MENOPAUSE EXPERT is committed to ensuring that those who use its services are readily able to access information about how to make a complaint and that the issues raised are dealt with promptly and fairly.
MENOPAUSE EXPERT aims to provide a complaints service that meets the needs and objectives of the complainant, whilst at the same time complying with the requirements set out within this policy.
MENOPAUSE EXPERT recognises that the information derived from complaints provides an important source of data to help make improvements in our services. Complaints can act as an early warning of failings in systems and processes which need to be addressed.
MENOPAUSE EXPERT makes sure that the care of people who make complaints about its services will not be adversely affected because they have complained. Complaints correspondence is stored and recorded separately from healthcare records.
MENOPAUSE EXPERT serves a diverse patient population. We are committed to providing a complaints service to all regardless of their racial or cultural background, gender or sexual orientation, religion or disability.
This policy relates to patient-related complaints only. All formal patient complaints, however received, should be managed as set out in this policy.
Within this policy the term formal complaint refers to any written complaint received from a patient or a representative of the patient. Under the NHS Complaints Regulations on receipt of any written complaint from a patient MENOPAUSE EXPERT is required to follow the process set out in this document.
A verbal complaint may be treated as a formal complaint if on discussion with the complainant he/she wishes his/her concerns to be treated formally. In this case a detailed written record must be made by the recipient of the complaint and sent to the complainant with an invitation for it to be signed for accuracy and returned to the Registered Manager. Patients and carers wishing to raise informal complaints can speak directly to any member of staff or can be directed to a senior manager within the MENOPAUSE EXPERT.
5 Duties & Responsibilities
5.3 The Clinical Director
- To note reports about the operation of the complaints procedure and the effect on service improvement.
- To ensure that emerging themes are investigated and acted upon, and that themes that are consistent with those raised elsewhere (e.g. serious incidents) are identified and acted upon.
- To ensure that the complaints procedure features in patient satisfaction surveys and/or is subject to a separate survey.
5.4 Registered Manager
The responsibilities of this role are as follows:
- Receive and manage all formal complaints in accordance with this policy and procedure and within timescales set out in this policy.
- Manage the complaints handling process within MENOPAUSE EXPERT.
- Ensure that the Director is made aware of any actual or potential issues arising from complaints that could put MENOPAUSE EXPERT at risk, including potential legal claims.
- Ensure that information about the complaints procedure is available to patients and anyone else who requests it.
- Draft responses to complaints to ensure they meet the standards expected.
- Is responsible for review of all complaints to ensure that lessons are learnt as appropriate.
6.1 Aim of Local resolution
The main objective of local resolution is to ensure that complaints are dealt with promptly and satisfactorily by ensuring that MENOPAUSE EXPERT:
- Investigates each complaint thoroughly
- Identifies any lessons to be learnt
- Ensures that appropriate remedial actions are taken
- Communicates effectively with the complainant and resolves the matter to the satisfaction of the complainant.
6.2 Verbal Complaints
Wherever possible complaints and concerns should be dealt with at the time they arise by Katherine Cooke, the Registered Manager.
6.3 Formal Complaints
People wishing to make formal complaints should be advised to put their concerns in writing and address them to the Registered Manger.
6.4 Time Limit for Making a Formal Complaint
A complaint should be made within twelve months of the time the event(s)
6.5 Who May Complain
A complaint may be made by a patient, a person acting on behalf of a patient, or anyone who has been affected by any action/omission/decision of MENOPAUSE EXPERT. Where a complainant is acting on behalf of a patient, written consent must be obtained from the patient before a response can be sent. Where the patient is a child without capacity, a complaint may be made by the parent or guardian. Where the patient has died, the complaint may be made by the named next of kin or by a person nominated by the named next of kin. In other circumstances where the complainant may have difficulty complaining on their own behalf or have other requirements e.g. vulnerable children and adults, or people with mental health difficulties, the Director will review each situation in light of current legal requirements and good practice guidance from the Department of Health and offer help and support to a complainant as appropriate.
6.6 Handling a Complaint
On receipt of a formal complaint the Registered Manager will:
- Acknowledge a written complaint within three working days of receipt, enclose complaints leaflet, or give a brief indication of the process and the anticipated time for response.
