Eiriol Putting Things Right Report July 09

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Putting Things Right A consultation on how to change complaints and compliments procedures in mental health CONTENTS 1. Easy Read Summary 2. Background to this document 3. The mental health context – service user experience 4. The Government Policy context 5. Recommendations to the Putting Things Right Project.

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5.1 Improvement to the compliments and complaints process

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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a better service 21 7) How could this be delivered in practice? 26 8) Being heard – Getting a better service - Draft guidance for service users, carers and their families on putting things right, when the need arises 27 Appendices 1. Consultation Questions 39 2. Who attended the workshop day 40 3. Comments from the consultation day under headings 41 4. Current support for clients, and useful contacts 51 5. The Mental Health Context – service user experience 58 6. 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’ when things go right in the health service and how to put things right when they go wrong. The people thought about what was different and special about mental health, so that they could give ideas about what needs to be different about how things are put right. There was time for everybody to put forward their ideas. This booklet is about 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 friends with the staff. This part explains what happens to mental health service users, how people decide what to do, and how difficult it can be for service users to feel that what they say will make any difference to their life. The paper talks about the extra danger mental health service users face from wanting to hurt or kill themselves. Staff, who work with service users 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 say they 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 to spend time and money on and they want to make us feel better about the care we get. 3

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 users to feel that someone is listening to them. How to help service users feel that 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 is unhappy with their care. They must explain that staff who don’t need to know, will not be told about their worries about their care, and that bad things will not happen to their care, because they have told someone that 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, and without fuss. It says that people need to know where to find help. The service user needs a bigger say in what happens after they tell someone that something has gone wrong. Things need to be done very fast for people who may harm themselves or commit suicide if their problem is not solved quickly. It says that service users need people to talk to them before, during and after a problem 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 is more difficult to solve problems when more than one service is involved, like the police and the health service. The health service is asked to find ways 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 working with people, so that someone else can later decide if they have done things the best way. 4

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 be for 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 solved fairly, 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 help improve 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 how they can help to put things right. When people hurt themselves, or kill themselves, someone must find out if staff did anything which played a part in the person feeling hopeless or distressed, or if they could have done more to help. The health service must be happy to let people see what they do with complaints, and they must always try to do better. It must be easy to see how service users’ comments make the service better.

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 communication 2. Treat people fairly 3. Help people make as many of their own choices in life as possible 4. Try new things, and do things differently to suit each person, as they get better 5. Work together to keep safe 6. 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 might make 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 the NHS. 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 it is not. This part is based on the stories of other service users and carers. It tells you what you need to think about when you complain. It warns 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 how things really are. What might help, and what could go wrong. It should help you to decide what you want to do.

2) Background

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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 might be improved. These recommendations aim to address the specific issues raised by participants at that time, and subsequently in informal discussion. The comments and suggestions of the group are given in appendix 3. At the time of writing, Local Health Boards (LHBs) are joining up with Trusts so references to LHBs throughout this document, relate to the new joint organisations. The following recommendations are a possible response to these comments. They are draft only. All your comments will be welcome. Please pass on your comments to Penny Gripper, Eiriol, 59 King St, 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 health service is one where the risks to the individual service user, and sometimes to the community are potentially devastating and far reaching. The following key issues affect 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 arranged instead.

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 • • • • •

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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 taken seriously, or in extreme cases, can lead to being sectioned under the Mental Health Act. Decisions taken without talking to the client feel oppressive We need to be allowed to make mistakes

3.5 Collaboration and relationships • • • •

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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 any need to change the way they do things. This avoidance is not a good role model. 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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8 Staff are discouraged from reporting unmet needs because it places an obligation on the LHB. The most common cause of needs not being met is insufficient 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 clients o 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 Context The Welsh Assembly Government has demonstrated its commitment to improving the experience of people who use the services it provides, such as the NHS. Many policy documents talk of putting the ‘citizen at the centre’. The Assembly have also pledged to make mental health a priority and have promised additional funding to demonstrate that. Policy seeks to involve service users more in decisions about their treatment and their lives. Users should have access to services according to need, which prevent deterioration, treat symptoms and their causes, reduce potential harm, and assist rehabilitation. Service users and the public should be protected, there must be support 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 to get supply and demand into balance. Beecham in ‘Beyond Boundaries’ wants organisations to be ‘mature enough to apologise when things go wrong, move away from a blame culture, and to be intolerant of substandard work’. Further details on the gist of policies, with quotes from documents are given in Appendix 6.

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5) Recommendations to the ‘Putting Things Right Project’ 5.1 Improvement to the compliments and complaints process 5.1 a) Starting right •

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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 seems happy 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’s contact 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 service provider must carry the burden of proof that such relationships have not in any way compromised the quality of service offered to the individual. This can ONLY be proven if assessors, staff and investigators have adequate distance from the team concerned.

5.1 d) Recognition of achievement •

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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 is particularly 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 point of contact.

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5.1 e) Problem solving and grievance protocols 5.1 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 to this 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 resolution process 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 • • • • •

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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 involved in 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 to reflect 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 opinion from an appropriate professional, who is independent of the team involved in the client’s care before being asked, and involve that professional in the investigation 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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12 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 to be 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 • • •

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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 not mean 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 the records and or memories of service users and/or their advocates, support workers, or carers. A failure to be impartial is likely to cause a complaint to be 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 the investigator face to face, even when the problem appears to be straight forward. (“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. The meeting felt strongly, both staff AND service users, that an independent mediation 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 investigators to hear their response to the LHB’s/staff’s position. The best way to do this is to 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 that such symptoms are increased as a result of distress. The service user’s pain must be addressed. It is too easy in mental health to dismiss problems as ‘not our 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 any complaint

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13 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, and vulnerable 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 discussion between 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 any investigation, and be given equal weight to witness evidence from within the NHS 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 to staff 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 the complaint, in giving consent for access to records.

5.1 e) vii) The response • • •

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The quality of the NHS’s response to problems and grievances is critical. The link between complaints and service improvement must be transparent and consistent. 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 following o 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 incident o 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 required will be to pass on the issue to the appropriate body, and politicians. There needs to be a prioritising process to determine a proportionate response to actions identified through complaints. Issues which

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14 frequently 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 include consideration 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 by being refused something they do want o Possibility of suicide in response to a failure to address service user beliefs about their hope of survival o Damage to the client’s relationship with the team where a confrontational approach is adopted o 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 comfort zone. 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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15 The NHS needs to coordinate with professional bodies to give their members guidance on how to challenge existing norms, and to support them to innovate safely, whilst keeping their members from encroaching on the roles of 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 a request 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 meeting regulatory 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 the evidence required by the team to underpin and justify their response. This must :o Include evidence from an independent second opinion from a member of the profession concerned o Withstand scientific and legal challenge o If the decision is based on a lack of resources, it must be supported by a 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’s alternative to the profession requested, to underpin this extension to their normal professional role.

