Burton Hospitals NHS Foundation Trust POLICY DOCUMENT. On: 26 October Review Date: October Department Responsible for Review:

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1 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 / Non Clinical Department Responsible for Review: Non Clinical Complaints & PALS Distribution: Essential Reading for: Information for: All individuals involved with patients & their representatives, including independent providers of services for the Trust All staff Policy Number: 16 Version Number : 14 Signature: Chief Executive Date: 26 October 2017 Complaints Policy and Procedure / Version 14 / October 2017

2 Burton Hospitals NHS Foundation Trust POLICY INDEX SHEET Title: Complaints Policy and Procedure: Listening, Learning and Improving Original Issue Date: Pre May 2000 Date of Last Review: January 2015 Reason for amendment: Responsibility: Routine Review Complaints & PALS Manager Stored: PALS & Complaints Office / Trust Intranet Linked Trust Policies: Being Open Policy (incorporating Duty of Candour) Claims Handling Policy & Procedure Confidentiality Policy Consent Policy Disciplinary Policy & Procedure Equal opportunities Policy Grievance Policy & Procedure Healthcare Information Guidance Health & Safety Policy Information Security Policy Managing Performance and Supporting Staff Policy Patient & Public Involvement Strategy Incident & Serious Incident Management Policy & Process Records Management Policy Risk Management Policy Risk Management Strategy Whistleblowing Policy E & D Impact Assessed EIA 199 Consulted Complaints Policy and Procedure / Version 14 / October 2017 Executive Directors, Divisional Directors, Divisional Medical Directors, Consultants, Divisional Nurse Directors/Head of Midwifery, Matrons, Department Heads, Lead Secretaries

3 REVIEW AND AMENDMENT LOG Version Type of change Date Description of Change 12 Review December Administrative changes January Review October 2017 Significant review to include amendments following the Francis Injury Report (January 2013) and the Putting Patients Back in the Picture review by Rt Hon Ann Clwyd MP and Professor Tricia Hart. Revision to the independent advocacy details To incorporate Care Quality Commission (CQC) Standards Health & Social Care Act 2008 (Regulated Activities) Regulation 14 Complaints Policy and Procedure / Version 14 / October 2017

4 CONTENTS Paragraph Number Subject Page Number 1 Introduction 1 2 Purpose of This Policy 2 3 Legal Requirements and Obligations 2 4 Policy Objective and Principles 3 5 Definitions 4 6 Scope of Policy 4 7 Support for Complainants 6 8 Key Duties & Responsibilities 6 9 Complaints Relating To More Than One Service Provider 9 10 Lessons Learned and Changing Practice 9 11 Monitoring and Effectiveness Publicity Media and Reputation Management Parliamentary and Health Service Ombudsman Review 13 Appendix 1 Complaints Procedure Introduction 14 1 Stage 1 Local Resolution 14 2 Stage 2 Independent Review 22 3 Complaint Team SOP 23 4 Complaint Toolkit Template 23 Complaints Policy and Procedure / Version 14 / October 2017

5 1. INTRODUCTION Burton Hospitals NHS Foundation Trust COMPLAINTS POLICY AND PROCEDURE 1.1 Burton Hospitals NHS Foundation Trust (the Trust) acknowledges the importance of complaints, concerns and comments. The Trust actively seeks feedback on its services and is dedicated to learn from less positive experiences to improve the experience of patients and visitors to the organisation. Following the second Francis Inquiry Report (January 2013), Sir Robert Francis QC called for regulators to make better use of the information contained in complaints and made a number of recommendations for the Care Quality Commission (Recommendations 38; 39; 40; 121), in addition the Rt Hon Ann Clwyd MP and Professor Tricia Hart undertook a review of the complaints system in 2013 Putting Patients Back in the Picture. These documents, along with effective complaint handling guidance as set by the CQC and Social Care Act 2008 (Regulated Activities) Regulations 14: Regulation 16 have influenced the policy and procedures for complaint handling at Burton Hospitals NHS Foundation Trust to ensure that we provide the most efficient and patient focused service for anyone wishing to raise a complaint. The Francis report [2013] makes recommendations with regard to Openness, Transparency and Candour and these principles underpin complaint investigations at this Trust. Although, Being Open policy and Duty of Candour apply principally to incidents, this good practice should be applied to complaint investigations as robust complaint investigating will support learning to improve and change the way care is provided; candour to support sharing information with others, including patients, their families and accountability if failings are found (CQC Learning, candour and accountability Dec 2016). The Trust wholeheartedly supports the Parliamentary and Health Service Ombudsman Principles of Good Complaint Handling and endeavours to ensure its internal investigations match the standards set by this independent body. In February 2014 a new complaint handling process was initiated to support divisional ownership of complaints to support learning and service changes/improvements where appropriate. The Trust has a Freedom to Speak Up Guardian who is available to support any staff that raise concerns in relation to patient safety, a bullying culture or other such issues. If, via a formal complaint or formal complaint investigation there are any concerns raised about these issues which relate to staff members, this should be discussed with the Freedom to Speak Up Guardian who can support and advise Investigating Officers (IO) or other staff on what the next steps are. The Freedom to Speak Up Guardian is also available to advise the Complaints Manager/department on whether an issue needs reporting under the Whistleblowing policy and can provide guidance and support through the process. Complaints Policy and Procedure / Version 14 / October

