Listening and responding to concerns and complaints policy (formally complaints handling policy)

1 Introduction

Rotherham, Doncaster and South Humber NHS Foundation Trust (thereafter referred to as the trust) places a high priority upon the handling of complaints and aims to promote a culture in which all forms of feedback are listened to and acted upon in order to learn lessons and implement improvements to services.

The trust is committed to ensuring that concerns raised by people using its services, their carers and families are acknowledged and dealt with fairly, effectively and as soon as possible. The trust will identify learning opportunities from the findings of our investigations and from those directly involved in the complaint. No one should be inhibited or disadvantaged when making a complaint and that anyone making a complaint will be treated fairly and equally.

In dealing with complaints made against members of staff the trust will adopt a supportive and “just culture” approach and will not seek to blame individuals involved in complaints unless negligence, malpractice or other misconduct is proven.

This complaints policy outlines the process by which complaints will be handled and that procedures are in place to address the issues and concerns raised, with the aim of achieving early resolution where possible, and to deal with formal complaints where this has not been possible.

The trust will also work in line with the PHSO National NHS Complaint Standards updated 2022. The Complaint Standards set out a single vision for staff and NHS service users (and people who support them) of what is expected when a complaint is raised. This will help make sure everyone experiences a culture that seeks out learning from complaints, and meets the outcomes also set out by the PHSO.

A key priority for the trust is to adopt the four ‘living principles’ of the NHS Standards (2022) which are:

promoting a learning culture
welcoming complaints in a positive way
being thorough and fair
giving fair and accountable responses

Compliance with this policy and procedure is mandatory for all trust staff.

It should be read along side ombudsman complaint handling guidance (opens in new window).

2 Purpose

It’s good to talk, proactive patient engagement helps resolve concerns and improve services.
Embraces complaints, key to developing and shaping services.
Understanding complaints, adopting a just and learning culture.

The trust has adopted the “my expectations for raising concerns and complaints,” report, a user led ‘vision’ of the complaints system developed by the PHSO and Healthwatch England following the Francis report (2013) on mid Staffordshire and the Clwyd-Hart review (2013) into the NHS complaints system.

The vision lays out a series of ‘I statements’ describing what good outcomes for patients and service users look like if complaints are handled well.

I felt confident to speak up.
I felt that making my complaint was simple.
I felt listened to and understood.
I felt that my complaint made a difference.
I would feel confident making a complaint in future.

Ombudsman report, my expectations for raising concerns and complaints (opens in new window).

Ombudsman report, my expectations for raising concerns and complaints easy read format (opens in new window).

This policy aims to ensure that:

all complaints are well managed as quickly as possible and in accordance with national assurance frameworks
patients, their families and carers feel listened to
staff are empowered to deal with complaints as they arise in an open and non defensive way
the learning from complaints is identified and used for service development and improvement
the complaints service is accessible, well publicised, open and transparent
the complaints procedure is supportive for those who find it difficult to complain
young people, adults with a learning disability, autism or their care, are able to access the complaints system

This policy has been developed and is in line with the Local Authority Social Services (LASS) and the NHS Complaints (England) Regulations 2009

The purpose of the policy is to ensure that the trust complies comply with the Parliamentary and Health Service Ombudsman (PHSO, 2009, updated 2022) and principles of good complaint handling (see appendix A), these include:

all complaints are well managed as quickly as possible and in a sensitive manner
staff are empowered to deal with complaints as they arise in an open and non defensive way
responses are open and transparent
the trust seeks continuous improvement arising from feedback
complainants are kept informed of the progress and outcome of the investigation
staff involved in complaints are given support
action to rectify the cause of complaint is identified, implemented and evaluated
meaningful apologies are offered as appropriate

3 Scope

This policy covers all activities of the trust and is appropriate to all colleagues including temporary staff.

Issues which cannot be dealt with under this procedure are:

a complaint made by an employee of the trust about any matter relating to their employment.
a complaint made by an NHS or local authority social care body which relates to the exercise of its functions by another NHS or local authority social care body
a complaint which has previously been investigated under these or previous regulations
a complaint which is the same issue as a complaint that has previously been made and was resolved
a complaint that has been or is being investigated under the previous complaints regulations, or by the parliamentary health service ombudsman
a complaint arising out of the trust’s alleged failure to comply with a data subject request under the Data Protection Act 1998 or a request for information under the Freedom of Information Act 2000

4 Definition

A complaint is ‘an expression of dissatisfaction received from a patient, carer, family or a patient representative. A complaint can be made via any communication route including written, via email, in person or over the telephone. Complaints require a formal response from the trust.

A concern is an issue which may require further enquiry, advice or information in order to resolve them. These are best dealt with by the patient advice and liaison service (PALS) and, or the service in which the concern originated. When a concern is raised which cannot be satisfactorily resolved without an investigation, then it is to be processed.

It is however sometimes difficult to clearly differentiate between a concern and a complaint and must therefore be considered on a continuum.

5 Responsibilities, accountabilities and duties

5.1 Chief executive

The chief executive has ultimate overall responsibility for complaints.

5.2 Executive director of nursing and allied health professionals (AHP)

The executive director of nursing and allied health professionals (AHP) is the nominated board member with responsibility for compliance with the arrangements made under the complaints regulations and the monitor compliance framework requirement to report serious complaints to NHS improvement, and for taking any required action as a result.

5.3 Director of quality, safety and improvement

Director of quality safety and improvement is responsible for:

informing the executive director of nursing and AHP of any serious complaints and significant trends in complaints, in order that these may be reported accordingly
reporting on performance and any matters for escalation to the quality committee
providing information, advice, and support to distressed members of the public or patients or carers where large scale failures of services have occurred
monitoring compliance with statutory responsibilities and regulators

5.4 Deputy director for organisational learning, patient safety and inquests

Deputy director for organisational learning, patient safety and inquests is responsible for:

advising the relevant care group director, and director of quality safety and improvement or deputy director of nursing of any directorate or corporate risks which need to be on the relevant directorate risk register (see the trust risk management framework for further guidance
escalating any delays with care group leaders and matrons to support the timely response to complaints according to this policy
informing the director of quality safety and improvement of any serious complaints and significant trends in complaints, in order that these may be reported accordingly
monitoring that the procedures are followed in practice and review the procedures as and when required
approving draft investigation response letters prior to submission to the chief executive

5.5 Head of complaints

Head of complaints has the responsibility to:

manage the procedures for handling and considering complaints in accordance with the arrangements under the regulations
monitor complaint action plans, ensures completion and reports progress to the deputy director
ensure that clear and accessible information about the complaints procedure is widely available for service users and carers. This will include how people can contact the parliamentary health services ombudsman and the care quality commission. Telephone and email contact details will be included in the trust’s complaints leaflet which will be made widely available throughout the trust
identifies and collates learning to promote ongoing improvement and organisational learning
monitor the live tracker and escalate weekly to the deputy director when complaints are outside of the agreed response times and reasons
review and monitor trends in complaints and escalates to the deputy director any areas of concern
provide a monthly thematic report, highlighting any trends and emerging themes for the deputy director
ensure that systems are in place so that patients, their relatives, and carer are not treated differently as a result of raising a concern or a complaint
escalate any comments or complaints received which describe events considered to be patient safety events to the deputy director or head of investigations
ensure that all complaints are fully investigated and adhere to the required timeframes
undertake complaints Investigations as required
ensure that information is provided for the complaints Investigation team dashboard
provide learning reports for inclusion in the clinical learning briefs
ensure that when complaints involve doctors in training that information is provided to the director and deputy directors of postgraduate medical education

