HR Policies Report

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Human Resources

Policies andProcedures for theSouth WestStrategic HealthAuthority

19 March 2010





South West Strategic Health Authority

Human Resources Policies and Procedures for the

South West Strategic Health AuthorityPaper for the meeting of the South West Strategic Health Authority on 15 April 2010Author Lisa Wyatt-Jones, Interim Head of

Human ResourcesResponsible Director John Bewick, Director of Strategic

Development and Interim Director ofWorkforce

Main aim To report on updates made to HumanResources policies and procedures

Outcome of equality impact assessment

process

All policies have been screened and

amended in line with the equality impactscreening process

Actions taken and planned as a result ofthe equality impact assessment, withdetails of action plan withtimescales/review dates as applicable

No further assessments or actionrequired

Groups/individuals consulted with as partof the impact assessment

Joint Management and Staff Committeerepresentatives

Link to strategic objectives and priorities Supports strategic objectives andpriorities

Risk register n/a

Risks identified if not on risk register n/a

Current controls to reduce risk n/a

Options/recommendations n/a

Resources implications n/a

Details of residual risk following

recommendations

n/a

Any legal implications or links tolegislation

Ensures Human Resources policies arecompliant with current legislativerequirements

Freedom of information includingrestrictions

No risk

Public involvement history N/a

Previous considerations Senior Management Team meeting on11 January 2010 and Steering Groupmeeting on 16 February 2010.





Preface

This paper sets out the thirty Human Resources Policies andProcedures and five Health and Safety Policies and Proceduresthat have been either created or updated and amended as a result ofroutine review period; changes in legislation or recommendationsfrom the South West Strategic Health Authority audit reviews.

Sir Ian Carruthers OBEChief Executive19 March 2010






Human Resources Policies and Procedures for the


Table of contents

Page No.

Assessment sheet

Preface

Table of contents

Section 1 Introduction............................................................................... 1

Section 2 Amendments to the policies.................................................... 3

Section 3 Recommendations .................................................................. 7

Appendices

Appendix 1 Absence Management policy ................................................. 11

Appendix 2 Appraisal policy ....................................................................... 31

Appendix 3 Dignity at Work policy.............................................................. 43

Appendix 4 Disciplinary policy.................................................................... 63

Appendix 5 Emergency Response policy................................................... 119

Appendix 6 Establishment Control policy.................................................. 129

Appendix 7 Family Friendly policy.............................................................. 135

Appendix 8 Flexible Working policy ........................................................... 165

Appendix 9 Grievance policy....................................................................... 185

Appendix 10 Health and Wellbeing policy.................................................... 197

Appendix 11 Hospitality, Gratuities and Inducements policy..................... 233

Appendix 12 Lease Car policy....................................................................... 241

Appendix 13 Leave Entitlement policy ......................................................... 253

Appendix 14 Mobile Phone policy................................................................. 265



Appendix 15 Organisational Change policy................................................. 269

Appendix 16 Pay Protection policy ............................................................... 289

Appendix 17 Performance Improvement policy........................................... 295

Appendix 18 Professional Registration policy............................................. 315

Appendix 19 Redeployment policy ............................................................... 321

Appendix 20 Recruitment policy ................................................................... 329

Appendix 21 Representation at Work policy................................................ 363

Appendix 22 Retirement policy ..................................................................... 371

Appendix 23 Secondary Employment policy ............................................... 377

Appendix 24 Secondment policy................................................................... 381

Appendix 25 Staff Involvement and Internal Communications policy ....... 385

Appendix 26 Study Leave and Development policy .................................... 391

Appendix 27 Travelling and Subsistence policy.......................................... 397

Appendix 28 Valuing Diversity policy........................................................... 405

Appendix 29 Whistleblowing policy.............................................................. 411

Appendix 30 Work Experience policy........................................................... 417

Appendix 31 Adverse Incident policy ........................................................... 421

Appendix 32 Fire Prevention policy .............................................................. 433

Appendix 33 Health and Safety policy.......................................................... 441

Appendix 34 Lone Workers policy ................................................................ 449

Appendix 35 Zero Tolerance policy .............................................................. 455



Section 1

Introduction

This section sets out the background to the changesrequired to the relevant Human Resources Policiesand Procedures.





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1. Introduction

1.1 The majority of the Human Resources policies and procedures of the SouthWest Strategic Health Authority were approved in July 2006 and due forroutine review by July 2009.

1.2 All policies that are either written or reviewed are subject to Equality ImpactAssessments. All of the policies contained in this report have been screenedand any necessary amendments have been incorporated into the policies,therefore full equality impact assessments have not been necessary.

1.3 The Joint Management and Staff Committee have been consulted about theproposed changes to the respective policies and where appropriate furtheramendments have been agreed.

1.4 A Steering Group comprising members of Human Resources, and

Directors/Representatives have reviewed all of the policies and after minoramendments have agreed for the policies to progress to the AuthoritySeminar for consideration.

1.5 A number of Human Resources policies and procedures have been thesubject of Audit reviews and changes recommended, which are fully reflectedin the revised documents.

1.6 Where policies were linked or overlapped significantly, they have beenincorporated or amalgamated into an integrated policy, for ease of use by staffand managers, for example the Leave Entitlement policy.

1.7 This report contains thirty five policies and procedures that have either beenamended or created in response to an identified need:

• revised Absence Management policy (Appendix 1);

• revised Appraisal policy (Appendix 2);

• revised and incorporated Dignity at Work policy (Appendix 3);

• revised Disciplinary policy (Appendix 4);

• revised and incorporated Emergency Response policy (Appendix 5);

• revised Establishment Control policy (Appendix 6);

• revised and amalgamated Family Friendly policy (Appendix 7);

• revised and amalgamated Flexible Working policy (Appendix 8);

• revised Grievance policy (Appendix 9);

• revised and amalgamated Health and Wellbeing policy (Appendix 10);

• revised and incorporated Hospitality, Gratuities and Inducements policy(Appendix 11);



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• revised Lease Car policy (Appendix 12);

• revised and amalgamated Leave Entitlement policy (Appendix 13);

• revised Mobile Phone policy (Appendix 14);

• new Organisational Change policy (Appendix 15);

• revised Pay Protection policy (Appendix 16);

• revised Performance Improvement policy (Appendix 17);

• revised Professional Registration policy (Appendix 18);

• revised Redeployment policy (Appendix 19);

•

revised and amalgamated Recruitment policy (Appendix 20);

• revised Representation at Work policy (Appendix 21);

• revised and incorporated Retirement policy (Appendix 22);

• revised Secondary Employment policy (Appendix 23);

• revised Secondment policy (Appendix 24);

• revised Staff Involvement and Internal Communications policy

(Appendix 25);

• revised Study Leave and Development policy (Appendix 26);

• revised Travelling and Subsistence policy (Appendix 27);

• revised Valuing Diversity policy (Appendix 28);

• revised Whistleblowing policy (Appendix 29);

• revised Work Experience policy (Appendix 30);

• revised Adverse Incident policy (Appendix 31);

• revised Fire Prevention policy (Appendix 32);

• revised Health and Safety policy (Appendix 33);

• revised Lone Workers policy (Appendix 34);

• revised Zero Tolerance policy (Appendix 35).

1.8 Details with regard to the amendments are explained further in Section 2,

Amendments to the policies.



Section 2

Amendments to the policies

This section sets out a summary of the amendmentsand updates that have been made to the HumanResources Policies and Procedures in order tocomply with legislation, Equalities ImpactAssessments and recommendations from AuditReviews.





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2. Amendments to the policies

2.1 The Absence Management policy has been significantly amended to beclearer about responsibilities and introduces trigger points for short termabsence management. Therefore the process for managing and taking action

is more specific and can be more tightly managed and supported. The policywas renamed from the Sickness Absence policy. The Equality ImpactAssessment raised issues with regard to potential inequality due to disability,however these have been addressed in the policy.

2.2 The Appraisal policy now includes a section on employee responsibilities anda commitment to the equality of opportunity. The policy has been renamedfrom the Individual Performance Review policy.

2.3 The Dignity at Work policy has been incorporated with the EqualOpportunities policy and now includes the staff rights and responsibilities set

out under the NHS constitution. The revised policy gives more clarity thatinvestigations will follow the same process as that of a grievanceinvestigation. Detailed procedural guidance for managers on differentmanagement behaviours has been provided. The new role and contactdetails of Employee Support Advisors has also been provided.

2.4 The Disciplinary policy has been completely rewritten and now has asummary and a larger step-by-step user guide. All appeals will in future becoordinated in the first instance by the Associate Director of HumanResources.

2.5 The Emergency Response policy has been amalgamated with the PandemicFlu Policy and the Severe Weather policy and has been extended to cover allemergency situations.

2.6 The Establishment Control policy has had minor amendments to ensureconsistency.

2.7 The Family Friendly policy has amalgamated the Maternity Leave, AdoptionLeave, Parental Leave, Paternity Leave, Career Breaks and Special Leave.

2.8 The Flexible Working policy has been incorporated with the Job Share policy

and the layout has been simplified.

2.9 The Grievance policy has had a title change from Grievance and Disputespolicy and has been amended to follow ACAS guidelines and timescales.Also the timescales now match those of the disciplinary policy for consistency.

2.10 The Health and Wellbeing policy has amalgamated the Alcohol and DrugsMisuse, Eye Tests, Health problems in disability in employment, Managementof Stress, No Smoking and Occupational Health Services. The definition ofstress has been amended to include the difference between positive pressureand the harmful affects of pressure that is beyond a person’s ability to cope.



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2.11 The Hospitality, Gratuities and Inducements policy has incorporated aspectsof staff conduct to address issues of duplication.

2.12 The Lease Car policy has been amended in line with age discriminationlegislation, therefore reference to a drivers age has been changed from 21 to

17 years of age. Clarification is given on travel to or from work as beingclassed as “normal commuting” and not official business mileage. To worktowards the carbon reduction targets of the Strategic Health Authority, it isproposed that a lease car would not be provided over the level of Band F CO2emission. In addition, a handover of the vehicle will be undertaken for eachemployee at which point any visible defects will be identified.

2.13 The Leave Entitlement policy title has been changed to reflect theamalgamation of the Annual Leave, Civic and public duties leave, Jury andwitness special leave and Reserve Forces leave. The policy now makes clearthat sickness absence during annual leave can only be reclaimed if there is a

valid GP certificate covering the whole period.

2.14 The Mobile Phone policy was updated due to changes in the charging systemfor personal calls.

2.15 The Organisational Change policy is new as the previous policy was put inplace for the Commissioning a Patient Led NHS changes. There is now clearand detailed procedural and management guidance which recognises theneed for an objective, fair and equitable approach, and recognises thepotential impact of change on staff. It explains in detail the appointmentprocesses to be followed when undergoing organisation change and provides

a flow chart summarising the process.

2.16 The Pay Protection policy has been separated from the Redeployment policyand is now set out as a stand alone policy.

2.17 The Performance Improvement policy has had a title change from Capabilityand is now simplified and in line with current legislation.

2.18 The Professional Registration policy now covers independent contractors andgives employees whose registration has lapsed a clear timescale (fiveworking days) to renew their professional registration. The policy requires

Human Resources to update professional registration details on the electronicstaff record system and conduct annual checks. Guidance is also providedfor the management of staff who are unable to maintain professionalregistration due to disability and a flow chart summarising the process hasalso been included.

2.19 The Redeployment policy now includes the employee's responsibility to applyfor suitable alternative posts at their previous salary level when on payprotection. The policy has also been re-titled from the Staff Redeploymentand Displacement.



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2.20 The Recruitment policy now amalgamates, Recruitment and selection,Relocation and expenses, Employment of partners, Guidance on startingsalaries, Induction and Disclosure policies. The policy has been updated inline with the Human Resources processes to match NHS Jobs recruitmentprocess and requirements of NHS employers, Counter Fraud and audit.

2.21 The Representation at Work policy has been consistency checked andincludes the latest Joint Management and Staff Committee Terms ofReference.

2.22 The Retirement policy has been re-written to assist managers dealing withrequests to continue working beyond retirement age.

2.23 The Secondary Employment policy has been created to support auditrequirements.

2.24 The Secondment policy now includes 'normal' time period of secondments ofsix to twenty four months and a commitment to the fair and equitabletreatment of staff, to provide equity for career development opportunities.

2.25 The Staff Involvement and Internal Communications policy has beenconsistency checked and the Staff Charter is now a stand alone document onthe intranet site.

2.26 The Study Leave and Development policy has been revised and re-titled fromthe Education and Development policy following suggestions from the JointManagement and Staff Committee. The Equality Impact Assessment raised

issues with regard to potential inequality due to age and length of service andthese have been addressed in the policy.

2.27 The Travel and Subsistence policy was amended due to an Audit reviewwhich recommended that annual vehicle checks should be carried out toensure that employees claiming mileage hold valid motor insurance whichincludes business usage, current driving license and motor insurance. Themileage rates were also updated.

2.28 The Valuing Diversity policy has been updated and reviewed by the Equalityand Human Rights Manager to ensure that we meet our legislative

requirements.

2.29 The Whistleblowing policy has been revised to reflect current best practiceand is supported by Public Concern at Work.



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2.30 The Work Experience policy has been amended so that candidates can nowbe 14 years old or above to accommodate students on their relevant workexperience year. Internships have been included as an example of workexperience placement. There is a requirement for South West StrategicHealth Authority supervisor and mentor to have CRB enhanced disclosure

and registered to work with children under the age of 16 in line with changesintroduced by the Independent Safeguarding Authority. There is also arequirement to make reasonable adjustments to accommodate individualswith special requirements.

2.31 All Health and Safety policies have been reviewed by a Health and SafetyProfessional to ensure they are up to date on any new legislativerequirements.

2.32 The Adverse Incident policy has had the scoring process brought into line withthe 5 x 5 matrix used in the scoring roles for the Risk Register to ensure

consistency of approach and understanding.

2.33 The Fire Prevention policy is now a stand alone policy instead of beingincorporated with the Health and Safety policy.

2.34 The Health and Safety policy has been updated in line with the professionaladvice received.

2.35 The Lone Workers policy has been updated in line with the professionaladvice received.

2.36 The Zero Tolerance policy has been updated in line with the professionaladvice received.

2.37 All of the Human Resources and Health and Safety policies have beenthrough the Equality Impact Assessment screening process and whereappropriate, amendments have been made.





Section 3

Recommendations

This section contains recommendations for theAuthority Seminar.





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3. Recommendations

3.1 It is therefore recommended that the Authority Seminar confirm agreement ofthe thirty five Human Resources policies and procedures included in thisreport.

3.2 The policies attached to this report are consistent with current UKemployment legislation and where appropriate, Audit recommendations andare also robust in terms of the conditions of employment for NHS staff.

3.3 The policies have been fully reviewed by the Joint Management and StaffCommittee and have been Equality Impact Assessed.

3.4 It is therefore recommended that the following policies should be agreed forapproval by the Authority Public meeting on the 15 April 2010.

3.5 Where applicable, relevant policies will be reviewed by the Local CounterFraud Service (LCFS) and the Local Security Management Service (LSMS).

3.6 The Human Resources and Health and Safety policies have also beenassessed to establish when upcoming legislation or organisationalrequirements may indicate an appropriate review date and Equality ImpactAssessment. Therefore the recommendation is that the following policies arereviewed again by April 2011.

• Absence Management;

•

Appraisal;

• Dignity at Work;

• Family Friendly;

• Lease Car;

• Pay Protection;

• Retirement;

• Travelling and Subsistence;

• Valuing Diversity;

• Work Experience.

3.7 It is therefore recommended that the following policies should be agreed forapproval by the Authority and then reviewed and Equality Impact Assessedagain by April 2012:

• Disciplinary;

• Establishment Control;



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• Flexible Working;

• Grievance;

• Hospitality, Gratuities and Inducements;

• Organisational Change;

• Performance Improvement;

• Redeployment;

• Recruitment;

• Representation at Work;

•

Study Leave and Development;

3.8 It is therefore recommended that the following policies should be agreed forapproval by the Authority and then reviewed and Equality Impact Assessedagain by April 2013:

• Emergency Response;

• Health and Wellbeing;

• Leave Entitlement;

• Mobile Phone;

• Professional Registration;

• Secondary Employment;

• Secondment;

• Staff Development and Internal Communications;

• Whistleblowing;

• Adverse Incident;

• Fire Prevention;

• Health and Safety;

• Lone Workers;

• Zero Tolerance.





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Appendices

Appendix 1 Absence Management PolicyAppendix 2 Appraisal PolicyAppendix 3 Dignity at Work PolicyAppendix 4 Disciplinary PolicyAppendix 5 Emergency Response PolicyAppendix 6 Establishment Control PolicyAppendix 7 Family Friendly PolicyAppendix 8 Flexible Working Policy

Appendix 9 Grievance PolicyAppendix 10 Health and Wellbeing PolicyAppendix 11 Hospitality, Gratuities and Inducements

PolicyAppendix 12 Lease Car PolicyAppendix 13 Leave Entitlement PolicyAppendix 14 Mobile Phone PolicyAppendix 15 Organisational Change PolicyAppendix 16 Pay Protection PolicyAppendix 17 Performance Improvement PolicyAppendix 18 Professional Registration PolicyAppendix 19 Redeployment PolicyAppendix 20 Recruitment PolicyAppendix 21 Representation at Work PolicyAppendix 22 Retirement PolicyAppendix 23 Secondary Employment PolicyAppendix 24 Secondment PolicyAppendix 25 Staff involvement and Internal

Communications PolicyAppendix 26 Study Leave and Development PolicyAppendix 27 Travelling and Subsistence Policy

Appendix 28 Valuing Diversity PolicyAppendix 29 Whistleblowing PolicyAppendix 30 Work Experience PolicyAppendix 31 Adverse Incident PolicyAppendix 32 Fire Prevention PolicyAppendix 33 Health and Safety PolicyAppendix 34 Lone Workers PolicyAppendix 35 Zero Tolerance Policy





Appendix 1

Absence Management Policy

This appendix sets out the revised AbsenceManagement Policy for the South West StrategicHealth Authority.





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Absence Management Policy

1. Introduction

1.1 The South West Strategic Health Authority is committed to improving thehealth, well being and attendance of all our employees. We recognise thevaluable contribution that our employees make in achieving our aims.

1.2 The Absence Management policy and procedure will ensure that allemployees are supported when sick and enabled to return to work as soon aspossible to continue their contribution to our success.

1.3 Any enquiries with regard to sickness absence must be discussed with theemployee’s line manager who, in turn, may contact the Human Resources

team for advice.

1.4 The South West Strategic Health Authority aims to promote equality anddiversity and the value the benefits this brings. It is our aim to ensure that allstaff feel valued and are treated fairly and equitably at work.

1.5 It is the intention of this policy and procedure to ensure that all employees aretreated fairly and consistently in the management of sickness absence.

1.6 This policy should be read in conjunction with the:

• Dignity at Work policy;

• Disciplinary policy;

• Family Friendly policy;

• Flexible Working policy;

• Health and Safety policy;

• Health and Wellbeing policy;

• Organisational Change policy;

• Performance Improvement policy.



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2. Policy principles

2.1 The Absence Management policy and procedure is based upon the followingprinciples:

• regular, punctual attendance is a requirement for the employmentrelationship. The South West Strategic Health Authority expects eachemployee to take responsibility for achieving and maintaining goodattendance;

• the South West Strategic Health Authority will support employeesduring and after periods of sickness. This support will include:

∗ occupational health support and advice;

∗ access to counsellors where necessary;

∗ sheltered return to work following long-term sickness absence;

• all line managers will ensure a safe working environment whichincludes the awareness that stress can lead to short and long termabsence;

• special consideration will be given to those employees who may haveprotection under the Disability Discrimination Act 2005. Each case willbe treated on its own merits and individual circumstances;

• take into account the needs of those staff who may have protectionunder the Sex Discrimination (Gender Reassignment) Regulations1999. Each case will be treated on its own merits and individualcircumstances;

• the South West Strategic Health Authority respects the confidentialityof all information relating to an employee’s sickness. This policy will beimplemented in line with all data protection legislation and the Accessto Medical Records Act 1988.

3. Responsibilities of employees

3.1 The responsibilities of the employees include the need to:

• take responsibility for achieving and maintaining good attendance;

• comply with the Absence Management policy and procedure and to co-operate with their line manager in its implementation;

• notify the nominated person (normally the line manager) on the firstday of absence by 10am or as soon as reasonably practicable; statingthe reason for absence, the date they first became ill and the likely

duration of absence (a third party should only be used to notifysickness absence when it is not practically possible to do so);



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• keep their line manager informed during their absence and provide allnecessary information to allow their line manager to support them;

• inform their line manager when they are well enough to return to work,even if it is a day off or annual leave;

• attend meetings and occupational health reviews to enable the linemanager to discuss the reason for, and cause of, absence andanything the line manager can do to help and that the employee is fit towork. Failure to do so may result in disciplinary action and/or decisionbeing made in their absence or the absence of medical advice.

4. Responsibilities of employers

4.1 The responsibilities of the employer include the need to:

• demonstrate that a fair and consistent procedure has been metincluding attending management training on this policy procedure andkeeping up to date with any changes;

• proactively manage and support their employees;

• keep accurate records on their employees which will be storedconfidentially in the employee’s personnel file in line with all dataprotection legislation and the Access to Medical Records Act 1988;

• notify Human Resources of an employee’s sickness and return to work

within the set payroll deadlines to ensure employees receive theircorrect pay entitlement;

• ensure that employees are aware of and understand the AbsenceManagement procedure;

• maintain reasonable and sensitive contact with employees who areabsent due to sickness;

• seek Occupational Health and Human Resources advice and supportwhere appropriate in order to promote the health and wellbeing of

employees;

• ensure that, at every stage in the policy, the employee is aware of theirright to be accompanied by a Trade Union representative or workcolleague (not acting in a legal capacity); this does not extend to theright of legal representation, partners and family members.

5. Reporting of absence

5.1 Line managers must ensure that all employees are aware of the procedure forreporting absence to either themselves or a nominated person.



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5.2 The line manager or nominated person must complete a Notification ofAbsence form to be sent to the Human Resources team.

5.3 All sickness absence must be recorded from the first day of reported sickness,even if that day was a day off or annual leave for the employee concerned.

5.4 When an employee hits one of the short term absence trigger points, the shortterm absence procedure will be followed.

5.5 Failure to notify sickness absence will be treated as unauthorised absenceand may result in the decision to withhold pay and/or use the Disciplinarypolicy of the South West Strategic Health Authority.

5.6 The line manager or nominated person must record the sickness absence ona Sickness Absence Notification Form which should be sent to the HumanResources team to record as sickness absence.

5.7 Should the period of absence continue for eight days or more (includingSaturday and Sundays) a medical certificate must be submitted by theemployee to their line manager, to cover the entire absence. Failure to supplythese certificates regularly and on time may result in pay being withheld.

5.8 If an employee is absent during a period of annual leave, they must follow thereporting procedure as detailed above and submit a medical certificate inorder for their line manager to consider reinstating their annual leave.

5.9 Sickness absence at work:

• if an employee is unwell whilst at work and leaves work early, it mustbe reported to their line manager or nominated person;

• will be monitored but will not be counted as a sickness absence unlessit is the third or more occasion of part day absence in the twelve monthrolling period;

• part day sickness absence must be recorded on a Sickness AbsenceNotification Form.

6. Return to work6.1 On return from sickness absence, a self-certification form must be completed

by the employee and submitted to their line manager.

6.2 The line manager or nominated deputy will carry out a Return to WorkInterview during the employees first day back at work. In cases where this isnot possible, they must be completed within 48 hours.

6.3 The purpose of a Return to Work Interview is to discuss the reason for andcause of absence, identify any support the line manager is able to offer andconfirm that the employee is fit to work.



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6.4 Return to work interviews are recognised as the most effective way to reduceabsence and support employees in the workplace.

6.5 Employees have the right to be accompanied by a Trade Union representativeor work colleague (not acting in a legal capacity).

6.6 During a return to work interview a line manager can:

• express their concerns, if any, with regard to their health problems;

• let them know they were missed and make arrangements to updatethem on any information they have missed;

• identify any underlying problems;

• draw attention to frequent absence following days off, weekends and

so on;

• refer the employee to Occupational Health should any medicalcondition be identified that is likely to affect the employee’sperformance in their job; this must be with the employee’s consent.

6.7 The Return to Work form must be completed in full and retained in theemployee’s personal file.

7. Formal sickness reviews

7.1 A formal review will be triggered by:

• frequent short term absences;

• long term absence;

• frequent part day absences.

7.2 A formal review will consist of a Return to Work interview and, should there beno subsequent improvement in short term absence over the agreed period oftime, may lead to:

• a referral to Occupational Health to help identify the nature of anemployee’s illness and provide advice on how best to improve theemployee’s health and well being;

• formal meetings to discuss the employee’s absence;

• agreed targets for improvement over a set period of time;

• dismissal should the employee fail to meet the required levels ofattendance in line with the South West Strategic Health AuthorityAbsence Management procedure.



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8. Short term sickness absence

8.1 A short term absence is any period of absence that lasts less than fourcontinuous weeks.

8.2 In order to manage sickness absence, the following trigger points have beenidentified:

• two occasions of absence in a three month period; or

• three occasions of absence in a twelve month year; or

• eleventh day of absence in a twelve month rolling year.

8.3 When an employee hits one of the short term absence trigger points, the shortterm absence procedure must be followed.

Stage one – formal return to work interview

8.4 This stage acts as an indicator to employees that their absence is causingconcern and that monitoring will commence on the next occasion of absence.The aim is to try and prevent any further absence by identifying andaddressing issues and considering support required as part of the return towork interview.

8.5 The standard return to work interview form is completed by the line manager.However, it is recorded that this is a formal return to work interview by ticking

the appropriate box at the top of the form and recording that the stage oneformal return to work interview has taken place.

Stage two – first formal review

8.6 This stage takes place when an employee has another period of absencefollowing the stage one formal return to work interview, for example:

• the third occasion within three months; or

• the fourth occasion in a twelve month rolling year; or

• the eleventh day of absence in a twelve month rolling year.

8.7 On their return from the absence the line manager will carry out a return towork interview with the employee and during this inform them that a meetingwill be arranged to discuss their absence.

8.8 The line manager will invite the employee, in writing, to the meeting. Theletter will give seven days notice of the meeting; explain their right torepresentation and provide a copy of the policy.



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8.9 The aim of the meeting is to:

• discuss the episodes and reasons for the absence and ensure that theemployee is aware of the absence triggers that they have hit;

• assess the possibility of an underlying medical condition by referringthe employee to Occupational Health;

• inform the employee that continued absence periods are unacceptableand state that the employee’s continued employment could be at risk(dismissal due to failure to meet the required levels of attendance inline with the South West Strategic Health Authority’s AbsenceManagement policy);

• consider any personal problems or worries the employee may have,with discussion on the ways in which they may be resolved;

• agree that the employee’s attendance will be monitored for a period ofsix months, setting a target of no more than one occasion of absenceduring the monitoring period.

(In the case of an employee being covered by the DisabilityDiscrimination Act 2005, consideration should be given to adjusting thetargets. Guidance must be sought from the Human Resources teamon setting these targets and, if the post cannot support adjustedtargets, consideration should be given to redeployment);

• inform the employee that there will be monthly review meetings duringthe monitoring period;

• details of the meeting must be confirmed in writing to the employeewithin five working days of the meeting taking place.

8.10 A review meeting will be held at the end of the agreed monitoring period.

8.11 The employee will be advised that they have been taken off monitoring. Itmust be explained to them that should their sickness absence levels reach atrigger point again within the next six months, the policy may be used again at

the next stage.

8.12 If during the monitoring period the employee has exceeded the targets set,then they will asked to attend a meeting where they will be informed that therehas been no satisfactory improvement and that they will proceed to the nextstage of the policy.

Stage three – further formal review

8.13 Where the targets set in Stage Two - First Formal Review are not met, aStage Three - Further Formal Review meeting will be arranged with the

employee’s line manager and their Human Resources Advisor.



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8.14 The line manager will invite the employee, in writing, to the meeting. Theletter will give seven days notice of the meeting and explain their right torepresentation by a Trade Union representative or work colleague (not actingin a legal capacity).

8.15 The meeting should follow the same process as for Stage Two - First FormalReview. However, the employee should be advised that the monitoring periodwill be for six months with a target of no more than two occasions of absence.In the case of an employee being covered by the Disability Discrimination Act2005, consideration should be given to adjusting the targets. Guidance mustbe sought from Human Resources team on setting these targets.

8.16 The line manager must make a further referral to Occupational Health toexclude any underlying health issues.

8.17 The consequences of not reaching the given targets must be clearly indicated,

this will involve consideration of termination of employment.

8.18 The meeting will be summarised in writing to the employee including what theconsequences will be if these targets are not met.

8.19 A review meeting will be held at the end of the agreed monitoring period, ifsatisfactory improvement is achieved and sustained during the monitoringperiod no further action will be taken.

8.20 The employee will be advised that they have been taken off monitoring. Itmust be explained to them that should their sickness absence levels reach a

trigger point again within the next six months the policy may be used again atthe next stage.

8.21 If during the monitoring period the employee exceeds the targets set, thenthey will be asked to attend a meeting where they will be informed that therehas been no satisfactory improvement and it is, therefore, necessary toproceed to the next stage of the policy.

Stage four – final review meeting

8.22 Progression to Stage Four – Final Review meeting will occur when the agreed

targets set at Stage Three – Further Review have not been met andOccupational Health has not identified an underlying health problem.

8.23 The termination of an employee’s contract will not normally be consideredunless a recent assessment by Occupational Health has occurred. However,if an employee refuses to attend an Occupational Health review without anexplanation that is satisfactory to the South West Strategic Health Authority,the Final Review Meeting will proceed and a decision will be taken on theinformation that is available.



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8.24 An Executive Director or Chief Executive will Chair the Final Review Meeting.A Human Resources representative who has not previously been involved inthe case will also be present to advise the Chair on matters of procedure andfairness.

8.25 The employee must be given at least seven days written notice of the decisionto hold a Stage Four - Final Review Meeting. The letter must include thefollowing information:

• date, time and venue for the meeting;

• purpose of the meeting;

• right to be accompanied;

• who will be the management representative;

• arrangements for the exchange of the management statement of case;

• the possible outcome of the meeting will be termination of their contractof employment.

8.26 The management statement of case should normally include the followingdocumentation:

• a complete sickness record including a summary of reasons forabsence;

• copies of all letters sent throughout the process;

• copies of all return to work interview records;

• copy of the formal return to work interview record;

• copy of all Occupational Health and/or specialist medical reports;

• summary of management procedure including a time plan which setsout the key dates for the whole process;

• any other information as deemed relevant.

8.27 Any new information given at the meeting regarding ill health or a change inthe nature of the sickness must be assessed with a referral to OccupationalHealth Department, which may result in the review meeting being adjourned.

8.28 Having considered the employee’s submissions the possibility of terminatingthe employee’s contract should be considered.

8.29 If dismissed the employee should be notified in writing of the reason for theirdismissal and their right to appeal. The appeal process will be the same asthe Disciplinary Appeal process. Please see the Disciplinary policy for details.



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9. Long term absence procedure

9.1 When an employee hits the long term absence trigger of four continuousweeks of absence, the long term absence procedure must be followed.

9.2 Long term sickness absence must be handled sensitively and with care. It isimportant that appropriate action is taken without undue delay to help both theemployee concerned, as well as their colleagues.

9.3 Line managers are required to maintain reasonable contact with employeeson an agreed basis, but not less frequently than fortnightly. If the employee isnot happy for their line manager to be their point of contact then they canrequest for an agreed third party to maintain contact. However, the linemanager must be kept up to date at all times and a record of all contact mustbe kept.

9.4 Line managers must refer an employee to Occupational Health when they hitthe long term absence trigger, this referral should be made as soon as the linemanager is aware that the absence will be for four weeks or more.

9.5 Once a management referral has been made to Occupational Health, all longterm absence cases must be discussed and monitored through the CaseConference system at the appropriate time. These will provide a forum toidentify appropriate ways of supporting the employee to return to work at theearliest opportunity. Line managers must remind the employee they have theright to representation at the case conference.

Employee is fit to return to work

9.6 Line managers should normally allow a sheltered return to work and monitorthe situation.

Employee is capable of returning to their current post but cannot fulfilall of the duties.

9.7 Line managers must seek advice from Human Resources.

Redeployment (employee is not fit to return to their current post but is

capable of other work)9.8 There is a legal obligation to consider the employee for any suitable

vacancies. The Redeployment policy of the South West Strategic HealthAuthority should be followed.

9.9 An induction programme should also be considered where appropriate.





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• Option two – Termination of employment:

* Where an alternative post is not available, and all appropriateavenues have been considered or the medical report states thatthe employee will be unfit to return to work, a final review

meeting will be held and the employee’s contract of employmentwill be terminated with the appropriate notice; procedures for thefinal review meeting are attached at Annex 1.

9.14 Where terminal illness is diagnosed it may be appropriate to take no furtheraction and advice must be sought from Human Resources.

The final review process

9.15 Progression to Stage Four - Final Review (see Annex 1) meeting will occurwhen the agreed targets set at Stage Three – Further Review have not been

met and Occupational Health has not identified a relevant underlying healthproblem.

9.16 The termination of an employee’s contract will not normally be consideredunless a recent assessment by Occupational Health has occurred. However,if an employee refuses to attend an Occupational Health review without anexplanation that is satisfactory to the South West Strategic Health Authority,the Final Review Meeting will proceed and a decision will be taken on theinformation that is available.

9.17 An Executive Director or Chief Executive will Chair the Final Review Meeting.

A Human Resources Representative who has not previously been involved inthe case will also be present to advise the Chair on matters of procedure andfairness.

9.18 The employee must be given at least seven days written notice of the decisionto hold a Stage Four - Final Review Meeting. The letter must include thefollowing information:

• date, time and venue for the meeting;

• purpose of the meeting;

• right to be accompanied;

• who will be the management representative;

• arrangements for the exchange of the management statement of case;

• the possible outcome of the meeting will be termination of their contractof employment.



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9.19 The management statement of case should normally include the followingdocumentation:

• a complete sickness record including a summary of reasons forabsence;

• copies of all letters sent throughout the process;

• copies of all return to work interview records;

• copy of the formal return to work interview record;

• a copy of all Occupational Health and/or specialist medical reports;

• summary of management procedure including a time plan which setsout the key dates for the whole process;

• any other information as deemed relevant.

9.20 Any new information given at the meeting regarding ill health or a change inthe nature of the sickness must be assessed with a referral to OccupationalHealth Department, which may result in the review meeting being adjourned.

9.21 Having considered the employee’s submissions the possibility of terminatingthe employee’s contract should be considered.

9.22 If dismissed the employee should be notified in writing of the reason for their

dismissal and their right to appeal. The appeal process will be the same asthe Disciplinary Appeal process. Please see the Disciplinary policy for details.

9.23 On return to work after a long term absence, a Return to Work interview willbe carried out to discuss anything the line manager can do to help andconfirm that the employee is fit to work.

9.24 The line manager will make arrangements to update the employee onprogress in their work and workplace development that have occurred duringtheir sickness absence. An induction programme will be arranged whereappropriate.

9.25 Regular reviews of sickness absence between the employee and linemanager will be arranged at reasonable intervals as appropriate.

9.26 In some cases, Occupational Health may recommend a sheltered return foran employee; this will be a temporary change for either a period of part timework or a post with alternative or less demanding duties.

9.27 Statutory leave will continue to be accrued during all sickness absence.



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10. Sickness absence due to a work related cause

10.1 Any sickness absence from work that is caused by an injury sustained duringyour normal duties or due to a disease or condition caused by youremployment, must be reported to your line manager or nominated person

using the Reporting procedure outlined in Section 1 above.

10.2 If the absence exceeds four weeks, it will be treated as a long term absenceas detailed in Section 4 above.

11. Non-reported absence

11.1 Non-reported absence occurs when an employee fails to follow the Reportingprocedures as detailed in Section one. In the event of Non-ReportedAbsence the line manager should follow the following procedure:

• on the first day the line manager should attempt to make contact bytelephone;

• if the employee returns, the line manager conducts a Return to Workinterview as per section 6.6 and additionally:

• explore the reasons for the Reporting procedure not having beenfollowed;

• ensure that the employee understands the reporting procedure.

11.2 If the employee does not return to work on their expected next day of work,the line manager should send a letter inviting the employee and arepresentative to a meeting to discuss their non-attendance. The employeeshould be given seven days notice of the meeting.

11.3 If the employee responds to the letter, a meeting should be held with the linemanager, employee and a representative present to explore the reasons fornon-attendance and failure to follow the Reporting procedure.

11.4 If the employee does not respond to the letter, the disciplinary procedure maybe invoked and may result in dismissal due to the employee failing to fulfil

their contract by attending work. Should the employee remain un-contactable,this may ultimately result in any disciplinary action proceeding in theirabsence.

11.5 If the employee does not return on their expected next day of work, the linemanager will make contact in writing to arrange a meeting to explore thereasons for absence.

11.6 Employees have the right to be accompanied by a Trade UnionRepresentative or work colleague (not acting in a legal capacity).

11.7 If the employee reaches the trigger points for short term absence, the shortterm absence procedure will be followed as detailed in Section 8.



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12. Other paid employment

12.1 If the employee works for a second employer in their own time they mustdeclare who is their main employer for Statutory Sick Pay purposes.

12.2 The South West Strategic Health Authority must be informed of any otheremployment or business activity and give consent for such employment.Consent may be withdrawn if, in the opinion of the South West StrategicHealth Authority, such activity conflicts with your performance and duties.

12.3 The main employer should be in receipt of the medical certificate; the secondemployer should receive a copy of the certificate.

12.4 In the event of an employee’s General Practitioner deciding that the employeeis fit to carry out the duties for one employment but not fit to carry out theiremployment duties with the South West Strategic Health Authority the

employee must inform their line manager as this may affect Sick Paypayments. Failure to do so may result in formal action being taken under theDisciplinary policy of the South West Strategic Health Authority.

13. Role of Occupational Health

13.1 Advice will be sought from Occupational Health in order that sicknessabsence is managed effectively.

13.2 Employees may also self-refer at any stage to Occupational Health.

13.3 A free confidential staff support service is also available to all employees on aself-referral basis.

14. Occupational Health Service

14.1 Occupational health is a distinct branch of medicine concerned with how aworker’s health can affect his or her ability to fulfil their job and how work andthe work environment can affect an employee’s health.

14.2 Occupational health is about the effect work has on health and about makingsure employees are fit for the work that they do. As a result of a management

referral occupational health can provide advice to line managers and aim toassist employees with health problems.

14.3 Management referrals to Occupational Health must be made with the fullknowledge of the employee concerned, encouraging open exchanges ofinformation.

14.4 It is important that the occupational health advisor is made aware of allrelevant facts about a case to ensure that objective advice is given, based ona full understanding of the issues of concern to the referring line manager.



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14.5 The Occupational Health Referral Form is designed to help managers providesufficient information and specify the type of advice they are seeking whenmaking a referral. Occupational Health will then:

• review the information provided by the line manager;

• elicit further information from the employee;

• carry out any appropriate examination relevant to the employee’shealth problems;

• subject to the employee’s written consent, obtain, if necessary, furthermedical information from the employee’s own General Practitioner orHospital Specialist;

• determine the advice that will be offered to the line manager and

advise the employee of this;

• arrange a follow-up appointment if required.

14.6 Advice given to the line manager will not contain confidential medical detail,but is concerned with matters of employment and fitness and will contain thefollowing:

• whether or not the employee is suffering from a health problem whichwill have an impact upon their fitness to carry out their duties. Wherethere is no medical evidence or any medical problem to account for an

employee’s absence record, this will be clearly stated;

• the potential effects of the problem on current and future performanceor attendance;

• adjustments to the work place or tasks that would assist in maintaininghealth and reducing the effects of the health problem on attendanceand performance;

• the likely duration of any period of absence or, if it is not possible to beprecise about this, the minimum likely period of absence.

14.7 Where the employee becomes fit to work, whether it will be on return to fullduties or whether limitations should apply:

• if limitations will apply, whether these limitations are likely to betemporary or permanent;

• if an individual will not be fit again for normal duties, the nature of othertypes of duties for which they will be fit;

• the likelihood of ongoing episodes of sickness absences, whether such

episodes may be of long or short duration and the period of time duringwhich such absences are likely to occur;



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• whether the employee’s health problem may in any way be related totheir duties;

• arrangements that have been made for further review of the employee;

• opinion on the implications of the Disability Discrimination Act 1995;

• the potential for an individual to maintain a good attendance record,and if appropriate, suitability for Ill Health Retirement.

14.8 If the line manager has concerns or questions relating to the advice providedthen they should contact Staff Occupational Health for further clarity.

14.9 In the event of conflicting medical reports occupational health will obtain areport from the medical practitioner and/or seek to obtain their medical file.

15. Medical suspension15.1 Medical suspension is applied in a situation where a General Practitioner

would certify a member of staff fit to work. However, the South West StrategicHealth Authority or Occupational Health have deemed them not able to workfor a defined period. For example, this situation may apply because of aninfectious condition which could place patients or other members of staff atrisk. This medical suspension should be recorded on the weekly sicknessreturn as medical suspension and not as sickness.

15.2 In every case the line manager should discuss with Occupational Health if

temporary redeployment or different duties could support the employeereturning to work sooner, and where possible should support this.

16. Case conferences

16.1 Case conferences are an opportunity for all parties to sit down together anddiscuss the employee’s absence and look at the process and support neededto either stop the employee going off sick, or to support the employee inreturning to work.

16.2 The case conference will comprise of the employee and their representative,

the line manager, a Human Resources Advisor and an Occupational Healthrepresentative.

16.3 During the case conference no medical information will be discussed unlessthe employee is happy for this to be shared with all parties.

16.4 The case conference will provide a regular setting to assess and monitoremployees who are off sick, and provide an opportunity to determine whataction is required.



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16.5 The case conference is not the forum for formal discussions to take place, forexample: placing on the redeployment register, serving notice and so on.However, discussion taking place at the case conference will form the basis ofdecisions which are made about moving forward.

17. Intended outcomes

17.1 The intended outcomes of this policy are to ensure that:

• all employees will have been treated fairly and consistently whenabsent due to sickness;

• the needs of individuals are balanced with the overall requirements ofthe South West Strategic Health Authority;

• all employees have a clear understanding of the roles and

responsibilities for line managers and themselves in managingabsence.

17.2 An impact assessment for this policy will be completed every three years.

Policy Approved: April 2010

Review By: April 2011



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Annex 1


Procedure for conducting Final Review Meetings

1. Introduction

1.1 The following should be noted when considering the procedure for conductingFinal Review Meetings:

• the following guidelines will inform all Final Review Meetings but theDirector will be responsible for determining the procedure for theconduct of the meeting, taking advice from the Human Resources teamas required;

• throughout this document, the term ‘employee’ will be deemed toinclude his or her representative at the hearing, if the employee haschosen to be represented.

2. The final review meeting procedure

2.1 The following procedure will normally apply to disciplinary hearings:

• the Chair will confirm that the employee has received a copy of thereport of the line managers written statement of case;

• where the employee is unaccompanied, confirm that the employee hasbeen made of their right to representation and is happy to proceedwithout;

• the line manager will present their report. No new additional writtenevidence will be allowed unless all parties present at the hearing agreethat is should form part of the hearing;

• the member of staff may make a statement in respect of their case.The Chair and the line manager may ask questions of the member ofstaff concerning this statement;

• the line manager will summarise their management case;

• the member of staff will summarise their case;

• the Chair will call on both parties to withdraw but may recall either partyin the presence of the other for a point of clarification;

• the Chair may depart from this sequence if clarification of issues isconsidered necessary, whether requested by the parties to the FinalReview Meeting or because the Chair believes that immediate

clarification will enable the Final Review Meeting to proceed mosteffectively;



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• the Chair will recall both parties and inform them of their decision;

• the Chair will confirm the decision in writing within five working daysand in the event of the decision to dismiss, will inform the member ofstaff of their right of appeal;

• either party may request an adjournment at the discretion of the Chair.The Chair will agree to this unless the request is unreasonable.



Appendix 2

Appraisal Policy

This appendix sets out the revised Appraisal Policyfor the South West Strategic Health Authority.





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Appraisal Policy

1. Introduction

1.1 The South West Strategic Health Authority believes that the Appraisal iscritical for the effective development of staff to meet the aims and objectivesof the South West Strategic Health Authority.

1.2 Appraisal is a contractual obligation for all staff in the South West StrategicHealth Authority.

1.3 All staff in the South West Strategic Health Authority should use this Appraisalprocedure, although the application of and links with the NHS Knowledge andSkills Framework do not apply to those on Very Senior Manager Terms and

Conditions of Service.

2. Philosophy

2.1 The South West Strategic Health Authority is committed to the fair andconsistent treatment of staff regardless of their sex/gender, sexual orientation,religion or religious beliefs, race, age, or disability. Where evidence ofinequality or adverse effect is found the South West Strategic Health Authoritywill take appropriate action.

2.2 Staff work more effectively if they clearly know what is expected of them andhow well they are performing.

2.3 Openness and constructive dialogue between the reviewer and staff memberare of more importance than a detailed written record.

2.4 All staff should have the opportunity to develop in their job and be givensupport and training to do so.

3. Principles

3.1 The Appraisal process should be a positive and supportive experience

encompassing the principles of lifelong learning and continuous skillsenhancement.

3.2 Appraisals should represent a part of an on-going process of communicationbetween the manager and the staff member.

3.3 All staff should have a current job description, set of objectives, PersonalDevelopment Plan and, except for those on Very Senior Manager terms, aNHS Knowledge and Skills Framework outline.

3.4 All managers who undertake appraisals must attend any training provided.



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3.5 All new staff should receive an introduction to the Appraisal procedure of theSouth West Strategic Health Authority and an explanation of the NHSKnowledge and Skills Framework.

3.6 This policy should be read in conjunction with the following policies and

procedures of the South West Strategic Health Authority, where appropriate:


• Grievance policy;


• Performance Improvement policy;

• Professional Registration policy;

• Retirement policy;

• Secondment policy;

• Study Leave and Development policy.

4. Objectives

4.1 The objectives of the policy are to:

•

improve performance;

• improve communication;

• develop staff in line with business objectives and enable training needsto be identified, collated and delivered;

• facilitate workforce succession/career planning;

• improve the working lives of staff;

• embed the NHS Knowledge and Skills Framework into Appraisal.

5. Responsibilities

Line manager responsibilities

5.1 Line managers are responsible for setting objectives and reviewing theperformance of their staff.

5.2 The role of each manager is to:

• ensure legitimate and realistic objectives are set for their staff;



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• encourage and coach the member of staff and be continually aware ofthe progress that is being made;

• identify obstacles to success and remove them;

• ensure employees have sufficient financial support and time to fulfiltraining and development needs;

• provide praise or appreciation where performance is good.

‘Grandparent’ responsibilities

5.3 The “Grandparent” (the Manager’s manager) will:

• ensure the objectives are fair and timescales realistic;

•

be conscious of any interpersonal conflicts that may distort the processand take action to correct them;

• ensure the manager is acting on legitimate comments and suggestionsfor the person being reviewed.

Employee responsibilities

5.4 Employees are responsible for:

• fully participating in the Appraisal process;

• agreeing legitimate and realistic objectives, personal developmentplans, and an NHS Knowledge and Skills Framework outline (KSFoutline);

• working with their manager to fulfil agreed development plans;

• meeting their responsibilities under the Study Leave and Developmentpolicy.

6. Timing

6.1 The Appraisal will normally take place during May, June or July of each year.Mid year reviews must take place after six months.

6.2 The Head of Human Resources will monitor the timeliness and effectivenessof the procedure.

7. Preparation

7.1 Preparation by both managers and staff will be the key to a successfulAppraisal.



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7.2 Managers must ensure that all staff have access to:

• the Business Plan of the South West Strategic Health Authority;

• a job description for their role;

• Appraisal paperwork;

• NHS Knowledge and Skills Framework outline, except for those onVery Senior Manager terms.

7.3 All staff will be provided with notice of at least one week to prepare for theirAppraisal.

8. The Appraisal documentation

8.1 Linked to this policy is a series of documents available on the intranet thatshould be completed in support of the appraisal discussion. These are set outbelow.

Document Purpose

NHS Knowledge andSkills FrameworkOutline

A copy of the NHS Knowledge and SkillsFramework outline for the individual with space torecord their progress towards its achievement (seesection 7).

Objectives Form Listing the key objectives agreed as a result of themeeting.

PersonalDevelopment Plan

Outlining the training and support which will helpthe employee achieve those objectives.

9. About NHS Knowledge and Skills Framework Outlines

9.1 An NHS Knowledge and Skills Framework outline identifies the degree of

competency required to function most effectively in any given role.

9.2 The NHS Knowledge and Skills Framework itself is made up of a list ofcompetency areas called dimensions. Every job is considered to be made upof some combination of these dimensions of competency.

9.3 All jobs are considered to contain six core dimensions. These are:

• communication;

• personal and people development;

• health, safety and security;



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• service improvement;

• quality;

• equality and diversity.

9.4 Most jobs include additional, more specialised, competencies above andbeyond these core ones. To account for this, the NHS Knowledge and SkillsFramework contains a list of 24 specific dimensions which may, or may not,apply to any given job.

9.5 A NHS Knowledge and Skills Framework outline is generated by using the jobdescription for the role to determine which of the dimensions (areas ofcompetency), core and specific, are applicable to it.

9.6 Once the applicable dimensions have been decided on, the degree to which

each competency is required in order to do the job needs to be determined.

9.7 Each dimension is divided into four levels of competency numbered inascending order from 1 to 4.

9.8 A completed NHS Knowledge and Skills Framework outline will thereforeshow all the areas of competency (the dimensions) associated with a job andthe corresponding degree (or level) to which that competency needs to bedisplayed by the post-holder, an example is included as Annex 1.

9.9 When appraising staff and identifying their development needs, managers

should use this outline as a guide.

9.10 By matching the post-holder against the outline for the job, it is possible toidentify what development needs they have with respect to reaching therequired standards of competency in all areas of the role.

9.11 The appraisal process will therefore require appraisers to consult the NHSKnowledge and Skills Framework and the relevant outline when agreeingindividual objectives and their Personal Development Plan.

9.12 You can find more details about the NHS Knowledge and Skills Framework onthe Department of Health website www.dh.gov.uk.

10. Linking the NHS Knowledge and Skills Framework to payprogression

10.1 The NHS Knowledge and Skills Framework is linked directly to staff members’progression through the standard NHS Pay Bands. The right to a payincrement is linked to the progress of the post-holder against the NHSKnowledge and Skills Framework outline.

10.2 Progress is measured at two points in the progression through the pay band.

These points are called gateways.



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10.3 If the staff member has not demonstrated the required progress against theNHS Knowledge and Skills Framework outline, they will stop at one of thesegateways until such time as they have demonstrated the required competencylevel.

10.4 The two gateways are the:

• foundation gateway: reached after one year;

• secondary gateway: reached when the individual is between one andthree points from the top of the pay band.

10.5 The foundation gateway represents a subset of the total skills required toachieve the full NHS Knowledge and Skills Framework outline. It can belooked at as the minimum acceptable competency level required to do the job.

10.6 The secondary gateway represents the full NHS Knowledge and SkillsFramework outline whereby the post-holder must demonstrate that they haveachieved all the necessary competencies in their entirety.

10.7 Between gateways, the post-holder will continue to receive an increment yearon year whilst working to develop the skills necessary to satisfy the NHSKnowledge and Skills Framework outline.

10.8 Fig. 1 shows how the gateways might be distributed throughout the pay band.The exact position of the secondary gateway is dependent on the pay band inquestion.

Fig. 1: Notional Diagram of Pay Band X and the Gateway Positions

Point 9Point 8Point 7Secondary gatewayPoint 6Point 5Point 4Point 3

Point 2Foundation gatewayPoint 1 (start)

10.9 It is the responsibility of the post-holder and the employer in partnership tosupport the development required to move through each gateway. It is notacceptable for either party to ignore this obligation.

10.10 The post-holder cannot be denied an increment if the organisation has failedto support their development needs in the manner outlined in their PersonalDevelopment Plan (see below).

PayProgression



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10.11 Correspondingly, the post-holder is not entitled to move through a gateway ifthey have not been active in taking their Personal Development Plan forward,or have refused to take part in any of the developmental work specified.

10.12 The appraisal process will be the mechanism for measuring progress and

should therefore be managed in the most open and equitable way possible.

11. Review meeting

11.1 The Appraisal will include, as a minimum, discussion on each of the followingfour areas to:

Assessment of past year

• review achievements over the past twelve months and agree any areaswhere further development is necessary;

• consider issues relating to improving working lives, including flexibilityof working hours, working environment, communication;

• future objectives;

• identify key objectives of the South West Strategic Health Authority andthe Directorate;

• identify the individual contribution to achieving these objectives;

•

include individual objectives not covered by the South West StrategicHealth Authority and/or the plans of the Directorate.

• personal development plan;

• identify training and development needs;

• develop a plan for meeting those needs in the most appropriate way;

• career/future plans;

•

discuss long term aspirations and how they can be realised.

12. Processes

12.1 The Appraisal should be given priority and sufficient time by both theemployee and the line manager.

12.2 The Appraisal should be informal and conducted in a non- threatening andneutral environment.

12.3 Open, honest and constructive feedback should also be provided by themanager in such a way as to motivate staff to improve and develop their skillswhere necessary.





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• all employees have a clear understanding of their role andresponsibilities;

• all employees remain competent to fulfil their professionalresponsibilities.

15.2 An equality impact assessment for this policy will be completed every threeyears.





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41


NHS Knowledge and Skills FrameworkSample Job Outline – Administrative Assistant

NHS KSF Dimensions NeededforPost?

Level for Post

1 2 3 4 NotesCore Dimensions –relates to all NHS posts1 Communication Y X FG = 3

2 Personal and people development Y X FG = 2

3 Health, safety and security Y X FG = 1

4 Service improvement Y X FG = 2

5 Quality Y X FG = 2

6 Equality and diversity Y X FG = 2

Specific DimensionsHealth And WellbeingHWB1

Promotion of health and wellbeing andprevention of adverse effects to healthand wellbeingHWB2Assessment and care planning tomeet people’s health and wellbeingneedsHWB3Protection of health and wellbeingHWB4Enablement to address health and

wellbeing needsHWB5Provision of care to meet health andwellbeing needsHWB6Assessment and treatment planningHWB7Interventions and treatmentsHWB8Biomedical investigation and

intervention



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NHS KSF Dimensions NeededforPost?

Level for Post

1 2 3 4 NotesHWB9

Equipment and devices to meet healthand wellbeing needsHWB10Products to meet health and wellbeingneedsEstate And FacilitiesEF1Systems, vehicles and equipment

EF2Environments and buildings

EF3Transport and logistics

Information And KnowledgeIK1Information processing

Y X FG = 2

IK2Information collection and analysis

IK3Knowledge and information resources

GeneralG1Learning and development

G2Development and innovation

G3Procurement and commissioning

G4Financial management

G5Services and project management

Y X FG = 1

G6People management

G7Capacity and capability

G8Public relations marketing



Appendix 3

Dignity at Work Policy

This appendix sets out the revised Dignity at WorkPolicy for the South West Strategic Health Authority.





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Dignity at Work Policy

1. Introduction

1.1 The South West Strategic Health Authority is striving to be an equalopportunity employer in all its practices and, as such, opposes all forms ofunlawful and unfair discrimination. We believe that all people have the right tobe treated with fairness, dignity and respect.

1.2 The South West Strategic Health Authority is committed to promoting a safe,healthy and fair environment for all its employees. By putting this policy intopractice, the authority has resolved to create a working environment that

supports the dignity of women and men at work and is free from harassment,intimidation, bullying and victimisation.

1.3 All employees have a clear role to play in helping to create a climate at workin which harassment or bullying behaviour is unacceptable. In particular,employees should be aware of their own conduct, avoid colluding withinappropriate behaviour and cooperate fully in any complaints procedure.

1.4 Managers and supervisors have a responsibility to raise awareness of theissue, respond positively to any complaints and challenge and stopunacceptable behaviour in the workplace.

1.5 Employees are encouraged to raise their concerns and have the right tocomplain about such behaviour. Allegations of a breach of dignity at work willbe treated seriously and sympathetically.

1.6 Upon becoming aware that harassment or bullying has taken place, the SouthWest Strategic Health Authority will take prompt corrective action, in-line withthis policy and the views of the individual(s) concerned.

1.7 Deliberate victimisation, serious bullying or harassment on the basis of anindividual’s sex, sexual orientation, religion or religious beliefs, race, age,

disability will constitute gross misconduct.

1.8 No employee will be treated less favourably for raising concerns or for actingas a witness.

1.9 Malicious complaints or retaliation against an employee complaining ofbullying or harassment is a disciplinary offence.

1.10 This policy should be read in conjunction with the following policies of theSouth West Strategic Health Authority:

•

Absence Management policy;




44




• Recruitment policy;

• Whistleblowing policy;

2. Scope of the policy

2.1 This policy applies to all employees and includes contractors and employeesof other organisations engaging with staff of the South West Strategic HealthAuthority.

2.2 There is a general consensus that the most effective way to tackle bullyingand harassment and other conflicts at work is informally and quickly ratherthan a formal route to grievance and disciplinary procedures.

2.3 Notwithstanding the above mentioned the Strategic Health Authority may, inaccordance with its duty of care to all its employees, have no alternative thanto use formal action.

3. Legal framework

3.1 There are a number of laws under which action can be taken that provides

employees with protection from discrimination, harassment and victimisation.

• Criminal Justice Act 1998;

• Criminal Justine and Public Order Act 1994;

• Disability Discrimination Act 1995, and (Amendment) Act 2005;

• Employment Equality (Religion or Belief) Regulations 2003 or theEmployment Rights Act 1996;

•

Employment Equality (Sexual Orientation) Regulations 2003;

• Employment Equality (Age) Regulations, 2006;

• Health and Safety at Work Act 1974;

• Human Rights Act 1998,and The Human Rights Act (2000);

• Protection from Harassment Act 1997;

• Race Relations Act 1976 and Race Relations Amendment Act 2000;

• Sex Discrimination Act 1975 (Amendment) Regulations 2008;



45

• The Public Order Act 1986;

• The Gender Recognition Act 2004.

3.2 Where harassment and/or bullying have occurred, the employer can be

ordered to pay unlimited compensation, including the payment of fines forinjury to feelings.

3.3 Staff who bully or harasses a colleague may find that their actions couldbreach criminal as well as civil law. Staff could personally be liable for anybullying and harassment and may have to pay compensation themselves.

4. Policy aims

4.1 The primary aim of this policy is to prevent behaviour that could be construedas harassment or bullying in the workplace. Where this does occur, the policy

aims to ensure that appropriate and effective action is taken to prevent anyrecurrence.

4.2 The specific objectives of this policy are to:

• ensure that all employees are aware of the types of behaviour whichmay constitute harassment or bullying and their responsibilities forpreventing such behaviour;

• ensure that all employees understand that behaviour that mayconstitute harassment or bullying is unacceptable and that appropriate

measures, including disciplinary action, may be taken;

• promote a climate in which employees feel confident in bringing forwardcomplaints of harassment or bullying without fear of victimisation;

• ensure that all allegations of harassment or bullying are responded toquickly, positively and in confidence;

• provide arrangements whereby complaints can be investigated in amanner which recognises the sensitivity of the issues raised andrespect the rights and confidentiality of all those involved.

5. Definitions

Harassment

5.1 The essential characteristics of harassment are that it is unwanted by therecipient and that it is for each individual to determine what behaviour isacceptable to them and what they regard as offensive. It is the unwantednature of the conduct that distinguishes harassment from behaviour betweenemployees that is welcome, mutual and appropriate in a working environment.



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5.2 Harassment occurs when someone engages in unwanted conduct which hasthe purpose or effect of violating someone else’s dignity or creating anintimidating, hostile, degrading, humiliating or offensive environment.

5.3 Harassment (or bullying) is not dependent on an intention to cause distress or

hurt but is assessed by the impact the behaviour has on the recipient. As aresult, it is possible that behaviour that is acceptable to some employees maycause embarrassment, distress or anxiety to others. It is recognised, therefore,that harassment (or bullying) relates essentially to the perceptions and feelingsof the recipient.

5.4 This policy deals with situations where employees are being harassed (orbullied) by colleagues, subordinates, managers or supervisors. Customers,clients and contractors may be involved, either as harassers or recipients andothers who are present can sometimes be affected as adversely as thosedirectly involved.

5.5 Harassment on the grounds of sex, race, disability, sexuality, age or religionor belief is unlawful and will not be tolerated in any form.

5.6 Any attention by an employee towards another employee, or group ofemployees, which is offensive to the recipient and creates an intimidating,hostile or offensive work environment for one or more employees isunacceptable. Harassment also includes the display of material that is offensiveto employees in the workplace.

5.7 ‘Work’ includes any place where the occasion can be identified with either the

requirements of the employer, or with social events linked to the sameemployment.

5.8 It is worth noting that whilst harassment often involves repeated acts of offensivebehaviour, a single incident may constitute harassment.

5.9 Harassment can take many forms. An illustration but by no means anexhaustive list may include:

• unnecessary and unwanted physical contact ranging from touching toserious sexual or physical assault;

• verbal conduct such as sexist, racist and homophobic comments orinnuendo; derogatory remarks about disability or age, comments of apersonal nature; inappropriate jokes or language;

• display, storage or circulation of offensive material (includinginformation held on computer);

• conduct that denigrates, threatens, ridicules, intimidates or abuses,undermines or undervalues an individual because of characteristics suchas gender, sexuality, disability, race, age or religion or belief including

derogatory or degrading remarks or insults or offensive comments aboutappearance or dress;



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• preventing individuals progressing by intentionally blocking promotion ortraining opportunities;

• unfair treatment, which might include deliberate exclusion fromconversations or events at work, for reasons based on characteristics

such as age, culture, disability, ethnic origin, gender, race, religion orsexuality;

• unfair rules and requirements or abuse of power, for example, settingunreasonable and often unachievable demands;

• withholding information and marginalising, with the intent of deliberatelyaffecting the performance of a colleague;

Bullying

5.10 Although harassment is often related to matters such as race, gender,disability, sexuality, age or religion or belief it is apparent that a more generalform of harassment may take place that is not based on any one clearlyidentifiable aspect of the person concerned.

5.11 This form of harassment may be described as bullying or aggressive orintimidating behaviour by one person towards another.

5.12 Bullying behaviour is largely identified, not so much by what has actually beendone, but rather by the effect that it has on the recipient.

5.13 People affected by bullying often feel the matter appears trivial or that they mayhave difficulty in describing it.

5.14 Bullying can be defined in many ways but is generally behaviour that isidentified as a misuse of power. It is usually persistent (i.e. more than a one-off incident), is offensive, abusive, intimidating, malicious or insultingbehaviour or unfair use of sanctions which makes the recipient feel upset,threatened, humiliated or vulnerable and undermines self confidence.

5.15 Bullying (and harassment) can undermine a person’s self confidence and maycause individuals to suffer stress, fear and anxiety, which can affect their life

outside of work.

5.16 It can manifest itself in many other conditions such as nervousness, poor workperformance, absenteeism.

5.17 At its most extreme, bullying can be physical for example hitting, pushing,damaging or stealing personal possessions. Examples of bullying couldinclude:

• persistent unjustified criticism;

• shouting at colleagues in public or private;

• deliberate isolation by ignoring or excluding a person;



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• withholding information or removing areas of responsibility without justification;

• spreading malicious rumours;

• making inappropriate personal comments;

• blocking leave or training applications without reason;

• setting objectives with impossible deadlines with the deliberateintention of undermining an individual;

• undermining a person's self respect by condescending, paternalistic orthreatening treatment that humiliates, intimidates or demeans.

5.18 Legitimate, constructive and fair criticism of an employee’s performance or

behaviour at work is not bullying. It is also recognised that an occasionalraised voice or argument in itself may not constitute bullying.

5.19 It is, however, unacceptable to condone bullying behaviour under the guise ofa particular management style. Effective management obtains results whilstensuring that employees are treated with dignity and respect.

6. Responsibilities

South West Strategic Health Authority responsibility

6.1 For the purposes of this policy, the term ‘manager’ is deemed to cover anyemployee who has responsibility for employees. The term ‘staff’ covers allemployees.

6.2 The South West Strategic Health Authority has an obligation and a duty ofcare to ensure the well being of the staff in the workplace and is, therefore,committed to eliminating harassment and/or bullying, and preserving anindividual’s dignity at work.

6.3 Action will be taken regarding behaviour by individuals or groups that causeoffence or embarrasses or threatens others.

6.4 Any allegation of harassment and/or bullying will be handled thoroughly andwith sensitivity.

6.5 Confidentiality will be maintained as far as practicable and appropriate.Confidentiality is vitally important to provide all parties concerned with adegree of security and to ensure that all procedural aspects are dealt withsympathetically, impartially and objectively.

6.6 The South West Strategic Health Authority encourages and will beunderstanding to all employees who raise any concerns and/or complain of abreach of dignity at work.



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6.7 The South West Strategic Health Authority will include questions in StaffSurveys about experiences of harassment and/or bullying and employeesconfidence in the effectiveness of the Dignity at Work policy.

Responsibility of all employees

6.8 Staff have a duty not to discriminate, on the grounds of age, sex, sexualorientation, disability, religion, belief or race, against their colleagues and thirdparties.

6.9 The intended ethos of the Strategic Health Authority is to value each personas an individual, respect their aspirations and commitments in life and seek tounderstand their priorities, needs, abilities and limits, making sure nobody isexcluded or left behind.

6.10 Individual employees at all levels have the responsibility to ensure that they

do not jeopardise the well being of their colleagues. Employees need to beaware of their behaviour towards other employees and other third parties toensure that they do not behave in a way which affects their dignity.

6.11 All members of staff are responsible for helping to ensure that individuals donot suffer from any form of harassment and/or bullying.

6.12 Members of staff who witness any form of harassment and/or bullying shouldreport it immediately to an appropriate manager or member of the HumanResources team and encourage others to report the incident(s).

7. Rights of all employees7.1 All members of staff should work with managers to create a positive

environment where everyone is free to concentrate on their work. Theprevention of harassment and/or bullying includes showing common courtesy,dignity and respect for others and avoiding behaviour that makes anyone feeluncomfortable, degraded, upset or victimised.

7.2 All staff should feel they have rewarding and worthwhile jobs. To do this theyneed to be trusted and actively listened to.

7.3 Staff have the right to healthy and safe working conditions and anenvironment free from harassment, bullying and violence.

8. Procedures

8.1 The Harassment and Bullying procedure contains two distinct elements: theinformal procedure, which may include mediation, and the formal procedure.

8.2 The formal procedure may be used before the informal procedure has takenplace, dependent upon the seriousness of the incident(s) and the views of theindividual(s).



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8.3 The individual also has recourse to the external processes for resolvingcomplaints of harassment and/or bullying at all times through statutory bodiesor the police.

8.4 Employee support advisors are available to staff who feel they are being

bullied or harassed.

8.5 It is important that any concerns and/or complaint(s) should be dealt withpromptly and from the perception of the individual(s) concerned, as it is theirperception which constitutes the definition of harassment and/or bullying ineach case.

8.6 Following an incident of harassment and/or bullying the individual concernedshould record details of all incidents (what, when, by whom, where and so on)including whether there are witnesses and then decide how to proceed.

8.7 It is important to keep an accurate record of incidents involving harassmentand/or bullying. Regardless of whether an incident becomes the subject offormal complaints, incidents raised informally will also be recorded in order toget a more realistic picture of the level and nature of harassment and/orbullying.

9. Informal action

Dealing with a complaint

9.1 Sometimes people are unsure whether or not the way they are being treated

is acceptable. If this is the case there are a number of things to consider.

9.2 It is important for individuals to be made aware that their behaviour is causingconcern and given an opportunity to rectify such behaviour in future. It istherefore important for those who feel they are being harassed or bullied ofany kind, to raise their concern at an early stage and accept the responsibilityfor raising these concerns. In the most serious of cases you should report itimmediately.

9.3 Try to talk over your concerns or worries with your immediate manager, or anappropriate member of the Human Resources team, or an Employee Support

Advisor or Union representative.

9.4 Where it is inappropriate to involve the line manager, then either HumanResources or an Employee Support Adviser will provide support and advice inidentifying who would be the most appropriate person to involve.

9.5 If you are unsure as to whether the issues are sufficiently serious to raisethem individually with your manager or the individual straight away, keep adiary of all incidents:

• records of dates and times;

• any witnesses;



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• your feelings;

• keep copies of anything that is relevant, for instance letters, memos, e-mails.

9.6 It is important that you try to tell the person to stop whatever it is they aredoing that is causing you distress, otherwise they may be unaware of theeffect of their actions.

9.7 During discussion:

• clearly describe the behaviour to the offending person;

• say that it is unwanted;

• describe the appropriate behaviour that should be used;

• seek agreement on this.

9.8 Contact one of the Employee Support Advisors at the Strategic HealthAuthority to talk through what has/is happening. You will find their contactdetails on the Human Resources intranet.

Putting your concerns in writing

9.9 If you cannot confront the alleged perpetrator, consider putting your concernsin writing. Keep a copy of this and any reply. Don’t make the letter too long

and don’t personalise any bad behaviours (for example say ‘the behaviourwas disrespectful’ rather than ‘you are disrespectful’, ‘the behaviour left mefeeling’, rather than ‘you made me feel’).

9.10 Try not to be too emotional in your language. Say how you want the situationresolved e.g. a meeting or acknowledgement of the letter, a meeting betweenyourselves and a manager.

9.11 Every incident will be treated seriously and follow the Dignity at Work policyhaving regard to the definition of harassment and/or bullying given in thepolicy.

Mediation

9.12 If the previous suggested actions do not change the situation, mediation willbe offered as the next step in the process.

9.13 Mediation is an alternative method of informal resolution using a process thatbrings together people in the presence of an impartial third party, whofacilitates a resolution. It is a confidential and voluntary process.

9.14 It is the disputants not the mediator who decide on the terms of anyresolution. The mediator does not offer advice or solutions but builds the

agreement for future working relationships.



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9.15 Mediation encourages feelings to be aired and empowers those involved. It is

most effective where there is a will on both sides to reach a solution.

Employees participating in mediation do so without prejudice.

