Policy No. (HR30) Whistleblowing Policy and Procedure (Raising Concerns at Work)

Policy No. (HR30) Whistleblowing Policy and Procedure (Raising Concerns at Work) The following personnel have direct roles and responsibilities in the implementation of this policy: All Trust Staff Version: 5 Ratified By: Executive Committee Date Ratified: March 2013 Specialist Forum Approved by: Hospital Management Forum Date Approved by Forum: February 2013 Date of Issue via Intranet: March 2013 Date of Review: Trust Contact: Executive Lead In line with changes in legislation or Department of Health recommendations or November 2015 [whichever is the soonest] HR Manager Director of HR HR30 Whistleblowing Policy and Procedure/V5/Final Approved/March 2013/Page 1 of 19

Version Control Schedule Final Version Issue Date Comments 1 March 2002 2 April 2006 Ratified by Executive Committee 19/04/2006 3 December 2008 Ratified by Executive Committee 10/12/2008 4 December 2009 Ratified by Executive Committee 09/12/2009 5 March 2013 HR30 Whistleblowing Policy and Procedure/V5/Final Approved/March 2013/Page 2 of 19

Statement on Trust Policies University Hospital of North Staffordshire NHS Trust Staff Side and Trade Unions The University Hospital of North Staffordshire NHS Trust is committed to ensuring that, as far as is reasonably practicable, the way in which we provide services to the public and the way in which we treat our staff reflects their individual needs and does not discriminate against individuals or groups on any grounds. Equality and Diversity The University Hospital of North Staffordshire aims to promote equality and diversity and value the benefits this brings. It is our aim to ensure that all staff feel valued and have a fair and equitable quality of working life. Equality Impact Assessment The organisation aims to design and implement services, policies and measures that meet the diverse needs of our service, population and workforce, ensuring that none are 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. Information Governance Any Trust policy which impacts on or involves the use and disclosure of personal information (patient or employee) must make reference to and ensure that the content of the policy is comparable with the relevant statutory or legal requirement and ethical standards Data Protection Act 1998 and the NHS Confidentiality Code of Practice The Data Protection Act (DPA) provides a framework which governs the processing of information that identifies living individuals. Processing includes holding, obtaining, recording, using and disclosing of information and the Act applies to all forms of media, including paper and images. It applies to confidential patient information but is far wider in its scope, e.g. it also covers personnel records. The DPA provides a legal gateway and timetable for the disclosure of personal information to the data subject (e.g. Health Record to a patient, personal file to an employee). Whilst the DPA applies to both patient and employee information, the Confidentiality Code of Practice (COP) applies only to patient information. The COP incorporates the requirements of the DPA and other relevant legislation together with the recommendations of the Caldicott report and medical ethical considerations, in some cases extending statutory requirements and provides detailed specific guidance. Freedom of Information Act 2000 The Freedom of Information Act 2000 (FOIA) is an Act which makes legal provision and creates a legal gateway and timetable for the disclosure, to the public, of the majority of corporate information held (but not necessarily created) by this Trust. The Trust has a legal responsibility to proactively provide a large amount of information to the public and to pro-actively respond to specific requests for information. Information will not be disclosed when the Trust can claim legal exemption. Any non-disclosure must be conveyed in writing; quoting the relevant exemption together with signposting to internal and external methods of compliant. Locally, guidance on the DPA, FOIA and COP can be obtained from the Information Governance Manager or the Caldicott Guardian. Mental Capacity Act Any Trust policy which may affect a person who may lack capacity should comply with the requirements of the Mental Capacity Act 2005 (MCA) The MCA and its associated Code of Practice provides the framework for making decisions on behalf of individuals who lack the mental capacity to do these acts or make these decisions for themselves. Everyone working with and/or caring for adults who lack capacity, whether they are dealing with everyday matters or life-changing events in the lives of people who lack capacity must comply with the Act. HR30 Whistleblowing Policy and Procedure/V5/Final Approved/March 2013/Page 3 of 19

