Professional Registration policy - NHS Grampian · responsible for checking registration details appropriately. ensure that they conduct the necessary online checks with the appropriate

Professional Registration policy

Co-ordinator: Director of Workforce

Reviewer: Grampian Area Partnership Forum

Approver: Grampian Area Partnership Forum (GAPF)

Date approved by GAPF 1 November 2013 Refresh 10 August 2017

Review Date 1 November 2018

Uncontrolled when printed

Version 4

The provisions of this policy, which was developed by a partnership group on behalf of Grampian Area Partnership Forum, apply equally to all employees of

NHS Grampian except where specific exclusions have been identified.

Professional Registration Policy v4 1

NHS Grampian

Professional Registration Policy

This document is also available in large print and other formats and languages, upon request. Please call NHS Grampian Corporate Communications on Aberdeen (01224) 551116 or (01224) 552245.

This Policy has undergone Equality and Diversity Impact Assessment.

Revision History:

Document Title Policy Version Date approved by GAPF Review Date

Professional Registration Policy

4 Agreed to be refreshed by the 10 August 2017 GAPF

1 November 2018


NHS Grampian Professional Registration Policy

Table of Contents

Section Section Title Page 1 Introduction 3

2 System for Checking the Registration of Newly Appointed

Employees 3

3 System for Checking/Monitoring Re-registration 3

4 Responsibilities 4

5 Process for Dealing with Lapsed Registration 6

Appendix 1 10

Staff Groups which require to hold professional registration

Appendix 2 12

Process for referral of nurses and midwives to the Nursing and Midwifery Council (NMC)

Appendix 3 19

Process for referral of Allied Health Professionals (AHP’s) to the Health & Care Professional Council (HCPC)


NHS Grampian Professional Registration Policy

1 Introduction

There is a professional, legal and contractual requirement for certain Professional health care staff who are employed by NHS Grampian to have current registration with a nominated professional regulatory body to enable them to practise in health care in the United Kingdom. Details of the staff groups which are required to hold professional registration are shown in Appendix 1.

The legal requirement to be registered in order to practice will be specified in the employee’s contract of employment and will be well known to the employees concerned through their membership of their professional body. The employee’s failure to maintain this registration will, consequently, constitute a breach of contract.

2 System For Checking The Registration of Newly Appointed

Employees

NHS Grampian’s Recruitment and Selection Policy, which is available on the intranet, sets out the process for Appointing Officers checking the registration of newly appointed employees.

3 System for Checking/Monitoring Re-Registration

Every line manager/professional head is responsible for checking the registration details of all those employees in their section/department/service who are required to be registered with a nominated professional regulatory body. Where an employee has more than one post, each line manager/professional head is responsible for checking their registration details appropriately. Registrations should be checked with the relevant regulatory body. The manager should also check with the regulatory body if the individual registrant is the subject of any fitness to practice investigations or restrictions.

As a monitoring process:

The HR Service Centre/Workforce Team is responsible for interrogating the Scottish Workforce Information Standard System (SWISS) on a monthly basis and compiling a list of those employee’s whose registration is due to expire. They then contact the relevant regulatory body for confirmation of registration/non-registration of each employee on the list.


Subsequently, details of any staff who have not renewed their registration are forwarded to the relevant line manager/professional head.

The line manager/professional head is responsible for checking the

registration of the staff listed and will sign, date and return a pro forma to the HR Service Centre/Workforce Team confirming this. Registration details are then updated on SWISS

When registration is not confirmed by the line manager/professional head within the specified time frame they should notify the responsible director (or equivalent) to ensure that appropriate action is taken.

4 Responsibilities

NHS Grampian There is a mandatory requirement by the regulatory body for an employee to undertake specified activities to ensure re-registration e.g. continuing professional development, appraisal, re-validation etc and therefore to meet the minimum requirements for their role in terms of the provision of safe, effective and person centred care. NHS Grampian acknowledges that it has a corporate responsibility to provide sufficient resources - time, funds etc., - to enable the employee to comply with these requirements. Employees

Employees who are required to be registered with a professional regulatory body in order to practice must:

ensure that their registration is kept up to date at all times, required fees are sent with adequate time for processing to the regulatory body and that they are received and processed appropriately.

