Speaking Up: Whistleblowing Policy and Procedure

Transcription

1 Speaking Up: Whistleblowing Policy and Procedure Executive Director lead Author/ lead Feedback on implementation to Deputy Chief Executive Deputy Director of Human Resources Director of Human Resources, Deputy Director of Human Resources Date of issue August 2013 Consultation period July / August 2013 Date of ratification of full policy 10 th January 2013 Ratified by Executive Directors Group Date for review September 2016 Target audience All SHSC staff (including staff seconded into or working in SHSC services) and the Trust Board This policy is stored and available through the SHSC website. This policy is based on good practice and complies with all relevant legislation. This policy was previously issued in February This latest version reflects the legislative changes effective from 1 st July 2013 under the Enterprise and Regulatory Reform Act. 1

2 Contents: Section Page Trust Policy Statement 3 4 Flowchart 5 Notes 6 1 Introduction Definitions 8 3 Scope 8 4 Purpose of this policy 8 5 Duties 9 6 Specific Details of the policy Dissemination, Storing and Archiving 15 8 Training and other resource implementation 15 9 Audit, monitoring and review Links to other policies, standards and legislation Contact details for Human Resources References 16 Appendix 1 Definitions 17 Appendix 2 Illustrative List of Whistleblowing Issues 18 Appendix 3 Procedure for Staff raising concerns internally Appendix 4 Framework for Partner Organisations 21 Appendix 5 Contact details 22 Appendix 6 Practical tips for managers 23 Supplementary Appendix A Equality Impact Assessment Form 24 Appendix B Human Rights Act Assessment Form and Flowchart Appendix C Development and consultation process 27 2

3 Trust Policy Statement: Speaking Up This statement is available for distribution to employees as a summary of the Trust s approach to whistleblowing. It is based on the template set out in Speak Up for a Healthy NHS. All of us at one time or another have concerns about what is happening at work. Usually these are easily resolved. However, when the concern feels serious because it is about a possible danger, professional misconduct or financial malpractice that might affect patients, colleagues or the Trust itself, it can be difficult to know what to do. You may be worried about raising such an issue and may think it best to keep it to yourself, perhaps feeling it is none of your business or that it is only a suspicion. You may feel that raising the matter would be disloyal to colleagues, to managers or to the organisation. You may have said something but found that you have spoken to the wrong person or raised the issue in the wrong way and are not sure what to do next. The Trust Board is committed to running the organisation in the best way possible and to do so we need your help. The Trust has introduced this policy to reassure employees that it is safe and acceptable to speak up and to enable the employee to raise any concern they may have at an early stage and in the right way. Rather than wait for proof, we would prefer you to raise the matter when it is still a concern. This policy applies to all those who work for the Trust: whether full-time or parttime, self-employed, employed through an agency or as a volunteer. If something is troubling you which you think the Trust should know about or look into, please use the whistleblowing procedure and seek advice, as appropriate. If, however, you wish to make a complaint about your employment or how you have been treated, please use the Grievance Policy or the Bullying and Harassment Policy, which you can obtain from the Trust Intranet, your manager or Human Resources department. If you have a concern about financial misconduct or fraud, please see the Fraud Policy. This Whistleblowing Policy is primarily for individuals who work for us and have concerns where the interests of others or of the organisation itself are at risk. If in doubt raise it! 3

4 The Trust s commitment to you Your safety The Board and the Chief Executive and the staff unions are committed to this policy. If you raise a genuine concern under this policy, you will not be at risk of losing your job or suffering any detriment (such as a reprisal or victimisation). Provided you reasonably believe that raising the concern is in the public interest, it does not matter if you are mistaken or if there is an innocent explanation for your concerns. So please do not think we will ask you to prove it. Of course we do not extend this assurance to someone who maliciously raises a matter they know is untrue. Your confidence With these assurances, we hope you will raise your concern openly. However, we recognise that there may be circumstances when you would prefer to speak to someone in confidence first. If this is the case, please say so at the outset. If you ask us not to disclose your identity, we will not do so without your consent unless required by law. You should understand that there may be times when we are unable to resolve a concern without revealing your identity, for example where your personal evidence is essential. In such cases, we will discuss with you whether and how the matter can best proceed. Please remember that if you do not tell us who you are it will be much more difficult for us to look into the matter. We will not be able to protect your position or to give you feedback. Accordingly you should not assume we can provide the assurances we offer in the same way if you report a concern anonymously. 4

