Civility, respect and resolution policy

1 Introduction

The trust is firmly committed to promoting civil, respectful, fair and equitable treatment of both existing and prospective employees in all employment matters.

This policy also affirms the right of each employee of the trust to be treated fairly and with civility, courtesy, consideration, dignity, respect and understanding of individual differences, as well as having personal responsibility for treating others in this way. This policy has been developed within the context of that commitment and outlines the process for employees and managers to follow if behaviours outside this commitment arise.

The trust recognises that to deliver excellent care to patients, the trust needs to be well led and have healthy, supportive, positive inclusive cultures that value diversity and promote inclusion for all staff groups. As part of this overall commitment, the trust has a duty to provide a psychologically safe environment in which all staff have the right to be treated with dignity and respect at work, where bullying and harassment is not tolerated and where staff feel safe to speak out and discuss matters of concern without fear of detriment.

We expect that when colleagues see a situation that isn’t acceptable for the trust, our patients or our colleagues, they can speak and challenge in the right way. Equally, if they themselves make a mistake a restorative just culture would empower them to be open, it would encourage them to readily question what had happened, why and, along with colleagues, learn in a way that greatly reduces the risk of anyone in a similar situation repeating actions that have given rise to harm. A restorative just and learning culture is not finger-pointing, nor blame-seeking. It’s about being open and transparent; asking what was responsible, rather than who is responsible and focusses on accountability. In the spirit of reflecting and learning these are the principles which we follow within the trust.

2 Purpose

The purpose of this policy is to provide a process for colleagues who, during the course of their employment have a concern or issue, conflict or complaint and ensure that they are dealt with quickly, fairly, and constructively. Similarly, the policy aims to encourage positive working relationships as well as constructive and lasting resolutions to workplace issues which have arisen. It is recognised that conflict in the workplace may occur and we endeavour to support colleagues and managers who have a concern, issue, conflict or complaint during their employment in a constructive way to prevent negative behaviours which are in breach of the trust’s values.

This policy aims to support creating and sustaining a working environment that is characterised by civility, mutual respect, tolerance, understanding dignity and respect across all our services and departments. The goal is to develop a working environment in which discrimination, bullying, and harassment does not happen and where everyone feels a personal responsibility to care for each other and behave in a civil, respectful manner to each other.

We expect all colleagues to consistently role model and live the trust values as below. Values drive our actions, behaviours, and decisions, and ultimately help create our culture.

• Passionate: we share our passion commitment and belief in a culture where people are heard, valued, and respected.
• Reliable: we can demonstrate that concerns are addressed with a just and restorative response.
• Caring and safe: we create environments where people feel safe to speak up.
• Empowering and supportive of staff: we lead with compassion, encourage all colleagues to challenge all uncivil behaviours, and facilitate cultural learning and development.
• Open transparent and valued: we believe that a culture that promotes civility and feels just and restorative will deliver our strategic promises.
• Progressive: we use continuous improvement to support our journey towards a restorative just culture

The values and behaviour framework is intended to be embedded within everyday processes so that the values and behaviours are visible to employees. Examples of everyday processes to consider include the following:

• supervision or personal development reviews
• one to one interaction
• recruitment and retention
• rewards
• team effectiveness meetings or team building events

For further guidance refer to appendix B.

The principles and values within this policy also underpin how the trust deals with disciplinary matters and the commitment that where appropriate issues are resolved at the earliest opportunity without resorting to a formal process.

2.1 Our organisational strategy

While we are very proud of the quality improvement we have achieved to date, in the spirit of continuous improvement and striving for more we recognise there is always room for more.

The trust strategy sets out our 28 promises and these guide and inform our work. This policy supports the delivery and achievement of promise 26: become an anti-racist organisation by 2025 as part of a wider commitment to fighting, discrimination and positively promoting inclusion.

At the trust we recognise that our colleagues are diverse, originating from various countries and different cultural backgrounds. Gender age, language, religion, sexual orientation, race, marital status and disability are specific to every colleague therefore, we aim to promote inclusivity, trust, honesty, and social justice through positively reinforcing cross-cultural communication skills in clinical and non-clinical setting in order to enhance psychological safety of both patients and colleagues within the organisation.

The trust is not neutral on racism and discrimination. The trust will take positive and swift action to address issues whilst ensuring a just and restorative approach is embedded. The trust recognises there is still work to do, despite that racism and or discrimination remain an offence in law.

