Handling and Learning from Complaints – Follow up.

9 October 2023

jerseyauditoffice.je  

R.150/2023

Contents

Summary ......................................................................................................................................... 3

Introduction........................................................................................................................ 3 Key Findings....................................................................................................................... 5

Conclusions ........................................................................................................................ 6 Objectives and scope of the review ............................................................................................ 8

Detailed findings ............................................................................................................................ 9

Culture ................................................................................................................................ 9

Principles ..........................................................................................................................18

People ...............................................................................................................................27

Process..............................................................................................................................33

Analysis .............................................................................................................................41 Appendix One – Audit Approach ..............................................................................................50

Appendix Two – Summary of Recommendations, Work planned that should be

prioritised and Areas for consideration ....................................................................................52

Summary

Introduction

1.  The way an organisation handles complaints is important. There are significant benefits to doing things well, including:

• providing valuable information about weaknesses in programmes of work, policies and service delivery

• stimulating improvement

• reassuring the public that the organisation is committed to resolving problems; and

• enhancing accountability and transparency.

3. Conversely, done badly it can:

• fail to produce learning and improvement

• lead to repetition and in some cases exacerbation of the underlying issue

• damage the organisation's reputation; and

• impact on the organisation's relationship with the public and other stakeholders.

3. In July 2020 I published a report Handling and Learning from Complaints which reviewed the development and implementation of the recently introduced Government-wide Customer Feedback Policy. In summary this review found that:

• the policy in most respects met the requirements of best practice

• responsibility for the management of complaints rested mostly with designated officers within departments, with a small corporate team providing an element of co-ordination but without a defined supervisory role

• a Customer Feedback Management System had been introduced that captures information on complaints across Government

• a single online channel was established for customers to submit feedback, including complaints, about any Government service

but

• there were no standardised corporate procedures to support the implementation of the Customer Feedback Policy. Departments relied on their own procedures that had not been updated consistently to reflect the Customer Feedback Policy

• there was inadequate consideration of the adaptations to corporate activities, including modernisation initiatives, necessary to secure their relevance to Non - Ministerial Departments

• limited information was captured and reported systematically to measure the efficiency and effectiveness of the complaints handling process; and

• although the tone from the top' had emphasised the importance of complaints as an integral part of public service provision, a consistent, shared culture of valuing and learning from complaints was yet to be embedded.

4. In July 2020 I concluded that the Government had taken important steps and invested in a sound approach, but that more work was required to secure consistent handling of and learning from complaints. I made 19 recommendations for improvement, all of which were accepted by the Government of Jersey. In particular, I identified the need to ensure that:

• staff handling complaints are people with the right skills, experience, training and supervision

• there are appropriate processes, consistently applied, to facilitate the delivery of the Customer Feedback Policy

• the Customer Feedback Management System is developed and its capacity fully used; and

• maximum value can be secured from the analysis of complaints and their handling.

5. Later in 2020 I published Management Information in Education – Follow Up (August 2020). In this review I found that the Children, Young People, Education and Skills Department (CYPES) did not keep a central record of complaints that were dealt with by schools. This meant that there was no evidence-based alert for CYPES that something may be causing concern either within a school or across a number of schools. I recommended that a mechanism be established to share information between schools and CYPES on the number, type and outcomes of complaints.
6. Since my 2020 reports, a decision has been made to develop a process, independent of Government, to resolve complaints which have resulted in alleged

injustice or hardship. This process will apply to specified bodies in Jersey where there is no other organisation already established to handle that complaint. In October 2022, as part of the new Council of Minister's 100-day actions, the Government published proposals to establish an independent Public Services Ombudsperson to help resolve complaints about public services in Jersey in a timely and transparent manner.

7. The Chief Minister subsequently submitted instructions for new legislation to be drafted to create a Jersey Public Services Ombudsperson (JPSO), to resolve complaints.
8. The States have made the decision that health care services (provided by Health and Community Services (HCS) and other public services) will not initially be included under the JPSO's remit. Health care complaints will remain in the scope of the Law but these will not be brought into force until the JPSO has been operational for a reasonable period'.

Key Findings

9. The key findings from my review are as follows:

• the Government has shown a significant commitment to and investment in relaunching and updating the Customer Feedback Policy since my 2020 review. There are important improvements in support of good practice in handling customer feedback. I have though found it difficult to fully understand the decision making, action and escalation responsibilities of the roles referred to in the Policy. It is also not always clear how leadership is brought to bear to ensure priorities and risks are addressed

• both the quality of information available on customer feedback and its analysis have significantly improved since my 2020 Report. However, improvements are chiefly focussed on the mechanics' of handling complaints and the types of complaints received. There has been much less focus on the efficiency, effectiveness and reputational benefits of ensuring that learning is taken from complaints

• the Policy and the commitments it sets out apply equally to all parts of Government except the police service. However, since it was first published, there have been inconsistencies in the way and the extent to which the Policy's commitments have been adopted by departments

• there is as yet no one, coherent, prioritised and resourced action plan to deliver on the stated duty to ensure all customers can easily provide feedback on public services

• processes to support and monitor compliance with the Customer Feedback Policy have been developed since my 2020 review. These have not yet been made fully effective to ensure high quality handling and learning are applied across all Government services and departments

• data from the most recent Quality Assurance Framework audit (covering the period from January to August 2023 and excluding HCS data) shows that: only 39% of complaints were recorded as having been acknowledged within the Service Level Agreement (SLA) target time (2 working days); closure of complaints was an average of 32 days over the SLA; and only 7.5% of complaints included an improvement action

• although there has been an expansion of the Key Performance Indicators used to monitor the delivery of the Customer Feedback Policy, there has been no development in the information which is made public. There is much more to do to ensure that the public has a good view of how the Government of Jersey performs against its Policy objectives, in particular in learning from complaints and avoiding repetition

• the Customer and Local Services Department (CLS) took ownership of most of the 19 recommendations from my Report Handling and Learning from Complaints (2020). CLS set up a project to manage implementation of the recommendations. A project manager oversaw work to implement the recommendations and undertook specific tasks. All recommendations were monitored through the Government's C&AG Recommendation Tracker and all recommendations were marked as complete. My follow up work has concluded that 14 of the 20 relevant recommendations made in the two 2020 reports have been implemented, five have been partially implemented and one has not been implemented.

Conclusions

10. The Government clearly recognises that a persistent and consistent focus on delivering the commitments and requirements of the Customer Feedback Policy is key to improving the quality of the services it provides.
11. Important progress has been made since my 2020 review. The Policy is aligned with good practice and associated high-quality processes are increasingly in place.
12. However, maximising the efficiency, effectiveness and reputational benefits of ensuring that learning is taken from complaints requires that:

• all Government departments set and uphold the same high standards of welcoming and managing complaints

• all customers of public services are equally enabled, encouraged and supported to provide feedback, including complaints

• arrangements extend to services that are commissioned with public funding; and

• information on complaint themes and also how they are managed clearly drives changes in practice.

13. Improvements made since my 2020 report are very encouraging: I have observed the Government's ambition to develop customer centric services through its Customer Experience and Customer Insight developments. Ensuring that a levelling up' approach is achieved, avoiding wide variation in how customers experience different Government services, should be the driver for future decision making.

Objectives and scope of the review

14. My review has considered:

• the progress made in implementing agreed recommendations

• the extent to which the recommendations as implemented have addressed the improvement areas identified in the report; and

• the adequacy of plans for the implementation of any outstanding recommendations.

15. In line with my 2020 review, this Follow Up has not extended to:

• a detailed review of the work of the Complaints Panel or Ministerial responses to Complaints Board findings

• the work of the Police Complaints Authority; or

• Arm's Length Organisations.

