Policy for the Management of Concerns and Complaints

Policy for the Management of Concerns and Complaints Controlled document This document is uncontrolled when downloaded or printed. Reference number Version 1 Author Name & Job Title Executive Lead WHHT: G029 Maureen Walton, Complaints & PALS Manager Chief Nurse Approved by/ Date Policy Review Group/9 th vember 2015 Ratified by Quality and Safety Group Date ratified 14 th December 2015 Committee/individual responsible Quality and Safety Group Issue date January 2016 Review date vember 2018 Target audience Additional Search Terms Previous Policy Name All WHHT Staff Complaints, Concern, PALS, Compliment Complaints and PALS Policy

CONTRIBUTION LIST Key individuals involved in developing this version of the document Document Control Panel Development and Consultation: Dissemination Implementation Training Audit Review Chief Nurse Associate Director of Governance Director of Corporate Affairs Director of OD and HR Director(s) of Communications and Engagement Patient Experience Manager Policy Review Group Patient Safety & Quality Committee Equality & Diversity Systems Advisor Dissemination will be through Staff Briefings and accessed through the Trust s intranet Chief Nurse Through team briefs, workshops 12 months from the date of implementation Complaints & PALS Manager Patient Safety & Quality Committee Equality and Diversity West Hertfordshire NHS Trust works within the Equality Delivery System Framework. This policy has therefore been impact assessed against our four goals:- Goal 1 Better health outcomes for all Goal 2 Improved patient access and experience Goal 3 Empowered, engaged and well-supported staff Goal 4 Inclusive leadership at all levels Change History Version Date Author Reason for change 1 v 2015 Maureen Walton New: Policy re-written to reflect significant change to process (replaces March 2015 version- now archived) Page 2 of 26

Definitions used in this policy A Complaint Issues/concerns Joint complaint PALS Chief Executive Chief Nurse Governance Lead Complaints & PALS Manager The Parliamentary & Health Service Ombudsman (PHSO) A written or oral expression of dissatisfaction with the service provided or the circumstances associated with its provision which requires a formal investigation and response. A written or oral expression of dissatisfaction with the service provided (or not provided) or the circumstances associated with its provision, but which can be resolved by the end of the day after which the complaint was made, without the need for formal investigation and formal correspondence. A complaint which involves more than one NHS body or an NHS body and another external organisation. Patient Advice and Liaison Service (PALS) provides advice and liaison to patients who have queries/concerns about the NHS. The Chief Executive (CEO) is the Accountable Officer for West Hertfordshire Hospitals NHS Trust. As such, the CEO is responsible for ensuring that the Trust achieves its Statutory Responsibilities as set out in the Health and Social Care Act 2012. The person identified in the Trust responsible for overseeing the complaints procedure The person identified in the Trust responsible for handling and investigating an individual complaint. Person responsible for the day to day operational management of concerns and complaints Referral body for complainants when a complaint cannot be resolved at local level. Page 3 of 26

Useful addresses: Name Address Purpose Chief Nurse Complaints Manager / team NHS England POhWER ICAS Healthwatch England Watford General Hospital Vicarage Road Watford Herts WD18 0HB Watford General Hospital Willow House Vicarage Road Watford Herts WD18 0HB Tel: (01923) 217866 Email: whertstr.complaintsteam@nhs.net PO Box 16738 Redditch B97 9PT Tel: 0300 311 22 33 Email: england.contactus@nhs.net Hertlands House Primett Road Stevenage Herts SG1 3EE http://www.pohwer.net Douglas Tilbe House Hall Grove, Welwyn Garden City Herts AL7 4PH Tel: 01707 275978 http://www.healthwatchhertfordshi re.co.uk/ Responsible for overseeing the complaints procedure within the Trust Provides advice and support in relation to NHS services Responsible for the day to day administration of this procedure Responsible for the management of complaints arising from primary care, military, offender health and specialised services Provides advocacy support to people who wish to make a complaint against the NHS. Independent consumer champion for health and social care in England. Ensures that voices of patients and service users reach the ears of the decision makers The Parliamentary & Health Service Ombudsman (PHSO) Millbank Tower Millbank London SW1P 4QP Tel: 0345 015 4033 Fax: 024 7682 1960 Referral body for complainants when a complaint cannot be resolved at local level. Page 4 of 26

CONTENTS 1. Summary 2. Introduction 3. Aim 4. Legislative Context 5. Scope 6. Mission Vision & Values 7. Accountability and Responsibility 8. Intended Users 9. Definition of a Complaint 10. Equality Impact Statement 11. Complaints Team 12. Complaints Procedure 13. Time Limit for Making Complaints 14. Persons who can raise complaints 15. Vexatious and Persistent Complainants 16. Complaints not handled by the Trust 17. Mediation 18. NHS England 19. Parliamentary & Health Service Ombudsman (PHSO) 20. Lessons learned 21. Working in Partnership 22. Accessibility 23. Monitoring and Performance Management of the policy Appendix A: Appendix B: Appendix C: Procedure for Handling Persistent and Vexatious Complainants Flowchart Overview of Procedure for the Management of Concerns and Complaints Key Performance Indicators (KPIs) Page 5 of 26

