Complaints and Concerns Policy
|
|
- Jessie Strickland
- 6 years ago
- Views:
Transcription
1 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
2 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 VERSION 8.3 (April 2016) Page 2 of 20
3 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 IMPLEMENTATION MONITORING REFERENCES BIBLIOGRAPHY REVIEW APPENDIX 1 Complaints Training Needs Analysis...19 APPENDIX 2 Equality Impact Assessment...20 VERSION 8.3 (April 2016) Page 3 of 20
4 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. VERSION 8.3 (April 2016) Page 4 of 20
5 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. VERSION 8.3 (April 2016) Page 5 of 20
6 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 , 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; VERSION 8.3 (April 2016) Page 6 of 20
7 The Trust will accept complaints made via any communication route, including written, verbal in person or by phone ; 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 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, VERSION 8.3 (April 2016) Page 7 of 20
8 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. VERSION 8.3 (April 2016) Page 8 of 20
9 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 vember 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 Coordinator & 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. VERSION 8.3 (April 2016) Page 9 of 20
10 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 VERSION 8.3 (April 2016) Page 10 of 20
11 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. VERSION 8.3 (April 2016) Page 11 of 20
12 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. VERSION 8.3 (April 2016) Page 12 of 20
13 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 Partly Upheld t Upheld Complaints in which the main or majority of concerns were found to be correct on investigation and an apology given. 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. 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 VERSION 8.3 (April 2016) Page 13 of 20
14 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. VERSION 8.3 (April 2016) Page 14 of 20
15 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. VERSION 8.3 (April 2016) Page 15 of 20
16 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. VERSION 8.3 (April 2016) Page 16 of 20
17 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. rmally, 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. VERSION 8.3 (April 2016) Page 17 of 20
18 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 ne 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. VERSION 8.3 (April 2016) Page 18 of 20
19 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 minated managers, clinicians and supervisors based on role and responsibilities One off training commencing winter Classroom based teaching VERSION 8.3 (April 2016) Page 19 of 20
20 APPENDIX 2 Equality Impact Assessment Yes/ Comments 1. Does the policy/guidance affect one group less or more favourably than another on the basis of: Race Ethnic origins (including gypsies and travellers) Nationality Gender Culture Religion or belief Sexual orientation including lesbian, gay and bisexual people Age Disability - learning disabilities, physical disability, sensory impairment and mental health problems 2. Is there any evidence that some groups are affected differently? 3. If you have identified potential discrimination, are any exceptions valid, legal and/or justifiable? 4. Is the impact of the policy/guidance likely to be negative? N/A 5. If so can the impact be avoided? N/A 6. What alternatives are there to achieving the policy/guidance without the impact? 7. Can we reduce the impact by taking different action? N/A N/A VERSION 8.3 (April 2016) Page 20 of 20
Policies, Procedures, Guidelines and Protocols
Policies, Procedures, Guidelines and Protocols Document Details Title Complaints and Compliments Policy Trust Ref No 1353-29025 Local Ref (optional) N/A Main points the document This policy and procedure
More informationComplaints, Compliments and Concerns (CCC) Policy
Complaints, Compliments and Concerns (CCC) Policy Central and North West London NHS Foundation Trust (CNWL) is committed to providing quality NHS services and adopting best practice in listening and responding
More informationCan I Help You? V3.0 December 2013
Can I help you? Policy for the provision and management of patient feedback: comments, concerns or compliments, or complaints about NHS 24 and its services. Author: Patient Affairs Manager/ ADoN Clinical
More informationFirst Community Health & Care Board POLICY FOR HANDLING COMPLAINTS
First Community Health & Care POLICY FOR HANDLING COMPLAINTS Version: 4 Name of Approval body : Name of Ratification Body: Date of Ratification April, 2013 Name of originator/author: Effective From April
More informationTHE ADULT SOCIAL CARE COMPLAINTS POLICY
THE ADULT SOCIAL CARE COMPLAINTS POLICY April 2009 Reviewed: January 2018 1 Cambridgeshire County Council Contents 1.0 Purpose Page 3 2.0 Principles Page 3 3.0 Accessing information about how to raise
More informationNHS CHOICES COMPLAINTS POLICY
NHS CHOICES COMPLAINTS POLICY 1 TABLE OF CONTENTS: INTRODUCTION... 5 DEFINITIONS... 5 Complaint... 5 Concerns and enquiries (Incidents)... 5 Unreasonable or Persistent Complainant... 5 APPLICATIONS...
