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Registration Number: {{org_field_registration_no}}

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Gender Reassignment Equality and Transgender Workplace Support Policy

1. Purpose

The purpose of this policy is to promote a safe, respectful, inclusive and legally compliant working environment for employees, workers, volunteers and job applicants who are transgender, non-binary, gender-diverse, proposing to undergo, undergoing or having undergone gender reassignment.

This policy explains how {{org_field_name}} will prevent unlawful discrimination, harassment and victimisation; support employees who are transitioning; protect confidential information; consider workplace arrangements fairly; and balance the rights, safety, privacy, dignity and legitimate needs of employees and individuals receiving care and support.

This policy supports compliance with the Equality Act 2010, the Gender Recognition Act 2004, applicable data-protection legislation, employment law, the Regulation and Inspection of Social Care (Wales) Act 2016, the Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, as amended, applicable Welsh Government statutory guidance, CIW inspection expectations and the Codes of Professional Practice issued by Social Care Wales.

{{org_field_name}} will not unlawfully discriminate because of gender reassignment, sex, sexual orientation, religion or belief, disability, race, age, pregnancy and maternity, marriage and civil partnership, or any other protected characteristic. Decisions under this policy will be made on the facts of the individual case and will not be based on stereotypes, assumptions or blanket rules.

This policy does not remove the need to comply with safeguarding obligations, professional boundaries, safer recruitment requirements, health and safety duties, lawful sex-based provisions, service users’ assessed care needs or the requirements of an individual’s personal plan.

2. Scope

This policy applies to:

• All employees, including care staff, management, administrative staff, and volunteers.
• Job applicants, ensuring fair and inclusive recruitment.
• Individuals receiving care and support, their representatives, visitors and commissioners, where their conduct, assessed needs, preferences, rights, safety or interactions with staff are relevant to the implementation of this policy.

This policy covers:

• Workplace rights and protections for transgender and non-binary employees.
• Procedures for name and gender marker changes in employment records.
• Guidance on facilities (e.g., restrooms, changing areas).
• Training and awareness to prevent discrimination and harassment.

This policy applies alongside, and does not replace, the organisation’s Equality, Diversity and Inclusion Policy, Recruitment Policy, Staff Conduct Policy, Disciplinary Policy, Grievance Policy, Data Protection and Confidentiality Policy, Safeguarding Policy, Lone Working Policy, Risk Assessment Policy, Personal Care and Intimate Care procedures, Complaints Policy and arrangements for meeting individuals’ personal outcomes.

3. Definitions and legal principles

For the purposes of this policy:

• Gender reassignment is the protected characteristic defined by section 7 of the Equality Act 2010. A person has this protected characteristic where they propose to undergo, are undergoing or have undergone a process, or part of a process, for the purpose of reassigning their sex by changing physiological or other attributes of sex. Medical treatment, surgery and a Gender Recognition Certificate are not required.
• Transgender or trans is an inclusive term that may be used by people whose gender identity differs from their sex. Not every person who uses this term will necessarily meet the legal definition of gender reassignment, although they must still be treated with dignity and respect and may be protected under other provisions of the Equality Act 2010.
• Non-binary or gender-diverse describes people whose gender identity is not exclusively male or female. A non-binary or gender-diverse person may be protected under the characteristic of gender reassignment where the statutory test is met. Protection will be considered on the individual facts rather than assumed or denied because of a label.
• Sex is a separate protected characteristic under the Equality Act 2010. Following the UK Supreme Court judgment in For Women Scotland Ltd v The Scottish Ministers, references to sex, woman and man in the Equality Act are interpreted by reference to biological sex.
• Gender Recognition Certificate, or GRC, means a certificate issued under the Gender Recognition Act 2004. An employee is not required to have or disclose a GRC to receive protection from gender reassignment discrimination or workplace support.
• Gender history means information concerning a person’s previous name, sex, transition or previous gender presentation. Such information must be handled as highly confidential personal information.
• Deadnaming means referring to a person by a former name in circumstances where the person no longer uses that name.
• Misgendering means referring to a person using words, titles or pronouns that do not correspond with the name, title or pronouns the person has asked colleagues to use.

