Thames Valley & Wessex Specialised Mental Health Provider Collaboratives are responsible for the commissioning of specialised mental health care for the network, providing a high standard of care and services that are flexible and responsive to the needs of the service user.
The Provider Collaborative is firmly committed to continuously improving the quality of services it provides or commissions by understanding the experiences of people accessing those services. Commissioned services are those that are paid for by the Provider Collaborative but provided by other organisations.
The Provider Collaborative understands that to continue to make improvements, it is essential to encourage, value, engage with and learn from all types of feedback. Therefore, theProvider Collaborative takes a proactive approach to handling complaints, concerns,comments and compliments as a genuine means to improving the experiences of service users and the quality of its services.
This policy incorporates the Provider Collaboratives obligations in the NHS Constitution and the Health and Social Care Act and responds to several key reports, guidelines and legislations which relate to the handling of complaints
This policy ensures that feedback is always:
- Actively encouraged and that people know how to give feedback and make a
- Taken seriously and responded to their feedback and complaint
- Investigated thoroughly and proportionately to the seriousness of the complaint
- Utilised as an opportunity to learn and The Provider Collaborative will:
- Ensure that this policy promotes a consistent and fair process for managing feedback and handling complaints.
- Ensure that it is easy for people to give feedback, and that the complaints process is accessible for all.
- Implement systems for monitoring, reporting and sharing information regarding feedback and complaints across the network, including lessons learned.
- Follow the full Oxford Health NHS Foundation Trust Concerns, Complaints and Compliments Policy and Procedure (Corp25), based on the NHS Complaints Standards. The Oxford Health website contains a summary of steps to help with understanding the process.
1) Introduction
Thames Valley & Wessex Specialised Mental Health Provider Collaborative is committed toproviding service users, their family members, carers or members of the public with the opportunity to seek advice, raise concerns, compliments and formal complaints about the Provider Collaborative and its services. The Provider Collaborative has adopted a person-centred approach to ensure that issues are dealt with in a way which empowers service usersand their loved ones to make choices about how their concerns are handled and in accordance with the Local Authority Social Services and National Health Service Complaints (England) Regulations 2009.
The Provider Collaboratives approach is structured around the ‘My Expectations’ report, published by the Parliamentary and Health Service Ombudsman, Local Government Ombudsman and Healthwatch. This report sets out a best practice framework to support a positive experience for people raising concerns and complaints in five steps:
- Considering a complaint: ensuring people are given information about how to complain, that they will be supported to do so, and care will not be compromised.
- Making a complaint: ensuring all staff can help, and that making a complaint is easy and convenient.
- Staying informed: keeping people up to date and making the response
- Receiving outcomes: resolving complaints and achieving an appropriate
- Reflecting on the experience: ensuring complaints are handled fairly and consistently, and that people understand how their feedback has helped to improve
2) Definition
The Provider Collaborative recognises and records feedback activity under the following categories:
Comments: Comments may be made either verbally or in writing to any member of staff within the Provider Collaborative. These may be general comments or opinions regarding NHS and Independent Sector services or may be specific to a service. Comments may offer observations or suggestions regarding services.
Concerns: An issue raised in writing, or verbally, identifying issues about a service or the Provider Collaborative.
Complaints: A complaint is an expression of dissatisfaction about any aspect of the Provider Collaborative and its commissioned services requiring a response.
Compliments: The Provider Collaborative recognises that compliments are also a valuable source of feedback. Positive feedback received regarding services can provide an opportunityto acknowledge improvements and successes, to recognise good practice and to apply this across other areas.
3) Purpose
The purpose of this document is to outline the Provider Collaboratives Complaints Policy to ensure that the Provider Collaborative meets it statutory obligations under the Local AuthoritySocial Services and National Health Services Complaints (England) Regulations 2009. This policy aims to ensure the following:
- To provide a clear, simple and easy to understand process for managing complaints which is fair and impartial, widely publicised and accessible to all.
- To ensure complainants and staff are provided with the necessary guidance and
- The causes of complaints and lessons learned are identified and utilised to improve services and prevent recurrence.
- Complaints are managed promptly and efficiently, and answers or explanations are provided quickly and within established time limits.
- Complainants are treated courteously and sympathetically, and care is not adversely affected as a result of having made a complaint.
