complaints and concerns policy - tameside and … · complaints and concerns policy ... complaint...

Complaints and Concerns Policy

EQUALITY IMPACT The Trust strives to ensure equality of opportunity for all both as a major employer and as a provider of health care. This policy has therefore been equality impact assessed by the Quality and Governance Committee to ensure fairness and consistency for all those covered by it regardless of their individual differences. Version: 8.3 Authorised by: Chief Executive Date authorised: Revised:

March 2014 April 2016

Next review date: September 2016 Document author: Director of Quality and Governance

Tameside Hospital NHS Foundation Trust Complaints and Concerns Policy

VERSION 8.3 (April 2016) of 20

Please check intranet for latest version

VERSION CONTROL SCHEDULE

Complaints Policy and Procedure

Version Number Issue Date Revisions from previous issue

8.3 April 2016 Policy updated to reflect changes in Committee structures and organisational changes and inclusion of community services. Further detail of Duty of Candour requirements




TABLE OF CONTENTS INTRODUCTION .................................................................................................................................. 4

TRUST STATEMENT .......................................................................................................................... 4

PURPOSE ............................................................................................................................................. 4

SCOPE ................................................................................................................................................... 5

DEFINITIONS ........................................................................................................................................ 5

DUTIES .................................................................................................................................................. 5

POLICY STATEMENT......................................................................................................................... 6

THE POLICY ITSELF .......................................................................................................................... 6

POLICY DEVELOPMENT & CONSULTATION ............................................................................ 15

IMPLEMENTATION ........................................................................................................................... 15

MONITORING ..................................................................................................................................... 16

REFERENCES .................................................................................................................................... 18

BIBLIOGRAPHY ................................................................................................................................ 18

REVIEW ............................................................................................................................................... 18

APPENDIX 1 – Complaints Training Needs Analysis ........................................................19

APPENDIX 2 – Equality Impact Assessment ....................................................................20




INTRODUCTION This policy and procedure identifies the process of making a complaint and the roles and responsibilities of those involved in dealing with complaints. It is written in line with the relevant national guidance and legislation. Trust Policies: Confidentiality & Disclosure of Information Policy Being Open Policy Stress Management Policy

Staff Support Policy Incident Reporting and Incident and Complaint Investigation Policy

Please note: Supplementary detailed procedure notes are available with the PALS and Complaints Team to supplement this policy and can support teams on steps taken to cover the period of receipt to final response.

TRUST STATEMENT Patients, relatives and carers can bring enquiries and concerns to the attention of any member of staff. Best practice is to attempt to diffuse the situation at the earliest opportunity by listening to the concerns raised in an appropriate and empathetic manner and to offer either to resolve the issues if possible or to refer them to a more senior manager.This may prevent an unneccessary formal process and lengthy investigation.

PURPOSE The purpose of this complaints’ procedure is as follows:-

1. to offer an open, honest, candid, fair and equitable system, which is non discriminatory and accessible to people of all backgrounds, by which people who are dissatisfied with the service they have received from the Trust have the opportunity to air their grievance and to receive a response to their concerns;

2. to ensure that the organisation uses information from complaints and other feedback to improve its services and where possible prevent a recurrence of the factors giving rise to a given complaint;

3. to ensure the Trust maintains data regarding its performance in relation to complaints, and provides such data to those bodies which have a legitimate interest in it;

4. to ensure that the concerns and complaints service offered by the Trust is consistent with all relevant legislation and best practice guidance.




SCOPE The policy applies to all groups of staff and anyone using the Trust’s services including those provided by THFT in the Community. Anyone who uses the Trust’s services may complain, including:

The patient

Someone acting on behalf of the patient, and with their written consent. (e.g. an advocate, relative, Member of Parliament);

Parents or legal guardians of children;

Someone acting on behalf of a patient who is unable to represent his or her own interests, provided this does not conflict with the patient’s right to confidentiality or a previously expressed wish of the patient.