1. Summary Policy & Procedure for the Management of Concerns and Complaints This policy outlines the process by which complaints and concerns are handled by West Hertfordshire Hospitals NHS Trust ( the Trust ). The primary function of this policy is to ensure that procedures are in place to address all concerns and complaints to ensure that information, findings and recommendations are implemented to improve quality standards. This policy outlines the process by which complaints and concerns will be handled when raised by or on behalf of the patient/service user. The primary function of this policy is to ensure that procedures are in place to address the concerns and complaints raised with or about the Trust. This will include providing: An explanation An apology (where appropriate) Assurance that the matter has been looked into; and Where a complaint is founded confirmation that action has been taken to prevent the same thing from happening again The secondary function is to ensure that information, findings and recommendations are provided to the relevant division or department to help assist quality standards. This policy will also outline the procedure to be followed when dealing with: Complaints about services not commissioned by the Trust Complaints relating to any action or decision taken by the Trust Complaints relating to other NHS trusts or local authority services Complaints relating to services provided by the independent sector and Complaints relating to more than one organisation. 2. Introduction The Trust recognises that comments, concerns and complaints are a valuable source of information from service users about the quality of the services it provides. It is essential that all complaints and suggestions are received positively, investigated thoroughly and promptly and responded to in an open and empathic manner, with action taken, where appropriate, to prevent a recurrence of the circumstances leading to the complaint. The Trust welcomes complaints as a valuable means of receiving feedback on the services it provides and also on the way the Trust goes about its business. The Trust aims to use information gathered from complaints as a means of improving its services. The Trust will seek to identify learning points that can be translated into positive action and, where necessary, provide redress to set right any injustice which may have occurred. Patients and service users are encouraged to express complaints, concerns and views, both positive and negative, about the treatment and services they receive, in the knowledge that: they will be taken seriously they will receive an efficient response outlining any investigations taken as a result appropriate action will be taken there will be no adverse effects on the care that they or their family members receive; and Page 6 of 26

lessons will be learnt and disseminated accordingly to the Trust s Quality and Performance teams to ensure that learning from complaints is monitored. 3. Aim The aim of this policy is to set out the Trust s approach to receiving, handling and responding to complaints made under the provisions of the Local Authority Social Services and National Health Service Complaints (England) Regulations 2009 (SI 20009/309) 1. The management of complaints and concerns is provided by the Trust s Complaints and Patient Advice & Liaison Service (PALS). The aim of this policy is to ensure that the complainant is at the centre of the process and the Trust strives to provide the complainant with a high quality service that will respond openly to the issues and concerns that have been raised. The Trust recognises that in some instances it may not be possible to provide satisfaction to a complainant and, where this is the case, the Trust will work closely and co-operatively with the Parliamentary & Health Service Ombudsman (PHSO) on any case the Ombudsman chooses to investigate. 4. Legislative Context (a) The Local Authority Social Services and National Health Service Complaints (England) Regulations 2009 ensure that the Trust, as a commissioner of health services, manages complaints in accordance with the NHS Complaints Procedure 2009: http://www.legislation.gov.uk/uksi/2009/309/contents/made (b) The NHS Constitution explains your rights as a patient or service user when it comes to making a complaint: http://www.nhs.uk/choiceinthenhs/rightsandpledges/nhsconstitution/ Documents/2013/the-nhs-constitution-for-england-2013.pdf and states that patients/service users have the right to: have their complaint acknowledged and properly investigated, discuss the manner in which the complaint is to be handled and know the period in which the complaint response will be sent to be kept informed of the progress and to know the outcome including an explanation of the conclusions and confirmation that any necessary action has been taken take their complaint to the independent Parliamentary and Health Service Ombudsman (PHSO) if they are not satisfied with the way the Trust has dealt with the complaint, make a claim for judicial review if they think they have been directly affected by an unlawful act or decision of the Trust, and receive compensation if harmed by negligent treatment This policy does not duplicate issues which are clearly set out in legislation, but adapts and supplements these to meet local needs and recent developments in the NHS. It also aims to meet the principles of good complaints handling laid down by the PHSO by: Getting it right 1 http://www.legislation.gov.uk/uksi/2009/309/pdfs/uksi_20090309_en.pdf Page 7 of 26

