS Foundation Trust
(2010)
Listening and Learning: the Ombudsman’s Review of complaint handling by
the NHS in England 2010-11
Building Partnerships, Staying Safe The Health Sector contribution to HM
Government’s Prevent Strategy: guidance for healthcare organisation (DH
2011)
‘Introducing the Statutory Duty of Candour’: a consultation on proposals to
introduce a d new CQC registration regulation, Department of Health, March
2014
Report of handling of complaints by NHS hospitals in England by Ann Clwyd
MP and Professor Tricia Hart October 2013
Policy and Procedures on Handling Concerns and Complaints, Derby
Hospitals NHS Foundation Trust (2013)
Complaints Procedure, Norfolk and Suffolk NHS Foundation Trust (2014)
Page 23 of 41
Appendix 1
Useful Contacts
Complaints Team – CPFT
Elizabeth House
Fulbourn Hospital
Fulbourn
Cambridge
CB21 5EF
Tel: 0800 0521411
Email: [email protected]
PALS – CPFT
Elizabeth House
Fulbourn Hospital
Fulbourn
Cambridge
CB21 5EF
Tel: 0800 3760775
Email: [email protected]
Caldicott Guardian (Medical Director) –
CPFT
Elizabeth House
Fulbourn Hospital
Fulbourn
Cambridge, CB21 5EF
Tel: 01223 726763
Freedom of Information Lead – CPFT
Elizabeth House
Fulbourn Hospital
Fulbourn
Cambridge, CB21 5EF
Tel: 01223 726759
Email: [email protected]
Information Governance Manager – CPFT
PO box 506
Edith Cavell Health Campus
Bretton Gate
Peterborough, PE3 9GZ
Tel: 01733 776010
Safeguarding Children Lead – CPFT
Elizabeth House
Fulbourn Hospital
Fulbourn
Cambridge, CB21 5EF
Tel: 01223 726770
Safeguarding Adult Lead – CPFT
(Cambridgeshire area)
Tel: 01480 415340
Safeguarding Adult Lead – CPFT
(Peterborough)
Tel: 01733 748409
Vulnerable Adults Lead
Box SS1007
Castle Court
Shire Hall
Cambridge, CB3 0AP
Tel: 01223 717330
Vulnerable Adults Lead
2nd Floor
Town Hall
Bridge Street
Peterborough, PE1 1FA
Tel: 01733 758433
Customer Care Manager
Social Care Complaints
Cambridgeshire County Council
Castle Court
Shire Hall
Cambridge, CB3 0AP
Tel: 01223 699665
The Central Complaints Office
Peterborough City Council
Bayard Place
Broadway
Peterborough
PE1 1FZ
Tel: 01733 345090
Page 24 of 41
Parliamentary and Health Service
Ombudsman
Millbank Tower
Millbank
London, SW1P 4QP
Tel: 0345 015 4033
Email:
[email protected]
The Local Government Ombudsman
PO Box 4771
Coventry, CV4 0EH
Tel: 0300 061 0614
Information Commissioner’s Office
Wycliffe House
Water Lane
Wilmslow
Cheshire, SK9 5AF
Tel: 0303 123 1113
POhWER (ICAS)
PO Box 14043
Birmingham
B6 9BL
Tel: 0300 456 2370
Email: [email protected]
Website: www.pohwer.net
Cambridgeshire Independent Advocacy
Service (CIAS)
MIND – mental health charity
www.mind.org.uk
Cambridgeshire:
Tel: 01223 218500
Peterborough and Fenland:
Tel: 01733 530650
Peterborough:
01733 530651
Huntingdon:
Tel: 01480 470480
Cambridge:
Tel: 01223 311320
Age Concern Mental Health Advocacy
Service
The Old White Lion
31 St Mary’s Street
Ely
Cambridgeshire, CB7 4HF
Alzheimer’s Society Advocacy Service
17 Manor House Street
Peterborough, PE1 2TL
Tel: 01733 893853
Making Space (Cambridgeshire Carer
Support Services)
Suite D2, Ambury Business Centre
89 High Street
Huntingdon, PE29 3DP
Tel: 01480 432504
Rethink Carer Support (Peterborough)
Litton House
Saville Road
Westwood
Peterborough, PE3 7PR
Tel: 01733 843344
Healthwatch Peterborough
16 -17 St Mark’s Street
Peterborough
PE1 2TU
Tel: 08451 202064
Email:
[email protected]
Healthwatch Cambridgeshire
The Maple Centre
6 Oak Drive
Huntingdon
PE29 7HN
Tel: 01480 420628
Email: enquiries@healthwatch
cambridgeshire.co.uk
Page 25 of 41
Appendix 2
Informal Complaints/Concerns Feedback Form
