"Letter on Complaints with Managers Job Performance"
Policies, Procedures & Guidelines Complaints Handling Policy Issue Number: Approved by: Issue Date: Clinical Governance December 2006 Committee – 18/01/07 and Social Care & Health 23/04/07 Originated by: Agreed by: Review Date: Clinical Leadership and Quality Or on receipt of new Department of Health guidance EXECUTIVE SUMMARY Purpose The purpose of the Complaints Handling Policy and Procedure is to: Alert the PCT to conditions of risk or poor quality which by suitable early management and remedial action can prevent complaints and adverse events occurring in the future. Fulfil the PCT‟s obligations to manage patient complaints under the NHS (Complaints) Regulations 2004 as amended by the National Health Service (Complaints) Amendment Regulations 2006. Fulfil the PCT‟s obligations to externally and internally report and record patient complaints. Ensure that the PCT makes a co-ordinated and efficient response to patient complaints in order to increase patient satisfaction, improve communication and ensure continuing service improvements. Provide a process whereby lessons can be learnt and the risk of future serious complaints is minimised. Provide an early warning of potential for litigation Proved an early warning of potential risks to patient and staff safety. Key Points This Policy: Shall apply to all PCT employees and employees providing a service under a service level agreement within Lewisham PCT and Non-Executive Directors of the Lewisham Primary Care Trust. Applies to any complaint regarding services provided by Lewisham PCT made by or on behalf of any patient of Lewisham PCT. Aims to support the development of appropriate systems and procedures for the management of complaints in accordance with the NHS (Complaints) Regulations 2004 as amended by the National Health Service (Complaints) Amendment Regulations 2006 and best practice in complaints handling. Aims to support the development of a fair blame culture where complaints are viewed as an opportunity for learning. Aims to ensure that staff are aware that patients care should not be adversely affected by the fact that the patient (or the relative or carer who complains on their behalf) has complained. 1. INTRODUCTION 2 1.1 Rationale The reporting and management of complaints within Lewisham Primary Care Trust is an essential element of the Risk Management, Controls Assurance and Clinical Governance programmes. The purpose of the complaints handling policy is to: Alert the PCT to conditions of risk or poor quality which by suitable early management and remedial action can prevent adverse events and complaints occurring in the future. Fulfil the PCT‟s obligations to externally report complaints. Ensure that the PCT makes a co-ordinated and efficient response to all complaints. Provide a process whereby lessons can be learnt and the risk of future such events and complaints minimised. Provide an early warning of potential for litigation. 1.2 Scope The PCT has developed this policy and will conduct complaints reporting, investigation and management in line with the NHS (Complaints) Amendment Regulations 2006. This Policy shall apply to all PCT employees and employees providing a service under a service level agreement within Lewisham PCT and Non-Executive Directors of the Lewisham Primary Care Trust. It applies to any complaint by any person who is affected by or likely to be affected by the action, omission or decision of the PCT, and to a complaint by anyone who is receiving, or has received, NHS treatment or services. There are specific circumstances to which this procedure does not apply, outlined in section 7 of the 2006 regulations and section 2 of Appendix 1 of this policy. 1.3 Principles This policy is based on the following principles: That the Policy shall define best practice in the reporting and management of all patient complaints. That complainants are communicated with fully. That everyone in the Trust is responsible and takes ownership of the reporting and management of patient complaints. That the culture of complaints handling within the organisation is seen as positive, supportive and non-threatening and encourages staff to participate in the investigation and learning from patient complaints without fear of unfair blame. That action shall be taken and documented in response to patient complaints. That staff have adequate knowledge to notify, report, investigate and respond appropriately to patient complaints. That formal debriefing and feedback to staff and service users, where applicable, involved in patient complaints be provided. That learning from complaints shall be shared appropriately in order to maximise the benefits of the reporting and management processes. 2. THE POLICY 3 2.1 Policy Statement The Trust will establish appropriate systems and procedures for the management of complaints to minimise harm to service users, carers, employees and other stakeholders, to maximise patient satisfaction and to develop a learning environment. These systems and procedures will be in accordance with the National Health Service (Complaints) Amendment Regulations 2006. 2.2 Definitions Complaint – formal/informal The NHS Executive has suggested that one definition of a complaint is “An expression of dissatisfaction that requires a response”. Clearly this is an extremely wide definition and it is not intended that every minor concern should warrant a full-scale complaints investigation. Rather, the spirit of the complaints procedure is that front line staff are empowered to resolve minor comments, grumbles and problems immediately and informally. This principle is underpinned by the introduction of PALS in its problem-solving role. The Primary Care Trust will therefore seek to distinguish between requests for assistance in resolving a perceived problem and an actual/formal complaint. The former will be dealt with in a flexible manner. Local Resolution The first stage of the complaints process. Local resolution aims to resolve complaints quickly and as close to the source of the complaint as possible using the most appropriate means. Conciliation Conciliation is a confidential process that aims to resolve difficulties that have arisen between a patient and a practitioner at the earliest stage possible. Independent Review The second stage of the complaints process. If a complainant is unhappy with the response to their complaint under the local resolution, they can ask the Healthcare Commission for an „Independent Review‟ of their case‟. Patient Advice and Liaison Service (PALS) PALS is a customer care service and does not replace the complaints procedure but is able to provide “on the spot” help to sort out any problems and concerns before they become complaints. PALS contact tel: 0800 587 7027 Independent Complaints Advocacy Service (ICAS) The aim of ICAS is to give independent help and advice to people who wish 4 to pursue complaints about NHS services. It‟s main goal is to ensure complainants have access to the support they need to put their concerns forward and navigate the complaints system. Local ICAS contact tel: 0845 337 3061 2.3 The Culture Patient complaints are used to: identify risk improve quality of service user care reduce the cost of litigation benefit the service user, staff, the general public and PCT services through the dissemination of learning from complaints The 5 main steps to gaining as much good as possible from an otherwise bad experience, and to enable learning from good outcomes are: 1. Identify and record 2. Classify 3. Investigate for root cause 4. Implement recommendations 5. Disseminate all learning to ensure benefits elsewhere The PCT will manage complaints within a culture of fair blame, aiming to identify and address all of the main causal factors, including systems failure, administrative failure and human error through the process of fundamental (root) cause analysis. The PCT will ensure that any failing is addressed appropriately and fairly with the aim of preventing reoccurrence. Unless an individual has acted deliberately to cause harm, or deliberately and knowingly in breach of policies and/or procedures designed to prevent harm, or there is a clear case of misconduct, it will not be considered appropriate or fair to use the PCT disciplinary route against any member of staff involved in a complaint. Effective complaints handling can only be achieved when staff value complaints as a positive working tool which support good practice and increase patient safety and patient satisfaction. All patient complaints will be considered an opportunity for learning with the aim of improving the quality of patient care, improving the safety of staff, patients and contractors, and preventing the occurrence of serious adverse incidents. 