1 April 2017

Complaints – Standard Operating Procedures

These standard operating procedures (SOP) implement changes to the complaint process, which was revised in early 2016 and launched in April 2016. The main objective of changes to the process was to ensure an improved personalised approach to the investigation of complaints. To ensure proportionate investigation reflecting the Patient Association standards, and in line with the Local Authority Social Services and National Health Service Complaints (England) Regulations (2009) (referred to as the Complaint Regulations in this SOP), the lead investigator should:

Undertake an initial severity assessment (based on a 5x5 tool)

Contact the complainant to check understanding of complaint, expectation for resolution and agree timescale of investigation (the complaint management documentation (CMD) will be the main document for capturing the investigation details and investigation timescales will be variable depending on complexity of complaint).

Note that complaints can be resolved verbally, by meeting or in writing.

Note that timescales for investigation should be more flexible, offering a 10 working day resolution for complaints to be resolved by telephone, or a 25, 40 and 60 working day option for a written response depending on the level of investigation required. In addition a meeting can be offered, and this must be organised at the earliest convenient date to the complainant.

Commence investigation whilst consent is pending to ensure no delay in individual or organisational learning opportunities, the investigator will be made aware of this in the initial notification. (In this case it will be highly unlikely that the complaint will be resolved by telephone and resolution meetings should not be held until consent is received.)

In the case of resolving a complaint by telephone, the complaint can be ‘closed’ as ‘verbally resolved’. The relevant aspects of the CMD will still need to be completed by the investigator and returned to the Complaints Team.

In the case of resolving by meeting, the complaint can be ‘closed’ as ‘by meeting’. The relevant aspects of the CMD will need to be completed by the investigator and returned to the Complaints Team. This should include details of the relevant investigation, a summary letter and minutes of the meeting, summarising the discussion and any actions agreed.

Note that Investigation of ‘complaints assessed as ‘High’ severity will utilise an independent investigator from within the directorate.

Undertake a final severity assessment (based on a 5x5 tool) and decide whether the complaint is upheld or not.

Note that Service Directors have delegated authority to sign off complaints that are assessed to be low or moderate severity after investigation. The complaints team will continue to issue (and save/circulate) all complaint letters, whether these are via the Chief Executive or approved by Service Director

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Contents

Section Title Pg

1 General Standard Operating Procedure 4

1.1 Definitions 4

1.2 How LPT listens to and responds to complaints 4

1.3 Saying sorry 4

1.4 New complaint – action to take upon receipt 5

1.5 Logging a complaint onto Safeguard 6

1.6 Consent and confidentiality 8

1.7 Assessment and triage process 8

1.8 Investigation process 9

1.9 Carrying out the investigation 10

1.10 Unreasonable and persistent complainant’s 11

1.11 Quality assurance 13

1.12 Closing a complaint 13

1.13 Action plans 14

1.14 Meetings 16

2 Joint complaints 17

2.1 If the Trust is the lead organisation 17

2.2 Consent to share with other organisation(s) 18

2.3 Timescales 18

2.4 Process for logging a joint complaint 18

2.5 Return of consent 20

2.6 If consent is refused 21

2.7 Sharing 21

2.8 If the Trust is the participant organisation 21

3 Reopened complaints 22

3.1 Dealing with further correspondence from complainants 22

3.2 If the complaint is to be re-opened 23

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3.3 Meetings for re-opened complaints 24

3.4 No further local resolution 24

3.5 If the complainant wishes to go to the Ombudsman 25

4 Parliamentary and Health Service Ombudsman (PHSO) 26

4.1 Dealing with initial enquiries and requests for information 26

4.2 Further questions or comments 27

4.3 Deadlines or extensions 28

4.4 Using the PHSO tab on Safeguard 28

4.5 Request to undertake further local resolution 28

4.6 Handling of PHSO decisions 29

4.7 Decisions 30

4.8 Learning and actions 30

4.9 How the PHSO handle complaints 31

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1.1 Definitions

A complaint is an expression of dissatisfaction about the standard of service, action or lack of action, by the Trust or its staff affecting an individual. Complaints require a formal response, communicated verbally, electronically or in writing following this standard operating procedure. A concern or enquiry is a problem raised that can be resolved or responded to locally and quickly. These are not reported as complaints and do not fall within the scope of this standard operating procedure or the national regulations. Any concerns or enquiries should be recorded using Safeguard web customer service or can be discussed with the Patient Advice and Liaison Service (PALS) on 0116 295 0830 or by email on pals@leicspart.nhs.uk

1.2 How LPT listens and responds to complaints

The majority of complaints arise as a result of communication issues. It is vital that every effort is made to ensure that service users and carers are provided with clear information about LPT services so they know what to expect and decisions made about care and treatment are fully discussed and agreed with them. If there is good inclusive communication between LPT staff and service users and carers, with staff taking the time to listen to and address worries and concerns as soon as they arise this can often prevent a concern escalating. Staff must ensure that any complaints raised do not impact on the service user’s on-going care and should provide reassurance to service users and carers that their care will not be disadvantaged as a result of making a complaint.

1.3 Saying sorry

Where service and /or care failings are identified staff should always offer an apology and reassurance to the service user/carer, apologies may be verbally or in writing. The NHS Litigation Authority gives the following reassurance to staff when offering an apology: “Saying sorry when things go wrong is vital for the patient, their family and carers, as well as to support learning and improve safety…Saying sorry is not an admission of legal liability; it is the right thing to do…”

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1.4 New complaint – Action to take upon receipt

All new complaints are received by the Complaints Team in the complainant’s chosen form. A complainant may write to the Trust, email, or call a member of staff. The Trust complaint form can also be completed by the complainant or a member of staff on their behalf. All complaints received will be handled in line with the Complaints Regulations.

Date stamp complaint on day of receipt

Review the contents of the complaint. Is there anything that requires urgent action i.e. appointment issues. If so, advise Complaints Manager or deputy for advice

The Complaints Manager, or deputy, must be alerted if the complaint correspondence raises any safeguarding issues, claims for compensation or legal action, contact with the media, or communication with the Care Quality Commission (CQC), Clinical Commissioning Group (CCG), NHS England, MP’s, Department of Health etc.

