Complaints Policy and Procedure - Ridgeway Partnership by dfsiopmhy6

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									   Ridgeway Partnership

                                 Complaints Policy Control sheet
The Trust Management Executive recommends that the Trust Board approve the Claims Policy and
confirms that it is in accordance with legislation and best practice.
Status new or review:                                        Review
Policy owner:                                                Clare Winton
Contact Details:                                             01865 228173
Sponsoring Director:                                         Deborah Lawrenson
Contact Details:                                             01865 228104
Date last reviewed:                                          January 2009
Approved By:                                                 Trust Board
Date Approved:                                               28 September 2010
Next Due for Revision:                                       June 2011
Date Policy Becomes Live:                                    30 September 2010
Policy number:                                               GOV/05/09/016
Equality Impact Assessment in place                          Yes
Summary of key updates since the last                        Policy updated due to national changes to health
review                                                       and social care complaints systems. Changes
                                                             made to ensure compliance.
Further comments to be considered at the      None
time of ratification for this policy (i.e.
National policy, Legislation and consultation
across SHA).

Compliance with –                                            The Local Authority Social Services and National
  • Mental Health Act                                        Health    Service     Complaints      (England)
  • Equality and Diversity                                   Regulations 2009
  • Human Rights Act
  • CNST                                                     Parliamentary and Health Service Ombudsman’s
  • NHSLA                                                    “Principles for Remedy”
  • CSCI
  • National Service Frameworks
  • Employment legislation
  • Standards for Better Health
  • Quality Accounts
  • Freedom of Information Act
  • Data Protection Act
  • Health and Safety Act

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Compliance with Monitor expectations:                        None at this stage – will be built in post
                                                             authorisation if required
Training needs analysis:                                     Customer Care Training on-going
                                                             Plans to target directorates on a quarter by
                                                             quarter basis for more in-depth training.
Consultation process followed:                               No

Is public or service user consultation
required – if so consult with Company
Secretary for approach to be used:
Version Information
Version No.         Updated By             Updated On Description of Changes
    2.0             Clare Winton            May 2009         New unified complaint system for the NHS and
                                                             Adult Social Care Services. The Policy and
                                                             accompanying documents were amended
                                                             accordingly.
    2.1             Clare Winton            Sept 2010        Minor details changed to comply with NHSLA
                                                             standards



                                        Complaints Policy
Table of contents
Page 1     1 Introduction
Page 1     2 Fit with Trust’s vision or strategic objectives
Page 1     3 General Policy statements and monitoring arrangements
Page 6     4 Fit with other key documents such as Quality Strategy
Page 7     5 Links to national agenda/policy or legislation
Page 7     6 Detail on any benchmarking
Page 7     7 Background to development of the policy, detail on any collaboration or
             consultation
Page 8     8 Communications and Training Plan
Page 9     9 Supporting templates
Page 9       References
Page 9       APPENDICES




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                                     COMPLAINTS POLICY

1.         Introduction

1.1        This policy, accompanying procedure and best practice guide replace the January
           2009 version.

1.2        This Policy sets out a framework for the management of complaints within the
           Ridgeway Partnership in line with best practice and the expectations of the
           Department of Health Guidance, Strategic Health Authority Guidance, Care
           Quality Commission, the NHS Litigation Authority and Commissioners.

1.3        All staff are required to be familiar with this policy and must understand and
           adhere to the policy’s underlying principles, and follow the specified procedures.

2          Fits with Trust’s vision or strategic objectives

2.1        Robust complaints management is an important element of the Trust’s
           governance, assurance and risk management processes.                Learning from
           complaints supports the organisation in its aim to continually improve services.

           General Policy statements
3
3.1        The purpose of this policy is to ensure that risks associated with comments,
           concerns and complaints are identified and managed in accordance with best
           practice, NHS Regulations, and with the expectations of The Local Authority
           Social Services and National Health Service Complaints (England) Regulations
           2009, the Department of Health, Strategic Health Authority, Commissioners, Care
           Quality Commission, and the Parliamentary and Health Service Ombudsman.

           Adherence to this policy will ensure that, in responding to comments, concerns,
           and complaints the Trust ‘puts things right’ and pursues continuous improvement
           whilst being customer-focused, and acting openly, fairly and proportionately.

3.2        The policy lays out a broad framework to guide staff in handling complaints and is
           characterised by a flexible and negotiated approach which is designed to ensure
           that each complaint is dealt with in a way that is tailored to the needs of the
           individual and the circumstances of the complaint.

           The Ridgeway Partnership recognises and works towards its responsibility to
           achieve the key objectives of its Policy and Procedure. The key aims of said
           Policy and Procedure are :-
               Open and easy to access, by being flexible about the ways in which people
               can complain and ensuring people are aware of support to do so if they wish to
               use it. The Ridgeway Partnership will also be open and honest about its
               activities, information and policies in line with “Being Open and Accountable”
               Policy written by the National Patient Safety Agency

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               Fair and Independent, with the emphasis on early and effective resolution so
               minimising the strain and distress for all concerned. People who complain
               should not fear retribution because of their complaint – staff working for the
               Ridgeway Partnership should continue to provide high quality professional
               support, regardless of any complaint made
               Responsive, providing appropriate and proportionate responses and redress
               Learning and developing, ensuring complaints are viewed as a positive
               opportunity to listen and learn from others, to drive continual improvement in
               services

3.3        Definition

           A complaint is defined by the NHS as “an expression of dissatisfaction requiring a
           response”. Complaints about the services the Ridgeway Partnership provides will
           be handled through the Complaints Procedure. For the purposes of this Policy
           and accompanying Procedure, the following is considered to be a ‘formal’
           complaint to be handled in accordance with the Ridgeway Partnership’s
           Complaint Procedure.

               any written and signed complaint about the services the Ridgeway Partnership
               provides; or
               a verbal concern which the complainant clearly states they wish to be treated
               as a complaint; or
               a verbal concern about a serious issue from someone who has a learning
               disability; or
               a complaint received electronically, i.e. by email, which is validated as
               genuine.

           In the case of a verbal complaint, the staff member receiving the complaint (or the
           Complaints Manager) should make a written record of the complaint, including the
           name of the complainant, the subject, and the date made, and should request that
           the complainant validates this record. (A form is available to complete, shown as
           Appendix 2 ‘Recording a verbal complaint about Ridgeway Partnership’s services’
           in the accompanying procedure).

           Email should not be used for complaint correspondence containing confidential
           material.

           Complaints received anonymously will not be accepted as they cannot be
           authenticated, issues will still be investigated however.

3.4        Who can complain

           The Ridgeway Partnership accepts complaints from anyone who wished to voice
           a concern about the Ridgeway Partnership’s services, who either receives a
           service provided by the Ridgeway Partnership, or is affected, (or likely to be
           affected) by action which is the responsibility of the Ridgeway Partnership. This
           includes people who use our services, staff, families, neighbours, the public, other
           service providers etc.

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           A complaint may be made by someone acting on behalf of someone else. If the
           person has not received consent to act as their representative, it is for the
           Complaints Manager, possibly following discussion with the Chief Executive and /
           or the Trust Board member with lead responsibility for complaint handling, to
           determine whether the complainant has ‘sufficient interest’ to act as a
           representative.     (There may, for example, be the need to respect the
           confidentiality of someone who receives services.) In the event that the
           Complaints Manager determines that a person is not suitable to act as a
           representative, they must provide full information outlining the reasons for the
           decision, in writing.

           In the case of a child, the representative should be parent, guardian, or other
           adult person who has care of the child. Where the child is in the care of a local
           authority or a voluntary organisation, the representative must be a person
           authorised by the local authority or the voluntary organisation.

3.5        Responsibility
           The Trust has a responsibility to establish a complaints procedure in line                  with
           statutory requirements and take steps to publicise these arrangements.                      The
           arrangements must be accessible and ensure that complaints are dealt                        with
           speedily and efficiently and that complainants are treated courteously                      and
           sympathetically

           Chief Executive
           The CEO has overall responsibility and accountability for the management of
           complaints of the Ridgeway Partnership.

           It is the responsibility of the Chief Executive or a person acting on his behalf,
           where for good reason the Chief Executive is not able to do so to sign the
           substantive response to all written complaints and all oral complaints, which are
           subsequently put into writing and signed by the complainant.

           Complaints Manager
           The Complaints Manager has the delegated responsibility to manage the
           complaints procedure on behalf of the Chief Executive.

           The prime responsibility is to oversee the complaints handling procedure, provide
           guidance and support, and to provide Senior Managers, EB and the Board with an
           overview of its complaints.

           The Complaints Manager should be readily accessible to the public.

           Trust Management Executive
           Directors have a responsibility to delegate the investigation of all complaints
           relating to their Directorate, ensuring that draft responses fully address the
           complainants concerns, and are available within requested deadlines.


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           Directors have a responsibility to ensure that all staff involved in a complaint,
           particularly those named, are aware of the contents of the complaint and the
           response.

           Learn from the complaint, improving systems and processes as necessary.

           Senior Managers
           All managers have a responsibility within the complaints procedure. It is part of
           the role of the manager to ensure that staff are confident in handling complaints
           and feel fully supported throughout, the handling of said complaint.

           To ensure that those who complain feel assured that it will not affect the support
           being provided.

           To maintain appropriate records.

           Front Line Staff
           Each member of staff has a responsibility to ensure that complaints and concerns
           are dealt with appropriately, as part of their own accountability for governance and
           development within the NHS Knowledge & Skills Framework.

3.6        Time Limits on Initiating a Complaint

           Usually a complaint should be made within 12 months from the incident that
           caused the concern / problem or within 12 months of the date on which the matter
           came to the notice of the complainant. When a complaint is made after this
           period, the Complaints Co-ordinator may investigate if he / she feels that :-

           Having looked at all the circumstances, the complainant has good reason for not
           making the complaint within the time period, e.g. severe distress

           It is still possible to investigate the complaint effectively and fairly without
           engaging unwarranted resources.

3.7        Complaints to Ridgeway Partnership

           The Complaints System will only consider complaints about services provided to
           users.

3.8        Local Resolution

           Complaints are often made directly to the staff providing the service, either in
           person or by letter. Complaints must be acknowledged in writing within 3
           working days, with a copy of the Public Information Sheet, preferably by the
           person receiving the complaint. If the complaint was made verbally, the
           Ridgeway Partnership’s form for recording verbal complaints should be completed
           (refer to Appendix 2 contained within accompanying procedure), and send to the
           complainant with a request that the complainant sign and return it.


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           The complaint should be referred to the Ridgeway Partnership’s Complaints Co-
           ordinator immediately. Further guidance for staff receiving complaints is available
           as an appendices within the Complaints Procedures (Appendix 5) and the Good
           Practice Guide for Managing Complaints

           The complaint will be assessed by the Complaints Co-ordinator to establish the
           appropriate response (i.e. how extensive an investigation is necessary and who
           should investigate) in consultation Service Director’s others such as senior
           managers as appropriate, to resolve it speedily and efficiently. This will include a
           Severity Rating Risk Assessment (Appendix 10 within accompanying Complaints
           Procedure), and may include the use of the Incident Decision Tree if appropriate (
           also within accompanying Complaints Procedure Appendix 11) Detailed guidance
           for managers is available as Appendix 6 within accompanying Complaints
           Procedure.

           The complainant will be offered a face to face meeting at the outset of a
           complaint, and kept informed of progress thereafter, a resolution date will be
           agreed with the complainant. The complaint will be properly investigated as
           quickly as possible. Every effort should be made to complete the investigation
           and inform the complainant of the outcome, within the timescales agreed, NB we
           should always aim to resolve within 25 working days of receipt of the complaint.

           The Ridgeway Partnership will offer a full written response to the complainant,
           including a summary of the nature and substance of the complaint, the
           investigation and its conclusions. The Ridgeway Partnership’s Chief Executive
           will write to the complainant to conclude the local resolution stage of the
           complaint. This letter will include details about how the complainant can ask for
           their complaint to be reviewed independently if they remain dissatisfied. It will
           also include a questionnaire to gather feedback from complainants to help
           improve the way the Ridgeway Partnership handles complaints (Appendix 13
           within Complaints Procedure), and a request to complete a Diversity form (see
           section 7.1 and Appendix 14) within Complaints Procedure) to support the
           analysis that staff and people who use services from ethnic minority groups are
           treated fairly.

3.9        Complaints which require a different process

           The Ridgeway Partnership may receive complaints which are about the Ridgeway
           Partnership and another organisation (e.g. landlord, Social & Community
           Services). In this case the Ridgeway Partnership should work in partnership with
           the other organisation in seeking to resolve the complaint.

           The Ridgeway Partnership may also receive complaints about issues that relate in
           their entirety about other organisations.

           For complaints of this nature, and that of above, please refer to the “Joint Working
           Protocol” contained as Appendix 2 within the Good Practice Guide to Managing
           Complaints.



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3.10       Parliamentary and Health Service Ombudsman

           If the Complainant is not satisfied with the way the Ridgeway Partnership has
           dealt with their complaint they can ask the Health Service Ombudsman to look
           into it.

           In addition, health and social care complaints are now part of the same
           complaints system. Social care complaints that are not resolved locally will need
           to be brought to the attention of the Local Government Ombudsman and the
           Ombudsmen can work together on complaints that cross the boundaries of both
           systems. For further information on the Health Service Ombudsman / Local
           Authority Ombudsman, please refer to the Complaints Procedure.

3.11       Monitoring


           This policy will next be reviewed in June 2011, and bi-annually thereafter taking
           into account any changes in National Regulations.

           Notification will be given to staff, via the Managers Bulletin

           The Complaints Co-ordinator is responsible for keeping informed of any changes
           in National Guidance, and will take all appropriate action to review the policy
           earlier if needs be.

           The Complaints Co-ordinator will audit the effectiveness of the policy, procedure
           and good practice guide annually and will report findings to the Risk Management
           & Service Governance Group. If standards fall short of compliance, then actions
           will be put in place to address any shortcomings. Please see Audit Tool Appendix

           Quarterly Reports on complaints activity, trend analysis and learning will be
           submitted to the Risk Management and Services Governance Group for review
           and comment.

4           Fit with other key documents such as Quality Strategy
               Whistle Blowing Policy
               Data Protection
               Risk Management Strategy & Policy
               Freedom of Information
               Safeguarding Vulnerable Adults Policy
               Grievance Policy & Procedure
               Disciplinary Policy & Procedure
               Information Protection & Confidentiality Policy
               Counter Fraud Policy and Reporting Procedure
               Claims Management Policy & Procedure
               Policy on Promoting Privacy and Dignity for Service Users
               Being Open Policy
               Child Protection Protocol
               Accident, Incident & Near Miss Reporting Guidelines
               Investigation of Incidents, Complaints and Claims

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5          Links to national agenda/policy or legislation

5.1            Parliamentary & Health Service Ombudsman’s “Principles for Remedy”
               The Local Authority Social Services and National Health Service Complaints
               (England) Regulations 2009
               Listening, Responding, Improving : A guide to better customer care

6          Detail on any benchmarking

6.1        The Complaints Co-ordinator will always work according to the standards set in
           The Local Authority Social Service and National Health Service Complaints
           Regulations 2009. The Complaints Co-ordinator also meets regularly with other
           complaints leads within Oxfordshire, so regular informal benchmarking does take
           place.

7          Background to development of the policy, detail on any collaboration or
           consultation

7.1        There were major changes to the NHS Complaints System introduced in April
           2009, after consultation.

           In her 2005 report, ‘Making things better? A report on the reform of the NHS
           Complaints Procedure in England’, the Health Services Ombudsman identified
           five key weaknesses in the then current NHS system and approach:

               Complaints systems are fragmented within the NHS, between the NHS and
               private health care systems, and between health and social care;
               The complaint system is not centred on user needs;
               There is a lack of capacity and competence among staff to deliver a quality
               service;
               The right leadership, culture and governance are not in place;
               Just remedies are not being secured for justified complaints.

           It is believed that one of the key features of high performing organisations is the
           way that they respond to customers who are unhappy about the service that they
           have received.

           Since April 2009 the chance for a common approach to handling complaints in the
           NHS and adult social care has been introduced and this provides an opportunity
           for all organisations to review their local systems so they can both respond flexibly
           to complaints, concerns and complements and feed the resulting lessons into
           their work on learning from patients’ feedback to improve services.

           The new approach focuses on the complainant and enables organisations to tailor
           a flexible response that seeks to resolve the complainant’s specific concerns. It is
           based on the principles of good complaints handling, which have been published
           by the Parliamentary and Health Service Ombudsman and endorsed by the Local
           Government Ombudsman:
           1. Getting it right

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           2. Being customer focused
           3. Being open and accountable
           4. Acting fairly and proportionately
           5. Putting things right
           6. Seeking continuous improvement

8          Communications and Training Plan

8.1        All staff should be aware of this policy and the accompanying procedure and good
           practice guide. Staff should know how to access a copy from ‘S’ Drive or the
           intranet.

           First line managers should read and understand the policy

           Executive Directors, Senior Managers and Team Leaders should have a good
           working knowledge of the policy

           Awareness of the policy should be included in both the Trust corporate Induction.