5.6 Complaints investigation team

Complaints Investigation team will:

undertake an initial conversation with the complainant to inform the best course of action and deal with any matters which can be resolved locally
manage the live tracker showing how many complaints are live in the system at one time
provide support and expertise in complaints handling to the care groups within the trust and be readily identifiable to matrons, and in some complex cases to complainants
advise care groups and complainants of the complaints process, including advocacy services available in their area where appropriate
work in partnership with advocacy groups and services representing complainants, to promote equality of access to the complaints process. It is recognised that advocacy is extremely important to service users
works with care groups where consent is required to respond to a complaint, in the absence of or where consent is required, an investigation will undertaken whilst consent is being secured
provides feedback to care groups on the outcome of investigations
work with specialist team leaders or subject matter experts for topic specific complaints, for example, tissue viability, continence, and infection prevention and control

5.7 Care group directors of nursing

Care group directors of nursing will:

oversee the complaints handling process within their service area
aim to provide an early local resolution if appropriate
review each complaint and feedback to the complaints investigator
ensure operational managers are aware of their responsibilities within this document, know where to find this procedure on the trust intranet site, and have the resources to implement this procedure
ensure that all questions raised receive a sufficient and appropriate response by care group staff
ensure that operational managers provide responses to the complaint within the given timescales
ensure that learning takes place as a result of feedback within their service area
ensure that operational managers complete the action plans, where appropriate, and inform the complaints team when actions are completed
work with the complaint Investigators to ensure that complaints made about staff are managed in line with just culture principles. provide support to staff

5.8 Operational managers

Operational managers will:

ensure that no barriers, perceived or real, are presented to individuals
wishing to make a complaint
ensure that notices are displayed in all public areas advising patients, their friends, carers, and the general public how to complain
ensure that contact information for the patient advice and liaison
service (PALS) is included in all patient information leaflets
where a concern cannot be resolved by the service, escalate to PALS or formal complaint as required
provide responses within required timeframes
ensure that, where the complaint concerns a member of staff, the member of staff is kept informed, supported, and supplied with a copy of the final response
ensure that when a complaint is linked to a patient safety event that this is escalated to the Incident Investigation team.
implement and monitor actions relating to lessons learnt from a complaint, within agreed timescales, to improve the quality of services for patients, their families, friends, and carers
make reasonable adjustments related to a disability for those requiring language interpretation or translation

5.9 PALS coordinator

PALS coordinator (see patient advice and liaison service (PALS) policy) is available to discuss any comments and concerns with service users and is also able to provide a range of information on associated support services. However, the PALS should only be utilised for quick resolution of concerns. Any continued dissatisfaction expressed by service users should be referred to the Complaints team.

The trust works with the principle that the earlier the concern is mutually resolved the less need there would be to progress to a complaint, claim or litigation.

The PALS coordinator will with the agreement of the complainant, work closely with the care group to resolve complaints which might be more appropriately addressed via PALS.

5.9.1 How to access PALS

By telephone on 0800 015 4334 during normal office hours, Monday to Friday (excluding public bank holidays). Your telephone call will be free from a BT landline. Please note, telephone calls from other networks, for example, a mobile telephone, may be charged. If patients inform us that they are calling from a mobile telephone, we can return their call directly.

In writing to the following address:

Patient Advice and Liaison Service
Rotherham, Doncaster and South Humber NHS Foundation Trust
Chestnut View
Cherry Tree Way
Tickhill Road
Balby
Doncaster
DN4 8QN

Email:  rdash.pals@nhs.net

6 Complaints procedure

A guide to the management of complaints is provided in appendix A and B.

6.1 Who can complain

Any person may make a complaint if they have received or are receiving care and services from the trust.

A complaint can also be made by someone acting on behalf of the person or who:

is a child (the trust must be satisfied that there are reasonable grounds for the complaint being made by a representative instead of by the child, for example, the capacity of the child)
is unable to make the complaint themselves because of physical incapacity or lack of capacity within the meaning of the Mental Capacity Act 2005
the person has died
has requested the representative to act on their behalf

If the trust is satisfied that a representative is not conducting the complaint in the best interests of a child or a person that lacks capacity, then the trust must not consider the complaint and will inform the representative of the reason for this decision.

6.2 How can someone complain

6.2.1 How?

Complaints can be made in a number of ways that are convenient to the complainant. Staff within the trust are empowered to use a range of methods to resolve complaints and are trained to respond to a complaint with confidence and to take immediate action where required.

Every assistance will be given for those with specialist needs (for example, interpreting services) to accommodate all those who may wish to raise a concern. All complainants should be treated fairly regardless of race, age, gender, disability, sexual orientation or religious views.

6.2.2 Support in providing feedback or making a complaint

Making a complaint can be stressful and many people who might wish to complain do not because they do not know how to do so or they find the process too intimidating. The trust therefore loses valuable feedback from its patients.

Complainants must receive a clear message that they will not be disadvantaged or adversely affected, either directly or indirectly because they have raised a concern or complain.

The Complaints team will support people who wish to raise issues. Support will continue to be provided through the complaints investigator who will maintain contact with the complainant during the investigation and will support at the point of feedback. Signposting may also be done to other support organisations.

Staff raising concerns will be supported to share and speak up.

The complaints team can help those individuals with specific needs, for example, literacy, interpreting services, to enable everyone who wishes to give feedback to be able to do so.

6.3 Consent

In accordance with the Data Protection Act and Caldicott principles, any service user having capacity will be asked to provide consent before their records are accessed to investigate a complainant.

6.3.1 Relative, carer or representative

If a carer or relative or representative (including advocacy organisations or solicitors) submits a complaint on behalf of a patient written consent is required. A consent form for the release of confidential information will be sent with the acknowledgement, which should include information regarding patient confidentiality.

Advocacy organisations or solicitors complaining on behalf of patient are expected to have obtained the written consent before submitting the complaint.

If the patient does not have capacity to give consent. In that case, a representative who makes a complaint on behalf of a person who lacks capacity within the meaning of the Mental Capacity Act 2005, can be accepted as the patient’s representative by the trust, provided that the trust is satisfied that the representative is conducting the complaint in the best interests of the person on whose behalf the complaint is made. The representative can be, for example, a family member, friend, solicitor or advocate or member of the care quality commission (CQC).

If consent is not received to proceed the investigation within 30 working days of the complaint being logged, the complaint will be closed and the complainant will be informed accordingly. Concerns however may be investigated outside of the complaints process if indicated.

6.3.2 Complaint received via an MP

If a complainant has approached their MP who then submits a complaint on their behalf, implied consent is assumed and written consent is not required. Members of Parliament (MP) are considered to have the consent of the patient when pursuing complaints on their behalf (Data Protection Act 1998, Processing Sensitive Personal Data, Elective Representatives Order 2002).

6.3.3 Children

If the complaint is regarding a child, dependant on the age of the child, discussion to be held with the care group or clinical team leader or service manager involved with the young person. If the young person is unable to give consent the lead investigator should seek guidance from the Caldicott guardian.

6.3.4 Deceased patients

Where the patient is deceased, ensure the complainant is the lawfully entitled personal representative of the patient. If the death is to go to the coroner please contact the deputy director in the first instance. If not seek guidance from the Caldicott guardian and information governance manager if this is not clear.

