Complaints Policy & Procedure

Introduction

The Phoenix Ultrasound Centre recognises that there will be times when service users, their families or carers, staff and others are dissatisfied with aspects of the care and services provided. The Phoenix Ultrasound Centre is committed to dealing with any issues that may arise as quickly and effectively as possible.

The potential effects on service users, relatives, and staff, when things go wrong, can be devastating. Duty of candour, implemented under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Regulation 20, outlines the principles that staff should use when communicating with service users, relatives and/or carers following an incident where harm has occurred, or where there is a risk or possibility that the incident could lead to or result in harm. It underpins a culture of openness, honesty and transparency, and is a duty on the organisation as a whole, as well as individual staff working within the organisation. (For more information on duty of candour, see the separate Duty of Candour Policy).

By making sure that concerns and complaints are dealt with in a timely manner the risk of escalation is minimised and the opportunity of finding a satisfactory resolution to the problem is maximised.

At the same time, compliments are an important means of identifying areas of good practice, and The Phoenix Ultrasound will seek to ensure that feedback on good practice is shared with employees to motivate and encourage staff members and ensure standards of care are improved wherever possible.

The Phoenix Ultrasound will ensure that the complaints procedure is fair and accessible to all.

Policy Statement

All concerns and complaints will be treated seriously and investigated promptly in accordance with the procedures outlined in this policy.Staff members will receive training in dealing with concerns and complaints and will ensure that all persons have access to guidance on the procedures for raising a concern or making a complaint.

How to Submit Feedback
Compliments and concerns can be given verbally or in writing to any staff member or submitted to the Registered Manager.

The Company Lead for compliments and complaints is Rasheed Sadegh-Zadeh.

Complaints must be submitted in writing (via email, text, or letter) to the Registered Manager (or the Managing Director if the complaint relates to the Registered Manager).

This is to ensure clarity of the full and specific details of the complaint. Where the complainant is unable to submit a complaint in writing, they should raise the complaint with the Registered Manager, who will then record the complaint.

Comments on social media websites will not normally be deemed to be formal complaints unless submitted in writing via one of the means outlined above.

Compliments Management Process
All compliments received in writing should be documented. They should also be circulated amongst relevant staff members so that they are aware of the number of compliments received, and the specific topics which are raised.

There is no requirement to record compliments which are received verbally, but this is encouraged wherever possible.

No formal acknowledgement of compliments is necessary, however where this is deemed appropriate, it should be encouraged.

Concerns Management Process

Many concerns arise out of a lack of information or understanding, and very often the matter can be resolved via the provision of further information, advice or an apology. This means they can often be dealt with at the time of their raising with a front-line staff member.

On receipt of a concern staff will:

• ensure that the immediate health care needs of the person affected by the concern are being met
• make sure that the person raising the concern does not wish to make a formal complaint
• undertake any enquiries required to resolve the matter respond to the person raising the concern with the appropriate information/advice/apology and/or explain what has been done to resolve the matter
• offer the person raising the concern the opportunity to discuss their concern further.

All concerns must be recorded on the incident management system. The record will include details of the concern, how it was resolved, and any further actions required.
Where the concern cannot be resolved in the above manner, it should be forwarded to the Registered Manager. The Registered Manager can discuss the issue with the person raising the concern and initiate the formal complaints process outlined below if required.

Complaints Management Process
Once a complaint has been received, it should be recorded on the incident management system and formally acknowledged within 5 working days of receipt. The acknowledgement should normally be in writing but can be given verbally if appropriate.
The Registered Manager will then either investigate the complaint fully themselves or nominate a ‘Lead Investigator’.

Complainants should ordinarily receive a written response within 21 working days from the date of receipt.

