Managing Conduct Policy

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1 Managing Conduct Policy Reference Number: 101 Author & Title: Gayle Williams, HR Manager Responsible Directorate: Human Resources Review Date: 11 March 2016 Ratified by: Lynn Vaughan Director of Human Resources Date Ratified: 11 March 2013 Version: 3 Related Policies Code of Expectations for Employees Tackling Harassment & Bullying Managing Performance Managing Health & Sickness Appraisal Substance Misuse Appeals Local Counter Fraud Protocol Author: Gayle Williams Page 1 of 22

2 Index: 1. Introduction 4 2. Scope 4 3. Purpose 4 4. Legislation and Guidance 5 5. Duties Employee Investigating Manager Hearing Manager/Panel Members Human Resources Trade Unions 6 6. Procedure Advice Right to be Accompanied Potential Fraud or Criminal Action Investigation Process Suspension from Work during an Investigation (paid leave) Employee Assistance Programme Informal Conduct Counselling Formal Disciplinary Action Preparing a statement of case & the Hearing process Levels of Action Following a Disciplinary Hearing Appeals against the Decision of the Disciplinary Hearing Mediation Raising a Grievance during Disciplinary Proceedings Records and Documentation Review References Training Equality Analysis Monitoring Compliance with the Policy 19 Document Control Information 20 Ratification Assurance Statement 20 Consultation Schedule 21 Equality Impact: (A) Assessment Screening 1 Author: Gayle Williams Page 2 of 22

3 Amendment History Issue Status Date Reason for Change Authorised 2 Approved 2 February 2012 Planned Review Strategic Workforce 3 Approved 18 March 2013 Review and applying new format Committee Lynn Vaughan Director of Human Resources Author: Gayle Williams Page 3 of 22

4 1. Introduction As a publicly funded organisation, the Trust expects high standards from all its employees in order to provide an efficient and effective service to our patients and value for money for tax payers. Each manager has responsibility for ensuring that each employee is informed of the standards of conduct and work performance expected in their job, and ensuring that all employees are also aware of this policy, the Trust respect behaviors, and the Trust Code of Expectations. Employees are required to know and follow the standards of conduct, work performance, and behavior detailed in Trust documents relevant to them and their functions within the Trust. They are also expected to follow the standards detailed in the Trust s Code of Expectations, the Trust Respect behaviors, and to cooperate with their managers. 2. Scope This policy applies to all employees of the trust including permanent, temporary and bank employees, and also Independent Contractors and their employees. This policy applies to all staff, including medical and dental employed by the Trust. However in the case of medical & dental staff this policy must be used in conjunction with Maintaining High Professional Standards in the Modern NHS and the General Medical Council guide to Good Medical Practice. Issues of capability and poor performance are not dealt with under this policy. This policy should be used in conjunction with the Trust s other relevant policies in dealing with misconduct for example related to smoking, substance abuse or protection of vulnerable groups e.g. child protection. Conduct external to work may be the subject of this disciplinary procedure where it can be demonstrated to have a bearing on the employment contract and employment relationship. 3. Purpose The purpose of this policy is to provide a non-discriminatory, fair and timely process for the management of misconduct matters in the Trust. Misconduct can be defined as a deliberate act, a failure to follow an instruction, or a breach of the Trust policies, procedures, and stated expectation or requirement. Author: Gayle Williams Page 4 of 22

5 4. Legislation and Guidance This policy has been developed in accordance with the Acas Code of Practice, relevant employment law as outlined in section 199 of the Trade Union and Labour Relations (Consolidation) Act 1992, and the NCAS guidelines for Medical and Dental staff. These bodies maintain that employers should make clear their expectations of staff in order that staff know the standards of work performance required of them in advance of carrying out that work. 5. Duties 5.1 Employee Employees are expected to act in accordance with the Trust Code of Expectations at all times. Employees are responsible for co-operating in the Managing Conduct procedure and should make every effort to attend any meetings arranged by management. Employees are responsible for arranging their own trade union representation or support throughout the Managing Conduct procedure. 5.2 Investigating Manager Conduct cases should be dealt with without any undue delay on the part of the manager. The investigating manager must view the case with an open mind and come to a fair and justifiable conclusion after a full investigation. Where it is decided that a case is to be referred to a conduct hearing the manager must prepare a thorough management case outlining their investigation for consideration by the hearing panel. 5.3 Hearing Manager/Panel Members The hearing manager and panel members must consider the management case and the staff side case fairly during the hearing and come to a fair and justifiable decision as to the outcome of the conduct hearing. The hearing manager must write to confirm the outcome of the hearing to the employee and investigating team within 5 working days of the date of the hearing. The hearing panel will consist of a manager with dismissal rights, an HR representative and where appropriate a third member may sit as an advisor to the panel. The third member will be registered Author: Gayle Williams Page 5 of 22