2.4 Procedural Principles The primary principle is that all complaints should be dealt with quickly and effectively. The responsible Service Manager using the PCT online reporting form within the Sentinel Risk Management System must report all patient complaints. (Please contact Complaints and Quality Support Manager for information 020 7206 3223). 5 On receiving a formal complaint you must follow the procedure detailed in appendix 1. On receiving a complaint, the primary responsibility is to identify and try, where possible, to resolve the patient‟s concerns. Until an initial investigation into the circumstances of the complaint takes place an informed decision cannot be made about the implications. All complaints will require basic initial investigation and, where necessary, risk assessment. The extent of further investigation will depend on the assessed severity of the actual complaint using the risk matrix. See appendices VIII and IX. A fundamental (root) cause analysis should be undertaken for any serious complaint. The complaint may also be related to an incident. (See Incident Reporting and Management Policy) 2.5 Complaint Review and Action An action plan must be developed by the investigating manager or other designated individual or group, to address the concerns identified following a fundamental cause analysis of any serious complaint. The action plan must detail a timetable for action, responsible individuals and/or teams, and a schedule for review. The Investigating Manager will provide a summary of actions taken following an investigation to the Complaints Manager. The summary will be prepared taking full account of duties with regard to confidentiality. Debriefing and encouraging formal and constructive discussion about complaints will enable both individuals and the service to learn from complaints. 2.6 Aggregated Data on Complaints The comprehensive system of reporting and analysing complaints will collect considerable quantities of useful data. It will act as an early warning system and provide up to date information on all the PCTs possible liabilities. The reporting of complaints will enable trends to be identified and reported to relevant departments, committees and the PCT Board in order that appropriate action may be taken, learning disseminated and better quality services delivered. In addition to anonymised aggregated data being made available to individual services, a quarterly report highlighting causes of complaints and the actions taken or proposed will be provided to the following groups: The Board The Clinical Governance Committee FLAG Service Team Leaders and Managers, including Neighbourhood Managers The Patient Forum Contracted Services, Staff and the public via the PCT website 2.7 Claims 6 In the case of legal action against the PCT by a patient, or other on behalf of a patient, the Associate Director for Quality should be informed to enable the immediate reporting of the claim to the NHS Litigation Authority. 2.8 Confidentiality Personal details will only be disclosed on a „need to know basis‟, to facilitate the investigation and management of the complaint. Where information regarding complaints is to be disseminated for learning purposes, the information will be carefully anonymised, and where possible and appropriate, aggregated data used in preference to individual reports. If the media approaches staff and managers they must seek advice in accordance with the Communication Guidelines, as contact with the media must be through agreed channels only. Where appropriate the Chief Executive will ensure that staff and managers are given instruction and support in handling the media. Whilst confidentiality is guaranteed within the PCT, there will be occasions, when for legal reasons, the Trust is required to disclose information to other parties. ALL reports and statements prepared during the course of an investigation should contain only factual information and never matters of opinion or conjecture. 2.9 Policy Review This Policy will be reviewed whenever the NHS complaint regulations change or every 3 years, whichever is soonest, by the Director of Neighbourhoods or Medical Direct (with responsibility for complaints) and the PCT Board. 2.10 Policy Audit A Trust-wide audit of compliance and/or quality improvements resulting from this policy will be undertaken twelve months following the full implementation of this Policy and every twelve months after that. 3. IMPLEMENTATION/COMPLIANCE 3.1 Responsibilities The Trust must designate a member of its board of directors to take responsibility for ensuring compliance with the NHS (Complaints) Amendment Regulations 2006. It is the responsibility of the director to ensure that action is taken in the light of the outcome of any investigation. All have a responsibility to ensure that: In any given situation patient, public and staff safety and security is given priority. That PCT policies and procedures are followed as appropriate. (see appendix X) That all complaints are reported and managed. That the PCT learns from its mistakes. 7 That patient complaints are welcomed as an opportunity to change and to learn and to improve patient safety, and not to blame colleagues when things go wrong. Staff have a responsibility to: Try and resolve patient concerns and queries as they arise Report any patient complaint, formal or informal, to their line manager. In the case of a formal complaint, to provide details to enable their line manager to complete the complaints report in a timely manner, and to take any immediate remedial action required. Reassure patients that their care will not be adversely affected by their complaint. Line Managers have a responsibility to: Ensure that reporting procedures are complied with. Provide information on support to staff affected by the complaints process. Undertake a full investigation of any patient complaint, in liaison with other managers where necessary. Prepare an action plan to address any concerns identified. Communicate with the complainant to keep him or her informed of the progress of any investigation and of the final outcome. Provide support to any investigating team or officer. Provide the opportunity for staff to de-brief and feedback on specific complaint that is documented and retained with the original incident form. Monitor trends within the area of responsibility Contribute to dissemination of lessons learned and implement any actions identified to be their responsibility, or the responsibility of their team. Service Leads have a responsibility to: Review monthly all reported complaints within their areas and agree any necessary actions or improvements required. Provide feedback on complaints review to the Clinical Governance Committee from their team leaders. Investigate serious complaints in liaison with specialist advisors where necessary. Assess all patient complaints, and where appropriate action plan to address the causal factors, and to ensure learning is disseminated. Monitor implementation of the action plan and of lessons learned Monitor the quality of complaints handling within their service area. The members of the FLAG have responsibility to: Encourage a culture of learning from patient complaints. Encourage a culture of fairness, so that the fundamental causes are addressed. Act as the point of referral, assessment, and action planning for serious complaints. Receive referrals where issues have been identified. Conduct a root cause analysis where appropriate. Review quarterly analysis of trends and outcomes. Report to the Clinical Governance Committee. Maintain clear records for the purpose of effective communication, transparency of the process, and for accountability. 