Compliments and complaints annual report - final

Annual Report 2014/15 Telling itlike it is Compliments, Comments & Complaints Annual Report 1 April 2014 - 31 March 2015

Complaints & ComplimentsChief Executive’s Foreword I am delighted to introduce this, the first of our new style annual reports on the compliments, comments and complaints the Trust receives. This new report is part of the steps we are taking to develop a real user-led system for raising concerns and complaints. Understanding the lived experiences of our service users and carers is at the heart of how we improve the quality of our services. At NEP we have nearly 2,500 staff who deliver care to more than 20,000 people. Most of the time we deliver that care well, and receiving the praise and compliments to our staff from service users is one of the best parts of my job, by far. However, while we strive to always maintain the highest standards, sometimes we do not meet peoples’ expectations and there are even occasions when we have let people down.We take all complaints very seriously and have in place a robust complaints process which hasbeen reviewed and simplified so that it reflects the principles outlined in the Francis report. Allcomplainants have the opportunity to discuss their concerns with us and we are open, honestand transparent in our responses. All complaints are reviewed at Executive Director level,and complaint response times, themes and trends are monitored by the Board of Directors.Monthly independent reviews of the complaints handling process are undertaken by the Non-Executive Directors to provide assurance that the Trust is providing high quality investigations andresponses, and appropriate learning actions are identified.If issues are raised about our staff, we discuss these issues with them and provide support andencouragement for them to reflect on their working practice and the way their actions could beperceived. I am very happy to say that complaints about our staff equate to less than one percentof the total workforce.We take every opportunity to learn from our complaints and improve our services as a result.Feedback is vital to us and gives us the chance to change and enhance the quality of our patientcare.I would also like to take this opportunity to thank everyone who takes the time and trouble to sendcompliments about our staff and services. This is very much appreciated and recognises the hardwork and dedication of our staff, their commitment and compassion.As the first of this new form of report I would welcome feedback and comments on both its contentand format.Andrew GeldardChief Executive2

Annual Report 2014/15Introduction This is the Complaints Annual Report for the period 1 April 2014 to 31 March 2015. North Essex Partnership University NHS Foundation Trust provides Specialist Mental Health services to people in North Essex. The Trust also provides children and young people’s services, older adults services, substance misuse, GP and community services. The complaints function is part of the Patient Safety Directorate. Approximately 1.3m people live in Essex. The Trust provides services for people in north Essex and beyond. It is worthy of note that the number of compliments the Trust receives annually, far outweighs the number of complaints it receives about the services the Trust provides. Some of the compliments the Trust has received this year are highlighted throughout this report. The time limit for making a complaint as laid down in the Local Authority Social Services and National Health Service Complaints (England) Regulations 2009 is currently 12 months after the date on which the subject of the complaint occurred or the date on which the matter came to the attention of the complainant. An acknowledgement of the received complaint is made within 3 working days, to acknowledge the complainant’s concerns. The Trust has adopted a process of complaint handling whereby an offer to meet with the complainant, if appropriate is made to try to agree a way forward to resolve the issues that they have raised. If the complainant does not wish to meet, the Trust will give a timescale of 30 days to respond. This decision is based on the type and complexity of the complaint allowing a swift response to ‘straightforward issues’, whilst at the same time allowing an achievable response time to be set for complex and cross-organisational or cross-Trust complaints. The complaints legislation indicates that ‘the Trust must investigate the complaint in a manner appropriate to resolve it speedily and efficiently and keep the complainant informed’. When a response is not possible within the agreed timescale, a new completion date should be agreed with the complainant, who, in addition, must be kept informed of progress throughout the investigation. The Trust aims to remedy complaints locally through investigation and meetings if appropriate; however if the complainant remains dissatisfied they have the right to refer their complaint to the Parliamentary and Health Service Ombudsman (PHSO) as the second stage. November 2014 saw the publication of ”A user-led vision for raising concerns and complaints” In 2013 a Complaints Programme Board was set up by the Department of Health, following the Inquiry into the failings at Mid Staffordshire NHS Foundation Trust, the Cwyd-Hart Review into NHS Complaints systems and the Governments responses to both, Hard Truths. 3