6 2. PURPOSE OF THIS POLICY The purpose of the policy is to make sure Trust procedures are fully compliant with the Local Authority, Social Services and the CQC Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Regulation 16 standards for Acute Trusts and supports sections 2a and 3b of the NHS Constitution. The policy explains: a. how patients and/or their carers/representatives can raise concerns and make a complaint b. the responsibilities of staff at Corporate and Divisional level c. the actions required of staff involved in complaints It also offers guidance on good practice at each stage of the process. 3. LEGAL REQUIREMENTS AND OBLIGATIONS 3.1 NHS Regulations The Local Authority, Health and Social Care Act 2008 and NHS Complaints (England) Regulations 2009 and CQC Regulation 16 details the procedures for the handling of complaints in relation to NHS bodies and set down the Parliamentary & Health Service Ombudsman s role in respect of NHS complaints. The NHS Constitution states that any individual has the right to: Have any complaint they make about the NHS services dealt with efficiently and have it properly investigated Know the outcome of any investigation into their complaint Take their complaint to the independent Health Service Ombudsman if they are not satisfied with the way the NHS has dealt with their complaint Make a claim for judicial review if they think they have been directly affected by an unlawful act of decision of an NHS body Receive compensation where they have been harmed by negligent treatment 3.2 Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Regulation 16 The intention of this regulation is to make sure that people making a complaint about their care and treatment are treated fairly. To meet the regulation the providers must have an effective and accessible system for identifying, receiving, handling and responding to complaints from people using the service, people acting on their behalf or other stakeholders. All complaints must be investigated thoroughly and any necessary action taken where failures have been identified. 3.3 Parliamentary and Health Service Ombudsman (PHSO) To ensure the Trust complies with the PHSO Standards of Good Complaint Handling which include Getting it right Complaints Policy and Procedure / Version 14 / October

7 Being customer focused Being open and accountable Acting fairly and proportionately Putting things right Seeking continuous improvements 3.3 Caldicott Principles and the Data Protection Act If a complaint is made by someone other than the patient, the patient s consent must be sought before confidential or sensitive information is released to a third party. If the patient is unable to act, or is deceased, it must be ensured that consent for disclosure is sought from the next of kin. Information collected for monitoring purposes will be anonymised to protect the confidentiality of those involved in complaints. 3.4 Complaints Records Complaint files will be kept for a minimum of 8 years from completion of action in accordance with the Records Management: NHS Code of Practice Part 2 (2 nd Edition) Files relating to returns made to the Department of Health will be closed annually and kept for 6 years following closure. All files will be destroyed at the appropriate time under confidential conditions. 4 POLICY OBJECTIVE AND PRINCIPLES 4.1 The Trust s approach to managing complaints will be to listen and respond to concerns raised by patients and/or their carers/representatives, to investigate and respond to these concerns and to ensure learning from these experiences and improve services accordingly. 4.4 The Trust s arrangements for the handling of complaints will ensure that: Complaints are dealt with efficiently Complaints are properly investigated Complainants are treated with respect and courtesy Complainants will be advised of timeframes for their response in line with Trust policy Complainants receive, so far as is reasonable practical i. Assistance to enable them to understand the procedure in relation to complaints, or ii. Advice on where they may obtain assistance from independent complaint advocacy services such as Healthwatch (Staffordshire), Citizens Advice (Derby), Mind (Derbyshire) or POhWER (Leicestershire). Where possible complainants will be kept updated on the progress of the investigations and if the response is delayed, complainants will be notified and advised when to expect the response will be completed by. Complaints Policy and Procedure / Version 14 / October

