Listening A guide to better customer careResponding Improving
DH INFORMATION READER BOXPolicy EstatesHR/Workforce CommissioningManagement IM & TPlanning/Performance FinanceClinical Social Care/Partnership WorkingDocument purpose Best practice guidanceGateway reference 11215Title Listening, Responding, Improving – A guide to better customer careAuthor Department of HealthPublication date 26 February 2009Target audience Health and social care staff involved in receiving feedback and resolving concerns and complaintsCirculation listDescription This guide is to help complaints professionals to work with colleagues to make their organisations better at listening, responding and learning from people’s experiences of care. It is designed to be accessible to all staff involved in receiving feedback and resolving concerns and complaints from people who use services and their representatives.Cross reference Listening, Responding, Improving Advice SheetsSuperseded documents N/AAction required N/ATiming The regulations come into effect from 1 April 2009Contact details Making Experiences Count Team Department of Health Room 5E43 Quarry House Quarry Hill Leeds LS2 7UE firstname.lastname@example.org www.dh.gov.uk/mecFor recipient’s use
1This guide has been developed to helpcomplaints professionals who are working withcolleagues to make their organisations betterat listening, responding and learning frompeople’s experiences.It is designed to be accessible to anyoneworking in health and social care organisationswho is involved in receiving feedback andresolving concerns and complaints frompatients, service users and their representatives.We have also produced additional advice sheetsfor complaints professionals, covering a rangeof specific issues. You can find more informationabout these in the ‘Helpful resources for you’section at the back of this guide.We hope you find this publication useful.If you have any suggestions for newadvice sheets please email us email@example.com
CONTENTS PageINTRODUCTIONExperiences count 4Improving customer care: why do things need to change? 4What is the new approach? 5LISTENINGAre you really listening? 11How easy is it for people to give you feedback? 11Making information engaging and accessible 14Dealing with complaints: how to get it right first time 14What rights do people have? 15RESPONDINGAssessing how serious the complaint is 18Handling issues involving more than one service 22Responding in the right way every time 22Giving people support and advice when they complain 25Investigating someone’s concerns 26When to mediate if an issue can’t be resolved 27Remedies to help put things right 28What to do if the complaint still can’t be resolved 30Handling unreasonable complainants 32IMPROVINGHow to keep improving your service 34Training for frontline staff and managers 37Top questions 40Helpful resources for you 43Endnotes 44
IMPROVING CUSTOMER CARE: WHY DO THINGS NEED EXPERIENCES COUNT TO CHANGE?In 2006, the Government committed to helping Health and social care staff work very hardNHS and adult social care organisations to to get the job right first time but, with busyimprove the way they deal with complaints, in services, mistakes can happen. But if servicesorder to make services more effective, personal can get their response to these mistakesand safe. right, the people affected are less likely to be unhappy and future problems canTo achieve this, it was decided that a single be prevented.approach would be introduced for dealing withcomplaints, to give organisations greater flexibility When a mistake has happened, it is importantto respond and encourage a culture that seeks to acknowledge it, put things right quickly andand then uses people’s experiences of care to learn from the experience.improve quality. This has been highlighted in many reports onOther reforms have since helped to strengthen this NHS and social care complaints.policy. The NHS Constitution makes clear what There is a clear need for services to get betterpeople should expect when they complain. The at dealing with complaints.combined health and social care regulator, the CareQuality Commission, will soon require registered In 2006/07, the NHS and local authoritiesproviders of services to investigate complaints received over 150,000 complaints abouteffectively and learn lessons from them. health and social care services.1 In every case, those who complained should haveAfter extensive consultation and testing on the felt confident that their complaint would beground, the new approach starts from April 2009. dealt with properly – in other words, that itHowever, in many areas it has already been would be handled efficiently and investigatedhelping to make a difference. The Making things better report2 highlights the problems faced by people using NHS services in getting a satisfactory response to a complaint and the failure of the NHS to learn lessons from complaints. 2005 2005The story so far A survey3 finds that many people using adult social care services see ‘no point’ in making a complaint.
Introduction 4|5 WHAT IS THE NEW APPROACH? thoroughly, and that they would be told the From April 2009, there will be a single approach outcome. What’s more, if they were in any way for dealing with complaints about NHS and ‘wronged’, they should have felt assured that adult social care services. things would be put right. Organisations will be encouraged to ask Government policies, such as those outlined people what they think of their care, to sort in the NHS Constitution,4 are already helping out problems more effectively and to use the people understand their rights when it comes opportunities to learn. to making a complaint. However, this is not Announced in 20065 and widely consulted upon the only reason services need to get better at since, the new approach ends the bureaucracy customer care. of the old system. It is also designed to bring By listening to people about their experiences real benefits for health and care organisations of health and social care services, managers and for the staff working in them. can resolve mistakes faster, learn new ways to improve and prevent the same problems from happening in the future. In short, by dealing with complaints more effectively, services can get better, which will improve things for the people who use them as well as for the staff working in them. That’s what this guide is all about. We hope you find it, and the new approach, useful.A government consultation6 A Healthcare Commission review8says that people think the finds that many NHS complaintsNHS complaints system is relate to the fundamentals of goodtoo inflexible and does not healthcare: effective communicationmeet the needs of the person with patients, the attitude of staff,complaining. record-keeping, privacy and dignity. In 19% of cases, there was also a problem with the way in which the complaint was handled.2007 2009 2008 A National Audit Office report7 on health and social care services says that people find making a complaint too complex and that many complaints take too long to resolve.
From the front linePaul Duffy works as a quality assurance manager for Oldham Council and isresponsible for dealing with complaints about adult social services. He explainshow the new approach has helped both his team and the services thecouncil provides.“Oldham is always looking for ways to improve the way it does things, so beingable to try out the new approach to complaints has been really useful.“In the old days, although we dealt with complaints well, we could get boggeddown in the process. Now, because the focus is on getting the best outcome forboth individuals and services, every complaint is seen as an opportunity to helpmake care better.“We now have a much more proactive approach and, if we know that somethingmay have gone wrong, we get in contact, say sorry and find out what we needto do to prevent the issue recurring.“People’s needs, not the complaints process, now drive our work and this hasalready made a difference.”