PLEASE ENSURE THIS FORM IS FILLED OUT
BY A MEMBER OF STAFF AND SEEN BY A
MANAGER BEFORE SENDING
Date received:
Date closed;
Name of staff completing form (please print clearly):
Telephone number of staff completing form:
Directorate and Team:
Contact Information of person raising concern
Full Name:
Address:
Tel: (home/mobile/work)
Email:
D.O.B:
Ethnic Origin:
Tick here if Service User
information is as above (if not fill in
details below)
Service user name:
Relationship to person raising
concerns
Address:
Service user Tel:
Service User D.O.B:
Consent: Please detail here if
consent is required, given or
denied by Service User
Details of informal complaint/query/issue:
Details of actions taken by staff to resolve the informal complaint/query/issue:
Send to PALS Team at [email protected]
Page 26 of 41
Guidance Notes for Staff
This form is to be completed by staff to ensure that staff are listening to concerns,
comments and informal complaints. Please complete all parts of the form and return
to PALS via email ([email protected]).
Please do not give this form to patients, carers or relatives to complete
If you receive a complaint or concern please ensure that there is no immediate risk
to the complainant and / or others involved.
If you suspect there may be safeguarding issues, please call the appropriate
Safeguarding Lead.
If you suspect a fraudulent act has been committed please contact the Counter
Fraud Team on
Fill in the form while the person is with you where possible and if they want to sign it,
they can do so in the ‘Consent’ box.
Suggest to the person that although PALS will see this form, they may wish to
contact PALS directly themselves to resolve issues speedily and informally. PALS
Freephone is 0800 376 0775 or via email: [email protected]
PLEASE NOTE: You must alert your Director or Line Manager immediately if
there may be indications of physical or sexual assault, financial misconduct or
criminal offence.
If out of hours, please contact the Manager on Call in first instance
Page 27 of 41
Appendix 3
Formal Complaints Handling Flow Chart
Patient / service user / representative make a formal complaint
which is received by a member of staff, manager or the Chief
Executive is passed to Complaint Team
Day 1
Send complaint to the Complaints Team within 24 hours of
receipt
Complaints Officer contacts the manager of the service to advise
them of the complaint
Day 2
Complaint sent to Appointing Officer who will nominate an
Investigating Manager (IM) and inform the Complaints Team
Day 3
Complaints Team will register and acknowledge the complaint
within 3 working days of receipt by the Trust
Day 4
Complaints Team to provide the IM with the complaints
documentation. The IM to commence investigation and complete
the risk matrix.
The IM is to notify the Complaints Team of any timeframe
concerns and to keep the complainant up to date with the
progress of the investigation
Complaints Investigation Pack including recommendations and
actions (if applicable) to be completed
Day 18
On completion of investigation the IM refers the complaint back
to the Service Managers for checking who then sends the
completed investigation pack to the complaints team
Day 19
Complaints Investigation Pack including recommendations and
actions (if applicable) to be sent to Complaints Team
Day 22
Complaints Team formulate the response letter and pass to the
Chief Executive to review and sign
Page 28 of 41
Appendix 4
Risk Grading
Please use the matrix below to determine the severity, likelihood and overall risk
grading of the complaint post investigation.