Nothing in this policy authorises harassment, intimidation, compelled disclosure of private information, unlawful discrimination or retaliation. The organisation will also respect lawful freedom of thought, conscience, religion and expression. Disagreement or a protected belief will not, by itself, amount to misconduct; however, the manifestation of a belief may be restricted where this is necessary and proportionate to protect the rights, dignity, safety or working environment of others.

4. Protection from discrimination

{{org_field_name}} will not unlawfully discriminate against, harass or victimise an employee, worker, volunteer or job applicant because:

• they have the protected characteristic of gender reassignment;
• they are perceived to have that protected characteristic;
• they are associated with someone who has that protected characteristic;
• they have raised, supported or given evidence concerning an equality complaint;
• they have done another protected act under the Equality Act 2010.

Protection applies throughout the employment relationship, including recruitment, selection, terms and conditions, induction, work allocation, training, supervision, appraisal, promotion, pay, benefits, absence management, disciplinary action, grievance handling and termination of employment.

The prohibited conduct may include direct discrimination, indirect discrimination, harassment and victimisation. Harassment will be assessed in accordance with the Equality Act 2010, including whether conduct has the purpose or effect of violating a person’s dignity or creating an intimidating, hostile, degrading, humiliating or offensive environment.

A person does not need to undergo medical treatment, surgery or obtain a Gender Recognition Certificate to be protected under the characteristic of gender reassignment.

Employees will not be treated less favourably in relation to an absence because of gender reassignment than they would be treated for an absence caused by sickness or injury, or for another absence where less favourable treatment would be unreasonable.

Alleged breaches will be considered fairly, impartially and in context. Disciplinary action will not be automatic and will only be taken following an appropriate investigation and the organisation’s disciplinary procedure.

5. Managing Gender Transition at Work

5.1 Confidentiality, privacy and disclosure

An employee is not required to disclose that they are transgender, have transitioned, intend to transition, have a Gender Recognition Certificate or have previously used another name, except where limited information is genuinely required for a lawful and specific employment purpose.

An employee who would like workplace support may approach their line manager, Human Resources or another designated senior manager. Information will be shared only with people who need it for an identified purpose and, wherever practicable, with the employee’s prior agreement.

Before information is shared, the employee and manager should agree:

• what information may be shared;
• with whom it may be shared;
• the reason it needs to be shared;
• when and how it will be communicated;
• how questions from colleagues or individuals receiving care will be managed.

Information about a person’s gender history, previous name, medical treatment, transition or GRC status must not be disclosed because of curiosity, convenience or routine discussion. Unauthorised disclosure may breach data-protection legislation, confidentiality obligations and, where the information is protected information acquired in an official capacity, section 22 of the Gender Recognition Act 2004.

A breach of confidentiality will be investigated and may result in disciplinary action. Information may be disclosed without consent only where there is a clear lawful basis, such as an immediate safeguarding concern, a legal obligation or another applicable statutory exception. Any disclosure must be limited to what is necessary and recorded.

5.2 Individual workplace support plan

Where an employee requests support in connection with transition, the employee and an agreed manager or Human Resources representative should prepare a confidential workplace support plan. The plan must be tailored to the employee and must not assume that every transgender person will follow the same process.

Where relevant, the plan may record:

• the employee’s preferred name, title and pronouns;
• the date from which workplace records and communications will change;
• whether, when and how colleagues or relevant third parties will be informed;
• arrangements for identification documents, photographs, email addresses, directories and payroll records;
• uniform and workplace-facility arrangements;
• anticipated appointments or absences;
• any temporary workplace adjustments;
• how inappropriate conduct, questions or disclosure will be addressed;
• a review date and the manager responsible for the agreed actions.

The employee will not be required to provide medical details that are unnecessary for employment purposes. Where occupational-health advice is required, only information necessary for assessing fitness, safety or adjustments will be requested and processed.

