Adverse Incidents and Near Misses Management Policy

Policy for the Management of Complaints, Concerns, Comments and Plaudits

Version 2

Name of responsible (ratifying) committee Patient Experience Steering Group

Date ratified 13 February 2012

Document Manager (job title) Patient and Customer Services Manager

Date issued 01 March 2012

Review date February 2015 (unless legislation changes)

Electronic location Corporate Policies Policy for the Reporting of Adverse Incidents and Near Misses; Policy for the Management of Serious Incidents Requiring Investigation; Policy for the Related Procedural Documents Management of Claims; Policy for Supporting Staff involved in an Incident, Complaint or Claim; Being Open Complaints, Concern, Comment, Plaudit, PALS, Key Words (to aid with searching) Ombudsman, Local Resolution In the case of hard copies of this policy the content can only be assured to be accurate on the date of issue marked on the document.

For assurance that the most up to date policy is being used, staff should refer to the version held on the intranet

Policy for the Management of Complaints, Concerns or Comments. Issue 2 01 March 2012 (Review date: January 2014 unless requirements change) Page 1 of 23 CONTENTS

QUICK REFERENCE GUIDE...... 3

1. INTRODUCTION...... 3

2. PURPOSE...... 3

3. SCOPE...... 3

4. DEFINITIONS...... 3

5. DUTIES AND RESPONSIBILITIES...... 3

6. PROCESS...... 3

7. TRAINING REQUIREMENTS...... 3

8. REFERENCES AND ASSOCIATED DOCUMENTATION...... 3

9. EQUALITY IMPACT STATEMENT...... 3

10. MONITORING COMPLIANCE...... 3

Appendix A...... 3

Appendix B...... 3

Appendix C...... 3

Appendix D...... 3

Appendix E...... 3

Policy for the Management of Complaints, Concerns or Comments. Issue 2 01 March 2012 (Review date: January 2014 unless requirements change) Page 2 of 23 QUICK REFERENCE GUIDE

For quick reference the guide below is a summary of actions required. This does not negate the need those involved in the process to be aware of and follow the detail of this policy.

Verbal Complaints:

1. Listen to what is said and provide advice and assistance 2. Apologise where necessary 3. Establish if you/your colleague/line manager can resolve the issue within 1 working day (this may involve a phone call from the relevant senior person) 4. If you are unable to resolve refer the complaint to Patient & Customer Services

Written Complaints:

Forward to the Patient and Customer Services Team ASAP either by:

1. Internal post: OR 2. Scanning and emailing to [email protected]

Out of Hours Complaints:

1. Try to manage immediately either yourself/involve a colleague/ your line manager 2. If the matter is urgent contact the Hospital Duty Manager 3. If the Hospital Duty Manager is unable to resolve inform the complainant that they will refer their complaint to the Patient and Customer Services Team above.

For help and advice, the Complaints Team can be contacted on 02392 286000 ext 6530 or by email: [email protected]

For reporting purposes all substantive plaudits should be referred to the Patient and Customer Services Team

Refer to Appendix B for grading events

Refer to Appendix E for patient information leaflet & poster: your experience matters to us or via the following links:

Poster:

Leaflet:

Policy for the Management of Complaints, Concerns or Comments. Issue 2 01 March 2012 (Review date: January 2014 unless requirements change) Page 3 of 23 1. INTRODUCTION The Trust views complaints positively and is committed to having an effective procedure in place to handle all issues brought to the attention of staff. The organisation will take an active approach to asking for people’s views, dealing with complaints effectively and using the information received to learn and improve. In keeping with the code of openness within the NHS, the Trust will always respond to a complaint in a non-defensive and open manner, apologising where appropriate.

Staff work very hard to get the job right first time but sometimes mistakes can occur. If services can respond to user feedback quickly and effectively, problems and mistakes can be prevented from happening again.

Complaints can often arise from differences of understanding, perception or beliefs but they provide a valuable indication of the quality of services provided and this information can, and will, be used to help improve services and to find better ways of meeting the needs of our patients.

Staff will treat all complaints seriously and listen to what service users have to say and provide assistance and advice on the process which the Trust follows. It should be recognised that patients in receipt of care can at times feel vulnerable and may feel that their care will be affected if they complain. Staff will do everything to dispel this impression. It is essential that patients and carers understand that they have a right to complain without fear of discrimination.

2. PURPOSE This policy describes how staff are expected to respond to complaints, concerns and comments raised by users of our services, their relatives, carers or friends. The policy reflects the needs of

 Complainants, with regard to accessibility, timeliness, empathy, clear communication, confidentiality, transparency and quality of service given  Staff: by creating a transparent and supportive culture  The Trust: by creating an open, efficient system which provides the basis for an overall culture of learning and improved care

3. SCOPE This policy applies to all permanent, locum, agency, bank and voluntary staff of Portsmouth Hospitals NHS Trust, the MDHU (Portsmouth) and Carillion, whilst acknowledging that for staff other than those directly employed by the Trust the appropriate line management or chain of command will be taken into account. Whilst the policy outlines how the Trust manage and learn from all complaints, implementation does not replace the personal responsibilities of staff with regard to issues of professional accountability for governance.

