PALS and Complaints Policy and Procedure

Version Control

Version	Date	Author and Role	Detail of Change
0.1	23/05/2024	Katy Walton, PALS and Complaints Team Manager	Initial draft
0.2	31/07/2024	Katy Walton, PALS and Complaints Team Manager/Sarra Bargent, Deputy Director of Nursing	Approved draft for wider sharing and comments.
0.3	30/08/2024	Katy Walton, PALS and Complaints Team Manager/Sarra Bargent, Deputy Director of Nursing	Final draft to be submitted to ICB QC for sign off

Approval History

Version	Date	Approver
0.3	12/09/2024	SNEE ICB Quality Committee

Next Review Date

The date this policy is due for review is August 2026.

1. Statement of Overarching Principles

All Policies, Procedures, Guidelines and Protocols of the Suffolk and North East Essex Integrated Care Board (ICB) are formulated to comply with the overarching requirements of legislation, policies or other standards relating to equality and diversity.

2. Introduction

NHS Suffolk and North East Essex Integrated Care Board (hereafter known as ‘SNEE ICB’) PALS and Complaints policy and procedure is written in accordance with The Local Authority Social Services and National Health Service Complaints (England) Regulations 2009 (legislation.gov.uk) which came into force on 1^st April 2009.

If a person is unhappy about any matter reasonably connected with the exercise of SNEE ICB’s functions, they are entitled to make a complaint, have it considered, and receive a response. These complaints may relate to the commissioning of health care or other services provided under an NHS contract or making arrangements for the provision of such care or other services with an independent provider or with an NHS trust.

SNEE ICB aims to manage complaints by the procedure of local resolution. The primary objective of this process is to provide the opportunity for investigation and resolution of the complaint, as quickly as is sensible in the circumstances and minimising the need for the complainant to escalate concerns to the Parliamentary and Health Service Ombudsman (PHSO). Local resolution should be open, honest and fair.

Complaints are recognised by SNEE ICB as a vital form of feedback to help improve both the service the organisation and providers offer. SNEE ICB aims to ensure all complainants feel listened to, have their complaint investigated thoroughly, and that any response is delivered in a personalised way.

3. Purpose

The purpose of this policy is to describe the systems in place to effectively manage the key statutory duties, accountabilities and responsibilities for all complaints received into the organisation in accordance with NHS complaints regulations.

It outlines the responsibilities and processes for receiving, handling, investigating and resolving complaints relating to the actions of the organisation (SNEE ICB), its staff and services.

The Policy also outlines the responsibilities and processes used for complaints received, which relate to commissioned services (such as Primary Care, NHS Trusts, Community Services and Independent Sector Providers) and how SNEE ICB support complainants with this process.

Furthermore, how SNEE ICB seek assurance that complaints handling within our commissioned services is provided to a good quality.

The purpose of this policy is to ensure SNEE ICB promotes best practice within its complaints management function, is compliant with the Local Authority Social Services and National Health Service Complaints (England) Regulations 2009 and the NHS Constitution including the pledges and rights covering complaint and redress.

This policy sets out how the NHS complaints procedure will be implemented locally and must be followed by all staff employed or hosted by SNEE ICB.

If a complaint that is received indicates that fraud, bribery or corruption may be involved then the matter must be reported to the Local Counter Fraud Specialist (LCFS) for investigation. Further information on the procedure to follow is given in Suffolk and North East Essex ICB Counter Fraud and Anti-Corruption Policy.

This Policy is an integral document in support of SNEE ICBs Quality Management System.

4. Equality Statement

This Policy will operate alongside SNEE ICBs Equal Opportunities, Diversity at Work Policy, and Equality Delivery System. SNEE ICB values the diversity of its employees, volunteers and people who are entitled to our services, irrespective of their race, disability, age, gender including sexual orientation, religion or belief, status, or grade.

The ICB assures employees, volunteers and people entitled to our services are treated fairly, equally and with respect and dignity. SNEE ICB will challenge discriminatory attitudes and provide rules and standards of behaviour.

The use of this Policy will not discriminate directly or indirectly on the grounds of race, gender, sexual orientation, ethnic or national origin, religion, culture, disability, age, membership of a trade union or staff organisation or political affiliation.

The ICB will monitor the use of this Policy, as far as it is able, and take action if it appears that it is has a disproportionate effect.

5. Scope

This policy applies to all employees of SNEE ICB, including fixed term employees when working within SNEE ICB and whilst on SNEE ICB business together with the expectations of our commissioned services in providing a quality complaints service.