5.3 Names, titles and employment records

An employee may request the use of a new name, title and pronouns without obtaining a Gender Recognition Certificate. A change of name may need to be evidenced for limited legal, payroll, pension, tax, safeguarding or identity-verification purposes, but the organisation will not require a GRC as evidence of a name change.

Subject to legal and operational requirements, records will be updated promptly, including:

• display names, email addresses and staff directories;
• identity badges and workplace photographs;
• rotas, supervision records and internal communications;
• personnel and training records;
• payroll, pension and HMRC-related records where the necessary legal information has been provided.

Historical records will not be altered where retention of the original information is required by law, necessary to preserve an accurate audit trail or required for safeguarding, payroll, pension, regulatory or legal purposes. Access to such records will be restricted to authorised persons.

The organisation will ensure that record changes do not compromise safer recruitment checks, DBS evidence, professional registration, identity verification, continuity of employment records or the accurate investigation of safeguarding and conduct matters.

The employee must be told:

• which records can be amended;
• which records must lawfully be retained;
• who will have access;
• how long relevant information will be retained;
• how inaccuracies can be corrected.

5.4 Uniform and dress requirements

Uniform and dress requirements will be based on the employee’s role, infection-prevention requirements, moving-and-handling safety, identification, professional presentation and the dignity and safety of individuals receiving care and support.

Employees may select from the approved uniform options available for their role, subject to legitimate health, safety, hygiene, safeguarding and operational requirements. Equivalent uniform options will be provided on an equal basis and will not impose a greater burden on an employee because of gender reassignment or sex.

Any request for an alternative uniform, fit or item will be considered sensitively and individually. The organisation may refuse or modify a request where this is objectively necessary for safety, infection prevention, identification, provision of intimate personal care or another legitimate operational reason. The reasons will be explained and an appropriate alternative considered.

Uniform discussions will be handled privately. Employees must not be subjected to intrusive questions about their body, medical treatment or gender history.

5.5 Toilets, washing and changing facilities

{{org_field_name}} will provide suitable and sufficient toilet, washing and, where required, changing facilities in accordance with workplace health and safety legislation.

Workplace arrangements will take account of:

• the statutory requirements concerning separate facilities for men and women, except where a facility is in a separate room intended for use by one person at a time and can be secured from the inside;
• the privacy, dignity, safety and welfare of all employees;
• the protection of employees from discrimination and harassment because of sex or gender reassignment;
• the physical layout and availability of facilities;
• any relevant risk assessment and current EHRC guidance.

Where practicable, the organisation may provide self-contained, single-user facilities that any employee may use. A gender-neutral facility will not be used as a punitive measure or as a means of humiliating or excluding an employee.

Requests and concerns about facilities will be considered individually, sensitively and promptly. No employee should be confronted, challenged or questioned about their body, medical history or GRC status by colleagues. Concerns must be raised privately with a manager.

Managers must not make an informal or unilateral decision about access to sex-specific facilities. Human Resources or appropriately qualified advice must be obtained, the relevant legal requirements considered, and the decision and reasons recorded.

Where care is delivered in an individual’s home, employees must respect the individual’s household rules and privacy. Access to a service user’s private facilities is not an automatic employment entitlement and should be agreed through normal operational arrangements.

6. Preventing Discrimination, Harassment, and Misgendering

6.1 Expected conduct

All employees, workers and volunteers must treat colleagues, individuals receiving care, representatives and visitors with dignity and respect.

Unacceptable conduct may include:

• transphobic abuse, threats, intimidation or ridicule;
• deliberately revealing a person’s gender history without lawful authority;
• targeted or persistent use of a former name or unwanted form of address for the purpose of humiliating, intimidating or degrading the person;
• intrusive questioning about a person’s body, surgery, medical treatment, sex life or GRC status;
• circulating offensive images, messages or materials;
• excluding a person from work, training or workplace activities because of gender reassignment;
• retaliation against a person who has raised or supported a complaint.

Employees should use the working name and professional form of address recorded by the organisation. Genuine mistakes should normally be corrected promptly and respectfully. Whether repeated misnaming, misgendering or other conduct amounts to misconduct will depend on the circumstances, including its nature, frequency, intent, impact, the employee’s response to guidance and whether it forms part of a pattern of harassment.

