Complaints Policy by L68q1x


									                        NHS WARWICKSHIRE POLICY FOR
                            HANDLING COMPLAINTS

Accountable Director:                            Director of Compliance

Policy Author:                                      Rachel Freeman
                                         Corporate Risk and Complaints Manager
Approved by:                             Quality, Safety & Governance Committee

Date approved:                                        20 August 2009

Issue date:                                           20 August 2009

Review date:                                             April 2011

Person responsible for instigation:                   Rachel Freeman

Implementation plan in place:                                Yes

Equality Impact Assessment (EIA):                            Yes

Version Control                       August 2003
                                      November 2004
                                      March 2007
                                      October 2008

NHS Warwickshire Complaints Policy
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        Section                                                              Page

       1.           Introduction                                              1

                    1.1 Rationale                                             1

       2.           Scope of Policy                                           1
       3.           Principles                                                2
       4.           Discrimination                                            3
       5.           Policy Objectives                                         3
       6.           Recognising a Complaint                                   3
       7.           Time Limits for Making a Complaint                        4
       8.           Overview of Complaints Procedure                          4
       9.           Who May Complain?                                         5
       10.          Roles and Responsibilities                                5

                    10.1 Chief Executive                                      5
                    10.2 Responsible Director                                 5
                    10.3 NHSW Complaints Manager                              5
                    10.4 All Staff                                            6
                    10.5 Investigating Officer                                6
                    10.6 Quality, Safety & Governance Committee               7
                    10.7 Conciliator                                          8
                    10.8 Patient Advice and Liaison Service                   8
                    10.9 Independent Complaints Advocacy Service              9
                    10.10 Health Service Ombudsman                            9

       11.          Training                                                  9
       12.          Monitoring, Audit and Learning                            10
       13.          Scheme of Delegation                                      10
       14.          Publicity                                                 11
       15.          Issues Affecting all Complaints                           11

                    15.1 Confidentiality                                      11
                    15.2 Disclosure of Documents                              11
                    15.3 Consent                                              11
                    15.4 Primary Care Complaints                              11
                    15.5 Complaints Involving other Organisations             12
                    15.6 Allegations of Theft                                 12
                    15.7 Complaints Leading to Legal Action                   12
                    15.8 Vexatious Complainants and Communications            13

       16.          Commissioners                                             14
       17.          Development and Consultation Process                      14
       18.          Policy Implementation Plan                                15
       19.          Equality Impact Assessment                                17


       1.           Complaints       Procedure   for   NHSW   Services   -    19

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       2.           Procedure for Handling NHSW Formal Complaints       20
       3.           Guidelines for Staff on Handling Complaints,
                    Concerns, Suggestions and Compliments               24
       4.           Risk Grading Matrix                                 28
       5.           Complaints Procedure (Independent Contractors)      29
       6.           Process for Joint Working                           36
       7.           Guidance for Handling Vexatious Complainants and
                    Communications                                      37

        For the purpose of this document NHS Warwickshire will be referred to as

        This policy will be read in conjunction with the following NHS Warwickshire

                   Statutory Instrument 2009 No. 309 – The Local Authority Social
                    Services and National Health Service Complaints (England)
                    Regulations 2009;
                   Policy for Handling Complaints (Community Services);
                   Complaints in Primary Care Guidance;
                   Complaints in Provider Services Guidance;
                   Good Practice Guidance for Root Cause Analysis Investigation
                   Patient Safety and Risk Management Strategy;
                   Root Cause Analysis Tool Pack;
                   Significant Event Auditing in Practice;
                   Raising Matters of Concern;
                   Consent Policy;
                   Being Open Policy
                   Access to Health Records Policy;
                   Parliamentary and Health Service Ombudsman:
                       o Principles of Good Administration
                       o Principles of Good Complaint Handling
                       o Principles for Remedy

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1.      Introduction

        In 2006 the Government committed to helping NHS and Adult Social Care
        organisations to improve the way in which complaints were dealt with, in order to
        make services more effective, personal and safe.

        It was decided that a single approach would be introduced for dealing with
        complaints, to give organisations greater flexibility to respond and encourage a
        culture that uses people’s experiences of care to improve quality of services.

        The new Regulations came into force on 1st April 2009 and the process allows
        the Complaints Manager and the complainant to agree on the best way to reach
        a satisfactory outcome. It should also allow people who use services, whatever
        their background or circumstances, to find it easier to make a complaint. The
        new system will also encourage services to learn from individual complaints and
        make improvement to services as a result.

        NHSW needs to have a consistent approach to the handling of complaints and
        to ensure that anyone making a complaint receives a timely explanation,
        apology and details of any action taken.

        NHSW, as a commissioner, is required to ensure that processes, systems,
        feedback and learning are robust and support patient safety to all NHS patients
        within Warwickshire.

        NHSW will ensure that when making arrangements for service provision with an
        independent provider, the provider has in place arrangements for handling and
        consideration of complaints that comply with the Regulations.

1.1.    Rationale

        Policy context

        If someone is unhappy with the treatment or service they have received from the
        NHS they are entitled to make a complaint, have it considered and receive a
        response. This policy supports NHS Warwickshire’s approach to hearing the
        views of patients and members of the public about the services they have
        received and learning from these in order to make changes to practice and
        services to ensure that the residents of Warwickshire receive a standard of
        service they have a right to expect.