16. I have considered the status of my 2020 recommendations against existing arrangements for handling and learning from complaints as well as the anticipated impact of the introduction of the JPSO.
17. In high performing organisations the principles, people and process for complaints handling and the analysis of complaints are underpinned by a culture that values complaints (see Exhibit 1).

Exhibit 1: Handling and learning from complaints: areas of focus

Principles People

Culture

Process Analysis

Source: Adapted from: Australian Commonwealth Ombudsman Better Practice Guide to Complaint Handling: five elements of effective complaint handling

18. This Follow Up report uses this structure to report my findings.

Detailed findings

Culture

19. The effectiveness of arrangements for handling and learning from complaints is underpinned by the culture of an organisation. Complaint handling works best where there is a shared view that complaints are valued as an opportunity to learn and in doing so, to improve public services.

Follow up of 2020 recommendation

20. In my 2020 Report I noted that in the context of a wider transformation of public services, the establishment of the Customer Feedback Project, development of a Customer Strategy and development of the Customer Feedback Policy, were important steps in establishing a culture that embraced complaints.
21. I also noted that the Government tone from the top' has emphasised the importance of complaints as an integral part of improving public service provision. However, it would require persistent, consistent effort and take time to embed a culture that values complaints and does not see them as a threat.
22. I made one overarching recommendation in this area (see Exhibit 2). While this recommendation was implemented there is more to be done to ensure consistency across all Government departments.

Exhibit 2: Progress against recommendations relating to culture

Recommendation Current Position  Evaluation

R19 Develop plans for a  The June 2022 relaunch  Implemented

relaunch of the Customer  comprised an updated

Feedback Policy to staff  Policy document, internal  There is though more to do following further work to  and external branding and  to ensure buy-in of all secure management buy-in  the roll out of a  Government services to a

and implementation of the  communications plan. It  single, agreed set of recommendations about  was managed alongside  standards for handling, complaints management  other aspects of improving learning from and contained in this report. the customer experience,  reporting on customer

including by developing  complaints.

insights into the customer  Despite the relaunch and journey' through a variety  the preparatory work, there of public services.  remain differences of

The Policy was refreshed in  practice which create

May 2023.  challenges in meeting the

requirements of the Policy and aligned quality

Recommendation Current Position  Evaluation

assurance and reporting processes.

There is also more to do to ensure all parts of Government welcome and value complaints.  

Source: Jersey Audit Office analysis

Leading and driving cultural change

23. The drivers for the 2022 relaunch of the Customer Feedback Policy include my 2020 Report, but also the Care of Children in Jersey Review Panel request that:

the Chief Minister ensures a campaign is conducted prior to the 2022 election to ensure that the public are fully aware of complaints processes'.

24. The Government has shown a significant commitment to and investment in launching and relaunching the Customer Feedback Policy. There are important improvements in support of good practice in handling customer feedback.
25. The Customer Feedback Policy designates specific roles and responsibilities in supporting its implementation. Exhibit 3 sets out the senior staff commitments' as they are listed.

Exhibit 3: Senior staff commitments' to Policy implementation

Source: Extracted from the Government of Jersey Customer Feedback Policy published in May 2023

26. The Policy also sets out the commitment of Department Feedback Managers (DFMs) and Section Feedback Manager (SFMs), as well as all staff members.
27. Although the commitments for senior managers describe the need to ensure action is taken to improve services in response to complaints, there is no explicit reference to roles in and responsibilities for:

• identifying where there is a need or opportunity for wider learning

• communicating and sharing across Government; or

• highlighting the efficiency, effectiveness and reputational benefits of ensuring that learning is taken from complaints.

28. Implementing the Customer Feedback Policy is one part of delivering the Government's Customer Strategy. In early 2023, following three years of overseeing the development of the Government's Customer Strategy, the Customer Strategy Board was renamed the Customer Experience Board.
29. The Board meets bi-monthly and comprises representatives from all Government departments. The responsibilities of Board members have been described and are chiefly operational. It is not clear what the Board's duties are to report, escalate or cascade information. No action notes are kept although there is a slide pack for each meeting which indicates the key focus.

30. I have found it difficult to fully understand the decision making, action and escalation responsibilities of the roles referred to in the Policy. It is also not always clear how leadership is brought to bear to ensure priorities and risks are addressed.

Risk management

31. The CLS Risk Register includes:

If the Government of Jersey does not handle complaints well, we risk not learning and improving our services and repeating poor practice. This would lead to regulatory action and reputational risk and a loss of trust in Government.'

32. This risk is rated as high' and notes a risk appetite of medium'. The risk is therefore outside the Department's tolerance level. The register notes the need to make improvements in two areas of mitigation, by enhancing:

• the Quality Assurance Framework; and

• take up of mandatory training.

34. Actions associated with these are set out as:

• the Customer Experience Team working with DFMs to ensure that there is better analysis and learning as a result of quality sampling; and

• continue to assess and roll-out training to relevant people. This includes customer service skills and complaints handling [and] accessibility of training for all staff.

34. However, no specific workstreams have been established to implement these actions. There is no clear documentation of:

• the responsibilities of the different parts of the delivery chain to implement these mitigating actions; or

• how oversight arrangements will enable monitoring to ensure that the risk is reduced to within tolerance.

Consistent application of the Policy

35. Both the quality of information available on customer feedback and its analysis have significantly improved since my 2020 Report. However, improvements are chiefly focussed on the mechanics' of handling complaints and the types of

complaints received. There has been much less focus on the efficiency, effectiveness and reputational benefits of ensuring that learning is taken from complaints. As yet, ambitions to actively capture, share and use learning to enable services to get things right first time' are not sufficiently well addressed.

36. The Customer Feedback Policy clearly sets out the areas that the Policy does not cover. Exceptions include, for example, complaints concerning General Practitioners, private healthcare, Crown Officers and States Members. In some cases the Customer Feedback Policy includes links to other applicable policies.
37. The only exception relevant to Government services is where complaints concern States of Jersey police officers. The Policy and the commitments it sets out apply equally to all other parts of Government. However, since it was first published, there have been inconsistencies in the way and the extent to which the Policy's commitments have been adopted.
38. For complaints made in relation to HCS, data is not managed through the Customer Feedback Management System but instead entered into a system called Datix. Datix is also the risk management system for HCS.
39. While it is clear that a positive decision has been made to use Datix to manage HCS complaints, the consequence is that complaints data covering all Government departments is not currently analysed and reported in a consistent and comparable way.  
40. HCS's performance in managing complaints is not assessed or reported against all of the Key Performance Indicators (KPIs) drawn up to reflect the requirements of the Customer Feedback Policy. Instead, performance in handling complaints within Datix is limited to the timeliness of responses, by HCS Care Group. There is no shared report from Datix focussing on the outcome of the complaint (for example, upheld, not upheld) or whether an improvement action has been taken. I understand that work is underway to ensure that an upgraded version of Datix - Datix B - can extract this performance information and that progress is being made.
41. The system that is used for recording complaints is not the only way in which departments vary in their response to the Government-wide Policy. At the time of my review HCS had produced a flowchart describing its process for managing complaints. This though did not follow the Government Policy's:

• timeframes for response; or

• stages' of complaints management.

42. Like other departments, HCS worked with the Customer Experience Team on the updated Policy which was issued May 2023. However, differences in practice and process remain.
43. The practice adopted by HCS does not meet the requirements of the Policy. The Policy sets out the criteria and the designated timeframes for complaints management through different stages. These are:

• acknowledge the complaint: within 48 hours

• Stage 1 - Frontline complaint handling and early resolution of complaints: five working days

• Stage 2 - Escalation to team leader or manager for issues that require further investigation or are complex: ten working days; and

• Stage 3 - Escalation to Chief Officer if the issue is still not resolved: ten working days.