9.16 Staff wishing to seek mediation as a means of resolving an issue, shouldcomplete the Mediation Request form which can be found on the intranet.This should be forwarded to the Head of Human Resources.

9.17 Mediation is not appropriate in the following circumstances:

• where an informal approach has been rejected;

• where mediation has already been tried and the mediator feels furthermediation would fail;

•

where issues of misconduct or incompetence are present;

• where there has been serious bullying or victimisation;

• where one or more people are unwilling to partake in the process ofnegotiation and mediation.

Coaching

9.18 Coaching may or may not be part of the formal disciplinary process, but isappropriate for dealing with some incidents of harassment and/or bullying.

9.19 The aim of coaching is to assist and encourage the member(s) of staff to meetthe standards of conduct and behaviour required. Notes of the key pointsreferred to in the coaching must be made and then issued to the member(s) ofstaff. The manager will keep a copy of the notes of the counselling for aperiod of six months after which time they will be destroyed. A note thatcoaching has taken place and the date will, however, be retained.

9.20 Managers should not refer to any instance of coaching that has taken placemore than six months earlier.

10. Formal action10.1 Where it has not been possible to resolve a complaint/grievance by informal

discussion, the formal procedure should be entered into by raising agrievance in writing.

10.2 The formal procedure should only be considered where personal or informalaction proves ineffective or formal action is appropriate due to the seriousnessof the allegations.

10.3 This will be done in line with the views of the individual(s) as far as is possible.However, the South West Strategic Health Authority must fulfil its duty of careto all its employees and may therefore have no alternative than to use theformal harassment and/or bullying procedure.



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10.4 The complaint must be made in writing, confirming the identity of the allegedperpetrator, the nature of the harassment and/or bullying, dates and details ofthe incidents and any approaches made asking the person being complainedagainst to stop. Details of witnesses to the incidents should be included ifthere are any.

10.5 Please refer to the Grievance policy for further information regarding theprocess that will be followed.

11. Harassment by third parties

11.1 Everyone has the right to be treated with dignity and respect in the course oftheir work and harassment and/or bullying of an employee by a member of thepublic is not acceptable.

11.2 Any member of staff who is harassed or feels threatened by a member of the

public should report this immediately to their line manager or to the mostsenior person on duty.

11.3 It will be the responsibility of the line manager/senior manager to take promptand appropriate action to resolve the situation. In dealing with the situation,the views of the recipient should be taken into account.

11.4 If the harassment and/or bullying continues after this the perpetrator will beinformed of the nature of further action to be taken. This might take the formof:

•

a report to the Police that an offence has been committed, for example,assault, indecent assault, an offence in contravention of Section 154 ofthe Criminal Justice Act, or an offence in contravention of theProtection from Harassment Act 1997;

• a report to the Commission for Racial Equality or the EqualOpportunities Commission that an offence has been committed;

• removal from the premises, if appropriate.

11.5 The South West Strategic Health Authority will support a member of staff if

they no longer wish to engage with a member of the public who has harassedthem.

12. Role of Human Resources

12.1 In view of the sensitive nature of disclosing harassment and/or bullying andthe many different forms it may take, the role of Human Resources in thisprocedure may be different.

12.2 It is not intended to infringe upon the right of the manager to manage, but isseen as having a valid role in providing a legitimate alternative source of

advice and support to any members of staff on matters concerning this issueonly.



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12.3 In consultation with the individual concerned, all allegations of harassmentand/or bullying should be notified to a member of the Human Resources teamfor monitoring progress as part of our equality duty. This will also ensure thatall matters are supported in a fair and consistent way and helps to identify anytrends.

13. The Role of the Employee Support Advisor

13.1 Employee Support Advisors are an informal route to resolving a problemquickly and concisely. Their approach is one of listening and coaching, ratherthan counselling.

13.2 Their role is to:

• act as an initial contact for staff who feel they have been on thereceiving end of harassment, bullying, or unacceptable behaviour at

work;

• listen to the member of staff and explain the options available to themunder the Dignity at Work policy of the South West Strategic HealthAuthority;

• coach the member of staff to take action (if appropriate), such astalking to the person concerned, seeking advice from HumanResources or their line manager;

• encourage the member of staff to accompany them to HumanResources for advice if it is believed that gross misconduct hasoccurred or other members of staff are likely to be the subject ofmisconduct;

• offer support to the alleged bully or harasser.

13.3 Employee Support Advisors should:

• treat all contacts with members of staff in confidence;

• attend training to ensure their skills are suitable for this role;

• keep up to date with issues surrounding harassment and bullying atwork;

• monitor contacts in accordance with the Authority’s procedures;

• network with other Employee Support Advisors.

13.4 Employee Support Advisors do not:

• investigate complaints;

• make a complaint on someone’s behalf;



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• persuade someone to make a complaint;

• approach the alleged perpetrator;

• enter into a formal counselling situation;

• mediate between the victim and alleged perpetrator;

• provide evidence at any formal proceedings.

13.5 How to contact an Employee Support Advisor:

• a list of trained Employee Support Advisors is available on the HumanResources intranet.

14. Role of a manager

14.1 If a personal approach fails or is inappropriate, informal action by a linemanager, with advice from Human Resources, may be more effective.

14.2 The advantages are that:

• it provides an opportunity for the manager to be satisfied that theperpetrator complained about fully understands the requirements of thepolicy;

• it provides a quick and effective resolution;

• it minimises disruption at work.

14.3 Managers dealing with an alleged incident must show the utmost sensitivitywhilst ensuring the following actions are taken:

• to listen sympathetically and sensitively to what has happened;

• to help the complainant to deal with emotions arising as a result of theharassment and/or bullying allegation and to give information aboutagencies which can give professional support;

• to give information on whatever courses of action, formal or informal,are open to the complainant;

• to keep matters confidential within the requirements of the Dignity atWork policy and/or the Grievance policy.

14.4 After discussing the issue of confidentially with the complainant, the managerwill speak to the perpetrator to attempt to resolve the issue. This informal andconfidential discussion should explore:

•

how the complainant is feeling as a result of their behaviour;



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• the views of the person being complained about;

• how the behaviour may be contrary to the Dignity at Work policy andthe required standards of behaviour;

• the likely consequences of continuing the behaviour;

• how the on-going situation will be monitored and over what timescale.

14.5 A note of both discussions will be kept confidentially at departmental level.

14.6 Following these discussions the manager will provide feedback to thecomplainant. If appropriate, the manager can offer to facilitate a joint meetingwith both sides to re-establish effective working relationships.

14.7 If no further harassment and/or bullying occurs after this, then further action

need not be taken.

14.8 Please refer to the Dignity at Work, Duty of Care Guidelines for Managers.The document refers to the responsibilities of managers.

15. Support

15.1 The individual(s) concerned may consult with their line manager, a colleague,a member of the Human Resources team, a Trade Union representative orthe Staff Counselling service.

15.2 The individual(s) will be supported throughout the procedure.

16. Victimisation

16.1 No member of staff will be treated less favourably for raising concerns or foracting as a witness. Any form of retaliation against a member of staff forcomplaining of bullying or harassment is a disciplinary offence.

17. Monitoring

17.1 Monitoring of this policy will be undertaken and include:

• anonymised statistics of number and type of allegations received (forexample, race, gender, or sex.);

• number of uses of the mediation service under this policy;

• number of informal and formal uses of this policy.



• all employees will have been treated fairly and consistently in terms ofequality in the workplace;



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• all employees have a clear understanding of the roles andresponsibilities for line managers and themselves with regards to

equality in the workplace.






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Annex 1

Dignity at Work duty of care guidelines for managers

1. Introduction

1.1 It is the aim of the South West Strategic Health Authority to create anenvironment where all employees are treated with dignity, fairness andrespect and to protect them from harassment and bullying

2. Awareness and attitude

2.1 Managers and supervisors have a clear duty to take positive steps to ensurethat the workplace for which they are responsible is free from harassmentand/or bullying and intimidation, or victimisation of any person who hascomplained of harassment and/or bullying.

2.2 Any member of staff experiencing such behaviour can look for and expectsupport from managers. It is the manager’s responsibility to ensure that all oftheir staff are aware of the Dignity at Work policy. The accepted language,behaviour and appearance of the workplace should not be liable to causeoffence to any worker, potential worker or member of the public.

2.3 Individuals can help to create a positive atmosphere free from harassmentand/or bullying by ensuring they do not behave in a way which affects thedignity of colleagues.

2.4 Consider your attitudes about people of the opposite sex, ethnic minorities,people with a disability, those who may have different religious views orbeliefs or of a different sexual orientation.

2.5 Avoid making assumptions and do not “go along with the crowd,” or acceptbehaviour that may be offensive. You may also be able to offer help andsupport to a colleague who is a victim of harassment and/or bullying.

2.6 Managers should be alert for signs of harassment and/or bullying and dealwith the perpetrator promptly. If a person’s work begins to deteriorate or showsigns of stress, consider the possibility that someone in that department is

causing them stress.

2.7 Have an “open door” policy and encourage employees to report any instancesof harassment and/or bullying, either experienced personally or observed inrelation to others.

2.8 Managers must ensure their staff are aware that if a member of the public isharassing them, they should report this immediately to the senior member ofstaff on duty. Prompt and appropriate action should then be taken to resolvethe situation.



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2.9 Staff experiencing harassment and/or bullying often suffer in silence ratherthan complain. In some instances, sympathetic managers and supervisorsmay be reluctant to tackle the matter for fear of upsetting other people. Thisis unacceptable and doing nothing is not a neutral position.

2.10 Any person who receives a complaint, or suspects that harassment and/orbullying is occurring, has a duty to take the appropriate action to ensure theharassment and/or bullying is stopped.

2.11 Managers are reminded of the importance of documenting actions taken inthe management of staff.

2.12 Further advice is available from the Head of Human Resources or appropriatemember of the Human Resources team.

3. Specific responsibilities of managers

3.1 The specific responsibilities of the Manager are:

• to ensure that all employees are aware of the aims and objectives ofthe South West Strategic Health Authority through effective inductionand appraisal of staff;

• to lead by example;

• to be proactive in addressing contributory causes of harassment and/orbullying (which may include, inter alia, poor management style,

organisational change, poor organisational culture, work pressure) aswell as the individual behaviour and approach of the perpetrator;

• to support individuals who experience harassment and/or bullying asappropriate;

• not to collude with adverse, discriminatory behaviour by staff ormembers of the public;

• to deal with incidents reported to them informally in a speedy, sensitiveand effective way and to ensure that the formal procedure is

implemented on request/where an informal approach is notappropriate;

• to be aware of the behaviour of their staff in relation to the respect anddignity of others and to challenge any inappropriate behaviour orattitudes;

• to take appropriate action against those who are behavingunacceptably;

• to identify and facilitate training where appropriate;



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• to advise their own line manager of any incidents of bullying andharassment and/or bullying.

4. Management of staff

4.1 As part of everyday management of staff managers are required to providestaff with feedback concerning their performance, conduct, time keeping andso on.

4.2 Feedback delivered in a constructive manner is beneficial to the employee,and provides them with the opportunity to reflect on their behaviour and makenecessary improvements.

4.3 Any feedback given in a critical manner can have a detrimental effect on staffmorale and the manager and employee working relationship.

4.4 Table 1 below gives examples of behaviours associated with firm but fairmanagement and management behaviours associated with harassmentand/or bullying.

Table 1: Examples of management behaviours

Behaviours associated with firm butfair management

Management behaviours associatedwith bullying or harassment and/orbullying

Consistent and fair. Aggressive, inconsistent and unfair.

Determined to achieve the best resultsbut reasonable and flexible.

Unreasonable and inflexible.

Knows their own mind and is clearabout their own ideas but willing toconsult with colleagues and staffbefore drawing up proposals.

Believes they are always right, hasfixed opinions, believes they knowbest, and not prepared to value otherpeople’s opinions.

Insists upon high standards of servicein quality of and behaviour in the team.

Insists upon high standards of serviceand behaviour but blames others ifthings go wrong.

Will discuss in private any perceiveddeterioration before forming views oftaking action and does not apportionblame on others when things gowrong.

Loses temper, regularly degradespeople in front of others, threatens.

Asked for people’s views, listens andassimilates feedback.

Does not listen, only tells people whatis happening.

Provides constructive feedback. Provides persistent unjustified

criticism.



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Appendix 4

Disciplinary Policy

This appendix sets out the revised Disciplinary Policyfor the South West Strategic Health Authority.





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Disciplinary Policy

Who is included: This policy applies to everybody who works in the South WestStrategic Health Authority.

Disciplinary is:

• the disciplinary procedure is intended for dealing with misconductissues;

• if issues relate to sickness absence, the absence management policyshould be followed;

• if issues relate to unsatisfactory performance, the performanceimprovement procedure should be followed.

1. Principles

1.1 Initially any issues relating to conduct should be dealt with informally throughone to one discussions and counselling. When the informal approach fails toresolve the problem, or the misconduct issue is serious, then the formaldisciplinary process should be followed.

1.2 The South West Strategic Health Authority is committed to the fair and

consistent treatment of staff regardless of their sex/gender, sexual orientation,religion or religious beliefs, race, age, or disability. Where evidence ofinequality or adverse effect is found the South West Strategic Health Authoritywill take appropriate action.

1.3 Each case will be dealt with as fairly, thoroughly and quickly as possible.

1.4 If an employee is subject to the formal procedure, they will be informed of thenature of the allegation in writing (see section 10 below: Rights of Staff).

1.5 Employees will be made aware of their rights to be accompanied at all formal

stages of the procedure by a representative of a Trade Union or a workcolleague not acting in a legal capacity.

1.6 No action will be taken against a Trade Union representative / official of arecognised Trade Union until the initial circumstances have been discussedwith a full time officer / senior official of the union concerned.

1.7 No employee will be disciplined without a thorough investigation into theallegations and full consideration of alternative action.



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1.8 In every case the employee must always be made aware as to why they havebeen disciplined, and the possible consequences, together with theemployees’ right of appeal.

1.9 Everything about the case will be kept strictly confidential and only released to

people who are authorised to receive this information.

1.10 Where offences are committed outside of the workplace, consideration ofdisciplinary action will only take place where it could have a bearing on theemployee’s employment.

1.11 Other than in cases of gross misconduct, no one will be dismissed for a firstbreach of discipline.

1.12 Suspension is not regarded as a disciplinary sanction. Suspension carries noassumption of guilt. The decision to suspend will not be undertaken lightly,

and suspension will only occur when deemed absolutely necessary.

2. Roles and responsibilities

Associate Directors, Directors and Chief Executive

2.1 Associate Directors, Directors and Chief Executive:

• promote the policy and ensure its effective implementation;

• ensure that all managers understand their responsibilities for action

and confidentiality and receive appropriate training;

• ensure consistency of approach;

• Be designated as the officer empowered to dismiss (this mayexceptionally be delegated to their deputy).

Line managers

2.2 The role of the manager is to:

• intervene early when there are concerns regarding conduct;

• promote understanding and a constructive outlook to help staff addressany problems identified;

• ensure that everyone understands acceptable standards of conductand behaviour – to instigate this procedure when standards ofbehaviour and conduct require this.

Staff

2.3 The role of the member of staff is to ensure that they understand acceptable

standards of conduct and behaviour.



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Human Resources

2.4 The role of Human Resources is to provide advice and guidance to everyoneon the application of this policy and to support the manager at either stagetwo or three of the disciplinary policy when dealing with an alleged offence at

a disciplinary hearing where the possible result could be a final writtenwarning or dismissal.

3. Procedure

3.1 If the employee is subject to formal action under this disciplinary procedure,they will be supplied with a copy of the disciplinary policy and procedure andUser Guide.

3.2 The employee has the right to be accompanied at formal investigatoryinterviews and disciplinary hearings, either by a Trade Union representative,

or a work colleague (not acting in a legal capacity).

3.3 Normally, a minimum of seven days notice (less by agreement) of adisciplinary hearing will be given to allow the employee to make necessaryarrangements for representation. It will be their responsibility to make sucharrangements.

4. Suspension

4.1 Suspension is not a disciplinary action and carries no assumption of guilt.

4.2 However, it may be decided to suspend an employee from duty in advance ofany investigation for any of the following reasons (this list is not exhaustive):

• where there is an allegation of gross misconduct;

• where it is felt necessary for the protection of the employee, otherpeople or public funds;

• where the employee’s continued presence at work could prevent athorough investigation;

•

to avoid undue pressure being placed on a member of staff underinvestigation by their continued presence at work.

4.3 The decision to suspend should not be undertaken lightly, and suspensionshould only occur when deemed absolutely necessary. Prior to suspension, amanager will consider whether there are alternative options, such astransferring the employee to another work location.

4.4 The employee may be suspended by any manager who has been givenauthority by a Director, Associate Director or their Deputy. Support must besought from Human Resources.



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4.5 If an employee has been suspended, they will receive written confirmationfrom the Director, Associate Director or their Deputy within seven days of thedate of suspension stating the reasons for the decision for example, details ofthe alleged offence, and the date and time from which the suspension willoperate.

4.6 It is recognised that suspension from duty will have an impact both on theemployee being suspended and the South West Strategic Health Authority,and therefore a review of the need will be carried out at least monthly.However, the employee will also be updated weekly, or as agreed on theprogress of the investigation by the Investigating Officer.

4.7 The employee will receive normal pay, including allowances, during theirsuspension.

4.8 Every effort will be made to contact the employee’s Trade Union prior to

suspension. In cases where this is just not possible the employee will beadvised to contact their Trade Union representative as a matter of urgency. Ifthe employee is not in a Trade Union they may wish to speak to a workcolleague. The unavailability of a Trade Union representative should notdelay the suspension process. In such cases the employee will be offered theopportunity to be accompanied by a work colleague.

5. The informal route

5.1 The informal disciplinary route consists of the following steps: initially anyissues relating to conduct should be dealt with informally through one to one

discussions and counselling. When the informal approach fails to resolve theproblem, or the misconduct issue is serious, then the formal disciplinaryprocess should be followed.

6. The formal route

6.1 The disciplinary route consists of the following steps:

• the Disciplining Manager (the manager potentially conducting theDisciplinary Hearing) has been made aware of an incident or formalcomplaint;

• the Disciplining Manager will seek advice on the case from the HumanResources team;

• the Disciplining Manager will appoint an Investigating Officer;

• the Investigating Officer will interview the member of staff and anywitnesses who may have relevant information and ensure thatreasonable adjustments are made particularly for individuals who havea disability or for whom English is not their first language;



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• the witness statements provided to the investigating officer may beused as part of the disciplinary hearing. If witnesses’ statements areused at a Disciplinary Hearing as part of the Management Statement ofCase, these witnesses must be available on the day of the Hearing sothat they may be called to give evidence.

6.2 The investigating officer will recommend:

• whether there is no case to answer;

• whether counselling is an appropriate outcome;

• whether a disciplinary hearing is necessary.

7. Disciplinary Hearing

7.1 The hearing will be conducted by the Disciplining Manager accompanied by aHuman Resources representative or another appropriately trained manager.

7.2 The Disciplining Manager will ensure that the employee is given at leastseven days written notice, informing them of the requirement to attend adisciplinary hearing and will detail:

• the date, time and place of the hearing;

• the nature of the alleged offence (enclosing copies of any relevantstatements and correspondence);

• the employee’s right to representation;

• who will be present, including the identity of witnesses;

• possible outcome of the hearing;

• the employee will be requested to submit relevant documents to theDisciplining Manager in advance of the hearing (this does not precludelater submission of information at the hearing);

•

if the employee is in a Trade Union it is important that they contact theirrepresentative immediately on receipt of the letter;

• the Disciplining Manager must be accompanied by a HumanResources representative. The Disciplining Manager may also seekadvice from a professional advisor (who has not been involved in theproceedings) as appropriate.

7.3 The Disciplinary Hearing will follow this format:

• the Investigating Officer (the Officer tasked with establishing whether

there is a case to answer) will first present the findings of theinvestigation and call witnesses as appropriate;



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• the employee and their representative will have the right to question allwitnesses and the investigating officer;

• the Disciplining Manager will have the right to question theinvestigating officer and witnesses;

• the Investigating Officer may re-examine any witnesses;

• the employee and their representative will then respond on theemployee’s case and the employee may call witnesses;

• the Investigating Officer will have the right to question the employeeand witnesses;

• the Disciplining Manager will have the right to question the employeeand witnesses;

• the employee or their representative may re-examine any witnesses;

• the Disciplining Manager may also, at any time question any party, oradjourn the hearing to allow further evidence of witnesses to be called;

• the Investigating Officer will sum up their case followed by theemployee or their representative. No new evidence should beintroduced at this stage.

7.4 The preparation of any records will be the separate responsibility of the

employee and the Disciplining Manager. The employee will be advised tokeep their own notes. Interviews or the Hearing may exceptionally berecorded using audio equipment. Therefore, at any level of this procedureeither party may request that interviews or the Hearing are recorded usingaudio equipment. The recording will only be transcribed in cases of dispute,and wiped by management side when all procedures have been exhausted.To reduce the need for this, Investigating Officers should ensure whereverpossible that written witness statements are provided, rather than just verbalevidence and that witnesses are also supported by a representative.

7.5 At the conclusion of the disciplinary hearing, the Disciplining Manager will

adjourn the proceedings to consider the appropriate action. In most cases adecision should be given that day.

8. Disciplinary rules

8.1 In deciding to impose any disciplinary sanctions, in accordance with thisprocedure, a Disciplining Manager must always:

• act in good faith and have a reasonable belief in the guilt of the staffmember, having taken into consideration mitigating circumstances.



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8.2 There are three levels for formal disciplinary sanctions:

Level one – written warning

8.3 Appropriate in cases involving offences of minor misconduct, or where

attempts at counselling have failed to secure improvement. This formalwarning will remain on record for a period of twelve months.

Level two – final written warning

8.4 Appropriate where there is a current written warning on file, or where seriousmisconduct is proven. A Final written warning will remain on record for aperiod of twenty four months. Written confirmation of the outcome will be sentto the employee and their representative within seven days of the hearing.

Level three – dismissal

8.5 Appropriate in cases of gross misconduct, or may be where there is a currentfinal written warning on file. The employee may be summarily dismissed (inother words dismissed without notice or a payment in lieu of notice) only in theevent of gross misconduct. Written confirmation of the outcome will be sent tothe employee and their representative within seven days of the Hearing. ADirector or Chief Executive will be designated as the Officer empowered todismiss (this may exceptionally be delegated to their deputy).

8.6 Once the effective period of the warning is spent, all documentation relating tothe disciplinary action, including any letters confirming the outcome will be

removed from the employee’s personal file. A letter confirming this will besent to the employee. If the employee does not receive this they shouldcontact the Human Resources team.

9. Appeals procedure

9.1 The employee has the right to appeal against disciplinary action if they do notbelieve that the Disciplining Manager has acted reasonably or fairly in theircase;

9.2 The grounds for appeal must be disclosed at the time the appeal is lodged;

9.3 Appeals should be lodged with the Associate Director of Human Resourceswho will arrange for an appropriate Panel to hear the Appeal;

9.4 The Director or Chief Executive may invite an advisor to provide them withprofessional advice.

10. Rights of staff under the disciplinary procedure

10.1 Where the employee has been advised of the possibility of disciplinary action,they will have the right to be:

10.2 Represented by either an accredited Trade Union representative oraccompanied by a work colleague (not acting in a legal capacity).



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10.3 Advised in writing of the alleged misconduct prior to any disciplinary hearingor investigatory interview taking place.

10.4 Allowed time to brief a Trade Union representative or to take advice andprepare a case.

10.5 Given, on request, a copy of any disciplinary letters that remain within theirpersonal file.

10.6 Made aware of the Officer who has the authority to discipline or dismiss.

10.7 Reminded where disciplinary action has been taken, of the right of appeal andwith whom they should register an appeal.

11. The role of counselling

11.1 It is expected that in many cases, minor disciplinary matters will be resolvedthrough informal counselling.

11.2 Counselling should not be seen as part of the formal disciplinary process.

11.3 During counselling, the employee should be made aware of any shortcomingsin conduct and improvement encouraged. The employee should be given theopportunity to discuss any underlying problems that could contribute todifficulties at work.

11.4 Counselling should end with a clear understanding by both manager and theemployee on what needs to be done, and if appropriate, how conduct will bereviewed, over what period of time and the potential consequences of theemployee conduct not improving.

11.5 Counselling is not formal disciplinary action. Managers must ensure that thecounselling interview does not turn into a formal investigatory interview ordisciplinary hearing.

11.6 Managers should also be aware that counselling may be used in support ofdisciplinary action, to encourage improved conduct.

12. Examples of matters of misconduct, which may result indisciplinary action:

12.1 Misconduct which will normally be resolved informally, but repeatedoccurrences may lead to formal steps:

• habitual poor timekeeping;

• discourteous or unacceptable behaviour to other members of staff,visitors or patients;



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• borrowing the South West Strategic Health Authority’s property withoutauthorisation (including excessive use of the South West StrategicHealth Authority’s internet at inappropriate times);

• damage caused by carelessness to property or equipment belonging to

patients, other staff, or the South West Strategic Health Authority;

• smoking in contravention of the health and wellbeing policy;

• unauthorised absence from work.

12.2 Misconduct, which may lead to formal disciplinary action:

• failure to respond to previous written warnings;

• unauthorised absence, without reasonable cause, whilst purporting to

be on duty;

• wilful refusal to carry out a lawful and reasonable order by anauthorised person;

• any discriminatory practice, including harassment;

• incapacity to perform normal duties through the consumption of alcoholor the misuse of drugs, unrelated to an underlying health problem;

• failure to comply with working procedures or safety regulations;

• disclosure of information in breach of the Confidentiality policy andData Protection requirements;

• prolonged or repeated unauthorised absence from work.

12.3 Gross misconduct, which may lead to dismissal:

• theft or dishonesty whilst working;

• wilful assault or ill treatment of patients;

• violent behaviour to another person whilst in duty or on the South WestStrategic Health Authority’s premises;

• deliberate failure to comply with working procedures or safetyregulations;

• deliberate disclosure of information in breach of the Confidentialitypolicy and Data Protection requirements;

• gross professional negligence;

• misconduct outside work that breaches the mutual trust and confidencebetween the employer and member of staff;



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• breach of the South West Strategic Health Authority’s policy ondeliberate personal use of the South West Strategic Health Authority’sinternet to access sites of a pornographic nature for example;

• deliberate breach of the equal opportunities and diversity policy.

12.4 The above lists are not exhaustive, nor prescriptive, but give a generalindication of the standards of conduct required.

13. Finding out more

13.1 For further information on the South West Strategic Health Authority’sDisciplinary policy all staff members are asked to speak to a manager or referto the ‘User Guide’ on Disciplinary in the first instance.

13.2 Additionally you may contact the Human Resources team.



• all employees will have been treated fairly and consistently when beinginvolved with disciplinary action;


• all employees have a clear understanding of the roles andresponsibilities for line managers and themselves in managingdisciplinary issues.






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Disciplinary Procedure

Section one – Staff guide

1. Introduction

1.1 We want you to carry out your job to the best of your ability at all times and weexpect high standards of behaviour at the South West Strategic HealthAuthority. Sometimes, there may be a problem with behaviour that needs tobe resolved and we will guide and support you to solve this in the bestpossible way. If problems are not being resolved, or if the nature of theproblem is more serious, we may have to use our formal disciplinary

procedure.

1.2 Unless it is stated otherwise, all time limits refer to consecutive calendar daysand not working days.

Why do we have a disciplinary policy and procedure?

1.3 The Disciplinary policy helps you understand what standard of conduct andbehaviour we expect from you, during your career with the South WestStrategic Health Authority. The rules of our policy ensure that we are:

• fair and consistent;

• thorough in our investigations;

• open in our dealings with you when misconduct arises;

• compliant with all legal requirements.

What are the core principles of our disciplinary procedure?

1.4 Our Disciplinary procedure is based on the twelve sound principles, which aredetailed fully in the disciplinary policy (see section on Principles).

1.5 We will always treat you fairly and with dignity, if you are subject to thedisciplinary policy and procedure. In summary, we will always try to deal withany conduct issue informally through one to one discussions and counselling.When the informal approach fails to resolve the problem, or the misconductissue is serious, then the formal disciplinary process will be followed. We willinvestigate the full facts before taking any action and you will have the right tobe accompanied at all formal stages by a Trade Union representative or awork colleague (not acting in a legal capacity). We will be open in ourdealings with you and keep the matter confidential at all times. You will alsohave the right to appeal against any sanctions which are applied.



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For what type of behaviour or conduct might the disciplinary policy beused?

1.6 The Disciplinary policy covers three different types of misconduct. These aregenerally known as minor misconduct, serious misconduct and gross

misconduct.

1.7 Minor issues such as poor timekeeping will generally be addressed informally,although if this becomes habitual behaviour and there are repeatedoccurrences, it may lead to more formal action being taken. Issues of a moreserious nature, such as a failure to respond to previous written warnings or asingle, more serious act of misconduct such as aggressive behaviour forexample, may result in formal disciplinary proceedings. Finally, grossmisconduct, such as theft or fraud, may lead to dismissal through thedisciplinary procedure.

1.8 Please refer to sections 13 – 15 of the disciplinary procedure for moreexamples. This is not intended to be an exhaustive list.

1.9 You will notice that the general theme of these types of offences is that themisconduct is such that it fundamentally breaches the mutual relationship oftrust and confidence, which we expect to have with our staff.

2. The informal procedure

How is misconduct handled informally?

2.1 If you commit a minor act of misconduct your manager will speak to youinformally to ensure that you are aware of what you have done wrong andhow proper standards of conduct can be restored. They will make it clear thata repetition of the misconduct may lead to more formal action being taken.Such discussions do not themselves constitute disciplinary warnings.However your manager will make a file note of what has been discussed andthis may be referred to if the minor misconduct should be repeated.

3. The formal procedure

How is the formal procedure of misconduct started?

3.1 If informal means have not led to the required improvement in conduct, or themisconduct is considered too serious to be classed as minor, formalprocedures will begin.

3.2 Where an alleged incident of misconduct has happened, your senior manager(sometimes referred to in the policy as the disciplining manager) will appointan Investigatory Officer to investigate the incident further. The InvestigatingOfficer remains impartial and will conduct an investigation to establish the fullfacts and determine if there is a case to answer, whether counselling may beappropriate or if a Disciplinary Hearing will take place.



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What happens during the investigation?

3.3 The Investigating Officer will contact you to arrange an investigatory interview.You have the right to be represented at this meeting (and all other meetings)by your Trade Union representative or a work colleague (not acting in a legal

capacity).

3.4 The interview is necessary to enable the Investigating Officer to establish thefacts of the case and understand whether there is a case to answer. Duringthe interview they will ask you about the alleged incident or misconduct andget your views, explanations and perception of the alleged incident.

3.5 They may also interview witnesses to the alleged incident, as part of their factfinding investigation. Witnesses will be asked to sign their statements andyou will be provided with a copy of all evidence gathered should the matter bereferred to a Disciplinary Hearing.

3.6 These interviews or the Hearing may exceptionally be recorded using audioequipment and either party can request this.

3.7 The Investigating Officer will then prepare a Management Statement of Caseand based on the evidence gathered, make a recommendation as to whetherthere is a case to answer and the matter may be referred to the DiscipliningManager to arrange a formal Disciplinary Hearing.

When is suspension from work necessary?

3.8

Sometimes, in order to carry out an investigation fairly and properly, it may benecessary to suspend you from work. This may happen for allegations ofgross misconduct, where your continued presence at work could prevent athorough investigation or where it is felt necessary for the protection ofyourself, other people or public funds.

3.9 This time away from work will be on full pay and will be for as short a periodas possible. Suspension does not imply guilt and is not a punishment.However, you will be instructed that you may not enter the South WestStrategic Health Authority premises or contact your colleagues. You will beexpected to attend any investigatory interviews and are entitled to meet with

your Trade Union representative or staff counsellor, which may be on theSouth West Strategic Health Authority’s premises. If, during this suspension,you need to enter the South West Strategic Health Authority’s premises forhealth care reasons or to visit relatives of friends, you should first discuss yourrequirements with the Disciplining Manager.

3.10 Suspension is not a decision we take lightly and if you are suspended you willbe informed of the reason, and this will be confirmed in writing within sevencalendar days.

3.11 If you are to be suspended from work, we will make every effort to contact

your Trade Union representative (should you have one) prior to yoursuspension so that you have representation at the suspension meeting.



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3.12 While you are suspended you are still required to attend the investigatory orDisciplinary Hearing or provide further information.

3.13 A decision to suspend you can only be taken by a Director, AssociateDirector, or their Deputy. Support must be sought from Human Resources.

The Director, Associate Director, or their Deputy may then authorise amanager to conduct the suspension meeting.

Will disciplinary action be taken by the same person who handles theinvestigation?

3.14 No. The investigation will be carried out by a manager who is impartial andwho will not be involved in deciding the outcome of the Hearing.

How is the formal Disciplinary Hearing arranged?

3.15 The Disciplining Manager will write to you to advise the date, time and locationof the Disciplinary Hearing.

3.16 The letter will also include the Management Statement of Case whichprovides a background of alleged incident, details of the investigation and thereason for the decision to hold a Disciplinary Hearing.

3.17 Formal meetings will be held privately and free from interruption.

3.18 You will be asked to submit details of any written evidence you wish topresent, and witnesses you may wish to call in advance of the Hearing.

Can I be accompanied to the Disciplinary Hearing?

3.19 You have the right to be accompanied to the Disciplinary Hearing by yourTrade Union representative or a work colleague (not acting in a legalcapacity).

How should I prepare for the Disciplinary Hearing?

3.20 You will need to set aside time to prepare for your Disciplinary Hearing. Makesure you have copies of all papers that will be discussed at the Hearing,wherever possible. All evidence related to your case will be made available to

you (and your Trade Union representative or work colleague), seven daysbefore the Hearing.

3.21 You may wish to prepare a written statement of some notes so that you canput forward your version of events clearly. You can then read from this, orrefer to it during the Hearing. If you are being accompanied by your TradeUnion representative or work colleague, they may be able to help you preparethis.



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What will happen at the formal Disciplinary Hearing?

3.22 The purpose of the Hearing is to hear evidence from all parties so that theDisciplinary Panel is able to reach a decision about what disciplinary sanction(if any) should be applied. The Disciplining Manager will normally be

accompanied by another manager who had had no previous involvement inthe case, and who will help them reach a decision. This may be a HumanResources representative, another manager from the South West StrategicHealth Authority or a professional advisor if appropriate.

3.23 The procedure needs to be fair and consistent so it will follow a set pattern:

• the Investigating Officer will first present the findings of theinvestigation and call witnesses as appropriate;

• you and your representative will have the right to question all witnesses

and the investigating officer;

• the Disciplining Manager will have the right to question theinvestigating officer and all witnesses;

• the Investigating Officer may re-examine any witnesses;

• you and your representative will then respond on your case and youmay call witnesses;

• the Disciplining Manager may also, at any time, question a party, or

adjourn the Hearing to allow further evidence or witnesses to be called

• the Investigating Officer will sum up their case first followed by you oryour representative. No new evidence shall be introduced at thisstage.

3.24 An adjournment of reasonable length will take place at this point to allow forthe manager to consider the discussion and review the evidence beforereaching their decision. The Hearing may be adjourned to a later date iffurther investigation is required before a decision can be made.

3.25 When the Hearing is reconvened:

• the Disciplining Manager will recap on what has been discussed andtell you their decision and their reasons for it;

• if appropriate, a formal warning or other sanction will be issued;

• if this happens, you will be reminded of your right of appeal – (seeWhen and how I can appeal against a disciplinary warning?);



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3.26 After the Hearing:

• the Disciplinary Manager will confirm the decision to you in writingwithin seven calendar days;

• originals of all information will be kept on your staff file according to theData Protection principles.

What sanctions might there be?

• you may be given a written warning in cases involving offences ofminor misconduct or where counselling has failed to improve thebehaviour. This written warning may stay on your file for a period oftwelve months. Any repetition of this type of misconduct within thistwelve month period may result in further disciplinary proceedingsbeing initiated against you;

• you may be given a final written warning where there is a currentwritten warning on file or where serious misconduct is proven. A finalwritten warning will remain on your file for twenty four months. Anyrepetition of this type of misconduct within this twenty four monthperiod may result in further disciplinary proceedings being initiatedagainst you. If proven, this misconduct may result in your dismissalfrom the South West Strategic Health Authority;

• you may be dismissed in cases of gross misconduct or where there is acurrent final warning on file. You may be summarily dismissed (without

notice or pay in lieu of notice).

3.27 You will be notified in writing (with a copy to your representative) within sevencalendar days of the Hearing.

4. The appeals process

When and how can I appeal against disciplinary action?

4.1 If you feel that the decision was unfair you can appeal against any formaldisciplinary action taken against you. Once you have received the disciplinary

outcome letter, you should lodge an appeal within fourteen calendar days.The decision outcome letter will tell you who to send your appeal to and youshould write to them, stating the grounds for the appeal.

4.2 The appeal will be heard by a more senior manager than has been previouslyinvolved.

4.3 You have the right to be accompanied by a Trade Union representative orwork colleague (not acting in a legal capacity).

4.4 The appeal will usually be heard within six weeks of receipt of your request.



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On what grounds can I appeal?

4.5 This is not an exhaustive list but the most likely grounds for appeal are one ofthe following:

•the action was too harsh;

• the investigation was incomplete;

• the manager was unfair;

• the Hearing was not fairly conducted;

• you have new evidence;

• you did not have all the information/documentation, which was relied

upon.

What will happen at an Appeal Hearing?

4.6 At the Appeal Hearing, you will have to explain why you feel the action takenagainst you was unfair. You will need to think carefully and prepare your casein advance. Your Trade Union representative or work colleague may be ableto help prepare you.

4.7 Remember, an Appeal Hearing is not usually a re-hearing of all the evidencebut rather concentrates on the specific grounds of appeal.

4.8 The possible outcomes from an Appeal Hearing are:

• original decision and penalty upheld;

• original decision upheld but penalty reduced, for example final warningturned into a written warning; or

• original decision overturned, penalty withdrawn.

4.9 The outcome of the appeal will be binding on you and us. A decision toappeal does not affect the date of dismissal unless the appeal decision

overturns the original disciplinary decision.

Section two: Manager guide

5. Introduction

5.1 To help maintain the high standards of behaviour that we expect at the SouthWest Strategic Health Authority, it’s essential to firstly let our staff know thestandard of conduct we expect. As managers we expect you to help yourteam members understand what acceptable standards of conduct andbehaviour are, and to address any potential misconduct issues promptly.



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5.2 This guide is intended to ensure consistency in our approach to maintaininghigh standards of behaviour at the South West Strategic Health Authority sothat we treat all staff fairly and with dignity if they are subject to ourdisciplinary procedure. In addition to this guide, the Human Resources teamwill provide support and guidance to you.

5.3 The disciplinary procedure is contractual, which means that failure to follow itwill be a breach of a staff member’s contract. Failure to follow the procedurealso significantly increases the risk that a dismissal could be found to beunfair if an Employment Tribunal claim is made against us, and this couldresult in significant costs, as well as damage to our reputation as the SouthWest Strategic Health Authority and as an employer.

5.4 Unless it is stated otherwise, all time limits refer to consecutive calendar daysand not working days.

When to use the disciplinary procedure

5.5 The disciplinary procedure is intended for dealing with misconduct issues,where a staff member’s behaviour falls below our expected standards. Itapplies to everyone who works within the South West Strategic HealthAuthority irrespective of the length of their service.

5.6 If the issue relates to absence, you should use the Absence Managementpolicy unless you believe that the absence is not due to genuine sickness (inother words you believe the staff member has deliberately misled you).

5.7 If the issues relate to unsatisfactory performance, you should use theCapability procedure.

5.8 It may be difficult to tell whether an issue relates to misconduct or capability,and you may need to explore this as part of your investigations. If a staffmember fails to meet performance standards due to deliberate carelessness,negligence or idleness, or they deliberately breach the South West StrategicHealth Authority’s policy, or they are persistently late, this is a misconductissue. If they can’t carry out their role acceptably, this is a capability issue(can’t as opposed to won’t is a good way to think of it).

5.9 Before using the formal disciplinary procedure, always consider whether itmight be possible to resolve the issue informally instead. Where possible, weshould attempt to resolve minor problems by taking prompt informal action,and therefore avoid the need to use the formal disciplinary procedure.

5.10 You should also consider:

• are you sure that the staff member is aware of the relevant standardsof conduct / the particular rule which they have broken?

• could there be a misunderstanding as to what is acceptable behaviour?



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• are there any personal circumstances, which you should be taking intoaccount?

5.11 Where informal action does not resolve the issue, where the misconduct issufficiently serious, or where the member of staff is already on a formal

warning for a related matter the formal disciplinary process will apply. Thiswill normally be the case for any act of gross misconduct (see policy forexamples).

5.12 Essentially the aim of the process is to ensure that the staff member’sbehaviour improves, rather than to ‘punish’ them. To maintain the dignity ofthe staff member during any stage of the disciplinary process, we will maintainconfidentiality at all times.

6. Taking informal action

What is informal action?

6.1 The informal approach to discipline is a one to one confidential conversationbetween the staff member and manager, which allows the manager tohighlight any unacceptable behaviour or conduct. It encourages an opendiscussion on how both can work together to help the staff member reach anacceptable standard quickly. As the manager, you may provide advice,counselling, coaching or training to support the staff member to understandand improve expected behaviours through an agreed action plan. You (themanager) should also ensure that the staff member understands theconsequences of future similar incidents, when formal action may be

considered.

6.2 In many cases a prompt and informal discussion with the staff member, abouttheir conduct, is the most effective way to manage the situation. By actingpromptly and fairly, the issue can be ‘nipped in the bud’ to prevent itdeveloping into a more serious problem, which can be time consuming andmay impact on the effectiveness of the team. Informal action also promotesstrong healthy working relationships and fits with our view of discipline beingabout ‘improvement’ not ‘punishment’.

6.3 Examples of misconduct, which may warrant informal action, include:

• unreliable behaviour such as persistent lateness;

• unauthorised absence;

• inappropriate or offensive behaviour .

6.4 This type of misconduct should be tackled informally the first time it occurs.Repeat offences of this nature will require formal disciplinary action to betaken.



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Quick reference guide to the informal disciplinary procedure

Note: This flow chart should be used in conjunction with the guidance notes whichfollow. You should refer to the Human Resources team for further advice.

Manager is informed ofor observes minormisconduct

Manager gathers factsabout the case

Manager informallyarranges one to onemeeting with staff memberto discuss concerns

Is there a caseto answer?YesManager provides

counselling, training,

advice and supportto resolve conduct.Discuss how toimprove. Ongoingmonitor and review No Case

closed

Does behaviourimprove? Yes Case closed

No Manager may usethe formaldisciplinaryprocedure



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How to take informal action

Step one – before the meeting

6.5 We all know that setting clear standards is the foundation to good

performance management. So when we have concerns about a staffmember’s behaviour falling below acceptable standards, we need to presentclear facts to the staff member to help them understand when this ishappening.

6.6 At this stage it is not necessary to conduct an investigation, although it isuseful (and good management practice) to provide specific examples ofbehaviour to the staff member when you meet with them.

6.7 If the behaviour is something that several members of staff are displaying,such as lateness, rudeness or taking too long on breaks, you might want to

address the whole team, by way of a team meeting and follow this up with amemo to staff. You can then be sure that all of the team are aware of what isexpected and that you are not unfairly picking on just one member, who youmay have noticed breaching the rules.

6.8 You will need to have a meeting with the staff member, which should be heldas soon as possible. The meeting should be kept informal and be on a one toone basis. If the staff member feels uncomfortable with this, it is at yourdiscretion whether you allow them to be accompanied.

Step two – during the informal meeting

6.9 The purpose of the informal meeting is to:

• advise the staff member of your concern about their behaviour;

• understand any reasons why the misconduct has occurred;

• agree an appropriate way forward.

6.10 It is useful to take notes during the meeting and note the outcome of themeeting in an agreed plan. If you decide that the issues are more seriousthan you originally thought, you may decide to adjourn the informal meetingand use the formal disciplinary procedure.



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Format of the meeting

Welcome

• explain the purpose of the meeting;

• explain how you intend to conduct the meeting.

Explain

• present the facts about observed behaviours or complaints received;

• explain why behaviour is unacceptable and the impact of behaviour on others.

Explore

Ask questions to understand

• why the staff member behaved in such a way;

• the staff member’s perspective of what happened to gain a fullerunderstanding of the situation;

• the staff member’s understanding of misconduct, standards of behaviour;

• what needs to be put in place to help.

Confirm

• the required standard and timescales for improvement;

• the staff member’s understanding of what needs to happen;

• the possible consequences of any repetition of behaviour (such as formaldisciplinary action and the penalties attached to that).

Agree Follow Up

• agree any actions on both your part and the staff member (write down anaction plan);

• agree a review date;

• review performance when you say you will.



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Step three – after the informal meeting

6.11 It is useful to keep a brief summary of the discussion at the meeting as arecord (including the date and time of the meeting) together with anyimportant information that you have obtained, and any agreed action as this

will help you monitor and review the behaviour and may be relevant if formalaction is taken at a later stage. The notes must be kept securely andconfidentially in compliance with the Data Protection policy. A copy of theagreed actions/record of the meeting should be given to the member of staff.

6.12 You may agree a review/monitoring period for the behaviour to improve to anacceptable level if, for example the staff member is regularly late. By the endof the period you will need to decide whether or not there has been anacceptable improvement. If not, you may decide to use the formal disciplinaryprocedure.





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7. The formal disciplinary procedure

7.1 We will always try to deal with any alleged conduct issue through one to oneconversations, but if this does not resolve the issue or if the nature of thealleged misconduct is of a more serious nature, it will be necessary to begin

the formal disciplinary process.



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Quick reference guide to the formal disciplinary procedure

Note: This flow chart should be used in conjunction with the guidance notes, which follow.You should refer to the Human Resources team for further advice.

Allegation ofmisconductmade

Is this potentialgrossmisconduct? No

DiscipliningManager appointsan InvestigatingOfficer to thecase. Letterissued to staffmember,informing themthat the allegedmisconduct isbeing investigatedunder the formaldisciplinaryprocedure (letterDIS3)

Investigating Officercontacts staff member vialetter (DIS4) and arrangesInvestigatory Interview,(include their right to beaccompanied). Holdsmeetings with witnesses toinvestigate full facts

Yes

Investigating Officerarranges for witnessesto sign statement

(DIS5)InvestigatingOfficer preparesmanagementstatement of case

Is there acase toanswer?

No

Yes Disciplining managersends letter to informstaff member ofoutcome and arrangesdisciplinary hearing(DIS8). Exchange

papers. Copy to TradeUnion rep/Colleague

Hold disciplinary hearing.Investigating Officerpresents case, callswitnesses, cross examinesstaff member and

summarises case

Is there acase toanswer?

YesIssue letter to confirmtype or warning andconditions of warningto the staff member(could be written orfinal written). If grossmisconduct sanctioncould be dismissalDIS9 or 11

Does the staffmember acceptthe outcome ofthe hearing?

Yes

No

(Send letter DIS10) Case closed

and employeeadvised. UpdateHuman Resourcesrecords

Yes(Send DIS 16)

Original sanction may bechanged (Send DIS 17).Case closed and staff

member advised.Update HumanResources recordsNo

Is the appealsuccessful?

Update HumanResourcesrecords.Monitor andreview ongoingconduct.

Staff membersubmits theirappeal andreasons for

appeal in writingwithin 14 daysof hearingoutcome letter

As an example, incase of Dismissal,Panel of 3Directors, NonExecutiveDirectors or Chief

Executive to hearappeal. Makesdecision on case

No

Contact HumanResourcesteam. Staffmember may besuspendedpendinginvestigation. Ifsuspendedissue letter

DiscipliningManagersissues one oftwo letters.DIS6 No caseto answerletter DIS7Refer tocounsellingletter



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8. Investigation

8.1 We can only take disciplinary action against alleged misconduct when we aresure that there is a case to answer. This means our first step to start theprocess is to gather all of the facts, in an appropriate way.

8.2 There are 2 main situations when we will need to conduct an investigation toestablish whether or not to call a Hearing:

• Repeated or continuous actions - which in themselves may not betoo serious but which, because of their continuous or repeated nature,have a serious effect on the staff member’s overall performance.There may already be records of previous discussions, attendancerecords as examples.

• Serious incidents – a specific incident of a more serious nature.

Step one – getting started

Appointing the Investigating officer

8.3 Employment law stresses that a disciplinary decision must be made on areasonable investigation of facts. The provision recognises that theinvestigation process should be separated from the decision making process.

8.4 To ensure that the staff member is treated fairly in the process, anInvestigating Officer will be appointed by the Disciplining Manager to arrange

an investigation to establish:

• is there a case to answer?

• will counselling (the informal approach) be a more appropriateoutcome?

• is a disciplinary Hearing necessary?

• when appointing an Investigating Officer, it is important that theDisciplining Manager is assured that this person has sufficient time and

resource to conduct the investigation in a timely manner.

8.5 If a Trade Union steward is being investigated, the full time officer must becontacted at the outset of the investigation.

Step two – gather the facts

8.6 The nature of the investigation will vary according to the circumstances ofeach case. It is important that facts are gathered as quickly as possible,whilst they are still fresh in everyone’s mind. The investigating officer’s role isto establish the facts and not to build a case against the staff member. It isalso important to gather relevant background information such as workingrelationships between staff, custom and practice.



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8.7 In some circumstances, it may be necessary to suspend the member of staffto enable the investigation to be carried out thoroughly and fairly. If this isrequired the Disciplining Manager (or delegated manager) will inform the staffmember of the reason why and confirm this to them in writing (DIS2) withinseven days of their suspension. A decision to suspend can only be taken by

a Director, Associate Director or their Deputy. They may then authorise amanager to conduct the suspension meeting.

8.8 The Disciplining Manager will write to the staff member to confirm the name ofthe Investigating Officer (DIS3). The Investigating Officer will contact the staffmember in writing (DIS4) to invite them to an initial interview to investigate theallegation. The staff member will have the right to be accompanied in thismeeting (and all other meetings) by a Trade Union representative or a workcolleague who is not a legal representative.

8.9 The key factors in conducting an investigation are to be thorough, discreet,

fair and reasonable, and considerate of the staff member.

Conducting fact finding interviews with witnesses

8.10 It may be necessary for the Investigating Officer to question others who werepresent or who have knowledge of the circumstances surrounding theincident. The Investigating Officer will also meet with any witnesses with aview to gathering full facts about the alleged misconduct.

8.11 The Investigating Officer will take notes during all meetings and arrange forthese to be checked for accuracy and signed by the witnesses (DIS5).

8.12 The witnesses may themselves wish to be represented at the fact findingmeeting and you should consider this request. It may be helpful if the witnessis likely to be anxious or emotional or if the case is particularly sensitive.However, the non-availability of a representative at this meeting should not beallowed to cause unacceptable delays to the overall process.

8.13 At the interviews, the Investigating Officer will cover the following with anywitnesses:

• what is the purpose of the interview;

• that their full co-operation is expected;

• in the interests of a fair procedure their statement will be shown tothose involved in the disciplinary processes, including the member ofstaff under investigation;

• the notes from the meeting must be signed by the witness and theinvestigating manager;

• when their statement or interview notes will be ready for them to check

and sign;



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• that if their statement is used at the Hearing, they will be requested tobe available to answer questions in person, at the Hearing;

• disciplinary action may stem from the information given.

8.14 Some witnesses may feel nervous or anxious, particularly at the thought ofappearing at a Hearing to give evidence in front of a staff member beingdisciplined. They may fear repercussions or be genuinely concerned for theirown safety and well being. It is not usually possible for witnesses andstatements to remain anonymous, but the Investigating Officer may need toconsider what steps they can take to ensure that the witnesses’ fears are notrealised. If further advice is needed on this matter, the investigating officershould contact the Human Resources team who will be able to providesupport and guidance.

8.15 Below are some practical guidelines on conducting the fact finding interview:

• state the purpose of the meeting, date, time and those present;

• record statements on a question and answer basis;

• attempt to record verbatim and stick to the facts. Interviews of theHearing exceptionally may be recorded using audio equipment.Therefore at any stage of this procedure either party may request thatinterviews or the hearing are recorded using audio equipment. Therecording will only be transcribed in cases of dispute by managementside when all procedures have been exhausted. To reduce the need

for this, investigating officers should ensure wherever possible thatwritten statements are provided, rather than just verbal evidence andthat witnesses are also supported by a representative;

• ask open questions such as those indicated below – what, when,where, how and who to gain maximum information.

Possible questions for staff members making allegation/complaint andwitnesses

• we understand that you may have witnessed an incident at xxx about

xxx time ago, where something happened/was said about xxx

• please explain exactly what happened?

• when and where did the incident take place?

• who was involved and who else witnessed this?

• what was your reaction, what did you say?

• what action did you take?

• did you speak to anyone else about this incident?



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• has anything like this ever happened before?

Investigatory meeting with the staff member

8.16 At the investigatory meeting, the Investigating Officer will

• arrange for the staff member (and their representative) to meet themfor an investigatory meeting;

• stress this is not a disciplinary hearing but a meeting to establish thefacts to decide whether there needs to be a formal disciplinary hearing;

• take full notes of the discussion, ideally arranging for a note taker to bepresent. These notes will need to be sent to the staff member as soonas possible after the meeting and checked and signed by them (seeearlier comments on recording using audio equipment);

• remind the staff member of their right to be accompanied by a TradeUnion representative or work colleague (not acting in a legal capacity);

• go through the evidence they have collected and ask the staff memberfor their comments;

• ask as many questions as they need to establish the facts, (rememberthis meeting is to enable them to decide if disciplinary action needs tobe initiated);

•

if new information comes to light, tell the staff member that furtherinvestigation will take place before they decide how to proceed;

• tell the staff member when they are likely to have made a decision onwhether to proceed.

Possible questions for staff member subject to investigation

• can you recall an incident which took place about xx weeks ago?

• have you ever . . . . . (describe the alleged event and use the exact

detail including the language used);

• X has stated that you . . . . (describe specific event) – what is yourresponse to this?

• Y has stated that they saw/heard you . . . .(describe specific event) – do you recall this?

• have you ever said anything to Z . . . . (refer to the informationpreviously received);

•

why would X say that you did this?



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• can you think why your actions may have been interpreted in thisway/seen as inappropriate?

• consider if the staff member has any health issues which might havecontributed to the misconduct. It might be necessary to seek

advice/opinion from Occupational Health to understand whether healthcan be used in mitigation.

Step three – make decision based on findings of investigation

8.17 Having conducted the appropriate investigatory interviews and gatheredrelevant paperwork, the Investigating Officer will make a recommendationwhether the case will go to a Hearing.

8.18 Decisions will be based on answers to the following:

•

is there a case to answer (has the allegation been substantiated?)They may find that some key facts are still being disputed by differentparties, so that it is one persons’ word against another’s. In thissituation the decision will need to be based on what they believe,taking all of the evidence into account, working on the balance ofprobability;

• what is the staff member’s employment record like to date?

• what guidance does the disciplinary procedure offer?

•

has the Investigating Officer ascertained all of the facts from which theymay reach a reasonable decision?

• what are the risks if the case does not go to Hearing?

• what is the decision? Should the case go to Hearing?

• why have they arrived at that decision?

Step four – write a Management Statement of Case (InvestigationReport)

8.19 The Investigating Officer will now complete a Management Statement of Caseto provide a factual summary of the investigation findings and recommend thenext course of action to the Disciplining Manager which could be:

• no case to answer;

• counselling is an appropriate outcome;

• a disciplinary hearing is necessary.



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8.20 The outline of Management Statement of Case (Investigation Report) is asfollows:

Section – background on staff member

8.21 In the section on background, give a brief paragraph(s) covering:

• staff member’s base/location/ward;

• brief description of work and work area;

• numbers on duty (if appropriate);

• append job description (if relevant);

• refer to training received (if relevant);

• refer to counselling/previous written warning(s) given (if relevant andcurrent);

• employment record to date.

Section – investigation

8.22 Give details of who was involved in the investigation and attach thestatements and evidence gathered.

Section – allegations and evidence

8.23 Set out the allegations made against the staff member and provide asummary of the evidence for and against each allegation.

Section – report summary conclusions

8.24 In this section, provide a summary of whether the evidence gathered supportsthe allegation or not. State the facts and cross refer to statements / documentation which supports the allegation.

Section – recommended actions

8.25 In this section, consider whether the evidence gathered supports the need tohold a disciplinary hearing or if other action is required.

8.26 When considering if this is or is not a disciplinary issue, the InvestigatingOfficer may consider the following:

• is this the first time it has happened?

• what were the expectations?

•what were the risks/consequences?



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• what is reasonable? Was this reasonable?

• what are the staff member’s professional responsibilities?

• what were the mitigating circumstances?

• was any remorse shown or apology given?

• what guarantees were there that this would not happen again?

• how would the staff member’s actions be regarded by others?

• had the staff member received support/training/guidance asappropriate?

• underlying medical factors.

8.27 Write down the recommendations and explain reasons for thisrecommendation, using answers to the above questions and evidencegathered . . .

Section – sign off

8.28 Sign the form and complete the appropriate dates for the investigation.

9. Suspension

9.1 Suspension is not a disciplinary sanction and carries no assumption of guilt. Itis a means of protecting the interests of the staff member and the South WestStrategic Health Authority whilst the investigation is taking place. A staffmember should be suspended pending the disciplinary investigation andhearing when you consider that having them in the office/ward poses asignificant and legitimate risk to the South West Strategic Health Authority, toour property, to other staff, or to themselves, or where you have any reason tobelieve that they may interfere with the investigation in any way. It is alsolikely to be appropriate if the nature of the misconduct is such that there hasbeen a serious breach in the trust and confidence resulting in a breakdown ofrelations.

9.2 It will normally be appropriate in cases of gross misconduct, but it is unlikely toapply to more minor incidents.

9.3 The decision to suspend should not be taken lightly, and suspensions shouldalways be kept to a minimum. Confidentiality must be maintained. You canonly suspend a staff member if you have been given authority to do so by aDirector, Associate Director, or their Deputy. If you are consideringsuspending a staff member, you should always get in touch with the HumanResources team to discuss the case.



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9.4 The process for suspension is as follows:

• the manager who becomes aware of the misconduct should discussthe matter with a Director, Associate Director or their Deputy, and theHuman Resources team;

• the Director, Associate Director or their Deputy, should considerwhether suspension is appropriate, and consider any alternatives tosuspension (for example moving the staff member or altering theirworking arrangements);

• once the decision has been taken by the Director, Associate Director ortheir Deputy, to suspend the member of staff, they may carry out thesuspension or delegate authority to another appropriate manager;

• the authorised manager should endeavour to find out whether the

member of staff is in a union, and if so, try to arrange for a unionrepresentative to be present at the suspension meeting. However, itmay not be possible to ascertain this information as quickly as isnecessary, or to find a Trade Union representative who can attend atshort notice. Neither of these circumstances should cause themanager to delay the suspension process. In these situations themember of staff should be given the opportunity to have a workcolleague present at the meeting (not acting in a legal capacity), shouldthey wish;

• the authorised manager should arrange a quiet room in which to meet

the staff member and then inform them of the reason for thesuspension and provide specific details of the concerns, includingnames if appropriate;

• the manager should advise the staff member not to make any responseto the allegations at this time but to explain that a full investigation willtake place during which they will be able to put their own views;

• the manager will organise collection of any South West StrategicHealth Authority property, including ID badge and any keys;

• the manager will advise the staff member that they should not comeonto South West Strategic Health Authority premises (unless as part ofthe investigation or if visiting Occupational Health to accesscounselling) and will give the name of a link manager who will maintaincontact with them during the investigation. This may be theInvestigating officer;

• issue suspension letter DIS2, within seven days of the suspension,following review and agreement by the Human Resources team.



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9.5 If you decide that it is necessary to suspend a staff member, the period ofsuspension will be on full pay and should be for as short a time as possible.The need for suspension should be reviewed on a regular basis to ensure thatthe suspension is still appropriate in the circumstances.

9.6 During this period, the staff member:

• must not carry out any of their normal duties. This includes overtimeand any Bank shifts that might be booked. They should provide youwith any outstanding work before the suspension starts;

• must not contact any colleagues, (with the exception of their TradeUnion representative or Staff Counsellor), or patients. If they have anyqueries, these should be referred to you or the line manager;

• will be required to maintain confidentiality, and not discuss the case

with patients or colleagues;

• is required to co-operate with any investigations.

Criminal matters

9.7 Staff may occasionally commit acts of misconduct, which are against the lawand need to be dealt with through the Criminal Justice System. Examplesmight be theft, assault or fraud.

9.8 Whether these offences are committed in work time or outside of work, they

will need to be dealt with if they have an impact upon the staff member’songoing employment with us, or if they breach the bond of mutual trust andconfidence between employer and employee.

9.9 In these circumstances it is appropriate to follow the South West StrategicHealth Authority’s Disciplinary procedure in the usual way and carry out a fullinternal investigation. You should contact the Human Resources team assoon as you become aware of the criminal act, and they will provide furtheradvice and support with the case.

9.10 It may be necessary to liaise with the police throughout the investigation

process, and also provide the police with any witness statements or otherevidence which you may gather. You are legally obliged to provide thisevidence if requested.

9.11 It is not necessary to await the outcome of any criminal process orprosecution before convening a disciplinary Hearing. Providing that aprocedurally fair and thorough disciplinary process has been carried out, anysanction, which might be given, will stand, regardless of the later outcome ofthe court case.



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9.12 Managers should be aware of the likely public interest in such cases and alsothe negative publicity that might result. You should therefore inform theDirector of Communications and Corporate Services Department immediatelyif you think the South West Strategic Health Authority is in anyway at risk interms of press interest in your case. Again, advice and support are available

through the Human Resources team.

Counter Fraud Service

9.13 The NHS has access to a Counter Fraud Service who are able to provideexpert advice and support with cases of suspected fraud. They are able toundertake investigations on behalf of the South West Strategic HealthAuthority and will provide managers with their evidence and conclusions, inorder that a Disciplinary Hearing can be arranged. You should contact theHuman Resources team in such cases who will advise how and whether tocontact Counter Fraud.

9.14 In accordance with the Secretary of State Directions only an accredited LocalCounter Fraud Specialist (LCFS) should conduct investigations into mattersrelating to fraud or corruption. Incidents of fraud should be reported by theHuman Resources team to the LCFs or the National Fraud and CorruptionReporting Line (0800 028 40 60) without delay. Where there is evidence offraud or an allegation of fraud is made, against an employee, the proceduresdetailed in the Fraud Response Plan will be followed. Such cases are likely toinvolve a criminal investigation being conducted by the LFCS and managersare reminded that close liaison with the LCFS will be necessary to avoidtaking action in isolation that could jeopardise the LCFS investigation. The

Fraud Response Plan and contact details for the LCFS can be found on theAuthority’s intranet site.

Non attendance at the Disciplinary Hearing

9.15 In the event of a resignation being tendered, it is the practice of South WestStrategic Health Authority to proceed with, and conclude any disciplinaryaction where the allegation could have resulted in dismissal for example anallegation of potential gross misconduct. This will apply even in cases wherethe individual is no longer an employee of the organisation, as a disciplinaryhearing may proceed in their absence.

10. Arranging the Disciplinary Hearing

10.1 To ensure the smooth running and effectiveness of the Disciplinary Hearing,the Disciplining Manager will need to make arrangements for the Hearing.They will need to:

• confirm that a confidential note taker will be available, if possible;

• book a suitable room, where privacy and confidentiality can bemaintained;





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• understands any reasons why the misconduct has occurred;

• to decide on what disciplinary action is appropriate and discuss thiswith the staff member.

11.2 The format of the Hearing is as follows:

Stage one – welcome

• the Disciplining Manager will introduce all present by name and jobtitle, and explain why they are there (for example in an advisorycapacity, to take notes or to accompany staff member);

• confirm the purpose of the Hearing, as mentioned in their letter dated(date), is to discuss (reason for disciplinary action);

•

confirm that the staff member has received their letter and is aware oftheir right to be accompanied. If they are happy not to be represented,ensure that this is noted;

• if the Hearing has previously been postponed because of illness,confirm staff member is fit and well enough to proceed with theHearing;

• explain that notes may be taken of the Hearing (possibly using a notetaker). Interviews of the Hearing may exceptionally be recorded usingaudio equipment. At any stage of the disciplinary procedure, either

party may request that the Hearing is recorded using audio equipment;

• explain the format the Hearing will take.

Stage two – explain

• the Investigating Officer will firstly give clear and specific details of thealleged misconduct with dates/details as appropriate;

• the Investigating Officer will describe the nature of the evidence andhow it was gathered. They will outline all evidence that has been

gathered to support the allegation including any witness statements.They will call their witnesses, who may read their statements andanswer any points of clarification;

• the Disciplining Manager, employee and their representative will havethe right to question all witnesses and the investigating officer;





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• the Disciplining Manager will let the staff member know there will be anadjournment, the reason for this (such as to carry out furtherinvestigations, or to consider their responses and make a decision) andhow long this is likely to be. If further investigation is required, this maytake several days.

Stage five – adjournment

11.3 The Disciplining Manager should always adjourn the Hearing for at least ashort time to consider the responses made by the staff member and to maketheir decision on what action will be appropriate. Normally the meeting will bereconvened the same day. They will also need to adjourn if the staff memberpresents new evidence before the summary has been made. In this case it islikely that the adjournment will need to be for several days to allow furtherinvestigation. The Disciplining Manager should make sure that they advisethe staff member that the disciplinary meeting will be reconvened following the

investigation, why this is necessary, and when this further meeting is likely totake place.

11.4 An adjournment may also be necessary:

• if the Disciplining Manager realises that the misconduct is either moreor less serious than originally thought;

• if tempers become frayed;

• if anyone is upset or overly anxious;

• if a natural break is needed.

11.5 The staff member or their Trade Union representative or work colleague mayalso request an adjournment at any time during the meeting.

11.6 During the adjournment, the Disciplining Manager, the Human Resourcesrepresentatives or other manager on the panel will:

• consider the facts and responses made by the staff member;

•

consider any mitigating circumstances;

• carry out further investigations if required;

• decide upon whether or not they genuinely have a reasonable beliefthat staff member has committed the alleged act(s) of misconduct,based on the evidence presented, and any action to be taken. (seefollowing section) Ensure the action is appropriate, taking intoconsideration :

∗ how serious is the offence?





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• the disciplinary penalty is appropriate to the act of misconduct and isconsistent with similar cases, whilst allowing for the individualcircumstances. It is unlikely to be reasonable to dismiss a staffmember for a first offence unless the offence is one of grossmisconduct. They must be sure of the seriousness of the issue and

whether it is classified as misconduct or gross misconduct. If they areunsure, discuss with your Human Resources representative.

An overview of the formal disciplinary sanctions

Written Warning A written warning is usually given in cases of lessserious misconduct, where no current warning is on file.A written warning will be placed on the staff member’spersonnel file for twelve months.

Final Written Warning A final written warning would normally be given if there

is:

• an accumulation of minor offences;

• a failure to respond to a previous writtenwarning; (required standards ofimprovement not met for example)

• a repeat of an act of misconduct duringthe life of a previous written warning;

• a more serious offence.

This warning will normally stay in place for a period oftwenty four months. The Disciplining Manager must bea Director or Associate Director.

Dismissal Dismissal may occur if:

• the staff member commits an act of grossmisconduct;

•the required improvements have not beenmade following a final written warning;

• there has been a further act of misconductduring the life of a final written warning.

Dismissal may be with notice or summary dismissal forgross misconduct.

The Disciplining Manager must be a Director or ChiefExecutive (a manager with authority to dismiss)



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Stage six – reconvene and close

11.9 Ideally the Hearing should be reconvened on the same day. However, thismay not be possible in all cases, for example if new evidence is provided atthe meeting. The Investigating Officer should be present at the reconvened

Hearing.

11.10 When the Disciplining Manager reconvenes the Hearing:

• recap on what has already been discussed;

• advise the staff member whether or not you believe that they havecommitted the alleged misconduct, and ensure that they understandthe reasons for your decision.

11.11 If the Disciplinary Panel does not believe that they committed the alleged

misconduct:

• explain what evidence has been taken into account (including anymitigating circumstances);

• explain what the disciplinary penalty will be and in the case of a writtenwarning, how long this will remain on their records;

• ensure that the staff member understands any standards of conductthey need to meet in the future and the details of any review period;

•

explain the right of appeal;

• ensure the staff member understands the consequences of any futuremisconduct;

• explain that the staff member will receive a letter confirming this.

11.12 If the decision is to terminate employment for gross misconduct, the panel willneed to decide whether dismissal will be summary dismissal or dismissal withnotice. If summary dismissal is appropriate, they will need to advise the staffmember that they are summarily dismissed, and are not entitled to pay in lieu

of notice. Confirm that arrangements will be made for salary and any accruedholiday entitlement up to and including today’s date, to be paid as soon aspossible.

Follow up actions

11.13 The Disciplining Manager will need to write to the staff member and theirTrade Union representative or work colleague within seven days of thehearing to confirm the outcome of the disciplinary hearing as follows:

• written warning – letter DIS9;

• confirmation that action is not appropriate – letter DIS10;



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• dismissal with notice or pay in lieu, or summary dismissal – letterDIS11;

• other sanction, such as demotion – letter DIS13.

11.14 If you are terminating employment, ensure that you liaise with the HumanResources team in order that the termination can be processed. You will alsoneed to arrange for the return of any company property if this has not alreadybeen done.

Disciplinary case files

11.15 It is important to ensure that every part of the process you have undertaken isfully documented, and that all the papers are sent for filing to the HumanResources team where they will be held in accordance with the DataProtection Act. You should place the papers in a sealed plain envelope

clearly marked ‘Confidential’ and send it securely to the Human Resourcesteam.

11.16 You can keep local files on individuals yourself for a maximum of twelvemonths, as long as they are current, relevant and secure.