DEFINITIONS A complaint is any expression of dissatisfaction, which requires a response. A complainant is the person making the complaint, whether on behalf of themselves or another. The person about whom the complaint is made is referred to as the subject.

DUTIES Chief Executive is responsible for ensuring that an effective and appropriate complaints’ system exists. Chief Nurse is the Executive Director responsible for the operational delivery of the described complaints’ system. Director of Quality & Governance is the Responsible Senior Manager who oversees the complaint process ensuring connectivity with Incidents, Claims, Inquests, Safeguarding and Mortality Review process. Has specific responsibilities as detailed in the job description and oversees Duty of Candour process for the Trust. Is responsible for ensuring the triage process is in place. Divisional Directors/Corporate Directors are responsible to ensure that complaints are received, disseminated to appropriate management teams, there is a thorough investigation and that the response letter is compiled appropriately covering all issues in a chronological order. The Divisional Director of Operations or designated Senior Manager is responsible for letting the PALS and Complaints Team know if the response will be outside the agreed time, the reasons for the delay and the expected date of completion. Head of Openness and Candour has the responsibility for day to day operationally managing the PALS and Complaints Team. This is delegated to the PALS and Complaints Co-ordinator & Complex Case Investigator. The PALS and Complaints Co-ordinator & Complex Case Investigator will ensure that the complaints triage is communicated to the PALS and Complaints Team daily, as specific responsibilities as identified in the Job Description.




PALS and Complaints Team The PALS and Complaints Team will undertake a central role in communicating with the complainant, ensuring an investigation is initiated by the division in which the complaint originated, and that the divisional response is comprehensive and compliant with the expected standard for the response letter. The PALS and Complaints Team will ensure that the designated Senior Manager is informed of a complaint so that it can be appropriately triaged, the team act upon the triage actions and that the Senior Manager is made aware of any problems in meeting the plan agreed with the complainant. The PALS and Complaints Team are responsible for the collection of data in relation to complaints and for entering the data onto the Trust’s database. All Trust staff are responsible for the effective implementation of the policy. This includes:-

Cooperating fully with the investigation of each complaint, and ensuring that any staff for which they have responsibility respond to investigations in a timely and appropriate manner;

Ensuring that action is taken and action plan implemented, following any complaint which gives rise to the need for wider scale implementation of change;

Enabling the processes of organisational learning following a complaint;

Ensuring that complaints are responded to within the agreed timetable;

Releasing staff for relevant training events. All staff have a role to play in reducing the numbers of complaints received by ensuring that:-

as far as possible, their attitude, approach or behaviour do not give service users cause for complaint,

they deal with any issues courteously and efficiently,

they keep good quality records,

they refer on to an appropriate officer if the limits of their authority or experience are exceeded.

POLICY STATEMENT All users of the Trust’s services will have equal access to a fair, modern, fit for purpose complaints’ system in which efforts are continually made to learn.

THE POLICY ITSELF Complaints made verbally but not successfully resolved within an agreed timescale,

and those made in writing or electronically, such as by email, will be acknowledged

within 3 working days. This can be done either verbally or in writing, but unless

exceptional circumstances prevail, it will normally be done in writing. This will also be

undertaken by a member of the Complaints & PALS Team;




The Trust will accept complaints made via any communication route, including written, verbal in person or by phone ; email or other electronic means; via an appropriate third party; via an interpreter etc.

Under this policy, the distinction previously made between “informal” and “formal” complaints is removed, attempts will be made to resolve concerns in a prompt and positive way thus avoiding complaints.

All concerns and complaints that cannot be resolved, in real time or where they meet KO41 criteria or are an MP enquiry will be triaged. Cases that are out of time and cannot be investigated as a KO41 complaint will be logged as a PALS L3. A letter or e-mail will be sent for the acknowledgement of the complaint. A leaflet will be included in each letter advising the complainant of sources of support, Independent Complaints Advocacy Healthwatch Tameside, next stage of the complaints process, and the Ombudsman’s Independent Review process.

