At Chase Lodge Hospital Ltd (CLH), our Complaint Policy serves as a valuable resource for feedback, providing early warnings of failures in service delivery. By handling complaints effectively, we create opportunities to enhance our service and reputation. All patients attending CLH will have access to our comprehensive complaints procedure.
The objectives of this Complaint Policy reflect the Principles of Good Complaint Handling (ISCAS, 2017):
This Complaint Policy outlines the different stages of the complaints procedure and includes arrangements for identifying, receiving, recording, handling, and responding to any complaint.
This policy should be read alongside our Duty of Candour Policy.
Please note: Distinguishing between a complaint and an incident can be subjective. For this reason, we capture all incidents (regardless of harm level) and verbal complaints in the same form. A senior manager determines whether an event is categorised as an incident, significant event, or complaint, and which policy should be followed.
Roles and Responsibilities
Hospital Manager
The Hospital Manager is accountable for:
Investigators
Investigators are responsible for ensuring:
All Staff, Including Locums and Associates
All staff are responsible for:
N.B. ISCAS (Nov 2018) states, “It is not acceptable for Consultants with practising privileges, or other persons engaged by the independent healthcare provider, to write separate responses to the complainant. Independent healthcare providers permitting multiple communication points and responses to the complainant will be deemed non-compliant with the ISCAS Code.” A single response to a complaint that incorporates feedback from all relevant clinicians, including registered message consultants with practising privileges, must be submitted.
Definitions
A complaint is defined as a concern or grievance raised by a user, family member, or carer of a user of independent healthcare facilities. It expresses dissatisfaction requiring a formal response. Complaints may be raised by the client or their authorised representative, relative, friend, carer, or insurer. To comply with GDPR, we must seek consent if a third party raises a complaint. Complaints can be made orally or in writing.
An authorised representative is an individual or client advocate who complains on behalf of a client. CLH ensures that the individual is a legitimate representative and that the complaint is made with the client’s knowledge and written consent. A comment is defined as a helpful observation—positive, negative, or simply a compliment made by a patient. A concern is defined as a minor criticism or expression of dissatisfaction that may require a response but may not necessitate a formal route.
Introduction
At times, patients’ expectations may not be met, resulting in a verbal or written complaint. Understanding issues from the complainant’s perspective offers CLH valuable insights that we welcome and use to improve patients’ experiences.
All complaints should be raised directly with CLH initially (Stage 1). Complaints should be made as soon as possible, ideally within six months of the event, or as soon as the matter comes to the complainant’s attention. Time limits can sometimes be extended if it is still possible to investigate the complaint. Extensions may apply in situations where it would have been difficult to complain earlier, such as during periods of grief or trauma.
If the complainant is unhappy with our response, they can escalate their complaint to Stage 2 by bringing it to the CEO of Chase Lodge Hospital. If they remain dissatisfied, they can seek independent external adjudication (Stage 3).
Complaints Made on Behalf of the Patient and Consent
If a patient is hesitant to make a complaint themselves, they may ask a relative or friend to do so on their behalf. In such cases, CLH will seek the patient’s written permission. This waiver allows the patient to share their clinical information with the person acting on their behalf.
When someone lacks the capacity to consent, CLH can only accept consent from an authorised person with Legal Power of Attorney (specifically, a Court of Protection appointed Deputy authorised to make health and welfare decisions).
Consent is also necessary for young children, severely ill individuals, or in cases where the individual has passed away, as outlined by the Access to Health Records Act 1990. Limited access rights apply for the personal representative of a deceased relative under the same Act.
Access to Health Records
Patients have the right to see their health records under the Data Protection Act 1998. However, access may be denied if disclosure could cause mental or physical harm to the patient or another individual.
A fee of £50 will be charged for granting access to health records. This fee represents the maximum charge in England, Scotland, Wales, and Northern Ireland as specified in the Data Protection Act.
The Complaints Process, Litigation, and Clinical Negligence
When a complainant indicates an intention to seek legal advice, Chase Lodge Hospital (CLH) will continue to follow the complaints procedure, whether at Stage 1 or Stage 2. We aim to resolve complaints wherever feasible and will not abandon the complaints process due to the potential for a legal claim.
