Complaints Policy v2 1 by jPw515q


									                 COMPLAINTS POLICY

Version:                2.1

Committee Approved by: Integrated Governance Group

Date Approved

Author:                 Corporate Risk Manager / Head of Corporate Governance

Responsible Directorate: Corporate Services

Date issued:            September 2011

Review date:            March 2013
                                  Version Control Sheet

Document Title: Complaints Policy

Version: 2

The table below logs the history of the steps in development of the document.

 Version        Date           Author              Status              Comment
 1.1         1 June 2009   Adam Bassett,       Draft
                           Corporate Risk
             5 July 2009   Andrea McCourt,     Draft
                           Head of Corporate
 1.2         13 August     Andrea McCourt,     Draft
             2009          Head of Corporate
 2           19 August     Adam Bassett,       Final        Approved at Governance
             2009          Corporate Risk      Approved     Committee 19 August 2009
                           Manager             Version
 2.1         15            Adam Bassett,       Final        Approved at Integrated Governance
             September     Corporate Risk      Version      Group on 4 October 2011
             2011          Manager             Approved

NHSLA Risk Management Standards Map
Level 1, Standard 5

Performance Indicators
Reports to local governance group, and on annual basis to Cluster Board, will include:
 Number of complaints per quarter, split by category
 Number of complaints per quarter split by provider
 Analysis of outcome of complaints

Section                                                                Page

1         Introduction                                                  4

2         Aims and Objectives                                           5

3         Scope of the Policy                                           6

4         Accountability                                                6

5         Equality Impact Assessment                                    7

6         Implementation and Dissemination                              7

7         General Guidelines                                            7

8         PALS / Complaints Interface                                   8

9         Monitoring Compliance with the Effectiveness of Procedural
          Documents                                                     10

10        References                                                    10

11        Associated Documentation                                      10

1.1    Introduction

NHS Wakefield District (NHSWD) is firmly committed to continuously
improving the quality of care and the services it provides, one of its aims is
to ensure the satisfaction of its customers and users. NHSWD is
accountable for its services and is keen to promote and adhere to the values
of public service. It therefore encourages the views, comments and
suggestions of its service users.

Competent handling of complaints can assist in improving the quality of care
and minimising claims by listening to the voice of service users and using
this as an opportunity for the organisation to learn from complainants. It is
therefore important that NHSWD has a consistent and orderly process for
receiving and handling complaints appropriately and makes positive use of
the information gained to avoid similar occurrences and to generally improve

This document identifies the aims of the complaints policy, accountability
arrangements for complaints management and the interface between
complaints and the Patient Advice and Liaison Service.

The complaints procedure should be read together with the complaints
policy as it details arrangements for dealing with NHS complaints. It also
provides guidance for staff writing statements as part of the complaints

This policy is written in consideration with the Local Authority Social Services
and National Health Service Complaints (England) Regulations 2009 and the
NHS Constitution. The NHS Constitution advises that:

“You have the right to have any complaint you make about NHS services
dealt with efficiently and to have it properly investigated.
You have the right to know the outcome of any investigation into your
You have the right to take your complaint to the independent Health
Service Ombudsman, if you are not satisfied with the way your complaint
has been dealt with by the NHS.
You have the right to make a claim for judicial review if you think you have
been directly affected by an unlawful act or decision of an NHS body.
You have the right to compensation where you have been harmed by
negligent treatment.

The NHS also commits:
•   to ensure you are treated with courtesy and you receive appropriate
    support throughout the handling of a complaint; and the fact that you
    have complained will not adversely affect your future treatment (pledge);
•   when mistakes happen, to acknowledge them, apologise, explain what
    went wrong and put things right quickly and effectively (pledge); and
•   to ensure that the organisation learns lessons from complaints and
    claims and uses these to improve NHS services (pledge)”.

1.2.   Definition

A complaint is an expression of dissatisfaction about any aspect of
NHSWD’s services and commissioned services from other healthcare
poviders requiring a response.

