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Patient advice and liaison service (PALS) policy

Contents

1 Introduction

Whilst we strive to ensure our patient’s, families and carers receive the best service possible within a changing NHS, there are occasions when the care we provide won’t meet with expectations or people will require extra information about their care. The patient advice and liaison service, known as PALS can be the first line of contact for those who require clarity about their care, or are unhappy with the care provided. PALS provide help in many ways. For example, it can:

  • help with questions about an individual’s healthcare
  • help resolve concerns or problems with trust services
  • tell people how to get more involved in their own healthcare, provide information about the trust complaints procedure, including how to get independent help from support groups and advocacy outside the NHS, for those who wish to complain
  • improve services by listening to concerns and suggestions

The trust acknowledges that whilst PALS will strive to resolve any concerns, this will not always be effective and individuals may wish to make a complaint. The PALS therefore, works closely with the Patient Safety and Investigation team, who can log and investigate complaints in conjunction with the complainant.

This policy identifies the core functions of PALS and outlines the roles and responsibilities of all staff in relation to patients, families and carers, who require support, when wishing to raise a concern or tell us about the good care they have received. In doing so, both staff and those coming into contact with our services can be aware of what should be provided and what to expect.

1.1 Being open and duty of candour

Being open and duty of candour, whilst employed at differing times (see being open policy (incorporating the duty of candour)) forms a set of principles and duties which support the trust to create robust procedures and an open and honest culture when patients and, or their family or carers ask us why things have gone wrong.

They are both part of communicating honestly and sympathetically with the ‘relevant people’ when something goes wrong with patient care. The relevant person could be the patient themselves or other relevant people such as a family member or another trusted person who supports the patient. Where consent is given by the patient or there are special arrangements, information can be shared with other relevant people.

It is therefore essential that when responding to relevant people, that the principles of being open are utilised.

1.2 PALS functions and core standards

The main functions and core standards of PALS are to:

  • be identifiable and accessible to patients, their carers, friends, families and members of the public, everyone who contacts PALS will be given information about options available to resolve an issue or concern
  • listen and provide relevant information and support to help resolve patients’ concerns quickly and efficiently
  • provide on the spot help, whenever possible, with the power to negotiate solutions and resolve problems as quickly as possible
  • enable people to access information about trust services and information about their health and social care provided by the trust
  • signpost and guide people through health and social care services provided by the trust
  • liaise with staff and managers, and where appropriate, with other PALS services and health related organisations, to facilitate a resolution
  • act as an early warning system if there are particular problems and, or concerns emerging
  • act as a gateway for advocacy or the complaints process
  • refer patients, when appropriate, to independent advice and advocacy support from local and national sources, including independent complaints advocacy services (ICAS), which is a free independent advocacy service that can help people make a complaint and locality advocacy services in use across the trusts localities.
  • establish and maintain effective systems for reporting on and learning from PALS contacts
  • operate within a local network with other PALS within the main geographical areas covered by the trust, to maintain a seamless service for patients who move between and use different parts of the NHS for the care they need
  • promote a culture in the trust that puts patients at the heart of service delivery
  • involve patients and carers where appropriate and with consent from the patient, in the planning, development and monitoring of PALS
  • whilst it is recognised that there will be occasions when those contacting the service may be distressed or deemed to be at risk, the PALS is not a crisis and emergency service, anyone requiring further support of this nature will be redirected to the appropriate service to ensure their needs are met

Following the publication of Making Experiences Count (Department of Health, 2007) and the enactment of The Local Authority Social Services and NHS Complaints (England) Regulations 2009, the PALS and Complaints functions work in an increasingly integrated way to resolve complaints which are risk assessed as low and moderate risk.

The trust ‘your opinion counts’ (YOC) and compliments systems are also functions of the PALS. The YOC is paper and web based form that allows people accessing our services, to pass on feedback about their recent experience of using our services.

2 Purpose

The purpose of this policy is to set out the trust’s arrangements for listening, responding and improving when patients and carers raise concerns and for monitoring and learning from those arrangements.