When refusing a service or innovation is at least as difficult as registering an unmet need, or offering the service, the aspiration for significant culture change to 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 clients from unqualified and unsafe practice. It is critical that generic working does not extend to professional roles, until a mechanism is in place to regulate such activities. These recommendations are made to address the comments made under ‘culture and 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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16 The meeting discussed the need for ‘Patient Support Officers’ to act as internal LHB advocates for service users with more minor concerns. This would increase the chances of getting a result through influence within the team If, a client is not enjoying the protections promised by complaints policies and guidance, there must be rapid intervention by an independent body or person to 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 the LHB. An independent facilitator would be more credible if they also had a compliance role to ensure that the LHB complies with any regulations or guidance on the complaints process.

5.1 h) Appeals • • •

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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 essential that it remains Because of the complexity of complaints and the difficulty clients with mental health problems can have in communicating their thoughts and feelings, an inflexible requirement for a written process only, excludes people. In order to make the process fully accessible to people with disabilities, there must be a procedure in place to enable complaints to be submitted verbally, where necessary The clinical reviewer has to identify whether the explanation given to the complainant is ‘adequate’. This cannot be done without speaking to the complainant, because the adequacy of an explanation depends upon the needs of the client, on their level of understanding and ability. It depends ultimately on whether the complainant felt it was adequate. The scope of the independent complaints process needs to be extended to include assessments of case management and the quality of clinical decisions, to identify clinical error, and poor or dangerous clinical practice. The clinical reviewer must be in a position to measure the performance of the clinicians involved against national standards, eg against the National Assembly’s CPA guidance, its National Service Framework for mental health, and against National Occupational Standards for the professional groups concerned 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, there must be a robust response to bad behaviour, or poor or dangerous practice by individuals or teams.

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Whilst there is a fine line between positive individual and team accountability and the need to avoid the maintenance of a ‘blame culture’, serious problems will not be picked up early enough to save lives or prevent serious harm unless the detail of who has done what and why, is addressed, and remedial action taken 17 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 is reported to another organisation, specifically to help them to improve their performance. They need to know where action has been taken to address the way a particular team is working, where training or additional supervision has been provided, as well as the organisational and management responses to increase patient safety The quality of the independent complaints review process needs to be improved. Guidance to reviewers, including clinical reviewers, needs to include an ethical code regarding impartiality, and the need to declare any conflicts of interest. It is wrong to assume that staff records will be more accurate than patient and witness recollections. Such preferences leave complainants feeling that the process is still biased against them, and therefore 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’. A meeting 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 address misunderstanding, misinterpretations or misinformation The current practice of sending out clinical review reports from the Independent Complaints Secretariat to the LHB, without first checking them for 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 give them 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 and second opinion. For transparency, their names must be on the reports, just as 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 and case 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 the Secretariat, to the LHB, to improve the future accuracy of records. This may include asking them to agree with a client what should be recorded at the time of contact Agreement to care plans or records can only be evidenced by a client signature

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The LHB should be asked to copy all documents or correspondence sent to the Complaints secretariat/Ombudsman to the client, at the same time they post it to the Secretariat or Ombudsman. The LHB must be accountable for the accuracy of any claims they make to the Secretariat 18

5.1 i) Training and Development •

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Staff need to be trained in procedures for resolving problems and dealing with grievances, and ‘supported/supervised’ with the process, to ensure quality is consistent and meets minimum standards for client support, safety and links to 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 individual level. 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 and moving, and first aid. Application of these standards needs to be monitored through staff appraisals to ensure that everyone is familiar with policy and procedures, and can demonstrate that they are applying them.

5.1 j) Investigations of serious incidents •

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All suicides and attempted suicides of people who have had any contact with the LHB, whether on-going or not, should be investigated to establish whether the LHB either had a causal role in them, or could have done anything 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, to impose treatment in such circumstances, is often seen by the bereaved as neglect, 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 potentially suicidal clients looked at risk factors or if it sought evidence of indicative behaviours from people in contact with the client.

5.1 k) Evaluation of the process of resolving problems and grievances and NHS accountability •

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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 the responses 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 into emerging collaborative structures for inspection and continuous improvement of standards.

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5.1 l) Taking complaints to independent appeal or to the Ombudsman 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. There needs to be an avenue through which to raise issues of poor case management , 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 to have the opportunity to see what the LHB is saying to the Ombudsman, so they 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, the time required to appeal against an inaccurate report, and identify the misleading or inaccurate source material is also very time consuming. Possibly more so. But most importantly for mental health service users receiving an inaccurate report is extremely distressing, and makes the problem worse, not better. Having to check information to refute an inaccurate report is very stressful. It is recommended that a pilot be run, to see if up front investment in checking the accuracy and completeness of information with the complainant, before report writing, does or does not save time and distress. In addition, that pilot should monitor how many people want to see source material first, or just be allowed to comment and make alterations to the report after it is written. This would give a full picture of the resource need. 5 It would be helpful to have a mental health liaison officer at the Ombudsman’s office to speak on the phone to, or meet complainants. This would make the process 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, and processes of the Ombudsman’s office, its accountability frameworks, its service quality, its transparency, its customer service ethic, and whether the legislation which governs which cases it takes on is adequate for today’s services, and provides a sufficiently comprehensive and fair appeals process, especially for those in mental health, whose access to service may be imposed rather than chosen. 7 Because the Ombudsman’s work is defined by law, it is not a flexible enough process, 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 that fewer 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’t have to. This does not feel like an accountable service. The recommendations of these bodies need to have legal weight, to be enforceable 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. 20

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 and complainants 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, and stress is a trigger to worse symptoms and sometimes life threatening. There is a need for more information to be given to complainants about how the individual clinicians in their care, who have been involved in a problem will change 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 complaints happening in the first place. It is recommended that work with people with mental health problems is underpinned by the following key principles of mental health care delivery, 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’s preferred language, and in different formats, to meet the client’s individual 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 in which the law requires information to be passed on, and the circumstances in which 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 fairly The client is treated fairly, with respect, and with dignity

6.2.2 What this means •

• • • • • •

Staff have access to guidance on equality and diversity, and regular training and support to understand and respond to the particular needs of service users 22 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 way they 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 the presence 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 line staff 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 is maximised 6.3.2 What this means • •

•

•

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 to take 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 out of 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 individual needs 6.4.2 What this means • • • •

• •

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 be negotiated. As in physical medicine, palliative care, and/or conservative treatment are always options which must be offered. The team must also consider the need for innovation in individual cases. Just because a client may not choose the mainstream option, it does not mean that they cannot be helped, 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 with the client to minimise and/or tolerate it.

