The Uplands Medical Practice is committed to providing a safe, comfortable environment where patients and staff can be confident that best Practice is being followed at all times and the safety of everyone is of paramount importance.

This Chaperone Policy adheres to local and national guidance and policy –i.e.: –

‘NCGST Guidance on the role and effective use of chaperones in Primary and Community Care settings’.

The Chaperone Policy is clearly advertised through patient information leaflets, website and can be read at the practice upon request. A Poster is also displayed in the Waiting Area and all consulting rooms (See example in Annex A).

All patients are entitled to have a chaperone present for any consultation, examination or procedure where they consider one is required. The chaperone may be a family member or friend, but on occasions a formal chaperone may be preferred.

Patients are advised to ask for a chaperone if required, at the time of booking an appointment, if possible, so that arrangements can be made and the appointment is not delayed in any way. The Healthcare Professional may also require a chaperone to be present for certain consultations.

Uplands Medical Practice operates a complaints procedure as part of the NHS system for dealing with complaints. Our system meets national criteria.

Our aim is to give you the highest possible standard of service and we try to deal with all the complaints as quickly as possible and within 90 days.

Complaints can be made in writing to the practice manager, Malisha Fatima, via email at BUCCG.UplandsMedicalPractice@nhs.net. Alternatively, please pass your telephone number on to a staff member so Malisha can call you back to discuss your concerns.

Alternatively, you can download our ‘complaints & comments’ leaflet here.

We very much welcome any suggestions for service improvement.

Please note due to sensitive information that may be contained and shared; we do not exchange responses by email.

We hope that if you have a problem, you will use our practice complaints procedure. We believe this will give us the best chance of putting right whatever has gone wrong and an opportunity to improve the services provided by our practice.

If you are not content with the outcome of your complaint at a local level you can ask the Ombudsman to independently review your case by writing to:

The Parliamentary and Health Services Ombudsman
Millbank Tower
Millbank
London
SW1P 4QP

Email: Phso.enquiries@ombudsman.org.uk
Phone: 0345 015 4033
Website: www.ombudsman.org.uk

Although the practice would welcome the opportunity to investigate your complaint, you may prefer to choose to make your complaint to NHS England; details as follows:

Email: england.contactus@nhs.net
Contact Number: 0300 311 2233

Postal address:
NHS England
PO Box 16738
REDDITCH
B97 9PT

Complaining on behalf of someone else

Please note that we keep strictly to the rules of medical confidentiality. If you are complaining on behalf of someone else, we have to know that you have their permission to do so. A letter signed by the person concerned will be needed, unless they are incapable (because of illness) of providing this.

The practice complies with data protection and access to medical records legislation. Identifiable information about you will be shared with others in the following circumstances:

• To provide further medical treatment for you e.g. from district nurses and hospital services.
• To help you get other services e.g. from the social work department. This requires your consent.
• When we have a duty to others e.g. in child protection cases anonymised patient information will also be used at local and national level to help the Health Board and Government plan services e.g. for diabetic care.

If you do not wish anonymous information about you to be used in such a way, please let us know.

Reception and administration staff require access to your medical records in order to do their jobs. These members of staff are bound by the same rules of confidentiality as the medical staff.

Freedom of Information

Information about the General Practitioners and the practice required for disclosure under this act can be made available to the public. All requests for such information should be made to the practice manager.

Access to Records

In accordance with the Data Protection Act 1998 and Access to Health Records Act, patients may request to see their medical records. Such requests should be made through the practice manager and may be subject to an administration charge. No information will be released without the patient consent unless we are legally obliged to do so.

GDPR Policy

Confidential information is defined as any information found in a patient’s medical record, personal information, and work-related information (including salary information). All information relating to a patient’s care, treatment, or condition constitutes confidential information. This confidentiality policy also encompasses any trade secret scientific or technical information developed by the practice or its personnel.

• Employees shall never discuss a patient’s medical condition with any non-employee of the company, friends, or family members. Confidential matters involving patients will not be discussed in areas where they might be overheard by other patients or other non-employees of the company. Staff members are to be aware at all times that conversations regarding patients are not to be overheard by others and take appropriate steps to ensure this confidentiality.

• All salary information is confidential and may not be shared with others in the company or with patients. Only authorised individuals may relay salary information to employees or non-employees.

• Any unauthorised disclosure of confidential information by employees could render the company liable for damages. Any employee who violates the confidentiality of the practice, medical- or employee-related information is subject to disciplinary action up to and including termination from employment.

Your Data Matters to the NHS

Information about your health and care helps us to improve your individual care, speed up diagnosis, plan your local services and research new treatments. The NHS is committed to keeping patient information safe and always being clear about how it is used.

How your data is used

Information about your individual care such as treatment and diagnoses is collected about you whenever you use health and care services. It is also used to help us and other organisations for research and planning such as research into new treatments, deciding where to put GP clinics and planning for the number of doctors and nurses in your local hospital.  It is only used in this way when there is a clear legal basis to use the information to help improve health and care for you, your family and future generations.

Wherever possible we try to use data that does not identify you, but sometimes it is necessary to use your confidential patient information.

You have a choice

You do not need to do anything if you are happy about how your information is used. If you do not want your confidential patient information to be used for research and planning, you can choose to opt out securely online or through a telephone service. You can change your mind about your choice at any time.

Will choosing this opt-out affect your care and treatment?

No, choosing to opt out will not affect how information is used to support your care and treatment. You will still be invited for screening services, such as screenings for bowel cancer.

What do you need to do?

If you are happy for your confidential patient information to be used for research and planning, you do not need to do anything.

To find out more about the benefits of data sharing, how data is protected, or to make/change your opt-out choice visit www.nhs.uk/your-nhs-data-matters

Download a copy of the patient leaflet

The Uplands Medical Practice is committed to providing diversity and equality to all employees whether full time, part time or temporary. We therefore wholeheartedly accept our legal obligations under the legislation, identified below, which makes it generally unlawful to discriminate directly or indirectly in recruitment, employment or after employment on the grounds of:

• Age
• Disability
• Gender Reassignment
• Marriage & Civil Partnership
• Pregnancy and Maternity
• Race (which includes colour, nationality and ethnic or national origins)
• Sexual orientation
• Sex
• Religion or belief

These are known as ‘protected characteristics’.

We also undertake not to discriminate unfairly on the grounds of trade union membership and activity, political belief and unrelated criminal convictions.

There are two types of discrimination that are unlawful: direct and indirect discrimination.

Direct discrimination is where a person is treated less favourably because of their race, sex, disability, sexual orientation, religion or belief, or age.

Indirect discrimination is where the employer applies a practice, requirement or condition, which applies equally to all individuals, but which:

• Has an adverse disproportionate impact on a group of people because of their race, sex, disability, sexual orientation, religion or belief, or age and;
• The employer cannot show it to be justified, and;
• It causes detriment to the individual.

Selection for employment, promotion, training or any other benefit will be on the basis of aptitude and ability.

Every employee is entitled to a working environment, which promotes dignity and respect to all. No form of intimidation, bullying, harassment or victimisation will be tolerated.