6. Cross Reference to Other Policies

Suffolk and North East Essex ICB Counter Fraud and Anti-Corruption Policy
Suffolk and North East Essex ICB Patient Safety Incident Response Framework (PSIRF) Policy
Suffolk and North East Essex ICB Patient Safety Incident Policy (draft)
Suffolk and North East Essex Safeguarding Adults at Risk Policy
Suffolk and North East Essex Safeguarding Children Policy
Suffolk and North East Essex ICB Incident Reporting and Information Security Policy
Suffolk and North East Essex ICB Freedom to Speak Up Policy
Suffolk and North East Essex ICB Continuing Healthcare Policy

The above policies can be accessed via the ICB’s policies and strategies page.

7. Policy Details

7.1 Patient Advice and Liaison Service (PALS)

PALS act on behalf of patients, family and unpaid carers concerns. They liaise with staff, managers, and where appropriate, other relevant organisations, to negotiate speedy solutions and to help bring about changes to the way those services are delivered.

PALS will also refer patients and families to local and national-based support agencies, as appropriate. Consent will be sought if the concern is raised on behalf of the patient, or if the enquiry requires redirection to another organisation. PALS will liaise with appropriate staff to resolve the concern or redirect the enquirer to the appropriate organisation.

A key role of the PALS service within SNEE ICB is to provide an early warning system by capturing trends and gaps in services and reporting these through the SNEE ICB governance systems and processes for action.

The PALS service covers all of Suffolk and north east Essex, providing a free confidential information service; giving on the spot help for patients, their families, unpaid carers and staff. The service supports and provides information on health-related matters and is the first point of contact for any feedback or concerns. PALS does not offer clinical advice.

Should an early resolution with PALS not be possible or the enquirer wishes to escalate to a formal complaint, the formal complaints process will then be followed.

PALS will:

Sort out problems that require a quick resolution.
Provide on the spot help with the power to negotiate immediate solutions or speedy resolutions to problems.
Be identifiable and accessible to patients, their unpaid carers and relatives.
Signpost to services and agencies.
Act as a gateway to appropriate independent advice and advocacy support from local and national sources.
Provide information to patients, their relatives and unpaid carers, about health-related issues and services within the Suffolk and North east Essex system.
Listen to concerns and suggestions.
Act as a catalyst for change and service improvement by providing SNEE ICB with information and feedback on problems arising and gaps in services.
Operate within a local network with other PALS and work across organisational boundaries.

PALS is a one stop shop, aiming to resolve and respond to queries in a timely manner. Should there be delays in responding, the team will ensure this is communicated with the enquirer. PALS at SNEE ICB can be contacted using the following contact details:

PALS and Complaints Team

Suffolk and North East Essex Integrated Care Board

Endeavour House

8 Russell Road

Ipswich

IP1 2BX

Tel – 0800 389 6819 (freephone)

Email – pals@snee.nhs.uk

7.2 Compliments

Any member of staff who receive a complimentary letter or expression of gratitude should inform the PALS and Complaints Team for recording centrally. All compliments received by the PALS and Complaints Team are shared with the relevant service and feed into SNEE ICB’s governance functions as a means of sharing best practice and recognising a strength-based approach to learning.

7.3 Complaints Handling Policy

7.3.1 What is a complaint?

A complaint is a verbal or written expression of concern or dissatisfaction about a matter relative to SNEECBs functions or decisions, which requires a response and/or remedy.

7.3.2 Responsibilities

SNEE ICB Board: The role of the Board is to receive assurances around the quality of services delivered by SNEE ICB PALS and Complaints team and that of its commissioned services, holding providers to account in relation to their responsibilities as indicated.

Chief Executive: Is accountable for the quality of the care commissioned and will, therefore, have an overview of all recorded dissatisfaction expressed by patients and service users.

SNEE ICB Quality Committee: The role of the Committee is to ensure that mechanisms are in place within commissioned services to review and monitor the effectiveness of the quality of care delivered. This includes reviewing patient experience data, assurance that lessons learned from complaints is captured and that learning is disseminated and embedded.

The Committee takes an active role in reviewing themes, trends and learning from complaints through regular reporting from providers. The Quality Committee triangulates information from complaints with other intelligence to inform the wider quality agenda.

Executive Director of Nursing and Clinical Quality: Is the senior person appointed by the Chief Executive to ensure the process for handling and reporting on complaints on behalf of SNEE ICB complies with this policy and is supported by the Deputy Director of Nursing (Quality, PALS & Complaints) in this function.

PALS and Complaints Team: Is responsible for the management of SNEE ICB complaints and concerns process, recognising the requirement for two separate pathways through which service users and carers can seek assistance with issues of concern but delivers benefits through shared management of services.

SNEE ICB PALS and Complaints Team report quarterly compliance against statutory duties, accountabilities and responsibilities for all complaints received into the organisation, in accordance with NHS complaints regulations into SNEE ICB Quality Committee.