Introduction 6|7 What is the new system trying to achieve? Put simply, the new system means: Better results: The old, process-heavy system is being replaced with one that allows you and the person complaining to agree on the best way to get a satisfactory outcome.A more personal approach:People who use services,whatever their background orcircumstances, should find iteasier to tell you what they thinkor make a complaint. Helping organisations learn: The new system will also encourage services to learn from individual complaints and improve as a result.
Principles of Good Complaint Handling Complaints and the lawThe Health Service Ombudsman, which is The law that dictates how NHS and localresponsible for investigating NHS complaints authority adult social care services need tothat can’t be resolved locally, has published deal with complaints is being simplified. FromPrinciples of Good Complaint Handling. April 2009, it is changing to support the newThe Local Government Ombudsman has complaints approach and give services morealso issued guidance. flexibility in how they handle complaints.In summary, the six principles are: It is important that you understand all the legislation. From March 2009,1. getting it right you can download the regulations.2. being customer focused3. being open and accountable4. acting fairly and proportionately5. putting things right6. seeking continuous improvement.Over 90 health and social care organisationshave already tested the new approach fordealing with complaints, which is based onthese principles. We asked those organisationsfor their views and experiences and we haveincluded them in this guide.
Introduction 8|9 The new system in a nutshellThe new system applies to your organisation if...... you provide or commission NHS care or are a local authority that fundsadult social services.Organisations will be encouraged to adopt good practice, whichrecommends that you:• publicise your complaints procedures• acknowledge a complaint when you receive it and offer to discuss the matter• deal efficiently with complaints and investigate them properly and appropriately• write to the person who complained once the complaint has been dealt with, explaining how it has been resolved and what appropriate action has been taken, and reminding them of their right to take the matter to the Health Service Ombudsman or Local Government Ombudsman if they are still unhappy• have someone senior within your organisation who is responsible for both the complaints policy and learning from complaints• help the person who is complaining to understand the complaints procedure• produce an annual report about complaints that have been received and outline what has been done to improve things as a result. Other things to know about the new system: • Generally speaking, a complaint has to be made within 12 months of an incident happening. • In the NHS, someone can choose to complain to a commissioner instead of the service provider. • If the complaint involves two or more organisations, the person complaining should get one, co-ordinated response.
Listening 10|11 HOW EASY IS IT FOR PEOPLE TOARE YOU REALLY LISTENING? GIVE YOU FEEDBACK?To gather people’s views about the service they This means thinking about all the different waysreceive, organisations have to make it clear that people find out about and interact with yourthey want to know what users think, they are service – from what your website says to thelistening and they want to learn from feedback. way your staff communicate with people.Evidence suggests that people often don’t know How to reach peoplehow to complain if they are unhappy or how tosuggest an idea for improving things. People are confronted with many messages every day. To make sure yours get noticed,People who use NHS and social care services all of your communication channels need tohave also said they often don’t say what they work together to give a consistent messagethink because they feel inhibited or think in a consistent tone. It’s crucial to think aboutservices won’t listen. the way in which people use your service and structure your communications with thatAll NHS bodies and local authorities have to in mind.make clear how people can complain. However,there is a lot more your service can do to makeit clear that all types of feedback – whethercomplaints, concerns or compliments –are welcome. Service (reception waiting room) Call centre Staff contact Internet Customer services or Patient Advice and Liaison Service (PALS) Correspondence Opinion formers Friends, family, media, etc Service user Communications Partners and intermediaries Publications, events, Advocacy services, eg the PR, marketing Independent Complaints Advocacy Service (ICAS), advice services, eg Citizens Advice Bureau, patient Service quality and user organisations Speed, politeness
From the front lineLiverpool City Council provides many different ways for people to tell them whatthey think about their social care services. Their scheme, called ‘Have Your Say’,is very well advertised. It allows people to give feedback:• in person at reception points and accessible one-stop shops, with translation and interpretation facilities if needed• by post using a Freepost address or email• online using a ‘Have Your Say’ form, which asks people what ideally they would like to happen as a result of their feedback• by phone using a 24-hour phone-line run by Liverpool customer services. This includes a Minicom phone service for people who are deaf• using kiosks located in the street and in places such as libraries where people can text, email or video their views.The council also uses an electronic management system to register and trackfeedback from receipt to resolution.Many of Liverpool’s services are run by independent providers. By asking thepeople who use them directly for their views, the council can spot issues and takeaction sooner.
Listening 12|13Health check YES NOIs your organisation good at letting people know you are listening andwant to know what they think?If you have a reception or waiting area, is there a poster or video that asksfor people’s views?When someone first makes contact with your service, do you explain howthey can offer feedback or complain?Do you have a suggestions box with pens and forms for peopleto complete?Do you regularly ask people who use your service about their experiencesof the care you provide?If anyone working in your service was asked about your complaintsprocess, would they be able to explain the basic system and tell the serviceuser where they could get more information and support?Is the information you provide accessible to all the people who use yourservices? For example, if someone does not speak English fluently, wouldthey still be able to complain?Is it clear to everyone working in your service, and the people who useit, what changes you have made in light of ideas or comments youhave received?Has your organisation ever run, or been part of, a campaign to get peopleto give their views?Do you use other sources of information about people’s experiences tohelp improve your service such as surveys and consultations?
MAKING INFORMATION DEALING WITH COMPLAINTS:ENGAGING AND ACCESSIBLE HOW TO GET IT RIGHT FIRST TIMEIt is important to provide information that The people who use health and social careexplains very clearly how people can give their services understand that mistakes sometimesviews. To encourage them to tell you what happen. When something goes wrong, oftenthey really think, this information needs to be all the person affected wants to know is how itengaging and accessible. happened, that you are sorry, and that steps will be taken to prevent it from happening again.What makes an effective complaints The initial contact an organisation has with aleaﬂet? person who is unhappy about their service is• Make your sentences short, punchy and key. It is crucial to obtain all the information to the point. Use everyday language and that will allow you to assess someone’s concerns avoid jargon. correctly, resolve them quickly if you can and• Explain that you want to know what build a good ongoing relationship with them. people think. Often the reason people give for being• Don’t just focus on complaints; make it clear unhappy about how their complaint has been that you also welcome compliments, concerns handled is poor communication by services. and any other comments. Things to remember to do when someone says• Use good design to make your materials they are unhappy: stand out and the information accessible. 1. Ask the person how they would like to• Make it clear that the information is available be addressed – as Mr, Mrs, Ms or by their in different formats and languages. first name.• Make it clear how people can get more 2. If someone has phoned you, offer to call information and support. them back and give them the chance to meet face to face to discuss the issue.It is also helpful to give people tangibleexamples of how you have changed things 3. Ask them how they wish to be keptin response to their feedback. informed about how their complaint is being dealt with – by phone, letter, email or through a third party such as an advocacy or support service. – If they say by phone, ask them for times when it is convenient to call and check that they are happy for messages to be left on their answerphone. – If they say by post, make sure that they are happy to receive correspondence at the address given.
