Raising Concerns at Work ( Whistleblowing ) Policy and Procedures

Transcription

1 Raising Concerns at Work ( Whistleblowing ) Policy and See also: Fraud and Corruption Policy Safeguarding Vulnerable Adults Policy and Safeguarding Children Policy and Untoward Incident Reporting and Investigation procedures Dignity at Work Disciplinary Policy and Procedure Grievance Policy and Procedure Personal Relationships Policy Located in the following Policy folder on the Trust Intranet Corporate and Risk Management Policies Corporate and Risk Management Policies Clinical Policies and Corporate and Risk Management Policies Workforce and OD Policies and Workforce and OD Policies and Human Resources Policies and Workforce and OD Policies and Service area Issue date Issue no. Review date Trust wide May May 2018 Ratified by Ratification date Responsibility for review: Board of Directors May 2015 Director of Corporate and Legal Affairs Amendments ratified by Quality Committee on behalf of Board Sept 2015 Document published on the Trust Intranet under: Corporate and Risk Management Policies and Did you print this document? Please be advised that the Trust discourages retention of hard copies of policies and can only guarantee that the Policy on the Trust Intranet site is the most up-to date-version

2 Checklist for Raising Concerns at Work ( Whistleblowing ) Policy and Name / Title Summary Raising Concerns at Work Policy (Whistleblowing) Provides details of how staff may raise concerns Working name/title of the policy/procedure Brief summary of main themes Sponsor Director of Corporate & Legal Affairs Name and job title of person taking through approval and signing off Author(s) Director of Corporate & Legal Affairs & Assistant Director Corporate & Legal Affairs Job titles of those involved in producing the document Reason for document production: Commissioning Individual or Group: Review Trust Board Individuals or Groups who have Date: been consulted: Risk & Quality Governance Committees 2 October Employee Strategy and 2014 Engagement Committee Trust Operational Management 10 October Meeting 2014 Trust Board approval and comments. Board approved 26/11/14 Trust Board approval and comments Version Control (for minor amendments) Response February 2013 Ratified Date Author Comment Consultation comments made Sept 15 Lorraine Bradshaw/Rachel Kempster Updated with recommendations from Freedom to Speak up Review Cross referenced to revised Personal Relationships Policy Page 1 of 17

3 Table of contents 1. Introduction Background Statement of Purpose Definitions How to Raise a Concern Scope Matters Regarded As Malpractice Matters Concerning Suspected Fraud Policy Support Stage One - Local Procedure Stage Two - Raising Concerns Outside The Immediate Management Structure Stage Three Stage Four - Raising Concerns Outside The Trust Access to Confidential External Advice Promotion Of This Policy Advice and Support for Staff and others who have concerns Monitoring Of Policy Appendix A: Raising Concerns at Work Response Evaluation Strictly Confidential Appendix B: Raising Concerns Guidance For Staff Page 2 of 17

4 1. Introduction 1.1 Background Raising Concerns at Work ( Whistleblowing ) Policy and In February 2015, Robert Francis QC published his report on the Freedom to Speak Up review. The report sets out 20 Principles and Actions which when implemented, aim to create the right conditions for NHS staff to speak up, share what works across the NHS, and get all organisations up to the standard of the best and provide redress when things go wrong in the future. 1.2 Statement of Purpose The provision of a high quality service is the most important priority within the Trust. On occasions, employees of the Trust may have concerns about the care being provided to patients, or about dangerous, fraudulent or other forms of malpractice. The Trust is committed to take seriously and investigate such concerns positively, quickly and reasonably. The Trust in addition requires all managers to ensure that any member of staff with a concern is treated reasonably and fairly. This statement of purpose is supportive of the Trust s core values, including:- We put patients at the centre of everything we do patients can expect safe, effective care which aids well-being and puts compassion at the heart of their care. Our staff will demonstrate trust and respect towards everyone. The purpose of this policy is to encourage a climate of openness where staff feel freely able to raise issues of concern about patient care and service matters. The Trust expects staff to raise concerns through the internal line management structures wherever possible. This policy sets out the course of action which staff should take if a matter is not addressed internally to their satisfaction, or where they feel unable to raise the matter internally in the first instance. Anonymous complaints cannot be considered within this policy but every effort will be made to keep a member of staff s identity confidential if they wish. If the nature of the concern relates to patient care matters, the Trust reserves the right to ensure that these concerns are reported immediately to the Board nurse in order that patient safety may be maintained. Should the nature of the concern involve matters of patient safety and require reporting to the Board nurse, the complainant will be made aware of this. Page 3 of 17