Senior Managers: All SNEE ICB Associate and Deputy Directors are responsible for ensuring that SNEE ICB’s PALS and Complaints Policy is implemented across their Directorates and complaints are investigated in accordance with this policy; to ensure satisfactory resolution of complaints, including the implementation of any lessons learned.

If a member of their staff is the subject of a complaint, senior managers must ensure that their staff member is informed and offered timely support including, where appropriate, referral to Occupational Health Services.

All staff: staff who receive a direct complaint must refer this to the SNEE ICB PALS and Complaints Team. All SNEE ICB staff, including temporary and agency staff, are expected to assist the PALS and Complaints Team to ensure complaints are properly investigated and ensure improvement of services and patient care through learning and development.

Providers: all providers of commissioned services by SNEE ICB under an NHS contract are required to evidence they:

provide a quality complaints service, meeting the requirements of the 2009 Complaints Regulations and working towards achieving the PHSO Complaints Standards.
Capture and share learning from complaints.
Seek feedback about the quality of their own complaint handling by engaging with complainants (via survey or other methods), advocacy providers and local Healthwatch.
Ensure actions arising from Parliamentary Health Service Ombudsman (PHSO) upheld complaints investigations are completed as appropriate for providers (PHSO are expected to copy SNEE ICBs into their reports/ findings).

Complainant: person making the formal complaint. Whether this is the patient or the patient’s representative, the complainant will be the contact for the PALS and Complaints Team. They will be asked to ensure they direct all their communication through the PALS and Complaints Team when making contact with SNEE ICB.

7.3.3 Who can complain?

A complaint can be made under this policy by a patient (or their representative) who is affected, or is likely to be affected, by the actions or decisions of SNEE ICB and/or about the care they have received by a commissioned service.

Anonymous complaints will be accepted but, if possible, the person should be encouraged to provide their name and other relevant details. If the person is unwilling to provide contact details, the PALS and Complaints Team will record the complaints and investigate if appropriate and possible.

A list of issues and complaints that cannot be addressed via this policy can be found in Appendix B.

When patient/complainant information needs to be shared by SNEE ICB with other organisations e.g. providers of services

If the complaint is made on behalf of another person, the patient must consent to that person acting for them. If the patient is unable to complain themselves then someone else, usually a relative or friend, can complain on their behalf provided consent is given.

In the case of a child or young person under the age of 16, a suitable representative would normally be a parent, guardian or other adult person who has care of the young person, or one who is authorised in the case of children in care.

If the patient is unable to act, for instance due to a lack of capacity within the means of the Mental Capacity Act (2005, revised 2007) the complaints regulations permit the responsible body for the complaint to take a view on whether the person is acting in the patient’s best interests. If it is considered that this is not the case the responsible body can refuse to handle a complaint made by that person.

If the patient has died, the complaint must be made by a suitable representative and they must provide documentation to evidence that they are an authorised executor or person with legal authorisation. If the PALS and Complaints Team Lead does not consider that the complainant is a suitable representative, they may decline to deal with the complainant and recommend that another person acts on the deceased patient’s behalf.

If a Member of Parliament (MP) makes a complaint, acting on behalf of a constituent without providing explicit consent from the constituent, implicit consent is presumed. This is because the constituent has by the nature of their contact with the MP requested they act on their behalf in contacting SNEE ICB. Consent will be sought if SNEE ICB needs to share the information from the MP with another organisation outside of SNEE ICB.

If in any case it appears that a representative does not have sufficient authority to act on a patient’s behalf, the PALS and Complaints Team will notify the person in writing, stating the reasons why.

7.3.5 Local resolution

The first stage of the NHS Complaints Procedure is called ‘local resolution’, and concerns should be brought to the attention, in the first instance, to the organisation providing the service.

Local resolution aims to resolve complaints quickly and as close to the source of the complaint as possible. Local resolution enables concerns to be raised immediately by speaking to a member of staff who may be able to resolve issues without the need to make a formal complaint.

There are two stages to the NHS complaints procedure:

Local resolution of complaint through investigation and response by SNEE ICB, NHS Trusts or service provider
Independent review of complaint by Parliamentary and Health Service Ombudsman (PHSO)

7.3.6 Making a formal complaint

A formal complaint should be made directly to the organisation concerned however if the complainant wishes, this can be made to SNEE ICB using the following contact details:

PALS and Complaints Team

Suffolk and North East Essex Integrated Care Board

Endeavour House

8 Russell Road

Ipswich

IP1 2BX

Tel – 0800 389 6819 (freephone)

Email – complaints@snee.nhs.uk

The complaint will be recorded as being made on the date on which it was received by the PALS and Complaints Team.

7.3.7 Time limit for making a complaint

A complaint should be made within 12 months of the event(s) concerned, or within 12 months of the date on which the matter came to the notice of the complainant.

