The NHS Complaints Procedure by ChrisBirchall


									         The State Hospital’s Board for Scotland


Policy Reference Number     RM05                                  Issue: 6
Lead Author                 Complaints Officer
Contributing Authors

Advisory Group              Risk and Governance Committee
Approval Group              Hospital Management Team
Implementation Date         May 2009
Review Date                 May 2012
Responsible Officer (SMT)   Director of Finance and Performance

1.    Background
2.    Principles for an effective complaints procedure
3.    Who can complain
4.    What can be complained about
5.    What the procedure doesn’t cover
6.    Staff Grievances
7.    Significant Complaints
8.    When can a complaint be made
9.    Joint complaints
10.   Roles and Responsibilities
      10.1 The State Hospitals Board for Scotland
      10.2 The Clinical governance Committee
      10.3 The Risk and Governance Committee
      10.4 The Hospital Management Team
      10.5 The Chief Executive
      10.6 The Finance and Performance Management Director
      10.7 The Complaints Officer
      10.8 The Risk Management Team
      10.9 Staff and Line Managers
      10.10 Patients’ Advocacy Services
11.   Dealing with a Complaint
      11.1 Acknowledging the complaint
      11.2 The Investigation
      11.3 Completing Local Resolution
      11.4 Withdrawn Complaints
      11.5 Unreasonably Demanding or Persistent Complaints
      11.6 Disciplinary Investigation
      11.7 Support framework
              Independent Advice & Support Services (IASS)
12.   Role of Ombudsman
13.   Learning from complaints
      13.1 Active Listening
14.   Monitoring of Complaints
      14.1 Informing the Board
      14.2 Annual Reports
      14.3 National monitoring
15.   Audit and Review
16.   Format

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                  The NHS Complaints Procedure within the State Hospital

1.       Background
The State Hospital is a learning, patient-focused organisation that welcomes feedback from users
of its services. Feedback may be received in the form of a compliment, a comment, a concern or
a formal complaint. All forms of feedback provide opportunities for reflection, learning and,
where appropriate, change. Within the State Hospital this feedback process is referred to as the
4 C’s.

Frontline staff are actively encouraged to resolve any issues or concerns as they arise although
there will be occasions when an individual or family will be dissatisfied with the explanation
given and want to raise the issue as a formal complaint. When this happens the service provider
will attempt to resolve the complaint as directly and quickly as possible, with the primary aim of
being fair to both the person making the complaint and where appropriate to staff complained
against. Addressing complaints earlier and more informally may avoid the need to access the
formal complaints procedure. It is acknowledged that this may result in formal complaints being
restricted to more difficult, complex or challenging issues.

A complaint is an “expression of dissatisfaction requiring a response”. As there is a very fine
line between a complaint and a concern, there should be an opportunity for the person to decide
if they wish the matter they are raising to be considered under the NHS Complaints Procedure or
through one of the other less formal feedback processes.

2. Principles for an effective complaints procedure
The aim of the State Hospital is to operate a complaints procedure which is credible, easy to use,
demonstrably objective, effective and sensitively applied. Making a complaint can be stressful
both for those making the complaint and for the staff involved. Arrangements should be fair to
both sides, supporting the person making the complaint and any staff named in the complaint.
The procedure also ensures that the NHS can learn and grow positively from the experience.

3. Who can complain?
Complaints may be made by a patient or former patient, any appropriate person in respect of a
patient who has died (e.g. the next of kin or their agent), someone on behalf of an existing or
former patient (e.g. a patient’s parent, carer, guardian or a visitor; an MP, MSP or local
Councillor), or an advocate or member of an independent advice and support organisation.

Where someone other than the patient or their authorised agent wishes to make a complaint, they
should be advised that they must be able to demonstrate that they have obtained the patient's
(normally written) consent to:
• Make a complaint on their behalf.
• Allow members of staff to examine the patient’s health records, if this should prove
necessary as part of the investigation of the complaint.