8 (see ToR of FLAG Appendix XI) The Complaints and Quality Support Manager has responsibility to: Ensure that the PCT is operating in accordance with current NHS (Complaints) Regulations, guidance and good practice. Ensure that the PCT communicates with the Healthcare Commission effectively and in a timely manner with regard to all Independent Review investigations, and other matters relating to the management of complaints. Receive and review all patient complaints. Maintain the complaint management database Monitor the quality of complaints responses and ensure that they meet national and local standards. Monitor the quality of complaints handling and patient communication relating to complaints Provide analysis of data and reports to the relevant groups and departments Provide support to Leads in monitoring improvement actions Co-ordinate the external reporting requirements Produce an annual Complaints Report to the Clinical Governance Committee Monitor complaints for the potential for legal action, and alert the Associate Director of Quality where legal action is identified as a possibility. Involve the complainant and seek to determine what they are hoping to achieve. Ensure that the complainant has the opportunity to understand all possible options for pursuing the complaint, and the consequences of those options. Throughout the process review what further action might best resolve the complaint. Keep the complainant informed. Maintain a documentary record of the handling and consideration of the complaint. Be readily accessible to the public and to staff. Be available to complainants who do not wish to raise their concerns with those directly involved with their care. The Director of Neighbourhoods/Medical Director has a responsibility to: Be the Board level Director with responsibility for complaints. Ensure that immediate concerns are reported directly to the Chief Executive. Ensure that the relevant Directors and Senior Managers are kept informed of specific complaints. Ensure investigation into a serious complaint is carried out and reported within the agreed timescales. The Chief Executives Office has a responsibility to: Manage the interface with the media. The Clinical Governance Committee has responsibility to: Monitor the implementation of the Complaints Handling Policy. Receive complaints reports from FLAG. Monitor that appropriate action and learning have been taken following 9 any formal patient complaint. The Board has responsibility to: Receive and review the quarterly complaints report. Ensure that the organisation develops a fair blame, risk aware culture. Ensure that the organisation develops a culture of reporting and learning from complaints. The Chief Executive has responsibility to: Receive, review and sign all complaints responses. 3.2 Training The Trust will ensure that the necessary training is provided for staff throughout the Trust to assist in the implementation of this Policy. All staff will be educated in the Trust‟s complaints handling procedure as part of their local induction. The policy requirements and the principles that underpin the Policy will also be included in on-site training. Managers and other key personnel will be instructed in investigative practice. Ongoing support and training will be provided as required by the Complaints Manager and the Training and Development Department. The Complaints Manager will maintain a record of training. The effectiveness of the training programme will be monitored and will be considered annually. 3.3 Compliance Managers are responsible for ensuring that their staff are aware of this Policy, and that this information is given to all new staff on induction. In addition managers are responsible for keeping staff up to date about any changes within the Policy. Managers will keep evidence of their compliance with the requirements of this section. Staff are responsible for strictly adhering to this Policy. 10 Appendix I Complaints Procedure ________________________________________________________ 1. Introduction See also the NHS (Complaints) Amendment Regulations 2006 The aim of this procedure is to ensure that all complaints are resolved quickly and effectively and that information gained from them is used to improve our services. Information on how to make a complaint will be readily available to patients, clients and their relatives and carers. The procedure will focus on satisfying complainants concerns while being fair to practitioners and staff. In line with the guidance on the Implementation of the NHS (Complaints) Amendment Regulations 2006, the procedure in Lewisham Primary Care Trust will only cover Local Resolution. A complainant may request the Healthcare Commission to conduct an Independent Review of their complaint if they remain dissatisfied with the outcome of local resolution. The Health Service Commissioner (Ombudsman) will be able to investigate complaints only after these stages have been exhausted. The same procedures must be followed for every complaint. The analysis of each complaint will help to identify adverse trends and to take action to improve the care provided to patients and clients of Lewisham Primary Care Trust. Quarterly monitoring reports are presented to the Trust Board. Advice on managing complaints is available from the Complaints Manager. A complaint can only be investigated once, under the Principle Regulations. 2. What is NOT covered by this Procedure Staff concerns / complaints or incidents Complaints about private treatment unless it has been commissioned by the PCT Complaints made by other NHS Bodies or Independent Bodies Complaints which are being or have been investigated by the Health Service Commissioner Complaints arising out of the Trust‟s alleged failure to comply with a data subject request under the Data Protection Act 1998 or a request for information under the Freedom of Information Act 2000 Events requiring investigation by a professional disciplinary body Events about which legal action is already being taken by the complainant The disciplinary procedure but if the investigation of a complaint identifies the need for disciplinary action then the normal disciplinary procedure will be followed. A complaint that relates to any scheme established under section 10 (superannuation of persons engaged in health services etc) or section 24 compensation for loss of office etc) of the Superannuation Act 1972 (a), or the administration of those schemes. 3. Who can complain? 11 Anyone who is receiving, or has received, NHS treatment or services. Any person who is affected by or likely to be affected by the action, omission or decision of the PCT. If a patient or user is unable to complain themselves, then someone else, usually a relative or close friend, can complain on their behalf if they have the consent of the patient or user. 4. Timescales It is important that complaints are made as soon as possible after the event occurs. Usually, complaints can only be investigated if they are: Made within 6 months of the event; or Made within 6 months of the complainant realising that they had something to complain about. There is discretion to extend the time limits, where it would be unreasonable in the circumstances of a particular case for the complaint to have been made earlier. When a complaint is made outside the time limits, it will be for the Complaints Manager (with advice from the Associate Director for Quality or Director of Neighbourhoods/Medical Director if necessary) to take responsibility for considering an extension of the time limit. 5. How should a Complaint be made? Complaints may be made verbally or in writing. A Complaint Form is available from the Complaints & Quality Support Manager for complainants to use if they wish. If the complaint is made verbally, then a written record of the complaint must be made and the record must be sent to the complainant for signature as a true record, and returned (see paragraph 8.3). If the complaint is made verbally, then a written record of the complaint must be made It must include the name of the complainant, the subject matter of the complaint and the date on which it was made. If the complaint is made in writing a record should be made of the date on which it is received. All complaints, verbal and written, must be reported to the Complaints Manager. Complaints may be made to any officer of the PCT. Any person who is affected by or likely to be affected by the action, omission or decision of the PCT may make a complaint. Where that person is a patient, the complaint may be made on their behalf by a representative if they have given them their express permission to do so. Written information should be made available to patients and clients on the PCT‟s Complaints procedure. A patients‟ complaint information leaflet is available. Complainants may also seek support in making their complaint from the Independent Complaints Advocacy Service (ICAS) or from the Lewisham PCT Patient Advice and Liaison Service (PALS). Information on both these services are included in the PCT complaints information leaflet which is available on the intranet. 5.1 Comments\Compliments\Suggestion Cards: Comments and compliments should receive an informal written response from the Service Manager and a copy sent to the Complaints Manager. Anonymised compliments will be published on the PCT website. Comments may be used to inform service improvements and development. The card should not be used for making complaints. 