Listening 14|15 WHAT RIGHTS DO PEOPLE HAVE?4. Check if the person has any disabilities or When someone is unhappy with your service, circumstances you need to take account of it is important to let them know their rights (for example, do they require wheelchair when it comes to making a complaint. In the access, or are they on medication that can NHS, these rights are articulated by the NHS make them drowsy?). Constitution.5. Offer to meet the person at a location The NHS Constitution states that “any convenient to them. individual has the right to:6. Make the person aware that they can • have any complaint they make about NHS request an advocate to support them services dealt with efficiently and have it throughout the complaints process, properly investigated including at the first meeting. • know the outcome of any investigation into7. Systematically go through the reasons their complaint for the complaint with the person who is unhappy – it is important that you • take their complaint to the independent understand why they are dissatisfied. Health Service Ombudsman if they are not (See ‘Assessing how serious the complaint satisfied with the way the NHS has dealt with is’ on page 18 for how to assess an issue.) their complaint8. Ask them what they would like to happen • make a claim for judicial review if they as a result of the complaint (for example, an think they have been directly affected by an apology, new appointment, reimbursement unlawful act or decision of an NHS body for costs or loss of personal belongings or • receive compensation where they have been an explanation). Tell them at the outset harmed by negligent treatment.” if their expectations are not feasible or realistic. People who use social care services have the9. Agree a plan of action, including when and right to take their complaint to the Local how the person complaining will hear back Government Ombudsman. from your organisation. (See ‘Responding in the right way every time’ on page 22 for more information on developing a plan).10. If you think you can resolve the matter quickly without further investigation do so as long as the person complaining is happy with that and there is no risk to other service users.11. For any complaint, remember to: – check if consent is needed to access someone’s personal records, and – let the complainant know the name and contact details of the manager who will investigate their complaint.
From the front lineGemma Seymour, Consumer Experience Development Manager for HampshirePartnership Trust, explains what she does when someone first gets in contact tosay they are unhappy.“When someone first complains – whether by phone or in person – it is essentialthat you understand the situation through their eyes. To do this, you need tolisten and let them tell their own story, in their own time.“Doing this helps me to establish the facts, which I always check with thecomplainant to ensure they are correct. At this stage, I also ask them what theywould like to see happen and explain what the organisation can realisticallydo. Once I understand the situation, if I can sort it out immediately I will – forexample, by offering an apology.“We get most of our complaints by phone and people are often distressed orangry. I try to make things as easy as possible. If someone needs advocacysupport I help arrange this. If someone wants to meet I offer them the chanceto do that.“People also appreciate being given as much of a say as possible. There isnormally more than one way of resolving a complaint, so I like to offer at leasta couple of options that are realistic for both parties. If someone wants theirconcerns investigated, we involve them in putting together the plan of action.“The fundamental point is that when you listen, involve and engage people,it makes it much easier to sort out the problem to everyone’s satisfaction.”
ASSESSING HOW SERIOUS THECOMPLAINT ISBy correctly assessing the seriousness of a It is useful to categorise a complaint when youcomplaint about a service, the right course first receive it, and then review that categoryof action can be taken. Many NHS and social based on the results of any investigation.care organisations use a three-step process to It is also important to remember that agauge the impact of complaints on the people complaint can have a very different effect oninvolved, the potential risks to the organisation an organisation compared with an individual.and the response required. This is especially important if someone is vulnerable for any reason, such as poor health, communication difficulties or recent bereavement. The following process can help you assess the seriousness of an issue and take the relevant action. Step 1: Decide how serious the issue is Seriousness Description Low Unsatisfactory service or experience not directly related to care. No impact or risk to provision of care. OR Unsatisfactory service or experience related to care, usually a single resolvable issue. Minimal impact and relative minimal risk to the provision of care or the service. No real risk of litigation. Medium Service or experience below reasonable expectations in several ways, but not causing lasting problems. Has potential to impact on service provision. Some potential for litigation. High Significant issues regarding standards, quality of care and safeguarding of or denial of rights. Complaints with clear quality assurance or risk management issues that may cause lasting problems for the organisation, and so require investigation. Possibility of litigation and adverse local publicity. OR Serious issues that may cause long-term damage, such as grossly substandard care, professional misconduct or death. Will require immediate and in-depth investigation. May involve serious safety issues. A high probability of litigation and strong possibility of adverse national publicity.
Responding 18|19 Step 2: Decide how likely the issue is to recurLikelihood DescriptionRare Isolated or ‘one off’ – slight or vague connection to service provision.Unlikely Rare – unusual but may have happened before.Possible Happens from time to time – not frequently or regularly.Likely Will probably occur several times a year.Almost certain Recurring and frequent, predictable. Step 3: Categorise the risk Seriousness Likelihood of recurrence Rare Unlikely Possible Likely Almost certain Low Low Moderate Medium High High Extreme
EXAMPLES OF DIFFERENT TYPES OF INCIDENTS Low (simple, non-complex Delayed or cancelled appointments. issues) Event resulting in minor harm (eg cut, strain). Loss of property. Lack of cleanliness. Transport problems. Single failure to meet care needs (eg missed call-back bell). Medical records missing. Moderate (several issues relating to Event resulting in moderate harm a short period of care) (eg fracture). Delayed discharge. Failure to meet care needs. Miscommunication or misinformation. Medical errors. Incorrect treatment. Staff attitude or communication. High (multiple issues relating See moderate list. to a longer period of care, Event resulting in serious harm often involving more (eg damage to internal organs). than one organisation or individual) Extreme (multiple issues relating Events resulting in serious harm or death. to serious failures, Gross professional misconduct. causing serious harm) Abuse or neglect. Criminal offence (eg assault).