Severity
Likelihood
Risk Grading
Most likely severity (if in doubt grade up, not down)
Insignificant (1)
Minor (2)
Moderate (3)
Major (4)
No injury or
identifiable damage
Mild injury (will probably
resolve in less than 1
month)
The impact would
threaten the efficiency of
some aspects of the
organisation
Some financial
implications
Some injury (emotional,
psychological or
physical), ill health,
damage or loss of
function likely to resolve
within a few months
Serious injury
(emotional,
psychological or
physical), ill health,
damage or loss of
function possibly with
prolonged disability
No disruption to
service or the
organisation
Financial implications
are negligible
e.g. spills of nonhazardous liquids,
paper cuts
1
e.g. absence from work
<3 days, incorrectly filed
documents
Disruption to
organisation could be
managed
Moderate financial
implications (>£50K)
e.g. RIDDOR reportable
injury, local adverse
publicity, lost claim file
Serious disruption to
the organisation
High financial
implications (>£500K)
e.g. large section of
roof falling in, national
adverse publicity,
computer network
failure >3 working
days, prolonged time
off work (>15 days),
theft of claim file
Catastrophic (5)
Death or significant
permanent disability
Organisation unable
to function
Very high financial
implications
(>£1million)
e.g. large scale
fraudulent claims
management,
international adverse
publicity, bomb
threat, anything
untoward that
involves >50 people
Likelihood:
Rare (1)
Cannot believe
that an even of
this type will
occur in the future
Unlikely (2)
Unlikely that this
type of event will
happen
Very Low
Very Low
Low
Low
Low
1
2
3
4
5
Very Low
Low
Low
Moderate
Moderate
2
4
6
8
10
Low
Low
Moderate
Moderate
High
3
6
9
12
15
Low
Moderate
Moderate
High
High
4
8
12
16
20
Low
Moderate
High
High
High
5
10
15
20
25
Likely (3)
This type of event
may well happen
(e.g. 50/50
chance)
Highly Likely
(4)
This type of event
will happen but is
not a persistent
concern
Certain (5)
This type of event
will happen
frequently
Page 29 of 41
Appendix 5
Advice Sheet – Investigating Complaints
Please contact the Complaints Department if you require a copy of this document.
Page 30 of 41
Page 31 of 41
Appendix 6
Guidance for Managers Interviewing Staff who are involved in Complaints
1. Introduction
Some reports and statements made by staff following an incident or complaint
can be incomplete, lack key information or can be ambiguous. Good interview
techniques can often increase both the quantitative and qualitative information
gained from staff involved in incidents and complaints.
It is important for managers to interview a wide range of people present at the
time of the incident in order to create a complete picture of what actually
happened.
2. Preparing for the interview
Staff should be formally invited to attend an interview and fully briefed on the
purpose of the interview. Staff members may wish to bring someone else with
them for support (i.e. a colleague, friend or Union Representative) and this should
be fully permitted although it should be made clear that their support must not
include active participation in the interview. The main reason for this is that any
interruptions whiles the interviewee is giving their account may interfere or
significantly affect memory retrieval.
Interviews should be held in a relaxed setting, preferably away from the
immediate place of work and in a private room. It is considered good practice to
have one person undertaking the interview and one person either recording the
conversation or taking notes. This enhances the flow of the information and
allows the interviewer to give their undivided attention to the interviewee. If it is
not possible to transcribe the interview then managers may wish to consider
recording the conversation with the consent of the interviewee and then have it
transcribed at a later date.
Firstly, managers should ensure that the member of staff being interviewed has
received written information explaining why the interview has been arranged. It
should also be explained in the information that the interview is not part of a
disciplinary process but a review of the complaint / incident to identify the cause.
In order to allow the interviewee to prepare, managers should provide;
The name of the person who will be conducting the interview and their role
in the investigation
Details of the incident or complaint being reviewed
Details of what documentation will be provided before and during the
meeting
Assurances that the interview will be confidential
The approximate time or duration of the interview
Interviewees should be informed about the process of the interview and what will
happen after the interview has taken place. This should include details of when
the report will be completed and when the interviewee can expect to see the
report in its draft stages. If a transcript has been made of the interview, managers
should provide a copy to the interviewee for agreement as soon as possible to
ensure accuracy.
