Policy and Protocol for Registration of Professional Staff



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REGISTRATION OF PROFESSIONAL STAFF -

POLICY AND PROTOCOL

|Version |12 |

|Name of responsible (ratifying) committee |HR Policy Group |

|Date ratified |05 July 2018 |

|Document Manager (job title) |Recruitment Manager |

|Date issued |03 August 2018 |

|Review date |03 August 2020 |

|Electronic location |Management Policies |

|Related Procedural Documents |Discipline for Staff Policy; Pre-Employment and Employment Checks Policy |

|Key Words (to aid with searching) |Professional registration; Professional registers; Professional regulations; |

| |Registration; Professional Staff; NMC; GMC; HPC; HPSET, Revalidation; Professional |

| |responsibility; Conditions of employment; Personnel procedures |

Version Tracking

|Version |Date Ratified |Brief Summary of Changes |Author |

|12 |05.07.18 |Review and update |Natalie Sanderson |

|11 | | Quick reference Guide – 1. Staff are responsible for ensuring they meet the |Head of Nursing & Midwifery |

| | |requirements set out by their professional body to maintain professional |Education |

| | |registration. 4. Definitions – Revalidation inserted. 5. Duties and | |

| | |Responsibilities – Professional Staff Addition to Nurse/Midwives/Health Visitors | |

| | |Section. 6.1.6 Replace Trained with ‘Registered’. 6.2.3 Add in Revalidation. | |

| | |6.2.4 Replace All relevant staff with Nursing and Midwifery Staff. Add in | |

| | |Revalidation for Nursing and Midwifery Staff. 6.3.1 Replace unqualified with | |

| | |unregistered. | |

| | |7.3 Add in Trust staff undertaking the role of confirmer for Nursing and Midwifery | |

| | |staff revalidation will be conversant with NMC guidance and have attended Trust | |

| | |training as appropriate. Appendix B Letter – Add in. | |

|10 |22/01/2015 |Review and update |Recruitment Manager |

CONTENTS

QUICK REFERENCE GUIDE 3

1. INTRODUCTION 4

2. PURPOSE 4

3. SCOPE 4

4. DEFINITIONS 4

5. DUTIES AND RESPONSIBILITIES 4

6. PROCESS 6

6.1 New Employees 6

6.2 On-going checks during employment 7

6.3 In the event of a lapsed registration 8

7. TRAINING REQUIREMENTS 8

8. REFERENCES AND ASSOCIATED DOCUMENTATION 9

9. EQUALITY IMPACT STATEMENT 9

10. MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS 10

APPENDIX A: Registration Renewal Reminder Letter 11

APPENDIX B: Revalidation Renewal Reminder Letter 12

EQUALITY IMPACT SCREENING TOOL 13

QUICK REFERENCE GUIDE

For quick reference the guide below is a summary of actions required. This does not negate the need for the document author and others involved in the process to be aware of and follow the detail of this policy.

1. Staff are responsible for ensuring they meet the requirements set out by their professional body to maintain professional registration.

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2. Staff are responsible for ensuring their professional registration fees are paid and that they are legally registered in order to practice.

3. The Human Resources Department will check and validate an employee’s Professional Registration at the start of their employment.

4. The Human Resources Department will undertake monthly checks of staff whose professional registration is due to lapse.

5. The Human Resources Department will then write to all staff whose professional registration is due to lapse to remind them to renew their registration.

6. Staff who fail to renew their professional registration will be referred to the Staff Discipline policy.

7. The Human Resources Department will record all lapses of professional registration; these will be escalated to the appropriate professional lead.

8. An exceptions report of staff whose professional registration has lapsed will be presented at Director of Workforce and Organisational Development and Workforce Governance Group on a quarterly basis.

1. INTRODUCTION

The verification of registration status of professional staff is essential to ensure that both Portsmouth Hospitals NHS Trust (“The Trust”) and the public can be confident that all professional staff providing a service are appropriately qualified, registered with the relevant body and meet statutory registration requirements.