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6.5.2 What this means • • • • •

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 as possible 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

6.5.3 Key outcomes of Principle 5 • • •

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, and consistently applied policies and procedures, whilst ensuring staff compliance through continuous evaluation processes 6.6.2 What this means • • •

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’s relationship 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 remedial action.

6.6.3 Key outcomes of Principle 6 • •

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 improvement The standards of service are continuously improving, through recognising, celebrating and sharing good practice, through learning from mistakes, and through making advances gained through innovation more widely available across Wales 6.7.2 What this means • • • • •

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 delivery are made below, not to prescribe solutions, but to illustrate how the principles might be practically applied. The following actions could help set up good communication and a good service experience 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 how referrals are handled. They ensure that the GP can and does give a clear verbal explanation 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 any information collected by professional staff. (Including an explanation of what the LHB means by the word ‘confidential’.) 7.1.3 Suggestion:- The assessor records the service user’s experience in their own words, 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 have less 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 to be 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 in their 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 how to get their comments heard, and action taken, when the need arises in the mental health services

8.1 Introduction The purpose of this document is to help you to get your problems solved. It will give you ideas based on the experience of other people, of what you need to do. It will warn you about possible difficulties you may face, and will give you ideas about how to try to avoid these problems. It will tell you about things that have been promised by the Welsh Assembly to help you, and what you can do if these promises are not kept. 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 is being 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 quality assurance for the NHS. If you telephone the switchboard of your LHB and ask to be put in through to the complaints 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. They will not tell anyone in the team that you have contacted them, when you are just asking for information. They will provide you with leaflets giving information from the National 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 LHB website. You may find the LHB Complaints guidance and contact information there. If you are not comfortable about speaking to someone from the LHB, your local independent mental health advocate (see finding help) may be able to explain how

things work. People from MIND, Hafal, or providers of ‘floating support’, may be able 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.

28 There may be notices up in the waiting area, where you go to meet your care coordinator, 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 can see 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’t pass your information on to anyone outside of the health service. If you don’t want the 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 health service, who would need your permission to pass any of your information to anyone outside their organisation. Be aware that letters get passed around and copied to different members of staff as a matter of course in the mental health service. Don’t say 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 are probably 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 to somebody else.

8.6 Who to go to If you go straight to another member of your care team, your care-coordinator or a local manager, they may be able to solve your problem. However, sometimes they will treat your complaint as a symptom, and may even refuse to look into it for that reason. You are most likely to get a serious response if you go through the local NHS complaints 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 unhappy with the information you get from the complaints department, you can still look for an informal response yourself. A member of management may be in a position to help solve 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.

29 It may be possible to speak to a manager directly on the phone. This is nice and informal, and may help, but if you don’t get the result you want, you will not be able to prove that your conversation took place. A phone call backed up by a letter will provide the evidence you need. Sometimes the manager will not speak to you, and may tell you through his or her secretary, that you should take your 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 a service user who wishes to raise a problem. If you are unhappy with being told to go to your care coordinator with complaints, tell the complaints department, and suggest the name of someone who would be acceptable, or, if you don’t have anyone particular in mind, just ask them to suggest someone else, maybe someone who 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, can be put on your clinical files, unless you specifically say that you are making a complaint. Even if you want to solve the problem informally you may decide you don’t want the issue raised on your records for anyone in the team to see. Sometimes you have to be VERY firm that what you are saying or writing is a complaint, and that it mustn’t go on your records. If you write to anyone about your problem, you are advised to write “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 that you 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 you are making a complaint, in order to get the safeguards that the complaints process provides.

8.8 Informal Problem solving You are entitled to an informal, local problem solving process. You do not have to go straight into a formal written complaint. If you feel best describing the problem in writing, then after stating that the letter is a complaint, as discussed above, then state 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 you can 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 from the complaints department. The benefit of a face to face meeting is that you can quickly see if someone does not understand you. You have a chance to respond to them, to put them right, or to explain if you are unhappy about a suggested solution. The whole thing can be resolved much more quickly with an early face to face meeting.

30 The problem with a letter, is that it has to be very brief, even if the problem is complicated, and because it is brief it can be misinterpreted. If not marked as a complaint, 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 mark the letter as a complaint, staff may decide that some parts of the letter are a complaint, and other parts are not, and then circulate it anyway. A letter invites, by implication, a response in kind. If you want a conversation about your problems, it is best to state only that you have a problem, and want a meeting with the staff member/manager as soon as possible to 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, because then the staff cannot convince themselves that they understand and can deal with the problem in writing only. There may be a problem that the staff member you are meeting may be very difficult to understand. You may feel intimidated by their questions, and be unable to respond ‘on the spot’. It helps if you can take notes with you about what is most important to you, but you may find you cannot take a full part in the conversation and look at your notes. An advocate, either independent or from the Community Health Council, can help you to put your views across at a meeting. In the end, if a meeting is only a partial success, you can still follow up with a letter. However, a meeting 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 the spot 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 a meeting can be, from your memory. Notes taken rarely reflect emphasis, and the interpretation of the note taker of the events, can be re-interpreted again when converting 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 say yes. 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 possible to solve your problem without them. But, if you choose to be low key, you must accept that you may be disappointed, your problem may take longer to solve, and it may 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 to fill in, or you may need to send a letter to the Chief executive of the LHB.

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8.13 A formal Complaint At 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 and reasonable. 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 be misinterpreted. 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 a meeting, 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 is kept, the Community Health Council Patient Complaints Advocates are very well placed 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 an administrator is only part time). From acknowledgement of receipt, you should have a response (according to 2008 rules) 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 be involved 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 complaint 2) Your treatment, or referral for treatment, must not be deferred until after the complaint has been investigated 3) You should not be discharged because of a complaint

32 4) and you or your carers or family should not be punished in any way as a result of your complaint If you feel that you are not being protected in these ways, then tell whoever has made 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 are punishing you, your carers or your family, then contact the complaints department to explain your concern. If the problem isn’t put right, the Community Health Council Patient Complaints Advocate may be able to help, or you may find a request for help from 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 and investigated by more than one person. You will need to pace yourself if this happens. Sometimes an investigator will ask for extra time to deal with a complex case, to get it right. If you agree to this it can be an open ended commitment, and leaving room for you to be too ill to deal with it sometimes, it may take years. You maybe need to ask advice from the Community Health Council Patients’ Advocate, on what time frames might be reasonable for your case, and respectfully request to the investigator that the process be completed within that period.

