Complaints Procedure

Complaints Procedure Version: 4.5 Bodies consulted: - Approved by: Governance Manager Date Approved: 30.4.14 Name of originator/ author: Pat...
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Complaints Procedure

Version:

4.5

Bodies consulted:

-

Approved by:

Governance Manager

Date Approved:

30.4.14

Name of originator/ author:

Pat Key

Lead Director:

Chief Executive

Date issued:

May 14

Review date:

Apr 18

Is this policy c urre C h e ck the intr nt? ane to find the late t version st !

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Contents

1 Introduction .......................................................................... 3 2 Purpose ................................................................................. 3 3 Scope .................................................................................... 4 4 Definitions ............................................................................. 4 5 Duties and responsibilities ..................................................... 5 6 Procedures ............................................................................ 7 7 Process for monitoring compliance with this Procedure ....... 16 8 References .......................................................................... 17 9 Associated documents ......................................................... 17 10 : Equality Impact Assessment ............................................... 18 Appendix A : Process for handling formal complaints ................ 19 Appendix B : Guidelines for staff on preparing a report ............. 20 Annex D: London partnership agreement for the handling of integrated complaints and concerns.......................................... 26

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Complaints Procedure 1

Introduction The Trust is committed to ensuring that those who use its services are readily able to access information about how to make a complaint and that the issues raised are dealt with promptly and fairly. We aim to provide a complaints service that meets the needs and objectives of the complainant, whilst at the same time complying with the requirements set out in the NHS Complaints Procedure. We recognise that the information derived from complaints provides an important source of data to help make improvements in our services. Complaints can act as an early warning of failings in systems and processes which need to be addressed. We make sure that the care of people who make complaints about our services will not be adversely affected because they have complained. Complaints correspondence is stored and recorded separately from healthcare records. The Trust serves a diverse patient population. We are committed to providing a complaints service to all regardless of their racial or cultural background, gender or sexual orientation, religion or disability.

2

Purpose This policy and procedure replaces the Trust’s Complaints Policy and Procedure issued in 2007. The purpose of this policy is to set out the processes for dealing with formal complaints in accordance with revised National Health Service (Complaints) Regulations 2009 no 309. Under the 2009 regulation the NHS Formal Complaints Procedure comprises two stages: Stage 1 Stage 2

Local Resolution Referral to the Parliamentary and Health Service Ombudsman

This policy and procedure details the following:

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  

The objectives, values and principles of the complaints process as well as the roles and responsibilities of staff dealing with complaints. The processes to be followed when dealing with complaints under Local Resolution, which is the first stage of the NHS Complaints Procedure. The Investigation by the Parliamentary and Health Service Ombudsman, which is the second stage of the NHS Complaints Procedure.

The key objectives of this policy and procedure are:        

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To provide an open and accessible mechanism by which people can raise concerns. To be easily understood by staff, patients and complainants. To seek early reconciliation between the Trust and the complainant. Whenever possible to ensure that complaints are dealt with at the time that they arise. To ensure that complaints are investigated thoroughly and fairly. To ensure that lessons are learnt from complaints and that appropriate action is taken to make improvements where deficiencies are identified. To ensure that all staff dealing with, and resolving complaints, are trained and supported to do so effectively. To provide the Clinical Quality, Safety, and Governance Committee with quarterly updates on complaints.

Scope This policy relates to patient-related complaints only. All formal patient complaints, however received, should be managed as set out in this policy. Complaints from staff are dealt with under the relevant Human Resources policies and complaints from trainees under relevant procedures managed by the Directorate of Education and Training.

4

Definitions Within this policy the term formal complaint refers to any written complaint received from a patient or a representative of the patient. Under the NHS Complaints Regulations on receipt of any written complaint from a patient the Trust is required to follow the process set out in this document. A verbal complaint may be treated as a formal complaint if on discussion with the complainant he/she wishes his/her concerns to be treated

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formally. In this case a detailed written record must be made by the recipient of the complaint and sent to the complainant with an invitation for it to be signed for accuracy and returned to the Complaints Manager. Patients and carers wishing to raise informal complaints can speak directly to their therapist or other member of staff or can be directed to the Trust’s Patient Advice and Liaison Service (PALS). Details of the PALS service are to be found in the PALS policy.

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Duties and responsibilities 5.1

Chief Executive

The Chief Executive is accountable for ensuring that the Trust’s Complaints Policy and Procedure meets the statutory requirements set out in National Health Service (Complaints) Regulations 2009 All written responses to formal complaints must be signed by the Chief Executive (or by his nominated deputy, in his absence). Under the Compliance Framework for Foundation Trusts the Chief Executive is responsible for reporting any serious complaints1 to Monitor. 5.2

Responsible Director

The Chief Executive retains this responsibility. 5.3

The Clinical Quality, Safety and Governance Committee

This committee (CQSG) is has delegated authority from the Board of Directors:   

To receive and note reports about the operation of the complaints procedure and the effect on service improvement. To receive assurance that emerging themes are investigated and acted upon, and that themes that are consistent with those raised elsewhere (e.g. serious incidents) are identified and acted upon. To receive assurance that the complaints procedure features in patient satisfaction surveys and/or is subject to a separate survey. To ensure that complaints about services are the subject of regular and public reporting to the Board of Directors, on at least a quarterly

1

Extract from Compliance framework 2011-11 paragraph 100 “When a complaint has arisen that may not be a serious incident requiring investigation but which may give rise to material adverse impact on the trust, this should be reported in a timely manner to Monitor”

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5.4

basis as noted in the CQSG report which is posted on the Trust website. To ensure that senior staff provide the necessary leadership, training and support to those dealing with complaints. Complaints Manager

The responsibilities of this role are as follows:    

    

5.5

Receive and manage all formal complaints in accordance with this policy and procedure and within timescales set out in this policy. Manage the complaints handling process within the Trust. Raise any issues related to an inability to complete the complaints process in line with this document with the Director of Corporate Governance and Facilities, who will advise on issues as they arise. Ensure that the Director is made aware of any actual or potential issues arising from complaints that could put the Trust at risk, including potential legal claims and involvement of H M Ombudsman. Ensure that information about the complaints procedure is available to patients and anyone else who requests it. Inform members of staff about complaints received about them. Draft responses to complaints to ensure they meet the standards expected. Provide data on clinical complaints to the Patient Safety and Clinical Risk (PSCR) Lead and all complaints to the Corporate Governance and Risk (CGR) Lead on a quarterly basis. Provide data by PCT to the Director of Service Development in line with contractual requirements Act as the Trust’s designated manager to liaise with the Parliamentary Health Service Commissioner (the Ombudsman) for complaints which proceed to the second stage of the NHS Complaints Procedure.

Director of Corporate Governance and Facilities The Director of Corporate Governance and Facilities had managerial responsibility for the complaints process and reports on this responsibility to the Chief Executive. The Complaints Manager will, by exception raise any issues related to an inability to complete the complaints process in line with this document to the Director who will advise on issues as they arise. The Director will receive a quarterly summary of all complaints for review in her role as Director of Corporate Governance

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5.6

All Directors Directors have a responsibility to:        

Ensure that formal complaints relating to their directorates are appropriately investigated within the timescales and guidelines specified in this document. Ensure that the outcomes of investigations are conveyed clearly and promptly to the Complaints Manager and Chief Executive. Where appropriate develop action plans to address shortcomings in services. Identify and implement any changes in practice within their division/directorate which are required as a result of complaint. Monitor the effective implementation of action plans. Report progress on action plans developed as a result of serious complaints to the PSCR and CGR leads. Report progress on the implementation of recommendations made following investigation by the Health Service Ombudsman to the relevant CQSG work stream lead. Ensure that members of staff against whom complaints have been made are appropriately supported throughout the investigation.

5.6

Medical Director

The Medical Director is responsible for review of all complaints to ensure that lessons are learnt as appropriate. This will be carried out both by supporting the relevant director during the complaints investigation and through review of the PSCR and CGF leads’ reports to the CQSG.

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Procedures Stage 1: Local Resolution 6.1

Aim of Local resolution

The main objective of local resolution is to ensure that complaints are dealt with promptly and satisfactorily by ensuring that the Trust: o o o o

Investigates each complaint thoroughly Identifies any lessons to be learnt Ensures that appropriate remedial actions are taken Communicates effectively with the complainant and resolves the matter to the satisfaction of the complainant.

