Policy and Procedure on Raising Issues of Serious Concerns at Work by sdfsb346f

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									Policy and Procedure on
    Raising Issues of
  Serious Concerns at
          Work
North Cumbria University Hospitals NHS Trust
Policy and Procedure on Raising Issues of Serious Concerns at Work
Publication Date: 04/12/2007                                                        Version 2.0

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Author/Contact                          Clinical Effectiveness Facilitator
                                        Email: policies@ncumbria-acute.nhs.uk

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                                        of Serious Concerns at Work final version TB.doc
Document Reference                      HR 7

Version                                 2.0

Status                                  Approved

Publication Date                        04/12/2007

Review Date                             04/12/2009

Approved/Ratified by                    Governance Committee               Date: 13/11/2007
                                        Trust Board                        Date: 04/12/2007

Review Process Prior to Ratification:

Name of Group/Department/Committee                                    Date
Governance Committee                                                  21/12/2004
Trust Board                                                           25/01/2005
Joint Staff Consultative Group                                        05/09/2007
Sub Group of JSCG                                                     10/09/2007
Staff and Staff Management Committee                                  12/09/2007
Trust Policy Group                                                    29/10/2007

SUMMARY

This Policy details the provisions made for anyone who works within the Trust to raise any
concerns about the services provided and the standards applied.

The Policy outlines the background principles that led to the formation of the Policy together
with the procedure to be followed and the Trust’s commitment to making the procedure work.

The main changes to the Policy are the inclusion of volunteers and people on work experience
in the Trust within the scope of the Policy, clarification of responsibilities and an updating of
the details of contacts within the Policy.




HR 7                                                                               Page 2 of 11
North Cumbria University Hospitals NHS Trust
Policy and Procedure on Raising Issues of Serious Concerns at Work
Publication Date: 04/12/2007                                                                                      Version 2.0

TABLE OF CONTENTS



SUMMARY ..........................................................................................................................2
1.  INTRODUCTION.......................................................................................................4
2.  OBJECTIVE ..............................................................................................................4
3.  SCOPE OF POLICY .................................................................................................4
    3.1   Who can use the Policy ..................................................................................4
    3.2   Types of Concern covered .............................................................................4
4.  POLICY.....................................................................................................................5
    4.1   The Trust’s Assurances..................................................................................5
    4.2   Independent Advice........................................................................................5
    4.3   Procedure for Raising a Concern ...................................................................6
          4.3.1 Raising a concern internally................................................................6
          4.3.2 External disclosure..............................................................................7
          4.3.3 Further Guidance................................................................................7
5.  RESPONSIBILITIES .................................................................................................7
    5.1   General Staff Responsibilities ........................................................................7
    5.2   Line Manager Responsibilities........................................................................7
    5.3   Trust “Champions” Responsibilities ................................................................8
    5.4   Human Resources Department Responsibilities ............................................8
6.  VALIDITY OF THIS POLICY .....................................................................................8
7.  AUDIT DETAILS .......................................................................................................8
8.  APPENDIX 1 CONTACTS .....................................................................................10
9.  SIGNATURE RECORD...........................................................................................11




HR 7                                                                                                            Page 3 of 11
North Cumbria University Hospitals NHS Trust
Policy and Procedure on Raising Issues of Serious Concerns at Work
Publication Date: 04/12/2007                                                        Version 2.0

1.     INTRODUCTION

       All of us, at one time or another have concerns about what is happening at work.
       Usually these concerns are easily resolved. However, when such concerns involve
       danger (to patients, public or colleagues), professional misconduct or financial
       malpractice, it can be difficult to know what to do.

       The Trust will deal with genuine concerns in a responsible, open and professional way
       and gives an unequivocal assurance that anyone who raises such a concern under this
       Policy will be treated with respect and will not be penalised or disadvantaged in any
       way for doing so. This assurance is not extended to someone who maliciously raises a
       matter they know is untrue.