Complaints & Compliments As part of the Complaints Programme Board, the Parliamentary and Health Service Ombudsman (PHSO) was invited to lead the development of a vision for complaint handling across both the health and social care sectors, in partnership with Healthwatch England (HWE) and the Local Government Ombudsman (LGO). The report presents the vision that was created and the findings of the primary research with patients, service users, frontline staff and stakeholders that lay behind it. The development of the vision was drive by certain key principles: • The need for a tool that will ensure that patient and service user expectations lie at the heart of any system approach to complaint handling; • The need to define what the outcomes of good practice should look like for patients and service users; • The need for a set of expectations of complaint handling that make sense to patients and services users themselves, so that they can hold complaint handling services to account; “If the latter stages of my assessment are carried out with the same kindness and understanding, I will be more than contented”4 Mid – Galleywood Ward

Annual Report 2014/155The vision as it stands, lays out a comprehensive guide to what good outcomes for patients andservices users look like if complaints are handled well. It does this by presenting a series of “Istatements” laid out across a complaint journey. The “I statements” are expressions of what patientsand service users might say if their expectations of making a complaint was a good one. The journeydescribes the different stages that patients and service user must go through when making acomplaint, from initial consideration, through to final reflection on the experience.

Complaints & ComplimentsNumber of formal complaintsreceived The total number of moderate complaints received for NEP In the year 2014/15 is 159. Complaints have risen by 13% when making a comparison to 2013/14. The following table illustrates the number of moderate complaints received by Area and Directorate.North East has the highest numbers received with 62, Mid with 49 and West with 34.6

Annual Report 2014/15The following table illustrates the percentage of complaints received by area in 2014/15 Comparison to 2013/14 in Area DirectorateAREA 2013/14 2014/15 Rise FallNorth East 7Mid 42 62 20WestCYPS 48 49 1GPCorporate 28 34 6Psych TherapiesSocial Care 13 6 374 011 3 Area not captured 1 Area not captured “Thank you for the loving care you showed to our mum, she would not have been treated better anywhere else”West – Kitwood Ward, St Margaret’s 7

Complaints & ComplimentsOutcome of complaints The following table illustrates the outcome of complaints in 2014/15 If a complaint has several issues raised, it is recorded as partially upheld if one element is upheld even if most elements are found not to be upheld. Last year’s figures are in the table below. Comparison to 2013/14 in OutcomeOutcome 2013/14 2014/15 Rise FallUnder Investigation Cat not captured 43 3Not Upheld 42 45 7Upheld 38 31 1 19Partially Upheld 55 36Not able to investigate 3 4 “Thank you for everything you have done”8 MID – Rainbow Unit

Annual Report 2014/15Percentage of complaintsresolved within agreedtimescale The following table shows the number of complaints resolved within timescales agreed with the complainant.3/30 days 3 days 30 days Over 3 days Over 30 daysQuarter 1 100% 95% NA 5%Quarter 2 69% 31% 55% 27%Quarter 3 74% (18% pending) 26% 20%Quarter 4 96% 38% 4% 13% (42% pending) 42% (45% pending)To note in Quarter 2 – 40% increase in volume of complaints in July 2014.Also to note “pending” percentage related to complaints still under investigation.The majority of the complaints closed outside of the agreed timescales were either complex ones,which involved multiple services, complaints involving several organisations or those which raisedadditional issues during the course of the investigation and therefore required extra time. Thefollowing table illustrates the nature of complaints for 2013/14To note the “All aspects of clinical care” category was captured in the first Quarter for 2014/15– the remaining quarters have been broken down into further categories explaining the spikeillustrated in the table. 9

Complaints & ComplimentsThe top three themes for complaints during 2014/15 are “Clinical Treatment”, “Staff Attitude” and“Access to Services”.Of the 61 complaints received in respect of those unhappy with their clinical treatment (inclusive ofall aspects of clinical care in the first quarter) a total of 35 were upheld or partially upheld.Again of the 23 complaints received in respect of staff attitude, a total of 12 were upheld orpartially upheld.Lastly of the 29 complaints received in respect of Access to Services, 7 were either upheld orpartially upheld.Complaints recorded as those resolved locally are usually carried out by front line staff who areable to resolve the client’s concerns/issues to their satisfaction, in a timely manner.The Trust actively encourages front line staff to deal with concerns as they arise so that they canbe remedied promptly, taking into account the individual circumstances at the time. This timelyintervention can prevent an escalation of the complaint.The Trust has agreed for the Patient Advice and Liaison Service (PALS) to manage and record thelow risk concerns which are resolved at local level. “Thank you for treating me with dignity and respect”10 Mid – Galleywood Ward