Advocacy organisations provide a useful service in assisting patients, service users, relatives and carers to make a complaint, especially where a complainant is unable to make, or is disadvantaged in being able to make a complaint personally.

6.3.5 Complaints received from the care quality commission

The trust has a point of contact for CQC concerns or enquiries. Any complaints received will be reviewed and undertaken as part of the complaints response. However if concerns are raised consideration will be given as to whether there is a need to escalate to an investigation under the patient safety incident response framework (PSIRF).

When requested to do so, the trust will provide CQC with a summary of complaints, responses and other related correspondence or information.

6.4 Confidentiality

Patient confidentiality must be maintained and security of data relating to individuals must be protected in accordance with the General Data Protection Regulation (2018). No confidential information relating to complaints will be disclosed to any third party unless the trust has the complainant‘s consent or some other lawful authority to do so.

7 Types of complaints

7.1 Complaints of a serious nature

At times the trust may receive a complaint which raises serious concerns about patient safety and may require urgent action or escalation. Enquires should be made to clarify if an Incident form has been completed and whether an Incident review will be undertaken.

The incident review will take precedent and the complaint will be closed. The complaints investigator will communicate with the complainant to explain how the findings of the review will be fed back to the complainant.

7.2 Complaints and disciplinary investigations

Following the investigation of the complaint, if any issues of a disciplinary nature need to be considered, this will be carried out in accordance with the trust’s disciplinary policy. This policy will only be concerned with resolving the complaint, not with investigatory disciplinary issues.

If the centre of the complaint relates to a staff member from an agency the lead investigator should communicate with the human resources department for further advice.

Any member of staff involved in a complaint should be fully informed of any allegations at the outset and given an opportunity to reply to the investigating officer. They will be advised that they may seek the assistance of their professional association or trade union.

7.3 Legal cases and potential litigation

In its investigations, the trust should ensure they do not prejudice police enquiries or court proceedings.

On receipt of a complaint where legal action is being taken, or the police are

Involved or investigating, the government expects discussions to take place with the relevant authority (legal advisors, police), to determine whether progressing the complaint might prejudice subsequent legal or judicial action. If so, the complaint will be put on hold, and the complainant will be advised of this. If not, an investigation into the complaint should commence.

When there is a concurrent investigation, for example, legal or disciplinary proceeding or other statuary body, the trust will consider how the complaint should be handled and will only proceed where it believes that its investigation would not compromise or prejudice the concurrent investigation.

If, throughout the above process, a complainant indicates either in writing or verbally that they intend to take legal action or there are concerns that the complaint may lead to litigation this will be escalated to the deputy director and advice can be sought from the trust’s legal advisors.

7.4 Suspicions of fraud

When a complaint is received and there are suspicions of fraud this must be dealt with in line with the counter fraud, bribery and corruption policy, the trust’s counter fraud specialist or the director of finance should be contacted prior to any investigation commencing.

7.5 Complaints and safeguarding

In respect of allegations relating to the ill treatment of service users, this policy must be followed in line with other relevant policies including Safeguarding adults policy and the procedure for managing allegations against people in positions of trust (PIPOT).

Allegations may come from service users themselves, their relatives and members of staff or outside agencies.

If, concerns are raised with regard to an adult at risk or relating to risks to a child advice should be sought from the trust safeguarding team.

If the complaint relates to a member of staff the chief executive, executive director of nursing and AHP and, or the executive medical director must be made aware of all allegations of ill treatment. The chief executive, together with the executive director of nursing and AHP or executive medical director will determine next steps which may include an immediate initial investigation to establish the nature and gravity of the complaint and to determine if any immediate action is required to safeguard the interests of the service users and to facilitate further enquiries.

The chief executive and executive director of nursing and AHP or executive medical director may decide that no further action is required. If, however, it appears that a criminal offence may have been committed, a report will be made to the police.

Care should be taken to support staff who make allegations of ill-treatment and who have allegations made against them, and they should be advised who to contact if they have further concerns or worries.

When staff are required to attend a fact-finding enquiry, they are entitled to be accompanied by a trade union representative if they so wish.

7.6 Police involvement

Following a complaint or investigation of a complaint, if it appears or is alleged that a criminal offence may have been committed, the matter should be reported immediately to the chief executive or executive director of nursing and AHP’s or executive medical director to advise on whether the police and If it is determined that police involvement is necessary who that will be undertaken by.

If the allegation is withdrawn, the chief executive or executive director of nursing and AHP’s or executive medical director will consider the circumstances and decide on what action should be taken.

7.7 Complaints raised through social media

Social media is monitored by the communications department and any complaints raised will be referred to the Complaints team who will process or liaise with the person raising the complaint.

7.8 Joint NHS and multi agency complaints

In the event of a complex complaint, for example where the complaint relates to a number of different NHS services or organisations, there is a statutory duty of collaboration on the agencies to provide a coordinated response. There will be an initial discussion between agencies and one agency will be identified to lead the response. If there are valid reasons why this may not be possible, for example, if it will unduly delay the response, the complainant should be informed, and it is their decision whether they have a joint or separate response. There will be a discussion and agreement with the head of complaints and the deputy director.

If the complaint is received by the trust, the complainant’s consent must be sought before forwarding the complaint to other organisation(s).

See appendix G and H, protocol for handling NHS or social services inter-agency complaints.

7.9 Complaints and executive

7.9.1 Where the chief executive is named in a complaint

The chairperson of the trust will be informed, who will determine if external support or advice is appropriate to aid investigation of the complaint. If external support is not deemed to be required, the chairperson will delegate an appropriate lead director to coordinate the investigation.

7.9.2 Where a director is named in a complaint

The chief executive will be informed, who will delegate an appropriate lead director to coordinate the investigation.

7.9.3 Where the medical director is named in a complaint

The chief executive will be informed, who will determine if external support or advice is appropriate to aid investigation of the complaint. If external support is not deemed to be required, the trust’s deputy chief executive will lead the investigation, with appropriate medical advice.

Depending on the nature of the complaint and the wishes of the complainant, the complaint may be dealt with directly and without the need for a written response, via PALS. This will ensure prompt and appropriate action and help to resolve the complaint at a truly local level.

Complaints will be investigated appropriately in line with the ethos and procedures set out within the policy and within the timescale agreed with the complainant wherever possible. If an investigation cannot be completed on time, direct contact will be made with the complainant as soon as this is apparent, an apology provided, and an extension period agreed and confirmed in writing.

7.10 Discriminatory complaints

Complaints may be made against an individual because of their colour, sexuality, gender, race, ethnic origin, religion or age. The trust will identify any complaint which amounts to harassment or abuse and the head of complaints will discuss any possible discriminatory complaints with the deputy director and determine whether the complaint should be progressed through the complaints process.

Where a complaint contains discriminatory language, but does raise some legitimate issues about clinical practice, procedures and communication, these will be reviewed using the complaints process, without prejudice to the outcome of the review. However the complainant will be advised that discriminatory language will not be tolerated.

7.11 Habitual, or unreasonable complainants

There will be occasions when the motive for the complaint is vexatious or malicious. Complainants may also become habitual complainers.

In determining arrangements for handling such complainants staff should identify the stage at which a complainant has become unreasonably persistent but also recognise that even persistent complainants may have issues which contain some substance. The need to ensure an equitable approach and to provide an open and honest response is, therefore, crucial.