In a day to day context mental capacity includes making decisions or taking actions affecting daily life when to get up, what to wear, what to eat etc. In a legal context it refers to a person s ability to do something, including making a decision, which may have legal consequences for the person lacking capacity, or for other people. The Code provides guidance to all those working with and/or caring for adults who lack capacity, including family members, professionals and carers. It describes their responsibilities when acting or making decisions with, or on behalf of, individuals who lack the capacity to do this for themselves. In particular, it focuses on those who will have a duty of care to a person lacking capacity and explains how the legal rules set out in the Act will work in practice. The Health Act: Code of Practice for the Prevention and Control of Health Care Associated Infections The purpose of the Code is to help NHS bodies plan and implement how they can prevent and control HCAI. It sets out criteria by which managers of NHS organisations are to ensure that patients are cared for in a clean, safe environment, where the risk of HCAI is kept as low as possible. Failure to observe the Code may either result in an Improvement Notice being issued by the Healthcare Commission, or in the Trust being reported for significant failings and placed on Special Measures. The Code relates to healthcare provided by all NHS bodies. Each NHS body is expected to have systems in place sufficient to comply with the relevant provisions of the Code, so as to minimise the risk of HCAI to patients, staff and visitors. The Trust Board must have an agreement outlining its collective responsibility for minimising the risks of infection and the general means by which it prevents and controls such risks. Effective prevention and control of HCAI must be embedded into everyday practice and applied consistently by all staff Human Rights The Trust is committed to the principles contained in the Human Rights Act. We aim to ensure that our employment policies protect the rights and interests of our staff and ensure that they are treated in a fair, dignified and equitable way when employed at the Trust. Sustainable Development University Hospital North Staffordshire NHS Trust recognises the impact that its operations have on the environment as well as the strong link between sustainability, climate change and health. The trust is committed to continual improvement in minimising the impact of activities on the environment and expects all members of staff to play their part in achieving this goal and in particular to work towards a 10% carbon reduction by 2015. The Green Aware Campaign is designed to support you to do this. All trust policy should embed sustainability and refer to our Sustainable Development Management Plan where relevant. Further information and guidance can be obtained from the Trust Sustainability Manager. HR30 Whistleblowing Policy and Procedure/V5/Final Approved/March 2013/Page 4 of 19

CONTENTS 1. Introduction 6 2. Policy Statement 7 3. Scope 9 4. Responsibilities 9 5. Reference to other bodies 11 6. Education and Training 11 7. Monitoring and Review 11 Appendix 1 Procedure for raising concerns under the Whistleblowing Policy 13 - Flow chart Appendix 2 How to raise a concern under the Whistleblowing policy informal 15 and formal procedures Appendix 3 Raising a concern report form 18 PAGE HR30 Whistleblowing Policy and Procedure/V5/Final Approved/March 2013/Page 5 of 19

1. INTRODUCTION University Hospital of North Staffordshire NHS Trust 1.1 The University Hospital of North Staffordshire NHS Trust is committed to ensuring the highest standards of service and the highest possible ethical standards. 1.2 Everyone at one time or another has 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. 1.3 As a member of staff or working for the Trust through an agency or as a volunteer 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. 1.4 The Board of the Trust are committed to running the organisation in the best way possible and to do so we need your help. This policy is in place to reassure you that it is safe and acceptable to speak up and to enable you to raise any concern you 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 supports the development of an organisational culture where staff feel able to raise genuine concerns about their work in a free and open manner. 1.5 If something is troubling you which you think we should know about or look into, please use this procedure. If, however, you wish to make a complaint about your employment or how you have been treated, please use the Grievance policy or the Dignity at Work policy which you can obtain from your manager, Human Resources or via the Trust intranet. (If you have a concern about financial misconduct or fraud, please see our Fraud and Corruption 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. 1.6 If your concern is about your manager it should be raised with the Chief Nurse or the Medical Director under Stage 2 (Formal procedure) 1.7 Our commitment to you Your safety The Trust Board and the Trade 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 demotion, withholding a pay rise, failing to gain promotion etc or victimisation as a result of making a protected disclosure. Any attempts to deter employees from raising a concern or any evidence of victimisation, as a result of the disclosure will be investigated in accordance with the Trust Disciplinary procedure. Provided you are acting in good faith (effectively this means honestly), 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. This would be regarded as a serious disciplinary offence and would be investigated in accordance with the Disciplinary procedure HR30 Whistleblowing Policy and Procedure/V5/Final Approved/March 2013/Page 6 of 19

