Policy and Procedure for The

Policy and Procedure for the

Management of Complaints

CLS

Version 3

POLICY AND PROCEDURE FOR

THE MANAGEMENT OF COMPLAINTS

SUMMARY POINTS (MAX 5 KEY POINTS)
This procedure policy
·  gives guidance on how to investigate complaints
·  identifies key roles and responsibilities
·  identifies the objectives for handling complaints
·  ensures that the Trust is compliant with the Statutory Instrument and Regulations for the handling of complaints
DOCUMENT DETAIL
Author: /

Carrie Stone

Job Title: / Legal Services Manager
Signed: /
Date: /

1 May 2009

Version No:
(Author Allocated) / 3
Document Reference No:
(Allocate from Directorate Policy Register)
Next Review Date: / 1 May 2012

Approving Body/Committee:

/ Board of Directors
Chair: / P Harvey

Signed:

Date Approved:

/ 27 May 2009
Target Audience: / All Staff
Date Equality Impact Assessment Complete: / May 2009
DOCUMENT HISTORY
Date of Issue / Version No. / Next Review Date / Date Approved / Director Responsible for Change / Nature of Change
July 2006 / 1 / July 2008 / July 2006 / Dr R Packham / Minor
July 2008 / 2 / July 2011 / Sept 2008 / Mr R Talbot / Minor amendment
May 2009 / 3 / May 2012 / May 2009 / Mr R Talbot / Re-write

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April 2009 Author: Carrie Stone

Policy and Procedure for the

Management of Complaints

CLS

Version 3

TABLE OF CONTENTS
1 / RELEVANT TO…………………………………………...………………………..… / 5
2 / PURPOSE………………………………………………...………………………….. / 5
3 / DEFINITIONS………………………………………………………………………… / 6
4 / DOCUMENT DEVELOPMENT……………………………………...……………... / 6
5 / WHO MAY COMPLAIN ……………………………………………...……………... / 6
6 / INDEPENDENT MENTAL CAPACITY ADVOCATES…...………………………. / 7
7 / ROLES AND RESPONSIBILITIES………………………………………………… / 7
8 / TIME LIMITS…………………………………………………………………………. / 9
9 / COMPLAINTS AND DISCIPLINARY PROCEDURES…………………………... / 10
10 / POSSIBLE CLAIMS FOR NEGLIGENCE………………………………………… / 10
11 / PROCEDURES……………………………...………………………………………. / 10
12 / VEXATIOUS COMPLAINANTS ……...……………………………………………. / 15
13 / COMPLAINTS RECORDING AND COMPUTER HELD RECORDS…………... / 15
14 / REPORTING AND MONITORING ………...…………………………………….. / 15
15 / DISSEMINATION …………………………………………………………………… / 17
16 / EQUALITY IMPACT ASSESSMENT……………………………………………… / 17
17 REVIEW/REVISION ARRANGEMENTS INCLUDING VERSION CONTROL / 18

18 REFERENCES…………………………………………………………………… 18

APPENDICIES:

APPENDIX A GRADING OF COMPLAINTS

APPENDIX B HOW TO HANDLE A COMPLAINT/CONCERN

APPENDIX C LETTERS OF ACKNOWLEDGMENT FROM CEO/PLM

APPENDIX D WRITTEN AUTHORITY

APPENDIX E LETTER INITIATING INVESTIGATION

APPENDIX F GUIDANCE FOR INVESTIGATION OF CLAIMS, COMPLAINTS AND UNTOWARD INCIDENTS

APPENDIX G CHECKLIST

APPENDIX H FLOW CHART FOR HANDLING OF JOINT

ORGANISATION COMPLAINTS

APPENDIX I HOLDING LETTER

APPENDIX J REMINDER LETTER

APPENDIX K LOCAL RESOLUTION PROCESS

APPENDIX L VEXATIOUS COMPLAINANT PROCEDURE

APPENDIX M KEY STAKEHOLDERS

APPENDIX N GUIDANCE ON WRITING STATEMENTS AND REPORTS

APPENDIX O EQUALITY IMPACT ASSESSMENT TOOL

1 RELEVANT TO

All Staff.

2 PURPOSE

2.1 Complaints provide a valuable insight into patients’ experiences of health services and how these services can improve. They provide the Trust with the opportunity to learn and change practice. The competent and consistent management of complaints can assist in reducing the number of disputes leading to litigation, encouraging a culture of openness between complainants and those complained against.

2.2  All complaints received by the Trust, relating to the services it provides, will be managed in accordance with the SI 2009 No 309 “NHS England, Social Care, England The Local Authority Social Services and NHS Complaints (England) Regulations 2009”.which provide the statutory framework of the complaints procedure. Note is also made of the following: “Health and Social Care (Community Health & Standards) Act 2003”. Explanatory Memorandum to the NHS England, Social Care, England The Local Authority Social Services and NHS Complaints (England) Regulations 2009 No 309, “The NHS Constitution”, DOH “Listening, Responding, Improving” and “Principles of Good Complaints Handling” – Parliamentary and Health Service Ombudsman.