Responding 20|21Assessing an issue in practiceHere are a couple of examples to give an idea of how different complaints would be graded.LowWhen visiting the home of an 89-year-old The manager discussed the issues with the districtman, a district nurse commented that the nurse, who agreed that the comments wereman seemed mobile and could have come inappropriate. The nurse explained how stressed heto the clinic for treatment. was with his current workload, and that this could be affecting his work.The man’s son called to complain about theservice. The complaint was passed to the The service manager rang both parties, apologisedservice manager. on the nurse’s behalf and explained that, although his behaviour was out of character, action wouldOn the same day, the service manager be taken.received a similar complaint by post fromthe family of another service user. A different nurse was assigned to each case and both parties said that they were satisfied with theThe manager contacted both unhappy response.parties. After discussing their concerns, sheasked them if she could look into the issue The nurse’s workload was reviewed in light ofand call them back within a few days. the stress he was experiencing. A note was alsoBoth agreed. made on his staff record in case something similar occurred again.ExtremeThe family of an elderly lady with mild Once safeguarding procedures were complete,learning disabilities became concerned about an investigation began. A case conferencethe standard of service in her residential care decided this was an example of abuse thoughhome. They expressed their concerns to the neglect.local authority. A social worker visited the lady The investigating officer upheld the complaintand was so concerned at her condition that and identified the main reason for the neglect:he arranged for her immediate admission the home’s lack of knowledge about the lady’sto hospital. mental capacity. Staff had assumed the lady wasThe lady had not been eating or drinking, and exercising choice when she refused food andher toenails were so long she couldn’t walk treatment. It also turned out the patient hadproperly. Her condition improved while in somehow fallen between learning disability andhospital and she was soon placed in another community health team jurisdictions.care home. Social services ordered a full Since this case, staff have received training oninvestigation. mental capacity, a review of learning disabilities services is under way and the home is being monitored to ensure that this type of situation does not occur again.
HANDLING ISSUES INVOLVING RESPONDING IN THE RIGHT WAYMORE THAN ONE SERVICE EVERY TIMELots of people receive care from more than one How can services ensure that they respond inhealth and social care organisation. If something the right way to every complaint? The followinggoes wrong with that care and a complaint is steps can go a long way towards improving themade, it is important that the organisations quality of your responses.involved provide a single point of contact and Step 1: Having a plana single response. Step 2: Deciding what to doIn many areas, services have already agreed aprotocol for handling complaints. Doing this can: Step 3: Deciding how long it should take• avoid any confusion for service users about how complaints will be dealt with and by What a plan might include whom The best plans for dealing with complaints are developed with input from those who make• provide clarity about the respective roles and them, and those whose job it is to resolve responsibilities of each organisation them. The most effective plans also focus on• ensure that complaints professionals the reactions or observations that can help your communicate regularly service improve.• ensure that any lessons that need to be Any plan you agree on needs to be learned are identified and addressed by the proportionate, achievable and cost-effective, relevant organisation. and it is important to update it as the issue progresses.There is now a draft protocol to help complaintsprofessionals from different services work better Any action plan also needs to take into account:together. See ‘Helpful resources for you’ for 1. a person’s legal rights when they make amore information. complaint (see ‘What rights do people have?’ on page 15) 2. what your service has agreed to do to resolve the issue 3. a timescale for doing so 4. how and when you will update the person on any progress 5. any support the person complaining might need with 6. the immediate actions staff might take, such ns for dealing th best pla d wi as an apology The evelope them ts are d omplain ose who make 7. how the complaint is categorised (see c ‘Assessing how serious the complaint is’ on m th i nput fro page 18).
Responding 22|23 Step 1: Having a plan If you can agree a clear plan and a realistic outcome with the person complaining from the start the issue is more likely to be resolved satisfactorily. Having a plan can help you respond appropriately. It also gives the person who is complaining more confidence that you are taking their concerns seriously.Step 2: Deciding what to doHaving a clear understandingof the complaints process isalso crucial in helping managersdecide on the best response.See the decision tree on the nextpage to help you. Step 3: Deciding how long it should take If someone makes a complaint, your organisation has to acknowledge it within three working days. The person making the complaint will want to know what is being done – and when. However, accurately gauging how long an issue may take to resolve can be difficult, especially if it is a complex matter involving more than one person or organisation. To help judge how long a complaint might take to resolve, it is important to: • address the concerns raised as quickly as possible • stay in regular contact with whoever has complained to update them on progress • stick to any agreements you make – and, if for any reason you can’t, explain why. It is good practice to review any case lasting more than six months, to ensure everything is being done to resolve it.
