concerns, complaints and compliments

Version 2.0 March 2019

Concerns, Complaints and Compliments

Target Audience

Who Should Read This Policy

All Trust Staff

Concerns, Complaints and Compliments Policy

Version 2.0 March 2019 2

Ref. Contents Page

1.0 Introduction 4

2.0 Purpose 4

3.0 Objectives 4

4.0 Process 5

4.1 Principles of Good Complaint Handling 5

4.2 Compliments 5

4.3 Comments 5

4.4 Concerns 6

4.5 PALS 6

4.6 Complaints 6

4.7 Investigations 9

4.8 Time Frames 9

4.9 Learning Lessons and Reducing Risks 9

5.0 Procedures connected to this Policy 11

6.0 Links to Relevant Legislation 11

6.1 Links to Relevant National Standards 12

6.2 Links to other Key Policies 14

6.3 References 15

7.0 Roles and Responsibilities for this Policy 16

8.0 Training 19

9.0 Equality Impact Assessment 19

10.0 Data Protection and Freedom of Information 19

11.0 Monitoring this Policy is Working in Practice 20

Appendices

1.0 A Guide to Formal Complaints 22

2.0 A Guide to a Reported Concern 24

3.0 Handling Unreasonable Callers 25

4.0 Effective Management of Vexatious and Habitual Complainants 26

5.0 Vexatious and Habitual Complainant Risk Assessment Form 29

6.0 Vexatious and Habitual Complainant Meeting Panel Review 31

7.0 Investigating Concerns 34

8.0 Treatment of Patients, Relatives and Carers after Raising a Concern 35

9.0 A Guide to Friends and Family Process 36



Explanation of terms used in this policy

Patient Advice and Liaison Service (PALS) - PALS helps improve services by listening to what

matters to service users and their loved ones, and making changes when appropriate

Concern - A concern is an issue requiring advice, support or explanation and usually in regard to

current care. A concern would not normally be considered under Complaint Regulations 2009. If the issue cannot be resolved or it is not possible to have a plan in place to resolve it, within 3 working

days, or the person wishes to make a complaint, the issue should then be managed as a complaint e.g. when a service user, carer or relative has an informal issue that they would like resolved quickly

Complaint - A complaint is an expression of dissatisfaction by an individual or by persons who

require a considered response from the Trust which addresses their concerns and attempts, by all

reasonable means, to resolve them to the point of satisfaction. For example when a service user, carer or relative has a formal issue that they would like investigated and which may take longer than a

concern to resolve

Comment - A comment is an observation made by those in receipt of services to provide feedback to

enable the Trust to measure services, delivery care or patient experience

Compliment - A compliment is an expression of satisfaction about the service e.g. when a service user, carer or relative gives a positive comment about the service or a member of staff

Tell Us How We Did – Trust feedback form for complaints, concerns, comments, compliments, friends & family Test and Patient reported and experience measures (PREM’s).

DATIX - DATIX is an electronic database used to record concerns, complaints and compliments and

any lessons learnt. This integrated system is used to help aggregate complaints incidents and claims used to record any lessons learnt

PEI – Patient Experience and Involvement Team and it offers a confidential and impartial service for service users, carers/external professionals/members of the public to feedback about their experience

about our service

Advocacy Service - Area free, independent and confidential services that helps someone to make a

complaint if they feel they have not had the service they expect from the NHS

Local Involvement Networks (LINks) - LINks is made up of individuals and community groups such as faith groups and residents associations working together to improve health and social care

services

Parliamentary and Health Service Ombudsman - The Ombudsman provides a service to the

public by undertaking independent investigations into complaints that the NHS in England has not acted properly or fairly or has provided a poor service

Decision – the following are resolution outcomes and can be made by Matrons or Clinical Leads or Lead Investigators;

Upheld - If you have been told that your compliant was upheld, it means that the Trust

agrees with you that the service you received did not meet the standard a person/service user/patient could reasonably expect.

Not Upheld - If you are told that your complaint is not upheld, it means that the Trust has

found that the service you/patient/service user received met the standard a person/service

user/patient could reasonably expect to receive. Where there is no evidence to support any allegations made, the complaint is recorded as ‘not upheld’.

Partially Upheld - If a complaint is made regarding more than one issue, and one or more

of these issues are upheld, the complaint is recorded as ‘partially upheld’.



1.0 Introduction Black Country Partnership NHS Foundation Trust is committed to providing a high quality service to all users of its services. Compliments, comments, complaints and concerns are an important aspect of governance, giving valuable feedback and providing information that can help to make improvements to services. Poor complaints handling can make a difficult situation worse for service users and their families and create unnecessary demands on NHS resources. Therefore the Trust is committed to apologising when things go wrong, providing clear and prompt explanations of what has happened and acting upon lessons learnt throughout and post management of the complaint. It is important that service users, carers and relatives receive a good service. However, sometimes things do go wrong. By listening to people about their experiences managers can resolve mistakes faster, learn new ways to improve and prevent the same problems from happening in the future. It is important that there are processes in place by which service users and carers can share their concerns or make a complaint. Service users, carers and relatives may also want to provide positive comments. This policy describes how staff should manage these processes.

2.0 Purpose The purpose of this policy is ensure the Trust has in place arrangements that manages complaints effectively in an open and transparent way and in accordance with regulatory requirements National Health Service Complaints Regulations (2009), mandatory guidance included in the NHS Constitution and best practice guidance as described in Listening, responding and improving: a guide to better customer care (Department of Health, 2009).

3.0 Objectives

To manage concerns, complaints and compliments effectively in an open and transparent way.

To ensure the complaints procedure is open, fair, flexible and conciliatory, encouraging communication on by all parties.

To ensure there is an understanding of the value and benefits of learning from concerns and complaints to improve the quality of services the Trust provides.

To ensure service users, carers and relatives are treated with respect and dignity, and their concerns and complaints are listened to empathy and compassion.

Provide advice and guidance to the complainant and investigation lead in relation to the Trusts process and procedures.

To ensure complaints are appropriately managed, investigated and responded to in a timely manner.

To promote a personal approach that makes it easier for people to tell us what they think about the care and treatment they have received.

To make sure it is easy for people to feedback about their experience of our services via the tell us how we did forms (Inc. FFT) and make sure we can see all feedback for services in order to make changes.

Ensure that all the lessons learnt are communicated to staff and embedded locally.



Ensure local divisional governance processes monitor and report on compliance to action plan, as a result of complaint outcomes

Support staff for the duration of the management of the complaint.

4.0 Process

4.1 Principles of Good Complaint Handling The Health Service Ombudsman, which is responsible for investigating NHS complaints that cannot be resolved locally, has published ‘Principles of Good Complaint Handling.’ The Local Government Ombudsman has also issued guidance. In summary, the six principles of good complaint handling are:

1. Getting it right 2. Being customer focused 3. Being open and accountable 4. Acting fairly and proportionately 5. Putting things right 6. Seeking continuous improvement

4.2 Continuous Improvement The Trust has a deep commitment to improving quality. Every team is actively engaged in continuous quality improvement as defined by the people who use their services. They do this through the team Quality Boards. These boards are updated quarterly and contain the number of complaints and compliments received by each team. Teams all have access to the Patient Experience data relating to this policy for their teams via the Datix dashboard. The Patient Experience Quality Board dashboard contains all the complaints, concerns, comments and compliments received by each team. This enables teams to plan improvements based on the feedback they are getting.

