COMPLAINTS 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 Paula Wedd, Director of Quality and Safeguarding, Debbie Smith, Patient Experience Manager, West Cheshire Clinical Commissioning Group Governing Body 2 years from date ratified Stakeholders of NHS West Cheshire Clinical Commissioning Group, NHS West Cheshire Clinical Commissioning Group members, governing body and employees. For publication on our web site Yes March 2016 1

Further information about this document: Document name Category of Document in The Policy Schedule Author(s) Contact(s) for further information about this document This document should be read in conjunction with Published by (Listening, Responding and Learning from Views and Concerns) Corporate Debbie Smith, Patient Experience Manager NHS West Cheshire Clinical Commissioning Group Paula Wedd, Head of Quality and Safeguarding, NHS West Cheshire Clinical Commissioning Group Pam Hughes Head of Business Solutions Cheshire and Merseyside Commissioning Support Unit Incident Reporting and Management Policy Disciplinary Policy and Procedure Individual and collective grievance and disputes policy and procedure Freedom of Information Act Policy Policy for the Management of Public Interest Disclosure (Whistleblowing) NHS West Cheshire Clinical Commissioning Group 1829 Building Countess of Chester Health Park Liverpool Road Chester, CH2 1HJ Website: www.westcheshireccg.nhs.uk Copies of this document are available from Copyright 2016. All Rights Reserved Version Control: Version History: Version Number Reviewing Committee / Officer 1.0 NHS West Cheshire Clinical Commissioning Group Governing Body 2.0 NHS West Cheshire Clinical Commissioning Group Governing Body 3.0 NHS West Cheshire Clinical Commissioning Group Governing Body 4.0 NHS West Cheshire Clinical Commissioning Group Governing Body Date April 2013 January 2014 January 2014 March 2016 March 2016 2

March 2016 3

March 2016 4

CONTENTS INTRODUCTION... 6 WHAT OUR COMMITMENT MEANS 6 SCOPE AND PURPOSE OF THE POLICY... 7 WHAT IS A COMPLAINT?... 8 WHO CAN COMPLAIN?... 8 TIME LIMIT FOR MAKING A COMPLAINT... 9 MANAGEMENT OF COMPLAINTS... 9 RESPONSIBILITIES FOR COMPLAINTS ARRANGEMENTS... 10 ESCALATION... 12 UNREASONABLE COMPLAINANT BEHAVIOUR (VEXATIOUS COMPLAINTS)... 12 SERVICE STANDARDS... 12 FURTHER GUIDANCE AND READING... 13 COMPLAINTS PROCESS MAP... 14 PROCESS FOR MANAGING UNREASONABLE COMPLAINANT BEHAVIOUR (VEXATIOUS COMPLAINTS)... 15 March 2016 5

INTRODUCTION 1. NHS organisations must make arrangements for dealing with complaints in accordance with The Local Authority Social Services and NHS Complaints (England) Regulations 2009 (the regulations). This policy will not duplicate this guidance and legislation but sets out our local response to these national regulations. 2. The founding principle of the NHS West Cheshire Clinical Commissioning Group policy is to have a user led system for raising concerns and complaints. This vision follows that outlined in the Ombudsman publication My Expectations for Raising Concerns and Complaints. This means that we are fully committed to proactively building continuous and meaningful engagement with the public and patients to shape services and improve health. Our system for complaints management is one of the ways we make sure local people get the health care that they need. It is a positive opportunity to involve complainants at all stages of their complaint, to learn from their feedback, and to take appropriate actions so that we improve patient and/or carer experiences. 3. Also, we want to set out what good outcomes look like from the point of view of a patient or service user who has made a complaint. We recognise that complaints across health and social care are complicated, both in terms of the statutory and regulatory contexts, the potential involvement from multiple organisations and the cultural differences that apply to complainants. For example, those patients and service users to whom the Mental Capacity Act 2005 and the Mental Health Act 1983 (amended 2007) specifically apply, are entitled, by law, to receive a service that meets specific standards in the event they make a complaint. 4. We have a service that gives people an opportunity to engage with us, through a Patient and Advice Liaison (PALS) Service. This service captures comments and concerns, and also provides patients with an information service. The information from this service contributes to the intelligence we use to inform our commissioning decisions. WHAT OUR COMMITTMENT MEANS 5. We are proactively building continuous and meaningful engagement with patients, relatives and carers to shape services and improve health. We will manage complaints in accordance with our obligations; our stated vision, goals and objectives. 6. We will ensure that complaints are managed promptly and efficiently, are properly investigated and that complainants are treated with respect. March 2016 6

