Our Policies

This Privacy Policy sets out the data processing practices carried out by Healthwatch Rochdale. If you have any requests concerning your personal information or any queries with regard to these practices, please contact Healthwatch Rochdale by emailing info@healthwatchrochdale.co.uk

Who We Are

Healthwatch Rochdale is the independent consumer champion for health and social care in Rochdale and is a part of Healthwatch England, a statutory committee of the Care Quality Commission. References to “we” or “us” below are to Healthwatch Rochdale.

This privacy statement covers the Healthwatch Rochdale website. This statement does not cover links within this website to other websites.

Information we collect

We collect personal information from visitors to this website through the use of online forms and every time you email us your details.

When you simply browse through the information on this website, it does not store or capture your personal information. We do log your IP address (as it is automatically recognised by the web server) but this is so you can download this website onto your device rather than for any tracking purpose.

We will only collect personal information volunteered by you, such as:

  • feedback from surveys and online forms
  • email addresses
  • preferred means of communication


Please be aware that some systems on our website require the use of cookies, but we will always state if this is the case. We will never collect and store information about you without your permission.
We will always take necessary steps to ensure that your information is protected and treated securely. Any details you give us will be held in accordance with the Data Protection Act 1998 and our data protection policy (part of our overall Information Governance Policy) and code of practice on confidential and personal information.
Healthwatch Rochdale uses Google Analytics, a web analytics service provided by Google, Inc. Google Analytics sets a cookie in order to evaluate your use of our website and compile reports for us on activity on it.

Google stores the information collected by the cookie on servers in the United States. Google may also transfer this information to third parties where required to do so by law, or where such third parties process the information on Google’s behalf. Google will not associate your IP address with any other data held by Google.
By using the website, you consent to the processing of data about you by Google in the manner and for the purposes set out above.
This website uses the Google AdWords remarketing service to advertise on third party websites (including Google) to previous visitors to our site. It could mean that we advertise to previous visitors who haven’t completed a task on our site, for example using the contact form to make an enquiry. This could be in the form of an advertisement on the Google search results page, or a site in the Google Display Network. Third-party vendors, including Google, use cookies to serve ads based on someone’s past visits to the Healthwatch Rochdale website. Of course, any data collected will be used in accordance with our own privacy policy and Google’s privacy policy.
You can set preferences for how Google advertises to you using the Google Ad Preferences page, and if you want to you can opt out of interest-based advertising entirely by cookie settings or permanently using a browser plugin.

Purposes for which we use the information collected

Personal information about you will be used for the following purposes:
• in our day-to-day work;
• to send you our newsletter where you have requested it;
• to respond to any queries you may have;
• to improve the quality and safety of care.
This may include any personal information that you choose to share with us, but we will treat this as confidential and protect it accordingly.
We will never include your personal information in survey reports.

Who we disclose the information to

In order to fulfil our remit, we may disclose the personal information that we obtain through this website to the Secretary of State for Health, other parts of the Care Quality Commission (CQC), Healthwatch England, the NHS Commissioning Board, Monitor and Rochdale Council, and suppliers we engage to process personal information on our behalf.

However, we will only disclose your personal information where we have your consent to do so, or where there is another very good reason to make the disclosure ­– for example, we may disclose information to CQC or a local authority where we think it is necessary to do so in order to protect a vulnerable person from abuse or harm. Any such disclosure will be made in accordance with the requirements of the Data Protection Act 1998.

Wherever possible, we will ensure that any information that we share or disclose is anonymised, so as to ensure that you cannot be identified from it.

How to obtain a copy of the information we hold about you

You have a right to access the personal information we hold about you. To obtain a copy of it, please email us at info@healthwatchrochdale.co.uk  or call 0300 3038811.

Changes to this Privacy Policy

From time to time we may update this Privacy Policy. When we do so we will publish the changes on this website. If you do not agree to these changes, please do not continue to use the website. If material changes are made to this Privacy Policy, we will notify you by email or by placing a prominent notice on the website.

Signing up to our newsletter

We use a third-party supplier to provide our newsletter service. By subscribing to this service you will be agreeing to them handling your data.

The third-party supplier handles the data purely to provide this service on our behalf. This supplier observes the requirements of the Data Protection Act 1998 in how they obtain, handle and process your information and will not make your data available to anyone other than Healthwatch Rochdale.

Complaints Policy

Healthwatch Rochdale Complaints Policy

Purpose of this document

Individuals and organisations have the right to express their views about the performance of Healthwatch Rochdale and the way in which it conducts its business.

Anyone who is dissatisfied with any aspect of the service received by Healthwatch Rochdale can make a complaint under Healthwatch Rochdale complaints policy.

We will treat both concerns and complaints in the same way.

We will review this policy on a regular basis.

This Policy does not cover:

1)            Complaints or concerns about the NHS, which should be dealt with through the NHS complaints procedure.

2)            Complaints about the provision of social care services which should be dealt with by Rochdale Council’s complaints procedure.

How to raise a concern or make a complaint about Healthwatch Rochdale

1)            In the first instance we would encourage you to raise a concern, or complaint, or to provide feedback on our service informally. Providing information or correcting misunderstandings or misconceptions at this early stage may enable the issue to be successfully resolved.

2)            If the concern or complaint is not resolved to your satisfaction, then you should notify us via email, letter or via a telephone conversation with a member of staff or a volunteer.

3)            Healthwatch Rochdale will acknowledge the concern/complaint in writing (or in the complainants preferred method of communication) within 5 working days.

4)            Attempts to resolve the concern/complaint will be completed within 15 working days of establishing the nature of the concern/complaint. Exceptionally, if further time is needed, where possible this will be agreed with you.

5)            The CEO will review all concerns/complaints. If you are not happy with the outcome you will be able to appeal. The concern/complaint will then be reviewed by Healthwatch Rochdale Board members who have not previously been involved in the matter. Once the appeal process has been completed the concern/complaint will closed.

6)            If there is a conflict with the CEO or Chair of Healthwatch Rochdale then the compliant will go straight to the board of directors.

7)            All complaints will be reported to Healthwatch Rochdale’s board during the monthly board meeting.

8)            Healthwatch Rochdale will retain all records on any complaints for 6 years In line with Healthwatch Rochdale’s Document retention policy.

Complaints Policy

Healthwatch Rochdale Complaints Policy

Purpose of this document

Individuals and organisations have the right to express their views about the performance of Healthwatch Rochdale and the way in which it conducts its business.

Anyone who is dissatisfied with any aspect of the service received by Healthwatch Rochdale can make a complaint under Healthwatch Rochdale complaints policy.

We will treat both concerns and complaints in the same way.

We will review this policy on a regular basis.

This Policy does not cover:

1)            Complaints or concerns about the NHS, which should be dealt with through the NHS complaints procedure.

2)            Complaints about the provision of social care services which should be dealt with by Rochdale Council’s complaints procedure.

How to raise a concern or make a complaint about Healthwatch Rochdale

1)            In the first instance we would encourage you to raise a concern, or complaint, or to provide feedback on our service informally. Providing information or correcting misunderstandings or misconceptions at this early stage may enable the issue to be successfully resolved.

2)            If the concern or complaint is not resolved to your satisfaction, then you should notify us via email, letter or via a telephone conversation with a member of staff or a volunteer.

3)            Healthwatch Rochdale will acknowledge the concern/complaint in writing (or in the complainants preferred method of communication) within 5 working days.

4)            Attempts to resolve the concern/complaint will be completed within 15 working days of establishing the nature of the concern/complaint. Exceptionally, if further time is needed, where possible this will be agreed with you.

5)            The CEO will review all concerns/complaints. If you are not happy with the outcome you will be able to appeal. The concern/complaint will then be reviewed by Healthwatch Rochdale Board members who have not previously been involved in the matter. Once the appeal process has been completed the concern/complaint will closed.

6)            If there is a conflict with the CEO or Chair of Healthwatch Rochdale then the compliant will go straight to the board of directors.

7)            All complaints will be reported to Healthwatch Rochdale’s board during the monthly board meeting.

8)            Healthwatch Rochdale will retain all records on any complaints for 6 years In line with Healthwatch Rochdale’s Document retention policy.

Confidentiality Policy
Healthwatch Rochdale Confidentiality Policy
This document sets out Health Rochdale’s policy position in relation to ensuring protection of information on staff, volunteers and Board members such that the integrity of the organisation is maintained.

This document applies to all staff, volunteers, trustees, trainees, consultants and contractors – termed as ‘personnel’ in this document – who undertake, work, duties or tasks on behalf of Rochdale Healthwatch.

Personal information relating to any customer, staff, volunteers or Board members obtained by HWR will not be passed on to anyone outside the organisation without the individuals express consent.
Comments /complaints/remarks or any other information regarding the experiences of the customer will not be directly attributable to the customer unless they expressly wish it.
Customers, staff, volunteers should never be asked personal information in front of others and any interviews relating to personal information should be held in private.

Healthwatch Rochdale is committed to equality and diversity. It will never use any information it receives to discriminate against its members or against the wider community, or for any other purpose than that stated to the person who gave it.
Healthwatch Rochdale is the independent consumer champion. Its work is based upon the gathering of views and experiences of people about health and social care services within and across the area it serves, and then ensuring that those views and experiences are taken into account by the providers and commissioners of health and social care operating within the area. To do this, Healthwatch will be party to and record information that could be considered confidential and in this respect, Healthwatch Rochdale will conduct itself as follows:-
• All meetings, involving personal or sensitive information should be conducted in appropriate surroundings and environment.
• When meeting with an individual or group the personnel conducting the meeting will make clear what will happen with any information given. They must ensure that those taking part are comfortable with how any information given will be recorded and used.
• Reports created by the Healthwatch Rochdale that contain evidence gathered from individuals or groups will not contain the names or any other identifying details of those that took part unless agreed.
• contact details or other personal information about an individual may not be passed on to a third party without the permission of the individual concerned
• Healthwatch Rochdale will not disclose sensitive information to a third party without the individual’s consent except in a situation where there is a considerable or significant risk of harm to an individual or to others, or where there is a legal duty to do so. (See Appendix 1).
• All confidential information will be stored securely in accordance with the Healthwatch Rochdale Data Protection Policy.
• Our Safeguarding Policy will also be taken into account in considering how we maintain confidentiality.
• At all meetings, internal and external to the organisation, where confidential information is discussed personnel will respect the bounds of confidentiality of that meeting, whether this be regarding an individual, commissioning or services.
Breaching Confidentiality
• If personnel are unsure whether a breach of confidentiality needs to occur, then they must discuss the matter with the Healthwatch Rochdale CEO, who will then make a decision as to whether to proceed further in reporting the matter to any authorities.
• Any information passed to the CEO for possible confidentiality breach will be assessed according to the Human Rights Act 1998, the Public Disclosure Act 2012, and any other relevant legislation.
• Should a breach of confidentiality be required then the Healthwatch Rochdale CEO will pass the information on to the appropriate body.
• Any confidential information passed to the CEO that is assessed as not needing to be passed on under these acts will be destroyed or stored appropriately.
Anyone who is unhappy with something that the organisation or personnel has done or said or who suspects that a breach of confidentiality has occurred may use the complaints procedure to lodge a complaint with Healthwatch Rochdale. Any complaints made using the policy will be treated with the utmost confidentiality and only those directly involved with investigating the complaint will know the identity of the complainant.

