Annual Report for Compliments and Complaints 2011-12

Annual Report for Compliments and Complaints 2011-12

Annual Report for Compliments and Complaints 2011-12

Introduction

The annual report provides information on the compliments and complaints received by the Trust during 2011- 2012.

2011-12 has seen the integration of Mental Health and Learning Disabilities Services with Community Health Services and where it was identified that there was an inconsistency in the complaints process used by the three organisations. During the first three quarter periods April to December 2011 complaints continued to be managed in line with previous processes but in January 2012 became integrated into a single process adhering to the principles of the Department of Health document Listening; Responding; Improving: A Guide to Better Customer Care

The annual report integrates the reports prepared for each quarter and it will be necessary because of changes in the reporting process to report on the period April- December 2011in an alternative format to that of January- March 2012. There are no comparative figures for previous years and this is a stand alone report

Compliments

Compliments forwarded to the complaints office are collated and recorded and during the year 2011-12. 691 compliments have been provided for the following services

Pharmacy: Community Mental Health Teams; Community Old Age Mental Health Teams; Inpatient POA (Charles Ward); CAMH Teams: FOI administration; Audiology; Community Nurses; Community Teams for People with Learning Disabilities; Garden clinic/sexual health; Henry Tudor Ward; Macmillan service; MSK Physio; Parkinson’s Nurse; Podiatry; Community Dieticians; Smoking cessation; St Mark’s Day Hospital; SWIHC; Trent Ward; Oakwood Unit; Highclere Ward; Community Nursing Teams; Speech & Language Therapy; Specialist Services; Parent Partnership (WAM), Learning Disabilities Services; FOI administration, Barkham Day Hospital, Eating Disorders Day Service; COPD Team; Mobility; MS Specialist Nurses; St Mark’s Day Hospital; WestCall; District Nursing Teams; Continence Advisory Service,; Health Visitors,; West Berks Community Hospital; West Berks Paediatric Speech & Language Therapy; Bluebell Ward; Upton Hospital Inpatients, Psychology; Prospect Park Hospital; Hazelwood; Walk in Health Centre; Community Matrons; West Berks Community Hospital; Ascot Ward; Occupational Therapy; Berkshire Adolescent Unit; Depression Management; Daisy Ward; Charles Ward; End of Life Care (Macmillan); CBNRT; Donnington Ward; Falls Prevention and Complaints Office

Complaints

All complaints are acknowledged within 3 working days (not counting the day of receipt)

Triage, in accordance with Department of Health guidance continued to be implemented for complaints received in respect of mental health services between April-December 2011 and since January 2012 for all complaints. On receipt of a complaint the concerns raised by the complainant are ’triaged’ using the matrix provided by the Department of Health document to assess the seriousness of the complaint against a rating of low, medium or high and the likelihood of reoccurrence.

Rare / Unlikely / Possible / Likely / Almost certain
Low / Low
Moderate
Medium
High
High / Extreme

The growth of the Trust, which has resulted in an increased number of complaints no longer allows for a consultation to be offered to all complainants but where the triage identifiesthe concerns raised to be of a high risk, where some clarity is required on the content of the complaint or when a discussion with the complainant would add to the understanding of the complaint the complainant would be offered the opportunity to meet or talk with the Complaints Manager. A consultation can allow for a better understanding of the complaint by establishing the details of the complaint, the context in which their concerns occur and the response thecomplainant would want or be satisfied with.

In cases where triage has identified a high risk and where immediate actions might be indicated a Senior Manager from the service that is the subject of the complaint is required to attend the consultation meeting. In other cases where there is no indication that actions are likely to be required the consultation meeting will be led by the Complaints Manager. Consideration is also given to whether there are any risk factors which might indicate a lone visit to be potentially unsafe.