7. We will comply with the Health Act 2009 and the NHS Constitution and ensure that patients, relatives and carers are informed about their rights to: Access an Independent Complaints Advocacy Service. The Independent Complaints Advocacy Service can be contacted on: 0300 456 8350 or by email at this address liverpoolicas@carersfederation.co.uk. The web site is http://www.carersfederation.co.uk/icas-parent/ Have any complaint about NHS services dealt with efficiently and to have it properly investigated Know the outcome of any investigation into their complaint Take their complaint to the independent Parliamentary and Health Service Ombudsman, if they are not satisfied with the way their complaint has been dealt with by us. 8. We will ensure that there are systems in place so that patients, relatives and carers who complain: have suitable, accessible information about how to feedback on the quality of services and raise complaints are treated equally and will not be discriminated against because of race, ethnic origin, nationality, gender, culture, religion or belief, sexual orientation, age, disability or marital status are assured that we act on any concerns, and where appropriate, make changes and improvements to service delivery and care 9. These form our obligations on which to ensure good complaint handling, as promoted by the Parliamentary and Health Service Ombudsman s Principles for Remedy in investigating and handling complaints. SCOPE AND PURPOSE OF THE POLICY 10. The purpose of this policy is to outline the way in which complaints will be handled, and sets out the scope of the complaints procedure in NHS West Cheshire Clinical Commissioning Group and the steps that will be followed. Complaints may arise when a concern reported to Patient Advice and Liaison Service has not been resolved. 11. This policy has two guiding principles: to resolve complaints more effectively by responding more personally and positively to individuals To ensure that opportunities to learn from feedback do not get lost, and enable us to make informed decisions about service improvement 12. The scope of this policy does not apply to any complaint: by third party organisations about contracts placed by NHS West Cheshire Clinical Commissioning Group made by an employee relating to their employment March 2016 7

which is being, or has been investigated, by the Parliamentary and Health Service Ombudsman WHAT IS A COMPLAINT? 13. A complaint or concern is an expression of dissatisfaction about an act, omission or decision, either verbal or written, and whether justified or not, which requires a response and/or redress.. 14. We want to resolve your concerns as quickly as possible. We have a Patient Advice and Liaison Service who aim to respond to your concerns and queries within 24 hours and if required, this service then also provides advice on how to proceed to make a complaint. You can telephone this advice service on 01244 650368 or 0800 132996. You can email this advice service at wchc.website@nhs.net: 15. Complaints are usually made in writing, by email or by letter. The email address to use is complaints.nhswestcheshireccg@nhs.net The postal address is: The Chief Officer West Cheshire Clinical Commissioning Group FREEPOST (CS 1528) 1829 Building The Countess of Chester Health Park Liverpool Road Chester CH2 1HJ 16. A telephone call is acceptable to initiate a complaint but a formal record needs to be made about the nature of the conversation. Where a complaint is made verbally we will send a written record of the concerns to the complainant for agreement as this will form the basis of what we then investigate. This will include details of the Independent Complaints Advocacy Service who can assist them if required. WHO CAN COMPLAIN? 17. A person (or their representative) who: receives or has received care from a NHS responsible body is affected, or likely to be affected by the action, omission or decision of the NHS responsible body which is the subject of the complaint 18. If you wish to make a complaint on behalf of an adult, we will require consent from that person giving us permission to release information to you, which may be confidential to them. We will provide a consent form for this purpose. March 2016 8

19. If you wish to make a complaint on behalf of a child and you are not the parent(s) or legal guardian of the child, we will require consent from the parent(s) or legal guardian. We will provide a consent form for this purpose. TIME LIMIT FOR MAKING A COMPLAINT 20. The time limit for making a complaint is normally within 12 months of the incident. However discretion can be applied by the Clinical Commissioning Group to vary this time limit where this is considered appropriate, such as following a recall of health care products. MANAGEMENT OF COMPLAINTS 21. The regulations do not allow for a second investigation by the Clinical Commissioning Group if the provider has already investigated and responded to a complaint. However, at the request of the complainant we may offer help to broker a resolution where it appears that more can be done by the provider to resolve the complaint. The complainant retains the right to go to the Health Service Ombudsman, and our support is not a formal part of the complaints process. 22. The process for managing complaints will be undertaken by our Clinical Commissioning Group Patient Experience Team. The Clinical Commissioning Group will be responsible and accountable for the outcome of each complaint. Our guiding principles will be reflected in the processes in Appendix 1. 23. The principles of being open; which encourage truthfulness, timelines and clarity of communications will be observed by all parties when investigating, and analysing practice as a result of complaints. We plan to resolve complaints effectively by responding personally and positively to individuals who have expressed dissatisfaction. 24. We will receive the complaint, make an entry in the risk management system (DATIX), and send an acknowledgement to the complainant within three working days. The complaints officer will contact the complainant to try to understand what an effective resolution would look like for them, and then agree an action plan. We will always seek consent as required. 25. Our intention is that complaints are dealt with flexibly; with the aim of achieving the desired outcome if that is possible, as early as possible. The action plan will include timescales and these will be as short as realistically possible. 26. We will assign to each complaint an Owner and Investigating Officer. We will ensure there is agreement on which organisation leads the Investigation where multi-agencies are involved. The Owner and Investigating Officer will adopt appropriate investigation methodology and scrutinise provider responses. March 2016 9

