Validation Date: January 2016 September Ratified Date: 20 th September 2016

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1 Document Type: PROCEDURE Title: Nursing and Midwifery Council (NMC) Health and Care Professions Council (HCPC) and Referrals Target Audience: All Registered Non-Medical Healthcare Professionals Author / Originator and Job Title: Simone Anderton, Deputy Director of Nursing Paula Roles, Deputy Director of Workforce and Operational Development Nicholas Lane, Head of Therapies Hazel Gregory, Head of Safeguarding Lisa Farrell, Named Nurse for Safeguarding Children and Adults Replaces: Version 1, CORP/PROC/494, Referral to the NMC and Health Professionals Council Validated (Technical Approval) by: Safeguarding Committee HR Policy Forum Ratified (Management Approval) by: Joint Negotiating Consultative Committee (JNCC) Description of amendments: N/a Validation Date: January 2016 September 2016 Ratified Date: 20 th September 2016 Review dates and version numbers may alter if any significant changes are made Unique Identifier: CORP/PROC/594 Version Number: 2 Status: Ratified Divisional and Department: Human Resources Risk Assessment: Not Applicable Which Principles of the NHS Constitution Apply? 3 Issue Date: 20/09/2016 Review Date: 01/09/2019 aims to design and implement services, policies and measures that meet the diverse needs of our service, population and workforce, ensuring that they are not placed at a disadvantage over others. The Equality Impact Assessment Tool is designed to help you consider the needs and assess the impact of your policy in the final Appendix.

2 CONTENTS 1 Purpose Target Audience Procedure Before Making a Referral Making a Referral Situations when a Referral must be made Lack of Competence Misconduct Health Related Concerns Alert Notices Urgent Referrals and Interim Orders Safeguarding Allegations against Staff Attachments Procedural Document Storage (Hard and Electronic Copies) Locations this Document Issued to Other Relevant / Associated Documents Supporting References / Evidence Based Documents Consultation / Acknowledgements with Staff, Peers, Patients and the Public Definitions / Glossary of Terms Author / Divisional / Directorate Manager Approval... 9 Appendix 1: Link to NMC and HCPC Referral Forms Appendix 2: Referral Decision Tree Appendix 4: Classification of Reasons for Suspension / Issuing an Alert Notice Appendix 5: Equality Impact Assessment Form Page 2 of 16

3 1 PURPOSE The purpose of this Procedure is to provide guidance on what issues require referral to the appropriate professional body, and at what point. These guidelines should be read in conjunction with from the NMC. and HCPC (See links in Appendix 2). All Blackpool Teaching hospital NHS Foundation Trust employees have a statutory duty to safeguard and promote the welfare of children and vulnerable adults, including: Being alert to the possibility of abuse and neglect to a child or adult through their observation, or by professional judgement made as a result of information gathered. Knowing how to deal with a disclosure or allegation of abuse to a child or adult; Undertaking training as appropriate for their role and keeping themselves updated; Being aware of and following the local policies and procedures if they have concerns about a child or adult; Ensuring that all staff and their managers discuss and record any safeguarding issues that arise in a timely manner. 2 TARGET AUDIENCE This policy covers all nurses, midwives and health professionals who are required to register with a statutory body for their role and for them to use a given title. This includes all permanent and temporary staff employed by Blackpool Teaching Hospitals NHS Foundation Trust and honorary contract holders, bench staff, students or agency / locum staff. 3 PROCEDURE 3.1 Before Making a Referral Professional organisations are concerned with cases where registration holders have been involved in a situation or incidents where their fitness to practice is impaired. A flowchart providing guidelines on referral to statutory bodies can be found at Appendix 3. Before a referral to a professional body is made for fitness to practice, a full investigation must be carried out. If during the preliminary stages of the investigation it shows that this is not the case the referral to health professional body is not required and the investigation should continue, in line with relevant Trust Policy or Procedure (See Section 7). Where the initial investigatory process highlights concerns of safeguarding and the situation concerns fitness to practice, then the case must be referred to the Director of Nursing immediately. The Director of Nursing will review the case immediately to determine if a referral to the relevant statutory body or whether the case should continue through full investigation and consideration given to referral at a later stage. Page 3 of 16