The Complaints Officer in discussion with the Chief Executive will determine whether the
person making a complaint is appropriate to represent a patient. This decision will depend, in
particular, on the need to respect the confidentiality of the patient, for example, the patient may
have made it known that their information should not be disclosed to third parties. If it is
decided that a person is not appropriate to act as the patient’s representative, they must be
provided with an explanation in writing outlining the reasons for that decision.
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Should the complainant be anonymous then a decision will be made as to whether or not an
investigation is initiated by the Complaints Officer, in consultation with the Chief Executive.

4. What can be complained about?
The potential subject of a complaint is wide and not just related to medical care. A complaint
may be about a decision taken by the State Hospital that is likely to affect the person making the
complaint or the person on whose behalf the complaint is made. Each complaint must therefore
be taken on its own merit and responded to appropriately.

The NHS complaints procedure primarily deals with concerns about patient or former patients
care provided by the State Hospital including the contracted Primary Care Services and Social
Work Services (See paragraph 9).

5. What the Procedure Doesn’t Cover
Members of the public, including patients, may raise concerns with the State Hospital which the
organisation needs to address, but which do not fall within the scope of the NHS Complaints
Procedure. Other appropriate management processes are in place to deal with these concerns.

If any complaint received by the State Hospital appears to raise matters normally dealt with:
• By the disciplinary procedure.
• By the prevention of bullying and harassment at work policy
• By a professional regulatory body.
• By an independent inquiry into a serious incident under Section 76 of the National Health
     Service (Scotland) Act 1978.
• By an investigation of a criminal offence, including fraud.
• By a possible claim for negligence.
• Under Freedom of Information.

The complainant should immediately refer the matter to the person appointed by the Hospital to
deal with such matters – the Complaints Officer will be able to advise on who this is. This
reference may be made at any point when dealing with a complaint. In these circumstances,
investigation of other aspects of the complaint will only be taken forward if they do not, or will
not, compromise or prejudice the matter under investigation.

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6. Staff Grievances
Staff concerns about the way in which they have been dealt with under the complaints procedure
can make use of the State Hospital Grievance Policy (HR12). Staff may also take their concerns
to the Ombudsman. The Ombudsman normally expects staff to have followed internal
procedures for resolving their complaint. However, the Ombudsman has the power to consider
complaints that have not been put to the relevant NHS body and/or where the internal procedure
has not been exhausted if, in the circumstances of the particular case, it is not considered
reasonable to expect this.

7. Significant Complaint
There are occasions when the allegations made by a complainant are of such severity that they
are considered to be categorised significant complaints. Such complaints are likely to cover
areas of neglect, abuse or unprofessional conduct. The State Hospital defines significant
complaints by reference to the guidelines from the Mental Welfare Commission that suggests
that significant complaints might be:

• alleged actual or intended physical or sexual abuse;
• allegations of other ill treatment or cruelty, neglect or abuse;
• failure to comply with statutory provisions, including improper detention and unlawful
• maladministration of patient funds or property; or
• failure to make satisfactory arrangements for care after discharge from the Hospital.

When a complaint is deemed significant in line with the above definitions then the Complaints
Officer will notify the following persons and where necessary clarify any points of the complaint
being raised before initiating a full significant complaint investigation:

•   the complainant;
•   staff who have had allegations made against them;
•   the line manager of staff referred to above;
•   the General Manager
•   the Lead Nurse;
•   the patient’s RMO;
•   the Occupational Health Department;

The Risk Management team will facilitate the investigation ensuring that the brief to the
investigation team will clarify their terms of reference. The terms of reference shall, as a
generality, include a timescale, the need to provide a full report, and an anonymised report to
protect patient, staff and third party confidentiality, and the need to inform the Chief Executive if
there is any delay in completing the investigation or providing the report(s) within the timescale,
in line with the hospital’s Incident Reporting and Review Policy (RM01).