Making judgements as to the validity or not of a complaint requires careful assessment and it is important to ensure that no material element of the complaint is overlooked,

It is also important that the fundamental right of a service user to make a complaint is preserved and not compromised.

See appendix F.

8 Responding to complaints

Staff are encouraged to resolve complaints as far as is practically possible within their local service area. Where this is possible the trust will formally record details of discussions held and actions agreed with the person raising the concerns.

The trust will ensure that staff are equipped and empowered to act decisively to resolve complaints.

Complaints and concerns are discussed at the trust daily Incident meetings and if indicated in the weekly patient safety huddle. This ensures that early learning cane be identified.

8.1 Formal complaints, stage 1 local resolution

Where local resolution is not possible, support should be given to the complainant to raise their concerns. Each complaint will be treated according to its individual nature and the wishes of the complainant, reinforcing the ethos of ensuring that the whole experience of making a complaint is simpler, more user-friendly, and far more responsive to people’s individual needs. The complainant will be advised if the trust cannot meet their wishes.

If, after approaching a member of staff to discuss a concern the complainant. remains unsatisfied and wants to raise a formal complaint, the staff member will provide details of the PALS and the Complaints team and if appropriate offer to record and submit the concerns on behalf of the complainant.

If a complaint is received a lead investigator will be appointed and will undertake an investigation.

When the investigation is complete, the lead investigator will submit a report of their findings, recommendations, full draft response and an action plan based on the recommendations, identifying areas for improvement where relevant and how this will be achieved to the care group director or executive medical director or executive director of nursing and AHP. The final response will be approved by the chief executive (or if relating to the chief executive, by the chair).

8.2 Formal complaints, stage 2 referral to the parliamentary health service ombudsman (PHSO)

If a complainant remains dissatisfied and the trust believes it has taken all reasonable steps to resolve the complaint, the complainant should be advised of their right to refer their complaint to the parliamentary health service ombudsman. Information on how to make a complaint to the PHSO is included in the complaint response letter.

9 Timeframes for responding to complaints and concerns

9.1 Reporting

The local authority social services and National Health Service Complaints (England) Regulations 2009 stipulate that a complaint should normally be made within 12 months of the event or within 12 months of the complainant becoming aware of a cause for complaint.

Discretion may be used to investigate complaints that fall outside these timescales if the complainant has good reasons for not making the complaint within this time limit and it would still be possible to investigate the complaint effectively and fairly.

The complaints administrator will discuss this with the relevant director or deputy director before rejecting any complaint that falls outside of this time period.

9.2 Timescales for completion

The trust will attempt to resolve concerns and complaints at the first point of contact and all staff are responsible for making reasonable attempts to do so. Where the complaint requires investigation, it will be escalated to a dedicated investigator.

9.3 acknowledgement

All complaints must be acknowledged within 3 working days which is the responsibility of the Complaints team.

9.4 Contact with the complainant

Contact will be made with the complainant within 7 working days.

9.5 Investigation timeframes

The maximum timeframes for response to a concern or complaint from the date of receipt is:

local resolution (PALS), 10 days
MP concerns, 10 days
formal complaint, 30 days
formal complaint, complex, 60 days

However a reasonable timescale for responding to the complaint will be agreed with the complainant by the investigator. The aim will be to complete Investigations within the trust target 30 working days which will depend on the complexity of the complaint.

In those cases which are more complex or where staff integral to the complaint are for example, on annual leave or absent due to illness, the response times will again be discussed and agreed with the complainant and a longer timescale will be provided on an individual basis but will be no later than six months from receipt of the complaint.

The response time may be paused in specific circumstances. These may include:

when information is being awaited from the complainant and there are delays in obtaining this
where key members of staff are on leave or have left the trust and will need to be contacted as part of the investigation
if disciplinary proceedings are taking place and a request has been made to halt the complaints process
when safeguarding or other investigations are taking place and the process may need to be delayed
where the timeliness of a response may be deemed insensitive or inappropriate, for example, over Christmas period or a significant anniversary

The local authority social services and NHS Complaints (Regulations) 2009 removed statutory timescales in responding to complaints. The timescale for resolution will be dependent upon the severity and complexity of the complaint. This will be assessed by the head of complaints taking advice from the care group director or deputy director of organisational learning, patient safety and inquests.

10 Receiving and storing complaints

When a complaint is received a file relating to the complaint and subsequent investigation will be opened on the L Drive. Complaint information should never be recorded in the clinical record. A complaint may be unfounded or involve third parties and the inclusion of that information in the clinical record will mean that the information will be preserved for the life of the record and could cause detrimental prejudice to the relationship between the patient and the healthcare team.

The Complaints team is responsible for keeping a copy of all documentation and correspondence relating to the complaint on the trust’s shared drive. Complaint files are disclosable should a legal claim be made to the trust following the outcome of a complaint. Complaint files will also be shared with the parliamentary health service ombudsman on request.

Complaint files will be kept for 10 years from completion of action before being destroyed in accordance with the Records Management Code of Practice for Health and Social Care 2016.

11 Training and other resource implications

All staff should be made aware of the complaints policy by their managers as part of local induction.

All staff must be made familiar with local complaints handling practices.

This will include details of how service users and, or their families or representative can make complaints and to whom, the process for complaints about areas of potential risk and those that constitute serious incidents.

All complaints Investigators must undertake identified complaints training.

The training needs analysis (TNA) for this policy can be found in the training needs analysis document which is part of the trust’s mandatory and statutory training policy located under policy section of the trust website.

As a trust policy, all staff need to be aware of the key points that the policy covers. Staff can be made aware through a variety of means such as:

all user emails for urgent messages
one to one meetings or supervision
continuous professional development sessions
posters
daily email (sent Monday to Friday)
practice development days
group supervision
special meetings
intranet
team meetings
local induction

12 Audit and monitoring

Review themes and trends in complaint reporting.

Monitor compliance with action plans arising from complaint investigations and seek assurance of risk mitigation for any actions not achieved in the agreed time frame.

Provide assurance to the board of directors in relation to complaint management, sharing of lessons learnt, and action taken to mitigate any identified risks.

12.1 Progress against complaints received, including stages of progress and timescales for responses

How: Report.
Who by: Head of complaints.
Reported to: Deputy director of organisational learning, patient safety and inquests.
Frequency: Weekly.

12.2 Number of complaints acknowledgements response times categories and themes

How: Patient safety report.
Who by: Deputy director of organisational learning, patient safety and inquests.
Reported to: Safety and quality committee.
Frequency: Bi-monthly.

12.3 Number of complaints acknowledgements response times categories and themes

How: Complaints dashboard.
Who by: Head of complaints.
Reported to: Care group quality meetings.
Frequency: Monthly.

12.4 How the trust listens and responds to concerns and complaints

How: Patients safety report.
Who by: Head of complaints.
Reported to: Safety and quality committee.
Frequency: Bi-monthly.

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

How: Individual complaints action plans, patient safety report, clinical learning brief.
Who by: Deputy director organisational, learning, patient safety and inquests or head of complaints.
Reported to: Care group quality meetings.
Frequency: Bi-monthly or monthly.

Complaints performance data and learnings identified from complaints are reported in the Patient Safety report.

An annual complaints report is produced and published on the trust website in accordance with legislation.

Risks arising from complaints will be escalated and reviewed in accordance with the risk management process.

