FLOWCHART SHOWING THE COMPLAINTS PROCESS AGAINST PCT STAFF

Meeting of South Gloucestershire Primary Care Trust Board To be held on: Monday 18th October 2004 1pm Location: Emersons Green Village Hall Agenda item 5.6 Revised Policy & Procedure for Complaints 1 Purpose To recommend a revised complaints policy to the Board. 2 Background/discussion of issues The long awaited guidance from the Department of Health on the new complaints system has still not wholly been agreed. However the first tranche of stage changes have been received regarding what to do when formal local resolution has not resolved a complaint. Where, in the past an unsatisfied complainant would apply to the PCT for an “Independent Review Panel”, this request for a review is now directed to the Healthcare Commission. This makes the second stage more independent as no one from the PCT is involved. This change in procedure, combined with the closer working between complaints and PALS has led to the closing down of the Central Complaints Team, based at Kings Square House. This team administered Independent Review Panels and assisted with complaints against independent practitioners. The policy has been amended to reflect these changes. 3 Implications for Health Inequalities Complaints can be useful in showing the PCT any inequalities of service, learning and changing following complaints is part of the culture of the trust. 4 Implications for Black and Other Minority Ethnic Issues All complaints are dealt with equitably – all complainants have access to translation services, advocates and PALS should they require any assistance. 5 Public Involvement Complaints and compliments are a very direct way for the public to influence the work of the PCT. 6 Implementation This policy will be reviewed when the second tranche of changes are received from the Department of Health (latest estimate is April 2005 at the earliest). Leaflets from the Healthcare Commission explaining its processes have been distributed to all practice managers in South Gloucestershire. D:\Docstoc\Working\pdf\008d9c20-89c4-4628-b639-6a115bd0e02b.doc Page 1 of 23 PCT leaflets will be amended to highlight to patients the changes and induction training will be amended to reflect the new procedure, although changes so far will have little impact on staff. Articles will be placed in The Bridge and the public newsletter to raise awareness in staff and the public 7 Recommendation(s) The Board is asked to adopt this revised policy, which reflects national and local changes, in order that the PCT may comply with the national structure. Frannie Aston October 2004 D:\Docstoc\Working\pdf\008d9c20-89c4-4628-b639-6a115bd0e02b.doc Page 2 of 23 Policy and Procedure for Complaints Issue Date: October 2004 Review Date: October 2005 (Or when further Department of Health guidance is received, whichever is soonest) D:\Docstoc\Working\pdf\008d9c20-89c4-4628-b639-6a115bd0e02b.doc Page 3 of 23 INDEX 1 2 Some principles to observe ..................................................................................................................... 6 What is a complaint?.............................................................................................................................. 7 2.1 2.2 2.3 2.4 3 4 5 6 7 8 What is a complaint? .................................................................................................................... 7 A complaint could be raised by: .................................................................................................. 7 Serious Complaints ....................................................................................................................... 7 Complaints that cannot be dealt with by this policy .................................................................. 8 Responding to Complaints ..................................................................................................................... 9 Informal Complaints ............................................................................................................................ 10 Third Party Confidence .......................................................................................................................... 10 Making and Receiving Formal Complaints - Local Resolution Stage............................................... 12 Investigating A Formal Complaint – Local Resolution Stage............................................................ 13 The HEALTHCARE COMMISSION ................................................................................................. 14 Other Policies And Procedures ............................................................................................................ 15 8.4 8.5 8.6 Complaints to the Mental Health Act Commission ................................................................. 15 Complaints to other PCTs, NHS Trusts or Social Services ..................................................... 15 Complaints about external contractors..................................................................................... 16 Complaints Wholly or Partly about Another Organisation ............................................................ 