27. A final response to the complainant is created following analysis of the investigation. This response is approved by the Accountable Officer. 28. The aim of investigations is to understand what went wrong and what actions (if any) should be taken. Lessons learned from complaints are discussed at senior management level. The purpose of the discussion is to use the information to: Ensure any common themes are visible to the Clinical Commissioning Group Make informed decisions about where improvements can be made Monitor progress against any action plans RESPONSIBILITIES FOR COMPLAINTS ARRANGEMENTS 29. It is the responsibility of all of our staff to be receptive to all forms of feedback, including complaints and appreciate that such information is an essential element of good governance. This section sets out what our roles and responsibilities are: The Accountable Officer 30. As Accountable Officer, the Chief Officer of NHS West Cheshire Clinical Commissioning Group is responsible and accountable for ensuring: Overall implementation, monitoring and effectiveness of the policy. Allocation of resources to provide compliance with the policy. Clinical Commissioning Group staff are aware of their responsibilities and comply with the policy All of our staff are receptive to all forms of feedback, including complaints and appreciate that such information is an essential element of good governance. Timely responses to complaints are approved and signed. The Director of Quality and Safeguarding 31. The Director of Quality and Safeguarding will: Have the authority to assign Owners and Investigating Officers to lead on complaints. Authorise our Patient Experience Team to escalate non-adherence to timetable /poor quality investigation reports to nominated member of senior management team in the Clinical Commissioning Group. Act as the interface between the Clinical Commissioning Group Senior Management Team and the Patient Experience Team. Enable a mechanism for sign off of letters in the absence of the Clinical Commissioning Group Accountable Officer. Ensure regular reports on trends from concerns and complaints are reported to the Clinical Commissioning Group Quality Improvement Committee. Escalate concerns and exceptions in the management of complaints to the Clinical Commissioning Group Governing Body. Monitor the performance of the policy against agreed key performance indicators (KPI). March 2016 10

Clinical Commissioning Group team 32. Our team will: Follow the agreed Complaints Management process shown at Appendix 1. Seek advice from our Patient Experience Team if they receive any intelligence from patients, relatives or carers, where dissatisfaction is indicated. On receipt of a formal complaint (email or by letter),direct all relevant details to the Patient Experience Team, on the day of receipt, and to do this in person if at all possible. Create meaningful updates to documentation such as the chronology of a complaint as they complete tasks or initiate actions Owners and Investigating Officers 33. Owners will: Be assigned to a complaint by the Director of Quality and Safeguarding. Take lead ownership for the complaint. Will work closely with the Investigating Officer in order to ensure the complaint is progressing as planned. Will approve drafts of response to complainants. 34. Investigating Officers will: Adhere to the agreed timescales for the management of complaints. Co-ordinate the investigation across all parties. Keep accurate records of conversations and actions and update records on the day these take place. Attend meetings with complainants when required and keep the complainant and their representatives involved throughout the course of the enquiry. Define the support needed for any meetings required as part of the investigation. Use a recognised methodology for identifying the root cause of the dissatisfaction. Develop an action plan that addresses the root causes identified. Quality assures the investigation with the owner of the complaint. Attend relevant training when required. Patient Experience Team 35. From October 1 st 2015, all complaints have been managed by our in house Patient Experience Team who: Work within the agreed Complaints Management process shown at Appendix 1. Support the complaint Owner and Investigating Officer. March 2016 11

Manage the time scales and the process, keeping accurate and timely records on the database (DATIX) system. Monitor the delivery of the duties assigned to the Owner and Investigating Officer. Keep complainants updated during the investigation at agreed points Establishing a timescale for each complaint.. Draft a complaint response letter and review with the Owner and Investigating Officer. Provide expert advice on de-escalation investigation methodology, and action planning. Provide expert advice on the legal and regulatory frameworks which apply, and updates to these. Reflect the vision and values of the Clinical Commissioning Group in the responses to complainants drafted for approval. Provide training to the Clinical Commissioning Group as required. Attend relevant training when required. ESCALATION 36. If the complainant remains dissatisfied with the actions undertaken following the investigation and the response received; they have the right to ask the Health Service Ombudsman to review their complaint. This right will be made clear in our correspondence with complainants. The Health Service Ombudsman is independent of the NHS. UNREASONABLE COMPLAINANT BEHAVIOUR (VEXATIOUS COMPLAINTS) 37. Unreasonable and unreasonably persistent complainants are those complainants who, because of the frequency or nature of their contacts, hinder the consideration of their own, or others, complaints. We will train our staff and investigating managers to respond with patience and sympathy to complainants, but it is recognised that there are times when there is nothing further that can reasonably be done to rectify a real or perceived problem. Our approach and process for managing unreasonable complainant behaviour is detailed in appendix 2 SERVICE STANDARDS 38. We have agreed a number of service standards to ensure that we monitor the performance of how we manage and respond to complaints. These standards are: We will acknowledge all complaints within 3 working days We will respond to all complaints within the timescale agreed with the complainant We will resolve your complaints to a level of satisfaction that avoids the need for you to escalate your concerns to the Health Service Ombudsman March 2016 12