When it is obvious that a complaint is significant, with a physical component when the original
allegations are made, the person in charge of the ward/area should ensure (after further
consultation and clarification if necessary) that the following procedure is carried out:
• arrange for a physical examination within two hours of the allegation or as soon thereafter
depending on the mental state/condition of the patient;
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• consider removing the patient and/or staff pending the outcome of an investigation. Should
this be necessary it will be done to ensure the protection of all involved and no conclusions or
guilt are implied and this action may be invoked at any stage of the process;
• determine whether the Police should be informed at this stage, should the Police be
informed at this stage then the complaints process will cease in accordance with paragraph 5
above and will only continue whenever appropriate clearance is given by the Police authority;
• determine whether or not the patient wishes his/her next of kin to be informed;
• advise the Complaints Officer immediately of the allegations and the action taken to date;
• advise Senior Nurse Cover and the Duty Security Manager; and
• determine whether the patient wishes the support of an Advocate.

8. When can a Complaint be made
Complaints are normally made at the time a patient or carer becomes aware of an issue or a
concern. Wherever possible they should be dealt with immediately to reduce the chance that the
passage of time, with inevitable staff changes etc, could hamper resolution. However, it is not
always possible for the patient to make a complaint immediately. In clinical complaints a
complication or other issue may not become apparent to the patient for sometime after the

Given the difficulties that the passage of time can make to the resolution of a complaint the
recommended timescale adopted by the State Hospital for accepting a complaint is:

•   Up to 6 months after the event which is the cause for the complaint, or
•   Up to 6 months from the patient becoming aware of a cause for complaint;
•   But, normally, no longer than 12 months from the event.

The State Hospital however operates these guidelines flexibly and accepts a complaint where it
would have been unreasonable for the patient to make it earlier and where they believe it is still
possible to investigate the facts. A decision not to extend these timescales must be agreed by the
Chief Executive or appointed deputy. A patient can appeal to the Scottish Public Services
Ombudsman against a decision not to accept their complaint.

9. Joint Complaints
Where a complaint relates to a patient receiving health and social care services the State
Hospital and the Local Authority responsible for the Social Work Services will agree who will
take the lead and work together to ensure that all matters raised are investigated. The person
making the complaint should be informed about which matters are being dealt with under which

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10. Roles and Responsibilities

10.1 The State Hospitals Board for Scotland
All staff that provide services on their behalf should be aware of and trained in the procedures to
be followed. As well as induction awareness training, dedicated training workshops are
provided. All staff have a responsibility to try to resolve issues as they arise but when this is not
possible they should provide the complainant with a range of options available.

10.2 The Clinical Governance Committee
The Clinical Governance Committee will receive quarterly “Learning from Compliments,
Comments, Concerns and Complaints (The 4c’s); improving patient safety” reports. The
Clinical Governance Committee will be assured of the effectiveness of the complaints process.
Reports from the Scottish Public Services Ombudsman relating to complaints against the State
Hospitals Board for Scotland will be referred to this committee when received.

10.3 The Risk and Governance Committee
The Risk and Governance Committee will receive regular quarterly incidents reports which will
include a section on “Learning from comments, concerns, complaints and compliments” and
ensures that risks are systematically identified, recorded, reported, managed and analysed
through incident reporting and investigation and the process of the 4Cs.

10.4 The Hospital Management Team
The Hospital Management Team will receive regular Risk Management Update reports which
will include a section on “Learning from comments, concerns, complaints and compliments”.
The Hospital Management Team will cascade information to relevant clinical teams and address
any hospital-wide issues identified through the various feedback processes.

10.5 The Chief Executive
The Chief Executive is responsible for signing off all complaint letters. In the absence of the
Chief Executive the responsibility will be delegated to the Deputy Chief Executive. Should both
the Chief Executive and the Deputy Chief Executive be absent then the Chief Executive will
nominate a Director to sign off the complaints during the period of absence.