2.2 Restorative, just and learning culture

The trust is continuing to embed a restorative just and learning culture where we put equal emphasis on accountability and learning.

The trust will support looking at incidents or events that have occurred and asking, “what was responsible, not who is responsible”, and aims to eradicate a blame culture.

3 Scope

This policy applies to all employees of the trust. This policy does not apply to ex-employees of the trust, however, if an ex-employee raises serious concerns, the trust may choose to investigate these. It does not address complaints of harassment by service users or members of the public which are addressed through other procedures. In addition, to the behaviours we expect from colleagues we also have a zero-tolerance approach to any form of unacceptable behaviour from our patients and or their relatives and we will ensure that action is taken to address any situations as deemed necessary to fully support our employees.

Where a complaint is raised involving an employee from another organisation, the People Experience team will liaise with the human resources department, where applicable, of the other organisation involved, to agree a way forward within the policy framework of each organisation.

This policy covers any behaviours which result in employees feeling that they are not being treated with civility and respect, this includes bullying and harassment. All employees are responsible for their own behaviours under this policy. Any complaints under this policy should be raised within 3 months of the incident or behaviour taking place in order so it can be addressed in a timely manner. Any exception to this should be discussed and agreed in conjunction with the People Experience team. It should be acknowledged that in some cases, small issues can happen repeatedly over a period and a build-up of these issues the complainant eventually may raise the matter informally or formally.

4 Responsibilities, accountabilities and duties

4.1 The role of the trust as an employer

The role of the trust as an employer is:

• to provide direction for line managers and employees who are responsible for operating this policy
• to create a positive working environment where employees feel able to discuss poor behaviour with each other through informal mechanisms and to detail how these concerns can be addressed through more formal routes

4.2 The director of people and organisational development

The director of people and organisational development has responsibility for the implementation of this policy and coordination of an appropriate communication and training strategy together with ensuring that appropriate monitoring arrangements are in place with a focus on early and informal resolution.

4.3 Line managers

Role model the standards of acceptable behaviour expected of colleagues. Line managers should ensure their own behaviour could not be construed as personal harassment by acting with civility, fairness and equity. This includes using their judgement to correct standards of conduct or behaviour which could be seen as harassment, and to remind colleagues of these standards. Each colleague carries responsibility for his or her own behaviours.

Managers have a responsibility for the following:

• facilitate the creation and maintenance of a positive working environment and positive working relationships
• seek relevant support and put action plans in place to address poor culture or relationship issues.
• to be aware of different methods and assess the most appropriate form of resolution of difficult working relationships, attempting to resolve informally at an early stage, and act fairly and consistently on the approaches available
• to work in partnership with trade unions or professional organisations and staff representatives and the Human Resources team to address issues promptly
• set team objectives
• plan regular team away days or time out where people can talk and discuss issues
• promote an open-door environment where staff are encouraged to raise concerns
• listen to what employees say, ask clarifying questions, and act where appropriate
• signpost employees to others if they feel unable to approach their line manager
• reflect on own performance and accept that you can learn from staff

4.4 All colleagues

All colleagues are personally responsible for their own behaviour and upholding the values of the trust as well as compliance with this policy and participation and co-operation with others to resolve workplace issues, conflicts, or complaints.

All employees have a responsibility to raise and challenge any behaviour or communication which they may witness or hear, even if it isn’t directed at them, if it doesn’t fit with the values and expectations of our trust.

All colleagues are required to participate and co-operate with others in ways aimed at resolving workplace issues, conflicts and complaints and to state what would be seen as a suitable and fair outcome.

4.5 The human resources department

The People Experience team are responsible for:

• advising managers on the fair and consistent application of this policy
• monitoring any incidences of bullying and harassment and initiating appropriate action
• supporting the network of freedom to speak up champions
• supporting managers and employees alongside trade unions or professional organisations and staff representatives to deal with concerns promptly and appropriately, and working in partnership with the Organisation Development team, specifically in reference to the Culture and Improvement team
• reviewing and amending this policy and procedure as necessary, working in partnership with unions
• raising awareness when the policy is reviewed or revised
• to liaise with colleagues in other relevant organisations in cases involving individuals from a separate employer

4.6 Freedom to speak up guardian and champions

The Freedom to Speak Up (FTSU) guardian role is an independent and impartial source of advice for employees at any stage in which a concern is raised with access to anyone in the organisation or if necessary, outside the organisation.