The Uplands Medical Practice as the ‘employer’ is committed to implementing equality of opportunity in carrying out all its various functions.

We are committed to the development of effective policy, strategy and standards and to the introduction of monitoring and information systems to review and evaluate progress towards the achievement of equality of opportunity.

The employer recognises the effects of historical disadvantage and past discrimination, and will, where appropriate and within the law, take positive action to achieve equality of opportunity.

We believe much can be achieved by developing policies, practices and procedures to eliminate unlawful and unfair discrimination and realise that real progress toward equality of opportunity requires a programme of action, which involves the commitment and participation of all staff.

The employer believes that equal opportunities require a genuine commitment to this policy from everyone. For us this includes a duty to adhere to the key guidance in establishing, monitoring and evaluating our responses to the Equality Act 2010 and Disability Discrimination Act [DDA] and all Amendments related to those Acts.

All members of staff, together with those involved in all activities, are required to conduct themselves in accordance with our Equality and Diversity Policy. They are required to take personal responsibility in this area and work towards promoting respect for individuals. This will entail identifying and removing inappropriate behaviour and changing practices that perpetuate inequality and taking necessary action to challenge unfair, discriminatory or racist practices.

Members of staff can be held personally liable as well as, or instead of the practice, for any act of unlawful discrimination. Members of staff who commit serious acts of harassment may be guilty of a criminal offence. Acts of discrimination, harassment, bullying or victimisation against employees or customers are disciplinary offences and will be dealt with under the practice disciplinary procedure.

Race Equality Policy

Rationale

The employer acknowledges that the society within which we live is enriched by the ethnic
diversity, culture and faith of its citizens.

We believe members of staff have a professional commitment to ensure that we know how to make effective personalised provision for employees, including those for whom English is an additional language or who have special educational needs or disabilities, and how to take practical account of diversity and promote equality and inclusion in our training.

The practice strives to ensure that the culture and ethos of our practice is such that, whatever the heritage and origin of our employees, everyone is equally valued and treats one another with respect.

All employees (including learners and apprentices) will be provided with the opportunity to experience, understand and celebrate diversity.

The definition of institutional racism is “the collective failure of an organisation to provide an appropriate and professional service to employees because of their culture, colour or ethnic origin.  It can be seen or detected in processes, attitudes and behaviour which amount to discrimination through unwitting prejudice, ignorance, thoughtlessness and racist stereotyping which disadvantages minority ethnic people.”

Definition of a racist incident:

“Any incident, which is perceived to be racist by the victim or any other person”

Our Aims:

Our aims for promoting racial equality and challenging racial discrimination include:

• Ensuring that staffs from all racial groups are encouraged to achieve to their full potential.
• Maintaining an inclusive ethos.
• Acknowledging the existence of racism and being proactive in tackling and eliminating racial discrimination.
• Promoting at every opportunity the practice ethos of welcoming and valuing everyone, irrespective of their race, colour, religion, ethnic or national origin, age or sexual orientation.
• Ensuring that equality is an integral part of all our training.

Actions to Ensure Race Equality

The practice will:

1. Where monitoring demonstrates disadvantages in employment or under-representation, the practice will undertake positive action measures allowed by law to rectify this, such as;

• Provide facilities or services to meet the particular needs of people from under-represented groups.
• Target job training at particular groups that are under-represented in a particular area of work.
• Encourage applications from groups that are under-represented in such areas.
• The Practice Manager will review the Policy annually.

2. The practice will ensure that our quality assurance processes identify good practice.

3. The practice will endeavour to ensure that our staff team reflects the multi-cultural and multi-ethnic society in which we live.

4. All racist incidents will be recorded and reported to the Manager. All incidents will be resolved sensitively, in a manner, which supports the victim and both sanctions and educates the perpetrator.

All staff, learners and apprentices will:

1. Be made to feel valued members of the practice.
2. Be encouraged to reach their full potential.
3. Be supported in their development.
4. Have their views, backgrounds and beliefs respected by colleagues and peers.
5. Act as role models through the positive relationships they foster with colleagues and peers.

Monitoring by Ethnicity

The practice recognises ethnic monitoring as essential to ensure that no ethnic group is being disadvantaged, and that monitoring leads to action planning.  We will build on that approach to tackle other key areas identified.

Implicit Bias

What are implicit biases?

Implicit biases are the unconscious prejudices, preferences or assumptions that the brain forms about certain groups of people. These associations are a fast and easy way for the subconscious to store information and enable quick judgements. It’s important to establish that holding these implicit biases is not the same thing as being overtly racist or sexist – they are formed automatically and involuntarily.

Studies have shown that implicit bias can have a direct impact on decision making – even where a company has a diversity policy and actively supports equality, it remains possible for such biases to come into play. Decisions on recruitment, performance, promotion, and even medical diagnoses have been found to alter when individuals are presented with similar situations where the only differences are characteristics such as gender or race.

How to counter implicit bias

Implicit biases are most likely to emerge when tired or making quick decisions. When rushed, low on sleep or under pressure, making a conscious effort to take extra time to assess the responses and judgements you are making can establish whether they are they based purely on facts, or if assumptions are playing a part. Alternatively, and if possible, consider anonymising job applications, CVs or requests from employees or patients to ensure implicit biases cannot impact on responses.

Legislative Framework

Equality Act 2010

(This act replaces the Equality Act 2006, the Race Relations Act 1976 and the Disability Discrimination Act 1995 and seeks to harmonise a number of previous pieces of equal opportunity legislation)

The purpose of the Equality Act 2010 is to simplify discrimination legislation and create a more consistent and effective framework, while at the same time extending discrimination protection.  The Act defines discrimination as less favourable treatment because of a ‘protected characteristic’. The protected characteristics under the Equality Act are: disability; gender reassignment; marriage and civil partnership; pregnancy and maternity; race; religion or belief; sex and sexual orientation. Indirect discrimination against individuals because they have a relevant protected characteristic is also covered (with the exclusion of pregnancy & maternity).

Other Legislation

General Data Protection Regulation 2018

The practice treats personal data collected for reviewing equality of opportunity in recruitment and selection in accordance with its General Data Protection Regulation Information about how data is used and the basis for processing is provided in the organisation’s Employee Privacy Notice.

Rehabilitation of Offenders Act 1974

The purpose of the Act is to benefit those people who have been convicted of a criminal offence in civilian life or in the services (Army, Navy or Air Force) and who have since not committed any crimes.

According to the Act, if a person is convicted of a criminal offence and receives a sentence of not more than 2½ years and is not convicted again during a specified period of time (known as the rehabilitation period) s/he becomes a rehabilitated person. The conviction for the offence then becomes ‘spent’, or forgotten, and the person in possession of a spent conviction can then have equal access to the same benefits as a person without the same conviction within the realms of employment, training and housing.

Police Act 1997 – section 122

This section of the Act requires the practice to publish a Code of Practice. This is to provide assurance to those applying for Standard Disclosures – (information contained in criminal record certificates) or Enhanced Disclosures (information contained in enhanced criminal record certificates), that the information released will be used fairly and stored securely.