Annual Report 2014/15Parliamentary and HealthService OmbudsmanUnder the current complaints legislation, Trusts have six months in which to endeavour to resolvea complaint to the complainant’s satisfaction. If the complainant remains dissatisfied with theresponse they receive and feel that all avenues to resolve it locally have been exhausted, they canask the Ombudsman to independently review the complaint.The Ombudsman may:• Refer the complainant back to the Trust to complete ‘local resolution’• Ask the Trust to consider if further local resolution is an option• Request the case file for screening assessment• Having assessed the case file, decide not to investigate further• Having assessed the case file, appoint an Investigating Officer to carry out an investigation and produce a draft report to the Trust outlining if they uphold the complaint.• Make recommendations for the Trust to apologise for any failings in care and/or provide financial compensation.During 2014/15 no complaints were referred to the Parliamentary & Health Service Ombudsman.When looking at 2013/14 –NEP had been contacted by the PHSO with regards to five cases.To date, there are three cases the PHSO are looking into as follows:Datix 184 – (North East, Peter Bruff, Inpatient) Complaint Received 23.4.14, response given on 16June 2014. PHSO are currently investigating.Datix 214 – (West) Complaint Received 1.7.14, response give on 22nd August 2014. Ombudsmanhave requested copy of complaint file.Datix 238 – (MID) Complaint Received 5.8.14, response given 16 Sept 2014. Ombudsman haverequested copy of complaint file. 11

Complaints & ComplimentsPatient Advice & LiaisonService (PALS)PALS offers support, advice and information to service users, carers, family and friends, andmembers of the public about Trust services. PALS is designed for easy usage to enable people toresolve issues and concerns quickly and effectively.A total of 703 enquiries were received during the period April 2014 - March 2015 - (11% increaseon 2013-14).North East: 98 – Mid: 113 – West: 71– CYPS: 14– Community Services: 2 – Corporate: 6 -Business Infrastructure: 10 – Total: 314.Information and Signposting: 322 were calls for information or signposting requests, e.g. access toother PALS, clearer understanding of mental health services, to discuss in confidence a concern,how to make a complaint etc.The following two graphs show a 3% increase in the number of LOW complaints that requiredfurther investigation during period 2014-15 compared with the period 2013-14.Graph 1: Breakdown of enquiries by Directorate (April 2014 – March 2015) NE Mid West CYPS Comm Bus Corp Total serv infra- 76 70 structure 74 94Apr-June 18 32 15 5 1 4 1 314July-Sep 21 27 17 3 0 1 1Oct-Dec 24 22 21 2 1 2 2Jan-Mar 35 32 18 4 0 3 2Total 98 113 71 14 2 10 6 “What makes you special is that you care, no text book or Master’s degree can teach you, that comes from within”12 North East – Holmer Court (CMHT)

Annual Report 2014/15Graph 2: Breakdown of enquiries by Directorate (April 2013 – March 2014) NE Mid West CYPS Psych Comm Sub Bus Medi- Cor- Total prate Serv - Mis- - Infra- cal 1 64 0 69 use str Direct 2 88 2 83Apr- 13 27 15 2 1 4010 5 304JuneJuly- 27 19 16 5 0 1001SepOct- 24 32 16 8 3 2100DecJan- 29 28 21 2 0 1000MarTotal 93 106 68 17 4 8111In total 314 Key issues were received by the Trust Directorates. All issues were resolved locallyeither by meeting or discussion with the enquirer, or responding by letter.Graph 3: PALS LOW Complaints (April 2014 – March 2015)PALS Categories 2013-14 2014-15 389Information 322 121 91Care & Treatment 117 17 14Communication 69 13 13Attitude 19 11 10Appointment 33 10 5Access to Services 11 3 3Facilities 13 2 1Medication 7 703Compensation/Reimbursement 9Change of mental health worker 14Health & Safety 3Confidentiality 2Respect & Dignity 3Service Re-provision 0Funding/Commissioning 4 626 13

