PALS PROCEDURE
Date effective from: / 2 January 2013Review date: / December 2015
Version number: / 3.0
See Document Summary Sheet for full details
CONTENTSDocument Summary Sheet / 3
Document Amendment sheet / 4
PART A
Section / Description / Page
1 / Executive summary / 6
2 / The Pals Procedure / 6
2.1 / Flow chart of procedure / 6
2.2 / Description of procedure/process / 7-11
3 / Duties / 11
4 / Training / 11
5 / Glossary of Definitions / 12
6 / Appendices relevant to the procedural document / 12
PART B
Section / Description / Page
7 / Purpose of Document / 14
7.1 / Policy statement / 14
7.2 / Purpose of document / 14
8 / Identification of Stakeholders / 14
9 / References, Evidence Base / 14
10 / Associated Documentation / 14
11 / Equality Impact Assessment / 15-18
12 / Dissemination and Implementation / 19
13 / Key Performance Indicators / 20
14 / Monitoring Compliance and Effectiveness / 21
DOCUMENT SUMMARY SHEET
ALL sections of this form must be completed. Those marked with * will be used as search information on Staffnet.
Document title*:
/ PALS ProcedureDocument Reference Number * / OP-0005
Member of the Executive Team Responsible* (Title): / Chris Butler Chief Executive
Document author* (Name and title): / Debbie Lilley
Approved by (group): / Means Goal 1&2 Care Planning Group
Date approved: / 23 November 2012
Ratified by (group/Board): / Means Goal 1&2
Date ratified: / 14 December 2012
Review date: / December 2015
Frequency of review: / Every 3 years
Responsible for the review: / Complaints & Claims Manager
Target audience:
(List, by title, the people this procedural document is essential for) / Head of Corporate Governance
Complaints & Claims manager
PALS Team
Responsible for dissemination: / Complaints & Claims Manager
DOCUMENT AMENDMENT SHEET
Please record what changes you have made to the procedural document since the last version.
This is a summary of changes to the document and is designed to show people exactly what has changed. The version number recorded below should correspond to the ratified version number shown on the Document Summary Sheet.
Version / Amendment / Reason1.0 / Format / Re-written in new procedural format
2.0 / Addition of revised section 8 on monitoring / To be compliant with NHSLA requirements
2.1 / Review of the procedure / To align it with the DH document on setting up a PALS service.
To change the name of the Trust.
2.2 / Review of procedure / To reflect comments obtained from consultation
2.3 / Review of procedure / To include reference to Advocacy for Mental Health & Dementia
3.0 / To comply with new document format issued by NHSLA / Requirements of new NHSLA document format met
PART A
1 EXECUTIVE SUMMARY
The Patient Advice and Liaison Service (PALS) is a Trust-wide service, which aims to act as a positive catalyst for change and contribute to the continual improvement of mental health and learning disability services. It is a free and confidential service for service users, carers and family members who have an issue or concern about the quality of care being received from a Trust Service.
PALS also acts as a signposting service, directing people to advice and support organisations outside the Trust, including other NHS Trusts and independent organisations. This advice is also available to Trust staff.
2 THE PALS PROCEDURE
2.1 Flow chart of procedure
2.2 Description of Procedure
2.2.1The PALS Team comprises of one full-time PALS Officer and one part- time PALS Officer.The PALS office is located in the Becklin Centre.
Information about the PALS service is available on the Trust’s website and Staffnet. Posters and leaflets are widely available throughout the Trust.
2.2.2The PALS service can be accessed by service users, carers, relatives, friends and members of staff.
2.2.3The core functions of the PALS service are
- To be identifiable and accessible to service users, carers, staff and members of the public who engage with our services. This will be achieved through methods such as signage; posters; leaflets and the Trust’s website
- To provide on the spot help in the Trust with the power to negotiate immediate solutions or speedy resolution of problems.
- To listen and provide relevant information and support to help resolve concerns quickly and efficiently, liaising with staff and mangers, and where appropriate, with other PALS services, health and related organisations to facilitate resolution.
- To act as a gateway to appropriate independent advice and advocacy support from local and national sources, including the Independent Complaints Advocacy Services (ICAS).
- Provide accurate information about the Trust’s services and other health related issues, using accredited, reliable sources, including drawing on the experience of some of the other departments internal to the Trust who also provide help and support to service users.