No employee will be disciplined merely for holding a lawful protected belief. However, the expression or manifestation of any belief must not amount to harassment, discrimination, bullying, intimidation, a breach of confidentiality, refusal to perform lawful duties or a failure to provide safe and respectful care.

Allegations will be considered under the appropriate grievance, dignity at work, safeguarding or disciplinary procedure. Outcomes will be based on evidence and a fair investigation rather than an automatic presumption.

6.2 Raising and responding to concerns

An employee who experiences or witnesses discrimination, harassment, victimisation, bullying or an inappropriate disclosure should, where they feel able, report the matter to their line manager, Human Resources or another manager identified in the Grievance Policy. Where the concern relates to the employee’s manager, an alternative manager must be available.

Concerns may be raised informally or formally, depending on their seriousness and the wishes of the person raising them. Serious allegations, safeguarding concerns or conduct that may place another person at risk may require formal action even where an informal response has been requested.

The organisation will:

• acknowledge the concern promptly;
• consider any immediate measures needed to protect those involved;
• maintain confidentiality as far as reasonably possible;
• avoid unnecessary disclosure of gender history;
• appoint an impartial person to consider or investigate the concern;
• give the person complained about a fair opportunity to respond;
• keep appropriate records;
• explain the outcome, subject to confidentiality;
• protect all parties from victimisation.

Mediation will only be considered where it is safe, voluntary and appropriate. It will not replace an investigation where there are serious allegations, safeguarding concerns or a significant power imbalance.

Support may include access to the Employee Assistance Programme, an employee representative, a trade union representative, occupational health or another appropriate support service.

7. Recruitment, Training, and Promotion

7.1 Recruitment and selection

Recruitment and selection decisions will be based on the requirements of the role, the applicant’s suitability, safer recruitment checks, qualifications, competence, experience and fitness to undertake the work after any required reasonable adjustments.

Job advertisements, application processes and interviews will not unlawfully discriminate because of gender reassignment, sex or another protected characteristic.

Applicants will not normally be asked whether they are transgender, whether they intend to transition or whether they hold a Gender Recognition Certificate. Information will only be requested where it is necessary for a lawful and clearly identified purpose.

Where a role is subject to a lawful occupational requirement connected with sex, the requirement must:

• be permitted by the Equality Act 2010;
• pursue a legitimate aim;
• be proportionate;
• be assessed for the specific role and duties;
• be reviewed rather than applied automatically to every care role;
• be documented and approved by Human Resources or an appropriately authorised senior manager.

Recruitment records and equality-monitoring information will be kept separate wherever practicable. Equality-monitoring information will not be made available to the selection panel unless there is a lawful and necessary reason.

7.2 Training, competence and management responsibilities

Relevant equality, dignity, confidentiality and professional-boundary training will be included in induction and refreshed at intervals determined by the organisation’s training-needs analysis.

Training must be accurate, balanced and appropriate to the responsibilities of staff. It should cover:

• the protected characteristics of sex and gender reassignment;
• direct and indirect discrimination, harassment and victimisation;
• respectful workplace conduct;
• confidentiality and gender-history information;
• responding to inappropriate conduct by colleagues, visitors or individuals receiving care;
• individualised decisions about intimate care, privacy, facilities and work allocation;
• fair handling of complaints;
• safeguarding, professional boundaries and personal plans;
• relevant Social Care Wales professional standards.

Managers responsible for implementing this policy must receive additional training on fair decision-making, documentation, risk assessment, competing protected rights, data protection and obtaining specialist advice.

Training must not require an employee to disclose personal information, state their beliefs or participate in an exercise that would unreasonably compromise their dignity, privacy, religion or protected belief. Staff may be required to demonstrate that they understand and will follow the organisation’s lawful standards of conduct and care.

7.3 Career Development and Promotion

• Transgender employees will have equal access to promotions and career development opportunities.
• No employee will be denied training, pay increases, or leadership roles based on their gender identity.