REGULAR COMMUNICATION CONSIDER APPROPRIATE SUPPORT Can the complaint be The complaint falls outside resolved straight away? complaints arrangements. YES Good practice to note any learning for organisation NO Acknowledge the complaintHas the complaint been made within three working days. Contact the complainantdirectly to the primary care as soon as possible totrust (PCT) Does the complaint fall within explain the decision YES the list of exclusions (for example, is it an employment matter?)? YES NODoes the PCT believe that it is Does the complaint involve more The organisations must agreeappropriate to consider the than one health or adult social which will take the lead incomplaint? YES care provider? YES responding and communicating with the complainant NO NONotify the complainant, and if If the PCT is consideringconsent given, notify the the complaint, notify theprovider to handle the complaint complainant and receive consent to send the complaint to the provider, then offer discussion with the complainant on an action plan, how the complaint will be handled and the expected timescale Investigate the complaint. Is the Review the case investigation concluded within six months, or will it be? NO YES Send the final report, signed off by a responsible person within Notify the complainant, in the organisation. Include the writing, explaining the delay. conclusion of the investigation Resolve complaint as soon and organisational learning as possible where applicable. Include recourse to the Ombudsman if the complainant is not happy Produce annual report; this should include actions taken to improve services. The report should be available to any person who requests it
Responding 24|25GIVING PEOPLE SUPPORT ANDADVICE WHEN THEY COMPLAINPeople using health or social care services often Advocacy: Some people will need help makingneed support if they wish to complain or they their complaint, and ongoing support while itwant to suggest an idea to improve something. is resolved for them. Independent advocacyIt is essential that staff are able to help people support can be invaluable here. In the NHS,find and use this advice and support effectively. advocacy is provided by the Independent Complaints Advocacy Service (ICAS).There are many reasons why someone mightneed support (eg disability, language, age), and For social care services, there are a number ofa number of services that can help. (See ‘Top local voluntary, community and self-help groupsquestions’ and ‘Helpful resources for you’ for who can offer this kind of support. It is a goodmore information on hard-to-reach groups.) idea to make the people who use your service aware of the local organisations that can help.Who can help? Independent advocates can support whoever’sCustomer services: Your NHS or local authority complaining by:customer service team or Patient Advice andLiaison Service (PALS) can provide valuable • helping them speak to someone independentadvice and support to people who use your and impartial in strict confidenceservice, and their representatives. The type • making their options clear to themof support may vary from area to area, but • supporting them throughout the complaintcan include: process (eg helping them write letters,• information about NHS and social care supporting them at meetings, contacting third services parties, etc).• help resolving concerns or problems To find out more about the advice and support• information on how to complain and how to available in your area, speak to customer service access independent help and advice or the PALS team (www.pals.nhs.uk), or visit:• helping people share their concerns, www.nhschoices.nhs.uk suggestions and experiences and using this information to improve services www.direct.gov.uk• putting people in touch with support groups and agencies who can offer additional help• showing people how to get involved in shaping local health and social care services• early warning systems for specific problems or gaps in services.
INVESTIGATING SOMEONE’SCONCERNSWhen something has gone wrong, it is vital to As the complaint progresses, it is importantestablish the facts about what happened in a to update the original plan to give a moresystematic way. For some serious complaints, complete record of how the case has beenit may be necessary to ask an independent handled. Updates could include:investigator to look into the case. But most • details from your investigation (interviews,complaints will be investigated by someone statements and facts)from within the organisation, who should beappropriately trained and independent of the • details of mediation or advice from clinicianspart of the service that is being complained about. or the results of an independent investigation • details of any policies, protocols or guidelinesInvestigations need to collect and examine that have or have not been followed properlyevidence in a variety of ways, which mayinclude: • the final report• carrying out interviews • anything that could help your service learn and improve• looking at written records and copies of documents • the sign-off by the senior manager responsible for your complaints policy.• carrying out site visits• taking expert advice (for example, on clinical To help complaints professionals, we have issues). also developed a separate advice sheet on investigating complaints. You will find this inOnce all the evidence has been gathered, it will ‘Helpful resources for you’.need to be assessed in order to decide what isfair and reasonable in the circumstances of eachcase. Where two sides of a story seem to be atodds, the investigator will try to decide, on thebasis of all the available evidence, which versionof events is more likely to have happened.
Responding 26|27WHEN TO MEDIATE IF AN ISSUECAN’T BE RESOLVEDIf someone is dissatisfied with your service, in What does mediation involve?most cases you will be able to resolve the issue Mediation can involve several stages. Thedirectly with them. However, some complaints mediator may first spend time meeting eachare more difficult to resolve, particularly when party separately to get to the bottom of thethere is a breakdown in a relationship. In these complaint issues. They may then bring bothcases, mediation can be useful. parties together to discuss the problem.What is mediation? What does it not involve?Put simply, mediation is a way to help resolve Mediation should not be confused with:disagreements. An impartial mediator helps • advocacy, which involves speaking on behalfboth parties reach an acceptable conclusion. of one party onlyIt can also help to re-establish a goodrelationship with the person who is unhappy. • counselling, guidance or adviceMediation is particularly useful when there is a • arbitration – a mediator does not normallyrisk of communication breaking down. When make decisions or offer solutions to theemotions are running high, the mediation problemprocess can help both parties express their • investigation into the complaint.9frustration or anger without affecting progresstowards an effective solution. Why does mediation work? Mediation gives everyone a chance to think about how they could put the situation right. It allows all the parties involved to come up with their own ways to rebuild relationships by working together towards the same goal. Mediation can also save time and money and lead to quicker solutions. Crucially, it can prevent problems becoming worse.
REMEDIES TO HELP PUTTHINGS RIGHTOften, when someone first complains, they Offering a full explanationsimply want to understand how the problem When someone makes a complaint aboutoccurred and get an apology or reassurance your service, they have the right to a responsethat the same thing won’t happen again. which explains how their concerns have been resolved, what action has been taken and theirThose who want some kind of redress often just right to take the matter further.want to be in the position they were in beforethey felt the need to complain. Every response will be different, especially for complex issues, but it may include some or allComplaints can be resolved more effectively if of the following:you are clear from the outset what the personcomplaining expects as an outcome. Also, if • a summary of each element of the complaintyou agree a plan with them and explain how • details of policies or guidelines followedthe issue has been resolved, all parties canbenefit from the process. (See ’Responding in • a summary of the investigationthe right way every time’ on page 22 for more • details of key issues or facts identified by aninformation on developing a plan). investigationBoth the Health Service Ombudsman and the • conclusions of the investigation: was thereLocal Government Ombudsman have made it an error, omission or shortfall by yourclear that if a service is in the wrong it must try organisation? Did this disadvantage theto put things right. complainant, and if so, how?There are a number of remedies that can be • what needs to be done to put things rightused. The remedy needs to be proportionate to • an apology, if one is neededthe circumstances. • an explanation of what happens next (eg what will be done, who will do it, and when) • information on what the person complaining should do if they are still unhappy (eg your organisation’s appeals process) • information on the relevant Ombudsman. more can be resolved the Com plaints u are c lear from ing ely if yo rson complain effectiv he pe outse t what t s an outcome a expects
Responding 28|29Different ways to put things rightYour response to a complaint will naturallydepend on the circumstances of each case.However, the Local Government Ombudsmanhas some useful advice:“There are some simple principles you canfollow when you want to put things right.Whenever possible: put someone in theposition they would have been if the fault hadnot occurred, make the remedy appropriateand proportionate to the harm suffered, takespecific action if it’s needed, offer compensationif appropriate and always apologise if you areat fault. Also consider whether any practices,procedures or policies should be reviewed.”For more information on putting things right,see the Health Service Ombudsman’s Principlesfor Remedy guidance.If you offer financial redress, it is a good ideato be familiar with the Treasury’s advice. There are lots of ways you can put things right: • Apologise. • Explain what happened. • Explain how you will try to ensure it does not occur again. • Take action to put things right.
