Disciplinary policy and procedures - QVH · Web viewDisciplinary rules and procedures are designed to assist in the standard setting for conduct and behaviour. It is important that

Disciplinary Policy & Procedure

CLASSIFICATION Human Resources

TRUST POLICY NUMBER HR.4001.2

APPROVING COMMITTEERATIFYING COMMITTEE Clinical governance group sub-group

DATE RATIFIED 2 November 2015

DATE FOR REVIEW 2 November 2018

DISTRIBUTION Qnet

RELATED POLICIES Appeals Policy

DIRECTOR LEAD Graeme Armitage, Director of Human Resources and Organisational Development

AUTHOR Olive Jones, Deputy Head of Human Resources

EQUALITY and HUMAN RIGHTS IMPACT ANALYSIS

October 15

CONSULTATION LNC

THIS DOCUMENT REPLACES HR.4001.1

This document is available in alternative formats upon request, such as large print, electronically or community languages.

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D i s c i p l i n a r y P o l i c y & P r o c e d u r e

Executive Summary

The disciplinary policy is aimed at ensuring that issues of misconduct are managed and dealt with in a fair and consistent manner.

The Trust promotes high standards of behaviour and conduct for all employees and takes appropriate corrective action where those standards are not met.

Disciplinary rules and procedures are designed to assist in the standard setting for conduct and behaviour. It is important that managers and employees understand them.

The disciplinary process is not intended to be punitive in nature. The procedure therefore describes the steps to be taken to deal with each situation reasonably and, wherever possible, help the person concerned to improve their standards of conduct of behaviour to reach acceptable standards.

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Contents

1. Scope ………………………………………………………………… Page 4

2. Definitions ……………………………………………………………. Page 4

3. Objectives …………………………………………………………… Page 4

4. General Principles ………………………………………………….. Page 4

5. Informal action ……………………………………………………… Page 5

6. Disciplinary Process – Flowchart …………………………………. Page 6

Formal Action Investigation ……………………………………. Page 7

6.1 Suspension / Exclusion on full pay …………………

6.2 Redeployment as an alternative to suspension / exclusion Page 7

7. Conducting an Investigation …...................................................... Page 8

8. The Disciplinary Procedure ……………………………………….. Page 8

9. Disciplinary Hearing ………………………………………………. Page 10

10. Decision ……………………………………………………………… Page 11

11. Notification of Outcome ……………………………………………. Page 12

12. Levels of Disciplinary Action ………………………………………… Page 12

13. Gross misconduct ……………………………………………………. Page 14

14. Expiry of Disciplinary Action ………………………………………… Page 14

15. Conviction or being charged with a criminal offence ……………… Page 14

16. Appeal Procedure ……………………………………………………. Page 15

17. Training and Awareness …………………………………………….. Page 15

18. Equality ……………………………………………………………….. Page 15

19. Review ………………………………………………………………… Page 15

20. Monitoring Compliance with this Policy …………………………….. Page 15

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1. Scope

This procedure applies to all staff except those who are within their probationary period, who are covered by the Trust’s Probation Policy and Procedure.

Issues of underperformance should be addressed in line with QVH's Capability Policy.

Issues relating to the underperformance of medical staff need to be dealt will under the Trust’s Policy and Procedure for Handling Concerns about a Doctor or Dentist’s Performance.

Suspected fraud or financial irregularity may need to be investigated outside this policy and procedure in compliance with QVH's Fraud Policy.

2. Definitions

In this procedure "employees" are people who work for QVH under a contract of employment.

3. Objectives

The purpose of this document is to set out the procedures to be followed when standards of conduct give rise to problems which cannot be resolved by advice and encouragement, training or increased support. QVH is committed to the avoidance of formal disciplinary procedures wherever possible by addressing problems as soon as they arise. This procedure is intended to provide consistency in the treatment of staff and, to ensure matters are dealt with promptly. QVH will take disciplinary action against employees only in accordance with the provisions of this procedure.

4. General principles

Fairness: The application of this procedure will be consistent, prompt, impartial, reasonable and applied without discrimination.

Confidentiality: Information relating to an allegation of misconduct will not be divulged to any parties not involved in the disciplinary process. Statements, letters and other communications will be strictly confidential to those involved in the disciplinary procedure and records will be kept in accordance with the Data Protection Act 1998.

Natural justice: At every formal stage of the disciplinary procedure, the employee will be advised of the nature of the complaint, and will be given the opportunity to state his / her case. Where a warning is given, the employee will be provided with appropriate support to improve his / her conduct.

