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Royal Surrey County Hospital Good

All reports

Inspection report

Date of Inspection: 16 August 2012
Date of Publication: 4 September 2012
Inspection Report published 4 September 2012 PDF

People should have their complaints listened to and acted on properly (outcome 17)

Meeting this standard

We checked that people who use this service

  • Are sure that their comments and complaints are listened to and acted on effectively.
  • Know that they will not be discriminated against for making a complaint.

How this check was done

Our judgement

There was an effective complaints system available. Comments and complaints people made were responded to appropriately.

The provider was meeting this standard.

User experience

When we spoke to in-patients we asked them if they would know how to make a complaint and if they had seen any information about this. Around half of the people who answered this question said they would not know how to make a formal complaint, but most people suggested they might approach ward staff, go on the internet, or contact PALS. Few people had seen information displayed, but several said that they had not looked for it, as they had no complaints.

On the Outpatients’ self completion questionnaires we also asked if people knew how to make a complaint. A total of 34 people said they did not know how to make a complaint, though the majority of those who said they did not know, noted that they would find out, or speak to a member of staff. Several people added comments to suggest they had no complaints.

Other evidence

During our visit we asked for a meeting with the complaints manager to get an overview of the complaints arrangements. A meeting was subsequently arranged with the complaints manager, and the communications manager. They gave us an overview of the comments and complaints arrangements.

The trust’s policy on complaints was currently being updated. It reflected NHS guidance and Regulations. A copy of the Complaints and Concerns Resolution Policy was provided.

We were told that the trust’s focus was on resolution of complaints at the front line and that formal investigation was the last resort. The trust hoped that most issues could be resolved informally by local managers and getting PALs involved at an early stage. The trust provided a document which gave staff advice about listening and responding to complaints and using PALs. Mandatory training included actively listening to patients and relatives for example. We noted during our two day visit that there was complaints information displayed in ward areas, in the main reception, in outpatients, and in corridors.

We were told that if a formal complaint was made then it would be acknowledged within three working days. All complaints were reviewed by the Director of Nursing before being sent to the appropriate manager for investigation. The investigating officer had to provide a report covering all areas of the complaint within 15 days. If there was more than one investigating officer then the complaints manager would pull a report together from the information provided.

CQC has received a number of complaints directly from members of the public over the last 12 months. Whilst we do not investigate individual complaints, we do follow up on most of these with the trust to find out how they have handled the complaint, and the outcome. On every occasion the trust responded to CQC in a timely way, and ensured that we were kept up-dated until an outcome had been reached. This was also the case with two issues highlighted to us during our visit to the hospital. Information was passed to us that required further investigation, and the trust immediately identified members of staff to take these matters forward. We had received an update on these before the draft report was sent out.

We asked the trust how they monitored trends in complaints. We were told that trends were considered by the Complaints Monitoring Group which met quarterly. Papers from the last meeting on 25 July 2012 were provided; these showed that at the previous meeting on 18 April 2012 trends were discussed, and actions had been proposed to address concerns. For the July meeting, papers outlined the numbers of complaints received across specialities for the first quarter of 2012/13. Papers to the meeting also suggested that appointments, communications and treatment were the most frequent complaint areas.

We asked what the trust had learned or changed as a result of the most recent complaints. The trust submitted a report which detailed changes in practice and improvements following complaint investigation. The report covered complaints received since November 2011 and listed 11 where improvements have been made. These covered areas such as additional staff training, improved communication, revision to documentation and changes to process. The trust highlighted two improvement actions in particular. One related to dealing with people with learning disabilities and the other was about improving the availability of a specialist type of scan out of hours.

The trust informed us, and we later saw this on the wards, that they had a system that informed patients and visitors about ‘patient experience.’ Every three months ward sisters were required to complete an update on patient experience and display it within the ward. The update gave details about issues that had been raised by patients and what ward staff had done to address these issues. It also listed positive comments made. There was a link to the