18 Monitoring of The Procedure .......................................................................................................... 19 9 10 11 Complaints Against Family Health Service Practitioners .................................................................. 17 Appendix 1 .................................................................................................................................................... 20 Appendix 2 .................................................................................................................................................... 21 Appendix 3 .................................................................................................................................................... 22 Appendix 4 .................................................................................................................................................... 23 D:\Docstoc\Working\pdf\008d9c20-89c4-4628-b639-6a115bd0e02b.doc Page 4 of 23 INTRODUCTION South Gloucestershire PCT views complaints positively and is committed to having an effective procedure for handling complaints. Complaints may be an indication of dissatisfaction about a decision made in regard to service or care, a failure to reach a decision, the nature or quality of a service, or a failure to provide a service. Complaints can be used as a means of getting feedback on performance and monitoring the quality of services. Patients, relatives or representatives can make complaints but if the complainant is not the patient, written consent must be obtained from the patient to enable that person to act on behalf of the patient. Every complaint is unique and individual care and attention must be given to each complainant. Procedures must be simple, widely publicised and easily understood. Patients have a right to challenge decisions and to be fully informed about the basis on which they have been made. Complaints should generate discussions aimed at resolving dissatisfaction - we should all be aware of the need to avoid defensive responses. It is particularly important to ensure support is available to patients with specific communication difficulties such as translators, communication aids, and signed communicators. Additionally, the publicity about the complaints procedure will need to be sensitive to the needs of people with communication difficulties. It is necessary to ensure that the policies and procedures of South Gloucestershire PCT complement those of other organisations significantly involved in service provision and that issues of complaints and representations are covered in contracts made with any organisations providing a service on behalf of South Gloucestershire PCT. Our procedure complies with national guidance and will be reviewed regularly to ensure continuing compliance. D:\Docstoc\Working\pdf\008d9c20-89c4-4628-b639-6a115bd0e02b.doc Page 5 of 23 1 1 SOME PRINCIPLES TO OBSERVE We can all make mistakes. Complaints often arise from differences of understanding, perceptions or beliefs and are more often about organisational matters than individuals. The Trust believes that complaints form a valuable indication of the quality of our services. We use this information to help us make adjustments to improve services and find better ways to meet patients’ needs wherever possible. Staff need to feel confident in dealing with complaints. The management style and culture in the team should help promote positive attitudes towards dealing with complaints. Staff who feel undervalued and defensive in their employment are unlikely to feel able to deal confidently with complaints. In order to ensure good care for patients/relatives and sensitivity to their views, we must treat staff well. Patients have a right to challenge decisions without fear of unpleasant consequences – complaints should be dealt with in confidence and be kept separately from the patient’s medical records. The credibility of our service depends largely on its attitudes towards patients as individuals and its capacity to respond to their particular needs. Arrangements for dealing with complaints need to ensure that complainants know that they have acted appropriately and the Trust is open to comments on performance and willing to reconsider and change decisions when necessary. 2 3 4 Complainants want something they feel is wrong to be put right. This should be done as quickly as possible. Delays or complex procedures are likely to fuel a complainant’s feelings of injustice. Quick responses and a willingness to apologise are much more likely to lead to satisfaction. The aim is to give, where appropriate, an immediate response to a complaint. Where this is not possible, a written acknowledgement will be given within two working days and a full response within 20 working days. The Trust aims to respond to complaints in a way that meets the needs of complainants, arranging a meeting between the complainant and relevant staff wherever possible and appropriate. We can offer an independent conciliation service by trained people. Procedures for complaining are simple. The procedure supporting the policy is intended to be easy to understand and follow. Complaint handling is everyone’s responsibility. We all have a responsibility to respond to complaints in a positive manner. The Chief Executive and the Trust Board are responsible for ensuring that complaints are dealt with properly. Where required, they will ensure that changes in practice take place as a result. All final responses will be signed off by the Chief Executive. 