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 assurance we offer in the same way if you report a concern anonymously. 1.8 Independent Advice If you are unsure whether to use this procedure or want independent advice at any stage, you may contact: Human Resources Your professional organisation or trade union, statutory bodies such as NMC, GMC etc. The independent charity Public Concern at Work on telephone number 0207 404 6609. They can give free confidential advice about raising a concern at work. Their website is www.pcaw.co.uk The National Fraud and Corruption Line (0800 028 40600 a confidential reporting service which has been established by The Counter Fraud and Security Management Service.] The Staff Counselling service 2. POLICY STATEMENT 2.1 The Trust promotes equality and diversity and values the benefits this brings. It is our aim to ensure that all staff feel valued and have a fair and equitable quality of working life. 2.2 This policy and procedure provides a process for individual employees to raise genuine and legitimate concerns and provides an opportunity for those concerns to be investigated and for appropriate actions to be taken to ensure that the matter is resolved effectively within the Trust wherever possible. It should not be used for the purpose of resolving any private dispute. 2.3 Members of staff or those working for the Trust through an agency or as a volunteer should, whenever possible, raise concerns informally. When they feel this is not possible, or there has been no change following the issue being raised informally, the formal procedure should be used. The procedure for raising concerns is outlined in the flow chart at Appendix 1.It may also be appropriate for employees to raise concerns with an outside regulatory body. (See section 2.8) 2.4 The procedure compliments professional and ethical rules, guidelines and codes of conduct on freedom of speech such as the code Standards of Conduct, Performance and Ethics for Nurses and Midwives, CCAB professional codes of conduct, and GMC Guidance. HR30 Whistleblowing Policy and Procedure/V5/Final Approved/March 2013/Page 7 of 19

2.5 The Trust s leads are the Chief Nurse and the Medical Director who will ensure that concerns are investigated effectively and are in line with the formal procedure described within this policy. They will have the responsibility to ensure that there is adequate communication and support for those individuals whom the allegations have been made against. It should be noted that if concerns remain or the matter is extremely serious, the Chief Executive or designated Trust Non-Executive Director may be contacted. In cases of alleged fraud, the Director of Finance should be informed. 2.6 Where the employee has any concerns that an individual may be susceptible to violent extremism or engaged in terrorist activity the Deputy Chief Nurse must be informed by the manager. The Trust is committed to ensuring vulnerable individuals are safeguarded from supporting terrorism or becoming terrorists themselves as part of the Home Office counterterrorism strategy Prevent. 2.7 The Public Interest Disclosure Act (PIDA) 1998 identifies that information disclosed must be a qualifying disclosure and should be raised internally in the first instance, other than in circumstances described in paragraphs 2.9. A qualifying disclosure means any disclosure of information which, in the reasonable belief of the employee making the disclosure, could show one or more of the following: Malpractice or ill treatment of a patient/client/customer by any member of staff, Repeated ill treatment of a patient/client/customer, despite a complaint being made, A criminal offence has been committed, is being committed or is likely to be committed, Suspected fraud, corruption or abuse of position Disregard for legislation, particularly in relation to health and safety at work, The environment has been, or is likely to be damaged, Breach of standing financial instructions and or Standing Orders Showing undue favour over a contractual matter or to a job applicant, A breach of a professional code of conduct Information on any of the above has been, is being or is likely to be concealed. Financial irregularity Unethical practise Negligence Maladministration 2.8 All concerns should normally be raised internally. However, employees may disclose information to a regulatory body where the issue in question relates to that specific regulatory body (e.g. to the Health and Safety Executive where an employee has concerns relating to the health and safety of an individual). For these disclosures to be protected the following requirements must be met: (i) the concern falls within the ambit of that regulatory body; and (ii) the employee must reasonably believe that the information is substantially true; and (iii) the disclosure is made in good faith 2.9 Where an employee believes that a fraud or corruption has occurred, suspicions should be reported to the Local Counter Fraud Specialist or the Director of Finance either directly or via the NHS Fraud and Corruption Hotline. They are trained to handle calls confidentially and will pass the information to the relevant authorities. (Reporting Line: 0800 0284060). The Director of Finance with advice from the Counter Fraud and Security Management Services will make the decision as to whether a case should be referred to the police. The protocol for the interaction between the Local Counter Fraud Specialist and Human Resources must be followed in cases when there may have been fraud by a member of staff HR30 Whistleblowing Policy and Procedure/V5/Final Approved/March 2013/Page 8 of 19

