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Administrative   Family I · People administration  ·  IoL Administrative Affairs

AW-09 · Staff Grievance, Conduct and Wellbeing Referral

Primary KPIsnone
Contributes to
TriggerA staff member raises a concern about their treatment, work or environment; a manager or colleague observes or receives a report of conduct falling below the code; a manager or staff member identifies a wellbeing or occupational health need
EndpointInformal resolution recorded and closed; formal grievance or conduct case handed to MBRU HR with the departmental file; wellbeing referral made and any adjustments recorded
OBEF touchpointNone.

BPMN 2.0 (ISO/IEC 19510), generated from the procedure section of this document. Lanes are the roles in the RACI; a cylinder marks a capture point and the KPI it feeds; a diamond is a decision point. Click a task to jump to its step. Scroll to zoom, drag to pan.

AW-09 — Staff Grievance, Conduct and Wellbeing Referral

Workflow ID AW-09
Pack owner IoL Administrative Affairs (decision of 2 September 2026; see Architecture/04_Ownership_Model.md)
Family I — People administration
Ownership Slice of MBRU Human Resources. MBRU owns the grievance procedure, the disciplinary procedure, the occupational health service and the employee assistance arrangements; IoL owns informal resolution, intake and routing, the departmental role in investigations and hearings, wellbeing referral, and the separation of these records from the personnel file [IoL to confirm]
Governing policy MBRU grievance procedure, MBRU disciplinary procedure, MBRU code of conduct, MBRU occupational health and employee wellbeing arrangements [IoL to confirm]; ISO 9001:2015 clauses 7.1.4 and 7.3; ISO 21001:2018 clause 7.1.4
Interfaces AW-07 personnel records; AW-16 data protection; AW-17 where a health or safety incident is involved; AW-24 where a systemic issue emerges; WF-11 and AW-20 boundaries
OBEF touchpoint None.
Process owner ______________
Version 0.1 draft
Effective
Next review

1. Purpose and scope

Purpose. To ensure that a member of IoL staff who raises a grievance, is the subject of a conduct concern, or needs wellbeing support is dealt with promptly, confidentially and under the institution's procedure, with a clear departmental role, protection from detriment for raising a concern, and records that are kept apart from the personnel file. The procedure exists so that the first response to a concern is consistent and recorded, not improvised by whichever manager hears it first.

Scope statement. This procedure manages IoL's departmental part of staff grievance, conduct and wellbeing matters from the point a concern is raised or observed to its closure or its handover to MBRU HR, using MBRU's case management arrangements as the system of record [IoL to confirm].

Applies to. All MBRU-employed staff line-managed within IoL, and hosted secondees for the wellbeing referral and informal resolution steps [IoL to confirm]. Conduct concerns about adjunct and clinical educator appointees are raised with their employer under AW-08 and are out of scope here.

Does not apply to. Learner academic appeals, academic integrity and learner complaints, which WF-11 owns. Non-academic complaints from learners and external parties, which AW-20 owns. Grievance and disciplinary policy, formal hearings, sanctions and appeals against sanctions, which are MBRU's. AW-09 is staff only: a concern raised by a learner about a staff member enters through WF-11 or AW-20 and reaches AW-09 only if MBRU HR opens a conduct case.

2. Trigger, boundary and interfaces

Trigger A staff member raises a concern about their treatment, work or environment; a manager or colleague observes or receives a report of conduct falling below the code; a manager or staff member identifies a wellbeing or occupational health need
Endpoint Informal resolution recorded and closed; formal grievance or conduct case handed to MBRU HR with the departmental file; wellbeing referral made and any adjustments recorded
Upstream AW-07 (the employment relationship); AW-17 (an incident that gives rise to a concern); WF-11 or AW-20 (a learner or external complaint that MBRU HR converts into a conduct case)
Downstream MBRU HR (formal procedure); occupational health and employee assistance (referral); AW-24 (systemic findings); AW-06 (where a pattern is a departmental risk)
Handoff to the academic pack None. The boundary with WF-11 is the identity of the person raising the matter: a learner's complaint stays in WF-11 even where a staff member is its subject, until MBRU HR opens a staff case.

3. Roles and accountability

Process owner. IoL Director or a delegate at a level senior to any line manager who may be the subject of a grievance [IoL to confirm].

Step Staff Member Line Manager IoL Director or delegate IoL HR Coordinator MBRU HR Occupational Health
Raise concern R I I I I I
Attempt informal resolution C A/R I C I I
Log and route a formal grievance R I A R I I
Conduct formal grievance procedure C C I I A/R I
Assess and log a conduct concern I R A/R C C I
Investigate or hear a conduct case C C C I A/R I
Make a wellbeing referral C A/R I I I R
Agree workplace adjustments C A/R C I C C
Confirm protection from detriment I I A/R I C I
Close and file the departmental record I I A R I I

[CONTROL] Segregation. A grievance about a line manager is received and handled by the manager's manager, never by the subject. The IoL Director does not investigate a case in which they are a witness or a subject; MBRU HR appoints someone else. The HR coordinator who holds the case file has no other role in the case. Wellbeing referral information is seen only by the referring manager, the staff member and the service; it does not reach the line manager's file.

4. Procedure

  1. Receive the concern and classify it. Whoever receives a concern records the date and, within one working day, classifies it as grievance, conduct, wellbeing, or a mix (a grievance with a wellbeing need is common, and both routes run). [CONTROL] The receiver does not decide the merits; they record and route. A concern that discloses a health and safety incident is also logged in AW-17 the same day.