           Managers responsible for undertaking investigations of incidents, complaints and
           claims should be Route Cause Analysis trained (as specified in the TNA)

8.2        Publicity – The Ridgeway Partnership must ensure that the right to complain,
           advice about how to use the complaints procedure and the help available to
           complainants from staff and other sources is well publicised to everyone using our
           services, families, stakeholders, members of the public and all other interested
           parties. This will be available through :-
               The Service Users Accessible Complaints Booklet will be made available to
               every user of Ridgeway services, e.g. those within Supported Living or Care
               Home arrangements, those residing in an in-patient unit and those accessing
               community learning disability team service. The Service User’s Guide will
               summarise the Ridgeway Partnership’s complaints procedure and provide
               contact details for the Care Quality Commission and Ombudsman
               Notices will be displayed appropriately at every in-patient unit
               The leaflet “How to complain if you are unhappy” will be made available to
               every person using the Ridgeway Partnership’s Services, families / carers and
               member of the public, should they require it
               Every leaflet produced by the Ridgeway Partnership will have a section
               explaining how to make a complaint. The Ridgeway Partnership produces a
               leaflet for every service area, an annual report and a general leaflet about
               services. These are available in accessible formats and in languages other
               than English on request
               Staff induction and awareness raising sessions around the Ridgeway
               Partnership, ensuring that staff are aware of the aims and philosophy of the
               Complaints Procedure, and their key role of managing complaints, supporting
               others to make complaints, and raising concerns themselves or on behalf of
               others
               LISTEN Service leaflets (for raising concerns) will be available at all service

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             areas, and public places. Posters will be displayed in public places.
             Information about the LISTEN Service is also provided to staff at induction
9          Supporting templates

9.1        Templates are provided within the accompanying appendices.

           APPENDICES

             A. Complaints Policy Audit Tool
             B. Complaints Procedure
             C. Good Practice Guide for Managing Complaints
             D. EIA




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Appendix A
                        COMPLAINTS POLICY AUDIT TOOL

Standard Statement                                     Yes %     No%       Evidence

Standard 1       Are staff aware of this policy?
Standard 2       Do staff know how to locate
                 policies on Trust intranet?
Standard 3       Do staff know how to access
                 information relating to
                 complaints? E.g. Policy,
                 Procedure and Good Practice
                 Guidance
Standard 4       Staff are aware of their duties
                 within this policy?
Standard 5       Service users are aware of
                 the system for raising
                 concerns and complaints
Standard 6       Lessons learnt are reported
                 and shared appropriately
Standard 7       Staff feel supported
                 throughout all aspects of the
                 complaints process
Standard 8       Staff involved in serious
                 complaints feel supported
                 throughout the process
Standard 9       Managers are aware of their
                 responsibilities in relation to
                 supporting staff
Standard 10 Internal and external
            communication occurs as
            appropriate for each
            complaint
Standard 11 Improvement in complainant
            satisfaction with process and
            outcome
Standard 12 Complaints are investigated
            according to their severity /
            grade
Standard 13 Action plans are followed and
            concluded




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Appendix B




            COMPLAINTS PROCEDURE




                                                                                      May 2009
                                                                        Review date: June 2011




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CONTENTS
1   BACKGROUND .................................................................................................. 1
  1.1    The NHS ...................................................................................................... 1
2 AIM...................................................................................................................... 2
3 THE COMPLAINT PROCEDURE ....................................................................... 3
  3.1    Definition – formal complaints and informal concerns .................................. 3
    3.1.1     What is a complaint?............................................................................. 3
    3.1.2     Who can make a complaint? ................................................................. 3
    3.1.3     Is there a time limit? .............................................................................. 4
    3.1.4     Verbal concerns – the LiSTEN Service. ................................................ 4
    3.1.5     Complaint or concern – which process? ............................................... 4
  3.2    Making a complaint ...................................................................................... 4
  3.3    Local resolution ............................................................................................ 5
    3.3.1     Conciliation............................................................................................ 5
    3.3.2     Staff who are the subject of a complaint. .............................................. 6
  3.4    Freedom of Information Act 2000 ................................................................. 6
  3.5    Parliamentary & Health Service Ombudsman .............................................. 6
  3.6    Staff complaints about The Ridgeway Partnership’s services ...................... 7
  3.7    Vexatious or habitual complainants.............................................................. 7
4 COMPLAINTS WHICH REQUIRE A DIFFERENT PROCESS ........................... 8
  4.1    Disciplinary proceedings. ............................................................................. 8
  4.2    Legal proceedings. ....................................................................................... 9
  4.3    Coroner’s cases. .......................................................................................... 9
5. CONFIDENTIALITY .......................................................................................... 10
  5.1    Access to complaint files. ........................................................................... 10
  5.2    Letters from Members of Parliament. ......................................................... 11
  5.3    Requests for information from the police or legal representatives.............. 11
6 STAFF TRAINING............................................................................................. 11
7 MONITORING REPORTING AND LEARNING ................................................ 12
  7.1    Diversity ..................................................................................................... 12
8 FURTHER HELP AND GUIDANCE .................................................................. 13
9 PUBLICITY ....................................................................................................... 14
10    REVIEW OF THIS PROCEDURE.................................................................. 15
11    APPROVAL OF THIS PROCEDURE ............................................................ 15
APPENDIX 1: The Ridgeway Partnership’s Vision Statement ............................ 16
APPENDIX 2: Recording a verbal complaint about Trust services .................... 19
COMPLAINANT ACTION PLAN.............................................................................. 21
APPENDIX 3: “How to handle concerns” – the LISTEN Service ........................ 22
  THE LISTEN SERVICE - CONCERNS FORM ..................................................... 24
APPENDIX 4: Public Information Sheet ................................................................ 25
  INFORMATION COMMISSIONER’S OFFICE ...................................................... 26
  The Parliamentary and Health Service and Ombudsman ..................................... 26
APPENDIX 5: Guidance for staff receiving complaints. ...................................... 27
    “Out of hours” .................................................................................................... 29
  HOW TO HANDLE CONCERNS - FLOWCHART ................................................ 30
APPENDIX 6: Guidance for managers receiving complaints.............................. 31
  COMPLAINTS PROCEDURE FLOWCHART FOR LOCAL RESOLUTION.......... 35
APPENDIX 8: Guidance for vexatious or habitual complainants. ...................... 40
APPENDIX 9: Key competencies of a Complaints Manager ............................... 44
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APPENDIX 10: Guidance to assess risk. .............................................................. 46
APPENDIX 11: Incident Decision Tree .................................................................. 47
APPENDIX 12: Summary sheet to identify learning ............................................ 48
APPENDIX 13: Feedback questionnaire to improve the system. ....................... 49
APPENDIX 14: Diversity form ................................................................................ 52
APPENDIX 15: Current post-holders, and their responsibilities ........................ 53




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                                                                    RIDGEWAY PARTNERSHIP
                                                (OXFORDSHIRE LEARNING DISABILITY NHS TRUST)


                             COMPLAINT PROCEDURE
1       BACKGROUND

1.1     The NHS
People who complain about NHS services usually want an apology, an explanation,
and reassurance that if something went wrong measures have been taken to minimise
the risk of it happening again in the future. They do not usually want compensation or
‘retribution’, but some feel forced to take issues further because they believe they have
not been listened to, or received a proper explanation.

In her 2005 report, ‘Making things better? A report on reform of the NHS Complaints
Procedure in England’, the Health Services Ombudsman identified five key
weaknesses in the current NHS system and approach:

    Complaints systems are fragmented within the NHS, between the NHS and private
    health care systems, and between health and social care;
    The complaint system is not centred on user needs;
    There is a lack of capacity and competence among staff to deliver a quality service;
    The right leadership, culture and governance are not in place;
    Just remedies are not being secured for justified complaints

Other issues identified during the course of reviews were :-

    Separate procedures for health and social services complaints “can cause
    problems for users of both sets of services when things go wrong”
    When complaints arise about both services “it is not always clear to service users
    which organisation is responsible for the services they receive”

The Local Government Ombudsmen have similarly identified problems in complaints
handling and redress within “Health and Social Care Partnerships and Citizen
Redress”

It has been decided that Health and Social Care Complaint Systems will be integrated
– there will be one unified system. Given the differing cultures, and history and timing
of complaints reform within health and social care, it is believed it is better to design
unified arrangements from basic principles, rather than adapting the procedures
already in place.

It is also believed that providing handling at local level is robust, effective,
comprehensive and proportionate, there is no purpose to be served by having
intermediary stages between local resolution and the Ombudsman, so therefore there
will be two stages :-

    Local Resolution
    Ombudsman



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                                   RIDGEWAY PARTNERSHIP (OLDT) COMPLAINTS PROCEDURE


The vision is that if complainants are involved throughout local resolution, with their
views and opinions being taken into account, there ought not to be a need to have
another go at getting it right.

The emphasis is very much on getting it right locally, and Health and Social Care orgs
are being encouraged to develop local approaches. The Parliamentary and Health
Service Ombudsman published two leaflets, which explain the basis for an effective
complaints process:-

    Getting it right
    Being customer-focused
    Being open and accountable
    Acting fairly and proportionately
    Putting things right
    Seeking continuous improvement

The DH believes that new complaints arrangements should meet the following basic
criteria :-

    Open and easy to access – flexible about the ways people could complain and
    with effective support for people wishing to do so
    Fair – emphasising early resolution so minimising the strain and distress for all
    those involved
    Responsive – providing appropriate and proportionate response and redress
    Providing an opportunity for learning and developing – ensuring complaints are
    viewed as a positive opportunity to learn from patients views to drive continual
    improvement in services

2       AIM
The Ridgeway Partnership’s aim is to offer a complaint procedure which meets the
needs of staff and people who use our services, their families and the public, and is:

•   Open and easy to access, by being flexible about the ways in which people can
    complain and ensuring people are aware of support to do so if they wish to use it.
    The Ridgeway Partnership will also be open and honest about its activities,
    information and policies in line with “Being Open and Accountable” Policy written by
    the National Patient Safety Agency
•   Fair and independent, with the emphasis on early and effective resolution so
    minimising the strain and distress for all concerned. People who complain should
    not fear retribution because of their complaint – staff working for the Ridgeway
    Partnership should continue to provide high quality professional support, regardless
    of any complaint made
•   Responsive, providing appropriate and proportionate responses and redress
•   Learning and developing, ensuring complaints are viewed as a positive
    opportunity to listen and learn from others, to drive continual improvement in
    services.



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3       THE COMPLAINT PROCEDURE

3.1     Definition – formal complaints and informal concerns
A complaint is defined by the NHS as “an expression of dissatisfaction requiring a
response”. Complaints about the services the Ridgeway Partnership provides will be
handled through the Complaint Procedure.

3.1.1 What is a complaint?
For the purposes of this procedure
   • any written and signed complaint about the services the Ridgeway Partnership
       provides; or
   • a verbal concern which the complainant clearly states they wish to be treated as
       a complaint; or
   • a verbal concern about a serious issue from someone who has a learning
       disability; or
   • a complaint received electronically, i.e. by email, which is validated as genuine;

is considered to be a ‘formal’ complaint to be handled in accordance with the
Ridgeway Partnership’s Complaint Procedure.

In the case of a verbal complaint, the staff member receiving the complaint (or                    the
Complaints Co-ordinator) should make a written record of the complaint, including                  the
name of the complainant, the subject and the date made, and request that                           the
complainant validates this record. (A form is available to complete, shown                          as
Appendix 2 ‘Recording a verbal complaint about Ridgeway Partnership services’).

E-mail should not be used for complaint correspondence containing confidential
material.

Complaints received anonymously will not be accepted as they cannot be
authenticated, issues will still be investigated however.

3.1.2 Who can make a complaint?
The Ridgeway Partnership accepts complaints from anyone who wished to voice a
concern about the Ridgeway Partnership’s services, who either receives a service
provided by the Ridgeway Partnership, or is affected, (or likely to be affected) by action
which is the responsibility of the Ridgeway Partnership. This includes people who use
our services, staff, families, neighbours, the public, other service providers etc.

A complaint may be made by someone acting on behalf of someone else. If the
person has not received consent to act as their representative, it is for the Complaints
Manager, possibly following discussion with the Chief Executive and / or the Trust
Board member with lead responsibility for complaint handling, to determine whether
the complainant has ‘sufficient interest’ to act as a representative. (There may, for
example, be the need to respect the confidentiality of someone who receives services.)
In the event that the Complaints Manager determines that a person is not suitable to
act as representative, they must provide full information outlining the reasons for the
decision, in writing.
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In the case of a child, the representative should be parent, guardian, or other adult
person who has care of the child. Where the child is in the care of a local authority or
a voluntary organisation, the representative must be a person authorised by the local
authority or the voluntary organisation.

3.1.3 Is there a time limit?
The Ridgeway Partnership will not usually accept complaints about something which
occurred more than 12 months before the complaint is made, or which the complainant
became aware of more than 12 months previously. These time restrictions reflect the
difficulty investigating and reaching a satisfactory conclusion for complainants and staff
in such situations.

These restrictions may be set aside at the discretion of the Complaints Co-ordinator
following consultation with appropriate senior managers/directors if the complainant
had good reasons for not making the complaint within that time limit and it is still
possible to investigate the complaint effectively and fairly.

If the Complaints Co-ordinator has decided not to investigate a complaint on the
grounds that it was not made with the time limit, a letter of explanation will be sent to
the complainant. The Complainant will have the opportunity to appeal to the
Ombudsman if they disagree with the Trust’s decision.

3.1.4 Verbal concerns – the LiSTEN Service.
All informal’ concerns, unless from someone who has a learning disability, should be
handled through the LiSTEN Service (refer Appendix 3, LiSTEN Service guide “How to
handle concerns” and accompanying form). The purpose of this process is to
encourage rapid resolution of concerns, with the minimum paperwork, when made
directly (verbally) to staff who are delivering the service. If someone is unhappy with
the way their concern has been handled through the LiSTEN Service they should ask
for their concerns to be investigated and registered as a formal complaint, through the
Complaint Procedure.

3.1.5 Complaint or concern – which process?
If someone who has a learning disability raises a concern verbally, wherever possible
the complainant’s view should be sought to find out whether they would prefer their
concern be handled using the Complaint Procedure or the LiSTEN Service. If there is
any doubt, the concern should be handled through the complaint process. If the
concern is about serious issues such as alleged abuse or fraud, the Complaint
Procedure must be used.


3.2     Making a complaint

Sometimes people who would like to make a complaint would like some help to do so.
Staff should suggest organisations who can help, with particular reference to the
Independent Complaints Advocacy Service (ICAS), which provides specialist support
for people who wish to complain about health care services. A list of organisations is
shown in Appendix 4 as part of the Public Information Sheet. If the person requiring
help has a learning disability, the Ridgeway Partnership’s booklet ‘How to Complain if
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you are Unhappy’ should be made available, and appropriate support offered to enable
the person to make a complaint. The Ridgeway Partnership will also provide a
translation or interpreting service for people whose first language is not English.

3.3     Local resolution
Complaints are often made directly to the staff providing the service, either in person or
by letter. Complaints must be acknowledged in writing within 3 working days,
with a copy of the Public Information Sheet enclosed, preferably by the person
receiving the complaint.     If the complaint was made verbally, the Ridgeway
Partnership’s form for recording verbal complaints should be completed (refer to
Appendix 2), and send to the complainant with a request that the complainant sign and
return it.

The complaint should be referred to the Ridgeway Partnership’s Complaints Co-
ordinator immediately. Further guidance for staff receiving complaints is available as
Appendix 5.

The complaint will be assessed by the Complaints Co-ordinator to establish the
appropriate response (i.e. how extensive an investigation is necessary and who should
investigate) in consultation with the Director of Operations others such as heads of
directorates as appropriate, to resolve it speedily and efficiently. This will include a
Severity Rating Risk Assessment Appendix 10, and may include the use of the
Incident Decision Tree if appropriate Appendix 11. Detailed guidance for managers is
available as Appendix 6

The complainant will be offered a face to face meeting at the outset of a complaint, and
kept informed of progress thereafter, a resolution date will be agreed with the
complainant and added to the complainants plan (Appendix 2). The complaint will be
properly investigated as quickly as possible. Every effort should be made to complete
the investigation and inform the complainant of the outcome, within the timescales
agreed beforehand with the complainant. NB we should always aim to resolve within
25 working days of receipt of the complaint unless otherwise agreed with the
complainant.

The Ridgeway Partnership will offer a full written response to the complainant,
including a summary of the nature and substance of the complaint, the investigation
and its conclusions. The Ridgeway Partnership’s Chief Executive will write to the
complainant to conclude the local resolution stage of the complaint. This letter will
include details about how the complainant can ask for their complaint to be reviewed
independently if they remain dissatisfied. It will also include a questionnaire to gather
feedback from complainants to help improve the way the Ridgeway Partnership
handles complaints ( Appendix 13), and a request to complete a Diversity form (see
section 7.1 and Appendix 14) to support the analysis that staff and people who use
services from ethnic minority groups are treated fairly.

3.3.1 Conciliation.
In some situations, it may be considered helpful to offer conciliation. This is essentially
a process of facilitating agreement between the complainant and complained against,
whether this is an organisation, a staff team or a person. It is most effective when
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used early in a complaint resolution process. The Complaints Co-ordinator will ensure
that there are suitable, independent, conciliators available, with costs met by the
Ridgeway Partnership. Confidentiality will be strictly observed during the conciliation
process. Conciliators will not be required to report to the Ridgeway Partnership the
details of cases in which they are involved.

3.3.2 Staff who are the subject of a complaint.
Any staff mentioned in the complaint will be informed, and offered support, which could
include the provision of a suitable “buddy”. They will receive copies of all relevant
correspondence. Staff will be kept informed of progress through their line manager.
They will be consulted in advance of the final response letter, and receive a copy of the
letter closing the local resolution stage of the complaint from the Chief Executive.
They will be offered a de-briefing session at the end of the complaint process.