12. The appeal process

12.1 If the staff member is not happy with the outcome of the disciplinary hearing,they have the right to appeal within fourteen calendar days to the AssociateDirector of Human Resources who will ensure that an appropriate panel is

convened. One appeal is allowed at each stage of the formal procedure. Theappeal should clearly state the basis on which it is made. The staff membershould put their appeal in writing, and if necessary be provided with thenecessary support to do so. The process is as follows:

Step Situation Action StandardLetter

DateCompleted

Appeal received – preparing for Hearing

1. Appeal

received

Check that the appeal is being dealt

with by a manager senior to themanager who imposed thedisciplinary sanction (or in the caseof a Director, by a panel consistingof 3 Directors, Non ExecutiveDirectors or Chief Executive), andmust not have been involved (evenindirectly) in the original decision. Inthe case of a dismissal, the appealmust be heard by a panel including3 Directors, Non Executive Directors

or the Chief Executive,accompanied by a Human



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DateCompleted

Resources representative. Checkthe appeal has been made on

acceptable grounds. These are:

• the procedure has not beencorrectly applied;

• the level of sanction isinappropriate (too severe);

• the staff member now hasadditional relevant evidence notpreviously taken into account.

2. Arrange Hearing to be held withinsix weeks of receipt of appeal andconfirm that note taker and aHuman Resources representativeare available.

3. Invite the staff member to themeeting. They may beaccompanied by a Trade Unionrepresentative or work colleague not

acting in a legal capacity.

DIS15

4. EmployeepostponesHearing

The meeting may be postponed byup to five days to enable their TradeUnion representative or workcolleague (not acting in a legalcapacity) to attend.

Appeal manager to rearrangemeeting and re-advise date.

5. Oncemeetingdate agreed

Appeal Manager to prepare for theHearing by reviewing all availableevidence. The Manager presentingthe management case should sendall evidence and ManagementStatement of Case to the AppealManager and the staff member wellin advance of the Appeal Hearing.The staff member should also sendtheir written grounds for appeal tothe panel in advance of the Hearing.



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DateCompleted

Hearing

6. At Hearing Hold Hearing, allowing both sides topresent their case and ask/answerquestions, taking full notes anddecide whether to uphold theoriginal decision, or to agree theappeal.

Reconvene Hearing and advise staffmember verbally of decision.

Following Hearing

7. Appealagreed(originaldecisionrevoked)

If Appeal Manager decides that theoriginal decision was incorrect, theymay decide to revoke this decision.In the case of dismissal, this willmean the staff member is reinstatedwith continuous service. Confirmdecision to the staff member.

DIS16

8. Sanctionreduced

If Appeal Manager decides that theoriginal penalty was too severe, they

may decide to give a lesser penalty,for example a final written warninginstead of a dismissal. Confirmdecision to the staff member.

DIS17

9. Sanctionupheld

If Appeal Manager decides that theoriginal decision was correct, advisethe staff member accordingly. If theappeal was against dismissal,dismissal date remains unchanged.

10. Finaldecision

Appeal manager’s decision will befinal.

Resignation during disciplinary proceedings

12.2 If a staff member wants to resign during the disciplinary process, orimmediately afterwards, you must contact the Human Resources team forguidance, and extreme care must be taken. Sometimes staff may tender aresignation subject to certain conditions and it is vital that you contact the

Human Resources team if this is the case.



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12.3 In the event of a resignation being tendered, South West Strategic HealthAuthority will proceed with and conclude any disciplinary action where theallegation could have resulted in dismissal, for example an allegation ofpotential gross misconduct. This will apply even in cases where the individualis no longer an employee of the organisation, as a disciplinary hearing may

proceed in their absence.

12.4 In exceptional circumstances, if the resignation is accepted including allconditions, letter DIS14 should be used following review and agreement by aHuman Resources Manager. If any or all conditions made as part of aresignation are unacceptable to the South West Strategic Health Authority youmust contact the Human Resources team for guidance.

Appeals regarding the disciplinary process

12.5 If a staff member has a grievance that the process has been applied outside

the agreed disciplinary procedure this can be raised separately to any appealagainst a disciplinary sanction applied.



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Annex 1 – Checklist for any stage of formal disciplinary procedure


DateCompleted

Before Hearing

1. Incidentoccurs orinformationbecomesavailablewhichindicatesthatmisconduct

may haveoccurred

Investigating Officer investigatesallegations and recommends whetherdisciplinary hearing is appropriate.The Investigating Officer will need to:

• collect and analyse statementsfrom any witnesses, or otherevidence;

• examine personnel file to checkfor any previous occurrences;(such as unexpired warnings)

• consider any possible mitigatingcircumstances that might be putforward;

• to proceed they must have areasonable belief that the staffmember may have committed the

misconduct – for example itappears more likely than not thatthey did so, and have reasonablegrounds to support that belief atthis stage.

2. Unlessallegationsclearlyunfounded

Recommend Hearing and confirmthat Disciplining Manager, HumanResources, Trade Unionrepresentative or work colleague andnote taker will hear the case.

3. Attendeesconfirmed

Investigating Officer prepares allrelevant documentation, which theywill rely on at the meeting. Preparesscript for Hearing. DiscipliningManager advises date of meeting tostaff member and Trade Unionrepresentative, giving at least sevendays notice and encloses copies ofall relevant documentation with letter.

Go to step 4/5/6 as appropriate.

DIS4



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DateCompleted

4. Staffmember

postponesHearing

The staff member may postpone theHearing for up to five working days in

order to allow their Trade Unionrepresentative or work colleague toattend.

Rearrange Hearing and re-advisedate. Go to step 6.

5. Staffmemberrefuses toattend

Investigate why the staff member isrefusing to attend. If there is noreasonable explanation, ensure thatthey understand that the Hearing will

proceed in their absence. If the staffmember cannot attend due to illness,Hearing should be rearranged for anappropriate date. If illness is likely tobe long term, consult with HumanResources team for advice.

6. OnceHearing dateagreed

Disciplining Manager holds Hearing,taking full notes and verbally advisesaction to be taken.

After Hearing

7. Hearing hasbeen held

Decision made to take one of thefollowing actions:

• Written warning agreed asappropriate action – go to step 8;

• Final written warning agreed asappropriate action – go to step 9;

• Other action to be taken – go tostep 10;

• No action necessary – go to step11;

• Dismiss employee – go to step12.



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DateCompleted

8. If writtenwarning

agreed asappropriateaction

Issue written warning specifyingperiod for monitoring (twelve

months).Ensure copy of warning isincluded on personnel file.

Go to step 14.

DIS9

9. If finalwrittenwarningagreed asappropriate

Issue final written warning, includingtime scale for monitoring (twenty fourmonths).

Ensure copy of warning is includedon personnel file.

Go to step 14.

DIS9

10. If otheractionagreed

Issue letter advising of action (suchas demotion).

For next step seek advice from theHuman Resources team.

DIS13

11. If no actionappropriate

Issue letter to staff member toconfirm that procedure is finished

and no further action will be taken.

DIS12

12. If dismissalappropriate(usually forgrossmisconduct)

Issue letter of dismissal or summarydismissal (for gross misconduct).

Go to step 14

DIS11

13. If appealreceived

See appeals procedure.

Go to step 14 is appeal unsuccessful.

14. If no appealorunsuccessfulappeal

Where a written warning has beenissued, monitor for agreed period. Atend of period go to step 15.

In case of dismissal, ensure allcopies of correspondence, the scriptof the Hearing, notes made and copyof completed checklist are sent to theHuman Resources team for filing onthe staff member’s personnel file.

No further action necessary.



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DateCompleted

15. Hasmisconduct

recurredwithin theperiod of thewarning?

No: Advise staff member that theprocedure has finished and warning

has expired. Ensure all copies ofcorrespondence, the script of theHearing, any notes and copy ofcompleted checklist are sent forfiling to the Human Resources teamwhere they will be held on theemployee’s personnel file. Theexpired warning andcorrespondence will be held in asection of the employee’s file, whichhas limited access to ensure

compliance with the data protectionprinciples.

Yes: Disciplinary procedure willrestart at next stage. Start a newchecklist.



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Annex 2 – Disciplinary authority

Note: the appropriate Officer will be determined in each case by the size, andorganisational structure of the department or section in question.

Disciplining Manager in case of potential:

Dismissal

Director or Chief Executive

Issue of first and final written warnings

Associate Director or Director

Appeal

Associate Director or Director not previously involved

Appeal against a Dismissal

Panel of 3 Directors, Non Executive Directors or Chief Executive not previouslyinvolved

Appeals should be submitted to the Associate Director of Human Resources who willarrange for an appropriate Panel to hear the Appeal.

Suspension

Authority to suspend may be delegated to a Manager by a Director, AssociateDirector or their Deputy.

Investigating Manager

As appointed by the Disciplining Manager.

In the case of the Chief Executive or other Executive Directors, this document needs

to be read in conjunction with the Terms of Reference for the Remuneration andTerms of Service Committee.



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Annex 3 – Summary of letters

All of these letters can be found on the intranet site

Letter Name When to use

DIS1 Confirmation of outcome ofinformal meeting

Following an informal meeting toconfirm actions/outcome

DIS2 Letter of Confirmation ofSuspension

When suspending employee suchas suspected of gross misconduct

DIS3 Notify Investigatory OfficerAppointed

To conform the name of theInvestigatory Officer appointed

DIS4 Invite to Investigatory Interview Confirm date of investigatoryinterview

DIS5 Letter to Witness Issue following interview withwitness

DIS6 Confirmation of Outcome ofInvestigatory Interview – No caseto answer

Issue following the investigatoryinterview

DIS7 Confirmation of Outcome ofInvestigatory Interview – Counselling

Issue following the investigatoryinterview

DIS8 Invite to formal DisciplinaryHearing

Use at stages 1, 2 and 3

DIS9 Formal Disciplinary Outcome – Written Warning

Written or Final Written Warning

DIS10 Formal Disciplinary Outcome – No Case to Answer

No case to answer following theDisciplinary Hearing

DIS11 Formal Disciplinary Outcome – Dismissal

Dismissal for Misconduct

DIS12 Confirmation of Standardsfollowing review

Following review period, to confirmno further action appropriate

DIS13 Offer of demotion To confirm demotionDIS14 Acceptance of resignation When employee resigns during

disciplinary procedure

DIS15 Acknowledgement of appeal andinvite to Hearing

When appeal received

DIS16 Decision withdrawn Where original decision overturned

DIS17 Decision altered Lesser sanction imposed followingappeal

DIS18 Decision upheld Appeal rejected





Appendix 5

Emergency Response Policy

This appendix sets out the revised EmergencyResponse Policy or the South West Strategic HealthAuthority.





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Emergency Response Policy

1. Introduction

1.1 The South West Strategic Health Authority is committed to ensuring that theorganisation is prepared to manage services and the workforce effectivelyduring an emergency situation, for example an outbreak of pandemicinfluenza, severe weather or mass causality incident.

1.2 During emergency situations, staff sickness and workforce issues will affectthe NHS South West and the South West Strategic Health Authority as anemployer. Employees may be directly or indirectly affected by an emergencyimpacting their ability to attend work.

1.3 An incident or emergency affecting staff may impact all Directorates resultingin a potential need to work differently and with different people. Some staffmay be redeployed into different roles and there may be an increase in theuse of volunteers and non-NHS sources for temporary cover. It is thereforenecessary to have a clear strategy to ensure continuity of business.

1.4 In developing this strategy the South West Strategic Health Authority hastaken account of the following guidance published by the Department ofHealth:

• responding to Pandemic Influenza - the ethical framework for policy

and planning;

• pandemic Influenza - Workforce guidance for NHS – developed on apartnership basis with the NHS Trade Unions and the Department ofHealth/South West Strategic Health Authority Employers;

• South West Strategic Health Authority Major Incident Plan

• South West Strategic Health Authority Business Continuity Plan.

2. Strategy outcomes

2.1 The intended outcomes of this strategy are as follows:

• to ensure that the South West Strategic Health Authority has anappropriate Human Resource policy to support the requirements on anemergency response.

• to provide an appropriate policy to support the Business Continuity planin maintaining the delivery of essential services during an emergencysituation;

• to ensure that the staff of South West Strategic Health Authority aresupported during an emergency situation.



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3. Principles

3.1 This Emergency Response policy does not override current workforce policieswhich already exist. These policies will continue to apply as normal but theEmergency Response policy sets out specific arrangements which will be

used for the duration of an emergency situation.

3.2 The Emergency Response policy of the South West Strategic Health Authorityis developed in the context of a duty to provide services to the population ofNHS South West, maintaining the continuity of the core business function, aswell as maintaining the health and safety of staff. The potential gravity of anemergency situation cannot be overemphasised. In all probability there will bea time when normal working arrangements are insufficient.

3.3 General experience has shown that staff respond well whenever there is amajor incident or set of unusual circumstances to deal with. In order to

respond to the needs of the local population it will be essential that all staffwork together for the common good. Only by working together will the SouthWest Strategic Health Authority be able to work through the problems whichwill inevitably face the organisation and the NHS South West.

3.4 The South West Strategic Health Authority will encourage a culture ofreasonableness and negotiation, coupled with an expectation that staff will actresponsibly. Wherever possible, volunteers will be sought from the existingworkforce, but where this proves to be inadequate, managers may need to bemore directive, but this will be for a time-limited period.

3.5 The South West Strategic Health Authority will take all reasonable steps toprotect staff health and safety, provide clear communication on risks andprovide support throughout the period of an emergency situation.

3.6 In developing the detailed actions to implement this strategy, the South WestStrategic Health Authority is committed to involving staff and theirrepresentatives.

4. Preparing for an emergency situation

Mapping the workforce

4.1 In order to tackle an emergency situation it will be necessary to takepragmatic decisions to help ensure business continuity.

4.2 The impact of an emergency situation will mean an increased workloadcoupled with a reduction in the staff available for work. It will therefore beessential that the capacity of the workforce of the South West Strategic HealthAuthority is increased by asking people to vary their normal pattern of work,increase their hours, or to work differently.

4.3 There may also be a need to call on professionals from partner organisations

or individuals who are not currently working to assist if existing staff areabsent.



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4.4 The standard contract of employment for the staff of the South West StrategicHealth Authority includes a mobility clause which will provide for reasonableflexibility of staff between locations. It is likely that the South West StrategicHealth Authority will need to invoke this contractual provision and will do so inline with the principles detailed in this policy.

4.5 The following actions have been undertaken to develop a comprehensiveinformation database to be accessed when the need arises. This data will becollected in accordance with the Data Protection Act and other NHS specificguidance, and will only be used for emergency planning purposes:

• details of staff arrangements for travelling to work have been collectedto identify risks of non-attendance due to transport or other factors, andto inform redeployment options;

• collecting up to date staff contact details, especially mobile telephone

and other emergency contacts which will be reviewed accordingly;

• a process has been established to enable details of staff dependantsand caring responsibilities to be gathered as these staff mayexperience more difficulties in attending for work due to illness orschool closures for example which will provide a valuable planning tool.

Developing a register of staff resources ‘Staff Pool’

4.6 A ‘pool’ of staff who have retired or left the organisation has been developedwithin the past two years and can be called upon to provide additional

resources.

4.7 Liaison with partners across the health community, including acute andprimary care trusts and independent sector providers, local authorities andindependent contractors, will ensure that they have assessed the impact ontheir own staff and are developing plans to maintain essential services. Inaddition we will seek to identify how we might work together to increasecapacity.

4.8 A review of training and development needs, putting in place skills refresherprogrammes for those staff who have moved out of clinical roles or are no

longer utilising key skills, and development packages as appropriate, todevelop capacity not solely for our own workforce but also the NHS SouthWest region will be undertaken.

Supporting the Major Incident Room

4.9 In the event of a Major Incident that requires regional coordination of theHealth service response, due to the impact of the emergency, the South WestStrategic Health Authority will activate its Major Incident Room. This facilitywill provide strategic command and control for the NHS South West.



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4.10 The operation of the Major Incident Room is over seen by the ResilienceTeam but relies on assistance from staff from all Directorates to perform keyroles. Staffing the Major Incident Room must meet the demands of theincident which may require evening and weekend working or even 24 houroperability.

4.11 Volunteers from all Directorates who have received Major Incident Roomtraining will be temporarily released from their posts to assists the incidentresponse in agreement with their line manager or as appropriate.

4.12 The Resilience Team will deliver training to volunteers in both AssociateDirector and support roles as appropriate. Staff volunteering to undergotraining for the Major Incident Room must do so in agreement with their linemanager or as appropriate.

On-call payments

4.13 It may be necessary to add staff to the on-call rota as part of the response tothe emergency situation. On-call payments are made in line with section 2.40of the NHS Terms and Conditions of Service Handbook. Dependent on thetimeframe of the emergency situation, these payments will be pro rata andpaid as part of their monthly salary. Please note that a local agreement foron-call frequency has been made for on-call frequencies less than 1 in 12which equates to 1.5% of the basic pay.

Review of Service Level Agreements

4.14 Where staff services are provided by other organisations, such asOccupational Health, the South West Strategic Health Authority has reviewedservice level agreements to ensure that contingency plans are in place formaintaining essential services.

Communication arrangements

4.15 Communication is seen to be a key factor in providing information and supportto staff during an emergency situation and the Communication strategy willensure that arrangements are in place.

4.16 The South West Strategic Health Authority recognises that there is likely to bea great deal of concern among staff about the potential risks and evolvingimpact of an emergency and is therefore committed to robust communicationwith staff.

4.17 Working with the Resilience Team, the Communications Team will ensure thatstaff are briefed and regularly updated on the incident as appropriate. Wherepossible, managers will maintain face to face communication in order torespond to staff concerns and sustain morale.



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Assessing the impact on staff

4.18 An emergency situation may affect staff in the following ways:

• staff may be directly impacted by the incident or emergency and

therefore unable to attend work;

• staff may be indirectly affected due to the impact on family;

• stress levels may be high due to the pressure the response, impact onwork load or working in an unfamiliar role.

During an emergency situation

Managing absence

4.19 As the strategic lead for the South West, the expectation is that staff will makeevery effort to attend their workplace and work flexibly to support theircolleagues across the South West.

4.20 During an emergency situation, normal reporting arrangements will applywhere possible and sickness records will be maintained to monitor absence.

4.21 If an employee feels that it is not reasonably practical to get to work, or it isunsafe to do so, or that it would take so long as to be pointless, they musttelephone their manager or nominated deputy and explain the situation by9.30am or as soon as possible after this time.

4.22 Wherever possible, the manager should find work that the employee is able todo from a remote location including their home.

4.23 If the manager feels that the employee has not made a reasonable attempt toattend, the employee will be required to take annual leave or to make up thelost hours.

4.24 In the event that line managers are themselves absent, or at the discretion ofManagement, alternative arrangements will be established.

4.25 The South West Strategic Health Authority aims to work with staff to allay any

fears and protect their health and safety and that of their families. However,professional codes of conduct and contracts of employment oblige staff toattend for work and discharge their responsibilities, and any unreasonablerefusal to attend could result in non-payment and appropriate disciplinarymeasures being taken following the emergency situation.



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Working flexibly

4.26 In relation to South West Strategic Health Authority Business Continuity Planthere are roles and functions that have been identified as critical andnoncritical. Therefore some non-critical functions could cease for a period of

time in the event of an emergency. This will release staff who can then bedeployed to work in different roles. South West Strategic Health Authorityreserves the right to redeploy staff as the need arises. This could be to adifferent role, function, or locality and in some circumstances may involvetransferring staff to other NHS organisations, such as acute hospitals.

4.27 Staff may also be requested to work different hours from those stated in theircontract of employment. Requests to make these alterations to work andworking patterns should not be unreasonably refused, and will be for theduration of the emergency situation as required. There will be no change tothe contract of employment and normal working hours will resume at the end

of the emergency. Staff will not be expected to undertake roles for which theyare not competent but there is an expectation that they will respond positivelyby rapidly learning new (non professional) skills that they will require.

4.28 In order to cover essential services staff may be asked to work more hoursthan normal. Staff up to and including Agenda for Change Band 7 will be paidfor the extra hours worked on their current grade regardless of the taskundertaken. For staff on Agenda for Change Band 8 or above, time off in lieuand over-time arrangements will be reviewed as appropriate during anemergency situation.

4.29 Providing more services out of normal working hours is likely to be necessaryin order to effectively respond to the demands of the emergency. Anymember of staff may therefore be asked to consider working during theevening/night and at weekends to ensure adequate cover. In some instances,this change in working pattern may be mutually beneficial if staff are alsotrying to juggle carer/domestic responsibilities.

4.30 In terms of remuneration, staff will be paid at their normal rates of payregardless of the work they are doing. For example, a Finance managerworking on a helpline will continue to receive their normal salary. Incircumstances where a person is working above their pay band for more than

65% of work time and has completed twenty eight days or more working atthat level, consideration will be given as to whether they should be re-bandedon a temporary basis.

4.31 With regard to indemnity, people undertaking different roles during theemergency will be considered to be working under the direction of theiremployer and their actions will be covered. It is important, however, thatpeople feel able to raise any questions or concerns they may have in fulfillingtheir new role and seek advice accordingly.



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Management arrangements

4.32 The operational management arrangements will remain in force during theemergency response however a protracted incident would necessitate backup arrangements. Contingency plans have been developed to provide cover

in the event of sickness or absence of managers and team leaders which willalso be applicable in protracted incidents.

Annual leave

4.33 It may be necessary for the duration of the emergency response to refuserequests for annual leave or even cancel leave (costs where incurred, may becompensated on a case by base basis). If the incident continues for a morethan twelve weeks, or is followed by subsequent activity, thus preventing stafffrom taking outstanding leave in accordance with normal arrangements, SouthWest Strategic Health Authority will increase the annual leave carry over

entitlement into the next annual leave year and, in exceptional circumstances,consider purchasing leave entitlement where staff have been unable to take it.

4.34 Staff who do not normally work on bank holidays may be requested to do so.In this event, payments will be in accordance with NHS Terms and Conditionsof Service Handbook.

4.35 During an emergency the operation of the employment policies of the SouthWest Strategic Health Authority will need to be reviewed in the light ofpressure on the service. Any changes to employment policies will bediscussed in partnership with staff representatives.

4.36 It is anticipated that during the emergency response, a number of non-statutory functions will need to be put on hold, such as undertakingAppraisals. Similarly, Knowledge and Skills Framework reviews, training andstudy leave may need to be postponed. It will be also be impractical toundertake job evaluation and hold re-banding panels, as these will thereforebe postponed.

4.37 All non-essential project groups and meetings will be suspended asappropriate during the response to an emergency.

Terms and Conditions of Employment

4.38 Normal terms and conditions of employment will apply with the exception ofalterations to place of work and working hours as indicated above.

4.39 The way services need to be delivered and the fact that staff may beundertaking new roles will mean that many staff may be working away fromtheir usual base and working with people they may not normally come intocontact with. Increased travel costs incurred by individuals travelling to fulfiltheir duties will be in line with their terms and conditions of employment.



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Working Time Regulations

4.40 The Working Time Regulations will remain in force but its application will needto be reviewed. In exceptional circumstances, which are beyond the controlof the South West Strategic Health Authority, some aspects of the

Regulations may not apply (such as night work limits and rest breaks). SouthWest Strategic Health Authority recognises the importance of the Regulationsfor the health and safety of staff and to maintain standards. However, theremay be a need to review the Regulations to allow for greater flexibility. TheSouth West Strategic Health Authority will involve staff representatives in thisreview process.

Health and safety

4.41 During an emergency situation the South West Strategic Health Authority willcontinue to take all reasonable steps to safeguard the health and safety of

staff.

4.42 The South West Strategic Health Authority will take all reasonable steps toimplement national guidance published by the Health Protection Agency, theHealth and Safety Executive and the Criminal Records Bureau (CRB).

4.43 Before redeploying staff with clinical skills to a clinical environment the SouthWest Strategic Health Authority will ask Occupational Health to review theindividual’s fitness to work in a patient environment. This will ensure that no‘vulnerable’ member of staff is placed at avoidable risk.

4.44 Staff will be provided with guidance on the risks of infection and steps to taketo avoid contracting the disease. Infection control procedures will also bereviewed to ensure that all measures are in place to minimise the spread ofinfection.

Disciplinary and grievance matters

4.45 The Disciplinary policy and procedure and Grievance policy and procedure ofthe South West Strategic Health Authority will continue to apply during anemergency situation. However, in applying these procedures due account willbe taken of the pressures under which all staff and managers will be working.

Where appropriate staff will continue to adhere to their professional codes ofconduct but will also be guided by ‘Responding to pandemic influenza: Theethical framework for policy and planning’ (DH 2007) on the decisions theytake during an outbreak of pandemic influenza. The framework is availableat:http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_080751

4.46 The South West Strategic Health Authority will ensure there is rapid learningfrom untoward incidents which may arise and will adopt a no-blame approachwhere staff have acted in good faith within their skill and competence. Any,

reckless or unreasonable behaviour will be dealt with in accordance withemployment policies of the South West Strategic Health Authority.





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• all employees will have been treated fairly and consistently during the

response to an emergency;


• all employees have a clear understanding of the roles andresponsibilities for line managers and themselves in managing theemergency response.






Appendix 6

Establishment Control Policy

This appendix sets out the revised EstablishmentControl Policy for the South West Strategic HealthAuthority.





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Establishment Control Policy

1. Introduction

1.1 The purpose of the document is to ensure a consistent and equitable processfor establishment control and help to ensure that recurring resources areavailable to fund permanent changes in establishment.

1.2 The document sets out the procedures for:

• the maintenance of the funded establishment for the South WestStrategic Health Authority;

• the processes of agreeing Directorate establishments and making

changes to the establishment.

2. Policy statement

2.1 In line with the established budget setting principles the South West StrategicHealth Authority is committed to an establishment control mechanism whichrequires formal approval of changes to the funded establishment prior toimplementation.

2.2 This process will incorporate all posts within the South West Strategic HealthAuthority.

2.3 The process will incorporate a robust workforce planning process, reflectingproposed changes in staffing levels and or skill, and will be linked to theStanding Orders and Standing Financial Instructions.

3. Definition of budgeted establishment

3.1 A budgeted establishment is the agreed recurrently funded level of staffing fora Directorate/area. This may be changed as a result of:

• funded developments whether permanent, fixed term, temporary, or

secondment;

• agreed transfers between budgets;

• permanent or temporary changes in skill mix and grade;

• successful Agenda for Change grading appeal;

• change of job description to an existing post;

• retraction of service;

• new pressures or work programmes.



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4. The South West Strategic Health Authority Establishment

4.1 The overall establishment figure is confirmed annually, as part of the annualreview to the management arrangements of the South West Strategic HealthAuthority.

4.2 Establishment figures confirm the number of staff employed by the SouthWest Strategic Health Authority in the form of whole time equivalents and thesalary structure.

4.3 The establishment figures are agreed to the organisational structure of theSouth West Strategic Health Authority.

4.4 The establishment cannot be changed without adherence to the followingprocess outlined in this document and with the approval of the ChiefExecutive, Director of Finance and Performance and Associate Director of

Human Resources.

4.5 The Director responsible for each Directorate will agree with the ChiefExecutive an annual plan (in a structure chart format) which shows:

• the reporting structure of the Directorate;

• each post – by unique post reference to ensure compliance withelectronic staff records;

• each post – by job title with job holder’s name as appropriate;

• each post – the whole time equivalent for each post (with the wholetime equivalent shown in brackets where this is different to theestablished post);

• each post – the agreed grade and actual salary for the current postholder.

4.6 The responsible Director should ensure that all posts:

• be described in the standard Job Description format as provided the

Human Resources;

• be supported by a person specification detailing the level ofqualifications, experience, skills and knowledge that the post holdermust possess as essential or desirable requirements;

• have the agenda for change banding confirmed via the Agenda ForChange job evaluation process.

• employment recruitment will only be permitted against agreedestablishment.



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4.7 Restructuring within a funded establishment will need to be approved by theChief Executive and Director of Finance and Performance to include sign offof costed proposals and the banding of new posts under the Agenda forChange process.

4.8 Posts must be disestablished in the event of a restructuring that introducesnew posts.

5. Responsibilities

5.1 The application and monitoring of this procedure is the ultimate responsibility ofthe Chief Executive, but it is executed by the Director of Finance andPerformance in conjunction with the Associate Director of Human Resources.

5.2 All Directors of the South West Strategic Health Authority with responsibility forthe recruitment and management of staff must adhere to this procedure.

5.3 The Assistant Director of Finance will be responsible for ensuring that thefunded establishment is entered onto the Electronic Staff Record.

5.4 The Assistant Director of Finance will be responsible for confirming funding isavailable within the appropriate budget.

5.5 Human Resources will be responsible for confirming the correct banding of thepost through the Agenda for Change matching process.

5.6 Human Resources will be responsible for confirming that vacant posts are

correctly detailed and verified against the registered employee records.

5.7 All Directors are responsible for managing the numbers, hours, bandings andcosts of staff set out in the agreed establishment for their directorate

6. Changes to the establishment procedure

6.1 There are a number of reasons why an agreed establishment may need to bechanged:

• changes to salary bandings arising from revised Job Descriptions and

person specifications that will require a written briefing to explain thechanges and the rationale behind this;

• changes to structure numbers (including hours if they are to increase)that will require a written briefing to explain the changes and therationale behind this.

6.2 This policy is not to be considered a substitute for the necessary discussionswhich may need to take place at senior level with regard to any proposedchanges. The policy therefore, is designed to ensure that agreedestablishment changes are recorded and actioned accurately but does not

guarantee approval.



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6.3 On identifying the need for a change the relevant Director should ensure thatthe principles are agreed at an early stage before the completion andsubmission of the form. An agreed business case or rationale will need to beprepared to support any decisions in addition to the completion of theEstablishment Change Form which can be found on the intranet.

6.4 The Director responsible for the post will complete the relevant sections of theEstablishment Change Form, attach a rationale which provides a business justification and financial implications of this proposed change, job descriptionand person specification, sign and forward to the Assistant Director of Finance(Headquarters and Accounts), who will determine whether there is adequatefunding to support the post for the period of employment or advise on thecosting of any proposed changes.

6.5 For new posts or existing posts with a revised Job Description the AssistantDirector of Finance will pass the form to Human Resources, who will ensure

the grade and contract type are appropriate. The Establishment Change Formwill then be returned to the Assistant Director of Finance (Headquarters andAccounts) for checking funding details.

6.6 The Establishment Change Form along with required attachments will then bepassed to the Director of Finance and Performance and Director of WorkforceDevelopment for approval. If approved, the Establishment Change Form willbe forwarded to the Chief Executive.

6.7 The Chief Executive will provide final approval and sign off to theEstablishment Change Form. If approved, the form will be passed to the

corporate Assistant Director of Finance to set up the position onto theElectronic Staff Record., before being passed to Human Resources tocommence the recruitment process.



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Flow Chart depicting Establishment Control process

A change in funded establishmentbudget is identified (see Sections 3

and 4)

Prior agreement in principle has been given by the Chief Executive and/orthrough the Senior Management Team meeting.

Director completes Establishment ChangeForm and attaches:

• rationale outlining the business justification, financial implications, andsource of funding;

• ob descri tion and erson s ecification.

Establishment change form is submitted for authorisation to:

Assistant Director of Finance

Director of Finance

Director of Workforce Development

Chief Executive

Change in Establishment is authorised

Yes No No further action

Yes No

Form is passed to:

Finance – to set up position on ESR;

Human Resources – to commence

recruitment process.

Form is returned to Director whoinitiated process



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Appendix 7

Family Friendly Policy

This appendix sets out the revised Family FriendlyPolicy for the South West Strategic Health Authority.





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Family Friendly Policy

1. Introduction

1.1 South West Strategic Health Authority is committed to promoting EqualOpportunities and the purpose of this policy is to promote flexible employmentwhich will provide the framework for improving the working environment andencouraging diversity in the workforce.

1.2 The South West Strategic Health Authority is committed to ensuring that allemployees are supported and provided with necessary and timely informationin respect of this Family Friendly policy.

1.3 The Family Friendly policy addresses a number of areas where employeesare provided and offered support:

• Maternity leave;

• Paternity leave (maternity support);

• Parental leave;

• Adoption / surrogacy leave;

• Career breaks;

• Special leave.

2. Maternity leave

Introduction

2.1 This information has been designed to give guidance on the maternity leaveand maternity pay entitlements within the South West Strategic Health

Authority. Although this is a complex area, this policy should answer mostquestions, helping to make informed choices and to plan ahead for when thebaby is due.

2.2 Maternity leave and maternity pay entitlements are governed by NHSregulations as well as statutory legislation. Therefore, the informationcontained in this guide is specific to NHS employees. Please bear this inmind if offered advice by friends or relatives. Please contact the HumanResources team if further information is required.



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Ante-natal care and official meetings in the adoption process

2.3 All employees are entitled to reasonable time off in order to attend ante-natalappointments and official meetings in the adoption process. If theseappointments fall during working hours, time off shall be paid at the normal

rate.

2.4 Employees are expected, where possible, to attend work prior to, or return towork following these appointments or meetings.

2.5 Employees should notify their line manager of the time of their ante-natalappointment and additional time off needed in respect of ante-natal care, forexample Aqua natal or Parentcraft classes, must be arranged with the linemanager of the employee, or another appropriate manager.

Meeting with a member of the Human Resources team

2.6 Written notification of pregnancy is required prior to the end of the fifteenthweek before the expected week of childbirth, (week twenty five of pregnancy)by the line manager. Employees are encouraged to contact HumanResources before this date, so that they may be fully informed of theirentitlements and any risk assessments that should be carried out.

2.7 An employee may commence maternity leave at any time between theeleventh week before the expected week of childbirth and the expected weekof childbirth, provided the required twenty eight days’ notice is given.

2.8 Should an employee subsequently wish to change the date on which theycommence maternity leave, they should provide written notification to theHuman Resources team at least twenty eight days prior to the date on whichthey intend to commence maternity leave or, if this is not possible, as soon asis reasonably practicable beforehand.

2.9 Following the contact with a member of the Human Resources team, anemployee will receive written confirmation of:

• entitlement to paid and/or unpaid maternity leave;

• expected return to work date, based on entitlement to paid and/orunpaid leave and the date on which the employee intends tocommence maternity leave;

• any annual leave entitlement, which in agreement with line manager,may be taken prior to, or at the end of, maternity leave or carriedforward to the next financial year, if appropriate;

• the requirement to provide twenty eight days notice of the date onwhich an employee intends to return to work, if this is before theexpected return date.



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2.10 As well as a copy of this information remaining on file in the HumanResources team, copies will also be forwarded to Payroll and the linemanager.

2.11 Employees are required to forward the MAT B1 certificate, available from a

general practitioner or midwife from week twenty one of the pregnancy, to theHuman Resources team. Maternity pay cannot be processed without thiscertificate. Human Resources will also provide you with form ML1 and 2,which will confirm your intended return date.

2.12 Prior to commencing maternity leave, employees are advised to discuss andagree with the line manager any voluntary arrangements for maintainingcontact during their absence. This will include awareness of developmentswithin the role and work place and measures to help facilitate the return towork. An employee will also be expected to advise their manager of anycircumstances that may affect their intended date of return.

Eligibility to maternity leave and pay

Compulsory maternity leave

2.13 Employees are not permitted to work, including working from home, for thetwo week period commencing with the date of birth of their baby. Thecompulsory maternity leave period falls within the ordinary maternity leaveperiod.

2.14 Employees who wish to return to work prior to the end of their ordinary

maternity leave period should discuss this option with their line manager anda member of the Human Resources team.

Maternity leave

2.15 Employees are entitled to take fifty two weeks of maternity leave.

2.16 The amount of maternity leave and pay entitlement depends on length ofservice prior to becoming pregnant and the intentions following maternityleave. Employees are not obliged to confirm at this stage their intentionsregarding returning to work following maternity leave, although they will beasked to sign form ML 1 and 2 to indicate their intentions. However, withoutthis indication, there is no way of providing guidance on entitlement to allowan employee to plan their time or finances during and following maternityleave.

2.17 Employees will be asked for their intentions regarding returning to work or notreturning to work, following maternity leave or whether they are undecided atthis stage of pregnancy what their intentions are. This, combined with thelength of continuous service with the NHS, will determine the amount ofmaternity leave and pay entitlement. Annex 1 provides an explanation of thisentitlement. However, payment can vary depending on individual’s

circumstances.



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2.18 Entitlement to receive Statutory Maternity Pay is dependent upon NationalInsurance contributions and, if applicable, will be paid concurrently with thethirty nine weeks leave and/or pay that an employee receives from theorganisation.

Maternity allowance

2.19 Employees who do not pay National Insurance contributions, and do not,therefore, qualify for Statutory Maternity Pay can claim Maternity Allowancefrom the Department of Work and Pensions. The employee should get anSMP1 form from their employer. An employee may also qualify for a SureStart Maternity Grant from the Department of Work and Pensions.

Returning to work

2.20 By prior agreement with the South West Strategic Health Authority, this

entitlement may be paid in a different way, for example in a fixed amountspread equally over the maternity leave period:

• twelve months continuous NHS service: an employee whoindicates that they intend to return to work following maternity leaveand who has at least twelve months continuous NHS service prior tothe eleventh week before their expected week of childbirth, will beadvised of the following entitlement:

* fifty two weeks maternity leave, during which the employee willreceive:

- full pay for the first eight weeks;

- half pay plus Statutory Maternity Pay for the nexteighteen weeks (providing this does not exceed normalfull pay);

- statutory Maternity Pay for the next thirteen weeks

• at least twenty six weeks continuous NHS service: an employeewho indicates that they intend to return to work following maternityleave and who has at least twenty six weeks continuous NHS serviceprior to the fifteenth week before their expected week of childbirth, willbe advised of the following entitlement:

* fifty two weeks maternity leave, during which the employee willreceive:

- 90% of their normal full pay for the first six weeks;

- statutory Maternity Pay for the next thirty three weeks;



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• less than twenty six weeks continuous NHS service: an employeewho indicates that they intend to return to work following maternityleave and who has up to twenty six weeks continuous NHS serviceprior to the fifteenth week before their expected week of childbirth, willbe advised of the following entitlement:

* fifty two weeks unpaid leave;

• irrespective of her entitlement to Statutory Maternity Pay and/orMaternity Allowance, the employee will have a statutory entitlement tofifty two weeks unpaid leave;

• employees entitled to the eight weeks full pay and eighteen weeks halfpay in their maternity leave are required to return to work for aminimum period of three months. This can be different hours of work,a different post or potentially a different NHS employer;

• the South West Strategic Health Authority has the right to recovermonies owed by employees who subsequently do not to return to workfor a minimum of three months following their maternity leave.

Not returning to work

2.21 If an employee chooses not to return to work with the same (or other NHSemployer) for a minimum period of three months after the maternity leave hasended, the entitlement of the employee will be affected if they have more thantwelve months continuous service prior to the eleventh week before their

expected week of childbirth. If they do not return for the minimum threemonths, their entitlement will revert to:

• fifty two weeks maternity leave, during which the employee will receive:

• 90% of their normal full pay for the first six weeks;

• statutory Maternity Pay for the next thirty three weeks.

Undecided whether to return to work following maternity leave

2.22 If undecided whether to return to work following maternity leave:

• employees indicating that they are undecided whether or not to returnto work following maternity leave will be paid in the first instance as ifthey were not returning. Should an employee then decide to return towork, any further monies owed to them will be paid, less the amountwhich has already been paid. This will be paid at the end of the leaveperiod. All other conditions applicable to those employees whoindicate that they intend to return to work will apply;

• should an employee decide not to return to work following maternity

leave, they should resign to the Human Resources team, givingrequisite notice.



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Calculation of maternity pay

2.23 Full pay will be calculated using the average weekly earnings rules used forcalculating Statutory Maternity Pay entitlements, subject to the qualifications.

Keeping in Touch (KIT) days

2.24 You can work for up to ten days during your Maternity Pay Period withoutlosing any Statutory Maternity Pay. These special days are known asKeeping in Touch days.

2.25 Keeping in Touch days are intended to help you keep in touch with yourworkplace and allow you to do some work during your Maternity Pay Periodwithout affecting your Statutory Maternity Pay. They could also help easeyour eventual return to work.

2.26 The type of work you do could be attending work for a training course or for anAppraisal, for example.

2.27 Whether you take advantage of these days is your choice. Both you and yourmanager should agree that you can work on those days.

2.28 Any work you do as a Keeping in Touch day, even as little as half an hour forexample will be counted as a whole day for Keeping in Touch days. They canbe taken as single days; in blocks of two or more days; or can be takenconsecutively.

2.29 Once you have used up your ten Keeping in Touch days and you do anyfurther work, you will loose a week’s Statutory Maternity Pay for the week inthe Maternity Pay Period in which you have done that work. If a week in yourMaternity Pay Period contains only Keeping in Touch days, you will be paidStatutory Maternity Pay for that week. If a week in your Maternity Pay Periodcontains the last Keeping in Touch day and you do a further days work in thesame week for the employer paying you Statutory Maternity Pay, you will loseStatutory Maternity Pay for that week.

2.30 You will be paid at your basic daily rate for any hours worked, less appropriatematernity leave payment.

Health and safety at work

2.31 Once an employee has notified the South West Strategic Health Authority thatthey are pregnant, their manager may need to take specific measures tosafeguard their health and that of their unborn baby. The measures taken willdepend upon the type of work they do and the environment in which theywork. It is therefore necessary for their manager to regularly assess thesituation by undertaking a work based risk assessment.

2.32 Where an employee has recently given birth, or is breastfeeding, the linemanager should carry out an additional risk assessment of her workingconditions. The Return to Work Risk Assessment, and the New and





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2.40 Maternity leave will start automatically on the first day after the first day ofabsence, if an employee is absent from work for a pregnancy related illnessduring the four weeks before the expected week of childbirth, regardless ofwhen they have actually said that they want their maternity leave tocommence.

Sickness during maternity leave

2.41 Please note that an employee will not be entitled to normal sick pay duringany period of paid maternity leave.

Sickness following maternity leave

2.42 Sickness absence from the expected date of return to work will be treated assick leave and appropriate medical certificates will be required.

The Occupational Health Service

2.43 A manager is able to refer an expectant employee to the Occupational HealthService if they have any concerns with regard to the workplace, duties or thehealth of the employee.

Returning to work

2.44 An employee has the right to return to her job under her original contract andon no less favourable terms and conditions.

2.45 An employee who intends to return to work at the end of her full maternity

leave will not be required to give any further notification, although if shewishes to return early she must give at least twenty eight days notice.

2.46 As in the paragraph of 2.21 above, employees who indicate that they intend toreturn to work following maternity leave are required to return for a minimumperiod of three months.

2.47 If an employee who has indicated her intention to return to work in accordancewith the paragraph 2.21 above does not do so within fifteen months of thebeginning of her maternity leave, she will be liable to refund the whole of hermaternity pay (unless it is illness related under the Disability Discrimination

Act), less any Statutory Maternity Pay received.

Return to flexible working arrangements

2.48 Where possible, any request for consideration to changes to contracted hoursupon return to work from maternity leave should be discussed with the linemanager in accordance with Flexible Working policy of the South WestStrategic Health Authority policy prior to commencing maternity leave.



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2.49 However, although the line manager must look at ways of meeting with therequest, the decision as to what can be offered must be in line with the needsof the service. The South West Strategic Health Authority fully supportsflexible working and recognises the value of retaining staff and everyendeavour will be made to accommodate requests where possible.

2.50 If it is agreed that the employee will return to work on a flexible basis,including changed or reduced hours, for an agreed temporary period, this willnot affect the employee’s right to return to her job under her original contractat the end of the agreed period.

Annual leave

2.51 Annual leave is accrued at the normal rate during ordinary maternity leaveand, if appropriate, additional maternity leave.

2.52 Employees whose maternity leave, whether ordinary or additional, falls acrosstwo financial years are entitled to carry forward one working weeks annualleave entitlement, following agreement with their manager. Therefore, it issuggested that employees who are due to commence maternity leave andhave an excess of annual leave, use any outstanding entitlement prior tocommencing maternity leave. This should be discussed and agreed with theline manager as per normal procedures for booking annual leave.

2.53 If, in exceptional circumstances, it is not possible for the employee to taketheir annual leave prior to commencing maternity leave, for example if thebaby is born prematurely, the outstanding balance of annual leave entitlement

will be paid at the end of the financial year.

2.54 Employees who arrange to change their contractual working hours on returnto work from maternity leave will have their annual leave entitlementcalculated on a pro-rata basis proportional to the date on which they return towork.

2.55 Bank holidays are not accrued during compulsory, ordinary or additionalmaternity leave. Part time employees will have their annual leave and Bankholiday entitlement recalculated to take account of this.

Pensions

2.56 Pension rights and contributions shall be dealt with in accordance with theprovisions of the NHS Superannuation Regulations. Any queries regardingPensions should be directed to the Pensions Supervisor.



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Organisational change resulting in redundancy

2.57 If, following an organisational change an employee’s post becomes redundantwhilst on maternity leave, she will be placed on the South West StrategicHealth Authority’s redeployment register and will be offered suitable

alternative employment where a suitable vacancy is available before hercontract ends. The employee is entitled to a four week trial period upon herreturn to work in accordance with the South West Strategic Health Authority’sOrganisational Change policy.

2.58 The new contract will take effect immediately on the ending of the originalcontract and must be such that the:

• work to be done by the employee is both suitable and appropriate forher to do in the circumstances;

•the capacity and place in which she is to be employed and the otherterms and conditions of her employment are not substantially lessfavourable to her than if she had continued to be employed under heroriginal contract;

• if the employee unreasonably refuses this suitable alternativeemployment, she may forfeit her right to redundancy;

• the contract of employment will terminate on the agreed date oftermination and the entitlement to occupational maternity pay willcease. However, the South West Strategic Health Authority will

continue to fulfil its statutory duty of paying Statutory Maternity Pay forthe period of time the woman would have been entitled to it had shenot been made redundant, but this period shall not be constituted asemployment by the South West Strategic Health Authority;

• if an employee on ordinary or additional maternity leave is maderedundant, her maternity leave period comes to an end. She willreceive a written statement of the reasons for the dismissal, regardlessof whether or not she had requested one, and regardless of her lengthof service.

Organisational change resulting in transfer of undertakings andprotection of employment transfer

2.59 Maternity leave and Statutory Maternity Pay will continue in accordance withTransfer of Undertaking and Protection of Employment regulations in theevent of a Transfer of Undertakings and Protection of Employment transfertaking place.



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Miscellaneous provisions

Increments

2.60 Absence on maternity leave shall count towards the normal annual increment

on the employee’s grading scale, and will not defer the normal incrementaldate.

2.61 In the event of a pay award or annual increment being implemented beforethe paid maternity leave period begins, maternity pay will be calculated asthough the pay award or annual increment had effect throughout the entireStatutory Maternity Pay calculation period. If such a pay award is agreedretrospectively, maternity pay will be re-calculated on the same basis.

2.62 In the event of a pay award or annual increment being implemented during thepaid maternity leave period, maternity pay due from the date of the pay award

or annual increment will be increased accordingly. If such a pay award isagreed retrospectively, maternity pay will be re-calculated on the same basis.

Fixed-Term contracts or training contracts

2.63 Employees subject to fixed-term or training contracts which expire after theeleventh week before the expected week of childbirth, and who have at leasttwelve months continuous NHS service prior to the eleventh week before theirexpected week of childbirth, shall have their contracts extended so as to allowthem to receive the thirty three weeks paid contractual maternity leave set outin paragraph 2.21 above.

2.64 If there is no right of return to be exercised because the contract would haveended if pregnancy had not occurred, repayment provisions will not apply.

2.65 Employees on fixed-term contracts who do not meet the conditions set out inparagraph 2.60 above may still be entitled to Statutory Maternity Pay.

Rotational training contracts

2.66 Where an employee is on a planned rotation of appointments with one ormore NHS employer as part of an agreed programme of training, she shallhave the right to return to work in the same post or in the next planned postirrespective of whether the contract would otherwise have ended if pregnancyand childbirth had not occurred. In such circumstances, the contract of theemployee will be extended to enable them to complete the agreed programmeof training.

Contractual rights

2.67 During maternity leave, both paid and unpaid, an employee retains all of hercontractual rights except remuneration.



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Continuous service

2.68 For the purposes of calculating whether the employee meets the twelvemonths continuous service with one or more NHS employers’ qualification setout in paragraph 2.20, please consult the NHS Terms and Conditions of

Service Handbook.

2.69 The South West Strategic Health Authority will count other previous NHSservice. The South West Strategic Health Authority has the discretion tocount other previous service with other employers but this does not confer anentitlement on any employee. Each case would be considered on itsindividual circumstances and on a non-precedent basis.

Further information

2.70 There are some issues that may arise during pregnancy and maternity leave,

which may not be covered by this policy. Further information and advice onthese matters is available from the Human Resources team.

2.71 The BERR document, “Pregnancy and Work, What you need to know as anemployee.” Is a useful document, and can be found at:http://www.berr.gov.uk/files/file34285.pdf

3. Paternity leave policy (Maternity support)

Introduction

3.1 This information has been designed to give you guidance on the parentalleave entitlements within South West Strategic Health Authority. Thisguidance on paternity leave and pay is part of a package of rights andbenefits designed to give support to working fathers, mothers and theirpartners. It covers the leave and pay rights for the partner of a woman who isexpecting a child or a partner in a family adopting a child.

3.2 Paternity leave and pay entitlements are governed by NHS regulations, aswell as statutory legislation. The information contained in this guide is specificto NHS employees.

Ante-natal care and official meetings in the adoption process

3.3 All employees are entitled to reasonable time off in order to attend ante-natalappointments or official meetings in the adoption process. For details of therules governing Ante-natal care and official meetings in the adoption process,please refer to the Maternity section of this policy, which applies in thisinstance.

Eligibility to paternity (maternity support) leave and pay

3.4 In order to qualify for paternity leave and pay, the employee must expect to

have responsibility for the upbringing of the child as the father of the child oradopter, or the husband or partner of the mother or adopter of the child.



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Paternity leave and pay entitlement

3.5 All employees are entitled to two weeks Paternity Leave (Maternity Support).The Parental Leave and Pay entitlements are as follows:

• twelve months continuous NHS service: an employee who hastwelve months continuous NHS service prior to the eleventh week

before their partner’s expected week of childbirth or prior to the week inwhich they are notified of having been matched with a child foradoption, shall be entitled to two weeks paternity leave during whichthey will receive full pay;

• at least twenty six weeks continuous NHS service: an employeewho has at least twenty six weeks continuous NHS service prior to thefifteenth week before their partner’s expected week of childbirth or priorto the week in which they are notified of having been matched with a

child for adoption, shall be entitled to two weeks paternity leave duringwhich they will receive Statutory Paternity Pay or 90% of their normalsalary, whichever is the lesser;

• less than twenty six weeks continuous NHS service: an employeewho has less than twenty six weeks continuous NHS service prior tothe fifteenth week before their partner’s expected week of childbirth orprior to the week in which they are notified of having been matchedwith a child for adoption, shall be entitled to two weeks unpaid paternityleave.

3.6 Paternity leave may be taken as a two week block, or in two blocks of oneweek, provided that all leave is taken within fifty six days of the birth of thechild or placement for adoption.

3.7 Paternity leave may be taken from the date on which the child is born orplaced for adoption, or on a predetermined date following this.

3.8 Your entitlement to receive Statutory Paternity Pay (SPP) is dependent uponyour National Insurance contributions and, if applicable, will be paidconcurrently with the two weeks leave and/or pay that you receive from theorganisation.

Notification

3.9 Employees should notify their manager of their intention to take paternityleave and pay prior to week twenty five of the pregnancy or within seven daysof the notification of adoption.

3.10 Using the Paternity Leave Request Form which can be found on the intranet,employees are required to provide the following information at least twentyeight days prior to commencing paternity leave:

•

the expected date of birth of the child or date of placement;



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• adoptive parents taking paternity leave should provide a MatchingCertificate issued by the Adoption Agency;

• details of when and how you intend to take paternity leave;

• when you plan your paternity leave to begin.

3.11 Your manager will forward a copy of the Paternity Leave Request Form to theHuman Resources team, who will in turn process the information with Payroll.

3.12 You will receive written confirmation of your arrangements for paternity leavefrom the Human Resources team within twenty eight days of their receipt ofyour Paternity Leave Request Form.

3.13 You are required to give at least twenty eight days notice should you wish tochange the dates of your paternity leave. If you are unable to give this notice,

notification should be made as soon as is reasonably practicable.

3.14 You are required to confirm with your manager the actual date of birth orplacement for adoption.

Miscellaneous provisions

3.15 An employee who is absent on paternity leave is entitled to the benefit of all ofthe terms and conditions of employment that would have applied if they hadnot been absent and is bound by any obligations arising under those termsand conditions.

3.16 An employee taking paternity leave is entitled to return from leave to the job inwhich they were employed before their absence, on terms and conditions notless favourable than those which would have applied if they had not beenabsent.

3.17 In the case of multiple births or adoptions, entitlement to paternity pay doesnot increase for each child.

Still birth

3.18 You can still take paternity leave if the child is stillborn after twenty four weeks

of pregnancy or is born alive at any point of the pregnancy.

Further information

3.19 There are some issues that may arise during paternity leave which may notbe covered by this policy. If you would like further information and advice onthese matters, or if you wish to clarify and discuss any other issues covered inthe policy in greater detail, please contact the Human Resources team.



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4. Parental leave

Introduction

4.1 This information has been designed to give you guidance on the parental

leave entitlements within the South West Strategic Health Authority.

4.2 Parental leave entitlements are governed by the NHS regulations as well asstatutory legislation. Therefore, the information contained in this guide isspecific to NHS employees. Please contact the Human Resources team if yourequire further information.

Eligibility for parental leave

4.3 Any employee requesting parental leave must have at least twelve monthscontinuous NHS service at the time of parental leave commencing.

4.4 Employees requesting parental leave must have nominated caringresponsibility for a child aged under 14 years, or 18 years in the case ofdisabled children.

4.5 All requests for parental leave should be made in writing directly to your linemanager, using the Parental Leave Request form which can be found on theintranet.

Parental leave provision

4.6 Parental leave provides employees with a right to up to thirteen weeks unpaidleave, or eighteen weeks unpaid leave in the case of disabled children.

4.7 The right of parents of adopted children to take parental leave applies for fiveyears from the date the child was placed for adoption or until the child’seighteenth birthday, whichever is sooner.

4.8 The way in which parental leave is taken should be flexible and should bearranged through negotiation with your line manager. However, as a rule,parental leave must be taken in blocks of one week, although in exceptionalcircumstances this need not be the case. Leave can be taken in any format

for parents of disabled children.4.9 Employees are entitled to take a maximum of four weeks’ leave in any one

year.

4.10 In exceptional circumstances, an agreement can be made with your linemanager to take the full entitlement of parental leave from work in days,weeks, one long block or as reduced working hours or a mixture of these,depending on the circumstances.

4.11 Parental leave may be added to any period of maternity, paternity or adoptionleave, provided the requisite notice is given.





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Further information

4.26 There are some issues that may arise during parental leave which may not becovered by this policy. If you would like further information and advice onthese matters, or if you wish to clarify and discuss any other issues covered in

the policy in greater detail, please contact the Human Resources team.

5. Adoption/surrogacy leave

5.1 You can take statutory adoption leave for up to fifty two weeks.

5.2 There are two types of adoption leave: twenty six weeks ordinary adoptionleave, immediately followed by twenty six weeks additional adoption leave,giving a total of up to fifty two weeks.

To qualify for adoption leave

5.3 You can claim Statutory Adoption Leave if you are an employee (and remainemployed until the date of the adoption or placement of the child) and either:

• adopting a child on your own;

• in a couple who are adopting together.

5.4 The provisions apply to placements for children up to 18 years old.

5.5 In the case of a couple, only one of them will be entitled to take the leave.

However, the other will be entitled to the two weeks paternity leave or parentalleave (if they qualify).

5.6 Adoption leave and pay does not apply to stepfamily adoptions. Fostercarers will qualify if they go on to adopt the child and the child was placedwith them by an adoption agency.

5.7 Same sex parents may qualify for adoption leave.

Paid adoption leave

5.8 To qualify for paid adoption leave an employee must:

• be newly-matched with a child for adoption by an approved adoptionagency, and;

• have worked continuously for the same employer for twenty six weeksleading into the week in which they are notified of the matched with achild for adoption (the 'matching week').

5.9 During ordinary and part of additional adoption leave you will be entitled toStatutory Adoption Pay (SAP) on a similar basis to that governing StatutoryMaternity Pay.

5.10 Statutory Adoption Pay is payable for thirty nine weeks.



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5.11 The rate of Statutory Adoption Pay is the same as the lower rate of StatutoryMaternity Pay. Adopters whose average weekly earnings are below the lowerearnings limit for National Insurance purposes do not qualify for StatutoryAdoption Pay but may qualify for other welfare benefits.

Less than twentysix weeks service

You can have up to fifty two weeks adoption / surrogacy leave. This leave will be unpaid

More than twentysix weeks but lessthan one yearsservice

You can have up to fifty two weeks adoption / surrogacy leave.

You will be entitled to Statutory AdoptionPay if your earnings are above the lowerearning limit. Statutory Adoption Pay will befor thirty nine weeks.

You can have up to fifty two weeks adoption / surrogacy leave.

The first thirty nine weeks will be paid and theremainder will be unpaid.

The thirty nine weeks paid leave will be madeup as follows:

More than oneyears NHS service

First eight weeks

Next eighteen weeks

Last thirteen weeks

Full pay

Half pay plusStatutory AdoptionPay (if eligible)

Statutory AdoptionPay (if eligible)

More than oneyear’s service

(deferred option)

This allows you to defer the above paymentsso that you receive a lump sum of eight weeksfull pay and fourteen weeks half pay, (lessStatutory Adoption Pay) three months afteryou return to duty.

You will receive Statutory Adoption Pay (ifeligible) during the adoption / surrogacy leaveperiod.

Returning to Work

Not returning towork

More than twentysix weeks service.

If you are entitled to Statutory Adoption Pay,you will receive Statutory Adoption Pay forthirty nine weeks.



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Notes 1. All above service periods relate to service at the sate of adoptionor placement of the child

2. The Statutory Adoption Pay is made up as follows:

• first six weeks – 90% average weekly earnings;

• next thirty three weeks current Statutory Adoption Pay (or90% average weekly earnings, whichever is the lesser).

When and how statutory adoption leave is taken

5.12 The employee can start their leave on any day of the week, either:

• from the actual date of the child's placement, or;

• from a fixed date up to fourteen days before the expected date ofplacement.

5.13 Only one period of leave is permitted for each placement regardless of howmany children are placed at that time as part of the same arrangement.

5.14 If, for some reason, the placement is not successful and ends during theadoption leave period, then the employee will be allowed to continue adoptionleave for a maximum of eight weeks after the placement ends, or until the endof the Statutory Adoption Pay period if that is sooner.

5.15 If the employee starts their adoption leave before the child is placed, theyneed to be sure that the placement is going to go ahead. If it is delayed oncethey have started their leave, they cannot stop their leave and start it again ata later date.

Giving the correct notice to take statutory adoption leave and receivestatutory adoption pay

5.16 The employee must notify the employer of their intention to take adoptionleave within seven days of being notified of a match by the adoption agency,unless this is not reasonably practicable.

5.17 The employee should confirm in writing:

• that they would like to take adoption leave;

• when the child is expected to be placed with them;

• when they would like their Statutory Adoption Leave/Statutory AdoptionPay to commence.

5.18 The adopter can change their mind over when they would like to commence

leave provided they give at least twenty eight days notice of the change(unless this is not reasonably practicable).





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5.28 Employees who have taken adoption leave will, in most cases, be eligible tomake a request to work flexibly. The employee has the right to return followingthe adoption leave to the same job on the same terms and conditions as ifthey had not been absent.

5.29 If the employee decides not to return to work at the end of either type ofadoption leave they must tender their resignation giving their usual period ofnotice.

Maintaining contact

5.30 The South West Strategic Health Authority will maintain regular contact withthe employee during leave to ensure they continue to feel part of theorganisation and not out of touch.

Keeping in Touch (KIT) days

5.31 The rules for Keeping in Touch days for Maternity Leave apply to theAdoption/Surrogacy Leave in the same way.

Official meetings in the adoption process

5.32 All employees are entitled to reasonable time off in order to attend officialmeetings in the adoption process. For details of these rules, please refer tothe Human Resources team for further clarity.

6. Career breaks

Introduction

6.1 The South West Strategic Health Authority values the accumulatedknowledge and skills of its staff and supports the use of innovative new waysof retaining them in post while allowing individuals to explore opportunities forpersonal development and fulfilment.

6.2 A career break allows staff to take an agreed period of time away from their job to pursue other interests on the understanding that they will return whenthat period has expired.

6.3 Such an opportunity encourages personal development whilst providing boththe staff member and the organisation with a degree of security over theircontinued employment.

6.4 A career break is not a substitute for a secondment or an opportunity for anindividual to work for another organisation.

Terms of the scheme

6.5 In order to be eligible to apply for a career break, the employee must havecompleted at least twelve months service with the South West Strategic

Health Authority.



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6.6 The minimum length of a career break is three months. Staff wishing to takeshorter periods away from work should consider unpaid leave which iscovered in the Special Leave section of this policy.

6.7 The length of break which an employee may apply for depends on their length

of service with the NHS:

Length of Service Length of Career Break

one to five years service three to six months break

five to ten years service maximum of twelve months break

ten years or more service maximum of twenty four monthsbreak

6.8 Any application for a career break should be made in writing and include anindication of the duration required and the purpose for which it is intended.

6.9 When agreeing the duration of a career break a balance should be maintainedbetween the needs of the applicant and those of the service.

6.10 Applicants for a career break must provide some detail of what they wouldwish to do with a career break opportunity.

6.11 Possibilities might include:

• caring for a dependant;

• childcare beyond statutory entitlement;

• pursuit of a hobby or interest;

• study or training opportunities;

• voluntary work or travelling abroad.

6.12 Employees must agree a return date prior to their departure and should beaware that it may not be possible to facilitate a return to work any earlier oncethis has been agreed.

6.13 Employees who wish to extend their career break whilst they are on it mayonly do so by arrangement with their line manager and up to the limitsprescribed in paragraph 5.7 above.

6.14 A period of a career break will be treated as continuous service after theemployee returns to work. It will not be treated as such if the employee doesnot return after the break period is complete.



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6.15 A career break is distinct from unpaid leave, which is appropriate for shorterperiods of authorised absence.

6.16 It is the joint responsibility of the staff member and the line manager thatduring the period of the career break the individual stays up to date with

organisational and service developments where possible. This is to ensurethe easiest reintegration back in to their role when it ends.

6.17 The organisation reserves the right to refuse a career break to an eligibleemployee where it can be demonstrated that their absence will negativelyimpact on the work of the South West Strategic Health Authority.

6.18 The employee must maintain any relevant professional registration includingany training courses required for updating. Evidence of renewal ofprofessional registration must be sent to the line manager, and a copy to theHuman Resources team for the employee file. Staff who are required to take

responsibility for their own continuous professional learning and developmentwill retain this responsibility during their career break.

Implementation

Staff

6.19 Staff who meet the eligibility criteria for a career break as outlined inparagraph 5.5, may apply for one at any time by writing to their line manager.

6.20 In the interests of ensuring that backfill can be arranged for an employee who

is going on a career break it is asked that a request be made at least threemonths before the proposed leaving date.

Line manager

6.21 On receipt of a written application from a member of staff, the line managermust arrange to meet with them within seven days for a preliminarydiscussion.

6.22 Having spoken with the staff member, the line manager should evaluate thelikely impact on the team, the organisation and on service delivery of grantinga career break.

6.23 If it is decided that a career break should go ahead then the manager shouldcomplete the authorisation section of the form and submit it to their Director tobe countersigned.

6.24 No career break can be finally authorised without signatures of both a linemanager and a Director.

6.25 An employee whose application is refused will be entitled to receive a writtenreason for the refusal.

6.26 If the line manager does not consider it possible to authorise a career break,they must respond within seven days of the preliminary discussion, returning



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the submitted form accompanied by a letter setting out the reasons for beingunable to authorise it.

6.27 Wherever possible the line manager should attempt to offer an alternativetime or length of career break that would be acceptable to the organisation.

6.28 Any decision deemed to be unfair by the employee may be appealed throughthe grievance procedure of the South West Strategic Health Authority.

Contractual position

6.29 During the period of the career break, the following conditions will apply:

• during the period of the career break, the employee would be requiredto sign a new contract reflecting their status. This would take the formof an agreement between the organisation and the employee;

• during the career break, the employee will maintain continuity ofservice from the point of view of the organisation for statutorypurposes;

• other provisions depending on length of service, such as Pensions,contractual redundancy payments or leave entitlements are suspendedfor the duration of the break. This will be reflected in the revisedcontract;

• it is not usual for an employee to enter in to paid employment with any

other organisation during the period of the career break. An employeewishing to do this requires written dispensation from a Director of theSouth West Strategic Health Authority;

• the employee and employer have joint responsibility to remain incontact during the period of the career break. It is suggested that thisshould not be less than one occasion in any six month period;

• on the completion of the career break, the employee will bereemployed by the organisation.

6.30 Any career break lasting less than one year entitles the employee to return tothe same post that they had vacated. Following any break of more than ayear, where the original post is not available, the South West Strategic HealthAuthority should ensure that a suitable alternative post is available at thesame level.

6.31 The organisation commits to providing reasonable and appropriate trainingand mentoring support to assist with the re-induction of the employee on theirreturn to work.

6.32 Employees may return to work earlier than expected or request an extension

to their career break whilst away from the organisation.



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6.33 A request for an extension should be made in writing in the same way as theoriginal application. No extension may exceed the maximum career breakentitlement open to the employee at the time they left the organisation.

6.34 Employees wishing to return to work early must give at least two months

notice for a career break of less than a year and at least six months notice ifthe break is more than a year.

7. Special leave

Introduction

7.1 The South West Strategic Health Authority recognises the importance ofsupporting staff in enabling them to balance work and the needs of theorganisation with personal and family commitments. This policy aims to takeinto consideration the individual needs of staff in a responsive and flexible

way at times of urgent or unforeseen circumstances or longer-term changes inpersonal commitments.

7.2 Leave granted on a paid basis is intended for short-term needs as opposed tolong-term domestic family commitments, which may be better catered forthrough parental leave or a career break.

7.3 Staff should make applications for special leave directly to their line manager.Further clarification of the provision of the leave included within this policy isavailable from the Human Resources team.

7.4 A record will be kept on the personal file of the employee of all leave that isgranted.

Special leave

7.5 The principal aim of special leave is to provide a fair and compassionateresponse to a range of immediate personal and domestic circumstances.

7.6 Whilst inevitably the needs will vary according to each set of circumstances,examples might include:

•

bereavement;

• care of dependents;

• domestic emergency;

• personal distress.

Entitlement

7.7 The extent to which leave is granted will be entirely dependent upon thecircumstances in each case and may range from an hour to several days. Asa guide, the maximum period of paid special leave that can be granted is sixworking days, although this may be extended in exceptional circumstances.



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7.8 Legal guidance suggests that three factors should be taken into account whengranting special leave: the nature of the incident; closeness of relationshipbetween employee and dependant; and the availability of others to help out.

7.9 The leave will be pro-rata to the hours worked and because of its nature it

would not be expected to be granted on a regular basis.

7.10 Special leave will normally be granted on a paid basis for the types of issuesdescribed above. However, if it is not clear whether the circumstanceswarrant paid leave in this context, then clarification should be sought from theHuman Resources team and if there is an ongoing need for time off, furtherunpaid leave may be available.

7.11 All requests for special leave should be discussed and agreed with the linemanager of the employee as soon as it is evident that leave is required.However, it is recognised that owing to the nature of the leave, individuals

may need to take time off before the detail of the arrangements can befinalised.

7.12 Line managers must ensure completion of the Application for Special Leaveand forward this to the Human Resources team when they have grantedspecial leave so that a record can be kept on personal files for monitoringpurposes.

7.13 Wherever possible, staff must make doctor/dentist/medical appointments outof normal working hours. However, if this is not possible, staff may bepermitted reasonable time off with pay to attend such appointments, when

specifically authorised by their line manager.

7.14 If staff wish to attend an interview or selection process for alternativeemployment outside the NHS they should take unpaid leave, use time owingor take annual leave.

7.15 Applicants for paid or unpaid special leave should be entitled to a writtenexplanation if the application is declined.

7.16 Appeals against decisions to decline an application for paid or unpaid specialleave should be made through the grievance procedure.

Additional unpaid leave

7.17 A period of unpaid leave up to twelve weeks can be authorised for staffrequiring time off in order to care for sick and elderly dependants or to dealwith other long-term family responsibilities without having first exhausted theirannual leave entitlement.

7.18 Approval of this type of leave will be at the discretion of line managers, inconsultation with the Head of Human Resources, who will need to identify andrespond to the individual needs of the staff concerned. Final authorisation willbe required from a Director.



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• all employees will have been treated fairly and consistently when

requiring leave that falls within the Family Friendly policy;


• all employees have a clear understanding of options available to themthrough this policy.






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163

Annex 1Maternity leave entitlement guide

Continuous

NHSService

IntentionFollowingMaternity leave

More than twelve

months continuousNHS service ateleventh week priorto Expected Weekof Childbirth

Over twenty six

weeks continuousNHS service atfifteenth week priorto Expected Weekof Childbirth

Up to twenty six

weeks continuousservice at fifteenthweek prior toExpected Week ofChildbirth

Intending to returnto work followingmaternity leave

Thirty nine weekspaid leavecomprising:Eight weeks at full

payEighteen weeks athalf payThirteen weeksStatutory MaternityPayThirteen weeksunpaid

Thirty nine weekspaid leavecomprising:Six weeks at 90%

of full payThirty three weeksat StatutoryMaternity Pay plusup to thirteenweeks unpaidleave

Fifty two weeksunpaid leave

Not intending toreturn to workfollowing maternityleave

Thirty nine weekspaid leavecomprising sixweeks at 90% offull pay, thirty threeweeks at StatutoryMaternity Pay plusup to thirteenweeks unpaidleave

Thirty nine weekspaid leavecomprising:Six weeks at 90%of full payThirty three weeksat StatutoryMaternity Pay plusup to thirteenweeks unpaidleave

Fifty two weeksunpaid leave

Undecided whetherto return to workfollowing maternityleave

Employees indicating that they are undecided whether or not toreturn to work following maternity leave will be paid in the firstinstance as if they were not returning. Should they then decideto return to work, further monies owed will be paid, less thatwhich has already been paid.

The payment of Statutory Maternity Pay is dependent on National InsuranceContributions.

Employees who do not qualify for Statutory Maternity Pay may be entitled to receive

Maternity Allowance, which is payable by the Department of Work and Pensions.



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Appendix 8

Flexible Working Policy

This appendix sets out the revised Flexible WorkingPolicy for the South West Strategic Health Authority.







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period might be advisable. Directors (or delegated authority) are advised toseek support and guidance from the Human Resources team when makingany decisions.