Is the subject of the complaint something that LPT is responsible for? If the complaint relates wholly to another organisation seek consent from the complainant before sending it through the appropriate channels to the other organisation.

Is another organisation involved? If so, check the Joint Complaint SOP

Is the complaint ‘out of time?’ If the complaint relates to something that LPT is responsible for, but does not fall within the last twelve months discuss with the Complaint Manager or deputy. Section 12 of the Complaint Regulations specifies that a complaint must be made not later than 12 months after the date on which the matter of the complaint occurred, or, if later, the date which the subject of the complaint came to the notice of the complainant. The Trust can investigate the complaint if it is felt that the complainant had good reason for not making the complaint within the time limit and it is still possible to investigate effectively and fairly. If the complaint is not to be investigated the Complaints Manager will write to the complainant using the ‘out of time’ acknowledgment letter template.

If the correspondence contains any request to access records send a copy of the correspondence to LPT-SARRequests@leicspart.nhs.uk. The following paragraph should be included into the acknowledgment letter: ‘Please note that your request to access your records has been forwarded to our Subject Access Request Team and they will be in contact with you shortly about this’. If in doubt please consult the Complaints Manager or deputy.

If the correspondence contains any freedom of information requests send a copy of the correspondence to LPT-FOIRequests@leicspart.nhs.uk. The following paragraph should be included into the acknowledgment letter: ‘Please note that your FOI request has been forwarded to our Freedom of Information Team and they will be in contact with you shortly about this’. If in doubt please

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consult the Complaints Manager or deputy.

If the complainant has not provided sufficient details please check the patient electronic record. It may be necessary to contact the complainant requesting further information either by telephone or using the appropriate letter.

All complaints received by the Trust into the generic complaints email inbox should be acknowledged, with the advice that their complaint will be logged and passed to the appropriate service for investigation. This does not remove the requirement for the complaint to be formerly acknowledged in writing.

Check the complainant’s details on Safeguard prior to logging. Has this complaint, or something similar, been logged by the same complainant? If no proceed with the complaint, if yes, discuss with Complaints Manager or deputy to agree a suitable way forward.

Does the complaint cover more than one service or team? If so, discuss with Complaints Manager

1.5 Logging a complaint onto Safeguard

All relevant fields and documents should be entered into or saved onto Safeguard. This enables accurate reporting and to ensure that the investigation lead has all the necessary information.

Open Safeguard, Customer Services and open ‘New Case Form’

Enter the enquirer’s details (this will be the complainant’s details)

If applicable, enter the ‘On Behalf Of’ details. This will usually be a patient if someone else is complaining on their behalf

Ensure ‘Case Type’ and ‘Grade’ are both listed as Complaint

Enter the relevant details on ‘Case’ ensuring that the current stage and status are accurate, and that the date received and acknowledged are correct.

The summary should have TBC entered, as this indicates that the deadline is still under negotiation

The details should be a brief summary of the complaint. The complaint, i.e. if an email, should not be copied and pasted into this box. The details should be ‘clean’ i.e. no names or any other confidential information as it can be used for reporting.

Under ‘Categories’ ensure that all relevant fields are completed. The outcome should be listed as ‘ongoing’

Insert the applicable ‘People Involved’

The ‘outcome’ tab is not completed until page 2 of the CMD is returned. This should therefore be left

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blank

When you save the record you will get your unique Case ID i.e. 12345

Open the shared Patient Experience folder. Under Complaints\Customer Service\Safeguard Documents. Open the applicable financial year and create a new folder using your unique case ID. All folder names should follow this format: LPT12345-1617 (the last two digits reflecting the current financial year)

Save the complaint into this newly created folder, this could be an email, scanned letter or completed contact form.

Import the complaint onto Safeguard with the title ‘Original Complaint’, including the date it was received.

Start ‘Mail Merging’ the documents ready to send to the service. This should include: - New CMD - Investigator Contact Letter - Response Letter - Acknowledgment letter - Severity Grading Tool

Check that the CMD has mail merged all relevant sections. The CMD will need some manual input on Advocate sections, or patient details, so ensure that it is fully completed. Whilst the information on Safeguard ‘Case’ tab (Details) should be brief so as not to affect reporting, it is acceptable to copy and paste the complaint (if received by email for example) into the CMD.

Email the documents, and the original complaint, to directorate staff, nominated investigator and any third party organisations (where applicable) using the email template.

Add the new complaint to the schedule, under the tab ‘Awaiting Page 2 CMD’

The acknowledgment letter will be checked by the Complaints Manager and signed. This can be completed by the deputy in the Complaints Manager absence.

If consent is required, a blank consent form is available on the shared drive to include with the acknowledgment letter.

The acknowledgment letter should contain a copy of the advocacy leaflet and the Complaints leaflet

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1.6 Consent and Confidentiality

If a complaint is raised by someone other than the patient, the patient’s consent is required before sharing confidential information about their care, treatment and/or the findings of a complaint investigation.

In the case of a patient who is deceased, consent must be sought from the next of kin. There must also be a consideration of what information can then be shared with the person who raised the complaint, especially if next of kin status cannot be proved. In the case of a deceased individual, disclosure of information falls under, either the Freedom of Information Act 2000 (FOI), or in the case of health records, under the Access to Health Records Act 1990 (AHRA).

Care must be taken when complaints are raised by third parties acting on behalf of the patient. Wherever the patient has capacity, express consent must first be sought. Where capacity does not exist in a patient aged 18 years or over, this should be verified with the clinician responsible for providing care. The complaint team will ascertain whether a Lasting Power of Attorney (LPA) for the patient’s health and personal welfare is in place. If so, consent must be sought from the attorney who will make a decision on behalf of the patient. If there is no LPA in place, liaison between the Complaints Team, the Caldecott Guardian and the Safeguarding Team will take place to review if there are best interest issues.