5 6 D:\Docstoc\Working\pdf\008d9c20-89c4-4628-b639-6a115bd0e02b.doc Page 6 of 23 2 2.1 WHAT IS A COMPLAINT? What is a complaint? A complaint is usually where someone expresses concern or dissatisfaction in relation to the services the Trust provides. It might express concern about: • • • • • 2.2 Something which is against the choice or wishes of a patient The way treatment, service or care has been provided to a patient Discrimination against a patient on grounds of disability, sex, age, race, sexual orientation or faith How a service has been managed, which has a direct impact on a member of the public Lack of a particular service. A complaint could be raised by: • • • • A patient A relative or carer An advocate on the patient’s behalf eg. an MP or local councillor Member of the public This is not an exhaustive list, there will always be complaints which do not fit into the above, if you are unsure consult your manager. The difference between an informal and a formal complaint is that they are different stages in the process of dealing with complaints. Stage One of a complaint is informal and is resolved locally on the spot by you or the most senior person on duty and it may go on to Stage Two, a formal complaint if it cannot be resolved immediately at local level. 2.3 Serious Complaints If a complaint is an allegation or suspicion of any of these: • • • • Physical abuse Sexual abuse Financial misconduct Criminal offence It should immediately go to Stage Two and be investigated as a formal complaint. In a situation where a person discloses physical/sexual abuse or financial misconduct it must be reported even if the person does not want to make a complaint. The confidentiality aspect should be maintained in such a way that only the managers and the staff who are leading the investigation know the contents of the case. It should not be “common knowledge” – anyone disclosing information to others who are not directly involved in the case should be dealt with under the disciplinary procedure. In the case of financial misconduct the Standing Financial Instructions must be adhered to. Any complaint, whether informal or formal, may not be straight forward and apart from the complaints procedure may lead to one or more of these: • • • Disciplinary procedure Criminal law/litigation Sexual harassment policy Page 7 of 23 D:\Docstoc\Working\pdf\008d9c20-89c4-4628-b639-6a115bd0e02b.doc • • 2.4 Grievance procedure Standing Financial Instructions Complaints that cannot be dealt with by this policy • • • • •  Events requiring investigation by a professional and/or a disciplinary body. Events requiring an independent enquiry into a serious incident under Section 84 of the National Health Service Act 1977. Events requiring investigation of a potential criminal offence. Legal action – The complaints procedure will cease immediately if the complainant explicitly indicates an intention to take legal action in respect of the complaint. Disciplinary procedures – The complaints procedure will be concerned only with resolving complaints and not with investigating disciplinary matters. The purpose of the complaints procedure is not to apportion blame amongst staff. Any disciplinary investigation arising from a complaint will be subject to a separate process of investigation in line with the Trust’s Disciplinary Policy. D:\Docstoc\Working\pdf\008d9c20-89c4-4628-b639-6a115bd0e02b.doc Page 8 of 23 3 RESPONDING TO COMPLAINTS Complaints are everyone's business - all staff should respond positively to any complaints made to them and feel confident to do so. Guidance and procedures are provided for staff and for patients, in order to avoid ad hoc, defensive, negative responses and uncertainty about what is expected of staff in responding to complaints. The Complaints Procedure is set in the context of the overall culture of South Gloucestershire PCT. Key principles are the need to respond quickly and seek to resolve complaints locally. Complaints procedures need to complement good practice and not become a substitute for good practice. This means information being readily available about what services or treatments may be provided. It requires patients (and where appropriate their next of kin/relatives) being involved in the decisions which affect them, having the opportunity for their views and wishes to be heard and taken into account. The emphasis should be on correcting faults - not finding fault or apportioning blame. The staff grievance and disciplinary procedures are clearly defined and operate quite separately form the Complaints Procedure. Complainants and staff need to know what the expectations are regarding timescales for dealing with complaints. This means time limits or targets are defined for dealing with complaints at each stage. A structured timetable (as shown at Appendix 2) known to all parties encourages a focus on problem solving rather than bureaucratic procedures, although the Trust