5 Any member of staff who is, or feels to be, being abused by another member of staff should raise their concerns following this policy and procedure. This includes any form of actual or potential abuse including sexual, physical or emotional manipulation, coercion or grooming. It is recognised that if the perpetrator is in a more senior position than the member of staff affected, they may feel it particularly difficult to raise the concern. However, staff are reminded that all concerns with be treated with the strictest of confidence. Confidentiality is paramount and a breach of this confidence may result in a review of practice and may include investigation into conduct and behaviour under the Trust Human Resource policies 2. Definitions Most whistleblowers are internal whistleblowers, who report misconduct to a fellow employee or superior within their organisation. A whistleblower is a person who raises a concern about a risk, serious wrongdoing or malpractice at work. Usually this person would be from that same organisation. Typically, a person is said to have blown the whistle if s/he has brought to the attention of the authorities, or the public, some form of malpractice or serious wrongdoing which has been perpetrated by or within the organisation in which s/he is employed or with which s/he is in some other way connected. 3. How to Raise a Concern Individuals must be encouraged to raise their concerns; they need to know how to do so and they need to have the confidence that, if they do, those concerns will be taken seriously and that they will not be victimised in any way. The Trust is committed to treating its employees fairly, equitably and reasonably and not to discriminate against individuals or groups on the basis of their ethnic origin, physical or mental abilities, gender, age, religious beliefs or sexual orientation. For concerns which relate to fraud, bribery or corruption these must be reported through the provisions within the Fraud, Bribery and Corruption policy, rather than through the Raising Concerns Policy. 4. Scope Staff have concerns about what is happening where they work. When the concern feels serious because it might affect patients or people receiving care, colleagues or the organisation it can be difficult to know what to do It may be that staff feel that raising the matter will be disloyal to colleagues, their manager or the Trust. However everyone working in the Trust has a duty Page 4 of 17

6 to follow their professional code of conduct, and put patients and the people they care for first and protect their safety. Ideally staff should resolve any concerns within the Trust first. If staff feel unable to do this, or feel that their voice is not being heard then they can speak to someone outside the Trust for support and advice (see Section 12). This Policy applies equitably to all employees of Derbyshire Healthcare NHS Foundation Trust. In addition, it covers other workers, including students, agency staff, volunteers, contractors and self-employed persons, e.g. doctors, dentists, ophthalmologists and pharmacists, who may work within the Trust. The policy addresses the main provisions of the Public Interest Disclosure Act 1998 (the Act) and the Enterprise and Regulatory Reform Act The Act ultimately provides statutory protection to whistleblowers from victimisation and dismissal where they raise in the public interest concerns about misconduct and malpractice. The Act affords the whistleblower compensation in law if their employment situation is adversely affected by any failure of the employer to correctly deal with a confidential disclosure. The Independent Inquiry into care provided by Mid Staffordshire NHS Foundation Trust within its recommendations identified the need to ensure that the Trust board should give priority to ensuring that in the event of any member of staff who raises an honestly held concern about the standard of safety of the provision of services to patients is supported and protected from any adverse consequences. A culture of openness should be encouraged. This Policy encompasses the principles contained within the recommendations of the Independent Inquiry with regard to the ability of staff to raise concerns and have their concerns addressed without recrimination. 5. Matters Regarded As Malpractice Disclosure or the reporting of concerns about the following, when made in the public interest, qualify for protection under the Act: A criminal act thought to have been committed, or likely to be committed A failure to comply with a legal obligation A miscarriage of justice A danger to health and safety of any individual Damage to the environment Or an attempt to cover up any of these. When someone blows the whistle they are raising a concern about risk, malpractice or wrong doing in the public interest. The person blowing the Page 5 of 17

