Promoting a just culture

Promoting a learning culture 

Senior staff make sure every member of staff knows how they can create and deliver a just and learning culture in their role. Staff can demonstrate how they meet these objectives through practical examples. 

Every organisation has appropriate governance structures in place to ensure that senior staff review information arising from complaints regularly, and are held accountable for making sure that the learning is acted on to improve services. 

Organisations make sure staff are trained to identify complaints in a way that meets the expectations set out in the Complaint Standards. 

Organisations have clear processes in place to show how they capture learning from complaints and use it to improve services. In their annual report, organisations provide details of what learning they have identified in complaints and they have used it to improve their services. This information is easy to compare with that of other organisations. 

Organisations put measures in place to capture feedback from those who make complaints (as well as the staff involved) on their experience. They use this to demonstrate how the organisation has performed towards meeting the Complaint Standards and what users expect to see, as set out in My Expectations.

Staff are trained to identify those complaints where mistakes have been made that may have resulted in significant impact. Staff ensure these mistakes are reviewed through the organisation’s Duty of Candour processes. Organisations routinely share learning from complaints with other organisations (both locally and nationally) to build on insight and best practice. 

Your organisation must designate a responsible person who ensure the organisation complies with these Regulations, and “ensuring that action is taken if necessary in light of the outcome of a complaint”. The responsible person will be the person who: 

(In an NHS body) acts as the chief executive; (In other responsible bodies) acts as the sole proprietor or (in a partnership) a partner; or (in any other case) a director of the responsible body or a person who is responsible for managing the responsible body. 

What the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 say 

Regulation 16 says: 

The person registered to carry out regulated activities in a healthcare setting must: 

• establish and operate effectively an accessible system for identifying, recording, handling and responding to complaints by service users and other persons in relation to the carrying on of regulated activity; 
• provide to the Care Quality Commission (within 28 days of request) a summary of: 
• complaints made and responses given to those complaints 
• any other relevant information in relation to such complaints as requested. 

Regulation 17 says: 

Your organisation must establish and set up effective systems and processes (governance) to: 

• assess, monitor and improve the quality and safety of services your organisation provides when carrying out regulated activity (including the quality of the experience of service users in receiving those services); 
• assess, monitor and mitigate the risks relating to the health, safety and welfare of service users and others who may be at risk which arise from your organisation carrying out regulated activity;  
• seek and act on feedback from relevant persons and other persons on the services your organisation provides when carrying out regulated activity, for the purposes of continually evaluating and improving such services; 
• evaluate and improve how your organisation captures and processes information relevant to the above. 

It also requires your organisation to send to the Care Quality Commission (upon request) the following written reports within 28 days: 

• an evaluation of how your organisation is complying with the assessment, monitoring and improvement of the quality and safety of services 
• mitigation of risks relating to the health, safety and welfare of service users 
• any plans your organisation has for improving service standards. 

Regulation 20 is known as the ‘Duty of Candour’. Under this regulation, all staff in your organisation: 

• act in an open and transparent way with relevant persons in relation to care and treatment provided to service users; 
• must (as soon as reasonably practicable after becoming aware) notify relevant persons that a ‘notifiable safety incident’ has occurred.  

A notifiable safety incident is ‘any unintended or unexpected incident that occurred in respect of a service user… that, in the reasonable opinion of a health care professional, could result in, or appears to have resulted in, the death of the service user… (or has) resulted in severe harm, moderate harm or prolonged psychological harm to the service user.’  

This must be done initially in person by staff and followed up in writing. Staff must provide an account (to the best of knowledge) that is true and contains all the facts known about the incident in question. Staff must also let the relevant persons know what further inquiries are appropriate and apologise for the impact caused by the incident. 

Find out more 

Care Quality Commission’s guidance on duty of candour provides more details on the specific requirements that providers must follow when things go wrong with care and treatment. 

Complaints give organisations a vital and direct insight into the quality of their services. They can offer a quick route to identifying how to improve a service, sometimes with changes that can be implemented immediately. But too often, organisations do not value or prioritise them. 

Find out more 
NHS Resolution’s Being Fair report explains why it is important to adopt a reflective approach to learning from incidents and supporting staff. It provides guidance on how organisations can do this. 

The role of senior leaders 

Good complaints handling must be led from the top. That means senior leaders need to follow best practice in handling and learning from complaints.  

For example: 

• Be engaged in complaints. 
• Be involved in the way complaints are handled. 
• Understand and act on the insight they provide. 
• Put a clear, straightforward complaints process in place. 
• Make sure staff are trained and empowered to handle complaints fairly, openly and with maximum accountability. 
• Ensure that effective governance systems are in place so that senior staff regularly oversee complaints. 
• At a fundamental level, senior leaders must actively make sure all their staff understand and recognise the core values of a learning culture. These values must also be demonstrated in practice, to build trust among staff.  

Tips: How to embed these core values 
- Make sure these values are included in your local complaints policy. This will help them become normal practice whenever someone makes a complaint. 
- Train all staff on how your organisation values and handles complaints.
- This includes explaining their role in embedding these values and how to challenge any colleagues who do not uphold them. 
- Include this information in your induction programme, so new staff are immediately aware of your organisational values. 

In an organisation with a well-developed learning complaints culture, senior staff play an active role in complaints handling. This often involves providing assurance and signing off complaint responses.  

Where this is not possible (for example, because of the size of the organisation), senior leaders must put in place processes to make sure colleagues escalate any complaints about serious or significant issues, for them to oversee and act on. 