Being customer focused Being open and accountable Acting fairly and proportionately Putting things right Seeking continuous improvement 5. Scope This policy applies to all concerns or complaints received by the Trust. This policy also covers those complaints where the Trust agrees with another organisation to take the lead. This policy and its procedures apply to both clinical and non-clinical complaints and relates to: complaints about services provided by the Trust; complaints regarding actions, behaviours or attitude of any person employed by the Trust; health related complaints that include elements relating to the Local Authority; complaints regarding access to or review of funded care; complaints regarding an NHS body or independent provider. and should be read in conjunction with other associated policies, Incident Reporting and Near Miss Incident & Serious Policy, Risk Management Strategy. The policy does not cover concerns or complaints raised by Trust staff in relation to employment matters which are handled separately through line management arrangements and Human Resource policies e.g. Grievance Procedure and Disciplinary procedures. 6. Our Values In the management of any concerns or complaints received, the Trust aims to be: Patient focused: Our population, patients and their families are at the centre of our thoughts and actions, we aim to provide a service which is adequate and tailored to their needs. Quality driven: We will constantly strive to be the best we can be as individuals and as an organisation and we will ensure that this is reflected in the service we provide. Work locally: We will always listen to our patients and take on board any suggestions for improvement. Excellent: Our aim is to be an excellent organisation for our communities, clinicians and our staff. 7. Accountability and Responsibility All Trusts are required to have their own arrangements for complaints handling in accordance with the Local Authority Social Services and National Health Service Complaints (England) Regulations 2009. The revised NHS Standard Contract for Acute Services requires each provider to: operate and publicise a complaints procedure that complies with the law; provide such details of its complaints procedure as its Commissioner may reasonably require and shall implement lessons learned from complaints and demonstrate at CQRs the extent to which service improvements have been made as a result. Page 8 of 26

The Chief Executive will oversee the complaints management process to satisfy itself that the required quality of service and decisions are achieved and maintained. This includes the responsibility for approving the Trust policy and procedures for the management of complaints and concerns. The Chief Executive is ultimately responsible for all complaints received by the Trust. However, this responsibility is delegated to the Chief Nurse as the Executive Director with corporate responsibility for ensuring the Trust has arrangements in place that comply with the regulations, and that appropriate action is taken arising from complaints. The person responsible for managing the Trusts complaints procedures in accordance with the arrangements made under the Regulations is the Complaints & PALS Manager. The Safety & Quality Committee is responsible for ensuring that the Trust is meeting its key performance indicator (KPI) obligations in relation to complaints management and ensures appropriate learning is identified and shared. The Committee will monitor the implementation of the policy and procedure, receive and review quarterly complaints reports including details on trends and themes, review issues and ensure that appropriate actions are taken, lessons are learned and making recommendations as necessary. The Complaints & PALS Manager is the person responsible for day to day management of complaints and takes responsibility for: Ensuring effective implementation of this policy The satisfactory management of complaints handling and coordinating the complaints process; Review all complaints received and preparing reports for the PSQ Committee, Information Commissioners and the PHSO as appropriate; Assess the severity of the complaint, whether escalation is required and/or the need to contact other agencies; Provision of advice/support to staff dealing with complaints; Providing information to complainants regarding sources of support such as ICAS/Pohwer and other advocacy services; Ensure publicity, explaining how to raise concerns/complaints, is accessible to the public and complainant; Summarise complaints information and conclusions to inform its commissioners for the purpose of quality monitoring and reporting; Develop and maintain a database to categorise and record all complaints received; The preparation of acknowledgement and response letters within the required timescale. All members of staff are responsible for acquainting themselves with the complaints policy and the complaints procedures relevant to their area of work. Members of staff will be expected to assist as required in any complaint investigation, eg service leads and senior staff. Members of staff with specific duties under the complaints procedure should ensure that a suitable colleague is nominated to deputise on her or his behalf in her or his absence. 8. Intended Users This policy is intended for use by the Trust s members and staff, persons wishing to make a complaint under the Regulations, parliamentary and other representatives who provide support to persons wishing to make a complaint. This policy is also available for scrutiny by external agencies with an audit and inspection role regarding the Trust s complaints function. Because of the diverse audience for which this policy is intended, it is written in such a way as to make it a practical guide to using the Trust s complaints handling service and the types of complaints the Trust covers. Page 9 of 26