Public Order Act 1986 and Criminal Justice Act 1994

In some cases, the offender may commit a criminal assault and criminal liability may arise under these Acts. It is an offence to intentionally cause harassment, harm or distress through using threatening, abusive or insulting words, behaviours or displays of material. There is a penalty of up to six months in jail and/or a fine of up to £5,000.

Protection from Harassment Act 1997

This imposes a criminal liability on the part of the offender. There is a penalty of up to 6 months in jail and/or a fine of up to £5,000.

Human Rights Act 1998

Human Rights Act incorporates rights under the European Convention of Human Rights into domestic law. Individuals can bring claims under the HRA against public authorities for breaches of Convention rights. UK courts and tribunals are required to interpret domestic law, as far as possible, in accordance with Convention rights. Previous case law may be overturned if there is a breach of Convention rights and the relevant law can be re-interpreted in a way that is compatible with Convention rights. Convention rights include a right not to be discriminated against on non-exhaustive grounds, which include that of sex, where another Convention right is engaged.

European Legislation

• The Pregnant Workers Directive
• Article 119 of the Treaty of Rome
• The Equal Treatment Directive
• The Equal Pay Directive

Grievance

If an individual feels this policy does not support them or that it is being implemented inadequately, they should report their grievance to the Practice Manager.

If an individual regards any matter as requiring formal resolution under this policy then such matters should be referred to the Grievance Policy & procedures.

The management team are responsible for ensuring the implementation of this policy.

How we use your personal information

This fair processing notice explains why the practice collects information about you and how that information may be used.

The health care professionals who provide you with care maintain records about your health and any treatment or care you have received previously (e.g. Hospital, GP Surgery, Walk-in clinic, etc.). These records help to provide you with the best possible healthcare.

NHS health records may be electronic, on paper or a mixture of both, and we use a combination of working practices and technology to ensure that your information is kept confidential and secure. Records which this GP Practice hold about you may include the following information;

• Details about you, such as your address, legal representative, emergency contact details
• Any contact the surgery has had with you, such as appointments, clinic visits, emergency appointments, etc.
• Notes and reports about your health
• Details about your treatment and care
• Results of investigations such as laboratory tests, x-rays etc
• Relevant information from other health professionals, relatives or those who care for you

Your records will be retained in accordance with the NHS Code of Practice for Records Management

To ensure you receive the best possible care, your records are used to facilitate the care you receive. Information held about you may be used to help protect the health of the public and to help us manage the NHS. Information may be used within the GP practice for clinical audit to monitor the quality of the service provided.

Some of this information will be held centrally and used for statistical purposes. Where we do this, we take strict measures to ensure that individual patients cannot be identified.

Sometimes your information may be requested to be used for research purposes – the surgery will always gain your consent before releasing the information for this purpose.

How do we maintain the confidentiality of your records?

We are committed to protecting your privacy and will only use information collected lawfully in accordance with:

• Data Protection Act 2018
• Human Rights Act 1998
• Common Law Duty of Confidentiality
• Health and Social Care Act 2012
• NHS Codes of Confidentiality and Information Security
• Information: To Share or Not to Share Review (click here to read further information about this)

Every member of staff who works for the Practice or another NHS organisation has a legal obligation to keep information about you confidential.

We will only ever use or pass on information about you if others involved in your care have a genuine need for it. We will not disclose your information to any 3^rd party without your permission unless there are exceptional circumstances (i.e. life or death situations), where the law requires information to be passed on for example Child/Adult Protection and Serious Criminal Activity.

Who are our partner organisations?

We may also have to share your information, subject to strict agreements on how it will be used, with the following organisations or receive information from the following organisations:-

• NHS Trusts / Foundation Trusts
• GP’s
• NHS Commissioning Support Units
• Independent Contractors such as dentists, opticians, pharmacists
• Private Sector Providers
• Voluntary Sector Providers
• Ambulance Trusts
• Clinical Commissioning Groups
• Social Care Services
• NHS Digital
• Local Authorities
• Education Services
• Fire and Rescue Services
• Police & Judicial Services
• Other ‘data processors’ which you will be informed of

You will be informed who your data will be shared with and in some cases asked for explicit consent for this happen when this is required.

We may also use external companies to process personal information, such as for archiving purposes.  These companies are bound by contractual agreements to ensure information is kept confidential and secure.

Access to personal information

You have a right under the Data Protection Act to request access to view or to obtain copies of what information the surgery holds about you and to have it amended should it be inaccurate.  In order to request this, you need to do the following:

• Your request must be made in writing to the GP – for information from the hospital you should write direct to them
• There may be a charge to have a printed copy of the information held about you
• We are required to respond to you within 30 days
• You will need to give adequate information (for example full name, address, date of birth, NHS number and details of your request) so that your identity can be verified and your records located
• If we receive more than two requests within a six month period, we reserve the right to charge a reasonable administrative fee in accordance the Data Protection Act 2018

Objections / Complaints

Should you have any concerns about how your information is managed at the GP, please contact the Practice Manager.  If you are still unhappy following a review by the GP practice, you can then complain to the Information Commissioners Office (ICO) via their website (www.ico.org.uk).

Change of Details

It is important that you tell the person treating you if any of your details such as your name or address have changed or if any of your details such as date of birth is incorrect in order for this to be amended.  You have a responsibility to inform us of any changes so our records are accurate and up to date for you.

Notification

The Data Protection Act 2018 requires organisations to register a notification with the Information Commissioner to describe the purposes for which they process personal and sensitive information.

This information is publicly available on the Information Commissioners Office website www.ico.org.uk

The practice is registered with the Information Commissioners Office (ICO).

Who is the Data Controller?

The Data Controller, responsible for keeping your information secure and confidential is:

THE PARTNERS

THE UPLANDS MEDICAL PRACTICE

BURY NEW ROAD

WHITEFIELD

M45 8GH

TEL: 0161 766 8221

All GP practices are required to declare the mean earnings (e.g. average pay) for GPs working to deliver NHS services to patients at each practice.

The average pay for GPs working at the surgery in the last financial year before tax and National Insurance was £59,488. This is for 3 part time GPs and 4 locum GPs who worked in the practice for more than 6 months.

Summary

In England, from the end of 2010 or early 2011 all medical practices and providers of healthcare, whether operating within the NHS or as independents, will be obliged under the Health and Social Care Act to register as a provider with the Care Quality Commission (CQC).

The Code of Practice on the Prevention and Control of Healthcare Associated Infections (HCAI) and related guidance outlines how NHS and independent dental providers can meet the registration requirements relating to HCAI set out in the regulations.

This information is made available to the general public via the CQC website and to commissioning agencies.

This topic explains the requirements for the management of occupational health service provision, staff immunisation and the management.

Employers’ Duties

Central to health and safety legislation and the Control of Substances Hazardous to Health (COSHH) Regulations 2002 in the UK and Northern Ireland is the duty for employers to assess work-related risks to staff, contractors, visitors and patients. This includes exposure to hazardous substances such as pathogens (called biological agents in COSHH). The employer must implement as far as is “reasonably practicable” measures to protect their staff and others who may be exposed to infectious pathogens in the workplace.