44. The Policy states that, for those complaints where customer consent to access information is required, day one of the timeframe will begin on the day that consent is received. System enhancements currently being developed are intended to enable cases to be flagged as awaiting consent' so that the system recognises day one' of the timeframe as the date that consent is received.
45. The Policy also makes it clear that:

• complaints which are clearly complex can go straight to a Stage 2 approach; and

• timeframes can be extended, by exception, in the case of more complex complaints.

46. These provisions enable all complaints to be managed within the Policy requirements. However, the HCS flowchart did not reference the three Stages or the agreed designated timeframes. It had just two timeframe requirements:

• acknowledge within three days in writing/verbally/via email; request consent if required; and

• maximum timescale for resolution: 28 days. If you will exceed this, permission must be gained from appropriate Executive.

47. Clearly some healthcare related complaints will be complicated and might require that consent to share information is granted before investigations can begin. These can be catered for within the Policy's guidelines. However, some

complaints will be more straightforward. HCS's Patient Advice and Liaison Service (PALS) team aims to acknowledge complaints either verbally or in writing within 48 hours of receipt. PALS also seeks to offer early resolution of complaints where this is possible. However, it is not currently possible to assess how well HCS manages the complaints compared to other departments.

48. HCS has acknowledged that the flowchart was incorrectly aligned to the Government-wide Policy and it has been withdrawn. I understand it is intended that a compliant version will be issued in the final quarter of 2023.

Feedback from DFMs and SFMs

49. As part of my follow up review I invited the network of DFMs and SFMs to complete a survey. It was responded to by eight DFMs and by 20 SFMs.
50. DFMs and SFMs in the main report that the Government as a whole and their specific Department are getting better at being:

• customer focussed; and  

• fair and proportionate in their response.

51. This is reassuring. The area where DFMs and SFMs have a potential difference of view concerns whether learning from complaints is helping to get things right first time' (see Exhibit 4).

Exhibit 4: Survey responses from DFMs and SFMs relevant to culture DFMs: As a Government we are getting better at:

7 6 5 4 3 2 1 0

Being customer focussed, open Ensuring that responses to Using learning from complaints to and accountable complaints are fair and get things right first time proportionate

Strongly agree Mostly agree Don't know

SFMs: As a Department we are getting better at:

12 10 8 6 4 2 0

Being customer focussed, open Ensuring that responses to Using learning from complaints to and accountable complaints are fair and get things right first time proportionate

Strongly agree Mostly agree Mostly disagree

Source: Jersey Audit Office survey and analysis

The Jersey Public Services Ombudsman (JPSO)

52. The Government is currently developing the Law which is planned to be lodged in the States Assembly in the last quarter of 2023. I understand that recruitment of the first Ombudsperson and the first Chair of the JPSO Board is planned to commence when the principles of the Law have been formally adopted by the States Assembly. The JPSO will then be established in shadow form before the Law is brought into force, to provide the JPSO with time to prepare properly to take on its statutory functions.
53. Of particular relevance to my Follow Up review is that the Law drafting instructions as at July 2023 include that the JPSO will:

• investigate complaints about any entity which receives public money or manages public assets to deliver services to the public, subject to certain exceptions which will be set out in the law

• produce minimum standards for how public bodies handle complaints, supporting them to learn from complaints and deliver service improvements

• be able to conduct own-initiative investigations where there is evidence of systemic service failure or maladministration by public bodies; and

• be able to undertake joint investigations with other bodies where appropriate.

54. That the Government can demonstrate a consistent, high-quality process for welcoming, managing and learning from customer complaints will be significant to how the JPSO acts.

R1 Establish governance arrangements that ensure that all parts of Government

implement complaints management procedures that align with the commitments stated in the Customer Feedback Policy.

R2 Be explicit about the roles, responsibilities and mechanisms for:

• ensuring robust action plans are in place and effective in mitigating the complaints' risk as set out in the CLS Risk Register

• ensuring a renewed focus on capturing lessons learned' from complaints received

• communicating and sharing learning across Government including, where relevant, to commissioned services; and

• evaluating the efficiency, effectiveness and reputational benefits to the Government of ensuring that the learning extracted from complaints is maximised.

Work planned that should be prioritised

P1  Until the JPSO's responsibilities also cover health services, make sure that

arrangements are clear and are communicated for how post Stage 3' health care related complaints will be managed.

Principles

55. In 2020 I reported that solid progress had been made in establishing the principles for handling complaints. The (then) new Customer Feedback Policy reflected many elements of best practice. It made clear that all complaints would be handled on merit and with transparency. Measures were set out to manage fairness, impartiality and confidentiality.
56. There was however scope for improvement, especially in relation to ensuring a cross-Government approach to:

• responding to particular needs and to more vulnerable complainants; and  

• complaints relating to more than one service provider, whether in the context of a contracted-out service or a complaint that relates to the Government and another public sector body.

57. The Policy was updated and relaunched in June 2022 and refreshed in May 2023.
58. I made three recommendations relating to the principles of the Government's approach, focussed on ensuring all Islanders would feel equally able to provide feedback on their experiences of public services, from any Government department. Progress against these recommendations is summarised in Exhibit 5. Action has been taken in respect of all three recommendations, with two implemented and one partially implemented.

Exhibit 5: Progress against recommendations relating to principles

Recommendation Current Position  Evaluation

R1 Include in the  A post-implementation review was  Implemented

planned  post- undertaken and a report issued  A comprehensive post - implementation review  internally in December 2021. This

consideration of  comprehensive document  impwas lemeundenrttaaketionn  rewhvieichw  solutions to the current  includes:

barriers to access,  consideration of the areas  identified some

including for:  identified in the  signProgressifican sint  accece tsshis issues.  

• children and young  recommendation review has not resolved people  identification of issues in five  all identified potential

• people with  key access areas:  barriers to access.

sensory disabilities   language

o

• those whose first  o  culture

language is not

English; and  o  skills and knowledge

• alternative channels; and

Recommendation Current Position  Evaluation

understanding of  There is no guidance to support  However, this is as yet the scope and  departments in ensuring contracts  not finalised or rolled responsibilities of  include the requirement for a  out.

each other's  suitable complaints management

complaints  policy and process.

processes; and  The Complaints Handling Manual

• there are mutually  includes a brief section on

agreed  complex complaints where

approaches to  multiple departments or teams are

handling  involved. Where no one

complaints relating  department is willing to take a

to more than one  lead', the Customer and Local

public body,  Services Department (CLS)

including coverage  oversees the process.

of information  However, the guidance does not

exchanges, joint

working and  cowhveere r heow to mxternal , comanag mie sitssionuationed ors  

monitoring the  contracted providers are involved.

effectiveness of

handling such

complaints.

Source: Jersey Audit Office analysis

Accessibility of providing feedback

59. The Government is aware that currently not all Islanders find it equally easy to provide feedback – comment, compliment or complaint - about their experiences of public services.
60. The 2021 post-implementation review concluded that:

• there was an absence of consistent, accessible information for the most vulnerable Islanders; and

• the current process for submitting feedback and tools/channels available were not fit for purpose.

61. A Complaints Handling Manual, launched in September 2021 to support use of the Customer Feedback Management System, notes the importance of recognising the barriers that some customers may face in making a complaint. It also recognises that customers may need support to overcome these barriers. The Manual sets out the duty to make the complaints service equally accessible to all, through, for example:

• helping vulnerable customers identify when they might wish to make a complaint (for example, by training frontline staff who provide services to known vulnerable groups)

• helping customers access independent support or advocacy to help them understand their rights and communicate their complaints (for example, through the Citizen's Advice Bureau and the Office of the Children's Commissioner); and

• providing neutral points of contact for complaints (where the relationship between customers and frontline staff is significant and ongoing).

