1 Complaints Policy V5

Management of Complaints Policy

ID Reference Number

GOV/POL/007

Category Policy

Classification: Governance

Search Criteria: Complaints

Purpose Defines how directorates manage and respond to complaints made by patients, clients, carers, relatives or friends, or on their behalf by an advocacy service or other bodies or individuals who have consent to act on behalf of the individual the complaint relates to.

Superseded Trust-wide Controlled Documents N/A

Version Number: 5.0

Date Approved by appropriate Group : December 2020 Complaints Policy Task & Finish Group

January 2021 Patient & Carer Experience & Involvement Group (PCEIG)

Date Approved by Controlled Document Review Group

14 January 2021

Date approved by Trust Board if applicable

Review Date: 6 January 2025 unless there is a legislative or evidence based change to practice.

Issue Date: January 2021

Title of Originator/Author Complaints Manager

Associate Director of Nursing

Title of Responsible Director: Director of Nursing

Impact / Equality Impact Assessed Yes

Target Audience All staff

If printed, copied or otherwise transferred from the Trust Intranet, policies and procedural documents will be considered uncontrolled copies. Staff must always consult the most up to date versions registered on the Trust Intranet.

2 Complaints Policy V5

Version Title of Trust Committee/Forum/Body/Group consulted during the development stages of

this controlled document Date

V5 Task and Finish Group established to review documents with all Directorates included. Completed 5.1.21. Raised with PCEIG 6.1.2021

Document Amendment Form

Number Date Page No. Amendment Authorised by

1.

12/21 All Full document review CDRG Jan/2021

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3.

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6.

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8.

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Table of Contents

Section Description Page

1 Introduction 4

2 Purpose & Scope 4

3 Policy Intention 4

4 Definitions 5

5 Duties and Responsibilities 5-6

6 Policy Details 7-14

7 Dissemination and Implementation 14

8 Document Control including Archiving Arrangements 14

9 Monitoring 15

10 GEH Associated Documents 15

11 References and Associated Bibliography 16

12 Staff Compliance Statement 16

13 Equality and Diversity Statement 16

13 Equality Impact Assessment Tool 17

14 Appendices: Appendix 1 Parliamentary and Health Service Ombudsman’s Principles for Remedy Appendix 2 Flow Chart Appendix 3 Easy Read - How to make a complaint leaflet

19 20 21-22

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1. Introduction

George Eliot Hospital NHS Trust (herein referred to as ‘the Trust’) believes that an open and transparent system for dealing quickly and effectively with complaints about healthcare is one measure of the standard of service we provide to our patients, service users, their families, friends and significant others. Complaints are a way of obtaining the views of our service users and are a valuable source of information about our organisation’s quality of service and an opportunity for improving quality of services. Feedback is important and the Trust actively encourages patients and the public to express their concerns either through the complaints process or if a more immediate solution is needed, the Patient Advice and Liaison Service (PALS). Complaints should be viewed as a positive way to improve services and avoid or reduce the risk of similar situations occurring for others, thus forming part of the Trust’s Clinical Risk Management Strategy. The link between incidents and complaints is important in achieving this. The policy is available to all patients, service users, their families, friends and significant others irrespective of language, ethnicity or disability. No person will be discriminated against on the grounds of ethnicity, gender, age or sexual orientation. There is an easy read leaflet and access to the Trust’s translation service is via translation@geh.nhs.uk. Patient care will not be compromised as a result of making a complaint. Where this is suspected, the patient or their representative must report this to the Complaints Service. This policy follows national guidelines and good practice as set out by the Parliamentary and Health Service Ombudsman. The current national pandemic,Coronavirus, SARS-CoV-2, (COVID-19) or other national emergency response situation, may influence reporting requirements not currently nationally determined. 2. Purpose and Scope This policy applies to all staff and services provided by the George Eliot Hospital NHS Trust. It defines how directorates manage and respond to complaints made by patients, clients, carers, relatives or friends, or on their behalf by an advocacy service or other bodies or individuals with consent to act on behalf of the individual. 3. The intention of the complaints policy is to: • Provide a policy that reflects national requirements and local directorate ownership. • Provide a service accessible to all with an easy read patient information leaflet

available (appendix 3). • Deal with complaints in an effective and efficient manner, mindful and sympathetic to

the circumstances. • Use complaints as a means of improving services, grouping and recording themes

and actions taken to address the complaints. • Involve the complainant and maintain regular dialogue as required. • Involving and engaging with the Directorate triumvirates and service management

teams. • Provide a balance between treating staff fairly and maintaining proper accountability

for their actions.