produce their registration details to their line manager promptly when

asked e.g. on commencement of employment, during regular registration checks and on renewal of registration

notify their line manager immediately they become aware that they are no longer registered. This applies to every post they hold within NHS Grampian

notify the appropriate professional regulator/organisation of any changes to personal circumstances promptly e.g. temporary or permanent change of address.


undertake appropriate activities in order that registration can be renewed e.g. continuing professional development, appraisal, re- validation etc and notify their line manager, at the earliest opportunity, if they are unable, for whatever reason, to meet those specified activities

notify their line manager if there are any restrictions to their practice

imposed by a regulatory body

ensure they are aware of the process required by their regulatory body

to gain re-registration

Managers

There is an obligation on line managers to check that employees who report to them are registered with the appropriate regulatory body and they are consequently required to:

ensure, where they are the Appointing Officer, that all newly appointed employees who require to be registered with a professional body are so registered as per NHS Grampian’s Recruitment and Selection Policy

ensure that employees are provided with sufficient support to meet any

requirements set out by their regulatory body for renewal of their registration

Ensure the registration details of all existing employees are checked

with the Regulatory Body in advance of the expiry date. If employees have more than one post then each line manager/professional head is responsible for checking registration details appropriately.

ensure that they conduct the necessary online checks with the appropriate regulatory body and confirm the outcome to the HR Service Centre /Workforce Team by updating, dating and returning the relevant pro forma to the HR Service Centre/Workforce Team

5 Process for Dealing With Lapsed Registration

When it becomes apparent that an employee’s registration has lapsed, the manager must meet with the employee at the earliest opportunity and certainly within a maximum of 5 working days to investigate the circumstances which led to their registration lapsing. At this point consideration should be given to an alternative role for the employee eg. working as a health care support worker until the investigation concludes and/or registration is confirmed. The employee remains on full pay pending the completed investigation. Details of the investigation process can be found in the appropriate employee conduct policy.


At the meeting the employee has the right to be accompanied by a Trade Union or Professional Organisation representative (including full-time Trade Union Officers), or be accompanied by a colleague, friend, or relative not acting in a legal capacity.

The purpose of the investigation is to allow the manager to ascertain which of the following applies:

the employee applied to renew their registration in time but the

regulatory body delayed renewal

the regulatory body has suspended the employee’s registration

pending investigation or

the employee’s registration has lapsed as a result of their failure

to follow the re-registration process required by the regulatory body

another reason is identified.

The manager must also identify the relevant re-registration process when they meet with the employee. The following flowchart and text should serve as a guide through the investigative process:


Flowchart for Dealing With Lapsed Registration

Employee’s registration lapses.

Employee ceases to practice with

immediate effect.

Manager investigates within a maximum of 5 working days and

ascertains that registration has lapsed

as a result of:

The regulatory body delaying renewal where application submitted correctly and in time.

Regulatory body suspending registration pending investigation

The employees’ failure to follow the re-

registration process required by NHSG

and/or the regulatory body

Employee either allocated duties for which

registration is not required, or suspended

– both options on full normal pay, pending re-

registration

The manager should discuss with an

appropriate member of their HR Team

The manager convenes a Disciplinary Hearing

in line with the provisions of the

Employee Conduct Policy/ Framework for

Support.


(a) The employee applied to renew their registration in time but the regulatory body delayed renewal

In circumstances where an employee submits an application for re- registration which meets the requirements set by the regulatory body e.g. within the laid down time-scale, making any requisite payment etc., the employee will not be held responsible for that body’s failure to re-register them on time. They will, however, be required to produce evidence that they have made all adequate provisions to renew their registration.

However, as the employee is not registered they will be unable to practice in the post in which they have been employed with immediate effect from the date of their registration lapsing until their registration becomes current.

While the employee remains unregistered, the manager will either allocate them duties related to their substantive post but for which registration is not required, or suspend them from duty, both of which options will be on full pay. In either case they will suffer no detriment in their terms and conditions of employment.

(b) A regulatory body suspends an employee’s registration pending

investigation

In circumstances where a regulatory body suspends an employee’s registration pending investigation, the options open to NHS Grampian are as follows:

(i) as the employee is not registered they will be unable to practice in

the post in which they have been employed with immediate effect from the date of their registration lapsing until their registration becomes current.

(ii) while the employee remains unregistered, the manager will either allocate them duties related to their substantive post but for which registration is not required, or suspend them from duty, payment for work will be in accordance with the role that they are undertaking at this time.