Senior leaders must make sure complaints insight is embedded into governance processes. This enables the organisation to continuously assess, monitor and improve the quality and safety of its services. 

What is the role of the board? 

It is a fundamental requirement that senior staff and (where appropriate) the organisation’s board must see regular reports on complaints. These need to provide periodic data on: 

• the number of complaints received 
• how many cases have been resolved at the frontline stage to the satisfaction of the complainant 
• the number of cases being looked at in more detail 
• details of cases that have been closed, including any findings or learning identified and what actions are being taken to improve 
• details of cases referred to the Parliamentary and Health Service Ombudsman (PHSO), including updates on any of the Ombudsman's recommendations for the organisation to take forward. 

Senior staff and boards must always review complaints data and insight alongside relevant periodic data from patient safety incidents and claims. They must use this triangulated analysis to identify any patterns or themes that indicate where system or service improvements can be made.  

Find out more 
The Good Governance Institute’s Board assurance prompt on complaints handling in the NHS is a good reference for best practice in complaints handling for leaders and staff. 

Using complaints panels 

Well-developed organisations set up a complaints panel to make sure senior staff regularly listen to complaint stories and keep up the momentum in learning from complaints and monitoring performance. 

Complaint panels are made up of senior leaders and staff who are responsible for handling complaints. Panel members meet regularly to: 

• review complaints data 
• discuss cases of interest 
• review actions to improve services as a result of learning from complaints. 

This approach has several benefits: 

• It helps make sure complaints remain a high priority within the governance process. 
• It enables senior staff to provide assurance on what the organisation is doing to monitor and assess the quality and safety of services, and efforts to improve them. 
• It supports and develops staff to reflect on learning from complaints. 

Case study: Keeping complaints high on the leadership agenda 

Newcastle Upon Tyne Hospitals NHS Foundation Trust runs a monthly complaints panel, which includes senior staff and their complaints team. The panel meets to scrutinise a range of complaints that have been made to the trust and hear about what action is being taken on learning from complaints. Representatives from the Patient Relations team present data and discuss how best to approach the issues arising. 

This case study was originally featured in the Ombudsman's report on Making Complaints Count (page 16).

Tip
Well-developed organisations promote an equal balance between: 
- encouraging staff to take responsibility for their actions 
- supporting staff to learn and improve from all types of feedback. 

• Make sure your staff have the opportunity to provide meaningful input into complaints about them, or complaints that impact on their role.  

For example: 

• make sure every member of staff complained about is supported and engaged during the handling of a complaint 
• create effective ways for staff feedback to be captured, shared and reviewed alongside complaints, claims and patient safety feedback at Board level and other senior leadership meetings
• build strong partnerships with staff representatives and networks to make sure feedback is used to support individuals and promote wider organisational learning.

Find out more 
- NHS Improvement’s guide on just culture encourages managers to treat staff involved in patient safety incidents in a consistent, constructive and fair way. 
- Being complained about, published by the University of Glasgow, provides practical approaches to how organisations can effectively support staff who are subject to a complaint. 

• Use NHS Resolution’s learning culture charter (set out in its report Being fair) as the core foundation for your approach to complaints, claims and patient safety incidents. Draw on this to create and publish guidance summarising what it calls the “fundamental principles of a learning culture which will be applied at all levels of our organisation, from the executive to the frontline” (page 10). 
• Make sure there is a close connection between the monitoring of complaints and all other feedback channels, including claims and patient safety data. This provides a detailed triangulation of key feedback to ensure you can confidently understand their quality, safety and impact on user experience. 
• Organise your teams so that staff responsible for complaints, claims and patient safety can work closely together. 
• In larger organisations make sure all complaints, claims and patient safety leads work within the same division (usually where the governance and/or quality improvement functions sit) and report to senior staff. Where this is not possible, make sure all relevant staff regularly collaborate to share insight and are responsible for joint reporting to senior leaders. 
• In smaller organisations make sure one person is responsible for analysing all this type of feedback. They should be empowered to report back to senior leaders on insights and how these can be used for improvements. 

Reporting on complaints insight is an essential pathway to cementing trust with staff and service users alike. It shows that your organisation highly values learning from complaints.  

• Make sure there is an open and transparent relationship with staff and service users. This includes feeding back results and learning to all staff and externally. 

Regularly communicate all actions that have been taken and explain how these have made a difference to learning and improvement. This shows staff and service users that complaints make a difference. It also helps those who complain know your organisation listens and is responsive and open to learning from feedback. 

• Regularly report summaries of complaints learning activity with staff, and with users through their website and with local Healthwatch, advocacy and service-user interest groups.  

Tip: You can also use this reporting in your organisation’s annual reporting process and to show the Care Quality Commission what you are doing to capture and monitor key insights on the safety of your services and use them to improve (as per the 2014 regulations). 

Find out more 
My expectations for raising concerns and complaints, produced by PHSO, NHS England, LGSCO and Healthwatch England, provides a powerful review of what service users expect to see from NHS and social care organisations when they complain about services. It includes a useful set of benchmarks for how every NHS organisation can measure performance in complaints handling. 

Your organisation is required to regularly evaluate and improve how it captures and processes information related to monitoring its services. 

You need to set up mechanisms to capture feedback about the process itself, from people who have complained and from staff who have been involved in the process. 

Tip
To do this, gather feedback through surveys or interviews with people who have been involved in your complaints process. You can measure the findings against the expectations set out in the Complaint Standards and My expectations.  

Find out more 
Being Complained About, published by the University of Glasgow, provides practical approaches on to how involve and support staff who are subject to a complaint.