4.3 Compliments Compliments provide important information about highlighting aspects of care that people have found invaluable. We share any good practice highlighted within any of our service areas to help improve working practices across the organisation. Compliments can be made, verbally or in writing, to either the individual(s) concerned, to the manager of the service, via the ‘Tell Us How We Did’ feedback form, directly onto Datix via the intranet or to the Patient Experience team. All compliments should be logged on Datix: Once logged on Datix, an anonymised copy of the compliment can also be sent to the Communications Department for inclusion in the Trust's e-bulletin or promotional material as appropriate.

4.4 Comments Service user and carer feedback about the services provided is essential to the organisation. Capturing and understanding service user and carer perspectives is very important for the Trust because acting on comments helps to ensure services are continually improving and tailored to provide a positive experience for all service users.

Comments are captured in various ways such as:

Localised service user surveys, questionnaires or focus groups

National Service User Surveys



PALS

Self-help/ self-support groups

Partners and intermediaries e.g. advocacy services, ICAS, Citizens Advice Bureau

Tell Us How We Did When a comment is received about the service or a member of staff, a copy should be sent to Patient Experience team to record. These are collated and reported on a monthly basis via the divisional Quality and Safety reports.

4.5 Concerns The majority of concerns can be, and are, resolved at local and operational level. Due to the responsiveness and explanation of effective staff teams concerns are resolved quickly at a local level. Concerns can be made either verbally or in writing to the individual(s) concerned, via the Tell Us How We Did leaflet or to the manager of the service area. All concerns should be reported to the Patient Experience Team. The member of staff or service receiving the concern would be expected to respond quickly and positively to the concerns with a view to resolution at local level. The Trust aims to resolve all concerns within 3 working days or longer with the agreement from the person raising the concern at the onset.

4.6 PALS All members of staff are obliged to listen and respond to service users, carers and relatives sometimes, they may wish to talk to someone independent of that service. PALs services are available via the Patient Experience Team. PALS was introduced by the Trust to ensure that someone listens to service users, carers and relatives and answers their questions and resolve their concerns as quickly as possible. Just as with complaints, the Trust treats concerns raised within PALS as an opportunity to learn and improve the quality of services it provides. PALS provides information, help with health-related enquires, resolves concerns or problems related to NHS care, sign-posts users to other agencies or support groups, provides information about the complaints service and how to get independent help if someone wants to make a formal complaint. Any concerns raised via PALS that are not resolved, or that there is not a plan in place to resolve will be revisited with the person raising the concerns to consider escalation to a concern or formal complaint by the complaints team.

4.7 Complaints We welcome complaints and/ or constructive criticism as they often provide an opportunity to do something different in the future and improve our services for other users. Complaints may be made in writing or verbally to the individual(s) concerned, via the Tell Us How We Did leaflet, to the manager of the service or to the Patient Experience Team.



The Patient Experience team is available from 9.00am to 5.00pm from Monday to Friday. Outside of these hours callers can leave a message on the answering machine, and a member of the Patient Experience Team will return the call within one working day. When a complaint is received a file is created that contains all notes, correspondence and actions related to the complaint, these are also recorded electronically on DATIX. The Trust will prepare data and analysis of complaints as required by internal and external stakeholders at a frequency agreed within these reporting frameworks. In line with the Parliamentary and Health Service Ombudsman’s Principles of Good Complaints Handling (2009), My Expectations (2014) and the NHS Constitution which includes a number of patient rights relating to complaints. In summary, these include patients’ rights to:

Have their complaint acknowledged and properly investigated.

Discuss the manner in which the complaint is to be handled and know the period in which the complaint response is likely to be sent.

To be kept informed of the progress and to know the outcome including an explanation of the conclusions and confirmation that any action needed has been taken on.

Take a complaint about data protection breaches to the independent Information Commissioners Office (ICO) if not satisfied with the way the NHS has dealt with this.

The complaint response prepared by the investigator must include:

An explanation of how the complaint has been considered.

An apology if appropriate

An explanation based on facts.

Whether the complaint is in full or in part upheld. The conclusions reached in relation to the complaint including any remedial action that the organisation considers to be appropriate:

Confirmation that the organisation is satisfied any action has been or will be actioned.

Where possible, we will respond to people about any lessons learnt.

Information and contact details of the Parliamentary and Health Service Ombudsman as the next stage of the NHS complaints process.

4.7.1 Complainants The Trust is satisfied that it is reasonable for a representative of a child, rather than the child, to pursue a complaint on their behalf.

Other complainants could be:

Persons who are using or have used services provided by the Trust

Representatives of persons (as defined above) at the request of such persons or where:

o The person has died o The person is a child (under the age of 16) o The person is physically unable to make the complaint themselves



- The person lacks capacity as defined within the Mental Capacity Act 2005

- Persons affected, or likely to be affected by any action, omission or decision made by the Trust

The Trust will not consider complaints when it is satisfied that the representative is not pursuing the complaint in the best interest of the person he/ she is representing

where consent has not been received from the patient for the complainant to pursue the complaint on their behalf (where relevant). Any concerns when attaining ‘consent’ from the affected individual or during the investigation process must be reported to the complaint manager to consider escalation if individuals suspect the complaint is being given under duress. 4.7.2 Complaints not Covered by this Policy Complaints not covered by this policy include those raised by/ in the following circumstances:

Local Authority NHS body, a primary care or independent provider, except where such an organisation originally received a complaint (after 1st April 2009), that it believed should be handled by this Trust.

Complaints made verbally and resolved to the complainants satisfaction within three working days of the complaint being made, or longer if agreed with the complainant at the onset.

Complaints previously dealt with, either locally within the Trust or by the Healthcare Commission or the Parliamentary and Health Service Ombudsman or the Local Government Ombudsman.

Complaints by employees, or secondees about their terms of employment or secondment.

Complaints of alleged failures of the Trust to comply with Freedom of Information Act 2000 requests.

Complaints relating to pension schemes established under the Superannuation Act 1972.

4.7.3 Complaints and Disciplinary Procedures Where it becomes apparent that there may be a need to undertake a disciplinary investigation, then the investigating officer must inform the HR Department in accordance with the Disciplinary Policy. The investigation of the complaint however, should continue as normal and the final response should be mindful of staff confidentiality. Members of staff who become involved in allegations of negligence or are involved in the complaints process can find it stressful and traumatic. Therefore, it is important that staff are supported, please refer to Supporting Staff Involved in an Incident, Complaint or Claim Policy for more information and guidance and counselling is offered by their line manager via Staff Support Services. 4.7.4 Joint Complaints It is sometimes the case that a complaint received by the Trust may relate to care or intervention provided by another organisation and vice versa.

In such cases the Trust will agree with the relevant other body who will lead the management and co-ordination of the complaint.



The Trust will also discuss how the complainant wishes to receive the response i.e. in one joint combined letter of response or separate from each provider referenced in their complaint.

Where this Trust leads the process, it shall be in accordance with this policy. Where another body leads the process, it shall be in accordance with the policy of that organisation. Please refer to Appendix 1 - A Guide to Formal Complaints, which explains the formal process and Appendix 2 - A Guide to a Reported Concern 4.7.5 Handling Unreasonable Callers Despite best efforts to resolve a concern the person making it may become aggressive or unreasonable. The Department of Health offers clear guidance on how to handle unreasonable callers. See Appendix 3 - Handling Unreasonable Callers. 4.7.6 Unreasonable and Persistent Complainants Persistent complainants represent a significant drain on the resources of the organisation and can be demoralising for staff. See Appendix 4 - Effective Management of Vexatious and Habitual Complainants/ Appendix 5 - Vexatious and Habitual Complainant Risk Assessment Form/ Appendix 6 - Vexatious and Habitual Complainant Meeting Panel Review

4.8 Investigations It is vital to establish the facts about what happened in a systematic way. The person investigating the concerns should be able to be independent enough to collect and examine evidence, find any lessons learnt and prepare a response. See Appendix 7 – Investigating Concerns and refer to Investigation of Incidents, Complaints and Claims Policy.

