SALISBURY NHS FOUNDATION TRUST HANDLING COMMENTS, CONCERNS, COMPLAINTS AND COMPLIMENTS POLICY

Transcription

1 SALISBURY NHS FOUNDATION TRUST PAPER: SFT 28 TITLE : HANDLING COMMENTS, CONCERNS, COMPLAINTS AND COMPLIMENTS POLICY PURPOSE OF PAPER The purpose of this policy is to ask the Trust Board to ratify a replacement policy for the process of handling comments, concerns, complaints and compliments. This Policy has been written to comply with The Local Authority Social Services and National Health Service Complaints (England) Regulations 29 No. 39 which came into effect on 1 April 29. EXECUTIVE SUMMARY The policy sets out the protocol for dealing with comments, concerns, complaints and compliments about any aspect of the care, treatment and service provided by the Trust. An important principle behind complaints reform is that all health and social care organisations work together, conducting joint investigations. This is to ensure co-ordinated handling and to provide the complainant with a single response when two or more organisations are involved. The Joint Board of Directors approved this policy on 12 March 21. ACTION REQUIRED BY THE BOARD The Trust Board is asked to ratify the policy. Tracey Nutter Director of Nursing

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21 Stage 1. Screening Name of activity: Handling comments, concerns, complaints and compliments. Date: FORM A Name of person responsible for the activity: Hazel Hardyman, Head of Customer Care Directorate: Nursing Directorate Names of people undertaking screening: Hazel Hardyman, Pat Peters Department: Customer Care Department Briefly describe the purpose of the activity: Who will benefit from this activity? To ensure all staff understand their responsibilities and the procedure for dealing with comments, concerns, complaints and compliments. Staff, patients, relatives and carers 1. Could or does the activity affect one or more of the equality groups in a different way to others? 2. Could or do different equality groups have different needs in relation to the policy? Yes No Please give details 3. Does the policy actually or potentially hinder equality of opportunity? 3. Does the policy actually or potentially contribute to equality of opportunity? 4. Does the policy offer opportunities to promote equality? 5. Does the policy offer opportunities to promote positive relations? Does this activity/policy require further impact assessment, action or amendment? (if yes, please contact pamela.permalloo-bass@salisbury.nhs.uk for further guidance) Please state in your policy documentation that it has been equality impact assessed and include your completed screening form (FORM A) as an appendix. Screening form completed by: When will the policy and screening be reviewed? Please forward a copy of your policy/activity document and completed screening form (FORM A) to pamela.permalloo-bass@salisbury.nhs.uk

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24 CUSTOMER CARE DEPARTMENT -! Record of discussion / Telephone conversation Date: Time: Patient s name: Address: Date of Birth: Hospital Number: Telephone Number: Enquirer s name: (if different to patient) Enquirer s relationship: Enquirer s address: (if different to patient) Enquirer s Tel No: Enquirer s address: Preferred method of contact with enquirer (please box): Telephone Written Face-to-face (If still in hospital) Nature of discussion (please box) Comment Concern Complaint Compliment Summary of issues (Please continue overleaf) /

25 What outcome does the complainant want? (e.g. to not happen to someone else; second opinion etc) What timescale have you agreed with the enquirer to respond to the issue? days (Comments and concerns -1 working days Complex concerns and complaints 1-25 working days) Summary of actions taken Date: Action: Staff name:.. Job title:... Ext No: Signature:.. Please this form to at the end of your session so that the information to date can be logged on our database (Datix). When you have resolved the issue with the enquirer, please make sure you have recorded all your actions on the form and send it again by so that Datix can be updated and the case closed. Thank you for your help. 3

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31 SALISBURY NHS FOUNDATION TRUST CUSTOMER CARE DEPARTMENT - ACTION PLAN -: Complaint Details: Name: Hospital No: Complaint No: Complaint Handler (Directorate): I have undertaken the investigation into the enclosed complaint and I am satisfied that the attached response covers all aspects of the complaint for my area. I have completed the Action Plan below. Signed: Date: (Investigating Officer) Risk grading Consequence: None Minor Moderate Major Catastrophic Likelihood of reoccurrence: Rare Unlikely Possibly Likely Certain Action Plan: No Action Required Please complete the action plan if you feel there are any issues arising from the complaint that require attention: Action Plan Implementation/ Review Date (Please continue overleaf) 3