- To act as a catalyst for change and improvement by providing a key source of information and feedback for the services provided in respect of any lessons learned. This will be done by:
accurately updating DATIX providing information on any issues raised and also any lessons learned.
providing input as required to the integrated Serious Untoward Incident, Complaints and PALS report which is collated by the Head of Risk Management.
establishing appropriate formal routes of feeding back emerging themes as agreed with the Complaints and Claims Manager
- To operate within a local network with other PALS teams in the area served by the Trust and liaise across organisational boundaries to ensure a seamless service for those individuals who move between and use different parts of the NHS for the care they need. (Note: PCT PALS teams will lead on cross-boundary issues).
2.2.4Normal service hours for PALS are: Monday to Friday, 9am – 5pm. Staff may be contacted by either telephone, letter or email, or alternatively, staff, service users, carers or members of the public may make an appointment to meet with a member of the PALS team face to face.
For telephone enquiries made outside of the above office hours, weekends and Bank Holidays, an answer phone system will be in operation, and enquiries will be responded to within the agreed response time set out below.The PALS service operates primarily over the telephone, however any queries received via email or in person. Requests for a face to face meeting will be arranged to take place at the Becklin Centre.
2.2.5Contact details:
Tel:0800 0525 790/ 0113 3055620/0113 3056675
Email:
PALS Office
Becklin Centre
Alma Street
Leeds
LS9 7BE
2.2.6The PALS service aims to close a case within 7 days. Details of cases and the outcomes are recorded on the DATIX database and any lessonsare also recorded for dissemination throughout the Trust
2.2.7As a professional service, PALS will have a consistent approach as to how queries are responded to. The service is provided to support a person with a problem or issue they have about their health care or that of someone they know.
2.2.8On receipt of a enquiry, a member of the PALS team will discuss concerns with the individual concerned and how the matter will be handled and whether it is a case for the Trust’s PALS Team to progress. If this is not appropriate, the individual concerned will be signposted onto another more appropriate service. Each contact will be recorded on DATIX.
2.2.9It will be agreed with the individual what service best fits their needs. PALS is a source of information about these services and leaves the decision about how to move forward with the individual.
2.2.10The PALS service does not provide clinical support to service users, neither should they represent a service user in a clinical setting as this is the role of the advocacy services.
2.2.11Where an individual is in crisis the limits of the PALS service in resolving individual mental health crises will be communicated to the enquirer, and an appropriate contact given to the service user. If the individual is currently known to the Trust, it may be appropriate for the PALS Team to inform the relevant clinical team of the contact, always acting in the individual’s best interests.
2.2.12All Trust staff have a duty to help resolve any queries or concerns raised by people receiving the service they provide, wherever possible. All members of staff have a role to attempt to resolve a person’s concerns wherever possible before referring to PALS.
2.2.13PALS can provide information and advice to members of staff who require help to resolve a query or concern raised by someone using Trustservices. Service users, relatives or carers will not be treated any differently as a result of accessing the PALS service.
2.2.14PALS aims to help individuals resolve their concerns at a local level wherever possible and in accordance with their wishes. This means that PALS will usually liaise with the staff member responsible for an individual’s care in the first instance (i.e. Care Co-ordinator) as part of responding to a concern, whilst being respectful of clinical decisions and clinical management structures.
If PALS is not able to achieve resolution through liaison with the Care Co-ordinator, PALS will contact the Clinical Team Manager and/or the Clinical Services Manager as appropriate. If the problem remains unresolved, there is the option to move on to a formal complaint. PALS will provide information on the options available which will include the Trust’s formal complaints process, the Independent Complaints and Advocacy Service (ICAS), MIND and Advocacy for Mental Health & Dementia. PALS can support people in accessing these services.
2.2.15The PALS service is a Trust service which is separate to, and does not replace, Independent Advocacy Services. It is different from an Independent Advocacy Service because PALS aims to provide quick resolution of individual concerns from within the Trust before they escalate into serious problems.
2.2.16The PALS service acts as a catalyst for change and improvement by influencing the organisation it works within. PALS provides immediate short-term help to people using the Trust’s services and will liaise with those services or point people in the right direction so they can resolve the issue for themselves if they wish to do so.
2.2.17Advocacy Services are able to provide both short term and ongoing independent support because they are separate to statutory providers of Mental Health services. They are able to provide advocacy to individuals whose concerns relate to a range of local services and will represent their interests and promote their rights for example in Care Programme Approach (CPA) meetings or Mental Health Tribunals etc.
2.2.18 The Mental Health Act 1983 places a statutory duty on ward staff to inform patients who are subject to detention or Supervised Community Treatment , of their right to access and Independent Mental Health Advocate (IMHA) Clinical staff are required under Section 132 of the Act to assist patients who are eligible to access an IMHA. Patients who do not have capacity to understand specific decisions should be referred to the IMHA service on the formulation of a clinical decision that it would be in the patient’s best interests to be supported by an IMHA.