5.2 The patient without capacity 12 Where a patient lacks capacity, a complaint may be made by another individual on his or her behalf. Lack of capacity will exist where the patient is not capable of knowing, retaining or understanding information in order to make a decision with regard to the particular circumstances complained about. An apparent lack of capacity to give consent to another complaining on the patient‟s behalf may in fact be the result of communication difficulties rather than genuine incapacity. The Service Manager and Complaint Manager will take steps to reassure themselves that the patient does lack capacity before accepting a complaint from a representative which may involve the release of confidential information about the patient or their care. This may include the involvement of appropriate colleagues in making such assessments of incapacity, such as specialist learning disability teams and speech and language therapists, unless the urgency of the patient‟s situation prevents this. If at all possible, the patient should be assisted to make and communicate their own decision, for example by providing information in non-verbal ways where appropriate. A complaint may be investigated if it is considered to be in the best interests of the individual to do so. From April 2007 an individual may appoint a Lasting Power of Attorney (LPA) to make decisions on their behalf. In such a case, advise should be sought as to the scope an extend of the LPA and of the validity.¹ Confidentiality must be safeguarded and the principles of the Data Protection Act 1998 considered at all times. 5.3 Deceased Patients If the patient is deceased, consideration should be given as to whether it is in the best interests to investigate. An investigation may highlight service failures or systems failures, it may satisfy bereaved relatives, and it may prevent similar problems from happening to another patient. Consideration should also be given as to whether the complainant has a right of access to information relating to the deceased person under the law (Access to Health Records Act 1990). Where there is doubt, advice should be sought from the Complaints Manager, the Associate Director for Quality, the Director of Neighbourhoods/Medical Director or the Shared Service Information Department. 6. Request for Medical Records Where medical records have been requested the Complaints Manager should be informed immediately. See Data Protection Act 1998, Access to Health Records Act 1990. Advice regarding the statutory requirements for release of Health Records may be obtained from the Shared Service Information Department, from the Complaints Manager, or from the Associate Director for Quality. 7. Staff complaints about Patient Care If staff wish to use the complaints procedure to express concerns about the treatment of patients and standards of care then the same process will be followed. In such cases, staff should always ensure that they have the consent of the patient to make a complaint on their behalf. 13 8. First Stage – Local Resolution (Also See Flow Chart - Appendix II and Appendix III - Roles) Managed Services The aim of the procedure is to ensure that all complaints are resolved quickly and effectively. The notes below and the attached flow chart are to be used when handling any complaint. Special attention should be given to people who may need advice and support in using the complaints procedure. 8.1 Initial Response All complaints whether written or verbal should receive the same consideration and sensitive treatment. Making early personal contact with the complainant can assist in getting a full picture, demonstrate a rapid response and provide an opportunity to offer an apology and explanation. Primarily, care should be taken to ensure that the immediate health care needs of the patient are met. It may be possible for staff to resolve the complaint at this stage and help initiate service improvement. There are various simple ways by which this might be achieved such as: Solving the complaint „on the spot‟ if possible. Listening sympathetically. Discussing the problem with the patient and what might be done about it. Apologising for delays Empathising with the patient. Informal complaints should be logged by the service/department so that local trends can be identified and appropriate action taken. All formal complaints received must be entered on the Sentinel complaints database or passed onto the Complaints Manager for logging if staff do not have access to it. The person complaining should be advised that they have the right to raise the matter with the Chief Executive and or the PCT Complaints Manager. If the complaint would be more appropriately dealt with by another local organisation, the complainant should be informed. If they give their permission, the complaint will be re-directed and the complainant informed that this has been done in the acknowledgement letter. 8.2 Investigation and/or conciliation On many occasions the complaint will be resolved following this initial response. On other occasions further investigation may be necessary. The level and type of investigation should be appropriate to the complaint. Every aspect of the complaint should be investigated with the intention being to respond fully to all complaints. Other staff and services should be involved where necessary, with information shared on a need to know basis only, i.e. with due regard for patient and staff confidentiality. The PCT‟s Conciliation Service should be involved where the investigating manager, staff involved, complainant and the Conciliator feel it is appropriate, and that it would assist in the satisfactory resolution of the complaint. Where there is a dispute with regard to clinical judgement, the clinician should be offered the opportunity to provide evidence to support their judgement. Where possible, the complainant should be offered an opinion from an independent source. 14 8.3 The NHS Procedure Refer to flow chart and detailed process notes Appendix II & III. Local Resolution Process Time Scale Informal Complaints Dealt with on the spot. Formal Complaints Acknowledgement sent to complainant Within 2 working days. Investigation completed and final response Within 25 working days. sent If it is not possible to complete the complaint within 25 working days, a letter of explanation will be sent to the complainant by the Complaints Manager at 25 working days, and then every 10 days thereafter until completion. It is therefore essential that the investigating officer informs the Complaints Team if for any reason, they are unable to complete the investigation within the timescales, in order that we can seek the complainant’s permission and explain the reason for the delay. The first letter acknowledging the complaint must be signed by the Chief Executive (use LH1) and sent within 2 working days by the manager who first received the complaint, a copy of the complaint leaflet should be enclosed. If the complaint was made orally, the acknowledgement must be accompanied by the written record made at the time the complaint was made with an invitation to the complainant to sign and return it. A Senior Manager should oversee all complaints relating to the service that they manage and will be responsible for ensuring that each complaint is investigated at the appropriate level. An initial assessment as to the seriousness of the complaint should be made. It may be helpful to use the risk matrix (Appendix VIII and IX) to make an assessment of risk presented by the complaint. Factors to consider should include harm to the patient(s), harm to staff, risk to the service, financial risk and risk to the reputation of staff, the service and the organisation. It should also be considered whether many complaints have been received about the same problem. Where the complaint is of a serious nature (a significant or high risk) it should be brought to the attention of the Director responsible for that service. 1 The Complaints Manager should immediately be informed (where staff do not have access to the Sentinel database) that you have received a complaint and sent all details. The complaints monitoring form should be sent to the Complaints Manager at the same time and must provide information on: date complaint received date acknowledged The original complaint letter, comment card or file note detailing the content of complaint should always be sent to the Complaints Manager while you retain a copy. The investigating manager dealing with the complaint should make personal contact with the complainant as soon as possible. 8.4 Recording the complaint investigation A clear written record should be maintained of the investigation detailing discussions with staff and complainant, covering what was asked and the responses given. 1 In the event of the complainant making direct contact with the Chief Executive’s office, this will help to ensure that the CEO is aware of the complaint. 