8 Complainants will receive a timely and appropriate response, with an acknowledgement and apology where appropriate for any upset or distress caused. Complainants are told the outcome of the investigation of their complaint and Following completion of the complaint, action is taken if necessary to ensure lessons are learned and to improve the quality of service provided. 4.5 Key Principles To ensure that issues raised are dealt with promptly, fairly and justly with the prime aim of resolving problems to the complainant s satisfaction as soon as possible To promote fairness for staff and complainants alike To ensure that complainants are not discriminated against and that any complaint made does not prejudice the care and treatment provided 5 DEFINITIONS A formal complaint is normally a written expression of dissatisfaction stating the desire to make a formal complaint, although this can also be received verbally. This also includes concerns raised at a local level, which have not been addressed to the satisfaction of the patient/carer/relative/visitor. A formal complaint which is handled by the Complaints Department in line with the Trust s Complaint Policy and in accordance with the NHS Complaints Regulations. This will be acknowledged within 3 working days of receipt. Where possible, it will be agreed with the complainant how they would like the Trust to respond, either with a written response following an investigation or a complaint meeting to discuss in person the outcome of the complaint investigations. A formal written response will be signed by the Chief Executive, or nominated deputy, and sent to the complainant within the agreed time frame offering an explanation, an apology where needed and detailing action taken as a result of the complaint. If a complaint meeting is requested, this will be recorded with the consent of those present at the meeting and copy of the meeting recording will be provided to the complainant and copy retained by the Trust. Any points not addressed at the meeting will be responded to in a manner agreed with the complainant and this may include a written response signed by the Chief Executive or nominated deputy. A PALS enquiry may be a concern or request for information, advice or support which is received by the Patient Advice and Liaison Service. PALS aim to resolve concerns informally by the end of the following working day; however it is acknowledged that they may be escalated to the formal process at the discretion of the complainant or the Complaints & PALS Manager if the case is potentially serious. 6 SCOPE OF POLICY 6.1 This policy relates to: A patient; or Any person who is affected by or likely to be affected by the action, omission or decision of the Trust Complaints Policy and Procedure / Version 14 / October

9 A suitable person acting on behalf of the above persons where that person o Has died o Is a child o Is unable because of physical or mental capacity to make the complaint themselves o Has requested the representative to act on their behalf Any other person as specified by Regulation 5 of the Local Authority, Social Services and NHS Complaints (England) Regulations In the case of the person being affected having died or being deemed as unable due to mental incapacity to raise a complaint themselves, a consent form is used to determine the relationship between the complainant/representative and the patient. The complainant/representative must be either a relative or other person who meets the criteria set by the Records Management Policy. People who are detained should be made aware of their entitlement at any stage of the complaints process to contact the Care Quality Commission (CQC) and be helped to do so if necessary. The CQC has the power to investigate complaints in relation to detention under the Mental Health Act (MHA) and can also support and advise detained people through the NHS complaint process, advising them of their rights and responding on their behalf with the Trust 6.2 Complaints excluded from this Policy are those stated in Regulation 8 of the Local Authority, Social Services and NHS Complaints (England) Regulations 2009 and include: A complaint by a responsible body eg local authority, NHS body, primary care provider or independent provider A complaint by an employee of the Trust about any matter relating to that employment A complaint which is made orally and is resolved to the complainant s satisfaction no later than the following working day after the date on which the complaint was made A complaint that has already been investigated under these Regulations or those it supersedes Complaints about private medical care provided by a Consultant outside of their NHS contract Complaints arising from the Trust s alleged failure to comply with a data request under the Data Protection Act 1998 or a request for information under the Freedom of Information Act 2000 Complaints relating to schemes established under sections 10 or 24 of the 1972 Superannuation Act here a complaint raises issues of a safeguarding nature, these complaints must be passed to the Safeguarding Team for review, should a safeguarding review be instigated, the complaint will be placed on hold until the review has been completed. Complaints being investigated by the Parliamentary &Health Service Ombudsman Where the Complaints Manager, following discussion with the relevant colleagues, decides that a complaint falls within any of the above criteria and that the Trust is not required to consider the complaint further, the complainant will be notified in writing, as soon as is practicable of the decision and the reason for it. Complaints Policy and Procedure / Version 14 / October

10 6.3 Time limit for making a complaint A complaint must be made within: 12 months of the date on which the issue occurred; or 12 months of the date on which the complainant became aware of the issue which is the subject of the complaint When a complaint is made after the expiry of the above periods, it may still be investigated at the discretion of the Complaints & PALS Manager following discussion with the appropriate Divisional Nurse Directors/Director of Midwifery if: The complainant had good reasons for not making the complaint within the time period and It is still possible to investigate the complaint effectively and fairly This discretion should be used flexibly and with sensitivity and monitored In any case where the Complaints & PALS Manager decides not to investigate a complaint on the grounds that it has not been made within the time limit, the complainant will be given information about how to request the Parliamentary & Health Service Ombudsman to consider their complaint. 7 SUPPORT FOR COMPLAINANTS Making a complaint can be difficult and stressful, details of specialist advocacy services and other support organisations are available from the Complaints & PALS Team. The Trust s Interpreter Policy advises on sources of support for communicating with people whose first language is not English or have hearing/vision problems. Reasonable adjustments must be made to this policy and the process if this is required for the reason of disability. There must be a culture of openness amongst staff to ensure a non-defensive attitude and approach towards the complainant, ensuring that they are not treated differently by raising a concern or making a complaint. Services will not be withdrawn from a patient because he/she makes a complaint. On rare occasions, where there may be a mutual loss of confidence and trust to the extent that the relationship between the patient and clinician is no longer sustainable, the Trust will ensure ongoing treatment and care is provided by alternative means, by referring the patient to another organisation with the agreement of the patient/complainant. Where necessary any persistent or perceived vexatious complainant may be subject to different treatment, which will be determined as per guidance in the Trust s Conflict Resolution Policy. 8 KEY DUTIES & RESPONSIBILITIES 8.1 The Trust Board of Directors The Trust Board is accountable for ensuring that effective controls are in place to support effective complaints management and organisational learning. The Quality Committee will receive quarterly Complaints & PALS report which provides details of complaints and Complaints Policy and Procedure / Version 14 / October