FURTHER GUIDANCE AND READING 39. This document has been produced with reference to the following documents: The Local Authority Social Service Complaints (England) Regulations 2009 http://www.opsi.gov.uk/si/si2009/uksi_20090309_en_1 NHS England good practice guide to assist Clinical Commissioning Groups to handle complaints well and comply with the regulations http://www.england.nhs.uk/wp-content/uploads/2012/03/20130513-goodcomplaints-handling-for-ccgs-final-version-for-publication.pdf Ombudsman s Principles for: Good complaint handling http://www.ombudsman.org.uk/improving-publicservice/ombudsmansprinciples/principles-of-good-complaint-handlingfull Good Administration http://www.ombudsman.org.uk/improving-publicservice/ombudsmansprinciples/principles-of-good-administration Remedy http://www.ombudsman.org.uk/improving-publicservice/ombudsmansprinciples/principles-for-remedy NHS Constitution https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/ 170656/NHS_Constitution.pdf Standards for Better Health http://www.cqc.org.uk/ March 2016 13

APPENDIX 1 COMPLAINTS PROCESS MAP Complaint received Meeting with complainant arranged if clarification of issues required by investigating officer Response received from investigating officer to complaints officer Logged on risk management system by Patient Experience team Investigating officer identified Draft letter created by complaints officer and sent for approval from CCG Accountable Officer Complaint acknowledged by Patient Experience Team, asking for consent if required Contact made by complaints officer with complainant to agree next steps Formal response sent to Complainant Direct communication with complainant Internal complaints actions March 2016 14

APPENDIX 2 PROCESS FOR MANAGING UNREASONABLE COMPLAINANT BEHAVIOUR (VEXATIOUS COMPLAINTS) 1. Unreasonable and unreasonably persistent complainants are those complainants who, because of the frequency or nature of their contacts, hinder the consideration of their own, or others, complaints. 2. It is important to appreciate that such complainants may have genuine grievances that should be properly investigated. We will first ensure that NHS West Cheshire Clinical Commissioning Group s complaints policy has been fully implemented and that no element of the complaint has been overlooked or not properly addressed. If all reasonable measures have been taken, the Head of Quality and Safeguarding will discuss the matter with the Accountable Officer and reach a decision on how to proceed. The options to be considered are: If the investigation is underway the Accountable Officer may write to the complainant setting parameters for a code of behaviour, and inform the complainant that if these parameters are contravened this may on the progress we can make against the action plan. If a final response has already been provided the Accountable Officer will write to the complainant informing them that a full response has been made to their complaint, that correspondence and personal interaction is at an end and reiterate the right of the complainant to contact the Ombudsman. 3. Where complaints have been identified as habitual or vexatious the Accountable Officer will ultimately determine what action to take. The Accountable Officer will implement such action and will notify complainants in writing, of the reasons why their complaint has been classified as habitual or vexatious and the action that will be taken. For completeness, this notification may be copied to any others involved for example a Conciliator. A record will be kept, for future reference, of the reasons why a complaint has been classified as habitual or vexatious. A Lay Advisor may be consulted in order to support the process. 4. The Clinical Commissioning Group may decide to deal with such complaints in one or more of the following ways: Set out in a letter a code of commitment and responsibilities for the parties involved if the Clinical Commissioning Group is to continue processing the complaint. If these terms are contravened, consideration will then be given to implementing other action as indicated below. Decline contact with the complainant, either in person, by telephone, by fax, by letter, by e-mail or any combination of these, provided that one March 2016 15

APPENDIX 2 form of contact is maintained. This may also mean that only one named Clinical Commissioning Group officer will be nominated to maintain contact (and a named deputy in their absence). The complainant will be notified of this person. Notify the complainant, in writing that the Clinical Commissioning Group has responded fully to the points raised and has tried to resolve the complaint but that there is nothing more to add and continuing contact on the matter will serve no useful purpose. The complainant will be notified that the Clinical Commissioning Group will acknowledge and respond to new complaints in accordance with the Concerns and. The Clinical Commissioning Group does not intend to provide a response to any letters which are threatening or abusive or old issues were a response has already been provided. The complainant will be advised that they are being treated as a habitual or vexatious complainant. Inform the complainant that in extreme circumstances the Clinical Commissioning Group reserves the right to seek advice on unreasonable or vexatious complaints from the Clinical Commissioning Groups solicitors. Temporarily suspend all contact with the complainant, in connection with the issues relating to the complaint being considered habitual and/or vexatious, while seeking advice or guidance from the appropriate sources. 5. Once complaints have been determined as habitual or vexatious, the Clinical Commissioning Group has a mechanism for withdrawing this status at a later date if, for example, a complainant subsequently demonstrates a more reasonable approach or if they submit a further complaint for which the normal complaints procedure would appear appropriate. 6. As was the case in originally identifying a complaint as habitual or vexatious, staff will use the same discretion in recommending that this status be withdrawn when appropriate. Where this appears to be the case discussion will be held with the Accountable Officer and subject to their approval, normal contact with the complainant will then be resumed. The Accountable Officer will advise the complainant of this, in writing. March 2016 16

