Complaints and Concerns Policy and Procedure v10.0
Complaints and Concerns
Policy and Procedure v10.0
Policy Statement: This policy and procedure sets out the way in which complaints and concerns will be handled by Heart of England NHS Foundation Trust. It is based on the the recommendations within national recommendations and key advisory documents. It includes guidance on how to manage complaints that may be termed vexatious.
Original Policy: October 2001
This Revision: January 2016
Review Date: January 2017
Document Title: / Complaints and Concerns Policy & Procedure v10.0Status / Live
Document Author: / Patient Services Manager and Interim Deputy Director of Patient Experience
Accountable Director: / Chief Nurse
Source Directorate: / Corporate Nursing
Date created: / October 2001
Date revised: / October 2015
Ratification date: / January 2016
Ratified by: / Trust Board
Date Of Release: / 31st January 2016
Review Date: / January 2017
Related documents / Access to Health Records Policy
Being Open
Clinical Claims Management Policy
Confidentiality Policy
Consent Policy
Data Protection Policy
Disciplinary Policy
Duty of Candour
Freedom of Information
Health and Safety Policy
Incident Reporting Policy
Information Governance
Non-clinical Claims Policy
Risk Management Policy
Risk Management Strategy
Safeguarding Policies
Whistle Blowing Policy
Superseded documents / Customer Relations and Complaints Policy and Procedure V9.0 (2001, revised 2012)
GP Complaints Procedure 2005
Relevant External Standards/ Legislation / · National Health Service Complaints (England) Regulations 2009
· Care Quality Commission Regulation 16: receiving and acting on complaints
· The Report of Mid Staffordshire NHS Foundation Trust Public Inquiry 2013
· Review of NHS Hospitals Complaints Systems, Clwyd & Hart 2013
· Good Practice Standards for NHS Complaints Handling, Patients Association 2013
· Principles of Good Complaint Handling, Parliamentary and Health Service Ombudsman 2009
· NHS England: Assurance of Good Complaint Handling for Acute and Community care 2015
· PHSO: A review into the quality of NHS complaints investigations
Stored Centrally: / SharePoint
Key Words / Complaints, Concerns
Table of Contents
Complaints Policy
1. Circulation ………………………………………………………………………………………. Page 4
2. Scope ……………………………………………………………………………………………. Page 4
3. Aims and Objectives …………………………………………………………………………… Page 4
4. Definitions of a Complaint or Concern.………………………………………………………. Page 4
5. Standards ……………………………………………………………………………………….. Page 5
6. Who can make a complaint?...... Page 5
7. Time scales for making a complaint …………………………………………………………. Page 5
8. Complaints not required to be dealt with under the NHS Complaints Regulations 2009. Page 6
9. Multi-agency & mixed sector complaints …………………………………………………….. Page 6
10. Serious Incidents (S I), Being Open and Duty of Candour ………………………………… Page 7
11. Trust Approach to Complaints Management ………………………………………………… Page 7
12. Responsibility for Complaints Management within the Trust ………………………………. Page 8
13. Training ………………………………………………………………………………………….. Page 12
14. Record Keeping ………………………………………………………………………………… Page 12
15. Monitoring and Compliance …………………………………………………………………… Page 13
16. Reporting ………………………………………………………………………………………… Page 14
17. Analysis ………………………………………………………………………………………….. Page 15
18. Improvement …………………………………………………………………………………….. Page 15
Complaints Procedure ……………………………………………………………………………..
Appendix 1: Complaints process and Escalation (a-c)…………………………………………… Page 16
Appendix 2: Procedure for handling unreasonable, persistent complainants (vexatious) …… Page 20
Appendix 3: Guidance for meetings with complainants …………………………………………. Page 24
Appendix 4: QA Checklist …………………………………………………………………………… Page 26
Appendix 5: Acknowledgement ……………………………………………………………………. Page 27
Appendix 6: CEO response letter ………………………………………………………………….. Page 39
Appendix 7: CEO response letter following complaint after bereavement of a patient ……….. Page 31
Appendix 8: Consent – single person ……………………………………………………………… Page 33
Appendix 9: Consent – NOK / POA / EOW………………………………………………………… Page 35
Appendix 10: Complaint Management Plan………………………………………………………… Page 36
Appendix 11: Guidance for Staff in Preparing Statements for Complaints Responses ………. Page 41
Appendix 12: Complaints not dealt with under NHS Complaints Regulations 2009 ………….. Page 44
Appendix 13: PALS/Patient Services Guide to Handling concerns …………………………… Page 45
Appendix 14: NPSA Risk Matrix Model …………………………………………………………… Page 46
Appendix 15: Equality and Diversity Checklist ……………………………………………………. Page 50
SECTION ONE: TRUST POLICY
1. Circulation
This Policy should be read by all staff and applies equally to staff in a permanent, temporary, voluntary or contractor role acting for or on behalf of Heart of England NHS Foundation Trust (HEFT).
