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Operational policy statement Managing the receipt of concerning

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					Operational policy statement
Managing the receipt of concerning information about
independent healthcare providers
Contents
1.      Overview .................................................................................................................................. 2
2.      Policy statement ..................................................................................................................... 3
3.      Equality impact assessment ................................................................................................ 12
4.      Policy implementation and operation audit........................................................................ 12
5.      Supporting documentation .................................................................................................. 13
6.      Policy maintenance .............................................................................................................. 13
        6.1 Triggers for policy review .................................................................................................. 13
        6.2 How the policy will be reviewed ........................................................................................ 13
        6.3 Who will be involved in reviewing the policy ..................................................................... 14
        6.4 The responsibilities of the policy review panel .................................................................. 14
        6.5 Superseded documents .................................................................................................... 14
7.      Document control information........................................................................................... 155
        7.1 Involvement in policy’s development............................................................................... 155
        7.2 Document history .............................................................................................................. 15



Author:                       Andrew Cook
Policy Reference:
Date:                         January 2008
Version:                      4.0




                                                                                                                                                    1
1.    Overview
1.1   This policy has been drawn up to provide clear governance for managing the receipt of
      concerning information about independent healthcare (IH) providers. For the purposes of
      this policy, ‘concerning information’ includes information from the public and staff employed
      by providers and/or other regulators about complaints, and concerns and/or allegations.

      The Healthcare Commission has no statutory powers to investigate any complaints made
      about IH providers and has no role prescribed within the Care Standards Act 2000 (the Act)
      or associated regulations to manage, arbitrate or resolve complaints, concerns or
      allegations in relation to IH providers.

      However, we will take account of all information received about registered providers and
      unregistered providers that we reasonably believe should be registered. In doing so, we will
      assess whether the information received suggests that an offence has been committed as
      set out in the Act, a regulation has been breached as set out in the associated regulations,
      or a condition of registration has been contravened as set out on the IH provider’s
      registration certificate. In circumstances where an offence or a breach is suspected, the
      Healthcare Commission is required to take appropriate and proportionate action to bring
      about improvement, such as prosecution, cancellation of registration, and/or imposition of
      conditions.

1.2   The purpose of the guidance is to help to improve the performance of the Operations Group,
      by providing a framework to support the implementation of the ‘concerning information’
      element of the RICE (Registration, Inspection, Concerning Information and Enforcement)
      process.

      In the acronym ‘RICE’, the “C” has traditionally represented ‘complaints’. However, as the
      Healthcare Commission is required to consider any information – not simply complaints –
      the “C” should now refer to ‘concerning information’.

      Despite the lack of legislative imperative to act as a stage 3 complaints handling service, the
      Healthcare Commission has evolved processes that engage closely with the complainant,
      seeking to satisfy the complainant’s expectations for the management of the complaint that
      they have referred to us.

      This policy re-aligns our activity with the Act and associated regulations, regarding
      information gathering as a tool to inform our regulation of providers rather than a task in its
      own right.

      The policy takes account of our responsibilities under the Data Protection Act 1998 and the
      Public Interest Disclosure Act 1998.

1.3   The policy is to be implemented by all regional operations teams.




                                                                                                        2
2.    Policy statement
2.1   Definitions

      For the purposes of this guidance the following terminology applies:

      Complaint – An issue raised about the service, or the experience of that service that was
      received by the informant from the provider, about which the informant is seeking resolution.
      A complaint is a matter the informant should normally raise directly with the provider.

      Concern/Allegation – An issue about a service that the informant may not necessarily have
      experienced themselves, but that worries or bothers them. It is a matter that they are not,
      usually, seeking to resolve for themselves, but are worried about the effect it may have on
      others. Concerns and allegations may not have been directly raised with the provider and, in
      the case of staff employed by the provider, are not required to be.