10.6 The Finance and Performance Management Director
The Chief Executive has appointed the Finance and Performance Management Director as the
executive lead with responsibility for Risk Management including patient feedback and

10.7 The Complaints Officer
The Complaints Officer is part of the Risk Management Team and should be readily accessible
to patients, the public and staff. The Complaints Officer works with staff involved in the
Patient Focus Public Involvement (PFPI) agenda and also the Equality and Diversity agenda in
order to develop ways of encouraging effective patient feedback and to:

• Continually develop processes to record the handling and consideration of each complaint.
• Continually develop processes to ensure organisational learning from the operation of the
Board’s patient feedback and complaints process, including statistical and trend analysis.

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• Ensure that a complete record is kept of the handling and consideration of each complaint.
These records will be particularly important if the complaint is referred to the Ombudsman.
Complaints records will be kept separate from health records.
• Ensure that appropriate clarification is sought where a complainant wishes to withdraw a
complaint (see paragraph 11.5).

The Complaints Officer manages the operation of the NHS Complaints Procedure within the
hospital to ensure that staff:

• Have the training, support and help they need to deal effectively with comments, concerns
and complaints, including those which are unreasonably demanding or persistent.
        o A register will be kept of staff who have undergone formal training such as
            Investigations Skills and or Root Cause Analysis training.
        o Where an investigator has not received formal training appropriate guidance will be
            given to ensure that good investigation principles are adhered to in the investigation
• Can advise the person making the complaint on how it will be dealt with, including
providing them with a copy of Health Rights Information Scotland’s leaflet Making a complaint
about the NHS, and about the role, availability and how to contact the relevant advice and
support services for example those that provide information, translation, interpretation etc.
• Know when to seek assistance and advice from senior staff.
• Have access to advice and support on associated issues, for example patient consent;
confidentiality; the operation of related legislation, such as the Data Protection Act, access to
medical records, Freedom of Information, etc.

The Complaints Officer should continually look at ways of capturing feedback from users of the
service and where appropriate meet with groups of carers and patients on a regular basis.

10.8 Risk Management Team
Members of the Risk Management Team will assist in the complaints process where necessary
by providing support for investigations, monitoring action plans, identifying risks and providing
specialist advice on Health and Safety issues. In particular the Risk Management team will
facilitate any Significant Complaint investigations.

10.9 Staff and Line Managers
All staff and line managers will:
     • Be responsive to frontline issues
     • Endeavour to resolve these issues locally, as they arise
     • Provide support where appropriate to both patients who have complained as well as staff
         complained against.
     • Be responsible in ensuring that lessons are learned
     • Ensure that actions that have been identified are followed through.

10.10 Patients’ Advocacy Services
An Advocate is recognised as an important way of enabling patients to make informed choices
about, and remain in control of, their own health care. Should a patient so wish the Patients
Advocacy Service can provide a supporting role for them when they wish to complain about
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their care and treatment and can provide support during the investigation process and through
later stages of the complaints process. Where possible the Advocate should consider encouraging
patients to resolve issues with front line staff in accordance with the NHS Complaints Procedure

11. Dealing with a Complaint
A complaint may be made in writing, by phone or in person. There may be the possibility that
the person wishing to make the complaint may still, at this stage wish to have the matter
resolved without entering the formal complaints procedure. This option should when possible be
explored with the complainant.

Where a complaint is made to a member of staff their first responsibility is to ensure that the
patient's immediate health care needs are being met. Secondly they should try to resolve the
issue locally prior to contacting the Complaints Officer.

If the complaint is made on behalf of somebody else, the Complaints Officer will ensure patients
consent has been obtained as outlined previously. Where the person wishes to proceed, the
Complaints Officer should agree the details of the complaint and confirm them in a letter of

11.1 Acknowledging a complaint
Complaints will be acknowledged or an initial response issued in writing within 3 working days
of receipt.