6 with the relevant professional body of the staff member whose case is being heard; i.e. in the case of a conduct regarding a nurse, a registered nurse would sit on the panel. If the outcome of a grievance is appealed the manager must provide the appeal panel with a statement of case 7 days in advance of the meeting. 5.4 Human Resources The Human Resources department is responsible for the creation and maintenance of records of conduct cases within the Trust in line with best practice for information governance. To support, where necessary, managers through the formal conduct procedure, including the appeal stage. The Human Resources department is responsible for the review and maintenance of the Managing Conduct policy through agreed forums within the Trust. 5.5 Trade Unions To represent employees through the conduct procedure where they are fully paid up members of that trade union or professional body. To ensure that all representatives have attended mandatory grievance and disciplinary training with their relevant trade union or professional body. To make every reasonable attempt to attend meetings at the scheduled time to support employees. To adhere to their respective trade union code of conduct when dealing with issues of grievance. Author: Gayle Williams Page 6 of 22

7 6. Procedure All staff have a responsibility for ensuring that the principles outlined within this document are universally applied. This policy applies to all members of staff who are involved in any aspect of the development and use of procedure development. The policy provides a process for the management of alleged misconduct and other matters including suspension from work (paid leave), investigation, the issue of formal warnings and decisions on dismissal. Separate procedures apply for the management of performance issues and absence as the result of sickness. Minor misconduct covers actions which normally result in an outcome short of dismissal. Examples may include but are not restricted to, lateness for work, absenteeism, less serious behaviour, and failure to follow a reasonable instruction. Where possible misconduct cases will be managed with the emphasis on encouragement to improve behaviour and the informal reinforcement of appropriate conduct; this is pursued through counselling and discussion. Gross misconduct is defined as a breach of the contract of employment which is at the basis of the employment relationship. Actions of this nature may result in dismissal without notice. Examples may include but, are not restricted to, assault and fraud. Conduct matters shall be treated with the highest degree of confidentiality. The nature of allegations, the process to be undertaken and the purpose of any meetings will be made clear at all stages of the conduct process. An investigation will be undertaken to determine the facts prior to the commencement of any formal action. Formal action will be undertaken through a Disciplinary Hearing with the outcome subject to appeal. There is no right to appeal against the outcome of an informal conduct counselling meeting. Any matter which may be fraudulent or criminal in nature will be managed in conjunction with HR, a relevant Trust Director and NHS Counter Fraud and/or the Police. This policy applies to all staff under contract of employment with the Royal United Hospital Bath NHS Trust. This includes those staff employed on honorary contracts. For matters involving Medical and Dental staff it is essential that the distinction between cases involving personal conduct, and those involving professional conduct/competence is carefully made. Cases involving personal conduct will be Author: Gayle Williams Page 7 of 22