The PALS and Complaints Team Lead has discretion to waive this time limit if there are good reasons for the complaint not having been made within that time frame if it is still practical and possible to investigate the complaint, for example, the records still exist, and the individuals concerned are still available to help with the investigation.

When a complaint is made outside these limits and the time limits are not waived, the complainant will be advised of their rights to request that the Parliamentary and Health Service Ombudsman (PHSO) consider their case.

7.3.8 Duty of Candour and Openness

SNEE ICB welcomes the government’s commitment to introducing a duty of candour within the NHS. This recommends that all providers of NHS care should owe a duty of candour to their commissioners under which they provide, amongst others;

Timely reports, prepared to an agreed protocol, of all complaints made by NHS patients;
- In cases when complaints are upheld, Complaint Action Plans will be completed to address the actions/learning that have been identified;
- Progress reports in relation to implementation of complaints action plans

SNEE ICB is committed to improving the quality of care and the services it commissions.

Providers/Contractors commissioned by SNEE ICB must establish and operate a quality complaints service, to receive and manage any complaints made to them directly in relation to any matter reasonably connected with the provision of services under the Contract. The complaints procedure must comply with the requirements of the Local Authority Social Services and National Health Service Complaints (England) Regulations 2009.

7.4 Complaints Handling Procedure

Complaints can be received by the team in writing, via email or verbally.

Where a complaint needs to be made verbally, a written statement will be taken from the complainant ensuring all salient points requiring a response are documented. The written statement will be sent to the complainant asking them to make any changes to ensure it is an accurate reflection of their complaint. The complainant will then need to sign and return the statement to the PALS and Complaints Team. The complainant will be advised that their complaint will not be processed until the signed statement is returned. A scanned copy of the form or emailed consent will also be accepted.

There may be instances when it is not appropriate to take a formal complaint over the telephone, for example, if the concerns raised are complex. In cases such as this and when the complaint cannot be provided in writing, a face-to-face meeting can be arranged to clarify the complaint or with the complainant’s permission, a referral can be made to the NHS Complaints Advocacy Service.

7.4.1 Acknowledgement

The PALS and Complaints Team will send the complainant a written acknowledgement of their complaint within three working days of the date on which the complaint was received.

This acknowledgement will include:

A consent form to be signed and returned to allow the investigation to commence
If consent is not required, the date by which the response is to be provided.
Information on how to access the local NHS advocacy provider
Contact details for the PALS & Complaints Team with an offer to discuss further

Where a very detailed or complex complaint is identified via the grading matrix (Appendix D), the PALS and Complaints Team will outline any points for investigation. These will be put in writing and the complainant will be asked to confirm they are correct. This may trigger a review by SNEE ICB Quality Lead(s) and on a rare occasion may progress to a clinical review.

When consent is required in order to investigate a complaint the timeframe for responding to a complaint starts upon receipt of appropriate signed consent.

If consent is not provided but the complainant wishes to continue with their complaint, the PALS and Complaints Lead will determine whether investigation can still be undertaken, and a response provided where the complaint is of a non-clinical nature.

Care will be taken at all times throughout the complaints procedure to ensure that any information disclosed about the patient/service user is confined to that which is relevant to the investigation of the complaint. Information will only be disclosed to people who have a demonstrable need to know it for the purpose of investigating the complaint or ensuring that the complaints process is followed.

In transferring complaints between agencies (including the PHSO) confidentiality will be maintained at all times. Every effort will be made to obtain the patient’s/service user’s (or their representative’s) consent before sharing the confidential information with another body or organisation. Consent will be obtained in writing or where this is not possible the PALS and Complaints Team will seek verbal consent.

7.4.3 Investigation and timeframe

The PALS and Complaints Team will:

Determine the level of risk using a grading matrix tool (Appendix D).
Forward the complaint to the appropriate lead for investigation with details of the issues to be investigated (points for investigation).
Notify the lead for the investigation if this has triggered a quality and/or clinical review and confirm who this is likely to be.
Concurrently, forward any ‘level 4 or 5 complaints to SNEE ICB Quality Leads as required. They will link in with the lead for the investigation and agree if this warrants a quality/clinical review. Should a clinical review be required, a complaint MDT will be convened and chaired by the ICB Medical Director (or suitably qualified deputy) to agree the scale and scope of clinical review required, inviting subject matter experts from system partners as necessary.
Chase the investigator at regular intervals for updates on the progress of their investigations. Where an investigation report is delayed the team will raise this within the respective SNEE ICB MDT and escalate to the Deputy Director of Nursing (Quality and PALS & Complaints) as indicated.
Keep the complainant informed and up to date with the progress of the investigation. As part of contacting the complainant the team will, where appropriate, advise a date by which they will be in touch again with a further update.