WHAT TO DO IF THE COMPLAINTSTILL CAN’T BE RESOLVEDIf you have done everything you can to resolve If an issue is about an adult social care service,a complaint, and a person is still not satisfied, the person complaining can contact the Localthey can ask the Health or Local Government Government Ombudsman by:Ombudsman to review the matter. • visiting www.lgo.org.ukIt is important that you are able to advise • calling the LGO Advice Team on 0845 602whoever is complaining about how they can 1983 (Mon–Fri 8:30am–5:00pm)exercise this right and the steps involved. • texting ‘call back’ to 0762 480 4323The Ombudsman – your questions • faxing 024 7682 0001answered • emailing: firstname.lastname@example.orgHow does someone contact the relevant • writing to:Ombudsman?If an issue is about an NHS service, the The Local Government Ombudsmancomplainant can contact the Health Service PO Box 4771Ombudsman by: Coventry CV4 0EH• visiting www.ombudsman.org.uk• calling the complaints helpline 0345 015 What factors does the Ombudsman 4033 (Mon–Fri 8:30am–5:30pm) look at?• emailing email@example.com The Health Service Ombudsman bases their• faxing 0300 061 4000 decisions on Principles of Good Complaint Handling, while the Local Government• writing to: Ombudsman has published guidance to help you understand what they regard asThe Parliamentary and Health Service good practice. OmbudsmanMillbank TowerMillbankLondon SW1P 4QP
Responding 30|31 How does the Ombudsman process work? Step 1: After ensuring that the complaint is within their jurisdiction the Ombudsman may check that everything has been done to resolve the issue locally. If they think more can be done, they will refer the issue back to the service.Step 2: Before taking thematter on, the Ombudsmanwill consider several factors:What has gone wrong? Whatinjustice has this caused?What is the likelihood ofachieving a worthwhileoutcome? Step 3: If the Ombudsman believes there is a case to answer, they will direct the organisation to put things right.
HANDLING UNREASONABLECOMPLAINANTSOn rare occasions, despite your best efforts • Only acknowledge correspondence youto resolve a complaint, the person making receive about a matter that has already beenit can become aggressive or unreasonable. closed.It is important to know how to handle • Explain that you do not respond tocircumstances such as these. correspondence that is abusive.There are a number of ways to help manage • Make contact through a third person such asthe situation: a specialist advocate.• Make sure contact is being overseen by • Ask the complainant to agree how they will a manager at an appropriate level in the behave when dealing with your service in organisation. the future.• Provide a single point of contact with an • Return any irrelevant documentation and appropriate member of staff and make it clear remind them that it will not be returned again. to the complainant that other members of staff will be unable to help them. When using any of these approaches to• Ask that they contact you only in one way, manage contact with unreasonable or appropriate to their needs (eg by phone). aggressive people, it is important to explain what you are doing and why, and to keep a• Place a time limit on any contact with the detailed record of the ongoing relationship. complainant.• Restrict the number of calls or meetings you You can read more advice on dealing with will have with them during a set period. unacceptable behaviour and unreasonably persistent complainants.• Ensure that any contact involves a witness.• Refuse to register repeated complaints about the same issue.
HOW TO KEEP IMPROVINGYOUR SERVICEListening to feedback about your services Tips for improving your customer focuscan uncover new ideas to help improve 1. Take a consistent approach to customerthe way in which you do things. This is contact, across all services.increasingly important for health and social careorganisations, who are expected to show how 2. Know what other services your customersthey use feedback to improve care. use. 3. Share information about customers andImproving customer focus communities across the services – to reduceWhat is a customer-focused service? unnecessary duplication.According to the Office of Government 4. Always create an opportunity for peopleCommerce, a customer-focused service: to give feedback or become involved if they can.10• understands its customers• makes sure that the way it operates is totally focused on the customer Using the ‘four Cs’ You can use any comments, compliments,• forms strong relationships with customers and concerns and complaints you receive to: encourages feedback • tell you what’s working• uses its knowledge of the customer to improve and develop the service it provides. • help you identify potential service problems • help you identify risks and prevent them fromWhat makes a happy customer? getting worsePublic services can raise levels of customer • highlight opportunities for staff improvementsatisfaction when they: • provide the information you need to review• do what people expect of them your services and procedures effectively.• handle problems effectively• provide a prompt service• provide accurate, comprehensive information and regular progress reports• have professional, competent staff who treat people fairly• are friendly, polite and sympathetic to individual needs.
Improving 34|35Using feedback to provide more The hospital’s customer service team receivedeffective care a complaint, which resulted in several meetingsEvery day, managers and commissioners across between Mrs L and the matron in charge.the country are using feedback to help improve As well as the specifics of the complaint, theservices. Here are a few examples. meetings raised additional concerns about communication with the families of patients.Identifying service problems The complaint was eventually resolved toFollowing a road traffic accident, the Mrs L’s satisfaction – she has also helped toDisablement Service Centre assessed Mr T for make improvements by sharing her experiencea wheelchair. Having waited a long time for in staff training sessions.his initial assessment, Mr T was unhappy withthe subsequent delay in receiving his chair – Identifying risksand the failure of the service to explain why. Mrs X’s husband was diagnosed with depressionEventually Mr T had to hire his own chair. and referred to the local community mentalMr T complained directly to the commissioner health service.of the service and the matter was investigated. After waiting some time for her husbandAs a result, Mr T was compensated and the to receive any service, and fearing that hisdelivery of his chair prioritised. condition was deteriorating, Mrs X complained.Following this complaint, along with an The complaints team arranged for a clinicalassessment of other complaints made, the psychologist to talk to Mrs X and hearcontracts were reviewed and the service was her concerns.improved. Mr T, and other people who had It became clear that Mrs X had receivedcomplained, were told that their feedback was confusing and conflicting information frombeing used to improve standards. different members of staff. She was offered anImproving staff learning apology and her husband was placed on the priority list for treatment.Mrs L’s mother was being cared for at acommunity hospital during her final illness. She The psychologist felt that effective care hadfell, broke her hip and died shortly afterwards. been hindered by miscommunication. ThisMrs L felt that the fall, and a general lack of could have had serious consequences for acare, contributed to her mother’s early death – more vulnerable patient. As a result, the serviceand robbed the family of the last few precious reviewed its procedures to minimise the chancesmonths with her. of a similar incident happening again.