More informationNHS England Complaints Policy
NHS England Complaints Policy 1 NHS England INFORMATION READER BOX Directorate Medical Operations Patients and Information Nursing Policy Commissioning Development Finance Human Resources Publications
More informationPatient Experience Policy
Teamwork Innovation Professionalism Caring Patient Experience Policy Complaints Concerns Healthcare Professional Feedback Compliments/Commendations Version: 3.0 Policy Lead: Head of Patient Experience
More informationUoA: Academic Quality Handbook
UoA: Academic Quality Handbook UNIVERSITY OF ABERDEEN COMPLAINT HANDLING PROCEDURE 1 POLICY The University is committed to providing a high level of service to students, applicants, graduates, and members
More informationComplaints and Suggestions for Improvement Handling Procedure
Complaints and Suggestions for Improvement Handling Procedure Date of most recent review: 20 June 2013 Date of next review: August 2016 Responsibility: Quality Officer Approved by: Learning, Teaching and
More informationCOMPLAINTS POLICY. Head of Complaints & Customer Service Improvement
COMPLAINTS POLICY POLICY REFERENCE NUMBER CP2 VERSION NUMBER 1 REPLACES SEPT DOCUMENT CP2 REPLACES NEP DOCUMENT CRP7 KEY CHANGES FROM PREVIOUS Not applicable VERSION AUTHOR Head of Complaints & Customer
More informationComplaints Handling. 27/08/2013 Version 1.0. Version No. Description Author Approval Effective Date. 1.0 Complaints. J Meredith/ D Thompson
Complaints Handling Procedure Version No. Description Author Approval Effective Date 1.0 Complaints Procedure J Meredith/ D Thompson Court (Jun 2013) 27 Aug 2013 27/08/2013 Version 1.0 Procedure for handling
More informationReplacement. Supersedes: Complaints Procedure ( ) and the Patient Advice and Liaison Service Policy ( )
Corporate Complaints: Standard Operating Procedure Document Control Summary Status: Replacement. Supersedes: Complaints Procedure (28.10.10) and the Patient Advice and Liaison Service Policy (28.07.11)
More informationBurton Hospitals NHS Foundation Trust POLICY DOCUMENT. On: 26 October Review Date: October Department Responsible for Review:
POLICY DOCUMENT Burton Hospitals NHS Foundation Trust COMPLAINTS POLICY AND PROCEDURE Approved by: Quality Committee On: 26 October 2017 Review Date: October 2020 Corporate / Division Corporate Clinical
More informationParkbury House Surgery
Parkbury House Surgery Complaint Policy and Procedures St Peters Street, St Albans, Hertfordshire, AL1 3HD Tel: 01727 851589 Fax: 01727 854372 parkburyhouse.info@nhs.net; www.parkburyhouse.nhs.uk Version
More informationComplaints Management Policy
Complaints Management Policy Policy Reference Number CMP001 Status Ratified Version 9 Implementation Date January 2002 Publication date June 2017 Current/Last Review Dates Dec 2006, Nov 2008, June 2009,
More informationPatient Experience Strategy
Patient Experience Strategy 2013 2018 V1.0 May 2013 Graham Nice Chief Nurse Putting excellent community care at the heart of the NHS Page 1 of 26 CONTENTS INTRODUCTION 3 PURPOSE, BACKGROUND AND NATIONAL
More informationComplaints Policy. Version: 4.2. Approved: 27/01/2015
Complaints Policy Policy Summary This policy and procedures exist to ensure that there are effective arrangements in place to be compliant with statutory obligations and ensure the process is open and
More informationCARERS POLICY. All Associate Director of Patient Experience. Patient & Carers Experience Committee & Trust Management Committee
CARERS POLICY Department / Service: Originator: All Associate Director of Patient Experience Accountable Director: Chief Nursing Officer Approved by: Patient & Carers Experience Committee & Trust Management