The Freedom to Speak Up guardian has been given special responsibility and training in supporting employees who have concerns about working relationships with other colleagues. This role is supported by freedom to speak up champions who can also support individuals.

4.7 Trade unions, professional organisations and staff representatives

Trade unions, professional organisations and staff representatives have a responsibility:

• to support the trust in its efforts to provide a positive working environment free of bullying, harassment and intimidation
• to help inform colleagues of the policy and to encourage employees who may have problems, to use the facilities and support mechanisms available within this policy and procedure
• to support their members to see incidents that have occurred through a restorative and just culture perspective and supporting these colleagues to utilise the informal resolution routes in the first instance (where appropriate and proportionate)
• to advise members of their rights and responsibilities under the policy and to be available to represent individuals at appropriate meetings
• provide feedback on any concerns experienced regarding compliance with this policy
• where appropriate, to work in partnership with line managers to address issues which are raised under this policy

Please note that trade union, professional organisation representatives work to the same code of practice in relation to confidentiality as all other employees.

4.8 Support officers

A support officer is an allocated colleague or manager who will keep regular contact with both the person who has raised a concern or complaint which is being investigated under the civility, respect and resolution policy and the colleague who has been alleged of bullying or harassment or uncivil behaviour.

The support officer will be a consistent point of contact to help with the health and wellbeing during the investigation or case period. They will have no other involvement in the investigation process. It is the responsibility of the support officer to make the initial contact with the colleague and arrange the regular catch-ups. Any significant concerns with the colleague’s health and wellbeing during this period should be raised to the commissioning manager for awareness and additional support.

A support officer should agree frequency of contact with the colleague. A support officer should keep a log and document all dates and support they have provided.

5 Definitions

6 Procedure

6.1 General principles

The trust recognises that a positive working environment and positive working relationships have a positive impact on employee wellbeing and engagement. A positive working environment can also lead to better performance, improved retention, reduced stress related sickness absence and a positive reputation for the organisation. Focusing on resolution is beneficial for the trust, employees, patients, and service users.

The trust recognises that conflict in the workplace may occur. In the event that this does happen, we endeavour to support colleagues and managers to work together to resolve issues and conflicts informally, constructively and in a timely manner.

The policy provides an overview of the process the trust will follow to resolve these issues without resorting to a formal process wherever possible. It is against the policy of the trust for any employee to bully and or harass another employee both directly and indirectly. Such conduct will not be accepted. Appropriate disciplinary action, up to and including dismissal for serious offences, will be considered against any individual who violates this policy.

All employees of the trust are responsible both legally and morally for ensuring that individuals and groups do not suffer from bullying or harassment and that they are encouraged and supported in any legitimate concern or complaint.

All employees are responsible for taking an active bystander approach and when witnessing bullying and harassment they act.

6.2 Maintaining a positive working environment

All colleagues should read this policy in conjunction with the civility and respect workbook (appendix E). There are steps that everyone can take to maintain a positive work environment.

Everyone:

• think about how you communicate, use transparent and open communication
• consider non-verbal elements like facial expression, body language and tone of voice
• respect each other and appreciate we are all different
• listen to each other
• provide positive reinforcement to your colleagues where it is needed
• make a commitment to prioritise your health and wellbeing
• take the time to celebrate team successes
• if you witness or hear any behaviour or language that isn’t in accordance with the spirit of this policy, take responsibility and challenge this behaviour to prevent escalation, the challenge should be in a non-confrontational style and approach
• take early intervention when you are facing relationship breakdowns

7 Resolution

7.1 Early intervention or informal resolution

7.1.1 Having an honest, respectful, and courageous conversation in a timely manner

An employee who feels bullied or harassed should tell the individual in the first instance if they are confident to do so. The employee should handle the conversation sensitively. The staff member should inform the other individual that their behaviour or words they use is unwelcome and that it is causing distress to them and ask them to stop.

The individual may be unaware of the effect of their actions, and an informal discussion can lead to greater understanding and an agreement that the behaviour will cease. The employee may wish to ask a colleague to be present when they speak to the person concerned. Alternatively, they may find it easier to write to them.

It must be recognised that we are all human, all feel different emotions and respond differently to difficult conversations and therefore if colleagues need time to reflect, all parties should respect this and agree at a mutually agreed time to continue such conversation effectively.