Appendix 1 legal provisions regarding confidentiality
Human Rights Act 1998
Article 8.2 of the Act makes a provision for organisations to breach confidentiality only if it satisfies the following three conditions:-
• Be in accordance with the law;
• There must be a proper legal basis, such as a piece of legislation or rules of a professional body;
• Must pursue the following identified legitimate aims:
• acting in the interests of national security, public safety or the economic well-being of the country;
• acting for the prevention of disorder or crime;
• acting for the protection of health or morals;
• acting for the protection of the rights and freedoms of others.
The Public Disclosure Act 2012
The Public Disclosure Act 2012 establishes a responsibility for all organisations to disclose information to the appropriate bodies regarding the following:-
• A criminal offence;
• Failure to comply with legal obligations;
• A miscarriage of justice;
• Danger to health or safety of any individual;
• Any damage to the environment;
• An attempt to cover up information that would provide evidence that any of these five practices occurred.

Data Protection Policy

Healthwatch Rochdale Data Protection Policy


Under the Data Protection Act 1998, Healthwatch has a responsibility to ensure that all data it holds on individuals or groups must only be held for valid reasons and must be held in a safe and secure manner.  It also gives the individual the right to know what information is held about them. The purpose of this document is to establish a clear and agreed understanding of what HWR will do to meet this responsibility.


This document applies to all staff, volunteers, trustees, trainees, consultants and contractors – termed as ‘personnel’ in this document – who undertake, work, duties or tasks on behalf of Rochdale Healthwatch.


Information Systems include all electronic data bases and paper based systems.

Not disclose Personal Data to any person other than to employees and sub-contractors to whom disclosure is necessary for the performance of the Service


The Data Protection Act, states that anyone who processes personal information must comply with eight principles, which make sure that personal information, is;

  • Fairly and lawfully processed
  • Processed for limited purposes
  • Adequate, relevant and not excessive
  • Accurate and up to date
  • Not kept for longer than is necessary
  • Processed in line with the rights of Data Subjects
  • Secure
  • Not transferred to other countries without adequate protection

The second area covered by the Act provides individuals with important rights, including the right to find out what personal information is held on computer and most paper records.


ï‚·            The Healthwatch Rochdale will take all reasonable steps to ensure that personal data held by the organisation is accurate and kept up to date. Personnel should always contact the HWR Officers should your personal information change for any reason, for example a change of surname, home address or telephone number. Out of date information or information that is no longer required will be deleted by HWR on a regular basis.

ï‚·            Healthwatch Rochdale is committed to the secure storage and where undertaken the secure transmission of all personnel’s personal data. Only members of staff within HWR have access to such data. All such data is protected by physical security, such as locks and technical security, such as usernames and passwords to access computer records and data. Such data is only disclosed on a “need to know” basis. To further ensure the security of such records the HWR reserves the right to monitor and keep detailed log file and computer data analysis of all accesses to all personnel’s personal data.

ï‚·            Personnel are reminded that unauthorised attempts to gain access to such data or accessing such data may constitute a criminal offence under the Data Protection Act 1998.

ï‚·            Where HWR uses third parties to process data and provide services or administer schemes around such data HWR will take reasonable steps to ensure that such third parties have in place their own data protection policies.

ï‚·            HWR maintains a database of contact details for its members and of those who have asked to be kept informed of its work. All details are stored by HWR which acts as the data controller.

ï‚·            Any information stored within the contact database is with the knowledge and consent of those to whom it relates, or is taken from the public domain where that person has freely placed it.

ï‚·            HWR respects people’s rights to privacy and to their right to change their mind about having their information kept in the contact database. Anyone wishing to know what information is stored about them within the contact database may do so by contacting HWR. Anyone wishing to have their information removed from the contact database may do so by contacting HWR. This will amount to ending membership of  Healthwatch. All requests must be in writing via an email to the official HWR email address or by post to Healthwatch Rochdale at the official office address.

ï‚·            Healthwatch Rochdale only uses the information stored within its contact database to pass on information relating to its work. HWR will not pass on any confidential information from its contact database without consent from the person to whom the information relates. Consent to pass on details of members have to be in written form, sent either by email or by post and only from the consenting member. Where there is dispute about consent, HWR may request proof of identification to be given.

ï‚·            Should HWR as constituted cease to be involved in the delivery of the service, then confidential information held by it will only be passed on to any other organisation with the consent of those to whom the information relates. Should permission not be given for this information to be passed on then it will be destroyed.


  1. Configure systems to store confidential and sensitive data in a secure manner:

             Where possible, data encryption should be used for all confidential data at rest.

             Data encryption solutions should be centrally managed.

             Paper based systems to be in locked cabinets with designated access by HWR Officers.

  1. Positively dispose of data that is no longer required:

             Use software or hardware delete functions to remove non-confidential data from systems once that data is no longer required.

             Use dedicated media wiping solutions to permanently remove confidential data from systems once that data is no longer required.

             Use secure disposal of paper based information.

  1. Configure systems to transmit confidential and sensitive data in a secure manner:

             Where possible, encrypted tunnels should be used for all electronic data transmissions.

             Where encrypted tunnels cannot be used for electronic data transmissions, data should be directly encrypted prior to transmission and/or password protected.

             Recorded or personal delivery by HWR Officers for paper based transmission.

  1. Configure systems to restrict and validate data input:

             Data should only be input by those with appropriate access and permissions.

             Inputted data should be checked for accuracy, authenticity, completeness and validity.


Breach of any of the constraints of these policies or procedures will be considered a security breach and depending on the nature of the breach, various sanctions will be taken:

             A minor breach may result in disciplinary action in line with Healthwatch Rochdale policies and procedures.

             Multiple minor breaches or a major breach may result in suspension.

             Multiple major breaches may result in termination of employment/volunteer placement

Document Retention Periods

No Information Retention Period
1 Business Incorporation Documents Indefinitely
  Insurance Records Indefinitely
2 Staffing Records –     Current Staff      Leaver Files During period of employment annually reviewed for outdated information

7 years post employment

3 Recruitment Information –

Unsuccessful Candidates      Successful Candidate

Destroy 1 year post recruitment Add to staff file
4 Disciplinary Records For the disciplinary period only
5 Health and Safety Records 7 years after case closed
6 Invoices and Receipts 6 years plus the current year
7 Payroll Records 6 years plus the current year
8 Banking Records 6 years plus the current year
9 Complaints 6 years
10 Legal and Litigation information 7 years after action completed
11 Contract information 6 years post contract
12 Service Level Agreements 6 years post agreement
13 Tenancy Agreements 6 years post agreement


Enter & View policy

Enter and View Policy


The Local Government and Public Involvement in Health Act 2007, makes provision about the establishment of LINks and also includes provisions relating to LINks ability to enter and view services. This information is revised in the Health and Social Care Act (2012), which makes provision about the establishment of local Healthwatch Rochdale (HWR), and therefore includes provisions relating to local HWRs right to enter and view services.

To enable HWR to carry out their activities effectively there will be times when it is helpful for authorised representatives to observe the delivery of services and for them to collect the views of people whilst they are directly using those services.

Correctly conducted and coordinated visits, carried out as part of a constructive relationship between a local HWR and organisations commissioning or providing health and social care services which may support ongoing service improvement. HWR’s role is not to seek out faults with local services, but to consider the standard and provision of care services and how they may be improved.

This code of conduct applies to any HWR work stream involved in planning or carrying out a visit to enter premises and view the delivery of services. It also applies to staff employed to support HWR, who may be involved in the planning and review of such visits.

Legal Framework

HWR shall act in accordance with the following legislation:

  • Data Protection Act 1998
  • Freedom of Information Act 2000
  • Health and Social Care Acts 2007 and 2012
  • The Information Sharing Agreement between Healthwatch England, Care Quality Commission and Local HWR.


HWR is committed to ensuring that anyone who represents the organisation or acts or speaks on its behalf, operates according to the Nolan principles of selflessness, integrity, objectivity, accountability, openness, honesty and leadership.

Furthermore, in respect of any visits to enter and view health and social care premises, HWR is committed to ensuring that:

  • the rights of patients, service users, staff and residents are respected and protected as are those of the authorised representatives undertaking the visit
  • visits are conducted in a spirit of openness and partnership between HWR, the provider of the service and the individuals receiving the service
  • relationships and dialogue between HWR, providers and the wider population remains positive and constructive

Adherence to this policy is essential in order to ensure that HWR remains a trustworthy and credible organisation able to fulfill its purpose.


  1. Services and premises that HWR can enter and view

The Government has introduced duties on certain commissioners and providers of health and social care services to allow authorised representatives of Local HWR to enter premises that providers own or control (with some exceptions), to observe the nature and quality of services.