Equality Analysis Stage 1 Scope of Work Piece of work being assessed: Directorate: Service area: Governance/Continuing Health Care/Clinical Commissioning Group Complaints and the Patient Advice and Liaison (PALS) Service Other partners or stakeholder: Name of lead or person: Date of assessment: Aims of the piece of work (policy / project / framework etc.) The purpose of this policy is to outline the way in which complaints will be handled, and sets out the scope of the complaints procedure in and the steps that will be followed. Complaints may arise when a concern reported to Patient Advice and Liaison Service has not been resolved. March 2016 17

Expected outcomes as a result of the piece of work, and how they will be measured: Stage 1 Initial EQA Screening to resolve complaints more effectively by responding more personally and positively to individuals to ensure that opportunities to learn from feedback do not get lost, and enable us to make informed decisions about service improvement Number of complaints acknowledged in 3 working days Performance Target to achieve 100%. Number of complaints responded to within timescale agreed with complainant Performance Target to achieve 95%. Number of complaints notified by the Ombudsman where further recommendations have been required, in relation to the Complaints Procedure Performance Target Nil. Protected characteristic Baseline Data and research What national data is available? What local data is available? What information is available relating to this specific area? Number of young people using a service etc. What does it show? Numbers involved (quantitative data); comments from people (qualitative data) Are there any gaps? Include consultation with users if available, comments, feedback from patients, users etc. Impact From the analysis of data and research? Is the service being used by all groups the same or one group more than others? Is the piece of work direct or indirect discrimina tion If indirect discrimination: Indirect discrimination service effects one group more than others but accidentally.what can we do to eliminate indirect discrimination? What reasonable adjustments can be made If direct discrimination: People are openly discriminated i.e. no blacks No gypsies, No disabled people. Age The 2011 Census population was 329,608: o 17.6% (58,135) were aged 0-15 (19.9% in 20011) March 2016 18

o 63.8% (210,373) were aged 16-64 (63.7% in 2001) o 18.5% (61,100) were aged 65+ (16.4% in 2001). Disability Chester 118,210 People who have a long-term illness or disability 16.6%. Ellesmere Port and Neston 81,672 People who have a longterm illness or disability 18.2%. 10,650 people received services in the local Authority During 2006 /07 8,503.00 80% of the total receiving services with the remaining 20% Comprised 2,147 people receiving residential and nursing services For the community services, 6,168 people, nearly three-quarters of all Service users are those with physical disabilities. Those with a mental May have a significant on some people from this diverse group. Importance of relevant awareness training regards potential attitude and behaviour sensitivity s on Disability Yes Assistance to be made available for customers who may have Learning disability/difficulty/ literacy issues. Health problem (including dementia) are the next most predominant group, with 1,525 service users, accounting for 17.9% of services this reflects the National picture Gender Reassignment Although it is recognised that there are currently no publicly available statistical data on transgender people, the Gender Identity Research and Education Society (GIRES, 2008) March 2016 19

suggests that the prevalence of people age 16 and over seeking help for treatment of Gender Dysphoria is 20 per 100,000 and is thought to be increasing by 15% annually. If this was applied to Cheshire West and Chester, this would equate to approximately 50 people in the Borough. The average age for seeking treatment for Gender Dysphoria is 42. In terms of the transgender population, GIRES gives an estimate of 600 per 100,000. If these figures were applied to the Cheshire West and Chester area, there may be around 1,500 trans people in the area http://www.doriconline.org.uk/groupquery.aspx?area=164&grou pid=9 Marriage & Partnership Marital and civil partnership status classifies an individual according to their legal marital or registered same-sex civil partnership status as at census day, 27 March 2011 in Cheshire West and Chester was 428 (2011 Census Key Statistics)http://www.doriconline.org.uk/groupquery.aspx?area=1 64&GroupID=9 Pregnancy & maternity Cheshire West & Chester All births 3,822 Cheshire West and Chester Male births 1,965 Female births 1,857 26/04/2012 next update 26/04/2013 March 2016 20