2.4 The South West Strategic Health Authority aims to:

• ensure that all requests for flexible working are treated fairly, impartiallyand in the most expedient manner possible;

• ensure that all staff have an equal right to investigate their flexibleworking options;

• be supportive of staff in meeting their flexible working requestswherever possible;

• promote flexible working as a tool for the positive growth and

improvement of individual employees and the organisation as a whole;

• support the implementation of this policy with appropriate resourcesand training;

• retain talent and expertise across the geographical area.

3. Definition of flexible working

3.1 Flexible working is any pattern of working that meets the needs of anindividual and the service requirements of an organisation. For the

organisation, benefits will include:

• optimising the talent and skills of staff;

• addressing the geographical constraints and specific needs of theSouth West;

• ensuring that staff are flexible in meeting the needs of the South WestStrategic Health Authority in terms of health and care service needs;

• ensuring that staff are flexible in meeting the requirements of their roles

within the South West Strategic Health Authority;

• ensuring the presence of staff at key events, including corporate days(where appropriate), in headquarters and throughout the South West atthe line managers discretion.

3.2 For employees, benefits will include:

• job sharing. Offers existing to prospective employees and anopportunity to undertake a whole time job on a part time or sharedbasis for domestic or other reasons;



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• avoidance of an excessive burden of travel, in terms of both distanceand the length of working day;

• allowing them to make optimum contribution to the work of the SouthWest Strategic Health Authority;

• knowing in advance when their attendance at the headquarters or otherdispersed premises used by the South West Strategic Health Authorityis required for corporate days;

• being able to plan their working and travel patterns aroundcommitments, which will require their presence at locations other thantheir local (including home) work base;

• knowing that their skills, experience and contribution are valued.

3.3 For the employee, flexible working can include:

• remote (in a local location agreed by the South West Strategic HealthAuthority) working and/or home based working on a short term orregular basis;

• flexitime. Staff can be flexible around start and finish times usually witha core time when they have to be at work in line with the needs of thebusiness and in agreement with their line manager. Excess hoursworked can be carried over from one week to another and used asflexi-leave. Similarly, a limited number of deficit hours can be made up

at a later date.

• annualised hours. Rather than agreeing to work a certain number ofhours in a week, the hours are agreed over the course of a year. Thisallows for flexibility and an uneven pattern of work throughout the yearbut the member of staff is usually paid in twelve equal portions;

• part-time hours, such as any hours that are less than the standardcontracted full-time hours (full time hours are 37.5 per week);

• voluntary reduced working time through an agreed temporary reduction

of hours.

4. Family Friendly policy

4.1 The policy offers existing and prospective employees an opportunity toundertake a whole time job on a part-time or shared basis for domestic orother reasons.

4.2 In addition to flexible working patterns, the South West Strategic HealthAuthority has a Family Friendly policy designed to help staff balance theirwork with their domestic responsibilities.





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6. Treating staff equitably

6.1 There is the need to consider the issue of precedent and equitable treatmentfor all staff. There needs to be equity and fairness for all, coupled with anunderstanding that precedents are not automatically set, and requests must

be balanced with the needs of the South West Strategic Health Authority todeliver its key role in the South West. The issue centres on equitableconsideration not necessarily identical treatment. It is important that all staffwho may be affected by the request of an individual to work flexibly areconsidered and consulted.

7. Process

7.1 When an individual wishes to make use of flexible working, they shouldcomplete an application form which can be found on the Human Resourcesintranet site, and submit this to their line manager. The line manager should

arrange to meet the staff member within twenty eight days of receiving theapplication. If there is agreement in principle, the proposal should be referredto the Director responsible (or delegated authority) who will have the authorityto approve it. Following the approval by the Director (or delegated authority),the line manager should complete the response form also found on theHuman Resources intranet site, confirming the change to the working patternof the employee.

7.2 Due consideration should be given to the effect on other staff in the team andany other consequences arising from the absence of the employee from basebefore approval is given. These issues should be addressed by the staff

member in their application and investigated by the manager when coming toa decision.

8. Guidance for managers

8.1 Given the wide range of possible flexible working options and the even widerrange of staff personal circumstances, it is not possible to provide prescriptiveguidance on when a request can be accepted. However, the following groundrules should be applied:

• the South West Strategic Health Authority will respond positively torequests received from existing or prospective staff to work flexibly;

• staff affected by any proposed changes to their working arrangements,whether directly or indirectly, have the right to be consulted but also theresponsibility to consider the interests of other team members;

• communication and openness are critical in dealing with an issue offlexible working, whether it is a change to the working pattern of anindividual or of a whole Directorate. Any decisions will be discussedwith all affected staff and confirmed in writing;

• changes to working arrangements can be made on a temporary orpermanent basis.



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8.2 The assessment criteria will need to be transparent and straightforward forboth managers and staff and could include the following questions:

8.3 Will the proposed change:

• reflect the geographical dimension of the NHS South West and allowlocal working consistent with the role and requirements of theorganisation?

• help to retain staff who might otherwise leave or retire?

• attract staff into areas of shortage?

• help build a more diverse range of skills within the team?

• help balance staffing levels and activity levels more efficiently?

• improve morale for either the team or the individual?

8.4 If the answer to some or all of the above questions is “Yes”, the next step is tolook at how to try to accommodate the request:

• can the work of the directorate be organised in a different way?

• what scope is there within the budget to recruit more staff?

• what impact will the change have on other staff?

• is it a permanent or a temporary change?

• how will the change be monitored?

8.5 If the request cannot be accommodated using the above criteria, is there acompromise that can be reached to meet the needs of both the individual andthe organisation? Another option where the impact of a change is uncertainwould be to agree to a trial period.

9. Reasons why the South West Strategic Health Authority could

refuse a request

9.1 The South West Strategic Health Authority may refuse a request where itconsiders that one or more of the following would apply:

• the burden of additional costs is prohibitive;

• a detrimental effect on the ability to meet service demand;

• an inability to reorganise work amongst existing staff;

• a detrimental impact on the quality of work;



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• a detrimental impact on performance, including the health and safety ofthe employee, colleagues or others;

• insufficient work during the periods the employee proposes to work;

• planned structural changes.

10. Appeals

10.1 If an employee is dissatisfied with a decision of a Director (or delegatedauthority) about any of the options outlined above, the employee has a right tomeet the Director, who must then confirm the outcome of the meeting withinfourteen days in writing. If the employee remains dissatisfied, they may raisea grievance through the grievance procedure, within fourteen days. Theemployee is entitled to be accompanied at the meeting with the Director by arepresentative of a Trade Union, or a work colleague (not acting in a legal

capacity).



• all employees will have been treated fairly and consistently whenapplying for flexible working arrangements;


• all employees have a clear understanding of the roles andresponsibilities for line managers and themselves in the application offlexible working arrangements.






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Annex 1

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Models of flexible working

Guidance to job sharing

1. Definition1.1 Job sharing is an arrangement which normally involves two people who

voluntarily share the duties and responsibilities of an established full-timepost. This requires co-ordination and collaboration between the job sharepartners to ensure that the whole job is done. Each sharer undertakes aproportion of the duties and responsibilities of the post and pay and conditionsof service are shared pro rata according to the number of hours workedunless specified otherwise in this document. Separate contracts are issued toeach sharer.

2. Designation of posts for job sharing2.1 All established posts will be eligible for consideration for job sharing. It is the

responsibility of the existing employee(s) and/or the relevant representative todemonstrate to the appropriate manager that job sharing is suitable andpracticable for a particular post.

2.2 If an existing full-time employee wishes to job share, they should apply inwriting to their manager in the first instance. The manager will discuss theproposed arrangements with the employee(s) concerned and forward detailsto the appropriate director for joint consideration. Advice on the suitability of

the post for job sharing will be obtained from the manager.

2.3 When a full-time post is vacant, job sharing will always be considered.

2.4 Where an existing full-time employee has received approval for their post tobe designated for job sharing, the post will be advertised as a vacancy for a job share partner. Shortlisted candidates will be given the opportunity to meetthe existing postholder in advance of the formal interview. Selection will bemade on the basis of suitability for the post and appointment will be subject tothe precise working arrangements having been finalised in consultation withthe existing postholder.

2.5 In the case of a vacant full-time post, candidates will be asked to statewhether they are applying to work with any job-share partner or if they areprepared to work only with a specific job sharing partner.

2.6 Candidates who wish to job share will be interviewed separately andprospective job sharers will be given the opportunity to meet prior to a formaloffer of appointment being made. No formal appointment shall be made untilprecise working arrangements have been finalised and agreed between the job share partners and the manager and drawn together into a written jobshare agreement.



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2.7 The individual job share agreement shall take account of operationalrequirements and constraints, the type of work involved and the special skills,knowledge and abilities required of the job share partners. The agreementshould contain the following:

• the split of hours between partners;

• the need for length of any handover period between partners;

• annual leave constraints;

• public holidays and annual leave pro rata arrangements;

• degree of supervision;

• allocation of duties and distribution of work;

• such other items as need to be determined in writing;

• any arrangements around lease cars must be agreed prior to the jobshare arrangements being put into practice.

3. Inability to recruit a job share partner

3.1 If, after advertisement and/or interview, no suitable job share partner is found,the post will be re-advertised where necessary including external advertising.If no suitable partner is found the following procedure shall apply:

3.2 If the post had not previously been a job share, then the employee concernedwill continue on the original contract and hours;

3.3 If the post had previously been a job share, the remaining employee will beoffered the post on a full-time basis or redeployment to another suitable post.

4. Contract of employment

4.1 Job sharers will be appointed on individual contracts of employment and theprovisions of the Job Sharing policy and the individual job share agreement

relating to the post will form part of the contract.

4.2 Where a post is converted from full-time to job share at the request of theexisting postholder, an amended contract of employment will be issued. Thiswill retain any service linked entitlements as appropriate.

4.3 Job sharers will be individually responsible to the relevant manager for theirown duties and attendance.

5. Salary

5.1 Job sharers will receive the appropriate rate for the post calculated pro rata tothe actual number of hours worked.



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5.2 The starting salary and incremental progression will be on an individual basiswithin the grade for the post, according to length of previous relevant service.

6. Pension scheme

6.1 All employees are eligible to join/remain in the NHS Pensions Scheme unlessthey opt out.

7. Annual leave

7.1 This will be pro rata to the full-time entitlement. Job sharers should agree withtheir line manager as part of the job share agreement whether it is preferablefor them to take leave separately or simultaneously, wherever possible. Theyshould also consult with each other before submitting a formal leave request.

8. Bank Holidays/Statutory Days

8.1 These will be applied pro rata to the hours worked and should be equallydistributed where possible. Job sharers may be required to redistributeworking hours as the need arises in order to avoid an imbalance of bankholidays, and these arrangements will form part of the job shareagreement/contract of employment.

9. Other leave

9.1 All entitlements associated with length of service, such as sick pay, longservice leave and maternity leave will be calculated on an individual basis.

10. Hours of work

10.1 The job share partners may undertake their duties by working a divided week(such as mornings/afternoons or specific days of the week) or alternate weeksby mutual agreement and approval by the manager. If a flexible workinghours arrangement exists in the department concerned, the job sharers maywork flexible hours only with the specific consent of the manager.

10.2 Where the full-time post entails on-call or standby working arrangements, thiscommitment will be shared equally between the job share partners.

11. Cover arrangements

11.1 There will be no compulsory requirement on a job share partner to workadditional hours to cover their partner’s short term absence during periods ofsickness or leave. However, the remaining job share partner may be requiredwithin the terms and hours of their job share agreement to undertake specifictasks normally undertaken by the absent partner until suitable alternativearrangements can be made. Additional hours may be offered at the discretionof the manager.



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12. Additional hours

12.1 A job sharer who is required to work in excess of their contracted hours butbelow whole-time shall be paid at the basic hourly rate for the additional hoursor qualify for time in lieu appropriate to their individual terms and conditions of

employment. If the job sharer agrees to cover the post on a whole-time basisin an emergency, any additional hours worked beyond the whole-time hoursfor the grade would be paid at enhanced rates unless time off in lieu wastaken.

13. Grading

13.1 The grading of a job share post will relate to all sharers employed against it.Any review of the grading of a post will assess the whole post and not theduties of an individual employee against part of it.

14. Car user classification

14.1 Eligibility for reimbursement of mileage expenses or for a lease car will bedetermined for each partner in accordance with the South West StrategicHealth Authority policy on travelling expenses.

15. Training and promotion

15.1 Each sharer will be considered separately in respect of training and promotionopportunities.

16. Termination of job share

16.1 If one partner in an existing job share resigns from their post, the manager willreview whether the job share shall continue. The views of the remainingpartner will be sought. If continuation of the job share arrangement is agreed,the recruitment procedure above will apply. If it is decided that the job sharearrangement will not continue, the procedure under section 4, contract ofemployment will apply.

16.2 In the event of an alteration in operational requirements, the manager seekingadvice from the Human Resources team retains the right to terminate the job

share agreement by giving notice to both job sharers according to theircontract.

16.3 If a job share arrangement is terminated, the individual job sharers shall havethe right to appeal against the decision by an interview with the manager andthe appropriate Director. They shall be each entitled to be accompanied by afriend or representative if they so wish.

17. Grievances

17.1 In cases of dispute over the application of this procedure, reference may be

made to the South West Strategic Health Authority Grievance policy.



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Guidance on remote and home working

1. Definitions

1.1 Regular Home Working is where an employee makes use of their home as aworkplace instead of, or as well as the premises of the South West StrategicHealth Authority. This can alleviate pressure on accommodation, help avoidunnecessary travel and help with travel to work difficulties.

1.2 Occasional Home Working is where employees are able to take advantage ofworking from home for short periods with the agreement of their Director (ordelegated authority). The principle of this is to enable the employee to havegreater control over how and when they work.

1.3 Remote workers are staff who predominantly work away from a main office

base, and who have infrequent contact with their line manager (for examplestaff based from home).

1.4 Remote workers need to complete timesheets to enable the Strategic HeathAuthority to comply with Audit requirements.

1.5 Circumstances where home and/or remote working may be appropriateinclude:

• when staff are out of the office for a part of the day on official businessinvolving visits to establishments in the course of their work, such as

NHS Trusts, Primary Care Trusts, educational institutions, stakeholderorganisations and attending national meetings and driving to the SouthWest Strategic Health Authority headquarters for the remainder of theworking day would take up a disproportional amount of time, or not beachievable within the working day;

• where exceptional skills would be lost to the South West StrategicHealth Authority because an employee could not travel to theheadquarters without detriment to their health and safety,personal/family life or effective working;

• where a local presence is required to fulfil the obligations of the SouthWest Strategic Health Authority;

• when staff are recovering from a period of sickness and are returning towork under a staged arrangement (see the Absence Managementpolicy);

• when staff have a circumstance, which makes it difficult for them totravel to the South West Strategic Health Authority headquarters, suchas domestic emergency (see also Family Friendly policy).



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Eligibility

1.6 Not all posts will be suitable for home working, occasional home working, orremote working. The Director (or delegated authority), in consultation with theemployee, should carefully balance the advantages and disadvantages before

agreeing that a staff member can work from home. For example, absencefrom the workplace may create problems for others in the Directorate. Withthis in mind, a trial period is advised in order to highlight any potentialdifficulties.

1.7 No arrangement would be agreed where it prevented the employee frommeeting the requirement to be available at South West Strategic HealthAuthority headquarters on designated corporate days.

Conditions and Considerations

1.8 If it is agreed that an employee can work from home or from an alternativework base approved by the South West Strategic Health Authority, thefollowing issues need to be considered:

• the place of work should be adequate in terms of space and lighting,should be able to accommodate any equipment required and beconducive to work;

• that Directors and Senior Managers will always, and other staffsometimes, be required to attend at the South West Strategic HealthAuthority headquarters on the designated ‘corporate days’ and on any

other occasion requiring their presence at the headquarters;

• employees ‘working at home’ will be expected to work the samenumber of hours as they would normally;

• no employee will work at home without the full knowledge andpermission of their line manager;

• diaries or electronic schedules will be available so that thewhereabouts of staff can be monitored for line management and healthand safety purposes and Directors can be contacted speedily when

required;

• staff on home working or remote working arrangements must becontactable by telephone/mobile at all times and the relevant telephonenumbers must be advised to the line manager, key staff within theDirectorate, Reception staff and Personal Assistants of Directors;



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• wherever appropriate, meetings should be arranged to take place inthe premises of the South West Strategic Health Authority, includingaccommodation secured in other organisation premises. Where,exceptionally, the meeting is held at the home of an employee or insingle occupancy remote working premises, then at least three people

should be present of whom two will, ideally, be employees of the SouthWest Strategic Health Authority;

• staff working remotely or at home should report any untoward incidentsor matters of concern to their line manager or the Human Resourcesteam as soon as is reasonably practicable;

• employees working from home may be required to work at otherlocations on an ad-hoc basis in response to conferences, meetings orteam based project work. Arrangements should be flexible enough toallow for this;

• any equipment provided by the South West Strategic Health Authorityfor home use should be recorded and returned once thearrangement/contract ends;

• conditions under which any expenses associated with Home Workingsuch as telephone and postage are paid should be agreed with theDirector;

• the employee must be able to retain security and confidentiality ofdocuments within the home and comply with information technology

security and data protection requirements;

• the Health and Safety at Work Act 1974 applies even if staff areworking from home. This means that the employee should ensure thatwork is carried out without risk to self or others. The South WestStrategic Health Authority has an obligation to ensure the health, safetyand welfare of its employees. This will involve carrying out a riskassessment and DSE Workplace assessment of the proposed area ofwork and any equipment to ensure the safety of the employee andhis/her family (please see the Information Technology SystemsSecurity policy and procedures);

• the following guidelines on levels of practical and financial support maybe considered and applied, although additional alternatives could bedevised to arrive at an agreed level of support to facilitate homeworking:

• level 1: Casual working from home, five to ten hours per week.Employee uses a dial up facility connecting via the 0800 number, usingequipment issued for day-to-day mobile working;





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Guidance on flexi-working

1. Definitions

1.1 Flexi-working allows staff to work contracted hours in a flexible manner whilst

ensuring that the needs of the service are not disadvantaged.

1.2 Flexi-working can be applied to all staff, although there may be difficulties inareas such as Reception, where consistent and continuous cover is required.

1.3 The Working Time Regulations state that individuals should not work morethan forty eight hours per week, averaged over seventeen weeks, unless theyopt out from these Regulations. However, the South West Strategic HealthAuthority believes that for staff to work at their best the regulations should beadhered to and therefore cumulative hours should not exceed forty eighthours per week.

Eligibility

1.4 All staff are eligible to be considered for flexi-working, including part-time staff.Flexi-time working presents staff with the opportunity to arrange part of theworking day to suit their own particular circumstances and needs. However, aprerequisite of the flexi-time working scheme is that the service to the publicand organisations reliant on the South West Strategic Health Authority is notaffected in a detrimental way.

Terms and conditions

1.5 The option to work on a flexi-time basis is subject to the needs of the serviceand agreement with line managers.

1.6 Part-time staff may use flexi-time on a pro-rata basis if agreed with their linemanager. With regard to core working time, staff are able to start work anytime between 7.30 am and 10.00 am and finish work any time between4.00 pm and 6.30 pm provided they are at work during the core times of10.00 am to 12.00 noon and from 2.15 pm to 4.00 pm (Annex 4 illustratesthis). Staff will only be able to claim flexi-time between 7.30am and 6.30pm.Hours worked outside of these times will not count for flexi-time, but asovertime or time off in lieu if staff have been required to work these hours withprior agreement with their line manager.

1.7 Staff working flexi-time who are contracted to work full time (37.5 hours perweek) should have worked 150 hours at the end of a four-week period.

1.8 Staff working flexi-time are required to maintain an up to date record of theirworking hours on the flexi-time form which can be found on the HumanResources intranet site and this must be submitted within one month ofcompletion. A false entry on a time record will be considered an act of grossmisconduct and the employee will be subject to disciplinary action, whichcould lead to dismissal.



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1.9 If the employee has worked for more than 150 hours over the four weekperiod, the extra time is rounded down to the nearest 15 minutes anddeducted from the 150 hours the employee would have to have worked in thesubsequent four-week period.

1.10 If the employee has worked for less than 150 hours, the lost time is roundeddown to the nearest 15 minutes and added to the 150 hours the employeewould have to have worked in the subsequent four week period.

1.11 An employee is allowed to accumulate a maximum of fifteen hours credit orseven and a half hours debit to take forward to the subsequent four weekperiod.

1.12 No more than two days leave may be taken in any four week period as aresult of flexi-time, unless agreed with their line manager.

1.13 Employees leaving the South West Strategic Health Authority must bring theircredit or debit hours to zero, or the outstanding debit balance will be deductedfrom the final salary.

1.14 Managers are responsible for monitoring the flexi-time process.

1.15 All absences from work are counted on the basis of a normal working day. Aday consists of seven hours and 30 minutes and a half day is three hours and45 minutes, however, flexi-time can also be taken in blocks of 1 hour.

1.16 Appointments such as with a doctor or dentist within work time should be

avoided. When this is not possible, the employee must inform their linemanager and the time will be deducted from the flexi-time record. However,hospital appointments are an exception and these can be taken with workingtime.



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Guidance on annualised hours

1. Definition

1.1 Under the system of annualised hours, staff are contracted to work a set

number of hours in a year rather than in a week.

1.2 The hours worked are calculated on a yearly basis rather than weekly. Fulltime hours are 1950 hours a year, which is the equivalent of 37.5 hours perweek, the normal weekly hours for that post.

1.3 Employees would receive the same monthly salary and any additional hoursthat are worked would be paid on a monthly basis.

Eligibility

1.4 All staff are eligible to be considered under this policy. However annualisedhours are offered at the discretion of the South West Strategic HealthAuthority and may not be suitable for everyone.

Conditions and considerations

1.5 Hours worked are monitored on a quarterly basis by the manager of theemployee. Any hours worked in excess of the contracted hours can be boughtback, or can be carried over to the next quarter, subject to approval by theDirector. If hours are owed at the end of a quarter they are carried forward tothe next quarter.

1.6 Hours worked should be recorded on a timesheet and regularly monitored bythe line manager to ensure that the contract is fulfilled.

1.7 Annual leave should be calculated in hours. The number of weeks’ entitlementshould be multiplied by the contracted hours per week.

1.8 If an employee is absent due to sickness of up to one month, the number ofhours recorded as sickness will be whatever they had been requested to workthat week. If a staff member is absent due to sickness more than one monthor takes annual leave, the number of hours recorded will be the averageweekly contracted hours for the job, that is, 1/52 of the annualised hours.

1.9 At the end of the final quarter any deficit in contracted hours must be paidback.





Appendix 9

Grievance Policy

This appendix sets out the revised Grievance Policyfor the South West Strategic Health Authority.





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Grievance Policy

1. Introduction

1.1 The purpose of this policy is to ensure that all grievances are settled in a fair,reasonable and consistent manner.


1.3 The policy and procedures provide a mechanism for employees to raise anygrievances arising from their employment with their managers. This includesconcerns from an employee about action the employer has already taken or isproposing to take in relation to them.

1.4 These may include:

• a change in the terms and conditions of employment;

• the introduction of new working practices;

• organisational change;

• discrimination;

• bullying;

• harassment;

• equal opportunities;

• health and safety.


2.1 This policy describes the process to be followed to address any individual orcollective grievances.

2.2 An individual grievance is a concern, problem or complaint that one employeeraises with their employer.

2.3 A collective grievance is a concern, problem or complaint raised by two ormore employees with their employer.



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2.4 The procedure for dealing with individual and collective grievances is thesame.

2.5 In the event of a collective grievance not being resolved internally, the SouthWest Strategic Health Authority may refer the grievance to an independent

body such as the Advisory Conciliation and Arbitration Service (ACAS) forconciliation.

2.6 Appeals against the grading of posts will be dealt with in accordance with theAgenda for Change Terms and Conditions of Service Handbook.


3.1 This policy exists to enable employees to raise any concerns, problems orcomplaints with their managers.

3.2 The aim is that all grievances will be resolved quickly, fairly and at a locallevel with the opportunity to appeal to a higher level if necessary.

3.3 The South West Strategic Health Authority recognises that all employeeshave the right to:

• be represented at all stages by a Trade Union representative or workcolleague (not acting in a legal capacity); (Annex 2)

• have appropriate support offered if the employee or their representativehas a disability or if English is not their first language.

3.4 Whilst a grievance is being considered under this procedure the working andmanagement arrangements (which may have given rise to the complaint) willcontinue until a resolution is reached or the procedure exhausted. If servicedelivery or health and safety are likely to be compromised alternative workingarrangements may be agreed.

3.5 In cases where it is inappropriate to submit the grievance to the personidentified (see section 4.0, overview of the procedure), a suitable alternativeperson should be advised by Human Resources in discussion with the TradeUnion representative and relevant Director.

3.6 Grievances should normally be made in writing using the Notification ofGrievance form which can be found on the Human Resources intranet site.However an employee may choose to inform their manager verbally of thebasis of their grievance, in which case the manager should document thediscussion on the Notification of Grievance form and agree the content withthe employee.

3.7 Written statements from employees, including letters of resignation, that detailemployee complaints will be dealt with under this policy.



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3.8 The policy may be implemented at either the first or second stage if the natureof the grievance warrants such action. The level that the grievance will beheard at will be determined by the receiving manager and a senior member ofthe Human Resources team.

3.9 Where an individual has left the employment of the South West StrategicHealth Authority the modified procedure (Annex 1) can be followed subject towritten agreement by both parties or in situations where it is not reasonablypractical for one or other party to carry out the standard procedure.

3.10 In the event of a grievance being raised during a disciplinary process, advicemust be sought from Human Resources as to whether the disciplinaryprocess could be suspended whilst the grievance is investigated or thegrievance may be investigated and heard concurrently if it is an integral partof the disciplinary investigation.

3.11 Grievance proceedings can be sensitive or controversial in nature, it isimportant that all information discussed as part of the grievance be keptconfidential by all parties.

3.12 All reference to days in this policy means calendar days. The time limitsreferred to in this policy may be varied by mutual agreement.

3.13 Written records should be kept at all stages of the grievance policy andprocedure. These should include:

• the nature of the grievance raised;

• a copy of the written grievance;

• the employers response;

• action taken;

• the reasons for action taken;

• if an appeal was lodged;

• the outcome of the appeal;

• any subsequent developments.

3.14 Copies of meeting records should be given to the employee including anyformal minutes that may have been taken; in exceptional circumstances (forexample to protect a witness) the employer might withhold some information.

3.15 If a grievance is raised against a third party, the South West Strategic HealthAuthority shall take the grievance as far as is possible and action taken toinform the third party of the grievance and the outcome.

3.16 In some cases it may be necessary to investigate the allegations (Annex 3).



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4. Overview of the procedure

Level Grievance Heard by: Manager toacknowledge &convene a

meeting in

Period tolodgegrievance at

next stageFirst Stage Line manager of the

employeefourteen days fourteen days

SecondStage

Associate Director orDirector of theemployee and HumanResourcesRepresentative

fourteen days fourteen days

Third Stage Director or ChiefExecutive (or nominee)and two BoardMembers*

Human ResourcesRepresentative

Secretary to the Panel

*At least one of theBoard members will bea Non-Executive

Director who will chairthe panel.

six weeks no furtherappeal. (seeparagraph 2.5for collectivegrievances)

5. Grievance Procedure

5.1 First Stage – Informal:

• on receiving a grievance, the manager should acknowledge receipt inwriting and invite the employee to a private meeting as soon as isreasonably practical and within fourteen days;

• the employee will have the right to be accompanied (see 3.3) and themanager should work with the chosen representative to find a suitabledate and time for the meeting so long as it is no more than five daysafter the original date;

• this is an informal meeting during which discussion may lead to anamicable resolution;

• the employee will have the opportunity to restate their grievance, callany witnesses they wish to and to make suggestions as to how the

grievance could be resolved. It should be recognised that a grievanceis often the last resort for an employee;



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• during the meeting, the manager may decide that they need to carryout further investigation in to the grievance or consult with others ashow to progress the grievance. In this instance the meeting should beadjourned to enable these steps to take place;

• the manager will keep a written record of the main discussion points ofany subsequent meetings;

• the manager will arrange a further meeting with the employee and theirrepresentative. At this meeting they will share with them the maindiscussion points of their meetings;

• the manager will then discuss the outcome with the employee and theirrepresentative and record the agreed outcome. A copy of this will besent to the employee, no later than seven days after the initial meetingand a copy retained on their personal file, together with the Notification

of Grievance form;

• it is anticipated that most day to day problems and grievances can bedealt with satisfactorily through this informal stage. In the event of nonresolution the employee has the right to invoke further stages in theprocedure;

• in order to do this, they must write to their Director within fourteen daysof receipt of the letter confirming the outcome of the first stage. Theymust state clearly their reasons for referring the matter to the nextstage of the grievance procedure.

5.2 Second stage – formal:

• on receiving a grievance, the Associate Director or Director shouldacknowledge receipt in writing and invite the employee to a privatemeeting as soon as is reasonably practical and within fourteen days;

• the employee will have the right to be accompanied (see Annex 2) andthe Associate Director or Director should work with the chosenrepresentative to find a suitable date and time for the meeting so longas it is no more than five days after the original date;

• this is a formal meeting during which discussion may lead to anamicable resolution;

• the employee will have the opportunity to restate their grievance, callany witnesses they wish to and to make suggestions as to how thegrievance could be resolved;

• during the meeting, the Associate Director or Director may decide thatthey need to carry out further investigation in to the grievance orconsult with others as how to progress the grievance. In this instance

the meeting should be adjourned to enable these steps to take place;



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• the Associate Director or Director will keep a written record of the maindiscussion points of any subsequent meetings;

• the Associate Director or Director will arrange a further meeting withthe employee and their representative. At this meeting they will share

with them the main discussion points of their meetings;

• the Associate Director or Director will then discuss the outcome withthe employee and their representative and record the agreed outcome.A copy of this will be sent to the employee, no later than seven daysafter initial meeting, and a copy retained on their personal file, togetherwith the Notification of Grievance form;

• in the event of non resolution the employee has the right to use afurther stage in the procedure.

5.3 Third stage – Appeal:

• the Director or Chief Executive (or nominated deputy) will acknowledgereceipt of the grievance and convene a panel (as detailed in 4.0) assoon as is reasonably practical and within six weeks of receipt of thegrievance letter;

• the employee will be required to provide a written statement of thegrounds on which the management action is being contested, inadvance of the panel hearing to enable the management side to drafttheir response;

• the management representative will submit a written statement settingout the reasons why they reached their decision and will include in thestatement a copy of the letter confirming the decision reached at thesecond Stage;

• the panel will be provided with these statements no later than sevendays before the hearing. The statements, together with the copies of allrelevant correspondence relating to the grievance will be circulated toall parties and the Panel members;

• the case for the employee shall be presented by the employee and/ortheir representative. The employee may be questioned by the Panelmembers;

• the case for the management will be presented by the manager whoheard the grievance at the previous stage. The manager may bequestioned by the Panel members and management, the employeeand/or their representative;

• the two parties are entitled to bring before the panel such witnesses asthey deem necessary to support their case. The respective parties are

responsible for the attendance of their witnesses;



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• witnesses for the two parties should wait in separate waiting roomswhere possible and should not be present at any part of the hearing,except where they are giving evidence;

• it is usual for witnesses to be questioned by both parties and by Panel

members. The Chair will decide on the admissibility of questions andevidence and all questions should be formally put through them;

• the employee and/or their representative may ask questions of theirown witnesses, the manager and their witnesses;

• the manager may ask questions of their own witnesses, the employeeand their witnesses;

• the two parties will have the opportunity to sum up their cases, theemployee first. During this summing up, no new evidence can be

produced;

• the decision of the Appeal Panel will be confirmed in writing to bothparties within seven days;

• the decision of the Appeal Panel represents the final stage of theinternal procedure.

5.4 In order to do this, they must write to the Director or Chief Executive withinfourteen days of receipt of the letter confirming the outcome of the secondstage. They must state clearly their reasons for referring the matter to the next

stage of the grievance procedure.



• all employees will have been treated fairly and consistently when beinginvolved with the Grievance procedure;


• all employees have a clear understanding of the roles andresponsibilities for line managers and themselves in managinggrievance.








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Annex 1

The modified grievance procedure

The modified grievance procedure can be used when the following conditions

are met:

1. The employee has ceased to be employed by the South West StrategicHealth Authority.

2. The South West Strategic Health Authority was either:

• unaware of the grievance before employment ceased or;

• aware of the grievance before employment ceased but the standardgrievance procedure was not started or was not completed before thelast day of the employee’s employment.

3. The South West Strategic Health Authority and the employee have agreed inwriting, either before, on or after the employee’s employment ended (but afterthe Authority had become aware of the grievance) that the modified procedureshould apply.

Process

4. First Stage: The ex-employee must send a written statement of grievance and

the basis of the grievance to the Human Resources team.

5. Second Stage: The Authority must reply to the ex-employee in writing givingtheir response to the points raised within seven days.



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Guidance note on the role of the representative

1. The employee may wish to be represented, this representative must be a TradeUnion representative or work colleague (not acting in a legal capacity).

2. The employee should inform the Manager of who they have chosen to be theirrepresentative as it is sometimes helpful for the Manager to make contact with therepresentative before the meeting.

3. The role of the representative is to:

• support the individual;

• make the views of the employee known to the employer;

•

make the views of the employer known to the employee;

• have a say at meetings/hearings to put the employees case across;

• sum up the employees case at hearings;

• respond on behalf of the employee to any view expressed at the meeting.

4. The representative may confer with the employee during the meeting and mayparticipate fully in the meeting, including asking witnesses questions. Therepresentative has no right to answer questions on behalf of the employee, or to

address the meeting if the employee does not wish it.

5. An employee who has agreed to represent a colleague will be entitled to take areasonable amount of paid time off to fulfil their responsibility. They will also begiven reasonable time to familiarise themselves with the case and confer with theircolleague before and after the grievance meetings.



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Guidance note on investigating a grievance

1.1 In some cases it will be necessary to investigate the allegation and take statementsfrom those involved. This should be undertaken discreetly and without breachingconfidences.

1.2 If the line manager of the employee is unable to investigate the grievance, theDirector should decide who is appropriate to undertake the investigation.

1.3 The manner in which the investigation is conducted, information obtained and themethod of presentation will depend on individual circumstances. Sometimes it willbe appropriate to obtain written statements and call witnesses to give evidence.

1.4 If the investigation takes longer than the prescribed time periods, progress shouldbe reviewed at fourteen day intervals and the employee should be notified of this inwriting.





Appendix 10

Health and Wellbeing Policy

This appendix sets out the revised Health andWellbeing Policy for the South West Strategic HealthAuthority.





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Health and Wellbeing Policy

1. Introduction

1.1 The South West Strategic Health Authority is committed to ensuring Health andWellbeing is there for all employees by providing a supportive, fit for purposeworking environment.

1.2 The Health and Wellbeing policy addresses a number of areas where employeesare provided and offered support:

• alcohol and drugs;

• eye tests;

• health problems and disability;

• no smoking;

• occupational health;

• stress management.

1.3 This policy should be read in conjunction with:

• Absence Management policy;

• Appraisal policy;




• Organisational Change policy;


• Recruitment policy.



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2. Stress management

Introduction

2.1 The South West Strategic Health Authority is committed to maintaining a healthy

and safe working environment for all its employees. It recognises that this duty ofcare extends to mental health as well as physical health at work. Mental healthproblems have many causes, including stresses in the workplace and in the life ofemployees away from work.

2.2 The South West Strategic Health Authority is committed to identifying sources ofexcessive stress in the workplace and taking action to reduce them.

Definition of stress

2.3 The Health and Safety Executive defines stress at work as follows: “the adverse

reaction people have to excessive pressures or other types of demands placed onthem”.

2.4 The ACAS guide Stress at Work states that positive pressure which can leadto improved motivation, job satisfaction and performance, should not beconfused with the harmful affects of pressure that is beyond a person’sability to cope.

2.5 Annex 1 sets out the main causes of stress and action that can be taken to addressthe situation.

The legal position

2.6 There is no specific law on controlling stress at work, but broad health and safetylaw applies:

• under the Health and Safety at Work Act 1974 employers have a duty toensure, so far as is reasonably practicable, the health, safety and welfare atwork of all their employees;

• under the Management of Health and Safety at Work Regulations 1999employers have a duty to assess the health and safety risks to which theiremployees are exposed at work; *stress risk management forms are held onthe intranet)

• under the Disability Discrimination Act 1995 employers have a duty not todiscriminate against employees on account of their disability as definedunder the Act. This involves making reasonable adjustments to theworkplace or to the way the work is done, if the existing workingarrangements or physical features place the disabled person concerned at asubstantial disadvantage. Ill health arising from, or exacerbated by, stress atwork may constitute a disability under the Act.



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2.7 Ill health resulting from stress caused at work has to be treated in the same way asill health due to physical causes in the workplace. This means that employers dohave a legal duty to take reasonable care to ensure that health is not put at riskthrough excessive and sustained levels of stress arising from the way work isorganised, or from the day to day demands placed on their workforce.

Aims and objectives

2.8 The aims and objectives of this Stress Management procedure are:

• to increase general awareness of stress and methods to prevent and combatharmful, excessive work place stress through training initiatives for Directorsand managers;

• to take action to combat and prevent workplace stress;

•

to assist staff in managing stress in others and themselves;

• to manage problems that do occur and provide a confidential referral service;

• to manage the return to work of those who have had stress related problems;

• to monitor and evaluate stress indicators.

Recruitment and selection

2.9 The full range of tasks and demands of a post should be set out clearly in the jobdescription and person specification which is sent out to all prospective candidates.Areas of potential pressure and stress should be identified and discussed in theinterview process. Where appropriate, referees should be asked specific questionsabout candidates’ ability to deal with stressful situations.

2.10 For posts where it is recognised that a higher than normal level of pressure andstress exists, candidates tolerance to stress should become an important factor inthe selection process.

Induction

2.11 All new staff must receive induction into their new posts, whether they are newlyappointed or are existing employees who have moved into a different post,seconded or temporary. Starting a new job can be stressful and a plannedprogramme of activity will help to eliminate many concerns.

Prevention of stress

2.12 The South West Strategic Health Authority recognises that the most effective way oftackling harmful, excessive work place stress is to prevent it at source, as part of acoherent overall prevention policy, covering a range of issues. This includescontinuous review of Human Resources policies, improving communicationsystems, redesigning jobs or continuing to encourage decision making and

autonomy.



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2.13 Early recognition of problems and encouragement of self-reporting before stressbecomes harmful is important.

2.14 Precise prevention strategies will vary. These can be assessed through induction,appraisal, exit information as well as through stress-related sickness, turnover rates

and the annual staff survey.

2.15 Some of the ways in which the South West Strategic Health Authority aims to createa healthy and supportive network/environment include:

• the development of a supportive organisational climate where stress is notperceived as a sign of weakness or incompetence;

• working to remove the stigma frequently attached to those adversely affectedby stress and maximise the support available to staff. Managers anddirectors have a crucial role in this respect;

• a demonstrable commitment to the issue of stress and mental health at work.This will require a dismantling of cultural norms within the organisation whichinherently promote stress. One example would be employees who feel theyhave to work excessively long hours and feel guilty about leaving on time;

• informing employees of sources of support and advice within theorganisation;

• extending and improving the inter-personal skills of Directors and managersso they convey a supportive attitude and can handle employee problems

more comfortably;

• developing mechanisms to advise and support individuals when majororganisational change is planned, during which either job changes orpotential redundancies are a possibility;

• the continuation of the staff development and training that already exists,including:

* mentoring;

*various courses covering inter-personal skills and management;

* stress management workshops with the aim of teaching individualsstress management skills and the ability to monitor and manage stresslevels in themselves, their staff and colleagues.

Early detection of stress

2.16 To increase the early detection of stress, managers should:

• discuss workload and other stress related factors in the Appraisal;

• check if work performance is impaired by stress so that problems can beresolved (such as by reviewing the person's duties);



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• consult the Human Resources team or the Occupational Health Service foradvice.

Action to take if you feel under stress

2.17 Any member of staff who feels that they are under stress should:

• not allow stress to increase to a level where it becomes intolerable. By takingaction early, it is possible to minimise the harmful effects of stress (seeGuidance Note 1);

• speak (or write) to your immediate manager as soon as possible. They maybe unaware of the stress you feel you are under and may be able to makechanges which alleviate the situation;

• a fully confidential counselling service is available for staff. Staff interested in

accessing this service should contact Somerset Occupational Health directlyon 01823 345800;

• seek advice from the Human Resources team or the Occupational HealthService;

• seek support from an Employee Support Advisor if the stress is related to anissue of bullying or harassment;

• seek the advice and support of your representative body.

Management of stress

2.18 Where the above preventive mechanisms fail, stress related conditions should berecognised as soon as possible. Facilities should be available for discussion, adviceand appropriate referral as necessary.

2.19 Most individuals who develop stress related conditions make a full recovery, oftenwithout interruption to working lives. If time off has been required, it can be far morecostly to retire an employee early on medical grounds, recruit and train a successorthan to spend time easing an individual back to work.

2.20 The South West Strategic Health Authority will provide confidential support via theHuman Resources team and the Occupational Health Service. Confidential andprofessional counselling services for any employees who are experiencingproblems in their workplace can be sought via the Human Resources team or directfrom Occupational Health.

2.21 When employees are absent from work as a result of stress, the return to work isalso likely to be a stressful experience. Employees are encouraged to discuss theirreturn to work with their manager. A manageable programme of work has to beworked out with the individual and the manager. If a referral to the OccupationalHealth Service has not already been made, this would be an appropriate time so

that fitness to return to work may be assessed and advice given on reasonablemeasures to be taken to avoid a recurrence of stress.



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Monitoring and evaluation

2.22 The measurement of levels of stress is complex. There are no simple measureswhich can be used as direct indicators of levels of stress. However, it is importantthat the South West Strategic Health Authority is committed to monitoring potential

indicators of stress so that both potential problems and variability in stress can beidentified. It is important to monitor potential indicators of stress such as:

• accident rate;

• early retirement records;

• exit information;

• sickness absence;

•

turnover.

3. Health problems and disability in employment

Introduction

3.1 The purpose of the Health Problems and Disability in Employment procedure is to:

• ensure the South West Strategic Health Authority and all its staff adhere tothe employment requirements of the Disability Discrimination Act 1995 andits underlying philosophy of eradicating workplace discrimination against

people with a health problem or disability;

• demonstrate commitment to equal opportunities by the South West StrategicHealth Authority;

• ensure that people with a health problem or disability are not deliberately orinadvertently excluded from or disadvantaged in employment.

Guidance on health problems and disability in employment

3.2 The Executive Board of the South West Strategic Health Authority has adopted this

policy statement as a public commitment to facilitating the important rights ofdisabled people and those with health problems not to suffer discrimination in:

• access to employment opportunities;

• access to its service;

• employment;

3.3 The policy statement and operational procedures are informed by the requirementsof the Disability Discrimination Act 1995 and by the following philosophy.



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3.4 For further advice see Guidance Note 2 on Financial Assistance available fromLocal Employment Services.

Philosophy

3.5 The South West Strategic Health Authority believes that it should relate to everyperson who uses, provides or is otherwise involved with its services on the basis ofhis or her abilities rather than any disabilities. The South West Strategic HealthAuthority takes the view that, with appropriate action, a health problem or disabilityis irrelevant in most circumstances and that the main barriers to the full involvementof people with health problems or disabilities are:

• inappropriate stereotypes;

• lack of understanding;

• inappropriate or ill-informed attitudes.

3.6 The philosophy of the South West Strategic Health Authority is that all barriers anddiscrimination should be eliminated, wherever possible and in accordance with therequirements of the Disability Discrimination Act 1995.

Expectations

3.7 The South West Strategic Health Authority is committed to carrying out goodpractice in this important aspect of our overall Equal Opportunities strategy and willtake all appropriate action to ensure compliance with the Disability DiscriminationAct 1995. Specifically, the South West Strategic Health Authority will:

• ensure that all its practices and activities are properly informed by andreflective of the principles and requirements of the Disability DiscriminationAct 1995;

• ensure that people with health problems or disabilities are not unlawfullydiscriminated against, whether they are:

∗ visitors to South West Strategic Health Authority premises;

∗ employees or applicants for employment with the South WestStrategic Health Authority;

∗ other service users/providers working in premises owned or occupiedby the South West Strategic Health Authority;

• actively promote the principles protected in the Disability Discrimination Act1995, engaging all staff in the process through training to develop a fullunderstanding of their individual and collective responsibilities.



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3.8 The South West Strategic Health Authority will undertake to:

• audit and monitor all aspects of the activity to ensure conformity with theprovisions of the Disability Discrimination Act 1995 as individuals apply to theSouth West Strategic Health Authority;

• provide an annual update to the South West Strategic Health AuthorityBoard, detailing activities in the preceding year;

• work with the local Employment Service Placing, Assessment andCounselling Team (PACT) to attain approval to promote and display inadvertisements and other appropriate documents the Department ofEmployment symbol of good practice, the “two ticks” symbol.

Pre-employment

Job specifications, job descriptions and advertisements

3.9 The job pack for all vacancies will include a job description, person specificationand draft advertisement which do not contain requirements, whether explicit or byimplication, which would exclude people with a health problem or disability fromconsideration.

Application records

3.10 The usual format for application for any post will continue to be by application form.However, the South West Strategic Health Authority will make alternativearrangements where a person advises that their disability makes this necessary.The process will be as follows:

• advertisements to include the “two tick” symbol to indicate the South WestStrategic Health Authority welcomes applications from people with a healthproblem or disability;

• application forms, which have been completed by a nominated person actingon behalf of the applicant will be accepted, but will require the applicant toconfirm the accuracy of the content by adding their own signature or mark.

3.11 The letter sent (or verbal advice given by the appointing manager) to all applicantsfor employment will contain the following statement:

• “The South West Strategic Health Authority is committed to the view thateverybody should be judged on the basis of their abilities and that allappropriate adjustments, as defined by the Disability Discrimination Act1995, should be made to allow someone with a disability to compete for a jobon an equal basis with people who do not have a disability. If you think youhave a particular need which may affect your ability to carry out the job youhave applied for or you think you may need support or special arrangements

at any interview, would you please enclose a covering letter with yourapplication, or alternatively, please contact the Human Resources team at



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the above number to give this information or to discuss any queries you mayhave”.

Shortlisting arrangements

3.12 The Human Resources Advisor will review all applications for each vacancy beforesending the file to the appointing manager for shortlisting for interview. Where anapplicant has given details of a health problem or disability which will/may affect theinterview or employment arrangements (including making adjustments to premises,equipment), the Head of Human Resources will discuss the application with theappointing manager.

3.13 The possible outcomes are as follows:

• that the applicant meets the minimum requirements for the post and thatadjustments are necessary and practicable (including availability of financial

and/or other resources) in relation to interview and selection processes,premises, equipment and working arrangements. The applicant and expertopinion should be consulted where necessary (for example, OccupationalHealth) and the Human Resources team will be responsible for ensuring thatall the arrangements are in place;

• the Human Resources team will agree with the appointing manager anychanges needed where a selection test or process would put the person witha health problem or disability at a disadvantage compared to the candidateswithout a health problem or disability. All applicants who have notified a

health problem or disability and who, disregarding the nature or effect of theirhealth problem or disability, meet the minimum job specificationrequirements and selection criteria for the post, will be shortlisted forinterview;

• that the applicant does not meet the minimum requirements for the post,independently of the effect of their health problem or disability and will nottherefore be shortlisted on those grounds alone;

• that a decision will be made that it is justifiable (as defined by the DisabilityDiscrimination Act 1995) not to employ the person (and, therefore, not to

offer an interview) on the grounds of the effects of their health problem ordisability. This may involve further correspondence or discussion with theapplicant before the final decision is made. The appointing manager isresponsible for making the final decision in such a case, taking expert advicewhere necessary (for example, Occupational Health), and for communicatingthe reason and the decision to the applicant.

3.14 The selection and interview procedures will be adapted as appropriate and theapplicant with the health problem or disability, and other applicants and staff ifappropriate, will be advised of the arrangements.





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• monitored to confirm their continuing suitability and any changes needed.

3.20 A flow checklist is attached as Annex 2 showing the steps to be followed to meetemployer obligations under the Disability Discrimination Act 1995.

Training

3.21 Managers with responsibility for the appointment of staff will be provided withtraining by the South West Strategic Health Authority in the application of this policyand will receive disability awareness training.

During employment

Terms of employment

3.22 The employee with a health problem or disability will not be appointed on terms and

conditions less favourable than the terms and conditions applying to someone in thesame role, who does not have a health problem or disability, notwithstandingadjustments made by the South West Strategic Health Authority.

Monitoring database

3.23 All new starters with a health problem or disability will be registered on the databaseand existing staff will be invited to register.

3.24 It will be the responsibility of the line manager to discuss and seek advice from theHead of Human Resources in the event of:

• any changes to the health problem or disability of the employee;

• any changes in the effects of that health problem or disability on theperformance of the employee or ability to carry out their duties;

• any employee who has acquired a health problem or disability or beendiagnosed as having a health problem or disability which may have an effectin due course;

• a past health problem or disability, as defined by the Disability Discrimination

Act 1995, which has come to light;

• any suspicions that an employee may have acquired or chosen not todisclose a health problem or disability.

Regular reviews

3.25 Each appointing manager will meet on a voluntary basis with any employee with ahealth problem or disability to review the effectiveness of adjustments made, anychange in the effect of the health problem or disability and will agree any newadjustments which may be needed.







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For reasons unconnected with the health problem or disability

3.36 The South West Strategic Health Authority may terminate the contract ofemployment of a person with a health problem or disability, without being guilty ofdiscrimination under the terms of the Disability Discrimination Act 1995, where the

reason for dismissal is unconnected with the health problem or disability and itseffects and where the health problem or disability or its effects do not provide anymitigation of the circumstances which led to termination of the employment. Such atermination would take place in accordance with either the PerformanceImprovement policy, Organisational Change, Disciplinary or Absence Managementpolicy of the South West Strategic Health Authority.

3.37 Where an employee with a health problem or disability is at risk of redundancy, thenormal redundancy and redeployment arrangements will be enhanced to take intoaccount the obligations the South West Strategic Health Authority has to thatperson under the Disability Discrimination Act 1995.

4. Alcohol and drugs misuse

Introduction

4.1 The purpose of this policy is to support any employee who has been identified withan alcohol or drug problem and also to support the manager of the employee.

4.2 This policy outlines the role a manager should play when the performance, conductor attendance of any member of staff is affected by continual or repeated drinking ordrug abuse. Isolated incidents of alcohol or drug misuse should be dealt with

through the disciplinary policy.

4.3 An employee who is identified as a problem drinker or drug user will be treated withunderstanding, sympathy and fairness.

Definitions

4.4 For the purposes of this policy:

• ‘alcohol misuse’ is defined as the drinking of alcohol to the extent that itcontinuously or repeatedly adversely affects the work performance, conduct,

attendance or normal behaviour at work of an employee;

• ‘drug abuse’ is defined as the deliberate use of drugs for the purpose ofintoxication or for any other reasons other than a genuine health reason.

4.5 This policy is not concerned with the use of drugs for legitimate purposes.

Procedure

4.6 Employees who suspect or know that they have an alcohol or drug related problemare encouraged to seek help voluntarily through their manager, the Human

Resources team, their general practitioner, the Occupational Health Service or anyother appropriate agency, such as Alcoholics Anonymous.



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4.7 Where it is apparent or suspected that an individual may have an alcohol or drugproblem, they should be referred by their manager to the Occupational HealthService for assessment, by contacting the Human Resource team.

4.8 Confidentiality will be observed where an employee with a drink or drug problem

requests advice or support. However, if the disciplinary route is applicable it maybe necessary during the course of disciplinary interviews, appeals or EmploymentTribunal hearings, to mention that help or treatment has been offered.

4.9 The South West Strategic Health Authority reserves the right to require anyemployee suspected of having an alcohol or drug related problem to take sick leavepending further assessment.

4.10 With the agreement of the manager absence from duty for assessment or treatmentwill be treated as sick leave.

Rehabilitation

4.11 The employee will be permitted to return to their post after treatment if the SouthWest Strategic Health Authority is satisfied that the employee is capable of workingto the required standards, unless:

• to do so could prejudice complete and satisfactory recovery;

• the effect of the problem prior to treatment has affected the ability of theindividual to such an extent that to continue in, or return to, the same postwould be unacceptable to the South West Strategic Health Authority;

• where, because of organisational needs, the post no longer exists or has hadto be filled.

4.12 If it proves impossible for an employee to return to the same post after treatment,the South West Strategic Health Authority will make every effort to offer analternative post and allow the employee to be considered for other suitablevacancies.

4.13 Should work performance, conduct or attendance deteriorate after the employeehas returned to work, the South West Strategic Health Authority reserves the right

to use the Disciplinary policy which could lead to the termination of employment.

4.14 In certain cases, the South West Strategic Health Authority may support anapplication for early retirement on the grounds of ill health.

4.15 Where an employee fails to accept or co-operate with treatment and theirperformance, conduct or attendance continues to be unsatisfactory, appropriateaction will be taken under the Disciplinary policy of the South West Strategic HealthAuthority, which may include dismissal.

Regular reviews

4.16 The performance of an employee receiving counselling and/or treatment should beregularly reviewed by their manager, at least at monthly intervals.



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4.17 The advice of the Occupational Health Service should be sought on the likelytimescale for a return to full health.

4.18 Action under this policy should usually be brought to a conclusion within six monthsof a problem first being recognised.

Special conditions

4.19 The consumption of alcohol on the premises of the South West Strategic HealthAuthority is only allowed with the express approval of the Chairman or ChiefExecutive of the South West Strategic Health Authority and should be limited tofestive celebrations, or occasionally, at leaving presentations. In granting approvalthe Chairman or Chief Executive must be satisfied that the amount of alcoholavailable will be strictly limited and that a senior member of staff will be present.Appropriate non-alcoholic beverages should also be available on these occasions.

4.20 Aware that the consumption of alcohol can exacerbate inappropriate behaviour,employees involved in South West Strategic Health Authority social events shouldat all times behave courteously to others whether at the workplace or in a venuechosen by the organisation to host an event. Behaviour that is intimidating orthreatening or unacceptable to another person will not be tolerated and theemployee involved may be subject to the disciplinary procedure if such behaviour isexhibited.

Responsibility of staff

4.21 Staff may render themselves subject to disciplinary action if it is suspected that their

ability to undertake their duties is impaired by alcohol or drugs.

4.22 Where staff are under medication from their doctor and have reason to believe thatthis may affect their performance at work, they must inform their manager of this inorder that alternative arrangements can be made. The co-operation of all staff isrequired in the implementation of this policy.

Appeals

4.23 If an employee receives a formal warning or has their employment terminated underthis policy, they have a right of appeal in accordance with the provisions of theDisciplinary policy. The letter confirming the action taken should remind theemployee of this right.

5. Occupational Health Services

Introduction

5.1 The Occupational Health Service aims to promote and maintain the highest degreepossible of physical, mental and social well being at work for all employees of theSouth West Strategic Health Authority. It is both a confidential and impartial service.



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5.2 The Occupational Health Service is in place primarily to give advice on all mattersrelating to the effect of ‘health on work’ and ‘work on health’. It assists the SouthWest Strategic Health Authority to discharge its obligations to protect the health andsafety of all staff in line with Health and Safety Legislation and Department ofHealth guidelines.

6. Services provided by Occupational Health Services to the SouthWest Strategic Health Authority

Pre-employment health assessments

6.1 To ensure that those appointed are fit for the full range of duties of their post orappropriate adjustments recommended.

Medical supervision

6.2 Provided when necessary during employment, such as blood pressure checks.

Immunisations

6.3 To provide protection at work as appropriate. Not available for travel immunisationsalthough advice can be given.

Sickness absence advice

6.4 Either formally through manager referral, or informally through manger referral, orself-referral.

Phased return to work

6.5 Arrangements for a gradual return to work rehabilitation programme after asignificant period of absence, working part-time but on full pay. This is monitoredby the Occupational Health Service in conjunction with management followingsurgery, accident or serious illness.

Environmental assessment and health surveillance

6.6 Advice given regarding use/handling of hazardous materials and regular healthsurveillance when and where indicated.

Health and safety

6.7 Including general advice to employees and management regarding environmentaland individual health and safety concerns. This includes, for example, adviceregarding pregnant workers, work stations assessment.

Health promotion

6.8 One to one support for staff wanting to lose weight, stop smoking, increase physicalactivity levels or manage stress.



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Counselling

6.9 Employees are entitled to up to six free counselling sessions. More may beavailable in exceptional circumstances.

Self-referrals

6.10 Employees may refer themselves to the Occupational Health Service for advice andsupport on all matters regardless of whether or not the matters relate to work.

Confidentiality

6.11 All information received from the Occupational Health Service will be treated in strictconfidence. Statements to managers about the health of members of their staff byOccupational Health are agreed with the employee and are only made with theagreement of the member of staff concerned.

6.12 The confidentiality of employees who self-refer themselves to the OccupationalHealth Service will be maintained. The Occupational Health Service will not provideany confidential information to the South West Strategic Health Authority that canbe traced back to any individual.

6.13 The South West Strategic Health Authority will treat all information held onemployees as confidential and no information will be divulged to third partieswithout the prior consent of the individual concerned.

Provider

6.14 The Occupational Health Service for the South West Strategic Health Authority isprovided by:

Daphne MarstonSenior Occupational Health NurseOccupational Health DepartmentYeovil District Hospital NHS Foundation TrustHigher KingstonYeovil, SomersetBA21 4AT Tel: 01823 345815

[email protected]

Further advice and support

6.15 Employees who require further advice or support may contact the HumanResources Advisor or the Head of Human Resources at the South West StrategicHealth Authority.



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7. No smoking

Introduction

7.1 All South West Strategic Health Authority owned and managed buildings are smoke

free. This policy applies to all staff, visitors and contractors.

Purpose

7.2 The smoking ban within all South West Strategic Health Authority buildings hasbeen brought into effect for two key reasons:

• the South West Strategic Health Authority is concerned about the health andwelfare of its employees. As a health employer it believes that it shoulddiscourage smokers from smoking in its buildings and, thereby, minimise therisk of passive smoking to non-smokers;

• as part of its corporate responsibility to develop non-smoking policies inhospitals and community sites within the NHS South West, the South WestStrategic Health Authority needs to set an example for these, and otheremployees, to follow.

General points

7.3 Managers will be expected to counsel employees who experience problems incoming to terms with the policy and encourage them to seek assistance from theHealth Promotion Department, the Stop Smoking Service or to a local Stop

Smoking organisation.

7.4 This policy extends to areas outside the South West Strategic Health Authoritybuildings, such as car parks and includes private vehicles parked on the premisesof the South West Strategic Health Authority. It also extends to lease cars providedthrough the Authority. The policy should be regarded as applying when onAuthority business such as in private cars when accompanied by work colleaguesor at non NHS premises such as private homes, meeting venues etc. whenaccompanied by colleagues or in the presence of patients, carers or relatives.

7.5 Failure to comply with any part of this policy will be deemed to be a disciplinary

offence.

7.6 The South West Strategic Health Authority will ensure that appropriate signs areposted at all entrances to Authority buildings and will also ensure that prospectiveemployees are informed of the policy.



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8. Eye tests, lenses and frames for display screen equipment users

Introduction

8.1 The South West Strategic Health Authority places a high value on maintaining the

health and safety of all its employees. While work with Display Screen Equipment(DSE) may not cause any permanent damage to eyes or eyesight, complaints oftemporary discomfort, eye strain and headaches are common. As with any workthat is visually demanding, users with existing uncorrected vision defects are morelikely to suffer fatigue and stress in DSE work.

Definition of a ‘user’

8.2 The Health and Safety Regulations 1992 require that the South West StrategicHealth Authority must determine which of its employees fall within the definition of auser. The guidance within the Regulations states that “where use is more or less

continuous on most days the employee will be deemed a user”. An employee willalso be classified as a user if most or all of the following criteria apply:

• the job cannot be done effectively or at all without Display Screen Equipment(DSE);

• the worker has no discretion over whether to use DSE;

• the job requires significant IT training or particular IT skills;

•

the worker uses Display Screen Equipment for periods of an hour or more ata time, more or less on a daily basis;

• the task depends upon the fast transfer of information between the workerand Display Screen Equipment;

• attention and concentration demands are high, such as where there may becritical consequences of an error.

8.3 The South West Strategic Health Authority defines a ‘user’ as an employee whouses Display Screen Equipment for three hours or more every day.

Eye tests and spectacles

8.4 The Regulations require the South West Strategic Health Authority to offer itsDisplay Screen Equipment users a free eye test and the cost of basic frames andlenses (this may include contact lenses) to be used for Display Screen Equipmentwork. The South West Strategic Health Authority will pay for an eye test once everytwo years and will only pay for frames and lenses if they are needed due tosignificant computer use. In exceptional circumstances, the South West StrategicHealth Authority will pay for more frequent tests, frames and lenses, where this isrequired. In all cases, a prescription/letter from the optometrists must state that

lenses (glasses or contacts) are needed for this reason.



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8.5 The South West Strategic Health Authority will fund the cost of an eye test and upto £85 towards the cost of basic frames and/or lenses, if required. In exceptionalcircumstances, this may be increased due to the value of the prescription required.

8.6 Employees who wish to purchase more expensive or designer frames are required

to fund the excess cost themselves.

8.7 Employees may also be eligible for funding via an NHS voucher, which can be usedto upgrade lenses and frames. Employees may like to check their eligibility withtheir local tax or benefits office.

Application for free eye test/lenses and frames

8.8 To access funding from the South West Strategic Health Authority for a free eyetest (and, if necessary, lenses and frames), employees should contact the HumanResource team prior to arranging an appointment with the optometrists.

8.9 The employee will then book the eye test and pay for this along with any correctivelenses and frames. The receipt and a copy of the prescription (if applicable) shouldbe forwarded to the Human Resource team and the employee will be reimbursedthrough their salary.



• all employees will have been treated fairly and consistently with regards to

their health and wellbeing;

• the needs of individuals are balanced with the overall requirements of theSouth West Strategic Health Authority;

• all employees have a clear understanding of the roles and responsibilities forline managers and themselves for their own health and wellbeing.

9.2 An equality impact assessment for this policy will be completed every three years.





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Annex 1

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Managing the causes of work-related stress (Health and Safety Executive GuidanceHSG218)

Main causesof stress

What can bedone

Examples of positivemanager behaviour

Examples of negativemanager behaviour

Demands:employeesoften becomeoverloaded ifthey cannotcope with theamount of workor type of workthey are askedto do.

Make sureemployeesunderstand whatthey have to doand how to do it.

Identify and meettraining needs.

Consider whether

working flexiblehours would helpemployees tomanage demands.

Bring in additionalresource to handleexcessive workloads.

Monitor team work load

Adjusting priorities andsetting realisticdeadlines.

Follow throughproblems on behalf ofemployees

Developing action plans

Breaking problemsdown into parts

Dealing rationally withproblems

Reviewing processes tosee if work can beimproved

Asking themselves‘could this be donebetter’

Prioritising futureworkloads

Working proactively

Delegating workunequally to team.

Creating unrealisticdeadlines.

Showing lack ofawareness of how muchpressure the team isunder

Asking for tasks withoutchecking workload first.

Listening but notresolving problems

Being indecisive aboutdecisions

Not taking problemsseriously

Assuming problems willsort themselves out

Not using consistentprocesses

Sticking too rigidly torules and procedures

Panicking about

deadlines rather thanplanning



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What can bedone



Control:employees can

feel disaffectedand performpoorly if theyhave no sayover how andwhen they dotheir work.

Involve employeesin the way work is

carried out.

Consultemployees aboutdecisions

Build effectiveteams withresponsibility foroutcomes

Reviewperformance toidentify strengthsand developmentneeds, and howthe developmentwill be obtained.

Trusting employees todo their work

Giving employeesresponsibility

Steering employees in adirection rather thanimposing direction

Provides opportunity toair views

Provides regular teammeetings

Prepared to listen toemployees

Knows when to consultemployees and when tomake a decision

Encourages staff to goon training courses

Provides mentoring andcoaching

Regularly reviewsdevelopment

Helps employees todevelop in role

Managing under amicroscope

Extending so muchauthority employees feela lack of direction

Imposing ‘my way is theonly way’

Not listening whenemployee asks for help

Presenting a finalsolution

Making decisions withoutconsultation

Refuses requests fortraining

Not providing upwardmobility in the job

Not allowing employeesto use their new training



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What can bedone



Support:levels of

sicknessabsence oftenrise ifemployees feelthey cannottalk tomanagersabout issuesthat aretroubling them.

Give employeesthe opportunity to

talk about issuescausing stress.

Be sympatheticand supportive.

Keep employeesinformed aboutwhat is going on inthe departmentand organisation.

Tackle anyinstances ofbullying andharassment andmake it clear suchbehaviour will notbe tolerated.

Communicating thatemployees can talk to

them at any time

Having an open doorpolicy

Making time to talk toemployees at theirdesks

Making sure everyone issafe

Structuring riskassessments

Ensuring all health andsafety requirements aremet

Praising good work

Acknowledgingemployees’ efforts

Operating a no-blameculture passing positivefeedback about theteam to seniormanagement

Provide regular one toones

Flexible when

employees need time off

Provides information onadditional sources ofsupport

Regularly asks ‘how areyou’

Being constantly atmeetings/away form desk

Saying ‘don’t bother menow’

Not attending lunches orsocial events

Not taking health andsafety seriously

Questioning the

capability of an employeewho has raised a safetyissue

Not giving credit forhitting deadlines

Seeing feedback as only‘one way’

Giving feedback thatemployees are wrong just because their way ofworking is different

Assuming everyone isokay

Badgering employees totell them what is wrong

Not giving enough noticeto shift changes

No consideration of work-life balance



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What can bedone



Relationships:failure to build

relationshipsbased on goodbehaviour andtrust can leadto problemsrelated todiscipline,grievances andbullying.

Ensure staff andmanagers are

aware of and fulfiltheir respectiveresponsibilitiesunder thePerformanceImprovement,Disciplinary,Grievance andDignity at WorkPolicies.

Listening objectively toboth sides of the conflict

Support andinvestigating incidents ofabuse

Dealing with conflicthead on

Following up on conflictsafter resolution

Having a positiveapproach to

Acting calmly whenunder pressure

Walking away whenfeeling unable to controlemotion

Apologising for poorbehaviour

Keeps employee issuesprivate and confidential

Admits mistakes

Treats all employeeswith the sameimportance

Wiling to have a laugh

and a joke

Socialises with team

Brings food and drinksin for team

Regularly has informalchats with employees

Not addressing bullying

Trying to keep the peacerather than sort out sortout problems

Taking sides

Not taking employeecomplaints seriously

Passing on stress toemployees

Acting aggressively

Losing temper withemployees

Being unpredictable inmood

Speaks about employeesbehind their backs

Makes promises, thendoesn’t deliver

Makes personal issuespublic

Criticises people in frontof colleagues

Pulls team up for talking / laughing during working

hours

Uses harsh tone of voicewhen asking for things

Keeps people in the dark

Holds meetings ‘behindclosed doors’

Doesn’t provide timely

communication onorganisational change



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What can bedone



Role clarity:employees

often feelanxious abouttheir work andtheorganisation ifthey don’tknow what isexpected ofthem.

Employees shouldhave clear job

descriptions.

There should beclose linksbetween anemployeesperformanceobjectives andorganisationalaims andobjectives.

New employeesshould attend thecorporateinduction andreceive a thoroughlocal induction.

Keeps team informed ofwhat is happening in the

organisation

Communicates cleargoals and objectives

Explains exactly what isrequired

Keeps people in the dark

Holds meetings ‘behindclosed doors’

Doesn’t provide timelycommunication onorganisational change



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What can bedone



Leadership Takingresponsibility

Knowledge of job

Empathy

Seeking advice

Leading from the front

Steps in to help outwhen needed

Communicating ‘thebuck stops with me’

Deals with difficultcustomers on behalf ofemployees

Able to put themselves

in employees’ shoes

Has enough expertise togive good advice

Knows what employeesare doing

Takes an interest inemployees’ personallives

Aware of differentpersonalities and stylesof working within theteam

Notices when a teammember is behaving outof character

Seeks help fromoccupational health

when necessary

Seeks advice from othermanagers with moreexperience

Uses Human Resourceswhen dealing with aproblem

Saying it is not myproblem

Blaming the team ifthings go wrong

Walking away fromproblems

Doesn’t have thenecessary knowledge todo the job

Doesn’t take time to learnabout the employees’ job

Insensitive to people’spersonal issues

Refuses to believesomeone is becomingstressed

Maintains a distancefrom employees – ‘usand them’

A fully confidential counselling service is available for staff. Staff interested in accessing

this service should contact Somerset Occupational Health directly on telephone 01823345800.



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Guidance Note 1

Managing stress: employee guidelines

When does pressure turn to stress?

1.1 Being under pressure can improve performance and be a good thing for somepeople. It is worth noting that stress is not the same as pressure. Problemsarise when pressure is too great, goes on for too long, or comes from toomany directions at once.

1.2 Stress is the reaction people have when they feel they cannot cope with thepressures of other demands placed upon them. Stress can be caused by awide variety of factors; accordingly the causes and effects of stress will bedifferent for each individual. People react differently to work pressures anddeadlines. What may motivate one employee may be a source of severe

stress to another. Employees will be a subject to pressures both inside andoutside the workplace and sometimes it may be a combination of thesepressures that results in stress.

Symptoms of stress

1.3 An important step in tackling stress is to realise that it is causing you aproblem. Sometimes things get too much and we begin developing a physicalor emotional reaction to our problems. You need to make the connectionbetween feeling tired or ill with the pressures you are faced.

1.4 Tackling work related stress requires a partnership between you, yourmanager and the policies/procedures/services provided by the South WestStrategic Health Authority.

1.5 These reactions are often warning signs of stress and that some action isnecessary, for example:

• poor timekeeping;

• increased consumption of alcohol, tobacco, caffeine or drugs;

•

frequent headaches or digestive problems;

• withdrawal from social contact;

• poor judgement / indecisiveness;

• not being able to sleep properly;

• constant tiredness or low energy;

• unusual displays of emotion;

• inability to concentrate and worrying;



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• feelings of irritation, anger and tension are early warning signs that thebody is wound up.