7 whistle is usually not directly, personally affected by the danger or the wrong doing. They are raising the concern so that others can address it. This is very difference to a grievance, which tends to be an issue about employment rights, whereby the person wishes to complain about their treatment, and they have a personal interest in ensuring the issue is addressed. All providers of health and social care are required by law to meet government standards of quality and safety. If staff have a concern about:- Poor patient care Abuse in care Breaches of health and safety law, including patient safety Breaches of people s privacy and dignity Knowledge or suspicion of false or artificial entries being made in official records Concern relating to professional competence staff should raise their concerns in accordance with the requirements of this Policy. Whistleblowing issues such as those cited above are to be distinguished from personal grievances in the workplace. 6. Matters Concerning Suspected Fraud, Bribery and Corruption For concerns which relate to fraud, bribery or corruption these must be reported through the provisions within the Fraud, Bribery and Corruption policy. Sections 9 to 12 of this policy do not apply to concerns of this nature. In accordance with the Fraud, Bribery and Corruption Policy, in instances where you suspect fraud, bribery or corruption to have occurred you must contact the Director of Finance or your Local Counter Fraud Specialist, Penny Gee on or penny.gee@nhs.net. All information received will be treated in the strictest confidence. Alternatively, you can call the NHS Confidential Fraud and Corruption Reporting line Stop NHS Fraud on to report any suspicions of fraud or corruption in the NHS or report the fraud via their website Interviews and investigations will be professionally undertaken by the Local Counter Fraud Specialist, who will ensure that any investigation is completed observing the standards defined in the Fraud and Corruption Manual. 7. Policy In order to safeguard the interests of patients, employees have a right and a duty to report any matter of concern about patient care. Health professionals and senior managers are also bound by their respective codes. Page 6 of 17

8 The Trust will promote a climate of openness and dialogue in order to encourage the free expression of views and concerns. All concerns raised within the Trust will be viewed seriously and given full and sympathetic consideration. Any manager or professional member of staff with whom a concern is raised will ensure that the matter is investigated promptly and any problem resolved as quickly as possible. The manager will explain how the matter will be handled and who can be contacted for further advice. The Trust has a duty to ensure that any member of staff who expresses concerns in accordance with this policy will not be subject to reprisals or retaliations at work. Individuals who harass or bully someone on the grounds they may have made a potential disclosure are personally liable for their actions. The Trust as an employer is also vicariously liable for such actions (subject to a defence that it has taken all reasonable steps to prevent workers acting in this way). All NHS staff have a duty of confidentiality to patients. Unauthorised disclosure of personal information about any patient will be regarded as a most serious matter and will render the person(s) responsible liable to disciplinary proceedings. It is recognised that staff may wish to report their concerns confidentially. They may do this in a letter to the Trust Chairman or a Non-Executive Director in a letter marked private and confidential, for addressee only. This will ensure that only the addressee will have access to the information contained within. 8. Support There is a range of persons to whom concerns can be reported easily and without formality. These are: Freedom to Speak up Guardians have been appointed by the Chief Executive to work in an independent capacity with regard to reporting concerns raised by staff. The Staff Governors have been identified as Freedom to Speak up Guardians. A nominated Non-Executive Director who will receive reports of concerns either directly or from the Freedom to Speak up Guardians. This is currently Maura Teager, who can be contacted in confidence via telephone number: extension A nominated manager in each service area to receive reports of concerns Independent external organisations that can provide staff with advice and support see Section 15 for contact numbers. Page 7 of 17

9 Where a NHS worker who has raised a concern cannot, as a result, continue in their current employment, the Trust will offer support to the member of staff in finding alternative employment in the NHS. 9. Stage One - Local Procedure If you see something being done that is wrong, consider whether you can tackle this yourself. A firm polite challenge is sometimes all that is needed. If you do not feel that this is appropriate the following may be pursued: Many concerns should be capable of resolution directly between the individual and their immediate line/professional manager. Normally any disclosure or report of a concern would be made orally or in writing in the first instance to the line manager. A representative, either from a professional organisation or a friend or colleague, may accompany staff when raising concerns. Personal employee support may also be arranged by the Staff Liaison officer. Staff must not be seeking personal gain from reporting their concerns. The manager receiving the disclosure or reported concern will: Ensure staff feel able to discuss the issue (in confidence if they request) without the fear of action being taken against them Take concerns seriously Seek advice from the designated senior officer Consider concerns fully and sympathetically Recognise that raising a concern can be a difficult experience Take a statement to confirm the nature of the concern Seek advice from healthcare professionals where appropriate Undertake any necessary investigation promptly and, upon conclusion of the matter, notify the individual of the outcome and any action taken in writing within 15 working days. A confidential copy of this response should be sent to the Director of Corporate & Legal Affairs, for monitoring purposes only. When action is not considered practicable or appropriate, the individual will be given a prompt and thorough explanation of the reasons for this, no later than 15 days after the matter was raised. They will also be advised of what further action is available under the procedure if they are not satisfied with the outcome. 10. Stage Two - Raising Concerns Outside The Immediate Management Structure Page 8 of 17

