Eiriol Putting Things Right Report July 09

8/14/2019 Eiriol Putting Things Right Report July 09

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Putting Things Right

A consultation on how to change complaints and complimentsprocedures in mental health

CONTENTS 11. Easy Read Summary 22. Background to this document 63. The mental health context – service user experience 64. The Government Policy context 95. Recommendations to the Putting Things Right Project. 10

5.1 Improvement to the compliments and complaints process

• Starting right• Joint working

• Conflicts of Interest

• Recognition of achievement

• Problem solving and grievance protocols

• The benefits of listening

• Management of the resolution of problems and grievances

• Appeals

•

Training and development• Investigations of serious incidents

• Evaluation of the process of resolving problems and grievances

and NHS accountability

• Taking complaints to independent appeal or to the Ombudsman

6)Getting things right first time – delivering a better service 217) How could this be delivered in practice? 26 8)Being heard – Getting a better service - Draft guidance for

service users, carers and their families on putting things right,when the need arises 27

Appendices1. Consultation Questions 392. Who attended the workshop day 403. Comments from the consultation day under headings 414. Current support for clients, and useful contacts 515. The Mental Health Context – service user experience 586. Policy context, quotes from documents 63



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1) Easy Read Summary

(Available in large print on request)

1.1 What Happened

A group of people got together to talk about how to say ‘thank you’ whenthings go right in the health service and how to put things right whenthey go wrong.

The people thought about what was different and special about mentalhealth, so that they could give ideas about what needs to be differentabout how things are put right.

There was time for everybody to put forward their ideas. This booklet isabout their ideas.

1.2 The way things are in mental health

The first part of this paper describes what it is like to be a service user,carer or a member of the service user’s family.

It talks about how helpful the service can be, how hard the staff work,and how caring they can be. It says how important it is to stay friendswith the staff.

This part explains what happens to mental health service users, howpeople decide what to do, and how difficult it can be for service users tofeel that what they say will make any difference to their life.

The paper talks about the extra danger mental health service users facefrom wanting to hurt or kill themselves. Staff, who work with serviceusers need to be careful to keep them safe.

This part tells the readers that there is not enough help to go around for everybody who needs it. Not everyone can be kept safe when they are

in danger.

1.3 The things the National Assembly Government saythey want to do.

This part tells you what the Assembly Government want to happen.They want to put mental health near the top of their list of things tospend time and money on and they want to make us feel better aboutthe care we get.

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1.4 Recommendations to the ‘Putting things right Project’

1.4 a) Improvements to how problems are put right

This part talks about how things could be better. How to make it easier

and safer, to say thank-you, or to complain. How to help service usersto feel that someone is listening to them. How to help service users feelthat someone understands why they are upset.

1.4 b) Making things easy

It says that the staff need to look for signs that the service user isunhappy with their care. They must explain that staff who don’t need toknow, will not be told about their worries about their care, and that badthings will not happen to their care, because they have told someonethat they are unhappy.

1.4 c) What is done, when, and who does it

This part talks about the need for problems to be solved quickly, andwithout fuss. It says that people need to know where to find help. Theservice user needs a bigger say in what happens after they tell someonethat something has gone wrong.

Things need to be done very fast for people who may harm themselvesor commit suicide if their problem is not solved quickly. It says that

service users need people to talk to them before, during and after aproblem is looked at.

1.4 d) Difficult situations

Things are more difficult when the service user is also a member of staff,or if they know someone very well, who is a member of the staff. It ismore difficult to solve problems when more than one service is involved,like the police and the health service. The health service is asked to findways to make things work better when these difficult things happen.

1.4 e) How people know what has happened

This part is about what staff need to do to show how they are workingwith people, so that someone else can later decide if they have donethings the best way.

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1.4 f) What happens to make things better

This is about what the staff need to say to the person who is upset.

• They need to apologise



• recognise what went wrong

• say what everyone will be doing to help

• how the health service will be better afterwards

• who will make things better

• and when they will do this.

It says that the service user needs to agree with the way things will befor them in future.

It says that the staff must be ready to try new ways of doing things, if this could help.

Sometimes the service user feels that their problem is not being solvedfairly, or not being solved in the right way. The paper says that there is

a need for someone to come from outside the health service to helpimprove the way the problem is sorted out.

1.4 g) Other things the health service must do

Staff need to be taught to see when things have gone wrong, and howthey can help to put things right.

When people hurt themselves, or kill themselves, someone must findout if staff did anything which played a part in the person feelinghopeless or distressed, or if they could have done more to help.

The health service must be happy to let people see what they do withcomplaints, and they must always try to do better.

It must be easy to see how service users’ comments make the servicebetter.

1.5 Getting things right first time – a better service

This part is about what could be done to stop problems before they start.

It says that there are seven big ideas that could make the service a lot

better. These are:-1. Good communication2. Treat people fairly3. Help people make as many of their own choices in life as

possible4. Try new things, and do things differently to suit each person,

as they get better 5. Work together to keep safe6. Staff do good work all of the time

7. Things always get better



For each idea it says what it would be like, and tells you how that mightmake people feel better about the mental health service

1.6 How can this be done in real life?

This part gives a few detailed ideas of what staff, and teams could do.1.7 Guide for service users and carers

This bit is some ideas for how you can sort out your problems with theNHS. It isn’t about promises or big ideas. It is about how things are,right now, good and bad. Some people make it all sound simple, but itis not. This part is based on the stories of other service users andcarers. It tells you what you need to think about when you complain. Itwarns you about problems, and suggests ways to help to get over them.It won’t raise your hopes so you get disappointed. It will just say howthings really are. What might help, and what could go wrong.

It should help you to decide what you want to do.



2) Background 6

About 40 people, (details in appendix 2) met in early July 2008 to discuss their experiences of the complaints procedure in mental health services and how it mightbe improved. These recommendations aim to address the specific issues raised by

participants at that time, and subsequently in informal discussion. The commentsand suggestions of the group are given in appendix 3. At the time of writing, LocalHealth Boards (LHBs) are joining up with Trusts so references to LHBs throughoutthis document, relate to the new joint organisations. The following recommendationsare a possible response to these comments. They are draft only. All your commentswill be welcome. Please pass on your comments to Penny Gripper, Eiriol, 59 KingSt, Carmarthen SA31 1BA, by 30th July 2009

3) The Mental Health Context – service user experience

(A fuller account is given in Appendix 5). The experience of the mental healthservice is one where the risks to the individual service user, and sometimes to thecommunity are potentially devastating and far reaching. The following key issuesaffect mental health service users:-

3.1 Staff achievements

• The mental health service is not an easy place to work.

• Staff work very hard, and often at anti-social times

• Most staff are committed and caring

• The service helps a lot of people

• Because of the service many people:

o

live longer, happier and more useful lives.o get better and become independent of secondary care

3.2 Communication:-

• Listening, understanding and being heard and understood are frequently a

problem

• Honesty and openness by staff is essential to build LHB and full involvement,

but is frequently not experienced

• Delivering bad news is high risk. Clients must be kept safe

• Our privacy matters. We want to know who will see our information, and how

they will use it• Telephone calls and letters must be carefully managed. Where there is a

need for support or any risk, a face to face meeting should be arrangedinstead.

3.3 Care Planning

• The CPA approach promises much that it fails to deliver

• Team decisions may be made without the service user’s involvement, with no

explanation to the client

• The client often feels excluded from decision-making

•The application of key parts of care planning is inconsistent

• Many service users feel that they do not get what they need



3.4 Balance of Power 7

• Not being given information excludes service users from involvement in their

care

• In mental health, client access to records can be denied

•

Complaints can be seen as indicators of illness and therefore not takenseriously, or in extreme cases, can lead to being sectioned under the MentalHealth Act.

• Decisions taken without talking to the client feel oppressive

• We need to be allowed to make mistakes

3.5 Collaboration and relationships• Staff, who go to the carer or family to support them to impose an intervention,

damage the family’s role in care

• Problems with relationships with staff are always detrimental

•When things go wrong, professionals can (and often do), blame the client for not engaging with treatment

• Professionals can avoid the need to; accept any culpability, or responsibility

for problems; reflect on whether they have made a mistake; or consider anyneed to change the way they do things. This avoidance is not a good rolemodel.

• Threats of discharge used to gain compliance, are oppressive

• The client has no power to do any other than accept what is offered on the

staff’s own terms

• There is no choice, no negotiation and often no agreement

3.6 Information

• In contrast to physical health, there is little ‘objective’ information in patient

records. Most of it is ‘perception’, ‘opinion’, and ‘interpretation ‘

• Our lives are deeply affected by these perceptions, opinions and

interpretations, which in turn, are based on records, which are neither consistently accurate nor reliable

• Sometimes staff decide that a claim is a delusion without checking the facts.

They can be wrong.

• Complaints investigations are based on inaccurate records, so cannot

substantiate or refute the client’s complaint• Inappropriate decisions are often based on inaccurate interpretations, which

are not open to client challenge

• Information is a powerful resource for recovery in mental health

3.7 Access to resources

• ‘Generic’ working creates the potential for unsafe clinical decisions, and can

prevent client access to services that could help them

• Resources in mental health are severely limited, and mostly targeted at the

people who have become more severely ill. People become more ill when not

helped at the right time, and then suffer more AND cost the system more.This can put people at life-threatening risk.



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• Staff are discouraged from reporting unmet needs because it places an

obligation on the LHB. The most common cause of needs not being met isinsufficient staff time

3.8 Safety

• It feels like the risk to the psychiatrist is more important than the risk to the

client.

• Crisis Intervention and Home Treatment teams, feel like they are keeping

people out of hospital, rather than keeping them safe.

• Up to one in five mental health patients die by suicide.

• Suicides can happen as a result of

o the way the service treats its clientso the way complaints are managed.

• Many people self-harm when they are distressed.

• Distressing processes are high risk



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4) The Policy ContextThe Welsh Assembly Government has demonstrated its commitment to improvingthe experience of people who use the services it provides, such as the NHS. Manypolicy documents talk of putting the ‘citizen at the centre’.

The Assembly have also pledged to make mental health a priority and havepromised additional funding to demonstrate that.

Policy seeks to involve service users more in decisions about their treatment andtheir lives. Users should have access to services according to need, which preventdeterioration, treat symptoms and their causes, reduce potential harm, and assistrehabilitation. Service users and the public should be protected, there must besupport following hospital discharge, record keeping should follow the guidance of individual professions, and professionals should be supported through supervision

with a constructive problem solving approach.

In ‘One Wales’ it seeks to draw up a charter of ‘Patients’ Rights’, improve patients’experience, and improve the accountability of the NHS. ‘Designed for life’ seeks toget supply and demand into balance. Beecham in ‘Beyond Boundaries’ wantsorganisations to be ‘mature enough to apologise when things go wrong, move awayfrom a blame culture, and to be intolerant of substandard work’.

Further details on the gist of policies, with quotes from documents are given inAppendix 6.



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5) Recommendations to the ‘Putting Things RightProject’5.1 Improvement to the compliments and complaints process

5.1 a) Starting right• At the first appointment explain the following

o How to raise and solve a problem or make a comment

o Where to find help when doing this

o What safeguards exist whilst a problem or grievance is being solved

o Provide a leaflet to reinforce your explanation, but NOT to replace

it

• The process needs to be accessible to all, to be sensitive to different cultural,

religious, language and disability/ability requirements

• Language must show that the client is unhappy, and be sensitive to the

feelings of professionals, who do what they think is best. No-one seemshappy with the current terms

• All staff need to be trained to respond quickly and informally to problems or

grievances, to solve most problems without the need for any other processes.

• The identification of a first point of contact and alternate for any ‘official or

formal’ problem solving process needs to be done very early on in the client’scontact with the service.

5.1 b) Joint working

• Where the NHS service works with other agencies, eg the police, and the

complaint relates to joint working, the LHB must work fully with the other agency to resolve the problem.

5.1 c) Conflicts of interest

• There needs to be a clear protocol for cases where the client is a member of

staff within the service or a relative or close friend to staff. The serviceprovider must carry the burden of proof that such relationships have not in anyway compromised the quality of service offered to the individual. This canONLY be proven if assessors, staff and investigators have adequate distancefrom the team concerned.

5.1 d) Recognition of achievement

• Rewarding excellence is critically important to service improvement. Both

service users and staff need to know when they are doing well. An award, or accolade for individuals and teams, and also for those whose help isparticularly valued by service users, would be welcomed.

• There must be a wide range of opportunities for comments on satisfaction

with the service. Short satisfaction surveys should be available at every pointof contact.



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5.1 e) Problem solving and grievance protocols5.1 e) i) Raising concerns

• All problems raised and the responses to them must be centrally logged in an

anonymous form to support service development.