       Following advice from the Commission for Health Improvement (now known as the
       Healthcare Commission), the former “Whistle blowing Policy” was renamed as the
       Policy & Procedure on Raising Issues or Serious Concerns at Work in January 2005.

       The policy and procedure reflects the principles of the Public Interest Disclosure Act
       (PIDA) 1998 and guidance published by the NHS Executive (HC 1999/198) and should
       be read in conjunction with relevant professional or ethical rules, guidelines and codes
       of conduct. Details for contacts referred to in the Policy are shown in Appendix 1.

       Our mission is to provide the best care and highest quality of service to the maximum
       benefit for all of our patients

2.     OBJECTIVE

       The Trust is committed to delivering high quality care to its patients and as part of this
       commitment it is important that everyone who works in the Trust has the opportunity to
       raise any concerns about the services provided and the standards applied.
       .
3.     SCOPE OF POLICY

       This Policy details how staff can raise serious concerns and can be found in the
       Human Resources Policy and Procedure manual which can be located in all Wards
       and Departments and also in the HR folder on the Intranet.

       3.1     Who can use the Policy

               Anyone who works within the Trust may use the procedure. This includes:
               employees; bank staff; people who work for contract organisations, agency
               workers; locum staff; students/trainees on placement; self-employed NHS
               professionals, people on work experience and volunteers.

       3.2     Types of Concern covered

               This Policy provides protection when raising genuine concerns of malpractice
               including:
                   • Inappropriate or ill treatment of a patient.


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North Cumbria University Hospitals NHS Trust
Policy and Procedure on Raising Issues of Serious Concerns at Work
Publication Date: 04/12/2007                                                         Version 2.0

                   •   Repeated ill treatment of a patient despite a complaint being made to line
                       management.
                   •   A criminal offence that has been, is being, or is likely to be committed.
                   •   Suspected fraud.
                   •   Disregard for legislation, for example, in relation to health and safety.
                   •   Breach of standing financial instruction.
                   •   Showing undue favour over a contractual matter.
                   •   Breach of a code of conduct.
                   •   Concealment of information on any of the above.

       If you have a grievance about your own personal position, you should follow one of the
       Trust’s Human Resources Policies e.g. the Grievance Procedure, Prevention of
       Harassment and Bullying at Work, Equal Opportunities Agreement or Recruitment and
       Selection Policy.

4.     POLICY

       4.1     The Trust’s Assurances

               The Trust Board and Chief Executive are committed to making this procedure
               work. If you raise a genuine concern you will not be at risk of losing your job or
               suffering any form of retribution as a result. Provided you act in good faith it
               does not matter if you are mistaken. This assurance does not extend to anyone
               who maliciously raises a matter they know to be untrue.

               The Trust will not tolerate the harassment or victimisation of anyone raising a
               genuine concern and will treat any such action as a serious disciplinary offence
               to be dealt with under the Disciplinary Procedure.

               If you ask for your identity to be protected, it will not be disclosed without your
               consent. If the situation arises where the Trust is not able to resolve the matter
               without revealing your identity (for instance because evidence is needed in
               court), the best way forward will be discussed with you.

               Whilst the Trust will consider anonymous reports, this Policy is not appropriate
               for concerns raised in this way. If the Trust does not know who has raised the
               concern it is much more difficult to investigate the matter, protect that
               individual’s position and give feedback.

       4.2     Independent Advice

               If you are unsure whether to use this procedure or want independent advice at
               any stage, you can contact:

                   •   Your union representative, or your professional or regulatory body e.g.
                       NMC, GMC
                   •   The independent charity Public Concern at Work which supports and
                       advises people who are concerned about wrongdoing at work. They



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North Cumbria University Hospitals NHS Trust
Policy and Procedure on Raising Issues of Serious Concerns at Work
Publication Date: 04/12/2007                                                           Version 2.0

                       provide a free confidential help line staffed by lawyers (see Appendix 1
                       for details).

       4.3     Procedure for Raising a Concern

               The Trust hopes that you will feel able to initially raise your concern internally as
               an effective way of resolving the matter and to provide the protection set out in
               law. However the Trust recognises that there may be circumstances where you
               can properly report matters to outside bodies, such as prescribed regulators.
               The steps for raising concerns internally and externally are set out below.