All 3,081 Asian 418 Black 288 White 1,981 Mixed, Chinese & any other ethnic group 220 Numbers Not stated 174 It is also identified that Gypsy/ Traveller have the Highest mortality rate. Gypsies and Travelers face the most serious disadvantages of all ethnic minority groups. Children have high mortality rates and the lowest educational attainment http://www.ons.gov.uk/ons/index.html http://www.homeoffice.gov.uk/equalities/equality-government Race o 94.7% (312,013) were White British (including Northern Irish) (96.5% in 2001) o 0.7% (2,337) were White Irish o 0.1% (213) were Gypsies or Irish Travellers o 2.0% (6,462) were from other White groups o 0.9% (3,050) were from mixed / multiple ethnic groups o 1.2% (4,097) were Asian / Asian British (includes Chinese) May have a significant on some people from this diverse group Importance of relevant awareness Yes Ensure that arrangements are made for people who do not speak or understand english March 2016 21

o 0.3% (908) were Black / African / Caribbean / Black British o 0.2% (528) were from other ethnic groups. In January 2008, there were 151 caravans belonging to Gypsies and Travellers in Cheshire West and Chester. training regards potential attitude and behaviour sensitivity s on this group Religion/Belief Religion 70.1% (231,126) of people said they were Christian (80.7% in 2001). 1.1% (3,560) belonged to other major world religions. 22.0% (72,649) stated they had no religion (11.5% in 2001). 6.5% (21,419) chose not to answer this question Christian 231126-70.1% Buddhist 776-0.2 % Hindu 653 0.2 % Jewish 653 0.2 % Muslim 1686-0.5% Sikh195-0.1% Other religion 854-0.3% No religion 72649-22% Religion not stated 21419-6.5 % Sexual There are inherent problems in estimating the number of gay, lesbian and bisexual people resident within the Cheshire West March 2016 22

Orientation and Chester population. However, the Family Planning Association estimates that the proportion of both men and women who have ever had a same sex partner to be 5.4% of men and 4.9% of women If the proportions reported in the Family Planning Association survey are applied to the Cheshire West and Chester adult population, there would be around 13,900 men and women who have ever had a same-sex partner within the local population. (DORIC Population Summary Information Gay, Lesbian And Bisexuals In Cheshire West And Chester 2012) Sex Western Cheshire has a population of around 260,000 people. Local Authority Area 329608 Males 160586-48.7% Females 169022-51.3% Stage 1 Initial EQA Action Plan Having undertaking the equality analysis, please complete the following action plan detailing how you will tackle and mitigate issues resulting from the findings of the Initial Screening: Equality Strand Issue Initially identified What information do I need and how will I get it? Timescale Lead March 2016 23

Consultation, Focus group, Survey, Research etc. Edits to the policy were made 28.12.12 no further action required Sex Race Disability Sexual Orientation Age Religion/Belief Marriage & Partnership Gender Reassignment Pregnancy & maternity March 2016 24

User Guide (Standard Operating Procedure) Handling Complaints Introduction This document is a guide for and details the process for handling Complaints/Concerns, and includes details of how to enter details onto the Complaints database (DATIX) Risk Management System. It also includes useful contact information for the West Cheshire Clinical Commissioning Group (CCG) team. There are two distinct parts to the Complaints Procedure: Stage One: Local Resolution by the West Cheshire Clinical Commissioning Group. 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. If this is not possible, then the complainant can chose to move to Stage Two, that is, an Independent Review. It is important not to introduce delays into the 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 as the Accountable Officer within 30 working days or the timescale as agreed with the complainant at the outset. First class post will be used for all correspondence with complainants. All communication will be marked Private and Confidential. 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. Try to deal with complaints promptly and at source. When support is required then staff are encouraged to consult their Line Manager or a member of the Clinical Commissioning Group Patient Experience Team. Every effort must be made to resolve the situation at the time.

Complaints received directly by Clinical Commissioning Group staff should be date stamped on receipt and delivered to the Patient Experience Team for handling in accordance with the Clinical Commissioning Group Complaints Policy. Support for complainants It is the responsibility of the Clinical Commissioning Group team to assure complainants and/or their representatives that any complaint made will not prejudice the treatment and care they receive from local providers, and to inform people of the support available to help them complain. Information and advice is available from the Patient Experience Team. The Clinical Commissioning Group Patient Experience team 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. 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 Patient Advice and Liaison Service (PALS) enquiry include: Those complaints requiring instant action to ensure that the immediate health care needs of the patient are being met. Requests for information and an explanation. Those which indicate a need for support and someone to listen. Those expressing a wish to be dealt with by the Patient Advice and Liaison Service. Complaints that may be best treated as a Formal Complaint include: Complaints received from a local Member of Parliament (MP) on behalf of a patient resident in his/her Constituency. Complaints received from an Advocate such as Healthwatch. Unresolved Patient Advice and Liaison Service (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. An express wish by the complainant to access the West Cheshire Clinical Commissioning Group s Complaint s Procedure.