• Protections for people raising complaints, must continue in any new process,

and must be obligatory, not just guidance.

• All complaints must go through an informal resolution process first, subject to

ensuring client comfort and support with the process, and their agreement tothis route

• At any time a problem is raised, the explanation of how to raise and solve

issues, where to find help and the safeguards in place during the resolutionprocess should be repeated, and written information should be given again.

• Staff must be proactive about concerns raised by acutely ill clients. Those in

hospital or under the CRHT, can be very distressed and vulnerable.

5.1 e) ii) Who investigates the complaint • Because of service users’ need to feel safe with the problem solving process,

there needs to be both negotiation and agreement about who is to be involvedin any complaint.

• No information given by the client with reference to a problem or grievance

should be passed on to any other staff without the client’s express consent.

• There needs to be an option to raise problems with someone not involved in

the client’s care, who also has the authority to require action and/or change.

• This person must have the authority to supportively help the staff involved toreflect on, and revise their approach.

• Where a complaint is about clinical decisions, regarding diagnosis, eligibility

for a service or treatment, the LHB must offer and provide a second opinionfrom an appropriate professional, who is independent of the team involved inthe client’s care before being asked , and involve that professional in theinvestigation of the complaint.

• The independent review should reinforce this requirement with the LHB, if it

has not already been done, to be delivered within a reasonable time frame.

• If an investigator is due to be away from work for any reason during the period

of the investigation, another investigator should be chosen

5.1 e) iii ) Formats for problem solving There needs to be a totally anonymous problem solving option within the LHB, for those who will not otherwise complain.

5.1 e) iv) How long should it take?

• Time limits must ensure that the client can be fully involved and get the best

result from the process.



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• Where a problem is causing so much stress/distress that the client’s clinical

condition is seriously deteriorating, especially if it is increasing the risk of suicide, a much faster, rapid response is required. A 48 hour response time

is suggested.• Where a complaint is dealt with over a long period of time, the complainant

may have new issues and/or ideas for resolution or redress. There needs tobe a mechanism to include these.

• Service users must be able to withdraw a complaint at any time, if it is too

distressing or unsafe to continue with it

5.1 e) v) Investigation and resolution

• There needs to be clear guidance for investigators on how to investigate a

complaint impartially and with minimum risk of it growing in intensity.

• An absence of evidence, or controversial or contested evidence does notmean that a problem did not occur.

• An investigation will not be considered impartial if, when contested, the

investigator puts greater credence to staff generated records, than to therecords and or memories of service users and/or their advocates, supportworkers, or carers. A failure to be impartial is likely to cause a complaint tobe referred to the next level.

• The investigation needs to explore the client’s position, to drill down to the

underlying problem, or goal, and focus on finding an acceptable solution

• Situations are rarely simple enough to be conveyed in full by correspondence.

The service user needs to be given the opportunity to explain to theinvestigator face to face, even when the problem appears to be straightforward. (“comprehensive”)

• The LHB must be obliged to offer meetings for resolution with the client and

relevant staff, and to provide them within an acceptable time frame. Themeeting felt strongly, both staff AND service users, that an independentmediation service is required

• If the staff and LHB have had an opportunity to justify their actions in any

investigation, then the complainant should have equal access to investigatorsto hear their response to the LHB’s/staff’s position. The best way to do this isto have discussions together with both parties.

• Where a complaint seems to arise as a result of a delusion, there still needs

to be an investigation and a response. Staff need to consider how their behaviour may have contributed to the expression of delusion, given thatsuch symptoms are increased as a result of distress. The service user’s painmust be addressed. It is too easy in mental health to dismiss problems as ‘notour fault’.

5.1 e) vi) Quality of evidence

• There needs to be an audit trail (creation of evidence), for procedures most

likely to lead to a complaint. This evidence needs to be independently

verifiable, to make it a valid source of information for the investigation of anycomplaint



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• The burden of proof to provide evidence that a problem did not occur needs

to rest with the more powerful party, the NHS, with minimum standards of

evidence required. The proof cannot be based on records written by, andvulnerable to being changed by, the people who are subject to the complaint

• Consideration should be given to the use of audio recordings of assessments

and care planning

• All emails about clients must be saved and filed on patient records unless the

email is part of problem solving or dealing with a grievance, or discussionbetween staff relevant to any problem or grievance, when it will come under the rules of record keeping for problems and grievances

• Where other witness evidence exists from people independent of the NHS,

eg independent advocates, carers, friends or relatives of the client, these

witnesses must be invited to give evidence, which must be considered in anyinvestigation, and be given equal weight to witness evidence from within theNHS

• There needs to be guidance to NHS services on acceptable evidence

requirements when a complaint has been made, both in defence of the claim,and in support of it.

• There needs to be a quality assurance process for record keeping, to monitor

and constantly improve the quality of written records

• Evaluation processes for assessing the quality of record keeping must be

credible. Eg unannounced spot checks, with audio recordings compared tostaff written records of the same contact.

• When records are requested by a service user because of a complaint, every

effort should be made to only involve those who already know about thecomplaint, in giving consent for access to records.

5.1 e) vii) The response • The quality of the NHS’s response to problems and grievances is critical. The

link between complaints and service improvement must be transparent andconsistent.

• Checks and balances are required to ensure that responses to complaints

pose no risk to the client, and are of a consistent standard.

• The response must include the followingo Apologies which recognise pain, if not culpability

o A statement of the problem in full, in the client’s own words

o The specific remedial action commitments made by all staff involved,

relating to their own role in the incidento An action plan from the LHB to address organisational issues, giving

names of responsible staff and time scales.o Where actions are required by another organisation, eg the

development of National Occupational Standards, the action requiredwill be to pass on the issue to the appropriate body, and politicians.

• There needs to be a prioritising process to determine a proportionateresponse to actions identified through complaints. Issues which



14frequently arise, with high impact processes, should command more

resources, and be dealt with more rapidly, for instance:-o Identification, discussion and management of risks

o The assessment process and eligibility for service

o Exclusion from service on the basis of disability (eg Personality

Disorder)o Confidentiality

o Unmet needs

o Admission and discharge processes and decisions

o Difficulty accessing services due to lack of transport

o The making and delivery of a diagnosis

o The making and agreement of a care plan• It is important to do more than just re-state the LHB’s pre-complaint position,

especially if that is reinforcing a confrontational approach to care.o The client deserves a full explanation of any disputed clinical decisions,

so that the client can identify where any second opinion may be helpful,or whether they wish to exclude any team member from further involvement in their care.

o If the client finds any such explanation either insufficient or

disempowering, further information must be provided.o The response to a problem or grievance needs to be appropriate to the

needs of the patient.

• With any difference of opinion about the best clinical approach, the client’s

feelings must be taken into account, in any deliberations. This must includeconsideration of:

o Extra costs of care should the client deteriorate as a result of feeling

coerced into accepting something they don’t want, or neglected bybeing refused something they do want

o Possibility of suicide in response to a failure to address service user

beliefs about their hope of survivalo Damage to the client’s relationship with the team where a

confrontational approach is adoptedo The benefits of engaging the client fully in a way which inspires their

faith that the proposal will work

• It is essential that the client is NEVER blamed for whatever has gone wrong,

or accused of being malicious simply because they have made a complaint.

5.1 f) The benefits of listening

• Remedies put in place to resolve differences of opinion between the service

user and staff can create a more responsive service, which is fit for purpose.

5.1 f) i) Creating a fit for purpose service

• A service user may want a service, which is beyond the professional’s comfortzone. The staff member may be worried about their position with regard to



professional conduct, and working within the limits of their training.

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• The NHS needs to coordinate with professional bodies to give their membersguidance on how to challenge existing norms, and to support them toinnovate safely, whilst keeping their members from encroaching on the rolesof other professionals.

• Staff members must be required to give a VERY good reason to refuse

‘personalisation of care’ in the absence of specific research, which shows arequest for personalisation to be detrimental.

• A client request for the involvement of a specific profession,

creates a platform through which to increase the effectiveness of multidisciplinary working, and to ensure that all staff recognise that

professions within the team have protection of title, and are regulated in order to provide a skilled and safe service to service users. ‘New ways of working’does NOT provide a route to practising another profession without meetingregulatory requirements.

• If a team chooses to refuse the client their choice of profession, because they

feel that there is an equivalent alternative, there needs to be guidance on theevidence required by the team to underpin and justify their response. Thismust :-

o Include evidence from an independent second opinion from a member

of the profession concernedo Withstand scientific and legal challenge

o If the decision is based on a lack of resources, it must be supported bya report of unmet need

o Give the client whatever evidence and reassurance they need of the

additional qualifications, experience and regulation held by the team’salternative to the profession requested, to underpin this extension totheir normal professional role.

When refusing a service or innovation is at least as difficult as registering anunmet need, or offering the service, the aspiration for significant culture changeto a more user orientated approach will be effectively realised.

This recommendation carries the opportunity to review the balance of professionals in mental health teams. It is important to ensure that

protection of title and professional regulation remain meaningful, to protect clientsfrom unqualified and unsafe practice. It is critical that generic working does notextend to professional roles, until a mechanism is in place to regulate suchactivities.

These recommendations are made to address the comments made under ‘cultureand values’, which might be summed up by the comment, “Just try listening for once”.

5.1 g) Management of the resolution of problems and grievances• It is imperative to address the client’s pain, and provide a high level of



support whilst resolution of the situation is being addressed

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• The meeting discussed the need for ‘Patient Support Officers’ to act asinternal LHB advocates for service users with more minor concerns. Thiswould increase the chances of getting a result through influence within theteam

• If, a client is not enjoying the protections promised by complaints policies and

guidance, there must be rapid intervention by an independent body or personto remedy the situation.

• There needs to be greater awareness of the Independent Complaints

Facilitator service. Client’s should be entitled to request this service from theLHB.

•

An independent facilitator would be more credible if they also had acompliance role to ensure that the LHB complies with any regulations or guidance on the complaints process.

5.1 h) Appeals• There must be an opportunity to appeal following an investigation, within the

LHB or to an independent body.

• The independent Complaints Secretariat can be more flexible than the

Ombudsman because it is not limited by legislation. It is therefore essentialthat it remains

• Because of the complexity of complaints and the difficulty clients with mental

health problems can have in communicating their thoughts and feelings, aninflexible requirement for a written process only, excludes people. In order tomake the process fully accessible to people with disabilities, there must be aprocedure in place to enable complaints to be submitted verbally, wherenecessary

• The clinical reviewer has to identify whether the explanation given to the

complainant is ‘adequate’. This cannot be done without speaking to thecomplainant, because the adequacy of an explanation depends upon theneeds of the client, on their level of understanding and ability. It dependsultimately on whether the complainant felt it was adequate.

• The scope of the independent complaints process needs to be extended toinclude assessments of case management and the quality of clinicaldecisions, to identify clinical error, and poor or dangerous clinical practice.The clinical reviewer must be in a position to measure the performance of theclinicians involved against national standards, eg against the NationalAssembly’s CPA guidance, its National Service Framework for mental health,and against National Occupational Standards for the professional groupsconcerned

• In order for the process to have credibility with the public, and for it to provide

sufficient assurance to induce public confidence in the health service, theremust be a robust response to bad behaviour, or poor or dangerous practiceby individuals or teams.



