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Complaints, Concerns and Compliments Policy

Author: Director of Nursing and Quality / Complaints Officer

Sponsor/Executive: Director of Nursing and Quality

Responsible committee: Clinical Governance and Patient Safety Committee

Ratified by: Quality, Safety and Governance Committee

Consultation & Approval:

(Committee/Groups which signed off the policy, including date)

Patient Safety and Clinical Risk Group 11 November 2016 Clinical Governance and Patient Safety Committee 28 November 2016

This document replaces: Complaints Policy

Date ratified: 18 December 2016

Date issued: 4 January 2017

Review date: November 2019

Version: 4

Policy Number: P51

Purpose of the Policy: To provide clear and concise guidance on how the Trust manages formal complaints, concerns and compliments.

If developed in partnership with another agency, ratification details of the relevant agency

Policy in-line with national guidelines:

NHS Complaints Regulation 2009

Signed on behalf of the Trust: ………………………………………………….. Aidan Thomas, Chief Executive

Elizabeth House, Fulbourn Hospital, Fulbourn, Cambs, CB21 5EF Phone: 01223 726789

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Version Control Page

Version Date Author Comments

1.0 22/08/2013 Melanie Coombes

Approved by Quality and Performance Committee 22 August 2013

2.0 Amber Woolner

The sections of the policy were re-organised for flow. PALS and Complaints teams were separated. Additional information regarding PALS and compliments was added. Stop the Clock was added and

3.0 28/04/2013 Amber Woolner

Following the agreement of a recommendation made to the Board of Directors the policy has been changed to 30 working days to respond to a complaint instead of 25.

4.0 14/11/2016 Amber Woolner

Updated appendices. Inclusion of additional appendices regarding the Fens Unit. Additional section on resolution meetings and LGO section.

Policy Circulation Information

Notification of policy release:

All recipients;

Staff Notice Board;

Intranet;

Key words to be used in DtGP search.

CQC Standards

Other Quality Standards

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12Contents

Section Page

1 Introduction 5

2 Purpose 6

3 Scope 6

4 Definitions 6

5 Duties 7

6 Complaints Process 12

7 Complaints Management 14

8 Complaints Procedure 15

9 Unreasonable and Persistent Complainants 20

10 Parliamentary Health Service Ombudsman (Stage 2) 20

11 Local Government Ombudsman (Stage 2) 21

12 PALS Management 22

13 Compliments 22

14 Confidentiality and Data Protection 22

15 PREVENT Strategy 23

16 Whistle Blowing 23

17 Being Open and Duty of Candour Policy 23

18 Support for Staff 24

19 Education and Training Requirements 24

20 Process for Monitoring Effective Implementation 24

21 Links to Other Documents 24

22 References and Acknowledgements 24

Appendices

Appendix 1 Useful Contacts 26

Appendix 2 Informal Complaints/Concerns Feedback Form 28

Appendix 3 Formal Complaints Handling Flow Chart 30

Appendix 4 Risk Grading 31

Appendix 5 Advice Sheet – Investigating Complaints 32

Appendix 6 Guidance for Managers Interviewing Staff who are involved in a Complaint

34

Appendix 7 Management of Complaints Satisfaction Questionnaire 36

Appendix 8 Joint Protocol between the Trust and the Local Authority for the Management of Complaints

38

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Section Page

Appendix 9 Guidance for handling Unreasonable Persistent Complainants 41

Appendix 10 The Fens Unit Complaints Protocol 45

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1. Introduction Complaints, Concerns and Patient Experience are one way of identifying the service users’ perspective of the service provided. They can act as an early indicator that a system may not be functioning effectively or may be placing patients at risk. Appropriate trend analysis of the factors which prompted complaints, concerns and enquiries can provide invaluable insight into areas where improvements may be required. The Local Authority Social Services and National Health Service Complaints (England) Regulations 2009 set out to sustain public confidence in the regulation of healthcare professionals. These regulations are the legislative framework for managing complaints against NHS bodies, all statutory providers of NHS care (including Foundation Trusts and Primary Care providers), Voluntary and Independent Sector organisations who provide services under contract to the NHS, and to Local Authorities who provide Adult Social Services and incorporates the need for effective handling of concerns about healthcare professionals. The NHS Constitution (DOH, 2012) outlines to the public their rights when making a complaint. The policy contains detailed guidance in relation to the stages of the NHS Complaints procedure: Local Resolution Investigation by the Parliamentary Health Service Ombudsman (PHSO) or

Local Government Ombudsman (LGO) The PHSO considers six principles in relation to management of complaints, these principles are listed below: Getting it Right Being Customer Focused Being open and accountable Acting fairly and proportionately Putting things right Seeking continuous improvement

Cambridgeshire and Peterborough NHS Foundation Trust (the Trust) must, under the regulations, make arrangements for the handling and consideration of complaints. The arrangements must ensure that: Complaints are dealt with efficiently Complaints are properly investigated Complainants are treated with respect and courtesy Complainants receive as far as is reasonably practical Assistance to enable them to understand the procedure in relation to

complaints Advice on where they can obtain such assistance Complainants receive a timely and appropriate response Complaints are told the outcome of the investigation of their complaint and

actions are taken if necessary in the light of the outcome of a complaint The arrangements will be accessible and such as to ensure that complaints are dealt with speedily and efficiently, that complainants are treated

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courteously and sympathetically, and as far as possible involved in decisions about how their complaints are handled and considered. The Trust takes all complaints very seriously. In addition, it welcomes all feedback, including concerns, suggestions and compliments, because it provides opportunities for service development and forms an important part of the Trust’s plans for improving the quality of services.

2. Purpose This policy describes the procedure by which the Trust will meet the statutory legislation and describes the means by which patients; relatives, carers and members of the public can make formal complaints, raise concerns and make suggestions and compliments. It also provides information for all Trust staff regarding their responsibilities should they receive a complaint. The policy outlines the process which will be followed by the Trust in response to such feedback and in addition, the process by which the Trust aims to make improvements to services as a result of the feedback. The purpose of the Complaints Procedure is not to apportion blame amongst staff but to investigate complaints to the satisfaction of the complainant whilst being scrupulously fair to staff and to learn any lessons for improvement in service delivery. However some complaints will identify information about serious matters which indicates a need for disciplinary investigation. Consideration as to whether disciplinary action is warranted must be subject to a separate process of investigation. Papers that have accumulated during the investigation of the complaint may be passed to the appropriate person who will be considering the need for disciplinary or any other form of investigation. Care must be taken by the Trust to bear in mind the right of staff to confidentiality and to avoid disclosure to the complainant of any disciplinary action that has taken place as a result of a complaint. The policy takes into account information from complainants who have given anecdotal feedback of the complaints handling process as well as a number of relevant public documents (refer to section 21).

3. Scope This policy applies to all CPFT staff and volunteers.

4. Definitions 4.1. Complaint – is defined as:

Any expression of dissatisfaction, about a Trust service or member of staff, who is undertaking duties on behalf of the Trust. Complaints can be made orally or in writing

Complaints are either locally resolved by no later than the next working day or they are dealt with under the NHS Complaints Procedure. Either way all complaints must be forwarded to the Complaints Department to be recorded and monitored

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Where the person would prefer support to resolve an issue rather than make a formal complaint they can be referred to the Patient Advice and Liaison Service if a member of staff is unable to assist Full details of types of complaint which fall outside this procedure can be found in Regulation 8 of the Local Authority Social Services and National Health Service Complaints (England) Regulations 2009. Refer to section 7.6.

4.2. Responsible Body – means a Local Authority, NHS Body, Primary Care

Provider or Independent Provider

4.3. Local Resolution – investigation and resolution of complaints under the first stage of the NHS Complaints Procedure.

4.4. Confidentiality – non-disclosure of personal information to a third party

4.5. Investigation – the act or process of investigating; a careful search or examination in order to discover facts

4.6. PALS – Patient Advice and Liaison Service is a service available to patients, relatives and carers that offers confidential advice, support and information, and can assist in resolving informal complaints or concerns.

4.7. Concerns/Informal Complaint – concerns are written or verbal expressions of dissatisfaction with a service or a staff member which can be resolved locally or by the PALS team without the need for a formal investigation.

4.8. Compliments – an expression of thanks and satisfaction with a service or

members of staff. 4.9. Working day – a working day in this context is a day from Monday to Friday

excluding bank holidays.

4.10. Upheld – means a high majority or all of the elements were investigated and found to be substantiated

4.11. Partially Upheld – means a majority (over a third) of the elements investigated were found to be unsubstantiated

4.12. Not Upheld – means a majority or all of the elements investigated were found to be unsubstantiated.

4.13. Undetermined – means that following investigation the elements of the complaint could not be evidenced as upheld or not upheld.

5. Duties 5.1. The Chief Executive

The Chief Executive is ultimately accountable for the quality of care within the organisation, and therefore, as part of governance arrangements, needs an overview of all recorded dissatisfaction being expressed by service users and

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carers. The results of all complaint investigations will be submitted to the Chief Executive who will sign the final letter of response to the complainant. Where for good reason the Chief Executive is not able to sign the letter, it will be countersigned by a nominated person acting on the Chief Executive’s behalf. The Chief Executive is made aware of all breaches in the timescale for providing a final response to complainants and the reasons for these.

5.2. Director of Nursing and Quality The Director of Nursing Quality has been designated by the Trust Board to take overall responsibility for the Trust Complaints and Concerns Policy and for ensuring that it complies with NHS Complaints Regulations.