62. The Government's Quality Assurance Framework established in March 2021 includes issuing an email to customers who have made a complaint, when their complaint is closed. The first question is How easy or difficult was the process of contacting us about your complaint?'. In the second quarter of 2023, 121 surveys were sent out and 37 returned. Of these, 67% reported that they were satisfied' or fairly satisfied' with ease of access (against a Government target of >80%). The proportion reporting being fairly dissatisfied' or dissatisfied' was 17%.
63. Following up immediately to understand how the complainant rates their experience is a good practice approach. However, performance is not currently meeting the Government's target. In addition, as this survey of complainants is limited to those who have provided an email address, it is unlikely to reach those customers who find it most difficult to access and use an online system.
64. In a parallel workstream, some customers who contact a department's telephone helpline' (for information and advice, not to make a complaint) have an opportunity at the end of the call to record a comment, including on how easy it was to access help. This is good practice. It is currently limited to those departments that use the Mitel telephone system, but this includes important customer facing services such as CLS and police. The customer recordings have been useful in identifying staff who have been particularly helpful in resolving queries. Outcomes have been celebrated in management reports.
65. This facility is only available to customers who seek support through established Government helplines. There is no equivalent facility for customers whose telephone contact is to make a complaint rather than seek advice.
66. The 2022 Disability and Inclusion Annual Report states that:

[We] encouraged Islanders to use the feedback routes to log accessibility issues and supported some Islanders to feedback specific communication barriers. Colleagues were asked to create customer journeys and explore how Islanders experienced our services, for example if they could not use the telephone, or the GoJ [Government of Jersey] website didn't work for them. The team highlighted when services weren't accessible and what that meant for customers.

Next year will see the introduction of an accessible communications standard, which will set out how the GoJ should communicate to ensure that this works for people with disabilities.'

67. The Government is undertaking significant work to understand potential barriers to customer feedback. The Government has joined with a wide range of stakeholders to develop clusters' and networks in the key areas of:

• Adult Mental Health

• Cancer Support

• Children

• Equality, Diversity and Inclusion

• Homelessness

• Learning Disability and Autism; and

• Older Persons.

68. Stakeholders including service users, professionals and members of the public meet to exchange information and share learning and experience. This approach has provided Government with opportunities to, for example, develop strategies and enhance ways of working to better meet needs. The barriers to making a complaint about Government services have been discussed in some groups. The Customer Experience Team intends to maximise the opportunities that these stakeholder groups present in moving policy, practice and accessibility forward.
69. There is however as yet no one, coherent, prioritised and resourced action plan to deliver on the stated duty to ensure all customers can easily provide feedback on public services.
70. While it is clear that there are ambitions to work closely with seldom heard voices' to fully understand cultural and other barriers, some areas that might be considered quick wins' have not been taken. Key amongst these are:

• clearly highlighting links to the Customer Feedback Management System from all Government services home' webpages. Currently all @gov.je pages provide a link in the administration' area of home pages, alongside Sitemap' and Terms and Conditions'. Customer feedback is not highlighted within the service pages in the same way as, for example, how to make a Freedom of Information request; and

• making sure that the Customer Feedback webpage highlights and links to, for example, the opportunity to provide feedback through the easy read' Government webpage.

71. Following an internal review of practice, in 2020 CYPES appointed an officer to manage feedback in Children's Services, to ensure that comments or concerns are resolved promptly and managed through a new user-friendly, robust and fit-for- purpose process'.
72. The work undertaken by the initial postholder is acknowledged by the Customer Experience Team to have made an important difference in enabling feedback from a range of service users on the performance of Children's Services.
73. It is though not clear that the expertise developed by the post holder has been utilised by other parts of Government to improve opportunities for children and young people to provide feedback on any publicly funded service.

Feedback from DFMs and SFMs

74. Charts in Exhibit 6 show responses from DFMs and SFMs to survey questions relevant to the principles of enabling customer feedback.

Exhibit 6: Survey responses from DFMs and SFMs relevant to principles

DFMs: My Department has assessed and resolved any barriers to customers being able to provide feedback, including complaints

5 4 3 2 1 0

Strongly Mostly Mostly Strongly Don't agree agree disagree disagree know

SFMs: My Section has assessed and resolved any barriers to customers being able to provide feedback, including complaints

12 10 8 6 4 2

0

Strongly Mostly Mostly Strongly Don't agree agree disagree disagree know

DFMs: Overall, I think my Department performs well in encouraging and facilitating feedback, including complaints

4 3

2 1 0

Strongly Mostly Mostly Strongly Don't agree agree disagree disagree know

DFMs: My Department receives feedback from a diverse range of our customers

4 3 2 1 0

Strongly Mostly Mostly Strongly Don't agree agree disagree disagree know

Source: Jersey Audit Office survey and analysis

SFMs: Overall, I think my Section performs well in encouraging and

facilitating feedback, including complaints

12 10 8 6 4 2

0

Strongly Mostly Mostly Strongly Don't agree agree disagree disagree know

SFMs: My Section receives feedback from a diverse range of our customers

10 8 6 4

2 0

Strongly Mostly Mostly Strongly Don't agree agree disagree disagree know

75. The DFMs' view on the diversity of customers providing feedback shows the biggest variation of response. This might indicate an opportunity to identify and replicate what is working well for some departments.
76. The Customer Experience Team at CLS intends to work increasingly closely with DFMs and SFMs to understand strengths and challenges within departments and across Government. This first survey should provide a useful baseline.

Provision of services by contracted or commissioned providers

77. Where publicly funded services are delivered by contracted or commissioned providers, sometimes off Island, there remains work to be done to ensure that customer feedback is consistently:

• welcomed, straightforward to provide and acted on; and

• supported by high quality processes which meet an agreed set of standards.

78. The Commercial Services function is currently reviewing contracts placed by Government departments to understand the quality of the terms and conditions as

set in each contract. Following this, the function intends to develop a contract template checklist' to support higher quality contracting of services, including to help departments ensure contractor arrangements on managing complaints dovetail with the commitments set out in the Customer Feedback Policy.

79. There are also issues with ensuring that those more remote' Government services such as care homes are compliant with the Customer Feedback Policy. The Case Study below sets out an example.

Case Study

In December 2021 the Jersey Care Commission inspected a Nursing Home run and managed by HCS. As part of that, Regulation Officers spoke with care receivers and relatives about what information they had received about how they might provide feedback, including making a complaint.

Care receivers and relatives responded that they had not been informed of the home's complaints policy or procedures. One relative commented that they had not received any information of this nature and wouldn't know how to formalise any concerns'.

The Care Commission's report set out that a record of all communication with complainants, results of investigations and outcomes should be maintained in the home and in the same way, a log of all compliments when received, should be maintained to share with the staff team. This was identified as an area in need of improvement, which the Registered Manager agreed to address.

However, in a follow up visit in October 2022 the Care Commission found there was no evidence of improvement. During this inspection, a relative informed the Regulation Officer that their experience of having raised concerns with the home had been met with a negative response. They reported that no attempts had been made to find an amicable solution and issues raised had not been acknowledged.

A further inspection in April 2023 found that the process for informing care receivers and relatives about how to make a complaint had been improved. The Regulation Officer noted that complaints information was displayed in the home.

80. The JPSO's role will extend to complaints about any entity which receives public money or manages public assets to deliver services to the public, (subject to certain exceptions which will be set out in the law).

R3 Develop an overarching, coherent, prioritised and resourced action plan to deliver

on the stated duty to ensure all customers can easily provide feedback on publicly funded services.

R4  Broaden the post-complaints follow up process to ensure that all complainants

(where contact information is held) have an opportunity to feed back on their experience, not just those that provide an email address.