      Concerning information – The details of a concern, complaint or allegation about an IH
      provider that is either registered or, in the case of a provider that is offering services that we
      reasonably believe should be registered, unregistered with the Healthcare Commission.

      Provider – The person registered with the Healthcare Commission, the person that the
      Healthcare Commission reasonably believes should be registered, or a person who was
      formerly registered with the Healthcare Commission.

      Informant – The person (a member of the public or a member of staff employed by a
      provider or other regulator) who provides us with the concerning information.

2.2   Legal responsibilities

      The Act, the Private and Voluntary Healthcare (England) Regulations 2001 (the
      Regulations), and the national minimum standards for independent healthcare (NMS) do not
      set out any specific responsibility for the Healthcare Commission to respond to complaints in
      relation to providers. Regulation 23 of the Regulations and NMS core standards C14 to C16
      set out the responsibilities of providers in the management of complaints.

      Click here for the Private and Voluntary Healthcare (England) Regulations 2001.

      Click here for the Care Standards Act 2000.

      Click here for the national minimum standards.

      Providers that are registered with the Healthcare Commission are required to ensure that
      the name and contact details of the Healthcare Commission are in their complaints literature
      (regulation 7(1)(f) (Patient Guide) of the Regulations, and regulation 23(4)(a) (Complaints
      Policy) of the Regulations). This leads to an implied role for the Healthcare Commission in
      complaints management.




                                                                                                           3
2.3   Key principles

      Information shared with us will be rigorously assessed, and appropriate and proportionate
      action will be taken.

      The process for decision-making will be robust, auditable and consistent.

      The responsibility for handling complaints about service(s) rests with the provider of that
      service. Our role is to ensure that the procedures in place for handling complaints, concerns
      and allegations are fit for purpose and meet the requirements of the Regulations and NMS.

      We will receive concerning information from informants only for the purposes of regulating
      the provider concerned. We will not receive concerning information about IH providers for
      the purposes of arbitration or adjudication.

      With regards to the provider, the Healthcare Commission’s role is active. With regards to the
      informant, the Healthcare Commission’s role is neutral or passive.

      Information gathered will be used, managed and retained in line with information
      governance and data protection requirements. Information collected will be used to inform
      risk assessment and targeted inspections.

      However, concerning information we receive may also be used more generally to inform our
      broader understanding of risk at the establishment and provider level, and across the wider
      independent healthcare sector.

      Equality and diversity issues identified will be managed in line with Healthcare Commission
      policy.




                                                                                                      4
2.4   Eligibility criteria

      Information can be received from any member of the public or other regulator.

      Consent – If the information relates to a named patient, then the patient must provide
      written consent for a third party to act on their behalf in raising the matter with the
      Healthcare Commission. This is important in case we need to request permission to access
      medical records. While we will ordinarily seek consent as a matter of course, this may not
      occur where the magnitude of the concerns is such that it would justify the use of our
      powers to access information without consent, and where it would not be practicable or
      would be prejudicial to the Commission’s functions to obtain consent.

      If the patient has died or is not competent to give consent, the informant may be the next of
      kin or guardian, or someone who has a legitimate interest in the welfare of the patient.
      However, it should be noted that the patient must be assumed to be competent to give
      consent unless it is demonstrated otherwise. Assessment of competence is a clinical
      judgement.

      Children – The person with parental responsibility may complain on behalf of children under
      16. However, where the children are mature enough to understand the nature of the
      complaint, the Department of Health guidelines for the consent of children and young people
      should be followed. Where the child requests that any information is not disclosed to their
      parents, this should normally be respected unless it is deemed to be in the child’s or the
      public’s interest to disclose.

      Anonymous informants – It is only on rare occasions that an informant wants to remain
      anonymous. In these circumstances it may be difficult to ascertain whether the information
      is a ‘complaint’ or a ‘concern/allegation’, given that it is unlikely the informant will want to
      speak directly with the provider. It is usually wiser to treat the information as a
      ‘concern/allegation’ and not require the informant to seek initial redress from the provider.