recognises that dealing with complaints in a fair and equitable manner will require flexibility within these targets. Staff and complainants should be advised of other courses of action available to them and other complaints procedures. These may include referring to their local councillor, member of parliament, the Ombudsman, the local Counter Fraud officer - or the police where possible criminal offences are involved. D:\Docstoc\Working\pdf\008d9c20-89c4-4628-b639-6a115bd0e02b.doc Page 9 of 23 4 4.1 INFORMAL COMPLAINTS Comments and suggestions about South Gloucestershire PCT services are welcomed. It is important for staff to acknowledge all comments and suggestions, and to let the person making them know that their comments will be treated constructively. All complaints are taken seriously and action should be taken in response. Complaints do not have to be in writing from the complainant for them to be responded to. Members of staff receiving comments and suggestions should consult with the most senior person on duty, and we all have a responsibility to give them consideration. A criteria for complaints - 'What is a Complaint' is set out in Section 2. As stated in Section 2, some serious complaints should always be investigated at the Formal Stage and referred to the Complaints Manager at Monarch Court. A suggestion becomes a complaint if the person making a comment is requiring an investigation, a decision or change of decision, some redress for decisions taken or wishes to highlight a deficiency in service provision. Most complaints can and should wherever possible be resolved by the member of staff in direct contact with the complainant and dealt with on the spot at a local level. This should be the normal practice. If staff are able to resolve the complaint they should:      Listen to the complainant, acknowledge their complaint and, if appropriate, obtain the patient’s written permission if the complainant is representing the patient. Express regret for any inconvenience/distress caused. Clarify the details of the complaint. Offer an explanation if appropriate and inform the complainant of any actions that will be taken in response to the complaint. Thank the complainant for raising the complaint. 4.2 4.3 4.4 It may be necessary to take the complainant somewhere private so that they can discuss their complaint more freely. 4.6 Some people wishing to make comments or suggestions may experience difficulty in doing so, and staff should look for ways to offer the person help by arranging an interpreter or other supportive service. In all instances staff must clarify with the complainant what the complaint is and if possible resolve the complaint to the person’s satisfaction at the time the complaint is made. If however staff feel unable to resolve the complaint, it should be referred immediately to the most senior person on duty. If the complaint still cannot be resolved on the spot the complainant should be referred to the Complaints Manager at Monarch Court. In instances where the complaint has been resolved locally, the informal complaint form (Appendix 1) should be completed and returned to the Complaints Manager at Monarch Court. Third Party Confidence 4.7 4.8 4.9 Information should not be disclosed to patients or complainants unless the person who has provided the information, has give written, explicit consent to disclosure of that information. Page 10 of 23 D:\Docstoc\Working\pdf\008d9c20-89c4-4628-b639-6a115bd0e02b.doc 4.10 Particular care must be taken where the patient’s record contains information provided in confidence by, or about, a third party who is not a health professional. Disclosure of information provided by a third party outside the NHS also requires the express consent of the third party. If the third party objects then the information can only be disclosed where there is an overriding public interest in doing so. It is not appropriate for someone to make this decision on their own, advice must be sought. 4.11 D:\Docstoc\Working\pdf\008d9c20-89c4-4628-b639-6a115bd0e02b.doc Page 11 of 23 5 MAKING AND RECEIVING FORMAL COMPLAINTS - LOCAL RESOLUTION STAGE 5.1 If a complaint cannot be settled informally by staff at local level, it should be explained to the complainant that they can make a formal complaint in writing. They should be encouraged to seek help in formulating their complaint if they wish (this may include the provision of interpreters or PALS). Discussion and conciliation may resolve the complaint at any time. If this occurs, the Procedure will be terminated unless the Director or Chief Executive considers particular issues should be pursued or that there has been evidence that a withdrawal of a complaint is the result of undue pressure. A written response should be made to all formal complaints. The complaint should be sent directly to the Complaints Manager at Monarch Court. The Complaints Manager at Monarch Court will acknowledge its receipt to the complainant within two working days. The complainant will be told that their complaint will be investigated and that they will receive a full response within 20 working days. The Complaints Manager at Monarch Court will appoint an appropriate manager to investigate and make the relevant Director aware of the complaint. Anonymous complaints are difficult to deal with because their investigation is always dependent upon limited and questionable information. Where anonymous complaints are made they will be treated seriously and referred to the Complaints Manager at Monarch Court who will take action based on their judgement of the information presented. 