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• Provide co-ordinated handling of those complaints which cross health and social care achieving a single response where possible.

4. Definitions Comments: Patients, service users, their families, friends and significant others may have valuable feedback good or bad relating to their experience and may wish to share this with the Trust Concern: Patients, service users, their families, friends and significant others may be worried about an aspect of the care and need some advice or clarification. These are issues that can often be resolved quickly in the interests of the patient and can be addressed informally for the purpose of service improvement. The complaint regulations support this approach. Complaint: A complaint is an expression of dissatisfaction, either in writing or verbally, about healthcare/treatment or services provided which requires an investigation and formal response. The Complaints Procedure referred to in this policy is in conjunction with the Local Authority Social Services and National Health Service Complaints (England) Regulations 2009. 5. Duties and Responsibilities Trust Board

The principal accountability of all providers of NHS-funded care is to patients, service users, their families, friends and significant others. In their fulfilment of this duty, the Trust Board accepts its responsibility to ensure that the Trust operates in the safest manner possible to protect users of its services and members of staff. Part of this responsibility is to ensure that an appropriate system is in place for the responding to formal complaints.

Chief Executive (CEO) The CEO has overall responsibility for patient experience and ensuring there are safe effective well led processes within the Trust which meet all statutory and regulatory requirements The CEO holds each line manager accountable for meeting objectives and to

work together towards meeting the objectives approved by the Board. Managing Director At George Eliot NHS Hospital Trust, the Managing Director has responsibility for formal complaints and fulfils the role of the responsible person under the Regulations. The Managing Director and the Medical Director are responsible for reviewing and signing off each individual complaint. In their absence the role is delegated to an Executive Member and one of the the Deputy Medical Directors. Director of Nursing The Director of Nursing is the nominated Executive with responsibility for complaints and will act for, and on behalf of the Trust Chief Executive Officer to ensure systems and processes are in place to lead the safe, effective, responsive, caring and well-led care and services for patients and their carers when accessing the complaints process at the Trust. More specifically, they have responsibility for ensuring there is a robust system in place for complaints management, for the regular reporting of complaints against the regulations and

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standards set within this policy and to ensure quality improvement is achieved to patient experience and outcomes for our patients. Directorate Management Team The triumvirate which is made up of: Clinical Director General Manager Matron(s) The triumvirate receive all formal complaints relevant to their Directorate to ensure the appropriate investigation, oversight and accountability. Investigation Lead Within each Directorate the complaint will be managed by the nominated Investigation Lead with support from the Clinical Lead and the Governance Co-ordinator Lead. It is their responsibility to carry out a full investigation into issues raised, ensuring all points are addressed, that staff are interviewed/statements obtained from those involved or those with a responsibility for the service. The Investigation Lead will draft or oversee the response letter and provide any action plan/service improvement for those considered upheld or partly upheld. If required they will be supported by the Governance Co-ordinator Lead. Complaints Service

To facilitate the complaints process ensuring we are adhering to policy. The service will co-ordinate all complaints received within the Trust, including acknowledgement/seeking of consent/clarification of issues/response time. They can also act as a point of contact.

To identify where the complaint primarily relates to and circulate to the relevant Directorate Triumvirate for investigation. They will ensure the Directorate adequately addresses all points/questions raised.

Will support staff with statement writing/draft responses where needed.

Will ensure public and staff awareness of the complaints process and how to access it, providing any support as necessary.

Will develop and maintain systems which ensure that complaints are managed promptly and effectively with meaningful data held.

To provide complaints performance reports both internally and externally to the Trust.

To ensure we signpost to the Parliamentary and Health Service Ombudsman for complaints that cannot be resolved locally.

Will liaise with the Legal Services Manager and the Head of Risk Management for complaints subject to a serious incident, inquest or litigation.