      ‘Whistle blowing’ – Staff expressing concerns about questionable or poor practice (whistle
      blowers) should not be required to deal with the matter directly with the provider as they
      may feel unable to do this. The Public Interest Disclosure Act 1998 (PIDA) allows for staff to
      raise concerns without having to give their personal details. The Healthcare Commission is
      required to respond regardless of anonymity.


      What can we accept information about?

      •   An establishment or agency that is registered with the Healthcare Commission under the
          Act.
      •   An establishment or agency that is not registered with the Healthcare Commission but
          should be.
      •   An establishment or agency that is going through the registration process, having made
          an application for registration to the Healthcare Commission.


      What issues fall outside our remit?

      •   Fees or other monies paid for services provided: We have no remit to obtain or to assist
          in obtaining the return of fees or monies paid. It may be appropriate to suggest that the
          informant may wish to get independent legal advice.




                                                                                                         5
•   Issues relating to services that are not required to register with the Healthcare
    Commission under the Act (we can consider directing the informant to other sources of
    assistance, such as another regulator).
•   The content of the Regulations or NMS: The responsibility for the content of the
    Regulations and the NMS rests with the Department of Health and therefore, we have
    no power to amend these. Individuals who have a comment to make should be invited to
    take their comments to their local MP.
•   Private treatment provided in a NHS Pay Bed: These facilities are currently not
    registerable under the Regulations. Elements of a complaint about this type of care,
    such as facilities and nursing care, can be considered by our NHS complaints team.
    Other concerns have to be raised directly with the consultant who carried out the
    treatment or procedure. If the information relates to the clinical judgment, decision-
    making or professional conduct of a doctor, the concern should be referred to the
    General Medical Council (GMC).
•   Issues relating to employment: This includes issues such as terms and conditions of
    employment. (Note: Concerns raised in regard to matters that affect patient safety, such
    as staffing levels, should be dealt with as ‘whistle blowing’.)
•   Eligible issues where legal process is in progress: Where the person providing the
    information has already commenced a legal process, we will normally stand back and
    await the outcome of such proceedings. Each case will be assessed on an individual
    basis and discussed with our Legal Team.
•   Complaints that started prior to 1 April 2002: The Care Standards Act 2000, which gives
    the Healthcare Commission (and previously the National Care Standards Commission)
    its powers, did not come into force until 1 April 2002.

Where the information is found not to be eligible for consideration, the correct
template letter should be selected using the CRM activity plans.




                                                                                               6
2.5   Information about NHS treatment provided by an independent provider

      The informant is eligible to use the NHS complaints process and/or the independent
      healthcare concerning information process. It is for the informant to decide which route to
      access at first, however, we may choose to refer the matter to the other route, internally, if it
      is appropriate to do so.

      It is important to ensure that the information is managed in a way that is efficient and
      effective for both the informant and us. This includes ensuring there is a clearly identified
      point of contact for the informant.

      However, these issues can arrive through two possible routes, which can make deciding
      whether they should be dealt with under the Regulations or the NHS initial considerations
      pathway confusing.

      As these services are all primarily registered under the CSA2000, the CSA2000 and the
      Regulations should be the default pathway for considering these referrals in the first
      instance. This is because the concern or complaint may constitute a breach of the
      Regulations and, in turn, an offence under the Act. If this is the case, then this must be dealt
      with before invoking the NHS initial considerations pathway.

      However, assessors must also remain vigilant to the fact that any concern or complaint
      about an independent sector treatment centre (ISTC) or NHS-funded care in an
      independent hospital may have an implication for our view of the NHS commissioning body.
      In turn, this may affect annual health check processes.

      Therefore, all concerns and complaints arising from this patient group should first be
      considered by the lead assessor with regards to the service's registration under the
      CSA2000, remembering that investigations should be notified of any possible consequences
      for the NHS commissioning body. The vast majority of these concerns and complaints are
      already managed in this way.