5 Flowchart The employee decides (with advice, as necessary from HR, Trade Union / Professional Associations, Internal Audit or Public Concern at Work) whether this is the appropriate procedure or whether a different procedure should be followed (e.g. the grievance procedure in respect of the individual s terms and conditions) or whether the Counter Fraud Plan should be used (in respect of fraud or financial irregularities) or whether the established processes for reporting incidents / raising complaints would be more appropriate in the first instance See notes 1, 2, 3 & 4. Whistleblowing Process STAGE ONE Employee raises concern either verbally or in writing with Line Manager or next level of management which is believed to have no involvement. See notes 5, 7 & 8. Manager acknowledges receipt, decides if investigation appropriate and notifies outcome in writing within 10 working days. See note 6. STAGE TWO If employee unhappy with outcome then raises concern either verbally or in writing with next level of management within 15 working days of receiving outcome of Stage One. Manager acknowledges receipt, decides if investigation appropriate and notifies verbally of outcome within 10 working days and confirms in writing within a further 5 working days. See note 6. STAGE THREE If employee unhappy with outcome then raises concern in writing with the next level of management within 15 working days of receiving written notification of outcome of the previous stage. Appropriate Procedure / Managers see notes 8 & 9 If employee still unsure whether to use procedure or feels cannot use normal procedure then can seek advice from or raise concern with the Deputy Chief Executive. See notes 5/7. Manager meets employee within 5 working days of receipt of letter and, as necessary, initiates investigation. Individual informed of final decision in writing within 10 working days of the meeting unless further investigation required. (If the issue was originally considered by the Deputy Chief Executive, Chief Nurse or Medical Director then this will be regarded as Stage 3. If the employee is unhappy with the outcome then in these circumstances the concern would be considered by the Chief Executive (or Deputy Chief Executive if not previously involved. See notes 6/7. Deputy Chief Executive considers issue and refers matter to the appropriate procedure / manager or takes forward the investigation. See Note 10. 5

6 Notes 1. For definition of whistleblowing see Appendix 1. For list of contacts see Appendix If the concern arises from someone from a Partner Organisation please refer to Appendix If the concern relates to a Partner Organisation then you can use their whistleblowing procedure or use the Trust s procedure. 4. For the definition of employee see Appendix Concerns are better raised in writing. If you are not able to put the concern in writing, you can telephone or arrange to meet the appropriate manager (see section 6.6). 6. Some concerns may be resolved without the need for investigation. Initial enquiries will be made to see if an investigation is appropriate and, if so, the nature of the investigation (see section 6.10). For practical tips on responding see Appendix At any meeting you have the right to be accompanied by a Trade Union representative or work colleague (see section 6.10). 8. A typical line manager reporting arrangement would be: Stage 1 - Ward Manager / Team Leader Stage 2 - Assistant Director Stage 3 - Service Director For junior doctors the typical reporting arrangement would be: Stage 1 - Consultant OR Deputy Training Programme Director Stage 2 - Clinical Director OR Director of Post-Graduate Medical Education Stage 3 - Medical Director Local arrangements may need to be separately specified in certain cases e.g. the Clover Group. (See Appendix 3 for the procedure itself). 9. Where an issue relates to matters believed to involve Executive Directors then this issue will be considered by the designated Non-Executive Director (see Appendix 3). 10. The Deputy Chief Executive may refer the matter to the appropriate Professional Lead (Chief Nurse / Medical Director) or other appropriate manager / procedure. 6

7 WHISTLEBLOWING POLICY AND PROCEDURE 1. Introduction 1.1 Employees are often the first to realise that there may be something seriously wrong within their service area and/or the Trust. However, they may not express their growing concerns because they feel that speaking up would be disloyal to their colleagues or to the Trust. They may also fear harassment or victimisation. In these circumstances, it may be easier to ignore the concern rather than report what may be just suspicion of malpractice and wrongdoing at work. 1.2 The Trust is committed to the highest possible standards of openness, probity and accountability. In line with this commitment, we encourage employees and others with genuine concerns about any of the Trust s work to come forward and voice those concerns. This policy document makes it clear that employees can do so without fear of victimisation. This Whistleblowing policy is intended to encourage and enable employees to raise such concerns within the Trust rather than overlooking a problem or waiting for proof. Employees of the Trust have a duty to raise concerns where the interests of service users may be at risk. 1.3 This procedure accords with the requirements of the Public Interest Disclosure Act 1998 and the Enterprise and Regulatory Reform Act It is compatible with the conventions contained in the Human Rights Act 1998.It also accords with the NHS Constitution and particularly - the legal right for staff to raise concerns about safety, malpractice or other wrong doing without suffering detriment - the pledge to support all staff in raising concerns about safety, malpractice or wrong doing at work, responding to these concerns and,where necessary,investigating the concerns raised - the expectation on staff that they will raise concerns about safety, malpractice or wrong doing at work which may affect patients, other staff or the organisation itself, as early as possible. Further guidance is contained in the NHS Constitution Handbook, which can be downloaded from the Department of Health Website The procedure also takes account of other relevant legislation and documentation (see section 10). The GMC has issued guidance setting out that all doctors have a duty to act when they believe patient safety is at risk or that patients care or dignity is being compromised. It highlights the GMC s expectation that all doctors will, whatever their role, take appropriate action to raise and act on concerns about patient care, dignity and safety. The Nursing and Midwifery Council has also issued guidance on raising and escalating concerns. 1.5 In order to help ensure that employees are fully aware of the Trust s commitment a Policy Statement is provided at the front of this Policy & Procedure. 7