13 Learning and analysis

The trust strongly believes that Information from concerns and complaints are key to improving the quality of care, treatment, services and facilities provided by the trust.

Complaints and concerns will be discussed at the daily Incident meeting and if indicated the weekly patient safety huddle.

On a weekly basis the complaints manager will provide the deputy director of organisational learning, patient safety and inquests and the care groups with a report on the status update on all open complaints within their services including any delays and the reasons.

Thematic analysis will be undertaken monthly and will form part of a rolling data set looking at:

number and subject of complaints, and the teams involved
identification of themes or trends
complainant satisfaction

Complaints information will be reported as part of the patient safety report

A sample of complaints files will be reviewed by the deputy director on a quarterly basis.

An action plan will be produced for those complaints where learning is identified. This learning needs to translate into improvement strategies that are developed and monitored through care group arrangements from wards and teams through to board level. These will be monitored by the complaints team.

14 Complaint satisfaction

Feedback is an important part of the complaints management process. It allows the trust to revisit the objectives of the policy. To ensure feedback is obtained a questionnaires will be sent to every complainant along with the response letters.

Analysis will be undertaken of the responses and used as part of service monitoring and review. The outcome of the complaints satisfaction surveys ill be included in the bi monthly trust patient safety report.

15 Equality impact assessment screening

To download the equality impact assessment for this policy, please follow this link: EIA v17.

15.1 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’.

Consequently, the trust is required to articulate its intent to deliver care with privacy and dignity that treats all patients 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).

15.1.1 How this will be met

No issues have been identified in relation to this policy.

15.2 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 employees working with individuals who use our service are familiar with the provisions within the Mental Capacity (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 rights of individual are protected, and they are supported to make their own decisions where possible and that any decisions made on their behalf when they lack capacity are made in their best interests and least restrictive of their rights and freedoms.

15.2.1 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).

16 Links to any other associated documents

17 References

Department of Health (2004), Guidance to support implementation of the National Health Service complaints regulations.
Mental Health Act 1983; (2015), Code of Practice.
NHS England, Assurance of Good Complaints Handling for Acute Care 2015.
NHS Resolution (2010), NHSR Risk Management Standards Monitor Compliance Framework.
Parliamentary and Health Service Ombudsman NHS Complain Standards 2022.
Right Honourable Ann Clwyd MP and Professor Tricia Hart (2013), A Review of the NHS Hospitals Complaints System Putting Patients Back in the Picture.
Robert Francis QC (2013), the Report if the Mid Staffordshire NHS Foundation Trust Public Enquiry.
The Local Authority Social Services and National Health Service.
Care Quality Commission (2014), Complaints Matter.

18 Appendices

18.1 Appendix A Process flow chart

Day 0 is the day the complaint was received by the trust. Timescales are in working days.

Day 0, compliant received by the complaints team.
Day 0, Complaints team assesses severity and record details
Day 1, Complaints team sends complaint to care group director
Day 3, Complaints team acknowledges receipt and where appropriate seeks service user’s consent to access their records
Day 3, Head of complaints allocates to a complaints investigator.
Day 5, Complaints investigator contacts complainant to advise they will be the named contact during the investigation of the complaint offers face to face meeting.
Day 5, Complaints investigator agrees timeline in conjunction with complainant.
Day 18, Investigator sends draft formal response and completed complaint Investigation form to the Complaints team secretary for quality checking purposes.
Day 20, Complaints team secretary sends the draft response to the care group.
Day 23, Care group sends approved complaint response to Complaints team email.
Day 26, Complaints team forward the approved complaint response to the deputy directors for final quality assurance.
Day 26, Complaint is sent by the deputy directors to the chief executive office for final sign off.
Day 30, Complaints team receive signed response from chief executive’s office and issues formal letter to complainant, with copy to care group and investigator for their files.
Until actions complete, Complaints team add actions from response letter into action tracker. Track actions to completion and share learning.
Monthly, head of complaints provides report for clinical learning brief of lessons learnt.

18.2 Appendix B Complaints administration flow chart

Appendix B Complaints administration flow chart (pending)

18.3 Appendix C A User-led vision for complaints

My expectations for raising concerns and complaints, a user-led vision for raising concern and complaints (opens in new window)

18.3.1 Key messages

The powerful contribution that users of services can make when they have the opportunity to contribute to the design of what ‘good’ looks like the collaboration of everyone working together to improve the way concerns and complaints are handled.

The ‘I statements’ are expressions of what patients and service users might say if their experience of making a complaint was a good one, We need to listen and hear what.

Feedback must include the resolution of their complaint and about actions that have been taken (or not) in response to their concerns. It is here that a patient or service user might receive a tangible demonstration that their complaint has been used to shape learning or improvement. Complainants are part of our learning.

What does the feedback say, do they have confidence in the system.

18.3.1.1 What do we want to hear?

‘I felt confident to speak up and making my complaint was simple. I felt listened to and understood. I feel that my complaint made a difference. I would feel confident making a complaint in the future’.

18.3.1.2 A vision for staff on the frontline

Use the vision as a guide to good practice when dealing with a patient or service user complaint.

Use it as part of staff induction and a guide that staff use as a point of reference when deliberating over how to handle a complaint or reflecting after the fact on how they have handled a complaint.

The power of the vision lies in its illustration of the expectations patients and service users have when making a complaint. As such it would allow frontline staff to put themselves in the shoes of their patients and clients and understand how their handling of a complaint might look to the recipient of their service.

18.4 Appendix D Role of the lead investigator

Role of the lead investigator:

contact complainant and introduce self, arrange face to face meeting, arrange for additional support (advocacy) or note taker and lead the discussion responding to any concerns raised
meet with complainant, identify any immediate resolutions
contact care group and service managers to arrange to meet staff involved in the complaint, offer face to face meeting
review relevant clinical records (SystmOne or Silverlink)
advise the staff member of the right to be supported via a colleague manager or union representative if required
meet with staff
request summary from staff involved, providing copy of complaint letter for them to respond to
following interview send interview notes for confirmation of key notes of discussion
respond to the complaint within the timescales identified at the start of the complaint. If this is not possible the lead investigator to inform the complainant and manager (verbally or via letter) explaining the reasons why the deadline cannot be met
meetings with complainant again if indicated
write full draft response to complaint
arrange completion of action plan with Clinical team, leaders or service and manager
send original complaint, draft response and completed action plan to complaints secretary for proof reading
secretary will send to care group director
amend response letter if required following review care group review
send final response to secretary who will send to deputy directors for final quality assurance

18.5 Appendix E Role of team secretary

Appendix E Role of team secretary (pending)

18.6 Appendix F Unreasonably persistent complaints

The difficulty in handling unreasonably persistent complainants can place a strain on time and resources and cause unacceptable stress for staff. NHS staff are trained to respond with patience and understanding to the needs of all complainants, but there are times when there is nothing further that can reasonably be done to assist them or to rectify a real or perceived problem.

This procedure should only be used as a last resort and after all reasonable measures have been taken, for example, all efforts to resolve complaints following the NHS complaints procedures have been exhausted.

This procedure should only be implemented following careful consideration by, and with authorisation of, the trust’s chair and chief executive or nominated deputy and subsequently ratified by the trust board through the confidential agenda.