      There are two policies to follow: the Enforcement Policy and the NHS Investigations Criteria.
      Those cases that fall outside of ‘business as usual/the improvement phase’ must be referred
      to the Senior Manager of Investigative Practice for them to investigate. This will then
      automatically be reviewed by the Initial Considerations Team to ensure that we fulfil our
      statutory responsibilities under the Health and Social Care Act 2003.




                                                                                                          7
2.6   Process guidance: Initial receipt

      The process is managed through CRM activity plans. Upon receipt of a complaint, a new
      RICE process should be established and the activity plans followed accordingly.

      The key principle in managing the process is that all concerning information should be
      received passively from the informant and then dealt with actively in the regulation of the
      provider. It is not our objective to give the informant satisfaction through arbitration,
      adjudication or investigation of the information.

      We are grateful to informants for the information they give us – and we thank them for doing
      so – but once the information is received, it is used solely for the benefit of the regulatory
      process between the Healthcare Commission and the provider. This is set out in the
      template letters sent to informants.

      The Healthcare Commission’s public accountability is to ensure that all concerning
      information is acted upon in a proportionate, efficient and decisive manner.

      When information is received
      Information can be received in a number of ways, such as via the telephone, a letter, or an
      email. It may be received by our helpline, our NHS complaints team or another agency.

      A file note must be kept of all telephone contact. This should include details of the date,
      time, reason(s) for the call and a summary of the issues discussed and agreed. If
      appropriate, the content of the discussion should be confirmed in a formal letter.

      The first team (such as the helpline, a regional office, or the Chief Executive’s office) to
      receive the concerning information is responsible for commencing the RICE process. The
      RICE process is linked to the provider (a new provider should be set up if they are not
      currently recorded on CRM) and then assigned to the appropriate staff member.

      Where the information is in relation to a suspected unregistered provider, the process
      should be assigned to the area manager for the relevant area team, or deputy if that person
      will be away from work for more than three days.




                                                                                                       8
Where the information is in relation to a registered provider or a provider going through
registration, the process should be assigned to the lead assessor, or the area manager if
the lead assessor will be away from work for more than three days.

The first activity plan involves screening the information against acceptance criteria. This
must be completed within three days of the information being received from the informant,
and one of the following letters should be generated:

•   Initial letter – Next steps: The information falls under the Healthcare Commission’s
    remit and no additional information is required from the informant.
•   Initial letter – Additional information required: The information falls under the
    Healthcare Commission’s remit but further information is required.
•   Initial letter – Medical records consent required: The information falls under the
    Healthcare Commission’s remit but consent to access the patient’s records is required.
•   Initial letter – Third party consent required: The information falls under the
    Healthcare Commission’s remit but consent is required from the patient to permit a third
    party to act on their behalf.
•   Closing letter – Issues are outside our remit: The information received relates to a
    request to either assist with getting compensation, assist with the recovery of fees paid
    or pricing, assist with an employment issue, and/or issues concerning the substance of
    the Regulations or NMS.
•   Closing letter – Issues do not relate to the Act or the Regulations: The issues
    raised do not constitute a breach of the Act or any associated regulations.
•   Closing letter – Provider is not aware of complaint: The issues relate to a ‘complaint’
    but the informant has not raised these through stages 1 and 2 of the provider’s own
    complaint policy.
•   Closing letter – Provider not required to be registered with the Healthcare
    Commission: The issues relate to a provider who does not require registration under
    the Act.

Where additional information and/or consent is requested at this initial stage, the informant
is given 28 days to reply. Where the information or consent is received within the 28 days,
the informant should be sent one of the following letters:

•   Initial letter – Next steps: The additional information confirms that the matter(s) fall
    under the Healthcare Commission’s remit.
•   Closing letter – Issues are outside our remit: The information received relates to a
    request to either assist with getting compensation, assist with the recovery of fees paid
    or pricing, assist with an employment issue, and/or issues concerning the substance of
    the Regulations or NMS.
•   Closing letter – Issues do not relate to the Act or the Regulations: The additional
    information now shows that the matter(s) do not constitute a breach of the Act or any
    associated regulations.