5.2 5.3 5.4 D:\Docstoc\Working\pdf\008d9c20-89c4-4628-b639-6a115bd0e02b.doc Page 12 of 23 6 6.2 INVESTIGATING A FORMAL COMPLAINT – LOCAL RESOLUTION STAGE The Complaints Manager at Monarch Court may delegate part or all of the investigation to an appropriate manager. The relevant Director may approach other areas for assistance if necessary, where there is felt to be a conflict of interest. Investigations should normally be completed within one week of the complaint being received. It is important to investigate and respond to complaints quickly. Delays in responding to complainants can exacerbate a complaint unnecessarily and make resolving the complaint more difficult. However, as long as the investigation is carried out and a draft response is written within 15 working days, this will be acceptable. If disciplinary action is involved the Procedure for Complaints will be suspended. However, every effort should be made to act as quickly as possible as it is not appropriate to tell the complainant that disciplinary action is taking place. The complainant should be informed of any changes to procedures etc following the disciplinary action but not the outcome of the action itself. At the end of the investigation, a response will be prepared locally and sent direct to the Complaints Manager at Monarch Court for consideration by the appropriate Director before being signed by the Chief Executive. An action form (Appendix 4) will be sent to the appropriate Director to be completed and returned to the Complaints Manager at Monarch Court within 20 working days. This should demonstrate and document that appropriate action has been taken. Where a complaint involves any form of personal injury to a patient or there is an allegation of Clinical or Medical Negligence against a member of staff, a copy of the report will be sent to the Chair of the Clinical Governance Committee. The response will include a summary of the conclusions reached in relation to the complaint investigated, the decisions taken and the reasons for them. The response will also refer to the complainant's right to ask the Healthcare Commission to fully investigate any outstanding issues, and that the complainant has fifty six calendar days from receiving a response to their formal complaint in which to pursue this course of action. A request to the Healthcare Commission will not automatically result in a panel convening. A clearly documented record of the investigation will assist in reducing the time the Healthcare Commission may have to spend researching the background of the complaint. 6.3 6.4 6.5 6.6 6.7 6.8 6.9 D:\Docstoc\Working\pdf\008d9c20-89c4-4628-b639-6a115bd0e02b.doc Page 13 of 23 7 7.1 THE HEALTHCARE COMMISSION The healthcare commission independently reviews NHS complaints. It can only review complaints that have already been raised with the organisation or practitioner concerned and the complainant is dissatisfied with the formal written response. The reasons for dissatisfaction that the commission will investigate are: The complainant feels the initial investigation by the PCT or practitioner was inadequate, incomplete or unsatisfactory. The complainant believes that the underlying issues, which led to the complaint, have not been fully uncovered or understood. The complainant feels that the organisation or practitioner’s response did not address all the issues raised by your complaint, for example, if more than one organisation was involved. 7.2 7.3 To be eligible: The complaint must be about a service funded by the NHS The request for the commission to review the complaint must be made within two months of receiving the final formal written response from the PCT or practitioner. 7.4 The Healthcare Commission can be contacted in many ways: Phone – 0845 601 3012 Post – HC Freepost NAT 18958 Complaints Investigation Team Manchester M1 9XZ Email – complaints@healthcarecommission.org.uk Website – www.healthcarecommission.org.uk D:\Docstoc\Working\pdf\008d9c20-89c4-4628-b639-6a115bd0e02b.doc Page 14 of 23 8 OTHER POLICIES AND PROCEDURES A number of other policies/procedures exist within the South Gloucestershire PCT which are not superseded by this Complaints Procedure. On receipt of a complaint the Complaints Manager at Monarch Court will consider the implications of other policies. This procedure will include clarification of the rights of individuals against whom a complaint has been made. 8.1 Nevertheless there may sometimes be rare occasions when a complaint is made which involves the possibility of an offence having been committed or which will require legal action. Where this appears to be the case, the Complaints Manager at Monarch Court will take legal advice. If a decision is taken that all or part of a complaint requires a legal investigation and court action then this Procedure will be suspended by the Chief Executive in relation to those investigations. The complainant will be informed that this decision has been taken and this will be the formal notification of the Trust's decision about those parts of the complaint. Complaints to the Mental Health Act Commission 8.4.1 Occasionally a patient who is detained under the Mental Health Act may be admitted for treatment under our agreement with AWPT. The Mental Health Commission has responsibility, under the Mental Health Act, for overseeing the detention and treatment of compulsorily detained patients; and a general responsibility for the care, treatment and after-care of all "mentally disordered people".