Policy for the Management, Investigation and Resolution of Complaints
Version / 3.01
Date / 16 September 2009
Review Date / 1 September 2011
Author / Customer Care Manager
Change Approver / Integrated Risk Sub-Committee
CHANGE CONTROL SHEET
This is a Controlled Document. The definitive version is on the intranet. Printed versions should be verified as valid with the intranet version.
POLICY DEVELOPMENT TEAMNameJob Title
J Holt / Nursing DirectorK Gilbey / Deputy Nursing Director
A M Peil / Customer Care Manager
Integrated Risk Sub Committee Members / All Divisions represented
AMENDMENT HISTORY
Revision No. / Date of Issue / Page/Section Changed / Description of Change / Review Date
V1.01 / 1/10/2004 / All / To reflect 2004 regulations / 1/11/2007
V2.01 / 1/11/2007 / All / Review of policy to reflect statutory regulations 2006 and changes to Trust’s internal structure. Pre-format to standardised Trust policy document style. / 01/11/2008
V3.01 / 16/09/2009 / All / To reflect 2009 Regulations / 1/09/2011
DISTRIBUTION PLAN
Dissemination lead: / Customer Care ManagerPrevious document already being used? / Yes
(Please delete as appropriate)
If yes, in what format and where? / Electronic - Trust Intranet
Proposed action to retrieve out-of-date copies of the document: / Substitution of document on intranet
To be disseminated to:
Chairpersons of approving committees, sub-committees or groups / Integrated Risk sub-committee
Divisional and Department Heads / All
Proposed actions to communicate the document contents to staff: / Include in the UHMB Weekly News policy page
DISTRIBUTION RECORD – to be completed following document approval
Date put on register of procedural documentsDisseminated to: (either directly or via meetings, etc) / Format (i.e. paper or electronic) / Date Disseminated / No. of Copies Sent / Contact Details / Comments
TRAINING IMPLICATIONS
Is training required to be given due to the introduction of this policy? / Yes(Please delete as appropriate)
If yes, describe arrangements / Consultants and front line staff to receive advisory written information.Junior doctors trained at induction and via Foundation Programme. Ward Managers, Matrons, Heads of Departments to attend session with Customer Care Staff.
EQUALITY & DIVERSITY IMPACT ASSESSMENT TOOL
Yes/No / Comments1. / Does the policy/guidance affect one group less or more favourably than another on the basis of:
- Race
- Ethnic origins (including gypsies and travellers)
- Nationality
- Gender
- Culture
- Religion or belief
- Sexual orientation including lesbian, gay and bisexual people
- Age
- Disability - learning disabilities, physical disability, sensory impairment and mental health problems
2. / Is there any evidence that some groups are affected differently? / No
3. / If you have identified potential discrimination are there any exceptions - valid, legal and/or justifiable? / N/A
4. / Is the impact of the policy/guidance likely to be negative? / No
4a / If so can the impact be avoided? / N/A
4b / What alternative are there to achieving the policy/guidance without the impact? / N/A
4c / Can we reduce the impact by taking different action? / N/A
If you have identified a potential discriminatory impact of this procedural document, please refer it to the HR Equality & Diversity Specialist, together with any suggestions as to the action required to avoid/reduce this impact.
For advice in respect of answering the above questions, please contact the HR Equality & Diversity Specialist, Extension 6242.