The Director of Nursing and Quality is also ultimately responsible for ensuring that action is taken if necessary in the light of the outcome of a complaint. The Director of Nursing and Quality will, in turn, delegate to the Head of Patient Safety and Complaints the responsibility for the operational management of the Trust’s complaints handling in line with its Complaints and Concerns Policy.

5.3. Head of Patient Safety and Complaints

The Head of Patient Safety and Complaints is responsible for operational management of the Trust’s complaint handling in line with the Complaints, Concerns and Compliments Policy.

5.4. Complaints Officer The Complaints Officer manages the Complaints Department which is overseen by the Head of Patient Safety and Complaints. The Complaints Officer is responsible for:

Overseeing the operation of complaints procedure including providing

support in ensuring staff awareness Providing support in ensuring public awareness, through the provision of

leaflets and posters Collating and recording of all complaints Ensuring that all formal complaints are dealt with and registered in

accordance with the Complaints Procedure Liaising with the relevant Director/General Manager/Directorate Head of

Nursing where necessary regarding the appointment of an appropriate Investigating Manager

Ensuring complaints are acknowledged within 3 working days Ensuring complaints are answered within the agreed timescale and ensure

non-compliance with timescales escalated to the Chief Executive together with the reasons for this

Completion of the Statutory Monitoring Forms (KO41A), for monitoring the Trust Register of Complaints

Prepare the Annual Report on Complaints for the Trust Board and the Care Quality Commission

Maintaining records of all outcomes and recommendations Monitoring action taken as a result of complaints and that where

appropriate lessons learned are shared across the Trust Liaising with the PHSO and LGO in relation to complaints that cannot be

resolved locally to the complainants satisfaction

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Ensuring that where relevant, complaints are highlighted as possible claims, safeguarding concerns or serious incidents

Ensuring Directorates are sent monthly reports on complaints data Complete a yearly audit on a random sample of 25% of the complaints

received to establish compliance with the policy 5.5. Complaints Coordinator

The Complaints Coordinator is responsible for the day to day administration of the Complaints Department which is overseen by the Complaints Officer. The Complaints Coordinator is responsible for:

Answering the telephone, and providing assistance and advise to

complainants and staff Day to day management of the Complaints mailbox and post Supporting the Complaints Officer to ensure formal complaints are dealt

with and registered in accordance with the Complaints Procedure 5.6. Head of Patient Experience

The Head of Patient Experience is responsible for the operational management of the Patient Advice and Liaison Service and leads on the Trust’s patient experience agenda.

5.7. Patient Experience / PALS Officer

The Patient Experience / PALS Officer is responsible for: First point of contact for patient, carers and the public to listen to their

concerns and issues, ensuring that learning and actions are implemented. Visit wards and have PALS drop in sessions across the Trust’s sites Log all PALS enquiries and compliments on Datix system Help to resolve PALS enquiries and concerns locally escalating to the

formal complaint process where necessary Signpost concerns to the relevant place or teams Collate PALS and compliments data as part of the Trust’s reporting for

quality and safety 5.8. Role of Directors and General Managers

Directors and General Managers have overall responsibility for the operation of this policy within their specific area. This involves ensuring that all staff are fully conversant and compliant with the policy, procedure and in completing the Risk Grading Matrix (Appendix 4).

The General Managers will, where appropriate, be responsible for ensuring the implementation of any service improvements that have been identified as a result of a complaint.

5.9. Directorate Heads of Nursing Directorate Heads of Nursing have been delegated responsibility from the General Managers to operationally manage the complaints process within their Directorate. This involves reviewing the complaint letters clinically to identify the urgency of the response, the coordination and appointment of Appointing Officers and Investigating Managers, In most directorates the Directorate Head of Nursing acts as the Appointing Officer. Reviewing and

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approving action plans and recommendations from complaints. They are responsible for acting as a central point of contact within the Directorate for formal complaints.

5.10. Role of Appointing Officers Appointing Officers are responsible for ensuring the appointment of suitable Investigating Managers with the relevant training and experience who have not been involved in the complaint. Where possible, good practise suggests Investigating Managers should not be from the same service area indicated in the complaint. They are also responsible for reviewing the complaint letters from a clinical perspective to identify the urgency of the response and if any immediate action needs to be taken.

5.11. Role of Investigating Manager (Refer to section 8.3) The Investigating Managers will be responsible for liaison with the complainant, ensuring that they carry out a thorough, fair and factual investigation into the complaint (see Appendix 5). They should ensure that they complete the report template provided to them to prepare an appropriate response letter detailing their findings, including a suggested response and complete the Risk Grading Matrix (Appendix 4) provided to them. All formal complaint investigations are completed within set timescales stated in this policy and agreed with the complainant.

5.12. Role of all Staff To make sure they have read the policy and know what their individual responsibilities are for handling complaints and concerns.

All staff should be aware of the correct procedure to follow should a patient or relative wish to make a formal complaint, raise a concern or pass on a compliment.

All staff, regardless of their role and seniority, are responsible for supporting complainants with help and information about the procedure and for trying to resolve complaints and concerns quickly and appropriately as they arise. This will be done in line with the Trust’s own values and with particular emphasis on treating complainants with respect and dignity.

All staff should request advice and guidance from the Complaints Department or PALS if they are unsure of what action to take.

On receipt of a complaint or concern, all staff will follow the procedure outlined in Appendix 2.

Suggestions and compliments also provide useful feedback and these should be sent to PALS who will register the feedback.

5.13. Clinical Governance and Patient Safety Committee

The Clinical Governance and Patient Safety Committee has responsibility for ensuring that complaint handling throughout the Trust is monitored on behalf of the Trust Board, including:

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Reviewing and revising the Complaints Policy, ensuring that it: Is easily accessible and well publicised Is applied Meets legal and other requirements Remains up-to-date in terms of regulations and Trust structural and

organisational factors

Receives and approves the quarterly thematic review on complaints management including: Numbers of opened, closed and re-opened complaints Subject matter Trends Response times Lessons learnt and actions taken as a result of complaints Details of complaints referred to the Ombudsman and the outcome of

these

Ensure that there is a robust system for auditing and sharing the lessons learned from complaints for service improvement. Should remedial action be required, an action plan will be formulated and monitored by the Clinical Governance and Patient Safety Committee.

5.14. Governance Forums

Governance Forums will receive a monthly report detailing the complaints, to include the recommendations, actions taken and the lessons learnt (if indicated).

5.15. Service Managers / Modern Matrons

Service Managers and Modern Matrons will ensure that staff, service users and carers are kept fully informed of the complaints process, taking into consideration the assistance required to support those complainants who may not be able to read or write, may not have English as their first language or may suffer from disabilities which make formal written complaints difficult. The Trust has access to interpretation at Translation Services and assistance in putting complaints in writing is available from the Complaints Departments. Service Managers, Modern Matrons or equivalent role are provided with a copy of the complaint letter at the time of registration and are responsible for reviewing the content from a clinical perspective to identify the urgency of the response and if any immediate action needs to be taken. They are also responsible for ensuring action plans are completed and evidence is provided.

5.16. PALS and Complaints

The Patient Advice and Liaison Service (PALS) and Complaints Department are separate services within the Trust.

There is a clear differentiation between PALS and Complaints. PALS do not investigate formal complaints and their role is to help resolve issues and concerns locally as quickly as possible and support people to access the complaints procedure when requested. However, the issues raised through PALS forms an important component of service user and carer feedback which helps us to improve our services.

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PALS provides assistance to members of the public, patients, service users and carers with queries about health related matters when they first have a concern or issue they wish to raise.

6 Complaints Process

6.1 Stage 1 – Local Resolution (Stage 1)

6.1.1 Informal Complaints and Concerns Informal complaints and concerns can often be resolved at the source. Concerns raised should be listened to sympathetically and it will frequently be possible for the member of staff to whom these were expressed, to provide an acceptable answer or explanation on the day where possible.

Where remedial action has been or is to be taken, its nature should be explained to the person raising the concern. A record of the informal complaint and any action taken, if appropriate, should be documented using the Trust’s Informal Complaints/Concerns Feedback form (Appendix 2) and sent to the PALS team via email at [email protected].

Staff should always attempt to deal with informal complaints/concerns swiftly at the informal stage so that the issue is resolved more quickly for the complainant. Staff should apologise and inform the patient/relative what can be done to address their concerns. If you need help/support with handling an informal complaint you should contact PALS team ([email protected]).

6.1.2 Formal Complaints

Who may complain? Complaints may be made directly to the Trust by:

A patient Any person who is affected by or likely to be affected by the action,

omission or decision of Trust A representative of either of the above in a case when that person:

Has died Is a child Is unable by reason of physical or mental incapacity to make the

complaint themselves Has requested the representative to act on his behalf and

provides consent to allow this How can a complaint be made? Complaints can be made directly to the Trust by:

Letter Email Telephone In person

mailto:[email protected]


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6.2 Complaints made by a person other than a patient If the patient has capacity to give consent and wishes a representative to act on their behalf, then signed authorisation will be sought by the Complaints Department. The Complaints Department will request consent and allow four weeks for the form to be returned. If the form is not received the Complaints Department will close the complaint. However, a full investigation will still take place to ensure that if any areas of improvement are identified and lessons are learnt to improve the service. If the patient has died, or is incapacitated, the Complaints Officer in conjunction with the Caldecott guardian must decide whether the complainant is a suitable person to pursue a complaint. Consideration must be given to all relevant factors such as the closeness of the complainant’s involvement with the patient over the time they had known them and the nature and frequency of their contact. Where the complainant has Lasting Power of Attorney (LPA) on behalf of a patient, the Complaints Department will ensure that this is valid, registered with the Office of the Public Guardian and the extent of the powers held, in order to decide whether consent from the patient is required. A copy of the LPA will be kept on the complaint file. Where the complaint is made on behalf of a child (under 18 years old), the Complaints Officer will check with the clinician to get an opinion as to whether the child has competency to give consent for the complaint to be made on their behalf by a parent, carer or advocate. If a child (under 18 years old) makes a formal complaint on their own behalf, the Complaints Officer will check with the clinician regarding their competency and the appropriateness of this.