More informationThe Social Work Model Complaints Handling Procedure
The Social Work Model Complaints Handling Procedure Issued: December 2016 Scottish Public Services Ombudsman The Social Work Model Complaints Handling Procedure I 2 The Social Work Model Complaints Handling
More informationThe Mental Capacity Act 2005 Legislation and Deprivation of Liberties (DOLs) Authorisation Policy
The Mental Capacity Act 2005 Legislation and Deprivation of Liberties (DOLs) Authorisation Policy Version Number 3 Version Date vember 2015 Policy Owner Director of Nursing and Clinical Governance Author
More informationNURSES HOLDING POWER SECTION 5(4) MENTAL HEALTH ACT 1983 NOVEMBER 2015
NURSES HOLDING POWER SECTION 5(4) MENTAL HEALTH ACT 1983 NOVEMBER 2015 This policy supersedes all previous policies for Nurses Holding Power Section 5(4) MHA 1983. 1 Policy title Nurses Holding Power Section
More informationLone worker policy. Director of Nursing Therapies Patient Partnership Author and contact number Safety and Security Lead
Document level: Trustwide (TW) Code: GR33 Issue number: 3 Lone worker policy Lead executive Director of Nursing Therapies Patient Partnership Author and contact number Safety and Security Lead 01244 397618
More informationPage 1 of 18. Summary of Oxfordshire Safeguarding Adults Procedures
Page 1 of 18 Summary of Oxfordshire Safeguarding Adults Procedures Page 2 of 18 Introduction This part of the procedures sets out clear expectations regarding the standards roles and responsibilities of
More informationSAFEGUARDING CHILDEN POLICY. Policy Reference: Version: 1 Status: Approved
SAFEGUARDING CHILDEN POLICY Policy Reference: Version: 1 Status: Approved Type: Clinical Policy Policy applies to : All services within SCH Serco Policy applies to (staff groups): All SCH Serco staff Policy
More informationSection 132 of the Mental Health Act 1983 Procedure for Informing Detained Patients of their Legal Rights
Section 132 of the Mental Health Act 1983 Procedure for Informing Detained Patients of their Legal Rights DOCUMENT CONTROL: Version: 11 Ratified by: Mental Health Legislation Sub Committee Date ratified:
More informationAnnual Complaints Report 2014/15
Annual Complaints Report 2014/15 1.0 Introduction This report provides information in regard to complaints and concerns received by The Rotherham NHS Foundation Trust between 01/04/2014 and 31/03/2015.
More informationStandards of Practice for Optometrists and Dispensing Opticians
Standards of Practice for Optometrists and Dispensing Opticians effective from April 2016 Standards of Practice for Optometrists and Dispensing Opticians Standards of Practice Our Standards of Practice
More informationThe Newcastle upon Tyne Hospitals NHS Foundation Trust
The Newcastle upon Tyne Hospitals NHS Foundation Trust Advance Decision to Refuse Treatment Policy (Advanced Refusal of Treatment/ Previously known as Living Wills) Incorporating the Mental Capacity Act
More informationComplaints policy RM07
Complaints policy RM07 Beware when using a printed version of this document. It may have been subsequently amended. Please check online for the latest version. Applies to: All service users Date of Board
More informationCOMPLAINTS MANAGEMENT PROCEDURE
COMPLAINTS MANAGEMENT PROCEDURE The key messages the reader should note about this document are: 1. All complaints received either in writing or done verbally should be forwarded onto the Complaints team
More informationPARLIAMENTARY AND HEALTH SERVICE OMBUDSMAN. Information Sharing Policy Sharing and Publishing information about NHS Complaints. Version 2.