Produce the quarterly statutory return (KO41a) for the Department of Health and Social Care and reports to the Quality Assurance Committee, Operational Quality and Safety Group and Trust Board as required.

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Produce and circulate a Trust-wide Complaints Tracker for Directorate oversight and to help us achieve the response rate.

6. Policy Details 6.1 Patient Advice and Liaison Service (PALS) The Patient Advice and Liaison Service (PALS) has an important role in supporting those who wish to raise concerns. Not all issues benefit from being escalated to a formal complaint (e.g. the process does not influence clinical decisions and reprioritise patients) and there is often scope for PALS to seek a quick resolution and avoid the issue becoming a formal complaint. PALS also have a valuable role to play in providing support and advice for anyone wishing to pursue their concern as a complaint. This may be helping a complainant to write their complaint letter, explaining how the complaints process works or attending a complaints meeting, if requested. PALS can be contacted by: Email - PALS@geh.nhs.uk Telephone - 02476 86550 6.2 Independent Complaints Advocacy Service (ICAS) ICAS are independent organisations whose primary function is to support those making a formal complaint about the NHS. The Trust must make the complainant aware of this service and our local providers:

VoiceAbility Warwickshire - 0300 222 5947

POhWER Leicestershire - 0300 456 2370

Healthwatch Coventry - 0300 012 0315

Healthwatch Staffordshire - 0800 051 8371

Healthwatch Warwickshire - 01926 422823 6.3 Local Resolution- Complaint received Local resolution is the first stage in the NHS complaints process and refers to the Trust taking all the appropriate steps to try and resolve the complaint. The Trust should observe the Parliamentary and Health Service Ombudsman’s Principles for Remedy and, My Expectations – a user led vision for raising concerns and complaints which the Trust has

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added its own commitment to. (Appendix 1).

Depending on the complexity of the issues, the Trust will aim to ensure all complaints that are not subject to a serious incident review, are addressed within 7, 25 or 60 working days (Appendix 2 – Flow Chart). If the investigation cannot be completed within this timeframe the complainant will be kept fully informed. The aim is to resolve the issues raised in a timely and fair manner for all parties involved. Good communication is paramount to resolving complaints and this should be effective first and foremost, with the complainant being offered a point of contact. Details for the Complaints Service will be provided but the Investigation Lead for the complaint within the Directorate should try and contact the complainant. There should also be close links with any additional NHS or local government organisation involved to ensure a collaborative approach to responding to complaints. 6.4 Equal Treatment There are occasions when there is an irretrievable breakdown in the clinician/patient relationship, but it is important that a patient’s care is not adversely affected due to making a complaint. Patients or their representative, need to be assured that they can raise concerns without fear of recrimination and they should be encouraged to raise concerns if they consider the patient is being treated differently due to making a complaint. Complaint correspondence must not be filed within the patient’s healthcare records. All registered complaints will be dealt with fairly and effectively and as promptly as possible. However, calls and method of contact may be limited where unreasonable behaviour has been noted as a concern and complainants may need to be managed under the Violence and Aggression Policy. 6.5 Time Limit for Making a Complaint A complaint should generally be made: • Within 12 months of the date when the event being complained about occurred or • Within 12 months of becoming aware of the event The Trust will consider complaints made outside this time, the reasons for this and, whether there is scope to investigate matters fairly and effectively.

6.6 Receipt of Complaints The Trust will accept complaints made in writing, orally or by e-mail. Complaints made in writing are preferable to ensure the Trust receives the complainant’s views first hand rather than try and interpret them and represent them in the form of a summary. It is recognised that some people may need support in writing/making a complaint and the complainant should be made aware of the Advocacy Service linked to their area and, the Patient Advice and Liaison Service (PALS). If a verbal complaint is accepted the issues shared should be typed up and forwarded to the complainant within 3 working days for verification. The investigation will not commence until the issues have been agreed, signed and returned. All written complaints will be acknowledged in writing by the Complaints Service within 3 working days.

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6.7 Persons who may make a Complaint A complaint may be made by:

Anyone who is receiving or has received care or treatment from the Trust.

A person who is affected or likely to be affected by an action, omission or decision of the Trust in relation to care or treatment.

A third party e.g. MP, relative, friend, carer, independent advocate on behalf of the patient.