2.      Scope of the Policy

        Complaints may be made to NHSW about any matter reasonably connected with
        the exercise of its duties, including any matter reasonably connected with:

               The provision of healthcare or any other services
               The function of commissioning healthcare or other services under a
                contract or making the arrangements for the provision of such care or
                service with an independent provider
               Services provided by Primary Care Practitioners

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               Services provided overseas or by the private sector where NHSW has
                commissioned these services

        There are some areas which fall outside the scope of the national and local
        complaints policy. These include:

               Complaints from other organisations i.e. local authority, NHS body,
                primary care provider or independent provider
               Complaints from employees about matters relating to employment
               A complaint that has been made orally and is resolved to the
                complainants satisfaction not later than the next working day after the
                complaint was made
               A complaint which has previously been resolved
               A complaint that has already been referred to the Health Service
               Complaints arising from alleged failure to comply with a request for
                information under the Freedom of Information Act 2000.

        NHSW will, however, support staff who are required to liaise with Provider
        Services as part of their duties, should the member of staff have cause to
        complain about the Provider.

3.      Principles

        No one is infallible and we can all make mistakes. Complaints often arise from
        differences of understanding, perceptions and belief and are often about
        organisational matters rather than individuals. Patients are greatly influenced by
        the attitudes of professionals towards them. The following basic principles will
        apply to all complaints received by NHSW:

            -   Staff must be able to recognise when a complaint is being made and
                need to be confident about dealing with complaints.
            -   Arrangements need to ensure that complainants know they have acted
                appropriately and that the organisation is open to comments on
                performance and willing to make changes when necessary.
            -   Most complainants want something they perceive to be wrong put right.
                Where justified and appropriate this should be done as quickly as
                possible as delays or complex procedures are likely to fuel a
                complainant’s feelings of injustice. A quick response and a willingness to
                apologise are much more likely to lead to satisfaction.
            -   Consider if any kind of redress is feasible in order to put the complainant
                back into the position they were in before they felt the need to complain.
            -   There is a need to ensure confidentiality at all stages of the complaints
                process not only for the complainant but also for those staff involved in
                the investigation.
            -   It is important that staff involved in a complaint should receive feedback
                on the outcome of the investigation.

4.      Discrimination:

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        Many people in contact with the National Health Service find it difficult to express
        their concerns, criticisms and complaints and worry that they may affect the
        treatment and care of themselves or those they care for. No person will be
        discriminated against for making a complaint. It is therefore essential that
        procedures ensure that people are enabled to communicate their complaints,
        and are assured they are being listened to with respect and concern, and that
        the response is swift, impartial and fair.

5.      Policy Objectives

          a) Getting it right
          b) Being customer focused
          c) Being open, honest and accountable
          d) To deal with concerns and complaints quickly, fairly and
          e) Offer an apology if one is needed
          f) Putting things right
          g) Seeking continuous improvement

        All complaints will be recorded on the electronic complaints reporting system.

        Any information provided through the system will be used to:

          a)     Produce statistics and to identify trends
          b)     Learn and change and service improvement

        Complaints reporting procedures will be annually monitored and audited,
        including investigations and subsequent actions taken.

6.      Recognising a Complaint

        Comments and suggestions about NHSW as the commissioner of services are
        welcomed. It is important that staff are able to recognise when a person is
        making an enquiry, asking for advice or making a constructive suggestion and
        not to misconstrue this as a complaint. In order to do this, it is crucial to obtain
        all the information that will allow an assessment of someone’s concern to be
        carried out correctly and to resolve the issue quickly.

        There may be occasions when the enquiry, suggestion or comment can be dealt
        with by NHSW Advice and Liaison Service (PALS) and this offer should be

        The member of staff in direct contact can sort out many concerns with the
        complainant. This should be the normal practice and staff will be empowered to
        resolve these on the spot. In all instances staff must clarify with the complainant
        what their concerns are and, if possible, the remedy.

7.      Time Limits for Making Complaints

        Normally a complaint should be made within 12 months from the incident that
        caused the problem, or within 12 months of discovering the problem. The

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        Complaints Manager has discretion to extend this time limit when it would be
        unreasonable in the circumstances of a particular case for the complaint to have
        been made earlier and when it is still possible to investigate the facts of the

8.      Overview of the Complaints Procedure

        The new NHS Complaints Regulations, which were introduced on 1 April 2009
        September sets out changes to the national complaints process. There are
        some changes that have an impact on NHSW:

        1.      Anyone wishing to make a complaint about a health related matter will be
                able to make this direct to the organisation who provided the service or to
                the commissioner of the service.

        2.      There is no longer a standard response time for complaints and the
                Department of Health have not set out a detailed prescriptive process.
                Complainants must be given the opportunity to be involved in how their
                complaint will be handled and the expected timeframe for a full response.

        3.      Where a complaint involves more than one organisation, those
                organisations should work together in order to provide the complainant
                with a co-ordinated response that covers all organisations.

        4.      All organisations will be expected to monitor their complaints handling
                arrangements, and produce an annual report.

        5.      A complaint may be made orally, in writing or electronically. If made
                orally, a written record must be made and a copy provided to the

        Details of the procedures to be followed for complaints received about NHSW
        are contained in the flowchart at Appendix 1 and the Procedure for Handling
        Formal Complaints at Appendix 2.

9.      Who May Complain?

        A complaint may be made by:

            A patient;
            Any person who is affected by or likely to be affected by the action, omission
             or decision of the organisation
            A representative of either of the above in a case when that person:
              Has died;
              Is a child;
              Is unable by reason of physical or mental incapacity to make the
                 complaint themselves;
              Has requested the representative to act on his behalf.