Once the timeframe for the method of resolution has been acknowledged with the complainant, the Trust will aim to achieve this unless exceptional circumstances prevail. Only the Trust Director or Designated Senior Manager can give authority for the timeframe and/or method of resolution to be varied;

The Trust will investigate the complaint in a manner appropriate to the nature of the issues it raises, aim to resolve it speedily and efficiently and, during the investigation, keep the complainant informed, as far as reasonably practicable, as to the progress of the investigation and any delays. The facility to agree a timeframe with the complainant will not be seen as a means of unduly extending the process of responding to complaints, but rather as a means of setting a realistic timescale given all the circumstances which may arise – the Trust will still aim to resolve the majority of non-complex complaints in 25 working days though for complex cases this may be 45 working days if investigation or Root Cause Analysis is required. Should this take longer or if information is needed from external third parties, longer timescales may need communicating to the complainant.The focus will be on quality, open candid investigations and responses which sometimes may necessitate a longer time period and a negoiated timescale agreed with the complainant.

Following investigation, the complainant must be sent a written response signed by the “responsible person”. The “responsible person” is the Chief Executive. However, the national regulations allow that the functions of the responsible person may be performed by any person authorised by the Trust to act on behalf of the responsible person. In the case of Tameside Hospital NHS Foundation Trust, this function can be performed by the Chief Nurse, the Medical Director, The Director of Operations and the Director of Quality & Governance. The response for the CEO will be checked by the Director of Quality and Governance or named deputy prior to sending to the CEO office.

The written response must contain text which provides a response to the issues raised or if a meeting is held an audio CD is provided covering all the issues.

The normal time limit whereby people can raise their complaint is 12 months. The Trust will maintain its long standing commitment to responding to all complaints,




irrespective of the time elapsed since the event(s) in question occurred, if there is a reasonable chance of being able to investigate and respond;

If necessary, complainants expressing concerns about events which occurred some considerable time ago will be informed of the limitations this is likely to impose on the response the Trust is able to give, if serious allegations are made they will be investigated if at all possible regardless of the time period. Should any interpretation of the Trust’s time limit regulations be necessary, this will be provided by the Director of Quality and Governance. As a general rule, the Trust expects every member of staff to try to deal with the complainant’s issues, and will provide a programme of training designed to give all staff the confidence and skills to do so. However, when the member of staff dealing with a given issue is unable to investigate or deal with the complaint adequately, or feels unable to give the assurances that the complainant is seeking, or the complainant remains dissatisfied, then the complaint should be referred to the relevant manager for further investigation. Should the complaintant be dissatisfied with the response to the complaint they should be offered a meeting with senior staff who are able to address the further issues. The meeting will be organised and attended by the Complaints & PALS Team whose role it will be to take meeting notes carefully listing the concerns raised at the meeting and ensuring that a satisfactory response is given; following the meeting the notes should be shared with the complainant. The Complaints & PALS Team will ensure that explanations offered during the meeting have been understood by the complainant and/or their representatives and that the complainant has had the opportunity to put all questions to the meeting. If all issues have been resolved a letter of closure to the complaint should be offered to the complainant.

Process for ensuring patients or their relatives / carers are not disadvantaged or treated differently as a result of a complaint Every assistance will be given to individuals who wish to make a complaint, including the provision of interpreter services or any other service or body which may serve to enhance the communication of the complaint to the organisation. Patients must be supported in expressing their concerns and must not be led to believe either directly or indirectly, that they may be disadvantaged because they have made a complaint. Making a complaint / raising a concern does not mean that a patient / complainant will receive less help or that things will be made difficult for them. Everyone can expect to be treated fairly and equally regardless of age, disability, race, culture, nationality, gender and sexual orientation. Within the acknowledgement letter the complainant will be advised that the Trust does not expect any patient to be treated differently as a result of making a complaint and explaining that no record of the complaint will be held in their medical records.