1.7 Assessment and triage process

To ensure complaints receive an appropriate level of investigation the investigator will triage all complaints received by the Trust. The Complaint Severity Assessment will inform the level of investigation. The level of investigation should be proportionate to the level of risk. Complaints triaged as ‘very low’ (green) and ‘low’ (yellow) are those that are fairly straightforward, simple, non-complex issues and require a minimum level of intervention. They are the type of complaint which require a minimal level of fact finding prior to resolution for example delayed or cancelled appointments, loss of property, single failure to meet care needs (missed call-back bell), medical records missing etc. Complaints triaged as ‘moderate’ (amber) relate to several issues over a short period of care for example events resulting in moderate harm, delayed discharge, miscommunication or misinformation, medical errors, incorrect treatment, staff attitude or communication. These complaints require a higher and more significant level of intervention such as root cause analysis.

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Complaints triaged as ‘high’ (red) are highly complex multiple issues relating to serious failures, causing serious harm for example abuse or neglect, event resulting in serious harm or death, assault, gross professional misconduct. These complaints should be investigated by an individual who is independent to the area which is subject to the complaint. However, ‘high’ complaints that subject of a ‘serious incident’ (SI) will be investigated in line with SI processes. Communication is essential between the Complaints Team and the SI team to ensure appropriate action is being taken.

1.8 Investigation process

The investigator should review all the relevant details of the complaint, including the original complaint, to gain a clear understanding of the issues raised The investigator should make contact with the complainant to agree a deadline and to agree the issues for investigation. If the investigator is unable, or it is not appropriate, to telephone the complainant to agree a timescale the investigator contact letter should be completed and sent back to the Complaints Team, who will post it to the complainant. The letter must include a timescale. Once the timescale and issues are agreed section 2 of the CMD should be completed and returned to the Complaints Team. The initial risk assessment must be completed, along with the number of working days to respond. Section 2 of the CMD must be returned within 5 working days of receipt. The CMD should also be reviewed to check staff involved and category of complaint is correct. Upon receipt of section 2 of the CMD the Complaints Team will review, upload to Safeguard and amend the schedule. The complaint should be moved from ‘Awaiting Page 2 CMD’ to ‘Under Investigation’ and the deadline for completion should be entered. Guidance on completing the schedule is available. The Complaints Team will advise the investigating team of the deadline. If, during the investigation, it becomes clear that the final response will not be available by the agreed timescale they should contact the Complaints Team to discuss the possibility of negotiating an extended timescale. Deadlines should only be extended with the agreement of the complainant, and whilst, should not exceed 10 days, there can be negotiation dependent on reason for extension. The Complaints Team will contact the complainant to agree the extension. If the complainant does not agree to an extension, the complaint will be classed as ‘in breach’ for reporting purposes and all efforts must be made to adhere to the

10 April 2017

original deadline. If the complainant makes any further contact with the Complaints Team during the investigation, the lead investigator must be made immediately aware of the nature of the contact and whether there are any further issues that require investigation. If further issues are added by the complainant it is reasonable to re-negotiate the deadline, depending on the circumstances. This should be completed by the investigator. If complainant requests meeting or telephone call as the method of resolution the investigator will provide a summarised written outcome and associated documentation to the complaint team for issue to the complainant. The complaint can be closed as resolved ‘verbally’ or ‘at meeting’.

1.9 Carrying out the investigation

The investigator undertakes investigation using the CMD. The investigator will ensure appropriate support for staff complained about is provided. Statements, interviews, contemporaneous notes and other documentation will be gathered and securely stored by the investigator until they are passed to the Complaints Team after investigation.

When compiling the response letter the investigator should ensure:-

that details of the person undertaking the investigation are included

the letter is written by the investigator in the appropriate tense, i.e. on behalf of the Service Director (for low and medium severity complaints) or the Chief Executive (for high severity complaints)

an apology is given if the response is overdue along with an explanation for the delay

an apology and/or condolences are included where applicable

each of the issues the complainant has raised have been addressed with a full explanation or the reason(s) has/have been given why it is not possible to comment and what was discovered

details of action, improvements or changes made as a result of the complaint are given

any positive comments made by the complainant are acknowledged

an offer to meet the complainant with key staff involved is included, when appropriate

the balance is right between being too personal or too factual

For complaints received from MP’s on behalf of constituents, care is taken to avoid including unnecessary clinical information.

the letter is checked for mistakes or inconsistencies e.g. Dr Brown then David Brown, use titles only

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not first names (except for young children)

The response must be checked to ensure it makes sense to the complainant, check for complex sentences, grammar and medical jargon.

The name and telephone number of the Complaints Team are given for further queries/discussion.

The investigator will conclude whether the complaint is upheld or not and will re-assess the severity grading of the complaint on Section 3 of the CMD.

When an investigator has completed their response letter, it must be sent to the Complaints Team for quality assurance (QA). The investigator should provide a completed CMD along with any documentary evidence of the investigation.

Letters for QA must be returned to the Complaints Team at least 5 working days before the final deadline. A letter will not be quality assured unless section 3 of the CMD is returned. Section 3 should be fully completed with a decision (i.e. upheld/not upheld) and the final risk assessment/severity grading. The investigator will share the draft letter and proposed improvement actions with staff involved.

1.10 Unreasonable and Persistent complainants

Persistent complainants can fall into the following categories:

People who make frequent complaints about a variety of different issues

People who persistently make the same complaint with minor differences, but who never accept the outcome of any investigation into their complaint

People who are seeking an unrealistic outcome and intend to persist until such an outcome is achieved

People who make the same complaint through different routes (e.g. Chief Executive, MP’s), or changing the wording of similar complaints, in the hope of getting a different response or applying pressure to the investigating or Complaints Team.

Persistent complaints are also likely to include all or some of the following:

Contact is frequent, often lengthy and is complicated. This takes up excessive time and commits the Trust to an unreasonable and unrealistic commitment of resources

The complainant behaves aggressively and provocatively towards members of staff, sometimes singling out or targeting specific individuals

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The complainant changes aspects of the complaint, or the desired outcome, part way through the investigation and/or after independent review.