6.3 Complaints made by Member of Parliament on behalf of Constituent Complaints, concerns or information requests from MP’s are usually addressed to the Chief Executive and where this is the case, the Chief Executive will send acknowledgment that the letter or email has been received and pass to the Complaints Department. The Complaints Department will review the letter in-conjunction with PALS and determine the best route for addressing the issues raised. If the letter or email is a formal complaint, this will be dealt with in the line with the Trust’s Complaints Procedure. Consent from the person concerned must be obtained if correspondence is to be copied to the MP (refer to section 7.3). All responses to MP’s are signed by the Chief Executive.

6.4 Stage 2 – Parliamentary Health Service Ombudsman (PHSO) and Local

Government Ombudsman (LGO) If, after all attempts at local resolution the complainant remains dissatisfied with the response to their formal complaint they have the right to ask the Parliamentary Health Service Ombudsman or Local Government Ombudsman to investigate their complaint.

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7 Complaints Management

7.1 Contacting the Complaints service

The CPFT Complaints Department can be contacted by Freephone 0800

0521411, via email: [email protected] or in writing to:

Complaints Department

Elizabeth House

Fulbourn Hospital

Fulbourn

Cambridge

CB21 5EF

7.2 Response Times

The team operates within normal office hours Monday to Friday excluding

bank holidays. The team will aim to respond to complaints or contact

regarding complaints within two working days. 7.3 Time limits for making complaints

A complaint should be made within twelve months from the incident that caused the problem or within twelve months of the complainant becoming aware of the incident. The Complaints Officer has discretion to extend this time limit when the complainant had good reason for not making a complaint within that time limit; and it is still possible to investigate the complaint effectively and fairly. When the timescale is not extended, complainants will be advised of their right to refer the complaint to the Parliamentary Health Service Ombudsman or Local Government Ombudsman for a review of this decision.

7.4 Matters excluded under the complaints procedure Some complaints fall outside of the remit of the NHS Complaints Procedure:

A complaint made by a Trust employee about any matter relating to his/her employment.

A complaint arising out of the alleged failure by the Trust to comply with a request for information under the Freedom of Information Act.

A complaint which has previously been investigated in accordance with the Trust’s formal complaints procedure and the complaints policy has been exhausted.

A complaint that is or has already been investigated by the Parliamentary Health Service Ombudsman or Local Government Ombudsman.

A concern that is raised by another NHS Trust, Clinical Commissioning group, local authority or independent provider. These concerns are dealt with in accordance with the Healthcare Professional Feedback procedure unless deemed to require a different process e.g. formal response, Serious Incident, Safeguarding.

7.5 Complaints, Legal Action and Criminal Proceedings

Where a complainant states they are commencing legal action against the Trust in relation to their complaint, the Complaints Department will notify the


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Trust Legal Team, and information collated during an investigation of a complaint, may have to be disclosed when legal action is taken. It should be noted that the updated Complaints Regulations 2009 no longer states that the complaint should be halted where legal action has started. It should also not necessarily be assumed that a complaint made via a Solicitor means that the complainant has decided to take legal action. If consent has been received, a response should be made in the normal matter. An apology is not necessarily an admission of liability. If the subject of the complaint is a matter being referred to the police, the complaints procedure will be suspended pending the outcome of that investigation and the complainant will be informed of the reasons for this delay. Once the outcome is known the complaint may continue if appropriate.

7.6 Complaints and Disciplinary Action Complaints can be investigated even if disciplinary action is being considered or taken against a member of staff. However, the confidentiality of the member of staff concerned must be respected and the Data Protection Act must be adhered to.

7.7 Discrimination Complainants need to feel confident that their care will not be affected as a result of their having made a complaint. This commitment will be communicated to patients throughout the Complaints Process. Complainants will be invited to complete a questionnaire (which is currently under review – Appendix 7) at the end of the procedure and results will be monitored to identify any discrimination and action to be taken. The questionnaire will also provide reassurance that internal complaint handling processes are being followed and that complainants are satisfied with this.

8 Complaints Procedure

8.1 Acknowledgments

All formal complaints must be acknowledged within 3 working days. If the complaint is addressed to a member of staff outside the Complaints Department, the addressee will send an acknowledgment confirming that the complaint has been referred to the Complaints Department. If a complaint is received outside of office hours or at the weekend the complaint will be recorded as being received on the next working day and the acknowledgement will be 3 working days from this date. The Complaints Department will send an acknowledgment of complaints received whether they were received directly from the complainant or via a member of staff. When a complaint is made orally which requires investigation as a formal complaint, the acknowledgment must be accompanied by a written account of the complaint, with an invitation to the complainant to confirm the accuracy by signing and returning it. Complaints Department will send the letter to Director of Nursing and Quality, and Service

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Manager/Modern Matron or appropriate equivalent within the three day timeframe. When the complainant is not the patient and written authority from the patient for the complainant to pursue the matter on their behalf has not been supplied, the completion of a consent form will be requested. Where consent cannot be obtained for a third party to make a complaint about the care and treatment of a patient, no response will be given which includes specific or confidential information about the patient. The acknowledgment will contain information about support available from Total Voice (Independent Health Complaints Advocacy Service – see Appendix 1) and information on the complaints process and about disclosure of information. Any disclosure must be confined to that which is relevant to the investigation of the complaint and only disclosed to those people who have a demonstrable need to know it for the purpose of investigating the complaint.

8.2 Complaints relating to Local Authority or other NHS Body (Appendix 5)

In cases when the complaint relates in part to a Local Authority, or another NHS body, the involved organisations must co-operate in coordinating the handling of the complaint and ensuring that the complainant, with their agreement, receives a coordinated response to the complaint. This includes agreeing which organisation takes the lead in coordinating the handling of the complaint and communicating with the complainant. This discussion will take place within a target of 2 working days of receipt of a complaint. Staff will endeavour to work with private organisations/agencies in the same way. Each organisation must provide information relevant to the complaint and attend any meeting required in connection with the complaint. When the complaint relates entirely to services provided by another NHS body, or local authority, the Complaints Department will seek the consent of the complainant to forward the complaint to the relevant body within a target of 3 working days.

8.3 Investigation

The Complaints Department will liaise with the Appointing Officer to ensure the allocation of an appropriate Investigating Manager. The Investigating Manager will be someone independent of the area(s) and staff that are subject of the complaint. This will be the start of the complaints handling process outlined in Appendix 3. The aim of an effective investigation is to gather a sufficient amount of relevant clinical, factual and other information to be able to determine what has occurred and to identify any appropriate action required (Appendix 5). Guidance of completing a complaints investigation can be sought from the Complaints Department. The Risk Assessment Matrix (Appendix 4) will assist in determining the level of investigation required. It can assist in ensuring that the process is proportionate to the seriousness of the complaint and the likelihood of recurrence.

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The investigation will be fair to all parties. Investigating Managers will ensure that anyone who is the subject of a complaint is given a proper opportunity to talk to them and is kept informed of progress. The Investigating Manager will need to complete the Complaints Investigation Paperwork and ensure all information relevant to the investigation is recorded, and this is sent back to the Complaints Department to be kept in the complaint file. This will include records of interviews and telephone conversations. The case file will be forwarded to the Complaints Department at the end of the investigation, as it may be required at a later stage by Commissioners or the Ombudsman. It is the Investigating Manager’s responsibility to determine if the elements of the complaint are upheld, partially upheld, not upheld or undetermined. The Complaints Department are responsible for providing a check on the outcome and recording this in the complaints database (refer to section 4.10 to 4.13 for outcome definitions). Where the complaint involves clinical issues, the findings and the response must be shared with the relevant clinicians to ensure factual accuracy in respect of those clinical issues. The findings of the investigation should be fed back to the team and develop an action plan with them (refer to section 8.8). The Complaints Department may, where appropriate and with the agreement of the complainant, make arrangements for conciliation, mediation or other assistance for the purposes of resolving the complaint. The Investigating Manager is responsible for ensuring that the complainant is kept up to date with progress at intervals agreed with them at the start of the complaint process. Where a complaint relates to the actions of the Chief Executive or Chairman of the Trust, special arrangements will be made to ensure a fair investigation. This may be for example via a neighbouring NHS Trust or Local Authority.

8.4 Stop the Clock

At times there may be reason to ‘stop the clock’ on the 30 working day

standard timeframe and a revised timeframe is used.

Reason to Stop the Clock Rule

Consent is required as the complaint

relates to more than one organisation

Consent is requested when the

acknowledgement is sent. If consent

is not received within 4 weeks the

complaint is closed.

Where elements of the complaint

relate to an on-going serious incident

investigation.

The 30 working day response time will

be calculated from the date the

Serious Incident investigation report is

submitted to the Clinical

Commissioning Group.

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Where the complaint raises issues of

a safeguarding nature

The complaint will be suspended and

will commence once the Safeguarding

Investigation has concluded and the

findings shared with the

patient/relative, or confirmation has

been received a safeguarding review

is not required.