18.6.1 Definition of unreasonably persistent complaints and or requests for information

Complainants and, or anyone acting on their behalf may be deemed to be unreasonably persistent where current or previous contact with them shows that they have met two or more (or are in serious breach of one) of the following criteria:

persisting in pursuing a complaint where the NHS complaints procedure has been fully and properly implemented and exhausted. For example, where investigation is deemed to be ‘out of time’ or where the Parliamentary Health Services Ombudsman has declined a request for independent review.
changing the substance of a complaint or persistently raising new issues or seeking to prolong contact by unreasonably raising further concerns or questions upon receipt of a response whilst the complaint is being dealt with. Care must be taken not to disregard new issues, which differ significantly from the original complaint. These may need to be addressed separately
unwilling to accept documented evidence of treatment given as being factual, for example, manual or computer records, or deny receipt of an adequate response despite correspondence specifically answering their questions or concerns. This also includes those persons who do not accept that the facts can sometimes be difficult to verify after a long period of time has elapsed
focusing on a trivial matter to an extent which, is out of proportion to its significance and continue to focus on this point. It should be recognised that determining what is trivial can be subjective and careful judgement must be used in applying this criterion
physical violence has been used or threatened towards staff or their families or associates at any time. This will, in itself, cause personal contact to be discontinued and will thereafter, only be pursued through written communication. All such incidents should be documented and reported using the trust’s incident management policy, and notified as appropriate, to the police
The complainant has had an excessive number of contacts with the trust when pursuing their complaint, placing unreasonable demands on staff. Such contacts may be in person, by telephone, letter, fax or electronically. Discretion must be exercised in deciding how many contacts are required to qualify as excessive, using judgement based on the specific circumstances of each individual case
the complainant has harassed or been abusive or verbally aggressive on more than one occasion towards staff, directly or in-directly, or their families and, or associates. If the nature of the harassment or aggressive behaviour is sufficiently serious, this could, in itself, be sufficient reason for classifying the complainant as unreasonably persistent. Staff must recognise that complainants may sometimes act out of character at times of stress, anxiety or distress and should make reasonable allowances for this. All incidents of harassment or aggression must be documented in accordance with the trust’s incident management policy
the complainant is known to have electronically recorded meetings or conversations without the prior knowledge and consent of the other parties involved. It may be necessary to explain to a complainant at the outset of any investigation into their complaint that such behaviour is unacceptable and can, in some circumstances, be illegal
display unreasonable demands or expectations and fail to accept that these may be unreasonable once a clear explanation is provided to them as to what constitutes an unreasonable demand, for example, insisting on responses to complaints being provided more urgently than is reasonable or recognised practice, presenting similar or substantially similar requests for information.

18.6.2 Options for dealing with unreasonably persistent complainants and, or persons requesting information

When complainants have been identified as unreasonably persistent, in accordance with the above criteria, the chair and chief executive (or their nominated deputy) will decide what action to take. The chief executive (or deputy or representative) will implement such action and notify the individual(s) promptly, and in writing, the reasons why they have been classified as unreasonably persistent and the action to be taken. This notification must be copied, for the information, to others involved in the complaint, for example, practitioners, advocates, Independent complaints advocacy service, member of parliament, etc. records must be kept, for future reference, of the reasons why the decision has been made to classify as unreasonably persistent and the action taken. The chair and chief executive (or delegated deputies or representatives) may decide to deal with unreasonably persistent complainants in one or more of the following ways:

Once it is clear that one or more of the criteria in section 3 has been seriously breached, it may be appropriate to inform the individuals, in writing, that they are at risk of being classified as unreasonably persistent. A copy of this procedure should be sent to them, and they should be advised to take account of the criteria in any future dealings with the trust and its staff. The complainant should be advised that they can seek advice from the independent complaints advocacy service or the parliamentary health services ombudsman with regard to taking their complaint further.

The trust should try to resolve the complaint before invoking this procedure by drawing up a signed agreement with the complainant, involving the relevant staff if appropriate, setting out a code of behaviour for the parties involved. If this agreement is breached, consideration would then be given to implementing other actions as outlined below.

The trust can decline further contact either in person, by telephone, fax, letter or electronically, or any combination of these, provided that one form of contact is maintained. Alternatively, a further contact could be restricted to liaison through a third party. A suggested statement has been prepared for use if staff need to withdraw from a telephone conversation. This is shown in the attached staff operational guidance.

Notify complainants in writing that the chairman or chief executive (or delegated deputies or representatives) has responded fully to the complaint, has exhausted local resolution, and that continuing contact on the complaint will serve no useful purpose. This notification should state that that no further correspondence will be sent and that further communications will not be responded to.

Inform complainants that in extreme circumstances the trust reserves the right to refer unreasonably persistent complaints to the organisation’s solicitors or the Information Commissioner and, or the police.

Temporarily suspend all contact, whilst seeking legal advice or guidance.

18.6.3 Staff guidance for handling habitual or unreasonably persistent complainants

The following form of words, or a very close approximation, should be used by any member of staff who intends to withdraw from a telephone conversation with a complainant. Grounds for doing so could be that the complainant has become unreasonably aggressive, abusive, insulting, or threatening to the individual dealing with the call or in respect of other NHS personnel. It should not be used to avoid dealing with a complainant’s legitimate questions or concerns which can sometimes be expressed extremely strongly. Careful judgement and discretion must be used in determining whether or not a complainant’s approach has become unreasonable.

18.6.4 Form of words

“I am afraid that we have reached the point where your approach has become unreasonable, and I have no alternative but to discontinue this conversation. Your complaint(s) will still be dealt with by the trust in accordance with the NHS complaints procedure. I am now going to put the telephone down but wish to assure you that the situation will shortly be confirmed in writing to you.”

18.6.5 Follow-up actions

The incident should immediately be reported to the Patient Safety and Investigation team and agreement reached on future means of communication with the complainant, together with any further action deemed necessary.

18.7 Appendix G Joint complaints between agencies Rotherham and Doncaster

18.7.1 Introduction

This protocol has been developed by representatives from the agencies mentioned below. This initial version will apply to Rotherham and Doncaster.

18.7.2 Aim

To provide a framework for dealing with complaints involving more than one of the participating agencies and, where possible, to result in a single reply.

18.7.3 Agencies

Rotherham, Doncaster and South Humber NHS Foundation Trust, Doncaster and Bassetlaw Hospitals NHS Foundation Trust, Doncaster Metropolitan Borough Council, Rotherham NHS Foundation Trust, Rotherham Metropolitan Borough Council, Yorkshire Ambulance Service NHS Trust.

18.7.4 Background

Recent guidance (SI 2006 No. 2084 Supporting Staff, Improving Services, Guidance supports the implementation of the NHS (Complaints) Amendment Regulations 2006), and emphasises the need for joint working or coordinated handling, to facilitate effective complaints handling, between health and social care organisations. This inter-agency protocol has therefore been developed for handling complaints, which cross boundaries between the responsibilities of both health and social services.

18.7.5 Framework

Complaints will be acknowledged by the receiving agency within two working days. The receiving agency will, as soon as possible, but within five working days of receiving the complaint:

clarify the complaint
check the authorisation of the complainant.

Seek the written consent of the patient or their representative to allow the receiving agency to send a copy of the complaint to other agencies involved. Confidential information should not be shared without such consent. If written consent is not possible, verbal consent should be recorded and a copy sent to the complainant.

Offer a single reply, on behalf of all the agencies involved, from the agency against whom the bulk of the complaint has been made (lead agency); however, if the complainant chooses and, or in extreme circumstances, where this is not possible, a separate response should be sent from all the agencies involved in the complaint, with the receiving agency monitoring the process of each response.