Showing that lessons are learntFrom April 2009, health and social care managers will have toshow how they use feedback to learn and improve.Under new complaints legislation, organisations will need toproduce an annual report detailing:• the number of complaints they receive• the issues that these complaints raise• whether complaints have been upheld, and• the number of cases referred to an Ombudsman.Organisations will also need to record any significant issues raisedby complaints, the lessons learnt and actions taken. Other ways in which providers will be held accountable: • Commissioners already have to show how feedback and data relating to people’s experiences affect future decisions. From April 2009, people can complain directly to a commissioner. • The NHS Constitution clearly states the standards people expect when using services. • The Care Quality Commission also requires registered providers of services to investigate complaints effectively and learn lessons from them.
Improving 36|37TRAINING FOR FRONTLINE STAFFAND MANAGERSEveryone who works for a health or social care Understanding the steps that can helpservice has a role to play in identifying mistakes, to resolve a complaintputting them right and learning from them, as Until March 2009, the Healthcare Commission13quickly as possible. But to do this effectively, reviewed NHS complaints that could not bestaff need the right knowledge and skills. resolved locally. The Commission recommendedIt is important that everyone who works in a number of steps that organisations can takeyour service has a good understanding of the to help to get a complaint resolved. It is acomplaints system and how it works within good idea to ensure that people who handleyour organisation. complaints regularly understand these steps:Staff also need to know how to handle, 1. Acknowledge the person’s right to complain.progress and resolve concerns and complaints – 2. Ensure that the complaint is assessed uponand help each other develop key skills, through receipt, so that any concerns about a risklearning and ongoing training. to the safe care of other patients can be identified promptly.The importance of being friendly 3. Clarify what the person’s concerns areA 2006 review11 found that staff attitude was and manage expectations about possibleone of the main factors influencing customer outcomes to the investigation of the complaint.satisfaction. 4. Consider the various options for resolving the complaint – for example, a meeting orThe following tips may seem obvious, but they reimbursement of costs.are frequently highlighted by service users asthings that concern them, and they serve as 5. Ensure that the person is kept informed ofa useful reminder of how important it is to be progress throughout the life of the complaint.friendly and polite and show empathy: 6. Confirm to the person what support is available to assist in making a complaint –• Answer the phone or greet people as quickly for example, the Independent Complaints as possible. Advocacy Service (ICAS).• Introduce yourself, so people know who 7. Take statements from, and interview if they’re talking to. necessary, those staff involved in the events• Take their name and contact details. leading up to the complaint. This should be done as soon as possible, so that events are• Listen to what is being said – try not to still fresh in the memory. interrupt. 8. Where necessary, obtain clinical advice on• Ask clarifying questions to ensure that you the matters raised. This advice must have a understand the issue. high degree of independence – for example,• Act on what the person tells you and offer a by obtaining advice from the trust’s medical solution if you can. director or from a clinician at another trust.• If you can’t help, find someone who can.• If necessary, take the details and get back to the person promptly.12
9. Ensure that any letters to the person making Supervision: helping people who deal the complaint are written in plain English with complaints and are as free as possible of clinical or People who handle complaints regularly, from other technical terminology. front-of-house staff to complaints managers,10. Offer an apology if appropriate. can benefit from the chance to talk about11. Ensure that general learning is taken from their experiences. specific complaints and is embedded into Regular supervision provides: the system of care for the future.12. Ensure that the boards of trusts are satisfying • an environment that encourages professional themselves that all the above are happening. development • a confidential way to reflect on the work being done, and the impact it may have on staff and their ability to do their jobs • an opportunity to identify the key skills and knowledge needed to perform the role effectively • ongoing assessment of any training and development needs • an opportunity to monitor personal strengths and weaknesses, and to ensure that staff receive appropriate training and support. o works one wh nding at every ndersta o rtant th u It is imp ice has a good and how it serv system in your plaints sation of the com in your organi ith works w
Improving 38|39Skills for managers who deal with complaints regularlyIf you are a manager who deals with complaints regularly or withpeople who are unhappy about your service, there are certainskills that, if you develop them, can help you do your job. The listbelow was compiled from suggestions made by complaintsmanagers themselves.It helps if you:• have excellent communication skills• have a good understanding of the complaints system and the rights of health and social care service users• understand policies and procedures relating to the handling of complaints• understand the different ways to resolve complaints and concerns• have good problem-solving and negotiating skills• have mediation and counselling experience• can work effectively with internal and external stakeholders• understand different cultural and special needs• have knowledge of local procedures such as child protection, court, disciplinary and grievance• have an understanding of national procedures relating to the courts, professional regulators and the Independent Safeguarding Authority• have an understanding of data protection, health and safety and human rights legislation.