If a member of staff is unhappy about the way the have been dealt with under the
complaints procedure, they should raise these issues using the Ridgeway
Partnership’s Grievance Policy. It they remain dissatisfied at the conclusion of this
process, staff may refer their complaint to the Parliamentary and Health Ombudsman.
Staff may take such a complaint straight to the Parliamentary and Health Service
Ombudsman (please refer to section 3.5 for more details), however the Ombudsman
will expect the Trust’s procedure to be followed unless there are particular
circumstances where it is reasonable not to do so.

3.4     Freedom of Information Act 2000
Complaints about the Ridgeway Partnership’s handling of requests for information
under the Freedom of Information Act (which replaced the Code of Openness) will be
investigated following local resolution processes as described in Section 3.3. Should a
complainant remain dissatisfied at the end of this stage they should request an
independent review by the Information Commissioner. For further information call the
Information Commission’s helpline: 08456 30 60 60 or 01625 545 745 (Monday –
Friday between 9am and 5pm), or visit their website: www.ico.gov.uk

3.5     Parliamentary & Health Service Ombudsman
The Parliamentary and Health Service Ombudsman carries out independent
investigations into complaints about unfair or improper actions or poor service by UK
Government departments and their agencies, and the NHS in England.

The Ombudsman works to put things right and share lessons learned to improve public
services.

The Ombudsman is independent of the NHS and of government and derives her
powers from the Health Service Commissioners Act 1993.

For details of the Ombudsman “Principles of Good Complaint Handling”, please refer
to Appendix 7.



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3.6     Staff complaints about The Ridgeway Partnership’s services
Managers should ensure that all staff feel able to express any concerns they may have
about the standard of care the Ridgeway Partnership provides. Such concerns should
be treated just as seriously as comments made by people who use Ridgeway
Partnership services, families, advocates or the public.

The process for dealing with complaints by staff will be just the same as that outlined
above, up to the conclusion of the Local Resolution Stage. If they remain dissatisfied
they should use the Ridgeway Partnership’s Grievance Policy.                  Under no
circumstances should staff be penalised for expressing concerns. Wherever possible
staff should be encouraged to raise concerns informally (i.e. with their line manager or
service manager, or through the LiSTEN Service), however sometimes staff may feel
unable to speak to their immediate line manager. In these cases, staff should contact
the Complaints Co-ordinator, the Chief Executive or the Trust Board lead for complaint
handling. They may involve their staff representative if they wish.

If a complaint remains unresolved, staff may contemplate consulting a Member of
Parliament or disclosing information to the news media. In such situations staff are
strongly advised to seek guidance from their professional or representative body, and
to refer to the Ridgeway Partnership’s Whistle blowing Policy. Unjustifiable contact
with the news media may result in disciplinary action.

In exceptional circumstances staff may wish to discuss something worrying them within
a protected environment. In this situation staff should use the Ridgeway Partnership’s
‘confidential line’ (tel: 01865-228173).

3.7     Vexatious or habitual complainants.

Habitual and/or vexatious complainants are becoming an increasing problem for the
NHS, placing a strain on time and resources, and causing undue stress for staff that
may need extra support in difficult situations. Sometimes there are times when there is
nothing further which can reasonably be done to assist a complainant, or to rectify a
real or perceived problem.

The following are situations where a complainant may be considered to be habitual
and/or vexatious:

    •   Persisting in pursuing a complaint where the procedure has been properly
        implemented and exhausted
    •   Continually changing the substance of a complaint, or continually raising new
        issues whilst the complaint is being addressed
    •   Unwilling to accept documented evidence as factual, or that facts can
        sometimes be difficult to verify
    •   Not clearly identifying the precise issue to enable a reasonable investigation
    •   Focusing on something trivial and demanding activity which is out of proportion
        to it
    •   Threatening or using physical violence or other abusive or harassing behaviour
        towards staff
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    •   Recording meetings or conversations without prior knowledge and consent of
        others involved.

For further information on dealing with vexatious complainants, please refer to
Appendix 8


4       COMPLAINTS WHICH REQUIRE A DIFFERENT PROCESS
The Ridgeway Partnership may receive complaints which are about the Ridgeway
Partnership and another organisation (e.g. landlord, Social & Community Services). In
this case the Ridgeway Partnership should work in partnership with the other
organisation in seeking to resolve the complaint.

The Ridgeway Partnership, may also receive complaints about issues that relate in
their entirety to other organisations.

For complaints of this nature, and that of above, please refer to the “Joint Working
Protocol” located as an appendix within the Good Practice Guide for Managing
Complaints


The complaints process summarised within this policy will not be used where one of
the following special procedures is required:

    a) Investigation by the Care Quality Commission (of any complaint involving
       application of the Mental Health Act): in this case staff will send the complaint to
       the Care Quality Commission

    b) Investigation into an allegation of abuse (the Safeguarding Vulnerable Adults
       Policy will be followed)

Anybody dealing with a complaint who thinks that the case may need to involve one of
the investigations above must refer the matter at once to their Director or the Chief
Executive for referral to the appropriate body. If one of these investigations has
already started, the complainant will be informed. They will be told what progress has
been made with their complaint so far, and what will happen next.

4.1    Disciplinary proceedings.
The complaints procedure is concerned only with resolving complaints and not with
investigating disciplinary matters. The purpose of the procedure is not to apportion
blame amongst staff. Some complaints will identify information about serious matters
and the Ridgeway Partnership may feel it appropriate to consider disciplinary
investigation at any point during the complaints procedure. This will be the
responsibility of the managers involved. It falls outside the complaints procedure and
is subject to the Ridgeway Partnership’s Disciplinary Policy, with separate processes
of investigation. Information gathered during the complaints procedure may be made
available for a disciplinary investigation.


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Staff who receive or are managing a complaint who feel that there are indications to
refer to any of the following:

    a) Investigation under the Ridgeway Partnership’s disciplinary procedure

    b) Referral to one of the professional regulatory bodies

    c) Independent inquiry into a major incident under Section 84 of the NHS Act 1977
       (the Policy for Dealing with a Major Clinical/Untoward Incident will be used)

    d) Investigation of a criminal offence

should at once pass the complaint to the Complaints Manager, who will ensure that it
is passed on to a suitable person who can make a decision as to whether to initiate
such action. This reference can be made at any point during the complaint process.
Investigation into other aspects of a complaint may continue if this does not
compromise or prejudice the concurrent action.

A full report of any complaint investigation which has taken place up to the point of
referral will be made available to the complainant, with an explanation about what will
happen next to their complaint. When other investigations are complete, the
complainant will be provided with a further response, outlining the outcome and any
actions to be taken, being mindful of staff and service user confidentiality at all times.

At the conclusion of other investigations, if there are outstanding matters in the
complaint which have not been resolved, the complaint procedure can recommence.

4.2     Legal proceedings.
If a complainant starts legal proceedings against the Ridgeway Partnership, the
complaints procedure will be brought to an end. The complainant will be told this in
writing. It will not be inferred that a complainant has decided to take formal legal
action, even if the complainant communicates through a solicitor’s letter. The
complaints process will continue, to try and resolve the complaint in an open and
sympathetic way, until the complainant either instigates formal legal action, or notifies
the Ridgeway Partnership in writing that they intend to do so. Please also see Claims
Policy.

4.3    Coroner’s cases.
If a death is referred to the Coroner’s Office, this does not mean all investigations into
a complaint need be suspended. The Ridgeway Partnership will consult the Coroner’s
Office and, where appropriate, initiate proper investigations.




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5.      CONFIDENTIALITY
All staff must remember that dealing with a complaint does not remove the need to
respect confidentiality. Unauthorised disclosure of personal information is a serious
offence and will always warrant disciplinary action. However, if a service user makes a
formal complaint, this will be accepted as implied consent for the Complaints Co-
ordinator, the Trust Board member with lead responsibility for complaints, and the
investigator (if one is appointed) to read relevant documents, including personal and
clinical records, if this is necessary for investigation of the complaint e.g these people
are acting within the service user’s best interests. This should be explained to the
service user, and their wishes respected if they object.

If a complaint is made on behalf of a service user who has not authorised someone to
act for them, personal information must not be disclosed to the complainant unless the
service user consents to this. If the service user lacks the capacity to consent the
Complaints Personnel should consult with the Medical Director and if appropriate
Psychiatrist to ascertain whether the sharing of this information and ultimately the
complaint would be within this person’s best interests. Discussions and ultimate
decisions must be recorded appropriately with a detailed rationale. Complaints
Personnel must also bear in mind that the person may have the capacity to agree to
someone sharing personal information even if they do not have the capacity to make
other decisions. The duty of confidentiality also applies to any third party who has
given information or is referred to in the service user’s records.

For further information about the Ridgeway Partnership’s approach, and it guidance for
staff regarding confidentiality and consent please refer to the Trust’s Policies: Consent
to Examination or Treatment, Information Security Policy and Sharing Information
Policy.

Information gathered in the complaints process will not be privileged: it may be given to
the Chief Executive, or to senior manager/directors who have to consider whether
there is any need for a disciplinary or other form of investigation.

5.1   Access to complaint files.
The Data Protection Act 1998 provides a legal right of access to complaint files for
anyone who is mentioned in that complaint file. There are some exceptions, for
example if this is likely to cause serious harm to the person involved. If someone
requests access to a particular file, this request will be considered by the Complaints
Co-ordinator, who will review the file to protect the confidentiality of third parties and
take advice from appropriate senior staff. Access to the file, or reasons for refusal,
must be provided within 40 days of the receipt of the request.

For further information for the Ridgeway Partnership’s approach to access to
confidential and personal material, please refer to the Trust’s Policy: Access to Medical
Records. Please note that a complaint file is not part of a medical record, although
parts of a medical record may be included within a complaint file. For the purposes of
Data Protection and Freedom of Information, the complaint file is private and
confidential to the service user, who may not be the complainant. If the service user is
an adult, their consent will be required to release any information private to them

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contained in their complaint file. This includes disclosures of such information to the
complainant.

5.2    Letters from Members of Parliament.
If an MP writes to the Ridgeway Partnership requesting information regarding a
complaint he/she has received about services the Trust provides, the response will not
contain any confidential material without the consent of the person involved.

5.3    Requests for information from the police or legal representatives.
Private and confidential information may not be released to the police or legal
representatives without consent (refer to 5.1 above). If the police or the Crown
Prosecution Service or solicitors request access to complaint files, and consent cannot
be obtained, the Ridgeway Partnership will seek advice from their legal
representatives, (and possibly the NHS Litigation Authority and/or the Information
Commissioner), to ensure confidentiality is not breached. Third party confidentiality
should be considered carefully. If files are provided without deleting all third party
references, the Ridgeway Partnership will inform everyone involved and offer
appropriate support, for example, if the Trust receives a Court Order to provide access
to complaint files.

The Ridgeway Partnership may release information to somebody who has recognised
Lasting Power of Attorney (LPA (they must be registered with the Public Guardian)).
Under a power of attorney, the chosen person (the attorney or donee) can make
decisions that are as valid as one made by the person (the doner). An attorney or
donee can legally make a range of decisions regarding property and affairs and
personal welfare for people who lack capacity. LPA’s can make decisions such as
rights of access to personal information and can also make complaints about the
donor’s care or treatment. LPA’s also have the authority to cover personal welfare e.g.
healthcare and consent to medical treatment. The donor can choose one person or
several to make different kinds of decisions. LPA’s must always act in the donor’s best
interests.

The Ridgeway Partnership will be expected to co-operate fully with any requests for
information from the Coroner’s Office.


6       STAFF TRAINING

Information about the complaint procedure and effective customer care is a core
element of the Ridgeway Partnership staff induction programme. Regular awareness
raising sessions will be held around the trust, and articles published in the Ridgeway
Partnership’s staff magazine on an adhoc basis.

The Ridgeway Partnership’s Complaints Co-ordinator, complaints staff, and the Trust
Board lead for complaint handling will undertake regular training as necessary to
ensure their skills and knowledge follow current best practice in the NHS. This will
include regular contact with colleagues in other NHS trusts to share learning and
support.


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The Ridgeway Partnership will ensure that there are sufficient senior managers trained
to undertake effective complaint investigations, including analysis of events to identify
learning and service improvement. The Ridgeway Partnership will ensure that senior
manager/directors develop and sustain a working environment which seeks to learn
from complaints


7       MONITORING REPORTING AND LEARNING
All information relevant to the investigation of each complaint will be recorded and kept
in the case file. This information will be kept in a manner so that should the complaint
progress to the Ombudsman, there will be no delays sending relevant information.

The Ridgeway Partnership’s aim is to learn from concerns and complaints so that good
services may be acknowledged and weaknesses may be improved. It is therefore
important to record and monitor informal and formal comments and complaints.

Staff should record informal concerns on the Ridgeway Partnership’s LISTEN forms
(see Appendix 3) and send these forms to the LISTEN Service promptly.

All letters, records of telephone conversations, meetings, investigations, etc. relating to
a complaint will be copied to the Complaints Co-ordinator to enable a complete record
to be compiled. This will be held by the Ridgeway Partnership in a safe and secure
place for a minimum of 12 years. Access to these files, and the processing of any data
contained in them, will be according to the Data Protection Act 1998, and the Freedom
of Information Act 2000.

Where appropriate Root Cause Analysis techniques will be used to investigate where
there is reason to believe that a detailed review of particular situations are warranted,
for example following a particularly serious event or a number of similar issues have
arisen (please refer to the Ridgeway Partnership’s Root Cause Analysis protocol).

A quarterly report of concerns and complaints activity, including learning for the
Ridgeway Partnership, will be submitted as part of the Service User Experience Report
to the following:

    •   Risk Management and Service Governance Group

An annual review of complaints activity will be reported to the Strategic Health
Authority, and reflected in the Ridgeway Partnership’s Annual Report.

Reports will be provided if requested, containing appropriate information (complying
with the Data Protection Act 1998, and respecting confidentiality), to the Care Quality
Commission, commissioners of services provided by the Trust, Registered Social
Landlords, and bodies inspecting Trust activities (e.g. the Strategic Health Authority).

7.1   Diversity
The Trust strongly believes in equality and is committed to ensuring that everybody
accesses the same quality services and is opposed to unfair discrimination. For
example, translation and interpreting services are available for people who use
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services and their families, should they require them, (please also refer to the
Ridgeway Partnership’s Single Equality Scheme for further information about the
Ridgeway Partnership’s strategy and plans in this area).

To enable analysis of fairness to complainants and staff who are the subject of
complaints, the Ridgeway Partnership will analyse data about the ethnic diversity of
complainants and staff involved in complaints. Complainants will be asked to complete
a Diversity form at the conclusion of the Local Resolution stage of their complaint (see
Appendix 14). The Ridgeway Partnership will refer to information provided by
individual staff concerned, as part of their employment record. All data will be handled
sensitively and in accordance with Caldicot Principles. Results of this analysis will be
reported annually through the service user experience report.

Any complaints which may include issues relating to race equality will be highlighted in
the service user experience report.


8       FURTHER HELP AND GUIDANCE

If you would like to talk to someone at the Ridgeway Partnership about a concern or
complaint you would like to make, or have received, you can call the Complaints Co-
ordinator on 01865-228173. This line has a voicemail facility, and someone will call
you back as soon as possible, usually within 24 hours.

If you are worried about something and would prefer not to use the Ridgeway
Partnership’s complaint system, for whatever reason, you can use the ‘confidential
line’ facility operated by the Complaints Co-ordinator (‘phone number as above). Your
confidentiality is assured, unless the issues raised are those where the Ridgeway
Partnership’s duty of care over-rides confidentiality. Examples of these are where they
may be acts of abuse of vulnerable people, fraud or other issues of gross misconduct.

Leaflets/information available to help people who would like to make complaints
include:

“How to Complain if you are Unhappy”, an accessible leaflet designed to help people
through the complaints procedure step by step
“Complaints – Listening, Acting, Improving”, a leaflet issued by the Department of
Health
“The Parliamentary Health Service Ombudsman’s Principles for Remedy”, a leaflet
issued by the HSO
The Department of Health’s website: www.dh.gov.uk
The Care Quality Commission’s Website: www.cqc.org.uk

Attached are the following Appendices with further guidance:

Appendix 1:     The Ridgeway Partnership’s Vision Statement
Appendix 2:     Recording a verbal complaint about Ridgeway Partnership Services
Appendix 3:     “How to handle concerns” – the LISTEN Service
Appendix 4:     Public Information Sheet for people who would like to make a complaint
Appendix 5:     Guidance for staff receiving complaints
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Appendix 6: Guidance for managers receiving complaints
Appendix 7: The Ombudsman’s Principles of Good Complaint Handling
Appendix 8: Guidance for vexatious or habitual complainants
Appendix 9: Key competencies of a Complaints Manager
Appendix 10: Guidance to assess risk
Appendix 11: Incident Decision Tree
Appendix 12: Summary sheet to identify learning
Appendix 13: Feedback questionnaire to improve the system
Appendix 14: Diversity Form
Appendix 15: Current post-holders, and their responsibilities


9       PUBLICITY

The Ridgeway Partnership’s complaint procedure will be publicised to people who use
services, their families and carers, visitors to trust premises, staff, and the public
generally, through:

    •   The Service User’s Accessible Complaints Booklet will be made available to
        every user of Ridgeway services e.g. those within Supported Living or Care
        Home arrangements, those residing in an in-patient unit and those accessing
        community learning disability team services. The Service User’s Guide will
        summarise the Ridgeway Partnership’s complaints procedure and provide
        contact details for the Care Quality Commission.
    •   The leaflet “How to Complain if you are Unhappy” will be made available to
        every person using the Ridgeway Partnership’s services, families / carers and
        member of the public, should they require it.
    •   Every leaflet produced by the Ridgeway Partnership will have a section
        explaining how to make a complaint. The Ridgeway Partnership produces a
        leaflet for every service area, an annual report and a general leaflet about
        services. These are available in accessible formats and in languages other
        than English on request.
    •   Staff induction and awareness raising sessions around the Ridgeway
        Partnership, ensuring that staff are aware of the aims and philosophy of the
        Complaints Procedure, and their key role of managing complaints, supporting
        others to make complaints, and raising concerns themselves or on behalf of
        others.
    •   LISTEN Service leaflets (for raising concerns) will be available at all service
        areas and public places. Posters will be displayed in public places.