The letter will:
• Outline the proposed course of action to be taken or the investigations being conducted.
• Offer the opportunity to discuss issues either with the Complaints Officer or, if appropriate,
with a senior member of staff.
• Where appropriate, provide information about the availability of independent support and
advice, or the possible use of conciliation where this may help and may be agreeable to both

First class post – or, exceptionally, special/recorded delivery – will be used in correspondence
with the person making a complaint with an address out with the hospital. All such
communications will be marked ‘Private and Confidential’. Written communication to patients
will be clearly marked to ensure patients receive the information confidentially.

11.2 The Investigation
It is important that a timely and effective response is provided in order to resolve a complaint,
and to avoid escalation. An investigation of a complaint should be completed, wherever
possible, within 20 working days following the date of receipt of the complaint. Where it
appears the 20 day target will not be met, the person making the complaint, and anyone named
in the complaint, must be informed of the reason for the delay with an indication of when a
response can be expected. The investigation should not, normally, be extended by more than a
further 20 working days.

While it may be necessary to ask the person making the complaint to agree to the investigation
being extended beyond 40 working days, for example because of difficulties caused by e.g. staff
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illness, they should be given a full explanation in writing of the progress of the investigation, the
reason for the requested further extension, and an indication of when a final response can be
expected. The letter should also indicate that the Ombudsman may be willing to review the case
at this stage should they not accept the reasons for the requested extension.

A complaint may best be resolved through face-to-face meetings being arranged with members
of staff and early consideration should be given to this approach. Equally, the Complaints
Officer may decide, on a case by case basis that other action would be helpful. A record will be
kept of all meetings and discussions and a letter issued setting out the agreements reached and
any action to be taken.

Every formal complaint will be investigated by the organisation through the commissioning of
an investigator/investigators. In the majority of cases the Complaints Officer will commission
the relevant ward/service manager or Responsible Medical Officer to undertake this
investigation. There are occasions, however where this may not be appropriate – in these cases
an alternative investigator will be appointed.

Impartiality is crucial to the success of any investigation. The investigating officer must
approach the complaint with an open mind, being fair to all parties. The investigation must not
be adversarial and must be conducted in a supportive atmosphere that demonstrates the
principles of fairness and consistency. Anyone identified as the subject of a complaint should be
provided with a full account of the reasons for the investigation and a proper opportunity to talk
to the investigating officer who should ensure they are kept informed of progress. The person
making the complaint and the person complained against should be informed of the support
services that are available to them. (See also Incident Reporting and Review Policy).

The Complaints Officer will ensure that all information relevant to the investigation is recorded
and kept in a case file. If, subsequently, the complaint is referred to the Ombudsman, this may
result in a request for all relevant papers and other information to be provided in good time to
the Ombudsman’s office. Complaints records should be kept separate from health records,
subject only to the need to record information which is strictly relevant to the patient’s health in
their health record.

Where the complaint involves clinical issues, the draft findings and response will be shared with
the relevant clinicians to ensure the factual accuracy of any clinical references.

11.3 Completing Local Resolution
The complaints process is completed by the Chief Executive reviewing the case to ensure that all
necessary investigations and actions have been taken. If the Chief Executive is satisfied that the
complaints process is complete, they will issue a letter to the person making the complaint. The
letter will be clear and easy to understand and:
• Address all the issues raised and show that each element has been fully and fairly
• Reflect accurately the findings from the investigation
• Include an apology where things have gone wrong.
• Report action taken or proposed to prevent any recurrence.
• Highlight any area of disagreement and explain why no further action can be taken.

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•    Indicate, where appropriate, that a named member of staff is available to clarify any aspect
    of the letter.
• Indicate that if they are not satisfied with the outcome of the local process, they may seek a
review by the Scottish Public Services Ombudsman.
• Include details of how to contact the Ombudsman office.

Once the final response has been signed and issued, the Complaints Officer files all
correspondence, liaises with local senior managers to ensure that all necessary follow-up action
is taken, sharing the outcome with those named in the complaint and report to the Board’s
Clinical Governance Committee when this has been done. The Complaints Officer will also
ensure that where staff are the subject of a complaint that they receive feedback.