PARLIAMENTARY AND HEALTH SERVICE OMBUDSMAN Information Sharing Policy Sharing and Publishing information about NHS Complaints Version 2.0 Page 1 of 8 Document Control Title: Policy Information Sharing
More informationA Case Review Process for NHS Trusts and Foundation Trusts
A Case Review Process for NHS Trusts and Foundation Trusts 1 1. Introduction The Francis Freedom to Speak Up review summarised the need for an independent case review system as a mechanism for external
More informationLearning from Deaths Policy A Framework for Identifying, Reporting, Investigating and Learning from Deaths in Care.
Learning from Deaths Policy A Framework for Identifying, Reporting, Investigating and Learning from Deaths in Care. Associated Policies Being Open and Duty of Candour policy CG10 Clinical incident / near-miss
More informationThis policy is intended to ensure that we handle complaints fairly, efficiently and effectively.
Introduction 1.1 Purpose This policy is intended to ensure that we handle complaints fairly, efficiently and effectively. Our complaint management system is intended to: enable us to respond to issues
More informationCentral Alerting System (CAS) Policy
Document Title Reference Number Lead Officer Author(s) (name and designation) Ratified By Central Alerting System (CAS) Policy NTW(O)17 Gary O Hare Executive Director of Nursing and Operations Tony Gray
More informationMORTALITY REVIEW POLICY
MORTALITY REVIEW POLICY Version 1.3 Version Date July 2017 Policy Owner Medical Director Author Associate Director of Patient Safety & Quality First approval or date last reviewed July 2017 Staff/Groups
More informationCUSTOMER CARE POLICY Compliments, Comments, Concerns and Complaints
CUSTOMER CARE POLICY Compliments, Comments, Concerns and Complaints Document reference number IML002 Status Approved Version number 5.0 Replacing/superseding policy or Customer Care Policy version 4.0
More informationComplaints Policy and Procedure
Complaints Policy and Procedure NHS East and North Hertfordshire Clinical Commissioning Group Page 1 of 45 DOCUMENT CONTROL SHEET Document Owner: Document Author(s): Version: 1 Directorate: Nursing and
More informationSummary guide: Safeguarding Adults: Pan Lancashire and Cumbria Multi Agency Policy and Procedures. For partner agencies staff and volunteers
Summary guide: Safeguarding Adults: Pan Lancashire and Cumbria Multi Agency Policy and Procedures For partner agencies staff and volunteers 1 1. Introduction This Summary Guide is designed to provide straightforward
More informationPHARMACEUTICAL REPRESENTATIVE POLICY NOVEMBER This policy supersedes all previous policies for Medical Representatives
PHARMACEUTICAL REPRESENTATIVE POLICY VEMBER 2017 This policy supersedes all previous policies for Medical Representatives Policy title Pharmaceutical Representative Policy Policy PHA39 reference Policy
More informationCompliments, Concerns and Complaints policy
Compliments, Concerns and Complaints policy Document information Document title Classification Compliments, Concerns and Complaints policy Open Document/Reference Number: 71229 Document Custodian: Other
More informationACCESS TO HEALTH RECORDS POLICY & PROCEDURE
ACCESS TO HEALTH RECORDS POLICY & PROCEDURE Document Number 2009/45 Version 3 Document Title Access to Health Records Policy & Procedure Author Karl Perryman Author s Job Title Head of Legal Services Department
More informationComplaints Policy. Local Authority Social Services and NHS Complaints (England) Regulations Version: 2. Status: For approval
Complaints Policy Version: 2 Status: Title of originator/author: Name of responsible director: Approved by group/committee and Date: Effective date of issue: (1 month after approval date) For approval
More informationIntegration Scheme. Between. Glasgow City Council. and. NHS Greater Glasgow and Clyde
Integration Scheme Between Glasgow City Council and NHS Greater Glasgow and Clyde December 2015 Page 1 of 60 1. Introduction 1.1 The Public Bodies (Joint Working) (Scotland) Act 2014 (the Act) requires
More informationPatient Advice and Liaison Service (PALS) policy
Patient Advice and Liaison Service (PALS) policy Incorporating Have Your Say (HYS) First Issued May 04 by Birkenhead & Wallasey PCT. Responsibility of Wirral PCT since October 2006 Issue Purpose of Issue/Description
More informationHow CQC monitors, inspects and regulates adult social care services
How CQC monitors, inspects and regulates adult social care services November 2017 Contents MONITORING AND INFORMATION SHARING... 3 How we monitor and inspect adult social care services... 3 CQC Insight...