8.18 Independent Complaints Facilitation This is a relatively underused service, because few seem to be aware of it. It can help 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 are responding in jargon. Independent facilitators are independent of the NHS, and are trained to help resolve your complaint. They encourage open discussion of your concerns, identify areas of conflict and may help to bring your concerns to a satisfactory conclusion, by resolving 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 complaints investigator, 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 and agree the best way forward. There may be a meeting between the facilitator and the people you are complaining about, and possibly a meeting with everybody involved. Your Independent Mental Health Advocate, or your CHC Patient Complaints Advocate 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 complaints procedure described below.

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8.19 Response from the LHB You should get the response to your complaint in writing. You may not be happy about 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 support worker, your carer, or a friend, so that they can be there for you when you read the letter. Don’t read the letter on a Friday or Saturday, in case you go into crisis and need 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 next if 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 from three 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 is not 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 the complaints secretariat after you have involved the Ombudsman. The Ombudsman is the final stage of the complaints process. There are no more appeals 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 help you. 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 the secretariat permission to have a copy of your medical records and/or the records of your complaint. If you don’t agree to access to these records the Secretariat cannot investigate further than the information that you have 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 the local resolution correspondence.

8.21.3 Complaints about assessment, diagnosis or treatment If your complaint includes clinical matters, they will ask an independent clinician to look at your case. You may wish to ask about the role and function of this person so that you can discuss with the Secretariat if you feel the clinician does not have the right 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 provide the service your complaint refers to, may therefore feel they can decide if the service 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 clinical records, 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 was adequate, whether there are any outstanding issues which require a response, any clinical 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 case management, or on their own clinical views about the case. They will not be overtly critical of any individual’s practice, but will concentrate on matters of procedure and policy only. The tone of the report may however indicate that there may be an issue with a clinical decision or an individual clinical professional, which may lead to a recommendation to refer the person on to the National Reporting and Learning Service, an organisation which helps individual doctors or nurses to improve their clinical performance. (This organisation does not take reports from individual service users.) You cannot see the clinical advisor’s report before it is sent to the LHB, but if you are worried that it may not fully address your problems, it is worth writing to the secretariat 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 you are 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 you do not like what it says, or feel it is unfair or inaccurate. You may then need to work on 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 make recommendations 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 it is going. If you want to know what is happening, you can phone the office to find out. The staff are very helpful. At the end of the investigation the Lay Reviewer will write to you with his conclusions and 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 is usual 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 NHS service provider, if they feel that more could be done by them. They will make specific 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 remit suggested by the Secretariat for the LHB, you can write back to the Secretariat to ask for greater clarity, or an expanded remit. Again they may not agree to this, but they definitely can’t facilitate it, if you don’t ask. If further Local Resolution is recommended and you remain dissatisfied after this has taken 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 one other person, all of whom are ‘lay’ (not associated with or working for, the health service). It will also include 2 clinicians with the relevant speciality. You will have the opportunity to agree the remit of the panel at this time. You will be invited to an interview with the panel, where you can make your case. They will separately interview 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 to suggest 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 than together, is a problem, maybe because it permits misconceptions, biases, and mistaken information to be perpetuated, you can ask for the process to be more inclusive and open. It is generally believed by the service that the more open process ‘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 independently chaired meeting, including all the people involved. If you are unhappy with any aspect of the process of the Independent Complaints Secretariat, you should write back to raise your concerns. They may be able to deal with your issues, and will do so, if they can. If the reviewer feels they are unable to accommodate your wishes, you could ask the secretariat manager if they could authorise a special response.

36

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 do no more, you can go to the Public Services Ombudsman. This service only deals with ‘maladministration and service failure’ . For more information and guidance, if you feel you want to talk to someone before making your complaint, call the Ombudsman’s office on 0845 601 0987. They cannot talk about your complaint in detail 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, which is in a leaflet called “How to complain about a public body”. You can ask the health service for one, or get one from the Ombudsman’s office, or from the website. You can 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 health service. If the Ombudsman’s office needs clarification or additional information before they decide whether or not to take on the case they may contact you informally, possibly by 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 someone to 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 must also 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 make your 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, unless there is adequate reason for doing so. They will take account of the time you have spent trying to resolve the problem locally. If the case is not taken forward, you will be given an explanation in writing. If you are not happy with this judgement you can appeal, as you can at any stage should the 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 office may 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 to respond within a given time period. The Assessors will carefully consider the information from the LHB, and from yourself. 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 this would be someone with the appropriate clinical expertise. The Wales office prefers to use English advisors to provide an extra degree of independence. They will come to a decision, which may include making recommendations to the LHB 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 the process, should you not be happy with a decision. Reports and meeting minutes are sent 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 that there 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 before taking 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 professional codes 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 covered by it. For those staff members not currently regulated in this way, there is the Protection of Vulnerable Adults process (POVA) which deals with cases where abuse has occurred, and there is a new process coming in whereby everyone who works with vulnerable groups, will have to be registered by the “Independent Safeguarding Authority”. People considered not suitable to 38 remain on this list may be barred from working with vulnerable people. This is a very basic 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 old laws and creating new ones, to fill the gaps identified when things go wrong, often as a result of cases that are brought to their attention, which haven’t been satisfactorily 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 good case, they may write to the minister on your behalf. Sometimes correspondence with politicians can lead to changes in policy, which change the LHB’s contractual obligations, 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 they are 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 may be able to take up this issue in future.

39 Appendix 1

Consultation Questions 1) If you were present at the Putting Things Right day, do you think this report adequately represents the discussions on the day, and in particular anything that you wanted to be heard? If not, please describe what you think should be added 2) Look at the list of comments from the day. ( Appendix 5) Tick those you agree with, add anything you think is missing. This will give us an indication of the areas a number of people think are most important 3) If you were not present at the Putting Things Right day, what key problems or possible solutions should be added to the report? 4) Would you like any further information added to this report? A summary of the presentations A report from the evaluation of the day Other - 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 have to be changed to reflect any changes in the current compliments and complaints 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

40 Appendix 2

Attendence - 22 service users 4 advocates 3 NHS LHB staff from Complaints, CPA and patient involvement 3 NHS clinical staff 1 NHS LHB Manager 2 Welsh Assembly Government managers 3 Voluntary sector staff 1 volunteer 1 Carer 1 Officer of a Community Health Council Total - 41 Booked but didn’t come -

3 advocates 3 staff (including one social worker) 2 service users 1 voluntary sector worker

Total no shows

9

Apologies -

2 service users 1 carer 3

Total -

Total booked for the event - 53.