Equal opportunities: This policy will be applied without any distinction to protected characteristics as defined by the Equalities Act 2010. The Trust monitors the use of its disciplinary procedure by the protected characteristics of those against whom action is taken to ensure that its implementation does not impact unfairly on any one group.

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Representation: The employee has the right to be accompanied by a companion who is a work colleague or trade union representative at every stage of the formal procedure. The companion shall have an opportunity to address the hearing, put and sum up the employee's case, respond on behalf of the employee to any views expressed at the meeting, and confer with the employee during the hearing. The companion does not have the right to answer questions on the employee's behalf, address the hearing if the employee does not wish it, or prevent management from explaining the case. Any request to be accompanied at a meeting must be reasonable i.e. the companion should not be someone who may have a conflict of interest or who may prejudice the hearing. The employee should notify the chair of the panel of his / her chosen companion prior to a meeting. Where the chosen companion is not available at the time proposed for the meeting, the employee has the right to request that the meeting be postponed and to suggest an alternative time within five working days of the original hearing date and all such reasonable requests will be agreed on one occasion only. In exceptional circumstances where the postponement of a meeting is due to circumstances beyond the employee’s control, a second postponement will be agreed and a third meeting arranged.

. Right of appeal: An employee has a right of appeal against any formal disciplinary

sanction, except an oral warning, and appeals will be heard by a senior manager and representative from Human Resources not previously involved in the case. Please refer to the Appeals Policy for further information.

Recordings: Audio / Visual recordings of the proceedings by the employee, his/her companion or management is acceptable at any stage of the disciplinary procedure, provided all parties agree.

Discipline and Grievance: Any concerns that an employee has regarding disciplinary action being taken against her or him should be raised as part of his / her response to the disciplinary action and will normally be considered within this procedure. Any grievance raised by an employee relating to the disciplinary process or the reasons for the disciplinary hearing, will normally be investigated concurrently with the disciplinary process and heard on completion of the disciplinary procedure.

The Disciplinary Procedure / Process

5. Informal action

Informal action should be taken in cases of minor misconduct. A one-to-one confidential discussion between the line manager and the employee should be held with the intention of gaining sustained improvement in the employee's conduct.

This discussion should enable the manager to provide constructive feedback and the employee to express views on the issue. It is important for both parties to understand that informal action is not formal disciplinary action and employees are not entitled to representation at this stage. Where the need for improvement is identified, the manager should explain to the employee what needs to be done and how the conduct will be reviewed in a given period.

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It is essential that brief confidential notes of the discussion(s) with the employee are kept by the manager on any agreed informal action. The manager should also write to the employee (a letter or email) to confirm what was agreed during the meeting within 10 working days.

Note: where there is no evidence that a minor misconduct has been managed informally, this may prevent the manager from proceeding to the formal stage of the process. This does not apply for matters which are considered as serious or gross misconduct.

6. Disciplinary process – Formal Action

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Formal action is usually taken when:

An allegation is made that an employee has demonstrated unacceptable behaviour / conduct (including gross misconduct)

A minor misconduct issue managed informally – has not improved

The line manager has witnessed unacceptable behaviour / conduct

Investigation Officer appointed – refer to

HR for advice

Behaviour / conduct considered as gross

misconduct?

If yes – consider

Suspension or exclusion if a doctor or dentist is under investigation

Redeployment to another area whilst investigation is undertaken

Refer to HR for advice

If no – employee remains in job role

whilst allegation investigated

Investigating Officer arranges to interview employee and witness (es) – who may bring a work companion /

trade union representative to the interview

HR representative to be present at investigation interview

Investigating Officer concludes investigation and

writes report

Recommends whether formal action required

Formal action recommended – Yes

HR arranges disciplinary hearing

6. Formal Action - Investigation

Prior to formal disciplinary procedures being invoked, an employee may have received from his / her line manager some informal indication that his / her conduct or behaviour is unsatisfactory. For more serious incidents of misconduct, it will be appropriate for this to be dealt with under the formal process in the first instance.

Disciplinary action will not be undertaken until the necessary facts have been established. An Investigating manager will be appointed by the Head of Service in conjunction with the HR team to investigate. The investigating manager will not normally be the employee’s line manager or the line manager of any person making a complaint that led to the disciplinary action, or someone who works closely with the individual concerned. The investigating manager will liaise with the HR team throughout the investigation.