If during the course of the investigation the complainant wishes to suspend

their complaint, the Complaints Department will record the complaint as

closed. If the complainant wishes to recommence their complaints

investigation within two months of the suspension the complaint will be re-

opened. If the complainant wishes to complain about the same circumstances

again in the future this will be recorded as a new complaint.

8.5 Response to Complainants

A final response letter will be sent out at the end of the investigation. In all cases the Investigating Manager will agree with the complainant, at the beginning of the complaint process, the date that they will receive their response. The Trust aims to provide a response within 30 working days from receipt of the complaint. If a complaint is received outside of office hours or at the weekend the complaint will be recorded as being received on the next working day and the response will be 30 working days from this date. There are circumstances when this is not possible and in this case the Investigating Manager will agree timescales with the complainant and will then notify the Complaints Department (refer to section 8.6). The final response letter will be signed by the Chief Executive. If for good reason the Chief Executive is not able to countersign the final response, it will be signed by a Director acting on behalf of the Chief Executive. The response will be in the format of a letter and will include a summary of the nature and substance of the complaint, an open and honest description of the investigation and its findings and any recommendations to be taken as a result of the complaint. It will also include appropriate apology for any omissions by the Trust and the distress caused. The response will also include the offer of further opportunities to clarify or discuss remaining concerns and advice to complainants, regarding the right to refer the complaint to the Parliamentary Health Service Ombudsman (see Appendix 1) if they remain dissatisfied following the Trust’s conclusion of the complaint.

8.6 Local Resolution Meetings If the complainant remains dissatisfied with the outcome of their complaint, the option for a local resolution meeting is available. Local resolution meetings should be held with relevant senior clinicians, senior managers, and a

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member of the Complaints Team. Local resolutions will be minuted (and a copy provided to all relevant parties).

8.7 Exceptional Circumstances

An exceptional circumstance refers to a reason why the complaints procedure may not be adhered to and there is a delay in the complainant receiving their response. Examples of these reasons are:

The patient is in acute phase of their illness/in hospital and the complaint is unclear and requires clarification with them, contact should be made with relevant clinician to establish this and must be documented.

The complaint is very complex e.g. involves a death, serious harm or goes back more than 12 months. This is likely to also fall under the Incident Management Policy including Serious Incidents and Near Misses.

Key witnesses whose statements are required are on annual leave or sick – this should be identified at the start of the investigation and explained to the complainant – if a member of staff is on long-term leave it may not be possible to wait. In these circumstances advice should be sought from the Complaints Officer.

The Investigating Manager goes on sick leave after starting an investigation – in this case the complaint should be reallocated immediately and any delays kept to the minimum.

Please note: if is it known that the Investigating Manager will be on planned leave this is not an exceptional circumstance and this must be considered when allocating a complaint to that person. They must be able to meet the 30 day deadline. The complainant must be informed in all cases of the above and agreement should be sought on when the complaint will be completed. Any extensions in excess of the 30 day timescale together with the reason must be documented and will be monitored closely. This will also monitored through the annual complaints audit.

8.8 Learning from Complaints As part of the investigation, where appropriate, the Investigating Manager, will identify areas of improvement and recommendations. The Investigating Manager will agree with the Ward/Team Manager, Service Manager/Modern Matron or General Manager, the findings of the investigation and where appropriate agree achievable actions and in collaboration/agreement with the Team/Service Manager develop an action plan to be submitted as part of the complaints investigation pack. The action plan will be sent by the Complaints Department to the relevant Directorate Head of Nursing for approval. The expectation is for the action plan to be approved within two weeks of receipt. An electronic tracker of the action plans will be regularly updated with evidence by the Complaints Department. This information will be reported to the Clinical Governance and Patient Safety Committee. Directorate Heads of Nursing will have access to the

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electronic action plan trackers and are responsible for ensuring they are disseminated, actions are implemented and evidence is provided. Where lessons from complaints have value, wider than the service concerned i.e. teaching staff and adoption of good practice, complainants will be approached to participate in ‘sharing their story’ (with their consent), for on-going dissemination and spread of lessons learnt across the organisation.

9 Unreasonable and Persistent Complainants

Habitual complainants are becoming an increasing problem for NHS Staff,

causing undue stress and placing a strain on time and resources. Staff are

trained to respond with patience and sympathy to the needs of all

complainants, but there are times when there is nothing further which can

reasonably be done to assist them or to rectify a real of perceived problem.

The Trust will ensure that the Complaints Procedure is followed so far as

possible and that no material element of a complaint is overlooked, as

complaints from unreasonable and persistent complainants may have some

substance.

In cases where an unreasonable and persistent complainant has been

identified, the Complaints Officer will discuss the case with the Chief

Executive and decide what action to take. This may include a review of all the

complaints documentation or seeking legal advice. Once a decision has been

made, the Chief Executive will write to the complainant and a record kept of

the reasons why a complainant has been classed as unreasonable and

persistent. Refer to the Guidance for Handling Unreasonably Persistent

Complainants (Appendix 9).

10 Parliamentary Health Service Ombudsman (Stage 2)

10.1 The Role of the Ombudsman

The Ombudsman is independent of the National Health Service and the

Government.

The Ombudsman is appointed by the Queen and is answerable to a Select

Committee.

The role of the Ombudsman is to identify cases of genuine hardship or

injustice or any unfairness of complaint management under the NHS

Complaint Procedure.

The Ombudsman may decide to investigate complaints about services

received from the NHS if not resolved to the complainant’s satisfaction locally

through Local Resolution.

The Ombudsman has powers to investigate complaints about NHS providers

and purchasers and non-NHS providers which are funded by the NHS, on

such matters as care and treatment, clinical judgment, maladministration

causing hardship or injustice, service provision and complaints handling. It is

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intended that complainants should fully exhaust the complaints procedure

before referring to the Ombudsman. However, the Ombudsman shall have

discretion, exceptionally, to override this requirement.

When investigating a complaint the Ombudsman will require access to all

papers relating to the Local Resolution of the complaint.

The Ombudsman will not investigate complaints about disciplinary or other

personnel matters.

The Trust works to the PHSO ‘Principles of good Complaint Handling’, which

identifies six principles an organisation is expected to understand when

dealing with complaints.

The six principles include:

Getting it right Being customer focused Being open and accountable Acting fairly and proportionately Putting things right Seeking continuous improvement

10.2 Responding to the PHSO

If the Trust received a notification that a case has been referred to the

Ombudsman the complaints department will: Ensure the PHSO is sent copies of the complaint investigation file

within the timescale set by the PHSO Liaise with the offices of the PHSO to provide additional information as

requested Update the central database in relation to the complaint to indicate its

referral to the Ombudsman Report any complaint referred to the PHSO via the Integrated Board

Report to the Trust Board Report any complaint referred to the PHSO to the Patient Safety and

Clinical Risk Group. Co-ordinate the formulation of an action plan for any actions identified

as needed as a result of the PHSO’s review of the complaint Communicate the outcomes of the PHSO’s reviews to the

Commissioners and Clinical Governance and Patient Safety Committee along with any action plans

Submit any action plan produced to the appropriate local governance group for monitoring

11 Local Government Ombudsman (Stage 2) 11.1 The Role of the LGO

The Ombudsman is independent of the local authorities and adult social care

providers. The role of this Ombudsman is to act as the final stage for

complaints and investigate complaints in a fair and independent way.

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The Ombudsman may decide to investigate complaints about services

received from the local authority or adult social care provider if they are not

resolved to the complainant’s satisfaction locally through Local Resolution, or

responded to within a reasonable time (usually up to 12 weeks). 12 PALS Management

12.1 Contacting the PALS team

The PALs team can be contacted by Freephone 0800 376 0775, via email:

[email protected] or in writing to:

Elizabeth House

Fulbourn Hospital

Fulbourn

Cambridge, CB21 5EF

The PALS and complaints teams work very closely together to ensure all informal and formal concerns are handled effectively and smoothly.

12.2 Response Times

The team operates within normal office hours Monday to Friday excluding

bank holidays. The team will aim to respond to contacts relating to concerns

or enquiries where possible the same day and no later than two working days.

12.3 PALS Drop-In sessions The PALS team offer drop-in sessions on the wards for inpatients. This service allows patients to ask for advice or voice concerns in a confidential and personal manner.

13 Compliments The PALS team record all compliments received by the Trust on the PALS database. If the compliments are received directly by the PALS team they will forward the feedback to the relevant team. The wards and teams are responsible for forwarding copies of any compliments they receive to the PALS team so these can be recorded on the central database and report as part of the Trust’s quality reporting.

14 Confidentiality and Data Protection

14.1 Data Protection Act

It is essential when dealing with complaints that staff comply with the

Confidentiality Policy, Data Protection Policy and Access to Health Records

Policy. Any request to access clinical/medical records will be dealt with under

the Data Protection Act (1998).

As the Data Protection Act only relates to living persons access to deceased

patient’s records is via the Access to Health Records Act (1990). Any

disclosure must be confined to that which is relevant to the investigation of the

complaint and only disclosed to those people who have a demonstrable need

to know it for the purpose of investigating the complaint.


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14.2 Record Keeping for PALS and Complaints

All concerns and enquiries will be analysed on arrival by PALS and coded by

main theme, sub theme, staff type and service. This information along with the

personal details of the person raising the concern or enquiry, and details of

the contact, will be entered onto the database, which will be kept up to date

and accurate. Clients may wish their personal details remain anonymous and

these wishes would be respected, however, the issue would be recorded on

the database so as to ensure that trends are identified and reported.

On receipt of a formal complaint the complainants and patients details are

inputted onto the complaints database, and an electronic folder is created.

Information pertaining to the complaint is held within the database and

electronic folder within a secure network.