In the context of the duty to allow entry, the organisations or persons concerned are:

  • NHS Trusts
  • NHS Foundation Trusts
  • Clinical commissioning s
  • Local Authorities
  • a person providing primary medical services (e.g. GPs)
  • a person providing primary dental services (dentists)
  • a person providing primary ophthalmic services (opticians)
  • a person providing pharmaceutical services (e.g. community pharmacists)
  • a person who owns or controls premises where ophthalmic and pharmaceutical services are provided
  • bodies or institutions which are contracted by Local Authorities or NHS Trusts, CCGs, NHS England


  1. Services and premises that HWR cannot enter and view

However, the Government believes that some exclusions from the duty to allow entry are essential. Therefore, the duty to allow entry does not apply in the following circumstances:

  • if the visit compromises either the effective provision of a service or the privacy or dignity of any person
  • if the premises where the care is being provided is a person’s own home (this does not mean that an authorised representative cannot enter when invited by residents – it just means that there is no duty to allow them to enter)
  • where the premises or parts of premises are used solely as accommodation for employees
  • where the premises are non-communal parts of care homes
  • where health and social care services are not provided at the premises (such as offices) or where they are not being provided at the time of the visit (for example when facilities and premises are closed)
  • if the visit is to observe any activities which relate to the provision of social care services to children, since there are already effective measures in place to scrutinise and oversee children’s social care
  • If in the opinion of the provider of the service being visited, the authorised representative, in seeking to enter and view its premises, is not acting reasonably and proportionately.


  1. Authorised Personnel

Only authorised HWR enter and view panel members may make a visit to enter and view premises and services on behalf of HWR.

The processes by which a HWR volunteer may become an authorised enter and view volunteer is detailed in the volunteer policy. In summary, the HWR board will be responsible granting authority. This authority will be delegated down the CEO of HWR.  Authorisation will be granted for a fixed term and will be reviewed periodically.

Once authorisation is granted, that panel member must undergo induction training and any other training deemed necessary by the HWR board before he/she may carry out a visit. On completion of such training, that panel member will receive an identity card, which may be used as proof of authority to enter and view premises on behalf of HWR.

Authorised representatives must only enter and view premises when carrying out the activities of HWR. A list of members of the panel who are authorised to enter and view premises and services on behalf of HWR will be made public both on the website and in the annual report within 3 months of training being received.

  1. Expectation of Authorised Personnel

HWR expects such authorised representatives to:

  • only carry out visits which have been organised by staff employed to support HWR and on instruction from a HWR board
  • clearly display their HWR identity card when carrying out a visit
  • treat staff, service users, residents, patients, their carers and families fairly, courteously, and with sensitivity and respect
  • ensure that the dignity and privacy of service users, residents patients, carers, families and staff are maintained at all times
  • be as unobtrusive as possible, and inform staff on duty about what they are doing at each stage of the visit
  • value people as individuals, respecting the different and diverse people they meet;
  • exhibit no discriminatory behaviour
  • have respect for individual confidentiality, not disclosing confidential or sensitive information unless there is a genuine and urgent concern about the safety and wellbeing of a user, resident or patient, or if the individual concerned consents to the sharing of the information
  • cooperate with requests from staff, users, residents, patients carers and their families if necessary, and comply with all operational or health and safety requirements
  • avoid interrupting the effective delivery of health or social are provision; authorised representatives should refrain from making unreasonable demands on staff, users and patients or disrupting services outside the agreed visiting schedule
  • recognise that user, resident or patient needs should always take priority
  • be guided by staff where operational constraints may deem visiting activities inappropriate or mean that staff are unable to meet the requests of the authorised representative
  1. Decision to make a visit

The decision to make a visit will be made by a HWR Board

  • Any visit instructed by a Board must:
  • be appropriate to the scope and remit of that particular Board
  • be reasonable and appropriate to the type and size of service being observed
  • be intended to gather information that is not available through some other source
  • have some genuine contribution to the work of that Board
    • In deciding to arrange a visit, the Board will:
  • Establish whether any other visits are being planned around the same time by, for example, care regulators or foundation trust governors, and whether the visits could be coordinated
  • Refer to any information HWR has already received about the service, including comments received from service users or their families, user s or forums
  • Refer to any public information about the service, such as:
  • Regulators monitoring and recommendations
  • Overview and Scrutiny Committee reviews and recommendations
  • Complaints information
  • Patient and Public Involvement and/or Patient Advice and Liaison Service intelligence held by the relevant premises being visited
  • Research into recommended practice/national minimum standards/core standards for the particular service area, numbers of staff, beds, activities, therapies, etc
  • Research the specific types of care provision to be observed in order to sufficiently understand methods deployed in different care environments and with different patient and user s, for example, people with dementia, people with challenging behavior, people who are close to death, etc



  • When deciding the format of the visit, the Board should:

think through the aim and desired outcomes of the visit

agree how the objectives of the visit will be achieved, for example:

  • by talking to staff, service users, patients – with their agreement – including meeting the user forum (where one exists) to hear their views
  • by observing the general interaction between staff, users and patients
  • by noting environmental aspects of the care setting
  • decide whether a particular service or specific aspect of a service should be the focus of the visit and whether the visit needs to be made at a specific time to coincide with certain activities

consider whether the visit should be announced or unannounced; although legislation allows for a local HW to make both announced and unannounced visits the duty to allow entry does not apply in circumstances where a visit is not reasonable and proportionate or would compromise the privacy or dignity of patients. HWR is aware that unannounced visits run the risk of being refused entry on these grounds, and so a Board may only instruct an unannounced visit when it considers that the standards of service would be significantly different than if observed as part of an announced visit.

consider the number of authorised representatives that is appropriate to visit; in arranging a visit, HWR will ensure that the number of authorised representatives is proportionate to the size of the establishment, with a minimum of two representatives being present at any one visit

identify any special support needs necessary to facilitate the visit for example, the use of interpreters, signers, advocates or private rooms

identify whether a specific mix of authorised representatives is appropriate to the setting to be visited (in terms of gender and diversity)

agree and allocate topics of enquiry to visiting representatives in advance;

agree an approach for collating and writing up notes and producing draft findings from the visit including whether additional concerns or complaints raised during the visit should be included with the overall outcomes and recommendations

  • Staff employed to support HWR will support the board in reaching a decision about when to make a visit, whether it should be announced or unannounced and how it may be planned.


  1. Arranging a visit

Once HWR board has reached a decision, staff employed to support HWR will make arrangements for the visit, including briefing the authorised panel members who will conduct the visits and, in the case of announced visits, liaising with the service or premises concerned.

  1. Pre-Visit Briefing

Staff employed to support HWR will brief authorised panel members who will be conducting a visit, on behalf of the Board. This briefing will include:

  • an overview of why the visit is being made and what the Board hopes to achieve from the visit
  • the place, date, time and expected duration of the visit
  • any supporting information about the service or premises which will help them to carry out the visit
  • the names of other authorised panel members or participants with whom they will be conducting the visit
  • details of the shape and format of the planned visit, for example
  • the staff, service users, and user forums that they will meet
  • the number and nature of discussions/meetings to take place and any special arrangements that have been made, such as communication aids or special access to buildings
  • the types of activities and service areas to be observed
  • whether they will have any HWR literature to distribute during the visit
  • whether staff and/or service users will accompany them during the visit and (if appropriate) their names and positions
  • details of questions to ask or points to check and how responses/outcomes will be recorded
  • how the Board and HWR as a whole will use information from the visit


  1. Liaising with Care Providers

Staff employed to support HWR will brief authorised panel members who will be conducting a visit, on behalf of the Board. This briefing will include:

  • an overview of why the visit is being made and what the Board hopes to achieve from the visit
  • the place, date, time and expected duration of the visit
  • any supporting information about the service or premises which will help them to carry out the visit
  • the names of other authorised panel members or participants with whom they will be conducting the visit
  • details of the shape and format of the planned visit, for example
  • the staff, service users, and user forums that they will meet
  • the number and nature of discussions/meetings to take place and any special arrangements that have been made, such as communication aids or special access to buildings
  • the types of activities and service areas to be observed
  • whether they will have any HWR literature to distribute during the visit
  • whether staff and/or service users will accompany them during the visit and (if appropriate) their names and positions
  • details of questions to ask or points to check and how responses/outcomes will be recorded
  • how the Board and HWR as a whole will use information from the visit


  1. Preparing a Visit Report

The Enter and View panel which conducts a visit on behalf of HWR will document their findings in a written report that clearly reflects the reasons for the visit being undertaken and how any information / evidence meets the visit objectives.

The visit report will identify sources of information / evidence and the weight assigned to it, taking care, of course, always to respect confidentiality. Such sources could include:

  • authorised representatives’ observations
  • discussions with staff
  • discussions with users
  • comments from carers and/or relatives
  • structured interviews
  • documentation provided by staff/the proprietor

The visit report will be factual and offer a balanced assessment of the service. In line with national best practice, a copy of the visit report will be provided to the care provider and allow them a minimum of ten working days to check for factual accuracy and make any additional comments.

  1. Preparing a recommendations report

The HWR Board that instructed the visit will receive a copy of the visit report, together with any comments from the care provider and any formal or informal notes taken as part of the visit. It will then make a decision about how to use the findings alongside other information available to the Board; at this stage, the Board may decide to prepare a recommendation report, or it may decide that further research is required before a recommendations report can be prepared.

In either case, once a recommendations report is produced it will include a full description of the role and scope of the Board, why it was established and what work it has done in order to reach the conclusions and recommendations it is making. This will include details of the visit and the visit report, as well as any other research or information that the Board has taken into consideration in making the recommendations.

HWR will send a copy of the recommendations report to the care provider who was subject to the visit and will ask them to respond to the recommendations within ten working days. This timescale is in line with national guidance from the Department of Health.

  1. Sharing the report with other organisations

HWR will use information from all reports to inform the overall picture of service being provided for the local community, what is being done really well, examples of good practice, and whether and how the needs and preferences of the community are being met. HWR will make all of its reports public (taking care to respect the confidentiality of individuals and proactively share them with other organisations as appropriate. Such organisations may include:

  • Commissioners of services – to ensure that the intelligence gathered by HWR concerning the needs and preferences of the local community can be appropriately considered as part of the commissioning process
  • Overview and Scrutiny Committee – it is not anticipated that this will be a routine occurrence, but in certain circumstances it could be appropriate, depending on:
  • the OSC’s planned programme of scrutiny
  • whether particular services have significantly deteriorated or improved
  • whether particular services have regularly failed to respond to recommendations for changes or improvements
  • whether service users and others have reported specific areas of concern that it would be appropriate for an OSC to follow up
  • Care regulators – HWR may wish to send findings from a specific visit to a regulator in circumstances where serious concerns are raised about patient safety, or the quality of care, and it would be appropriate for the regulator to decide if further action should be taken outside of the routine assessment of services. Alternatively, HWR may want to draw to the regulators’ attention an example of excellent service.
  • Other statutory bodies – HWR may wish to alert their findings to another statutory body such as the Health and Safety Executive or the Food Standards Agency for further inspection

In rare, extremely serious, cases, where criminal activity or abuse is suspected, HWR should also consider contacting the police or referring the matter to the commissioning body’s safeguarding officer.