2.10 Where an employee believes an act has occurred which affects the adequate provision of Trust Security Management, e.g. theft, criminal damage, the Trust s Local Security Management Specialist must be informed for further investigation as required by the Local Security Management Specialist/Security Advisor/Local Counter Fraud Specialist in conjunction with other relevant personnel or departments. The employee must appropriately report the incident through the Trust's incident reporting system. 2.11 Where the concern is around the care and treatment of children or vulnerable adults the Staffordshire Safeguarding Children Board [SSCB], or the Staffordshire and Stoke on Trent Adult Safeguarding Board or the Stoke on Trent Safeguarding Children Board [SCB] (whichever is appropriate) must be informed by the manager who the issue has been raised with. This also applies to knowledge of an individual s personal circumstances which may mean that they are not suitable to work with children or adults i.e. from a safeguarding perspective it is not just what happens in the Trust but outside of the Trust too. 2.12 Medical staff should read this policy in conjunction with Raising and Acting on Concerns about Patient Safety issued by the General Medical Council and the BMA guidance Practical steps when raising a concern. Medical staff who have concerns about patient safety can raise them with the General Medical Council through the confidential helpline (0161 9236399). 2.13 Nursing staff should read this policy in conjunction with Raising and Escalating Concerns issued by the Nursing and Midwifery Council. 2.14 An employee may seek, as a constitutional right, to approach his/her Member of Parliament at any time. It is hoped the positive use of this procedure will result in individuals only utilising this right if they remain dissatisfied with the Trust s actions. 2.15 An employee may also refer matters to the Health Service Ombudsman who may investigate complaints by staff on behalf of a patient; provided that he/she is satisfied there is no-one more appropriate such as an immediate relative to act on the patient s behalf. 2.16 The arrangements described within this procedure have been agreed between the Trust and those staff side organisations recognised by the Trust for negotiating purposes. 3. SCOPE In addition to Trust employees this policy refers to trainees, agency staff, work experience persons, volunteers, contractors, suppliers and all self-employed NHS professionals (e.g. doctors, dentists, optometrists, pharmacists etc). 4. RESPONSIBILITIES 4.1 Responsibility of the Trust Board The responsibility for the provision of the Whistleblowing Policy rests with the Trust Board. It is the responsibility of the Trust Board to ensure that the Policy is implemented through the Trust s Line management structure. 4.2 Responsibility of Non-Executive Director (NED) (in the case of allegations relating to financial irregularity, fraud etc the Chair of Audit should be the designated NED). HR30 Whistleblowing Policy and Procedure/V5/Final Approved/March 2013/Page 9 of 19

