PROFESSIONAL REGISTRATION POLICY (CLINICAL STAFF)

QSSD Mar 2008 PROFESSIONAL REGISTRATION POLICY (CLINICAL STAFF) Document Reference: Version: Ratified by: Date ratified: Name of originator/author: Name of responsible committee/individual: Date issued: Review date: Target audience: Document owner: Authorised signatory: Document Profile Box Mark Willis Policy Review Group All professionally registered staff Christopher Harrison

Contents Section Page 1 Introduction 3 2 Scope 3 3 Roles and Responsibilities 3 4 Requirements by the Trust (newly qualified Paramedics) 4 5 Verification of Registration 4 6 Recording of Registration Information 5 7 Failure to Maintain Registration 5 8 Fitness to Practice 5 9 Standards of Conduct, Performance and Ethics 6 10 Monitoring 7 11 Equality and Diversity Statement 7 12 Consultation, Approval and Ratification Process 7 13 Dissemination and Implementation 7 14 Further Information 8

1. Introduction This document outlines the and procedure for the North East Ambulance Service NHS Trust. The aim of this policy is to ensure that all persons being appointed to or holding positions which require professional or state registration in the Trust are appropriately registered. 2. Scope This procedure applies to permanent and voluntary staff as well as persons undertaking work on a casual/bank or contract basis. Examples of roles which require professional or state registration in the Trust include: State Registered Paramedics (Health Professions Council) State Registered Nurses (Nursing and Midwifery Council). Examples from the health profession include: Regulator General Medical Council (GMC) Nursing and Midwifery Council (NMC) Health Professions Council (HPC) General Dental Council (GDC) General Chiropractic Council General Optical Council General Osteopathic Council Royal Pharmaceutical Society of Great Britain Pharmaceutical Society of Northern Ireland Coverage includes Doctors Nurses and midwifes Paramedics, arts therapists, biomedical scientists, chiropodists, podiatrists, clinical scientists, dieticians, occupational therapists, operating department practitioners, orthoptists, physiotherapists, prosthetists and orthotists, radiographers, speech and language therapists Dentists, dental hygienists, dental therapists, clinical dental technicians and orthodontic therapists Chiropractors Opticians Osteopaths Pharmacists and pharmacy technicians (voluntarily at present) Pharmacists in Northern Ireland 3. Roles and Responsibilities All persons undertaking, or applying for, posts within the Trust which require professional or state registration are responsible for ensuring that they hold the necessary registration. They are also responsible for providing such information and documentation to confirm their registration status. Any lapses in registration are the sole responsibility of the post holder. 3.1.1 Individual - It is the individual s responsibility to ensure they are familiar with the standards and requirements of their individual regulatory bodies, and to ensure that they comply with those requirements.

3.1.2 It is the responsibility of the post-holder to notify their registering body of their home address and in the event of a change of address. NEAS premises cannot be used as a contact address. 3.2.1 Director to ensure that a process is set up and carried out within their Directorate to ensure that relevant staff have maintained their professional registration 4 Maintaining registration and membership: 4.1 The employee is required to maintain their level of membership in good standing and/or registration of the appropriate professional institution. Failure to satisfy this requirement will result in a review and if it is not satisfactory resolved within a reasonable period (14 calendar days) it will result in attempts to redeploy the individual and if that is not possible the employee will be regarded as being in breach of the terms and conditions of their employment. This is frustration of the contractual terms by the employee as they are unable to fulfil their contract and may, if found to be true, result in disciplinary action, which could lead to termination of employment 4.2 If current professional registration is a statutory requirement to practice the employee will not be deployed to undertake any activities which are reliant upon that registration until the matter is satisfactorily resolved. 4.3 On a regular basis the line manager will ensure that employees have maintained registration and membership. A report of membership/registration will be sent to Human Resources so that personal records can be maintained. 4.4 If an individual s registration or membership is suspended, cancelled or is no longer valid for example due to failure to pay membership fees the individual is required to inform their line manager immediately. Continuing to practice whilst unregistered or not a member may be regarded as gross misconduct. 4.5 Requirements by the Trust (newly qualified Paramedics) 4.5.1 It is an organisational expectation that Paramedics will register with the HPC within 12 weeks of successfully completing paramedic education. 4.5.2 On qualification and formal registration as a paramedic staff will be deployed wherever the service requirement is within the allocated division. This may be at a station different from where staff are currently based or on a rapid response vehicle. 4.5.3 Trainees by definition are only qualified once HPC registration is provided to the NEAS by the staff member. 5 Verification of Registration 5.1 Registered paramedics will be checked against the Health Professions Council Paramedic Register, on a quarterly basis by the clinical training administrator, and during annual appraisals. The register can be found at: http://register.hpc-uk.org/lisa/onlineregister/registrant If the individual is registered then their details will be listed on the screen together with details of their home town / Ambulance Headquarters. If the individuals name does not appear on the online register the Trust will take the view that they are NOT registered, unless member of staff can demonstrate that registration is current and valid.

