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Freedom to speak up policy, raising concerns (whistleblowing) policy

Contents

  1. Introduction
  2. Purpose and scope of the policy
  3. Procedure
  4. Equality impact assessment screening
  5. Appendices

1 Introduction

Rotherham, Doncaster and South Humber NHS Foundation Trust has adopted this national policy, with specific additions relevant to the trust, to help normalise speaking up for the benefit of patients, and workers. Its aim is to ensure all matters raised are captured and considered appropriately.

2 Purpose and scope of the policy

2.1 Speak up, we will listen

We welcome speaking up and we will listen. By speaking up at work you will be playing a vital role in helping us to keep improving our services for all patients and the working environment for our colleagues.

This policy is for all our colleagues. The NHS People Promise (opens in new window) commits to ensuring that “we each have a voice that counts, that we all feel safe and confident to speak up, and take the time to really listen to understand the hopes and fears that lie behind the words”.

We want to hear about any concerns you have, whichever part of the organisation you work in. We know some groups in our workforce feel they are seldom heard or are reluctant to speak up. You could be an agency worker, bank worker, locum or student. We also know that workers who are disabled or from a minority ethnic background or the LGBTQ+ community do not always feel able to speak up.

Key contacts:

Our freedom to speak up guardian (James Hatfield, 07836 680975, james.hatfield@nhs.net), who can support you to speak up if you feel unable to do so by other routes. The guardian sits within the organisation and is the only FTSU guardian within the trust. The guardian will ensure that people who speak up are thanked for doing so, that the issues they raise are responded to, and that the person speaking up receives feedback on the actions taken. You can find out more about the guardian role here.

Our people’s Experience team rdash.askhr@nhs.net.

Our senior lead responsible for freedom to speak up Toby Lewis, Chief Executive, tobylewis@nhs.net, they provide senior support for our speaking-up guardian and are responsible for reviewing the effectiveness of our FTSU arrangements.

Our non-executive director responsible for freedom to speak up Dave Vallance, dave.vallance@nhs.net, this role is specific to organisations with boards and can provide more independent support for the guardian; provide a fresh pair of eyes to ensure that investigations are conducted with rigor, and help to make sure that the concern is raised to the right people in the organisation and also help with escalation to board level, where appropriate.

3 Procedure

3.1 Quick guide

3.1.1 Who

Anyone who works in NHS healthcare. This encompasses any healthcare professionals, non-clinical workers, receptionists, directors, managers, contractors, volunteers, students, trainees, junior doctors, locum, bank and agency workers, and former workers.

3.1.2 What

You can speak up about anything that gets in the way of patient care or affects your working life. If it’s related to work you can raise it with freedom to speak up.

3.1.3 How

You can speak up to any of the people or organisations listed above in person, by phone or in writing (including email).

3.1.4 Action

The matter you are speaking up about may be best considered under a specific existing policy or process, for example, our process for dealing with bullying and harassment. If so, we will discuss that with you. If you speak up about something that does not fall into a human resources (HR) or patient safety incident process, this policy ensures that the matter is still addressed.

3.1.5 Outcome

The outcomes will be shared with you wherever possible, along with learning and improvement identified.

3.2 Freedom to speak up leaflet

3.3 What will happen when I speak up

We will:

  • thank you for speaking up
  • help you identify the options for resolution
  • signpost you to health and wellbeing support
  • confirm what information you have provided consent to share
  • support you with any further next steps and keep in touch with you

Steps towards resolution:

  • engagement with relevant senior managers (where appropriate)
  • referral to HR process
  • referral to patient safety process
  • other type of appropriate investigation, mediation.

Outcome:

  • the outcomes will be shared with you wherever possible, along with learning and improvement identified

Escalation:

  • if resolution has not been achieved, or you are not satisfied with the outcome, you can escalate the matter to the senior lead for FTSU or the non-executive lead for FTSU

Alternatively, if you think there are good reasons not to use internal routes, speak up to an external body, such as the CQC or NHS England

3.4 Making a ‘protected disclosure’

A protected disclosure is defined in the Public Interest Disclosure Act 1998. This legislation allows certain categories of worker to lodge a claim for compensation with an employment tribunal if they suffer as a result of speaking up. The legislation is complex and to qualify for protection under it, very specific criteria must be met in relation to who is speaking up, about what and to whom. To help you consider whether you might meet these criteria, please seek independent advice from the protect website (opens in new window) or a legal representative.

4 Equality impact assessment screening

To access the equality impact assessment for this policy, please email rdash.equalityanddiversity@nhs.net to request the document.

4.1 Privacy, dignity and respect

The NHS Constitution states that all patients should feel that their privacy and dignity are respected while they are in hospital. High Quality Care for All (2008), Lord Darzi’s review of the NHS, identifies the need to organise care around the individual, “not just clinically but in terms of dignity and respect”.

As a consequence the trust is required to articulate its intent to deliver care with privacy and dignity that treats all service users with respect. Therefore, all procedural documents will be considered, if relevant, to reflect the requirement to treat everyone with privacy, dignity and respect, (when appropriate this should also include how same sex accommodation is provided).

4.1.1 How this will be met

If colleagues are concerned about the privacy dignity and respect of patient in conjunction with the care they receive, or a colleague is concerned that their privacy dignity and respect is not maintained whilst at work, they can assess FTSU to make the organisation aware and come to some resolution.