11 concerns received during the period. In addition, quarterly and annual reports are provided by the Complaints & PALS Manager. 8.2 The Chief Executive is responsible for: o Undertaking the role of responsible person as defined in the Regulations, namely o Ensuring compliance with the arrangements made under the Regulations o Together with the Trust Board, Directors and Divisional Senior Management Teams they are responsible for ensuring that lessons are learnt and the standard of care and treatment provided to patients, carers and relatives is improved following the investigation of a complaint. o Collectively responsible for ensuring that this policy is implemented in an effective and timely manner across the organisation 8.3 Executive Chief Nurse The Executive Chief Nurse has board level responsibilities for the Patient Experience agenda, including overall management of the NHS Complaints process. 8.4 The Complaints & PALS Manager is responsible for: The implementation of the Trust s Complaint Policy and Associated Procedures and adherence to good practice Ensuring management of complaints adheres to agreed procedures in accordance with the Trust s Complaint Policy and statuary obligations Providing guidance and support for the management of complaints and PALS enquiries Maintaining documentary records of the handling of each complaint Collating information and the coordination of any independent reviews that are required Collating and coordinating information for independent reviews of complaints by the Parliamentary & Health Service Ombudsman when required Operational monitoring of the effectiveness of the complaints procedures 8.5 Divisional Nurse Directors/Director of Midwifery The Divisional Nurse Directors/Director of Midwifery have responsibility for ensuring the divisions appropriately and proportionately investigate and respond to complaints within Trust agreed timescales. They will ratify complaint investigation toolkits, ensuring the quality of information within the toolkit and the investigations undertaken, prior to forwarding to the Complaint Team for drafting. Once the complaint response is prepared, the Divisional Nurse Directors/Director of Midwifery will ratify the final draft in readiness for this being signed by the Chief Executive or nominated deputy. The Divisional Nurse Directors/Director of Midwifery or nominated officer will ensure any lessons learnt are fed back to the clinical teams. Overall responsibility of the management and review of these actions will be at the discretion of the Divisional Nurse Directors/Director of Midwifery. 8.6 Investigating Officers (IO s) Each division will have trained IO s who are responsible for undertaking an investigation into the points identified for investigation, coordinating responses, completing the complaint toolkit template and action plan. This will usually be staff of a sufficiently senior Complaints Policy and Procedure / Version 14 / October

12 level, ideally Band 7 or above. The completed toolkit will be returned to the Divisional Nurse Directors/Director of Midwifery for a quality check prior to sharing with the Complaints Team in readiness for drafting. The IO will ensure the toolkit is completed within the agreed the timescales as set out in the Complaints Standard Operating Policy (SOP). 8.7 The Complaints & PALS Team The Complaints & PALS Team is designated by the Trust to listen and respond to concerns, comments and complaints from patients and their carer s/ representatives. The team has responsibility for acknowledging the complaint and agreeing with the complainant how they wish to proceed with their complaint, either agreeing receipt of a written response or accepting an invitation to meet with senior Trust representatives. The Complaint & PALS Team will support the Divisional Nurse Directors/Director of Midwifery where appropriate and support the agreed SOP s to ensure an efficient complaint handling process is in place at the Trust. 8.8 The Legal Services Team Designated by the Trust to manage issues of Clinical Negligence, Personal Injury Claims and Inquest enquiries. 8.9 Divisional Directors, Divisional Medical Directors, Lead Clinicians, General Managers, Operations Managers and Matrons are responsible for: Ensuring their staff comply with the Trust s Complaint Policy and associated procedures and that appropriate support and training is provided to enable staff to deal with complaints at a local level where possible. Ensuring PALS literature is available and accessible to patients and staff throughout their area of responsibility. Informing the Complaints & PALS Manager of all written complaints. Ensuring that lessons are learned and appropriate actions are taken as the result of the outcome of complaints. Informing the Complaints & PALS Manager of remedial actions taken and monitoring the effectiveness of those actions. Ensuring that complainants are not discriminated against and that any complaint made does not prejudice the care provided All members of staff are responsible for: Ensuring they act in such a way that prevents complaints and concerns occurring Endeavouring to deal with problems and concerns at local level and resolving issues at the earliest opportunity. Escalating issues which they cannot resolve personally to ensure these are responded to and where possible resolved at point of contact Informing their Line Manager of any complaints/concerns received. Advising, patients, their relatives and visitors when required about the PALS service, who can support patients with information on hospital or other services Assuring patients and their representatives that any complaint/concern raised will not prejudice the treatment and care they receive. Working within the standards and guidelines as specified by the Trust s Complaint Policy and associated procedures. Complaints Policy and Procedure / Version 14 / October