5.2 State Registered Nurses and Midwives will be checked against the Nursing and Midwifery Council Register on a quarterly basis by the clinical training administrator, and during annual appraisals. The register can be found at: http://www.nmc-uk.org/anewsearchregister.aspx If the individual is registered then their details will be listed on the screen together with details of their home town. If the individuals name does not appear on the online register the Trust will take the view that they are NOT registered unless member of staff can demonstrate that registration is current and valid. 5.3 Other non-operational roles within the Trust which require professional clinical registration will be checked by their line manager. Each Directorate will confirm to Human Resources Department that their staff are registered on a 12 monthly basis. 5.4 The employee will advise their line manager immediately they are informed or become aware that their registration and /or membership have lapsed or is no longer in good standing. If current professional registration is a statutory requirement to practice the line manager will ensure the employee is not deployed to undertake any activities which are reliant upon that registration until the matter is satisfactorily resolved. The line manager will check that registration and/or membership is maintained and in good standing at least once a year. If following an investigation an employee s clinical fitness to practice is in question the senior manager who authorised the investigation will inform the registration body if required to do so by the rules of that body. If following a hearing (clinical review, capability or disciplinary) an employee s clinical fitness to practice is found wanting the Chair of the panel will inform the relevant registration body or institution. 6 Recording of Registration Information Documentary evidence of registrations will be retained on personnel files by the Human Resources Department. Details of registrations will also be recorded on the Trust s Electronic Staff Records (ESR) system. This electronic record will include details of the individual s registration (or pin) number and date of expiry. 7 Failure to Maintain Registration - Employees 7.1 Failure to maintain required registration is a serious matter which places the employees continued employment in that role at risk. If the employee has failed to register or re-register within the required time frame they will be unable to practice as a registered professional. Automatically from the point of non-registration they will be unable to fulfill the role for which they were employed hence individual will be down graded and be remunerated accordingly (see table below). It is the responsibility of the line manager in liaison with the Human Resources Department, to put in place remedial actions to ensure that the individual does not operate in a capacity for which they are not eligible to do so as a result of their non-registration and take appropriate steps to renew their registration. Current role Redeployed to Team Leader ECSW (or other Band 3 role) Paramedic ECSW (or other Band 3 role) Clinical Director To check Clinical Supervisors To check (Poss Call Operator) Occupational Health Nurse OH Administrative Assistant (or