8 1.6 Many concerns will be raised openly with line managers as part of normal day-to-day practice. The Trust also provides a number of policies and procedures by which issues can be considered without having to use to this policy. These include: Grievance Procedure Bullying and Harassment Procedure Incident Reporting and Investigation Policy Complaints Policy (including Fast-track Process see section 6.8 of Complaints Policy) Safeguarding Adults Policy Safeguarding Children Policy Resolving Differences of Opinion between Practitioners Fraud Policy and Response Plan The above policies can be found under the policies section of the Trust s website These whistleblowing arrangements are not intended to supersede or undermine this approach.the procedure is designed to seek to avoid conflict and allow the employee to raise a concern in a constructive way where the normal processes are not felt to be capable of resolving the concerns. 2. Definitions Definitions are given in Appendix Scope This policy applies to all employees which has a wider definition than normal (see definition in Appendix 1). It also applies to volunteers. 4. Purpose of this Policy 4.1 This policy aims to: provide a process for employees to raise concerns and receive feedback on any action taken; allow the employee to take the matter further if they are dissatisfied with the Trust s response; reassure the employee that steps will be taken to protect them from victimisation for whistleblowing undertaken in good faith. 4.2 There are existing procedures in place to enable employees to lodge a grievance relating to their own employment. This Whistleblowing Policy is intended to cover genuine concerns that fall outside the scope of these and other procedures as listed in the Introduction. That concern may be about something that: is unlawful; or is against the Trust s standing orders or policies; or 8

9 falls below established standards of practice or amounts to improper conduct; contradicts the Trust s codes of conduct. Further examples are provided at Appendix Duties The Board has a responsibility to ensure that action is taken to promote this policy and create a culture built on openness and accountability, where staff are empowered to speak out where they have concerns. A Non-Executive Director may be designated by the Board to deal with whistleblowing issues where it is believed that the issue to be considered involves Executive Directors. The Deputy Chief Executive (in conjunction with the Medical Director and Chief Nurse will be jointly responsible for ensuring the effective operation of this policy). The Deputy Chief Executive will act as the lead contact where it is believed that the normal processes for resolving issues through the Whistleblowing Policy is not appropriate. This will not prevent issues relating to doctors being raised with or considered by the Medical Director or issues relating to nursing staff being raised with the Chief Nurse. All employees and others covered by the policy have a duty to understand this policy and report any serious concerns. All employees and others covered by this policy should set an example in day-to-day activities by questioning behaviours that are believed not to be right, appropriate or lawful. All employees and others covered by the policy have a duty to have a responsible attitude to supporting staff who raise concerns and not to victimise anyone who raises a genuine concern. All employees should protect client confidentiality. The HR Department has a duty to help individuals with understanding the policy and supporting its operation. The individual raising a concern should reasonably believe it is in the public interest to do so. The manager with whom the concern is raised has a duty to apply the procedure fairly and take action appropriate to the nature of the concern (see Appendix 6 for practical tips for Managers on responding to a concern) This includes responding appropriately when concerns are raised. All managers should keep an accurate record of concerns raised and actions taken and contribute these to the evaluation of the procedure. Where an issue is raised with the Deputy Chief Executive, it may still be determined that the matter should be considered: - under another procedure - under the normal whistleblowing procedure 9

10 - by another more appropriate senior manager (e.g. Chief Nurse or Medical Director) / the designated Non-Executive Director 6. Specific Details of the Policy 6.1 Victimisation The Trust recognises that the decision to report a concern can be a difficult one to make, not least because of the fear of reprisal. The Trust will not tolerate victimisation (detrimental treatment) and will take action to protect employees when they raise a concern which they reasonably believe to be in the public interest. Any such victimisation will be regarded as a disciplinary offence, which could lead to dismissal. In addition, as with discrimination issues, individual workers can also be held personally liable in any subsequent Employment Tribunal proceedings. 6.2 Confidentiality The Trust recognises that some employees may be anxious about having their name revealed. However, the assessment of the issues and any investigation process is likely to be more effective if the concern is raised openly. Where confidentiality is requested then the Trust will not reveal the employee s name without their consent unless this is required by law. The individual needs to appreciate, however, that others may still speculate as to the identity of the person concerned (correctly or incorrectly) and that an open culture is the best way of avoiding such rumours. 6.3 Anonymous Allegations Employees are strongly encouraged to put their name to any allegation. Concerns expressed anonymously are much less powerful, but they may be considered at the discretion of the Trust. 6.4 Discretion In exercising discretion, the following factors will be taken into account when considering how to deal with any allegations: the seriousness of the issues raised; the credibility of the allegation; and the likelihood of confirming the allegation from attributable sources. 6.5 Malicious or Fabricated Allegations If the individual reasonably believes it is in the public interest to raise the concern but the concern is not substantiated by the investigation, no action will be taken against the employee 10