The law requires that employers engage the expertise of an occupational health services provider so as to ensure that employees are not a carrier or infected with a communicable disease. Employers have to be able to demonstrate that an appropriate employee immunisation programme is in place. They are obliged to pay for this service.

The occupational health provision should include the following services.

• Pre-employment health clearance of new staff.
• Ensure that existing staff receive all the recommended occupational immunisations and boosters.
• Immediate, 24-hour access to advice on post-exposure prophylaxis (PEP), to drugs and to appropriate support.
• All staff must be trained in the prevention and control of healthcare associated infections.

Employees’ Duties

The Health and Safety at Work, etc Act (1974) and the Health and Safety at Work (Northern Ireland) Order 1978 require employees to take reasonable precautions to ensure their own safety and the safety of others.

All GPs and Nurses have a professional duty to protect the health and safety of their patients in line with the GMC and NMC codes of conduct. . Registrants who believe that they may have been exposed to blood-borne viruses (BBV), such as HIV, hepatitis B (HBV) or hepatitis C (HCV), are under a legal and professional obligation to promptly seek and follow confidential advice on testing for BBVs. They are obliged to comply with expert recommendations and with national guidelines on practicing restrictions. A failure to do so would breach their duty of care to patients.

Medical personnel are advised not to rely on their own risk assessment. Instead, they should contact their occupational health service provider or local Director of Public Health in the Primary Care Trust for confidential advice on testing for BBVs.

Recommendations for Immunisation of Clinical Staff

Clinical staff should be immunised according to current guidance as recommended by the Care Quality Commission and the Green Book.  The purpose of immunisation is two-fold.

1. Immunisation helps to prevent transmission of communicable diseases to vulnerable and susceptible patients.
2. Immunisation protects the healthcare worker, their colleagues, friends and families from occupational exposure to infectious disease.

Furthermore, staff immunisation can help to maintain the continued running of a clinical service during outbreaks of highly contagious infections, eg seasonal and pandemic flu.

Varicella, Hepatitis B and MMR vaccinations provide additional protection to women of childbearing age. These viral infections cross the placenta and can cause deformities in the unborn child. It should be noted that during pregnancy the woman has reduced immunity to infection. She becomes more susceptible to viral infections that often manifest with more severe and life-threatening symptoms than in the general public.

All new staff and existing clinical staff should have received vaccinations and be up to date with boosters against the following diseases.

• Hepatitis B.
• Tuberculosis (BCG vaccine if no natural immunity).
• MMR. Rubella is no longer available as a single vaccine and is a component of the Measles Mumps and Rubella (MMR) vaccine. Satisfactory evidence of immunity includes documentary evidence of receipt of two doses of MMR or having had positive antibody tests for measles, mumps and rubella.
• Diphtheria, tetanus and polio.
• Varicella (Chicken pox). This vaccination is recommended if the person is shown to be non-immune on antibody testing or there is no definite history of chicken pox or shingles.
• Seasonal influenza, as an annual vaccination in the autumn is recommended for front-line healthcare workers with direct patient contact.
• Covid- 19

Note:

Although immunisation provides protection against infection, it must never be regarded as a substitute for good infection control and prevention practice.

Recommendation for Immunisation of Non-clinical and Support Staff

Hepatitis B vaccination is recommended for non-clinical staff who are:

• at risk of injury from blood-contaminated sharp, eg cleaners who handle hazardous clinical waste
• at risk of being of bitten or deliberately injured by patients.

BCG vaccine is not routinely recommended for non-clinical staff in healthcare settings.

All non-clinical staff should be up to date with their routine immunisations and boosters, eg tetanus, diphtheria, polio and MMR.

All staff at the practice will be offered the Seasonal Influenza Vaccine as per Public Health Guidance.

Hepatitis B Immunisation and Interpretation of Post-vaccination Antibody Levels

A standard Hepatitis B vaccination (HBV) course consists of three immunisations but there are a range accelerated dosing schedules which includes an additional dose at 12 months. The vaccine stimulates the production of specific antibodies to hepatitis B surface antigen (HBsAg). Therefore, the vaccine is not required in personnel who have proven natural immunity to hepatitis B arising from previous infection.

Evidence shows that 10–15% of adults fail to respond (< 10 IU /mL) or respond poorly (10–100 IU/mL) to a course of HBV immunisation. An inadequate response is more common in those aged 40 years+ and is associated with obesity, alcoholism, smoking and underlying immunosuppression.

Importantly the vaccine is also ineffective in those people with a current acute hepatitis B infection or asymptomatic carriers.

The immune response to the vaccine (antibody titre) is maximal 1–2 months after completing a full course of immunisation. Vaccine immune response rates vary.

Hence, antibody responses should be measured 1–4 months after completing the full primary course of immunisation to ensure that the person has mounted an adequate antibody response (hepatitis B surface antibody titre (HBs Ab positive) 100 IU/ml).

The member of staff and occupational health service must keep a record of the immune response results. Such information allows appropriate decisions to be made concerning post-exposure prophylaxis following known or suspected exposure to the virus.

Declining a Test

All staff at the Uplands Medical Practice have the right to decline testing, in which case they will be refused clearance to take up a post that involves exposure prone procedures (EPPs).. However, a positive test, or declining a test for hepatitis C or HIV, should not affect the employment or training of healthcare workers that do not perform EPPs.

It is recommended that HIV infected healthcare workers should remain under regular medical and occupational healthcare in accordance with good practice.

The Uplands recognises that they have a greater duty of care to HIV infected healthcare workers. The Disability Discrimination Act 2005 protects such workers from discrimination in the workplace due to their chronic disability.

Clinical healthcare personnel and students for whom hepatitis B vaccination is contra-indicated, who decline vaccination or who are non-responders to vaccine should be restricted from performing EPPs unless shown to be non-infectious (ie negative for hepatitis B surface antigen). Periodic re-testing may need to be considered as advised by the lead GP Dr Ifat Hussain, personnel lead.

If a sharps injury involving a patient occurs during this time the patient should be assessed by local medical experts for the necessity of post-exposure prophylaxis and other supportive measures.

If non-immune medical personnel decline a BCG vaccination, the risks should be explained by the lead GP and supplemented by written advice. The person should usually not work where there is a risk of exposure to TB. The employer has employment and health and safety obligations with regard to their employee and should consider each case individually.

The risk assessment will be affected by the prevalence of TB locally and the practice’s case mix. Respiratory precautions such as the use of masks and respirators and appropriate surgery ventilation will help mediate the risk.

Hepatitis B Immunisation and Interpretation of Post-vaccination Antibody Levels

A standard Hepatitis B vaccination (HBV) course consists of three immunisations but there are a range accelerated dosing schedules which includes an additional dose at 12 months. The vaccine stimulates the production of specific antibodies to hepatitis B surface antigen (HBsAg). Therefore, the vaccine is not required in dental personnel who have proven natural immunity to hepatitis B arising from previous infection.