Decisions about acting-up opportunities, work allocation, specialist duties, training, supervision, appraisal, promotion, pay and professional development must be evidenced against objective and role-relevant criteria. Managers must not make decisions based on assumptions about an employee’s appearance, transition, medical treatment, anticipated absence or the prejudiced views of another person.

8. Supporting Transgender Employees in Domiciliary Care

8.1 Care allocation and interactions with individuals receiving care

Employees will not be removed from duties, denied work or treated less favourably merely because they are transgender, are perceived to be transgender or have the protected characteristic of gender reassignment.

At the same time, {{org_field_name}} must provide person-centred care that protects and promotes each individual’s well-being, safety, privacy, dignity, autonomy, personal outcomes and relevant protected characteristics.

Where an individual or representative requests a particular worker, or asks not to receive care from a particular worker, the request must not be accepted or rejected automatically. A manager must establish and record:

• the nature of the care to be provided, including whether it involves intimate personal care, undressing, continence support, bathing, toileting or clinical procedures;
• the individual’s assessed needs, capacity, communication needs, wishes and feelings;
• any relevant requirement in the care and support plan, provider assessment or personal plan;
• whether the request is connected with sex, privacy, dignity, trauma, religion or belief, culture, previous abuse, safeguarding or another identifiable need;
• the employee’s rights, dignity, safety and contractual position;
• whether there is a lawful, proportionate and operationally reasonable way to meet the individual’s need without unlawfully discriminating against the employee;
• the effect on continuity of care, staffing, travel, call times and other individuals receiving the service.

A preference concerning the sex of a worker may be relevant where intimate personal care is involved, particularly where it is supported by the person’s assessed needs, trauma history, religion, culture, privacy or dignity. The organisation will consider such a request individually and will not describe every sex-based intimate-care preference as discriminatory.

A request based solely on hostility, abuse, degrading language or a desire to humiliate an employee will not be endorsed. The organisation will set clear behavioural boundaries and consider whether the service can continue safely.

Where practicable, managers should seek a solution that protects the dignity and rights of both the individual and the employee. This may include an alternative worker, a revised care arrangement, a discussion with the commissioner, a review of the personal plan, additional support or a documented risk-management plan.

Employees are not expected to tolerate abuse, threats, sexual harassment or violence. Immediate safety measures must be taken where required. Repeated or serious incidents must be considered under the safeguarding, lone-working, violence and aggression, incident-reporting and service-review procedures.

Any change to work allocation must be documented, regularly reviewed and must not be used to reduce an employee’s hours, opportunities or earnings without lawful and objectively justified reasons.

8.2 Inappropriate conduct by an individual, representative or visitor

Where an individual, representative or visitor uses abusive, threatening, sexually inappropriate, humiliating or persistently discriminatory language towards an employee, the employee should withdraw to a place of safety where necessary and report the incident promptly.

The manager will:

• assess immediate safety and safeguarding concerns;
• support the employee;
• record the incident;
• consider the individual’s cognition, capacity, health condition, communication needs and understanding;
• distinguish behaviour arising from an assessed condition from deliberate and informed abuse;
• review the individual’s risk assessment and personal plan;
• agree preventative or de-escalation measures;
• involve the commissioner, representative or relevant professionals where appropriate;
• consider whether the service remains suitable and can be delivered safely.

Any response must be proportionate and must not punish an individual for behaviour caused by dementia, cognitive impairment, acquired brain injury, learning disability, mental ill-health or another condition. This does not remove the organisation’s duty to protect employees from harm.

8.3 Health, well-being, appointments and absence

Employees may request support in relation to medical appointments, treatment, recovery or well-being associated with gender reassignment.

Absence connected with gender reassignment will be managed in accordance with section 16 of the Equality Act 2010 and the organisation’s Attendance and Sickness Absence Policy. An employee must not be treated less favourably than they would be for absence because of sickness or injury, or for another absence where less favourable treatment would be unreasonable.