• Whilst there is a fine line between positive individual and team accountability

and the need to avoid the maintenance of a ‘blame culture’, seriousproblems will not be picked up early enough to save lives or prevent seriousharm unless the detail of who has done what and why, is addressed, andremedial action taken

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• There needs to be a FULL report to complainants of any action taken to

address their concerns. They need to know, for instance, when a clinician isreported to another organisation, specifically to help them to improve their performance. They need to know where action has been taken to address theway a particular team is working, where training or additional supervision hasbeen provided, as well as the organisational and management responses toincrease patient safety

• The quality of the independent complaints review process needs to be

improved. Guidance to reviewers, including clinical reviewers, needs toinclude an ethical code regarding impartiality, and the need to declare anyconflicts of interest. It is wrong to assume that staff records will be moreaccurate than patient and witness recollections. Such preferences leavecomplainants feeling that the process is still biased against them, andtherefore not independent

• Before appointing a clinical reviewer, the client must be asked which

discipline they feel would be best placed to review their case

• At some point in the official process after local mediation of a complaint at a

LHB, there must be the opportunity for an independently chaired ‘hearing’. Ameeting where there can be discussion between all concerned, for

clarification, explanation, the hearing of external/independent witnesses, or professional expert witnesses, or the opportunity to addressmisunderstanding, misinterpretations or misinformation

• The current practice of sending out clinical review reports from the

Independent Complaints Secretariat to the LHB, without first checking themfor accuracy with the client, must stop

• Sometimes the clinical review report is likely to make the situation worse, not

better. The complainant needs to see the report before it is sent out to givethem the opportunity to prevent it being sent to the LHB

• Like any other clinical professionals, clinical reviewers must be accountable

for the quality of their work. Their reports must be open to challenge andsecond opinion. For transparency, their names must be on the reports, justas expert witnesses in court are not anonymous

• Any independent clinical review must involve a second opinion assessment of

the client, together with a discussion with the client of the clinical records andcase history to establish where accounts of the facts vary

• Where LHB records, or staff accounts, differ from that of the complainant OR

other credible witnesses, recommendations should be made by theSecretariat, to the LHB, to improve the future accuracy of records. This mayinclude asking them to agree with a client what should be recorded at the timeof contact

• Agreement to care plans or records can only be evidenced by a client

signature



• The LHB should be asked to copy all documents or correspondence sent to

the Complaints secretariat/Ombudsman to the client, at the same time theypost it to the Secretariat or Ombudsman. The LHB must be accountable for the accuracy of any claims they make to the Secretariat

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5.1 i) Training and Development• Staff need to be trained in procedures for resolving problems and dealing with

grievances, and ‘supported/supervised’ with the process, to ensure quality isconsistent and meets minimum standards for client support, safety and linksto service improvement

• There needs to be national minimum standards for dealing with complaints in

mental health. This will include, requirements at a LHB, team and individuallevel. There need to be National Occupational Standards to underpin

compulsory elements for staff training (CPD) within the NHS skills framework.This training should have the same status as fire safety training, lifting andmoving, and first aid. Application of these standards needs to be monitoredthrough staff appraisals to ensure that everyone is familiar with policy andprocedures, and can demonstrate that they are applying them.

5.1 j) Investigations of serious incidents

• All suicides and attempted suicides of people who have had any contact with

the LHB, whether on-going or not, should be investigated to establishwhether the LHB either had a causal role in them, or could have doneanything more to prevent them.

• People who are suicidal may not want help. However, their intentions may be

reported by others. A failure to assess the individual, or, if necessary, toimpose treatment in such circumstances, is often seen by the bereaved asneglect, and therefore as assisting in suicidal completion.

• Asking someone if they are suicidal will often get a denial, from the people at

most risk. Suicide investigations should check if the assessment of potentiallysuicidal clients looked at risk factors or if it sought evidence of indicativebehaviours from people in contact with the client.

5.1 k) Evaluation of the process of resolving problems and

grievances and NHS accountability• The NHS service providers must be accountable for the quality of service

offered. There must be greater involvement and enforcement powers of inspection bodies in monitoring the quality of the complaints process, and theresponses to complaints that have been raised.

• LHB complaints and investigations records must be open to spot checks, with

the complainants’ views used to evaluate public satisfaction with the process.

• Complaints need to contribute to service evaluation and have a clear and

sustainable influence on service development and policy making, fitting intoemerging collaborative structures for inspection and continuous improvement

of standards.



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5.1 l) Taking complaints to independent appeal or to theOmbudsman

1 Submitting a complaint to the Ombudsman’s office needs to be, transparent,open to scrutiny, and accountable.

2 The Ombudsman only deals with maladministration and service failure. Thereneeds to be an avenue through which to raise issues of poor casemanagement , clinical errors, or poor clinical performance, and any other issues not covered by the current legislation.

3 For a fair, impartial and just process, it is important for the complainant tohave the opportunity to see what the LHB is saying to the Ombudsman, sothey can point out any errors in the LHB’s understanding of the situation,inaccuracies, incompleteness or bias of evidence. (see last 2 bullets under 5.1 h) ‘Appeals’ above)

4 Checking information before report writing, may be time consuming, but, thetime required to appeal against an inaccurate report, and identify themisleading or inaccurate source material is also very time consuming.Possibly more so. But most importantly for mental health service usersreceiving an inaccurate report is extremely distressing, and makes theproblem worse, not better. Having to check information to refute an

inaccurate report is very stressful. It is recommended that a pilot be run, tosee if up front investment in checking the accuracy and completeness of information with the complainant, before report writing, does or does notsave time and distress. In addition, that pilot should monitor how manypeople want to see source material first, or just be allowed to comment andmake alterations to the report after it is written. This would give a full pictureof the resource need.

5 It would be helpful to have a mental health liaison officer at the Ombudsman’soffice to speak on the phone to, or meet complainants. This would make theprocess more accessible, and provide a calming and supportive source of initial advice, on whether a case is likely to be heard.

6 There needs to be a fundamental review of the purpose, functions, andprocesses of the Ombudsman’s office, its accountability frameworks, itsservice quality, its transparency, its customer service ethic, and whether thelegislation which governs which cases it takes on is adequate for today’sservices, and provides a sufficiently comprehensive and fair appeals process,especially for those in mental health, whose access to service may beimposed rather than chosen.

7 Because the Ombudsman’s work is defined by law, it is not a flexible enoughprocess, for a first independent appeal against a health service decision.Even though there may be administrative difficulties with what will be an older complaint, an improved Independent Complaints process should ensure thatfewer cases go on to the Ombudsman

8 At present, whilst the NHS does usually implement the recommendations of



the Independent Complaints Secretariat, or the Ombudsman, they don’thave to. This does not feel like an accountable service. Therecommendations of these bodies need to have legal weight, to beenforceable to ensure public protection. There should be ‘special measures’to ensure that recommendations are put into practice if the LHB doesn’t act on

them within a reasonable time frame.

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5.1 m) Behind the scenes• There are organisations working behind the scenes to improve clinical safety

and performance. They do not take direct referrals from the public andcomplainants are not always informed of their involvement, if a clinician or team is referred to them. Confidence in the clinical service is essential,especially in mental health where liberty is at risk, paranoia is a problem, andstress is a trigger to worse symptoms and sometimes life threatening. Thereis a need for more information to be given to complainants about how theindividual clinicians in their care, who have been involved in a problem willchange their practice to prevent a reoccurrence.



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6) Getting things right first time

– delivering a better service

It was clear from the day that much could be done to prevent complaintshappening in the first place.

It is recommended that work with people with mental health problems isunderpinned by the following key principles of mental health caredelivery, in order to deliver key outcomes.

Key Principles

6.1.1 Principle 1 – Good communication

Communication is clear, honest and accurate, available in the client’spreferred language, and in different formats, to meet the client’sindividual needs.

6.1.2 What this means

• Frontline staff give a clear explanation about what is going to happen, which is

easy to understand

• Any assessment creates a record of the client’s

problems/experiences/symptoms described in their own words

• Staff don’t offer a service unless they are sure that it can be provided

• Any offer that is made is put in writing at the time it is made, and is honoured

• Communication and confidentiality policies are explained. The client will know

who can see their records without the client’s permission, who will see any

letters they may write, even if marked ‘confidential’, the circumstances inwhich the law requires information to be passed on, and the circumstances inwhich information will be kept separately to the clinical notes

6.1.3 Key outcomes of principle 1

• The client’s expectations are realistic

• The clients feel that they have been heard

• The client has confidence in the staff

• The client trusts the team

6.2.1 Principle 2 – Treat people fairlyThe client is treated fairly, with respect, and with dignity




• Staff have access to guidance on equality and diversity, and regular training

and support to understand and respond to the particular needs of serviceusers

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• Treatment and support are offered on the basis of need, irrespective of

diagnosis, age, disability, religion, sexuality, race or gender

• Client values, beliefs and culture are recognised and respected by staff, and

taken into account in all elements of assessment and treatment

• Staff follow the client’s ‘rules’ and ‘standards’ in the client’s home – eg

removal of shoes inside the house

• Treatment is offered without coercion through threats

• Procedures are in place to ensure that clients have information at all times

about, and access to, ways to raise any concerns they have about the waythey are being treated

• Measures are in place to ensure that the client is safe from abuse, especially

when alone with any member of staff, eg direct independent observation of all contacts with the client is possible and in place, either through thepresence of an independent witness chosen by the client, or through audio or video recording that can be viewed as evidence

6.2.3 Key outcomes of Principle 2

• Client confidence that the service will give them the help they need

• The client feels safe from emotional or physical harm at the hands of front linestaff in the NHS

• The client is reassured that problems will be resolved fairly

6.3.1 Principle 3 – Maximise client choice

The client’s autonomy to make decisions about their own life ismaximised


• Client’s set their own goals for recovery, and the team work with them• Informed consent is required for treatment interventions which carry risks, eg

medication, self-management without medication, and psychotherapy.Service users sign a form to confirm that they understand and are willing totake the risks identified

• Clients are informed about all the services which may be of help to them, and

are given choices to access assessments at all appropriate key points in their treatment/life. (NB an assessment, however recent, may quickly become outof date and need repeating as the client’s condition fluctuates.)

• Clients are informed of resources, such as books, internet resources, self-help

groups and self-management courses (the meeting discussed the value of having such resources available at the points of access to



• the service – the wards and the CMHTs)

• Clients are supported to help them manage their condition themselves,

• Clients are invited to sign their agreement to their own care plan, which is

only valid once so signed

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6.3.3 Key Outcomes of Principle 3• The client feels more in control of their own life

• The client feels more independent

• The client feels involved

• The client takes a greater responsibility for their own care

• The client feels they are a part of their own recovery

6.4.1 Principle 4 – Flexibility to meet needs

The delivery of services is flexible and innovative to meet individualneeds


• Services provide choices, and respond to the wishes of the client

• Frontline staff contribute to service planning and have the authority to adapt or

develop service in response to client need

• Services are tailored to the needs of the client• Where a client is eligible for a service, and does not wish to be discharged,

or to accept the staff’s preferred treatment offer, a new offer must benegotiated. As in physical medicine, palliative care, and/or conservativetreatment are always options which must be offered. The team must alsoconsider the need for innovation in individual cases. Just because a clientmay not choose the mainstream option, it does not mean that they cannot behelped, and should therefore be discharged

• Staff are willing to extend their comfort zone, by doing something new at the

request of a particular client, or in response to an individual’s special needs.

• Management are willing to support staff innovation, and protocols are put in

place to minimise the risks

6.4.3 Key Outcomes of Principle 4• The client is at the centre of the service

• The service is fully collaborative

• Treatment compatibility with client is maximised

• Advances are made in practice

• Client feels involved in their own care

• Client feels heard

•Client is fully committed to the treatment process

• The staff are good role models for clients in trying out new things



• Staff feel involved in service development, listened to by managers, and have

a high morale

6.5.1 Principle 5 – A safe service

Risk is discussed regularly with the client and plans are put together withthe client to minimise and/or tolerate it.

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• Staff and service user, carer and/or families talk about their fears and worries,

and how to keep the service user and others (where applicable) as safe aspossible

• The line between over-protection and safety is consciously managed through

informed discussion, consent and acceptable risk taking in line with stage of recovery

• Regularly means whenever anybody, staff, service user, carer, family, or

others propose a change to treatment or raise a concern, or whenever any of these people feel a precaution, currently in place, is no longer needed.

• Risk includes the risks that arise from treatment and/or from the condition

• Plans might include self-management training, use of voluntary sector support

services, change in medication, hospitalisation, High dependency unit,involvement of the police (section 136), or other sections as necessary


• Service user feels as safe as possible, but not stifled

• Family, carers and staff are aware of the risks and know how to minimise

them

• Families, carers, staff and the community are confident that they and the

service user are as safe as possible

6.6.1 Principle 6 – Consistent high standards of care

Services are delivered according to minimum standards, andconsistently applied policies and procedures, whilst ensuring staff compliance through continuous evaluation processes


• Staff have a clear statement of the standards expected of them

• Staff inform service users of these standards, to remind staff of their own

commitment to them, and to clarify to the client, the nature of the staff’srelationship with them

• Staff adherence to minimum standards is monitored, through proportionate,

and cost effective, in-built checks and balances, through recording methods,supervision and sign offs. These measures are open to spot checks, to



provide evidence for inspections, which have the power to require remedialaction.


• The service user and the public feel that the service is fit for purpose and

accountable

• The public perception is that the mental health service in Wales works for

service users and the community, in every part of Wales

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6.7.1 Principle 7 – Continuous improvementThe standards of service are continuously improving, throughrecognising, celebrating and sharing good practice, through learning

from mistakes, and through making advances gained throughinnovation more widely available across Wales


• There are opportunities to thank front-line staff at every contact, in every

building through which a service is developed, at every level of management,and in public

• The benefits of innovation are reported locally within teams, and all across

Wales

• Individuals and teams who are performing at a particularly high level are

awarded accolades which celebrate their contribution

• Teams and services that meet a higher than average standard are recognised

through the new Chartermark system in Wales (see page 27 of “Better Customer Service”)

• You know that staff will learn from mistakes

6.7.3 Key Outcomes of Principle 7

• Staff are motivated to achieve high standards

• Service users are pleased with staff achievements

•

The service becomes increasingly fit for purpose• The funding is spent more effectively and has more impact



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7) How could this be delivered in practice?