32 Action Plan Implementation/ Review Date Staff Involved Staff Name & Grade Staff Role Code Codes for Staff Role ASSIST Assisting with care delivery / procedure / treatment DIRADM Directly administering to patient(s) INFORM Informed of incident LEADUP Involved in the lead-up to the incident OTHER Other RESP Overall responsibility for the patient(s) involved WITN Witness to the incident 5

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42 Protocol for Managing Customer/Patient Feedback Date June 29 Review date April 21

43 1. Introduction 1.1. Sometimes a concern or complaint crosses over boundaries between the NHS and a local authority. Where this happens, people who use services should not have to worry about who to approach with complaints about different aspects of the service that they receive. Instead, the complaint can be made in its entirety to any one of the bodies involved. The purpose of this protocol is to set out the arrangements for the successful handling of cross boundary issues within the boundaries of the Great Western Ambulance Trust and Avon & Wiltshire Mental Health Partnership Trust boundaries including the following organisations (the West Country health and social care organisations): Great Western Ambulance Service Avon & Wiltshire Mental Health Partnership Trust NHS South Gloucestershire South Gloucestershire Council NHS Bristol Bristol City Council University Hospitals Bristol North Bristol NHS Trust NHS B&NES B&NES Council Royal United Hospital Bath Royal Hospital for Rheumatic Diseases NHS North Somerset North Somerset Council Weston Area Health Trust NHS Wiltshire Salisbury NHS Foundation Trust Wiltshire County Council Great Western Hospitals NHS FoundationTrust NHS Swindon Swindon Borough Council NHS Gloucestershire & Gloucestershire Care Services Gloucestershire County Council Gloucestershire Hospitals Foundation Trust 2gether Foundation Trust for Gloucestershire 2

44 1.2. This protocol has been developed to formally record the agreement between the West Country health and social care organisations on how to process customer/patient feedback. As such it is produced for those members of staff in these organisations who have responsibility for managing feedback and is not intended as a public document. The aim of this protocol is to ensure that the customer/patient does not need to know who does what but has confidence that their feedback will be appropriately managed. Literature specifically designed for customers/patients has been developed and produced This protocol has been developed in accordance with the Local Authority Social Services and National Health Service complaints (England) Regulations Each organisation has their own systems for recording and reporting of complaints. Each organisation must record the complaint within their own system for tracking, monitoring and reporting on learning within their organisation. 2. Problem solving 2.1. Both the NHS, through the Patient Advice and Liaison Service (PALS), and the local authorities have been developing a more customer/patient focussed way of dealing with complaints. Both services offer an opportunity for people to raise issue or concerns that can be resolved without invoking the complaints process. It is important that each organisation has robust mechanisms to record feedback and to ensure that learning from issues is fed back into the organisation. 3. Making a Complaint Handling issues involving more than one service Lots of people receive care from more than one health and social care organisation. If something goes wrong with that care and a complaint is made, it is important that the organisations involved provide a single point of contact and a single response The regulations require that if the complaint includes matters relating to both the NHS and Social Care, these bodies must cooperate for the purposes of 3