It is important to be aware that this list is not exhaustive, and the complainant may act in a manner different to those listed above. If in doubt always consult a senior manager and/or the Complaints Manager for advice. If, once the complaint is responded to, the complainant remains dissatisfied and declines to follow the procedures defined for re-opened complaints, the Complaints Team should advise that the matter is now closed and that no further correspondence will be entered into, unless a new complaint is raised. This new complaint must not relate to that which has been through the procedure and which could not have been raised with the original complaint. Staff should not be expected to tolerate verbal abuse from complainants either over the telephone or face to face. If a complainant is abusive over the telephone, staff should first identify the caller (if possible) and advise them that they are not prepared to continue with the call if the abuse continues. If the complainant continues with the abuse, staff should state “I am ending this call” and put the telephone down. An incident should be completed in line with the Trust’s incident reporting process. In the case of persistent abuse, the complainant should be advised in writing that all future communications will be in writing only. This must be subject to accessibility considerations. All such incidents must be fully documented in line with the Trust’s incident reporting process. If it is likely that an individual who is attempting to investigate a complaint is considered to be at risk of violence because of previous incidents, appropriate steps must be taken to create a safe environment for any face to face interviews with the complainant. If, in the event of a face to face meeting and wherever appropriate, the complainant should be advised that the interview will be terminated in the event of any risk of violence or threatening behaviour. Under the provisions of Health and Safety legislation, the Trust is under an obligation not to knowingly place an employee at risk and therefore in the last resort, LPT could refuse to investigate the complaint. If there were to be a challenge to such a decision, LPT would have to demonstrate that it acted reasonably. When using any of the above approaches to manage contact with unreasonable or aggressive people, it is important to explain what you are doing and why, and to keep a detailed record of the ongoing relationship.

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1.11 Quality Assurance

It is appropriate that all complaints severity graded Low/Medium are signed off by the Service Director. All complaints severity graded as high must be signed off by the Chief Executive.

When an investigator has completed their response letter, it must be sent to the Complaints Team for quality assurance (QA). The investigator should provide a completed CMD along with any documentary evidence of the investigation.

Letters for QA must be returned to the Complaints Team at least 5 working days before the final deadline.

The Complaints Team will QA the response, using the complaint response checklist

If there are amendments or queries this must be returned to the directorate

Once the letter is approved and signed it is returned to the Complaints Team. The directorate should not be sending out final signed response letters. The Complaints Team will post the letter, and update the relevant fields on the case on Safeguard and the schedule

If consent has not been received the Complaints Team should send a reminder, advising that the investigation has been completed and that the Trust is unable to share the results of the investigation until consent is received.

If the letter is a response to a high severity complaint and meets the required standard this should be forward to the Chief Executive’s office for signoff. Again, check consent before it is posted

After the Chief Executive has signed the letter, the Chief Executive’s office will scan the signed letter, sending the original to the complainant and the copy to the Complaints Team

The Complaints Team should complete any outstanding fields on Safeguard and the schedule

Electronic signatures are acceptable If the complainant has requested a meeting or a telephone call as the method of resolution the investigator will provide a summarised written outcome and associated documentation to the complaint team for issue to the complainant. The complaint can be closed as resolved ‘verbally’ or ‘at meeting’. Section 3 of the CMD must still be completed, so the outcome and final risk assessment is known.

1.12 Closing a complaint

If the complaint had no actions as a result it can be closed on Safeguard once the final signed response is posted to the complainant.

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If the complaint has actions as a result evidence from the investigator must be provided before the complaint can be closed on Safeguard. If actions were completed as part of the investigation, evidence should be submitted with Section 3 of the CMD when the complaint was being quality assured. Section 3 of the CMD has an option for actions required from an investigation. This should be completed, where relevant, and the Complaints Team will input the information on the ‘Action Plan’ tab on Safeguard. Only when evidence of the actions has been received can the complaint be closed.

1.13 Meetings

Meetings can be effective to diffuse a potential complaint, resolving an ongoing complaint, or clearing up outstanding issues following a written complaint response. Meetings should be seen as a tool to assist resolution of the matter and lessen the likelihood of an escalation of the complaint.

Preparation for Meeting

The directorate responsible for the complaint will:

Chair the meeting, check with the complainant what the issues are, who they expect to meet with, and if anyone will be attending the meeting with them

Identify any preferential dates and times and any dates and times to be avoided

Arrange a suitable venue for the meeting. It may be best in some cases to meet at an offsite, neutral venue at a time negotiated between both parties

Set up the meeting as soon as possible within the agreed timescale.

Draft a letter to confirm the meeting date, time, venue and attendees, specifying who is attending and who is expected to attend with the complainant. This should be sent to the Complaints Team to be posted out.

A timescale for the meeting should be set.

A meeting arrangement template letter is attached. Please complete the necessary details and forward to the Complaints Team for them to send out and ensure correct information is recorded on Safeguard.

Before the meeting the chair will review the circumstances and the details with staff involved, reminding them of the need to maintain honesty, integrity, and consistency

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The chair will ensure all staff are kept up-to-date: including clinical staff, secretaries and relevant others

If the chair is concerned that the complainant or their family may be intimidating to a staff member they may use their discretion and decide not to have that staff member at the meeting

The chair will ensure attending staff are briefed and offered support.

The venue should offer appropriate facilities, including appropriate refreshments

The service will be responsible for ensuring case note availability for the meeting

Holding the meeting

The chair will lead introductions and confirm the reasons for the meeting

During the meeting, notes will be taken including any follow-up action identified and any key admissions.

Listen – ask the complainant to outline their key issues. Clarify outstanding issues from those that might already have been addressed

If you are unsure what you will say, then have a script and have the complaint file and case notes to hand for reference.

Where necessary accept responsibility for errors and provide apologies

At the end of the meeting summarise the key points and any actions agreed, together with who will undertake them.

Tell the complainant what will happen next and when

Stick to the timescales you have agreed

After the meeting

Meeting notes must be written up, approved by the relevant service lead and quality assured and sent to all participants at the meeting within 10 working days. A copy of the meeting notes should also be sent to the Complaints Team. The investigator will draft a response letter using the original response template, amended appropriately. The letter can be a cover letter to the notes detailing any action points agreed and following the sign off process identified above. Complaints Team will ensure that the signed response is saved onto Safeguard as per section 6 and 7 of this procedure.