8 dealt with under the provision of this policy. Matters involving professional conduct/competence must be dealt with using Maintaining High Professional Standards in Modern NHS for doctors and dentists, following reference to NCAS. 6.1 Advice A senior member of the HR team should always be consulted in matters relating to issues of conduct, for advice on the application of the policy and procedure as well as documentation to be used. In order to investigate matters thoroughly, it may be appropriate to seek advice from the Occupational Health Department or other expert or professional advisers where jobs incorporate highly technical aspects or elements which are not familiar to the manager, the investigating manager, (if different to the line manager), or a disciplinary hearing panel. 6.2 Right to be Accompanied In all cases where formal action is being taken, the employee has the right to be accompanied by an accredited representative from a trade union or professional association or by a colleague, provided the companion is not acting in a legal capacity. However, where a manager has reasonable grounds to consider that there is an immediate or urgent need to suspend an employee from work at short notice it may not always be possible for a suitable companion to be available. It is the responsibility of the employee to arrange to be accompanied and to pay any fees levied by any companion. Employees are free to choose an official from any trade union to accompany them at a formal meeting. It is the responsibility of the employee to arrange for suitable companion to be available. Where the chosen companion cannot attend on the date proposed, the employee can offer an alternative time and date so long as it is reasonable and convenient for the manager and falls within the period of five working days beginning with the first working day after the day proposed by the manager. The employee is required to confirm in writing the name and status of the companion at least one working day before any formal meeting to the manager chairing the meeting. If an employee wishes to be accompanied by a trade union official, either lay or full-time, the Trust may require that official to provide evidence in writing from their union that they have experience of or have received training in, acting as an employee s companion at Author: Gayle Williams Page 8 of 22

9 disciplinary or grievance hearings. Such certification may take the form of a card or a letter. There is no duty on a fellow worker or trade union official to accept a request to accompany an employee and no pressure should be brought to bear on an individual if they do not wish to act as companion or representative. An employee or lay trade union official employed by the Trust who has agreed to accompany a colleague also employed by the Trust is entitled to take a reasonable amount of time off to fulfill this responsibility. The time off should not only cover the hearing but also should allow a reasonable amount of time off for the accompanying person to familiarise themselves with the case and confer with the employee before, and after the meeting. A companion may address a formal meeting to present and sum up the employee s case, ask questions and respond on the employee s behalf to a view presented. However, they may not answer questions asked directly to the employee. The companion will also be allowed time to confer with the employee during the meeting. 6.3 Potential Fraud or Criminal Action Matters, which may potentially be fraud or criminal in nature, should be advised immediately to the Director of the Human Resources team or Deputy, Counter Fraud Specialist, the head of security, and/or Police and the appropriate director of service. Until these parties make a decision on how to proceed with the allegation strict confidentiality will be maintained. The method of investigation and whether independent investigations are to be conducted will also be subject to a decision at this level. No investigation should commence until this decision is advised. An allocated member of the Human Resources team will be responsible for ongoing management of these cases. The Trust reserves the right to take disciplinary action when events or allegations are the subject of police investigations or legal process. It is the duty of the employee to inform the Trust if criminal proceedings are being pursued for alleged conduct or incidents committed outside the workplace. Criminal conduct or alleged criminal conduct outside employment may lead to dismissal in certain circumstances. The main consideration will be whether the situation is one that makes the employee unsuitable for his or her work or unable to fulfil the obligations of the contract of employment in a satisfactory manner. Misconduct outside the Trust where it has a direct bearing upon the Trust s operation or reputation Author: Gayle Williams Page 9 of 22

10 may also render an employee liable to disciplinary action up and including dismissal. 6.4 Investigation Process Managers should ensure that an appropriate and thorough investigation into the allegation or incident is carried out before any disciplinary action is taken. The purpose of an investigation is to establish the facts relating to the allegation and provide the employee with an opportunity to respond. The manager carrying out the investigation should not be the one who is ultimately the disciplining manager except when informal conduct counselling is the outcome. An employee who is subject to a disciplinary investigation will usually be interviewed as part of the investigation to determine whether formal action should be taken. It may be necessary to provide an employee who is suspended with the opportunity to obtain material from the work place to support their case. If this is requested by the employee, their manager s permission must be obtained, and the manager must arrange for this to take place under their supervision. All employees, whether or not they are the subject of the investigation, have the right to be accompanied at an investigation meeting. 6.5 Suspension from Work during an Investigation (paid leave) When it is considered inappropriate or unsafe to allow the employee to remain at work, or to protect the employee from the possibility of further allegations, it may be decided to suspend the employee from work on full pay. This decision may be taken on the basis of the seriousness of the available evidence, and will usually take place following an initial informal conversation with the employee or witnesses to verify the facts. Every effort must be made to ensure that the member of staff is offered the appropriate support during this meeting, be it a member of staff side or a work colleague. Alternatives, such as assignment to other duties appropriate to the employee s pay band, a set cooling off period, alternative management Author: Gayle Williams Page 10 of 22