A complaint may be made by a representative where that person:

• has died • is a child • is unable by reason of physical or mental incapacity to make the complaint

themselves • has requested the person to act on their behalf

6.8 Consent GDPR (General Data Protection Regulation) is important to the Trust and we have a duty to ensure that any information shared is for a legitimate purpose especially in circumstances where a complaint is made on behalf of a patient. If the patient is in a position to provide consent this must be obtained before an investigation commences. Where the complaint is made in respect of a person who has died the Trust will ask for the Executor or the Personal Representative to provide written consent along with supporting documentation such as the Grant of Probate or Last Will and Testament. When these are not in place a decision must be made by the Trust about the appropriateness of the person

making the complaint and the right to confidential information. When a patient lacks capacity to make a complaint themselves, the Trust must consider the role/relationship of the representative and that they are acting in the interests of the patient and, have a legitimate right to confidential information. The Caldicott Guardian may need to be involved to consider the position of the Trust and the person making the request. Please see the Information Governance Policy 2019. 6.9 Complaints Handling – Investigation - Outcome Incorporating the Parliamentary and Health Service Ombudsman Principles for Remedy and My Expectations is fundamental to resolving the complaint in the interests of both the Trust and the complainant. It is important that we:

invite the complainant to get in touch if a discussion would be helpful following receipt of their letter

establish what happened

what should have happened

establish if the issues need to be passed to the Risk Management Team and subject to review by the Serious Incident Group (SIG)

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who was involved

obtain comments from those involved verbal or preferably written in response to all of the issues raised

seek comments if appropriate from those not directly involved but with a responsibility for the service or a more senior opinion

provide a written reply to the concerns in full within 25 or 60 working days with the exception of when a meeting being agreed in preference and the complainant is not available within the timescale.

make sure an appropriate and sincere apology is made if we have done wrong

identify any lessons learned and where applicable any actions which can be implemented

determine whether the complaint should be upheld, partially upheld or not upheld. Ideally the person who leads/investigates the complaint should arrive at this decision and input the ‘outcome’ code but may need to seek clinical advice on complex issues

ensure the time taken to respond to a complaint does not exceed 6 months. 6.10 Duty of Candour (Being Open and Transparent) In November 2014 and following the Francis Inquiry (2013) it is a legal requirement for Trusts under Duty of Candour to be open and transparent with people who use the services when something goes wrong that may have caused or lead to, significant harm in the future. Complaints are often linked to Duty of Candour and the Trust must be honest and open in its dealings with its patients and ensure staff know their responsibilities as set out in the Duty of Candour Policy and Process. 6.11 Potential Serious Incident (SI) All complaints are serious to those making them but it is recognised that some issues highlight a potentially serious clinical, procedural failure or allegation and are not known as the subsequent care has taken place at another provider. If the issue is not already being investigated under our Governance arrangements the Complaints Service will ensure that: • An incident is completed. • The complainant is informed (if Duty of Candour has not already been performed)

that a Root Cause Analysis (RCA) is to be undertaken which takes 60 working days to complete and that the Risk Management Team will be taking over the case with the appropriate Investigation Lead contacting them to see if they would like to contribute to the investigation with contact details for the Investigation Lead provided.

6.12 Disciplinary Action Staff must be supported in any complaint received but it is recognised that some complaints may lead to disciplinary and conduct procedures being instigated separately. It is not the Trust’s policy to share this action and any outcome with the complainant. The complainant can be advised that if disciplinary action or performance management is indicated they will not be informed of the outcome but that the staff member may be subject to further Trust policies/procedures. 6.13 Further Local Resolution Although the aim of following the above process is that the complaint will be resolved, the Trust recognises that complainants may not always be satisfied with the explanations and any remedial action identified. It is also possible that the information provided may lead to