It is the responsibility of the Non-Executive Director receiving the disclosure to meet with the employee and seek clarification of the concerns raised and make recommendations if appropriate in respect of further action to be taken, this may include internal or external investigation. The Non-Executive Director should remain impartial in the process acting as a conduit for staff who feel it necessary to raise their concerns in line with Step 2 of the process. The Non-Executive Director shall remove themselves from any discussion undertaken by the Board as a whole in relation to the concerns raised until the point that the issue has been resolved in full. 4.3 Responsibility of the Board Secretary It is the responsibility of the Board Secretary to support the designated Non-Executive Director. The level of support required will depend on the complexity of the concerns. The Board Secretary shall ensure the Non-Executive is advised in respect of applying the policy in line with the timescales, and assisting in the production of any documents, reports and or minutes taken as a result of meetings held between the Non-Executive Director and the Whistle blower. The Board secretary will report on the number and type of concerns raised on an annual basis to the Quality Assurance Committee. 4.4 Responsibility of the Chief Executive It is the responsibility of the Chief Executive to respond to recommendations presented by the designated Non-Executive Director. If disclosure is made directly to the Chief Executive he/she shall meet with the employee and seek clarification of the concerns raised and make recommendations if appropriate in respect of further action to be taken, this may include internal or external investigation. 4.5 Responsibility of the Chief Nurse and Medical Director It is the responsibility of the Chief Nurse and the Medical Director to ensure that concerns are investigated effectively and the investigations are in line with the formal procedure described within this policy. It is also their responsibility to ensure that there is adequate communication and support for those individuals whom the allegations have been made against. It is their responsibility to report cases that have been dealt with to the Board secretary 4.6 Responsibility of the Human Resources Directorate It is the responsibility of the HR Directorate to provide Managers with initial training and to support with the application of the Policy. It is also the responsibility of the HR Directorate to ensure that the Policy is regularly updated. It is the responsibility of HR to report cases that have been dealt with to the Board secretary When a potential fraud may have been highlighted the protocol for the interaction between the Local Counter Fraud Specialist and Human Resources must be followed. 4.7 Responsibility of Managers It is the responsibility of Managers to: Ensure that employees are made aware of the Whistleblowing Policy and their responsibilities under the Policy. Notify the Chief Nurse or Medical Director of any disclosures received under this Policy. HR30 Whistleblowing Policy and Procedure/V5/Final Approved/March 2013/Page 10 of 19

Listen to concerns, record these and investigate Provide support for staff raising concerns Record all concerns and all meetings held including action taken and outcomes. Inform the Staffordshire Safeguarding Children Board or the Stoke on Trent Safeguarding Children Board if the concern is around the care and treatment of children. Inform the Staffordshire and Stoke on Trent Adult Safeguarding Board if the concern is around the care and treatment of adults. This also applies to knowledge of an individual s personal circumstances which may mean that they are not suitable to work with children or adults i.e. from a safeguarding perspective it is not just what happens in the Trust but outside of the Trust too. Inform the Deputy Chief Nurse if the concern raised relates to an individual who may be susceptible to violent extremism or engaged in terrorist activity 4.8 Responsibility of Employees It is the responsibility of all employees to raise any concerns they may have at the earliest opportunity using the procedure in this policy. To raise a concern, employees must use the form (Appendix 3) It is the responsibility of employees to be aware of the Whistleblowing Policy and comply with its requirements. Employees must raise an issue in good faith. If it is found to have been raised maliciously it will be regarded as a serious disciplinary offence. Where there were no reasonable grounds for believing that the information supplied was accurate, disciplinary action will be taken against the employee. 4.9 Role of Staff Side It is the role of Staff Side employee representatives to raise a concern, or provide support on a member s behalf as necessary in relation to this policy. Those staff who do not feel able to raise concerns in line with stage 1 or stage 2 of this policy should contact staff side representatives to discuss their concerns. Staff side employee representatives should encourage staff to make the appropriate disclosure however if they receive information in line with section 2.9 of this policy they have a duty to raise these issues directly 5. REFERENCE TO OTHER BODIES See Section 2. to 2.16 above. 6. EDUCATION AND TRAINING Training on this policy will be provided by the Divisional Human Resources Teams. All training received should be recorded in staff personal records ideally within ESR. 7. MONITORING AND REVIEW 7.1 This policy will be subject to on-going discussions with managers and recognised trade unions and staff organisations. 7.2 The policy will be reviewed following a major whistle blowing issue being raised to ensure the policy is fit for purpose HR30 Whistleblowing Policy and Procedure/V5/Final Approved/March 2013/Page 11 of 19