Evidence shows that 10–15% of adults fail to respond (< 10 IU /mL) or respond poorly (10–100 IU/mL) to a course of HBV immunisation. An inadequate response is more common in those aged 40 years+ and is associated with obesity, alcoholism, smoking and underlying immunosuppression.

Importantly the vaccine is also ineffective in those people with a current acute hepatitis B infection or asymptomatic carriers.

The immune response to the vaccine (antibody titre) is maximal 1–2 months after completing a full course of immunisation. Vaccine immune response rates vary.

Hence, antibody responses should be measured 1–4 months after completing the full primary course of immunisation to ensure that the person has mounted an adequate antibody response (hepatitis B surface antibody titre (HBs Ab positive) 100 IU/ml).

The member of staff and Practice Manager must keep a record of the immune response results. Such information allows appropriate decisions to be made concerning post-exposure prophylaxis following known or suspected exposure to the virus.

Policy Statement

The Uplands Medical Practice is committed to the control of infection within the building and in relation to the clinical procedures carried out within it.

The Uplands Medical Practice will undertake to maintain the premises, equipment, drugs and procedures to the standards detailed within the General Practice Infection Control Self-Assessment Tool Appendix 3 and will undertake to provide facilities and the financial resources to ensure that all reasonable steps are taken to reduce or remove all infection risk.

Proposals for the Management of Infection Risk
The Interim lead clinician for Infection Control is Dr Ifat Hussain [Lead GP] and the non-clinical lead for Infection Control is Malisha Fatima [Practice Manager].

The Practice Nurse/s with the added support from Healthcare Assistants will be responsible for the maintenance of personal protective equipment and the provision of personal cleaning supplies within clinical areas and the management team for the maintenance of the provision of personal cleaning supplies within non-clinical areas.

The following general precautions are applied:

• A daily, weekly, monthly and 6 monthly cleaning specification is applied and followed by the cleaning staff. Please refer to our Cleaning Plan and Cleaning Logs.
• Infection Control training is attended by all the responsible member of staff which included hand washing procedures. Hand washing Guidelines – separate protocol.
• Hand washing posters are displayed at each designated hand basin.
• A random and unannounced Infection Control Inspection using the Checklist is done at least on monthly basis and the findings are discussed in practice meetings for any remedial action.

The following measures ARE taken by all staff to limit the risks of infection from the following biological substances.  Local and national guidelines relating to the control of infection ARE consulted.

All new staff are trained on infection control as part of induction procedures, and will also receive an annual update.

General Precautions – Spillages

If there is any blood or other body fluid spillage outside the workplace then it can be rinsed away with a 2% bleach / water solution.

If there is spillage within the workplace a spillage kit is available containing antiseptic granules, which may be poured onto blood spills, leave for 2 minutes, and removed using paper towels. The kit also contains rubber gloves (to be replaced if used once) and goggles to prevent splashes into the eyes. Disposable aprons should also be used.

Block off spillage areas from patients and staff until the spillage has been removed. Always use Personal Protective Equipment (PPE), and note the following general guidelines:

• Paper towels etc., once used, should be placed in clinical waste
• Non-disposable items such as buckets etc. should be disinfected using a suitable bleach / disinfectant solution
•  All used PPE should be disposed of as clinical waste
• Always was your hands using thorough techniques immediately after the event

It is the responsibility of ALL staff members to ensure that they have mandatory vaccination to cover for occupational risk as per the “Green book” published by the Public Health. This protects you, your families and the patients.

www.gov.uk/government/uploads/system/uploads/attachment_data/file/503768/2905115_Green_Book_Chapter_18_v3_0W.PDF

www.gov.uk/government/uploads/system/uploads/attachment_data/file/147882/Green-Book-Chapter-12.pdf

The above 2 documents are filed in the Practice Policies folder and also on the desktop.

In the case of infection by an HIV patient drugs are available which, if administered within 1 hour will give an 80%+ chance of killing the HIV infection.

Handling of Pathology Specimens – Danger of Infection samples

Labelled to alert laboratory staff that the specimen may requires special handling.

Clinical judgement is required in deciding to label samples correctly, and the onus is on the requestor to label correctly. Samples from the following will require “Danger of Infection” labelling:

• Patients with proven infection with a Hazard Group 3 (HG3) pathogen e.g. Hepatitis B and C, HIV, Tuberculosis and other mycobacteria, typhoid, brucella and anthrax.
• Patients suspected of having a HG3 pathogen (information from clinical history and examination e.g. injecting drug user, haemophiliac vCJD)
• A patient who is part of an on-going outbreak caused by HG3 pathogen.
• Inmates of prisons.

The remainder of this protocol will deal with specific substances and procedures listed below:

• Blood
• Urine
• Faeces
• Vomit
• Semen
• Sputum/phlegm
• Vaginal specula
• Microbiological swabs
• Vaccinations
• Decontamination and disposal of materials contaminated with biological substances
• Transportation of biological specimens

BLOOD

Two major potential hazards from blood are contraction of Hepatitis B and C and the AIDS virus. The risk of contracting any of these is minimal if the operator does not inject his or her self with the patient’s blood.  If the operator has an open wound and spills an infected patient’s blood there is a potential for transmission of one of these infective agents; in these circumstances it is advisable that the operator wears gloves.

Medical personnel who either handle blood samples or take blood from patients are therefore to take the following precautions:

The taking of Blood:

The risk of contamination to personnel is always less if the patient and the operator are relaxed and still.  It is recommended that patients lie down during bloodletting where appropriate.  It is imperative that the operator takes his/her time and does not rush.

Sterile disposable syringes and needle are to be used only once. Care is to be taken that no blood comes into contact with the operator’s skin by taking the following precautions:

• Always withdraw the needle from the vein whilst covering the site of the needle puncture with a cotton wool ball (not a medi-swab).

• Should a drop of blood escape from the end of the needle following the withdrawal, allow it to drip into the cotton wool ball.

• Do not sheath the needle, as this is the most common cause of needle stick injury.

• If a vacutainer system is not used, carefully pull back on the syringe to draw a little air into it.

• Carefully remove the needle from the syringe/vacutainer holder and place it immediately into the sharps box.

• Where syringe and needle are used, insert the required amount of blood into the bottle and do not fill beyond the line, since these increases the risk of spillage during transportation.

• With the introduction of vacutainers, the risk of spillage from filling bottles has diminished but care still needs to be taken when removing the bottle from the inducer when two or more specimens are needed to be collected.

• Replace the cap on the bottle and ensure a good seal.

• If required the bottle may be mixed with the preservative by gently rolling or tipping the bottle.  Do not shake.

• When the required number of bottles has been filled, the syringe and any contents need to be disposed of in the sharps box.  This will decrease the risk of spillage of blood onto the outside of the container from the syringe.

• If the amount of surplus blood in the syringe is more that 5 ml it should first be sealed in a blood bottle, like other blood samples, to reduce the risk of spillage.