The policy details the processes through which concerns will be handled thoroughly and without delay in an open and honest way, with the aim of achieving a successful outcome for the patient, whilst being fair and open with all those involved.

3 Scope

The PALS offers support to anyone who requires signposting to specific services, information or support to access the appropriate service or support resolving any issues they may have.

The policy covers all people who are accessing trust services including patients, families, carers and all staff working for the trust.

The PALS will have an active role in monitoring and reporting on the incoming YOC form and responding accordingly.

The trust’s arrangements for complaints are set out within a separate policy entitled listening and responding to concerns and complaints policy (formally complaints handling policy).

The detailed arrangements for the development of written information are set out within the patient and carer information policy.

This policy does not cover the arrangements for staff who wish to raise concerns. This is covered within the policy entitled freedom to speak up policy: raising concerns (whistleblowing) policy.

4 Responsibilities, accountabilities and duties

4.1 Board of directors

The board of directors is responsible for monitoring concerns raised by patients, the arrangements for achieving satisfactory and timely resolution and, learning and improvements arising from concerns.

4.2 Executive director of nursing and allied health professionals

The director of nursing and AHPs is the designated director for PALS and as such is responsible ensuring that an effective and appropriate PALS system exists.

4.3 Head of patient safety

  • Using all available data to identify themes for staff training needs and ensuring training is arranged.
  • Ensuring there are systems in place to ensure that patients, their relatives and carers are not treated differently as a result of raising a concern or a complaint.
  • Ensuring PALS literature and YOCs are available in suitable formats and are responded and dealt with accordingly.
  • Managing the PALS coordinator.
  • Monitoring and ensuring information is provided for the Patient Safety and Investigation team dashboard, the quality committee and the trust annual report.

4.4 Care group directors

  • Making PALS literature, promotional materials and your opinion counts (YOC) forms available across all clinical and public areas for which they are responsible.
  • Making information available for patients and carers relating to conditions, treatments, care, medication, service provision and choices, including any undesired effects.

See patient and carer information policy.

  • Taking prompt and effective action in response to concerns raised so that they can be investigated and resolved.
  • Monitoring feedback gained via each YOC form received that is relevant to their care group.
  • Discussing and disseminating learning from concerns, YOC and compliments and implementing any identified policy and practice changes required to promote ongoing learning and improvement.

4.5 Patient advice and liaison coordinator

The role of the PALS coordinator is to :

  • Deal with low risk or minor complaints from the patient, family or carer and public enquiries and, or concerns. When required and with the complainants permission, liaise directly with the relevant service area to resolve the problem. Where a person is deemed to be at risk or requiring immediate support, the PALS Coordinator should escalate the concern to the relevant team for a response and access support from the Patent Safety and Investigation team.
  • Seek to acknowledge all queries or concerns by the next working day. If PALS is unable to resolve the query at this point, it will keep people informed of progress and set realistic timescales for resolution. (Note: ‘working day’ is defined as Monday- to Friday). Individuals raising concerns will be offered, wherever possible, an opportunity to discuss concerns in private, maintaining confidentiality as far as is reasonably practicable. (Any continued dissatisfaction expressed by service users should be referred to the head of patient safety).
  • Record all PALS contacts on Ulysses or Safeguard and manage the reporting of activity to the Performance team on a monthly basis and on an ad hoc basis to meet particular service needs as required.
  • Monitor content of the YOC forms and follow up any concerns that have been raised. Forward any applicable your opinion counts (YOC) forms to the relevant matron, deputy care group director service manager for information and action and record appropriately.
  • Operate within a local network with other PALS within the main geographical areas covered by the trust to maintain a seamless service for patients who move between and use different parts of the NHS for the care they need.
  • With the head of patient safety, identify themes and hotspots which highlight the need for training in specific areas.
  • Offer the patient carer or relative a choice to ensure that the right staff member is dealing with the concern.
  • Work closely with the Patient Safety and Investigation team and Patient and Public Engagement team in agreement with the complainant, to resolve complaints which might be more appropriately addressed via PALS.