Example suggestions, which meet the key principles for mental healthcare deliveryare made below, not to prescribe solutions, but to illustrate how the principles mightbe practically applied.

The following actions could help set up good communication and a good serviceexperience from the beginning.

7.1 Clients referred through their GP for assessment at the CMHT

7.1.1 Suggestion:- Link workers from the CMHT keep GPs up to date with howreferrals are handled. They ensure that the GP can and does give a clear verbalexplanation to the client of what to expect. Not all clients are well enough to be able

to read a leaflet. The client needs time to ask questions.7.1.2 Suggestion:- The client is told at the very beginning what will happen to anyinformation collected by professional staff. (Including an explanation of what theLHB means by the word ‘confidential’.)

7.1.3 Suggestion:- The assessor records the service user’s experience in their ownwords, and does not attempt to interpret those words.

7.2 Admission via section.

This is a deeply traumatic and distressing process. Patients can feel that they haveless protection of civil liberties and rights than those subject to either civil or criminal

law. These decisions are frequently highly contentious and therefore more likely tobe the subject of a complaint.

• Suggestion:- Where staff are entering a client’s home, remember that this is

their own, private refuge, where their own standards and wishes apply.Respect any requests made by the client regarding the way you behave intheir home.

• Suggestion:- Treat clients with kindness , HONESTY, and compassion.



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8) Being heard, getting a better service

This section gives draft guidance for service users, carers and their families on howto get their comments heard, and action taken, when the need arises in the mentalhealth services

8.1 Introduction

The purpose of this document is to help you to get your problems solved. It will giveyou ideas based on the experience of other people, of what you need to do. It willwarn you about possible difficulties you may face, and will give you ideas about howto try to avoid these problems. It will tell you about things that have been promisedby the Welsh Assembly to help you, and what you can do if these promises are notkept. It will guide you towards the organisations that can help you, and give you

more information about the different ways that you can seek a solution to your problem. It will help you to make a case, should you feel the way the problem isbeing handled is unfair, or causes you distress. It will be realistic about whether you are likely to be successful or not.

This document aims to help you to choose what you do with the best chance of success, and full knowledge of what could go wrong.

8.2 Information

Some contact information is given in Appendix 4 on organisations involved in qualityassurance for the NHS.

If you telephone the switchboard of your LHB and ask to be put in through to thecomplaints department, you will be put in touch with someone who can answer your questions. This person is not involved in your care. It is their job to help you. Theywill not tell anyone in the team that you have contacted them, when you are justasking for information. They will provide you with leaflets giving information from theNational Assembly and from the LHB about the complaints process. Please note,the information from the assembly is guidance, not law.

If you have access to the internet it may be worth seeking information from your LHBwebsite. You may find the LHB Complaints guidance and contact information there.

If you are not comfortable about speaking to someone from the LHB, your localindependent mental health advocate (see finding help) may be able to explain how



things work. People from MIND, Hafal, or providers of ‘floating support’, may beable to advise you.

8.3 Finding help

The Assembly booklet gives you information on how to find your local Community

Health Council, where you can be put in touch with a Patient Complaints Advocate.

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There may be notices up in the waiting area, where you go to meet your carecoordinator, or in local organisations like Hafal or MIND, about where to find your

local Independent Mental Health Advocates.

Sometimes it is worth seeking advice and help from your local Assembly Member, if your initial attempts to be heard are unsuccessful.

8.4 General Confidentiality

Check with your care coordinator what happens to your information, and who cansee it without your permission. Usually the NHS staff have a very different view of confidentiality to you. They feel they are being confidential as long as they don’tpass your information on to anyone outside of the health service. If you don’t wantthe whole team to know something, don’t tell any of them. If you want total

confidentiality, go to a private practitioner, or someone working outside the healthservice, who would need your permission to pass any of your information to anyoneoutside their organisation. Be aware that letters get passed around and copied todifferent members of staff as a matter of course in the mental health service. Don’tsay anything you wish to keep private in any letter.

8.5 Where do I start?

You may want to start by talking to the person who has upset you. They areprobably the best placed to help if the solution is easy.

If you are no longer seeing the person who upset you, or if you don’t want to speak

to them directly, or if they have already failed to help, you may choose to go tosomebody else.

8.6 Who to go to

If you go straight to another member of your care team, your care-coordinator or alocal manager, they may be able to solve your problem. However, sometimes theywill treat your complaint as a symptom, and may even refuse to look into it for thatreason.You are most likely to get a serious response if you go through the local NHScomplaints department, and ask them to see if they can help broker local problem

solving. You will need to be specific to ask the complaints staff to speak for you,because if they just give you a name to phone or write to, you may find that that



person does not take your communication as a complaint.Often the complaints department is able to solve the problem. If you are unhappywith the information you get from the complaints department, you can still look for aninformal response yourself. A member of management may be in a position to helpsolve your problem discretely. Ask the complaints department who would be the

best person to approach. If you are unhappy with the name they suggest, ask for the next higher manager.

29It may be possible to speak to a manager directly on the phone. This is nice andinformal, and may help, but if you don’t get the result you want, you will not be ableto prove that your conversation took place. A phone call backedup by a letter will provide the evidence you need. Sometimes the manager will notspeak to you, and may tell you through his or her secretary, that you should takeyour concerns to someone else. This may be your care coordinator.Some LHBs have a policy requiring someone to act as a first point of contact for aservice user who wishes to raise a problem. If you are unhappy with being told to goto your care coordinator with complaints, tell the complaints department, andsuggest the name of someone who would be acceptable, or, if you don’t haveanyone particular in mind, just ask them to suggest someone else, maybe someonewho doesn’t have any say in your day to day care.

8.7 Confidentiality of Complaints

At this point it is very important to know that anything you say, or write in a letter, canbe put on your clinical files, unless you specifically say that you are making acomplaint.

Even if you want to solve the problem informally you may decide you don’t want theissue raised on your records for anyone in the team to see. Sometimes you have tobe VERY firm that what you are saying or writing is a complaint, and that it mustn’tgo on your records. If you write to anyone about your problem, you are advised towrite “This is a complaint, and must not be put on my clinical files”, on the very first

line of your letter. If you only speak to someone, it may be difficult to prove later thatyou made it clear that you were making a complaint that should not go on your clinical file. You may have to write, or get someone else to write for you, that youare making a complaint, in order to get the safeguards that the complaints processprovides.

8.8 Informal Problem solving

You are entitled to an informal, local problem solving process. You do not have to gostraight into a formal written complaint. If you feel best describing the problem inwriting, then after stating that the letter is a complaint, as discussed above, thenstate that you are seeking local informal resolution as a first step.



8.9 Ways to talk about the problem

If you can, it is best to ask for an interview, whether you phone or write. Then youcan take someone with you as a support and as a witness, and you can ask for someone else to come to take minutes. This may be a secretary, or someone fromthe complaints department. The benefit of a face to face meeting is that you canquickly see if someone does not understand you. You have a chance to respond tothem, to put them right, or to explain if you are unhappy about a suggestedsolution. The whole thing can be resolved much more quickly with an early face toface meeting.

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The problem with a letter, is that it has to be very brief, even if the problem iscomplicated, and because it is brief it can be misinterpreted. If not marked as acomplaint, this letter can be circulated to any other member of the staff team, and/or placed on your clinical records where team staff can all see it. Even if you do markthe letter as a complaint, staff may decide that some parts of the letter are acomplaint, and other parts are not, and then circulate it anyway. A letter invites, byimplication, a response in kind.

If you want a conversation about your problems, it is best to state only that you havea problem, and want a meeting with the staff member/manager as soon as possibleto see if a solution can be found informally. The less information you give about your problem, when asking for an interview, the more likely you are to get one, becausethen the staff cannot convince themselves that they understand and can deal withthe problem in writing only.

There may be a problem that the staff member you are meeting may be very difficultto understand. You may feel intimidated by their questions, and be unable torespond ‘on the spot’. It helps if you can take notes with you about what is mostimportant to you, but you may find you cannot take a full part in the conversationand look at your notes. An advocate, either independent or from the CommunityHealth Council, can help you to put your views across at a meeting. In the end, if ameeting is only a partial success, you can still follow up with a letter. However, ameeting may be refused once the correspondence has started, because the staff

concerned become worried that they will look bad, and will not want to be put on thespot themselves.

8.10 Records of interviews

Whoever takes the minutes of your interview, you need to ask to see their record,before it is finalised, because it is surprising how completely different a record of ameeting can be, from your memory. Notes taken rarely reflect emphasis, and theinterpretation of the note taker of the events, can be re-interpreted again whenconverting the note back into a report. The best record is a video or audio recording.This is not yet standard practice in the health service. It is always worth asking,because eventually, when enough people have asked, someone in the NHS will sayyes. In the mean time, ask the question, but expect a negative response.



8.11 Choice

You may not want to take all these precautions given above, and it may be possibleto solve your problem without them. But, if you choose to be low key, you mustaccept that you may be disappointed, your problem may take longer to solve, and itmay get more complicated because of the way it is handled.

8.12 If an informal approach does not work, what next?

Ask the complaints department how you need to proceed. There may be a form tofill in, or you may need to send a letter to the Chief executive of the LHB.

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8.13 A formal ComplaintAt this stage it is very important to get help from someone who is not involved in your care. You are likely to be most successful if your letter is calm, polite andreasonable. This is very difficult when you are feeling very angry or very distressed.Another pair of eyes may help you to ensure that your letter is less likely to bemisinterpreted. However, experience shows that what other people read into letters,is unpredictable. Don’t expect people to read what you mean. Again, if you want ameeting, say less in your letter and request the meeting to discuss fully the nature of your problem, because you don’t feel able to put it all into writing.

Again, start the letter “This is a complaint and must not be put on my clinical file.”

For formal written complaints, and help at complaints meetings, in setting them up,getting what you want discussed on an agenda, and ensuring a proper record iskept, the Community Health Council Patient Complaints Advocates are very wellplaced to get things working as well as possible.

8.14 After the complaint has been made

Once you have written an official complaint there are clear guidelines and policies,which should be met.

Your letter should be acknowledged within a specific time period (some say 48

hours, but letters sometimes get lost in the system, or held up because anadministrator is only part time).

From acknowledgement of receipt, you should have a response (according to 2008rules) within 20 working days (about one month).

You can ask for a meeting, but as already discussed, you may not get one.

8.15 Who gets involved in the complaint

Only the people directly involved in the problem you have described should beinvolved in working out what happened and what needs to be done about it.However, some people who look at complaints, are more liberal in their view of who

needs to be consulted, than others. Ask the investigator to let you know who he or she intends to involve, and if you are unhappy, you then have a chance to tell them



that. If there is someone who you definitely want to be kept out of the investigation,say so in your first formal letter of complaint.

8.16 Safeguards

No information about your complaint should be put on your clinical records

No-one not directly involved in the incident or grievance should be informed of your complaint

1) Your care should not be affected in any way by your complaint2) Your treatment, or referral for treatment, must not be deferred until after the

complaint has been investigated3) You should not be discharged because of a complaint

324)

and you or your carers or family should not be punished in any way as a resultof your complaint

If you feel that you are not being protected in these ways, then tell whoever hasmade your care less good, that they are acting against the complaints process. If they do not immediately reverse the action that reduces the quality of your care,remove information about your complaint from your records, or if you feel they arepunishing you, your carers or your family, then contact the complaints department toexplain your concern. If the problem isn’t put right, the Community Health CouncilPatient Complaints Advocate may be able to help, or you may find a request for helpfrom your Assembly Member, gets your treatment plan re-installed at the same level.

8.17 Complicated problems

When a complaint is very complicated, it may be broken down into smaller parts andinvestigated by more than one person. You will need to pace yourself if thishappens. Sometimes an investigator will ask for extra time to deal with a complexcase, to get it right. If you agree to this it can be an open ended commitment, andleaving room for you to be too ill to deal with it sometimes, it may take years. Youmaybe need to ask advice from the Community Health Council Patients’ Advocate,on what time frames might be reasonable for your case, and respectfully request tothe investigator that the process be completed within that period.

8.18 Independent Complaints FacilitationThis is a relatively underused service, because few seem to be aware of it. It canhelp when you feel unable to speak directly to the people you are complaining about,or if you feel they are not taking your complaint seriously enough, or if they areresponding in jargon.