(iii) in the event that NHS Grampian also conducts it’s own investigation

in to the matters connected/or unconnected to the regulatory body’s investigation, the alternatives available will include those recorded in the Employee Conduct Policy or, for medical and dental staff, Framework for Support. These can be found on the NHS Grampian intranet, or can be obtained from a manager, a member of HR staff or a staff side representative

(c) A regulatory body withdraws an employee’s registration

Where the outcome of the regulatory body’s investigation results in the employee’s registration being withdrawn on either a permanent or


prolonged basis, the options open to NHS Grampian will be as outlined in (d) below In these circumstances, the manager concerned should discuss the matter fully with an appropriate member of their HR Team

(d) An employee’s registration lapses as a result of their failure to

follow the re-registration process required by the regulatory body

Where a manager is satisfied, following investigation, that the lapse in registration is as a result of an employee’s failure to ensure registration, they should set up a Disciplinary Hearing. This should be in line with the provisions of the Employee Conduct Policy or, in the case of medical and dental staff, Framework for Support.

The outcome of a Disciplinary Hearing can be dismissal where the employee is found to be culpable of breaching their contract of employment with NHS Grampian.

Where the Panel finds that the employee is not culpable for their registration lapsing, their case will be dealt with under the provisions noted in Section 5(a) above.

Exceptionally, where the employee is found to be culpable for their registration lapsing, the Panel hearing the case may consider that there are mitigating circumstances which will allow the individual to be retained in employment pending their registration being renewed.

Under such exceptional circumstances there may be a number of mitigating circumstances that may require to be taken into account.

It should also be noted that:

(a) a finding of the Panel that the employee has been culpable but should, if possible, be retained in employment will not preclude them from awarding a penalty under the Employee Conduct Policy/Framework for Support e.g. a Final Written Warning and

(b) If there is a requirement for support and supervision as part of

development which the employee is required to undergo in order to re-instate their registration this will be endorsed by NHS Grampian. However the costs of any education/ training which may be required will be met by the individual member of staff.

(c) any time which the employee spends on unpaid leave under these

circumstances will count towards their continuous service with NHS Grampian.


Appendix 1

Staff Groups Which Require to Hold Professional Registration

Nursing, Midwifery and Health Visitors

To work in the UK all nurses, midwives and specialist community public health nurses must register with the NMC and renew their registration every three years. It should be noted, however, that fees fall due for payment on an annual basis and registration will lapse if the appropriate payments are not made.

Medical Dental and Pharmacy Staff

All Medical, Dental and Pharmacy staff are required to be registered with the General Medical Council (GMC), the General Dental Council (GDC), or the General Pharmaceutical Council (GPhC) respectively and this is renewable annually.

Professions Regulated by the Health & Care Professions Council

There are 14 professions regulated by the Health & Care Professions Council (HCPC), with a number of protected job titles within these professions. Details of the 14 professions and protected titles are shown below.

Further information on the registration requirement for each profession can be obtained on the Council’s web site - http://www.hcpc-uk.org/ Profession Protected Title Art Therapists Art physiotherapist; Art therapist;

Dramatherapist; Music Therapist. Biomedical Scientists Biomedical Scientist. Chiropodists/Podiatrtists Chiropodist; Podiatrist Clinical Scientists Clinical Scientist. Dietitians Dietitian; Dietician. Occupational Therapists Occupational Therapist. Operating Department Practitioners

Operating Department Practitioner.

Orthopists Orthoptist. Paramedics Paramedic. Physiotherapists Physiotherapist; Physical Therapist. Practitioner Psychologists Practitioner Psychologist; Registered

Psychologist; Clinical Psychologist; Counselling Psychologist; Educational Psychologist; Forensic Psychologist; Health Psychologist; Occupational Psychologist; Sport and Exercise Psychologist.

http://www.hcpc-uk.org/


Profession (contd) Protected Title Prosthetists/Orthotists Prosthetist; Orthotist. Radiographers Radiographer; Diagnostic Readiographer;

Therapeutic Radiographer Speech and Language Therapists Speech and Language Therapist; Speech

Therapist Social Workers Public Health Practitioners UK Public Health Register


Appendix 2

Staff Procedure for Referring Nurses and Midwives to the Nursing and Midwifery Council (NMC)