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6.2

Verbal Complaints

Wherever possible complaints and concerns should be dealt with at the time they arise by the appropriate clinician and/or departmental manager and/or director. The Patient Advice and Liaison Service (PALS) can provide information and help for patients and their representatives to resolve concerns quickly. A record of complaints handled verbally should be sent to the Complaints Manager. Refer to the Trust PALS procedure 6.3

Formal Complaints

People wishing to make formal complaints should be advised to put their concerns in writing and address them to the Chief Executive or alternatively to contact the Complaints Manager. If a formal complaint is made orally to the Complaints Manager or other member of staff, a written record detailing the issues of concern should be prepared by the member of staff who has spoken to the complainant. This should then be forwarded to the complainant asking them to confirm that the issues of concern have been correctly understood and to sign the written record. 6.4

Time Limit for Making a Formal Complaint

A complaint should be made within twelve months of the time the event(s) (note this has been extended from 6 months in the 2006 regulations) that has given rise to the complaint. This time limit can be extended at the discretion of the Chief Executive. 6.5

Who May Complain

A complaint may be made by a patient, a person acting on behalf of a patient, or anyone who has been affected by any action/omission/decision of the Trust. Where a complainant is acting on behalf of a patient, written consent must be obtained from the patient before a response can be sent. Where the patient is a child without capacity, a complaint may be made by the parent or guardian. Where the patient has died, the complaint may be made by the named next of kin or by a person nominated by the named next of kin.. In other circumstances where the complainant may have difficulty complaining on their own behalf or have other requirements e.g. vulnerable children and adults, or people with mental health difficulties, the Chief Executive will review each situation in light of current legal requirements and good practice guidance from the Department of Health and offer help and support to a complainant as appropriate.

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6.6

Handling a Complaint

On receipt of a formal complaint the Complaints Manager will: 

Acknowledge a written complaint within three working days of receipt, enclose complaints leaflet, or give a brief indication of the process and the anticipated time for response.



Send a copy of the complaint to the relevant director or service lead asking them to advise on the most appropriate way of resolving the complaint, e.g. by a meeting, telephone call or investigation and formal letter.



Ask the relevant director or service lead for a report on the concerns raised by the complainant



Upon receipt of the advice from the department, send a letter to the complainant on behalf of the CEO with either an offer of a meeting or telephone conversation with relevant staff in the department, or confirmation that a formal investigation is underway (again indicating anticipated time for response).



Record the details of the complaint onto the Trust’s complaints register.



Advise the Director of Corporate Governance and Facilities of any complaints that may have legal implications.



Monitor the agreed time scale for response to a complaint (this can be a Trust-set target)



If the Directorate decides to resolve the complaint by way of a formal letter of response to the complainant, draft a written response for the Chief Executive to consider alongside the information received from the relevant Clinical Director or Service Lead. This may be in the form of a letter or an investigation report together with a covering letter.



Include in the response details of any action, which is being taken to implement changes in practice and procedure identified as a result of the complaint.



Ensure final letters of response or investigation reports are sent to the appropriate staff for approval of the content before being sent to the complainant.



Send approved final response to complainant within agreed set timescale. If the final response will be delayed inform complainant in writing.



Ensure that response advises the complainants of their right to contact the Health Services Ombudsman if they are not satisfied

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with the way that their complaint has been dealt with. Information on how to contact the Health Services Ombudsman is contained within the Trust’s complaints leaflet. 

Ensure copies of the response to the complaint are sent to the relevant staff.



Be responsible for maintaining secure and accurate records of each complaint.



Monitor complaints which are reopened to identify whether the initial investigation and response was appropriate or whether new issues have been raised.

Appendix A shows the process to be followed when investigating a formal complaint. Appendix B provides guidance on writing a report in response to a complaint. The annex sets out the process to be followed when complaints involve the Trust and one or more social services organisations. 6.7

Action Plans

Where the investigation of a complaint identifies the need to make changes in practice and systems, it is important that all remedial measures are clearly documented, acted upon and monitored. When staff are asked to provide accounts during an investigation they should be asked to provide details of any action or procedural change which may be made as a direct result of the complaint. The relevant director will be responsible for agreeing any procedural changes and the development of action plans in conjunction with the Trust Director if the plan is relevant to more than one directorate and for monitoring adherence to them and their effectiveness. Action plans should be developed after the completion of the investigation into the complaint (see appendices E, F & G). When a complaint involves care provided by several organisations, the Complaints Manager will liaise with those organisations to identify the most appropriate handling process for the investigation and who will lead on co-ordinating the complaint. 6.8

Complaints that have Medico-legal Implications

Complaints of a medico-legal nature will be passed to the Director of Corporate Governance and Facilities who will review the complaint and the outcome of the investigation when this has been completed. The complaint will remain on the complaints register and documentation will be filed in the complaints department. The exception to this will be if

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the complaint becomes a legal claim when it will be managed under the Trust Procedure for Claims Management. 6.9 Details of Complaints which Warrant Professional Disciplinary or Criminal Investigation Complaints such as professional misconduct, poor performance, theft, assault, wilful negligence or abuse will be passed to Director of Human Resources and Trust Director for consideration and possible action. 6.10

Complaints about Members of Staff

Where complaints are expressed against a member of staff, the following process should be followed (except where professional, disciplinary or criminal investigation is warranted). When a complaint is received regarding a member of staff, information should be obtained from the member of staff via interview or statement. The member of staff’s line manager will then be asked to review this. Following review by the line manager, action such as counselling, supervision or training should be initiated by the line manager as appropriate. 6.11

Complaints Involving Other Organisations

Where a complaint is received which involves a local healthcare partner, wherever possible a joint investigation should be carried out with the permission of the complainant. The Complaints Manager dealing with the complaint should contact the partner organisation when the complaint is received. Agreement should be reached on who will prepare the joint response and the complainant advised accordingly. The complaints manager should refer to the London Partnership Agreement for the handling of integrated complaints and concerns, see annex.

6.12

Help for people wanting to make a complaint

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Any person making a complaint should be advised that they can seek support from the Independent Complaints Advocacy Service (ICAS). ICAS provides free, impartial, confidential and independent support to people who wish to complain about health care services. Information on how to contact ICAS is contained in the Trust’s complaints leaflet. A copy of the leaflet is included at Appendix G. 6.13

Complaints received via the media

The Trust will not enter into correspondence with complainants via the media. People who get in touch with the local press to complain about the care they or their relatives have received should be advised to contact the complaints department if they wish to pursue a formal complaint against the Trust. Where a complainant has contacted the media because they are dissatisfied with the way in which their complaint has been dealt with by the Trust, they should be reminded of their right to contact the Ombudsman if they remain dissatisfied with the Trust’s handling of their complaint. The Complaints Manager will work with the communications department to prepare statements on specific issues where this is considered to be appropriate. 6.14

What cannot be investigated as a formal complaint

The formal complaints process will be suspended if:  

The complainant expresses an intention to pursue a legal claim against the Trust. The complaint concerns a member of staff who is, or may be, subject to disciplinary proceedings relating to the issue raised in the complaint.

In either of the above circumstances, the complainant will be notified in writing that the complaints procedure has been suspended and that the matter is being dealt with in accordance with medico-legal or human resources policies and procedures. There will be ongoing liaison with the complainant where appropriate.

6.15 Performance standards for stage 1

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The Trust has set the following performance standards: o Formal complaints must be acknowledged by the complaints department on the first working day of the complaint manager after receipt of the complaint (usually within 3 days) If this is not achieved then an explanation for the delay should be included on the complaints file o The Trust’s target timescale for responding to formal complaints is twenty five working days, unless the matter is complex, (eg involves other organisations) in which case the target time will be agreed with the complainant. The Trust recognises that it is not always possible to achieve this particularly where a complaint is complex. However, it is the responsibility of the Trust to ensure that timescales set out in the NHS Complaints Procedure are adhered to wherever possible. Timescales will also be monitored via the quarterly complaints reports to the PSCR and CGF leads. Conciliation/mediation Where appropriate, and with the agreement of the complainant, the Complaints Manager may involve an independent conciliator or mediator to try to resolve a complaint. 6.16

Trust’s handling of persistent complainants

Complaints received by the Trust are a form of feedback on our services from service users and their carers. It is important, therefore, that robust processes are in place to investigate appropriately and respond in timely and constructive way. It is important that service users who choose to complain are not subsequently discriminated against or experience different care/treatment as a result of complaining. . However, complainants who display unreasonable behaviourin relation to complaints put a strain on time and resources and cause stress to staff. Whilst staff are expected to to respond to complainants with patience and sympathy there are times when unreasonable behaviour is extreme or persistent and there is nothing further which can be reasonably done to assist the complainant or to rectify a real or perceived problem. The aim of this section of the policy is to help identify situations where a complainant may legitimately be regarded as ‘behaving unreasonably’ and to outline ways of responding in such situations. The decision to deem a complainant’s behaviour unreasonable should only be made after all

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appropriate steps have been taken to try and resolve the complaint through the Trust’s normal Complaints Procedure. Any cases of this kind must have the explicit support of the Chief Executive. Where appropriate the complainant should have been encouraged to contact the Independent Complaints Advocacy Service (ICAS) for help and advice and to seek the support of an ICAS representative to provide liaison with the Trust. Staff concerned should ensure that there is a complete record of the steps that have been taken. Judgment and discretion will be needed in deciding the action to be taken in specific cases. Appendix C sets out the process for terminating this process on these grounds..

