Principles

• Complaints will always be taken seriously, acknowledged speedily and investigated thoroughly.
• Posters and information sheets are displayed throughout the Hospice in order to make service users aware of their right to complain if they are dissatisfied with any aspect of their care or treatment from the Hospice.
• Service users will be assured that they will not be discriminated against for making a complaint.
• Service users who are dissatisfied with their care or treatment from St Joseph’s Hospice, but who are unable to compile a formal complaint due to language, literacy or other difficulties will be offered assistance to make a formal complaint if they wish to do so.
• Complaints should normally be made within 12 months of the event(s) that is (are) being complained about.
• Written complaints, and oral complaints or informal criticism treated as written complaints, will be acknowledged within five working days. A detailed response will be sent within ten working days thereafter. Where this is not possible a letter outlining progress in the investigation will be sent regularly until a final response can be sent.
• Complainants will be offered an opportunity to meet with senior members of Hospice staff to discuss their concerns.
• Complainants will be kept informed of the progress of investigations where there is any delay in coming to a conclusion.
• At the end of the investigation, the Hospice Chief Executive will write to complainants outlining the investigation and the conclusions reached.
• The Hospice will offer an apology where appropriate.
• The Hospice will take all possible steps to work with other relevant care providers to co-ordinate a response to any complaint that relates to care that has been shared with other agencies.
• As part of the final report complainants will be informed that, if they are dissatisfied with the Hospice response, they may refer the matter to the Health Service Ombudsman, who may be able to undertake an independent investigation.
• All investigation and reporting of complaints will take care to protect the right to confidentiality of patients, relatives, complainants and members of staff. Matters will be discussed only with those who have a “need to know”. The protection of confidentiality will also apply to debriefing and education following complaints.
• At the conclusion of the investigation of a complaint, discussion will take place with staff involved or affected to agree learning from the issues raised, and action to be taken to improve care or services.
• The Clinical Governance Lead will maintain a database of all complaints, formal and informal.
• A summary of complaints and informal criticisms and the actions taken in response to them will be reported annually to the Clinical Governance and Ethics Committee.
• The Clinical Governance Lead will assess all complaints on receipt. Serious complaints will be reported to the next meeting of the Clinical Governance and Ethics Committee, or earlier to the Chair of the Board of Management if the complaint constitutes a serious risk to the Hospice.
• Serious complaints will be reported to the Care Quality Commission.
• A summary of complaints and the actions taken in response to them willbe sent to the Care Quality Commission when requested.
  Responsibility/ Accountability

Responsibility/Accountability

Trustees as advised by Board of Management
●  Overall responsibility for ensuring that the organisation has a system in place for responding to complainants and that appropriate action is taken in response to findings of investigations following complaints.

Chief Executive
●  Ensuring that complaints are acknowledged and investigated.
●  Sending a response to the complainant on completion of the investigation.
●  Ensuring that action is taken to minimise the likelihood of recurrence of the circumstances leading to a complaint.

Senior Management Team
●  Ensuring that processes are in place to make staff aware of their responsibilities to act openly and non-defensively when complaints are made, and to report all complaints to their line manager.
●  Ensuring that the organisation has systems in place for informing service users of their rights to complain about care and treatment provided by the Hospice.

Director of Care as Registered Manager (CQC)
●  Sending to the Care Quality Commission, when required, a summary of complaints received, and responses from the Hospice.

Clinical Governance Lead
●  In liaison with the Chief Executive, making an initial formal response to complaints or informal criticism received.
●  Ensuring that investigations into complaints are conducted.
●  Following investigation, liaising with the investigator to make recommendations for response to complainants and action to improve practice or services where required.
●  Liaising with the Education Team to ensure that appropriate education and training is put in place where required.

Heads of Department
●  Informing the Clinical Governance Lead of any informal criticism received.
●  Informing the Clinical Governance Lead, relevant senior manager and the Chief Executive of any formal complaint received.
●  Liaising with the Clinical Governance Lead to ensure appropriate investigation of complaints.
●  Ensuring that information about the right to complain and the complaints procedure is openly available to service users in their departments.
●  Ensuring that staff within their departments are aware of their responsibility to respond openly to complaint or criticism and to follow relevant procedures.
●  Supporting staff affected by complaints or informal criticism during the investigation process.
●  Ensuring that agreed action is implemented following investigation of a complaint.
●  Working with the Senior Management Team, the Personnel Department and the Clinical Governance Lead to put in place strategies to improve performance and processes when required following a complaint.

All staff
●  Responding openly and non-defensively to any complaint or criticism.
●  Facilitating service users to make formal complaints if they wish to do so.
●  Informing the relevant Head of Department of any informal criticism received.
●  Co-operating with investigations of complaints, both internal and by external regulating bodies.
●  Taking action as required in response to a complaint and/or to minimise the likelihood of recurrence of the circumstances leading to a complaint.

Staff Training Requirements

• During the orientation programme, staff will be made aware of the commitment of the Hospice to an open and non-defensive response to complaints and criticism, and to the policy and procedure. All staff are required to read the policy and to be aware of the procedure.

Related Hospice Policies/ Procedures

• Procedure for Responding to Complaints

Compliance with Statutory Requirements
Regulations 17, 19 of the Health and Social Care Act 2008 (Regulated Activities)
Regulations 2010
Equality Act 2010
 

Key Words
Complaints
Criticism, informal
Oral complaint