6.1 Suspension/ Exclusion on full pay

There may be occasions where suspension or exclusion in the case of doctors and dentists, is necessary, and this is usually where the allegation made, if proven, would be gross misconduct. Further details of matters considered as gross misconduct are outlined in Appendix 1 – the list is not exhaustive. Where suspension or exclusion is invoked, it will be on full pay and only for such time as is necessary to permit proper investigation or to arrange a hearing date. Careful consideration must be given before a decision to suspend or exclude a doctor or dentist is taken.

Suspension or exclusion is not a disciplinary sanction and is not an assumption of guilt. Normally an employee will be suspended by the Head of Service or an authorised deputy, and only when approved by a member of the Senior Management Team (SMT). Where suspension is approved a meeting should be arranged with the employee and the Head of Service and a representative from HR. The employee should be advised of the reason(s) for the suspension, the terms of the suspension/exclusion, provided with contact details of the Employee Assistance Scheme and handed a letter to confirm the discussion during the suspension meeting. In the case of a doctor or dentist the relevant section in the Policy for Handling Concerns about a Doctors or Dentists Performance should be followed.

The period of suspension/exclusion will be kept under regular review. The fact and conditions of the suspension/exclusion will be confirmed in a letter to the employee immediately. Where it becomes evident that the period of suspension/exclusion will be long term then the suspension/exclusion should be reviewed every 4 weeks and confirmed in writing

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Exceptionally, it may be necessary for a Head of Service to send an employee home before being able to consult with a member of SMT. In such a case, formal written confirmation of the suspension and the reasons for it will be confirmed by the Head of Services as soon as a member of SMT has been informed of the circumstances, and confirmed that suspension/exclusion is appropriate.

6.2 Redeployment as an alternative to suspension/exclusionDuring the initial stages the facts may not be clear and therefore managers should consider – where possible – redeploying the individual to another area of the Trust until such time that the facts are established. The investigating officer should arrange a meeting with the employee, and a representative from HR to outline the details of the redeployment and the terms. The employee should be provided with a letter confirming the details of the redeployment during the meeting. If it is not possible to provide a letter during the meeting, the Head of Service must send a letter to the employee, within 5 working days of the suspension meeting taking place.

7. Conducting an investigation

The Investigating manager will conduct an investigation which is confined to establishing the facts of the case and will include all aspects of the allegation including who made the allegation. There may be exceptional circumstances where the identity of the person making the complaint will not be revealed as part of the investigation report i.e. where someone may be put at risk.

The nature and extent of the investigation will depend on the seriousness of the matter. The Investigating manager will advise the employee who is the subject of the allegation of the details in writing and invite his / her response. An investigatory interview with the employee will be appropriate in most cases. The employee must be notified in writing of the meeting at least 5 working days before it takes place so she / he has reasonable time to prepare.

The investigation will also include the collation of evidence for a possible hearing, taking statements from, and usually meeting with relevant parties, including where appropriate any witness(es) to the alleged incident(s) of misconduct. Any witness to the alleged misconduct will be asked to sign their written statement for accuracy as soon as possible after the investigation meeting.

The Investigating manager will be accompanied by a colleague from Human Resources at such meeting(s) to provide advice and guidance. The employee concerned may be accompanied at such meeting(s) by a companion (as defined in section 4 - Representation). Where the employee against whom a disciplinary allegation has been made is a trade union representative, the Director of Human Resources will (after obtaining the employee's agreement), inform a senior member of the relevant trade union in advance of any interview under this procedure.

The Investigating manager will prepare a report based on the findings of his / her investigation, including where evidence was not found. The Head of Service or authorised deputy with advice from HR will determine whether or not a disciplinary hearing is required based upon the findings of the investigation. In the case of doctors and dentists, the Case Manager, usually the Medical Director, will undertake this role. If the Head of Service / deputy consider that it is not appropriate to convene a formal disciplinary hearing, but that informal advice or guidance is appropriate, any resulting discussion will be in private and the employee will be informed that no disciplinary action is being taken.

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8. The disciplinary procedure

Where there is believed to be a disciplinary case to answer, the Head of Service will consult with the Human Resources Team before arranging a disciplinary hearing.

Where it is identified that a disciplinary hearing is required, the disciplinary procedure should be conducted within the following timescales. In exceptional circumstances, it may be necessary to extend these time limits in discussion with both parties.