4 Where the Director of Nursing is unavailable, then the case must be referred to either, the Deputy Director of Nursing and Quality, Head of Safeguarding or Head of Midwifery who will make the decision on the Director of Nursing s behalf. 3.2 Making a Referral Once it has been decided that a referral is required, then the Matrons the Professional Leading the Internal Investigation will be responsible for contacting the relevant Statutory Body and advise them appropriately in line with their referral requirements. The referrer must liaise with the relevant Human Resources (HR) Business Partner, who will ensure a file note is recorded on the individuals HR file. The referrer must keep the HR Business Partner updated with progress on the case and trial outcome and any sanctions of the NMC HCPC. The HR Business Partner will keep the HR case management system up to date with progress of individual cases and this will provide a central system for reviewing statutory bodies referral activity. Where staff members have been referred to statutory bodies by individuals external to the Trust, those informed of the referral by the statutory body must ensure the Director of Nursing (or one of the agreed deputies) is appraised of the referral. The relevant HR Business Partner must also be appraised of the referral and they will enter the detail on the individuals electronic HR file on the HR case management system Links to the referral form for NMC and HCPC registered professionals are included in Appendix 1. The Statutory Body will require the following information in order to make a judgement on their next steps: Name and Job Title of the person referring. Name of the professional involved. Date of the incident(s). Where the incident(s) took place. Detail of the incident(s). Witness details. What action has been taken. Consent to disclose. PIN Number 3.3 Situations when a Referral must be made There are certain situations where a referral must always be made. However in all cases authority must be sought from the Director of Nursing or one of the aforementioned deputies (Section 3.1) prior to a referral being made. The following are cases where referral must always be made: Page 4 of 16

5 There has been a serious risk to patient safety (Please see CORP/GUID/077 Managers and Employees Dealing with Allegations of Child Abuse against an Individual Member of Staff). Dismissal is the outcome of the full investigation and subsequent HR process Activity contrary to legislation or relevant codes of conduct. Serious or real harm been caused. The profession is being brought into disrepute. Fitness to practice concerns are proven following a full investigation. Full guidance on raising and escalating concerns for nursing, midwifery and healthcare professional staff is provided by the NMC and HCPC. Their guidance is available through the links within Appendix Lack of Competence In the case of lack of competence, then matters should only be referred to the Statutory Body if attempts to address competence via the Performance Management Policy CORP/POL/517(See Section 7) have failed. 3.5 Misconduct Misconduct is behaviour which falls short of that which can be reasonably expected of a nurse / HCPC Professional. The Nursing and Midwifery Councils code: Standards of conduct, performance and ethics for nurses and midwives is the foundation of good nursing and midwifery practice, and is a key tool in safeguarding the health and wellbeing of the public. If nurses and midwives don t follow the code, they may be guilty of misconduct and therefore might not be fit to practice, this principle is relevant to all health care professionals. The most common examples of proven health care professionals individual failure of misconduct include: Physical or verbal abuse of colleagues, patients or members of the public. Theft Significant failure to deliver adequate care. Significant failure to keep proper records. 3.6 Health Related Concerns In the case of ill health of the health professional, then matters should only be referred to the Statutory Body if the condition is affecting performance and is not being addressed via the Attendance Management Sickness Absence or Capability Performance management Policies. Where ill health is being managed locally, then no referral is necessary. Page 5 of 16

6 3.7 Alert Notices When cases are referred to either the NMC or HCPC these bodies will perform their own investigation, the outcome of which may be an ALERT notice. An alert notice is a way of notifying NHS bodies, or other organisations providing services to NHS bodies, about registered health professionals whose performance or conduct could pose a significant risk of harm to patients, staff or the public. It is the responsibility of Recruiting Officers, to comply fully with the Trusts Recruitment Policies and to ensure Alert Notice held with professional bodies and disclosing and barring service records are checked prior to appointments being made. 3.8 Urgent Referrals and Interim Orders As an employer the Trust has the power to suspend or dismiss a member of staff, but this will not prevent them from working elsewhere as a registered health care professional if registered accordingly. The NMC or HCPC are the only organisations with the powers to prevent registered health care professionals from practicing if they present a risk to patient safety. In very serious cases it will therefore be appropriate to refer a nurse at an early stage, even before an organisational investigation has been conducted. This allows for the possibility of the NMC or HCPC to issue an interim suspension or to restrict practice of the nurse concerned until the case has been thoroughly investigated. Examples of reasons for interim suspension orders issued by the NMC or HCPC have included: Theft of medication. Assault of patient. Possession of drugs with intent to supply. Aggressive behaviour toward a colleague. Allegation of sleeping on duty. Persistent failings in the registrant s standard of practice over a 2 year period. Serious allegations of patient neglect and theft from patients. Multiple medication errors including failure to administer and administration of a stopped Medication. Allegations of criminality 3.9 Safeguarding Allegations against Staff Where cases are referred to the NMC or HCPC consideration of safeguarding should be discussed with the Named Senior Officer (NSO), the Head of Safeguarding. Cases to be considered are where allegations are made about the NHS staff that indicate that children, Page 6 of 16