10.    Role and Responsibilities

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        10.1    Chief Executive

                The Chief Executive is ultimately accountable for the quality of care within
                the organisation, and therefore, as part of governance arrangements,
                needs an overview of all recorded dissatisfaction being expressed by
                service users. The results of all complaint investigations will be submitted
                to the Chief Executive who will sign the final letter of response to the
                complainant. Where for good reason the Chief Executive is not able to
                sign the final letter, a person acting on the Chief Executive’s behalf will do

        10.2    Responsible Director

                The Director of Compliance has been designated by the Trust Board to
                take overall responsibility for the NHS Warwickshire Complaints Policy
                and Procedure and for ensuring that it complies with the Complaints

        10.3    NHS Warwickshire Complaints Manager

                The NHS Warwickshire Complaints Manager is responsible                     for
                overseeing the operation of the procedure, including:

                   Providing support in ensuring staff awareness;
                   Providing support in ensuring public awareness, through the provision
                    of leaflets and posters;
                   Collating all complaints and concerns
                   Ensuring that all formal complaints are registered in accordance with
                    NHS Warwickshire Complaints Procedure;
                   Agreeing the timescale for responding with the complainant
                   Liaising with the relevant Manager where necessary regarding the
                    appointment of an investigating officer
                   Ensure complaints are resolved within the agreed timescale;
                    Maintaining records of all outcomes and recommendations;
                   Ensuring quarterly and annual complaints monitoring reports are
                    compiled for NHSW Board, the Department of Health and any other
                    regulatory body;
                   Ensuring that where relevant complaints are highlighted as possible
                   Monitoring action taken as a result of complaints and that where
                    appropriate lessons learned are shared across NHSW;
                   Ensuring that trends in complaints are identified and reported to the
                    appropriate Committee, who will report directly to NHSW Board;
                   Liaison with the Parliamentary Health Service Ombudsman in relation
                    to complaints that cannot be resolved locally to the complainant’s

        10.4    All Staff

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                On receipt of a complaint or concern, all staff will follow the guidelines
                outlined in Appendix 3.

                Suggestions and compliments also provide useful feedback for the
                organisation and these should also be recorded. Compliments will be
                published in The Exchange (NHSW weekly staff bulletin) and a formal
                letter of thanks sent to the appropriate Directorate.

        10.5    Investigating Officer

                An Investigating Officer will be appointed by the appropriate Manager
                within 2 working days of the complaint being received. The Investigating
                Officer will have undertaken Root Cause Analysis training, which includes
                Investigating Officer training and will use the Root Cause Analysis
                concept to undertake the investigation.

                On receipt of a complaint, the Investigating Officer will be responsible for:

                   Identifying with their Manager the time resource required for the
                   Identifying the issues to be investigated.
                   Informing the individual member of staff that a complaint has been
                    made about them and providing them with a copy of the complaint.
                   Obtaining the relevant documents, i.e. incident reports, medical notes,
                    care plans etc.
                   Ensuring that the member of staff being interviewed is aware that a
                    copy of their statement could be requested under the Freedom of
                    Information Act.
                   Identifying who needs to be interviewed, including the complainant
                    where appropriate.
                   Risk Grading the complaint using the risk grading matrix which will be
                    sent with the complaint. Appendix 4
                   Maintaining an accurate record of all interviews and discussions.
                   Involving, where appropriate, other agencies such as Police, Social
                    Services, HSE, Probation etc.
                   Providing feedback to the staff involved in the complaint within 2
                    weeks of the completion of the investigation.
                   Sending details of the feedback to staff including the format this took
                    and the learning points to NHSW Complaints Manager.

                Where an unexpected delay or complication becomes evident the
                Investigating Officer must inform the appropriate Manager and NHSW
                Complaints Manager immediately.

                On completion of their investigation the Investigating Officer will write a
                report using the standard format on the outcome that will be forwarded to
                NHSW Complaints Manager by the agreed date. The report will address
                all of the issues raised and include recommendations and learning points.

        10.6    Quality, Safety & Governance Committee

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                The Quality, Safety and Governance Committee is a sub committee of NHS
                Warwickshire Trust Board, and is in place to assure the Board on quality, safety
                and risk management issues in relation to commissioned services.

                The Quality, Safety and Governance Committee will ensure NHS Warwickshire
                has an appropriate assurance framework with robust controls and assurance in
                place to minimise the risks to the delivery of corporate objectives.


                Two Non Executive Directors
                Chief Executive
                Director of Quality & Safety; Executive Nurse
                Director of Public Health
                Director of Compliance
                Medical Director
                Director of Community & Primary Care
                LINKs Representative

                In terms of complaints, the Committee will:

                   Monitor the processes and outcomes of the complaints.
                   Make recommendations to the Chief Executive on any further actions
                    required to improve the quality of service.
                   Identify any trends, common factors or patterns in complaints and
                    inform the Chief Executive as appropriate.

        10.7    Conciliator

                Conciliation is a way of dealing with complaints that helps to avoid
                adversarial situations. By bringing the two sides together with a neutral
                conciliator it aims to come up with a satisfactory conclusion for both the
                complainant and the organisation complained about. There is a statutory
                requirement to provide conciliation as an option during the complaints
                procedure for the benefit of both those complaining and those being
                complained about. Either the complainant or the complained against can
                request conciliation but both must agree to the conciliation process taking

                The conciliator is a layperson used by NHSW on an ad hoc basis, They
                are not employees of NHSW. The conciliator is not an advocate for either
                party. Their role is to give impartial support to both sides.

                The conciliator will adopt procedures that are most appropriate for
                conducting the conciliation process. Conciliation can be joint, both parties
                present or a separate meeting for each party with feedback from the

                The conciliator will hear what has happened from each individual
                perspective. The conciliator has no advisory or decision making role.

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                Following the conciliation meeting(s) the conciliator will inform NHSW
                Complaints Manager of the outcome.

        10.8    Patient Advice and Liaison Service (PALS)

                NHS Warwickshire has a separate Patient Advice and Liaison Service

                PALS will provide up-to-date and accurate information about the services
                available. They will tell patients about other organisations that can help,
                such as support groups. PALS will also help patients to resolve any
                issues they might have and that have not been resolved by staff.

