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Inspection report

Date of Inspection: 11 January 2011
Date of Publication: 9 February 2011
Inspection Report published 9 February 2011 PDF

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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

We found evidence that comments and complaints were listened to and acted on effectively. No gaps in assurance or areas of concern were identified during the assessment of this outcome for this location.

User experience

We asked patients on the site visit if they knew how to raise a complaint. All were aware and one had made a complaint who felt action had been taken to address the issues raised.

Other evidence

The provider declared compliance with this outcome at this location at registration with CQC in April 2010. Our provider level QRP for this outcome contained positive information. None of the external stakeholders referred to within outcome one who responded raised any areas of concern specifically relating to this location or outcome.

As part of the assessment of this location the provider submitted a provider compliance assessment which explained in detail against individual prompts how the outcomes were being met. The self assessment explained the policies, systems and processes that have been used to handle complaints and that it “sees complaints as an opportunity to improve and make things better”. We found the Complaints procedure to contain a locally agreed protocol for handling inter-agency complaints across the city of Sheffield along with a range of additional templates and tools. Quarterly and annual complaints reports have been produced and the provider explained these are available on request from the complaints and litigation manager.

People who use services have been able to make their concerns known verbally, electronically via the website, or in writing. A ‘Fastrack’ system has been made available to allow people who use services or carers to raise a concern, comment or compliment at any location with staff support if required. Additionally people who use services have been able to access a range of advocacy services, for example, the mental health advocacy services to raise any concerns they may have.

The provider offered additional evidence which was the Complaints and Complements Quarterly Report for the period 1 July to 30 September 2010. The report was a detailed and informative document containing a number of direct quotes regarding complements received from people who used services. The report also contained service specific sections outlining issues raised in formal complaints along with the outcome and recommendations for each one. A number of action plans were also included demonstrating that the provider listens to and actions improvements arising out of complaints.

Additional evidence was sought from the provider in the form of an annual team governance report for Rowan ward covering the period April 2009 to March 2010. The report included sections on complaints and compliments covering all acute wards. The numbers of formal complaints ranged from none to well below 10 and verbal complaints averaging between 10 and 20 for each ward area showing the numbers of complaints received was low during the period of the report.