Where the informant fails to supply the information requested within 28 days, they should be
sent the Closing letter – Failed to submit additional information or consent, and the
matter should be closed. If the informant submits the information after this letter has been
sent, then they should be contacted and asked to start the process again, as explained in
the closing letter.




                                                                                                9
      Many people use email to provide us with information. A record must be kept of all email
      correspondence and further contact should be converted to ‘hard copy’ wherever possible.
      Email must not be used to send confidential information to email addresses outside the
      Healthcare Commission, apart from those agreed in the corporate policy(s).
      Managing Corporate Email Policy.
      Corporate electronic filing instructions.
      Managing your email guide.

      The information we receive often contains personal and sensitive information.
      Security policies.

2.7   Process guidance: Investigation

      Once the activity plans establish that further review of the concerning information is
      required, the assessor is responsible for undertaking this.

      The purpose of the review is to decide whether a breach of the Act or any associated
      regulation has taken place and, where this is established to be the case, all appropriate
      improvement and enforcement action is undertaken.

      Other process documents exist for:

      •   the inspection of establishments
      •   enforcement activity.

      The role of the assessor is to complete these processes, with the regulation of the provider
      being the primary focus of attention – not the arbitration, adjudication or investigation of the
      issues for the benefit of the informant.

      Information relating to any investigation should be stored electronically according to the
      Information handling handbook.

      Consent

      Where the information required involves obtaining documents that contain confidential
      personal information (CPI) from the provider, consent of the patient should ordinarily be
      obtained in the first instance unless to do so would not be practicable or would prejudice the
      Commission’s functions. Where consent to access the documents is obtained, a copy of the
      completed consent form should be sent to the provider when requesting the required
      records. If it is considered that it would be impracticable or prejudicial to the Commission’s
      functions, advice should be sought from the information governance team in line with the
      established policies.

      If the informant requests to remain anonymous to the provider, the provider should be
      assured, in writing, that the proper consent has been obtained but that this cannot be
      shared with them at the informant’s request. In these circumstances, the information will be
      obtained under our powers to ask for information for the purposes of regulation alone.

      Where the information required is likely to include CPI in relation to a number of individuals
      (for example, staff training records), the provider should be asked to anonymise these.
      Where this is not possible or would detract from the value of the information, the procedure
      for obtaining authorisation to access CPI without consent must be followed. This is set out in
      the Information handling handbook.




                                                                                                         10
      Where enforcement action arises from the review of the concerning information, this should
      be undertaken in accordance with the IH Enforcement Framework and Procedure and
      supervised by an advanced investigative practitioner.

      Investigations should be undertaken through the principles of risk-based inspection.
      Wherever possible, information required to complete the investigation should be gathered
      remotely and any inspections undertaken should be assessed using the regulatory
      assessment record. This should be managed by establishing a new inspection RICE
      process in CRM.

      Once the investigations are completed, the assessor should decide on the final outcome
      and use the appropriate template letter from CRM to notify the informant and close the
      matter. The template letters are:

      •   Closing Letter – Issues are outside the Healthcare Commission’s remit: The
          information received relates to a request to either assist with getting compensation,
          assist with the recovery of fees paid or pricing, and/or assist with an employment issue.
      •   Closing Letter – Issues do not relate to the Act or the Regulations: The issues
          raised do not constitute a breach of the Act or any associated regulations.
      •   Closing Letter – Breaches: The investigations confirm that the provider has breached
          the Act or any associated regulations, and appropriate, proportionate action has been
          taken.
      •   Closing Letter – No breaches: The investigations confirm that the provider has not
          breached the Act or any associated regulations, and no further action is to be taken.