Uncontrolled When Printed

Version 1

1st July 2012


NHS Grampian Staff Procedure for Referring Nurses and Midwives

to the Nursing and Midwifery Council (NMC)



Revision History:

Document Title Policy Version

Date Approved by GAPF

Review Date


NHS Grampian Staff Procedure for Referring Nurses and Midwives to the Nursing

and Midwifery Council (NMC)

Table of Contents

Section Section Title Page 1 Introduction 15

2 Referral to the NMC 15

Flowchart I – Concerns about Conduct of a

Nurse / Midwife 17

Flowchart II – Concerns about competence

of a Midwife 18


1 Introduction

The NMC’s role is to protect the public when a nurse’s or midwife’s fitness to practice is impaired, and their situation cannot be managed locally. It is therefore incumbent on the organisation that every reasonable step has been taken to manage the individual practitioner performance in accordance with local policy before referring to the NMC.

This document outlines the NHS Grampian procedure for referral to the NMC. Whilst technically any person may refer a nurse or midwife to the NMC, this procedure is designed to ensure the effective discharge of NHS Grampian’s corporate and clinical governance responsibilities.

2 Referral to the NMC

A referral to the NMC can be on the following

grounds:

Misconduct

Lack of competence*

Conviction or caution

Physical or mental health

Finding by another regulatory body that fitness to practice is impaired

Fraudulent or incorrect registration

A referral by an employer for lack of competence will only be accepted after all other avenues have been exhausted. Guidance on this and the other grounds for referral are readily available on the NMC’s website – www.nmc-uk.org http://www.nmc-uk.org/Publications/Information-for-employers/

The NMC requires all referrals to be made on its official referral document, and accompanying check list (see NMC website).

In all circumstances the Board’s Director of Nursing must be consulted for advice before any referral of a nurse or midwife is made.

Once satisfied that all processes have been followed, the Board’s Director of Nursing will ask the relevant Head of Nursing, or Midwifery, or Lead Nurse to oversee and direct the processing of the referral. (Please see attached flowchart I). Copies of the referral paperwork must be submitted to the Board Director.

http://www.nmc-uk.org/

http://www.nmc-uk.org/Publications/Information-for-employers/

http://www.nmc-uk.org/


Referral of a midwife should be made in one of two ways: 1. Misconduct – via the Head of Midwifery (or in her absence the Lead

Midwife) in conjunction with the Local Supervising Authority Midwifery Officer (LSAMO) (please see attached flowchart I).

2. Lack of competence – via the supervisory route with referral by the LSAMO (please see the attached flowchart II).

If any other member of staff considers a referral to the NMC may be appropriate, they should seek the advice of the Lead Nurse/Lead Midwife in their sector. The provisions of NHSG’s Employee Conduct and Employee Capability policies, plus other appropriate policies must be taken in account and adhered to at all times. Additionally other helpful information about professional issues in relation to conduct, capability and NMC referral can be found on the NHSG Intranet on the Learning Zone in the ‘Being a Manager’ section.. Any member of the public who wishes to refer a nurse/midwife to the NMC may seek the help and support of the Lead Nurse/Lead Midwife, Head of Midwifery, LSAMO or the Board Nurse Director to do so.


Misconduct identified, referred to Nurse/Midwifery Manager

and General Manager

Lead Nurse/Midwife

completes referral

Referral of a midwife due to misconduct may be made by the LSAMO if the case has been investigated through supervision e.g. the midwife

has stolen drugs for their own use

Lead Nurse/Lead Midwife

Board Nurse Director consulted for advice and

decision to proceed

Lead Midwife in consultation with the Head of Midwifery for advice and decision to proceed

Flowchart I – Concerns about Conduct of a Nurse / Midwife

Board Nurse Director consulted for advice and

decision to proceed

LSA Midwifery Officer for information to consider a midwives practice from a

supervisory perspective


Failed

Program of Developmental Support

Program of Supervised Practice

Successful Successful Failed

Flowchart II – Concerns about competence of a Midwife

Supervisor of midwives is informed

Must investigate LSAMO informed Manager informed

Manager may

suspend from duty

If unfitness to

practice not proven

If unfitness to

practice proven

Local Action LSAMO informed SOM submits formal report and

recommendations

No Action

LSAMO

May request further supervised practice

Suspend from practice before referring to NMC

Informs Local Managers

Must investigate

LSAMO completes referral to NMC


Appendix 3

Procedure for Referring Allied Health professionals to the Health & Care Professions