The Local Authority and NHS Complaints (England) regulations 2009 do not stipulate any timeframe in which a response should be made to complaint; however, the Trust has elected to maintain a framework for complaints. Offering a consultation can, however, impact on the start of the investigation process whichcan follow four timelines

  • When a consultation takes place: from the agreement of the notes of the consultation meeting and action plan with the complainant.
  • When a consultation is offered and declined by the complainant: from the date of the consultation being declined
  • When a consultation is offered but no response received: from 10 working days of the offer of the consultation meeting
  • When a consultation is not considered to be appropriate or indicated: from the date of the triage

For complainants where it has been agreed with the complainant that an investigation will be likely to take longer progress reports will be provided to the complainant at periods agreed with them.

An investigation template has been developed to ensure that there is continuity in the manner in which complaints are investigated and recorded and it is expected that all Investigating Officers use this.

At the completion of the investigation a response will be made by the Chief Executive to the complainant. The complainant is offered the option to return to the Trust if dissatisfied with the response made to them and an undertaking that the Trust will review the investigation. If the complainant remains dissatisfied they then have the right to refer their case to the Parliamentary and Health Service Ombudsman for consideration.

Complaints received in the year 2011/12

There were 232formal complaints made to the Trust during this period but as this isthe first year of the new organisation there no comparative figures to previous years in respect of Community Health Services.However, we can report that there were 123 complaints received in respect of mental health and learning disability services, a decrease of 11 on the previous year.

Complaints received April –2011- March 2012

Complaints received January- March 2012 whereall services now come within the remit of Locality Directors and the Head of MH Inpatient & Urgent Care

The higher number of complaints for the Wokingham Locality during this period are as a result of the 9 complaints attributed to WestCall

Within the Performance Assurance Framework the Trust hadagreed for 300 complaints per year allowing for an average of 25 per month for 2011-12. At the end of the year the number received was 232 but it was identified that as service users became aware of the procedure whereby they were able to raise concerns the numbers of complaints has increasedand the decision made that the figures should be kept to the same number for 2012-13.

Complaints measured against patient contacts and population

In measuring complaints received by the Trust against the population of Berkshire and the number of patient contacts per year the following information had been established.

Population (figures taken from the 2001 census as figures for the 2011 census will not be available until late 2012): 800, 818

Patient contacts as reported under the Monitor Schedule 2 submission: 1,049, 342

Source of Complaints

All complaints raised by individuals other than the service user are required to have the consent of the service user to proceed unless they are deceased, are a child or lack capacity as defined in the Mental Capacity Act.

Services subject to complaints

Service / Number of complaints
Adult Mental Health Inpatient Services / 45
Adult Mental Health Community Service / 38
Child & Adolescent Mental Health Services / 15
Urgent care / 8
Community Hospital Inpatient Services / 23
WestCall / 20
Community Nursing (including District Nursing, Intermediate Care etc. / 18
Health Visitors / 5
Other Mental Health Services with 4 or less complaints / 33
Other Community Care Services with 4 or less complaints / 27

Nature of complaints received

Some complaints may contain concerns with regard to more than one issue

Nature of concerns / Quarter 1 / Quarter 2 / Quarter 3 / Quarter 4
Attitude/behaviour of staff / 19 / 21 / 21 / 19
Care & treatment issues / 37 / 23 / 28 / 16
Admission/discharge/transfer / 2 / 1 / 3
Concerns over withdrawal of care package / 2
Diagnosis/assessments / 1 / 1
Detention under MHA/use of S17 leave of absence / 2
Communication / 10 / 6 / 12 / 7
Conduct of Care Programme Approach meeting / 1
Allegation of staff smoking on site / 1
Medication/medication monitoring / 2 / 3
Request for change in medical team due to alleged language barrier / 1
Property / 2 / 1
Alleged lack of support on discharge / 1
Alleged lack of support to family / 1 / 1
Expectations of family re- delivery of service / 1
Concerns at difficulty in phone access to clinic / 1
Waiting times for clinic / 1
Lack of appropriate wheelchair / 1
Access to records / 1
Issues over telephone consultation / 1
Concerns patient not visited at home following a fall / 1
Alleged failure of doctor to diagnose and treat / 1
Respite care / 1
Alleged failure to liaise with mother / 1
Alleged failure to take into account wishes of an adolescent and abide by Gillick competencies / 1
Alleged failure to take into account advice of another professional / 1
Delay in appointment / 4 / 1 / 6
Issues over noise on ward, TV & music / 1
Alleged breach of confidentiality / 2 / 2
Issue over search for appropriate placement / 1
Delays in provision of supplies / 1
Delay in receipt of treatment / 1 / 1 / 1
Lack of resources / 2 / 1
Issues over notes / 2 / 1
Alleged breach of dignity / 1
Environment / 1
Access to Continuing Healthcare / 2
Re- injury caused by fellow patient / 1