This may be adapted sensitively in the case of deceased patients when it would not be appropriate. The complainant is asked to inform the Complaints & PALS Team if they feel this has occurred, who will then alert senior managers within the Trust to investigate the claim and seek resolution.

Duty of Candour Requirements The regulations for Duty of Candour require all providers registered with CQC, both healthcare and adult social care providers, to be open and transparent with service users about their care and treatment. From November 2014 the regulations also imposed a more specific and detailed Duty of Candour on all providers where any harm to a service user from their care or treatment is above a certain harm-threshold. Where there is a clinical incident involving a patient, the Consultant (or nominated deputy) responsible for the patient together with the appropriate Divisional General Manager, Senior Nurse or nominated deputy will be responsible for ensuring the communication of what has happened and the action intended to the patient and the patient’s family in accordance with the Trust “Being Open Policy” and the duty of candour requirements. Where it comes to light following a concern or complaint raised by the patient or a person acting on behalf of the patient that a patient has been exposed to harm, the Medical Director and/or the Chief Nurse, or Director of Quality and Governance will be responsible for ensuring that they and their relatives are informed. This will be coordinated by the Head of Openness and Candour or the PALs and Complaints Co-ordinator & Complex Case Investigator or Safeguarding Lead in the Quality and Governance Unit. The Trust’s “Being Open” policy must be utilised and actions meet the requirements under duty of candour. The requirements are also outlined in more detail in the Incident Reporting and Incident and Complaints Investigation Policy.

Process for the handling of joint complaints between organisations The Trust will co-operate in resolving complaints that relate to more than one body with the relevant organisations, and as far as possible ensure that the complaint is addressed by a single organisation. Trusts have a duty to co-operate with other organisations ensuring that the complainant receives a single response where their complaint involves more than one organisation. The organisation receiving the complaint must ensure that the complainant receives a full response. Whilst the organisation receiving the complaint would usually be expected to coordinate the investigations and response, there will be occasions when the complaint is predominantly about another organisation’s services and in such cases, and with the complainant’s agreement, the third party organisation will co-ordinate the investigation and response. Where it is identified that the complaint relates to services provided by another organisation such as a Mental Health Trust, other Hospital Trusts, Adult Social Care Services or General Practitioner, the complainant will be contacted and consent will be sought for the complaint to be shared with the other parties involved. Agreement will then be sought as to which organisation will take the lead and the complainant will be duly informed.




Risk Management of Complaints Received Each complaint will be triaged and graded by the office of Quality & Governance or designated Senior Manager, based on the level of known harm. This will determine the level of investigation required and whether any additional actions need to be taken, such as a Serious Incident Review by Root Cause Analysis, or liaison through HM Coroner or involvement of the Trust Safeguarding Team. It will also contribute to the Trust’s body of feedback evidence for service improvement. This triage will identify the next steps for each complaint and the action staff must follow for the complaint, that means complaints do not fall into a ‘one size fits all’ approach. In exceptional circumstances, a complaint may be considered to be so serious that all or part of the investigation of the complaint needs to be undertaken with the assistance of external agencies. Such as independent clinical advisers or legal advisers. If such a complaint is received, the Director of Quality & Governance will usually determine the reporting requirements, determine which agencies are to be involved and coordinate the utilisation of the external body in the complaint process, keeping the Chief Executive (and any other relevant Executive Director) fully appraised of progress and developments. Complainants will be informed of the process.

When the complainant is not the patient If the complainant is not the patient and consent is needed, the Complaints & PALS Team issue a standard form to the patient requesting their permission to release confidential information to the complainant. The investigation can commence at this point (if there is no reason to believe the patient will not give their permission) but no response should be given to the complainant until the signed and dated consent form has been received by the Complaints & PALS Team. If a consent form is issued but not returned, the complaint shall be deemed closed within 10 working days of issue, thereafter the agreed timescale of compliance will commence from the time that the consent form is received.