7.3 Whistleblowing cases can be raised in various ways e.g. to the Chief Nurse/Medical Director, to Human Resources, to the Director of Finance, the Deputy Chief Nurse etc. When a case has been dealt with, this must be reported to the Board Secretary. The Board secretary will report to the Quality Assurance Committee with details of the number and type of concerns raised on an annual basis. 7.3 The policy will be reviewed in three years unless legislation is changed when the policy will need to be updated to reflect these requirements. This will be in joint agreement with the recognised trade unions and staff organisations as above. HR30 Whistleblowing Policy and Procedure/V5/Final Approved/March 2013/Page 12 of 19

PROCEDURE FOR RAISING CONCERNS UNDER THE WHISTLEBLOWING POLICY APPENDIX 1 Please note that the completion of this procedure will not prevent urgent action from being taken in the interests of patient safety Informal Procedure (Stage 1) In the first instance raise concerns with immediate line manager (see 1.6), lead clinician or the individual the concern is regarding. Concerns raised with line managers or lead clinicians should be made in writing using the form in Appendix 3 and any personal interest should be declared at the outset. Every effort should be made to resolve the matter informally, initially through discussions with the individual(s) concerned. In cases of suspected fraud or corruption, individuals should report their concerns directly to the Trust Local Counter Fraud Specialist or the Director of Finance or ask their manager to do so on their behalf. In cases where the employee has any concerns that an individual may be susceptible to violent extremism or engaged in terrorist activity the Deputy Chief Nurse must be informed by the manager. There is no requirement for referrals of this nature to be made in writing If the employee is not satisfied that the concern has been dealt with adequately at the informal stage, or feels unable to raise it with the line manager, lead clinician or the individual concerned in the first instance, then the formal procedure should be followed Formal Procedure (Stage 2) Report to Chief Nurse or Medical Director in writing using the form at Appendix 3 and inform of any personal interest at the outset If concerns remain or the matter is extremely serious, report to Chief Executive or Non Executive Director in writing and inform of any personal interest at the outset. If the allegation relates to any financial irregularity, fraud etc then the Chair of the Audit committee should be the designated NED. Confidential interview arranged with employee making allegation within 7 days of receipt of letter. Employee has right of representation. If the employee presents evidence which is substantial and requires detailed review, the employee should be informed of any anticipated time delays that may be required to review the evidence. Following interview, a hard copy of the notes (minutes of the meeting or reports collated as a result of the meeting will not be circulated electronically) to be sent to employee to be checked, signed and returned promptly. Notes will be prepared within 10 working days unless the issue is complex. The employee should be notified at the close of the meeting if it is expected to exceed 10 working days. If the employee does not agree or wishes to clarify certain point with the notes/minutes he/she should make this know prior to signing. If necessary an additional meeting can be arranged. HR30 Whistleblowing Policy and Procedure/V5/Final Approved/March 2013/Page 13 of 19

Pursue matter via alternative procedure following discussion with employee making allegation. No Is the matter to be dealt with via the whistleblowing policy? (Line manager or lead clinician to decide). Recommended next steps to be recorded. Yes Investigation to commence within 7 days, where possible, of original interview. Need to complete within 4 6 weeks. This timescale may not be possible if external experts are required to complete all or elements of the investigation Employee to be informed. In cases where employee held genuine concern line manager or lead clinician to ensure employee suffers no reprisals. No * Line manager or lead clinician to consider results of investigation report. Is there evidence to justify the complaint? Yes Line manager or lead clinician to make recommendations on actions to take. Chief Nurse or Medical Director to be informed of any action to be taken Matter can be raised confidentially with Chief Executive or non Executive Director in line with Step 2 of the formal procedure No Is employee satisfied the concerns were dealt with correctly? Yes No further action required Further interview to be held within 7 days. Chief Executive to decide if further investigation is required. Employee to be informed of decision HR30 Whistleblowing Policy and Procedure/V5/Final Approved/March 2013/Page 14 of 19