All colleagues should reflect on their own behaviour as relationships and self-reflection is an important part of learning and growth.

7.1.2 Request for informal resolution

If an honest and respectful conversation has not gone to plan or does not feel appropriate, the colleague should complete the request for informal resolution form, see appendix A. The trust will always advocate to continue resolving issues on an informal basis where appropriate, proportionate, and possible to do so. Seeking informal resolution in a timely manner generally supports all parties involved in gaining resolution and sustains well-being and relationships within the work environment. There are a number of different options open on the request for informal resolution form.

7.1.2.1 Facilitated meeting

A facilitated meeting is usually a meeting led by the line manager or the most appropriate level of manager depending on the circumstances. The manager will facilitate the meeting with both parties to seek resolution. The manager facilitating the meeting should remain neutral and not take sides. The manager should ensure that both parties conduct themselves with respect and civility, ensuring that both parties listen to each other and that the meeting focuses on resolution. Managers should read the guidance on conducting a facilitated meeting at appendix D or seek the appropriate support from the Human Resources team.

7.1.2.2 Mediation

Mediation is a confidential and voluntary process which all parties must agree to. It brings together people who are experiencing problems with work-related relationships. Mediation takes place in the presence of an impartial, third party who has had specialist training to become a mediator. During mediation individuals will be encouraged to relay their experience and air their feelings. It empowers those involved, as the disputants not the mediators, to decide on the terms of any resolution. The mediator does not offer advice on how to solve the problem. People participating in mediation do so without prejudice.

7.1.2.3 Informal discussion with service manager or department

An informal discussion with the management of department may be beneficial when you have concerns around relationships generally or concerns around the culture in the team or department. Requesting an informal discussion with the manager of the service should be without prejudice and be an avenue to be listened to. The service manager or Manager of the department should agree an action plan to address the issues on being informed on this and should give updates to the individual where appropriate. Alternatively, this could also be done by raising concerns to the Freedom To Speak Up Guardian.

7.1.2.4 Coaching and mentoring

Support for this can be offered from the organisational development department and through legacy mentors who may be able to guide individuals through how to deal with workplace conflicts in an effective manner. 7.1.3 There will be occasions where it is not possible to maintain a positive working environment or relationship. The trust will only consider concerns under the formal procedure where informal action has been unsuccessful or where there has been a significant breach of this policy.

All allegations of bullying and, or harassment will be dealt with seriously, swiftly, and sensitively, with due regard to the rights of all parties involved.

It is important to note that not all differences can be resolved, and colleagues may wish to have or remain with differing views regarding a situation. However, they must have had the opportunity to share their feelings or views either during the informal and, or formal procedures and the trust must do all it can to support all parties, to move forward.

7.2 Formal procedure

A director within a care group or directorate will only consider invoking the formal procedure on request of the individual upon the informal procedure being attempted first hand and whereby there has been a significant breach of policy. On occasions and when proportionate, necessary and potentially unlawful will the formal procedure be invoked without exploring the informal procedure.

Should this conflict what is potentially to be explored under the formal procedure be between senior leaders or within the senior leadership team it should be escalated to the Care Groups Senior Leadership team. Similarly, if there is a potential conflict on who should be the decision maker on invoking the formal procedure advice should be sought from the human resources department.

There may also be occasions whereby the disciplinary policy will be invoked rather than a formal complaint under this policy. An example of this would be if a colleague sexually harassed another colleague in or outside of work, or if there is clear evidence a colleague has said a racist remark or comment and potentially had been racially discriminatory to another colleague.

The employee must notify their care group director in writing that they wish to make a formal complaint using appendix A. The complaint must include the nature of the concerns and how they have attempted to resolve these informally. If colleagues are in a union, they are encouraged to seek support from them in the first instance on this.

The director will then write to the employee within 7 working days to confirm the next steps which may include the following:

• further discussion and, or actions to take place as part of the informal procedure
• a meeting with the individual employee to explore the concerns further
• request for further information
• a decision to progress to the formal procedure and an investigating officer appointed to investigate the concerns

This is not an exhaustive list, and other resolutions may be considered in conjunction with the employees concerned.

Should the decision be taken to formally investigate the concerns by a deputy director or director, the employees who are the subject of the complaint will be informed by an impartial manager, or their representative, that a formal complaint has been made.