Work planned that should be prioritised

P2 Develop and implement a checklist' to support departments in ensuring

contractor arrangements on managing complaints dovetail with the requirements of the Government's Customer Feedback Policy.

People

81. Good complaints handling relies on the engagement and use of staff with the right skills, experience, training and supervision to deal directly with complaints as well as a wider awareness of complaints management amongst all staff in an organisation.
82. In 2020 I reported that the model adopted by the Government of Jersey involved:

• a small corporate team in CLS comprising a Customer Experience Manager and a Customer Feedback Manager; and

• designation of DFMs and SFMs who have a key role to perform in handling complaints.

83. I noted that the process of identification of staff to perform these roles had been impacted by the roll out of the Government's Target Operating Model and that no clear role descriptors were agreed and in place.
84. Also lacking was a clear, documented structure for corporate training and support for departmental complaint handlers. As part of this, there was a need for more clarity on arrangements for oversight and monitoring of departmental complaints handlers, to mitigate the risk of complaint handling that is not in accordance with the Customer Feedback Policy.
85. The Government had recognised that, although some staff will focus on complaints, all staff have a role to play in the management of complaints and that wide understanding of corporate policies and processes is vital. Mandatory on - line training on the Customer Feedback Policy for all staff, including agency staff was established. However:

• there was no corporate policy on whether volunteers should undertake the training; and

• take-up of training had been variable across departments.

86. I made four recommendations relating to the people engaged in delivering the Customer Feedback Policy. Progress in implementing these recommendations is summarised in Exhibit 7. Three recommendations have been implemented and one has been partially implemented.

Exhibit 7: Progress against recommendations relating to people

Recommendation Current Position  Evaluation

R4 Develop and adopt a  The Customer Feedback Policy  Implemented common role description  was updated in July 2022 and in

for key departmental staff  May 2023.

involved in handling  Both updates include role

complaints.  descriptions for Chief Officers,

Departmental Senior

Management Teams (SMTs),

DFMs, SFMs and all staff.

R5 Develop, agree and  As well as mandatory training, a  Implemented implement corporate  suite of optional online training

arrangements for support,  covers, for example, managing

including training for and  complex complaints.

oversight of departmental  Corporate arrangements for

complaints handlers. oversight and support of DFMs

needs some clarification. DFMs

and SFMs are required by the

Policy to work with advisors'

but there is no detail on the

nature of this relationship.

R6 Develop, adopt, roll out  A guide has been developed  Implemented and monitor compliance  for volunteers which covers

with corporate standards  Dignity and Respect, Diversity

for promoting awareness of  Inclusion and Belonging and

complaints handling  Health and Safety.

processes for volunteers. There is a specific focus on

signposting and enabling

customers to provide feedback,

including complaints.

Recommendation Current Position  Evaluation

R7 Identify barriers to take- The Government has resolved  Partially implemented up of mandatory on-line  an issue with the visibility of  Compliance with training and take  data on the take-up of Virtual  mandatory training appropriate corrective  College online training. This  requirements is poor in action.  means managers now have  some areas and no

good information on who has  coherent plan is in place completed, started or not  to resolve this issue. accessed mandatory training.

Since my 2020 Report, Customer Feedback training has been re-issued. Line managers are responsible for ensuring staff can access and have time to complete this.

However, compliance is poor in some areas. By June 2023, completion levels were:

• Treasury and Exchequer: 95%

• Department for the Economy: 91%

• CLS: 87%

but:

• CYPES: 25%; and

• HCS: 35%.

Source: Jersey Audit Office analysis

87. Implementing the Customer Feedback Policy is one part of delivering the Government's Customer Strategy. In early 2023, following three years of overseeing the Government's Customer Strategy, the Customer Strategy Board was renamed the Customer Experience Board.
88. The Board meets bi-monthly and comprises representatives from all Government departments. The responsibilities of Board members have been described and are chiefly operational. It is not clear what the Board's duties are to report, escalate or cascade information. No action notes are kept although there is a slide pack for each meeting which indicates the focus.
89. The role of the Customer Experience Board in supporting delivery of the Customer Feedback Policy is not set out in the Policy. Of relevance to handling and learning from complaints, the Board's stated priorities for 2023 include to:

• improve complaints handling, reporting on lessons learned / improvements (You said, We did) and Quality Assurance processes

• design and conduct a gap-analysis / maturity-level assessment (MLA) within/across departments to help identify appropriate actions that can be implemented to improve customer experience; and

• create departmental improvement plans based on findings from MLA and have them signed-off at senior management level.

Feedback from DFMs and SFMs

90. The survey of DFMs and SFMs indicates that in most cases roles and responsibilities are understood and agreed. There is though variation (see Exhibit 8) in the extent to which:

• both DFMs and SFMs feel there is a good balance in roles and responsibilities

• DFMs report they have adequate time and space to undertake the role; and

• SFMs consider they are properly trained and supported.

Exhibit 8: Survey responses from DFMs and SFMs relevant to people

DFMs: The balance of roles and responsibilities in my Department, including of SFMs and all members of staff, works well in managing complaints

4 3 2 1 0

Strongly Mostly Mostly Strongly Don't agree agree disagree disagree know

SFMs: The balance of roles and responsibilities in my Section, including those of all members of staff, works well in managing complaints

8 6 4 2 0

Strongly Mostly Mostly Strongly Don't agree agree disagree disagree know

DFMs: I have time allocated and a suitable place / space to perform this role

2 1 0

Strongly Mostly Mostly Strongly Don't agree agree disagree disagree know

DFMs: I have the training and feel properly supported by the CLS Customer Experience Team to deliver my role and responsibilities

4 3 2 1 0

Strongly Mostly Mostly Strongly Don't agree agree disagree disagree know

Source: Jersey Audit Office survey and analysis

SFMs: I have time allocated and a suitable place / space to perform this role

14 12 10 8 6 4 2 0

Strongly Mostly Mostly Strongly Don't agree agree disagree disagree know

SFMs: I have the training and feel properly supported by my DFM to deliver my role and responsibilities

14 12 10 8 6 4 2

0

Strongly Mostly Mostly Strongly Don't agree agree disagree disagree know

91. Across Government departments, some DFMs are substantive posts and for others, managing customer feedback is one part of their wider responsibilities. The survey results indicate an opportunity to consider whether time and space allocation for both DFMs and SFMs is proportionate to the current need but also adequate to manage future plans for levels of customer feedback.
92. Comments from my survey of DFMs and SFMs include the opportunity to ensure that wider training opportunities are understood and promoted for those most likely to handle complaints.

Recommendations

R5  Implement a specific workstream to understand and resolve the low level of

compliance with mandatory customer feedback training requirements in relevant Government departments.

R6  Ensure that the line managers of DFMs and SFMs determine the need and

opportunities for extended training so that DFMs and SFMs can deliver their roles.

Work planned that should be prioritised

P3  Ensure that the gap analysis / maturity-level assessment to be undertaken in each

Government department includes a review of the resources (including time and space) allocated to DFMs and SFMs to carry out their wider role in supporting customer feedback, to ensure their adequacy now and in the future.

Area for consideration

A1  Review the operation of the Customer Experience Board to make sure that

arrangements for:

• setting agendas

• noting and monitoring actions agreed; and

• reporting, escalating and cascading information are clear.