13 Reviewing their practice as a result of any complaint or concern raised or received. Co-operating with investigations as requested and providing information to the Complaints & PALS team in a timely manner. 9 COMPLAINTS RELATING TO MORE THAN ONE SERVICE PROVIDER WHERE A JOINT RESPONSE IS REQUIRED 9.1 If the complaint involves more than one health and/or social care organisation, there will be full co-operation in seeking to resolve the complaint through each organisation s local complaints procedure. 9.2 It is accepted that the complainant reserves the right to determine how their complaint is handled and whether they wish a joint response to be provided or to receive a separate response from each of the organisations involved. 9.3 It is usual for one Trust to take the lead and coordinate a joint response so that the complainant receives one full written response answering all their concerns and ensuring one point of contact for the complainant. Each Trust will acknowledge the complaint, explaining which organisation will take the lead in responding and collating comments from all parties involved to ensure the complainant receives a comprehensive response which addresses all areas of concern. 9.4 Each organisation will ensure that the correct consent to share information and release of information has been received. If the complainant is happy to share their consent, copy confirmation of this will be required prior to any information being shared 10 LESSONS LEARNED AND CHANGING PRACTICE 10.1 Local Learning Remedial action plans will be developed by the Divisions where change and improvement are indicated as a result of complaint investigations. Where changes in practice or service improvements are identified in Divisional reports prior to a response being sent to the complainant, this information will be included as part of the complaint response letter. Such information may include: What action has/will be taken following the complaint What changes in practice have/will be implemented What new guidelines have/will be developed What staff training has/will be implemented Following investigation of a complaint, it is the Division s responsibility to identify what measures need to be put in place, monitor completion of any necessary actions and evaluate effectiveness of the action plan. Complaints Policy and Procedure / Version 14 / October

14 10.2 Organisational Learning Examples of lessons learned will be included in the Complaints & PALS monthly, and quarterly reports. Divisional management teams can request reports to support them to identify trends in complaints and incidents. Examples of changes to practice will also be included in the Annual Complaints & PALS Report. Learning from complaints may be disseminated to staff through internal Trust publications or internal communication procedures, usually via the Divisions. Where specific issues relate to a Clinical Incident, Health & Safety or Manual Handling concern the appropriate Governance Manager will be informed and an incident form will be requested. Issues relating to any breaches of the information governance policy will be logged on the Trust s Datix system and alerted to the Trust s Caldicott Guardian, Information Governance Lead for learning and awareness, as well as being shared at the Trust s monthly Information Governance review meeting. Where a complaint relates to an individual member of medical staff, this will be recorded and the information shared with the Medical Director for staff appraisal. As per the guidance and requested by the Trust s Director of Learning and Education any issues relating to doctors in training will be shared with the Trust s Director of Learning and Education to be raised with the Medical School Deanery. 11 MONITORING AND EFFECTIVENESS OF COMPLAINT INVESTIGATIONS, ADHERANCE TO THIS POLICY AND PERFORMANCE 11.1 Complaint investigating and adherence to this policy Divisional Nurse Directors/Director of Midwifery and where appropriate Divisional Medical Directors and Divisional Directors will monitor the implementation of this policy and other associated procedures within their area of responsibility and ensure that all complaints are managed in accordance with the Policy and within the agreed timeframe. Any issues of concern regarding the timeliness of reports will be raised in the first instance with the Complaints and PALS Manager/deputy and the Divisional Nurse Director/Director of Midwifery. If delays are ongoing the Complaints and PALS Manager will escalate any issues to the Executive Chief Nurse for nursing/allied health professional staff delays or the Executive Medical Director for medical staff delays. If any issues are raised by the complainant or others involved in relation to patients and/or their carers being treated differently and/or being disadvantaged as a result of making a complaint these will be dealt with either as an additional issue within the complaint or as a separate complaint, as appropriate. The complaint will be referred to the relevant professional lead(s) to address with the staff involved as per the Trust s performance monitoring and management policies and procedures. Such issues will be documented as discrimination to facilitate monitoring of potential trends Performance Following the recommendations of the Keogh review, key performance indicators (KPI s) for complaints have been agreed Complaints Policy and Procedure / Version 14 / October