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1.14 Action plans

Section 3 of the Complaint Management Document (CMD) has a table entitled “Improvement actions required.” This is used to identify any actions that may have resulted out of the complaint. It is important to ensure that these improvement actions are accurately recorded, both onto Safeguard (for reporting purposes) and to the complaint schedule. 1. The complaint has identified no actions If this is the case, the complaint can be closed on Safeguard and the schedule once the final signed response (FSR) has been sent out to the complainant. 2. The complaint has identified actions, all of which have been completed The actions need inputting onto Safeguard and the complaint can be closed, but only if the evidence of these completed actions has been included. For example the action may have been a discussion with staff however the Complaints Team would require evidence of this discussion. The simplest way to provide evidence is to embed documents into the CMD Section 3 when it is returned for quality checking. This could be a staff statement, minutes of a meeting, evidence of training etc. 3. The complaint has identified actions, some of which have been completed Same as 2 above for the completed actions. However the actions that have yet to be completed should have a target date and a responsible person. These actions need logging onto Safeguard and the complaint should be moved from the relevant directorate on the schedule to the ‘Evidence of Actions’ tab. The complaint must not be closed until evidence that these actions are completed has been received. 4. The complaint has identified actions, none of which have been completed Actions that have yet to be completed should have a target date and a responsible person. These actions need logging onto Safeguard and the complaint should be moved from the relevant directorate on the schedule to the ‘Evidence of Actions’ tab. The complaint must not be closed until evidence that these actions are completed has been received. At no point should a final signed response be delayed because of evidence outstanding. There will be occasions where actions have a deadline of many months in advance and it would be unreasonable to hold onto a response for this reason.

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Complaints – Joint Complaints

Joint complaints are complaints where another organisation’s input is required to ensure a full response is provided to a complainant. The 2009 Local Authority Social Services and National Health Service Complaints (England) Regulations (referred to as 2009 Regulations in this standard operating procedure) includes a duty to co-operate (regulation 9). It requires the Trust, and the other organisation(s), to co-operate for the purpose of:- - Co-ordinating the handling of the complaint and - Ensuring that the complainant receives a co-ordinated response to the complaint Each involved organisation has a duty:

To seek to agree which of the two organisations should take the lead in co-ordinating the handling of the complaint and communicating with the complainant

To provide to the other organisation information relevant to the consideration of the complaint which is reasonably request by the other organisation

To attend, or ensure representation at, any meeting reasonably required in connection with the consideration of the complaint It is recognised that the Trust may be the lead organisation or a participant in an investigation lead by another organisation. This SOP is therefore composed of two parts, detailing the different responsibilities and requirements.

2.1 If the Trust is the lead organisation

The Trust will lead a joint complaint if:

- The complainant has expressed so either verbally or in writing

- It is clear from the complaint that the Trust will lead. This may be due to the number of or complexity of

issues the complainant has raised for the Trust to respond compared with relatively few for any other

organisation(s).

If it is not clear which organisation will lead, communication should be made with the other organisations

involved to ensure clarification. This must only take place, however, once consent has been provided from the

complainant.

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2.2 Consent to share with other organisation(s)

Consent to approach any other organisation(s) involved must always be sought, in writing, before the Trust shares the detail of the complaint.

Whilst there will be occasions where the complainant has already given permission, i.e. by stating this in the complaint itself, other organisations may have processes which require a separate consent form to be completed. To avoid any delay in responding to a complaint, a consent form (and return envelope with the Patient Experience freepost address) should always be sent to the complainant in a letter.

In addition the usual guidelines regarding consent must be adhered to. If the complainant is not the patient, consent must be obtained from the patient before the complaint can be shared with another organisation involved. If in doubt liaise with the Team Leader or the Complaints Manager as to the correct course of action.

2.3 Timescales

The timescale for responding to a joint complaint will be subject to the timescales of the other organisation(s) involved. It must be made clear to the complainant in the initial correspondence from the service that the deadline for completion will be dependent upon this. It is recommended that for any complaint involving other organisations a 60 day timescale for completion is suggested. This can be reduced to 40 days if necessary.

2.4 Process for logging a joint complaint – once consent to share has been received

Responsibility for acknowledging the joint complaint lies with the lead organisation.

On receipt of a joint complaint the Complaints Team will date stamp. The Complaints Manager must be alerted immediately if the correspondence raises:- a) Safeguarding issues e.g. patient threatening suicide, self-harm, domestic violence, abuse of children or vulnerable adults b) Potential claims for compensation or taking legal action c) Contact with the media, including Leicester Mercury, radio, television etc. d) Communication with the CQC, CCG’s, NHS England, MP’s, Trust Development Authority, DoH etc.

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Is the subject of the complaint something that the Trust was responsible for within the last twelve months? If no please discuss with team leader or Complaints Manager. The 2009 Regulations specify that a complaint must be made within twelve months of the date on the subject of the complaint or if later the date on the subject of the complaint came to the notice of the complainant. The Trust will investigate if the complainant had good reason for not making the complaint within that timeframe and it is still possible to investigate effectively and fairly. If on review the Complaints Manager believes that this is not possible he/she will write to the complainant explaining this. If the correspondence contains any request to access records the Complaints Administrator will ensure a copy of the correspondence is sent to LPT-SARRequests@leicspart.nhs.uk. The complainant should be made aware that this action has been taken by including an acknowledgment in the letter. This also applies to Freedom of Information (FOI) requests, however please note the email address LPT-FOIRequests@leicspart.nhs.uk. Under no circumstances should the service be approached to ask if they will liaise with the FOI. It is the expectation and responsibility of the Complaints Team to ensure this request is noted and forwarded appropriately. This will avoid any delays or potential breaches.

If you have insufficient details (after checking the electronic record) to be able to progress the complaint, contact the complainant requesting further information. This may be by telephone, email or writing to them. A search should be performed on Safeguard to determine whether this complaint, or something similar, was logged before by the same complainant. If there is no evidence on Safeguard to indicate that this is the case proceed with logging the complaint. If this has been logged previously, or the issues are very similar to a previous complaint made by the complainant, discuss with the Complaints Manager to agree an appropriate response.