Actions taken as a result of issues identified in formal complaints will be reported to the Risk
and Governance Committee via the relevant section of the quarterly Incidents Report.

11.4 Withdrawn Complaints

Where a complainant wishes to withdraw a formal complaint, written notification should be sent
to the Complaints Officer. This should adequately describe how the issues have been resolved.
There may be occasions when the Complaints Officer will require further clarification to be
satisfied that all the issues have been resolved. Should there be outstanding issues then further
investigation will take place and the complainant will be informed.

Significant complaints that are subsequently withdrawn will be reviewed by the Chief Executive
and the reasons for the withdrawal will be reported to the Hospital Management Team, Risk and
Governance Committee and Clinical Governance Committee as part of the quarterly reports.

11.5 Unreasonably Demanding or Persistent Complaints
NHS staff should be trained to respond with patience and empathy to the needs of people who
make a complaint, but there will be times when there is nothing further which can reasonably be
done to assist them or rectify a real or perceived problem. Where this is the case and further
communications would place inappropriate demands on NHS staff and resources, consideration
may be given to classifying the person making the complaint as an unreasonably demanding or
persistent complainant.

On occasions it may be considered appropriate to meet with the complainant and members of the
appropriate clinical team to endeavour to support and manage the individual’s concerns, thus
preventing the classification of the individual as an unreasonably demanding or persistent

Classifying a person making a complaint as unreasonably demanding or persistent will only
occur in exceptional circumstances when it can be shown that:
• the complaints procedure has been correctly implemented
• all reasonable measures have been taken to resolve the complaint
• no material element of the complaint has been overlooked or inadequately addressed

and a full written case has been submitted to and approved by the Chief Executive and Chair of
the Board.
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Before agreeing to classify a correspondent as unreasonably demanding or persistent,
consideration should be given to dealing with future correspondence in one or more of the
following ways:
• By drawing up a signed “agreement” with the correspondent (and if appropriate involving
     any relevant practitioner in a 2-way agreement) which sets out a code of behaviour for the
     parties involved if the complaint is to continue to be processed. If these terms are
     contravened, consideration would then be given to implementing other action as indicated
• Declining contact with the correspondent either in person, by telephone, by fax, by letter or
     any combination of these, provided that one form of contact is maintained
• Temporarily suspending all contact with the correspondent or investigation of a complaint
     whilst seeking legal advice or guidance from other relevant agencies.

Where a decision is taken to classify a correspondent as an unreasonably demanding or
persistent complainant, the Chief Executive will notify the person in writing of the reasons why
they have been so classified and the action which will be taken with future correspondence or
calls. The letter will provide a summary of the hospital’s position on their complaint indicating
• they have responded fully to the points raised and, as there is nothing more to add,
     continuing contact on the matter will serve no useful purpose
• that further correspondence will simply be acknowledged unless it raises a new matter of

In extreme cases the correspondent might also be advised that the hospital reserves the right to
pass future correspondence to their solicitors.

This notification letter may be copied for the information of others involved in the process. A
record will be kept of the reasons why a complainant has been classified as unreasonably
demanding or persistent.

It is important when considering classifying an individual from an equality group as an
unreasonably demanding or persistent complainant to make appropriate checks to ensure that the
decision is in no way based on institutional discrimination or on a lack of knowledge of the
specific needs of that individual.

The decision to classify a complainant as unreasonably demanding or persistent will be reviewed
should they subsequently demonstrate a more reasonable approach. The decision to withdraw
this classification is subject to the approval of the Chief Executive and Chair of the Board.

11.6 Disciplinary Investigation
If a disciplinary investigation is considered appropriate then the complaints investigation will
stop, except for any issues not covered by the disciplinary investigation. The complainant may
be informed of the decision to initiate the disciplinary procedure but cannot object to it. This
will be done in writing at the time it happens.

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11.7 Support Framework
The hospital acknowledges the stress that an investigation as a result of a complaint can have on
both staff and patients and support frameworks will be developed for staff and patients.