The Investigator will:

Establish what happened, what should have happened and who was involved and make written records of the investigation/staff statements.
Make sure a sincere and appropriate apology is made as appropriate.
Identify what actions can be implemented to ensure there is no recurrence and address any training issues and learning points. The action plan template will be completed by the Investigating Officer to capture this information.
Draft a report addressing the issues raised by the complainant and comment on what action is being taken to prevent a reoccurrence in the future.

Staff involved in a complaint:

Are required to cooperate with the complaints procedure.
Will be made aware of the complaint by the Investigating Officer and will be asked to prepare a written statement, if appropriate.

SNEE ICB aims to respond to complaints within 30 working days. If for any reason a response cannot be made within the agreed timescale (for example a person involved in the complaint is absent from work) the complainant will be contacted by the PALS and Complaints Team and an extension to the specified reviewed timescale will be made.

Where SNEE ICB is investigating a complaint with a service provider, the timeframe for response will be determined by the service provider. SNEE ICB will confirm this with the complainant at the time of acknowledgement/once consent has been received.

SNEE ICB PALS and Complaints Team will help support and ensure timely communication and updates by the provider.

A response must be sent within six months of the date of a complaint being received.

7.4.5 Multi-organisation complaints

When complaints are received about both health and local authority services, or where a complaint spans several organisations, with the complainant’s consent, the organisations involved will work together to address the aspects of the complaint that relates to them. All parties will agree who will lead on the complaint and will aim to provide a single coordinated response.

7.4.6 Response

The PALS and Complaints Team will ensure a final response is drafted and where necessary, approved by the Service Lead/Investigator.

The written response will include the investigation report (where appropriate) and will;

Address all the issues raised by the complainant.
Provide explanation and apologies, where appropriate.
Indicate lessons learned from the complaint.
Include what steps have been taken to prevent a reoccurrence.
Where appropriate, offer a meeting with the SNEE ICB Director of Nursing and/or Medical Director and/or Service Lead
Outline what options are available if the complainant is not satisfied with the response, including details of the Parliamentary and Health Service Ombudsman.

The final response will be reviewed, signed and sent by the Chief Executive. This will include details of how to progress the complaint to the second and final stage of the complaints process, the Parliamentary and Health Service Ombudsman (PHSO).

Upon completion of each complaint its status will be reported on Datix as either upheld (agree there were deficiencies and actions taken to rectify this and prevent similar occurrences happening again), partially upheld or not upheld. Reasons for why this decision was made will also be recorded.

If a complainant is dissatisfied with the response, the complaint will be reopened and every effort will be made to achieve a satisfactory outcome at local level by identifying outstanding issues, arranging local resolution meetings and/or providing a further written response. If, following all attempts to resolve the complaints locally, the complainant remains dissatisfied, they will be notified that local resolution is at an end and that they can ask the Parliamentary and Health Service Ombudsman to consider their case. Information on the Parliamentary and Health Service Ombudsman will be routinely given to complainants at the completion of local resolution.

7.5 Parliamentary and Health Service Ombudsman (PHSO)

SNEE ICB will follow the principles of good administration outlined by the PHSO and will consider the impact of the organisation’s actions on the individual concerned. The key principles are as follows:

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

The PHSO is completely independent of the NHS and of government and derives his powers from the Health Service Commissioners Act 1993. The Ombudsman is the final arbiter in the complaints process where it has not been possible to resolve concerns locally. SNEE ICB will co-operate fully with any investigation undertaken by the Ombudsman. Further information on the role and work of the Ombudsman is available at:

Parliamentary and Health Service Ombudsman
Citygate
Mosley Street
Manchester
M2 3HQ

Tel: 0345 015 4033
e-mail: phso.enquiries@ombudsman.org.uk
Website: www.ombudsman.org.uk

7.6 Organisations that can help

There are a number of organisations that can provide help and advice to individuals who want to complain about NHS services:

The NHS Complaints Advocacy Service provides a free, independent and confidential advocacy service for people who require help and support to make a complaint about the NHS. The PALS and Complaints Team will provide complainants with information about their local NHS Complaints Advocacy Service at the time of acknowledgment. The services can be contacted as follows:

For Suffolk complainants, the provider is POhWER;:

Tel: 0300 456 2370
E-mail: suffolkadvocacyservices@pohwer.net
Website: www.pohwer.net/nhs-complaints-advocacy

For North East Essex complainants, the provider is Voiceability;

Tel: 0300 303 1660
Email: helpline@voiceability.org
Website: www.voiceability.org/about-advocacy/types-of-advocacy/nhs-complaints-advocacy

Healthwatch can provide information and signposting to patients to help understand what to do when things go wrong. Healthwatch have the strength of the law behind them and can challenge services to ensure the patients voice is heard where it matters and where decisions are made.