Policy for the Management, Investigation and Resolution of Complaints / Page 1 of 27Valid to 31/08/2011
Copyright © 2006 University Hospitals of MorecambeBay NHS Trust
University Hospitals of MorecambeBay NHS Trust
REFERENCES (Include references to all relevant Trust Policies and Guidelines)
Number / References
1 / The Local Authority Social Services and National Health Services Complaints (England) Regulations 2009 (309)
2 / Principles of Good Complaints Handling Parliamentary and Health Service Ombudsman 2009
3 / Making amends: a consultation paper setting out proposals for reforming the approach to clinical negligence in the NHS Department of Health 2003
4 / Being Open Policy. National Patient Safety Agency May 2004
5 / Records Management NHS Code of Practice Department of Health 2009
6 / The Health & Social Care (Community Health and Standards) Act 2003
7 / Patient Safety Incident Investigation Policy
8 / Freedom of Information Policy
9 / Being Open Policy
10 / Analysis of Claims, Complaints and Incidents Policy
11 / Claims Policy
12 / Supporting Staff following traumatic or stressful incidents policy
13 / Whistle Blowing Policy
GLOSSARY
Abbreviation / Definition
PALS / Patient Advice and Liaison Service
ICAS / Independent Complaints Advocacy Service
UHMBT / The University Hospitals of MorecambeBay NHS Trust
KPI / Key Performance Indicator
CPCT / Cumbria Primary Care Trust
NLPCT / North Lancashire Primary Care Trust
PHSO / Parliamentary & Health Service Ombudsman
Contents
PageTitle / 1
Change Control / 2
Policy Development Team / 2
Amendment History / 2
Distribution Plan / 3
Distribution Record / 3
Training Implications / 3
Equality & Diversity Impact Assessment / 4
References / 5
Glossary and Definitions / 5
Contents / 6
1 / Introduction / 7
2 / Policy statement / 7
3 / Roles and Responsibilities / 7
4 / Complaints and Being Open / 9
5 / Supporting staff involved in complaints / 9
6 / Preventing Discrimination / 9
7 / Exclusion Criteria / 10
8 / Complaints and Coroners’ Investigations / 11
9 / Raising Concerns / 11
10 / Communication and Publicity / 12
11 / Complaints Management Process / 12
12 / Ombudsman / 15
13 / Service Improvement / 16
14 / Analysis and Reporting / 16
15 / Monitoring Compliance / 16
16 / Training / 17
17 / Whistle Blowing / 17
Appendix 1 / Complaints process (Summary) / 18
Appendix 2 / Complaints process flowchart / 19
Appendix 3 / Assessment and risk rating / 20
Appendix 4 / Vexatious and persistent complaints / 25
1. INTRODUCTION
Complaints are a means of identifying the users’ perspective of the service we provide. They can act as an early indicator of problems within a system and trend analysis of the factors causing the complaint can help to identify areas where improvements may be necessary. An important element of governance is to detect, analyse and learn from patients’ experiences, including adverse events and symptom failures.
A complaint is any expression of dissatisfaction with the services, care or facilities provided by the Trust that requires a response.
In line with the Principles of Good Complaint Handling published by the Parliamentary and Health Service Ombudsman (PHSO) the Trust aims to:
- Get it right
- Be customer focused
- Be open and accountable
- To act fairly and proportionately
- To put things right
- Seek continuous improvement
Every effort should be made to resolve complaints as they arise, particularly those involving relatively minor criticisms. Comments, queries, concerns and suggestions are not complaints but staff should endeavour to respond to these promptly and to give appropriate advice and information in order to prevent them escalating and becoming complaints.
2.POLICY STATEMENT
All appropriate complainants will be able to access the Trust’s Complaints Procedure and will be treated sympathetically and with respect throughout the process. Their concerns will be investigated in line with the requirements of the statutory regulations and a detailed written response will be provided to them as promptly as possible. The Trust will identify necessary service improvements arising from complaints and will implement change in relation to these. Neither complainants nor patients will be discriminated against as a result of having made a complaint.
3.ROLES AND RESPONSIBILITIES
This section outlines the roles and responsibilities of individual postholders in relation to the investigation of complaints.
3.1The Chief Executive is responsible for signing off the complaint response. On occasions where he is not available to do so another member of the executive team will sign the response on his behalf. The Chief Executive has overall accountability for ensuring compliance with the Statutory Regulations and that appropriate action is taken at the conclusion of a complaint investigation.
3.2Executive Directors are responsible for deciding whether or not it is appropriate to inform the police, and at what stage, if it is reported to them that a complaint alleges, or it becomes apparent during the investigation, that a criminal offence may have been committed.
3.3The Director of Nursing and Modernisation oversees the complaints management process.
3.4The Customer Care Manager is the Trust’s Complaints Manager and is responsible for the management of all complaints received by the Trust, in accordance with the Regulations.