This policy is not for the purpose of addressing complaints raised by any member, or former member of staff, unless the member is a service user and the complaint is regarding the service received, or the member of staff is a family member, carer or a representative of a person affected by the services provided by the Trust.

‘In the event of an infection outbreak, flu pandemic or major incident, the Trust recognises that it may not be possible to adhere to all aspects of this document. In such circumstances, staff should take advice from their manager and all possible action must be taken to maintain ongoing patient and staff safety’

4. DEFINITIONS A complaint: an expression of dissatisfaction requiring a response. Complaints received may be informal or formal.

Policy for the Management of Complaints, Concerns or Comments. Issue 2 01 March 2012 (Review date: January 2014 unless requirements change) Page 4 of 23 Concern/comment: an expression of dissatisfaction made by a service user, their family or carer, a person acting as a representative or any person with an interest in, or affected by, the staff or services provided by the Trust.

Investigation: a detailed inquiry or systematic examination

Root Cause Analysis: a formal, well recognised way of investigating incidents, claims and complaints, which offers a framework identifying what, how and why an event happened. Analysis can then be used to identify areas of change, develop recommendations and look for new solutions.

The Independent Complaints Advocacy Service (ICAS) supports patients and their carers wishing to pursue a complaint about their NHS treatment or care.

5. DUTIES AND RESPONSIBILITIES

Patient and Customer Services Manager manages the Patient and Customer Services Team which consists of the Complaints Team and also the Patient Advice and Liaison Service (PALS). The Patient and Customer Services Manager is authorised by the Trust to manage the complaints procedures, to ensure compliance with the Local Authority Social Services and National Health Service Complaints (England) Regulations 2009. The Manager will ensure that:

 Guidance and support is provided to staff and the public as required  The Trust Board receives: . Information on complaints management, as part of the monthly Quality Exception Report . Complaints management informs the quarterly, aggregated Quality Report  Clinical Service Centres receive information on complaints management, for onward dissemination to staff  The Commissioners receive quarterly reports in line with the Quality Contract

Managers have a responsibility for promoting an effective complaints handling process and ensuring there are operational systems in place within their teams to fulfill the requirements of this policy and that there is implementation and monitoring of any changes that may be necessary following an investigation into a complaint. Within that context, managers must ensure that their staff are fully assisted, feel fully supported throughout the handling of any complaint and are released for appropriate training. Where staff are experiencing particular difficulties associated with a complaint, managers should consider referring the staff member or members to the Occupational Health Department or Director of Postgraduate Medical Education, in accordance with the Human Resources Policy for supporting staff

All Staff are required to comply with the NHS Complaints Procedure by cooperating in the investigation of complaints, concerns or comments received by the Trust and, as such, respond in an open and timely manner to any request for information necessary to resolve those complaints.

In addition, all staff should be aware of the Trust’s ‘Being Open’ Policy. This highlights that communicating honestly and sympathetically with patients and their families when things go wrong is a vital component in dealing effectively with errors or mistakes in the care provided. The ‘Being Open’ Policy advises healthcare staff to apologise to patients, their families or carers if a mistake or error is made and to explain clearly what went wrong and what will be done to stop the problem happening again.

Patient Experience Steering Group (PESG) is convened to steer and report on key work- streams that are set to deliver the Trust objective of Best Care and will formally report on progress to the Governance and Quality Committee.

Policy for the Management of Complaints, Concerns or Comments. Issue 2 01 March 2012 (Review date: January 2014 unless requirements change) Page 5 of 23 The Patient Environment Partnership Group reports to PESG, on any environmental issues that may impact on the patient experience e.g. food, cleanliness.

Clinical Service Centre (CSC) Governance Committees The Committees are responsible for monitoring the action plans and recommendations arising from relevant complaints, concerns and comments and ensuring learning and the implementation of any changes in practice required in the light of those recommendations. The Committees are also responsible for undertaking monthly reviews of the CSC risk registers, including the monitoring of risks identified from the receipt of complaints, comments and concerns.

6. PROCESS

In anticipation of the changes to the National Health Service Complaints Regulations on 1 April 2009, the Trust merged its Complaints and PALS Teams into the Patient and Customer Service Team, creating a single point of access for those who wish to raise a complaint, concern or comment.

The system is designed to keep the complainant at the centre of the process; this requires a flexible system but one which operates within a defined structure that is robust, equitable and accessible.

The overall aim is to provide a speedy, comprehensive response to concerns, comments or complaints, ensuring that apologies and, if possible or required, redress is offered when errors are identified and the Trust learns from mistakes.

Whilst the Trust has merged the two teams into one there remains two distinct roles within that team.

PALS will:  Ask initial questions in order to help users understand issues and to aid clear explanations and quick responses. However the team do not conduct formal investigations  Not ask for written statements from individual members of staff and/or collate these into a formal response  If necessary, request a service manager to provide a general statement on behalf of a service  Provide service users with information about the Trust and help with other enquiries  Help resolve informal concerns or problems encountered by patients and visitors to the Trust  Provide information about, and signpost or refer to agencies and support groups outside the Trust  Inform users about getting involved in their own healthcare and with the Trust  Listen to concerns, suggestions and experience and ensure that people who design and manage services are aware of the issues raised  Act as an early warning system for the Trust and monitoring bodies by identifying and reporting problems or gaps in services.