4) Scope
This policy applies to all complaints, comments, concerns and compliments received by the Provider Collaborative and must be followed by all staff employed by the Provider Collaborative, including those employed as part of a temporary or honorary contract, or any other person that is acting on behalf of the Provider Collaborative. Additionally, all commissioned Providers must ensure that they have robust policies and procedures in place to support service users, carers and their families.
Under the Local Authority Social Services and National Health Service Complaints (England)Regulations 2009 complainants have the choice of making a complaint to either the provider or the commissioner of services, but not both.
5) Exceptions
In accordance with the NHS Complaints regulations the following complaints will not be dealt with under this policy:
- A complaint made by a Local Authority, NHS body, Primary Care provider or independent provider.
- A complaint made by an employee of a Local Authority or NHS body about any matter relating to employment.
- A complaint which is made orally and is resolved to the complainant’s satisfaction no later than the next working day after the day on which the complaint was made.
- A complaint which is the same as a complaint that has previously been made and
- A complaint which has been investigated by a Health Service Commissioner under the 1993 Act.
- A complaint arising out of the alleged failure by the organisation to comply with a request for information under the Freedom of Information Act 2000.
Where a complaint is not to be investigated under the NHS Complaints Regulations 2009, where possible the complainant will be signposted appropriately to progress their concern.
Complaints should be submitted to the Provider Collaborative within 12 months of the event in question, orwithin 12 months of the date on which the complainant first became aware that there was cause for complaint. In exceptional circumstances, this timeframe may be extended at the discretion of the Associate Director or ClinicalDirector of the Provider Collaborative. If a decision is made not to extend the time limit, the complainant will be notified in writing and provided with an explanation.
6) Process and procedures for handling complaints – local resolution
In line with the NHS Complaints Regulations 2009 complainants should be offered a choice ofraising their concerns or making a formal complaint to either the service provider directly, or the commissioner.
All avenues must be explored to resolve issues at a local level, including a review of the complaint, if the complainant is not initially happy with the outcome.
A complaint can be made orally, in writing or electronically. If a verbal complaint is receivedthe staff member should establish whether it is a matter that they or a colleague can respondto immediately. If the verbal complaint can be resolved to the complainant’s satisfaction within one working day, then this will not be recorded as a formal complaint but will be documented. If a verbal complaint is a formal complaint, then the member of staff receiving the complaint must make a written record of the complaint and provide a copy as soon as possible.
All complaints, comments, concerns and compliments should be addressed to the related Provider Collaborative, and sent to:
Address:
Thames Valley & Wessex Specialised Mental Health Provider Collaborative
Slade House
Horspath Driftway
Headington
Oxford OX3 7JH
If emailing, please use: ForMePC@oxfordhealth.nhs.uk
All contacts will be acknowledged within 3 working days of receipt. Following receipt, the Provider Collaborative, in discussion with the complainant, will agree:
- The way the complaint is to be handled, including an offer to meet the patient if
- The timescale for providing a
- The desired outcomes from raising their
Should the complainant wish to meet with the Provider Collaborative to discuss the contents of their complaint this will be arranged. All meetings are to be held on NHS premises with twomembers of staff present. This meeting will be documented and a copy of this shared with the complainant.
When a complaint is received by the Provider Collaborative but is considered more appropriate for the relevant Provider organisation to investigate, the Provider Collaborative team will seek the complainant’s consent to share the details of the complaint with thatProvider. If consent is given, the Provider Collaborative will forward the complaint to the Provider organisation for investigation and response.
If the complainant states that they would prefer for the Provider Collaborative to deal with the complaint on their behalf, the Provider organisation will be notified of this.
If a complaint has previously been investigated by a Provider organisation and the complainant remains dissatisfied with their response, then the complainant has the right to escalate this to the Parliamentary & Health Service Ombudsman. The Provider Collaborativeare unable to reinvestigate a complaint which has already been investigated by a Provider organisation unless any new issues are raised.
If the content of a complaint highlights serious concerns which meet the criteria of an incident, the complaint will be investigated under the Lead Provider (Oxford Health NHS FT) IncidentManagement Policy and the complainant informed. If a safeguarding concern is identified, thenadvice will be sought from the Safeguarding Lead to ensure the safety and best interests of the patient.