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10      REVIEW OF THIS PROCEDURE
This procedure will be reviewed bi-annually, facilitated by the Complaints Co-ordinator.
The next review will be completed by 30 June 2011.


11      APPROVAL OF THIS PROCEDURE
This procedure was last approved by the Strategic Development Team at their meeting
on 14th March 2006

This procedure was last endorsed by the Trust Board at their public meeting held on
29 March 2006.



Complaints Co-ordinator




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APPENDIX 1: The Ridgeway Partnership’s Vision Statement

Vision

The Trust’s vision for the future is to be the leading specialist in the South of England
providing integrated, tailor-made specialist services for people with complex support
needs and long-term health conditions. By 2014, the Trust will have –

        •   A turnover of £60 million
        •   Extended its geographical reach and diversified into new markets;
        •   Improved its margins on all contracts; and
        •   Consolidated Supported Lifestyles Directorate at the high value end of the
            market, supporting more people who would traditionally have been unable to
            remain at home.

We believe that each individual has the right to a fulfilling life, to be treated with dignity
and respect, to make choices and decisions about their own lives, to be valued by
others and to be actively involved in their local and wider communities. Our
organisation is thus committed to the following values:

        •   Listening to individuals:

            We are committed, through skilled listening, to becoming informed and to
            understanding the needs, wishes and aspirations of each person about how
            he or she want to live now and in the future.

        •   Designing and delivering a person-centred and tailored service:

            We are committed both to responding to information about each person’s
            needs, wishes and aspirations and to delivering relevant, flexible and
            affordable services which are informed by evidence of best practice.

        •   Working with others:

            We are committed to working in partnership with families/carers,
            commissioners and other agencies, as well as with social networks and
            communities to build a society in which everyone can participate as equal
            and valued citizens.

        •   Investing in our staff:

            We are committed to creating a working environment which celebrates
            diversity, promotes the active involvement of staff in the design and delivery
            of person-centred services and responds to their needs for training,
            development and support.




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APPENDIX 2: Recording a verbal complaint about Trust services
                                                                                      Ridgeway Partnership

CONFIDENTIAL
Slade House
Horspath Driftway
HEADINGTON
Oxon OX3 7JH

Complaint Co-ordinator: 01865-228173


What is a complaint?

A ‘formal’ complaint (to be handled in accordance with the Trust’s Complaint Procedure) is:
    1. any written and signed complaint about the services the Trust provides; or
    2. a verbal concern which the complainant clearly states they wish to be treated as a
       complaint; or
    3. a verbal concern about a serious issue from someone who has a learning disability; or
    4. a complaint received electronically, i.e. by email, which is validated as genuine.

This form should be used when someone clearly states that they would like their concerns
handled as a formal complaint (point 2 above).
For complaints made as (1), (3) or (4) please refer to the trust’s Complaint Procedure.

The member of staff receiving the complaint will either:

  complete this form, sending the
    original to the complainant requesting them to sign and return to the Complaints
    Manager, and
    copies of the unsigned form to the Complaints Co-ordinator and their line/service
    manager;
OR
  complete this form with the complainant asking them to sign immediately, if this is more
  convenient, in which case
    copies of the signed form should be sent to the complainant and the line/service
    manager, and
    the original sent to the Complaints Co-ordinator.

The staff member should ensure that the complainant receives a copy of the trust’s Public
Information Sheet (“Making a comment or complaint – what to do”), which includes details of
organisations who can offer support and advice.

It will be also be necessary to explain to the person who wishes to complain that all private
information will be treated with respect in accordance with the trust’s policies around
confidentiality and consent. In order to resolve concerns, it is sometimes necessary to share
private information with a small number of senior managers. If the person wishing to complain
is unhappy to give consent for this to happen, this may limit the ability of staff to resolve the
complaint. Further advice can be sought from the Complaints Co-ordinator (01865-228121)
Please note that consent cannot be given on behalf of another adult.
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Date:

Name of staff member receiving the complaint:

Name of the person wishing to complain:

Contact details of the person wishing to complain:




                                                                        Tel:

What is the relationship between the trust and the person wishing to complain?
(For example, are they a service user, family/carer of someone who uses trust services, or a
neighbour.)


Brief details of the complaint:




What the person complaining would like to see happen:




Action agreed to take forward this complaint:
.



I/We confirm the above details as an accurate record of my/our complaint.
I/we agree that information related to these issues can be shared with others, confidentially, as
required to assist in the resolution of my/our complaint.

Signature: …………………………
Date: ………………………..

Please return by hand to a member of trust staff, or by post to the Complaint Co-
ordinator at the address at the top of this form.




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                                              RIDGEWAY PARTNERSHIP (OLDT) COMPLAINTS PROCEDURE


COMPLAINANT ACTION PLAN


Complainant Complaint              What         What    is      How and          Is     there    Does     the
Name & Log                         have we      our             when will        any             complainant
Number                             agreed       timescale       we update        immediate       need     any
                                   to           for doing       on     any       action we       additional
                                   resolve      so?             progress?        might take      support? If
                                   the                                           to resolve      so is this
                                   issue?                                        the issue?      being
                                                                                                 provided?




This agreement was developed in partnership between myself the complainant
and the Ridgeway Partnership’s Complaints Co-ordinator. I understand the action
being taken to resolve my complaint, how I will be communicated with and when I
can expect a full response from the organisation.

Signed          ____________________________




Date            ______________________________




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APPENDIX 3: “How to handle concerns” – the LISTEN Service

This procedure is intended as a step by step guide for all staff, who may be involved
in handling concerns which are raised verbally – face-to-face or on the ‘phone. (Any
concerns raised in writing, or serious issues raised by someone who has a learning
disability, are complaints and should be handled using the Trust’s Complaint
Procedure.)

Step 1

• You are receiving a concern, listen carefully to everything the person is saying.
  Make sure you understand clearly what the person is worried about. If you are
  not sure, politely ask them to go through things again, explaining that you need to
  be sure to be helpful.
• You have now listened to the concern and need to find out:-

    1. Is this a concern about services provided by the Ridgeway Partnership? If
       yes, refer to Step 2.
    2. If not, do you know whose service it relates to? Do you know how to refer the
       person to the right organisation? If not please contact the Complaints Co-
       ordinator on 01865-228173 for advice and information. You should use the
       LISTEN Enquiry Form to record what you do.

Step 2

• If you have established that this concern relates to a service provided by the
   Ridgeway Partnership, you should take down some details using the LISTEN
   Service Concerns form including :-

    1. Name and address of person raising concern including contact telephone
       number.
    2. Whether they are a service user, relative, neighbour or member of staff.
    3. Date and time of concern.
    4. Brief details of the concern
    5. What the person would like to see happen – their preferred outcome.

•   Having established what the person would like to see happen:

    1. Is this something you can help with? If yes, agree what you will do, and how
       you will keep in touch with the person to tell them what is happening.
    2. Is this something your line manager can help with? If yes, tell the person who
       this is, and when they can expect to be contacted by them,
    3. Provide the person with the leaflet explaining how the Ridgeway Partnership
       handles concerns, and reassure them that the Ridgeway Partnership will
       handle personal information confidentially, complying with the Data Protection
       Act and the Caldicott Principles.



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If you have answered no to both the above you need to ring the Complaints Co-
ordinator on 01865 228173 for advice and information.

Step 3

•   When you have carried out all of the above and taken whatever action is
    necessary to try to resolve the concern, you need to ‘close’ the concern, but
    before you do that you need to :-

    1. Inform the person raising the concern how to complain formally.
    2. Check that the person raising the concern is satisfied.

    • Having recorded all of the above on the The LISTEN Service Concerns form
        and copied any correspondence/ relevant paperwork, send to the Complaints
        Co-ordinator at Slade House.

Step 4

    • A member of the LISTEN team may contact you and/or the person raising the
        concern to complete a feedback questionnaire, to help improve the way the
        service is run.


If you are unsure about what to do at any point you should call the
Complaints Co-ordinator for help on 01865-228173




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THE LISTEN SERVICE - CONCERNS FORM
Please use this form to record all concerns made to you face to face or on the telephone.
Please contact the Complaints Co-ordinator on 01865 228173 if you have any queries

Name and address of the person raising concern:


Contact telephone number(s):

Any other relevant information (e.g. if they are a service user, relative, neighbour, member of staff,
etc.)



Date and time of the concern:

Brief details of the concern:



What the person raising the concern would like to see happen:



Have you informed them how to                        Yes      No
raise concern formally (complain)?
Have you checked that they are                       Yes      No
satisfied?
Have you closed this concern?                        Yes      No        Date Closed :


Your name, job title and where you work:


What action you have taken, with dates (please use the other side of the form/more paper if required):



What action your line manager has taken, with dates:



Date form sent to Complaints Co-ordinator, Slade House:


    Don't forget to attach copies of any letters or reports you have written about this concern.
  (NB Written complaints, or a concern about serious issues from someone who has a learning
         disability require written acknowledgement within 3 working days – use the Complaint
                                                  System)




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APPENDIX 4: Public Information Sheet
     MAKING A COMMENT OR COMPLAINT - WHAT TO DO
We will always try to give a good service. But you may want to suggest how we could
improve our services. Sometimes you may be unhappy with the service. You may
want to complain. This leaflet tells you how to comment or complain.

Step 1 – now handled by the LISTEN Service (please see separate leaflet)
Talk to the staff. Tell them your suggestion or your complaint. Staff will talk the
problem over with you, find out what you would like to happen, and work out what to
do next. Staff will try to help you if you have a complaint about another organisation.
We hope that most problems can be cleared up in this way.

You may prefer not to speak directly to staff. You can speak or write to:-
                                The LISTEN Service
                          Ridgeway Partnership (OLDT)
                         Slade House, Horspath Driftway
                          Headington, Oxford OX3 7JH
                                  Tel: 01865 228173

Step 2
If staff cannot sort out the problem and you are not satisfied, you can speak or write
to the Complaints Co-ordinator:
                               The Complaints Co-ordinator
                              Ridgeway Partnership (OLDT)
                             Slade House, Horspath Driftway
                              Headington, Oxford OX3 7JH
                                    Tel: 01865 228173

If you wish, you can ask a member of staff to help you make your complaint. There
are other organisations you can ask for help too. They are listed on the other side of
this paper.
Your complaint will be acknowledged promptly. We will investigate the problem to
find out what went wrong and what can be done. (We may need to look at personal
records). The Chief Executive will write to you within five weeks (or longer with your
consent) to let you know the results.

Step 3
If you are not satisfied with the response from the Chief Executive, you can ask for
your complaint to be looked at by someone independent of the Ridgeway
Partnership. If your complaint is about social care services provided by the
Ridgeway Partnership, you should make this request to the Local Government
Ombudsman, by visiting their website: www.lgo.org.uk or telephoning the LGO
Advice Team on 0300 061 0614 or 0845 602 1983. If your complaint is about health
care services provided by the Ridgeway Partnership, you should make this request
to the Parliamentary and Health Service Ombudsman by using a form which is
available on the website: www.ombudsman.org.uk, or by ‘phoning their helpline:
0345 015 4033


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  ORGANISATIONS WHICH MAY BE ABLE TO HELP YOU WITH ADVICE

THE CARE QUALITY COMMISSION
Responsible for regulating health and adult social care services, whether
provided by the NHS, local authorities, private companies or voluntary
organisations. And, protecting the rights of people detained under the Mental
Health Act
Care Quality Commission , National Correspondence, Citygate, Gallowgate,
Newcastle upon Tyne, NE1 4PA, Email: enquiries@cqc.org.uk
  Tel: 03000 616161

INFORMATION COMMISSIONER’S OFFICE
Only for complaints about Freedom of Information and Data Protection issues
Wycliffe House , Water Lane, Wilmslow , Cheshire. SK9 5AF,
Email: mail@ico.gsi.gov.uk: Tel: 01625 545 700

MENCAP
Provides support for people with learning disabilities and their carers
Local Contact: Karen Akers, Community Development Office for Oxfordshire,
Berkshire & Buckinghamshire
  Tel: 07776-228987

INDEPENDENT COMPLAINTS ADVOCACY SERVICE
ICAS is a free, impartial and independent service for people wishing to
complain, or who have already complained, about services provided by the
NHS. If you require more information about their service, or to arrange
support, you can contact ICAS. For Buckinghamshire and Oxfordshire write to
3rd Floor Kingfisher House, Walton Street, Aylesbury, Email:
aylesbury.icas@seap.org.uk Tel: 01296 468170. For Wiltshire write to Unit
3, Premier House, Willowside Park, Canal Road, Trowbridge, Wiltshire, BA14
8RH, Email: trowbridge.icas@seap.org.uk Tel: 01225 762723

The Parliamentary and Health Service and Ombudsman
If, once the Trust has had the opportunity to address all your concerns, you
remain dissatisfied, the next stage is to ask the Ombudsman to review your
complaint. You will be informed by the Trust when it considers that this is the
next option. For Health complaints please refer to The Parliamentary and
Health Service Ombudsman, Millbank Tower, Millbank, London, SW1P 4QP,
Website: www.ombudsman.org.uk             Tel: 0345 015 4033. For Social Care
complaints, please refer to the Local Government Ombudsman, by visiting
their website: www.lgo.org.uk or telephoning the LGO Advice Team on 0300
061 0614 or 0845 602 1983




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APPENDIX 5: Guidance for staff receiving complaints.


             WHAT TO DO IF SOMEONE MAKES A COMPLAINT
         Comments and complaints procedure: detailed guidance for staff


What is a complaint?

A complaint is defined by the NHS as “an expression of dissatisfaction requiring a
response”. Complaints about the services the Ridgeway Partnership provides will be
handled through the Complaint Procedure.

What is a complaint?
For the purposes of this procedure
   • any written and signed complaint about the services the Ridgeway Partnership
       provides; or
   • a verbal concern which the complainant clearly states they wish to be treated
       as a complaint; or
   • a verbal concern about a serious issue from someone who has a learning
       disability; or
   • a complaint received electronically, i.e. by email, which is validated as
       genuine;

is considered to be a ‘formal’ complaint to be handled in accordance with the
Ridgeway Partnership’s Complaint Procedure.

Who can make a complaint?
The Ridgeway Partnership accepts complaints from anyone who wishes to voice a
concern about the Ridgeway Partnership’s services, who either receives services
provided by the Ridgeway Partnership, or is affected, (or likely to be affected) by
action which is the responsibility of the Ridgeway Partnership. This includes people
who use our services, staff, families, neighbours, the public, other service providers,
etc.

A complaint may be made be someone acting on behalf of someone else. If the
person has not received consent to act as their representative, it is for the
Complaints Co-ordinator, possibly following discussion with the Chief Executive
and/or the Trust Board member with lead responsibility for complaint handling, to
determine whether the complainant has ‘sufficient interest’ to act as a representative.

Time limits?
The Trust will not usually accept complaints about something which occurred more
than 12 months before the complaint is made, or which the complainant became
aware of more than 12 months previously. In exceptional circumstances these
restrictions may be set aside at the discretion of the Complaints Co-ordinator.

Verbal concerns – the LiSTEN Service.
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All verbal (‘informal’) concerns, unless from someone who has a learning disability,
should be handled through the LiSTEN Service (refer Appendix 3, LiSTEN Service
guide “How to handle concerns” and accompanying form). The purpose of the
separate process is to encourage rapid resolution of concerns, with the minimum
paperwork, when made directly (verbally) to staff who are delivering the service. If
someone is unhappy with the way their concern has been handled through the
LiSTEN Service they should ask for their concerns to be investigated as a formal
complaint, through the Complaint Procedure.

Complaint or concern – which process?
If someone who has a learning disability raises a concern verbally, wherever possible
the complainant’s view should be sought to find out whether they would prefer their
concern be handled using the Complaint Procedure or the LiSTEN Service. If there
is any doubt, the concern should be handled through the complaint process. If the
concern is about serious issues, the Complaint Procedure must be used.

What should you do if someone complains verbally?

If someone complains to you face to face or on the telephone, stay polite even if they
are rude. Allow the person to talk about their complaint. Don't be afraid to say sorry.
Even if you don't agree with them, you can always say you're sorry that they felt it
necessary to complain.

A verbal concern should be handled through the LISTEN Service (see Appendix 3).
You should check that the person has a copy of the Ridgeway Partnership’s Public
Information Sheet, and offer to give them a copy immediately, or send one in the post
to them (see Appendix 4).