Whilst PALS do not have a role in the formal complaints procedure they provide advice to service users about the Trust’s Complaints Procedure as a PALS enquiry may be the first contact when an issue is raised.

Policy for the Management of Complaints, Concerns or Comments. Issue 2 01 March 2012 (Review date: January 2014 unless requirements change) Page 6 of 23 COMPLAINTS TEAM Whilst the Complaints Team will answer any concern or comment that is brought to their attention, they are more involved in managing the formal Complaints Procedure within the Trust.

6.1 Local Resolution Procedure Under the Local Authority Social Services and National Health Service Complaints (England) Regulations 2009 complaints can be made about:

 Any perceived failure or shortcoming of the services provided by the Trust  When an event takes place that is in opposition to the choice or wishes of a patient  The way treatment, service or care has been provided to a patient  Discrimination against a patient, their family or carer  How a service has been managed  Lack of a service  Problems accessing a service  The attitude or other behaviour of staff

Please note this list is not exhaustive

6.1.1 Formal complaints A formal complaint can be made verbally, in writing or electronically.

Written Complaints Any written complaint received by staff, including the Chief Executive, must be sent immediately to the Complaints Team, by hand, fax or email

A member of the Complaints Team will ensure that the complaint is acknowledged within 3 working days of receipt.

Where possible a member of the Complaints Team will have a conversation with the complainant to negotiate and agree the following issues

 The manner in which the complaint is to be handled.  A telephone call from the manager in charge of the service complained about may resolve the problems  A meeting to talk about the concerns may be required  The complainant may want a full investigation and a written response  The provision of any required consent (see Appendix A for guidance on who can complain)  The period of time in which the complaint is likely to be completed: a reasonable timescale should be agreed if a thorough investigation is to be carried out

If the complainant does not wish to participate in the above conversation, the member of the Complaints Team will apologise for contacting them by telephone, assure them that the complaint will be investigated as quickly as possible and that they will receive a written response from the Chief Executive.

The details of all contact with the complainant will be recorded in the individual complaint file.

Verbal Complaints Any member of staff receiving a verbal complaint should establish whether the matter is one that they, a colleague, their line manager or PALS can respond to immediately

Policy for the Management of Complaints, Concerns or Comments. Issue 2 01 March 2012 (Review date: January 2014 unless requirements change) Page 7 of 23 If a member of staff is approached by a service user, a family member or carer who wishes to make a verbal complaint, which the member of staff is able to resolve to the complainant’s satisfaction within one working day, then the issue will not be recorded as a formal complaint. If the complaint cannot be resolved it must be referred to the Complaints Team.

A member of the Complaints Team will then contact the complainant asking them to agree a summary of their complaint. The member of the Complaints Team will:

 Listen carefully to the complainant to understand their concerns and what they wish to achieve  Summarise their understanding of the complaint and record it as far as is possible in bullet format  Record the complaint factually and objectively

Out of Hours Complaints If a complaint (either written or verbal) is received outside working hours and cannot be resolved immediately by staff then the Hospital Duty Manager must be contacted

The Hospital Duty Manager will speak to the complainant in order to try and resolve the complaint. If that is not possible, the Hospital Duty Manager will inform the complainant that the complaint will be referred to the Complaints Team. A member of the Complaints Team will then contact the complainant to confirm the details of the complaint and discuss the manner in which the complaint is to be handled.

6.1.2 Assessing Complaints By correctly assessing the seriousness of a complaint, the right course of action can be taken. Each complaint will be reviewed and assessed in accordance with the risk matrix (Appendix B). The assessment grading is recorded on the individual complaint folder.

Any complaint that receives a high ‘red’ grading will be shared with the Head of Risk Management and Legal Services and the Legal Services Manager, as there may be either a requirement to undertake a parallel investigation under the serious incident policy or to inform the National Health Service Litigation Authority (NHSLA) of a potential claim.

6.1.3 Meeting with Complainants During the initial discussion with the complainant, they may request to meet with the relevant members of staff. If a meeting is arranged, details of the time, venue and attendees will be provided in writing by a member of the Complaints Team. The member of the Team will also inform the Patient and Customer Services Manager who will attend such meetings as she deems appropriate. If the Patient and Customer Services Manager considers it necessary, she will notify the Director of Nursing.

The meeting will be recorded electronically or in the event of the recording equipment not being available, detailed minutes will be taken and written up within 48 hours of the meeting taking place. The recording or the minutes will then be sent to the complainant.

6.1.4 Conciliation/Mediation Conciliation/mediation are effective ways of resolving conflict. It involves an independent, specially trained third party listening to the complaint and using the information to help the parties reach a resolution to which they both agree. The decision to go to conciliation/mediation will be made by the Patient and Customer Services Manager in conjunction with the Director of Nursing.

6.1.5 Investigation

Policy for the Management of Complaints, Concerns or Comments. Issue 2 01 March 2012 (Review date: January 2014 unless requirements change) Page 8 of 23 The member of the Complaints Team with responsibility for managing a complaint will ensure that any complaint is investigated and responded to as speedily and efficiently as possible and in accordance with the timescale agreed with the complainant. If any delay in meeting the agreed timescale becomes apparent, the member of the Complaints Team will contact the complainant to re-negotiate that timescale

The member of the Complaints Team will send the complaint to the appropriate CSC for investigation, and ask any member of staff named in the complaint to provide a statement in response to the issues raised in a timely manner. (Appendix C gives guidance on writing statements).