Page 32 of 41
3. Arranging the interview
When arranging interviews with staff who may be involved in complaints or
incidents, managers should consider the following points as examples of good
practice;
Always ensure that a private and undisturbed room is booked for the
interview.
Try to avoid holding the interview at the end of the interviewee’s shift.
Inform the interviewee’s manager, supervisor or clinical Lead that the
interview is taking place so that staff can be released and their shift
covered.
Some staff will find the process very upsetting and disturbing and may not
feel able to return to work immediately afterwards. Staff should be offered
information on how to access support services after the interview if
required.
Arrange the room in an informal way – try to avoid placing physical
barriers such as desks or tables between parties.
Ensure plenty of water is available.
Make sure that telephones are diverted and mobile phones are switched
off during the interview.
4. During the interview
At the start of the interview, the interviewers should be introduced and their roles
in the process explained, followed by an explanation of the sequence of the
interview and approximate time it will take. Managers should try to reiterate any
written information given to the interviewee prior to the interview and stress that
the process is not part of any disciplinary procedure. Always allow time for the
interviewee to ask questions.
5. Essential factors for a successful interview
Ensure that the interviewee is aware that they are in control over the process and
not the interviewer.
Always allow the interviewee to ‘tell their story’ and recall their experience without
interruption. Interruptions can reduce the interviewee’s ability to recall memories
and will lead to incomplete or inaccurate information.
Try to ask questions in the order that the incident is presented to aid memory
retrieval and improve information given.
Ensure that you share your understanding of the interviewee’s account with them
before asking any questions. This will correct any misunderstandings and will
serve as a ‘prompt’ to jog their memory about facts and important points that may
have been forgotten.
Try to avoid open-ended, rhetorical or quick-fire questions. It may be that the
interviewee gives short answers that do not fully provide the information
necessary to understand the incident.
Try to keep the discussion as open as possible and avoid making judgmental or
critical comments as this is likely to make the interviewee defensive and less
likely to present the facts.
Page 33 of 41
Appendix 7
Management of Complaints Satisfaction Questionnaire
The Trust is currently reviewing the satisfaction questionnaire.
Page 34 of 41
Appendix 8
Joint Protocol between the Trust and the Local Authority for the Management
of Complaints
1.
The Local authority Social Services and National Health Service Complaints
(England) Regulations 2009 provides a framework for NHS and Local Authority
Adult Social Care services to collaborate in handling complaints to ensure;
1.1. A single consistent and agreed contact point for complainants
1.2. Regular and effective liaison and communication between Complaints
Managers and complainants
1.3. That learning points arising from complaints covering more than one body are
identified and addressed by each organisation
2.
This form the basis of an agreed approach to handling complaints about
integrated mental health services provided by the Trust.
3.
The Trust shall endeavour to resolve complaints about Health Services and the
services through its own complaints procedures, where possible integrating its
responses with that to any linked complaints about Health Services and in
accordance with the Local Authority Social Services and National Health
Service Complaints (England) Regulations 2009 (the ‘Complaints Regulations’).
It shall publicise the existence of a complaints procedure to those who have a
right to complain and ensure that complainants who receive Mental Health
Services are informed of their right to complain to the Council under the
Complaints Regulations if they are not satisfied with the Trust’s response.
4.
If Service Users make complaints directly to the Council, the Council shall seek
to arrange for these to be dealt with in the first instance by the Trust, wherever
that is reasonable and can be agreed with the complainant.
5.
Where a complaint is formally investigated by the Council under the Complaints
Regulations, the Trust shall provide all necessary assistance with the
complaints investigation. The response to such a complaint shall be jointly
agreed between the Trust and the Council. If there is disagreement which
cannot be resolved, the complainant shall be informed of both the Council’s and
Trust’s response, and (as in all other cases) shall be notified of the right to take
the complaint to the complaints review panel arranged by the Council.
6.
The Trust will encourage service users and their carers to challenge decisions
and actions they do not understand or perhaps agree with. A process for
achieving this will be developed by the Trust.