In all cases, in coming to a decision about whether to refer matters to other organisations, HWR should consider whether it is reasonable and proportionate to do so based on the evidence, and take care to maintain confidentiality.

  1. Breaches of this Enter and View Code of Conduct

All reports of action outside of this Enter and View Code of Conduct will be investigated according to the HWR Complaints Procedure and remedial action sought as follows:

12.1 Enter and View panel members authorised to conduct visits

If a panel member who is authorised to conduct visits on behalf of HWR is found to have breached any part of this Enter and View Code of Conduct, they must step down from their role of enter and view volunteer immediately.

Substantial or repeated breach of any part of this Code of Conduct may result in removal from HWR. This will be at the discretion of the HWR board, whose decision is final.

12.2 Care providers

Care providers are not bound by the terms of this Enter and View Code of Conduct but such organisations are subject to legislation concerning how they work with HWR.

HWR expects care providers to consider this document as a guiding tool for a strong and positive relationship with HWR in relation to making visits to enter premises and view service delivery.

If HWR considers that a care organisation is not adhering to the spirit of this document, it will, in the first instance raise the matter according to that organisation’s complaints procedure. If HWR considers that a care organisation is in breach of any legislative duties upon it, it will seek to resolve the matter through official channels.

Equality & Diversity Policy

Equality and Diversity Policy and Procedure


This policy aims to outline Healthwatch Rochdale Rochdale’s commitment to ensuring equality of opportunity and equal treatment for all staff, volunteers and board members in terms of employment and access to services and to provide guidance on anti-discriminatory practice.  This policy is non-contractual. This policy will be reviewed on an on-going basis and amended in line with new developments in Equality and Diversity best practice.

Healthwatch Rochdale’s commitment to anti-discriminatory practice relates to any type of discrimination.

Legal Framework 

Healthwatch Rochdale shall act in accordance with the following legislation:

  • Equalities Act 2010


The policy applies to employees directly employed by Healthwatch Rochdale, to workers employed via agencies, contractors in terms of employment, directors/board members, volunteers, service users and the general public in terms of service provision.  The policy applies specifically to discrimination and equality of opportunity in respect of ‘protected characteristics’ as defined in the Equalities Act 2010

  • Age
  • Disability
  • Race
  • Sex
  • Religion or cultural beliefs
  • Gender reassignment
  • Marital status and civil partnership
  • Sexual orientation
  • Pregnancy and maternity


Healthwatch Rochdale values its staff and volunteers and expects them to be treated in a respectful manner.  Accordingly, everyone has a responsibility to treat others with dignity and respect.  The Healthwatch Rochdale CEO is responsible for providing advice and guidance on equality and diversity issues, and to ensure the Policy document is kept up to date.


Healthwatch Rochdale is committed to valuing diversity and working with equality as a core value, Healthwatch Rochdale aims to:

  • Promote equality of opportunity
  • Celebrate and value diversity
  • Eliminate unlawful direct and indirect discrimination

Healthwatch Rochdale will provide equality of opportunity and equal treatment as an integral part of good practice.  The organisation is committed to a working environment in which the contribution and needs of everyone are fully valued and recognised.

It will support staff, volunteers and members in not tolerating any inappropriate, violent or abusive behaviour from colleagues, other organisations or clients.

General purpose

Healthwatch Rochdale’s practices will ensure that staff, volunteers, service users and the general public will not be discriminated against on any grounds including age, disability, race, sex, religion or cultural beliefs, gender reassignment, marital status and civil partnership, sexual orientation, pregnancy and maternity.


  1. Employment Practices

Healthwatch Rochdale aims to promote equality and diversity as an employer and to ensure that no job applicant, volunteer applicant or employee receives less favourable treatment or is disadvantaged by conditions or requirements that cannot be shown to be justifiable in the context of the policy.

Selection, recruitment, training, promotion and employment practices will be subject to regular review to ensure that they comply with the Diversity and Equalities Policy.  All training opportunities will be published widely to all appropriate employees and not in such a way so as to exclude particular groups.

Healthwatch Rochdale regards discrimination, abuse, harassment, victimisation or bullying of staff, volunteers, clients or others in the course of work as disciplinary offences that could be regarded as gross misconduct.



  1. Healthwatch Rochdale as a Service Provider

In developing its services and publicity materials, Healthwatch Rochdale will seek to ensure that access is equitable for all.  This will include, wherever practicable, making specific access arrangements for people with disabilities or learning difficulties, or any other protected characteristic which may apply, such as religion and belief.  Healthwatch Rochdale will attempt to ensure that none of its policies discriminate directly or indirectly against any group or individual.

  1. Our aims

Healthwatch Rochdale fully supports the principle of equality and diversity. It aims to encourage, value and manage diversity and recognises that talent and potential are distributed across the

population. Not only are there moral and social reasons for promoting equality of opportunity, it is in the best interest of this organisation to recruit and develop the best people for our jobs from as wide and diverse a pool of talent as possible.

Healthwatch Rochdale recognises that certain groups and individuals in society are oppressed and disadvantaged due to discrimination directed against them. In all its work Healthwatch Rochdale will work to remove any barriers, bias or discrimination that prevents individuals or groups from realising their potential and contributing fully to our organisation’s performance and to develop an organisational culture that positively values diversity.

When listening to communities and individuals Healthwatch Rochdale will make every effort to understand the context in which people live their lives.  Where understanding is more difficult Healthwatch Rochdale staff and volunteers will be supported in respectfully seeking information.

Those people experiencing discrimination may experience particular issues when accessing health and social care services. When working with partner organisations Healthwatch Rochdale will be aware of discriminatory practice and how this may manifest itself. Staff and volunteers will be supported in bringing any issues to the attention of partner organisations. Whenever practical and possible Healthwatch Rochdale will support public sector organisations in undertaking Equality Impact Assessments.

Discrimination operates through commonly held assumptions and prejudices, which are reinforced by laws, rules and customs.  This makes discrimination appear normal and inevitable.  Discrimination works by stereotyping people into different roles, by treating some people worse than others, or simply by ignoring them.

All forms of discrimination are unacceptable, regardless of whether there was any intention to discriminate or not. Staff and volunteers have a duty to co-operate with Healthwatch Rochdale to ensure that this policy is effective in ensuring equal opportunities and in preventing discrimination. Employees and volunteers should draw the attention of their line manager to suspected discriminatory acts, practices or cases of bullying or harassment.

Healthwatch Rochdale recognises that the promotion of equal opportunities requires more than passive opposition to discrimination; it is therefore committed to taking positive action towards equality of opportunity, recognising that the limited resources and the operational needs of the organisation may impose justifiable restrictions upon our ability to take such action.

  1. Complaints

Healthwatch Rochdale will treat seriously any complaints of unlawful discrimination on any of the stated grounds made by employees, volunteers, clients or third parties and will take action where appropriate.

All complaints made by external parties will be investigated in accordance with Healthwatch Rochdale’s Complaints Procedure and the complainant will be informed of the outcome.

In the event of an investigation concerning a complaint against an employee, the Grievance Policy and Procedures will be followed and any action necessary dealt with under Disciplinary Procedure.

Escalation Policy

Escalation Policy & Procedure

  1. Why have an Escalation Policy & Procedure?

The escalation process is a formal process that has been established to allow Healthwatch Rochdale (hereafter HWR) to share with Healthwatch England issues about health and social care services that HWR is unable to resolve locally and that it proposes Healthwatch England takes forward. A formal process is in place so that Healthwatch England can log and respond to issues escalated from HWR. It also allows Healthwatch England to assess whether an issue is indeed one that is best taken up by Healthwatch England or if it is something that can be better resolved through additional signposting and support to HWR.

This policy is a statement of intent and will be implemented as a procedure in accordance with Healthwatch England’s guidance.

  1. What can be done to avoid escalation?

HWR aims to work in partnership with health and social care services and whenever possible to facilitate a culture of collaborative working in the best interests of the local community. During the course of its work, however, there may be times when HWR wish to voice concerns about a service provider, commissioning decision or unmet need. On these occasions HWR will exhaust all local avenues for resolution before escalating an issue to Healthwatch England. These include:

  • Trying to resolve the issue directly with the commissioner and/or service provider, including (if unresolved) escalating the issue to the Chief Executive or other NHS or Local Authority directors
  • Identifying a local charity or campaign group who is already focusing on the issue and is better-placed to lead on it because of their knowledge and expertise
  • Contacting the Care Quality Commission or the appropriate regulatory and seeking their advice and support
  • Bringing the issue to the attention of the Health Overview Panel
  • Consulting with other local Healthwatch to see if anyone else has already tackled something similar
  • Contacting Healthwatch England to find out if the issue is best dealt with at a national level without the need for a formal escalation
  • If appropriate, contacting local MPs or local media to leverage action on the issue
  • What are the reasons for escalation?
  • There are two reasons why HWR will escalate an issue to Healthwatch
  • A local issue that HWR has not been able to resolve at a local level
  • A local issue that is irresolvable locally as it relates to national policy and cannot be addressed at a local level

If the issue is related to a safeguarding concern it must be addressed in accordance with HWR’s Safeguarding Policy & Procedure.

  1. How to escalate an issue?

HWR can escalate an issue via the web form www.healthwatch.co.uk/escalation, which will require the provision of the following information:

  • Date of escalation
  • Description of the issue being escalated and the reasons why
  • Details of how the issue come to the attention of HWR
  • Other organisations involved in the issue
  • Related reports or recommendations
  • Evidence to show what HWR has done to resolve the issue locally
  • Expectations of Healthwatch England
  1. What happens next?

5.1 Reporting and Safeguarding

After an escalation notification is received by Healthwatch England it is screened for any safeguarding issues. HWR should resolve any safeguarding issues prior to escalating a case but Healthwatch England retains this double-check.