Records pertaining to a formal complaint or that a patient/relative has made a

formal complaint should not be kept in a patient’s clinical records. The

complaint files are held separately to the patient’s clinical records to ensure

patients are not discriminated against for raising concerns.

14.3 Confidentiality and Consent

Both the Complaints Department and PALS team will treat all information

received about patients and staff in strict confidence. Information about a

caller, including the fact that they have made contact, will not be disclosed to

a third party even to a partner or family member without the express consent

of the caller.

The majority of concerns or enquiries will be received by telephone. In order

to facilitate the speedy response of enquiries, verbal consent will be gained

from enquirers. If the enquiry is on behalf of a child under the age of 16, it is

not necessary to obtain consent from the child.

The process for obtaining consent for formal complaints is outlined in section

7.3 and 7.4.

15 PREVENT Strategy

If a staff member becomes concerned that an adult with risk behaviour indicates they may be being drawn into terrorist-related activity should contact the Trust Prevent Lead as soon as possible.

16 Whistle Blowing

The Whistleblowing (Open Practice) Policy should be accessed instead of the Complaints Policy when an employee or worker provides certain types of information, usually about illegal or dishonest practises to the employer or a regulator, which has come to their attention through work.

17 Being Open and Duty of Candour Policy

From October 2014 all NHS organisations will be required to comply with the Duty of Candour and tell patients if their safety has been compromised. CPFT will ensure that patients (and their carers if appropriate) receive a prompt

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apology for any incidents when this has occurred, whether or not a complaint has been made or information has been requested and ensure that lessons are learnt to prevent them from being repeated.

18 Support for Staff

The Trust recognises that complaints made against individual members of staff can be distressing. Support is available for staff from their Line Managers, the Occupational Health Department, and Union Representatives.

19 Education and Training Requirements

Complaints information relating to this policy will be provided through Trust Induction, and Investigating Managers training sessions within service areas. It is preferable for Investigating Managers to have undertaken Root Cause Analysis training. The Complaints Department provided in-house complaints investigation training.

20 Monitoring Compliance The Trust monitors its management of complaints, concerns and compliments through: The production of monthly reports to the Trust Board, a quarterly thematic

review, and annual reports. An annual complaints audit is undertaken to review the complaint

procedure and the reports are presented to the Clinical Governance and Patient Safety Committee.

21 Links to Other Documents Other related Trust procedural documents should be identified here. Incident Management Policy including Serious Incidents and Near Misses Being Open and Duty of Candour Policy Whistleblowing Policy Access to Health Records, Personnel Records, and CCTV Data Protection

Act 1988 Policy Confidentiality Policy Freedom of Information Policy Health Records Management Policy Safeguarding Children Policy Safeguarding Adults Policy Supporting Staff Following Traumatic or Distressing Events Policy Disciplinary Policy and Procedure

22 References and Acknowledgements The following documents and publications have been directly referenced or have been considered in the drafting of this policy:

Access to Health Records Act (1990)

Data Protection Act (1998)

The Principles of Good Complaint Handling (Parliamentary Health Service

Ombudsman, 2008)

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Listening, responding, and improving a guide to better customer care. Local

Authority Social Services and NHS Complaints England DH, 2009

NHS Consultation (DH 2012)

NHS Litigation Authority Guidance about Complaints

The Local Authority Social Services and National Health Service Complaints

(England) 2009

Being Open – Communicating Patient Safety Incidents with Patients and their

carers (NSPA, 2009)

Robert Francis Inquiry Report into Mid-Staffordshire NHS Foundation Trust

(2010)

Listening and Learning: the Ombudsman’s Review of complaint handling by

the NHS in England 2010-11

Building Partnerships, Staying Safe The Health Sector contribution to HM Government’s Prevent Strategy: guidance for healthcare organisation (DH 2011) ‘Introducing the Statutory Duty of Candour’: a consultation on proposals to introduce a d new CQC registration regulation, Department of Health, March 2014 Report of handling of complaints by NHS hospitals in England by Ann Clwyd MP and Professor Tricia Hart October 2013 Policy and Procedures on Handling Concerns and Complaints, Derby Hospitals NHS Foundation Trust (2013) Complaints Procedure, Norfolk and Suffolk NHS Foundation Trust (2014)

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Appendix 1

Useful Contacts

CPFT Complaints Department Elizabeth House Fulbourn Hospital Fulbourn Cambridge CB21 5EF Tel: 0800 0521411 Email: [email protected]

CPFT PALS Elizabeth House Fulbourn Hospital Fulbourn Cambridge CB21 5EF Tel: 0800 3760775 Email: [email protected]

CPFT Caldicott Guardian (Medical Director) Elizabeth House Fulbourn Hospital Fulbourn Cambridge, CB21 5EF Tel: 01223 726763

CPFT Freedom of Information Lead Elizabeth House Fulbourn Hospital Fulbourn Cambridge, CB21 5EF Tel: 01223 726759 Email: [email protected]

CPFT Information Governance Manager PO Box 506 Edith Cavell Health Campus Bretton Gate Peterborough, PE3 9GZ Tel: 01733 776010

CPFT Safeguarding Children Lead Elizabeth House Fulbourn Hospital Fulbourn Cambridge, CB21 5EF Tel: 01223 726770

CPFT Safeguarding Adult Lead (Cambridgeshire area) Tel: 01480 415340

CPFT Safeguarding Adult Lead (Peterborough) Tel: 01733 748409

Vulnerable Adults Lead Box SS1007 Castle Court Shire Hall Cambridge, CB3 0AP Tel: 01223 717330

Vulnerable Adults Lead 2nd Floor Town Hall Bridge Street Peterborough, PE1 1FA Tel: 01733 758433

Customer Care Manager Social Care Complaints Cambridgeshire County Council Castle Court Shire Hall Cambridge, CB3 0AP Tel: 01223 699665

The Central Complaints Office Peterborough City Council Bayard Place Broadway Peterborough PE1 1FZ Tel: 01733 345090




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Parliamentary Health Service Ombudsman Millbank Tower Millbank London, SW1P 4QP Tel: 0345 015 4033 Email: [email protected]

The Local Government Ombudsman PO Box 4771 Coventry, CV4 0EH Tel: 0300 061 0614

Information Commissioner’s Office Wycliffe House Water Lane Wilmslow Cheshire, SK9 5AF Tel: 0303 123 1113

Total Voice Cambridgeshire and Peterborough Independent Health Complaints Advocacy Tel: 0300 222 5704 Email: [email protected] Website: www.totalvoicecp.org

Cambridgeshire Independent Advocacy Service (CIAS) Cambridgeshire: Tel: 01223 218500 Peterborough: 01733 530651

MIND – mental health charity www.mind.org.uk Peterborough and Fenland: Tel: 01733 530650 Huntingdon: Tel: 01480 470480 Cambridge: Tel: 01223 311320

Age Concern Mental Health Advocacy Service The Old White Lion 31 St Mary’s Street Ely Cambridgeshire, CB7 4HF

Alzheimer’s Society Advocacy Service 17 Manor House Street Peterborough, PE1 2TL Tel: 01733 893853

Making Space (Cambridgeshire Carer Support Services) Suite D2, Ambury Business Centre 89 High Street Huntingdon, PE29 3DP Tel: 01480 432504

Rethink Carer Support (Peterborough) Litton House Saville Road Westwood Peterborough, PE3 7PR Tel: 01733 843344

Healthwatch Peterborough 16 -17 St Mark’s Street Peterborough PE1 2TU Tel: 08451 202064 Email: [email protected]

Healthwatch Cambridgeshire The Maple Centre 6 Oak Drive Huntingdon PE29 7HN Tel: 01480 420628 Email: enquiries@healthwatch cambridgeshire.co.uk



http://www.totalvoicecp.org/

http://www.mind.org.uk/

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Appendix 2 Informal Complaints/Concerns Feedback Form

PLEASE ENSURE THIS FORM IS FILLED OUT BY A MEMBER OF STAFF AND SEEN BY A

MANAGER BEFORE SENDING

Date received:

Date closed;

Name of staff completing form (please print clearly):

Telephone number of staff completing form:

Directorate and Team:

Contact Information of person raising concern

Full Name:

Address:

Tel: (home/mobile/work)

Email:

D.O.B:

Ethnic Origin:

Tick here if Service User information is as above (if not fill in details below)

Service user name:

Relationship to person raising concerns

Address:

Service user Tel:

Service User D.O.B:

NHS Number / RiO Number

Consent: Please detail here if consent is required, given or denied by Service User

Details of informal complaint/query/issue:

Details of actions taken by staff to resolve the informal complaint/query/issue:

Send to PALS Team at [email protected]


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Guidance Notes for Staff

This form is to be completed by staff to ensure that staff are listening to concerns, comments and informal complaints. Please complete all parts of the form and return to PALS via email ([email protected]).

Please do not give this form to patients, carers or relatives to complete If you receive a complaint or concern please ensure that there is no immediate risk to the complainant and / or others involved. If you suspect there may be safeguarding issues, please call the appropriate Safeguarding Lead. If you suspect a fraudulent act has been committed please contact the Counter Fraud Team on Fill in the form while the person is with you where possible and if they want to sign it, they can do so in the ‘Consent’ box. Suggest to the person that although PALS will see this form, they may wish to contact PALS directly themselves to resolve issues speedily and informally. PALS Freephone is 0800 376 0775 or via email: [email protected] PLEASE NOTE: You must alert your Director or Line Manager immediately if there may be indications of physical or sexual assault, financial misconduct or criminal offence. If out of hours, please contact the Manager on Call in first instance



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Appendix 3

Formal Complaints Handling Flow Chart

Day 1

Patient / service user / representative makes a formal complaint; which is received by a member of staff or the Chief Executive is

passed to the Complaints Department and acknowledged.