41 Appendix 3

Comments from consultation day Comments from flip charts organised for easier interpretation. Some comments fitted under more than one heading.

Communication Inaccurate information in reviews Complaints are negative at first, how to overcome this - communication between complainant, person complained about and a third person. Tell people how to find an advocate CPN discharge for no reason. Write to Chief Executive Staff could be asked to talks by service users and vice versa. More mental health awareness of issues for service users Point of call - be able to contact someone to discuss feelings/issues Communication and education and training Listen to patients Acknowledge evidence when it is offered Communication Confidentiality issues need to be brought up (explained) early specific service info/guidance, and scenarios around confidentiality (possibly 1. clinical care, 2. re; complaints Clear guidelines may be adequate for post-acute/rehab stage, but acute care different ALL NURSES HAVE TO SMILE its OK to talk - actually it's part of the job Clarify (on both "sides") what a complaint means, what a suggestion means, but they both should be considered More honest up front communication and information to avoid complaints eg weight gain due to medication Warmth should not be seen as unprofessional

Communicate Helpline - crisis resolution team confidentiality, diazepam Check list of things that need to be said at specific meetings eg at first referral assessment, at CPA reviews, or when client first raises a concern Don'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 about treatment, eg risks, benefits, duration, commitment, how it will be monitored. Give mental health service users the same rights of access to medical records as those with physical health problems. Don't have multi disciplinary meetings without the service user present Don't have psychotherapy case reviews without the service user present Stop Chinese whispers - no diagnosis or assessment of need for a service without both the client AND the appropriate professional whose service is being considered present together. 42 Make sure service user is fully informed of everything they need to know to make informed choices about their own care

Resources Not enough CPN's - cannot give enough time to everyone Lack of on-going support Bigger picture - need to consider that a little resource in the right place at the right time, can massively reduce resource needed if not spending the money causes a deterioration which leads to hospitalisation. Listen to the service users - they know what works for them. Working with service users, rather than against them will cost much less.

Feelings Dissatisfaction with advocacy (by who?) Feeling of not getting anywhere anyway Stigmatised Vulnerability - not heard Stop being scared of us patients. Staff don’t care Staff 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 my life mattered a toss to someone.

Needs Alone - need easy access to a listener, easy access to information, short time span to implement. Ability to pursue a complaint up to 6 months ? and more. Easy access to information on complaints handling Need 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 wrong time Discuss when best time is to give this to help understanding Info on complaint procedure at the start and as an on going thing - explain what advocacy is. More info on alternative therapies Choice without recrimination Volunteer to take service user home and see basic needs can be met, and to have a cup 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 hospitalisation 2) Safe contact/support post hospitalisation 3) Better application of drugs prescriptions

43 4) 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' needs so 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 an unmet need even if the service is there.

Culture and values Staff -pro-active Humane attitude - lack of understanding from staff Deal in the truth, be open and transparent Acknowledge evidence when it is offered Can do philosophy Culture of everybody responsible for change NHS culture - staff responsible for dealing with things and apologising treat everyone as an equal. Recognising where things have gone wrong Stop suppressing and controlling people Choice without recrimination Dealing with obstacles Courage to change and complain/comment Visit - break institutional cycle Increase understanding of man’s variety and virtues Break 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 they can tolerate, comply with, and respond well to. Just try listening for once!

Procedures General DIFFERENT WAY OF BEING ADMITTED Not going through A+E as unsympathetic to service user issues Not take people with mental health issues to police or casualty Improve coordination and fluidity of the system - too much specialisation causes gaps 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 cards Place of safety other than police station 44 1) safe contact/support prior to need for hospitalisation 2) safe contact/support post hospitalisation 3) Better application of drugs prescriptions 4) Increase police familiarity with mental health BY visiting wards, groups, etc. out of uniform) Advocate training classes.

Specific to complaints Acknowledge evidence when it is offered Clear guidelines may be adequate for post-acute/rehab stage, but acute care different CHC, MHA commission/, HIW, CSSIW Being able to make a complaint to someone who is not providing your care. Most problems stem from institutional acceptance of existing structures Clarify (on both "sides") what a complaint means, what a suggestion means, but they both should be considered More honest up front communication and information to avoid complaints eg weight gain due to medication Complaints are negative at first, how to overcome this - communication between complainant, person complained about and a third person. Service user must have control over the complaints process, who is involved, and what happens when. They must be able to pull out at any stage if they feel the risk to their care, or even their life, is too great. No report back to a complaint should be made until AFTER a face to face discussion between the investigator and the service user, summing up the findings, and allowing the service user to respond as to whether they feel the investigation actually addresses their complaint at all.

Training More mental health awareness of issues for service users specific service info/guidance, and scenarios around confidentiality (possibly 1. clinical care, 2. re; complaints Manager should go and talk to people where it works well Do 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 patient through 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 ward Recognising where things have gone wrong Give them clear codes of conduct and have ward meetings with patients and staff as 'therapy' for both parties GPs need training on complaints advocacy and mental health in general. DACE do course on empowering service users Advocate 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 on confidentiality for this process, including consultants, at least once every three years. 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 between organisation and patient Information giver as a full time job An independent officer

Volunteer to take service user home, to check basic needs can be met and to have a cup of tea. New post needed Helpline crisis resolution team Community police officers go to Mind, ward round, MDF meetings - out of uniform

ALL NURSES HAVE TO SMILE

Things that cause problems Qualification based nursing not properly motivated Nurses’ fear influences the way they handle things Lack of willingness of staff and lack of respect Confidentiality not being observed People being discharged without care plans People not properly involved in their case No support structures put in place No meeting/CPA before discharge

Confidentiality being broken - in care and in the complaints process Most problems stem from institutional acceptance of existing structures Break the pattern of power abuse We all have preconceptions Any clinical condition blamed on mental health problem