7 young people or adults at risk are believed to have suffered, or likely to suffer, significant harm. (See CORP/GUID/077 Managers and Employees Dealing with Allegations of Child Abuse against an Individual Member of Staff). The allegation or issue may arise either in the employee s / professionals work or private life. Examples include: Commitment of a criminal offence against or related to children, young people or adults at risk. Failing to work collaboratively with social care agencies when issues about care of children, young people or adults at risk for whom they have caring responsibilities are being investigated. Behaving towards children, young people and adults at risk, in a manner that indicates they are unsuitable to work with children, young people and adults at risk of harm or abuse. Where an allegation or concern arises about a member of staff, arising from their private life such as perpetration of domestic violence or where inadequate steps have been taken to protect vulnerable individuals from the impact of violence or abuse. Where an allegation of abuse is made against someone closely associated with a member of staff such as a partner, member of the family or other household member. Consideration of referral to DBS, CORP/POL/202, should be made according to Nursing and Midwifery Council (NMC) Health and Care Professionals Council (HCPC) and Referrals. 4 ATTACHMENTS Appendix Number Title 1 NMC and HCPC Referral Form. 2 Raising Concerns Guidance for Nurses, Midwives and HCPC Registered Professionals 3 Referral to Statutory Body Flowchart 4 Classification of Reasons for Suspension / Issuing an Alert Notice (for NMC registrants) 5 Equality Impact Assessment Tool 5 PROCEDURAL DOCUMENT STORAGE (HARD AND ELECTRONIC COPIES) Electronic Database for Procedural Documents Held by Procedural Document and Leaflet Coordinator 6 LOCATIONS THIS DOCUMENT ISSUED TO Copy No Location Date Issued 1 Intranet 20/09/ Wards, Departments and Service 20/09/2016 Page 7 of 16

8 7 OTHER RELEVANT / ASSOCIATED DOCUMENTS Unique Identifier CORP/GUID/077 CORP/POL/011 CORP/POL/517 CORP/POL/525 CORP/PROC/636 CORP/POL/202 Title and web links from the document library Managers and Employees Dealing with Allegations of Child Abuse against an Individual member of Staff doc Attendance Management Policy docx Performance Management docx Disciplinary Policy docx Disciplinary and Appeal Procedure docx Criminal Records Bureau Policy docx (this is the version currently under review) 8 SUPPORTING REFERENCES / EVIDENCE BASED DOCUMENTS References In Full Health and Care Professionals Council. Fitness to practise referral form for employers. Available: Last accessed 22/02/2016. Health and Care Professionals Council. Concerns. Available: Last accessed 22/02/2016. Nursing and Midwifery Council. Home. Available: Last accessed 22/02/2016. Nursing and Midwifery Council. (31/03/2015). The Code for nurses and midwives. Available: Last accessed 22/02/2016. Nursing and Midwifery Council. (2015). Raising concerns: Guidance for nurses and midwives. Available: Last accessed 22/02/2016. Nursing and Midwifery Council. (20/01/2016). Referral forms. Available: Last accessed 22/02/ CONSULTATION / ACKNOWLEDGEMENTS WITH STAFF, PEERS, PATIENTS AND THE PUBLIC Name Designation Date Response Received Andrea Padgeon Resource and Contracts Manager Sonya Clarkson Head of HR Service Centre Page 8 of 16

9 9 CONSULTATION / ACKNOWLEDGEMENTS WITH STAFF, PEERS, PATIENTS AND THE PUBLIC Name Designation Date Response Received Paula Roles Deputy Director of Workforce & Operational Development ADONs Unscheduled Care, Scheduled Care, Adult and Long Term Conditions and Families Divisions Hazel Gregory Head of Safeguarding Lisa Farrell Named Nurse for Safeguarding Children and Adults Nicholas Lane Lisa Farrell Head of Therapies Named Nurse for Safeguarding Children and Adults 10 DEFINITIONS / GLOSSARY OF TERMS DBS Disclosure and Baring Service HCPC Health and Care Professions Council HR Human Resources LADO Local Authority Designated officer NMC Nursing and Midwifery Council NSO Named Senior Officer 11 AUTHOR / DIVISIONAL / DIRECTORATE MANAGER APPROVAL Issued By Simone Anderton Checked By Marie Thompson Job Title Deputy Director of Nursing and Quality Job Title Director of Nursing and Quality Date September 2016 Date September 2016 Page 9 of 16

10 APPENDIX 1: LINK TO NMC AND HCPC REFERRAL FORMS Page 10 of 16

11 APPENDIX 2: REFERRAL DECISION TREE The Decision Tree can help to guide decisions about whether a referral to the professional body is necessary or whether issues can be managed at a local level. You can make a referral to the professional body at any time, even if your local investigation is not complete. If in the course of a local investigation you become aware of any serious risks to patient safety you should refer to the professional body immediately. If you dismiss a member of staff, or suspend them because of patient safety concerns for anything more than a short period of investigation, you should also make a referral to the professional body. Page 11 of 16