7.
The Trust will aim to resolve complaints locally, investigating and answering as
close to where the problem occurred as possible. Where local resolution takes
place, this will be within 1 working day.
8.
In order to provide a coherent response to adult and older people receiving
integrated mental health services from the Trust;
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8.1. The Trust’s Complaints Lead will co-ordinate the consideration of all NHS and
social Care complaints issues relating to the Trust’s services, acting as the first
point of contact for staff within the Trust, customers and their carers and
complaints professionals within their organisations and ensuring appropriate
registration and monitoring of complaint investigation processes.
8.2. If the issues of complaints relate to both the Local Authority and the Trust, the
Trust’s Complaints Lead will liaise with the Local Authority’s customer Relations
Team to determine which organisation should take the lead in investigating the
complaint.
8.3. Where the Local Authority has delegated any of its social care functions relating
to adults or older people with mental health difficulties to the Trust, the Trust will
be responsible for investigating complaints about the discharge of those
functions in accordance with the above Complaints Regulations.
8.4. The Trust Complaints Lead will ensure that appropriate consideration is given
to the need of the additional advice and support for the complainant.
8.5. Where the Local Authority has retained responsibility for a social care function,
Trust’s Complaints Lead will forward the complaint to the Local Authority’s
Customer Relations Team.
8.6. All complaints about integrated services must be subject to a comprehensive
risk assessment by an appropriate Trust Manager and urgent action must be
taken to alert partners if a high risk situation is indented.
8.7. The Trust’s Complaints Lead will provide the Trust with regular information
about the complaints received within the Trust, and will share the information
with the Local Authority’s Customer Relations Team.
8.8. The Trust’s Complaints Lead will also have due regard for all relevant protocols
regarding information sharing and information governance, human resource,
performance management and disciplinary issues in the coordination of
complaints activity.
9.
If a complaint involves both NHS and Adult Social care issues, the Trust
Complaints Lead will arrange a strategy discussion with the Local Authority’s
Customer Relations Team within a target of 2 working days of receipt of a
complaint which relates wholly or partly to social care functions. Agreement will
be reached on;
Relevant complaints and / or other procedures
Investigation parameters
Extent to which social care and NHS investigation activity can be coordinated
Sharing of information relevant to the complaint
Access to interview Trust staff
How results of investigation are to be shared
Lead responsibility for co-ordination communication with complainant
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10. The Trust Complaints Lead should advise people who wish to complain about
their detention under the Mental Health Act 1983 (as amended by the 2007 Act)
of their right to appeal to the Mental Health Review Tribunal. However,
complaints about the actions of the Approved Mental Health Professional’s
actions during the process are covered by the social care complaints
procedures and the Trust’s Complaints Officer should liaise with the Local
Authority’s Customer Relations Team to pursue their complaint through the
social care procedures.
11. Upon notification of an investigation to be undertaken by any Ombudsman,
each partner shall respond to requests for information and / or interview within
time limits set by the Ombudsman and provide access to relevant records.
12. Quarterly reports regarding comments, complaints and compliments will be
provided as part of the S75 performance monitoring arrangements.
13. Where there is a finding of mal-administration by an Ombudsman in respect of
services provided by partners under this agreement after the commencement
date. Where that Ombudsman finds that the Trust’s negligence including
breach of duty (statutory or otherwise) is the cause, the Trust shall be
exclusively responsible for meeting any request for payment of compensation.
14. The partners shall review these arrangements if there are any changes to the
Complaints Regulations with the aim of moving as closely as is permitted by
guidance and regulations to a fully integrated process for handling all
complaints about services.
15. In respect of liabilities arising from any indemnity in this Agreement, the Trust
shall maintain membership of the liabilities to third parties scheme and the
clinical negligence scheme for Trusts or such other schemes as may be
operated from time to time by the National Health Services Litigation Authority
and the Council shall maintain such insurance as it considers appropriate.
16. The Partners shall co-operate with each other in the defence of any claim
arising under this Agreement using the insurance protocol agreed between
Local Authorities and NHS bodies in operating partnership agreements under
Section 75 or the 2006 Act as guidance.