* Patients detained under the Mental Health Act and their carers may complain directly to the Commission and it is hoped that the Commission will ask for such complaints to be investigated through this Procedure where it is appropriate to do so. * Terminology used in the legislation. 8.5 Complaints to other PCTs, NHS Trusts or Social Services 8.5.1 People who receive a service from South Gloucestershire PCT may also receive services from other agencies eg: Other NHS Trusts - ie. Outpatient appointments, accident and emergency treatment, specialist treatment or continence supplies. Other PCTs - ie. Occupational therapy. Social Services Departments - ie. Social workers, day service placement, occupational therapy, transport or home helps. 8.5.2 Patients/relatives or carers may have difficulty distinguishing between the range of agencies involved when making a complaint made up of components which are the responsibility of different organisations. 8.2 8.3 8.4 D:\Docstoc\Working\pdf\008d9c20-89c4-4628-b639-6a115bd0e02b.doc Page 15 of 23 8.5.3 It has been agreed with other local Trusts that when their complaint concerns more than one Trust a complainant should be fully informed as to who will be dealing with their complaint at the other Trust. The first agency receiving the complaint or the Trust where the main complaint rests would liaise with the other agencies concerned to activate their complaints procedure for full investigation and that agency would then respond directly to the areas of complaint that affects that agency. The following set of principles will be adhered to: 1st Principle: Wherever possible the Complainant will not be asked to write separately to another organisation. The receiving organisation will respond on issues relating to it and will advise the complainant of the other relevant organisations to whom the letter had been forwarded for response. 2nd Principle: Any organisation responding to a complaint will not misrepresent another organisation. 8.5.5 8.6 8.6.1 Complaints about external contractors There may be contractors providing services to South Gloucestershire PCT or working on premises which may in turn have an impact on patient care or the delivery of services. Each of the contractors is expected to respond positively and take action where appropriate in regard to complaints. Complaints about contractors may concern the actual service provided to the Trust i.e. decoration, repairs, site construction or the behaviour of staff working for the contractor. Where patients or staff wish to raise complaints regarding contractors they should contact the Complaints Manager at Monarch Court as soon as possible who will make arrangements for the complaint to be referred to the appropriate contractor. 8.6.2 8.6.3 D:\Docstoc\Working\pdf\008d9c20-89c4-4628-b639-6a115bd0e02b.doc Page 16 of 23 9 COMPLAINTS AGAINST FAMILY HEALTH SERVICE PRACTITIONERS 9.1 Family health service practitioners (GPs, dentists, opticians and pharmacists) have in place and operate practice based complaints procedures which comply with minimum national criteria, to deal with complaints about the services they, or their staff provide. The aim will be to ensure that most complaints are settled by local resolution at practice level. These practice based complaints procedures have been established in consultation with the PCT who will continue to support both patients and practices whenever help is requested. Calls and letters received by the PCT regarding complaints about family health service and practitioners will be directed to the Practice Manager concerned. If the complainant does not feel comfortable talking to the Practice Manager, they can be assisted by the Complaints Managers or PALS. It is expected that in a few cases, a complainant may use the practice based complaints procedure but remain dissatisfied. In such a case the complainant can be referred to PALS who will discuss the complainant’s concerns and consider, with the agreement of the complainant and the practice, whether anything more can be done by the Team, assisted by a lay conciliator if required, to resolve the complaint informally at practice level. If further action, as described in 9.6 is not appropriate, or cannot be agreed by the complainant and the practice, the Practice Manager will explain to the complainant that they may request the Healthcare Commission to investigate their complaint and the time limit (56 days) for such a request. Practice Managers have been advised of the wording to be used in advising of this step and have also been provided with leaflets from the Healthcare Commission. Should any matter arise, as the result of a complaint which indicates the need for a disciplinary procedure against a practitioner, it will be treated separately under disciplinary procedures. This will be a matter for the Clincial Governance Committee to decide following the full conclusion of complaints procedures. Complainants may ultimately appeal to the Ombudsman if they remain dissatisfied. 