                If a patient is dissatisfied with any aspects of the care and/or services
                provided by NHS Warwickshire, PALS staff will discuss these with the
                patient and advise them of the options available to find a resolution,
                improve things or to take things further and make a formal complaint.

                The PALS team can also provide support to patients who wish to follow
                the NHS Complaints procedure or direct them to independent
                organisations who can undertake this role.

                Where appropriate, there will be consultation between the PALS and
                Complaints teams to ensure that the patient receives the best outcome
                following the raising of their concern.

                Information on how to access PALS and how they can help will be
                available within all areas of the organisation, partner organisations and
                other public areas.

        10.9    Independent Complaints Advocacy Service (ICAS) / Advocates

                ICAS has an important role in supporting individual complainants and
                particularly in representing the needs of vulnerable groups when making
                complaints. ICAS is a free service. Complainants should be advised
                about how ICAS can help them and how they can access this service.

        10.10 Parliamentary Health Service Ombudsman

                The Health Service Ombudsman will look into complaints made by or on
                behalf of people who feel they have received unsatisfactory treatment or
                service by the NHS which they do not feel have been satisfactorily
                resolved at local level.

11.     Training

        NHSW requires all staff to be familiar with the complaints policy and to know
        who they should contact for advice on handling complaints and therefore training
        will be key to ensuring that the complaints procedure is effective and operates

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        smoothly. Staff at all levels will be made aware of the complaints procedure and
        the role they play in it.

        An overview of NHSW complaints process will be given at Induction which is
        held monthly for all new staff. This will also be covered in local induction. In
        addition to induction, the Compliance Team will provide awareness training for
        all NHSW staff. This will include complaints and incidents.

12.     Monitoring, Audit and Learning

        NHSW Manager is responsible for the completion of the Statutory Monitoring
        forms (KO41A), for monitoring NHSW register of complaints and for preparing
        the annual report on complaints for the relevant Committees within the
        organisation, including the Trust Board.

        All complaints will be recorded on the appropriate system and the Quality, Safety
        and Governance Committee will review information on complaints quarterly

           Numbers and categories
           Subject matter of complaint
           Trends
           How complaints were handled including the outcome of the investigation
           Timescales
           Action proposed / taken as a result of complaints

        The KO41B which, records the number of complaints about Independent
        Contractors (GP’s and Dentists only), is also co-ordinated by NHSW Complaints
        Manager. Complaints regarding all Independent Contractors handled by the
        PCT on behalf of a complainant are reported quarterly in the Patient Safety and
        Risk Management Report.

        In respect of services commissioned by NHSW, complaints will be monitored
        through the Clinical Quality Review meetings held on a monthly basis with
        individual Provider Services.

        All organisations, including NHSW, will, on an annual basis, produce a report on
        complaints. This information will be adapted for public use and displayed in
        public areas, such as waiting rooms and web sites. Primary Care Independent
        Contractors and those NHS Providers from which services are commissioned,
        will send a copy of their annual report on complaints to NHSW Complaints

13.     Scheme of Delegation

        All activities relating to the Complaints Procedure including any developmental
        work, will be reported to and performance managed by the NHSW Quality,
        Safety and Governance Committee. Reports on complaints, to include learning
        and change, will be provided by the NHSW Complaints Manager and published
        within the quarterly Risk Management Report.

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        An Annual Risk Management Report will be produced by NHSW Complaints
        Manager, this will go directly to the Trust Board: an NHS Litigation Authority
        requirement and will include an annual review and report on complaints.

14.     Publicity

        NHSW has produced a leaflet which explains the Local Resolution stage of the
        NHS Complaints Procedure.

        It is important that patients and their relatives or carers know about NHSW
        Complaints Policy and how comments, suggestions or complaints about NHSW
        are used. They are also advised to speak NHSW Patient Advice and Liaison
        Service (PALS) if they wish to discuss their concerns informally.

        It is important to remember that complainants may be unable to read or write,
        may not have English as their first language or may suffer from disabilities that
        make formal written complaints difficult.    NHSW has access to interpretation
        and translation services to assist with this. Assistance is also available from
        NHSW Complaints Department to help those unable to put their complaint in

15.     Issues Affecting all Complaints

        15.1    Confidentiality

        It is essential when dealing with complaints that employees of NHSW observe
        the legal obligation not to release information relating to the patient to a third
        party without consent.

        15.2    Disclosure of Documents

        Any request to access clinical / medical records will be dealt with under the Data
        Protection Act 1998. Refer to the Access to Records Policy.

        15.3    Consent

        Due to the Data Protection Act and patient confidentiality, when a complainant is
        not the patient, consent is required from the patient for the organisation to
        manage and respond to the complaint. The acknowledgement to the
        complainant should explain the process for obtaining consent and enclose the
        appropriate form.

        Exceptions would be if the patient lacks capacity, has died or is a child, for
        further information refer to the Local Authority Social services National Health
        Service Complaints (England) Regulations 2009.

        15.4    Primary Care Complaints

        For the majority of complaints about primary care independent contractors,
        NHSW do not have an investigating role. They do, however, have a role in
        supporting patients who may wish to complain about treatment or services

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        received from their GP, Dentist, Pharmacist or Ophthalmologist. NHSW will,
        therefore, have an overview of the investigation and response to all complaints
        that are referred to them about care and treatment by independent contractors
        services. Complaints Procedure (Primary Care) is attached as Appendix 5

        15.5    Complaints involving other Organisations

        If a complaint is received about care delivered by more than one organisation, it
        is important to provide a single point of contact and a single response to the

        On receipt of such a complaint, NHSW Complaints Manager will contact the
        complainant to obtain consent to share their concerns with the other
        organisations involved. The lead organisation will be agreed and they will be the
        point of contact for the complainant. The lead organisation will be determined by
        taking into account which organisation manages integrated services; which
        organisation has the most serious complaint about it; whether a larger number of
        the issues in the complaint relate to one organisation.