If a member of the public would like their concerns to be handled as a formal
complaint, you should offer to write their concerns this down for them, and send it to
them to check and agree. If the person would like to do this, you should use the
Verbal Complaints form (see Appendix 2).

If the person has a learning disability, you can work through the illustrated guide for
service users with them (“How to Complain if you are Unhappy” – a copy of this guide
is available for everyone who receives a service from the trust). You can use this if
you are helping someone to make a complaint, or complaining on their behalf.

If the problem is something you can deal with, or you and your line manager can sort
it out, try to agree with the person what you will do. You should try to satisfy their
complaint if you can.

You may find the flowchart within this section helpful for handling concerns within the
LISTEN Service, and the flowchart within the next section helpful for handling
complaints within the Ridgeway Partnership’s complaint procedure.




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“Out of hours”

If someone contacts you out of normal office hours to raise a serious concern which
requires immediate action you should call your appointed ‘on call’ contact for
guidance. This also applies if you are unsure what you should do - see also
Appendix 11 for help with a risk assessment.

What should you do if someone complains in a letter?

You should contact the Complaints Co-ordinator and your immediate line manager as
soon as possible, preferably by telephone to inform them of the letter, (or the letter
you are writing to acknowledge their verbal complaint,) and its contents. This will
enable a proper assessment of the complaint and ensure an appropriate response is
made as quickly as possible (see also Appendix 11 Severity Rating guidance.)

You will write an acknowledgement letter on the same day as you have received the
complaint (this must be within 3 working days of the receipt of the letter by the
Ridgeway Partnership). This letter should say that your letter is to acknowledge
receipt of their letter, and to enclose a copy of the Public Information Sheet. You
should write down everything you have done and send this information, together with
copies of any correspondence, to the Complaints Co-ordinator immediately.

If a person complains to you about something which is to do with another
organisation, try to help them find out how to complain to that organisation. (You
could ask the Complaints Co-ordinator if you are not sure). In the Learning Disability
Teams any complaints about care management should be referred to the team
managers.

Your responsibilities as front line staff

Your responsibilities within the complaint system include:
  To be familiar with and to adhere to the complaints procedure
  Involve your line manager and the Complaints Co-ordinator at the earliest
  opportunity
  Remain polite, courteous and professional at all times
  Listen to the complaint and check that you have understood it
  Where appropriate seek to resolve the complaint immediately
  To record and report complaints as quickly as possible, even if already addressed
  Offer an apology in recognition o the person’s experience

Remember your duty of confidentiality to service users at all times.

Please contact the Complaints Co-ordinator on 01865 228173 if you have any
queries about this procedure or would like copies of the complaints leaflet or
the illustrated guide for service users.




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  HOW TO HANDLE CONCERNS - FLOWCHART

  CONCERN RAISED

Is the concern in writing
or does the person wish            Yes                  Refer to        Trust
the concern to be treated                               Complaints
as a complaint?                                         Procedure


                No                                                                    If you are unsure of
                                                        Refer              to         what to do please
      Is this concern about        No                   appropriate                   contact the Complaints
      the Trust?                                        organisation                  Co-ordinator on 01865
                                                                                      228173


                Yes
                                                                                    Provide Line Manager with
      Is this something            No                   Refer   to        Line      all relevant details, including
                                                        Manager                     when       person       raising
      you can help with?
          Yes                                                                       concern expects to be
                                                                                    contacted.
          Yes

      Use a LISTEN Concerns Form to record key
      information. Agree action and how you will
      keep in touch. Provide the person with the
      leaflet explaining how concerns are handled
      and reassure them that personal information
      will remain confidential.




    If both yourself and your Line Manager are unable to help with the persons concerns, you will need
    to contact the Complaints Co-ordinator on 01865 228173




                                                              .
    When you have carried out whatever action is              Remember to check that the person
    necessary to try to resolve the concern, you              raising the concern is satisfied and
    need to ‘close’ preferably by letter stating what         inform them how to use the complaint
    action has been taken.                                    procedure should they remain unhappy.




     Record all the above on the verbal concerns                  A member of the LISTEN Team may
     form and copy any correspondence / relevant                  contact you and/or the person raising the
     paperwork to the Complaints Co-ordinator at                  concern to complete a feedback
     Slade House.                                                 questionnaire to improve the way
                                                                  concerns are handled




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APPENDIX 6: Guidance for managers receiving complaints.
MANAGER'S GUIDE TO THE COMPLAINTS PROCEDURE

CONCERNS – the LISTEN Service (see Appendix 3)

If these are quickly and easily resolved, they will not usually require a written
response. However, you may feel that it would be helpful for both you and the
complainant to have a record of what was agreed. Write to them, with a copy to the
LISTEN Service, enclosing the Public Information Sheet (see Appendix 4). End by
saying that they should contact you again if the problem is not resolved or if it recurs,
or they can make a formal complaint.

You should make sure that the record sheet for handling concerns has been
completed and copied to the LISTEN Service.

If someone who has a learning disability raises a concern verbally, wherever possible
the complainant’s view should be sought to find out whether they would prefer their
concern be handled using the Complaint Procedure or the LiSTEN Service. If there
is any doubt, the concern should be handled through the complaint process.

WRITTEN/ELECTRONIC COMPLAINTS OR WHEN SOMEONE SAYS THEY
WOULD LIKE TO MAKE A COMPLAINT VERBALLY

Refer to the complaint procedure sections 3.1, 3.6 and 4 to check that the criteria for
accepting a complaint are met. You should also consider the issues around
vexatious or habitual complainants, as described in section 3.7. If you are not sure if
the complaint should be accepted, perhaps because it is about something which
happened more than 12 months ago, you should contact the Complaints Co-
ordinator as soon as possible. If the complaint requires a different process, you
should take appropriate action as set out in section 4.

If the issue raised is of a serious nature, you may wish to use the Incident Decision
Tree (Appendix 12).

Any staff mentioned in the complaint will be informed, and offered support. They will
receive a copy of the complaint (if a letter/email) and the acknowledgement letter.
Staff will be kept informed of progress through their line manager or the Complaints
Co-ordinator. They will be consulted in advance of the final response letter, and
receive a copy of the letter closing the local resolution stage of the complaint from the
Chief Executive. They will be offered a de-briefing session at the end of the
complaint process. Please see section 3.3.2 for further details.

All formal complaints must be acknowledged in writing within three working days.
If a complaint has been made verbally, refer to section 3.3 to ensure that you
acknowledge their complaint (and request their agreement) in writing with the correct
information.

If the complaints process is not the appropriate way forward, a letter must still be sent
explaining what should happen next or referring the complainant to the appropriate
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organisation. Copy the complaint letter and your acknowledgement immediately to
the Complaints Co-ordinator.

If the complaint process is to be used, there will be an initial assessment of the
complaint by the Complaints Co-ordinator to establish the appropriate response (i.e.
who should investigate) in consultation with yourself, directors and others as
appropriate. The Incident Decision Tree may be used as a tool to inform these
discussions (see Appendix 12). In some situations a Root Cause Analysis may be
commissioned, either at this stage, or following the complaint investigation (please
refer to the Ridgeway Partnership’s Root Cause Analysis protocol). The Severity
Rating risk assessment guidance will be used (see Appendix 11). Minor issues may
be investigated locally, more serious issues may require the independence of an
investigation led by someone from a different service area.

Use of a conciliator to help resolve a complaint should be considered at every stage
of the process. Further details are included in section 3.3.1.

The aim is to investigate and make a formal written response either within 25
working days or whatever the agreement is with the complainant. This will
require the release of the investigating officer from normal operating duties for
(usually) 2 weeks.

The investigation. The investigating officer will involve everyone concerned in the
investigation. The investigator will offer to meet the complainant at an early stage,
usually with the Complaints Co-ordinator, to confirm the details of the complaint and
any other relevant information. The investigator can also contact the Trust Board
lead for complaint handling for advice at any time.

The investigator should be mindful that should a complainant request an independent
review the Parliamentary & Health Service Ombudsman / Local Government
Ombudsman will request full information about the complaint. Records should be
kept in a manner which will be clear and understandable to anyone who requires
access to them.

Staff interviews will not be recorded verbatim, or require signed statements. Staff
should be supported to view the complaint investigation as an opportunity to reflect
and improve practice as well as providing an explanation of what has happened. For
the purposes of learning from complaints, disciplinary action will be reserved for
serious issues only, i.e. those which require a formal disciplinary investigation.
Please refer to section 4.1 for further details. Should the investigating officer believe
this is the case, he/she should immediately suspend the complaint investigation (or
part of it) during the period of the disciplinary investigation. The complainant and the
staff involved should be informed immediately in writing, respecting staff
confidentiality. The complaint investigation will resume following the conclusion of
the disciplinary process.

Sometimes investigation takes longer than 2 weeks. In this case the complainant
should be kept informed of progress, in writing, at least every 4 weeks. Copies of all
letters should be sent to the Complaints Co-ordinator.

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Please refer to the Ridgeway Partnership’s “Operational Guide to Root Cause
Analysis Investigations” for further guidance, and a range of investigatory tools.

Following the conclusion of the investigation, the investigating officer will send their
report to the Complaints Co-ordinator to review. The report will include the following
information:

    •   A summary of the complaint, and specifically what the complainant is seeking
        as an outcome. This may be an explanation or a particular action, or both.
    •   A summary of the evidence relied upon. This will usually be a list of people
        interviewed (including the complainant) and when, and a list of documents,
        letters and other printed material
    •   Setting the context of the complaint, providing relevant information to aid
        understanding of the main issues. This may include a timeline.
    •   A response to the specific issues in the complaint, if possible set out for each
        issue separately
    •   An overview to bring together the bigger picture
    •   Recommendations for action in response to the investigation.

The report will not include copies of records of meetings, discussions or copies of
documents. These will remain within the investigating manager’s file, to be retained
as confidential material within the complaint file.

The complainant will be sent a copy of the report, and an opportunity to meet with
appropriate people to discuss the report. The investigation may require staff/senior
manager/directors to agree to an action plan to improve services. In addition to
meeting the complainants, the investigation officer will make themselves available to
meet with any staff complained about, and with any staff groups/teams as necessary
to improve services. One of the actions arising from the investigation may be to hold
a Root Cause Analysis (refer to the Root Cause Analysis Protocol for further
information).

The overall responsibility for delivering the action plan rests with the director for the
service(s) involved, who will decide, in consultation with the Complaints Co-ordinator
and others, the appropriate forums for the action plan. This may be, for example, at
a team meeting, a directorate meeting, an Executive Board meeting, or a RMSG
meeting. The service director(s) may delegate responsibility for delivery of the action
plan to a line manager or a team/committee as appropriate. The confidentiality of all
the parties involved in the complaint must be protected at all times.

Formal written responses
These must be signed by the Chief Executive and copied to the Complaints Co-
ordinator. You can either draft a letter for signature, or write a report which could be
attached to a short covering letter. The letter must end with the following paragraph

"This letter completes the Trust's complaints procedure. If you remain unhappy with
our response to your complaint, you have the right to ask the Parliamentary and
Health Service Ombudsman to review your case.


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You can contact the Parliamentary and Health Service Ombudsman on 0345 015
4033 or write to them at: The Parliamentary and Health Service Ombudsman,
Millbank Tower, Millbank, London, SW1P 4QP phso.enquiries@ombudsman.org.uk .”


The ‘closing letter’ will also include a request to complete a questionnaire about how
the complaint was handled from the complainant’s perspective, and asking them to
return it in the stamped addressed envelope provided. This will help to improve the
complaint system itself. (See Appendix 14.) A Diversity Form should also be sent
(see Appendix 15) to support analysis that staff and people who use services from
ethnic minority groups are treated fairly.

You may find the flowchart later in this section helpful.

Your responsibilities
These include:
   Ensuring that complaints are dealt with and investigated properly within required
   time scales
   Ensuring that a copy of any written complaint is immediately forwarded to the
   Complaints Co-ordinator
   Identifying lessons to be learned and actions to be taken as a result of complaints
   Facilitation of shared learning at a local level and across services and teams
   Ensuring that proposed actions identified as a result of a complaint are
   implemented within required time scales
   Ensuring that staff follow the complaint procedures
   Ensuring that appropriate support is provided to staff who are investigation a
   complaint, or who are the subject of a complaint
   Ensuring that staff involved in a complaint receive feedback about the outcome of
   the complaint
   Ensuring that the relevant information leaflets and posters are made available to
   all
   Ensuring that staff have the necessary skills to manage and/or investigate
   complaints and have access to relevant training.

Responsibilities of an investigating officer
These include:
   Introducing themselves to the staff complained about, and complainant if
   appropriate, and explaining the rationale and process of the investigation
   Undertaking an appropriate investigation involving all people concerned
   Consulting with senior clinicians, e.g. Heads of Professions, and senior managers
   Compiling an investigation report with supporting documents
   Drafting the letter of response to the complainant
   Making recommendations for learning and service improvement
   Meeting with complainants, staff and staff groups as appropriate to feed back
   outcomes and learning

If you would like advice about the comments & complaints procedure or about
a particular complaint, do contact the Complaints Co-ordinator at Slade House
on 228173.

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 COMPLAINTS PROCEDURE FLOWCHART FOR LOCAL RESOLUTION

   Complaint made                                                       Refer to the joint working protocol.
                                                No

    Is it about the Trust?

        Yes                                                    No       Handle according to LISTEN
                                      Is the complaint from             Service guidance (see Appendix 3)
                          No          someone who has a
Is the complaint in                   learning disability?
writing or has the                                               Yes
person stated this is a
complaint?                                                              Refer to Section 3.1 of the
                                                                        complaints procedure and decide if
    Yes                                                                 this should be formal or informal.
                                                  Formal complaint
    •     Refer to Complaints Co-ordinator
    •     Refer to line manager
    •     Write an acknowledgement letter
          within 3 working days enclosing
          Public Information Sheet


                          Does the complaint require a different process?
                          • Application of the Mental Health Act
                          • Investigation through Disciplinary Procedure
                          • Referral to a professional regulatory body
                          • Inquiry into a Major Untoward Incident
                          • Allegation of abuse
                          • Investigation of criminal offence
                          • The complainant has started legal proceedings.
                          For any of the above, refer to Section 4 of the Complaints Procedure.



    Complaints Co-ordinator to assess risk
    and appoint investigating officer.
    Investigation and report to be
    completed within 2 weeks.



                                       Full response sent to complainant from Chief Executive
                                       within 25 working days (or time agreed with
                                       complainant) of receipt of the complaint.



              Complainant satisfied                                          Complainant not satisfied


        Staff de-briefing & action plans                               Complainant refers to Parliamentary &
        developed                                                      Health Service / Local Government
        Learning recorded through                                      Ombudsman or Grievance Policy for
        Quarterly SU Experience Report                                 complaints from staff.

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             CHECKLIST FOR HANDLING COMPLAINTS

Complainant Name:                                       Log Number:

Date Received:

    o Is this a complaint about services delivered by the Ridgeway
      Partnership and Staff employed by the Ridgeway Partnership

    Yes
    No

    o If complaint about a partner organisation, write to complainant to seek
      consent to share

    Done

    o If complaint is about services provided by / staff working for Ridgeway
      Partnership, risk rate the complaint and note requirements resulting from
      risk rating

    Done

    o Are desired outcomes clear? If not may need to check with complainant

    Done

    o Inform Director / Service Manager (depending on severity and risk
      rating) – complete an initial review to assess and agree how to take
      forward and review risk rating accordingly

    Done

    o Discuss with Director / Service Manager whether POVA Guidelines
      need to be implemented and if so alert relevant LDT

    Done

    o Acknowledge complaint in writing within required timescales (e.g. within
      3 working days), remembering to enclose public information sheet

    Done


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    o Inform subject of complaint within a supportive environment

    Done

    o Inform Line Manager (if this is not the Director / Senior Manager)

    Done

    o Arrange meeting with complainant in necessary (this can be suggested
      via the acknowledgement letter or on the ‘phone)

    Done

    o Facilitate and co-ordinate investigation

    Done

    o Agree extension with complainant if necessary

    Done

    o Diary reminders for any follow through actions

    Done

    o Arrange closing letter (seeking JM’s signature), ensure enclosures sent
      and send a copy of the letter to cc list as well as complainant

    Done




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APPENDIX 7: The Ombudsman’s Principles of Good Complaint Handling

Getting it right

    Acting in accordance with the law and relevant guidance, and with regard for the
    rights of those concerned.
    Ensuring that those at the top of the public body provide leadership to support
    good complaint management and develop an organisational culture that values
    complaints.
    Having clear governance arrangements, which set out roles and responsibilities,
    and ensure lessons are learnt from complaints.
    Including complaint management as an integral part of service design.
    Ensuring that staff are equipped and empowered to act decisively to resolve
    complaints.
    Focusing on the outcomes for the complainant and the public body.
    Signposting to the next stage of the complaints procedure, in the right way and at
    the right time.

Being customer focused

    Having clear and simple procedures.
    Ensuring that complainants can easily access the service dealing with complaints,
    and informing them about advice and advocacy services where appropriate.
    Dealing with complainants promptly and sensitively, bearing in mind their
    individual circumstances.
    Listening to complainants to understand the complaint and the outcome they are
    seeking.
    Responding flexibly, including co-ordinating responses with any other bodies
    involved in the same complaint, where appropriate.

Being open and accountable

    Publishing clear, accurate and complete information about how to complain, and
    how and when to take complaints further.
    Publishing service standards for handling complaints.
    Providing honest, evidence-based explanations and giving reasons for decisions.
    Keeping full and accurate records.