11 or an alternative place of work, will always be considered and, if appropriate, discussed with an employee before they are suspended from work. If an employee refuses to agree to alternative arrangements, suspension may be the only option. The decision regarding suspending an employee will be made by a manager delegated to issue a Final Written Warning or above (see Attachment 1) in conjunction with a senior member of the HR team. Out of Hours this decision rests with the Senior Manager on call. For Medical and Dental staff the situation must be reviewed by a Case Manager and a senior member of the HR team and referred to NCAS. The exclusion from duty will be managed using the process outlined in the Trust Policy for Managing Professional Conduct/Capability for Doctors and Dentists. An employee who is suspended must be informed clearly of the reason. Following suspension, written confirmation of the action and reasons must be sent to the employee immediately, or no later than two working days after the meeting at which the employee is suspended. It is the responsibility of the employee s line manager to regularly update the employee on the progress of the investigation and likely timescales for conclusion. Continuation of suspension is not automatic it will be regularly reviewed by the employees line manager. If the original reasons for the suspension no longer apply or an alternative arrangement is available, this should be discussed with the employee, who should be required to return to work if appropriate. During a period of suspension, an employee should remain available for work and can reasonably be expected to attend meetings in normal working hours, unless a period of holiday has been booked in advance of the period of paid leave. They must not enter Trust premises without the manager s prior permission, unless as a patient or to access trade union advice and representation. Suspension will usually be on full pay. However, if the employee unreasonably refuses to consider alternative arrangements, unreasonably refuses to attend meetings or leaves the country without prior permission, pay may be suspended, but only with the authority of the Director of Human Resources in consultation with the manager who commissioned the investigation. Where an employee has no right to work in the United Kingdom, suspension will be with no pay. Suspension from work is a neutral act and never a disciplinary measure; it must not be used to imply guilt or misconduct. The purpose of suspension is to allow an unhindered investigation of the allegation which has been made. Author: Gayle Williams Page 11 of 22

12 An employee who wishes to appeal against a decision to put them on paid leave should make a written request for a review to the manager of the person who placed them on paid leave at any stage during the period of suspension. It is important to give consideration as to how a member of staff who has been placed on suspension is re-introduced into the workplace. The line manager should consider whether support from occupational health or the Employee Assistance Programme should be sought and what local support may be required in the work place. 6.6 Employee Assistance Programme Employees involved in disciplinary investigations and proceedings are reminded that the Trust provides access to a confidential free counselling service through the employee assistance programme. 6.7 Informal Conduct Counselling This is not part of the formal disciplinary procedure and this informal stage would be relevant to minor misconduct or carelessness. The objective of such discussion is to remedy and document the matters of concern. Formal disciplinary action should follow only where such problems persist or are so serious as to warrant formal action. It is not necessary for a member of the HR team or an employee representative to be present at this meeting which should be held between the employee and their line manager. Following the meeting, the notes of the informal warning will be placed on the employee s file for 12 months. There is no right of appeal against this informal counselling. 6.8 Formal Disciplinary Action Where, based on the evidence in the management case, the manager who requested the investigation considers formal action may be required then a Disciplinary Hearing will be held. The purpose is to review the evidence available from the investigation and provide the employee an opportunity to respond while in possession of the investigation data. Author: Gayle Williams Page 12 of 22