Council (HCPC)

Uncontrolled When Printed

Version 1

1st June 2013


NHS Grampian Procedure for Referring AllIed Health Professional to the Health

Care Professions Council (HCPC)



Revision History:

Document Title Policy Version

Date Approved by GAPF

Review Date


NHS Grampian Procedure for Referring Allied Health Professionals

to the Health Care Professions Council (HCPC)

Table of Contents

Section Section Title Page

1 Introduction 22

2 Referral to the HCPC 22

Flowchart I – Concerns about Conduct of an AHP 24


NHS Grampian Procedure for Reporting Allied Health Professionals* to the Health Care Professions Council (HCPC)

The HCPC’s role is to protect the public when an AHP’s fitness to practice is impaired as a result of issues with proficiency, conduct, health, performance and ethics and the situation cannot be managed locally through either formal or informal processes. It is incumbent on managers that every reasonable step has been taken to manage the individual practitioner’s performance in accordance with local policy and guidelines when considering reporting a member of staff to the HCPC. If a manager has concerns about an individual practitioner that they think may impact on their fitness to practice, and the manager is about to instigate formal performance management procedures, the manager should make early informal contact with the HCPC to gain advice regarding fitness to practice. No further action will be taken by the HCPC unless a formal report is made, although HCPC may assign a case worker, request information about the standards being set, and request an update on progress. HCPC will continue to provide advice regarding the need to make a formal report, but will also “step down” if standards are met within the timeframe designated by standard setting procedures.

A report to the HCPC can be made on the following grounds:

Misconduct

Lack of competence/capability*

Conviction or caution

Physical or mental health

condition/problem Fraudulent or incorrect registration

* A report by an employer for lack of competence will only be accepted after all

other local avenues have been exhausted. Guidance on this and the other grounds for reporting are readily available on the HCPC’s website – www.hcpc- uk.org using the “reporting a fitness to practice concern” form.

The HCPC requires that all formal reports be made in writing identifying the AHP and the nature of the concern.

Whilst any person may report an AHP to the HCPC, this policy is designed to ensure that managers effectively discharge NHS Grampian’s corporate and clinical governance responsibilities.

In all circumstances the Board’s Director of Nursing & Quality and the AHP Associate Director must be consulted for advice before any formal report of an AHP by a Manager/Lead is made to the HCPC.

Once satisfied that all processes have been followed, the Board’s Director of Nursing and/or AHP Associate Director will ask the relevant Manager/Lead to process the report. (Please see attached flowchart I). Copies of the reporting paperwork must be submitted to the Board Director of Nursing & Quality and AHP Associate Director.

If any other member of staff considers that a report to the HCPC may be




appropriate, they should seek the advice of the relevant Manager/Lead. Any member of the public who wishes to report an AHP to the HCPC may seek the help and support of the relevant Manager/Lead, AHP Associate Director or the Board Director of Nursing to do so.

When considering a report to HCPC please also refer to uni-professional documents, eg, Code of Conduct and uni-professional standards.

AHPs is a generic term covering Art Therapy, Dietetics, Occupational Therapy, Orthoptics, Physiotherapy, Podiatry, Prosthetics & Orthotics, Radiography & Speech and Language Therapy.


Flowchart I – Concerns about Conduct of an AHP

Manager/Lead informs Sector

General Manager of issue

Misconduct identified/ reported to

Manager/Lead in a Sector

Manager/Lead liaises with HR,

OHS, staff side rep etc as required for local management

processes

Manager/Lead commences local

investigation

Manager/Lead makes informal

contact with HCPC to discuss

AHP Associate

Director informs Director of Nursing

Manager/Lead consults with relevant

Professional Head and/or AHP Associate

Director

Information on outcome of investigation or

outcome of standard setting provided to AHP Associate Director and

Director of Nursing

Manager/Lead informs General Manager, AHP Associate Director and Director of Nursing of

outcome of local investigation and need

for formal report to HCPC

Copy of formal

report to HCPC is provided for AHP

Associate Director and Director of

Nursing

Manager/Lead completes formal reporting to HCPC

NB: Procedure will be reviewed when new AHP leadership arrangements are in place

Documents

Professional Registration policy - NHS Grampian · responsible for checking registration details appropriately. ensure that they conduct the necessary online checks with the appropriate