5.2 Screening

The case is then checked against the escalation criteria. If it does not meet the criteria HWR will be contacted by the Healthwatch England development team who will provide support to resolve the issue locally. If local action still does not lead to a resolution, the issue can be re-submitted as an escalation.

5.3 Investigation

Each escalation case will be designated a single point of contact within Healthwatch

England. This person will coordinate investigation of the case, remain in contact with

HWR and advice on next steps. At this point the case will be taken up by the intelligence and policy teams within Healthwatch England. The intelligence team will look at how widespread the issue is within the Healthwatch network and will also look at whether there is any other relevant national data on the issue. The policy team will undertake some basic research to understand how the issue could be resolved e.g. what national policy does the issue relate to, who is affected by the issue, which stakeholders are involved, who is involved in funding/commissioning/service provision.

5.4 Actions

Based on the research and intelligence gathered, a recommendation will be made as to how Healthwatch England can push for the issue to be resolved. Actions could include:

  • Using the issue as evidence if it relates to a wider piece of Healthwatch England work
  • Informally or formally raising the issue with a statutory body
  • Using Healthwatch England’s information or advisory powers with a statutory body or Secretary of State
  • Carrying out media work to gain traction on the issue
  • Carrying out more in-depth investigation on the issue e.g. focus groups with specific consumer groups
  • Taking forward the issue in a Healthwatch England special report/inquiry/thematic brief

5.5 Timelines

A definitive time line for the escalation process cannot be set out as each escalated case is unique and takes varying amounts of research and action to resolve. HWR should however expect an automated response when the e-form is submitted; an acknowledgment that the escalated issue has been received and is being processed within one week of submission, and an initial response from the lead person who will be investigating the case within two weeks. If there has been a surge in cases, or if there is any other reason why the investigation of HWR’s case will be delayed, this should be indicated in the acknowledgement HWR will receive within one week of submission. Once the case has been taken up by a lead person they will be in regular communication with HWR to update on progress. Any queries during any stage of the process HWR can contact the lead

person within Healthwatch England or contact


  1. References

The following publication was used to produce this document:

Healthwatch England: Escalation Process, 2014

Governance Policy

Healthwatch Rochdale Governance Policy


This document sets out how Healthwatch Rochdale (hereafter HWR) will carry out its governance. Good governance is critical to the success of HWR, particularly as it is an organisation embedded in a diverse community, which engages with a large number of people, many of whom volunteer their time to participate in the work of HWR. Consequently it is essential that HWR is a credible body and is run in an open and transparent manner, legally compliant and financially sustainable. This document aims to show how good governance will enable HWR to be seen as a publically accountable body that advocates on behalf of the community by working in partnership with local stakeholders such as the voluntary and community sector, NHS Trusts, Rochdale Metropolitan Borough Council (RMBC) and Heywood, Middleton and Rochdale Clinical Commissioning Group (HMR CCG) and in so doing maintain its independence.

About HWR

Healthwatch Rochdale is here to make improvements in Health and Social Care services for ordinary people. We believe that the best way to do this is by designing local services around their needs and experiences.

Healthwatch Rochdale gives the opportunity for residents of the Borough to have a powerful voice locally and nationally. At a local level, Healthwatch Rochdale will work to help people living in the Borough of Rochdale get the best out of their Health and Social Care services, whether it’s improving them today or helping to shape them for tomorrow.

Healthwatch Rochdale is the public’s voice and we promote the value the general public could have, to shape delivery and design of local services. Not just people who use them now, but anyone who might need to in the future.

As a company limited by guarantee HWR is regulated by its Memorandum of Association and as such is governed by a Board of Directors (who are also referred to as board members).

The objects of the company are the advancement of health and the relief of those in need including by reason of youth, age, ill-health, disability or financial hardship primarily for the population of Rochdale by:

  • Provide an opportunity for people living in the Borough of Rochdale to be involved in local and national Health and Social Care issues.
  • Become the single point of contact for members of all communities who need information and advice about Health and Social Care services.
  • Help individuals to help themselves whilst providing any additional help needed to understand and access the support available.
  • Be recognised and trusted by the local community, to ensure they feel confident that in sharing any views, concerns and experiences, both positive and negative, they can help to make a difference.
  • Build strong relationships with other organisations and networks and ensure that those who make decisions on health and social care are aware of local views and concerns.
  • Maximise the use of the input and expertise of volunteers.

The powers and duties of the company are set out in full in the Memorandum of Association and this document aims to ensure that governance arrangements are fit for purpose and proportionate to the nature and scale of HWR business. Appendix 1 details the Standing

Orders that HWR will use to conduct its business openly and transparently.

Legal Framework

Section 221 of the Local Government and Public Involvement in Health Act 2007 as amended by the Health and Social Care Act 2012 details the activities that HWR must carry out to fulfil its statutory duties, such as:

  • Promoting and supporting the involvement of local people in the commissioning, the provision and scrutiny of services
  • Obtaining the views of local people regarding their needs for, and experiences of, services and to make these views known to commissioners and providers of services
  • Enabling local people to monitor the standards of provision of services and whether and how services could and ought to be improved
  • Making reports and recommendations about how services could or ought to be improved which should be directed to commissioners and providers of services and people responsible for regulating services such as the Care Quality Commission(CQC)
  • Providing advice and information about access to services so choices can be made about services
  • Formulating views on the standard of provision and whether and how services could and ought to be improved, and sharing these views with Healthwatch England

An annual report, as directed by the Secretary of State, must be produced in relation to these activities at the end of each financial year, which must include details of expenditure.

HWR has a number of statutory rights that are related to the governance of other statutory bodies. The Local Authority (Public Health, Health and Wellbeing Boards and Health Scrutiny) Regulations 2013 state that HWR can escalate a matter relating to the planning, provision and operation of the health service in its area, for review and scrutiny, to the Health Overview Panel of RMBC, which must acknowledge receipt and keep HWR informed of any action it takes.

The Health and Social Care Act 2012 states HWR has a right to attend RMBC’s Health and Wellbeing Board and the National Health Service (Quality Accounts) Regulations 2010

3 (amended 2012) state that NHS service providers such as an NHS Trust must send HWR a draft version of their Quality Account by 30th April, which HWR may wish to provide a statement that has to be included in the appendix of the Quality Account. In accordance with the National Health Service Act 2006, if an NHS Trust is found to be financially unsustainable then the regulator Monitor will appoint a Trust Special Administrator who must offer to meet HWR and ask for a written response.

Critical features of good governance

The Board of Directors (hereafter Board), as the governing body, must act in accordance with the following good governance features:

  • Clarity of purpose and priorities
  • Clear, effective and transparent decision making processes
  • Clarity of roles, responsibilities and accountabilities
  • Effective strategic relationships
  • Robust performance management and financial governance

What this will mean in practice is that HWR will implement the highest standards of Propriety involving impartiality, integrity and objectivity in relation to the stewardship of public funds, the management of the organisation and the conduct of its business. This will include adopting behaviours as published by the Committee on Standards in Public Life (1995) known as the ‘Nolan Principles’ as set out in the Code of Conduct and acting in accordance with the Equality Act 2010 and Freedom of Information Act 2000. Anyone will have the right to express their views about the governance of HWR and the way it conducts its business by providing feedback, raising a concern or making a complaint.

Governance is a formal role and the Board of Directors require the appropriate mix of skills, knowledge and experience relative to the powers and duties set out in the Memorandum of Association to ensure due diligence. This requires HWR to have Directors:

  • With adequate time and ability to invest in the organisation
  • Whose values and goals are aligned with those of the organisation and have a balance of personalities
  • With specialist knowledge and skills such as governance, IT, finance, legal and other professional areas that will broaden the expertise of the Board
  • With diverse and relevant areas of expertise and experience that can provide a range of insights and perspectives and are complementary to the activities of the organisation
  • Who have connections with key stakeholder groups that the organisation seeks to engage and influence

The Board should be expected to develop and adapt in line with the needs of the organisation. This will involve reviewing strategic direction, the role of the Board, active affiliates and the staff team, including and most importantly identifying opportunities to increase public involvement.

The principle aim of HWR’s governance structure and operational arrangements is to maximize participation from the public in the actual carrying out of HWR’s statutory functions. Consequently it is vital the Board and the staff team have the skills and expertise to engage with the public so that they can:

  • Inform people about services that affects them by providing balanced and objective information
  • Consult with people so that they have a direct say about decisions and services that affects them
  • Involve people in the co-production of services including allowing people to see for themselves the results of their participation
  • Collaborate with people so that alternatives to service delivery can shape service development (i.e. supporting grassroots led initiatives)
  • Empower people to have a say in final decision making such as allowing communities to take action for themselves

In accordance with good governance, HWR will provide the public with opportunities to participate in processes for involving them in making relevant decisions. This will include:

  • Board meetings in public
  • Task Group or other HWR project groups
  • Stakeholder and community engagement activities
  • Focus groups
  • Surveys, questionnaires and consultations

Maintaining independence

HWR needs to be independent and accessible to all sections of the community. Specifically to be seen by the public as part of the community they live in and able to reflect the experiences that they have shared about services. To maintain this independence requires

HWR to behave in a particular way that enables it to listen to the voice of the community carefully and impartially. It is independence of purpose, voice and action which should set HWR apart from the statutory structures it works within, enabling it to effectively deliver its statutory functions as the consumer champion for health and social care.



Board of Directors

Term of Office

If a board member wishes to resign they must ensure before doing so that there is enough remanding board members remaining to continue the governance of the Healthwatch Rochdale Board.

In order to ensure a fresh and dynamic approach for Healthwatch Rochdale, no board member will be able to remain on the Board for more than2 terms of office- 10 years.   In this instance a board member must stand down for at least one year prior to re-applying as a Board member.  Honorary Office bearers will need to stand down from office after a maximum of 5 years, with a statutory gap of one year prior to being able to hold an Honorary Office position once more. Ex staff members have to be out of employment under Healthwatch Rochdale for 12 months prior to them applying for a position on the board. Board members can apply for a second term of office with agreement from the board members.

Removal from Office

Additional to being removed from office under any relevant legislation, Healthwatch Rochdale wish to make it clear that it is possible to remove a board member from office in the following circumstances:

  • A board member does not attend three consecutive Board meetings (Exceptions will apply in the area)
  • A Board member contravenes any of the Healthwatch Rochdale policies
  • Removal from office will be discussed by the Healthwatch Rochdale board members.