Where a complainant indicates they intend to take legal action, the matter should be referred to the Provider Collaborative programme Senior Responsible Officer, to ensure due consideration and collaboration with relevant individuals. If there is no indication that a complaint investigation will prejudice any legal proceedings, the complaint will be registered and dealt with through the complaints process. In some circumstances it may be appropriate to cease action under the complaint’s procedure.
7) Unreasonable complaints
The Provider Collaborative recognises that it is the right of every individual to pursue a complaint. However, on occasions, staff may consider that a complaint is unreasonable
e.g. the complainant raises the same issues repeatedly despite having received a comprehensive response, or the complainant becomes aggressive, threatening, abusive or violent towards those involved in the complaints process. If it is considered that a complainant is becoming unreasonable, the member of staff should refer this to the Associate Director or Clinical Director of the Provider Collaborative who will manage the situation in accordance with the Unreasonable Complaints Procedure (Appendix B).
8) Confidentiality
Feedback and complaints will always be handled in the strictest confidence and in accordance with the Lead Providers information governance policy. Where it is necessary to seek input from organisations external to the Provider Collaborative, written consent from thepatient should be obtained prior to sharing any information. If consent cannot be determined, following multiple attempts, the complaint will be closed.
Information will only be disclosed to those individuals who are investigating the complaint or have been asked to provide a statement directly in relation to the contents of the complaint. Information will not be disclosed to service users or complainants unless the person has givenwritten explicit consent to the disclosure of that information. In the case of a complaint raised by a third party (e.g. family member, carer, MP, representative) including those regarding apatient who has died or who lacks capacity, the representative must be a relative or other person who had or has a sufficient interest in the patient’s welfare and is a suitable person toact as representative. Every case should be considered on an individual basis before a response is provided, and where possible evidence, such as identification or legal documents, will be required.
There may be instances where the investigation of a complaint reveals further information of a particularly sensitive nature that the complainant could feel uncomfortable being disclosed tothird parties. Where explicit consent to reveal such information is not already present, complaints made by representatives, including MPs, may require the Provider Collaborative to gain written consent from the patient prior to sharing confidential or personal information.
There are some instances where the Provider Collaborative is required to disclose patient information without consent to the appropriate body e.g. safeguarding, police or a senior person involved in providing their health care. This must be conducted in accordance with current data protection legislation and may involve cases where the law requires disclosure of information which will be:
- If the health and/or welfare of a child or young person is at
- If the complainant admits to committing a serious
- An individual who may be put at significant risk or their life
Prior to any disclosure where consent has not been provided the Lead Providers Caldicott Guardian must be consulted and recorded within the Caldicott Log (held by the Caldicott Guardian). Following disclosure, a written explanation to the person involved must be provided. Information governance advice may be sought from the Lead Providers Information Governance Lead.
Under the General Data Protection Regulation (GDPR) individuals have the right to complain to the Information Commissioner’s Office if they feel their rights under the regulation have been infringed.
10) Investigation and response
The Provider Collaborative will investigate a complaint in a manner appropriate to resolve it as quicklyand efficiently as possible after receiving the complaint. The complaint must be carried out by someone not directly involved in the events leading to the complaint. The Provider Collaborative will keep the complainant informed throughout the investigation process, as far as reasonably practicable, informing the complainant of any delays.
Where a complaint involves more than one organisation it will be agreed at the beginning of the process which organisation will manage and coordinate the complaint. This is usually the organisation that has the majority of issues, or the highest risk issues. The lead organisation will coordinate a single comprehensive investigation and response to the complaint, as set out in Local Authority Social Services and National Health Service Complaints (England) Regulations 2009.
The Provider Collaborative has contracts in place with multiple Providers and under the 2009 Regulations a patient can choose to approach either the provider or the commissioner to make a complaint. If a complaint received by the Provider Collaborative concerns a commissioned service, the team, in discussion with the complainant, will decide who the most appropriate body is to handle the complaint.
It is not possible to raise the same complaint with the service provider as well as the commissioning organisation.