9. Definition of a Complaint For the purposes of this policy a complaint is defined as an expression of dissatisfaction received from a patient, carer, service user or third party representative about any aspect of the local health services which requires a response. Such expressions of dissatisfaction may be made in a variety of ways; verbally, in person, by telephone, in writing, including electronically by email or fax. This wide definition empowers staff to resolve minor comments, grumbles and problems immediately and informally. The decision as to whether a matter is dealt with informally as a concern or as a formal complaint will depend on whether an immediate response can be given or whether further investigation is required. 10. Equality Impact Statement The Trust welcomes feedback on this policy and the way it operates. We are interested to know of any possible or actual adverse impact that this policy may have on any groups in respect of gender or marital status, race, disability, sexual orientation, religion or belief, age, deprivation or other characteristics. The person responsible for the equality impact assessment for this policy is the Chief Nurse. This policy has been screened to determine equality relevance. The policy is considered to be high in equality relevance particularly in relation to: age, disability, race, gender, religion/belief, sexual orientation, transgender and deprivation. It is important for staff to remember that complainants may not be able to read or write, may not have English as their first language or may have disabilities which make it difficult for them to express their complaint. There are many groups in our communities that find it hard to access the services that they need. Therefore, it is important that the Trust has arrangements in place to ensure that all groups are given the opportunity to access proper health care services. This policy embraces diversity, dignity and inclusion in line with statutory requirements and human rights guidance. The Trust recognises, acknowledges and values differences across all people. Every person will be treated with respect, courtesy and with consideration for their individual backgrounds. The Trust will ensure that everyone is treated fairly and conveys equality of opportunity in service delivery and employment practice. Practically, this means that the Trusts will anticipate and take steps to meet individual needs. This will include making reasonable adjustments to processes and communications to help ensure their accessibility to all. 11. The Complaints Team The Trust s Complaints Team will provide all necessary activities to enable the Trust to meet its statutory duties and obligations as set out in the 2009 Complaints Regulations. The key elements are: A central access point (Mon to Fri 9am to 4.30 pm) exc bank holidays; A dedicated telephone number and e-mail address; Page 10 of 26

Provide details of the Trust s procedure and related NHS procedures to customers and complainants Acknowledgement of concerns or complaints: Record all contact details and maintenance of internal database, together with the outcomes on a complaints database; Identification of the main issues and the outcomes required to resolve the case for the complainant or customer Analysis of data and production of quarterly and annual reports Point of contact and liaison with the PHSO office; Facilitate and support face to face meetings between Trust staff and complainants Signpost patients to appropriate agencies and support groups outside of the NHS Identify the appropriate Service or Division Lead to secure the information and facts which enable a full response to be made; Provide Service Lead/manager with details of the case and timescales for completion. Co-ordination of and support to the investigation including obtaining consent where appropriate, chase progress on the complaint investigation, send reminders of response deadlines and negotiate extensions with the complainant when more time is required; Preparation of response letters following clarification and investigation ensuring that all issues identified in the complaint have been addressed; where findings do not fully address all of the issues raised, identify the issue, feedback to the Service Lead for further information and negotiate revised timescales for a response. Ensure that the Trust lead receives updates as agreed throughout the process and quality check draft response letters; Arrange for signature of response letter and sending to complainant. 12. Complaints Procedure 12.1. The Trust s Complaints Procedure aims to meet the following criteria: Be well publicised and easy to access. Simple to understand and use. Fair and impartial. Complaints dealt with within a pre-advised timescale of between 25-35 days which is dependent on the issues and nature of the complaint raised Provides a thorough mechanism for resolving complaints and investigating matters of concern. Be regularly reviewed and amended if necessary. Be consistent with National Guidance. 12.2. The Trust s Complaints Procedure consists of two elements: Local Resolution Local Resolution aims to provide the fullest possible opportunity for the investigation and resolution of the complaint and will be tailored to meet the needs of the complainant. The Parliamentary and Health Service Ombudsman (PHSO) If a complainant is dissatisfied with Local Resolution they have a right to refer their outstanding concerns to the PHSO. Local Resolution Procedures 12.2.1. Complaints about the Trust and its staff Page 11 of 26

All staff are encouraged to deal with concerns and requests for information for which they can provide an immediate response. If a matter remains unresolved the complainant should be informed about the formal complaints procedure and provided with the relevant information. Details of any formal complaints should be passed promptly to the Complaints Team, to be acknowledged within three working days of receipt, and forwarded to the appropriate divisional lead for investigation. If the complainant is not the patient, appropriate consent will be sought. Although there is no statutory deadline for providing a response, the Trust aims to provide a response within 25 working days. If the complaint is complex and it is felt that the investigation will require more time, the complainant will be advised that extra time is required in order to carry out an investigation and provide a substantive response. Upon receipt, all complaint correspondence will be triaged to determine the most appropriate pathway for resolution. All complaints are risk assessed to determine whether immediate action or escalation is necessary. In the event of a potential risk to the Trust, its staff, visitors or patients, the appropriate directors and/or service leads will be notified. Where it is considered that the issues raised by a complainant are complex, the complainant will be contacted and advised of the option to meet with the Trust staff. Such meeting Local Resolution Meeting (LRM) will take place within 20 workings days of receipt of the initial complaint letter. All LRMs will be recorded, and a letter, including details of actions taken or agreed, will be provided to the complainant within 5 working days of the LRM being held. All complaint correspondence will be sent to the relevant Division in order that an investigation can be carried out and a response provided. The draft response will be sent to the Corporate Complaints Team (CCT) for quality checking. Should any changes be made during the quality checking process, the draft response will be returned to the Division and named clinician for approval. A period of 3 working days will be applicable in these circumstances following which the response will be submitted to the Chief Executive for signature. On submission to the CCT, the Divisional lead will indicate whether they consider the complaint upheld in its entirety or not. Where a complaint is considered unfounded, a further quality check will be carried out by the executive director. In the event that an outcome cannot be agreed, arrangements will be made for the matter to be discussed in order that an agreement can be reached. Complainants will be encouraged to put their concerns in writing so that an accurate interpretation of events can be forwarded on for a response. The Complaints Team will provide support to Independent Providers to ensure that they comply with the NHS Complaints procedure. Where appropriate, the Complaints & PALS Manager will arrange conciliation for the parties involved. In some cases, it may be appropriate for the Complaints & PALS Manager to act as an intermediary between the organisation and the complainant. The Complaints & PALS Manager will remain impartial during this process and only advise parties of the complaints process and options available to them i.e. conciliation if appropriate. All contractors are expected to have local complaints procedures which are comparable to those operated in the NHS. Complaints directed to the Trust which relate to the services provided by the Trust will be forwarded for Page 12 of 26