Complaints procedure - stage 2: Investigation by the parliamentary and health service ombudsman: 6.17 The Parliamentary (Ombudsman)

and

Health

Service

Commissioner

Complainants who remain dissatisfied with the way their complaint has been handled following referral to the Trust have the right to ask the Parliamentary and Health Service Ombudsman to review their complaint. The Ombudsman is authorised to investigate complaints in which a failure in service, or maladministration, has allegedly caused injustice and hardship. The Ombudsman will not usually investigate a complaint which has not been through the Trust’s Complaints Procedure. Reports and recommendations produced by the Ombudsman will be formally presented to the CQSG. What the Ombudsman Will Do On receipt of a complaint, the Ombudsman will check that it is a complaint that s/he has the legal power to consider. The Ombudsman can consider complaints about:   

Unsatisfactory care or treatment. Failure to provide a service that should have been provided. Poor administration, errors, attitude, misleading advice.

The Ombudsman cannot consider complaints about:  

Private health care not funded by the NHS. Refusal of access to medical records.

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 

Matters on which legal action has been or is about to be taken. Personnel matters relating to recruitment, pay or discipline.

6.18

Role of the Complaints Manager during Stage 2

The Complaints Manager will be the Trust’s nominated contact for liaising with the Parliamentary and Health Service Ombudsman investigating officer, to include the following responsibilities:   

Provide copies of documentation as requested by the Ombudsman. Ensure that all staff involved in the complaint are informed of the Ombudsman’s involvement and are updated on developments and decisions. Ensure that decisions by the Ombudsman are communicated to the appropriate staff and acted upon promptly.

6.19

What the Ombudsman May Decide

Having completed the investigation the Ombudsman may decide to uphold the complaint in part or in full, or not at all. S/he will set out her findings and the reasons for those findings in the report. Where the complaint is upheld or partially upheld, s/he may make recommendations for appropriate redress which might include, an apology, an explanation, improvements in practices and systems, or, where appropriate, financial redress. S/he also has the power to refer clinicians to regulatory bodies in the interests of patient safety. The Ombudsman will expect any recommendations to be fully implemented and the Trust is required to demonstrate that this has been done. Clinical divisions and functional directorates will be responsible for the development of an action plan to implement the Ombudsman’s recommendations and for monitoring adherence to them. 6.20

Implementation of Recommendations Made by the Ombudsman

Other than in exceptional circumstances, all action plans should be implemented within a maximum of 6 months. It is the responsibility of the relevant Director to draft the action plan. The action plan should then be presented to the PSCR or CGR lead as appropriate. A date will be agreed for a progress report on the action plan to be presented to the Trust’s CQSG. In the meantime, action plans should be monitored on a regular basis by the director.

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Reports produced by the Ombudsman following a review of a complaint will be presented, together with the action plans, to the Management Committee by the relevant Director. 6.21

Making changes as a result of a complaint

Whilst the Trust generally receives fewer than 10 formal complaints a year, it makes every effort to learn from them and where appropriate make changes to practice to reduce the chance of a similar complaints being received again and/or improve the experience for future patients. This will be achieved through the detailed analysis and consideration of each individual complaint by the Complaints Manager, in conjunction with the Chief Executive and the relevant Director who together will see what lessons can be learned and changes made as appropriate to the circumstance of the complaint. The Complaints Manager will provide a detailed report to the PSCR and CGR leads on a quarterly basis and the CQSG may consider what if any lessons can be learned/changes made as a result of complaints received and subsequent investigation of those complaints. Lessons to be learned from the complaints report will be included in the aggregate analysis report. A summary of the changes resulting from complaints received will be included in the Annual Risk Management Report to the Board of Directors.

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Process for monitoring compliance with this Procedure The complaints manager will provide a quarterly report to the PSRG and CRG leads detailing the progress of management for any complaint received in the year (and any open complaints from the previous year). The report will show compliance with the complaints process by indicating the identification of the lead for preparing a response and timeliness of response. It will detail any lessons learned and any actions taken or planned in response to the complaint. The PSCR and CGR leads will report assurance of compliance with the procedure to the CQSG, and refer any matters arising from complaints to the Management Committee for action if required.

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Monitoring of changes agrees as a result of feedback from complaints will be monitored by the PSCR and CGR leads.

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References The Local Authority Social Services and National Health Service Complaints (England) Regulations 2009 http://www.opsi.gov.uk/si/si2009/uksi_20090309_en_1 Department of Health (2009) Listening responding and improving health care http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/Publicatio nsPolicyAndGuidance/DH_095408 National Patient Safety Agency. (2005). Patient Briefing - Saying Sorry When Things Go Wrong. London, National Patient Safety Agency. National Patient Safety Agency. (2005). Being Open Communicating Patient Safety Incidents with Patients and Their Carers. London: National Patient Safety Agency. The Data Protection Act 1998 London: Office of Public Sector Information. Available at: www.opsi.gov.uk Freedom of Information Act 2000 London: Office of Public Sector Information. Available at: www.opsi.gov.uk

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Associated documents2 This policy should be read in conjunction with the following Trust policies and procedures:    2

Incident Reporting Policy Risk Management Strategy PALS Policy and Procedure For the current version of Trust procedures, please refer to the intranet.

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Claims Management Procedure

10 : Equality Impact Assessment 1. Does this Procedure, function or service development affect patients, staff and/or the public? YES

2. Is there reason to believe that the Procedure, function or service development could have an adverse impact on a particular group or groups? NO

3. If you answered YES in section 2, how have you reached that conclusion? (Please refer to the information you collected e.g., relevant research and reports, local monitoring data, results of consultations exercises, demographic data, professional knowledge and experience)

4. Based on the initial screening process, now rate the level of impact on equality groups of the Procedure, function or service development: Negative / Adverse impact: Low……. (i.e. minimal risk of having, or does not have negative impact on equality)

Positive impact: Low………

Date completed 26.7.13 Name Jonathan McKee Job Title Governance Manager

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Appendix A : Process for handling formal complaints

Process for Handling Formal Complaints: (Trust target timetable)

Day 1 Receipt of complaint First working day of complaints manager, after receipt of complaint Complaints manager acknowledges receipt and advises complainant of process and timescale First working day of complaints manager, after receipt of complaint Complaints manager logs complaint; sends details to the complaints lead in the relevant Directorate with the request that they investigate the complaint and send details of the investigation, including any reports obtained, to the Chief Executive Response requested within two weeks* of details being sent to the Directorate; response to clearly state whether elements of the complaint are upheld or not upheld. If a complaint is upheld, state what lessons will be learnt from the complaint, and what actions will be taken by the service. *giving leeway of up to three weeks By day 20 Complaints investigation completed* Complaints manager formulates response for Chief Executive consideration. Proposed response checked for accuracy and approved by Directorate *If report/statement(s) is not available, the appropriate Director is advised so that they can chase the response Day 22-24 Final revision of response If there is an unavoidable delay so that the response cannot be completed within 25 days, the complaints manager will contact the complainant to inform them of the expected timescale By day 25 Finally approved letter signed by Chief Executive and posted to the complainant

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Appendix B : Guidelines for staff on preparing a report Guidelines for staff on preparing a report for an internal investigation or in response to a complaint, legal claim or other formal investigation You may be required to prepare a factual account of your involvement in the care of a patient for a variety of purposes. These can be:    

As part of an internal investigation, following an incident In response to a letter of complaint In response to an indication that a patient or relative is considering legal action against the Trust In response to a request from a patient or patient’s advisor in relation to a third party matter. In all cases there are some basic principles that should be followed:

  



a report (or indeed a letter) once signed and ‘on the record’ is difficult to retract Such a report does not form part of the clinical records however, the patient usually has the right to see a copy under the Data Protection Act. 1998 The granting of ‘legal professional privilege’ (ie preventing the patient form obtaining a copy of a report) is only possible once there is a clear indication that a patient/relative is suing and the ‘primary purpose of such a report is in support of a defence of a case. Following an adverse event or a serious complaint, there will now be an expectation that a report will be prepared and therefore such reports are likely to be seen by the patient on request. Therefore the following guidelines should be adopted whenever you are called to write a report:

1. Do not write in haste or from memory. Ensure that you have the available factual evidence to hand (i.e. clinical notes/other records relating to the patient) 2. Start your report in the following way I am Dr/Ms/Mr/Mrs…..(full name). I hold the qualifications of ……………….. I am currently in the post of, a post that I have been in since…………. If you are not still in the post that you held at the time of the event provide details of that post and your role on the day in question , e.g. clinical psychologist in the x team If you are a trainee/recently qualified briefly describe the relevant experience that you had had up to the event.