2.2.19The guiding principles of the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards places a responsibility on Health and Social Care staff to instruct an Independent Mental Capacity Advocate (IMCA) in supporting people without capacity to make specific decisions. Clinical staff need to consider instructing an IMCA if the patient is without capacity to make a specific decision and they are un-befriended, or where there is conflict with carers/family.
An IMCA must be instructed then consulted, for people lacking capacity who have no-one else to support them (other than paid staff) whenever:
An NHS body is proposing to provide withholding or stopping serious medical treatment
An NHS body or Local Authority is proposing to arrange/change accommodation in hospital or a care home
The person will stay in hospital longer that 28 days or
They will stay in the care home for longer than 8 weeks
May become involved in care reviews or safeguarding
People using PALS will be informed about local Independent Advocacy Services and will be referred to these organisations if they request this.
2.2.20It is the choice of an individual to use either PALS or the Trust’s Complaints Management Procedure and there is no requirement for individuals to use PALS first if they wish to make a formal complaint. PALS will provide information about the complaints process and help individuals to access it if they ask us to.
Formal complaints are made in writing to the Chief Executive and will be investigated in accordance with the Trust’s Complaints Management Procedure. PALS should not be used once the Trust’s Complaints Management Procedure has been instigated.
2.2.21The PALS service is a confidential service and will only help to resolve a concern if the individual gives their informed consent to do so.
PALS will only approach professionals involved in an individual’s care with the service users’ consent and will limit any information shared on a “need to know basis”.
Individuals using the PALS service will be kept fully informed and involved at all stages of the process to help resolve a concern. Confidentiality will only be breached in exceptional circumstances if it is believed that someone may be at risk of significant harm to themselves or to others.
Should an independent third party wish to discuss a concern on behalf of a service user, PALS will recommend that they arrange for the service user to contact PALS to give express verbal or written consent to share information.
In the case of a third party contacting PALS with concerns about risk where contact or consent would not be forthcoming, PALS will confirm that they will pass details to the relevant clinical team and explain that no information would be shared without the service user’s consent, however, PALS will at all times, act in the service user’s best interests.
Decisions to share information about service users should always be based on:
Subject consent
Statutory obligation
Data Protection Act schedule 2/schedule 3 conditions for processing (including vital interest of the subject; medical purposes; detection of unlawful activity; protection of the public; policing requirements and disclosures largely in the public interest)
The issues highlighted in Schedule 3 are the basis of the “best interests” decisions. The law allows information to be used in the service user’s best interests to provide or support care services. This may include sharing information with a 3rd party, relative or otherwise, when the service user has given consent or if acting in the service user’s best interests.
3 DUTIES AND RESPONSIBILITIES
The duties within the organisation are as follows:
Staff group / DutiesHead of Corporate Governance / Ensure that there is an up to date PALS procedure in place. Provide support to PALS staff
Complaints & Claims Manager / Ensure that PALS staff are fully conversant with the PALS Procedure and receive appropriate training
PALS Officers / Ensure PALS Procedure is appropriately implemented and adhered to
4TRAINING
Training is provided by the Complaints & Claims Manager to the PALS Officers.
Awareness of the role and availability of the PALS service is provided to staff on a quarterly basis through Complaints & PALS Training co-ordinated by the Trust’s Development and Events service.
5GLOSSARY OF DEFINITIONS
The following definitions are of relevance to this document:
Definition / MeaningPALS / Patient Advice and Liaison Service
ICAS / Independent Complaints Advocacy Service
A4MH&D / Advocacy for Mental Health and Dementia
6APPENDICES
None for this document
PART B
7PURPOSE OF DOCUMENT
7.1 Policy Statement
The PALS Service aims to act as a positive catalyst for change and provide a contribution to the continual improvement of mental health and learning disability services.
7.2 Purpose of Document
The purpose of this document is to outline the role and functions of the PALS Service in line with the guidelines and principles as set out in the Department of Health Guidelines “Supporting the Implementation of Patient Advice and Liaison Services”; to outline the function of PALS and identify boundaries of service delivery; and to describe the role of PALS and how the service enhances choice for service users, carers, family members and the public and members of staff.