4.6 Matrons or deputy care group directors or corporate heads of service or managers team or ward managers

  • Ensuring PALS literature and YOC forms are freely available taking into consideration diversity of client groups and needs relating to this.
  • Organising training with the relevant people, where the analysis of PALS data and feedback identifies training needs
  • Ensuring staff reassure patients, their relatives and carers that they will not be treated differently as a result of raising a concern or a complaint.
  • Responding to issues according to their urgency, and whenever possible, within 2 working days.
  • Monitoring information submitted in connection with written compliments received.
  • Reporting action taken in response to YOC forms to PALS.
  • Feeding back to staff compliments and acknowledgements of efforts which offer an opportunity to learn from and build on good practice and which can have a positive impact on staff morale and performance.

4.7 All staff

The delivery of an effective PALS service is the responsibility of all staff, so that information, advice, signposting and a willingness to deal with concerns is readily available for people, within their area of knowledge, responsibility and expertise.

4.8 The quality committee and care group quality meetings

The quality committee and care group quality meetings will enable the board of directors to obtain assurance that high standards of care are provided by the trust and, in particular, that adequate and appropriate governance structures, processes and controls are in place throughout the trust

This will include:

  • monitoring trends in concerns and complaints received by the trust and commissioning actions in response to adverse trends where appropriate
  • Identifying areas for improvement in respect of concerns and complaints trends and ensuring appropriate action is taken

5 Procedure or implementation

The PALS service is open to all those accessing RDaSH services.

PALS leaflets and your opinion counts forms should be freely available and visible in all clinical areas. Leaflets can be made available in other languages to suit individual needs and upon request.

See patient and carer information policy.

Whilst the following procedure relates to all staff, including the PALS coordinator, it is acknowledged that there will be limitations on the PALS coordinator with regard to clinical knowledge about specific conditions. This information should be provided to patients by clinical staff who, have a clearer understanding.

  • In clinical areas provide information to patients and carers, relating to the condition, treatment, care, medication, service provision and choices, including any undesired effects, using the approved information available to staff on the trust intranet. If the information requested is not found within these resources staff should contact the head of patient safety.
  • Where people raise concerns, a sincere apology should be offered to the person raising the concern. An apology does not constitute an admission of liability or unsatisfactory professional performance but provides acknowledgement of the concern.
  • Those raising a concern should also be signposted to local advocacy services and, or the independent complaints advocacy services (ICAS) which is a free service.
  • Attempt to resolve any concerns that have been raised or provide information as quickly as possible. However, it may be necessary for the concern to be referred to their manager or an identified senior member of the team for advice and resolution.
  • Deal with issues according to their urgency, and whenever possible, within 2 working days.
  • Ensure the individual raising the concern is kept informed of all progress made and is fully involved throughout the process. It is important that, wherever possible, when an individual raises a concern, a named member of staff deals with the concern through to its conclusion. This assists with the communication process and will facilitate understanding and develop trust. Should an unavoidable situation arise where a member of staff cannot see an issue through to its conclusion, full details must be passed on to an appropriate colleague. The individual raising the concern must be kept informed of the situation.

PALS is always an option for those requiring support and those raising a concern. Individuals should be made aware that they could at any time be supported by the PALS coordinator. This information can also be found in appendix B Flowchart.

Clinical areas should be mindful that when a person raises a concern, local resolution in the first instance can be beneficial for all concerned.

Staff experiencing difficulties resolving the more complex issues can also access support of their line manager or modern matron or service manager in the first instance. Patients and carers should be made fully aware that they are able to pursue a formal complaint at any time. It should be made clear to these individuals that PALS will not be able to assist with their concern whilst a formal complaint is being pursued, although PALS can support people through the complaints process.

Details of any written compliments received should be passed to the designated ‘nominated officer’ for the care group for recording.