Where a complaint concerns or involves one or more health or social care organisation the Patient and Customer Services Manager will contact the relevant organisation to agree which organisation will lead on the investigation. Where it is agreed that an organisation other than the Trust will lead, the Patient and Customer Services Manager will ensure that any information required by the external organisation will be provided and within requested timescales.

For further details on the Trust’s investigation processes, refer to the Trust’s Policy for the Investigation of Incidents, Complaints and Claims

6.1.6 Final Written Response A member of the Complaints Team will draft a response based on the findings of the investigation for signature by the Chief Executive: or a person acting on her behalf, where for good reason she is not available.

The final written response will be sent within the agreed timescale and include:

 A detailed explanation, from the staff involved, regarding the questions raised in the complaint  Conclusions reached in relation to the complaint, including appropriate remedial action  An apology

6.1.7 Complaints made on behalf of a Patient A member of the Complaints Team will contact the complainant advising them that the complaint cannot be investigated without the written permission of the patient. Verbal consent will be accepted at the discretion of the Patient and Customer Services Manager.

If through physical or mental incapacity, the patient is unable to give consent the complaint can be investigated through the NHS Complaints Procedure.

If consent is not received from the patient, the complainant cannot be given a full response or details of the care provided to the patient. The Trust will, however, ensure that the patient is receiving the correct care and that any issues raised in the complaint are investigated and rectified, where possible

6.1.8 Discrimination against Patients who raise a Complaint, Comment or Concern To ensure that patients who raise a complaint, comment or concern are not treated differently as a result of making that complaint:

 Complaint information / related statements / letters will not be kept in the patient’s health records  Information regarding complaints will be shared on a demonstrable ‘need to know’ basis only  Complaint files will be stored securely

Policy for the Management of Complaints, Concerns or Comments. Issue 2 01 March 2012 (Review date: January 2014 unless requirements change) Page 9 of 23  Complaint files will be inaccessible to members of the public or unauthorized members of staff  Patients and carers will be handled respectfully and efficiently with consideration given to all elements of the protected characteristics as outlined in the Equality Act 2010. For further information please visit the Legislation website http://www.legislation.gov.uk

The Trust will address any instances where it is evident that staff have discriminated against a patient, relative or carer following the raising of a complaint or concern. All such matters will be dealt with through the disciplinary route, ensuring the appropriate level of involvement from line management and Human Resources.

6.2 Parliamentary and Health Service Ombudsman (PHSO) If, after all attempts at local resolution the complainant remains dissatisfied, they have the right to ask the PHSO to review their complaint.

6.2.1 The Role of the PHSO The PHSO is independent of the National Health Service and the Government and is answerable to a Select Committee

The PHSO has powers to investigate complaints about NHS providers, purchasers and non-NHS providers which are funded by the NHS, on such matters as:

 Care and treatment  Clinical judgment  Maladministration causing hardship or injustice  Service provision  Complaints handling

It is intended that complainants should fully exhaust the Trust’s complaints procedure before referring to the PHSO, although the PHSO has discretion, exceptionally, to override this requirement.

The PHSO will not investigate complaints about disciplinary or other personnel matter

The PHSO has published the following principles so that organisations understand what is expected from an NHS Trust when dealing with complaints. The six principles which the Trust will work to are:

 Getting it right  Being customer focused  Being open and accountable  Acting fairly and proportionately  Putting things right  Seeking continuous improvement

Further information on the role of the PHSO and the Principles of Good Complaint Handling can be found at: www.ombudsman.org.uk

6.3 The interface between PALS and the Complaints Team When patients make initial contact with the Trust to raise an issue or make a complaint both the PALS and the formal complaints pathway will be offered as options. PALS contacts/users who wish to make a formal complaint will be provided with the relevant information. This will normally be the Complaints Leaflet, which also includes information about the ICAS and the Ombudsman

Policy for the Management of Complaints, Concerns or Comments. Issue 2 01 March 2012 (Review date: January 2014 unless requirements change) Page 10 of 23 When the Complaints Department receives a formal complaint that also includes concerns or comments that would normally be handled by PALS, the Customer and Services Manager may choose to deal with the concerns or comments as well as the formal complaint. Alternatively, the Patient and Customer Services Manager will agree actions to be taken by PALS, whilst ensuring the formal aspects of the complaint are dealt with under the Trust’s Complaints Procedure.

When a PALS contact wishes to raise a concern that appears to require a full investigation or where they raise several concerns about a care episode they will be advised of the option to complain formally. However, if the contact does not wish to do this and requests informal feedback, the aim will be to accommodate that request as much as possible. It will be made clear that the contact can always take their concern(s) through the Complaints Procedure at a later date. It will also be made clear that PALS cannot investigate the concerns as a formal complaint and does not offer a detailed, written response.