Depending on the circumstances, support may include:

• reasonable flexibility in arranging shifts or appointments;
• annual leave, sickness absence or another applicable form of leave;
• a temporary adjustment to duties;
• a phased return to work;
• occupational-health advice;
• access to the Employee Assistance Programme;
• review of lone-working or manual-handling risks.

There is no automatic entitlement to unlimited paid leave or to every requested adjustment. Requests will be considered promptly, consistently and individually, taking account of the law, the employee’s health, service-user safety, staffing requirements and the organisation’s applicable leave policies.

Medical information will be limited to what is necessary to manage the employee’s fitness, safety, absence or workplace support. Managers must not seek details of surgery, anatomy or treatment that are not necessary for an employment decision.

9. Addressing possible breaches

A possible breach of this policy will be considered under the procedure most appropriate to the circumstances, which may include informal management action, supervision, additional training, mediation, grievance, disciplinary action, safeguarding procedures, whistleblowing or referral to an external body.

No disciplinary sanction will be imposed without a fair and proportionate process. The organisation will consider:

• what was said or done;
• the context and seriousness;
• whether the conduct was accidental, negligent, reckless or deliberate;
• whether it was repeated after advice or instruction;
• its actual or reasonably foreseeable impact;
• any relevant protected belief or expression rights;
• whether the conduct amounted to discrimination, harassment, victimisation, bullying, insubordination, breach of confidentiality or unsafe practice;
• any mitigating factors;
• consistency with comparable cases.

Possible outcomes may include guidance, an agreed conduct plan, supervision, training, a formal warning, redeployment where lawful and appropriate, or dismissal in cases of sufficiently serious misconduct.

Where conduct may also raise a safeguarding, fitness-to-practise, criminal or regulatory concern, {{org_field_name}} will consider whether notification or referral is required to the local authority safeguarding team, police, DBS, Social Care Wales, CIW or another professional body.

Individuals receiving care, representatives and visitors are not subject to the employee disciplinary procedure. Concerns about their conduct will instead be managed through risk assessment, personal planning, behavioural agreements, safeguarding procedures, commissioner involvement, complaints arrangements and, where necessary, review or termination of the service in accordance with the service agreement and applicable law.

10. Individual decision-making and equality assessment

Decisions concerning facilities, work allocation, intimate care, disclosure, uniform, occupational requirements or competing rights must not be made through a blanket rule.

The responsible manager must:

• identify the precise decision required;
• establish the relevant facts;
• consult the affected people where appropriate;
• identify applicable protected characteristics and legal duties;
• consider privacy, dignity, safety, safeguarding and service-user outcomes;
• consider less restrictive alternatives;
• obtain Human Resources, safeguarding or legal advice where the issue is complex;
• record the decision, reasons, evidence and review date;
• communicate the decision sensitively and only to those who need to know.

An equality impact assessment should be completed where a new organisational rule, facility arrangement, uniform requirement or service-wide practice may materially affect people sharing a protected characteristic.

11. Data protection and record keeping

Personal information obtained under this policy will be processed in accordance with the organisation’s Data Protection and Confidentiality Policy, privacy notices and retention schedule.

Information about gender identity is sensitive personal information and must be handled with particular care. It may also reveal special-category information, such as health information, depending on what is recorded. The organisation must identify an appropriate lawful basis and, where special-category data is processed, an applicable condition under data-protection legislation.

Records must be:

• adequate, relevant and limited to what is necessary;
• accurate and kept up to date;
• accessible only to authorised persons;
• retained only for as long as required;
• stored and transmitted securely;
• disclosed only where there is a lawful and necessary reason.

A confidential workplace support plan must not be placed where it is routinely available to scheduling staff, colleagues or persons who do not need the information.

Records concerning a GRC application, GRC status or a successful applicant’s previous gender may constitute protected information under section 22 of the Gender Recognition Act 2004. Such information must be subject to enhanced access controls and must not be disclosed unless a statutory exception applies.

12. Responsibilities

The service provider and responsible individual will:

• ensure this policy remains consistent with legislation, statutory guidance, the statement of purpose and other organisational policies;
• monitor whether the policy is understood and operated effectively;
• ensure managers receive appropriate training;
• review relevant complaints, grievances, safeguarding events and workforce information for learning and improvement.