15 Statements should record the subject/purpose of the statement, who the statement is by, their job title, their work address and the date the statement was made. The statement must contain only the known facts; opinions must not be recorded. The statement must be signed by the author and dated. A member of staff may be accompanied by a companion/Trade Union Representative in the following circumstances: If requiring help with writing a statement During interview/s as part of the investigation If police are involved and wish to interview staff a solicitor either via a trade union or the Trust solicitor may represent the member of staff. Managers have a responsibility to support staff during this process. Where the police wish to interview a service user the Responsible Medical Officer must be involved. File notes should record the subject/purpose of the file note. The name, job title and work address of the person making the file note and the date the note was made. Please note that all statements, file notes, correspondence and other written information including e-mails are disclosable2 in a claim for clinical negligence. Please ensure that all such information is full, accurate, contemporaneous and factual. 8.5 The response The investigating manager will produce a written report and draft response in „plain English‟ on behalf of the Chief Executive which should always contain the following points: A formal apology Ensure all issues of the complaint have been addressed Where appropriate, an explanation of what went wrong and an outline of the action that has been taken to try to prevent future occurrences of the same problem3 The investigating manager should send the draft response and report to the Manager of the Service. Once the Manager of the Service has agreed the letter of response, he/she will send it to the Complaints Manager together with the report. The Complaints Manager will then send the response to the Chief Executive for approval and signature. Once the Chief Executive has signed the letter, it is sent to the complainant. A copy of the letter will be retained by the Complaints Manager and kept in the Master file. A copy of the letter will also be sent to the investigating manager for their file. The letter sent to the complainant by the Chief Executive will formally close the complaint and will include information on how to request an Independent Review (IR). 8.6 Learning from complaints Lewisham Primary Care Trust considers that complaints are an important measure of people‟s satisfaction with the NHS. The PCT recognises that correct handling of complaints can result in both increased patient satisfaction and an improvement in the quality of care for future patients. Patients, their relatives and carers 2 Except where made in direct contemplation of legal proceedings. 3 This may not be appropriate where a complaint has been made due to a misconception regarding the service complained about, in which case, the response should address the misconception and be used as an opportunity to inform the complainant. 16 are therefore encouraged by the Primary Care Trust to make their concerns known in order that these may be responded to appropriately. The major benefits of a robust complaints procedure are: Prevention of mistakes and learning from them will reduce complaints. Fewer formal complaints will speed up the overall process for others An action plan should be put into place for any improvements that are identified. This should also include risks reduced as a result of complaints. The plan will be monitored by the manager for the service and a 3 monthly progress report provided for the Complaints Manager. The Complaints Manager will produce a quarterly report and trend analysis which will be presented to FLAG, the Clinical Governance Committee and the PCT Trust Board. The report will be shared with Service Managers who will cascade the information to their staff to ensure appropriate changes to services are made an acted upon. The For Learning and Action Group will also review complaints received and actions arising at their quarterly meetings. Recommendations will be made by the group as necessary to improve complaints handling and improve service delivery. Lessons learned from complaints will be used in an anonymised form to inform other staff and services about good complaints handling. Training will be provided for frontline staff who often face complainants and managers who have the responsibility for conducting investigations. This will help change staff attitudes to complaints so they are valued as a way of driving service improvement. By improving the patient experience in the way staff deal with them, fewer complaints will be made. All new staff have a compulsory complaints handling session during their induction training. Copies of all correspondence and associated file notes should be kept to ensure that all issues are dealt with appropriately and lessons are learned. All original documents must be sent to the Complaints Manager who will retain them as part of the Master File. 8.7 Closing a complaint Once all letters are sent, the monitoring form will be completed and closed by the Complaints Manager noting the action taken and the response made. The Complaints Manager will also close the complaint on the complaints database. The complaints procedure should cease if the complainant explicitly indicates an intention to take legal action and claim for negligence. Advice should be sought from the Complaints and Quality Support Manager or Associate Director for Quality. The complaint should be closed if, as a result of its investigation, disciplinary proceedings are begun against a member of staff. See appendix VII. 9 Vexatious Complaints Staff are trained to deal sympathetically with patients, assisting them through the complaints process. Exceptionally, there are occasions when the complainant persists with a complaint when there is nothing more that can be reasonably achieved in respect of the problem raised. The decision to end a complaint as vexatious rests solely with the Chief Executive who must be satisfied that that the PCT has made every effort to answer the complaint appropriately and the complainant is exhibiting one or more of the following: Behaving in a manner which could be judged as unfair harassment Rejecting accurate documented evidence Refusing to define a complaint that can be investigated Continuing to evolve the content of the complaint to prolong the complaint 17 unreasonably Has threatened or used actual physical violence or been personally abusive or verbally aggressive on more than one occasion towards staff dealing with their complaint or their families or associates. Staff should document all incidents of harassment. In extreme cases, Lewisham PCT will reserve the right to take legal action against the complainant. Where the Chief Executive has decided that a complainant is vexatious, a letter will be written to patient informing them that: The reply to the complaint has fully responded to the points raised Every effort has been made to try to resolve the complaint There is nothing more that can be added and the correspondence is now at an end Future letters will be acknowledged but not answered. They have the right to take their complaint to the Healthcare Commission. 10 Primary Care Complaints for Family Health Service Practitioners (General Practitioners and Dentists) There is separate guidance policy for FHS practitioners entitled „Complaints in Primary Care‟. This is available from the complaints department. 11 Complaints Received from Members of Parliament The same process is followed for complaints from patients sent through their MPs although there are a number of additional steps involved. The response to the complaint is always sent from the Chief Executive and the Complaints Manager to the MP and not to the complainant unless the MP stipulates otherwise. If a letter is received from an MP with a complaint about their constituent‟s care, please send it IMMEDIATELY to the Chief Executive‟s office or the Complaints Manager. 