investigation if the complainant wishes this to happen. Progress and resolution of the complaint will be monitored by the Complaints Team. The Trust will co-operate in the investigation of any multi-sector complaints in which they are involved. The Trust will comply with any requests for information received by its commissioners or other agency in relation to the number of complaints received, of those the number of justified complaints, the subject matter of the complaints and actions taken to improve services as a result of the consequences of the complaint. 12.2.2. Complaints About or Involving Another Sector of the NHS and/or the Local Authority/Inter Agency and Multi Agency Complaints Complaints may sometimes need to be redirected to another organisation within the NHS or to the Local Authority. This will be done promptly by the Complaints Team in consultation and with the consent of the complainant, and details of the forwarding process should be recorded. Sometimes complaints will require multi-agency investigation. Local protocols are in operation and in such cases discussions will take place between the relevant complaints managers of the organisations involved as to who will coordinate and lead the response. When an approach is agreed the complainant should be provided with details of how the investigation will take place, and the appropriate NHS timescales should apply. The time limit for responding to a complex complaint will be agreed with the complainant, and any delay will be put in writing with an explanation for the delay and a new response date given. A local protocol has been agreed for handling these complaints. 12.2.3. Complaints received from a Member of Parliament (MP) Complaints received through Members of Parliament will invariably be addressed to the Chief Executive. As in all other complaints the Chief Executive will sign the reply. However, in some cases, the complaint will be handled directly by the Complaints & PALS Manager with the complainant and in such cases a letter stating that this is happening may be an appropriate reply to the MP. 12.2.4. Complaints already investigated by the Trust The 2009 NHS Complaints Regulations provide for a two-stage complaints process: Stage 1 being local resolution by the provider concerned, Stage 2 being a review by the Health Service Commissioner (Ombudsman) There is no provision in law for the Trust to be an intermediary between stages 1 and 2 where the complaint has already been made to and responded by the provider that is the subject of the complaint. At the end of Stage 1, local resolution, the response to the complainant should include details of how to raise the matter with the Ombudsman if the complainant is not satisfied with the final response. The Trust is aware that sometimes this does not happen, and in some instances complainants are misinformed that the Trust is the next stage in the complaints process. In these circumstances the Trust will inform the complainant of the correct procedure to follow and will not conduct a review of the complaint. Page 13 of 26