11 who raised the concern. If, however, there are malicious or fabricated allegations, then disciplinary action may be taken. 6.6 How to Raise a Concern As a first step, the employee should normally raise concerns with their immediate manager or the next line manager. This depends, however, on the seriousness and sensitivity of the issues involved and who it is thought may be involved in the malpractice. If it is believed that the immediate line manager or another senior manager is involved, the employee should approach the next level of management or, if it is felt that they may be involved, the relevant Executive Director. In some situations the consultant for the service in question or the Deputy Training Programme Director will be the relevant line manager (e.g. for junior doctors) and the next line manager would then be the Clinical Director or Director of Post-Graduate Medical Education followed by the Medical Director. (See note 8 to the flowchart). The guiding rule is to address the complaint to a level of management who it is believed is most appropriate and has no possible involvement. 6.7 If in Doubt Raise it! Advice and Guidance on how matters of concern may be pursued can be obtained from: the line manager Human Resource Department Director of Nursing and Integrated Governance It is also possible to seek advice from outside the Trust as set out in section (See Appendix 5 for list of contacts). All employees can, at one time or another, have concerns about what is happening at work. Usually these concerns are easily resolved. However, this is less likely to be the case when they are about areas such as:- unlawful conduct dangers to the public or the environment delivery of care to a service user health and safety Concerns are better raised in writing. Employees are invited to set out the background and history of the concern, giving names, dates and places where possible, and the reason why there is a particular concern about the situation. If the employee is not able to put their concern in writing, they can telephone or arrange to meet the appropriate manager (see Appendix 3). This policy has been jointly developed by the Trust and the Joint Staff Side, and if someone wishes to have the support of their union at any stage of the process, then the Trust would encourage their involvement. 11

12 The earlier the concern is expressed, the easier it is for the Trust to take action. Although employees are not expected to prove the truth of an allegation, they will need to demonstrate to the person contacted that there are sufficient grounds for initial enquiries to be made. The Trust recognises that raising concerns will in most circumstances be extremely stressful, and will ensure that employees are provided with as much support as practicable within the resources available to the Trust. The nature of this support will be discussed at the earliest stages of the process. When an employee raises a concern it will be helpful to know how they think the matter might be best resolved and whether they have any personal interest in the matter. REMEMBER if in doubt raise it! 6.8 Fraud / Bribery & Corruption Whilst the procedure could be used to raise concerns about financial irregularities or fraud, the Trust already has in place a Fraud Response Plan which encourages staff to raise such issues with the Local Counter Fraud Specialist, the Director of Finance, or the National Fraud and Corruption Reporting line (See Appendix 5). Concerns about bribery and corruption may be reported using this policy. However, the Trust has made arrangements to deal with suspected bribery or corruption in accordance with the Bribery Act 2010 and has designated the Director of Finance as the Senior Compliance Officer with overall responsibility for ensuring the Trust has a proportionate and adequate programme of anti-corruption and bribery initiatives. Any concerns about bribery or corruption may also be directed to the Director of Finance and/ or the Local Counter Fraud Specialist. 6.9 Partner Organisations The Trust realises that colleagues from partner organisations may on occasions have concerns about The Trust s services. In Appendix 4 attached it is suggested how they may raise such concerns. Similarly, someone may, through their work with the Trust, have concerns about services provided by other organisations who work in partnership with the Trust and may be unsure about how to raise them. Under the 1998 Act all public bodies are required to introduce a policy and process similar to this one, and as such you might refer to their policy to see if it provides guidance on how best to proceed. In the event that it does not, the employee might then proceed in accordance with Appendix 4 or Section 6.11 of this policy, as considered appropriate How the Trust will respond The action taken by the Trust will depend on the nature of the concern. The matters raised may: be investigated internally (which may involve an informal review, an internal inquiry or a more formal investigation) ; be referred to the police; be referred to the Local Counter Fraud Specialist (6.8); be referred to the external auditor; 12

13 form the subject of an independent inquiry. In order to protect individuals and the Trust, initial enquiries will be made to decide whether an investigation is appropriate and, if so, what form it should take. Concerns or allegations which fall within the scope of specific procedures (for example, child protection or harassment issues) will normally be referred for consideration under those procedures. Some concerns may be resolved without the need for investigation. Within ten working days of a concern being received, the Trust will write to the employee to: (see Appendix 3). acknowledge that the concern has been received; who is handling the matter; how they can be contacted ; indicate how the Trust proposes to deal with the matter; give an estimate of how long it will take to deal with the matter; advise whether any initial enquiries have been made; and inform whether further investigations will take place, and if not, why not. (If the employee requests, or the concerns are felt not to be sufficiently clear, the Trust will summarise the concerns. Should this occur then the employee needs to advise the Trust as to whether the Trust has misunderstood the concern or there is any information missing). The amount of contact between the officers considering the issues and the employee will depend on the nature of the matters raised, the potential difficulties involved and the clarity of the information provided. If necessary, further information will be sought from the employee. When any meeting is arranged to discuss the concerns, the employee has the right, if they so wish, to be accompanied by a trade union representative or work colleague who is not involved in the area of work to which the concern relates and who also could not be called as a witness. The Trust will take steps to minimise any difficulties, which may be experienced as a result of raising a concern. For instance, if an employee is required to give evidence in criminal or disciplinary proceedings, the Trust will advise about the procedure. The Trust accepts that employees need to be assured that the matter has been properly addressed. Thus, subject to legal constraints or matters of confidentiality, the employee will receive information about the outcome of any investigations The Independent Options This policy has been developed in order to provide employees with guidance on how to raise a matter of concern within a safe environment and without fear of victimisation, and the procedure set out in Appendix 3 has been designed to facilitate this process. If, however, an employee is unsure whether to use this procedure or feels that they cannot raise an issue within the 13