               4.3.1 Raising a concern internally

                       If you feel able to, you should discuss the matter initially with your Line
                       Manager. In many instances they will be able to resolve the matter
                       themselves.

                       If you feel that the matter has not been dealt with satisfactorily or feel
                       unable to raise it with your manager, the Trust has designated three
                       members from the Trust Board to act as champions, to demonstrate
                       openness in such circumstances and accept a special responsibility for
                       dealing with your concern.

                       The champions are the Director of Nursing and two Non Executive
                       Directors. Please contact any of them and tell them that you have a
                       concern under the Policy (see Appendix 1).

                       They will arrange an initial meeting with you to take place within three
                       working days or, if the view is that serious harm may come to patients or
                       staff as a result of delay, within 24 hours. You will be asked whether you
                       wish to make a written or verbal statement. Either way, the designated
                       person will write a brief summary of the meeting, which will be agreed by
                       both of you. You will also be asked whether or not you wish your identity
                       to be protected. (Depending upon the nature of your concern you may
                       also be advised to use another Trust procedure e.g. Grievance
                       Procedure).

                       The champion may notify the Chief Executive at this stage and complete
                       an Incident Report Form. An assessment will be made of further action
                       required. Any preliminary investigation should be completed within 10
                       days and a report sent to the Chief Executive or Chairman.

                       The champion will continue to be your point of contact and will let you
                       know the planned timescales, progress and outcome of any investigation
                       and action taken as a result. The Trust may not be able to tell you the
                       precise action taken where this would infringe a duty of confidence owed
                       to someone else (such as the nature of any disciplinary action).




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North Cumbria University Hospitals NHS Trust
Policy and Procedure on Raising Issues of Serious Concerns at Work
Publication Date: 04/12/2007                                                           Version 2.0

               4.3.2 External disclosure

                       In most cases raising your concern through the internal channels will be
                       sufficient to resolve it. However, if you are not satisfied with the outcome
                       of the internal investigation, or do not feel able to raise the matter
                       internally, you may also raise your concern with one of the regulators
                       prescribed by the Public Interest Disclosure Act

                       The full list of prescribed regulators, which includes such organisations
                       as the Health and Safety Executive and the Audit Commission, is
                       available from Public Concern at Work.

                       If you approach any of these regulators, you will have the same
                       protection as if you were making an internal disclosure provided that you:

                           •   Have an honest and reasonable suspicion that the malpractice
                               has, is or is likely to occur.
                           •   Honestly and reasonably believe that the information and any
                               allegation contained in it are substantially true.

                       The Trust recognises its accountability within the NHS. In light of this
                       you can contact the NHS Fraud and Corruption Reporting Line for any
                       concerns about financial malpractice.

                       Wider disclosures (e.g. to the police, the media, MP’s and non-
                       prescribed regulators) may be justified in exceptional circumstances.
                       However they must meet the above tests for regulatory disclosure, must
                       not be made for personal gain and must have been raised with the Trust
                       or a prescribed regulator first. The only exception to this is if you believe
                       that you would be victimised, there is no prescribed regulator and you
                       reasonably believe that there would be a cover up or if the matter is
                       exceptionally serious. In such circumstances you may wish to take
                       advice from one of the organisations mentioned at Section 4.2.

               4.3.3 Further Guidance

                       If you need any further help with this policy and procedure please contact
                       one of the champions listed in Appendix 1 or the Human Resources
                       Department.

5.     RESPONSIBILITIES

       5.1     General Staff Responsibilities

               Raising a concern through the internal channels or one of the regulators
               prescribed by the Public Interest Disclosure Act.


       5.2     Line Manager Responsibilities


HR 7                                                                                  Page 7 of 11
North Cumbria University Hospitals NHS Trust
Policy and Procedure on Raising Issues of Serious Concerns at Work
Publication Date: 04/12/2007                                                          Version 2.0

                 Line managers will investigate any issues of serious concern raised by their
                 staff and provide feedback to staff as appropriate.