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further concerns being raised. The complaint response should provide the opportunity for the complainant to approach the Trust again and if a meeting is not indicated a further written response should, where possible, be provided within 25 working days. It is beneficial to receive from the complainant the outstanding issues in order to reply further or, to place the correct staff in a meeting to ensure a helpful discussion can take place. 6.14 Parliamentary and Health Services Ombudsman (PHSO) review Local Resolution is not always possible even when further responses or a meeting have been provided. The details for the PHSO must be given within the first response to the complaint in the event the complainant remains dissatisfied and does not wish to engage further with the Trust. The Trust equally, can reach the point where local resolution has been exhausted and consider the complainant will benefit from the independence of the PHSO. In the interests of resolving the complaint the Trust needs to fully cooperate with any requests made by the PHSO. The contact details for the PHSO are: The Parliamentary and Health Service Ombudsman Millbank Tower Millbank London SW1P 4QP Telephone 0345 015 4033 Email - phso.enquiries@ombudsman.org.uk 6.15 Care Quality Commission (CQC) The Health and Social Care Act (2008) (Regulated Activities) Regulations (2014), Regulation 16, is to ensure that people can make a complaint about their care and treatment. To meet this regulation we have to ensure we have an effective and accessible system to manage complaints that must be thoroughly investigated with actions taken where failings are identified. Although not involved in investigating complaints, it is recognised that the CQC may be contacted by a complainant and may need to request details of the complaint or, seek reassurance the matter is/has been dealt with. The Trust needs to comply with any requests made by the CQC. 6.16 Publicity The Trust has a statutory duty to make information available to the public on the complaints process. Information is detailed on the Trust’s website and an easy read leaflet on how to make a complaint is available throughout the Trust. This provides contact details on the Independent Complaints Advocacy Service (ICAS) and Patient Advice and Liaison Service (PALS). It is important to be aware that complainants may be unable to write, may not have English as their first language or have disabilities which make writing formal complaints difficult. PALS and ICAS can assist with these issues by sourcing services to assist complainants who need to communicate verbally, who require interpreting or translation services, services for blind/partially sighted or deaf/impaired hearing and for those unable to put their complaint in writing.

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6.17 Exclusions Exclusions from the Trust’s Complaints Policy:

a complaint that has already been investigated under the NHS Complaints Procedure

complaints by a responsible body1

complaints regarding NHS employment

private healthcare.

a complaint made orally that is resolved satisfactorily

complaints regarding requests under the Freedom of Information Act 2000 6.18 Complaints involving more than one organisation When a complaint is received that involves more than one NHS organisation and/or social care the recommendation is to provide a coordinated response having established who should lead and communicate with the complainant. Due to the varying response timeframes across the organisations this may not always prove possible and Trusts on occasion, may need to reply in isolation. Permission should be sought from the complainant in advance of sharing the complaint with any other provider. If a complaint is received by the Trust that is solely about the services provided by another organisation the complainant must be referred to the relevant organisation and informed by letter or email as appropriate.

6.19 Unreasonable behaviour The Trust is committed to dealing with complaints fairly and compassionately to any clinical conditions the person may have. Persistent complainants can however occur and place undue stress on NHS staff with little hope of resolution. Whilst there may be substance to the complaint and this must be dealt with in accordance with the regulations. We do not expect staff to endure difficult situations or behaviour that is offensive, abusive or frequent in nature. We may, on occasion need to restrict how someone can contact us. It is important that as a Trust we:

Record any incident of unreasonable behaviour or excessive contact on DATIX so that we can monitor the frequency and nature of the contact and who is involved.

Confirm the issues to ensure they are appropriate to the NHS Complaints Procedure, are within time and have not already been subject to the process

Exhaust all reasonable efforts to engage with the complainant to resolve the issues

Provide details of an advocacy service.

Determine whether we need to restrict contact in the form of nominating a particular person or service, method of contact eg written correspondence only and if a timescale needs to be attached to the restriction. This needs to be done in writing and with a letter from the Chief Operating Officer or their representative.

Inform the complainant why we believe their behaviour is unacceptable and what action we have decided to take eg written correspondence only.

Where needed invoke the Management of Violence and Aggression Policy

1 Responsible body means Local Authority, NHS Body, Primary Care provider or Independent provider.

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6.20 Litigation or allegations relating to serious misconduct If litigation is indicated or commenced, the Trust will need to ensure that the complaints process will not prejudice any legal or judicial action. It is unusual for complaints and legal action to run concurrently but if there are no contra-indicators, the complaint investigation can commence alongside litigation. Where a complaint alleges serious misconduct or issues of a criminal nature the relevant Director should be notified immediately to enable decisions on the most appropriate way forward as the complaints process may no longer remain relevant.