4.9 Time Frames Concerns and complaints will only generally be dealt with if they are received no later than 12 months after the actual date of the matter or date on which the matter came to the attention of the service user, carer or relative.

A longer time limit may be allowed where the Trust considers it reasonably justified and where it believes it can handle the concern or complaint effectively and fairly.

There are key time limits when handling complaints, which are outlined below:

Complaints must be acknowledged within 3 working days of its receipt, and may be made either verbally or in writing only

Final responses should be prepared and sent to the complainant within 6weeks after a final complaint plan is agreed. For more complex cases or as agreed with the complainant, a date later than 6 weeks can be agreed but no later than 6months.

4.10 Learning Lessons and Reducing Risks The identification of lessons learned, reduction of risks, improvement and development is dependent on the findings, accuracy and timeliness of the investigation and as such it is imperative that robust investigations are undertaken by the identified leads and reports and responses are accurate.



When a concern is raised regarding a service area, the Patient Experience Team will liaise with the Service Manager/ Team Leader, to gather a response. This response may involve comments about improving that particular area. These issues should be discussed in team meetings, and where relevant improvements made.

Following the completed complaint investigation and where improvements / recommendations are identified, an action plan will be developed in agreement with the relevant services involved (some complaints may involve a number of different specialties). The complaint lead is responsible for ensuring the action plan is devised, timescales and leads assigned to each action, actions are uploaded to Datix, progress monitoring, review and implementation of actions is monitored at the relevant divisional meetings. Oversight for monitoring will be undertaken by the Service Managers and Matrons. Upon completion of a complaints investigation, or where the result of a concern/ comment has improved that particular service area, the Patient Experience Team will provide monthly status reports to the division for inclusion in the respective Quality & Safety Reports. Improvements to current practice may include, for example:

Policy review

Review of training analysis needs

Improving the methods used to communicate to staff, service users

Improving the arrangements for joint working with partners

Review of staffing and skills mix

Creation of new post or review or re-allocation of duties to staff in post

Introduction of new procedures, SOPs

Better consultation and involvement of stakeholders

Greater emphasis on planning earlier/more effectively

Review of multi-disciplinary working practices

Introduction of, or increase in the frequency of audits

Review relevant data differently or more frequently

In order to monitor the effectiveness of the complaint department, the Trust will require the following data to be collected which, as a minimum, will identify;

The number of informal enquiries received

The number of complaints received

The number of complaints upheld

The subject of those complaints

The outcome of the complaints investigation i.e. upheld/not upheld

The learning and improvement actions taken as a result of complaints

The number of responses within agreed timescales

The number of complaints referred to the Parliamentary and Health Service Ombudsman



5.0 Procedures connected to this Policy There are no Standard Operating Procedures linked to this policy.

6.0 Links to Relevant Legislation Human Rights Act 1998 One of the main laws protecting human rights in the UK, it contains a list of 16 rights (called articles) which belong to all people in the UK, and outlines several ways that these rights should be protected. These rights are drawn from the European Convention on Human Rights, which were developed by the UK and others in the aftermath of World War II. The Human Rights Act may be used by every person resident in the United Kingdom regardless of whether or not they are a British citizen or a foreign national, a child or an adult, a prisoner or a member of the public. The Human Rights Act has two main aims, to promote a ‘culture of human rights’ by making sure that basic human rights underpin the workings of government at the national and local level and enabling access to human rights here at home, instead of only being able to go to the European Court of Human Rights It does this by placing a legal duty on all public authorities, including NHS organisations and staff and mental health tribunals carrying out public functions, to respect and protect human rights in everything that they do. This means that public authorities have legal responsibilities for respecting, protecting and fulfilling human rights. This duty is important in everyday situations because it enables individuals to challenge poor treatment and to negotiate better solutions. Data Protection Act 2018

The Data Protection Act 2018 became law on the 23rd May 2018. It sets standards that must be satisfied when obtaining, recording, holding, using or disposing of personal data.

The Act is implemented in seven parts.

This Act makes provision about the processing of personal data.

Most processing of personal data is subject to the GDPR.

Part 2 supplements the GDPR and applies a broadly equivalent regime to certain types of processing to which the GDPR does not apply

Part 3 makes provision about the processing of personal data by competent authorities for law enforcement purposes and implements the Law Enforcement Directive.

Part 4 makes provision about the processing of personal data by the intelligence services.

Part 5 makes provision about the Information Commissioner.

Part 6 makes provision about the enforcement of the data protection legislation.

Part 7 makes supplementary provision, including provision about the application of this Act to the Crown and to Parliament.

The Act introduces new offences that include knowingly or recklessly obtaining or disclosing personal data without the consent of the data controller, procuring such



disclosure, or retaining the data obtained without consent. Selling, or offering to sell, personal data knowingly or recklessly obtained or disclosed would also be an offence,

Essentially, the Act implements the EU Law Enforcement Directive, it implements those parts of the GDPR which 'are to be determined by Member State law' and it creates a framework similar to the GDPR for the processing of personal data which is outs Freedom of Information Act 2000 This Act provides public access to information held by public authorities. It does this in two ways, public authorities are obliged to publish certain information about their activities and members of the public are entitled to request information from public authorities. The main principle behind freedom of information legislation is that people have a right to know about the activities of public authorities, unless there is a good reason for them not to. This is sometimes described as a presumption or assumption in favour of disclosure. The Act does not give people access to their own personal data (information about themselves) such as their health records. If a member of the public wants to see information that a public authority holds about them, they should make a subject access request under the Data Protection Act 1998. Health and Social Care Act 2012 The Health and Social Care Act introduces a number of key changes to the NHS in England. These changes came into being on 1 April 2013. The changes include:

Giving groups of GP practices and other professionals – clinical commissioning groups (CCGs) – 'real' budgets to buy care on behalf of their local communities

Shifting many of the responsibilities historically located in the Department of Health to a new, politically independent NHS Commissioning Board (this has now been renamed NHS England)

The creation of a health specific economic regulator (Monitor) with a mandate to guard against 'anti-competitive' practices

Moving all NHS trusts to foundation trust status

1.1 Links to Relevant National Standards

CQC Regulation 10: Respect and Dignity The intention of this regulation is to make sure that people using the service are treated with respect and dignity at all times while they are receiving care and treatment. To meet this regulation, providers must make sure that they provide care and treatment in a way that ensures people's dignity and treats them with respect at all times. This includes making sure that people have privacy when they need and want it, treating them as equals and providing any support they might need to be autonomous, independent and involved in their local community.