More informationEQUAL OPPORTUNITY & ANTI DISCRIMINATION POLICY. Equal Opportunity & Anti Discrimination Policy Document Number: HR Ver 4
Equal Opportunity & Anti Discrimination Policy Document Number: HR005 002 Ver 4 Approved by Senior Leadership Team Page 1 of 11 POLICY OWNER: Director of Human Resources PURPOSE: The purpose of this policy
More informationThe Newcastle upon Tyne Hospitals NHS Foundation Trust. Introduction and Development of New Clinical Interventional Procedures
The Newcastle upon Tyne Hospitals NHS Foundation Trust Introduction and Development of New Clinical Interventional Procedures Version No.: 2.1 Effective From: 27 November 2017 Expiry Date: 7 January 2019
More informationHow we use your information. Information for patients and service users
How we use your information Information for patients and service users What we record about you Pennine Care NHS Foundation Trust provides mental health and community health services to people living in
More informationLearning from Deaths Policy LISTEN LEARN ACT TO IMPROVE
Learning from Deaths Policy LISTEN LEARN ACT TO IMPROVE EQUALITY IMPACT The Trust strives to ensure equality and opportunity for all, both as a major employer and as a provider of health care. This policy
More informationPolicy for the Management of Complaints/Concerns
Document Title Policy for the Management of Complaints/Concerns Document Description Document Type Policy Service Application Trust Wide Version 2.0 Name Phao Hewitson Garry Perry Lead Author(s) Job Title
More informationPolicy for the recording, investigation and management of complaints / concerns & compliments
Document level: Trustwide(TW) Code: GR4 Issue number: 9 Policy for the recording, investigation and management of complaints / concerns & compliments Lead executive Authors details Type of document Target
More informationComplaints Sanctuary Students Procedure SS/LW0315/CP. Sanctuary Group:
Subject/Title: Complaints Procedure Sanctuary Students Business Function: Complaints Procedure Sanctuary Students Author(s): Operations/Accommodation Manager Other Contributors: Director of Operational
More informationThe University of Edinburgh Complaint Handling Procedure
University of Edinburgh Complaint Handling Procedure April 2016 P a g e 1 The University of Edinburgh Complaint Handling Procedure April 2016 University of Edinburgh Complaint Handling Procedure April
More informationMANAGEMENT OF COMPLIMENTS, COMMENTS, CONCERNS AND COMPLAINTS POLICY
Ref No: 221 MANAGEMENT OF COMPLIMENTS, COMMENTS, CONCERNS AND COMPLAINTS POLICY SECTION 1 PROCEDURAL INFORMATION Version: 3 Ratified by: Date ratified: March 2014 Title of author: Title of responsible
More informationMortality Policy. Learning from Deaths
Mortality Policy Learning from Deaths Name of Author and Job Title: Frank Jacobs, Datix project manager Ian Brandon, Head of governance and risk Name of Review/ Development Body: Ratification Body: Mortality
More informationA Guide for Parents/Carers About Making a Complaint
Education Young Children s Service Nursery School and Young Children s Centres A Guide for Parents/Carers About Making a Complaint YCS COMPLAINTS PROCEDURE Introduction The Local Ombudsman s guidance states
More informationThe NHS Scotland Complaints Handling Procedure. NHS Highland
The NHS Scotland Complaints Handling Procedure NHS Highland April 2017 National Health Service Scotland Complaints Handling Procedure Foreword Our complaints handling procedure reflects NHS Highland commitment
More informationAnnual Complaints Report 2017/2018