In conducting the investigation, the lead investigator may undertake any of the following:

• contact the complainant to identify the outcome that they are seeking
• provide the complainant the opportunity to give their account and views of what took place
• review the relevant documentation, checking for evidence regarding issues raised
• interview any staff members involved in the incident
• develop a timeline of what happened
• identify any shortfalls in level(s) of care provided
• when appropriate, using a Root Cause Analysis, identify the causes/contributory factors/validity of the concerns that have been raised
• identify clear and assigned actions to prevent recurrence and to improve care quality.
• The lead investigator will then:
• decide whether the complaint should be upheld in full, upheld in part or not upheld
• make a record of the details of the investigation, outcomes and actions to be taken on the incident management system.
• It is essential that every stage of the investigation is based on the best available evidence. The formal response from the Lead Investigator should be structured as follows:
• outline how the complaint has been considered
• explain how conclusions have been reached in relation to the complaint and whether it was upheld in part, in full or not upheld
• describe how any action needed as a result of the complaint has been taken, or is proposed to be taken
• explain that if they are not happy with the findings, an internal appeal is possible
• provide details of the regulatory body, should the complainant still be unhappy and wish for their complaint to undergo external review.

The Lead Investigator should ensure that the full written response is filed alongside the initial complaint on the incident management system. If, after receiving the formal response, the complainant is not happy with the outcome, they may write to the Senior Management Team to request an internal appeal.

Internal Appeal
Upon receipt of an appeal the Senior Management Team will:

• take the time to understand the details of the initial investigation and outcome
• contact the complainant to understand the reason(s) why they are not happy with the initial investigation outcome
• appoint an appropriate independent (non-biased) individual within the business to carry out the appeal investigation
• provide the complainant with the name and contact details of the Independent Investigator.
• The Independent Investigator will:
• review the initial investigation and outcome
• meet with or contact the complainant to discuss their continuing concerns
• carry out further investigation, if necessary
• decide whether or not the initial investigation outcome should be upheld
• provide the complainant with relevant feedback and inform them of the appeal outcome.

Once completed, the Independent Investigator will ensure that the incident management system is updated with comprehensive details of the appeal, including actions taken and outcome. They will also report their findings to the Senior Management Team.

Independent Review:

Independent Sector Complaints Adjudication Service (ISCAS).
Details are available at Complaints process – ISCAS (cedr.com)

Monitoring and Learning from Complaints

The Registered Manager will then be responsible for discussing the most appropriate method of sharing proposed service improvements with the Senior Management Team.
Issues arising from complaints should be a standard agenda item for discussion at the Senior Management Team meeting and the Registered Manager should ensure that themes and trends and lessons learned are shared with staff.

The Lead Investigator will ensure that:

• a staff member is given guidance as to what areas of information they will require from them in a timely manner, allowing time for staff to gain support from colleagues and/or unions
• good information governance practice is maintained and that information regarding specific individuals is treated confidentially and with respect; sharing will only take place as far as required to conduct the investigation
• conduct interviews in a professional and supportive manner
• ensure that staff know that the review is being conducted as part of a learning and safety culture, as opposed to the apportioning of blame
• keep staff up to date on the review’s progress.

Records Management
All feedback paperwork will be retained for a minimum of 10 years. Any archived paper files will be stored in a secure manner, to preserve confidentiality. The security and retention of information on the incident management system is the responsibility of the Registered Manager.

Monitoring
The implementation and levels of compliance with this policy will be monitored by 1:1 supervision sessions, with lessons learned shared through this channel as well as the Senior Management Team.

Related Policies and Procedures
Duty of Candour Policy and Procedure
Grievance Policy and Procedure
Information Governance and Record Keeping Policy and Procedure
Safeguarding Adults Policy and Procedure
Safeguarding Children Policy and Procedure
Whistleblowing Policy and Procedure

Legislation and Guidance
Care Act 2014
Compensations Act 2006
Complaints in health and social care: standards & guidelines for resolution and learning, Department of Health, Social Services and Public Safety, June 2013.
Complaints Matter, CQC, December 2014
Data Protection Act 2018
How to complain about a care home or care in your home – self-funded or council-funded, Local Government Ombudsman, February 2015.
Human Rights Act 1998
Mental Capacity Act 2005
Mental Capacity Act Code of Practice
Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry, Francis, 2013.
The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
The Local Authority Social Services and National Health Service Complaints (England) Regulations 2009