2. Scope
This policy applies to the management of all complaints and concerns made about the services provided by HEFT.
3. Aims and Objectives
This policy and procedure is based on the model of the NHS Complaints Regulations 2009 and Principles of Good Complaint Handling released by the Parliamentary and Health Service Ombudsman (PHSO).
The aim of this policy is to provide all those involved in the complaints process with a clear understanding of the Trust’s expectations and requirements. The policy is based on legislation, best practice and guidance from national bodies and helps ensure that:
· There is an early distinction made between complaints and concerns
· Complaints are dealt with efficiently and to a high standard
· Complaints are investigated thoroughly
· Complainants are treated with respect and courtesy
· Complainants are provided with
o advice to understand the complaints procedure
o advice on where assistance may be obtained
· Complainants are responded to timely and appropriately as agreed with the complainant
· Complainants are told of the outcome of the investigation
· Minimise the recurrence of mistakes through learning lessons
· Action is taken if necessary in light of the outcome of a complaint
· Trust staff are appropriately supported through the complaints process.
The policy also contains guidance on the assessment and management of complaints that may be termed vexatious.
4. Definitions
A complaint or concern can be defined as: “an expression of dissatisfaction about an act, omission or decision, either verbal or written, and whether justified or not, which requires a response and/or redress.”
Use of the word “complaint” should not automatically mean that someone expressing concern enters the complaints process. It may be more appropriate for a “complaint” to be dealt with and resolved in a more immediate and timely manner and as long as this is done with the agreement of the person raising the concern and the outcome is to their satisfaction then this approach would be deemed appropriate and, in many cases, preferable.
The Patient Services team provides support for concerns and complaints raised.
A complaint may be made orally or in writing (letter, email or complaints inbox) and the procedure is set out in this policy detailing how each type of complaint should be dealt with (Attachment 1).
Complaints may be made to any department within the organisation and irrespective of the route are to be managed in line with this policy. This includes complaints addressed to the Chief Executive Officer.
Complaints received from General Practitioners (GP) are managed in line with this policy. This policy replaces the ‘GP Complaints Procedure 2005’.
5. Standards
The PHSO’s Principles of Good Complaint Handling will be used by the Trust as the standards to be observed in the handling of all complaints; they are summarised as follows and can be found in detail at attachment 1 to this policy:
· Getting it right
· Being patient focused
· Being open, honest and accountable
· Acting fairly and proportionately
· Putting things right
· Seeking continuous improvement
The Trust recognises that patients and their relatives have a fundamental right to raise concerns about the services they receive. Accordingly it is expected that staff will not treat patients or their relatives unfairly as a result of any complaint or concern raised by them. Any complaints, by patients or their relatives, of unfair treatment as a result of having made a complaint will be investigated as a separate complaint and appropriate action will be taken.
6. Who can make a complaint?
- The patient themselves
- A relative/friend on behalf of the patient if the patient is:
- Is under 16 years of age
- Has died
- Has mental or physical incapacity
- Has given consent for someone to act on their behalf
- Persons with Power of Lasting Attorney
- A member of Parliament
7. Time scales for making a complaint
A complaint must be made no later than 12 months after:-
· the date on which the matter which is the subject of the complaint occurred; or
· If later, the date on which the matter which is the subject of the complaint came to the notice of the complainant.
This time limit will not apply if the Trust can be reasonably satisfied that:
· the complainant had good reasons for not making the complaint within that time limit; and
· notwithstanding the delay, it is still possible to investigate the complaint effectively and fairly.