When logging on Safeguard the complaint must be logged as a complaint not as a joint/multi-agency complaint. If the Trust is to lead a complaint logging it as a multi-agency complaint will affect monthly, quarterly and annual reports. Only if the Trust is a participant organisation should the complaint be logged as a joint/multi-agency one. The relevant files must be completed on Safeguard and page one of the Complaint Management Document (CMD) completed. The lead directorate and others involved must be identified and please complete input to Safeguard ensuring date of complaint received, consent required is not left blank. The acknowledgment letter should be prepared, printed and checked by the Team Leader or Complaints Manager. The Complaints Administrator will scan the signed acknowledgement onto Safeguard and post the letter to the complainant with a copy of the Complaints leaflet, the advocacy leaflet and the necessary consent forms.

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A free post envelope (envelope with label) should be enclosed so the complainant can return the consent form.

Email complaint to directorate staff, nominated investigator using email template, ensuring that the Complaint Management Documentation, LPT complaint severity grading tool, guidance for deciding on timescales for responding to complaints, the template letter for initial contact with the complainant and the response letter template are all attached. The complaint should be saved and then included onto the schedule. There is no separate tab for joint complaints. The complaint will be saved onto “Awaiting Page 2 CMD” until the CMD is returned by the service providing timescales and plan for investigation.

2.5 Return of consent

Once the consent form is returned, and signed, by the complainant giving authority to share details with the other organisation(s) involved this must be date stamped and saved onto Safeguard. A copy of the consent form, copy of the original complaint and any other relevant correspondence must be sent to the other organisation(s) involved. It must be made clear to the other organisation(s) what part of the complaint they need to respond to. Ideally the completed Page 2 CMD will detail what parts of the complaint the Trust can respond to, and what parts other organisation(s) need to respond to. If this is unclear please liaise with the service/lead investigator to clarify. The email to the other organisation(s) must include:

- A deadline to receive their response to the Complaints Team so this can be merged into the LPT response

- A clear indication of what the other organisation(s) needs to answer - An explanation that the Trust will require their response as part of a co-ordinated response

Other organisation(s) should not be sending their response to the complainant separately. As explained the 2009 Regulations require the Trust and other organisation(s) to work together to provide a co-ordinated response to the complainant. If the other organisation(s) involved request that they send their response separately this must be discussed with the Complaints Manager and with the complainant to agree a suitable approach. Only under certain circumstances would this be approved, i.e. express wish of the complainant.

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2.6 If consent is refused

If the consent form is returned unsigned, or the complainant contacts the Complaints Team/Lead investigator/Service asking that the Trust do not approach the other organisation(s) please speak to the Team Leader or Complaints Manager. It must be explained to the complainant that the Trust will be unable to comment on any aspects of care that is provided by other organisation(s) and that this is the reason consent was requested. It may be that the complainant is unaware of which service(s) are provided by the Trust or other organisation(s) and every opportunity must be taken to ensure that they are made aware of this. If, after these efforts are made, consent is still denied to pass onto other organisation(s) this must be clearly documented on Safeguard. At no point should other organisation(s) be approached until this consent is granted.

2.7 Sharing

The lead organisation should always make sure the other organisation(s) involved have the opportunity to

review the final response before it is sent to the complainant.

2.8 If the Trust is the participant organisation

If the Trust is the participant organisation the same approach should be taken as indicated in the General SOP. The other organisation should indicate clear timescales on when they require a response and what action is required by the Trust. The CMD should still be completed, although it is recognised that the lead organisation will have made contact with the complainant, so this is not usually required by a participant.

Once the investigation is complete and signed off the Complaints Team should send the response to the lead organisation. The lead organisation should always make sure the other organisation(s) involved have the opportunity to review the final response before it is sent to the complainant.

22 April 2017

Complaints - Re-opened complaints (Further complaint correspondence)

It is recognised that a complainant may have further questions, or is unsatisfied with their response. The complainant may not accept the explanation provided by the Trust, the concerns raised may not have been answered, or the letter did not offer assurance that learning would take place.

This provides guidance on the management in these situations, and details circumstances in which the complaint should be re-opened and re-investigated.

3.1 Dealing with further correspondence from complainants

After a complainant has received their response from the Trust they may contact, at any time, to discuss the findings of the investigation. This correspondence may be positive, or it may necessitate further work to address the complaint. It is important however that the way in which the Trust will respond must be agreed with the complainant to ensure that they are fully informed and aware of the approach the Trust intends to take. Positive/Complimentary If a complainant wishes to pass on thanks to the investigator for providing the necessary assurance, or undertaking an investigation that has satisfied their concerns, this should be documented on the complaint section of Safeguard and passed onto the relevant investigator for their information. - Documents received need to be saved onto Safeguard and then emailed to the investigating team - Telephone calls need to be documented onto Safeguard and then emailed to the investigating team Potential re-opening (clarification) There may be circumstances when a complainant contacts the complaints team and is unsure of how to proceed. They may have further questions, or are only seeking clarification on a single aspect of the investigation. It is important for the Complaints Team to ensure that the complainant’s wishes are fully understood so the appropriate action can take place. By telephone - If a complainant has telephoned the Complaints Team and is unsure whether they wish for further investigation, discuss with them about their concerns and what aspects of the complaint they feel have been unanswered to their satisfaction. It may be that the complainant wishes to seek clarification on a part of the investigation, especially if this has been unclear in the Trust’s response. - Agree with the complainant on the appropriate course of action. A further telephone call from the

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investigating officer may be sufficient to address their concerns. If necessary seek advice from the Complaints Manager or Team Leader

By letter - If a complainant has written to the Complaints Team and the contents indicate that there may be further clarification required, email this to the investigating team and request immediate action to be taken to make contact with the complainant. Ensure all the relevant documents are uploaded onto Safeguard and a timescale is given to the investigating team to make contact. - If it becomes clear from the investigating team that the complaint will need to be re-opened, contact must be made with the Complaints Team so the complaint can be re-opened on Safeguard.