- IDENTIFICATION OF STAKEHOLDERS
The table below should be used as a summary
Stakeholder / Level of involvementHead of Corporate Governance / Development Group
PALS Officers / Development Group
Complaints & Claims Manager / Development Group
Involving People Council/Head of Inclusion / Consultation
Means Goal 1&2 Standing Support Group / Approval
Means Goal 1&2 / Ratification
- REFERENCES, EVIDENCE BASE
Department of Health Guidelines “Supporting the Implementation of Patient Advice and Liaison Services”
- ASSOCIATED DOCUMENTATION
Trust’s Complaints Management Procedure
PALS Information Leaflets and Posters
- EQUALITY IMPACT ASSESSMENT
The general equality duty that is set out in the Equality Act 2010 requires public authorities, in the exercise of their functions, to have due regard to the need to:
- Eliminate unlawful discrimination, harassment and victimisation and other conduct prohibited by the Act.
- Advance equality of opportunity between people who share a protected characteristic and those who do not.
- Foster good relations between people who share a protected characteristic and those who do not.
Please complete the template by following the instructions in each box. If you require any guidance on how to complete the template please contact the Diversity and Inclusion Team on 0113 2954413.
Title: PALS ProcedureWhat are the intended outcomes of this work?
To provide an effective PALS procedure across the Trust
Who will be affected?
Service users/carers/relatives/advocates/staff
Evidence
What evidence have you considered?
Advice from Diversity and Inclusion Team
Disability Consider and detail (including the source of any evidence) on attitudinal, physical and social barriers.
No perceived disadvantage
Sex Consider and detail (including the source of any evidence) on men and women (potential to link to carers below).
. No perceived disadvantage
Race Consider and detail (including the source of any evidence) on difference ethnic groups, nationalities, Roma gypsies, Irish travellers, language barriers.
No perceived disadvantage
Age Consider and detail (including the source of any evidence) across age ranges on old and younger people. This can include safeguarding, consent and child welfare.
No perceived disadvantage
Gender reassignment (including transgender) Consider and detail (including the source of any evidence) on transgender and transsexual people. This can include issues such as privacy of data and harassment.
No perceived disadvantage
Sexual orientation Consider and detail (including the source of any evidence) on heterosexual people as well as lesbian, gay and bi-sexual people.
Religion or belief Consider and detail (including the source of any evidence) on people with different religions, beliefs or no belief.
No perceived disadvantage
Pregnancy and maternity Consider and detail (including the source of any evidence) on working arrangements, part-time working, infant caring responsibilities.
No perceived disadvantage
Carers Consider and detail (including the source of any evidence) on part-time working, shift-patterns, general caring responsibilities.
Other identified groupsConsider and detail and include the source of any evidence on different socio-economic groups, area inequality, income, resident status (migrants) and other groups experiencing disadvantage and barriers to access.
No perceived disadvantage
Engagement and involvement
How have you engaged stakeholders in gathering evidence or testing the evidence available?
Stakeholder engagement plan
How have you engaged stakeholders in testing the policy or programme proposals?
For each engagement activity, please state who was involved, how and when they were engaged, and the key outputs:
Summary of AnalysisConsidering the evidence and engagement activity you listed above, please summarise the impact of your work. Consider whether the evidence shows potential for differential impact, if so state whether adverse or positive and for which groups. How you will mitigate any negative impacts. How you will include certain protected groups in services or expand their participation in public life.
Now consider and detail below how the proposals impact on elimination of discrimination, harassment and victimisation, advance the equality of opportunity and promote good relations between groups.
Eliminate discrimination, harassment and victimisation Where there is evidence, address each protected characteristic (age, disability, gender, gender reassignment, pregnancy and maternity, race, religion or belief, sexual orientation).
No evidence
Advance equality of opportunity Where there is evidence, address each protected characteristic (age, disability, gender, gender reassignment, pregnancy and maternity, race, religion or belief, sexual orientation).
No evidence
Promote good relations between groups Where there is evidence, address each protected characteristic (age, disability, gender, gender reassignment, pregnancy and maternity, race, religion or belief, sexual orientation).
No evidence
What is the overall impact?Consider whether there are different levels of access experienced, needs or experiences, whether there are barriers to engagement, are there regional variations and what is the combined impact?
Same level of access available to anyone using PALS
Addressing the impact on equalities Please give an outline of what broad action you or any other bodies are taking to address any inequalities identified through the evidence.
No inequalities perceived
Action planning for improvementPlease give an outline of the key actions based on any gaps, challenges and opportunities you have identified. Actions to improve the policy/programmes need to be summarised (An action plan template is appended for specific action planning). Include here any general action to address specific equality issues and data gaps that need to be addressed through consultation or further research.
For the record
Name of person who carried out this assessment:
Date assessment completed:
Name of responsible Director/Director General:
Date assessment was signed:
Date effective from: 2 January 2013 Page 1 of 22