Good things to aim for Holistic - task orientated Patients should have more involvement with care plan Stopping the same thing happening to others support networks, caring networks, responsibility for oneself Informed choice, control, complaint shared with minimum number of people Managing boundaries for acute patients in community (more of it now) 46 Can do philosophy Advanced directives/ self management programmes (eg MDF) NHS should be more proactive about going to voluntary organisations eg MIND, MDF Organisations are able to plan and are able to respond to unmet needs (which lead to complaints) eg local services not England Proactive home treatment for substance misuse Use complaints constructively to have a positive effect and highlight what needs improving Better manage situations when tension is rising between clinician and patient through improving supervision. Recognising where things have gone wrong Often only issue is to make sure that same doesn't happen to someone else. Stop suppressing and controlling people More info on alternative therapies Choice without recrimination Advocacy acknowledged as important Advocacy high on list of priorities

Reports of events Crisis resolution team - withdrew (telephone) number due to volume of calls Nurse discharged someone without reason

Quality issues 1st point of contact Quality improvement targets - asking people what they think of the quality of care (eg questionnaires) 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 wrong Stop suppressing and controlling people

Police Police stripping people naked - need education

Police lack of education and respect Community policing Advocate service for people in police stations Police duty of care Place of safety other than police station Ideas - Community police officers - go to , Mind, ward round, MDF meeting- out of uniform All talked of good experience - with some workers. Police good men in all walks of life. 1) safe contact/support prior to need for hospitalisation 2) safe contact/support post hospitalisation 3) Better application of drugs prescriptions 4) Increase police familiarity with mental health BY visiting wards, groups, etc. (out of uniform) Advocate training classes. 47

Problems with current complaints approach Complaints system failing patients Long, drawn out and difficult Confidentiality being broken - in care and in the complaints process Don't always get an apology litigation not knowing which policy to follow confusion between informal and formal managers speak language we cannot understand - need to speak clearly concerns 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 boxes of what is available and seen as a pain. Experience of complaints process - not following procedure, false information Becomes adversarial - have to resort to legal side because they won't listen Unequal power - system has its own support, but service user is alone, and including the way things are written. Advocates are limited in what they can do/advise Difficult to find an independent solicitor End up being caught in the system Concern that services only worried about people making a claim, so act defensive, don't listen Long processes are detrimental to people’s mental health, can cause further problems/relapse Can 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 and fear recrimination

Good things about current complaints process We've got one (even though everyone may not know about it) CHC and other broader systems that complaints relate to.

Language Words instead of complaint - votes given for question, discuss and issue Challenge, Concern, Question, Discuss, Issue, Difficulty, Enquire Comment - both good and otherwise, Grievance, Problem, Appeal

How to prove what happened Take notes We can't listen "equally", "impartially" to both sides How about more formal meetings being tape recorded or at least independently minuted? (NB minute taker must understand terminology - and check with participant, if unsure what they mean) Tape record 48 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 by service user/patent etc, might help. But as we know from other contexts, there are often powerful motivations on both sides not to record the sort of matter that come into dispute.

Risk and safety Duty of care/confidentiality can be fluid, but can make service users feel unsafe. Info from complaints may need to be shared 'cos of safety issue Issues of what to disclose, for service users Place of safety outside the police station House of safety run by service, 24 hours manned Break the pattern of power abuse

Evaluation, continuous improvement and learning Evaluation feedback need to be stronger. ? everytime we have contact? On discharge perhaps. Also after CPA reviews? Every 6 months? Short, support to fill in. Need to make sure services change as a result of feedback Is 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 needs improving Prioritise the parts of the system that have broken down. Recognising where things have gone wrong We are making improvements

Praise and reward Compliments/acknowledgement balances complaints Rewarding staff who do well What 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 fit Other systems – CPA Stop recording disagreements about CPA on CPA report Don't have a working way of looking at unmet need Access 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 records ONLY from professionals already involved in the complaint Letters policy – all letters go on clinical file, need exception for complaints to be included in policy

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

Solutions A lot depends on the way you are treated Patient councils Opportunity to chat through issues Help with signposting Raise issues with managers Funding should not be left to the voluntary sector Opportunities for peer advocacy? Implement across the board Example of water dispensers - letters ignored - press not Patient councils - not all patients are in hospital, community captured views - bigger challenge Solution - listening to problem at start, spoken to and respected service user, do not discriminate Recognising where things have gone wrong

Miscellaneous comments Doctors and nurses should try their own drugs. If they're good enough for them, then maybe we could consider taking them. Institutionalised The staff canteen serves fresh, wards get cook chill Alternative 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 that is causing them discomfort - it is not for anyone else to impose their views on another's perception Complaints are subjective and personal (usually) The service user or carer who puts it forward, NOT LHB staff

More Self-Help, please Why is it that in Mental health services that we are always tinkering with the service and 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 care Taking one day at a time Thinking before you speak - respond, don't react Keeping an open mind Drinking water, food , exercise Food and mood Taking responsibility Info on how to help yourself Information on conditions to help individuals understand 50

Service user stories of complaining Long waiting time for service to be delivered, complaining made it happen Saying it not fit for purpose Complaint process worked - only because it was taken to the nth degree Most 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 - without discussing it with me first, and that I have a right to veto passing on anything which doesn't have to be passed on by law. To trust processes, trust that I will be listened to, to have a separate and independent mediation body that is impartial Advocacy Supporting people to tell their story Concerns discussed with an independent person

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

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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”, are available 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 to have choices, and to ensure your rights are respected. They will work with you on day to day issues regarding getting access to the right services, having choices about who treats you, and supporting you in meetings. Advocates will help with complaints, if that is what you choose to do, but in many cases they may be able to help you resolve issues without having to make a formal complaint. It is useful to copy letters to your advocate, both those you send and those you receive. The advocate will then have a complete file of the process you have been through, which will 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 regarding NHS 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 not undertake any further action without your consent, unless there are issues of safety involved. If further informal/anonymous complaints are raised against the same member of staff, the matter is then referred further within the CHC. This may lead to further action being taken. With formal complaints, where you wish to receive an individual response from the NHS organisation concerned, full details must be available and you will have to give your written consent. The CHC advocate will guide you through the process, help with any correspondence, and provide structure and support to get the best result as efficiently as possible. As with the independent advocate, the CHC Patients’ Complaints Advocate will be better 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 the Advocate. Sometimes complaint issues can be dealt with by telephone, email or

written correspondence. In more complex matters, a face to face appointment is preferable. Where complaints cannot be resolved through a formal response from the LHB, a meeting may be needed. The advocate can accompany you to such meetings. Where letters of meetings with the organisation involved have not managed to address your complaint to your satisfaction, the Patient Complaints Advocate can assist you with further stages of the NHS Complaints Procedure, namely Independent Review and Ombudsman. 52

Local NHS Complaints Departments The complaints department at hospitals have a team, whose job it is to help you with your 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, unless there is a clear request for an informal approach, and, if treated formally, are acknowledged within two days in writing. After investigation of the complaint, a full written response is sent to the complainant signed by the Chief Executive of the LHB or hospital. The Welsh Assembly Government monitors how well LHBs or hospitals stick 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, more complex concerns will have to be dealt with by the appropriate manager. In all circumstances 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 to give their consent in writing before an investigation can take place.