12 APPENDIX 2: REFERRAL DECISION TREE Page 12 of 16

13 APPENDIX 3 NURSING AND MIDWIFERY COUNCIL (NMC) AND HEALTH AND CARE PROFESSIONALS COUNCIL (HCPC) REFERRALS Nursing and Midwifery Council (NMC) Health and Care Professions Council (HCPC) Fitness to practise concern identified / Behaviour constitutes bringing profession into disrepute / Criminal conviction Identified by the Trust Identified and referral made by independent source Matron / relevant manager commence investigation Inform / consider relevant support measures for individual referred Statutory Body contacts Trust to notify of independent referral Preliminary findings indicate fitness to practise concerns Director of Nursing (or nominated other) informed of details and decision made on requirement of immediate referral No Yes Consider referral to DBS/LADO with named Senior Officer, Head of Safeguarding Yes Log informing Head of Safeguarding via electronic incident reporting safeguard system Receiving individual informs Director of Nursing or (nominated other) of detail Receiving individual informs relevant HR of detail of referral HR enters detail on relevant electronic case management file Complete investigation Review with Director of Nursing (or nominated other) investigation outcome and decision made on requirement of referral Yes Refer to Statutory Body via electronic referral system by Matron / Clinical Manager Allocated HR Lead manager enter details on relevant electronic case management file Matron/Relevant Manager refer to DBS as per policy (Corp/Pol/202) Page 13 of 16

14 APPENDIX 4: CLASSIFICATION OF REASONS FOR SUSPENSION / ISSUING AN ALERT NOTICE Page 14 of 16

15 APPENDIX 5: EQUALITY IMPACT ASSESSMENT FORM Department Clinical Governance Service or Policy None Medical Professional Groups Date Completed: 7/01/16 GROUPS TO BE CONSIDERED Deprived communities, homeless, substance misusers, people who have a disability, learning disability, older people, children and families, young people, Lesbian Gay Bi-sexual or Transgender, minority ethnic communities, Gypsy/Roma/Travellers, women/men, parents, carers, staff, wider community, offenders. EQUALITY PROTECTED CHARACTERISTICS TO BE CONSIDERED Age, gender, disability, race, sexual orientation, gender identity (or reassignment), religion and belief, carers, Human Rights and social economic / deprivation. QUESTION RESPONSE IMPACT What is the service, leaflet or policy development? What are its aims, who are the target audience? Does the service, leaflet or policy/ development impact on community safety Crime Community cohesion Is there any evidence that groups who should benefit do not? i.e. equal opportunity monitoring of service users and/or staff. If none/insufficient local or national data available consider what information you need. Does the service, leaflet or development/ policy have a negative impact on any geographical or sub group of the population? How does the service, leaflet or policy/ development promote equality and diversity? Does the service, leaflet or policy/ development explicitly include a commitment to equality and diversity and meeting needs? How does it demonstrate its impact? Does the Organisation or service workforce reflect the local population? Do we employ people from disadvantaged groups Will the service, leaflet or policy/ development i. Improve economic social conditions in deprived areas ii. Use brown field sites iii. Improve public spaces including creation of green spaces? Does the service, leaflet or policy/ development promote equity of lifelong learning? Does the service, leaflet or policy/ development encourage healthy lifestyles and reduce risks to health? Does the service, leaflet or policy/ development impact on transport? What are the implications of this? Does the service, leaflet or policy/development impact on housing, housing needs, homelessness, or a person s ability to remain at home? Are there any groups for whom this policy/ service/leaflet would have an impact? Is it an adverse/negative impact? Does it or could it (or is the perception that it could exclude disadvantaged or marginalised groups? Issue Action Positive Negative Provide clear guidance on referral processes Ensure appropriate referral to regulatory bodies in relation to behaviour and conduct concerns No No No Encompasses all groups Explicitly supports protection of vulnerable groups of all ages N/A NA NA NA No NA NA encompasses protection of all groups Provides clear guidance on referral to professional bodies to ensure all groups particular those vulnerable of all ages are protected. Page 15 of 16

16 APPENDIX 5: EQUALITY IMPACT ASSESSMENT FORM Does the policy/development promote access to services and facilities for any group in particular? Does the service, leaflet or policy/development impact on the environment During development NA NA At implementation? ACTION: Please identify if you are now required to carry out a Full Equality Analysis Name of Author: Simone Anderton Signature of Author: Yes No (Please delete as appropriate) Date Signed: Name of Lead Person: Signature of Lead Person: Name of Manager: Signature of Manager Simone Anderton Marie Thompson Date Signed: Date Signed: Page 16 of 16