10 Where an individual is not satisfied with the outcome of the initial investigation, or if it is considered that it is too serious to be raised and resolved through normal local channels, the following procedure should be used. Whilst in normal circumstances the individual should approach their immediate manager, this may be considered inappropriate: When the immediate line/professional manager is potentially implicated in the matter When the immediate line/professional manager has previously been involved in attempts to address the concern When the concern is regarded as too serious to be handled at local level When it is considered that the immediate manager would not have the authority to deal with the matter. In these circumstances the individual should raise this matter with the next level of authority, who will assist in preparing a statement if necessary. At this stage staff may also contact the Director of Corporate & Legal Affairs who is the designated senior officer with responsibility under the Act for addressing concerns raised outside the normal management chain, for advice on how to proceed. Concerns raised in this manner will be investigated promptly and the manager receiving the concern will inform the individual who is investigating the matter, and the arrangements for keeping them informed of progress. The outcome, and action taken, will be communicated in writing within 15 days. Where the matter is raised in confidence arrangements will be made to protect confidentiality wherever possible. 11. Stage Three Where the employee has a continuing concern following the responses at Stage Two, they may approach the Chief Executive of the Trust. At this stage a Non-Executive Director of the Trust, nominated for this purpose by the Board, may alternatively be contacted for advice and support. Currently this responsibility is fulfilled by Maura Teager who can be contacted in confidence via telephone number: extension The nominated Non Executive Director will receive reports of concerns from the Freedom to Speak up Guardian. The Chief Executive may commission a fresh investigation. He may seek advice from professionals or professional bodies from outside the Trust where appropriate. A written explanation of the outcome will be provided within one week of the completion of the investigation. The individual raising the concern will be notified of the procedures being taken and estimated time for completion of the investigation. Page 9 of 17

11 Employees may be accompanied by their representative, professional organisation, friend or colleague at all stages of the procedures. The nominated officer will also deal with any case where an employee feels that they are being victimised or treated badly having raised a concern. 12. Stage Four - Raising Concerns Outside The Trust An employee who has exhausted the Trust procedures, and who has taken account of the advice and explanations given, who remains dissatisfied with the outcome, may wish to inform the Care Quality Commission or any of the public bodies referred to in paragraph 15 below. Information disclosed to the Care Quality Commission may be given anonymously or in confidence. The alerter should have reason to believe that the information they give is substantially true. Alternatively they may wish to consult their Member of Parliament in confidence. Following the use of the procedure, as a last resort an employee may contemplate the disclosure of the concern to the media. Significant additional conditions apply to these forms of disclosure in order for disclosure to remain protected. Advice should be taken from a Trade Union or the Whistleblowing Helpline if such an option is being considered., The Trust s policy for dealing with the media is that all media contact should be handled through the Chief Executive s office. Only specified identified officers of the Trust are authorised to speak on its behalf. If, in a personal capacity, any member of staff communicates directly with the media on any issue relating to Trust business, its customers, its suppliers or other interest, the information disclosed must not be misleading, inaccurate or malicious, nor result in damage to the organisation or any of its staff. Members of staff are advised to contact the Communications Team for further advice. 13. Access to Confidential External Advice (see Section 15 for further contact details) At any stage of this procedure, staff will have the right to consult, seek guidance or support from their trade union, professional organisation, or from other statutory bodies such as the NMC, GMC, etc. Independent help can be obtained from Public Concern At Work, an independent charity. Free information and advice can also be obtained from the Advice, Conciliation and Arbitration Service (ACAS) The Care Quality Commission have a specially trained team who process all whistleblowing concerns. The follow up of concerns is handled by the by the local Compliance Inspector who will take appropriate action to ensure the safety of the patient and to investigate the concerns raised. Page 10 of 17

12 An employee contemplating making a disclosure to the media is urged to seek further specialist guidance from one of the above organisations. 14. Promotion Of This Policy To ensure the effectiveness of this policy, it is imperative that all staff are made aware of these arrangements. This should be done systematically by inclusion in: Corporate Induction Workplace Induction Mandatory Training Fixed term contracts, Agency and temporary staff contracts The checklist for on-site contractors, e.g., facilities and estates Regular communications to staff. Periodic additional training will be provided for senior managers. 15. Advice and Support for Staff and others who have concerns This policy is intended to provide employees with an opportunity within the Trust to raise concerns. You may feel that it is more appropriate to report a matter of concern to another organisation. Other organisations concerned with standards in the NHS include: The Whistleblowing Helpline free advice for the NHS and Social Care this is a confidential advisory service only Public Concern at Work the leading independent authority in the UK on whistleblowing. It provides confidential advice to individuals who witness wrongdoing at work and who are unsure as to how to raise a concern. Call Care Quality Commission (CQC) - employment protection for whistleblowers is provided by the Public Interest Disclosure Act 1998 (PIDA). CQC is a body described by PIDA for receiving complaints from people working in the services it regulates about matters relating to that service Call or at enquiries@cqc.org.uk. Write to CQC National Correspondence Citygate Gallowgate Newcastle upon Tyne NE1 4PA Monitor the sector regulator for health services website Nursing and Midwifery Council: Raising Concerns Guidance for Nurses and Midwives (September 2014) website General Medical Council: Raising and Acting on concerns about patient safety (2012) website Health and Care Professions Council website Page 11 of 17