Following the completion of the investigation and within the timescales agreed with the complainant, the Provider Collaborative will send a formal response in writing to the complainant which will include:
- An explanation of how the complaint was
- Honest explanations based on facts and where it is clear that there has been a mistake or failure inprocedures, this should be clearly stated and an apology given, in line with duty of candour.
- The conclusions reached including any remedial action that the organisation considers to be appropriate.
- Clearly demonstrate how the complaint and findings have improved services or led to
- Invitation for the complainant to contact the complaints team if they have any outstanding concerns.
- The complainants right to ask the Parliamentary and Health Service Ombudsman to review their complaint if they are dissatisfied with the Provider Collaboratives
- Following a response being offered, the Provider Collaborative will actively seek feedback from complainants regarding their experience of making a complaint, which will be recorded and used to inform future policy and process change.
10) Final stage: independent review
If a complainant remains dissatisfied with the response gained at a local resolution stage, they can ask the Parliamentary and Health Service Ombudsman (PHSO) to review the case. The PHSO may review a complaint where:
- A complainant is not satisfied with the result of the investigation undertaken by the Provider Collaborative.
- The complainant is not satisfied with the response and does not believe the Provider Collaborative has resolved their concerns.
- The Provider Collaborative has decided not to investigate a complaint on the grounds that it was not made within the required time limit.
Complainants must have complained to the Provider Collaborative or service provider involved before contacting the PHSO. The PHSO require that a complaint is referred within a year after the day on which the complainant first identified the issue, unless the PHSO considers that it is reasonable to review the complaint outside of this timescale.
Upon request, the Provider Collaborative will provide copies of all records and correspondence relating to the complaint and co-operate fully with the PHSO. If a complaint is upheld by the PHSO, the Provider Collaborative will co-ordinate any points of action requiredto ensure that actions are completed, and a response is provided within the set deadline established by the PHSO.
11) Ensuring learning
Learning from complaints is critical to the delivery of safe and effective services within the Provider Collaborative. Each complaint is an opportunity to improve services and must be used as an opportunity for learning and improvement.
The Provider Collaborative will record the conclusion, lessons learned and agreed actions for each comment, concern or complaint and the area it relates to prior to closing the complaint file. This ensures any themes or emerging trends can be identified.
Themes and trends for complaints are regularly reviewed within the Provider Collaborative Quality Assurance monthly meeting and Provider Collaborative Governance Board. These themes and trends, in a non-identifiable format, are also shared with relevant Provider organisations.
Compliments received within the Provider Collaborative are used to inform good practice which can be applied to other areas to support service development.
12) Compliments
The Provider Collaborative maintain a record of all letters of praise and compliments received.Compliments about healthcare services, or a specific individual received within the Provider Collaborative are shared with the relevant Provider organisation, team, or individual and are includedwithin regular reports. Compliments are an effective source for informing service improvement and for sharing best practice.
13) Implementation and training
The Provider Collaborative will ensure that all staff are aware of this policy and the supporting procedures and have access to the associated documents. To support staff the complaintsprocess forms part of the provider collaborative induction programme and on-going training is available.
14) Monitoring compliance and effectiveness
The complaint process will be monitored by the Provider Collaborative to review the effectiveness of the process as well as how information about complaints is being used to improve services. The Provider Collaborative team will ensure:
- This policy and relevant processes remain in line with current legislation and guidance and continue to reflect models of best practice.
- The policy remains up to date and continues to represent the practice of staff dealing with concerns, comments, complaints and feedback. Any changes to the process should be reflected within the policy.
- The policy continues to place the patient first and that feedback and suggestions from complainants regarding the complaints process are used to inform and continually improve the process.
15) Reporting requirements
The Provider Collaborative team will produce regular reports on patient experience. These will provide an overview of the numbers and types of feedback received across the network, including information relating to the theme/subject of the complaint, and the service area towhich the complaint relates. This enables any emerging themes and trends to be identified andappropriately escalated. Details of formal complaints are also reported within the Provider Collaborative annual report.
Information relating to complaints, including equality data, is provided to the Health and Social Care Information Centre (HSCIC) in line with national requirements. This is provided via Oxford Health as the lead provider.
The Provider Collaborative receives and reviews regular complaints reporting from the providers of its commissioned services. These are reviewed at the CQRM meetings in conjunction with the provider, and data is triangulated to provide a detailed understanding of patient experience.