Disciplinary Procedure

Process Timeframe

Head of Service / Panel Chair notifies employee in writing that she / he is required to attend a disciplinary hearing.

Employee is provided with details of the disciplinary allegations and names of any witnesses who will be called by management – the Management Case.

No later than 10 working days before the date of the hearing

Employee contacts HR to advise if any witnesses are to be called at hearing. Employee organises own witness statements, and their attendance at the hearing.


HR invites all witnesses to be called by management to hearing, providing a copy of this procedure. HR to provide a copy of this procedure to witnesses to be called by the employee.

No later than 5 working days before the date of the hearing.

All further written submissions including witness statements to Head of Service / Panel Chair


Both parties involved in the hearing to be provided copies of all written submissions received


HearingHead of Service / Panel Chair notifies employee orally of outcome of disciplinary hearing.

Within 1 working day of the decision and no later than 48 hours of the hearing, unless it is agreed that further evidence is required.

Head of Service / Panel Chair notifies employee of outcome of disciplinary hearing in writing and informs employee of his / her right to appeal

No later than 10 working days of the hearing

Right of appeal to Director of HR Must be done no more than 10 days after the letter has been sent to the employee.

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Outlined below are the levels of management that are authorised to chair a disciplinary panel depending on the charge:

Charge Level of Management / Chair of the panel

Minor misconduct Manager (Band 7 and above)

Misconduct Head of Service / deputy

Serious misconduct Head of Service

Gross misconduct Director / deputy

In the case of doctors and dentists, the relevant section of the Policy for Handling Concerns about a Doctor or Dentists Performance should apply. Where there is a prior sanction in place and therefore the outcome of the hearing may result in the dismissal of the employee, it must be heard by a director / deputy. In all cases a representative from HR must be present to advise the chair of the panel.

The Panel Chair will advise the employee, in writing (providing the appropriate notice) that she / he is required to attend a disciplinary hearing at a specified place and time. The letter will outline the details of the allegations that have been made against him / her with sufficient information about the alleged misconduct and its possible consequences, to enable him / her to prepare to answer to the case at a disciplinary hearing.

The employee will be advised that she / he has the right to be accompanied at the hearing and will be provided with a copy of this policy and procedure. The employee must be given all relevant documentation gathered in relation to the alleged misconduct and names of any witnesses who will be called at the hearing to enable him / her to prepare.

The employee should inform HR in writing (an email is acceptable) of the names of witnesses she / he would wish to call with brief reasons for each request, within the appropriate timescales (as specified in the table above). The employee is responsible for providing written statements by his / her witnesses in advance of the hearing, where statements have not already been provided as part of an investigation. The Panel Chair is entitled to query the purpose of any witness being called and the potential for new, relevant information that the witness can offer. In such circumstances, and following consultation with the relevant parties, the Panel Chair will decide which witnesses will be called at the Hearing. If there are difficulties with the release of staff to attend the hearing as witnesses, HR should be informed so they can assist with these arrangements.

In exceptional circumstances where it is not practical for witnesses to attend, the Panel Chair may continue to proceed with the hearing if she / he is of the view that verbal evidence from the witnesses will not affect the consideration of the complaint.

If the employee wishes to present any additional documentation in response to the allegation, it must be presented to the Panel Chair (within the timescales specified in the table above) in order that it can be distributed to all parties.

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The employee and his / her companion must make every effort to attend the hearing. The employee may offer a reasonable alternative date if his / her chosen companion cannot attend the hearing. If the employee fails to attend for reasons outside of his / her control e.g. sickness, another suitable date may be proposed for the hearing. If on more than one occasion, without good reason, an employee does not attend the disciplinary hearing, the hearing may proceed in his / her absence and a decision will be made on the evidence available. The employee will be informed in writing at least 5 working days before that hearing that it will be taking place.

9. Disciplinary hearing

The Panel Chair will ensure equal treatment of all parties and ensure they have received copies of all relevant papers. The Panel Chair will also ensure that all aspects of the case are considered and may seek further clarification of the written submissions from whomsoever they feel appropriate. The Panel Chair will decide if the hearing needs to be adjourned if new facts emerge that require further investigation.