Triage

Between April and December 2011 triage was restricted to complaints from Mental Health Services. Of the 93 complaints received during this period 86 were assessed as being of a ‘low risk’, 6 as being of a ‘moderate risk’ and 1 of being a ‘high risk’ to the organisation because of potential litigation, however, the service user refused consent for her father to pursue the complaint.

Between January and April 2012 of the 71 complaints received in this period 63 were assessed as being of a ‘low risk’, 7 as being of a ‘moderate risk’ and 1 of being a ‘high risk’ to the organisation.The high risk is in relation to an allegation of misdiagnosis and failure to administer the appropriate treatment leading to the patient requiring admission to hospital and surgery.

Outcome of investigations

Of the 208 cases where a response was made by the Chief Executive 56 were upheld completely, 74 where a proportion of the complaint was upheld and 78 where no part of the complaint was upheld.

Of the 2 complaints that remain open, one is subject to confirmation of consultation meetings requested by the complainant and/or their advocate and an extended period provided for investigation of the second case due to the complexity of the concerns

raised.

Ombudsman

The Trust has been requested to provide the complaints file and clinical notes to the Parliamentary and Health Service Ombudsman for 9 complainants. The Ombudsman did not open any referral to investigation, however, in 2 cases at the suggestion of the Ombudsman the Trust reviewed its investigation and a further response was made. In 4 cases the Ombudsman ruled that the Trust had done all that it could and that they would not open the case to investigation.

Issues and actions

Points of learning from complaints form part of the quarterly reports are discussed within the Patient Engagement and Experience Group and submitted to the Executive Quality Assurance Group and cascaded for discussion and action at Operational Team Meetings to ensure learning from all complaints occurs across the organisation.

Issues raised by complainant or identified during investigation / Learning Outcomes and Actionstaken to address identified issues
Issues over lack of information on the ward particularly about observations at night and missing property when transferred from one hospital to another /
  • Staff to provide the ward information leaflet to all patient and relatives at the point of admission and explain observations to all patients, particularly those experiencing a first admission.
  • Staff to assist the patient in collecting all their belongings at the point of discharge/transfer.

Failure to inform the family of the full reasons why the patient was transferred to A&E and omitting that they had had a fall and lack of availability of staff to give information to the family on the ward /
  • The Ward Manager to ensure that a member of staff is available at some point during visit from family to respond to requests to talk.
  • To ensure that if a patient is transferred to A&E, the appropriate relative is contacted and provided with the full facts.

Differing perception of agreed of route of communication leading to a breakdown in communication and failure to address concerns. /
  • When discussing concerns held by the parent all communication should be via a meeting or telephone conversation to ensure there is a clear understanding of the issues and how these may be resolved.

Confusion on the part of staff when service users state they do not wish information to be given to relatives/carers. /
  • Staff to be aware there is a difference in giving information in these circumstances which would be a breach of confidentiality and in listening to information provided by relatives/carers who may have a greater depth of knowledge of the service user and able to identify established patterns of behaviour.