Consideration will need to be given to appropriate action in order to relieve the stress and pressure on one or both parties and to prevent the risk of further incidents occurring whilst the investigation takes place.

This may include the following.

• Temporarily restricting the duties of both parties.
• Re-arranging duty rotas or arranging temporary workplace transfers to minimise contact between both parties for the duration of the investigation. Due consideration will be given to travel arrangements and working hours.
• Arrangements for all parties to ensure that they are fully supported throughout the investigation, this may include counselling, occupational health, employee assistance programme, the support of a mentor or coach. This is not an exhaustive list and the Line manager, and the investigating officer must ensure that adequate support arrangements are implemented.
• A support officer is allocated to both the claimant and respondent to support their wellbeing while the investigation process is ongoing., see section 4.8.
• Suspension of the subject of the complaint would be an extremely exceptional step only to be considered in serious cases as a last resort. Such action will not be prejudicial, but a measure to protect both parties and to establish the facts of the matter without delay. Information can be found further on suspension within the disciplinary policy.
• While there is no set terms of reference for the formal investigations, it should be agreed with the individual raising the concern what the scope of the investigation will be. Similarly, the responding colleague should be informed of the nature of the complaint made under this policy so they can prepare to respond within their investigation meeting. This will be communicated to the individual in writing and be given examples, so they have time to prepare for their investigation meeting.
• All parties involved should be made aware that they may not be privy to all the information collated by the Investigating Officer. Should there be no case to answer or informal action as part of the conclusion, then parties involved will be given a summary of the findings, whilst witnesses will remain confidential on the information that they have shared. Should a colleague be referred to a disciplinary hearing from the investigation they will be given the full report and appendices as per the disciplinary policy but the individual who requested for the formal procedure to be invoked will not receive this.

A full investigation will be initiated as timely as possible. An appropriate, independent Investigating Officer will be appointed, with consideration given whether they require knowledge of the area concerned. As far as reasonably practicable, formal investigations should be completed within 2 months of commencement. However, it is recognised that in some cases the complexities involved may mean this is not achievable. In the event of a formal investigation taking longer than 2 months the investigating officer will be responsible for keeping all parties informed of the delay and anticipated time frame for completion. The complainant and the employee who is the subject of the complaint should be informed of progress at regular intervals (preferably every 4 to 6 weeks).

The investigating officer will seek to establish the facts of the case promptly, before recollections fade, taking account of available evidence and written statements from the complainant and from witnesses. They may also explore the actions taken as part of the informal procedure (as appropriate).

Once the investigation has been completed, the investigating officer will present their findings and recommendation to the director who granted the complaint to be investigated. Only if the recommendation is agreed that disciplinary hearing under the disciplinary policy is invoked will the investigating officer be required to formalise their findings into an investigation report.

If the complaint is found to be unsubstantiated or agreed on informal recommendations, both the complainant and the subject of the complaint will be informed by the investigating officer via a meeting and in writing that the investigation has been concluded and a summary of the outcomes, without breaching confidentiality of those interviewed as part of the investigation process. The complainant will be the first to be informed of the outcome of the investigation and where possible the subject of the complaint should be informed on the same day or week when possible. The outcome and feedback should focus purely on the findings, conclusions, and recommendations in respect of the allegations made by the complainant. If a complaint is unsubstantiated, and others have been involved in the investigation, all involved should be supported and receive a debrief (which must not breach confidentiality) and closure following the investigation process where appropriate.

Should the investigation have informal recommendations the investigating officer should meet with the manager of the service or department to hand over these recommendations for action. Recommendations from an investigating officer may include culture and improvement work to be facilitated or alike.

If the complaint is found to be substantiated and the recommendation is to progress to a disciplinary process, the subject of the complaint will be informed in writing of this by the commissioning manager or their representative as well as the next steps. The disciplinary policy will then be invoked regarding the disciplinary hearing. If others have been involved in the investigation, all involved should be supported and receive a debrief (which must not breach confidentiality) and closure following the investigation process where appropriate.

If it is considered that the complaint has been made with malicious or frivolous intent, this will be investigated and, if necessary, addressed under the trust’s disciplinary policy.

Any employee who intimidates, victimises or retaliates against either anyone making a complaint or assisting in an investigation or against the subject of a complaint, whether the complaint is found to be substantiated or unsubstantiated, will be dealt with under the trust’s disciplinary policy, as such conduct will be regarded as a serious offence.