Organisations involved in quality assurance for the NHS The 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 a complaints resolution function per se, but they are all interested to hear about problems with the service, and will bring information from such reports together to promote 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 7814 Fax : 02920 235574 Address:Board of Community Health Councils in Wales 2nd Floor 33-35 Cathedral Road Cardiff CF11 9HB

53

Healthcare Inspectorate for Wales The Inspectorate are pleased to hear about your experiences of the service. They are happy to have comments and suggestions, and will try to answer your questions about their role. They will use your comments, experiences and suggestions to inform their work to report on NHS service quality and promote improvement. Website : www.hiw.org.uk Email [email protected] Tel: 02820 928850 60 Address:-

Healthcare Inspectorate for Wales Bevan House Caerphilly Business Park Van Road Caerphilly CF83 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 the Mental Health Act. Website: www.mhac.org.uk/ Tel: 0115 943 7100 Address:Mental Health Act Commission Maid Marian House 56, Hounds gate Nottingham NG1 6GB

Care and Social Services Inspectorate for Wales The inspectorate inspects social care services which are under license, such as residential care, and child care. They are also responsible for inspecting social services run by local authorities. Website : www.cssiw.org.uk Email : [email protected] Tel: 01443 848450 Fax: 02920 823417

54 Address:-

Care and Social Services Inspectorate for Wales Cathays Park Cardiff CF10 3NQ

Independent Complaints Secretariat This is the first level or independent appeal, after the formal complaints process within the LHB. All Wales Secretariat - Tel: 01495 332487 Mid and West Wales – Tel: 01874 712748/ Fax: 01874 712756 South Wales - Tel: 02920 376840/ Fax : 02920 376826 North Wales – Tel: 01352 700227/ Fax: 01352 754649 Addresses : Mid and West Wales South Wales North Wales PO Box 2 PO Box 21 PO Box 125 Brecon Cardiff Mold Powys CF10 2ZR CH7 1WH LD3 0XR

The Public Services Ombudsman for Wales This is the last resort for complaints following the official public sector legal complaints pathway. Website : www.ombudsman-wales.org.uk Email : [email protected] Tel: 0845 601 0987 Address:Public Services Ombudsman for Wales 1 Ffordd yr hen Gae Pencoed CF35 5LJ

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

experience necessary to hold the professional title. They set the entry criteria, and standards of training, and any requirements for professionals to maintain on-going registration, such as complying with a code of ethics, conduct or practice, and keeping up to date through ongoing training and experience, or meeting performance 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 (Health Professions 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 will expel people who do not comply with their ethical code. An example organisation is given 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 they may take someone off their list. If this happens that person will lose their job. If you feel a professional you have seen is not fit to practice, you can get advice from these organisations. They will provide you with copies of their codes, and will often give 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] Tel: 02920 504060 Address:-

General Medical Council in Wales Regus house Falcon drive Cardiff bay CF10 1RU

Doctor’s Fitness to Practise Email; [email protected] Tel: 0845 357 0022 Other General Enquiries Switchboard : 0845 357 8001

RCP - Royal College of Psychiatrists Psychiatrists have to be registered with BOTH the GMC and the RCP, and have to follow both sets of professional codes. Website: www.rcpsych.ac.uk

Welsh division: www.rcpsych/college/division/welsh.asp Email: [email protected] Tel/fax : 02920 489006 Address:Royal College of Psychiatrists, Welsh Division Baltic House Mount Stuart Square Cardiff CF10 5FH National Headquarters Address:17 Belgrave Square London SW1X 8PG 56 RCP (continued) Tel: 0207 235 2351 Fax: 0207 245 1231

NMC - Nursing and Midwifery Council This is the body that regulates nurses Website: www.nmc-uk.org/ Address: Nursing and Midwifery Council 23 Portland Place London W1B 1PZ General Enquiries- Tel:

0207 637 7181 0207 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/ Email: [email protected] Tel: 02920 226257 Minicom: 02920 780680 Fax: 02920 384764 Address:Care Council for Wales Southgate House Wood Street Cardiff CF10 1EW

Investigations team Tel: 0845 0700 248 Fax: 02920 780 661 Email: [email protected] Or write to the Investigations Team at the address above.

HPC - Health Professions Council This organisations registers a number of professionals including Occupational Therapists, and physiotherapists. It may also be taking on the compulsory registration of psychotherapists in the near future. Website: www.hpc-uk.org/ Tel: 0845 3004 472 0207 840 9802 57 Fax: 0207 840 9801 Address:Park House 184 Kennington Park Road London SE11 4BU

BSP - British Psychological Society This is the regulatory body for psychologists Website: www.bps.org.uk Email: [email protected] Tel: 0116 254 9568 Fax: 0116 227 1314 For complaints :- Regulatory Affairs team Email: [email protected] Tel: 0116 254 9568

BACP - British Association of Counselling and Psychotherapy This is a professional body for psychotherapists and counsellors. It will investigate complaints about its members, where they have breached the organisation’s code of ethics. However not all psychotherapists belong to this organisation. Membership is not 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 a list of local practitioners in your area from this organisation. You will need to check that your psychotherapist is on their lists before you go any further with any complaint. 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

Email: [email protected] Client Information Helpdesk Tel: 01455 883316 Professional Conduct: 0870 443 5217 Email: [email protected] Related Organisation UKRCP 0870 443 5232 When making a complaint you are referred to WITNESS – an independent advocacy service with experience of the BACP conduct procedures. WITNESS Tel: 0845 4500 300 Website: www.witnessagainstabuse.org.uk

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Appendix 5 The Mental Health Context – service user experience The experience of the mental health service is one where the risks to the individual service user, and sometimes to the community are potentially devastating and far reaching. The following key issues affect mental health service users:-

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 live longer, happier and more useful lives. Because of the service many people get better and become independent of secondary care

Communication:• • •

•

Mental health service users have, at times of illness, particular problems with communication, both in their ability to listen and engage, and in their ability to express themselves effectively Tendencies to paranoia, make honesty and openness by staff particularly important It is important to ensure the client is supported and safe when being given difficult information, e.g. if bad news is delivered by post to arrive on Friday or Saturday, it may trigger a crisis, or even a suicide attempt, because there is no-one available to help quickly It is essential that clients understand what is meant by confidentiality with