Where is it apparent, either on receipt of a complaint or during the investigation that a serious untoward incident has, or may have, occurred the Customer Care Manager ensures that it is reported to the Risk Manager or Health & Safety Manager as appropriate.
Should it be alleged, or become apparent, during the complaint investigation that a criminal offence may have been committed, the Customer Care Manager will report this immediately to the Director of Nursing and Modernisation or another Executive Director.
If the Customer Care Manager becomes aware during any complaint investigation that patients or complainants are being discriminated against the Customer Care Manager will take appropriate action to ensure that the discrimination is addressed immediately and that this is taken up with staff members involved via relevant procedures.
3.5Case Officers are responsible for co-ordinating the investigation of complaints within their designated specialties. They will arrange for the complaint to be investigated, draft complaint response letters, arrange and attend local resolution meetings and provide information to the Customer Care Manager in relation to the Independent Review of complaints. Should Case Officers become aware, on receipt of a complaint, or during an investigation, that a serious untoward incidence or criminal offence has or may have occurred they must immediately report it to the Customer Care Manager.
Case Officers should work closely with the Divisional Management Teams to which they are aligned, particularly in relation to the implementation of service improvements identified as necessary at the conclusion of complaint investigations.
3.6Divisional Management teams will be copied in on complaints received and on requests for information made by Case Officers. It is expected that the members of the Divisional Management team will advise the Case Officer if they have relevant information relating to the complaint or if they believe that the Case Officer should be seeking additional information from personnel other than those approached.
The Divisional Management team are responsible for ensuring that necessary service improvements identified as a result of a complaint investigation are implemented and will work closely with the designated divisional complaint officer(s) to implement action plans.
Divisional Management teams will receive regular reports from the Customer Care Department detailing complaints received during a specific period and incorporating information in relation to cause of complaint, location, staff groups involved, target response date etc.,
3.7Consultants, matrons and specialty leads are responsible for investigating those elements of the complaints relating to them and their staff and for providing the Case Officer with appropriate statements, overviews and action plans within specified time frames.
3.8Every member of staff has a responsibility for prompt and effective resolution of complaints within their area as they arise. All staff also have a responsibility to provide any information reasonably requested from them during the investigation of a complaint.
All staff must be aware of the Patient Advice & Liaison Service (PALS) and their role in helping to resolve concerns quickly. Contact details are available on the PALS leaflet and on the Compliments, Comments and Complaints leaflet.
4.COMPLAINTS AND BEING OPEN
In 2003, the Department of Health published a consultation document “Making Amends”. The document detailed the need to communicate well with patients and relatives when a moderate to severe incident had occurred or if something had gone wrong with their care.
UHMBT aims to provide all complainants with an honest, open response to the concerns which they raise. It is common practice for complainants to be offered local resolution meetings to discuss their concerns or any unresolved issues as appropriate and for a record of such meetings to be written up and provided to the complainant.
While a complaint identifies a serious patient safety incident or it is considered by the Customer Care Manager to highlight serious concerns in relation to the care received, UHMBT’s “Being Open” policy will be invoked.
5.SUPPORTING STAFF INVOLVED IN COMPLAINTS
UHMBT recognises that staff whose actions are the subject of a complaint may be upset and distressed and require support during the process. Details of the way in which this support is provided are available in UHMBT’s policy for supporting staff involved in traumatic or stressful incidents.
NHS staff may complain about the way they have been dealt with under the Complaints Procedure via UHMBT’s grievance procedure.
6.PREVENTION OF DISCRIMINATION AS A RESULT OF COMPLAINTS
UHMBT expects all staff to treat patients and complainants with respect at all times and will not tolerate discrimination against them as a result of a complaint being made. During any complaint investigation, if it becomes apparent that patients or complainants may be being discriminated against, the Customer Care Manager will take appropriate action to ensure that the discrimination is addressed and appropriate action taken in relation to the staff members involved.
All staff should be aware that documentation relating to complaints should not be filed in patients’ case notes as this causes concern that it may give rise to future discrimination. Medical Secretaries should maintain a separate folder for complaints as Consultants will require the information annually when undergoing appraisal.