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3. Consider carefully what you write, stick to the facts of which you are certain, and do not stray into areas of practice that are outside your area of expertise 4. Account for your actions. Think of the report as relating your thought processes, -why you wrote what you did, how did you arrive at your diagnosis and treatment plan. Do not simply regurgitate the clinical record. 5. Do not be afraid to be over detailed. If it is fact then it can only help 6. If, in the clinical record, you used any acronyms or diagrams explain them. 7. If you genuinely cannot remember the particular patient/episode of care then it is acceptable to state this, e.g., “I only have a hazy recollection of this patient/this event, and therefore I am making this record from the records that were made by me and colleagues at the time and my usual practice. Be clear in such situations to state whether you are interpreting the records without direct memory or just stating your usual practice. Keep it factual Concentrate on what was done, by whom. Do not stray into what might have happened Do not record opinions in such an account. Usually at the early stages of an investigatory process your opinions as to what went wrong are best kept to yourself, or discussed verbally with the investigation when your factual account is complete If you are inexperienced at preparing such a report seek advice from the Director of Corporate Governance and Facilities, who may access legal advice on your behalf if required. Present the advisor with a draft and do not sign it until you have obtained advice. When the final version is complete, destroy drafts, or they may become part of the legal documentation. (Drafts, if not destroyed can be requested as disc losable documents).

Guideline prepared by Governance and Risk Adviser

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Appendix C : terminating the complaints management process following unreasonable behaviour 1) Criteria for application of this process Complainants (and/or anyone acting on their behalf) may be deemed to be unreasonable where previous or current contact with them shows that they meet one of the following criteria: a) Persist in pursuing a complaint when the Trust’s complaints procedure has been fully and properly implemented and exhausted, or is not within the Trust’s remit to investigate; or b) Change the substance of a complaint or continually raise new issues or seek to prolong contact by continually raising further concerns or questions upon receipt of a response whilst the complaint is being addressed (Care must be taken not to discard new issues which are significantly different from the original complaint. These should to be addressed as separate complaints); or c) Are unwilling to accept documented evidence of treatment given as being factual, e.g. records, or d) Deny receipt of an adequate response in spite of correspondence specifically answering their questions; or e) Do not clearly identify the precise issues which they wish to be investigated, despite reasonable efforts of Trust staff and, where appropriate, the aid of advocacy services to help them specify their concerns. Or the concerns identified are not within the remit of the Trust to investigate but they continue to be raised; or f) Focus on a trivial matter to an extent that is out of proportion to its significance and continue to focus on this point. (It is recognised that determining what is a “trivial” matter can be subjective and careful judgement must be used in applying this criteria); or g) Have in the course of addressing or raising a complaint had an excessive number of contacts with the Trust placing unreasonable demands on staff. (A contact may be in person or by telephone, letter or fax. Discretion must be used in determining the precise number of “excessive contacts” applicable under this section, using judgement based on the specific circumstances of each individual case); or h) Have harassed, threatened, or used actual physical violence, been personally abusive or verbally aggressive, racist or homophobic towards staff dealing with their complaint or their families or associates. This will in itself cause personal contact with the complainant and/or their

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representatives to be discontinued with immediate effect and the complaint will, thereafter, only be pursued i) through written communication. (Staff must recognise that complainants may sometimes act out of character at times of stress, anxiety, or distress and may make reasonable allowances for this. They must document all incidents of harassment using the Trust’s incident reporting system). 2) Process for declaring a complainant’s behaviour unreasonable a) The Complaints Manager (or Director of Corporate Governance and Facilities.) shall:i.

consider whether the complaints procedure has been correctly implemented so far as possible and that no material element of a complaint and

ii.

prepare the evidence of meeting the these criteria above to the Chief Executive who shall consider such cases. b) The Chief Executive, shall consider the complaint and any response(s) to it together with evidence presented regarding the complaints process or the criteria above and any other relevant information and shall declare or otherwise whether the above criteria has been met and provide direction as to the nature of any future communication of the Trust with the complainant and others. c) The approved decision must be recorded in writing with the reasons for the decision for the decision and a copy provided to the complainant and their representative together with any direction as to communication and copy to others already involved in the complaint (such as practitioners and clinicians, conciliators, advocacy services, Member of Parliament) d) The Chief Executive may, but is not limited to, directing the following: i.

try to resolve matters by drawing up a signed “agreement” with the complainant (and if appropriate involving the relevant clinician in a twoway agreement) which sets out a code of behaviour for the parties involved if the Trust is to continue processing the complaint. If these terms are contravened consideration would then be given to implementing other action; and/or

ii.

decline contact with the complainants either in person, by telephone, by letter or any combination of these, provided that one form of contact is maintained.

iii.

(If staff are to withdraw from a telephone conversation with a complainant the following statement or other alternative may be used: I’m sorry I am unable to deal with your complaint. I understand your

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complaint is being dealt with by .................., please contact telephone number ...........................); and/or iv.

restrict communication through a third party by negotiation; and/or

v.

notify the complainant in writing that the Trust has responded fully to the points raised and has tried to resolve the complaint but there is nothing more to add and continuing contact on the matter will serve no useful purpose. The complainants should also be notified that the correspondence is at an end and that further letters received will be acknowledged but not answered (NB: before this action is taken, the Complaints Manager must ensure that the complainant has been informed of their right to request an Independent Review by the Ombudsman); and/or

vi.

inform the complainants that in extreme circumstances the Trust reserves the right to pass unreasonable or vexatious complaints to the Trust’s solicitors; and/or

vii.

temporarily suspend all contact with the complainants or investigation of a complaint whilst seeking legal advice or other relevant agencies; and/or

viii.

time limit the declaration or make it subject to its review or reconsideration;

3) Effect of declaration Subject to the terms of the Chief Executive’s decision, a complainant whose behaviour is declared unreasonable does have the right to make new complaints if they wish and they shall be considered on merit (if they fall outside the Chief Executive’s direction) by the Complaints Manager or referred to Chief Executive for consideration and direction. The complainant should be treated fairly during the investigation of new complaints; however, the complainant should conduct themselves in an acceptable and courteous manner and not verbally harass or cause offence to Trust staff and other service users or be breach of any direction of the Chief Executive’s decision.

4) Victims Of Harassment Where staff have been assaulted, verbally abused or harassed the Trust will consider whether it is appropriate to report the facts to the police with a view to criminal prosecution. If the police and the Crown Prosecution Service decide not to prosecute, the Trust will advise its staff to consider the commencement of a private prosecution. (The Trust will also advise its staff as to the commencement of appropriate civil action such as an injunction if appropriate. The Trust will provide the member of staff with the appropriate support in taking such action).

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5) Reviewing decisions The Chief Executive may determine at a later stage that the complainant is no longer unreasonable if, for example, complainants subsequently demonstrate a more reasonable approach.

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Annex D: London partnership agreement for the handling of integrated complaints and concerns A process for the handling of joint complaints which relate to two or more health and social care organisations.

Document Lead: Approval Committee: Status of document: Approval date Review date

Lotte Higginson Complaints Manager for TPFT PASC Appendix to complaints policy January 2012 to remain current until revised version issued

Essential reading for the following staff groups:  Staff in local Complaints/PALS departments Following staff groups should be aware exists for reference purposes:  Communication teams  Directors

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Organisations consulted in the development of this document : Trust/ Member Barnet & Chase Farm Hospital Barnet Social Services Barnet, Enfield & Haringey Mental Health trust Camden & Islington Foundation Trust Camden Adult Social Care Camden Children Schools and Families Camden Provider Services (CNWL) Central And North West London NHS Foundation Trust Central London Community Healthcare (Barnet Provider) Enfield Adult Social Care Great Ormond Street Hospital Haringey Adult Social Care Islington Adult Social Services London Ambulance Service NHS Trust Moorfields Hospital NHS North Central London – (NHS Camden, Islington, Barnet, Enfield & Haringey commissioning) Royal Free Hampstead NHS Trust Royal National Orthopedic Hospital Tavistock and Portman NHS Foundation Trust University College London NHS Foundation Trust (UCLH) Whittington Health (Whittington Hospital, Islington & Haringey Provider Services)

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Contact Helen Ridler Jennifer Watson-Roberts Shivon Genus Brett Vallance Phill Sowter Phill Sowter Laxmi Devi Shrestha Jacent Tracey Tony Fishenden Lesley Howard Donna Kennerson Lesley Clay Yvonne Lehmbach Gary Bassett Helen Tate Siobhan Singlehurst

