Formal Employee Grievance & Third-Party Harassment Lodgement Form (HR-F048) EMPLOYEE GRIEVANCE LODGEMENT FORM (HR-F048) Contact EMPLOYEE GRIEVANCE LODGEMENT FORM Formal Employee Grievance & Third-Party Harassment Lodgement Form (HR-F048)SECTION 1: ASSESSMENT BASELINE & TRIGGERTitle- Select -MrMrsMissMsMxOtherStaff Member NameStaff_IDOperating Local Authority- Select -HaringeyIslingtonBarnetWaltham ForestCamdenHackneyBrentHarrowRedbridgeNewhamCity of LondonWestminsterTower HamletsBarking and DagenhamHaveringKensington and ChelseaHammersmith and FulhamEalingHillingdonHounslowSouthwarkLambethLewishamGreenwichWandsworthRichmond upon ThamesMertonKingston upon ThamesSuttonBexleyBromleyCroydonOtherWho or what is this Grievance primarily regarding?- Select -A ColleagueMy direct Line Manager / Field SupervisorThe Registered ManagerThe Nominated Individual / Company Director (System LogicA Third Party (e.g., Service User, Family Member, External NHS Professional).A systemic company issue (e.g., payroll, rota allocations, working conditions).System Routing Confirmation- Select -I confirm I understand this system automatically bypasses the individual(s) implicated to ensure a fair, unbiased, and confidential investigation.SECTION 2: CATEGORISATION, LEGAL FRAMEWORK & DETAILS OF THE GRIEVANCEPrimary Category- Select -Bullying, Victimisation, or Workplace Toxicity.Sexual Harassment (Internal or Third-Party).Discrimination or Harassment related to a Protected Characteristic.Health and Safety / Working Environment failures.Terms and Conditions of Employment (Pay, Hours, Contracts).Unfair or oppressive management practices.Equality Act 2010 Mapping: If you selected Discrimination/Harassment, which Protected Characteristic does this relate to?AgeDisability (including neurodivergence)Gender ReassignmentMarriage / Civil PartnershipPregnancy / MaternityRace / Ethnicity / NationalityReligion or BeliefSexSexual OrientationN/AThe FTSU / Whistleblowing Intersection (Safe QS1): Does this grievance also involve the abuse, neglect, or unsafe clinical care of a Service User?- Select -YesNoN/ARoute the HR elements to the Investigating Officer- Select -Route the HR elements to the Investigating Officer, trigger an immediate, concurrent statutory alert to the Registered Manager and the Freedom to Speak Up (FTSU) Guardian for clinical safeguarding triage).Factual Summary of your Grievance- Select -Verbal/EmotionalPhysical/IntimidationExclusion/VictimisationProcedural/ContractualDigital/CyberThird-Party ConductFrequency and Location of Incidents- Select -Single, isolated incident during a domiciliary care visit.Single, isolated incident at the corporate office/during training.Ongoing, repeated incidents over a period of time during care visits.Ongoing, repeated incidents at the corporate office.Incident occurred digitally or outside of standard working hours.Witness Corroboration- Select -Yes - Another Mutima Care staff member was present.Yes - A Service User or their family member was present.Yes - An external professional (e.g., District Nurse) was present.No - It was a 1 on 1 situation with no direct witnesses.No direct witnesses, but I have digital/documentary evidence.Documentary Evidence: Do you have any emails, messages, Nourish app screenshots, or timesheets that support your grievance?- Select -YesNoN/AAttach and Email screenshots, or timesheets- Select -hr@mutimacare.co.ukHave you attempted to resolve this issue informally (e.g., via a conversation with the person involved or your manager)?- Select -Yes - I tried, but it was unsuccessful.No - The issue is too serious for informal resolution.No - The issue involves my manager, and I do not feel safe raising it with them.Briefly describe the informal steps takenVerbally requested the individual to stop the behavior.Sent a written message/email to the individual addressing the issue.Raised the issue informally with the Field Supervisor / Care Coordinator.Requested an informal mediation chat, which was refused or failed.No informal steps taken due to fear of retaliation or the severity of the incident.Next Review Date:SECTION 3: DESIRED OUTCOME (THE RESOLUTION), STATUTORY RIGHTS & FORMAL DECLARATIONWhat outcome are you seeking by lodging this formal grievance?- Select -An apology from the individual(s) involved.Formal mediation between myself and the individual(s).A permanent change to my rota to prevent contact with the individual(s) or third party.A formal review and correction of a specific management decision (e.g., payroll error).A formal disciplinary investigation into the individual(s) conduct.Re-training for the team/individual on specific policies (e.g., Equality & Diversity).Specific Outcome Categorisation- Select -RestorativeProtectiveCorrectiveDisciplinaryRight to Accompaniment- Select -I understand I have the statutory right to be accompanied by a Mutima Care colleague or a certified Trade Union representative at any subsequent Formal Grievance HearingProtection from Detriment- Select -I acknowledge Mutima Care's legal commitment that raising a grievance in good faith will not negatively impact my employment status, rotas, or career progression.Data Privacy & Confidentiality- Select -I understand that to conduct a fair investigation, the core allegations and my name will normally need to be disclosed to the person I am complaining about, to allow them the right of reply.Employee Declaration- Select -I confirm that the information provided is true and factual to the best of my knowledge. I understand that raising a maliciously false grievance is a Gross Misconduct disciplinary offence.SUBMIT FORM