5.1 Accessing PALS

  • PALS may normally be accessed Monday to Friday between 9am and 3pm, except Bank Holidays. However the service offered will also be flexible as far as is reasonably practicable to accommodate those who cannot access or make contact during these hours.
  • If a patient wishes to speak to the PALS coordinator outside of normal office hours, this will be organised by prior arrangement, where reasonably practicable.
  • An answer-machine is available 24 hours a day to take messages for PALS. Should contact be required, this will be made at the earliest opportunity.
  • The PALS coordinator and Patient Safety and Investigation team are based at Chestnut View, Woodfield Park, Tickhill Road, Balby, Doncaster, DN4 8QN.

The PALS Coordinator and Complaints Managers can be accessed by:

  • Your opinion counts (YOC) form. This form is available within all trust services. When completing the form, the service that is being commented upon is to be clearly recorded, and if a response is required, this should be clearly indicated on the form. This form should then be posted to the PALS office at Chestnut View, Woodfield Park, Tickhill Road, Balby, Doncaster, DN4 8QN.
  • Staff members
  • PALS from other trusts.
  • External organisations.

5.1.1 Letter

Letters should be addressed to:

The PALS Coordinator
Chestnut View
Woodfield Park
Tickhill Road
Balby
Doncaster
DN4 8QN

Calling in to the PALS office

The PALS Coordinator
Chestnut View
Woodfield Park
Tickhill Road
Balby
Doncaster
DN4 8QN

This should be done by prior arrangement to ensure that the PALS coordinator is available. A private meeting room facility can be made available. 

The PALS coordinator may visit patients at a place of their choice if they cannot, or do not wish to visit the PALS office. This must be by prior arrangement and subject to the requirements of the lone working policy.

Breastfeeding facilities can be made available when required.

The PALS coordinator, Patient Safety and Investigation team and the head of patient safety, recognise that occasionally complex issues may require immediate attention and support. However, PALS is not a crisis intervention service, nor are the PALS coordinator and complaints manager able to provide medical advice.

5.2 Supporting patients who raise concerns

Anyone raising a concern either in their own right, or on behalf of a patient, should be reassured that they will not be treated any differently as a result of raising a concern.

The best way to support the person is to provide them with accurate and timely information, and in order to minimise or prevent any feelings of discrimination, no documentation relating to the concern or any subsequent investigation is to be held on the patient’s clinical record.

In the event that the concern is about a member of staff involved in the care of a patient, consideration should be given by the Manager to the allocation of that patient’s care to another worker while the concern is investigated.

In the event of the person requiring religious or spiritual support, advice would be sought from the trust’s chaplaincy.

5.3 Confidentiality

The nature of PALS work means that it will be necessary to hold personal data. It is of paramount importance that all PALS staff maintain confidentiality as far as is reasonably practicable.

This means that PALS staff will not disclose, under normal circumstances in line with the Data Protection Act (2018), any information about patients or their representatives, or information about them to any unauthorised person without prior permission.

Particular care is needed to avoid unintentional breaches of confidence arising out of conversations with colleagues.

In order to adhere to the rules governing confidentiality, PALS staff must actively seek permission before divulging personal information.

See information governance policy and management framework (includes data protection policy content).

5.4 Storage of information

All PALS contacts reported to PALS are recorded and stored within a secure database managed and accessible by the patient advice and liaison and the Patient Safety and Investigation team.

5.5 What if PALS outcome does not fulfil expectations?

PALS will endeavour to reach a resolution in all cases. However, both the enquirer and PALS must accept that in cases when all possible identified options for resolution have been exhausted, it will be an appropriate juncture for PALS to close the matter or refer to a more appropriate body.

Where PALS staff are subjected to violent or abusive behaviour, appropriate action will be taken to protect staff and to take action against those who abuse or attempt to abuse them, which may include the withdrawal of the PALS service.

Where the PALS service is withdrawn, other sources of assistance, where required will be explored.

See reducing restrictive interventions (RRI) policy (formerly PMVA policy).

5.6 Procedure for responding to web postings

People are more often using the internet or web and social media as a way to communicate and feedback about their experiences (both positive and negative) of health and social care. These include the trust’s, Twitter and Facebook pages, NHS Choices and other patient opinion websites.

Such postings can be anonymous; to protect the identity of the person, but some can be through direct messaging (private) via Facebook and X formally Twitter where their X and Facebook identity is displayed. Alternatively to their followers on X or Facebook groups and even within the public domain.