Edith Adejobi Kim Harris Lotte Higginson Lesley Creasey/John Mahoney Cassie Williams

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Table of contents:

1

Introduction

4

2

aims and general principles

4

3

current legislation and guidance

4

4

current procedures

5

5

definitions

6

6

scope of the agreement

7

7

consent and confidentiality

7

8

9

10

The procedures and agreed guidance for IMPLEMENTATION

Monitoring compliance, recording and Learning Outcomes

APPENDICES

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7

12

14

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Partnership arrangement for the handling of integrated complaints and concerns 1 Introduction Complaints may sometimes need to be redirected to other NHS or Local Authority agencies, some cases may also require multi-agency investigations. This Agreement has been established to ensure consistent joint working practices for such cases within the remit of the existing legislation (see Appendix A). There is now a duty under Regulation 9 of The Local Authority Social Services and National Health Service Complaints (England) Regulations 2009 (“The Regulations”) for local authorities and the NHS bodies to cooperate in coordinating the handling of a complaint which contains material affecting both (see Appendix B) This agreement supplements the Regulations, and provides a protocol in order to comply with the duty to cooperate under Regulation 9. 2 Aims and General Principles Complainants should only have to make one complaint and follow one procedure. The Recipient Organisation has a duty to ensure that the complaint is brought to the attention of any other agency involved. The Organisations are committed to resolving complaints wherever possible through the initial investigation stages within the required time scales. There is an obligation on the Organisations to co-operate at all stages in the complaints process, with a view to the complainant receiving a coordinated response to the complaint wherever possible. 3 Current Legislation And Guidance Complaints about health and adult social care services are governed by: The Health and Social Care Act (2008) Local Authority Social Services and NHS Complaints (England) Regulations (2009) and the Local Authority Social Services and NHS Complaints (England) (Amended) Regulations (2009) Section 75 of NHS Act 2006 (on services provided by partnership arrangements) ‘Listening, Responding, Improving- A Guide to Better Customer care’ Department of Health guidance (February 2009) ‘Principles of Good Complaint Handling’ The Parliamentary and Health Service Ombudsman (November 2008) ‘Guidance on running a complaints system’ The Local Government Ombudsman (March 2009)

4 Current Procedures

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Below is a brief summary of the comparable complaints procedures LOCAL AUTHORITY NHS TRUSTS AND ADULTS INDEPENDENT CONTRACTORS Initial investigation stages covered by this Agreement Initial response by Team Manager/Head of Service or detailed investigation by Assistant Director/ Chief Operating Officer depending on the complexity of the complaint. Further Review if requested Review by staff member not involved in the complaint or service area. Consider (if complex or contentious) whether an independent external Investigating officer would be appropriate. Ombudsman Local Government Parliamentary Ombudsman Health Service Ombudsman

LOCAL AUTHORITY CHILDREN Initial investigation stages covered by this Agreement Initial response by Team Manager/Head of Service or/followed by a detailed 2nd stage independent investigation. The response to that investigation is from an Assistant Director. Review Stages Review Panel hearing by three Independent people who send recommendations to the Director. Ombudsman Local Government Ombudsman

5 Definitions For the purposes of this Protocol: Complaint Complainant

Complaints Manager

Council

Independent Contractors Informal resolution / PALS

An expression of dissatisfaction requiring a response and falling within the 2009 Regulations Person with the right to make a complaint under Regulation 5 of the Local Authority Social Services and National Health Service Complaints (England) Regulations 2009 (i.e. Service User, person affected by decision of the authority or any recognised representative acting on their behalf of such persons in accordance with Regulation 5(2). Manager with responsibility for coordinating response to complaints about services provided by their authority (i.e. the local authority or NHS body), appointed in accordance with Regulation 4 of the Local Authority Social Services and National Health Service Complaints (England) Regulations 2009. Social Services Departments of Local Authorities/Councils, with particular reference to complaints handling for children and adults NHS GPs, dentists, pharmacists and opticians Issue where the service user/complainant does not wish to pursue a formal complaint or does not wish a formal written response to concerns raised, such as through informal resolution or Patient Advice & Liaison Service (PALS) or equivalent.

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Investigation stage Integrated Service

Period of time handling the complaint through the Regulations A service delivered in partnership where there is a statutory duty on both Organisations to provide services, but a formal agreement is in place for one Organisation to deliver the services on behalf of both Organisations (agreement under s75 of the National Health Service Act 2006) Joint A complaint that has issues that require investigation by both Complaint the local authority and NHS agency, or agencies Lead The Complaints Department of the Organisation that has Organisation agreed to send a joint response to the complainant on behalf of the Organisations complained about. Local Includes references to Social Services and Children’s Services Authority (LA) Departments. Organisation(s) One or more of the signatories to this document (i.e. the Local Authority or NHS body). Recipient The Organisation receiving the complaint. Organisation Secondary The Complaints Department/Organisation that it has been Organisation agreed will not send a written response to the complainant. This can also refer to the Complaints Department sending a separate written response to the complainant that will be copied to the relevant Organisations Trusts Includes all NHS Trusts, i.e. Foundation, Primary Care Trusts, Acute and Mental Health Trusts. 6 Scope of the Agreement 6.1 Problems/Concerns The aim is that all Organisations will co-operate in solving any joint informal problems or concerns raised by, or on behalf of the complainant, for example issues raised through the Patient Advice and Liaison Service (PALS) of an NHS Trust or Local Authority service managers. The decision as to whether an issue is dealt with as an informal problem or as a complaint will be primarily client led, and will include advice from the Complaints Manager. 6.2 Complaints This agreement is made in compliance with Regulation 9 of the NHS Complaints Regulations 2009 and Section 75 of the National Health Service Act 2006 covers complaints received by any of the Organisations which relate:   

solely to another Organisation to a jointly managed service, or to the services of more than one Organisation

The complaints procedure does not apply to complaints relating to:  private care  grievance

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 

personnel issues complaints that have already been dealt with already through the procedure

6.3 Time limits Complaints can be accepted within one year of the event or the date that the complainant became aware of it. For out of time complaints, the Complaints Manager(s) of the Organisation(s) complained about may decide to accept it if it is thought that the complainant had good reason for the delay and that it is still possible to investigate the complaint. Where it is still possible for one Organisation to respond to the issues, but the other Organisation(s) are unable to investigate the complaint, the complainant should be given an explanation for this. This agreement in no way affects a complainant’s statutory rights of complaint through any Organisation (e.g. advocacy service, Trust or Local Authority outside of the Partnership). Where there is a discrepancy between this document and complaints and/or other regulations then the regulations take precedence. Statutory responsibility ultimately still lies with each individual Organisation for responding to issues relating to their own service. These procedures are subject to, and must be read in conjunction with, the Regulations. 7 Consent and Confidentiality 7.1 Protecting confidentiality is a fundamental principle underlying this protocol. Whilst the confidentiality of a service user is important, this should not stop Organisation forwarding on a concern highlighted in a complaint to another Organisation or other relevant Organisation, with or without the consent of a service user, if a particularly serious risk or high-level concern is identified. 7.2 This procedure recognises that an Organisation may owe a complainant a duty of confidentiality in respect of personal information. Information will, generally, not be disclosed to an Organisation or other agency without consent. 7.3 However, in certain circumstances, information will be shared in the absence of consent, where there is an overriding and proportionate public interest in disclosure. An example is where the disclosure of serious child protection or safeguarding adults concerns. 7.4 Discretion will be used by the Complaints Manager of the Organisation(s) in discussion with parties concerned, particularly where there are integrated teams or services. 8 The Procedures And Agreed Guidance For Implementation

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8.1 Receipt of a complaint which falls wholly within the remit of another Organisation When a written or oral complaint is received by an Organisation, which falls wholly within the remit of another Organisation, the Complaints Manager of the Recipient Organisation will: 

Contact the complainant in writing or verbally within 3 working days, informing the complainant that the complaint falls outside their remit and, seeking consent to forward the complaint to the appropriate Organisation. (See templates 1, 2 and 3 at Appendix D). Complaints Managers will have the discretion to accept verbal consent, although this should be logged as having been sought and given.



Provide contact details for the relevant Organisation should the complainant wish to contact the relevant service directly.



Send a copy to the relevant Organisations’ complaints manager within 2 working days of receipt of the complainant’s consent to forward the complaint. (See template 4, Appendix D).