Tips for reducing stress

1.6 Taking good care of yourself can really help to reduce stress. Here are sometips:

• good health – eat sensibly and get enough rest. Do not drink too muchcaffeine;

• if possible, try to keep smoking and drinking to a minimum. They mayseem to reduce tension, but in fact they can make problems worse;

• try to be physically active – some form of physical exercise (e.g.walking) can get your body’s defences working and help bring stress

levels down.

• talk to family or friends about what you are feeling – they may be ableto help you and provide the support you need to raise your concerns atwork;

• rest and relaxation – make time for yourself. Enjoy leisure activitiesand interests outside work;

• if you feel your workload is excessive or you are under pressure to takework home inappropriately, speak to your manager or another (see

‘useful contacts’).

Your responsibilities

1.7 You as an employee also have responsibilities to help protect yourself fromsuffering stress. These are:

• getting support early rather than waiting until things go wrong;

• taking reasonable steps to notify the South West Strategic HealthAuthority, your manager or Trade Union representative at an early

stage about working practices and environments, which, if allowed tocontinue, may lead to stress or other related hazards;

• trying to channel your energy into solving the problem, rather than justworrying about it. Think about what would make you happier at workand discuss this with your manager;

• ensuring that annual leave and flexible working are used to good effect;

• not taking on more than you can handle. If unrealistic demands aremade on your time, be prepared to be assertive and say no;

• if you believe you are suffering from stress talk to your manager, if theydo not know there is a problem, they cannot help. Explain what iscausing the stress;



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• supporting colleagues if they are experiencing work related stress.Encourage them to talk to their manager or seek professional advice;

• not being afraid to seek advice if you feel you are no longer able tomanage things on your own. If you don’t feel able to talk directly to

your manager then contact Occupational Health, your doctor, tradeunion or the Human Resources team;

• take your break entitlements during your working day.

Get the support you need

1.8 Seeking support from other people can be key to getting through stressfulsituations. Taking the time to talk things through with someone else can bean important step. You can talk to your manager, Occupational Health(including their counsellors), your doctor, your Trade Union or Human

Resources. If it is your managers or colleagues that are a source of stressthen there are other people in the South West Strategic Health Authority whoyou can talk to.

1.9 Remember : stress is not a weakness and you do not have to suffer. TheSouth West Strategic Health Authority has a duty to protect your health andsafety at work and to take steps to reduce risks at work, including those fromstress. As an employee there is a legal requirement on you to tell youremployer about any shortcomings in workplace health and safetyarrangements.

Useful external contacts :

Samaritans –

08457 909090, [email protected]

UK helpline for anyone experiencing emotional distress. Someone to talk toin confidence 24 hours a day.

CRUSE Bereavement Care –

0117 9264045, www.crusebereavementcare.org.uk/

Local office is 9A, St James Barton, Bristol (just off St James Bartonroundabout, around corner from Nationwide). A national voluntaryorganisation offering bereavement counselling and advice to all bereavedpeople.

Relate –

0845 1304010, www.relate.org

Provides couples counselling for breakdown within relationships.



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National Debt Line –

0808 8084000, www.nationaldebtline.org.uk

A helpline that provides free confidential and independent advice to deal with

debt problems.

Alcoholics Anonymous –

0845 7697555, www.alcoholics-anonymous.org.uk

Alcoholics Anonymous is a fellowship of men and women who share theirexperience, strength and hope with each other that they may solve theircommon problem and help others to recover from alcoholism.

Narcotics Anonymous –

0117 9240084, www.ukna.org

Narcotics Anonymous is a fellowship of men and women for whom drugs hadbecome a major problem – recovering addicts who meet regularly to helpeach other stay clean.

Bristol Drugs Project –

0117 9871500; www.bdp.org.uk

BDP is an independent agency, delivering an accessible and confidential

information, advice and counselling service to drug misusers, their relativesand friends, and to other professionals working with drug misusers.

Other useful contacts

• Occupational Health;

• Counsellors (Occupational Health);

• Human Resources manager for your Directorate;

• Health and Safety Executive website : www.hse.giv.uk

• keep an eye out for health promotion information / support in yourplace of work e.g. lunch time walks.



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Annex 2South West Strategic Health Authority

ChecklistMeeting obligations under the Disability Discrimination Act 1995

Is the person disabled as defined under the DDA?

NO No Legal ObligationsYES

Does the person require any special consideration oradjustment to perform the job?

No Legal Obligations

NOYES

Is the adjustment required to prevent substantialdisadvantage. For example, is it material/substantial?

NO No Legal Obligations

YES

Would the employee be able to do the job after theadjustments?

NO No Legal Obligations

YES

Is the adjustment reasonable?NO No Legal Obligations

YES

Adjustment has to be made Failure likely to be Unlawful

If Done

Meets the requirements of the DDA



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Guidance Note 2

Financial assistance available from local employmentservices

1. Background

1.1 Financial assistance may be available from a local Employment ServicePlacing, Assessment and Counselling Team (PACT), who may be able tooffer assistance on an individual basis. Several schemes and financialavailability may be considered.

2. Job introduction scheme

2.1 If you have reservations about employing an individual with a health problem

or disability, or retaining an existing employee who acquires a health problemor becomes disabled, a trial period may help. The Employment Service maymake a contribution towards the salary or wage during the trial period.

3. Adaptation to premises and equipment

3.1 Grants may be available to contribute towards the cost of adjustments in orderto accommodate a new or existing employee with a health problem ordisability.

4. Fares to work scheme

4.1 A grant towards the cost of fares may be payable to certain people whosehealth problem or disability prevents them from using public transport in orderto get to their place of employment.

5. Special aids to employment

5.1 Equipment may be used on a free permanent loan scheme to an individual,whether they work from their own home, or in a separate place ofemployment.

6. Working at home with technology

6.1 Help may be available to set up a home-based environment for a worker witha health problem or disability.



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7. Supporting employment

7.1 This scheme may be accessed if an individual with a health problem ordisability is unable to complete particular tasks within a job specification, orwhere there is a loss of productivity, to which an individual with a health

problem or disability, through their health problem or disability, may besubjected. Finances are available from the Employment Service, in order tosubsidise disabled people in “open employment” with a host employer, or in asheltered workshop environment.

7.2 This means that, for example, an individual who is unable to undertake all ofthe duties within a particular job, will continue to receive a salary for thegrade, but compensation may be available to employ further support toundertake duties they are unable to complete, for example, tasks requiringfine finger movement.

7.3 Authorisation to this scheme is via the Disability Employment Adviser, basedat Employment Centres. More information is available from the HumanResources team.



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Appendix 11

Hospitality, Gratuities and Inducements Policy

This appendix sets out the revised Hospitality,Gratuities and Inducements Policy for the South WestStrategic Health Authority.





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Hospitality, Gratuities and Inducements Policy

1. Introduction

1.1 South West Strategic Health Authority staff and Non Executive Members will,in the course of carrying out the business of the Authority, meet with peoplefrom the NHS, other public sector organisations and the private sector.Where the South West Strategic Health Authority is responsible for hostingsuch an occasion, hospitality expenses may be incurred where it is clearly inthe interest of the South West Strategic Health Authority for such an event totake place.

1.2 Such expenditure must be justified in terms of the use of public funds andshould only be authorised where it is in the interest of the South WestStrategic Health Authority. In addition, there should be no appearance ofextravagance which might give rise to criticism that the South West StrategicHealth Authority staff and Non Executive Members were benefiting at theexpense of the taxpayer. When providing hospitality for guests, the number ofSouth West Strategic Health Authority ‘hosts’ must be kept to an absoluteminimum and should normally form a minor part of the group. Hospitalityshould only be extended to spouses in very exceptional circumstances, forexample, leaving or retirement occasions.

2. Management hospitality

2.1 Hospitality can take the form of either general hospitality or a workinglunch/supper.

General hospitality

2.2 This describes an occasion when a guest is bought a meal or snack eitherduring or outside of normal working hours. Reimbursement will cover the costof food and, if appropriate, drinks, normally non-alcoholic, taken with the meal

or snack, for both host and guests.

Working lunch/supper

2.3 Working lunches or suppers are provided where the formal business of ameeting, conference or seminar continues through a lunch period or into theevening.

2.4 Working lunches or suppers should normally take place on South WestStrategic Health Authority premises and organisers should use staff cateringfacilities (if available) or, where better value for money can be achieved, an

outside caterer. Standard buffet menus should be used and drinks should benon-alcoholic. Occasionally it may, however, be appropriate for a lunch or



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supper to take place outside the South West Strategic Health Authorityheadquarters or other NHS premises. Expenditure for such meals shouldnormally be in line with NHS Terms and Conditions of Service Handbook.

General refreshments

2.5 The general rules and guidance on entertainment do not apply to theprovision of tea, coffee and biscuits. A decision to provide refreshments atpublic expense must receive due consideration to cost and in relation to thetotal hospitality budget.

3. Hospitality in support of training and development

3.1 It is accepted practice that public funds should not be used for theentertainment of South West Strategic Health Authority employees. However,there are occasions when, in the interests of good management, some

expenditure would be appropriate.

3.2 The South West Strategic Health Authority is committed to a programme oforganisational and personal development for all staff. This might take theform of meetings to bring together senior and junior Managers from within theSouth West Strategic Health Authority or other NHS organisations, teambuilding exercises or ‘away days’ for groups of staff where a period of timeaway from the headquarters of the South West Strategic Health Authoritymight assist in working through particular work issues or projects. In thesesituations, the use of hotels, the provision of refreshments including mealsand, on some occasions, overnight accommodation might be appropriate.

Such expenditure should normally be in line with, or to the level of, NHSTerms and Conditions of Service Handbook.

3.3 Similarly, it would be appropriate to provide hospitality at events such as amanagement seminar programme which may bring together staff from otherStrategic Health Authorities, and NHS Trusts and other organisations oragencies, or to visitors from other parts of the country or overseas guests whocome to share their experiences and expertise. In these situations, it wouldbe appropriate for the South West Strategic Health Authority to meet the costsof overnight accommodation and other expenses of the visitor and reasonableexpenses on the part of staff who agree to entertain the visitor out of normal

working hours. Again, such expenditure should normally be in line with, or tothe level of, the NHS Terms and Conditions of Service Handbook.

3.4 The South West Strategic Health Authority is also committed to a trainingprogramme for Non-Executive Members, as well as employees of theAuthority. Training sessions and away days for the Board would be funded aspart of the wider organisational and personal development programmes of theSouth West Strategic Health Authority. These events will normally take placeaway from the headquarters building but should not be disproportionatelylavish in terms of accommodation or refreshments provided.

3.5 Authorisation of expenditure for such events should be agreed with theDirector of Workforce Development.



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4. Declaration of interests

4.1 To protect employees, the South West Strategic Health Authority maintains aRegister of Interests. This Register records, in advance, any matters thatmight lead to, or be perceived to lead to, a conflict of interest. An important

principle however, is that if in any doubt at all it is always better to register thematter.

Interests in a business

4.2 If you, or a close relative, have a controlling interest or significant financialinterest in a business (including a private company, partnership, voluntaryorganisation, public sector organisation or other statutory organisation), or anyother activity or pursuit which may compete for an NHS contract to supplyeither goods or services, then this interest should be declared as soon as youstart employment with the NHS or as soon as that interest is acquired.

Outside employment

4.3 Staff and Non Executive members should not be engaged in outsideemployment or consultancy that may conflict with their NHS work, or bedetrimental to it. If you have any concerns it is better to register this matterand to discuss the issue with your line manager.

Commercial sponsorship

4.4 Commercial sponsorship of staff to attend courses or conferences and

sponsorship of South West Strategic Health Authority posts or other work by acommercial organisation may be acceptable but only where permission isreceived in advance from the South West Strategic Health Authority.

How to register interests?

4.5 You should register by completing the Declaration of Staff Interests formwhich is available on the Human Resources team or the intranet, or by writinga letter of sending an email which clearly details all interests you hold.

What happens to the register?

4.6 The Register is held at South West Strategic Health Authority Headquartersand is a public Register available for inspection by any member of the publicor interested party. The form, letter or e-mail is held on this file as a publicrecord and retained for the period laid down by Statute that can be up to thirtyyears.



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Failure to declare

4.7 Failure to declare an interest under the Standards of Business Conduct mayresult in South West Strategic Health Authority invoking the Disciplinarypolicy, and could potentially result in dismissal for gross misconduct. All staff

are therefore advised to familiarise themselves with their responsibilitiesunder the following organisational documents and policies, all of which areavailable on the intranet:

• Standards of Business Conduct for NHS Staff;

• South West Strategic Health Authority Standing Orders;

• South West Strategic Health Authority Standing Financial Instructions;

• Disciplinary policy of the South West Strategic Health Authority;

5. Acceptance of hospitality and gifts

5.1 This section sets out some general guidance to which South West StrategicHealth Authority staff should refer in exercising judgement on offers ofhospitality. HSG(93)5 includes detailed guidance on the responsibility of NHSstaff, principles of contact in the NHS and acceptance of casual gifts andhospitality.

Acceptance of hospitality

5.2 Individuals must consider whether:

• the hospitality is likely to help in the effective discharge of their job, orpromote the interests of the South West Strategic Health Authority ortaxpayer, for example, through improved understanding;

• the hospitality is a reasonable means to that end in the circumstances,that is:

* not over frequent;

* nor, so far as the individual is aware, part of a pattern ofinvitations to that person and colleagues from one particularorganisation which taken together is excessive;

* nor disproportionately prolonged or lavish given the nature of therelationship.

5.3 If any doubts could arise on any of the above grounds, individuals shouldconsult the Director of Workforce Development. In particular:

• if the individual thinks there is a case for accepting hospitality, theyshould always have approval before accepting and an entry should bemade into the hospitality book;



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• the Director of Workforce Development must consider whether theevent is disproportionately lavish;

• all offers of entertainment at the opera, theatre, sporting events or thelike should be declined;

• think how Parliament or the media might interpret the behaviour andhow this would be justified.

Acceptance of gifts

5.4 As set out in HSG(93)5, the receipt of casual gifts offered by contractors orothers, at Christmas or other festive occasions, may not necessarily constitutean offence under the Prevention of Corruption Act as long as the gift is notconnected with the performance of the duties of an individual as an employeeor representative of the South West Strategic Health Authority. Such gifts, or

offers of gifts, should nevertheless be politely, but firmly, declined. Articles oflow intrinsic value, such as diaries and calendars, need not necessarily berefused. In cases of doubt, staff should consult their line manager or politelydecline acceptance.

5.5 Declarations of gifts, benefits, hospitality or sponsorship of any kind (providedtheir value is assessed to be worth at least £25), whether refused oraccepted, must be entered in a register and held in Reception. Staff will bereminded annually of this requirement.

5.6 Declarations are verified by the Centre Fraud and Security Management

Service. Withholding or providing false information may result in action underthe Disciplinary policy of the South West Strategic Health Authority andcriminal or civil proceedings.

6. Private transactions

6.1 Staff having official dealings with contractors and other suppliers of goods orservices should avoid transacting any kind of private business with them byany means other than through normal commercial channels. No favour orpreference as regards price or otherwise which is not generally availableshould be sought or accepted.

7. Interest in contracts

7.1 If it comes to the attention of any employee that the South West StrategicHealth Authority has, or intends to, enter into a contract in which they have afinancial interest, other than where the employee is known to be part of thecontract, then the employee must declare that interest in writing to the ChiefExecutive.

7.2 In the case of married persons, or persons living together as though married,the interest of one partner shall, be deemed to also be the interest of the

other.



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8. Candidates for appointment

8.1 Candidates for any appointment with the South West Strategic HealthAuthority shall, when applying, disclose in writing if they are related to anyDirector or employee of the South West Strategic Health Authority. Failure to

disclose such a relationship may disqualify or, if appointed, make the personliable for disciplinary action, including dismissal.

8.2 A member of an appointment panel which is to consider the employment of aperson to whom they are related must declare the relationship before aninterview is held.

8.3 Relationships to which these rules apply are those of immediate family of theemployee, or partner, as defined in the South West Strategic Health AuthorityStanding Orders.

9. Canvassing for appointments

9.1 Canvassing of Directors of the South West Strategic Health Authority, or anymembers of an appointments committee, either directly or indirectly, shalldisqualify a candidate. Any employee of the South West Strategic HealthAuthority shall not solicit for any person an appointment with the South WestStrategic Health Authority. This shall not preclude an employee from giving awritten reference or testimonial of a candidate's ability, experience orcharacter for submission to an appointments panel.

10. Guide for staff

10.1 Staff who are unsure of the guidelines should obtain a copy of the Standardsof Conduct, which were attached to HSG(93)5, and Section 8 of the SouthWest Strategic Health Authority Standing Orders and/or consult with anappropriate manager. It is the responsibility of each member of staff toensure that the Standards and/or Standing Orders are complied with both inthe letter and the spirit of ensuring that the conduct of staff in the NHS is notonly scrupulously impartial and honest but also beyond the reach of suspicion.

11. Guide for managers

11.1 It will be the responsibility of the Human Resources team to ensure that thisdocument, together with a copy of the South West Strategic Health AuthorityStanding Orders, Reservation and Delegation of Powers and StandingFinancial Instructions are issued to new employees.

11.2 Individual South West Strategic Health Authority directors will be responsiblefor ensuring that employees sign and return a form to the Human Resourcesteam in order to confirm their acknowledgement and understanding of thedocuments referred to in paragraph 10.1 above.



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12.1 Intended outcomes of this policy are:

• all employees are impartial and honest in the conduct of their business;

• the South West Strategic Health Authority is seen as impartial andhonest by employees, other organisations and the public;

• all new employees will have been issued with a copy of this policyalong with the South West Strategic Health Authority Standing Orders,Reservation and Delegation of Powers and Standing FinancialInstructions.






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Appendix 12

Lease Car Policy

This appendix sets out the revised Lease Car Policyfor the South West Strategic Health Authority.





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Lease Car Policy

1. Purpose

1.1 The purpose of the South West Strategic Health Authority in making leasecars available is:

• to ensure that those who need to travel on official business can do soefficiently and economically;

• to provide such transport at a cost which is commensurate with thefinancial and employment aims of the South West Strategic HealthAuthority.


2. Eligibility

2.1 Any regular car user may, with the approval of the relevant Director, beallocated a lease car. A regular car user is one who is required by the SouthWest Strategic Health Authority to travel on NHS business:

• an average of more than 3,500 miles a year;

• an average of at least 1,250 miles a year and:

* to need to use a car an average of three days a week;

* to spend an average of at least half their time on visits;

• an average of at least 1,000 miles a year and to spend an average ofat least four days a week on visits.

2.2 A lease car may also, with the approval of the relevant Director, be allocatedto any car user who, in the opinion of that Director, has a business need to bemobile, even though not necessarily qualifying as a regular user.

2.3 No leased vehicle will be allocated for the use of an employee who has notheld a full driving licence for at least twelve months.

2.4 The South West Strategic Health Authority reserves the right to refuse an

application for a lease vehicle for objective business reasons. The reasonsfor refusal will be explained to the employee and be relevant to the aboveguidance.



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3. Provision of a lease car

3.1 The day to day administration of the lease car scheme is outsourced toPlymouth Finance Shared Services. References to tasks performed by aScheme Manager within this policy refer to the tasks outsourced to Plymouth

Finance Shared Services.

3.2 Applications for a lease car should be addressed to the Human Resourcesteam on the appropriate form and should include:

• an estimate of business and private mileage over the next three years;

• the appropriate benchmark vehicle (Table 1);

• details of vehicles the employee would like quotes on, maximum ofthree.

Forms are available on the intranet.

3.3 Applications require the approval of the Director to whom the employee isresponsible, who should certify that the employee meets the criteria set out inSection 2 above and that the estimate of business mileage appearsreasonable.

3.4 An employee allocated a lease car may choose any vehicle that is suitable forthe performance of their duties. Cars will normally be provided on three-yearleases, but in certain circumstances (such as impending retirement, or a

particularly high or low estimated level of annual mileage) the South WestStrategic Health Authority may consider that a shorter or longer lease isappropriate.

3.5 However, the South West Strategic Health Authority will not order lease carsabove a band F, CO2 emissions (see Appendix 1). The level of CO2emissions will be reviewed annually to ensure that we meet our obligation toreduce carbon emissions.

3.6 Lease Contracts are entered into by the South West Strategic HealthAuthority using the Pan-Government Lease of Cars Framework negotiated by

NHS Buying Solutions. The Scheme Manager will obtain competitivequotations for the contract hire of up to three different vehicle specificationsrequested, including any extras, on the basis of monthly rental paymentsusing the Pan-Government Lease of Cars Framework. Rentals will includeRoad Fund Licence, breakdown cover and the costs of maintenance(including servicing and the replacement of tyres where the need results fromfair wear and tear) during the lease period.

4. Benchmark cars

4.1 An employee of the South West Strategic Health Authority is eligible for a

benchmark car based on their position within the organisation.

4.2 Benchmark cars will be kept under review by the Scheme Manager.



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4.3 The following table sets out for illustrative purposes the suggested cars foreach banding:

Table 1: Benchmark cars

Chief Executive, Deputy Chief Executive

Audi A4 2000 SE

Directors and Senior Managers onAgenda for Change at pay band 9

Ford Mondeo 2.0 Edge, 5 doorhatch

Senior Managers on Agenda for Changeat pay band 8A, 8B, 8C and 8D

Ford Focus 1.8 litre Style, 5 doorhatch

All other staff on Agenda for Change atpay band 7 and below. Ford Fiesta 1.4 Style Climate, 5door hatch

4.4 Employees may, however, choose any reasonable vehicle, paying regard topublic perception and the image of the South West Strategic Health Authorityas a publicly funded organisation.

4.5 Employees choosing to lease a more expensive car than the allocatedbenchmark car will pay the whole extra cost over the duration of the contract.

5. Contributions5.1 The South West Strategic Health Authority will meet the cost of the first 6,000

miles of the lease, or the amount of business mileage if that is greater. Anemployee will pay the difference between the 6,000 mile lease cost (or thegreater business mileage) and the total cost of the lease for the combinedbusiness and private mileage.

5.2 The South West Strategic Health Authority will also pay 80% of the insurancecosts.

5.3 An employee will meet the cost of:

• the balance of the lease costs over the 6,000 miles (or the greaterbusiness mileage);

• all the additional costs if a more expensive car is selected;

• a charge to cover private use insurance (this is calculated at 20% ofthe insurance premium);

• an administration charge.

5.4 Where an employee requires a car with special features (such as automatictransmission) because of a disability, the additional cost will be borne by theSouth West Strategic Health Authority.



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5.5 Employee contributions, including VAT, will be paid monthly throughdeductions from salary over the life of the lease. The full amount of anycontribution by the employee, including VAT, will be treated as a contributionto the cost of private motoring.

5.6 In the event of the employee leaving the employment of the South WestStrategic Health Authority, the Strategic Health Authority is empowered todeduct from salary or other payment due to the employee any sumsremaining outstanding under the agreement.

6. Review of contributions

6.1 An employee is required to keep records of their official mileage. At eachanniversary of the lease the Scheme Manager will request a mileage readingwhen providing a new road fund licence. From records of official mileageclaimed and the mileage reading provided the Scheme Manager will carry out

a review of contributions. Should actual mileage over the life of the leaseexceed that originally estimated, any excess charge payable will be met:

• by the South West Strategic Health Authority if business mileage isabove estimate and private mileage equal to or below estimate;

• by the employee if private mileage is above estimate and businessmileage equal to or below estimate;

• by the South West Strategic Health Authority and the employee prorata the respective additional business and private mileages if both

business and private mileages are above estimate.

6.2 Excess charges payable by an employee will be recovered throughadjustment of monthly contributions where possible or otherwise at the end ofthe lease. Adjustments to the lease can only be made during the first twoyears of the lease.

6.3 At the end of a lease an employee may also be required to pay any additionalcharge imposed in respect of unrepaired damage to the vehicle going beyondreasonable wear and tear (and not recoverable from insurers) or cleaningcosts if the vehicle is not returned in a satisfactory condition.

6.4 The personal contributions payable by an employee will be adjusted from timeto time to reflect changes in the premiums for insurance, Road Fund Licenceand administration charge.

6.5 The South West Strategic Health Authority also reserves the right to rechargean employee any additional costs which cannot be recovered throughinsurance, such as the replacement of damaged aerials, door mirrors or(where not solely due to fair wear and tear) tyres.

7. Mileage allowances

7.1 Fuel costs for official mileage will be reimbursed at a rate set by the SouthWest Strategic Health Authority.



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7.2 The current business mileage reimbursement rate is 15p per mile. This rateapplies to all lease cars regardless of the model or type.

7.3 Mileage allowances will be reviewed annually.

7.4 The review of the mileage allowance will be undertaken by the South WestStrategic Health Authority and will be notified to the Scheme Manager.

8. Insurance

8.1 The South West Strategic Health Authority will maintain comprehensive fleetinsurance cover for all vehicles within the scheme.

8.2 Motor policy premiums are reviewed annually by the insurer and are subjectto market forces. Any changes to the terms of insurance, premiums or excesspayable, will be notified to affected drivers and appropriate adjustments made

to the employees monthly deductions. All drivers of lease cars must haveheld a full UK licence or EEC category B driver’s licence or equivalent for atleast twelve months.

8.3 Drivers under the age of 25 years are subject to special terms with regards toinsurance excess, details are given in paragraph 8.4. Drivers under the ageof 25 years are considered to be ‘young drivers’ under the terms of our motorpolicy and will be subject to a higher policy excess. Cover for ‘young drivers’must be agreed in writing by our insurer prior to them commencing driving.The insurer’s decision is final.

8.4 Any excess payable in the event of an accident resulting from business usewhich is not recoverable from a third party will be treated in the following way:

• one accident in the year: the South West Strategic Health Authority willpay the excess;

• two accidents in the same year: excess payment shared 50:50between the South West Strategic Health Authority and the employee;

• three accidents in the same year: employee pays excess payment intotal.

8.5 Excess payments are as follows:

• if the driver is aged 25 or over and has held a full licence for twelvemonths: £100;

• if the driver is aged 25 or over and has held a full licence for less than12 months: £250;

• if the driver is aged 18 to 24: £350.

8.6 Any excess payable in the event of an accident resulting from private use ofthe car which is not recoverable from a third party will be the responsibility ofthe person to whom the car has been allocated.



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8.7 With the exception of excess mileage payments, travel to and from work isclassed as ‘normal commuting’ and is not official business mileage.

8.8 The South West Strategic Health Authority reserves the right to pass on anyother excesses or to vary the levels of excess payable by an employee.

9. Termination of lease

9.1 The contract between the South West Strategic Health Authority and theemployee will be terminated at the expense of the South West StrategicHealth Authority in the following circumstances:

• on the death of the employee;

• on termination of employment by the South West Strategic HealthAuthority;

• on retirement to pension (including ill-health);

• on grounds of health and safety;

• in the event of prolonged absence of the employee, where the period isin excess of four months;

• if a South West Strategic Health Authority initiated change ofemployment affects the entitlement of the user to a lease vehicle;

•

if the contract between the South West Strategic Health Authority andthe lease company is terminated due to any of the conditions in thelease contract.

9.2 The contract between the South West Strategic Health Authority and theemployee will be terminated at the expense of the employee in the followingcircumstances:

• termination of employment by the employee;

• breach of any of the lease contract conditions by the employee;

• when the contributions of the employee cannot be recovered from theirsalary;

• if the user becomes disqualified from holding, or for any reason ceasesto hold, a valid licence entitling them to drive a car.



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10. Replacement vehicle

10.1 Fleet insurance arrangements include provision of a replacement vehiclewhen a lease car is not roadworthy following an accident and while damage isbeing repaired. An employee should make their own arrangements for

replacement vehicles to cover routine servicing. The Scheme Manager canmake arrangements to hire replacement vehicles when required, but any hirecharges will normally be charged to the employee.

11. Employee obligations

11.1 An employee shall notify the Scheme Manager promptly of any faults in thecar allocated which are apparent on delivery and of any defects or symptomsof defects that are not rectified in the course of routine servicing.

11.2 An employee shall:

• send a photocopy of their driving licence, and a photocopy of all thenamed drivers driving licences, to their line manager on an annualbasis;

• ensure that routine servicing and maintenance are carried out at theintervals recommended by the manufacturers;

• at regular intervals check and maintain the oil, water, battery and brakefluid levels and tyre pressure and tyre conditions;

• take all reasonable precautions against frost damage and ensure thatantifreeze in the engine coolant system is of adequate strength;

• keep the car clean and presentable at all times;

• obey all regulations as applicable to the vehicle or use or possession,and exercise all reasonable care to keep the vehicle in good condition,both mechanically and otherwise, and avoid loss or damage to thevehicle whether on the road or not;

• pay the South West Strategic Health Authority any amounts due under

the agreement.

11.3 A female employee who has a lease car, and becomes pregnant shall notifytheir line manager as soon as reasonably practicable so that a health andsafety assessment can be undertaken.

11.4 No car may be modified or altered, or any parts removed or identification marknumbers changed. The Scheme Manager, or any person authorised by theSouth West Strategic Health Authority, will have the right to inspect the car atany time.

11.5 An employee will be responsible for all parking and other fines incurred duringthe period of the lease. Any charges imposed for handling unpaid fines will bepassed on to the employee to whom the car is allocated.



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11.6 Lease cars must be available for official use at all times (other than in theevent of accident or breakdown). A lease car must be used in preference to aprivately owned car on all official business, particularly where two or moreemployees travel together.

11.7 All employees wishing to take the lease vehicle abroad must give two weeksnotice to the Leasing Company who will arrange the necessary authority. Anyadditional costs will be borne by the employee.

11.8 When the vehicle is involved in any accident or damaged, then LinkfieldAccident Management must be contacted immediately via their 24 hourAccident Management Service.

12. Application process

12.1 An employee who wishes to apply for a lease car needs to discuss the matter

with their line manager and/or Director. If their line manager/Director agreesin principle to a lease car, form F4/1 (available on the intranet) should becompleted. The completion of form F4/1 does not commit either party to alease car.

12.2 On completion of form F4/1, the Human Resources team for the South WestStrategic Health Authority will forward the form to the Scheme Manager. TheScheme manager will send the employee quotations on three vehicles.

12.3 Once a lease car has been chosen, form F4/2 is to be completed. Form F4/2authorises an employee to receive a lease car and an order for the selected

vehicle to be placed by the Scheme Manager.

13. Delivery of lease car

13.1 A delivery schedule is unique for each vehicle.

13.2 All lease cars will be delivered to South West Strategic Health Authority,South West House, Blackbrook Park Avenue, Taunton, TA1 2PX. TheHuman Resources team will conduct a handover of the vehicle for eachemployee at which point any visible defects will be identified.

13.3 An information pack giving instructions about what to do regarding servicing,breakdown or in event of an accident will be provided with the car. Thisinformation pack should be kept with the car at all times.

14. Mobile phones, alcohol and drugs misuse and smoking

14.1 The South West Strategic Health Authority has policies with regard to the useof mobile phones, the consumption of alcohol, drugs and not smoking in leasecars. Employees should refer to policies:

• Mobile Phone policy;

• Health and Wellbeing policy.



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15. Further information

15.1 For further information on lease cars please contact the Human Resourcesteam.



• all employees will have been treated fairly and consistently whenapplying for lease cars;


• all employees have a clear understanding of their responsibilities when

approving an application for a lease car or leasing a car.






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Appendix 1Examples of CO2 emissions and tax bandings.

For further examples please see: CO2 emissions on other makes of cars please goto: Direct Gov, Act on CO2, on the move/what car.

http://campaigns.direct.gov.uk/actonco2/home/on-the-move/top-10-fuel-efficient-cars.html

Petrol Cars

Rank Make Model EditionGearbox

Fuel

TaxBand /CostP/A

CO2 (g/km)

1 TOYOTA Aygo

1.0 VVT-i 3 &

5 door M Petrol B/ £35 108

1 CITROEN C11.0i 3 & 5door

M Petrol B/ £35 108

2 PEUGEOT 107 1.0 (68 bhp) M Petrol B/ £35 1093 DAIHATSU Charade L251 1.0L EFi M Petrol B/ £35 1144 KIA Picanto 1.0 M Petrol B/ £35 1175 SUBARU Justy 1.0R M Petrol B/ £35 118

5 KIA Picanto1.1 (14"wheels)


5 DAIHATSU SirionM300 1.0L

EFi


6 CHEVROLET Matiz0.8 S 5 doorHatchback


6 HYUNDAI i101.1l SOHC(13" & 14"wheels)


6 FIAT 500 1.2 M Petrol B/ £35 1196 HYUNDAI i10 1.2l SOHC M Petrol B/ £35 119

Diesel Cars


Fuel

TaxBand /CostP/A

CO2 (g/km)

1 VOLKSWAGENPolo 3 / 5 Door

1.4 TDI (80PS)BLUEMOTION with DPF

M Diesel A/ £0 99

1 SEAT Ibiza1.4 TDI80PSEcomotion

M Diesel A/ £0 99



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Fuel

TaxBand /CostP/A

CO2 (g/km)

2 MINI MINIHatchback R56

MINI Cooper

D Hatchback- withparticle filter

M Diesel B/ £35 104

3 SKODANewFabia

1.4 TDI80PS Green-Line withDPF


3 SKODANewFabiaEstate

1.4 TDI PD80PS Green-Line withDPF


3 CITROEN C1 1.4HDi M Diesel B/ £35 109

MINIMINIClubmanR55

MINI CooperD Clubman -with particlefilter


4 FIAT 5001.3 16vMultiJet


4 FORD

NewFiesta,2009

ModelYearOnwards

1.4 Duratorq

TDCi (68PS)


4 FORD

NewFiesta,2009ModelYearOnwards

1.6 DuratorqTDCi (90PS)




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Appendix 13

Leave Entitlement Policy

This appendix sets out the revised Leave EntitlementPolicy for the South West Strategic Health Authority.





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Leave Entitlement Policy

1. Introduction

1.1 The south west strategic health authority is committed to ensuring that allemployees receive their full entitlement in the following:

• Annual leave;

• Civic and Public Duties leave;

• Jury and Witness Service leave;

• Reserve Forces leave.

1.2 Taking adequate and appropriate leave supports the south west strategichealth authority in achieving its ambitions for staff wellbeing as well asmeeting the commitments under the working time directive.

1.3 The leave entitlement policy also supports the aims of the health andwellbeing policy.

1.4 For career breaks see the Family Friendly policy.

2. Annual leave

2.1 The annual leave year for the South West Strategic Health Authorityemployees runs from 1 April to 31 March in any year.

2.2 Annual leave requests must be discussed at least two weeks in advance, withthe employee’s line manager. On agreement, the line manager will recordand authorise the annual leave on the annual leave card prior to the annualleave being taken.

2.3 Any enquiries with regard to annual leave must be discussed with your linemanager who, in turn, may contact the Human Resources team for advice.

Entitlement

2.4 Entitlements to annual leave are set out in Annex 1.

2.5 Generally, public holidays include bank holidays, holidays by RoyalProclamation and “common law holidays”. When public holidays in theChristmas and New Year period fall on a weekend, alternative week days aredeclared as Public Holidays.

2.6 The eight statutory bank holidays in the year are:

• Christmas Day;



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• Boxing Day;

• New Years Day;

• Good Friday;

• Easter Monday;

• May Day;

• Spring Bank Holiday;

• August Bank Holiday.

2.7 Employees who wish to calculate their annual leave entitlement in hours cando so using the ready reckoner in Annex 2.

2.8 An employee, who joins the South West Strategic Health Authority part waythrough the annual leave year, will have their annual leave entitlement basedon the period from the end of their first month of employment until the annualleave year ends. This will be calculated pro rata for the entitlement for a fullyear.

2.9 An employee who becomes eligible for an increase in annual leaveentitlement due to the completion of either five or ten years service, willreceive that entitlement pro rata from the end of the month they becomeeligible to the end of the annual leave year. (see Annex 2)

2.10 Employees are encouraged to take two consecutive weeks annual leaveduring each annual leave year. In peak holiday periods for exampleChristmas and June to September it may not be possible to grant requests fortwo consecutive weeks leave.

2.11 Employees may request annual leave in excess of two and up to a maximumof four consecutive weeks and/or unpaid leave to run consecutively as anagreed long holiday. The employee’s line manager will consider theserequests and seek to balance the needs of the individual employee with thoseof the South West Strategic Health Authority.

2.12 Employees who are required to work on a Public Holiday will be entitled toequivalent time to be taken off in lieu at a date agreed by their line managerand recorded on the annual leave card.

2.13 Public Holiday will be paid at plain time rates in addition to the appropriatepayment for the duties undertaken on the Public Holiday.

2.14 Employees who work part time are entitled to paid public holidays. Theentitlement is based on that of a full time worker and adjusted to reflect thehours worked by the part time employee. Entitlement is rounded up to thenearest hour.



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2.15 The paid entitlement to public holidays for part time employees forms part oftheir annual leave entitlement. As a result, any public holidays that fall ontheir normal working days must be booked as annual leave if they are notrequired to work.

2.16 Payment received during annual leave is calculated on the basis of what theemployee would have earned had they been at work. It includes:

• supplements that form part of your regular pay;

• recruitment and retention premia;

• payments for work outside of normal hours;

• high cost area supplements.

2.17 An employee who takes a period of annual leave without authorisation will beconsidered by the South West Strategic Health Authority to have had a periodof unauthorised absence, which would usually be unpaid and may constitutemisconduct (which will be managed through the Disciplinary procedure).

Responsibilities of Employees


• ensure that their annual leave is planned and taken at regular intervalsthroughout the year;

• request annual leave as specified in 2.2 above;

• make every effort to reach agreement with their line manager withregard to annual leave but, in the event of a dispute, to follow thegrievance procedure.

Responsibilities of Employers

2.19 The responsibilities of the employers include the need to:

• ensure that the Leave Entitlement policy is applied fairly to all;

• ensure that all employees are aware of the procedure for requestingannual leave and their own entitlement;

• keep accurate annual leave records of all employees for monitoringpurposes;

• ensure that employees take adequate and appropriate time away fromtheir duties to allow for rest and recreation.

• respect cultural and religious beliefs, as far as possible when managing

annual leave requests.



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• ensure that employees with caring responsibilities are notdisadvantaged, as far as possible when managing annual requests.

Carry over of leave

2.20 Employees may be permitted to carry over up to one week’s annual leaveentitlement to the next annual leave year. Any such request will beconsidered by their line manager and granted if it meets the needs of both theSouth West Strategic Health Authority and the individual employee. Theentitlement to be carried over will be recorded on the annual leave cards forboth years.

2.21 In exceptional circumstances, it may be possible to carry more than oneweek’s annual leave over to the next annual leave year. If a request isapproved by the relevant director, the leave should be taken as soon as isreasonably practicable to ensure that the right balance is achieved between

rest and work. The entitlement to be carried over will be recorded on theannual leave cards for both years.

2.22 Any request to carry leave over must be discussed with the employee’s linemanager prior to 1 February in each annual leave year in order to allow timefor the remaining leave to be taken should it not be possible to grantpermission to carry the leave over.

2.23 An employee who is absent from work during an annual leave year due tostatutory maternity leave, paternity leave, parental leave or adoption/ surrogacy leave period will be subject to special conditions. These conditions

will be outlined by their line manager on commencement of their leave periodand any adjustments to their annual leave entitlement recorded on theirannual leave card.

Sickness absence during annual leave

2.24 An employee who is absent due to sickness immediately prior to or during aperiod of annual leave may request that their leave be treated as sicknessabsence and their annual entitlement reinstated.

2.25 An employee must report their sickness in line with the Absence Management

policy, as stated below:

• on the first day of absence the employee should notify the nominatedperson, in accordance with the reporting sickness absencearrangements. They should give the reason for the absence and in thecase of sickness, the date that they first became ill (includingSaturdays, Sundays and holidays) and the likely duration of absence.The nominated person must record that sickness has been reported bycompleting the Sickness Absence Notification form and forward it to theHuman Resources team.

2.26 In order for the line manager to consider such a request, the employee will berequired to provide supporting evidence in the form of a medical certificate tocover this period.



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Unpaid leave

2.27 An employee may request unpaid leave for the purposes of, for example, anextended holiday, sabbatical and further training. In this instance, unpaidleave of up to one week may be granted over and above the annual leave

entitlement. If the request is for more than one week, an employee is requiredto use their annual leave entitlement for the remaining period.

2.28 Information and guidance on unpaid leave due to maternity, paternity,parental leave and adoption/surrogacy can be found in the Family Friendlypolicy.

2.29 Line managers are required to inform the Human Resources team in writing ofany unpaid leave that is granted and to record the unpaid leave on the annualleave card. The Human Resources team will inform Payroll so that thenecessary adjustments to pay can be made.

3. Civic and Public Duties leave

Introduction

3.1 Under the Employment Rights Act 1996, employers are required to permitemployees who hold certain public positions reasonable time off to performtheir duties. Those who are eligible are:

• Justices of the Peace;

• members of local authorities;

• members of statutory tribunals;

• members of police authorities;

• members of a board of prison visitors or a prison visiting committees;

• members of a relevant health body, such as NHS Foundation Trusts’Board of Governors;

•

members of a relevant education body including school governors;

• members of the service authority for the National Criminal IntelligenceService;

• members of the General Teaching Councils for England and Wales;

• members of the Environment Agency.

3.2 Duties that are covered are:

• attendance at meetings of the body or any of its committees or sub-committees;



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• the performance of the duties approved by the body, the purpose ofwhich is the discharge of the functions of the body in question or any ofits committees or sub-committees.

3.3 In deciding what is reasonable time off, the manager should take into

consideration the following aspects:

• the time required to perform these duties;

• the amount of time already taken off for these duties;

• the circumstances within the specific department of the South WestStrategic Health Authority from which the employee comes and theeffect of the absence of the employee.

3.4 There is no requirement for the leave to be paid, however the South West

Strategic Health Authority will grant up to six days paid leave per annum if theemployee has at least one year of continuous service in the South WestStrategic Health Authority. Further periods of unpaid leave may be granted atthe discretion of the manager.

3.5 Pay will be constituted as basic earnings during a normal working weekincluding performance bonus payments and excluding overtime.

3.6 An application for Civic and Public Duties Leave should be made by theindividual concerned in writing to their manager at least two months beforeeach occasion. Such leave must be approved by the manager and authorised

by the Head of Human Resources.

3.7 Any employee holding additional positions, such as those listed in paragraph3.1, should refer to the Secondary Employment policy and declare in writing tothe Chief Executive of the South West Strategic Health Authority any possibleconflict of interest.

4. Jury and Witness Service leave

Introduction

4.1 Under the provisions of the Juries Act 1974, men and women between theages of 18 and 70 may be summoned to attend for jury service in the CrownCourt, the High Court, a Coroner’s Court or the County Court, subject tocertain limited exceptions and disqualifications.

Exemptions

4.2 A person can only be excused or exempted if they have a mental illness, acriminal conviction, insufficient command of the English language, certaincare responsibilities or religious beliefs or other ‘compelling’ reasons for beingunable to sit in the twelve months from being summoned; they can defer jury

duty on the grounds of death or illness of a close relative, a pre- bookedholiday, religious festivals or essential military service.



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4.3 The previous list of people entitled to be excused from such service, amongstthem doctors, ceased to have effect following the passing of the CriminalJustice Act 2003.

Avoidance

4.4 It is not normally possible for either an employee or the employer to avoid asummons to attend court as a juror. However, if it can be shown that there isa ‘good reason’ why it is not appropriate for them to attend then jury servicecan be deferred.

4.5 An employee may argue that a prolonged absence from work may mean thatthe work of the South West Strategic Health Authority would suffer, whichwould be detrimental to the public interest. The final decision rests with the judge.

Time off arrangements

4.6 The South West Strategic Health Authority will grant paid leave at normalsalary for staff called for jury service regardless of the length of time the juryservice is for.

4.7 A juror is usually called for two weeks or ten days, but if the trial exceeds tenworking days, the juror is required to remain until the trial finishes.

5. Reserve Forces policy

Introduction

5.1 The Reserve Forces Act 1996 allows the compulsory mobilisation ofreservists for military operations. There is protection for employers of keypersonnel including exemptions and deferrals.

5.2 Members of the Armed Forces Reserves include the Royal Navy Reserve,Royal Marines Reserve, Territorial Army and Reserve Air Forces.

5.3 For attending annual camp the South West Strategic Health Authority willallow two weeks leave, one week will be paid, the other will either be unpaid

or taken from the annual leave entitlement of the employee.5.4 Application for Reserve Forces Leave should be made by the individual

concerned in writing to their manager at least two months before eachoccasion. Such leave must be approved by the manager and reported to theHead of Human Resources.



• all employees will have been treated fairly and consistently whenrequesting leave;



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• all employees have a clear understanding of the roles andresponsibilities for line managers and themselves in the booking and

management of annual leave and unpaid leave.






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Annex 1

Annual leave tables

Agenda for change

Length of Service inyears

Annual Leave (in days) General PublicHolidays (in days)

On appointment 27 8After five years service 29 8After ten years service 33 8

Very Senior Managers

Length of Service inyears

Annual Leave (in days) General PublicHolidays (in days)

On appointment 27 8After five years service 29 8After ten years service 33 8

Medical and Dental

As per the individual terms and conditions of service as found on NHS Employerswebsite.

http://www.nhsemployers.org/PAYANDCONTRACTS/Pages/Pay-and-contracts.aspx



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Annex 2South West Strategic Health Authority

Agenda for Change annual leave entitlement for complete yearsinclusive of Bank Holidays

Weekly BasicContracted Hours

On Appointment After 5 YearsService

After 10 YearsService

35 days 37 days 41 daysHours Equivalent:

37.5 263 278 30837.0 260 274 30436.5 256 271 30036.0 252 227 293

35.5 249 263 29235.0 245 259 28734.5 242 226 28334.0 238 252 27933.5 235 248 27533.0 231 245 27132.5 228 241 26732.0 224 237 26331.5 221 234 25931.0 217 230 255

30.5 214 226 25130.0 210 222 24629.5 207 219 24229.0 203 215 23828.5 200 211 23428.0 196 208 23027.5 193 204 22627.0 189 200 22226.5 186 197 21826.0 182 193 21425.5 179 189 210

25.0 175 185 20524.5 172 182 20224.0 168 178 19723.5 165 174 19323.0 161 171 18922.5 158 167 18522.0 154 163 18121.5 151 160 17721.0 147 156 17320.5 144 152 169

20.0 140 148 16419.5 137 145 160



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Weekly BasicContracted Hours

On Appointment After 5 YearsService

After 10 YearsService

35 days 37 days 41 daysHours Equivalent:

19.0 133 141 156

18.5 130 137 15218.0 126 134 14817.5 123 130 14417.0 119 153 14016.5 116 123 13616.0 112 119 13215.5 109 115 12815.0 105 111 12314.5 102 108 11914.0 98 104 115

13.5 95 100 11113.0 91 97 10712.5 88 93 10312.0 84 89 9911.5 81 86 9511.0 77 82 9110.5 74 78 8710.0 70 74 829.5 67 71 789.0 63 67 748.5 60 63 708.0 56 60 667.5 53 56 627.0 49 52 586.5 46 49 546.0 42 45 505.5 39 41 465.0 35 37 414.5 32 34 374.0 28 30 333.5 25 26 29

3.0 21 23 252.5 18 19 212.0 14 15 171.5 11 12 131.0 7 8 90.5 4 4 5

Note: Formula Is Weekly Contracted Hours X No. Of Days Entitlements



Appendix 14

Mobile Phone Policy

This appendix sets out the revised Mobile PhonePolicy for the South West Strategic Health Authority.





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Mobile Phone Policy

1. Introduction

1.1 The South West Strategic Health Authority provides a mobile phone orBlackberry (hereafter both devices will be referred to as a “mobile phone”) toemployees who need to contact and be contactable while on Strategic HealthAuthority Business. This policy has been compiled to help ensure that SouthWest Strategic Health Authority employees use mobile phones safely,securely and in line with the law. The policy should be read in conjunction withDepartment of Health – Patient Power Review Group Use of Mobile Phones inHospitals and other NHS Premises available through the link below.

http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4138658

1.2 It is the responsibility of the Directors of the South West Strategic HealthAuthority to implement and administer this policy. However, it is theresponsibility of the users to comply with, and adhere to, this policy.

2. General

2.1 Where a mobile phone is provided to an employee this will include a voicemailfacility to ensure no calls are missed while employees are in appointments ordriving.

2.2 A mobile phone is provided for essential business and emergency calls.Personal calls made using a Strategic Health Authority mobile phone shouldbe avoided where possible. However, where employees do choose to makepersonal calls, users will be required to reimburse the cost of personal calls tothe Strategic Health Authority.

2.3 This will be done through a payroll deduction or directly invoiced to the staffmember dependent upon whether they are paid through the Strategic HealthAuthority payroll.

3. Issue and agreement

3.1 Any employee who requires the use of a mobile phone to support their workmust have authorisation from their Manager and Director before one can bepurchased. The authorisation form can be found on the intranet entitled‘Information Technology (IT) Set Up and Property Request Form’.

3.2 An Agreement for Acceptable Use of Mobile Phones must be signed by allemployees issued with a mobile phone which can be found on the intranet.This is the joint responsibility of the line manager and user. Failure to complywith the requirements of this policy may lead to disciplinary action beingtaken.



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3.3 Included in the Agreement for Acceptable Use of Mobile Phones, all mobilephone users will agree for private call charges to be recovered through payrolldeductions or separate billing. The private call charges recoverable will beinformed by an individual Call Details Statement, issued quarterly andcompleted by the user.

4. Camera phones

4.1 South West Strategic Health Authority business will not normally requireemployees to use cameras installed in mobile phones and employees areasked not to use this facility on business. Camera phones should be usedwith extreme care and should not be turned on in clinical environments orpatient areas (except in an emergency), to protect patient privacy and dignityand safeguard both the South West Strategic Health Authority and itsemployees from litigious claims. It is also a courtesy not to use mobilephones in these areas as it can be intrusive and impact adversely on the

therapeutic environment and some sensitive clinical equipment.

4.2 All employees in possession of a mobile phone, whether issued by theStrategic Health Authority, or a personal mobile should not capture anyimages of employees or patients on mobile phone devices. This appliesunless written permission by the third party has been granted for an image tobe captured.

5. Legislation

5.1 The Highway Code specifically warns drivers that they must be in proper

control of their vehicle at all times and strongly advises drivers not to usemobile phones whilst driving. Telephone conversations while driving, ifbusiness related, may be urgent, tense and provoke higher stress levels. Theconversation itself is the most distracting factor, meaning that hands free kitsare little safer than holding a mobile phone. Research has revealed thatdrivers talking on a mobile phone are four times as likely to crash comparedwith other drivers.

5.2 The South West Strategic Health Authority does not require employees toanswer mobile phones whilst they are driving.

5.3 Regulation 104 of the Vehicle Construction and Use Regulations indicatesthat drivers may face prosecution if they are not at all times in proper controlof their vehicle. This Regulation has already been used as the basis forprosecution by police officers nationwide.

5.4 If you use a mobile phone whilst driving, you may be charged with:

• failing to exercise proper control of a vehicle;

• careless and inconsiderate driving;

• dangerous driving.



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5.5 It is an offence to use a hand held mobile phone whilst driving. Prosecutionmay follow an offence of this nature. Such an offence could lead to a fixedpenalty, the awarding of penalty points and/or a fine.

5.6 It is not illegal to use a hands free mobile phone, however, the police may

prosecute if an incident should occur. Proof of use of a mobile phone isreadily available to the authorities.

5.7 The South West Strategic Health Authority has a legal duty of care underhealth and safety legislation to ensure the safety of their employees and ofanyone else who may be affected by their activities. This duty applies whenemployees are driving for work purposes, including travelling to meetings.

6. Employee obligations

6.1 Employees are required to make full use of the message (voicemail) facility

available and only make and receive calls whilst the vehicle is stationary, withthe engine switched off and it is completely safe to do so. Employees shouldnot make calls from petrol station forecourts.

6.2 Employees who personally choose to use a wireless hand free system areencouraged to use the most up to date equipment and, ideally, a voiceactivated system.

6.3 All employees have an obligation to comply with the law and any prosecutionunder any of the above legislation will be the full responsibility of the driver incharge of the vehicle. You should be in proper control of your vehicle at all

times.


7.1 The intended outcomes of this policy are:

• line managers and directors approve the issue of a mobile phone to anemployee;

• all users sign the Agreement for Acceptable Use of Mobile Phones;

•

all drivers issued with a mobile phone comply with the law and areaware of their responsibilities;

• all users only use camera phones where strictly necessary for businessuse and do not turn on camera phones in hospital units, aroundchildren or vulnerable people.


Policy approved: April 2010

Review by: April 2013



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Appendix 15

Organisational Change Policy

This appendix sets out the revised OrganisationalChange Policy for the South West Strategic HealthAuthority.





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Organisational Change Policy

1. Introduction

1.1 The purpose of this policy is to set out the key elements which should beapplied where there is a need for organisational change affecting theprovision of services and staff terms and conditions of employment.

1.2 Organisational change decisions and actions will be recorded and monitoredby the Human Resources team to ensure that the procedure is operated fairlyand consistently to all staff regardless of their sex/gender, sexual orientation,religion or religious beliefs, race, age, or disability. Where evidence ofinequality or an adverse effect is found the South West Strategic HealthAuthority will take appropriate action.

1.3 The policy aims to acknowledge that each situation may be different andrequire an individual approach.

1.4 Any change is a potential stressor and therefore the South West StrategicHealth Authority will ensure (so far as is practicable) that an assessment ofrisk is undertaken at the start of any organisational change programme. Allreasonable steps will be taken to reduce the risks to staff. It is recommendedthat the Stress Management section of the Health and Wellbeing policy of theSouth West Strategic Health Authority be considered in conjunction with thispolicy.

1.5 Nothing in this policy and subsequent procedure and guidelines has the effectof limiting or attempting to limit the statutory rights of employees or theirrepresentatives, or the statutory obligations on the South West StrategicHealth Authority as an employer.

1.6 The importance of a well thought out organisational change programme is keyto a successful implementation and the ongoing success of the South WestStrategic Health Authority.

1.7 If the outcome of the organisational change is likely to result in a reduction ofposts then Section 16 of the NHS Terms and Conditions Service Handbookand the Redeployment policy and procedure of the South West StrategicHealth Authority should be referred to, in conjunction with advice from asenior member of the Human Resources team.

1.8 This policy and procedure will apply when considering a transfer ofemployment under the Transfer of Undertakings (Protection of Earnings)Regulations 2006.



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2.1 The policy applies to all staff whose job content, hours, work base orconditions of service are affected by organisational change. Staffrepresentatives will be notified of affected staff.

2.2 This policy and procedure will not normally cover change of on-site work baseor changes in line management arrangements unless there is an impact onthe employee’s terms and conditions of service.


3.1 This policy and procedure applies in full to any proposed changes which areof a temporary nature but expected to last for four months or more. Fortemporary changes lasting less than four months, the principles of this policyshould still be considered as good management practice.

3.2 Early advice should be sought from the Human Resources team on theappropriateness and application of this policy and procedure.

3.3 This policy should be read in conjunction with:





• Pay Protection policy;

• Recruitment policy

• Redeployment policy;

• Staff Involvement and Internal Communications policy.

3.4 Planning and introduction of organisational change must involve staff andtheir representatives as set out in the Staff Involvement and InternalCommunications policy. Full and open communication with staff will takeplace throughout the process to facilitate meaningful consultation, allowingadequate time to consider responses and give feedback on the decisionstaken.

3.5 With all organisational change a Lead Manager will be identified who will takeresponsibility for leading and managing the change programme throughout allstages given in this policy. The Lead Manager will normally be a Director oran Associate Director.



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3.6 The Lead Manager will ensure that a risk assessment is carried out to identifyany potential risks of the organisational change programme to staff, and thatthis risks are acted upon so far as reasonably practicable.

3.7 The South West Strategic Health Authority will seek to maximise the

opportunities for existing staff to apply for posts within new structures, givingprior consideration to existing post holders (subject to fulfilling the essentialcriteria required) and thereby minimising the risk of redundancy.

3.8 Where staff can not be accommodated in new structures, the South WestStrategic Health Authority will seek to retain staff through the application ofthe Redeployment policy.

3.9 The South West Strategic Health Authority will ensure that new structures areimplemented with fairness, sensitivity and consistency. In managingorganisational change the Lead Manager must demonstrate consideration to

the following:

• the anxiety of staff and the need to retain staff commitment, continuityand stability;

• the requirements to achieve change effectively, in a timely way andwith the minimum disruption to the South West Strategic HealthAuthority business;

• the need to comply with employment legislation (Human Resourcesadvice must be obtained);

• ensuring new posts have an appropriate job description, personspecification that has been evaluated in line with the NHS JobEvaluation Handbook.

3.10 At all stages of organisational change the employee will have the right to beaccompanied at meetings by a Trade Union representative or work colleague(not acting in a legal capacity).

3.11 A Lead Manager has responsibility to ensure that appropriate support isavailable to employees who have particular requirements.

3.12 The South West Strategic Health Authority supports managers to makedecisions based upon the needs of the service. In doing this the views ofothers will be taken into consideration, so that any decisions taken are on aninformed basis. However it is important to recognise that not all views will beseen as appropriate by management and meaningful feedback will be given.

3.13 The Lead Manager will follow the Organisational Change procedure andGuidance set out in Annexes 1 and 2.



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4. Monitoring and review

4.1 It is the responsibility of the Human Resources team to:

• monitor and review this policy;

• consider the results of the Staff Survey and where appropriate endorseactions to update the management of organisational changeprocedures that have been identified from this;

• monitor organisational change in the South West Strategic HealthAuthority, to ensure compliance with this policy and actions that maybe appropriate beyond it.

5 Intended outcomes


• all employees will have been treated fairly and consistently andsupported during organisational change;


• all employees have a clear understanding of the roles andresponsibilities for line managers and themselves during theconsultation, and implementation of organisational change.






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Annex 1

Organisational Change Procedure

Flow chart summarising the organisational change process

Draw up a formal consultation paper for consultation.Following approval of the organisational change proposal, the Lead Manager writes aformal organisational change consultation paper (see template given in Annex 3) indiscussion with Human Resources and Staff Representatives. The formal paper willinclude an explanation as to why change is necessary, any options available, impact onstaff, set out the timetable for consultation and proposed implementation plan.

Formal Consultation paper is submitted for consultation.The finalised formal organisational change consultation paper is circulated to all partiesdirectly affected by the proposed organisational change.

Consultation process.The Lead Manager will formally brief staff of the change and answer any questions. Inaddition, individual meetings will be held with staff whose posts have been identified atrisk.

Staff must provide written feedback by the end of the consultation period.

The Lead Manager will:• give serious consideration to the feedback to develop a final organisational

change paper and implementation timetable;

• provide written response to the feedback;• issue the final organisational change paper, brief staff, and arrange individual

meetings with staff whose posts have been identified at risk.

Implementation process.

Any new job descriptions will be submitted for evaluation in line with the NHS JobEvaluation Handbook.

The Redeployment Policy will be followed for staff whose posts have been identified asbeing at risk.



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275

Annex 2

Organisational procedure and guidance for managers

1. Identify the case for change and obtain appropriate

authorisation to proceed

1.1 Managers should determine what they are aiming to achieve and whetherorganisational change is the most appropriate process, for example would acollective agreement be more appropriate. In determining this, managersmay wish to discuss with staff representative and their Human Resourcesteam. At this point any proposals would need to be agreed and signed off at asenior level within the organisation, such as Senior Management Team andthe Management Board.

1.2 A clear business rationale will be provided for any proposed organisational

change. The business rationale should reflect the potential risks on otherDirectorates, departments and staff not directly affected by the change, andwhere necessary these aspects should be reflected in the formal consultationprocess.

Lead manager and their responsibilities

1.3 A Lead Manager will normally be a Director or Associate Director and isresponsible for:

• compliance with this policy;

• obtaining the necessary authorisation and sign off to proceed;

• briefing Senior Management, Human Resources and recognised staffrepresentatives on initial proposals;

• writing the initial draft consultation paper;

• leading on formal/informal briefing sessions with affected staff;

• carrying out a risk assessment;

• reducing the risks as far as possible;

• reviewing the risk assessments throughout the project to ensurecorrect actions are in place;

• updating the Senior Management Team and other formal meetings onactions taken around proposals;

• ensuring all those involved in the proposed changes are fully aware oftheir responsibilities;

• ensuring appropriate paperwork is completed;



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• ensuring the correct process is completed, in a fair and equitablemanner;

• managing the timeframes for which the change is completed within,this will include judging when the timeframe needs to be extended to

ensure a transparent and fair process to be followed;

• recording and monitoring all actions taken (briefing sessions, groupmeetings, for example) and ensuring adequate administrative support;

• ensuring all those supporting the change process are adequatelyequipped;

• identifying any relevant support needed for staff affected by thechange;

• maintaining up to date records/documents completed as part of thechange process;

• ensuring someone is available at all times to deal with questions orissues relating to the change, particularly with a presence at key stagesof the process;

• ensure Staff Occupational Health is informed of the proposed scope ofthe organisational change, to anticipate scale and likely demand ontheir services to ensure adequate support for those affected.

Support for staff

• the South West Strategic Health Authority does not underestimate theimpact that proposals and changes will have on members of staff.Lessons learnt from previous changes have been incorporated withinthis document, especially regarding communication and support tostaff;

• staff are entitled to support from their Trade Union representative,Occupational Health Department and Staff Counsellor, and the HumanResources team. One to one meetings will provide opportunities to

discuss any personal issues, preferences for redeploymentopportunities, and other options as appropriate;

• if individuals are required to re-apply for posts, consideration must begiven to providing support around preparation of a Curriculum Vitae(CV) and for interview and advice around providing referees;

• it may be appropriate to organise ‘Question and Answer’ sessions withstaff affected by the organisational change, this should be timetabled inat the start of the change process together with the names of thosewho will be in attendance. This should be done in partnership with staff

representatives;



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• all meetings and question and answer sessions will be minuted andcopies provided to all staff affected by the organisational change. TheLead Manager is responsible for providing staff the administrationsupport to carry this out.

• support is offered to staff in a number of different ways and will bedependent on each individual’s needs and requirements throughout theprocess. Formal and informal support is offered through the followingindividuals and departments:

* line manager and colleagues;

* Human Resources team;

* staff Occupational Health;

* pensions/payroll.

2. Preparation of a formal consultation paper setting outproposed changes

2.1 For all consultations, a formal paper must be prepared by the Lead Managersetting out the rationale for change and the options available;

2.2 The formal paper must be discussed/developed with staff representative andthe Human Resources team before formal consultation commences;

2.3 Once the formal paper is agreed by the above it should be circulated forformal consultation to all parties that are likely to be directly affected by theproposals.

Guidance for managers

2.4 It may be appropriate to carry out a situation analysis – an activity whichidentifies barriers, levers and facilitators for change – this is an important firststep in designing a change management strategy that will meet local needs;

2.5 A formal paper will need to set out all the options with their respective

advantages and disadvantages (strengths, weaknesses, opportunities andthreats analysis could be a useful tool, although it needs to be carefullyconsidered, and with the end in mind rather than as a process in its ownright);

2.6 There should be a formal risk assessment done on any planned proposals;

2.7 Proposals need to be written in plain English;

2.8 There will need to be sufficient time allowed for staff to consider and respondto the contents of the consultation paper;



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2.9 In line with legislation consultation periods should not be less than:

• 1 – 20 staff two weeks

• 21 – 99 staff four weeks

• 100+ staff twelve weeks

2.10 When calculating consultation periods managers should be mindful of staffwishing to involve their unions and the availability of this.

2.11 Where there are potential redundancies please see Section 16 of the NHSTerms and Conditions Service Handbook, which is available on the intranet orfrom Human Resources.

2.12 The consultation paper should invite comments, suggestions and feedback. It

should also ensure that the implications of the proposed change are clear,including a clear plan with timescales for consultation feedback, review of thefeedback, confirmation of the final proposals and proposed implementationplan.

3. Briefing of staff representatives and affected staff

3.1 The purpose of the briefing is to explain the proposals, content of the formalpaper and set out the plan and timescales for implementation with affectedstaff, including those on extended leave (such as maternity leave, careerbreaks).

Guidance for managers

3.2 It will be mutually beneficial for the Lead Manager to ensure that the JointManagement and Staff Committee is briefed on the proposals and theassociated timescales prior to any consultation paper being circulatedamongst affected staff. The purpose of this briefing will be to explain theproposals, the content of any consultation paper, and to set out the plan andtimescales for sharing this information with affected staff.

3.3 The next stage in the process will be to brief affected staff on the proposed

changes. The scale and format of this will be dependent upon the specificnature of the changes and the number of individuals affected. This may entailthe organisation of group and also individual meetings with staff, taking careto recognise the grapevine effect and thus avoiding this as much as possible.

3.4 Managers embarking upon a change process must also ensure that theymake contact with any staff that may be on extended leave, whether it is longterm sick leave, maternity leave secondment and career breaks.

3.5 Where staff in another department may be affected by the proposals thereshould also be communication with the staff and of the area concerned.

3.6 It is essential that proposals are communicated to staff clearly in plain English.



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4. Consult with affected staff

4.1 It is important to recognise the impact on individuals at this stage.

4.2 In consulting on change the Lead Manager is required to consider in an open-

minded way the feedback received on the proposals and to examine anyalternative suggestions.

4.3 It is recommended that the Lead Manager sets up a panel of suitablepersonnel (this may involve a staff representative and Human Resourcesrepresentative) to consider feedback and investigate suggestionsappropriately before decisions are made.

4.4 If in the light of the feedback, if the proposals are significantly amended, arevised consultation paper will be issued and a further consultation willcommence. The length of the second round of consultation should reflect the

degree of change from the original proposals, but will not be less than twoweeks.

4.5 At the end of the consultation process the Lead Manager should communicatethe decision made and the reasons for this, including an explanation of whyany other options put forward were not accepted – with if necessary a furthergroup meeting or one to one if appropriate.

4.6 It must be recognised that managers have the right to manage and makechanges, whilst not under estimating the effect that this can have on somemembers of staff.

4.7 At the end of the consultation the Lead Manager will communicate thedecision made and the reasons, including a brief explanation as to why anyoptions put forward that were not accepted were deemed unsuitable.

5. Implementation of change

5.1 The importance of a well thought out and communicated implementation planis key to a successful change programme.

5.2 Managers should seek to reach a consensus on the change proposals.

However, in the absence of this, formal notification of change will be issuedwith appropriate notice periods being given.

5.3 It is recommended that if changes affect large groups of individuals a date offour months hence is determined as the change of date to capture allindividuals.

5.4 If a decision has been agreed regarding the proposals, notice periods can bewaived by staff and it may be appropriate to agree a date of implementation,which should then become the effective date agreed by all.



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5.5 Following the consultation process there needs to be a clear implementationplan, which also needs to be communicated to affected staff setting outspecific changes. Staff should be offered one to one meetings with their linemanager to discuss the effects of the changes. Staff will be entitled torepresentation by a Trade Union or accompanied by a work colleague (not

acting in a legal capacity) at these discussions.

5.6 Every effort will be made to ensure appropriate training and support.Managers and staff will also need to consider the effect of the changes on anyexisting Personal Development Plans in light of the NHS Knowledge andSkills Framework.

5.7 Where teams are merging consideration should be given to the benefits ofteam coaching either before or during the implementation of any change.

6. Appointments

6.1 This section explains in detail eligibility for slotting-in, ring-fenced competitionand pay protection arrangements.

6.2 It is essential that the Lead Manager ensures that all posts have a detailed jobdescription and person specification prepared. These will include theessential skills, qualifications, experience and qualities required of the post-holder. All jobs will have undergone job evaluation and a properly constitutedpanel will have banded them.

7. Eligibility for posts

7.1 Substantive staff affected by the change programme are eligible to beconsidered for posts in the new structure through either slotting in or ring-fenced competition, (this includes those on fixed term contracts andtemporary contracts of more than twelve months). Staff on secondment oracting-up will be considered on the basis of their substantive post, not theirseconded/acting up role.

7.2 Eligibility for posts will be assessed by matching the content of the new poststo those in their present post.

Slotting in process

7.3 This process will be monitored by the Lead Manager with support fromHuman Resources. Any member of staff who feels that they have beenincorrectly excluded or included for consideration for any post has the right ofappeal through the South West Strategic Health Authority GrievanceProcedure – they should initially seek advice from their Trade Union orHuman Resources representative.

7.4 Where there is a single post in the new structure, the content of which issubstantially similar (at least 70%) to one in the old structure, the present

substantive and permanent incumbent will be the natural successor to thepost in the new structure.



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7.5 That person therefore, will be the sole initial candidate for the position andproviding that essential criteria contained in the person specification are met,that person should be slotted in.

7.6 Where there is a post or posts in the new structure which clearly result from

the merging of two or more posts form the old structure then the incumbentsof the old posts will be the initial candidates for the new post or posts. In thisinstance, ring-fenced competition may apply.

7.7 Where a person accepts slotting in either as a sole initial candidate or as aresult of a job merger, then they will not be eligible for ring-fenced competitionfor any other posts in the new structure. However they may apply for postsadvertised in open competition after the ring-fenced stage.

7.8 If the employee does not accept slotting in to a suitable post, the South WestStrategic Health Authority will not be obliged to offer further employment

opportunities and the individual will forfeit their right to any redundancypayment. Staff considering such a step will be urged to seek advice from theirTrade Union representative or Human Resources before rejecting any offersof employment.

How the Slotting in process works in practice

7.9 Slotting in is the very first process to attempt to appoint within a band, forexample, a band 7 post is filled by an employee currently on a band 7.

7.10 Slotting in is very appropriate where the number of suitable staff is equal to or

less than the number of posts available, if there are more suitable staff thenposts would go to ring-fenced competition.

7.11 To qualify for slotting in, there should be a match of at least 70% of the dutiesfrom the old to the new post as set out in the job description/personspecifications and known job content.

7.12 It is a management decision regarding individuals qualifying for slotting in. If astaff member is not happy with the decision, they must take Human Resourceand Trade Union advice to assist with addressing this.

7.13 Appointments to the new structure will be made by descending grade, level bylevel in the organisation structure. However, staff at risk will not beconsidered for posts in the next level of the structure until the first round ofslotting into that structure has been completed; individuals do notautomatically take a post at the next band down.

Ring fencing of posts in the new structure

7.14 Once slotting in arrangements have been completed ring-fenced competitiontakes place before the posts are opened to internal competition.