The Complaints Team is located at Queen Alexandra Hospital and can be contacted:

 By telephone: 02392 9228 6530  By email: [email protected]  By letter: The Chief Executive Trust Headquarters Queen Alexandra Hospital Southwick Hill Road Cosham Portsmouth PO6 3LY

The PALS Team is located in the main reception area, on A Level in the Health Information Centre at Queen Alexandra Hospital, and can be contacted:

 By telephone: 0800 917 6039  By email: [email protected]

6.4 Communicating with and supporting staff Where a complaint has been received all members of staff directly involved must be kept informed and appropriately communicated with: this is crucial to the development of an open and honest culture. The communication will be through the CSC structure and should include information about the investigative process, the likely timeframe for completion and, most importantly the outcome of the investigation and any actions that will be taken to prevent a similar incident happening again.

Where staff experience particular difficulties as a result of a complaint, it is essential that they feel supported. Support for staff can take a number of forms: what is right for one member of staff or one situation may not be right for another. Managers should also be aware that staff needs change over time and as they come to terms with events. Sensitive and ongoing communication will ensure that needs are identified and addressed wherever possible. As well as personal support through the line management structure, managers should also consider referring the staff member or members to the Occupational Health Department, or the Director of Postgraduate Medical Education, in accordance with the Human Resources Policy for supporting staff

6.5 Communicating with and supporting patients, carers and relatives When things go wrong one of the biggest concerns for patients, relatives and carers who have been affected by a complaint is lack of information. Providing factual information in a sensitive way is helpful and is not an admission of liability for the incident itself.

Policy for the Management of Complaints, Concerns or Comments. Issue 2 01 March 2012 (Review date: January 2014 unless requirements change) Page 11 of 23 Communication may be through the appropriate healthcare professional or through the use of a facilitator, a patient advocate or a national organisation or charity who will be responsible for identifying the patient’s needs and communicating them back to the healthcare team. More information and advice on support for patients, families and carers can be obtained from the Trust’s Being Open Policy, PALS or from Patient UK on www.patient.co.uk

6.6 Management of Plaudits It is essential that information about plaudits is collected, as well as complaints, concerns and comments; in order to demonstrate a well balanced view of the Trust’s position. Staff in the Patient and Customer Services Team will collect and maintain information on plaudits from across the Trust, for inclusion in the CSC monthly reports, the monthly Quality Exception and quarterly Quality reports to the Trust Board and to the Governance and Quality Committee

Staff in the Patient and Customer Services Team will ensure that a copy of any plaudit received in their Department is forwarded to the relevant manager

6.10 Organisational Learning No adverse event policy will be effective unless there is organisational learning and feedback on the lessons learned and any required changes in practice implemented. The Trust has introduced a number of processes to enable learning and feedback, which include:

Internal

 A systematic approach to the recording and trending of incidents through the use of an electronic database;

 Monthly Quality Exception reports to the Trust Board;

 Monthly Business Intelligence reports to the Trust Board;

 Quarterly Quality Report to the Trust Board and Governance and Quality committee. The report provides an aggregated view of issues concerning patient safety, patient experience and clinical effectiveness;

 CSC Members of the Governance and Quality Committee will ensure the relevant section of the quarterly quality report is disseminated to CSC staff;

 Monthly reports to the Patient Experience Steering Group and CSCs which include complaint numbers for each CSC, complaints in relation to target per CSC, subject of complaint per CSC and location within the CSC. PALS contacts and plaudits are also included within the report;

 Monthly CSC Performance Reviews, at which the status of incidents is monitored;

 Production of reports specifically tailored to the needs of various groups e.g. End of Life Care Steering Group and working groups looking at specific issues.

 CSC action/learning logs, for recording and monitoring the implementation of actions and recommendations made in the light of complaint, concerns and comments;

Policy for the Management of Complaints, Concerns or Comments. Issue 2 01 March 2012 (Review date: January 2014 unless requirements change) Page 12 of 23  The placement of any risks and associated action plans onto the appropriate risk register, CSC or Trust, until the risk has been resolved or mitigated to an acceptable level.

External

 Monthly review of Board Quality Exception Reports with commissioners as part of the Contract Review Meeting;

 Review of quarterly Board Quality Report with commissioners as part of Contract Review Meeting

 Quarterly review of contractual requirements.

 Attendance at Patient Experience Council to share and learn from the experience of others.

 Receiving and acting upon information provided by the Parliamentary and Health Service Ombudsman.

 Undertaking an annual survey to monitor the degree of patient satisfaction with the Trust’s complaints handling process and identify any required changes.

7. TRAINING REQUIREMENTS 7.1 Training forms part of the Trust’s Essential Skills and Training Requirements; as identified in the Training Needs Analysis. It is included in mandatory Corporate Induction and in Essential Updates

7.2 Staff attend classroom delivered Essential Update training every three years and undertake refresher training via the Electronic Staff Record (ESR) system in the intervening years

7.3 Monthly training is delivered as part of the Registered Nurse and Healthcare Support Worker Induction Programme

7.4 Specific training is provided to departments and wards, either on request or when an area of issue with complaints had been identified

7.5 All training is recorded on the ESR from which the Learning and Development Team provide a monthly heat map to each CSC, to enable monitoring of compliance

