BOARD OF DIRECTORS PAPER COVER SHEET Meeting date: 7 September 6 Agenda item: 7.3 Title: COMPLAINTS REPORT QUARTER 1 6/7 (1 APRIL 6 3 JUNE 6) Purpose: To update the board on the number and type of complaints received in Quarter 1 of 6/7 and the changes made as a result of the investigation process. Summary: In quarter 1, 77 formal written complaints were received. (A further 13 requests for loss and compensation were also received). 88% of complaints were fully responded to within working days, an increase from 8% in quarter of the previous year. The trust also received 198 letters of thanks/commendation for quarter 1. Recommendation: For Information Prepared by: Michael Norton, Complaints Lead Presented by: Marie-Noelle Orzel, Director of Nursing & Service Improvement This report covers: (Please tick relevant box below) Healthcare Standards (CORE C1 Monitor please specify which standard) Healthcare Standards (DEV T Finance please specify which standard) Service Development Strategy Performance Management Local Delivery Plan Business Planning Assurance Framework Complaints Other (Please specify)
COMPLAINTS & COMMENDATIONS Quarter 1 5/6 1 April 6 to 3 June 6 Compiled by the Complaints Department for Marie-Noelle Orzel, Director of Nursing and Service Improvement. Please contact her on (139) 356 with any queries or comments. 1. Developments Information about the number of complaints received, acknowledgement responses, investigations completed within working days, and the commendations received will now be presented using SPC charts so that any trends can be identified. This format will also be used to identify trends in the five themes we report our formal complaints against. An additional section describing the training and awareness sessions carried out for staff and the public has been added to the report. Collection and reporting of this information is required to ensure that the trust remains compliant with healthcare standard C1. Notification was received from the Department of Health during August that amendments have been made, with effect from 1 September 6, to the NHS (Complaints) Regulations. Notable amendments are that: The Trust now has 5 working days to complete an investigation. This can be extended following prior agreement with the complainant. The Department of Health has confirmed that the 5 day period commences on the day the complaint is received. Complainants not satisfied with our response now have up to 6 months (previously ) to refer their complaint to the Healthcare Commission.. Summary of Activity A total of 77 formal written complaints were received this quarter (9 formal written complaints last quarter and 69 in the same quarter last year). In addition to the 77 formal written complaints, the trust received 13 requests relating to Loss and Compensation claims. 15 1 9 6 3 Complaints & Compensation Claims Received Q /1 Q3 /1 Q /1 Q1 1/ Q 1/ Q3 1/ Q 1/ Q1 /3 Q /3 Q3 /3 Q /3 Q1 3/ Q 3/ Q3 3/ Q 3/ Q1 /5 Q /5 Q3 /5 Q /5 Q1 5/6 Q 5/6 Q3 5/6 Q 5/6 Q1 6/7 Of the 77 formal complaints received: 6 were made directly by the patient; 8 complaints were made by relatives, and 3 complaints were made by an advocate (i.e. ICAS or solicitor), friend or MP. With 11,6 patient episodes for this quarter, formal written complaints represent less than.7% of overall patient activity with the Trust. This equates to one formal written complaint for every 137 patient episodes. The number of commendations decreased slightly from 1967 to 198. The ratio of commendations to complaints for this quarter is: 5:1 1
3. Response Rates 3.1 Complaint letters acknowledged within working days: 96% (98% last quarter, 85% in the same quarter last year). Percentage 11 1 9 8 7 6 Acknowledged Within Days Q /1 Q3 /1 Q /1 Q1 1/ Q 1/ Q3 1/ Q 1/ Q1 /3 Q /3 Q3 /3 Q /3 Q1 3/ Q 3/ Q3 3/ Q 3/ Q1 /5 Q /5 Q3 /5 Q /5 Q1 5/6 Q 5/6 Q3 5/6 Q 5/6 Q1 6/7 3. Response to letter of complaint completed within working days: 88% (8% last quarter, 7% in the same quarter last year). Percentage 1 1 8 6 Response in Days Q /1 Q3 /1 Q /1 Q1 1/ Q 1/ Q3 1/ Q 1/ Q1 /3 Q /3 Q3 /3 Q /3 Q1 3/ Q 3/ Q3 3/ Q 3/ Q1 /5 Q /5 Q3 /5 Q /5 Q1 5/6 Q 5/6 Q3 5/6 Q 5/6 Q1 6/7. Commendations Commendations received for this quarter: 198 (1967 last quarter and 153 for the same quarter last year). Number received 35 3 5 15 1 5 Commendations Q /1 Q3 /1 Q /1 Q1 1/ Q 1/ Q3 1/ Q 1/ Q1 /3 Q /3 Q3 /3 Q /3 Q1 3/ Q 3/ Q3 3/ Q 3/ Q1 /5 Q /5 Q3 /5 Q /5 Q1 5/6 Q 5/6 Q3 5/6 Q 5/6 Q1 6/7 A sample of 185 commendations (letters/cards of appreciation received) was taken from the Directorate of Medicine and analysed against the five Department of Health headings used to identify the themes complaints are recorded against. The breakdown was compared against the number of complaints received by the directorate during the same period. The results are as follows:
Commendations Complaints Access and waiting 7 Clean, safe place to be 3 Information, communication and choice 1 Building relationships 13 Safe, high quality care 79 1 Whilst this analysis was interesting to carry out it was found that many of the commendations are of a very general nature and so are difficult to categorise, and the analysis is also extremely time consuming. Having carried out this exercise, it is not felt that the information generated is of sufficient usefulness to warrant the time spent to continue the exercise on an ongoing basis. 5. Face-to-face Meetings Four meetings were held this quarter ( last quarter and for the same quarter last year). Current status of face-to-face meetings: all closed. 6. Trends and Patterns The analysis of complaints provides the Trust with a range of users views relating to the service experienced. For quarter one this year, the Trust received 77 formal written complaints. (A further 13 requests for Loss and Compensation were also received. These 77 complaints are reviewed under the following themes: 11 related to Access and Waiting (11 in the previous quarter) related to Clean, Safe Place to be (7 in the previous quarter) 7 related to Information, Communication and Choice (1 in the previous quarter) 16 related to Building Relationships ( in the previous quarter) 39 related to Safe, High Quality care (38 in the previous quarter) These figures are plotted on a monthly basis as follows, to ensure any trends are identified: 1 1 1 8 6 Access & Waiting Jul- Aug- Sep- Oct- Nov- Dec- Jan-5 Feb-5 Mar-5 Apr-5 May-5 Jun-5 Jul-5 Aug-5 Sep-5 Oct-5 Nov-5 Dec-5 Jan-6 Feb-6 Mar-6 Apr-6 May-6 Jun-6 5 Clean, Comfortable, Safe Place 3 1 Jul- Aug- Sep- Oct- Nov- Dec- Jan-5 Feb-5 Mar-5 Apr-5 May-5 Jun-5 Jul-5 Aug-5 Sep-5 Oct-5 Nov-5 Dec-5 Jan-6 Feb-6 Mar-6 Apr-6 May-6 Jun-6 3
Information, Communication & Choice 1 8 6 Jul- Aug- Sep- Oct- Nov- Dec- Jan-5 Feb-5 Mar-5 Apr-5 May-5 Jun-5 Jul-5 Aug-5 Sep-5 Oct-5 Nov-5 Dec-5 Jan-6 Feb-6 Mar-6 Apr-6 May-6 Jun-6 1 Building Relationships 8 6 Jul- Aug- Sep- Oct- Nov- Dec- Jan-5 Feb-5 Mar-5 Apr-5 May-5 Jun-5 Jul-5 Aug-5 Sep-5 Oct-5 Nov-5 Dec-5 Jan-6 Feb-6 Mar-6 Apr-6 May-6 Jun-6 Safe, High Quality Care 5 15 1 5 Jul- Aug- Sep- Oct- Nov- Dec- Jan-5 Feb-5 Mar-5 Apr-5 May-5 Jun-5 Jul-5 Aug-5 Sep-5 Oct-5 Nov-5 Dec-5 Jan-6 Feb-6 Mar-6 Apr-6 May-6 Jun-6 7. Management Actions and Reviews to Procedures A record of the number and type of complaints are routinely sent to directorate managers and matrons. They are encouraged to provide examples of changes that have been implemented, or are planned, as a result of their complaint investigation. Some of these changes are listed below: Changes implemented: A patient complained that on discharge he was supplied with duplicate medication and expressed concern with cost implications to the hospital. As a result of the complaint, ward staff now ask all patients about what medicine supplies they have at home to avoid duplication and unnecessary cost. (Directorate of Medicine) A complaint was received regarding the general care experienced following an admission to the Maternity Unit. Following this complaint, the senior matron has revised the midwives rota so that they remain in one allocated area for 6 weeks rather than rotate on a day-to-day basis. Further, a new document has been produced titled Contingency Plan for Management of Unexpected Staff Shortages or Excessive Workload in the Maternity Unit. (Directorate of Child & Women s Health)
Following a complaint received regarding the use of a wheelchair voucher, changes have been made to the voucher paperwork and the wheelchair voucher, which now clarifies the process and time limits for redeeming vouchers. (Directorate of Professional Services) A patient complained about the wait experienced before drugs could be administered prior to a regular procedure. The ward has now implemented a telephone triage system to check a patient s fitness for treatment which now allows the required drug(s) to be made available in advance, which reduces the time patients need to wait. (Directorate of Medicine) A patient raised concern over the availability and visibility of the emergency admission leaflet for the Gynaecology Department. Following this complaint, leaflets are now displayed more prominently in the ward, and copies have been laminated and displayed in the treatment room. (Directorate of Child & Women s Health) The Directorate of Trauma & Orthopaedics have established a monthly complaints audit. This involves the directorate manager, senior managers and senior nurses reviewing all complaints received in the month to see if they were avoidable and what measures can be taken to prevent any reoccurrence in the future. If successful, this will be extended to the Directorate of Critical Care. (Directorate of Trauma & Orthopaedics) Changes planned: Following a complaint about dual waiting times in both the Walk in Centre and the Emergency Department, staff are to undergo a training programme to develop skills in eye examinations to reduce the number of referrals required between departments. (Directorate of Critical Care) A patient s relative complained about delays in admitting a patient who suffers from dementia to the ward. Following this, the consultant has advised that he will introduce a procedure to allow patients with dementia to be admitted directly to the ward and to discuss the required treatment with relatives to minimise the waiting time in the hospital. (Directorate of Medicine) 8. Training and Awareness For this quarter, the complaints lead has presented 5 complaint procedure training programmes to, in total, 6 staff. An external awareness-raising presentation was also made to 8 members of the Third Age Group (TAG) in Exmouth. 9. Ethnicity monitoring 3 (%) ethnic monitoring forms were returned (9% last quarter and 5% for the same quarter last year): 31 returned as White British ; one form returned as Other White; one form returned endorsed Human Being ; and one form returned Not Stated. 5