If a service is delivered by one Organisation acting on behalf of another, this allows for the whole complaint to be considered by the service Organisation under their complaints procedure. 8.2 Receipt of a complaint that has overlapping issues for the Organisation 8.2.1 A joint response from one Organisation on behalf of all Organisations is preferable at the initial investigation stages of the complaint if the complaint has been sent as a single letter. In other circumstances, the Organisations should co-operate fully in achieving this outcome wherever possible and appropriate. 8.2.2 Within 3 working days of receipt of the complaint, the Recipient Organisation should acknowledge the complaint. (See templates 5, 6 and 7, appendix D). The acknowledgement should:   

 

Ask the complainant whether s/he consents to the complaint to be forwarded to the other relevant Organisation(s). State that no further action can be taken on the issues that relate to the other Organisation(s) without this consent. Explain that, unless requested otherwise by the complainant/patient, consent will encompass agreement to share information, including all relevant medical and personal records, between the Organisations involved in the complaint, on a need to know basis, to enable the investigation and any identified improvements in service to take place. Explain that the Organisations will aim to provide a joint response, unless the complainant would prefer separate responses, and, If a GP practice or other contractor is involved in the complaint that GP / contractor will have the right to choose to respond independently.

8.2.3 A copy of the complaint will be sent to the other Organisation’s Complaints Manager within 2 working days of receipt of consent. If the complainant does not

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provide consent, the service will provide relevant contact details should the complainant wish to contact the relevant service directly. The file for the Organisation’s aspects of the complaint will be closed. 8.2.4 Once consent is received the relevant Organisation’s Complaints Departments will agree:     

Which will be the Lead Organisation (within 3 working days) The time scale within which it is anticipated the complaint will be investigated, How the investigation will take place Appropriate advocacy arrangements to be offered to the complainant, bearing in mind the restrictions of the Independent Complaints Advocacy Service (ICAS) to provide support only in relation to NHS complaints. To consider whether a local resolution meeting should be offered to the complainant

8.2.5 The Lead Organisation should inform the complainant in writing, if reasonably practicable within 3 working days of receipt of consent (see Template 8, Appendix D):     

That the complaint has been forwarded to the other Organisations. That that Organisation will be acting as the lead. How the investigation will be conducted Within what time scale the response will be sent. Details of appropriate advocacy.

8.3 Factors to consider when determining the Lead Organisation at local resolution     

If the complaint relates to integrated services, the Organisation that manages that service. The Organisation that has the most serious complaints relating to it. If a disproportionate number of the issues in the complaint relate to one Organisation compared to the other Organisation(s). The Organisation that originally receives the complaint (should the seriousness and number of complaints prove roughly equivalent). If the Complainant has a clear preference for which Organisation takes the lead.

The Organisation can agree separately from the above should other factors be pertinent. For example, if they impact on the individual Organisation’s governance arrangements. 8.3.2 If the complainant requests a particular Organisation to lead, the Complaints Manager will explain the reason behind the decision to appoint the other agency as the Lead Organisation. The Complainant will be notified of the role of each Organisation. From this point the Lead Organisation’s Complaints Manager will be the key contact for the complaint. It is their responsibility to keep the complainant informed of delays and progress. 8.4 Responsibilities of the Lead Organisation The role of the lead Organisation is to:

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        

Act as the contact point for the complainant Provide all relevant information to the complainant about the investigation, available relevant advocacy and the complainant’s rights Liaise with other Organisation and the complainant throughout the investigation Ensure that all aspects of the complaint are addressed by the appropriate Organisation within the time scale set Provide holding letters to the complainant if time scales cannot be met Collate the final response to be agreed with all Organisations Inform the complainant of the various paths of redress open to them in line with the appropriate legislation Arrange for the response to be signed and copies distributed to all relevant parties. (see template 9, appendix d) Where possible obtain feedback from the complainant on the process used

8.5 Responsibilities of the Secondary Organisation(s) The secondary Organisation will:     

Provide details of any relevant advocacy, immediate service action or support necessary Investigate the aspects of the complaint which relate to their Organisation Participate in any meeting with the complainant when appropriate Provide the lead Organisation with a report/response on the outcome of their investigation within the timescale set by the Organisation Agree the final response from the draft provided by the lead Organisation

8.6 Timescales/ Delays 8.6.1 It is essential that complainants receive timely responses, aiming for completion as soon as possible, however, some investigations may take longer and for non complex complaints the Organisations will aim to respond within 40 working days from the point of consent3. If one Organisation has completed its investigation and is ready to respond, but the other Organisation(s) is not, then the Organisation that is ready to respond should discuss with the other Organisation(s) to determine if it is free to send its response separately. However, the importance of quality of response and gaining the agreement of the complainant to an extension, over meeting timescales should always be the determining factor in the decision. The Organisation that is ready to respond must, in this case, inform the complainant in the response letter that the other Organisation(s) will be responding separately. 8.6.2 In the case of complaints of a complex nature, it may be necessary to extend the investigation timescale, dependant on the issues and the number of Organisations involved. A date by which the response will be provided by the lead Organisation should be agreed with the complainant, but a reasonable timescale for such complaints would be 65 working days. 8.7 Investigations 3

This time scale has been agreed in order to ensure that response times fall within local timescales of all Organisations. However, it should be recognised that complaints dealt with under this Agreement, by their very nature are likely to be more complex and may therefore take more time.

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8.7.1 The method of investigation will adhere to the Regulations. 8.7.2 An attempt to resolve the complaint locally should be made in the first instance, if the complainant is not happy with the outcome an alternative investigator may be appointed, if the complainant has not approached the ombudsman. 8.7.3 All Organisations agree to co-operate in any meetings with complainants/representatives aimed at reaching a resolution. 8.7.4 Where a complaint is complex in nature, it may be advisable to appoint an independent investigating officer, so as to avoid unnecessary delays and errors. (The cost of which should be shared between the Organisations, with the majority cost going to the Organisation where a greater proportion of the complaint resides). 8.7.5 Where the investigations completed by the Organisations appear to contradict other Organisations findings, the difference of opinion should be discussed in an attempt to prevent the final response containing contradictory information. 8.8 Signature on final response 8.8.1 Once the final response has been agreed, the relevant officer under the Lead Organisation’s Organisation will sign the joint complaint response letter on behalf all involved Organisations. 8.8.2 In order not to delay responses it is agreed that signatures from representatives of all involved Organisations are not needed as long as all relevant parties have agreed the wording of the letter and are copied into all correspondence. 8.8.3 In signing this agreement NHS Trust Chief Executives will be agreeing the delegation of signatory status for this purpose. 9 Monitoring compliance, recording and Learning Outcomes 9.1 The Lead Organisation, at the end of the process, should, where possible, send a questionnaire to the complainant to gain feedback on the process. This should be shared with the Secondary Organisations. 9.2 Each Complaints Manager is responsible for their own monitoring and recording of joint complaints. 9.3 To maximise joint working, the Organisations Complaints Departments will liaise on a regular basis to discuss complaint issues that are relevant/significant to the other Organisation(s). Agreement for this to take place between the Organisations on an annual basis. 9.4 The Organisations will use the information gained through the complaint process to improve the quality of the services provided by means of regular review, through their statutory reporting systems and local governance arrangements.

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9.5 To ensure anonymity, specifics should be avoided that may identify a particular complainant. This means trends, information and learning outcomes can be shared between Organisations to improve joint working and standards without the need for consent. This agreement will be the subject of a formal review 12 months after agreed or at such earlier date as:   

Any change in the relevant statutory frameworks for complaints is made, or Any changes to an Organisation’s local policy which may affect this agreement, or If it is felt by the Organisations that, through experience or complainant feedback, the agreement needs to be modified.