2.3 To provide a flexible approach towards handling individual complaints, which focuses on the needs and wishes of the people involved;

To provide the fullest possible opportunity for the investigation and local resolution of the complaint as quickly as is appropriate to the circumstances;

To provide a co-ordinated handling of cross boundary complaints

To learn and change to improve services.

2.4 Investigations will be objective, impartial and open in accordance with the “Principles of Good Complaints Handing – Parliamentary and Health Service Ombudsman” and the Being Open Policy. Investigations will provide an explanation, an apology where appropriate, a description of lessons learned and the identification of guidance/policy/systems requiring review and/or amendment. This will enable the Trust to:

● Handle complaints objectively, consistently and fairly

● Bring complaints to a rapid and satisfactory conclusion

● Maintain a constructive and non-punitive approach

● Act proportionately

● Maintain a positive relationship with the complainant

● Identify and implement changes/improvements in practice/services

● Review changes

3 DEFINITIONS

3.1 A complaint can be defined as “an expression of dissatisfaction, grievance and/or injustice requiring a response”.

4 DOCUMENT DEVELOPMENT

This policy has been developed to ensure that all staff have clear guidance on the procedures and standards for the handling of complaints.

5 WHO MAY COMPLAIN:

A complaint may be made by:

5.1 Existing or former patients using the Trust’s services or facilities, or

An individual who is affected, or likely to be affected, by the action, omission or decision of the Trust.

5.2 A relative/significant other of the patient. If the patient is a child, has died, is unable to put forward a complaint because of physical incapacity, lack of capacity within the meaning of the Mental Capacity Act 2005 or has requested a representative to act on their behalf, then the complaint will be accepted from a relative/significant other or suitable representative body, or any person who is affected by or likely to be affected by the act, omission or decision of the Trust, providing it is the subject of the complaint. The patient will, however, receive the written response unless his/her permission is received, authorising the Trust to correspond with a third party. If the patient is unable to act, by reason of incapacity, consent is not needed but the Patient Liaison and Legal Services Manager (PLM) will determine whether the complainant has “sufficient interest” in the patient’s welfare and is conducting the complaint in the best interests to be suitable to act as a representative. If the PLM determines that a person is not suitable, a full explanation outlining the reasons for the decision, must be provided.

6 INDEPENDENT MENTAL CAPACITY ADVOCATES (IMCA)

6.1 Patients who lack capacity to make particular decisions and have no-one else to support them whenever serious medical treatment is proposed, or the hospital is proposing to arrange or change accommodation in hospital or a care home, must be referred to an IMCA. In these circumstances and where there is a disagreement between the IMCA and the decision maker, then a complaint will be accepted.

7 ROLES AND RESPONSIBILITIES

7.1 The post holder with responsibility for the management of complaints is the Patient Liaison and Legal Services Manager (PLM): this post reports to and is accountable to the Medical Director who, in turn is responsible to the Chief Executive and Board of Directors for the proper management of complaints, under The Local Authority Social Services and National Health Service (England) Regulations 2009. The Chief Executive will ensure that action is taken if necessary in the light of the outcome of the complaint. The Chief Executive will sign all final written responses to complaints, this to be delegated to the Medical Director in the Chief Executive’s absence.

The Patient Liaison and Legal Services Manager:

7.2 Investigates all complaints made by patients/representatives as described in paragraphs 4 and 5 in line with the Regulations, ensuring best practice with regard to the handling and management of complaints on behalf of the Chief Executive. The PLM agrees with complainants as to how the complaint will be dealt with and the timescales for completion.

7.3 Meets complainants to resolve issues of concern at the Local Resolution Stage

7.4 Provides advice and support to Trust staff involved at all stages of the Complaints Procedure

7.5 Prepares reports to the Board of Directors on investigations undertaken by the Parliamentary and Health Service Ombudsman, liaising with involved staff and ensuring follow-up action is taken as agreed

7.6 Provides quarterly reports to the Board of Directors and quarterly performance reports to the Clinical Care Groups, maintaining a database of complaints information

7.7 Works with colleagues across the Trust, using information gained from the investigation of complaints to ensure that practices which minimise the risk of re-occurrence are shared and implemented across the organisation

7.8 Evaluates adverse clinical incidents which may lead to a complaint and ensures statements are obtained and all material evidence preserved