The decision to investigate complaints made outside the 12 month timeframe is the responsibility of the Deputy Director of Patient Experience; taking advice from relevant clinicians, Patient Services team members and Executive Directors. The Deputy Director of Patient Experience may seek guidance from the Chief Nurse and/or Medical Director in support of a decision. The decision must be noted on Datix and a written response provided to the complainant.
8. Complaints not required to be dealt with under the NHS Complaints Regulations 2009
The Trust is not required to deal with some types of complaints under the NHS Complaints Regulations 2009, in particular:
· a complaint by a responsible body (that is a local authority, NHS body, primary care provider or independent provider);
· a complaint by an employee of a local authority or NHS body about any matter relating to that employment;
· a complaint which is resolved to the complainant’s satisfaction within 24 hours Monday to Friday;
· a complaint previously investigated by the Trust or provider under current or the previous NHS Complaints Procedures;
· a complaint, the subject matter of which has been or is being investigated by a Health Service Commissioner under the 1993 Act (the PHSO is empowered by the Health Service Commissioners Act 1993 to investigate complaints about the NHS in England);
· a complaint arising out of the alleged failure by a responsible body to comply with a request for information under the Freedom of Information Act 2000; and
· A complainant has stated in writing the intent to take legal proceedings in relation to the substance of the complaint where it will prejudice the proceedings.
Where the Trust receives a complaint that falls into one of the above categories then a written reply should be sent to the complainant explaining why the issues they have raised will either not be dealt with or will be dealt with outside of the NHS Complaints Regulations.
During the complaints process Trust staff may have contact with a small number of complainants who require a disproportionate and unreasonable amount of NHS resources in dealing with their complaints. For guidance please review Appendix 1, Procedure for handling unreasonable, persistent complainants (vexatious). This identifies situations where a complaint might be considered to be unreasonable in their behavior (also referred to as vexatious), provide guidance on how to assess and manage such complaints and where to seek support in the management of such situations.
Complaints should only be termed unreasonable (vexatious) as a last resort and after all reasonable measures have been taken to try to resolve the complaint by local resolution. Judgment and discretion must be used in applying the criteria to identify potential vexatious complaints action taken should be on a case by case basis. The policy should be implemented following careful consideration by, and with the authorisation of, the Chief Nurse or their nominated deputy.
9. Multi agency & mixed sector complaints
In cases where a complaint is received which also concerns services provided by another organisation, agency or provider, the Patient Services Team will seek consent to forward any correspondence / information received to the other relevant organisation(s). The Patient Services Team will be responsible for facilitating an appropriate response to this type of complaint. The Directorate team responsible for handling the complaint will work to:
· Agree a lead organisation.
· agree who will answer which parts of the complaint
· agree who will be the central contact point for the complainant
Every effort should be made to resolve the complaint in a cooperative manner, with a coordinated response sent to the complainant unless specifically requested otherwise. Time limits for responding to multi-agency complaints will be agreed on an individual, case-by-case basis with the complainant and other organisations involved. Trust staff have a duty to cooperate in this situation.
10. Serious Incidents (SI), Being Open and Duty of Candour
A number of complaints will be identified and investigated as a part of the Trusts’ SI process. This will be decided on a case by case basis in agreement with the Senior Patient Services Manager and the Head of Investigations and Legal.
On occasion the process of Root Cause Analysis (RCA) and investigation may highlight that a complaint may be deemed a serious incident. The complaints investigator/patient services staff will liaise with the Safety and Governance department to instigate the SI process.
Staff should consider their responsibilities under Duty of Candour and Being Open when managing complaints and concerns.
11. Trust Approach to Complaints Management
The Trust will follow the national 2 stage process in dealing with complaints, that is:
Stage 1 – Trust resolution
This involves working with the complainant to understand and resolve their concerns in a timely and appropriate fashion.
Direct contact with the complainant at this stage to discuss issues and negotiate timescale for response is encouraged by the Parliamentary Health Service Ombudsman (PHSO) and should be undertaken for all complaints. This should be carried out within 24 hours (Monday – Friday) of the complaint being received by the Patient Services Team. Where the issues are unclear or it is very obvious that a reasonable complaint response time cannot be met then the Directorate/Department lead with support from Patient Services Team should automatically contact the complainant.
A pre investigation contact/conversation with the complainant is recommended and may help Trust staff to understand the real issues behind the complaint. All contact, discussion and agreement must be documented or recorded.