The trust treats all postings and opinions in the same way as in a written letter or telephone call regardless of the communication method used and responds to each, according to the agreed procedures.

The Communications team monitor the trust’s Twitter and Facebook accounts between 9am and 5pm Monday to Friday and will forward messages through the most relevant team for advice and appropriate response.

The PALS coordinator is notified by the trust’s Communications team of any messages on the trust’s social media accounts related to patient care or complaints or compliments. External websites including NHS choices and other patient opinion digital platforms are managed and monitored by the PALS team.

The PALS coordinator will offer an initial response to the posting which may include an apology for any distress that may have been caused. This will then either be forwarded to Communications team to post the reply on social media or PALS will respond directly to other sites such as NHS choices.

The appropriate director or deputy care group directors or corporate heads of service or service managers will be notified and asked to offer a further response where required.

See procedure for patient opinion postings.

5.7 How the trust makes improvements as a result of a concern

The trust systems for the monitoring and analysis of complaints and concerns will help to facilitate organisational learning and the information will be used to improve services and care available to patients.

PALS, YOC, complaints, incidents, claims data and compliments are examined through the) to allow trends to be identified and improvements implemented. This can lead to the prevention or recurrence of incidents and concerns. The sharing of lessons learned from one service to other areas of the trust will allow for any system failures discovered during investigation to be adopted by the trust as a whole and prevent pockets of good practice from being isolated.

In addition, the sharing of compliments received about services are collated and analysed thematically in order to share good practice. Compliments and acknowledgements of efforts offer an opportunity to learn from and build on good practice and can have a positive impact on staff morale and performance. Therefore, it is important that the Trust has a robust system in place for reporting written compliments, which includes a process for the feedback of positive comments to staff (See appendix A).

  • Training will be organised where the analysis of complaints data identifies a need.
  • The trust is committed to undertaking this activity in a regular and systematic way to facilitate ongoing improvement through organisational learning.

6 Training implications

Within the trust induction programme, all staff commencing employment with the trust are given information regarding the functions of the Patient Advice and Complaints team, which includes information about PALS and the role of staff in the delivery of PALS.

7 Monitoring arrangements

7.1 Duties, how the trust listens and responds to concerns and complaints from patients, their relatives and carers

  • How: Patient experience report.
  • Who by: Head of patient engagement and experience.
  • Reported to: Quality committee.
  • Frequency: Annually.

7.2 How the trust makes sure that patients, their relatives and carers are not treated differently as a result of raising a concern or a complaint

  • How: Complaints report.
  • Who by: Head of patient safety.
  • Reported to: Quality committee.
  • Frequency: Montly.

7.3 How the trust makes improvements as a result of a concern or a complaint

  • How: Quality improvement report.
  • Who by: Head of patient engagement and experience.
  • Reported to: Quality committee.
  • Frequency: Annually.

8 Equality impact assessment screening

To download the equality impact assessment associated with this policy please follow the link: Equality impact assessment.

8.1 Privacy, dignity and respect

The NHS Constitution states that all patients should feel that their privacy and dignity are respected while they are in hospital. High Quality Care for All (2008), Lord Darzi’s review of the NHS, identifies the need to organise care around the individual, ‘not just clinically but in terms of dignity and respect’.

As a consequence the trust is required to articulate its intent to deliver care with privacy and dignity that treats all service users with respect. Therefore, all procedural documents will be considered, if relevant, to reflect the requirement to treat everyone with privacy, dignity and respect, (when appropriate this should also include how same sex accommodation is provided).

8.1.1 How this will be met

There are no additional requirements in relation to privacy, dignity and respect.

8.2 Mental Capacity Act

Central to any aspect of care delivered to adults and young people aged 16 years or over will be the consideration of the individual’s capacity to participate in the decision making process. Consequently, no intervention should be carried out without either the individual’s informed consent, or the powers included in a legal framework, or by order of the court.