Healthwatch Suffolk can be contacted on:

Tel: 01449 703949 or info@healthwatchsuffolk.co.uk

Healthwatch Essex can be contacted on:

Tel: 0300 500 1895 or enquiries@healthwatchessex.org.uk

Independent Mental Health Advocates (IMHAs); patients subject to certain aspects of the Mental Health Act 1983 have statutory access to an Independent Mental Health Advocate (IMHA). IMHAs can help and support patients to understand and exercise their legal rights. To request the help of an IMHA, the local Voiceability Suffolk office can be contacted on:

Tel: 01473 857631 or tvspartnership@voiceability.org

The Care Quality Commission (CQC); is the independent regulator of health and social care in England. The CQC does not have a role in handling individual complaints, but it does have powers to ensure registered service providers are handling individual complaints properly. It will also use feedback from users of NHS services to spot patterns of incidents indicating that there could be a problem.

Action against Medical Accidents (AvMA); is an independent UK wide charity. It can help patients to consider the options that may be open to them after suffering a medical accident, including providing contacts for specialist solicitors. AvMA can be contacted on Tel: 0845 123 2352.

7.7 Safeguarding

All adults and children at risk of abuse and neglect should be able to access public organisations to obtain appropriate interventions which enable them to live a life free from fear, violence and abuse. A child is considered to be under the age of 18 years old and an adult over the age of 18 years old. There is clear safeguarding legislation for both children and adults.

During a complaint investigation, it may become apparent that a vulnerable adult or child at risk may have been abused or may have made allegations of abuse. In these circumstances, it is essential that appropriate pathways are accessed in order that appropriate personnel can intervene to alleviate any distress being experienced and to progress the matter in line with SNEE ICB’s Safeguarding Policies and Procedures.

If the PALS and Complaints Team is made aware that a vulnerable adult or child at risk, may have been abused or is experiencing abuse, they will notify the Multi Agency Safeguarding Hub (MASH). Contact details for the MASH are as follows;

Suffolk: 0345 606 1499

Essex (concerns regarding a child): 0345 603 762

Essex (concerns regarding an adult): 0345 603 7630

Sometimes complainants may make statements regarding their mental health and present in mental health crisis If staff are concerned for the callers safety, callers will be encouraged to seek help by calling NHS 111 (option 2) Crisis Line or (if they already have one) their mental health team. Details of The Samaritans and the Mental Health Team PALS can also be given.

Samaritans: 116 123

Norfolk and Suffolk Foundation Trust: 0800 279 7257

Essex Partnership University NHS Trust: 0800 0857935

7.8 Patient Safety Incident Response Framework (PSIRF)

The procedure for investigating patient safety incidents is separate from the complaints procedure and is managed in accordance with the relevant organisations PSIRF policy. If, during the course of a safety investigation response, including a Patient Safety Incident Investigation (PSII), a complaint is also received, the incident procedure will normally take precedence over the complaint investigation. In these circumstances the investigators of the incident should, following PSIRF standards, engage with the patient and/or family concerned to ensure any questions form part of the safety investigation.

If a complaint reveals there is a patient safety incident which requires investigation using the PSIRF this should be reported as a clinical incident. In the alternative, complaint details should be shared with the provider organisation concerned for onward incident reporting and investigation.

In these circumstances the complainant will be notified of the PSIRF investigation by the organisation leading that investigation and will also be kept updated on the progress. The PALS and complaints team will also track the progress of the investigation. It should be remembered that the issues raised in a complaint will not always be exactly the same as those investigated under the PSIRF procedure and in this instance a separate and full response to the complaint will be required.

7.9 Withdrawal of a Complaint

Any concern or complaint received by SNEE ICB, either verbally or in writing, can be withdrawn at any stage of the procedure. Any issues against an individual, those complained against will be informed. Where possible, learning will be shared with the appropriate teams or individuals.

7.10 Managing Habitual, Aggressive or Repetitive Complaints

Habitual, unnecessarily aggressive or repetitive complainants are an increasing problem for staff, reflecting a pattern experienced throughout the NHS.

The difficulty in handling such complainants can place a strain on time and resources and cause undue stress for staff that may need support in difficult situations. Staff are trained to respond in a professional and helpful manner to the needs of all complainants. However, there are times where nothing further can reasonably be done to assist the complainant or to rectify a real or perceived problem.

Appendix 2 sets out the procedure for the management of habitual, unnecessarily aggressive or repetitive complainants. It is ultimately the decision of the Chief Executive as to whether a complainant is classified as unreasonably persistent.

7.11 Staff support

It can be very stressful for those involved in the complaints process and advice and support is available to staff by contacting the PALS and Complaints Team. Further support is available via line their manager and HR, who can also provide details of external support options if necessary.