6.21 Learning from Complaints Remedial Action and Compensation It is important to share all complaints even those which are not considered upheld and that we learn from those that are with foundation. The Directorate must detail within their responses, a full explanation to the issues raised coupled with any action that has been taken as a result of the complaint. If the complaint is subject to a root cause analysis (RCA) the final report overseen by the Risk Management Team will be made available to the complainant. Any concerns outside of the scope of the RCA will be investigated by the Directorate and included in a covering letter with the RCA. Complaints must be discussed at ward and departmental meetings, directorate governance meetings and reports will be received at Operational Quality and Safety Group and Quality Assurance Committee to ensure ward to board feedback. Not all complaints require financial remedy and complainants often seek an apology when we have done wrong. The Trust should consider all forms of remedy, such as acknowledging if a mistake has been made, an explanation of events, action taken as a result and, where appropriate, financial reimbursement. Ex-gratia payments in respect of expenses incurred by patients should also be considered where the Trust is found to be at fault. The PHSO may also recommend redress for the complainant in instances where they partly uphold or fully uphold a complaint following investigation. Complainants seeking compensation for a non-quantifiable loss, eg negligence and distress are to be advised to seek independent legal advice. 6.22 Retention of Complaints Documentation Registered complaint files will be kept for 10 years in the archive storage area. It is imperative that complaint correspondence is not filed in a patient’s health records. A copy of a complaint file can be requested under GDPR. 6.23 Complaints Reporting The Complaints Service will provide reports for the relevant committees for oversight and assurance purposes and reporting will include:

Monthly reports for the Directorates

A quarterly K041a report

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Contribute to the quarterly Patient Experience Report which feeds into Operational Quality & Safety Group and Quality Assurance Committee. The Complaints Manager will contribute to an Annual Patient Experience Report.

This report will include:

Numbers of complaints received.

Categories and areas complained about.

Whether the complaint was upheld, partly upheld or not upheld

Any complaints referred to the Parliamentary and Health Service Ombudsman and their decision.

Any significant lessons learned and actions taken.

Response rate

7. Dissemination and Implementation The Policy will be saved on the Trust’s intranet system and is available to all Trust staff. Key risk committees will receive notification of its renewal and the Policy will be signed off by the Controlled Document Review Group, (unless there are any significant changes made to the National Policy in the interim). Training will be available to staff to ensure they understand the requirements of the NHS Complaints Procedure and their responsibilities. 8. Document Control/Archiving The document will be managed as per the process described within the Trust’s Policy for the Development and Management of Controlled Documents. This policy will be reviewed at the date specified or earlier if circumstances dictate. This document will be included on the Trust intranet site under the Master Policy Library.

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9. Monitoring The Trust will maintain a record of:

Each complaint received

The subject matter

Whether the complaint is well-founded

Response time

Lessons learnt and any actions taken

Aspect of compliance or effectiveness being monitored

Monitoring method

Individual or department responsible for the monitoring

Frequency of monitoring activity

Group/ Committee/ forum which will receive the findings/ monitoring report

Committee/ individual responsible for ensuring that the actions are completed.

a. Response timeframe

Weekly tracker Monthly report

Complaints Manager and Directorate Manager

Weekly Monthly

Operational Quality & Safety Group Quality Assurance Committee

Trust Board

b. Complaint Management

Number of Complaints received for further local resolution

Complaints Manager

Weekly Operational Quality & Safety Group

Quality Assurance Committee

c. Learning Investigation Lead

Complaints Manager

Quarterly Operational Quality & Safety Group

Quality Assurance Committee

d. Accessibility Assurance visits

Compliance Ad-hoc CQC Leads Complaints Service

10. GEH Associated Documents

Duty of Candour Policy – Review date 03/2021

Duty of Candour Procedure – Review date 10/2021

Violence and Aggression Policy- Review date 01/2022

Managing of Serious Incidents & Never Events Policy Review date 08/2020

Information Governance Policy – Review date 12/2022

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11. References and Associated Bibliography