7.15 At this stage, all eligible employees will receive a letter detailing the postsavailable to them. The letter will include job descriptions and personspecifications for each of the relevant posts.



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7.16 It will also include details of how to apply, the closing date and the method ofselection. Job share applications will be considered for all posts.

7.17 If applicants are applying (other than in open competition) for more than onepost at any one phase there will be no need to complete multiple application

forms.

7.18 The Lead Manager will indicate whether a standard application form orshortened version is to be completed for all posts applied for, to beaccompanied by a letter from the applicant listing the posts for whichapplication is being made and, where appropriate, indicating an order ofpreference.

7.19 Application forms should demonstrate how the candidate meets the essentialcriteria for the post. One employment-related referee will need to be given;however they will only be contacted where external assessors are involved in

the appointment process.

7.20 All applicants will be considered for their preferences subject to them meetingthe essential requirements of the person specification for the post, and takingfurther training into consideration where appropriate.

7.21 In circumstances where there are more posts than applicants, selectioninterviews will be held.

7.22 Short-listed candidates will be given reasonable notice of the interview dateand every effort will be made to see all candidates on the same date or within

a reasonable time thereafter. Consideration will be given to those membersof staff who have flexible working patterns for which interviews may have tobe re-arranged.

7.23 The interview arrangements will take into account accessibility requirementsof candidates.

7.24 Selection panels will consist of at least two members, including the linemanager. External assessors may be used for some senior technical andprofessional posts.

7.25 Interviews will be co-ordinated to ensure that the interview process iscompleted as swiftly as possible without unnecessary duplication ofinterviews. Any member of staff who is interviewed is expected to maintainconfidentiality and not share the information, questions asked, and so on withany other candidates – a breach of this may result in any offer of employmentbeing withdrawn and potential disciplinary action.

7.26 The Chair of the selection panel will also ensure that the conduct of theinterview does not directly or indirectly discriminate against any individualcandidate.



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7.27 The Chair will record in writing the panel’s findings and the reasons for thedecisions reached on each candidate. All offers of posts will be confirmed inwriting by Human Resources when all interviews for that group of staff arecompleted.

7.28 Internal candidates who are unsuccessful at interview will be offered post-interview feedback and counselling by a designated manager. The timing ofthis feedback should be considered sensitively.

How ring fenced competition works in practice

7.29 Once slotting in arrangements have been confirmed then ring fencedcompetition will take place for staff identified as being at risk, before the postsare opened to internal competition. This may include staff at risk in lower paybands being eligible to apply for a post one band higher than their substantivepost. Human Resources advice must be sought.

7.30 If individuals are displaced from their substantive post, there is no automaticright to a post that has been ring-fenced in the new structure.

7.31 To be able to apply for a ring-fenced post the essential criteria of the personspecification needs to be met, or is able to be met with a reasonable amountof training (normally within four months of commencement of the post).

8. Protection of pay

8.1 Where an individual is appointed to a post at a lower salary, or there are

differences in the contracted hours of work, pay protection as outlined in thePay Protection policy of the South West Strategic Health Authority will apply.

8.2 For large scale changes key members of staff from Human Resources andPayroll will be designated on leading this aspect of the advice to staff.

9. Failure to match staff affected by the organisational change toavailable posts

9.1 In circumstances where the appointments process, described above, fails tomatch an employee affected by the organisational change to an available post

the following arrangements will apply:

• staff who are not matched to posts in the new structure will beconsidered for any suitable alternative employment in line with theRedeployment policy and procedure;

• the individual will be consulted to identify scope for matching to suitableemployment;

• staff at risk will, when they apply, receive priority consideration forinterview for all posts at or below their current salary in the occupations

agreed as suitable alternatives before these posts are externallyadvertised;



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• staff at risk will not be able to apply or be considered for posts in thenext level of the structure until the first round of matching to thatstructure has been completed;

• any posts remaining vacant after the redeployment exercise has taken

place will be subject to open competition;

• in exceptional circumstances where posts are newly created and it isbelieved that no current employee meets the person specification,open competition will take place in the first instance.

10. Internal (open) competition

10.1 If no appointment is made or if there are no ring-fenced applicants, the postwill be advertised in the internal vacancy bulletin and subject to opencompetition. Posts at this stage will be available to existing employees of

South West Strategic Health Authority.

11. Transfer of undertakings (protection of employment)regulations 2006 (TUPE)

11.1 The Transfer of Undertakings (Protection of Employment) Regulations (TUPE)protects employees terms and conditions of employment when a business istransferred from one owner to another. Employees of the previous ownerwhen the business changes hands automatically become employees of thenew employer on the same terms and conditions. It’s as if their employmentcontracts had originally been made with the new employer. Their continuity ofservice and any other rights are all preserved.



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Annex 3

Template Consultation Document

The following standard document has been written to assist managers and Human

Resources staff in the delivery of a consistent approach in accordance with thepolicy.

Where it is necessary to amend the document to meet the requirements of anindividual case advise must be sought from the Human Resources team.

Template consultation paper with guidance

1. Introduction

1.1 This document explains the xxx Directorate’s proposal to XXXX. It is

presented in the form of proposals and is intended as a consultationframework for employees potentially affected by the reorganisation.

1.2 The process for managing any changes will be undertaken in line with currentlegislation and the Organisational Change policy and procedure andRedeployment policy and procedure of the South West Strategic HealthAuthority; these policies can be found on the South West Strategic HealthAuthority intranet or hard copies can be obtained through your Manager,Human Resources or your Trade Union representative.

1.3 The Directorate will work closely with recognised Trade Unions and staff

representatives throughout this process. Staff are encouraged to access Staffor Trade Union representatives for further information, advice and support ifthey wish.

2. Background

2.1 Insert the economic and business climate that lead to the change.

3. Existing arrangements/structure

3.1 Managers to explain existing arrangements

4. The rationale for change

4.1 Identifying the case for change – a clear rationale reflecting the potentialimpact on all areas.

5. The options (if appropriate)

5.1 Respective advantages and disadvantages/ and strengths, weaknesses,opportunities and threat analysis (SWOT) if appropriate. Risk Assessment(s)to have been undertaken and incorporated



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6. The implications of the proposed change

6.1 Dependent on the circumstances of the proposed changes the following areexamples of words to be used:

6.2 Once the consultation process is concluded, staffing establishments and skillmix will be produced to identify specific posts in the new structure.

(If able to share at this stage, incorporate proposed new reporting structure)

6.3 All reasonable steps will be taken to minimise the impact of organisationalchange. Apart from normal staff turnover, and holding of any suitable existingvacancies for those affected by the change, we will seek to maximise theopportunities for existing staff to apply for posts within the new structure, andsupport will be available with interview preparation and techniques.

6.4 In order to ensure a fair and transparent process the Organisational Changepolicy and procedure of the South West Strategic Health Authority will befollowed.

6.5 Posts in the new structure will be ring fenced for those directly affected staff,and where suitable, slotting in arrangements will apply. Where there is morethan one person for a job, there will be selection interviews.

6.6 In the event where there are staff that cannot be accommodated in thestructure, the South West Strategic Health Authority will seek to retain staffthrough redeployment, thereby minimising the risk of redundancy.

Then, highlight specifics of this proposal . . . . . . . .

Numbers of people affected

Job Titles

Skills mix considerations

Any costings available at this stage

6.7 As part of the consultation process with staff, staff are invited to respond with

their views and suggestions for further consideration on the proposals forreorganisation of xxxx.

6.8 The impact on staff in the affected areas cannot be underestimated and theSouth West Strategic Health Authority will endeavour to facilitate theappropriate redeployment for all affected staff.



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7. Plan and timescales

7.1 We aim to consult with staff for a period of at least x days.

(This needs to reflect the number of staff affected by the proposals –

depending on the nature of the proposals this might affect staff on theincoming and receiving wards/areas – the minimum period is two weeks. For20+ staff it should be thirty days, for 100+ staff it should be ninety days.)

7.2 Also confirm time for Consultation feedback by

Review of feedback by

Date when final proposals will be confirmed

Implementation plan – taking into account

the selection process for example.

8. Comments and feedback

8.1 During the consultation period there will be the opportunity to meet again ingroups and on an individual one to one basis so that you can tell us yourviews, make any comments and put forward suggestions.

8.2 Consultation is undertaken when the aim of achieving full understanding forstaff and facilitating their participation in the process towards reachingagreement on the proposal. Depending on the feedback, a revised

Consultation paper may be issued for consideration. At the end of theprocess, taking in account the outcome of consultations with staff, the SouthWest Strategic Health Authority will communicate an explanation of thoseoptions that are viable and why other options put forward are not suitable.

8.3 The times for feedback meetings have been scheduled as follows:

Group meetings : xxxx

Individual sessions : xxxx

You may also formally respond to the proposal(s) in writing to xxxx by xxxx.

Name of Lead Manager

Date



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Appendix 16

Pay Protection Policy

This appendix sets out the revised Pay ProtectionPolicy for the South West Strategic Health Authority.





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Pay Protection Policy

1. Introduction

1.1 This policy outlines the short term protection of earnings and/or long termprotection of basic wage or salary on downgrading and applies to anyemployee who, as a consequence or organisational change,

(i) is redeployed to a new post on a lower grade (long termprotection);

or

(ii) suffers a reduction in basic hours worked within the standardworking week (short term protection);

or

(iii) suffers a loss of ‘protectable’ earnings (short term protection).

1.2 The South West Strategic Health Authority is committed to the fair andconsistent treatment of staff regardless of their sex/gender, sexual orientation,religion or religious beliefs, race, age, or disability. Where evidence ofinequality or adverse effect is found the South West Strategic Health Authority

will take appropriate action.

2. Definitions

Short term protection

2.1 The protection of earnings following a reduction in contract hours or changesin working arrangements with a consequent loss of enhancements andallowances for example.

Long term protection

2.2 The protection of basic salary following downgrading.

Organisational change

2.3 Any structural or managerial change.

Basic wage or salary

2.4 The weekly or monthly sum due in respect of basic hours worked by theemployee concerned within the standard working week, but excluding theallowances in paragraph 12.



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Protectable earnings

2.5 The basic wage or salary plus the allowances are given in paragraph 12.

Earnings in the new post

2.6 The total of basic wage or salary in the new post plus earnings in respect ofover time, shift work or other additional allowances or duties.

Downgrading

2.7 When the new post, irrespective of its grade title, carries an hourly rate or asalary scale, at the maximum point, lower than that applying to the postpreviously held or lower than that of the personal grade held in the previouspost.

A more senior post

2.8 A post which carries an hourly rate or new salary scale with a maximum point,higher than that applying to the new post or any subsequent post to which anemployee may have moved, or be requested to take up.

Reckonable service

2.9 Total continuous NHS service but excluding any service which has beensubject to a redundancy payment by the South West Strategic HealthAuthority, its predecessors or another NHS employer.

3. Short term protection

3.1 An employee to whom this agreement applies is entitled to have certainearnings (‘protectable earnings’) in the former post protected for a period ofup to twelve months as set out in table 1 below.

Table 1

Reckonable Service Protection Period (months)

Less than twelve months Two months

More than one year but less than two years Six months

More than two years but less than five years Nine months

More than five years but less than ten years Twelve months

More than ten years Twenty four months



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3.2 Earnings in the new post will be offset against protectable earnings. If for anyparticular pay period the earnings in the new post exceed the protectableearnings, protection of earnings is extinguished and earnings in the new postare paid in full for that particular pay period.

3.3 When calculating earnings in the new post the rates used for calculatingpayments in respect of over time, shift work or other additional duties shall bethose applicable to the new post.

4. Long term protection

4.1 An employee to whom this agreement applies who is moved from one post toanother and who is downgraded as a result of the move is entitled to fullprotection of basic wage or salary, with benefit of any subsequentimprovements or increments applying to the scale until:

Table 2

Reckonable Service Protection Period

Less than one year No protection

More than one year but less than two years One year

More than two years but less than three years Two years

More than three years but less than four years Three years

More than four years but less than five years Four years

Five years or more Five years

(a) the period of protection expires as set out in table 2 above. In addition,a member of staff who has occupied a grade for four years or more atthe time the protection is applied, the period of protection given in table2 above will be extended by six months;

(b) the employee is appointed to a post in which the normal basic wage orsalary is equal to or exceeds the protected basic wage or salary;

(c) the employee moves on their own application to a post with a basicwage or salary which is lower than that of the existing post;

(d) the employee retires.

4.2 Where an employee moves on their own application to a post where the basicwage or salary is higher than the existing post, but not as high as the formerpost, the protection shall continue for the period remaining as a result of 4.1

(a) or until 4.1 (b) – (d) occur.



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4.3 Any additional earnings derived from work in the new post will beremunerated at the rate appropriate to the new post.

5. Interaction between short and long term protection

5.1 Where an employee has the right to long term protection and an initialconcurrent right to short term protection; until the short term protection expiresthe employee shall be paid according to the conditions of whichever right isthe more favourable to the employee. Thereafter payment is on the basis ofthe ongoing entitlement to long term protection. Details of protectableearnings are given in paragraph 12 of this policy.

6. Protection of conditions of service, hours and annual leave

6.1 employees required to move to a new post will acquire the contracted hoursappropriate to the new post. Annual leave and other terms and conditions will

be protected with subsequent improvements whilst basic pay is protected.

7. Entitlement to opt for terms and conditions of new post

7.1 Employees with an entitlement to long protection may, at any time, opt for thecomplete package of remuneration and conditions of service applicable to thenew post. This option, once exercised, cannot be cancelled.

8. Conditions

Short term protection

8.1 Short tern protection of earnings is conditional on the employee undertakingany overtime, shift work or other additional duties which may be required up tothe level at which earnings in the new post equal the protected earnings.

8.2 Short term protection of earnings is also conditional on the employeeaccepting any subsequent offer of another suitable post which attracts a basicwage or salary in excess of the basic wage or salary applying to the new post.

Long term protection

8.3 Long term protection (where downgrading is involved) is also conditional onthe employee undertaking to apply to a more senior position within the SouthWest Strategic Health Authority, provided that it is suitable alternativeemployment. This undertaking will be deemed to have been accepted unlessan employee advises their manager, in writing, within four weeks of the dayon which the downgrading takes effect. If the employee notifies that thisundertaking will not be given or subsequently refuses to apply for or accept amore senior post within the South West Strategic Health Authority thenprotection will case to apply, unless exceptionally, continued protection isagreed at the discretion of the South West Strategic Health Authority.

Appeals



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8.4 Where an individual considers that the interpretation and/or the application ofthis procedure is incorrect they are entitled to exercise their right under theGrievance policy of the South West Strategic Health Authority.

Subsistence and travelling

8.5 Where an individual is required to travel further from home to base in theirnew post than their previous post they will be required to claim travellingexpenses on a short term basis, as set out in the document setting out ExcessTravel and Protection Arrangements.

Subsequent change of post under organisational change

8.6 Each subsequent change of post due to organisational change is covered bythis agreement and will attract protection in its own right.

9. Part time staff9.1 Where a part time employee is moved to a new post and downgraded and the

hours in the new post are the same or fewer than before, long term protectionentitlement is assessed on the basis of the actual hours worked in the newpost paid at the hourly rate applicable to the previous post. If the hours in thenew post exceed hours worked previously, long term protection entitlement isbased on:

Hours worked previously x rate applicable previously.

The additional hours in the new post are paid at the rate applicable to the newpost.

10. Effect on pension

10.1 The NHS Pension Scheme allows staff with at least two years service toprotect their benefits accrued if they suffer a reduction in their pensionablepay as a result of imposed organisational changes. Staff affected should writeto the Pensions Officer in the Finance Department within three months of theirpay going down. This applies equally to the loss of enhancements at the endof short term protection. Preserved benefits are indexed-linked until

retirement. Confirmation of this arrangement may be read in the generalpension guide which employees hold.

11. Payments included in reckonable pay

11.1 The following payments must be a regular requirement of the job to beincluded in ‘reckonable pay’ for protection purposes. The value of thesepayments for protection purposes shall be based on the average payments forthe four months (seventeen weeks) prior to the date on which protectionapplies.



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11.2 The following payments will constitute protectable earnings and will qualify forshort term protection:

• shift duty;

• night duty;

• split duty;

• unsocial hours;

• stand by and on call;

• special duty payments;

• formal contractual regular roistered overtime.

11.3 The following payments will be excluded in the calculation of protection of thebasic wage and salary:

• overtime;

• bonus and incentive payments;

• excess hours payments;

• domiciliary fee payment;

• acting up.



• all employees will have been treated fairly and consistently withregards to pay protection;


• all employees have a clear understanding of the roles andresponsibilities for line managers and themselves with regards to payprotection.






Appendix 17

Performance Improvement Policy

This appendix sets out the revised PerformanceImprovement Policy for the South West StrategicHealth Authority.





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Performance Improvement Policy

1. Introduction

1.1 The policy aims to encourage all employees to achieve and maintain highstandards of performance and that improvement is made when required.

1.2 The policy aims to ensure that all managers adopt an appropriate andeffective approach to matters of performance below an acceptable standarddue to a lack of capability.

1.3 All employees should be aware of the standards required of them as well astheir professional codes of conduct. The policy requires that all managersprovide their employees with the appropriate training and instruction toperform their duties effectively.

1.4 All managers have a responsibility for setting realistic and achievablestandards which provide a means of advising individual employees whatstandards of performance are expected of them and a means in which theirachievement of these can be judged. The South West Strategic HealthAuthorities Appraisal provides a method by which realistic standards ofachievement can be agreed, that are measurable both in terms of quality andquantity.

1.5 The purpose of this policy is to ensure that all matters concerning work belowan acceptable standard are dealt with in a fair, reasonable and consistentmanner.


2.1 This policy exists to help an employee achieve the standards of performancerequired.

2.2 It is the responsibility of employees to familiarise themselves with standard ofperformance expected of them in their job role.

2.3 In order to achieve this, managers must be accessible to their employees andset with them realistic and achievable standards of performance.

2.4 In order to ensure that employees are appointed to a job role that isappropriate for their skill and/or experience, the Recruitment policy should beused.



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2.5 It is the manager’s responsibility to ensure that all employees take part in acomprehensive induction programme on appointment to a new job role. Thiswill comprise of a Corporate Induction together with a Directorate LocalInduction. The latter will enable the manager and employee to discuss therequirements and standards expected within the job role and thus to identify

any development needs the employee may have. The manager will then beresponsible for addressing these development needs in the most appropriatemanner.

2.6 All employees should take part in an annual Appraisal with their manager.These should be a two way discussion that review past performance againstthe agreed standards, identify current realistic standards of achievement thatare measurable both in terms of quality and quantity and identify futuredevelopments both within the current job role and future roles if applicable.

2.7 The discussion at the annual Appraisal may lead to development needs being

identified in order to enable the employee to be more effective in their current job role or to prepare them for a future job role. It is the manager’sresponsibility to ensure that opportunities are made available to the employeein order that they might fulfil their development needs.

2.8 On going reviews and discussion of performance in the job role should takeplace throughout the year.

2.9 In the event of unacceptable performance being identified, the manager willspeak with the employee as soon as the concerns arise.

2.10 The South West Strategic Health Authority recognises that all employeeshave the right to:

• be accompanied by a Trade Union representative or work colleague(not acting in a legal capacity);

• respond to any concerns regarding their performance;

• have appropriate support offered if they have a disability or if English isnot their first language;

•

confidentiality at all stages of the policy and procedure;

• receive clear, concise written documentation of each meeting which is jointly agreed with the manager;

• receive support from Human Resources at any time;

• appeal at any of the formal stages of the procedure.



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3.1 Work below an acceptable standard which is due to a genuine lack ofcapability that is due to lack of skill, knowledge, experience or aptitude shouldbe handled under the Performance Improvement policy.

3.2 In the event of an employee failing to reach the required standards for their job role as a result of health the Absence Management policy will be followed,with reference to the Health Problems and Disability in Employment section ofthe Health and Wellbeing policy.

3.3 In the event of an employee failing to reach the required standards for their job as a result of misconduct or poor behaviour the Disciplinary policy andprocedure will be followed. Managers need to distinguish between negligenceand unacceptable performance; Guidance Note 1 provides some guidelineson how to make this distinction.

3.4 There may also be issues of capability which straddle the boundary betweencompetence and health for example in relation to alcohol or drug abuse orstress which can affect an employee’s capability within their job role. In thesecases the issues may need to be managed under the PerformanceImprovement policy and in conjunction with the Alcohol and Drugs section ofthe Health and Wellbeing policy.

3.5 The following policies should also be read in conjunction with the ManagingPerformance Improvement policy:

• Dignity at Work policy – if the performance below an acceptablestandard is due to bullying or harassment;

• Recruitment policy – if the employee has been appointed to a job thatis inappropriate for their skills and/or experience;

• if the employee has been appointed and reasonable adjustments havebeen met;

• all appropriate codes or conduct/rules for professional bodies.

4. Methods of reviewing performance

4.1 It is the responsibility of managers and supervisors as part of their daily dutiesto identify instances of performance that does not meet the requiredstandards. Problems should be raised appropriately by the manager as nearto the occurrence as is reasonably practical, to enable the employee torespond.

4.2 Managers may review an employee’s work performance in a number of wayswhich may include:

• day to day management review/supervision;



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• regular one to one meetings (between the employee and manager);

• peer/colleague reviews;

• complaints, comments or compliments;

• annual appraisal.

4.3 In the event of unsatisfactory performance being identified for example:

• poor standards of work;

• recurring mistakes;

• non completion of tasks;

•

not achieving agreed standards of performance;

• impact on the team/peers for example high absenteeism, turnover;

• complaints.

4.4 The manager may use the Managing Performance Improvement procedurewhere there are recurring instances of poor performance or an instance ofgross incompetence has occurred.

5. Overview of the procedure

5.1 The Managing Performance Improvement policy has the following stages:

Stage Action taken

Informal Conversations aboutperformance below standards

Training needs indentified and undertakenand/or standards of performance clarified

Informal Meeting Informal Performance Improvement Plan

First Formal Meeting Formal Performance Improvement Plan

Second Formal Meeting Formal Performance Improvement Plan

Performance Improvement Warning

Third Formal Meeting Potential Dismissal

5.2 Annex 1 contains a flow chart that outlines the process.

5.3 An employee should not normally be dismissed because of failure to performto the required standards unless reviews and an opportunity to improve have

been given. However, there may be exceptional circumstances where it maynot be appropriate to follow the full process.



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5.4 This would be due to serious/gross incompetence where it can be

demonstrated that an employee cannot achieve acceptable levels ofperformance or where the lack of capability creates an immediate danger toother employees or members of the general public. In these situations it may

be necessary to start the procedure at the third formal meeting and suspendthe employee until the meeting can take place. Suspension should follow theprocedure as set out in the Disciplinary policy and procedure.

6. Managing performance improvement procedure

Informal Stage

6.1 The informal meeting will enable the manager to raise concerns with regard tothe employee’s capability at the earliest opportunity and may be part of a dailyone to one meeting or regular review meeting.

6.2 As it is an informal meeting, it is not necessary for a Human ResourcesRepresentative to be present or a Trade Union representative or workcolleague. However, if the employee wishes to arrange representation theymay, with a minimal delay to the meeting.

6.3 Guidance Note 2 explains the process to be followed during the informalmeeting.

6.4 As a result of the meeting a Performance Improvement Plan should be agreedthat details the actions that’s should be taken in order for the employee’s

performance to reach a satisfactory standard. This may include training to beundertaken.

6.5 The Performance Improvement Plan should also detail the agreed standardsof performance to be reached within a suitable time period. These must bemeasurable in terms of quality and quantity.

6.6 A record of the meeting will be made by the manager and sent, together withthe Performance Improvement Plan, to the employee within seven workingdays of the meeting.

6.7 During the review period the manager and employee should meet regularlythat is monthly, to see if the performance is improving, objectives are beingmet and if any further support is needed. These informal meetings should bedocumented on the Performance Improvement Plan.

6.8 If the performance improves during the review period and the managerbelieves that this improvement will be sustained, the manager may decide totake no further action. This will be confirmed in writing to the employee andHuman Resources team. The Performance Improvement Plan will remain onthe employees file for nine months. Any recurrence of the same poorperformance may be dealt with at the Informal Stage.



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6.9 If there is little or no change during the review period or performancedeteriorates the manager may wish to review the Performance ImprovementPlan during the review period. The decision may be taken to reduce theperiod and if at the end there is no improvement the employee should beinvited, in writing, to attend the first formal meeting.

Informal Meetings

6.10 The first and second formal meetings will follow the same process, seeGuidance Note 3.

6.11 The employee must be invited in writing, at least seven working days prior tothe meeting taking place.

6.12 The employee should be reminded of their right to be accompanied by aTrade Union representative or a work colleague (not acting in a legal

capacity).

6.13 As a result of the meeting a Formal Performance Improvement Plan should beagreed that details the actions that’s should be taken in order for theemployee’s performance to reach a satisfactory standard. This may includetraining to be undertaken.

6.14 The Formal Performance Improvement Plan should also detail the agreedstandards of performance to be reached within a suitable time period. Thesemust be measurable in terms of quality and quantity.

6.15 A record of the meeting will be made by the manager and sent, together withthe Formal Performance Improvement Plan, to the employee within sevenworking days of the meeting.

6.16 In the case of this being a second Formal Meeting, a PerformanceImprovement Warning will also be issued. A Performance ImprovementWarning is a formal written warning which confirms to the employee that thereis a shortfall in their performance. Guidance Note 4 contains furtherinformation with regard to Performance Improvement Warnings.

6.17 During the review period the manager and employee should meet regularlythat is monthly, to see if the performance is improving, objectives are beingmet and if any further support is needed. These informal meetings should bedocumented on the Formal Performance Improvement Plan.

6.18 If the performance improves during the review period and the managerbelieves that this improvement will be sustained, the manager may decide totake no further action. This will be confirmed in writing to the employee andHuman Resources team. The Formal Performance Improvement Plan willremain on the employees file for twelve months. Any recurrence of the sameunsatisfactory performance may be dealt with at the Informal Stage.



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6.19 If there is little or no change during the review period or performancedeteriorates the manager may wish to review the Performance ImprovementPlan during the review period. The decision may be taken to reduce theperiod and if at the end there is no improvement the employee should beinvited, in writing, to attend the second formal meeting or in the case of it

being a second formal meeting, the third formal meeting.

6.20 Once the employee has reached the second formal meeting stage of theprocedure, the manager will need to explore with the employee and theHuman Resources team any redeployment opportunities. Redeploymentwould be to a job within the same or lower banding that better matches theemployees skills and capability. The South West Strategic Health Authority isunder no obligation to create a post. The Authority will continue to seek asuitable alternative post throughout the review period through theRedeployment Register.

Third Formal Meetings

6.21 The employee must be invited in writing, at least seven working days prior tothe meeting taking place; the letter must inform them that a potential outcomeof the meeting could be dismissal.

6.22 The employee should be reminded of their right to be accompanied by aTrade Union representative or a work colleague (not acting in a legalcapacity).

6.23 The meeting should be conducted by the appropriate Director, with both

parties and a Human Resources representative.

6.24 Guidance Note 5 explains the process to be followed during the third formalmeeting.

6.25 The Director will give consideration to the comments given by both parties.

6.26 If the Director believes adequate improvement is possible by extending theassistance offered or the time scale agreed, then a further FormalPerformance Improvement Plan will be agreed, with a review date and time. Itmust be made clear that failure by the employee to meet the required

standard of performance in this time period is likely to result in dismissal.

6.27 If the Director believes that the required level of performance has not beenachieved and that all reasonable action, including sourcing suitable alternativeemployment, has been considered or if the employee has declined this; thenthe South West Strategic Health Authority will have no alternative but todismiss the employee.

6.28 The employee should be advised of the outcome of the third formal meetingverbally at the end of the meeting. A record of the meeting will be made by themanager and sent, together with the Formal Performance Improvement Plan if

applicable, to the employee within seven working days of the meeting.



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6.29 In the event of dismissal, the employee shall be given their appropriate noticeor payment in lieu of notice and any outstanding holiday pay if applicable.

7. Appeals

7.1 The employee has the right to appeal against any decision at any of theformal stages of the procedure.

7.2 At each formal stage of the procedure, the employee will be informed of theirright to appeal, who to appeal to and the time scales within which the appealshould be submitted.



• all employees will have been treated fairly and consistently when goingthrough the Performance Improvement process;


• all employees have a clear understanding of the roles andresponsibilities for line managers and themselves in the application for,monitoring and recording performance;






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Guidance Note 1

Distinguishing between negligence and performance below anacceptable standard

1. A clear distinction should be made between work below an acceptablestandard which is due to negligence and that due to lack of ability, skill,knowledge, experience or aptitude.

2. Negligence will normally involve some degree of personal culpability in thatthe employee is capable of doing the job, but the level of performance is notto the required standard due to lack of reasonable care or attention. Thesecan be considered as wilful negligence and/or misconduct and shouldtherefore be addressed using the Disciplinary policy and procedure; as theemployee has the ability to perform to the required standard but is not

exacting the principle of a duty of care.

3. Performance below an acceptable standard which is due to a genuine lack ofcapability as a result of a lack of skill, knowledge or aptitude; should behandled under the Performance Improvement policy.

4. A genuine lack of capability may be due to a number of factors for example:

• promotion beyond the employee’s capability;

• underlying health issues;

• personal circumstances;

• appointment to a job that is inappropriate for the individual’s skillsand/or experience;

• development in job demands over the years or changes brought aboutby outside influences such as new technology, legislation;

• changes in work place environment;

• qualifications;

• bullying and harassment.

5. There may be occasions when poor performance may highlight the need touse the Performance Improvement policy in conjunction with another policyfor example Dignity at Work in the instance of bullying and harassment orabuse or the for example Health and Wellbeing policy in instances of healthissues or disability.



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305

Guidance Note 2

Guidelines for conducting an informal meeting

1. The manager should explain that they are meeting informally with theemployee to discuss the concerns they have with the employee’s current levelof performance.

2. They should recap on the informal discussions they have previously had withthe employee and explain why they have moved to the informal stage of theManaging Performance Improvement policy.

3. The manager should establish if the employee has previously been managedunder the policy or been issued with a Performance Improvement Plan.

4. The manager should then review the employee’s performance over the

previous months and establish when the performance deteriorated beforeinvestigating with the employee the possible reasons for the shortfall in theirperformance against the required standard.

5. The standard of work expected from the employee should then be explainedand the manager should ensure that the employee is clear about their dutiesand responsibilities as outlined in their job description.

6. The manager and employee should then discuss any measures that mayassist the employee in reaching the required standard of performance forexample job shadowing, coaching, counselling and any other reasonable

measures discussed and agreed.

7. The manager should then discuss and agree with the employee the standardof performance that is expected from them and the time period over whichthey should be achieved. These may be recorded as objectives with a clearmeasure of both output and time.

8. A review period should be agreed and regular interim reviews planned.

9. The employee should be clear that failure to improve their standards ofperformance may lead to the formal stages of the policy and procedure.

10. They should be issued with a copy of the policy.



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307

Guidance Note 3

Guidelines for conducting the first and second formal meetings

1. The manager should collate the relevant evidence that illustrates the fact that

the required improvement has not been made since the last meeting. Thiscould include:

2. Observation records.

3. Feedback from a coach.

4. Complaints.

5. Factual evidence, for example statistics, performance figures.

6. The manager should remind the employee of their right to be represented, inthe event of their not having a representative present.

7. The manager should introduce those present; that is the employee, theirrepresentative and the manager.

8. The manager should discuss the measures put in place at the previous stageof the policy and why is has been necessary to use the next stage of theprocedure.

9. They should explain the purpose of the meeting that is to discuss concerns

with the employee’s performance and seek measures to improve this.

10. The manager should clarify the requirements of the role and the standardsexpected of the employee and highlight their shortcomings; using the jobdescription and any documentary evidence.

11. The employee should be invited to give their views on the reasons for theircontinued failure to deliver to the required standards.

12. The employee should be asked if there are any other measures that can betaken to support them in achieving a satisfactory level of performance.

13. The employee may wish to explain any mitigating circumstances that mayhave contributed to them not performing satisfactorily in their role.

14. The manager should then discuss and agree with the employee the standardof performance that is expected from them and the time period over whichthey should be achieved. These may be recorded as objectives with a clearmeasure of both output and time. These should form part of the FormalPerformance Improvement Plan together with any measures that have beenagreed to support the employee.

15. A review period should be agreed and regular interim reviews planned.



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16. The employee should be clear that failure to improve their standards ofperformance may lead to the next formal stage of the policy.

17. In event of this being a second formal meeting, a Performance ImprovementWarning should be issued verbally at the meeting. This will be confirmed in

writing together with a record of the meeting and the Formal PerformanceImprovement Plan, within seven days of the meeting.

18. The manager should arrange a meeting with the employee, theirrepresentative and a Human Resources representative to explore possibleredeployment opportunities with the employee.



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Guidance Note 4

Guidelines on issuing a performance improvement warning

1. The manager may issue a Performance Improvement Warning during any ofthe formal stages of the policy but would normally do so at the end of asecond formal meeting.

2. A Performance Improvement Warning is a formal written warning whichconfirms to the employee that they are not achieving the required standard ofperformance and that an unsatisfactory outcome within the review period mayresult in dismissal.

3. The employee will be notified verbally of this during the meeting and then itwill be confirmed in writing in the form of a letter within seven days of the

meeting.

4. Performance Improvement Warnings should stay on the personal file fortwelve months.

5. In order to move to the third formal meeting the Performance ImprovementWarning must be valid within twelve months of it being issued.

6. Any written Performance Improvement Warning must be authorised by theHead of Human Resources or a delegated member of the Human Resourcesteam before it is issued.

7. The Human Resources team will be responsible for retaining the Warning onfile for the agreed period, before removing it and informing the employee thatit has been removed.



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311

Guidance Note 5

Guidelines for conducting a Third Formal Meeting

1. The Director will introduce those present; the manager, employee, employee’srepresentative and the Human Resources representative.

2. The Director should invite the manager to outline the steps that have beentaken in the previous stages of the procedure, the outcomes and anyevidence supporting those outcomes.

3. The employee should then be invited to state any genuine mitigatingcircumstances they may have for failing to meet the required standards andalso to give their opinion on the progress they have made; the level of supportand training they have been given and any other relevant comments relating

to the management of their performance.

4. The Director will give consideration to the comments of both parties and mayadjourn the meeting in order to reach their decision.

5. The employee should be advised of the outcome of the third formal meetingverbally at the end of the meeting.

6. If the Director believes adequate improvement is possible by the extendingthe assistance offered or the time scale agreed, then a further FormalPerformance Improvement Plan will be agreed, with a review date and time. It

must be made clear that failure by the employee to meet the requiredstandard of performance in this time period is likely to result in dismissal.

7. In this event the a record of the meeting will be made by the Director andsent, together with the Formal Performance Improvement Plan to theemployee within seven working days of the meeting.

8. If the Director believes that the required level of performance has not beenachieved and that all reasonable action, including sourcing suitable alternativeemployment, has been considered or if the employee has declined this; thenthe South West Strategic Health Authority will have no alternative but to

dismiss the employee.

9. In the event of dismissal, notice of termination will be given in accordance withthe employee’s Contract of Employment. This notice may be paid in lieu if it isfelt to be in the best interest of the employee and the department.

10. The reasons for the decision for dismissal will be confirmed in writing to theemployee within seven calendar days together with the notification of theirright to appeal, who to appeal to and the timescale within which to appeal.This would normally be to the Chief Executive within fourteen calendar days.



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Annex 1

Flow Chart of Managing Performance Improvement

Unsatisfactory performance isidentified by Manager

Informal meeting held with employee atwhich a Performance Improvement Plan isagreed and a review date set. Carry outmonthly reviews.

No further action, PerformanceImprovement Plan on file fornine months.

The necessary improvementhas not been made.

Employee invited to a firstformal meeting, in writing atleast seven days before themeeting.

Formal meeting held with employee and arepresentative, at which a PerformanceImprovement Plan is agreed and a reviewdate set. Carry out monthly reviews.

Review meeting held at whichthe Performance ImprovementPlan is reviewed.

No further action.Performance ImprovementPlan on file for twelve months.

The necessaryimprovementhas been made.

Employee invited to asecond formal meeting, inwriting at least seven daysbefore the meeting.

The necessary improvement has

not been made.



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Review meeting held atwhich the FormalPerformance ImprovementPlan is reviewed.

No further action.Formal PerformanceImprovement Plan onfile for twelve months.

The necessaryimprovementhas been made.

The necessary improvement has

not been made.

Employee invited to a thirdformal meeting, in writing atleast seven days before themeeting.

Formal meeting held by Director with employee, representativeand a Human Resources representative at which the Director canagree a Further Performance Improvement Plan or discussredeployment or if redeployment not appropriate or declined, thendismiss the employee.

If Formal Improvement Plan,review date to be agreed;monthly reviews to be carriedout.

Formal meeting held with employee and arepresentative, at which a Formal PerformanceImprovement Plan is agreed & a review dateset. Redeployment is discussed with theemployee and Human Resources Team.

Monthly reviews to be carried out. PerformanceImprovement Warning issued.

Formal meeting held by Director with employee, representative and

an Human Resources representative at which if the employee hasmade the necessary improvement, no further action will be takenand the Formal Performance Improvement Plan will remain on filefor twelve months.or if the necessary improvement plan has not been made, discussredeployment or dismiss the employee.



Appendix 18

Professional Registration Policy

This appendix sets out the revised ProfessionalRegistration Policy for the South West StrategicHealth Authority.





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Professional Registration Policy

1. Introduction

1.1 It is the policy of the South West Strategic Health Authority to ensure that allstaff and independent contractors required to hold a professional qualificationin order to practice their profession are appropriately registered with theirprofessional regulatory body at all times.

1.2 The South West Strategic Health Authority has responsibility to ensure thatprofessional standards are met and maintained.

1.3 Registration with the relevant professional regulatory body is a pre-requisitefor employment with the South West Strategic Health Authority wherepossession of a professional (clinical and non-clinical) qualification is essentialfor the post.

1.4 Where an individual’s registration has lapsed they will no longer be eligible foremployment with the South West Strategic Health Authority in theirprofessional capacity.

1.5 The South West Strategic Health Authority is committed to the fair andconsistent treatment of staff regardless of their sex/gender, sexual orientation,

religion or religious beliefs, race, age, or disability. Where evidence ofinequality or adverse effect is found the South West Strategic Health Authoritywill take appropriate action.

1.6 The registration details of individual employees will be entered onto theirElectronic Staff Record and held in their personal file.


2.1 The following professional groups of employees or independent contractorsare required to hold professional registration:

• accountants;

• allied health professionals;

• dentists;

• health visitors;

• human resources;

• medical staff;



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• midwives;

• nurses;

• opticians;

• pharmacists.

2.2 This policy should be read in conjunction with the following policies of theSouth West Strategic Health Authority.

• Data protection and Information and confidentiality policy;






• Redeployment policy;

• Study Leave and Development policy.

3. Responsibilities of employees3.1 New employees will be required to provide evidence of their professional

registration and qualifications prior to commencement with the South WestStrategic Health Authority.

3.2 It is the responsibility of employees to register with their professionalregulatory body and provide evidence of their continuing professionaldevelopment to ensure the registration is up to date.

3.3 Copies of relevant documents will be placed on the personal file of theemployee. Employees failing to provide such evidence will not be allowed tocommence duties. Validity of all nursing qualifications will be confirmeddirectly with the Nursing and Midwifery Council prior to the start date andevidence will be required at the interview.

3.4 Individual employees will ensure that their manager is provided with evidenceof their registration and expiry date on renewal of registration.

3.5 Where an employee is unable to renew their professional registration theymust inform their manager immediately.



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4. Responsibility of independent contractors

4.1 It is the responsibility of the independent contractor to hold the requiredprofessional registration and any conditions attached to this to the South WestStrategic Health Authority.

5. Responsibilities of the manager

5.1 Directors are required to ensure locally that registration is renewed. They willmonitor renewal of registration on a monthly basis.

5.2 Directors are required to confirm the registration status of independentcontractors required to hold professional registrations.

5.3 Directors will issue a reminder to all staff, including those on long termabsence, (career breaks, maternity leave for example) to renew their

registration one month before their registration is due to lapse.

5.4 For medical and dental staff, responsibility for ensuring registration lies withthe Director of Public Health for the South West Strategic Health Authority.The Director of Workforce has responsibility for checking the registrationstatus of the Director of Public Health.

5.5 An electronic record of professional registrations will be kept and maintainedby the Human Resources team through the use of the Electronic Staff Recorddatabase.

5.6 The manager will obtain evidence of renewed registration and send acountersigned photocopy to the Human Resources team for retention on thepersonal file of the employee, and their electronic staff record.

5.7 Other than when confirmation of registration is delayed by the ProfessionalRegulatory Body, employees who fail to be registered will be prevented frompracticing in a professional capacity until such time that evidence ofregistration is provided.

6. Failure to provide proof of or renew professional registration

6.1 If proof of professional registration is not received, on or prior to the renewaldate, the Director will meet the employee informing them that proof of renewalof their registration is required within five working days and they are on unpaidleave during this period.

6.2 Alternatively, it may be possible for the employee to be utilised in anothercapacity during the intervening period. However, this shall be at the discretionof the manager and payment shall be at the rate for the role undertaken.



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6.3 Failure of an employee, or independent contractor, to renew or comply withtheir professional registration may result in the decision to suspend them fromduty and to invoke the Disciplinary policy, which may potentially result in thetermination of an employee’s contract of employment or the termination of anindependent contractor’s contract for service.

6.4 Where an employee is unable to renew professional registration due to illhealth or disability, the Health Problems and Disability in Employment sectionof the Health and Wellbeing policy will apply.




• conduct annual checks on employees and independent contractorsregistration with professional regulatory bodies to ensure compliancewith this policy and actions that may be appropriate beyond it.



• new employees provide evidence of their registrations prior tocommencing employment with the South West Strategic HealthAuthority;

• existing employees maintain their professional registration;

• all employees remain competent to fulfil their professionalresponsibilities;

• employees who fail to renew registration are treated fairly.






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Annex 1

Flow chart depicting the monitoring process for professional registration ofclinical and non-clinical staff

Current registration with professionalregulatory body essential for post

New Staff Existing Staff

Human

Resourcesconfirmsregistration withregulatory body

Registrationdetails are storedon employee’s

personal file andelectronic staffrecord

Registrationprocesssubsequentlymanaged as

existing employee

Line managerundertakes

monthly checksand issuesreminder to staff

Registration hasbeen renewed

Registrationdetails are storedon employee’spersonal file andelectronic staffrecord

Registrationchecks areconducted onannual basis

Employee

• given five days fromexpiry of registration torenew registration. Duringthis period they will eitherbe required to take unpaidleave or utilised in a

different role and paid atan appropriate rate;

or

• managed under theHealth and WellbeingPolicy where disability hasprevented renewal ofprofessional registration.

Yes

No – registrationhas lapsed



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Appendix 19

Redeployment Policy

This appendix sets out the revised RedeploymentPolicy for the South West Strategic Health Authority.





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Redeployment Policy and Procedure

1. Introduction

1.1 The South West Strategic Health Authority has a duty to the public to use itsresources as effectively, but also to consider at every stage the welfare of itsemployees.

1.2 The South West Strategic Health Authority is committed to retaining itsworkforce essential skills, knowledge and experience, and recognises theimportance of maintaining continuity of employment of staff whose currentpost is no longer tenable including posts identified as at risk of redundancy.

1.3 The South West Strategic Health Authority is committed to the fair and

consistent treatment of staff regardless of their sex/gender, sexual orientation,religion or religious beliefs, race, age, or disability. Where evidence ofinequality or adverse effect is found the South West Strategic Health Authoritywill take appropriate action.

1.4 The purpose of this policy is to set out an understanding and a frameworkwhereby staff whose posts have been identified ‘at risk’ will be managed in anappropriate and sensitive manner.

1.5 The South West Strategic Health Authority is committed to seeking suitablealternative employment for employees whose post is no longer tenable or at

risk and aims to balance the needs of the organisation with the individual’scircumstances.

1.6 The Redeployment policy and procedure covers situations where anemployee’s current post is no longer tenable or at risk of redundancy due to:

• organisational change;

• capability issues due to Ill health;

• capability issues relating to poor performance;

• some other substantial reason (for example change of post followingagreed outcomes of bullying, harassment, disciplinary or grievancecases).

1.7 The Redeployment policy does not apply to employees who are looking for acareer change or seeking to move to a different post for on their own volition.

1.8 This policy should be read in conjunction with the following policies of theSouth West Strategic Health Authority:

•

Absence Management policy;





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• at the end of the period on the Redeployment Register, where nosuitable alternative employment has been found, the employee will bemanaged under the policy which led to the decision to seek suitablealternative employment;

• that employees who express interest in a redeployment opportunity willbe offered a four week trial. This may be extended up to six weeks bymutual agreement with the receiving manager and the employee;

• the trial period gives an employee and the receiving manager theopportunity to decide whether the new post is suitable;

• where more than one employee is ‘matched’ to a post and offered atrial period, each employee will be objectively assessed against theessential criteria. In this circumstance, a Human Resourcesrepresentative must be present at the final review meetings or interview

process.

4. Suitable alternative employment

4.1 In establishing the suitability of an alternative post, the following factors will betaken in consideration:

Pay

4.2 Wherever possible employees will be offered the same grade of post basedupon the employees knowledge and experience, skills and aptitude. Where

this is not possible posts a grade lower will be offered and the pay protectionarrangements may apply where the criteria in the Pay Protection policy is met.

Location

4.2 A change in location will normally be considered suitable where it does notincur additional mileage from home to base. However, this cannot beguaranteed and if an employee accepts a post a greater distance away,excess mileage will be paid in accordance with the NHS Terms andConditions of Service Handbook.

Working environment

4.3 Any change in working environment will be taken into consideration. TheSouth West Strategic Health Authority is committed to making reasonableadjustments for staff with a health complaint or physical disability.

Hours of work

4.4 Wherever it is not possible to offer alternative employment on the same hours,the pay protection arrangements may apply where the criteria in the PayProtection policy is met. In addition, employee’s individual personal

circumstances will be taken into account when assessing the suitability of thehours.



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Offers of suitable alternative employment

4.5 Employees who unreasonably refuse an offer of suitable alternativeemployment may lose any entitlement to redundancy pay. For example,refusing a job where the differences from their old job are negligible may be

considered unreasonable.

5. Manager responsibilities

5.1 The line manager has responsibility to ensure:

• Human Resources team is notified when an employee’s post has beenidentified as no longer tenable or at risk of redundancy;

• they identify and agree with the employee any suitable training anddevelopment that will assist the employee in finding suitable alternative

employment;

• they formally write to the employee confirming the full details of thearrangements for redeployment, including the period for which they willremain on the Redeployment Register and any training anddevelopment agreed;

• they allow the employee reasonable time off to attend interviews duringthe period on the Redeployment Register;

• they confirm in writing details of all trial periods, including the date the

trial period starts and ends;

• they inform Human resources of any subsequent developments orchanges in an employees circumstances;

• they fund the salary cost of trial periods;

• they attend the final review meeting.

5.2 The receiving manager has responsibility to:

•

give prior consideration to staff on the Redeployment Register andarrange for departmental visits;

• provide full and prompt information regarding the post to employees;

• obtain occupational health advice regarding reasonable workplaceadjustments, where an employee has been placed on theRedeployment Register due to ill health. Wherever practicablypossible, the adjustments must be made before the trial periodcommences;

•

objectively assess the employee suitability for the post against theessential criteria at interview and during any trial period;



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• ensure the trial period is, as far as practicably possible, a fairrepresentation of the job, and promptly identify any training anddevelopment needs of the employee;

• conduct weekly reviews with the employee during a trial period and

make any reasonable adjustments;

• confirm outcome of weekly review meetings in writing and issue thispromptly to the employee;

• update Human Resources of the weekly reviews during the trial period;

• a final review is undertaken at the end of the of the trial period.

6. Responsibility of the Human Resources team

6.1 The Human Resources team has responsibility to:

• provide advice and support at meetings with the line manager of theemployee whose post has been identified as no longer tenable or atrisk of redundancy;

• maintain the Redeployment Register, including specific requirements ofindividuals;

• keep a record of all vacancies notified to individual employees, theemployee’s decision, dates of trial periods, and outcome of final review

meetings;

• identify suitable alternative employment opportunities by ‘matching’vacancies to the employees knowledge, skills and experience, andattributes, and ensuring consideration is given to staff ‘at risk’ beforevacancies are advertised;

• advise employees on the Redeployment Register of suitablevacancies, allowing five working days for them to express interest;

• notify the appropriate manager when a post is withheld from going to

advert pending consideration of employment;

• progress the redeployment process with the individual and receivingline manager.

7. Employee responsibilities

7.1 The employee has responsibility to:

• promptly provide a detailed, and accurate information throughout theredeployment process;



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• cooperate fully in the process for seeking suitable alternativeemployment, including attending informal interviews, undertaking anytraining and development that has been agreed, weekly reviewmeetings, occupational health reviews where this is consideredappropriate;

• inform their line manager and human resources of any change to theircircumstances.




• conduct regular checks on the management of staff placed on the

Redeployment Register to ensure complains with this policy andactions that may be appropriate beyond it.



• all employees will have been treated fairly and consistently;


• all employees have a clear understanding of the roles andresponsibilities for line managers and themselves whilst on theredeployment register.






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Annex 1

Redeployment Procedure

1. Ongoing management

1.1 At the end of the period on the Redeployment Register, where no suitablealternative employment has been found, the employee will be managed underthe policy which led to the decision to seek suitable alternative employment.

1.2 An employee is entitled to be accompanied by a Trade Union representativeor work colleague (not acting in a legal capacity) at all meetings related tofinding suitable alternative employment.

2. Entry onto the Redeployment Register

2.1 Human Resources will place employees on the Redeployment Registerwhose posts have been identified as no longer tenable or at risk ofredundancy.

2.2 The line manager and a member of the Human Resources team will meet withthe employee to inform them of the Redeployment policy and procedure andassist the completion of the Redeployment Personal Details form which canbe found on the intranet.

2.3 The line manager will write to the employee confirming details placed on theRedeployment Register, including start and end dates, the responsibilities of

the employee, specific requirements including reasonable adjustments andtraining and development requirements agreed to.

2.4 Human Resources will ‘match’ vacancies to the skills, experience andknowledge of employees on the register.

2.5 Human Resources will notify in writing all potentially suitable posts (including job description, person specification, Knowledge and Skills Framework outlineand advert) to employees on the register and request that a decision is madewithin five working days of the notification. In ill health and disability cases,Human Resources will seek occupational health advice on the suitability of

the post and work place adjustments.

2.6 Human Resources will suspend the recruitment process until such time as theoutcome of the offer is known and advise the recruiting manager of thesituation.

2.7 The employee will confirm in writing their decision as to whether they wish toproceed to informal interview or their reasons for rejecting the vacancy.



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3. Informal interviews

3.1 Where the employee has expressed an interest in the post, HumanResources will arrange for an informal interview to take place whereverpossible within five working days of the expression of interest. The line

manager of the employee may be present at the informal interview.

3.2 The purpose of the interview is to ensure the employee’s suitability for thepost is objectively assessed against the essential criteria or would be able tomeet the essential criteria within three months, if provided with suitabletraining and development needs. Where the employee meets the selectioncriteria from the Redeployment Personal Details form, an offer of a trial periodwill be made to the employee.

3.3 The outcome of the informal interview will be confirmed in writing and includestart and end dates of the trial period and any agreed training and

development, date of the first review meeting, and any pay protectionentitlement should the trial period be successful.

3.4 Recruitment to the vacancy will be suspended during the duration of the trialperiod.

4. Trial period

4.1 During the trial period, the employee will remain on the register and benotified of any other suitable vacancies. If the employee subsequentlychooses to commence a trial period in a different post, they lose their

entitlement to return to the former trial period, and the post will be advertised.

4.2 Trial periods will normally last four weeks, although in exceptionalcircumstances can be extended beyond this.

4.3 Weekly review meetings will be undertaken to review the employee’s progressand identify any additional support or action required.

4.4 A final review meeting with the employee, their line manager, the recruitingmanager and a member of the Human Resources team will take place in thefinal week of the trial period.

4.5 If all parties are satisfied then employee will be redeployed into the post on apermanent basis. This offer will be confirmed in writing, including protectionof pay and conditions of service.

4.6 Where the post is not considered suitable, the objective reasons will beconfirmed in writing to the employee and the post will be released to advert.

5. Removal from the Redeployment Register

5.1 Employees will be removed from the redeployment register when a

permanent offer of suitable alternative has been accepted or when the agreedperiod has come to an end.



Appendix 20

Recruitment Policy

This appendix sets out the revised RecruitmentPolicy for the South West Strategic Health Authority.





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Recruitment Policy

This policy had been updated in line with our processes and to match NHS Jobsrecruitment process and the requirements of NHS employers, Counter Fraud andaudit.

This policy now incorporates:

• Disclosure policy;

• Employment of partners policy;

• Guidance on starting salaries Induction policy;

• Relocation expenses policy.

1. Introduction

1.1 The recruitment process is often the first experience an individual has of theSouth West Strategic Health Authority. It is important, therefore, that therecruitment and selection process is as professional as possible and that itpromotes a positive image of the South West Strategic Health Authority.

1.2 In order to comply with NHS Employers, audit and counter fraud requirementsthe South West Strategic Health Authority has robust recruitment processes inplace.

2. Recruitment process

Identification of a post

2.1 As soon as a vacancy is identified, the manager should undertake an analysisof the post in order to:

• consider whether does the post really need to be filled;

• check with Finance that funding is still in place or if the establishmentchange policy applies;

• consider whether the job content has changed significantly;

• consider whether the job structure within the Directorate be shouldreviewed.



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2.2 A Request to Recruit form and establishment change form, if required, shouldbe completed with the appropriate signatures and sent to the HumanResources team along with an advert, job description, person specificationand Knowledge and Skills Framework outline.

Job description

2.3 Once the decision has been taken to fill the vacancy, the job descriptionneeds to be created or updated to ensure that it accurately reflects the natureof the work to be undertaken. Job descriptions are for guidance of the mainduties of the post and need not be an exhaustive list of tasks; they thereforeneed to be concise, accurate and up-to-date. There is a standard templateavailable for job descriptions.

Person specification

2.4 The person specification is an objective description of the essential attributesrequired to carry out the job. In compiling the specification, the focus needs tobe directly on the requirements of the job, including:

• a statement on the type of experience necessary;

• a statement on the skills, aptitudes or knowledge required;

• the level of competence required;

• previous specific job-related training;

• education and training requirements.

2.5 The format of the person specification sets out the headings under which theattributes of the ideal candidate, taken from the job description and jobanalysis, can be classified and distinguishes only the features that areessential, as these are essential to the performance of the job.

2.6 To enable objective and measurable short-listing all criteria must bequantifiable, either by reference to personal records, particular knownachievements, testing and/or at interview.

2.7 Any criteria must be explicitly clear, objective and measurable.

Job evaluation

2.8 All new job descriptions and person specifications will require evaluation by apanel to be matched to the correct Agenda for Change banding. Anyamendments to existing job descriptions may require a job evaluation. Allmanagers should seek advice from Human Resources.



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Experience

2.9 When making decisions about the type and level of experience, it is importantto consider what you require the successful candidate to be able to do inrelation to skills and what you require them to know. Therefore experience

can be broken down into two key elements:

• skill requirements;

• knowledge requirements.

Skills

2.10 Skills may be broken down into the following areas shown in Table 1.

Table 1: Categories of Skill

Category of Skill Examples

Professional Skills attained through a professionalqualification of comparable academic route.

Communication andinterpersonal

Importance of confidentiality, lines ofcommunication (accountability), method ormanner of communication, level of competencyboth orally and written, effective workingrelationships, dealing with conflict, role as amember of a team.

Judgement andproblem solving

Ability to exercise professional judgementappropriate to a given situation.

Management Appraisal, supervision, performancemanagement, deputising, gained through eitherpractical experience or theoretical knowledge.

Technical Ability to undertake specific defined proceduresor to use equipment/systems, such asrequirement to have keyboard skills.

Administrative Processing, analysing and reporting of

information within organisational systems, suchas Standing Financial Instructions.

Research Ability to undertake research appropriate to roleor understanding of evidence-based practice.

Customer care Ability to understand and adhere to definedquality standards, such as patient carestandards.

Financial Budget management, monitoring, resourceallocation.



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Knowledge

2.11 This statement should detail the type and level of knowledge appropriate tothe duties of the job. In doing so, a distinction should be made between theskills you require and the knowledge an individual will need to underpin and

further develop those skills.

2.12 A template job description and person specification are shown at Annex 1.

3. Advertising

3.1 Best practice in recruitment is to recruit solely on the basis of ability to do the job and to create a diverse and multi-talented workforce. Consequently, theaim of recruitment advertising is to attract sufficient numbers of suitablyqualified candidates. Advertisements should, therefore, always be designedto ensure that they are tailored to the level of applicant targeted and every

effort made to ensure that advertisements are clear, easily understood andcomply with the Dignity at Work policy of the South West Strategic HealthAuthority.

3.2 All vacancies will be advertised on NHS Jobs and will necessarily comply withthe requirements of NHS Jobs systems and protocols.

3.3 All adverts must comply with the nationally prescribed NHS RecruitmentAdvertising Guidelines issued in March 2000. This sets out a corporate styleto be adopted throughout the NHS, which allows the use of the official NHSlogo and recognised marks such as Investors in People and Improving

Working Lives.

3.4 All vacancies must be advertised internally as a minimum using NHS Jobs asthe medium in order to comply with the Dignity at Work policy.

3.5 In specific circumstances adverts may reflect whether applications arerestricted to:

• internal employees only;

• the NHS South West.

3.6 No advert should be placed unless the Request to Recruit form has been fullycompleted and signed.

3.7 Acting up arrangements may be made to cover vacant posts, long termsickness or other absence without advertisement and interview provided thatthe period of the acting up arrangement does not exceed a total of six months.The only exception to this will be for acting up arrangements to be extendedas agreed by the Chief Executive.

3.8 Any post which is to be filled permanently following acting up arrangementsmust follow the formal recruitment procedure outlined in this policy.



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3.9 Staff who are subject to redundancy in their present post, or redeployment onmedical or other management grounds, must be given prior consideration forany suitable post before the recruitment procedure is followed. HumanResources hold a comprehensive redeployment register.

3.10 The South West Strategic Health Authority uses an advertising agency forplacing advertisements in the required publication(s). The agency will provideproof documents prior to placement, which enables the presentation, contentand detail of the advertisement to be assessed. Confirmation of agreement toadvertise will be sought along with authorisation to proceed from the budgetholder.

3.11 The content of advertisements will vary according to the vacancy, but thefollowing checklist gives items which must be included:

• NHS South West logo (external publications only);

• NHS Jobs post reference number (external only);

• job title and base;

• salary range and type of contract, including hours;

• duration of contract;

• brief description of main tasks and responsibilities;

•

closing date;

• interview date, if available;

• contact name and details for further information regarding the vacancy;

4. Post specific information

4.1 The Human Resources team must receive a job description, personspecification and Knowledge and Skills Framework outline electronically with

every recruitment request.

4.2 NHS Jobs will contain all relevant information for each post. Additionalinformation can be added via a link or uploaded document.

4.3 Should applicants require assistance with the completion of their applicationform, they will be invited to contact the Human Resources team.



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4.4 Successful applicants who have applied via NHS Jobs will be asked to sign aprinted copy of their application form to confirm that the details recorded arecorrect and complete. In doing so the employee declares that if the details arefound to be false or misleading this could result in prosecution and/ordismissal. Under no circumstances should an employee commence

employment without a signed application form.

5. Shortlisting

5.1 Applications will automatically be accepted if received by midnight on thespecified closing date. Late applications will only be accepted in extenuatingcircumstances and must have the approval of the Head of Human Resources.

5.2 Anonymised applications for posts advertised will be sent (electronicallywhere requested) to the Shortlisting Panel on the working day following theclosing date.

5.3 It is recommended that a minimum of two appropriate staff members carry outthe shortlisting process.

5.4 On the Shortlisting Form enter only the criteria that you are able to assessfrom the application form. Shortlisting and selection must be based solely onthe extent to which candidates fulfil the criteria for the post based on the jobdescription/person specification – no other factors should be taken intoaccount, including previous knowledge of an individual or informalrepresentations made by others. Reliance on facts is less likely to lead to anill-informed decision and complaint of discrimination.

5.5 Candidates who do not meet the minimum criteria should not be shortlisted forinterview. Wherever possible, internal candidates should be given theopportunity of being interviewed, provided that they meet the shortlistingrequirements. Disabled candidates who meet the essential criteria for the jobmust be shortlisted.

5.6 All applicants will be notified if they are not shortlisted for interview.

5.7 Every effort should be made to ensure there are at least ten clear working daysbetween completed shortlists being returned to the Human Resources team

and the interview date.

5.8 It is the responsibility of the manager to arrange the interview venue andpanel membership.

5.9 For senior posts the manager is also responsible for arranging an externalassessor who will participate in the shortlisting process and form part of theinterview panel.



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5.10 If the interview includes a presentation or exercise, the manager shouldarrange the equipment required. The title of any presentation or exerciseshould be provided to the Human Resources team with the completedshortlist in order that shortlisted candidates can be advised in their invitationto interview.

6. Interviews

6.1 The interview remains the most widely used selection tool. However, in orderto be effective, the process requires adequate planning and due considerationshould be given to the:

• venue;

• timetable;

• date;

• assessment methods.

Venue

6.2 The appropriate setting for an interview must be considered and the followingtaken into account:

• location and accessibility of the room and its suitability to hold a privateconversation;

• arrangement of furniture within the room;

• possibility of interruptions from visitors and telephone calls, which willintrude and impede the flow of the interview;

• equipment requirements for practical assessments.

Timetable

6.3 The amount of time required for each interview can be approximatelydetermined and a gap of five to ten minutes allowed between each interview.Clearly, the level of appointment and numbers of the panel will be an indicatoras to the appropriate length for each interview.

Assessment methods

6.4 Certain posts may benefit from the incorporation of a practical assessmentinto the interview process. Methods include typing tests for secretarial staffand presentations for senior posts. They must relate to the requirements ofthe post.

6.5 Further advice on assessment methods can be obtained from the HumanResources team.



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Interview packs

6.6 Human Resources will provide each member of the interview panel with aninterview pack, either electronic or paper as required. This will comprise of:

•application forms;

• job description;

• person specification;

• Knowledge and Skills Framework;

• timetable;

• interview question form;

• interview score sheet;

• illegal interview questions;

• process for checking identity.

6.7 For completion at the end of the process, the Chair will also be provided with:

• an interview panel decision form;

• appointment offer form;

• IT set up form;

• salary scale information.

Interview panel membership

6.8 The interview panel should consist of at least two appropriate members ofstaff, preferably those that shortlisted the applications and provide an equalrepresentation across gender and ethnic groups as far as practicablypossible.

6.9 Where a member of the interview panel personally knows a candidate thepanel member should notify the other panel members and declare this on theinterview score sheet. The panel member may remain on the panel but theyshould adhere to strict criteria in order to limit the potential to discriminate.Further guidance can be obtained from the Human Resources team.

6.10 If the interview panel member is the manager of the candidate, or hassupervised the candidate either currently or previously, no other informationother than that provided on the application form or prior knowledge of theindividual should come into play and have any bearing on the decision-making.



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6.11 Panel members should normally be on a higher grade than the post to whichthey are interviewing.

Notification of interviews

6.12 Shortlisted applicants will receive a written communication inviting them toattend for interview. Applicants will also be advised of the requirement to seedocumented evidence that they are legally entitled to work in the UnitedKingdom and documented evidence of their professional registration whereappropriate. If the interview includes a presentation, the Human Resourcesteam will advise candidates of the details in their invitation to interviewincluding the equipment available to them.

Pre interview

6.13 A designated administrator will meet the candidates, check and photocopy the

original qualification certificates as stated on the application form and certifythem as true copies of the original. These will be kept on the successfulcandidate’s personal file.

6.14 It is recommended that all panel members meet prior to the commencementof the interviews to prepare suitable questions and plan how the interview willbe conducted. Interviewers should work to a structure of questions based onthe job description and person specification and each interviewer shouldidentify the question(s) they will ask the candidates.

6.15 The same questions need to be asked of all candidates and must be written

down to ensure that no deviation occurs.

Conducting the interview

6.16 Structured interviews will ensure that broadly the same areas are covered forall candidates. A structure will also aid the panel to more easily monitor theprogress of the interview and to ensure that the discussion remains job-related. Adherence to a structure exposes gaps in the evidence collectedwhich might otherwise be overlooked.

6.17 Attention should be paid to the employment history of the applicant and anygaps scrutinised in order to establish justification for any breaks inemployment.

6.18 The opportunity should always be given to candidates to ask questions aboutthe organisation and the job for which they are applying. Interviewers shouldendeavour to have the information to hand on any questions that are likely tobe raised and the interview should be planned to ensure that there is sufficienttime in which the applicant may ask them.

6.19 Any notes recorded at the interview should be factual and objective. Thisevidence could be requested by a candidate at a later date in the event thatthe selection process is challenged.



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Post interview

6.20 After the interviews, panel members are required to complete the InterviewScore Sheet clearly stating why a candidate was/was not selected forappointment. No collective discussion should take place prior to the

completion of the Interview Score Sheet. Once the process has beencompleted and the collective discussion has taken place, the Chair shouldcomplete the Interview Panel Decision Form.

6.21 It is good practice to give candidates feedback on their interview performance.A panel member may telephone candidates to advise them of the outcome ofthe interview and give feedback. The Human Resources team should also beadvised which of the panel members will give this feedback.

7. Clearance

Health clearance

7.1 The successful applicant will be asked to complete a confidential healthquestionnaire which will be forwarded to the Occupational Health Service.

7.2 Sickness absence recorded on the reference forms of the successfulcandidate will be referenced against information submitted by the candidateon their statement of general health form.

References

7.3 The purpose of a reference is to obtain in confidence factual information abouta prospective employee. References are confidential documents and shouldbe treated as such.

7.4 The Human Resources team will take up a minimum of two references andsend these to the Chair of the panel. A reference should provide confirmationof what has already been established at interview.

7.5 The application form requests that one referee should be the current or mostrecent employer. If, for any reason, it is established that this is not the case,the situation must be followed up with the applicant immediately and an

appropriate referee sought.

7.6 Clarification should also be sought on any ambiguous statements containedwithin references. A telephone call to the referee will suffice as long as thecontent of the discussion is documented.

7.7 A member of the interview panel is not precluded from giving a reference for ashortlisted candidate, however, it must be in writing (even if it is brief). Whenproviding a reference in such circumstances, the panel member must ensurethat the content of their reference relates only to the performance of theindividual and focuses directly on the job related issues.



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Criminal Records Bureau Clearance

7.8 Since 1 March 2002, criminal records checks, known as ‘Disclosures’ havebeen carried out by an Executive Agency of the Home Office called theCriminal Records Bureau (CRB).

7.9 The Disclosure service co-ordinates the information held on the PoliceNational Computer (PNC) and on lists held by the Department of Health andthe Department for Education and Employment. It offers an additional tool touse in the recruitment process that can reduce the risk of employing a personconsidered unsuitable to work with children, vulnerable adults or occupationsset out in the Rehabilitation of Offenders Act 1974.

7.10 Possession of a criminal record will not necessarily be a bar to employment.The decision to appoint or not is the responsibility of the Chair of the InterviewPanel and will be taken following full consideration of the nature of the

position applied for and the circumstances and background of an applicant’soffences, together with an overall assessment of an applicant’s applicationform, interview and references and the outcome of an Occupational HealthService assessment.

7.11 All applicants for posts working exclusively or occasionally with childrenand/or young people under the age of eighteen or vulnerable adults will berequired to provide a Criminal Records Bureau Enhanced Disclosure beforean offer of employment will be considered, the cost of this will be covered bythe South West Strategic Health Authority.

7.12 In addition to criminal record information, an Enhanced Disclosure willdisclose if the applicant’s name is included on the Protection of Children Actlist and/or the Department for Education list of people considered unsuitableto work with children. The Enhanced Disclosure process allows the ChiefConstable of the local Police force to disclose, separately from the mainDisclosure, Police intelligence information which may be relevant to theemployment decision. Intelligence information will not be disclosed, nor itsexistence revealed, to the applicant.

7.13 Applicants for posts working in financial services may be required to provide aStandard Criminal Records Bureau Disclosure.

7.14 If a Disclosure is required ensure that an open and measured discussiontakes place, at interview or in a separate discussion, on the subject of anyoffences or other matter or other matter that might be relevant to the position.Failure to reveal either on the job application form or at interview, informationthat is directly relevant to the position sought could lead to the withdrawal ofan offer of employment.

7.15 In the event of a dispute relating to the content of a Disclosure, or the identityof an individual for whom a Disclosure has been received, the South WestStrategic Health Authority will follow the Criminal Records Bureau Complaints

Procedure, details of which can be obtained from the Human Resourcesteam.



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7.16 The South West Strategic Health Authority reserves the right to require anemployee to provide a Criminal Records Bureau Disclosure at any time duringtheir employment. The cost of obtaining a Disclosure will be borne by theSouth West Strategic Health Authority.

7.17 Members of staff are asked to be vigilant at all times. Any concerns about theconduct or behaviour of another member of staff must be reported to their linemanager immediately, so that an investigation can be conducted into thealleged conduct or behaviour. Any information disclosed will be treated withthe utmost sensitivity. The Whistleblowing policy of the South West StrategicHealth Authority may be used to raise concerns about the conduct andbehaviour of any other member of staff.

7.18 Disclosure information is only used for the specific purpose for which it wasrequested and for which the full consent of the applicant has been given.

7.19 Timescales for processing disclosures will vary according to individualcircumstances, but as a guide it will take approximately three weeks.

7.20 In exceptional circumstances, employment can commence prior to the receiptof the Criminal Records Bureau report, if required. However, the recruitingmanager takes responsibility to ensure that the person works under fullsupervision or, if this is not possible, they either do not come into contact withchildren or do not attend work until the Criminal Records Bureau report hasbeen obtained.

7.21 Should the South West Strategic Health Authority subsequently receive a

Criminal Records Bureau disclosure that would have barred employment atthe recruitment stage, the organisation may terminate this employment withimmediate effect.