Independent facilitators are independent of the NHS, and are trained to help resolveyour complaint. They encourage open discussion of your concerns, identify areas of conflict and may help to bring your concerns to a satisfactory conclusion, byresolving the problem.

They would normally be offered to you if the LHB feel that they would be helpful, or they may be suggested by the Independent Complaints Secretariat. If you feel this



service would be helpful, and no one has offered it, you could ask the complaintsinvestigator, although they may not be obliged to agree to your request.

If you are offered this service you have to agree in writing. The appointed facilitator will contact you and discuss your concerns. They will explain the process to you andagree the best way forward. There may be a meeting between the facilitator and thepeople you are complaining about, and possibly a meeting with everybody involved.Your Independent Mental Health Advocate, or your CHC Patient ComplaintsAdvocate can support you through this process if it would be helpful to you.

If this process doesn’t solve the problem you can continue with the NHS complaintsprocedure described below.

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8.19 Response from the LHBYou should get the response to your complaint in writing. You may not be happyabout the contents of this letter. It would probably be a good idea if you can put off opening the letter until someone is with you, who can help you if you are upset by it.If you do not trust yourself to be so patient, ask in your first letter of complaint, for the response to be sent to your independent mental health advocate, your supportworker, your carer, or a friend, so that they can be there for you when you read theletter. Don’t read the letter on a Friday or Saturday, in case you go into crisis andneed additional support, which is harder to get at the weekend.

Whether you are happy with the letter or not, it is a good idea to write back to the

chief executive to thank him/her if you are happy, or to explain what you will do nextif you are not happy.

8.20 What next if the problem is still not solved?

If you are not happy with the LHB’s response to your problem you can choose fromthree options.

• The investigator who has looked at your issues within the LHB may be willing

to revisit parts of the response. Because this is not an ‘official’ process, it isnot tied to any limits on timing or quality of response.

• You can go to the Independent Complaints Secretariat, to have your problem

looked at by people who are completely independent of the local LHB.

• You can go straight to the Ombudsman without going through the

Independent Complaints Secretariat, but you cannot go back to thecomplaints secretariat after you have involved the Ombudsman. TheOmbudsman is the final stage of the complaints process. There are no moreappeals without entering into legal proceedings. The Ombudsman has a lot of discretion but his powers to investigate are limited by the law.

8.21 Complaining to the Independent Complaints Secretariat

There are three regional offices and their contact details are in the Assembly

Government’s Guidance on Complaints. Your CHC Patients’ Advocate can helpyou. If they do the secretariat will copy everything they send to you, to the CHC



advocate as well.

8.21.1 Forms

You should write to the secretariat giving full details of your complaint.

You will then be asked to sign a consent form, which will give thesecretariat permission to have a copy of your medical records and/or therecords of your complaint. If you don’t agree to access to these recordsthe Secretariat cannot investigate further than the information that youhave sent them.

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8.21.2 What happens to your complaint

A lay advisor and a lay reviewer will look at your complaint. They will look at thelocal resolution correspondence.

8.21.3 Complaints about assessment, diagnosis or treatment

If your complaint includes clinical matters, they will ask an independent clinician tolook at your case. You may wish to ask about the role and function of this person sothat you can discuss with the Secretariat if you feel the clinician does not have theright qualifications to understand your issues.

In mental health, professionals seem to increasingly be trying to do each others’work, due to the ‘integration’ of the teams. A professional not regulated to providethe service your complaint refers to, may therefore feel they can decide if theservice was right or not. You cannot assume the right discipline will be involved.The lay reviewer will advise you of the options available to you.

The clinician will also look at the local resolution correspondence and your clinicalrecords, and will write a report, which the lay reviewer and lay adviser will consider.The clinical reviewer’s remit is to ascertain whether the explanation given to you wasadequate, whether there are any outstanding issues which require a response, anyclinical issues which have not been addressed, and any practical actions required to

give a better explanation to you. They are not supposed to comment on casemanagement, or on their own clinical views about the case. They will not be overtlycritical of any individual’s practice, but will concentrate on matters of procedure andpolicy only. The tone of the report may however indicate that there may be an issuewith a clinical decision or an individual clinical professional, which may lead to arecommendation to refer the person on to the National Reporting and LearningService, an organisation which helps individual doctors or nurses to improve their clinical performance. (This organisation does not take reports from individual serviceusers.)

You cannot see the clinical advisor’s report before it is sent to the LHB, but if youare worried that it may not fully address your problems, it is worth writing to thesecretariat to ask if they can look at it again. They may be willing to ask the LHB to



wait to implement their recommendations, until you have agreed the report. If youare unhappy they may be willing to look into it further.

Once the report has been forwarded to the LHB, it cannot then be withdrawn if youdo not like what it says, or feel it is unfair or inaccurate. You may then need to workon a response to the report to go onto your file explaining your problems with it.This will be helpful should you need to take the complaint further.

At the end of this investigation the lay advisor and reviewer may makerecommendations to the organisation complained about.

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8.21.4 The response from the Secretariat

The secretariat will write to you as the complaint is processed, to let you know how itis going. If you want to know what is happening, you can phone the office to findout. The staff are very helpful.

At the end of the investigation the Lay Reviewer will write to you with his conclusionsand any recommendations to refer the case back to the LHB, convene a panel or draw the issue to a close. He will also include a copy of any clinical report. Similarly,a letter and the clinical report will be sent to the organisation complained about. It isusual for NHS organisations to act on any recommendations made, but they don’t

have to.

The Independent Complaints Secretariat may send your complaint back to the NHSservice provider, if they feel that more could be done by them. They will makespecific recommendations to focus on actions that are needed eg a meeting, or areas where more information is required. If you do not agree with the remitsuggested by the Secretariat for the LHB, you can write back to the Secretariat toask for greater clarity, or an expanded remit. Again they may not agree to this, butthey definitely can’t facilitate it, if you don’t ask.

If further Local Resolution is recommended and you remain dissatisfied after this hastaken place, then you can ask the Independent Complaints Secretariat for a second

review of your complaint.

If the Secretariat decides to take your case further themselves they will convene a‘panel’. This includes the Independent reviewer, the independent advisor, and oneother person, all of whom are ‘lay’ (not associated with or working for, the healthservice). It will also include 2 clinicians with the relevant speciality. You will havethe opportunity to agree the remit of the panel at this time. You will be invited to aninterview with the panel, where you can make your case. They will separatelyinterview the staff from the LHB, and any other witnesses. You will see a copy of their report of the salient points from your interview only. You have the opportunity tosuggest corrections or amendments to that report, which will be considered, but may

or may not lead to a change in the report. The panel will them consider their findings from this process, and may make recommendations to the LHB.



If you feel that the process of the panel interviewing people separately, rather thantogether, is a problem, maybe because it permits misconceptions, biases, andmistaken information to be perpetuated, you can ask for the process to be moreinclusive and open. It is generally believed by the service that the more openprocess ‘would be unproductive’, but very occasionally they have done things

differently. It is worth asking if you want the panel to be run as an independentlychaired meeting, including all the people involved.

If you are unhappy with any aspect of the process of the Independent ComplaintsSecretariat, you should write back to raise your concerns. They may be able to dealwith your issues, and will do so, if they can. If the reviewer feels they are unable toaccommodate your wishes, you could ask the secretariat manager if they couldauthorise a special response.

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8.21.5 If you are still unhappy, what next?

If you are unhappy with responses to your concerns from the health service or Independent Complaints Secretariat, and you have been advised that they can dono more, you can go to the Public Services Ombudsman. This service only dealswith ‘maladministration and service failure’ . For more information and guidance, if you feel you want to talk to someone before making your complaint, call theOmbudsman’s office on 0845 601 0987. They cannot talk about your complaint indetail at this stage but can give general guidance.

8.22 Making a complaint to the public Services Ombudsman

8.22.1 Submitting your complaint

The Ombudsman requires a complaint in writing. You will need to get a form, whichis in a leaflet called “How to complain about a public body”. You can ask the healthservice for one, or get one from the Ombudsman’s office, or from the website. Youcan submit the form on line if you wish.

You will need to send copies of all the correspondence that you already possess,about the complaint so far, both with the Review Secretariat, and/or the healthservice.

If the Ombudsman’s office needs clarification or additional information before theydecide whether or not to take on the case they may contact you informally, possiblyby phone. They may also contact the health service in the same way.

The Ombudsman’s office aims to be accessible.

If you need help submitting your complaint, and are having difficulty finding someoneto help you, phone the office on 0845 601 0987 and they will find a way to help.

The Ombudsman’s details are in appendix 4

8.22.2 Advocacy help

If an advocate is going to help you there is a separate part of the form, which mustalso be filled in to give your consent to this. If an advocate has already been



involved in your complaint and you have a file of relevant documents, this will makeyour submission much easier now.

8.22.3 The Ombudsman cannot always take your complaint

The powers of the Ombudsman are limited by legislation. They cannot investigate

every complaint,

The Ombudsman will not normally take on a case more than 12 months old, unlessthere is adequate reason for doing so. They will take account of the time you havespent trying to resolve the problem locally.

If the case is not taken forward, you will be given an explanation in writing. If youare not happy with this judgement you can appeal, as you can at any stage shouldthe case be closed later in the process.

37

You cannot guarantee that your complaint will be taken forward, or resolved to your satisfaction. You need to be prepared for the worst.

8.22.4 If there is an assessment of your case

If your case is fairly straight forward and easy to resolve, the Ombudsman’s officemay choose to try to resolve it informally before further investigation.

If they do decide to assess your complaint they will write to the LHB to invite their comments and any relevant papers, which relate to your case. The LHB has torespond within a given time period.

The Assessors will carefully consider the information from the LHB, and fromyourself. If they think that there has been a service failure they will take it further,and if not they will close the case.

8.22.5 If fault is found

In the event that they decide to take your case forward, they may take further advice. With clinical issues this would be from an Independent Public Advisor (IPA)or an External Public Advisor (EPA). Depending on the nature of the complaint thiswould be someone with the appropriate clinical expertise. The Wales office prefersto use English advisors to provide an extra degree of independence.

They will come to a decision, which may include making recommendations to theLHB to put things right.

The whole process can take a very long time, even a year in some cases.

For an official complaint there are opportunities to appeal at various points in theprocess, should you not be happy with a decision. Reports and meeting minutes aresent to you to check for accuracy or comments (as applicable).

8.22.6 Final options.

An internal review process exists within the Ombudsman’s service, but after thatthere are no more options.

If you have exhausted the Ombudsman’s process you can still go to judicial review.



This can be a costly process. You would be sensible to speak to a solicitor beforetaking this option.

8.23 The Professional Regulation and Safeguarding routes.

You can start a separate action against an individual through their professional body

at any time, if their behaviour does not meet the requirements of their professionalcodes of practice. You can often get some advice over the phone about your case,or you can be sent their code, so you can decide for yourself if your case is coveredby it.

For those staff members not currently regulated in this way, there is the Protectionof Vulnerable Adults process (POVA) which deals with cases where abuse hasoccurred, and there is a new process coming in whereby everyone who works withvulnerable groups, will have to be registered by the “Independent SafeguardingAuthority”. People considered not suitable to

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remain on this list may be barred from working with vulnerable people. This is a verybasic measure, which will only deal with the most extreme cases.

8.24 Beyond the law.

The law is not always the final moral arbiter. Politicians are continually reviewing oldlaws and creating new ones, to fill the gaps identified when things go wrong, oftenas a result of cases that are brought to their attention, which haven’t beensatisfactorily resolved because the law is inadequate.

You can follow a political route to addressing your problems if the law seems to be

inadequate in your case. However, this could be a life-time’s work.It is worth speaking to your Assembly member, and if they think you have a goodcase, they may write to the minister on your behalf. Sometimes correspondencewith politicians can lead to changes in policy, which change the LHB’s contractualobligations, making a resolution possible.

If your problem is one which happens to a lot of people, it is worth going to the larger mental health campaigning organisations, like Hafal or MIND Cymru, to see if theyare already working to raise awareness of problems like yours with politicians. If they are not working on the issue now, let them know what you think, and they maybe able to take up this issue in future.



39Appendix 1

Consultation Questions

1) If you were present at the Putting Things Right day, do you think thisreport adequately represents the discussions on the day, and inparticular anything that you wanted to be heard? If not, please describewhat you think should be added

2) Look at the list of comments from the day. ( Appendix 5) Tick thoseyou agree with, add anything you think is missing. This will give us anindication of the areas a number of people think are most important

3) If you were not present at the Putting Things Right day, what keyproblems or possible solutions should be added to the report?

4) Would you like any further information added to this report?

A summary of the presentationsA report from the evaluation of the dayOther - please specify

5) Do you think the draft guidelines “Being heard – getting a better service” are useful, as a pattern for guidance, given that they will haveto be changed to reflect any changes in the current compliments andcomplaints process? Please comment on how they might be improved?