2. PURPOSE

The purpose of this policy is to outline the responsibilities and processes for managing the new and ongoing verification registrations of Professional Staff within the Trust.

3. SCOPE

This policy applies to all directly employed Trust Staff, including bank, temporary and substantive staff. All temporary (agency) staff are either employed through NHS Professionals or Crown Commercial Service (CCS) approved agencies. In these cases the checking of professional registration is the responsibility of the agency concerned and is written into the agreements the Trust has with such agencies. Crown Commercial Service are audited to ensure compliance.

In the event of an infection outbreak, flu pandemic or major incident, the Trust recognises that it may not be possible to adhere to all aspects of this document. In such circumstances, staff should take advice from their manager and all possible action must be taken to maintain ongoing patient and staff safety.

4. DEFINITIONS

Electronic Staff Record (ESR): HR and payroll system, which records personal data of all employees.

General Medical Council (GMC): Professional Registration body for Medical Staff.

General Dental Council (GDC): Professional Registration body for Dentist, dental nurse, dental hygienists.

Health and Care Professions Council (HCPC): Professional Registration body for Allied Health Professionals.

Hospital Play Staff Education Trust (HPSET): The Hospital Play Staff Education Trust (HPSET), formerly the Hospital Play Staff Examination Board (HPSEB), is the registration body for Qualified Hospital Play Specialists.

Nursing and Midwifery Council (NMC): Professional Registration body for Nurses and Midwives.

Crown Commercial Service (formally Government Procurement Service): an executive agency of Department of Health, in place to manage the NHS supply chain.

Revalidation for Nurses and Midwives: 3 yearly process to confirm nurses and midwives comply with statutory requirement to maintain registration with NMC.

5. DUTIES AND RESPONSIBILITIES

The Director of Workforce and Organisational Development is responsible for ensuring that there are robust processes and procedures in place to allow for effective and ongoing registration checks for professional staff and that associated policies remain up to date and in line with current legislation.

Workforce Governance Group, chaired by a Non Executive Director and comprising, the Director of Workforce and Organisational Development, Deputy Director of HR, Head of Learning and Development, Head of Workforce Planning and Intelligence, Head of Employee Resourcing, Head of Organisational Development. It is responsible for ensuring that all exception reports are reviewed and appropriate action plans developed to address any identified issues.

The Head of Employee Resources/ is responsible for ensuring that:

• Effective and robust systems and processes are in place for all registration checks to be undertaken legally and in line with good practice.

• Training is provided to HR staff to enable them to operate within best practice and legal parameters.

The Human Resources Team is responsible for ensuring that the processes outlined in this policy are adhered to and any issues with compliance are escalated to the Head of Human Resources.

The Operational HR Team is responsible for:

• Taking the appropriate steps to stop a staff member working, should their registration have lapsed.

• Escalating any issues concerning removal of a staff member from their professional register to the individual’s line manager and Professional Lead

Recruiting / Line Managers are responsible for ensuring that all employment policies and procedures are adhered to, in respect of both new and current staff and that any advice received from Human Resources Team is followed. Managers will also report any potential exceptions to the Head of Employee Resources.

Professional Leads are responsible for ensuring that any advice received from the Human Resources Team is followed and appropriate action taken; with regard to issues of their staffs’ professional registration.