Providers must have due regard to the protected characteristics as defined in the Equality Act 2010. CQC Regulation 13: Safeguarding Service Users from Abuse and Improper Treatment The intention of this regulation is to safeguard people who use services from suffering any form of abuse or improper treatment while receiving care and treatment. Improper treatment includes discrimination or unlawful restraint, which includes inappropriate deprivation of liberty under the terms of the Mental Capacity Act 2005. To meet the requirements of this regulation, providers must have a zero tolerance approach to abuse, unlawful discrimination and restraint. This includes:

Neglect

Subjecting people to degrading treatment

Unnecessary or disproportionate restraint

Deprivation of liberty Providers must have robust procedures and processes to prevent people using the service from being abused by staff or other people they may have contact with when using the service, including visitors. Abuse and improper treatment includes care or treatment that is degrading for people and care or treatment that significantly disregards their needs or that involves inappropriate recourse to restraint. For these purposes, 'restraint' includes the use or threat of force, and physical, chemical or mechanical methods of restricting liberty to overcome a person's resistance to the treatment in question. Where any form of abuse is suspected, occurs, is discovered, or reported by a third party, the provider must take appropriate action without delay. The action they must take includes investigation and/or referral to the appropriate body. This applies whether the third party reporting an occurrence is internal or external to the provider. CQC Regulation 16: Receiving and Acting on Complaints The intention of this regulation is to make sure that people can make a complaint about their care and treatment. To meet this, regulation providers must have an effective and accessible system for identifying, receiving, handling and responding to complaints from people using the service, people acting on their behalf or other stakeholders. All complaints must be investigated thoroughly and any necessary action taken where failures have been identified. When requested to do so, providers must provide CQC with a summary of complaints, responses and other related correspondence or information. CQC Regulation 17: Good Governance The intention of this regulation is to make sure that providers have systems and processes that ensure that they are able to meet other requirements in this part of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (Regulations 4 to 20A). To meet this regulation; providers must have effective governance, including assurance and auditing systems or processes. These must assess, monitor and drive improvement in the quality and safety of the services



provided, including the quality of the experience for people using the service. The systems and processes must also assess, monitor and mitigate any risks relating the health, safety and welfare of people using services and others. Providers must continually evaluate and seek to improve their governance and auditing practice. In addition, providers must securely maintain accurate, complete and detailed records in respect of each person using the service and records relating the employment of staff and the overall management of the regulated activity. As part of their governance, providers must seek and act on feedback from people using the service, those acting on their behalf, staff and other stakeholders, so that they can continually evaluate the service and drive improvement. When requested, providers must provide a written report to CQC setting out how they assess, monitor, and where required, improve the quality and safety of their services. CQC Regulation 19: Fit and Proper Persons Employed The intention of this regulation is to make sure that providers only employ 'fit and proper' staffs who are able to provide care and treatment appropriate to their role and to enable them to provide the regulated activity. To meet this regulation, providers must operate robust recruitment procedures, including undertaking any relevant checks. They must have a procedure for ongoing monitoring of staff to make sure they remain able to meet the requirements, and they must have appropriate arrangements in place to deal with staffs who are no longer fit to carry out the duties required of them. Employing unfit people, or continuing to allow unfit people to stay in a role, may lead CQC to question the fitness of a provider. If CQC considers that a breach of this regulation is also be a breach of another regulation(s) that carries offence clauses, then we can move directly to prosecution without serving a Warning Notice. For example, in situations where the care and treatment is provided without the consent of a person using the service or someone lawfully acting on their behalf, and where it is unsafe, does not meet the person's nutritional needs, results in abuse, or puts the person at risk of abuse. CQC Regulation 20: Duty of Candour The intention of this regulation is to ensure that providers are open and transparent with people who use services and other 'relevant persons' (people acting lawfully on their behalf) in general in relation to care and treatment. It also sets out some specific requirements that providers must follow when things go wrong with care and treatment, including informing people about the incident, providing reasonable support, providing truthful information and an apology when things go wrong. The regulation applies to registered persons when they are carrying on a regulated activity.

6.2 Links to other Key Policies

Incident Reporting Policy The purpose of this policy is to make clear the system used for reporting incidents involving patients, staff and others undertaking activities on behalf of the Trust.



Being Open and Duty of Candour Policy The purpose of this policy is to explain the meaning of Being Open and Duty of Candour in practice by providing clear information to staff to enable them to have the confidence to communicate and act appropriately with patients, their families and carers when things go wrong. Safeguarding Adults at Risk and Safeguarding Children Policies Black Country Partnership Foundation Trust has a duty to safeguard adults and children from abuse. The Purpose of this policy is to provide guidance for staff to assist them in identifying adults and children at risk and recognising abuse. The Policy applies to all staff employed by the Trust including students and volunteers and will provide information regarding their duties and responsibilities in relation to responding to any concerns. Raising Concerns at Work (Whistleblowing) Policy The purpose of this policy is to provide staff with clear guidance on the Trust’s commitment to ensure that fair and non-discriminatory systems are in place for staff to raise concerns under this policy. Claims Management Policy The purpose of this policy is to provide guidance to both managerial and clinical staff on the Trust’s procedure for handling clinical negligence and personal injury litigation in accordance with NHSLA requirements and relevant legislation.

Also relates links to: Records Management Policy Analysis and Improvement of Incidents, Complaints and Claims Policy Investigating Incidents, Complaints and Claims Policy Supporting Staff Involved in an Incident, Complaint or Claim Policy Stress Management Policy Disciplinary Policy

6.3 References

Listening, Responding, Improving - A guide to better customer care Department of Health (2009)

Tackling Concerns Locally Department of Health (2009)

Feeding Back: Learning from complaints handling in health and social care National Audit Office (2008)

Principles for Remedy Parliamentary and Health Service Ombudsman (2009)

Principles of Good Complaint Handling Parliamentary and Health Service Ombudsman (2009)

The Local Authority Social Services and National Health Service Complaints (England) Regulations 2009

NHS Resolution Risk Management Standards 2013-14



7.0 Roles and Responsibilities for this Policy

Title Role Key Responsibilities

All staff Adherence - Listen and respond to service users, their carers and relatives to the best of their abilities. All staff have a responsibility to act openly and honestly and treat service users, carers and relatives with dignity and respect

- Resolve concerns locally, quickly and effectively. Staff should do everything possible to resolve enquiries and concerns at local level ensuring that those who raise them receive prompt and accurate information

- Ensure that service users and their carers are provided with appropriate information about PALS and the complaints

process, including leaflets and posters being accessible and well displayed at all times - Ensure the complaint is referred to the PEI team as quickly as possible after receipt when a matter becomes a complaint

- Co-operate fully when trying to help resolve an issue or enquiry for a service user, carer or relative - Do not discriminate, reprimand or treat any one differently in their care for raising a concern or complaint, to do so is in

breach of this policy and may result in disciplinary action

Patient safety / complaints manager

supported by Complaint Lead

Operational - Develop and manage procedures relevant to this policy - Ensure that those making complaints are not treated any differently as a result of raising their concerns

- Provide literature in different formats when necessary to meet the needs of the individual and provide interpreters as necessary

- Ensure that leaflets, posters clearly state that complainants will not be discriminated against and should they feel this is the

case to report it to the PEI team immediately - Ensure suitable and accessible information is provided and made easily available so that service users, carers and relatives

know how to access the complaints procedures - Work with LINks to establish contacts with less accessible groups within the local community

- Provide information about independent advocacy services or ICAS to callers as appropriate

- Monitor the overall implementation of this policy ensuring there is open communication between healthcare professionals, organisations, healthcare teams, staff, service users, carers and relatives

- Assist staff members, as appropriate, towards the objective of giving an effective and timely response to all complaints - Provide advice and assistance to staff in dealing with concerns, complaints and compliments

- Provide data and information to the relevant groups to assist those groups in the monitoring and of complaints received - Contribute to the analysis of data

- Advise managers on the process of investigation

- Provide 1:1 support to all investigators and support divisional training schedules to ensure a high level of competency across allocated investigators




Matrons / Service Managers/ Professional

Leads/ Team Managers/ Leaders

Operational - Ensure this policy is bought to the attention of all staff within their areas of responsibility and implemented by staff - Agree the process of investigation and prepare a formal response within the agreed timescales

- Ensure those who raise complaints, compliments or concerns are not treated differently or discriminated against as a result of raising the issues

- Ensure suitable and accessible information is available so that service users, carers and relatives know how to access the

process for raising concerns, complaints and compliments - Assist PALS in resolving concerns about current care quickly