Care Quality Commission (2016) Learning, candour and accountability. Available at: http://www.cqc.org.uk/sites/default/files/20161213-learning-candour-accountability-full-report.pdf (Accessed: 11 January 2021). Freedom of Information Act 2000, c. 36. Available at: https://www.legislation.gov.uk/ukpga/2000/36/contents (Accessed: 12 January 2021). Health and Social Care Act 2008, c. 14. Available at: http://www.legislation.gov.uk/ukpga/2008/14/contents (Accessed: 11 January 2021). Local Government Ombudsman (2014) My Expectations for Raising Concerns and Complaints. Available at: https://www.ombudsman.org.uk/sites/default/files/Report_My_expectations_for_raising_concerns_and_complaints.pdf (Accessed: 11 January 2021). Parliamentary and Health Service Ombudsman (2009) Principles for Remedy. Available at: https://www.mbudsman.org.uk/about-us/our-principles/principles-remedy (Accessed: 11 January 2021). The Local Authority Social Services and National Health Service Complaints (England) Regulations 2009. (SI 2009/309). Available at: http://www.legislation.gov.uk/uksi/2009/309/contents/made (Accessed: 11 January 2021). The Mid Staffordshire NHS Foundation Trust Public Enquiry (2013) Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry (Francis Report). Available at: https://www.gov.uk/government/publications/report-of-the-mid-staffordshire-nhs-foundation-trust-public-inquiry (Accessed: 12 January 2021).

Department of Health and Social Care (2021) NHS complaints guidance. Available at: https://www.gov.uk/government/publications/the-nhs-constitution-for-england/how-do-i-give-feedback-or-make-a-complaint-about-an-nhs-service (Accessed: 12 January 2021). 12. Staff Compliance Statement All staff must comply with the Trust-wide controlled document and failure to do so maybe considered a disciplinary matter leading to action being taken under the Trust’s Disciplinary Procedure. Actions which constitute breach of confidence, fraud, misuse of NHS resources or illegal activity will be treated as serious misconduct and may result in dismissal from employment and may in addition lead to other legal action against individual concerned. 13. Equality and Diversity Statement The Trust aims to design and implement services, policies and measures that meet the diverse needs of the needs of our service, population and workforce, ensuring that none are placed at a disadvantage over others.

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14. Equality Impact Assessment Tool

Yes/No Comments

1. Does the document/guidance affect one group less or more favourably than another on the basis of:

No

Race No

Ethnic origins (including gypsies and travellers)

No

Nationality No

Gender No

Culture No

Religion or belief No

Sexual orientation including lesbian, gay and bisexual people

No

Age No

Disability - learning disabilities, physical disability, sensory impairment and mental health problems

No

2. Is there any evidence that some groups are affected differently?

No

3. If you have identified potential discrimination, are there any exceptions valid, legal and/or justifiable?

N/A

4. Is the impact of the document/guidance likely to be negative?

No

5. If so, can the impact be avoided? N/A

6. What alternative is there to achieving the document/guidance without the impact?

N/A

7. Can we reduce the impact by taking different action?

N/A

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Appendix 1

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Appendix 2 Complaint received & registered by Complaints Team

(Timeframe to be determined)

7 day response Simple issue minimal investigation required.

Can be resolved quickly/over telephone

Letter to confirm outcome/resolution

within 25 working day response standard

25 working day standard response

Detailed letter/multiple

questions Requires thorough

investigation & multiple service input.

Letter to confirm outcome/resolution

within 25 working day response standard

60 day response (by exception)

Complex complaint/spans services/organisations Must be agreed with

complainant and complaints team Letter to confirm

outcome/resolution must not exceed the 60 working day agreement response

standard

Complaints subjected to clinical/serious incident/root cause analysis will be managed under The Serious Incident (SI) process by the

investigation lead for the incident.

Acknowledgement letter issued within 3 working day of

receipt

Complaint issued to Lead Directorate

Directorate identify investigating officer/complaint lead & inform Complaints Team Complaint triaged

Complainant contacted by telephone within 3 working days of receiving complaint to inform them of the Investigation Lead and response date

Draft letter checked by Complaints Team

Executive Sign off

Days

1

2

3

Reminder Day 10

Draft

Response Day 15

(unless 60 day

response)

Day 25 Response to be sent

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Appendix 3

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Appendix 1