17. The Partners shall be responsible for all legal liabilities to third parties arising
under this Agreement on a claims incurred basis and shall indemnify the
Council in respect of all such liabilities, costs, expenses and claims, except
where such responsibility remains with the Council under liabilities created by
statute or where the Council’s negligence including breach of duty (statutory or
otherwise) was the cause.
18. Damages, claims and liabilities shall include the obligation to pay sums
recommended by an Ombudsman or under other complaint process.
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Appendix 9
Guidance for handling Unreasonably Persistent Complainants
1. Introduction
Complainants whose behaviour is unreasonable and persistent can become a
problem of NHS staff. Handling such complainants can place a strain on time and
resources and can cause undue stress for staff who may need support in difficult
situations. NHS staff are trained to respond with patience and empathy to the
needs of all complainants but there are times when complaints have been fully
investigated and there is nothing further which can reasonably be done to assist
them to rectify a real or perceived problem.
In determining arrangements for handling such complainants staff are presented
with two key considerations. The first is to ensure that the complaints procedure
has been correctly implemented and that no material element of a complaint is
overlooked or inadequately addressed. It is important to appreciate that even
vexatious complainants may have issues which contain some genuine
substance. The need to ensure an equitable approach is crucial. The second is to
be able to identify the stage at which a complainant’s behaviour has become
unreasonable and persistent. One approach to the situation is to develop an
approved procedure which is formally incorporated into the complaints procedure.
Implementation would only occur in exceptional circumstances. Information on
the handling of unreasonable and persistent behaviour from complainants should
also be made available to the public as part of the material on the complaints
process as a whole.
2. Purpose of this Guidance
Complaints about Trust services are processed in accordance with NHS
complaints regulations. During this process, staff inevitably have contact with a
small number of complainants who absorb a disproportionate amount of NHS
resources in dealing with their complaints. The aim of this guidance is to identify
situations where the complainant may be considered unreasonable and to
suggest ways of responding to these situations.
It is emphasised that this procedure should only be used as a last resort and after
all reasonable measures have been taken to try to resolve complaints following
the NHS complaints procedures, for example through local resolution, conciliation
or involvement of the Independent Complaints Advocacy Service (ICAS) as
appropriate. Judgement, discretion and sensitivity must be used in applying the
criteria to identity potentially unreasonable and persistent complainants and in
deciding what action to be taken in specific cases. The procedure should only be
implemented following careful consideration by and with the authorisation of the
Chief Executive or deputy. Where a deputy is used, the reason for the nonavailability of the Chief Executive must be recorded on the file.
3. Definition of an unreasonable and persistent complainant
Complainants (and / or anyone acting on their behalf) may be deemed to be
unreasonable and persistent where previous or current contact with them show
that they meet ONE OR MORE of the following criteria where complainants;
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Persist in pursing a complaint where the NHS complaint procedure has
been fully and properly implemented and exhausted.
Change the substance of a complaint or continually raise new issues
or seek to prolong contact by continually raising further concerns or
questions, either upon receipt of a response or whilst the complaint is
being addressed. (Care must be taken not to discard new issues which are
significantly different from the original complaint as these might need to be
addressed as separate complaints).
Are unwilling to accept documented evidence of treatment given as
being factual or deny receipt of an adequate response in spite of
correspondence specifically answering their questions or do not accept
that facts can sometimes be difficult to verify when a long period of
time has lapsed.
Do not clearly identify the precise issues which they wish to be
investigated, despite the reasonable efforts of staff and, where
appropriate, ICAS to help them specify their concerns, and /or where the
concerns identified are not within the remit of the Trust to investigate.
Focus on a trivial matter to an extent which is out of proportion to its
significance and continue to focus on this point. It is recognised that
determining what is a ‘trivial’ matter is can be subjective and careful
judgement must be used in applying this criteria.
Have threatened or used actual physical violence towards staff or their
families or associates at any time – this will in itself cause personal contact
with the complainant and / or their representatives to be discontinued and
the complaint, will thereafter, only be pursued through written
communication. All such incidents should be documented.
