Capturing and reporting on learning from complaints

Promoting a learning culture

• Appropriate governance structures are in place so that senior staff regularly review information that arises from complaints and are held accountable for using the learning to improve services. There are clear processes in place to show how organisations do this and this information is included in their annual report.
• Organisations take appropriate measures to capture feedback about the complaints process from those who make complaints and from the staff directly involved. They use this to demonstrate how the organisation has performed towards meeting the Complaint Standards and what users expect to see, as set out in My Expectations.
• Organisations routinely share learning from complaints with other organisations (both locally and nationally) to build on insight and best practice.
• Organisations that outsource the provision of NHS services to a contractor or private provider have meaningful strategic oversight of how these services are performing. They know how these organisations handle complaints and how they meet the expectations set out in the Standards.

At section 18, the Local Authority Social Services and National Health Service Complaints (England) Regulations 2009 say:

(1) Each responsible body must prepare an annual report for each year which must

(a) specify the number of complaints which the responsible body received;

(b) specify the number of complaints which the responsible body decided were well-founded;

(c) specify the number of complaints which the responsible body has been informed have been referred to—

(i)the Health Service Commissioner [Parliamentary and Health Service Ombudsman] to consider under the 1993 Act; or

(ii)the Local Commissioner [Local Government and Social Care Ombudsman] to consider under the Local Government Act 1974; and

(d) summarise—

(i) the subject matter of complaints that the responsible body received;

(ii) any matters of general importance arising out of those complaints, or the way in which the complaints were handled;

(iii) any matters where action has been or is to be taken to improve services as a consequence of those complaints.

(2) In paragraph (1), “year” means a period of 12 months ending with 31st March.

(3) Each responsible body must ensure that its annual report is available to any person on request.

Regulation 16 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, :

16.2 The registered person must establish and operate effectively an accessible system for … recording … complaints

16.3 The registered person must provide the Commission, when requested to do so and by no later than 28 days … a summary of –

1. complaints made …
2. responses made …
3. any other relevant information in relation to such complaints as the Commission may request

… Providers should monitor complaints over time, looking for trends and areas of risk that may be addressed … Providers must maintain a record of all complaints, outcomes and actions taken in response to complaints. Where no action is taken, the reasons for this should be recorded.

… CQC can ask providers for information about a complaint; if this is not provided within 28 days of our request, it may be seen as preventing CQC from taking appropriate action in relation to a complaint or putting people who use the service at risk of harm, or of receiving care and treatment that has, or is, causing harm. This can include requests for details on how the process is administered and reviewed, including whether it has an independent review stage. The 28-day period starts the day after the request is received.

The Data Protection Act 2018 and the UK General Data Protection Regulations are highly relevant to how organisations capture, record and use data and personal information. Organisations should ensure that all relevant legal and regulatory requirements are followed to protect service users, staff and the organisation. You can find more advice at www.ICO.org.uk. Specific advice on how to anonymise data and letters is available here.

The data required for this collection are:

• organisation details and organisation site details
• summary of overall numbers of complaints
• age of patient
• status of complainant
• service area
• subject area of complaint

You should have a system that you can use to capture the data that you must share in your annual report. This data includes:

• the number of complaints you received – you can break this down into clinical areas or different services
• the number of complaints where you found that something went wrong
• a summary of the issues raised in each complaint to help you identify themes or trends
• any action taken to put things right for the person who complained and to improve services for others, with details of the person responsible for the action
• the number of complaints referred to the Parliamentary and Health Service Ombudsman or the Local Government and Social Care Ombudsman
• important issues that arose from complaints or complaint handling.

You should capture data on the performance of your complaints service, including:

• the number of complaints resolved using an ‘early resolution’ approach and the average time it took to resolve them
• the number of complaints considered through a ‘closer look’ approach and the average time it took to resolve them
• percentage of complaints dealt with within the timescale that you shared with the person who made the complaint at the start of the process
• feedback on your complaints service to demonstrate that you are meeting the expectations set out in the Complaint Standards from:
• people who have complained and those that support them, such as NHS advocacy providers (NHS England has published a model survey to measure the experiences of those who have made a complaint. It is based on My Expectations, which underpins the Complaint Standards. You can find all these resources and the survey toolkit on the NHS England website: Surveying people who make a complaint).
• any staff members complained about and involved in the complaints process, and
• those delivering your complaints service.

It is also sensible to look at all sources of feedback on your service so that you can compile a complete picture of how your service is performing. This additional insight could include:

• compliments, thanks and positive feedback
• results of the friends and family test
• insight from patient safety or serious incident investigations
• claims data
• staff surveys
• feedback from patient experience groups and networks
• feedback from local NHS advocacy providers and Healthwatch
• social media comments
• data from staff grievances
• whistleblowing
• Freedom to Speak Up casework
• CQC and NHS England feedback surveys.