Professional Staff

Any member of staff employed in the following staff groups is required to maintain professional registration with their professional body whilst employed in the NHS. The Trust will not employ anyone within these staff groups unless they are registered.

|Grade |Professional Registration Body |Annual Registration Date |

|Doctors |General Medical Council |Variable |

|Dentists |General Dental Council |31 December |

|Nurses /Midwives / Health Visitors |Nursing and Midwifery Council |Variable annual reregistration and |

| | |variable 3 yearly revalidation date |

|Pharmacists |Pharmaceutical Society of Great Britain |31 December |

|Chiropodists |Health and Care Professions Council |30 June (30 September) |

|Dieticians |Health and Care Professions Council |31 May (31 August) |

|Occupational Therapists |Health and Care Professions Council |30 September (30 December) |

|Orthoptists |Health and Care Professions Council |31 July (31 October) |

|Physiotherapists |Health and Care Professions Council |31 March (30 June) |

|Radiographers |Health and Care Professions Council |31 January (30 April) |

|Biomedical Scientists |Health and Care Professions Council |31 October (31 January) |

|Clinical Scientists |Health and Care Professions Council |30 September |

|Dental Hygienists |General Dental Council |31 December |

|Operating Department Practitioners |Health and Care Professions Council | |

|Opticians |General Optical Council |31 March |

|Chaplains from Church of England/ Catholic|Bishops License |5 yearly |

|Pharmacy Technicians |Pharmaceutical Society of Great Britain |Variable |

|Voluntary Registration can be undertaken in the following fields |

|Finance / Accounting Professionals |CIMA / ACA / AAT |Variable |

|HR Professionals |Chartered Institute of Personnel and Development |Variable |

|Hospital Play Specialists |Hospital Play Staff Education Trust |Variable |

Dates in brackets indicate the date by which the Health and Care Professions Council guarantees to have completed renewal of registration. Registration only lapses after this date.

6. PROCESS

1 New Employees

6.1.1 All potential new staff will have their professional registration status confirmed before being offered a position with the Trust.

2. Confirmation of registration of new staff will be made by the Human Resources Department at the time an offer of employment is made.

3. Human Resources will contact the relevant registration body and request confirmation of the potential employee’s status in accordance with the relevant registration body’s processes.

4. All staff attending interview will be required to provide full registration documents at interview.

5. Staff may be offered a post as a ‘student awaiting PIN’ or equivalent if they have not received confirmation of their professional registration. At this time candidates will need to refer to the Special Conditions paragraph within their contract of employment.

6. During the period prior to registration confirmation, staff may not work in any capacity as a ‘Registered’ Nurse/Midwife or Theatre Practitioner, Radiographer, Pharmacy Technicians.

7. A doctor or dentist may not work until their registration is confirmed via the GMC/GDC however it may be appropriate for an individual to observe for training purposes whilst waiting for registration applied for to come through.

8. It is the line manager’s responsibility to update the information using ESR Manager Self Service, when the individual staff member’s registration is confirmed. This cannot and will not, under any circumstances, be back dated to the starting date.

9. The need for an individual to have professional registration will be stated in the contract of employment.

2 On-going checks during employment

1. Staff have a responsibility to ensure that their professional body renews their registration; in most cases this will involve making a declaration of intention to practice and a payment.

2. Staff are reminded that they must ensure they are registered with their professional body even if they are absent from work due to Sickness, Maternity/Paternity/Adoption leave or Career Break. It is a contractual requirement that staff maintain their professional registration at all times.

6.2.3 The Human Resources Department will run a monthly report using the Electronic Staff Record (ESR) to identify staff whose professional registration/revalidation for Nursing and Midwifery Staff: is due to expire.

4. All relevant staff will be reminded (Appendix A and B) by the Human Resources Department that their registration/ revalidation for Nursing and Midwifery staff is due to expire: one week prior to expiry. A notification will also be sent to the line manager

5. At such time staff will be advised that a failure to renew their registration could lead to the following actions:

• Downgrading to an appropriate unqualified grade until such time as registration is renewed;

• Suspension from work until such time as registration is renewed.

6. The Human Resources Department will check staff registration via the professional body website on the day they are due to expire, where they have failed to renew their professional registration,

7. As staff renew their registrations, ESR will be updated in order to ensure that when the report is rerun, any outstanding expired registrations will be identified. The NMC and GMC automatically updates to ESR, therefore there is no requirement to update ESR manually for those staff registered with this professional body.