. Annual Complaints Report 2017/2018 CCG Information Reader Box Document Purpose CCG Website Link Title Author For information www.easterncheshireccg.nhs.uk NHS Eastern Cheshire Clinical Commissioning
More informationThe NHS Constitution
2 The NHS Constitution The NHS belongs to the people. It is there to improve our health and wellbeing, supporting us to keep mentally and physically well, to get better when we are ill and, when we cannot
More informationSCHOOL COMPLAINTS POLICY AND PROCEDURES
SCHOOL COMPLAINTS POLICY AND PROCEDURES Updated: September 2016 Review: September 2019 This Policy is founded within our School ethos which provides a caring, friendly and safe environment for all members
More informationCOMPLAINTS, CONCERNS and COMPLIMENTS POLICY
COMPLAINTS, CONCERNS and COMPLIMENTS POLICY 2017-2019 V 4 May 2017 Version: 4 Ratified by: Date ratified: Name of originator/author: Name of lead: Date issued/published: Stephen Hendry, Senior Corporate
More informationVersion: 3.0. Effective from: 29/08/2012
Policy No: RM51 Version: 3.0 Name of policy: Learning from Experience Policy A systematic approach to incident, complaint and clai management, analysis and sharing safety lessons Effective from: 29/08/2012
More informationCounselling Policy. 1. Introduction
Counselling Policy 1. Introduction Counselling is an intervention that children or young people can voluntarily enter into if they want to explore, understand and overcome issues in their lives which may
More informationQuality Assurance Framework Adults Services. Framework. Version: 1.2 Effective from: August 2016 Review date: June 2017
Quality Assurance Framework Adults Services Framework Version: 1.2 Effective from: August 2016 Review date: June 2017 Signed off by: Sharon Gogan Title: Head of Adult Social Care Date: 20 th May 2014 Quality
More informationRaising Concerns or Complaints about NHS services
Raising Concerns or Complaints about NHS services Raising concerns and complaints A step by step guide Raising concerns and complaints Questions to ask yourself: 1. What am I concerned or dissatisfied
More informationManagement of Reported Medication Errors Policy
Management of Reported Medication Errors Policy Approved By: Policy & Guideline Committee Date of Original 6 October 2008 Approval: Trust Reference: B45/2008 Version: 4 Supersedes: 3 February 2015 Trust
More informationFreedom to speak up: raising concerns (whistleblowing) policy
Freedom to speak up: raising concerns (whistleblowing) policy When using this document please be sure that the version you are using is the most up to date either by checking on the Trust intranet or if
More informationQuality and Safety Committee Terms of Reference
Approved May 2016 Quality and Safety Committee Terms of Reference 1. Constitution The Quality and Safety Committee is established as a sub-committee of The Hillingdon Hospitals NHS Foundation Trust (THH)
More informationA concern means any complaint, claim or reported patient safety incident.
PUTTING THINGS RIGHT ANNUAL REPORT -2017 Introduction The Putting Things Right Annual Report provides information on the progress and performance of Powys Teaching Local Health Board (hereafter, the health
More informationStaffordshire and Stoke on Trent Adult Safeguarding Partnership Board Safeguarding Adult Reviews (SAR) Protocol
Staffordshire and Stoke on Trent Adult Safeguarding Partnership Board Safeguarding Adult Reviews (SAR) Protocol SAR Process July 2014 (revised August 2017) Page 1 Contents 1. Introduction 2. Criteria 3.