45 a) coordinating the handling of the complaint; and b) ensuring that the complainant receives a coordinated response to the complaint Each organisation has a duty to publicise their complaints procedures and provide details as to how to make a complaint. Provision must be made for complainants to make their complaint in the most appropriate format for them; this may be verbally or in writing. Each organisation has a duty to cooperate with all other agencies involved in a complaint, in order to best resolve the issues raised In some circumstances an advocate may provide support to the person making the complaint and the health and social care organisations publish the arrangements by which Advocacy Services may be contacted. 4. Receiving the Complaint 4.1. Acknowledgements may be oral or written. When a joint complaint is received, the acknowledgement must be made within three working days and permission from the complainant to share the complaint with another body should be sought at this time. The organisations must agree the time scale with the complainant If the complaint is solely for another organisation then the Complaints/PALS Manager should seek permission from the complainant to pass the complaint onto the relevant organisation on their behalf If the complaint is received by one body and it includes elements for another body it will be necessary to alert the complainant to this during the initial contact. Where this is the case then the lead organisation should advise the complainant of this, and agree timescales accordingly The flowchart at appendix 1 sets out the steps to be taken. 5. Consent and Information Sharing 5.1. We will seek consent from the complainant to share information with another body within acknowledgement. Once consent is received, the information will be passed to the other body within three working days. An example consent form is attached at appendix four. 4

46 5.2. Information should be shared between organisations via secure methods. It is the responsibility of each organisation to ensure it follows organisational information governance policy whichever method of sharing information is used In the event that consent is denied, the complainant will need to be informed that there is likely to be a limit to what any investigation can consider and respond to. They should be advised that separate complaints must be made to those organisations involved and that this is the responsibility of the complainant. 6. Factors to Determine the Lead Organisation 6.1. The following factors should be taken into account when determining which organisation will take the lead role with any cross boundary/multi agency complaint: The organisation that manages integrated services 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 If the complainant has an established relationship with one of the agencies The organisations can agree separately from the above should other factors be pertinent. For example, if the impact on the individual organisation s governance arrangements. 7. Agreeing the issues and the complaint plan 7.1. Where there are elements of complaints for both bodies there will be close cooperation and discussion between Complaints/PALS Managers in identifying which issues are for which organisation. These elements need to be clearly identified and recorded as part of the outline complaint plan. See appendix There may be some elements of a complaint that can be resolved quickly at a local level with the complainant s agreement. This would be agreed with the 5

47 complainant during a conversation about the complaint plan and would then be referred to in the final response From initial discussions with each other the Complaints/PALS Managers will need to agree the following: Which body will discuss the complaint plan with the complainant, thereby acting as the lead? Who will make the initial contact with the complainant? Who will be the named point of contact for the complainant? What are the timescales for completion of response? What are the milestone deadlines for sharing information during the investigation process and who will keep the complainant informed? Are there any elements that may be more appropriately dealt with by other routes, for example, legal proceedings, Safeguarding or grievance disciplinary procedures? Who will carry out the investigation and how; agree how the complaint will be best dealt with? Who will meet the complainant to discuss the issues, outcomes and timescales? This discussion with the complainant also needs to confirm the method of response. When will the draft response be submitted to each organisation for approval? Who will sign off the response? 7.4. The complainant will need to agree as to which body has responsibility for which elements of complaint and the timescales for completion If an appropriate timescale cannot be agreed with the complainant, the organisations involved will agree and the lead body will inform the complainant in writing. 8. Responding to the Complainant 8.1. A coordinated response must be sent to the complainant. The lead body will send the agreed final response If one organisation is having difficulty meeting the agreed timescale this should be discussed at the earliest opportunity. The lead will then contact the complainant to agree an extension with them and keep updating all involved. 6

48 8.3. A draft response needs to be shared with the appropriate Officers for signing off. Each body will agree to the draft but only the Officer of the lead organisation needs to formally sign. The response will make it clear that it is on behalf of the other organisation as well. The sharing of the draft response is an opportunity to address any discrepancies and identify areas for joint learning The response needs to clearly explain the next step in the complaints process should the complainant remain dissatisfied Where national guidance or policy is implicated in a response, the relevant document should be quoted A copy of the final response should be passed to all other responding bodies. 9. Improving 9.1. Action plans should be prepared jointly to demonstrate learning and organisational improvement. These should be shared across the organisations concerned. Each organisation is responsible for the implementation and monitoring of any learning that comes from the complaint The organisations involved should agree a date for a review of the complaint; how it was handled and any learning outcomes. 1. Disputes between organisations 1.1. If there is a difference of view during any stage of the complaint handling process the matter should be passed to an appropriate senor manager in each organisation for agreement on the way forward. Any dispute must not cause any delay or other inconvenience to the complainant. 7