      All correspondence with providers relating to the review of the concerning information
      should be completed as bespoke correspondence or using templates within the inspection
      and assessment, and/or the enforcement procedures.

2.8   Timescales

      In preparation for merger, these timescales mirror those of the Commission for Social Care
      Inspection (CSCI).

              Acknowledge receipt of initial information.                  Three working
                                                                           days
              Confirm with the informant what action we are planning       Seven working
              to take (such as refer back to the provider, manage          days from receipt
              ourselves, or refer to another agency) or of reason(s) for   of information
              delay in providing a response.
              If we manage the information and an inspection is not        20 working days
              required, a response will be sent to the informant and       from receipt of
              the provider to inform them of our findings.                 initial information
              If an inspection is required, our enquiries will be          20 working days
              concluded and a report sent to the informant and the         from receipt of
              provider.                                                    initial information
              If enquiries take us outside the timescale, the informant    20 working days
              will be notified in writing.                                 from receipt of
                                                                           initial information.
                                                                           Regular updates
                                                                           to be provided




                                                                                                      11
2.9     Responsibilities

        The person having first contact with the concerning information is responsible for
        establishing the RICE process in CRM and assigning it to the appropriate member of the
        Area Team to investigate or review.

        Activity plans are primarily followed by assessors and area managers, but where any given
        step is hierarchy dependent, this is annotated in the step.

2.10    Responses to closing letters

        There is a single response under the complaints, concerns and allegations procedure.
        There is no escalated right of appeal other than formal action against the provider.

        If informants wish to complain about the actions of the Healthcare Commission, they must
        use its corporate complaints procedure.

        On completion of the Healthcare Commission’s corporate complaints procedure, if the
        informant remains dissatisfied with the response, they may wish to consider discussing their
        concerns with their MP. The MP will then make a decision as to whether the matter should
        be referred to the Parliamentary Ombudsman.

        All closing letters bring the matter to a close. Where informants request further consideration
        of the matter, and given the position of the preceding paragraphs, the area manager may
        consider reviewing how we handled the concerning information to ensure:

        •   this policy was followed
        •   that appropriate investigations were undertaken
        •   that the conclusion (breaches or no breaches) was reasonable given our initial findings.

        The area manager may then confirm the findings of this review to the informant, detailing
        whether further actions are to be taken (but not necessarily explaining what those are) and
        confirming that the matter is closed.

2.11    Vexatious contacts

        There may be occasions where the informant may, for a variety of reasons, believe that their
        concerns are not being taken seriously or addressed appropriately. On rare occasions, this
        can result in excessive numbers of letters, emails or telephone calls.

        It is recognised that this can be a stressful experience for staff and in these circumstances,
        our policy for managing vexatious complaints should be followed.

3.     Equality impact assessment

3.1    This policy has been assessed for impact on equality through a general Planning for
       Inclusion Process (PIP) review of the concerning information process.

4.     Policy implementation and operation audit

4.1    An audit has not been designed to measure the implementation of this policy.




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5.     Supporting documentation

 5.1    The policy makes reference to a number of supporting documents that form the overarching
        governance and delivery framework for the management of concerning information. The
        name and location of each document are outlined in table 1.


 Table 1: Supporting documentation
 Supporting document                                 Version     Location
 Concerning information CRM activity plans           NA          CRM
 Information handling handbook                                   Healthcare Commission
 Private and Voluntary Healthcare (England)          NA          www.opsi.gov.uk/si/si2001/2001396
 Regulations 2001                                                8.htm
 Care Standards Act 2000                             NA          www.opsi.gov.uk/acts/acts2000/uk
                                                                 pga_20000014_en_2
 Managing Corporate Email Policy                                 Healthcare Commission
 Corporate electronic filing instructions                        Healthcare Commission
 Managing your email guide                                       Healthcare Commission
 Vexacious Complaints Policy                                     TBC
 Corporate Complaints Policy                                     TBC
 Security Policies                                               Healthcare Commission


 6.     Policy maintenance

6.1     Triggers for policy review

 6.1.1 The policy will be reviewed as a result of:

        •   the expiry of the review date
        •   potential improvements to working practices identified by the operations group
        •   a significant deviation from anticipated levels of performance
        •   the introduction of changes to the process.