The registered manager will:

• implement this policy consistently;
• ensure care-allocation decisions take account of personal plans and assessed needs;
• maintain safe staffing and continuity of care;
• ensure incidents involving discrimination, abuse or threats are recorded and addressed;
• seek advice where competing rights or complex legal issues arise.

Managers will:

• maintain confidentiality;
• respond promptly to requests for support;
• avoid assumptions and blanket decisions;
• document significant decisions;
• address inappropriate conduct fairly and consistently.

Employees, workers and volunteers will:

• treat others with dignity and respect;
• maintain confidentiality;
• follow personal plans, risk assessments and lawful management instructions;
• report discrimination, abuse, unsafe practice and safeguarding concerns;
• cooperate with training and investigations;
• comply with the Social Care Wales Code applicable to their role.

Human Resources or the person performing that function will:

• advise on employment, confidentiality and records;
• support fair recruitment and investigation processes;
• maintain secure employment information;
• arrange specialist advice where required.

13. Related policies and procedures

This policy must be read alongside:

• Equality, Diversity and Inclusion Policy (DCW30);
• Safeguarding Adults from Abuse and Improper Treatment Policy (DCW13);
• Staff Conduct and Code of Ethics Policy (DCW28);
• Disciplinary and Grievance Policy (DCW31);
• Recruitment and Selection Policy;
• Data Protection and Confidentiality Policy;
• Attendance and Sickness Absence Policy;
• Bullying and Harassment or Dignity at Work Policy;
• Whistleblowing Policy;
• Lone Working Policy;
• Violence and Aggression Policy;
• Risk Assessment Policy;
• Personal Care and Intimate Care procedures;
• Complaints Policy;
• Staff Support, Supervision and Development Policy;
• Service User Rights, Dignity and Respect Policy;
• Professional Boundaries Policy;
• Record Keeping Policy.

14. Legal and regulatory references

This policy has regard to:

• Equality Act 2010;
• Gender Recognition Act 2004;
• Human Rights Act 1998;
• UK General Data Protection Regulation and Data Protection Act 2018;
• Employment Rights Act 1996;
• Health and Safety at Work etc. Act 1974;
• Workplace (Health, Safety and Welfare) Regulations 1992;
• Regulation and Inspection of Social Care (Wales) Act 2016;
• Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, as amended;
• Welsh Government statutory guidance for service providers and responsible individuals;
• applicable CIW inspection framework and Code of Practice for Inspection;
• Social Care Wales Codes of Professional Practice and applicable practice guidance;
• applicable EHRC statutory Codes and guidance;
• applicable Acas guidance.

15. Monitoring and review

The registered manager and responsible individual will ensure that this policy is reviewed:

• at least annually;
• following a material change in legislation, statutory guidance, CIW requirements, EHRC guidance or Social Care Wales standards;
• following a relevant court or tribunal judgment;
• after a serious complaint, grievance, safeguarding incident or confidentiality breach;
• where monitoring identifies inconsistent implementation or an adverse impact.

The review will consider, where relevant:

• anonymised complaints and grievances;
• incidents involving harassment, abuse or discriminatory conduct;
• recruitment, retention, training and progression information;
• employee feedback;
• feedback from individuals receiving care and representatives;
• whether care-allocation decisions have been documented and reviewed;
• confidentiality and data-protection incidents;
• learning from safeguarding and disciplinary matters.

Monitoring information must be collected and reported in a way that protects confidentiality and does not identify a transgender employee or reveal a person’s gender history without a lawful and necessary reason.

Material amendments will be communicated to staff. Where changes affect the provision of care or the rights of individuals receiving the service, the organisation will also consider whether personal plans, the written guide, staff training, service agreements or the statement of purpose require review.

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Responsible Person: {{org_field_registered_manager_first_name}} {{org_field_registered_manager_last_name}}
Reviewed on: {{last_update_date}}
Next Review Date: {{next_review_date}}
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