Complaints, Compliments and Concerns (CCC) Policy Central and North West London NHS Foundation Trust (CNWL) is committed to providing quality NHS services and adopting best practice in listening and responding to all patient and carer feedback. It recognises the absolute need to welcome, value and respond to feedback from the patients and carers that use our services. By listening to feedback, we can identify things that have gone wrong and put them right, resolve mistakes in a timely way, and learn new ways to improve and prevent problems from happening in the future. By dealing with all types of patient or carer feedback effectively, services can improve, making things better for the people who use them as well as for the staff working in them. This policy provides the framework by which the Trust receives feedback on its services. This policy is essential reading for the following groups: Patient Support Service and Quality Team Divisional & Borough Directors Divisional Medical Directors and Divisional Directors of Nursing Service Managers, Team Managers, Matrons and Ward Managers Investigators Patients and Carers External Stake holders Scope The policy includes a clear and robust framework for all staff employed by the Trust in how to receive, record, investigate, manage and respond to patient or carer feedback (Compliments, Comments, Concerns and Complaints). The policy is supported by the Complaints, Compliments and Concerns Procedure. Key points of the policy CNWL must adhere to the Local Authority Social Services and NHS (England) Complaints Legislation 2009 and follow good complaint handling principles. All patient and/or carer feedback (Complaints, Compliments, Comments and Concerns) received by staff/services must be logged onto the Trust s electronic database (Datix). An initial response/action should be taken by the staff member or service in receipt of feedback. A concern should be responded to within 3 working days. A complaint that warrants further investigation should be responded to within 25 working days (or a timescale agreed with the Complainant). Any necessary follow up action will be taken by the service responsible and the service will establish early and regular communication with the patient and/or carer. Evidence of all communications and documentation arising from the complaint investigation process must be logged on to Datix by the investigating officer. The service manager must make sure that actions taken and lessons learnt as a result of the feedback are recorded on Datix, to support Trust-wide sharing of learning. CNWL will apologise if we made a mistake, do what we can to put things right and to make sure that it doesn t happen again. Page 1 of 12
Complaints, Compliments and Concerns (CCC) Policy Policy lead: Ratifying Committee / Group: Status of policy: Policy Reference: Head of Patient and Carer Involvement CNWL Operational Board Final TW/00338/15-17a Signed: Andy Mattin Approval date: 12 May 2017 POLICY IMPLEMENTATION DATE: July 2015 DATE POLICY TO BE REVIEWED: July 2018 2
Contents 1. Purpose...5 2. Requirements...5 3. Responsibilities...6 4. Definitions...8 5. Patient Support Service...8 6. Complaint Handling Process...9 7. Independent review by the Health Service Ombudsman...10 8. Duty of candour...10 9. Confidentiality...10 10. Consent...11 11. Capacity...11 12 Complaints related to Deceased patients...11 13 Advocacy and support for patients...11 14. Interagency complaints...11 15. Litigation...11 16. Aggressive and Vexatious Complainants...11 17. Governance...12 18. Consultation...12 19. References...12 3
1. Purpose This policy sets out a framework for listening and responding to feedback received by Central and North West London NHS Foundation Trust (The Trust) from patients, their families or carers. The policy is supported by the Complaints, Compliments and Concerns Procedure which provides clear and robust guidance for all staff employed by the Trust in how to receive, record, investigate, manage and respond to patient or carer feedback (Complaints, Compliments, Concerns and Comments). It identifies the roles and responsibilities of staff at the Trust in making sure that feedback is acknowledged, investigated and responded to fully and promptly. It outlines the requirements and regulations the Trust adheres to and the processes and timescales our staff must follow in managing feedback. The Trust recognises the importance of all feedback (Compliments, Comments, Concerns and Complaints) to help the Trust identify and respond to issues, to learn from feedback, to improve the experience and quality of our services and reinforce good practice. This policy adheres to all national guidelines and regulatory requirements. 2. (Compliments, Comments, Concerns and Complaints)Requirements All patients and carers will be informed on how to give feedback at their first contact with CNWL services. All CNWL sites will display visible information for its visitors on how to give feedback (posters/leaflets). All forms of feedback must be recorded on to the Feedback Database (Compliments, Concerns, Comments and Complaints). See definitions below. All concerns must be resolved within 3 working days. All complaints will be acknowledged by the Patient Support Service within 3 working days. Appointed investigators will contact the complainant to discuss the issues and agree an investigation plan and desired outcome. All complaints will aim to be investigated and responded to within 25 working days or a timescale agreed with the Complainant. All staff will be trained on how to deal with feedback. Appointed investigators must contact the Complainant to discuss the issues and agree an investigation plan and to discuss the findings and outcome of the investigation. All investigations must be impartial and forensic in approach. The Patient Support Service will provide support to all staff when required and provide training on handling/responding to feedback and the investigation of complaints. The Patient Support Service will review Complainant satisfaction with an agreed methodology (written/telephone Survey) within an agreed timeframe. Local Authority Social Services and National Health Service Complaints (England) Regulations 2009 The Complaint Regulations came into force on 1st April 2009. The Regulations require that arrangements for dealing with complaints must ensure that: 4