• Once the sharps box is two thirds full it is to be sealed and returned for disposal.  Under no circumstances attempt to force a syringe into a sharps box.

• All specimens are to be sealed in plastic pathology sample bags ready for transportation. Each sample should have its own bag.  All forms that accompany the sample should be in a separate part of the plastic bag.

• Specimens should be stored in a cool safe place.

• All personnel who work with or may handle blood or pathological specimens are vaccinated against Hepatitis B and have their antibodies measured following vaccination to reduce the risk of contracting this infection.

Handling of Samples:

• All samples of blood are to be in the approved sample tubes provided, which are sealed by a top.  If should leakage of blood occur due to imperfections in the bottle or incorrect fitting of the top, the sample is not to be transported out of the practice in the container.

• All sample tubes containing blood are to be inserted into an approved plastic bag, which should be sealed to minimise the risk of contamination of personnel should leakage occur.

• If there is a leak or spill the action will depend on the extent of the leak.  If the leak is contained within the plastic bag the bag should not be opened and should be inserted within another plastic bag, which should then be sealed. A suitable person (doctor/nurse) is to be informed if a leak occurs and will decide whether to dispose of the sample or to transfer the remains of the sample into another bottle.  The transfer of blood should only be undertaken when the risk of contamination of personnel is minimal and when gloves are used.    Otherwise the sample is to be disposed of as above in a plastic bag inserted to the clinical waste container.

• If the leak is not contained within the bag and contaminates either the outside of the bag or external objects the following action is to be taken:

• Avoid any further contamination by containing the sample within another plastic bag – if possible without undoing the bag. Tighten the top of the tube, as this may be loose.

• Dispose of the sample within an approved clinical waste container.

• Ensure that your hands are washed thoroughly with hot water and/or alcohol gel or soap. Any cut or open wound that comes into contact with the patient’s blood should be thoroughly washed to ensure that none of the patient’s blood remains in contact with the wound.

• Any contaminated objects should be cleaned and disinfected as described below.
• All blood should be treated as high risk and universal precautions applied.

Sharps Boxes:

The purpose of a sharps box is to protect personnel from injury. The most likely time that injury will occur is when inserting an object into the sharps box. Therefore it is important that the box is not used beyond the two-thirds full stage.  If the box is more that two thirds full, seal it and start a new box.  Never force objects into the box – if the syringe is too big to fit into the box, even though the box is not yet two thirds full, start a fresh box.

The HCA and the Practice Nurses are responsible for sharps bin storage. The bins must be labelled, signed, dated and secure. In the absence of the clinicians the practice management team will take on this responsibility. Person/s carrying out this task must be administered the HEP B vaccination and evidenced.

Patients who are bleeding:

The situation of a patient who is bleeding rarely poses a significant risk to the staff.  However, some risk does exist and extra precautions and therefore needed:

• Always wear gloves when dealing with open wounds whether or not they have stopped bleeding.

• In the event of significant bleeding, such that would lead to contamination of medical staff clothing, a plastic apron must be worn.

• Patients should not leave the practice whilst they are still bleeding as this poses a risk to the general public.

• Contaminated clothing belonging to the patient should be placed inside a plastic bag and returned to the patient with appropriate advice about soaking clothing in cold water before washing and about prevention of contamination of the clothing of other personnel. The patient should be advised to disinfect the bowl or sink that the clothing is soaked in.

Major Accidents:

Occasionally, personnel will be involved with a major incident or accident where many people are injured, possibly seriously. All personnel are to take reasonable steps to protect themselves from injury and contamination. However, it is recognised that this may fall far short of the guidelines above.  Personnel should remember that their prime duty under these circumstances is to the patient whilst maintaining as many safety precautions as possible.  For this reason vaccination with the Hepatitis B vaccine is mandatory for all medical personnel.

URINE

Urine, whether non-infected or infected, poses less of a risk than blood. However sensible precautions should still be taken to avoid contamination of personnel or their clothing. Gloves should be worn when handling urine containers, as it is impossible to tell whether or not the container is contaminated with blood or faeces.

Samples in Sealed Containers

Samples of urine in sealed containers should pose no health risk provided that the bottle is adequately

sealed and no urine contaminates the outside of the bottle.

Analysis of Samples of Urine

• Pregnancy tests and dipstick testing make necessary the opening of urine bottles and exposure of personnel to urine. Gloves should be worn whilst testing urine and hands must always be washed after handling urine and testing urine.

• Disposal of Urine. Urine is to be disposed of down the sluice or toilet. Under no circumstances may it to be disposed of down a sink.

• Disposal of Urine Containers. Urine containers are disposable and are to be used once only. Urine bottles are to be emptied when analysis is complete, rinsed and the bottle resealed and disposed of in the clinical waste bin.

FAECES

Faeces pose a risk to medical personnel. Through faeces a number of diseases are transmitted that can be serious (though they are rarely as serious as blood diseases).  It is important to handle specimens correctly to avoid the risk of disease.

Samples:

• Samples should be handed in inside a blue top specimen pot. Other containers are not acceptable. The patient should label his specimen container before defecation with his name, date of birth and date and time of production. The specimen should then be placed inside a specimen bag and sealed by the patient. The patient should be advised to wash his hands thoroughly after defecation before touching the specimen pot and again after inserting the specimen pot into the bag.

• The cleaners will clean the toilets 5 times a week. In the event of a patient having diarrhoea the patient should clean the toilet if they are well enough, or by medical staff in the event of the patient being too ill to perform this task. Medical staff and cleaners should wear gloves when cleaning the toilet. Hands must always be washed afterwards.

VOMIT

Vomit can contain infective organisms and is thus a risk to personnel. Always work on the assumption that the vomit is infected.  Patients will usually have time to obtain a bowl or find their way to the toilet, but occasionally patients will vomit on the floor or furnishings.

Disposable paper bowls are available in reception, but if any other container is used it should be emptied down the sluice or toilet and washed out immediately after being emptied and then disinfected.  Toilets should be cleaned and sterilised in the same way that they are for diarrhoea. Personal Protective Equipment should be used. Spillages are to be cleaned in accordance with the practice spillage guidelines within this document.

SEMEN

Semen should be collected by the patient into a universal container and delivered to NPH LAB

SPUTUM/PHLEGM

Sputum should be collected by the patient into a universal container and labelled by the patient.  The container should be inserted into a plastic specimen bag with the request form in the pocket separate to the specimen itself.  In the event of the specimen leaking out of the bottle or the bottle breaking the specimen is to be disposed of and a new specimen obtained.

VAGINAL SPECULA, SPATULA AND SMEARS

• Two types of speculum are currently in use; the disposable speculum. The doctors and qualified nurses are the only persons permitted to perform vaginal examinations and smears. Disposable specula are to be put in the clinical waste bag after use and appropriately trained staff that may be assisting with the procedure can do this. Gloves are to be worn when disposing of these instruments.  Used spatula is to be placed in the clinical waste bag.  .

• Cervical smear specimens are to be placed upon a collection box to dry following collection or directly into the slide specimen box.