6.2.8 Where an individual member of staff has still not renewed their registration and they have not been in contact with the Human Resources Department to advise of any problems, the Human Resources Department will escalate the issue to the individual employee’s Professional Lead and Line Manager.

6.2.9 Whilst it is recognised that some professional bodies allow for a period of grace in relation to renewal of registration, the Trust does not and it is the employees responsibility to ensure their registration is renewed prior to its expiry date.

6.2.10 In circumstances where professional bodies have advised that their on-line registrations are not up to date, staff will be required to produce evidence of their registration to Human Resources department, when requested.

3 In the event of a lapsed registration

6.3.1 Consideration will be given to establish whether a member of staff can work as an unregistered member of staff at the appropriate rate of pay until such time as registration can be renewed.

2. If working at a lower level is not appropriate, staff will be stopped from working and given time to renew their registration. If this is not renewed on the same day, steps will be taken, in conjunction with the Operational HR team, to suspend the staff member without pay until such time as professional registration is renewed.

3. This will not be dealt with as a disciplinary issue if the staff member is able to evidence attempts to renew but there has been an administrative failure by the professional body.

4. Failure to re-register within an agreed time frame will result in the case being escalated, in line with the Trust Policy[1].

5. If the Trust is contacted by a Professional Body and informed that a staff member has been removed from their register, the case will be referred to the Operational HR team and the issue escalated to the individual’s line manager and Professional Lead.

6. In the above circumstances, the staff member will be immediately suspended and the Staff Discipline Policy followed.

6.4 Non-Employees (Agency/Honorary Staff)

6.4.1 All staff supplied by CCS will be checked in line with this policy.

2. All staff booked via a non-CCS agency will be required to provide proof of their registration.

3. For staff booked out of hours via a non-CCS, the agency in question will be requested to fax or scan evidence of professional registration to the Duty Manager booking the worker.

4. All staff undertaking work in an unpaid capacity for the Trust will be checked in line with this policy

5. A audit will be undertaken to ensure that checks are carried out by external agencies as part of the regular external audit on temporary staffing arrangements.

7. TRAINING REQUIREMENTS

7.1 All staff within the Human Resources Team who are responsible for advising managers will receive training as part of their induction, and receive on-going updates in relation to updated Employment Legislation.

7.2 The Human Resources Department will follow guidance as given in this policy and the departmental Desk Top Procedures.

7.3 Trust staff undertaking the role of confirmer for Nursing and Midwifery staff revalidation will be conversant with NMC guidance and have attended Trust training as appropriate.

8. REFERENCES AND ASSOCIATED DOCUMENTATION

Internal

Human Resources Desk Top Procedures

Policy and Protocol on Pre-employment and Employment Checks

Discipline for Staff policy

External Documentation

NHS Employers

Health Circular HC (staff and HSG (94) 43

Data Protection Act 1998

Care Standards Act 2000

Child Protection Act 1996

Criminal Justice and Court Services Act 2000

Gender Recognition Act 2004

Human Rights Act 1998

Immigration, Asylum and Nationality Act 2006

Police Act 1997

Protection of Vulnerable Adults Regulations 2002

The Disability Discrimination Act 2005

The Employment Equality (Sexual Orientation) Regulations 2003

The Employment Equality (Religion and Belief) Regulations 2003

The Employment Equality Age Regulations 2006

The Equality Act 2006 (Gender Equality Duty)

The Race Relations Amendment Act 2000

9. EQUALITY IMPACT STATEMENT

Portsmouth Hospitals NHS Trust is committed to ensuring that, as far as is reasonably practicable, the way we provide services to the public and the way we treat our staff reflects their individual needs and does not discriminate against individuals or groups on any grounds.

This policy has been assessed accordingly

Our values are the core of what Portsmouth Hospitals NHS Trust is and what we cherish. They are beliefs that manifest in the behaviours our employees display in the workplace.