6) Should there be an ‘easy read’ version? (cf summary at beginning of main document)

Please return your comments to Penny Gripper c/o Eiriol, 59 King St,Carmarthen, SA31 by 30th July 2009



40Appendix 2

Attendence - 22 service users

4 advocates3 NHS LHB staff fromComplaints, CPA and patient involvement3 NHS clinical staff 1 NHS LHB Manager 2 Welsh Assembly Government managers3 Voluntary sector staff 1 volunteer 1 Carer 1 Officer of a Community Health Council

Total - 41

Booked but didn’t come - 3 advocates3 staff (including one social worker)2 service users

1 voluntary sector worker

Total no shows 9

Apologies - 2 service users1 carer

Total - 3

Total booked for the event - 53.



41

Appendix 3

Comments from consultation dayComments from flip charts organised for easier interpretation. Some commentsfitted under more than one heading.

CommunicationInaccurate information in reviewsComplaints are negative at first, how to overcome this - communication between

complainant, person complained about and a third person.Tell people how to find an advocateCPN discharge for no reason.Write to Chief ExecutiveStaff could be asked to talks by service users and vice versa.More mental health awareness of issues for service usersPoint of call - be able to contact someone to discuss feelings/issuesCommunication and education and trainingListen to patientsAcknowledge evidence when it is offeredCommunicationConfidentiality issues need to be brought up (explained) earlyspecific service info/guidance, and scenarios around confidentiality (possibly 1.clinical care, 2. re; complaintsClear guidelines may be adequate for post-acute/rehab stage, but acute caredifferentALL NURSES HAVE TO SMILEits OK to talk - actually it's part of the jobClarify (on both "sides") what a complaint means, what a suggestion means, butthey both should be consideredMore honest up front communication and information to avoid complaints eg weight

gain due to medicationWarmth should not be seen as unprofessional



CommunicateHelpline - crisis resolution team confidentiality, diazepamCheck list of things that need to be said at specific meetings eg at first referralassessment, at CPA reviews, or when client first raises a concernDon't be scared to give the service user information about the diagnosis, how it is

made, and its consequences including how the patient can manage it, or abouttreatment, eg risks, benefits, duration, commitment, how it will be monitored.Give mental health service users the same rights of access to medical records asthose with physical health problems.Don't have multi disciplinary meetings without the service user presentDon't have psychotherapy case reviews without the service user presentStop Chinese whispers - no diagnosis or assessment of need for a service withoutboth the client AND the appropriate professional whose service is being consideredpresent together.

42Make sure service user is fully informed of everything they need to know to makeinformed choices about their own care

ResourcesNot enough CPN's - cannot give enough time to everyoneLack of on-going supportBigger picture - need to consider that a little resource in the right place at the righttime, can massively reduce resource needed if not spending the money causes adeterioration which leads to hospitalisation.

Listen to the service users - they know what works for them. Working with serviceusers, rather than against them will cost much less.

Feelings

Dissatisfaction with advocacy (by who?)Feeling of not getting anywhere anywayStigmatisedVulnerability - not heardStop being scared of us patients.Staff don’t careStaff dig in their heels as a matter of principle on particular issues, because they

fear that ‘giving in’ will encourage the service user to plead for something else.Actually it would just feel that the service was responsive and caring, and that mylife mattered a toss to someone.

NeedsAlone - need easy access to a listener, easy access to information, short time spanto implement. Ability to pursue a complaint up to 6 months ? and more.Easy access to information on complaints handlingNeed to anticipate problems.Advocacy support structures in the community - no follow on.specific service info/guidance, and scenarios around confidentiality (possibly 1.

clinical care, 2. re; complaints)Need more personalised packages of care



Frightening to go into hospital - need information, but may be given at the wrongtimeDiscuss when best time is to give this to help understandingInfo on complaint procedure at the start and as an on going thing - explain whatadvocacy is.

More info on alternative therapiesChoice without recriminationVolunteer to take service user home and see basic needs can be met, and to have acup of tea. Need new post to do this.House of safety run by services, 24 hour manned (use in Pembroke and Swansea.)1) Safe contact/support prior to need for hospitalisation2) Safe contact/support post hospitalisation3) Better application of drugs prescriptions

434) Increase police familiarity with metal health BY visiting wards, groups etc (out of uniform) Advocate training classes.Loads of needs, but how to find answers?Better unmet need process - should be independent of NHS as they 'cover up' needsso that they don't have to respond to them.If people are not getting a service because there are not enough staff, it is still anunmet need even if the service is there.

Culture and values

Staff -pro-activeHumane attitude - lack of understanding from staff Deal in the truth, be open and transparentAcknowledge evidence when it is offeredCan do philosophyCulture of everybody responsible for changeNHS culture - staff responsible for dealing with things and apologisingtreat everyone as an equal.Recognising where things have gone wrongStop suppressing and controlling peopleChoice without recrimination

Dealing with obstaclesCourage to change and complain/commentVisit - break institutional cycleIncrease understanding of man’s variety and virtuesBreak the pattern of power abuse. Staff are not always conscious of being abusive.Need specific training to help them to be more aware of the effects of their behaviour, and communication style on vulnerable/potentially paranoid people. Stop confrontational approach to care planning.Empowering a service user does not mean losing power yourself.Respect the service users beliefs about what works for them.Only say no, if it is completely and totally impossible to say yes.

A service user who has insight, knows better than anyone else what treatment theycan tolerate, comply with, and respond well to. Just try listening for once!



ProceduresGeneral DIFFERENT WAY OF BEING ADMITTEDNot going through A+E as unsympathetic to service user issues

Not take people with mental health issues to police or casualtyImprove coordination and fluidity of the system - too much specialisation causesgaps in the system, that people can fall through, such as alcoholism, definition of serious mental illness.Managing boundaries for acute patients in community (more of it now)Advanced directives/ self management programmes (eg MDF)Crisis cardsPlace of safety other than police station

441) safe contact/support prior to need for hospitalisation2) safe contact/support post hospitalisation3) Better application of drugs prescriptions4) Increase police familiarity with mental health BY visiting wards, groups, etc. out of uniform) Advocate training classes.

Specific to complaintsAcknowledge evidence when it is offeredClear guidelines may be adequate for post-acute/rehab stage, but acute caredifferent

CHC, MHA commission/, HIW, CSSIWBeing able to make a complaint to someone who is not providing your care.Most problems stem from institutional acceptance of existing structuresClarify (on both "sides") what a complaint means, what a suggestion means, butthey both should be consideredMore honest up front communication and information to avoid complaints eg weightgain due to medicationComplaints are negative at first, how to overcome this - communication betweencomplainant, person complained about and a third person.Service user must have control over the complaints process, who is involved, andwhat happens when. They must be able to pull out at any stage if they feel the riskto their care, or even their life, is too great.No report back to a complaint should be made until AFTER a face to face discussionbetween the investigator and the service user, summing up the findings, andallowing the service user to respond as to whether they feel the investigation actuallyaddresses their complaint at all.

TrainingMore mental health awareness of issues for service usersspecific service info/guidance, and scenarios around confidentiality (possibly 1.clinical care, 2. re; complaints

Manager should go and talk to people where it works wellDo something (?training?) about attitudes, values and its OK to talk - actually it's part



of the job and treat everyone as an equal.Better manage situations when tension is rising between clinician and patientthrough improving supervision.Create opportunities to reduce institutionalised organisations eg ward staff -community example given - if a community staff is rude you won't let them in your

house - don't have that choice on the wardRecognising where things have gone wrongGive them clear codes of conduct and have ward meetings with patients and staff as'therapy' for both partiesGPs need training on complaints advocacy and mental health in general.DACE do course on empowering service usersAdvocate training (for police in mental health matters)Need specific training to help them to be more aware of the effects of their behaviour, and communication style on vulnerable/potentially paranoid people.

45

(for staff)All staff should be trained in LHB policy on resolving problems, and onconfidentiality for this process, including consultants, at least once every threeyears.All staff should be trained in no blame problem solving, and in conflict resolution.

New ideas and solutions

Mental health casualty unit

Patient support officers - Carmarthenshire LHB ( someone within service

to listen/ and/or deal with minor concerns)

Independent mediation to help address the inequalities betweenorganisation and patient

Information giver as a full time jobAn independent officer

Volunteer to take service user home, to check basic needs can be metand to have a cup of tea. New post needed

Helpline crisis resolution teamCommunity police officers go to Mind, ward round, MDF meetings - out of uniform

ALL NURSES HAVE TO SMILE

Things that cause problemsQualification based nursing not properly motivatedNurses’ fear influences the way they handle thingsLack of willingness of staff and lack of respectConfidentiality not being observedPeople being discharged without care plansPeople not properly involved in their case

No support structures put in placeNo meeting/CPA before discharge



Confidentiality being broken - in care and in the complaints processMost problems stem from institutional acceptance of existing structuresBreak the pattern of power abuseWe all have preconceptionsAny clinical condition blamed on mental health problem

Good things to aim for Holistic - task orientatedPatients should have more involvement with care planStopping the same thing happening to otherssupport networks, caring networks, responsibility for oneself Informed choice, control, complaint shared with minimum number of peopleManaging boundaries for acute patients in community (more of it now)

46Can do philosophyAdvanced directives/ self management programmes (eg MDF)NHS should be more proactive about going to voluntary organisations eg MIND,MDFOrganisations are able to plan and are able to respond to unmet needs (which leadto complaints) eg local services not EnglandProactive home treatment for substance misuseUse complaints constructively to have a positive effect and highlight what needsimprovingBetter manage situations when tension is rising between clinician and patient

through improving supervision.Recognising where things have gone wrongOften only issue is to make sure that same doesn't happen to someone else.Stop suppressing and controlling peopleMore info on alternative therapiesChoice without recriminationAdvocacy acknowledged as importantAdvocacy high on list of priorities

Reports of eventsCrisis resolution team - withdrew (telephone) number due to volume of calls

Nurse discharged someone without reason

Quality issues1st point of contactQuality improvement targets - asking people what they think of the quality of care (egquestionnaires) sent to people centrally not by team providing the care.Prioritise the parts of the system that have broken down.Recognising where things have gone wrongStop suppressing and controlling people

PolicePolice stripping people naked - need education



Police lack of education and respectCommunity policingAdvocate service for people in police stationsPolice duty of carePlace of safety other than police station

Ideas - Community police officers - go to , Mind, ward round, MDF meeting- out of uniformAll talked of good experience - with some workers. Police good men in all walks of life.1) safe contact/support prior to need for hospitalisation2) safe contact/support post hospitalisation3) Better application of drugs prescriptions4) Increase police familiarity with mental health BY visiting wards, groups, etc. (out of uniform) Advocate training classes.

47

Problems with current complaints approachComplaints system failing patientsLong, drawn out and difficultConfidentiality being broken - in care and in the complaints processDon't always get an apologylitigationnot knowing which policy to followconfusion between informal and formalmanagers speak language we cannot understand - need to speak clearlyconcerns about whether you will be heard because you are very ill - should be

looked at again when better "Attention seeking", "manipulative", - people can get blamed for not fitting the boxesof what is available and seen as a pain.Experience of complaints process - not following procedure, false informationBecomes adversarial - have to resort to legal side because they won't listenUnequal power - system has its own support, but service user is alone, and includingthe way things are written.Advocates are limited in what they can do/adviseDifficult to find an independent solicitor End up being caught in the systemConcern that services only worried about people making a claim, so act defensive,

don't listenLong processes are detrimental to people’s mental health, can cause further problems/relapseCan cause trust to collapse in the service - could this then cause a need for further services.People can be worried about losing a service or being punished.People who want changes made or to change their care team can be labelled andfear recrimination

Good things about current complaints processWe've got one (even though everyone may not know about it)

CHC and other broader systems that complaints relate to.



LanguageWords instead of complaint - votes given for question, discuss and issue

Challenge, Concern, Question, Discuss, Issue, Difficulty, EnquireComment - both good and otherwise, Grievance, Problem, Appeal

How to prove what happenedTake notesWe can't listen "equally", "impartially" to both sidesHow about more formal meetings being tape recorded or at least independentlyminuted? (NB minute taker must understand terminology - and check withparticipant, if unsure what they mean)Tape record

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When is 'proof' one way or the other relevant? To the extent that it is greater transparency about recording - note of meetings as drafts requiring approval byservice user/patent etc, might help. But as we know from other contexts, there areoften powerful motivations on both sides not to record the sort of matter that comeinto dispute.