        The response to the complainant will be co-ordinated by the lead organisation
        and a joint response will be sent. Set out at Appendix 6 is the process for
        dealing with a complaint about more than one organisation.

        15.6    Allegations of Theft

        With regard to allegations of theft made against NHSW staff, NHSW will not
        register it as a formal complaint unless the complainant is prepared to inform the
        police. Upon confirmation from the police, the complaint may be registered and
        investigated under the complaints process.

        15.7    Complaints leading to Legal Action

        With the new reforms issued in April 1999 early disclosure of information is
        essential where a claim is possible. Information collated during an investigation
        of a complaint may have to be disclosed when legal action is taken.

        When an investigation of a complaint has been carried out it may be evident that
        a claim could be possible i.e. where medical negligence has been inferred.
        NHSW will need to be in a position to respond to such a claim and NHSW
        Complaints Manager will:

                   Secure all records relating to the case
                   Staff who were involved with the incident and/or complaint will be
                    identified together with their current whereabouts.
                   Signatures on documents which may be disclosed will be identified.

        In cases where legal action is being taken or there is police involvement in
        relation to the complaint, NHSW should hold discussion with the relevant body to
        determine whether progressing the complaint might prejudice subsequent legal
        or judicial action. If this is the case, the complaint will be put on hold. If there

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        would be no affect on any other investigation, the complaint will be investigated
        under the complaints procedure in the normal way.

        15.8    Vexatious Complainants and Communication

        Habitual and/or vexatious complainants are becoming an increasing problem for
        NHS staff, causing undue stress and placing a strain on time and resources.
        Staff are aware of the need to respond with patience and sympathy to the needs
        of all complainants but there are times when there is nothing further which can
        reasonably be done to assist them or to rectify a real or perceived problem.

        NHSW will ensure that the complaints procedure is followed so far as possible
        and that no material element of a complaint is overlooked as habitual and
        vexatious complaints may have some substance.

        NHSW will use the following criteria in determining when a complaint has
        become vexatious/habitual. The complainant will usually have:

               persisted in pursuing a complaint when the NHS Complaints Procedure
                has been exhausted
               changed the substance of a complaint or continually raised new issues
               been unwilling to accept documented evidence of treatment given as
                being factual e g GP manual or computer records, drug charts, nursing
               not clearly identified the precise issues they wish to be investigated
               focused on a trivial matter to an extent which is out of proportion to its
               threatened or used actual physical violence towards staff at any time
               had an excessive number of contacts with NHSW by telephone, letter or
               harassed or been abusive or verbally aggressive towards staff dealing
                with their complaint.

        In these circumstances NHSW Complaints Manager will discuss the case with
        the Chief Executive and decide what action to take. This may include a review
        of all the complaints documentation or seeking legal advice. Once a decision
        has been made the Chief Executive will write to the complainant and a record
        kept of the reasons why a complainant has been classed as vexatious.

        Further details on vexatious complainants and communications can be found at
        Appendix 7.

16.     Commissioners

        NHSW as the lead commissioner for services, will consider all complaints
        referred to them within the spirit of the complaints process reforms. In the
        majority of cases, where a complaint has been received by NHSW about care
        and treatment by a provider service or primary care contractor, it will be
        appropriate for that organisation to investigate and respond.

NHS Warwickshire Complaints Policy
August 2009 - Final
            There will be times, however, when a complaint is considered to be of a more
            serious nature and NHSW will be part of the investigation process and will also
            co-ordinate the response, in these situations. It should however, be noted that a
            complaint cannot be properly investigated unless the provider as had an
            opportunity to respond.

            Complaints which relate to commissioning policies and decisions will be handled
            under NHSW complaints procedure. Complaints should receive proper
            consideration and should not be dismissed solely on the basis that they
            challenge policy.

17.         Development and Consultation Process

17.1        JNCC is consulted when the policy directly affects staffs’ terms and conditions
            and/or their working environment.

17.2        The following individuals/groups have been involved in the development of this
            policy, or are key stakeholders:

Name of Individual/Group                          Representing
All staff                                         Via The Exchange
Pam Wilcox                                        Head of Clinical Governance
                                                  Primary Care
Maggie O’Rourke                                   HR, EIA
Complaints Managers                               NHS Warwickshire Community
                                                  South Warwickshire General
                                                  George Eliot NHS Trust
                                                  Coventry & Warwickshire
                                                  Partnership Trust
Customer Services Manager                         Warwickshire County Council
Dr A Kennedy                                      Local Medical Committee
Dr D Pulsford                                     Local Dental Committee
Ms Faye Chapman                                   Local Pharmaceutical Committee
Mr M Beaver                                       Local Optometry Committee

      18.      Policy Implementation Plan

            Accountable Director:               Director of Compliance

            Policy Author:                      Rachel Freeman, NHSW
                                                Complaints Manager

                                           Issues identified/Action to be taken   Time-scale

NHS Warwickshire Complaints Policy
August 2009 - Final
Co-ordination of implementation               Policy put on web by web lead.               Within 1
 How will the implementation plan be                                                      month of
     co-ordinated and by whom?                To be circulated via The Exchange            policy
Clear co-ordination is essential to monitor                                                ratification.
and sustain progress against the              Policy circulated to Directors for onward
implementation plan and resolve any           circulation to managers.
further issues that may arise.
                                              Community Services to adhere to policy
                                              and produce a procedure to compliment