2      Aims and Objectives

The aim of this complaints policy is to meet the following criteria:

(For Patients)
    Ensure that the complaints procedure is flexible and meets the needs
      of patients
    Meets the principles laid down by the Parliamentary and Health
      Service Ombudsman and The Local Authority Social Services and
      National Health Service Complaints (England) Regulations 2009
    To use information from complaints to improve services where
    To be well publicised, so that complainants are helped to make
    Simple to understand and use
    Fair and impartial
    Complaints are dealt with promptly and as close to the point where
      they arise as possible
    Provide answers or explanations quickly and within established time
    Ensure that rights to confidentiality and privacy are respected
    Provide a thorough and effective mechanism for resolving complaints
      and also investigating matters of concern
    Ensure patients’ care actively promotes their privacy and dignity and
      protects their modesty
    Ensure that the unique needs of children and young people are met in
      terms of compliments and complaints
    Ensure complainants are treated courteously and sympathetically
    Regularly reviewed and amended if found to be lacking in any respect

(For Staff)
    To support staff who may be the subject of a complaint

    To ensure that it meets the principles laid down by the Parliamentary
      and Health Service Ombudsman and The Local Authority Social
      Services and National Health Service Complaints (England)
      Regulations 2009 and the principles established by the Parliamentary
      and Health Service Ombudsman
    To ensure the essential information is obtained to respond fully to the
      complainant, to monitor response timescales and report externally to
      the Department of Health.

       Lessons are learned from complaints to improve the quality of

3       Scope of the Policy

        This policy must be followed by all staff who are employed by
        NHSWD and those on temporary or honorary contracts,
        secondments, pool staff and students.

        This policy will also apply to complaints received by NHSWD
        concerning local providers of NHS services. Under the
        The Local Authority Social Services and National Health Service
        Complaints (England) Regulations 2009 complainants have the
        choice to make a complaint to either the provider or the commissioner
        of services.

        Independent Contractors are responsible for the development and
        management of their own procedural documents and for ensuring
        compliance with relevant legislation and best practice guidelines.
        NHSWD will provide advice and support as required.

4       Accountability

        Chief Executive. The person with overall responsibility for the
        complaints process for NHSWD is the Chief Executive.

        Caldicott Guardian – has the responsibility for safeguarding the
        confidentiality of patient information

        Chief Operating Officer is the person responsible for ensuring the
        complaints policy and procedure is in place.

        Head of Corporate Governance is the officer responsible for
        administrative co-ordination and ensuring that complaints are
        actioned in line with the guidance.

        Corporate Risk Manager is the person defined as the Complaints
        Manager and has responsibility for managing the complaints process.
        In the absence of the Complaints Manager the Complaints Officer can
        be contacted for advice on the process. The role of Complaints
        Manager can be delegated for purposes of annual leave and sick

        Complaints Officer – has the responsibility for the administration of
        the complaints process, including the acknowledgement and
        response to complaints and the maintenance of a complaints register.

5   Equality Impact Assessment

    A screening template for Equality Impact Assessment has previously
    been completed.

6   Implementation and Dissemination

    This policy will, following ratification the Integrated Governance
    Group, be disseminated to staff via NHSWD’s intranet.

7   General Guidelines

    7.1 General Principles

    It is important that the correct procedures are followed and that the
    contents of the complaints policy and complaints procedure are
    brought to the attention of all staff that are likely to receive complaints.

    Complaints should be viewed in a positive way, making sure that
    experiences help to improve services.

    NHSWD has a statutory duty to respond to complaints and to do all
    that is possible resolve situations for patients as soon as possible.

    Great emphasis is placed on resolving complaints quickly and where
    possible by those on the spot. This may be through an immediate
    informal response by a front-line member of staff or practitioner, or
    through subsequent investigation.

    7.2 Who can complain?

    Any person who has received NHS care or treatment commissioned
    by NHSWD or other health related services and is dissatisfied with
    the care or treatment they have received or the commissioning
    decisions made by NHSWD is entitled to make a complaint. If the
    person has died or is otherwise unable to act for him or herself, a
    close relative or friend, or an independent advocate may register a
    complaint on their behalf. The Complaints Officer should ensure that
    a complaint made by a third party is made with the full consent of the
    patient or carer.

    As the commissioner, complaints made can be made to NHSWD
    concerning any provider of NHS services to patients resident within
    the Wakefield district. This includes independent contractors, NHS
    trusts and other providers of NHS services. In most cases this will be
    a handling role though NHSWD may choose to investigate the
    complaint itself if it feels this is necessary.

    7.3 Complaints to NHSWD

    A complaint to NHSWD may be about any matter reasonably
    connected with:

       A person who receives or has received services from a
        responsible body; or
       A person who is affected, or likely to be affected by the action,
        omission or decision of the responsible body which is the subject
        of the complaint.

