Document Title: Complaints Policy

Document Title: Complaints Policy

Complaints Policy

Document No. / EDRMS000037NC / Version No. / 5.0
Approved by / Non-clinical PAG / Date approved / 01/11/2012
Ratified by / Patient Safety and Quality Committee / Date ratified / 07/02/2012
Date Implemented / 05/11/2012 / Next Review Date / 07/02/2014
Status / Approved
Target Audience / Staff, Patients and Carers
Accountable Director / Director of Workforce & Education
Policy Author/Originator / Head of Patient Experience
Implementation Lead / Head of Patient Experience
If developed in partnership with another agency, ratification details of the relevant agency / n/a

Equality Impact

Great Western Hospitals NHS Foundation Trust (‘GWH’) strives to ensure equality of opportunity for all service users, local people and the workforce. As an employer and a provider of health care, GWH aims to ensure that none are placed at a disadvantage as a result of its policies and procedures. This document has therefore been equality impact assessed in line with current legislation to ensure fairness and consistency for all those covered by it regardless of their individuality. This means all our services are accessible, appropriate and sensitive to the needs of the individual. The results are shown in the Equality Impact Assessment Tool at APPENDIX A.

Contents

1 Document definition 5

1.1 Introduction 5

1.2 References, further reading and links to other policies 5

1.3 Glossary/definitions 7

1.4 Document description 7

1.5 Purpose of the document 7

1.6 Scope 7

1.7 Regulatory position 8

1.8 Special cases 8

1.9 Acute and Maternity Standards Criterion 8

1.10 Consultation Process 8

1.11 Comments 8

2 Main Policy Content Details 8

2.1 Overview 8

2.2 Who May Complain? 9

2.2.1 Making a complaint 10

2.3 Confidentiality & Consent 10

2.4 Time Limits 11

2.5 Local Resolution: Informal Complaints 11

2.5.2 Learning from informal complaints 13

2.6 Local Resolution: Formal Complaints 13

2.6.1 Learning from formal complaints 15

2.7 Secondary Complaints 15

2.8 Independent Complaints Advocacy Services 16

2.9 Legal Implications 16

2.10 Support for staff involved in a complaint 16

2.11 Serious Allegations and Disciplinary Investigations 17

2.12 Staff Grievances 18

2.13 Complaints brought by Members of Parliament (MP) on behalf of constituents 18

2.14 Fraud and Corruption 18

2.15 Internal Evaluation of the Complaints Process 18

2.16 External Evaluation of the Complaints Process 19

2.17 Complaints about services provided by other agencies 19

2.18 Coroner’s Cases 20

2.19 Complaints about the Data Protection Act 1998 and the Freedom of Information Act 2000 20

2.20 Complaints about Carillion Facilities Management (including CCTV access) 20

2.21 Complaints Regarding Private Care 20

2.22 Access to Health Records 20

2.23 Recording Complaint Meetings 21

2.24 Media Interest 21

2.25 Procedure for Handling Unreasonably Persistent Complainants 21

2.25.1 Definition of an unreasonably persistent Complainant 21

2.26 Options for Dealing with Unreasonably persistent Complaints 22

2.27 Withdrawing ‘Unreasonably persistent’ Status 23

2.28 Aggregated Analysis – Incident/Complaints/Claims. Lessons Learnt and Recommendations 23

3 Duties and responsibilities of individuals and groups 25

3.1 Chief Executive 25

3.2 Executive Directors 25

3.3 The Chairman and Non-Executive Directors 25

3.4 Governors 26

3.5 Associate Medical Directors and General Managers 26

3.6 Managers (DGM/Matron/Ward Managers) 26

3.7 PALS 26

3.8 All Staff 26

4 Education and training requirements 27

4.1 Education and training plan 27

5 Communication plan 27

5.1 Communication action plan 27

5.2 Distribution and communication channels 28

6 Monitoring compliance and effectiveness of implementation 29

7 Review date and arrangements 30

APPENDIX A – Equality Impact Assessment Tool 31

APPENDIX B – Quality Impact Assessment Tool 32

APPENDIX C - Staff Guidance (Leaflet) 34

APPENDIX D – Staff Guidance for Verbal Concerns (Flow Chart) 36

APPENDIX E – Formal Complaint Process (Flow Chart) 37

APPENDIX F – Guidance for staff on obtaining information 38

APPENDIX G – Advice for the public (leaflet) 40

APPENDIX H – Complaint Investigation Summary 42

APPENDIX I – Guidance for Governors on complaints 44

APPENDIX J – Directorate Complaints handling process (flowchart) 45

APPENDIX K – Aggregated Analysis 46

1  Document definition

1.1  Introduction

Great Western Hospitals NHS Foundation Trust is committed to listening to the views of patients and the public about the care we provide, and values feedback on the experiences of our patients.