When the complainant requests access to health care records A proportion of complainants request access to healthcare records in the context of their complaint. Should such a request be made, the PALS and Complaints Team will send an “Access to Health Records Request Form” to the complainant; In certain circumstances, the Trust will waive the fee which normally applies. This decision will usually be taken by the Director of Quality & Governance or designated Senior Manager. The department or division to which the complaint relates will meet the costs of duplication and postage in all such circumstances.

Investigation and Management of Complaints The PALS and Complaints Team will undertake a central role in communicating with the complainant, ensuring an investigation is initiated, check the appropriateness of the divisional written response before presenting for signature by the “responsible person”. The PALS and Complaints Team will make an appropriate senior manager aware of any problems encountered by the division in meeting the plan agreed with the complainant; The Complaints Teams will enter the details of each complaint on to the Safeguard




System (Complaints data base).

Role of the Investigating Officer and Process of Investigation For each complaint, an Investigating Officer will be identified. This will normally be an experienced Senior Manager or Clinician, alternatively it may be led and managed by the in house legal services contact provider who has received training in and/or has extensive experience of the management of complaints. The Investigating Officer may delegate all or part of the investigation to a suitably qualified and/or experienced colleague, but will retain overall responsibility for the quality and content of the investigation and complaint response. An investigation will be overseen by the Investigating Officer, and may involve collecting verbal or written statements from current or former staff, and examination of the relevant documentation and other sources of evidence. It is important that data is collected systematically, recorded at an appropriate professional standard, and filed according to a logical system. The data used in the investigation of a complaint is always requested when the Ombudsman undertakes a second stage independent review. Once the complaint response is completed, the Investigating Officer will ensure that any action and learning is progressed and developed and shared with the relevant staff. For serious complaints the Quality & Governance Unit and designated Senior Manager may initiate investigation aligned to the Serious Incident, Safeguarding or Inquest process as described in the Incidents, Complaints and Claims Reporting and Investigation Policy and if necessary align this to a Serious Incident, Inquest, Claim or Safeguarding process

Meeting a Complainant If a meeting is arranged with the complainant at any point in the process of dealing with a complaint, the Investigating Officer, in collaboration with the PALS and Complaints Team, will ensure that:-

an appropriate time and setting for the meeting has been arranged,

enough time for discussion has been allowed,

the complainant should be advised they can bring a friend, relative or member of an external agency to the meeting,

the relevant Trust personnel are present at the meeting,

the meeting is attended by a member of the PALS and Complaints Team or Divisional Complaints Team.

The meeting will normally form part of, or be subsumed into an agreed plan; Wherever possible the meeting will be at the agreement of the complainant , digitally recorded and the complainant is given a copy of the CD after the meeting.




The Investigating Officer will within 4 weeks maximum of the meeting provide to the complainant a written record, summarising what was said and agreed, in the form of a letter. If it is the Trust’s intention that the complaint be closed via this formal written response, the text should clearly indicate that local resolution has been exhausted. All of the foregoing should be explained to the complainant before the meeting commences. The need to maintain appropriate written, dated and signed records at all stages of the complaints process, and particularly in these circumstances, cannot be stressed too highly.

Complaints giving rise to issues which are the concern of other agencies Occasionally, concerns may arise from complaints which need to be referred to other agencies (e.g. the police, professional regulatory bodies, the Coroner, or the Child or Safeguarding Adult protection structures). In such cases, the advice of the Quality & Governance Unit should be sought. This will normally be the Director of Quality & Governance, the Director of Human Resources or the Medical Director.

Complaints about the Freedom of Information or Data Protection Act Complaints about the operation of the Freedom of Information Act and the Data Protection Act are dealt with via separate structures and procedures. The Head of Assurance and Governance is responsible for the operation of these structures, and should be contacted in the first instance.