Complaints regarding a GP Practice, GP, Dentist or Pharmacy These complaints are to be acknowledged by the Patient Experience Team and consent requested from the complainant to forward the complaint to NHS England on the complainant s behalf. Complaints involving a number of NHS Organisations: If the complaint is regarding a number of health organisations including a GP Practice within the West Cheshire Clinical Commissioning Group catchment area, the Patient Experience team will collate the response letters from all of the organisations and provide a unified response. If a complaint is specifically about one Primary Care organisation, NHS England will send the complaint response to us and will only deal with the complaint. For example: A complaint is received regarding a GP Practice this is to be forwarded to NHS England. However, if a complaint is received regarding a GP Practice, Hospital and a Community service, then this complaint will be handled by the Clinical Commissioning Group and NHS England will send the GP Practice response to us to collate with the other responses. Dealing with Formal Complaints: On receipt of a Formal Complaint the Patient Experience Team 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. Always consider consent. Necessary action will be needed if one, or both of these conditions have not been met in order that the complaint can be investigated Where a complaint is made orally, the Patient Experience Team will make a written record and ensure with the complainant that the essence of their issues has been captured. Where the complaint is made in writing or received electronically, the Patient Experience Team 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 Patient Experience 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.

Notify the Director of Quality and Safeguarding of receipt of the complaint. The Director of Quality and Safeguarding will respond by nominating: The Owner of the Complaint Member of staff who will lead the investigation into the complaint. The Investigator of the complaint Member of staff who will carry out all duties pertaining to the investigation of the complaint. Enter the complaint onto the Datix (database) system: To add complaints onto the system, this requires a log in. Once you receive your log in details and log in successfully, the first screen should look the same as below. All complaints sit under the complaints tab.

Click onto the complaints tab to access all complaints onto the system. Then click on add a new complaint The following form will show up: Going through the form, please answer as many of the fields as possible. Fields marked with a Red Star (*) are mandatory fields.

Below is a brief description of the fields for completion within the form: Type of contact - this will provide you with a number of options on what the communication is about. Once the Forename and Surname are completed, click Search. The following box will come up:

If the complainant is known to us you will be able to choose that contact and link them with any previous correspondence: Demographics the next information required is the complainant s information. Person Affected this is completed if the complainant isn t the patient involved. Always add the patient that is affected first before any other patients or family members involved. Make sure all patient names included in the complaint are added under the persons affected. 7

To add another person affected, click the grey add another button. This is highlighted above. For each person affected, each contact will need to be approved Details of contact this requires the full information of the complaint. Assign yourself as the Handler. Reason for discrepancy, this text box should be used if there is a delay of dates from when the communication was first initiated to when the Clinical Commissioning Group received the information. Summary of Complaint This should be a brief description of the complaint / enquiry / MP letter and should not include any patient names. Subject of complaint please select the subject/reason for the complaint and also the name of the organisation named in the communication. Keep this information anonymous, using non identifiable information. We require this to remain anonymous so that when the reports are ran for quality purposes do not include any patient information. 8

Consent With all complaints, we require consent. This consent can be verbal (if the complaint is about something that has affected them) or written. Anyone over the age of 16 will need to provide consent in order to investigate a complaint. If the person does not hold capacity to provide consent the relative that holds Power of Attorney will need to provide consent. The report of the complaint cannot be released to any other family member apart from the Power of Attorney unless the Power of Attorney provides consent for this to happen. For example, a daughter makes a complaint regarding her father s care. The father does not have capacity to consent to the complaint and the mother has Power of Attorney, we would require consent from the mother. The requirement of consent should always be addressed at the outset of recording the complaint. Seek advice where necessary. Consent forms can be sent with acknowledgement letters and a prepaid return envelope for the convenience of the complainant. Subjects add all the subjects the complaint is regarding. Further subjects can be added by clicking add another try and put as much detail in as possible. Attach any documents all written or emailed correspondence needs to be attached to Datix and also saved to the S Drive. NB: Written documents will need to be scanned first 9

Progress Notes: Any actions taken regarding a complaint should be recorded on the progresses notes, and attach any documents of evidence. For example, telephone calls, chase emails etc. Acknowledging a complaint Once you have added the complaint onto the system, it needs to be acknowledged. Using the template out of the Complaints folder on the CCG S Drive the acknowledgement letter should be completed. An example of the letter template is shown in the Appendix of this report, and the whole suite of letter templates can be located at S:\West Cheshire CCG\3. Quality and Engagement\1. Patient Experience Team\6. Templates\CCG Templates Summary points of the complaint should be picked out of the complaint; this provides us with a guide on what should be provided within the complaint. Once this letter has been approved, go back onto Datix, open up the complaint, and make you way down to the complaint chain. Click on the date that the acknowledgement has been done. The acknowledgement letter will need to be sent to the complainant along with a blank consent form and a prepaid envelope. The complaint should not be fielded until the consent is received. Once the consent is received the complaint can be fielded. 10