Complainants and their families or carers are listened to Complaints are dealt with efficiently Complaints are properly investigated and a range of interventions are available to assist resolution Complainants are treated with respect and courtesy and involved in the process Complainants receive, so far as is reasonably practical, assistance to enable them to understand the procedure in relation to complaints; or advice on where they may obtain such assistance Complainants received a timely and appropriate response Complainants are told the outcome of the investigation of their complaint Action is taken when necessary in the light of the outcome of the complaint and shared with operational services by the Investigating officer. These actions will be monitored and audited by the operational services. Parliamentary Health Services Ombudsman (PHSO) The PHSO has an expectation that all complaints relating to the provision of health care should be resolved in line with the six common themes highlighted within the Principles of Good Administration, Principles for Remedy and Principles of Good Complaint Handling: Getting it right Being customer focused Being open and accountable Acting fairly and proportionately Putting things right Seeking continuous improvement The Care Quality Commission (CQC) The CQC published its report Complaints Matter in December 2014, which stated that informal and formal complaints tell the CQC how responsive the Trust is, how safe, effective, caring and well-led the services are. It also stated that complaints feedback will be central to and inform their inspections about how responsive the Trust is to people s needs. 3. Responsibilities Individual Key Responsibilities Chief Executive Responsibility for ensuring compliance with the NHS Complaints Legislation and the Patient and Carer Feedback Policy and Procedure. Executive Director of Nursing / Associate Responsibility for supporting the development of the Patient and Carer Feedback policy and its implementation. Director of Quality Overall responsibility for ensuring that complaints are handled in line with the Patient and Carer Feedback Procedure Responsibility for providing and presenting reports to the Trust Board and to the Trust Quality and Performance Committee as necessary. Head of Patient and Carer Involvement Responsibility for managing the Patient Support Service Manager and overseeing the implementation of the Patient and Carer Feedback Policy and Procedure. Retaining oversight of all complaint reviews that are commissioned, reporting on these to the Associate Director of Quality. 5
Patient Support Service Manager Responsibility for managing the Patient Support Service, provision for providing a single point of access to people wishing to seek advice, raise a concern or make a complaint. Responsibility for the implementation of the Patient and Carer Feedback Policy and Procedure across the Trust. Responsibility for ensuring that all complainants receive timely information on the support they will receive. Responsibility for ensuring the attainment of Trustwide targets in relation to feedback, ensuring that all complaints are acknowledged within 3 days of receipt, and reporting on whether complaints are responded to within the agreed timescale. Responsibility for overseeing the training of staff in the use of the Patient and Carer Feedback Procedure. Making available Trustwide reports to the Board, and other meetings as required, to aid organisational learning. Also assisting in the provision of local feedback for Divisions and Boroughs. Providing support to staff investigating complaints and some to staff named in complaints. Support for staff named in complaint is mainly provided by HR. Divisional Directors Responsibility for ensuring that appropriate systems are in place to support effective and efficient management of feedback, and compliance with the requirements of this Policy and Procedure. Overall responsibility for complaints raised about the services they oversee. Responsibility for responding to complaints relating to their area of local responsibility in a timely way and ensuring that there is a nominated deputy to take responsibility for this in their absence. The Divisional Director will ensure a written response of an appropriate standard is sent at the end of the process Service / Borough Directors Ensuring that services act on all aspects of feedback outlined in this policy and monitor its implementation in the services that they are responsible for. Ensuring there is a robust local system for reviewing all complaints within their sphere of responsibility, so lessons learned are shared across the Borough / Division, as appropriate. Ensuring all complaints are risk graded and supporting local managers undertaking the investigation of high risk, complex or sensitive complaints. Meeting with complainants where appropriate. Investigating Leads Ensuring that complainants are fully informed and involved in the process of resolving their complaint. Providing an impartial investigation that is open and transparent. Maintaining regular contact with the complainant throughout the investigation. Ensuring all supporting documentation related to the complaint including investigation notes is available on the Datix system. Ensuring Actions Taken and Lessons Learnt following the complaint are recorded on the Datix system to facilitate organisational learning. All Staff Dealing with all feedback, concerns and complaints in a timely / sensitive manner. Ensuring that the individuals raising feedback are treated with respect and courtesy and provided with the space and time to talk through any concerns they have. Ensuring their compliance with this Policy and the related Procedure, and cooperating as necessary with any investigations. 6