Responding to the complainant and concluding the complaint process The Investigating Officer or PALS and Complaints Officer will produce a draft letter of response in sufficient time to meet the response deadline agreed with the complainant. This will be written as though from the Chief Executive. To enable the CEO to personally review and sign it. It will convey to the complainant that their complaint has been taken seriously, appropriately investigated and be written in an appropriate tone. It will indicate what action the complainant can immediately take if not satisfied, and where appropriate contain an apology. It will respond to all of the issues raised by the complainant, normally in the order presented by the complainant, and provide background information, such as a clinical chronology, if this will assist in the explanation. Health care terminology will be avoided, or defined in lay person’s terms when used.




Similarly, any abbreviations used will be both written in full and defined on the first occasion they appear in the letter of response. It will describe how the complaint has been considered, what conclusions have been reached and what actions, if any, have or will be taken as a result. The draft final response is sent by the PALS and Complaints Teams as a printed draft copy to the designanted Senior Manager for checking. If the Director of Quality and Governance is unavailable through planned absence, a deputy will be identified. Where absence is unforeseen the Chief Executive will nominate an Executive Director to undertake the roles.

Defining Outcomes

We use the following criteria:

Upheld Complaints in which the main or majority of concerns were found to be correct on investigation and an apology given.

Partly Upheld Complaints in which, on investigation, the main concerns were not found to be upheld, however some of the concerns or issues raised by the complainant were found to be correct and an apology given.

Not Upheld

Complaints in which the main or majority of concerns were not found to be correct on investigation. If a complaint is not upheld, we still recognise the validity of the concern to that complainant and we acknowledge that we have failed to meet their expectations.

Closure of Complaints Once a final letter has been sent from the Chief Executive (or the process agreed with the complainant has been completed, if different), the Complaint is closed on the system. It may not be possible to resolve a complaint where the complainant’s expectations of the outcome are unrealistic or a matter of opinion. However, complaints should only be re-opened where evidence can be provided that the original issues raised have not been addressed. In this case the complaint is referred to as a ‘further’ complaint and shoud be investigated as soon as possible and the investigation and letter should follow the process flow as for the orginal complaint. The expectation of the Trust is that the response should be sent as soon after receipt of the futher letter but should aim to give a timescale based upon the level of further investigation detail, though further extension may be needed depending on the further issues. If the complainant raises new issues, the designated Senior Manger will formally determine whether the complaint should be deemed a new complaint and advise the




PALS and Complaints Team to update the database accordingly. If the complainant makes comments on the Trust’s final response, requests further information, requests access to healthcare records, or makes other enquiries without additional complaints, this will not be regarded as a new complaint, but a continuation of a previous complaint. In these circumstances the Trust will respond in the manner it considers most appropriate. Records will be maintained to demonstrate the Trust’s continuing commitment to patient satisfaction.

Requests for Compensation All requests for compensation and losses will be considered in accordance with the:

NHS Finance Manual

PHSO Principles of Redress

Civil Litigation Protocols that are in place All requests for compensation must be discussed with and considered by the Director of Quality and Governance or a nominated deputy and be in line with Standing Financial Instructions.

Complainants who cannot be satisfied by the Trust’s procedure Occasionally a situation may arise where, despite every effort made by the Trust, the Complainant remains dissatisfied and continues to make complaints. Provided the Complainant has been informed of his/her rights to request an Independent Review from the Ombudsman, a decision will be taken by the Designated Director. The Chief Executive will write to the complainant informing them of this decision and that no further action will be taken by the Trust on their complaint, but reiterating the alternatives open to the complainant.

Vexatious Complainants The Chief Executive, in consultation with the Director of Quality & Governance (as appropriate) may also deem a complainant to be “vexatious”, that is, a complainant who does not intend that his complaint should ever be resolved, and is pursing the complaint for other reasons. Again, the Chief Executive will write to the complainant informing them of this decision, and that no further action will be taken by the Trust on their complaint, but reiterating the alternatives open to the complainant. The Complaints Teams will keep a record of all Vexatious Complainants, and share the names with the Foundation Trust Membership Office, since Vexatious Complainants are not allowed to hold Membership of the Foundation Trust.