Tip
The Patient Experience Library puts a wealth of patient experience evidence in one place that you can search free of charge. You can use its Patient Surveys Tracker to look at survey data for every NHS rust in England, and the service can also help you set up a library suitable for your own needs.

You may also want to capture and review demographic data on the people who use your service and who raise complaints. This will help make sure your services, and in particular your complaint service, are accessible and are meeting their needs. You should regularly engage with representatives from across your community to gather their views and feedback on how you are doing.

Tip
The Healthcare Complaints Analysis Tool (HCAT) is a method for systematically analysing complaints and grouping key insights gathered from the thousands of experiences patients report to healthcare institutions every year. The tool is free to use. It allows staff to:

- codify and assess the problems reported in complaints
- grade their severity and the harm caused to patients
- identify where in the hospital system these problems occurred.

Senior staff are accountable for using learning from complaints to improve services. As part of this, they must regularly review the information that arises from complaints.

They should also have meaningful strategic oversight of any organisations that provide services on their organisation’s behalf. This will make sure that everyone is meeting the expectations set out in the Complaint Standards.

Reviews of complaints data and the resulting insight should be a regular standing agenda item for partnership, senior leadership or board meetings.

A senior member of the organisation such as a senior partner, chief executive or non-executive board member, should be responsible for ensuring that the organisation learns from complaints. They should:

• familiarise themselves with the NHS Complaint Standards
• make sure the organisation, and any organisation that provides services on its behalf, has assessed how the organisation is currently performing against the Standards using the NHS Complaint Standards Organisational assessment tool
• make sure the organisation, and any organisation that provides services on its behalf, has reviewed the model complaint handling procedure to identify any necessary changes to its own procedure to meet the Complaint Standards
• regularly meet staff who deal with complaints to fully understand the issues and barriers the organisation faces when dealing with complaints, and work with staff to overcome these
• make sure members of staff who deal with complaints are fully supported, resourced and trained, and know what is expected of them
• make sure the organisation has a robust system in place for capturing the data described in the section above and that appropriate audit and quality checks are in place
• review the data regularly (at least quarterly) to identify recurring themes and issues and any matters of general importance
• make sure that, where failings are identified, there is a clear action plan that sets out:
  • how the matter has been/will be put right for the individual
  • how the learning has been/will be embedded to improve services (if appropriate) and what that will look like once it is complete (see section below for further detail)
• regularly review action plans to make sure they are being/have been completed appropriately
• review feedback on the way your organisation handles complaints and periodically meet with people who have made a complaint, those that support them (such as NHS advocacy providers), and staff members who have been complained about. This will help you identify areas for improvement.

If you identify learning from a complaint, put a clear plan of action in place. This will demonstrate to the people who use your service and the wider community that you have listened and from the complaints you receive. Include in your action plans:

• the specific actions you have taken or plan to take to remedy the failings (and any impact you identified) to stop them happening again
• the name of the person or team responsible for completing each action
• when the actions will begin, and when they will be completed
• how you will make sure that the actions comply with relevant professional or appropriate standards
• how you will involve the person(s) who has made the complaint (see below)
• how and when you will review progress against the plan
• how and when you will review completed actions to make sure they have been successfully completed
• how you will monitor and audit the actions you have made to make sure any improvements to your service are maintained
• how you will measure the impact of those actions so that you can prove to the individual(s) and wider community that you have learnt.

Tell the person who has made the complaint about the action you intend to take. Ask them how they would like to be kept informed and involved as the actions are carried out. Make sure you capture this in the action plan.

The person may agree to:

• assist with a review of guidance, policies or procedures
• contribute the development of a training plan
• visit your organisation to see the changes in action
• share their story as part of organisational learning events or on your organisation’s communication channels, such as your website
• take part in any monitoring or audit of improvements once they are complete.

You should make sure the person is satisfied that the actions you have taken, or plan to take, will lead to improvements in care and service so that the issues they complained about do not happen to someone else.

Tip
The Ombudsman has published a short guide to writing action plans which includes a template and a checklist that you may find helpful.

The Complaint Standards recommend that you routinely share any learning from your complaints with other organisations (both locally and nationally) to build on insight and best practice. Some of the easiest ways to do that are to:

• publish what you have learned and the actions you have taken on your website
• share the information with your Integrated Care Board or any local or national networks you are part of.

The NHS Complaint Regulations say that you must provide your annual report on complaints to any person on request. However, you should be more proactive and not wait for people to ask for it. Publish it on your website and share it with your key stakeholders. These will include:

• your Integrated Care Board
• local Healthwatch
• local NHS advocacy providers
• patient experience networks
• colleagues
• local community groups
• local press.