12 Procedure for dealing with Complaints – Health and Local Authority (Social Care) There is a duty to co-operate between NHS bodies and local authorities where a complaint concerns more than one organisation. In these circumstances, discussions should take place between the relevant Complaints Managers from each organisation, as to whether the issues should be handled separately or as a joint response. In the case of a joint response, one Manager will be nominated to co-ordinate the investigation(s), and to be the main point of contact for the complainant during the investigation. Complaints relating to NHS bodies will be dealt with in accordance with the Principal Regulations, as amended by the 2006 Regulations. For those complaints relating to local authorities, these will be handled by them under the Social Services Complaints Regulations. However, where complaints concern both NHS and Local Authority Services, where the complainant so wishes, the organisations involved must co-operate to deal with part of the complaint that relates to them and provide a co-ordinated response to the complaint. The PCT‟s Complaints Manager must notify the complainant as detailed below: 18 12.1 Complaints Procedure – Health and Local Authority (Social Care) Complaints Manager - receives a complaint by letter, email, telephone or facsimile If the complaint relates to (1), (2) or (3) the following will be applied: (1) (3) NHS only (2) Local Authority Complaint will be handled NHS & Local Authority Complaint will be handled under the under the NHS Complaints Complaint involves both NHS and Local Social Services Complaints Procedure Authority Services Regulations Complainant’s Consent Complainant’s Consent If a complaint involves both NHS and Local Must obtain the complainant‟s Authority Services, the Complaints Manager will consent to send a copy to the need to obtain the complainant‟s consent within 10 other agency‟s Complaints working days of receipt of the complaint. Manager within 5 working days. Consent not received Consent received Inform complainant that they are unable to Forward the complaint to Local Authority deal with the complaint and advise them of as soon as possible the contact details of the relevant Local Authority Consent not received Consent received Inform complainant that they are unable Forward the complaint to Local to deal with the complaint and advise Authority as soon as possible them of the contact details of the relevant Local Authority 12.2 Consent and Patient Confidentiality In transferring complaints between agencies (including the Healthcare Commission), it is particularly important to ensure that patient confidentiality is maintained at all times. Consent to share information should be obtained in writing wherever possible. If this is not possible, verbal consent should be logged and a copy sent to the complainant. 19 13 Second Stage – Independent Review (IR) When a complainant is not satisfied with the response to his/her complaint, he/she may request an Independent Review. The Healthcare Commission is responsible for reviewing formal complaints about the NHS that have not been resolved under Local Resolution. Complainants will be advised in the final response from the PCT that, should they remain dissatisfied with the response they have received, they have the right to ask the Healthcare Commission for an Independent Review of their complaint. They will further be advised to make the request direct to the Healthcare Commission within six months of receiving of receiving their final response. 14 Letters of Thanks/Compliments Procedure ________________________________________________________________ The aim of this procedure is to ensure that all letters of thanks and appreciation are made known to people in the Trust and that the information is included in the quarterly monitoring reports to the Trust Board. It is important for the Chief Executive via the Complaints and Quality Support Manager to receive copies of letters of thanks concerning PCT services. These letters and cards indicate how highly our services are regarded and the value placed on them by patients, clients and their relatives and carers. Details of all letters of thanks are included on the PCT website. Good practice identified will be shared across Directorates and teams. 20 15 Performance Management – Data Collection Quarterly Reports will be produced for the Trust Board, FLAG and the Clinical Governance Committee for information. An annual report will be provided for the Clinical Governance Committee, who will: Monitor the implementation of this policy and procedure Monitor arrangements for local complaints handling Monitor the quality of local complaints handling Review trends in complaints and monitor that appropriate action has been taken Consider any lessons that can be learnt from complaints and monitor that this information has been disseminated. The annual report will also be provided to: The London Health Authority and The Healthcare Commission. Quality Standards All complaints acknowledged within 2 working days The majority (80%) of complaints resolved in 25 working days All complaints resolved within 30 working days. In exceptional circumstances where this cannot be achieved, an explanation and update will be provided to the The 2006 Regulations stipulate that the 25 day deadline can be extended, but only by agreement with the complainant. In cases where the Investigating Manager considers it appropriate to seek an extension of the complainant every 10 working days by the Complaints and Quality Support Manager. time limit i.e. because of the complexity of the complaint, they should contact the complainant to invite their agreement, explaining the reasons for the request. It is therefore important the Complaints Manger is kept informed about potential delays. Managers will provide quarterly updates to the Complaints manager on the implementation of agreed actions/recommendations following complaints. 21 Appendix II Lewisham Primary Care Trust COMPLAINTS FLOW CHART COMPLAINTS REGISTERED Letter Email Verbal – try to obtain in writing if possible Independent Complaints Advocacy Service PALS Health Authority Send proforma acknowledgement letter within 2 working days from receipt of complaint Send copy of: Acknowledgement letter Complaints monitoring form Details of the complaint To the Complaints Manager at Cantilever House Register the complaint on the Sentinel Database All complaints seen by Chief Executive Investigation not completed 25 working days Complaints Manager will contact complainant every 10 days and record dates of contact Investigation completed in 25 working days Investigation completed 35 working days Full written response to complainant Full written response to complainant Complete monitoring form Complete monitoring form Send copy of complete file to Complaints Send copy of complete file to Complaints Manager Manager Investigation not completed in 35 working days Complaints Manager will contact complainant every 10 days and record dates of contact Investigation completed Full written response to complainant Complete monitoring form Send copy of complete file to Complaints Manager Final closing letter from Chief Executive formally closing the complaint The Complaints Manager will send the final letter, signed by the Chief Executive, and will formally close all complaints. (NHSE requirement) If the complainant is not satisfied they can request further investigation at Local Level or an Independent Review from the Healthcare Commission. Information about the Independent Review is provided in the Chief Executive letter. Advice available from the Complaints Manager, Cantilever House. 22 Appendix III Handling complaints - Roles Investigating Manager: Clinical Lead Service Department Manager Director On the day the complaint is received: Complete a monitoring form. Send the proforma acknowledgement letter (LH1) to the person who has complained. Send copies of the file including details of the complaint/the complaint letter, a copy of the acknowledgement letter and a copy of the monitoring form to the Complaints Manager who will maintain the master file. The complainant will sometimes contact the CEO directly on receipt of the acknowledgement letter. Therefore, the Chief Executive will read the master file for her information. Next steps: It is good practice for the investigating manager to make early contact with the complainant. It is recommended that direct contact be made, followed by a letter. Keep a file note on all discussions, telephone conversations and interviews with staff and complainant. Completion On resolution of the complaint, the Investigating Manager should produce a report and draft response on behalf of the Chief Executive and send to the manager of the service for their agreement. The response should confirm the outcome, the agreed action, explanation and apology. The manager of the service should make any necessary adjustments to the draft response and send to the Complaints Manager. The Complaints Manager will forward the response to the Chief Executive for approval and signature On completion of the complaints process, the Complaints Manager will complete the monitoring form and close the complaint on the complaints database. Copies of correspondence and all documents relating to the complaint must always be copied to the Complaints Manager. Advice on all aspects of the Complaints Procedure is available from the Complaints Manager, who can also support you in writing a final letter. Appendix IV Complaints Monitoring Form Name of complainant_______________________________________________________________________________________ Address__________________________________________________________________________________________________ _____________________________________________ Tel No: ____________________________________________________ Date received_____________ Date acknowledged____________ Ethnic Group Recorded *? Y/N If Yes, specify______________ Locality/Department……………………………………………………Service…………………………..