13 6.9 Preparing a statement of case & the Hearing process Before any formal disciplinary hearing the employee will be written to and advised of the allegations which will be considered at the hearing. All the documents which will be considered at the meeting will be enclosed with the letter in the form of a management statement of case. The letter will also remind the employee of his or her right to be accompanied and will be sent to the employee at least five working days before the date of the meeting. If there are references to other employees, patients, or third parties or to other issues not directly related to the employee who is subject to the formal action in the material to be circulated these may be removed prior to its being sent out in the interests of confidentiality. Employees who are registered with, and who are subject to discipline by, professional bodies, are reminded that the Trust is entitled to refer any instances of possible or proven misconduct to that body, who may subsequently investigate the case. The Trust may also separately investigate the circumstances and take appropriate disciplinary action. In addition to the management side presenting a case, the employee may also provide the panel with a statement of case. What is a Statement of Case? A Statement of Case is a detailed written account of the reasons for contesting the allegation(s) or providing mitigation and a rationale for the allegation(s) the employee is being accused of. Why is a statement of case required? A statement of case will:- Allow the members of the Panel to prepare for the hearing and gain initial understanding of the facts from both the management and employee s perspectives. Allows each of the parties to gain a full understanding of each other's case in preparation of the hearing. What will happen with the employee s statement of case? The employee s statement of case along with the management statement of case and any other relevant information (e.g. the investigation report, minutes of interviews held) will be submitted to the Appeals Panel prior to the hearing. This will form the conduct pack which will be issued to all parties at least 5 calendar days before the hearing. What should be included in the employee s statement of case? Author: Gayle Williams Page 13 of 22

14 As a suggested format the statement of case submitted by the employee may include:- A simple chronology, (list in order) of events. Reason(s) for their actions or conducts (mitigation) Any supporting statements or documents (including written evidence and s) should be attached if appropriate. Give each document a page number and include a contents page so that it is easyfor everyone to follow at the appeal. What is the Management Statement of Case? It is a clear summary of the findings of the conduct investigation containing the evidence collected during the investigation and a conclusion and rationale as to why the decision to refer to a conduct hearing was made based on these findings. The potential outcomes of a formal disciplinary meeting include no action and one of the sanctions set out below: Levels of Action Following a Disciplinary Hearing On occasions it may be necessary, according to the severity of the alleged conduct, to move towards a final written warning or dismissal where a lesser sanction would be considered inappropriate. For example, where conduct has been such that repetition would not be tolerated, a final written warning would be appropriate. Except for gross misconduct (defined below), no employee will be dismissed for a first breach of discipline. There are four levels of action, other than a finding of no case to answer, which can be taken as the result of a Disciplinary Hearing. The Disciplining manager may issue one of the following:- Informal conduct counselling This is issued only for minor offences and will be delivered verbally by the disciplining manager. A conduct counselling letter will then be issued by the Disciplining manager to the employee and a copy will be placed on employee s personal file. There is no right of appeal to this informal warning. First Written Warning If the allegation is upheld, the first step is to issue a first written warning, setting out the nature of the misconduct and the change in behaviour required. If appropriate, an alternative sanction, such as demotion, without protection of pay, or transfer may be considered. Author: Gayle Williams Page 14 of 22

15 The warning will be kept on the employee s personal file for 24 months and will be disregarded for disciplinary purposes after this time. However a record of the warning, whilst spent, will remain on the employee s file indefinitely. The employee should be informed that the warning is a formal disciplinary warning and of the consequences of a failure to change the behaviour which has led to its issue. Depending upon the circumstances, the consequences could be a final written warning or dismissal. The employee should also be advised of the procedure for appealing against the warning. Final Written Warning Where there is a failure to respond to the first written warning or where the alleged conduct is sufficiently serious and the allegation is upheld, the employee should be issued with a final written warning setting out the nature of the misconduct and the change in behaviour required. If appropriate, an alternative sanction, such as demotion, without protection of pay, or transfer may be considered. The warning will be kept on the employee s personal file for 24 months and will be disregarded for disciplinary purposes after this time. However a record of the warning, whilst spent, will remain on the employee s file indefinitely. The employee should be informed that the warning is a formal disciplinary warning and of the consequences of a failure to change the behaviour which has led to this issue. Depending upon the circumstances, the consequences could be dismissal. The employee should also be advised of the procedure for appealing against the warning. Dismissal Where there is a failure to respond to a formal first or final written warning, or Where the alleged conduct is sufficiently serious, the employee may be dismissed. If appropriate, an alternative sanction, such as demotion, without protection of pay, or transfer may be considered. Dismissal may only be applied by a manager with the authority to dismiss. The employee should also be advised of the procedure for appealing against dismissal. Acts of Gross Misconduct will normally result in the employee being dismissed without notice, (summary dismissal). Summary dismissal is dismissal without notice, without any further payment to the employee, and will only be used in cases of gross misconduct. Gross misconduct is an act or a series of acts which result in a serious breach of contractual terms, including a breach of the implied term of Author: Gayle Williams Page 15 of 22