Roles and Responsibilities of Healthwatch Rochdale Board members

The Roles of a Board of Board members

  • The Board of Board members is the governing body of an organisation and it holds the ultimate power and responsibility. Boards are made up of volunteers who have to set aside their personal interests giving their time and carrying out their duties for no payment. However, you should not be out of pocket financially for the work that you do.  The organisation benefits from the objectivity such a board brings as well as the skills and experience of its members.
  • Board members are not often permanent – some board members have an unlimited term of office but many will need to stand for re-election or take a break at least every 5 years.

Board members and Management

The success of Healthwatch Rochdale depends to a large extent on the way board members discharge their managerial responsibilities.  Within Healthwatch Rochdale the day to day management is delegated to the Chief Executive Officer.

It is important that the focus of board membership should be on governance rather than management.  Governance is concentrating on setting policy and longer term strategy, and monitoring and evaluation performance and progress.

The Board’s duty is to act in the interest of the local population of the Borough of Rochdale.  It should ensure that Healthwatch Rochdale has a clear direction and purpose and a sense of urgency to get on with the work it was established to so.  The Board’s duty is to set the strategic direction Healthwatch Rochdale, ensuring that the organisation lives up to its shared vision, aims, and values.  Board members will be responsible collectively for the governance and strategy of Healthwatch Rochdale.

Please see appendix 2 Scheme of delegation for CEO

The Board’s role is to:

  • Ensure that all Healthwatch Rochdale’s activities are within the law
  • Develop and agree organisational policies and review regularly.
  • Develop and agree the organisational strategic plan
  • Monitor financial performance
  • Ensure the organisation has adequate resources
  • Ensure the organisation’s assets and other resources are protected and managed
  • Ensure accountability as required by law
  • Review annually the performance of the Board of Board members
  • Act within the powers as set out in the [name of the organisation’s governing document e.g. constitution].
  • Appoint staff
  • Act as a court of appeal on personnel matters
  • In order to carry out its role the board must
  • Meet as often as necessary for the proper administration of the organisation
  • Seek professional and expert advice where necessary

Sources of help and advice

Board membership is about working together.  No matter what happens, you will always have to try to get along with your fellow board members: this means listening to others board members and advisors, saying what you think and accepting the majority decision.

Keeping up to date on the facts – To do your job properly will involve finding out about the organisation – its services, staffing, future plans, what might affect its services and future funding opportunities and risks.

Healthwatch Rochdale is committed to providing ongoing training for both its staff and volunteers. Board Members are encouraged to join local and national networks.


The following publications were used to produce this document:

  • Local Government Association: Establishing Local Healthwatch (Governance), 2012
  • Local Government Association: Delivering effective local Healthwatch (key success features), 2013
  • Local Government Association: Local Healthwatch Outcomes and Impact
  • Development Tool, 2013
  • Local Government Association: Local Healthwatch Governance (a self-assessment toolkit), 2015
  • The King’s Fund: Local Healthwatch (progress and promise), 2015
  • Healthwatch England: Understanding the Legislation, 2015
  • Healthwatch England: Maintaining Independence, 2015
  • Healthwatch England: Draft Quality Statements, 2015


Appendix 1

Standing Orders

  1. Introduction

1.1 These Standing Orders set out the rules and procedures by which the Healthwatch

Rochdale (HWR) Board will conduct its business. They should be read in conjunction with HWR’s Memorandum of Association, which they complement.

1.2 The Chair of the Board of Directors has a duty to ensure all Directors understand their responsibilities. These Standing Orders, as far as they are applicable, apply with appropriate alteration to meetings of any sub-committee established by the Board.

1.3 At any meeting, the Chair of the Board of Directors must have the final decision on the interpretation of these Standing Orders.

  1. Interpretations and Definitions

2.1 These Standing Orders are made pursuant to the Health and Social Care Act 2012.

Any expression to which a meaning is given in the Act or in Regulations made under it shall have the same meaning in these Standing orders, unless the context requires otherwise. In addition:

“Board” means the Healthwatch Rochdale’s Board of Directors, which consists of a Chair and Directors.

“Chair” is the person appointed to ensure that the Board successfully discharges its overall responsibility for the work of HWR. The Board may also choose to elect a Deputy or Vice Chair(s). Where appropriate the expression the “Chair” shall be taken to refer to the Deputy or Vice Chair, if the Chair is absent from the meeting or otherwise unavailable.

“CEO” is the senior HWR employee accountable to the Chair for the range of HWR business. The CEO is invited to sit with the Board and has the right to participate in, but not vote on, Board proceedings. At the time of writing the CEO is an employee of Healthwatch Rochdale

  1. Composition of the Board

3.1 The Chair and Directors of the Board

3.1.1 The Board will comprise the Chair and a minimum of two other board members, no maximum number is provided in the Memorandum of Association

3.1.2 The process of recruiting and appointing directors will be determined by the Board. The appointment of the Chair and, if deemed necessary, Deputy or Vice Chair(s), will be by a simple majority of the Director’s present at a relevant meeting determined by the Board.

3.1.4 The Chair is appointed for three years in the first instance, renewable once.

3.1.5 In appointing Director’s, the Chair is responsible for:

  1. Ensuring as far as possible that all Directors have relevant skills, knowledge and experience in order to discharge the Board’s functions under section 45A of the Health and Social Care Act 2012.
  2. Ensuring that the process of appointment is transparent and in accordance with criteria laid down by the Commissioner for Public Appointments’ Code of Practice.
  3. Having regard to the need to encourage diversity in the range of people appointed

3.1.6 The term of appointment of each director will be confirmed in the letter of appointment. Directors may be reappointed for a further term but are not eligible for further appointment until a term has elapsed.

3.2 Termination of Appointment

3.2.1 A Director may resign at any time by giving notice in writing to the Chair.

3.2.2 A person ceases to be a director as soon as:

  • A bankruptcy order is made against that person
  • is made with that person’s creditors generally in satisfaction of that persons debts:
  • a registered medical practitioner who is treating that person gives a written option to the company stating that the person has become physically or mentally incapable of  acting as a director and may remain so for more than three months;
  • by reason of that person’s mental health, a court makes an order which wholly or partly prevents that person form personally exercising any powers or rights which that person would otherwise have;
  • notification is received by the company from the director that the director is resigning from office, and such resignation has taken effect in accordance with its terms.
  1. Conduct of Directors

4.1 Directors must act in accordance with the provisions of the Memorandum of Association and act in the best interests of HWR.

4.2 Directors are required to comply with HWR’s Code of Conduct and act in accordance with other policies and procedures relevant to their role as a Director.

  1. General Meetings of the Board

5.1 Convening General Meetings

5.1.1 Subject to the Memorandum of Association general meetings of the Board will be held at such times and places as the Board may determine.

5.1.2 The Board need not but may hold an annual general meeting.

5.1.3 The Chair may call a general meeting of the Board at any time, provided 14 clear days’ notice is given.

5.3 Notice of General Meetings

5.3.1 Before each general meeting of the Board, a notice of the general meeting, specifying the business proposed to be transacted at it, must be delivered to ever Director or sent by post, e-mail or fax to the correspondence address supplied by them, at least 5 Clear Days before the day of the general meeting. Supporting papers will, wherever possible, accompany the agenda.

5.3.2 The business of the general meeting will not be invalidated where any member fails to receive notification.

5.3.3 In the case of a general meeting being called by the Director in default of the

Chair, the notice must be signed by those Directors and no business can be transacted at the general meeting other than that specified in the notice.

5.3.4 Before each public general meeting of the Board, a public notice of the time and place of the general meeting, and the public part of the agenda, must be displayed on the HWR website at least five working days before the general meeting.

5.4 Chairing General Meetings

5.4.1 At any general meeting of the Board, the Chair, if present, will preside.

5.4.2 If the Chair is absent, or is disqualified from participating, the Deputy Chair will preside or, in the Deputy Chair’s absence a Director chosen by the Directors will preside.

5.4.3 The decision of the Chair of the general meeting on questions of order, relevancy, regularity and any other matters will be final.

5.5 Quorum for General Meetings

5.5.1 The quorum for director’s meetings may be fixed from time to time by a decision of the directors, but it must never be less than two, and unless otherwise fixed it is two, these numbers are in addition to the Chairman of the meeting.

5.5.2 If the persons attending a general meeting within half an hour of the time at which the meeting was due to start are not constitute a quorum, or if during a meeting a quorum ceases to be present, the chairman of the meeting must adjourn it.

5.5.3 The chairman of the meeting must adjourn a general meeting if directed to do so.

5.6 Voting

5.6.1 The general rule about decision-making by directors is that any decisions of the directors must be either a majority decision at a meeting or a decision taken during a unanimous decision.

5.6.2. If-

  • the company only has one directors, and
  • no provision of the articles requires it to have more than one director,

The general rule does not apply, and the director may take decisions without regard to any of the provisions of the article relating to directors decision making.

5.6.3 A decision of the directors is taken when all eligible directors indicate to each other by any means that they share a common view on the matter

5.6.4 If the number of votes for and against a proposal are equal, the chairman or other director chairing the meeting has a casting vote.

5.6.5 But this does not apply if, in accordance with the articles, the chairman or other director is not to be counted as participating in the decision making process for quorum or voting process

  1. Setting the Agenda

6.1. The Chair will set the agenda for each general meeting.

6.1.1 The agenda will be sent to the directors at least 5 Clear Days before the meeting and supporting papers will accompany the agenda, but will certainly be dispatched no later than three Clear Days before the meeting

6.1.2 It is within the discretion of the Chair of a general meeting to allow urgent items not on the published agenda to be discussed at the relevant general meeting. The reasons for allowing such action should be indicated by the Chair.

6.2 Record of Attendance

6.2.1 The names of the Chair and directors present at the general meeting must be recorded in the minutes.

6.3 Minutes

6.3.1 the directors must ensure that the company keeps a record, in writing, for at least 10 years from the date the decision is recorded, of every unanimous or majority decision taken by the directors.

  1. Conflicts of interest

7.1. If a proposed decision of the directors is concerned with an actual or proposed transaction or arrangement with the company in which a director is interested, that director is not to counted as participating in the decision-making process for quorum or voting purposes.