Send complaint to the Complaints Department within 24 hours of receipt

Complaints Department register and acknowledge the complaint within 3 working days of receipt by the Trust

Day 3

Complaint sent to Director of Nursing and Quality, and Service Manager/Modern Matron or appropriate equivalent

Complaint sent to Appointing Officer who will nominate an Investigating Manager (IM) and inform the Complaints

Department

Complaints Department to provide the IM with the complaints documentation. IM to commence investigation and complete the

risk matrix

IM to identify recommendations and learning, and discuss and agree action plan with service

Day 4

Day 18

The IM is to notify the Complaints Department of any timeframe concerns and to keep the complainant up to date with the

progress of the investigation

Complaints Investigation Pack including recommendations and actions (if applicable) to be sent to Complaints Department Day 20

Complaints Department formulate the response letter. Send any queries to IM to address

Day 30 Complaint response letter pass to the Chief Executive to review

and sign

Day 25

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Appendix 4 Risk Grading

Please use the matrix below to determine the severity, likelihood and overall risk grading of the complaint post investigation.

Severity

Likelihood

Risk Grading

Most likely severity (if in doubt grade up, not down) Insignificant (1) No injury or identifiable damage No disruption to service or the organisation Financial implications are negligible e.g. spills of non-hazardous liquids, paper cuts

Minor (2) Mild injury (will probably resolve in less than 1 month) The impact would threaten the efficiency of some aspects of the organisation Some financial implications

1 e.g. absence from work <3 days, incorrectly filed documents

Moderate (3) Some injury (emotional, psychological or physical), ill health, damage or loss of function likely to resolve within a few months Disruption to organisation could be managed Moderate financial implications (>£50K) e.g. RIDDOR reportable injury, local adverse publicity, lost claim file

Major (4) Serious injury (emotional, psychological or physical), ill health, damage or loss of function possibly with prolonged disability Serious disruption to the organisation High financial implications (>£500K) e.g. large section of roof falling in, national adverse publicity, computer network failure >3 working days, prolonged time off work (>15 days), theft of claim file

Catastrophic (5) Death or significant permanent disability Organisation unable to function Very high financial implications (>£1million) e.g. large scale fraudulent claims management, international adverse publicity, bomb threat, anything untoward that involves >50 people

Likelihood:

Rare (1) Cannot believe that an even of this type will occur in the future

Very Low 1

Very Low 2

Low 3

Low 4

Low 5

Unlikely (2) Unlikely that this type of event will happen

Very Low 2

Low 4

Low 6

Moderate 8

Moderate

10

Likely (3) This type of event may well happen (e.g. 50/50 chance)

Low 3

Low 6

Moderate 9

Moderate

12

High

15

Highly Likely (4) This type of event will happen but is not a persistent concern

Low 4

Moderate 8

Moderate

12

High

16

High

20

Certain (5) This type of event will happen frequently

Low 5

Moderate

10

High

15

High

20

High

25

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Appendix 5

Advice Sheet – Investigating Complaints Please contact the Complaints Department if you require a copy of this document.

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Appendix 6

Guidance for Managers Interviewing Staff who are involved in Complaints 1. Introduction

Some reports and statements made by staff following an incident or complaint can be incomplete, lack key information or can be ambiguous. Good interview techniques can often increase both the quantitative and qualitative information gained from staff involved in incidents and complaints. It is important for managers to interview a wide range of people present at the time of the incident in order to create a complete picture of what actually happened.

2. Preparing for the interview

Staff should be formally invited to attend an interview and fully briefed on the purpose of the interview. Staff members may wish to bring someone else with them for support (i.e. a colleague, friend or Union Representative) and this should be fully permitted although it should be made clear that their support must not include active participation in the interview. The main reason for this is that any interruptions whiles the interviewee is giving their account may interfere or significantly affect memory retrieval. Interviews should be held in a relaxed setting, preferably away from the immediate place of work and in a private room. It is considered good practice to have one person undertaking the interview and one person either recording the conversation or taking notes. This enhances the flow of the information and allows the interviewer to give their undivided attention to the interviewee. If it is not possible to transcribe the interview then managers may wish to consider recording the conversation with the consent of the interviewee and then have it transcribed at a later date. Firstly, managers should ensure that the member of staff being interviewed has received written information explaining why the interview has been arranged. It should also be explained in the information that the interview is not part of a disciplinary process but a review of the complaint / incident to identify the cause. In order to allow the interviewee to prepare, managers should provide;

The name of the person who will be conducting the interview and their role in the investigation

Details of the incident or complaint being reviewed Details of what documentation will be provided before and during the

meeting Assurances that the interview will be confidential The approximate time or duration of the interview

Interviewees should be informed about the process of the interview and what will happen after the interview has taken place. This should include details of when the report will be completed and when the interviewee can expect to see the report in its draft stages. If a transcript has been made of the interview, managers should provide a copy to the interviewee for agreement as soon as possible to ensure accuracy.

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3. Arranging the interview When arranging interviews with staff who may be involved in complaints or incidents, managers should consider the following points as examples of good practice;

Always ensure that a private and undisturbed room is booked for the interview.

Try to avoid holding the interview at the end of the interviewee’s shift. Inform the interviewee’s manager, supervisor or clinical Lead that the

interview is taking place so that staff can be released and their shift covered.

Some staff will find the process very upsetting and disturbing and may not feel able to return to work immediately afterwards. Staff should be offered information on how to access support services after the interview if required.

Arrange the room in an informal way – try to avoid placing physical barriers such as desks or tables between parties.

Ensure plenty of water is available. Make sure that telephones are diverted and mobile phones are switched

off during the interview. 4. During the interview

At the start of the interview, the interviewers should be introduced and their roles in the process explained, followed by an explanation of the sequence of the interview and approximate time it will take. Managers should try to reiterate any written information given to the interviewee prior to the interview and stress that the process is not part of any disciplinary procedure. Always allow time for the interviewee to ask questions.

5. Essential factors for a successful interview

Ensure that the interviewee is aware that they are in control over the process and not the interviewer. Always allow the interviewee to ‘tell their story’ and recall their experience without interruption. Interruptions can reduce the interviewee’s ability to recall memories and will lead to incomplete or inaccurate information. Try to ask questions in the order that the incident is presented to aid memory retrieval and improve information given. Ensure that you share your understanding of the interviewee’s account with them before asking any questions. This will correct any misunderstandings and will serve as a ‘prompt’ to jog their memory about facts and important points that may have been forgotten. Try to avoid open-ended, rhetorical or quick-fire questions. It may be that the interviewee gives short answers that do not fully provide the information necessary to understand the incident. Try to keep the discussion as open as possible and avoid making judgmental or critical comments as this is likely to make the interviewee defensive and less likely to present the facts.

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Appendix 7

Management of Complaints Satisfaction Questionnaire

Formal Complaints Handling Survey

Complaints Procedure

Were you satisfied with:

The information provided to you about the complaints process Yes No

The content of the acknowledgement letter Yes No

The contact you had with the Complaints Department Yes No

The contact you had with the Investigating Manager(s) Yes No

The length of time to receive a formal response to your complaint Yes No

Complaint Response

Did you find your response understandable? Yes No

Did you feel all the elements of your complaint were addressed? Yes No

Did you feel confident about the investigation that took place? Yes No

Do you feel the response has provided you with a full explanation? Yes No

Your view on the Complaints Procedure

Yes No

I felt confident to make a complaint Yes No

I felt that making a complaint was simple Yes No

I felt listened to and understood Yes No

I felt my complaint was taken seriously Yes No

I felt that my complaint made a difference Yes No

I feel confident to make a complaint in the future Yes No

In order for the Trust to improve our services, we would appreciate your views on the

handling of your formal complaint. As a Trust we encourage feedback and would be

grateful if you could complete and return this survey in the self addressed envelope.

If you wish to provide any comments regarding the complaints procedure please use

the comments box provided on the back of this page

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Please provide your comments here:

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Appendix 8 Joint Protocol between the Trust and the Local Authority for the Management

of Complaints 1. The Local authority Social Services and National Health Service Complaints

(England) Regulations 2009 provides a framework for NHS and Local Authority Adult Social Care services to collaborate in handling complaints to ensure;

1.1. A single consistent and agreed contact point for complainants 1.2. Regular and effective liaison and communication between Complaints

Managers and complainants 1.3. That learning points arising from complaints covering more than one body are

identified and addressed by each organisation

2. This form the basis of an agreed approach to handling complaints about integrated mental health services provided by the Trust.

3. The Trust shall endeavour to resolve complaints about Health Services and the services through its own complaints procedures, where possible integrating its responses with that to any linked complaints about Health Services and in accordance with the Local Authority Social Services and National Health Service Complaints (England) Regulations 2009 (the ‘Complaints Regulations’). It shall publicise the existence of a complaints procedure to those who have a right to complain and ensure that complainants who receive Mental Health Services are informed of their right to complain to the Council under the Complaints Regulations if they are not satisfied with the Trust’s response.

4. If Service Users make complaints directly to the Council, the Council shall seek to arrange for these to be dealt with in the first instance by the Trust, wherever that is reasonable and can be agreed with the complainant.