Process

93. Consistent implementation of complaints handling across Government requires that clear, accessible processes covering all stages of complaints handling are adopted across all Government departments.
94. In 2020 I reported that a Customer Feedback Management System had been established to log and capture information about the handling of complaints. However it was not supported by comprehensive corporate procedures to ensure it was used consistently and in line with the Customer Feedback Policy.
95. There were also opportunities to improve both the type of information captured by the Customer Feedback Management System and the format in which it was captured, to provide a richer analysis of feedback.
96. In addition, a corporate approach to reviewing the processes used within departments and to monitor departmental compliance with the Customer Feedback Policy in key areas (for example, confidentiality) was yet to be developed.
97. I made five recommendations in my report Handling and Learning from Complaints (July 2020) and one relevant recommendation as part of Management Information in Education – Follow Up (August 2020). Progress against these is set out in Exhibits 9 and 10.

Exhibit 9: Progress against Handling and Learning from Complaints (July 2020) recommendations relating to process

Recommendation Current Position  Evaluation

R8 Develop, adopt and roll The Complaints Handling  Implemented

out operating procedures  Manual, launched in September

and model documentation  2021, is an accessible guide  Gopueidrataninceg p onro cedures to support application of  focussing on areas such as:  has been significantly

the complaints policy  receiving and seeking to  enhanced and a covering:  resolve complaints, with a  process established

• initial contact  focus on fairness and  to assess practice.

• complaint assessment  confidentiality

and assignment of  Service Level Agreement

priority  (SLA) time commitment for

• planning of the  stages of a complaint complaint investigation  what type of investigation is

• securing fairness in the  required (including

templates) and whether

investigation

immediate escalation to

• complaint response Stage 2 is indicated; and

Recommendation Current Position  Evaluation

improvement on closure of a complaint.

Currently:

• there is no analysis of the remedy being sought' as this is free text; and

• Quality Assurance Framework audits show information to enable identification of systemic issues is not well recorded.

R11 Establish and  A Quality Assurance Framework  Partially

implement procedures for  is in place and requires that  implemented  

quality assurance of all  each month, departments audit  More is needed to departmental procedures a sample of complaints against  ensure that:

for handling complaints.  the required standards.

• HCS fully

The Framework reflects the

participates in the introduction of:

R12 Establish and  Quality Assurance implement procedures for  customer satisfaction emails  Framework audit monitoring departmental  on complaint closure; and  process; and compliance with corporate  audit methodology to test:    quality assurance policy.

  communication  procedures lead to

o

improvements in

• policy adherence all Government
• process adherence; and  departments, in particular in
• improvements identified.  logging and

HCS does not participate in this  sharing

Quality Assurance Framework  improvements audit. The recently upgraded  identified.

Datix system can provide the

required information and the

volume of sampling has

increased. However the full

audit is not yet routinely

undertaken.

Source: Jersey Audit Office analysis

Exhibit 10: Progress against the Management Information in Education – Follow Up (August 2020) recommendation relating to complaints

Recommendation Current Position  Evaluation

R12 Develop mechanisms  The 2023 Customer Feedback  Not implemented within CYPES for systematic  Policy sets out that, in education

monitoring of and shared  services, Stage 1' complaints  FCYurtPhEeS to enr work sub re it is y learning from schools  should be managed by schools. aware of all Stage 1,

complaints.  If there is not a satisfactory  Stage 2 and Stage 3

resolution at Stage 1, then Stage  complaints is planned 2 and Stage 3 complaints can be  for quarter four of managed by:  2023.

• the Head Teacher It is expected that this

• the school Board of  enabling work will assist in the planned

Governors; or

roll out to all schools

• CYPES.  in early 2024.

There are no criteria for how the decision on management is made. CYPES is not informed of any complaints managed by schools, Head Teachers or school Boards.

A pilot scheme, whereby a school would complete a monthly online form with the number of Stage 2 and Stage 3 complaints, with themes, was introduced in 2022. However this was rejected by Head Teachers and does not operate.

Source: Jersey Audit Office analysis

Monitoring compliance

98. Processes to support and monitor compliance with the Customer Feedback Policy have been developed since my 2020 review. These have not yet been:

• made fully effective to ensure high quality handling and learning; or

• applied across all Government services and departments.

99. Data from the most recent Quality Assurance Framework audit (covering the period from January to August 2023 and excluding HCS data) shows that:

• only 38% of complaints were recorded as having been acknowledged within SLA (two working days)

• closure of complaints was an average of 32 days over the SLA; and

• only 7.5% of complaints included an improvement action.

100.  The audit also showed that overall compliance with standards is::

• 72% for communication standards

• 87% for policy adherence; and

• 84% for process adherence.

101.  To date in 2023, reporting of performance against the Quality Assurance

Framework to the Executive Leadership Team and Operating Committee has not included any written narrative on improvements required and their priority.

102.  The process to implement the Policy includes that, where the need for service

improvement is identified and authorised:

• an officer (or team) should be designated the 'owner' of the issue, with responsibility for ensuring the action is taken

• a target date must be set for the action to be taken

• the designated individual must follow up to ensure that the action is taken within the agreed timescale

• where appropriate, performance in the service area should be monitored to ensure that the issue has been resolved; and

• any learning points should be shared with relevant staff.

103.  The Policy sets out that senior management will:

• review the information reported on complaints regularly to ensure that any trends or wider issues which may not be obvious from individual complaints are quickly identified and addressed; and

• take appropriate action, monitored to ensure that the issue has been resolved.

104.  Once established, the JPSO's role will include production of minimum standards

for how public bodies handle complaints, supporting them to learn from complaints and deliver service improvements.

Feedback from DFMs and SFMs

105.  In my survey of DFMs and SFMs, it was clear that the weaker part of the process in

their view was in identifying learning and escalating risks and opportunities (Exhibit 11).

Exhibit 11: Survey responses from DFMs and SFMs relevant to process DFMs: My Department uses CFMS (Datix) well in:

4 3 2

1 0

Logging all feedback received Managing all feedback Identifying learning and escalating risks and opportunities

Strongly agree Mostly agree Mostly disagree

SFMs: My Section uses CFMS (Datix) well in:

10 9 8 7 6 5 4 3 2 1 0

Logging all feedback received Managing all feedback Identifying learning and escalating risks and opportunities

Strongly agree Mostly agree Mostly disagree Strongly disagree Don't know

Source: Jersey Audit Office survey and analysis

106.  Comments from the survey of DFMs and SFMs included that:

• the Customer Experience Team are helpful and receptive to requested changes to the Customer Feedback Management System; but

• feedback on trends and hot spots' could be strengthened.

Coverage of the process

107.  Identifying what is or is not a complaint' is clarified within the Complaints Handling

Manual by the statement that:

The Government of Jersey's definition of a complaint is: An expression of dissatisfaction, either spoken or written, about the organisation, its products, services, staff or its administration, that requires a response.'

108.  It further establishes that complaints dealt with may relate to:

• the standard of service we provide

• how we administer services and the processes we use

• the advice we have given

• the behaviour of our staff

• any action or lack of action by staff affecting a customer or group of customers of the department; or

• policy or Law.

109.  However, there is more to do to ensure that public correspondence received by

officers which might fall within the definition of a complaint is handled and learned from within the Customer Feedback Policy. Failure to ensure such correspondence is properly managed increases the risk that good practice timeframes and standards of response are not met and the complaint escalates.

Recommendations

R7  Ensure that the Quality Assurance Framework can be and is applied across all

Government departments and that all outcomes can be and are compared and reported together.

R8  Require schools to provide information to CYPES on numbers, themes and

outcomes of complaints they receive which:

• are resolved at Stage 1; and

• are managed by the Head Teacher or the school's Board of Governors at Stage 2 and Stage 3.

R9  Establish criteria - and report the outcome of their implementation - to guide

decisions on whether school complaints that go to Stage 2 and Stage 3 are investigated by:

• the Head Teacher

• the school's Board of Governors; or

• CYPES.

R10  Update the Customer Feedback Policy and the Complaints Handling Manual to

help officers identify whether correspondence they receive should be handled as a complaint.