Extended delay in assessment process for ASD and failure to respond to contact from parents. /
  • Review of skill mix in team to enable other clinicians to assess and diagnose ASD
  • Systems to be developed in service to ensure all contacts are logged and followed up

Concerns over attitude of staff accusing patient of requesting and taking S17 leave of absence after it had been withdrawn. /
  • When a decision is made to withdraw S17 leave of absence it is the responsibility of the professional to score this through and inform nursing staff. It is the responsibility of the Nurse in Charge to ensure all staff are aware of this decision.

Concerns on the part of the mother that the CPA process was a ‘tick box’ exercise with decisions previously made. /
  • where there has been a pre-CPA meeting between the Service User and Care Manager to flag up difficulties and provisionally agree a plan this should be explained to the relative/care present at the CPA meeting
  • Arrangements made for Locality Manager to meet with the Carers Group to address their concerns over the CPA process.

Concerns that a member of staff undertaking level 2 observations, where a patient is required to be within visual range of a designated member of staff at all times, did not adhere to this. /
  • it is the responsibility of all staff to be fully cognisant with the ‘Safe and Supportive Observation of, and Engagement with Patients’ policy and when delegated to undertake Level 2 observations to adhere to the requirements of this level of observation

Concerns over a prolonged delay in acknowledging a referral to psychology and then offering an appointment and where the information given to the patient on the ward indicated that the timeframe would be shorter. Lack of support in interim period. /
  • Acute wards to be contacted to ensure that correct information is given on the waiting time for psychology appointments and to allow for the patient to be referred to the CMHT for interim support if required.
  • The service to consider how it manages referrals received and their timely acknowledgement in the absence of the administrator.

Lack of documentation in recording that an OPA did not take place and lack of planned follow up. /
  • All outcomes of planned appointments to be documented with expected follow up by team

Failure to advise Service User of outcome of assessment. /
  • Review of systems to ensure that in the case of ‘one off’ assessments where the individual is not open to the service they will be informed in writing of the outcome of the assessment and the reasons why their case would not be opened.

Difficulty in identifying a stress fracture for patient with Idiopathic Juvenile Osteoporosis and the impact on treatment. /
  • Warning flag attached to computer records re- medical history and a low threshold for referral for investigation to an acute hospital to be maintained in the event the patient believes eh has suffered a bony injury

A young child with short history of gastroenteritis who developed hypoglycaemia and other metabolic disturbance. /
  • a letter sent to all GP’s in WestCall alerting them to the situation, though rare, is a possibility that professionals should bear in mind when dealing with very young children with gastroenteritis particularly if vomiting is prolonged.

Failure to visit an elderly service user following a fall at home /
  • GP seen by Medical Director and asked to review management of such cases in the future and to gather sufficient clinical information to be able to make an appropriate clinical decision.

Concerns over the failure of respite care to take into account the needs of the child and her mother /
  • When planning respite care each case to be looked at and managed on an individual basis.

Concerns raised over the admission to the unit by family including communication and attitude of staff. /
  • admission leaflet, which explains the purpose and process of the ward, to be given to all patients and relatives at point of admission
  • All staff to undergo customer service training including learning from complaints.
  • Tea and coffee facilities now available in OT kitchen to allow staff to provide refreshments when servery closed.
  • To ensure all staff are aware, understand and follow ‘Being Open when Patient are Harmed’ policy.
  • Activity Coordinator now in post to provide and support activities

Difficulties when there is no provision for a patient to alert staff they have arrived for a clinic /
  • Systems/signage to inform patient where they should report their arrival for an appointment to be reviewed and where necessary improved.

Failure to document pain assessments and to ensure effective pain control /
  • Pain assessments will be conducted and recorded and where indicated pain relief medication will be reviewed and prescribed.

Investigation identified poor practice on ward and where the standard of care fell below the levels that would be expected. /
  • Review of internal processes
  • Review of clinical paperwork and formal notes audit
  • All staff to have 1-1
  • All patients to have a named nurse on admission
  • All staff to have appraisals with clear objectives and identifying training needs
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