7.1.1 All conflicts of interested should be announced at the beginning of each board meeting and minutes taken on the conflict relating to any agenda items

7.1.2 The CEO will, at least annually, in March of each year, ask directors to confirm their interests for inclusion on the Register of Conflicts of Interests maintained by them. Nevertheless, directors should inform the CEO of any changes in their interests as they occur, both for the purposes of updating the Register and, if necessary, for formal reporting to the Board.

Appendix 2

CEO Scheme of Delegation

Healthwatch Rochdale board of directors delegate the day to day operational running of Healthwatch Rochdale to the CEO. Below is a list of reserved decisions that the board hold responsibility for:

Decisions reserved for the board

  1. Alterations to constitution and rules, membership and governance structures
  2. Appointment of board members; appointment of honorary officers; setting terms of reference for board committees and working groups
  3. Setting the scheme of delegation and standing orders (including finance and contracts)
  4. Approving and signing the annual report and accounts
  5. Agreeing the scope, timetable and process for internal policy review
  6. Agreeing the organisation’s values, vision and mission
  7. Approving the overall strategy and strategic direction
  8. Approving the high level budget and any significant in-year changes to projected outturn
  9. Agreeing the organisation’s performance framework and the scope, timetable and process for performance monitoring
  10. Approving and when appropriate (depending on level of risk) developing and negotiating formal partnerships and collaborations
  11. Setting the principles for taking organisational ‘policy positions’ and where significant

(depending on level of risk) agreeing and approving them

  1. Approving the employment contract and agreeing any alterations to salary scales, terms and conditions
  2. Approving significant changes to the management structure and senior management roles
  3. Any other decision when:-
  • it sets a precedent
  • it could be considered a significant reputational issue
  • it could damage relationships with our members or stakeholders
  • it could be viewed as not ‘party politically’ neutral

Guiding principles for delegation

The scheme of delegation:

  • Should be driven by risk
  • Decision making should be at the lowest level possible, conducive to risk
  • Should recognise statutory responsibilities
  • should support timely decision making
  • should recognise distinctive roles of board governance, and execution by management
  • Should be supportive and add value to decision making
  • The board cannot delegate its legal responsibilities
Healthwatch Rochdale Code of Conduct


The code of conduct applies to ALL Healthwatch Rochdale volunteers whichever volunteer role that they are undertaking. It also applies to staff working on behalf of the Healthwatch Organisation and is based on the Nolan Principles of Public Life. The Code of Conduct applies to all types of activity undertaken on behalf of Healthwatch Rochdale and the methods of communication used by volunteers and staff including verbal, electronic, written and body language.

The Code of Conduct will:

  • Create a positive environment for the Healthwatch Organisation to develop within and for staff and volunteers to work.
  • Ensure that all volunteers can contribute to the work of Healthwatch Rochdale effectively and are treated with respect and courtesy.
  • Provide guidance to Healthwatch Rochdale representatives, (support staff and volunteers), and others about what is expected of their behaviour and actions during any activity they undertake on behalf of the organisation.
  • Create a core set of values that will underpin the behaviour, actions, attitudes and decisions of Healthwatch Rochdale staff and volunteers at all times.

Key principles of the Code of Conduct

All Healthwatch Rochdale representatives agree to uphold the following principles (based upon the Nolan Principles of Public Life):


Healthwatch Rochdale representatives undertake not to make assumptions based upon their own personal response to what they see or hear, when communicating with volunteers of the public on behalf of Healthwatch Rochdale. Any activity undertaken on behalf of Healthwatch Rochdale will be for the benefit of the organisation, not the individual, and information will be discussed and shared on that understanding, not making comparisons to one’s own experience but purely listening to the information shared and providing sign posting information where possible to support the person to access individual help if required.


Healthwatch Rochdale Representatives agree to act appropriately and treat people equally with respect and courtesy at all times.  This applies to any member of the community and other Healthwatch Rochdale volunteers and support staff, it is important for Healthwatch Rochdale Representatives to be sensitive to issues of cultural diversity and of difference in general when representing Healthwatch Rochdale.

Accountability and Openness 

Healthwatch Rochdale Representatives are accountable to the Healthwatch Rochdale Board, the public and to all appropriate scrutiny bodies for any decisions and actions they take during engagement activities.  Therefore all dealings as a Healthwatch Rochdale representative must be fair, open and transparent and bound by this code of conduct.


Healthwatch Rochdale representatives have a duty to declare any private and professional interests they have that relate to their public duties with Healthwatch Rochdale where there may be a conflict of interest (financial or otherwise).  In this case Volunteers need to act honestly and withdraw from any engagement activity that may create any conflicts, in order to protect the public interests of the Rochdale Community.

Objectivity and Best interests

Healthwatch Rochdale Representatives will act only in the best interests of the Rochdale people in their engagement activities, promoting public confidence in Healthwatch Rochdale, and accurately representing the different views of residents and their relatives when reporting their discussions.

All decisions about the Healthwatch Rochdale Representatives engagement work plan will be made on merit and in the public interest, signed off by the Healthwatch Rochdale Chair and Board volunteers, providing a rationale for the choice of engagement activities to be carried out.


Healthwatch Rochdale Representatives must not place themselves under any obligation, financial

or otherwise to a person or organisation that may influence their performance, decisions or actions on behalf of Healthwatch Rochdale. All Healthwatch Rochdale Representatives having access to sensitive information or working with vulnerable people, training will be provided to ensure these individual cases are dealt with appropriately.

Representatives undertaking certain roles will attend refresher training sessions as requested to

help consolidate their skills and develop mentorship roles towards newly trained Healthwatch Rochdale Representatives. The frequency of refresher training required will be identified within the volunteer roles that people choose to undertake.


Healthwatch Rochdale Representatives will take responsibility for promoting and supporting

these principles and leading by example in order to maintain and strengthen both the public’s

trust and confidence, and that of regulators and commissioners, in the integrity of the

Healthwatch Rochdale in conducting public business through engagement activity within the

local community.


Equality and diversity

Healthwatch Rochdale places great emphasis on understanding, acceptance and appreciation of individual differences.  As such, Healthwatch Rochdale Representatives will treat everyone they are in contact with in the course of their engagement activities with dignity and respect, recognising the value of each individual and their experience.  Healthwatch Rochdale expects volunteers to demonstrate attitudes and behaviours which support this position and will not tolerate discrimination by Healthwatch Rochdale volunteers arising from, (but not limited to), employment status, ill health, social exclusion, ethnic origin, gender, disability, age, sexuality and religion.

Acting as a Healthwatch Rochdale Representative

Any role undertaken by a person representing Healthwatch Rochdale, including any potential contact with the media, must be authorised first by the Healthwatch Rochdale Board and includes an obligation to represent the best interests of Healthwatch Rochdale and the wider community, rather than their own individual views and experiences. There is a further obligation to provide feedback whenever such activity should occur, to support staff for reporting to the Governing Board.  When speaking on behalf of Healthwatch Rochdale as a representative, comments will reflect Healthwatch Rochdale priorities and policies even when these do not reflect personal views and no information must be divulged unless the support staff team is in possession of evidence to back up any statements made.


Volunteers and support staff will respect all confidences they are party to as a Healthwatch Rochdale representative and will not divulge third party confidences without their agreement or that of the Healthwatch Rochdale Board, in line with governing or local safeguarding policies and the law on data protection.

Healthwatch Rochdale Representatives will hear personal information in the course of discussions during engagement activity and shall treat this with the highest confidentiality.  Healthwatch Rochdale Representatives will abide by the regulations of the Data Protection Act which governs the use, handling and storage of personal information that may be held in Healthwatch Rochdale’s database.

Law, Healthwatch Rochdale values and policies

Healthwatch Rochdale Representatives must behave lawfully at all times and not act in disregard of Healthwatch Rochdale policies, procedures and code of conduct in their relationships with anyone they come into contact with when acting in this role.

Participation in Community Engagement Activities

It is an acknowledged fact that Healthwatch Rochdale Representatives will bring their own views and opinions to role, however none of this should in any way affect any decisions made with

regard to their work as a Healthwatch Rochdale Representative. Any community engagement work carried out by Healthwatch Rochdale Representatives should be authorised and organised by the Governing Board and support staff team as part of the work plan. Reports of any discussions or information shared during such activity, should be made to the support staff verbally or in

writing following any engagement in order to enable support staff to add the information to the Healthwatch Rochdale database.

Community engagement activity will be carried out with support from staff wherever possible to

ensure that Healthwatch Rochdale Representatives have access to the support and information they

may require when acting on behalf of the organisation.

Breach of Code

Any breach of this Code of Conduct will be dealt with by the Healthwatch Rochdale Board and may necessitate a review of the Healthwatch Rochdale Representatives’ role, including possible removal from the Healthwatch Rochdale Representatives register, or even suspension of volunteering from all Healthwatch Rochdale activities, depending upon the severity of the breach.

Joint Safeguarding Policy

Safeguarding Policy


This document sets out Healthwatch Rochdale’s policy position in relation to the Safeguarding of Children and of Vulnerable Adults both those who use Healthwatch Rochdale’s services directly and those who contact us for advice and support.  The document also sets out the support system that is in place for Healthwatch Rochdale staff and volunteers who may recognise and be required to respond to safeguarding situations in the course of their duties.


This document applies to all staff, volunteers, trustees, trainees, consultants and contractors – termed as

‘personnel’ in this document – who undertake, work, duties or tasks on behalf of Healthwatch Rochdale.


A vulnerable adult is defined as:

  • a person aged 18 years and over “who is or may be in need of community care services by reason of mental or other disability, age or illness”
  • one who is or may be unable to take care of him or herself or unable to protect him or herself against significant harm or exploitation (No Secrets, 2000)

The safeguarding of children relates to:

  • Children and young people below the age of 18
  • Protecting children from maltreatment
  • Preventing impairment of children’s health or development
  • Ensuring that children are growing up in circumstances consistent with the provision of safe and effective care
  • Undertaking that role so as to enable those children to have optimum life chances and enter adulthood successfully.

Abuse relates to:

“A violation of an individual’s human and civil rights by any other person or persons” (No Secrets 2000). Abuse is behaviour towards a person that causes him or her harm, distress, endangers life or violates their rights.