Complaints & ComplimentsKey Issues (April 2014 – March 2015)Key Issues 2013-14 2014-15 % 121 +3%Care & Treatment 117 91 +14% 17 -10%Communication 69 14 +58% 13 +15%Attitude 19 13 0% 11 +63%Appointment 33 10 +10% 10 -38%Access to Services 11 5 +60% 3 +33%Facilities 13 3 0% 2 +100%Medication 7 1 -75% 314Compensation/Reimbursement 9Change of mental health worker 14Health & Safety 3Confidentiality 2Respect & Dignity 3Service Reprovision 0Funding/Commissioning 4 304 PSC Referrals: PALS referred 9 LOW complaints to PSC team compared to 20 for the year 2012-13.Graph 4: Referred to MEC TeamKey issue 2013-14 2014-15 1Attitude 1 0 4Bed shortages 1 2 1Care & Treatment 6 0 1Communication 1 9Confidentiality 0Facilities 1Medication 0Total 1014

Annual Report 2014/15Learning outcomes• Improved communication between staff, service users and family• Identified staff training issues• Service provision: Improved Occupational Therapy services• Medication: improved communication between Consultant and GP• Administration: Franking of outgoing mail• Compensation: Accurate record keepingLow risk concernsTriaged LOW concern as enquirer requires a speedy and less formal approach. 82% of LOW con-cerns are resolved within five working days. Those that take longer are with the agreement of theenquirer.Graph 5: Outcome of LOW concerns (April 2014 – March 2015)Outcome TotalUpheld 16Partial Upheld 46Not Upheld 248Outstanding 4Total PALS 314Marilyn Williams – PALS Facilitator “In a few short weeks I have a completely different outlook on life” West – Derwent Centre 15

Complaints & ComplimentsMP enquiries on behalf ofConstituentsThe Trust receives enquiries from MPs on behalf of their constituents. These are recorded as alocal resolution and are captured within the total number of complaints received for 2014/15. Asfrom April 2015, the Patient Safety and Complaints Team will report specifically in regards to MPenquiries for future quarterly and annual reports. “Many thanks for the fantastic care you have shown my father”16 MID – Crystal Centre

Annual Report 2014/15Matters of general importancearising out of complaintsLooking at trends, the largest category of complaints overall is in relation to clinical treatment. Thiscategory has increased from 45 in 2012/13 rising to 48 in 2013/14, with 61 in 2014/15. Of the 61complaints, 35 were upheld or partially upheld. (57%).The number of staff attitude complaints has decreased from 30 in 2013/14 to 23 in 2014/15, it isthe category with the lowest (12) proportion of complaints being upheld/partially upheld. (52%)Staff attitude can often be the complainant’s perception of the way they were addressed or treatedby staff. Upheld complaints about staff attitude can result in disciplinary action.In 2014/15 the number of complainants stating that they did not feel that they had been listened to(capture in communication category both written and oral) has highest number of upheld/partially.Out of the 19 complaints reported, 12 have been upheld/partly upheld (63%).The Trust recognises the importance of lessons that can be learned from complaints, and the Trustwide value in sharing these with appropriate members of staff.To ensure organisational learning from complaints, any recommendations made followinginvestigation of a complaint are actioned and monitored through internal audit. A log is kept toensure that any recommendations from complaint investigations are implemented. The Trust has aLessons Learned Group which meets bi-monthly to share any learning and discuss any emergingtrends or themes.We continue to review the lessons learned process and have introduced a system trend analysisin order to enable the Trust Board to monitor and act upon any recurring themes. One of ourcorporate objectives this year will be to review and strengthen the lessons learned process toensure it is robust.The table below highlights a selection of some of the lessons learned from complaints over thepast year. 17