Risk and safetyDuty of care/confidentiality can be fluid, but can make service users feel unsafe.Info from complaints may need to be shared 'cos of safety issueIssues of what to disclose, for service usersPlace of safety outside the police station

House of safety run by service, 24 hours mannedBreak the pattern of power abuse

Evaluation, continuous improvement and learningEvaluation feedback need to be stronger. ? everytime we have contact? Ondischarge perhaps. Also after CPA reviews? Every 6 months? Short, support to fillin.Need to make sure services change as a result of feedbackIs some good practice - how do you share this?Use inspections/reviews either planned/unplanned to learn and improve the system.Use complaints constructively to have a positive effect and highlight what needsimprovingPrioritise the parts of the system that have broken down.Recognising where things have gone wrongWe are making improvements

Praise and rewardCompliments/acknowledgement balances complaintsRewarding staff who do wellWhat can we do to let patients know what they are doing well and to reward them?We all agreed that there are some excellent staff within the health service

Increase understanding of man's variety and virtues



Context - the processes within which a complaints process must fitOther systems – CPAStop recording disagreements about CPA on CPA reportDon't have a working way of looking at unmet needAccess to medical records – the request for records has to be approved. It is not

uncommon for the whole multi disciplinary team to be asked about access. For complaints there should be a protocol for requesting access to medical recordsONLY from professionals already involved in the complaintLetters policy – all letters go on clinical file, need exception for complaints to beincluded in policy

49Confidentiality policy – needs to specifically include the additional confidentialitybetween staff on complaints

SolutionsA lot depends on the way you are treatedPatient councilsOpportunity to chat through issuesHelp with signpostingRaise issues with managersFunding should not be left to the voluntary sector Opportunities for peer advocacy?

Implement across the boardExample of water dispensers - letters ignored - press notPatient councils - not all patients are in hospital, community captured views - bigger challengeSolution - listening to problem at start, spoken to and respected service user, do notdiscriminateRecognising where things have gone wrong

Miscellaneous commentsDoctors and nurses should try their own drugs. If they're good enough for them,then maybe we could consider taking them.

InstitutionalisedThe staff canteen serves fresh, wards get cook chillAlternative therapies are available to staff - but not to service users.CBT was found to be less effective.Voluntary sector need to look at themselves

Who decides what is a complaint and how?Naturally the person with the complaint decides that it is a complaint a situation thatis causing them discomfort - it is not for anyone else to impose their views onanother's perception

Complaints are subjective and personal (usually)The service user or carer who puts it forward, NOT LHB staff



More Self-Help, pleaseWhy is it that in Mental health services that we are always tinkering with the serviceand problem solving there - and not in our personal life?We all look to services to improve things but we need to look at ourselves

Alcoholics Anonymous model for self careTaking one day at a timeThinking before you speak - respond, don't reactKeeping an open mindDrinking water, food , exerciseFood and moodTaking responsibilityInfo on how to help yourself Information on conditions to help individuals understand

50

Service user stories of complainingLong waiting time for service to be delivered, complaining made it happenSaying it not fit for purposeComplaint process worked - only because it was taken to the nth degreeMost people would not have the energy or the knowledge to take it that far.Was assertive, had done it before.

What do you need to feel safe and comfortable to talk?Absolute guarantee that nothing will be passed on to clinicians AT ALL - withoutdiscussing it with me first, and that I have a right to veto passing on anything whichdoesn't have to be passed on by law.

To trust processes, trust that I will be listened to, to have a separate andindependent mediation body that is impartialAdvocacySupporting people to tell their storyConcerns discussed with an independent person

What do NHS staff need to feel safe, and comfortable to respondopenly, positively, and kindly to grievances and concerns?Drugs and lobotomiesGood management , psychological independence rewarded.Support network of mixed patient and nursing staff - interface café.



51

Appendix 4

Copies of the Welsh Assembly Government’s leaflet “Complaints about the NHS

Treatment and Care – A guide to making a complaint about the NHS in Wales”, areavailable from www.wales.gov.uk/nhscomplaints

Current support for clients

Independent Mental Health Advocacy

Independent Mental Health Advocates support you to be heard. They help you tohave choices, and to ensure your rights are respected. They will work with you onday to day issues regarding getting access to the right services, having choicesabout who treats you, and supporting you in meetings. Advocates will help withcomplaints, if that is what you choose to do, but in many cases they may be able tohelp you resolve issues without having to make a formal complaint. It is useful tocopy letters to your advocate, both those you send and those you receive. Theadvocate will then have a complete file of the process you have been through, whichwill be very helpful if you ever go to the Ombudsman.

Community Health Council Patient Complaints Advocates

The CHC patients’ advocate is well-placed to offer and advice and support regardingNHS complaints. If you want to complain informally or anonymously about a staff member, the CHC will record details of your complaint on file. They will notundertake any further action without your consent, unless there are issues of safety

involved. If further informal/anonymous complaints are raised against the samemember of staff, the matter is then referred further within the CHC. This may lead tofurther action being taken.

With formal complaints, where you wish to receive an individual response from theNHS organisation concerned, full details must be available and you will have to giveyour written consent. The CHC advocate will guide you through the process, helpwith any correspondence, and provide structure and support to get the best result asefficiently as possible.

As with the independent advocate, the CHC Patients’ Complaints Advocate will bebetter able to help you if he or she has a complete set of all the letters or documents

you have relating to your complaint. It is not always essential to meet with theAdvocate. Sometimes complaint issues can be dealt with by telephone, email or

http://www.wales.gov.uk/nhscomplaints

http://www.wales.gov.uk/nhscomplaints



written correspondence. In more complex matters, a face to face appointment ispreferable. Where complaints cannot be resolved through a formal response fromthe LHB, a meeting may be needed. The advocate can accompany you to suchmeetings.

Where letters of meetings with the organisation involved have not managed toaddress your complaint to your satisfaction, the Patient Complaints Advocate canassist you with further stages of the NHS Complaints Procedure, namelyIndependent Review and Ombudsman.

52

Local NHS Complaints Departments

The complaints department at hospitals have a team, whose job it is to help you withyour complaint. The Complaints Officer assists with, and facilitates all aspects of complaints that are received from clients/patients, relatives, advocates, Community

Health Council, MP’s and AM’s. Complaints come in the form of letters, emails,people calling in the office and telephone calls and are classified as informal or formal complaints. Normally all written complaints are classified as formal, unlessthere is a clear request for an informal approach, and, if treated formally, areacknowledged within two days in writing. After investigation of the complaint, a fullwritten response is sent to the complainant signed by the Chief Executive of the LHBor hospital. The Welsh Assembly Government monitors how well LHBs or hospitalsstick to Assembly guidelines on the how to deal with complaints. (See more detail of guidelines in section 8)

In the case of informal concerns, which are usually received by telephone, the team

will attempt to resolve the issues as soon as possible. Sometimes , however, morecomplex concerns will have to be dealt with by the appropriate manager. In allcircumstances the complainants are kept informed by the complaints department of the steps that have been taken to resolve the issues raised.

Whenever a complaint is made on behalf of a patient it is necessary for the client togive their consent in writing before an investigation can take place.

Organisations involved in quality assurance for the NHSThe following organisations have a role in inspecting and reporting on the quality of

health services. Apart from the Community Health Councils, they do not have acomplaints resolution function per se, but they are all interested to hear aboutproblems with the service, and will bring information from such reports together topromote improvement and change.

Community Health Councils

You can find your local Community health Council in the local telephone directory, or through the Board of Community Health Councils in Wales.



Website : www.patienthelp.wales.nhs.uk

Email: [email protected]

Tel: 0845 644 7814Fax : 02920 235574

Address:- Board of Community Health Councils in Wales2nd Floor 33-35 Cathedral RoadCardiff CF11 9HB

53

Healthcare Inspectorate for Wales

The Inspectorate are pleased to hear about your experiences of the service. Theyare happy to have comments and suggestions, and will try to answer your questionsabout their role. They will use your comments, experiences and suggestions toinform their work to report on NHS service quality and promote improvement.

Website : www.hiw.org.uk

Email [email protected]

Tel: 02820 928850

60Address:- Healthcare Inspectorate for Wales

Bevan HouseCaerphilly Business ParkVan RoadCaerphillyCF83 3ED

Mental Health Act Commission

(This may be re-organised to come under HIW)Deals with the quality of service and experience of service users detained under theMental Health Act.

Website: www.mhac.org.uk/

Tel: 0115 943 7100Address:- Mental Health Act Commission

Maid Marian House56, Hounds gateNottinghamNG1 6GB

http://www.patienthelp.wales.nhs.uk/

mailto:[email protected]

http://www.hiw.org.uk/


http://www.mhac.org.uk/

http://www.patienthelp.wales.nhs.uk/


http://www.hiw.org.uk/


http://www.mhac.org.uk/



Care and Social Services Inspectorate for Wales

The inspectorate inspects social care services which are under license, such asresidential care, and child care. They are also responsible for inspecting socialservices run by local authorities.

Website : www.cssiw.org.uk

Email : [email protected]

Tel: 01443 848450Fax: 02920 823417

54Address:- Care and Social Services Inspectorate for Wales

Cathays ParkCardiff CF10 3NQ

Independent Complaints Secretariat

This is the first level or independent appeal, after the formal complaints processwithin the LHB.

All Wales Secretariat - Tel: 01495 332487

Mid and West Wales – Tel: 01874 712748/ Fax: 01874 712756South Wales - Tel: 02920 376840/ Fax : 02920 376826

North Wales – Tel: 01352 700227/ Fax: 01352 754649Addresses : Mid and West Wales South Wales North Wales

PO Box 2 PO Box 21 PO Box 125Brecon Cardiff MoldPowys CF10 2ZR CH7 1WHLD3 0XR

The Public Services Ombudsman for Wales

This is the last resort for complaints following the official public sector legalcomplaints pathway.

Website : www.ombudsman-wales.org.uk

Email : [email protected]

Tel: 0845 601 0987

Address:- Public Services Ombudsman for Wales1 Ffordd yr hen GaePencoedCF35 5LJ

Professional RegulatorsThese organisations keep a register of people who have the qualifications and

http://www.cssiw.org.uk/


http://www.ombudsman-wales.org.uk/


http://www.cssiw.org.uk/


http://www.ombudsman-wales.org.uk/




experience necessary to hold the professional title. They set the entry criteria, andstandards of training, and any requirements for professionals to maintain on-goingregistration, such as complying with a code of ethics, conduct or practice, andkeeping up to date through ongoing training and experience, or meetingperformance criteria. Anyone who is not on these lists is not legally entitled to

practice in that profession.

(NB the psychotherapists will be subject to registration with the HPC (HealthProfessions Council), from July 2009, but it will be a while before there are clear entry requirements and a code of conduct. Until then they can in addition,voluntarily belong to a professional body, which has entry standards and which willexpel people who do not comply with their ethical code. An example organisation isgiven here)

55

Professional regulators have a role in investigating issues of professional conduct(misbehaviour) and can apply sanctions if cases are proven. In serious cases theymay take someone off their list. If this happens that person will lose their job. If youfeel a professional you have seen is not fit to practice, you can get advice fromthese organisations. They will provide you with copies of their codes, and will oftengive advice over the phone regarding whether your complaint comes under their area of responsibility and how to make a complaint.

GMC - General Medical Council

This is the regulatory body for Doctors, including GPs and psychiatrists.

Website: www.gmc-uk.org/

Email: [email protected]: 02920 504060

Address:- General Medical Council in WalesRegus houseFalcon driveCardiff bayCF10 1RU

Doctor’s Fitness to Practise

Email; [email protected]

Tel: 0845 357 0022

Other General EnquiriesSwitchboard : 0845 357 8001

RCP - Royal College of Psychiatrists

Psychiatrists have to be registered with BOTH the GMC and the RCP, and have tofollow both sets of professional codes.

Website: www.rcpsych.ac.uk

http://www.gmc-uk.org/



http://www.rcpsych.ac.uk/

http://www.gmc-uk.org/



http://www.rcpsych.ac.uk/



Welsh division: www.rcpsych/college/division/welsh.aspEmail: [email protected]

Tel/fax : 02920 489006

Address:- Royal College of Psychiatrists, Welsh Division

Baltic HouseMount Stuart SquareCardiff CF10 5FH

National HeadquartersAddress:- 17 Belgrave Square

LondonSW1X 8PG

56

RCP (continued)Tel: 0207 235 2351Fax: 0207 245 1231

NMC - Nursing and Midwifery Council

This is the body that regulates nurses

Website: www.nmc-uk.org/

Address: Nursing and Midwifery Council23 Portland Place

LondonW1B 1PZ

General Enquiries- Tel: 0207 637 71810207 436 2924

Fitness to Practice- Tel: 0207 462 5801/5811

Care Council for Wales

This is the regulatory body for Social Workers, and for other social careworkers.