- Upon receipt of the advice from the department, send a letter to the complainant on behalf of the MENOPAUSE EXPERT with either an offer of a meeting or telephone conversation with relevant staff in the department, or confirmation that a formal investigation is underway (again indicating anticipated time for response).
- Record the details of the complaint onto the MENOPAUSE EXPERT’s complaints register.
- Monitor the agreed time scale for response to a complaint
- Send approved final response to complainant within agreed set timescale. If the final response will be delayed inform complainant in writing.
- Be responsible for maintaining secure and accurate records of each complaint.
- Monitor complaints which are reopened to identify whether the initial investigation and response was appropriate or whether new issues have been raised.
6.7 Action Plans
Where the investigation of a complaint identifies the need to make changes in practice and systems, it is important that all remedial measures are clearly documented, acted upon and monitored. The Registered Manager will be responsible for agreeing any procedural changes and the development of action plans. These should be developed after the completion of the investigation into the complaint
When a complaint involves care provided by several organisations, the Registered Manager will liaise with those organisations to identify the most appropriate handling process for the investigation and who will lead on co-ordinating the complaint.
6.8 Details of Complaints which Warrant Professional Disciplinary or Criminal Investigation
Complaints such as professional misconduct, poor performance, theft, assault, wilful negligence or abuse will be passed to Katherine Cooke, Director & Registered Manager.
6.10 Complaints Involving Other Organisations
Where a complaint is received which involves a local healthcare partner, wherever possible a joint investigation should be carried out with the permission of the complainant. The Registered Manager dealing with the complaint should contact the partner organisation when the complaint is received. Agreement should be reached on who will prepare the joint response and the complainant advised accordingly.
6.11 Complaints received via the media
MENOPAUSE EXPERT will not enter into correspondence with complainants via the media. People who get in touch with the local press to complain about the care they or their relatives have received should be advised to contact the complaints department if they wish to pursue a formal complaint against the MENOPAUSE EXPERT.
The Registered Manager will work with the communications department to prepare statements on specific issues where this is considered to be appropriate.
6.13 What cannot be investigated as a formal complaint
The formal complaints process will be suspended if:
- The complainant expresses an intention to pursue a legal claim against MENOPAUSE EXPERT.
In this circumstance, the complainant will be notified in writing that the complaints procedure has been suspended and that the matter is being dealt with in accordance with medico-legal. There will be ongoing liaison with the complainant where appropriate.
Performance standards for stage 1
MENOPAUSE EXPERT has set the following performance standards:
- Formal complaints must be acknowledged by the complaints department on the first working day of the registered manager after receipt of the complaint (usually within 3 days) If this is not achieved then an explanation for the delay should be included on the complaints file.
- MENOPAUSE EXPERT target timescale for responding to formal complaints is twenty working days, unless the matter is complex, (e.g involves other organisations) in which case the target time will be agreed with the complainant.
MENOPAUSE EXPERT recognises that it is not always possible to achieve this particularly where a complaint is complex. However, it is the responsibility of the MENOPAUSE EXPERT to ensure that timescales set out in ‘this complaints policy’ are adhered to wherever possible.
Handling of persistent complainants
Persistent or habitual complainants can cause significant problems for the organisation both in terms of staff time and emotional stress. Such complainants tend to make frequent complaints but each one is distinct. The amount of time taken to investigate each issue should be determined by the seriousness of the issue and not by the type of complainant. Therefore, in some instances, only a brief response may be required whilst in others a more detailed explanation will be needed.
At the same time the MENOPAUSE EXPERT has a duty to protect staff against outright abuse of their person or time and it is necessary to identify unreasonably persistent complainants and to have in place a procedure for dealing with this.
A persistent or habitual complainant may meet one or more of the following criteria:
- Is in frequent contact with the complaints department, sometimes making daily contact.
- Will contact the department by telephone or in person despite having been given a date for a meeting or advised of the timescale for a written response.
- Is aggressive or abusive towards staff.
- Is adamant their concerns have not been addressed despite having received detailed responses.
- Having received a response contacts the complaints department immediately with a new set of questions or presents the original problem in a different way.