7.12 Learning from complaints and monitoring compliance

Every opportunity will be taken by SNEE ICB to learn from complaints, enquiries, feedback and compliments, and ensure that future commissioning arrangements are positively influenced by patient feedback.

The insight and experience of complainants will be used to resolve the complaint or issue and reduce the risk of it reoccurring. Where possible and practicable complainants will be offered the chance to review and contribute to problem solving arising from their complaint and commenting on changes made as a result.

There is regular interface between SNEE ICB PALS and Complaints Team with the SNEE ICB Quality Leads to ensure complaints information and learning is shared in real time with commissioning teams.

Quarterly reports containing PALS and Complaints data are produced by the PALS and Complaints Team Manager as part of quality governance reporting into SNEE ICB Quality Committee. The report will provide information about the number of complaints; the services involved; the reasons for complaints and any ongoing trends, including compliments and areas of best practice. Other ad-hoc reports are produced as and when required to support service reviews.

Quarterly reports will also include learning from any Parliamentary and Health Service Ombudsman (PHSO) reports, highlighting where SNEE ICB has been required to undertake further investigations or changes to the way a complaint has been handled will be reported and reviewed to determine if amendments to this policy are required as a result.

SNEE ICB commits to reporting complaints data to NHS England via the Strategic Data Collection System (SCDS) on an annual basis.

SNEE ICB will publish an annual complaints report in line with The Local Authority Social Services and National Health Service Complaints (England) Regulations 2009; demonstrating evidence of a good quality complaints service, capturing and sharing learning, feedback about the quality of complaint handling, assurance that actions arising from PHSO upheld complaints investigations are completed as appropriate for both SNEE ICB and providers.

7.13 Records Management

Staff dealing with complaints must maintain accurate and up to date complaints files at all times in accordance with the principles of good record keeping. The complaints record will not be filed within a clinical record but held within a separate complaints file.

All complaint files will be kept electronically via Datix and the organisational IT system. Access to the network drive where the files are held is restricted to relevant personnel.

Complaint records will be stored in accordance with the NHS Records Management Code of Practice. Complaint files relating to SNEE ICB complaints investigations will be held by the organisation for a minimum of 10 years.

7.13.1 Access to personal information

Under the General Data Protection Regulation and the Data Protection Act 2018, individuals (both service users and employees) have certain rights regarding the way information about them is collected and used.

Both the GDPR and Data Protection Act 2018 provides the following rights for individuals:

The right to be informed
The right of access – Subject Access Request (SAR)
The right to rectification
The right to erasure
The right to restrict processing
The right to data portability
The right to object

Some of these individual rights will have exemptions applied to them.

Where clinical records are used in a complaint investigation, investigating officers must comply with regulations within the procedure for sharing of information across services or external agencies (incorporating the code of practice on openness in the NHS).

Any request received for access to complaint documentation will be sent to the Information Governance Department for appropriate action.

8 Appendix A: Abbreviations and Definitions

Abbreviation / Item	Definition
CE	Chief Executive
ICB	Integrated Care Board
SNEE ICB	Suffolk and North East Essex Integrated Care Board
ICP	Integrated Care Partnership
ICS	Integrated Care System
NHS	National Health Service
SC	Social Care
We	The ICB
PHSO	Parliamentary and Health Service Ombudsman
PALS	Patient Advice and Liaison Service
PSIRF	Patient Safety Incident Response Framework
PSI	Patient Safety Incident

9 Appendix B: Matters That Cannot Be Addressed Within the Complaints Procedure

This policy does not address:

Complaints that have already been locally investigated under the complaint’s regulations. Complainants can only make their complaint to one organisation, either the provider of the service or the commissioner, not both.

A complaint which is being investigated or has been investigated by the PHSO or Local Government Ombudsman.

A complaint made by a responsible body to another responsible body. For example disputes on contractual matters between independent contractors should not be handled through this procedure.

A complaint about which the complainant has stated their intention to take legal action.

Complaints regarding privately funded treatment or non-NHS services. The complainant will be advised of the correct agency to contact and will offer to forward the complaint for investigation. Beyond this, SNEE ICB will have no further input.

Complaints regarding an alleged failure to comply with a request for information under the Freedom of Information Act (2000). These will be dealt with via Information Governance processes.

A complaint made by an employee about any matter relating to his/her employment. These matters will be handled via human resources procedures.

Where a complaint is received that is disputing a funding decision for example an Individual Funding Request/NHS Continuing Healthcare case, this will be handled in accordance with the appropriate appeals process. However, the complainant can use the complaints procedure to raise concerns about the processes used.

If the organisation decides that a complaint meets any of the criteria detailed in the sections above the complainant will be notified in writing of this decision and the reasons why.