Our Values were developed after listening to our staff. They bring the Trust closer to its vision to be the best hospital, providing the best care by the best people and ensure that our patients are at the centre of all we do.

We are committed to promoting a culture founded on these values which form the ‘heart’ of our Trust:

Working together….

for Patients

with Compassion

as One Team

Always Improving

This policy should be read and implemented with the Trust Values in mind at all times

10. MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS

This document will be monitored to ensure compliance

|Minimum requirement to be monitored |Lead |Tool |Frequency of |Reporting arrangements |Lead(s) for acting on |

| | | |Report of | |recommendations |

| | | |Compliance | | |

APPENDIX A: Registration Renewal Reminder Letter

REGISTRATION RENEWAL REMINDER LETTER

PRIVATE & CONFIDENTIAL

«Initals_» «First_Name_» «Surname»

«Address_Line1»

«Address_Line2»

«Address_Line3»

«Address_Line_4»

«Postal_Code»

Dear

Registration Renewal Reminder

Your registration is due to expire on:      

You may have already taken steps to renew your registration, if so please disregard this letter. According to our records your registration with the       is due to expire on      .

If you have not already re-registered, please ensure that you have contacted the       and provided any requested information along with your payment to ensure that your registration is renewed and does not lapse.

Please note that it is not necessary to contact the Human Resources Department if you have already taken steps to renew your registration.

Yours sincerely

Human Resources Department

APPENDIX B: Revalidation Renewal Reminder Letter

REVALIDATION RENEWAL REMINDER LETTER

PRIVATE & CONFIDENTIAL

«Initals_» «First_Name_» «Surname»

«Address_Line1»

«Address_Line2»

«Address_Line3»

«Address_Line_4»

«Postal_Code»

Dear

Revalidation Renewal Reminder

Your revalidation (App 3) is due on:      

You may have already taken steps to revalidate, if so please disregard this letter. According to our records your revalidation with the       is due to expire on      .

If you have not already re-registered, please ensure that you have contacted the       and provided any requested information along with your payment to ensure that your revalidation is renewed and does not lapse.

Please note that it is not necessary to contact the Human Resources Department if you have already taken steps to renew your registration.

Yours sincerely

Human Resources Department

EQUALITY IMPACT SCREENING TOOL

To be completed and attached to any procedural document when submitted to the appropriate committee for consideration and approval for service and policy changes/amendments.

|Stage 1 - Screening |

| |

|Title of Procedural Document: Registration of Professional Staff Policy |

|Date of Assessment |31 May 2018 |Responsible Department |Human Resources |

|Name of person completing assessment |Susie Lowe |Job Title |Corporate HR Manager |

|Does the policy/function affect one group less or more favourably than another on the basis of : |

| |Yes/No |Comments |

|Age |No | |

|Disability |No | |

|Gender Reassignment |No | |

|Pregnancy and Maternity |No | |

|Race |No | |

|Sex |No | |

|Religion or Belief |No | |

|Sexual Orientation |No | |

|Marriage and Civil Partnership |No | |

|If the answer to all of the above questions is NO, the EIA is complete. If YES,| | |

|a full impact assessment is required: go on to stage 2, page 2 | | |

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|More Information can be found be following the link below | | |

|.uk/ukpga/2010/15/contents | | |

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|Stage 2 – Full Impact Assessment |

|What is the impact |Level of Impact |Mitigating Actions |Responsible Officer |

| | |(what needs to be done to minimise / remove the | |

| | |impact) | |

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|Monitoring of Actions |

|The monitoring of actions to mitigate any impact will be undertaken at the appropriate level |

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|Specialty Procedural Document: Specialty Governance Committee |

|Clinical Service Centre Procedural Document: Clinical Service Centre Governance Committee |

|Corporate Procedural Document: Relevant Corporate Committee |

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|All actions will be further monitored as part of reporting schedule to the Equality and Diversity Committee |

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