If a legal claim has been initiated, CLH will not consider the parts of the complaint central to the legal claim (such as clinical negligence and issues of causality) under the complaints procedure. However, other aspects may still be addressed.
Chase Lodge Hospital is dedicated to collecting, investigating, and analysing patient feedback, including complaints, as part of our quality improvement plans. Patients can provide feedback, both positive and negative, through the following methods:
All complaints will be treated confidentially, with details shared only with those necessary to address the complaint.
Both verbal and written complaints will be recorded in the complaints log, which includes:
Verbal complaints should be managed by the staff member being complained about, with the aim of swift resolution. Alternatively, the matter can be addressed by their line manager or the most senior staff member available at that time. Details of the complaint must be recorded on the incident/complaints/significant event form (Appendix 1) before the staff member’s shift ends and forwarded to the Senior Manager for confirmation that it is treated as a complaint rather than an incident, and then on to the Executive PA for logging.
All written complainants will receive a written acknowledgment of their complaint within two (2) working days. The Registered Manager will contact the complainant to discuss the handling of the complaint and potential resolutions. During this conversation, we will gather the following information as applicable:
The Duty of Candour will be applied in all relevant cases.
An investigation will be conducted by the most appropriate person, and a full written response will be sent to the complainant by the Registered Manager within twenty (20) working days of receiving the complaint. The draft response will be shared with the involved staff to confirm its accuracy before the Registered Manager reviews and signs the final version.
If a complete response cannot be provided within twenty (20) working days, the Registered Manager will inform the complainant of the delay and provide a full response within five (5) days of concluding the investigation.
If the complainant is dissatisfied with the outcome, CLH will guide them on escalating the complaint to Stage 2 through the Independent Doctors Federation. Alternatively, complainants may approach professional registrant bodies, such as the NMC and GMC. Complaints can also be sent to the Care Quality Commission (CQC), but please note that the CQC does not investigate complaints on behalf of complainants.
The Registered Manager, on behalf of CLH, will cooperate with any independent review of an escalated complaint.
When an anonymous complaint is received, CLH will use discretion and investigate as far as reasonably possible.
If the complainant remains dissatisfied after Stage 1, they may proceed to Stage 2 by writing to one of the Directors, namely Natasha Cherrett or Dr Sarah Lotzof, who will re-evaluate the issues raised.
To proceed to Stage 2, the complainant must write to:
Natasha Cherrett
Chase Lodge Hospital
Page Street
Mill Hill
NW7 2ED
The letter should include:
If the complainant remains dissatisfied with the outcomes of Stages 1 or 2 or any alternative resolutions offered, they have the right to refer the matter to independent external adjudication. This referral must occur within six months of receiving the hospital’s final letter, which reminds the complainant of this right. After this period, access to the adjudication service may no longer be possible. The complainant should write to the ISCAS Secretariat to request Stage 3 at:
Independent Sector Complaints Adjudication Service
70 Fleet Street
London
EC4Y 1EU
info@iscas.org.uk
020 7536 6091
Please note there is no appeal from the independent external adjudication procedure. The Independent Adjudicator’s decision is final regarding the complaints procedure, but it does not affect the complainant’s statutory rights.
Guidance for Managing Unacceptable Behaviour by Complainants – ISCAS (May 2019)
Acknowledgment
ISCAS expresses gratitude to Priory Healthcare for sharing its organisational policy, which has contributed to the creation of this ISCAS guide.
Overview
Occasionally, services may encounter a small number of complainants whose behaviour consumes a disproportionate amount of staff resources. It is crucial to identify situations where a complainant might be acting unacceptably and to propose fair responses for both the complainant and the staff involved.
Unacceptable behaviours may include, but are not limited to:
In extreme situations, the manager reserves the right to initiate legal action against the complainant.
If complainants cease unacceptable behaviour, there should be a mechanism to indicate that the policy on unacceptable behaviours no longer applies, particularly if they demonstrate a more reasonable approach or submit a further complaint suitable for the normal process.
As staff exercise discretion in identifying unacceptable behaviours, similar discretion should be applied when recommending that the policy be rescinded.
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