The main points of contact for staff during the complaints process will include:
•     line management;
•     staff representatives;
•     Occupational Health (where it is a significant complaint the Complaints Officer will notify
      Occupational Health that an investigation is underway and will ensure that the
      confidentiality of staff involved is maintained );
•     Human Resources (Employees Relations Manager); and
•     Independent Counselling and Advisory Service (ICAS).

The main points of contact for patients during the complaints process will include the:
•    Patients’ Advocacy Service;
•    Ward Manager;
•    patient’s next of kin;
•    any other appropriate support depending on level of disability; and
•    or any other specified person;

Independent Advice & Support Services (IASS)

NHS Scotland [HDL (2006) 13 provides a national framework for IASS which should be
available to the patients, carers and service users of all NHS Boards in Scotland, including
Special Health Boards and National Services Scotland. The Health Department have been
working with Citizens Advice Scotland, the NHS the voluntary sector and Citizens Advice
Bureaux to develop this national framework which will ensure quality and equity of services
across NHSScotland.

The IASS operating in geographical NHS Board areas should provide advice and support for
patients, carers and service users who reside in their area and who want to complain about a
service provided by the State Hospital. Arrangements have been made with NHS Lanarkshire to
provide this service for patients and carers from Northern Ireland. Leaflets are available in the
Carer’s Centre showing users how to access this service.

12. Role of the Ombudsman
The Scottish Public Services Ombudsman Act 2002 established a ‘one-stop shop’ ombudsman
service, headed by the Scottish Public Services Ombudsman, to deal with complaints formerly
handled the Scottish Health Service Ombudsman. The new Ombudsman also took over the
Mental Welfare Commission's function of investigating complaints relating to mental health.

The Ombudsman can in principle investigate complaints from aggrieved persons that have
sustained injustice or hardship as a result of maladministration or service failure on the part of
an authority within the Ombudsman's jurisdiction. Such authorities (referred to as “listed
authorities”) include all NHS organisations.
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The Ombudsman’s office can generally consider complaints only when they have been fully
considered under a listed authority’s internal complaint procedures - although this requirement
can be waived in exceptional circumstances. Complaints should generally be made to the
Ombudsman within 12 months of the events giving rise to them, or within 12 months of the
complainant becoming aware that there were grounds for complaint, although there is scope to
waive this requirement if there are special circumstances.

The Scottish Public Services Ombudsman Act 2002 requires listed authorities, such as NHS
Boards and family health service providers, to take reasonable steps to publicise -
• the right conferred by the Act to make a complaint to the Ombudsman
• the time limit for doing so
• how to contact the Ombudsman.

13. Learning from Complaints
Data on complaints is collected so that lessons can be learned which can help improve service
delivery throughout the organisation. Processes are continually being developed for collecting
and disseminating the information, themes and good practice gained from patients’ views,
experiences and complaints, concerns, comments and compliments and ensuring they are used to
improve service quality. The State Hospital is keen to listen to and act on complaints from those
who feel let down by the service they have received as well as being quick to learn from what
patients say has worked well for them.

The hospital is working to strengthen the voices and influence of people who use our services
and use a range of approaches and opportunities to hear their complaints, concerns, comments
and compliments, learn from them and change the way that things are done. The hospital will
work towards encouraging the meaningful involvement of those who know how services are
currently delivered, and make a special effort to hear from those whose voice is not normally
heard or who would otherwise be excluded. The hospital will encourage the creation of a
culture where complaints, concerns, comments and compliments are welcomed and acted upon
by all staff.

The Hospital is committed to learn from other organisations where things have gone wrong as
well as building on areas of good practice. The Scottish Public Services Ombudsman monthly
commentary reports are systematically analysed to ensure that lessons are learned from examples
of good and bad practice delivered in similar settings to The State Hospital.

Staff will treat patients, carers and visitors politely and with respect. Violence, racial, sexual or
verbal harassment of staff will not be tolerated within the State Hospital.