- Ensure a thorough and timely investigation is undertaken in relation to all complaints received and, where necessary, the introduction of measures to improve local delivery/quality of services

- Ensure they attend meetings with complainants to agree the issues of concern and desired outcomes in relation to the

resolution of complaint - Ensure a clear and detailed reply is provided in response to complaints made to the Patient Experience and Involvement

Team as soon as possible within the agreed timescales - Ensure progress made against recommendations is monitored at local level

- Liaise with the Patient Experience and Involvement Team in a timely manner, providing timely clear information necessary to respond to complaints effectively

- Provide staff with information on how to access Staff Support Services and their rights to staff side representation as

appropriate in addition to normal support from the Patient Experience and Involvement Team and managers. Staff involved in a complaint may find it stressful and difficult to handle

Heads of Nursing,

divisional Directors and clinical directors

Implementation - Ensure all managers are aware of the policy and promote good practice

- Provide support, guidance and resources to enable this policy to be implemented - Ensure Divisional Lesson Learnt Bulletin encompasses the outcome/lessons learnt from complaints

Head of governance Implementation Lead - Ensure that concerns and complaints are used to inform risk management and claims management processes

Heads of nursing,

Divisional and Clinical Directors

Responsible - Management of concerns and complaints within their Group

- Lead discussions on issues arising from concerns and complaints within their Group at Group Quality and Safety Steering Group meetings

- Oversee the completion of audits on issues arising from concerns and complaints - Provide updates on the management of concerns and complaints within their Group to the Quality and Safety Steering

Group

Divisional Quality and Safety Groups

Monitoring - Divisional Governance leads will receive information on concerns and complaints on a monthly basis for discussion at their meetings identifying any themes or emerging patterns for Group learning arising from within their Group. Membership is

representative of the Group as a whole multi-disciplinary in nature, with a mix of representatives from each of the service

areas, professional leads, practice development professionals and representatives from clinical sub-groups - Receive the results and recommendations of all completed clinical audits on issues arising from concerns and complaints

within their Group

Quality and Safety

Steering Group

Monitoring,

Scrutiny and

Performance

- Oversee the implementation of a systematic and consistent approach to the management of concerns and complaints

- Provide exception and progress reports to the Quality and Safety Committee




Quality and Safety Committee

Scrutiny and Performance

- Ensure that concerns and complaints are managed efficiently and effectively in accordance with the Board’s Assurance Framework and the primary objective to provide high quality safe care

Trust Board Strategic - Strategic overview and final responsibility for overseeing the management of concerns and complaints in the Trust in

accordance with its primary objective to provide high quality safe care

Executive Director of

Nursing, AHPs and Governance

Executive Lead - Ensure the Trust’s concerns, complaints and compliments policy is discharged appropriately and has lead responsibility for

the implementation of this policy - Trust strategic direction for this policy

- Lead on strategies and innovations to reduce the number of concerns and complaints occurring within the Trust - Ensure that any serious concerns regarding the implementation of this policy are brought to the attention of the Board

Executive Director Accountable - Provide assurance that this policy has been implemented within the Trust - operational responsibility has been delegated to

Executive Director of Nursing, AHPs and Governance - Oversee the management and monitoring of Concerns, Complaints and Compliments

- Establish and maintain an effective strategy management of Concerns, Complaints and Compliments



8.0 Training An overview of the complaints process and SPEI is offered to all new members of staff as part of the induction process. All staff who are requested to carry out complaint investigations, as identified by their Line Manager, are required to attend Investigating Complaints Process Training provided by PEI on a quarterly basis.

What aspect(s)

of this policy will require staff

training?

Which staff groups require this

training?

Is this training covered in the Trust’s Mandatory and Risk

Management Training Needs Analysis document?

If no, how will the training be delivered?

Who will deliver the training?

How often will staff require

training

Who will ensure and monitor that staff have

this training?

Investigation of

Incidents,

Complaints

Staff/ roles

identified as

requiring this training from

appraisal or via the annual Training

Needs Analysis process

Yes Learning and

Development Team

or Patient Experience Team

One off Workforce Committee

9.0 Equality Impact Assessment Black Country Partnership NHS Foundation Trust is committed to ensuring that the way we provide services and the way we recruit and treat staff reflects individual needs, promotes equality and does not discriminate unfairly against any particular individual or group. The Equality Impact Assessment for this policy has been completed and is readily available on the Intranet. If you require this in a different format e.g. larger print, Braille, different languages or audio tape, please contact the Equality & Diversity Team on Ext. 8067 or email [email protected] 10.0 Data Protection and Freedom of Information

Data Protection Act provides controls for the way information is handled and to gives legal rights to individuals in relation to the use of their data. It sets out strict rules for people who use or store data about individuals and gives rights to those people whose data has been collected. The law applies to all personal data held including electronic and manual records. The Information Commissioner’s Office has powers to enforce the Data Protection Act and can do this through the use of compulsory audits, warrants, notices and monetary penalties which can be up to €20million or 4% of the Trusts annual turnover for serious breaches of the Data Protection Act. In addition to this the Information Commissioner can limit or stop data processing activities where there has been a serious breach of the Act and there remains a risk to the data. The Freedom of Information Act provides public access to information held by public authorities. The main principle behind freedom of information legislation is that people have a right to know about the activities of public authorities; unless there is a good reason for them not to. The Freedom of Information Act applies to corporate data and personal data generally cannot be released under this Act.

mailto:[email protected]

http://simple.wikipedia.org/wiki/Information

http://simple.wiktionary.org/wiki/right



All staffs have a responsibility to ensure that they do not disclose information about the Trust’s activities; this includes information about service users in its care, staff members and corporate documentation to unauthorised individuals. This responsibility applies whether you are currently employed or after your employment ends and in certain aspects of your personal life e.g. use of social networking sites etc. The Trust seeks to ensure a high level of transparency in all its business activities but reserves the right not to disclose information where relevant legislation applies. The Information Governance Team provides a central point for release of information under Data Protection and Freedom of Information following formal requests for information; any queries about the disclosure of information can be forwarded to the Information Governance Team.

11.0 Monitoring this Policy is Working in Practice

What key elements will be monitored?

(measurable policy objectives)

Where described in

policy?

How will they be monitored?

(method + sample size)

Who will undertake this

monitoring?

How

Frequently?

Group/Committee that will receive and

review results

Group/Committee to ensure actions

are completed

Evidence this has

happened

All complaints will be

acknowledged with the complainant within 3

working days

All compliant responses will

be sent to the complainant within the agreed

timeframes but no longer

that 6 months, unless agreed with the complainant

4.8 Timeframes

Monitoring of all concerns and

complaints

Patient Experience Team

weekly

Weekly incident

report and sharing of Patient Experience

Tracker

Quality and Safety Steering Group and

Divisional Quality and Safety Groups

Minutes of meetings and

monitoring templates

In addition, the

Governance Assurance Unit provides quarterly

feedback to the

Quality and Safety Steering Group and

Quality and Safety Committee to

triangulate how well

concerns and complaints are being

managed within the Trust

Governance

Assurance Unit

Quarterly



What key elements will be

monitored? (measurable policy objectives)

Where

described in policy?

How will they be

monitored? (method + sample size)

Who will

undertake this monitoring?

How

Frequently?