More informationTHE CODE. Professional standards of conduct, ethics and performance for pharmacists in Northern Ireland. Effective from 1 March 2016
THE CODE Professional standards of conduct, ethics and performance for pharmacists in Northern Ireland Effective from 1 March 2016 PRINCIPLE 1: ALWAYS PUT THE PATIENT FIRST PRINCIPLE 2: PROVIDE A SAFE
More informationPOLICY FOR THE REPORTING AND MANAGEMENT OF COMPLAINTS, COMMENTS & CONCERNS
POLICY FOR THE REPORTING AND MANAGEMENT OF COMPLAINTS, COMMENTS & CONCERNS October 2017 Authorship: Patient Experience Manager, Directorate of Quality & Assurance, NLCCG Quality & Experience Manager, Directorate
More informationDiagnostic Testing Procedures in Urodynamics V3.0
V3.0 09 01 18 Table of Contents Summary.... 1. Introduction... 3 1.1. Diagnostic testing information... 3 2. Purpose of this Policy/Procedure... 3 2.1. Approved Document Process... 3 3. Scope... 3 3.1.
More informationGUIDELINE FOR THE USE OF KEYS AND KEYSAFE CODES FOR ADULT COMMUNITY HEALTH TEAM WORKERS
GUIDELINE FOR THE USE OF KEYS AND KEYSAFE CODES FOR ADULT COMMUNITY HEALTH TEAM WORKERS Guideline Reference: 1686 Version: 3.0 Status: Approved Type: Clinical Guideline Guideline applies to (Staff Group)
More informationSafeguarding Adults Reviews Protocol
Staffordshire and Stoke on Trent Adult Safeguarding Partnership Board Safeguarding Adults Reviews Protocol July 2016 SAR Process July 2014 (revised July 2016) Page 1 Contents 1. Introduction 2. Criteria
More informationMental Health Act Policy. Board library reference Document author Assured by Review cycle. Introduction Purpose or aim Scope...
Mental Health Act Policy Board library reference Document author Assured by Review cycle P041 Associate Director of Governance, Quality and Regulatory Compliance Quality and Standards Committee 1 Year
More information12. Safeguarding Enquiries: Responding to a Concern
12. Safeguarding Enquiries: Responding to a Concern 1 12.1 Statutory Safeguarding Enquiries Section 42 Councils are required by law to carry out safeguarding enquiries for those individuals who meet the
More informationMedicines Reconciliation Policy
Medicines Reconciliation Policy Lead executive Medical Director Authors details Senior Clinical Pharmacy Technician - 01244 39 7494 Document level: Trustwide (TW) Code: MP19 Issue number: 3 Type of document
More informationRemoval of Annual Declaration and new Triennial Review Form. Originated / Modified By: Professional Development and Education Team
Review Circulation Application Ratificatio n Author Minor Amendment Supersedes Title DOCUMENT CONTROL PAGE Title: Mentorship in Nursing and Midwifery Policy Version: 14.1 Reference Number: Supersedes:.14.0
More informationSUGGESTIONS, COMPLIMENTS & COMPLAINTS POLICY
SUGGESTIONS, COMPLIMENTS & COMPLAINTS POLICY Responsible Senior Manager: Vice Principal Business Services & People Approved by: Corporation Related Policies: Equality & Diversity Effective from: September
More informationADVOCATES CODE OF PRACTICE
ADVOCATES CODE OF PRACTICE Owner: Liz Fenton, Strategic Services Delivery Manager Approver: Management Team Date Document Version Draft/Final Distribution Comment 04/2006 1.0 Final All 12/2010 2.0 Final
More informationStandards conduct, accountability
Standards of conduct, accountability and openness Standards of conduct, accountability and openness Throughout this document: members refers to all members of a board the Chair, the non-executives, the
More informationALAT and Bright Tribe Trust Complaints Procedure
+ ALAT and Bright Tribe Trust Complaints Procedure Contents 1. Mission Statement... 2 2. Principles and Values... 2 3. Objectives of this Procedure... 2 4. General Principles... 4 5. Vexatious Complaints...