The Trust’s Strategic Objectives incorporate three elements that feed directly into patient experience:

·  To improve the patient and carer experience of every aspect of the service and care that we deliver

·  To ensure that staff are proud to work at GWH and would recommend the Trust as a place to work, or to receive treatment

·  To work in partnership with others so that we provide seamless care for patients

The Patient Advice and Liaison Service (PALS) is led by the Head of Patient Experience and reportable to the Head of Marketing and Communications. PALS is at the forefront of gaining feedback and being a point of contact for our patients and their carers to seek advice and give their views.

The PALS Department actively seeks the views of patients and the public about the quality of our services and feeds back the information to the Trust and staff and ensure appropriate action is taken to improve services. Under the NHS Constitution, people have the right to have their complaint dealt with efficiently.

Compliments, comments, complaints and suggestions from patients, carers and the public are encouraged and welcomed. Should patients, carers or the public be dissatisfied with the care provided they have a right to be heard and for their concerns to be dealt with promptly, efficiently and courteously. Under no circumstances should patients, relatives or carers be treated any differently as a result of making a complaint or raising a concern.

We welcome all forms of feedback and use this to improve the service we provide.

1.2  References, further reading and links to other policies

The following is a list of other policies, procedural documents or guidance documents (internal or external) which staff should refer to for further details:

Ref. No. / Document Title / Document Location /
1 / Department of Health NHS Complaints Procedure / http://www.nhs.uk/choiceintheNHS/Rightsandpledges/complaints/Pages/NHScomplaints.aspx
2 / Statutory Instrument 2006 No. 2084. The National Health Service (Complaints) Amendment Regulations 2006 / http://www.opsi.gov.uk/si/si2006/20062084.htm
3 / Handling complaints in the NHS – good practice toolkit for local resolution / http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4084866
4 / Guidance to support implementation of the national Health Service (complaints) Regulations 2004 / http://www.dh.gov.uk/assetroot/04/08/81/57/04088157.pdf
5 / Health and Social Care (Community Health and Standards) Act 2003 / http://www.legislation.gov.uk/ukpga/2003/43/contents
6 / Social Services Complaints Procedure for Adults / http://www.adviceguide.org.uk/index/your_family/health_index_ew/nhs_and_local_authority_social_services_complaints.htm
7 / The Shipman Inquiry / http://www.shipman-inquiry.org.uk/
8 / Incident Management Policy / Trust Intranet
9 / Being Open Policy / Trust Intranet
10 / Child Protection Procedures / Trust Intranet
11 / Safeguarding of Vulnerable Adults Policy / Trust Intranet
12 / Managing Challenging Individuals and Violence Prevention Policy / Trust Intranet
13 / Health Records Subject Access Requests Procedure / Trust Intranet
14 / Freedom of Information Requests Procedure / Trust Intranet
15 / NHSLA Risk Management Standards, April 2007 / www.nhsla.com
16 / Parliamentary and Health Service Ombudsman Report: Care and Compassion February 2011 / http://www.ombudsman.org.uk/care-and-compassion/home
17 / Parliamentary and Health Service Ombudsman Principles of Good Complaint Handling / http://www.ombudsman.org.uk/improving-public-service/ombudsmansprinciples/principles-of-good-complaint-handling-full
18 / Information Commissioners Officer / http://www.ico.gov.uk/
19 / Department of Health – Information Policy, Patient Confidentially and Caldecott Guardians / http://www.dh.gov.uk/PolicyAndGuidance/InformationPolicy/PatientConfidentialityAndCaldicottGuardians/fs/en

1.3  Glossary/definitions

The following terms and acronyms are used within the document:

CCTV / Closed Circuit Television
CQC / Care Quality Commission
ICAS / Independent Complaints Advocacy Service
MP / Member of Parliament
NHS / National Health Service
NHSLA / National Health Service Litigation Authority
NPSA / National Patient Safety Agency
PHSO / Parliamentary and Health Service Ombudsman
PALS / Patient Advice and Liaison Service
SEQOL / Social Enterprise Quality of Life (Integrated Health and Social Care provider)

1.4  Document description

This document is the Trust wide policy on how individuals and the organisation manage complaints. It contains flow charts and guidance for staff to refer to.

1.5  Purpose of the document

The purpose of the complaints policy is to explain how Great Western Hospitals NHS Foundation Trust acknowledges and implements the National Health Service Complaints Regulations. The policy has been merged to include the Wiltshire Community Health Services and is to be used by staff across the organisation to standardise complaint management.