14 procedure, the Trust is keen to ensure that they are aware of alternative sources of help and advice. Within the Trust you may approach HR and/or the Director of Nursing and Integrated Governance directly to express concerns or for advice on how to do so. In what the Trust would hope would be exceptional circumstances, an employee may feel it appropriate or indeed necessary to raise their concerns outside the Trust. As such they can contact: NHS Sheffield or the Care Quality Commission (South Yorkshire Area) via NHS Sheffield Independent advice outside the Trust is also available at any stage from: the relevant Trade Union or Professional Body (e.g. BMA / RCN). The independent charity Public Concern at Work. Their lawyers can give free confidential advice about how to raise a concern about serious malpractice at work. Students / trainees may wish to speak to their relevant training body. The Department of Health provides a free independent and confidential whistleblowing helpline for health and social care (this is also open to employers for good practice) which is provided in Appendix 5. The Care Quality Commission have produced a quick guide for care staff who think they may need to raise a concern with the CQC. This encourages staff to try to resolve any concerns within the organisation first but indicates that if an employee feels unable to do this or their voice is not being heard then they can contact the CQC. Details are in Appendix 5. The General Medical Council / medical defence bodies / Royal College of Psychiatry The Nursing and Midwifery Council The Media The Trust advises that before involving the media in concerns about malpractice in the Trust, employees give serious consideration to the issues of confidentiality for the service users and other members of staff who might be involved. Under its duty of care to its service users, the Trust would need to consider action within the context of its disciplinary procedure if it felt that disclosure to the press had resulted in a breach of this duty of care. Furthermore, employees need to be aware that should the concerns prove to be unfounded or misplaced, after they have been published in the press, issues of libel or slander may arise. The Trust, therefore, urges employees to fully utilise the process set out in this policy and its appendices, before considering involving the media If an employee is dissatisfied If an employee is unhappy with the Trust response (including lack of any response) to an issue they have raised,they can go o to other levels within the procedure or to the independent bodies identified in this policy. If they are dissatisfied with the action taken or not taken after reporting the matter to the Deputy Chief Executive (Medical Director or Chief Nurse) then the issue can be raised with the Chief Executive. Whilst the Trust cannot guarantee that it will respond to all matters in the way that an employee might wish, the Trust will strive to handle the 14

15 matter fairly and properly. By using this policy, employees will help the Trust to achieve this outcome Contact Names Titles rather than the individual names have been used throughout the main body of this policy to avoid the need to revise and reissue it, if the people in the posts change. It is recognised however, that it may be easier to approach someone if you have the name of the contact. In Appendix 5 the names of current postholders and some useful contact numbers are provided. The appendices will be updated and reissued as necessary during the life of the current version of the policy. 7. Dissemination, Storing and Archiving Human Resources policies and procedures are referred to in all employees contracts of employment and statement of terms. Policies are available through the Human Resources portal and are also listed alphabetically on the Trust intranet. If necessary, a paper copy can be provided by the Human Resources Department. Policies are agreed with Staff Side in the first instance. An will be sent to all SHSC employees informing them of the revised policy. The previous policy will be removed from the intranet and replaced with the new version by HR. Managers are responsible for ensuring the hard copies of the previous versions are removed from any policy/procedure manually or files stored locally. There are no specific significant resource implications. A copy of the policy will also be issued to the employment agencies with whom the Trust recruits agency workers. 8. Training and other resource implementation There are no specific training requirements as part of the dissemination of this revised policy. HR also offer support on the application of its policies in individual cases. 9. Audit, monitoring and review HR policies are subject to joint monitoring and review between Management and Staff Side in the Trust s Joint Consultative Forum. An evaluation of the cases will be carried out each year by the Deputy Chief Executive with the assistance of HR and any areas of concern reported to the Executive Directors Group. As part of the evaluation, feedback sessions may be arranged to ensure appropriate action has been 15