Group/Committee

that will receive and review results

Group/Committee

to ensure actions are completed

Evidence

this has happened

How the organisation listens and responds to concerns

and complaints from patients, their relatives and

carers

4.9 Learning Lessons and

Reducing Risks

As above and Thematic review of all

complaints

Nominated Complaints lead -

Non-Executive Director of the

Board

6 Monthly/ Annually or

more frequently if

circumstances

require this

Quality and Safety Committee/ Trust

Board

Quality and Safety Committee



How joint complaints are

handled between

organisations

4.6.4 Joint

Complaints/ 4.9

Learning Lessons and

Reducing Risks

6 monthly/ Annual

review of complaints concerns and

compliments process

Nominated

Complaints lead -

Non-Executive Director of the

Board

6 monthly/

Annually or

more frequently if

circumstances require this

Quality and Safety

Committee/ Trust

Board

Quality and Safety

Committee

Minutes of

meetings and


How the organisation makes

sure that patients, their relatives and carers are not

treated differently as a result of raising a concern or

complaint

4.9 Learning

Lessons and Reducing Risks

6 monthly/ Annual

review of complaints concerns and

compliments process

Nominated

Complaints lead - Non-Executive

Director of the Board

6

monthly/Annually or more

frequently if circumstances

require this

Quality and Safety

Committee/ Trust Board

Quality and Safety

Committee

Minutes of

meetings and monitoring

templates

How the organisation makes improvements as a result of

a concern or complaint

4.9 Learning Lessons and

Reducing Risks

Review findings and recommendations of

each report or audit

reviewing issues arising from concerns

and complaints reported through each

divisional Quality and Safety report

Group Quality and Safety Steering

Groups

As and when required

Quality and Safety Steering Group

Quality and Safety Steering Group


monitoring

templates


Appendix 1

A Guide to Formal Complaints and Escalation Framework

How is the complaint completed and progress monitored?

The lead investigator should review the complaint plan, make contact with the complainant to introduce themselves discuss /agree the level of engagement throughout the investigation process. This should include the offer to meet at various stages of the investigation process.

The lead investigator completes the investigation within the timescale as agreed by the complainant, or by no later than 6 weeks following allocation and submission of a final complaint plan.

PEI will liaise with the investigator to assess progress on a fortnightly basis.

The lead investigator drafts the response letter including details of the investigations and sends to Head of Nursing or allocated Matron for approval.

Head of Nursing or allocated Matron approves complaint and forwards to PEI for review

PEI will submit to Chief Executive to sign and informs the lead investigator once a final review within GAU and Divisional Director. (Copy uploaded to Datix and Divisional Governance Teams informed)

Final complaint response sent to complainant unless they have requested feedback meeting

Timeline for Response: 6 weeks internal deadline from receipt of approved complaint plan If complaint is high level the deadline may be extended with agreement with your Head of Nursing, Divisional Director or Clinical Director.

How is the complaint initiated?

PEI will acknowledge the complaint within 3 working days.

PEI will liaise with complainant via various means and obtain an agreed complaint plan. This should be finalised within 2 weeks of initial contact or sooner unless agreed with the complainant.

The complaint will be allocated by Division to a lead investigator- this must be confirmed 5 days after the request for allocation is made.



Escalation:

A Divisional complaint summary will be sent to senior staff each week.

Failure to provide a draft response to a complaint investigation will be escalated to Divisional Director, Head of Nursing and Clinical Director immediately prior to the 6 week deadline.

Executives will be notified of all complaint responses that have not been submitted 3 months after allocation.

Reporting on complaints and

Monthly Divisional Quality and Safety Reports with actions and lessons learnt.

Weekly summary of active complaints to senior divisional leads

Complaints data is in the Clinical Dashboard, which is shared with the Board of Directors and Clinical Commissioning Groups

Patient Experience and Involvement Annual Report

What should happen during complaint meetings?

Listen to the complainant

Discuss how the complaint has/is being managed i.e. process

Present investigation findings and discuss with complainant

Answer /explain what happens next (implementation action plan)

Give complainant copy of response letter



Appendix 2

A Guide to a Reported Concern

What if a service user, carer or relative wants to raise a concern? Patient Experience Team (PEI) coordinate, record and report on concerns. If you receive : A concern is an informal issue that can be resolved locally within 3 working days of the Trust being notified or longer if agreed with the complainant at the onset

Verbal concern – Inform PEI team how this is going to be managed locally Free phone 0800 587 7720 or 0121 612 8165 for advice.

Written concern - forward the email to [email protected] or send the letter in internal post to PEI Team, Delta House. Identifying how this is going to be managed locally.

PEI Team coordinates the concerns in accordance with the complaints policy:

Register concern

Contact the Head of Nursing or identified matron/service lead (copy to divisional Group Director, clinical director to inform them of the concerns raised and if known how it is going to be managed locally. If not known ascertain who will speak to complainant.

If concern is not resolved within 3 working days or longer if agreed with the complainant at the onset

the PEI team will consider registering this as a formal complaint (see formal complaint guide)

What do I do if I’m requested to investigate?

Contact complainant to discuss complaint and ascertain if issues reported can be resolved immediately

Confirm complainant is happy for it to be resolved locally Gathering information. Speak to staff if involved. Report finding back to complainant If complainant is happy with outcome document in notes and inform the

PEI team it has been resolved so the outcome can be recorded on Datix.



Appendix 3

Handling Unreasonable Callers

Despite your best efforts to resolve a concern the person making it can become aggressive or unreasonable. It is important to know how to handle circumstances such as these. There are a number of ways to help manage the situation:

Make sure contact is being overseen by a manager at an appropriate level in the organisation

Provide a single point of contact with an appropriate member of staff and make it clear to the complainant that other members of staff will be unable to help them

Ask that they contact you only in one way, appropriate to their needs (such as by phone)

Place a time limit on any contact with the complainant

Restrict the number of calls or meetings you will have with them during a set period

Ensure that any contact involves a witness

Refuse to register repeated complaints about the same issue

Only acknowledge correspondence you receive about a matter that has already been closed

Explain that you do not respond to correspondence that is abusive

Make contact through a third person such as a specialist advocate

Ask the complainant to agree how they will behave when dealing with your service in the future

Return any irrelevant documentation and remind them that it will not be returned again

When using any of these approaches to manage contact with unreasonable or aggressive people, it is important to explain what you are doing and why, and to keep a detailed record of the ongoing relationship. Reference: Department of Health - Listening, Responding, Improving: A guide to better customer care

http://webarchive.nationalarchives.gov.uk/20130107105354/http:/www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_095439.pdf

http://webarchive.nationalarchives.gov.uk/20130107105354/http:/www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_095439.pdf



Appendix 4

Effective Management of Vexatious and Habitual Complainants

Introduction Vexatious and habitual complainants represent a significant drain on the resources of the department and can be demoralising for staff. These guidelines exist to assist in management of such complainants, thus releasing valuable resources.

Purpose These guidelines should only be considered after all reasonable measures have been taken to resolve complaints in accordance with Trust Procedures. The integrity of the Trust Complaint Procedures should be maintained at all times.

Definitions A complainant (and / or anyone acting on their behalf) may be deemed to be a continual or vexatious complainant where previous or current contact with them shows that they meet two more of the following criteria:

Is in frequent contact with the complaints department. They make contact every day, and in some cases, more frequently, either by telephone or by physically calling into the department

Persist in the pursuing a complaint where the NHS complaints procedure has been fully and properly implemented and exhausted

The substance of an ongoing complaint is changed or new issues are raised in an effort to prolong contact following a final letter of response

Challenges written documentation by claiming that the records have been altered

Complainant does not clearly identify the precise issues they wish to be investigated despite all reasonable efforts being made to assist in this process, using Trust customer services staff and / or external advocacy services

Receives a response and immediately responds by either raising new concerns, or presenting an old problem in a different way

Any form of violence has been used or threatened towards staff, their families or associates; this includes verbal aggression, homophobic, racist or sexist

Complainant has had an excessive number of contacts with the Trust in pursuance of a registered complaint thus placing unreasonable demands upon staff.