APPENDIX 2 HOW TO RAISE A CONCERN UNDER THE WHISTLEBLOWING POLICY - PLEASE NOTE THAT THE COMPLETION OF THIS PROCEDURE WILL NOT PREVENT URGENT ACTION FROM BEING TAKEN IN THE INTERESTS OF PATIENT SAFETY 2.1 Informal Procedure If an employee has a concern about a risk, malpractice or wrongdoing at work they will hopefully feel able to raise it with their line manager or lead clinician or the individual the concern is regarding. This should be done in writing using the form in Appendix 3. The line manager or lead clinician will make every effort to resolve the matter informally, through discussion with the member(s) of staff concerned. In cases of suspected fraud or corruption individuals should report their concerns directly to the Trust Local Counter Fraud Specialist or the Director of Finance. Alternatively they can ask their manager to report it on their behalf. In cases where the employee has any concerns that an individual may be susceptible to violent extremism or engaged in terrorist activity the Deputy Chief Nurse must be informed by the manager. If an employee is not happy that the matter has been dealt with adequately by the line manager or lead clinician, or does not feel able to raise the matter with the individual the concern is regarding, their line manager or lead clinician in the first instance, then the formal procedure should be invoked. 2.2 Formal Procedure Step 1 If an employee is not comfortable with the informal procedure or does not feel able to raise the matter with the individual the concern is regarding, their line manager or lead clinician, for whatever reason, the report should be made to the Chief Nurse or the Medical Director. Step 2 If the above channels have been followed and there are still concerns, or it is felt that the matter is so serious that is cannot be raised with any of the above, the concern should be raised with the Chief Executive or a designated Non-Executive Director of the Trust. 2.3 In reporting their concern the employee should establish the nature of the concern as clearly as possible and put the concern in writing using the form at Appendix 3. If the employee has any personal interest in the matter, it is vital to inform the line manager / lead clinician /Chief Nurse or Medical Director at the outset. Anonymous allegations will be considered although it makes it a lot more difficult for the Trust to investigate and protect the individual s position if the concern is raised anonymously. Upon receipt of the disclosure, the line manager or lead clinician will inform the Chief Nurse or Medical Director that they have received a disclosure under this policy and will arrange for an interview with the employee making the allegation. The interview will be held in the strictest of confidence and within 7 days of receipt of the letter wherever possible. The employee may be accompanied by a friend, colleague or union representative not acting in a legal capacity. Wherever possible an independent witness should be present at the interview. Under no circumstances should the interview be tape recorded by either party, any attempts to record the discussion without the knowledge and/or consent of the designated officer is deemed to be a breach of the Data protection Act. HR30 Whistleblowing Policy and Procedure/V5/Final Approved/March 2013/Page 15 of 19