Ombudsman Investigations A complainant who remains dissatisfied has the right to request an Independent Review of their case by the Ombudsman.




This advice is contained in the complaints leaflet given to all persons making a formal complaint and is enclosed with the acknowledgement letter to all complainants; for the sake of monitoring this requirement the PALS and Complaints Team makes an entry on Safeguard that the Complaints Leaflet has been sent out. The Trust will provide every assistance to the Ombudsman, and in particular will ensure that all requested information is provided within stated deadlines and that all the principles of redress are considered.

Management and Storage of Complaints Files A complaint file has the same status as any other created by a healthcare organisation, and is thus a confidential record. The Trust will therefore at all times provide facilities for the storage of complaints files which enable complaints files to:

be easily located by appropriately authorised individuals;

be retained safely, without danger of damage or corruption, and in a complete state;

be easily retrieved and understood, in the event of further inquiry;

contain relevant items such as statements or investigation notes, or to clearly identify where such materials are located;

be kept for 10 years from the date upon which the complaint was completed;

be disposed of confidentially when they have expired;

be kept separately from the healthcare record – similarly, the healthcare record should contain no material from or reference to a complaint or its investigation.

The Trust will ensure that its’ management and storage of complaints files is consistent with any relevant guidance which may apply. All Complaints will be logged on the Trust Risk management database. Should any material relating to a complaint be discovered in a health care record, it will be removed and reconciled with the complaint file. The person misfiling the material will be reminded of Trust policy, if they can be identified.

POLICY DEVELOPMENT & CONSULTATION

This policy builds on previous versions and iterations, and reflects current guidance and legislation. The policy was updated with contributions from members of the Trust Executive Management Team, Senior Nurse & Midwifery Manager’s Group, Quality and Governance Committee and the Nursing Directorate.

IMPLEMENTATION The policy will be implemented with immediate effect and issued to the organisation on the understanding that it completely replaces version 8.2.




Structures for the implementation of the complaints system, including audit and reporting already exist. The policy will be widely and positively promoted within the organisation, and will ensure that the complainants do not feel they will be discriminated against if they make a complaint, but rather that their complaint will help to improve services for future patients. The Trust will continue to offer training to all staff, providing bespoke sessions where required. The training will be offered by the Quality and Governance Unit.

MONITORING Monitoring of the Complaints System and Policy The monitoring of this policy is specified. Where monitoring has identified deficiencies, recommendations and action plans will be developed and changes implemented accordingly, these will be monitored by the Chief Nurse.

Governance structure Concerns and Complaints are included and discussed

at every Board Meeting as they are included Integrated Quality Account Performance Report and in the Aggregated Learning Summary. Complaints that have been converted to Serious Incidents are included in the Part 2 Serious Incident update to Trust Board. There are designated groups and Committees with operational responsibility for oversight and monitoring of the complaints process. The Executive Management Team review the number of on-going complaints and cases of specific concern are discussed if required. The Quality and Governance Committee receive monthly information on Complaints through the Aggregated Learning Report. The Service Quality & Operational Governance Group (SQOGG) also receives the Aggregated Learning Report and summaries of minutes from Divisional Governance meetings. At a Divisional level, governance meetings are held within each Division on a monthly basis and complaints are included as a standard agenda item for these meetings. The Learning from complaints is incorporated on the agenda and discussed within these meetings. There is a Trust wide Learning from Experience Group and Patient Experience Group where complaints are discussed and reviewed. An Annual Complaint report will be generated and reported through the Trust Governance structures and publlished on the Trust website as required by statutory regulation.

Learning from Complaints As can be seen from the previous section, the Trust has available a number of means by which complaint data is collated, analysed and distributed.