Fielding the complaint The complaint will need to be fielded to the relevant organisations. This may be more than one organisation. Once this is completed, field to the relevant organisation. Update the complaints chain, the progress notes and also add the fielding form and fielding email onto the documents section of Datix. Within the fielding email, make ensure the date for the return is clear within the email. The complaints chain may require a review at this point depending on when the consent form has been returned and the dates to be completed manually. The Action date, 18 working days is given to the provider to respond to the fielding form. Our response will total to 30 w o r k i n g d a y s once the completed consent form has been received. Investigation After alerting the complaint to the Owner and Investigator, an investigation of the issues will be undertaken by the designated Investigating Officer. This could include statements, notes from interviews with staff and review of appropriate documentation i.e. health records. All investigations should be conducted in a manner supportive to those involved and take place in a blame free atmosphere. Investigation should not be adversarial and must uphold the principles of fairness and consistency. The nominated Investigator identified to undertake a complaint investigation, will ensure the complaint is read carefully and the points for investigation are responded to thoroughly. In formulating a comprehensive response it may be necessary to examine relevant documents, including both electronic and paper records. Where a delay is likely this should be highlighted as soon as possible to Patient Experience Team to avoid any delays in the final complaint response. Response Due The response is due 18 working days after the fielding form is sent to the provider. If you haven t received it you will need to chase the organisation. Firstly via email, making sure you record on the progress notes and save the email on the documents. If you have no luck you need to phone the relevant complaints department. If the organisation is unable to provide the response within the timeframe provided, we will need to contact the complainant and advise them that we are unable to provide the response within the given time frame. Using the holding letter (saved on the shared drive), agree an extension with the provider and send the letter to the complainant. The complainant may not be happy with the delay but if you explain the reasons why within the response the complainant usually accepts the extension. 11

Replied by This is the date that our final response is required by the Clinical Commissioning Group. This will total 30 working days from when the completed consent has been received. Response Letter The response letter should be put together using the template (from the C lin i c a l C o m m i s s i o n i n g G r oup shared drive). The response will: Thank the complainant for expressing their concerns Be empathetic in tone. Be written in Plain English and avoid jargon. Explain any clinical terminology or technical terms used, and are expressed in terms that a person who is not a clinician can understand. Summarise the nature and substance of the complaint. Describe the investigation. Address all the issues raised in an open and honest way. Detail any actions taken, including any appropriate managerial and/or remedial action taken or recommended, or explanation of why no action is appropriate. Summarise conclusions. Express regrets or apologies as appropriate, and be conciliatory in tone Include further options if complainants remain dissatisfied with the Trust s investigation and response, or have further questions. Complainants will be invited to contact the Chief Executive and may be offered a meeting with the staff involved in their complaint. Inform the complainant of their right to have their complaint considered by the Parliamentary & Health Service Ombudsman The draft response will need to be sent to the Patient Experience Manager and then to the Chief Executive Officer for approval. Once approved, the Chief Officer s electronic signature is to be added onto the bottom of the letter and the FINAL response c onv e r t e d t o PDF format. Within the correspondence saved onto the S Drive, please save numerically in date order as it make it easier to find documents within the folders as there can sometimes be a lot of correspondence. Always remember CONSENT! 12 Always record everything. You can never have too much information. For any CHC Retrospective Complaints, please send a copy of the final response to NW CSU.ClosedownComplaints@nhs.net

Follow Up If a complainant remains dissatisfied with the CCG s investigation and response, the Patient Experience Team may: o Initiate further investigation if supplementary questions are raised. Whilst there is no set time limit for second responses related to a complaint, the CCG will aim to acknowledge further concerns within three working days and to provide further responses within 30 days of the subsequent complaint being received or as agreed with the complainant (dependent on the complexity of the issues needing to be addressed). o Offer a meeting or arrange a teleconference to discuss concerns. The Patient Experience Team will offer to accompany staff during any such meetings. Stage Two: Independent Review The Parliamentary & Health Service Ombudsman (PHSO) If the complainant is still dissatisfied after local resolution has been completed they may wish to ask the Parliamentary and Health Service Ombudsman to investigate their case. Complainants can be advised to call the Ombudsman direct on 0345 015 4033, or they can write to the Health Service Ombudsman, Millbank Tower, Millbank, London, SW1P 4PQ or email phso.enquiries@ombudsman.org.uk. The Ombudsman is completely independent of both the NHS and the government and investigates complaints about NHS services as well as complaints about the process. Advice and support will be offered to the complainant if they wish to pursue this option. The Clinical Commissioning Group will proactively respond to any requests from the PHSO and fully comply with any requests. 13

APPENDIX Letter Template Your Ref: Our Ref: Date: Private & Confidential Insert Address 1829 Building Countess of Chester Health Park Liverpool Road Chester Telephone: 0800 132 996 E-mail: complaints.nhswestcheshireccg@nhs.net foirequests.nhswestcheshireccg@nhs.net enquiries.wcheshireccg@nhs.net Website: www.westcheshireccg.nhs.uk Dear XXXXXXXX Yours sincerely Alison Lee Chief Executive Officer 14