MICROBIOLOGICAL SWABS

Swabs are taken of many infected areas of the body to assess the cause of the infection. Thus a swab by definition contains an unknown hazard. Provided the swab is not removed from the transport medium, no risk of transmission of infection exists unless there has been contamination of the outside of the container.  The following guidelines are to be followed:

Taking Swabs from Infected Lesions:

• The infected area must not be touched with the hands.

• The infected area must not come into contact with the operator’s clothes.

• The container for the swab and the patient are to be as close together as is reasonably possible in order to minimise the distance that the swab needs to travel once the specimen has been taken.

• Care is to be taken that the swab contains enough material for analysis but not so much that there is a likelihood of dripping pus during the transit of the swab from the patient to the specimen container.

• The top of the bottle must be sealed adequately before insertion into a sealed plastic hazard bag. The form that accompanies the specimen is to be placed in the appropriate pocket of the bag and not in the same compartment as the specimen.

• In the event of the top becoming loose and parting from the container whilst in the bag, the top is to be re-sealed either through the bag, or by opening the bag.

• The transport medium is solid and unlikely to leak out of the bag, however, in the unlikely event of this occurrence it has to be assumed that microbiological material has also leaked. Therefore the specimen is to be disposed of and re-taken.

VACCINATIONS

Advice about blood taking also applies to vaccination of patients. Always avoid contact with blood by the use of cotton wool swabs after withdrawing the needle. Never sheathe the needle, always dispose of needles safely and without delay. When disposing of the needle it is to remain attached to the syringe, unlike blood letting where the purpose of removing the needle is to avoid haemolysis of the blood cells.

DECONTAMINATION AND DISPOSAL OF MATERIALS CONTAMINATED WITH BIOLOGICAL SUBSTANCES

Clothes:

Precautions should always be taken to avoid contamination of clothing whenever possible, by the use of protective clothing, e.g. disposable plastic apron when the situation can be anticipated.  However there will be occasions when it is difficult to anticipate the situation. Contamination of clothes with biological material necessitates the following measures:

• Remove as much surplus material as possible using gloves and a disposable wipe.

• Change into clean clothing if there exists any risk to either the operator or patients whom the operator will treat during that shift. If in doubt – change.

• Personnel should ensure that the clothing does not come into contact with any surface on which food is prepared.

• Blood stained clothing should be soaked in cold water prior to washing to facilitate removal of the stain.

• Soiled clothing should ideally be washed separately from other non-soiled clothing and the washer used at the maximum temperature that the clothing could tolerate without being damaged.

• There may be occasions when it is deemed fit for an item of clothing to be destroyed due to contamination with biological material. Under these circumstances the item is to be sealed in a hazard bag and disposed of in the clinical waste bin.

TRANSPORTATION OF BIOLOGICAL/CLINICAL WASTE

• Biological or clinical waste is to be placed in appropriate containers only. Sharps are to be placed only in sharps boxes. Only contaminated material that cannot penetrate the plastic is to be placed in hazard bags. Contaminated or non-contaminated material that may penetrate the hazard bags most be placed in a sharps box.  This includes unbroken glass that may become broken if the bag is damaged in transit.

• Yellow hazard bags are to have no contamination of their outer surface. If there is contamination of the outer surface of the bag with biological material, the bag is to be placed inside another bag and sealed ready for transportation.

• Once boxed or bagged in hazard containers, waste is to be stored in the Clinical Waste bin in the lockable cupboard near to reception. The waste material is to remain inside these solid containers until collected by the clinical waste contractor.

All our patients have an allocated named GP, which is your registered GP. If you wish to know who this is, please ask at reception.

Please note that you can still choose to see the GP of your choice.

When you are offered an appointment at one of the Bury GP Federation Extended Access Hubs outside of the Practices normal opening hours, you will be asked for your consent to share your medical records with the healthcare staff working in the service.

Without this consent, you will not be able to be seen at one of the GP Hubs as the healthcare staff would not have access to your medical records.

You will then need to wait for the next available appointment at your registered Practice.

Full details of how and when your records will be shared

INTRODUCTION

This Policy should be read in line with other staffing policies in place including but not limited to disciplinary and grievance policy, IT and policies covering discrimination, bullying and harassment. This policy will set out rules in relation to the use of all forms of social media. Failure to comply could result in disciplinary action leading to dismissal depending on circumstances.

Definition of Social Media

Social media is a type of interactive online media that allows parties to communicate instantly with each other and allows the sharing of data in a public forum. Social media covers, bit is not limited to (X) Twitter, Facebook, Instagram, TikTok, Snapchat, LinkedIn, You Tube and Flicker.

Personal use of Social Network at Work

Practice staff are NOT permitted to access social media websites from the surgery’s computers or other electronic devices for personal use at any time.

Business Use of Social Media

There may be times when you may need as part of your job to use social media and in these circumstances it will be made clear as to what is or is not allowed. You may contribute to the use the surgery’s Social Media activities by possibly providing blogs or articles. The Practice Manager should approve these. If you are contacted for comments on the surgery for publication anywhere and you should discuss your response with your line manager to ensure that it is appropriate and represents the values of the surgery.

Responsible use of Social Media

You should remember that you are always representing the surgery and must therefore ensure the communication has a purpose and is intended for public benefit.

In both business and personal use you should ensure the following.

• Use your common sense before you post anything and think about what you are saying at to the public
• Ensure that you do not post any disparaging or defamatory statements about the Surgery, Staff (current and Past), Patients (current and past) other surgeries and organisations within the NHS or connecting areas
• You should not post images or links to inappropriate content.
• You must breach in any way confidentiality
• Do not use social media to bully, harass or discriminate against any party
• You must not express any strong religious or political points
• You must not enter into any contractual agreements without the express consent of your manager
• You must refrain from any illegal activity
• You should not enter any online fights, personal attacks or hostile postings

The golden rule is to ask yourself whether what you are about to post could cause offence to

anyone. If the answer is yes, then do not make the posting.

Monitoring

If you are allowed to use the surgeries computers or other electronic devices for business use

the surgery has the right to monitor such use. Unauthorised use during working hours will

result in disciplinary action.

In the event of misuse being found then the surgery may limit your access rights in addition too any other action that’s deemed necessary.

Social Media in your personal life

The surgery recognises that many employees use social media in a personal capacity

and again, in that capacity you must not post anything that damages the reputation of the

surgery. You are allowed to state that you work at the surgery however your online

profile/username must not contain the surgery’s name. You must not use your working email

address in any communication in a personal capacity. You should not discuss your working life

via social media.

Disciplinary Action

Any breach of this policy may result in disciplinary action being taken against you. Serious

breaches of this policy could constitute gross misconduct and could lead to dismissal.

The Surgery may request you to remove any posting that is deemed to be offensive or not

appropriate and failure to comply may constitute an act of gross misconduct for failing to

follow a reasonable management request.

The NHS operate a zero tolerance policy with regard to violence and abuse and the practice has the right to remove violent patients from the list with immediate effect in order to safeguard practice staff, patients and other persons. Violence in this context includes actual or threatened physical violence or verbal abuse which leads to fear for a person’s safety. In this situation we will notify the patient in writing of their removal from the list and record in the patient’s medical records the fact of the removal and the circumstances leading to it.