8. Employment of partners and/or relatives

8.1 Ordinarily, the employment of partners or relatives in South West StrategicHealth Authority should be of no significance but there are limitedcircumstances where managers should exercise caution.

8.2 Where there is the possibility of partners or family members working in posts

which have a direct line management relationship such that one would beinvolved in appointing, managing, counselling, appraising and/or disciplining theother, or where both would be members of a management group with corporateresponsibilities, division of loyalties or conflicts of interest may occur. Thesecircumstances should be avoided and the following procedures provideguidance.



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Procedures

8.3 So as to avoid difficulties related to the employment of partners and/or relatives,the following procedures must apply:

• all posts must be advertised and filled through the Human Resourceteam;

• a member of an appointment panel must declare any relationship whichthey have with an applicant at interview;

• in the event that both parties will occupy senior positions in the SouthWest Strategic Health Authority it would be highly desirable to sever adirect management relationship by altering accountability arrangements;

• Standing Financial Instructions must be followed in all instances where a

contract is being considered which involves a relative or partner.

8.4 It must be clear that the requirements of the equal opportunities and sexdiscrimination legislation must be scrupulously observed and selection forappointment, training and promotion must not be affected by marital or familystatus.

8.5 All employees must be treated fairly and the South West Strategic HealthAuthority must be seen as a fair employer with a high level of integrity.

9. Employment offer

9.1 A verbal offer may be made by a manager following interview provided that itis made clear to the candidate that the offer is conditional and subject to thefollowing conditions:

• verification of a minimum of 3 years previous employment;

• references and medical clearance satisfactory to the South WestStrategic Health Authority;

• eligibility to work in the UK;

• proof of identity;

• proof of qualifications declared on your job application form;

• the South West Strategic Health Authority being satisfied of suitabilityfor a position of trust.

9.2 All references will be retained on the successful applicant’s personal file. Anindividual should not commence employment unless satisfactory referencescovering a minimum of three years employment (or education) have been

provided. Telephone references are not acceptable.



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9.3 It is good practice for the interview panel chair to notify unsuccessfulapplicants by telephone and Human Resources will then confirm with an emailvia NHS Jobs.

9.4 A conditional offer letter will be sent to the successful candidate who will be

asked to confirm in writing their acceptance of the post. Candidates areadvised that if they resign from their previous post before references, policechecks and health clearance have been obtained, they do so at their own risk.The offer letter will be sent out within one working week of papers beingreceived by the Human Resources team.

9.5 Professional registration will be checked by the Human Resources team,usually prior to appointment. Evidence of professional registration checks willbe retained on the employee’s personal file. If registration is not satisfactorilyconfirmed South West Strategic Health Authority may withdraw the offer ofemployment.

9.6 The Chair will ensure all interview packs are returned to the HumanResources team, including those of the successful candidate. HumanResources will not be able to issue a conditional offer letter or requestreferences without return of fully completed and signed:

• interview panel decision form;

• appointment offer form;

• IT set up form.

10. Guidance on starting salaries (non-medical appointments)

10.1 If a manager wants to make an appointment on a salary above the minimumof the scale advertised, an award to incremental credit form must becompleted by the recruiting manager and signed off by the relevant directorand Human Resources.

Internal transfers or staff transferring from elsewhere in the NHS

10.2 Staff transferring from one post to another in the same pay band within the

NHS will enter the band on the same point as they were previously on.Confirmation of previous salary will be required and this should be confirmedby the manager having sight of the most recent pay slip at interview (copy toHuman Resources).

10.3 Staff who move to a lower pay band (whether voluntary or not) will enter theband at the point they would have reached if all their NHS service in anequivalent or higher pay band had been worked in the lower band.



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10.4 Staff appointed under paragraphs 1.2 and 1.3 will retain their previousincremental date unless they have had a break from NHS employment ofthree months or more. Where staff have had a break of less than threemonths, their incremental date will be deferred by an equivalent number ofdays to the length of the break.

10.5 Staff promoted within the NHS will enter the new pay band at the minimum orthe first point of the new pay band that provides them with an increase insalary.

10.6 Where necessary, individuals can be appointed temporarily to a higher payband when a vacancy is unfilled (but being advertised) or when the post isbeing held open for someone to return (such as secondment, long-term sickleave or maternity leave). Usually, such temporary appointments will last forno more than six months, unless a longer duration is known from the outset,such as where the secondment has been agreed for twelve months.

10.7 When deciding a starting salary for a returner to the NHS, breaks in servicemay be ignored when deciding the incremental point a person should be on,that is, the employee need not start again at the bottom of the scale if there isa break and any promotion may be calculated as if there was no break. Indeciding whether to give incremental credit for all previous service,consideration should be given to the length of the break and whether theperson has kept their continuous professional development up to date.Relevant experience outside the NHS should also be taken into account.Advice on what is ‘relevant’ should be sought from the Human Resourcesteam.

10.8 Once a starting salary has been accepted and the contract signed,progression through the pay scale will be annually in line with the identifiedincremental date of the individual, under Agenda for Change Terms andConditions.

New staff with no previous NHS employment

10.9 In general, new starters to the NHS should start on the bottom of the payband and work their way up through the incremental scale. Giving incrementalcredit without demonstrated justification is contrary to the principles of fairness

and equity that underpin these terms and conditions. It may also lead todiscrimination or equal pay claims. However, in exceptional circumstances,new starters can be placed at a point above the bottom of the pay band.

10.10 In certain circumstances, managers may offer new entrants a salary abovethe minimum of the scale in order to recognise relevant experience at thesame or greater level of responsibility gained outside of the NHS. A managermust be able to justify their decision, including the impact on:

• other staff already in post in their team;

• other staff within the South West Strategic Health Authority, outside oftheir immediate Directorate/department/team;



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• budgetary implications;

• consistency in the NHS South West.

10.11 Current salary should not be used alone as a way of determining a starting

salary, but it could be a factor when deciding to take previous relevantexperience into account. Appointing managers should point out the benefitsof the whole remuneration package, including pension contributions, annualleave, flexible working, relocation expenses and so on.

10.12 Any decision to award incremental credit to a new employee without NHSexperience must be authorised beforehand by the Human Resources teamand, if necessary, the Director of that service. Managers will be required toprovide written justification and supporting evidence to support their decisionand a copy of this will be retained on the personal file of the employee. Theattached authorisation form, including proof of current salary for example,

most recent pay slip should be used in these circumstances.

10.13 Relevant experience should be verified through the application form andreferences.

10.14 In fairness to existing staff or those who have been internally promoted, caremust be taken that incremental points in recognition of experience onlyrecognise completed years of experience at the level of the pay band inquestion, and not below it.

11. Additional procedures for dealing with high risk posts

11.1 Posts that are considered to be of high risk to the security of the South WestStrategic Health Authority will attract additional recruitment and selectionprocedures. These procedures are in place to guard the South WestStrategic Health Authority against collusion, corruption and fraud.

11.2 Additional procedures will only be applied to posts that have the potential toplace the South West Strategic Health Authority in a vulnerable position.Example of such posts include:

• Chair;

• Chief Executive;

• Directors.

11.3 Additional procedures will consist of:

• Criminal Records Bureau checks;

• additional references;

•

rigorous questioning at interview.



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11.4 If it is established that the applicant is related to another member of staff in ahigh risk post, this does not necessarily mean the applicant cannot beappointed. However, as described in Section 8, procedures will need to bedeveloped to ensure the risk of collusion, corruption or fraud is removed

12. Feedback and complaints

12.1 All candidates, whether internal or external, will routinely be offered theopportunity to receive feedback. Therefore, the Chair of the interview panelshould be prepared to provide such information. Feedback should always beconstructive and conveyed in a positive manner.

12.2 In addition, any applicant who feels unhappy with the way in which theirinterview was conducted, may write a letter of complaint either to the Chair ofthe interview panel or the Head of Human Resources.

13. Offer of employment

Unconditional offer letter

13.1 Once all checks have been satisfactorily met, an unconditional offer letter willbe issued along with a Statement of Main Terms and Conditions and StarterForm.

13.2 Appointed candidates who have a health problem or disability will beappointed on the same terms and conditions as someone in the same rolewho does not have a health problem or disability, notwithstanding adjustments

made by the South West Strategic Health Authority

Personal file

13.3 The Human Resources team will set up a personal file as soon as possibleafter an offer of appointment has been made.

Contract of employment

13.4 All employees of the South West Strategic Health Authority are entitled toreceive a written statement of particulars of employment no later than two

months after commencing work. Therefore, in order to comply with this legalrequirement, new employees will be issued with a Statement of Terms andConditions of Employment. The Human Resources team will ensure that onecopy of the contract is signed by the employee and filed in the personal file.

New starter documentation

13.5 On the new employee’s first day, the Starter Form should be completed by theemployee and the manager if not already done so. This must be returned toHuman Resources.

13.6 The appropriate payroll documentation will be sent to Payroll, a copy of whichwill be placed in the personal file of the employee.



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13.7 The Starter Form must include the continuous NHS service date whichHuman resources will verify.

14. Induction

14.1 Induction marks the beginning of the relationship between employer andemployee and is of fundamental importance in setting standards and patternsof behaviour for the organisation. It requires a structured and committedapproach to be successful.

14.2 Every new member of staff and every individual that transfers job requires aninduction. Some staff, such as individuals returning from a career break,people with disabilities, senior and non NHS Managers, will have specialinduction needs because the extent of their knowledge and experience willvary widely. In these circumstances, the Directorate of WorkforceDevelopment and the line manager should draw up a programme tailored to

the needs of the individual.

Responsibility for induction

14.3 Line managers have the primary responsibility for inducting members of theirteams. As well as being the most appropriate people to deliver on the jobtraining, participation in induction helps managers get to know and encouragethe progress of new employees.

14.4 The Staff Contact is a specially nominated colleague, chosen from the samework group as the new recruit who will act as a guide and adviser in the early

stages of employment. The Staff Contact will deal with the introduction ofother colleagues and the other items identified on the induction checklist.

15. Induction procedure

15.1 Whilst induction training should be informal, it must follow a structured plan. Achecklist will ensure that all the core issues are addressed. Managers should,however, tailor the induction to include their specific departmentalrequirements.

15.2 The South West Strategic Health Authority recognises that the induction

process begins during recruitment and selection, when contact is first madewith potential employees. Therefore, when the job offer has been made andaccepted, an induction programme should be drawn up for use during theearly stages of the new recruit’s employment.

15.3 The new employee should, in all but exceptional circumstances, be welcomedby their line manager at a specified time on the first day. The Staff Contactwill also welcome the new employee.



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15.4 The appointing manager will meet on a voluntary basis with the employee inorder to review the effectiveness of adjustments made to accommodatehealth problems or disabilities. If appropriate, changes in the effect of thehealth problem or disability would be discussed and any new adjustmentswhich might be needed agreed.

15.5 All new members of staff must complete the South West Strategic HealthAuthority Induction Process. New employees must comply withinduction/training requirements within three months of commencingemployment with the South West Strategic Health Authority.

Induction pack and staff handbook

15.6 The Human Resources team will provide the line manager with a standardinduction pack. However, it should be noted that the induction required for anemployee will vary according to the nature and seniority of the post being

filled.

15.7 The forms included in the induction pack must be returned, signed, by the endof the first week.

15.8 The employee will also receive a copy of the South West Strategic HealthAuthority Staff Handbook. This is a key element of the induction process andwill be sent to the employee with their contract prior to joining.

Checklist

15.9 Progress through the induction programme will be reviewed by the individualand line manager and, on satisfactory completion, the new employee will signthe checklist to confirm all elements have been understood. The linemanager will also sign to confirm the induction programme has been fullycompleted. The checklist will then be kept in the personal file of theemployee.

15.10 Whilst the induction programme should take approximately one month tocomplete, it is essential that Section A is carried out on the first day and thatthe signed sheet is returned to Human Resources.

15.11 Sections B and C should be returned to Human Resources after the first weekand first month respectively.

Corporate induction day

15.12 An invitation to attend the quarterly Corporate Induction day will be emailed tonew members of staff. Line managers should ensure their staff are availableto attend the entire day.

16. Monitoring

16.1 The Human Resources team is responsible for monitoring the inductionprocedure to ensure that new employees are properly inducted into theorganisation.



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17. Record keeping

17.1 The recruitment process should be accurately recorded and the informationon all applicants treated as confidential and only accessible to those directlyinvolved in the process. Records will be kept for one year. Should an

Employment Tribunal result from the recruitment process, the South WestStrategic Health Authority will be required to disclose documentsused/obtained in the process of recruiting any individual.

18. Monitoring and evaluation

18.1 The Human Resources team will undertake random sampling of candidatesinvited to attend for interview, in order to monitor and evaluate theeffectiveness and implementation of this policy.

19. Interview expenses

19.1 Interview expenses may be reimbursed in accordance with Agenda forChange travel and subsistence limits. Claim forms will be sent to allcandidates who request them. Candidates may submit claim forms at theinterview or send them in subsequently. Interview expenses forms should bereturned to the Human Resources team.

20. Relocation expenses

20.1 Expenses should be payable to employees who need to move home in orderto take up employment with the South West Strategic Health Authority.

20.2 The scope and level of assistance will be determined by the South WestStrategic Health Authority, in consultation with the individual, prior to the postbeing accepted.

20.3 Normally the assistance to be provided will conform to the list of expensesand benefits qualifying for exemption from Income Tax and NationalInsurance as allowed by HM Revenue and Customs. Additional expensesmay be approved by the Chief Executive of the South West Strategic HealthAuthority in conjunction with the Chairman where there is a particular difficultyin recruitment.

20.4 The application of this policy will satisfy the Dignity at Work policy of the SouthWest Strategic Health Authority.

20.5 The level of relocation expenses will be determined by reference to a movebetween comparable properties in the old and new areas of residence.Betterment should not be funded by the public purse. Normally, relocationexpenses will be limited to £10,000 and in any circumstances the totalreimbursement should not exceed £25,000.

20.6 The South West Strategic Health Authority will require an employee to repay

all or part of relocation expenses if the employee leaves the organisationwithin three years of the appointment that gave rise to their expense.



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Eligibility

20.7 Relocation expenses will only be paid if an employee is required, by thedistance or logistics of travel, to move home as a result of:

•commencing permanent employment with the South West StrategicHealth Authority;

• an organisation change;

• taking up a post which is regarded as suitable alternative employmentfor the purposes of excluding entitlement to redundancy.

20.8 Previous employment in the NHS is not required.

20.9 Relocation expenses will be payable to staff joining the South West Strategic

Health Authority in Agenda for Change Band 6 or above.

20.10 Relocation expenses will normally only be paid if the existing property isoutside of a 45 mile radius of the new base. However, expenses may be paidif the logistics of travel are such that the travelling time from the home of theemployee to their new base is in excess of one hour calculated at the usualtime of travel.

20.11 Where an employee has to provide emergency on-call services which wouldrequire attendance at the normal base, discretion may be exercised forrelocation expenses to be paid if the existing property is outside of a 25 mile

radius or 30 minutes travelling time.

Procedure

20.12 Where a successful candidate or existing employee meets the eligibilityrequirements above, the appointing manager will refer to their respectiveDirector who is responsible for determining the level of support to be provided.

20.13 Where an appointing manager considers that discretion should be exercisedthen a case should be submitted to the Director of Workforce Developmentwho will ensure that consideration is given by the Chief Executive inconjunction with the Chairman.

20.14 An employee must indicate, in writing, the need to claim relocation expensesprior to commencing employment and initiate the claim process within threemonths of taking up the appointment. Where an employee fails to give suchindication in time the employee may not be eligible to claim.

20.15 When the Director agrees to the payment of relocation expenses, the HumanResources team will be informed and will provide the employee with theRelocation Expenses form.



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20.16 Details of the Relocation Expenses Assistance which an individual may claimare set out at Annex 2. Annex 3 sets out details of the repayment ofrelocation expenses where an individual chooses to leave the employ of theSouth West Strategic Health Authority within three years of appointment.

Monitoring of expenditure

20.17 The individual is required to submit receipts before any reimbursement can bemade.

20.18 With the prior approval of the Director of Workforce Development, ornominated deputy, one advance that does not exceed £2,000 or 25% of theagreed expenses, may be made for an approved purpose. In this instance,receipts should be submitted retrospectively. Any advance paid will beincluded in the overall allowance.

Taxation of relocation expenses

20.19 Relocation Expenses are regarded as part of earnings for Income Tax andNational Insurance contributions purposes. Under this policy a contribution ofup to £25,000 may be made. It should be noted that the first £8,000 of anypayment is exempt from Income Tax and National Insurance contributionssubject to HM Revenue and Customs conditions being satisfied.



• all applicants will have been treated fairly and consistently when goingthrough the recruitment and selection process;


• all involved with the recruitment process have a clear understanding of

• the roles and responsibilities involved.






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Job Description

Job title:Grade/Pay band

Base:

Responsible to: Post title of the manager the post holder reports to.

Accountable to: Post title of the person the post holder is accountable toin respect of service/professional issues.

Manageriallyresponsible for:

Post titles of all posts that report directly to the postholder, and clearly indicate whether the employeesupervises/manages/reviews these post holders as partof the Appraisal process.

Directorate:

Job reference:Last update (insertdate):

Key relationships: This section should list the individuals or bodies the postholder will come into contact with as part of their roleincluding both internal and external relationships.

1. Job purpose

1.1. This section should clearly state the role of the post holder – what they will do

and the expected purpose (or outcome) and its principle activities (or input).

2. Organisational position

2.1. This section should show the Directorate organisation chart and identify theposition of the post holder.

3. Role of directorate

3.1. This section should explain what service the Directorate provides and how ithelps the organisation achieve its objectives.

4. Key result areas

4.1. This section should clearly identify the key areas of achievement for the postholder.

5. Communications and working relationships

5.1. This section should set out the:

• skills required of the post holder to communicate, establish andmaintain relationships and gain the cooperation of others;



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• extent to which the post holder will be required to motivate, negotiate,persuade, make presentations, train others, empathise, communicateunpleasant news sensitively and provide counselling and reassurance;

• extent to which the post holder may have difficulty in exercising theseskills.

6. Knowledge, training and experience

6.1. This section should set out the minimum knowledge, training and experiencerequired to undertake the role satisfactorily. This includes theoretical andpractical knowledge, professional, specialist or technical knowledge; andknowledge of policies, practices and procedures associated with the job.

6.2. It should outline the educational level expected of the post holder as well asthe equivalent level of knowledge required without undertaking a formalcourse of study (without stating the number of years required – as this isdiscriminatory under age discrimination legislation), and the practicalexperience required to fulfil the job.

7. Freedom to act, analysis and judgement


• post holder’s freedom to act and identify at what stage they would be

expected to seek advice;

• analytical and judgemental skills required to fulfil the post holder’sresponsibilities satisfactorily, including the extent to which the postholder will be expected to understand complex situations andinformation and use judgemental skills to formulate solutions torecommend/decide on the best course of action.

8. Planning and organisation


• planning and organisational requirements of the job, including therequirement to planning and organise service, departments, rotas,meetings, conferences and for strategic planning;

• degree of complexity and uncertainty involved in these activities shouldalso be described.



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9. Physical, mental, emotional and environmental demands ofthe job

9.1. This section should include the:

• nature, level, frequency and duration of physical effort required – suchas carrying, lifting, working in an awkward position for a sustainedamount of time;

• the nature, level, frequency and duration of the mental effort requiredfor the job, such as concentration, responding to unpredictable workpatterns, interruptions and the need to meet deadlines;

• the scope of the emotional effort required of the post holder, includingdirect or indirect exposure to emotional or distressing circumstances,

such as imparting unwelcome news to staff, disciplinary hearings,typing reports concerning child abuse;

• the level of IT/keyboard skills required;

• an explanation of the working environment – such as open plan offices;

• the amount and nature of travelling required;

• the level of interruptions the post holder will experience and the extentto which this will require them to stop what they are doing and change

to another task;

• the predictability of the workload and level of requests for help.

10. Patient and client involvement

10.1. This section should outline the nature of patient/client contact the post holderwill experience, this may range from incidental patient contact, toresponsibility directly managing a whole service including employees whoprovide a direct patient/client care.

11. Policy and service development

11.1. This section should set out:

• responsibilities of the post holder for the development andimplementation of policy and/or services;

• nature of the responsibility and the extent and level of the post holder’scontribution to the relevant decision-making process, for instancemaking recommendations to decision makers;



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• extent to which the relevant policies or services relate to a function,department, directorate, organisation, or wider than this;

• degree to which the responsibility is shared with others.

12. Finance and physical resources

12.1. This section should outline the:

• responsibility for financial resources - such as vouchers, cheques,invoice payment, budgets, revenues, invoice payment; and the natureof the responsibility - such as careful use, maintenance, budgetary andordering responsibilities, the frequency with which it is exercised, thevalue of the responsibility and the extent to which it is shared withothers;

• responsibility for physical assets, such as office equipment, tools andinstruments, stocks and supplies.

13. Systems, equipment and technology


• systems, equipment and machinery the post holder will be required touse;

• responsibilities of the post holder for information resources (paperbased and computerised) and information systems (both hardware and

software);

• nature of the post holder’s responsibility for security, processing andgenerating information, creation, updating and maintenance ofinformation databases and systems.

14. Research and development

14.1. This section should set out the extent and nature of informal and formal

research and development activities required by the postholder underpinnedby appropriate methodology and documentation.

15. Most challenging parts of the job

15.1. This section should set out the most challenging and difficult parts of the job.



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16. Health, safety and risk management

16.1. Under the Health and Safety at Work Act 1974, as an employee, you musttake reasonable care for the health and safety of yourself and for otherpersons who may be affected by your acts or omissions at work. The Act also

states that you must not intentionally or recklessly interfere with or misuseanything provided in the interests of health, safety and welfare.

16.2. You are also required to make yourself aware of, and must at all times complywith, the South West Strategic Health Authority Health and Safety policy andassociated procedures; in particular, but not exclusively, those relating to fireregulations, office safety, moving and handling, visual display unit and firstaid. You should follow the agreed safe working procedures and reportincidents using the South West Strategic Health Authority Incident ReportingSystem.

16.3. You are required to inform your line manager of any safety issues that couldaffect you or others in the work place. You are responsible for your own healthand safety and must co-operate with management at all times in achievingsafer work processes and work places, and in particular where it can impactothers.

16.4. You will be trained in the correct use of any equipment provided and arerequired to use the equipment when necessary and as instructed. It is yourresponsibility to ensure equipment is safe to use prior to its use. Any defectsmust be reported immediately to your line manager.

17. Personal development review, training and personaldevelopment

17.1. You must take personal responsibility, in agreement with your line manager,for your own personal development and should take a proactive approach toyour own personal development and to co-operate with the Knowledge andSkills Framework and Personal Development Review processes to ensurethat competences, skills and knowledge consistently match the changingrequirement of the post.

17.2. Each year personal objectives will be agreed with you. Performance inachieving these objectives will be discussed regularly and there will be anannual Appraisal.

17.3. A Personal Development Plan will be agreed with you and updated at leastannually.

17.4. You must undertake all mandatory training required for the role, includingequality and diversity, disability awareness, fire safety, health and safety, andmanual handling.



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18. Confidentiality

18.1. It is the responsibility of all employees to ensure the preservation ofconfidentiality, integrity and availability of data. In the discharge of your dutiesyou may often be in possession of confidential or personal information. You

must not disclose or discuss such information, unless with authorisedparties/persons identified by the Chief Executive or another Senior Officer ofthe South West Strategic Health Authority.

18.2. Disclosure of any confidential information to any unauthorised third party willbe considered a disciplinary offence which, depending upon the severity ofthe offence could result in the possibility of dismissal of the offender. Thisdoes not affect your rights under the Public Interest Disclosure Act (1998).

19. Equality and diversity

19.1. All duties must be carried out in a manner that recognises and promotes theabsolute commitment and duty of the South West Strategic Health Authority toachieve diversity and equal opportunities.

19.2. You must co-operate with all the policies and procedures designed to ensureequality of employment. Colleagues and visitors must be treated equallyirrespective of gender, marital status, disability, religion, creed, colour, race,ethnic or national origin, sexual orientation or social background.

20. Flexibility

20.1 This job description is designed to identify the principle responsibilities of thepost only, and is subject to review in the light of the changing needs of theproject. The post holder is required to be flexible in developing this role torespond to new and changing demands;

20.2 The post holder is expected to take a proactive approach to his/her owndevelopment and to co-operate with the Knowledge and Skills Framework andpersonal development review processes to ensure that competences, skillsand knowledge consistently match the changing requirement of the post.

21. General duties

21.1. The post-holder is required to adhere to the policies and procedures of theSouth West Strategic Health Authority at all times.

22. Review

22.1. This job description is designed to identify principle responsibilities only. Thepost holder is required to be flexible in developing the role in accordance withthe agenda and priorities of the South West Strategic Health Authority. Any

formal review of this job description will be undertaken in consultation with thepost holder.



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Person Specification

Essential Desirable Method ofAssessment

Qualifications Outline theessentialeducation andqualificationsrequired for therole and theequivalent level ofknowledge gained

withoutundertaking aformal course ofstudy. (Do notstate the numberof yearsexperiencerequired as this isdiscriminatoryunder agelegislation.)

This might alsoinclude specifictraining andcourseattendance.

Indicate themethod by whichthe criterion will beassessed, such as:

• applicationform;

•

proof ofqualifications;

• interview;

• presentation;

• skills exercise;

• references.

KnowledgeThis should link tothe NHSKnowledge andSkills FrameworkFoundation

Outline.

This should link tothe NHSKnowledge andSkills FrameworkFull Outline.

ExperienceDo not state thenumber of yearsexperiencerequired as this isdiscriminatoryunder agelegislation.

This should link tothe NHSKnowledge andSkills Framework

This should link tothe NHSKnowledge andSkills FrameworkFull Outline.



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FoundationOutline

SkillsThis should link tothe NHSKnowledge and

Skills FrameworkFoundationOutline

This should link tothe NHSKnowledge and

Skills FrameworkFull Outline.

Job Description and Person Specification Agreement

Job Holder’s Name: ................................................................................................

Job Holder’s Signature:......................................................... Date: ..................

Manager’s Name:....................................................................................................

Manager’s Signature:............................................................ Date: ..................



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Relocation expenses assistance

1. Approved assistance payments

1.1 The sum total of assistance offered will not exceed £25,000 of which

£8,000 may be subject to tax exemption.

1.2 The expenses must be incurred by the applicant who must certify thatthey are not recoverable in full or part from any other source.

2. Accommodation

2.1 Accommodation and living costs shall be allowed during an individual’ssearch for accommodation at the rate set out under “Night Allowances:First 30 nights” of Annex N to the Agenda for Change: NHS terms andConditions of Service Handbook. (Currently a maximum of £55 per

night.) With prior agreement by the Director of WorkforceDevelopment, an additional payment of £25 per night may be paid foraccommodating the partner of the individual and/or other dependents.

3. Expenses connected with the sale of accommodation.

3.1 Expenses which may be claimed in respect of a sale of a property,subject to satisfactory receipts, include:

• legal fees and services including mortgage/loan redemptionfees;

• Home Information Pack (HIP) where required by law;

• estate agents/auctioneers fees and services;

• advertising;

• disconnecting services, such as gas and electricity;

• continuing commitment in the old area, such as houseinsurance, but excluding mortgage payments, council tax, re-

directing mail.

4. Expenses connected with the purchase of a new home

4.1 Expenses which may be claimed related to the purchase of the newhome, subject to satisfactory receipt, include:

• legal fees and services;

• loan arrangement costs and mortgage indemnity premiums;

• structural surveys and valuations;



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• Stamp Duty and Land Registry fees;

• connection fees for services.

5. Removal and storage of furniture

5.1 Removal and storage may include any reasonable costs including:

• removal of furniture and effects from the old to the new home,including packing and unpacking;

• storage of furniture and effects for up to a maximum of sixmonths;

• insurance of goods in transit and storage;

• hire of suitable vehicle for up to three days where a removalcompany is not used.

5.2 Where a removal company is used three quotations should be obtainedand produced; the lowest of the three quotes should be accepted.Where a vehicle is hired the applicant should be able to provideevidence that it was the lowest cost option.

6. Return travel to the old home

6.1 An employee may claim travel expenses to return to the old home:

• at weekends where the family is still resident in the old home;

• not more frequently than monthly where the family has moved tothe new area;

• to supervise the removal from the old home;

• travel expenses will be reimbursed at either second class railfare, public transport mileage rate or lease car mileage rate,whichever is appropriate.

7. Leave for supervising a move

7.1 An employee may be given up to two days paid leave to supervise amove either out of or in to a property.

8. Miscellaneous expenses

8.1 The South West Strategic Health Authority may make a payment of upto £500 for the cost of fitting carpets, curtains, television aerials andsuch like, but not the purchase cost of these items, where the goods in

the old home are unsuitable for installation in the new home. Receiptswill be required for any individual expenditure over £50.



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9. Betterment

9.1 For the purpose of calculating expenses under this policy the propertybeing purchased in the new area should be of a similar standard to thatbeing sold in the old area.

9.2 If the type of house in the new area is deemed to be of greater notionalvalue than the house in the old area (such as a four bedroom detachedhouse replacing a three bedroom semi-detached) expenses will bereduced in proportion to the selling price of the old property. Wheresale has not taken place at the time of the purchase of the new house anotional assessment will be made to the value of the property beingsold. The employee will be advised of any adjustment to the expensesallowed.

10. Taxation of relocation expenses

10.1 The allowance payable for relocation expenses within this policy areconsidered to be within the exemptions allowed by the HM Revenueand Customs up to a limit of £8,000. However, any matters of taxationare for decision between the employee and the HM Revenue andCustoms.

10.2 To be eligible for tax relief the relocation expenses must be incurred, orthe benefits provided, before the end of the tax year following the onein which the employee starts the new job. A tax year runs from 6 Aprilin one year to 5 April in the next. Appointing offices should be aware

that an appointment made between the 1 to 4 April will constitute anappointment within one tax year.



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Relocation expenses agreement

1. Termination of employment1.1 Where an individual who has received Relocation Expenses under this

policy leaves the South West Strategic Health Authority, whether byresignation or disciplinary action, within three years of the date ofcommencement of employment, the employee shall be required to:

• notify the South West Strategic Health Authority of the intentionto leave as soon as possible or at least in accordance with thecontractual period of notice;

• repay to the South West Strategic Health Authority a percentageof the said Relocation Expenses on the basis as detailed below:

Leaving within andup to

Amount to be Repaid

1 year 90% of expenses to be repaid2 years 60% of expenses to be repaid3 years 30% of expenses to be repaid

1.2 Where termination of employment from the South West Strategic

Health Authority results from compulsory redundancy, or redeploymentto avoid compulsory redundancy, the Authority may, at its discretion,forgo any claim to repayment of relocation expenses.



Appendix 21

Representation at Work

This appendix sets out the revised Representation atWork Policy for the South West Strategic HealthAuthority.





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Representation at Work Policy

1. Introduction

1.1 The South West Strategic Health Authority recognises all Trade Unionsregistered with the Trade Union Congress and professionalorganisations to which members of staff belong as staffrepresentatives.

1.2 In the event of staff who are members of representative bodies beingtransferred to the employment of South West Strategic Health Authorityunder the provisions of the Transfer of Undertakings (Protection ofEmployment) Regulations 1981 (as amended), Trade Unionsrecognition rights will be preserved in accordance with the Regulations.

1.3 The South West Strategic Health Authority is committed to the fair andconsistent treatment of staff regardless of their sex/gender, sexualorientation, religion or religious beliefs, race, age, or disability. Whereevidence of inequality or adverse effect is found the South WestStrategic Health Authority will take appropriate action.

2. General principles and scope of policy

2.1 The South West Strategic Health Authority and the representativeorganisations have a common objective in ensuring the continuingprovision of efficient, high quality treatment and/or care to patientswithin the catchment area of the South West Strategic Health Authority.

2.2 All sides recognise that pursuit of this common objective under thispolicy shall be by:

• negotiation for the purpose of reaching agreement and avoidingdisputes. The scope of such negotiation shall be those areasdefined in Section 178 of the Trade Union and Labour Relations(Consolidation) Act 1992;

• consultation:

* the exchange of views based on the general principle thatthe mere exchange of information is not consultation.Consultation involves an opportunity to influencedecisions and their application;

* in particular, consultation will cover:

− consequent operational decisions, especially thoselikely to affect the job prospects or job security of

particular groups or occupations;



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− all aspects of the immediate job environment andthe employment relationship between the SouthWest Strategic Health Authority and its employees;

• information by which management and staff representatives

agree to ensure effective dialogue by supporting systems ofcommunications employed within the South West StrategicHealth Authority.

2.3 Representative bodies recognise the responsibility of management toplan, organise and manage the activities of the South West StrategicHealth Authority according to the objectives set by the South WestStrategic Health Authority and associated health and social careorganisations.

2.4 The South West Strategic Health Authority recognises the responsibility

of the staff representatives to represent the interests of their membersemployed by the South West Strategic Health Authority and to work forimproved employment and working conditions.

2.5 The South West Strategic Health Authority considers that the pursuit ofsound employee relations is facilitated by its employees beingmembers of representative bodies.

2.6 All sides agree that it is in their mutual interest to observe soundnegotiating and consultative procedures by which all issues arisingbetween them can be considered and resolved.

2.7 In the event of a dispute (collective grievance) being raised by one ormore representative bodies and a resolution is not achieved throughthe South West Strategic Health Authority Grievance policy, the mattermay be referred to the Advisory, Conciliation and Arbitrary Service(ACAS) for conciliation by either side or for arbitration.

2.8 In keeping with the Grievance policy of the South West Strategic HealthAuthority, the status quo shall apply until the above provisions areexhausted.

3. Representation

3.1 The South West Strategic Health Authority recognises the right ofrepresentative bodies to elect representatives to act as lead bodies ontheir behalf in accordance with this policy.

3.2 Representative bodies agree to provide representatives with writtencredentials and notify management of those representatives and theirconstituencies.



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4. Consultation and negotiating procedures

4.1 The agreed constitution of the South West Strategic Health AuthorityJoint Management and Staff Committee is attached as Annex 1.

4.2 The South West Strategic Health Authority Joint Management and StaffCommittee may, from time to time, establish working parties to dealwith matters of specific interest to a particular group of employees. Theterms of reference and level of authority of such working parties will bedetermined by the South West Strategic Health Authority JointManagement and Staff Committee.



• all employees will have been treated fairly and consistently andhave a right to representation at work;

• the needs of individuals are balanced with the overallrequirements of the South West Strategic Health Authority;

• all employees have a clear understanding of the roles andresponsibilities of Trade Union representation in terms of thework place

5.2 An impact assessment for this policy will be completed every three

years.

Policy Approved : April 2010




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Annex 1


Joint Management and Staff Committee Constitution

1. Title of the Committee

1.1 The Committee will be called the Joint Management and StaffCommittee (“the Committee”).

2. Terms of reference

2.1 The aims of the Committee are:

• to promote effective communications within the Strategic HealthAuthority;

• to ensure that our staff are able to contribute to the formation ofnew employment policies and working practices;

• to promote recognition that all our staff have a mutual interest inensuring the Strategic Health Authority supports the delivery ofappropriate health care to the South West population.

2.2 The Committee may discuss the following matters:

• health and safety (but not replace a formal Health and Safety

Committee);

• Human Resources policies;

• working practices;

• the business activities of the Strategic Health Authority asoutlined in the Business Plan or any matters arising from this. Insuch matters the Committee will be consultative.

2.3 In fulfilling the above aims it is accepted that:

• working parties may be set up as required, on a short-term orcontinuing basis, although any agreements reached by aworking party are subject to ratification by the full Committee;

• issues relating to individual members of staff, particularlycounselling, disciplinary matters or individual grievances, will bedealt with through the use of agreed policies and proceduresand not within the Committee;

• any issues which only affect a specific Directorate will first be

addressed with the appropriate Director;



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• issues relating to local pay and conditions of employment will notbe dealt with by the Committee;

• the Committee will not have the authority to make budgetarydecisions;

• where the Strategic Health Authority is already obliged orempowered to consult its employees and Trade Unionrepresentatives, whether under a discretionary, contractual orstatutory regime then it reserves the right to deal with suchmatters exclusively under that regime and not as part of theterms of reference of the Committee. Examples of the types ofcases include consultation in relation to:

• business transfers under Transfer of Undertakings (Protection ofEmployment) Regulations 1981;

• redundancies, whether collective, in accordance with the TradeUnion and Labour Relations (Consolidation) Act 1992, orindividual;

• health and safety issues;

• pensions issues.

3. Membership

3.1 The Committee will be composed of elected members of staffrepresenting all Directorates of the South West Strategic HealthAuthority and the Severn and Peninsula Deaneries. Two employeeswill be elected from each Directorate – a representative and deputyrepresentative.

Staff representatives

3.2 A nominations process has taken place to enable staff to nominate andelect Staff Representatives for each Directorate and Deanery to sit onthe Committee. The Strategic Health Authority will encourage, as much

as is reasonably possible, that coverage includes a mix of full and parttime employees from both the headquarters and satellite sites.

3.3 If the Staff Representatives are also Trade Union members theirattendance will be in their role as a member of staff, not a TradesUnion representative. If a Trade Union representative wishes to attenda Committee meeting they will provide notice to the CommitteeSecretary of their intention to do so at least three working days inadvance of the meeting.



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3.4 Staff Representatives are entitled to take reasonable time off duringworking hours to attend meetings to enable them to perform their rolesas Representatives, and to be paid for this time. However, sucharrangements should be agreed and discussed with the manager ofindividual employees.

3.5 Each Staff representative will initially be elected for a period of oneyear. At the end of the year’s term, the Committee will reviewextending the term of office. This provides a sense of continuity andallows relationships and experience to develop. Arrangements for re-election will comprise the same format as the originating nominationsand election process, and will ideally be staggered to allow forcontinuity of the Committee. Employees will be entitled to be nominatedfor re-election.

Management representatives

3.6 Management representation will consist of:

• the Director of Communications and Corporate Services (Chair);

• the Director of Workforce Development;

• a member of the Human Resources team;

• other managers co-opted as required.

4. Confidentiality4.1 The Committee will be an open forum. However, matters discussed at

Committee meetings may (rarely) be sensitive or confidential in nature,therefore Members are reminded of their agreement to their generalcontractual duty of confidentiality. Broadly speaking, however, theassumption should be that Staff Representatives should not be boundby a confidentiality obligation unless the Chair explicitly asks for it.

4.2 Any breach of confidentiality will be dealt with in accordance with theSouth West Strategic Health Authority Disciplinary procedure and could

ultimately result in loss of office. The South West Strategic HealthAuthority also reserves the right to undertake such legal action as isnecessary where the misuse (including without limit disclosure ofinformation) damages the South West Strategic Health Authority.However, no action will be taken where the Staff Side Representativereasonably believes the disclosure of confidential information to be a“protected disclosure” within the meaning given to that expressed bySection 43a of the Employment Rights Act 1996.



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4.3 There will also be a clear understanding about the position of anyexternal parties invited to Committee meetings such as Trade UnionRepresentatives or consultants/representatives. It is important that allparties understand what information they need to treat as confidentialand why.

5. Communications

5.1 Meetings will be held bi-monthly but this period may be varied at therequest of a Representative subject to the approval of the Chair. Itemsfor the agenda should be submitted ten working days before themeeting and the agenda should be published five working days inadvance of the meeting.

5.2 Reporting back and seeking opinion about what happens in Committeemeetings should usually be the responsibility of Staff Representatives

at Directorate or team meetings. However, management should alsohelp disseminate the information from Committee meetings to theStrategic Health Authority employees. Representatives should reportback to employees as soon as possible. Any delay in reporting backcould lead to frustration and allow scope for rumours to develop inplace of hard information.

5.3 Formal minutes should be prepared by the Committee Secretary withinseven working days, distributed to the Committee Representatives byemail for onward circulation. The minutes should also be madeavailable electronically on the intranet, on notice boards and in the Staff

Room. The Chair of the next Committee meeting should sign off theminutes.

5.4 Minutes will also be circulated to the Senior Management Team forinformation.

6. Constitution

6.1 The Constitution will be agreed in partnership between managementand staff representatives. It will be ratified at the first meeting of theCommittee, and reviewed on an annual basis.

Staff Representative Signature: ……………………………… Date: ………………

Chair Signature: ……………………………………………….. Date: ………………



Appendix 22

Retirement Policy

This appendix sets out the revised Retirement Policyfor the South West Strategic Health Authority.





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Retirement Policy

1. Introduction

1.1 The Employment Equality (Age) Regulations 2006 came into effect onthe 1 October 2006 and employees approaching 65 are entitled to beoffered the chance to continue working on after the date of their 65th birthday. Every member of staff must be informed between six totwelve months before they reach their intended retirement date theyhave the right to request to continue working, and must have aninterview with their line manager to discuss this (See Annex 1).

1.2 The South West Strategic Health Authority is committed to the fair andconsistent treatment of staff regardless of their sex/gender, sexual

orientation, religion or religious beliefs, race, age, or disability. Whereevidence of inequality or adverse effect is found the South WestStrategic Health Authority will take appropriate action.

2. Scope

2.1 This policy applies to all employees of the South West Strategic HealthAuthority.

3. Retirement age

3.1 The Default Retirement Age is 65 years.

3.2 Staff may be able to access their NHS pension form the age of 60,dependent on the pension scheme to which they contribute.

3.3 Some nurses, midwives, health visitors, occupational health nurses andphysiotherapists are able to retire on full benefits from age 55, providedthat their last 5 years membership is in one of these jobs and that theywere members of the scheme prior to 6 March 1995.

3.4 Some men in the jobs referred to in section 3.3 can also retire from age

55, but their benefits are only based on membership from 17 May1990. Benefits for membership before that date will not be paid untilage 60 unless they choose to take early retirement benefits.

3.5 All members can choose to retire early from age 50 years, but benefitswill be actuarially reduced to cover the extra cost of being paid forlonger. This reduction also applies to those staff identified in sections3.3 and 3.4 who retire before the age of 55 years. Acceptance ofvoluntary early retirement is not guaranteed.



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3.6 For Medical and Dental Staff this policy is modified by paragraph 200 ofthe Terms and Conditions of Service for Hospital Medical and DentalStaff (England and Wales) and paragraph 200 of the Terms andConditions of Service for Doctors in Public Health Medicine (England &Wales). Details held with NHS Employers.

3.7 Nothing in this policy detracts from the right of individuals to take earlyretirement under the provision of the NHS Superannuation Scheme.

3.8 Nothing in this policy shall inhibit the freedom of staff to choose to retireearlier than the retirement ages stipulated.

3.9 Early retirement on health grounds or organisational change willoperate in appropriate cases in accordance with current terms andconditions of service.

4. Flexible retirement options

4.1 there are a number of flexible retirement options available to staff whichinclude:

Winding Down

• Working fewer hours in an existing post. There is a generalmisconception that moving into part time work in the yearsleading up to retirement may reduce eventual pension.However, pensions for part time staff are actually calculated on

the whole time equivalent salary, so moving from full time to parttime work, rather than retiring, should not reduce the levelpension although it will reduce the level of service.

Stepping Down

• Defer retirement by ‘stepping down’ to a less demanding, lowergraded (paid) post. Subject to the Trust’s agreement, pensionrights will be preserved at the previous higher level.

Working when needed

• Retirement, but remaining available to work through registeringfor bank work or by advising availability for work during peakperiods.

4.2 Staff considering flexible retirement options should discuss these in thefirst instance with their Head of Department. Such requests will beconsidered in light of service and organisational requirements. Staffare also advised to contact the Trust’s Pension Officer to determine theimplications of flexible retirement on their pension.

4.3 The most popular flexible retirement option is where a member of staffretires, releasing their pension and lump sum and subsequently returnsto work.



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4.4 Staff who retire under normal age provisions (60 or 65) must have abreak in service of 24 hours and cannot work more than sixteen hoursper week for the first calendar month following retirement. There is nolimit in what a person can earn if they return to work following normalage retirement.

4.5 Where a member of staff pursues voluntary early retirement and takesan actuarially reduced pension or has Mental Health Officer status andretires at age 55, the provisions in 4.4 above apply and in addition theemployees combined pension and post retirement earnings must notbe greater than their salary upon retirement. Where this occurs, thepension is reduced to bring the income down to the required level.

5. Retirement function/party and gratuity

5.1 For employees with ten years or more service with the South West

Strategic Health Authority or its predecessor organisations, an amountof £3.00 per year up to a maximum of £80 will be offered towards aretirement function or party.

5.2 This sum may only be used for the specified purpose and cannot begiven to the employee or used as a contribution towards a gift orpresent.

5.3 All requests for retirement function or party funding must be made inwriting by the immediate line manager/Director of the retiring employee.

5.4 All requests must be made at least four weeks before the retirementfunction or party to allow sufficient time for the catering arrangements.

5.5 The line manager/Director will approve the charging of the cost of theretirement party to their budget with the caterers.

5.6 All written requests for funds must include the name of the employee,grade, Directorate, starting and termination dates, together with anyindication of breaks in service.

5.7 If the employee expresses a wish not to have a retirement function or

party, a request for funds should not be made.

Retirement gratuity

5.8 Employees of the South West Strategic Health Authority who havecompleted twenty years or more of continuous service with the NHSmay receive a gratuity of £10 per completed year of service (pro ratafor part-time staff) up to a maximum of £250.

5.9 Requests for a staff gratuity should be made using the appropriate formfound on the intranet which should be completed by the immediate linemanager/Director of the employee and sent to the Human Resourcesteam.



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5.10 The retirement gratuity may be used to purchase or contribute towardsa gift or a cheque can be made payable to the retiring member of staff.(Cheques payable to retiring staff are subject to tax by the InlandRevenue).

5.11 The Staff Retirement Gratuity Form (found on the intranet) must becompleted and submitted to the Human Resources team at least fourweeks before the date of retirement.



• all employees will have been treated fairly and consistently whenrequesting flexible retirement options;


• all employees have a clear understanding of the roles andresponsibilities for line managers and themselves in thesupporting and managing flexible retirement.

6.2 An equality impact assessment for this policy will be completed everythree years.





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Annex 1

1. Retirement procedure

Duty to inform the employee:

1.1 Every six months the Human Resources team will send Directors a listof staff who are due to reach the intended retirement date of 65 withinthe next twelve months.

1.2 Managers have a duty to write to each individual at least six monthsprior to their 65th birthday, to advise them of their intended retirementdate and arrange to meet with the individual to discuss whether or notthey wish to work beyond 65 years of age (template letters areavailable on the intranet). Please note the employee can beaccompanied at this meeting by a Trade Union representative or work

colleague (not acting in a legal capacity).

Working beyond 65 (intended retirement date) and 67 (extendedretirement date)

1.3 Where an employee wishes to work beyond 65 the manager andemployee must discuss the employee’s request between three and sixmonths before the Intended Retirement Date. An employee who isallowed an extension to their age of retirement may be offered or mayrequest an extension of service on a modified contract, for example, forfixed period of time or indefinitely.

1.4 The Manager needs to confirm in writing to the individual the detailsand terms of the post within fourteen days of the meeting (letteravailable on the intranet) with a copy to the Human Resources teamand appropriate paperwork to Payroll.

1.5 The request by the employee is to continue working under the sameterms and conditions before the retirement date. If the employeerequests a different working pattern, less hours, less responsibility themanager should consider this however; there is no obligation for eitherthe employee or the manager to accept the proposals. If the employee

voluntarily requests and accepts a job of less responsibility, payprotection will not be applicable.

Refusal to work beyond 65 (intended retirement age), 67 (extendedretirement age)

1.6 If the Manager decides not to fully accept the request (for example theemployee has requested to continue working indefinitely but decidesthat the employee can continue working only for a fixed period of time)they must write to the employee within fourteen days of the meeting(letter available on the intranet) setting out the reasons for this.



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1.7 If the Manager decides to refuse the request outright the decision mustbe confirmed to the employee setting out the reasons for this andgiving a date when their employment will be terminated (letter availableon the intranet).

1.8 Employees will have the right of appeal against either decision usingthe Grievance policy and procedure of the South West Strategic HealthAuthority.

1.9 Please note that if the manager has agreed to allow the employee tocontinue working for a fixed period of time, when the employee reaches67 years of age (extended retirement age) this process must befollowed a second time.

2. Returning to work

2.1 If an employee retires from the South West Strategic Health Authorityand subsequently wishes to return the manager must go through thevacancy approval process for the post.

2.2 Current NHS pension arrangements indicate that employees who areretiring on an NHS pension must have a minimum break of twenty fourhours and must not work for more than sixteen hours per week for thefirst month after retiring.

2.3 Someone who is age 60 or over who returns to work will not have theirpension reduced no matter how may hours they work or how much

salary they earn, provided that they adhere to the above.

2.4 A person under age 60 who returns to work may have their pensionreduced or suspended if the sum of their pensionable earning in theirnew post plus their pension is greater than their previous pensionableearnings. This is also provided they adhere to the above.

2.5 Once you have taken an early pension, you can not rejoin the schemeif you rejoin the NHS, unless you retired because of ill health and youreturn to work in the NHS before you reach age 50.



Appendix 23

Secondary Employment

This appendix sets out the revised SecondaryEmployment Policy for the South West StrategicHealth Authority.





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Secondary Employment Policy

1. Introduction

1.1 Whilst the Strategic Health Authority recognises that staff may engagein employment in addition to their post with the Authority, it is importantthat other work or activities do not adversely affect the employee’sperformance or attendance, or break the terms of the EuropeanWorking Time Regulations. Therefore you must notify HumanResources of all other employment which you undertake.

2. Policy

2.1 This policy applies to all employees and prospective employees towhom a job offer has been made, of the South West Strategic HealthAuthority. The policy also applies to staff seconded to the HealthAuthority even if a declaration has been made to the substantiveemployer.

2.2 In this policy the term Secondary Employment covers

• paid employment outside the Authority including private practice;

•

unpaid employment and/or voluntary work;

• self employment including franchise working;

• bank/agency/locum work.

2.3 The purpose of the policy is to:

• ensure that employees do not engage in other work that mayconflict with or affect their performance or attendance under theirContract of Employment with the Authority;

• prevent employees contravening legislation on working time,including total hours worked, breaks between shifts and annualleave;

• ensure that employees who are seconded full time to the SouthWest Strategic Health Authority comply with this policy duringthe secondment; where employees are seconded part-time tothe Strategic Health Authority and retain work with theirsecondary employer then the above principles will be applicableto both parts of the employment arrangement.



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2.4 Some employees will have Contracts of Employment which maycontain more specific provisions about secondary employment. In suchcases these will apply in addition to the provisions of this policy.

3. Procedure

3.1 The Human Resources team will forward a copy of the SecondaryEmployment policy to all appointees together with a copy of theDeclaration of Staff Interests form which can also be found on theHuman Resources Intranet site.

3.2 Appointees will be asked to disclose any existing secondaryemployment which will continue after commencing employment withthe Authority including paid or voluntary work by completing andreturning the pro-forma.

3.3 The returned form will be forwarded to the line manager if there is anypositive disclosure. The line manager should consider if the secondaryemployment needs to be discussed with the appointee and if anyparameters need to be established and discussed with the appointee toensure that there is no adverse impact on/implication for the main job.The outcome of any said discussion will be recorded on the pro-formaand sent to the Human Resources team for retention on the personalfile.

3.4 Managers should take a balanced view of the diverse needs ofindividuals against those of the business during these discussions.

3.5 Where a person has disclosed that they will continue with secondaryemployment the Human Resources team will inform OccupationalHealth to ensure that there are no health implications.

Post appointment

3.6 Where an employee is considering taking up secondary work they mustadvise their line manager by completing the Notification pro-forma.

3.7 On receipt of the pro-forma the manager should meet with the

employee to discuss the proposed secondary employment andpotential impact on their current employment, performance and/orattendance. The meeting should take place within a mutually agreedtime period.

3.8 The manager should consider all the factors and decide if thesecondary employment is likely to be detrimental or not. A decisionshould be made and conveyed to the employee in writing withinfourteen days of the discussion.

3.9 The pro-forma should be duly completed and sent to the Human

Resources team for retention on the personal file.



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3.10 If a request for secondary employment is refused the employee mayuse the Authority’s Grievance Procedure if dissatisfied.

3.11 It is the responsibility of the employee to notify the line manager if thesecondary employment ceases or changes, such as an increase in

hours or greater responsibility.

4. Employee responsibilities

Sickness

4.1 Employees should normally refrain from their secondary employment ifthey are on sick leave from the Authority. This includes any workduring which would normally be off duty periods unless specificallyauthorised by your line manager.

If the employee does not think the secondary employment would bedetrimental to their health and recovery they should seek advice fromthe Human Resources team which will confirm any decision with theline manager before advising the employee.

Working time regulations

4.2 Employees must ensure that their total working hours do not exceedthe limits and that they comply with the required rest periods within theWorking Time Regulations.

(go towww.direct.giv.uk/employment/employees/workinghoursandtimeoff )

The working time regulations are Health and Safety legislation anddesigned to ensure no-one works when they are too tired to do sosafely. Staff should also consider the implications of travelling,particularly driving, when tired. Where there is evidence of a breach ofthe Working Time Regulations the matter will be investigated inaccordance with the Authority’s Disciplinary procedure as such abreach would be regarded as misconduct.

Attendance/time keeping4.3 Any adverse impact on attendance and/or time keeping attributed to

secondary employment will be investigated under the Authority’sDisciplinary procedure.



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Capability/performance

4.4 As part of their role, all managers should monitor the performance oftheir staff regularly, if the performance of a member of staff falls belowthe acceptable standards the manager needs to investigate this.

Performance issues can arise from a number of reasons such as illhealth. However, if it is found that the adverse impact on performanceis as a direct result of secondary employment the manager should takeappropriate action under the terms of the Authority’s performance / disciplinary procedures.

Private practice/fee paying services

4.5 Medical staff must adhere to the conditions set out under their termsand conditions of employment with regard to private practice (excludingwork undertaken under contract as a General Practitioner) and fee

paying services.



• all employees will be treated fairly and consistently with regardto secondary employment;


• all employees have a clear understanding of the roles andresponsibilities for line managers and themselves in managingsecondary employment.






Appendix 24

Secondment Policy

This appendix sets out the revised SecondmentPolicy for the South West Strategic Health Authority.





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Secondment Policy

1. Introduction1.1 The South West Strategic Health Authority is committed to developing

strategies that enable the successful recruitment, retention anddevelopment of staff.

1.2 Secondments can provide employees with wider opportunity for theirpersonal and career development.

1.3 The purpose of this policy is to provide a framework which ensuressecondment opportunities are fair and effective, as well as meet theneeds of the individual and the South West Strategic Health Authority.

1.4 The South West Strategic Health Authority aims to promote equalityand diversity, and value the benefits that this brings.

1.5 It is the intention of this policy to ensure that all staff are treated fairlyand equitably and have equal access to personal and careerdevelopment opportunities.

2. Scope

2.1 This policy applies to all employees of the South West Strategic HealthAuthority.

3. Definition

3.1 One definition of a secondment may be “the temporary loan orattachment from or to another organisation or a different department ordirectorate of the South West Strategic Health Authority for a specificpurpose and for a defined period”.

3.2 The key element of a secondment is that there is no change inemployment status during the secondment. The secondee’s contract ofemployment remains unaffected, they remain an employee of theseconding organisation, and will return to their original post with theseconding organisation at the termination of the secondment. The Hostorganisation takes on no employment liability for the secondee at thetermination of the secondment.

3.3 The secondment agreement will set out the specific local terms andconditions of the secondee’s time with the Host, in other words they willbe managed in line with their terms and conditions of employment.Thus any grievance, performance issues, attendance or disciplinaryaction for example will be managed in accordance with the employer’spolicies.



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4. Principles

4.1 A secondment can be initiated either by an employee or by theirmanager. However, there is no absolute right for any employee to beseconded from their post to another post either within the South West

Strategic Health Authority itself or to another employer within or outsidethe NHS.

4.2 Secondment requests will be considered in line with business needsand may be refused on that basis.

4.3 The duration of a secondment must form part of the agreementbetween the employee, Host and Employer. A secondment must havean end date, and would normally last for a maximum of three years.Secondments can be extended with the express authority of eachparty.

4.4 Secondees to South West Strategic Health Authority should allcomplete Pre-employment Health Questionnaire, and Statement ofHealth forms with a view to identifying any reasonable workplaceadjustments that should be considered.

4.5 A risk assessment should be carried out for each secondee at thecommencement of their secondment. Risk Assessment forms shouldbe provided to the prospective line manager at the organisationseconded to, if not South West Strategic Health Authority.

5. Application

5.1 All secondments to, or released from, the South West Strategic HealthAuthority must be approved by the relevant line manager, Director andthe Chief Executive or nominated deputy.

5.2 Detailed arrangements must be agreed between the original manager,the new manager and the employee. A Notification of SecondmentArrangements form should be completed and returned to the HumanResource team.

5.3 The terms and conditions of the secondment (the SecondmentAgreement) will be confirmed in writing by the Human Resources teamand signed by the Employer Manager, Host Manager and theemployee, with a copy to each party, including the personnel file of theemployee.

5.4 The secondment may be on the same grade/terms/conditions/hours orsome/all of these may be amended. These must be agreed with thetwo managers and the employee, and will form part of the terms andconditions of the secondment.



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5.5 Where an employee is seconded from the South West Strategic HealthAuthority they will normally return to their substantive post. In the eventof an organisational change occurring this will be dealt with in line withnormal procedures of the South West Strategic Health Authority.

6. Pay arrangements

6.1 Payroll costs and expenses will normally be reclaimed from theorganisation the employee has been seconded to.

6.2 Expenses incurred by secondees in the performance of their duties suchas travel will normally be claimed to their employer, using theiremployer’s normal expenses procedures. Expenses should beauthorised by the employer in the usual way, unless stipulated otherwise

6.3 There must be a clear understanding and agreement of the position

regarding pay awards, annual increments and the original incrementaldate during the period of secondment. This should be clarified in theNotification of Secondment Arrangements form and the SecondmentAgreement itself.



• all managers and secondees have a detailed understanding ofthe arrangements surrounding secondments;

• all employees will have been treated fairly and consistentlythroughout the secondment process;

• the needs of individuals are balanced with the overallrequirements of the South West Strategic Health Authority.

7.2 An impact assessment for this policy will be completed every threeyears.

Policy Approved : April 2010

Review by : April 2013



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Appendix 25

Staff Involvement and Internal Communications Policy

This appendix sets out the revised Staff Involvementand Internal Communications Policy for the SouthWest Strategic Health Authority.





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Staff Involvement and Internal Communications Policy

1. Introduction1.1 The South West Strategic Health Authority is committed to excellence

in the area of communication and staff involvement in line with theprinciples embodied within the NHS Constitution and Staff Charterwhich can be found on the intranet.

1.2 The South West Strategic Health Authority is committed to continuingto develop a culture in which staff and their representatives areinformed about, and are involved in, decisions that affect them and theservices they deliver.

1.3 The South West Strategic Health Authority is committed to the fair andconsistent treatment of staff regardless of their sex/gender, sexualorientation, religion or religious beliefs, race, age, or disability.

1.4 By involving staff it enables the South West Strategic Health Authorityto:

• develop an effective two-way communication process;

• educate staff more fully about the nature of the organisation andthe services in which they work;

• raise awareness of the issues facing particular services, theSouth West Strategic Health Authority and the NHS as a whole;

• listen to the concerns of the staff;

• engage staff to generate ideas and to draw on their knowledge,ideas and expertise to develop services for the future.

2. Values

2.1 The South West Strategic Health Authority believes that there aresignificant benefits for all parties in achieving an involving, open andhonest culture in the workplace.

2.2 The South West Strategic Health Authority believes that the followingvalues are key and underpin the approach to staff involvement:

• the development of strong relationships between staff andmanagement;

• consultation with staff and their representatives in a timelymanner about decisions that affect them and the services theydeliver;



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• to listen and give feedback to staff and their electedrepresentatives;

• the commitment of time and resources to develop an involvingculture;

• raising awareness of all staff that the philosophy of staffinvolvement will have a significant impact on management andemployment practices and on service delivery.

3. Definitions

3.1 For the purpose of this policy, communication and staff involvementmeans:

• a partnership characterised by openness and transparency;

• the taking place of two-way communication;

• an informed workforce who understands the issues facing theNHS and their impact from different perspectives;

• a healthier, better motivated workforce;

• the ability to manage change effectively;

• the ability to engage in innovative work.

4. Procedural implications

4.1 Non-Executive Members are to be included in the induction process.

4.2 All matters of strategic and operational significance will becommunicated to recognised staff representatives through the JointManagement and Staff Committee.

4.3 Minutes from the Joint Management and Staff Committee meetings willbe circulated throughout the South West Strategic Health Authority.

4.4 Information about the South West Strategic Health Authority will beprovided through appropriate methods of communication, includingteam briefings, electronic, newsletters.

4.5 The maximum use of technology will be made to improvecommunication in line with the Information Technology policy andGuidelines. This will include effective use of e-mail and the intranet siteof the South West Strategic Health Authority.

4.6 Information on a more informal basis will be provided through line

managers or via staff notice boards, where staff can also makecontributions.



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4.7 The South West Strategic Health Authority will strongly support theJoint Management and Staff Committee.

4.8 The Joint Management and Staff Committee meetings will be used toshare information and seek views and opinions on important issues.

4.9 The Health and Safety Committee will ensure there is representationfrom staff and health and safety issues will be discussed openly.

5. Responsibilities

5.1 Everyone in the organisation has a role to play in developing theinvolving culture.

Chief Executive

5.2 To be committed to the philosophy of communication and staffinvolvement throughout the South West Strategic Health Authority.

5.3 To ensure that the Staff Involvement and Internal Communicationpolicy is implemented and that audit is carried out through the annualstaff survey.

Director of Workforce Development

5.4 To evaluate the progress of the South West Strategic Health Authorityand work collaboratively with the other parties to develop ideas as tohow to build on existing practice.

5.5 To implement and evaluate the results of the annual Staff Survey.

Line managers

5.6 To take steps to inform and consult employees and theirrepresentatives in a timely manner on issues affecting staff and theservices in which they work.

5.7 To conduct regular staff meetings.

5.8 To carry out annual Appraisals.

5.9 To ensure distribution and access to:

• team Brief;

• other relevant information and newsletters.

5.10 To actively support the development of the involving culture of theSouth West Strategic Health Authority by promoting the principles ofthis policy.



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5.11 To ensure that any person who has a disability, which could affectcommunication, is not discriminated against or put at anydisadvantage. Each circumstance needs to be individually assessedand action taken to optimise communication and involvement.

5.12 To ensure regular meetings with individual staff members to improvecommunication. Frequency to be agreed between the manager andstaff member.

5.13 To have an “open door” policy for all staff.

Employees

5.14 To participate positively, and co-operate fully, in the opportunities thatare presented to offer opinions and views on the development ofservices and employment issues.

5.15 To work co-operatively and positively with colleagues and managers toresolve problems and reconcile competing needs.

Joint Management and Staff Committee Representatives

5.16 To consult and share information with staff on a regular basis.

5.17 To support the implementation of joint decisions and agreements.

5.18 To work in partnership with other Joint Management and StaffCommittee representatives to ensure a coherent input into the

processes of the South West Strategic Health Authority.

Chair of Joint Management and Staff Committee Representatives

5.19 To provide effective leadership for members of the Joint Managementand Staff Committee.

5.20 To ensure that all points of view are aired within the Joint Managementand Staff Committee and passed on to management or back to staff,and to bring to management/staff’s urgent attention any likely problemsand to ensure fast and effective response/resolution.



• all employees will have been treated fairly and consistently withregards to involvement and communications;




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• a review of the policy will be completed every three years by theDirector of Workforce Development and the Director ofCommunications and Corporate Services and recommendationsfor improved practice will be made and implemented.






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Appendix 26

Study Leave and Development Policy

This appendix sets out the revised Study Leave andDevelopment Policy for the South West StrategicHealth Authority.





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Study Leave and Development Policy

1. Introduction

1.1 The South West Strategic Health Authority is committed to the training,education and development of its employees.

1.2 The South West Strategic Health Authority believe that in supportingour employees’ to make the most of their learning opportunities anddevelop their personal and professional career potential; we will deliverour aim of improving services for patients in the South West andhealthcare standards that surpass national targets and rank alongsidethe very best in Europe.

1.3 It is expected that training, education and development needs ofindividuals will be identified as part of the annual appraisal processwhich will be set out in a Personal Development Plan linked to theemployee’s work.

1.4 Any enquiries with regard to Study leave and/or Development Fundingmust be discussed with the employees line manager who, in turn, maycontact the Human Resources team for advice.

1.5 Study leave requests must be discussed at least four weeks in advance

with the employee’s line manager. On agreement, the line managerwill record and authorise the study leave on the annual leave card priorto the study leave being taken as well as confirming the availability offunding with the appropriate budgetary authority.

1.6 Financial constraints may prevent the South West Strategic HealthAuthority from meeting the development needs of all employees at thetime of the request. In the event of demand exceeding funding,development needs will be prioritised by category (see table 1) withthose in category one being funded first.

2. Entitlement

2.1 Study Leave can be any training and development activity that requiresan individual to be absent from their normal place of work. This caninclude:

• conferences;

• internal and external courses;

• e-learning;

• secondments;



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• workshops;

• formal assessment (for example examinations);

• shadowing;

• job rotations (this list is not exhaustive).

2.2 Applications for Study Leave will be considered by category as detailedin Table 1.

Table 1: Category of study

3. Leave and development

3.1 In the case of work based learning activities it may be that theemployee is not absent from their normal work but needs time toparticipate in the learning activity “on the job” for example NationalVocational Qualifications.

Level Funding Study Leave

1. Mandatory/statutory/essentialfor job role

100% 100%

2. Development or educationthat has been agreed as partof a personal developmentplan to enhance current roleor to meet changes in rolethrough promotion orredeployment.

100% Negotiated by theline manager withthe expectationthat individuals willcommit to homestudy whereappropriate.

3. Development/educationagreed as part of thepersonal development plan

to enhance future careerdevelopment within thecurrent role/profession.

Managers may consider bothfunding and study leave orfunding but not time off ortime off, not funding.

50 – 80%Negotiated bythe line

manager andemployee

Negotiated by theline manager withthe expectation

that individuals willcommit to homestudy whereappropriate

4. Development/educationagreed as part of personaldevelopment plan but not

directly linked to currentcareer or job role but willenhance career prospects.

None Negotiated by theline manager withthe expectation

that individuals willcommit to homestudy whereappropriate



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3.2 In order to apply for study leave an employee would normally havebeen employed for a year and have completed an annual appraisaltogether with a Personal Development Plan in which their developmentopportunity has been identified.

3.3 An employee, who joins the South West Strategic Health Authority partway through the appraisal year, will be able to apply for study leave if adevelopment opportunity is identified by their line manager andthemselves a part of a formal review process for example, during theirInduction period.

3.4 Part time employees will be entitled to apply for study leave that is prorata to their normal working hours.

3.5 Travel expenses and subsistence allowances will be at PublicTransport rates.

3.6 Employees taking study leave should first make use of all internalresources for example intranet, internet, journals and so on. If books orother materials are required the employee may be required to pay forthem. If the South West Strategic Health Authority agrees to fundbooks (to a maximum of £50 per year) they will be the property of theSouth West Strategic Health Authority and on completion of studyshould be returned for inclusion in South West Strategic HealthAuthority resources.



• prepare for their annual appraisal in advance;

• prepare and agree a Personal Development Plan together withtheir line manager;

• complete an application form for Study Leave and/orDevelopment Funding which can be found on the intranet;

•attend all supported study leave events and learningexperiences; any non attendance including annual leave, mustbe discussed in advance with the line manager/course provider;

• report sickness absence to the nominated person as normal andto the Course Leader; coach or mentor;

• complete the course or learning experience and submit allrequired written assignments and practical competencies; failureto do this may result in further study leave being withdrawn;



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• discuss with their line manager and Course Leader, coach ormentor progress including if you are experiencing any difficultiesin completing the academic requirements of the course;

• inform their line manager of the outcome of the course or

learning experience, including results and provide evidence ofthis (for example a certificate);

• complete an Study Leave and Funding for Developmentevaluation form together with their line manager which can befound on the intranet;

• share learning with peers as appropriate and apply in practice;

• ensure, if a professional, they meet the continuing professionalrequirements of their professional body;

• commit where the level of study is either over a twelve monthperiod or costs over £1000, by signing the Study Leave andFunding for Development Learning agreement form which canbe found on the intranet to repay the course fees should theyvoluntarily leave the South West Strategic Health Authorityeither during study or within twelve months of completing theirstudy.

5. Responsibilities of employers

5.1 The responsibilities of the employers include the need to:

• carry out one to one reviews with employees on a monthly basis;

• conduct annual appraisal and development reviews withemployees;

• ensure that the objectives set are recorded;

• at regular one to one meetings review progress and identify anyneed for additional support or guidance;

• complete an application form for Study Leave and/orDevelopment funding which can be found on the intranet;

• ensure that “on the job” study leave is provided for work basedlearning;

• support employees in transference of learning in to practice;

• evaluate the course once completed and review how learningcan be shared with colleagues as appropriate;

• complete the annual leave card when study leave is taken;



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• complete and update training record cards;

• ensure that the agreed funding is available and invoices areprocessed in a timely manner;

• ensure that reasonable adjustments are taken into account and /or addressed in order to assist in your employees learningexperience (please refer to the Health Problems and Disability inEmployment section in the Health and Wellbeing policy);

• ensure that authorisation to access opportunities to study andyour funding decisions are based on the criteria outlined in Table1. Decisions to fund individuals should not be based on age,length of service or the potential of a pending retirement, norgender or ethnicity;

• ensure that decisions for approval/non approval are documentedand kept on file.



• all employees will have been treated fairly and consistently whenrequesting Study Leave and Funding for Development;

• the needs of individuals are balanced with the overall

requirements of the South West Strategic Health Authority;

• all employees have a clear understanding of the roles andresponsibilities for line managers and themselves in theapplication for, monitoring and recording of study leave andfunding.






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Appendix 27

Travelling and Subsistence Policy

This appendix sets out the revised Travelling andSubsistence Policy for the South West StrategicHealth Authority.





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Travelling and Subsistence Policy

1. Introduction

1.1 This policy sets out the travelling and subsistence rates paid to all staffof the South West Strategic Health Authority, including the Chairmanand Non-Executive Members.

1.2 These allowances have either been approved by the Secretary ofState, or agreed under the NHS Terms and Conditions of ServiceHandbook or by local agreement.