Therefore, the trust is required to make sure that all staff working with individuals who use our service are familiar with the provisions within the Mental Capacity Act (2005). For this reason all procedural documents will be considered, if relevant to reflect the provisions of the Mental Capacity Act (2005)to ensure that the interests of an individual whose capacity is in question can continue to make as many decisions themselves as possible.

8.2.1 How this will be met

All individuals involved in the implementation of this policy should do so in accordance with the guiding principles of the Mental Capacity Act (2005) (section 1).

9 Links to any other associated documents

10 References

  • Data Protection Act 1998
  • Department of Health (2000) The NHS Plan A plan for investment. A plan for reform
  • Department of Health (1997) Caldicott Report
  • Department of Health (2007) Making Experiences Count
  • The Local Authority Social Services and National Health Service Complaints (England) Regulations 2009

11 Appendices

11.1 Appendix A Process relating to the reporting of written compliments

11.1.1 Introduction

Compliments and acknowledgements of efforts offer an opportunity to learn from and build on good practice and can have a positive impact on staff morale and performance. It is important therefore that the trust has a robust system in place for reporting written compliments, which includes a process by which positive comments are fed back to staff.

11.1.2 Definition of a written compliment

A compliment can be recorded if it is:

  • written in the form of a letter
  • written in the form of an email
  • written on a thank you or birthday or Christmas card

A compliment cannot be recorded if it is:

  • a gift, unless it is accompanied by a written compliment as detailed above
  • a donation, unless it is accompanied by a written compliment as detailed above
  • a verbal compliment

If you are unsure whether a compliment can be recorded, please contact the PALS coordinator on 0800 015 4334 for guidance.

11.1.3 Process

  1. A written compliment is received by a member of staff.
  2. Notification of and, or details of the compliment should be passed to the ‘nominated officer’ within their care group. A ‘nominated officer’ is someone who has been designated to manage information in connection with compliments received for their own care group by the relevant care group director. (Note that in some care groups, more than one ‘nominated officer’ has been appointed).
  3. The ‘nominated officer’ inputs information into a spreadsheet on the shared L drive to reflect the number and nature of compliments received for each service area covered within their care group and is responsible for keeping this up to date (note that care group directors and some identified managers also have access to the relevant spreadsheet in order that they can monitor information that is submitted).
  4. The PALS coordinator (who has access to each of the spreadsheets on the K drive) will send an email to all ‘nominated officers’ at the beginning of every month advising them of a deadline date when their spreadsheet will need to be fully completed to reflect compliments received within the month that has just passed. The deadline date will usually be the tenth working day into the month that has just commenced but this may vary depending on reporting requirements.
  5. ‘Nominated officers’ will ensure that the spreadsheet is up to date before the deadline date that has been set by the PALS coordinator.
  6. The PALS coordinator will review the information held within each of the spreadsheets immediately after the deadline date has passed and include this within routine monthly reporting to the Performance team.
  7. Care groups should develop their own mechanisms for ensuring that positive feedback is shared with staff accordingly.

11.2 Appendix B PALS process flowchart

  1. Person requires support or raises a concern.
  2. Speak directly with the clinical team for local resolution or contact PALS directly by telephone e-mail or letter. The person should be made aware of the PALS and complaints process and their entitlement t an independent advocate.
  3. If the problem is not resolved, the person should be asked if they wold like to make a formal complaint and e provided with information relating to the complaints process leading to a formal complaint (see listening and responding to concerns and complaints policy (formally complaints handling policy)).
  4. The formal complaint is referred to the Patient Safety and Investigation team for allocation and information is provided about the complaints process and the person’s right to and advocate and the process for referring their case to the health ombudsman

Document control

  • Version: 6.4.
  • Unique reference number: 316.
  • Ratified by: Corporate policy approval group.
  • Date ratified: 05 March 2024.
  • Name of originator or author: Head of patient safety.
  • Name of responsible individual: Corporate policy approval group.
  • Date Issued: 11 March 2024 (extension).
  • Review date: 31 July 2024.
  • Target audience: All staff.

Page last reviewed: March 12, 2024
Next review due: March 12, 2025

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