7.9 Provides education programmes on complaints appropriate for all disciplines within in the Trust

7.10 Grades complaints on receipt and at the conclusion of the investigation (Appendix A)

The role of the front-line staff

7.11 Where appropriate the recipient of the complaint will ensure the immediate health care needs of the patient are met

7.12 Consultant staff who receive written complaints will notify the PLM immediately

7.13 Written complaints referred to Associate Directors of Operations (ADOs)/Heads of Department will be forwarded immediately to the PLM, following acknowledgement of the complaint

7.14 Staff will often receive informal comments and suggestions and these may include expressions of dissatisfaction. If staff receive verbal comments from patients/service users, the person receiving the comment should establish the facts and clarify whether a complaint is being made. Staff are encouraged, in conjunction with their line manager and, if appropriate, PALS, to deal with verbal complaints to which they can provide an immediate response. The aim is to resolve the matter causing concern, to reassure the complainant, to learn from the complainant’s experience and to eliminate the potential for similar problems. Verbal complaints or concerns received by front-line staff on wards, clinics or reception desks should be dealt with quickly in line with the Trust’s guidance “How to handle a Complaint/Concern” (Appendix B)

7.15 Where the recipient of the complaint is unable to investigate and resolve the complaint adequately, or feels unable to provide the outcome that the complainant is seeking then with the complainant’s consent the complaint will be referred to the PLM

7.16 Some complainants may prefer to make their initial complaint to someone who has not been involved in their care. In these circumstances, they should be advised to address their complaint to the PLM, ADO/Head of Department or to the Chief Executive. Advice on the Independent Complaints Advocacy Service (ICAS) and PALS should be provided.

8 TIME LIMITS

8.1 Complaints should be made within 12 months after the material event, or within 12 months of the date of knowledge. Those received outside this time-scale will be investigated at the discretion of the PLM, taking into account the reasons for not making the complaint within the time-scale and whether it is still possible to investigate the complaint effectively and fairly. In those instances where the PLM has decided not to investigate the complaint the reasons for this must be put in writing to the complainant by the PLM.

9 COMPLAINTS AND DISCIPLINARY PROCEDURES

9.1 If any complaint indicates a prima facie need for a referral for an investigation under the Trust’s disciplinary procedures, one of the professional regulatory bodies, an independent inquiry into a serious incident under Section 84 of the NHS Act 1977 or investigation of a criminal offence, the PLM will refer the case to the Director of Human Resources, Director of Nursing, and/or the Medical Director and advise the CEO.

10 POSSIBLE CLAIMS FOR NEGLIGENCE

10.1 Where a possible clinical negligence claim is intimated before a complaint has been resolved the PLM will consider whether by dealing with the complaint it might prejudice the potential defence of the clinical negligence claim. Where it is thought that dealing with the complaint might prejudice the legal action, resolution of the complaint will be deferred until the legal action is concluded. The PLM must inform the complainant why the complaint process has been put on hold. In those circumstances where following an investigation under the complaints procedure there is a prima facie case of clinical negligence, a full explanation will be provided and if appropriate, an apology offered to the complainant. The PLM will notify the NHSLA under the CNST scheme reporting guidelines and the Policy and Procedure for the Management of Clinical Negligence Claims, Employer/Public Liability Claims and Property Expenses Scheme claims.

11 PROCEDURES

Local Resolution

11.1 A complaint may be made orally, in writing or electronically.

On receipt of a complaint consideration will be given by the PLM to conciliation, mediation or a meeting with the complainant for the purposes of resolving the complaint.

11.2 Complaints received by the Chief Executive or PLM, either directly or via front-line staff/ADOs, will be acknowledged within 3 days of the date received by the Trust. (Appendix C)

The acknowledgement letter will include an offer by the PLM to discuss with the complainant the manner in which the complaint is to be handled, the period within which the investigation of the complaint is likely to be completed and when the response is likely to be sent to the complainant. If the complainant does not accept the offer of a discussion, the PLM will decide on the response time and notify the complainant in writing.

11.3 Where a complaint is made orally, the acknowledgement must be accompanied by the written record, with an invitation for the complainant to sign and return it to the PLM.

11.4 When a complaint is received by a third party, a written authority will be forwarded to the patient/complainant for their completion and return (Appendix D)

11.5 An investigation will be initiated on the same day or next working day. (Appendix E) A copy of the complaint, together with the original healthcare records for clinical complaints, will be forwarded to the relevant ADO and/or consultant by the PLM, requesting a written response to the PLM within 10 working days following the Guidance for the Investigation of Claims, Complaints and Untoward Incidents (Appendix F). In those instances where junior medical staff are involved, the Consultant, will ensure the comments of the medical staff are obtained, prior to replying to the PLM. ADO/Heads of Departments will ensure all relevant non-medical staff have access to the letter of complaint and healthcare records, where appropriate, to assist staff in responding to a complaint. ADOs and Consultant staff will aim to respond to the PLM within 10 working days with the completion of the check-list. (Appendix G)