Website: www.ccwales.org.uk/


Tel: 02920 226257Minicom: 02920 780680Fax: 02920 384764Address:- Care Council for Wales

Southgate HouseWood StreetCardiff

CF10 1EW

http://www.rcpsych/college/division/welsh.asp


http://www.nmc-uk.org/

http://www.ccwales.org.uk/


http://www.rcpsych/college/division/welsh.asp


http://www.nmc-uk.org/

http://www.ccwales.org.uk/




Investigations team Tel: 0845 0700 248Fax: 02920 780 661


Or write to the Investigations Team at the address above.

HPC - Health Professions Council

This organisations registers a number of professionals including OccupationalTherapists, and physiotherapists. It may also be taking on the compulsoryregistration of psychotherapists in the near future.

Website: www.hpc-uk.org/

Tel: 0845 3004 4720207 840 9802

57Fax: 0207 840 9801Address:- Park House

184 Kennington Park RoadLondonSE11 4BU

BSP - British Psychological Society

This is the regulatory body for psychologists

Website: www.bps.org.uk


Tel: 0116 254 9568Fax: 0116 227 1314

For complaints :- Regulatory Affairs teamEmail: [email protected]: 0116 254 9568

BACP - British Association of Counselling and Psychotherapy

This is a professional body for psychotherapists and counsellors. It will investigatecomplaints about its members, where they have breached the organisation’s code of ethics. However not all psychotherapists belong to this organisation. Membership isnot compulsory. Being a member does provide you with some reassurance that your therapist is ethical and qualified. If you seek private psychotherapy, you can get alist of local practitioners in your area from this organisation. You will need to checkthat your psychotherapist is on their lists before you go any further with anycomplaint. You can also complain about a psychotherapist who has been on their list but is not on it any more.

Website: www.bacp.co.uk/

General Enquiries Tel: 01455 883300


http://www.hpc-uk.org/

http://www.bps.org.uk/



http://www.bacp.co.uk/


http://www.hpc-uk.org/

http://www.bps.org.uk/



http://www.bacp.co.uk/





respect to their notes and any letters they send

• It can be useful for some service users and carers to have a leaflet, others

would be unable to read one because their distress or agitation makes itimpossible for them to concentrate

• Telephone calls are potentially a source of distress. If a member of staff

refuses to speak to a service user on the phone, the service user is likely toread more negativity into that than is intended. On the other hand staff needto be very careful on the phone to be aware of how the service user may feelabout what they say, and how they are saying it. If there is any need tochallenge the service user, it may be best to arrange a meeting. However,reassurance and help are very valuable over the phone

Care Planning• The care plan approach in mental health is intended to deliver an agreement

of a care plan together with all the agencies, the service user and the carer

59

• However the care plan does not have to be ‘signed off’ by the service user,

and therefore can contain elements which are contrary to the client’s wishes,and with which they may not comply

• The care plan approach is meant to ensure that the service user is always

involved in decisions about their care, but because the team often makedecisions in the absence of the service user, this frequently does not happen

• Because decisions are made in a team, service users and carers may have

no opportunity to challenge the views of individual staff, or to have anyinfluence over that decision. “It was a team decision” can be used as anabdication of responsibility when a service user is unhappy with a decision

• The approach is based on having a ‘care coordinator’ who in principle is

supposed to advocate for the client’s needs for services within the team, butwho in practice can become the team’s deliverer of bad tidings, and a gate-keeper, rather than a gateway, to care.

• The approach requires the assignment of a ‘CPA level’, either ‘standard’, or

‘enhanced’. The Assembly give clear guidelines on the criteria for theselevels, but the actual application can be inconsistent with these criteria, andbetween service users

• The care plan approach is intended to ensure continuity of care and smooth

transitions from one part of a service to another. However, whilst thereshould be a care package in place BEFORE someone is discharged fromhospital or from the crisis and home treatment team, often there is not.

Balance of Power

• There is a real imbalance of power between the service user and the NHS,

which is exacerbated in the complaints process

• Withholding of information such as a diagnosis, can be perceived by the

service user as oppressive. Knowledge is power. Not having knowledgeexcludes service users from involvement in their care

• In mental health the consultant has to be asked before medical records canbe released to the service user. Many people will not ask for records because







therefore unpredictable, than to admit, even on a voluntary basis, someonewho is at very high risk of suicide. The experience of hospitalisation becomescontrary. It feels like, whichever option the client would prefer is the veryopposite to that which is enforced.

• Crisis Intervention and Home Treatment teams, feel like they are target

driven, based on keeping people out of hospital, even when they would besafer in it.

• Depending on the diagnosis, 10-20% of mental health patients die by suicide.

The service therefore needs to be especially sensitive, to provide for safety atany time of transition or when a decision, such as an assessmentrecommendation, a diagnosis, or a complaint report is made.

• Suicides happen as a result of the way the service treats its clients. Any

advocate will be able to provide stories of when this has happened. Suicidescan also happen as a result of the way complaints are managed

62

• Many people self-harm when they are distressed. Self-harm in adults is not

taken seriously at present, and very little is done to prevent it, or to supportpeople after they have harmed themselves. This again means mental healthservice users are more at risk if a complaint process is excessively drawn out,if something goes wrong with it, or if they are unhappy with the outcome.



63

Appendix 6

Policy Context

Document summaries

“One Wales”This is a description of the 2007 National Assembly Government’s workcommitments for their term of office.

We will:-

“place a new priority on providing for mental health”

“draw up a charter of Patients’ Rights and legislation on NHS redress”

“deliver…. Improving patients’ experience”

“reform LHBs to improve accountability both to local communities and to theassembly government.”

We note:

“ a positive experience of care speeds recovery”

For a fair and just society the Assembly is:

“unswerving in its adherence to the principles of inclusion, pluralism and fairness”

“Protects vulnerable individuals or groups from suffering harm or and discrimination”

“People, Places, Futures – The Wales Spatial Plan – Nov 2005”

This is a document which describes how Wales can achieve National and Regional

prioritiesIt aims include to:



4) “Address health inequalities”5) “Achieving sustainable accessibility”

Designed for Life

Aims to :

• Focus on health and well-being, not illness

• Get supply and demand into balance

It has three design principles, which include:

• User-centred services;

• Targeted continuous improvement

64

Making the Connections

Describes a vision to:

“…ensure services are more citizen-focused, responsive…, driven by a commitmentto equality, (and) social justice…”

It has 4 principles which include:

“Citizens at the centre: services more responsive to users…”

Beyond Boundaries – Citizen–centred local services for Wales.

(Beecham – 2006)This document gives a lot of information about the issues and problems whichcurrently exist in public services. This includes comments about

• why it is difficult for services to improve,

• what is needed to improve services

It concludes that “ Transformation to deliver for citizens depends on…

citizen engagement which:

• Requires a relationship of trust between service users and providers

• Information to underpin trust and confidence

“….continuous dialogue with well-informed citizens…” challenge through:

• “.should include simple and speedy processes for complaint and redress”

• “Organisations must be mature enough to apologize when things go wrong,

put things right and provide suitable redress”

• “must create a culture that ..does not tolerate substandard performance or

mediocrity.”

• “blame cultures need to be challenged, and learning and innovation

encouraged”

•“The approach to performance and satisfaction information needs to be lessdefensive”



It then makes recommendations which include:-

1. “Citizens receive speedy and appropriate redress”2. “Citizen’s voice is heard and listened to….”3. “Citizen’s …..see that organisations are being held vigorously to account by

their representatives.”4. “Systems of complaint and redress are simple, accessible,”5. “establishing clear lines of accountability for performance”6. “research on patient satisfaction, drawing on the expertise of CHCs and other

advocates.”

65

Making the Connections – Delivering Beyond Boundaries (Nov2006)

This documents follows up from the last one by describing the actions the Assemblywill take to realise its vision.

It says:-

“The..report Beyond Boundaries …demonstrated that we need to drive through thechanges faster and more rigorously. It showed that we are on secure ground inconcentrating on behaviour and cultures….It called for public services to be muchmore ambitious and innovative, making a step change in how they engage withcitizens…..”

Making the Connections – Building Better Customer Service

This document describes the commitment of the Assembly to improve users’experience of public services. It describes five core principles, which are:-

• Access- : “Citizens will be able to find and access information and advice

about services……and get a timely

• response with information and advice they are able to understand.”

• Personal Experience- : “Citizens will be dealt with politely, shown care and

dignity, have options explained openly and constructively, and be keptinformed of progress…”

• Responsiveness - : “Citizens will be offered services that take into account

their needs, circumstances and any barriers they might face.”

• Language Options- : “Citizens who prefer to access and use services in

English or Welsh, or need to use minority ethnic languages or British SignLanguage will be able to do so.”

• Redress- : “Citizens will find it easy to complain and get things put right when

the service they receive is not good enough.”

The Assembly are also working on a statement about ‘public engagement’ and

another on ‘access transformation’. The latter will look at improving access toservices through the use of technology.



It says about complaints:-

“Research..has identified that citizens want to be able to complain if they are notsatisfied with public services, and they want to do so in a way that results in anyproblem being put right quickly. They do not want to resort to a formal complaintsprocedure as the only option.”

“Routine complaints should be dealt with quickly and with a minimum of formality for the service user.”

“A good service is one where citizens:

• …will be listened to and responded to promptly, effectively, fairly and

objectively and be kept informed of progress. Their expression of dissatisfaction will be recognised as a complaint

“…a good service will need to ensure that:

66

• complaints are seen as an opportunity to learn and improve the service for all

users; and

• training and support is provided to staff so that they understand how they

should respond to complaints.”

Fulfilled Lives, Supportive Communities: A Strategy for SocialServices in Wales over the next decade

This gives principles for better services in Wales, including:-

• Getting straight through to the service you need whatever your starting point

• Much greater say in how services are provided to you

• More reliable protection of vulnerable people

• Services that help you to lead as full a life as possible

• Clear, simple systems of complaint and redress

Adult Mental Health Services for Wales – Equity, Empowerment,Effectiveness, Efficiency (Sept 2001)

This is a 10 year strategy for mental health in Wales. The aims and objectives

clearly reflect the comments made on the consultation day, and the kind of problemsand complaints which are most frequently raised.

“The strategy sets out the principles on which services must base a high quality ,empowering, person-centred and responsive approach. This is a service in whichpeople have choices, and are supported in those choices.”

“Four principles underpin the whole Strategy…..

Equity

Mental health services should be available to all allocated according to individualneed



Empowerment

Users and their carers need to be integrally involved at all levels,.. Informed choicefor all users is central to this principle… Those detained under the Mental Health Actshould be encouraged to participate actively and willingly in their own care…

EffectivenessMental health services should provide effective interventions that improve quality of life by treating symptoms and their causes, preventing deterioration, reducingpotential harm and assisting rehabilitation. …. Service providers must beaccountable for the quality of services.

Efficiency

….There should be interagency working especially between health and socialservices, other parts of local Government, voluntary agencies and the private sector ….

67

In it’s aims and objectives the document describes many aspirations that wouldprevent complaints if properly applied.

These include:

• “to protect services users and the public from avoidable harm, while

respecting the rights of users and their carers.

• “Discharge plans must ensure that all users are provided with suitable support

and follow-up after in-patient admission.”

• “Advocacy seeks to address ….imbalance by ensuring that their voice is

heard, their choice is real and their rights are safeguarded”• “The rules of record keeping should follow the guidelines relating to individual

professional practice”

• “..regular supervision and professional support provided within a constructive

problem solving environment rather than pursuing a culture of blame”

The National Service Framework for Mental Health

Standard 6 – states that “mental health services should be responsive, effective andoffer high quality, evidence based care in an environment and atmosphere thatpromotes dignity, privacy and support”

Stronger in Partnership 2

This document gives guidance on how to improve service user involvement in mentalhealth, and underpins service user hopes for how they contribute to their own care.Failure to deliver on these principles often leads to complaints.

The following are some of the things it says.

“..it is the people who use the services who are the experts on how they feel andwhat the aims and ambitions for treatment and care should be…”

“…service providers are responsible for acting on advice from service users and

providing explicit feedback on action taken.”“Empowering service users and carers involves professionals relinquishing a degree



of their own power and enabling service users and carers to have a greater choiceand control over their lives.”

“The Care Programme Approach (CPA) is a co-ordinated system of caremanagement that focuses on the needs of the individual where service users and,where appropriate, carers are fully involved in the formulation of the service users’own individual care plan. These should be formally agreed and signed by theservice user and appropriate health care professional and copies given to theservice user and with their agreement to any carer”

(italics from document editor)

Documents

Eiriol Putting Things Right Report July 09