13. Time Limit for Making Complaints The statutory time limit for making a complaint is 12 months from the date on which the matter being complained about occurred, or 12 months from the date on which the complainant became aware that they have grounds for complaint, whichever is the later. A complaint made outside of the time limit can be considered if the Trust decides there are good reasons for the complaint not being made within the time-limit and the case can still be properly investigated. 14. Persons who can raise complaints Generally it will be the person who has received the service that makes the complaint. However, the Trust appreciates that there are circumstances in which another person can make a complaint on behalf of the patient, which are: If the patient is a child who is not able to make the complaint on their own behalf; or Is a person who has been assessed under the provisions of the Mental Capacity Act 2005 as not having capacity in this matter; Where the patient with capacity has given consent for another person to act on their behalf; Where a person is deceased (the Trust will seek consent from the next of kin or power of attorney to progress the complaint). With regards to children and people without capacity, the Regulations permit the responsible body for the complaint to take a view on whether the person is acting in the patient s best interests and, if it is felt that this is not the case, then the responsible body can refuse to handle the complaint person. This means that the Trust will not assume that a parent or guardian can make a complaint on behalf of a child if it is felt that the child has sufficient maturity and capacity to make, or withhold, consent. The Trust will only exercise this power after full and proper consultation with relevant other parties. If an adult with capacity consents to a third person acting on their behalf, and the appointed person can provide a valid and acceptable form of consent, the Trust will regard the appointed person as a proxy for the patient in the complaint process. However, where a third person claims to be making a complaint on behalf of someone with capacity and does not have that person s valid consent in place, the Trust will require their consent for the complaint to proceed. This will assure the Trust that the patient provides consent to the complaint being made. Where this consent is not provided the Trust will not act. The Trust will also seek written consent for complaints submitted by representatives or other third parties on behalf of an individual or family member in order to demonstrate that the representative is acting in accordance with the individual instructions. 15. Vexatious and Persistent Complainants The Trust is committed to treating all complaints equitably and recognises that it is the right of every individual to pursue a complaint. The Trust therefore endeavours to resolve all complaints to the complainant s satisfaction. However, on occasions, the Trust may consider that a complainant who persists in making complaints raising the same or similar issues repeatedly, despite having received full responses to all the issues they have raised, may be identified as a persistent complainant. Where a complainant is considered persistent in nature, the Complaints & PALS Manager will, in agreement with the Trust s executive team, follow the Trust s Procedure for the Handling Persistent Complainants (Appendix A). Zero tolerance Page 14 of 26

The Trust operates a zero tolerance policy for complainants who chose to be rude or abusive in the manner by which they communicate their complaint. This is in accordance with the Trust s Dignity at Work policy. In this instance the Trust may protect its staff by limiting the communication channels open to the individual making the complaint. This may include individuals who are persistent or vexatious complainers. 16. Complaints not handled by the Trust The following complaints are not required to be dealt with in line with the Regulations and in light of the changes to the NHS System from 1 April 2013: A complaint about a primary care provider (GP, dentist, optician, pharmacist), these are now within the remit of NHS England (Tel:0300 311 22 33) or email england.contactus@nhs.net A complaint about private treatment A complaint made by another responsible body A complaint made by an employee of a local authority or NHS body about their employment A complaint made orally and resolved to the complainants satisfaction no later than the next working day on which the complaint is made A complaint that has already been resolved A complaint that has already been investigated under these Regulations or previous regulations A complaint arising from the alleged failure to comply with a request for information under the Freedom of Information Act 2000 A complaint from another responsible body, e.g. a hospital trust, GP practice, or independent provider; Matters relating to the employment arrangements of an employee of an NHS body; A complaint the subject matter of which has been previously dealt with under complaint regulations; An oral complaint that has been dealt with and resolved to the complainant s satisfaction within a working day of the complaint being voiced. a complaint which has been previously handled and a final response directing the complainant to the PHSO provided; and Matters that have been referred to or have been investigated by the PHSO. Additionally the Trust will consider declining to handle a complaint: made beyond the time limit for making complaints and for which a reasonable explanation of the delay has not been given or accepted; In which the Trust is not satisfied that a third party is a suitable person for making a complaint on behalf of the patient; made by an adult on behalf of a child who is capable of making the complaint themselves and has chosen not to do so, or has not provided consent for the complaint to be made on their behalf; From an individual whom the Trust has determined to be persistent and vexatious as outlined in Appendix A of this policy and no satisfactory change in behaviour has been identified. Where the Trust declines to handle a complaint, it will notify the complainant in writing of the decision and the reasons, providing signposting information of other organisations who may be able to support the complainant. Page 15 of 26

17. Mediation The Trust is not in a position to provide a formal mediation service for complainants who are having difficulty resolving a complaint. However, it may be able to provide advice on how to resolve a complaint to either party but this will not involve a representative from the Trust attending meetings. Where it is appropriate, the Trust will advise the complainant of the services of the Independent Complaints Advocacy Service that is established to assist complainants with the management of their complaint. 18. Parliamentary & Health Service Ombudsman (PHSO) The Trust welcomes the closer involvement of the PHSO with regards to complaints as a result of the 2009 Regulations. The PHSO is in a position to take an independent view of how the Trust has handled and responded to a complaint, and whether it has provided sufficient redress where an injustice has taken place as a result of the matters being complained about. By taking the approach that the Trust will seek to provide the best answer it can in the final response, and by taking whatever time is reasonably necessary in order to ensure the best quality response, the Trust will regard a referral to the PHSO in a positive light. There will be one of two outcomes from a referral to the PHSO: it will either be decided that we have provided an appropriate response and no further action will be taken; or the PHSO will investigate and provide a view on the handling and outcome of the complaint. If the PHSO should choose to investigate and find failings or omissions in the Trust s response then that will provide learning opportunities that can be put to use in future investigations. The Trust will not regard a referral to the PHSO as an indicator of failure to properly investigate and respond to a complaint because it is acknowledged that a full response may not always provide the complainant with answers that will satisfy them. This is particularly relevant to cases where the redress sought by the complainant is beyond the power or lawful authority of the Trust to deliver. The Trust will co-operate fully with the PHSO on any complaint that is referred to it and will take action on any findings that the PHSO makes as a result of a complaint. It should be noted that the PHSO will be primarily concerned with identifying whether any maladministration has taken place in the matters raised in the complaint, or in the handling of the complaint, and whether the Trust has failed to provide a service that it is statutorily required to provide. The PHSO will not necessarily challenge a decision made by the Trust as long as it can be demonstrated that no maladministration or failing has taken place in the process by which the decision was made. 19. Lessons learned The Complaints & PALS Manager will provide a learning and outcomes based report to the Trust Quality & Safety Committee. This report will provide details of the nature of concerns and complaints which have been raised, what lessons have been learned and key outcomes and changes made as a result. Should a complaint identify: risks that the Trust needs to record on its risk register; or A potentially serious or untoward incident; or A safeguarding issue Page 16 of 26