  2. Offer informal resolution for grievances. The line manager (or the next level up where the manager is the subject) meets the staff member within 5 working days, listens, agrees any actions, and records a short note of the outcome that the staff member sees. Informal resolution is offered, not required; the staff member may go formal at any time. Decision point. Resolved: the note is filed as an AW-09 record, not on the personnel file. Not resolved, or the staff member declines informal handling: step 3.

  3. Log and route a formal grievance. The HR coordinator opens a case, gives the staff member the MBRU grievance procedure and its timelines, and passes the written grievance to MBRU HR within 2 working days. IoL's role from here is to provide information, release staff for meetings and implement the outcome. [CONTROL] IoL does not run its own formal grievance process; a parallel departmental procedure would undermine the institutional one.

  4. Assess a conduct concern. The line manager brings the concern to the IoL Director or delegate, who decides within 3 working days whether it is a performance or expectation issue to be managed under AW-07 (informal conversation, recorded), a minor conduct matter for a documented informal warning under MBRU procedure [IoL to confirm], or a matter for MBRU HR under the disciplinary procedure. Anything involving learner safety, patient safety, harassment, dishonesty, data breach or criminal conduct goes to MBRU HR on the day it is assessed. [CONTROL] A conduct concern is never handled by a manager who has a personal relationship with either party.

  5. Support the MBRU investigation or hearing. IoL provides the case file, releases witnesses, and does not discuss the case beyond those with a need to know. Where MBRU HR decides on precautionary measures (suspension, restriction of duties, removal of access), the IoL Director implements them through AW-15 and WF-08 on the day of instruction and records the instruction. IoL does not decide sanctions.

  6. Make a wellbeing or occupational health referral. Where a staff member's health, workload or circumstances are affecting them, the line manager offers a referral to MBRU occupational health or the employee assistance route [IoL to confirm], with the staff member's consent, and records the referral date only. Any adjustments recommended are agreed with the staff member, recorded, and reviewed at a stated date. [CONTROL] Health information stays with the staff member and the service; the departmental record holds the adjustment, not the diagnosis.

  7. Protect from detriment. The IoL Director confirms in writing to any staff member who raises a grievance, reports conduct or acts as a witness that they will not suffer detriment for doing so, and reviews their situation at 3 months. Any allegation of detriment is itself a conduct concern and goes to MBRU HR. [CONTROL] The 3-month review is recorded.

  8. Implement the outcome. Whatever MBRU HR decides, IoL implements: a change of reporting line, a development plan through AW-07, an adjustment, a restoration of access. Implementation is recorded and confirmed to MBRU HR.

  9. Close and file. The HR coordinator closes the departmental case record, noting only the category, dates, route and whether the outcome was implemented. The case file is held in the restricted AW-09 store, separate from the personnel file, and disclosed only under AW-04 or on MBRU HR instruction. [CONTROL] Nothing from an unsubstantiated concern is placed on the personnel file.

  10. Look for the pattern. Quarterly, the IoL Director reviews anonymised case categories and timelines. Two or more cases pointing to the same team, workload or practice are raised in AW-24 as a systemic issue and, where the department's operation is at risk, in AW-06.

Exception routes. Immediate risk to a person (threat, self-harm, violence): safety first, security and emergency services as needed, AW-17 logged, MBRU HR informed the same day. A grievance against the IoL Director: received by the HR coordinator and passed directly to MBRU HR without departmental handling. Anonymous concerns: assessed under step 4; the absence of a named complainant limits but does not prevent action.

5. Service standards

Service Standard
Concern classified and routed 1 working day
Informal resolution meeting offered 5 working days
Formal grievance passed to MBRU HR 2 working days from receipt in writing
Conduct concern assessed 3 working days; same day where safety or dishonesty is involved
Precautionary measures implemented Same day as MBRU HR instruction
Wellbeing referral offered 5 working days from need identified
Protection-from-detriment letter 5 working days from concern raised
Outcome implemented 10 working days from MBRU HR decision, or as the decision states

6. Records, retention and controls

Record System Retention Owner
Concern log (category, dates, route only) Restricted AW-09 log ______ years [IoL to confirm] IoL Director
Informal resolution note Restricted AW-09 store ______ years Line Manager
Formal grievance or conduct case file MBRU HR case system; departmental copy in restricted store Per MBRU HR schedule [IoL to confirm] MBRU HR
Precautionary measure instruction and implementation Restricted AW-09 store Per MBRU HR schedule IoL Director
Wellbeing referral date and agreed adjustments Restricted AW-09 store Employment plus ______ years Line Manager
Protection-from-detriment letter and 3-month review Restricted AW-09 store ______ years IoL Director
Quarterly pattern review, anonymised AW-24 file ______ years IoL Director

Key controls. (1) Every concern classified and routed within one working day. (2) No grievance handled by its subject. (3) No departmental formal grievance or disciplinary process parallel to MBRU's. (4) Safety, harassment, dishonesty and data breach matters go to MBRU HR the same day. (5) Health information is never held in the departmental record. (6) Protection from detriment confirmed in writing and reviewed. (7) AW-09 records separated from the personnel file, access-restricted, and disclosed only under AW-04.

OBEF touchpoint. None. This procedure produces no data for the academic pack.

7. Performance measures

Dimension Measure Target
Timeliness Concerns classified within 1 working day 100%
Timeliness Formal grievances passed to MBRU HR within standard 100%
Compliance Cases with a segregation breach found on review 0
Compliance Unsubstantiated concerns found on a personnel file at audit 0
Accuracy Case records with category, dates and route complete at closure 100%
Experience Staff confidence in raising a concern, annual staff survey item [IoL to confirm] Improving

8. Change control

Date Version Change Reason Approved by
2026-09-02 0.1 Initial draft IoL administrative pack draft, unapproved