Complaints & ComplimentsWhat our patients said What we didDifferences in admission procedures ondifferent wards. Welcome packs give on one Apology and explanation given. All patients onward but not by another. admission to receive welcome packs on every inpatient ward across NEP. Staff to ensure theyDischarge from Section 117 aftercare. Seeks wear ID badges at all times.to have S117 reinstated and to be supported inthe community. Professionals meeting completed. S117 reinstated in order to provide aftercare servicesInappropriate information given regarding that is not limited to assistance in obtainingimplementation of the MHA 1983. accommodation and finances.Dissatisfaction in MH services currently being Apology and explanation given. Area Directorprovided. and Area Medical Director met with patient with further offer to meet with Doctor who appliedComplaint regarding doctors attitude and lack the section. SEAP advocacy also involved toof help and support when discharged from support patient with complaint.CMHT. Action plan agree in meeting with patient. CrisisLack of communication with family members. contingency plan written and implemented. Professionals meeting completed outlining further options explored with patient. Local resolution meeting took place. Careplan to be shared when patients are receiving CRHT input. CRHT to ensure appropriate handover of care to CMHT when discharged from CRHT intervention. Apology and explanation given. Family to be encouraged to join CPA reviews, if patient does not object.“Thank you for all the amazing support”18 North East – CRHT – The Lakes

Annual Report 2014/15ComplimentsA total of 349 written compliments were received during 2014/15. An increase of 83 complimentsin the previous year.It is important that positive feedback is shared with staff and services across the Trust, all staffare encouraged to send the compliments they or their service receive to the Patient Safety andComplaints Team to be logged and reported.It should be noted that the number of compliments received verbally cannot be realisticallycounted. The top two categories of compliments received are the same nationally as locally, andas in previous years, are appropriate care and treatment and staff attitude.It is worth noting that these categories are also the same top two categories that are received forcomplaints.Top 5 teams 2014/15 19

Complaints & ComplimentsCompliments Comparison of2013/142013/14 NEP units 31 2014/15 NEP units 15Gosfield Ward (Lakes) 30 CAMHS (Trust Wide) 19Rainbow Ward St Alburn Centre(Linden) 27Ardleigh Ward (Lakes) 16 Linden Centre 34Crystal Centre 12 Lakes 17Braintree CMHT Kitwood Centre 18The above demonstrates a consistent positive feedback for our inpatient units over the last twoyears. Of note is the rise in compliments received from Kitwood Centre with particular mentions toteam Manager Pippa Crockett.Compliments are displayed throughout this report, illustrating how much thanks and appreciationis given to staff working in front line services. “Thank you for all the support you have given to help me move forward in such difficult times”20 Mid – Galleywood Ward

Annual Report 2014/15Aims for 2015/16• Patient Safety and Complaints Team continue to increase their knowledge of complaints handling and legislation by attending national conferences and participating in local networking events• Proactively providing directors with quarterly reporting which enables them to hold learning events with their teams ensuring learning outcomes are embedded into service delivery• We will continue to be open, honest and transparent in our complaint responses• We will review the lessons learned process in line with Department of Health guidelines and Francis and Clwyd/Hart recommendations• We will review the logging of the compliments process in line with Department of Health guidelines and Francis and Clwyd/Hart recommendations.• We will continue to look at improving our response timescales ensuring that any responses taking longer than 30 days for mental health are justifiable• We will continue to increase the number of local resolutions to complaints• Work towards merging “low concern” complaints into the Patient Safety and Complaints Team function• Revision of NEP’s Complaints and Compliments Policy to incorporate a “User-led vision for raising concerns and complaints”• Revision of NEP’s information leaflets on complaints handling for both patients and staffNEP aims at all times to provide the best possible service to patients but when we do not meettheir expectations, we strive to put things right by:• listening to what they say• responding in an open and honest manner• learning from the feedback• ensuring we have handled our patient’s complaint in a positive and timely manner.Of the 159 complaints reported in 2014/15, 31 were upheld (19.4%) with 34 partially upheld(21.3%). Overall (40%) of all complaints have required the Trust to address the concerns raisedwith an opportunity to implement organisational change.We view the complaints handling process as an opportunity to improve our customer service andmake our patient’s experience better in the future. 21

Complaints & ComplimentsThe CQC has adopted the “user led vision for raising concerns and complaints” as a measurementtool for future inspections. We will ensure this vision is embedded within our practice throughout allareas of the Trust.We are confident that we have a well-managed complaints process and will continue to build onwith policy, information leaflet revisions due in June 2015.For more information please contact Sandie Warden, Patient Safety and ComplaintsManager at North Essex Partnership University Foundation Trust, Trust Headquarters,Stapleford House, 103 Stapleford Close, Chelmsford, CM2 0QX or by email:[email protected] “Thank you so much for everything you have done for me and my family, you are all stars!”22 North East – Gosfield Ward, The Lakes

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