       5.3       Trust “Champions” Responsibilities

                 The champions are the Director of Nursing and two Non-Executive Directors.
                 They will arrange any initial meeting to take place within three working days or,
                 if the view is that serious harm may come to patients or staff as a result of
                 delay, within 24 hours. The champion will make an assessment of the concern
                 and take action as appropriate.

                 The champion will be the point of contact and will let staff know the planned
                 timescales, progress and outcome on any investigation and action taken as a
                 result.

                 The PA to the Director of Nursing will maintain a central record of issues under
                 this policy and will submit details on a quarterly basis to the Staff and Staff
                 Management Committee.

       5.4       Human Resources Department Responsibilities

                 Provide guidance, advice and support to anyone working in the Trust who
                 wishes to raise a concern under the scope of the Policy.

6.     VALIDITY OF THIS POLICY

       This policy should be reviewed every two years under the authority of the Director of
       Human Resources (or nominated Deputy) or sooner in light of changing employment
       legislation or best practice.


7.     AUDIT DETAILS

             •   The Staff Survey includes specific questions on reporting concerns, the results
                 of which are reported throughout the Trust.
             •   Reports of investigations undertaken following a concern raised internally are
                 sent to the Chief Executive or Chairman.




HR 7                                                                                 Page 8 of 11
North Cumbria University Hospitals NHS Trust
Policy and Procedure on Raising Issues of Serious Concerns at Work
Publication Date: 04/12/2007                                                       Version 2.0




                                       Audit Tool Guidance

STATEMENT


The Trust will work towards effective Governance and to demonstrate this, regular audits
against policy compliance will be carried out. Policy authors will be encouraged to attach audit
tools to their policies.

It is suggested that there are three standard statements to each audit tool and that the author
will identify a minimum of 5 audit statements to ensure compliance and efficacy against the
policy. Members of staff from each hospital site will be selected to assess the audit tool
statement questions and the findings of the audit will be reported on the Clinical Audit &
Effectiveness Committee.


Policy and Procedure on Raising Issues of Serious Concerns at Work
Standard Statement                                                Yes %             No%
Statement 1         Are staff aware of this policy?
Statement 2         Do staff know how to locate policies on staff
                    web?
Statement 3         Have staff had any formal / informal training
                    In using computer to access the staff web?
Statement 4         Have any issues of concern been raised in
                    the Staff Opinion Survey?
Statement 5         Have quarterly reports been submitted to
                    Staff and Staff Management Committee?




HR 7                                                                              Page 9 of 11
North Cumbria University Hospitals NHS Trust
Policy and Procedure on Raising Issues of Serious Concerns at Work
Publication Date: 04/12/2007                                                          Version 2.0




8.     APPENDIX 1              CONTACTS



Trust Champions



Acting Director of Nursing         Sandy Brown                       01946 523072


Non-Executive Director             Roxine Beaumont-Sempill           01946 523717
                                   Until 30-11-07                    01228 814010


Non-Executive Director             Ray Wager                         01946 523717
                                                                     01228 814010



Public Concern at Work

Telephone: 0207 404 6609
www.pcaw.co.uk



NHS Fraud and Corruption Reporting Line

Telephone: 0800 028 4060


Human Resources Department

West Cumberland Hospital              01946 523722
Cumberland Infirmary                  01228 814092




HR 7                                                                                Page 10 of 11
North Cumbria University Hospitals NHS Trust
Policy and Procedure on Raising Issues of Serious Concerns at Work
Publication Date: 04/12/2007                                                  Version 2.0

9.     SIGNATURE RECORD


             Policy and Procedure on Raising Issues of Serious Concern at Work

This sheet should be used to record the names of staff members who have read and
understood the above policy document.

By signing this document, I acknowledge I have read the above named policy.
Name                      Job Title          Date         Signature
(please print)




Please print this page for your records




HR 7                                                                      Page 11 of 11

								
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