The Trust is strongly committed to the concept of organisational learning, and recognises that whatever the circumstances, and however regrettable these may be, each complaint provides opportunities for organisational learning to occur. Sometimes, the complaint has Trust wide, or supra divisional implications. Normally, the learning for such complaints will be included in the Learning from Experience Newsletters and Aggregated Learning Report produced by the Quality and Governance Unit. The Trust’s Duty of Candour report contains examples of changes in practice or other forms of organisation learning which have arisen following complaints received in the period to which the Duty of Candour report relates. For Divisional complaints with a more local focus, the manager for the area in which the complaint occurred will produce action in order to improve the service and avoid repetitions of the incidents giving rise to the complaint. These actions will be subject to periodic evaluation by an appropriate part of the organisation, such as the Divisional Management Team or the Ward Managers’ meetings for the respective division. Implementation of action plans will be monitored by the Quality & Governance Unit. The Trust also requires that feedback is given to the individuals involved in the circumstances giving rise to the complaint. The manager for that area will identify the most appropriate means of providing feedback, which may include direct verbal or written briefing and which may lead to the implementation of other measures such as further training, disciplinary procedures, recorded counselling, or no further action.

Staff Training Complaints Management and Investigation training for all eligible

staff across the Trust. Delivered in line with the TNA attached as Appendix 1. Senior staff to attend to ensure familiarisation of the Trust’s complaints Policy and expected standards in relation to complaints.




REFERENCES “Complaints: Listening … Acting … Improving - Guidance on the Implementation of the NHS Complaints Procedure’ (Department of Health, 1996)

“Cause for Complaint? An evaluation of the effectiveness of the NHS complaints procedure” (Public Law Project, 1999)

“Effective Responses to Complaints About Health Services - A protocol” (Healthcare Commission, 2006)

“Management of Complaints Files – Good Practice Guide” (Healthcare Commission, 2006)

“National Health Service Complaints Regulations 2004, Amended 2006” (HMSO, 2006)

“Principles for Remedy” Parliamentary & Health Service Ombudsman (HMSO, 2006)

“Is Anyone Listening? – A Report on Complaints Handling in the NHS” (Healthcare Commission, 2007)

“Handling Complaints within the NHS – Complaints Toolkit” (Healthcare Commission, 2008)

APPENDIX 1. Complaints Training Needs Analysis 2. Equality Inpact Assessment

BIBLIOGRAPHY None

REVIEW This policy will be formally reviewed September 2016, or earlier depending on the results of monitoring and/or changes to national legislation or guidance which may be produced in the intervening period.




APPENDIX 1 – Complaints Training Needs Analysis

Complaints Management and Investigation.

Training needs analysis.

Issue Staff Group Frequency Method

Induction. Information training induction

slide

All

As a minimum at

commencement of employment, as part of

corporate induction

Slides at induction

Complaints and concerns

handling

Front line managers and

supervisors, nominated key individuals

One off training scheduled 4

sessions annually

One off training

1 day RCA training provided by

an external company

Nominated managers,

clinicians and supervisors based on role and

responsibilities

One off training commencing

winter 2014.

Classroom based teaching




APPENDIX 2 – Equality Impact Assessment

Yes/No Comments

1. Does the policy/guidance affect one

group less or more favourably than

another on the basis of:

Race No

Ethnic origins (including gypsies and travellers)

No

Nationality No

Gender No

Culture No

Religion or belief No

Sexual orientation including lesbian, gay and bisexual people

No

Age No

Disability - learning disabilities, physical disability, sensory impairment and mental health problems

No

2. Is there any evidence that some groups

are affected differently?

No

3. If you have identified potential

discrimination, are any exceptions

valid, legal and/or justifiable?

N/A

4. Is the impact of the policy/guidance

likely to be negative?

No

5. If so can the impact be avoided? N/A

6. What alternatives are there to achieving

the policy/guidance without the impact?

N/A

7. Can we reduce the impact by taking

different action?

N/A

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