Acting fairly and proportionately

    Treating the complainant impartially, and without unlawful discrimination or
    prejudice.
    Ensuring that complaints are investigated thoroughly and fairly to establish the
    facts of the case.
    Ensuring that decisions are proportionate, appropriate and fair.
    Ensuring that complaints are reviewed by someone not involved in the events
    leading to the complaint.
    Acting fairly towards staff complained about as well as towards complainants.

Putting things right
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    Acknowledging mistakes and apologising where appropriate.
    Providing prompt, appropriate and proportionate remedies.
    Considering all the relevant factors of the case when offering remedies.
    Taking account of any injustice or hardship that results from pursuing the
    complaint as well as from the original dispute.

Seeking continuous improvement

    Using all feedback and the lessons learnt from complaints to improve service
    design and delivery.
    Having systems in place to record, analyse and report on the learning from
    complaints.
    Regularly reviewing the lessons to be learnt from complaints.
    Where appropriate, telling the complainant about the lessons learnt and changes
    made to services, guidance or policy.

Further information
Further information on the role and work of the Ombudsman is available by calling
0345 015 4033 or at her website: http://www.ombudsman.org.uk/




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APPENDIX 8: Guidance for vexatious or habitual complainants.

DETAILED GUIDANCE FOR HANDLING VEXATIOUS OR HABITUAL
                   COMPLAINANTS

INTRODUCTION

Habitual and/or vexatious complainants are becoming an increasing problem for NHS
staff. The difficulty in handling such complaints is placing a strain on time and
resources and is causing undue stress for staff who may need support in difficult
situations. NHS staff are trained 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.

In determining arrangements for handling such complaints staff are presented with
two key considerations. The first is to ensure that the complaints procedure has
been correctly implemented so far as possible and that no material element of a
complaint is overlooked or inadequately addressed and to appreciate that even
habitual or vexatious complaints may have aspects which contain some
genuine substance.

Implementation of this guidance should only occur in exceptional circumstances.
This guidance on the handling of habitual and vexatious complaints will also be made
available to the public as part of the material on the complaints process in
appropriate circumstances.

The aim of this guidance is to identify situations where the complaint might be
considered to be habitual or vexatious and to outline ways of responding to these
situations.


DEFINITION OF A HABITUAL OR VEXATIOUS COMPLAINANT

Complainants (and/or anyone acting on their behalf) may be deemed to be habitual
or vexatious complainants where previous or current contact with them shows that
they meet two or more of the following criteria:-

Where complainants –

    Persist in pursuing a complaint where the complaints procedure has been fully
    and properly implemented and exhausted (e.g. where a complaint is about issues
    which happened too long ago for a meaningful investigation, or where a convenor
    has declined a request for independent review).

    Change the substance of a complaint; or continually raise new issues; or seek
    to prolong contact by continually raising further concerns or questions whilst
    the complaint is being addressed. (Care must be taken not to discard new issues
    which are significantly different from the original complaint. These might need to
    be addressed as separate complaints.)
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   Are unwilling to accept documented evidence as being factual, e.g. drug
   records, accident and incident reports; or deny receipt of an adequate response
   in spite of correspondence specifically answering their questions; or do not
   accept that facts can sometimes be difficult to verify when a long period of
   time has elapsed.

   Do not clearly identify the precise issues which they wish to be investigated,
   despite reasonable efforts of Ridgeway Partnership staff (and/or other
   organisation such as the Independent Complaints Advocacy Service) to help
   them specify their concerns; and/or where the concerns identified are not
   within the remit of the Ridgeway Partnership to investigate.

   Focus on a trivial matter to an extent which is out of proportion to its significance
   and continue to focus on this point. (It is recognised that determining what is a
   “trivial” matter can be subjective and careful judgement must be used in applying
   this criterion.)

   Have threatened or used actual physical violence towards staff or their
   families or associates at any time – this will in itself cause personal contact with
   the complainant and/or their representatives to be discontinued and the complaint
   will thereafter only be pursued through written communication. (All such incidents
   should be documented.)

   Have in the course of addressing a registered complaint, had an excessive
   number of contacts with the Ridgeway Partnership, placing unreasonable
   demands on staff. (A contact may be in person or by telephone, letter or fax.
   Discretion must be used in determining the precise number of “excessive
   contacts” applicable under this section, using judgement based on the specific
   circumstances of each individual case.)

   Have harassed or been personally abusive or verbally aggressive on more
   than one occasion towards staff dealing with their complaint or their families or
   associates. (Staff must recognise that complainants may sometimes act out of
   character at times of stress, anxiety, or distress and should make reasonable
   allowances for this. They should document all incidents of harassment.)

   Are known to have recorded meetings or face-to-face/telephone conversations
   without the prior knowledge and consent of the other parties involved.

   Display unreasonable demands or patient/complainant expectations and fail
   to accept that these may be unreasonable (e.g. insist on responses to
   complaints or enquiries being provided more urgently than is reasonable or
   normal recognised practice).




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OPTIONS FOR DEALING WITH HABITUAL OR VEXATIOUS COMPLAINANTS

When faced with a potentially habitual or vexatious complainant the Complaints Co-
ordinator will ensure that the complaints procedure has been correctly implemented
as far as possible, appreciating that even habitual or vexatious complaints may have
aspects which contain some genuine substance. In some circumstances it may be
appropriate for this guidance to be sent to the complainant, informing the
complainant about the potential outcome of habitual or vexatious behaviour. This
may be appropriate action when one of the above criteria has been met.

If the complaint procedure has been correctly applied, two or more of the criteria
outlined above apply, and the complainant continues to complain, the Complaints
Co-ordinator will

    •   if appropriate, take clinical advice to consider whether or not habitual or
        vexatious complaining is part of the complainant’s illness, and
    •   request that the Chief Executive and the Board lead for complaint handling
        (and/or the service director) review the case, to consider the most appropriate
        action in the particular circumstances. The decision may be to consider the
        complainant to be habitual or vexatious.

Where a complainant has been identified as habitual or vexatious, the Chief
Executive (and/or service director) will determine what action to take. The Chief
Executive will write to the complainant to explain the reasons why he/she has been
classified as habitual and/or vexatious, and the action to be taken. This notification
may be copied to others already involved in the complaint (e.g. Independent
Complaint Advisory Service, Member of Parliament, partner organisations). A record
will be kept within the complaints system for future reference of the reasons why a
complainant has been classified as habitual or vexatious.

The Chief Executive (and/or service director) may decide to deal with complaints in
one or more of the following ways:-

    Try to resolve matters and enable the complaint to be processed, draw up a
    signed “agreement” with the complainant which sets out a code of behaviour for
    the parties involved. If these terms were contravened consideration would then
    be given to implementing other action as indicated in this section.

    Decline contact with the complainants either in person, by telephone, by fax, by
    letter or any combination of these, provided that one form of contact is
    maintained. An alternative would be to restrict contact to liaison through a third
    party. (If staff are to withdraw from a telephone conversation with a complainant it
    may be helpful for them to have an agreed statement available to be used at such
    times.)

    Notify the complainants in writing that the Chief Executive has responded fully to
    the points raised and there is nothing more to add. The complainants should be
    advised that continuing contact on the matter will serve no useful purpose and
    that further letters received will be acknowledged but not answered.

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    Inform the complainants that in extreme circumstances the Ridgeway Partnership
    reserves the right to pass unreasonable or vexatious complaints to the Ridgeway
    Partnership’s solicitors.

    Temporarily suspend all contact with the complainants or investigations of a
    complaint whilst seeking legal advice or guidance from the Ridgeway
    Partnership’s solicitors, the NHS Litigation Authority, Thames Valley Strategic
    Health Authority, NHS Executive, or other relevant agencies.

RESTORING NORMAL PROCEDURES

If at a later date the complainant demonstrates a more reasonable approach, or if
they submit a further complaint for which normal procedures would appear
appropriate, the complainant’s status should be reviewed by the Chief Executive and
the Board lead for complaint handling (and/or service director) with the Complaints
Co-ordinator. Staff involved in the original contact should also be consulted if
appropriate. Normal contact with the complainant and application of the full
complaint process can resume if this is considered reasonable, and the complainant
should be notified of this decision in writing.




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APPENDIX 9: Key competencies of a Complaints Manager

A Complaints Manager needs a wide range of skills and experience in order to fulfil
the duties and responsibilities of the role. This summary sets out these key
competencies in broad terms.

There are 5 main functions underlying the role of a complaints manager:

        Creating professional relationships
        Searching for the truth
        Communicating the truth
        Managing complaints handling
        Facilitating learning from complaints.

1. Creating professional relationships

This will be supported by the following competencies:

        Developing and sustaining relationships with groups and individuals who
        either complain or are involved in the complaints handling process
        Equipped to handle people perceived as difficult and/or challenging situations
        Identifying, communicating and/or referring any issues arising out of the
        complaint that may be outside one's limits
        Identifying groups or individuals in need of further support resulting from the
        circumstances they find themselves in
        Identifying and communicating individuals and/or organisations able to assist
        those requiring support beyond the capability and/or responsibility of
        complaints managers
        Equipped to close down the professional relationship in a timely way

2. Searching for the truth

This will be supported by the following competencies:

        Developing a range of strategies to gather accurate information through
        interview
        Developing strategies to overcome potential barriers to effective interviewing
        Ability to analyse data from numerous sources effectively

3. Communicating the truth

This will be supported by the following competencies:

        Adopting a rational approach and presenting the analysis logically and in a
        well reasoned manner
        Ability to write letters, statements, reports and summaries providing clear,
        concise and structured information for complainants and/or the organisations



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4. Managing complaints handling

This will be supported by the following competencies:

        Constructing an effective system for handling complaints
        Responding to the requirements of legislation and policy
        Assessing and managing risk
        Managing change
        Setting and monitoring standards
        Developing successful partnerships

5. Facilitating learning from complaints

This will be supported by the following competencies:

        Identifying where improvements to services can be made and influencing the
        change
        Analysing data to demonstrate the need for improvement
        Influencing policy development for improved practice
        Using appropriate negotiation techniques
        Developing networks within and outside of the Ridgeway Partnership to work
        in partnership to achieve improvement.




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APPENDIX 10: Guidance to assess risk.

Severity Rating - Guidance Notes for Complaints Management

Likelihood of Adverse Outcome

                                                                                       Consequence
                                            5                        4                       3                  2                   1
Likelihood                            Insignificant                Minor                  Moderate             Major           Catastrophic
A – Almost certain
B – Likely
C – Possible
D – Unlikely
E - Rare


                 Green                                    Yellow                                  Orange                        Red

Risk Rating
Green – Low / Insignificant Risk follow usual process, delegate responsibility.

Yellow – Minor Risk, follow usual process but take responsibility to conclude within 20 working days

Orange – Moderate Risk, inform relevant managers as soon as possible, aim to conclude within 10 working days and keep Directors & CEO fully
informed.

Red – Major Risk, inform Chief Executive and relevant Directors immediately, take all necessary measures to conclude asap (3 working days) with full
CEO / Director involvement.


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APPENDIX 11: Incident Decision Tree




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APPENDIX 12: Summary sheet to identify learning

                                    CLOSING RECORD SHEET

Date of Complaint:

Date Received:

Date Acknowledged:                                        By:

Complainant Name and Log Number:


Was this complaint concluded within 25 working days or date agreed with complainant?

Yes              No              End Date:

If not why not and has permission been sought for extension?




Action by Service Area to take forward




Outcome for Complainant




Lessons Learned for the Organisation




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APPENDIX 13: Feedback questionnaire to improve the system.




     COMPLAINTS                                               QUESTIONNAIRE




1.      Did you feel we understood your complaint and took it
        seriously?

        Yes ☺                   No

        If not, why not?




2.      Did you feel we were doing all we could to help?

                                        Yes ☺                    No

                                        If not, why not?




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3.      Did you understand what we were doing to deal with your
        complaint?


                                Yes ☺                    No

                                If not, why not?




4.      Did we give a clear and understandable answer?

                                Yes ☺                   No

                                If not, why not?




5.      Were you happy with the time we took to handle your
        complaint?

                                  Yes ☺                    No

                                  If not, why not?




6.      Were the staff who handled your complaint helpful and
        friendly?

                            Yes ☺                    No

                            If not, why not?


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7.      If someone else was unhappy, would you recommend that
        they complain?

                            Yes ☺                    No

                            If not, why not?




8.      What do you think we could do to make our complaints
        services better?




Please return this questionnaire in the stamped addressed
envelope provided. Thank you for your help.


Complaints Co-ordinator




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APPENDIX 14: Diversity form

                                        ETHNICITY
The Ridgeway Partnership (OLDT) strongly believes in equality and is
committed to ensuring that everybody accesses the same quality services
and is opposed to unfair discrimination

To help us to evaluate whether ethnicity affects the likelihood of complaining we
have developed this simple tick box form. This form is purely for statistical
purposes and is optional.

Please tick the appropriate answers to the following:

1.      How would you describe your ethnic origin? Please tick one of the following:

A.      White                                           D.      Black or Black British

        British                                                 Caribbean

        Irish                                                   African

        Any other white background                              Any other black background


B.      Mixed                                           E.      Other Ethnic Groups

        White & Black Caribbean                                 Chinese

        White & Black African                                   Any other ethnic group

        White & Asian
        Any other mixed background

C.      Asian or Asian British

        Indian
        Pakistani
        Bangladeshi
        Any other Asian background



I do not wish to state my ethnicity

(This ethnic group classification was developed for the 2001 Population Census)


Thank you for completing this form.




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APPENDIX 15: Current post-holders, and their responsibilities

Post holders

At July 2009, the following people are in post:

Chairman                                                        Julia Clarke
Chief Executive                                                 John Morgan
Complaints Lead (Board)                                         Catherine A’bear
Executive Lead for Complaints                                   Deborah Lawrenson
Complaints Co-ordinator                                         Clare Winton

The Service Directors are:

Director of Health and Social Care                              Jeremy Taylor
Director of Human Resources                                     Faye Trodd
Director of Finance & Estates                                   Andrew Hall
Interim Medical Director                                        Matthew Stephenson
Director of Nursing, Information & Performance                  John Turnbull

Responsibilities and accountabilities

Responsibilities of the Chief Executive within the complaint procedure are:

The Chief Executive has overall responsibility and accountability for the
management of complaints for the Ridgeway Partnership (Oxfordshire Learning
Disability NHS Trust).

The Complaints Manager               is   accountable      to   the   Chief     Executive,   and
responsibilities include:

        Ensuring that appropriate and relevant information about the complaints
        procedure is widely available and accessible for service users, relatives,
        carers and members of the public
        Being personally readily accessible to service users, staff and the public
        Ensuring all complaints are dealt with appropriately in accordance with
        national and local policy and procedures and within required time scales
        Supporting complainants during the complaint process and ensuring they
        understand the rationale and procedure for investigating complaints
        Overseeing the daily management of complaints
        Maintaining records of complaints
        Monitoring the investigation process and time scales, alerting the Chief
        Executive and directors if complaints are likely to breach time limits
        Reporting complaints through the Quarterly Performance Report to the Risk
        Management and Service Governance Group
        Recording and monitoring “lessons learned” and changes to service
        Identifying common trends or patterns arising from complaints. Facilitating
        shared learning Trust-wide for overall quality improvement
        Appointing Investigating Officers in liaison with senior managers, directors
        and the Chief Executive as relevant
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        Supporting Investigating Officers in the investigation of complaints
        Checking      that    investigations,   investigation    reports,    supporting
        documentation and draft responses are appropriate before submitting to the
        Chief Executive and complainants
        Providing training for staff on the complaints procedure
        Reviewing complaints procedure, policy and development within the
        Ridgeway Partnership as necessary

The Board lead for complaint handling is accountable to the Trust Chairman, and
should be a member of the Ridgeway Partnership (OLDT) Trust Board.
Responsibilities of the Board lead include

        Ensuring that the Ridgeway Partnership’s complaints procedure complies
        with the Complaint Regulations
        Supporting the development of close links between the complaints
        procedure with clinical governance process and risk management strategies
        Providing a source of support and advice for staff, and staff managing the
        complaint process
        Supporting the development of policy, process and management of
        complaints for the Ridgeway Partnership

The Service Directors’ responsibilities include:

        Reviewing investigations, investigation reports and draft responses as
        appropriate
        Ensuring that Investigating Officers are appropriately trained and are able to
        access relevant training
        Ensuring that everyone involved is aware when complaints are concluded
        (‘closed’)
        Ensuring that lessons are learned and improvements are made as a result
        of complaints




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    Appendix C

       Ridgeway Partnership’s Good Practice Guide for
             Managing Concerns & Complaints

Introduction
This booklet is intended to act as a guide for all staff who may need to handle, respond to
or investigate complaints. It aims to share good practice, provide support and encourage
trust wide consistency.

This is intended as a guide only and should be used in conjunction with the Ridgeway
Partnership’s Complaints Policy and Procedure.

Any member of staff and particularly those delivering services may receive a complaint.
All staff are responsible for ensuring that they are familiar with Trust procedures. Training
is available through corporate induction and through Trust wide awareness raising
sessions.

All members of staff should support service users to make their complaint, this may mean
by helping to draft their concerns, helping them access advocacy or in some situations
raising concerns on behalf of the service user

Concerns

Some issues can be resolved on the spot / or within the day. Any member of staff, who is
approached with a concern, should do their best to resolve the matter then and there. If
the matter is serious or cannot be resolved at the time, the member of staff should pass
on to a senior colleague or manager. A step by step guide explaining how to handle
concerns is attached as Appendix A, along with a form for recording these issues.