Ensuring complainants are listened to and individuals have opportunities to provide feedback and raise concerns. Ensuring an open and transparent approach so that compassion and respect is at the forefront of the support provided in helping individuals to provide feedback. Responsibility for understanding the process for logging feedback and receiving any necessary training to achieve this. Ensuring all feedback is logged onto the Trustwide Datix web system. Definitions Compliment Is defined as an expression of praise and can be provided both in writing and verbally. Comment / Enquiry Is when a patient, carer or member of the public makes a remark relating to the Trust or makes a request for information. This covers a range of areas and includes, but is not limited to, a specific period of care and treatment and details of the types of services provided by the Trust. Concern Is an expression of dissatisfaction, that is communicated to any member of staff verbally or in writing. Concerns should be resolved locally before the end of 3 working days or within a timescale agreed with the person raising the concern. Some concerns may require a written response from the Trust. This should be sent within 5 working days of resolving the matter. Any concern that cannot be resolve locally before the end of the next working day or within a timescale agreed must be escalated to a complaint with the agreement of the person raising the concern. Complaint Is defined as an expression of dissatisfaction requiring an investigation and written response, received from patients, carers and anyone who may be affected by the actions or decisions of the Trust. A complaint may be made verbally, or in writing. Local and informal resolution of a complaint should always be considered in the first instance, as above, if the complaint can be resolved by the end of the next working day, or within a timescale that is acceptable to the complaint. However, complaints will need to be investigated formally if: The complaint is in the form of a letter or email. The complaint is verbal, but of a serious nature and judge that it cannot be dealt with in any other way. The Complainant makes a verbal request for a matter to be dealt with in this way. Staff must also be aware that certain comments, concerns, suggestions or enquiries may present issues that need to be brought to the immediate attention of their Line Manager. This includes issues relating to patient or staff safety and safeguarding. 4. The Patient Support Service 5.1 Access to the Patient Support Service is simple and without varied contact points, the Service has: 7
One dedicated e-mail address Feedback.cnwl@nhs.net One dedicated telephone number 0300 013 4799 A freepost postal address Freepost RSTJ-LART-UBYA Patient Support Service CNWL Stephenson House 75 Hampstead Road London NW1 5.2 The Team will monitor all feedback logged onto Datix; scrutinise all feedback and make decisions as to whether a concern raised needs to be investigated formally as a complaint; and alerting the relevant Borough and Divisional Directors where a complaint needs to be investigated. 5.3 The Team will provide support to Investigators, and advice and input in relation to more complex and vexatious complaints. 5. Complaint handling principles The Trust will ensure that: 6.1 The Divisional Director, in consultation with the Director responsible for the service in which a complaint has arisen, will arrange the appointment of a lead investigator for each complaint capable of ensuring a thorough investigation takes place and that the Complainant receives ongoing feedback in regards to the status of the complaint. The Divisional Director will ensure a written response of an appropriate standard is sent at the end of the process. 6.2 All complainants will be offered the opportunity to meet with the lead investigator so they can discuss the issues of concern and the outcomes they are seeking, understand how the investigation will be carried out and agree how long the process should take. 6.3 Every effort will be made to satisfy the Complainant that their concern has been taken seriously, investigated thoroughly and that they will be responded to honestly throughout the process. 6.4 Complainants will also be offered the opportunity to meet with the lead investigator towards the end of the process to discuss the outcome of the complaint and ensure that they are satisfied with the response being offered. 6.5 All complaints raised with the Trust will receive a written response once the investigation has concluded. Reponses will acknowledge where mistakes have been made and apologise whilst also explaining what happened in terms of any care or service delivery problems. The response will also include details of any actions being taken to facilitate lessons learnt. 6.7 All closure communications will invite the patient or carer to give feedback on their experience and satisfaction with the process. 8