                                              Annual review in the light of “Making
                                              Experiences Count” - The Proposed New
                                              arrangements for Handling Health and
                                              Social Care Complaints.
Engaging staff
 Who is affected directly or indirectly by   Directly – all Trust Directors and           Receive within
   the policy?                                Managers, and Staff. This includes           1 month of
 Are the most influential staff involved     agency staff and contracted staff.           ratification
   in the implementation?                     Indirectly – Independent contractors,
 How will the policy be communicated         partner organisations, service users
   to staff?                                  Staff influential in implementation –
                                              Directors and Line Managers,
                                              Policy on web. Overview at Staff
Involving service users and carers
 Is there a need to provide information      Can be involved/influence at
    to service users and carers regarding     development stage via representation on
    this policy?                              the various committees at ratification, or
 Are there service users, carers,            during consultation phase.
    representatives or local organisations
    who could contribute to the

 What are the key messages to                Knowledge of existence of policy – via       Sept 2009
   communicate to the different               web and line managers
 How and to who will these messages          Process for managing complaints at front     Ongoing
   be communicated?                           line and organisationally. All staff to be

NHS Warwickshire Complaints Policy
August 2009 - Final
 What are the training needs related to        Ongoing awareness by manager, eg in           Ongoing
    this policy?                                team     meetings,   or    following an
     Are people available with the skills to   Induction (Trust and local) for new
      deliver the training?                     members of staff.
                                                Briefing for agency staff on commencing
                                                a shift.
                                                One-to-one feedback on individual
                                                RCA training for Managers

                                                Line managers can brief on the policy.
                                                Brief delivered at induction
                                                One-to-one feedback available from line
 Have the financial impacts of any             Unlikely to have direct financial impacts –
   changes been established?                    eg costs of development, ratification and
 Is it possible to set up processes to re-     communication limited.
   invest any savings?
 Are other resources required to enable        Cost relates to improvements in services
   the implementation of the policy eg          to avoid litigation.
   increased staffing, new                      Redress under the procedure may have
   documentation?                               some financial implications
Securing and sustaining change
 Have the likely barriers to change and        Barriers would be due to poor
   realistic ways to overcome them been         communication.     Wide circulation and
   identified?                                  placing on the intranet should minimise
 Who needs to change and how do you            this.
   plan to approach them?
 Have arrangements been made with              Comments could be made in team brief.
   service managers to enable staff to
   attend briefing and training sessions?
 Are arrangements in place to ensure
   the induction of new staff reflects the
 What are the main changes in practice         Standardisation of use.
   that should be seen from the policy?         Unclear investigation.
 How might these changes be                    Monitoring by the Complaints Manager,
   evaluated?                                   and reporting quarterly ie to Assurance
 How will lessons learnt from the              and Governance Committee.
   implementation of this policy be fed         Lessons learned will be fed back in a
   back into the organisation?                  variety of formats eg:
                                                Investigating Officer to Service
                                                Team meetings
                                                Line managers
                                                Training sessions

Other considerations                            None

19.       Equality Impact Analysis


NHS Warwickshire Complaints Policy
August 2009 - Final
Please note: where the term ‘other diverse groups’ is referred to below, this covers gender,
disability, sexual orientation, religion/belief and age.
Dept/Service     Compliance          Section      Risk Management Person        Rachel
Area                                                              Responsible   Freeman
                                                                  for the
Name of the policy to be                                          Is this a new Revised
assessed                             NHSW Policy for Handling     or existing
                                     Complaints                   policy?
In what areas are there any concerns that the policy could have   Date of the   29.04.2009
an adverse/differential impact?                                   assessment

RACE              AGE                    DISABILITY



 1    What is the aim/objective/purpose of the                 To ensure that there is a robust process in
      policy/service?                                          place to manage complaints and concerns
                                                               raised by members of the public, patient’s
                                                               carers or relatives.
                                                               To meet national requirements for the
                                                               management of complaints.
                                                               As above
2     What are the expected outcomes of the policy? What
                                                               Complaints are investigated and managed
      are we trying to achieve?
                                                               There is learning and change from
                                                               No – scope is for all patients
3     Are there any groups who might be expected to
      benefit from the intended outcomes but who do not?

4     How does/will the policy meet needs, particularly with
      regard to race, gender disability?

5     Are there any obvious barriers to accessing the          N/A
      service? eg language, physical access?

6     How does the policy fit in with NHSW wider               It is part of NHSW key aims:
                                                               To ensure that the PCT meet the
                                                               requirements of the Care Quality
                                                               To earn a reputation for high quality
                                                               services that patients want to use.

7     Explain why there are concerns that this policy could    N/A
      be affecting different groups in different ways, or
      could be having an adverse/negative impact on
      particular groups

8     What existing data is there in-house/externally to       There will be current complaints reports
      support this? Is there a need to collect primary data    and reports on trends. However, the
      or any additional data to assist in the determination    reports will be on the nature of the
      about the level of adverse impact?                       complaint, not necessarily the individual
                                                               who made the complaint

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9       If the policy is indirectly discriminatory could it still be    N/A
        justifiable under legislation?
10      Is there any evidence of unmet needs that can affect            Not aware of any.
        different groups?
11      What advice/information is available from experts or            EIA – current legislation
        interest groups?
12      Please explain in detail the views/evidence that they           Informed the implementation and training
        have been able to provide.                                      for EIA.