• •

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 it impossible 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 to read more negativity into that than is intended. On the other hand staff need to be very careful on the phone to be aware of how the service user may feel about what they say, and how they are saying it. If there is any need to challenge 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 make decisions 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 any influence over that decision. “It was a team decision” can be used as an abdication 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, but who in practice can become the team’s deliverer of bad tidings, and a gatekeeper, 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 these levels, but the actual application can be inconsistent with these criteria, and between 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 there should be a care package in place BEFORE someone is discharged from hospital 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 knowledge excludes service users from involvement in their care In mental health the consultant has to be asked before medical records can be released to the service user. Many people will not ask for records because

• • •

they fear that the consultant will be angry with them for asking, and may, not only refuse access, but also punish them for asking. Fear of lack of access to medical records, adds to the clients fear that they are being ‘locked out’, and that bad practice can be hidden, or go unchallenged. Complaints can be seen as indicators of illness and therefore not legitimate If interpreted as a sign of paranoia, hallucinations or delusions of grandeur, a complaint can lead to section and loss of liberty The imbalance of power feels more oppressive when complaints investigations and decisions take place, ‘behind closed doors’. It is difficult for a service user to accept a decision or investigation, which has not involved talking to them about their experience and concerns, and given them a chance to respond to the justifications, defences or evidence presented by the people who are the subject of the complaint

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Collaboration and relationships •

• • •

•

Sometimes, if the service user doesn’t want a particular intervention the staff will go to the carer or family to support them to impose the intervention. This undermines service user trust in both the staff member and in their family or carer. Mental health problems are generally long term, so potential damage to relationships through making a complaint is a real disincentive to speak up Problems with relationships with staff are always detrimental to the care offer Because of the nature of psychological ‘recovery’, the service user has to be an active part of the process, and has to take responsibility to some extent for how much they benefit from the service. Unfortunately this means that when things go wrong, professionals can (and often do), blame the client for not engaging with the treatment, and by doing so the professional avoids the need to; accept any culpability, or responsibility for the quality of the service offer; reflect on whether they have made a mistake regarding the best treatment approach or the involvement of the best placed professionals; or to consider any need to change the way they do things. There is a strong and frustrating feeling for service users, that professionals, especially psychotherapists, can never be wrong. Because the client needs to be a part of the recovery process, they have to believe in the treatment they are being offered, especially non pharmaceutical solutions. However, it can feel like the only person who has to change, to ‘collaborate’ is the client. The client has no power to do any other than accept what is offered on the staff’s own terms.

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 Inaccuracy of records means that complaints investigations cannot access the necessary evidence to substantiate the client’s complaint Treatment decisions are often based on second hand information, and can become based on increasingly remote sources, on letters based on letters, based on discussions in the team, based on presentations from staff who carried out the assessment, summarised, filtered and prioritised according to that individuals views. Sometimes , like Chinese whispers, an inappropriate decision is based on inaccurate interpretations. Information is a powerful resource for recovery in mental health

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Access to resources •

•

•

Assessments are often done by one professional in the field of another, and hence decisions about the need for a service are made by people who don’t work in that field, and don’t have professional qualifications in it. Eg, a social worker might be assessing whether a client needs a nurse or an OT. This kind of cross professional, ‘generic’ working is not an issue in many other parts of the NHS, and creates the potential for unsafe clinical decisions, which 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. This is despite the Assembly’s commitment to earlier intervention, and frequently results in people becoming more ill and needing the higher level of intervention at a later date. It is ultimately a high cost strategy. Inability to provide a service which is likely to help a service user is supposed to be registered as an unmet need, in order to help redeploy resources or plan for a better service. However, the process of recording an unmet need is internal to the LHB. It would appear that staff are discouraged from reporting unmet needs because it places an obligation on the LHB to provide the appropriate service or to pay someone else to do so. The way unmet need is defined in many LHBs, is as a service that they do not have the physical structure (eg medium secure units) or the expertise (eg EMDR) to deliver. However the most common cause of needs not being met is insufficient staff time

Safety • •

It is hard for staff to let clients take risks. But service users need to be allowed to make mistakes sometimes, to build up their confidence and to reduce their dependence It feels like the risk to the psychiatrist is more important than the risk to the client. A psychiatrist is more likely to section someone who is manic, and

• •

•

•

therefore unpredictable, than to admit, even on a voluntary basis, someone who is at very high risk of suicide. The experience of hospitalisation becomes contrary. It feels like, whichever option the client would prefer is the very opposite 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 be safer 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 at any time of transition or when a decision, such as an assessment recommendation, 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. Suicides can 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 support people after they have harmed themselves. This again means mental health service 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.

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Appendix 6

Policy Context Document summaries “One Wales” This is a description of the 2007 National Assembly Government’s work commitments 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 the assembly 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 priorities It 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

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Making the Connections Describes a vision to: “…ensure services are more citizen-focused, responsive…, driven by a commitment to 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 which currently 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 less defensive”

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.”

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Making the Connections – Delivering Beyond Boundaries (Nov 2006) This documents follows up from the last one by describing the actions the Assembly will take to realise its vision. It says:“The..report Beyond Boundaries …demonstrated that we need to drive through the changes faster and more rigorously. It showed that we are on secure ground in concentrating on behaviour and cultures….It called for public services to be much more ambitious and innovative, making a step change in how they engage with citizens…..”

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 kept informed 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 Sign Language 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 to services through the use of technology.

It says about complaints:“Research..has identified that citizens want to be able to complain if they are not satisfied with public services, and they want to do so in a way that results in any problem being put right quickly. They do not want to resort to a formal complaints procedure 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 Social Services 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 problems and 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 which people 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 individual need

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

Effectiveness Mental health services should provide effective interventions that improve quality of life by treating symptoms and their causes, preventing deterioration, reducing potential harm and assisting rehabilitation. …. Service providers must be accountable for the quality of services.

Efficiency ….There should be interagency working especially between health and social services, other parts of local Government, voluntary agencies and the private sector …. 67 In it’s aims and objectives the document describes many aspirations that would prevent 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 and offer high quality, evidence based care in an environment and atmosphere that promotes dignity, privacy and support”

Stronger in Partnership 2 This document gives guidance on how to improve service user involvement in mental health, 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 and what 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 choice and control over their lives.” “The Care Programme Approach (CPA) is a co-ordinated system of care management 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 the service user and appropriate health care professional and copies given to the service user and with their agreement to any carer” (italics from document editor)