7.6 Compliance is further monitored through the CSC performance reviews with the Executive Team

8. REFERENCES AND ASSOCIATED DOCUMENTATION External  Data Protection Act 1998 www.opsi.gov.uk/acts/acts1998  Freedom of Information Act 2000 www.opsi.gov.uk/acts/acts2000  Care Quality Commission Standards www.cqc.org.uk/publications  Department of Health: Making Experiences Count 2007 www.dh.gov.uk  The NHS Constitution: 2009 www.dh.gov.uk  Listening, Responding, Improving. A guide to better customer care. 2009 www.dh.gov.uk  Parliamentary Health Service Ombudsman: Principles of Good Complaint Handling www.ombudsman.org.uk

Policy for the Management of Complaints, Concerns or Comments. Issue 2 01 March 2012 (Review date: January 2014 unless requirements change) Page 13 of 23 Internal  Policy for the Management of Adverse Incidents and Near Misses  Policy for the Management of Serious Incidents Requiring Investigation  Policy for the Management of Complaints, Concerns, Comments and Plaudits  Claims Policy  Being Open Policy  Risk Management Strategy  Supporting Staff involved in an Incident, Complaint or Claim

9. EQUALITY IMPACT STATEMENT Portsmouth Hospitals NHS Trust is committed to ensuring that, as far as is reasonably practicable, the way we provide services to the public and the way we treat our staff reflects their individual needs and does not discriminate against individuals or groups on any grounds.

This policy has been assessed accordingly

Policy for the Management of Complaints, Concerns or Comments. Issue 2 01 March 2012 (Review date: January 2014 unless requirements change) Page 14 of 23 10. MONITORING COMPLIANCE As a minimum, the following elements will be monitored

Policy for the Management of Complaints, Concerns or Comments. Issue 2 01 March 2012 (Review date: January 2014 unless requirements change) Page 15 of 23 Appendix A WHO MAY COMPLAIN

A complaint may be made by:

Minimum requirement Lead Tool Frequency of Reporting arrangements Lead(s) for acting on to be monitored Report of recommendations Compliance Process for listening and Patient and Audit of user Annually Policy audit report to: Patient and Customer responding to concerns: Customer surveys  Patient Experience Services Manager 100% of user surveys Services Steering Group demonstrate positive Manager response to question about listening and responding Process for the handling Patient and Audit of joint Annually Policy audit report to: Patient and Customer of joint complaints: 100% Customer complaint files Services Manager Services  Patient Experience of joint complaints were Steering Group handled by the agency Manager with the predominant responsibility Process for ensuring Patient and Audit of user Annually Policy audit report Patient and Customer patients, relatives, carers Customer surveys Services Manager Services  Patient Experience are not treated differently Steering Group as a result of a raising a Manager concern/complaint: 100% of user surveys demonstrate assurance that they were not treated differently Process by which the Patient and Measurement Annually Policy audit report Heads of Nursing: CSCs organisation aims to Customer against Services  Patient Experience Senior Managers CSCs improve as a result of performance Steering Group concerns/complaints Manager target: no more being raised than 42 complaints received Trust- wide per month

 A patient; or  Any person who is affected by or likely to be affected by the action, omission or decision of the Trust

A complaint may be made by a person (a representative) on behalf of a person mentioned above where that person:

 Has died;  Is unable by reason of physical or mental incapacity to make the complaint him/herself;

 Has requested the representative (including: MP, GP, Nursing Home Manager) to act on his/her behalf; or  Is a child (a person under 16 years of age)

The representative must be a relative or other person who, in the opinion of the Patient and Customer Services Team Manager, had or has a sufficient interest and is a suitable person to act as that representative.

Policy for the Management of Complaints, Concerns or Comments. Issue 2 01 March 2012 (Review date: January 2014 unless requirements change) Page 16 of 23 If in any case the Patient and Customer Services Team Manager considers that a representative does or did not have a sufficient interest or is unsuitable to act, the Manager must notify that person in writing stating precise reasons.

In the case of a child, the representative must be a parent, guardian or other adult who has the care of the child. Where the child is in the care of a local authority or a voluntary organisation, the representative must be a person authorised by the local authority or voluntary organisation.

This policy is not for the purpose of addressing complaints raised by any staff, or former staff, unless the member of staff is a service user and the complaint is regarding the service received, or the member of staff is a family member, carer or a representative of a person affected by the services provided by the Trust.

Appendix B

Guidance on Grading Events

All incidents and complaints must be graded. Claims are slightly different, as each one undergoes a similar investigation process. The grading will help you to determine the significance of any event and the required management actions. That is events graded green, yellow, amber or red will have differing levels of investigation requirements and/or urgency

How to Grade Events The Trust has a standardised process for assessing and grading risks and this has been adapted to grade incidents, complaints and claims. An event is made up of two components: likelihood and consequence/seriousness

The consequence, or potential consequence, of the event and the likelihood of the it happening again are scored separately and the values are multiplied to produce the final event grading. So for example, if the event likelihood is scored as ‘3’ which is ‘possible’ with a consequence (seriousness) rating of ‘2’ which is ‘minor’, then the final score would be ‘6’ and the event graded green. Similarly, if the event likelihood is scored as ‘5’, which is almost certain, with a consequence (seriousness) rating of ‘4’, which is major, then the final score would be ‘20’ and the incident graded red.