TOP QUESTIONSI am a GP, dentist, optician or • Ensure that you work with partners in otherpharmacist. Does the new complaints local health and social care organisationssystem apply to me? to provide a coherent, single approach for complaints involving pathways of care.It applies to all independent contractors thatprovide NHS services in a primary care setting. • Have a single point of contact for peopleWe will be publishing a supplement to this wishing to complain.guide, to help you provide a bespoke service in • Support your local complaints network, offeryour particular setting. However, there are some peer support and share best practice – to helpthings you need to consider and implement to ensure that all organisations embed theimmediately, including: new arrangements quickly and successfully.• publicising that you want to receive feedback of various kinds, including complaints I am a service manager. What is the • ensuring that anyone using your services and best way to resolve complaints about their families know how to complain and to my area? whom• making someone responsible for handling • Make yourself available and approachable to and responding to complaints people wishing to complain.• acquainting yourself with the new regulations • Communicate and investigate. Find out what and guidance to ensure that you are meeting went wrong and why, offer an apology and the legal requirements. be prepared to acknowledge what went wrong and what shouldn’t have happened – or should have happened and didn’t.I am a chief executive or director • Offer a full explanation and, if appropriate, aof social care. How can I help to solution or redress. Give assurance that youimplement the new approach, and have taken the information on board, and willwhat is my ongoing role? ensure that it won’t happen again.• Ensure that all staff are aware of the • Ensure that your complaints manager has all new approach and that they adapt to it the information and support they need to accordingly. This means welcoming feedback resolve issues satisfactorily. and advising people who want to complain • Ensure that any staff you are responsible about their rights and what to do. for are fully aware of the new approach –• Make sure that all staff receive training on the and what it means in terms of being open, new approach to complaints. receptive, empathetic and responsive.• Provide leadership and face-to-face support for customer services and complaints staff.• Ensure that what staff report is acted on, so that you learn from complaints and use the information to continually improve services.
Improving 40|41I am a medical director. How can I best I am a commissioner of services.help to resolve complaints? How can I access and help ‘hidden populations’ to engage equally?• Provide leadership for your clinical colleagues. Complaints are a valuable source of • Commissioners need to carry out a clear information about people’s experiences, not risk analysis of the people for whom they just of colleagues’ clinical expertise but also commission services. They then need to their general approach – which is equally identify those who may find it difficult to important. express their views and experiences (including• Remember that most people simply want an concerns and complaints). These difficulties explanation, an apology and assurance that it could be due to: won’t happen again, to them or to anyone else. – the environment where their care • Ensure that you and your teams are flexible takes place about how you communicate with people – the person’s own barriers throughout the complaints process – that – factors such as language or culture doesn’t have to be a report; a meeting can be the best means of explaining things. Also – the relationships between the users and have arrangements in place for people with people who provide services, for example other first languages or communication the GP or residential care staff. difficulties. • All organisations need to ensure that they• Ensure that your teams understand the new understand the diverse needs of their local complaints approach and equal treatment population, so that anyone wishing to requirements, and that they support their complain or express concern about health complaints and management colleagues and social care services can do so. when they are attempting to resolve issues. • Organisations also need to make sure that• Following a complaint, ensure that you and specialist, high-quality support is available your teams make the necessary improvements, for people making complaints. This could be to show that lessons are learnt, and prevent through PALS, customer services, advocacy the problem occurring again for other patients. services, counselling services, independent organisations with specialist advisers, or peer support for specific people or groups.
How can complaints inform the What does ‘inform the commissioningcommissioning of services? of services’ mean for providers?Commissioners can only introduce and develop Providers need to show that they are usingservices if they are in meaningful contact with complaints and other forms of feedback tothe people they serve. Any information and continuously improve services.feedback should be a two-way process, and • They need to ensure that they havehelp to inform the development of the most introduced improvements as a result ofeffective services. complaints, comments or concerns.According to World Class Commissioning • They need to report on these improvementsCompetency level 3: and be able to demonstrate how they are a• the role of the commissioner is to direct result of individual complaints raised. “proactively build continuous and meaningful • They will be best placed to achieve this by: engagement with the public and patients, to – ensuring that patients and users who shape services and improve health” wish to make a complaint are fully• public and patient engagement is equipped with the information and “information from patients and the public means to do so, and that has a direct impact on quality and – implementing the new approach, and improvement” applying the learning from complaints• in order to improve the patient experience, as part of overall resolution and it is essential that organisations obtain “real organisational responsiveness. time feedback from users on services” and then demonstrate “how ongoing, integrated patient experience data systematically drives commissioning decisions”• commissioners should “effectively manage systems and work in partnership with providers to ensure contract compliance and continuous improvement in quality, outcomes and value for money”. listening responding improving
Improving 42|43HELPFUL RESOURCES FOR YOUAdvice sheets for complaints Advice from the Ombudsmenprofessionals Principles of good complaint handlingInvestigating complaints The Health Service Ombudsman has publishedThis advice sheet sets out some of the issues six principles of good complaint handling.that you might want to consider if you are Principles for remedyinvolved in investigating a complaint. The Health Service Ombudsman has publishedJoint working on complaints principles for remedy.Organisations that provide care together Running a complaints system, goodcan find it useful to have a joint protocol for administrative practice and remedieshandling complaints. This advice sheet includesan example protocol, an example consent form The Local Government Ombudsman hasand a flow chart showing how joint complaints produced good practice notes covering differentmight be handled. aspects of complaint handling.Dealing with serious complaints Dealing with unreasonably persistent complainants and unreasonable complainantThis advice sheet outlines some of the things behaviouryou should bear in mind when dealing witha complaint that has safety implications for The Local Government Ombudsman hasservice users or the public. produced good practice notes on this issue.www.dh.gov.uk/mec People’s rights NHS Constitution In the NHS, patients have certain rights when it comes to making a complaint. These are set out in full in the NHS Constitution and the accompanying handbook.
ENDNOTES1 Healthcare Commission, Spotlight on complaints: A report on second-stage complaints about the NHS in England, 2009.2 The Health Service Ombudsman for England, Making things better? A report on reform of the NHS complaints procedure in England, The Stationery Office, 2005.3 Department of Health commissioned survey, 2005.4 Department of Health, The NHS Constitution, 2009.5 HM Government, Our health, our care, our say: a new direction for community services, The Stationery Office, 2006.6 Department of Health, Making Experiences Count: A new approach to responding to complaints, 2007.7 National Audit Office, Feeding back? Learning from complaints handling in health and social care, The Stationery Office, 2008.8 Healthcare Commission, Spotlight on complaints: A report on second-stage complaints about the NHS in England, 2009.9 Source: Health Mediation Service for Kent leaflet.10 Source: The Improvement Network.11 The Customer Voice in Transforming Public Services, independent report by Bernard Herdan, Cabinet Office, 2006.12 Source: Southampton University Hospitals NHS Trust.13 Healthcare Commission, Spotlight on complaints: A report on second-stage complaints about the NHS in England, 2009.