5. Where a complaint is formally investigated by the Council under the Complaints Regulations, the Trust shall provide all necessary assistance with the complaints investigation. The response to such a complaint shall be jointly agreed between the Trust and the Council. If there is disagreement which cannot be resolved, the complainant shall be informed of both the Council’s and Trust’s response, and (as in all other cases) shall be notified of the right to take the complaint to the complaints review panel arranged by the Council.

6. The Trust will encourage service users and their carers to challenge decisions and actions they do not understand or perhaps agree with. A process for achieving this will be developed by the Trust.

7. The Trust will aim to resolve complaints locally, investigating and answering as close to where the problem occurred as possible. Where local resolution takes place, this will be within 1 working day.

8. In order to provide a coherent response to adult and older people receiving integrated mental health services from the Trust;

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8.1. The Trust’s Complaints Lead will co-ordinate the consideration of all NHS and social Care complaints issues relating to the Trust’s services, acting as the first point of contact for staff within the Trust, customers and their carers and complaints professionals within their organisations and ensuring appropriate registration and monitoring of complaint investigation processes.

8.2. If the issues of complaints relate to both the Local Authority and the Trust, the

Trust’s Complaints Lead will liaise with the Local Authority’s customer Relations Team to determine which organisation should take the lead in investigating the complaint.

8.3. Where the Local Authority has delegated any of its social care functions relating

to adults or older people with mental health difficulties to the Trust, the Trust will be responsible for investigating complaints about the discharge of those functions in accordance with the above Complaints Regulations.

8.4. The Trust Complaints Lead will ensure that appropriate consideration is given

to the need of the additional advice and support for the complainant. 8.5. Where the Local Authority has retained responsibility for a social care function,

Trust’s Complaints Lead will forward the complaint to the Local Authority’s Customer Relations Team.

8.6. All complaints about integrated services must be subject to a comprehensive

risk assessment by an appropriate Trust Manager and urgent action must be taken to alert partners if a high risk situation is indented.

8.7. The Trust’s Complaints Lead will provide the Trust with regular information

about the complaints received within the Trust, and will share the information with the Local Authority’s Customer Relations Team.

8.8. The Trust’s Complaints Lead will also have due regard for all relevant protocols

regarding information sharing and information governance, human resource, performance management and disciplinary issues in the coordination of complaints activity.

9. If a complaint involves both NHS and Adult Social care issues, the Trust Complaints Lead will arrange a strategy discussion with the Local Authority’s Customer Relations Team within a target of 2 working days of receipt of a complaint which relates wholly or partly to social care functions. Agreement will be reached on;

Relevant complaints and / or other procedures Investigation parameters Extent to which social care and NHS investigation activity can be co-

ordinated Sharing of information relevant to the complaint Access to interview Trust staff How results of investigation are to be shared Lead responsibility for co-ordination communication with complainant

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10. The Trust Complaints Lead should advise people who wish to complain about their detention under the Mental Health Act 1983 (as amended by the 2007 Act) of their right to appeal to the Mental Health Review Tribunal. However, complaints about the actions of the Approved Mental Health Professional’s actions during the process are covered by the social care complaints procedures and the Trust’s Complaints Officer should liaise with the Local Authority’s Customer Relations Team to pursue their complaint through the social care procedures.

11. Upon notification of an investigation to be undertaken by any Ombudsman, each partner shall respond to requests for information and / or interview within time limits set by the Ombudsman and provide access to relevant records.

12. Quarterly reports regarding comments, complaints and compliments will be provided as part of the S75 performance monitoring arrangements.

13. Where there is a finding of mal-administration by an Ombudsman in respect of services provided by partners under this agreement after the commencement date. Where that Ombudsman finds that the Trust’s negligence including breach of duty (statutory or otherwise) is the cause, the Trust shall be exclusively responsible for meeting any request for payment of compensation.

14. The partners shall review these arrangements if there are any changes to the Complaints Regulations with the aim of moving as closely as is permitted by guidance and regulations to a fully integrated process for handling all complaints about services.

15. In respect of liabilities arising from any indemnity in this Agreement, the Trust shall maintain membership of the liabilities to third parties scheme and the clinical negligence scheme for Trusts or such other schemes as may be operated from time to time by the National Health Services Litigation Authority and the Council shall maintain such insurance as it considers appropriate.

16. The Partners shall co-operate with each other in the defence of any claim arising under this Agreement using the insurance protocol agreed between Local Authorities and NHS bodies in operating partnership agreements under Section 75 or the 2006 Act as guidance.

17. The Partners shall be responsible for all legal liabilities to third parties arising under this Agreement on a claims incurred basis and shall indemnify the Council in respect of all such liabilities, costs, expenses and claims, except where such responsibility remains with the Council under liabilities created by statute or where the Council’s negligence including breach of duty (statutory or otherwise) was the cause.

18. Damages, claims and liabilities shall include the obligation to pay sums recommended by an Ombudsman or under other complaint process.

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Appendix 9 Guidance for handling Unreasonably Persistent Complainants 1. Introduction

Complainants whose behaviour is unreasonable and persistent can become a problem of NHS staff. Handling such complainants can place a strain on time and resources and can cause undue stress for staff who may need support in difficult situations. NHS staff are trained to respond with patience and empathy to the needs of all complainants but there are times when complaints have been fully investigated and there is nothing further which can reasonably be done to assist them to rectify a real or perceived problem. In determining arrangements for handling such complainants staff are presented with two key considerations. The first is to ensure that the complaints procedure has been correctly implemented and that no material element of a complaint is overlooked or inadequately addressed. It is important to appreciate that even vexatious complainants may have issues which contain some genuine substance. The need to ensure an equitable approach is crucial. The second is to be able to identify the stage at which a complainant’s behaviour has become unreasonable and persistent. One approach to the situation is to develop an approved procedure which is formally incorporated into the complaints procedure. Implementation would only occur in exceptional circumstances. Information on the handling of unreasonable and persistent behaviour from complainants should also be made available to the public as part of the material on the complaints process as a whole.

2. Purpose of this Guidance

Complaints about Trust services are processed in accordance with NHS complaints regulations. During this process, staff inevitably have contact with a small number of complainants who absorb a disproportionate amount of NHS resources in dealing with their complaints. The aim of this guidance is to identify situations where the complainant may be considered unreasonable and to suggest ways of responding to these situations. It is emphasised that this procedure 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 procedures, for example through local resolution, conciliation or involvement of Total Voice (the Independent Health Complaints Advocacy Service) as appropriate. Judgement, discretion and sensitivity must be used in applying the criteria to identity potentially unreasonable and persistent complainants and in deciding what action to be taken in specific cases. The procedure should only be implemented following careful consideration by and with the authorisation of the Chief Executive or deputy. Where a deputy is used, the reason for the non-availability of the Chief Executive must be recorded on the file.

3. Definition of an unreasonable and persistent complainant

Complainants (and / or anyone acting on their behalf) may be deemed to be unreasonable and persistent where previous or current contact with them show that they meet ONE OR MORE of the following criteria where complainants;

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Persist in pursing a complaint where the NHS complaint procedure has been fully and properly implemented and exhausted.

Change the substance of a complaint or continually raise new issues or seek to prolong contact by continually raising further concerns or questions, either upon receipt of a response or whilst the complaint is being addressed. (Care must be taken not to discard new issues which are significantly different from the original complaint as these might need to be addressed as separate complaints).

Are unwilling to accept documented evidence of treatment given as being factual or deny receipt of an adequate response in spite of correspondence specifically answering their questions or do not accept that facts can sometimes be difficult to verify when a long period of time has lapsed.

Do not clearly identify the precise issues which they wish to be investigated, despite the reasonable efforts of staff and, where appropriate, Total Voice to help them specify their concerns, and /or where the concerns identified are not within the remit of the Trust to investigate.

Focus on a trivial matter to an extent which is out of proportion to its significance and continue to focus on this point. It is recognised that determining what is a ‘trivial’ matter is can be subjective and careful judgement must be used in applying this criteria.

Have threatened or used actual physical violence towards staff or their families or associates at any time – this will in itself cause personal contact with the complainant and / or their representatives to be discontinued and the complaint, will thereafter, only be pursued through written communication. All such incidents should be documented.

Have, in the course of addressing a registered complaint, had an excessive number of contacts with the Trust, placing unreasonable demands on staff. A contact may be by telephone, letter or fax. Discretion must be used in determining the precise number of ‘excessive contacts’ applicable under this section, using judgement based on the specific circumstances of each individual case.

Have harassed or been personally abusive or verbally aggressive on more than one occasion towards staff dealing with their complaint of their families or associated. Staff must recognise that complainants may sometimes act out of character at time of stress, anxiety or distress and should make reasonable allowances for this. They should document all incidents of harassment. Clinical guidance should also be sought where clarification is needed on this.

Are known to have electronically recorded meetings or face to face / telephone conversations without prior knowledge and consent of other

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parties involved.

Display unreasonable demands or expectations, and fail to accept that these may be unreasonable (e.g. insist on responses to enquiries being provided more urgently than is reasonable or recognised practice or that which has been set out in the national guidance on complaints handling).

4. Options for dealing with unreasonable and persistent complainants

Where complainants have been identified as unreasonable and persistent in accordance with the above criteria, the Chief Executive (or appropriate deputy) will determine what action to take. The Chief Executive (or deputy) will implement such action and will notify the complainants in writing of the reason why they have been classified as unreasonable and persistent complainants and the action to be taken. This notification may be copied for the information of others already involved in the complainant, e.g. practitioners, conciliators, Total Voice, Member of Parliament. A record must be kept for future reference of the reasons why a complainant has been classified as vexatious. The Chief Executive or Deputy may decide to deal with complainants in one or more of the following ways:

Try to resolve matters before invoking this procedure by drawing up a

‘signed agreement’ with the complainant (and if appropriate involving the relevant practitioner in a two way agreement) which sets out a code of behaviour for the parties involved if the Trust is to continue processing the complaint. If these terms are contravened consideration would then be given to implementing other actions such as indicated in this section

Write to inform them that they must be classified as an unreasonable and persistent complainant, copy this procedure to them and advise them to take account of the criteria in any further dealings with the Trust. In some cases it may be appropriate at this point, to copy this notification to others involved in the complaint and to suggest that complainants seek advice in processing their complaints e.g. through Total Voice.