13      Taking into account the views of these                          N/A
        groups/experts and the available evidence, please
        clearly state the risks associated with the policy,
        weighed against the benefits of the policy.
        Is there anything you can do now, based upon the
14                                                                      N/A
        evidence available, to
        a) Remove or minimise the adverse/differential
        b) Address any unmet needs?
15      What plans do you have for further consultation with            Non ate present in addition to those listed
        the different groups?                                           in 17.2

16      What monitoring arrangements will you put in place              To take account of this when policy is
        to monitor the future impact of this policy, especially         reviewed.
        in relation to race, gender and disability?
                                                                        To review trends and feedback

As a result of the EIA, is a Full Impact Assessment (FIA)               No
(FIA required if EIA identifies the need for: policy rewrite
requiring MDT input and consultation)

Date by which FIA to be completed:                                      N/A

Signed by

                                                                                                      Appendix 1

                  Complaints Procedure for NHSW Commissioning Services

                          Person makes complaint/criticism about Commissioning Service

            To Directorate involved       To Chief Executive or Chairman            To NHSW HQ

       Can complaint/criticism be             Can complaint/criticism be successfully dealt with by
         successfully dealt with                       supporting agency i.e. PALS, ICAS
          quickly at source (by
          Directorate involved)Policy
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August 2009 - Final
         Yes                No                        No                             Yes

       Log within          Register with NHSW Complaints Manager at           No further action by
      Directorate                 HQ and obtain unique number.                      NHSW
      and identify             Acknowledge within 3 working days.
        actions              Investigation from Directorate involved.

                                                       Local Resolution

                           Investigating Officer provides report for NHSW Complaints
                           Manager 5 working days prior to agreed response time. Final
                            response sent from Chief Executive. Complete Committed
                                                   Action Plan.

                          NHSW to send holding letter to complainant if unable to meet
                                            agreed response time                                       Offer meeting
                                                                                                      with Directorate,
                                                                                                     conciliation and/or
          Yes              Is complainant satisfied with final response?            No                      PALS

          Ensure           Advise complainant of their right to ask the             No                 Is complainant
        Committed          Health Service Ombudsman to independently                                   satisfied with
        Action Plan                  review their complaint                                               outcome


                                 Monitor through Quality, Safety and                                 Ensure Committed
                                       Governance Committee                                            Action Plan is

                                                                                                     Appendix 2

                                      NHS WARWICKSHIRE
                                   PROCEDURE FOR HANDLING
                                     FORMAL COMPLAINTS


        1.1     Formal complaints can be verbal or in writing, including
                electronic. Complaints given verbally will be typed and a
                copy provided to the complainant. Assistance will be given to
                those people unable to put their complaint in writing.

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August 2009 - Final
        1.2     Written complaints wherever they are received in the first instance must
                be forwarded immediately to NHSW Complaints Manager for
                acknowledgement and processing.

        1.3     NHSW Complaints Manager will register the complaint
                and contact the appropriate Manager to appoint an Investigating Officer.
                The Investigating Officer will be responsible for fully investigating the
                complaint using Root Cause Analysis methods and tools.

        1.4     Complaints will be formally acknowledged within three working days.
                NHSW Complaints Manager will discuss with the complainant how their
                complaint will be investigated and agree a reasonable time scale for a
                final response.

        1.5     Staff should be advised that they have the right to be supported by their
                relevant professional organisation when providing a written statement.
                Staff who are the subject of a complaint should be fully informed of any
                allegation at the outset and given the opportunity to respond. A copy of
                the complaint must be given to them by the Investigating Officer.

                The Investigating Officer must also bring to the attention of any member
                of staff who provides a statement or attends interview meetings, the fact
                that, any statement they may give or notes of meetings they may be
                involved in in relation to the complaint may be disclosed to the

        1.6     All staff have a professional responsibility/duty to co-operate
                with internal and external investigations.

        1.7     Where the complaint involves issues that relate to clinical
                judgement, appropriate professional advice will be sought where this is

        1.8     In some cases it will be appropriate to involve other organisations when
                investigating a complaint, i..e Social Services, Police, Coroner. NHSW
                Complaints Manager will ensure that appropriate consent is obtained and
                in order that the appointed Investigating Officer can liaise with the
                organisations involved at the relevant stage of the investigation.

                Where a complaint relates to more than one service, i.e. Health and
                Social Services, NHSW Complaints Manager will obtain consent and
                liaise with the other organisations involved to agree the lead for the

                In situations where legal or judicial processes are involved, such as the
                Police, discussions will take place with that organisation to determine
                whether progressing the complaint might prejudice this action, if so the
                complaint will be put on hold.

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        1.9     In cases where investigations are expected to be in excess of the agreed
                timescale for completion, NHSW Complaints Manager will contact the
                complainant explaining the position and outlining a timetable for
                completion.    It should be noted that, dependant on the severity and
                seriousness of the concerns raised, no complaint should take longer than
                six months to respond to.

        1.10 On completion of the investigation a report on the outcome of the
             investigation will be prepared by the investigating officer. This should
             include details of any action that has or will be taken as a result of the
             complaint and any learning points. The report and supporting information
             such as witness statements, any quality improvements and the risk-
             grading matrix will be sent electronically to NHSW Complaints Manager.

        1.12    Following the final report from the Investigating Officer a draft
                Response will be prepared by NHSW Complaints Manager for the Chief
                Executive, who will sign this and send the final response to the

                The response will include an invitation for the complainant to meet with
                relevant staff within NHSW to discuss any remaining concerns they may
                have or any questions that arise from the response.

                With the response letter, the complainant will be sent an action plan,
                setting out the outcome of the investigation, any learning and
                recommendations and the how NHSW propose to implement these, by


        2.1     Early disclosure of information is essential where a claim is possible.
                Information collated during an investigation of a complaint may have to be
                disclosed when legal action is taken.

        2.2     When an investigation of a complaint has been carried out it
                may be evident that a claim could be possible.

                       All records relating to the case should be forwarded to NHSW
                        Claims Manager.

                       Staff who were involved with the incident/complaint will be
                        identified together with their current whereabouts.

                       Signatures on documents which may be disclosed will be identified.