    A complaint may be made by a person acting on behalf of another
    person. Who:

    Has died
    Is a child
    Is unable to make the complaint themselves
    Has requested the representative to act on their behalf

    -     NHSWD must be satisfied that the representative is
    conducting the complaint in the best interests of the person on
    whose behalf the complaint is being made.

    -     Where complaints are made by a representative
    appropriate written consent will be sought.

    Matters that cannot be dealt with by NHSWD under the NHS
    complaints procedure are shown in appendix 5.

    7.4 Communicating with the Complainant

    The following principles are to be applied in any communication with
    the complainant:
          A flexible approach to complaints handling
          Listen to the concerns being expressed
          Be open, fair, flexible and conciliatory
          Be courteous and sympathetic
          Be apologetic where appropriate. An apology is not an
           admission of liability.
          Be prompt and follow the established time limits for reply
          Exhibit empathy and gain an agreed understanding of the

8   The PALS-Complaints Interface

    It should be the choice of the individual to use either the Patient
    Advice and Liaison Service (PALS) or the NHS Complaints
    Procedure; there should be no requirement for service users to

use the PALS service first if they wish to make a formal

There is close collaboration between the PALS service and the
Complaints team to ensure a coherent and seamless approach to
resolving patients’ concerns. There is a clear differentiation between
the roles of PALS and Complaints Departments. PALS will not
investigate complaints and their role is to inform and support people
to access the complaints procedure when requested.

PALS provides assistance to members of the public, patients
and carers with queries about health related matters when patients
first have a concern or issue they wish to raise, their first point of
contact will often be with a member of staff or PALS.
A key PALS role is to help people to talk through their concerns
so that they can identify the nature of the problem and work out
various options, including use of the formal complaints
procedure, for resolving the issue, explaining the potential
consequences of each option. Where an individual approaches
PALS and subsequently decides to make a formal complaint, this is
referred to the complaints team.

There may be occasions when patients, their carers or relatives
contacting PALS have previously made a formal complaint, or
taken other action to gain resolution regarding an issue. Patients
should not use PALS to pursue a concern once the complaints
procedure has been exhausted. PALS staff may decide that no
action they can take will provide an effective and speedy
resolution, and that the issue is outside their remit. PALS should
provide information regarding appropriate independent
advocacy or alternative means of pursuing the matter. It is
important that PALS are able to work in an independent way and
inform people of all their options and rights.

Contacts with PALS may initially frame their concern in the form of a
complaint but the PALS staff should seek to identify if the concern can
be dealt with informally through PALS. In all cases the choice of
action should be agreed with the person raising the concern or issue.

Using PALS will not remove the right of patients to pursue the
complaints option at any stage; however, it would not be
appropriate to use PALS and the Complaints Department
simultaneously to address the same problem. PALS will act as a
gateway to the complaints service in NHSWD. In certain cases it
will be necessary to refer an individual to the complaints
procedure. For example:

   The person chooses to use the complaints procedure rather than
    the informal process.
   The issue cannot be resolved through the informal process.

        Allegations of staff assault or incidents of similar seriousness.

9    Monitoring Compliance with and the Effectiveness of Procedural

     Monitoring and compliance of the policy will be undertaken by the
     Integrated Governance Group.

     Responsibility for Learning Lessons from complaints will be
     undertaken in line with the Learning from Experience Policy.

10   References

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

     Department of Health (2009) Listening, responding, improving: a
     guide to better customer care

     Department of Health (2009) Implementation of the right to choice
     and the information set out in the NHS Constitution

     Parliamentary and Health Service Ombudsman (2009) Principles for

     Parliamentary and Health Service Ombudsman (2009) Principles of
     for Good Administration

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

     NHS Constitution

11   Associated Documentation

     Complaints Procedure (tbc);

     Being Open;

     Risk Management Strategy (August 2007);

     Incident Reporting and Investigation Policy;

     Serious Untoward Incident Policy (December 2007);

     Fraud and Corruption Policy (December 2006);

     Stress Policy (October 2007);

     Disciplinary Procedure (May 2007);

Communications Strategy;

Procedure for Accessing Legal Advice and Services (August 2007);

Supporting Staff;

Learning from Experience Policy;

Claims Policy;

Complaints Interagency Protocol.


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