3.2 If the complaint is to be re-opened

Correspondence received, by letter or telephone, will often expressly indicate concerns about the investigation and a desire for the complaint to be re-investigated. There are several reasons for why a complainant may wish for their complaint to be re-investigated: - The complainant does not accept the explanation provided by the Trust - The response did not address the concerns raised - The response did not assure the complainant that learning would take place - The response has raised further questions In these circumstances: - The Complaints Team will date-stamp correspondence and save all documents onto Safeguard - A copy of the request will be sent by email to the investigator asking them to arrange the required work and specifying the date a response is required. The completed CMD should be sent to the investigator the completed CMD that had been sent back initially, with instructions to complete Page 4 and send it back to the Complaints Team in 5 days. The email template must be used, ensuring that the original complaint, the original response, the letter template and any further correspondence is attached. - An acknowledgment letter will be sent to the complainant by the complaints team outlining the planned action. This should be completed within 3 working days. If there are occasions where it is not possible to confirm to the complainant about the action being taken, a letter should be sent indicating that their further correspondence is being reviewed by a senior member of service staff. - A reopened complaint should usually be completed within 25 working days, unless there are clear reasons

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as to why a longer timescale would be necessary. A longer timescale must be documented as agreed with the complainant along with the reasons provided. - The signoff and quality assurance process for a re-opened complaint will be undertaken in the same process as the handling of the original complaint. The Complaints Team will receive the letter from the service for quality assurance process and then returned for signoff.

3.3 Meetings for re-opened complaints

Meetings can be effective to resolve a re-opened complaint. Meetings should be seen as a way to assist resolution of the ongoing concerns. Section 1.13 of this SOP details preparations for the meeting, holding the meeting and what actions are required after the meeting. This should be followed for any re-opened complaints.

3.4 No further local resolution

By letter If the complainant has indicated that a further response, or a meeting is not required, and/or local resolution has been completed the Complaints Team will acknowledge receipt of the letter. The letter will thank the complainant/author of the letter for the feedback received and upload the letter to Safeguard. A copy of the letter should also be sent to the investigating team for their information. By telephone The same process above applies for telephone calls, however the contact of the telephone call should be documented on Safeguard and an email outlining the nature of the telephone call passed onto the investigating team.

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3.5 If the complainant wishes to go to the Parliamentary and Health Service Ombudsman (PHSO)

A complainant may contact the Trust to enquire about taking their complaint to the PHSO. This would normally occur if the complainant remained unsatisfied with their original response, or had reopened their complaint and did not feel that, after further investigation or clarification, the complaint had addressed their concerns. It is important to consider these queries carefully and to ensure that the Trust is confident that local resolution has been resolved. Have all options to answer the complainant’s concerns been undertaken? If this information is not clear on Safeguard the service involved would need to be contacted to ascertain their opinion and whether any further measures could be taken to ensure the complainant has a satisfactory response.

If local resolution is considered complete, then a complainant does have the right to take their complaint to the PHSO. If a complainant wishes to take their complaint to the PHSO and is asking the Complaints Team for advice it is important to ensure the complainant is aware of the information the PHSO is likely to ask them. They PHSO will ask the complainant about: - The complaint - When it happened - How it affected the complainant(s) - What the complainant would like the PHSO to do to put things right

In most circumstances the PHSO will want the complainant to have a copy of the Trust’s final decision letter to hand.

The PHSO will take complaints from complainants directly, either online or by phone. Someone can register for an account on www.ombudsman.org.uk or they can call 0345 015 4033. They will take the complaint over the telephone and then send a summary of it to the complainant to approve. If in doubt at all please contact the Complaints Team Leader or Complaints Manager for further guidance.

26 April 2017

Complaints - Parliamentary and Health Service Ombudsman (PHSO)

The PHSO look into complaints where an individual believes the NHS has not acted properly or fairly, or has provided a poor service and not put things right. Their powers are set out in law and they are the final stage for complaints about the NHS in England and public services delivered by the Government.

The PHSO will ask that an individual complains to the organisation they are unhappy about first. This gives the organisation that chance to put things right. Only if there is a dispute about the complaint after the organisation has replied will the PHSO look into the complaint. The PHSO will assess the complaint using the Principles of Remedy, Good Administration and Good Complaint Handling (2009).

This provides guidance on how to manage requests for information from the PHSO. If in doubt, please always ask the Complaints Manager for support.

4.1 Dealing with initial enquiries and requests for information

The PHSO will always notify the Trust of their intention to investigate a complaint by letter. An example letter is included. This letter will usually be addressed to the Chief Executive and will detail what action, if any, is required.

Upon receipt of this letter the Chief Executive’s office: - Will ensure the Chief Executive is aware of the request and then pass to the Complaints Team for immediate action. This should be sent electronically to complaints@leicspart.nhs.uk with the hard copy sent in the post. Upon receipt of the PHSO letter (whether by email or post) the complaints team must: - Ensure the Complaints Manager (or deputy) is made aware that the PHSO have notified the Trust of their intention either to investigate or to request further information. This will depend upon the individual case. The Complaints Manager or Team Leader will review the contents of the letter and, if necessary, make contact with the nominated caseworker at the PHSO. This will depend upon the circumstances and whether any relevant information needs to be passed to the PHSO immediately (i.e. if the member of staff involved in the complaint no longer works at the Trust). The Trust, however, will still be required to comply with requests and outcomes as directed by the PHSO.) Whilst each PHSO investigation notification will differ depend upon the nature of the complaint the PHSO will usually request copies of medical records and the complaint file. In some cases a checklist is provided to

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ensure the Trust provides all the required information.

There are occasions when the PHSO will be enquiring with the Trust if local resolution has ended. It may be that there are further options to resolve a complaint that have not yet been undertaken and the Trust would seek to explore these before local resolution is completed.