6.8 Where a Complainant remains dissatisfied with the response, the Trust will continue its efforts to resolve the complaint by offering a meeting with a senior manager from the service that investigated the complaint. This process will be supported by the Patient Support Services. 6.9 A Complainant remaining dissatisfied had the option to ask for a management review to assess whether the complaint investigation has been fair, impartial and robust. Such reviews are to be carried out by a member of staff not previously involved in either their care or the complaint. 6. Independent Review by the Health Service Ombudsman 7.1 If a Complainant is dissatisfied with the outcome of the Trust s investigation and review process they have the right to ask the Health Service Ombudsman to independently review their complaint. 7.2 Information on how to obtain an independent review will be provided to all Complainants by the Trust. The Health Service Ombudsman will decide how to take such requests forward but this can include referring the complaint back to the Trust for local resolution or undertaking its own investigation. 7.3 Staff in CNWL will work the Health Service Ombudsman, and co-operate with any investigations undertaken, including the disclosure of documentation, reports, statements, etc. The Trust will also consider and respond to all formal recommendations made in response to their independent review of a complaint. The Parliamentary and Health Service Ombudsman can be contacted as follows: 7. Duty of candour 8.1 If any feedback received identifies an incident or serious incident, the Service Manager, lead investigator or the Patient Support Service must check to see if this has been recorded as an incident on DATIX. 8.2. The Service Manager or lead investigator must ensure that this is communicated to their Service/Borough, and also that the Complainant is informed as soon as is reasonably practical of the details of the error and the actions that have been taken to prevent such a situation from happening again. 8.3 Details of the error and actions taken must be included in the written complaint response to the Complainant, to ensure that all errors are dealt with in an honest and open manner. 8. Patient confidentiality 9.1 No patient information will be given to a third party without the appropriate consent being obtained from the patient unless there is a legal requirement to share information. 9.2 Complaints records must be kept separate from health records unless there is a clinical requirement to record the complaint and/or recommendations. 9.3 Details of complaints made against identifiable employees of the Trust and the investigation findings will be retained on Datix. Where disciplinary proceedings are undertaken this information may also be held on the HR records of those staff and will be used as part of the revalidation process. 9
9. Consent Where a concern or complaint is raised by a third party, written consent from the patient will be obtained for the matter to be investigated and where relevant for disclosure of clinical information. 10. Capacity 11.1 Should a patient lack capacity appropriate actions/steps will be taken to ensure that the best interests of the patient are pursued. Clinical staff will lead on decisions relating to capacity and best interest in accordance with the relevant Trust policy and procedure. 11.2 Where proceeding with investigation of the complaint is not considered to be in the patient s best interests, they will receive written notification stating the reason for this decision. The Trust will ensure that the concerns raised are reviewed and reported internally. 11. Complaints relating to the care of a deceased patient When addressing a complaint relating to the care of a deceased patient, careful consideration will be given prior to the release of information. In all cases consideration should be given to the Access to Health Records Act and the Serious Incident Policy. Further advice on this matter can be obtained from the Head of Information Governance or Head of Safety. 12. Advocacy & support for patients If the patient raising the concern/complaint requires the support of an advocate the trust will provide contact details on receipt of the feedback, and consider any other support needed such as an interpreter. The local service investigating the complaint will provide a single point of contact for the complainant, and also access to the Patient Support Service. 13. Interagency complaints The complainant will be asked to clarify whether they are seeking a single or joint response to their complaint, and will be asked provide their consent for the sharing of information relating to the complaint between agencies. Further detail can be found in the Patient and Carer Feedback Procedure. 14. Litigation A threat of litigation will not be a barrier to investigation of a complaint. Advice can be sought from the Patient Support Service 15. Aggressive and Unreasonable Complainants There may be occasions where complainants may be aggressive or habitual. In these instances the Patient Support Service will work with clinicians and where appropriate Managers to agree an appropriate way forward. Further detail can be found in the Patient and Carer Feedback Procedure. 10
16. Governance Board-led Scrutiny of Complaints The Associate Director of Quality will have responsibility for the management of complaints performance (ie. response time, patient satisfaction with complaint resolution). The Patient Support Service and Quality Governance teams will work closely together to drive improvements from handling feedback. Local investigation Local experts in service provision should be tasked with investigation of complaints. An appropriate choice of investigator is key to ensuring that the investigation is seen as objective and thorough. Continuous Improvement of the handling of feedback and complaints will be driven by monitoring the experiences of patients/carers who made a complaint or submitted feedback. 17. Consultation A broad range of CNWL staff, patient/carer and governor workshops and consultation was undertaken as part of the Trust s review of how it handles patient and carer feedback. This policy has been cross referenced against national review papers with careful consideration of both the Francis Report and Clwyd review of Complaints Handling to further support best practice. 18. References The Local Authority Social Services and National Health Service Complaints (England) Regulations 2009, Department for Health (2009) A guide to better customer care, Department of Health, February (2009) Principles of Good Complaint Handling, Parliamentary and Health Service Ombudsman (2008) Access to Health Records Act, 1991 Recommendations made by Francis and Clywd/Hart Reports (2013). 11
12