15 Key Performance Indicators To maintain complaint numbers in line with designated years (currently ) 90% of written complaints responded to within initial timescale agreed with complainant (monthly trajectory to be established ) 100% of complaints acknowledged within 3 days Reduce % of complaints that are reopened In addition the number of PHSO referrals and the number of PHSO referrals upheld will be monitored and benchmarked against other similar sized Trust s following publication of the PHSO s quarterly and yearly report Complaints about acutetrusts Internal Monitoring In order to achieve improvement, the Trust will monitor performance against the agreed KPI s. The Complaints & PALS Manager will monitor the progress of each complaint to ensure timescales are observed and that complainants are kept informed of progress and any potential or actual delays. The Trust s Quality Committee will receive and be asked to monitor Complaints and PALS activity via the reporting mechanisms and compare this against other governance reports to enable efficient governance and scrutiny of Trust services. The monthly Complaints & PALS report will also be shared and discussed at the Trust s monthly Patient Experience and Staff Wellbeing Group. These reports will be reviewed at the monthly meeting with local commissioners (CQRM) and any issues escalated and actioned as appropriate. Complainant satisfaction questionnaire responses will be reviewed and any issues highlighted will be actioned to improve complaint handling performance. Complaint procedures and complaint handling may be subject to both internal and external audit and peer review 11.4 External Monitoring Complaints may be monitored by a number of external stakeholders. A copy of Complaint & PALS reports will be made available to the local Clinical Commissioning Group (CCG) following its approval by the Board of Directors. In accordance with the present contract, the CCG will also receive a monthly report indicating the number of complaints and PALS enquiries received, with details of the departments to which the concerns relate and the category under which these have been recorded on the Safeguard database. Additional information relating to trends will be summarised within this report. Any response to questions raised by the CCG, relating to the provision of this report or the contents within, will be coordinated by the Executive Chief Nurse/deputy or nominated deputy. Complaints Policy and Procedure / Version 14 / October

16 The Annual Complaints and PALS report detailing the handling and consideration of complaints will be made publicly available via the Trust s website and also available to the Trust s Auditors Data Collection Formal complaints and PALS enquiries will be recorded on the Datix reporting which the Complaints and PALS team implemented in October Historic complaints will be reopened will be updated in the previous recording database recording system Safeguard. All information will be used to identify and monitor trends relating to patient experience. 12 PUBLICITY It is important that patients, their representatives, visitors and staff are aware of the Trust s arrangements for handling complaints. PALS leaflets and posters will be available in each department/public area. The PALS leaflet provides an opportunity to raise a concern or share a compliment with the Trust. The Trust has developed a Share your Experience form to ensure making a formal complaint is easy and accessible to all patients. This formal can be translated into other languages on request and additional assistance to complete the form will be available to anyone with a learning difficulty or sight impairment. The form is available either on request from the ward/department or the Complaint and PALS team or can be downloaded from the Trust s public website. PALS leaflets are available in Polish and Urdu and other languages can be requested. PALS leaflets are also adapted for those with sight impairment and printed on yellow paper. 13. MEDIA AND REPUTATION MANAGEMENT At any stage of a complaint where a complainant indicates an intention to contact the media, staff will notify the Trust s Communication Team to enable appropriate action to be taken to manage the potential reputational risk to the Trust. Comments received via social media will be monitored via the Trust s Communication Team for Facebook and Twitter comments and the Complaints and PALS team will be responsible for the monitoring of any feedback received via NHS Choices and the Patient Opinion websites. Any comments received via these modes of communication will be acknowledged and responded to appropriately with encouragement to the commentator to contact the PALS service for any support in relation to concerns or complaints. In accordance with Trust policies and effective information governance good practice, staff should never provide any confidential patient information when responding to social media comments or posts. 14. PARLIAMENTARY AND HEALTH SERVICE OMBUDSMAN (PHSO) Where complainants or their advocates make a complaint and are dissatisfied with the outcome and final response, the Trust will endeavour to try and resolve the issues through local resolution; however if this is not possible, the complainant or their advocate will be given clear information on the next steps available to them through the PHSO. Complaints Policy and Procedure / Version 14 / October

17 When the Complaints & PALS Team are notified of complaints to be investigated by the PHSO, they will inform the relevant Divisional Nurse Directors/Director of Midwifery, Divisional Medical Director, Divisional Director, Executive Chief Nurse/deputy and those involved in the original complaint. 15. REVIEW This Policy shall be reviewed within three years of its ratification or sooner should legislation / guidance be amended. Complaints Policy and Procedure / Version 14 / October