……………………………………… Name of Investigating Manager and contact details ………………………………………………………………… ……………………………………………..…..………………………………….. Name & Contact Details of others involved in investigating/processing complaint …………………………………………………………………………………………………………………………………………………………. Nature of main complaint as expressed by the complainant Code Please tick Code Please tick one only one only 01 Discharge and Transfer arrangements 11 Patients Property 02 Aids & Appliances, Equipment, 17 Discrimination (e.g. racial, Premises (including access) cultural, gender, age & religion) 03 Appointments Delay/Cancellation 05 Staff Attitude 07 Communication 19 Transport 15 Health Records (including medical) 22 Hotel Services 09 Complaints Handling 23 Other: 06 Direct Care/Clinical Care a) Violence/Assault 08 Consent to Treatment b) administration 10 Patients Privacy & Dignity including c) Interpreting Service confidentiality and Patient status 16 Failure to follow agreed procedures Action Taken: Tick date Tick Date Complaint passed on for investigation Investigation completed Complainant visited Complainant informed of outcome Complainant telephoned Meeting arranged with complainant Please indicate the main actions resulting from the investigation of the complaint (tick any that apply) Apology given although complaint unfounded Environment improved Apology given Recommendation for action sent to Board Member Procedure to be changed Staff to receive training New Procedure to be introduced Staff disciplined Information leaflet to be produced Other action, please specify Information leaflet to be amended Now send this form and a copy of All correspondence including the original complaint or a report if a written complaint to The Office of the PCT Complaints Department at Cantilever House. Please ensure you have file copies of all the information relating to the complaint, including a copy of this form. *Record ‘Yes’ only where your Department is recording this information according to the National 16 + 1 categories. Appendix V Definition of Category of Patient Complaints. ______________________________________________________________________ Transfer/Discharge Arrangements - component of the complaint relates to services, waiting times or delay around the discharge or transfer of a patient from hospital or from care, includes bereavement arrangement and management. Also relates to transf er between Lewisham PCT Services e.g. Health Visitor to School Nurse. Aids and appliances, Equipment, Premises (including Access) - an element of the complaint relates to the environment of care, adequacy of facilities, timeliness or quality of support services. Any part of Lewisham PCT‟s facilities, aids, appliances, equipment or complaints arising from the environment which includes any difficulties in accessing premises and facilities within. Appointment Delays/Cancellation - the component of the complaint relates to not sending, or delays in appointment being offered, not responding or delayed response to messages or to correspondence or any errors in administration. Cancellation - the complaint relates to the cancelling of a service, appointment or visit regardless of who may have cancelled it. Waiting Times - relates to time waiting to get an appointment, to receive a visit or to access a service. This can also relate to time spent waiting for continuation of care once in contact with the service. Communication - the component of the complaint relates to mis-information, lack of information or lack of timely information from any staff member; relates specifically to the content of communication, the presence-absence of communication or to the means of communication. This should also cover lack of appropriate translation or interpretation of information. Personal Records including medical and/or complaints - an element of the complaint relates to the ability of the client or his/her carer to access their records, the contents of their records, the loss of records, or any breech of confidentiality in any form whether verbal or written. Complaints handling - Anything to do with the way the complaint has been handled. To be counted as a separate complaint from the original one. Direct Care/clinical care - an element of the complaint relates to the content or nature of care provided by direct care staff whether they be medical, nursing, chiropody or therapy. Consent to treatment - (Formal Consent) an element of the complaint relates to patients consent to treatment, medical, nursing or therapy. e.g. Consent for immunisation, school medicals, and consent to therapy treatments. Patients Privacy and Dignity - The component of the complaint relates to not ensuring patients privacy and dignity as defined by the patient. This includes issues of Patient Confidentiality and status. Failure to follow agreed procedures - An element of the complaint relates to specifically to failure to follow or inapt agreed National or local procedures. Patients Property - The component of the complaint relates to any loss or damage to patients property. Discrimination (e.g. Race,culture, gender, age and religion) - Any complaint whereby any employee of the Trust is accused of any form of discrimination towards a staff/patient/client/relative or any member of the public in contact with Lewisham PCT. Staff Attitude - the component of a complaint refers to the attitude of one or more staff members e.g. rudeness, flippancy, generalised complaints about the manner of communication. Transport - the component of the complaint relates any aspect of transport provided by Lewisham PCT. Hotel Services, includes - Catering, Portering, Security, Domestic, Car Parking, Stores/Supplies, and Telecommunications. Other: Violence/Assault - any complaint whereby any employee of Lewisham Primary Care Trust is accused of assaulting or otherwise harming a patient, client or relative. Complaints covering members of the public using our buildings and assaulting either staff/patient/client or another member of the public should also be included. Administration/Handling not included elsewhere - the component of the complaint relates to losing notes, not responding to correspondence or any errors in administration. It does not only relate to clerical staff alone but to any part of Lewisham PCT. Interpreting Service - Specific complaints which relate to this service. 3 Appendix VI STAFF/CUSTOMER FEEDBACK FORM Here at Lewisham PCT we welcome your feedback. This comment card will help us collect any comments or suggestions you may have about our services and the treatment you have received. However, if you wish to make a complaint about the treatment you have received, please contact reception who will try to resolve it for you. If you still wish to make an official complaint you should not use this form. Instead, you need to write to the PCT Complaints Manager at the Trust Headquarters, Cantilever House, Eltham Road, Lee Green, SE12 8RN. Your comments will help us to monitor the quality of our services and allow us to make improvements where necessary. Please help us by completing this comment card and placing it in the box provided at reception. COMMENTS AND SUGGESTIONS Name of Clinic/Health Centre and service used: __________________________ If you would like a response, please Office use: enter your details below. You can stay anonymous if you wish. Name: ________________________ Response by: __________________ Address:_______________________ Job title/department: _____________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ Date: _________________________ Appendix VII Management action in the case of an investigation leading to suspension of/or disciplinary action against a member of staff. Suspension Suspension is a neutral act which removes an individual from the situation while an investigation is carried out. It serves to protect both the service users and the staff member. The NHS Complaints process should continue during the period of the investigation. The complainant should continue to be informed every 10 days of the progress