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APPENDICES APPENDIX A STATUTORY LEGISLATION AND RELATED GUIDANCE AND STATUTES Core Legislation The Local Authority Social Services and National Health Service Complaints (England) Regulations (2009) http://www.legislation.gov.uk/uksi/2009/309/contents/made The Local Authority Social Services and National Health Service Complaints (England) (amendment) Regulations (2009) http://www.legislation.gov.uk/uksi/2009/1768/contents/made The Health and Social Care Act (2008) http://www.legislation.gov.uk/ukpga/2008/14/contents (changes still outstanding) Primary Guidance Listening, Responding, Improving: A Guide to Better Customer Care: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndG uidance/DH_095408 Related Guidance and Statutes National Health Service Bodies and Local Authority Partnership Arrangements Regulations 2000 http://www.opsi.gov.uk/si/si2000/20000617.htm Handling complaints in the NHS - good practice toolkit for local resolution http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndG uidance/Browsable/DH_4108465 The NHS (General Medical Services Contracts) Regulations 2004 – SI 2004 No. 291 http://www.opsi.gov.uk/si/si2004/20040291.htm Effective Care Co-ordination in Mental Health Services 1999 http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndG uidance/DH_4009221 Care Home Regulations 2001 www.hmso.gov.uk/si/si2001/20013965.htm Children Act 2004 http://www.legislation.gov.uk/ukpga/2004/31/contents Care Standards Act 2000

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www.hmso.gov.uk/acts/en2000/2000en14.htm The Children Act 1989 Representations Procedure (England) 2006 SI 1738 www.opsi.gov.uk/si/si2006/20061738.htm Get It Sorted: Providing Effective Advocacy Services for Children and Young People making a Complaint under the Children Act 1989. http://publications.teachernet.gov.uk/eOrderingDownload/GIS04.pdf Regulations and guidance on providing effective advocacy services for children and young people making a complaint under the Children Act 1989 LAC (2004) 11 http://www.dh.gov.uk/en/Publicationsandstatistics/Lettersandcirculars/Localauth oritysocialservicesletters/DH_4078372 Data Protection Act 1998 www.hmso.gov.uk/acts/acts1998/19980029.htm Freedom of Information Act 2000 www.hmso.gov.uk/acts/acts2000/20000036.htm Human Rights Act 2000 www.hmso.gov.uk/si/si2000/20001851.htm ‘Principles of Good Complaint Handling’ The Parliamentary and Health Service Ombudsman (November 2008) http://www.ombudsman.org.uk/improving-public-service/ombudsmansprinciples ‘Guidance on running a complaints system’ The Local Government Ombudsman (March 2009) http://www.lgo.org.uk/publications/advice-and-guidance ‘Access to Health Records Act 1990’ http://www.legislation.gov.uk/ukpga/1990/23/contents ‘NHSLA Risk Management Standards for NHS Trusts providing Acute, Community, or Mental Health & Learning Disability Services and Independent Sector Providers of NHS Care (2011-2012)’ http://www.nhsla.com/RiskManagement

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APPENDIX B Regulation 9 of the Local Authority Social Services and National Health Service Complaints (England) Regulations 2009 (for complaints made on or after 1st April 2009): Duty to co-operate 9.—(1) This regulation applies where— (a) a responsible body (“the first body”) is considering a complaint made in accordance with these Regulations; and (b) it appears to the first body that the complaint contains material which, if it had been sent to another responsible body (“the second body”), would be a complaint which would fall to be handled in accordance with these Regulations by the second body. (2) The first body and the second body must co-operate for the purpose of— (a) co-ordinating the handling of the complaint; and (b) ensuring that the complainant receives a co-ordinated response to the complaint. (3) The duty to co-operate under paragraph (2) includes, in particular, a duty for each body— (a) to seek to agree which of the two bodies should take the lead in— (i) co-ordinating the handling of the complaint; and (ii) communicating with the complainant; (b) to provide to the other body information relevant to the consideration of the complaint which is reasonably requested by the other body; and (c) to attend, or ensure it is represented at, any meeting reasonably required in connection with the consideration of the complaint Extract from: Getting the Best from Complaints - Social Care Complaints and Representations for Children, Young People and Others – guidance on The Children Act 1989 Representations Procedure (England) Regulations 2006 Complaints made to a local authority about an NHS body Sometimes a complaint crosses over boundaries between a local authority and the NHS. Where this happens, children and young people should not have to worry about who they should approach with complaints about different aspects of the service they receive. Instead, the complaint can be made in its entirety to any one of the bodies involved. The local authority has a responsibility to work with other bodies to establish which agency should lead on handling the complaint and to ensure that the complainant is kept informed and receives as comprehensive a reply as possible. Both bodies should aim to address the complaints as fully as possible by answering questions, providing

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information and attending meetings in connection with the consideration of the complaints where appropriate. Both the local authority and the NHS staff should consider meeting the child or young person together if this will facilitate a more effective outcome. Ideally, both investigations should be completed simultaneously and reports delivered to the child or young person together. In order to facilitate this, the two bodies should aim to work to the shorter of their respective complaints procedure timescales. The arrangements set out above for identifying a lead body apply only where the matters raised concern both bodies. However, sometimes, one body receives a complaint about the actions of another. This can happen where the child or young person does not understand which Organisation is responsible for which service, but can also happen where there is an important issue of trust – a child or young person might, for example speak to a social worker he trusts about concerns over his treatment by the NHS or approach a District Nurse about a carer employed by the local authority. The Complaints Manager of the body receiving the complaint should record the outline of the complaint and, with the consent of the complainant, refer it formally to the other. It should then be for the Complaints Manager of the body complained against to make sure the complaint is dealt with properly.

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APPENDIX C: Staff contact list Trust

Barnet & Chase Farm Hospital

Contact

Helen Ridler

Contact Address Barnet Hospital, Complaints Department, Wellhouse Lane, Barnet, Hertfordshire, EN5 3DJ Chase Farm Hospital, Complaints Department, The Ridgeway, Enfield, EN2 8JL

Contact Details Tel: 0208 216 4625 (Barnet) E-mail: [email protected] Tel: 0208 375 2667/1961(direct) (Chase) E-mail: [email protected]

London Borough of Barnet, North Tel: 020 8359 4299 London Business Park, Bldg 4, Oakleigh Mob: 07747 868 966 Road South, London N11 1 Fax: 0870 889 5476 E-mail: [email protected] Admin Block, Room 14, St Ann's Tel: 0208 442 5415/5884 Hospital, St Ann's Road, London N15 Shivon Genus Fax: 0208 442 6622 3TH E-mail: [email protected]

Jennifer Barnet Social Services WatsonRoberts Barnet, Enfield & Haringey Mental Health trust Camden & Islington Foundation Trust

Camden Adult Social Care

Camden Children Schools and Families Camden Provider Services (CNWL) Central And North West London NHS Foundation Trust Central London Community

Advice and Complaints Service, St Brett Vallance Pancras Hospital, 4 St Pancras Way, London, NW1 0PE London Borough of Camden, 3rd Floor, Bidborough House Phill Sowter 38-50 Bidborough Street, London, WC1H 9DB

Phill Sowter

Tel: 0203 317 3117 Fax: 0207 530 3735 E-mail: [email protected] Telephone number: 020 7974 4341 Fax: 020 7974 5822 (Temporary) Email: [email protected]

Children Schools & Families, London Borough of Camden, Tel: 0207 974 6673 Crowndale Centre, 218 Eversholt Street, Fax: 0207 974 1439 London NW1 1BD Email: [email protected]

Laxmi Devi Shrestha

3rd Floor Bedford House, 125-133 020 7685 5973 Camden High Street, London NW1 7RJ [email protected]

Jacent Tracey

Stephenson House, 67-87 Hampstead Road, London, NW1 2PL

Tel: 020 3214 5784 E-mail: [email protected]

Tony Fishenden

7th Floor, 64 Victoria Street, London, SW1E 6QP

Tel: 0800 368 0412 or 020 7798 1436 Email: [email protected]

Complaints Procedure, Ver 4.5, May 2014

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Trust Healthcare (Barnet Provider) Enfield Adult Social Care Great Ormond Street Hospital Haringey Adult Social Care

Contact

Islington Adult Social Services

Yvonne Lehmbach

London Ambulance Service NHS Trust

Gary Bassett

220 Waterloo Road, London, SE1 8SD

Moorfields Hospital

Helen Tate

162 City Road, London EC1V 2PD

NHS North Central London – (NHS Camden, Islington, Barnet, Enfield & Haringey commissioning)

Siobhan Singlehurst

5th Floor Stephenson House, 67-87 Hampstead Road, London, NW1 2PL

Lesley Howard Donna Kennerson Lesley Clay

Contact Address

Contact Details

PO Box 59, Civic Centre, Silver Street, Enfield, EN1 3XA Great Ormond Street, London, WC1N 3JH 40 Cumberland Road, London, N22 7SG Customer Service Team, 338-346 Goswell Road, London EC1V 7LQ

Kim Harris

Tavistock and Portman NHS Trust

Lotte Higginson

UCLH

Brockley Hill, Stanmore, Middlesex, HA7 4LP

Tavistock Centre, 120 Belsize Lane, London NW3 5BA Governance Department, 2nd Floor Lesley Creasey/ West, 250 Euston Road, London, NW1 John Mahoney 2PG

Whittington Health Whittington Hospital, Magdala (Whittington Hospital, Cassie Williams Avenue, London, N19 5NF Islington & Haringey Provider Services) Complaints Procedure, Ver 4.5, May 2014

0207 813 8402 [email protected] Tel: 0208 489 3398 E-mail: [email protected] Tel: 0207 527 8047 Fax: 0207 527 8367 E-mail: [email protected] Tel: 020 30690240 E-mail: [email protected] [email protected] Tel: 0207 566 2324/2325 020 3317 3003 [email protected] Tel: (020) 7794 0500 x38263 Direct Line: (020) 7317 7525 E-mail: [email protected]