16 trust and confidence between employees and their employer. The following list, which is neither exhaustive nor exclusive, gives examples of Gross Misconduct, which may lead to Summary Dismissal: Physical violence - This may include an assault on a fellow employee or member of the public, fighting or physical abuse. Theft or fraud - This may include the receipt of money, goods or pecuniary advantage in respect of any services rendered any deliberate attempt to defraud the Trust, member of staff or member of the public, or the falsification of time or other records. Serious bullying, discrimination or harassment - Reference should be made to the Authority s Bullying and Harassment and Equal Opportunities policies. A single act of bullying, discrimination and/or harassment if found to be sufficiently serious could also be considered gross misconduct. Deliberate and serious damage to Trust property or the property of fellow employees or other workers Serious insubordination Serious misuse of the Trust s property or name Bringing the Trust into serious disrepute - This may include displaying photographs, or referring to the Trust or any employees in the context of work through internet sites, for example Facebook or other media, in such a way as to seriously compromise the reputation of the Trust. Reference should also be made to the Information Goverance Acceptable Use Policy, and the Trust s Code of Expectations. Serious incapability at work brought on by alcohol or illegal drugs - Reference should be made to the Trusts alcohol and substance abuse policy Serious negligence which causes or may cause unacceptable loss, damage or injury Serious breach of health and safety procedures and regulations Serious breach of confidence, subject to the terms of the Public Interest (Disclosure) Act This includes serious breaches in relation to mechanisms in place to keep personal data secure; Deliberately accessing internet sites containing pornographic, offensive or obscene material or forwarding these images to others. Author: Gayle Williams Page 16 of 22

17 6.11 Appeals against the Decision of the Disciplinary Hearing Appeals will be handled in line with the Appeals Policy Mediation Consideration will be given to whether the involvement of a third party might assist in addressing disciplinary issues and in rebuilding relationships after a disciplinary procedure. Mediation is an entirely voluntary process for both sides in any issue and does not preclude the use of other stages of this policy if it is not successful Raising a Grievance during Disciplinary Proceedings If an employee raises a formal grievance or a formal complaint of bullying or harassment during the course of a disciplinary case, consideration will be given to suspending the disciplinary procedure while the grievance or complaint is dealt with. Where the grievance and disciplinary cases are related, it may be appropriate to deal with both issues concurrently. If an investigation concludes that the grievance or complaint was groundless and raised solely with the intention of ending the disciplinary action, the disciplinary process will be resumed and consideration given to whether further disciplinary action should be taken. Author: Gayle Williams Page 17 of 22

18 6.14 Records and Documentation 7. Review Any type of warning will be confirmed to the employee in writing within five working days. It is important and in the interests of the Trust and its employee s that records of disciplinary proceedings are kept. These will be treated as confidential and will be kept by Human Resources for no longer than necessary and in accordance with the principles of the Data Protection Act. This policy will be subject to a planned review every 3 years as part of the Trust s Policy Review Process. It is recognised however that there may be updates required in the interim, arising from amendments or release of new regulations, Codes of Practice or statutory provisions or guidance from the Department of Health or professional bodies. These updates will be made as soon as practicable to reflect and inform the Trust s revised policy and practise. 8. References ACAS code of practice, Disciplinary and Grievance Procedures Agenda for Change Terms and Conditions Handbook Maintaining High Professional Standards in Modern NHS for doctors and dentists NHS Employers website; 9. Training Staff will receive advice and information regarding the effective management of Conduct from a number of sources: Trust Policies Line Manager HR Team Other communication methods (e.g. team brief, team meetings) Staff should refer to the staff development pages available on the intranet, to identify what training in relation to managing sickness absence is available. Author: Gayle Williams Page 18 of 22