Have, in the course of addressing a registered complaint, had an
excessive number of contacts with the Trust, placing unreasonable
demands on staff. A contact may be by telephone, letter or fax. Discretion
must be used in determining the precise number of ‘excessive contacts’
applicable under this section, using judgement based on the specific
circumstances of each individual case.
Have harassed or been personally abusive or verbally aggressive on
more than one occasion towards staff dealing with their complaint of their
families or associated. Staff must recognise that complainants may
sometimes act out of character at time of stress, anxiety or distress and
should make reasonable allowances for this. They should document all
incidents of harassment. Clinical guidance should also be sought where
clarification is needed on this.
Are known to have electronically recorded meetings or face to face /
telephone conversations without prior knowledge and consent of other
parties involved.
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Display unreasonable demands or expectations, and fail to accept
that these may be unreasonable (e.g. insist on responses to enquiries
being provided more urgently than is reasonable or recognised practice or
that which has been set out in the national guidance on complaints
handling).
4. Options for dealing with unreasonable and persistent complainants
Where complainants have been identified as unreasonable and persistent in
accordance with the above criteria, the Chief Executive (or appropriate deputy)
will determine what action to take. The Chief Executive (or deputy) will implement
such action and will notify the complainants in writing of the reason why they
have been classified as unreasonable and persistent complainants and the action
to be taken. This notification may be copied for the information of others already
involved in the complainant, e.g. practitioners, conciliators, ICAS, Member of
Parliament. A record must be kept for future reference of the reasons why a
complainant has been classified as vexatious.
The Chief Executive or Deputy may decide to deal with complainants in one or
more of the following ways:
Try to resolve matters before invoking this procedure by drawing up a
‘signed agreement’ with the complainant (and if appropriate involving the
relevant practitioner in a two way agreement) which sets out a code of
behaviour for the parties involved if the Trust is to continue processing the
complaint. If these terms are contravened consideration would then be
given to implementing other actions such as indicated in this section
Write to inform them that they must be classified as an unreasonable and
persistent complainant, copy this procedure to them and advise them to
take account of the criteria in any further dealings with the Trust. In some
cases it may be appropriate at this point, to copy this notification to others
involved in the complaint and to suggest that complainants seek advice in
processing their complaints e.g. through ICAS
Inform the complainant of the form of contact which will be maintained, be
it in person, by telephone, by fax, letter or any combination of these.
Alternatively, to restrict contact liaison through a third party. If staff are to
withdraw from a telephone conversation with a complainant it may be
helpful for them to have an agreed statement available to be used at such
times.
Notify the complainant in writing that the Chief Executive has responded
fully to the points raised and has tried to resolve the complaint but there is
nothing more to add and continuing contact on the matter will serve no
useful purpose.
The complainants should also be notified that the correspondence is at an
end and that further letters received will be acknowledged but not
answered.
Inform the complainant that in extreme circumstances the Trust reserves
the right to pass unreasonable and persistent complainants to its solicitors.
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Temporarily suspend all contact with the complainant or investigation of a
complaint whilst seeking legal advice or guidance from the Parliamentary
Health Service Ombudsman or other relevant agencies.
5. Withdrawing ‘unreasonable and persistent complainant’ status
Once complainants have been determined as unreasonable and persistent there
must be a mechanism for reviewing this status at a later date. If, for example,
complainants subsequently demonstrate a more reasonable approach, or if they
submit a further complaint for which normal complaints procedures would appear
appropriate. Staff should previously have used discretion in recommending the
use of this guidance at the outset and discretion should similarly be used in
recommending that the status be withdrawn when appropriate. Where this
appears to be the case, discussion will be held with the Chief executive or their
deputy. Subject to their approval, normal contact with the complainants and
application of the NHS complaints procedures will then be resumed. The
complainant will be informed in writing of the lifting of this status.
However, an unreasonable and persistent complainant should not be denied the
opportunity to raise new issues and all vexatious complaints should have their
status reviewed annually.
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