- Changes the complaint or what they want to achieve part-way through the process.
- Dictates who they will speak to and/or meet with.
- Seeks an unrealistic outcome and expresses an intention to pursue the complaint until that is achieved.
A complainant may meet some or all of the above criteria; the final decision about what action to take will rest with the Director In all cases where a complainant is classified as being ‘unreasonably persistent’ a letter will be sent to them explaining why it is believed that their behaviour falls into that category and what action the MENOPAUSE EXPERT is taking. The options are most likely to be:
- Requesting that they contact MENOPAUSE EXPERT in a particular form (e.g. by letter only).
- Requesting that they make contact with one particular named person.
- Restricting their telephone calls to specific days and times and/or
- Asking them to enter into an agreement about their future behaviour.
Where the complainant fails to comply with the above and continues to behave in a way which is unreasonable, the MENOPAUSE EXPERT may decide to terminate further contact with the complainant. The complainant will be advised of this in writing by the Director. Any further correspondence which is received will be read but not acknowledged unless there are new issues of concern.
New complaints received from people who have been dealt with under the persistent complainants policy will be assessed by the Registered Manager and dealt with as considered to be appropriate.
Process for monitoring compliance with this Procedure
The registered manager will draft a quarterly report detailing the progress of management for any complaint received in the year (and any open complaints from the previous year). The report will show compliance with the complaints process by indicating the identification of the lead for preparing a response and timeliness of response. It will detail any lessons learned and any actions taken or planned in response to the complaint.
The Registered Manager will report assurance of compliance with the procedure and take any actions if required.
The Local Authority Social Services and National Health Service Complaints (England) Regulations 2009 www.legislation.gov.uk
Department of Health (2009) Listening responding and improving health care.
Publications Policy And Guidance www.dh.gov.uk
National Patient Safety Agency. (2005). Patient Briefing - Saying Sorry.
When Things Go Wrong. London, National Patient Safety Agency.
National Patient Safety Agency. (2005). Being Open Communicating.
Patient Safety Incidents with Patients and Their Carers. London: National Patient Safety Agency.
The Data Protection Act 1998 London: Office of Public Sector. www.opsi.gov.uk
Freedom of Information Act 2000 London: Office of Public Sector. www.opsi.gov.uk
Information. Available at: www.opsi.gov.uk
Appendix A : Equality Impact Assessment
1. Does this Procedure, function or service development affect patients staff and/or the public? YES / NO
2. Is there reason to believe that the Procedure, function or service development could have an adverse impact on a particular group or groups? YES / NO
3. If you answered YES in section 2, how have you reached that conclusion?
(Please refer to the information you collected e.g., relevant research and reports, local monitoring data, results of consultations exercises, demographic data, professional knowledge and experience)
4. Based on the initial screening process, now rate the level of impact on equality groups of the Procedure, function or service development:
Negative / Adverse impact:
(i.e. minimal risk of having, or does not have negative impact on equality)
Date completed: _________________________________________________
Job Title: _______________________________________________________
Appendix B : Process for handling formal complaints
Process for Handling Formal Complaints: (target timetable)
Receipt of complaint
First working day of registered manager, after receipt of complaint
Registered manager acknowledges receipt and advises complainant of process and timescale
First working day of registered manager, after receipt of complaint
Registered manager logs complaint; sends details to the complaints lead in the relevant Directorate with the request that they investigate the complaint and send details of the investigation, including any reports obtained, to the MENOPAUSE EXPERT Response requested within two weeks* of details being sent to the Directorate;
Response to clearly state whether elements of the complaint are upheld or not upheld. If a complaint is upheld, state what lessons will be learnt from the complaint, and what actions will be taken by the service. *giving leeway of up to three weeks
By Day 20
Complaints investigation completed*
Registered manager formulates response for the Board of Directors
Proposed response checked for accuracy and approved by Directorate
*If report/statement(s) is not available, the appropriate Director is advised so that they can chase the response
Final revision of response. If there is an unavoidable delay so that the response cannot be completed within 25 days, the registered manager will contact the complainant to inform them of the expected timescale.
By Day 25
Finally approved letter signed by Registered Manager and posted to the complainant.