Upon receipt of the patient or their representative’s consent, a copy of the complaint letter and the receiving agency’s responses will be sent immediately, but in any event no later than within 48 hours, to the other agencies involved in the complaint. This may be via safe haven fax initially.

The lead will be taken by agreement between the respective complaints managers but will usually be the agency against whom the bulk of the complaint is made. Irrespective of lead responsibility, however, each body retains its duty of care to the complainant and must handle its part of the complaint in accordance with its own regulated procedures. Where agreement to identify the lead is not possible, the relevant directors should seek to reach agreement. The responsibilities of the lead agency are detailed at paragraph 5.

If the complainant does not want the complaint forwarded to other involved agencies, the receiving agency will inform the complainant of a named person, address, and telephone number for each part of the complaint should they wish to pursue it. The respective agencies will then investigate the complaint via their respective complaints’ procedures.

If the complainant does want a coordinated response:

the lead agency will obtain responses from all the organisations involved and prepare a final response to the complainant
the complaints managers for each agency will coordinate any requests for responses or information to the lead agency, ensuring that agreed deadlines are met
the local authority will deal with its part of the complaint under the social services regulations and cooperate with the NHS body that received the complaint with the aim of providing a coordinated response and resolving the entire complaint
the agencies should consider a joint meeting with the complainant if this will facilitate a more effective outcome, joint conciliation may be considered
the complainant must be kept informed of any delays. If difficulties arise with meeting the relevant timescales, the complainant should be consulted at the earliest opportunity and agreement sought in writing, or, if not possible, verbal agreement should be recorded, to any extension of the timescales
the final reply must identify which issues relate to which agency, state the complainant’s right to refer the matter to a named regulatory body should they wish to pursue the complaint further and be approved by the other agencies involved before being sent
the chief executive of the lead NHS agency, or the responsible manager of the local authority, must sign the response
should the second stage of the NHS or Social Services complaints procedure be requested, the agencies will liaise and separate if necessary, keeping the complainant informed

18.7.6 Summary of responsibilities of the Lead agency

Identify the responsible agency for each aspect of the complaint.
Consider whether a single response on behalf of involved agencies would be feasible.
Discuss and agree methods of effective communication between the respective complaints managers throughout the process.
Agree timescales with the complainant and other agencies. Joint handling of a case should not affect the need to meet statutory deadlines for providing a response to the complainant, and both agencies should seek to avoid any unnecessary delay.
If difficulties arise with meeting the timescale, the complainant should be consulted at the earliest opportunity, and agreement sought in writing regarding how to proceed.
Keep the complainant updated on action being taken.
Answer any queries during the process.
Ensure a coordinated and comprehensive response is received by the complainant following investigation(s).
Identify any learning points that arise from the complaint and how these might be shared between the complainant and the other agencies.

18.7.7 Compliance

There is an expectation that the organisations or agencies highlighted in point 2 of this document will comply with the agreed protocol, and, or national directives.

18.7.8 Review of protocol

The respective heads of complaints will review this protocol every twelve months.

Chief executive sign-off (individual respective organisations).

18.7.9 How joint complaints are handles between organisations, inter-agency complaints procedure

Complaint made to agency.
Agree lead and identify responsibility for each aspect of complaint.
Obtain consent (to be request within five days of receiving) to share complaint with other agencies.
Consent obtained?
No, advise complainant unable to respond to all aspects of the complaint. Investigate aspects of complaint within restrictions. Respond to complainant within agreed timescale (refer to individual complaint plan).
Yes, share complaint with other agencies.
Agree if response will be joint or separate.
All agencies to investigate within timescales.
Respond to complainant within agreed timescale (refer to individual complaint plan).

18.7.10 Joint agency complaint form

Joint agency complaint form

18.8 Appendix H Joint complaints between agencies North Lincolnshire

Protocol for the handling of complaints, comments, concerns, or compliments that involve more than one organisation Humber making experience count (MEC) group 1.

18.8.1 Introduction

This protocol applies to feedback (complaints, comments, concerns and compliments) that require co-ordinated handling across organisations. It is approved of and agreed to by the organisations named below. The protocol is to be used by these organisations to address all issues falling under the making experiences count procedure that involve two or more of them. (See appendix A for definitions)

18.8.2 Principles

The provision of health and social care services is an increasingly complex arrangement of interagency responsibility. Service users, their careers, friends, and relatives cannot be expected to have a detailed understanding of these relative responsibilities and should not have to navigate their way through them in order to have their feedback addressed. This protocol is intended to ensure that any feedback about a jointly provided service or that involves services provided by more than one organisation is dealt with seamlessly, promptly, and clearly through a single co-ordinated process. Complainants will be given the advice and assistance they need to make the experience as straightforward as it can be.

The protocol aims to promote open and honest communication with service users and their carers as soon as possible following an incident and will follow the principles identified in each NHS organisation’s ‘being open’ policies and procedures. It also should enable a fair, rapid, open and sensitive response to feedback that respects people’s human rights and diversity.

This protocol will require:

openness and co-operation between agencies at each stage of the process
a designated lead and contact for the complainant
clarity about the way in which each issue will be addressed
single response
shared learning

18.8.3 Process

18.8.3.1 Receiving the complaint

Feedback can be made verbally or in person or in writing at any organisation. Front line staff should be aware that they can take issues relating to other organisations and that representatives should not be asked to make their feedback in another form or at another place.
Any feedback that involves more than one organisation should be passed to the person within the organisation designated to deal with these issues (referred to in this document as the complaints manager.
The head of patient safety will be responsible for co-ordination of the complaint along with their counterpart in the other organisation(s).
The representative should be made aware of any relevant advocacy service.

18.8.3.2 Establishing the lead

For each feedback it will be necessary to establish the lead organisation. The complaints manager for the lead organisation will take responsibility for managing the feedback handling, providing the response, and keeping the representative informed.

The lead organisation will be that which:

is responsible for an integrated service
has responsibility for the majority of issues in the feedback
is accountable for the most significant issues
the representative requests
received the feedback, should the issues be evenly divided
is determined by the respective lead investigators

In addition the representative’s wishes can be considered.

If feedback is received by one organisation, which they have no authority to investigate, the lead investigator will contact the representative within 2 working days and advise them that the feedback will have to be forwarded to the relevant organisation and seeking their consent for this.

18.8.3.3 Grading

A feature of the making experiences count process is the initial impact or risk assessment. This assessment looks at the potential significance of the issues raised by the feedback. It begins to determine the means by which the feedback will be addressed by allocating a grading. This process of grading the feedback cannot be carried out by one organisation on behalf of another and therefore must be conducted by each of the organisations concerned in co-operation. It will be the responsibility of the lead organisation to co-ordinate the process, but each organisation is accountable for the grading of issues relating to its own services. Where it is necessary to contact the representative for the purpose of grading the complaint agreement will be reached between complaints’ managers about how this is best done to avoid repeated contact.

18.8.3.4 Planning for resolution

Clarity will be agreed for addressing the issues raised. This will:

set out each element of the feedback
state how each element will be addressed and by whom
establish timescales
record the preference for method of contact, for example, in person, in writing
agree advocacy involvement where appropriate
establish the relevant consents (consent should be sought only once and should apply to all organisations involved)

In addition clear agreement should be reached about the process of adjudication, arrangements for the response and organisational sign off.