        3.1    Request for records by the patients Legal Adviser should provide sufficient
               information to inform NHSW that an adverse outcome has been serious or

NHS Warwickshire Complaints Policy
August 2009 - Final
                had serious consequences and be as specific as possible about which
                records they may require.

        3.2     Request for patients clinical records should be made by solicitors using
                the Law Society approved form.

        3.3     The copy records should be provided within 40 days of the request. If
                NHSW fail to provide the documents within this time, unless the difficulty
                has been explained to the solicitor, the solicitor can apply to court for an
                order for pre-action disclosure. The law may also impose costs on the
                Trust for unreasonable delay in providing records.


        4.1     When a complaint is received which involves more than one organisation,
                NHSW Complaints Manager will liaise with the complainant to obtain
                consent to refer the complaint to those organisations. Once this has been
                received, the lead organisation will be agreed and they will be responsible
                for co-ordinating the investigation and final response.


        5.1     Complaints that relate to commissioning policies and decision will be
                managed in line with the NHS Complaints Procedure. Such complaints
                should receive proper consideration and should not be dismissed solely
                on the basis that they challenge policy.


        6.1     ICAS has an important role in supporting individual
               complainants and, particularly, in representing the needs of
               vulnerable groups when making complaints. Complainants
               should be advised about how ICAS can help them and how
               they can access this service. Details can be obtained from
               NHSW Complaints Manager.


        The PCT has in post a PALs Co-ordinator who is available to assist
        and advise patients and carers should they have any concern about care or
        services provided.

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                                                                               Appendix 3


NHS Warwickshire welcomes suggestions, compliments and also complaints, which
reveal concerns people, have about our services. They provide opportunities for
service development and form an important part NHSW plans for improving the quality
of services. The ways in which we respond to concerns will reflect this. Remember,
when you receive a complaint or other stated concern, you are acting on behalf of
NHSW. The NHSW Board takes a keen interest in the management of complaints and
other comments received from the users of our services. Our performance in
responding to complaints is monitored nationally.

What you should do if you receive a complaint, concern, suggestion or compliment.

1.      The first responsibility of any member of staff receiving a complaint or concern is
        to take any urgent action which is necessary to protect the health and safety of
        the complainant and others involved.

2.      After any urgent action has been taken it is the responsibility of any member of
        staff receiving a complaint or concern (whether verbal or written) to complete the
        form immediately (see attached). Whenever possible this should be done with
        the person making the complaint and they should be asked to sign it.

NHS Warwickshire Complaints Policy
August 2009 - Final
3.      If it is possible to resolve the problem immediately, then do so.
        Note your action on relevant form.

4       If the complaint or concern is an allegation or suspicion of any of the
              Physical Abuse
              Sexual Abuse
              Financial Misconduct
              Criminal Offence
              Discrimination

        please ring NHSW Complaints Manager immediately on: 01926 493491 ext 419

5.      Send the relevant form to NHSW Complaints Manager either by fax 01926
        478109 or by post or deliver by hand to NHSW Complaints Manager, NHS
        Warwickshire, Westgate House, Warwick, CV34 4DE. Do this immediately. If
        the complaint or concern was expressed in writing, please attach a copy of it to
        the relevant form.

     6. Inform your Line Manager as soon as possible.

     7. The relevant form must not be completed in place of other documentation, e.g. if
        someone was injured, and this contributed to the person expressing concerns, a
        separate incident form must also be completed.

8.      The relevant form should also be completed when comments, suggestions and
        compliments are received.

What will happen

     1. If further action is needed, NHSW Complaints Manager will allocate a reference
        number and ensure that a written acknowledgement is sent within 3 working
        days. If the original complaint was made verbally, the acknowledgement letter
        must include full details of the complaint. The complainant should be asked to
        confirm in writing that the details are correct.

2.      The Director or General Manager will where necessary, nominate a Senior
        Manager to investigate the concerns. It is the responsibility of the Investigating
        Officer to: -

          i.    liaise directly with the person raising the concerns. All communications
                should be marked “Private & Confidential “ and/or “Personal”;

          ii.   ensure that when the complaint is made on behalf of a patient, that the
                consent of the patient is obtained;

         iii.   ensure that the patient is aware that, in order to investigate the complaint
                it may be necessary to examine their health records;

         iv.    advise the complainant that advice and support can be provided by the
                Independent Complaints Advocacy Service (ICAS) – 0845 337 3056

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          v.    send a copy of the complaint and acknowledgement to any member of
                staff identified in it as the subject of the complaint;

         vi.    keep detailed records of the investigation and forward in entirety to
                NHSW Complaints Manager, together with the full report, when the
                investigation is complete.

        In the case of clinical complaints, the investigating officer must consult a clinician
        of the appropriate specialty, and ensure that the person named in the complaint
        sees the response letter before it is sent.

3.      The Chief Executive will ensure that a full response is given to the complainant
        within the agreed timescale. If there is a delay the complainant must be kept
        informed of progress in writing.

4.      The Chief Executive must sign the final response letter to the complainant. If, for
        good reason, the Chief Executive is unable to sign, another Director may do so
        on their behalf. The letter must include an explanation of the complainant’s right
        to apply to the Health Service Ombudsman for an independent review of their

5.      The Investigating Officer must ensure that feedback on the outcome of the
        complaint is given to those complained against.

6.      Any recommendation made as a result of the investigation will become the
        responsibility of the appropriate Director or General Manager who will decide on
        the necessary course of action. The implementation of the action will be
        monitored on behalf of the Chief Executive by NHSW Complaints Manager.

7.      NHSW Complaints Manager will monitor complaints’ outcomes in terms of how
        satisfied complainants are with the way their concerns and complaints were
        managed. Learning and outcomes will be reported to the Quality, Safety &
        Governance Committee on a quarterly basis.

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