However, the matrix is only an aid to decision making, and whilst it is a robust system it is not meant to replace clinical or management judgment in regard to the significance of individual Policy for the Management of Complaints, Concerns or Comments. Issue 2 01 March 2012 (Review date: January 2014 unless requirements change) Page 17 of 23 events. For example, an incident with a catastrophic consequence (such major permanent harm or affected multiple patients) but which is considered rare would still be reported as a ‘red’ event simply because of the catastrophic outcome for the individual(s) and the potential for litigation and adverse impact on the Trust.

If you are concerned that a low or medium rated event could also be determined as a significant incident then contact your line manager to discuss the apparent circumstances and remedial actions to be taken.

Consequence Likelihood Insignificant Minor Moderate Major Catastrophic (1) (2) (3) (4) (5) (1) Rare / impossible 1 2 3 1 5 (Can’t believe this will ever happen again) (2) Unlikely 2 4 6 8 10 (Do not expect it to happen again, but it is possible) (3) 3 6 9 12 15 Possible (May recur occasionally) (4) Likely 4 8 12 16 20 (Will probably recur, but it is not a persistent issue) (5) Almost certain 5 10 15 20 25 (Almost undoubtedly occur, possibly frequently)

1 – 3 Low Risk 8 – 12 High Risk

4 – 6 Moderate Risk 15 – 25 Extreme Risk

For complaints, it may also be appropriate to consider the following

Seriousness Description Low Unsatisfactory service or experience, not directly related to care. No impact or risk to the provision of care OR Unsatisfactory service or experience related to care. Usually a single resolvable issue. Minimal impact and relative minimal risk to the provision of care or the service. No risk of litigation Moderate Service or experience below reasonable expectation in several ways, but not causing lasting problems. Has the potential to impact on High service provision. Some potential for litigation Extreme Significant issues regarding standards, quality of care, safeguarding or denial or rights. Complainants with clear quality assurance or risk management issues that may cause lasting problems for the organisation and so require full investigation. Possibility of litigation and adverse local publicity OR Serious issues that may cause long term damage, such as grossly substandard care, professional misconduct or death. Will require immediate and in-depth investigation. May involve serious safety issues and may require a serious untoward incident investigation along side the complaints investigation. A high probability of litigation

Policy for the Management of Complaints, Concerns or Comments. Issue 2 01 March 2012 (Review date: January 2014 unless requirements change) Page 18 of 23 and strong possibility of adverse national publicity.

Policy for the Management of Complaints, Concerns or Comments. Issue 2 01 March 2012 (Review date: January 2014 unless requirements change) Page 19 of 23 Appendix C

GUIDANCE ON WRITING STATEMENTS

You may be asked by the Patient and Customer Services Team or your manager to write a statement /report in response to a request for information to resolve a complaint.

When writing a statement it is important to remember that although the majority of statements / reports will go no further they may used as evidence in: defending a legal claim; in a Coroner’s Inquest; in a Judicial Review or in a Public Enquiry. The statement may also be disclosable under the Freedom of Information Act and/or Data Protection Act 2000

The statement should:  Be prepared only after reviewing any medical records  Be written or typed on Trust headed paper, if not using email  Be honest  Be in the first person singular (For example: ‘I saw’).  Be thorough. Include a full recollection of the circumstances, including workload, others on duty, any small detail which may be important (For example: a bank holiday or illness affecting staffing levels)  Include quotes from the medical records, where appropriate, and any such quotations must be completely accurate (do not guess or paraphrase). Where shorthand or abbreviations are used in the medical records they should be fully explained  Be in chronological order  Be factual – stick to the facts. Make clear what part is from memory, what part from the notes and what part from your recollection of your standard practice at that time. Where information is referred to which was given by another person, this should be made clear and the name and full details of the person supplying the information must be stated.  Be written in clear, unambiguous style avoiding the use of abbreviations or jargon  Explain any technical terms. It may be read by non-medical people  Be as detailed as possible, giving dates, times, locations and amounts/readings  Be read and double-checked by yourself before signature  Concluded with the phrase: ‘The contents of this statement are true to the best of my belief and knowledge’  Be signed and the dated

It should not:  Be written in haste / be brief or dismissive  Include statements beyond your recollection or knowledge: if you cannot be sure of a certain aspect or recall the matter in question, say so.  Be made up, include ambiguous statements / include speculation or conjecture  Just regurgitate what is in the case notes  Express opinions on the care given or the actions taken by other staff or blame other staff or departments in any way / speculate on what others were doing or thinking  Be hostile, rude or unnecessarily defensive (remember complainants may request sight of your statement, which they are entitled so to do)  Be derogatory or defamatory / seek to blame others  Include subjective comments (For example: opinion about the patient or others)  Relate conversations that you were told by someone else, after the event in question  Attempt to cover up any shortfalls in the standard of care or any errors made  Be placed in the medical records of any patient  Be signed until you are happy with it

If you want any help in writing a statement, please contact the Patient and Customer Services anager who will be able to advise you. You should retain a signed copy of any statements you are asked to provide. Policy for the Management of Complaints, Concerns or Comments. Issue 2 01 March 2012 (Review date: January 2014 unless requirements change) Page 20 of 23 Appendix D GUIDANCE ON VEXATIOUS COMPLAINANTS