7.EXCLUSION CRITERIA
7.1Under section 8 a – h of the legislation the following complaints are not required to be dealt with:
i)complaint made by a responsible body
ii)complaint made by an employee of a local authority or NHS body about any matter relating to that employment
iii)complaint which is made orally and is resolved to the complainant’s satisfaction not later than the next working day after the day on which the complaint was made
iv)a complaint the subject matter of which is the same as that of a complaint that has previously been made and resolved in accordance with sub-paragraph c
v)a complaint the subject matter of which has previously been investigated under these regulations; the 2004 regulations; the 2006 regulations; or a relevant complaints procedure in relation to a complaint made under such a procedure before 1 April 2009
vi)a complaint the subject matter of which is being or has been investigated by a local commissioner under the Local Government Action 197(a) or a health service commissioner under the 1993 Act
vii)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 (b)
viii)a complaint which relates to any scheme established under section 10 (superannuation of persons engaged in health services etc) or section 24 (compensation for loss of office etc,) of the Superannuation Act 1972 © or to the administration of those schemes.
7.1.2Data Protection
If complaints received allege a breach or suspected breach of the Data Protection Act 1998, the Customer Care Manager should inform the Trust’s Data Protection Manager.
Complaints are recorded on the Trust’s Risk Management database and associated documents are scanned and attached to the electronic file.
Hard copy files containing the original documentation will be retained for 8 years from the date of closure. The archive is reviewed annually and files closed more than 8 years previously are destroyed in accordance with the Trust’s arrangements for confidential waste.
7.1.3Complaints which may lead to Litigation or Criminal Proceedings
When legal action is being pursued at the same time that a complaint relating to the same matter is made, or when an investigation is ongoing into a criminal offence, the Trust should consult with its legal advisors and/or the Police in order to determine whether progressing with the complaint might prejudice subsequent legal or judicial action. If this is deemed to be the case the Trust will notify the complainant, in writing, that further investigation is not possible.
8.COMPLAINTS WHERE A PATIENT’S DEATH HAS BEEN REFERRED TO THE CORONER.
The fact that a death has been referred to the Coroner does not mean that investigations into any complaint about the patient’s care should be suspended. Appropriate investigations should be undertaken, regardless of the Coroner’s enquiries, but it is advisable to notify the Head of Legal Services, who is the Coroner’s point of contact with UHMBT, and that she is kept informed of the progress of the complaint investigation.
9.RAISING CONCERNS
9.1Informal Concerns
9.1.1Minor criticisms can often be addressed immediately. Concerns raised should be listened to sympathetically and it is frequently possible for the member of staff to whom these are expressed, or the person in charge at the time, to provide an acceptable answer or explanation.
All staff should be aware of the correct procedure to follow should a patient or relative wish to make a complaint. A flow-chart for ease of reference is available (see Appendix 1).
Where the matter is resolved, staff should make a record of the concerns, the outcome and any action taken on a verbal complaint form.
9.1.2Staff should complete a verbal complaint form giving details of the complaint and the top copy should be sent to the Customer Care Department.
9.1.3If staff require support in order to resolve an informal complaint they should contact the ward or department manager, the appropriate Matron or the PALS service.
9.1.4PALS
When patients and/or their relatives and friends request support to help them raise concerns they should be advised to contact PALS who can help resolve issues quickly. All wards and departments should have PALS leaflets and contact details available.
9.1.5Formal Complaints
A complainant whose concerns cannot be resolved verbally and/or
who wishes to make a formal complaint should be advised to write to the Chief Executive. Information is available in the “Compliments, Concerns and Complaints” leaflet. If a complainant is unable or unwilling to put their concerns in writing the person to whom the complaint is made should do so on their behalf and have the document signed by the complainant to confirm the content and sign it themselves. The document should then be forwarded to the Customer Care Team.
9.1.6Out of Hours Arrangements
If concerns are raised out of hours and the staff are unable to resolve them, or the matter is considered serious, then the senior manager on-call should be informed via the switchboard operator. Details should be accurately recorded and the Customer Care Manager should be informed of the matter on the next working day.