The employee shall attend throughout the hearing and may call witnesses. The Panel Chair shall be empowered to call witnesses who have been identified to the employee prior to the hearing. Witnesses who are required to attend meetings under this procedure at times other than their normal working hours will be paid plain time or given time off in lieu.The order of the hearing will be as follows:

A. Introductions as appropriate B. Panel Chair will explain the complaint / allegations C. The investigating manager will present the findings of their report and present any

witnesses and explain the evidence supporting the charges to the Panel D. The Panel shall have the opportunity to ask questions of the investigating manager and

any witnessesE. The employee (or his / her chosen companion) shall have the opportunity to ask

questions of the investigating manager and witnesses and raise points about information provided by them

F. The employee or his/her chosen companion will then set out his / her case and present any witnesses in response to the charges

G. The Panel shall have the opportunity to ask questions of the employee and any witnesses

H. The investigating manager shall have the opportunity to ask questions of the employee and witnesses and raise points about information provided by them

I. The panel shall have the opportunity to ask any final questions of the employee, investigating manager or witnesses

J. The investigating manager shall have the opportunity to sum up his / her caseK. The employee (or his / her chosen companion) shall have the opportunity to sum up his /

her case L. The Panel Chair shall sum up the main points of the evidence put forward M. If considered necessary by the Panel Chair, the meeting shall be adjourned to allow

further investigation into the matters raised or to ask questions of any witnesses who were unable to attend the hearing.

N. If further evidence or witnesses are sought, and the Panel Chair relies on this evidence to form a decision, they will reconvene the hearing to allow consideration of the evidence by both parties and / or cross-examination of witnesses

O. The hearing should end with the Panel Chair asking the employee if they have anything further to say

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P. The Panel Chair should advise the employee when they might reasonably expect an outcome / decision within the timescales of this procedure.

Notes will be taken of all disciplinary hearings which will be typed as soon as possible after the hearing. The typed notes will always be made available to all parties in advance of an appeal hearing. The Parties should raise any factual inaccuracies of notes with the Panel Chair within five working days of receipt.

10. Decision

After the hearing, the Disciplinary Panel, having fully considered the circumstances of the case and conducting further checks where necessary i.e. where there are disputes over the facts, will decide whether or not a disciplinary sanction is justified. For a disciplinary sanction to be justified in a situation where the facts of the case have been in dispute and a full investigation has been conducted, there must be a reasonably held belief on the grounds of probability, that the employee committed the act in question.

10.2 The decision will be provided to the employee orally within 1 working day of the decision being made (no later than 48 hours). Written confirmation with full reasoning for the decision will be provided to the employee no later than 10 working days after the hearing.

11. Notification of outcome

Where disciplinary action is taken, the employee will be informed of the outcome as soon as possible, including:

1. The nature of the misconduct.2. The disciplinary sanction awarded including the level of any warning given.3. The reasons why the disciplinary action was taken.4. The consequences of any further failure to adhere to acceptable standards of conduct. In

cases where a final written warning is given it should be made clear that further formal disciplinary action may result in dismissal.

5. The provision of any support, counselling or corrective action that is required and if not immediate, the time within which improvement will be expected.

6. The period given for improvement and the improvement expected.7. The time period within which the warning will be considered to have lapsed 8. The fact that a record of warnings will be kept.9. The right of appeal, advising that this should be formally submitted in writing to the

Director of Human Resources and Organisational Development, and the right to representation at any future appeal hearing.

A formal written warning will normally be accompanied by the withholding of incremental progression (where the employee is eligible for progression) for the period during which the warning is current, unless this is deemed inappropriate by the Head of Service or Disciplinary Panel hearing the case. Incremental progression, where it is due, will resume on the 1st April following the date on which the warning ceases to be current. There are different arrangements for medical and dental staff.

Note: where an employee is dismissed from the employment of QVH or receives a disciplinary sanction and there is a duty to inform another statutory or professional body, QVH will inform the organisation and provide details of the circumstances.

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12. Levels of disciplinary action

Disciplinary action can range from an oral warning to dismissal. The levels of disciplinary action that may be applied are as follows:

Disciplinary Action / Sanction Details

Formal oral warning Normally be issued if:

it is considered that the conduct of an employee has fallen below an acceptable standard and the member of staff has committed a minor offence.

where it is found that such a disciplinary offence has occurred, the outcome will normally consist in the first instance of an oral warning, which will be recorded by the manager concerned, and copy will be held by HR on the employees personal record.

A formal oral warning will be issued in writing and will normally lapse 6 months after issue.

Note: although there is no right of appeal against a Formal Oral Warning, any response to a formal oral warning by an individual will be recorded on the practitioner’s personal record.