Full notes of the interview will be produced and a copy will be sent (in hard copy format) to the employee raising the concern to check for accuracy and that they are a true reflection of the interview and they must be signed and returned as soon as possible. All notes should include the following information:- 1. Who was present at the interview, name and job title. 2. Contemporaneous notes of all issues discussed at the interview. (where allegations concern patients, anonymise patients in the notes, use patient id or initials and DOB if available) 3. Summary and next steps 4. Recommendations The line manager/lead clinician and the employee should both sign the finalised notes and a master copy should be held on file. The line manager/lead clinician will then decide whether it is a matter to be dealt with via this procedure. If it is decided that the matter would be more correctly dealt with via another procedure i.e. the Trust s Disciplinary or Grievance procedure or Major Clinical Incident procedure then the matter will be referred to be dealt with in accordance with those procedures AFTER discussion with the person making the allegation. 2.4 If the matter is to be dealt with via this procedure the line manager or lead clinician will be responsible for investigating the allegation and may appoint an appropriate investigating officer. Arrangements will be made to begin investigating the allegation within 7 days of the original interview wherever possible, and will involve any other appropriate persons. In cases referred directly to the Non-Executive Director he/she shall make recommendations which may or may not include an internal or external investigation and discuss these with the Chief Executive. The Chief Executive shall instruct the appropriate person/person or body to complete the investigation. A file should be set up to include all documentation relating to the case, the file should contain the following: A copy of the form on which the concern was raised i. Master copy of the notes from the interview. Copies of all correspondence relating to the concerns, from the initial letter raising the concern to correspondence exchanged with the employee. ii. Details of any verbal communication to be kept in a daily log, particularly in relation to notifying the employee of any delays and the reasons why. iii. An index of any evidence presented by the employee with each separate piece of evidence referenced appropriately. iv. All evidence presented (original if possible, where not possible copies) v. The file should be marked confidential and kept in a secure, locked cabinet. The line manager/lead clinician should attempt to complete the investigation within a 4-6 week timescale. If it is likely that the investigation will exceed this timescale, this should be communicated to the individual raising the concern and his/her representative. In cases where detailed reviews of clinical information by external experts are required this should be arranged as soon as possible. The employee raising the concern will be kept informed of the progress of the investigation and when it is likely to be concluded. 2.5 All employees are expected to co-operate with any request made by the line manager or lead clinician. The investigating officer shall be at liberty to obtain outside legal or other independent professional advice and any outsiders with the relevant experience and expertise shall attend any meeting if this is considered necessary. Where appropriate, the line manager or lead clinician may obtain advice from the Human Resources Director, the Chief Executive or the Chairman but shall be under no obligation to make a disclosure of any information given in confidence. HR30 Whistleblowing Policy and Procedure/V5/Final Approved/March 2013/Page 16 of 19

The investigation may require involvement of other employees who will be informed of the concern and interviewed, unless it would prevent a correct investigation to take place. Any employee interviewed will have the right to be accompanied by a union representative, full time union official, work colleague or other person not acting in a legal capacity. Once the investigation has been completed, a report will be produced. The report will be considered by the line manager or lead clinician and if they are satisfied that there is evidence to justify the complaint; they will make recommendations on the action to be taken. This may involve the Trust s Disciplinary procedure, or civil or criminal proceedings and the employee raising the concern will be informed of the outcome. The Chief Nurse or Medical Director will also be informed of any action taken. If there is evidence to suggest a criminal activity has occurred, is occurring or is likely to occur, the Police will be informed. Where there is no case to answer, but the employee held a genuine concern and was not acting maliciously, the line manager/lead clinician should ensure that the employee suffers no reprisals. 2.6 Any employee who is not satisfied that their concern is being dealt with correctly by their line manager or lead clinician, shall have the right to raise the matter in confidence with the Chief Executive or a Non-Executive Director of the Trust. A further interview will be held and the Chief Executive will decide if further investigation is required and the employee will be informed of the decision within 7 days. 2.7 The confidentiality of employees raising concerns in line with this policy will be maintained wherever possible HR30 Whistleblowing Policy and Procedure/V5/Final Approved/March 2013/Page 17 of 19

APPENDIX 3 RAISING A CONCERN Report Form Name: Date: Location/department: Please give a brief outline of your concern (please give relevant names, dates, locations etc. Did you take any action at the time? If so, please outline what action you took? If you did not take any action can you explain why not? HR30 Whistleblowing Policy and Procedure/V5/Final Approved/March 2013/Page 18 of 19

Signatures Signed Management Side Representative: Printed: Date:... Signed Staff Side Representative TJNCC: Printed: Date:... Signed Staff Side Representative LNC: Printed: Date:... HR30 Whistleblowing Policy and Procedure/V5/Final Approved/March 2013/Page 19 of 19