Healthwatch Rochdale recognises that we have a particular role to play in terms of protecting adults and children who, for many different reasons, may be vulnerable.

We have a duty and a role in supporting and enabling children and adults and/or their advocates to deal with any abusive or safeguarding situation they are experiencing.

In addition, the nature of Healthwatch Rochdale’s work means that we are sometimes made aware of situations where an absence or failure of services has safeguarding implications.


Healthwatch Rochdale is committed to the implementation of the Rochdale Council Safeguarding Adults Policy and Procedure, and Child Safeguarding Policy and Procedure and to any periodic revising of these Policies and Procedures.

Healthwatch Rochdale has its own internal procedure (see below) for dealing with cases where safeguarding may be a concern. This Procedure should be seen as a first step and as dovetailing with the wider safeguarding programme in Rochdale.

Rochdale Healthwatch recognises its role within the Rochdale Council Procedures as an ‘alerting’ organisation and is committed to ensuring that alerts are reported following recognised procedure and within stipulated timescales.

This Policy covers five distinct circumstances where Rochdale Healthwatch may become involved in a safeguarding issue:

  • Where an allegation of abuse or a safeguarding issue is made against a member of Healthwatch Rochdale’s personnel.
  • Where an allegation of abuse is made or a safeguarding issue raised by the alleged victim against another alleged perpetrator. For example an unpaid carer, family member, friend, neighbour, acquaintance or paid carer from another organisation or agency.
  • Where an allegation of abuse or a safeguarding issue is made by someone other than the alleged victim (the reporter) against another alleged perpetrator.
  • Issues of self-neglect or the inability of a person to meet their own basic needs.
  • Instances where an absence or failure of services has potential safeguarding implications for the person involved.

Healthwatch Rochdale recognises that conflicts may arise between maintaining confidentiality, discharging our responsibilities under the Safeguarding Policy and Procedures and our duty of care to our personnel. This Policy sets out the circumstances when it may be appropriate to break a person’s confidentiality and this includes whenever a safeguarding allegation or concern is raised and it has not been possible to gain permission to make an alert from the alleged victim.

It is also recognised that personnel may be asked to provide information to the Safeguarding Team as part of an ongoing investigation not triggered by an alert from us.  In all such instances the CEO must be consulted before details are divulged.

Healthwatch Rochdale is committed to providing initial training for staff and volunteers on the principles of safeguarding for vulnerable adults and children and the implementation of Healthwatch Rochdale’s Safeguarding Procedures.

Healthwatch Rochdale commits to reviewing its Safeguarding Policy and Procedure at least annually.

Refresher training for staff and volunteers will be undertaken on an annual basis or following a change of procedure or as otherwise required.


1 Point of Disclosure 

  • A concern may arise either as a result of a direct disclosure or (more commonly) as a result of an individual reporting a broader problem or issue concerning their experiences of accessing health and social care. In either case, when the procedure to follow is;
  • The staff member/volunteer should;
  • Make clear to the reporter that s/he has a concern
  • Make clear s/he may have an obligation to report the concern.
  • Complete the Incident Record Form
  • Take contact details for the reporter (including an address)
  • Make clear notes of the discussion
  • Explain the reporting process that will be followed; in the first instance to Healthwatch Rochdale’s CEO, and then, if she feels it appropriate, to the relevant authorities
  • If at all possible obtain consent to discuss with other relevant organisations (although we are not dependent on consent if an issue is recognised a safeguarding issue, obtaining consent will allow Healthwatch Rochdale to raise any issues with the relevant operational bodies and thus seek resolutions to the situation.

1.3 All incidents must be reported as soon as possible to the CEO or a designated deputy.

2) Decision-making, reporting and escalations

2.1 The CEO and/ or their designated deputy and the Chair will discuss the concern, where possible the staff member/volunteer who has referred the matter will be party to these discussions.


2.2 The CEO will make decisions on reporting, referrals and escalations of the issues raised based on Healthwatch Rochdale’s responsibilities in law, the duties of local Healthwatch and the best interests of the person about whom the concern is raised.

2.3 If a safeguarding issue is identified by this meeting then reports will be made, in writing (email) and in a timely manner, to the relevant Safeguarding Teams.

3) Follow –up and monitoring

3.1 In keeping with Healthwatch Rochdale’s practice in regards to following up issues raised, Healthwatch Rochdale will receive assurances about the next steps from the safeguarding team.

3.2 Where possible and appropriate, the relevant staff member will contact the original reporter to explain these next steps.

4) Record keeping,

4.1) Personnel will keep accurate records as follows:

  • Log of contacts
  • Summary of the issues, identifying the potential safeguarding concerns and
  • Log of the steps taken.
  • Reporting Officers must be careful to record concerns in a way that replicates, as closely as possible, the words of the reporter.


4.2) All records relating to safeguarding issues will be kept securely in accordance with the requirements of the Data Protection Act.

4.3) The CEO will provide a report of all Safeguarding alerts, escalations or enquiries to the Board Trustee Members of Rochdale Healthwatch on a quarterly basis at the normally held Board Meetings.


4.4)  Any trends, issues or omissions obtained from these reports are to be addressed through Healthwatch Rochdale’s internal procedures and external work with relevant providers, commissioners and other public authorities.

Whistle blowing Policy

Whistle Blowing Policy and Procedure


Whistleblowing encourages and enables employees to raise serious concerns within the organisation rather than overlooking a problem or ‘blowing the whistle’ outside.

Employees are often the first to realise that there is something seriously wrong with a service that is being provided. However, they may not express their concerns as they feel that speaking up would be disloyal to their colleagues or to the organisation.

Legal Framework

Healthwatch Rochdale shall act in accordance with the following legislation:

– Public Interest Disclosure Act 1998


Healthwatch Rochdale is committed to the highest possible standards of openness, probity and accountability. In line with that commitment, it expects Healthwatch Rochdale board members, volunteers and staff employed to support Healthwatch Rochdale and other members of the public or agencies that it deals with, to come forward and voice any serious concerns about any aspect of the Healthwatch Rochdale work. It is recognised that in most cases it will have to proceed on a confidential basis.

This Whistle Blowing policy makes it clear that anyone who has a serious concern can voice it without fear of victimisation, subsequent discrimination or disadvantage. This policy is intended to encourage and enable people to raise serious concerns within Healthwatch Rochdale rather than overlooking a problem or ‘blowing the whistle’ outside.

The policy aims to:

  • Encourage confidence in raising concerns and to question and act upon concerns about practice.
  • Provide avenues to raise concerns in confidence and receive feedback on any action taken.
  • Ensure responses to concerns and an awareness of how to pursued if an outcome is not satisfactory
  • Reassure that individuals will be protected from possible reprisals or victimisation if they have a reasonable belief that a disclosure is in the public interest


  1. Concerns covered by this policy

The Whistle Blowing policy is intended to cover major concerns that include:

  • Conduct which is an offence or a breach of law.
  • Failure to comply with a legal obligation.
  • Disclosures related to miscarriages of justice.
  • Health and safety risks, including risks to the public as well as other employees.
  • Damage to the environment.
  • The unauthorised use of public funds.
  • Possible fraud and corruption.
  • Sexual, physical or other abuse of clients.
  • Other unethical conduct.
  • Actions which are unprofessional, inappropriate or conflict with a general understanding of what is rights and wrong.

The Healthwatch Rochdale CEO will ensure the maintenance and operation of this policy and that a record of concerns raised and the outcome (in a form, which protects confidentiality) is recorded.

  1. Raising a concern

2.1 The process for raising a major concern under this Whistle Blowing policy is as follows:

Concerns must be recorded, either by the person raising the concern or by a member of the staff team using the agreed pro forma. The staff member will deal with the concern accordingly, raising the issue with the Healthwatch Rochdale CEO or and Healthwatch Rochdale Chair if necessary. An appropriate course of action will be agreed following discussions with the whistle blower.

If it is a safeguarding issue then the matter must be dealt with as a matter of urgency.

2.2 The decision to raise a concern under this Whistle Blowing policy should not be taken lightly. However, the earlier a concern is raised, the easier it will be for Healthwatch Rochdale to take action.

2.3 If someone raises a concern, they do not have to prove beyond doubt the truth of an allegation, but reasonable grounds for the concern must be demonstrated.

  1. Responses to Concerns

Healthwatch Rochdale will investigate and respond in a timely manner.  A response can be expected within ten working days if that is not possible, an update should be provided every ten working days until resolution. Where appropriate, the matters raised could be referred to the police or another appropriate body.

In order to assure the person who raised the concern that the matter has been properly addressed Healthwatch Rochdale will (subject to legal constraints) inform them of the outcome of any investigation.

  1. Confidentiality

All concerns will be treated in confidence and every effort will be made not to reveal the whistle blower’s identity if required.  5. Anonymous allegations

  1. Anonymous allegations

This policy encourages the whistle blower to put their name to their allegation whenever possible. Concerns expressed anonymously are much less powerful but will be considered at the discretion of Healthwatch Rochdale. In exercising this discretion, the factors to be taken into account would include:

  • the seriousness of the issues raised
  • the credibility of the concern
  • the likelihood of confirming the allegation from attributable sources


  1. Harassment and victimisation

Healthwatch Rochdale recognises that the decision to report a concern can be a difficult one to make. Healthwatch Rochdale will not tolerate any harassment or victimisation (including informal pressures) and will take appropriate action to protect anyone who raises a concern in good faith.

  1. Untrue allegation

If an allegation is made in good faith, but it is not confirmed by the investigation, no action will be taken against the person who raised the concern. If, however, an allegation is made frivolously, maliciously or for personal gain then Healthwatch Rochdale will take the matter very seriously and it will be considered a breach of the Healthwatch Rochdale Code of Conduct.

  1. Raising concerns outside Healthwatch Rochdale

This policy is intended to provide an avenue to raise concerns within Healthwatch Rochdale. However, if someone wishes to raise a major concern and feels it is appropriate to do so outside Healthwatch Rochdale, they may do so by contacting:

  • Local Council
  • Citizens Advice Bureau
  • Relevant professional bodies or regulatory organisations such as Care Quality Commission or Healthwatch Rochdale England
  • Relevant voluntary organisation
  • Police

If concerns are raised to any of the above agencies Healthwatch Rochdale request information to be shared with HWR CEO Or HWR Chair when it is appropriate to do so.