10 Appendix C: Managing Habitual, Aggressive or Repetitive Complaints

Introduction

This guidance should only be used as a last resort and after all reasonable measures have been taken to assist the person concerned. All staff are expected to be familiar with the NHS Complaints Procedure.

The decision to categorise a person as a habitual, unnecessarily aggressive or repetitive complainant will follow discussion between SNEE ICB’s Chief Executive, PALS and Complaints Team and an appropriate member of the Executive Management Team.

It should be emphasised that the classification of an individual as a ‘habitual, unnecessarily aggressive or repetitive’ complainant will NOT mean that any new issues, having no connection with original concerns, will not be dealt with through the usual process.

Criteria for definition of a habitual, unnecessarily aggressive or repetitive caller or complainant

Complainants may be deemed to be habitual, unnecessarily aggressive or repetitive callers where previous or current contact with them shows that they meet two or more of the following criteria:

• Persist in pursuing a complaint where the NHS Complaints Procedure has been fully and properly implemented and exhausted

• Change the substance of a complaint or continually raise new issues or seek to prolong contact by repeatedly raising further concerns or questions upon receipt of a response whilst the complaint is being addressed. (Care must be taken not to discard new issues that are significantly different from the original complaint. These might have to be addressed separately)

• Do not clearly identify the precise issues they wish to be investigated, despite reasonable efforts by staff and others (e.g. advocacy agencies) to help them specify their concerns

• The complaint or issue is trivial or appears to consume an excessive amount of resources

• Having, in pursuing their concerns, had an excessive number of contacts with SNEE ICB by telephone, letter or email. Staff should be instructed to keep a clear record of the number of contacts to demonstrate their excessive nature

• Display unreasonable demands or expectations and fail to accept these may be unreasonable, for example insist on immediate responses from senior staff when they are not available and this has been explained

• Have threatened or used actual physical violence. All cases must be documented, in case of further action.

• Have harassed or been personally abusive or verbally aggressive on more than one occasion towards staff dealing with them. All cases must be documented, in case of further action.

The use of actual physical violence, albeit on one occasion only, will result in the application of measures described under (3) to limit the personal contact ordinarily available to complainants.

Procedure for staff handling habitual, unnecessarily aggressive or repetitive callers or complainants

• Ensure all relevant procedures and reasonable action has been correctly implemented. If you are at all uncertain, please check with SNEE ICB’s PALS and Complaints or HR department.

• Even the most difficult of callers may have issues that contain genuine substance.

• Remain professional and polite. This does not mean that you have to listen continually to the same story of complaint, nor that you cannot politely, but firmly terminate the call.

• Record the date, time and how long you were on the telephone and inform SNEE ICB’s PALS and Complaints Team as soon as possible.

• When a caller has been officially declared a habitual, unnecessarily aggressive or repetitive caller, SNEE ICB’s Chief Executive may decide no further telephone communication will be accepted.

• Where there is ongoing correspondence or investigation, SNEE ICB’s PALS and Complaints Team Lead will write to the caller setting the parameters for a code of behaviour and the lines of communication. These will be communicated to all appropriate staff to ensure consistency of approach.

Where investigation or correspondence is completed, SNEE ICB’s Chief Executive will, at an appropriate stage, write to the complainant informing them SNEE ICB has responded fully to the points raised and that there is nothing further that can be added, therefore correspondence is at an end. SNEE ICB may wish to state that further correspondence will be acknowledged, but not answered.

It should be emphasised that the classification of an individual as habitual, unnecessarily aggressive or repetitive will not mean that any new issues having no connection with the original complaint or dispute will not be dealt with in the normal way.

11 Appendix D: Grading matrix tool

Grading	Examples	Response
Level 1 concern	Low level concern about commissioning policies/decisions Requests for information Signposting to other services	Manage within the PALS and Complaints Team
Level 2 concern	Minor concern about an unsatisfactory experience. Or relates to a single resolvable issue with minimal impact to risk to provision of care or service; for instance prescribing query.	Manage within the PALS and Complaints Team
Level 3 concern	A complaint or concern which raises issues regarding standards or quality of care. Patient experience appears to be below reasonable expectation in several ways, but not causing lasting problems.	Manage within the PALS and Complaints Team
Level 4 concern	A significant complaint or concern which could include multiple issues and multiple providers. Could also include concerns of moderate physical or psychological harm. Clinical review may be required.	PALS & Complaints Team to share with Quality Lead for decision and action.
Level 5 concern	A serious issue which may cause long term or permanent damage, misconduct and a high risk of litigation or adverse publicity. For example; Events resulting in serious physical or psychological harm or fatal harm. Alleged criminal offence (i.e. assault). Alleged abuse or neglect. Clinical review will be required.	PALS & Complaints Team to share with Quality Lead for decision and action. PALS & Complaints Team to share with Chief Executive and Director of Nursing and Clinical Quality.