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New Trust Policies and Procedures

14 December 2016

The HR Directorate has released the first tranche of new and revised policies taking effect in December 2016. 

The HR Directorate is pleased to release the first tranche of new and revised policies to take effect from December 2016. 

We would like to thank Staffside and management for the tremendous care and effort they have invested in helping us to revise the existing documents and to create new policies.  We hope they will provide clarity and guidance, and underpin good, collaborative employee relations.

There will be opportunities to attend sessions to familiarise yourself with the policies but in the meantime, any queries should be directed to your line manager, HR or union representative in the first instance, or to Barbara Macanas (Senior HR & Policy Manager) or Karen Lavender (Employee Relations & Policy Manager).

These policies and procedures are available to download here




It is important with all the new technology at our finger tips, to have clear, reasonable guidelines for employees on acceptable and appropriate use of social networking and social media platforms. 

The policy sets out the Trust’s and employees’ responsibilities and duties to patients, colleagues, third parties and the general public, and how to avoid disclosing confidential or private information.  It explains the actions the Trust will take where behaviour falls below expected standards and how to raise concerns about misuse of social media.

Please note: we are calling an amnesty on this policy until 1 February 2017.  Please ensure you understand the requirements, remove any material from social media which may breach the policy and adhere to the policy in the meantime and going forward.

Inappropriate and unacceptable comments, behaviours, content and images are defined.  Breach of confidentiality, privacy and information security are explained and examples are given of social media disclosures that may compromise a person’s right to privacy. 



These guidelines provide a framework within which investigating managers can plan and carry out an impartial investigation, gathering and analysing all evidence and providing a balanced and objective report of the findings.

They explain the role of the commissioning manager, the investigating manager and the importance of an investigation plan.  They provide key points for the investigating manager, guidance on preparing and conducting investigation interviews and how to accommodate reluctant witnesses, and a template for the investigation report.


The policy sets out how the Trust will manage any allegations against employees relating to the abuse of children and adults at risk.  It seeks to prevent and address abuse by those who work with both children and adults at risk, and gives direction to enable the Trust to deliver an appropriate response.  The multi-agency approach is explained, where the responsibility for investigation rests, and the responsibilities of the Trust’s officers and employees.

The procedure defines allegations of this nature and how they may arise, immediate action that must be taken, and what support can be given to the employee concerned and other Trust employees affected by the situation.  Risk assessments and investigations are explained, consideration of suspension from duty, the purpose and context of strategy meetings, and final case reviews.


The following policies have been restructured for clarity and ease of use.  Responsibilities have been expanded and explained.  Information has been added on equality and reasonable adjustments, mediation, welfare and support, confidentiality and data protection.  Legal advice has been taken to ensure they are in line with current employment legislation.



The policy and procedure sets out the framework within which concerns about the conduct or behaviour of individuals will be addressed and resolved in a fair and consistent way, and in accordance with the principles of the ACAS Code of Practice and guidance.

Key changes to note:

Informal reprimand may be recorded and kept locally. 

Levels and warnings explained, and revised competency levels for issuing warnings.

Repeated failure to attend hearings reduced from 2 to 1 occasion, but working patterns are taken into consideration. 

Number of panel members reduced by 1. 

Role of companion explained. 

Grievance during disciplinary explained. 



The policy and procedure sets out the framework within which any concerns, problems or complaints raised by employees will be addressed and resolved in a fair, consistent and timely manner as near as possible to the point of origin.  The process is simplified and now has a specific appeal stage.

Legal advice has been incorporated with regard to who and what the policy/procedure covers, or does not, monitoring requirements, confidentiality and requirements under the Data Protection Act and the importance of recognising a grievance (whether verbal or written).

To ensure compliance with the ACAS Code and guidance:

·      The recommended three-step approach to prompt resolution has been incorporated, i.e. to hold a meeting with the employee and if necessary, investigate; make a decision on the appropriate action; allow an appeal against the decision.  This replaces the previous 1 informal and 3 formal stages which involved prolonged escalation. 

·      Formal grievances should be set out in writing, including any relevant evidence that will help to resolve the matter, and what action or desired outcome is sought.  The notification form is not now mandatory as it may discourage employees from bringing a formal grievance but is given as an appendix for use by employees and managers if they choose.

·      Mediation is included and where it may or may not be suitable.

·      The role of the companion is now clarified, and who can accompany.

·      At Appendix A, there is a procedure for conducting a formal grievance meeting, to supplement how to conduct a grievance appeal hearing.



The policy and procedure sets out the options, principles and actions through which bullying and harassment can be eliminated and prevented within the Trust, and the support available to employees.  It helps the Trust to promote a zero-tolerance approach to bullying and harassment behaviours and to encourage employees to speak out, and to hold each other to account wherever there is behaviour which falls short of our values.

There is an updated explanation and definition of bullying, harassment, victimisation and whistleblowing, and to raise awareness an appendix has been added setting out examples of bullying and harassment behaviours. 



The policy and procedure sets out a fair and effective framework to ensure consistent and fair treatment for all employees who experience difficulties in performing their duties to the required standards.

To ensure a smoother and more timely resolution of issues:

·      informal stages are reduced from 2 to 1 and formal stages from 4 to 3

·      number of formal warnings is reduced from 4 to 3 with the maximum warning of 12 months rather than 24 months

·      number of panel members reduced at Stage 3 Meetings/Appeal Hearings from 3 to 2

Explanation is provided about what happens at various stages and how warnings relate to review periods.

Legal advice is incorporated with regard to the right to be accompanied, the role of companion and who can accompany, and when warnings may not be appropriate. 



This policy covers concerns where the interests of others or of the Trust itself are at risk, the primary focus being about clinical matters, the care of patients and the general way patients are treated by Trust staff.  It may also be used to raise concerns about non-clinical matters e.g. financial irregularities or failure to comply with health and safety legislation. 

The policy has been amended as a result of audit.  The duty of candour is explained, how individuals who raise concerns are protected and the type of disclosures that qualify for protection under legislation.  The policy sets out how to raise concerns and where to find independent advice including internal and external contacts, and how responses are made to issues raised

Barbara Macanas, enior HR & Policy Manager

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