Inform the complainant of the form of contact which will be maintained, be it in person, by telephone, by fax, letter or any combination of these. Alternatively, to restrict contact liaison through a third party. If staff are to withdraw from a telephone conversation with a complainant it may be helpful for them to have an agreed statement available to be used at such times.

Notify the complainant in writing that the Chief Executive has responded fully to the points raised and has tried to resolve the complaint but there is nothing more to add and continuing contact on the matter will serve no useful purpose.

The complainants should also be notified that the correspondence is at an end and that further letters received will be acknowledged but not answered.

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Inform the complainant that in extreme circumstances the Trust reserves the right to pass unreasonable and persistent complainants to its solicitors.

Temporarily suspend all contact with the complainant or investigation of a complaint whilst seeking legal advice or guidance from the Parliamentary Health Service Ombudsman or other relevant agencies.

5. Withdrawing ‘unreasonable and persistent complainant’ status

Once complainants have been determined as unreasonable and persistent there must be a mechanism for reviewing this status at a later date. If, for example, complainants subsequently demonstrate a more reasonable approach, or if they submit a further complaint for which normal complaints procedures would appear appropriate. Staff should previously have used discretion in recommending the use of this guidance at the outset and discretion should similarly be used in recommending that the status be withdrawn when appropriate. Where this appears to be the case, discussion will be held with the Chief executive or their deputy. Subject to their approval, normal contact with the complainants and application of the NHS complaints procedures will then be resumed. The complainant will be informed in writing of the lifting of this status. However, an unreasonable and persistent complainant should not be denied the opportunity to raise new issues and all vexatious complaints should have their status reviewed annually.

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Appendix 10

Fens Unit Protocol Subject: Complaints and Concerns Responsibility: All staff and prisoners Review: August 2016 Author: Des McVey, Deputy Clinical Director for the Fens Unit Amber Woolner, Complaints Officer for CPFT (This document is adapted from the Complaints, Concerns and Compliments Policy of Cambridgeshire and Peterborough NHS Foundation Trust (CPFT). The adaptation takes into account the specific multi-agency working of The Fens Service in which the patients are prisoners who meet the criteria for Dangerous and Severe Personality Assessment and Treatment)

CPFT, under the Local Authority Social Services and National Health Service

Complaints (England) Regulations 2009 must make arrangements for the handling

and consideration of complaints. The arrangements must be accessible, speedy and

efficient and ensure that complainants are treated courteously and sympathetically and

as far as possible involved in decisions about how their complaints are handled and

considered.

The prisoners who are subject to assessment and treatment within The Fens Service

have the right to make complaints about the clinical service that they receive.

If you are unhappy with the treatment or service you have received from the clinical

staff employed to work on The Fens Service you are entitled to make a complaint,

have it considered, and receive a response.

PALS AND COMPLAINTS

The Patient Advice and Liaison Service (PALS) and Complaints Department are

separate service within the Trust.

There is a clear differentiation between PALS and Complaints. PALS do not

investigate formal complaints and their role is to help resolve issues and concerns

locally as quickly as possible and support people to access the complaints procedure

when requested. However, the issues raised through PALS forms an important

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component of service user and carer feedback which helps us to improve our

services.

PALS provides assistance to members of the public, patients, service users and

carers with queries about health related matters when they first have a concern or

issue they wish to raise.

WHO CAN COMPLAIN

Any patient or person, affected or likely to be affected by the actions or decisions of

the clinical team on the unit, can make a complaint. Someone acting on behalf of the

patient or person, with that person’s consent, can also make a complaint.

WHAT IS THE TIME LIMIT FOR MAKING A COMPLAINT

A complaint should be made within twelve months of the incident that caused the

problem or within twelve months of the complainant becoming aware of the incident.

The Complaints Officer has discretion to extend this time limit when the complainant

had good reason for not making a complaint within that time limit; and it is still

possible to investigate the complaint effectively and fairly.

COMPLAINTS PROCEDURE

Stage 1

The first stage of the complaints procedure is to attempt to locally resolve the

concerns being raised within the team through a general application. Your complaint

should be raised in the first instance with the person providing the service, i.e. the

clinician you are complaining about. Every attempt should be made to resolve

concerns informally, if possible. Stage one aims to resolve complaints quickly and as

close to the source of the complaint as possible using the most appropriate means.

Where managers are responding to a concern on an informal basis they should

ensure that you clearly understand that the issues are being dealt with are not being

registered as a formal complaint under the NHS Regulations.

The Deputy Clinical Director, who acts as the Complaints Manager for the Fens Unit,

will hold a record of complaints dealt with under stage 1. These records will include

details of how the issues have been dealt with, what information has been provided

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and what actions have been taken to resolve your concerns. This record may be

used at a later stage if you decide to progress your complaint to stage 2 and 3, as a

formal complaint, as outlined below.

If the complaint cannot be resolved with the member of the clinical team, or by a

manager on an informal basis, you can refer your complaint to the next stage.

Stage 2

In order to progress your complaint to stage two your concerns need to be raised

with the Deputy Clinical Director, who acts as the Complaints Manager for the Fens

Unit, either verbally or in writing.

If you make your complaint verbally, the person to whom you have complained

should make a written record of that complaint and pass this to the Complaints

Manager. Where a complaint has been made verbally, the written record will be sent

to you and you will be asked to sign and return it.

The Complaints Manager will then formally log your complaint and refer it to an

appropriate member of staff to investigate. The Complaints Manager must send a copy

of the complaint and acknowledgment to any person identified in the complaint. The

manager involved will investigate the complaint and respond to you both verbally and

in writing, and informing you of what, if any, course of action will be taken to resolve

the issue.

Complaints should be made as soon as possible after an event has occurred, as this

will allow for a more effective investigation as it will be more likely those involved will

be able to recall the event and circumstances surrounding it.

The final response will be sent to you within 20 working days from the date the

complaint was made under stage 2 of the process, or where that is not possible, as

soon as reasonably practicable. In cases where it is not possible to respond within

this timeframe, or should there be a delay in responding, you will be given an

apology and explanation, together with a date by which a full response can be

expected. The final response will also advise you of what to do if you remain

dissatisfied.

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The CPFT Complaints Department will hold a record of complaints dealt with under

stage 2; which may be used at a later stage if you decide to progress your complaint

to stage 3, as a formal complaint, as outlined below.

Stage 3

All formal complaints at this stage will be sent to CPFT’s Complaints Department. If

your complaint is still not resolved, you can send the complaint back to the

Complaints Manager who will pass your complaint onto the CPFT Complaints Officer

for further investigation.

In line with CPFT’s Complaints, Concerns and Compliments Policy, your complaint

will be allocated to an independent senior manager who will complete an

investigation into your formal complaint. A formal response from the Chief Executive

should be provided to you within 30 working days of the Trust receiving the

complaint. If it is not possible to respond within this timeframe you will be informed

and provided with the reasons for the delay and an updated timeframe.

Stage 4

Parliamentary Health Service Ombudsman (PHSO)

If, after all attempts at resolution you remain dissatisfied with the response to your

formal complaint you have the right to ask the Parliamentary Health Service

Ombudsman to investigate the complaint. The contact details for this service will be

provided to you during stage 3.

GUIDANCE FOR HANDLING UNREASONABLY PERSISTENT COMPLAINANTS

Complainants whose behaviour is unreasonable and persistent can become a problem

for NHS staff and services. The handling of such complainants can place a strain on

time and resources and can cause undue stress for staff who may need support in

difficult situations. NHS staff are trained to respond with patience and empathy to the

needs of all complainants but there are times when complaints have been fully

investigated and there is nothing further which can reasonably be done to assist them

to rectify a real or perceived problem.

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In determining arrangements for handling such complainants staff are presented with

two key considerations. The first is to ensure that the complaints procedure has been

correctly implemented and that no material element of a complaint is overlooked or

inadequately addressed. It is important to appreciate that even vexatious complainants

may have issues which contain some genuine substance. The need to ensure an

equitable approach to the situation is to develop an approved procedure which is

formally incorporated into the complaints procedure. Implementation would only occur

in exceptional circumstances.

Full guidance on the handling of unreasonably persistent complainants can be found

under Appendix 9 of CPFT’s Complaints, Concerns and Compliments Policy.

REPORTING AND LEARNING FROM COMPLAINTS

Every year a report of the complaints made in relation to the clinical team of The Fens

Unit will be collated. The report must specify the number of complaints received and

their subject matter. The report should summarise the handling and outcome of

complaints. When the Parliamentary Health Service Ombudsman are involved the

report will also provide details of where recommendations of the Parliamentary Health

Service Ombudsman were and were not acted upon.

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Complaints Handling Flow Chart

HMP Whitemoor Process CPFT Process

This policy has been agreed by The Fens Unit Senior Management Team and is operational with immediate effect. Signed………………………………….. Date……………….........

General Application Stage One

Complaint Form / Letter Stage Two

Stage Three

Stage Four

Complaint Letter to CPFT

Complaint Letter to Ombudsman