7.3 Appeal

The claimant has the right to appeal if they do not feel like the process has been followed, or if new unseen substantial evidence has been made available which was not available during the original investigation.

However, colleagues are unable to appeal on the grounds that they are not satisfied with the outcome or conclusions. The claimant should write within 21 days of receipt of their written outcomes and summary from the investigating officer. The appeal should be sent to the director who granted the formal stage being invoked. The appeal submission should state from the claimant why they believe the policy has not been followed. If the director feels that the investigating officer has been thorough and followed the policy on the concerns raised, then the investigation will not be re-opened, and the decision will be final. The director should write to the colleague with their rationale. Should a colleague remain dissatisfied they will be unable to raise a grievance under the grievance and dispute policy, for the same reason.

8 Right of representation

At all stages of the procedure the employee is entitled to be accompanied by a companion. The chosen companion may be a fellow worker, a trade union representative, or an official employed by a trade union and can be contacted through their trade union website.

9 Support mechanism

Taking care of and valuing our staff is at the heart of our ambition to make the NHS the best place to work. Creating a healthy, inclusive and compassionate culture is paramount to delivering the care patients expect.

It is not acceptable that our NHS people experience any form of discrimination from other employees, patients or the public at work.

The trust is committed to achieving informal resolution of concerns raised under this policy wherever possible. It is acknowledged that it can be extremely stressful for any employees involved in this process and the trust has a number of support systems which are in place as follows:

• occupational health: a referral can be made by the line manager.
• 24-hour employee assistance programme
• Human Resources team: rdash.askhr@nhs.net
• staff side or trade union colleagues
• Freedom to Speak Up champions
• Freedom to Speak Up guardian
• increased supervision
• Equality, Diversity, and Inclusion team
• health and wellbeing champions
• civility and respect workbook
• legacy mentors

10 Legislative frameworks

There are legislative frameworks in place which seek to eliminate discrimination.

The Equality Act (2010) covers the same groups that were protected by existing equality legislation:

• age
• disability
• gender reassignment
• race
• religion or belief
• sex
• sexual orientation
• marriage and civil partnership
• pregnancy and maternity

but extends some protections to groups not previously covered and strengthens particular aspects of equality law.

The Protection from Harassment Act (1997) prohibits the pursuit of a “course of conduct which amounts to harassment of another”.

Worker Protection Act (Amendment of the Equality Act 2010) 2023, covers employers having a legal obligation to protect workers from sexual harassment, to ensure there is obligation from the employer to challenge inappropriate conduct, and not the individual or victim.

11 Training implications

11.1 Managers

• How often should this be undertaken: on revision of the policy.
• Delivery method: daily communications and directorate care group meetings.
• Training delivered by whom: People Experience team through the communications department and via managers for newly appointed employees.

11.2 Employees

• How often should this be undertaken: introduction of the policy from the previous protocol document and on revision of the policy or new appointment or promotion.
• Delivery method: local induction and team meetings.
• Training delivered by whom: managers.

11.3 Staff side or trade unions

• How often should this be undertaken: introduction of the policy from the previous protocol document and on revision of the policy or new appointment and promotion.
• Delivery method: through policy forum and trust staff council.
• Training delivered by whom: People Experience team.

As a trust policy, all staff need to be aware of the key points that the policy covers. Staff can be made aware through a variety of means such as,

• all user emails for urgent messages
• one to one meetings and supervision
• continuous professional development sessions
• posters
• daily email (sent Monday to Friday)
• practice development days
• group supervision
• special meetings
• intranet
• team meetings
• local induction

12 Monitoring arrangements

12.1 Duties under this policy

• How: staff survey analysis cross-referenced to employee relations case data to identify areas of concern regarding care group areas or protected characteristics
• Who by: human resources.
• Reported to: The People and Organisational Development Committee.
• Frequency: Annually.

12.2 What should be done once a concern has been raised

• How:
  • review of human resources data such as the number of complaints raised in relation to the policy
  • communicate any lessons learnt
  • monitor how many cases are managed informally
  • monitor timeframes
• Who by: human resources.
• Reported to:
  • People and Organisational Development Committee
  • people and teams group
• Frequency: annually.

13 Equality impact assessment screening

To access the equality impact assessment for this policy, please see the overarching equality impact assessment.