A written warning Normally be issued if:

there is no improvement in conduct about which the employee has previously been warned or

another related instance has occurred during the currency of a previous warning or

misconduct is confirmed and the conduct is of such seriousness that an oral warning is not appropriate.

Where it is found that such a disciplinary offence has occurred, a written warning will be given to the employee and a copy placed on his / her personal record within HR.

A written warning will normally lapse 12 months after issue.

Final Written Warning Normally issued if:

A written warning has already been issued and another instance of misconduct has occurred while it is current or

there is no improvement in the conduct about which the employee has previously been warned or

the conduct is of such seriousness that verbal of further

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written warning are not appropriate but would not justify a dismissal.

Where it is found that such a disciplinary offence has occurred, a final written warning will be given to the employee and a copy placed on his/her personal record within the Human Resources Division.

A final written warning will normally lapse 18 months after issue.

Dismissal Normally occurs if:

an allegation of gross misconduct is found to be proven or

there is no improvement in the conduct within the specified period which has been the subject of a final written warning or

another instance of misconduct has occurred during the currency of a previous warning and a final written warning has already been issued.

Where a member of staff is dismissed; she / he will receive a written statement of the reasons for his / her dismissal, the date on which the employment contract will end, the appropriate period of notice or payment in lieu, payment of any outstanding annual leave and the right of appeal.

Should the Disciplinary Panel consider that in light of all the circumstances, dismissal is not warranted, an alternative to dismissal may be imposed in the form of extending the period of the existing final written warning for up to a further twelve months or demotion to a lower graded job role.

13. Gross misconduct

Some acts termed gross misconduct are so serious in themselves or have such serious consequences that they may call for a dismissal on the first offence. Any dismissal for gross misconduct will take immediate effect once the decision has been made and the employee will be entitled to no notice period regarding the termination of his / her employment. Below is a list of some examples of gross misconduct which may result in dismissal.

This list is not exclusive or exhaustive.

serious or gross negligence resulting in unacceptable loss, damage or injury intentional serious breach of QVH policy or regulations or improper conduct in relation to

job responsibilities serious breach of a professional code of conduct bringing QVH into serious disrepute serious breach of QVH policy on Harassment and Bullying theft, fraud or deliberate falsification of records or QVH documents assault or attempted assault of a physical or sexual nature malicious damage to QVH property

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deliberate refusal to comply with reasonable instructions or requests made by a line manager within the work place

a breach of health and safety rules which places a member of staff or others in danger intentional misuse of confidential information fraudulent misuse of the QVH's property or name unauthorised entry to computer records or inappropriate use of QVH data or computing

equipment.

14. Expiry of disciplinary action

Disciplinary action taken will normally be disregarded for disciplinary purposes after the warning has expired. The decision to dismiss will not be based on an expired warning but there may be occasions where the existence of such a warning will explain the reasoning behind a decision to dismiss e.g. where an employee's conduct is satisfactory throughout the period a warning is valid, but ceases to be satisfactory very soon thereafter.

15. Conviction or being charged with a criminal offence

Conviction or being charged with a criminal offence outside the workplace and normal working hours may be deemed as misconduct or gross misconduct depending on the nature of the offence, effect of the charge on the employee's suitability to do the job and his/her relationship with QVH, colleagues, patients and those external to QVH and the sentence incurred.

16. Appeal Procedure

Where an employee is notified that a disciplinary sanction has been awarded against him/her, she / he will also be notified of the right of appeal. Where an employee feels the decision taken against him / her is wrong or unjust, she / he may appeal against the decision. Details of the appeals procedure can be found in the Appeals Policy which is available on Qnet.

17. Training and Awareness

The Disciplinary Policy is available on the Trust intranet and managing misconduct best practice training sessions are provided quarterly through the Staff Development Centre to ensure compliance with the policy.

18. Equality

This policy will be equality impact analysed in accordance with the Trust Procedural Documents Policy, the results of which are published on our public website and monitored by the Equality and Diversity Operations Committee.

19. Review

This policy will be reviewed in 3 years. Earlier review may be required in response to exceptional circumstances, organisational change or relevant changes in legislation or guidance.

20. Monitoring Compliance with this Policy

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The HR team is responsible for managing the impact of disciplinary action against staff to ensure that no group is disadvantaged by the policy. HR also report on the number of cases (not specific details) to the board for information purposes. The data has to be used fairly, ethically and confidentially and in accordance with the sensitive personal data provisions of the Data Protection Act 1998.

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