13 Health and Safety Executive NHS Fraud and Corruption Reporting Line A.C.A.S Health and Safety Executive Mark Stocks, Auditor, Grant Thornton Penny Gee, Counter Fraud Specialist Monitoring Of Policy Whistleblowing incidents are monitored by the Trust Executive Leadership Team. The Audit Committee has an independent responsibility for reviewing the overall arrangements. The Trust Board will receive a quarterly anonymised bulletin of concerns which have been raised and substantiated, as well as those raised and found unsubstantiated. In addition to the requirement that any concern relating to patient safety or poor care is reported immediately to the Board Nurse (see introduction), the Medical Director and CEO (in his regular report to Board) may also report any significant whistleblowing concerns to Board members. An evaluation form is attached (Appendix A). This should be completed to provide feedback on the response to the member of staff who has raised concerns under this policy and the effectiveness of the policy in general. The Policy will be reviewed on a 3 yearly basis. Staff will be advised of revisions to the Policy through regular policy bulletins and weekly communications. Page 12 of 17

14 Appendix A: Raising Concerns at Work Response Evaluation Strictly Confidential This evaluation is intended to provide an evaluation of the response to concerns raised by staff under the Raising Concerns at Work Whistleblowing Policy. When completing this brief evaluation, please do not include your name. 1. Are you happy that your concerns were taken seriously when reported? Yes/No (please circle) Comments 2. Was the subsequent investigation conducted as you would have expected? Yes/No (please circle) Comments 3. If you did not wish to be identified when raising your concern did you feel that your confidentiality was preserved? Yes/No (please circle) Comments 4. Did you receive regular updates to ensure that you were informed of progress of the investigation? Yes/No (please circle) Comments. 5. Are you satisfied with the outcome? Yes/No (please circle) Comments Many thanks for taking the time to complete the evaluation. Please return to Director of Corporate and Legal Affairs, Bramble House, or alternatively speak to the Director in strictest confidence by calling ext Page 13 of 17

15 Appendix B: Raising Concerns (except fraud, bribery or corruption) Guidance For Staff Individual raises concerns oral or written Line Manager Investigates Response satisfactory No further action Provides written response within 15 days Copy of response to Director Corporate/Legal Affairs Report patient safety concerns to Board nurse Response unsatisfactory Approach Director Corporate/Legal affairs for advice Statement to next level of authority Response satisfactory No further action Investigates written response within 15 days Copy of response to Director Corporate/Legal Affairs Response unsatisfactory Nominated Non- Executive Director for advice/support Chief Executive commissions investigation Response satisfactory No further action Written response in 1 week Response unsatisfactory Reports concerns Page 14 of 17 outside the Trust

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17 Equality Impact Analysis (EIA) form for Raising Concerns at Work ( Whistleblowing ) Policy and To be completed and attached to any policy document when submitted to the appropriate committee for consideration and approval. Yes/No Comments 1. Does the document/guidance affect one group less or more favourably than another on the basis of: No Race No Ethnic origins (including gypsies and travellers) No Nationality No Gender (including gender reassignment) No Culture No Religion or belief No Sexual orientation No Age No Disability - learning disabilities, physical disability, sensory impairment and mental health problems No 2. Is there any evidence that some groups are affected differently? 3. If you have identified potential discrimination, are there any valid exceptions, legal and/or justifiable? 4. Is the impact of the document/guidance likely to be negative? No No No 5. If so, can the impact be avoided? No 6. What alternative is there to achieving the document/guidance without the impact? 7. Can we reduce the impact by taking different action? N/A N/A Completed by: Lorraine Bradshaw Date: April 2015 If you have identified a potential discriminatory impact of this policy document, please refer it to the Policy Sponsor together with any suggestions as to the action required to avoid/reduce this impact. For advice in respect of answering the above questions, please contact the Assistant Director Engagement Page 16 of 17