13.1 Privacy, dignity and respect

The NHS Constitution states that all patients should feel that their privacy and dignity are respected while they are in hospital. High Quality Care for All (2008), Lord Darzi’s review of the NHS, identifies the need to organise care around the individual, “not just clinically but in terms of dignity and respect”.

As a consequence, the trust is required to articulate its intent to deliver care with privacy and dignity that treats all service users with respect. Therefore, all procedural documents will be considered, if relevant, to reflect the requirement to treat everyone with privacy, dignity and respect, (when appropriate this should also include how same sex accommodation is provided).

13.1.1 How this will be met

Policy does not relate to patients.

13.2 Mental Capacity Act (2005)

Central to any aspect of care delivered to adults and young people aged 16 years or over will be the consideration of the individuals’ capacity to participate in the decision-making process. Consequently, no intervention should be carried out without either the individuals informed consent, or the powers included in a legal framework, or by order of the court.

Therefore, the trust is required to make sure that all employees working with individuals who use our service are familiar with the provisions within the Mental Capacity Act (2005). For this reason, all procedural documents will be considered, if relevant to reflect the provisions of the Mental Capacity Act (2005) to ensure that the interests of an individual whose capacity is in question can continue to make as many decisions for themselves as possible.

13.2.1 How this will be met

All individuals involved in the implementation of this policy should do so in accordance with the guiding principles of the Mental Capacity Act (2005) (section 1).

14 Links to any other associated documents

• Supervision policy
• Grievance and dispute policy
• Corporate and local service induction policy
• Disciplinary policy
• Employee usage of social media policy
• Healthy workplaces, staff support and stress at work policy
• Sexual safety policy

15 References

• Equality Act (2010)
• The protection from Harassment Act (1997)
• Worker Protection Act (2023)
• Freedom to Speak Up (staff access only)
• NHS terms and conditions of service handbook, NHS Employers. Agenda for change terms and conditions of service handbook, section 32, dignity at work
• Respect and civility workbook

16 Appendices

16.1 Appendix A resolution request: workplace respect, civility and resolution form

Refer to appendix A: resolution request: workplace respect, civility and resolution form (staff access only).

16.2 Appendix B values and behaviour framework

16.4.1 Passionate

• We work hard to deliver a quality service.
• We are determined to do what’s right for people.
• We are positive in all that we do.
• We endeavour to be our best through personal development.
• We do our best to make a positive difference to people.

16.4.2 Reliable

• We follow through on what we say we will do.
• We take responsibility for things we can do something about.
• We take ownership to know and follow best practice.
• We are accessible whenever possible.
• We turn up on time and complete tasks in the time agreed.

16.4.3 Caring and safe

• We promote equality, diversity and inclusion.
• We take a person-centred approach.
• We take time to listen with empathy and compassion.
• We introduce ourselves.
• We make sure we keep people safe and speak up when something is wrong.

16.4.4 Open

• We include people in the decisions that affect them and keep them informed.
• We give and receive purposeful feedback.
• We acknowledge our own biases and learn from others perspectives.
• We celebrate our successes and learn together from our mistakes.
• We are honest and accountable taking responsibility for our actions.

16.4.5 Supportive

• We encourage good physical and mental health including promoting a healthy work-life balance.
• We appreciate and respect other people’s input and ideas.
• We value our patients, their families, their carers and each other.
• We work together as #onerdash team.
• We help each other to do the best job we can.

16.4.6 Progressive

• We work together for continuous improvement.
• We seek out and share information, knowledge, and experiences.
• We are adaptable and flexible, open to innovation and change.
• We strive for excellence through identifying and testing new ways of working.
• We take responsibility to share and learn from and about each other.

16.3 Appendix C mediation booklet

Refer to appendix C: mediation booklet (staff access only).

16.4 Appendix D managers guidance for leading a facilitated meeting

Refer to appendix D: managers guidance for leading a facilitated meeting (staff access only).

16.4 Appendix E respect and civility workbook

Refer to appendix E: respect and civility workbook (staff access only).

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Document control

• Version: 9.
• Unique reference number: 246.
• Approved by: people and teams group.
• Date approved: 9 December 2025.
• Name of originator or author: associate human resources partner.
• Name of responsible individual: director of people and organisational development.
• Date issued: 22 December 2025.
• Review date: 31 December 2026.

Page last reviewed: December 24, 2025
Next review due: December 24, 2026

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