Practice Policy

Introduction

The Uplands Medical Practice helps protect the rights of its patients by providing a means for its employees to report any suspected malpractice, failure or malfunction at the surgery that could potentially endanger, or put at-risk, patients who use its services.

The means for the above procedure is provided through The Public Disclosure Act 1998; often referred to as the ‘Whistleblowing Act’. This Act provides protection for workers from being subjected to any detriment by their employer, and protection against victimisation and dismissal.

The Uplands Medical Practice is committed to effectively and promptly dealing with any malpractice, failure or malfunction that occurs and has numerous policies, procedures and systems in-place to help prevent such occurrences.

The Uplands Medical Practice follows the guidelines suggested in the revised version of the GMC document “Raising and acting on concerns about patient safety”, effective 12 March 2012, a copy of which can be downloaded here:

www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/raising-and-acting-on-concerns

The Uplands Medical Practice will not tolerate victimisation, harassment or detriment to any worker who has exercised their right and raised a concern under the Act.

The Uplands Medical Practice will ensure that all concerns raised are taken seriously and are fully investigated.

Detriment

The Uplands Medical Practice recognises a detriment as any one of the following:

• A restriction or a denial of promotion;
• Facilities;
• Training opportunities, or;
• Opportunities, which may have been offered if a disclosure, had not been made.

Concerns

A malpractice, failure or malfunction which is believed to be currently occurring, has previously happened, or is likely to happen in the future will not be tolerated by this surgery, and includes such events as:

• Any criminal offence;
• Any breach of a legal obligation;
• A miscarriage of justice;
• Endangering the health or safety of any worker or patient;
• Damage to the environment, or;
• Any deliberate cover-up of information in relation to any of the above.

Confidentiality

The Uplands Medical Practice will maintain complete confidentiality when any concerns are raised using the internal ‘Whistleblowing’ procedure.

Applicability

The ‘Whistleblowing’ policy and procedure applies to the following groups of workers:

• Employees under regular contracts of employment;
• Locums and other NHS contracted workers;
• Contractors providing services;
• Temporary or day workers;
• Trainees on vocational and work experience schemes.

Procedure

The following procedure must be adopted when raising a concern:

• If you wish to raise a malpractice, failure or malfunction which you believe to be currently occurring, has previously happened, or is likely to happen in the future, you must inform the duty GP (in writing) of your concern;
• If the above person is the subject of the concern, you should inform their immediate superior (in writing) of your concern;
• You should fully explain the nature and extent of your concern;
• Your concern will be investigated fully and you will be promptly advised of the progress;
• On conclusion you will receive a written response to your concern detailing the outcome of the investigation;
• If you are not satisfied with the investigation or the outcome of the investigation then you have the right to notify the appropriate prescribed person. Malisha Fatima, Practice Manager, holds a list of prescribed persons;
• If you believe you have been subjected to victimisation, harassment or suffered a detriment (at any time) due to you raising a concern, then this is regarded as a serious disciplinary offence and will be dealt with in-line with normal Practice disciplinary procedure;
• In the first instance you must inform the duty GP (in writing) of your detriment;
• If the above person is the subject of the detrimental behaviour, you should inform their immediate superior (in writing) of your detriment;
• A full investigation into the suspected victimisation, harassment or detriment will then be conducted.

If we conclude that you have made false allegations, whether in relation to raising a concern maliciously, in bad faith or with a view to personal gain, then you will be subject to disciplinary action.

We have put this policy in place to allow you to raise concerns internally with the assurance that this will be dealt with adequately. We feel that this should mean that you would not need to make a disclosure externally.

The law recognises that in some instances external disclosures, to a regulator for example, will be required. We strongly encourage you to seek advice before reporting a concern to anyone external.

You can call ‘The independent whistleblowing charity’ which has changed its name to PROTECT, speak up, Stop Harm, if you have a concern. They operate a confidential helpline (020 3117 2520).

They also have a list of prescribed regulators for reporting certain types of concern.

RAISING A CONCERN WITH A REGULATOR

If the employers are registered with a regulatory body, such as the General Medical Council (GMC) or the Care Quality Commission (CQC), then you may wish to contact them to investigate the issue in circumstances where;

• You feel that the responsible person or local body is part of the problem you wish to report
• Concerns have been raised through local channels but not satisfied that adequate action has been taken by the responsible person/body
• You feel there is an immediate and serious risk to patients and a regulator (or a similar external body) has the responsibility to act or intervene.

RESOURCES

Whistleblowing: Quick Guide to Raising a concern with CQC

REGULATORY AND INVESTIGATORY BODIES

General Chiropractic Council – Website: www.gcc-uk.org; Phone: 020 7713 5155

General Dental Council – Website: www.gdc-uk.org; Phone: 020 7887 3800

General Medical Council – Website: www.gmc-uk.org; Phone: 0161 923 6602

General Pharmaceutical Council – Website: www.pharmacyregulation.org

Phone: 020 3365 3400

Pharmaceutical Society of Northern Ireland – Website: www.psni.org.uk; Phone: 028 9032 6927

Health Professions Council – Website: www.hpc-uk.org; Phone: 020 7582 0866

Nursing and Midwifery Council – Website: www.nmc-uk.org; Phone: 020 7637 7181

OTHER REGULATORY AND INVESTIGATORY BODIES

Care Quality Commission – Website: www.cqc.org.uk; Phone: 03000 616161

Monitor – Website: www.monitor-nhsft.gov.uk; Phone: 020 7340 2400

National Patient Safety Agency – Website: www.npsa.nhs.uk ; Phone: 020 7927 9500

NORTHERN IRELAND

Regulation and Quality Improvement Authority in Northern Ireland

Website: www.rqia.org.uk; Phone: 028 9051 7500

SCOTLAND

The Care Inspectorate

Website: www.scswis.com; Phone: 0845 600 9527

Healthcare Improvement Scotland

Website: www.healthcareimprovementscotland.org; Phone: 0131 623 4300

WALES

Healthcare Inspectorate Wales

Website: www.hiw.org.uk; Phone: 029 2092 8850

IF YOU NEED TO RAISE A CONCERN AND UNABLE TO SPEAK TO SOMEONE IN THE PRACTICE OR THE NOMINATED FREEDOM TO SPEAK UP GUARDIAN THEN PLEASE SEE THE NEXT PAGE WITH DETAILS OF PEOPLE YOU CAN CONTACT.

Need to raise a concern about Patient or Staff Safety

How do I tell CQC?

You can contact us by telephone, email or letter. Please tell us that you are raising a concern and that you are a worker who is either employed by, or providing services to, a registered provider.

Call us on: 03000 616161

Email us at: enquiries@cqc.org.uk

Our opening hours are:

Monday to Friday: 8.30am – 5:30pm

Write to us at:

CQC National Correspondence

Citygate Gallowgate

Newcastle upon Tyne

NE1 4PA