Complainants (and/or anyone acting on their behalf) may be deemed to be habitual or vexatious complainants where previous or current contact with them shows that they meet TWO OR MORE of the following criteria.  Insist in pursuing a complaint where the NHS complaints procedure has been fully and properly implemented and exhausted.  Change the substance of a complaint or continually raise new issues or seek to prolong contact by continually raising further concerns or questions upon receipt of a response whilst the complaint is being addressed. (Care must be taken not to discard any new issues that are significantly different from the original complaint. These might need to be addressed as separate complaints).  Are unwilling to accept documented evidence of treatment given as being factual, e.g. drug records, Clinician records either paper or computer records, nursing records or deny receipt of an adequate response in spite of correspondence specifically answering their questions or do not accept that facts can sometimes be difficult to verify when a long period of time has elapsed.  Do not clearly identify the precise issues which they wish to be investigated, despite reasonable efforts of Trust staff (and, where appropriate ICAS) to help them specify their concerns, and/or where the concerns identified are not within the remit or the Trust.  In the course of addressing a registered complaint, have had an excessive number of contacts with the Trust placing unreasonable demands on staff. (A contact may be in person or by telephone, letter or fax). Discretion must be used in determining the precise number of “excessive contacts” applicable under this section, using judgement based on the specific circumstances of each individual case).  Have harassed or been personally abusive or verbally aggressive on more than one occasion towards staff dealing with their complaint or their families or associates. (Staff must recognise that complainants may sometimes act out or character at times of stress, anxiety or distress and should make reasonable allowances for this. They should document all incidents or harassment).  Are known to have recorded meetings or face-to-face/telephone conversations without the prior knowledge and consent of other parties involved.  Focus on a matter to an extent that is out of proportion to its significance and continuing to focus on this point. (It is recognised that determining what is justified can be subjective and careful judgment must be used in applying this criterion)  Display unreasonable demands and fail to accept that these may be unreasonable (e.g. insist on responses to complaints or enquiries being provided more urgently than is reasonable or normal recognised practice)

Complainants (and/or anybody acting on their behalf) may be deemed to be vexatious where they have threatened or used actual physical violence towards staff or their families at any time. Such incidents must be documented and will in themselves cause personal contact with the complainant and/or their representative to be discontinued. The complaint may, thereafter, only be pursued through written communication.

OPTIONS FOR MANAGING WITH PROLIFIC OR VEXATIOUS COMPLAINTS

 Where complainants have been identified as prolific or vexatious in accordance with the above criteria, the Chief Executive (or appropriate deputies in his / her absence) will determine what action to take. The Chief Executive (or deputy) will implement such

Policy for the Management of Complaints, Concerns or Comments. Issue 2 01 March 2012 (Review date: January 2014 unless requirements change) Page 21 of 23 action and will notify complainants in writing of the reasons why they have been classified as prolific or vexatious complainants and the action to be taken. This notification may be copied for the information of others already involved in the complaint. A record must be kept for future reference of the reasons why a complainant has been classified as prolific or vexatious.  The Chief Executive (or deputies) may decide to deal with complaints in one or more of the following ways:  Try to resolve matters before invoking this procedure, by drawing up a signed “agreement” with the complainant (if appropriate, involving the relevant practitioner in a 2-way agreement) which sets out a code of behaviour for the parties involved if the Trust is to continue processing the complaint. If these terms were contravened consideration would then be given to implementing other action as indicated in this section.  Once it is clear that complainants meet any one of the criteria above, it may be appropriate to inform them in writing that they may be classified as habitual or vexatious complainants, copy this procedure to them, and advise them to take account of the criteria in any further dealings with the Trust. In some cases it may be appropriate, at this point, to suggest that complainants seek advice in processing their complaint, e.g. through ICAS.  Decline contact with the complainants either in person, by telephone, by fax, by letter or any combination of these, provided that one form of contact is maintained or alternatively to restrict contact liaison through a third party. (If staff are to withdraw from a telephone conversation with a complainant it may be helpful for them to have an agreed statement available to be used at such times).  Notify the complainant in writing that the Chief Executive has responded fully to the points raised and has tried to resolve the complaint but there is nothing more to add and that continuing contact on the matter will serve no useful purpose. The complainants should also be notified that the correspondence is at an end and that further letters received will be acknowledged but not answered.  Inform the complainant that in extreme circumstances the Trust reserves the right to pass unreasonable or vexatious complainants to the Trust’s solicitors  Temporarily suspend all contact with the complainant, or investigation of a complaint, whilst seeking legal advice.

WITHDRAWING PROLIFIC OR VEXATIOUS STATUS Once complaints have been determined prolific or vexatious, there needs to be a mechanism for withdrawing this status, if, for example, complainants subsequently demonstrate a more reasonable approach or if they submit a further complaint for which the normal complaints procedure would appear appropriate. Staff should previously have used discretion in recommending habitual or vexatious status at the outset and discretion should similarly be used in recommending that this status be withdrawn when appropriate. The ultimate decision to withdraw this status rests with the Chief Executive. Subject to such approval, normal contact with the complainant will be resumed

Policy for the Management of Complaints, Concerns or Comments. Issue 2 01 March 2012 (Review date: January 2014 unless requirements change) Page 22 of 23 Appendix E

Policy for the Management of Complaints, Concerns or Comments. Issue 2 01 March 2012 (Review date: January 2014 unless requirements change) Page 23 of 23