9.2 9.3 9.6 9.7 9.8 9.10 D:\Docstoc\Working\pdf\008d9c20-89c4-4628-b639-6a115bd0e02b.doc Page 17 of 23 10 COMPLAINTS WHOLLY OR PARTLY ABOUT ANOTHER ORGANISATION 10.1 Complaints about non-NHS organisations Complaints about non-NHS organisations (e.g. Social Services) must be referred to that organisation. The PCT is unable to investigate or respond to such complaints and this should be explained to the complainant. If the complaint is partly about the PCT, that element only of the complaint should be investigated by the PCT. 10.2 Complaints about other NHS organisations Complaints solely about another organisation must be referred to that organisation. 10.3 If the PCT receives a complaint that is partly about the PCT and partly about another NHS organisation then, the complainant will be informed that the area of complaint about the other organisation will be passed on to the Complaints Manager of that organisation. Redirecting complaints If the PCT receives a written complaint about another organisation, it must seek the permission of the complainant before passing the complaint on to the other organisation for investigation and response. Some complainants may prefer to write direct to the other organisation themselves. 10.4 10.5 D:\Docstoc\Working\pdf\008d9c20-89c4-4628-b639-6a115bd0e02b.doc Page 18 of 23 11 11.1 MONITORING OF THE PROCEDURE The Director of Planning will be primarily responsible for monitoring the Trust's Procedure for Complaints. Regular reports will be made to the Trust Board. The Complaints Manager at Monarch Court will collate the complaints into a quarterly report for the Trust Board. Following consideration by the Trust Board the complaints figures and appropriate information about the operation of the procedure will be included in the Trust’s Annual Report. The Director of Planning will also monitor the operation of the procedure through liaison with staff at all levels; in promoting the philosophy behind the procedure throughout the Trust; by involvement in training programmes; and by contributing to various means of quality assurance and quality control. This could include local initiatives with staff such as Complaint Review Panels, exploring in detail how resolved complaints were handled to identify any possible lessons, improvements to complaints handling or suggestions for changes in practice. 11.3 11.4 11.5 D:\Docstoc\Working\pdf\008d9c20-89c4-4628-b639-6a115bd0e02b.doc Page 19 of 23 APPENDIX 1 SOUTH GLOUCESTERSHIRE PRIMARY CARE TRUST INFORMAL COMPLAINT FORM Please complete if a verbal complaint about the PCT is received and pass to the Complaints Manager at Monarch Court Date Received Name of Complainant Address Tel Number Summary of Complaint Key Issues What would complainant like to happen? Action taken (or if not, why not?) Name of person responding to complaint Any other information * if complainant is not the patient, remember that the patient’s written permission, if they are able to give it, must be obtained before dealing with the complaint. In this case, please attach permission to this form. D:\Docstoc\Working\pdf\008d9c20-89c4-4628-b639-6a115bd0e02b.doc Page 20 of 23 APPENDIX 2 Summary of Performance Target Time Limits Event Time Allowed Original complaint Can be brought up to 6 months from the event or 6 months from becoming aware of a cause of complaint, with discretion to extend Local Resolution Verbal complaint Acknowledgement Dealt with on the spot or referred 2 working days of receipt, or full reply within 5 working days 20 working days of receipt Full response by PCT Healthcare Commission Complainant to request investigation 56 days D:\Docstoc\Working\pdf\008d9c20-89c4-4628-b639-6a115bd0e02b.doc Page 21 of 23 APPENDIX 3 FLOWCHART SHOWING THE COMPLAINTS PROCESS AGAINST PCT STAFF Complaint received by member of staff CM notifies appropriate Director for info 1 Director therefore aware of complaint 2 Director has opportunity to appoint different investigating officer if deemed necessary Fax to Complaints Manager (CM) for acknowledgement to be sent within 2 working days CM instructs relevant manager to investigate Investigating manager investigates complaint and drafts a response to Complaints Manager within 15 working days If draft is not provided at this time, CM to inform relevant Director CM notifies appropriate Director of complaint response and asks them to confirm they are happy with response within 24 hours Action form sent to Director CM submits draft letter to Chief Executive for signature Completed action form returned to CM within 20 working days D:\Docstoc\Working\pdf\008d9c20-89c4-4628-b639-6a115bd0e02b.doc Page 22 of 23 APPENDIX 4 Complaint summary Action required Manager responsible Date actioned Please return to the Complaints Manager within 20 working days D:\Docstoc\Working\pdf\008d9c20-89c4-4628-b639-6a115bd0e02b.doc Page 23 of 23