Advisors Occupational Health Nurse Manager other Band 3 role) OH Administrative Assistant (or other Band 3 role) 7.2 If an individual s registration or membership is suspended, cancelled or is no longer valid for example due to failure to pay membership fees the individual is required to inform their line manager immediately. Continuing to practice whilst unregistered or not a member may be regarded as gross misconduct. 7.3 It is the responsibility of the individual to contact their registering body to resolve any queries they may have regarding their registration. 7.4 If the individual can produce evidence that they have commenced the process of re-registration within 14 calendar days of their registration lapsing, then they will be given a further 28 calendar days to complete the re-registration process. They will remain in the redeployed role and at the redeployed salary until they can produce evidence of registration. 7.5 Failure to comply with this process may result in disciplinary action which could result in termination of employment. 8 Fitness to practice 8.1 Fitness to practise includes health and character, as well as the necessary skills and knowledge and application to do the job safely, effectively and to the required professional standard. 8.2 If following an incident, complaint or as a result of audit or similar activity the professional competence and fitness of an individual is questioned the Trust will consider the risk to the individual, patients, other employees, the Trust and the wider NHS community. Depending upon the outcome of that assessment the Trust may restrict or change the duties of the employee or suspend the employee (with pay) without prejudice pending the conclusion of an investigation. 8.3 If an employee is suspended it is their responsibility to notify their regulatory body of their suspension. NEAS reserves the right to advise the regulatory body of a suspension within 7 calendar days. 8.4 If following the investigation it is determined that there is a case to answer the appropriate policy concerning capability or discipline will be instigated. 8.5 If the issue being addressed raises questions about the person s fitness to practice the investigating manager will consult the rules and regulations of the appropriate professional body or institution to confirm if they require to be informed following investigation or if at the conclusion of a capability or disciplinary hearing the person is found to be unfit to practice either temporarily or permanently. The investigating manager will include this as a finding of the investigation and the senior manager receiving the report will ensure that the professional body or institution is informed as necessary if it is decided there is a disciplinary, capability or clinical review case to answer. If following a hearing the individual s fitness to practice is found wanting the Chair of the panel will inform the professional body of the conclusion of any hearing and appeal. 8.6 Being a paramedic on the HPC register is a protected title, and is a criminal offence for someone to claim they are registered when they are not. Staff on the HPC paramedic register must be fit to practice in the profession and with the NEAS, and this can be affected by: Misconduct

Lack of objectives - clarify whether this is CPD or practicing hours Conviction or caution in the United Kingdom Impairment of Physical or mental health Investigation by another source (i.e. NEAS) This list is not exhaustive 9 Monitoring and Compliance a. Periodically, the Training Department will make random checks of persons in positions requiring registration to ensure that their registration is current and that the Trust is in possession of the required documentary evidence and that this information is recorded on ESR. b. The Workforce Development Department and the Human Resources Department will liaise to ensure that this information is recorded on the ESR. c. Compliance with this recording will be periodically audited by the Internal Auditors. 10 Equality and Diversity Statement The Trust is committed to providing equality of opportunity, not only in its employment practices but also in the services for which it is responsible. As such, this document has been screened, and if necessary an Equality Impact Assessment has been carried out on this document, to identify any potential discriminatory impact. If relevant, recommendations from the assessment have been incorporated into the document and have been considered by the approving committee. The Trust also values and respects the diversity of its employees and the communities it serves. In applying this policy, the Trust will have due regard for the need to: Eliminate unlawful discrimination Promote equality of opportunity Provide for good relations between people of diverse groups For further information on this, please contact the Equality and Diversity Department. 11 Consultation, Approval and Ratification Process Consultation Process This policy has been discussed with the Policy Review Group which includes representatives from staff side and all directorates. Policy Approval Process This policy has been submitted to the Policy Review Group for approval. Ratification Process This policy has been approved by the Policy Review group and submitted to the JCC for ratification. 12 Dissemination and Implementation Dissemination Once ratified this policy will be added to the Document Quality Control System and added to the Intranet site to which all staff have access. Earlier versions of the document will be archived in the quality system. Implementation of Procedural Documents

Information about this policy will be added to Statutory and Mandatory Training which is delivered to all staff on an annual basis. 13 Further Information a. Further advice or information is available from: The HR Department Health Professions Council - 020 7582 0866 - www.hpc-uk.org Nursing and Midwifery Council - 020 7333 6600 / 020 7333 9333 - www.nmc-uk.org