The aims of this policy are to:

·  Ensure that our complaints procedure is easy to understand and simple to use.

·  Make sure that investigations are thorough, fair, responsive, open and honest.

·  Demonstrate that we will learn from complaints and use them to improve the services for patients.

·  Ensure that our service is accessible to everyone.

·  To answer complaints in a timely manner.

·  Show we will respect individuals’ rights to confidentiality.

·  Ensure the Trust Board is accountable for improving the quality of services.

·  Enable staff to respond positively to complaints and endeavour to resolve issues as soon as possible.

·  Satisfy the complainant by conducting a thorough investigation and providing a full explanation.

·  Ensure that patients, relatives and their carers are not treated differently as a result of making a complaint.

1.6  Scope

This policy applies to all staff, patients and carers.

1.7  Regulatory position

·  The National Health Service (Complaints) Regulations 2006.

·  Trusts are required by the NHSLA to achieved Data Accreditation Stages 1 and 2, which involve assessment by an external auditor.

·  The Care Quality Commission inspections rely on information based on sound data.

·  The Data Protection Act requires that information held on computer systems is accurate and up to date.

·  Freedom of Information Act requires organisations to make some documents publicly available.

·  This document is required for the NHSLA Risk Management Standards.

1.8  Special cases

Where it has been identified that the complainant or patient is a vulnerable adult or there are concerns around capacity, advice should be sought from the Head of Patient Experience or Safeguarding Lead.

This policy does not apply when a complaint relates to a serious incident which is investigated under the Incident Management Policy.

This policy does not apply to complaints where a letter of claim has been received. In these cases the complaint file will be closed on confirmation from the Legal Service Team that a letter of claim has been received.

1.9  Acute and Maternity Standards Criterion

This document does not contain diagnostic testing procedures and / or screening procedures.

1.10  Consultation Process

The following is a list of consultees in formulating this document:

Job Title / Department /
Company Secretary
Matrons and General Managers
Legal Services Manager
Director of Nursing & Midwifery

1.11  Comments

Any comments on this policy should, in the first instance be addressed to the author.

2  Main Policy Content Details

2.1  Overview

Under the Government’s Guidance on the implementation of the NHS Complaints Procedure there are two stages for dealing with complaints:

Stage 1: Local Resolution

Stage 2: Parliamentary and Health Service Ombudsman

Complaints may be made about any matter reasonably connected with the exercise of the functions of the Trust, including any matter reasonably connected with:

·  Its provision of health care or any other services

·  The function of commissioning health care or other services under an NHS contract or making arrangements for the provision of such care or other services with an independent provider or an NHS Foundation Trust.

Matters excluded from consideration under the arrangements are:

·  A complaint made by an NHS body, which relates to the exercise of its functions by the Trust

·  A complaint made by a primary care provider which relates either to the exercise of its functions by the Trust or to the contract or arrangements under which it provides primary care services.

·  A complaint made by an independent provider or an NHS foundation trust about any matter relating to arrangements made by the Trust with that independent provider or NHS foundation trust.

·  A complaint made by an employee of the Trust about any matter relating to his contract of employment

·  A complaint which is being or has been investigated by the Ombudsman.

·  A complaint arising out of the Trust's alleged failure to comply with a data subject request under the Data Protection Act 1998 or a request for information under the Freedom of Information Act 2000

·  A complaint about which the complainant has stated in writing that he intends to take legal proceedings.

·  A complaint about which the Trust is taking or is proposing to take disciplinary proceedings in relation to the substance of the complaint against a person who is the subject of the complaint.

·  At present the NHS complaint process is not able to offer any form of reimbursement or compensation. This will be subject to review when the NHS Redress Scheme is enacted through Parliament.

2.2  Who May Complain?

Complaints may be made by:

·  A patient

·  Any persons who are affected by or likely to be affected by, the action, omission or decision of the Trust

·  The carer of a patient, with the patient’s consent

A complaint may be made by a representative acting on behalf of a patient or any person who is affected by or likely to be affected by the action, omission or decision of the Trust, where that person:

·  Has died.

·  Is a child.

·  Is unable by reason of physical or mental incapacity to make the complaint himself.

·  Who has requested the representative to act on his behalf and given consent for this.

·  Complaints made by Members of Parliament on behalf of their constituents.

Where a patient or person affected who has died or who is unable to raise concerns themselves, the representative must be a relative or other person who, in the opinion of the PALS Department, has a sufficient interest in their welfare and is a suitable person to act as representative.

The Patient Support Officer is responsible for determining whether the complainant has ‘sufficient interest’ in the deceased or incapable person’s welfare to be suitable to act as a representative. The need to respect the confidentiality of the patient is a guiding principle.