Work planned that should be prioritised

P4  Keep the Complaints Handling Manual up to date, including to reflect changes:

• such as the introduction and expansion of the post-complaint satisfaction survey and criteria for its use; and

• as a consequence of the introduction of the JPSO.

P5 Ensure that the capability of the system or systems used in capturing information

about complaints is fully exploited, including by making it mandatory to consider raising an improvement on closure of a complaint.

Analysis

110.  To secure best value from complaints handling, organisations should look beyond

individual complaints to learn in a structured way from complaints as a whole. This includes both lessons to improve public services and also lessons about complaints handling practices.

111.  In 2020 I acknowledged that the Government had:

• recognised the importance and value of analysis of complaints

• implemented a system to capture and allow reporting of key metrics about complaints; and

• provided reporting on complaints to the Executive Leadership Team and departmental management.

112.  However, my review also found:

• weaknesses in ensuring the completeness and accuracy of data captured

• a limited range of KPIs, including to monitor the overall objectives of the Customer Feedback Policy; and

• that valuable information about the performance of individual members of staff and teams in handling and learning from complaints was not routinely used to support performance management.

113.  I also noted that improving the culture so that complaints are welcomed and

learned from relied on staff buy-in' to the Government's Customer Feedback Policy objectives. I recommended that metrics be identified to evaluate the extent to which the objectives are understood and owned with a view to using those to drive improvement.

114.  There were six recommendations relating to analysis (see Exhibit 12). Progress is

being made in implementing these recommendations with one recommendation partially implemented and five recommendations fully implemented.

Exhibit 12: Progress against recommendations relating to analysis

Recommendation Current Position  Evaluation R13 Develop a clear  The quality of data logged in the  Implemented

plan for improvement in  Customer Feedback Management

data quality regarding  System has been improved

complaints and monitor  through three key mechanisms:

its implementation.  system upgrades to better

define data types; and

• development of:

• the Complaints Handling Manual; and
• the Quality Assurance Framework.

R14  Expand data  The range and quality of data used  Implemented capture and KPIs to  to report on the implementation of

cover:   the Customer Feedback Policy  TMhane Cuagemstomenet Syr Festeedm back

• characteristics of  have significantly improved since  does not yet though complainants  my 2020 Report.  capture data to

• geographical spread There has been active  specifically identify consideration of the type of data it  complaints that expose

• complaints that  is appropriate and helpful to  Government weaknesses expose weaknesses  capture. Data on characteristics of  or raise questions about

or raise questions  complainants and geographical  integrity and reputation. about integrity and  spread is not currently collected.  This is a gap in data and reputation   The Customer Experience Team  KPI.

• instances of  recognises that richer information

unreasonable  is needed in support of, for

behaviour by  example, the focus on seldom

complainants  heard voices'. There are though no

• the outcome of  specific plans in place to capture

richer information.

complaints

• the themes from complaints on a structured basis; and

• measures of efficiency and effectiveness of complaints handling, including the timeliness of complaints handling and complainant satisfaction.

reasonable KPI or proxy for objectivity and fairness

• percentage of cases where the States of Jersey Complaints Panel found a service failure and / or maladministration [objectivity, fairness]

• percentage of customers satisfied with the handling of their feedback [objectivity, fairness]; and

• channels (face to face, online, telephone) [accessibility, flexibility]

R17  Develop plans to  I reported in 2020 that the  Implemented

use information from the  Customer Feedback Management  However full Customer Feedback  System can be a valuable source of  implementation of the Management System for  information about the  Quality Assurance performance  performance of individual staff and  Framework across all management purposes.  teams.  departments and

Its use in supporting appraisals is  consistent use of its

in its infancy but there has been  finding in support of some progress. appraisals is not yet The Quality Assurance Framework  achieved.

includes a monthly audit of a

sample of complaints. Each DFM is

responsible for addressing issues

identified within their area. This

can include provision of mentoring

for customer-facing colleagues.

The Customer Experience Team has fed into some DFMs' appraisal processes.

R18  Identify and use  There have been some important  Partially implemented relevant metrics to  steps forward by some

evaluate the extent to  departments in handling and  Tmeasuhere is nre to o spindeicatcific e which the Government's  learning from complaints. This  understanding,

objectives in relation to  includes participation in Customer  ownership and adoption complaints are  Insight and wider Customer

consistently understood  Experience initiatives.  opfoltheicy Gacroovessrnment's and owned.  However, stress' indicators which  departments.

might signal a lack of Policy

ownership include:

• the take-up of training in some departments

• an activity flowchart' issued by HCS not complying with Policy requirements

• the delays in updating the Customer Feedback Management System (for example the number of complaints logged as still being at Stage 1)

• slippage in meeting / recording SLA timeframes for managing complaints; and

• relatively poor customer reviews of their satisfaction with the process (not just the outcome) of their complaint.

Source: Jersey Audit Office analysis

Data quality

115.  Work to improve the quality of data recorded in both the Customer Feedback

Managements System and in Datix is on-going. There is as yet insufficient focus on the learning that is captured, shared and used. Continuous data improvement is a focus for the DFM meetings but more could be done to set milestones towards overarching objectives.

116.  There remain data quality issues to resolve and opportunities to take. For example:

• a June 2023 report noted that the high volume of complaints (94%) being dealt with at Stage 1 feels incongruous with the policy'

• complaints received and resolved by schools are not logged on the system and so are not analysed to understand themes and learning

• a Freedom of Information request for data on HCS complaints showed that in 2023 (to 15 March) 22% of complaints (26 in total) had no primary cause' recorded (for example: appointments; discharge from hospital; care; attitude and behaviour). From 2018 to 2022 a total of only six entries had no record of the primary cause of the complaint

• the HCS Annual Quality Account for 2022 notes that currently reporting on complaints received is quantitative and that this limits the thematic review of feedback; and

• planned system updates to require information about what improvements have been made before the closure of a complaint, have not yet been implemented.

Feedback from DFMs and SFMs

117.  A considerable proportion of DFMs and SFMs mostly disagreed' that robust

arrangements are in place to:

• identify themes and systemic issues; and

• (where relevant) ensure complaints lead to changes in practice.

118.  Most DFMs responded that senior managers engage with the outcome of

complaints analysis. SFMs were less confident that – or did not know if - this is the case (see Exhibit 13).

Exhibit 13: Survey responses from DFMs and SFMs relevant to analysis

DFMs: My Department has robust arrangements in place to ensure

ALL customer complaints:

4 3 2 1 0

Are properly logged to enable identification of themes Lead to changes in practice

and any systemic issues

Strongly agree Mostly agree Mostly disagree

SFMs: My Section has robust arrangements in place to ensure

ALL customer complaints:

12 10 8 6 4 2 0

Are properly logged to enable identification of themes Lead to changes in practice

and any systemic issues

Strongly agree Mostly agree Mostly disagree Don't know

DFMs: Senior managers and key leaders in my Department actively

engage with the outcome of the analysis undertaken

3 2 1 0

Strongly Mostly Mostly Strongly Don't agree agree disagree disagree know

Source: Jersey Audit Office survey and analysis

SFMs: Senior managers and key leaders in my Section actively

engage with the outcome of the

analysis undertaken

10 8 6 4

2 0

Strongly Mostly Mostly Strongly Don't agree agree disagree disagree know

Public reporting of performance in handling and learning from complaints

119.  Although there has been an expansion of the KPIs used to monitor the delivery of

the Customer Feedback Policy, there has been no development in the information which is made public.

120.  The Policy sets out that the Chief Executive's role extends to reporting publicly on

the Government of Jersey's handling of customer feedback. It states that regular reports will be run on a comprehensive list of indicators, including:

• actionable insights and action taken; and

• improvements made in response to customer feedback.