1.3 The Travelling and Subsistence policy is necessary to ensure:

• payment of allowances are managed effectively;

• all claims are submitted promptly and are properly authorised;

• all staff, including the Chairman and Non-Executive Members,do not receive any allowances to which they have noentitlement;

• records of the various payments are adequately maintained;

• the South West Strategic Health Authority complies with allstatutory legislation and submits necessary returns promptly;

• the South West Strategic Health Authority meets therequirements of both statutory and internal auditors.


2.1 When claiming for mileage for car journeys, it is the legal duty of eachemployee driving the vehicle to hold valid motor insurance which

covers business use, a current driving licence and MOT certificatewhere applicable. Employees will need to provide a copy of theirdriving license, motor insurance, MOT (where applicable) and vehicleregistration document on an annual basis for auditing purposes.

2.2 All claims must be an accurate record of official business expensesincurred. Any falsified expenses or subsistence claims will bemanaged under the Disciplinary policy and could potentially result indismissal for gross misconduct and prosecution. Employees aretherefore advised to familiarise themselves with their responsibilitiesunder the following organisational documents and policies, all of which

are available on the intranet:



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• Standards of Business Conduct for NHS Staff;

• South West Strategic Health Authority Standing Orders;

• South West Strategic Health Authority Standing Financial

Instructions;

• Disciplinary policy of the South West Strategic Health Authority;

• Hospitality Expenses policy of the South West Strategic HealthAuthority;

• Mobile Phone policy of the South West Strategic HealthAuthority;

• Guide to Expenses and Allowance Rates for Employees of

South West Strategic Health Authority.

3. Travelling allowances

3.1 These are paid in accordance with the NHS Terms and Conditions ofService under the following categories:

• use of lease car;

• use of private car;

•public transport (rail, bus, air, taxi).

Lease car users

3.2 Staff entitled to a lease car under the Lease Car policy of the SouthWest Strategic Health Authority are eligible to claim reimbursement offuel costs for all mileage travelled in connection with the business ofthe South West Strategic Health Authority.

3.3 Claims for reimbursement of these allowances must be authorised andsubmitted for payment within three calendar months or they will not be

paid. In extenuating circumstances, this three calendar month rule canbe relaxed but approval must be obtained from the Director of Financeand Performance.

Private car users

3.4 Staff who are ineligible for a lease car are classified as a ‘private caruser’. Under this classification staff will be entitled to a mileageallowance which is dependent on the engine capacity and the totalannual official business miles.



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3.5 Claims for reimbursement of these allowances must be authorised andsubmitted for payment within three calendar months or they will not bepaid. In extenuating circumstances this three calendar month rule canbe relaxed but approval must be obtained from the Director of Financeand Performance.

3.6 Staff driving a vehicle for official business must hold a valid drivinglicence, motor insurance which covers business use, and MOTcertificate if required.

Public transport

3.7 This refers to travel on official journeys by means other than a lease orprivate car.

3.8 If staff intend to travel by train they should contact their Directors

Personal Assistant or member of staff with delegated authority, who willarrange the purchase of the ticket prior to the journey. The ticket willnormally be for second class travel. In exceptional circumstances theChief Executive or Director of Finance and Performance may authorisefirst class travel.

3.9 Claims for travel by other public services (including car parking) mustbe authorised and submitted for payment within three calendar monthsor they will not be paid. In extenuating circumstances, this threecalendar month rule can be relaxed but approval must be obtainedfrom the Director of Finance and Performance.

3.10 Receipts must be attached to the claim. Claims must be made on aseparate form for each month, photocopied and submitted double sidedand be completed correctly as Payroll will return incorrect claims. TheSouth West Strategic Health Authority reserves the right not toreimburse staff travel if no receipt or proof of payment is submittedattached with the claim, unless it clearly states that no receipt isrequired for this allowance.

4. Subsistence allowance

4.1 These are paid in accordance with the NHS Terms and Conditions ofService and claims can be made when:

• an employee stays overnight in an hotel, guest house or othercommercial accommodation;

• an employee stays for short overnight periods with friends orrelatives or in caravan accommodation;

• travelling overnight in a sleeping berth (rail or boat);

•

travel costs are incurred for short term temporary absence;



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• an employee has to stay away in the same location for overthirty nights;

• an employee spends more on meals than they would have spentat their headquarters and has to travel more than five miles from

headquarters when on business.

4.2 The terms and current amounts which can be claimed are as follows.

Short overnight stay in hotel

4.3 The actual receipted cost of bed and breakfast is up to a normalmaximum limit of £55 per night plus a meal allowance of £20 per nightto cover the cost of a main evening meal and one other daytime meal(where meals are not provided). No reimbursement will be made forany alcoholic drinks purchased. This will be reviewed again by April

2011.

4.4 When a short overnight stay in a hotel in a large city is required, themaximum limit is increased to £120 per night plus (or a value deemedreasonable by the relevant Director or delegated authority) a mealallowance of £20 per night. This will be reviewed again by April 2011.

4.5 Where the rates available through approved agents, taking into accountpublished government rates, and the business in a genuine reasonwhich must be stated on the claim, additional assistance may begranted at the discretion of the Chief Executive or Director of Finance

and Performance.

Short overnight stay in non-commercial accommodation

4.6 A flat rate of £25 is payable for short overnight periods with friends orrelatives when away on South West Strategic Health Authoritybusiness. No receipts are required for this allowance.

4.7 An employee who is staying in accommodation provided free shall beentitled to claim an allowance up to £20 per day to cover meals notprovided free of charge. No receipts are required for this allowance.

4.8 When accommodation and meals are provided free of charge anincidental expense allowance of £4.20 per day will be payable. This issubject to tax and national insurance deduction. No receipts arerequired for this allowance.

Travelling overnight in a sleeping berth

4.9 The cost of a sleeping berth and meals, excluding alcoholic drinks, willbe reimbursed subject to the production of receipts.

Short term temporary absence travel costs



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4.10 The cost of travelling between the hotel and temporary place of workwill be separately reimbursed on an actual cost basis.

Long term overnight stays

4.11 A maximum amount of either £35 or £25 per night is allowed,depending on the personal circumstances of the claimant. Furtherdetails are given in NHS Terms and Conditions of Service Handbookwhich can be found on the intranet.

Day meals subsistence allowance

4.12 A lunch allowance of £5 if more than five hours away from the officeincluding the lunch time between 12.00 noon and 2.00 pm, if a meal isnot provided free of charge. A receipt is not required for this allowance.

4.13 An evening meal allowance of £15 when away from base for more thanten hours and unable to return to base or home before 7.00 pm, if ameal is not provided free of charge. A receipt is not required for thisallowance.

4.14 There may be some circumstances when an employee could qualify forboth allowances. The NHS Terms and Conditions of ServiceHandbook sets out these circumstances.

4.15 An allowance of £3.25 when an employee is required to work late atnight. This will be subject to tax and national insurance deductions.

Excess travelling allowances

4.16 These are payable to those staff who incur additional travelling costswhen required to change their headquarters. These allowances will besubject to tax and national insurance deductions.

4.17 The excess shall be calculated on the basis of bus or second class railfares, or public transport rate/lease car mileage rates and is payable fora period of four years.

Hotel facilities

4.18 There will be occasions, because of work commitments, when staff willbe offered or expected to stay overnight in hotel accommodation.

4.19 The South West Strategic Health Authority will be responsible forpaying the full cost of the accommodation.

4.20 All control of this arrangement will be the responsibility of theappropriate Director (or delegated authority) who must countersign theclaim form.



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Business expenses of the Chief Executive

4.21 The Chief Executive will be entitled to use a banker’s card to settlebusiness expenses incurred solely on South West Strategic HealthAuthority business.

4.22 A schedule will be prepared by listing all items of expenditure andaccompanied by receipts for approval by the Chairman.

4.23 The Director of Finance and Performance will then ensure that theschedule is checked against the imprest bank statement.

Telephone calls/rental

4.24 Staff who are regularly required to be on-call in evenings andweekends and hence need to be contactable by telephone are entitled

to a refund of their telephone line rental. This sum will be refunded onthe submission of a relevant telephone bill.

4.25 In other cases it may be necessary for an employee to make abusiness call on their private telephone. An itemised telephone billshould be submitted with the claim form.

4.26 An employee issued with a business mobile phone is required to sign adeclaration as to whether or not it is being used for making or receivingprivate calls. If it is, the employee is liable to pay the total cost of thesecalls (including VAT).

4.27 An account is sent to the South West Strategic Health Authority on amonthly basis which has to be settled within fourteen days. Theindividual employee must sign the account as being correct, identifyingany private calls. The account will then need to be authorised by theline manager of the claimant.

4.28 The cost incurred for repairs resulting from misuse of the telephone willhave to be paid for by the individual.

4.29 A mobile telephone is available on an ad hoc basis to any member ofstaff who is away from headquarters on South West Strategic HealthAuthority business or is required to work late. The Directorate ofFinance and Performance will issue a telephone in suchcircumstances.

5. Authorising travel and subsistence claims

5.1 Fully completed claim forms must be approved for payment by theauthorised budgetary signatory before being submitted to Payroll by thefourth day of the month, if they are to be included with the salary forthat month. Claims received after this date may not be paid until thefollowing month’s salary payment.



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5.2 Incorrectly completed claims should not be signed by the authorisedbudgetary signatory of the claimant but returned to the individual forcorrect completion prior to authorisation.

5.3 Authorised signatories need to be aware of the importance of

scrutinising all claims prior to authorisation to assure themselves thatthe claims are legitimate and that the claimant holds a current drivinglicence and MOT certificate and valid motor insurance which coversthem to use their vehicle for business purposes.

5.4 Claims for reimbursement of these allowances must be authorised andsubmitted for payment within three calendar months or they will not bepaid. In extenuating circumstances this three calendar month rule canbe relaxed but approval must be obtained from the Director of Financeand Performance. A separate form must be submitted for eachcalendar month in which expenses have been incurred.

5.5 The Chairman will authorise the claims from the Chief Executive. TheChief Executive will authorise claims from the Chairman and Directors.The Directors (or delegated authority) and line managers will approveall claims from staff who are directly accountable to them.

5.6 The Secretariat Manager will authorise the claims from Non-ExecutiveDirectors.

6. Travel and subsistence for the Chairman and non-Executive Directors

6.1 The allowances payable to the Chairman and Non-Executive Directorsare determined by the Secretary of State for Health. They comprise:

• travelling allowances;

• overnight absence allowance;

• day subsistence allowance.

Travel allowances

6.2 The Chairman and Non-Executive Directors are entitled to claim amileage allowance which is dependent on the engine capacity and thetotal annual miles necessary to travel in the course of their duties.

6.3 The mileage allowance claimed when travelling to and from the placewhere the duties of the post are normally performed are taxable.

6.4 Special arrangements have been agreed with the Inland Revenuewhereby the Chairman and Non-Executive Directors can elect to havethese expenses tax-free. Any income tax that becomes liable is paid

by South West Strategic Health Authority.



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Overnight absence and day subsistence

6.5 The Chairman and Non-Executive Directors are entitled to claim theseallowances up to the current agreed limits for expenditure actuallyincurred in the course of their duties.

6.6 Any subsistence claimed when no refreshments are provided aretaxable if they relate to days attending the place where the duties of thepost are performed.

6.7 Special arrangements have been agreed with the Inland Revenuewhereby the Chairman and Non-Executive Directors can elect to havethese expenses tax-free. Any income tax that becomes liable is paidby South West Strategic Health Authority.



• all employees will have been treated fairly and consistently whenrequesting and claiming for travel and subsistence;


• all employees have a clear understanding of the roles andresponsibilities for line managers and themselves in requesting

and claiming for travel and subsistence.






Appendix 28

Valuing Diversity Policy

This appendix sets out the revised Valuing DiversityPolicy for the South West Strategic Health Authority.





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Valuing Diversity Policy

1. Introduction

1.1 The South West Strategic Health Authority recognises the benefit of a diverseworkforce and values each employee as an individual.

1.2 People are not alike and everyone is different. Diversity therefore consists ofvisible and non-visible factors, which include personal characteristics such asbackground, culture, personality and work-style as well as the characteristicsthat are protected under discrimination legislation in terms of race, disability,gender, religion and belief, sexual orientation and age.

1.3 Harnessing these differences will create a productive environment in whicheverybody feels valued, their talents are fully utilised and organisational goalsare met.

1.4 Diversity is about ensuring that all employees have the opportunity tomaximise their potential and enhance their self-development and theircontribution to the organisation.

1.5 It recognises that people from different backgrounds can bring fresh ideas andperceptions, which can make the way work is done more efficient and deliverservices better. Managing diversity successfully will help the Strategic HealthAuthority to nurture creativity and innovation and thereby to tap hiddencapacity for growth and improved effectiveness.

1.6 The Strategic Health Authority is committed to ensuring that all staff will betreated in accordance with the above ethos and principles and will promotethe positive management of diversity, a work/life balance, and the provision ofequality of opportunity that is free from discrimination, victimisation orharassment.

2. Scope

2.1 This policy applies to all staff and is consistent with service aims and currentlegal requirements. The content of this policy influences all employment andworking practices within the South West Strategic Health Authority and shouldtherefore be read in conjunction with the following policies:




• Leave Entitlement policy;



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• Work Experience policy.

3. The aims of valuing diversity

3.1 The South West Strategic Health Authority aims to provide a professional andeffective service underpinned by dignity and respect for all.

3.2 Within this context, the South West Strategic Health Authority is committed todeveloping a workforce which is valued and whose diversity reflects, as far aspossible, the community served. The South West Strategic Health Authoritybelieves that this contributes to delivery of the best possible healthcareservices to local people.

3.3 To support this, the South West Strategic Health Authority aims to be a place

where people want to work and to be a leader in best employment practice.

3.4 This will be achieved by building on the current legal framework in equalopportunities by the establishment of good practice, ensuring all who work orapply to work at the South West Strategic Health Authority are treated fairlyand valued equally.

3.5 All conditions of service and job requirements should therefore fit with boththe needs of the service and those working within it, enabling all staff toachieve their full potential in an environment characterised by dignity andmutual respect.

3.6 The South West Strategic Health Authority is working towards equality ofopportunity by viewing diversity positively and in recognising that everyone isdifferent, valuing equally the unique contribution that individual experience,knowledge and skills can make.

3.7 In summary, this policy will ensure that the South West Strategic HealthAuthority will:

• demonstrate a commitment to the NHS equality agenda;

• make full use of the talents and diversity of all the workforce;

• ensure equal access to opportunities for everyone;

• ensure staff are treated with dignity and respect;

• ensure employment policies and procedures promote good and lawfulpractice

• attract and retain new recruits of the highest calibre, recruited fairly andon their ability to do the job.



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4. Fair recruitment

4.1 The South West Strategic Health Authority will show its commitment topositive diversity and equality in practice through the implementation of theRecruitment and Selection Policy which incorporates best practice for

recruitment.

5. Improving working lives

5.1 The South West Strategic Health Authority recognises that being able to workflexibly, take career breaks, job share and have access to support fordependants are important for equality and managing the different personalcircumstances and needs of staff.

6. Training and development

6.1 To provide the highest quality services possible, the South West StrategicHealth Authority will aim to develop a committed and highly motivatedworkforce. This involves continually improving communications throughoutthe organisation, providing training and development for staff at all levels andmanagement leadership that encourages staff involvement.

7. Positive action to equalise opportunities

7.1 The South West Strategic Health Authority is committed to ensuring theeffective management of diversity. Positive action is one measure which will

be taken where appropriate. In order to facilitate this there may beopportunities to help individuals access available opportunities by, forexample, encouraging applications from those under-represented groups. Itcan also mean removing requirements which do not affect ability to do the jobbut which may disadvantage some people. It is particularly important toensure that jobs are open to all at every level and in every type of work withinthe organisation. The South West Strategic Health Authority policy ondisability sets out the support provided to those with a disability.

8. Implementing the Valuing Diversity policy – dealing with

discrimination8.1 The South West Strategic Health Authority is committed to dealing sensitively,

firmly and effectively with all complaints of discrimination, victimisation orharassment in accordance with the Dignity at Work policy.



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8.2 It is important to understand the types of possible discrimination as part of theimplementation of this policy. The main types of discrimination are:

Direct discrimination

• takes place when a person or group of people is treated lessfavourably than other people in the same or similar circumstances. Forexample, choosing not to employ people who meet the requirementsfor the job because of the colour of their skin or because they aremarried with children would constitute direct discrimination;

Indirect discrimination

• takes place when a requirement or condition has the effect ofdiscriminating unfairly and unjustifiably between one group or individualand another. Particular attention must be given to avoiding this form ofdiscrimination. For example, standard entry qualifications appliedautomatically across a wide range of jobs may lead to a situation whereapplicants are asked to meet requirements which are not relevant tothe needs of the job. Insisting on higher language standards than arenecessary for safe and effective job performance would tend todisqualify people for whom English is not their first language. Insistingon an unnecessary physical requirement could discriminate againstone sex in favour of another or against someone with a disability;

Institutional discrimination

• takes place when established policies, practices and procedures withinan organisation have discriminatory effects, whether intentional or not.For example, allowing an organisational culture to develop whichtolerates remarks which may be of detriment to particular individuals.When policies and procedures are introduced or reviewedconsideration needs to be given to this possibility.

9. Responsibilities for valuing diversity

Responsibilities of all staff

9.1 We all have a responsibility to work towards valuing diversity and equality ofopportunity in the South West Strategic Health Authority and to promote thevalues incorporated within this policy, through managing and training andgood practice, as outlined in this policy.

Responsibility of the Board

9.2 The South West Strategic Health Authority Board has primary legal and moralresponsibility for ensuring that it and its employees do not discriminate on anymatters detailed in this policy. The Senior Management Team also has a role

to develop positive policies to promote diversity and equal opportunity inemployment.



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• all employees will have been treated fairly and consistently in terms of

their own diversity;


• all employees have a clear understanding of the roles andresponsibilities for line managers and themselves with regards tovaluing diversity.






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Appendix 29

Whistleblowing Policy

This appendix sets out the revised WhistleblowingPolicy for the South West Strategic Health Authority.





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Whistleblowing Policy

1. Introduction

1.1 All of us at some time or other have concerns about what is happening atwork. Usually these are easily resolved. However, when the concern feelsserious because it’s about a possible danger, professional misconduct orfinancial mispractice that might affect patients, colleagues, or the South WestStrategic Health Authority itself, it can be difficult to know what to do.

1.2 You may be worried about raising such an issue and may think it best to keepit to yourself, perhaps feeling it’s none of your business or that it’s only asuspicion. You may feel that raising the matter would be disloyal to

colleagues, to managers or to the organisation. You may have said somethingbut found that you have spoken to the wrong person or raised the issue in thewrong way and are not sure what to do next.

1.3 The Board of the South West Strategic Health Authority is committed torunning the organisation in the best way possible and to do so we need yourhelp. We have introduced this policy to reassure you that it is safe andacceptable to speak up and enable you to raise any concern you may have atan early stage in the right way. Rather than wait for proof, we would preferyou to raise the matter when it is still a concern.

1.4 This policy applies to all those who work for us; whether full-time or part-time,employed through an agency, as a volunteer or in a self-employed capacity.

1.5 If you have concerns which you think we should know about or look into,please use this procedure. If, however, you wish to make a complaint aboutyour employment or how you have been treated, please use the grievancepolicy or bullying/harassment policy – which you can get from your manageror the Human Resources team. (If you have a concern about financialmisconduct or fraud, please see our Counter-Fraud Policy). ThisWhistleblowing Policy is primarily for concerns where the interests of others orof the organisation itself are at risk.

If in doubt – raise it!

2. Your safety

2.1 The South West Strategic Health Authority, Senior Managers and tradeunions are committed to this policy. If you raise a genuine concern under thispolicy, you will not be at risk of losing your job or suffering any form ofretribution as a result. Provided you are acting in good faith (effectively thismeans honestly), it does not matter if you are mistaken or there is an innocentexplanation for your concerns. So please do not think we will ask you to prove

it. Of course we do not extend this assurance to someone who maliciouslyraises a matter they know is untrue.



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3. Staff confidence

3.1 The South West Strategic Health Authority will not tolerate the harassment orvictimisation of anyone raising a genuine concern in good faith. However, it isrecognised that staff may nonetheless want to raise a concern in confidence

under this policy. If this is the case, please say so at the outset. If you ask usnot to disclose your identity, we will not do so without your consent unlessrequired by law. You should understand that there may be times when we areunable to resolve a concern without revealing your identity, for example whereyour personal evidence is essential. In such cases, we will discuss with youwhether and how the matter can best proceed.

3.2 Please remember that if you do not tell us who you are it will be much moredifficult for us to look into the matter. We will not be able to protect yourposition or give you feedback. Accordingly you should not assume we canprovide the assurances we offer in the same way if you report a concern

anonymously.

3.3 With these assurances, we hope you will raise your concern openly.

4. How to raise a concern

4.1 If you are unsure about raising a concern at any stage you can getindependent advice from your trade union representative or Public Concern atWork (see contact details under Independent Advice).

4.2 Please remember that you do not need to have firm evidence before raising a

concern. However, we do ask you to explain as fully as you can theinformation and circumstances that gave rise to your concern.

Step one

4.3 If you have a concern about a risk, malpractice or wrongdoing at work, wehope you will feel able to raise it first with your line manager or lead clinician.This may be done verbally or in writing. Staff may wish to speak to a tradesunion or another staff organisation representative. Staff representatives canassist in the initial stage and, if necessary, report the issue to other levels ofthe organisation.

Step two

4.4 If you feel unable to raise the matter with your line manager or lead clinician,for whatever reason, please raise the matter with:

• Head of Human Resources, Sue Taylor on extension: 1125;

• Associate Director of Human Resources, Steven Keith on extension:1129;

• Interim Director of Workforce, John Bewick on extension 1268;



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• Director of Finance and Performance, Bill Shields on extension: 1355.

4.5 These people have been given special responsibility and training in dealingwith whistleblowing concerns.

4.6 If you want to raise the matter in confidence, please say so at the outset sothat appropriate management arrangements can be made.

4.7 The senior staff shown in 4.3 will advise the member of staff what action isbeing taken.

Step three

4.8 If these channels are followed and a member of staff still has concerns, orthey feel the matter is so serious they cannot discuss it with any of the above,they should contact Sir Ian Carruthers OBE, or Charles Howeson. Contact

details are in Table 1.

Table 1: Contact details

Name Position Telephone EmailSir IanCarruthersOBE

Chief Executiveof the SouthWest StrategicHealth Authority

Ext. 1303 [email protected]

Charles

Howeson

Chair of South

West StrategicHealth Authority

Ext. 1301 [email protected]

4.8 The South West Strategic Health Authority recognises its accountability withinthe NHS. In light of this you can contact:

• NHS Counter Fraud Line on 0800 028 40 60 if your concern is aboutfinancial malpractice;

•

Department of Health (Customer Service Centre, Department ofHealth, Richmond House, 79 Whitehall, London SW1A 2NS; Email:[email protected]; Telephone: 0207 210 4850.

Independent advice

4.9 Any staff unsure of whether or not to use this procedure or who wantindependent advice at any stage should contact their local trades union orprofessional body representative or the independent whistleblowing charityPublic Concern at Work on 0207 404 6609 or by email [email protected]. Their lawyers can talk you through your options and

help you raise a concern about malpractice or wrongdoing at work.



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4.10 Information on the current local trade union or professional bodyrepresentatives can be obtained from the Human Resources team.

5. How we will handle the matter

5.1 Once you have told us of your concern, we will assess it and consider whataction may be appropriate. This may involve an informal review, an internalinquiry or a more formal investigation. We will tell you who will be handling thematter, how you can contact them, and what further assistance we may needfrom you. If you ask, we will write to you summarising your concern andsetting out how we propose to handle it and provide a timeframe for feedback.If we have misunderstood the concern or there is any information missingplease let us know.

5.2 When you raise the concern it would be helpful to know how you think thematter best be resolved. If you have any personal interest in the matter, we do

ask that you tell us from the outset. If we think your concern falls moreproperly within our grievance, bullying and harassment or other relevantprocedure, we will let you know.

5.3 Whenever possible, we will give you feedback on the outcome of anyinvestigation. Please note, however, that we may not be able to tell you aboutthe precise actions we take where this would infringe a duty of confidence weowe to another person.

5.4 Whilst we cannot guarantee that we will respond to all matters in the way thatyou might wish, we will strive to handle the matter fairly and properly. By using

this policy you will help us achieve this.

6. External contacts

6.1 While we hope this policy gives you the reassurance you need to raise yourconcern internally with us, we recognise that there may be circumstanceswhere you can properly report a concern to an outside body. In fact, we wouldrather you raised a matter with the appropriate regulator – such as the CareQuality Commission, the Independent Regulator of NHS Foundation Trusts(Monitor), your professional regulator, the Audit Commission or the NationalPatient Safety Agency – than not at all. Your union or Public Concern at Work

will be able to advise you on such an option if you wish.

7. Monitoring

7.1 The South West Strategic Health Authority will annually, on a completelyanonymous and confidential basis, receive information on all reports whichhave been received under this policy. The purpose of this review will be toensure that the policy is working effectively and that issues raised are beingdealt with in an appropriate and timely manner. The South West StrategicHealth Authority Board will also be seeking reassurance that no form ofharassment or other disadvantage has been taken against staff who have

raised matters under this policy in good faith.



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• all employees will understand the process of raising a concern if the

need arises;


• all employees have a clear understanding of their roles andresponsibilities with regards to whistleblowing.


This policy has been drawn up in consultation with (the Joint Management and StaffCommittee and Public Concern at Work. The South West Strategic Health Authority willreview the policy regularly and welcomes your comments.





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Appendix 30

Work Experience Policy

This appendix sets out the revised Work ExperiencePolicy for the South West Strategic Health Authority.





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Work Experience Policy

1. Introduction

1.1 The South West Strategic Health Authority promotes a positive attitude towardswork experience. To achieve a useful experience for both the work experiencecandidate and South West Strategic Health Authority the following guidelineshave been produced.

1.2 In addition to work experience placements, the South West Strategic HealthAuthority is keen to arrange customised visit days for individuals or smallgroups who would like to gain information on a specific department, role or job.

1.3 Work experience provides candidates with the skills and attitudes needed by aprogressive NHS organisation. It addition, a positive work experience may leadto attracting high calibre of employment candidates in the future.

1.4 The South West Strategic Health Authority aims to promote equality anddiversity, and value the benefits that this brings. It is our aim to ensure that allwork experience candidates feel valued and treated fairly and equitable.

2. Definitions

2.1 For the purposes of this policy, work experience is defined as a placementincluding internship on the premises of the South West Strategic HealthAuthority in which a candidate carries out a particular task, duty or range oftasks or duties more or less as would an employee under the directsupervision.

2.2 A candidate is defined as an individual aged 14 or over.

3. Pre-placement requirements

3.1 All potential work experience placements or customised visit days should be

discussed with the Human Resources team.

3.2 In the event of the candidate being aged under 16, their supervisor and/ormentor at the South West Strategic Health Authority must be registered withthe Independent Safeguarding Authority and hold a satisfactory enhancedCRB Disclosure as required by the Vetting and Barring Scheme.

3.3 All applications for work experience must be made in writing together with aCurriculum Vitae and a statement from the candidate on what they would liketo achieve from the work experience and what benefits it will provide. A letterof support from a professional person, for example, a tutor or previous

employer, is also required.



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3.4 It is recommended that candidates be interviewed before a placement isconfirmed.

3.5 Occupational Health clearance must be obtained, in order to identify anyreasonable work place adjustments required.

3.6 Details of the work experience placement, candidate and correspondencerelating to the placement should be submitted to the Head of HumanResources prior to commencement of the placement.

4. Managerial responsibilities

4.1 The responsibilities of the manager are to:

• ensure the work experience candidate receives a structured induction.This should include elements on health and safety, fire procedures and

an introduction to the Human Resources team;

• ensure that reasonable work place adjustments are which balance theneeds of the business with the needs of the individual (for exampledisability or candidates where English is a second language);

• ensure that appropriate action is taken in the event of an accident andthat an accident form is completed;

• allocate an appropriate mentor who should be available throughout theplacement and ensure that adequate supervision is provided;

• be responsible for completing any evaluations of the placement;

• arrange and undertake regular and a final review so as to ensure that thework experience individual has benefited from the placement.

5. Candidate responsibilities

5.1 The work experience candidate needs to inform their mentor, as soon aspossible, of any concerns they may have regarding any element of theirplacement.

5.2 All work experience candidates are expected to:

• have clear, written learning goals;

• willing to negotiate their learning requirements in a responsible andreasonable manner;

• be punctual.



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5.2 The work experience candidate will be asked to complete a short write-up oftheir placement at the end of the placement which should indicate what theyhave learned or gained from their experience at the South West StrategicHealth Authority.



• all work experience individuals gain a positive image of the South WestStrategic Health Authority as a good employer;

• all individuals receive a structured induction;

• all work experience individuals benefit from their placements.






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Appendix 31

Adverse Incident Policy

This appendix sets out the revised Adverse IncidentPolicy for the South West Strategic Health Authority.





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Adverse Incident Reporting Policy

1. Introduction

1.1 The South West Strategic Health Authority is committed to ensuring:

• the health, safety and welfare of its staff, visitors and contractors;

• the security and safety of its assets;

• security of its data and records;

• business continuity;

• the Reputation of the organisation its upheld and quality is consistent.

1.2 The South West Strategic Health Authority will therefore ensure that incidentsare treated as an opportunity to learn and will endeavour to ensure that allstaff are aware of this incident reporting policy and report incidentsappropriately

1.3 The South West Strategic Health Authority is committed to the fair andconsistent treatment of staff, volunteers and contractors regardless of theirsex/gender, sexual orientation, religion or religious beliefs, race, age, or

disability. Where evidence of inequality or adverse effect is found the SouthWest Strategic Health Authority will take appropriate action.

1.4 This document sets out the procedure for recording, reporting, investigating,monitoring and learning from adverse or near miss events. It should be readin conjunction with the Risk Management Strategy and policy, and the Healthand Safety policy.

2. Definitions

Incident

2.1 Any event or circumstance that could have, or did, lead to unintended orunexpected harm, loss or damage.

Adverse incident

2.2 An incident which lead to unintended / unexpected harm, loss or damage.

Near miss

2.3 An incident that did not lead to harm, loss or damage but had serious potential

to do so.



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3. Responsibilities

Staff responsibilities

3.1 All staff, under the requirements of this policy are responsible to report any

adverse incident or near miss which they have been involved in or havewitnessed. Incidents must be reported by completing the South WestStrategic Health Authority Incident Report form (Annex 1). These forms canbe downloaded from the forms section of the South West Strategic HealthAuthority intranet site.

3.2 Completed Incident Report forms should be sent to the Director ofCommunications and Corporate Services no more than ten working days afterthe incident. If any supplementary information has been collected (forexample photographs of the scene, witness statements) this should be sentwith the Incident Report form. Copies of the form can be taken for a member

of staff’s own records if required.

3.3 In the event that an incident has caused an injury to a member of staff, visitoror contractor the person in charge at the time of the incident must ensure thatthe injuries and details of the person affected are also recorded in theAccident Book, which is located in the reception area of the South WestHouse Building. This should be completed in addition to an Incident Reportform.

3.4 For any employees working in areas outside of the main South West StrategicHealth Authority Building (Deanery’s) an accident book should be used in

these areas to record injuries. Incidents and injuries, which occur in theDeanery’s, should be reported and recorded by using the Strategic HealthAuthority incident reporting form.

Manager’s responsibilities

3.5 In addition to the responsibilities set out in 3.1, all managers must ensure

• immediate action is taken to prevent recurrence where appropriate;

• if the consequence of the incident appears to be orange or red, report

incident immediately to Director of Communications and CorporateServices;

• staff receive medical attention as appropriate;

• incident forms are completed and submitted;

• staff receive feedback on action taken;

• respond to recommendations / instructions following a review of theincident;



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Director of Communications and Corporate Services

3.6 The Director of Communications and Corporate Services has overallresponsibility for the incident reporting process and ensures processes are inplace to effectively deliver the following objectives:

• incident Report Forms are available to all staff;

• new staff are instructed in the incident reporting process;

• existing staff are kept up to date with policy requirements;

• incident Reporting Forms are kept for a minimum of three years andare stored in a safe place and summaries are recorded onto anelectronic database;

•

the Incident Reporting Policy is kept up to date and effective;

• RIDDOR reports to the Health and Safety Executive are reported withinthe prescribed time frames.

3.7 On receiving completed Incident Reporting Forms the Director ofCommunications and Corporate Services will ensure processes are in placeto carry out the following requirements:

• a consequence score is assigned. This will ensure that the severity ofthe incident is ascertained and action can be taken promptly as

required (see Annex 1);

• incidents are investigated so far as is reasonably practicable:

∗ all Incidents of a consequence score of 3, 4 or 5 are investigatedand action plans are produced and monitored to ensure lessonsare learnt;

∗ incidents of a lower consequence (1 and 2) are monitored fortrends;

∗

near miss incidents (consequence 0) are assessed to identifyany significance.

• lessons are learnt and any staff involved are given feedback asappropriate;

• the Director of Communications and Corporate Services is responsiblefor ensuring incidents are reviewed and action plans are carried out asappropriate.



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Risk monitors

3.8 Risk monitors have received extended training in incident investigation andmanagement and will assist managers and the Director of Communicationsand Corporate Services.

3.9 Specifically, the Risk Monitors can assist with

• encouraging staff to report incidents;

• assisting in incident investigations;

• providing knowledge and support to managers on risk assessment;

• carrying out audits of the Incident reporting process and feeding backto the Director of Communications and Corporate Services.

4. Reporting and monitoring requirements

4.1 Health and Safety related incidents (including for example fire, security,ergonomics or injury) are reported to the Joint Management Staff Committeefor consideration and action as necessary. This may include requesting riskassessments are carried out in those areas where incidents have occurred.The Director of Communications and Corporate Services will ensure this datais available for the Joint Management Staff Committee to review.

4.2 The Director of Communications and Corporate Services is responsible for

ensuring incidents are reviewed at these committees.

5. External reporting requirements

5.1 Under the requirements of the Reporting of Injuries Diseases and DangerousOccurrences Regulations (RIDDOR) any injury (major injury or injury whichprevented an employee working for more than three days after the incident),dangerous occurrence or disease will be reported by the South West StrategicHealth Authority to the Health and Safety Executive (HSE).

5.2 The Director of Communications and Corporate Services will carry this out

with the support from the South West Strategic Health Authority’s CompetentHealth and Safety Advisor as appropriate. Any external reports to the Healthand Safety Executive will be reported to the Joint Management StaffCommittee.



• all staff are aware of their responsibility to report incidents and nearmisses;



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• all adverse incidents / near misses will be recorded on an adverseincident report and near miss report form so that actions can be carriedout to eliminate, control or reduce the risk;

• all red and orange incidents will be investigated for purposes of

learning;

• the external reporting requirements (RIDDOR) are carried out inaccordance with Health and Safety Legislation.






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Annex 1

Risk and consequence scoring matrices

Consequence scores are attributed to incidents to understand the significance

of the incident

Consequence Score

Score 1 2 3 4 5Descriptor Insignificant Minor Moderate Major Catastrophe

No time offwork

Less than 3days off work

3 – 15 daysoff work(RIDDORreportable)

Less than15 days offwork

Unable toreturn towork

Physical / psychologicalharm to staff,visitor ormember of the

public

Minor injury

requiringminimalintervention

Minor injury

requiringintervention

Moderate

injuryrequiringprofessionalintervention

Major injury

or long termincapacity

Death or

majorpermanentincapacity

Potentialfailure tomeetstandards

Noncompliancewith internalstandards

Noncompliancewith nationalstandards

Noncompliancewith nationalstandardswithsignificantrisks tovisitors or

staff

Noncompliancewith nationalstandardswith seriousrisks tosafety

Quality andbest practice

Barelynoticeablereduction inquality

Minorreduction inquality

Reduction inscope orqualityrequiringapproval

Secondaryobjective notmet

Key objectivenot met

Objectives / businessinterruptions

Loss / interruptionof service forless than 1hour

Loss / interruptionof servicebetween 1 to24 hours

Loss / interruptionof servicebetween 1and 7 days

Loss / interruptionof servicemore than 1week

Permanentloss ofservice / facility

Single loss / capital spendmore than£10,000



Single loss / capitalspend morethan £1m

Single loss / capital spendmore than£3m

Finance / adversepublicity / reputation risk

Rumours Local media – short term

Local media – long term

Nationalmedia – lessthan 3 days

Nationalmedia morethan 3 daysPublic inquiry



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Likelihood score

Likelihood scores are used to determine likelihood or frequency the incident ismost likely to occur

1 2 3 4 5Descriptor Rare Unlikely Possible Likely Almost

certainFrequency Not

expected tooccur foryears

Expected tooccur atleastannually

Expected tooccur atleast weekly

Expected tooccur atleast weekly

Expected tooccur atleast daily

Probability Less than1%

1 – 5 % 6 – 20% 21 – 50% More than50%

Risk score

Use the consequence score and multiply with the likelihood score to identifythe overall risk score

Most likely consequences(if in doubt grade up, not down)

1 2 3 4 5LikelihoodInsignificant Minor Moderate Major Catastrophic

1 – Rare 1 2 3 4 5

2 – Unlikely 2 4 6 8 10

3 – Possible 3 6 9 12 15

4 – Likely 4 8 12 16 20

5 – AlmostCertain 5 10 15 20 25



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Annex 2

Risk treatment and action required

Risk Status Further Action Required

Low

Range

1 – 6

Acceptable risk

Inform all appropriate stakeholders

Record on central database;

Maintain paper records

Discuss whether any further actionshould be taken to reduce risk

Moderate

Range

7 – 11

Unacceptable risk

As above plus :

Report to Senior Management Team

Review at appropriate Committeeidentifying options and monitoringaction plans

High

Range

12 – 25

Significantunacceptable

risk

As above plus :

Report to Board identifying optionsand monitoring action plans



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Annex 3

Adverse Incident and Near Miss Reporting Process

Adverse Incident / Near Miss Occurs

Incident Form is completed by Memberof Staff or Person in Charge at the Time

of the Incident

Any necessary Action is taken to PreventReoccurrence

Manager Considers Severity of IncidentSuspect Red / Orange Incident? Report

by phone or email to Director

Completed Adverse Incident form is sent

to Director of Communications andCorporate Services within 10 days

Part 2 of the Form is Completed by theDirector of Communications and

Corporate Services and information islogged onto Incident Spreadsheet

Incidents are reviewed at the Risk

Monitors Safety Meeting

Safety incidents are reported to theSouth West Strategic Health Authority

Joint Management and Staff SideCommittee

Annual Safety Report to the Board

RIDDOR report asnecessary

Feedback to staff

Annual review ofincident reporting

processeffectiveness



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Appendix 32

Fire Safety Policy

This appendix sets out the revised Fire Safety Policyfor the South West Strategic Health Authority.





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Fire Safety Policy

1. Scope

1.1 This policy encompasses the management of the fire safety in South WestHouse.

1.2 The aim of the South West Strategic Health Authority is to ensure, as far aspossible, that outbreaks of fire do not occur. If an outbreak cannot beprevented it must be rapidly detected, effectively contained and quicklyextinguished without risk to staff, clients or visitors. A commitment to be awareof fire precautions is a basic duty of all staff and an essential obligation for

everyone with management responsibility.

1.3 The South West Strategic Health Authority is committed to the fair andconsistent treatment of staff, volunteers and contractors regardless of theirsex/gender, sexual orientation, religion or religious beliefs, race, age, ordisability. Where evidence of inequality or adverse effect is found the SouthWest Strategic Health Authority will take appropriate action.

2. Objectives of the policy

2.1 The objectives of the policy are:

• to ensure that all appropriate fire safety measures are provided tomaintain a safe environment for staff and visitors.

• to ensure that all staff are trained and accept responsibility for firesafety. All staff must be competent to manage fire safety within theirarea of work.

• to ensure that all staff are aware of the action to take in the event of afire or suspected fire.

•

to ensure that the Strategic Health Authority is compliant with allrelevant Fire Safety Legislation and appropriate guidance andapproved codes of practice.

3. Purpose

3.1 All NHS organisations are required to provide a clearly defined Fire SafetyPolicy.

3.2 This policy must comply with the Firecode, an NHS guidance documentoutlining the fire risks associated with healthcare provision and identifying a

framework of precautionary measures.



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3.3 The South West Strategic Health Authority Fire Safety Policy and associatedFire Safety Procedures are based on the framework recommended asrepresenting best practice by Health Technical Memorandum HTM 05-01“Managing Healthcare Fire Safety”, published by the Department of Health.HTM 05-01, which follows the principles of BS5588-12: 2004 requires those

responsible for Fire Safety within healthcare premises in England to:

• comply with prevailing legislation;

• implement fire precautions through a risk managed approach;

• comply with monitoring and reporting mechanisms appropriate to themanagement of fire safety;

• develop partnership initiatives with other agencies and bodies in theprovision of fire safety.

3.4 The South West Strategic Health Authority Fire Safety Policy and Fire SafetyProcedures sets out the requirements to enable the Strategic Health Authorityto identify the principle roles and responsibilities of management andemployees to achieve compliance with the legislation and best practice.

4. Policy statement

4.1 South West Strategic Health Authority recognises and accepts its obligationsrelating to the management of fire prevention and fire safety, so far as isreasonably practicable. As such it is the intention of the Strategic Health

Authority to minimise:

• the incidence of fire throughout South West House;

• the impact from Fire on life safety, delivery of service, the environmentand property.

4.2 This policy will be implemented across the Strategic Health Authority and isintended to safeguard all who have access to South West House, including,employees, visitors and contractors.

4.3 This policy should be read in conjunction with related policies including Healthand Safety policy, and Disciplinary rules and procedures.

5. Roles and responsibilities

The Chief Executive

5.1 The Chief Executive is responsible for ensuring that the Strategic HealthAuthority complies with current fire safety legislation and the implementationof Firecode Guidance in South West House.



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5.2 The Chief Executive will nominate a Board level Director who will beaccountable to the Chief Executive for all fire safety issues. The Director willbe the Director of Communications and Corporate Services. It will be theresponsibility of the Chief Executive in conjunction with the Director ofCommunications and Corporate Services to ensure:

• the Strategic Health Authority has an effective Fire Safety ManagementSystem;

• an audit of Fire Precautions is undertaken to advise the SeniorManagement Team of the Strategic Health Authority on the currentstate of fire safety within South West House;

• an annual statement of Fire Safety, required by the Department ofHealth, confirming that all premises which the Strategic HealthAuthority owns or occupies, have had risk assessments undertaken in

compliance with the Regulatory Reform (Fire Safety) Order 2005, issubmitted to the Department of Health Estates and FacilitiesManagement Information Centre on time.

The Director of Communications and Corporate Services

5.3 The Director of Communications and Corporate Services, nominated by theChief Executive, is delegated to take formal responsibility and play an activerole in managing Fire Safety:

• ensuring that the Chief Executive and the Board are given the

appropriate reassurances that the requirements of fire safety legislationand the objectives of Firecode are being met;

• ensuring that Fire Safety Policies are uniformly and correctly applied;

• ensuring that where fire safety knowledge has been identified orspecific groups or individuals, such as training, information andinstruction is provided and applied;

• determining the appropriate level of management knowledge within theStrategic Health Authority to manage the fire safety obligations.

The Building Facilities Manager

5.4 The Building Facilities Manager is responsible to the Director ofCommunications and Corporate Services for advising senior managementand others on professional and technical issues and for monitoring thestandards of fire safety in South West House.

5.5 The Building Facilities Manager is responsible for:

• an awareness of fire safety features and their purpose;

• liaison with the fire safety advisory service of the Department of Health;



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• fire safety risks particular to the organisation;

• requirements for disabled staff and visitors related to fire procedures;

• advising on compliance with legislation;

• development and implementation of the organisations Fire SafetyPolicy;

• reviewing the Fire Safety Policy of the Strategic Health Authority atregular intervals to ensure that any recommendations or changes arebrought to the Joint Management Staff Committee for agreement;

• development and delivery of an effective training programme;

• the reporting of fire incidents in accordance with current practice;

• liaison with enforcing authorities;

• liaison with fire wardens in each Directorate;

• monitoring of inspection and maintenance of fire safety systems.

Fire Wardens

5.6 Fire Wardens should be appointed in all Directorates to provide localleadership and direction in Fire Safety matters.

5.7 The Fire Warden should:

• act as a focal point on fire safety issues for local staff;

• organise and assist in the fire safety regime within local areas;

• raise issues regarding local area fire safety with local management;

• assist with coordination of the response to an incident within theimmediate vicinity;

• be responsible for the roll call during an incident;

• be trained to tackle fire with first aid fire fighting equipment whereappropriate;

• support the Building Facilities Manager on fire safety issues andundertaking fire safety inspections;

• participate in the fire warden training and apply the information to theworkplace.



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General duties and responsibilities of all staff

5.8 All employees of the South West Strategic Health Authority have a duty toensure that they comply with the Fire Safety arrangements and procedures attheir workplace and that they do not commit acts which could lead to an

outbreak of fire. All employees have a duty under the Health and Safety atWork Act to take reasonable care of their own health and safety at work andof other persons who may be affected by their acts or omissions.

5.9 All employees are required to attend a class based fire safety training sessionevery three years and undertake refresher courses on line every year.

5.10 All employees of the South West Strategic Health Authority have duty tocooperate with South West Strategic Health Authority and report hazards.

5.11 Staff shall not recklessly interfere with anything provided in the interests of

health and Safety.

6. South West House

6.1 The Directorate of Communications and Corporate Services has overallresponsibility for ensuring that the following areas of Fire Safety infrastructureare maintained in accordance with the Fire Safety Policy of the StrategicHealth Authority.

6.2 All outside contactors working at South West House must comply with thepolicies of the Strategic Health Authority.

6.3 All contracts for construction works, equipment supplied and works completedat South West House, will comply with the policies of the Strategic HealthAuthority.

6.4 All mandatory and advisory signage in respect of Fire Safety shall conform tothe current British Standard/HTM. Signage should be replaced, wherenecessary, when premises are refurbished or redecorated.

6.5 The maintenance of fire-fighting equipment shall be carried out in accordancewith BS5306: Parts 1 and 3 1985. Records of all works undertaken shall be

maintained for each appliance.6.6 Fire plans will be maintained of South West House. The plan will indicate the

positions of the following Fire Safety infrastructure:

• the location of essential elements of fire detection and fire alarmsystems, including health and smoke detector call points, sounders,visual indicators, alarm and indicator panels.

• the location of each addressable element of an addressable analoguefire system.

• the location and position of compartment and sub-compartment wallsand floors indicating their periods of fire resistance.



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• the location of all fire-resting doors indicating their periods of fireresistance.

• the location of all final exit doors indicating their type of security device.

• the location and type of first aid fire-fighting equipment.

• the location of the fire services access to the fire hydrants and by-passvalves at South West House.

• the location of known hazards and risk including the boiler and serverrooms.

6.7 A programme of planned preventative maintenance shall be undertaken tohelp ensure that the fire safety infrastructure remains in a fully serviceableand operational condition. All records must be retained for a minimum of 11

years.

6.8 The inspection and testing of fire alarm systems will be undertaken on aweekly, quarterly and annual test-basis in accordance with BS5839: Part 1and HTM82.

6.9 The fire integrity of all designated firewalls and cavity barriers will bemaintained to the standards specified in the fire plans.

6.10 The inspection of fire doors and final exit doors will be undertaken at 6monthly periods in accordance with BS8241.

6.11 All automatic fire suppression systems will be maintained in accordance withthe manufacturer’s instruction.

6.12 All fixed electrical equipment will be subject to periodic inspections inaccordance with BS7671.

6.13 All portable electrical equipment will be inspected and tested in accordancewith BS5266.

6.14 All works/repairs will be monitored and actioned using a valid work permitsystem. Any special works involving isolation or disabling of any firedetection/monitoring equipment shall not be carried out without a valid permitissued by the Building Facilities Manager.

7. Fire Policy Monitoring

7.1 The Building Facilities Manager shall ensure the following are in place:

• fire risk assessment and an action plan completed and reviewed atleast annually;

• all fire fighting and monitoring equipment is maintained by a competentcontractor. (currently ADT);



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• conduct and carry out six monthly fire evacuation test and complete anaction plan and monitoring record as required;

• ensure the appropriate number of fire wardens are trained and in placein accordance with the fire risk assessment;

• carry out weekly fire inspections of the premises both internally andexternally;

• liaise with and establish links with the Devon and Somerset FireService;

• collate and action incident and investigations and risk assessmentreviews including any information provided by the department firewardens, and complete an action plan;

• collate and set up log book of all risk assessments;

• maintain log of reports/information from fire wardens;

• liaise with the Joint Managing Committee to change or amend anypolicy or risk details.



• all employees are aware of their responsibilities regarding fire safety;

• appropriate training of staff and wardens is provided;

• incidents are reported to the Joint Management Staff Committee.


Policy approved: April 2010

Review by: April 2013



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Appendix 33

Health and Safety Policy

This appendix sets out the revised Health and SafetyPolicy for the South West Strategic Health Authority.





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Health and Safety Policy

1. Statement of intent

1.1 The South West Strategic Health Authority is committed to providing a safeand healthy environment for its staff, visitors and contractors, so far as isreasonably practicable, and recognises it’s legal and moral duties to staff,visitors and contractors. The Strategic Health Authority will do all that isreasonably practicable to ensure their health, safety and welfare whilstaccessing the organisation.

1.2 This policy is the South West Strategic Health Authority’s overarching Healthand Safety policy, which sets out the duties of the directors, managers andstaff in achieving compliance with legislation. Policies relating to specificsafety legislation such as Fire, Stress and Display Screen Equipment forexample, all give detailed instructions on requirements and can be found onthe Intranet site of the South West Strategic Health Authority.

1.3 The South West Strategic Health Authority is committed to the fair andconsistent treatment of staff, volunteers and contractors regardless of theirsex/gender, sexual orientation, religion or religious beliefs, race, age, or

disability. Where evidence of inequality or adverse effect is found the SouthWest Strategic Health Authority will take appropriate action.

1.4 This policy should be read in conjunction with the Risk Management Strategy,Incident Reporting policy and all relevant specialist health and safety policies.

2. Policy statement

2.1 South West Strategic Health Authority will do all that is reasonably practicableto prevent injury or loss to any person by fully accepting and acting effectivelyupon the following responsibilities:

• comply with the Health and Safety at Work Act 1974 and all otherrelevant Health and Safety Legislation;

• set out clear lines of accountability for the management of health andsafety;

• ensure suitable and sufficient risk assessments are undertaken, andthat any action plans made as a result are acted upon within anacceptable time period, so far as is reasonably practicable;



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• provide all employees with suitable and sufficient information,instruction, training and supervision so as to ensure all staff arecompetent to work safely and are clear as to their legal responsibilitiesfor health, safety and welfare at work;

• provide and maintain the premises and all items of plant and machineryso as to ensure that it is safe and without risk to health;

• where applicable, select and provide suitable and sufficient personalprotective equipment necessary for work activities, ensure that staff aretrained in its use and that personal protective equipment is maintainedand stored appropriately;

• design and implement effective procedures for fire and othercatastrophes, ensuring, through practice drills, persons recognise thesignal to evacuate the premises and understand how to proceed when

the signal is given;

• provide adequate financial and physical resources for theimplementation of this policy content;

• keep adequate records of accidents and incidents and monitor inaccordance with the South West Strategic Health Authority’s IncidentReporting policy;

• provide competent occupational health services, which will be availableto all employees where necessary;

• ensure that systems are in place to ensure any member of staffreturning to work, following an injury or ill health resulting from workactivities, is supported and is safely integrated back to work;

• appoint competent persons to assist and advise in the measuresnecessary to comply with the requirements of all relevant legal duties;

• ensure that co-operation and co-ordination is achieved betweenemployers when contractors are working on the South West StrategicHealth Authority premises.

3. Responsibilities

3.1 Overall accountability for ensuring compliance with Health and SafetyLegislation rests with the Chief Executive of the South West Strategic HealthAuthority. The Chief Executive of the South West Strategic Health Authoritydelegates responsibility to the Director of Communications and CorporateServices who is responsible for devising and implementing effectiveprocesses to manage and improve health and safety provision.



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3.2 Director of Communications and Corporate Services has overall responsiblefor providing effective systems and procedures to ensure the suitable andsufficient management of health and safety is achievable across the SouthWest Strategic Health Authority. Specifically the Director of Communicationsand Corporate Services will:

• ensure policies are up to date and remain effective;

• ensure effective process are in place for the identification of hazardsand that these identified risks are acting upon so far as is reasonablypracticable;

• organise and ensure the delivery of suitable and sufficient training forall employees;

• inform the Board of any significant health and safety risks which could

impact upon an employee and / or the organisation;

• disseminate health and safety information and instruction in the form ofcirculars, safety alert bulletins and updated policies and procedures;

• ensure that relevant health and safety forums and committees are inplace;

• ensure staff have access to relevant Occupational health advice andsupport when necessary;

• ensure competent health and safety advice is available as required;

• report “RIDDOR” injuries, diseases or dangerous occurrences to theHealth and Safety Executive as required under the Reporting ofInjuries, Diseases and Dangerous Occurrences Regulations.

Directors

3.3 The responsibility for the implementation of the Health and Safety policywithin the Directorates rests with each Director. Each Director will:

•

be aware of the Managers requirements with the specific Health andSafety policies;

• ensure each Directorate has at least one trained Workplace RiskMonitor;

• gain assurance that all staff within the Directorate have all receivedappropriate training;

• disseminate all safety relevant information;

•

respond to audit outcomes and develop action plans to address anydeficiencies;



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• ensure that financial resources are available to address safetyconcerns so far as is reasonably practicable;

• ensure that systems are in place and effective for return to work of anystaff member returning from work relating injury or ill health.

All managers

3.4 Managers are key to ensuring the operational delivery of the Health andSafety Policies and will:

• be fully aware of the managers responsibilities set out in Health andSafety policies;

• ensure all staff are aware of their responsibilities set out in Health andSafety policies;

• ensure all employees receive appropriate training including inductionfor new staff and mandatory training for existing staff;

• carry out risk assessments and develop action plans to address andrisks so far as is reasonably practicable;

• ensure all staff are aware of how to report hazards (incident reportingand risk assessment);

• report any “RIDDOR” injuries, diseases or dangerous occurrences to

the Director of Communications and Corporate Services;

• assist with incident investigations according to the requirements of theincident reporting policy;

• participate in any South West Strategic Health Authority health andsafety audit programme;

• fully support the role of the Directorate Workplace Risk Monitor andrespond appropriately to recommendations;

•

cascade any safety information or bulletins to employees as necessary;

• ensure that risk assessments are carried out to ensure the safe returnto work of any staff member returning from work relating injury or illhealth;

• refer staff to Occupational health service as necessary;

• allocate reasonable funds and resources to ensure the safety andwelfare of staff;



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All employees

3.5 Under the requirements of the Health and Safety at Work Act, 1974 allemployees have specific responsibilities:

•to report to their manager or supervisor any incident / accident / untoward occurrence / near miss or potential risk which has or may,lead to loss, injury or damage, using the Incident Reporting form,according to the Incident Reporting policy

• report any defect in equipment to manager ensuring that anyequipment is removed from service and made safe before any furtheruse;

• use all personal protective equipment provided in the interests of healthand safety, and ensure that it is kept safe and free from damage;

• attend all relevant Health and Safety training as required;

• co-operate with managers to ensure that safety measures, systemsand policies are followed appropriately and report if, for any reason,safety measures cannot be followed;

• raise concerns if any Health and Safety information, instruction andtraining is not understood;

• co-operate with any investigation being undertaken as a result of an

accident/incident which has affected staff, visitors or contractors;

• participate in the undertaking of risk assessments;

• be aware that reckless interference with items provided in the interestof Health and Safety will not be tolerated and is an offence under theHealth and Safety at Work Act 1974;

• take reasonable care while at work for the health and safety of yourselfand any other person that could be affected by your actions;

•

support the Workplace Risk Monitors in the monthly workplaceassessment process;

Workplace risk monitors

3.6 Each Directorate will ensure that there is a trained Workplace Risk Monitor.The Risk Monitor is responsible for:

• carrying out monthly workplace assessments and reporting results tothe Director;

•

identifying hazards and assisting managers with risk assessments;



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• assisting with incident investigations;

• raising awareness of risk issues;

• supporting staff to report incidents;

• attending relevant meetings and training updates.

Competent health and safety advice

3.7 The South West Strategic Health Authority have access to competent adviceon all health and safety matters. This advice is currently sought from the RiskManagement Department at Taunton and Somerset NHS Foundation Trust(01823 342489). Any person employed by the South West Strategic HealthAuthority can access this advice as necessary.

4. Safety arrangements4.1 The South West Strategic Health Authority has developed systems, tools and

reporting processes to ensure the health, safety and welfare of staff, visitorsand contractors. These arrangements are detailed below. More specificguidance on specific safety subjects may be found in supporting specialisthealth and safety policies (for example the Display Screen Equipment policy).

Risk assessment

4.2 Risk Assessment is a legal requirement under the Management of Health and

Safety at Work Regulations. Any hazard, which poses a significant risk tostaff, visitor or contractor, must be formally documented using the South WestStrategic Health Authority’s standard Risk Assessment Form which can befound on the intranet. In addition, specialist risk assessment tools such as theStress Risk Assessment tool and Display Screen Equipment self assessmenttools are all available assist in the assessment of risk. These forms are allavailable on the intranet on the Human Resources pages.

4.3 All staff should be made aware of, and have open access to, riskassessments relevant to the daily tasks they perform. Staff must follow allactions and guidance given within the assessment. Any action plans made as

a result of a risk assessment should be completed as soon as is reasonablypracticable. Risk assessments must be reviewed and updated as necessaryin response to any incident that poses a significant risk to staff, visitors orcontractors.

4.4 Use of generic risk assessments should be avoided. Generic risk assessment(typically the sharing of risk assessments between departments) can lead tounsuitable assessment of the risks. All risk assessment must be specific tothe staff member or service they are pertaining to.



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Risk register

4.5 The South West Strategic Health Authority has a risk register that includesdetails of all risks identified from any source including health and safetyrelated risks. All risk assessments carried out by an employee of the South

West Strategic Health Authority should be submitted to their manager. Anyrisk assessments containing personal staff information should not be added tothe register.

4.6 A log of all risk assessments is maintained in reception to allow a clear view ofthe priorities for the organisation. Risk assessments are scored and areincluded in the Risk Register for the organisation as appropriate. See theSouth West Strategic Health Authority’s Risk Management Strategy for moreinformation on the Risk Register process.

Workplace assessments and inspections

4.7 Risk Monitors carry out monthly inspections and assessments of theworkplace incorporate all aspects of Risk Management including Health andSafety and manual handling issues. Risk inspections occur on a monthlybasis and findings must be documented and reported to the manager.Inspections must be tailored to individual departmental needs and shouldreflect the associated risks. Action should be taken as necessary to reduceany risks to the lowest level reasonably practicable. Any risks identifiedshould be added to the risk assessment log as appropriate.

4.8 In additional to the in-house monthly assessments and annual audit, the

Health and Safety Executive (HSE) have the legal power of warrant to inspectany area of South West Strategic Health Authority without notice orpermission at any time.

Health and safety training

4.9 The South West Strategic Health Authority will ensure that all staff appropriatehealth and safety training on induction and thereafter on mandatory training.Further advice for managers on training requirements can be sought from theDirectorate of Communication and Corporate Services.

Incident reporting

4.10 Employees are required by law to report hazards. Incident reporting allows theSouth West Strategic Health Authority to identify potential risks, and to learnfrom incidents to prevent a reoccurrence. All health and safety relatedaccidents or incidents should be reported in the same way as all otherincidents; by using the standard South West Strategic Health AuthorityIncident Report form and investigation process thereafter. Specific details onthe incident reporting process can be found within the South West StrategicHealth Authority Incident Reporting policy.



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4.11 South West Strategic Health Authority Joint Management and Staff Healthand Safety Committee is the Health and safety committee for the organisation.

4.12 The Health and Safety committee will ensure that health and safety mattersraised by staff and Risk Monitors are discussed and actioned so far as is

reasonably practicable. This will include any heath and safety relatedincidents reported by staff.

5. Policy review

5.1 The Health and Safety Committee, in conjunction with the competent Healthand Safety Advisor shall review the Health and Safety Policy every threeyears unless a significant change occurs.



• all employees are aware of their responsibility to report heath andsafety incidents;

• the organisation is aware of the potential areas of risk and activelymanages them to minimise their impact;

• internal reporting of health and safety issues are routinely made to theJoint Management Staff Committee;

• the external reporting requirements (RIDDOR) are carried out inaccordance with the policy.






Appendix 34

Lone Workers Policy

This appendix sets out the revised Lone WorkersPolicy for the South West Strategic Health Authority.





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Lone Workers Policy

1. Introduction and aim

1.1 South West Strategic Health Authority is committed to ensuring the Health,Safety and Welfare of its staff. In accordance with the Health and Safety atWork Act 1974 and the Management of Health and Safety at WorkRegulations 1999, the Strategic Health Authority will ensure that all that isreasonably practicable to do, is done to ensure the safety and well being of itsemployees who are defined as a lone worker.

1.2 The South West Strategic Health Authority recognises that due to the natureof its activities, some staff are required to work alone.

1.3 The South West Strategic Health Authority will do all that is reasonablypracticable to assess the risks to these staff and reduce risks to the lowestlevel possible.

1.4 This policy is applicable to any employee, volunteer or contractor who may beconsidered a lone worker whilst undertaking work prescribed by the SouthWest Strategic Health Authority.

1.5 This policy should be read in conjunction with the Risk Management Strategy,Incident Reporting policy, Health and Safety policy, Security policy, Mandatory

Training policy, Induction policy and the Violence and Aggression policy.

2. Definitions

2.1 Lone Workers are those who work by themselves without close or directsupervision such as:

2.1.1 Staff in fixed establishments where:

• only one member of staff works in the area;

• staff work separately from others;

• staff work outside of normal hours.

2.1.2 Mobile Lone Workers working away from their base and wheretheir work may be carried out in:

• other NHS organisations or businesses premises;

• working at home;

• working whilst travelling around NHS South West or elsewherein the UK.



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2.2 It is acknowledged that any member of staff may spend a limited amount oftheir time working ‘Alone’. Effective local procedures in these circumstancesshould be put into place.

3. Responsibilities

3.1 To ensure responsibilities are met, the Chief Executive delegate’sresponsibilities to the Director of Communications and Corporate Services.

Director of Communications and Corporate Services

• gain assurance on behalf of Directorates that they are doing all that isreasonably practicable to protect the health, safety and welfare of LoneWorkers;

• ensure an effective incident reporting and review procedure is in place

(see Trusts incident reporting policy);

• ensure that the Risk Register process is effective (See RiskManagement Strategy).

Managers and supervisors

3.2 Any person who is responsible for the management of staff who are definedas a lone worker must:

• ensure that suitable and sufficient Risk Assessments are carried out;

• design and implement safe systems of work and regularly review thesystem’s effectiveness, providing equipment where necessary;

• ensure procedures are in place to investigate any incident involving aLone Worker and that support is offered to the employee following anyincident;

• ensure that action plans developed as a result of risk assessments/ incidents are carried out and are effective;

• ensure that all staff defined as lone workers are aware of the LoneWorker policy;

• ensure the lone worker attends the appropriate training (see theMandatory Training policy)

Lone Workers

3.3 Any employee who is deemed a Lone Worker must:

• ensure that any items provided for them in the interested of Health,

Safety or Welfare and South West Strategic Health Authority are used,stored and maintained appropriately;



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• report incidents in line with the Strategic Health Authority IncidentReporting policy;

• ensure that they cooperate with their manager particularly with regardssystems that have been set up to reduce the risks of working alone;

• report any system errors or concerns regarding the Lone Worker safesystems of work;

• undertake any training or instruction required;

• take reasonable care of themselves and any other person who may beaffected by their actions;

• assist managers and the team in carrying out risk assessments anddeveloping safe systems of work.

Staff Occupational Health Department

• provide counselling support for any Lone Worker who requires it afterany incident which has affected their Health, Safety or Welfare.

Organisational arrangements

• the South West Strategic Health Authority is committed to providing asafe and healthy workplace for its staff, visitors and contractors.Arrangements are in place to ensure this can happen.

4. Risk assessment

4.1 All managers must ensure that risk assessments have been undertaken toidentify the risk to any Lone Workers working at or for the South WestStrategic Health Authority. Under no circumstances must generic riskassessments be used when assessing the risk to Lone Workers. All loneworker risk assessments must be carried out with knowledge of the role andmust be specific to each team or individual carrying out that role.

4.2 The first step in the risk assessment process is to create a list of all people

within a Directorate who work alone. Once this is compiled an additional list isneeded to identify all the tasks they perform and the risks involved with eachtask. For example:

• do they have sole responsibility for large sums of money or expensiveequipment?

• do they carry, or are the public likely to believe they carry, drugs?

• does their job involve giving bad news to people?

• does the job involve going into stranger’s houses?



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• will the job/ task put the employee into a hazardous environment (forexample plant rooms or roof)

4.3 Following this, it is necessary to ask if the risk can be eliminated – can thetask be eliminated all together? If the task cannot be eliminated, a safe

system of work must be designed to ensure that task can be undertaken assafely as possible. Any systems, which are put into place to reduce the risk,must be reviewed and evaluated to ensure they are working suitably.

4.4 If a risk assessment is required the following components must be considered(lists are not exhaustive)

Site based Lone Workers

• safe access, entrance and exit;

• risk or verbal or physical abuse;

• safety of equipment for individual use;

• channels of communication in an emergency;

• security and security arrangements.

Mobile Lone Workers

• travelling;

• reporting and recording arrangements / appointments;

• communications and traceability;

• personal safety/ security.

4.5 If potential risks are identified, suitable safeguards must be put in place beforepersonal contact is made. Their precise nature will depend on the situation,but any of the following may be appropriate:

•

arrange for meetings to be held at the South West Strategic HealthAuthority or other suitable premises;

• allocate two members of staff to make a visit;

• arrange for a reliable relative to be present, if, for example, anemployee might be vulnerable to sexual harassment or allegations of it.

4.6 It is essential for staff safety that people working alone and away from theoffice can be located by their work team. To facilitate this, the followingsystems should be considered.



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• up-to-date records of the make, colour and registration number ofvehicles being used should be maintained;

• a readily-available system to track staff visits should be in place, andthe information updated as required;

• procedures for checking out and in should be robust. These shouldinclude agreed return and/or ring-in times. If staff expects to finishoutside normal office hours, arrangements for checking in should beconsidered. The relevant Directorate must be fully aware of thesearrangements;

• following a risk assessment, some Directorates may decide that mobilephones should be provided.

5. Incident reporting process

5.1 The incident reporting process must be followed in the event of any adverseincident or near miss. This is to ensure that managers have an opportunity tolearn from incidents and to rectify any gaps in the safe system of work. Nearmiss reporting (something could have happened, but didn’t) is vital to ensurethat potential future incidents are prevented. Any situation where staff feelthreatened or vulnerable must be reported.

5.2 Incidents will be reported to the Joint Management Staff Committee on aregular basis.

6. Training

6.1 Managers should review the Mandatory Training policy to identify the trainingrequirements for the employee.

6.2 The Induction policy should be referred to when considering inducting newstaff.

7. Support for staff

7.1 Occupational Health has counselling facilities available for any member of

staff who needs it. If a Lone Worker has been involved in an incident forwhich they may require support from a counsellor, managers must make areferral to occupational health as soon as possible. Staff are also welcome tomake a self referral.

8. Monitoring/review

8.1 The Joint Management and Staff Committee will monitor the effectiveness ofthis policy by monitoring numbers of Lone Worker reported incidents

8.2 Once per annum they will commission an audit to identify if Lone Worker Risk

Assessments have been undertake in accordance with this policy. This willinclude reviewing a sample of lone worker safety arrangements in each



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Directorate. The results of this audit will inform a Strategic Health Authoritywide action plan.

8.3 This policy will be reviewed in three years, or earlier if there are any significantchanges to guidance or practice.

9. References

9.1 Working Alone: Controlling the Risks of Solitary Work, Health and SafetyExecutive Publication, 1998.



• the health and safety risks to lone workers are assessed and reduced

to the lowest possible level.






Appendix 35

Zero Tolerance Policy

This appendix sets out the revised Zero TolerancePolicy for the South West Strategic Health Authority.





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Zero Tolerance Policy

1. Policy

1.1 In accordance with its responsibilities for the health, safety and welfare of allits employees, the South West Strategic Health Authority will take allreasonably practicable steps to prevent, control and eliminate violence andaggression at work.

1.2 The South West Strategic Health Authority will not tolerate violence andaggression in any form against its employees. The South West StrategicHealth Authority will, therefore, adopt a number of actions to facilitate this.

These may range from withholding admittance into a building, to supportingemployees who want to take legal action against the perpetrators of violence.

2. Definition

2.1 In accordance with Health Service Circular 1999/129, violence is defined as:“any incident where employees are either verbally or physically abused,threatened or assaulted (including any application of force), in circumstancesrelated to their work where there is an explicit or implicit challenge to theirsafety, well-being or health”.

2.2 Work-related violence includes any harm or damage occurring to any personsor property such that a risk to others exists or may exist; the carrying,concealment or use of offensive weapons and any threats of violence,aggression or racial harassment which may be face-to-face, written, via thetelephone or via e-mail.

3. Aims and objectives

3.1 The aim of this policy is to protect employees and others from work-relatedviolence. In doing so, this policy will:

•

contribute to staff morale, reduced absenteeism, and provide the bestpossible environment for the delivery of services;

• ensure that the best possible support is provided to staff who havebeen involved in violent or aggressive incidents;

• confirm the responsibilities of employees at all levels, to minimise therisk of violence;

• support the identification of training needs and the provision of training,enabling employees to carry out their duties in the safest possible

manner and environment;



• ensure the risks of violence are properly identified and assessed, andthat suitable local procedures and control measures are introduced.

4. Responsibilities

4.1 The responsibilities of the Chief Executive and Directors are as follows:

• ensure that appropriate arrangements operate within the South WestStrategic Health Authority for reducing the risk of violence to the lowestlevel that is reasonably practicable and for periodically reviewing theeffectiveness of this policy;

• ensure appropriate support is provided to employees followingincidents of violence and aggression;

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