Complainant is known to have electronically recorded meetings or discussions without the prior consent of the other parties involved.

Complainant has made defamatory comments to the press about staff.

Seeks an unrealistic outcome and displays unreasonable demands and intends to continue until that outcome is achieved. Examples could include wanting to have a member of staff dismissed.

Tries to manipulate the complaint by:

Complaining about the member of staff dealing with the complaint

Dictating who they will and will not speak to e.g. wanting to speak directly to the Chair of the Trust, or the Chief Executive.



Stating they wish to meet with a person, and then either refusing to arrange a date, or not turn up after the meeting has been arranged

Making the same, or a slightly different, complaint to other people, e.g. the Press, the local Member of Parliament, the Health Secretary Etc.

Handling Continual/Vexatious Complainants The Chief Executive should agree that the complainant falls into the category of a continual/vexatious complainant. The decision should be recorded and the reason for the decision should also be noted. To check that the complainant’s concerns have been fully investigated and that the information has been forwarded, the complainant should be encouraged to request a review by the Health Service Ombudsman. This would mean that the initial complaints handling process would be scrutinized by independent people and if, in their opinion, the aims of local resolution had been met, the request would be refused. If the complainant is not prepared to request a review, or insists on raising the same issue again, they should be advised that as the Chief Executive has responded fully to the points raised, the matter is now closed. The following should be advised. No further correspondence will be entered into unless they have a new complaint Method to be used Vexatious or habitual complaints should be reported to the Patient Experience Team and any that fall into this category, should be discussed within the department on a regular basis Where a service manager identifies the possibility that a complainant is showing signs of being either vexatious or habitual this should be discussed with the respective Group Director and Complaint Officer and the appropriate Risk Assessment Form completed (Appendix 5). On receipt of the completed risk assessment form, the Complaint Officer will convene a vexatious and habitual complainant panel review meeting within 10 days unless mitigating circumstances dictate that this should occur sooner as identified by the Group Director (Appendix 6) The review panel will decide if formal allocation of vexatious and habitual complainant status applies in each individual case and determine subsequent management strategies. The Review panel should be made up from the following:

Executive Director

Lead Clinician

Service Area Manager

Complaint Manager



The objectives of the review meeting

Review chronology

Assign and devise status and identify vexatious/ habitual behaviour in line with policy

Advise future method of communication with client

Consider what action already taken

Risk score

Agree draft letter on behalf of Chief Executive

Decide a review date Options The listed options can be implemented individually or in combination with others and can occur in any order:

A signed agreement can be drawn up which sets out the code of behaviour for the complainant when dealing with the Trust. Such an agreement should detail the possible actions if the agreement is breached. In such cases, a further written notification to the complainant is required giving the reasons for the change.

Provided that at least one form of contact is maintained with the complainant, other means of contact can be declined.

Examples

If a complainant is abusive on the telephone, the Trust can specify that all future communications be conducted by letter.

Large numbers of, or abusive emails can be filtered out following written notification to the complainant.

Complainants who exhibit vexatious or habitual behaviour during visits to Delta House.

Inform complainants that the Trust reserves the right to refer unreasonable or vexatious complainants to the Trust solicitors or police.

Temporarily suspend all contact with complainant, or suspension of investigation whilst seeking legal advice or guidance from outside agencies.

There will be two stages following the review meeting:

Stage 1 - Once a letter has been sent out if the person continues to ignore letter a decision needs to be made by Chief Executive if stage 2 needs to be followed.

Stage 2 - Copy of notes go to Litigation Coordinator for decision as to whether an injunction is placed on the person. The Group director to then hold an emergency briefing with necessary staff.

The Chief Executive will notify the complainant, in writing, the reasons why they have been classified as habitual or vexatious and the action to be taken. Such notification will be considered on a case by case basis. This notification must be shared for the information of others involved in the complaint and be kept on file as part of the complaint record. Withdrawal of Status Each classification should be reviewed at regular intervals and changes to the classification notified to the complainant and other involved parties.



Appendix 5

Vexatious and Habitual Complainant Risk Assessment Form

Complaint Ref:

Group:

Date of Initial Complaint:

Service Area:

Complaint Lead :

Complainant’s Name:

Address:

DOB: Status: Service user/Relative/ other

Complaint Summary:

(Brief summary of initial complaint)

Chronology of Events

(If complainant is a service user Include relevant details of clinical presentation)

Category of vexatious and habitual behaviour ( tick 2 or more)



Persist in the pursuit of a complaint where the complaints procedure has been fully implemented and exhausted

(Tick)

The substance of an ongoing complaint is changed or new issues are raised in an effort to prolong contact following a final letter of response.

Challenges written documentation by claiming that the records have been altered. Refuses to accept contemporaneous notes, even though different people have made them.

Complainant does not clearly identify the precise issues they wish to be investigated despite all reasonable efforts being made to assist in this process, using Trust Customer services staff and /or external advocacy services.

Receives a response and immediately responds by either raising new concerns, or presenting an old problem in a different way.

Any form of violence has been used/ threatened towards staff, their families or associates; this includes verbal aggression, homophobic, racist or sexist remarks.

Complainant has had an excessive number of contacts with the Trust in pursuance of a registered complaint thus placing unreasonable demands upon staff.

Complainant is known to have electronically recorded meetings or discussions without the prior consent of the other parties involved.

Complainant has made defamatory comments to the press about staff

Seeks an unrealistic outcome and displays unreasonable demands and intends to continue until that outcome is achieved. Examples could include wanting to have a member of staff dismissed.

Summary of Management plan instigated to date:

(Strategies implemented to address vexatious/habitual behaviour and copies of correspondence)

Supplementary information:

(Other information to support the risk assessment)


Appendix 6

Vexatious and Habitual Complainant Meeting Panel Review

Date: Time:

In Attendance:

Complainant’s Name: DOB:

Address:

Risk Assessment presented by (Name and job title)

Comments from Panel:

Risk Score

Recommendations:

Assign vexatious and Habitual status

Yes/No

If no : Detail recommendations for further action :

If yes: Recommendations for future contact with complainant

Draft letter to complainant discussed/approved

Vexatious and habitual complainant status review date:



Appendix 7

Guidance for Concerns / Complaint Investigating Officer

Timescales The Trust recognises that investigating a complaint takes time and that it is in addition to your normal duties. It is therefore important for you to note that the period of six weeks given for investigating the issues raised in the complaint is a directive from the Executive Director of Nursing, AHP, Governance and organisational Development. A request to extend this period should only be made to the PEI team in exceptional circumstances and a reason must be documented.

Support for the Complaint Investigating Officer Once you have been confirmed as the Investigating Officer, the PEI team will contact you to offer to support to review the complaint; familiarise you with the Datix Complaints Module and discuss the issues to be investigated. All relevant documentation will also be uploaded to Datix. The Investigating Officer is responsible to ascertain if the actions of the staff were appropriate and if not, what action should have been taken at the time and will be taken to address that to prevent a recurrence of the situation. Responsibilities First and foremost, it is vital to answer the questions posed by the complainant. As obvious as this may seem, it is easy to lose track of the issues, particularly in very long, complex cases. The following points may be of help when preparing your report:-

Request the patient’s records as soon as you are confirmed as the lead and secure them appropriately. If you think there will be a delay in obtaining them, let the PEI team know immediately. Where possible, please retain these records until you are advised that the complaint has been signed by the Chief Executive and closed on Datix.

Read the complaint letter – this will give context to the questions identified from it.

Prepare a timeline of events leading up to the complaint.

When writing your report, stick to the facts and always include job titles when naming members of staff.

Explain what did happen and why?