of the investigation as set out in the Trust‟s Complaints Policy. Disciplinary Action If, as a result of the investigation, a decision is made to invoke the Trust‟s Disciplinary Procedure the Complaint should be closed. The complainant should be informed that this decision has been taken and a copy of the closing letter sent to the Complainant and the Complaints Manager as required by the Complaints Policy. The NHS Ombudsman also considers that it is good practice to inform the complainant of the outcome of the disciplinary action. This should have due regard for the confidentiality of the staff member and should not include any detail of hearings. Appendix VIII Risk Impact Matrix Impact level Insignificant Minor Moderate Major Catastrophic Financial Up to £1,000 £1k-5k £5k-£10k £300k £1M 5% project budget 10% project budget 1% income Injury Near miss Verbal abuse Over 3 day absence or Death of patient Deaths of patients Up to 3 days absence additional hospital stay. (depends on (depends on RIDDOR reportable circumstances) circumstances) accident Permanent disability Multiple deaths Long term recovery Hostage /continuing counselling Legal Early compromise Improvement notice Prohibition notice Criminal prosecution agreement with full Civil action Prosecution – some – no defence disclaimer Industrial tribunal defence Executive director imprisoned Reputation Local press adverse National press mention Commons select comments M.P. interest committee Malicious negative appearance rumour National press M.P. negative interest Quality Failure to meet internal Repeated failure to Intermittent failure to Sustained failure to And standards meet internal standards meet professional meet national Performance Failure to meet national standards and/or professional performance statutory requirements standards and/or statutory requirements Appendix IX Qualitative Risk Assessment Matrix Level of Risk Rating LIKELIHOOD/PROBABILITY OF REPEAT CLASS OF Rare Unlikely Possible Likely Almost INCIDENT: 20% 60% 90% Certain CONSEQUENCES/ chance chance chance IMPACT 1 2 3 4 5 1 – Insignificant 1 2 3 4 5 2 – Minor 2 4 6 8 10 3 – Moderate 3 6 9 12 15 4 – Major 4 8 12 16 20 5 – Catastrophic 5 10 15 20 25 GRADE OF INCIDENT 1-3 Low Risk: To be brought to the attention of the Department/Team Leader. Manage by routine procedures 4-6 Moderate Risk: To be brought to the attention of the Department/Team Leader. Specific responsibility for risk assessment and action planning must be allocated to a named person. Deadline for completion will usually be within 6 to 12 months and will depend on the availability of resources. 8-12 Significant Risk: Urgent attention required. To be brought to the attention of the responsible Director. Within one month of identification appropriate action must be agreed. The deadline for implementation and reassessment will normally be no later than 6 months from identification. 15-25 High Risk: Immediate action required. To be brought to the attention of the PCT Board and Risk Committee/Clinical Governance Committee. A Director must be informed and he/she will take responsibility for immediately planning action. Appendix X Policies and Procedures Reference may need to be made to the following Policies or Procedures, to establish whether further immediate action needs to be taken or if any other people require contacting: Major Incident Policy Directions on work to tackle violence against staff and professional who work in or provide services to the NHS (See Appendix 6) Child Protection Procedures Personal Safety Policy Incident Reporting and Management Policy Claims Handling Policy Whistle blowing Policy Health & Safety Policy Guidance on Medical Device Incidents Manual Handling Policy Security Policy Withdrawing Care and Treatment Procedures Communications Guidelines Infection Control Policy Fire Safety Policy Fraud and Corruption Policy Appendix Xl For Learning and Action Group Terms of Reference Lewisham PCT Clinical Governance Sub Groups Terms of Reference Purpose and Principles The current purpose of FLAG is 2-fold A. Performance Management To provide a forum to support the responsible officer in decision making with regard to issues of concern that arise in relation to independent contractors. To provide a forum to support PCT managers in decision making relating to serious untoward incidents B. Learning from adverse events To encourage a culture of learning from adverse events and near misses To encourage a culture of fairness so that the root cause of adverse events is addressed Objectives A . Performance management 1. To act as a central local referral point for performance issues relating to independent contractors within the PCT performance issue impacting on patient care and relating to employed healthcare professionals within provider services 2. Support responsible officer (MD/Director of Neighbourhood development in decision making and assessment in accordance with the PCT Performance Framework 3. To act in accordance with other PCT policies including whistle blowing, incident reporting and management and complaints handling 4. To act on the findings of the analysis in accordance with PCT policy and to agree onward referral if necessary. 5. To advise the Senior Management Team of actions taken 6. To advise PCT Board of issues of serious concern B learning from adverse events 1. To act as central local referral point for looking at adverse events 2. Undertake root cause analysis of serious adverse events and nears misses 3. Produce action plans to address causes and provide support and ongoing monitoring 4. Ensure dissemination of learning from good practice adverse events and near misses 5. To ensure that the process is disseminated to all those working in the PCT and that reporting and referral mechanisms are disseminated to the other stakeholders 6. To provide anonymised minutes of Flag meetings to Clinical Governance Committee 7. To maintain clear records for the purpose of effective communication, transparency of the process and for accountability Core Membership A core membership will form the Performance advisory Group responsible for the Performance management objectives of FLAG. These members will be: - Medical Director (Chair) AD Primary Care LMC representative AD Quality Non –Executive Director Other Members will be cooped at times to advise where appropriate. These will include LOC representative or other Optometry adviser LDC representative or other dental advisor AD Pharmacy or other pharmacist adviser ADS provider services – adult and children‟s divisions FLAG Full Membership The core members plus AD pharmacy AD adults AD Children‟s Complaints manager PALS manager Quorum A quorum will be 75% of core membership Frequency of meetings Performance Advisory group Meetings monthly to consider new cases and review progress where matters are ongoing Full Flag Quarterly meeting to review action plans and issues arising from PAG and also review complaints, SUIs, claims and appraisal issues, and review learning from these cases. Frequency of meetings will be reviewed periodically to assess whether it meets identified need Review These terms of reference will be reviewed in November 2008. Appendix Xll LEWISHAM PRIMARY CARE TRUST END OF QUARTER COMPLAINTS REPORT FOR THE PERIOD ………………………….. 1. Overall Summary of Complaints Qtr 1 Qtr 2 Qtr 3 Qtr 4 PCT Managed Services - Formal - Informal FHS Practitioners - GPs - Dentists - Pharmacists - Opticians Other Trusts/organisations MP Enquiries/complaints Details of individual complaints for quarter ………. are attached as an appendix to this report. 2. Performance Indicators (Qtr …… only) National performance standards: Standard 1:100% complaints acknowledged within 2 working days Standard 2: 80% complaints resolved within 25 days Standards achieved by managed services for the quarter ending ………. by Lewisham PCT: Standard 1: Standard 2: 3. Independent Review Requests – Healthcare Commission 4. Compliments Although this report focuses on complaints, it should be noted that individual staff and departments within the PCT receive thank you letters and compliments. These are reported in anonymised form in the PCT newsletter. The complaints department received ..... compliments for the following service areas (examples). Foot Health ….. Sexual & Reproductive Health Department ….. Walk in Centre ….. Name……….. Complaints & Quality Support Manager Date……. APPENDIX (To quarterly report) District Nursing Ref Date Date of Response Summary of Issues Outcome Received Child Health Ref Date Date of Response Summary of Issues Outcome Received Adult Physiotherapy Ref Date Date of Response Summary of Issues Outcome Received Public Health Ref Date Date of Response Summary of Issues Outcome Received