Receiving and Acknowledging Complaints

All complaints must be passed to the Complaints Co-ordinator immediately and
acknowledged by the Complaints Co-ordinator within three working days. A copy of the
Trust’s public procedure sheet should be enclosed with the letter of acknowledgement
(this can be found within the Complaints Procedure as Appendix 4).

Mixed Sector Complaints

Where a complaint involves more that one health or social care provider, there should be
full co-operation in seeking to resolve the complaint through each body’s local complaints
procedure. For more information, please see the joint working protocol, Appendix 2




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The Investigating Officer

The Director of Operations or Directorate Managers will determine who the investigating
officer will be for each complaint. This will usually be the service manager, but there may
be occasions when it is advisable for the complaint to be investigated by a service
manager from another part of the organisation.

The Investigation

Personal contact with the complainant, either by telephone or by offering a face to face
meeting is important. This can be helpful in terms of confirming the details of the
complaint, assessing the feelings of the complainant and establishing what they are
looking for as a result of the investigation. All meetings must be minuted and copies
forwarded to Complaints Co-ordinator and the Complainant for approval. It can be useful
for the Complaints Co-ordinator to be present at meetings with complainants, but is not
essential. All complainants should be offered the opportunity to have someone with them
for support if they wish and made aware of the ICAS Service.

There is an investigators check list (Appendix 3) and a protocol for investigating managers
(Appendix 4) attached at the end of this document

Documenting

All aspects of the investigation must be clearly recorded and all documentation should be
copied to Complaints Co-ordinator immediately. Staff should be aware that, should the
matter proceed to litigation, all complaints documentation is subject to disclosure.

Extensions

If it is likely that the complaint will not be resolved within the timescales agreed with the
complainant, the complainant will be contacted as soon as possible and made aware of
the reasons for delay and an extension deadline should be agreed.

Completion of the investigation

Having completed the investigation, the investigating officer must complete the report
(Report Template attached as Appendix 5,) and send it to the Complaints Co-ordinator as
soon as possible – managers need to bear in mind, that we try to resolve complaints and
send the final closing letter within 25 working days. Ideally the report should be forward
by the 15th working day.

Support / Feedback to staff

Staff who are the subject of a complaint can be anxious about the process and their
position.

It is important that they are kept informed about progress with the investigation and that
they are offered the opportunity to discuss the matter with a colleague (‘buddy’). They

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should be given the opportunity to comment on the accuracy of the draft response and
they should be shown a copy of the final response to make them aware of the content.


Disciplinary Process

The complaints procedure is concerned only with resolving complaints and not with
investigating disciplinary matters. The purpose of the procedure is not to apportion blame
amongst staff. Some complaints will identify information about serious matters and the
Ridgeway Partnership may feel it appropriate to consider disciplinary investigation at any
point during the complaints procedure. This will be the responsibility of the managers
involved. It falls outside the complaints procedure and is subject to the Ridgeway
Partnership’s Disciplinary Policy, with separate processes of investigation. Information
gathered during the complaints procedure may be made available for a disciplinary
investigation.

Service Improvement / Organisational Learning

It is important that we identify learning at the close of a complaint and other issues for
feedback such as lack of resources, staff shortages etc.

It is the responsibility of the appropriate manager to ensure that specific actions identified
as a result of the complaint are implemented, either by taking action personally or
delegating to others.

Any service improvements which could be made, or are made, as a result of a complaint
must be reported to the complaints co-ordinator, who will then report them to the
complainant.

The Complaints Department will produce Learning from Experience Action Plans for each
Directorate, running throughout the year, and will report on progress each quarter to the
Risk Management and Service Governance Group.

The Ombudsman

If a complainant remains dissatisfied, they may refer their complaint to the Ombudsman
(Health and Parliamentary for health care complaints, and Local Government for social
care complaints) for consideration. In order for the Ombudsman to consider any
complaints referred to them, they will request copies of all the Trust’s complaint
correspondence. It is absolutely vital that this file holds all details in relation to the case.

Vexatious Complainants

There may be occasions when staff find themselves in a situation where the complainant
is abusive and / or uses threatening or bad language. In these circumstances, the
member of staff should remain calm and inform the complainant that he / she is not
prepared to continue communicating unless the complainant modifies his / her language.
The staff member should document the incident and report it to the line manager or

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another senior colleague as soon as possible. All incidents of verbal abuse should be
reported on the Trust’s “accidents, incidents or near-miss” reporting forms.

There may be occasions when staff encounter a complainant who is vexatious i.e. the
complainant raises the same or similar issues repeatedly, despite having received full
responses to all the issues they have raised.

If it is considered that a complainant is becoming vexatious the complaints department will
follow protocol for dealing with such persons, as specified in the complaints procedure
(appendix 8)

Also included within this good practice guide are:-

    The do’s and don’ts of complaint handling as Appendix 6
    Helpful phrases for inclusion in letters, etc as Appendix 7

Clare Winton
Complaints Co-ordinator
May 2009




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APPENDIX 1: “HOW TO HANDLE CONCERNS” – THE LISTEN SERVICE

This procedure is intended as a step by step guide for all staff, who may be involved in
handling concerns which are raised verbally – face-to-face or on the ‘phone. (Any
concerns raised in writing, or serious issues raised by someone who has a learning
disability, are complaints and should be handled using the Trust’s Complaint Procedure.)

Step 1

• You are receiving a concern, listen carefully to everything the person is saying. Make
  sure you understand clearly what the person is worried about. If you are not sure,
  politely ask them to go through things again, explaining that you need to be sure to be
  helpful.
• You have now listened to the concern and need to find out:-

    3. Is this a concern about services provided by the Ridgeway Partnership? If yes,
       refer to Step 2.
    4. If not do you know whose service it relates to? Do you know how to refer the
       person to the right organisation? If not please contact the Complaints Co-
       ordinator on 01865-228173 for advice and information.
Step 2

• If you have established that this concern relates to a service provided by the Ridgeway
   Partnership, you should take down some details using the LISTEN Service Concerns
   form including :-

    6. Name and address of person raising concern including contact telephone number.
    7. Whether they are a service user, relative, neighbour or member of staff.
    8. Date and time of concern.
    9. Brief details of the concern
    10. What the person would like to see happen – their preferred outcome.

•   Having established what the person would like to see happen:

    4. Is this something you can help with? If yes, agree what you will do, and how you
       will keep in touch with the person to tell them what is happening.
    5. Is this something your line manager can help with? If yes, tell the person who this
       is, and when they can expect to be contacted by them,
    6. Provide the person with the leaflet explaining how the Ridgeway Partnership
       handles concerns, and reassure them that the Ridgeway Partnership will handle
       personal information confidentially, complying with the Data Protection Act and the
       Caldicott Principles.

If you have answered no to both the above you need to ring the Complaints Co-
ordinator on 01865 228173 for advice and information.




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Step 3

•   When you have carried out all of the above and taken whatever action is necessary to
    try to resolve the concern, you need to ‘close’ the concern, but before you do that you
    need to :-

    3. Inform the person raising the concern how to complain formally.
    4. Check that the person raising the concern is satisfied.

    • Having recorded all of the above on the LISTEN Service Concerns form and copied
        any correspondence/ relevant paperwork, send to the Complaints Co-ordinator at
        Slade House.
Step 4

    • A member of the LISTEN team may contact you and/or the person raising the
        concern to complete a feedback questionnaire, to help improve the way the service
        is run.


If you are unsure about what to do at any point you should call the
Complaints Co-ordinator for help on 01865-228173




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THE LISTEN SERVICE - CONCERNS FORM
Please use this form to record all concerns made to you face to face or on the telephone
Please contact the Complaints Co-ordinator on 01865 228173 if you have any
queries
Name and address of the person raising concern:


Contact telephone number(s):

Any other relevant information (e.g. if they are a service user, relative, neighbour, member
of staff, etc.)


Date and time of the concern:

Brief details of the concern:



What the person raising the concern would like to see happen:



Have you informed them how to                        Yes       No
raise concern formally (complain)?
Have you checked that they                           Yes       No
are satisfied?
Have you closed this concern?                                           Yes       No            Date
       Closed :

Your name, job title and where you work:


What action you have taken, with dates (please use the other side of the form/more paper
if required):



What action your line manager has taken, with dates:



Date form sent to Complaints Co-ordinator, Slade House:

Don't forget to attach copies of any letters or reports you have written about this
concern. (NB Written complaints, or a concern about serious issues from someone
who has a learning disability require written acknowledgement within 3 working
days – use the Complaint System)

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            APPENDIX 2: PROTOCOL FOR THE HANDLING OF
         INTER-ORGANISATIONAL COMPLAINTS IN OXFORDSHIRE
                                                between

Please Note: The Oxfordshire joint complaints managers working protocol has been sent
to complaints contacts in Wiltshire and Buckinghamshire, with a request that they sign up
to this or similar protocol with the Trust

NHS Trusts                                            PCT
Nuffield Orthopaedic Centre NHS Trust                 Oxfordshire Primary Care Trust
Oxfordshire & Buckinghamshire Mental
Health NHS Foundation Trust
Oxford Radcliffe Hospitals NHS Trust                  Local Authority
Ridgeway       Partnership     (Oxfordshire           Oxfordshire County Council
Learning Disability NHS Trust)
South Central Ambulance NHS Trust


All signatories to this protocol will require their Independent Providers to adhere to the
protocol as part of their contractual commitment.

Similarly, organisations party to this protocol working in partnership with bodies outside
the protocol (e.g. prison healthcare) will ensure that any complaints arising from the joint
working are handled in line with this protocol.

Legislative framework

        Data Protection Act 1998
        Freedom of Information Act 2000
        Human Rights Act 1998
        Local Authority Social Services and National Health Service Complaints
        Regulations 2009 (SI 309)
        Supporting Staff, Improving Services (Department of Health 2006)
        The Care Standards Act 2000




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1.      Introduction
1.1     Public bodies in Oxfordshire health and social care are committed to high
        standards in the management of complaints which are fundamental to ensuring that
        service users and patients who complain either to social services or to NHS bodies
        are provided with a prompt, systematic and consistent response.
1.2     This protocol has been put into place in response to the Local Authority Social
        Services and National Health Service Complaints (England) Regulations 2009 (SI
        309), the Department of Health (DoH) Guidance “Listening, Responding, Improving:
        A guide to better customer care” 2009 and the DoH Advice Sheet 2: “Joint working
        on complaints – an example protocol”.

2.      Aim
2.1     To provide a framework for collaboration in handling complaints, to ensure:

              a single consistent and agreed point of contact for complainants
              regular and effective liaison and communication between complaints
              managers and complainants, and
              that learning points arising from complaints covering more than one body are
              identified and aggressed by each organisation

3.      The Role of the Complaints Manager
3.1     For each signatory organisation, the designated Complaints Manager is
        responsible for co-ordinating whatever actions are required or implied by this
        protocol.
3.2     To co-operate with other Complaints Managers and to agree who will take the lead
        role in inter-organisational complaints.
3.3     To clarify whom any requests for collaboration under this protocol should be
        addressed when s/he is absent (through leave, illness etc).
3.4     In the unlikely event that Complaints Managers are unable to reach agreement
        about any matter covered by this protocol, they should each refer the matter
        promptly to the relevant Directors/Senior Managers in their respective organisations
        for resolution.

4.      Factors to determine the lead organisation
4.1     The following factors should be taken into account when determining which
        organisation will take the lead role with any inter-organisational complaint:

              The organisation that manages integrated services;
              The organisation that has the most serious complaints relating to it;
              If a disproportionate number of the issues in the complaint relate to one
              organisation compared to the other organisation(s);
              The organisation that originally receives the complaint (should the seriousness
              and number of complaints prove roughly equivalent);
              If the complainant has a clear preference for which organisation takes the
              lead;
              The organisations can agree separately from the above should other factors
              be pertinent. For example, if the impact on the individual organisation’s
              governance arrangements.


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5.      Process
5.1     A flowchart which outlines the process to be used when dealing with inter-
        organisational complaints can be found in Appendix 4.
5.2     It is desirable, where possible, for all responses to be provided to the complainant
        as a composite, or at least to be delivered within a single cover. The Complaints
        Managers will need to co-operate closely for this purpose, in agreement with the
        complainant.

6.      Complaints about one organisation which are addressed to
        another organisation
6.1     On occasion, a complaint which is concerned in its entirety with social care is sent
        to an NHS body, or vice versa. This may be due to lack of understanding about
        which body is responsible for which service, or because the complainant chooses
        to entrust the information to a professional person with whom they have a good
        relationship.
6.2     The Complaints Manager of the organisation receiving such a complaint should
        contact the complainant within two working days. They should advise them that the
        complaint has been addressed to the wrong organisation and ask if they would like
        it to be forwarded to the other organisation on their behalf. Providing the
        complainant consents, the complaint should be sent to the other organisation at
        once, and a written acknowledgement should be sent to the complainant detailing
        where the letter has been sent and including the contact details.
6.3     In the event of several organisations receiving the complaint as an apparent
        original, contact will be made with the other organisations and a decision made as
        to which will be the ‘lead organisation’. The lead organisation will acknowledge
        within two working days on behalf of all organisations involved and will clarify the
        complaint and explain the role of the other organisations.

7.      Complainant’s consent to the sharing of information between
        agencies
7.1     There is nothing contained within this protocol that removes the obligation to
        ensure that information relating to individual service users/patients is protected in
        line with the requirements of the Data Protection Act, Caldicott principles and the
        confidentiality policies of each signatory organisation. It is for this reason that the
        complainant’s consent must always be sought before information relating to the
        complaint is passed between organisations. Moreover, the complainant is entitled
        to a full explanation of why their consent is being sought.
7.2     Consent to the passing on or sharing of information under this protocol should, in
        the first instance, be obtained orally and properly recorded. Where this is not
        possible, written consent should be sought.
7.3     If the complainant withholds consent to the complaint being passed to the other
        organisation, the Complaints Manager of the organisation receiving the complaint
        will seek to engage with them to resolve any issues or concerns about remit and
        responsibility and offer any liaison which could contribute to the resolution of the
        matter of concern. The complainant should be reminded of their entitlement to
        directly contact the other organisation.
7.4     The only circumstances in which a complainant’s lack of consent could be
        overridden would arise if the complaint included information which needed to be
        passed on in accordance with Safeguarding Children or Protection of Vulnerable

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        Adults procedures or other service user safety issues. In such cases, the
        complainant would be entitled to a full written explanation as to the agency’s duty of
        care and its obligation to pass on the information.
7.5     A form is attached to this protocol as Appendix 2, which records the consent of
        complainants for their case records to be disclosed for the purpose of complaints
        investigations.
7.6     Close co-operation between Complaints Managers will be crucial in ensuring that
        confidential case-file information is shared appropriately, and that the necessary
        safeguards are put in place. Information exchanged under this protocol must be
        used solely for the purpose for which it was obtained.
7.7     Where a complaint may be shared, the lead organisation will confirm to the
        complainant a named person, address and telephone number to identify where
        each part of the complaint is being investigated. This letter will also confirm
        registration of the complaint and will be copied to other organisations involved in
        the complaint.

8.      Complaint Grading
8.1     It will be the responsibility of the lead organisation to ensure that an assessment is
        undertaken to determine the seriousness and urgency of the complaint. In
        undertaking this assessment, the Complaints Manager should liaise with the
        Complaints Managers of the other involved organisations.

9.      Learning from complaints
9.1     All complaints services are fully committed to facilitating organisational learning and
        development through complaints resolution. Resolving the individual complaint is
        only part of the process.
9.2     Taking positive steps to identify communication, procedural, operational or strategic
        issues within and across each agency is a vital role in ensuring a relevant and
        positive complaints service.
93      To achieve this aim, all complaints services will together undertake a review of joint
        complaints including consideration of action taken and improvements in practices.
        As a minimum these will take place on a quarterly basis.
9.4     At the end of the process, the lead Complaints Manager will check with the
        complainant that they are satisfied with the outcome of their complaint and seek
        feedback on the complaints process. This will be communicated to the Complaints
        Managers of all involved organisations.
9.5     Annual and quarterly complaints reports will be shared between the organisations.
        The Complaints Managers will meet quarterly.
9.6     Complaints activity will be reported separately by the complaints services in
        accordance with their own agreed procedures.

10.     Protocol Review
10.1    The operation of this protocol should be reviewed at least every twelve months or
        when statutory changes dictate.


April 2009
Date of Next Review: April 2010 It is noted that there was a review date on the
Oxfordshire Joint Protocol for April 2010 – this has not happened yet, but will be
discussed at the Complaints Managers Network Meeting in October
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Appendix 1
Complaints Managers and other contacts in signatory organisations


Organisation                   Complaints Manager                          Other contact in Complaints Chief Executive / Date        of
                               (including name, contact number and email   Manager’s absence (including Director of Social approval
                               address)
                                                                           name, contact number and email address) Services approval
Nuffield      Orthopaedic
Centre NHS Trust
Oxfordshire              &
Buckinghamshire Mental
Health NHS Foundation
Trust
Oxfordshire        County
Council
Oxfordshire Primary Care
Trust
Oxford Radcliffe Hospitals
NHS Trust
Ridgeway       Partnership
(Oxfordshire      Learning
Disability NHS Trust)
South Central Ambulance
NHS Trust




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Appendix 2


Statement of consent for the disclosure of personal records

Complainant’s Name:             ________________________________________

Complainant’s Address:          ________________________________________

                                ________________________________________

                                ________________________________________

                                ________________________________________

Telephone Number:               ________________________________________


I hereby give my consent for the organisations listed below to share any relevant
information in order to complete the investigation into my complaint. I understand
that this is likely to include disclosure of information contained within my personal
records.