121.  The list is followed by a commitment to publish reports to the public on Gov.je.

However, at present:

• the only data published is the number of complaints received by each department, which is meaningless in terms of understanding how these have been handled and learned from; and

• the published data is part of the Jersey Performance Framework and is not easily identified from a generic internet search. It is not linked from the webpage which contains the Policy or from the Customer Feedback Management System.

122.  There is much more to do to ensure that the public has a good view of how the

Government of Jersey performs against its Policy objectives, in particular in learning from complaints and avoiding repetition. The States of Jersey Group 2022 Annual Report and Accounts notes the enhanced focus on voice of the customer' but only reports the number of complaints recorded. There is no analysis of performance against the stated aims of the Customer Feedback Policy and no examples of complaint themes, what improvements were made as a result or what learning has been captured and shared to prevent reoccurrence.

123.  The survey of DFMs and SFMs indicates that most feel their department or section

is making headway in welcoming complaints. However, it was clear from the comments received that some departments or sections that are less obviously customer facing' would benefit from more support to ensure that engaging with customer feedback is seen - across the department - as important.

Recommendations

R11  Develop a clear plan to:

• expand the information and data published on the Government's performance in handling and learning from complaints, in line with the commitments set out in the Policy; and

• ensure the data and information are easily accessible to all stakeholders.

R12 In individual staff and team performance management (including as part of the

Connect People system) ensure that any information on how well customer complaints have been responded to, is properly used.

Work planned that should be prioritised

P6 Establish a process and timeframe for periodic review of decisions about:

• what data about those who provide feedback is captured; and

• how captured data is evaluated and reported

in support of wider Government of Jersey objectives.

P7 Routinely review the Customer Feedback Policy KPIs (or proxies), their targets or

tolerances and how KPIs are reported and overseen, so that Government can

demonstrate the extent to which its associated corporate objectives are being met. P8  When implementing the planned system upgrade to make it mandatory to

consider raising an improvement in response to each complaint, ensure that

corresponding actions and / or changes in practice are also logged so that they

can be evaluated and reported.

Area for consideration

A2  Set out proactive – rather than reactive – priorities, milestones and monitoring

arrangements to improve the quality of data recorded in systems managing customer feedback, including complaints.

Audit Approach

The review included the following key elements:

• review of relevant documentation provided by the Government of Jersey

• interviews with key officers within the Government of Jersey; and

• an anonymous online survey of Department Feedback Managers and Section Feedback Managers.

Key documents reviewed included:

• C&AG Recommendations Tracker (relevant section)

• Complaints Handling Manual

• Customer Experience Board presentations

• Customer Feedback Management System User Guide

• Customer Feedback Policy

• Customer Strategy Board presentations

• Department Feedback Manager meeting presentations

• Government of Jersey Service Performance Measures

• Health and Community Services Annual Quality Account 2022

• Performance reports to the Executive Leadership Team and OpCo

• Quality Assurance Framework

The following people contributed information through interviews or by correspondence:

• Chief Officer, CLS

• Customer Experience Manager, CLS

• Customer Feedback Manager, CLS

• Customer Insight Manager, CLS

• Department Feedback Managers (discussions by request)

• Group Director, CLS

• Head of Commercial, Treasury and Exchequer

• Interim Associate Director, Mental Health and Wellbeing, CYPES

• Interim Chief Nurse, HCS

• Section Feedback Managers

The fieldwork was carried out by an affiliate working for the Comptroller and Auditor General, between June and early August 2023.

Summary of Recommendations, Work planned that should be prioritised and Areas for consideration

Recommendations

R1 Establish governance arrangements that ensure that all parts of Government

implement complaints management procedures that align with the commitments stated in the Customer Feedback Policy.

R2 Be explicit about the roles, responsibilities and mechanisms for:

• ensuring robust action plans are in place and effective in mitigating the complaints' risk as set out in the CLS Risk Register

• ensuring a renewed focus on capturing lessons learned' from complaints received

• communicating and sharing learning across Government including, where relevant, to commissioned services; and

• evaluating the efficiency, effectiveness and reputational benefits to the Government of ensuring that the learning extracted from complaints is maximised.

R3 Develop an overarching, coherent, prioritised and resourced action plan to deliver

on the stated duty to ensure all customers can easily provide feedback on publicly funded services.

R4  Broaden the post-complaints follow up process to ensure that all complainants

(where contact information is held) have an opportunity to feed back on their experience, not just those that provide an email address.

R5 Implement a specific workstream to understand and resolve the low level of

compliance with mandatory customer feedback training requirements in relevant Government departments.

R6 Ensure that the line managers of DFMs and SFMs determine the need and

opportunities for extended training so that DFMs and SFMs can deliver their roles. R7  Ensure that the Quality Assurance Framework can be and is applied across all

Government departments and that all outcomes can be and are compared and

reported together.

R8  Require schools to provide information to CYPES on numbers, themes and

outcomes of complaints they receive which:

• are resolved at Stage 1; and

• are managed by the Head Teacher or the school's Board of Governors at Stage 2 and Stage 3.

R9  Establish criteria - and report the outcome of their implementation - to guide

decisions on whether school complaints that go to Stage 2 and Stage 3 are investigated by:

• the Head Teacher

• the school's Board of Governors; or

• CYPES.

R10  Update the Customer Feedback Policy and the Complaints Handling Manual to

help officers identify whether correspondence they receive should be handled as a complaint.

R11  Develop a clear plan to:

• expand the information and data published on the Government's performance in handling and learning from complaints, in line with the commitments set out in the Policy; and

• ensure the data and information are easily accessible to all stakeholders.

R12 In individual staff and team performance management (including as part of the

Connect People system) ensure that any information on how well customer complaints have been responded to, is properly used.

Work planned that should be prioritised

P1  Until the JPSO's responsibilities also cover health services, make sure that

arrangements are clear and are communicated for how post Stage 3' health care related complaints will be managed.

P2 Develop and implement a checklist' to support departments in ensuring

contractor arrangements on managing complaints dovetail with the requirements of the Government's Customer Feedback Policy.

P3  Ensure that the gap analysis / maturity-level assessment to be undertaken in each

Government department includes a review of the resources (including time and

space) allocated to DFMs and SFMs to carry out their wider role in supporting customer feedback, to ensure their adequacy now and in the future.

P4  Keep the Complaints Handling Manual up to date, including to reflect changes:

• such as the introduction and expansion of the post-complaint satisfaction survey and criteria for its use; and

• as a consequence of the introduction of the JPSO.

P5 Ensure that the capability of the system or systems used in capturing information

about complaints is fully exploited, including by making it mandatory to consider raising an improvement on closure of a complaint.

P6 Establish a process and timeframe for periodic review of decisions about:

• what data about those who provide feedback is captured; and

• how captured data is evaluated and reported

in support of wider Government of Jersey objectives.

P7 Routinely review the Customer Feedback Policy KPIs (or proxies), their targets or

tolerances and how KPIs are reported and overseen, so that Government can

demonstrate the extent to which its associated corporate objectives are being met. P8  When implementing the planned system upgrade to make it mandatory to

consider raising an improvement in response to each complaint, ensure that

corresponding actions and / or changes in practice are also logged so that they

can be evaluated and reported.

Areas for consideration

A1  Review the operation of the Customer Experience Board to make sure that

arrangements for:

• setting agendas

• noting and monitoring actions agreed; and

• reporting, escalating and cascading information are clear.

A2  Set out proactive – rather than reactive – priorities, milestones and monitoring

arrangements to improve the quality of data recorded in systems managing customer feedback, including complaints.

55 | Handling and Learning from Complaints – Follow Up