The Complaints Team will: - Input the request to the case onto Safeguard, completing the relevant fields on PHSO tab and in contacts - Upload the letter of request to Safeguard inform the relevant service - Send a copy of the request by email to LPT-SARS, providing the date that the PHSO require the medical and complaint records. LPT-SARS will release medical records directly to PHSO. The SARS team should complete their part of the checklist (if included) and send back to complaints team. The complaints team will release the complaints file from Safeguard - Ensure a copy of the complaint file is disclosed to the PHSO as per the agreed format. If the PHSO require this electronically, they will specify an email address/uploading link. If the complaint file is to be posted it must be sent by Special Delivery to protect the contents. If the service is asked to provide comments, or the PHSO ask for the letter to be shared with named staff, do not send complaint file without these comments. - If a checklist is provided by the PHSO, this must be checked and signed off by the Complaints Manager or deputy - A copy of the covering letter will be uploaded to Safeguard

All releases will be checked by complaint manager (or deputy) and must contain whole file, including signed responses, drafts, statements etc.

4.2 Further questions or comments

On occasion, the PHSO may require additional comments or questions to be answered by the relevant service. The Complaints Team will liaise with the service ensuring that they are aware of the PHSO’s request and what information is required of the service. This must be done in accordance with the timescales prescribed by the PHSO. The service is responsible for ensuring all relevant information is provided. Any correspondence will be passed through the Complaints Team and saved onto Safeguard.

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4.3 Deadlines and extensions

The PHSO will include deadlines in their letters and these must be adhered to. If, after consultation with other relevant departments, it is clear that the deadline will not be met the PHSO must be contacted and an extension requested. The reason for the deadline must be made clear to the PHSO and documented on Safeguard.

4.4 Using the PHSO tab on Safeguard

Each case on Safeguard has a PHSO tab and this is identified by the PHSO logo, which is opposite. Any complaints, which the PHSO have notified the Trust of their intent to investigate after 1 August 2016, must input data and information directly onto the PHSO tab. This will allow for correct reporting. When inputting information onto the tab: - The date the PHSO notified the Trust must be included - The date records were sent to the Trust must be included - There is a section entitled ‘Correspondence with the PHSO’ – this is to be completed with any relevant actions.

4.5 Request from the PHSO to undertake further local resolution

The Complaints Team will liaise with the nominated investigator and key service staff if the Trust is able to undertake any further local resolution. To do this the request will be: - Uploaded to the case on Safeguard the letter of request and complete relevant fields - Send a copy of the request by email to the nominated investigator/key service staff asking them to undertake the further work requested and providing the date the PHSO require a response. - The nominated investigator will undertake the required further local resolution, which may include further investigation, meeting with the complainant and/or confirming service improvements as a result of the feedback. A letter to the complainant will be prepared by the nominated investigator outlining the further investigation outcome or other action. - The Service Director will provide a response to the complaint team for release to the complainant and copy to the PHSO confirming what further work has or will be undertaken. The letter will be saved on Safeguard.

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4.6 Handling of PHSO decisions

The PHSO aim to complete investigations within three to six months. It may take longer on some occasions but 98% are resolved within a year. Complex cases can take longer and the PHSO may seek advice from healthcare professionals or their own legal team to understand the issues fully and come to a decision.

When the PHSO is towards the end of their investigation they will send the Trust, and the person who made the complaint, their draft report on the investigation. It will include the PHSO’s provisional views and recommendations and how the Trust can put things right. This draft report will give the Trust, and the person who made the complaint, the opportunity to comment on the proposed decision and what is said in the report. It may be that there are errors in the report or there is new information the PHSO had not looked at. The Trust is usually given two weeks to respond. It is important that these are sent out straight away to the relevant service. If the CEO has not been copied in, for example on email correspondence, it is important that the electronic copy of the draft decision is sent to the CEO for review.

The Complaints Team will: - Input onto Safeguard, completing relevant fields and uploading the letter - Send a copy of the draft report by email to the Service Director and key service staff asking for them to review the draft report and confirm they accept the recommendations and offer any comments - Inform relevant Trust Directors of the draft report/recommendations as required - On receipt of the response from the Service Director, a letter will be sent to PHSO with any comments and whether the Trust accepts the report and recommendations - A copy of the letter should be uploaded to Safeguard The Complaints Team will send the electronic copy of the draft decision to the CEO and to the service with clear instructions on deadlines for return of comments. If the Service does not accept the recommendations they will be required to provide a response to the Complaints Team so this can be forwarded to the PHSO within the PHSO requested deadline The PHSO will then consider these comments and whether any more work is needed before they make a final decision. It is important to note that decisions are made in relation to both the care provided and how the complaint was managed.

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4.7 Decisions

The PHSO can fully uphold, partly uphold or not uphold a complaint.

If a complaint is fully upheld it would indicate that the Trust made mistakes or provided a poor service and that this has had a negative effect on the individual which has not yet been put right. If a complaint is partly upheld the PHSO found that the Trust got some things wrong, but not all of the issues that had been complained about or that the mistakes did not have a negative effect on anyone.

If the complaint is not upheld the PHSO found that the Trust either acted correctly in the first instance or, if mistakes were made, actions have been taken to put things right for the affected person(s).

On receipt of notification that the PHSO will not be undertaking a review of a referred complaint (what about upheld ones), the Complaints Manager will - Distribute the notification by email to the nominated investigator, key service staff, and the Patient Experience & Improvement Lead who will advise the Chief Nurse. The Complaints Team will: - Input onto Safeguard, completing relevant fields and uploading the letter

4.8 Learning and actions

If a complaint is fully or partly upheld the PHSO will list the actions or remedies. These may include: - An action plan - Financial redress - A letter of apology This list is not exhaustive and the PHSO will be clear on what action the Trust needs to take. The PHSO will also prescribe the timescale in which these actions should be completed and how the Trust can evidence completion.

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4.9 How the PHSO handle complaints

When the PHSO receive a complaint they will complete some initial checks to ensure they can deal with it. They will check whether they can look into the organisation being complained about and whether that person has already been the organisation’s complaints process. They aim to complete these checks within five working days.

If they decide to deal with the person’s complaint they will take a closer look at the complaint. They will consider:

1. Whether the person has been affected personally by what happened 2. Whether they complained within a year of knowing about the issue 3. Whether they have, or had, the option of taking legal action 4. Whether there are signs that the organisation got things wrong that have had a negative effect that

has not yet been put right

The PHSO aim to give a decision within 20 working days. If the PHSO decide to investigate they will aim to complete these investigations within three to six months. Some decisions take longer than this, but they aim to complete 98% within a year.