the Complaints & PALS Manager will notify the relevant service lead(s) to ensure appropriate actions are taken to mitigate or eliminate the risk as per the Trust s Risk Management Strategy and Incident & Serious Incident policy. 20. Working in Partnership Multi-Agency Complaints te: This section is founded on regulation 9 duty to co-operate and will only apply where a section of the complaint is about the Trust s exercise of its functions. If no element of the Trust s functions can be identified within the complaint, the Trust will not act as broker for the complaint and will pass it on to the organisation with the majority of the content of the complaint. Complaints can feature more than one service or organisation and the 2009 Regulations permit responsible bodies to agree that one body should take the lead in the handling of a complaint. Where it is considered appropriate for the Trust to take the lead in handling a multi-agency complaint it will do so, and will work closely with the other agencies involved to ensure that the complaint is properly investigated and the issues complained about are addressed. Where the Trust is not the lead agency but a party to the complaint, it will make all best efforts to ensure full co-operation and relevant sharing of information with the lead agency. Where the Trust is the lead agency in handling a complaint and for any reason finds an agency to be uncooperative in assisting with the proper handling of the complaint, the agency will first be reminded of its obligations under the Regulations and any relevant legislation. If this does not resolve the issue then the lack of co-operation will be clearly identified in the complaints response. It will then be a matter for the complainant to decide whether they wish to raise these matters with the PHSO or other relevant body, such as the Information Commissioner. Patient Advice & Liaison Service (PALS) The Trust s PALS team is based on the ground floor in the main hospital building therefore providing easy access to assistance or to address any enquiries or concerns raised by or on behalf of a patient in relation to NHS services. The team can assist with all enquiries and will provide a signposting service where necessary. The team are also on hand to assist both visitors, patients and staff in relation to access to various services, ie, interpretation services. NHS Complaints Advocacy It is not the role of the Trust s Complaints Team to provide advice on the merits of a complaint, or on how the complaint should be framed, but it can advise on the process that will be followed for handling and responding to complaints. NHS Complaints Advocacy has been established by the Department of Health to provide complainants with an advocacy service that can assist complainants with writing letters, preparing for and attending meetings, the options available at each stage of the complaint and help with making decisions on the complaint. The contact details for Complaints Advocacy service for the Hertfordshire and Bedfordshire region are: POhWER NHS Complaints Advocacy Hertlands House Primett Road Page 17 of 26

Stevenage Herts SG1 3EE Telephone: 0845 456 1082 Email: pohwer@pohwer.net 21. Accessibility The Trust is committed to ensuring that the guidance in this policy is accessible to all. This means that, as required, additional support will be provided to help ensure that the information in this policy can be understood and its guidance followed. This support includes (but is not limited to): The provision of the policy and any associated documents in alternative formats. Enabling individuals to have an advocate or interpreter involved for support with communication Making reasonable adjustments, in discussion with individuals or their representative, to procedures where these are necessary to ensure their accessibility All staff involved in the implementation of this policy will need to proactively consider the additional actions that might be required to ensure that individual needs can be met as far as is practicably possible. Ensuring accurate and appropriate communication will help to reduce communication errors and the effective and fair handling of complaints. Actions to improve communication could include providing: easy read, Braille, pictures and symbols, or other formats when explaining information a translator for people for whom English is not their first language information using picture communication symbols Supplying correspondence and leaflets in alternative languages and formats, including easy read Information about access to advocacy services if needed telephone advice and support using alternative languages and formats 22. Key Performance Indicators Details of the Trust s Key Performance Indicators (KPIs) are outlined in Appendix C to this Policy and reported on a monthly basis. 23. Monitoring and Performance Management of the policy In addition to the quarterly reports, an annual combined summary will be produced at the end of each year including lessons learned and changes made as a result of complaints and concerns raised with the Trust. This report will be presented to the Safety & Quality Group. The Trust shall also receive reports on complaints handled by the providers it commissions services from and will use information obtained from these reports to inform their contract monitoring and evaluation work. This policy is scheduled for a review every 3 years or earlier should a change in legislation occur. OCTOBER 2015 Page 18 of 26