We do also need your opinions – would you have done the same thing in the same situation? If not, an action is needed.

If a member of staff has taken an action, tell us why the particular was taken, then explain whether this was acceptable or not.

Include full dates, for example: referrals (when made and when received), admissions, attendances, discharges, DNAs, etc.

Please respond to all questions raised, this includes those questions outside of your particular team / service / department. This may require you to liaise with other teams / services / departments within the organisation or with agencies outside of the organisation where the Trust contracts services.

Please remember that if something is not documented, it is likely that the patient’s/complainant’s version of events will be accepted.



Remain objective, put yourself in the patient’s position – how would you have felt if the same thing had happened to you or a member of your family?

What response would you be happy to receive?

Keep the PEI team informed of your progress and if you encounter any difficulties, let us know straight away – we can’t help you if we don’t know.

Speak to every member of staff involved in the patient’s care. If you know, or you discover, that a member of staff is off work for any length of time, let the PEI team know straight away.

If the PEI team contacts you, please respond even if it is just to tell us you have no further information. If you don’t respond, the matter will be escalated to your Head of Nursing / clinical director.

Writing your response:

When writing your letter of response, stick to the facts, answer the questions posed by the complainant and always include job titles when naming members of staff.

Do not use jargon and/or abbreviations

Explain what did happen and why?

Explain what should have happened, and why?

We do also need your opinions – would you have done the same thing in the same situation? If not, an action is needed.

If a member of staff has taken an action, tell us why it was taken, then explain whether this was acceptable or not.

Include full dates, for example: referrals (when made and when received), admissions, attendances, discharges, DNAs, etc.

Please remember that if something is not documented, it is likely that the patient’s/complainant’s version of events will be accepted.

Submitting for Sign off Your report and your action plan should be submitted to your Head of Nursing by the deadline. This will be reviewed and any changes will then be returned to you to confirm that the information is accurate and has been interpreted correctly. Please note, if the complaint is very near to the breach date this may not be possible.

If there are any issues that require clarification, these will be highlighted in a different coloured text.

Once you have confirmed the accuracy of the information, the draft letter should then be returned to your Head of Nursing.

Once signed off at divisional level the compliant and response will be submitted to the Executive Director of Nursing, AHP, Governance and organsational Development for approval.

Once approval has been received, it will be returned to PEI team to be submitted to the Chief Executive for signing.

The PEI team will provide support throughout the investigation and drafting stages of the process. Arranging a 1:1 meeting to go review the response with one of the PEI Team,



especially if the letter has been returned to you numerous times or if the complaint is particularly complex, may be beneficial. Whilst the Trust has a maximum of six months to respond to complaints, we endeavor to respond well within that timeframe where possible. However, the longer the delays in responding to complaints the less accurate the report and response is likely to be, this is why your cooperation is vital and that you respond to the PEI team as soon as possible with the answers to any queries. It is a good idea to retain the records, until the Chief Executive has signed the response letter. Once the response letter has been signed, you will receive a copy for your action/information as appropriate. If you are the manager for the service involved, please ensure that you involve your staff in your investigation where appropriate and that the final signed response is shared with them.


Appendix 8

Treatment of Patients, Relatives and Carers after Raising a Concern

For the Complainant: 1. The PEI team ensures independence and provides assurances about the process

and attends any meetings as an independent person to support the process and ensure process is being followed

2. If necessary the PEI team will suggest an independent advocate attends meetings and will liaise regularly with the IMHA (Independent Mental Health Advocacy) service and POhWER as required.

3. Staff should inform the complainant to make contact with Patient Experience Team following completion of the complaint if they believe they have been treated unfairly as a result of making a complaint

4. The PEI team makes a written file note of the discussion 5. The PEI team reports back to the Complainant to ensure they are happy with

outcome 6. The PEI team shall include any relevant contacts in their reports

For Staff: 1. Staff must ensure they are professional and follow relevant codes of practice to

ensure they do not treat a service user or carer or relative differently as the result of a complaint

2. They must ensure that they act fairly and reasonably and responsibly when dealing with service users, carers or relatives should they have to meet them again following a complaint

3. Staff should seek advice and support from the PEI team as required or their manager

4. Should a service user become unreasonable or persistent as a result of the outcome of a complaint, staff should refer to the Vexatious process attached to this policy



Appendix 9

A Guide to Friends and Family Process

“TUHWD” Tell Us How We Did

Leaflets/Flyers

Tell Us How We Did Flyers should be given out to all patients when admitted to the wards and also sent out with generic clinic correspondence.

Posters, leaflets and Flyers should be displayed in all patient/public areas.

Inpatient and Community staff to give out Tell Us How We Did leaflets to patients, families, carers across all Divisions.

The Tell Us How We Did leaflet should be given to patients / carers / relatives when discharged or every 6 months if still engaging with Trust Services. The questionnaire should not be given out at every appointment and/or every visit.

TO ENSURE DEPARTMENT GET FEEDBACK PLEASE LABEL ALL LEAFLETS WITH YOUR DEPARTMENT BEFORE GIVING LEAFLET OUT

Responses

All responses should clearly document where they are from i.e. Team/Service/Location etc.

All responses are to returned to PEI team at Delta House

All Inpatient PALS boxes should be emptied each Friday and sent in the internal post.

Patient / Carers / Families can also use online portal to respond

Analysis

Performance team will use portal to collate responses for up loading to Unify, in either MH, LD or Community categories.

The data will then be analysed and broken down into divisional / Services / Teams, providing the questions have been completed on the leaflet

This information will be disseminated to divisions to include in their Monthly quality and safety reports



Policy Details

* For more information on the consultation process, implementation plan, equality impact assessment, or archiving arrangements, please contact Corporate Governance.

Title of Policy Concerns, Complaints and Compliments Policy

Unique Identifier for this policy BCPFT-PEI-POL-03

State if policy is New or Revised Revised

Previous Policy Title where applicable n/a

Policy Category Clinical, HR, H&S, Infection Control etc.

Patient Experience

Executive Director whose portfolio this policy comes under

Executive Director of Nursing, AHPs and Governance

Policy Lead/Author Job titles only

Risk and Governance Manager

Committee/Group responsible for the approval of this policy

Patient and Involvement Group

Month/year consultation process completed *

May 2019

Month/year policy approved October 2019

Month/year policy ratified and issued October 2019

Next review date October 2022

Implementation Plan completed * Yes

Equality Impact Assessment completed * Yes

Previous version(s) archived * Yes

Disclosure status ‘B’ can be disclosed to patients and the public

Key Words for this policy

Comment, concern, independent complaints advocacy service, local involvement links, patient advice and liaison service, ombudsman, good complaint handling, complainants, disciplinary procedures, joint complaints, handling unreasonable callers, unreasonable and persistent complainants, learning lessons



Review and Amendment History

Version Date Details of Change

2.0 Mar 2019

Policy fully reviewed to reflect current process, national standards and legislation based on feedback revised as part of consultation. Amendments made to the font, layout and approved BT changes. Changes made to the F&F Process to incorporate TUHWD. Changes made to the name complaint lead – to Investigating Officer; Drafting your report – changed to letter of response & Joint complaint responses – amendments made

1.4 Oct 2016 Updated guidance for complaint leads and revised KPIs

1.3 May 2016 New policy format and updated flowcharts in Appendices 1, 2 and 9 to reflect current practice

1.2 Apr 2015 Minor amendments – Flowcharts in Appendices 1 and 2 updated based on changes in the allocation of complaints

1.1 Jan 2014 Minor changes; new guidance and Internal Audit report

1.0 Nov 2012 New policy for the new organisation BCPFT; alignment of policies following TCS

concerns, complaints and compliments

Documents