18 Appendix 1 Burton Hospitals NHS Foundation Trust COMPLAINTS PROCEDURE Introduction There are two distinct parts to the Complaints Procedure: Stage One: Local Resolution by the Trust Stage Two: Independent Review by the Parliamentary & Health Service Ombudsman if the complainant is dissatisfied by Local Resolution 1. Stage One: Local Resolution Every avenue will be explored under local resolution in order to achieve a satisfactory solution to the complaint before the complainant moves to Stage Two: Independent Review. It is important not to introduce delays into system by exceeding agreed stated time limits. The aim will be to process the complaint speedily and thoroughly at all stages. The standard is that complaints are acknowledged within three working days and that a full response is sent from the Chief Executive within 25 working days or the timescale as agreed with the complainant at the outset. First class post will be used for all correspondence with complainants. Exceptionally, special mail delivery may be used and any recordings of complaint meeting will be sent to the complainant or advocate via Special Mail Delivery to ensure the safety of confidential and sensitive patient information. All communication will be marked PRIVATE and CONFIDENTIAL. 1.1 Receipt of complaints Complaints will be treated with consideration and sensitivity whether received verbally or in writing. However, care should be taken to ascertain sufficient detail to allow appropriate response to the issues raised If a verbal complaint is taken, a comprehensive record of the conversation and concerns, along with all relevant details (names, contact details, etc.) must be made. Do not include personal judgements and opinions Local resolution will always be the preferred option. Staff are encouraged to deal with concerns/complaints promptly and at source and to involve their Line Manager/Matron/Consultant and the Patient Advice and Liaison Team when support is required. Out of hours staff should contact the on-call Manager/Consultant. Every effort must be made to resolve the situation at the time Complaints Policy and Procedure / Version 14 / October

19 Where a complainant s concerns are not resolved, advice about how to contact the Trust s Patient Advice and Liaison Service (PALS) Team or the Complaint Team will be offered. The Complaint & PALS Team will provide support and advice, including information on the NHS Complaints Process where appropriate. If complainants prefer to make their initial complaint to someone not involved in their care they should be directed to the Complaint & PALS Team. Staff should inform their Line Manager/Matron of any complaint they receive Staff are encouraged to advise the Complaints Office of the receipt of written or unresolved complaints at the earliest opportunity, so that an appropriate letter of acknowledgement can be sent and the complaint dealt with in the most appropriate manner Complaints received directly by Clinicians or Managers should be date stamped on receipt and referred promptly to the Complaints Office for handling in accordance with this policy. 1.2 Support for complainants It is the responsibility of all staff to assure patients and their representatives that any complaint made will not prejudice the treatment and care they receive and to inform people of the support available to help them complain. This information is available in the PALS: We re here to help Leaflet which is provided to complainants with a written acknowledgement of receipt of their complaint. PALS can offer support and advice to both members of the public and staff and are available to provide guidance to people wishing to raise a concern or explore more formal complaint options. An Independent Complaints Advocacy Service can provide complainants with free and confidential advice and support throughout the NHS Complaints Procedure. Communication Support: If complainants have difficulty communicating, or their first language is not English, the Trust has access to communication support services, including interpreting services, to facilitate understanding. To access these services: Refer to your Departmental Communication Resource Pack; or Contact PALS on telephone extension 5284; or Refer to the PALS Intranet Site > Communication Support Contact the Trust s Safeguarding Matron advice on learning disabilities and special needs 1.3 Acknowledgement and record of complaint All complaints received by the PALS and Complaints Department will be reviewed to assess the appropriate course of action. Complaints that may be best treated as a PALS enquiry include: Those complaints requiring instant action to ensure that the immediate health care needs of the patient are being met Complaints Policy and Procedure / Version 14 / October

20 Requests for information and explanation Those which indicate a need for support and someone to listen Those where a meeting with the staff, if this is acceptable to those involved, would be beneficial. Early consideration will be given to this approach Those expressing a wish to be dealt with by PALS Complaints that may be best treated as a Formal Complaint include: Complaints referred by the Independent Complaints Advocacy Service unless PALS involvement is requested by the Case Worker Unresolved PALS enquiries Complaints which indicate the possibility of clinical negligence Complaints relating to serious issues such as alleged: Breaches of confidentiality; Data Protection contravention; Criminal offences and assault Complaints relating to the care and treatment afforded to deceased patients Very complex complaints Complaints which potentially involve compensation and ex gratia payment issues Complainants who become vexatious An express wish to access the Trust s Complaint s Procedure On receipt of a Formal Complaint the Complaints & PALS Department will: Date stamp receipt of the correspondence Ensure that the complaint is made within appropriate time limits and is from a person entitled to make a complaint. Necessary action will be needed if one or both of these conditions have not been met in order that the complaint can be investigated. Give the complaint a File Number and complete an Audit Trail Form. The Complaint File will be kept apart from the patient s health care records. Where a complaint is made orally, the PALS and Complaints Coordinators will make a written record and ensure with the complainant that the essence of their issues has been captured. A copy of this record will be sent with an acknowledgement, inviting the complainant to confirm their agreement of the issues recorded and the plan of action proposed. This record will form the basis of the subsequent investigation and should reflect the issues the complainant wants looking into. Where the complaint is made in writing or received electronically, the PALS and Complaints Coordinators will attempt to contact the complainant by telephone within three working days to acknowledge receipt of their complaint and to discuss the outcome required. A provisional timeframe within which the investigation into their concerns is to be completed should also be discussed. The complainant will then be sent an acknowledgement with details of what has been agreed verbally. Where it is not possible to contact the complainant by telephone, an acknowledgment will be sent to the complainant, inviting them to make contact with the team to agree a way forward but advising in the meantime the complaint investigations will commence and information on the Trust s response times will be included. Complaints Policy and Procedure / Version 14 / October