It is the responsibility of the complaints manager in each organisation to ensure that the necessary people, records, procedures etc. are available to the complaint investigator, without separate requests having to be made, and check that appropriate consent(s) have been received.

18.8.4 Response

It should always be the aim to have a single response to inter-organisation feedback. In some circumstances this may not be possible, for example if one issue is going to take significantly longer to deal with than others. Representatives should always be advised of this as soon as possible.

If the feedback requires adjudication or management meeting again this should be a joint process to facilitate the single response. If adjudication cannot be held jointly, they should take place within a timescale that would not prolong the response. The appropriate managers in each organisation must agree or sign off the responses before they are sent.

18.8.5 Findings

If there has been no formal adjudication then the lead manager should seek to identify, with the officer(s) who handled the feedback, whether there are any identified learning issues or actions. The manager will forward to the relevant organisation.

Learning from feedback is a vital feature of the process and inter-organisation feedback handling offers an opportunity for organisations to learn from each other. The process of adjudication should ensure that issues requiring action or service improvements are identified. If the lead complaints manager is involved in the adjudication process, they should ensure that any learning points or identified actions are forwarded to their counterpart in the relevant organisation.

The lead complaint manager will follow up with user feedback or satisfaction surveys to the representative.

18.8.6 Consent to information sharing

In order to deal with feedback effectively it will be necessary for organisations to make information that they hold on individual service users or patients available to investigators from other organisations. Similarly they will be required to give access to internal policies or procedures.

In respect of personal information this must be handled in line with the principles of the Data Protection Act, Caldicott and any confidentiality policies the respective organisations may have. Investigators should also be aware of their responsibilities in respect of confidentiality.

Consent to share information must be sought from the representative and, if different, from the service user or patient. If the service user or patient is deemed not to have capacity in this respect, then consent can be sought from their representative.

Wherever possible consent should be given in writing, if this is not possible consent should be recorded carefully on file. Consent should be sought only once for each investigation and should apply to each organisation involved.

If consent is not given to share information, then it should be explained to the representative that they can i) take the issues direct to the organisation concerned ii) pursue their issues through the joint route but with the understanding that the investigation will be compromised through lack of access to information iii) withdraw feedback that cannot be effectively looked into without access to some records.

Once consent to access to information is given organisations should make every effort to ensure the requested information is readily available to the investigation. This includes verbal information from the staff of the organisation.

Information that is made available to the investigation of a complaint must only be used for the purpose for which it was obtained. Only information that is relevant to the feedback and its investigation should be shared.

18.9 Appendix I Complaint against a doctor

All letters of complaint are emailed to the executive medical director, by the Complaints team secretary; copied to the medical directorate manager, within 3 working days of receipt within the Complaints team.
The executive medical director or medical directorate manager will identify any further circulation, for example, to the director of postgraduate medical education.
The executive medical director will assess if there has been any medical involvement which relates to the complaint and advise the Complaints team within 10 working days.
Where there has been medical involvement, the medical director will nominate a medical investigating officer.
The Complaints team secretary will email the lead investigator the complaint letter, draft response letter template, and action plan template and advise the lead investigator, when a draft response is required by.
The lead investigator will also be informed that staff statement must also be returned with the draft response and action plan. This will be copied to the care group director for information.
On completion of the complaint, the Complaints team secretary will email the final response letter to the lead Investigator and will chase for the action plan and, or statements if these have not yet been received.
On completion of the complaint, the team secretary will email the final response letter to executive medical director and medical directorate manager for use at doctor annual appraisals as indicated.

18.10 Appendix J Risk matrix

Appendix J Risk matrix

18.11 Appendix K Guidelines for writing a report

Staff who have been involved in an event which results in a complaint, may be asked to write a statement in order that facts about events are made clear.

The following is intended as practical guidance for anyone asked to write a factual statement (write in black ink or 12-point Ariel typescript on A4 paper).

Essential details to be included:

name of person (in block capitals) making the report, position, pay band, and area of work.
date and time of event or incident
full name of any other individuals involved, for example, patient, visitor, and other staff members, (or any person in the vicinity at the time)
detailed account of events and time that they occurred
signature
date of making statement

Detail a factual account of your personal involvement. How, why, and when were you involved?

All detail should be in chronological (date then time) order. Refer to any records made. Are there any inconsistencies between the records in question and the content of your statement? Identify other people involved.

Only record information involving others, that you saw and, or heard personally. Comment on each point in the complaint regarding your own involvement. State the facts and avoid opinions. Always attach any supporting documentation.

If you require assistance, seek advice from your staff side organisation, or if you deem it to be appropriate, your immediate line manager.

If you keep a copy of your statement, please ensure that you respect guidelines (Caldicott) regarding the use or retention of confidential patient information.

18.12 Appendix L Definitions

Being open, National Patient Safety Agency initiated policy for NHS organisations to communicate openly and honestly with service users and their carers following a patient safety incident or related complaint or concern.
Head of complaints, person within the organisation designated to deal with complaints under regulation 4(1), (b).
Feedback, complaints, comments, concerns and compliments that require action and a response.
Representative, person making the complaint, comment, concern or compliment. It may be the service user or someone acting on their behalf.
Service user representative or person acting on behalf of the service user, person defined in regulations 5(2), 5(3).
Regulations, the local authority social services and National Health Service Complaints (England) Regulations 2009

18.13 Appendix M Diversity monitoring form

Appendix M Diversity monitoring form

18.14 Appendix N Guidelines for writing letter of apology

Occasionally, staff who have been involved in a complaint and are named in the complaint may be asked to write a letter of apology to the complainant. It is sometimes appropriate to do so and can help to reach a resolution with the complainant. When such letters have been written previously, they have been recognised by the parliamentary and health services ombudsman as not only good practice, but over and above what they would expect from a trust.

The following is intended as a practical guidance for anyone asked to write such a letter and for their manager. Whilst these may all seem obvious; they can be easy to overlook when you may be feeling anxious about writing such a letter.

18.14.1 Guidelines for staff writing the letter

Remember that saying sorry is not an admission of liability but an expression of your empathy with the recipient.

You may feel that you have done nothing wrong; you may in fact have done everything to the best of your ability and according to policy and procedures. Nevertheless, something in your actions or behaviour has caused this person distress, anxiety, or added to their bereavement, for example:

consider how you would feel if your roles had been reversed
think carefully about your response and you may wish to write out a draft version first
consider if you were the one receiving the letter:
- how would it come across?
- would it sound defensive?
- would it sound sincere?
make sure that you include the “niceties” of letter writing, for example, address it to “Dear Mrs Smith” for example and sign off “Yours sincerely”
check your spelling. In particular, check that you have spelled the recipient’s name correctly
check the grammar of the letter. Spelling and grammar may not seem important, but errors in these will make the letter seem rushed and therefore insincere

18.15 Appendix O Guide for investigators completing complaint responses

Appendix O Guide for investigators completing complaint responses

Document control

Version: 18.1.
Unique reference number: 314.
Approved by: Director of safety and quality.
Date approved: 25 January 2024.
Name of originator or author: Deputy director organisational learning, patient safety and inquests.
Name of responsible individual: Executive director of nursing and allied health professionals.
Date issued: 30 January 2024.
Review date: 31 December 2026.
Target audience: All staff (including temporary staff).

Page last reviewed: April 15, 2024
Next review due: April 15, 2025

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