6.2     How the policy will be reviewed

 6.2.1 The policy will be reviewed by the author and submitted for consideration to the Project and
       Business Analysis Manager, the Operations Policy and Practice Manager, our legal team and
       the RICE policy group. It will then be given to Independent Healthcare Delivery Team (IHDT)
       for sign off and endorsement.

 6.2.2 The Project and Business Analysis Manager, the Operations Policy and Practice Manager,
       our legal team and the RICE Policy Group will be notified of the reason for review and
       provided with a list of requested changes prepared by the author. Each change request will
       be reviewed by the IHDT to assess whether it would fulfil its responsibilities by approving it.

 6.2.3 The Project and Business Analysis Manager, the Operations Policy and Practice Manager,
       our legal team and the RICE Policy Group will provide a decision for each change request on
       whether it is accepted, requires revision or is declined. They will then pass this information to
       IHDT to endorse.




                                                                                                         13
6.3    Who will be involved in reviewing the policy?

6.3.1 The Project and Business Analysis Manager, the Operations Policy and Practice Manager,
      our legal team and the RICE Policy Group will collectively be responsible for the review of
      this policy and for making recommendations to the IHDT to endorse it. Other teams will be
      invited to participate at the discretion of the author.

6.3.2 For further information on the teams and roles consulted, please refer to the Participants and
      roles chart (section 7.1).

6.4    The responsibilities of the policy review panel

6.4.1 The policy review panel is tasked with:

       •   Ensuring that the policy complies with our customer care charter.
       •   Ensuring the policy provides a clear framework for decision making.
       •   Ensuring work practices are aligned with the rules defined in the policy statement.
       •   Ensuring that all proposed changes to the policy have been assessed in terms of their
           impact on working practices, operational capability and responsibilities under corporate
           governance.
       •   Signing off each agreed change to the policy and the revised policy for publication.

6.5    Superseded documents

6.5.1 This policy replaces the document(s) or previous versions listed below. The below
      documents should be withdrawn from use and local copies deleted immediately:

       •   IHC Commission Process for handling Complaints, Concerns and Allegations Jan 07 V2
       •   Moving complaints to the regions SECOND DRAFT 10 Dec 06
       •   Stage 1 Decision Making Tool
       •   Stage 2 Decision Making Tool
       •   Stage 3 Decision Making Tool.




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7.          Document control information
7.1         Involvement in policy’s development

Responsibility or author(s)                                  Andrew Cook               Independent Healthcare Policy and
The person(s) who produced the                                                         Practice manager
document
Accountable owner                                            Gary Needle               Head of Assessment and Methods
The person with accountability for the
quality and delivery of the document
Consulted                                                    Richard Mash              Legal
The business unit(s) consulted during                        Deirdre
the development of the document                              Johnson
                                                             Debbie Mead               Operations Policy and Practice
                                                                                       Manager
                                                             Laurence                  Project and Business Analysis
                                                             Coman                     Manager
                                                                                       RICE Process Group
Informed                                                                               Operations
The business unit(s) who have received
                                                                                       Operations Group Leadership Board
the document for their information

Endorsed                                                     Maureen                   Acting Head of Independent
The person(s) or business unit(s) who                        Cambell                   Healthcare
must approve the document before its                                                   IHDT
publication

7.2         Document history

Version                      Sign off date                   Review date               Reason for updating 1
0.0




1
    Please insert one reason from the list provided in section 4.1 Triggers for reviewing the policy.
    Where there have been a number of contributory factors leading to the review of the policy, please record only the primary reason.
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