Appendix A: Procedure for Handling Vexatious & Persistent Complainants Appendix A PROCEDURE FOR HANDLING VEXATIOUS & PERSISTENT COMPLAINANTS 1. INTRODUCTION 1.1. Persistent complainants can place a strain on resources and cause undue stress. All staff are trained to respond with patience and understanding to the needs of all complainants but there are times when nothing further can be done to assist them or rectify a real or perceived problem. 1.2. In determining arrangements for handling such complainants, staff are presented with two key considerations. 1.2..1. The first is to ensure that the complaints procedure has been correctly implemented so far as possible and that no material element of a complaint is overlooked or inadequately addressed. In doing so it should be appreciated that even persistent complainants may have issues which contain some genuine substance. The need to ensure an equitable approach is therefore crucial. The second is to be able to identify the stage at which the complainant has become unreasonably persistent. It is emphasised that the identification of a complainant as persistent should only be used as a last resort and after all reasonable measures have been taken to try to resolve complaints following the NHS complaints procedure. 2. IDENTIFING A PERSISTENT COMPLAINANT A persistent complainant may display some or all of the following behaviour: The complainant changes the substance of a complaint or continually raises new issues or seeks to prolong contact by continually raising further concerns or questions upon receipt of a response whilst the complaint is being addressed. The complainant is unwilling to accept documented evidence of treatment given as being factual, e.g. drug records, General Practitioner manual or computer records, nursing records The complainant denies receipt of an adequate response in spite of correspondence specifically answering their questions. The complainant does not accept that facts can sometimes be difficult to verify when a long period of time has elapsed. The complainant does not clearly identify the precise issues which he/she wishes to be investigated, The complainant does not accept that the concerns identified are not within the remit of the Trust to investigate. The complainant persists in pursuing a complaint where the NHS complaints procedure has been fully and properly implemented and exhausted. The complainant makes an excessive number of contacts with the Trust and places unreasonable demands on staff. The complainant is known to have recorded meetings or face-to-face/telephone conversations without the prior knowledge and consent of other parties involved. The complainant makes unreasonable demands and fails to accept that these may be unreasonable (e.g. insists on responses to complaints or enquiries being provided more urgently than is reasonable or normal recognised practice). Page 19 of 26

3. AGGRESSIVE / ABUSIVE COMPLAINANTS 3.1. Staff should be aware that some complainants may: Threaten or use actual physical violence towards staff or their families or associates. Harass or be personally abusive or verbally aggressive on more than one occasion towards staff dealing with their complaint or their families or associates. This will include racial harassment. (Staff must recognise that complainants may sometimes act out of character at times of stress, anxiety, or distress and should make reasonable allowances for this. They should document all incidents of harassment). 4. OPTIONS FOR DEALING WITH A PERSISTENT, AGGRESSIVE OR ABUSIVE COMPLAINANT 4.1. Where a complainant persists with displaying any of the above behaviour, the Patient Experience Manager, in agreement with a relevant senior manager and Chief Officer, should take the following action: Warn the complainant that if they persist with the approach they are taking, they will be classed as a persistent complainant. Warn the complainant that in extreme circumstances the Trust reserves the right to pass unreasonably persistent complaints to the Trust s solicitors. If appropriate, draw up a signed agreement with the complainant which sets out a code of behaviour for the parties involved if the Trust is to continue processing the complaint. Consider involving the Local Security Management Services (LSMS) should the Trust consider such action necessary for the protection of its members. 4.2. If any of the above actions do not elicit the required behaviour, the patient / complainant will be advised that they are being classed as an unreasonably persistent complainant, the reasons why will be clarified and a temporary suspension of all contact with the complainant or investigation of a complaint will be noted. Legal advice or guidance from the relevant agencies such as the Counter Fraud and Security Management Services. 4.3. This notification may be copied for information of others already involved in the complaint, e.g. staff, ICAS or Member of Parliament and a record kept for future reference of the reasons why a complainant has been classified as persistent. 5. WITHDRAWING PERSISTENT COMPLAINANT STATUS 5.1. Where a complainant subsequently demonstrates more reasonable behaviour on submission of a further complaint, a discussion will be held with the Chief Officer and appropriate senior manager regarding the complainant s status. Subject to their approval, normal contact with the complainant and application of the NHS complaints procedures will then be resumed. 6. REVIEW OF PROCEDURE This procedure will be reviewed and revised every 3 years as appropriate in line with the Trust s Complaints Policy and Procedure on a yearly basis. OCTOBER 2015 Page 20 of 26