________________________________________ (Lead Organisation)

________________________________________ (Organisation)

________________________________________ (Organisation)

This will assist the investigation of my joint-organisation complaint, which is being
coordinated by:

____________________________________ (Name of Complaints Manager) of

____________________________________ (Organisation)

The reason for and the implications of this have been explained to me by the above
named Complaints Manager. I understand that information exchanged as agreed
by me must be used solely for the purpose for which it was obtained.

Signed:         ________________________________________

Date:           ________________________________________



Once completed, please return this consent form to…………………………………..


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Appendix 3

Form of Authority

To be completed by the complainant

Complainant’s Name:             ________________________________________

Complainant’s Address:          ________________________________________

                                ________________________________________

                                ________________________________________

                                ________________________________________

Telephone Number:               ________________________________________


I, the above-named, give consent for

Name:                           ________________________________________

Address:                         ________________________________________

                                ________________________________________

                                ________________________________________

Telephone:                      ________________________________________

to contact
____________________________________ (Name of Complaints Manager) of

____________________________________ (Organisation)

on my behalf, and for the Complaints Manager named above to discuss my
complaint with him/her.

Signed:         ________________________________________

Date:           ________________________________________



Once completed, please return this consent form to ……………………………



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Appendix 4
Flowchart for the handling of joint organisation complaints


                                           Complaint Received


    Recipient initiates general conversation with other involved organisations to agree
    lead organisation and discuss how complaint may be handled.



    Lead Complaints Manager contacts complainant to discuss their complaint, agree
    how it will be handled and confirm the issues to be addressed. Complaints
    Manager to explain the implications of a joint organisation complaint and who will
    co-ordinate the response. Oral consent to be sought if required.



    Lead Complaints Manager to contact the other organisations to confirm the
    arrangements for handling the complaint.



    Acknowledgement letter and relevant consent forms sent to complainant within two
    working days, with copy of complaint plan. Commence investigation process.




    Complaint investigation completed and joint response agreed. Signed response
    sent to the complainant.




   Lead Complaints Manager to contact complainant to check if complaint has been
   resolved and if any further actions are required. Seek feedback on the process.




    Feedback, learning and action plans to be shared with all involved organisations




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APPENDIX 3: COMPLAINT INVESTIGATION CHECKLIST

Name of complainant                             -------------------------------------------------


Complaint Ref                                   -------------------------------------------------


Investigating Officer                           ------------------------------------------------


Date final response due                         -----------------------------------------------



Identify all issues raised in complaint




Identify staff involved in complaint. Ensure that they are aware of the
complaint and have access to management and / or professional support if
required. Interview staff directly involved or who may be able to provide
useful information e.g. witness




Identify and obtain information required to assist with investigation e.g.
previous correspondence, medical records, Trust policies




Consider all the information received. Is it consistent? Does it address the
complaint? Is any further information required?




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Is clinical or professional advice needed?




Identify and initiate actions to prevent recurrence (e.g. review of procedure,
additional training) and person responsible for implementing action. Liaise
with other managers / clinicians as appropriate




Draft response to complainant, ensuring all issues are addressed




Complete Investigating Officers report and send to Complaints Co-ordinator
with draft response




Provide feedback to staff involved on outcome of investigation




Audit that all agreed actions have been implemented




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APPENDIX           4:    PROTOCOL FOR                    THE       INVESTIGATION         OF
                         COMPLAINTS

Your role as an investigator

The role of the investigator is to ascertain the facts relating to a complaint, assess
the evidence by:-

    Talking to all those involved within the complaint to provide a balanced view
    Reviewing written documentation, this might include medical files, nursing
    notes, handover sheets etc

Once the evidence has been reviewed, report findings, including where appropriate
any recommendations to take forward.

As an investigator you should always aim to be independent and examine all
pieces of evidence logically. You are neither an advocate for the complainant nor a
spokesperson for the organisation, you are impartial.

Be clear about what you are investigating
It is important to be clear from the very beginning about what exactly you are
investigating and to ensure that all parties (complainant and organisation are in
agreement). The complaints department will full details of the complaint and
complainants signed action plan.

When planning your investigation, you should consider the following:-

    1.   What should have been provided or what was expected?
    2.   What was provided? What actually happened?
    3.   Is there a difference between 1 and 2
    4.   If the answer to 3 is yes, why?
    5.   If the answer to 3 is no, why does the complainant think otherwise?
    6.   What was the impact?
    7.   What should be done to put things right?
    8.   What should be done to prevent a recurrence?

Understand the complaint from the complainant’s perspective

Talk to the complainant, a conversation can:-

    Help you define your investigation by understanding from their perspective, the
    gap between what has happened and what should have happened or how the
    situation could have been prevented
    Provide you with the opportunity to clarify what they would like to see happen
    and to manage any unrealistic expectations (although this will have been done
    to a certain degree by complaints department)
    Help to obtain any information or documentation you need

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Can you reach robust conclusions?

The key question to consider before beginning your investigation is whether you
will be able to reach a robust conclusion. Consider the following questions before
starting your investigation:-

    Is the complaint based solely on a reasonable assessment of what the
    organisation should have provided?
    Will it be possible to establish relevant facts?
    Can an investigation and any subsequent actions achieve what the complainant
    wants; are the expectations reasonable and proportionate?
    Is there any immediate action that can be taken to resolve the complaint?

Develop a robust plan for your investigation

A plan will help you to focus on the key issues and highlight any problems early on
that may need to be addressed. Things to consider when writing your plan are:-

    What defines the investigation, things to consider might be 1) what happened 2)
    what should have happened 3) what are the differences between the two.
    Background information.        This is essential, consider whether you have
    everything you need, or whether you need to request additional information
    from either the complainant or the relevant directorate
    Whether there are any additional factors that might impact your investigation
    e.g. legal issues, other investigation disciplinary, etc.

Obtaining your evidence

It is likely that most of the evidence needed will come from files, such as medical
notes, nursing notes etc. Sometimes however it will be necessary to interview
individuals to obtain the evidence you need. When conducting interviews it is
important to:-

    Consider the needs of the person and background to the complaint
    Know and prepare the questions you need to ask in advance
    Ascertain beforehand whether the individual requires any support
    Let the interviewee know in advance the questions you are likely to ask, so that
    they may be fully prepared. You will also need to let them know that you will be
    taking notes and ask for their permission to do this
    Hold the interview in a private place, where you are unlikely to be interrupted.
    For the complainant suggest coming to their home, they are likely to be most
    comfortable within their own environments.

Reach a conclusion and make recommendations

When your investigation is complete and you are ready to draw your conclusions,
run through the questions you used to define your investigation and ensure you
have answered these questions.

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When it comes to making any recommendations, it is important to consider the
factors that led to the complaint, these might include:-

    Communication breakdown
    Behaviour of staff
    Procedural or administrative problems
    Services not delivering
    Organisation failing to understand or deliver its responsibilities

When making recommendations, ensure that they are practical, proportionate to
the complaint and constructive

Preparing your final report

Your report should explain and record the conclusions you have reached. A good
report should be:-

    COMPLETE – It should cover all relevant aspects of the complaint and address
    all issues.
    RELEVANT – The report should demonstrate your understanding of the issues
    and how you have reached your conclusions and subsequent
    recommendations.
    BALANCED – The report should be impartial, factual and measured in its tone.
    It should deal with the issue from the viewpoint of the complainant but also
    establish the right context for the actions of the organisation.
    ROBUST – The report should make sense and clearly demonstrate how the
    investigator has reached the conclusion and recommendations.

Before the report is finalised it should be circulated to all parties for comment and
feedback – mainly to allow correction for any factual inaccuracies before
finalisation.

If the report is changed in a major way this should also be flagged up to all parties
to provide an opportunity for views before final circulation.




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APPENDIX 5: INVESTIGATING OFFICER’S REPORT

Name of Complainant:                                                     Log No:


Date final response is due:

Brief summary of complaint and key issues raised




Provide brief details of any meetings held with complainant (date, those
present, purpose etc)




Action taken as part of the investigation ( any statements taken, documents
reviewed etc)




Conclusions of investigating officer




Action recommended




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APPENDIX 6: The do’s and don’ts of complaint handling

DO                                                 DON’T

    Give your name                                     Argue with the complainant
    Find out straight away what the                    Get into a blame conversation or
    person complaining wants as an                     undermine the Trust
    outcome of raising their issue                     Pass the buck
    Explain their options and what might               Ask the complainant to raise their
    happen next                                        issue in writing, talk to another
    Get their personal details e.g. name,              person, or come back later
    address, contact number                            Try to deter people from making
    Take detailed notes                                complaints
    LISTEN                                             Take the complaint personally
    Be clear about what can and cant be
    done, and pass it on to somebody
    more senior if you are unable to help
    personally
    Stay calm and professional, ever if
    the complainant becomes emotional
    Empathise with emotion not the
    cause
    Treat complainants with courtesy
    and respect
    Take the complainant seriously
    Allow them the time and space to
    talk through their issue
    Remember complaints are positive –
    they allow us to improve our services
    for others




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APPENDIX 7: Helpful Phrases

Apology / Distress

    I would like to take the opportunity to apologise for any inconvenience or
    distress that this incident may have caused you
    I am always concerned when people are not entirely happy with the services
    provided
    I would like to assure you that steps are being taken to ensure that this does not
    happen again in the future
    I am sorry that your experience was unsatisfactory
    I am sorry that you feel that you have been let down by our service
    I was sorry to hear that you were unhappy with ……………………….
    I was sorry if you found ……….. to be upsetting as this was not the intention
    Normal practice would be …………. I am sorry that in this instance this did not
    occur
    I would reassure you that the actions taken were considered to be in your /
    person’s name best interests
    It is our aim to provide a high quality service to all our service users and this
    was clearly not achieved on this occasion, for which I apologise.
    It is always our intention to provide an excellent service and I am sorry if this
    was not the case
    I am anxious that our staff maintain the highest levels of courtesy and
    consideration towards both service users and their families / carers and I am
    sorry if you felt that this was not the case on this particular occasion
    I would like to apologise of the distress caused and for your experience of the
    service at this time
    Your experience of our services falls short of the standards we set and I would
    like to apologise, as would all staff concerned, for the stress and anxiety this
    experience has caused you

Thanks

    Thank you for your kind comments about…………… these are much
    appreciated and I shall be pleased to convey them to all staff concerned
    Thank you for expressing your concerns so clearly
    I would like to thank you for bringing your concerns to our attention and helping
    us to improve our service for others.

Reassurance

    I hope that this letter reassures you that positive steps have been taken to
    address the issues you have raised / any shortcomings which have been
    identified in the service.
    I trust that my letter has answered the issues you have raised and I sincerely
    regret that this situation arose.
    I hope that I have reassured you of our commitment to provide you / person’s
    name with the quality of service that you / he or she is / are entitled to.

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Different interpretation of Events

    It can be difficult to resolve complaints of this nature when the individuals
    concerned may have a different interpretation / recollection of events.
    I have taken the opportunity to reinforce the need for staff to be sensitive in
    comments which, whilst well intentioned, could cause distress when perceived
    by others.

Disciplinary Procedures

    Consideration as to whether or not disciplinary action is warranted is a separate
    matter for management outside the complaints procedure and must be subject
    to a separate process of investigation. It would therefore be inappropriate for
    me to comment further.
    I can confirm that the appropriate management action has been / is being
    taken.

Requests for amendments to health records

    If you would like to write indicating which statements you disagree with and
    appending your own account, this will be placed on your records so that any
    clinician you / person’s name might see in the future will be aware of your
    views.

Unsubstantiated Complaints

    From the information I have received, I believe that ………behaved in an
    entirely appropriate and professional manner.
    I am satisfied that ………… acted in good faith and in your best interests / the
    best interests of ……………
    I know that you will be disappointed that this letter is not along the lines that you
    were hoping for.

Verification of information received

    I hope you feel that my notes represent an accurate reflection of our
    conversation but, if you wish to add or amend anything, please do let me know
    as soon as possible.


Withdrawn Complaints

    I understand that you have now discussed the matter with ………that you are
    satisfied with the outcome of your discussion and do not wish to proceed further
    with your complaint.



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    Appendix D – EIA
                                                                 Ridgeway Partnership
                                                                Equality Impact Assessment

    Policy/Function Name: Complaints Policy

    Names of persons completing Assessment: Clare Winton and Sue Chapman
                                                                  (Please print names

    Lead Director for Policy/Function: Jenny Vaux

    Date of Policy/ Function: June 2009 Date Policy/Function assessed: June 2009

    Policy/Function review date: June 2011

    When completed this Assessment should be attached to the policy/function and distributed accordingly.

The main aims and impacts of the
                                                                                             Brief description/explanation
        policy/function

1. What is the purpose of the                To enable fair and easy access for all to the Complaint System.
policy/function/development?



2. Who is intended to benefit from           All members of Trust staff
the policy/function/ development?

(Who are the target group? Who will          All those who are supported by the Trust
benefit directly or indirectly?)             Family members / carers of those supported by the Trust
                                             Members of the public
                                             Stakeholders


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 The main aims and impacts of the
                                                                                     Brief description/explanation
            policy/function
3. Is there any adverse impact (s)
from the policy/function/
development on individuals from
the following groups - service users,
staff, carers, members of the public -
in relation to need, equal treatment,
inclusion/ exclusion - based on:
   a) Age                                    No – the policy is relevant for everyone and there is no distinction given to anyone on the
                                             grounds of age.

   b) Gender (male/female)                   No - the policy is relevant for everyone and there is no distinction given whether they are male
                                             or female. If someone requested to discuss the complaint with someone of the same sex, that
                                             would be accommodated

   c) Learning Disability                    No accessible booklet available and support would be given to enable a person with a learning
                                             disability to express their concerns in whatever format suited them best

   d) Mental Health need                     No support would be available or sought for anyone who required it to enable them to express
                                             their views

   e) Sensory Impairment                     No different formats and mechanisms would be explored to enable people to express their
                                             concerns and views and to receive relevant information back to them

   f) Physical Disability                    No the policy is relevant to everyone and there is no distinction given to anyone on the grounds
                                             of disability

   g) Race, Ethnicity, Religion,             No, policy and procedure available in a different format upon request and support via
      Spiritual belief (incl other           interpreting services would be offered. If other people needed to be included in any meetings
      belief), Language or Culture           e.g. chaplain, family members, etc, that would be arranged

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The main aims and impacts of the
                                                                                     Brief description/explanation
        policy/function
  h) Sexual Orientation                      No the policy is relevant for everyone and there is no distinction given to anyone on the grounds
                                             of sexual orientation

   i) Any Long Term condition                No the policy is relevant for everyone and there is no distinction given to anyone on the grounds
                                             of sexual orientation


4. Is responsibility shared with             Yes, Trust wide
another department to deliver the
policy/function/development? How is          The Complaints Policy is managed by the Complaints Co-ordinator within the Corporate
this managed?                                Services Team and there is an initial point of contact. However, all staff have a responsibility to
                                             initially discuss a persons concern and to try and resolve the issue informally prior to it being
                                             reported as a formal complaint where possible


5. Has anyone been involved in the           Not the recent review, but the original development the following were involved
development of the policy/
function/development?

 If so, who, e.g. service users, staff,      Executive Directors
professional groups, H&S Executive,          Senior Managers
stakeholders, partners?                      Stakeholders (such as commissioner)
                                             LISTEN Working Group

How were they involved?                      They were passed a copy of the procedure and asked to comment. Any comments were
                                             reviewed and the policy was developed from the procedure.

Should anyone else have been                 The Policy needs to be re-launched as a result of the national changes
involved – if so how will they now be
consulted?

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The main aims and impacts of the
                                                                                    Brief description/explanation
        policy/function

6. What information has helped Evidence of previous complaints and what has worked well or not so well within the process
towards    the  Equality  Impact
Assessment? E.g. Audit reports,
feedback from groups/ committees,
surveys etc.


7. Which groups of service users, This EIA is in the development stage, users, staff, stakeholders, partners and members of the
staff, carers, members of the public, public will need to be suitably consulted.
stakeholders, partners, have been
consulted      with   during    this
assessment?

What    information       have       they
provided?



8. Is there any evidence that some People who are suffering from acute mental illness, may make irrational complaints and place
people      may      have     different unreasonable demands on the system.
expectations      of    the     policy/
function/development? E.g. different
racial groups, people with a
disability, people with different
religious beliefs, or on the grounds
of age, gender, or sexuality.




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The main aims and impacts of the
                                                                                     Brief description/explanation
        policy/function

9. Is more information required?             Need to consult on policy, please see action plan.

 If so, what information and how will
you get it?




10. Action Plan
                                            Who is responsible for                    When will the action be        When will the
What Action is required as result           implementing this action?                 implemented by?                policy/function be re-
of this assessment?                                                                                                  assessed for any adverse
                                                                                                                     impact?
Need to consult on the policy with Complaints Co-ordinator                            Throughout quarter 2.          September 09
staff, service users, stakeholders
and partners



    This Assessment is completed and any adverse impacts have been identified and action agreed.

    Name Clare Winton                                        Date June 2009


        Signed……………………………………………………………………………………

        Deborah Lawrenson, Company Secretary
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