4.2 Mental Capacity Act 2005

Central to any aspect of care delivered to adults and young people aged 16 years or over will be the consideration of the individuals’ capacity to participate in the decision-making process. Consequently, no intervention should be carried out without either the individual’s informed consent, or the powers included in a legal framework, or by order of the court.

Therefore, the trust is required to make sure that all staff working with individuals who use our service are familiar with the provisions within the Mental Capacity Act (2005). For this reason all procedural documents will be considered, if relevant to reflect the provisions of the Mental Capacity Act (2005) to ensure for that the rights of individual are protected and they are supported to make their own decisions where possible and that any decisions made on their behalf when they lack capacity are made in their best interests and least restrictive of their rights and freedoms.

4.2.1 How this will be met

If colleagues are concerned that the organisation or individuals within the organisation are not adhering to the principles of the Mental Capacity Act 2005, they can access FTSU to make the organisation aware and come to some resolution.

5 Appendices

5.1 Appendix A Manager’s template

5.2 Appendix B Responsibilities, accountabilities and roles

Most speaking up happens through conversations with supervisors and line managers where challenges are raised and resolved quickly. We strive for a culture where that is normal, everyday practice and encourage you to explore this option, it may well be the easiest and simplest way of resolving matters.

5.2.1 The trust

Having policies and procedures in place to support best practice, effective management, service delivery, management of associated risks and meet national and local legislation and requirements. Ensuring that there are systems in place that do not obstruct anyone from exercising the duty. The trust is committed to the freedom to speak up guardian role and will periodically review its implementation. For further details regarding freedom to speak up guardian’s (opens in new window).

5.2.2 Executive director, with lead responsibility (chief nurse)

Executive director, with lead responsibility (chief nurse) is the lead executive director for this policy. They are responsible for the effective management of clinical risk, by liaising with the care group directors who are responsible for the effective management of clinical risk within the trust’s clinical services. This includes ensure that appropriate mechanisms are in place to enable individuals to raise their concerns. It must also ensure that these concerns are taken seriously and dealt with confidentially, within reasonable time limits in the most appropriate way and they must also ensure that people raising concerns do not suffer from detriment.

5.2.3 Non-executive responsible for freedom to speak up

Non-executive responsible for freedom to speak up should act as the designated “senior independent director” to ensure that the trust adheres to accepted standards of behaviour in public life, including probity and integrity.

5.2.4 Freedom to speak up guardian

Freedom to speak up guardian has the responsibility to support the trust to continually build a healthy and just culture where colleagues feel safe and confident to raise concerns at work.

To provide confidential advice and support to colleagues in how to raise their concerns about colleagues and patient safety and the way their concerns were handled.

To identify and report broad areas of concern with the chief executive, Executive Management team and trust board via the lead guardian.

5.2.5 Care group directors, nurse directors, service managers and modern matrons

Care group directors, nurse directors, service managers and modern matrons are responsible for the dissemination and implementation of this policy within their departments. They are also responsible for creating an environment within their services where the principles of freedom to speak up and adhered to and promoted whilst also making sure that colleagues do not suffer detriment when rising concerns.

5.2.6 Managers or leaders

Managers or leaders have the responsibility of:

  • being aware of this policy and how to deal with concerns raised (including concerns regarding fraud, corruption and bribery) in a timely manner
  • ensuring appropriate action is taken to consider and resolve the concern and to clearly document all action taken to address the concern and the solutions reached
  • ensuring that no colleague is subject to a detriment for raising a concern. Encouraging open discussion around concerns as part of everyday business

5.2.7 Colleagues and others

Colleagues and others are responsible for:

  • understanding the importance of raising concerns
  • raising honest and genuine concerns about any risk, malpractice or wrongdoing in accordance with this policy

Contractors or employees of contractors may contact the chief executive or chief people officer.

5.2.8 Trade unions

Trade unions are responsible for:

  • supporting the implementation of this policy, provide advice and encourage their members to raise concerns through this policy
  • supporting and representing their members through any formal processes

5.3 Appendix C Monitoring arrangement

5.3.1 Concerns raised; themes, breakdowns of concerns raised, open concerns

  • How:
    • SBAR report
    • POD report
    • board report
  • Who by: FTSU support and FTSU guardian.
  • Reported to:
    • executive director of people and organisational development
    • director of quality, safety and improvement
    • deputy director of nursing
    • chief nurse
  • Frequency:
    • monthly
    • bi-annually
    • annually

5.3.2 Concerns raised, profession of people making concerns, themes

  • How: NGO data added to NGO website.
  • Who by: FTSU support and FTSU guardian.
  • Reported to: National Guardian office (NGO)
  • Frequency: Quarterly

Document control

  • Version: 8.
  • Unique reference number: 237.
  • Ratified by: Clinical policy review and approval group.
  • Date ratified: 2 April 2024.
  • Name of originator or author: Trust freedom to speak up guardian.
  • Name of responsible individual: Director for people and organisational development.
  • Date issued: 25 April 2024.
  • Review date: 30 April 2027.
  • Target audience: Trust wide.

Page last reviewed: November 13, 2024
Next review due: November 13, 2025

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