16 taken to investigate and, if necessary, resolve problems indicated by whistleblowing, as well as providing appropriate feedback to the individuals concerned. The Audit & Assurance Committee will also issue each year a letter to all staff reminding them of the policy and also setting out that issues relating to service provision can also be raised with the relevant Staff Governors. 10. Links to other policies, standards and legislation Linked policies are set out in Section 1.6. The principal legislation is the Public Interest Disclosure Act Other relevant Acts and Statutory Instruments include: Employment Rights Act 1996 Employment Rights Act 1996 Management of Health and Safety at Work Regulations 1999 (SI 1999/3242) Public Interest Disclosure (Compensation) Order 1999 (SI 1999/1548) Public Interest Disclosure (Prescribed Persons) Order 1999 (SI 1999/1549) Public Interest Disclosure (Prescribed Persons) (Amendment) Order 2003 (SI 2003/1993) Public Interest Disclosure (Prescribed Persons) (Amendment) Order 2004 (SI 2004/3265) Public Interest Disclosure (Prescribed Persons) (Amendment) Order 2005 (SI 2005/2464). Human Rights Act 1998 Enterprise and Regulatory Reform Act 2013 The British Standards Institute and Public Concern at Work have developed a standard for whistleblowing Whistleblowing Arrangements Code of Practice (July 2008) which is available as a Publicly Available Specification for individual use as a download from either organisation. Whilst it has been developed jointly by these organisations, it is not to be regarded as a British Standard. When handling issues that arise as part of this policy, consideration should be given to the Code of Practice but it is not to be regarded as binding. Other documents taken into account include Speak up for a Healthy NHS (issued by Public Concern at Work and the Social Partnership Forum), Speaking up for Vulnerable Adults April 2011 (issued by Public Concern at Work), Raising a concern with the CQC (Care Quality Commission), Raising and acting on concerns about patient safety (General Medical Council) and the NHS Constitution. The Speaking Up Charter outlines a commitment by the NHS Employers organisation, regulators, professional regulatory bodies, health unions and professional associations to work together to support staff when raising a safety concern or issue at work. 11. Contact Details for Human Resources Human Resources staff are available for support and advice. The contact details are available through the Human Resources portal on the Trust s intranet. 12. References This policy is based on the legislation listed above and good practice. Further information is also available on the web from 16

17 DEFINITIONS APPENDIX 1 Whistleblowing The official name for whistleblowing is making a disclosure in the public interest. It means that you have a reasonable and honest suspicion there is wrongdoing in your workplace (e.g. your employer is committing a criminal offence). You can report this by following the correct processes and your employment rights are protected. Generally when someone blows the whistle they are raising a concern about a danger or illegality that affects others (e.g. clients, members of the public or their employer). The person blowing the whistle is usually not directly, personally affected by the danger or illegality. Consequently the whistleblower rarely has a personal interest in the outcome of the investigation of their concern. The whistleblower is raising the concern so that others can address it. A whistleblowing concern is about risk, malpractice or wrongdoing. This is different from a complaint where the individual is seeking redress for themselves (e.g. grievance or bullying and harassment) and has a vested interest in the outcome. It is usually a complaint about action which the employer has taken or is contemplating taking in relation to him/her. The individual, therefore, is directly involved in the process and in presenting the evidence to support the concern, the whistleblowing policy would not be the most appropriate route. In some situations, it may be difficult to make the distinction and advice should be sought from an appropriate source such as your Trade Union / Professional Association or Public Concern at Work. Malpractice This would be improper, illegal or negligent behaviour by anyone in the workplace. Employees As well as employees this policy includes agency workers, those in training placements, and those on secondment to the Trust and NHS practitioners (e.g. GPs). Some self-employed people may be considered to be covered by this procedure on whistleblowing depending on the nature of the arrangements including such factors as whether they are supervised or work off-site. Victimisation This is any detriment carried out by the employer or any employee or worker against the employee because a disclosure was made. This potentially covers a wide range of unfavorable treatment including failure to promote, refusal of training or other opportunities, unjustified disciplinary action, reduction in pay or dismissal. 17

18 WHISTLEBLOWING ISSUES APPENDIX 2 This list illustrates the kind of issues the Trust would consider as malpractice or wrongdoing that could be raised under this Whistleblowing Policy. However, the list is not exhaustive. Poor or unprofessional practice by a member of staff or an agency which results in the service user not getting the same quality of service which is available to others; Improper/unacceptable behaviour towards a service user which could take the form of emotional, sexual or verbal abuse, rough handling, oppressive or discriminatory behaviour or exploitative acts for material or sexual gain; Any unlawful activities, whether criminal or a breach of civil law; Fraud, theft or corruption; Concerns regarding possible breaches of Health and Safety Regulations; Harassment, discrimination, victimisation or bullying of employees and/or service users; Leaking confidential information in respect of Trust activities and/or records; Undertaking of undisclosed private work which may conflict with duties and responsibilities, or which are being carried out during working time; Inappropriate contact with members of the public within Trust facilities, or whilst carrying out Trust duties; Bribery - Receiving or offering gifts or inducements; Inappropriate use of external funding; Breach of any statutory Code of Practice; Breach of, or failure, to implement, or comply with any Trust policy; Misuse of Trust assets, including computer hardware and software, buildings, stores, vehicles. 18