49 Appendix 1 FLOWCHART: MANAGING CROSS BOUNDARY/MULTI AGENCY COMPLAINTS Complaint received Acknowledge within 3 working days and process under own procedure No Is another body involved? Yes Acknowledge and seek consent to share with other body within 3 working days Identify and separate out issues and areas of responsibility for each body. Decide which body will lead Agree milestones and timescale for response with complainant Draft response shared between agencies and final response agreed Lead organisation sends response to complainant 8

50 Appendix 2 Example for complaint plan Complaint Plan Contact Information Contact s Details: Name: Address: Telephone No.: Home: Work: Mobile: Contact times: Service user s details (if different) Name: Address: Telephone No.: Home: Work: Mobile: Contact times: Date of discussion With PALS/Complaints Contact assessed by Case Number and date of birth Date of discussion and agreement on actions with contact Investigator Directorate/Business Unit Service Location 9

51 Details of Concerns / Complaints Summary of Concern / Complaint Contact / Complainant s expectations and desired outcomes Additional support arrangements e.g. advocacy Additional information to note, e.g. any special contact arrangements Preferred method of contact Agreed response date Written reply Meeting Other please state Verbal reply Initial Risk Grade (see Risk Assessment Guidance below) Date consent received (if applicable) including to share information if other organisations involved Date sent to other organisation 1

52 Agreed way forward / investigation methods e.g. Formal investigation, meeting with staff, mediation etc Agreed dates for updates (if requested) Date Closed Conclusion risk grade Date of any action plan to be sent following investigation Agreed dates for any further updates on service improvements to be sent Evaluation questionnaire sent 11

53 Risk Assessment Guidance Step 1: Decide how serious the risk is Step 2: Decide how likely the issue is to recur 12

54 Step 3: Categorise the risk 13

55 Appendix 3 Customer Feedback Journey Map: Handling complaints across NHS and Adult Social Care Customer expectation Customer makes a complaint to one organisation but the complaint is also about another Doesn t want to have to make two separate complaints Expects a response to the complaint Wants to know what to do next if they don t like the outcome organisation Broad Process Customers will generally phone the number they were last Customer gives consent for one organisation to make contact with One response is provided, where possible Customer informed of next steps if they remain dissatisfied provided with and may make a the other organisation to discuss couple of calls until they are put complaint Follow up with satisfaction survey to in touch with the PALS / check all OK now Complaints Service for whichever organisation they contact Complaint acknowledged Consent received complaint Any extensions required Response includes concluding Quality Standards within three working days Issues, expectations and outcomes broadly agreed shared with other organisation within five working days Agree lead and one point of should be agreed with other organisation and customer Copies of draft responses paragraph advising what to do next and who to contact Response also includes Consent sought to share contact for customer exchanged between information about any action from complaint with other Agree complaint plan with organisations the complaint organisation other organisation and Response to customer within Each organisation is responsible Customer advised that they customer agreed timescales for implementation and will receive confirmation of All receive copy of complaint Copy provided to all monitoring of any learning from who will be handling their plan organisations involved the complaint complaint and of the Agree review date timescales 14

56 Statement of consent for the disclosure of personal records (example) Appendix 4 Complainant s name: Complainant s address: Telephone number: I hereby give my consent for the organisations listed below to share any relevant information in order to complete the investigation into my complaint. I understand that this is likely to include disclosure of my personal records. (Lead organisation) (Organisation) (Organisation) This will assist the investigation of my joint organisation complaint, which is being co-ordinated by: (Name of complaints manager) of (Organisation) The reason for, and the implications of, this have been explained to me by the above-named complaints manager. I understand that information exchanged as agreed by me must be used solely for the purpose for which it was obtained. Signed: Date: Once completed, please return this consent form in the envelope provided. 15