More informationThe Newcastle upon Tyne Hospitals NHS Foundation Trust. Implementation Policy for NICE Guidelines
The Newcastle upon Tyne Hospitals NHS Foundation Trust Implementation Policy for NICE Guidelines Version No.: 5.3 Effective From: 08 May 2017 Expiry Date: 02 March 2019 Date Ratified: 23 February 2017
More informationPositive and Safe Management of Post incident Support and Debrief. Ron Weddle Deputy Director, Positive and Safe Care
Document Title Reference Number Lead Officer Author(s) (name and designation) Ratified by Positive and Safe Management of Post incident Support and Debrief NTW(C)13 Ron Weddle Deputy Director, Positive
More informationAccess to Health Records Procedure
Access to Health Records Procedure Version: 1.0 Ratified by: Date ratified: 11/03/2015 Name of originator/author: Name of responsible individual: Information Governance Group Medical Records Manager, Jackie
More informationCode of professional conduct
& NURSING MIDWIFERY COUNCIL Code of professional conduct Protecting the public through professional standards RF - NMC 317-032-001 & NURSING MIDWIFERY COUNCIL Code of professional conduct Protecting the
More informationThe Newcastle upon Tyne Hospitals NHS Foundation Trust. Central Alert System (CAS) Policy and Procedure
The Newcastle upon Tyne Hospitals NHS Foundation Trust Central Alert System (CAS) Policy and Procedure Version No.: 4.1 Effective From: 6 August 2013 Expiry Date: 6 August 2016 Date Ratified: 2 August
More informationSAFEGUARDING ADULTS POLICY
SAFEGUARDING ADULTS POLICY This document may be made available in alternative formats and other languages, on request, as is reasonably practicable to do so. Policy Owner: Approved by: POVA Operational
More informationComplaints Procedures for Schools
Title : Complaints Procedures for Schools Status : Current Approval Date : December 2008 Date for Next Review : December 2012 Originator : Page 1 of 9 CONTENTS 1. Stage 1 Initial Approach 2. Stage 2 Formal
More informationCOMPLAINTS POLICY. Date Ratified PROPOSED FOR APPROVAL March Governing Body
COMPLAINTS POLICY Version Version 4 Ratified By Date Ratified PROPOSED FOR APPROVAL March 2016 Author(s) Responsible Committee / Officers Date Issue January 2014 Review Date Intended Audience Impact Assessed
More informationLearning from Deaths Policy
Learning from Deaths Policy The Learning from Deaths Policy sets out the minimum acceptable standards of the national learning from deaths programme. Policy group General Document Detail Version 1 Approved
More informationPolicy for Critical Care Training and Education
Policy for Critical Care Training and Education 1 Policy Title: Executive Summary: Critical Care Policy for Training and Education This policy provides guidance for the management of learning and development
More informationSouth Tyneside NHS Foundation Trust. Clinical Policy. Chaperoning Policy. Review Date June 2011
South Tyneside NHS Foundation Trust Clinical Policy Chaperoning Policy Date Approved by Version Issue Date June 2009 2 June Executive 2009 Director of Nursing & Clinical Services Procedure /Policy number
More informationCOMPLIMENTS & COMPLAINTS PROCEDURE
We welcome all forms of feedback from our residents and those dealing with us, whether positive or negative. You may wish to let us know if: You would like to compliment us on a job well done. You have
More informationHigh level guidance to support a shared view of quality in general practice
Regulation of General Practice Programme Board High level guidance to support a shared view of quality in general practice March 2018 Publications Gateway Reference: 07811 This document was produced with
More informationBare Below the Elbow Supplementary Policy for Hand Hygiene
Bare Below the Elbow Supplementary Policy for Hand Hygiene 2.1 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
More informationSAFEGUARDING ADULTS COMMISSIONING POLICY
SAFEGUARDING ADULTS COMMISSIONING POLICY Director Responsible: Responsible person Target Audience: Name of Responsible Committee Nursing Matt O Connor Safeguarding Adults Lead All NHSBA staff and contractors
More information