19 WHISTLEBLOWING POLICY APPENDIX 3 A PROCEDURE FOR STAFF RAISING CONCERNS INTERNALLY If an employee sees something being done wrongly then can they tackle it themselves there and then? A firm challenge is sometimes all that is needed. If not, then talk to your line manager, if possible, or someone more senior in the Trust about the problem. If you do not feel able to raise your concern in this way seek further advice from the sources listed in Section If a concern is raised under this policy then the stages are set out below. In some circumstances it may be more appropriate for the concern to be raised with the relevant lead clinician e.g. for junior doctors. Stage One If you have a concern you should consider raising this in the first instance with your line manager, either verbally or in writing. Your line manager will investigate and you should be notified in writing of the outcome within 10 working days. (If you feel unable to use the normal procedure then you should contact the Deputy Chief Executive. If after this discussion it is identified that the normal procedure is not appropriate then the Deputy Chief Executive will direct you to the appropriate procedure, professional lead or other manager to take the issue forward instead of the line manager. (See Note 3 below) Stage Two If you feel unhappy with the outcome from Stage One (including where no response has been provided within the appropriate timescale), or if you feel unable to raise the matter with your line manager, you should use Stage Two. You should inform the next level of management of your concerns either verbally or in writing within 15 working days of receiving the outcome of stage one or within 15 working days of the date when this should have occurred if no response received. The manager will investigate and you should be notified verbally of the outcome within 10 working days. This should be confirmed in writing within a further 5 working days. Stage Three If you are unhappy with the outcome from Stage Two, you should use Stage Three. You should inform the next level of management of your concerns in writing, within 15 working days of receiving in writing the outcome of the previous stage or 15 working days of the date when this should have occurred if no response received. They, or their nominated deputy, will meet you within 5 working days of receiving your letter and may initiate an investigation if they think it is necessary. You will be informed in writing of the final decision in writing within 10 working days of your meeting, unless there is a further investigation. In such an eventuality, you will be informed of the timescale for the investigation and when you will receive written notification of the final outcome. 19

20 Notes 1. You are encouraged to use the above procedure to raise concerns you may have. However, if there are circumstances which make it difficult to work within the above some independent options are available and these are described in Section 6.11 of the Policy. 2. The Trust will seek to meet the above timescales for response but the nature of the issue will have a bearing on both the amount of investigation required and the type of investigation undertaken e.g. it may be that a forthcoming audit or review would be the best way to address the issue. In such circumstances the individual will be informed of the revised timescales. 3. Where the concern was originally considered by the Deputy Chief Executive, Chief Nurse or Medical Director as it was felt the normal procedure could not be used then this will be regarded as Stage Three of the procedure. If the employee is unhappy with the outcome then in these circumstances the concern would be considered by the Chief Executive or Deputy Chief Executive (if not previously directly involved in the investigation). The timescales relating to Stage 3 would also apply to the consideration by the Chief Executive / Deputy Chief Executive. 4. Where the issue relates to matters involving Executive Directors, then the Deputy Chief Executive will consider referring the matter to the Board who will then decide whether to appoint a Non-Executive Director to lead any investigation with the issue. 20

21 APPENDIX 4 WHISTLEBLOWING POLICY A FRAMEWORK WITHIN WHICH COLLEAGUES FROM OUR PARTNER ORGANISATIONS AND AGENCIES CAN RAISE CONCERNS We recognise that in working with Sheffield Health & Social Care Trust to deliver care to people in Sheffield there may be occasions when your experience leads you to have concerns about our services. We hope that you will feel able to do this by raising such concerns with the staff themselves or with their manager. We realise though that there may be occasions when this is not appropriate. In such cases you may contact the Trust s Deputy Chief Executive or, if you wish to speak to someone who is independent of the Trust then you could contact the Chief Operating Officer of NHS Sheffield. (See Appendix 5 attached for contact names and numbers). In either case the matter will be pursued in line with the principles set out in this policy. 21

22 WHISTLEBLOWING POLICY APPENDIX 5 Contact Details (February 2013) Set out below are the names of the individuals filling the posts referred to in the above policy at the date shown in the heading. This Appendix will be revised and re-issued as the names change: Chief Executive Kevan Taylor Kevan.taylor@shsc.nhs.uk Deputy Chief Executive Clive Clarke Clive.clarke@shsc.nhs.uk Director of Finance Paul Robinson Paul.robinson@shsc.nhs.uk Medical Director Tim Kendall Tim.kendall@shsc.nhs.uk Chief Nurse Liz Lightbown Liz.lightbown@shsc.nhs.uk Complaints & Litigation Lead Wendy Hedland Wendy.hedland@shsc.nhs.uk Sheffield Clinical Commissioning Group Idris Griffiths, Chief Operating Officer (designate) Counter Fraud Service Local Counter Fraud Specialist Robert Purseglove - robert.purseglove@nhs.net National Fraud and Corruption Reporting Line Public Concern at Work helpline@pcaw.co.uk Department of Health Helpline (Royal Mencap Society) Care Quality Commission