19 10. Equality Analysis An Equality Impact Analysis has been carried out on the content of this policy. 11. Monitoring Compliance with the Policy The HR Department will be responsible for monitoring that this procedure is followed and may be consulted at any stage through the process to offer advice to those involved. Monitoring information will be published within the HR Performance Report, which in turn will be reported to the Strategic Workforce Committee. Should the monitoring uncover any shortfalls in the implementation of the policy, the HR team will work with the relevant management team to draw up an action plan for improvement. This action plan may include: Additional training for line managers and/or employees; A risk assessment; An action plan in support of the risk assessment. Author: Gayle Williams Page 19 of 22

20 Document Control Information Ratification Assurance Statement Dear Lynn Please review the following information to support the ratification of the below named document. Name of document: Managing Conduct Policy (Reference 101) Name of author: Gayle Williams Job Title: HR Manager I, the above named author confirm that: The Policy presented for ratification meets all legislative, best practice and other guidance issued and known to me at the time of development of the Policy; I am not aware of any omissions to the Policy, and I will bring to the attention of the Executive Director any information which may affect the validity of the Policy presented as soon as this becomes known; The Policy meets the requirements as outlined in the document entitled Trust-wide Policy for the Development and Management of Policies (v4.0); The Policy meets the requirements of the NHSLA Risk Management Standards to achieve as a minimum level 2 compliance, where applicable; I have undertaken appropriate and thorough consultation on this Policy and I have documented the names of those individuals who responded as part of the consultation within the document. I have also fed back to responders to the consultation on the changes made to the Policy following consultation; I will send the Policy and signed ratification checklist to the Policy Coordinator for publication at my earliest opportunity following ratification; I will keep this Policy under review and ensure that it is reviewed prior to the review date. Signature of Author: Name of Person Ratifying this policy: Job Title: Lynn Vaughan Director of Human Resources Date: Signature: Date: 11 March 2013 To the person approving this policy: Please ensure this page has been completed correctly, then print, sign and post this page only to: The Policy Coordinator, John Apley Building. The whole policy must be sent electronically to: Author: Gayle Williams Page 20 of 22

21 Consultation Schedule Name and Title of Individual Date Consulted HR Department May 2011 December 2011 Speciality Managers December 2011 Matrons December 2011 Facilities management team December 2011 Reviewed 08 October 2012 HR Operational Team 08 October 2012 Staff side representatives 08 October 2012 Speciality Managers 08 October 2012 Matrons and Ward Managers 08 October 2012 Name of Committee Date of Committee TCNC Policy Sub Group October 2011 TCNC Policy Sub Group November 2011 TCNC Policy Sub Group December 2011 Reviewed TCNC Policy Sub Group 29 th November 2012 Author: Gayle Williams Page 21 of 22

22 Equality Impact: (A) Assessment Screening To be completed when submitted to the appropriate Executive Director for consideration and approval. Person responsible for the assessment: Name: Gayle Williams Job Title: HR Manager Does the document/guidance affect one group less or more favourably than another on the basis of: Yes/No Comments Race Yes No Ethnic origins (including gypsies and travellers) Yes No Nationality Yes No Gender (including gender reassignment) Yes No Culture Yes No Religion or belief Yes No Sexual orientation Yes No Age Yes No Disability (learning disabilities, physical disability, sensory impairment and mental health problems) Yes No Is there any evidence that some groups are affected differently? Yes No If you have identified potential discrimination, are there any valid exceptions, legal and/or justifiable? Yes No N/A Is the impact of the document/guidance likely to be negative? Yes No If so, can the impact be avoided? Yes No N/A What alternative is there to achieving the document/guidance without the impact? Yes No N/A Can we reduce the impact by taking different action? Yes No N/A If you answered NO to all the above questions, the assessment is now complete, and no further action is required. If you answered YES to any of the above please complete the Equality Impact: (B) Full Analysis Document name: Managing Conduct Policy Ref.: 101 Issue date: 2013 Status: Draft Author: Gayle Williams Page 1 of 22

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