Royal Free Hampstead Edith Adejobi Pond Street, London, NW3 2QJ NHS Trust Royal National Orthopedic Hospital

Tel: 0208 379 3933

Tel: 020 8909 5717 [email protected] Tel: 0208 938 2335 E-mail: [email protected] 0845 155 5000 ext 4797 [email protected] Tel: 0207 288 5969 E-mail: [email protected]

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APPENDIX D EXAMPLE TEMPLATE LETTERS (These are intended as helpful guides and are not mandatory) TEMPLATE 1 ACKNOWLEDGEMENT BY RECEIVING ORGANISATION WHERE COMPLAINTS FALL WHOLLY WITHIN THE REMIT OF ANOTHER ORGANISATION Dear I am writing to acknowledge receipt of your complaint, dated ………, in which you raise concerns about …………….. The services to which you refer are actually managed by …………………………… I am therefore seeking your consent to forward your letter to that Organisation in order that they can investigate your concerns and respond directly to you. Alternatively if you wished to correspond directly with …(said Organisation)………………….. the contact details are: Enter contact name, address, phone number, e-mail address. I attach a consent form for your completion and return in the pre-paid envelope provided. *As you are complaining on behalf of the patient/service user*, ……(Organisation)…. … are likely to require the patient/service user’s consent to share personal information with you in responding to your concerns. The attached consent form makes allowances for this. Please let me know if I can be of any further assistance. Yours sincerely * delete where appropriate

Trust Complaints Policy, Ver 4.3, 2012

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TEMPLATE 2 FOLLOW UP LETTER IF CONSENT NOT RECEIVED WITHIN TWO WEEKS OF SENDING ACKNOWLEDGEMENT Dear I am writing further to my letter of ……………….. As I have not heard from you with consent to forward your complaint to the ………….. (Organisation)…… , I am assuming that you have contacted them directly and we will therefore take no further action. Yours sincerely

Trust Complaints Policy, Ver 4.3, 2012

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TEMPLATE 3 CONSENT FORM FOR INCLUSION WITH TEMPLATE 1 I, (name) …………………………………………………………………..… of (address) …….………………………………………………………………………………………………… ….give consent for my letter of complaint, dated …………… to be forwarded to …………………………………………. If you are not the patient/service user, and they are unable to act on their own behalf please give below the reasons why the patient cannot give consent and your relationship to that patient or status on which you are acting for them (eg executor of will). If you have evidence of that status please attach a copy: Signed ………………………………………………………….. Date ………………………… If you are not the patient/service user, and they are able to give consent, please ask the patient/service user to complete and sign the following statement. I, (name of patient/service user) ………………………………………………………… am happy for (name of complainant ………………………………………………………………………………… to act on my behalf in relation to the complaint they have raised. In giving this consent I also agree that relevant personal information about my care can be shared with (name of complainant) ………………………………………to the extent which is required to respond to the complaint. Signed ………………………………………………………… Date ……………………………

Trust Complaints Policy, Ver 4.3, 2012

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TEMPLATE 4 LETTER TO RECEIVING ORGANISATION WHERE THE COMPLAINT RELATES WHOLLY TO THEM. Dear I am enclosing a complaint received from ………………………… date ………………… as the concerns relate to services your Organisation provides. A copy of the consent form provided by ……………………….. is enclosed Or Consent to forward this to you was obtained verbally from the complainant. I would ask that you correspond directly with ……………………..once this is received. Thank you for your assistance. Yours sincerely

Cc

complainant

Trust Complaints Policy, Ver 4.3, 2012

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letter

TEMPLATE 5 ACKNOWLEDGEMENT BY RECIPIENT ORGANISATION WHEN PARTS OF THE COMPLAINT RELATE TO ANOTHER ORGANISATION(s) AND A JOINT RESPONSE IS APPROPRIATE (i.e. there are overlapping issues) * delete where appropriate Dear I am writing to acknowledge receipt of your complaint, dated ………, in which you raise concerns about …………….. (Offer condolences in the case of a bereavement). The issues raised in your complaint would also require the involvement of .…………… ……………….... who would need to investigate your concerns relating to ………….. It would be our aim to liaise with ……………………………. in order to provide you with a joint response to cover all your concerns. To do this we will require your consent to share your letter of complaint with ……………………………., and also for any relevant personal information about your/the patient’s* care to be shared, on a need to know basis, between the Organisations. Please complete and return to me, in the prepaid envelope provided, the enclosed consent form in order that this action can be taken. If we do not receive consent from you to share your complaint with the other appropriate Organisation(s) by …………………….. (date 2 weeks from date of letter), we will assume that consent is withheld. In this case we will respond to the concerns relating to our own Organisation as far as is possible and no further action will be taken with regard to the issues relating to ……………………………………., although you will be free to contact …………………………. (other Organisations) direct for a separate response. If you would like any independent support or advice you can contact ……………….. advocacy service. Please contact me if you would like to discuss the contents of this letter in more detail. Yours sincerely

Trust Complaints Policy, Ver 4.3, 2012

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TEMPLATE 6 CONSENT FORM FOR COMPLAINTS REQUIRING A JOINT RESPONSE I, (name) …………………………………………………………………..… of (address) …….………………………………………………………………………………………………… ….give consent for my letter of complaint, dated …………… to be forwarded to …………………………………………. In order that I can receive a joint response to the issues I have raised. I also give consent for any personal information, relevant to the complaint, to be shared between the agencies involved. If you are not the patient/service user and they are unable to act on their own behalf, please give below the reasons why the patient cannot give consent and your relationship to that patient or status on which you are acting for them (eg executor of will). If you have any evidence of this status please attach a copy: Signed ………………………………………………………….. Date ……………………… If you are not the patient/service user, but they are able to give consent, please ask the patient/service user to complete and sign the following statement. I, (name of patient/service user) ………………………………………………………… am happy for (name of complainant) …………………………………………………………………………… to act on my behalf in relation to the complaint they have raised. In giving this consent I also agree that relevant personal information about my care can be shared with (name of complainant) ………………………………………to the extent which is required to respond to the complaint and also between the Organisations who were involved in the care which is the subject of the complaint. Signed ………………………………………………………… Date ……………………………

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TEMPLATE 7 FOLLOW UP LETTER IF CONSENT NOT RECEIVED WITHIN TWO WEEKS OF SENDING ACKNOWLEDGEMENT Dear I am writing further to my letter of ……………….. As I have not heard from you with consent to forward your complaint to the ………….. (Organisation)…… , I am assuming that you do not wish this aspect of your complaint to proceed. We will therefore respond to your concerns using the information this Organisation alone holds. This may restrict the detail of the response but we will do our best to provide you with as much information as we can. If you would like to contact ……………….. directly to obtain a separate response to the issues relating to the services they provide you can contact: (name, address etc) Continue with usual information about time scales, advocacy etc Yours sincerely

Trust Complaints Policy, Ver 4.3, 2012

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TEMPLATE 8 LETTER TO COMPLAINANT FOLLOWING RECEIPT OF CONSENT AND AGREEMENT BETWEEN ORGANISATIONS AS TO HOW TO PROCEED. Dear I am writing further to my/ Organisation’s* letter of ………………….. We have received the consent to share information and a joint investigation of your complaint has now commenced. I will be your point of contact and will liaise with ……………………………….. (other Organisations) throughout the investigation, collating the information gathered from each Organisation and organising the response. If appropriate add a paragraph about the process if it differs from straight forward collation of information eg if mediation is to take place or a meeting is being offered.. (If appropriate: Part of your complaint did relate to your GP. We have been in contact with Dr ……… and s/he has requested that he respond independently. You will therefore be receiving separate correspondence from the practice.) We would aim to respond to you by ………………….. If this proves not to be possible I will contact you again to let you know the reasons and to agree with you an alternative time scale. If you require any independent support and advice you can contact …………………….. who provide an advocacy service. Please do not hesitate to contact me if you have any further queries at this stage. Yours sincerely Cc Other Organisations

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TEMPLATE 9 SUGGESTED STRUCTURE FOR FINAL RESPONSE             

The letter can either: be a covering letter to separate reports from the Organisation agencies, or incorporate responses from the Organisations within the body of the letter. The structure of the letter should be: Introduction, referring to previous correspondence Apology/condolences Summary of concerns How the investigation took place (staff involved, review of records etc) Response to each issue as listed in the summary of concerns. If the responses are incorporated in attached reports, refer to the reports Offer of meeting/chance to raise any questions Summary of action being taken as a result of the complaint Details of redress – should be in accordance with legislative framework Reiteration of apology Contact details for further enquiries Details of the Parliamentary and Health Service Ombudsman

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Trust Complaints Policy, Ver 4.3, 2012

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