21 Enter the complaint onto the Trust s Database. Scan the complaint correspondence and to the Divisional Nurse Directors/Director of Midwifery who will allocate an IO and ensure the complaint investigation is commenced within the agreed SOP timescales. Clinical Directors and Associate Directors will be copied into this for information. Relevant staff with responsibility for investigating complaints (IO s) within the Division(s) involved will be notified without delay and responses requested within agreed Complaint Team SOP timescales. Investigating Officers will usually be suitably senior staff, Band 7 or above and have received the necessary complaint investigation training in order to undertake a robust complaint investigation. Responsibility for accessing all relevant information sources will be determined by the IO with the support of the Divisional Nurse Director/Director of Midwifery. If the issues raised should potentially be considered for either an internal safety alert (ISA) or Serious Incident (SI) investigation, this will be alerted to the Divisional Nurse Directors/Director of Midwifery and left to their discretion to instigate appropriate alerts to the Clinical Risk Management service. Consent will be obtained by the Complaints Team from the next of kin when the patient is deceased or from the patient where the complainant is a third party. The complainant will be advised of the Trust s willingness to investigate the issues raised. They will be requested to ask the patient or, if the patient is unable to act or is deceased, the next of kin, to confirm their consent for disclosure of information to a nominated third party. A consent form will be provided to enable this information to be recorded. If authorisation is not received within 25 working days, a reminder will be sent informing the complainant that the complaint will be closed within the next 10 working days if consent is not received. Dependent on the nature of the issues and who is making the complaint, the acknowledgement from the Trust will include: o An acknowledgment that the complainant has a concern o Offer of condolences when required o In more complex complaints, if we have not been able to speak to the individual raising the concern, a request will be made to them to make contact with the Complaints Team to discuss their concerns/complaint. o A request for consent to disclosure where appropriate. o Reassurance that any disclosure will be confined to that which is relevant to investigation of the complaint and only disclosed to those people who have a demonstrable need to know it for the purpose of investigating the complaint o Confirmation of a meeting if appropriate at this stage o A brief summary or questions which will be answered as agreed with the complainant or a summary of the complaint issues if this has been given verbally for approval. o A copy of an independent complaints advocacy service leaflet/information explaining the right to assistance o A copy of the PALS Leaflet Complaints Policy and Procedure / Version 14 / October

22 o If required information about the Parliamentary and Health Service Ombudsman service provided Meetings will always be offered to complainants as it is felt this is often a more constructive way for the Trust to respond to the concerns raised. This approach will be suggested, but will be left to the discretion of the complainant. If an initial written response is requested, the opportunity to meet will be available throughout the complaint process and can be offered if there are any outstanding issues following receipt of a written response. The complainant is able to invite a friend, relative or advocate to any meeting arranged Complaint meetings will be facilitated by a member of the Complaints & PALS Team. In preparation for the meeting, an IO will have completed an investigation and the complaint toolkit and this will be available to share if required, along with the outcome of the enquiries with the complainant. A complaint report or response can be made available in readiness for the meeting. The meeting will be recorded and a copy of the recording provided to the complainant either after the meeting or sent by special delivery through the post. Additional copies of the meeting recording can be requested by the complainant. A copy of the meeting recording will be kept also in the complaint file. Following a meeting, a post-meeting letter will be sent to the complainant and/or advocate, which will include a summary of the points discussed, answers to any outstanding questions and information on any further points raised during the meeting discussions. In addition, information on learning, action plans or changes that have occurred as a result of the complaint will be shared. If a meeting is declined, or otherwise felt to be not appropriate, the Complaints & PALS team will ensure the complaint investigation process is undertaken as agreed within the Complaint Team SOP s Delays to responses, any toolkits not received within the specified timeframe will be requested as a matter of urgency. Any issues of concern regarding the timeliness of receipt of completed toolkits will be raised in the first instance with the Divisional Nurse Directors/Director of Midwifery. Following this escalation of any delays will be in line with the agreed Complaint Team SOP s, including escalation to the Executive Chief Nurse, Executive Medical Director or the Chief Executive of the Trust. Complainants will be kept informed of progress or reasons for delay and, where necessary, interim replies or holding letters will be sent within 25 working days of receipt of the complaint. 1.4 Investigation After alerting the complaint to the Divisional Nurse Directors/Director of Midwifery an investigation of the issues will be undertaken by the designated IO following the guidance within the Complaint Toolkit template, this could include statements, notes from interviews with staff and review of appropriate documentation i.e. health records, Meditech, HISS notes. Complaints Policy and Procedure / Version 14 / October