                                                                          The State Hospital
                                                                          Draft Complaints Procedure
                                                                          Page 14 of 16
                                                                          Issue date: May 2009
                                                                          Review date: May 2012
13.1 Active Listening
The hospital is continually developing feedback systems that encourage users of the service to
express their views and have an opportunity to raise issues in a variety of ways.

The following processes have been developed and are continually being reviewed to enable users
and carers a wider opportunity to voice their views on service delivery and particularly when
they do not wish to enter the formal NHS Complaints Procedure. These include:
• Community Ward Meetings: Any patient can raise an issue at their Community Ward
Meetings. Usually the issue is discussed and actioned immediately but there are times when the
issue cannot be resolved and may require to be referred to the Patient Partnership Group.
• Patient Partnership Group: any issue raised by a patient representative will be action by
the Group or one of the Sub Groups and feedback will be passed back to the wards via the
patient representative and via the dissemination of approved minutes.
• Informal Complaints: There are occasions where a patient, carer or representative does
not wish to enter into the formal complaints procedure but nonetheless wishes feedback on an
issue, request for information etc. The complaint recording software system allows the
monitoring of these informal complaints. The person raising the issue can, if they are unsatisfied
with the response enter the formal complaints procedure at this stage.
• Comments/Suggestion box: Every ward, the Carer’s Centre, and some Patient Activity and
Recreational Services (PARS) Centres have suggestion boxes where users are encouraged to
make any comments they wish about the services the hospital provides. The comment can be
anonymous but if feedback is required then a contact will require to be given. The box is sealed
and emptied every month with the issues being raised/actioned at the appropriate fora.
• Compliments: These are welcomed as it helps inform the hospital of the positive things
that users are saying about staff and services. These are recorded and shared with the
appropriate services and/or specific staff.

The Complaints Officer monitors the types of issues raised via these processes to provide a wider
perspective on user feedback. Statistics are reported to the Hospital Management Team, Risk
and Governance Committee and Clinical Governance Committee.

14. Monitoring Of Complaints

14.1 Informing the Board
Arrangements are in place to monitor the complaints process with due regard to the principles of
equality and diversity in terms of the person making the complaint, the person complained
against and the content of the complaint. Quarterly reports to the Hospital Management Team,
Risk and Governance Committee and Clinical Governance Committee, and identifies:
• trends in complaints, concerns, comments and compliments
• the effectiveness of local complaints handling and service user feedback systems
• the lessons learned and shared from both internal and external sources and the result in terms
    of service improvement.
• identifying exceptions to performance targets
• monitoring the patients’ experiences over the period

An important point is to ensure that complaints (and comments, concerns and compliments) are
handled sympathetically, effectively and quickly and that lessons are learned and result in
service improvement.
                                                                        The State Hospital
                                                                        Draft Complaints Procedure
                                                                        Page 15 of 16
                                                                        Issue date: May 2009
                                                                        Review date: May 2012
14.2 Annual Reports
The State Hospital publishes in their Annual Reports a report on patient feedback and
complaints handling which explains some of the statistics.

14.3 National Monitoring
The Information and Statistic Division (ISD) will continue to collect statistics on the number
and type of complaints made to the State Hospital.

15. Audit and Review
The procedure will be reviewed every three years as a minimum, sooner should national
guidance be reviewed. Complaints data will be reported to hospital management and governance
committees on a quarterly basis.

16. Format
The State Hospital is committed to ensuring that, as far as it is reasonably practicable, the way
we provide services to the public and the way we treat our staff reflects their individual needs
and does not discriminate against individuals on grounds of their ethnic origin, physical or
mental abilities, gender, age, religious beliefs or sexual orientation. Should a member of staff or
any other person require access to this policy in another language or format (such as Braille or
large print) they can do so by contacting the Head of Communications.

                                                                          The State Hospital
                                                                          Draft Complaints Procedure
                                                                          Page 16 of 16
                                                                          Issue date: May 2009
                                                                          Review date: May 2012

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