23 APPENDIX 6 Handling whistleblowing: practical tips for managers As a manager you can lead by example. Be clear to your staff what sort of behaviour is unacceptable and practice what you preach. Encourage staff to ask you what is appropriate if they are unsure before not after the event. If you find wrongdoing or a potential risk to patient safety, take it seriously and deal with it immediately. Responding to a concern Thank the staff member for telling you, even if they may appear to be mistaken. Respect and heed legitimate staff concerns about their own position or career. Manage expectations and respect promises of confidentiality. Discuss reasonable timeframes for feedback with the member of staff. Remember there are different perspectives to every story. Determine whether there are grounds for concern and investigate if necessary as soon as possible. If the concern is potentially very serious or wide-reaching, consider who should handle the investigation and know when to ask for help. Put your response in writing. Always remember that you may have to explain how you have handled the concern. Feedback any outcome and/or remedial action you propose to take to the whistleblower but be careful if this could infringe any rights or duties you may owe to other parties. Consider reporting to the Director of Nursing and Integrated Governance the outcome of any genuine concern where malpractice or a serious safety risk was identified and addressed. Record-keeping it makes sense to keep a record of any serious concern raised with those designated under the policy, anonymising these where necessary. 23

24 Equality Impact Assessment Process for Policies Developed Under the Policy on Policies Stage 1 Complete draft policy Stage 2 Relevance - Is the policy potentially relevant to equality i.e. will this policy potentially impact on staff, patients or the public? If NO No further action required please sign and date the following statement. If YES proceed to stage 3 This policy does not impact on staff, patients or the public (insert name and date) Stage 3 Policy Screening - Public authorities are legally required to have due regard to eliminating discrimination, advancing equal opportunity and fostering good relations, in relation to people who share certain protected characteristics and those that do not. The following table should be used to consider this and inform changes to the policy (indicate yes/no/ don t know and note reasons). Please see the SHSC Guidance on equality impact assessment for examples and detailed advice this can be found at Does any aspect of this policy actually or potentially discriminate against this group? See below. Can equality of opportunity for this group be improved through this policy or changes to this policy? Can this policy be amended so that it works to enhance relations between people in this group and people not in this group? AGE No N/A N/A DISABILITY No GENDER REASSIGNMENT No PREGNANCY AND MATERNITY No RACE No RELIGION OR BELIEF No SEX No SEXUAL ORIENTATION No Stage 4 Policy Revision - Make amendments to the policy or identify any remedial action required (action should be noted in the policy implementation plan section) Please delete as appropriate: Policy Amended / Action Identified / no changes made. Impact Assessment Completed by (insert name and date) Nigel Donaldson, 7 th January

25 Appendix B - Human Rights Act Assessment Form and Flowchart You need to be confident that no aspect of this policy breaches a persons Human Rights. You can assume that if a policy is directly based on a law or national policy it will not therefore breach Human Rights. If the policy or any procedures in the policy, are based on a local decision which impact on individuals, then you will need to make sure their human rights are not breached. To do this, you will need to refer to the more detailed guidance that is available on the SHSC web site (relevant sections numbers are referenced in grey boxes on diagram) and work through the flow chart on the next page. 1. Is your policy based on and in line with the current law (including caselaw) or policy? Yes. No further action needed. No. Work through the flow diagram over the page and then answer questions 2 and 3 below. 2. On completion of flow diagram is further action needed? No, no further action needed. Yes, go to question 3 3. Complete the table below to provide details of the actions required Action required By what date Responsible Person 25

26 Human Rights Assessment Flow Chart Complete text answers in boxes and highlight your path through the flowchart by filling the YES/NO boxes red (do this by clicking on the YES/NO text boxes and then from the Format menu on the toolbar, choose Format Text Box and choose red from the Fill colour option). Once the flowchart is completed, return to the previous page to complete the Human Rights Act Assessment Form. 1.1 What is the policy/decision title? What is the objective of the policy/decision? Who will be affected by the policy/decision?. 1 Will the policy/decision engage anyone s Convention rights? YES Will the policy/decision result in the restriction of a right? 2.2 YES 2.1 NO NO Flowchart exit There is no need to continue with this checklist. However, o Be alert to any possibility that your policy may discriminate against anyone in the exercise of a Convention right o Legal advice may still be necessary if in any doubt, contact your lawyer o Things may change, and you may need to reassess the situation Is the right an absolute right? 3.1 YES NO 4 The right is a qualified right Is the right a limited right? YES 3.2 Will the right be limited only to the extent set out in the relevant Article of the Convention? 3.3 NO YES 1) Is there a legal basis for the restriction? AND 2) Does the restriction have a legitimate aim? AND 3) Is the restriction necessary in a democratic society? AND 4) Are you sure you are not using a sledgehammer to crack a nut? YES NO Policy/decision is likely to be human rights compliant BUT Policy/decision is not likely to be human rights compliant please contact the Head of Patient Experience, Inclusion and Diversity. Get legal advice Regardless of the answers to these questions, once human rights are being interfered with in a restrictive manner you should obtain legal advice. You should always seek legal advice if your policy is likely to discriminate against anyone in the exercise of a convention right. Access to legal advice MUST be authorised by the relevant Executive Director or Associate Director for policies (this will usually be the Chief Nurse). For further advice on access to legal advice, please contact the Complaints and 26 Litigation Lead.